very much the same order, the lower central incisors appearing before the upper, the upper lateral incisors before the lower, the upper bicuspids before the lower, etc.*

As these teeth approach the surface, absorption begins in the alveoli and at the roots of the deciduous teeth, and this continues until the teeth are loosened and readily extracted, or if this be not done, until little is left but their crowns.

When the first and second molars approach the surface, the gums, just as in primary dentition, become red, swollen, rounded and tender. The salivary secretion is increased, the mouth is hot, the patient complains of aching in the gum, and, on account of tenderness, refuses food requiring mastication. With the other sets there is a gradual loosening of the superimposed temporary teeth, pain on mastication, redness and tumefaction of the gum, and augmented flow of saliva. As there is no impairment of the general health, these trifling symptoms must be regarded merely as manifestations of the progress of a physiological process. Such are the normal manifestations.

The most common disorders of second dentition, are (a) those of the mouth and throat; (b) of general nutrition; (c) of the stomach and intestinal canal; these, only, will be considered at present. Other affections often encountered are those of the skin; of the cervical lymphatic glands; of the eyes; of the ears; of the lungs; and of the nervous system.

(a) Oral pain is often intense. It is lancinating or neuralgic in character and may either be limited to the position of the advancing tooth or extend throughout the upper and lower jaws -the region supplied by the dental branches of the trifacial nerve. Sometimes the pain is referred to the eye, the ear, the face, or even to the forehead. Pain associated with tenderness most frequently attends the eruption of the first molars; then there is also redness and marked swelling of the gum, as in primary dentition.

The redness and swelling about an advancing tooth or around a loosened milk tooth may, in debilitated or strumous subjects, extend to the mucous membrane of the whole mouth and give rise to catarrhal stomatitis. Again, as one of the first or second molars advances, the mucous membrane of the gum, directly over the tooth breaks down and a circular ulcer is formed. This ulcer possesses all the characteristics of the marginal ulcer of ulcerative stomatitis, and is very liable, provided such favoring

*For order of eruption of milk teeth, see "STARR: Diseases of Digestive Organs in Children," page 86.

conditions as scrofula, over-crowding and bad hygiene exist-to run around the alveolar border, and extend to the inside of the cheek. A case has recently been under my care, in which all of the six year molars were cut in this way, the resulting ulcerative stomatitis producing considerable discomfort, but yielding readily to treatment.

Superficial ulcers upon the edges and tip of the tongue are often encountered. These ulcers correspond in position and number to loosened and perhaps decaying deciduous teeth; are due to constant irritation of the mucous membrane; are the seat of moderate pain, and more or less interfere with the movements of the organ in mastication and speech. They vary in shape and size but are generally oval, with the greater diameter-rarely more than half an inch-extending in the direction of the axis of the tongue. Their bases are smooth, red and shining, and their edges red, indented, somewhat indurated and surrounded by a narrow band of white fur formed upon the neighboring healthy epithelium.

A boy, ten years old, was recently brought to consult me about the condition of his tongue. Nearly two months before the anterior deciduous molars had commenced to loosen. Soon after two ulcers appeared upon the tongue at points corresponding to the loose teeth in the lower jaw. These caused considerable discomfort and interfered with the movements of his tongue. Six weeks later the four loose teeth were extracted. At the time of his visit the points of the permanent teeth were distinctly visible. The ulcers, which presented the characteristics already described, were present, too, but they were much contracted and evidently in process of healing. This case is a clear illustration of the etiology of the condition, and of the rapid effect of the removal of the cause.

Loss, or perversion of taste, depending upon reflected irritation of the gustatory and glosso-pharyngeal nerves, has occasionally arisen in my experience. It is a feature that may be readily overlooked in childhood, and without doubt has never received due credit as a cause of the anorexia so often observed during second dentition.

Of throat affections, simple hypertrophy of the tonsils and follicular tonsilitis seem particularly apt to arise in late childhood. The extension of catarrhal inflammation from the mouth to the throat is certainly an element in the causation of the conditions, though anorexia, imperfect digestion and fever are more potent, as they lead to impaired nutrition and increased sus

ceptibility to the action of cold and bad hygienic surroundings. The treatment of this class of affections must vary with the symptoms presented. Should there be much inflammation and pain about a loose tooth, great relief can be obtained by painting the gum three or four times daily with a solution of:

R. Cocaine hydrochlorate........

Glycerinæ......
Aquae, q. s., ad....

M. S. For local use.

gr. iv. tzii.

fzi.

When the first or second molars cause the trouble, free lancing with an oblique crucial incision, is to be recommended. Much good can also be done in the way of softening the gums and lessening pain by a thorough application of:—

M. S. Apply to tender gums with a brush or soft cloth thrice daily. Such measures, too, will be more successful in relieving referred pains than any direct application to the place of reference. Catarrhal and ulcerative stomatitis demand the usual methods of treatment.

Superficial ulcers on the tongue can often be healed by a daily application of a solution of nitrate of silver (ten grains to one fluid-ounce) and the frequent use of a borax or chlorate of potassium wash (fifteen grains of either to one fluid-ounce). Should there be much pain and discomfort, the solution of cocaine recommended above may be used two or three times daily. When the deciduous teeth are decayed, however, nothing short of their extraction will cure the ulceration.

Nothing can be done for loss or perversion of taste except removing loose teeth and freely lancing the gum over advancing molars.

Hypertrophy of the tonsils and follicular tonsilitis must be treated in the same way as when they occur independently of dentition, the question of the propriety of extraction and of lancing being always borne in mind.

(b) After safely passing through primary dentition children usually grow robust and enjoy good health, unless they be attacked by some one of the acute contagious diseases to which their age is liable. This state of affairs may happily endure throughout the remainder of childhood, but it is often supplanted, during the sixth and following years, by a condition best described as one of "general debility."

This ill-health is neither produced by disease of important viscera, as of the lungs, heart, kidneys and digestive organs, nor can bad hygiene be blamed in many cases. For the explanation one must look rather to an impairment of nutrition, resulting from the constitutional strain of cutting the second teeth, from the moderate fever associated with the process, and from the diminished consumption of food, attending oral discomfort and painful mastication. The severity of the symptoms depends somewhat upon the general vigor of the subject, though in my experience it bears little or no relation to the difficulty or ease of cutting the milk teeth.

Early in the sixth year, children so affected begin to lose their rosy cheeks; the lips grow pale; the skin of the body becomes sallow and harsh; the hair dry and lustreless, and there is moderate loss of flesh with flabbiness of the muscles. The face wears an anxious expression and the temper is unstable; by day frequent complaints of weariness are made and little interest is taken in play, while at night sleep is restless and there is often slight fever. Pain and discomfort in the mouth are constant symptoms and as these are increased by mastication, there is apparent anorexia. Examination of the mouth reveals redness, swelling and tenderness of the gums over advancing molars, or if these have been cut, around loose temporary teeth. The bowels are inclined to constipation and the urine limpid and voided in abundant quantity; the pulse is rather feeble though normal in frequency, and, as a rule, there is no cough nor other alteration in the respiratory function. Careful investigation shows an absence of lesion in the heart, lungs or kidneys, and of disease of the abdominal glands or digestive tract. As the teeth of the advancing group are cut, the symptoms disappear, to return with the approach of each succeeding group, but the anterior molars generally give rise to more marked disturbance than any of the teeth that replace the temporary set.

In addition to the ordinary risk of intercurrent disease, existing in every case of general debility, the condition just described is very apt to be complicated by bronchitis or catarrh of the gastro-intestinal canal. Pyrexia, although it is comparatively slight in second dentition, accounts for this, for a feverish child is very susceptible to cold, and very liable to have his digestion disorded by food upon which he has previously thriven. The first cause, by driving the blood from the surface, produces bronchitis; the second, by direct and indirect irritation, leads to

catarrh of the mucous membrane of the stomach and bowels. This knowledge taken in connection with the course and history of the case and the condition of the mouth, should enable the observer to attribute the illness to its proper source rather than to any complicating affection although the latter undoubtedly accentuates the symptoms, and may force itself into prominence. The negative results of physical exploration of the heart, lungs, and abdominal organs,-particularly the mesenteric glands-and of examination of the urine, are also important in establishing the correct relations of cause and effect.

Careful regulation of the diet and the administration of tonics, the methods of treatment that would naturally be suggested, are of little avail, unless oral pain and difficulty of mastication be relieved. Even then, it is often impossible, to do more than maintain a moderate degree of health until advancing teeth are completely free.

Free lancing of the gums over molars, the application of cocaine to painful gums surrounding loose temporary teeth; the extraction of these when the substituting teeth are so advanced as to run no risk of impairing the arch of the jaw; regulation of the diet and hygiene, and the employment of tonics and laxatives are the measures to be recommended. The diet must be simple, non-farinaceous and nutritious; it is better to allow four small meals a day than three large ones. Of tonics a good formula is:

R. Tr. nucis vomicæ........

Elix. cinchon. ferrat..
Syrupi.........

Aquæ, q. s., ad..............

mxij.

f3vj.

f3ss.

fziij.

M. S. Two teaspoonfuls thrice daily at the age of six years. Syrup of the iodide of iron, bitter wine of iron and an emulsion. of cod-liver oil with lacto-phosphate of lime, are also very useful. The best laxatives are fluid extract of senna, which may be combined with the tonic mixtures; tincture of aloes and myrrh in small doses three times daily, compound licorice powder, gluten suppositories or laxative tamarinds.*

Bronchitis and catarrh of the gastro-intestinal canal demand active attention and little else can be accomplished until they are relieved.

(c) Disorders of the digestive system, while unattended by such marked symptoms and rarely reaching the same degree of danger as in primary dentition, are among the most common of the disturbances produced by the eruption of the second teeth.

*See "STARR: Diseases of Digestive Organs in Children," page 211.