DENT AL CARIES 
 
 ITS CAUSES. 
 
 INVESTIGATION INTO THE INFLUENCE OF FUNGI 
 IN THE DESTRUCTION OF THE TEETH. 
 
 DRS. LEBER AND ROTTENSTEIN. 
 
 TRANSLATED BY 
 
 THOMAS H. CHANDLER, D. M. D., 
 
 PROFESSOR OF MECHANICAL DENTISTRY IN THE DENTAL SCHOOL OF HARVARD UNIVERSITY. 
 
 WITH ILLUSTRATIONS. 
 
 PHILADELPHIA: 
 LINDSAY & BLAKISTON. 
 
 18 73.
 
 Entered according to Act of Congress, in the year 1873, 
 
 By LINDSAY & BLAKISTOX, 
 
 In the Office of the Librarian of Congress, at Washington, D. C. 
 
 SHERMAy d- CO., PRINTERS, 
 PHILADELPHIA.
 
 
 TEANSLATOR'S PREFACE. 
 
 Having accidentally met with Leber and Rottenstein's Recherches 
 sur la Carie Dentaire, I was so struck with its views upon a cursory 
 examination that I was induced to give it a more careful perusal, 
 and finally to translate it, that others might have the benefit of them. 
 
 Since the publication of Dr. Bowditch's investigations, some thirty 
 years ago, vague ideas of "Animaculse" in the mouth, and of their 
 influence upon the teeth, particularly in the formation of tartar, have 
 prevailed, not only among dentists^ but their patients. There have 
 also come to us across the water rumors and indefinite statements of 
 discoveries of Fungi in diseased matter of all kinds, and, ou the 
 principle "omne ignotum pro mirifico," these statements have been 
 adopted without investigation,, and the invisible world has seemed 
 to be coming at once to the front, and claiming a much larger share 
 of our life and welfare than the visible. 
 
 Fungi have also been described in the teeth, but, until the publi- 
 cation of the present treatise, nobody has seemed to put his finger 
 upon a fungus, and point out its work in any specific way. The 
 authors have stated their points clearly,, and have given their methods, 
 so that those who desire can easily follow in their tracks either to 
 verify or confute. Meanwhile I have thought it worth my while to 
 enlarge their audience by putting their work into an English dress,
 
 IV TRANSLATOR s PREFACE. 
 
 for which purpose I have used much of my little leisure of the year 
 past. 
 
 Hoping it may stimulate to investigation, and either by the con- 
 firmation or disproval of its statements advance the knowledge of 
 the whole subject, I dedicate the result of my labors to the dental 
 profession. 
 
 The Translator. 
 
 January, 1873.
 
 AUTHORS' PREFACE. 
 
 We began our inquiries into Dental Caries nearly two years ago, 
 and continued them up to about the middle of last year. The pub- 
 lications uj^on the same subject which have appeared in the interval 
 have not discouraged us. The study of the histologic changes 
 undergone by the dental tissues attacked by caries had led us to 
 new results, and appeared to have furnished us with important 
 details which had escaped the attention of other observers. 
 
 We hope, in publishing the result of our investigations, to throw 
 some light upon the much-disputed subject, the nature of Dental 
 Caries. 
 
 Our work is not a monograph. The limits we have assigned to it 
 are much more modest. We shall confine ourselves to stating the 
 results of our observations, giving upon the progress, the symptoms, 
 and the consequences of caries, only the details indispensable to the 
 exposition of our subject, and shall conclude with some very brief 
 therapeutic deductions. 
 
 In view of the great diversity of opinion among authors upon the 
 nature of Dental Caries, it has seemed useful to preface our work by 
 a review of the investigations made and theories held upon this 
 question up to the present time.
 
 VI AUTHORS PREFACE. 
 
 If we succeed in making the nature of Dental Caries better 
 understood, we shall have attained that end of our labors which 
 alone we had proposed to ourselves. 
 
 The Authors. 
 
 March 25th, 1868.
 
 CONTENTS. 
 
 PAOE 
 
 Tra2TSlator's Preface, ........ 3 
 
 Authors' Preface, 5 
 
 i. résumé of the inquiries made, up to the present 
 
 Day, INTO THE Nature of Dental Caries, . 9 
 
 II. Anatomical Alterations of the Teeth during 
 
 Caries, ......... 17 
 
 Central Caries, . . .17 
 
 Caries of the Enamel, ....... 19 
 
 Histologic Changes in Caries of the Enamel, ... 21 
 
 Leptothrix Buccalis, 23 
 
 Caries of the Dentine, . . . . . . .33 
 
 Microscopic Changes of the Dentine in a Carious State, 39 
 
 III. Considerations upon the Progress and Symptoms 
 
 OF Caries of the Teeth, 59 
 
 Stationary Caries, ........ 74 
 
 IV. Causes of Caries, 80 
 
 Predisposing Causes of Caries due to the Form and 
 
 Structure of the Teeth, ^ 69 
 
 Influence of Acids upon the Production of Caries of the 
 
 Teeth, 74 
 
 Influence of Leptothrix upon the Production of Caries of 
 
 the Teeth, 96 
 
 Therapeutic Conclusions, 98 
 
 Explanation of Plates, 101
 
 INQUIRIES 
 
 DENTAL CARIES. 
 
 RESUME OF THE, INQUIRIES MADE, UP TO THE 
 
 PRESENT DAY, INTO THE NATURE OF 
 
 DENTAL CARIES. 
 
 Under the name of Dental Caries is comprehended a path- 
 ologic process which, after having more or less softened and 
 destroyed the tissues, occasions a loss of substance, and ends, 
 after the destruction of the pulp, in the entire loss of the 
 dental organ. This process has nothing in common with 
 caries of the bones but the name. It diliers from it entirely 
 in its nature. Nevertheless, the name of caries has come 
 into so common use that it would be difficult to replace it 
 by another, and as for the rest, no one will ever confound 
 dental caries with the attection of the bones which passes 
 by the same name. 
 
 The nature of dental caries has for ages been the subject 
 of investigation. The ancient physicians, the dentists of 
 their times, who engaged in this inquiry, confined them- 
 selves to making hypotheses more or less ingenious, and 
 founded them upon experience and clinical observation. In- 
 vestigation, in its proper sense, was only possible when the 
 histologic structure of the dental tissues was known. 
 
 For a long period two hypotheses held a balanced sway : 
 
 2
 
 10 INQUIRIES INTO DENTAL CARIES. 
 
 one, cheminai^ explained caries by the action of chenfical 
 agents, acids in particular; the otter, vital, considered dental 
 caries as a veritable malady, caused by an organic change, 
 and the reaction of the dental tissues against an external 
 irritation. 
 
 The defenders of the chemical theory did not trouble 
 themselves about the vital properties of the dental tissues. 
 Some denied that the developed organs had any such prop- 
 erties; others thought they possessed so little energy that 
 the}'- must always yield under the action of injurious agents, 
 without being able to react in any manner against this irri- 
 tation. 
 
 For them the process followed its course just as though 
 the vital properties had never existed. 
 
 These different opinions remain to-day unsolved in spite 
 of the researches which have been made upon this subject. 
 It is true, that in these later days, the chemical theory has 
 seemed to have the upper hand, although quite recently an 
 attempt has been made to reinstate the vitalist theory by 
 the aid of histologic investigations. But by the side of these 
 two hypotheses, other observers, particularly in Germany, 
 assert the parasitic character of caries, attributing it step by 
 step to the action of animal or vegetable parasites. 
 
 The results published by these latter authors have not as 
 yet been criticized very vigorously ; for, accepted too hastily, 
 in Germany especially, they seem completely ignored in other 
 countries. Messieurs Klencke and Ficinus were among the 
 first to occupy themselves with the histologic alterations of 
 the teeth, and, although their labors have no longer any 
 more than a purely historic interest, we will yet give a short 
 résumé of them. 
 
 Ficinus attributed dental caries to a putrefaction pro- 
 duced by the minute infusorial animalcules which live in 
 the mouth and to which he has given the name of Denticola. 
 These infusoriae are found in great numbers in the mucus 
 which covers the teeth, as well as in the carious cavities. 
 They produce, according to him, a kind of putrefaction 
 which, after having first attacked the enamel cuticle, pro-
 
 INQUIRIES INTO THE NATURE OF DENTAL CARIES. 11 
 
 ceeds to consume the enamel itself and afterwards the den- 
 tine. He thinks that the fibres described bj Biihlraann, and 
 which are no other than the filaments of the Leptothrix huc- 
 calis, derive their origin from the infusorife which he calls 
 denticola^ and that the former are formed by contact with 
 the latter. 
 
 But this theory does not explain the disappearance of the 
 calcareous salts, which are soluble only in acids, while the 
 process of putrefaction supposes an alkaline reaction. 
 
 The investigations of M. Kleucke were published a little 
 later. This author adopts several opinions otiered by M. 
 Ficinus, but he admits, besides the process of putrefaction, 
 several species of caries. 
 
 And first he distinguishes central caries from the common 
 peripheric caries. The former commences in the cavity of 
 the pulp, the latter in the external portions of the teeth. 
 
 He also subdivides this latter into three diiferent kinds. 
 
 1st. A soft caries, caused by putrefaction. 
 
 2d. A soft caries, due to the proliferation of a vegetable 
 parasite called protococcus dentalis. 
 
 AVe must remark here that the existence of this epiphyte 
 has not been confirmed by later observers, and that, in spite 
 of all the pains which we have taken in the search for it, we 
 have not been able to find it. 
 
 3d. The so-called dry caries, with which the parasites have 
 nothing to do. It is caused by the chemical action of acids 
 upon the dental tissues. 
 
 The histologic alterations of which the dental tissues are 
 the seat in caries, were described for the first time with ac- 
 curacy by Air. J. Tomes. According to this author, the 
 changes of the enamel are caused, in the majority of cases, 
 by an imperfect development, with a greater porosity of the 
 tissues ; a porosity which increases with the progress of the 
 caries. 
 
 The canaliculi of the dentine present remarkable altera- 
 tions during caries. In a cross-section we see them sur- 
 rounded by a thickish sheath. One might say that the con- 
 tours of the old cells of the dentine are re-established, and
 
 12 INQUIRIES INTO DENTAL CARIES. 
 
 that the tissue is resolved into its pi-iiiiitive elements of for- 
 mation. We know, in fact, that the dentine is formed at 
 the expense of cylindrical juxtaposed cells which unite dur- 
 ing the ossification of the dentine and become impregnated 
 with calcareous salts. The dental canaliculi alone remain 
 free in the mass with the soft fil)rils, discovered by Mr. 
 Tomes, in the very centre of these canaliculi. 
 
 In a more advanced stage the elements lose the sharpness 
 of their contours and the entire tissue takes a tinelj" granular 
 aspect. If the destruction is rapid, we tind, on the contrary, 
 the canaliculi expanded and with badly deiined contours. 
 
 The pathologic alteration proceeds along the canaliculi 
 towards the cavity of the pulp, giving, in most cases, to the 
 carious portion of the dentine the form of a brownish cone, 
 with the base turned outwards. In cases where a more ex- 
 tended surface of the enamel has been attacked at once by 
 caries, and where the destruction proceeds rapidly, the cone 
 may exist incompletely, or be entirely wanting. 
 
 Around the cone is found a zone relatively transparent, in 
 which the canaliculi contain dental fibrils calcified, which 
 are often separated into portions more or less long, and in 
 some preparations extend be\'ond the extremities of the ca- 
 naliculi. 
 
 Mr. Tomes attributes this calcification of the canaliculi to 
 an organic reaction of the dentine against the pathologic 
 irritation, and he believes that it retards ov arrests the prog- 
 ress of the caries. 
 
 Another manifestation of the vital properties of the dentine 
 consists, according to him, in the augmentation cf sensibility 
 in this tissue which is observed in some cases of caries. He 
 concludes from this that the dentine is sensitive of itself, 
 and not through its neighborhood to the pulp. 
 
 According to Mr. Tomes, acids are the principal cause of 
 dental caries. After having first destroyed the vitality of 
 the parts the acids decompose them little by little. But we 
 do not succeed in producing artificially, by the action of 
 acids upon the dentine, histologic changes like those which 
 we observe in carious teeth. jSI^evertheless, the decalcification.
 
 INQUIRIES INTO THE NATURE OF DENTAL CARIES. 13 
 
 the softening, the destruction of the teeth are all phenomena 
 due to the chemical nature of the process. But the dental 
 tissues, while undergoing destruction, react against the ac- 
 tion of the destroying agents, and this reaction is ma(ie 
 manifest by the calcification of the dentinal fibrils in the parts 
 which surround the carious dentine, and also by increased 
 sensibility. 
 
 The observations of Mr. Tomes upon the histologic struc- 
 ture of the dentine have been confirmed and in part com- 
 pleted by a more recent work of M. E. Neumann.* Mr. 
 î^eumann endeavors to prove by his observations, which 
 bear almost exclusively upon the caries of the dentine, that 
 this attection has, in part at least, an inflammatory nature. 
 According to this author, the injurious agents irritate the 
 dentine and produce phenomena of organic irritation which 
 end by causing the destruction of the tissue. lie distin- 
 guishes two series of alterations, viz. : 1st, those of the sheaths 
 of the dental canaliculi and of the intertubular substance, 
 which have the character of simple degeneration, and are 
 found in all cases of caries ; 2d, those of the fibrils contained 
 in the canaliculi, produced by an inflammatory process. 
 
 The alterations of the first series, identical with those of 
 which Mr. Tomes has given the description, are characterized 
 by a thickening of the walls of the canaliculi. Nevertheless, 
 M. ISTeumann does not believe, with the English author, that 
 the dentine is formed directly hy the calcification of the cells 
 of the dentine. Accordino- to him the intertubular substance 
 is formed at the expense of an exudation, and the cells of 
 the dentine furnish only prolongations which are transformed 
 into the fibrils contained in the interior of the canaliculi. 
 According to Mr. Tomes, the thickened walls of the ca- 
 naliculi are formed by the old cells of the dentine which 
 have acquired new contours. M. Neumann sees in this only 
 a thickening of the normal walls of the canaliculi or dental 
 sheaths, at the expense of the intertubular substance, with 
 consequent obliteration of the canaliculi. 
 
 * Sur la nature de la carle dentaire (Archiv. fur Klin. Cliir., torn, v, fasc. 
 l,p. 117).
 
 14 INQUIRIES INTO DENTAL CARIES. 
 
 The second series of alterations consists, according to ^^. 
 Neumann, in a thickening of the dental fibrils in the interior 
 of the canaliculi. These fibrils liave considerably increased 
 in diameter and are divided into little bundles slightly sepa- 
 rated from each other. He considers them as cells produced 
 by division of the fibrils. If this explanation is correct we 
 should not find in teeth of substitution, whether obtained 
 from man or animals, alterations analogous to those of living 
 teeth. M. Neumann had had occasion to examine a peg of 
 ivory which, inserted into a bone for the purpose of efiecting 
 the cure of a pseudarthrosis, had been attacked by the caries 
 of the bone. iSTone of the changes observed in carious teeth 
 were found. M. Neumann concludes from this that experi- 
 ments made upon substituted teeth would probably lead to 
 the same negative result, and that their caries is essentially 
 ditierent from that of living teeth. 
 
 At the beginning of this year (1868) appeared the " Trea- 
 tise upon Dental Caries " by M. E. Magitot. Some chapters 
 of this work had been published separately the year preced- 
 ing. The author wishes to prove that the acids contained 
 in the saliva, or mixed with it, are the cause of dental caries, 
 and that the nature of this afiection is consequently purely 
 chemical. He has made experiments with the object of arti- 
 ficially producing caries, by the action, during a sufficiently 
 long period, of diluted acids upon teeth. The teeth were, iu 
 fact, destroyed, and the author observed curious difierences 
 in the action of the various acids upon each of the dental 
 tissues. The teeth destroyed were not submitted to micro- 
 scopical examination. 
 
 The book of M. Magitot contains no ncAv facts upon the 
 subject of the pathologic alterations of the dental tissues. 
 He does not even mention the alterations described by 
 Messrs. Tomes and Neumann, and contents himself with 
 saying that the canaliculi contain sometimes a finely granu- 
 lated substance. 
 
 Pie attaches great importance to the calcareous deposits 
 in the interior of the canaliculi. and considers them as the 
 result of a secretion from the irritated pulp. While the
 
 INQUIRIES INTO THE NATURE OF DENTAL CARIES. 15 
 
 enamel is disappearing under the action of acids, the irrita- 
 tion is conveyed across the dentine even to the pnlp, which, 
 reacting, throws out a calcareous exudation. This exuda- 
 tion fills the canalicnli from without inwards, towards the 
 cavity of the pulp, and, when they are entirely filled, it is 
 deposited at times on the internal wall of the pulp-cavity 
 under the form of dentine of new formation. The deposition 
 of calcareous salts in the interior of the canaliculi, and the 
 production of true dentine in the pulp-cavity, are, according 
 to M. Magitot, two analogous phenomena. 
 
 The portions of the dentine containing these canaliculi ob- 
 literated by calcareous deposits, form a cone or zone of trans- 
 parent substance, which must be destined to arrest or retard 
 the march of the malady. M. Magitot does not, therefore, 
 attribute caries exclusively to chemical destruction. He ad- 
 mits at the same time the irritation of the pulp which, by a 
 cal(^areous exudation, can arrest the destructive progress. 
 The cavity of the pulp once opened, inflammatory symptoms 
 manifest themselves, after which the rest of the tooth, no 
 longer protected by the pulp, undergoes decomposition by 
 the acids. 
 
 Before concluding our résumé let us remark upon a strange 
 idea, started a little while ago in England. It would explain 
 not only the destruction but also the formation of the teeth 
 b}^ electricity. This publication, coming from Mr. K. Bridg- 
 man, has been indorsed by the Odontological Society of Lon- 
 don. The author has demonstrated by his experiments that 
 teeth can be destroyed by electrolysis. But his whole sys- 
 tem is based upon a series of hypotheses ; he attributes en- 
 tirely arbitrarily, different electric properties to different 
 parts of the teeth. The pulp vessels should be charged with 
 negative electricity, the normal pulp with positive elec- 
 tricity ; but, in a pathologic state, the surface of the dentine 
 as well as the roots would be charged with negative elec- 
 tricity. It is useless to dwell upon this work, inasmuch as 
 no direct proofs are offered of the existence of these positive 
 or negative qualities, nor of the currents which result there- 
 from.
 
 16 INQUIRIES INTO DENTAL CARIES. 
 
 If we review the numerous and diverse opinions wliich we 
 have just passed in review, we see that their authors differ 
 in points the most essential. We have said above that the 
 different theories can bé ranged in three categories — chem- 
 ical, vital, and parasitic — which can in their turn be sub- 
 divided. 
 
 In general, we can say that the chemical process plays an 
 essential part in the production of caries ; but it is a question 
 if the organic processes enter equally for a certain share. 
 We shall show in the course of this work, that the organic 
 process is nothing, or nearlj' so, and that a parasitic element 
 plays an important part in the production of caries, but in a 
 wholly different way from wdiat has been described up to 
 the present time.
 
 II. 
 
 ANATOMICAL ALTERATIONS OF THE TEETH 
 DURING CARIES. 
 
 Caries, at least in a majority of cases, commences at the 
 surface of the teeth ; it attacks first the enamel, which alone 
 is exposed, while the dentine is covered entirely, either hy 
 the enamel itself or by the cementum ; this last is moreover 
 protected by the gums. 
 
 Caries rarely attacks the exposed portions of the necks 
 of teeth, and, when it does, naturally has its origin in the 
 cementum. We shall dwell particularly upon the alterations 
 undergone by the enamel and dentine when attacked by ca- 
 ries, as these are the most important tissues of the teeth, 
 and shall speak of its effects upon the cementum only as 
 connected with these tissues. 
 
 Of Central Caries. 
 
 Many authors, Klencke among others, have asserted the 
 existence of a caries which originates in the interior of the 
 tooth and in the cavity of the pulp. ISTowadays most den- 
 tists pronounce against the existence of a central caries. It 
 is true that the process of destruction often begins in a mi- 
 nute crevice or furrow in the surface, and so penetrates the 
 dentine even to the pulp-cavity, where it performs its rav- 
 ages, while the enamel of the surface seems intact, at least 
 to a superficial examination. This caries, although central, 
 has yet its origin at the surface of the tooth. Therefore, in 
 these latter days, the existence of a true central caries ha& 
 been generally denied. 
 
 Although in most cases the caries called central is so only 
 in appearance, there are cases, very rare it is true, where the
 
 18 INQUIRIES INTO DENTAL CARIES. 
 
 destructive process lias commenced in the dental pulp itself. 
 In support of this 'opinion we will cite the following obser- 
 vation, the sole case which has presented itself during the 
 long practice of one of us. Therefore it must be concluded 
 that such cases are extremely rare. 
 
 A lady of 21 years of age presented herself and complained 
 of three teeth, one inferior and two superior incisors which 
 had an extraordinary bluish tinge. They were not painful, 
 and one only caused any disagreeable sensation to the pa- 
 tient. She had consulted several dentists, who had told her 
 that her teeth were dead, and there was no remedy. At the 
 surface of these teeth no trace of caries was to be found. 
 The blue color alone met the view and proved their death. 
 
 In piercing the posterior face of one of these teeth it was 
 found completely softened, even to the enamel, and the tis- 
 sues had a brownish color. The root itself was hollowed to 
 a considerable extent. The same was found to be the case 
 with one of the other teeth. The third, whose color was not 
 so marked and which caused no unpleasant sensation, Avas 
 let alone. As the cause, the patient referred to a blow from 
 a fall which she had had in childhood, and which was fol- 
 lowed by a swelling of the face. The pierced teeth were 
 filled with gold. As for the inferior, there subsequently de- 
 veloped an abscess which was treated by puncturing the root. 
 
 It follows, from these observations, that the vessels and 
 nerves of the pulp had been lacerated at the time of the fall 
 of the patient, which lesion was followed by the death of the 
 pulp. But this might have taken place without the destruc- 
 tion of the dentine following. We cannot explain in this 
 case the cause of the destruction of the dentine, for the teeth 
 could not be examined by the microscope. Facts of this 
 kind must never be confounded with those of ordinary den- 
 tal caries, which is due essentially to the action of destruc- 
 tive agencies acting from the ex'terior. 
 
 "We believe then that there exist cases where the dental tis- 
 sues are attacked and destroyed from the cavitj' of the pulp ; 
 but these cases are extremely rare, and the conditions of their
 
 CARIES OF THE ENAxMEL. 19 
 
 production are not jet well understood, except perhaps the 
 previously necessary death of the tooth. 
 
 Cauies of the Enamel. 
 
 Since caries begins ordinarily at the crown of the teeth, 
 the caries of the enamel constitutes the first stage of the 
 process. The destruction reaches the dentine later, but the 
 first pathological phenomena make their appearance in it, 
 even before the enamel is destroyed in its whole thickness. 
 Most frequently there is seen a black or brownish point in 
 one of the furrows or folds of the crown. On examining a 
 section of the diseased portion the dark color is seen to have 
 its seat in the superficial layers of the enamel, and pene- 
 trates clear to the bottom of the furrow, where the thickness 
 of the enamel is, in general, less than at other poiiîts. 
 
 If, on the contrary, the caries begins on a smooth surface, 
 the approximal face of the tooth, for example, there appears 
 an opaque spot of a yellowish or brownish shade. The points 
 where anomalies of form, of thickness, of quality of dentine 
 exist, are the preferred seats of caries. The dark color of 
 the spots increases with the progress of the disease ; some- 
 times the centre is of a dark brown while the periphery has 
 a yellowish or whitish tinge. The harder the enamel the 
 darker is the color, for in a dense enamel the progress of the 
 caries is slower and the intensity of the color increases more 
 rapidly than the process, which is a long time in extending 
 itself to the periphery, and to any depth. 
 
 The carious spots are easily distinguished, for in them the 
 enamel has utterly lost its normal appearance ; it is trans- 
 formed into a chalky mass, analogous to that which forms 
 the congenital white spots of the enamel, which are also a 
 frequent seat of dental caries At the carious points the 
 enamel also possesses less hardness than in the normal con- 
 dition ; but it is sometimes so resistant that it is almost im- 
 possible to detach fragments at the surface. Often the super- 
 ficial seats seem to otter greater resistance than those whicli 
 are deeper, which, the former once removed, permit them- 
 selves to be more easily excavated.
 
 20 INQUIRIES INTO DENTAL CARIES. 
 
 In other cases the consistency of the enamel is much fee- 
 bler ; it is no more than a chalky mass, or even of no greater 
 consistency than paper-pulp. These ditterences are exj)lained 
 partly by the stage of destruction, the density of the enamel 
 diminishing with its progress ; but the pre-existing differ- 
 ences of the chemical composition, or consistency of the 
 tooth, take an equal part, for the enamel is softened much 
 more rapidlj' in some teeth than in others. At the begin- 
 ning, the surface of the enamel is smooth and uniform ; the 
 fine and parallel stria3 which are ordinarily noticed on its 
 surface, are well defined ; there is, as yet, no loss of sub- 
 stance. This stage, in which the alterations maj' reach even 
 to a considerable depth in the dentine, is generally described 
 under the name of dry caries. The more the tooth resists 
 the longer is the duration of this stage; but, in many cases, 
 this stage has but a short life, and the disease rapidly passes 
 on to the humid form. 
 
 Soon the portions of the enamel transformed by the caries 
 are destroyed ; there is a loss of substance sometimes spread 
 over the surface, or forming a carious cavity, but, generally, 
 this destruction has little extent before the dentine has been 
 attacked in its turn. In this latter case the caries progresses 
 rapidly, and extends itself in depth and laterallj'. The por- 
 tions of the enamel situated at the borders of the cavity are 
 undermined at their base, or greatly softened on their in- 
 ternal surface, and break in because they have no longer the 
 natural support, the dentine. 
 
 We may distinguish two forms in the destruction of the 
 enamel ; on« progressive, extending itself over the surface, the 
 other penetrating. The former shows itself especially in cases 
 where the caries has attacked a smooth surface of the eiiamel, 
 the latter is found where the caries has commenced in a 
 furrow. In the former case the caries has attacked, at the 
 beginning, a considerable part of the surface, and the de- 
 struction will be quite extensive before it has penetrated as 
 far as the dentine. In the latter case, on the contrary, the 
 alteration of the enamel is limited by the sides of the 
 furrow. The enamel is generally thin at this point, so that
 
 HISTOLOGIC CHANGES IN CARIES OF THE ENAMEL. 21 
 
 the dentine rapidly becomes exposed, and its quick destruc- 
 tion causes the phenomena of the caries of the enamel to pass 
 to the second form. 
 
 When a carious cavity is formed in the enamel, it is not 
 unusual to see this tissue become carious, sooner or later in 
 one or several other points ; these new points of disease pro- 
 gress by themselves, or add their forces to those already in 
 existence. It is more rare to see the caries spread itself at 
 once over a large surface ; there are, nevertheless, cases 
 where the greater part of the enamel is attacked or de- 
 stroyed by caries, and, at the same time, one or several 
 carious cavities formed. In such cases there are generally 
 faults of formation of the enamel, which presents, at several 
 points, depressions, hollows, &c., or anomalies of structure. 
 Each one of these points may then originate, either simul- 
 taneously or successively, the production of caries. 
 
 Histologic Changes in Caries of the Enamel. 
 
 Great importance has generally been attributed to the 
 enamel cuticle, discovered by ISTasmyth, in the production of 
 caries, some regarding it as a protecting covering, others as 
 the seat of the disease. 
 
 The cuticle of the enamel is, as is known, a very thin 
 membrane, whose existence is easily shown by immersing a 
 tooth for a short time in a weak solution of hydrochloric 
 acid. We can thus readily detach the cuticle from the 
 tooth's surface. This membrane, according to the investi- 
 gations of M. Waldeyer, must be the vestige of the first 
 formative strata of the enamel, and particularly of the in- 
 termediate layer and the external epithelium. After the 
 development of the enamel has been completed the elements 
 of these strata are transformed into a pavement-epithelium 
 composed of two or three layers of large polygonal cells, 
 which cover the surface of the enamel. These cells become 
 smooth, little by little, till their nuclei are diilicult to be 
 seen; and, during the dental evolution, they unite into a 
 membrane of homogeneous appearance, in which is to be
 
 22 INQUIRIES INTO DENTAL CARIES. 
 
 seen neither nucleus nor cell, and in whicli Mr. Waldejer, 
 by means of a solution of silver, has been able to render 
 again visible the cell contours. 
 
 It is generally thought that the cuticle, on account of its 
 great resistance to chemical agents, must protect the teeth. 
 In fact, according to Ficinus, neither maceration nor boiling 
 in water atlected it, and concentrated mineral acids did not 
 dissolve it. Potassa and soda gave it a whitish appearance, 
 and caused it to swell, but without making it lose its con- 
 sistency. But it must be remembered that if this membrane 
 cannot be attacked by acids, it permits itself to be pene- 
 trated by diffusion ; we must not then lay too much stress 
 upon its role of protection. If the acids can reach the 
 enamel by passing through it, as the method for the isolation 
 of the membrane has already proved, it can at the most re- 
 tard their action, but cannot hinder it completely. It may 
 then be useful in cases where the acids act onlj- in a transi- 
 tory manner ; as, for example, when they have been intro- 
 duced into the mouth with the food, or where they have 
 come from the stomach, as happens in certain diseases, and 
 are immediately removed from the mouth. But if a con- 
 tinuous acid reaction takes place in the mouth, as happens 
 in the case of fermentation, then the protective office of the 
 cuticle is nil. 
 
 In many cases we cannot even invoke the protective office 
 of the cuticle, for it is often worn away on the masticating 
 surface of the teeth, and may be wanting entirely to a 
 greater or less extent. This cuticle is frequently wanting in 
 the furrows or chinks of the masticating surface, which are 
 also the favorite seats of caries. It has been deduced from 
 this fact that caries is developed on account of the absence 
 of the cuticle, but this chosen seat is explained as well by 
 the presence of the furrows which favor the development of 
 fermentations and chemical decompositions. 
 
 It is astonishing to see authors defending the protective 
 rôle of the cuticle, and at the same time admitting that it 
 is the seat, the abiding-place of caries. ^lessrs. Ficinus and 
 Klencke share this opinion. They admit with Erdl, that at
 
 LEPTOTHRIX BUCCALIS. 23 
 
 the beginning of caries, the cuticle, at the surface of the 
 brown spots, is covered Avith a deposit whose nature they do 
 not agree upon. Ficinus says this deposit is formed of 
 vibrios, and of the fibres called by Biihlmann filaments of 
 the leptothrix. According to Klencke it consists of these ele- 
 ments sometimes, bnt, in other cases, there are found the 
 cells of his pretended yrotococcus dentaUs. 
 
 It is in fact easy to show that, at the point of the carious 
 spots, the cuticle is almost always covered with the accumu- 
 lated deposits of leptothrix huccalis ; there is found there a 
 substance finely granular, or bed of fungi, which is composed 
 of very minute sporules. At the surface of this granular 
 substance there are also to be found at times very delicate 
 filaments which spring from it, and which are identical with 
 the fibres of Biihlmann. As this fungus* plays a very im- 
 portant part in the production of caries, w^e will proceed to 
 study it more in detail. 
 
 Leptothrix Buccalis. 
 
 There is almost ahvays found in the mucus of the mouth, 
 at the surface of the tongue, and in the interstices of the 
 teeth, a whitish, cheesy substance, formed in great part by 
 the leptothrix buix-alis. Under the microscope we see a gray, 
 finely granular mass, gangue or matrix, then filaments deli- 
 cate and stifi", of various lengths, which erect themselves 
 above the surface of this granular substance, so as to resemble 
 an uneven turf. It is in the interstices of the teeth that 
 this fungus attains its greatest size, when we do nothing to 
 check its development ; its filaments there attain consider- 
 able length, and form bundles, sometimes parallel and uudu- 
 
 * It may astonish some to see us designate the leptothrix huccalis by the 
 name of fungus, and not by that of alga. Opinions are divided on this 
 question which, for the rest, seems to have no great importance for our sub- 
 ject. We have simply used the name most common in German}', without 
 permitting ourselves to judge a question purely botanic. Yet, if it should 
 come to be shown that the opinion of M. Hallier is correct, which is that the 
 leptothrix is only a form of develo])menl of the fungus penicilliiDii glaucuin, 
 it must be admitted as without doubt tluit the leptothrix is a fungus.
 
 24 INQUIRIES INTO DENTAL CARIES. 
 
 lous, at others firmly interlaced among one another. On the 
 surface of the tongue we see cylindrical or club-shaped ele- 
 ments, which are epithelial prolongations of the filiform 
 papillae of the tongue, as IvoUiker has proved. 
 
 These prolongations are covered by a rather thick mass of 
 granular substance of leptothrix, bristling at times with short 
 filaments. In the fluids of the mouth, detached filaments 
 are often met. The epithelial cells of the mouth are also 
 frequently covered with numerous fine, oblong granulations, 
 identical with those which compose the bed of the fungus. 
 If we closely examine the grayish masses which the granu- 
 lations form at the surface of the filiform papillfe, we see 
 that they are composed of epithelial cells, detached in part, 
 and dissociated, covered with thick masses of granulations 
 which unite and make of them a compact mass. The club- 
 shaped prolongations which result have often very well- 
 marked contours, and the granulations are so intimately in- 
 terwoven that the substance often appears homogeneous, but 
 the addition of a little acidulated liquid permits the granular 
 elements to be readily isolated. The cheesy matter which 
 collects in the interstices of the teeth has an analogous 
 structure, except that the granulations, instead of attaching 
 themselves to the epithelial cells, are joined to the filaments 
 of the fungus, cover and unite tham. 
 
 It is easy to follow^ the formation of this substance. "We 
 observe, under the microscope, filaments upon which granu- 
 lations have fixed themselves ; some enveloped by a sheath 
 of granulations, some united and intermingled with them. 
 Frequently a great portion of the cheesy substance is exclu- 
 sively composed of the granulations, fine, and generally a 
 little drawn out, of which we have spoken. 
 
 These granulations are, according to M. Hallier,* only 
 movable spores in repose, which wander during a certain 
 period in the liquid, but finally attach themselves some- 
 where and increase by forming new articulations. If these 
 observations are exact, as we are inclined to think, the 
 
 * Die pflanzlichon Parasiton des mensohliclu'ii Krerpors. Lcijizig-, 180G, 
 p. 66.
 
 LEPTOTHRIX BUCCALIS. 25 
 
 inoval)l6 spores resemble vibrios which are found in the 
 nnicns of the nioutli, and possess the power of rapid move- 
 ment. These organisms, called dtnticolcc by M. Ficinus, be- 
 long then not to the animal but rather to the vegetable 
 kingdom. Moreover, M. Ficinus compared them with the 
 so called filaments of Biihlmann, or filaments of leptothrix. 
 He had seen spores, which he considered infusoria, move for 
 a time in the liquid among the filaments of the leptothrix 
 and epithelial cells, and afterwards attach and fasten them- 
 selves to one of the filaments. Soon others were added, and 
 thus was explained the formation of the filaments and epi- 
 thelial cells covered with granulations of which we have 
 just spoken M. Ficinus also believes that the filaments are 
 due to the juxtaposition of the granulations, which is not 
 correct. It appears, on the contrary, that the granulations 
 push out prolongations, and that thus is formed successively 
 an articulated chain. As M. Ficinus took the denticolœ for 
 infusoria, he could not have had a just idea of the nature of 
 the fibres of Biihlmann. Later the vegetable nature of the 
 filaments was recognized, but that of the granular substance 
 could not be explained. M. Robin among others thought 
 it was formed by the débris of alimentary substances. This 
 supposition is false ; for, if this were so, the granular sub- 
 stance would not always present the same characteristic 
 aspect. Composed, in fact, of granulations, fine, elongated, 
 and shining, it has a peculiar matted appearance, by which 
 it is easily recognizable. 
 
 According to M. Hallier, to whom we owe the opinions 
 just given upon the spores of leptothrix, this fungus may be 
 only a form of development of the yenidlliinn glaucinn If 
 so this fungus should always be produced when the spores 
 0Ï penicilliam are kept in a watery liquid. We have not 
 verified the truth of this opinion. However this may be,, 
 M. Hallier explains by his theory the formation of the- 
 granular substance, and teaches us the nature of the denticolœ 
 of ]\[. Ficinus. 
 
 It remains to explain wh}', in the mouth, the spores so 
 quickly lose their movements; in the cheesy substance^
 
 26 INQUIRIES INTO DENTAL CARIES. 
 
 where the granulations are found closely packed, no move- 
 ments are perceived. A portion of the elements which move 
 about in the saliva, as vibrios are larger than the little granu- 
 lations of the leptothrix, which can nevertheless change both 
 form and volume. 
 
 In cultivating the leptothrix in the saliva with tlie addition 
 0Î sugar, or any other appropriate liquid, we ordinarily see 
 developed movable spores in numberless quantities, and en- 
 dowed with a power of very rapid motion. If the move- 
 ments cease, which is observed on the edges of the prepara- 
 tion where it begins to dry, the spores resemble exactly the 
 granular masses of the leptothrix which are met with in the 
 mouth. The cessation of movement in the mouth can be 
 explained b}^ the viscosity of the medium, and by the pres- 
 ence of the buccal mucus.* 
 
 We have already observed that it is always very easy to 
 recognize the elements of the leptothrix by their characteristic 
 aspect ; but it is always desirable to have at hand a chemical 
 reagent which will enable us to perceive the existence of the 
 fungus when its external aspect is deceptive. This reagent 
 we have found in iodine and the acids, which give to the 
 
 * Tlie detail?? which we have just given explain equally well the various 
 opinions which have been» expressed upon the conipositi(jn of the tartar of 
 the teeth, and upon the inferior orders of being wliich it contains. Accord- 
 ing to M, Mandl, the tartar may be composed of the calcareous carapaces of 
 infusoria which live by millions in the mucus of the mouth, ftl. Ficinus 
 had the same opinion, as his dentir.olœ are evidently the equivalent of the in- 
 fusoria of M. Mandl. Formerly the tartar was rescarded as a deposit of salts 
 dissolved in the saliva; its chemical composition, analogous to that of the 
 inorganic products of the salivary liquids, still pleads in favor of this opinion. 
 M. Eobin found in the tartar tilaments of leptothrix, and doubted the indi- 
 cations of M. Mandl. According to our researches there do exist in the 
 tartar filaments and granulations of leptothrix. They are easily recognized 
 after treating the tartar with diluted acids. It is probable that it ma}' con- 
 tain at times more filaments, at others more granulations of leptothrix, so 
 that there may occur cases where there can be found only granular masses, 
 which would very closely resemble the indications of M. Mandl. The infu- 
 soria with calcareous shells must be rejected. As for the salts of the tartar, 
 they are precipitated very jirobably in the saliva, mixed with viscous mucus 
 which incloses the filaments of leptothrix, and dejiosited gradually upon the 
 burlace of the teeth.
 
 LEPTOTHKIX BUCCALIS. 27 
 
 elements of Icptothrix a beautiful violet tinge. We obtained 
 this reaction in trying the eiFeet of that for cellulose (colored 
 blue by iodine and sulphuric acid) npon our fungus, and we 
 have noticed that MM. Leyden and Jatfé had already recom- 
 mended the same reagent for the leptothrix vrhich is found 
 in putrid sputa, and in the lungs.* They are treating of 
 fungi which are discovered in sputa which have become 
 putrid in cases of gangrene of the lungs, 'i he sputa had a 
 very acid reaction. The fungi were colored a beautiful 
 violet by the simple addition of iodine. The fungi of the 
 mouth which have undergone no change are colored, for the 
 most part, 3'ellow by iodine ; generally we notice a violet 
 color only after adding an acid. Sometimes we obtain a 
 violet reaction by the aid of iodine alone, a fact which we 
 must attribute to acidity of the buccal mucus. It is not 
 necessary to make use of sulphuric acid, as in the case of the 
 reaction of cellulose ; but any acid whose action is not too 
 violent will render the same service. We have obtained ex- 
 cellent effects by the use of weak hydrochloric acid, by 
 acetic, and by lactic acid. Sulphuric acid has with us less 
 generally succeeded, because it occasions so rapidly other 
 decompositions. The reaction which we have obtained is 
 identical with that which MM. Leyden and Jafie have de- 
 scribed, for the color is likewise that of a beautiful violet 
 (not blue as in the action with cellulose), and it is the con- 
 tents of the iilaments and not their envelope which is colored. 
 We know this by the circumstance that the sejJta of the fila- 
 ments remain inaccessible to all coloration. It results from 
 this that the presence of an acid is indispensable to obtain 
 the reaction. JSTevertheless it will be useless to have recourse 
 to any acid when the liquid which contains these fungi is 
 acid enough, as is the case in putrid sputa, and even, at 
 times, in the mucus of the mouth. 
 
 We almost always find, as we have already observed, at 
 the surface of the carious points of the enamel, a coating of 
 
 * Vide Leyden and Jaffé. Sur les crachats putrides, la gangrene pulmo- 
 naire et la bronchite putride. (Archives ixUemandes de clinique médicale. 
 Tomes ii, iv, and v, 1866, p. 488.)
 
 28 INQUIRIES i>:to dental caries. 
 
 leptothrix, even when this surface seems still polished and 
 intact. This coating adheres strongly, and is not so casily 
 renioved as the cheesy masses of leptothrix which cover other 
 parts of the surface. AVhen, by the aid of a weak acid, the 
 enamel cuticle is I'emoved, we find this coating thickened, 
 composed most frequently of the accumulations of granular 
 matters, and there is rarely to be recognized the presence of 
 filaments of leptothrix:. The fungi seem to have penetrated 
 through the enamel cuticle, as they adhere to it strongly ; 
 but, at this stage, it is not possible to prove their presence 
 in the enamel itself. 
 
 The filamentous and granular matters of lejjtothrix which 
 are found accumulated on the cuticle of the tooth are not 
 arranged in any regular manner ; we often see them under 
 the form of rounded and irregularly disposed masses. 
 Neither are these masses well defined, but are joined one to 
 another by delicate beds of granular matter. It is probable 
 that these appearances have formed the base of the observa- 
 tions of MM. Erdl, Ficinus, and Ivlencke; but they have not 
 given us exact descriptions of them. We have never been 
 able to perceive the presence of the cells described and pic- 
 tured by M. Klencke in his Protococcus dentalis, and we think, 
 after investigations made upon a great number of teeth which 
 have all ^ùelded us identical results, that his conclusions are 
 founded in error. We are the more convinced of the cor- 
 rectness of our own results, in that no observer has succeeded 
 in confirming the facts as stated by M. Klencke. Yet it is 
 hard to say what could have given, rise to this error, inas- 
 much as there exists absolutely nothing which offers any 
 analogy to the facts as stated. M. Klencke describes cells 
 of from jl^ to 3^0'" i^^ diameter, which would be collected, 
 at the beginning of the caries, in simple beds crowded to- 
 gether upon the enamel cuticle, and, later, these same cells 
 would form layers superposed, and vcapable of multiplying 
 by division or by endogenous proliferation. The mode of 
 propagation of these cells penetrating the dental substance 
 is described and pictured with so great exactness that we
 
 LEPTOTHRIX BUCCALIS. 29 
 
 may be permitted to wait, at least until the discovery again 
 of some analogous elements. 
 
 We find, occasionally, after having removed, by the aid of 
 a weak acid, the cuticle which covers the tooth, minute ele- 
 ments, crowded against each other upon the denuded surface, 
 which might be confounded with a sort of granular epithelium 
 with ill-defined contours. These are nothing but the extremi- 
 ties of the enamel prisms left adhering to the cuticle. It is 
 impossible to confound them with the cells of the fungus. 
 It might with equal probability be supposed that such an 
 error could spring from portions of vegetable or other ali- 
 mentar}^ substances which are found adhering to the teeth. 
 It seems to ns, from certain indications, that the round, 
 granular masses of leptothrix which form upon the surface of 
 the cuticle have given rise to this error, although a certain 
 power of imagination is necessary to consider these irregular 
 and badly defined masses as cells. In caries of the enamel 
 these fungi, as we shall show, appear not to play a part as 
 important as in that of the dentine. The action of acids and 
 the decomposition of oi-ganic substances, which is its conse- ■ 
 quence, and which is recognized by a brown color, seem to 
 us to demand more attention. Yet equal account should be 
 made of the efl:ect produced by the fungi. 
 
 The seat of leptothrix seems generally to be confined to the 
 surface of the tootb as long as the dental substance remains 
 intact. It may be otherwise when the teeth are covered with 
 a o;reenish coatino;, and the lesion seems to have its seat in 
 the very substance of the enamel. 
 
 We meet with this greenish coating in j'oung people and 
 upon the front teeth. It is generally attributed to the alter- 
 ation of the enamel cuticle. The action is not bounded by 
 the surface of the tooth, but penetrates even into the sub- 
 stance of the enamel. We have examined but a single case 
 of this kind. We removed from the surface of the tooth 
 small green and rather hard portions which resembled tar- 
 tar, but which appeared to be rather minute fragments of 
 enamel. JSTevertheless it was impossible, after examining 
 them under the microscope, to decide whether it was enamel
 
 30 INQUIRIES INTO DENTAL CARIES. 
 
 or not. After having dissolved out the calcareous portions, 
 we were convinced that the whole substance was strewn with 
 granular matter oî leptothrix. The greenish tinge was found 
 only at the surface of the pieces ; the acids could not destroy 
 it ; it had an appearance of shreds, delicate and plicated, or 
 perhaps granular, and without other structure. It is im- 
 portant, therefore, to make new experiments to ascertain if, 
 at the place of this green color, the fungi penetrate the sub- 
 stance of the enamel, or if we must attribute it to a particular 
 kind of tartar, as appears much less probable. If the iirst 
 supposition should be confirmed, we must seek to find why 
 and how the fungi succeed in penetrating the enamel. It 
 will not be less interesting to know the origin and the cause 
 of this greenish color. 
 
 As regards the elements of the enamel, no particular change 
 seems to precede its alteration. It can only be shown by the 
 aid of the microscope that it is easier to recognize in minute 
 fragments of diseased enamel the structure of this tissue, than 
 in its fragments in a state of health, when the union of the 
 prisms can with difficulty be perceived. This phenomenon 
 can be explained by the disappearance of the calcareous salts 
 consequent upan the work of caries. Carious enamel appears 
 under the microscope like that which has been submitted to 
 the action of acids, and diliers only by a little more or less 
 brownish color. The farther the work of caries has pro- 
 ceeded, the easier it is to prove this difterence. There are 
 found in minute cavities of the enamel delicate débris of this 
 tissue. The extremities of the enamel prisms and their ob- 
 lique strife have contours so fine that it is only by the shade 
 of brown that we can recognize them. This occurs likewise 
 when we employ acids. We find no more than a residue, 
 very delicate and of a membranous nature, which reveals 
 the composition of the enamel, whose total destruction is 
 not slow in taking place. 
 
 The porosity of the carious enamel, which makes this 
 tissue lose its normal transparency and its hardness, is the 
 same as in enamel exposed to weak acids. It is quite easy 
 to detach from it portions which, under a moderate pressure,
 
 LEPTOTllRIX BUCCALIS. 31 
 
 are reduced to minute débris. By these processes the enaniel 
 prisms separate only exceptionalh' ; the fragments have, for 
 the most part, a direction inclined and oblique, and the 
 isolated prisms appear onlj^ under the form of very short 
 fragMuents The porosity cannot then be attributed to a 
 diminution of cohesion between the enamel prisms, but we 
 may admit, as very probable, that fissures or meshes of a 
 very great delicacy traverse the enamel in directions the 
 most varied, and completely independent of its histological 
 composition. The porosity is equally due to the action of 
 acids. It is produced by the dissolution of the calcareous salts, 
 and perhaps by the production of carbonic acid, which may 
 cause the dissociation of the smaller particles of the enamel. 
 The brownish color of carious enamel, which exists also in 
 carious dentine, arises probably from the change of the 
 organic portion of these tissues. In no case is this color 
 caused by the leptothrix, which remains colorless, or causes a 
 slightly yellowish shade only when in beds of great thick- 
 ness. In a good number of cases, and notably in carious 
 cavities, the leptothrix appears to produce a yellow color, but, 
 on attentively examining, we shall be convinced that this 
 color proceeds from the surrounding diseased materials. 
 We can, on the other hand, in microscopic preparations, 
 easily distinguish by their brown color the residues of dental 
 tissues, which are covered wdth massesof/(?/9to^/(n'.r, while the 
 leptotfirix alone will have a grayish appearance. The color 
 will vary in intensity, as we have already shown, and, in 
 general, it will be dark in proportion to the hardness of the 
 tooth, the age of the caries, and the time the color has had 
 to develop itself. When the enamel has not yet undergone 
 decomposition, Ave ordinarily observe this color only upon the 
 upper layers, without doubt because the cuticle contains a 
 greater proportion of organic elements subject to change. 
 We might think that this was caused also by the easy access 
 of the air to the parts; nevertheless, and contrary to this 
 opinion, we can say that this color is formed anew in the 
 dentine after having disappeared from the deeper parts of 
 the enamel, and that it gradually lessens as it extends to the
 
 32 INQUIRIES INTO DENTAL CARIES. 
 
 cavit}^ of the dental palp (Plate I, Fig. 2\ where, upon a 
 point of the left side of the crown, the brown color of the 
 enamel diminishes little bj little from the surface to the deep 
 parts, and becomes again more intense at the surface of the 
 dentine. 
 
 When the caries has occasioned a loss of substance at the 
 surface of the enamel, the bottom of the cavity is always 
 covered bj' the granular masses, and by filaments of leptothrix, 
 which penetrate the inequalities and excavations of the sur- 
 face. The minute cavities frequently found in the depths of 
 the enamel are filled with lepioihrix, and with débris of 
 enamel mixed with it. It is in general very difiicult to 
 recognize by the aid of the microscope the elements of the 
 enamel when they have become greatly softened. Yet, in 
 cases where the oblique striation is well pronounced, w^e 
 sometimes find fragments of enamel colored brown, and 
 almost entirely deprived of calcareous matters. Masses of 
 leptofhrix envelop them, and contribute, by their prodigious 
 proliferation, to their destruction. 
 
 In our opinion the progress of caries of the enamel is this: 
 By the action of an acid the enamel becomes porous at some 
 point, and loses its normal consistence. At the same time 
 there is seen to appear a brown color, in consequence of the 
 change which has taken place in its organic structure. 
 There is formed at the surface a bed of leptofhrix, which 
 probably penetrates the dental cuticle, if it still exists, and 
 destroys it. Chinks and fissures are opened in the enamel, 
 which has become less consistent. Acid liquids and granu- 
 lations 0Î leptothrix penetrate there, while minute fragments 
 become detached, and are promptly enveloped by the elements 
 of leptothrix, which, joined to the continued action of the 
 acids, hasten the dissolution. There are many cases where 
 the work may be stationary for a long time, and perhaps for 
 always, corresponding to that of the caries called dry, char- 
 acterized only by the brown color of the surface, and a little 
 more porosity, which should be attributed to the more decided 
 action of acids. In answer to what we have just said may 
 be cited the alterations of the enamel which appear almost
 
 CARIES OF THE DENTINE. 33 
 
 immediately after the commencement of the diseased action, 
 when the brown color has hardly had time to become formed. 
 We can attribute these difterences in the progress of the dis- 
 ease only to particular predispositions, due, it may be, to 
 vicious structure, or to ditfering consistency, or resistance of 
 the enamel. 
 
 Caries of the Dentine. 
 
 In the dentine the work of caries begins generally as soon 
 as that of the enamel has pentrated to its surface. Particular 
 circumstances enable us to ascertain whether any alteration, 
 properly so called, and loss of substance at the surface of the 
 enamel, have or have not preceded this morbid action. We 
 can also divide into two periods the action of caries in the 
 dentine, viz., that of the preparatori/ work of the caries, and the 
 loeinod of âestractioii. Before decaying the dentine also under- 
 goes certain transformations wdiich can be recognized, as in 
 the alterations of the enamel, b}' a brownish color more or 
 less marked, and by a lessening of consistency, due to the 
 loss of a portion of the calcareous salts. We observe, more- 
 over, when the disease has j^rogressed to a certain degree, 
 certain histologic changes which were thought to l)e the 
 result of an active, vital action, and which can only be 
 attributed to the proliferation of the leptothrix. 
 
 These same vegetations play also a very important part in 
 the definitive alteration which takes place in caries of the 
 dentine. The caries ordinarily proceeds from the enamel to 
 the dentine; more rarely it has its point of departure in the 
 cement, when this has become exposed, or is defective. 
 Caries maj^ also commence directly in the dentine Avhen it is 
 denuded, whether by a vice of conformation, or by an external 
 lesion. The march of caries is still more rapid in the dentine 
 than in the enamel. Starting from a minute point upon the 
 surface, the caries may promptly extend through a great 
 part of the dentine; that of the enamel cannot make such 
 rapid progress. The more rapid march of the caries in the 
 dentine is occasioned by its structure. The minute dentinal
 
 34 INQUIRIES INTO ÊENTAL CARIES. 
 
 canaliculi, so accessible to liquids, oiler to the action of 
 destructive agents a much more extended surface, and per- 
 mit them to penetrate to the depths of the dentine, an action 
 not possible in the enamel which has not these canals. 
 
 Another cause, which, in the majority of cases, explains 
 the more rapid march of caries of the dentine, is this, viz., 
 the carious cavity once formed, the destructive process can 
 develop itself freely without hindrance from the friction of 
 the teeth during mastication, or from the cleansing of the 
 mouth. While at the surface of the teeth the injurious sub- 
 stances are continually removed, and the enamel forms upon 
 the borders of the cavity a protecting wall, favorable to the 
 development -of caries behind it. Its canaliculous structure 
 appears, however, to be the main cause of the more rapid 
 progress of caries in the dentine, and the observation of the 
 facts leaves no doubt upon this subject. The caries follows 
 chiefly tJie direction of the dentinal cancdiculi, and extends itself 
 less easily and with less rapidity in the direction of the width 
 of the tooth than in that of its depth, that is to say, towards 
 the cavit}' of the pulp. 
 
 If we divide a carious tooth in the direction of its length, 
 we find, as Tomes has first remarked, that the dentine altered 
 by caries, when no destruction has as yet taken place, pre- 
 sents the form of a cone with its base turned outwards, and 
 of a brownish color, which ow^es its origin to that which the 
 caries follows in its progressive march, viz., the direction of 
 the canals towards the pulp ; the conical form is determined 
 by the convergent direction of the dentinal canaliculi. (Plate 
 I, Figs. 1 and 2, shows, three times magnified, cones of den- 
 tal caries upon a tooth divided lengthwise, with and without 
 alteration at the surface.) 
 
 When a portion of the dentine has been destroyed by 
 caries, it can no longer have the form of a perfect cone ; but 
 there is always found, at the circumference of the carious 
 cavity, a zone of altered substance which goes on diminishing 
 in thickness in the direction of the pulp. We find these 
 cones in teeth altered by caries at a period when the exterior 
 surface of the enamel has still all its polish, and, consequently,
 
 CARIES OF THE DENTINE. 35 
 
 has lost IK) part of its substance.* But, at this epoch, the 
 whole thickness of the enamel is already changed, and there 
 exists no covering of normal enamel at the surface of the 
 dentine. j\I. Magitot says that the cone commences some- 
 times at a point at a distance from the surface of the tooth. 
 We believe that the tooth pictured by this author can be ex- 
 plained by supposing that the section, in the direction of its 
 length, has not been made across the centre of the caries, and, 
 consequently, has not touched the point whence the morbid 
 action has been propagated from the enamel to the dentine. 
 The alterations effected by the caries in the dentine nui}^ 
 have extended themselves laterally to a slight depth, and 
 have left untouched the more superficial portions. When 
 we have made sections of teeth across the centre of the caries, 
 we have constantly observed that the alteration had its be- 
 ginning at the surface of the dentine. The cones which we 
 have mentioned have also been spoken of and described b}' 
 various authors, and especially by MM, Tomes and Magitot. 
 Nevertheless we have reason for surprise that these cones 
 have not been considered as the point of de[)arture of the 
 caries itself, but rather as the result of an organic reaction 
 which preceded the caries, and opposed itself as much as 
 possible to its progress. After our experiments made upon 
 a great number of teeth cut across in every direction, we 
 cannot share this opinion. We think, as does also Mr. 
 iSpence Bate,! the cones are only the first degree of the work 
 of caries in the dentine This results from their physical 
 properties ; the color is brownish ; the consistence lessened ; 
 and the transparency greater. 
 
 We have found the broicnish color in all the cones, whether 
 there has or not been loss of substance at the surface of the 
 tooth. In speaking of the enamel, we have already expressed 
 the o[)inion that the brownish color is due to a decomposition 
 of the organic portions of the tooth. The intensity of this 
 color difiers in the dentine as in the enamel. It is darker as 
 
 * Traité de la carie dentaire, 8, 26. 
 
 t Ilcport of the Sitting's of the Odontologie Society of London. March 7, 
 1864. JJrit. .Journal of Dental Science.
 
 36 INQUIRIES INTO DENTAL CARIES. 
 
 the progress of the caries is slower and tlie density of tlie tooth 
 greater. As a general rule we may say that the color is 
 diffused ; from time to time we find in the dental canaliculi 
 minute granulations of pigment which are deposited there in 
 greater or less quantity. The hardness of the substance lohich 
 has acquired the conical form also varies greatly. When there 
 has not yet occurred any destruction of substance, nor any 
 carious cavity, this hardness may, in certain circumstances, 
 be quite marked, above all in the deeper seats, and in teeth 
 which are naturally very hard, and consequently in the cases 
 of caries called dry. Notwithstanding, it is easy to convince 
 oneself that, even in this form of caries, the consistence of 
 the cone, however hard it may be, is always less than that 
 of the sound portion of the same tooth. In other cases, on 
 the contrary, all the substance which constitutes the cone is 
 manifestly more softened than the dentine in its normal 
 state. It is to be remarked that the deeper seats of the dis- 
 ease are always less softened than those at the surface. This 
 is markedly the case when the caries has hollowed out a 
 cavity. We find then, among the most sujjerficial layers, 
 always a softened layer of dentine which is on the way to 
 complete dissolution. The thickness of this layer varies 
 greatly ; in moist caries it is quite thick, and insensibly ex- 
 tends itself to the deeper parts of the cone. 
 
 In the drier caries, the softeued layer of the surface has a 
 much less thickness, and at times is wanting altogether. 
 These difl^erences evidently depend upon the rapidity of the 
 evolution of the caries of the dentine. If the pathologic 
 alteration of the dentine which has preceded its decomposi- 
 tion has occasioned a considerable softening of the substance, 
 the caries will naturally make more rapid strides, and a 
 thick layer of substance undergoing decomposition is upon 
 the point of detaching itself at the surface. But, if the den- 
 tine is very hard and little softened by the work of the caries, 
 the decomposition extends itself but slowly, and the destroyed 
 sul)stance at the surface forms but a thin layer, and some- 
 times seems not to exist at all. 
 
 The transjxirent appearance of the conical substance ecpially
 
 CARIES OF THE DENTINE. 37 
 
 proves that it is the commencement of the work of caries. 
 It is especially easy to recognize it in thin portions which 
 are detached without difRculty from the softened carious 
 substance ; or, if this is too hard, we can always perceive it 
 in sections rubbed down with pumice. The brownish color 
 is scarcely seen in such thin preparations ; we see it well only 
 when it is very intense ; therefore MM. Tomes and Magitot 
 have not attached a sufficient importance to it. 
 
 The dentine, as regards transparency, has properties the 
 very opposite of those of the enamel. AVhile the enamel is 
 translucent in its normal state, the dentine presents an opaque 
 wdiitish or yellowish shade; the enamel loses its translucence 
 by caries, while the dentine becomes more translucent and 
 almost cartilaginous. We have already remarked, in treat- 
 ing of caries of the enamel, that we must attribute its loss of 
 transparency to the action of acids. We shall take occasion 
 to show fucther on that acids produce the same effect out of 
 the mouth as in it. 
 
 Experiments also lead us to the same results with the den- 
 tine. If, by the aid of an acid, we decalcify the dentine, it 
 becomes transparent and acquires the aspect and consistence 
 of cartilage. AVhen the dentine is incompletel}^ decalcified, 
 it resendjles, minus the brown tinge, certain kinds of dentine 
 altered by caries. Yet, at a more advanced stage of the dis- 
 ease, carious dentine is distinguished by less consistence, and, 
 moreover, by peculiarities of structure, inasmuch as the action 
 of acids alone is not enough to produce caries. It ought not, 
 therefore, to be any longer doubted that the transparency of 
 carious teeth should be attributed to the loss of their calca- 
 reous salts. 
 
 Mr. Tomes and, after him, ]\I. Magitot have endeavored to 
 explain this transparencj- otherwise. Mr. Tomes attributes 
 it to the calcification of the fibrillœ which he discovered in 
 the interior of the dentinal canaliculi. In fact, we also have 
 been able to verify very often, and notably at the borders of 
 the diaphanous zone, in the direction of the still sound den- 
 tine, the existence of a considerable number of minute cavi- 
 ties and of granulations ranged side by side, formed by cal-
 
 38 INQUIRIES INTO DKNTAL CARIES. 
 
 caroons salts and situated in the interior of the dentinal 
 canaliculi. 
 
 Xeverthcless it is impossible that the transparency shonld 
 be due to the presence of these concretions, for we do not 
 always meet with them, and when tliey do exist they are 
 not found in every part of the transparent substance. They 
 generally show themselves only in the form of a very slender 
 zone at tlie limits of the portion of the dentine altered by the 
 malady. It is easy to recognize in sections for the microscope 
 that the transparency does not exist except where these con- 
 cretions are seen, and that these same concretions form no 
 part of the appearance which the tissue presents to the naked 
 eye. Finally, it is easy to demonstrate a jpriori that these 
 concretions cannot in any manner cause the transparency of 
 these tissues. They could do so only by rendering them 
 more homogeneous ; that is to say, tlie matters deposited in 
 the canaliculi ought to have the same index of fefraction as 
 the intercellular substance; the boundaries of the canaliculi 
 would thus become, in the sections, paler and less obscure. 
 The opaque aspect of the dentine in its normal state depends, 
 at least in part, upon its structure. It is composed of parts 
 which have different indices of refraction (the canaliculi and 
 the intercellular substance\ and which alternate regularh^ in 
 position. But the concretions contained in the dentinal ca- 
 naliculi ought rather to produce an opposite elfect. In fact 
 they are distinguished under the microscope by their dark 
 margins, which proves that their index of refraction is dif- 
 ferent from that of the surrounding substance. They are, 
 moreover, dispersed in little parcels, which increase the ine- 
 qualities of the structure and lessen the transparency-. In 
 this connection we here remark the opacity which is pro- 
 duced in the tissues by minute globules of fat, ranged side 
 by side, whose power of refraction is well known. If, in spite 
 of this, the tissue remains transparent, we can explain the 
 fact only by admitting that the disappearance of the calca- 
 reous salts has much to do with it, and it cannot be sensibly 
 affected by slight inequalities of tissue. 
 
 We shall recur, in the course of this treatise, to the origin
 
 MICROSCOPIC CIIAN(JES. 39 
 
 of these calcareous concretions in the canalienli, and upon 
 the eftects which MM. Tomes and M agi tot have sought to 
 attribute to their presence. We confine ourselves, for the 
 moment, to asserting that the transj)arency of the carious 
 dentine cannot at all be attributed to them. 
 
 It results, from what we have just said, that the cones, 
 formed of a brownish and more diaphanous substance, make 
 an integral part of the commencement of the Avork of decay, 
 and should not be considered as a peculiar morbid condition 
 preceding the caries properly so called. All can easily verify 
 this for themselves by examining a great number of sections 
 of carious teeth, for thus the different forms and periods can 
 be followed and compared, from teeth where the cones are 
 hard and where doubts may exist, to those whose cones are 
 formed of a substance very distinctly softened and on the 
 road to decomposition. 
 
 Microscopic Changes of the Dentine in a Carious State. 
 
 The microscopic changes which are undergone by dentine 
 during the work of caries are of great importance in resolv- 
 ing the doubts wdiich exist upon the nature of this malady, 
 and especially in ascertaining whether or not organic action 
 is to be regarded as among its causes. 
 
 We have established hereinbefore (in our review of what 
 we actually know^), that different authors have ascertained 
 the existence in the dentine of histologic changes, upon the 
 nature of which, nevertheless, they are far from agreement. 
 Perhaps their differences would have disappeared if more 
 importance had been attached to the manner in which the 
 tissue was destroyed. We distinguish in dentinal caries two 
 periods which cannot be rigorously defined ; the preparatory 
 ■peno(^ of decalcification and softening ^à\xv'mg\\\\\<i'h. the micro- 
 scopic changes in question are to be observed; and the period 
 of direct decomposi ion. Up to the present time it has been 
 the custom to admit in general that the dentine, deprived of 
 its calcareous salts, is dissolved by a sort of putrefaction. 
 But it is not difficult to demonstrate that the influence of
 
 40 INQUIRIES INTO DENTAL CARIES. 
 
 leptothrix is very great in this work of destruction, inasmucli 
 as it penetrates very deeply into the clefts and interstices of 
 the decalcified dentine, which it reduces into small fragments. 
 It is equally probable that this same leptothrix plays, by its 
 extension, an active and direct part in the absorption of the 
 carious tissue. 
 
 We shall demonstrate farther on that a great part, if not 
 the whole, of the microscopic changes observed in carious 
 dentine should be attributed to the introduction of the ele- 
 ments of leptothrix into the dentinal canaliculi, and in part 
 into the iutertubular substance. AVe will first examine the 
 phenomena which characterize the direct decomposition of the 
 tissue. We follow, it is true, a method just the opposite of 
 that which the changes themselves have taken. Yet this 
 ofters no inconvenience, for the knowledge of these phenom- 
 ena is indispensable in order to comprehend the changes 
 which precede the caries. 
 
 If we examine the disorganized substance which covers 
 the superficies of a carious cavity, and which, moreover, 
 presents an acid reaction, we are truly astonished at the 
 quantity of elements of leptothrix which are found there. 
 The superficial layers, with the exception of some particles 
 of food, are formed exclusively by the granular masses, and 
 by the filaments of leptothrix. On removing these we come 
 upon layers which possess sufficient consistency to permit us 
 to make sections. These latter, as is shown in Plate II, 
 Fig. 2, consist of irregular minute fragments of carious den- 
 tine of a brown color. They are enveloped and united by 
 masses of lei^tothrix ; above- all, granular leptothrix. In the 
 layers which lie still deeper the volume of the dentine in- 
 creases; the lej^tothrix diimnishes in such a proportion that 
 the dentine here forms the principal part. We see, then, in 
 the carious portions, colored brown, irregular chinks and 
 interstices filled with leptothrix and its elements (Plate II, 
 Fig. 1). This arrangement may well be compared to the 
 canals and veins which are exhibited by certain stones. The 
 leptothrix always diminishes in proportion to the depth; yet 
 sometimes it is found at a remarkable depth, where it takes
 
 MICROSCOPIC CHANGES. 41 
 
 a direction parallel to the dentinal canaliculi. "We recognize 
 very clearly this arrangement in sections of decalcified teeth, 
 or in those ground thin with pumice. The images ohtained 
 in this manner do not permit us to doubt that these fungi 
 by their extension have deepl}^ penetrated the dentine, and 
 have not confined themselves to simply filling pre-existent 
 cavities. We find these latter nowhere, and we shall prove 
 by and by that the minute dentinal canaliculi constitute the 
 principal roads by wdiich the leptothrix penetrates the dental 
 tissues. 
 
 We often observe in sections islets which are filled with 
 the finely granular matter of the fungus (Plate II, Fig. 6). 
 The origin of these islets is easily explained by the direction 
 of the sections which cross a conduit filled with leptothrix^ 
 and which, in consequence, oft'er the image of an isolated 
 islet. We see there, moreover, other conduits which corre- 
 spond with the surface. Up to the present time observers 
 have confined themselves to proving the presence of the 
 leptothrix in the carious cavities of the tooth, but without 
 assigning it any influence in the work of decomposition. 
 The}^ have not noticed the introduction of the leptothrix into 
 the softened substance of the dentine; and its presence in 
 the carious cavities has consequently been considered as 
 accidental and without importance. According to our ob- 
 servations we cannot refuse to admit that the proliferation 
 of the fungus plays an important part in the decomposition 
 of the dental tissue. What explains the ignorance of authors 
 upon this point is that they confounded the vegetable granu- 
 lations with the organic matters in decomposition, and that 
 the elements proper to leptothrix passed unperceived. The 
 reaction with iodine and the acids, which produces a beauti- 
 ful violet color, as well with the granular masses as with the 
 filaments, leaves no doubt about the nature of the granular 
 leptothrix. 
 
 The figures and their explanations of Ivlencke, upon the 
 penetration of the protococcus deritalis into the dentine, have 
 a certain analogy with the images which we have just de- 
 scribed above. The analogy, nevertheless, holds on\y as to 
 
 4
 
 42 INQUIRIES INTO DENTAL CARIES. 
 
 the mode of penetration of the cells, as he calls them, into 
 the interior of the dentine. His Figure 15* (loc. cit., S. 57), 
 might cause it to be thought that he had under his eyes the 
 same image as we. Yet all that concerns, in these consid- 
 erations and in these sketches, the form, &c., of the extension 
 of these parasitic plants is, as we have already remarked, but 
 the work of the imagination. The opinion of Ficinus, who 
 figured at the surface of the carious dentine a considerable 
 number of vibrios, called by him dentieolœ/is explained in the 
 simplest manner by the theory of M. Hallier, if he is correct. 
 According to this author the granulations of the leptothrix 
 are spores which have come to a state of repose. 
 
 In our researches upon carious teeth we have, it is true, 
 seen the granular masses of the leptothrix stationary, and in 
 proportion but a small quantity of granulations in movement. 
 ÎNTevertheless we believe that there may be great variety in 
 the cases, and that, in given circumstances, we may come 
 across considerable masses of spores dispersed and moving. 
 The observations of Ficinus will thus become conformed to 
 ours, when it will be necessar}^ to consider the presumed 
 infusoria as scattered spores of leptothrix. 
 
 Let us pass now to the examination of the changes ichich 
 take place in the dentine before direct decomposition of the tissue. 
 The softened dentine of a brownish color and of a feeble con- 
 sistence, situated under a carious surface, presents, after re- 
 moval of the masses of leptothrix which penetrate there, pecu- 
 liar changes in the dentinal canaliculi. These changes become 
 in general more and more perceptible as we proceed from the 
 depths of the dentine to its surface. It is easy to see in cross- 
 
 * We have just learned that M. Georges Pouchet had expressed a similar 
 opinion to ours upon the nature of the granulations of leptothrix. He con- 
 sidered them as one of the phases of development of the plant. This author 
 has not noticed movements in the granulations which compose the granular 
 masses, and he has concluded from this that they are always immovable. 
 The movements which others have observed may be caused by vibrios which 
 have penetrated the granular mass. New observations will show if we must 
 receive the opinion of M. Pouchet, or that of M. Hallier, who thinks that 
 the granulations of leptothrix before coming to a state of repose, move through 
 the liquids in every direction, under the form of movable spores.
 
 MICROSCOPIC CHANGES. 43 
 
 sections of teeth that the ccmaliculi become vn y gradually laraer^ 
 till they reach a considerable size, by the accumulation in their in- 
 terior of a finely gi^amdar substance. The canals so enlarged 
 present for the most part a double contour, invisible in the 
 normal state, a fact which indicates that the bore is bounded 
 by thick walls. The thickness of the walls varies, but less 
 than the calibre of the canals. Taking for our point of de- 
 parture the portions which remain sound, we can observe in 
 the sections the passage of the dentinal caualiculi from those 
 without distinct walls to those whose walls are thickened, 
 and whose dilatation goes on increasing by means of the ac- 
 cumulation of foreign substances (see Plate II, Fig. 2). In 
 the latter case, there may still exist a wall distinct from the 
 material contained in the canals ; nevertheless, when the di- 
 latation is very great, it maj' happen that this wall entirely 
 ceases to be visible. Finally, if, in other cases, the canaliculi 
 are but little dilated, while the walls are much thickened, 
 we observe rings quite large, brilliant, and crowded upon 
 each other, which have a brownish-yellow color, like the in- 
 terposed substance. Close observation is necessary to distin- 
 guish the granular contents from the wall, which presents a 
 brilliant aspect (see by the aid of a feeble magnifier Plate II, 
 Fig. 3, where the walls are not at all visible). 
 
 At times the dilatation is carried so far that the canals, 
 crowded together, not onlj^ touch at their circumferences, 
 but become reciprocally flattened. We then observe in trans- 
 verse sections polygonal instead of circular figures. At flrst 
 sight, we might be disposed to think that the canaliculi be- 
 come gradually obliterated by the successive thickening of 
 the walls, according to the opinion of M. IS'eumann,* while 
 Mr. Tomes compares the dentinal canaliculi with thickened 
 walls to pipe-stems, and does not admit of complete oblitera- 
 tion. Xevertheless, we have come to be convinced that in 
 all cases the tubes of the canaliculi are increased and filled 
 with a mass which ordinarily will he finely granular and 
 sometimes homogeneous, surrounded with more or less thick- 
 ened walls. 
 
 * See loc. cit. Archives de Clinique Chirurgicale, t. vi, p. 1.
 
 44 INQUIRIES INTO DENTAL CARIES. 
 
 The principal reason which has caused M. Xeumann to 
 believe in the obliteration of the caualiculi by the successive 
 thickening of the walls, is the images which are obtained 
 after impregnating the preparation with carmine. The 
 thickened walls do not take the color from carmine, while 
 the matter contained in their interior is sometimes very 
 strongly colored by it, and is thus very clearly distinguished 
 from the walls. Sometimes, nevertheless, the contents are 
 but slightly colored ; it is then difficult to distinguish it 
 from the thickened and brilliant wall, which gives rise to 
 the belief that the canal is completely obliterated ; but an 
 attentive examination will always reveal the true state of 
 things. The most remarkable varieties of coloration by car- 
 mine manifest themselves in the intertubular substance. In 
 the normal state this substance is colored, feebly it is true, 
 by the carmine ; in the carious portions, on the contrary, 
 and particularly when the brown color is stronglj' marked, 
 this substance entirely resists coloring, so that these parts, 
 including the dilated canaliculi whose contents remain 
 equally inaccessible to coloration, contrast by their yellow 
 hue with the surrounding parts colored red. On the con- 
 trary, in other circumstances, this same substance will take 
 the color. This is the case with preparations made from the 
 superficial layers, where the intertubular substance shows 
 itself spotted throughout with very fine granulations. It 
 may be said that the brown color is opposed to the red of 
 the carmine, for this latter is perceived nowhere where the 
 brown is strongly marked. AVe must not, therefore, place 
 any great importance upon the coloration Avith carmine. 
 We cannot share the opinion of M. jS^eumann who distin- 
 guishes two kinds of changes : 1st, obliteration of the canal- 
 iculi by successive thickening of the walls ; and 2d, thicken- 
 ing of the fibrils contained in the dentinal canaliculi, and 
 their division into successive cellular elements. 
 
 As for us, we attribale all the changes to a gradually increas- 
 ing dilatation of the canaliculi hy the formation of a finely gran- 
 ular substance which is more or less strongly colored by 
 carmine, and to a thickening of the walls of these same canals.
 
 MICROSCOPIC CHANGES. 45 
 
 In longitudinal sections, which rarely furnish images as 
 distinct as oblique ones, we often see the contents of these 
 dilated canaliculi reduced to the condition of small threads 
 which at times become separated by minute intervals. Thus 
 the dilatation of the canaliculi may become very consider- 
 able ; but we find the threads in the canals already slightly- 
 dilated, and, in this case, carmine colors them a bright red 
 (they correspond to the cellular elements which, according 
 to M. Neumann, come from the thickening and division of 
 the dentinal fibrils). In cases where the contents of the 
 canaliculi does not take the carmine and, as well as the in- 
 termediary substance, presents a yellowish-brown shade, we 
 perceive, in general, the canaliculi thickened only in a con- 
 fnsed manner in the longitudinal sections ; we can prove 
 only that the dentinal canaliculi are badly defined, and that 
 their contours are replaced by longitudinal stv'vre but little 
 marked. 
 
 Analogous images under the form of bandies of rods, but 
 in general of a smaller diameter and rebellious to the action 
 of carmine, arise from deposits of calcareous salts in the 
 canaliculi. We shall recur again to this subject farther on. 
 
 As M. Neumann has already observed, we can easily 
 isolate the thickened dentinal canaliculi by macerating them 
 in nitric or hydrochloric acid, just as is done for the normal 
 ones (Plate II, Fig. 5). It is not rare to observe in the same 
 canal the passage from the minute dimensions of the normal 
 state to a pathologic thickening (Fig. 5, b). The isolated 
 canals also present difierences in the degree of coloration by 
 carmine, and very often the division of their contents into 
 threads can be recognized. The contents of the canaliculi 
 often projects beyond their ends, and is seen under the form 
 of a prominence with fine granulations, or else as a brilliant 
 and viscous drop ; in general the extremity of the canaliculi 
 is then contracted. Sometimes, also, there can be distin- 
 guished throuo;h the walls in isolated canaliculi the contents 
 composed of fine granulations. 
 
 Another peculiarity belonging to the thickened canaliculi 
 consists of partial varicose dilatations and the sinuosities
 
 46 INQUIRIES INTO DENTAL CARIES. 
 
 which they present ; this contributes towards rendering 
 them susceptible of acquiring at these points a relatively 
 considerable thickness. 
 
 The mean diameter of the thickened canalicule of a tooth 
 was from .003 to .006 of a millimetre ; some presented a 
 much greater diameter, notal)ly at the thickened and vari- 
 cose points; the normal canalicule of the same tooth showed 
 a diameter of only from .001 to .0015 of a millimetre. To 
 form an opinion upon the nature of the changes just men- 
 tioned, it is of the highest importance to well consider the 
 condition of the dentine in the caries of natural teeth of implan- 
 tation. 
 
 The solution of this question will lead us to know if the 
 changes are in part or wholly of a vital nature, or not. M. 
 ISTeumann has expressed the same opinion, for he has declared 
 that his conclusions would cease to be true if it should come 
 to be proved that, in the caries of natural implanted teeth, 
 the same changes take place as in living teeth. It is a well- 
 known fact, long since observed, that false teeth, whether 
 procured from man or made from the ivory of the elephant 
 or hippopotamus, decay in the mouth as well as the natural 
 teeth. Caries, indeed, establishes itself very quickly in these 
 false teeth, and begins ordinarily in the points where the 
 teeth are fastened upon the plates, or kept in place by the 
 aid of wires. These places constitute, for the development 
 of morbid phenomena, points of departure as favorable as 
 the clefts in the enamel, or interstices in the teeth. 
 
 The partisans of the chemical theory of caries of teeth 
 have always cited, as proof of their opinion, the caries of 
 natural teeth of substitution. JSTevertheless it could be ob- 
 jected that there is but an external analogy between the 
 caries of these teeth and that of living ones, and that there 
 may exist between the two essential histologic ditferences. 
 This is the opinion of M. jSTeumann. lie found, especially 
 in examining a piece of ivory inserted in a bone and attacked 
 by caries, that the characteristic changes of the dentine, as 
 they have been described, were wholly wanting. lie con- 
 cluded from this that the caries of artificial teeth of ivory
 
 MICROSCOPIC CHANGES. 47 
 
 may, in all probability, also not resemble tliat of the natural 
 ones. On the contrary, we have remarked, in examining 
 several teeth made of hippopotamus ivory, as well as three 
 human teeth of substitution which had all decayed in the 
 mouth, that the microscopic changes of the dentine, as they 
 have been described, take place equally in these artificial 
 teetli. In every case the canaliculi were more or less dilated, 
 sometimes even extraordinarily so, and their contents were 
 generally susceptible of being colored by carmine. Above 
 all, in preparations made from hippopotamus ivory, we were 
 able to observe these changes in the most marked maimer 
 (Plate II, Fig. 6). The isolated canals were in part very 
 much thickened and presented the varicosities which we 
 have spoken of. At the greatly dilated points these canals 
 attained a diameter of .009 of a millimetre. There were even 
 some of them which measured as much as .015 ; their con- 
 tents were finely granular and were easily colored by carmine 
 (Plate II, Fig. 7). It is true, we did not find in these the 
 elements in the form of threads, but it is equally true that 
 they are not always found thus in caries of the living teeth. 
 Nevertheless, we have observed these same thread-like ob- 
 jects in the canaliculi of carious pivoted human teeth. The 
 threads then do not form special elements, and the mass 
 which fills the dilated canaliculi, and which is susceptible of 
 coloration by carmine, ought not to be considered a substance 
 of a difterent nature. In teeth made from hippopotamus 
 ivory we do not see the walls of the canals thickened us in 
 human teeth of substitution. In fact, the pieces made with 
 human teetli of substitution present no difference from the 
 preparations made from natural teeth. 
 
 Aside from these considerations there exist still other 
 reasons for combating the opinion of M. jSTeumann, who 
 admits a vital action in the changes we have just mentioned. 
 
 M. Xeumann himself declares that the transformation of 
 the dentinal fibrils, deprived of nucleic into cellular elements 
 ranged one after the other, appeared extraordinary. Farther, 
 as to the cells, we cannot reasonably expect to see their di- 
 mensions vary within too narrow limits. But, indeed, the
 
 48 INQUIRIES INTO DENTAL CARIES. 
 
 threads are already seen in canaliculi which exceed but 
 slightly their normal thickness, as well as in those which 
 have acquired a considerable dilatation, and the vohmie of 
 the threads corresponds to the dilatation of the canaliculi. 
 From time to time we see the contents of the canaliculi 
 divided into minute and rather short fragments ; in other 
 cases divisions are noticed only here and there at great dis- 
 tances, and often they are entirely wanting for a large extent. 
 
 It would as well be permitted to suppose that, by the fact 
 of maceration in mineral acids, the cells are completely de- 
 stroyed, and that the threads no longer exist. But it is by 
 no means so ; the threads are excellently preserved, a fact 
 which proves that they are composed of a material more re- 
 sistant than the substance of which the animal cells are 
 formed. 
 
 We profit by this circumstance to call attention to the fact 
 that in artificial teeth caries extends equally and by prefer- 
 ence along the dentinal canaliculi. 
 
 In the human teeth of substitution which we have had 
 the opportunity of examining, the caries did not commence 
 on the natural surface, but rather on one which had been cut 
 away ; thus the formation of a cone became impossible, inas- 
 much as this can be produced only by the convergence of the 
 dentinal canaliculi which proceed from the surface into the 
 central portion of the tooth. In spite of this we could per- 
 ceive clearly that, at the points where the dentinal canaliculi 
 were perpendicular to the surface, the changes had penetrated 
 much more deeply than there where the canaliculi presented 
 a direction parallel to the surface. 
 
 If, in accordance with what has just been said, the changes 
 mentioned do not owe their origin to a vital action, it be- 
 hooves us now to inquire into their true nature. 
 
 One might think, a priori^ that they had been occasioned 
 by the action of acids. Nevertheless, this cannot be proved 
 experimentally, and as Mr. Tomes has well said, we do not 
 succeed in any manner in imitating artificially the caries of 
 the teeth. The experiments of M. Magitot, in Avhich he has 
 succeeded in producing profound changes in teeth submitted
 
 MICROSCOPIC CHANGES. 49 
 
 for a very long time to the action of diluted acids, are not at 
 all conclusive, inasmuch as they are not supported ])y any 
 microscopic examination. In fact, examination under the 
 microscope is indispensable, because by this alone can we 
 verify the changes characteristic of caries. In the second 
 place, it is possible that the elements of lejjtothrix, which 
 take an essential part in the final destruction of carious den- 
 tine, occasion as well the changes of the canaliculi which 
 precede this destruction. This opinion alone is capable of 
 explaining the changes undergone by artificial teeth, and is 
 completely confirmed by the facts ; for the contents of the 
 dilated canals presents the same violet reaction as the lep- 
 tothrix. In preparations in which are found together elements 
 of leptothrix and thickened canals, we obtain in a like manner 
 the violet coloration, which gives us beautiful images of the 
 contents of the dilated canals. 
 
 It is useless to remark that we have satisfied ourselves 
 that with the normal dentine such a reaction never takes 
 place. Iodine and the acids color it nothing but yellow. 
 The reaction is independent of the coloration of the contents 
 of the dentinal canaliculi by the carmine. In transverse sec- 
 tions of the canals the rounded and brilliant disks, which are 
 rebellious to the coloration by carmine, give the reaction, as 
 well as the dilated canals which contain a finely granular 
 matter susceptible of taking a vivid color from carmine. 
 
 We easily distinguish, in the first, the contents from the 
 walls, and these contents have also taken a finely granular 
 appearance. 
 
 The difference of coloration by the carmine does not then 
 establish 'àwy essential difference between the minute canals. 
 It, perhaps, has for its cause, in part at least, a differing state 
 of development in the spores of the leptothrix. AYe have at 
 least noticed that the masses of leptothrix taken from the sur- 
 face of the tongue, and older, to judge from the strong adhe- 
 sion of their elements, are less strongly colored by carmine 
 than the more recent masses whose elements are more easily 
 isolated. Iodine alone colors the canals yellow. There are, 
 nevertheless, cases where the violet reaction has taken place
 
 50 INQUIRIES INTO DENTAL CARIES. 
 
 ])}' the simple addition of iodine. The fungi situated at the 
 surface are generally colored more strongly. The concen- 
 trated acids, in which teeth are placed for the purpose of de- 
 calcification, appear to render the reaction impossible. This 
 is the reason, without doubt, that ^NI. j^eum^un obtained no 
 violet reaction upon prepared portions of decalcified teeth. 
 
 There is, then, no manner of doubt that the elementary 
 parts of tlie fungus penetrate into the interior of the canals, 
 and there develop in a manner to acquire a relatively con- 
 siderable diameter. It also results, from the very fact of the 
 dilatation of the canals, that the appearance of the fungus is 
 not accidental, and that it is not by a purely passive action 
 that it invades the canals. It is necessary that there be a 
 proliferation of spores infinitely minute and innumerable of 
 the fungus to efiect the dilatation of the dentinal canals. It 
 is, moreover, very important that the elements of the lep- 
 tothrix should have, at a certain stage, a mol)ilit.y of their 
 own, in virtue of which they easily penetrate the interior of 
 the canals. As for the rest, we have met in the canals with 
 only the granular masses of the leptothrix, and never the 'fila- 
 ments which appear to show themselves only at the surface.* 
 
 According to experiments actually made are also explained 
 the formation of conduits and clefts filled with granular masses 
 of leptothrix^ which are found in the superjicial layers of carious 
 dentine. 
 
 They spring from the dilatation, gradually increasing, of 
 
 * The fungi described by MM. "Wedl and Heider (see Wedl " upon a 
 fungus developed in the dentine") (Comptes rendus de l'acadeniie de Vienne, 
 1864, t. 1, p. 173-193) bave, according to the description of these authors, 
 notbing in common with the Icptothrix These develop, after some days, in 
 the cement and dentine of sound teeth which have been extracted and placed 
 in water. The fungi from tbe cement penetrate the dentine, after ten days, 
 to a depth of from .2 to .25 of a millimetre. Portions of dentine which were 
 exposed to their invasions wore, after three or four weeks, pierced like a 
 sieve. These experiments come to the aid of ours, inasmuch as they prove 
 tbat fungi can develop in tbe cement and dentine, even when these tissues 
 still possess all their calcareous salts. 
 
 The soft filament:- which Mr. Tomes has found in tbe interior of tbe canals 
 are probably too tender to resist the invasion of the elements of lepiothrix, 
 and appear therefore to be promptly destroyed.
 
 MICROSCOPIC CHANGES. 51 
 
 certain minute canals. Under the influence of this morbid 
 action, the walls and a part of the surrounding tissue com- 
 pletely disappear. It will, then, be wrong to conclude from 
 this the introduction of the fungus into pre-existing Assures. 
 We can, in fact, observe all the transitions between the den- 
 tinal canals greatly dilated and the conduits tilled with lep- 
 tothrix^2i\\(\. thus assist at the development of these conduits. 
 At the outset these latter alwa3's follow a direction parallel 
 to the dentinal canals ; in consequence, at certain points, 
 more marked dilatations are found corresponding to the 
 varicosities of the dilated canals. jSTeio-hboring: conduits 
 may meet at these points and anastomose with each other. 
 By the incessant development of leptotlirix the softened den- 
 tine becomes decomposed into irregular parcels, which, 
 towards the surface, become more and more minute and 
 finally separate, completing the destruction of the tissue. 
 
 We conceive that the dilatation of the dentinal canals, 
 found in the tissue situated" immediately below the carious 
 surface, may be more or less pronounced and not always 
 reach the highest degree of • development. If, in certain 
 canals, the extension of the leptothnx is more considerable, 
 the intermediate parts may be isolated and undergo decom- 
 position, even when the canals have undergone but a mode- 
 rate extension. The decomposition of the substance may, it 
 is true, likewise commence at the very beginning of the 
 carious surface, which is constantly covered with a prodigious 
 quantity of leiJtothrix. It frequently happens that, in the 
 layers of the surface, the leptothnx also infiltrates the whole 
 intertubular substance, which then presents a granular ap- 
 pearance, and the contours of the canals thus become.very 
 confused. In these cases iodine and the acids produce upon 
 the whole tissue a violet reaction. 
 
 The thickenino^ of the walls can, it is true, have for its 
 cause an action purely mechanical following upon the dis- 
 tension of the canals and the consequent thickening of the 
 environing substance. Yet, w^e must remark, that we have 
 observed similar walls where the canals have not been at all 
 dilated. In cases where the action of caries has just com-
 
 52 INQUIRIES INTO DENTAL CARIES. 
 
 menced, we have seen a portion of the canaliculi moderately 
 dilated and filled as usual with leptothrix. Other canals, on 
 the contrary, had a normal calibre; they may even have 
 been a little narrow, very pale, and surrounded with glisten- 
 ing walls ; whilst the walls of the dilated canals were dif- 
 ficult to distinguish. Nevertheless, we are not quite sure 
 that the phenomenon is analogous to that which presides 
 over the dilatation of the canals. By the aid of maceration 
 in hydrochloric acid the canals are easily isolated ; they pre- 
 sent their normal delicacy ; whilst there, where the canals 
 are dilated, the walls are isolated at the same time with 
 the canals ; in the former case the wall evidently offers less 
 resistance to the action of the acid than in the latter. 
 
 Accordino- to Mr. Tomes the thickening of the walls in 
 caries is the result of the regeneration of the contours of the 
 organic cellules of the dentine. 
 
 M. Xeumann declares, on the other hand, that the dentinal 
 walls are thickened at the expense of the intercellular sub- 
 stance. These authors explain differently the manner in 
 which dentine is formed by the aid of dentinal cells, and it 
 is YQYY difficult to say what is or is not the truth among such 
 different statements. The opinion of Mr. Tomes is based 
 upon the following supposition : According to him the den- 
 tinal cells are penetrated with calcareous salts, except an in- 
 terior portion which is left free, and which forms the dentinal 
 canaliculi with the fibrils which are found there. At the 
 same time there is seen to form a certain quantity of inter- 
 cellular substance which is impregnated, as well as the cells, 
 with calcareous salts, and becomes so fused together with 
 them that their proper contours disappear. 
 
 M. Neumann, on the contrary, considers all the intercellu- 
 lar substance as the product of a secretion ; as for the cells 
 of the dentine they send out very delicate prolongations 
 which go to form the fibrils found in the canaliculi. How- 
 ever this may be the question still remains how the connec- 
 tion of the fused cells comes to he dissolved ; or, if the opinion 
 of M. Neumann is preferred, from whence springs the thick- 
 ening of the dentinal walls? AVe have already remarked
 
 MICROSCOPIC CHANGES. 53 
 
 that acids give rise to uo such alterations. To recapitulate, 
 it appears to us very probable that the thickening of the 
 walls of the dilated canals is produced mechanically, on ac- 
 count of the pressure of the surrounding substance. Here, 
 nevertheless, we are obliged to acknowledge that in some 
 rare cases there are found walls thickened without the canals 
 being dilated, and we confess our ignorance of the cause. 
 Perhaps we may be permitted to suppose a chemical action 
 by the elements of the IcptotJirix upon the environing tissue. 
 
 We have already remarked that during the action of caries 
 there are often formed calcareous deposits in the interior 
 of the dentinal tubes, deposits which Mr. Tomes and M. 
 Magitot have regarded as of great importance. They are 
 seen ranged singly, or in groups, under the form of minute 
 threads, or bundles of them, more or less long ;. or else under 
 the form of separate cylindrical granulations. On submitting 
 them to the action of acids they dissolve, and leave, most 
 frequently, an organic residue, which preserves the same 
 form. 
 
 At times the masses of leptothrix contained in the dilated 
 canals are also impregnated with calcareous salts ; but oftener 
 we meet these deposits in the undilated canals of the deep 
 layers of dentine changed by caries. We likewise find from 
 time to time minute calct^reous granulations in the inter- 
 globular spaces of the dentine. They are observed most fre- 
 quently in sections of carious teeth in which the changes are 
 not far advanced. In these cases they are always found in 
 a zone which surrounds this altered portion of the dentine 
 whose canaliculi are dilated, and show a very intense brown 
 color (see Plate I, Fig. 4, which represents a portion of the 
 dental section pictured in Fig. 3; we see here that the cal- 
 careous deposits do not begin to appear until at a certain 
 depth from the surface). If the change of the dentine has 
 but just begun we sometimes meet the calcareous deposits 
 throughout the greater part of the cone. We have already 
 demonstrated that the transparency of carious dentine cannot 
 be attributed to the presence of calcareous salts in the inte- 
 rior of the canals. These deposits should rather diminish
 
 54 INQUIRIES INTO DENTAL CARIES. 
 
 the transparency ; and yet the zone which contains them is 
 more transparent than in the normal state. We can there- 
 fore attribute it only to the abstraction of a portion of the 
 calcareous salts. These deposits of calcareous salts in the 
 interior of the dentinal canaliculi are considered by Mr. 
 Tomes, and after him by M. Magitot, as the product of a 
 vital action. But inasmuch as these same calcareous salts 
 are likewise found in carious artificial teeth, we can also 
 adduce here all the objections already made against the vital 
 character of the other changes which we have descril)ed. 
 
 AVe are still more inclined to believe that these calcareous 
 deposits are formed by a purely chemical process; that is to 
 say, by the residue resulting from the solution of the calca- 
 reous salts by contact with acids. 
 
 In the work of caries a portion of the calcareous salts of 
 the teeth is always dissolved out ; these same salts, so dis- 
 solved, must bj' difiusion penetrate the canals towards the 
 cavity of the pulp; there in contact with the neutral or alka- 
 line liquid which fills the interior of the canals, or which 
 penetrates the dentinal fibrils, a precipitate is formed. If we 
 drop upon the section of a sound tooth, placed under the 
 microscope, a little concentrated acid, then, shortly after, 
 some drops of water, we see a great number of needle-shaped 
 crystals immediately form, which arrange themselves in the 
 form of rosettes. 
 
 These crystals must be composed of phosphate of lime. In 
 glasses, in which we have for some time preserved carious 
 teeth in water slightly acidulated, we have seen an abundance 
 of these same crystals precipitate themselves upon still farther 
 weakenino; the solution bv the addition of water. The cal- 
 careous salts which have been dissolved by the acids are pre- 
 cipitated by the simple addition of a neutral liquid, and still 
 more by the mixture of a liquid slightly alkaline. From 
 this it is easy to understand why the calcareous deposits are 
 always found at the extremity of that part of the dentine 
 which is altered b}'' caries ; and it is not necessary to admit 
 that they are formed in the pulp-cavity. 
 
 Mr. Tomes compares the calcareous deposits which form
 
 MICROSCOPIC CHANGES. 55 
 
 at the extremity of the diseased dentine to the work of 
 exfoliation in the parts bordering upon a portion of necrosed 
 bone or gangrened tissue. In the two cases the reaction 
 takes place in the surrounding sound parts, Avith this differ- 
 ence, nevertheless, that in dental caries there is no elimina- 
 tion of the diseased tissues 
 
 M. Magitot, on the contrary, believes that the calcareous 
 deposits spring from the pulp; this being irritated gives out 
 a calcareous exudation which at first fills the canals, from 
 W'ithout inwards, and which, in fine, according to circum- 
 stances, is deposited as dentine of new formation upon the 
 interior surface of the pulp-cavit}'. It is, nevertheless, abso- 
 lutely proved that the calcareous deposits in the interior of 
 the canals cannot be identified with the new layers of dentine 
 w-hich are formed at the surface of the pulp-cavity. These 
 formations, in fact, as well as the normal dentine, take their 
 origin from the dentinal cells of the pulp. If the calcareous 
 deposits arise from the pulp, why are they at first so far from 
 it? and why are they not always found in its immediate 
 vicinity? As for the rest, all explanations of this class are 
 formally refuted by the formation of calcareoui^ salts in the 
 caries of artificial teeth, and it is therefore useless to seek 
 for other explanations. Calcareous deposits are more abun- 
 dant in proportion as the progress of the caries is slower, and 
 they develop themselves in an especial manner when the 
 caries remains at rest during a certain time. 
 
 The protection w'hich these calcareous deposits seem to 
 furnish to the dentine can, consequently, be of no great ac- 
 count. As soon as the caries makes new progress, they are 
 dissolved, and probablj" with more facility than the normal 
 calcareous salts of the dentine. From the fact that these 
 deposits manifest themselves more particularly when the 
 march of the caries is slow, it has been concluded that they 
 oppose the morbid action ; while according to our views the 
 slow march of the caries has, on the contrary, for its effect, 
 the formation of the calcareous deposits. 
 
 It remains now to examine if the phenomena ichich ice have 
 just described^ and which relate to the action of acids and of the
 
 56 INQUIRIES INTO DENTAL CARIES. 
 
 leptothrix, are the only ones which, are to be observed in caries of 
 the dentine, and if, hereafter, ice are authorized to deny all inter- 
 vention of vital action. Although we have demonstrated that 
 all the changes described heretofore do not have for their 
 base any vital action whatsoever, we are not permitted, a 
 priori, to reject it as impossible. 
 
 We can have no doubt of a certain vital action in an or- 
 ganic tissue like the dentine, even when it has reached its 
 complete development, even if these vital properties are but 
 little marked. We can very well conceive that the delicate 
 fibrils which, according to Mr. Tomes's discovery, fill the 
 interior of the canals, and preside, in all probability, over the 
 phenomena of nutrition in the dentine, may become changed 
 by an abnormal excitation and thicken like cellular elements 
 irritated or inflamed, and produce by division new elements, 
 as M. Xeumann has established. It is evident that we must 
 admit changes of this nature at the outset of the diseased 
 action, and before the elements of the leptothrix have pene- 
 trated into the dentinal canals and destroyed the fibrils 
 which they find there. 
 
 We have already established that the first changes mani- 
 fest themselves in the dentine, when the enamel is carious 
 throughout its thickness, though there may not be even the 
 slightest loss of substance at the surface of the tooth. As 
 the leptothrix is obliged to traverse the enamel to reach the 
 dentine, and as, in our researches, we have found no element 
 of leptothrix in carious enamel, as long as the caries has not 
 attacked the surface of the dentine, we should expect to ob- 
 serve, at this first degree of the malady, isolated changes of 
 the dentine completely foreign to the action of the leptothrix. 
 To the naked eye, the dentine ofters, at this period of the 
 malady, the same brownish appearance as later ; we remark 
 also that its consistency is not sensiblj^ diminished, except at 
 the surface, in the vicinity of the enamel, and then only in a 
 very tbin layer; its hardness increasing rapidly as we go 
 towards the deeper portions. In most cases we have found, 
 at this stage of caries, no alteration of the canals; their dila- 
 tation is normal, and they are but rarely to be distinguished
 
 MICROSCOPIC CHANGES. 57 
 
 from the iiitertubular substance by less marked contours. 
 In consequence, this dentine gives no reaction which indicates 
 the presence of leptothrix. Yet, exceptionally, we have found 
 in the superficial layers changes resembling those which we 
 have heretofore described, but thej^ have been very much 
 less developed. Sometimes the canals were little dilated, 
 and their walls were thickened at certain points. In the 
 small number of cases, where we have had the opportunity 
 of verifying this result, we have not been able to obtain any 
 reaction capable of indicating the presence of the fungus ; 
 nevertheless this does not prove the absence of the leptothrix, 
 inasmuch as at that time we happened to use too strong acids, 
 and so failed of the reaction, even when the presence of the 
 fungus was certain. As the changes existed only in an ex- 
 ceedingly thin layer under the surface of the dentine, the 
 substance capable of giving the reaction was present in but 
 a very minute quantity. We think, nevertheless, from the 
 identity of the phenomena which were present in this case 
 with those which determine the introduction of the leptothrix 
 into the canals, that they depend upon the same cause. It 
 is true that we have not succeeded in proving the presence 
 of the leptothrix in the substance of the enamel, but its sur- 
 face was usually covered with a granular mass of leptothrix. 
 Yet it is possible that, on account of the extreme minuteness 
 of the elements of the fungus, we have not been able to see 
 in the enamel the very delicate chinks through which the 
 fungus would have to travel to reach the dentine, and there 
 develop in a more favorable soil. This point, nevertheless, 
 will agree with still other observations. 
 
 In all cases it results from this that the introduction .of 
 the fungus into the dentine does not take place during the 
 first evolution of the caries ; at this epoch of the malady, we 
 remark only the loss of calcareous salts, and the decomposi- 
 tion of organic substances, then diminution of consistency, 
 transparent appearance, and brownish color. 
 
 At this stage the histologic examination permits us to 
 view, in the structure of the dentine, no marked change. 
 We cannot say that there are already calcareous deposits in 
 
 5
 
 58 INQUIRIES INTO DENTAL CARIES. 
 
 the canals, inasmucli as we have not given sufficient attention 
 to that point ; nevertheless these deposits may be early 
 formed, even at a time when no marked change of the tooth 
 is yet perceptible. 
 
 From what has just been said we conclude that there exists, 
 up to the present time, no observation which authorizes us 
 in admitting in caries of the teeth an active reaction on the 
 part of the dentine — an inflammation, for example, ^"e as- 
 sert that this caries comes not from such causes, although it 
 is impossible to deny with certainty that there exist slight 
 histologic changes of the dentine, observed at the beginning 
 of the malady, which are not due to the action oî leptothrix. 
 We ought to add here that the leptothrix acts in like manner 
 in the destruction of the cement by caries, when it has its seat 
 at the neck of the tooth. 
 
 We have seen, in cases of this kind, the granular masses 
 of the fungus buried in the chinks and excavations of the 
 cement, just as we see them at the surface of the dentine. 
 We have not been able to prove a particular change in the 
 bony corpuscles ; and, further, there is wanting every indi- 
 cation which can cause a suspicion of an inflammatory state 
 of these elements. As the number of cases in which we have 
 had an opportunity of examining caries of the cement is but 
 small, we cannot draw from them general conclusions as to 
 the absence of inflammatory changes. Such changes would 
 not, however, be surprising, inasmuch as the causes of irrita- 
 tion of the periosteum of the root of the tooth, as well as the 
 production of cémentons substance of new formation, can be 
 considered as ordinary consequences of dental caries.
 
 HT. 
 
 CONSIDERATIONS UPON THE PROGRESS AND 
 SY3IPT0MS OF CARIES OF THE TEETH. 
 
 Having described the anatomo-pathologic changes which 
 take place in caries of the enamel, and of the dentine, we 
 will now proceed to define in a few words the variations of 
 the progress, symptoms, cSrc, of this attection, and to show 
 that these variations are perfectly explained by the results 
 of our researches. 
 
 First, the different varieties of the beginning of caries have 
 received a considerable number of denominations, but we are 
 obliged to confess that we have not found essential ditferences, 
 and we think they can all be explained by a greater or less 
 duration, by the variable resistance of the dental tissue, and 
 by the lesions, more or less extensive, which exist from the 
 first in the enamel. AVe have already remarked that there 
 can be distinguished a form of caries \ohich is propagated more 
 towards the surface., and another whose character is to burrow 
 into the deeper portions ; these two forms do not ofter any 
 other essential difierence. The caries called d.ry is, properly 
 speaking, only the first degree of the work of the malady, 
 when the dentine is as yet but incompletely decalcified, 
 when no element of leptotJirix has yet penetrated there, and 
 no change has manifested itself at its surface. Then the 
 enamel as well as the dentine is transformed by mechanical 
 action into a rather fine, hard, pulverulent mass ; while in 
 the so-called filn*illary caries, the suljstance of the dentine, 
 much softer, and as it were cartilaginous, appears to be com- 
 posed of very fine filaments. This filamentous texture de- 
 pends upon the great dilatation of the dentinal canals. 
 
 The tooth will remain in the state of dry caries the longer
 
 60 INQUIRIES INTO DENTAL CARIES. 
 
 in proportion as it shall offer by its density greater resistance 
 to the invasion of tlie malady, so that the fibrillary or humid 
 caries may perhaps at times never become established there. 
 The carious substance is at such times marked by a very 
 dark color. 
 
 When the caries, on the other hand, makes rapid progress 
 in a tooth of little resistance, it may happen that the destruc- 
 tion follows promptly the preparatory changes. In this case 
 the dry caries may pass wholly unperceived, or be observed 
 but a short time; the brown discoloration wdll also be but 
 slight. The enamel and the dentine are in such cases changed 
 into a soft, whitish, pulpy mass, and the tooth promptly 
 reaches its total destruction. 
 
 There is distinguished a form of caries which attacks the 
 necks of the teeth. It attacks almost always, and at the 
 same time, all the teeth in front, and more particularly those 
 of the lower jaw. It forms at the necks of the teeth a smooth, 
 gutter-like furrow. This is often so marked and so polished 
 that one might say it had been made wdth a file. Generally 
 it is only the incisors and canines which are attacked ; yet, 
 sometimes, this caries extends to all the teeth of a jaw, but 
 the incisors and canines are alwa3^s more strongly attacked 
 than the molars. 
 
 A'^ery often the gutters which exist across the necks of the 
 teeth are of a normal white color, and wholly smooth, as if 
 'they had been polished. In other cases the surfiice of the 
 gutters is smooth, it is true, but has the brownish coloring 
 of caries. We have had opportunities of examining anatomi- 
 cally two teeth of this kind. Upon a section made longitu- 
 dinally we have observed that, proceeding from the gutter, 
 there was only a feeble trace of a brownish cone looking 
 towards the pulp- cavity, for this reason, the changes which 
 precede the caries of the dentine extended to but a slight 
 depth, and were not marked. The density of the dentine 
 was but little less than normal; there was, just below the 
 surface, a slightly marked brownish shade. Under the 
 microscope we observed in this superficial layer, as usual, 
 the dentinal canals filled with Icptothrix. The surface was
 
 PROGRESS AND SYMPTOMS OF CARIES. 61 
 
 smooth, and it was impossible to find there a laj-er evidently 
 softened. The enamel had been wanting for a long tune in 
 the greater part of the gutter; but, on the side of one tooth, 
 we observed that the gutter, in becoming of less and less 
 depth, extended for a short space across a bit of carious 
 enamel of a brownish color. Upon the other tooth the gutter 
 stopped suddenly with well-defined outlines on every side. 
 In a vertical section it presented the form of a triangle 
 with its base turned outwards, and its vertex towards the 
 cavity of the pulp. On the lower side of this triangle there 
 appeared a brownish cone directed towards the pulp-cavity. 
 Upon the interior surface of the pulp-cavity, at the place 
 corresponding to the gutter without, there was found at the 
 extremity of the brownish cone a projection formed of den- 
 tinal substance, of new formation, which had penetrated the 
 pulp-cavity to a considerable depth. 
 
 In this observation it was evident that the caries was of a 
 very slow progress, but had, notwithstanding, all the essen- 
 tial characters of this aftection. The surface changes took 
 place slowly, and the afiected portions were with proportion- 
 ate slowness involved, while the surface was kept constantly 
 smooth by friction with the brush. The polish of the surface 
 is sometimes so great that it might be supposed to be efiected 
 by friction against a 'tooth ; yet this is impossible for the 
 neck, in consequence of the position of the teeth. To exphiin, 
 therefore, the polish of the surface, we can invoke only the 
 action of the brush, and the friction of the lips and of the 
 tongue. It remains, nevertheless, to inquire if these gutters, 
 with so highly polished surfaces, must be considered as sta- 
 tionary, as most authors think. There are cases where the 
 teeth always preserve a white and polished surface, and in 
 which, nevertheless, the aftection makes incessant progress, 
 but in a manner so slow that years often roll by before only 
 a thin w^all separates the caries from the pulp-cavity. The 
 aftection, arrived at this stage, ends by exposing the dental 
 pulp, and the tooth is often broken at this point. Doubtless 
 the progress of the caries can be retarded by dentine of new 
 formation deposited upon the interior surface of the dental
 
 62 INQUIRIES INTO DENTAL CARIES. 
 
 canal, otherwise we should see, particularly in the incisors, 
 this thin wall of dentine niucli sooner destroyed, and the 
 canal opened. If we consider isolated facts of this kind, we 
 feel little disposed to take these pljenomena for symptoms of 
 veritable caries ; but by analogy with other facts, where the 
 nature of the caries is shown, we are compelled to admit 
 equally for these exceptional cases that we have to do with 
 a caries whose progress is very slow, which, for a time, may 
 be really stationary, and afterwards take on new life under 
 the influence of a favorable cause. 
 
 J^evertheless, it should not be asserted that all cases of 
 caries of the neck have this slow evolution. There are cases 
 where its march is absolutely the same as in ordinary caries. 
 It would appear that the cause of this caries is the denuda- 
 tion of the neck by the absence of the gum. Upon the 
 slightly rough surface of the cement fermenting mucus and 
 fragments of food are more easily deposited, and these same 
 agents fixed bet^^•een the gums and the neck of the tooth are 
 less easily removed. It ma}' then happen in cases where the 
 injurious causes are weak, or the teeth of a special hardness, 
 that it is just the necks of the teeth which are more likely 
 to be aifected. 
 
 In some very rare cases we notice a peculiar wasting of 
 the incisor and canine teeth, attacking as well the enamel 
 as the dentine, and which shows its greatest intensity upon 
 the centrals. There, when the mouth is closed, the cutting 
 edges of the teeth form arcs of opposite concavity, and show 
 a longitudinal interval between them. For want of sufficient 
 observations it is not possible for us to say if these morbid 
 phenomena belong or not to caries. The form of the wasting 
 does not permit us to attribute it to mechanical action. 
 
 Stationary Caries. 
 
 In what is called stationary caries reference is often had 
 to dry caries onlj' whose progress is very slow, or is distin- 
 guished by longer or shoi-tcr times of rest. There are, never- 
 theless, cases where the disease is really stationarj^, but this
 
 STATIONARY CARIES. 63 
 
 can be only where the teeth possess great power of resistance, 
 and when the caries has a very slow progress. It is, not- 
 withstanding, necessary to distinguish the difterent stages of 
 caries in which it becomes stationary. 
 
 In the dry caries, when there does not yet exist any change 
 at the surface, it seems that the caries may easily become 
 stationary. This is readily understood, inasmuch as it is 
 enough to suppress the action of acids, the tooth having still 
 sufficient hardness, and being still free from all attack of 
 leptothrix. Yet it may sometimes happen, when the caries 
 has reached a stage where the greater part of the enamel and 
 a superficial layer of dentine are destroyed, that the n:ialady 
 is stopped. This is seen in molar teeth whose depressions 
 are incompletely provided with enamel, and which show 
 defects upon their surfaces. In these cases we see ordinarily, 
 from the beginning of the malady, a great part of the surface 
 of the enamel attacked by caries ; the dentine may be still 
 sound, and ofier great resistance. While the enamel is so 
 rapidly destroyed, as far as the surface of the dentine, the 
 softening of this latter, and the loss of its calcareous salts, 
 are carried to but a slight depth. The relation between the 
 rapidity of the destruction of the enamel and that of the 
 dentine is then, in such cases, the inverse of that which 
 exists in the normal state. When the caries has attacked 
 the surface of the dentine, which, in consequence of the 
 defective structure of the enamel, takes place at once over 
 the greater part of it, the dentine is but slightly softened, 
 and to but a very little depth. The most superficial layers 
 of the dentine are removed, and by friction upon the smooth 
 surface the work of the caries is arrested, the surface becomes 
 more and more polished, and ofters less opportunity for the 
 accumulations of mucus and particles of food undergoing 
 acid fermentation ; finally there results from all this a sta- 
 tionary condition. The tooth presents a polished surface, 
 but of a brownish color, as if to attest that the substance at 
 the surface has been the seat of caries. 
 . The considerations presented by Mr. Tomes and M. Magitot 
 upon the cause which determines the stationary state of
 
 64 INQUIRIES INTO DENTAL CARIES. 
 
 caries are founded upon the presence of calcareous deposits 
 in the minute dentinal canals. As we explain the matter, 
 the calcareous salts deposited in the canals should have the 
 ability to arrest the work of the caries, and give the already 
 softened dentine a greater density. Yet, as the formation 
 of these calcareous deposits cannot be attributed to a vital 
 action, we are led to believe that they are secondary, and 
 that they become abundant only when, from some cause, the 
 action of the acids has ceased ; then the calcareous salts 
 which existed in a state of solution are precipitated. Neither 
 do we believe that the dentine can become harder in station- 
 ary caries, excepting, perhaps, the surface, where mechanical 
 means, such as friction or pressure, may produce a slight 
 condensation. To explain the facts it is sufficient to admit 
 that the dentine had not yet lost its normal hardness, or at 
 least had lost it in but a veiy slight degree. 
 
 In these cases of slow and stationarj- caries we also very 
 often find the formation oi new dentine at the inner surface 
 of the dental cavity. We can explain this phenomenon by 
 the fact of a long irritation which the pathological action of 
 the caries exercises upon the pulp. It contributes very much 
 in the given circumstances to the preservation of the tooth. 
 
 When the caries is farther advanced there are formed in 
 the dentine cavities, generally rounded, which communicate 
 with the surface of the tooth by a greater or less opening; 
 or the morbid action occasions loss of substance more exten- 
 sive, and without depth. Little by little the disorganization 
 reaches the cavity of the pulp; this is exposed at some point, 
 and very often, in consequence of its irritation, successive in- 
 flammations are excited which end in its destruction. 
 
 It has been observed that when the pulp is destroyed the 
 caries proceeds much more rapidly, and from this fact the 
 proof has been sought to be drawn that, as long as the pulp 
 retains its vital properties, it contributes to the preservation 
 of the tooth ; while the contrary happens immediately upon 
 its ceasing to exist. But the more rapid progress of the 
 caries after the destruction of the pulp is explained by the 
 fact of there then being a much greater surface exposed to
 
 STATIONARY CARIES. 65 
 
 its action, inasmucli as now the destruction works in every 
 direction, not only from the ancient cavity, but from the 
 pulp-cavity which corresponds to it. It is not necessary, 
 therefore, to attribute to the pulp a conservatory action for 
 the tooth, excepting, indeed, the dentine of new formation 
 which it builds up, and which really protects the tooth 
 
 While the caries continues its ravages the walls of the 
 cavity, which are formed by the sides of the crown, break 
 down, so that the tooth is destroyed down to the level of the 
 roots. Starting from this point we observe, in most cases, 
 the caries take up anew a slower action, such that the roots 
 which remain may be preserved for a long time in their 
 alveoli. It may be that the friction which must be con- 
 tinually acting may be the cause of this, in part at least, 
 opposing itself to the progress of the disease by oiiering a 
 more polished surface. Another reason which seems to us 
 still more important is that which is derived from the direc- 
 tion of the dentinal canals. These proceed at the surface of 
 the teeth more or less vertically from the pulp towards the 
 exterior, so that, taking this part for its point of departure, 
 the caries is able to propagate itself easily to the interior, 
 following the direction of the canals. 
 
 At the commencement of the surface of the roots, on the 
 contrary, these little canals have a direction oblique, and 
 parallel to this surface. Then, when the tooth is decayed 
 away np to the root, the direction of the canals no longer 
 favors the introduction of the acids and the elements oîle.p- 
 tothrix into the deeper parts. This explains the slower prog- 
 ress of the caries when it reaches this point. In the same 
 way may be explained the fact that caries is never seen to 
 be developed around the walls of a canal artificially pierced 
 at the neck of a tooth (Hulihan's operation); the little den- 
 tinal canals, following a direction parallel to that of the walls 
 of the artificial canal, also in this case, do not permit the in- 
 troduction of injurious elements. 
 
 The sensibility of carious dentine may be occasioned by a 
 greater irritability of the pulp. Yet it is difficult to explain
 
 6Q INQUIRIES INTO DENTAL CARIES. 
 
 why the superficial layers of the dentine are very often more 
 sensitive than those which are deeper. 
 
 To Mr. Tomes this consideration appeared to have great 
 weight. AVe observe, in fact, that quite frequently the least 
 touch causes the acutest pain in the carious dentine, at a 
 stage when the cavity of the pulp is still far from being 
 reached. At such times the removal of the superficial lay- 
 ers of carious dentine occasions excessive pain ; but as soon 
 as this layer is removed the sensibility of the subsequent 
 layers is seen to be very much less. The greatest sensibility 
 ordinarily exists at the extremity between the enamel and 
 the dentine We especially remark this in the incisors at 
 their acute angle, where the anterior and posterior surfaces 
 come together. Mr. Tomes has concluded from these facts 
 that the dentine itself is endowed with sensibility, and that 
 this is not due, at least exclusively, to contact with the 
 pulp. He believes that this sensibility is occasioned by the 
 soft fibrils which he has discovered in the interior of the 
 dentinal canaliculi; he does not consider them as true ner- 
 vous fibrils, but thinks they may be agents of sensibility. 
 This opinion cannot be reconciled with the actual state of 
 physiology. Either the fibrils of Mr. Tomes are truly en- 
 dowed with sensibility, and are therefore true nervous fibrils, 
 or they have no nervous nature, and cannot transmit sensi- 
 bility, inasmuch as this function belongs essentially to the 
 nature of nerves. But every consideration is opposed to 
 considering them as nerve fibrils, and their origin above all. 
 They are prolongations of the cells of the dentine, a fact 
 which establishes their analogy with the ramifications of 
 osteoplasts, or the plasmatic cells of the cornea. Xerves 
 have not been found in the dentine, and, in the absence of 
 all anatomical proof, we must not be too hasty to attribute 
 sensibility- to it. Assuredly the facts we have mentioned 
 would be easily explained if the dentine had a sensibility of 
 its own, because then certain diseased parts would acquire 
 more sensibility than others. This sensibility may be ex- 
 plained, perhaps, by a certain direction of the canaliculi, or 
 at least by a more considerable expansion at the surface,
 
 STATIONARY CARIES. 67 
 
 which may be more accessible to mechanical actions, and 
 may transmit them to the pulp. Experiments, whose object 
 should be to inquire into the rapidity with which the slight- 
 est contacts are followed by pain, would perhaps give new 
 enlightenment upon the subject. But until nerves are dis- 
 covered in the dentine, and clinical experiment has furnished 
 us with authentic facts, we shall feel more inclined to at- 
 tribute the sensibility to the irritated pulp than to the den- 
 tine itself.
 
 IV. 
 
 CAUSES OF CARIES. 
 
 From what has been said it results that two principal phe- 
 nomena manifest themselves in the formation of dental caries, 
 viz., the action of acids ^ and ihejrapid development of a parasitic 
 plant, the leptothrix huccalis. In the following chapter we 
 shall have to examine more in detail the mode in which these 
 agents proceed and the conditions of their appearing. 
 
 The action of injurious elements is favored by predisposing 
 circumstances which consist mainl}^ in the structure and in 
 the incomplete development of the dental tissues. The in- 
 fluence exercised upon the formation of caries by constitu- 
 tional anomalies and by certain coexisting maladies may be 
 referred principally to two circumstances : first, we very 
 often remark troubles in the development of the teeth 
 during the existence of certain maladies, or when there exist 
 constitutional anomalies. The tissue of the teeth is, in such 
 cases, incompletely formed, and unsuited to resist the action 
 of injurious agents ; then local conditions of the buccal cavity 
 may favor the formation of acids, as well as of the para- 
 sitic plant, the leptothrix. Likewise many maladies of_the 
 mouth and certain states of the stomach cause to arise in the 
 buccal cavity an abnormal work of fermentation which is 
 accompanied by a more abundant formation of acids, and 
 favors the production of the fungi. The progress of the 
 caries is equally favored w^hen, in consequence of sickness or 
 from any other cause, the saliva is secreted in too small a 
 quantity, thus preventing the neutralizing or diluting of the 
 acids.
 
 CAUSES OF CARIES. 69 
 
 I. PREDisposma Causes of Caries due to the Form and 
 Structure of the Teeth. 
 
 We have first to examine the incomplete development of 
 the dental tissues, above all of the enamel and the dentine, 
 which is a predisposing cause of the greatest importance. 
 
 In congenital anomalies of the enamel we may distinguish 
 anomalies quantitative and anomalies qualitative. 
 
 The quantitative anomalies are manifested under very 
 diverse forms. The surface of the enamel is irregular, pre- 
 sents inequalities and depressions more or less developed, and 
 which may be few in number, or scattered over the whole 
 surface of the crown. These teeth are sometimes designated 
 as "honeycombed" teeth, from their resemblance to that 
 article. In other cases we see the cutting edge of the incisors 
 notched or toothed, and sometimes of a conical shape, both 
 which forms are caused by deficiency of the enamel ; or the 
 teeth present parallel furrows crossing them horizontally. 
 
 The name of erosion is given to those lesions which show 
 themselves at once upon several teeth, and yet they are but 
 incomplete developments of the enamel which have of erosion 
 only the form. Finally, the enamel is sometimes complerely 
 wanting upon a greater or less extent of the crown. 
 
 The anomalies just described must be onlj^ too favorable 
 to the establishment of caries, inasmuch as the agents of an 
 injurious nature deposited in the cavities and irregularities 
 of the tooth can extend their action without obstacle, and 
 much better than on a polished surface. The fissures of the 
 enamel occasioned by sudden changes of temperature may 
 exercise the same influence. Doubts have been raised upon 
 the possibility of seeing fissures of the enamel caused by 
 changes of temperature, but these fissures are sufificiently 
 frequent. In many cases the enamel of the greater number 
 of the teeth, and sometimes even of all, is seen covered with 
 chinks in every direction. They are most frequently caused 
 by sudden changes of temperature, but sometimes are due to 
 a traumatic action. We have convinced ourselves of the
 
 70 INQUIRIES INTO DENTAL CARIES. 
 
 direct influence of the first of these causes by plunging the 
 teeth alternately into hot liquids of a temperature about 
 equal to that of hot meats, and then into iced water. It 
 seems, nevertheless, that these fissures have less influence 
 than the defects of the enamel upon the formation of caries, 
 supposing that it possesses a normal density and hardness. 
 "VVe find, in fact, teeth whose enamel shows fissures in every 
 direction, and which, after a long time, have not been at- 
 tacked by caries. But if the fissures appear in teeth whose 
 enamel is primitively less resistant, it is clear that they oflfer 
 greater oj^portunity to the action of injurious agents. 
 
 The qualitative anomalies which depend upon an incom- 
 plete development of the enamel often coincide with the 
 quantitative; they may, however, exist separatel3\ They 
 are distinguished, in general, by a less hardness and by an 
 opaque appearance of the enamel. Mr. Tomes distinguishes 
 two kinds : in one the enamel presents a brownish and dead 
 color, showing itself more particularly upon teeth which are 
 marked, as has been said above, with congenital fissures and 
 depressions, and the excavations are marked in general by a 
 somewhat darker color. The other kind presents itself under 
 the form of white spots of greater or less extent. 
 
 In the first kind were discovered by Mr. Tomes deposits 
 of minute calcareous o-ranulations in the interior of the 
 enamel prisms, at the same time that the peripheric layers 
 of the prisms were impregnated with calcareous salts in a 
 homogeneous manner. We speak here of an insufiiicient 
 quantity of calcareous salts in the central portions of the 
 enamel prisms, a circumstance which is but an exaggeration 
 of the physiologic condition. In fact, according to Mr. 
 Tomes, the central portions of the prisms in the normal state 
 become impregnated more slowly with calcareous salts, and 
 are therefore more promptly deprived of them by weak acids 
 than are the layers of the periphery. In some cases ]\Ir. 
 Tomes observed minute excavations in the interior of the 
 prisms of this incompletely developed enamel. 
 
 In the congenital white patches of the enamel i\Ir. Tomes 
 found the fibrillary structure of this tissue more or less well
 
 CAUSES OF CARIES. 71 
 
 preserved, inasmuch as the prisms are less stronglj' united to 
 one another, while this structure is lost ordinarily by the 
 fusion of the peripheric layers of the prisms of the enamel. 
 
 We have had very little opportunity of examining these 
 anomalies ; our experience being confined to two cases of 
 congenital patches upon the enamel. But these two teeth 
 presented in the middle of the patches a dark brown color, 
 like the sign of commencing caries ; yet the sharp contour 
 of the spots and the well-marked white color left nothing in 
 doubt. They were really congenital patches which were 
 commencing to be affected b}'^ caries. 
 
 The consistency of the enamel had considerably diminished, 
 the lightest pressure sufBcing to reduce to powder the de- 
 tached fragments. Very rarely a column was seen to separate 
 from the neighboring columns, and then only for a small ex- 
 tent; the contours of the prisms being very distinct, w^iile 
 the oblique striœ were so in only one of the two cases. 
 
 The prisms of the enamel were strongly enough united in 
 the two cases, and their cohesion was not diminished, as Mr. 
 Tomes has asserted. In view of the paucity of observations, 
 we will not venture to draw from these facts other conclu- 
 sions, still less as it is impossible to establish with certainty 
 what ought to be placed to the account of caries and what 
 to congenital alterations of structure. 
 
 As for the rest, the jiredisposition to caries in these con- 
 genital anomalies of the enamel is sufRcientlj^ proved by the 
 lesser hardness of the parts. 
 
 It is remarked also that there is often a coincidence be- 
 tween these anomalies of structure of the enamel and an 
 incomplete development of the dentine, 3'et the anomalies of 
 structure show" themselves less often in the dentine than in 
 the enamel. In most cases there exists in the dentine a 
 great number of interglobular spaces ; according to the dis- 
 covery of M. Magitot, these are seen sometimes in several 
 layers parallel to the surface of the dentine, and spaced in a 
 pretty uniform manner. This anomaly has for cause a defect 
 of development which, in its turn, hinders the calcareous
 
 72 INQUIRIES INTO DENTAL CARIES. 
 
 salts from penetrating certain parts of the tooth in sufficient 
 quantit}'. 
 
 We meet this anomaly more particularly in cases of those 
 more considerable defects of the enamel which go by the 
 name of erosion ; while there, where the enamel presents 
 cracks, holes, and furrows, such as we see in " honeycombed" 
 teeth, the dentine very often offers a great resistance. 
 
 The causes of the trouble in the development of the tissues 
 of the tooth, as well of the enamel as of the dentine, are of 
 several kinds. Some local affections of the mouth and gen- 
 eral maladies of very different nature may cause perturbations 
 i n the development of the teeth. Mr. Hutchinson has marked, 
 as a very frequent cause of this anomaly, constitutional 
 syphilis, j^evertheless, it is well proved that many other 
 maladies occasion the same phenomena. Setting aside the 
 greater defects of development, the dental tissues present, in 
 their hardness and chemical composition, varieties which 
 render them more or less fitted to resist external influences- 
 This is easil}' seen by the difierence in the color of the teeth, 
 and by the appearance they present, and it is from these 
 different properties that classifications have been made. 
 
 Considering the lack of positive observations upon the 
 subject in question, we can give only our suppositions upon 
 the causes of the varieties of color and of appearance in 
 teeth. The relative quantity of organic substances, and of 
 substances inorganic, seems to be of especial importance. A 
 priori^ the existence of these varieties of enamel as well as of 
 dentine could not be doubted, and analysis has confirmed the 
 supposition. Xevertheless, the teeth offer us no physical 
 indication by which we are enabled to recognize with cer- 
 tainty one or other variety in their chemical composition. 
 The teeth of different individuals offer in general aspects 
 sufficiently various, but we may say that they diverge in 
 two different directions from that which we have taken as 
 a standard, viz., a white color combined with a moderate 
 transparency of the enamel. The teeth are either much 
 bluer and more transparent than the average, or else yellow 
 and more opaque. There is among them every variety of
 
 CAUSES OF CARIES. 73 
 
 different type. The blue and transparent teeth have little 
 power of resistance, while those of a yelloAv and much less 
 agreeable tinge are distinguished by their very great resist- 
 ance to the attacks of caries. 
 
 It is generally believed that the less power of resistance a 
 tooth has to caries the more organic substance it should 
 possess in proportion to the inorganic; and, in the contrary 
 case, that the inorganic substances should predominate. A 
 jmori, this theory cannot be admitted. In the experiments 
 which we give farther on concerning the action of acids upon 
 the teeth, it has been demonstrated that the enamel is always 
 the seat of the first changes, while the dentine and the cement 
 are attacked only after some time. It is .easy to conceive 
 that a slight diminution of the calcareous salts may become 
 very sensible in the enamel, because the quantity of organic 
 substance is too weak to preserve the form and consistence 
 of the tissue after the subtraction of a portion of the salts; 
 the dentine, on the contrary, preserves, even after the total 
 loss of the calcareous salts, its former" shape, and presents a 
 consistency not unlike that of cartilage. Yet are we not 
 permitted to draw from this the conclusion that the richer 
 the dentine or the enamel are in organic matters, the more 
 capable are they of resisting the attacks of caries, inasmuch 
 as many other causes may act at the same time. In spite of 
 this it appears to us probable that the bluish and transparent 
 teeth are relatively less well provided with organic matters, 
 especially in the enamel, than the yellow teeth, which resist 
 better. 
 
 Are there still other anomalies of composition, especially 
 in what concerns the quantity of the ditierent salts which 
 influence the predisposition to caries? We as yet know 
 nothing positive thereupon. As for the enamel, the most 
 recent analyses of M. Hoppe have shoAvn that the relative 
 quantities of phosphate and carbonate of lime are sufficiently 
 constant in animals belonging to the most varied species. 
 There are, on the average, three elementary molecules of 
 phosphate of lime for one of lime united with chlorine, fluo- 
 
 6
 
 74 INQUIRIES INTO DENTAL CARIES. 
 
 rice, or carbonic acid.* According to this, at least as regards 
 the enamel, it will be less probable that variations of the 
 proportions of the different salts will ever be proved. 
 
 It appears that there exist, also, in the physical hardness 
 of teeth difierences which may natnrally have a great impor- 
 tance in the predisposition to caries. 
 
 II. Influence of Acids upon the Production of Caries 
 OF THE Teeth. 
 
 No one at thi s da y can refuse to believe in the necessity of 
 the action of acids to occasion caries of the t^eth. The salts 
 contained in the enamel and in the dentine cannot be dis- 
 solved in water; acids are indispensable to work their solu- 
 tion. But it is not at all necessary to employ strong acids 
 for the purpose of separating the carbonic, or even the phos- 
 phoric acid from the lime with which they are combined. 
 The calcareous salts of the tooth, as well the carbonate as the 
 phosphate of lime, are dissolved in some acid, even in water 
 which contains carbonic acid, as they are changed into acid 
 salts which water dissolves with sufficient ease. In fact it 
 is acknowledged that the surface of carious teeth very often 
 presents an acid reaction. This reaction is constant upon 
 the contents of carious cavities in which the disease is in 
 active progress. Mr. Spence Bate cites an observation from 
 which we might draw the conclusion that pure water can 
 dissolve the teeth. 
 
 A lady had two cases of artificial teeth ;t she wore one of 
 these until the teeth were carious, while the other was care- 
 fully kept in water. After a period of seven years, wishing 
 to change the worn out case for that which she had preserved 
 in water, she found this latter just as corroded as the one she 
 had worn in her mouth. Does not this case find its explana- 
 tion in the observations cited by MM. Wedl and Heider, ac- 
 
 * Eecherches sur la composition de l'email des dents (Virchow's Archiv, 
 xxiv, p. 13). 
 f Human teeth.
 
 PRODUCTION OF CARIES. ' 75 
 
 cording to which, at the end of only ten days, fungi had at- 
 tacked the enamel and tlie dentine of teeth "placed in pure 
 water? A few weeks sufficed to change the tissues to such 
 a point that they were pierced with holes like a sieve. If 
 the action of acids alone could occasion caries of the teeth, 
 it should be eas}' to demonstrate the phenomena out of the 
 mouth. It is not so. Acids cause, it is true, a portion of 
 the a ltera tions pX caries, but its totality differs essentially 
 from the_effeçts which they produce. Several authors have 
 studied the influence of acids, and of different other agents, 
 upon the tissues of the teeth. We will meutioiL-espedally 
 exjj e rim en ts made in 1843, in I^orth America, by Mr. A. 
 Westcott, with the assistance of Mr. DaliympTe. These au- 
 thors obtained the following results: 
 
 1st. All the m ineral, as well as the ve getable acids, act 
 promptly upon the teeth. Acetic and citric acids, for ex- 
 ample, in forty-eight hours, corroded the enamel to such a 
 degree as to permit a great portion of it to be scratched 
 away with the nail; malic acid also produced very rapid 
 eflects. 
 
 2d. The salts whose acids have a greater affinity for lime 
 than for their own bases also acted upon the teeth. The 
 acid tartrate of lime verj^ rapidly destroyed the enamel; 
 gr apes , at the end of forty-eight hours, had already acted so 
 strongly that the surface of the enamel presented the appear- 
 ance of chalk. 
 
 3d. Vegetable su bstances have iio action until they fer- 
 ment,_ajid acetic acid is formed. Sugar, for example, which 
 by itself had no action, produced its effects only in a state of 
 acid fermentation. 
 
 4th. Animal substances acted very slowly, and only when 
 they had reached a very advanced stage of putrefaction. 
 
 Mr. Allport obtained identical results* in his researches 
 into the action of different acids upon the teeth, making use 
 of very dilute acids, such as are used in medicine. All the 
 mineral acids, as well as citric and acetic acids, in a few hours 
 produced very marked action upon the enamel. 
 
 * Vide American Journal of Dental Science, April 30th, 1858. 
 
 ( 
 \
 
 76 • INQUIRIES INTO DENTAL CARIES. 
 
 M. Mantegazza engaged in tlie same investigations, and 
 obtained identical results.* Sugar acted upon the teeth 
 only when, by eftect of fermentation, it was partially changed 
 into acetic or lactic acid. Lactic acid, vinegar, strong or 
 diluted, and lemon-juice, acted on the teeth. 
 
 We had begun our investigations upon caries of the teeth 
 when the book of M. Magitot appeared.f The results of his 
 experiments which are there given should prove not only 
 that acids and the acid salts act upon the teeth, but also 
 that these are the sole agents of caries, and that the phe- 
 nomena produced upon the teeth by their action are entirely 
 identical with those of caries of the teeth. 
 
 The substances employed by M. Magitot in his experi- 
 ments were, at first, solutions of a great number of acids, of 
 some acid salts, and, moreover, solutions of sugar, albumen, 
 table-salt, and alum. He submitted teeth to the action of 
 these agents for two years. At the end of this time, the 
 solutions which contained the teeth, in many cases, were 
 covered with thick coatings of mould ; the acid solutions 
 had sometimes become neutral, and the teeth were more or 
 less attacked, softened, and destroyed. In a great number 
 of cases the enamel presented a white, earthy appearance. 
 It was chalky and profouudl}' changed. The dentine was 
 brown or yellow, deprived of its salts, and softened, thus 
 having the aspect of carious dentine. 
 
 Moreover, remarkable ditFerences were observed in the 
 action of agents upon the ditierent tissues of the teeth. M. 
 Magitot distinguishes, from the results of his experiments, 
 four categories of substances in relation to their action upon 
 teeth. 
 
 These are, according to him, 
 
 1st. Suhsta.nces which aitack_qlik e all the tissues of Jeeih. In 
 this category belong the varieties of sugar (but only in a 
 state of fermentation), lactic acid, butyric acid, citric, acid, 
 
 * Mantegazza sur l'action du sucre et de certains acids sur les dents. 
 Milan, 1862. Trans, in Brit. Jour, of Dent. Se, 1804, vol. viii. No. 92. 
 
 f Etudes et experiences sur la salive considérée comme agent de la carie 
 dentaire. Paris, 1866.
 
 PRODUCTION OF CARIES. • 77 
 
 malic acid, carbonic acid, the products o f the decom position 
 of albumen and albunnnoid substances. 
 
 2d. Substances ichich have the particular and exclusive prop- 
 erty of destroying the enamel: Alum, oxali c acid an d its acid 
 salts. '"' 
 
 3d. Substances which act exclusively upon the dentine and, 
 ■upon the cement: Acetic acid, tartaric acid and their acid 
 salts, and tannin. 
 
 4th. Substances lohich have no action upon the dental ti^sues^ 
 as common salt and the great majority of other neutral sub- 
 stances which are found in the mouth. 
 
 These results do not entirely agree with those of MM. 
 Westcott, Allport, and Mantegazza. In order to verify the 
 experiments of M. IMagitot, we submitted a series of teeth 
 to the action of the principal substances used by this author, 
 but we have not been able to convince ourselves that the 
 action of acids alone can produce clianges identical with 
 those of caries. 
 
 In repeating the experiments of M. Magitot, we have ab- 
 stained from using the same time. If caries depends upon 
 simple chemical action upon the teeth, it is not necessary to 
 wait years in order to see the effect. When there is a suf- 
 ficient quantity of the acid solution, we are able to perceive, 
 at the expiration of but few daj^s, a very considerable alter- 
 ation in the dental tissues, even with the feeble solutions 
 which M. Magitot has used in his experiments. If we leave 
 for years in the liquids the teeth upon which we are experi- 
 menting, without assuring ourselves of the quantity of acids 
 which they contain, and witliout restoring to them the por- 
 tion of these same acids which they lose by their neutraliza- 
 tion in combining with the calcareous salts, it will not be 
 possible to attribute the results obtained to the sole influence 
 of the acids ; but it will be necessary also to take account of 
 the decomposition taking place in the organic substance of 
 the tooth, of the putridity of the fermentation, and of the 
 action of the vegetable and animal microscopic growths 
 which are there developed. 
 
 The acid reaction of the liquids in which the teeth had
 
 78 INQUIRIES INTO DENTAL CARIES. 
 
 been placed had given place to a neutral one in several of 
 the experiments made by M. Magitot. This proves that in 
 the last portion of time and perhaps for a considerable period 
 the acids had taken no part in the destruction produced. 
 
 If the work of caries is, in general, much slower in the 
 mouth, this may depend on the habitual want of a sutiicient 
 quantity of acids. Perhaps these exert their action only in- 
 termittently, and each time during a rather short period. 
 Our own researches upon the penetration of le'ptothrix into 
 the interior of dental substances, and the observations of 
 M^r. Wedl and Heider upon the introduction of fungi into 
 teeth which have been extracted, demonstrate, according to 
 the evidence, the part which may be due to these agents in 
 M. Magitot's experiments. 
 
 Nevertheless, as no investigations upon these corroded 
 teeth have been made with the microscope, we have noth- 
 ing but presumptions. The resemblance to caries which 
 has been found in these experiments relates therefore only 
 to the diminution of the consistency of the enamel, which 
 became tender and friable as in caries, with a brown or yel- 
 low color, and to a more or less advanced softening of the 
 dentine. This softening sometimes reached a very high 
 degree. 
 
 But these external resemblances do not prove that this 
 was veritable caries, and, even if, by microscopical research, 
 symptoms had been found identical with those of caries, it 
 would not then be demonstrated that they are due exclu- 
 sively to the action of acids. 
 
 It follows that the results of our experiments are not com- 
 pletely accordant with those of M. Magitot, while they con- 
 firm precisel}^ those obtained by MM. Westcott, AUport, and 
 Mantegazza. 
 
 ^Ye have found that all substances capable of changing 
 the dental tissues produce, at first, a deterioration of the 
 enamel, which is soon followed by that of the dentine. The 
 enamel, which, in its normal state, is transparent, becomes 
 white and opaque, milky, and, in a more advanced state, 
 chalky. At the beginning, and, above all, when the enamel
 
 PRODUCTION OF CARIES. 79 
 
 is very hard, there is sometimes seen only a whitish color 
 and the disappearance of the transparency. The surface 
 may, in such cases, remain polished and shining ; later, it 
 hecomes rough and uneven, and the enamel thus acquires an 
 earthen, chalky appearance. The softening increases little 
 by little, and gains in depth ; so that in a short time we can 
 scratch awa}^ the enamel with the nail, or break it off in 
 bits. In using certain acids, which form salts difficult of 
 solution, we see the enamel and also the root covered with 
 innumerable and very beautiful crj'Stals. 
 
 "When the enamel presents the first degree of alteration, 
 the appearance of the dentine and also that of the cement is 
 normal, and its hardness has not as yet undergone any 
 change ; we recognize the alteration which follows by a 
 more transparent look to the roots, which, at first, can be 
 cut with a knife at the surf^ice ; soon after we can cut them 
 more deeply ; at a more advanced period we can even bend 
 them. It is true that sound dentine can also be slightly cut 
 with a knife, but, in doubtful cases, it has always been our 
 habit to compare the dentine submitted to the action of 
 acids with normal dentine. 
 
 In proof of our statements w^e give here a few extracts 
 from our experiments. 
 
 1st. Tartaric Add. 
 {a.) Solution ^l in 100. 
 
 At the end of two days the enamel was seen to be covered 
 with minute crystals ; these removed, the enamel had lost 
 its brilliancy and taken a white, earthy aspect. Xo change 
 remarked at the root. 
 
 At the end of eight days the alteration of the enamel was 
 increased : with a knife slices could be taken from the 
 surface. 
 
 At the end of a fortnight the alteration of the enamel had 
 made new progress, while the root was only slightly softened 
 at the surface.
 
 80 INQUIRIES INTO DENTAL CARIES. 
 
 [b ) Grapes. 
 
 Some teeth were placed among crushed grapes whose juice 
 was rather acid. 
 
 After forty-four hours the surface of the enamel was very 
 rough and covered with numerous crystals. Upon brushing 
 these away, the enamel appeared uneven and slightly chalky ; 
 its brilliancy was gone. The root was likewise slightly cov- 
 ered with minute crystals ; it had not yet undergone notice- 
 able change. 
 
 At the end of eleven days the experiment was ended. The 
 divided enamel presented, throughout its whole thickness, 
 an earthy, white appearance, and was porous ; the root was 
 scarcely changed. 
 
 2d. Acetic Acid. 
 
 Solution Jj^ ix 100. 
 
 At the end of ten days the enamel was found to have on its 
 anterior surface an earthy, white appearance ; it could be 
 removed with the finger-nail ; while, on the posterior sur- 
 face, it remained almost in its normal state. The surface of 
 the root could be cut with a knife. 
 
 A i the end of seventeen days the enamel could everywhere 
 be broken ofl'in great pieces ; the subjacent dentine was also 
 decalcified. With a knife the root could be easily cut. 
 
 3d. Oxalic Acid. 
 Solution ^l ix lOO. 
 
 After seven days the bottom of the glass was covered with 
 a thick laj'er of white powder composed of minute crystals 
 of oxalate of lime. The enamel, of an earthy white, could 
 be removed with the finger-nail ; a part of the crown had 
 preserved its polish. The root did not seem altered. 
 
 At the end of fourteen days the enamel Avas everywhere of 
 an earthy white, and could be easily removed with the nail. 
 The root could be cut with a knife, especially at the ends, 
 with o^reater ease than in its normal state.
 
 PRODUCTION OF CARIES. 81 
 
 4-th. Alum. 
 
 Solution 1 in 100. 
 
 At the end of tim days no trace of clian2;e. 
 
 After six days the polish at the lower part of the enamel 
 was seen to be (Jiminished, and the enamel was covered at 
 the same part with a light earthy layer which was easily 
 removed. The root appeared to remain intact. 
 
 At the end of twenty days the enamel could be easily re- 
 moved with the nail ; no other changes. The root could be 
 cut more readily than in the normal state. 
 
 5th. Lactic Acid. 
 
 {a.) Solution J^ in 100. 
 
 At the end. of ten days it was impossible to perceive any 
 alteration in one of the teeth, a very strong molar; in another 
 tQoth the enamel was everywhere whitened, part roughened, 
 part still polished ; everywhere it was easily removed. The 
 root was not sensibly altered. 
 
 After seventeen days, on the first tooth was seen, at the 
 extremity of the crown, a slight milky color without loss of 
 polish. At this part, with a knife, small shavings could be 
 removed. Eoot intact. On the second tooth the alteration 
 of the enamel had increased ; its root could be cut with a 
 knife more easily than in its normal state. 
 
 (b.) Solution 1 in 100. 
 
 After two days the enamel was earthy and without polish ; 
 tlie root was normal. 
 
 At the end of thirteen days the enamel could be everywhere 
 removed with the nail. The root was decalcified on tlie sur- 
 face ; it was easily cut with a knife, but only to a slight 
 depth. 
 
 It appeared to us superfluous to prolong further our ex- 
 periments ; we usually interrupted them after having become 
 well satisfied that the dentine was beginning to be decalcified ;
 
 82 INQUIRIES INTO DENTAL CARIES. 
 
 any ulterior action possessed no interest for us, and we cared 
 little to know if it was possible to completely decalcify the 
 teetli or not by the aid of diiierent concentrations of acids. 
 "We have been able to convince ourselves, in some of our ex- 
 periments in which the teeth have remained subjected to the 
 action of acids for a long time, that it is possible even with 
 very weak acid solutions to decalcify teeth pretty completely. 
 
 It results, from the experiments which have just been 
 related, that tartaric and acetic acid s, even y jry \\ieak,jpi'0- 
 duce upon the enamel the same changes as other, espeMally 
 the lactic and oxalic acids, while M. Magitot asserts that 
 tartaric and acetic acids attack only the dentine and never 
 the enamel. ^Ve know not how M. Magitot has obtained 
 such opposite results; we content ourselves with remarking 
 that he also noticed that tartaric acid had produced a layer 
 of little crj'stals upon the surface of the enamel, and that 
 they adhered to it sometimes very strongly. Yet, according 
 to him, beneath these crystals the enamel was found in a 
 normal state. We, on the contrary, have noticed, after 
 having removed these crystals, that the surface was left un- 
 even and roughened ; the enamel was transformed to an 
 earthy mass even to a great dej^th. Perhaps this difference 
 of results can be explained by the supposition that in the 
 experiments of ]\I. Magitot, although there may have been 
 no loss of substance in the enamel, yet it may have been 
 transformed into a chalky mass. On the other hand, it is 
 possible that the differences in the consistency and perhaps 
 also in the chemical composition of the enamel, fram which 
 results a different resistance to the action of acids, have acted 
 in the manner described in our experiment Xo. 5. 
 
 Our experiments are in harmony with those of Afr. West- 
 cott, of Mr. Allport, and of M. ]N[antegazza, who found that 
 all the vegetable acids, without distinction, attacked the 
 enamel of the teeth. 
 
 Our experiments do not permit us to admit, as M. Magitot 
 asserts, that oxalic acid and alum attack neither the cement 
 nor the dentine. It is true that the diminution of the hard- 
 ness of the dentine beo-ins always later than the lirst altera-
 
 PRODUCTION OF CARIES. 83 
 
 tion of the enamel, but all the acids produce the same eftect; 
 so we stopped pushing farther our experiments, with the end 
 of decalcifying more completely the dentine. It would be 
 easy to show the diminution of the hardness of the root of 
 the tooth by the action of oxalic acid, or of a solution of 
 alum ; nevertheless, it appeared to us that oxalic acid, tar- 
 taric acid, and solutions of alum, attack the dentine a little 
 more slowly than does acetic acid, for example; lactic acid 
 much weakened, acts also very slowly. 
 
 The specific action which M. Magitot has attributed to 
 certain substances upon the dental tissues must therefore 
 have for cause some fortuitous circumstance, inasmuch as 
 subsequent experiments, made in the same manner, entirely 
 fail to confirm it. 
 
 As for the action of sugar, all experiments result in show- 
 ing that in its normal state it never attacks the teeth; it 
 acts only on passing into the state of acid fermentation. We 
 have obtained identical results. The most decisive experi- 
 ments upon this point have been made by M. Magitot. He 
 boiled a solution of sugar, deposited the teeth in it, and closed 
 the neck of the bottle hermetically, by heating it to a white 
 heat, drawing out and twisting it. No fermentation was 
 then possible, and at the expiration of two years the teeth 
 were found entirely untouched. 
 
 The difterent action of acids upon the different tissues of 
 the teeth is explained by the presence of variable proportions 
 of organic substances which enter into the composition of 
 the enamel, the dentine, and the cement. 
 
 In the enamel, where the organic substances enter only in 
 the proportion of some hundredths, the least diminution of 
 the salts should produce great disorder in the molecular com- 
 position, and, consequently, upon the physical properties of 
 this tissue; while a slight loss of inorganic substance would 
 not be easily perceived in the dentine, for the organic mat- 
 ters which it contains would suffice to maintain its consis- 
 tence. 
 
 The enamel, stripped of its calcareous salts, possesses only 
 a minute quantity of organic elements, ^which, placed under
 
 84 INQUIRIES INTO DENTAL CARIES. 
 
 the microscope, present for ouly an instant the enamel struc- 
 ture; they are seen promptly to dissolve. The dentine, 
 deprived of its salts, has, on the contrary, the consistence 
 of cartilage, and entirely keeps the form of undecalciiied 
 dentine. 
 
 The acids produce upon the enamel phenomena which are 
 likewise found in caries of the enamel ; thus, these latter 
 may be explained by the action of acids. In both cases the 
 enamel, being deprived of a portion of its salts, becomes por- 
 ous, opaque, and softer. 
 
 Out of the mouth the action of acids is always perceived 
 first upon the enamel. It remains to be ascertained if the 
 dissolution of the calcareous salts of the dentine does not 
 take place at the same time as that of the enamel, although 
 not manifesting itself to the observer until later. AVe are in- 
 clined to think so, inasmuch as we have no reason for admit- 
 ting that the salts of the dentine are less soluble than those 
 of the enamel. As for the rest, there are in the hardness of 
 the enamel and of the dentine differences which predispose 
 them to be more or less rapidly attacked, and whose influence 
 U23on the production of caries we have long appreciated. 
 
 As to the utility of all these experiments, the}' teach us 
 that sugar and sugared liquids, placed in circumstances 
 favorable to acid fermentation, are able to exercise by this 
 alteration an injurious action upon the teeth. In the mouth 
 are found all conditions favorable to this fermentation, there- 
 fore all solutions of sugar are capable of acting in precisely 
 the same manner as acids. 
 
 To sugar is very generally attributed an injurious action 
 upon the teeth. That this opinion is well founded is con- 
 firmed by the oft-repeated observation that caries is especi- 
 ally common and intense with persons of certain professions, 
 such as confectioners and cooks, who eat or taste many sweets, 
 and who, moreover, take sugar into the mouth in the form 
 of dust while jjulverizing or sifting it. 
 
 It is true that other observations would seem to prove the 
 contrary. The blacks of the East Indies who eat enormous 
 quantities of sugar are remarkable for very beautiful and
 
 PRODUCTION OF CARIES. 85 
 
 very sound teeth. M. Mantegazza confirms tliis fact by Ins 
 own experience, and adds further that the Indians, who eat 
 constantly the sugar cane and other products of their coun- 
 try rich in sugar, have likewise excellent teeth. ]^everthe- 
 less, M. Mantegazza does not attach much weight to these 
 observations; he thinks that these populations differ from 
 us in their whole organization too much for us to be justified 
 in drawing from them conclusions applicable to civilized 
 people. Yet we may deduce from these facts the consequence 
 that teeth w^ell developed, hard, and strong, will not suffer 
 from even the freest use of sugared aliments, while those of 
 a less dense structure may suffer from it considerably. 
 
 It would seem to result from all this that the Europeans, 
 and the races sprung from them, as for example, the iSTorth 
 Americans, have teeth less perfectly developed, and less re- 
 sistant than the negroes aud the natives of America. From 
 this we are not permitted to attribute the great amount of 
 caries of the teeth which is found among the Europeans and 
 ISTorth Americans solely to their more refined manner of liv- 
 ing, and to the use of substances little favorable, and even 
 injurious to the teeth; but we are compelled to admit that, 
 with them, the disposition and the development of the teeth 
 are less perfect. 
 
 It is impossible for us here to enlarge further upon the 
 causes of these singular phenomena, which refer evidently to 
 the characteristic development of the races. We must, how- 
 ever, refer in this connection to the remarkable differences 
 in frequency of caries in the different parts of France; M. 
 Magitot has given special attention to this point.* 
 
 The experiments which we have made upon the action of 
 acids upon teeth have led us on to a series of other observa- 
 tions which have reference to the origin of caries of tlie teeth. 
 
 Some observations establish that, at the end of a somewhat 
 prolonged course of grape cure, patients have perceived that 
 their teeth have become affected. Their surfaces have be- 
 come rough, a superficial layer of enamel has been destroyed, 
 
 * Traité de la carie dentaire, p. 61-66.
 
 86 INQUIRIES INTO DENTAL CARIES. 
 
 and, ill some cases, true caries has been developed. "We can 
 confirm from our own experience the fact of the roughness 
 of the teeth, and the production of caries as a result of courses 
 of grape cure. In one case, where the teeth were extraordin- 
 arily hard and dense, and where the cure had been interrupted 
 at the moment when the teeth began to grow rough, there 
 was no caries, and the roughness gradually disappeared. In 
 other cases, on the contrary, a greater or less loss of enamel 
 W'as observed, and caries appeared. The roughness is, with- 
 out doubt, the consequence of the alteration of the superficial 
 layers of the enamel, and the deposit of very minute crystals 
 of tartrate of lime, as we have seen produced in our experi- 
 ments with tartaric acid and the juice of the grape. It will 
 therefore be well to caution those -whose teeth are of poor 
 quality against the use of such cures, except with the utmost 
 precaution, forewarning them that the juice of the grape may 
 injure their teeth. 
 
 Afte_r having established by our experiments that acids of 
 the most various kinds attack the teeth, it behooves us to 
 inquii-e what are the acids which take part in the caries of 
 the teeth, and how they get into the mouth. "We know 
 that acids are always introduced into the mouth with our 
 food and drink: acetic acid is associated with great numbers 
 of viands as a condiment ; malic, citric, and tartaric acids 
 are found in different kinds of fruits, and in the drinks 
 which are made from them ; oxalic acid is found in certain 
 plants; lactic acid in sour milk, and so on. AVe have, more- 
 over, pharmaceutic remedies which contain mineral acids 
 and their acid ethers; then tannin, some salts, alum, for in- 
 stance, are able to attack the teeth. All these sul)stances 
 may easily bring on caries or contribute to hasten its prog- 
 resa; but we think that the acids formed in the mouth as 
 the result of decomposition, or those which are found in the 
 buccal secretions, play in this matter a much more important 
 part. The liquid which exists in the buccal cavity is com- 
 posed, as is well known, of a mixture of the secretions of the 
 salivary glands and of the mucous follicles of the mouth. 
 The secretions of these different glands are almost all, at
 
 PRODUCTION OF CARIES. 87 
 
 least in the normal state, neutral or alkaline ; the liquids, 
 then, which are in the mouth, cannot be acid, not taking 
 into consideration the acids which are directly introduced 
 either by an anomaly in the secretion, or else in consequence 
 of fermentation caused by particles of food remaining in the 
 mouth. 
 
 Among the secretions of the salivary glands, that of the 
 parotid alone may be feebly acid ; that of the submaxillary 
 and sublingual glands is, on the contrary, constantly alkaline. 
 This fact has been proved by the aid of sounds introduced 
 into the efterent canals of these glands. The secretion of 
 the parotid is sometimes acid when first collected ; but this 
 reaction passes promptly to the neutral state, or to one 
 slightly alkaline, when the liquid loses the clearness which 
 it possessed at first. This acid reaction arises, according to 
 M. Œhl,* from the carbonic acid absorbed in the liquid, 
 which holds in solution the carbonate of lime with which 
 the liquid secreted by the parotid is abundantly provided. 
 When the carbonic acid disappears, the acid reaction ceases 
 to take place and the carbonate of lime which it holds in 
 solution is precipitated. 
 
 This circumstance explains the formation of the tartar 
 upon the teeth. The fact that this sometimes contains a 
 large quantity of pliosphate of lime at the same time with 
 the carbonate is not in contradiction with this explanation, 
 inasmuch as the carbonic acid may hold phosphate as well 
 as carbonate of lime in solution. The precipitates of the 
 calcareous salts inclose numerous elements of leptothrix and 
 of other products which are met with in the mucosities of 
 the mouth, such as epithelial cells, leucocytes, &c., as we 
 have hereinbefore shown. 
 
 The numerous minute follicles of the buccal cavity secrete 
 a liquid which goes by the ordinary name of buccal mucus, 
 and which, very probably, in its properties resembles the 
 secretions of the submaxillary and sublingual glands. Ac- 
 
 * La saliva liumana, &c. Puvia, 1864. Vide Meissner's Jahresber. 
 (Meissner's Annalen f. rat. Med., xxv Bd. 2 H., S. 242.)
 
 88 INQUIRIES INTO DENTAL CARIES. 
 
 cording to their seats tliey are called follicles of the lips, of 
 the cheeks, of the palate, of the tongue. Their structure is 
 perfectly identical with that of the salivary glands, and their 
 secretions contain, like those of the suhniaxillary and suh- 
 lingual glands, a great quantity of mucus which conies from 
 the epithelial cells of the follicles, while the secretion of the 
 parotid is very liquid and contains no mucus. 
 
 The particular reaction of the mucous secretion furnished 
 by the buccal cavity naturally cannot be established in a 
 direct manner in man; nevertheless, from the fact that the 
 mixture of all the secretions of the mouth, which constitutes 
 the ordinary saliva, has, as a rule, an alkaline or neutral re- 
 action, we may conclude that the secretion of the mucous 
 follicles of the mouth is in like manner neutral or alkaline. 
 This has been proved directly b}' an exiieriraent made on a 
 dog b}' M. CI. Bernard. After having made a section of all 
 the salivar}^ conduits, he found that the liquids contained in 
 the mouth, which clearly could no longer be mixed with 
 secretions supplied by the salivary glands, were alkaline ; 
 the secretion of the mucous follicles, at least of dogs, must 
 then be alkaline. 
 
 It has also been asserted that the mucous membrane of 
 the buccal cavity can, independently of the mucous follicles 
 which it contains, give out an acid secretion, especially" when 
 irritated. 
 
 Mr. Tomes shares this opinion, which he rests principally 
 on TIîê^Tact that cotton placed between the teeth, in such a 
 manner as to irritate the gum, evidently favors the progress 
 of the caries which exists at any point. But these facts can 
 be refuted by considering that the cotton, as a porous sub- 
 stance, must necessaril}' favor the work of decomposition 
 and of fermentation which is going on at this spot. It has 
 not as yet been showai directly, and we may say that it is 
 not very probable, that the mucous membrane of the mouth, 
 aside from the secretions of the glands which it contains, 
 -.jiecretes a fluid peculiar to itself in any great abundance. 
 
 it is, nevertheless, a fact which is commonly observed, 
 that the interior of the mouth, but above all, the surface of
 
 PRODUCTION OF CARIES. 89 
 
 the teeth and gums, shows aii_acid reaction. This reaction 
 may, <x ^non, he attributed to two causes: first, to the ab- 
 normaT^nature of the secretions of the mouth, and, second, 
 to an acid fermentation of particles of food. 
 
 As for the reaction of the liquids of the mouth, we have 
 already remarked that the secretions of the parotid possess, 
 in most cases, an acid reaction ; hence it may be presumed 
 that, in given circumstances, the acidity of the saliva may 
 be sufficiently increased for the teeth to be affected by it. 
 The momentary acid reaction which the secretion of the 
 parotid possesses in the normal state, and which is caused by 
 carbonic acid, can naturally have no injurious influence upon 
 the teeth, seeing that it is even powerless to prevent the tar- 
 tar from precipitating from it. If this acid saliva were able 
 to dissolve a greater quantity of calcareous salts than that 
 which it already holds in solution, we should never see any 
 portion of these salts form a precipitate ; but, as all saliva 
 deposits more or less tartar, it is very improbable that it can, 
 in general, attack the teeth. 
 
 It is true that cases are found, where the caries has a very 
 rapid progress, in which there is almost a total absence of 
 deposits of tartar ; but we generally find in such cases a 
 diminution of the salivary secretion, which explains the ab- 
 sence of tartar. The acids which form in the mouth are no 
 longer neutralized and diluted by the saliva ; therefore they 
 have a greater facilitj' for attacking the teeth. We believe, 
 on the contrary, that the saliva protects the teeth against 
 the action of acids, from Avhence arises the particular immu- 
 nity which the canines and incisors of the lower jaw seem to 
 possess; teeth which are constantl}^ bathed in saliva. Those 
 persons who secrete but a small quantity of saliva have pre- 
 dispositions to caries of the teeth ; a particular predisposition 
 to this aftection springs, in like manner, from the diminution 
 of the saliva which takes place during the course of certain 
 maladies. 
 
 The action of tobacco-smoke, which favors the salivary 
 secretion, appears to be salutary ; in no case does it ever 
 
 7
 
 90 INQUIRIES INTO DENTAL CARIES. 
 
 exert an injurious eftect upon the teeth, although, in time, 
 it gives them a color far from agreeable. 
 
 An acid reaction has often been attributed to the secretion 
 of the mucous follicles of the buccal cavity. This opinion is 
 based upon a layer of mucus situated upon the surface of the 
 interior of the mouth, and, especially, upon the gums and 
 teeth, which has an acid reaction, and in which are found 
 tlie elements of leptofhrix, the epithelial cells of the mouth, 
 leucocytes, &c. It appears, nevertheless, that the acid reac- 
 tion has nothing in common with the follicular secretion ; it 
 should be attributed to the acid fermentation which takes 
 place in this secretion, or in the saliva mixed with starchy 
 or sugary liquids. It is when fasting that the acid reaction 
 is the most marked ; that is to saj', at the moment when the 
 salivary secretion is reduced to its minimum, so that the 
 acids which form are not at once neutralized and diluted. 
 M. Œhl, nevertheless, found that, even when fasting, no 
 acid reaction took place when the mouth had been scrupu- 
 lously rinsed after eating, 
 
 M. Œhl has made a comparison between the changes which 
 take place in pure saliva and that mixed with alimentary 
 débris, when exposed to the air. lie collected one portion 
 of saliva after the ingestion of amylaceous substances, and 
 another after the mouth had been thoroughly rinsed. The 
 two liquids destined for the experiment were then filtered, 
 and left to themselves. The former, which contained starch, 
 reduced sulphate of copper, proving that a portion of the 
 starch had been converted into sugar. It remained several 
 days in a state of acid fermentation before passing to the 
 state of putrefaction with alkaline reaction. In the second 
 liquid, which contained only pure saliva, there was no acid 
 reaction, but on adding starch or sugar to this saliva, primi- 
 tively pure, in like manner as in the former, an acid fermen- 
 tation was seen to take place. îs^evertheless, the presence of 
 the saliva was necessary to produce this acid fermentation, 
 inasmuch as a solution of starch paste, or of sugar, free from 
 all other mixture, and placed in the same conditions, did not 
 become acid in the same space of time. Where sugar or
 
 PRODUCTION OF CARIES. 91 
 
 starch was held in the mouth, when its reaction was alkaline, 
 an acid reaction was found at the end of from twenty to 
 forty minutes, and even sooner, when grape sugar was used. 
 The acid reaction of the saliva which we meet in persons 
 afflicted with diabetes is, according to M. Œhl, due to the 
 same cause, inasmuch as sugar is found not only in the urine 
 of such persons, but in nearly all the secretions, and especi- 
 ally in the saliva. The secretion of the parotid was able in 
 the first experiments to give by itself an acid reaction, which 
 was not the case with the saliva coming from the submax- 
 illary glands, but was from a mixture of the two, especially 
 when mixed with mucus. The acid arising from this fer- 
 mentation is, according to M. Œhl, probably the lactic. 
 
 It_results from these experiments that the saliva of man, 
 when starch or sugar is mixed with it, can produce an acid 
 fermentation, and that an identical fermentation can take 
 place in the mouth. The possibility of the acid fermentation 
 of a solution of starch is subordinated to the propert}^ pos- 
 sessed by the saliva of changing starch into sugar, which, in 
 contact with a ferment, undergoes an acid fermentation. It 
 is now acknowledged that, in man, it is not only the mixture 
 of the difterent secretions of the mouth, but also the isolated 
 secretion of the parotid and that of the submaxillary glands 
 which are able to change starch into sugar. 
 
 If, according to this, the acid reaction of the mouth should 
 be attributed chiefly to the presence of alimentary débris, we 
 should always take into consideration the relative quantity 
 of saliva and of mucus. Besides the influence exercised by 
 the quantity of the saliva, whose action is to dilate and to 
 neutralize the acids, a greater quantity of mucus may also 
 possess importance, inasmuch as, by its viscosity, it hinders 
 the too rapid mixture with the saliva, a fact which explains 
 the possibility of finding locally, at the surface of the teeth, 
 for example, acids inclosed in a thick m ucus ; whilst, in other 
 portions of the buccal cavity, a neutral reaction can be found,, 
 or even one slightly alkaline. 
 
 In opposition to our opinion, which consists in asserting- 
 that the acid reaction is caused chiefly by alimentary débris
 
 92 INQUIRIES INTO DENTAL CARIES. 
 
 in tlie month, it may be objected that during the course of 
 certain acute diseases, and especiall}^ in typhoid fever, the 
 teeth are strongly attacked by caries, and that, in spite of 
 the diet habitually prescribed, there is an increase of acidity. 
 It must, nevertheless, be considered that the diet is never 
 absolute, and that constantly sugar, and very often acids, 
 are introduced into the mouth by means of medicines; the 
 amount of this sort of drinks is indeed considerable, on ac- 
 count of the thirst from which patients suffer. A cause, in 
 like manner very important in the production of an acid fer- 
 mentation in these maladies, is the diminution of the salivary 
 secretions, which are more concentrated, and contain more 
 mucus, so that the elements necessary to fermentation are 
 not wanting; whilst the acids which are formed, on account 
 of the small quantity of saliva, cannot be properly diluted or 
 neutralized. 
 
 The lack of mastication must at the same time favor in 
 certain parts of the buccal cavity the accumulation of viscous 
 mucus in a state of acid fermentation. Under the influence 
 of like causes there is established in the mouth an enormous 
 mass of elements of leptothrix^ which form upon the tongue 
 and teeth a portion of the sooty layer, Avhitish at first, after- 
 wards dry and brown, which is found there. 
 
 The most various irritations of the buccal cavity, and gen- 
 erally all the acute or chronic affections of the digestive 
 canal, as well as the acute idiopathic maladies, exercise an 
 influence upon the production of caries. Likewise, in these 
 maladies, the mouth contains a greater quantity of this vis- 
 cous coating, which gives an acid reaction. It appears that, 
 in these cases, the mucus mixes in considerable proportions 
 with the secretions of the buccal cavity, whilst the quantity 
 of saliva is not positively diminished. But it is just the 
 great viscosity of the mucus which hinders the mingling of 
 the liquids in the mouth, and favors the production of par- 
 tial fermentation. "We have already called attention to the 
 acids which come directly from the stomach to the mouth 
 in cases of dyspepsia. We have likewise had occasion to 
 remark the frequent cases of caries of the teeth which are
 
 PRODUCTION OP CARIES. 93 
 
 met with in persons afflicted with diabetes ; they are attrib- 
 uted to the sugar}'- matters which the saliva contains, and 
 which are changed, according to M. Œhl, into lactic acid. 
 
 Nearly all observers have remarked the frequency of caries 
 of the teeth in pregnant females. This is sufficiently ac- 
 counted for by the troubles which they experience with their 
 digestion, which are accompanied by the formation of acids 
 in the mouth during the continuance of this condition. I 
 think it is not necessary to find here any analogy, as many 
 observers have done, with the osteomalacia^ sometimes met 
 with in pregnant women. There are seen, it is true, in preg- 
 nant women, cases of osteomalacia^ which must be caused by 
 their state of pregnancy. Cases of cure of this malady have 
 been recorded where it had aflected the pelvis, and which 
 recurred again during another pregnancy, to be again cured 
 after delivery. But aside from the extreme rarity of these 
 cases it is not proved, it is not even probable, that the calca- 
 reous salts of the dentine can be taken up again in the same 
 manner as the salts of the bony tissue in general ; we must 
 therefore refuse to admit such an explanation. 
 
 If we recapitulate, we shall find in the work of fermenta- 
 tion which takes place in the mouth a continual source of 
 acidity. This acidity, by its action on the teeth, without 
 doubt acts with much greater energy than the acids formed 
 transiently by the alimentary débris, or by any other sub- 
 stance introduced into the mouth. The rôle of the saliva is 
 here to change into sugar the starch contained in the food ; 
 moreover, the sugar contains fermentable substances which 
 produce an acid reaction. I^evertheless, the saliva dilutes 
 and neutralizes the acids, when it exists in sufficient quan- 
 tity, and thus hinders their action on the teeth. We cannot, 
 then, justify the assertion of M. Magitot that the saliva is 
 the veritable agent of caries of the teeth. He contradicts 
 himself, adding, in the same phrase, that the saliva cannot 
 produce this effect when it retains its original composition, 
 but only in consequence of certain modifications occasioned 
 by the presence of injurious substances formed spontaneously, 
 or introduced from without. It appears, then, evident that
 
 94 INQUIRIES INTO DENTAL CARIES. 
 
 it is not the saliva, but rather these injurious substances 
 which should be considered as the agents of caries of the 
 teeth. 
 
 As far as we know, the veritable nature of the acids found 
 in the mouth has not yet been demonstrated by any direct 
 experiment; nevertheless, it is generally thought to be lactic 
 acid, and this opinion has the greatest probabilities in its 
 favor. 
 
 As a general rule, it is lactic acid which is produced by 
 the fermentation of sugared liquids and others, when there 
 are present at the same time albuminoid substances. This 
 fermentation is particularly favored by the presence of the 
 carbonate of lime, which neutralizes the acids gradually as 
 the}^ are formed ; whilst the fermentation itself is hindered 
 by a little more considerable abundance of acids. 
 
 Xow all these conditions are fulfilled in the buccal cavity ; 
 the saliva and the mucus contain albumen, and carbonate of 
 lime exists in great quantity in tartar and the dental tissues. 
 We know not whether or not there are formed still other 
 acids. We might expect to find in the mouth the fun^i 
 which, according to M. Pasteur, should accompany and pro- 
 duce the lactic fermentation, "ferment de l'acide lactique de 
 Pasteur." But the opinions of authors upon the ferment of 
 lactic acid difler so greatly that it is impossible for us to at- 
 tribute any great value to the presence of this ferment in the 
 mouth. According to M. Pasteur the elements of the ferment 
 of lactic acid are molecular corpuscles, verj' minute, which pre- 
 sent a very marked Brunonian movement whose dimensions 
 he does not state on account of their extreme minuteness. 
 In the work of one of his pupils, M. Van Tieghem, upon the 
 fermentation of urine, there is a figure of one of these fungi 
 in which these latter are contracted in the middle and larger 
 than the spores of the urine ferment which are pictured by 
 their side, and have a diameter .0015 millimetre. The form 
 of these fungi, according to M. Van Tieghem, is identical 
 with that of the mycoderma aeeti of ^I. Pasteur, of which the 
 diameter is likewise .0015 millimetre. This figure, then, 
 does not at all agree with those given by M. Pasteur.
 
 PRODUCTION OF CARIES. 95 
 
 The observations of M. Ilallier upon the ferment of lactic 
 acid {oïdium Ick-Hs, Fresenius) are entirely ditïerent from 
 those of M. Pasteur. According to him the elements of this 
 ferment consist of great cells of a rounded quadrangular 
 form ; they should be constantly found in the acid fermenta- 
 tion of milk, and, moreover, upon all substances in a state of 
 acid fermentation. 
 
 We have ourselves found, in milk soured at a low temper- 
 ature, minute corpuscles endowed with power of very rapid 
 motion, which appeared to us to be identical with those de- 
 scribed by M. Pasteur. We have also encountered elements 
 of this kind in saliva containing sugary matters, which had 
 passed into a state of fermentation ; united, these elements 
 presented the appearance of granular masses of leptothrix, 
 especiall}^ near the margins of the preparation, where, in 
 consequence of the evaporation of the liquid portions, their 
 movements had been arrested. Nevertheless, in no one of 
 these cases have we been able to obtain a reaction either 
 with iodine or with the acids. 
 
 We greatly regret that there are so few methods of dis- 
 tinguishing with exactness the different species of fungi, and 
 we cannot set ourselves the task of undertaking researches 
 so extensive, and demanding so much time. We contine 
 ourselves in consequence to presenting some observations 
 upon the possil)le coincidence of the acid fermentation in 
 the mouth with the presence of a development of fungi. 
 
 Besides the presence of a great quantity of leptothrix, we 
 see in the mouth but a very small number of spores and fila- 
 ments of a fungus which bears a resemblance to oidium.. 
 But the masses of leptothrix are so predominant that we are 
 disposed to believe in their participation. If, in general, the 
 fungi play a role in the acid fermentation of the mouth, 
 which is not proved, we are inclined to attribute it to the 
 leptothrix. This opinion is founded upon the resemblance 
 which the corpuscles in movement during the fermentation 
 of the saliva and of milk present to the lactic acid ferment 
 of M. Piisteur, and to the masses of leptothrix which are 
 really formed in the mouth.
 
 96 INQUIRIES INTO DE-NTAL CARIES. 
 
 The absence of the violet reaction, so characteristic, which 
 we find in the former case, depends perhaps upon a difi'erent 
 degree of development. 
 
 III. Influence of Leptothrix upon the Production of 
 Caries of the Teeth. 
 
 "We have already several times remarked that the action 
 of acids alone does not account for all the phenomena which 
 appear in caries of the teeth. It is true that acids, even very 
 much diluted, can attack the dental tissues ; but we find, in 
 their mode of action, difierences which distinguish them 
 from the phenomena and from the j^rogress of dental caries. 
 The acids attack first the enamel and rapidl}' change it to a 
 chalky mass ; later only, their action is felt in a marked 
 manner upon the dentine, which becomes more transparent 
 and, in fine, as if cartilaginous, by the very slow but pro- 
 gressive loss of its calcareous salts. 
 
 Caries, on the contrary, proceeds slowly in the enamel ; it 
 is much swifter in the dentine, where it proceeds promptly 
 along the canaliculi. This difterence of progress must be at- 
 tributed to the participation of the fungi in the work of the 
 caries. The elements of the fungus glide easily into the in- 
 terior of the canaliculi, which they dilate, and thus favor 
 the passage of the acids into the deeper parts ; these same 
 elements cannot penetrate a compact enamel, or at least they 
 enter more slowly, and only when the elements which form 
 it have been greatly changed by the action of acids. 
 
 Leptothrix is found almost constantly in the buccal cavity, 
 if great care is not taken to rinse the mouth frequentl}^ 
 Mr. Bowditch, in examining forty persons of difi'erent pro- 
 fessions, and living difterent kinds of life, found in almost 
 all vegetable and animal parasites. Those only were found 
 to be free who cleaned their teeth several times a day, and 
 at least once with soap. The parasites were numerous in 
 proportion to the neglect of cleanliness. The means ordina- 
 rily employed to clean the teeth had no efiect upon these 
 parasites, whilst soap appeared to destroy them.
 
 PRODUCTION OF CARIES. 97 
 
 M. Kolliker, out of twenty to thirty young and well per- 
 sons, found hardly one the papillœ of whose tongue was free 
 from a grayish and granular coating; he more rarely met 
 with filaments of the fungus. It is true that regard must 
 be had to the hour of the day at which the examinations 
 were made ; it is natural that all these matters should always 
 be more abundant when the individual is fasting. 
 
 But, while in ordinary circumstances, the fungi are found 
 only at the surface of the buccal cavity, they are seen to 
 penetrate into the interior of teeth during the progress of 
 caries. For them to be able to penetrate thus it is necessary 
 that the teeth be in a suitable condition; the enamel and 
 the dentine must have lost their density by the action of 
 acids. 
 
 It seems that the fungi are not able to penetrate an enamel 
 of normal consistency. The dentine itself, in its normal con- 
 dition of density, oflers great difficulties to their entrance, 
 and we are not yet sure that the leptothrix could triumph 
 over this resistance. We do not speak here of the greenish 
 deposit found upon teeth, which difters from caries, and upon 
 which' we have not yet sufficiently experimented. It may 
 happen that, under favor of this deposit, fungi may penetrate 
 into the superficial layers of the enamel, which does not 
 appear to be the case in ordinary caries. Habitually the 
 teeth expose to the action of injurious agents only their 
 crowns covered with enamel, and this protects them from 
 the attacks of the fungus. We cannot decide, at present, if 
 the leptothrix is able to penetrate sound dentine, when from 
 any abnormal circumstance it happens to be denuded. But 
 if the enamel or the dentine are become less resistant at any 
 point through the action of acids ; or if, at the surface of 
 the dentine, a loss of substance has occurred, then the ele- 
 ments of the fungus can pass into the interior of the dental 
 tissues, and produce by their extension, especially in the den- 
 tine, efiects of softening and destruction much more rapid 
 than the action of acids alone is able to accomplish. 
 
 The participation of the fungus is constant in the progress 
 of caries which has reached this stage. As soon as a loss of
 
 98 INQUIRIES INTO DENTAL CARIES. 
 
 substance can l)e shown there is found thcpresence of the 
 fungus, so tliat the question whether or no the acids alone 
 could produce ravages more considerable is without impor- 
 tance. But in the early stage, w^hen the surface of the tooth 
 is still polished and intact, we have never been able to prove 
 the presence of the fungus ; it appears, therefore, that at this 
 stage of the malady, which constitutes the dry caries, prop- 
 erly so called, all the disorders must be attributed to the sole 
 action of acids. 
 
 The development of the fungus seems to be favored by a 
 neutral or slightly acid medium, whilst it cannot flourish in 
 a strongly alkaline liquid. We have already called attention 
 to the observation of Dr. Bowditch, who has seen the para- 
 sites disappear upon rinsing the mouth with a solution of 
 soap. M. A. Vogel found that the fungus, oidium albicans^ 
 continued to develop in pure water, in solutions of salts with- 
 out alkaline reaction, and especially in solutions of sugar; 
 whilst no proliferation could take place in solutions slightly 
 alkaline. These observations, to judge of them by analogy, 
 seem likewise to prove that alkaline liquids may exercise a 
 destructive action upon the leptotlirlx. 
 
 IV. Therapeutic Conclusions. 
 
 It is not without importance to cast an eye, before con- 
 cluding, upon the therapeutic conclusions which should be 
 drawn from the results -which we have reached, and to see 
 if they are in accord with the experience of practitioners. 
 
 Before all, as regards the prophylactic indications, it can 
 be said that we should seek to neutralize the acids which 
 form in the mouth, and to prevent all work of fermentation 
 and of development of fungi by proper care for cleanliness. 
 Teeth well formed may be spared by caries in spite of the 
 greatest negligence; but we should take the greater care of 
 our teeth in proportion as they are badly developed or irregu- 
 larly arranged. With great care even malformed teeth may 
 be preserved from caries. In cleaning the teeth such brushes 
 should be used as are not too hard, and which, by a slight
 
 THERAPEUTIC CONCLUSIONS. 99 
 
 pressure, can be made to enter the spaces between the teeth. 
 We may advise, as useful for this purpose, the emploj-ment 
 of soap, which, by imparting a slightly alkaline quality to 
 "the Avater, neutralizes the acids and hinders the development 
 of fungi.* 
 
 In many cases the soap does not suffice to remove entirely 
 tlie deposit formed upon the teeth ; in such case there should 
 be added to it powders which act mechanically, but care 
 should be taken that they are not too gritty ; the disagree- 
 able taste of soap may be easily corrected. 
 
 We can a lso recommend the permanganate of potassa dis- 
 solved in water as an excellent mouth wash, inasmuch as 
 this remedy is a very excellent antiseptic, and at the same 
 time the best means of preventing fermentation; this water 
 exercises a beneficial action upon the mucous membrane of 
 the mouth. 
 
 As regards the artificial treatment of caries our observa- 
 tions are at every point in accordance with the experiments 
 made up to this time. In filling the teeth the air and liquids 
 are hindered from penetrating, and all work of fermentation, 
 and all development of fungi, become impossible. 
 
 There has appeared lately in the Archives of Virchoio, vol. 
 xli, an article by Dr. Hertz upon "Dental Caries." This 
 author, having no knowledge of our experiments, has not 
 discussed our opinions, although his mémoire appeared some 
 time after ours. In a note added to the end of his work he 
 wrongly accuses us of rejecting all vital action of the den- 
 tine in the production of caries. 
 
 As for the rest, the opinions of Hertz are nearly in agree- 
 ment with those of jSTeumann. He asserts that he has never 
 observed alteration of dentinal fibrils in natural teeth of 
 substitution, ^^^e maintain the correctness of our observa- 
 tions on this subject. It only remains to determine if the 
 alterations we have described are constant, or if they are 
 wanting in certain cases. 
 
 * T'/f/c J. B. Kotteristein. Des soins à donner aux dents. Frankfort-sur- 
 le-Maine, 1857.
 
 I p I 
 
 'A 
 
 
 m 
 
 7 
 
 PUdel 
 
 Û 
 
 W 
 
 
 m. LEB£F. FROM NATURE DEL. 
 
 T.siNciAiRasc\ nrn. fh/i<-
 
 EXPLANATIOIT OF THE PLATES. 
 
 PLATE I. 
 
 Fig. 1. (Magnified three diameters.) 
 
 Longitudinal section of a carious bicuspid. The section is slightly slanted 
 across a large carious cavity ; upon the left side of the crown a cone of a 
 dark color is seen in the dentine altered by caries ; this cone extends in the 
 direction of the dentinal canals from the surface even to the pulp-cavity, and 
 presents a radiated striation which corresponds to these canals. Upon the 
 surface of the section the loss of substance extends only upon the enamel, 
 whilst upon the neighboring parts it penetrates deeply into the interior of 
 the dentine. Upon the masticating surface of the enamel are seen two 
 fissures. 
 
 Fig. 2. (Magnified three diameters.) 
 
 A longitudinal section of a canine tooth with commencing caries. In the 
 centre of the crown is a small carious point in a depression of the enamel ; the 
 caries has not as j^et attacked more than a superficial layer of the enamel. 
 A similar point exists at the left side of the crown, also without loss of sub- 
 stance, and it is from this point that the caries has extended across the whole 
 thickness of the enamel, and nearly across the whole thickness of the dentine 
 to the neighborhood of the pulp-cavity. 
 
 The outermost layers of the dentine are of a darker color than the deepest 
 layers of the enamel, the color diminishing in both from the surface inwards. 
 There are, moreover, three small carious cavities which reach to the surface 
 of the dentine; also cones of carious dentine are seen to start from these 
 cavities and point to the pulp-cavity; one of these cavities exists at the right 
 side of the crown, the two others are found at the neck of the tooth. 
 
 Fig. 3. (Magnified three diameters.) 
 
 Section of a human molar with caries commencing. In the middle of the 
 crown a loss of substance in the enamel (the enamel has been broken away 
 at the sides in the process of preparation) ; in the dentine a cone of a clear 
 color altered by caries ; this clear color is due to the transparency of the
 
 102 EXPLANATION OF THE PLATES. - 
 
 tissue ; the brownish color cannot be perceived on account of the thinness of 
 the specimen. 
 
 Fig. 4. 
 
 A fragment of this same section magnified one hundred diameters. A 
 very thin hiyer of enamel is seen on a level with the loss of substance; the 
 most superficial layers are very transparent in consequence of the disappear- 
 ance of the calcareous salts. It is seen, also, that the surface is irregular and 
 covered with fissures and cracks. The layer of leptothrix is not preserved at 
 the surface, but there exist at one point masses of granular leptothrix which 
 have penetrated the dentine across a fissure of the enamel. The outer layers 
 of dentine are dark and the canals more difficult to distinguish ; in the deeper 
 layers are found little deposits of calcareous salts in the canals and inter- 
 globular spaces. 
 
 PLATE II. 
 
 Fig. 1. (Magnified one hundred times.) 
 
 Section of the surface of a carious cavity. The dentine is reduced to frag- 
 ments enveloped with leptothrix. On the free surface delicate filaments of 
 the fungus are seen crossinij; the granular masses. 
 
 Fig. 2. (Magnified one hundred times.) 
 
 The decomposition of the dentine has made still greater progress. The 
 débris are much smaller and less voluminous than the masses of leptothrix 
 which surround them. 
 
 Fig. 3. (Magnified one hundred times.) 
 
 Transverse section made at the surface of a cavity across the carious den- 
 tine. The dentinal canals are greatly thickened (which is difficult to observe 
 in the longitudinal section of Figs. 1 and 2) ; at the surface is a thick layer 
 of very fine filaments of leptothrix. 
 
 Fig. 4. (Magnified two hundred and fifty times.) 
 
 Transvei-se section of an artificial human tooth attacked by caries. The 
 changes are identical with those of the natural teeth. The canals are more 
 or less dilated; some are considerably so and have thickened walls, that 
 which could not be distinguished upon those of the canals which were the 
 most thickened.
 
 
 700 
 
 
 7(Xi 
 
 7 
 
 J f 
 
 / / 
 
 
 ~ 1 
 
 i^?r?S':. 
 
 PlatelL 
 
 
 ^. A*^*?^,©-£:<:^" 
 
 2i^ '\. «.ei*' 
 
 0®®^': ' 
 
 «^ <-/ 
 
 20ty 
 
 £>/? /£S£/i FROM NAT UREJJEl 
 
 T. SINCLAIR 3 SON UTH.PHW-
 
 EXPLANATION OP THE PLATES. 103 
 
 Fig. 5. (Magnified two hundred and fifty times.) 
 
 Canals isolated by hydrochloric acid, and coming from the carious dentine 
 of man. These canals show various degrees of thickening; their contents 
 are divided in the form of little bundles. In a a minute canal is seen greatly 
 dilated, from which spring several undilated ramifications which are de- 
 tached near their point of origin by the act of preparation. In b two small 
 tubes very slightly dilated, one of which becomes gradually thicker. 
 
 Fig. 6. (Magnified two hundred times.) 
 
 Transverse section of a carious tooth, one made of hippopotamus ivory. 
 A layer of leptoihrix at the surface; similar masses penetrate (in a), pro- 
 ceeding from the surface, into the interior of the tissue (in b) ; they seem 
 separate from the surface, because they have been crushed obliquely by the 
 section. The dentinal canals are for the most part dilated (c) ; some of them 
 still present the normal state {d). 
 
 Fig. 7. (Magnified two hundred and fifty times.) 
 
 Canals of the same tooth (hippopotamus) greatly dilated and presenting 
 varicose sinuosities. At the right some of them are still united by very fine 
 fibrils, wjiich appear to be the residue of the dentine.
 
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 INCLUDING WORKS ON 
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 December, 1872. PHILADELPHIA.
 
 Ts^EW BOOKS AND NEW EDITIONS, 
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 edged to be in advance ot all other works on "'/lie Science mid Pi'actice of Medicine." It is a moat thorough 
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 logical and pathological principles and the present state of science. For the practitioner it will be found 
 equally accepta-ble as a work of reference. 
 
 The author's plan has been carried out to that perfection that the treatise is as complete a one a» can be • 
 found in any language. Every department of medicine, whether relating to pathology, nosology, diagnosis, . 
 or treatment, is most elaborately and thoroughly discussed. The editor, Dr. Meredilh Clymer, ha» coatrib- 
 uted his share to the work by many judicious additions to the original text, which makes the work particu- 
 larly valuable to the American practitioner. As a whole, it now forms a complete cyclupa'dia of medicine^, 
 and commends itself to those practitioners and students who have a desire to perfect their knowledge of our ; 
 wt, and gain much of that information which is crowded out of the smaller text-books. 
 
 iV. r. Medkal Eecurd. 
 
 It must now be looked upon as the standard text-hook in the English language. 
 
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 All the light which recent advances have made in the method of examining, diagnosing, and treating of ■ 
 âiBoases are here imparted. British and Foreitjn iledieo-Odrurgieul JSeview. 
 
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 It is the most comprehensive work that has ever been published on the Practice of Medicine. 
 
 British Medical Journal. 
 
 By the student tt will bo found to be the most useful and coi»p»»hensive text-hook extant. 
 
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 The great merit of this work of Dr. Aitken's is, that it treats the various forms of disease according (c 
 % scientific classification. Atfi,enieum. 
 
 Dr. Aitken's work at once took the first place among text-books, and will hold that position for years to 
 come. Medical Mirror. 
 
 Dr. Aitken's work is an admirable one for the student and busy practitioner. A more excellent one we. 
 really do not know. London Lancet, May 13, 1865. 
 
 In Dr. Aitkei."B book, diseases are described which have hitherto found no place in any English systen^ 
 • Rework. WMiminsie} Uevi«w^
 
 New Book on Diseases of Women. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 
 Atthill's Clinical Lectures on Diseases Pecul- 
 iar to Women. Bj Lombe Atthill, M.D., Fellow and 
 Examiner in Midwifery, King and Queen^s College of Physicians: 
 OhMetric Physician to the Adelaide Hospital, and formej'ly Assistant 
 Physician to the Rotundo Lying-in Hospital. Demy Octavo, with 
 Illustrations. Now Ready. Price, 32.25 
 
 " This excellent little book has three great merits. It treats of very common diseases 
 which are generally very badly taught in our Schools. Secondly, it treats of them in 
 a thoroughly clinical and practical way ; and finally, without being too short, is a 
 compact book, calculated to be very useful to the practitioner. Dr. AtthilTs practice, 
 if not original, is thoroughly independent, and he illustrates it \ùih. a copious quota- 
 tion of good cases. We commend the whole book to the careful attention of advanced 
 students and general practitioners." — Lance/,March 23, 1872. 
 
 " The lectures before us have the merit of calling attention to this important subject 
 with the voice of personal experience. Those on Menorrhagia, endo-Metritis, and 
 endo-Cervicitis, we would specially point out as worthy of note ; and, without endors- 
 ing the author's therapeutic treatment of those ali'ections, we cannot but admire the 
 clearness of style and practical character of their literary treatment." — Glasgow 
 Medical Journal, May, 1872. 
 
 " Tliese lectures form an admirable text-book for students. Dr. Atthill, as Examiner 
 in the Queen's University and College of Physicians of Ireland, discovered the utter 
 ignorance of the majority of students on the important subject of Diseases Peculiar to 
 Women. The publication of this little volume supplies a want that has long been felt 
 by students preparing for examination. In these lectures is to be found a clear and 
 concise summary of the clinical practice of the diseases peculiar to women. The work 
 is the result of large and accurate Qlinical observation, recorded in an admirably terse and 
 perspicuous stj'le, and is remarkable for the best qualities of a practical guide to the 
 student and practitioner." — British Medical Journal, May 11, 1872. 
 
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 that cannot fail to be of great use to students, and that will guide them to a right 
 understanding of the cases brought before them in their hospital practice. Nor is 
 this all; to the busy practitioner this book will be of use in many an emergency, not 
 only assisting him in the recognition of the various forms of disease most frequently 
 met with, but also forming a safe and reliable guide to their treatment on sound and 
 scientific principles. We think Dr. Atthill has done good service in publishing his 
 lectures, and we strongly recommend them to the careful and attentive perusal of all 
 who wish to study the diseases of women." — Dublin Journal of Medical Science, Novem- 
 ber, 1871. 
 
 "A very useful and judiciously written work." — British and Foreign Medico- Chirur- 
 gical Review, April, 1872. 
 
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 pensive treatise on the more commonly met with forms of Uterine disease. We cannot 
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 cnliir, November 15, 1871. 
 
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 most u.seful kind. The lectured are strictly clinical, and the conciseness with which 
 Ur. Attliill discusses his sutjjects will make the work a favorite with general practi- 
 tioners, and this it deserves to be." — The Doctor, April 1, 1872. 
 
 ArnOtt on Cancer, itsVarieties,th.eir Histology and Diagnosis 
 By Henky Arnott, F.R.C.S., Assistant Sur^geon to St. Thomas' Hos- 
 pital. Illustrated by Five Lithographic plates and Tioenty-two Wood 
 Engravings, drawn from Nature. Octavo. Price, . . $2 25
 
 LINDSAY AND BLAKISTON'S PUBLICATIONS. 
 
 Allingliam on Fistula, Haemorrhoids, Painful 
 
 Ulcer, Stricture, Prolapsus, and other Diseases of 
 the Rectum, their Diagnosis and Treatment. By William Allino- 
 HAM, Fellow of the Royal College of Suri/eous of E»gla)id, Surgeon 
 to St. Mark^s Hospital for Fidula, &c. New p]dition preparing. 
 
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 til approach Mr. AUingham's in precision, clearness, and practical good sense " 
 
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 Adams on Club-Foot. 
 
 Its Causes, Pathology, and Treatment. Being the Jacksonian Prix 
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 A.ithaus' Medical Electricity. 4 xtw u.avery much 
 
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 A Theoretical and Practical Treatise, and its Use in the Treatment of 
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 nn Wood Price, ... . . . 85.00
 
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 On the Chronic Inflammation and Displacement of the Unimpregnated 
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 Black on the Functional Diseases of the Renal, 
 
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 THE ARCHIVES OF MEDICINE. Part XVII. noio ready. Price, $1.50. 
 
 CoNiENTS. — Medicine uiiler the Romans — Action of Eyelids in Expiration; F. 
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 THE MOST COMPLETE TEXT-BOOK NOW PUBLISHED. 
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 CWNTAINING 175 ILLUSTRATIONS. 
 
 A Theoretical and Practical Treatise on Midwifery, including the Diseaft» 
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 Price, bound in Cloth, bevelled boards, . . . $6.50 
 " " Leather, , 7.5Ô 
 
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 them a body of doctrine, and a system of practical rules, which he illustrates and enforcen 
 in the clearest and most simple manner possible. 
 
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 "It is unquestionably a work of the highest excellence, rich in information, and perhaps fuller in details 
 than any text-book with which we are acquainted. The author has not merely treated of every que*>- 
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 "In the multitudinous collection of works devoted to the propagation of human beings, and to th; 
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 "Among the many valuable treatises on the science and art of obstetrics, the work of Cazeaux stands 
 pre-eminent." — St. Louis Med. and Surg. Journal. 
 
 " M. Cazeaux's book is the most complete we have ever seen upon the subject. It is well translated,- 
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 Ils Therapeutics and Practice. A Treatise on the Inhalation of Gases, 
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 American Journal of Medical Science, July, 1868. 
 
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 Of the University of Pennsylvania, from its Foundation in 1*765: loitk 
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 Dunglison's History of Medicine, 
 
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 to the Vienna Medical School. 
 
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 Gioss' American Medical Biography of the 
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 HOW, M.D., Fellow of the Royal College of Physicians, £c., £c. 
 
 Price, $2.00 
 
 "In vivid pictures of the sort of cases wliicli a pi-actitioner encounters i:» his daily walks, and in examples 
 of the way iu wliicli a student ought to turn them over in his mind ùnd make them tools for Beif-improve- 
 ment, we have rarely seen a volume richer." — £rit. and For. Medico-CHirura. .Çet-i<«»-. 
 
 Garratt's (Alfred C.) Guide for "Dosing Medical 
 Batteries. 
 
 Shoiving the most approved Âpj)aratus, Methods, and Rules for the Medical 
 
 • Employment of Electricity in the Treatment of Nervotis Diseases, &c., &e. 
 
 With numerous Illustrations. One Volume, octavo, . . 62.00 
 
 "The large work on the same subject, and by tVie same author, is pretty well known to the Profession, buî 
 It is bulky and cumbrous, and by no means so practically useful. The present comparatively brii'f volume 
 contains every thing of importance in regard to the various apparatuses useful to the Medical Electrician 
 tnd the various modes of application foi therapeutic purposes." — Lancet and Observer. 
 
 Godfrey's Diseases of Hair. 
 
 A Popular Treatise upon the Affections of the Hair System, with Advice 
 upon the Preservation and Management of Hair. By Benjamin 
 Godfrey, M.D., F.R.A.S. Price, ..'... $1.50 
 
 Chapter 1. Introduction. 2. Anatomy and Physiology of Hair. 3. Excess of Hair. 4. Baldness. 5. Tri- 
 chionosis Cana. 6. Albinism. 7. Hair in the wrong place. 8. Vegetable Parasitic Diseases. 9. Morbui 
 Paxtonii. 10. Chignon Fungus. 11. Plica Polonica. 12. Diseases of Color of the Hair. 13. Pityriasis. 14. 
 Phtheiriasis. 15. Diseases of Hair Follicles. 16. Trichiasis Ciliorum. 17. Color of Ilair in relation to Char- 
 acter and Disease. 18. Cleanliness. I'J. Hair Dyes. 20. The Beard. 
 
 Gardner on Sterility. Its Causes and Cura- 
 tive Treatment. WUh illustrations. Octavo. . $3.00 
 
 Holden's Manual of the Dissection of the 
 
 Human Body. WUh Notes and Additions. Plustrated. 65.00 
 
 Hillier's Clinical Treatise on the Diseases of 
 
 ChlKiren. By Thomas Hillier, M.D., Physician to the Hospitoi 
 fcr Sick Children, and to University College Hospital, &c., êc. Octavo. 
 
 Price, S3.00 
 
 «Our apace is exhausted, but ■we have said enough to indicate and illustrate the excellence of Dr. Hillier'i 
 Toltime. It is eminently the kind of book needed by all medical men who w «h to cultivate cliuital acr-ir«cj 
 tkvi sound practice." — Ltmdon Lancet.
 
 LINDSAY AND BLAKISTON S PUBLICATIONS. 
 
 Harris' Principles and Practice of Dentistry. 
 
 The Tenth Revised Edition. In great part Re-written, Re-arranged, 
 and with many New and Important Illustrations. Including 
 
 1. DENTAL ANATOMY AND PHYSIOLOGY. 3. DENTAL SURGERY. 
 
 2. DENTAL PATHOLOGY AND THERAPEUTICS. 4. DENTAL MECHANICS. 
 
 By Chapin a. Harris, M.D.,D.D.S., &c. The Tenth Edition, Revised 
 and Edited, by P. H. Austen, M.D., Professor of Dental Science and 
 3Iecha.nisni in the Baltimore College of Dental Surgery, with nearly 
 400 Illustrations, includiyig many new ones made especially for (his 
 edition. Royal Octavo, in Cloth, ..... 86.50 
 " " Leather, 7.50 
 
 This new edition of Dr. Harris's work has been thorouglily revised in all its parts — more so than any pre- 
 vious edition. So great have been the advances in many branches of Dentistry, that it was found necessary 
 to rewrite the articles or subjects, and tliis has been done in the most efficient manner by Prof Austen, for 
 many years an associate and friend of Dr. Harris, assisted by Prof Gorgas and Thus. S. Latimer, M.D. The 
 publishers feel assured that it will now be found the most complete text-book for the student and guide for 
 the practitioner in the English language. 
 
 Harris' Dictionary, the third revised edition. 
 
 A Dictionary of Medical Terminom)gy, Dental Surgery, and the 
 Collateral Sciences. The Third Edition, carefully Revised and 
 Enlarged, by Ferdinand J. S. Gorgas, M.D., D.D.S., Professor of 
 Dental Surgery in the Baltimore College, &c., &c. • 
 
 Royal Octavo, in Cloth, $6.50 
 
 " " Leather, 7.50 
 
 Prof. Gorgas is Dr. Harris's successor in the Baltimore Dental College, and he has in a most satisfactory 
 manner revised this edition of bis work, having added nearly three thousand new words, besides making 
 many additions and corrections. The doses of the more prominent medicinal agents have also been added, 
 and in every way the book has been greatly improved, and its value enhanced as a work of reference. 
 
 Handy's Text-book of Anatomy, 
 
 And Guide to Dissections. For the Use of Students of Medicine and 
 Dental Surgery. With 312 Illustrations. Octavo. . . $4.00 
 
 Hardwick's Manual of Photographic Chemis- 
 try. With Engravings. Eighth Edition. Edited and Re-arranged hy 
 G. Dawson, Lecturer in Photography, &c., &c. 12mo. In preparation. 
 
 Harley's Urine and its Derangements, 
 
 With the Application of Physiological Ghemistrt/ to the Diagnosis and 
 Treatment of Constitutional as well as Local Disease. By George 
 Harley, M.D., F.R.S., late Professor in the University College, Lon- 
 don, &c., &c. With Illustrations. One volume. Price, , $2.75 
 CosTENT.s. — Chapterl. What is Urine? 2. Changes in the Composition of the Urine, 
 induced by Food, Drink, Medicine, and Disease. 3. Urea, Ammonajmia, Urœmia. 4. 
 Uric Acid. 5. Hippuric Acid, Chloride of Sodium. 6. Urohaematin, Abnormal Pig- 
 ments in Urine. 7. Phosphoric Acid, Phosphatic Gravel and Calculi. 8. Oxalic Acid, 
 Jxaluria, Mulberry Calculi. 9. Inosite in Urine, Creatin and Creatinine, Cholesterin, 
 Cystin, Xanthin, Leucin, Tyrosin. 10. Diabetes Melitus. 11. Albuminuria. 
 
 The subject-matter of this volume was delivered in a conrse of lectures before the c!.i.ss at the University 
 College, London, and puldished in detached irortinns in the London Medical Times and Gazelle, where they 
 were so favorably received that the author has been induceil to revise and enlarfre them, presenting them in 
 a far more accessible form to the Profession. Professor Harley's book now offers facilities for the study of 
 Physiological and Pathological Chemistry, as applied to a class of diseases that is otherwise very imjerf«cUj 
 arovided for.
 
 LINDSAY AND BLAKISTON'S PUBLICATIONS. 
 
 Hewitt on Woman, a new, enlaeged, and im- 
 proved EDITION. WITH NEW ILLUSTRATIONS. 
 
 The Diagnosis, Pathology, ant» Treatment op Diseases of Women, 
 including the Diagnosis of Pregnancy. Founded on a Course oj 
 Lectures delivered at St. Mary's Hospital Medical School. By G rail y 
 Hewitt, M.D. Lend., M. R. C. P., Physician to the British Li/ing-in 
 Hospital ; Lecturer on Midwifery and Diseases of Women and Chil- 
 dren at St. Mary''s Hospital Medical School ; Honorary Secretary to 
 the Obstetrical Society of London, éc. The Third Edition, Revised 
 and Enlarged, with new Illustrations. Octavo. Price in Cloth, $5.00 
 
 " " Leather, 6.00 
 
 "Dr. Graily Hewitt has always been remarkable as one of the most careful, well- 
 read, thoughtful, and conscientious Physicians in his department of practice. These 
 quali'ies give great literary value to his treatises; they are completed by the careful 
 and intelligent application which he has made of his clinical study of a large body of 
 cases, and it would be difiBcult to name any work equally satisfactory in its completeness 
 of research, judicious discrimination of the grounds of diagnosis, and practical illua- 
 tration of all that can throw light upon the treatment of the diseases of women and the 
 diagnosis of pregnancy, both under ordinary and extraordinary cases. It is one of 
 the books which do credit to our literature." — Brilish Medical Journal. 
 
 "We know of no work on the Diseases of Women which we can with greater con«- 
 dence recommend. The various subjects are treated with a fulness and completeness ■ 
 which they have not heretofore received in this country, and which reminds us of the 
 exhaustive methods followed in some of the best works of French and German medical- 
 wriiers." — Lancet. 
 
 'To younger practitioners the book will be found to present a great charm in the 
 calm, thorough, and impartial examinations it enters into, of the various questions that 
 are still sub j'udice as to the pathology and treatment of some of the diseases to which, 
 women are subject." — Dublin Quarterly Journal. 
 
 "We would heartily commend Dr. Hewitt's work as a sound guide, not only in. 
 diagnosis, but also in treatment." — Ranking and Radcliffe's Half-Yearly Abstract. 
 
 " It is especially a safe and valuable guide to the practitioner." — British and Foreign 
 Medico- Chirurgical Review. 
 
 " Readers of the former editions will not require to be told that the additions now 
 made are of the highest possible excellence." — Times and Gazette. 
 
 " It is one of the most useful, practical, and comprehensive works upon the subject 
 in the English language, a true guide to the student, and an invaluable means of 
 reference for the teacher." — N. Y. Medical Record. 
 
 " The second edition of the excellent work of Dr. Hewitt presents in a form well 
 adapted to conduct the student to a knowledge of the Diseases of Women, and to assist 
 the young practitiou'-r in his study of tliese diseases at the bedside of the patient — a 
 very full and clear exposition of the views entertained by the most authoritative teachers 
 as to their patliological treatment and their correct Diagnosis. This commendation 
 applies especially to the present edition. Although the first edition was a particularly 
 excellent e.Kponent of the subject, the second, besides being brought down to a later- 
 date, presents a fuller and more systematically arranged account of the Pathology of 
 the diseases of the female in connection with their treatment." — Amer. Med. Journal. 
 
 Haberslioii on the Diseases of the Liver. 
 
 Their Pathology and Treatment. Being the Lettsonian Lectures, deliv- 
 ered at the Medical Society of London, 1 872, by S. 0. IIabershon, M.D., 
 Physician to G uy^ s Hospital, éc. Price, .... SI. 50
 
 LINDSAY AND BLAKISTON'S PUBLICATIONS. 
 
 Headland on the Action of Medicines in the 
 
 System. sixth American edition. 
 
 By F. "W. Headland, M.D., Fellow of the Eoyal College oj Physiciam^ 
 &c., &G. Sixth American from the Fourth London Fdiiion. lievi-t<ed 
 and enlarged. One Volume, octavo So.^O 
 
 Dr. Headland's work has bceu out of print in this country nearly two years, awp't- 
 ing the revivions of the author, which now appear in this edition. It gives the Oi)l3 
 Bcientific and satisfactory view of the action of medicine; and this not in the way of 
 idle speculation, but by demonstration and experiments, and inferences almost as in- 
 disputable as demonstrations. It is truly a great scientific work in a small compass, 
 and deserves to be the handbook of every lover of the Profession. It has received the 
 most unqualified approbation of the Medical Prf^s, both in this country and in Europe, 
 and is pronounced by them io be the most oriyinal and practically useful work that has 
 been published for many years. 
 
 Hille's Pocket An.^iomist. 
 
 Being a Complete Description of the Anatomy of the Suman Body ; for the 
 Use of Students. By M. "W. Hilles, formerly Lecturer on Anatomy and 
 Physiology at the Westminster Hospital School of Medicine. 
 
 Price, in cloth, $1.00 
 
 " ifl Pocket-book form, 1.26 
 
 Heath on the Injuries and Diseases of the Jaws. 
 
 The Jacksonian Prize Essay of the Eoyal College of Surgeons of Eng 
 land, 1867. By Christopher Heath, F.R. C.S., Assistant Surgeon ti 
 University College Hosjiital, and Teacher of Operatii^e Surgery in Uni- 
 ver sity College. Containing over \bO Illustrations. Octavo. Price, S'>. Of 
 
 Hodge on Foeticide, or Criminal Abortion. 
 
 By Hugh L. Hodge, M. D., Emeritus Professor in the Uni'jcrsity of 
 Pennsylvania. Fourth Edition. Price in paper covers, 30 
 
 flexible clo^h, 50 
 
 This little hook is intended to place in tlie hands oi professional men and others thp mépris of «cowering 
 ïatisfactorily and intelligently any iucjuiiiea that may be made of them in conueotioii .<i,h this important 
 niliject. 
 
 Holmes' Surgical Diseases of Ii7fancy and 
 
 C hlldhood. By J. PIoLMES, M.A., S'Uigejn to the Hospital fa-- 
 Si?k Children, (èc. Second Edition. Revised and Enlarged. Octavo. 
 
 Price, $7.50 
 
 Hufeland's Art of Prolonging Life. Eduedbv 
 
 Erasmus Wilson, M.D., F R.S. Author of "A System of IJuman 
 Anort-omy,'^ " Diseases of the Skin.^- &c., &c. 12mo. Cloth. $1.25
 
 LINDSAY AND BLAKISTON's PUBLICATIONS. 
 
 Hewsoii's Earth in Surgery. 
 
 EAKTH AS A TOPICAL APPLICATION IN SURGEET. 
 
 Being a full Exposition of its use in all the Cases requiring Toj/ical Appli- 
 cations admitted in the Men's and Women's Surgical Wardb of the Fenrir 
 sylvania Hospital daring a period of Six Months in 1869. With Four 
 full-page Photo-Relief Illuslraiioyis. By Addinell Hewson, M.D., one 
 of the Attending Surgeons to the Pennsylvania Hospital. 
 "What I'elates to Truth is greater than what relates to Opinion." — Bacon. 
 
 CONTENTS. 
 
 Preface; Introduction; Histories of Cases; Comments as to the Effects of the Contact 
 of the Earth; Its Effects on Pain; Its Power as a Deodorizer; Its Influence over Inflam- 
 mation ; Its Influence over Putrefaction ; Its Influence over the Healing Processes ; 
 Modus Operandi of the Earth; As a Deodorizer and over Putrefaction; In its Effects on 
 Living Parts. 
 
 In One Volume. Price, $2.50. 
 
 This volume presents the results of researches by the author into the 
 actions of Earth as a surgical dressing, and embraces the histories of over 
 ninety cases which occurred in the wards of the Pennsylvania Hospital some 
 three years since, but whose publication has been delayed until now, for the 
 double purpose of weighing them by subsequent expei'ience, and of inter- 
 preting their meaning by a careful study of the various subjects which they 
 involve. 
 
 The illustrations are introduced for the purpose of giving a demonstration as strong 
 as possible of the successes attending these experiments, and are from photographs 
 reproduced by a method that would seem to leave nothing to be desired as to perma- 
 nency, as well as faithfulness and accuracy of representation. 
 
 Opinion o/S. D. Gross, M.D., LL.D., Professor of Surgery in the Jefferson Bledical College, 
 
 Philadelphia. 
 
 I have perused with great interest and profit the work of Dr. Addinell Hewson, en- 
 titled "Earth .is a Topical Application in Surgery," and regard it as a highly valuable 
 contribution to the literature of the profession, destined as it is from the novelty of the 
 subject of which it treats to attract general attention, inquiry, and experiment. The 
 author has shown himself to be an original thinker, and the treatment which he is 
 laboring to introduce is worthy, as I can testify from personal observation, of a fair 
 and impartial trial. 
 
 April 6, 1872. 
 
 Extract of a Letter from Jos. Pancoast, M.D., Professor of Anatomy in Jefferson Medical 
 
 College, Philadelphia. 
 
 I am glad you have brought the subject so perfectly to the notice of the profession, 
 as Earth Treatment is destined hereafter to be one of the acknowledged resources of 
 Surgery. 
 
 March 2, 1872. 
 
 The cases conclusively show that, as a rule, the contact of the earth is cooling and 
 pleasant to the wound, reduces the pain, deodorizes, prevents putrefaction, and hastens 
 the healing process. These results are the highest possible testimonials in its favor. 
 No surgeon should neglect to read this evidence, the means being so simple and obtain- 
 able. — Medical and Surgical Reporter, March 23, 1872. 
 
 The subject is one of much practical importance, and the book will amply repay 
 both physician and surgeon for the time involved in its careful reading. — Ghicaga 
 Medical Examiner, March 1, 1872.
 
 LINDSAY AND BLAKISTON^S PUBLICATIONS. 
 
 Kirkes' Hand-Book of Physiology. 
 
 THE EIGHTH LONDON EDITION. 
 
 HAND-BOOK OF PHYSIOLOGY, by Will: am Senhocse KiRKEa 
 M.D. Seventh Edition, edited byW. Morrant Baker, F.R.C.S., Lec- 
 turer on Physiology, &c., &c. With 241 Illustrations. In one volume, 
 demy-octavo, containing over 800 pages. Price, bound in cloth, $.5.00, 
 
 Tbia edition of Br. Kirkes' Hand-Book of Physiology is fully brought up to the times, and forms oua of tho 
 most complete! and convenient Text-Books on the subject, for the Student of Medicine, now iu print. 
 
 Lewin on Syphilis. With Illustrations. 
 
 THE TREATMENT OF SYPHILIS with Subcutaneous Sublimate 
 Injections. With a Lithographic Plate illustrating the Mode and Proper 
 Place of administering the Injections, and of the Syringe used for the 
 purpose. By Dr. Georg Lewin, Prof essor at the Fr.-Wilh. University, 
 and Surgeon-in- Chief of the Syphilitic Wards and Skin Diseases of 
 the Charity Hosjntal, Berlin. Translated by Carl Prœgler, M.D., 
 late Surgeon in the Prussian Service and in the United States Army, 
 and E. H. Gale, M.D., late Surgeon in the United States Army. 
 
 In One Yolume. small Octavo. Price, . . . 82.25 
 
 Legg on Urine, the third london edition. 
 
 A Guide to the Examination of the Urine. For the Practitioner and 
 Student. By J. Wickuam Legg, M.D., Member of the Royal College 
 of Physicians, &c., &c. Third Edition. 16mo. Cloth. Price, 75 cts. 
 
 "Dr. LegK's little manual has met with remarkable success, and the speedy exhaustion of the first edition 
 tas enabled the author to make certain emendations which have added greatly to its value. VTe can now 
 confidently commend it to the student as a safe and reliable guide to such examinations of the urine as he 
 may be called upon to make.'" — London Medical Times and Gazette. 
 
 Lawson's Diseases and Injuries of the Eye, 
 their Medical and Surgical Treatment, wuh 
 
 Illustrations. By George Lawson, F.R.C.S., Surgeon to the Royal 
 London Ophthalmic Hospital, and Assistant Surgeon to the Middlesex 
 Hospital. In one volume, royal 12mo. Price, . . . $2.50 
 
 This Manual comprises a brief account of all the Medical and Surgical 
 Affections of the Eye, with the Treatment essential for their relief, each 
 subject being discussed in a separate section under its own peculiar head- 
 ing. The numerous and very favorable notices of the volume attest its 
 great value to the student. 
 
 Le Gros Clark's Outlines of Surgery and 
 
 Surgical Pathology, including the Diagnosis and Treatment of Obscure 
 and Urgent Cases, and the Surgical Anatomy of some Important Struc- 
 tures and Regions. By P. Le Gros Clark. F.R.S., Senior Surgeon 
 to St. Thomas's Hospital. Assisted by W. W. Wagstaffe, F.R.C.S., 
 Resident Assistant-Surgeon of, and Joint Lecturer on Anatomy at, St. 
 Thomas's Hospital. Second Edition, Pvevised and Expanded. Octavo. 
 
 Price, $4.25
 
 Meigs and Pepper on Children. :^ 
 
 FOURTH EDITION, ENLARGED AND IMPROVED. 
 The publishers have selected the following notice, from a late number of 
 the London Lancet, of the New Edition of this work, as indicating, per- 
 haps, more fully than any other of the numerous favorable criticisms that 
 have appeared of it elsewhere, its great value to the Pracliiioner and 
 Student of Medicine. 
 
 •'It is not necessary to say much, in the way of criticism, of a work so well known 
 as Meigs on Diseases of Children,' especially when it has reached a fourth edition. 
 Our duty is wellnigh restricted to the point, of ascertaining; how far, mider an old 
 color, it preserves the freshness and the value of a new book — how fai' it incorpo- 
 rates whai, is new with what is old without unseemly marks of mere joining. There 
 is some advantage in starting entirely afresh, in being merely clinical, or in being very 
 short, and limiting one's self to the expression of one's own views and experience. 
 But such is not the nature of this book, and the advantages of it are ditierent. It is a 
 work of more than 900 good American pages, and is more encyclopœdial than clinical. 
 But it is clinical, and withal most effectually brought up to the light, pathological and 
 therapeutical, of the present day. 
 
 "Tlie book is like so many other good American medical books which we have lately 
 ûad occasion to notice; it marvellously combines a résumé of all the best European 
 literature and practice with evidence throughout of good personal judgment, knowl- 
 edge, and experience. It is gratifying to see how our English authors are quoted, and 
 especially how the labors of Hillier, who died so prenuxiurely, are recognized. But 
 the book abounds in exposition of American experience and observation in all that 
 relates to the diseases of children. Not the least intere^-ting additions to the volume 
 are several extensive tables, exhibiting the mortality in Philadelphia of some of the 
 most common and fatal diseases in connection with the variations of the temperature, 
 and prepared with great care from the records of the Board of Health. 
 
 "The thoroughly fresh nature of the book is especially seen in the care with which 
 certain articles have been written. Such are those on Rickets and Tuberculosis, Infan- 
 tile Atrophic Paralysis, and Progressive Paralysis. No book now on diseases ef chil- 
 dren is complete which does not treat specially of constitutional or diathetic diseases, 
 such as rickets and tuberculosis, sypliilis, &c. 
 
 "Among other articles of great interest and value we would mention those on Dis- 
 eases of the Cœcum and Appendix Vermiformis, on Indigestion in Children, on Diar- 
 rhoea, on Entero-Colitis, on Intussusception, on Chronic Hydrocephalus, and on Croup 
 and the value of Tracheotomy. 
 
 "The difiiculties of editing a new edition of a medical book of some standing are 
 not more felt in the region of pathology and the classification of disease than in that 
 of therapeutics. In this work this difficulty has been fairly faced by the authors. 
 They have to confess to having changed their practice very materially in the treatment 
 of acute diseases, to having given. up mercury in most inflammatory diseases, and ahuost 
 given up bloodletting. We recommend the views of these authors as to the injurious 
 îffects of calomel and antimony to careful consideration. They do not entirely abjure 
 the use of bloodletting in certain cases of pneumonia and meningitis. Indeed, we 
 think they will find reason in future editions to talk a little less freely than they do 
 about bleeding and cupping very young children in certain circumstances of pneumonia, 
 and in certain cases of simple meningitis. With a few exceptions of this kind, the 
 therapeutics are sound and commendable, great importance being given to proper 
 feeding and the general management of infancy and childhood. It is due to authors 
 of so much fai'-ness and experience to publish widely their opinion of the injurious 
 and depressing effects of antimony in the inflammations of children. To infants under 
 two years of age they think it best to give no antimony even in pneumonia. They dp 
 lot use tartar emetic at all in the cases of children, but small doses, such as the twelf'.h 
 of a grain, of the precipitated sulphuret of antimony, every two, three, or four hours, 
 watching its effects, and withdrawing it quickly if symptoms of prostration appear, 
 perhaps without any vomiting. 
 
 "We are glad to add this work to our library. There are few diseases of children 
 which it does not treat of fully and wisely in the light of the latest^ physiological, 
 pathological, and therapeutical science." — London Lancet, July 23, 1870 
 
 I'rice, handsomely bound in Cloth . ... . . • . $lj 00 
 
 " " " Leather 7 00 
 
 LINDSAY & BLAKISTON, PUBLISHERS, 
 
 m IL À DELPUIA.
 
 Mackenzie on Growths in the Larynx. 
 
 With Numerous Colored and other Illustrations. 
 
 TriEiR History, Causes, Symptoms, Diagnosis, Pathology, Prognosis, 
 AND Treatment. Wilh Reports avd Analysis of One Eundred Con- 
 secKfim Gases treated by the Author ; and a Tabular Statement of evert) 
 published case treated since the invention of the Laryngoscope. By 
 MoiiELL Mackenzie, M.D., Physician to the Hospital for Diseases 
 of the Throat, author of " The Laryngoscope,^^ &c. Octavo, Price $3.00 
 
 "Dr. Mackenzie snows possession of what has buen well called ' the complete professional mind.' " — Tht 
 
 Lancet. 
 
 " The most complete and original essay on new formations in the larynx." — Medical Times and Gazelle. 
 " A model of honest and complete work, and honorable to British medicine, as it is useful to practitioner» 
 of every country." — Brilisk Medical Journal. 
 
 "This work will certainly at once take its place as the author's chief one, and on it alone he may be content 
 
 to let his reputation rest The book is as complete as it is possible to make it." — Medical Press. 
 
 "A storehouse of sound knowledge on the subject it treats." — Practitioner. 
 
 "The entire profession is under a deep obligation to Dr. Mackenzie for his really interesting, instructive^ 
 •Jid opportune essay." — Edinburgh Medical Journal. 
 
 " Contains a large amount of information which is of the very greatest value." — Glasgow Med. Jomiial. 
 
 " Of extreme interest and value, and reflects the greatest credit on Dr. Mackenzie." — Birmingham Med. Rev. 
 
 "The essay can hardly fail to increase Dr. Mackenzie's already honorable position as an accomplished 
 laryngologiet and instructor. We trust that the work will find readers, not only among physicians espe- 
 cially interested in the subject ol which it treats, but among general practitioners as well. They will find it 
 particularly free from the technicalities which often make works on special subjects dull reading." — Amer. 
 Journal of Medical Science. 
 
 " As a w'ork which contains much that is new and cannot be found elsewhere, we bespeak for it a welcome 
 in America. It contains the most perfect and satisfactory tabular record that any laryngoscopist ha« ever 
 presented to the profession." — JVew York Medical Journal. 
 
 "It is not ia mere compliment that we say that no practitioner engaged in the surgical treatment of laryn- 
 geal tumors can afford to forego the study of Dr. Mackenzie's volume." — New Turk Medical Record. 
 
 "This is certainly the chefd'ceurre of Dr. Mackenzie's productions The last and decidedly the best 
 
 section of the book is upon treatment. It is especially commendable for the perspicuity and fairness with 
 which it discusses the comparative merits of the different operations and instruments." — Phila. Med. Times. 
 
 Mackenzie on the Laryngoscope in Diseases 
 
 Of the Throat, with an Appendix on Rhinoscopy, and an Essay on 
 Hoarseness, and Loss of Voice. With additions, by J. SoLis Cohen, 
 M.D., Author of " Lihalation, Its Therapeutics and Practice,''^ &c. Il- 
 lustrated by two Lithographic Plates, and 51 Engravings on Wood. 
 Price $3.00 
 
 " The Use of the Laryngoscope in Diseases of the Throat, and Essays on Hoarseness, 
 &c., are two monographs of first-rate merit. Dr. Mackenzie's Essays would do honor 
 to any place ; and he has used tlie opportunities aflorded to diligence and skill to make 
 solid and enduring contributions to science and practice. Both works are, throughout, 
 models of honest and complete work, and are honorable to medicine, as thej' are useful 
 to practitioners of every country. The completeness of the clinical records, the abun- 
 dant graphic illustrations, and the fulness of bibliographical references, are excellent 
 features." — British Medical Journal. 
 
 Mackenzie's Pharmacopoeia of the Hospital 
 
 For Diseases of the Throat, containing upwards of 150 Formulée for 
 Gargles, Throat Collyria, Lozenges, Inhalations, éc, adapted for 
 Throat Diseases. Based on. the British Pharmacopoeia o/ 186T. In 
 Cloth, . $1.25
 
 LINDSAY AND BLAKISTON S PUBLICATIONS. 
 
 Meadows' Manual of Midwifery, a New Text-Book. 
 
 Including the Signs and Symptom.^ of Pregnancy, Obstetric Operations, 
 Diseases of the Puerperal State, éc, &c. By Alfred MEiJDOWS, 
 M.D., llember of the Royal College of Physicians, &c., &c. First 
 American from the Second London Edition. With numerous Illustra- 
 tions. Price, $3.00 
 
 "Those who read the first edition of this work will bear us out iu thinking that Dr. Moaduws's Manual 
 forms one of the most convenient, practical, and coucise books yet published on the subject. It was e8i)e- 
 cially good as a student's manual, and the author ha.s, iu his second edition, sought to make it of equal value 
 to the practitioner. The part which treats of obstetric operations has been well revised, and has received 
 numerous additions, uud the several chapters on Unnatural and Complex Labors likewise comprise much 
 new matter. Upwards of ninety new engravings have been inserted iu this edition, and, with a view to 
 facilitate reference, the author has furnished it with a very full and complete table of conteuts and iudex. 
 We can cordially recommend this manual as accurate and practical, and as containing iu a small compass 
 a large amount of the kind of information suitable alike to the student and practitioner." — London Lajicel, 
 May 6, 1871. 
 
 " This new edition of a book which was at once recognized as a good manual, is a considerable improve- 
 ment on its predecessor. It is eminently a book which will teach the student. . . . Not merely is the prac- 
 tical treatment of Labor, and also of the Diseases and Accidents of Pregnancy, well and clearly tauglit.but 
 the anatomical machinery of parturition is more effectively explained than in any other treatise that we 
 remember; and besides tliis, the book is honorably distinguished among manuals of Midwifery by the fid- 
 ness with which it goes into the subject of the structure and development of the ovum. Dr. Meadows has 
 done good seivice in giving a clear account of this subject in a very short space, yet with suiEcient fulness. 
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 mittee of the Hospital Staff, J. M. DaCosta, M.D., and William 
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 At last, however, the work has been commenced, the Philadelphia Physicians being 
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 No. 5. The Lymphatics or Absorbents. 
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 No. 9. The Textures. — Microscopic Struc- 
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 On account of their large size and the great distinctness of the figures on them, there 
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 The series, illustrating the whole Human Body, are life-size, each map printed on a 
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 No. 4. The Heart and principal Blood- 
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 Prepared under the direction of John Marshall, F.R.S., F.R.C.S., Pro- 
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 Price of the Set, Nine Maps, in Sheets, .... $50.00 
 
 " " " " handsomely Mounted on 
 
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 Though designed more, especially for purposes of general education, supplying an 
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 Containing, 
 
 1. A Report on the Condition of, and Advances made in, Plastic and 
 
 Orthoj)edic Surgeiy up to the Year 1871. 
 
 2. A New Classification and Brief Exposition of Plastic Surgery. 
 
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 Translated from the Second German Edition, by Wm. C Kloman, 
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 For the fii'st time since microscopical anatomy has become the basis of a true pathol- 
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 pathology has been limited to a comparative few who were familiar with the German 
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 an excellent guide, but actually the best which could be made available, either to 
 practitioner or student. It would be impossible, and it is indeed needless, to present 
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 lators has been well done, and although a few idiomatic sentences have crept into the 
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 physician or student should be without it. — Ptdladelphia Medical I'imes, Feb. 1, 1872. 
 
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 The scope of the whole work is thoroughly carried out, and to any one desiring a 
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 efficient guide. — BritisJi and Foreign Medico- Chirurg. Review. 
 
 Reynolds' Lectures on the Clinical Uses of 
 
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 FIFTH AMERICAN, FROM THE SIXTH LONDON EDITION. 
 
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 There is a common character about the writings of Dr. Tanner — a character which constitutes one of their 
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 THIRD AMERICAN EDITION, REVISED AND ENLARGED. 
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 Operative Dentistry. This gentleman's position as a teacher must have rendered him familiar with the most 
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 Lectures on Clinical Medicine, delivered ai the Hôtel-dieu, Paris. Bj 
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 reduced the price to Five Dollars per volume. 
 
 C'^NTENTS OF VoLUME L — TramlaUd and Edited by P. Victor Bazire, M. D., êçc. — 
 Lecture 1. On Venesection in Cerebral Ilœmorrhage and Apoplexy. 2. On Apoplec- 
 tiform Cerebral Congestion, and its Relations to Epilepsy and Eclampsia. 3. On 
 Epilepsy. 4. On Epileptiform Neuralgia. 5. On Glosso-laryngeal Paralysis. 6. Pro- 
 gressive Locomotor Ataxy. 7. On Aphasia. 8. Progressive Muscular Atrophy. 9. 
 Facial Paralysis, or Bell's Paralysis. 10. Cross-paralysis, or Alternate Hemiplegia. 
 11. Infantile Convulsions. 12. Eclampsia of Pregnant and Parturient Women. 13. 
 On Tetany. 14. On Chorea. 15. Senile Trembling and Paralysis Agitans. IG. Ce- 
 rebral Fever. 17. On Neuralgia. 18. Cerebral Rheumatism. 19. Exophthalmic 
 Goîtie, or Graves' Disease. 20. Angina Pectoris. 21. Asthma. 22. Hooping Cough. 
 
 23. On Hydrophobia. 
 
 Contents of Volume II. — Translated from the Edition of 1868 [being the last revised 
 and enlarged edition), by John Rose Cormack, M. D., Edin., F.R.S.E., êfc. — Lecture 1. 
 Small-pox. 2. Variolous Inoculation. 3, Cow-pox. 4. Chicken-pox. 5. Scarlatina. 
 6. Measles, and in particular its unfavorable Symptoms and Complications. 7. Rubeola. 
 8. Erythema Nodosum. 9. Erythema Papulatum. 10. Erysipelas, and in particular 
 Erysipelas of the Face. 11. Mumps. 12. Urticaria. 13. Zona, or Herpes Zoster. 
 14. Sudoral Exanthemata. 15. Dothinenteria, or Typhoid Fever. 16. Typhus. 17. 
 Membranous Sore Throat, and in particular Herpes of the Pharynx. 18. Gangrenous 
 Sore Throat. 19. Inflammatory Sore Throat. 20. Diphtheria. 21. Thrush. 
 
 Contents of Volume III. — Translated from the Edition 0/I868, by John Hose Cormack, 
 M.D., Edin., F.R.S E., ^c. — Lecture 22. Specific Element in Disease. 23. Contagion. 
 
 24. OzEena. 25. Stridulous Laryngitis, or False Croup. 26. Œdema of the Larynx. 
 27. Aphonia: Cauterization of the Larynx. 28. Dilatation of the Bronchi and Biou- 
 chorrhœa. 29. Hemoptysis. 30. Pulmonary Phthisis. 31. Gangrene of tlie Lung. 
 32. Pleurisy: Paracentesis of the Chest. 33. Traumatic Effusion of Blood into the 
 Pleura: Paracentesis of the Chest. 34. Hydatids of the Lung. 35. Pulmonary 
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 PEREIRA'S Physician's Prescription Book.— The Fifteenth Revised Edition. 
 
 REESE'S Analysis of Physiology.— Second Edition. 
 
 WYTHES' Pocket Dose and Symptom Book.— Tenth Edition, with Additions. 
 
 BARTH & ROGER'S Manual of Auscultation and Percnssion.-eixth Edition. 
 
 CLEAVEEAND'S Pronouncing Medical Eexicon.— Thirteenth Edition. 
 
 Eâ^GG'S Guide to the Examination of the Urine.— Third London Edition. 
 
 ÏÎIEE's Pocket Anatomist, for the use of Students. 
 
 TANNER'S Memoranda of Poisons. — From the Third London Edition. 
 
 RIGBIT'S Obstetric Memoranda. Fourth EdiUou. 
 
 yf complete Descriptive Catalogue of their Publications^ together 
 with a classified and priced list of all recent Medical Books^ American 
 and English^ furnished or mailed free on application.
 
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 Los Angeles 
 
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