DECAY
TERM
DER
F
3:
W
198
THE
CAUSE AND PREVENTION
OF
DECAY IN TEETH
WALLACE

ARTES
LIBRARY
1837
VERITAS
SCIENTIA
OF THE
UNIVERSITY OF MICHIGAN
PLURIBUS UNUM
TUEBOR
SIQUAERIS PENINSULAM AMOENAM
CIRCUMSPICE
DENTAL
LIBRARY
1
DENTAL LIBY
RK
33
-W 19
1902
THE CAUSE AND PREVENTION
OF
DECAY IN TEETH
THE CAUSE AND PREVENTION
OF
118154
DECAY IN TEETH
AN INVESTIGATION INTO THE CAUSES OF THE
PREVALENCE OF DENTAL CARIES; TO WHICH
ARE APPENDED SOME SUGGESTIONS ON
ITS PREVENTION
BY
J. SIM WALLACE, M.D., D.Sc., L.D.S.R.C.S.
HON. DENTAL SURGEON WEST END HOSPITAL FOR NERVOUS
DISEASES; HON. DENTAL SURGEON PRINCESS LOUISE HOME AND
NATIONAL SOCIETY FOR THE PROTECTION OF YOUNG GIRLS;
HON. DENTAL SURGEON KINGSTON VICTORIA HOSPITAL;
ASSISTANT DENTAL SURGEON NATIONAL
DENTAL HOSPITAL, LONDON, W.

MEDICINA
LITERIS
SECOND EDITION
LONDON
J. & A. CHURCHILL
7 GREAT MARLBOROUGH STREET
1902
O
59.0
PREFACE TO THE SECOND EDITION
THE Second Edition is simply a reprint of the First,
together with the record of an experiment, originally
published in the Journal of the British Dental Association,
entitled "Experimental Demonstration of the Cause of
the Early Decay of Teeth.”
J. SIM WALLACE.
30A WIMPOLE STREET, W.
June 1902.
""
PRESS OPINIONS ON FIRST EDITION
We believe the conclusions are fair, and the day is not far
distant when the dental world will come to believe them as he
believes them. We believe no progressive, up-to-date Practitioner
of Dentistry ought to be without the book, to at least get the
measure of himself by it, or to model his views upon it."
Dental Headlight, U.S.A.
“MR. WALLACE ably champions his own views, and the work
has many points to stimulate thought; we can recommend its
perusal to our readers.”—Dental Record.
"If not absolutely convincing, is none the less of great importance
in calling a'tention to the dental dangers arising from our civilised
methods of preparing food."
Journal of the British Dental Association.
"DR. SIM WALLACE has advanced an ingenious theory to
account for the increasing prevalence of dental caries."-The Lancet.
"The work is the result of seven years investigation of a question
which has never been satisfactorily answered, and DR. WALLACE
is to be congratulated upon the result of his labours."
Birmingham Medical Review.
"MR. WALLACE has certainly written a readable manual, and
further, has brought forward a theory to account for dental decay,
now so prevalent, which seems novel, and yet likely to 'hold
water'
we have no hesitation in recommending this short
work to the attention of those who are interested in this important
question."-Dublin Journal of Medical Science.
•
1
PREFACE
UNDER the title of "The Etiology of Dental Caries," I
published a series of articles in the Journal of the British
Dental Association, which I am now publishing in book
form, together with an introduction and chapter on the
Prevention of Dental Caries.
I do so in order that the views which I have put
forward may gain further recognition, and in the hope
that the conclusions arrived at may form a rational basis
for the prevention of this most prevalent and painful
disease.
April 1900.
J. SIM WALLACE.
CONTENTS
CHAP.
INTRODUCTION
I. DENTAL CARIES AND ITS CAUSATION IN GENERAL
II. INFLUENCE OF HEREDITY
PAGE
1
3
19
III. CIVILISATION
32
IV. CAUSES OF IRREGULARITY OF TEETHI
42
•
V. EFFECTS OF IRREGULARITY
VI. RECESSION OF THE GUMS
VII. FOOD-STUFFS .
64
75
81
:
VIII. PREVENTION OF DECAY IN TEETH
86
INTRODUCTION.
THE etiology of dental caries is a subject which has
occupied the attention of physicians since the time of
Galen, and fortunately, especially in recent years, much
progress has been made in its elucidation. At the present
day the pathology of the disease is well known, and its
direct or exciting cause is all but universally recognised
to be chemico-parasitical. With regard to the direct
causation of the disease, therefore, I need say but
little. I intend to direct attention to the causes ΟΙ
conditions which lead up to the direct or exciting cause,
and to try to account for its extraordinary and increasing
prevalence.
During the last decade the importance of arriving at
a correct solution of the causes of the prevalence of this
disease has been widely recognised, and has brought into
existence many ingenious theories, none of which, however,
seem to be gaining the general assent of those interested
in the subject.
Although it has taken several years' investigation for
me to arrive at the explanation which I am now about to
advance, I believe its simplicity and its easy verification
will commend it, if not wholly, at least in part. Never-
A
2
INTRODUCTION
J
theless, I am quite aware that but few will for a time
admit its truth, for though, as far as I know, it is in
strict accord with current biological principles and
accumulated facts, it is admittedly rather at variance
with the currently accepted views among dental surgeons
and medical practitioners.
CHAPTER I.
DENTAL CARIES AND ITS CAUSATION
IN GENERAL.
THERE is fortunately much unity of opinion as to the
nature of caries, and the following definition by Dr. Miller
sums up what is currently accepted. He says, "Dental
decay is a chemico-parasitical process consisting of two
distinctly marked stages, decalcification or softening of
the tissue, and dissolution of the softened residue. In the
case of enamel, however, the second stage is practically
wanting.
99 *
Mr. Tomes makes the following summary of the direct
or immediate causation of the disease: "That caries is an
effect of external causes, in which the vital forces of the
individual play no part.
"That it is due primarily to the solvent action of acids
generated by fermentations occurring in the mouth, micro-
organisms playing no small part in the causation of those
fermentations.
"That once a breach being made by decalcification,
others, or it may be the same organisms, take an active
share in the further disintegration, partly by a peptonising
action upon the organic basis of the tooth, and partly
* Miller, "Micro-organisms of the Human Mouth," p. 205.
4
DENTAL CARIES AND ITS
perhaps by boring through and breaking up the softened
dentine.
Bearing in mind what caries is, we may next pro-
ceed to consider the conditions under which it takes
place.
A variable number of micro-organisms are always
present in the mouth, which, being a moist warm chamber
richly supplied with food, might almost be compared to a
well-devised incubator in which the micro-organisms
multiply. At some places-e.g., in the hollows of, and
spaces between, the teeth-these micro-organisms are
liable to be present in considerable numbers, and in these
places too a certain amount of the food which was
intended for the stomach is liable to lodge, together with
epithelial cells, salivary mucus, and débris from various
sources. When food and micro-organisms are left together
in the mouth fermentation is set up, the numerous pro-
ducts of which are given rise to. The products of the
oral micro-organisms vary both with the kinds of organisms
and with the nutritive media in which they live. In
general, if they live in an albuminous medium the products
are those of putrefaction, and give rise to an alkaline
reaction. In a saccharine, amylaceous, or mixed medium,
acid products are the result. When acid fermentation
takes place and a certain percentage of acid is formed
in the medium, the further production of acid is retarded
and ultimately stopped/when the percentage of acid
reaches about 75.†
* Tomes, J. and C. S., "Dental Surgery," fourth edition, p. 255.
+ Miller, "Micro-organisms of the Human Mouth," p. 14.
CAUSATION IN GENERAL
5
:
Although the products of the fermentation caused by
micro-organisins are numerous and diversified, our chief
consideration at present is with regard to the generation
of acid, for although the various products of fermentation
affect the gums and soft tissues of the mouth, and under
certain conditions of depressed vitality may give rise to
diseases, local and general, I intend to limit my remarks
at present to those products which have a solvent action
on the teeth.
Attention must be drawn to the action of the micro-
organisms upon the various food-stuffs which are consumed
by man. (1) Allnuminous food-stuffs or proteids. The
action of the mouth bacteria upon these is such as to
give rise to the products of putrefaction with an alkaline
reaction. They have consequently no solvent action on
the teeth, and, indeed, neutralise to a certain extent the
acids with which they may come in contact. (2) Fats.
The action of the mouth bacteria upon fats, as far as is
known, is practically nil. (3) Carbo-hydrates (starch and
sugar). The result of the chemical decomposition by the
micro-organisms of the mouth on this group of food-stuffs
is the production of acids, chiefly lactic, and various
other by-products which act but slightly and indirectly
upon the enamel. They will be referred to later. The
action of lactic acid is well known. It dissolves the
mineral matter of the enamel and dentine whenever it
reaches a certain degree of concentration. All enamel
is subject to its decalcifying action when it reaches a
certain strength. It may be assumed that the rapidity of
its action may be greater in badly formed enamel, though
6
DENTAL CARIES AND ITS
no definite experiments have as yet shown that badly
formed enamel is more rapidly dissolved than that which
is well formed. From a chemical point of view, the
mineral matters consumed as food have no effect upon
the teeth.
That it is the carbo-hydrates in certain forms which give
rise to caries of teeth receives support not only from the
facts revealed directly, and from experiments on fermenta-
tion of those substances under conditions similar to those
which prevail in the mouth, and from observations and
experiments in the mouth, but also from observations
which show that races which subsist largely on proteids
and fats are peculiarly free from caries, e.g., Esquimaux,
Maoris, Icelanders.*
I have also found among my own
patients that those who like meat, fish, and fat in prefer-
ence to carbo-hydrates almost invariably have relatively
good teeth, while those who are more addicted to sugary
and starchy foods are, as a rule, predisposed to rapid and
extensive caries. (This is a general statement, and other
causes and modifying conditions will be referred to
later.)
Caries is invariably initiated by the acid formed by the
action of micro-organisms upon the carbo-hydrates which
lodge after each meal in crevices and spaces between the
teeth, and is continued in similar manner, the decalcified
part acting as a more perfect receptacle for carbo-hydrates
and micro-organisms. The micro-organisms when in the
decalcified dentine also give rise to the destruction of its
* Mummery, Transactions of the Odontological Society, New
Series, vol. ii. p. 7.
CAUSATION IN GENERAL
7
organic basis. The rate of the destruction of the tooth
substance varies principally with the supply of carbo-
hydrates to the micro-organisms in the carious cavity. If
the orifice of the cavity is such that the supply of carbo-
hydrates is but small, the carious action is slow, and if, for
example, the supply should be practically cut off, as by the
extraction of a neighbouring tooth whose position previous
to extraction was such as secured a regular supply of carbo-
hydrates, the decay will cease altogether. There are other
circumstances which exercise an influence on the rapidity
of caries, such as the acidity or alkalinity of the saliva, the
perfection of the calcification of the teeth, &c., but these
are of little importance.
The several conditions which predispose to caries may
now be considered.
Firstly, the physical properties of the food-stuffs are of
considerable importance. Certain food-stuffs, as a rule, on
account of their physical properties, lodge about the mouth,
others do not. This may be easily seen by eating a
biscuit or a piece of cake and observing how many particles
lodge in crevices, while fibrous food-stuffs, e.g., stale bread,
fish or meat are not so liable to lodge. This statement
is made with a reservation, for in many mouths where the
teeth have taken up abnormal positions, and especially
when they have been imperfectly filled, teeth are particularly
liable to catch these fibrous food-stuffs. As regards the
common sites of caries in molars, meat, fish and fibrous
matter generally are less liable to lodge on the crown than
baked foods, especially those which are "short." I have
made some six hundred experiments to endeavour to find
8
DENTAL CARIES AND ITS
the food-stuffs which are more apt to lodge, but I do not
care to place any too definite stress on the results, as the
crevices examined were somewhat abnormal, inasmuch as
they had been filled, and so did not represent the normal
shape of the teeth. However, the experiments show that
cake, biscuits, bread, especially toasted bread, are very
liable to lodge from one meal to another, while raw vege-
tables, fruit, meat, fish, were by no means so apt to remain.
There was one place, however, the crevice formed by the
neck of the lower wisdom tooth, the edge of the gum and
the fold of mucous membrane of the cheek, which was
more liable to retain fish and meat. This position is,
however, compared with the crowns of molars, a relatively
infrequent seat of caries. The reasons for this will be
more fully accounted for if we consider the chemical com-
position of food.
There are some foods which from their physical properties
appear to clean the teeth, while others tend to leave a
coating over them. Soft, non-fibrous foods which do not
require to be chewed, especially those with much sugar,
leave the teeth with a coating in those parts which are
least rubbed by the tongue and cheeks. This is easily
noticed by observing the state of the teeth after eating,
e.g., chocolate or other kinds of soft sweets, or even milk
puddings. I have not been able to arrive at a conclusion
as to whether the viscidity of the saliva and oral mucus
tends to augment this: possibly it does.
There are some races which eat largely of fish from cer-
tain rivers which contain much fine sand; the effect of this
on the teeth is to wear down the crowns, and yet these
CAUSATION IN GENERAL
9
races are practically free from caries; for instance, some
North American Indians.* So also races which subsist
largely on roots, which, as they prepare them, are not only
fibrous, but gritty from the earth which they contain, have
teeth practically free from caries; for example, Kaffirs.*
It is noteworthy, too, that when sugar is obtained by
sucking and chewing the sugar-cane, no harm seems to be
done to the teeth, probably on account of the cleansing
action of the fibrous part of the sugar-cane, and on
account of the sugar being free from mixture with
matter which tends to lodge in the crevices of the
teeth.
The physical properties of fats in acting as lubricants to
the foods taken with them are probably of some impor-
tance. I have made numerous observations which seem to
me to indicate that the relative freedom from caries among
people who eat much fat is out of all proportion to what
one might expect if one considered fat as neutral in its
action on the teeth. Nor do I think that we can
account for this freedom from caries in fat-eaters by
the fact that these people may eat relatively less carbo-
hydrates.
That eating of fat is not conducive to caries, if it is not
positively inimical to it, has been proved by experiment by
Dr. Miller,† independent of any observations I have made,
and it may further be mentioned that races which subsist
largely on fats are peculiarly exempt from caries, e.g.,
* Mummery, Transactions of the Odontological Society, New
Series, vol. ii. p. 7.
+ Miller, "Micro-organisms of the Human Mouth,” p. 209.
10
DENTAL CARIES AND ITS
Icelanders and Esquimaux,* &c., and lastly, generally
speaking, caries is less frequent and less rapid in people
after the age when they begin to eat more fats.
The physical and chemical properties of the secretions of
the mouth probably exercise some influence on the causa-
tion of caries. The saliva, though normally faintly alka-
line, is frequently neutral or slightly acid, and sometimes
viscid.
This viscidity and chemical reaction may to a certain
extent be due to the by-products of the micro-organisms
which are fed and incubated in the mouth. In some
cases, for example in fevers, the influence of the buccal
secretions and general state of the mouth is marked, and
much harm may result to the teeth, but this is perhaps
principally due to the kind of food taken during such
illness rather than to the peculiarity of the secretions; one
of the most certain methods of inducing caries being to sip
constantly at liquid foods, and to dispense with the use of
the tooth-brush. The presence of micro-organisms in
numbers is also a condition that favours caries. It has
been shown that, when carbo-hydrates are lodged in a
dirty mouth, the rapidity with which acid is produced,
and also the quantity, are very much greater than if the
mouth had been previously cleansed with tooth-pick,
tooth-brush, &c. On the other hand, certain food-stuffs
which have been sterilised by boiling are much less liable
to give rise to acid than when unsterilised. Thus milk
which has been boiled may remain in the mouth for many
* Mummery, Transactions of the Odontological Society, New
Series, vol. ii. p. 7.
CAUSATION IN GENERAL
11
hours without giving rise to much acid, while unboiled
milk rapidly develops acid fermentation when lodged in
the mouth.
The length of time which elapses between meals seems
to have some influence on the initiation and rapidity of
decay. Millers as a rule have carious teeth, which is
probably due to the continual breathing in of flour dust,
&c.; so, too, have cooks and confectioners, who frequently
taste the foods they are preparing.
Some kinds of meals are undoubtedly more harmful
than others. Afternoon tea is as a rule very injurious to
the teeth. The infusion of tea is in itself harmless, but
the milk, the sugar, and the bread and cakes are all very
harmful, especially when taken with a liquid which enables
the consumer to take the meal with very little exercise to
the jaws. After such a meal as this the mouth is left in a
very excellent state for the development of acid, and for
the multiplication of the millions of micro-organisms in
the mouth. All sloppy meals, such as are often prescribed
for invalids, are seen to leave the mouth very much more
dirty than meals which require much chewing. Liquids,
when taken with food, are harmful when taken to soften the
food, but when taken in quantity, especially after meals, are
of considerable benefit in checking the formation of acid,
as they mechanically cleanse the mouth and dissolve some
of the carbo-hydrates which would otherwise have lodged
in the mouth.
The microscopical and chemical structure and composi-
tion of the teeth is often said to be a predisposing cause
of caries, but there is little to support this theory. Gene-
.
12
DENTAL CARIES AND ITS
·
rally speaking, the molar teeth, which are most highly
calcified, are most liable to decay. (Black,* Tomes,† Leon
Williams.‡)
The idea prevalent that in localities where there is little
lime salts in the water the teeth are imperfectly calcified,
and more liable to caries on that account, has no basis on
statistical data. The degree of calcification of a tooth in
no way influences the production of acids by micro-organ-
isms and carbo-hydrates. After caries has started, how-
ever, an ill-calcified tooth may probably be slightly more
rapidly decayed than one which is more perfectly calcified,
as the acid-forming micro-organisms have a more easy prey.
There are several conditions which favour the lodgment
of food and micro-organisms about the teeth. The natural
crevices of the teeth themselves are liable to retain many
of the food-stuffs which are commonly consumed at the
present day. If a mouth be examined in which the teeth
have all been filled at regular short intervals by a dentist,
it will be readily seen how faithfully caries originates and
progresses in these crevices. It will be noticed in examining
such a mouth that the fillings are invariably in such places
as are protected from friction by the tongue, by the cheeks,
or by the opposing teeth. Thus the rounded surfaces next
the tongue or cheeks, or the cusps which occlude with
opposing teeth, are practically never the seat of caries, but
the crevices between the cusps, or the crevices or pits on
* Black, "Dental Cosmos," 1895.
† Tomes, Transactions of the Odontological Society, New Series,
vol. xxviii. pp. 118 et seq.
Williams, "Dental Cosmos," 1897.
CAUSATION IN GENERAL
13
the surfaces of the teeth, are invariably the sites of the
fillings. Not only is this so, but the caries extends at first
as a rule in the direction in which the crevice runs. Thus
in the lower molar teeth the filling should be shaped like
a cross +, the dentist thereby not only removing all the
decayed matter, but also filling in the whole of the crevice
with a filling material which is not acted upon by the food
and micro-organisms which may lodge. If the fillings are
not made to fill the crevices, but only a circular filling
made when the caries is removed by the dentist, the result
is generally that in course of time the tooth becomes
carious in the crevice at the sides of the filling, and decay
proceeds till the filling or the tooth is lost.
So, too, fillings are frequently seen on the approximal
surfaces between the front teeth, and a broad smile or a
laugh by a person with such fillings is sufficient to show
the food which lodges in these situations after most meals.
If attention is now drawn to the lower front teeth it will
very generally be found that these are not filled and do
not require filling, because, on account of their shape and
the arrangement of the gum and the action of the tongue
in dislodging matter between the teeth, or causing a
current of saliva to pass between them, food does not lodge
there and undergo acid fermentation. This fact is the
more remarkable as these teeth are not so highly calcified
as the molars, and should, according to most of the current
theories on the causes of caries, be the most liable to be
attacked. When the crevices or pits in teeth are abnor-
mally deep the tendency for food-stuffs and micro-organisms
to collect is augmented, and the liability to caries is greater.
Uer M
14
DENTAL CARIES AND ITS
|
Teeth are, however, fortunately seldom what may be called
abnormal in shape, so that this is only occasionally a pre-
disposing cause of caries. The arrangement of the teeth
among themselves is, however, a very general cause of the
lodgment of food about the teeth. A normal set of teeth
is so arranged that food, at least coarse food, is but little
liable to lodge, but unfortunately few people have a regular
set of teeth. When the normal relation of one tooth to
another is broken it becomes a task of very much greater
difficulty to prevent the lodging of food, especially between
the teeth, and all the precautions which will be mentioned
later for the prevention of caries must be carried out much
more thoroughly than is necessary when dealing with a
regular set of teeth. It happens that to a great extent
the conditions which are favourable to the development of
caries are similar to those which favour irregularity. In
general, when the temporary teeth are well used by properly
masticating reasonably coarse and fibrous foods, they
remain sound till they are naturally shed. Moreover,
when the teeth are honestly put to perform their natural
function, the jaws grow, and so give sufficient room for the
taking up of the normal positions of the permanent teeth.
There is an unfortunate belief which seems to be current
that the jaw of man is not normally large enough for the
teeth; that in fact, in the transition from the large-jawed
savage to the small-jawed civilised man, the jaw has
diminished in size more rapidly than have the teeth. This
appears to be supported by the fact that the teeth of bull-
dogs are crowded and large relative to the jaw. Of course
in the case of dogs the effect of artificial selection is con-
CAUSATION IN GENERAL
15
fined to what is shown externally. In the case of man,
however, even though a small-jawed individual may be
presumed to be more beautiful and, cæteris paribus, more
liable to be preserved and have offspring, equally, however,
are small teeth regarded as beautiful, and might be sup-
posed to be equal factors in sexual selection. This subject
will be referred to more fully in chap. v.
The relative sizes of the teeth and jaws have little to do
with æsthetic considerations, and indeed the wisdom tooth
has diminished in size much more quickly than has the
jaw. The principal reason for the want of growth of the
jaw is the fact that it is not sufficiently used, and does not
develop to its normal size. The crowns of teeth, however,
being fully formed as regards size beneath the gum before
they are functionally active, the size of the teeth is inde-
pendent of the amount of use they are put to by the
individual. Hence a quick transition from coarse food to
soft food in one generation brings about a crowded and
irregular set of teeth, and an accompanying amount of
dental caries. The cause of the smallness of the jaws
compared with the teeth may easily be shown to be due to
the non-development of the jaw-bone through lack of the
proper amount of work being thrown upon it and the
tongue.
The exceedingly bad results of feeding children on soft
foods after they have got their temporary teeth may be
indicated by tracing what happens as a rule in these
circumstances. A child gets its temporary teeth, and
assuming even that they are not decayed, the teeth of the
permanent set replace the incisors, then the bicuspids
16
DENTAL CARIES AND ITS
displace the temporary molars, and the second molar
coming into place presses forward the first molar, as the
jaw has scarcely expanded enough to let it form and take
its position. Then at the same time the canine, which
forms deep in the jaw-bone, tries, as it were, to take up its
normal position, but is crowded out. The result is an
irregular set of teeth, and, the soft foods being continued,
caries is started in some of the spaces where food is so
very apt to lodge; one or more teeth become carious, and
further tend to make the patient stop masticating his
food and so cleansing his teeth in a natural manner. Two
or three years probably elapse, during which the mouth is
crammed with micro-organisms and liberally supplied with
food for acid fermentation.
When such a course of events takes place we need
hardly be surprised if a few of the teeth fall a prey to the
acid developed. What usually takes place, however, is
that the temporary molars are lost before their successors
are ready to take their places, and so the first permanent
molar slips still further forward. The space in the jaw
available for the twenty front teeth is made still smaller,
and the evil results are augmented.
The above is but a rough indication of a cause which
leads indirectly to the irregular position of the teeth and
consequent lodging of food and micro-organisms resulting
in caries. As children of the same family are usually
brought up on similar food, and their tastes are more or
less alike, caries is commonly more pronounced in some
families than in others, and as the initial causes are so
remote and difficult to trace, there is a popular impression
CAUSATION IN GENERAL
17
that the tendency to caries is constitutional. Caries is
also for similar reasons supposed to be hereditary, but
strictly speaking it is not. It is invariably acquired from
external influences, and is never inherent.
Another circumstance which gives rise to conditions
favourable to the lodging of food is recession of the gums.
When this takes place the space formed by the gum, the
buccal side of the teeth, and the buccal mucous membrane
is increased, and food is apt to lodge. The spaces between
the teeth are also increased by the recession of the gums,
and food is more liable to lodge here too. It is princi-
pally on this account that these are more commonly the
sites of caries among adults, and less frequently in child-
hood and adolescence. The wearing of artificial dentures
is also a frequent cause of caries by lodging food-stuffs and
micro-organisms about the teeth. In this respect metal
plates are more objectionable than vulcanite, inasmuch as
they are never made to fit sufficiently closely to prevent
the lodgment of some food, and are generally held in place
by bands which clasp the teeth, and destroy them quickly
or slowly according to the amount of food which accumu-
lates about the bands. Vulcanite plates held up by metal
bands are harmful in the same way, but may, however, be
made to fit so accurately when worked from a plaster
impression that bands are as a rule unnecessary.
Lastly, there are indirect causes which render the lodg-
ment of food and consequent caries liable to occur. Many
people are careless in the use of means to clean the teeth,
using neither tooth-pick, brush, nor powder, either from
ignorance, carelessness, or laziness. During many illnesses
B
+
18 DENTAL CARIES AND ITS CAUSATION
the lassitude which they induce often gives rise to a
certain amount of negligence which is not wholly natural
to the patient. Hence during illness or pregnancy this
cause acts more pronouncedly than at other times.
The prevalent erroneous beliefs that caries is hereditary,
that it is constitutional, that it is due to civilisation, all
tend to make people careless, and cause them to leave
their teeth to fate, or at the best, to their dental surgeon.
Fortunately caries is no more constitutional than small-
pox or measles, no more hereditary than frost-bite or
tattoo-marks. All are the result of external causes. Nor
is civilisation, strictly speaking, a cause of caries. But
upon the subjects of heredity and civilisation I intend to
dwell more fully in the following chapters.
*
CHAPTER II.
INFLUENCE OF HEREDITY.
THERE are many theories at present in vogue which
attempt to elucidate the cause of the increased frequency
of caries of the present day. Chief among these is the
theory of the degeneracy of teeth. The belief in the
inherent degeneracy of teeth has taken such a hold of
many authors that they have gone still further, and
advanced a theory to explain the cause of the supposed
degeneracy. A favourite explanation has been the theory
of the inheritance of acquired characteristics; the belief
that in the development of the body in infancy the over
pressure of intellectual education has deprived the teeth
of their due proportion of nutrition, has also had its
advocates; and recently another theory, that the abnormal
temperature of the food given to infants acts injuriously
on the developing teeth, has been advocated by Mr. Cantlie
in the attempt to explain this degeneracy in teeth.† The
belief in the degeneracy of teeth due to the inheritance of
acquired characteristics might be held by those few who
still cling to the theory that acquired characteristics are
* Smale and Colyer, "Diseases and Injuries of the Teeth,"
Introduction, p. xii. and p. 146.
† Cantlie, Brit. Med. Journ., Sept. 2, 1899, p. 5. 2.
20
INFLUENCE OF HEREDITY
inherited, were it not for the fact that the injury pro-
duced on the teeth by caries is essentially a mutilation,
caused chiefly by acid, and it is now many years since the
idea that mutilations were transmitted was altogether
abandoned.
With regard to the developmental theory, I shall take
the liberty of quoting from a recent article in the British
Medical Journal on the subject, by Mr. James Cantlie,
M.B., F.R.C.S., with whom, in what I am about to
quote, I quite agree.
He says:
"The developmental
idea is a favourite theme; it is even seriously discussed by
persons of respectable scientific attainments. The idea is,
that in our quest after education, we are attracting a
superfluity of blood to our brains and thereby starving
our teeth and our jaws. A very pretty theory indeed, but
it is not true."
Whether it is that dentists, in their endeavour to make
an explanation of the increased prevalence of dental caries,
have concentrated their attention on the teeth, and have
been unable to look outside the teeth themselves for the
causes of caries, or whether they have been confused by
the loose use of the word degeneracy, I can hardly say.
To
say that the prevalence of caries is due to the defective
constitution of the tooth is a convenient way to evade
giving a scientific answer to the question. But it has yet
to be discovered and proved that the constitution of the
teeth of, say, the Icelanders in any way differs from that
of the English, or in what respect the constitution of the
teeth of the present day differs from that of our ancestors.
Certainly the hygienic conditions of the English of to-day
INFLUENCE OF HEREDITY
21
Q
compare favourably with those of our forefathers or of the
Icelanders; and as a matter of fact, the teeth of the
present day are as perfectly formed from a chemical and
microscopical point of view as are the teeth of those races
which are practically free from caries.
In considering this subject it is well to observe what is
meant by degeneracy of teeth. In one sense the teeth of
civilised peoples may be called degenerate, inasmuch as
they are deteriorated by the ravages of caries; but this of
course cannot be called a cause of caries, otherwise we
should be calling caries the cause of caries. This error is
only fallen into by a few writers on this subject, and the
degeneracy in teeth is considered by most authorities to
mean a structural defect in the constitution of the tooth
which renders it liable to be attacked by the acids which
the micro-organisms give rise to in the mouth. Structural
defects do occur, and when they take the form of pits or
crevices, certainly facilitate the lodgment of carbo-hydrates
and micro-organisms, and so give rise to caries; but these
structural defects occur amongst the uncivilised as
frequently at least as among the civilised.
Mr. Tomes says, "It would really almost appear as
though bad teeth were inherited with more certainty than
good teeth."*
This is apparently quite a general belief.
The fact of the matter is that the teeth are inherently
just as excellent in structure as they were generations
before. Hereditary peculiarities, which may or may not
favour the lodgment of food and micro-organisms, may be
assumed to exist, but the reason for the increased preva-
* Tomes, “Dental Surgery,” p. 253.
22
INFLUENCE OF HEREDITY
•
lence of caries is due to the fact that food-stuffs are
gradually becoming more apt to lodge in the mouth on
account of their physical properties being changed; all
coarse, fibrous and gritty food-stuffs (which on being
masticated cleanse the mouth) being gradually superseded
by soft, fine, "short" and "sugar-coated" food-stuffs,
which, on being squashed in the mouth, get jammed
into all the crevices of the teeth to be worked into acid
by the micro-organisms which are lying in wait for their
appetising repast.
I wish now to deal more particularly with the subject
of heredity in its relation to caries in teeth. Professor
Weissman, who is perhaps the most generally accepted
authority on heredity, makes the following definition :
"By the term heredity is simply meant the well-known
fact that living organisms are able to produce their like,
and that the resemblance between a child and its parent,
although never perfect, may nevertheless extend to the
most minute details of construction and functions.” * If
we accept such a definition (which is true, whether, we
believe in Prof. Weissman's conclusion or not), then
heredity refers to the fact of a certain resemblance
spring to parent.
off-
If we consider, as scientists do, that heredity is the
potentiality of organisms or of their germ-plasm, by
which certain peculiarities are repeated generation after
generation, we cannot at the same time say that it is the
potentiality of the germ-plasm by which peculiarities
spring up in one generation which were wanting in pre-
*Weissmann, "Germ Flasm," p. 20.
INFLUENCE OF HEREDITY
23
vious generations. It is thus distinguished from spon-
taneous variation. Heredity therefore can in no way
account for the increased amount of caries at the present
day. As this point is of much importance and is generally
overlooked, I shall repeat this truth in different language.
Heredity refers to a fact, the fact of the resemblance of
offspring to parents, though what many authors claim as
caused by heredity is the supposed difference of the consti-
tution of the teeth of the present generation from the
constitution of the teeth of ancestors.
In speaking of the hereditary nature of disease, John
Hunter says: "I do not know that we have an instance
of observation which proves that the circumstance of a
person's having had the disease renders him more liable to
communicate that susceptibility to his offspring than if he
had only the susceptibility for the disease without the
action taking place. If it was a fact that the parents
having simply had the disease in some degree entitled
their offspring to it, the human species would soon become
extinct in those places where such diseases arose ;
and if
the parents having had the disease increased the suscepti-
bility in the offspring, both smallpox and lues would have
become incurable by this time. So that the immediate
cause, whatever this may have been, does not, in conse-
quence of its having had its full effect, either give, or even
add to, the disposition for such action.”* And the truth
of Hunter's observations is borne out by the attitude of
scientists at the present day.
Furthermore, it is generally admitted that the pre-
* Hunter's Works, Palmer's edition, p. 358.
24
INFLUENCE OF HEREDITY
disposition to certain discases among different races is
inversely proportional to the number of generations during
which the disease has been prevalent. Thus, for example,
malarial fever is less liable to afflict peoples who have for
generations lived in malarious districts; and measles is a
much more terrible disease to certain tribes where it has
recently been introduced than it is among ourselves, where
it has been prevalent for many generations.
There are two factors which influence the growth and
development of organisms; one is heredity, the other
environment. These factors are often confused. Let us
take a simple analogy which will bring out what I wish to
draw attention to. A chemist had a son who was also a
chemist. The father frequently had stains on his fingers
due to the falling of acid upon them. Likewise the son
had frequently stains on his fingers from the same cause.
We do not say that the stains were due to heredity or
any rent tendency, we say that they were due to the
acid or to the environment in which the chemists worked.
Nor do we say that the occupation which predisposed
them to have stained fingers (viz., the fact of each being a
chemist) was inherited. So, too, when speaking of the
decalcification of the enamel by the acids produced by
micro-organisms. The cause of the decalcification is due
to the acid, and the predisposition to the presence of acid
must be sought in the conditions which favour its presence
and development. Only the other day I observed what
appeared to me another instance of this confusion of
heredity and environment. Dr. Black, while combating
the theory that the predisposition to caries exists in the

INFLUENCE OF HEREDITY
25
teeth themselves, continuing, says: "I suppose the here-
ditary predisposition of certain families to caries has been
so generally observed that it will not be questioned, and
only needs mention. In the practical consideration of
cases as they are presented to us when we have the care of
families of children, the hereditary predisposition to caries
is of the first importance." *
I think he has been misled by not observing that what
he calls a hereditary predisposition is really an environ-
mental one, otherwise he would hardly have advanced the
theory that the predisposition to caries is due apparently
to the hereditary character of the oral secretions. This
belief has certainly as little to commend it as the one he
combats, since the environment of the teeth is altered
directly and indirectly by every food-stuff which enters the
mouth, and the oral secretions are influenced by the foods
directly and indirectly, by the micro-organisms directly and
indirectly, by the odour of food, and even by the thought
of it. I think any one will be able to produce the gelati-
nous coating he refers to as necessary for the initiation of
caries by eating sweets, as mentioned in the last chapter.
We are certainly not justified in expecting a predis-
position to the formation of acid to exist in the enamel,
which is a wholly inorganic substance. We are therefore
compelled to admit that the predisposition exists solely
in the environment of the teeth. I have observed numerous
cases, of some of which I have a written record taken
when the teeth were either particularly ravaged by, or
particularly free from, caries, and in no case have I found
* Black, "Dental Cosmos," September 1899, p. 829.
26
INFLUENCE OF HEREDITY
an instance where the food-stuff's which were usually con-
sumed were not, as far as I could judge, sufficient to
account for the freedom or otherwise from caries. And I
am strongly of opinion that even the rapidity of the caries
is almost solely due to the kinds of foods consumed,
together with the other conditions already mentioned in
the foregoing chapter, and not to any inherent defective
structure of the tooth itself. It will probably have struck
most dentists, and I have seen it commented upon in
works on dental surgery, that honeycomb teeth, which are
the most grossly defective that we ordinarily meet with,
are not apparently prone to rapid decay.
With regard to the fact that caries is generally found
to affect some families more than others, the principal
cause of this is that the foods consumed are, allowing for
individual tastes, generally the same, and the cleansing of
teeth is neglected or otherwise, according to the habits of
the parents. The fact that caries is often strongly marked
in certain families has given rise to the supposition that
there is a strongly marked inherited tendency, although
all that is strongly marked is the similarity of the environ-
ment, or, in other words, of the conditions-chiefly dietetic
-which prevail in certain families. This "inherited pre-
disposition" is supposed to extend to whole races, and is
apparently assumed to be due to defective developments.
Again, I must point out that the environment of the
teeth due to dietetic customs does produce a tendency
to caries, but that environment is not inherited. It
fortunately happens that most, if not all, races show
plainly that it is not any inherited racial predisposition
•
INFLUENCE OF HEREDITY
27
The
which is the cause of caries. Thus, for example, in the
Caucasian race, certain branches are peculiarly affected
with caries, others are almost wholly exempt from the
disease. The most interesting example of this occurs in
the Teutonic branch. The English have very carious
teeth, while in Icelanders caries is almost unknown.
American Indians show the same fact both in North and
South America; some have practically no caries, whilst
others, chiefly living in cities, have a considerable amount.
So it is with the Mongols. The Chinese have carious
teeth; the Samoyedes are practically free from it.
Professor Wedl says: "If it be true that geological
and climatic conditions, and the means of subsistence
which are connected with the same, have such a prepon-
derating influence in respect of the frequency of caries, then
it is impossible to explain the fact that foreigners belong-
ing to different races, who are exposed to the same con-
ditions with the native inhabitants, still retain the typical
structure of their teeth as well as that of their bodies, and
continue to furnish the proportion of dental caries peculiar
to their race.
This is found to be the case with the
isolated Sclavonic races of Austria, and the descendants
of the Celtic race in France.” * Let us first discover if it
be true that the foreigners belonging to different races
are exposed to the same conditions as the native in-
habitants. First, as regards the isolated Sclavonic races
of Austria. It is one thing to live in the same country,
and quite another to live under the same conditions.
Thus on turning to the "Encyclopædia Britannica," we
* Wedl, "Pathologie der Zähne," p. 323.
28
INFLUENCE OF HEREDITY
read, “The population of Austria is made up of a number
of distinct races, differing from each other in manners,
customs, language and religion, and united together only
by living under the same government."* From ethno-
graphical details it appears that the Germanic peoples,
generally speaking, centre round towns, unlike their
Sclavonic neighbours,† hence these Germanic peoples are
more subject to the influences of a "civilised" diet, living
as they do where there is an interchange of food-stuffs,
which are much refined.
As regards the Celtic race in France it is easy to show
that the food-stuffs, and consequent environment of the
teeth, are different from those of the rest of the popula-
tion. One of the principal industries of Brittany is
fishing. Fish is plentiful. Agriculture is in general in
66
(6
รา
"In-
a very backward condition." Dairy produce forms a
very important item in the food of the people.
dustrial pursuits, except in a few seaport towns, which are
rather French than Breton, have hitherto received little
attention. The Bretons are by nature conservative.
They cling with almost equal attachment to their local
customs and their religious superstitions." Thus it will
be seen that the customs of these Celts, even as regards
diet, differ considerably from the customs as regards
cuisine of the typical French. Moreover, ethnologically
there is not a great gulf between the French generally and
this more traditionally Celtic stock. The really great
"Encyclopædia Britannica," ninth edition, vol. iii. p. 118.
† Times Atlas, Ethnographical Map of Austria-Hungary, p. 46.
"Encyclopædia Britannica," ninth edition, vol. iv. p. 354.
INFLUENCE OF HEREDITY
29
gulf between them is principally linguistic, so that from
this point of view the argument that the French have bad
teeth, and the Bretons good teeth, must rather be taken
as an argument that the difference as regards caries is not
racial, but rather a difference due to dietetic customs.
As to Dr. Hitchcock's remark, on the other hand, that
"as geological, climatic, and social conditions exercise a
preponderant influence upon the growth and development
of the various races, mentally as well as physically, it is
evident that the development of the dental organs cannot
fail to be controlled by the same causes. In this country,
which is annually receiving large numbers of foreigners by
immigration, the typical traces of race are usually effaced
after the lapse of a generation or two, the descendants
possessing all the peculiarities, and their teeth apparently
being as liable to caries as the teeth of Americans
generally; "* it is well known to biologists that these
conditions do not exercise a preponderant influence on
growth and development; besides Dr. Hitchcock's state-
ment is absolutely contradicted by the negroes in his own
country (America) who resemble the African negro in
every physical and mental characteristic, while the whites
are almost indistinguishable from the whites of Europe.
On the whole, however, as regards dietetics, there is a con-
siderable similarity in the customs of the blacks and
whites of America, and a considerable amount of caries in
both cases. As regards the whites more especially, the
dietetic customs of the various peoples who emigrate to
* Wedl, “Pathologie der Zähne," translated by W. E. Boarman,
with notes by T. B. Hitchcock, p. 401.
30
INFLUENCE OF HEREDITY
:
the United States gradually change with the changes in
pecuniary circumstances in which the children more
especially are placed; and also as soon as they forget the
language of the nation from which they sprang, they lose
the customs of their nationality. Thus in a generation or
two, generally speaking, they adopt the dietetics and
customs of the Americans, and have carious teeth accord-
ingly. If the typical traces of racial characteristics were
effaced after a generation or two, or even after a score of
generations, due to geological, climatic and social con-
ditions, the sciences of anthropology and ethnology would
require to be reorganised. It is, in fact, the extreme
tenacity of typical racial characteristics, quite independent
of geological, climatic and social conditions, upon which
both of these sciences are based.
To prove how mistaken Dr. Hitchcock's remark is, we
find the English, in any quarter of the globe, retaining
essentially the typical characteristics of their English
origin (provided always there has been no intermarriage).
Notwithstanding geological, climatic, and social conditions
depending thereon, the Europeans of North America are
as distinct from the North American Indians as the
Europeans themselves. Intermarriage among other
Europeans in America will certainly tend to obliterate
the more minute racial differences. The mixture of Latin-
American and Anglo-Saxon American probably does
produce a somewhat different type from any to be found
in other parts of the globe. But the point which I wish
to insist upon is, that the people of America have caries
to an amount much exceeding the average amount of the
INFLUENCE OF HEREDITY
31
various races who emigrated to the United States. It has
not yet been shown that the development of the teeth has
suffered structurally by the crossing of the races, and
indeed instead of the crossing being a cause of degeneracy
in the structure of the teeth, resulting in caries in America
at the present day, it should rather be expected that there
should be less caries in that country, as according to the
laws of heredity when varieties of a species are crossed
there is a tendency to reversion to ancestral type.
It appears to me that there is no other explanation of
the excessive frequency of caries in the teeth of Americans
than that which attributes it to the kind of diet to which
they are addicted.
..
:
!
.
CHAPTER III.
CIVILISATION.
THAT the prevalence of caries among civilised people is
greater than among savages is a well-established fact, and
it is argued that civilisation is a predisposing cause of
caries. This supposed cause is too indefinite for any
practical purposes, and I shall endeavour to show that
although caries is intimately connected with the advance
of civilisation, the resulting caries is, as it were, an
accident, and need not be a necessary consequence of
civilisation.
In glancing over the history of the civilised from the
time of their uncivilised forefathers, it is obvious that
much of the advance has absolutely nothing to do with
caries in teeth. I think it will be admitted, however, that
if we direct our attention to the evolution of the means of
obtaining food, and of the processes to which foods are
subjected, the investigation may presumably be in a
profitable direction.
In the early periods of man's existence there was little
social cohesion, and each individual had to a great extent
to concern himself with securing food, and, when he had
the opportunity or inclination, with cooking it. It is
known, however, that cookery was indulged in from very
CIVILISATION
33
;)
early times. Even before the introduction of suitable
utensils which could be used for boiling over a fire, it was
to a certain extent managed by the introduction of hot
stones into the liquid foods, which were collected in what-
ever utensils were most convenient for holding them.
Methods were in use for roasting meat, fish, roots, nuts,
&c., which, together with fruit, seemed to have supplied
the needs of remote savages.
When we compare such a state of affairs with the
various methods of securing food at the present day, and
the elaborate machinery (flour mills, rice mills, sausage
mills, sugar refineries, meat juice factories, &c.) by which
many of the foods are refined, not to speak of the pro-
cesses to which foods are subjected in our bakehouses,
biscuit factories and kitchens, we see that there is some
difference in the food of the present day from that in past
ages. It may be said, however, that, after all, the food-
stuffs have not essentially altered. We require proteids,
carbo-hydrates, fats, water and mineral matter, much in
the same proportion as our ancestors, and this is what we
get. There is one change, however, which has gone on,
and is at the present time going on, till it has reached a
stage which is absolutely detrimental to the well-being of
the teeth, stomach, alimentary tract and body generally.
There is a gradual elimination of all the coarse, fibrous,
inert and undissolved earthy matters which are present
more or less in the food of savages. The teeth are no
longer used and burnished by these natural tooth brushes
and tooth powders, and the stomach and intestines no
longer have their movement sufficiently stimulated by the
34
CIVILISATION
!
natural excitation of the food-stuffs.
66
By many,
the
effects which should be secured by innutritious matter are
secured by the daily use of aperients in order to keep the
intestines in proper condition, and by as many the teeth
are kept in a fairly good condition by an annual visit to
the dentist. That there may be authoritative support for
much of the above, I shall quote from Sir Henry Thomp-
son's work on "Food and Feeding." Remarking on
whole wheat meal bread he says:
no portion of
the husk of the grain should be removed from the wheat
when ground, whether coarsely or finely, into meal. That
a partial removal is systematically advocated by some as
an improvement, is one of the numerous illustrations of
the modern and almost universal craze which just now
exists among food purveyors of almost every description,
for eliminating all the inert or innutritious matter from
the food we eat. This extraordinary care to employ
nothing in our diet but matter which has nutritive value,
that is, can be absorbed into the system, is founded upon
want of elementary knowledge of the first principles of
digestion.
And again, “It seems to me now to
be almost overlooked that no proper action of the in-
testines can take place unless a very considerable quantity
of inert matter is present in our daily food, existing as
material which cannot be digested. .. When there is a
considerable proportion of this in the food the bowels can
act daily and regularly, having a mass which they can
transmit. When, on the other hand, the food is so
' nutritious as to be almost entirely absorbed, there is
* Thompson, “Food and Feeding,” tenth edition, p. 78.
""*
CIVILISATION
35
A
very little solid matter to transmit, and the action of the
bowels is therefore scanty, irregular and insufficient. This
is, in fact, a very extensively recognisable cause of a great
deal of the habitual constipation so prevalent among the
middle classes at the present time."*
That a craze for eliminating the inert matter should be
so universal when it is detrimental to the well-being of the
body may well cause surprise. Why should the craving
for the nutritious only have sprung up? The answer is
simple. The nutritive instinct is the most primitive, the
most fundamental, and the most ineradicable with which
we are endowed.† Throughout the whole course of
evolution, at least up to the advent of a moderately high
standard of civilisation, this desire for the nutritious and
aversion to the innutritious has been a beneficent instinct
to all who possessed it, for during all that time, however
strong was the desire for that which was nutritious, there
was always too much of that inert and coarse matter
which is now so necessary. It is unfortunate that this
instinctive preference for soft nutritious foods exists in so
marked a degree at the present day, when it is detrimental
to a certain extent, and I fear it must remain yet, for
multitudes of generations to come, a serious hindrance to
the prevention of caries. Whether reason and the know-
ledge of what is the correct thing, together with the
possible influence of fashion, based on physiological prin-
ciples, which may spring up, will counterbalance the evil,
time alone will tell. I need not point out in how many
* Thompson, "Food and Feeding," tenth edition, p. 88.
† Ribot, "Psychology of the Emotions," pp. 199 et seq., and 432.
36
CIVILISATION
ways this preference for the succulent and nutritious must
have been advantageous to primitive man, who required to
subsist to a large extent on roots, berries, grain and fruits,
supplemented by what little fish or meat he could secure.
It will suffice to note that he required to carry about with
him a larger and heavier digestive tract than does civilised
man,* and much of the energy which we can now utilise in
other ways was utilised by primitive man in extracting
nutriment from coarse, fibrous, and more or less nutritious
food-stuffs.
With the advent of civilisation there have come the
machinery and methods of preparation which strip even
the inner husk from the grain, and then grind this already
refined food-stuff to an impalpable powder (flour, maize,
rice, &c.), to be ready for further preparation by the
modern art of cooking. Other means are adopted for
extracting merely the juices of roots and plants (sugar).
Numberless examples will present themselves to the reader
which show how the carbo-hydrates especially are ridded
of the fibrous matters with which in the natural state they
are mixed.
In the case of children's food this process of
elimination is carried to a still greater extent, and many
children are brought up on softened derivations of food-
stuffs administered in the form of paps.
This fact, together with the instinctive dislike of fats
and preference for sugar, accounts almost wholly for the
relatively greater frequency of caries among children. I
need not pursue this subject further. It is tolerably clear
that what was at one time performed by the teeth and
* Spencer, "Principles of Sociology,” p. 46.
}
CIVILISATION
37
stomach is now too largely done by machinery and
cookery. The cause par excellence of the prevalence of
caries at the present day is the elimination of the fibrous
matter which accompanies the carbo-hydrates in their
natural state, and their presentation in a form which
readily lodges and undergoes acid fermentation in the
mouth.
It is important to note, however, that although the food
consumed at the present day is conducive to caries, it is
not conducive to inherent or developmental deterioration
of the structure of the teeth. The enamel is formed
below the surface of the mucous membrane, and is com-
plete in form and structure before it cuts the gum, and
although the teeth are unused or only partially used, there
is no reason to expect a deterioration of structure. Nor
do I believe that the temperature of the food given to
infants in artificial feeding* has the slightest influence on
the developing tooth germs any more than I believe that
the hands are imperfectly formed because they are sub-
jected to greater vicissitudes of temperature than the
clothed part of the body. This negative belief is sup-
ported inductively.
If it could be shown that a deteriorated structure of the
teeth had been advantageous to those races in which it
might be assumed to have originated, then perhaps by the
agencies of natural selection the structural degeneration of
the teeth might have been brought about. But this
assumption cannot be granted, and truly it would be most
Cantlie, "Early Decay of Teeth in Great Britain," Sept. 2,
1899, p. 592.
X
38
CIVILISATION
disheartening if we had to believe that the teeth of the
present day were so much deteriorated, that the hope of
regaining the perfection in structure of the teeth of
savages was only to be again arrived at by a process of
natural selection. We cannot believe in a degeneration of
the teeth themselves unless we wish to believe in the
inheritance and augmentation by inheritance of something
which is detrimental, an idea which has not even the
support of the theory of the preservation and augmentation
of useful characteristics through adaptive modifications.
It has been suggested that mixed feeders are more liable
to caries than people who subsist almost wholly on meat.
No doubt this is true, and it is important to recognise this
fact, but it is possible for people to be mixed feeders and
even vegetarians, and yet be little prone to caries, e.g.,
Polynesians, Fiji Islanders, East Indians (Mummery's
Tables).* It is impossible to make man a flesh eater.
except in certain latitudes. As far as my experiments on
the lodgeability of food-stuffs in the mouth go, there are
certain mixtures which do not tend to lodge in the crevices
of the teeth as much as some unmixed food-stuffs. Thus,
for example, meat and potatoes, or meat and bread, are
much less liable to lodge than are potatoes or bread separ-
ately. When fibrous food is chewed together with non-
fibrous, the non-fibrous is swallowed first, and the fibrous
follows after further chewing. This fact may be easily
observed while eating meat and potatoes, the potato being
swallowed a considerable time before the meat, which
* Mummery, Transactions of the Odontological Society, New Series,
vol. ii. p. 7.
CIVILISATION
39
requires to be chewed longer. During the process of
mastication the bolus is crushed again and again between
the molars and bicuspids, and the part which has been
partially softened is pressed between the dorsum of the
tongue and the rugæ of the palate. The fluid and finely
ground part, which is principally carbo-hydrate from the
potato mixed with saliva and the other juices, is pressed
backward to be swallowed, while the roughened surface of
the dorsum of the tongue arrests the passage backwards of
the fibrous part of the food by pressing it against the rugæ
of the palate. The tongue then returns this fibrous part
to the side of the mouth to be further disintegrated. If
an unsavoury simile may be used, this process may be
likened to the mopping up of the dirt and water from a
floor which is being cleaned; the fibrous mop or cloth is
rubbed on the floor, and the water and dirt which it
gathers up are wrung out into the bucket, and the mop
again applied to the floor, the dirt and water soaked up,
and the process repeated. This is essentially Nature's
method of cleaning the teeth, and is, I believe, more effi-
cacious than a tooth-brush, as it polishes the surface of
the teeth and creates a healthy flow of saliva while
removing the non-fibrous food-stuffs. This latter function
is not performed by the tooth-brush.
The same remarks are applicable to fibrous food-stuffs
which contain much starch and require to be chewed.
From a physiological point of view also, the fibrous matter,
which in the natural state is incorporated with starchy
food, ought to be retained, as this necessitates a thorough
mastication, and so allows the ptyalin of the saliva to act
40
CIVILISATION
upon the starch, and supplies at the same time the requi-
site inert matter for the proper action of the bowels, as
well as supplying the requisite cleansing matter for the
teeth. Certain mixed foods, however, do lodge in the teeth
when eaten together, e.g., biscuit and cheese, both being
non-fibrous.
With regard to food-stuffs in which the coarse and
fibrous parts are removed, the beneficial function which
these fibrous parts perform in the cleansing of the teeth is
lost. In eating a biscuit, for instance, a considerable part
of it is crushed into the crevices of, and between, the teeth,
and there is no natural method for its removal.
Another effect produced by the elimination of the coarse
and fibrous parts of many food-stuffs is to encourage the
habit of swallowing the food without much mastication.
This is especially the case with children who are brought
up on soft foods, and there are, I believe, many people
who are so accustomed to eating food that requires little
chewing, that they often swallow food unchewed which
otherwise would be subjected to a certain amount of
mastication. Of course in such cases the teeth are not
thoroughly cleaned, and caries is liable to be more fre-
quent.
Now, although civilisation has brought about the
removal of Nature's tooth-brush, it is, as it were, an
avoidable accident caused by a "want of elementary
knowledge of the first principles of digestion," and if we
look into the more or less distant future we can easily
perceive that civilisation will bring back, in some form or
another, that which it is at present so careful to remove,
CIVILISATION
41
and we may look forward to the time when the food of
the civilised may be less conducive to caries than the food
of the uncivilised is to-day. Moreover, there is good
ground for believing that with more exact knowledge of
the causes and prevention of caries, it may one day become
as infrequent as many diseases at one time so prevalent
and now so rare.
CHAPTER IV.
CAUSES OF IRREGULARITY OF TEETH.
In the following chapter I intend to direct attention to the
forces which conspire to bring about a regular set of teeth,
and to try to arrive at some satisfactory explanation of
the causes of irregularity, as irregularity is admittedly a
predisposing cause of caries, or, as I should prefer to put
it, a condition which facilitates the lodgment of food and
micro-organisms.
Firstly, I shall refer to the general law that functional
activity is antagonistic to growth. I shall assume that
the reader is acquainted with this principle, and need say
no more on this subject at present than merely to mention
that, during gestation, developmental activity is at its
maximum and functional activity at its minimum. Akin
to this is the fact that, when from disease or other cause a
person is confined to bed during the period of growth, a
considerable development in the length of the bones takes
place. Thus, increase in length of bone takes place inde-
pendently of functional activity. Furthermore, although
an organ or part of the body may be wholly or partially
disused for generations, this fact does not tend to diminish
the amount of growth in size or structural perfection, or
the functional activity of these organs or parts in future
CAUSES OF IRREGULARITY OF TEETH 43
generations (A. R. Wallace,* Weissmann †). Thus, though
the ladies of China have for generations had their feet
bound up and their normal growth prevented, and though
their feet have been practically functionally useless
throughout life, their children are born with perfect feet,
which grow and are as useful, perfect and large (if they
are not subjected to pressure from bandaging) as their
mothers' feet ought to have been. I refer to the above
principally to point out that the comparative non-use of
the jaws at the present day is a wholly inadequate explana-
tion of their want of development.
Were these the only principles we had to deal with, the
jaws would grow to pretty much their normal size and
shape independent of their functional activity. But there
is another consideration which we must bear in mind,
that in certain tissues and organs full development is not,
as a rule, attained without a normal amount of functional
activity.
This is perhaps best seen in the development of muscle.
In this case the development is, to a great extent, depen-
dent on the amount of use to which the muscle is put, as
in muscle there exists the potentiality for a certain amount
of hypertrophy or atrophy according as it is used or
unused. In the case of bone there is no hypertrophy or
atrophy in length under similar conditions. There is
obviously some utility in this hypertrophy or atrophy
according as the muscle is used or unused, and this power
must be conceded to have been acquired by the germ
* Wallace, "Darwinism," p. 413 et seq.
† Weissmann, "Germ Plasm," p. 392.
44 CAUSES OF IRREGULARITY OF TEETH
plasm and the potentiality transmitted hereditarily. On
the other hand, beyond the effect which greater use would
necessitate in developing bone of attachment, and thicken-
ing it and strengthening it, the utility for the acquiring
of the potentiality of hypertrophy or atrophy would be of
little or no use in bone, and we find it is, as a matter of
fact, non-existent as regards development in length. The
reason for referring to the above will be observed after
further consideration of other circumstances.
Another consideration to which I would call attention
is the fact that in bilaterally symmetrical parts variations
are generally bilaterally symmetrical, and normal varia-
tions, as well even as abnormal ones, are carried out to the
most minute details on both sides of the body. It seems
as if the potentiality for developing such parts was
originally one and the same process; the two sides remain
as it were under essentially one denominator, though they
are as absolutely different as the right and left hands.
However difficult it is to imagine by what means the
germ plasm brings about this remarkable bilateral sym-
metry, there is apparently something conceivable in it,
and, as a matter of fact, we know that bilateral symmetry
is brought about to a very great degree of nicety, though
it is perhaps never quite perfect. It might be conceived
that, if the jaws were formed by some such method as
might be supposed to follow from metameric homology, a
certain very definite amount of concomitant variation
might be common to both, and so might bring about
the accurate antagonism of the teeth which is so necessary,
but as the jaws originate from buds from the first visceral
CAUSES OF IRREGULARITY OF TEETH 45
arch, neither bilaterally symmetrical nor metameric varia-
tion can help to bring about the perfect arrangement and
antagonism of the teeth.
I think we are left with no alternative but to assume
that, as far as direct hereditary influence is concerned in
the production of the necessary arrangement and relative
sizes of the antagonising teeth, there is nothing but corre-
lation in growth to fall back upon.
When we consider that, in order to get an efficient
masticatory organ it is necessary that all the teeth should
articulate with the greatest nicety, we are brought face to
face with one of two alternatives: either the correlation of
growth of the upper and lower jaws and teeth must be
extremely exact and definite, which it is not, or there
must be some controlling influence common to both,
which, as it were, guides the teeth to their exact position
and arrangement. Nature seems not to miss any means
of arriving at the desired result, and I believe both
methods are utilised. From some observations which I
have made, the concomitant variation of the upper and
lower teeth, except in the case of the wisdom tooth, is
fairly accurate. However, the arrangement of the teeth
is undoubtedly modified by one common denominator,
which is the tongue, together with the cheeks and lips.
The provision, which nature has accepted to a certain
extent, of taking the tongue as a common denominator for
the correlation of the arrangement of the upper and lower
teeth, is the chief cause of the crowding and irregularity
of the teeth of the present generation; because the tongue
does not attain, as a rule, at the present day to its normal
46 CAUSES OF IRREGULARITY OF TEETH
size, on account of its functional activity falling far short
of normal. The food of the present day is ridded of its
coarse and fibrous material, the amount of mastication to
which it is subjected is relatively little, and the amount of
use to which the tongue is put during the process is much
less than when foods were subjected to the relatively great
amount of mastication required before the advent of civili-
sation.
When we remember what has already been said on
muscular hypertrophy and atrophy it will be obvious that
the muscular fibres are not so thick and numerous as they
would be if the tongue were put to ten times the amount
of use which it gets when "civilised" foods are masticated.
I have paid some little attention to the size of the
tongue in mouths in which there was a large and well-
developed arch of teeth, and also in cases in which the
arch was contracted, with the result that to all appear-
ances those people who had large tongues had also well-
developed arches of teeth, and in those cases in which the
tongue was large, the ordinary diet was one which required
a considerable amount of mastication.
I had intended making a series of measurements of the
breadth of the arches of teeth of savages, as I conceived
that on account of the greater amount of use in mastica-
tion to which the tongue was put, and the consequent
greater size of that organ, that the size, and especially the
breadth, of the arches of teeth of savages would be greater
than the size of the arches of teeth of the civilised, and
more especially than those of the upper classes, who do
not give their tongues a normal amount of use in mastica-
CAUSES OF IRREGULARITY OF TEETH 47
tion. Fortunately, however, I discovered that this had
already been done, and as the measurements were made
independently of the theory which I am putting before
you, they may the more readily be accepted as sub-
stantiating it.
Dr. Talbot has collected a great number of measure-
ments of the breadth of the upper jaw, or rather of the
breadth between the outer sides of the first molars. In
the case of the measurements of skulls of savage races
collected in various American and European museums, the
average breadth was 2.28 inches, while in the measurement
of living persons, who were almost all civilised, the average
breadth was 2.14 inches. I have not endeavoured to get
results suitable for my argument by taking any special
cases recorded by Dr. Talbot; he himself says, "In com-
paring the measurements of the uncivilised races with those
of the civilised, it will be observed that the jaws of the
former are much larger than those of the latter."* And
again, "There is also a marked difference between the
diameters of the jaws of dispensary patients and poorer
patients and those observed in private practice among the
wealthier classes."† He also points out that "the early
Britons possessed [upper] jaws which measured from 2·12
to 2·62 in their lateral diameters, while the jaws of the
English people measure from 1.88 to 2.44 inches."† Dr.
Talbot also points out that among the Europeans the
Cretins of Switzerland have large jaws.† This, according
* Talbot, “Etiology of Osseous Deformities of the Head, Face,
Jaws, and Teeth," p. 67.
† Ibid. p. 66.
48 CAUSES OF IRREGULARITY OF TEETH
to my argument, is to be accounted for by the fact that
the tongue among these people is large. The Cretins are
doubly interesting in furthering the theory that the tongue
gives rise to enlargement of the arch of the teeth, of the
alveolus, and perhaps of the rest of the jawbone, as in
other respects they are a small and ill-developed people,
and they do not use their jaws much in mastication. The
tongue is, however, pathologically large. The Esquimaux
too have relatively broad and well-developed jaws, but in
this case the size of the tongue, and so of the jaw, is
brought about normally by their having to masticate an
almost wholly fibrous (meat and fish) diet, which generally
requires an excessive amount of chewing, being often eaten
raw. The stature of the Esquimaux is otherwise small.
Now, although Dr. Talbot arrives at the conclusion that
the diminished size of the jaws at the present day is due
to the crossing of races, his statistics are much more
adequately explained by the fact of the diminished size of
the tongue depending on the diminished amount of masti-
cation among the civilised. Moreover, his conclusion is at
variance with the law that crossing of races tends to rever-
sion to ancestral type. I may state here that I fully admit
hereditary, family, and racial differences in the size of the
arches of teeth, though combating the theory that the
diminished size of the arches of teeth in civilised races is
due to anything but the diminished use, and consequent
size, of the tongue. Were I writing specially on the
irregularity of teeth as a subject in itself, I should enter
into this subject much more fully, as it is specially inter-
esting in showing that this acquired characteristic is not
CAUSES OF IRREGULARITY OF TEETH
49
inherited. In the meantime I must content myself with a
mere outline of what I believe to be the true theory of the
causes of the crowding and irregularity of teeth, as it still
further strengthens my argument on the etiology of caries.
I shall now direct your attention to certain forces which
play an important part in modifying the position of the
teeth, namely, the forces arising from the increasing size
of the tongue. It is well known that continuous gentle
pressure on a tooth causes it to move away from the point
of pressure, and when a tooth is thus moved the alveolus
follows. I suppose all dentists will admit this, otherwise
the mechanical treatment of irregularity would be sheer
waste of time. The plasticity of the alveolar part of the
jaws is in fact so pronounced, compared with other bones,
that we must admit this to be a special hereditary charac-
teristic. With my way of looking at the subject this is
to ensure a regular arrangement of the teeth and an exact
antagonism, for, were the arches not to a certain extent
controlled by the tongue, the slightest variation in shape
of the upper and lower arches of teeth would make the
dental armature useless for its normal functions.
The modelling of the dental arches round the tongue
may now be traced. During the period of suckling the
tongue is much used in the process, and grows, and the
jaws, which at this time are almost all alveolus, grow
rapidly under this stimulus. Owen's remark is suggestive;
he says, speaking of the more intellectual as compared
with the lower races: "The fore-parts of the upper and
lower jaws, concomitantly with earlier weaning, are less
produced, and the contour descends more vertically from
D
50 CAUSES OF IRREGULARITY OF TEETH
the longer and more prominent nasal bones.”* During
the first six months, while the infant is suckling, the two
halves of the lower jaw are separate, and the growth of the
bone takes place in the fibro-cellular tissue connecting
them. If the tongue is well developed by its activity in
suckling, a stimulus is given to the development of bone
in the fibro-cellular tissue. The consequence of this is a
broadening of the jaw at its anterior part. As regards
the lower jaw, the effect of this is to give rise to greater
breadth in the neighbourhood of the mental prominence.
I have, as yet, not been able sufficiently to verify this
inductively, although the few cases I have investigated go
to show that the jaw in the region of the mental pro-
minence, that is, the part which is more especially in-
fluenced during the suckling period, is better developed
in those who have been naturally suckled during infancy.
Now, if the sucking process is made too easy, and the
tongue does not get a normal amount of exercise, I think
we are justified in the assumption that it will not grow so
fully as if it were put to a normal amount of activity.
At the present day ease in alimentation is fostered nearly
from birth. When, in place of the mother's breast, a
bottle and india-rubber teat are substituted, the hole
through which the milk is to be sucked is made too large,
so that the child may suck the milk quickly and easily.
If the hole in the rubber teat is made small the child takes
too long, and makes too much noise for the patience of
the mother or nurse.
Owen, "Comparative Anatomy and Physiology of the Verte-
brates," vol. ii. p. 569.
!
CAUSES OF IRREGULARITY OF TEETH
51
Now let us direct attention to the stage when the
temporary teeth are all in position and completed as far
as the crowns are concerned, that is, about the age of three
and a half years. At this period the arch of the teeth is
regular, and has been brought about in the following
manner :-The vital forces bring about the general arrange-
ment of the teeth, and as the teeth and jaws are correlated
in their growth, the positions which the teeth come to
occupy are to a great extent determined by vital forces.
Nevertheless, if we examine carefully the individual teeth
as they make their appearance through the gum, we note
that they are not so perfectly arranged as after they are
fully in position. That is to say, that without the aid of
a mechanical force (that is, the tongue, especially) the
arrangement of the teeth is imperfect. On coming
through the gum the incisors may be found slightly rotated
on their axes, or they may appear through the gum in a
rather more anterior or posterior position than may be
considered normal, and within a certain latitude they vary
as regards time of eruption. Although the correlation in
growth is sufficiently accurate for the lower teeth to appear
at intervals more or less constant from the appearance of
the corresponding upper teeth, yet this is not always
quite constant, and the lower may not precede or follow
the corresponding teeth of the upper jaw in the normal
time of succession; that is to say, the correlation in the
eruption and arrangement of the teeth of the upper and
lower jaws is not perfect. Now let us consider what happens
when, for example, some one or more of the incisors do
not grow up to meet the corresponding tooth of the upper
52 CAUSES OF IRREGULARITY OF TEETH
jaw in that most excellently regular arrangement which
they as a rule arrive at when the first dentition is com-
plete. Let us assume that one lower incisor is a trifle too
anterior, and the other a trifle too posterior. The action
of the corresponding upper tooth in biting soon presses
more strongly upon the more anterior lower incisor, and
this pressure is supplemented by the slight pressure brought
upon the upper tooth by the lip. Should the pressure
from the under tooth be so great as to slightly displace
the upper incisor forward, then the greater part of the
pressure of the lip is thrown upon this upper incisor, and
presses it backwards. Then the other lower incisor which
we have assumed to have erupted a trifle more posterior
to its fellow gets greater pressure from the tongue behind
it, and is not pressed upon by the corresponding incisor of
the upper jaw until it has been moved forward by the
pressure of the tip of the tongue. If there is any slight
lateral rotation this is rectified in a similar manner. If,
from muscular inactivity or other cause, the tongue falls
short of its normal size, it is obvious that the teeth will
not be forced out so much as they otherwise would have
been. Up to this stage, however, the variation in the
normal size of the tongue is slight, and so, notwithstanding
what has been said about the development of the tongue
during the suckling stage, only a trifling want of develop-
ment of the jaw can be assumed to have been brought
about by this cause. Now let us pass to the next stage.
Let us consider the stage when the deciduous teeth have
performed their function and are about to begin to be
shed. At this period it will be observed that there
CAUSES OF IRREGULARITY OF TEETH 53
arc.
generally are slight spaces between the teeth. It is
obvious that now the teeth occupy an arc of a larger
circle than they did when they first came into position and
were in contact. They consequently must have been
translated outwards, and the alveolar part of the jaw must
have grown outwards also. I do not say that this has
been a purely mechanical process, due solely to the increas-
ing size of the tongue, nevertheless the increasing size of
the tongue is certainly a factor, if not the chief one. It is
well known that the teeth yield in position to a constantly
acting force, and if the tongue did not grow normally, the
crowns of the teeth would not be forced into this larger
Not only do the crowns of the teeth come to occupy
a more forward position, or rather, a position in the arc of
a larger circle, than they did when first they came into
their fully erupted position, but the roots likewise occupy
the arc of a larger circle. How this force affects the latter
change may be elucidated by the following explanation :
the tongue presses upon the backs of, for example, the
lower incisors, and so tends to force the crown outwards;
this force acts upon the tooth at a certain distance from its
apex; the apex of the tooth is, as it were, fixed by the
opposing upper tooth, and so the pressure tends to push
the tooth bodily forward. To put it in mechanical
language, the lower tooth is a lever, the fulcrum is at the
apex, where it impinges on the upper tooth, and the power
which acts outwards is the tongue, the resistance is the
alveolus covering the anterior part of the root. In the
upper jaw, the top of the crown of the lower tooth which
is forced forward by the enlarging tongue is the power, the
54 CAUSES OF IRREGULARITY OF TEETH
་
lip pressing against the anterior surface of the lower part
of the upper incisor is the fulcrum, and the resistance is the
alveolus covering the anterior surface of the root. I do not
intend to indicate that this is the sole means of bringing
about the outward translation of the tooth, but it acts as a
guide to the vital forces in giving rise to the necessary amount
of absorption of the posterior surface of the alveolus cover-
ing the anterior surfaces of the roots of the incisor teeth,
which in its turn stimulates a deposition of bone on the
anterior surface of the alveolus. What part the develop-
ing crowns of the permanent teeth take in stimulating an
outward translation of the roots of these temporary teeth
it is difficult to say, but in any case the pressure of the
tongue on the teeth is the controlling force, and though
the vital forces might be supposed to produce a bodily
translation of the tooth, it is ultimately dominated by the
pressure of the tongue. I trust I have made it clear that
the teeth must have been translated bodily outwards, and
that, were it not for the growth of the tongue, the teeth
could not possibly have undergone the change in position
which is brought about.
During the few years that the deciduous teeth are
capable of full functional activity, what must be the effect
on the tongue of eating the soft pap, liquid extracts and
refined foods of the present day, which require little or no
chewing? I think it will be evident, from what has been
said on the influence of functional activity on the growth
of muscle, that the development of the muscular fibres of
the tongue is not as great as if it had been used while
chewing fibrous food-stuffs, which require at least ten times
CAUSES OF IRREGULARITY OF TEETH 55
*
the amount of mastication. The consequence of this is
seen in the fact that the deciduous teeth are sometimes
not translated outwards, and the spaces which should
develop between them do not form, and the alveolar arch
is not as broad as it ought to be.
In the next stage the temporary teeth are shed and the
permanent ones takes their place, and if the tongue has
developed normally, and the deciduous teeth have been
translated outwards, with the result that the alveolus has
also grown outwards, then there is every probability of the
permanent teeth taking up a regular position, even though
there has been an irregularity in their eruption, as
there frequently is. This is brought about by the same
forces as those which have been described as bringing
about the regular arrangement of the deciduous teeth. If,
however, the tongue has not developed sufficiently, and the
temporary teeth have not been translated outwards
together with the alveolus, the permanent teeth cannot
occupy this contracted arch without irregularity, as the
sizes of the crowns of the permanent teeth are considerably
greater than the crowns of the temporary set (excepting
the temporary molars). If the tongue has not developed
by a normal amount of activity, the teeth at the side of
the mouth are not forced outwards, but fall inwards.
Then the posterior permanent molars begin to take up
their position in an arch which is not quite large enough
to contain them, and the teeth which have fallen inwards
have this available space still further encroached upon by
the tendency to forward translation which these molar
teeth have. The result is inevitable, and is seen in
56 CAUSES OF IRREGULARITY OF TEETH
V-shaped and saddle-shaped arches, &c. Such a condition
often appears to be inherited, as parents, as a rule, bring
up their children in much the same style as they were
brought up themselves.
In further support of this theory of the causes of
irregularity, I would point out that irregularities are
most marked in the upper jaw, i.e., the normal expansion
of the upper jaw is not so great as that of the lower, and
this notwithstanding the fact that the amount of available
space for the teeth in the lower jaw is very markedly
limited by the ascending ramus. This is caused by the
tongue lying in the floor of the mouth, and although its
normal size is diminished, yet it keeps up a certain amount
of lateral pressure on the lower teeth and alveolus.
think this fact suggests the explanation of the external
cusps of the lower teeth frequently falling outside the
corresponding cusps of the upper jaw, and also the occur-
rence of underhung jaws.
I
There is a current assumption that the early extraction
of the temporary teeth gives rise to contraction of the
jaw, and although this belief is not shared by all authors,
there is certainly much clinical evidence which appears to
support it. It is a fact that in mouths where the
temporary teeth have been removed early there is, as a
rule, in later life a crowding of the permanent teeth which
take their place, but the removal of the teeth is not
the cause of the irregularity. The temporary teeth are
generally extracted early because of their being carious,
and caries is brought about by causes similar to those
which bring about insufficient development of the tongue
CAUSES OF IRREGULARITY OF TEETH 57
and the contraction of the jaws, viz., principally the
elimination of the coarse and fibrous matter from the
food-stuffs. Further, when the temporary teeth are pre-
maturely extracted, the outward pressure of the tongue is
diminished by the expansion of that organ where the gaps
exist, and consequently the remaining teeth are allowed
to occupy a slightly smaller arch than they otherwise
would have done.
Another fact of importance, when the teeth are not
used to masticate more or less fibrous food, is that
their upward growth from the alveolus is not completely
checked by the opposing teeth; that is, they are not
arrested by full functional activity. In childhood, if the
food consist of broths, milk puddings, and paps, there is
very little functional activity. The consequence of this
is that the teeth rise, as it were, in their sockets, and
the alveolus accompanies them. This is well seen in cases
in which the molars only occlude, and there is an open
bite. In this case the development of the alveolus at
the front of the mouth is very great, and I have no
doubt that the reader has seen an illustration of this
condition in the text-books on dental surgery.
My own observations show that a want of full use of
the teeth gives rise to high palate, and this is supported
by the fact that among patients of the upper classes-
who are brought up on soft, refined foods—a high palate
is much more frequent than among the working classes.
This tends to augment irregularity, as the space for the
tongue is vertically larger and the soft parts of the cheek.
press rather more on the buccal surfaces of the teeth
58 CAUSES OF IRREGULARITY OF TEETH
than does the tongue on the lingual surfaces under
normal conditions. More marked cases of high palate
are presumably brought about for the following reason.
Not only are the food-stuffs so soft that the downward
growth of the teeth and alveolus is not quite checked,
but also nasal breathing is not fully performed. The
mouth is kept almost constantly open, and so further
tends to allow of the downward growth of the upper
teeth. In these cases, too, the arch is always contracted,
as the force of the tongue acts principally only when the
mouth is closed, and this force, which normally holds the
teeth outwards, is to a great extent diminished, and
almost wholly lost as regards the upper jaw. Whether
only disease, such as enlarged tonsil, is the cause of this
mouth breathing, or whether the habit of nasal breathing
is not sufficiently enforced through a normal period of
normal suckling, I have so far been unable to find out.
Another point to which I wish to refer. When the
teeth are put honestly to perform their natural function,
and by the forces which have been referred to a fine
broad arch of teeth has been brought about, there is a
liability for slight spaces to exist, as in normally developed
mouths ample, though not lavish, space is provided for
the teeth. When there are slight spaces between the
molar or bicuspid teeth, food is apt to lodge, and the
teeth on the approximal surfaces are liable to become
carious. There is a provision for obviating this, and
through this provision the exquisite arrangement of the
teeth which we so rarely see in civilised countries is made
almost perfect. The molar teeth, after cutting the gum,
CAUSES OF IRREGULARITY OF TEETH 59
grow upward, and, if spaces exist in front of them, are
bodily translated forwards. I suppose all dentists have
seen numerous cases in which, for example, the second
bicuspids above and below have been extracted in youth,
the molar teeth have been translated forwards, and the
space completely filled up. This change of position, when
it occurs under normal circumstances, is not a tilting
forward of the crown while the apex of the root remains
stationary. The translation comes about, I believe, in
the following manner. There is a forward force which
is the resultant of the outward and slightly forward
pressure of the tongue, and the inward and forward
pressure of the buccinator muscle. (These are not
imaginary forces, as the mucous membrane of the cheek
at the side of and behind the hindmost molars is
frequently marked and indented by its pressure on these
teeth, and the marks caused by the pressure of the lower
teeth on the tongue may also frequently be seen.) The
resultant of these forces tilts the crown forward as we
occasionally see it in an exaggerated form, and then, if
the opposing teeth are not wanting, the posterior cusps
occlude with the antagonising tooth. Then there is also
the vital force which makes the tooth grow upwards to
meet its fellow, but as the posterior part of the tooth
is arrested by occlusion with the opposing cusps, the
only result of this is the rising of the anterior part of
the crowns, and by this motion the roots also are carried
forward. However beneficent this force ought under
normal conditions to be, under the very abnormal condi-
tions which exist among civilised peoples it becomes a
60
CAUSES OF IRREGULARITY OF TEETH
cause of irregularity, for if the normal arch has fallen
in, and is already too small, this force only tends to
increase the mischief; so much so is this the case that
we frequently see a tooth, for example a second bicuspid,
which has been forced inwards out of the arch altogether,
while the remaining teeth occupy a more or less regular
position.
66
I have not deemed it advisable to introduce special
cases to confirm much of what I have said; it might easily
be done, but it would be open to the objection that the
cases were selected to confirm my views. I shall therefore
content myself with referring to a case the models of which
were taken by Mr. Merryweather and are now in the
Museum of the Royal College of Surgeons. It is described
by Mr. Tomes in the Transactions of the Odontological
Society for April 1892.* The following extract from
Mr. Tomes' “Dental Surgery" will recall the case:
a bilateral asymmetry (which was ultimately met by the
extraction of a tooth on one side) had asserted itself at a
time when precisely the same teeth had been shed and
replaced upon the two sides. Another respect in which
the mouth was irregular lay in the height of the lower
incisors. These had grown up too high, in spite of the
fact that the upper incisors were vertical instead of being
inclined outwards; and so the lower incisors, so far from
having no opposing teeth, were driven to take a position
sloping inwards."† He further says, "Thus two forms
Tomes, "Studies in the Growth of the Jaws," Transactions
of the Odontological Society, New Series, 1892, p. 143 et seq.
† Tomes, "Dental Surgery," p. 60.
CAUSES OF IRREGULARITY OF TEETH 61
of slight irregularity occurred which could by no pos-
sibility be referred to merely mechanical causes.
**
Nothing is recorded about the amount of development
of the tongue, and as the models were taken recently, one
may be justified in assuming that the individual from
whom the models were taken had indulged in a “civilised "
diet, which means that mastication is reduced to a mini-
mum, and the tongue does not quite develop to what
might be considered its normal extent. We are justified
in assuming that the tongue was rather smaller than what
might be considered normal, as the arch of the teeth
gives a fairly accurate measurement of it, as it occupies
the space within the arch. Now what must be the effect
of a small tongue on the incisors? The crowns are not
forced or kept forwards, and the lower teeth, instead of
meeting the upper lying at an angle which would bring
the lower incisors into aĺmost direct contact with the
posterior bulge of the upper incisors, fall backwards and
meet with no resistance till they grow upwards and are
arrested by the pressure of the gum. (Normally the upper
incisors are kept from being pushed forward by having the
lower ends of their crowns held inwards by the lower lip,
and the lower teeth from being forced inwards by the
pressure of the tip of the tongue.) With regard to the
bilateral asymmetry, this, too, is susceptible of a mechanical
explanation, though not being sufficiently acquainted with
the case I will only hint that the amount of mastication
on either side was probably unequal, as it usually is.
From what I have said, it might be assumed that I
* Tomes, "Dental Surgery," p. 61.
62 CAUSES OF IRREGULARITY OF TEETH
believed the vital forces played a small part in the arrange-
ment of the teeth, but this would be a great mistake. I
only maintain that Nature does not scorn mechanical
forces when it suits her purpose to make use of them. It
is difficult to conceive what Nature could be supposed to
have been doing if it were assumed that irregularity of
the teeth had become an inherited characteristic. Surely
irregularity in the arrangement of the teeth cannot be
considered beneficial, and that being so, why should natural
selection be supposed to have chosen such a disadvan-
tageous peculiarity as a thing worthy of hereditary trans-
mission? If it be said that irregularity of the teeth had
come about by spontaneous variation, and the point being
of little importance it was allowed to be continued, my
reply is that variations from the ancestral type, when they
are neither good nor bad, do not get stereotyped, but
sink out of existence by continued amphimixis (e.g., poly-
dactylism); that is, in simple language, through dilution,
as it were, of the characteristic by intermarriage.* The
foregoing explanation of the common forms of crowding
of the teeth is not meant to be an exhaustive explanation
of all forms of irregularity, nor of the already well-
investigated method of the development of the jaw, but
merely to supplement the ordinary description with which
it is assumed the reader is acquainted, and to direct his
attention to the causes of the diminished size of the
arch of the teeth, and of the alveolus, among the civilised
races at the present day. Where my explanation is
contradictory to current theories I mean it to be so, and
* Weissmann, "Germ Plasm," Section "Amphimixis.”
CAUSES OF IRREGULARITY OF TEETH 63
however heterodox the explanation may appear to be, I
certainly maintain that it is in accord with biological
principles, and that therefore it is the current theories
on the causes of irregularity which really are behind the
times, if they are not heterodox. I further hope that I
have shown that there is some tangible cause of irregularity
which might be combated, and that the subject may some
day be extricated from the hopeless confusion that has
hitherto surrounded it.
In conclusion, I would point out that this lengthy
digression on the crowding of the teeth has been necessi-
tated by the absence of a rational explanation of its
causation, and to enforce still further the fact that the
elimination of the coarse and fibrous part of the food is
the principal cause of irregularity, and the consequent
lodging of food and micro-organisms, and therefore a pre-
disposing cause of caries.
CHAPTER V.
EFFECTS OF IRREGULARITY.
HITHERTO I have taken it for granted that irregularity of
the teeth predisposes to caries; I wish now to show why it
is a predisposing condition. In order to elucidate this
point I shall recall to the reader a condition which he may
have observed, or if not, which he may easily observe on
directing his attention to the subject. When caries starts
at the neck of a tooth it will be noticed that it com-
mences at a slight distance from the edge of the gum.
The part which exhibits, in the early stages, the maximum
amount of decalcification is removed from the edge of the
gum about a millimetre. Now, if the crevice formed by
the edge of the gum and the neighbouring part of the
tooth be filled with food, as it frequently is, it will be
observed that the greatest depth of food is immediately
under the gum, and not a millimetre from it. From this
it is presumable that the gum exercises an influence
antagonistic to the formation of acid. This is further
supported by the fact that at almost the same place in
certain mouths there is a deposit of tartar. However, the
tartar is deposited close to the gum, and in fact, if the
formation is not great, at the distance of a millimetre
from the gum there is no deposit of tartar at all. This
EFFECTS OF IRREGULARITY
65
may be easily seen at the neck of the canine, where either
of these conditions may be found with almost equal
frequency.
The observation of these facts led me to doubt the
truth of the curren statement that the secretion of the
gum was slightly acid. I therefore tested the reaction of
the secretion, and at first it appeared correct, but on
further testing I found that the reaction varied at different
parts-that, in fact, round the necks of the teeth the
reaction of the secretion after cleansing the mouth was
distinctly alkaline. This may be verified by moulding a
piece of wet litmus paper into the crevices at the gingival
margin.
The rationale, no doubt, of the slight acidity of the
secretion of the gums is to prevent to a certain extent the
flourishing of the micro-organisms of the mouth, and
although the alkalinity at the gum margin allows of a
rapid development of micro-organisms, the amount and
strength of the alkaline solution is in fairly clean mouths
sufficient to keep the teeth from destruction by acid pro-
duced in fermentation. It will be observed, however, that
it would only increase the number and activity of the
mouth bacteria if the secretion of the mucous membrane
at all parts were alkaline, as these micro-organisms grow
best in a slightly alkaline medium.* I think it will
be noticed that this distribution of acidity and alka-
linity is the best possible for the prevention of caries.
It suggests caution in using alkaline mouth washes.
* Goadby, "Bacteriology of the Mouth," Transactions of the
Odontological Society, 1898, p. 179.
E
66
EFFECTS OF IRREGULARITY
In the regular arrangement of the teeth the spaces
between them are V-shaped, the apex of the V being
directed upwards in the case of the lower teeth. The gum
bulges into this wedge-shaped space, and so very little
of the approximal surfaces of the teeth is more than a
millimetre removed from the gum when it has not receded.
Further, it will be observed that the piece of gum filling
this space presents a large surface of gum-and so secreting
surface to the approximal surface of the teeth, and we
may well be justified in assuming that the antacid or
neutralising action of this is two or three times as strong
as in the case of the eye-tooth at the spot referred to,
especially as the action of the lip is not so near as it is at
the buccal side of the neck of the eye-tooth.
If acid-forming food does lodge in these spaces it must
be small in amount, and not only is there the influence of
the gum to check the amount of acid formed where certain
foods lodge, but there is also the neutralising action of
the saliva, which, when mastication is thoroughly per-
formed, is constantly rushing through these spaces, and so
tending to dislodge any food or acid which may be there.
When, however, the arch of teeth is irregular, this V-shaped
interspace is nearly obliterated, and the teeth frequently
have a relatively long line of contact, or even a surface of
contact, extending from the neck of the tooth to near the
coronal surface. The beneficial action of the secretions of
the gum on the fermenting food, if it lodges in such places,
is at a greater distance than in the normal V-shaped spaces,
and there is a diminished gum surface to throw out the
alkaline secretion. Moreover, irregular teeth often lodge
EFFECTS OF IRREGULARITY
67
food-stuffs more readily than regular teeth. Another effect
of irregular teeth is to keep off the tongue and cheeks
from the less inwardly or outwardly projecting teeth, and
to diminish the amount of cleansing by the friction of the
tongue and cheeks and of the movements of the saliva over
certain protected parts of the irregular teeth.
While speaking of the influence of the gums in thus
being a prominent factor in the prevention of caries, I
may refer to the fact that some authors appear to blame
the secretions of the gums, not only for being slightly
acid, but also for being normally viscid and a cause of
caries. I can at will produce a viscid coating over my
teeth by eating sweets, and after having set others to do
likewise have found the same coating on their teeth. I
see no reason whatever to blame the gums for this condi-
tion, especially as cane sugar stimulates the secretion of
mucous and is known to undergo a viscous or mannitic
fermentation. Schützenberger gives the following equa-
tion, which will explain what theoretically takes place :
25(C12H22O11) + 25(H₂O)
Cane sugar
Water
12(C12H20O10) + 24(C¿H1406) + 12(CO₂) + 12(H2O).*
Gum
Mannite
Carb. diox.
Water.
No doubt this viscous gum acts as a very effective
barrier to the beneficent influence of the saliva, and as
this fermentation takes place along with lactic acid and
other fermentations, and the deposited gum acts as a food-
catcher, retainer, and acid fermentation protector, we need
scarcely wonder that there is a popular impression that
→ Schützenberger, "Fermentation," p. 292.
*
68
EFFECTS OF IRREGULARITY
sweets are bad for the teeth. It may here be observed
that sugar does not appear to be one of the lodgeable
food-stuffs, and when it is consumed quickly alone, or with
fibrous foods, little or no lodging results. But if it be
taken in the form of sweets, which gradually melt and are
swallowed, and if this be persisted in for some considerable
time, there is continuously a little converted into gum by
the viscous fermentation. This accumulates as long as
the eating of sweets is continued. It is impossible to
observe the coating after eating a little sugar when the
teeth are originally well cleaned, and in order to get the
gummy coating well marked it is necessary to eat sweets
more or less continuously for hours. Similarly when
grapes are eaten to a great extent, as in the "grape cure,"
the same results seem to be brought about by the con-
tinuous supply of sugar, and on account of the skins not
being chewed, and the presence of the pips encouraging
merely the bursting of the grape, practically no chewing is
performed, and the resulting effect on the teeth is injurious.
So, when infants are given a sucking-bag, to soothe them,
containing sugar and milk, there is rapid destruction of
the teeth.
The gummy deposit of the mannitic fermentation does
not become formed when cane sugar is taken even in
quantity if the fibrous part of the sugar cane is chewed
with the sugar, as the juices are swallowed before the
mastication is finished, and the fibrous part of the cane
cleanses the teeth more effectually than a tooth-brush in
the manner I have already pointed out, and further the
salivary and other secretions are sufficiently stimulated to
EFFECTS OF IRREGULARITY
69
be able to carry away the sugar before mannitic or other
fermentation has had time to take place. On the other
hand, the viscidity due to mannitic fermentation is seen in
an exaggerated degree when salivary secretions are more
or less arrested, as in some fevers.
Having shown in what manner the crowding of the
teeth very seriously increases the liability to be attacked
by caries, I shall now refer briefly to two theories of the
causes of crowding of teeth, which have gained currency in
our best text-books on dental surgery. I shall firstly refer
to the theory that children may inherit large teeth from
one parent while inheriting small jaws from the other.*
Were this theory true we might equally expect to find
teeth set widely apart through the inheritance of small
teeth from one parent and large jaws from the other; but
we do not. Mr. Tomes has brought forward evidence
which goes a long way to prove that the growth of the
body of the jaws is greatly dependent on the developing
teeth. On à priori grounds we may be justified in going
still further by saying that the size of the body of the jaw
is greatly dependent on the size of the crowns of the
developing teeth. The growth of the jaws
intimately associated, and from what has been already
said, we may be pretty certain that the teeth and jaws are
closely correlated in their growth. I think we are, there-
fore, compelled to dismiss this piecemeal conception of
hereditary transmission, just as we would discard any
theory of heredity which would have us believe that we
p. 40.
and teeth are
Smale and Colyer, "Diseases and Injuries of the Teeth,"
70
EFFECTS OF IRREGULARITY
might inherit the right leg from one parent and the left
from the other.
With regard to the second theory of the causation of
crowding, namely, the theory that sexual selection has
brought about a diminished size of jaw and a consequent
inability for it to afford room for ample dental arches,
Mr. Tomes, while admitting that much may be said
against the theory, argues as follows:-" For if the type
of face nowadays considered to be beautiful be investi-
gated, it will be found that the oval, tapering face with a
small mouth, &c., does not afford much room for ample
dental arches. On the other hand, the type of face which
we considered bestial has a powerful jaw development.
Perhaps generations after generations seeking refinement
in their wives may have unconsciously selected those whose
type of face hardly allows the possibility of a regular
arrangement of the full number of teeth.”*
Now on æsthetic points there is room for considerable
divergence of opinion, and I have no doubt there are many
artists who consider a well-developed chin and mental
prominence to be a characteristic which is certainly more
human than bestial, and that the broad dental arches
giving fulness to, and preventing the falling in of, the
cheeks, and consequent prominence of the cheek bones,
may help to beautify a face. So, too, full arches of teeth
prevent the inane appearance caused by the falling in of
the arch in the canine region. Nor is the oral orifice
necessarily large when the oral cavity is large; indeed, the
oral orifice appears somewhat smaller when the arch of
* Tomes, "Dental Surgery," p. 112.
EFFECTS OF IRREGULARITY
71
teeth is of normal breadth. Add to this the fact that
crowding of the teeth very frequently gives rise to
anterior protrusion of the upper incisors, and then add
the effects of the greater frequency of caries, toothache,
probable loss of teeth, possibly suppurating roots, anæmia,
digestive troubles, ill health, ill temper, &c., following in
their wake, and we may be justified in doubting whether
man did, generation after generation, select such types.
But let us look at the question from another point of view.
If there has arisen in man an unconscious preference for
small-jawed women, this must have come about in one of
two ways; either those possessing this instinctive prefer-
ence have survived, and the others, who did not possess it,
have fallen out of existence, or there must have been a
superorganic evolution of an ideal of beauty which was
more or less universally recognised. I think the former
idea is out of the question, and the latter would have no
appreciable effect, compared with the natural, inherent,
powerful passion which attracts the sexes. Since Darwin's
time, ideas on the subject of sexual selection have been
greatly modified, and with regard to mankind, further
than the effect which it has in selecting types with
qualities arising from full vitality, good health and its
concomitants, it has little effect, and it must always be
ultimately controlled by natural selection.*
Now let us consider what must have been the effect of
natural selection on the teeth since the advent of civilisa-
tion, or since many of the food-stuffs were more or less
ridded by machinery and injudicious cookery of their
* Wallace, "Darwinism," pp. 265 et seq., and 294.
72
EFFECTS OF IRREGULARITY
accompanying fibrous part. I have pointed out that this
gives rise to a diminished size of tongue, to a crowded and
irregular set of teeth, and to caries. We know that, when
an organ breaks down from the effects of disease, the
individual is at a disadvantage in the struggle for exist-
ence. That this is recognised with regard to the organs
of mastication need hardly be more than mentioned, as
already many civil, military and public appointments may
not be held by those who have bad teeth, and indirectly
the influence of diseased teeth on the general health is
only too well known. Unfortunately, too, the influence
on the general health may extend over the larger and
more important part of a lifetime. Now dental caries is
said to be the most prevalent disease that afflicts mankind,
and irregularity of the teeth is the rule rather than the
exception among the civilised. Since this very prevalent
condition of irregularity predisposes to caries and its con-
sequences, it will be obvious that those people who have
rather small teeth will be more likely to have a regular set
of teeth, as such teeth will be able to arrange themselves
round the small civilised tongue with regularity. Conse-
quently, since the advent of civilisation, and concomitant
refinement of food-stuffs, those people with large teeth were
likelier to be at a disadvantage in the struggle for exist-
ence through a considerable predisposition to a very pre-
valent disease, and so, on the whole, left fewer offspring
than did those with relatively small teeth. We should
also expect from this cause a correlative diminution of
the alveolar part of the jaw at least. Now if we compare
well-developed teeth among the uncivilised with well-
EFFECTS OF IRREGULARITY
73
developed teeth among the civilised, we find that the teeth
of the latter have diminished in size. This theory there-
fore we see is strictly in accordance with facts accumulated
inductively. We find, however, that the mental pro-
minence is more developed among the highly civilised, and
this suggests the explanation of the reason of the exist-
ence of the mental prominence. I think it might be
reasonably supposed that it is, as it were, the rudiment of
the more anterior prolongation of the body of the mandi-
ble in lower animals.
We find, too, that the wisdom tooth, more than any
other, has diminished in size. This, according to the
theory which I have put forward, is to be accounted for in
the following way. As was pointed out in a previous
chapter, the position of the teeth is determined to a great
extent by the tongue. Now if during the advance of
civilisation the tongue, from the causes mentioned, has
diminished in size, the prominence of the teeth, and so of
the basi-alveolar line, must have diminished anteriorly,
and has brought about orthognathism. The whole arch
of the teeth must be more posterior, and if the diminished
size of the tongue is slight, as we may assume it was in the
earlier stages of civilisation, the arch of teeth would tend
to be regular until the appearance of the wisdom tooth.
When, however, the tooth is taking up its position, the
more posterior position of the rest of the teeth makes it
press unduly from behind, and either the whole arch of
teeth must be thrust forward, and a space be formed in
front of the tongue, or some one or more of the teeth must
take up an irregular position, and this latter we know does
74
EFFECTS OF IRREGULARITY
occur. Now as this would predispose to caries (and we
know that even the most savage races are not wholly
exempt from this disease) and the sequelæ already referred
to, those individuals with relatively small wisdom teeth
would have the advantage, and have a greater chance of
leaving offspring than would those who had large wisdom
teeth, and unlike the more anterior teeth, variability in
shape during the diminution in size would be of relatively
little consequence. Thus we have a substantial reason for
the more rapid diminution in size of the wisdom tooth.
than of any of the others of the series without assuming
the inheritance of acquired characteristics. Hence, too,
arises the benefit of retarded eruption of the wisdom
teeth.
CHAPTER VI.
RECESSION OF THE GUMS.
I WISH now to refer to a condition predisposing to the
occurrence of caries to which I have hitherto not alluded,
and though it is not always recognised it is mentioned by
Dr. Miller as a predisposing cause. I refer to the recession
of the gums. This condition is often accompanied by the
formation of a deposit of tartar at the neck of the tooth,
and as long as this remains the subjacent tooth is not
attacked by caries. Nevertheless as the recession of the
gum takes place, whether caused by this tartar or other-
wise, it is obvious that the part of the crown of the tooth
which is normally near to the edge of the gum gradually
becomes more or less distant from it, and so becomes less
subject to the beneficent effect of the alkaline secretions at
the edge of the gum. Moreover the spaces between the
teeth gradually become larger on account of the recession
of the gum, and more food is apt to lodge in such situa-
tions. Although the irritation of this slowly formed dark
tartar may possibly stimulate the secretion in their neigh-
bourhood, still when the gums have receded a certain
distance, the amount of food which lodges in the inter-
stitial spaces gives rise to too much acid fermentation for
even this to control; consequently caries takes place. As
76
RECESSION OF GUMS
we know, this condition generally occurs after early middle
life, and is said to be natural to old age. When this
disease becomes acute it is spoken of as pyorrhoea alveolaris
on account of the slight oozing of pus round the neck of
the tooth in many cases. With regard to this disease
Mr. Tomes says, "the causes and pathology of the disease
are very obscure.” This unfortunately is very true.
Perhaps the best and most recent investigation of the
subject is that of Dr. Miller, who says, "In my opinion
three factors are to be taken into consideration in every
case of pyorrhoea alveolaris: (1) predisposing circumstances,
(2) local irritations, (3) bacteria." As predisposing circum-
stances he mentions constitutional and local complaints,
abnormal composition of the blood, digestive troubles,
unfavourable hygienic conditions (poor quarters, bad food,
bad air, want of exercise), and then gives a catalogue of
diseases mentioned by various authors, chief among which
he seems to consider rickets. As local irritants he men-
tions tartar, food particles, or any other chemical or
mechanical agent. With regard to bacteria, he says it is
not caused by any specific bacterium, but does not claim to
be able to form any decision as to whether local irritants
be at all requisite to the initiation of the disease, although
he thinks it unquestionably certain that the symptoms are
greatly aggravated by local irritations.*
I do not intend to go into the pathology of this disease,
but merely to point out the principal initial causes.
Before doing so, however, I must remind the reader of
what I pointed out in the last chapter, namely, that the
→ Miller, "Micro-organisms of the Human Mouth," p. 330.
RECESSION OF GUMS
77
but on
secretion of the gum at the neck of the tooth is alkaline.
This appears to me to point to the rational explanation
of the cause of this disease. There are two more or less
distinctly differentiated types of tartar, one light brown in
colour, generally deposited on the outer surface of the
upper molar teeth, opposite the opening of Steno's duct,
and on the back of the lower incisor teeth. This tartar is
obviously, and is known to be, a deposit from the saliva.
The other form of tartar is dark in colour, harder and
relatively small in amount, and is formed at the necks of
the teeth close to and even under cover of the margin of
the gum. Before it was recognised that the secretion in
this situation was alkaline, it was naturally practically
impossible to account for the presence of the tartar, and
hence the peculiar conjectures as to its cause;
recognising this fact it becomes obvious that this hard
dark tartar is a deposit from this alkaline secretion.
Under natural conditions and normal stimulation this
secretion does not give rise to any deposit at the neck of
the teeth, as in savages, and in wild animals in their
natural state. It may here be asked, what is this natural
and normal stimulation? and the answer is the mastica-
tion of coarse and fibrous food-stuffs, for when such foods
are masticated, the slight amount of motion allowed the
tooth by its means of fixture by the periodontal membrane
creates a normal flow of this slightly alkaline secretion;
but if the food is ridded of its coarse and fibrous part the
secretion is allowed to stagnate more or less and the
deposit is very apt to occur. Furthermore, as I have so
often pointed out, the food when ridded of its fibrous part
78
RECESSION OF GUMS
is liable to lodge, the food and micro-organisms are not
brushed away, and the micro-organisms which are usually
found in such quantities in these situations give rise to
their various pathogenic products. These act upon the
gum and give rise to inflammation, chronic or acute, and
going deeper disorganise the periodontal membrane and
surrounding alveolus independently at times of the hard
tartar, which, when it forms, augments the irritation and
the disease. I think, to those acquainted with the morbid
anatomy in the several stages of this disease, the above
explanation of its causation may appear at least a plausible
hypothesis.
Dr. Miller, in his investigation on this subject, says,
“Wild animals kept in captivity, lap-dogs, especially pugs
and other ladies' dogs, which have little exercise and eat
all kinds of unhealthy stuff, very often lose their teeth,
exhibiting symptoms characteristic of pyorrhoea alveolaris,
while, as far as I could find out, hunting dogs and such as
live under natural conditions are never, or but rarely,
afflicted with it. Dr. Fröhner, professor at the Veterinary
High School of Berlin, informed me that particularly dogs
that are fed on potatoes, farinaceous foods, and sugar are
often afflicted with this disease." *
It may be asked what is meant by "all kinds of
unhealthy stuff," and though no food is specified by Dr.
Miller, my answer would be, food that is refined, similar
to the food which the ladies themselves are accustomed to
eat, these lap-dogs sharing as a rule the food which is
prepared for the table. With regard to the foods men-
* Miller, “Micro-organisms of the Human Mouth,” p. 332.
RECESSION OF GUMS
79
tioned by Dr. Fröhner, they will be observed to be foods
which have been ridded of the fibrous part and prepared,
as in the case of potatoes, in a manner which disintegrates
the little fibre which they possess.
A case is recorded by Mr. Bland Sutton, of a monkey
in which on one side the teeth were almost exposed to the
ends of the roots, and were covered with tartar, while on
the other side the teeth showed only incipient signs of the
progress of the disease. Of this case Mr. Tomes says:
"The tartar is mainly of the soft, light-coloured kind,
and it extends up upon the working surfaces of the teeth,
so that it proves conclusively that this side of the mouth
was out of work in the way of mastication for a consider-
able time prior to the animal's death." This case indicates
clearly that the side with the advanced disease had not
been functionally active for some considerable time, and
that the presence of the disease, however initiated, had
ultimately rendered the teeth so tender that the other,
the relatively healthy side, became, to a certain extent,
functionally inactive, and so had commenced to give rise
to the disease on this side also. Innumerable examples of
similar conditions from similar causes may be observed in
the human subject; I refer more particularly to animals
to indicate that if men have a constitutional tendency to
take this disease, animals are, under similar conditions,
predisposed to it also.
In the human subject it will often be observed that
teeth which have no antagonists are very liable to be lost
by recession of the gum. These teeth are of course
functionally inactive, as is the case also with prominent
80
RECESSION OF GUMS
and outstanding teeth in the front of the mouth. I need
not say more to enforce my argument that the elimination
of those fibrous food-stuffs which put the teeth to full
functional activity is conducive to the recession of the
gums, and so to a condition which predisposes to caries.
By the above I do not mean to infer that there are no
constitutional causes of the recession of the gums, for
indeed if from any cause there is diminished vitality of the
gum and inability to resist the irritants which are liable
to lodge at the neck of the tooth, it matters little whether
it comes from senility or disease, or from lack of the use
which is necessary for maintaining the cleanliness and
physiological activity of the part.
CHAPTER VII.
FOOD-STUFFS.
I SHALL NOW direct attention to the food-stuffs which are
commonly consumed, and in doing so I shall lightly touch
upon the origin and progress of this investigation.
Nearly ten years ago when I started as a student in
dentistry I was fresh from the study of biology, and at my
brother's instigation became particularly interested in the
question of the transmissibility of acquired characteristics
by inheritance, and being persuaded that a correct solution
of this problem was necessary in order to form true con-
clusions, not only with regard to biological, but also to
psychological, educational, political, and ethical problems,
I pursued the subject further. Notwithstanding my great
admiration for Mr. Spencer's judgment, I came to the con-
clusion that those who maintained that acquired charac-
teristics were not transmissible had the best of the argument,
and consequently held this view. It occurred to me,
however, that if this view were correct then the idea that
heredity is an "important factor" in the causation of
dental caries must be wholly a mistake. I was, therefore,
left to consider whether it might be due to defects in the
development of the teeth from defective hygienic condi-
tions or disease, or whether it was due to the condition of
F
82
FOOD-STUFFS
the mouth brought about by the food which was con-
sumed. With regard to the defective development idea
I felt that it was inadequate, for except in those few cases
of imperfect development such as we see in honeycombed
teeth, the teeth in themselves exhibited almost invariably
an appearance which to me seemed delightfully perfect,
nor did the results of chemical and microscopical investi-
gation, made by others in the meantime, support this
hypothesis. For these and other reasons I gave up the
developmental idea and devoted my attention to the food.
My method of investigation at first was simply to ask
patients what food they ate, in order to find which were
most harmful. I then constructed hypotheses that such
and such foods were bad and asked specially about those.
I found that though some of my hypotheses were generally
wrong, that some were apparently pretty correct. For
years I pursued this method, and in a general way seemed
to have a fairly good idea of what foods were or were not
harmful. I then made several experiments on the lodge-
ability of food-stuffs, and found that the food-stuffs which
perhaps might have been expected to lodge did not, and
vice versa. It was not until about two years ago that I
observed that it was not so much any particular food-stuffs
which seemed to induce caries as the elimination of the
fibrous part and its destruction by most methods of
cookery. I had, in fact, been searching for about seven
years for something injurious in the food, and had not
observed that the absence of the fibrous part (which cleans
the teeth during mastication) was a very considerable
factor in the causation of the disease.
FOOD-STUFFS
83
I now intend to put before you a table of food-stuffs,
knowledge of which has been gained from these clinical
investigations and experiments, and from acquaintance
with the food-stuffs of savages with little dental caries, and
classified according to the theory which I have been
advancing.
(1) Foods from which the fibrous part has been removed
by machinery and often reduced to powder-e.g., wheat
flour, Indian corn flour, rice and farinaceous food generally.
Derivatives of above-e.g., biscuits, white bread.
(2) Food from which the fibrous part is totally excluded,
the food being derived from a liquid extract—e.g., sugar,
sweets, malt extract, extract of meat, and generally the
chemical foods and perfect (?) foods advertised for
children.
(3) Foods which have the fibrous part almost wholly
destroyed by cookery, and frequently have it further
eliminated by the process of "putting through a sieve "
e.g., soups, broths, stewed fruits, potatoes.
(4) Foods which are subjected to more than one of the
above processes
e.g., milk puddings, jams and fruit-
jelly, preserves, sauces, and toast.
(5) Foods in which the fibrous part is retained (some-
times partly destroyed by cookery)—e.g., coarsely ground
wholemeal bread, sugar-cane, fresh fruits, raw vegetables,
some cooked vegetables, fish, poultry, pork, beef, mutton,
tripe.
Some foods which do lodge may not directly undergo
acid fermentation, and only do harm by augmenting the
number of micro-organisms, and helping to retain some of
84
FOOD-STUFFS
the carbo-hydrates with which they are generally con-
sumed. These are more conducive to irritating the gums
and inducing recession. It will be observed that the
principal difference between the food of savages and that
of the civilised is physical, though it must be remembered
that boiled starch is more rapidly decomposed in the
mouth than is unboiled starch.
In estimating the share that these food-stuffs take in
the causation of caries, it is of course necessary to take
into consideration the various conditions which have been
spoken of in previous chapters, and it is especially necessary
to bear in mind that in certain combinations the fibrous
food annuls to a great extent the harmfulness of the non-
fibrous—e.g., meat and potatoes, mutton and jelly, pork
and apple sauce, game and bread sauce, fish and white
sauce, bacon and toasted bread.
Whether the fact of foods being cooked in fat diminishes
their lodgeability as it diminishes the convertibility of starch
into sugar and acid, and whether the acids in some fresh
fruits and vegetables tend to dissolve the gummy coating
which often covers parts of the teeth, I can as yet hardly
say. In any case, the amount of benefit got in these ways
appears to be very little, if any.
The following generalisation will be found to put in a
few words the conclusion at which I have arrived. It will
moreover be found, I think, to be a satisfactory answer to
the common question, why the teeth of the present gene-
ration are so liable to become decayed.
The cause of the prevalence of dental caries is that the
natural food-stuffs are to a large extent ridded of their
+
FOOD-STUFFS
85
accompanying fibrous parts, and prepared and consumed in
a manner which renders them liable to lodge and undergo
acid fermentation in the mouth; while from this same cause
and the induced conditions the micro-organisms of the mouth
lodge and multiply, and augment the rapidity and intensity
of the acid fermentation.
CHAPTER VIII.
PREVENTION OF DECAY IN TEETH.
In writing upon the causes of a disease such as dental
caries, one is continually conscious that the ultimate
object is the prevention of the disease. In this
chapter, however, I intend treating of the prevention of
dental caries in order to direct attention to the causes
from a different point of view, and to advance further
arguments in support of the conclusions as to the cause of
its prevalence, for "only by varied iteration can alien con-
clusions be forced upon reluctant minds." The reader
may almost surmise the method of prevention which is
about to be advocated. It is that the diet of the civilised
must be altered in order to suit the physiological require-
ments of the teeth, but before entering upon this subject
it will be necessary to discuss some psychological considera-
tions. It is quite useless to advocate something which is
antagonistic to the instincts and desires of the great
majority; we know that although men are perfectly alive
to the fact that certain conduct, e.g., intemperance, will
bring about certain results, and though those results may
be more harmful and painful than those brought about by
caries, if the desire for the alcoholic stimulant be con-
siderable it is folly to advocate a method of treatment
PREVENTION OF DECAY IN TEETH
87
&
'1;
which does not take into account a consideration of this
desire and its probable results.
It has for some time past been recognised and insisted
upon that beneficial results to the teeth are certain to
accrue from the constant use of the tooth-brush, but we
know that this method of keeping the teeth in good order
is not resorted to by the great majority of those who will
readily admit that its use night and morning would save
them a considerable amount of pain and anxiety on coming
to the dentist. Even dentists themselves who are daily
insisting on their patients brushing their teeth are
frequently delinquents in this matter, and since this is so,
we need hardly wonder that children sometimes forget the
use of the tooth-brush. This method of preserving the
teeth has been insisted on for some considerable time, and
yet caries is on the increase, and that too among the very
class in which the benefit from such a procedure is most
thoroughly recognised. I think that this method has had
a fair trial, and that, partly perhaps from the impossibility
of getting people to do it, and partly from other reasons,
it is futile to expect from this means alone any substantial
change for the better in the condition of the teeth.
If I advocate that the fibrous matter which accom-
panies the carbohydrates in their natural state should not
be eliminated, or if eliminated that it should be consumed
together with or followed by some food-stuff which is
fibrous, e.g., meat, the question arises, Would people do
this, even though they were thoroughly persuaded that
this would prevent the decay in their teeth? Even the
most sanguine who have had, for example, to advocate
I
88
PREVENTION OF DECAY IN TEETH
!
dieting patients for dyspepsia, might despair of this
method. Nor can we be altogether hopeful that mothers
would change the food of their children, and bring it into
accord with the physiological requirements of the teeth.
Still, there is a numerous and increasing class of women
who do make some attempt to acquaint themselves with
the principles of physiology, and more especially of hygiene
and dietetics, and bring up their families accordingly.
Among this class we may be hopeful of success to some
slight extent. Then there are many people who are not
very particular what they eat, and by whom little selec-
tion in the matter of food is made. These people are
in the habit of eating whatever is put before them, and as
they pay little attention to dietetics, they simply eat
whatever is considered good, wholesome, food, so that this
class is particularly amenable to the treatment about to
be advocated. In fact, as it is, those men who are not too
dainty in their tastes, and who will not discard a piece of
meat or other food-stuff because it is a trifle tough,
generally have a fairly good set of teeth. Some men
indeed, have a decided preference for eating things which
they can feel between their teeth and which require to be
chewed. Possibly it is to a certain extent due to their
being deprived of a reasonable amount of fibrous food
requiring chewing that some men satisfy their instinctive
desire to masticate by chewing tobacco. Perhaps also it
is this same instinct which makes many children relish so
highly such a food-stuff (if it may be so termed) as
liquorice-root. Certainly in countries where it grows,
children greatly relish eating sugar-cane. In this latter
PREVENTION OF DECAY IN TEETH
89
case there is in addition the satisfaction of gratifying the
physiological requirement which the child has for sugar.
In civilised countries, however, the craze for the elimina-
tion of the innutritious fibre, and the taking of the sugar
in a form which can be wholly assimilated, prevents the
importation of the fibre into the country, and the physio-
logical necessity of the alimentary canal for non-assimilable
matter is met by the sweeping down of some assimilable
matter with a liquid extract or powder of liquorice.
But let us consider the subject from the beginning. It
is, of course, necessary that an infant or child should be
brought up under hygienic conditions in general, in order
that the normal growth may take place. The natural
food, of course, ought if possible, to be given, i.e., mother's
milk, and when the teeth are about to come through the
gum, teething powders containing mercury should not be
given, as it appears that mercury has a specific action on
the developing enamel and gives rise to a very ugly mark,
caused by arrested or mal-development of the enamel
which in later life is liable to lodge micro-organisms and
food-stuffs. A similar condition sometimes apparently
brought about by the exanthemata may be avoided by
hygienic means. So, too, syphilitic teeth may be avoided
by proper precautions.
As regards the diet of children after the teeth have
come into position their natural instinctive preferences are
on the whole a very good guide, but these are very different
from the guides which are followed. Perhaps the great
majority of children after they have got their complete set
of temporary teeth have a dietary such as the following:
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PREVENTION OF DECAY IN TEETH
Breakfast.-Bread and milk or porridge. Milk, tea,
coffee, or cocoa. Bread and butter, perhaps an
egg.
Dinner.—Potatoes and gravy or meat. Milk pudding.
Tea.-Milk or tea with bread and butter. Jam.
Cakes.
Supper.-Bread or biscuit and milk.
Such a diet as the above is not sufficiently varied, and
as will be observed from what has been said, it is on the
whole a very bad one for the teeth, and it would indeed
be difficult to choose a diet so well calculated to bring on
caries. With the exception of the meat at the mid-day
meal almost everything is apparently calculated to lodge
and undergo rapid acid fermentation. The milk which
is often a prominent part of young people's diet may,
indeed, be harmless when consumed alone, as under such
conditions it does not lodge to any appreciable extent, but
when it is taken with toast, biscuits, milk puddings, &c.,
it is apt to a certain extent to lodge with such lodgeable
food-stuffs and promote the rapidity of the acid fermenta-
tion.
Now let us consider what might be an improvement
from the point of view of the preservation of the teeth,
while at the same time keeping the diet as good, if not
better, from the point of view of the physiological require-
ments of the body. I think it would be found advan-
tageous for children who are undergoing rapid development
to have more albuminous matter, and inasmuch as eggs
are not fibrous and do not clean the teeth to any extent
PREVENTION OF DECAY IN TEETH
91
during mastication, nor are they particularly easily digested,
this concentrated form of albumen might be limited in
amount, and a considerable amount of fibrous albuminous
matter could be taken instead. Thus, at breakfast, fish
or bacon might always be taken in sufficient quantity to
ensure mastication and the cleaning of the teeth. The
toast or bread had better, too, be changed for coarsely
ground whole-meal bread.
With regard to the children's midday meal, the potatoes
might be supplemented by vegetables, preferably in the
raw form, such as salad, and along with the meat also, if
more carbohydrates be deemed necessary, boiled rice,
Yorkshire pudding, jelly, or other suitable adjunct to the
particular kind of meat or fish might be taken without
harm resulting. Then fruit might be given to finish the
meal. I think if fresh vegetables and fruit were more in
the routine of children's food, it would prevent the violent
excesses sometimes indulged in when children get into an
orchard, or even a turnip-field, on some special occasion.
There is no doubt that the continual non-satisfaction of
the physiological want of vegetable acids and possibly
uncooked fibre, is the chief reason for the excess
sometimes indulged in, and at least it is improbable
that if children had a proper amount of wholesome,
ripe fruit and fresh vegetables, they would be likely to
take an excessive quantity of unripe fruit when occasion
offered.
Then with regard to the tea, bread, jam, and cake.
This again is a particularly harmful meal. The bread
should be of the whole-meal variety, stale, and it might
92
PREVENTION OF DECAY IN TEETH
be eaten in the form of cress or tomato sandwiches. If
jam or jelly is taken, it ought to be supped alone, or
with cream or milk, and swallowed without mastication,
and followed by something fibrous. A little fruit might
preferably be substituted for jam at this meal too, or
better still, some sugar-cane might be chewed. The
liquid, i.e., the tea, should be taken after all that is to
be eaten has been eaten.
With regard to supper, if milk alone is not sufficient
and it be deemed necessary to have something more
substantial, then fish or some light meat should be eaten
with the bread.
What I have just said is in no way meant to indicate
the dietary necessary for children, but to show the
practical application of my theory to the prevention of
caries, and to point out that it is possible, even under
existing circumstances, to give a child sufficient albuminous,
amylaceous, fatty, saccharine, mineral, and innutritious
matter, without everlasting milk puddings and bread and
milk. That is to say, the physiological requirements o
the body may be satisfied while giving the child a diet
necessitating the learning of the habit of mastication,
which is very important from a stomachic point of view, as
well as from the point of view of the preservation of the
temporary teeth till the permanent ones are ready to take
their place in a regular and natural manner. When we
consider the ugliness and the remote consequences of an
irregular set of teeth, I think it will be admitted that
the extra amount of chewing which would be necessitated
by the diet advocated would be well compensated for
PREVENTION OF DECAY IN TEETH
93
even though it only partially diminished the amount
of caries and the irregularity of the teeth.
With regard to the diet of adults further suggestions
here are hardly necessary. These may be found in pre-
vious chapters. Fortunately there is among adults a
greater freedom to eat what is gratifying, and to eschew
what is not, and notwithstanding the temptation of
refined foods, undoubtedly there exists in some people,
especially men, a gratification in eating what requires a
decided amount of chewing.
In considering the prevention of dental caries it will be
well to refer to the filling of teeth, for, as a rule, fillings
are inserted with a view, not only to arresting the pro-
gress of caries, but also to prevent its recurrence in the
neighbourhood of the filling. So long as we dentists are
ignorant of the cause of caries, and the conditions which
give rise to it, so long as we are content to assume,
erroneously, that heredity, civilisation, deterioration in
structure of the teeth, constitutional causes, abnormalities
of the buccal secretions, &c., are in part or wholly, the
causes of the disease, then so long must the operation
of filling be an empirical operation. When, however,
we distinctly recognise the cause of caries, and the condi-
tions which are necessary antecedents, positive and
negative, then it emerges from empiricism, and becomes
a scientific operation. Recognising that food lodges in
crevices, &c., and that this food forms a suitable nidus
for acid fermentation, then all fillings must be so shaped
that no food may lodge at the edges of the filling.
94
PREVENTION OF DECAY IN TEETH
When, for example, a filling is inserted in a crown cavity,
say
of a molar tooth, it is necessary that the decay should
be removed, but further than this, the junction of the
filling, and the tooth must not be made in any hollow
which would presumably lodge food, nor must the surface
of the filling form an angle with the neighbouring surface
of the crown of the tooth, otherwise food would be liable.
to lodge in the angle, and so recommence decay at the
edge of the filling. This unfortunate occurrence is the
cause, I feel sure, of the large majority of failures in
fillings, and if the cause of caries were only definitely
kept before the mind of the operator, this very common
cause of failure would seldom, if ever, be met with.
Some operators recognise that in interstitial cavities.
the fillings must be constructed so that food will not
lodge at the junction of the enamel and the filling.
They admit, in fact, that it is the lodging of the food
which in this situation gives rise to the decay, and a
little careful observation will show them that certain
foods lodge on the crowns of the teeth also, and that no
tooth decays without the lodgment of food; further, that
if a tooth commence to decay at the edge of the filling
it is because the filling has been inserted in such a manner
as to allow of food lodging. This latter condition is
almost invariably preventible.
When the approximal surfaces of a tooth require to be
filled it is almost always necessary to contour the teeth,
not only to prevent the lodging of food at the edge
of the filling, but also to prevent change of position
of the teeth. This is often neglected, and the teeth
PREVENTION OF DECAY IN TEETH
95
change their position by approximating each other; their
normal relative position to the neighbouring teeth is
disturbed, a form of irregularity is produced; food lodges
in the new spaces formed and decay is set up, not only
on the approximal sides of the teeth which are filled,
but also on the remoter teeth whose position may have
changed. Thus, then, it will be seen that a few bad
interstitial fillings may predispose ultimately to a succes-
sion of carious cavities. It is important, too, to recognise
the cause of caries from another point of view. It some-
times happens that the removal of a particular piece of
partly decayed dentine may, for some reason or other,
be inadvisable. We must, for example, recognise that we
want to do the maximum amount of good with the
minimum amount of pain, and whether we may leave
a particular part of partly decayed dentine will depend
on whether food and micro-organisms can lodge in the
space or not. If food would not lodge at the particular
spot if the dentine were left, then it may be left; if
otherwise, it must be removed.
Another point of importance which will be useful if
we are to give our patients the miminium pain: When
the decay is rapid, that is when the kind of food eaten
is liable to lodge and undergo rapid fermentation, as so
frequently is the case with children's food, if the diet
cannot be altered, then the tooth must be cut away much
more freely from any spot where the food might lodge.
On the other hand, when the decay is very slow the
removal of the decay and proper shaping of the cavity
and edges of the filling will be all that is required.
96
PREVENTION OF DECAY IN TEETH
There is little connected with dental surgery and
pathology which may be considered settled with scientific
accuracy, and my attitude to current ideas and methods
has led me to doubt if even the time-honoured method of
cleaning the teeth with tooth-brush and powder can be
advocated without considering that it may possibly be
harmful. We are aware that mouths which have never
felt a tooth-brush may occasionally be seen in which the
teeth are all perfectly sound, and that at least equally
frequently people who are scrupulously particular in the
use of the tooth-brush have every tooth excepting the
lower front teeth decayed and stopped in two or more
places. Nor is this all. It frequently happens that the
gums recede very rapidly in the mouths of those who use
the tooth-brush most, and among this class too that
painful and troublesome condition of erosion takes place
at the neck of the teeth with or without recession of the
gums or caries following.
Before stating the effect of the use of the tooth-brush
let us consider Nature's methods of preserving the enamel.
First, it may be preserved by being kept perfectly free
from adherent matter as occurs on the crown surfaces of
the teeth of those who eat coarse and non-lodgeable food-
stuffs. Secondly, a protective layer of matter which does
not become acid in reaction under normal circumstances
may be deposited on the surface of the enamel and protect
it from injury. Although this latter method is not recog-
nised, I believe it is one which is utilised by nature, and
is perhaps the only possible and satisfactory method at
certain situations on the teeth. Hitherto this coating
PREVENTION OF DECAY IN TEETH
97
has received little attention. It has been considered as
merely so much deposit from the mucus of the saliva in a
vitiated condition, or from other sources, and it is assumed
that this ought to be got rid of by the aid of the tooth-
brush as quickly as possible. I intend, however, to point
out that this coating on certain parts of the teeth may be
considered physiological, and only becomes pathological
under certain conditions.
*
Let us now consider the nature and source of this
coating. There is reason to believe that its basis is buccal
and salivary mucus. This is described as a viscid albu-
minous material containing albuminous mucous corpuscles
frequently mixed with salivary epithelium and débris. In
the situations where it adheres to the enamel of the teeth,
and is not removed during mastication or by the tooth-
brush, it may be felt by the tongue as a very slightly
rough coating. It presents a different feeling to the
tongue than does the polished enamel. It is frequently
discoloured either from chromogenic micro-organisms or
the pigments in the food, or from tobacco. From its
albuminous nature and its being infected with micro-
organisms it undergoes slow change. Its reaction on
the surface of the teeth in the mouth is (as far as my
testing with litmus shows) practically neutral. This
reaction comes about presumably from the albuminous
* The data from which the following opinions have been derived
were experiments chiefly carried out on one mouth. They have
been confirmed by observations on others. There is no reason to
consider that the mouth specially under consideration was in any
way abnormal. It was selected simply because it was continu-
ously under the writer's personal observation.
G
98
PREVENTION OF DECAY IN TEETH
nature of the buccal mucus and corpuscles and salivary
epithelium.
Although there are micro-organisms which infest this
coating when no carbohydrates are mixed with or adhere
to it in quantity, acid is not produced, at least in any
quantity. Moreover, on account of the thinness of the
coating, even if a small amount of acid is at times pro-
duced, it is neutralised by the saliva. I have found that
in the morning, even after having eaten sweets on the
previous evening, this coating is neutral in reaction.
The conclusion that this coating is normally of a
neutral reaction is indicated by the fact that tartar is
deposited in it in certain situations, e.g., round the necks
of the teeth, with almost equal frequency as the decalcifi-
cation of the enamel in similar situations. The cause of
both decalcification and the deposit of tartar is similar—
viz., the elimination of the coarse and fibrous matter from
the food-stuffs and the lodging in quantity of food at the
places referred to. In the one case, however, the reaction
given rise to as the joint result of saliva, buccal secretions,
and food, is acid (carbohydrates being in excess), in the
other it is alkaline (albuminous matter being in excess).
When a tooth-brush is frequently used the protective
coating is brushed away from the necks of the teeth, and
if lodgeable amylaceous or saccharine food is then eaten,
the coating having been brushed away, the starchy matter
lodges close to the necks of the teeth and the intensity of
the acid formation is greater in close proximity to the
enamel than it would have been had it been protected by
a layer of albuminous mucus and corpuscles.
PREVENTION OF DECAY IN TEETH
99
I think, moreover, there is perhaps even greater evidence
which goes to show that this albuminous coating protects
the necks of the teeth from the eroding action of the
buccal mucous membrane or its secretions which are or
become acid, and lodge in the triangle formed by the
enamel, the edge of the gum, and the buccal mucous
membrane. Assuming this to be true, we have another
reason why the tooth-brush should not be used except for
the coronal surfaces of the tooth when erosion exists at
the neck of the teeth.
Thus, then, it appears that the tooth-brush is not an
unmixed blessing, but nevertheless until the ordinary food
consumed is changed or has its fibrous element restored,
perhaps the tooth-brush may be usefully advocated at
least for brushing the coronal surfaces of the teeth.
With regard to antiseptic mouth washes, they too are
not without their objectionable features. Beneficial they
may be in exceptional circumstances, but under normal
conditions their use is, I believe, to be deprecated.
The mouth has never in the history of man or animal
been an aseptic chamber, and paradoxical as it may seem,
and contrary to all recent ideas relative to methods for the
combating of caries, I will affirm that under proper dietetic
conditions the bacteria of the mouth are valuable agents
in the preservation of the teeth. The mouth bacteria
give rise to the continual disintegration and removal of
the protective mucous coating supplied by the buccal
secretions. It is difficult to imagine a better method for
the prevention of caries at those places where the friction
of fibrous food cannot dislodge all adherent matter, for
DorM
100
PREVENTION OF DECAY IN TEETH
while the mucous coating protects the necks of the teeth
the bacteria provide a means for the removal of all accu-
mulations of débris, whether it be decomposing food or
incipient tartar deposit.
I need not insist upon how important it is that a
method should obtain preserving the teeth from destruc-
tion by acid on the one hand and from the deposit of
tartar on the other. Nor has any artificial method been
suggested which arrives at this result so satisfactorily as is
provided for by the means indicated, provided only that
the food is sufficiently coarse and fibrous to ensure a fair
amount of friction, a small amount of lodging food
particles, and a sufficient amount of stimulus for the
physiological uses of the teeth.
Now let us consider the objects aimed at and the
methods advocated in text-books on dental surgery. The
object is to free the buccal cavity from micro-organisms
and the mucous, albuminous, and other matters which
cling about the teeth. For this purpose the tooth-pick,
floss silk, the tooth-brush, tooth-powders, tooth-soaps, and
antiseptic mouth washes are advocated to be persisted in
with irksome regularity and at inconvenient times. If the
aim were achieved the very means for the natural method
of preservation of the teeth would be destroyed. Fortu-
nately the methods employed are so ludicrous, inefficient,
and seldom performed that the total amount of good or
harm resulting is relatively small.
We hear much of the great advances in dental surgery
during the last thirty years, but unfortunately the advance
PREVENTION OF DECAY IN TEETH
101
is not in the most desirable direction, for though the art
has reached a great degree of perfection, and the instru-
ments and mechanical means to ends show the most
plausible ingenuity, still decay in teeth, irregularity,
recession of the gums, and other dental diseases are
increasing with marked rapidity. So long as the atten-
tion of dentists is absorbed in the art of filling and
making teeth, so long as we are ignorant of the causes of
the diseases we attempt to combat, even so long will
dental surgery be merely an empirical art, and the
suffering of mankind from dental decay and its conse-
quences will go on apace. On the other hand, I maintain
I have shown that there is the strongest evidence for
believing that it is the food-stuffs which are the cause of
caries, and that the weight of the authority of biological
science strongly supports this view. If we devote our
attention to the causes of dental caries there is every
reason for hoping that our services as dental surgeons
may be almost wholly unnecessary, and that we may
devote our energies to productive labour instead of
living, as it were, on the infirmities and suffering of our
fellow men.
:
APPENDIX
EXPERIMENTAL DEMONSTRATION OF THE CAUSE
OF THE EARLY DECAY OF TEETH
SOME time ago you kindly published a series of articles on
"The Etiology of Dental Caries,” in which I put forward
the view that "the cause of the prevalence of dental
caries is that the natural food-stuffs are to a large extent
ridded of their accompanying fibrous parts, and prepared
and consumed in a manner which renders them liable to
lodge and undergo acid fermentation in the mouth; while
from the same cause, and the induced conditions, the
micro-organisms of the mouth lodge and multiply, and
augment the rapidity and intensity of the acid fer-
mentation."
It was after what, to my mind, was proof positive that I
wrote the articles, and fortunately the arguments then
brought forward have convinced many and partially con-
vinced others. I was persuaded, however, that no amount
of argument would convince many who believed in the
hereditary and constitutional nature of the disease, nor
those who were confirmed in the belief that the teeth of
civilised man had become degenerate.
If the theory I put forward were true, it occurred to me
that the teeth of many of the lower animals might probably
be no more immune to caries than are the teeth of men. I
APPENDIX
103
came to the conclusion that the freedom was due almost
solely to dietetic causes. In order to test this I bought a
monkey and tried to put it on a dieċ from which all coarse
and fibrous matter had been removed, such as fine biscuits,
toast, bread and milk, chocolate, cheese, meat juice, &c.
At first I had provided the monkey with a bed of hay, and
after it had satisfied itself with biscuits and milk it imme-
diately commenced chewing the hay. This, of course,
spoiled the experiment, so I removed the hay, but as the
weather was cold I supplied the monkey with a little box
lined with cork. Unfortunately, again it took to chewing
the cork between meals. I next removed the cork and
box, as I thought it would be better to let it sleep on the
bare floor of the cage than have it chewing fibrous material
for a considerable part of the day. Still, however, it did
not understand the nature of my experiment, and persisted
in nibbling off little pieces of wood from the sides of the
wooden cage and running about with them in its mouth. I
then rubbed the cage with quinine at all places which were
accessible to the teeth or hands of the monkey, and it
gradually gave up the habit of chewing these little pieces
of wood. I mention these facts, not to amuse the reader,
but to show how this animal and, I presume, other
monkeys, preserve their so-called "immunity" to dental
caries.
The diet which the monkey received from this time
onwards consisted almost wholly of fine biscuits, toast,
bread and milk, and milk. It also had frequently a little
treacle (one pound in all during about six months).
Occasionally it had milk pudding, and, perhaps about a
104
APPENDIX
dozen times, potatoes and milk; it had also a little
chocolate, about two or three ozs. in all, and about thirty
lumps of loaf sugar.
At the end of the first four months I examined its teeth
carefully, but although I thought there seemed to be slight
indications of caries on the symphysial side of the first left
lower molar, I thought it better to wait for more positive
signs, and so did not trouble to examine the teeth for six
months. On this second examination I found in the two
upper first molars (which were the hind-most teeth in this
monkey's head, as the animal was young and the other
molars had not yet erupted) tiny discoloured crevices
between the anterior and posterior interior cusps, which
seemed very much like caries. I extracted these two upper
molar teeth and ground them down in order to see the
suspicious spots under the microscope, with the following
result:
Upper right molar. The crevice was found to be more
than half the depth of the enamel, and around the deepest
part of the crevice the enamel to the naked eye showed a
chalky appearance. The margin of the crevice appeared
stained brownish yellow under the microscope. From the
bottom of the crevice there descended, nearly to the
dentine, a strand of apparently disintegrating enamel.
The dentine beneath this enamel was translucent, the
translucency penetrating the dentine more than half-way
to the pulp. The edges of the crevice were somewhat
rough and cracks penetrated it.
A few days later, after the animal died, I examined the
left lower molar. It showed on section, under the micro-
APPENDIX
105
scope, the enamel completely removed at one spot down to
the dentine. The dentinal tubules immediately below the
denuded part were swollen and granular, and some
apparently filled with micro-organisms. I may mention.
that a transparent cone of dentine reached from the dis-
integrated enamel to the pulp, when the section was
examined before mounting in Canada balsam. Both of
these teeth, therefore, presented appearances, at least,
strongly simulating incipient dental caries.
The upper left molar, though discoloured in the crevice,
showed no sign of caries.
It will be seen that the caries had not extended very far,
but it must be remembered that the animal started with a
set of teeth which were very actively used, so regular, so
well polished, so small, and so protected by the gum
coming up over the enamel, that I almost doubted
whether I should see caries in its teeth at all unless it lived
a very considerable time. I may state that it seemed in
my opinion next to impossible for almost any teeth in this
monkey's head to decay, as the natural fissures-for
example, in the premolars had been completely worn out,
and a beautifully polished smooth surface was left on which
food could hardly by any possibility lodge, and as I have
just mentioned, the gums overlapped the enamel and came
up between the teeth in a manner which seemed very
perfectly adapted for preventing caries. I hoped for
recession of the gums to take place under the diet, or that
the more posterior molars should, on coming into position,
be more liable to lodge food. Fortunately the crevices in
the first molars were sufficient, and if the amount of caries
106
APPENDIX
observed was brought about in, say nine months, what sort
of state would these molars be in at the end of five years?
I
suppose pretty much the same state as are the first molars
of children who are fed on the most " approved" principles,
five years after their eruption.
It may be asked why I did not let the experiment go on
longer before writing about it. Unfortunately the experi-
ment came to a sudden end on account of a heating
apparatus giving rise to a fire, which suffocated the monkey.
Still, the nine months have, I think, just been sufficient.
Perhaps some other investigator will be more fortunate and
continue the experiment for four or five years as ought to
have been done.
The liability to caries, therefore, appears to be almost
solely due to the fact that the food-stuffs are refined and
administered in a form which is very much more liable to
lodge in the natural crevices of the teeth, and there is
practically no need for the assumption that the liability to
caries has been brought about by any hereditary degenera-
tion of the teeth, nor by any molecular structural alteration
due to defective nutrition of the teeth, nor by any supposed
vitiation of the buccal secretions, nor by any constitutional
states of the system brought about by indigestion, nor by
any other of the multitudinous suppositions which have
been advanced from time to time.
I have advanced arguments elsewhere,* not only from
my own observations, but from the accumulated mass of
facts which have been heaped up for years; unfortunately,
however, arguments which necessarily involve close following
* "Cause and Prevention of Decay in Teeth."
APPENDIX
107
and an abandonment of many current prejudices do not
convince every one. Very many of the same facts have in
other theories been continually misinterpreted, mainly, I
believe, from the persistent habit of looking to the teeth and
not to the food for the explanation, and from the almost
universal belief that the disease is inherited. If it is
supposed that the disease is inherited, then of course the
causes which lead up to it would require to be sought for
throughthe constitution. Hence has resulted the fact that
some recent observers,* having seen the futility (after chemical
and microscopical examination of the teeth) of seeking the
cause of susceptibility to caries in the teeth themselves, have
found it necessary to seek it through the oral secretions.
I may state that I endeavoured to ensure that the food
should be in no way deficient in nutritive value lest it
might be said that the teeth became predisposed or less
resistant to caries through defective nutrition of the tooth.
It should also be noted that the food was of such a quality
that the jaws were required to be exercised, e.g., biscuits,
toast, loaf sugar, so that if it be said that "the pressure
brought to bear upon the teeth by mastication causes a
more lively circulation in the periosteum and in the pulp,
thereby inducing an increased deposit of lime salts or a
more complete calcification,"† then this method of securing
immunity was not disregarded. And I think it could not
be said that the soft quality of the food this animal had
previously consumed had brought about "a soft porous
dental substance."‡
+
Black, "Susceptibility and Immunity to Dental Caries."
† Millar, "Micro-organisms of the Human Mouth."
‡ Millar, ibid.
108
APPENDIX
#
I mention this, as it is important (from the point of
view of prevention) to differentiate between the dietetic
theories which trace the predisposition through the sup-
posed nutritional changes in the teeth and the theory which
I put forward tracing the prevalence of caries to the
relative lodgeability of the food-stuffs.
The experiment just recorded was not carried out with
as much precision as it deserved. Unfortunately during
the greater part of the time I was prevented by illness from
giving it my personal attention. The experiment, too, was
merely a preliminary one, and as I have said, was
prematurely ended. Still I trust that the recording of this
experiment, abortive though it may be, may prevent it
being said again that the reason for the immunity to
dental caries in animals has still to be discovered, or that
the cause of the early decay of teeth is still unknown.
Until at least some similar experiment, more thoroughly
carried out, negatives the inferences I have made, we may
be justified in believing that "the cause of the prevalence
of dental caries is that the natural food-stuffs are to a large
extent ridded of their accompanying fibrous parts, &c."*
* Were I to perform such an experiment again I should not
allow toast. As far as I can discover from clinical evidence it does
not seem to be harmful. Probably toast is sufficiently coarse to
dislodge the micro-organisms where they usually lodge and
multiply.
Printed by Ballantyne, HANSON & Co.
London & Edinburgh
No. 3.
A
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June, 1902.
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LONDON: 7, GREAT MARLBOROUGH STREET.
INDEX TO J. & A. CHURCHILL'S LIST.
Allen's Chemistry of Urine, 11
Commercial Organic Analysis, 13
Armatage's Veterinary Pocket Remembrancer, 14
Auld's Pathol. Researches, 2
Ballantyne's Antenatal Pathology and Hygiene, 2
Barnes (R.) on Obstetric Operations, 3
on Diseases of Women, 3
Beale (L. S.) on Liver, 6
Slight Ailments, 6
Urinary and Renal Derangements, 12
Beale (P. T. B.) on Elementary Biology, 2
Beasley's Book of Prescriptions, 5
Druggists' General Receipt Book, 5
Pharmaceutical Formulary, 5
Bell on Sterility, 4
Bentley and Trimen's Medicinal Plants, 5
Bentley's Systematic Botany, 5
Berkart's Bronchial Asthma, 6
Bernard on Stammering, 7
Berry's (Jas.) Thyroid Gland, 9
(R. J.) Regional Anatomy, I
Bigg's Short Manual of Orthopædy, 9
Birch's Practical Physiology, 2
Bloxam's Chemistry, 12
Laboratory Teaching, 12
Bousfield's Photo-Micrography, 14
Bowlby's Injuries and Diseases of Nerves, 9
Surgical Pathology and Morbid Anatomy, 9
Brockbank on Gallstones, 8
Brown's (Haydn) Ringworm, II
(Campbell) Practical Chemistry, 13
Bryant's Practice of Surgery, 8
Bulkley on Skin Diseases, Io
Burdett's Hospitals and Asylums of the World, 2
Butlin's Operative Surgery of Malignant Disease, 11
Malignant Disease of the Larynx, 11
Buzzard's Diseases of the Nervous System, 7
Peripheral Neuritis, 7
Simulation of Hysteria, 7
Cameron's Oils, Resins, and Varnishes, 14
Soaps and Candles, 14
Campbell's Dissection Outlines, I
Carpenter and Dallinger on the Microscope, 14
Cautley's Infant Feeding, 4
Charteris' Practice of Medicine, 6
Chauveau's Comparative Anatomy, 14
Chevers' Diseases of India, 5
Churchill's Face and Foot Deformities, 9
Clouston's Lectures on Mental Diseases, 3
Clowes and Coleman's Quantitative Analysis, 13
Elmntry Practical Chemistry, 13
Clowes' Practical Chemistry, 13
Coles on Blood, 6
Cooley's Cyclopædia of Practical Receipts, 14
Cooper on Syphilis, 12
Cooper and Edwards' Diseases of the Rectum, 12
Corbin and Stewart's Physics and Chemistry, 12
Cripps' (H.) Ovariotomy and Abdominal Surgery, 9
Cancer of the Rectum, 12
Diseases of the Rectum and Anus, 12
Air and Fæces in Urethra, 12
Cripps' (R. A.) Galenic Pharmacy, 4
Cuff's Lectures to Nurses, 4
Cullingworth's Short Manual for Monthly Nurses, 4
Dalby's Diseases and Injuries of the Ear, 10
Short Contributions, 10
Dana on Nervous Diseases, 7
Day on Headaches, 8
Domville's Manual for Nurses, 4
Druitt's Surgeon's Vade-Mecum, 8
Duncan (A.), on Prevention of Disease in Tropics, 5
Dunglison's Dictionary of Medical Science, 12
Edwards' Chemistry, 14
Ellis's (T. S.) Human Foot, 9
Encyclopædia Medica, 14
Fagge's Principles and Practice of Medicine, 6
Fayrer's Climate and Fevers of India, 5
Fenwick (E. H.), Electric Illumination of Bladder, 11
Tumours of Urinary Bladder, II
Ulceration of Bladder. II
Symptoms of Urinary Diseases, 11
Atlas of Electric Cystoscopy, II
Obscure Diseases of Urethra, 11
Fenwick's (S.) Medical Diagnosis, 6
Obscure Diseases of the Abdomen, 6
Fenwick's (S.) Outlines of Medical Treatment, 6
Ulcer of the Stomach and Duodenum, 6
The Saliva as a Test, 6
Fink's Operating for Cataract, 9
Fowler's Dictionary of Practical Medicine, 5
Fox (G. H.) on Skin Diseases of Children, 10
Fox (Wilson), Atlas of Pathological Anatomy of Lungs, 6
Treatise on Diseases of the Lungs, 6
Frankland and Japp's Inorganic Chemistry, 13
Fraser's Operations on the Brain, 8
Fresenius Qualitative Analysis, 13
Quantitative Analysis, 13
Galabin's Diseases of Women, 3
Manual of Midwifery, 3
Gardner's Brewing, Distilling, and Wine Manuf., 14
Glassington's Dental Materia Medica, 10
Godlee's Atlas of Human Anatomy, 1
Goodhart's Diseases of Children, 4
Gorgas' Dental Medicine, 10
Gowers' Diagnosis of Diseases of the Brain, 7
Manual of Diseases of Nervous System, 7
Clinical Lectures, 7
Epilepsy, 7
Medical Ophthalmoscopy, 7
Syphilis and the Nervous System, 7
Granville on Gout, 7
Gray's Treatise on Physics, 14
Green's Manual of Botany, 5
Vegetable Physiology, 5
Greenish's Materia Medica, 4
Groves' and Thorp's Chemical Technology, 14
Guy's Hospital Reports, 7
Habershon's Diseases of the Abdomen, 7
Hadley on Nursing, 4
Haig's Uric Acid, 6
Diet and Food, 2
Harley on Diseases of the Liver, 7
Harris's (V. D.) Diseases of Chest, 6
Harrison's Urinary Organs, II
Hartridge's Refraction of the Eye, 9
Ophthalmoscope, 9
Hawthorne's Galenical Preparations of B.P., 5
Heath's Injuries and Diseases of the Jaws 8
Minor Surgery and Bandaging, 8
Operative Surgery, 8
Practical Anatomy, 1
Surgical Diagnosis, 8
Clinical Lectures, 8
Hedley's Therapeutic Electricity, 5
Hewlett's Bacteriology, 3
Hill on Cerebral Circulation, 2
Holden's Human Osteology, I
Landmarks, I
Hooper's Physicians' Vade-Mecum, 5
Horrocks' Bacteriological Examination of Water, 3
Horton-Smith on Typhoid, 7
Hovell's Diseases of the Ear, 10
Hughes and Keith's Practical Anatomy, I
Human Nature and Physiognomy, 14
Hyslop's Mental Physiology, 3
Impey on Leprosy, 10
Ireland on Mental Affections of Children, 3
Jacobson's Operations of Surgery, 8
Jellett's Practice of Midwifery, 3
Gynæcology, 3
for Nurses, 3
Jessop's Ophthalmic Surgery and Medicine,
Johnson's (Sir G.) Asphyxia, 6
Medical Lectures and Essays, 6
(A. E.) Analyst's Companion, 13
Journal of Mental Science, 3
Kelynack's Pathologist's Handbook, I
Keyes' Genito-Urinary Organs and Syphilis, 12
Kohlrausch's Physical Measurements, 14
Lane's Rheumatic Diseases, 7
Langdon-Down's Mental Affections of Childhood, 3
Lawrie on Chloroform, 4
Lazarus-Barlow's General Pathology, I
Lee's Microtomist's Vade Mecum, 14
Lewis and Balfour's Public Health, 2
Lewis (Bevan) on the Human Brain, 2
Liebreich (O.) on Borax and Boracic Acid, 2
Liebreich's (R). Atlas of Ophthalmoscopy, 10
Lucas's Practical Pharmacy, 4
MacMunn's Clinical Chemistry of Urine, 1I
[Continued on the next page.
LONDON: 7, GREAT MARLBOROUGH STREET.
INDEX TO J. & A. CHURCHILL'S LIST-continued.
Macnamara's Diseases and Refraction of the Eye, 9
Diseases of Bones and Joints, 8
McNeill's Epidemics and Isolation Hospitals, 2
Malcolm's Physiology of Death, 9
Martin's Ambulance Lectures, 8
Maxwell's Terminologia Medica Polyglotta, 12
Maylard's Surgery of Alimentary Canal, 9
Mayne's Medical Vocabulary, 12
Microscopical Journal, 14
Mills and Rowan's Fuel and its Applications, 14
Moore's (N.) Pathological Anatomy of Diseases, 1
Moore's (Sir W. J.) Family Medicine for India, 5
Manual of the Diseases of India, 5
Morris's Human Anatomy, I
Anatomy of Joints, I
Moullin's (Mansell) Surgery, 8
Murray's Hare-Lip and Cleft Palate, 8
Nettleship's Diseases of the Eye, 9
Notter's Hygiene, 2
Oliver's Abdominal Tumours, 3
-Diseases of Women, 3
Ophthalmic (Royal London) Hospital Reports, 9
Ophthalmological Society's Transactions, g
Ormerod's Diseases of the Nervous System, 7
Parkes' (E.A.) Practical Hygiene, 2
Parkes' (L.C.) Elements of Health, 2
Parsons Ophthalmic Optics, 9
Pavy's Carbohydrates, 6
Pereira's Selecta è Prescriptis, 5
Phillips' Materia Medica and Therapeutics, 4
Pitt-Lewis's Insane and the Law, 3
Pollock's Histology of the Eye and Eyelids, 9
Proctor's Practical Pharmacy, 4
Pye-Smith's Diseases of the Skin, 10
Ramsay's Elementary Systematic Chemistry, 13
Inorganic Chemistry, 13
Richardson's Mechanical Dentistry, 10
Richmond's Antiseptic Principles for Nurses, 4
Roberts' (C. H.) Gynecological Pathology, 3
Roberts' (D. Lloyd) Practice of Midwifery, 3
Robinson's (Tom) Eczema, 11
Illustrations of Skin Diseases, 11
Syphilis, 11
Ross's Diseases of the Nervous System, 7
St. Thomas's Hospital Reports, 7
Sansom's Valvular Disease of the Heart, 7
Scott's Atlas of Urinary Deposits, II
Shaw's Diseases of the Eye, 9
Shaw-Mackenzie on Maternal Syphilis, 12
Short Dictionary of Medical Terms, 12
Silk's Manual of Nitrous Oxide, 10
Smith's (Ernest A.) Dental Metallurgy, 10
Smith's (Eustace) Clinical Studies, 4
-Disease in Children, 4
Wasting Diseases of Infants and Children, 4
Smith's (F. J.) Medical Jurisprudence, 2
Smith's (J. Greig) Abdominal Surgery, 8
Smith's (Priestley) Glaucoma, ro
Snow's Cancer and the Cancer Process, II
Palliative Treatment of Cancer, 11
Reappearance of Cancer, II
Solly's Medical Climatology, 8
Southall's Materia Medica, 5
Squire's (P.) Companion to the Pharmacopoeia, 4
London Hospitals Pharmacopœias, 4
Methods and Formulæ, 14
Starling's Elements of Human Physiology, 2
Sternberg's Bacteriology, 5
Stevenson and Murphy's Hygiene, 2
Sutton's (J. B.), General Pathology, 1
Sutton's (F.) Volumetric Analysis, 13
Swain's Surgical Emergencies, 8
Swayne's Obstetric Aphorisms, 3
Taylor's (A. S.) Medical Jurisprudence, 2
Taylor's (F.) Practice of Medicine, 6
Thin's Cancerous Affections of the Skin, ro
-Pathology and Treatment of Ringworm, 10
on Psilosis or " Sprue," 5
Thompson's (Sir H.) Calculous Disease, 11
Diseases of the UrinaryOrgans,11
Lithotomy and Lithotrity, 1I
Stricture of the Urethra, 1I
Suprapubic Operation, 11
Tumours of the Bladder, 11
Thorne's Diseases of the Heart, 7
Thresh's Water Analysis, 2
Tilden's Manual of Chemistry, 12
Tirard's Medical Treatment, 6
Tobin's Surgery, 8
Tomes' (C. S.) Dental Anatomy, 10
Tomes' (J. and C. S.) Dental Surgery, 10
Tooth's Spinal Cord, 7
Treves and Lang's German-English Dictionary, 12
Tuke's Dictionary of Psychological Medicine, 3
Turner on Sinuses of the Nose, 10
Tuson's Veterinary Pharmacopoeia, 14
Valentin and Hodgkinson's Practical Chemistry, 13
Vintras on the Mineral Waters, &c., of France, 8
Wagner's Chemical Technology, 14
Wallace on Dental Caries, ro
Walsham's Surgery: its Theory and Practice,
Waring's Indian Bazaar Medicines, 5
Practical Therapeutics, 5
Watts' Organic Chemistry, 12
West's (S.) How to Examine the Chest, 6
White's (Hale) Materia Medica, Pharmacy, &c., 4
Wilks' Diseases of the Nervous System, 7
Wilson's (Sir E.) Anatomists' Vade-Mecum, 1
Wilson's (G.) Handbook of Hygiene, 2
Wolfe's Diseases and Injuries of the Eye, 9
Wynter and Wethered's Practical Pathology, I
Year-Book of Pharmacy, 5
Yeo's (G. F.) Manual of Physiology, 2
N.B.—J. & A. Churchill's larger Catalogue of about 600 works on Anatomy,
Physiology, Hygiene, Midwifery, Materia Medica, Medicine, Surgery, Chemistry,
Botany, &c. &c., with a complete Index to their Subjects, for easy reference,
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