of the breath, some profuse secretion of offensive saliva, and swelling of the cheek, are the first circumstances which are observed. The characters of the swelling of the cheek are almost pathognomonic. It is not a mere puffiness, but is tense, red, and shining-looking "as if its surface had been besmeared with oil, and in the centre of the swollen part there is generally a spot of a brighter red than that around. The cheek feels hard, and is often so unyielding, that the mouth cannot be opened wide enough to get a good view of its interior. The disease is almost always limited to one side, and generally to one cheek." Occasionally, it begins in the lower lip, never in the upper, but it may extend to either. "Whatever be the situation of the external swelling, there will generally be found. within the mouth, at a point corresponding to the bright red central spot, a deep excavated ulcer, with irregular jagged edges, and a surface covered by a dark, brown, shreddy slough. The gums opposite to the ulcer are of a dark color, covered with the putrilage from its surface, and in part destroyed, leaving the teeth loose, and the alveola denuded. Sometimes, especially if the disease be further advanced, no single spot of ulceration is recognizable, but the whole inside of the cheek is occupied by a dirty putrilage, in the midst of which large shreds of dead mucous membrane hang down. As the disease extends within the cheek, a similar process of destruction goes on upon the gum, and the loosened teeth drop out one by one. The saliva continues to be secreted profusely, but shows by the changes which take place in its character the progress of the disease. At first, though remarkable for its fetor, it is otherwise unaltered, but afterwards loses its transparency, and receives from the putrefying tissues over which it passes, a dirty, greenish, or brownish color, and at the same time acquires a still more repulsive odor. While the gangrene is thus going on inside the mouth, changes no less remarkable are taking place on the exterior of the face. The redness and swelling of the cheek extend, and the deep red central spot grows larger. A black point appears in its midst; at first, it is but a speck, but it increases rapidly, still retaining a circular form-it attains the bigness of a sixpence, a shilling, a half-crown, or even a larger size. A ring of intense redness now encircles it, the gangrene ceases to extend, and the slough begins to separate. Death often takes place before the detachment of the eschar is complete; and it is fortunate when it does so, for sloughing usually commences in the parts left behind. The interior of the mouth is now exposed, its mucous membrane and the substance of the cheek hang down in shreds from amidst a blackening mass," which exhales a horrible fetor. There is no acute pain throughout, the patient is generally rather drowsy, and death takes place quietly in most cases. No cause has been assigned for the occurrence of gangrene in this part; all that can be said is that a true mortification or death of the textures seem to take place, which is itself the primary evil, and not the result of inflammation, disease of the vessels, or obstruction of their channels. This is a good illustration of the doctrine we maintained, when speaking of mortification, viz: that it essentially consisted in a loss of the vital powers which maintain, in opposition to those of inorganic chemistry, the complex constitution of the animal tissues.

The tongue is liable to be affected by inflammation, or glossitis, as it is termed. This in some rare cases, said by Dr. Salter to occur most often in scrofulous persons, causes the formation of abscess. On the matter being evacuated, the tongue speedily returns to a healthy state. Sometimes a partial inflammation of the tongue is met with, the morbid process being confined to the portion of the base bounded in front by the V-shaped line of circumvallate papillæ. It occurs as an extension of tonsillitis, which we shall presently notice. Deglutition in these cases is seriously interfered with. The inflammation of the gums, which is produced by mercury, sometimes involves the tongue, and occasions, in some cases, very great and rapid swelling. It does not seem to have even produced suppuration. One variety of glossitis has been distinguished by the term erectile, by Dr. Salter. He describes "the morbid condition of the tongue in this disease as consisting in an enormous and rapid distension of the organ by blood, rendering it very large,

hard, and stiff. The distension becomes so great that respiration through the mouth is quite prevented, and even can with difficulty be performed through the nostrils. Though the congestion becomes so intense that the organ is of a dark black color, neither mortification nor abscess appears to have ever taken place. Free incisions give exit to the blood, and recovery ensues. Sometimes one-half of the tongue only is affected. In most cases it occurs in persons who are in perfect health, and without any manifest exciting cause."

Severe and deep ulcerations of the tongue may arise "from mere disorder of the alimentary canal," especially in debilitated persons. Some of these, attended with much induration, may bear a very close resemblance to cancerous ulcers. Constitutional syphilis produces small superficial circular ulcers, which sometimes extend in depth, and sometimes in length only. Rhagades or fissures result from the same cause; they often occupy the medium line in the front part of the organ; they may be mere cracks, or extend three-quarters of an inch in depth, with irregular ulcerated edges. Often, they are associated with tubercles of the surface of the tongue. These, which are admirably described by Dr. H. Salter, under the name of glossy tubercle, appear to be of the same nature as the syphilitic tubercles termed gummata. Ricord speaks of them as deep-seated tubercles of the subcutaneous areolar tissue, a

kind of chronic furuncles; and refers to two cases of recurring syphilis, in which the tongue was so full of them that it felt as if stuffed with nuts. According to the French observer, they produce horrible destructive ulcerations. Dr. H. Salter describes them "to consist in an effusion of lymph into the cellular tissue underlying the mucous membrane; this effusion is very dense, and raises and distends the surface of the tongue at the affected part above the surrounding portions; the effect is that the papillæ near it are opened out, and sometimes totally obliterated. Hence the surface of the tubercles is smooth, and, as they become absorbed, the papillæ reappear again.

The tongue is liable to be the seat of cancerous growths of the scirrhous and epithelial species. The former is described by Mr. Travers as at first being an irregular rugged knob, generally situated in the anterior third, and midway between the raphé and one edge. Ulceration sometimes takes place very rapidly; the surface at the same time throwing out luxuriant fungous growths: in other cases it "is very uneven, clear and bright granulations appearing in parts, and in others deep and sloughy hollows." In a peculiarly interesting case of epithelial cancer, carefully watched by Dr. H. Bennett, the first appearance. of the disease was a small ulcer on the margin of the tongue. This extended, in spite of its being shielded from the pressure of the teeth, and had hard, everted edges, undermined some way by ulceration. These became more ragged, and here and there over the surface some degree of suppuration and sloughing occurred. Much improvement followed the excision of the tumor-the wound healed favorably. Not long after, however, the glands under the jaws enlarged, and were removed; and, in about nine months after this, the disease returned in the tongue and proved fatal. The morbid growth which had been removed presented, on a transverse section, a tract of white, indurated, convoluted structure immediately below the ulcer, and above the muscular substance of the tongue. This indurated tract was half an inch thick posteriorly, and consisted of a fibroid structure inclosing debris of muscular fibre, and some of the characteristic circular loculi of epithelial cancer. The surface of the ulcer was covered with papillary elevations, which consisted chiefly of enlarged, softened epithelial scales splitting into fibre, so as to form a kind of fringe. This history shows, we think, beyond any doubt. that what Dr. Bennett would distinguish as cancroid, are in many, if not most cases, as true cancers as any of the other species. The circumstance mentioned by Dr. Bennett in his Appendix to his work is curious and significant, viz: that the enlarged glands beneath the jaw contained quantities of epithelial scales similar to those found in the primary growth. This indicates a potentiality in the blastema, absorbed from the epithelial tumor, to cause a reproduction of like cell-structure.

Fatty tumors and simple cysts are occasionally met with in the tongue, and Dr. Salter mentions the occurrence of pediculated polypoid growths, which seem to be of the nature of fibrous tumors, or, perhaps, in some cases of enchondroma. The tongue is liable to be affected by an extraordinary hypertrophic enlargement, in consequence of which it protrudes from the mouth, sometimes as much as two and a half inches. The

structure is altered, becoming much more dense than natural; but it has not been determined exactly in what the alteration consists. In one case, recorded by Mr. Liston, the enlargement of the organ seems to have been occasioned by the development of nævus-like structure. Atrophy of the tongue only occurs as the consequence of paralysis, from division of the hypoglossal nerve, or attacks of hemiplegia. It is, of course, confined to the affected side. Dr. Salter gives an interesting account of the morbid changes which the lingual papillæ undergo. The circumvallate papillæ may be hypertrophied, and form little tumors as large as peas. The epithelial caps of the conical or filiform papillæ may become extraordinarily elongated, so as to be half an inch long; they are of a dark color, and look exactly like little brown hairs. Minor degrees of this condition are, we think, not uncommon. The papillæ sometimes become atrophied. "Mr. Lawrence mentions the case of a person, in whom, from habitual drinking, the tongue was, for the greater part of its surface, destitute of papillæ : it was white, smooth, and opaque on the surface." Blood and lymph may be effused into the substance of the fungiform papillæ. The pus which so commonly collects on the surface of the tongue in disease, consists of detached, and more or less disintegrated epithelium, with varying proportions of amorphous matter. We can corroborate Dr. Salter's statement, that, in some healthy persons, the tongue is habitually furred. In very rare cases the frænum of the tongue is so short that it is quite tied down to the floor of the buccal cavity, and cannot perform its proper movements. Minor degrees of the same condition are not infrequent, and gradually improve of themselves. In the opposite condition, "the movements of the tongue are too free; it can be inverted, and its apex thrown back into the pharynx, which embraces it," and thus the access of air to the lungs through the glottis is prevented. The sides of the tongue have been known to become closely adherent to the internal surface of the cheeks.

The tonsils are a more common seat of inflammation and its consequences. In an acute attack they become more or less, sometimes enormously swollen, so as to impede the respiration. The pillars of the fauces, and the soft palate, are also involved in the inflammation. Suppuration often occurs, and is, perhaps, the best result, next to complete resolution; but more frequently, the imperfectly subdued hyperæmia produces actual enlargement, and fresh attacks recurring, a chronic hypertrophy of the gland is the result. We have examined some enlarged tonsils which had been excised, and found their structure to be quite identical with that of the healthy gland, so that the alteration constituted a true hypertrophy. It seems worth while to notice briefly the structure of the tonsils, which we think is not well understood, as it explains in some measure their great liability to hypertrophic enlargement. They are made up of a number of duplicatures and involutions of the mucous membrane, which, however, is differently constituted here to what it is in other parts in the vicinity. A vertical section shows the thin surface layer of scaly epithelium with a thick underlying stratum, consisting of nuclear, or very slightly developed celloid parti

cles. This layer is traversed by vessels, which are of capacious size in hypertrophied specimens, running up to the basement-membrane which supports the layer of scaly epithelium. When there is any habitual hyperæmia, and consequent exudation, this low submucous celloid growth readily assimilates the effused plasma into similar substance, and so the enlargement continually goes on. The morbid condition which most resembles it is enlargement of the Peyerian patches, which we shall presently describe. Induration not unfrequently occurs as the result of inflammation, and depends, beyond doubt, on a fibroid development of the exudation. Rokitansky says: "In scrofulous subjects the tonsils are often affected, in addition 'to hypertrophy and habitual hyperæmia, with a peculiar blennorrhoea, and the purulent secretion not unfrequently becomes inspissated, so as to form tubercular cheesy plugs, or even chalky concretions. These, in their turn, keep up a perpetual state of irritation in the tonsils.' Cancerous disease is very rare in this situation, but common indurated enlargement has often been spoken of as scirrhous.

II. MORBID CONDITIONS OF THE TEETH.

The brief summary that we shall give of these conditions is taken from the excellent work of Mr. Tomes on the subject, to which we must refer for fuller information. Malposition of the other teeth is scarce more than a disfigurement, but when the wisdom teeth take a wrong direction the effects produced are sometimes very mischievous. Those of the lower jaw cause more serious evil by their wanderings than those of the upper. Sometimes the tooth, though not deviating from its proper position, is held down by indurated gum. Esquirol mentions a case in which mental derangement depended on this cause. The wisdom tooth may take a false direction inward or outward, and cause by its pressure, ulceration of the tongue or the cheeks. It may grow directly forwards against the posterior surface of the second molar, which has proved the source of severe pain, resisting all treatment but that of extracting the offending tooth. Lastly, the tooth may advance against the coronoid process, causing disease and necrosis of the bone, and inflammation and abscess in the surrounding parts. The teeth are very liable to caries, which is an affection very much of the same kind as that occurring in bones. Mr. Tomes believes that "the dentine, from abnormal (nutritive) action, loses its vitality," and therewith becomes liable to be decomposed by the fluids of the mouth. It seems necessary that both conditions should exist, that the tissue should be dead, and that the oral fluids should be in an acid state, capable of dissolving it. Test paper applied to carious teeth almost invariably shows the presence of free acid. Healthy saliva is alkaline, while that of dyspeptic persons is prone to be acid, and it is in such that caries is most apt to occur. The enamel is, of course, first affected, but a very small perforation through this tissue may exist with a considerable amount of disease in the subjacent dentine. It appears that when the acid solvent has once