A SYSTEM 
OF 
ORAL SURGERY: 
- 
V 
BEING A TREATISE ON THE 
DISEASES AND SURGERY 
OF THE 
MOUTH, JAWS, FACE, TEETH, 
AND 
ASSOCIATE PARTS. 
BY 
JAMES E. GARRETSON, A.M., M.D., D.D.S., 
President of the Medico-Chirurgical Hospital, and Emeritus Professor of Oral and General 
Clinical Surgery in the Medico-Chirurgical College; Dean of the Philadelphia 
Dental College; Surgeon in Charge of the Hospital of Oral Surgery; 
Member of the Philadelphia County Medical Society, etc., etc. 
Illustrated tuith Humorous Wooi-tuts mid Steel plates. 
FIFTH EDITION, THOROUGHLY REVISED, WITH ADDITIONS. 
PHILADELPHIA: 
J. B. LIPPINCOTT COMPANY. 
LONDON: 10 HENRIETTA STREET, COVENT GARDEN. 
189 0. Copyright, 1881, by J. B. Lippincott & Co. 
Copyright, 1884, by J. B. Lippincott & Co. 
Copyright, 1890, by J. B. Lippincott Company. I Dedicate This* 
THE FIFTH EDITION OF MY WORK, 
IX WARM AFFECTION, TO THE 
GARRETSONIAN SOCIETY, 
ADDING TO THE ELEVEN HUNDRED NAMES CONSTITUTING ITS MEMBERSHIP, 
THAT OF MY GRANDSON, 
EDMUND GARRETSON COOK. PREFACE TO THE FOURTH EDITION 
In presenting the fourth edition of this work to a professional public, the 
author desires to acknowledge the encouragement and stimulation derived 
from the continued generous reception and the constantly-increasing sale. 
The present book is enlarged by addition of several chapters on subjects 
not heretofore embraced. Exertion has been increased to condense and sim- 
plify. Illustrations to the extent of seventy-five new cuts have been added. 
Every part of the volume has been rearranged, rewritten, or complemented. 
The fact that this 11 system" has come into common use by dental colleges 
makes desirable unexceptionable fulness in the direction of things considered 
by the specialty. Effort has been made to have no principle absent. Irrele- 
vant matter is not present to perplex. 
The teachings and demonstrations being prepared specially for the guidance 
of students and practitioners of oral surgery, the author offers them as a 
result of thirty years of practice. Time has been taken for experimentation, 
for consideration, and for execution. The responsibility has been continuously 
in mind. The writer has done all he finds himself able to do. 
It is desired to express special obligation to Professor D. Hayes Agnew 
and Dr. James W. White for the free use of costly diagrams, and to the 
publishers for the courteous attention and care shown while the work was 
passing through the press. 
J. E. G. PREFACE TO THE FIFTH EDITION. 
The interim between the present and the immediately preceding edition of 
this book has been occupied in a continuation of work by its author with 
view to enlarging and elaborating experiences that might prove of benefit to 
his patients, his students, and himself. An observer, in looking over the vol- 
ume in hand, and comparing it, even with the last of former issues, will find 
continued increase in the way of new chapters, together with many added illus- 
trations, while alterations and interpolations will meet his eye on almost every 
page. This new matter and manner replace in no sense the old, for the 
writer, happily, is without occasion to change any opinion or judgment that has 
been advanced. The meaning of the additions lies with the rapid growth and 
advance of the specialty. As to change of manner to be seen, this is with 
view to a still further condensation of the matter of the book and to such 
elaboration in way of presentation of the subjects treated in it as shall make 
them easier of comprehension by a student, and, if possible, more practical. 
Oral surgery, twenty years back, was without so much as a name. To- 
day, oral surgery, as a specialty in medicine, is not surpassed, as to its range 
and as to requirements looked for on the part of its practitioners, by any de- 
partment of the healing art. It has become what it is by reason of the need 
for its existence. 
As expounded in the present work, and as the specialty might not other- 
wise have existence, oral surgery includes dentistry; it includes it in a purely 
surgical sense, thus assuming dentistry to be, not a profession in itself, but part 
of medicine at large; such assumption being founded on an experience which 
clearly enough exhibits that where medical knowledge is lacking dentistry is 
of very little use to a community. 
What oral surgery is, and what dentistry is when practised from the stand- 
point of oral surgery, it is left to the volume to show. 
The author is under large and continued obligations to Professor D. Hayes 
Agnew and to Dr. James W. White, whose generosity has contributed largely 
VII VIII 
PREFACE TO THE FIFTH EDITION. 
to the free illustration of his work. He is also indebted to Professor J. M. 
Da Costa for loan of cuts. The legends of the anatomical illustrations are 
mostly from the invaluable work of Professor Joseph Leidy. Dr. Formad, 
Pathologist to the University of Pennsylvania, has freely contributed of his 
skill in the way of microscopic drawings. Certain of the cuts that appear in 
the section on Harelip, from Ashhurst's " System of Surgery," have been 
kindly loaned by the Messrs. Lea. Also indebtedness is to be expressed to 
them for use of some half-dozen of the diagrams employed in illustrating the 
pages treating of Partial Dentures. The surgical instrument makers of his 
city have been profuse in their offers of illustrative help, and it is a pleasure 
to mention especially the names of Kolbe, Gemrig, and Lentz. As to his pub- 
lishers, the J. B. Lippincott Company, the work itself shows them to have 
spared neither time nor expense in its production ; they have denied its author 
nothing. 
1537 Chestnut Street, Philadelphia, 1890. 
The Author. CONTENTS. 
CHAPTER I. 
DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
PAGE 
Introductory-The Human Head-Form of Head-Skull-Skeleton of the Mouth- 
Skeleton of the Nose-The Orbital Cavity-Canine and Myrtiform Fossae-Alveolar 
Processes-Temporal, Zygomatic, and Spheno-maxillary Fossae-Pterygo-maxillary 
and Spheno-maxillary Fissures-Sutural Relations of Skull-Superior and Inferior 
Maxillary Bones-Palate Bone-Vomer Bone-Turbinated Bones-Ethmoid Bone- 
Sphenoid Bone-Nasal Bone-Malar Bone-Lachrymal Bone-Hyoid Bone-Frontal 
Bone-Occipital Bone-Temporal Bone-Parietal Bone 25 
CHAPTER II. 
THE MUSCLES OF EXPRESSION AND MASTICATION. 
Fronto-palpebral, Nasal, and Oral Groups of Muscles-Relations and Actions of Muscles 
of Expression-Blood-vessels, Nerves, and Lymphatics of Muscles-Description of 
Individual Muscles-Muscles of Mastication ........ 69 
CHAPTER III. 
ARTERIES AND VEINS OF FACIAL REGION. 
The Heart-General View of Head Circulation-Arterial Circulation of Facial Regions 
-Primitive Carotid Arteries-External Carotid Arteries and Branches-Internal 
Maxillary Arteries and Branches-Internal Carotid Arteries and Branches-Circle 
of Willis-Analysis of Venous Circulation of Head and Neck-Vena Cava Superior- 
Jugular Veins, External and Internal-Formative Branches of Jugular Veins- 
Internal Maxillary Vein-Sinuses of the Dura Mater-Temporo-maxillary Vein and 
Tributaries . .............. 80 
CHAPTER IV. 
LYMPHATIC VESSELS AND GLANDS OF THE HEAD. 
Office of-Lymph-Vessels-Glands-Glands and Vessels of Cranium-Superficial of 
Face-Deep of Face-Superficial of Neck-Regions and Number of Glands . . 99 
CHAPTER V. 
THE FACIAL NERVE. 
Diagram of Distribution-Anatomy of Origin-Nerves of Communication-Nerves of 
Distribution .............. 103 
IX X 
CONTENTS. 
CHAPTER VI. 
FIFTH PAIR OF NERVES. 
PAGE 
Diagram of Distribution-Diagram of Origin-Character of Nerve-Ganglion of Gasser 
-Ophthalmic Branch-Primary Division and Ultimate Distribution of Ophthalmic 
Branch-Superior Maxillary Branch-Relation with Meckel's Ganglion-Supply of 
Teeth-Branches all Sensory-Primary Division and Ultimate Distribution-Inferior 
Maxillary Branch-Compound Character of-Supply of Muscles of Mastication- 
Gustatory Nerve-Supply of Inferior Teeth-Primary Division and Ultimate Dis- 
tribution-Ganglia and Functions of Fifth Nerve 106 
CHAPTER VII. 
THE MOUTH. 
Boundaries of Oral Cavity-Vestibule-Lips and Cheeks-Mucous Membrane-Mucous 
Glands-Fraena-Sectional Dissection of Mouth-The Tonsil Glands-The 
Tongue-The Epiglottis-The Salivary Glands-The Temporo-maxillary Articula- 
tion 122 
CHAPTER VIII. 
ANATOMY OF THE TEETH. 
A Tooth a Body sui generit-Dissection of a Tooth-The Pulp-The Dentine-The 
Enamel-The Ceinentum-The Periodonteum-The Interglobular Spaces-Relation 
of Teeth with Jaw-The First and Second Sets of Teeth-Classification of Teeth- 
Descriptions of Teeth-Analysis of Dentine-Analysis of Enamel-Analysis of 
Cementum 135 
CHAPTER IX. 
DENTITION. 
Origin and Meaning of the Term-Origin of the Teeth-The Dental Germ-Tunica 
Propria-Tunica Reflexa-Formation of Dentine-Formation of Enamel-Growth 
of Roots of Teeth-Nutrition of Teeth-Involution of Epithelium-Clinical Con- 
sideration of Dentition-Order of Eruption of Temporary Teeth-Germs of Perma- 
nent Teeth-Antagonism of Permanent and Deciduous Teeth-Absorbed Deciduous 
Roots-Arrangement of Teeth-Articulation of Teeth 145 
CHAPTER X. 
ASSOCIATIVE LESIONS OF FIRST DENTITION. 
Fatality associated with the Period-Irritation-Diseases associated with Denti- 
tion-Stomatitis-Irritative Fever-Diarrhoea-Spasms-Eruptions on Skin of Scalp 
and Face-Lancing the Gum-Hemorrhage in Lancing-Cachexia-Tickling and 
Rawness of Throat-Chronic Angina-Spasm defined . . . . • .161 
CHAPTER XI. 
ANOMALIES OF SECOND DENTITION AND THEIR SURGICAL RELATIONS. 
Teeth Eruption, External or Internal to the Arch-Teeth denied Space in the Arch- 
Encysted Germs-Supernumerary Teeth-Third Dentition-Periodonteal and Peri- 
osteal Associations-Germs with Heterogeneous Development-Illustrations . . 186 CONTENTS. 
XI 
CHAPTER XII. 
THE TEETH AND THEIR DISEASES. 
PAGE 
Caries-Health in the Dental Organism-Causes Provocative of Caries-Serofulosis- 
Rickets-Shapes of the Teeth-Nutritional Circumstances-Relation of Organs with 
each other-Self-cleansing Features-Constitutional Relations-Character of Agents 
in Contact with the Teeth-Mucous Deposits-Acid Secretions-Parasites-Electro- 
chemical Relations-Medicines and Articles of Food-Accidental Influences . . 197 
CHAPTER XIII. 
SURGICAL CONSIDERATION OF DENTAL CARIES. 
Phenomenal Expressions of Caries-Principles of Treatment-Neutralization of Ad- 
verse Oral Fluids and the Induction of a State of General Health in the Mouth- 
Medical Treatment of the Teeth-Characteristics of Saliva-Teeth of Sanguine and 
Allied Temperaments-Teeth having a Blue Shade-Chalky Teeth-Pearly Teeth- 
Soft Dentine-Zinc Chloride-Filing as a Prophylactic and Curative Agent-Vitri- 
faction-Inclined Surfaces-Illustrations in Filing 242 
CHAPTER XIV. 
DENTAL THERAPEUSIS. 
Inertness of Gold as a Filling Material-Therapeutical Plugs-Recalcification of 
Teeth-Oxychloride of Zinc-Gutta-Percha-Copper Dust-Oxide of Tin-Electrical 
Disturbance-Parasiticides-Creasote-Corrosive Sublimate . . . . 252 
CHAPTER XV. 
THE ORAL FLUIDS. 
Saliva-Composition of; Characteristics of-Mucous Oral Detritus-Analyses of Oral 
Fluids-Saliva unduly Alkaline-Healthy Saliva-Parotid Secretion-Submaxillary 
Secretion-Accessory Parotid Secretion-Saliva and Food Bolus-Saliva unduly 
Acid-To make Analysis of Saliva-Abnormal Saliva-Accidental Substances 
found in Saliva-Carbolic Acid and Saliva-Magitot's Experiments with Acids and 
Teeth-Sordes-Excess of Ptyaline-Acids of Fruits in Relation with Soft Teeth . 255 
CHAPTER XVI. 
THE TEETH AND THEIR DISEASES. 
ODONTALGIA. 
Causes of Toothache-Sensitive Dentine-Exposure of Pulp-Disease of Periodon- 
teum-Pus and Gas in the Pulp-Cavity-Granules of Osteo-dentine in a Pulp- 
Sympathetic Toothache-Recession and Absorption of Gum and Alveolus . , 263 
CHAPTER XVII. 
THE TEETH AND THEIR DISEASES. 
PERIODONTITIS. 
Synonymes-Acute Periodontitis-Chronic Periodontitis-Case of Ringed Root- 
Treatment of Periodontitis 286 XII 
CONTENTS. 
CHAPTER XVIII. 
THE TEETH AND THEIR DISEASES. 
ALVEOLO-DENTAL ABSCESS. 
PAGE 
History and Meaning of-Local Features of-Prophylaxis of-Abortive Treatment of- 
Anomalous Cases of-Discoloration of Dead Teeth-Abscess venting upon Cheek- 
Abscess associated with Wisdom-Teeth-Abscess and Maxillary Sinus-Osseous Cysts 
and Abscess-The Nares and Alveolo-dental Abscess-The Wisdom-Teeth and Alveolo- 
dental Abscess-The Duct of Steno and Abscess-Discharge of Abscess through 
Dental Foramen-False Abscess-Chronic Abscess-Rheumatic Diathesis-Gout in 
Abscess-Discharge of Pus-Abscess discharging through Pulp-Canal-Counter- 
Outlet-Improper Canal Filling as Cause of Abscess-Malarticulation-Abscess as- 
sociated with Temporary Teeth-Imprisoned Teeth-Protoplasmic Degeneration- 
General Indications . ' . . . . 292 
CHAPTER XIX. 
THE TEETH AND THEIR DISEASES. 
THE PULP-CHAMBER AND CANALS. 
Death of Pulp-Removal of, from Cavity-Multiple-rooted Teeth-Indications fol- 
lowing Removal of a Dead Pulp-Littlejohn's Flexible-shafted Bur-A Temporary 
Canal Filling-Retention of Test Filling-Continuous Irritability-Causes of-Per- 
manency of Quiet-Gold in Root Filling-Cotton and Gold conjoined as a Canal 
Filling-Gold forced beyond Foramen-Enlarging a Canal-The Broach-Conduc- 
tion and Non-conduction-Rest-Filling over Exposed Pulps-Illustration-Thin 
Plate of Dentine-Oxychloride of Zinc as a Pulp Capping-Oxychloride of Zinc 
as an Intermediate-Pain as Result of Capping Application-Quill as a Capping- 
Oiled Silk as a Capping-Oxysulphate of Zinc-Various Preparations used for 
Capping-Orifices with Jagged Edges ......... 306 
CHAPTER XX. 
DISCOLORED TEETH. 
Impossible to restore Translucency in a Dead Tooth-Checking advancing Discolora- 
tion-Bleaching-Removal of a Bleaching Agent-Zinc used in Place of Lime- 
Bleachers-Chlorate of Potassium as a Bleacher-Labarraque's Solution-Immediate 
Bleaching-Whitening-Manners of Whitening-Haematin as a Discolorer-Dead 
Pulp as a Discolorer-Whitening rather than Bleaching ...... 316 
CHAPTER XXI. 
REPLANTATION, TRANSPLANTATION, AND IMPLANTATION OF TEETH. 
Definition of Terms-Initiative Performance-Replantation-Mistakes in Extraction 
-Dental Abscess-Treatment of a Tooth to be replanted-Treatment of the Socket 
to be occupied-Relation of an Extracted Tooth and Cavity-Closing an Outlet- 
Artificial Fistule-Drain-Tubes-Gold Apices-Transplantation of Brutes* Teeth into 
Human Sockets-Report of Cases-Length of Time a Tooth may remain unused- 
Advantage lying with Root-Canals filled after Extraction-Tooth replanted in 
Restitution-Tooth transplanted by Transposition-Implantation an Unsurgical 
Procedure-Method of-Practice-Preliminary Treatment of Tooth-Preparing the 
Cavity-Exposing the Bone-Removing Periosteum-To cut Cavity in Bone-Ob- 
jection to Trephine-Reamer Blades-Ottolengui's Bur-Spiral Knives-Younger's 
Reamers-Anatomy of the Maxillae-Dental Canal-Implanted Teeth as Posts for 
Bridge-Work-Theories concerning Reunion-Absorption of Planted Roots-Illus- 
trations from Practice of Dr. Weld 320 CONTENTS. 
XIII 
CHAPTER XXII. 
DENUDATION. 
PAGE 
Common Seat of the Disease-Diversity of Opinion concerning Cause-Electro-chemi- 
cal Experiments of Kencely Bridgman-Abrasion of Cutting Faces-Caused by Mal- 
articulation-Influence of Food-Treatment 335 
CHAPTER XXIII. 
OPERATIVE DENTISTRY. 
INSTRUMENTS USED IN PREPARATION OF CAVITIES. 
Illustration of a Perfect Denture-Imperfect Denture-Size, Shape and Location of 
Cavities-Excavators-Drills, Rose and Spear-Merry's Drill-Bur Thimble-Dental 
Engine - White's and Bonwill's Engines - Chisels - Jack's Double-end Enamel 
Chisels-Files-File-Carriers-Miller's File-Carrier-Forbes's File-Carrier-Line's 
File-Carrier-Saws used for separating Teeth-Clapp's and Kaeber's Saw-Carriers 
-Corundum Disks-Objects of Saws and Corundum Disks-Other Means of sepa- 
rating Teeth-Drop-Tubes-Herrick's Fountain Drip-Point-Chip-Blower-Water- 
Syringes-Exposure of Cavities-Wedges-Anagnostakis's Ophthalmoscopic Glass . 337 
CHAPTER XXIV. 
OPERATIVE DENTISTRY. 
EXCAVATION, OR PREPARATION, OF CAVITIES FOR FILLING. 
Simple Cavities-Complicated Cavities-Approximal Cavities-Illustrations of-Use of 
Convex File-Use of Chisel-Use of Separators-Modification of Excavators- 
Cavities in Bicuspid Teeth-Complications in Cavity Relations-Grinding Faces of 
the Bicuspidati-Approximal Faces of Molars-Excavating for Contour Filling- 
General Rules for Excavating-Regard to Proximity of Pulp-Tact and Rules-Prac- 
tice out of the Mouth-Herbst's Obtunder-Nitrous Oxide Spray as an Obtunder . 351 
CHAPTER XXV. 
OPERATIVE DENTISTRY. 
RELATIONS OF MOISTURE. 
Necessity for Dryness-Dental Napkin applied to Lower Denture-To hold a Floor- 
Pad firmly-Flagg's Tongue-Holder-Morrison's, Smith's, and Osborn's Compressors 
- Dibble's Saliva-Pump-McQuillen's Extension-Finger-Taft's Thimble-Rich's 
Duct-Compressor-Barnum's Rubber Dam-Application of Rubber Dam-Depressed 
Dam and Mirror-Means for holding Rubber in Place-Rubber-Dam Applier- 
Clamps-Forms of Clamps-To put on Clamps-Application of Rubber to Special 
Cases-Coffer-Damming viewed Mechanically and Surgically-Direct Drying of 
Cavity-Rubber Dam applied.-Hot-Air Syringe 362 
CHAPTER XXVI. 
OPERATIVE DENTISTRY. 
MATERIALS USED IN FILLING TEETH. 
Amalgam-Difference between an Alloy and Amalgam-Townsend's Amalgam and 
Formula-Claims for Different Preparations-Flagg's Submarine Alloy-" Usual" 
Alloy-" Contour" Alloy-" Front-Tooth" Alloy-" Facing" Alloy-Weston's Soft 
Alloy-Tin, Silver, Zinc, Copper, Gold, Platinum, and Cadmium as Components of 
Alloy-Edge Strength in Alloy-Plasticity in Alloy-Fusing-Point of Metals used 
in making Dental Alloys-Making an Alloy-Cutting an Alloy-Cleaning an Alloy 
-Aging Alloy-Influence of High Melting-Point in Metals on the Setting of Amal- XIV 
CONTENTS. 
PAGE 
gam-Bulging or Spheroiding-Qualitative Testing of Amalgam Alloys-Tests for 
Tin, Gold, Platinum, Copper, Silver, Cadmium, and Zinc-Manner of using an Alloy 
-Mercury-Plug Mass-Chloride of Zinc-Employment of Amalgam necessitated- 
Explanation of Bad Repute-Manner of introducing Amalgam Fillings-The Plug 
Mass-Kneading the Mass-Amalgam Carriers-Amalgam Pluggers-Illustrations 
in Amalgam Practice-Objections urged to Use of Amalgam-Putrescency of Pulp- 
Temporary Salivation-Bad Taste in the Mouth-Systemic Complications in Con- 
nection with Use of Amalgams-Place for, and Use of, Amalgam-Formulae for 
making Amalgam-Chemistry <jf Amalgam-Gutta-Percha-Compatibility with 
Tooth-Bone-Resistive Character of Gutta-Percha-Brittleness in Gutta-Percha- 
Test of Quality of Gutta-Percha-Hill's Stopping-Use of Gutta-Percha in Seasons 
of Dental Metamorphosis-Red Gutta-Percha-Instruments used with Gutta-Percha 
-Introduction of Material into Cavity-Smith's Plastic Fillers-Stickiness- 
Cooling and Hardening-Forms in which Gutta-Percha is furnished-Oxychloride 
of Zinc-Formula of-Shading-Mixing Plug Mass-Use in Frail Teeth- 
Viewed Mechanically-Freedom from Moisture-Expediting Setting-As Founda- 
tion for Gold-Temporary Nature-As a Support to Frail Walls-Zinc Phos- 
phates-Difference as to Material-Varieties-Phosphoric Acid less an Irritant than 
Chloride of Zinc-Cement Plombe-Lasting Capability of Zinc Phosphate Fillings 
-Pierce's Formula for making Zinc Phosphate-Manner of working-Tests of a 
Good Material-Tin as a Filling Material-For Usein Children's Teeth-Plastic Tin 
-Tin-Gold-Herbst's Glass Filling-Gold as a Material for Filling Teeth-Variety 
as to Form-Watt's Crystal Gold-Sheets-Mats-Pellets-Cylinders-Blocks- 
Ribbons-Twists 374 
CHAPTER XXVII. 
OPERATIVE DENTISTRY. 
FILLING TEETH. 
Filling Teeth with Gold, Non-Cohesive-Use of Cylinders, Mats, Ribbon, and Twist- 
Plans of filling Teeth, using Non-Cohesive Gold-Redman's Pluggers-Cavities 
Difficult of Access-Matrices-The Loop Matrice-The Jack Matrice-Guilford's 
Matrices-Miller's Matrice-Application of Matrice-Using Cohesive Gold-Heavy 
Foils-Cohesive Gold and Atmospheric Influences-Annealing-Sun-Rays as an 
Annealer-Instruments for working Cohesive Gold-Atkinson's Pluggers-Butler's 
System-D. D. Smith's Set-Abbott's Pattern-College Operating-Case-Fillings of 
Cohesive Gold-Practical Experiment in working Cohesive Gold-Simple Crown 
Cavity-Approximal Cavities-Plans of filling Cavities-Bicuspid Teeth and Plan 
of filling-Filling Lower Teeth-Gold Crowns-Contour Filling-Preparation for 
Contouring-Illustrations from Marshall Webb-Studies from Dr. Weld-Contour 
Work in Progress-Plans for Contouring-Automatic Mallets-Bonwill's Electro- 
magnetic Mallet-Buckingham's Mallet-Holmes's Mallet-Rotation Method of fill- 
ing Teeth-Finishing a Plug-Burnishing Instruments-Porte Polishers-Corun- 
dum Disks-Hard Stone-Corundum Tape-Corrugated Disks-Wood Points-Con- 
densing a Surface-Condensation of a Filling-Finishing Approximal Surfaces- 
Polishing and Finishing a Filling-Dressing Contour Fillings-Principles govern- 
ing filling Teeth-Plugs made of Cohesive Gold Defective-Tin-Gold-Operating- 
Chair-Office Conveniences 396 
CHAPTER XXVIII. 
OPERATIVE DENTISTRY. 
THE EXTRACTION OF TEETH. 
Indications for Extraction-Dead and Loose Teeth-Teeth being thrown off-Teeth 
having Fungoid Excrescences-Teeth afflicted with Incurable Abscesses-Teeth PAGE 
unduly crowded and wedged-Teeth unduly sympathetically involved-Teeth 
associated with Antral Disease-Teeth worn to the Gums-Teeth without Useful- 
ness- Roots interfering with Comfort-Removal of a Tooth-Consideration of the 
Different Classes of Teeth-Extraction of Teeth considered by Classes-Six Classes 
-Instruments used for Extraction-Incisor Forceps-For Superior Incisors-For 
Superior Laterals-For Inferior Centrals and Laterals-Special Forceps-Forceps 
adapted to the Ten Anterior Upper Teeth-Study of Root of Cuspidatus-Forceps 
for extracting Cuspid and Bicuspid Teeth-For extracting Superior Molar Teeth- 
Treatment of Anomalous Roots-Teeth out of the Arch-Forceps to be used on 
LTpper Molar of Both Sides-Cow-Horn Forceps-Application of Cow-Horn Forceps 
-Combination Forceps for Superior Molar Teeth-Harris's Wisdom-Tooth Forceps- 
Cow-Horn Forceps for Lower Molars-Wolverton's Forceps-Hutchinson's Lower 
Molar Forceps-Booth's Claw-Forceps-Forceps for Superior Wisdom-Teeth-Treat- 
ment of Bifurcating Roots-Physick's Forceps-Key Instrument-To use the Key- 
Elevators-To use Elevators-Forceps for Lower Wisdom-Teeth-Fulcrum Forceps- 
E. M. Jones's Forceps-H. II. Perrine's Forceps-Modifications of the Key-Con- 
cerning Fulcrum Forceps-Hurd's Forceps-Extraction of Fractured Teeth and 
Roots of Teeth-Illustrations in Root-Extractions-To use Cutting Forceps-Trial 
with Elevator to precede Cutting-Illustration-Dental Screw-Dubs's and Hulli- 
hen's Compound Forceps-Use of Compound Forceps-Removal of Molar- and 
Wisdom-Teeth Roots-Beaked Forceps-Illustration of Root Forceps-Sub-alveolar 
Forceps-Deformed Teeth-Illustration in extracting Deformed Teeth . . . 428 
CHAPTER XXIX. 
OPERATIVE DENTISTRY. 
GENERAL REMARKS ON EXTRACTION. 
Association of Teeth with Alveoli-Influence of Associate Relation with Extraction- 
Fracture attending Extraction-Laceration of Gum-Paralysis following Extrac- 
tion-Hemorrhage after Extraction-Hemorrhage of Local Signification-Hemor- 
rhagic Diathesis-Illustrative Cases-Erigeron Canadense as an Haemostatic- 
Hemorrhage dependent on the Typhoid Condition-Purpura as a Predisposition- 
Vicarious Hemorrhage-Use of Cardiac Sedatives-Lead and Opium-Rest a Means 
-Signification of Local Treatment-Clotting Agents-Astringents and Stimulants 
-Alum as an Haemostatic-Chemical Astringents-Actual Cautery-Compression in 
Hemorrhage-Luxation of the Inferior Maxilla-Local Anaesthetics in Extraction- 
Ice as a Local Anaesthetic-Aconite-Chloroform and Laudanum-Strong Iodine 
Tincture-Electro-galvanism-Ether and Rhigolene Spray-Evaporating Ether- 
Objection to Cold-Hydrocarbon not satisfactory-Cocaine-Nitrous Oxide . . 452 
CHAPTER XXX. 
OPERATIVE DENTISTRY. 
CAP-CROWNING, THE PIVOTING PROCESSES, AND BRIDGE-WORK. 
Broken Teeth-Metal Cap-Crowns-Likeness to Enamel-Cap-Illustration of Cap- 
Crowns-Making and applying a Cap-Crown-Crown-Surface, how made-Talbot's 
Cap-Crown-Bing's Method-Cryer's Plan-Starr's Root Reducers-Pivot Teeth- 
Devitalizing Pulp-Consideration of Pulp-Pulp Nodules-Excising Forceps- 
Crown Saw-Pivot File-Clearing the Canal-Use of Dental Engine-Selection of a 
Crown-Accuracy of Fit of Crown-Hand-Lathe-Foot-Lathe-Grinding Instru- 
ments-Character of Pivots-Faulty Articulation-Inflammatory Complication- 
Metal Pivot Case-Screw Receiver-Canals out of Correspondence-Carious Roots 
-Combination Pivoting-Vulcanized Pivot-Mack's Screws-Flagg's Method of 
Pivoting-Dennet's Plan-Bonwill's Method-Amalgam a Discolorer-Pivoting to 
CONTENTS. 
XV XVI 
PAGE 
correct Irregularity-Fixation by Slots-Porcelain Facing-Rambo's Porcelain 
Facing-liarrower's Method of Porcelain Facing-Diamonds in Teeth-Plastic 
Facings-Ferruling-Bonwill's General Views of Pivoting-Means for Escape of Gas 
-Objection to Use of Amalgam-Use of a Collar-Excising the Crown-Shape of 
Root-Posts, or Pins-Crown Adjuster-Grafting Crowns-Darby Crown-Stowell 
Crown-Parmley Brown Crown-Dewey Crown-Richmond Crown and Method of 
Mounting-Kirk's Method-Meriam's Method - How's System - Dovetail Tooth- 
Crown-Logan Crown and System-Logan's Method of Setting-Measuring a Root 
-Fitting Crown-Recess for Amalgam-Distal Root-Gutta-Percha as a Fixer of 
Crowns-Combination Holder-Dryness a Necessity in Setting-Gates's Crown and 
Method - To make Crown-Seat-Gauge - Face-Extension Wheel - Supplemental 
Gauge-Staple as Bond between Body and Root-Consideration of a Possible 
Pathological Condition-Advantage of Open Passage-Amalgam as a Setting Agent- 
Gutta-Percha as a Holder-Reaming the Canal-Determination of Position of Crown- 
Seat-Adaptation to Bridge-Work-How's Crown and Setting-Manner of Setting- 
Special Cases-Decayed Root-Use of Tapering Post-Bridge-Work-Necessity for 
Skill and Understanding-Introductory of the Subject-Illustrative of a Bridge- 
The making and articulating of a Bridge-Studies in Bridge-Work-Removable 
Bridge Denture-Richmond's Work-Illustration in Bridge-Work-Curtis's Bridge- 
Removal of Bridge-Porcelain Facings on Living Teeth-Brown's Porcelain Bridge- 
Work-Composition of Bridge-No Occasion to excise Teeth or devitalize Pulps- 
Manner of Attachment-Extension of Wings-Method of making Porcelain Bridge- 
No Occasion for Use of Pins-Baking-Test for the Baking-Attachments-Material 
used for Anchoring-Preparatory to fixing Bridge-Seamless Collars-Reducing- 
Plates and other Instruments-To secure Measure and Shape of Root-Evans's System 
of Seamless Gold Contour Crowns-Method of inserting Seamless Gold Contour Crowns 
-Preparation of the Natural Crown or Root-Restoring by Amalgam-How to select 
a Suitable Crown-Measuring Cervix of Root to be crowned-Fitting the Crown- 
Enlarging Collar-Shaping Collar or Side of Crown-Examining the Occlusion- 
Strengthening the Crown-Packing the Prepared Filings-Trimming away Excess 
of Solder-Suggestion of Insecurity-Cementation-Addendum ..... 461 
CHAPTER XXXI. 
OPERATIVE DENTISTRY. 
IRREGULARITIES OF THE TEETH-ORTHODONTIA. 
Condition to be appreciated-Treatment and Dyscrasia-Sex to have Consideration- 
Influence of Age-Character of Alveolar Process-Importance of retaining Decidu- 
ous Teeth-Change induced in Alveoli-Consideration of Results-Causes of Irreg- 
ularity-Foetal Enervation-Syphilitic Impression-Premature Extraction-Undue 
Retention-Nasal Obstruction-Thumb-Sucking-Nipple-Sucking-Complexity in 
Apparatus signifies Lack of Skill-Conditions to consider-Stumpy Roots-Recog- 
nition of Irregularity-Expression as influenced by the Teeth-V-shaped Arch- 
Interference to be deprecated-Natural Tendency to Self-Correction-Teeth held in 
False Position-Character of Correcting Apparatus-Relation of Means to Necks of 
Teeth-Support of Changed Teeth-Illustrative Cases-Regard for Facial Expres- 
sion-Key-stones to the Arch-Overriding Eye-Teeth-Development of Teeth for- 
ward-Slight overriding-Two Lines of Practice-Appliances used in Correcting 
Irregularities-White's Apparatus-Westcott's Appliance-Coffin's System-Dispart- 
ment-Use of Steel Wire-As a Separator-A Second Study-McQuillen's Bar- 
Rubber Rings and Ligatures-Flagg's Method-Extraction of Crowding Teeth- 
Tubing-Bar and Band Operation-Undue Projection of Lower Anterior Teeth- 
Antagonizing Direct Occlusion-Underlying Jaw-Anatomico-physiological Con- 
sideration-Occipito-mental Sling-Fault with Upper Jaw-Kingsley's Method- 
CONTENTS. COSTENTS. 
XVII 
Extraction in Treatment of Protruding Lower Jaw-Redman's Plate-To move a 
Particular Tooth-Antagonism lying with Articulation-Wrench and Screw-Illus- 
trative Cases-From Kingsley-From Farrar-Physiological versus Pathological 
Changes-Motive-Power employed-Special Instruments used-Exhibit-First 
Consideration-Rotation-Application of Farrar's Method-Illustrations-Danger 
from swallowing Small Pieces-Harm over Good ....... 523 
CHAPTER XXXII. 
PROSTHETIC DENTISTRY. 
Preparation of Mouth-Teeth standing Alone and Roots of Teeth-Soft Teeth not 
to be clasped-A Cachectic Mucous Membrane-Congested Membrane-Taking an 
Impression-Trays-A Tray to be Large Enough-Teeth Long and Prominent- 
Modified Trays-Trays with False Bottom-Impression Materials-White Wax- 
Yellow Wax-To soften-Position when taking Impression--Manipulation-Break- 
ing Suction-Before taking an Impression-Bromide of Potassium-Cocaine- 
Hardening the Wax-Sulphate of Lime-Plaster of Paris-Using Plaster of Paris- 
Employing the Material for the Upper Arch-For the Lower Arch-Getting the Im- 
pression-Consistency of Batter-Time required for Setting-Time for Removal 
from the Mouth-Slow-Setting Plaster-Adaptation to Edentulous Arches-Used for 
Partial Impressions-Broken into Pieces-Modelling Compound as an Impression 
Agent-Gutta-Percha for taking Impressions-Troublesome to Manipulate-Gutta- 
Percha and Wax-The Model Plaster Impression and Plaster Model-Insurance 
against Chipping-The Denture-Procedure as related with the Practice of an Oral 
Surgeon-To make a Trial Plate-Plates used for Dentures-Where all the Teeth are 
gone-Plate holding by Atmospheric Pressure-Shape of Palatine Arch-Leather- 
Sucker Cavities-Beer's Disk-Clifford's Disk-Cavities not Necessary-Use of Spiral 
Springs-Articulation-For the Partial Denture-Satisfied as to the Adaptability of 
the Plate-For the Half-Denture-For Articulation of Complete Denture-Peculiari- 
ties as to Articular Relations-False Bites-Articulating a Full Denture in the Mouth 
-Illustration of Articular Relation-Faulty Articulation the Rule-Appreciation 
of Articulation-Addenda-Arranged and ground to suit-Prosthetic Dentistry 
viewed as Art-Work-Artificial Denture relates many Indications-Few Dental 
Artists-Illustration in Arrangement of Teeth-Moffitt's Anatomical Articulator- 
Plaster Articulator-Filling of the Spaces-Unset Teeth-Alsthetical Arrangement 
of the Teeth 544 
CHAPTER XXXIII. 
PROSTHETIC DENTISTRY. 
LABORATORY. 
Mechanical Wants in Oral Surgery-Illustration in Denture-Making-Tools used for 
Vulcanite and Celluloid Work-Tools used for Metal-Work-Laboratory Conveniences 
-Fitting up a Workshop-Vulcanite-, Celluloid-, and Metal-Work-Soldering and 
Appliances-ProperUse of Blow-Pipe-Bunsen Burner-Fletcher's Radial Burner- 
Mellotte's Soldering Appliances-Mellotte's Gas Blow-Pipe-Mellotte's Blow-Pipe 
Pad-Treadle Blow-Pipes-Mouth Blow-Pipes-Soldering : how learned . . 562 
CHAPTER XXXIV. 
PROSTHETIC DENTISTRY. 
THE MATERIALS VULCANITE AND CELLULOID. 
Vulcanizing Process-Dental Plates as an Example-To replace Wax Base with Vul- 
canite-Varnishing and Oiling-Separating Flask-Antagonizing Defects-Packing 
Vulcanite-Forcing the Paste-Vulcanizing Instruments-Consideration of Temper- XVIII 
CONTENTS. 
PAGE 
ature-The Process of Cooling-Concluding Steps in Vulcanizing-Chemical Mean- 
ing of Dental Plate-Vulcanite Plates from a Medical Stand-point-Black and Red 
Vulcanite-Making a Celluloid Denture-New Mode Heater-Repairing Celluloid 
Dentures-Cryer's Method-Herbst's Method-Detaching Teeth from Celluloid 
Plates-Celluloid for Purpose of Continuous-Gum Work-Directions for Working- 
To put on the Gum-Removal of Plate-Celluloid Gum upon Metal Base . . 570 
CHAPTER XXXV. 
PROSTHETIC DENTISTRY. 
ARTIFICIAL DENTURES UPON GOLD OR SILVER BASE. 
Test Plate-To make a Base Plate-Making the Die-Testing Accuracy of Die- 
Making the Counter-Die-Making Die direct from Impression-Measuring the Plate 
-Annealing-Swaging the Plate-Pickling-Filing and Fitting the Plate-Taking 
the Bite-Kind of Teeth used-To secure Kind of Teeth to be used-Grinding and 
Fitting Teeth-Centre of Gravity-Peculiarities of Bite and Peculiar Teeth-Casing 
the Teeth-Backing the Teeth-Soldering the Denture-Parr's Flux-Flux united 
with Wax-Formulae for Silver and Gold Solders-Finishing a Denture-Fitting a 
Plate to the Mouth-Interlocking of Cusps-Biting the Check-Cutting the Labial 
or Buccal Frmna-Intrusion of Plate on Soft Palate-Defect in Suction-Gagging 
and Retching-Pain resulting from Over-Suction-Paralysis of Oral Roof- 
Lower Teeth partly worn away-Gums showing unduly-Rimming a Plate- 
Means for holding Plates in Place-Atmospheric Pressure and Vacuum-Chamber- 
Preparing a Plaster Model for the Mould-The Palatine Rugae-Upper and Lower 
Dentures-Partial Sets of Teeth-Manner of holding Partial Dentures-Bands and 
their Relation with Plate-Making Partial Plates-Continuous-Gum Work-Incas- 
ing Continuous-Gum Work-Asbestos, Sand, and Plaster as the Investing Batter- 
Soldering with Pure Gold-Pickling-Defects-Testing for Warping-Scratching 
the Plate-Building the Gum-Baking Continuous Gum-White's, Teese's, Verrier's, 
and Parker's Furnaces-Charging a Coke Furnace-Baking-Cracking-Putting on 
the Gum-Material used for Continuous-Gum Work-Body Material-Flux-Gran- 
ulated Body-Moffitt's Body Formula-Enamel Formula-Purple of Cassius-To 
make Gum Frit-Caution against Metallic Admixture-Objections to Mineral 
Continuous-Gum Work-Recommendations of-Moffitt's Aluminium Dentures . 581 
CHAPTER XXXVI. 
PROSTHETIC DENTISTRY. 
OBTURATORS. 
Definition of Term-Vela-Where used-Designed to meet Various Indications- 
Simple Obturators-Consideration of Requirements-Means that enlarge an Aper- 
ture-Cotton as an Obturator-Specific Diseases as Cause of Break-Simple Plate- 
To make Obturator-Arching the Palate-Making Dies-Model of Palate in Metal- 
To make a Counter-Model-Conforming a Plate to Die-Modification of Obturator 
-Plan of fixing the Apparatus to the Mouth-Other Modifications of Obturator- 
Illustrative Cases-Vulcanite for Obturators-Desirabode's Obturator-A Complicated 
Obturator-Substances used for making an Artificial Nose-Securing Likeness to 
Flesh-Study in Mechanical Appliances-Springs in Relation with Whiskers and 
Moustache-Origin of Obturators-Garangeot's and Snell's Instruments-Defects in 
the Soft Palate - Mechanical Means for Correction-Steam's Velum-Kingsley's 
Velum-Suersen's Velum-Booth's Velum-Baker's Velum-To secure Lightness 
in Velum-Facial Masks-Principle of the Mask-Masks Complete or Partial-To 
make a Mask-To fit a Mask-Burne's Mask-Steps of Manufacture-Securing 
Fixation to Face.............. 601 CONTENTS. 
XIX 
CHAPTER XXXVII. 
PYORRHCEA ALVEOLARIS. 
PAGE 
Features and Causes-Salivary Calculus and Serumic Deposits as Cause-Lack of Ar- 
ticular Antagonism in the Teeth-Undue Antagonism-Insoluble Dentifrices-Plugs 
in Necks of Teeth-Denture Clasps-Caustic Agents-Sordes-Scurvy-Mercurial 
Medicines-Lack of Use of the Dental Apparatus-Epulic Growths and Necrosis- 
General Debility-Principles of Treatment-Typical Case-Serumic Tartar-Ex- 
pressive of Serumic Deposits-Diagnostic Symptoms-Illustration, by Dissection, of 
Pyorrhoea Alveolaris-Absence of Tartar-Serumic Tartar 639 
CHAPTER XXXVIII. 
SALIVARY CALCULUS. 
Analysis of Saliva-Analysis of Salivary Calculus-Sluggish Salivary Secretions- 
Effects of Salivary Calculus-An Anomalous Condition-Calculi in Steno's Duct- 
Removal of Calculi in Ducts and Glands-Calculus in Substance of Submaxillary 
Gland-An Unique Example-Tartar-Color-Fungi--Treatment of Collections of 
Tartar - Acids in Treatment of Calculus - Parasiticides - Revolving Brushes- 
Serumic Deposit .............. 645 
CHAPTER XXXIX. 
THE GUMS AND THEIR DISEASES. 
Gums, Healthy State of-Accumulations of Tartar-Green and Black Discoloration- 
Yellow Tartar- Periodontitis - Mercurial Impression - Boro-glyceride-Tinctura 
Capsici et Myrrhae-Sloughing-Scurvy-Syphilis-Dead or Loose Teeth-Over- 
crowded Condition of the Dental Arch-Use of Improper Dentifrices and Brushes- 
Dentifrices mechanically and otherwise Irritating-Creasote as an Irritant-Silver 
as an Irritant-Congestion as measured by the Teeth-Borate of Zinc-Borate of 
Potassa-Subiodide of Bismuth-Cases of Hypertrophy-As General Hypertrophy 
of the Gums is concerned-Hypertrophy associated with Vacuum-Chambers- 
Treatment-Example of General Ulitic Hypertrophy-A Second Cause-Depressed 
Conditions of the Life-Force-Anaemic Conditions-Treatment-Congenital Union 
of Gums-Conjoined Malformations-Unique Case-Anomalies associated with In- 
ferior rather than with Superior Orifices-Congenital Adhesions about the Mouth- 
Imperforate Nares-Conjoined Closure of Nares and Mouth-Maternal Impres- 
sions-Stomatitis and Pharyngitis Leucaemia-Specific Disease-Blue Line in Satur- 
nine Affections, and its Pathognomonic Value-Blue Line is the Livery of the Lead- 
Worker-Impossibility of reproducing the Blue Line artificially-The Line is the 
Result of an Elimination of the Lead-Lead Line depending on Deposit of Black 
Pigment-Examination with High Magnifying Powers-Line not the only Effect of 
Lead upon the Gums-Saturnine Gingivitis-Capillary Circulation of the Gum is 
constituted by the Plexuses-Mechanism of the Production of the Line-Osteo-gin- 
givitis Gangraenosa Neonatorum-Proliferative Gingivitis in Pregnancy, or Frog- 
Spawn Gum-Radical Treatment-Gangrene of Gums following the Exanthems and 
other Diseases-Measles is the most Common Condition-Tonicity-Reliance to be 
placed on the Aromatic Sulphuric Acid-Tincture of Calendula-A Rinse to be 
recommended-Touching with Tincture of Iodine-Oidium Albicans-Cryptogamic 
Spores-Cleanliness is a Necessity-Calcified Dentinal Tubules ..... 654 
CHAPTER XL. 
THE APHTH.E. 
Derivation of Term-Ulcers of Various Signification found in the Mouth-Type of the 
Aphthae-Aphtha one with Canker-Analysis-Oidium Albicans not Aphtha- XX 
CONTENTS. 
PAGE 
Thrush-Exhibit of Aphtha through Dissection-Heat and Fever-Double Signifi- 
cation of Thrush-Follicular Inflammation-Termination of Follicular Inflam- 
mation-Relation with Dentition-Confluent Form-Cancrum Oris-The same 
Pasty Bottom-Confined to no Exact Locality-Phagedenic Expression-History 
of Cancrum Oris-Gangraena Oris-Associate of the Dentitional Period-Consti- 
tutional Nature of this Affection conspicuous-Support to Parasites-Variability 
of the Condition-Habitation of the Fungi-Review-Upon the Sores-Infants' 
Sore Mouth-Muguet-Modification which a Hospital gives it-Its Mildest 
Form White-Severe Form Dark-Brownish Color-Red-Affection Symptomatic- 
Disposition to Sleep-The Bowels-Condition of Alimentary Canal-The Stomach 
deranged-Becomes debilitated-Harassed by Severe Colic-The (Esophagus- 
Popular Belief-Coat after Coat of Aphthae-Examined Body after Death- 
Dr. Heberden says-Dr. Good-Not to take too much for Granted-Aphtha 
communicating itself by a Specific Contagion-Complaint occasionally Epidemic- 
Sympathetic Origin of Aphtha questioned-Affection not confined to Early 
Infancy-not essentially accompanied with Fever-Weakly Children Obnoxious 
-Jourdain on Aphthae-In True Aphthae there is no Erosion or Decrease of 
Substance-Commence by Small White Spots-Confusion as to Etiology-On 
the Origin-Relation with Crisis-Diuretics and Gentle Enemas aid Recovery 
-Difference as to Causes or Antecedents-Seventh-Day Crisis-Preceded by 
Febrile Miasmata-Vessels concerned in the Critical Discharge-Lymphatic 
Engorgement-Influence as to Climate and Living-Diagnosis Easy-Urinary 
Symptoms-Different Forms of Fever-The Vital Function-Caution as to Prognosis- 
Derangement of the Menstrual Flux is Unfavorable-Wood on the Aphtha;-Pro- 
posed to restrict it to a Peculiar Vesicular Eruption-Small Ulcers with Whitish 
Surface-Most Frequent Source of Aphthae-The Vesicles-Produces little or no 
Constitutional Disorder-Confluent Variety-Muguet of French Writers-Classed 
as Follicular Inflammation-Treatment-Viewing the Fungus as an Accidental 
Parasite-Compelled to consider Constitutional Associations-Appearing in Connec- 
tion with Dyscrasic Conditions-Manifesting in Cancroid Lesions-Sulphate of 
Copper-Iron and Quinine-A Powder-Solutions of Alum-Hydrochloric Acid- 
Irritable Condition-Tincture of llamamelis-Phenate of Soda-Local Treatment- 
Periodic in some Persons-Thrush and its Demands-To prescribe Neutral Mixture 
-Powders-A Combination-Cases associated with Intestinal Disturbances-A 
Child One Year of Age-Concerning Diet-Milk of Mother to be examined-Gangraena 
Oris-May have a Local Excitant-A Common Form of Sloughing Stomatitis- 
Treatment of Gangraena Oris 675 
CHAPTER XL I. 
WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
Incised-Lacerated - Punctured - Penetrating-Compound - Lesions relate-Syphi- 
litic - Erysipelas - Pyaemia-Tetanus-First Indication - Hemorrhage-Shock - 
Poisonous - Foreign Particles - Hemorrhage, Arterial, Venous, Capillary-To 
prevent tearing the Artery - After ligating a Vessel-Torsion-Acupressure - 
Use of Pad-Rest upon a Bony Floor-Facial-Temporal-Supraorbital-Infra- 
orbital-Knotted Bandage-Cold or Hot Water-Throwing a Jet-Monsel's Salts- 
Venous or Capillary Hemorrhage-Shock-Definition of-Shock in Prostration- 
Mistakes in Judgment-Interference with Function-Characterized by varying 
Expressions-Primary Shock-Consecutive Shock-Deceptive Character-Relation 
of Shock with Visceral System-Collapse-Fright as cause of Shock-Idiosyncrasy 
-To treat Shock-Patient doing well to be let alone-Do Nothing-Indications- 
Use of an Emetic-Anodynes-Combating Visceral Determinations-Virus-Pri- 
mary Indications-Nitrate of Silver-Suction-Excision-Tiding-Healing Wounds 
-How Wounds heal-Methods of Treating-Adhesive Plaster-A Stitch-Pins- CONTENTS. 
XXI 
PAGE 
Silver or Lead Wire-Time to remove Pins or Stitches-How to remove Pins or 
Ligatures-Rotation--Cut the Wire at Side of Knot-Support-Cicatrix-Allow 
the Blood-matted Silk to remain-Use of Plasters--Removal of a Plaster-Re- 
applying-Plaster by Meade-Complicated Wounds, Illustrative Cases-Injuries of 
the Soft Palate-Tannic Acid--Iced Water - Serre-fine-Haemostatic Forceps - 
Stitching together Breaks-Inflammation-Aplastic Meaning-Erysipelas-Degen- 
eration of Edges of a Wound-Dangerous Swelling of the Uvula-Burns and Scalds 
-Classification-First Indication-First Application-Prognosis-Superficial Burns 
-To protect a Burned Part from the Air-Common White Paint-Carron Oil- 
Carded Cotton-Vaseline - Cosmoline - Starch Poultice - Scrapings of Potato, 
Apple, and Carrot-Earth-Cod-Liver Oil - Deep' Burns-Poultices-Stimulating 
Unguent-Tinctura Capsici et Myrrhae-Bismuth and Iodoform-lodoform-Poison- 
ing - Erysipelas Threatening - Sloughing - Loss from Eschar-Skin-Grafts and 
Epiderm-Scrapings of Epiderm-Operation for Removal of Scar-Tissue-Removal 
of Scars-Pathology of Severe Burns ......... 693 
CHAPTER XL 11. 
THE TONSIL GLANDS. 
Character of Tonsil Glands-Simple Tonsillitis-Treatment-First-Dry Cups-Second 
-Third-Cocaine-Care to be taken-A Third Medicament-Sulphate of Copper 
-Cocaine Hydrochlorate-Turpentine and Chlorate of Potassium as a Specific- 
Phenol-Sodique-Tincture of Belladonna-Diminishing the Calibre of Capillaries- 
Gargarysma Guaiaci Composita-Sympathetic Inflammations-Incipient Condition 
-Free Scarification-Dry Cups-Leeches-Hot Foot-Baths-Spiritus Mindereri- 
Flaxseed Tea-Tincture of Veratrum Viride-Swelling of Uvula-Tincture of Iodine 
-Immediate Resort-Section of the Mucous Sac-Suppuration-Formation of Pus 
-Caution as to Loss of Blood-Constitutional Expressions-Possible Conditions- 
Inflammation of Infra-tonsillar Glands-Herpes as a Lesion-Characteristic Symp- 
toms-Treatment of Herpes-Hypertrophy-Differs in Different Cases-Interference 
with Hearing-To be treated from a Constitutional Stand-point-Remedies used 
in Treatment-Sulphate of Potassium-Diathesis as influencing Treatment-Acetate 
of Zinc as a Systemic Remedy--Local Treatment-Pressure by the Finger-Use of 
London Paste-Equal Parts of Finely-pulverized and Well-mixed Caustic Soda and 
Unslacked Lime-To apply the Paste-A Cocaine Application-Time required- 
Experience of Author makes him unwilling to agree - Digression - Rumbold's 
Treatment by Injection-Amputation of Gland-Fahnestock Blade-The Physick- 
The Kolbe-To apply a Tonsillotome-Billings-Use of a Volsella-Use of Bis- 
toury-Operating on Young Children-Questions as to Double Operation-Favors 
decidedly Two Operations-Means in Anticipation of Inflammation-Coating of 
Gum Acacia-Hemorrhage not Common-Ulceration as an Associate Condition-The 
Cancerous Ulcer-Complete Extirpation of Tonsil-Cystic Disease-Abscess-Syphi- 
litic Affections-Anomalous Case .......... 717 
CHAPTER XLIII. 
BRONCHOTOMY. 
Illustrative Anatomy-Laryngotomy-Tracheotomy-Manner of Operation-Incision 
to be kept Open-The Thyroid Arteries-Thymus Gland as a Complication-Surgical 
Study-Use of Canula-Necessity of Absolute Exposure of Trachea-Moisture to 
relieve Dryness of Trachea and Bronchi--Thyrotomy-Intubation-Instruments 
used in the Operation of Intubation-Gag-Laryngeal Tube-Obturator-Depositor 
-Withdrawer-Measure-Doing the Operation-Introducing the Tube-Spasm and 
Cough-Time for wearing the Tube-Feeding after Intubation-Difficulties in Feed- 
ing-Experiences-Withdrawal of the Tube-Remarks-Unsuccessful Operations- 
Illustrations of Tracheal and Bronchial Deposits-Epithelioma of Larynx . . 730 XXII 
CONTENTS. 
CHAPTER X L I V. 
THE TONGUE AND ITS DISEASES. 
PAG1 
Tongue a Sentinel of Medical Diseases-Meanings expressed by Changes in the 
Tongue-Illustrations-Local, or Surgical, Lesions-Examples of Local Lesions- 
Localization of Diseased Action-Glossitis-Syphilitic Lesions-Induration and 
Hypertrophy-Cracks and Fissures-General Thickening-Bald Tongue-Gummata 
of the Tongue-Psoriasis Contagious-Tongue Ulcers Secondary as to Consideration 
-Bichloride of Mercury-Tonics in Combination with Mercury-Pyrophosphate of 
Iron-Process of Cure one of Repair-Iodide of Potassium-Tertiary Syphilis and 
Mercury-Effects of Iodide of Potassium-Medicines used in Treatment of Syphilitic 
Affections-Mucous Lesions resultant of Smoking and Drinking-Tongue enlarged 
from abuse of Mercury-Rational Treatment of Mercurial Conditions-Direct Appli- 
cations-Chronic Phagedaena-Fungus Hsematodes-Histology of Scirrhous Carci- 
noma-Heteroclitic Cells-Cancer commences on Sides of Tongue-Treatment of 
Cancer of Tongue-Distinction between Syphilitic and Carcinomatous Lingual 
Ulcers-Tobacco Tongue-White Tongue-Tubercle-Cystic Tumors-Hypertrophy 
of Circumvallate Papilla-Danger of Severe Glossitis-Abscess of Tongue-Neuralgia 
of Tongue-Raw Tongue-Erysipelas-Bites of Insects-Injury from Teeth-Erec- 
tile Tumors-Fatty Tumors-Metastatic Disease-Urticaria-Treatment of Lingual 
Hypertrophy-Atrophy-Errors of Nutrition-Papilloma-Venous Tumors-Arterial 
Naevi-Cartilaginous Tumors-Immobile Tongue-Operations practised upon the 
Tongue-Prolapsus of Tongue-Speedy Union in Partial Amputations-Means used 
in Amputation-Harris's Cases-Treatment of Resisting Ulcer by Ligature-Ecra- 
seur-Ligature Extemporanee- Illustrations of Ablations-Regnoli's - Syme's- 
Nunneley's-Billroth's-Paget's-Whitehead's-Tongue-Tie-Dewees's Membrane- 
Congenital Tongue-Tie-Cutting the Fraenum-Swallowing the Tongue . . .743 
CHAPTER XLV. 
THE UVULA AND ITS DISEASES. 
Enlargement of Uvula-Elongation of-Serous Infiltration of-Bifid Uvula-True 
Hypertrophy-Neoplasms-Fibrous and Fatty Tumors-Amputation for Serous Effu- 
sion-Sorbefacients for Hypertrophic Enlargement-Syphilis of Uvula-Condylomata 
-Corrosive Sublimate as an Application-Use of Tobacco-Irritation-Restrictions 
-Hemorrhage from Amputation .......... 785 
CHAPTER XLVI. 
DISEASES OF THE FLOOR OF THE MOUTH. 
Anatomy of Part-Ranula-Illustration of-Watery Contents of-Thin Cysts-Char- 
acter of Trouble-Thickened Cysts-Ranulae holding Calculi-Differential Diagnosis 
-Lipoma-Superficial and Deep Ranulae-Temporary and Permanent Signification 
of Ranulae-Tube not necessarily closed in Ranula-Indolent Enlargement of Sub- 
lingual Gland-Illustrative Cases-Muciparous Cysts-Enlargement of Sublingual 
Folds-Fleischman's Synovial Sac-Epithelioma-Venous Aneurism . . . 789 
CHAPTER XL VI I. 
HYGROMATA OF THE NECK. 
Bursae of Front of Neck-Example of Ranula situated in Front of Neck-Illustrative 
Treatment of Case-Bell's Case of Hygroma-Deep-seated Ranula-Illustration of. 796 CONTENTS. 
XXIII 
CHAPTER XL VI11. 
DISEASES OF THE PHARYNX. 
PAGE 
Communications with Pharynx-Dissection of-Oro- and Naso-pharynx-Soft Palate 
-Pharyngitis-Angina Simplex-Ulceration and Gangrene-Follicular Inflamma- 
tion-Treatment of-Pharyngitis Sicca-Treatment of-Herpes-Effusions-Post- 
pharyngeal Abscess-Specific Conditions-Tubercles-Nebulization of Fluids- 
Wounds-Gun- or Pistol-Shot Wounds-Incised Wounds-Emphysema of Neck- 
Stricture of Pharynx-Globus Hystericus-Spasm-Imperforate Pharynx-Neo- 
plasms-Fibromata-Polypi-Uvula-Irremovable Causes-Foreign Bodies in 
Pharynx-Probangs-Swallowing a Pin-Swallowing a Fish-Hook-Soft Bodies 
impacted in (Esophagus-(Esophageal Bougies-Feeling not Evidence of Presence 
-Cutting a Blood-Vessel-Vaso-pharyngoscopy-Rhinoscopy-Electric Illuminator 
-Different Instruments used in Rhinoscopy-Depression of Tongue and Relaxation 
of the Uvula-Rhinoscopic Image .......... 801 
CHAPTER XLIX. 
PALATINE DEFECTS, AND THEIR TREATMENT BY OPERATION. 
Cleft Palate-Fissure of the Hard Palate-Congenital Fissure-Operative Procedure for 
Immediate Cure of Cleft of Velum-Preparation of Patient for Operation-Surgical 
Anatomy of Soft Palate-Removal of Strain-Muscles of Soft Palate-Other Anatom- 
ical Elements-Operation of Staphylorraphy, by whom first practised-Stages of 
Operation-Roux's Operation-Warren's-Mettauer's-Fergusson's-Difficulties- 
Silk an Irritant-Instruments required-Relative Positions of Surgeon and Patient 
-Steps of Operation-Undue Tension-Ligatures to Remain-Wounds to be left to 
Nature-Needles and Carrier-Holes in the Palate-Small and Large Breaks-Sur- 
gical Treatment of-Bridging Chasms-Dieffenbach's Treatment-Uranoplasty- 
Langenbeck's Modification of Warren's Operation-Use of Gag-Forms of Gag- 
Uncertainty, and Dissatisfaction, as to Results-Mechanical Treatment of Cleft 
Palate ............... 814 
CHAPTER L. 
THE NOSE AND ITS DISEASES. 
Surgical Anatomy of Internal Nose-Deviation of and Breaks in Septum-Vault of Nose 
-Inside Anatomy of Nose-Communications with Nasal Fossa-Meatuses-Superior 
and Inferior Canals-Functions of Nose-Surgical Points-Diseases of the Nose- 
Simple Nasal Catarrh-Sneezing-Bromide of Potassium-Erysipelas-Hemorrhage 
-Lesional Epistaxis-Plethoric Epistaxis-Passive Epistaxis-Traumatic Epistaxis 
-Treatment of Epistaxis-Plugging Nares-Belloc's Canula-Use of Tampon-Con- 
stitutional Conditions-Relaxation of Vessels-Vicarious Epistaxis-Hemorrhagic 
Diathesis-Traumatic and Adenoid Ulcers-Scrofulous Ulcers-Strumous Rhinorrhoea 
-Treatment of Scrofulous Ulcers-Syphilitic Ulcers-Septic Discharges-Neuro- 
paralytic Ulcers-Scorbutic Ulcers-Glanders-Cancer-Exanthems-Polypi-Gela- 
tinoid Polypi-Origin of Growth-Moisture and Polypi-Treatment of Polypi- 
Powder Blowers-Torsion Forceps-Use of Snare or Forceps-Fibrous Polypi- 
Peduncle-Sarcomatous Polypi-Frog-Face-Nasal Abscess-Ivory Exostosis- 
Antral Exostosis-Sphenoidal Exostosis-Use of Burs-Exostosis of Body of Sphenoid 
Bone-Ozaena-Indefinite Character of the Term-Accumulation and Degeneration 
of the Antral Secretion-Fetid Discharges depending on Tooth-Abscesses-Ulcera- 
tion of Mucous Membrane of Antrum-Nature of Ulceration-Mercurial Ulcer of 
Antrum-Diagnosis of Scrofulous Ulcers-Treatment of Scrofulous Ulcers-Syphi- 
litic Ozaena-Gumma-Sense of Congestion-Forced Expirations Diagnostic-Bones 
Primarily Diseased-Diagnosis of Inflammation of Nasal Boundaries-Prognosis- XXIV 
CONTENTS. 
PAGE 
Anti-Venereal Treatment-Iron and Quinia-Necrosis-To procure Rest-Lodge- 
ment and Retention of Foreign Bodies-Rhinolites-Removal of Foreign Bodies 
from Nose-Douche Bath-Syphilitic Coryza in Infants-Washing out the Nose- 
Anterior Rhinoscopy-Metz's Nasal Reflector-Frankel's Nasal Speculum-Sunlight 
in Rhinoscopy-Tobold's Apparatus-Manner of making a Posterior Rhinoscopy- 
Neoplasms-Hypertrophy of Nasal Mucous Membrane-Deviations of Septum- 
Nasal Bougies-Gonorrhoea of Nares-Subnitrate of Bismuth-Chancre of the Nose 
-Imperforate Nares-Foreign Bodies in Associate Sinuses-Fly-Larvaj-Diagnosis 
of Nasal Parasites-External Nose-Tumors of-Ulcerations of-Caustic Applica- 
tions-Fractures of the Nose-Displacement of Septum-Displacement of Nasal 
Bones-Mechanical Support-Complications-Principles of Cure-Loss of Substance 
-Rhinoplasty-Methods in-Tagliacozzi's Method-Von Graefe's Method-Indian 
Method-English Method-Studies in Rhinoplasty ....... 833 
CHAPTER LI. 
DISEASES OF THE FACE. 
Immediate Diseases-Mediate Diseases-Callositas-Cornu Cutaneum-Lichen Pilaris- 
Vitiligo-Naevus Pigmentosus-Lentigo-Chloasma-Naevus Pilosus-Scleroderma 
-Dermatolysis-Hypertrophy of Mucous Surface of Lip-Unilateral Atrophy- 
Elephantiasis - Morphoea-Framboesia-Verruca-Ichthyosis-Seborrhoea-Comedo 
-Milium-Molluscum Sebaceum-Sebaceous Tumors-Hyperidrosis-Chromidrosis 
- Anidrosis - Sudamina - Keloid - Molluscum Fibrosum - Xanthoma - Rhino- 
scleroma- Enchondromata - Angeioma - Mother-Mark-Arterial Tumor-Venous 
Tumor-Illustrative Tumor-Capillaiy Naevi Maculae-Port-Wine Stain-Strangu- 
lation as a Means of Cure-Subcutaneous Strangulation-Arrangement of Ligatures 
-Compression as a Means of Cure-Use of Injections-Caustic Remedies-Blistering 
Collodion-Treatment of Slough-Starvation as a Means of Treatment-Use of 
Seton-Some General Considerations-Electrolysis-Treatment by Tearing-Use of 
Red-Hot Needle - Scrofuloderma - Syphiloderma - Facial Tubercles - Gumma of 
Forehead-Parasites, Animal and Vegetable-Barber's Itch-Diagnosis of a Peculiar 
Tinea-Tinea Circinata-Acne Rosacea ......... 877 
CHAPTER LI I. 
LUPUS. 
Lupus Erythematosus-Manner of Beginning-Scales of-Views of Dermatologists as 
to Origin-Lupus Vulgaris-Manner of Beginning-Parasitic Theory-Lupus Tuber- 
culosis-Infiltrating Lupus-Progressive History of-Direction of Extension-Patho- 
logical Anatomy of Lesion-Acne Rosacea ........ 906 
CHAPTER LI 11. 
EPITHELIOMA. 
Definition of Term-Cancerous Epithelioma-Local Significance-Carcinoma and Epi- 
thelioma - Diagnosis - Varying Attributes - Self-Classification - Histogenesis- 
Forms of Epithelioma-Microscopic Character of-Likeness to Split Turnip-Granu- 
lative Expression of-Significance of-Gland-like Ingrowths-Epithelial Pearls-Use 
of Caustics-Mackey's Cauterant-Resorcin-Nitrate of Silver-Conditions inviting 
Operation-Illustrative Cases-Glacial Acetic Acid and Monsel's Solution of Iron- 
Hydrastis Canadensis-Vallet's Mass-Ammonia-Chloride of Iron-Chloride of 
Zinc-Tuson on Use of Chlorine-Necessity of Opiates-Morphia as commonly used 
-Supervention of Erysipelas-Salivation-Chlorate of Potassium-Bacilli Theory- 
Treatment by Erosion-Author's Treatment-Illustrative Cases .... 910 CONTENTS. 
XXV 
CHAPTER LIV. 
OPERATIONS UPON THE LIPS AND CHEEK. 
PAGE 
Harelip-Significance of Operation-General Considerations-A Basis Operation - 
Means for Retaining Paring in Apposition-Regarding Removal of Pins-Affording 
Support-Necessity for Dryness-Agnew's Wire Suture-Hidden Suture-Rubber- 
Ring Suture-Sheet-Lead Plate Suture-Hainsby's Compressor-Hemorrhage from 
Coronary Artery - Compression of Facial Arteries - Linear Cicatrix-Union of 
Wound-Cicatricial Notch-Healing by First Intention-Illustrative Cases-Com- 
plications-Levis's Operation-Double Harelip-Operation for Double Harelip- 
Incisor Teeth projected into the Cleft-Pushing the Teeth Back-Alveolar Process 
projected into the Cleft-Association of Centre Slip and Nasal Septum-Addendum- 
Position of Surgeon and Patient-Gauze and Collodion as a Plaster-Studies in 
Complicated Harelip-Intermaxillary Complications-Door-Knob and other De- 
formities-Relation of Head of Pin to Line of Cut-Caution regarding Strain . 925 
CHAPTER LV. 
OPERATIONS UPON THE LIPS AND CHEEK. 
Atresia Oris-Operation after Dieffenbach-Mechanical Modification-Preliminary 
Performance-Studies-Operation after Mutter-After Tagliacotius-After Mott- 
After Pancoast--After Chopart-After Lallemand-After Malgaigne-After Roon- 
huysen-After Dupuytren-After Celsius-After M. Serres-After T. W. Roux- 
After P. Roux-After Morgan-After Blasius-After Liston-Removal and Restora- 
tion of Lower Lip-Transplantation of Particles of Skin-Removal and Restoration 
of Parts of Upper and Lower Lips-Removal and Restoration of Upper Lip-Loss 
of Nose and Upper Lip-Showing Restored Lip-Leidillot's Operation-Deformity 
existing in Paralysis - Artificial Muscle - Cicatrices from Burns - Maxims of 
Dupuytren-Danger from Erysipelas-Size of Flap-Cutting and Laying a Flap- 
Dressing a Plastic Operation-Treatment of Wound left by Transfer of Flap . . 942 
CHAPTER LVI. 
LIGATION OF ARTERIES. 
Preliminary Study of Ligation-Study in Anastomosis-Anastomosis of Internal 
Carotid Arteries-Basilar Anastomosis-Cervical Anastomosis-Thyroid Axis Anas- 
tomosis-Thoracic Anastomosis-Pelvic Anastomosis-Review-Facial Anastomosis 
-Internal Maxillary Anastomosis-Lines for Locating Vessels-External Carotid 
Artery-Lingual Artery-Venous System of Face-Arrestation of Hemorrhage- 
Ligation of Facial Artery-Ligation of Temporal Artery-Ligation of Occipital 
Artery-Ligatures in Position-Thyroid Artery-Lingual Artery-Ligation of Ex- 
ternal Carotid Artery-Ligation of Primitive Carotid Artery-Superior Triangle 
-Inferior Triangle-Dissection-Submaxillary Triangle-Anterior Inferior Tri- 
angle ................ 958 
CHAPTER EVIL 
THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
Offices of Antrum-Concerning its Diseases-Surgical Anatomy of-Relation with 
Spheno-maxillary Fossa-With Lachrymal Fossa-With Orbital Cavity-Possible ' 
Anomalies-Sequelae as Lesions-Diseased Teeth as Lesions-Dento-alveolo-antral 
Abscess-Illustrative Cases - Antral Diseases Common to Mucous Membrane - 
Dropsy of the Antrum-Temperament and General Condition-View of Purulency 
-Cause of Retained Secretions-Diagnosis of Muco-puruloid Engorgement-Neu- XXVI 
CONTENTS. 
PAGE 
ralgia associated with Engorgement-Treatment of Antral Purulency-Antral Break 
not to be closed-Injections and Injecting-Antral Drainage-Tubes-Purulent For- 
mations connected with the Antrum-Treatment on Principle-Local and Con- 
stitutional Significance-Cause in Nasal Catarrh-Increase of Mucus-Decrease of 
Mucus-Significance of Nasal Dryness-Teeth found in the Antrum-Furuncular 
Epidemics-Scorbutus-Mercurial Diathesis-Syphilis-Illustration in Anomaly- 
Mechanical Diseases of the Antrum-Tumors of the Antrum-Abscess of Frontal 
Sinus-Illustrative Cases of 970 
CHAPTER LVIII. 
SALIVARY FISTULA. 
Meaning of Fistule-Causes of-Subcutaneous Ulceration of Gland-Cure of Salivary 
Fistule-Test for Salivary Fluid-Cauterization-Operative Means in Treatment of 
Salivary Fistule-Horner's Operation-Author's Operation-Agnew's Operation-De- 
struction of Gland-Probing the Duct-Foreign Bodies in the Canal-Pseudo-Fistule 
-Dribbling 990 
CHAPTER LIX. 
CARIES OF THE MAXILLAE. 
Caries Analogous to Ulceration-Diagnostic Expressions of-Examination through 
Touch-Variations in Phenomena-Illustrative Case-Conditions that Modify-Af- 
finity of Caries for Cellular Bone-Inflammation preceding Ulceration-Clinical 
Peculiarities presented by Carious Bone-Virchow on Caries-Miller on Caries- 
Treatment of Caries-Necessity for Constitutional Support-Use of Surgical Engine 
and Burs-Necessary to follow the Disease-Use of Syringe-Acid Treatment-Dis- 
solving Dead Bone-Use of Caustic Potash-Use of Sulphuric Acid-Illustrative 
Cases-Pollock on Use of Acid 995 
CHAPTER LX. 
NECROSIS. 
Significance of Term-Consideration of Inflammatory Conditions-Osteitis as a Primary 
Condition-Causes of Necrosis and Order of Frequency-Dental Necrosis-Nutrition 
of Supply of Teeth-Refinements in Tooth-Nutrition-Irritable Systems-Caries as 
Cause of Dental Necrosis-Significance of Tunica Propria-Haversian System of 
Cementum-Exfoliation of Dead Tooth-Death of Teeth from Structural Consolida- 
tion-Alveolar Necrosis-Resultant of Arsenical Applications-From Chloride of 
Zinc-From Mal-eruption of Wisdom-Tooth-Burrowing of Pus-Exfoliation of 
Laminae-Syphilitic Necrosis-Treatment of Local Applications-Internal Remedies 
-Ulcer of Necrosis-Incision as Remedy-Correction of Breaks into Nose by Use of 
Obturator-Freshening and Stimulating Edges of Ulcer-Recurrence of Ulcer-Sig- 
mund on Syphilitic Manifestations-Mercurial Necrosis-State of Salivation--Scari- 
fication and Use of Iodine-Sequestra to be detached by Nature-Ill Odor and Pu- 
trescence-Necrosis from Injuries-Exanthematous Necrosis-Phosphor-Necrosis- 
Graham's Respirator-Prodromata in Phosphor-Necrosis-First Signs of Seat of Pre- 
dilection of-History of-Pathological Porosity-Osteophytes in Inverse Proportion 
to Pus-Condition of Complexion-Salivation a Marked Characteristic-Likeness of 
Sequestra to Rotten Sponge-Separating Periosteum and Bone-Stimulant and Anti- 
septic Washes-Dressing Sinuses-Time of Separation of Sequestra-Supporting the 
System-Hemorrhage-Preliminary to removing Body of Lower Jaw-Excess of 
NewBoneabout Floor ofMouth-Phosphor-Necrosis attacking Upper Jaw-Resection 
to be Condemned ..... ....... 1005 CONTENTS. 
XXVII 
CHAPTER LX I. 
DISLOCATION OF THE INFERIOR MAXILLA. 
PAGE 
Forms of Submaxillary Displacement-First Form-Second Form-Third Form- 
Fourth Form-Diagnosis of-Exciting Causes of-Predisposing Causes of-Condi- 
tion of Parts in-More Common to Women than to Men-Unreduced Luxations- 
Reducible after Long Periods-Subluxations Common-Luxation and Fractures- 
Congenital Luxations-Treatment of Luxation-Stromeyer's Forceps-Kolbe's 
Mouth-Opener-Nelaton's Method of reducing Jaw Luxations-Use of Anaesthetics 
-After-Treatment 1031 
CHAPTER LX II. 
FRACTURES OF THE MAXILLARY RONES. 
Divisible into Two Classes-Lower Jaw most Liable to Fracture-Weak Line of 
Lower Jaw-Fractures likely to be Compound-Character of Fractures influenced 
by Causes-Openness of Symptoms-Fractures of Upper Jaw-Illustrative Cases- 
Intersection of Jaw-Gunshot Injuries-Treatment of Fractures-Pasteboard or 
Gutta-Percha Splint-Barton's Bandage-French Dressing-Hamilton's Dressing- 
Simple Form of Interdental Splint-Gibson's Jaw Bandage-Author's Modification 
of Barton's Bandage-Bean's Splint-Sudduth's Splint-Failure of Fractures to 
Unite-Nutrition as related with Ununited Fractures-Treatment of Complications 
on General Principles-Where Teeth are Broken-Complications in Breaks of 
Superior Jaw-Fragments of Bone to be replaced-Skin not to be removed- 
Plastic Operations-Controlling Inflammation-Secondary Breaking-Interdental 
Splints-Vulcanizable Rubber Splints-Gutta-Percha Splints-Vulcanizing a 
Rubber Splint-Angle's Manner of Fixation-Illustrative Cases. 
Fracture of Hyoid Bone-Fractures of the Cartilages of the Trachea and Larynx- 
Fractures of Skull, and Trephining .......... 1036 
CHAPTER LXIII. 
EXSECTIONS OF THE MAXILLARY BONES. 
History of-Observation of Accidents-First and Succeeding Operations-Improvement 
as to Operating-Meaning of Ill Results-Nature's Correction of Deformity-Im- 
portance of Periosteum-Periosteum not to be saved if Unhealthy-Preliminary to 
Exsection-Uncovering the Bone not always Necessary-Horner's Operation-Ordi- 
nary Operation for Removal of Superior Maxilla-Use of Circular-Saws-Attention 
required by Hemorrhage-Packing for Control of Hemorrhage-Objection to Use 
of Sponge-Phenol-Sodique as a Dressing-Pad and Strip not to be allowed to Dry- 
Removal of Stitches-Withdrawal of Packing-Fergusson's Operation-Operation 
for Removal of both Superior Maxillae-Heyfelder's Operation-Tumors back of the 
Maxillae-Cheever's Modification of Langenbeck's Operation-Nasal and Naso- 
pharyngeal Polypi-Tumors at Base of Skull-Ollier's Operation-Exsection of 
Inferior Maxilla-Keeping the Mouth Open-Section of the Lip-Exposure of Left 
Half of Lower Jaw-Exposure in full of Body of Jaw-Barton's Operation- 
Dupuytren's Operation-Removal of One-Half of Maxilla-Maxillary Resections- 
Deadrick's Operation-Illustrative Operation-Obstruction by Undeveloped Teeth- 
Chain-Saw, Use of-Surgical Engine in Oral Practice-Preventing Deformity after 
Complete Section of the Jaw ........... 1059 
CHAPTER LXIV. 
ANCHYLOSIS OF THE JAW. 
Definition of Term-Intra-Articular Anchylosis-Extra-Articular Anchylosis-Charac- 
ter and.Nature of Lesion-Constitutional Significance-Complicated Arthritis- XXVIII 
CONTENTS. 
Double Diagnostic Significance-Synovitis Proper - Subacute Synovitis - Acute 
Synovitis-Suppuration in a Joint-Specific Indications-Arthritis-Treatment of 
Arthritis Proper-Rheumatoid Arthritis-Tetanus-Tetanus divided into Traumatic 
and Idiopathic-Predisposing Causes of-Symptoms of-Prodromata of-Risus Sar- 
donicus-State of Bowels in Tetanus-Duration of Disease-Pathology of-Spinal 
Medulla-Generation of an Animal Poison-Holmes on Tetanus-External Means 
employed in Treatment of Tetanus-Internal Means-Woorara Treatment-Calabar 
Bean-Hydrate of Chloral and Croton-Chloral-Trismus Nascentium- Relation 
with Excito-inotor System-Not confined to Hot Climates-Symptoms-Fully-devel- 
oped Stage-Causes-Treatment-Trismus Dentium-Dental Significance-Lesions 
relating with Retracted Dental Arch-Relief afforded by Extraction of Teeth- 
Periodonteal Troubles-Unappreciated Causes - Illustrative Practice - Partly- 
erupted Wisdom-Teeth - Operculum-excising Forceps - Secondary Relations of 
Partly-erupted Wisdom-Teeth-Inflammation arising out of Opercula-Considera- 
tion of Wisdom-Teeth-Protracted Lockjaw-Persistency of Anchylosis-Question 
as to the Advisability of breaking up Fixation-Trismus resulting from the Pivoting 
Process-Trismus after plugging Teeth-Trismus Traumaticus-Simple Means for 
opening the Jaw--Illustrative Practice-Kolbe's Mouth-Opener-Cases of False 
Anchylosis-Trismus the Result of Mercurials-Means for cutting Cicatrices-Inad- 
visability of using the Knife externally-Bridges of Bone-Anchylosis depending 
on Superficial Cicatrices-ResumS .......... 1076 
CHAPTER LXV. 
NEURALGIA. 
Definition-Character of Pain-Diagnosis-Neuralgia a Disease-Neuralgia a Phe- 
nomenon-Predisposing Causes of Pain-Radiation-Posterior Root of Spinal Nerve 
the Seat of Neuralgia-Malaria as Cause-Syphilis as Cause-Catarrh as Cause- 
Epitome-Conditions-Use of Opiates-Neuralgia an Effect-Tooth and Eye-Ear 
and Maxillary Region-Tooth and Ear-Antrum and Forehead-Maxillary Nerves 
and Head - Tooth and Scalp - Supernumerary and Non-Erupted Teeth - Urine 
and Nervous System - Inferior Maxillary Nerve and Face-Nerves of Gum- 
Neuralgia of Gums and Tip of Tongue-Treatment of Neuralgia-Valerianate of 
Zinc-Tincture of Cannabis Indica-Calomel-Tincture of Benzoin-Aconite-Tinct- 
ure of Veratrum Viride-Tincture of Digitalis-Colchicum-Salicylate of Sodium 
- Arsenic - Exolgine -Gelsemium Sempervirens - Tonics - Opium and Ether - 
Muriate of Ammonia-Oil of Turpentine-Chloroform and Camphor-Vermifuges- 
Cathartics - Strychnine - Rauque's Liniment - Morphia Endermically - Hot and 
Moist Applications-Snuff and Quinine-Common Table Salt-Meigs's Ether Treat- 
ment-Creasote-Kirby's Liniment-Grave's Plaster-Cazenave's Pomade-Hydrate 
of Chloral-Salicylic Acid-Salicylate of Cocaine-Ear-Drops-Napheys's Recipes- 
Ludlow's Formula-Compression of Arteries-Massage-Unique Case-Errors in Re- 
fraction and Posterior Conus as Causes of Neuralgia 1102 
CHAPTER LXVI. 
NERVE LESIONS PROPER AND THEIR TREATMENT BY SECTION. 
Author's Operations-Section of Inferior Maxillary Nerve at Oval Foramen-Opera- 
tion by Removal of Coronoid Process-Section of Superior Maxillary Nerve-Nerve 
Lesions of the Maxillary Sinus-Criticism on Operations-Carnochan's Operation 
for Neurectomy of Second Branch of Trifacial Nerve-Langenbeck's Operation- 
Pancoast's Operation-Author's Operation-Study of Skull-Clean Cut required in 
Neurectomy 1121 CONTENTS. 
XXIX 
CHAPTER LXVII. 
EXPOSURE OF NERVES.-NERVE LESIONS PROPER AND THEIR TREATMENT BY 
STRETCHING. 
PAGE 
Definition-Scientific Meaning of Operation-Extra- and Intra-Lesions-Great Oc- 
cipital Nerve-Gustatory, or Lingual, Nerve-Auriculo-temporal Nerve . . . 1131 
CHAPTER L XVI11. 
TUMORS OF THE MOUTH AND FACE AND THEIR CLASSIFICATION. 
Definition-Variety as to Signification-Clinical and Histological Study of Tumors- 
Division of Tumors into Two Classes-Homologous Tumors-Heterologous Tumors- 
Clinical Illustration in Differential Diagnosis-Example-Judgment out of Exclu- 
sion-Tumors Benign or Malignant-Simplicity in Clinical Distinction-Relation- 
ship-Progress of Homologous Tumors-Simple Inflammatory Tumors-Influence 
of Inflammation on a Part-Effusions in Inflammation-Watery Effusions-Fibro- 
serous Effusions - Lymph Effusions - Lymph Tumors - Hypertrophic Tumors- 
Tumors which result from Interference with Function-Tumors Histologically Classi- 
fied-Analysis of Names-Synonymes of the Word Tumor-Scirrhoma-Value of 
Histological Distinctions 1136 
CHAPTER LXIX. 
THE TUMORS OF THE MOUTH. 
THE EPULIDES. 
Definition-Histological and Clinical Classification of the Epulides-Benignancy and 
Malignancy - Epulo-Pulp-Fungoid Tumors - Study of Pulp-Fungoid Tumors - 
Diagrammatic Illustrations-Complicated Form-Epulo-erectile Tumor-Arterial, 
Venous, and Capillary Epulides-Treatment of Erectile Growths-Seton as Means 
of Cure-Electrolysis-Piecemeal Removal-Use of Serres-fines-Use of Pressure- 
Local Significance of Erectile Epulides-Epulides of the Second Class-Not Self- 
explaining-Cancer to be treated in Consideration of Condition-Practice pertaining 
to an Epulic Tumor-Illustrative Cases ......... 1146 
CHAPTER LXX. 
THE TUMORS OF THE MOUTH. 
OSTEOMA AND SUBACUTE INFLAMMATORY TUMORS. 
Definition-Varieties of Ostosis-Hyperostosis-Free Exostosis-Non-specific Exos- 
tosis-Around the Base of the Alveolar Processes-Operation demanded-Exostosis 
Dentium - Diagnosis of Exostosis Dentium - Anomalous Case - Warty Teeth - 
Enamel Nodule-Rare Case-Microscopical Section-Difference between Scrofulous 
and Venereal Forms of Exostosis-Treatment of Specific Exostosis-Non-specific 
Exostosis-Spongy Exostosis-Treatment of Spongy Exostosis-Obscurity in Diag- 
nosis-Hyperostosis-Illustrative Cases-Hyperostosis one with Exostosis or Enos- 
tosis-Rates of Growth-Remarkable Specimen-Tuberculated Specimen-Enlarge- 
ment of Whole Side of Face-Osseous Tumor of Right Superior Maxilla-Commonness 
of Hypertrophy of Maxillary Tuberosity-Neoplasms ...... 1159 
CHAPTER LXX I. 
THE TUMORS OF THE MOUTH. 
SELF-EXPLAINING CYSTIC TUMORS. 
Simple Cyst-Diagnostic Illustration-Location-Manner of Treating-Cutting off 
Root and replanting-Illustrative Cases-Odontocele Proper-Employment of Ex- XXX 
CONTENTS. 
1 AliE 
ploring Needles-Illustrative Cases-Supernumerary Teeth-Undeveloped Teeth as 
Cause of Osteo-dental Tumors-Complex Osteo-dental Tumors-Microscopic Study- 
Cystoma of Maxillary Ramus-Anomalous Case-Forget's Rare Case-Description of 
-Fistulous Openings-Functional Disorders-Anatomical Examination of Tumor- 
Dental Germ in Abnormal Position-Parts of a Tooth surgically considered-Dental 
Pulp - Periodonteal Membrane-Perversion in Tooth Development-Enamel - 
Cement-Common Likeness in Anomalous Incongruities-Ordinary Dental and Ma- 
lignant Osteoid Tumors-Data for the Study of the Odontomata-Preservation of 
Continuity-Application of Interdental Splints-Stuffing Cysts-Departure from 
Homologousness-Hypothesis of Cause-Teeth most frequently found Encysted- 
Cystiform Antra-Tenacity of the Antrum, functionally considered-Hydrops Antra 
-Intra-antral Cyst-Multiple Antral Cysts-Meningocele-Aneurisinal Cyst-Osteo- 
enchondroina-Hydatid Cysts 1170 
CHAPTER LX XI I. 
THE TUMORS OF THE MOUTH. 
TUMORS NOT EXPLAINABLE IN LOCAL CONDITIONS. 
Constitutional Import of Tumors-Differentiation of Tumors of Constitutional Import- 
Making a Diagnosis-Study of Cancer-Tumors not self-explainable-Extremes- 
Histologically-Histological Classification-Clinical Classification-Fibrous Tumors 
-Diagnosis of-Myomata of Virchow-Fibro-sarcoma of Rokitansky-Myeloid of 
Paget-Microscopic Study of Fibro-recurring Tumor-Enclosed Myeloid Tumor- 
Microscopic Study of Myeloid Growths-Myeloid Growths epitomized-Braithwaite 
on the Fibromata-Cysto-sarcoma-Approach to Self-explainable Cystomata-Cysto- 
sarcoma Phyllodes-Enchondromata-Cause of Formation of Osteo-sarcomatous 
Tumors-Rapid Growth of a Tumor-Changes relating with Sarcomatous Tumors- 
Softening-Suppuration-Histoid Mixed Tumors-Scirrhus-Features of Advancing 
Development-Multiplication of the Scirrhomata-Duration of Scirrhus-Micro- 
scopic Studies of Scirrhus Cancer-Encephaloma-Not Encapsuled-Illustrative 
Cases-Goitre, or Bronchocele-Diagnosis of Goitre-Treatment of-Illustrative Cases 
of Tumors at large . 1193 
CHAPTER LXXIII. 
MEDICAL DIAGNOSIS. 
BEING PRELIMINARY TO THE STUDY OF ANAESTHETICS AND AN.ESTHESIA, AND APPRECIATIVE 
OF DISEASE IN GENERAL. 
Definition of Disease-Disease a Generic Term-Foundation of Diagnosis-Ability to 
Diagnose Proportional with Knowledge-Study of Diagnosis-Suggestions in Diag- 
nosis-Diagnosis a Matter both of Principle and Detail-Treatment founded on Di- 
agnosis-Physical Condition-External and Internal-The Process of Exclusion- 
Consideration of Common Expressions-Diagnosis as applying to Anesthesia and 
Anesthetics-Requirements of an Anesthetist-Tripod of Life-Diseases of the 
Heart-Locating the Heart and Mapping its Size-Percussion and Auscultation-Sys- 
tole and Diastole as furnishing Information of Condition of Heart-Recognition of 
Force of Heart-Sounds heard in Stenosis and Anemia-Sound of Regurgitation- 
Locating Lesion of Tricuspid Valve-Of Mitral Valve-Of Semilunar Valves- 
Studies of the Heart-Hypertrophy of the Heart-Association of, with Kidney Dis- 
ease-Common Cause of-Obliteration of Pericardial Sac as Cause of-Males more 
Subject to than Females-Dilatation of the Heart-Area of Dulness on Percussion- 
Murmur influenced by Circumstances-Expressions of Weak Heart-Fatty Heart- 
Definition of-Judgment of Existence of through Inspection-Antecedents related CONTENTS. 
XXXI 
with-Alcoholism as Cause-Diagnostic Symptoms-Pericardial Effusion-Diagnostic 
Signs-Valvular Affections-Definition of-Location of Valves-Use of Valves- 
Healthy Valvular Action-Unhealthy Valvular Action-Endocardium-Regurgi- 
tation-Stenosis-Results and Conditions of Regurgitation and Stenosis-Aortic 
Aneurism-Emphysema of the Lungs as Cause of Aneurism-Other Causes of Aneu- 
rism-Kinds of Aneurisms-Phantom Aneurism-Displaced Heart-Cause of-Heart- 
Sound in Anaemia-Tobacco Heart-Exophthalmic Goitre-Confusions-Rasping of 
the Heart-Diseases of the Lungs-Lungs in Position and Relation-Character of 
Lungs-Pleural Sac-Shape and Relation of Lungs-Composition of-Trabeculae- 
Pneumatosis-Apneumatosis-Respiratory, or Vesicular, Murmur-Use of Stetho- 
scope-Palpation-Inspection-Differentiation between Sounds in Health and Dis- 
ease-Tracheal Sound-Bronchial Sound-Rales or Rhonchi-Dry Rale-Moist Rale 
-Crepitant-Cavernous-Crackling-Pleural Friction-Vocal Resonance-Broncho- 
phony-Pectoriloquy-ASgophony-Emphysema-Cause and Diagnosis of-Atrophy 
-Cause and Diagnosis of-Collapse-Cause and Diagnosis of-Hydrothorax-Cause 
and Diagnosis of-(Edema-Cause and Diagnosis of-Hemorrhage-Cause and Diag- 
nosis of-Induration - Cause and Diagnosis of-Phthisis-Cirrhosis - Cancer- 
Hydatids 1215 
CHAPTER LX XIV. 
ANESTHESIA AND ANESTHETICS. 
Definition-History-Agents used-Manner of Use-Agents acting locally-Agents 
acting systemically-General Considerations-Local Use-Systemic Use-Inter- 
mediate Use-Difference as to Action-Local Agents divisible into-Anaesthetics 
systemically used. Agents Acting upon the Skin-Camphor-Chloral Hydrate- 
Camphor and Chloral Hydrate-Ph^nol-Sodique-Camphorated Phenol-Carbolic 
Acid - Campho-Phenique - Arnica-Aconite - Chloroform-Oil of Eucalyptus- 
Menthol - Rhigolene - Ether used locally-Nitrous Oxide used locally. Agents 
Acting upon the Mucous Membrane-Cocaine-Tendency of, to undergo Decomposi- 
tion-Anhydrous Cocaine Hydrochlorate-Oleate of Cocaine-Bromide of Potassium- 
Carbolic Acid-Menthol-Iodine-Hamamelis-Chloral Hydrate-Creasote. Inter- 
mediate Use of Obtunding Agents-Morphia used endermieally-Used hypodermati- 
cally-Atropia Antidotal to Morphia Sick Stomach-Cocaine used hypodermatically 
-Corning's Method. Accidents related with the Hypodermic Use of Cocaine- 
Respiratory Symptoms related with-Cardiac Symptoms related with-Brain 
Symptoms related with-Preliminary Precautions related with-Treatment of 
Accidents related with-Valerianate of Ammonia. Suppositories-Formulae for . 1248 
CHAPTER LXXV. 
anesthesia and anesthetics-Continued. 
Alcohol-Ether, History of-Manner of Preparation-Physical Characteristics-Jack- 
son's Formula-Conditions Necessary to Successful Use-Instruments employed in 
Administering-Time required to induce Ether Anaesthesia-Necessity for Vigorous 
Employment-Effects of Over-Dilution with Air-Supervening Excitement-Action 
of Ether and Spirits the same-Difference in Time of Effect of Alcohol and Ether- 
Influence of Familiarity-Immediate and Obvious Effects of Ether-Progressive 
Effects of-General Harmlessness of-Absolute Rules for Exhibition of, not possible 
-Flourens's Experiment--Agent and Administration-Quantity required-Criterion 
of Condition-Respiration-Sick Stomach-Continuance of Anaesthetic State-Tem- 
perature in Ether-Idiosyncrasies-Etherization by Rectum-Chloroform-History 
of-Preparation of-Appearance of-Tests of Purity-Degraded by Alcohol-Action - 
on Heart-Quantity required to be used-Danger of Limited Admixture with Air XXXII 
PAGE 
-Absorption and Respiration-Cardiac Syncope-Chloroform in the Sitting Position 
-Prefatory Stimulation-Sulphate of Strychnia-Ether conjoined with Chloroform- 
Exhibition as influencing Result-Admixture with Air-Induction of Insensibility 
varying with Patient-Condition of Narcotism-Three Degrees of Narcotism- 
Snow on Circumstances which influence Effects of Chloroform-Age of Patient- 
Strength or Debility-Hysterical People-Diseases of the Lungs as related with 
Use of Chloroform-Diseases of the Heart as related with Use of Chloroform- 
Criticism on Overconfidence-Recovery from Anaesthesia-Chloroform in Insanity 
and in Delirium Tremens-Accidents happening with the Skilful-Accidents not 
Traceable to Overdoses-Restoration of the Abeyant Circulation-Influence of Oil of 
Turpentine on Chloroform-Inverting a Patient-Artificial Respiration-Use of 
Nitrite of Amyl-Nitrous Oxide Gas-History of-Manner of Preparation-Appa- 
ratus used in making-Washing-Collecting-Dispensing-Liquefied Nitrous Oxide 
-Fresh Gas Better than Old-Interruptions to Exhibition-Action of-Bonwill's 
Method of Rapid Breathing in Connection with the Use of Nitrous Oxide-Ethyl 
Bromide-Hypodermatic Narcotism-Morphia and Atropia-Chloroform used sub- 
cutaneously-Studies-Possible Accidents in Relation with the Use of Anaesthetic 
Agents-Apnoea-Asphyxia-Ether and Chloroform compared-Use of, in Children 
and the Aged-Organic Diseases and Chloroform-Stenosis, Hypertrophy, Dilatation, 
and Ether-Emphysema and Ether-Stenosis and Chloroform-Emphysema and 
Chloroform-Combating Dangerous Symptoms in Use of Ether-In Use of Chloro- 
form-Silvester's Method-Marshall Hall's Method-Alcohol, Chloroform, and Ether 
used in Combination 1260 
CHAPTER LXXVI. 
INFLAMMATION. 
Understanding of Inflammation one with Understanding of Surgery-Definition of- 
Cause of-Perversion of Circulation-Definition of-Examples in-Study of Inflam- 
mation-Caused by Presence of an Irritant-Appreciation of Irritants-Result of 
Presence of-Local and General Disturbance-Inflammatory Effort-Illustrative 
Demonstration-Inflammatory Act-Inflammation of Systemic Import-Systemic 
Irritants-Local Treatment of Inflammation-Primary and Secondary Indications 
-Getting Blood away from a Part-Dry Cups-Wet Cups-Use of Leeches-Use of 
Fly-Blisters-Venesection-To Check the Flow of Blood-Antiphlogistic Applica- 
tions-Phenol-Sodique-Hydrochlorate of Ammonia as a Sorbefacient-Goulard's 
Extract-Hamamelis Virginica-Rest as a Factor-Veratrum Viride and Bromide 
of Potassium-Dover's Powder-Febrile Condition-Epsom Salts-Domestic Mode 
of Sweating-Diet as an Element in Treatment-Cooling the Surface of Body- 
Tincture of Digitalis-Diuretics-Narcotics-Hyoscyamus and Belladonna-Specific 
Inflammation-Iodide of Potassium-Malarial Complication-Specificity residing 
with Iron-Scrofulous Inflammation-Activity and Chronicity in Inflammation- 
Indications in Active Inflammation-Indications in Chronic Inflammation-To Un- 
load Capillaries passively or chronically congested-General Tonicity-Sheet Salt- 
Bath-Massage-Chronic Inflammation associated with Joints-Suppuration-Red- 
ness, Heat, Pain, Swelling, Functional Disorder-Morphia the most Reliable of 
Pain-Obtunding Agents-Changes in the Blood-Swelling and Hypertrophy-Para- 
dox of Congestion-Repair-Lymph 1292 
CHAPTER LXXVII. 
ERYSIPELAS. 
Diagnosis of-Idiopathic - Tendency to spread-Various Expressions of-Simple 
Erysipelas-Treatment of-Costiveness - Purging Weakly People - Cleanliness- 
CONTENTS. PAGE 
Phlegmonous Erysipelas-Treatment of-Constitutional Support-Tension and Free 
Incisions-Formulae-Relation with Poisoned Wounds-Danger from Septicaemia- 
Aconite-Erysipelatous Lymphangitis-Erysipelatous Phlebitis-Erysipelas attack- 
ing Throat-Causes of Erysipelas 1313 
CHAPTER LXXVIII. 
ANTISEPSIS. 
Derivation of Term-Double Effect of Sepsis-Healthy and Unhealthy Pabulum- 
Germ Theory-Koch's Bacillus-Listerism-Stimulants Identical with Antiseptics 
-Zinc Chloride as an Antiputrefactive-Use of Aromatic Sulphuric Acid-Of Cor- 
rosive Sublimate-Of Chalk-Of Charcoal, Bismuth, and Iodoform-Of Peroxide of 
Hydrogen-Of Monsel's Solution of Persulphate of Iron-Of Potassio-mercuric 
Iodide-Of Hydro-naphthol-Of Aseptol-Of Fluosilicate of Soda-Of Styrone- 
Forms of Micro-organisms-The Micrococci-The Diplococci-The Streptococci- 
The Staphylococci-The Bacilli ........... 1317 
CONTENTS. 
XXXIII LIST OF ILLUSTRATIONS. 
FRONTISPIECES. 
I. Antero-lateral View of Skull. 
II. Base of Skull-External View. 
III. Base of Skull-Internal View. 
IV. Lower Jaw-Bone-External View. 
V. Lower Jaw-Bone-Internal View. 
fig. PAGE 
1. The skull 27 
2. Septum narium . . . .29 
3. Outer wall of nose . . . .30 
4. Section of cranium . . . .35 
5. Section of cranium . . . .35 
6. Section of cranium . . . .36 
7. Section of cranium . . . .36 
8. External face of superior maxillary 
bone ...... 37 
9. Internal face of . . . .37 
10. Section of maxillary bone . . 38 
11. Inferior maxillary bone . . .43 
12. Internal view of . . • .45 
13. Section of side of skull . . .45 
14. Palate bone 46 
15. Palate bone . . . . .46 
16. Vomer bone . • . . .48 
17. Articular relations of . . .48 
18. Turbinated bones in position . . 49 
19. Ethmoid bone . • . . .50 
20. Ethmoid bone 51 
21. Ethmoid bone . . . . .51 
22. Sphenoid bone . . . .52 
23. Sphenoid bone . . . .52 
24. Nasal bone 56 
25. Malar bone . . . . .57 
26. Lachrymal bone . . . .58 
27. Hyoid bone . . . . .58 
28. Antero-posterior section of cranium 58 
29. Base of skull . . . . .59 
30. Frontal bone . . . . .60 
31. Frontal bone . . . . .60 
32. Occipital bone. . . . .62 
33. Occipital bone . . . . .62 
34. Temporal bone . . . .64 
35. Temporal bone . . . .65 
36. Temporal bone . . . .66 
FIG. PAGE 
37. Parietal bone . . . . .68 
38. Parietal bone 68 
39. Muscles of the face . . . .69 
40. Temporal muscle . . . .76 
41. Masseter and pterygoid muscles . 77 
42. Muscles of neck . . . .79 
43. Heart and great blood-vessels . . 80 
44. Common carotid artery . . .82 
45, Arteries of face . . . .83 
46. Internal maxillary artery . . 86 
47. Arteries of base of brain . . 91 
48. Deep venous circulation of facial 
region . . . . .95 
49. Veins of head and neck . . .96 
50. Sinuses of the dura mater . . 97 
51. Temporo-maxillary vein and its trib- 
utaries . . . . .98 
52. Lymphatics of the head and neck . 99 
53. Lymph-corpuscles . . . .100 
54. Lymph-corpuscles .... 100 
55. Lymphatic vessel laid open . . 101 
56. Lymphatic gland and vessels . . 101 
57. Section of lymphatic gland . .101 
58. Facial nerve . . . . .103 
59. Trifacial nerve .... 106 
60. Base of the brain . . . .107 
61. Trifacial division and ganglion . 108 
62. Superior maxillary nerve . .112 
63. Inferior maxillary nerve . . 114 
64. Ophthalmic ganglion . . . 117 
65. Spheno-palatine ganglion and olfac- 
tory nerve . . . . .118 
66. Otic ganglion and connections . 119 
67. Sectional view of nose, mouth, and 
pharynx 125 
68. Muscles of tongue .... 127 
69. Upper surface of tongue . . 128 
XXXV XXXVI 
LIST OF ILLUSTRATIONS. 
fig. page 
70. Papillae of tongue .... 129 
71. Papillae of tongue .... 129 
72. Temporo-maxillary articulation . 133 
73. Temporo-maxillary articulation . 133 
74. Vertical section of cuspid tooth . 135 
75. Magnified dental pulp . . . 136 
76. Nerves of dental pulp . . . 136 
77. Dentine and enamel . . . 136 
78. Dentine and cement . . . 137 
79. Enamel columns .... 137 
80. Section of enamel .... 137 
81. Interglobular spaces . . . 138 
82. Vertical section of molar tooth . 138 
83. Transverse section of molar tooth . 138 
84. Deciduous teeth . . . .139 
85. Permanent teeth of superior jaw . 140 
86. Permanent teeth of inferior jaw . 140 
87. Lateral view of teeth . . . 143 
88. Section of lower jaw . . . 145 
89. Diagrams of tooth development . 151 
90. Crown of tooth .... 152 
91. Relation of enamel, tunica propria, 
and dentine .... 153 
92. Tooth-sac ..... 154 
93. Involution of epithelium . . 155 
94. Involution of epithelium . . 155 
95. Section of tooth . . . .157 
96. Dentitional processes . . . 159 
97. Eruption of an eye-tooth . .164 
98. Lancing tooth .... 164 
99. Lancing tooth .... 164 
100. Eruption of molar tooth . .164 
101. Lancing molar tooth . . . 164 
102. Anomalous teeth .... 193 
103. Cauliflower-like tooth . . . 193 
104. Odontoma ..... 194 
105. Section of odontoma . . . 194 
106. Intramaxillary bone and teeth . 195 
107. Tumor of ramus of lower jaw . 195 
108. Osseous cyst in upper jaw . . 195 
109. Intramaxillary osseous tumor . 196 
110. Microscopic section of . . . 196 
111. Superior dental arch, perfect . . 211 
112. Superior dental arch, imperfect . 212 
113. Section of carious tooth . . . 243 
114. Filed teeth ..... 248 
115. Examples of filing teeth . . 250 
116. Examples of filing teeth . . 250 
117. Examples of filing teeth . . 251 
118. Examples of filing teeth . . 251 
119. Disks for separating teeth . . 251 
120. View of separated teeth . .251 
121. Sharp and dull burs . . . 266 
122. Seption of tooth .... 279 
FIO. PAGE 
123. View of diminished pulp-cavity . 279 
124. Deposit of secondary dentine . 280 
125. Deposit of secondary dentine . 280 
126. Nodular dentine .... 281 
127. Ringed tooth 289 
128. Metal cap used in periodontitis . 291 
129. Sac of tooth abscess . . . 292 
130. Opening into alveolar abscess . 294 
131. Imprisoned tooth .... 302 
132. Imprisoned tooth .... 302 
133. Imprisoned tooth .... 303 
134. Imprisoned tooth .... 303 
135. Imprisoned tooth .... 304 
136. Imprisoned tooth .... 304 
137. Nerve extractor .... 307 
138. Nerve extractors .... 307 
139. Nerve-canal pluggers . . . 310 
140. Pulp caps ..... 314 
141. Herbst's retaining rubber . . 321 
142. Rollins's tubular knife . . . 328 
143. Trephines for jaw .... 329 
144. Younger's reamers. . . . 329 
145. Spiral knives ..... 329 
146. Ottolengui's combination instru- 
ment 329 
147. Expressive of implantation . . 329 
148. Expressive of implantation . . 330 
149. Expressive of implantation . . 331 
150. Lower jaw at various ages . . 332 
151. Implanted tooth-post . . . 332 
152. Absorption of implanted tooth . 334 
153. Absorption of implanted tooth . 334 
154. Absorption of implanted tooth . 334 
155. Absorption of implanted tooth . 334 
156. Absorption of implanted tooth . 334 
157. Denudation of teeth . . . 335 
158. Denudation of teeth . . . 335 
159. Superior dental arch . . . 337 
160. Superior dental arch . . . 338 
161. Hoe excavators and modifications . 338 
162. Hatchet excavators and modifica- 
tions 339 
163. Rose drills and spear drills . . 339 
164. Merry's drill ..... 340 
165. Bur thimble ..... 340 
166. Dental engine, White's . . . 341 
167. Dental engine, Bonwill's . . 341 
168. Section of mandrel . . . 342 
169. Section of mandrel . . . 342 
170. Chisels used in dentistry . . 343 
171. Jack's chisels. .... 343 
172. Forbes's and Jack's chisels . . 345 
173. Separating files .... 345 
174. Separating files . ■ . . 346 LIST OF ILLUSTRATIONS. 
XXXVII 
TIG. PAGE 
175. Separating files .... 347 
176. Forbes's file-carrier . . . 347 
177. Miller's file-carrier . . . 348 
178. Knife-edged saw .... 348 
179. Side view of disk .... 348 
180. Disks of corundum . . . 348 
181. Herrick's fountain drip-point . 349 
182. Water-syringe .... 349 
183. Cavities in teeth .... 351 
184. Cavities in teeth .... 352 
185. Cavities in teeth .... 352 
186. Cavities in teeth .... 352 
187. Cavities in teeth .... 352 
188. Cavities in teeth .... 353 
189. Carious denture .... 353 
190. Carious denture .... 354 
191. Carious denture .... 355 
192. Jarvis's separators. . . . 356 
193. Complicated cavities . . . 357 
194. Complicated cavities . . . 357 
195. Modification of excavators . . 358 
196. Flagg's tongue-holder . . . 363 
197. Morrison's compressor . . . 363 
198. Saliva-pump ..... 364 
199. McQuillen's extension-finger . . 364 
200. Taft's thimble .... 365 
201. Rich's duct-compressor . . . 365 
202. Depressed rubber dam . . . 366 
203. Rubber-dam mirror . . . 366 
204. Perforated rubber dam . . . 366 
205. Rubber-dam applier . . . 367 
206. Rubber-dam clamps . . . 367 
207. Rubber-dam clamps . . . 367 
208. Hickman's clamp .... 368 
209. Elliot's clamp .... 368 
210. Buckman's clamp .... 368 
211. Ottolengui's clamp .... 368 
212. How's clamp .... 369 
213. Johnson's clamp .... 369 
214. Palmer's clamp .... 369 1 
215. Palmer's rings .... 369 
216. Palmer's clamp .... 369 
217. Palmer's clamp .... 369 
218. Barnes's adjustable clamp . .370 
219. Barnes's adjustable clamp . . 370 
220. Barnes's adjustable clamp . . 370 
221. Application of rubber dam . . 370 
222. Rubber-dam weight . . .371 
223. Rubber-dam holder ... . 371 
224. Rubber-dam appliers . . . 372 
225. Rubber dam applied . . . 373 
226. Hot-air syringe .... 373 
227. Amalgam cups .... 382 
228. File flat amalgam-carrier . . 382 
TlG. PAGE 
229. Amalgam pluggers . . . 382 
230. Smith's plastic fillers . . . 389 
231. Gold cylinders .... 395 
232. Gold mats and blocks . . . 395 
233. Introducing cylinders . . . 396 
234. Introducing mats .... 397 
235. Principle of wedging . . . 397 
236. Foil-carrier ..... 397 
237. Redman's pluggers . . . 398 
238. Loop matrices .... 400 
239. Jack's matrice .... 401 
240. Jack's matrice .... 401 
241. Jack's matrice .... 401 
242. Guilford's matrices . . . 401 
243. Miller's matrice .... 402 
244. Cavities exposed .... 402 
245. Section of cavities . . . 402 
246. Atkinson's pluggers . . . 405 
247. Burnishers ..... 406 
248. Butler's pluggers .... 406 
249. Smith's pluggers .... 407 
250. Abbott's pluggers .... 408 
251. Plugging mallets .... 410 
252. Prepared cavity .... 412 
253. Illustration from Marshall Webb . 414 
254. Illustration from Marshall Webb . 414 
255. Illustration from Marshall Webb . 415 
256. Studies from Dr. Weld . . .415 
257. Studies from Dr. Weld . . . 415 
258. Studies from Dr. Weld . . . 415 
259. Studies from Dr. Weld . . . 415 
260. Studies from Dr. Weld . . . 415 
261. Contour-work in progress . . 416 
262. Contour-work in progress . . 416 
263. Contour-work done . . .416 
264. Cavities for contour-work . . 416 
265. Fixing first pieces .... 416 
266. Automatic mallet . . . .417 
267. Electro-magnetic mallet . .417 
268. Buckingham's mallet . . . 418 
269. Herbst's pluggers . . . .419 
270. Finishing files .... 420 
271. Bur and wheel files . . . 421 
272. Burnishing instruments . . 421 
273. Porte polishers .... 422 
274. Corundum points .... 423 
275. Stone points ..... 423 
276. Corrugated disk .... 424 
277. Wood polishing-points . . . 424 
278. White's head-rest .... 427 
279. Permanent teeth of upper jaw . 429 
280. Permanent teeth of lower jaw . 429 
281. Tooth forceps 430 
282. Tooth forceps ..... 430 XXXVIII 
LIST OF ILLUSTRATIONS. 
FIG. PAGE 
283. Tooth forceps ..... 431 
284. Tooth forceps 431 
285. Tooth forceps . .... 431 
286. Tooth forceps..... 432 
287. Tooth forceps..... 432 
288. Tooth fiorceps 432 
289. Tooth forceps..... 432 
290. Tooth forceps. .... 433 
291. Tooth forceps. .... 434 
292. Tooth forceps ..... 435 
293. Tooth forceps. . . . .435 
294. Tooth forceps 435 
295. Tooth forceps. . . , . 435 
296. Tooth forceps..... 436 
297. Tooth forceps ..... 436 
298. Tooth forceps..... 437 
299. Tooth forceps ..... 437 
300. Cow-horn forceps .... 438 
301. Cow-horn forceps .... 438 
302. Tooth forceps 439 
303. Cow-horn forceps .... 439 
304. Cow-horn forceps .... 440 
305. Cow-horn forceps .... 440 
306. Wolverton's tooth forceps . . 441 
307. Hutchinson's tooth forceps . . 441 
308. Tooth forceps. . . . .441 
309. Physick's forceps .... 442 
310. Elevators used in extracting teeth . 443 
311. Tooth forceps. .... 443 
312. Jones's fulcrum forceps . . . 444 
313. Jones's fulcrum forceps . . . 444 
314. Jones's fulcrum forceps . . . 444 
315. Jones's fulcrum forceps . . . 445 
316. Relation of fractured roots to alveo- 
lar line ..... 446 
317. Stellwagen's incising forceps . . 446 
318. Stellwagen's incising forceps . . 446 
319. Screw used for extracting roots . 447 
320. Dubs's screw forceps . . . 448 
321. Hullihen's screw forceps . . 448 
322. Root forceps ..... 449 
323. Root forceps ..... 449 
324. Root forceps ..... 449 
325. Root forceps ..... 449 
326. Root forceps ..... 449 
327. Root forceps ..... 450 
328. Deformed roots .... 450 
329. Anomaly ..... 451 
330. Anomaly ..... 451 
331. Spray apparatus .... 458 
332. Spray apparatus .... 459 
333. Cap-crowns ..... 461 
334. Cap-crowns applied . . . 462 
335. Talbot's crown .... 463 
FIG. PAGE 
336. Grooving bur engine-bit . . 463 
337. Bing's crowns .... 464 
338. Starr's root-trimmers . . . 464 
339. Root reduced .... 464 
340. Pivot crown applied . . . 465 
341. Excising forceps .... 467 
342. Saw for excising crown . . . 467 
343. Pivot files ..... 468 
344. Hand-lathe ..... 469 
345. Foot-lathe 469 
346. Bonwill's pivoting process . . 473 
347. Components of ... . 473 
348. Components of ... . 473 
349. Pivoting process .... 474 
350. Pivoting process to correct irregu- 
larity 474 
351. Screw-driver ..... 474 
352. Pivoting process .... 475 
353. Pivoting process . . . .475 
354. Porcelain facing .... 475 
355. Porcelain facing .... 476 
356. Setting crowns . . . .476 
357. Harrower's method of porcelain 
facing ..... 477 
358. Pivoting in absence of root . . 480 
359. The How system of pivoting . 487 
360. Illustrative of How system . . 488 
361. Illustrative of How system . . 488 
362. Illustrative of How system . . 488 
363. Illustrative of How system . .488 
364. Illustrative of How system . . 488 
365. Illustrative of How system . . 488 
366. Illustrative of How system . . 489 
367. Illustrative of How system . . 489 
368. Illustrative of How system . . 489 
369. Illustrative of How system . . 489 
370. Illustrative of How system . . 489 
371. Illustrative of How system . . 490 
372. Illustrative of How system . . 490 
373. Illustrative of How system . . 490 
374. Illustrative of How system . . 490 
375. Illustrative of How system . . 490 
376. Illustrative of How system . . 490 
377. Logan crown and setting . . 491 
378. Illustration of .... 491 
379. Illustration of ... . 491 
380. Illustration of .... 491 
381. Illustration of ... . 491 
382. Illustration of .... 491 
383. Illustration of ... . 492 
384. Illustration of .... 492 
385. Illustration of .... 492 
386. Illustration of .... 492 
387. Illustration of ... . 492 LIST OF ILLUSTRATIONS. 
XXXIX 
fig. page 
388. Logan crown and setting . . 492 
389. Illustration of ... 493 
390. Illustration of ... . 493 
391. Illustration of ... . 493 
392. Illustration of ... . 493 
393. Gates's crown and method . . 495 
394. How's improved crown and setting 499 
395. Illustration of ... . 499 
396. Illustration of ... . 499 
397. Illustration of ... . 499 
398. Illustration of ... . 499 
399. Illustration of ... . 499 
400. Illustration of ... . 500 
401. Illustration of ... . 500 
402. Illustration of ... . 500 
403. Illustration of ... . 500 
404. Illustration of ... . 500 
405. Illustration of ... . 500 
406. Illustration of ... . 500 
407. Illustration of ... . 500 
408. Illustration of ... . 501 
409. Illustration of ... . 501 
410. Illustration of ... . 501 
411. Illustration of ... . 501 
412. Illustration of ... . 501 
413. Illustration of ... . 501 
414. Introductory of bridge-work . . 502 
415. Illustrative of ... . 502 
416. Illustrative of .... 502 
417. Illustrative of ... . 502 
418. A dental bridge .... 502 
419. Dental bridge applied . . . 502 
420. Starr's operation in bridge work . 503 
421. Removable bridge-work . . 504 
422. Removable bridge-work, Rich- 
mond's ..... 505 
423. Illustration of ... . 505 
424. Illustration of ... . 505 
425. Bridge-work, Curtis's . . . 507 
426. Illustration of . . . . 507 
427. Illustration of ... . 508 
428. Illustration of ... . 508 
429. Illustration of ... . 508 
430. Illustration of ... . 508 
431. Seamless collars .... 513 
432. Illustrative of ... . 514 
433. Illustrative of ... . 514 
434. Illustrative of ... . 514 
435. Illustrative of . . . .515 
436. Illustrative of ... . 515 
437. Illustrative of ... . 515 
438. Illustrative of ... . 515 
439. Illustrative of ... . 516 
440. Illustrative of ... . 516 
FIO. PAGE 
441. Seamless collars . . • .516 
442. Illustrative of . . . .516 
443. Illustrative of . . . .516 
444. Illustrative of ... . 516 
445. Illustrative of . . . .516 
446. Illustrative of ... . 516 
447. Illustrative of . . . .516 
448. Illustrative of ... . 516 
449. Method of inserting seamless gold 
contour crowns . . . .517 
450. Illustration of . . . .517 
451. Illustration of ... 517 
452. Illustration of ... • 517 
453. Illustration of ... 518 
454. Illustration of ... . 518 
455. Illustration of ... • 518 
456. Illustration of ... • 518 
457. Illustration of ... • 518 
458. Illustration of ... 519 
459. Illustration of ... 519 
460. Illustration of ... 519 
461. Illustration of ... 521 
462. Illustration of ... 521 
463. Orthodontia, illustration of . . 527 
464. White's correcting apparatus . 528 
465. Westcott's appliance . . . 529 
466. Posterior position of lateral incisor 
teeth ...... 531 
467. McQuillen's bar .... 531 
468. Application of rubber ring . . 531 
469. Dental irregularity . . • 532 
470. Ligature as a corrective means . 532 
471. Ligature as a corrective means . 532 
472. Normal dental arch . . . 533 
473. Cap for front teeth . . • 533 
474. Projecting lower jaw . . . 534 
475. Lower jaw at different ages . . 534 
476. Occipito-mental sling . . . 535 
477. A result in orthodontia . . . 536 
478. Hedman's plate .... 536 
479. Correction through use of wedges 537 
480. Correcting apparatus . ... 537 
481. Protrusion of upper jaw. . . 538 
482. Jack-screw correction plate . . 538 
483. Farrar's system, illustrative of . 538 
484. Farrar's system, illustrative of . 539 
485. Farrar's system, illustrative of . 539 
486. Farrar's system, illustrative of . 540 
487. Farrar's system, illustrative of . 540 
488. Farrar's system, illustrative of . 540 
489. Farrar's system, illustrative of . 541 
490. Farrar's system, illustrative of . 541 
491. Farrar's system, illustrative of . 541 
492. Farrar's system, illustrative of . 542 XL 
LIST OF ILLUSTRATIONS. 
fig. PAGE 
493. Farrar's system, illustrative of . 542 
494. Impression tray .... 545 
495. Impression tray . . . . 545 
496. Impression tray .... 546 
497. Impression ready to receive plas- 
ter batter ..... 550 
498. Rim to support plaster batter . 550 
499. Plate made ready for bite . . 554 
500. Plate made ready for bite . . 554 
501. Plate made ready for bite . . 554 
502. Plate made ready for bite . . 554 
503. Illustrative of articulation . . 556 
504. An articulator .... 557 
505. Arches in articular relation . . 558 
506. Illustrative of setting teeth . . 559 
507. Illustrative of setting teeth . . 559 
508. Illustrative of setting teeth . . 559 
509. Illustrative of setting teeth . . 559 
510. Illustrative of setting teeth . . 560 
511. Illustrative of setting teeth . . 560 
512. Illustrative of setting teeth . . 561 
513. Illustrative of setting teeth . . 561 
514. Corundum stick .... 563 
515. Shop-furnace 564 
516. Foot-lathe 564 
517. Alcohol lamp ..... 565 
518. Kerosene lamp .... 565 
519. Rivet punch 565 
520. Illustrative of flame . . . 566 
521. Bunsen burner .... 566 
522. Fletcher's radial burner. . . 567 
523. Fletcher's blow-pipe . . . 567 
524. Mellotte's gas blow-pipe . . 568 
525. Blow-pipe pad .... 568 
526. Reverse face of ... . 568 
527. Handle of .... . 568 
528. Treadle blow-pipes .... 569 
529. Mouth blow-pipes .... 569 
530. Teeth used with vulcanite . . 570 
531. Vulcanite apparatus . . . 571 
532. Vulcanite apparatus . . . 572 
533. Vulcanite apparatus . . . 573 
534. Vulcanite apparatus • . . 573 
535. Campbell's new mode heater . . 575 
536. Sectional view of new mode heater 576 
537. Vulcanite case ready for gum . 579 
538. Celluloid blank rim . . . 579 
539. Metal plate with celluloid gum . 580 
540. Moulding-flasks .... 58,1 
541. Casting-flask ..... 582 
542. Plain teeth ..... 583 
543. Gum teeth in blocks . . . 584 
544. Arches of the superior and inferior 
jaws 585 
FIG. PAGE 
545. Studies in articulation . . . 587 
546. Denture incased in batter . . 588 
547. An upper plate with rim . . 592 
548. Vacuum-chamber .... 593 
549. Partial denture .... 594 
550. Plate cut out ready for swaging . 594 
551. Partial plate ..... 595 
552. Partial plate ..... 595 
553. Partial plate ..... 596 
554. Partial plate ..... 596 
555. A reinforced plate .... 596 
556. Continuous-gum work . . . 597 
557. Teeth used with continuous-gum 
work 598 
558. Teeth used with continuous-gum 
work 598 
559. The White furnace . . . 600 
560. The Teese furnace . . . 600 
561. The Parker furnace . . .601 
562. Case for obturator . . . .612 
563. An obturator ..... 612 
564. Case for obturator . . . .614 
565. An obturator ..... 614 
566. Case for obturator .... 615 
567. An obturator ..... 616 
568. Case for obturator . . . .617 
569. Case for obturator .... 618 
570. An obturator . . . . .618 
571. Face without nose .... 620 
572. Internal view of superior arch . 621 
573. Illustration of nose with attach- 
ments 623 
574. Illustration of nose with attach- 
ments 623 
575. Face with artificial nose . . 624 
576. Face without nose or upper lip . 625 
577. Case after making new lip . . 625 
578. A photograph .... 625 
579. An artificial nose .... 625 
580. Artificial velum . . . 627 
581. Artificial velum .... 627 
582. Illustration of Kingsley's velum . 628 
583. Illustration of Kingsley's velum . 629 
584. Illustration of Kingsley's velum . 629 
585. Illustration of Kingsley's velum . 630 
586. Illustration of Kingsley's velum . 630 
587. Illustration of Kingsley's velum . 630 
588. Illustration of Kingsley's velum . 631 
589. Illustration of Kingsley's velum . 631 
590. Baker's velum .... 633 
591. Baker's velum .... 634 
592. Baker's velum .... 634 
593. Baker's velum. .... 635 
594. Illustration in pyorrhoea alveolaris 641 LIST OF ILLUSTRATIONS. 
XLI 
FIG. PAGE 
595. Illustration in pyorrhoea alveolaris 641 
596. Illustration in pyorrhoea alveolaris 641 
597. Illustration in pyorrhoea alveolaris 642 
598. Illustration in pyorrhoea alveolaris 644 
599. Instruments employed in removing 
tartar from teeth . . . 652 
600. Gums inflamed by vulcanite plate . 664 
601. Hypertrophy of gums . . . 665 
602. Chronic ulitis .... 666 
603. Crossed, or knotted, bandage . 694 
604. Burn of neck .... 714 
605. Tonsil glands .... 719 
606. Cupping-glass, with elastic ball . 720 
607. Cupping-glass, with air-pump . 720 
608. Scarificator ..... 720 
609. Kolbe's artificial leech . . . 720 
610. Hypertrophied tonsil . . . 722 
611. Hypertrophied tonsil laid open . 723 
612. Physick's tonsillotome . . . 726 
613. Kolbe's tonsillotome . . . 726 
614. View of the air-tubes . . . 731 
615. Anatomy of front of neck . . 732 
616. Anatomy of front of neck . . 732 
617. Tracheal retractors . . . 733 
618. Mackenzie's dilator . . . 733 
619. Tracheal forceps .... 734 
620. Position for doing tracheotomy . 734 
621. Tracheal tubes .... 735 
622. Bougie leading canula . . . 736 
623. Trachea exposed .... 737 
624. Canula tied in place . . . 737 
625. Tracheal forceps .... 737 
626. Instruments used for the operation 
of intubation .... 739 
627. Extension of exudate from trachea 
into bronchi .... 742 
628. Epithelioma of larynx . . . 742 
629. Epithelioma of larynx . . . 742 
630. Microscopic view of cancer-cells . 754 
631. Cystic tumor of tongue . . . 758 
632. Amputation of tongue by strangu- 
lation 776 
633. Double ligature .... 777 
634. Chassaignac's ecraseur . . . 777 
635. Ligature extemporanee . . . 777 
636. Application of 6craseur . . 778 
637. Two ecraseurs used in making sec- 
tions ...... 778 
638. Regnoli's operation for ablation of 
tongue ..... 779 
639. Syme's operation for ablation of 
tongue ..... 779 
640. Nunneley's operation for ablation 
of tongue ..... 779 
FIG- PAGE 
641. Paget's operation for ablation of 
tongue 780 
642. Operation for tongue-tie . . 784 
643. Operation for tongue-tie . . 784 
644. Amputation of uvula . . . 786 
645. Uvula scissors .... 786 
646. Superficial ranula, showing seton 
introduced 793 
647. Hygroma of neck .... 796 
648. Deep-seated ranula . . . 800 
649. Side view ofpharynx and its muscles 801 
650. Posterior view of the muscles of 
pharynx 801 
651. Nebulizer ..... 806 
652. Bond's oesophagus forceps . . 808 
653. Bristle probang .... 809 
654. Bristle probang .... 809 
655. (Esophageal bougie . . . 810 
656. Laryngoscopy by sunlight . . 811 
657. Laryngeal image .... 812 
658. Electric illuminator . . . 812 
659. Naso-pharyngoscopic view . . 813 
660. Closing break in hard palate . . 818 
661. Cleft-palate operation . . . 826 
662. Curved needles .... 826 
663. Curved needles . . . 828 
664. Needle-carrier .... 828 
665. Combined needle and carrier . . 828 
666. Instruments used in uranoplasty • 830 
667. Kolbe's screw lever . . . 831 
668. Mears's gag ..... 831 
669. Goodwillie's gag .... 831 
670. View of nasal septum . . . 833 
671. Inside of nose .... 834 
672. Belloc's canula .... 838 
673. Manner of using canula . . 839 
674. Kolbe's powder insufflator . . 844 
675. Hibbard's powder blower . . 845 
676. Areling-Hodge polyptrite . . 845 
677. Goech's double canula . . . 845 
678. Torsion forceps .... 846 
679. Polypus forceps t 846 
680. Frog-face ..... 847 
681. Polypus related with turbinated 
bone ...... 847 
682. Removal of polypi . . . 847 
683. Removal of polypus . . . 848 
684. Scoop for removing foreign bodies 
from the nose . . . .861 
685. Frankel's nasal speculum . . 862 
686. Tobold's illuminating apparatus . 862 
687. Rhinoscopy by artificial light . 863 
688. Rhinoscopic examination of naso- 
pharynx 863 XLII 
LIST OF ILLUSTRATIONS. 
fig. PAGE 
689. Adams's forceps for straightening 
nasal septum .... 867 
690. Adams's nasal screw plates . . 867 
691. Illustration in rhinoplastic surgery 870 
692. Illustration in rhinoplastic surgery 870 
693. Illustration in rhinoplastic surgery 871 
694. Illustration in rhinoplastic surgery 871 
695. Illustration in rhinoplastic surgery 871 
696. Illustration in rhinoplastic surgery 871 
697. Illustration in rhinoplastic surgery 871 
698. Illustration in rhinoplastic surgery 872 
699. Illustration in rhinoplastic surgery 872 
700. Illustration in rhinoplastic surgery 872 
701. Illustration in rhinoplastic surgery 872 
702. Illustration in rhinoplastic surgery 874 
703. Illustration in rhinoplastic surgery 875 
704. Use of nasal douche . . • 876 
705. Naso-pharyngeal syringe . . 876 
706. Horns growing from the nose and 
face ...... 878 
707. Section of a horn, showing its lam- 
inae ...... 878 
708. Dermatolysis ..... 881 
709. Hypertrophy of mucous surface of 
lip 882 
710. Small sebaceous tumor . . . 887 
711. Keloid of neck .... 889 
712. Arterial naevus .... 893 
713. Venous naevus .... 893 
714. Naevus of face .... 894 
715. Naevus of lip . . . 895 
716. Transfixing ligatures . . . 897 
717. Transfixing ligatures . . . 897 
718. Oidium albicans .... 902 
719. Acne rosacea .... 904 
720. Lupus erythematosus . . . 906 
721. Lupus vulgaris .... 907 
722. Cancer of lip . . . . 914 
723. Cancer of lip .... 914 
724. Cancer of gum .... 914 
725. Cancer of lower part of face . . 915 
726. Cancer of eyelid . . . .919 
727. Flap operation illustrated . . 920 
728. Flap operation illustrated . . 921 
729. Flap operation illustrated . . 921 
730. Microscopic view of squamous epi- 
thelioma ..... 924 
731. Harelip operation .... 927 
732. Harelip operation .... 930 
733. Harelip operation .... 933 
734. Harelip operation .... 933 
735. Harelip operation .... 934 
736. Harelip operation .... 934 
737. Harelip operation .... 934 
FIG. PAGE 
738. Harelip operation . . . 934 
739. Harelip operation . . . 935 
740. Harelip operation . . . 935 
741. Harelip operation . . . 936 
742. Study in complicated harelip . 939 
743. Study in complicated harelip . 939 
744. Study in complicated harelip . 939 
745. Study in complicated harelip . 939 
746. Study in complicated harelip . 939 
747. Study in complicated harelip . 940 
748. Making twisted sutures . • 941 
749. Lip supporter .... 944 
750. Operation on lip . . . . 949 
751. Operation on lip . . . . 949 
752. Operation on lip . . . . 949 
753. Operation on lip .... 950 
754. Operation on lip . . . . 950 
755. Operation on lip . . . • 950 
756. Operation on lip . . . . 951 
757. Operation on lip . . . . 952 
758. Operation on lip . . . . 952 
759. Operation on lip . . . . 952 
760. Operation on lip . . . . 952 
761. Operation on lip . . . . 953 
762. Operation on lip . . . . 953 
763. Operation on lip . . . . 954 
764. Operation on lip . . . . 955 
765. Arterial circulation of neck . 958 
766. Arterial circulation of face and 
head ..... 959 
767. Arterial circulation of deep parts 
of face ..... 960 
768. Study in anastomosis . . .961 
769. Exposure of arteries . . . 964 
770. Exposure of lingual artery . . 965 
771. Surgical exposure of neck . . 968 
772. Manner of tying ligatures . . 969 
773. Tenaculum ..... 969 
774. Maxillary sinus and its associa- 
tions ..... 971 
775. Farrar's curved safety-tube . . 982 
776. Spraying maxillary sinus . . 982 
777. Antral drainage-tube . . . 983 
778. Salivary fistule .... 990 
779. Operation for salivary fistule . 991 
780. Cotton tent ..... 993 
781. Wire seton ..... 993 
782. Arterial supply of tooth . . 1009 
783. Necrosis of skull . . . 1015 
784. Sequestrum after measles . . 1020 
785. Phosphor-necrosis sequestrum . 1025 
786. The face and phosphor-necrosis . 1029 
787. Dislocation of jaw . . . 1031 
788. Reducing luxation of jaw . . 1034 LIST OF ILLUSTRATIONS. 
XLIII 
FIG. PAGE 
789. Vertico-mental cap . . . 1034 
790. Kolbe's mouth-opener . . . 1035 
791. Simple fracture of lower jaw . 1036 
792. Compound fracture of lower jaw . 1036 
793. Compound fracture of jaws . . 1039 
794. Section of jaw .... 1040 
795. Barton's bandage . . . 1041 
796. French dressing for jaw fracture 1041 
797. Hamilton's dressing for jaw fract- 
ure 1041 
798. Gibson's bandage . . . 1043 
799. Author's bandage . . . 1043 
800. Bean's splint .... 1044 
801. Bean's splint applied . . . 1044 
.802. Sudduth's mento-dental splint . 1045 
803. Metal interdental splint . . 1048 
804. Interdental splint . . . 1049 
805. Interdental splint . . . 1049 
806. Angle's jaw splint . . . 1050 
807. Angle's regulating and retaining 
appliances .... 1051 
808. Fracture of jaw .... 1052 
809. Clasp-bands .... 1053 
810. Jaw fracture .... 1053 
811. Bullet-wound of skull . . . 1056 
812. Arrow-wound of skull . . . 1056 
813. Indian arrow-head . . . 1056 
814. Conical trephine .... 1057 
815. Conical trephine .... 1057 
816. Operation of trephining . . 1057 
817. Button of bone .... 1058 
818. Elevator ..... 1058 
819. Hey's saw ..... 1058 
820. Excision of upper maxilla . . 1062 
821. Cutting and lion forceps . . 1065 
822. Bone scissors .... 1066 
823. Mouth-stretcher applied . . 1068 
824. Lip retractor .... 1068 
825. Section of lower jaw . . . 1070 
826. Tumor of jaw .... 1070 
827. Tumor of jaw .... 1071 
828. Exsection of lower jaw . . 1072 
829. Exsection of lower jaw . . 1072 
830. Chain-saw ..... 1072 
831. Chain-saw in use .... 1073 
832. Surgical engine and appliances . 1073 
833. Apparatus for holding an exsected 
jaw apart .... 1075 
834. Illustration in bridging a gap . 1075 
835. Operculum-excising forceps . . 1093 
836. Mal-developed wisdom-tooth . 1093 
837. Kolbe's mouth-opener . . . 1098 
838. Wedge of Scultetus . . . 1099 
839. Wedge of Scultetus . . . 1099 
FIG. PAGE 
840. Buckland's cicatrix cutter . . 1099 
841. Section of cicatricial tissue . .1100 
842. Exhibit of inferior maxillary 
nerve 1121 
843. Author's operation for exposure 
of inferior maxillary nerve . 1122 
844. Author's operation for exposing 
foramen ovale . . . .1124 
845. Neuroma of nasal arch . .1125 
846. Operation on nasal bone . . 1126 
847. Pancoast's operation for exposure 
of coronoid process . . . 1128 
848. Author's operation for exposure 
of foramen rotundum . . 1129 
849. Exposure of infraorbital nerve . 1133 
850. Exposure of supraorbital nerve . 1133 
851. Exposure of auricularis magnus 
nerve ..... 1134 
852. Exposure of auricular nerve . 1134 
853. Exposure of occipital nerve. . 1134 
854. Hypertrophic fatty tumor . . 1142 
855. Fatty tumor exposed . . . 1142 
856. Epulo-or dental-fungoid tumors . 1147 
857. Odonto-periosteal growth . . 1148 
858. Ulitic tumor . . . . 1148 
859. Epulic tumor .... 1153 
860. Epulic tumor .... 1153 
861. Epulic tumor .... 1153 
862. Epulic tumor .... 1153 
863. Epulic tumor .... 1153 
864. Epulic tumor .... 1153 
865. Section of maxillary bone . . 1156 
866. Odontoma ..... 1161 
867. Odontoma 1161 
868. Microscopic section . . .1162 
869. Hyperostosis .... 1164 
870. Osseous tumor . . . .1166 
871. Hyperostosis .... 1168 
872. Microscopic section . . . 1169 
873. Cystoma ..... 1171 
874. Cystoma 1172 
875. Cystoma ..... 1173 
876. Cystoma ..... 1173 
877. Odontoma 1176 
878. Microscopic section . . . 1177 
879. Cystoma of ramus . . . 1178 
880. Tooth tumor .... 1178 
881. Osteo-odontoma .... 1179 
882. Osteo-odontoma .... 1181 
883. Osteo-odontoma .... 1181 
884. Microscopic section . . . 1182 
885. Antral cyst ..... 1189 
886. Secondary cyst of antrum . . 1190 
887. Meningocele .... 1192 XLIV 
LIST OF ILLUSTRATIONS. 
FIO. PAGE 
888. Fibrous tumor .... 1194 
889. Microscopic appearance of fibroma 1195 
890. Microscopic appearance of fibro- 
recurring tumor . . .1196 
891. Sarcomatous tumor . . . 1197 
892. Microscopic appearance of myeloid 1199 
893. Osteo-sarcoina .... 1204 
894. Cysto-sarcoma .... 1204 
895. Multiplied scirrhomata . . 1205 
896. View of cancer-cells . . . 1206 
897. View of cancer-cells . . . 1206 
898. Encephaloid tumor . . . 1207 
899. Encephaloid tumor . . . 1208 
900. Encephaloid tumor . . . 1208 
901. Encephaloid tumor . . . 1209 
902. Encephaloid tumor . . . 1209 
903. Encephaloid tumor . . . 1210 
904. Encephaloid tumor . . . 1210 
905. Microscopic appearance of enceph- 
aloid tumor .... 1210 
906. Cancer-cells ..... 1211 
907. Cancer-cells ..... 1211 
908. Cancer-cells ..... 1211 
909. Cancer-cells ..... 1211 
910. Cancer-cells ..... 1211 
911. Cancer-cells . . . . .1211 
912. Goitrous tumor . . . .1212 
913. Symmetrical goitre . . . 1212 
914. Cystic goitre .... 1212 
915. Clinical thermometer . . . 1218 
916. Study of the heart . . . 1222 
917. Study of the heart . . . 1223 
918. Study of the heart . . . 1228 
919. Study of the lungs . . . 1234 
920. Study of the lungs and associate 
parts . . . . .1235 
FIO. PAGE 
921. Primary lobules of the lungs . 1236 
922. Capillary nets of the air-cells of 
the lungs .... 1236 
923. Distinction between normal and 
consolidated lung . . . 1238 
924. Stethoscope ..... 1238 
925. Illustrative of dry and moist 
rales 1241 
926. Hypodermic syringe . . . 1256 
927. Ether inhaler, author's . . 1261 
928. Towel-cone inhaler . . . 1262 
929. Allis's inhaler .... 1262 
930. Nitrous oxide apparatus . . 1281 
931. Nitrous oxide inhaler . . . 1282 
932. Nitrous oxide stand . . . 1283 
933. Silvester's method of artificial res- 
piration, first motion . . 1290 
934. Silvester's method of artificial res- 
piration, second motion . . 1290 
935. Illustrative of inflammation . 1294 
936. Enlarged and varicosed capilla- 
ries ...... 1294 
937. Uninflamed wing of a bat . . 1295 
938. Inflamed wing of a bat . . 1295 
939. Showing process of circumvalla- 
tion ...... 1296 
940. Suction-cup ..... 1299 
941. Artificial leech .... 1299 
942. Arrangement of veins of arm . 1300 
943. Thumb lancet .... 1300 
944. Spring lancet .... 1300 
945. Positions occupied in inflamma- 
tion by blood-corpuscles . . 1311 
946. Pabulum exuding through the 
walls of vessels . . . 1312 
947. Forms of micro-organisms . . 1321 
PLATES. 
I. A view of operations performed on the trachea facing 742 
II. Operations on the tongue 784 
III. The operation of staphylorraphy " 832 
IV. Operations in rhinoplasty " 868 
V. Rhinoplastic and cheiloplastic operations ......" 872 
VI. Harelip and atresia oris " 928 
VII. Plastic surgery of lips " 946 
VIII. Resection of maxillaa " 1068 
IX. Appearance and position of some of the tumors seen about the neck . " 1214 FRONTISPIECE I-A Study. 
TtNDO OCULI- 
Antenor 
Nares 
Ant. Nasal Spine 
Incisive fossa. 
Groove for Facial aV 
Antero-lateral View of Skull. {After Gray.) FRONTISPIECE IT.-A Study. 
An? pala/tini fossa 
TrriJism^e left Na^o-palaZ. n. 
^TmnsmUe Arntpalat. vest. 
-Transmit* right Naso paZa^. n. 
Acemory palatini 
Foramina, 
■PviI.NmoI Spinr 
.Azvao« vvvtc 
- Hajrudar proc 
SphcnauLpwc, of Fsslm*. 
o-palatiM C■ 
-TENSOR TYMFANI. 
-PjACiTynQcal Spirit* far bup constrict 
qf JEatttwkuin Itd^SeCfinulTy*p 
.LAXATOR TYWIPANI 
~C(nud for JAoobsaut w. 
-Aqueduct. Cochlea. 
~~For. lace ru. neposter tut. 
-CaiialfvrAmold'i re. 
-tAuriCUlur flSSUrC 
Base of Skull-External View. {After Gray.) FRONTISPIECE III.-A Study. 
Groove for Super, lerngitud. Sinus 
Grooves for Anter Meningeal A'l- 
Foramen Caeiim- 
Crista Go, Ur 
Slit for Masai nerve- 
Groove for tiusal porpc. 
Anterior Ethmoiaal Jor.. 
Orifices for Olfactory'nerves 
Posterior Edivuiidul Eon 
Ethmoidal Spins 
Olfaotory Groove's- 
Optic Eoramcot- 
' Optic Groove. 
Olivary proe^ 
Anterior Clinoid proa- 
Middle Clinoid proc' 
Posterior Clinoid, proa. 
Groove for Cd! norve. 
Far" lac er tom medium-. 
Orifice of Carotid Cantal 
Depression for Gasserian Gamglion 
Meatus Auditor. Interwus- 
Slit for Dur&-Ma,te^- 
Sup. Petrosal groove- 
For laeerum pastorius ■ 
Anterior Condyloid For 
Aqueduct. Vestibule- 
Posterior Condyloid Ion 
Maj told lor. 
Post. MeningFttl Grooves. 
Foramen 
Mau num 
Base of Skull-Internal View. (After Gray.} FRONTISPIECE IV.-A Study. 
External view of lower jaw-bone. 1, body; 2, ramus; 3, symphysis; 4, base of 
body; 5, angle; 6, mental foramen; 7, condyle; 8, coronoid process; 9, semilunar 
notch ; 10, dental foramen ; 11, alveolar border, or process; 12, incisor teeth; 13, cuspid, 
or stomach, tooth; 14, bicuspid teeth, or premolars; 15, first and second molars and 
wisdom-tooth, or dentes sapientise. (See text, p. 43.) 
FRONTISPIECE V.-A Study 
Internal view of lower jaw-bone. 1, coronoid process; 2, condyloid process; 
3, posterior dental foramen ; 4, angle; 5, genial tubercles. (See text, p. 44; see Articular 
Relations, p. 133.) DISEASES 
OF THE 
MOUTH, JAWS, FACE, TEETH, 
AND 
ASSOCIATE PARTS. 
CHAPTER I. 
DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
Oral surgery, viewed as a specialty in medicine, claims to treat of the 
various lesions associated directly and indirectly with the mouth, jaws, face, 
teeth, and associate parts. 
Studies in special medicine are properly preceded by education in medicine 
at large, particularly as such education considers the relation and application 
of principles to practice. The present text assumes, in the treatment of its 
subjects, that a desirable preliminary study pertaining to foundational matter 
has been accomplished; otherwise, that general text-books are at hand for 
convenient reference. 
Of foundational matter, assumed to be elementary, knowledge of anatomy 
asserts itself as of primary importance. Another direction refers to physiology. 
Still another relates with pathology. These subjects understood, or otherwise 
contemporaneously studied with the topics of the volume in hand, full com- 
prehension of the details herein treated is arrived at easily. 
In order that any special practice be directed with that absolute expression 
of intelligence which is the presumed virtue of specialism it is to be accepted 
that the parts related with the specialty require to be thoroughly studied. 
Recognizing such necessity, and reminding of the parts related with a study 
25 26 
A SYSTEM OF ORAL SURGERY. 
of oral surgery, the work in hand is commenced by directing attention to the 
anatomy of the regions. 
The large and freely-marked illustrations of different aspects of a human 
skull here introduced have been specially prepared with a view to afford help 
in memorizing the features of the localities represented. It is advised that a 
student possess himself of two crania, one articulated, the other having all 
its parts separate. These pieces are to be kept in close relation with the 
study chair. By taking up the skull, or an individual bone, and comparing 
with the associate pictures, both those that precede and follow, a mastery of 
names and situations is quickly secured. Practitioners are to find in these 
diagrams a source of speedy and satisfactory reference as occasions arise to 
refresh the memory as to cases in practice. 
THE HUMAN HEAD. 
The Human Head is divisible, anatomically, into a cranial and a facial 
portion ; it is separable also into hard and soft parts. 
Cranial Portion of Head.-The cranial portion of a human head is 
all that superior posterior aspect related with accommodation of the brain 
and scalp. 
Facial Portion of Head.-The facial portion of a human head is all 
that inferior anterior division expressed in mouth, nose, orbits, the associate 
bones and muscles of expression. 
FORM OF HEAD. 
Fig. 1, which is supplemental of frontispiece, here introduced for conven- 
ient reference, represents with reliable accuracy, the articulation of the molar 
teeth excepted, the lateral and front regions of a skull. This conjunction 
approaches, as seen, the form of an oblong square. A modification on such 
square is found to exist in childhood, where the ramus of the inferior maxil- 
lary bone, Fig. 1, is at an obtuse angle with the body; also in the case of 
an adult with prominent forehead. In either of these cases this aspect is 
triangular. Squareness of head denotes harmony between mental and physical 
endowment. A receding os frontis (1), particularly if having associated with 
it obtuseness of the anterior nasal angle, implies deficiency as to intellectual 
endowment. Excess as to posterior development indicates animal propensities. 
THE SKULL. 
The hard framework of a head is called the skull; it is made up of twenty- 
two different bones. Of these bones eight pertain to the cranial, fourteen 
to the face portion. The names of the bones are as follows: Belonging to 
the cranium-sphenoid, ethmoid, frontal, occipital, two parietal, 
two temporal. Belonging to the face-inferior maxilla, two supe- 
rior maxillae, two nasal, two malar, two inferior turbinated, two DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
27 
lachrymal, two palate, and a vomer. The teeth, and the six bones 
associated with the auditory apparatus, are not commonly numbered. 
FEATURES OF ANTERO-LATERAL VIEW. 
The antero-lateral view of a skull (see Frontispiece 1, also Fig. 1) shows, 
by the figures of the latter diagram, 1, 2, and 3, respectively, the frontal, 
parietal, and sphenoid bones of the cranium; also, by figures 6, 7, 8, 9, and 
10, respectively, the superior 
maxillary, the malar, the lach- 
rymal, the nasal, and inferior 
maxillary bones of the face. 
Relating with these parts are 
the various anatomical locali- 
ties. 
Anterior View.-Prom- 
inent features attracting atten- 
tion are the orbital cavities for 
accommodation of the eyes; 
the nasal opening, a little be- 
low and between the orbits, for 
attachment of the soft parts 
of the nose; the double row 
of teeth, still below, which 
constitute the opening into the 
oral cavity; and yet still be- 
low, the lower jaw, with its 
hinge-like relation to the cen- 
tral portion of the parts above. 
Attention finds itself di- 
rected to the fact that of the 
twenty-two bones composing 
a skull the inferior maxilla is 
the only separate and distinct 
one, and that opening and 
closing of the mouth is by 
means of this part,-acting 
as a trap. 
Passing from these more 
immediately prominent features, a student who has fully scanned and informed 
himself as to localities illustrated in the frontispieces, is prepared to recognize 
that complete understanding of this anatomy lies with a process of refining 
from generals to particulars; with which purpose in view he is now to start 
forward with the pages. 
Fig. 1.-Front and Lateral Region of 
the Skull. 
The skull seen partly in front, and on the right 
side. 1, frontal bone; 2, parietal bone; 3, temporal bone, 
its squamous portion; 4, sphenoid bone, temporal sur- 
face of its great wing; 5, ethmoid bone, its orbital sur- 
face; 6, superior maxillary bone; 7, malar bone; 8, lach- 
rymal bone; 9, nasal bone; 10, inferior maxillary bone; 
a, orbital plate of the frontal bone; b, temporal surface; 
c, orbital surface of the great wing of the sphenoid bone; 
d, mastoid portion of the temporal bone; e, orbital sur- 
face of the malar bone ; f, orbital plate of the superior 
maxillary bone; g, infraorbital foramen; h, mental fora- 
men ; i, symphysis; j, ramus; k, coronoid process; I, 
neck supporting the condyle; m, angle; n, lachrymo- 
nasal duct. 28 
A SYSTEM OF ORAL SURGERY. 
SKELETON OF THE MOUTH. 
The skeleton portion of the mouth, or oral cavity, is made up of the in- 
ferior movable jaw, maxilla, or mandible, as the bone is variously called, below, 
and the two superior jaws, or maxillae, and the two palate bones, above. The 
extreme front and lateral boundaries of the cavity are with the teeth, as seen 
in the diagram. (See description of Maxillary and Palate Bones.') 
The roof of the mouth is a common plate with the floor of the nose, 
this plate being made up of processes from the maxillary and palate bones. A 
central suture, the intermaxillary, marks the position of relation of the two 
bones. Posteriorly, a transverse line, the palato-maxillary suture, shows the 
position and distinction of the palate bones. The central raph£, or line, is 
seen to lead forward to a fossa, the anterior palatine, out of foramina in which 
(see Frontispiece 2) issue the palatine nerves and vessels. The lateral lines 
lead, on either side, to foramina, the posterior palatine, which transmit, 
from a canal of the same name, an artery of size and importance. Immedi- 
ately back of these foramina two others are seen on either side, the accessory 
palatine. To the outside of these last are the tuberosities of the maxillae 
on either side. To the inside is a ridge constituting the lower osseous boun- 
dary of the outlet of the nose, and affording seat of origin for the tensor 
muscle of the soft palate. The post-nasal spine, seen at the centre, 
gives origin to azygos uvulae muscles. 
The oral roof is, ordinarily, concave as to form, being of saucer shape. 
At times the concavity reaches to a depth which terminates in a mere 
slit. In instances, as in cleft palate, it is congenitally wanting. (See 
Cleft Palate.) The sides of the oral roof are formed by the alveolar 
processes and teeth, which see. The central portion is made up of the 
palatal plates, or processes, of the superior maxilla and palate bones. The de- 
pressions seen over the part are for lodgement of palatal glands. Vari- 
ous foramina observed are for transmission of nutrient arteries. (See Vestibule 
of Mouth.) 
The inferior lateral osseous boundary of the cavity is made by the 
horseshoe-shaped inner face of the inferior jaw. (See Frontispiece 1.) This 
face is to be divided, from before backward, about midway, by a line named 
mylo-hyoid, to which is attached the floor muscle of the mouth. The parts 
above this line are alone in the mouth. The parts below relate anatomically 
with the neck. The principal points of interest lie with a fossa seen to the 
side of the symphysis, or middle line, which depression accommodates the 
lingual gland, and, high up in the ramus, a foramen, known as posterior 
dental, which receives the dental nerve and artery. (See Inferior Maxillary 
Bones.) 
SKELETON OF THE NOSE. 
The bones entering into the construction of the nasal cavity are fifteen in 
number. This cavity is osseously separated into two canals by a central DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
29 
septum, septum narium, made up of a perpendicular plate descending from 
the ethmoideus-which see-and a distinct bone known as the vomer, Fig. 2 
(11, 13). 
The nasal fossae aje bounded above by the base of the cranium, below 
by the roof of the mouth, laterally by the lachrymal, ethmoid, turbinated, 
superior maxillary, palate, and sphenoid bones. These fossae communi- 
cate, above and behind, with the frontal, sphenoidal, and ethmoidal sinuses, 
with the orbit cavity by means of the lachrymal duct, and with the cranium by 
means of the cribriform foramina. Laterally, communication exists on either 
side with the antra of High- 
more situated in the maxil- 
lary bones. Below, relation 
with the mouth is through 
the anterior palatine canal. 
A foramen, spheno-palatine, 
occasionally wanting, commu- 
nicates, when existing, with 
the spheno-maxillary fossa. 
The bones entering into com- 
position of the nasal cavity 
are, belonging to the head, 
three, frontal, sphenoid, and 
ethmoid; belonging to the 
face, all except the malar 
and inferior jaw. 
Reference to Figs. 2 and 3 
will make plain the form and 
manner of mesian and lateral 
boundaries of osseous nose. 
Fig. 2. Subfig. 13 shows 
position and shape of vo- 
mer. 11 is the descend- 
ing plate of the ethmoid. 
15 is a sphenoidal sinus. 2 is the frontal sinus. 12 is the crista galli, 
or ethmoidal crest; the continuation downward of which is the upper section, 
11, of the septum narium. 9 shows the opposite posterior naris. 
Fig. 3. Subfig. 21 shows the bottom of the nose, which is one with the 
inferior meatus, between which and 26 is shown the position and relations, 8, 
of the inferior turbinated bone ; the figure, 26, is placed at the outlet, 
into the middle meatus, of the antrum. 5 shows the ethmoid bone, 
together with 6 and 7, the scrolls, constituting the so-called superior and 
middle turbinated bones. 20 is the middle meatus. 16 is the 
superior meatus. 11 is the naso-palatine canal. 22 is the frontal 
sinus. 12 is the floor of the nose. 
Fig. 2. 
Vertical section of the face, exhibiting the osseous 
nasal septum. 1, frontal bone; 2, frontal sinus; 3, nasal 
spine of the frontal bone; 4, nasal bone; 5, nasal spine 
of the maxilla; 6, nasal process of the same bone; 7, 
border of the palate plate of the same; 8, incisive fora- 
men ; 9, left posterior nares ; 10, palate plate of the palate 
bone; 11, nasal plate of the ethmoid bone ; 12, ethmoidal 
crest; 13, vomer; 14, left turbinated bone; 15, sphenoidal 
sinus; 16, entopterygoid process; 17, ectopterygoid pro- 
cess. 30 
A SYSTEM OF ORAL SURGERY. 
Attention is to be directed to the orifices of the nose. Anteriorly, in 
the white race, the alveolar and palatine processes form a right angle. 
In the negro this is obtuse. 
The interior orifice is pyram- 
idal in form ; it is bounded 
above by the nasal bones and 
below by the alveolo-palatal 
juncture. The posterior 
outlet is vertically rectan- 
gular, and is bounded above 
by the basilar surface of the 
body of sphenoid bone and 
vaginal process of vomer, lat- 
erally by the internal plates 
of the pterygoid processes, 
and below by the horizontal 
plates of the palate bones. 
The roof of the cavity is 
constricted, being narrower 
behind than in front. Here 
are found the superior scroll, 
and the cribriform foramina 
transmitting from the olfac- 
tory bulb the filaments re- 
lated with the sense of smell. 
The floor is freely wide 
and concave, and is broader 
at its middle than in front 
or behind. In front it con- 
sists of the two palatal pro- 
cesses of the superior maxillse, and behind of the plates of the palate bones. 
Features of the floor are, directly in front, centrally, the anterior nasal 
spine ; back of this the superior orifice of the palatine canal; and along 
the middle crest a spine which articulates the vomer. (See the individual 
bones.) 
Fig. 3. 
VlEW OF THE OUTER WALL OF THE RIGHT NASAL CAVITY. 
1, frontal bone; 2, its orbital plate ; 3, its nasal spine; 4, 
nasal bone; 5, ethmoid bone; 6, supraturbinal; 7, meso- 
turbiual; 8, turbinal bone; 9, descending process of the 
lachrymal bone, within the position of which is the nasal 
duct; 10, nasal spine of the maxilla; 11, naso-palatine 
canal; 12, palate plate of the maxilla; 13, nasal pro- 
cess of the latter; 14, ectopterygoid process; 15, ento- 
pterygoid process; 16, nasal plate of the palate bone; 
17, its palate plate; 18, posterior palatine foramen; 19, 
superior meatus of the nose; 20, middle meatus; 21, 
inferior meatus; 22, frontal sinus; 23, sphenoidal sinus; 
24, its communication with the upper back part of the 
nasal cavity; 25, spheno-palatine foramen ; 26, orifice of 
the antrum. 
THE ORBITAL CAVITY. 
An orbital cavity, of which there are two, is bounded, circumferentially, 
by the supraorbital ridge and the angular processes of the frontal bone, by the 
nasal process of the superior maxillary bone, and by the malar bone. Its 
office is to hold and accommodate the organ of vision. Examining this 
cavity attentively, no less than seven pieces are observed entering into its 
composition, some of which pieces, in their relations, closely affect pro- 
ceedings in oral surgery. It is seen, for example, that a large portion 
of the floor of the cavity is made up by a process, the orbital (f\ which is DESCRIPTIVE AND SURGICAL ANATOMF OF THE HEAD. 
31 
a part of the superior maxilla; glancing at a disarticulated bone, represented 
by Fig. 8 (4), it is remarked that this process is as well the roof of the antral 
sinus; it is also to be noticed as being a very thin plate, and capable, pre- 
sumedly, of easy elevation or depression, according as pressure might be 
brought upon it from below or above. Constituting, as it does, a source of 
support to the eye, it will be accepted that, where possible, it is to be left 
undisturbed in operations demanding extensive interference with the bone 
of which it is a part. At the inner inferior aspect of the cavity a groove, 
Fig. 8 (8), is observed, the lachrymal, being the entrance to a canal, the 
ductus ad nasum, as it is called, which canal carries the tears from the 
orbit to the nose. The outer wall of this duct is made up by the inner face 
of the nasal process, Fig. 8 (5), another portion of the superior maxillary 
bone. Diseases of the sinus not infrequently react on the eye; this to such 
extent that blindness of several months' standing has been cured by so 
simple a proceeding as the extraction of a diseased tooth-root which had 
affected the antrum to its engorgement. Closure of the tear canal, Fig. 8 (8), 
is almost certain to occur if the nasal process become inflamed. Such inflam- 
mation is met with frequently as resultant of odontocele. 
INFRAORBITAL FORAMEN. 
Immediately below the inferior boundary of the orbit a foramen is seen, the 
infraorbital, Fig. 1 (y), for transmission of the infraorbital branch of the fifth 
nerve. Passing a bristle through this foramen, it is found to emerge in the 
groove marked on the floor of the orbit,-the infraorbital groove. This 
groove and this canal are both in the maxillary bone, and, alike with the 
ductus ad nasum, are influenced by its diseases. 
CANINE FOSSA. 
The canine fossa, seen back of and above the canine tooth, has, as its floor, 
a thin plate of bone, which plate is the external face of the antrum, and 
through which, if it be found necessary, the cavity is easily entered. The 
ridge forming the anterior boundary of this fossa bears the name of canine 
ridge: it divides the canine from the incisive, or myrtiform, fossa. The poste- 
rior boundary is the malar process: it separates the canine from the zygomatic 
fossa. 
INCISIVE, OR MYRTIFORM, FOSSA. 
This is the depression seen between the canine ridge and mesian line, later- 
ally, the inferior free border of the nose above, and the alveolar border of the 
incisor teeth below. Caries and necrosis have here a favorite seat. 
The tuberosity of the maxilla, occupied in part by the wisdom-tooth, is 
a point of surgical interest,-it being not at all uncommon to have necrosis 
MAXILLARY TUBEROSITY. 32 
A SYSTEM OF ORAL SURGERY. 
or caries of this portion, the result of an osteitis, induced and kept up by an 
imprisoned dens sapientiae. Standing, as it is seen to do, tubercle-like, 
it is plainly evident that neither deformity nor harm would result from its 
separation as a sequestrum. 
ALVEOLAR PROCESSES 
The alveolar processes (see stippled portion, Fig. 13) are remarked to con- 
stitute quite a large part of both the superior and inferior maxillae. These 
processes, vascular and spongy, accommodative of the roots of the teeth 
and subject to all irritations residing in their presence, are, without doubt, 
more liable to take on pathological action than any other portion of the ossa 
corporae. From the alveolo-dental periosteum spring epulic outgrowths 
of various signification. Sarcomatous degeneration finds here a favorite 
seat; simple and compound cysts are familiar ; degenerative osteitis is not 
uncommon, while abscess of alveolo-dental signification is found in almost every 
mouth. The association of the teeth with these spongy processes (Fig. 13) is 
a matter to receive close attention, the operation for the extraction of the 
organs being an every-day requirement. The processes, if examined in a 
number of bones, will be found to vary greatly in character: in some being 
of such loose structure that the teeth are capable of easiest separation ; in 
other instances being so firm and unyielding that it is quite an impossibility 
to make such extraction without more or less fracture. 
The number and shape of the roots of the teeth are to be fully exam- 
ined. A knowledge of relations and curves as to articular association of the 
organs with their alveoli contributes much to facility in their removal. Indeed, 
no one but the experienced can appreciate how much easier it is to extract 
teeth with than without the advantages of such understanding. (See chapter 
on Extraction.} 
MENTAL FORAMEN. 
The mental foramen, Fig. 1 (A), seen upon the inferior maxilla, a little 
anterior to the middle of the body, is the outlet of a canal traversing the 
centre of the bone, a canal conducting, beneath the teeth, the dental artery 
and nerve. The size, general character, and inlet of this conduit are to be 
thoroughly studied, as not infrequently injuries to the artery require that it be 
plugged, so far as either foramina are concerned which exist beneath each tooth 
or as the channel proper is interfered with in operations for removal of tumors 
or sequestra. 
Neuralgia of some of the peripheries of the inferior dental nerve makes 
necessary, occasionally, its section within the canal. To get at this nerve 
requires either that some tooth be extracted, and the section made from the 
base of the socket, otherwise that entrance is had from the outside. The 
easiest mode of performing such operation is to be observed and understood, 
as relation is had to location, and to character of the bone. (See Neuralgia.} DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
33 
NASAL BONES. 
The nasal bones, resting upon the nasal processes of the maxillae, forming 
in the conjunction the nasal arch, are to be examined in their relation to each 
other and to neighboring pieces. Articulating above with the perpendicular 
plate of the ethmoid, it has not infrequently happened that the depression 
of this arch as result of a blow received upon it has carried the crista galli 
into the substance of the brain, and thus produced fatal consequences. 
Nasal bones are frequently the seat of syphilitic degeneration ; destruc- 
tion of them allows the falling in of the arch, thus causing flattening of the 
bridge occasionally observed,-one of the most repulsive of deformities. • 
Viewed laterally (Fig. 1), the inferior jaw being lifted away, a skull pre- 
sents, as prominent features of interest and consequence, the temporal, 
zygomatic, and spheno-palatine fossae, the temporal, sphenoid, malar, 
and maxillary bones, and the external auditory meatus. For descriptive 
purposes this aspect is commonly divided into mastoid, zygomatic, and temporal 
portions. (See Temporal Bone.') 
Temporal Fossa.-This fossa is bounded below by the zygomatic 
arch, and above and laterally by the temporal ridge; a ridge seen to curve up- 
ward and backward from the external angular process of the frontal bone to 
end posteriorly at the mastoid process of the temporal bone. The floor of 
this fossa, which accommodates the temporal muscle and vessels, is 
made up, from behind forward, of the parietal, the temporal, the sphenoid, 
and the malar bones. In front it has a depth of over an inch, being con- 
cave to such extent, but it grows shallower as it reaches backward and above, 
until finally it becomes convex. The several bones assisting in the formation 
yield five sutures. 
Zygomatic Fossa.-This fossa is for accommodation of the pterygoid 
muscles, the third branch of the trifacial nerve and its lingual and other 
branches, the internal carotid and internal maxillary arteries, and is the 
seat of attachment of temporal muscle to coronoid process. The boun- 
daries are, externally, the zygomatic arch and ramus of lower jaw, in 
front, the posterior faces of the superior maxillary and malar bones, behind, 
the posterior border of the pterygoid process, and deeply, and most impor- 
tantly, two fissures and a fossa with which it communicates,-namely, 
the spheno- and pterygo-maxillary fissures and the spheno-maxillary fossa. 
The importance of a full and complete understanding of these parts to a 
student or practitioner of oral surgery is hardly to be overestimated. 
Referring to the diagram, Fig. 1, or, much better, to an articulated skull, the 
cavity will be found covered by the parts, classed, surgically, as its external 
boundary,-namely, the zygoma and ramus of jaw. A notch, or concavity, seen 
separating the coronoid and condyloid processes, and bounded above by the zygo- 
LATERAL REGION OF SKULL. 34 
A SYSTEM OF ORAL SURGERY. 
matic arch, allows of a limited space through which a bistoury could be passed 
from without into the fossa, but this space is guarded by the internal maxillary 
artery, which runs directly across it, while back of it, beneath the condyles, is 
found the internal carotid artery. Operations for neurectomy of the 
third division of the fifth nerve are commonly performed by getting at the 
oval foramen through removal of a coronoid process, thus securing expo- 
sure of the contents of the fossa considered. 
Spheno-maxillary Fossa.-Examination of the base of zygomatic 
fossa shows a depression, or fissure-like concavity, lying between a vertical and 
a horizontal fissure, the first existing between the pterygoid process of the sphe- 
noid bone and the posterior face of the maxilla, the second between the max- 
illary and great wing of sphenoid ; the first fissure is the pterygo-maxillary, 
the second, the spheno-maxillary. 
The fossa is formed, above, by a very limited portion of the body of the 
sphenoid, internally, by a plate of the palate, in front by the maxillary, and 
behind by the pterygoid process of sphenoid bone. It communicates with 
three other fossae,-namely, with the zygomatic, the orbital, and the 
nasal, and beside these, through the foramen rotundum, which relate the 
two, with the cranium. Beside the foramen named three others communicate 
with it,-vidian, pterygo-palatine, and spheno-palatine. This fossa 
is entered, in making neurectomy of the superior maxillary nerve, either 
from the zygomatic fossa or by removal of its anterior boundary, which is the 
posterior wall of the antrum of Highmore. 
Pterygo-maxillary Fissure.-This, the vertical of the two fissures, 
exists in a recession from each other of the maxillary and pterygoid relations. 
Above it is broadest, below it approaches the expression of pointedness. 
It connects the zygomatic and spheno-maxillary fossae and transmits 
branches of the internal maxillary artery. 
Spheno-maxillary Fissure.-This, the horizontal fissure, com- 
municates freely with the back and outer side of the orbit. It is formed 
by the malar and greater wing of the sphenoid on the outside, and on the 
inside, and below, by parts of the maxillary and palate bones. Its re- 
lation with the pterygo-maxillary fissure is at exact right angle. Com- 
munication is established between the orbit and three fossae by means of 
this fissure,-namely, temporal, zygomatic, and spheno-maxillary. It trans- 
mits the superior maxillary nerve, a branch from Meckel's ganglion, and the 
infraorbital artery. 
External Auditory Outlet.-Fig. 1 shows auditory outlet situated 
between d, mastoid process of temporal bone, and I, neck supporting condyle of 
lower jaw. This outlet communicates with the middle ear, being sepa- 
rated from it and the contained auditory bones by the membrana tympani. 
It gives attachment, by its surrounding lip, to the pinna, or auricle. (See Gen- 
eral Anatomy. 
Notch for Facial Artery.-The position of a notch for passage of the DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
35 
facial artery, seen on the inferior maxilla, is to be noticed, as location and as 
distance from the angle of the jaw are concerned,-the control of hemorrhage 
about the lips and cheeks being here secured through simple pressure on the 
vessel as it passes over the base. Here, too, is place of election for ligation. 
Subfig. 10 and letter m, marked on Fig. 1, designate the position of the notch, 
as it lies midway between them. 
SUTURAL RELATIONS 
The bones of the head, the inferior maxilla with the temporal excepted, are 
related with each other by means of sutures; these are known as articula- 
tions, and vary somewhat in character. The articulations find names 
in the relating bones, as, for example, temporo-maxillary, maxillo-malar, inter- 
maxillary, naso-frontal, etc.; that is to say, the lower jaw, maxilla, to make 
an example, relates with the temporal bone; hence the name of articular asso- 
ciation, temporo-maxillary, or maxillo-temporal; either being, of course, right 
and expressive. As character of articulation is concerned, the naming is 
directed to the peculiarity. The temporo-maxillary joint, to illustrate, admits 
of a gliding movement, its peculiarity being the relation of two free surfaces, 
one convex, the other concave; it belongs to diarthrodial, or movable joints, 
being, as understood, the only one of this class in the skull; its special feature 
of gliding places it in the subdivision Arthrodia. The relation of the parietal 
with the frontal bone is by indentations interlocking with each other,-sutura, 
a seam ; peculiarity puts it in a special subdivision called Limbosa, meaning 
that the edges are bevelled and that there are dentated processes. Gom- 
Fig. 4. 
Fig. 5. 
Transverse section through the front 
of the cranium. 1, transverse arch formed 
by the frontal bone; 2, great wing of the sphe- 
noid bone, including or overlapping the abut- 
ments of the frontal arch; 3, body of the sphe- 
noid bone, with its sinuses. 
Transverse section in advance of the 
middle of the cranium. 1, parietal bone 
forming with its fellow an arch; 2, great wing 
of the sphenoid bone; 3, horizontal portion of 
the wing; 4, body, with the sphenoidal sinuses. 
phosis is a term signifying the relation of a conical process with a socket; 
teeth in the articulation of their roots with the alveoli of the jaw-bones come 
under this signification. Harmonia refers to apposition of rough contigu- 
ous surfaces; the two upper jaw-bones as they come together at the median 36 
A SYSTEM OF Oli AL SURGERY. 
line of the face furnish illustration. Schindylesis distinguishes articulations 
where the thinned or bevelled edge of one bone is received into a fissure exist- 
ing in another; the relation of rostrum of sphenoid with free edge of vomer is 
illustrative. Dentata signifies teeth-like surfaces ; the parietal bones fit into 
Fig. 6. 
Fig. 7. 
Transverse section through the middle 
OFTHecranium. 1, parietal bone; 2. squamous 
portion of the temporal bone ; 3, petrous por- 
tion ; 4, body of the sphenoid bone, with the 
sphenoidal sinuses. 
Transverse section posterior to the mid- 
dle of the cranium. 1, back part of the pa- 
rietal bones; 2, mastoid portion of the temporal 
bone; 3, mastoid process with the sinuses; 4, 
petrous portion of the temporal; 5, sphenoidal 
body, or the basilar process. 
each other as the cutting faces of two saws might do; hence sutura dentata. 
All the articulations of the skull, save the temporo-maxillary, are classible 
under the head of synarthrodia, or immovable joints. The fontanels, 
anterior and posterior, as found in early infancy exist in a non-completion of the 
process of ossification. The situation of the first is the place of juncture of 
the frontal and parietal bones ; that of the second, the juncture of parietal and 
occipital bones. (See General Anatomy.) 
• From the limited observations now made of features related with the region 
under consideration, study, or review, as the case may be, is to pass to exam- 
ination of all the parts entering into the composition of a human head. 
Beginning is with individual bones. 
SUPERIOR MAXILLARY BONE. 
A superior maxilla, a part of large significance to the oral surgeon, consists 
of a series of processes, so grouped as to form, or rather to enclose, a cavity 
so large that the apparently solid body of the bone is seen to be simply a shell. 
This cavity of the shell is called the maxillary sinus, or the antrum of 
Highmore, Fig. 9 (9), also Fig. 10. It is a very irregular cavity, differ- 
ing, indeed, in shape in almost every bone ; generally, however, being found 
as a single cave, but not infrequently divided into two or more parts by septi 
of bone vertically placed. How far, in the mean of cases, the cave runs 
forward and how far backward; what, in the mean, is its relation to the roots 
of the various teeth; which of its boundaries are the thinnest, are matters 
which, because of their very practical signification, prove worthy of being DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
37 
attentively studied, the information being derived only by an observation of 
many bones. Abscesses of the roots of teeth frequently void them- 
selves into this cavity; we are to understand how and why, anatomically, such 
an accident occurs. Engorgements of the sinus, puruloid or dropsical, 
Fig. 8.-External Face. 
Fig. 9.-Internal Face. 
Superior maxillary bone of the left 
side, outer view. 1, body; 2, tuberosity; 3, 
alveolar border; 4, orbital plate; 5, nasal pro- 
cess; 6, nasal notch; 7, nasal spine; 8, lach- 
rymal groove; 9, entrance of the infraorbital 
canal; 10, infraorbital foramen; 11, orifices of 
the posterior dental canals; 12, malar process; 
13, articulation for the internal angular pro- 
cess of the frontal bone; 14, incisor teeth; 15, 
canine tooth; 16, premolar teeth; 17, large 
molar teeth. 
Superior maxillary bone of the left 
side, inner view. 1, nasal surface of the body; 
2, surface for the palate bone; 3, alveolar bor- 
der; 4, orbital plate; 5, nasal process; 6, ridge 
for the articulation of the turbinated bone; 
7, nasal spine; 8, groove contributing to form 
the lachrymo-nasal duct; 9, maxillary sinus; 
10, palate plate, its articulating border for the 
right maxillary bone; 11, incisive foramen 
continuous with the naso-palatine canals; 12, 
tuberosity; 13, articular extremity for the in- 
ternal angular process of the frontal bone; 14, 
incisor teeth; 15, canine tooth; 16, premolar 
teeth; 17, large molar teeth. 
bulge outward some part or other of the circumferential walls, throwing, per- 
haps, the eye upon the cheek, projecting the canine fossa, or making a 
tumor on the palatal aspect of the mouth; we are to appreciate why this 
bulging, from a common cause, is found so variously situated, and why the 
accumulations exist. 
If such section be made of a superior maxillary bone as exposes the floor 
of antral cavity, we find that in many cases, not in all, it is studded with 
little hills. Break into one of these, and it is found to be a very thin crust, 
concealing the root of some tooth. In infrequent cases, a root is found pro- 
jecting into the cavity entirely uncovered. Such exhibit explains satisfactorily 
the discharge of dental abscess within this sinus. 
Antrum.-The external wall of an antral cavity being removed (Fig. 10), 
an opening about the size of a goose-quill is seen, which relates the sinus 
with the middle meatus of the nose. This opening has, as boundaries, 
portions of the turbinated (17), the ethmoid (18), and the palate bone (19). 
The relation of these bones with the outlet and with the cavity are dis- 
played in the diagram. In the natural state they are covered with mucous 38 
A SYSTEM OF ORAL SURGERY. 
membrane, which reduces the size of the outlet to that of a crow-quill 
and renders it subject to inflammatory constrictions in attacks of nasal catarrh. 
A student is to observe closely the associations of the antrum, and as 
well the relations of the maxilla at large, as presented in Fig. 10. The 
frontal sinus (2) and 
the antrum are indirectly 
related with interme- 
diate cavities known as 
the ethmoidal and sphe- 
noidal cells, - see the 
bones,-all the cavities 
alike being lined by a 
common and continuous 
mucous membrane. The 
lachrymal fossa, while 
not connected with the 
antrum, is seen to have 
its separation by a process 
-the lachrymal (20)- 
which is of such delicate 
structure as quickly to 
yield before the advance 
of any antral disease. Sar- 
coma, a malignant lesion 
having great affinity with 
the antrum, is seen to find 
easy passage to the nose, 
and is too often mistaken 
and treated for polypus; 
on the other hand, nasal 
polypi work their way 
into the antrum, leading 
to unnecessary operations 
upon this cavity. The 
antral roof being one with the orbital floor (see diagram), and the superior 
posterior boundary of this cave one with a plate separating sinus and spheno- 
maxillary fossa (14), capability for extension of antral disease becomes 
plainly evident. (See Diseases of Antrum.') 
Fig. 10. 
Left side of face, with the outer walls of the 
ANTRUM REMOVED, SHOWING MAXILLA IN RELATION WITH 
NEIGHBORING BONES, AND THE INNER FACE AND BOUNDA- 
RIES of the sinus. 1, frontal orbital plate; 2, frontal sinus; 
3, lachrymal bone; 4, ethmoid bone; 5, 6, ethmoidal fora- 
mina ; 7, sphenoid bone; 8, optic foramen; 9, palate bone; 
10, spheno-palatine foramen; 11, rotund foramen; 12, ptery- 
goid canal; 13, pterygo-palatine canal; 14, termination of 
the spheno-maxillary fossa in the posterior palatine canal; 
15, posterior dental canal; 16, inner wall of antrum formed 
by the maxilla; 17, turbinal bone; 18, uncinate process of 
the ethmoid; 19, palate bone; 20, descending process of the 
lachrymal, behind which is the opening of the antrum into 
the nasal cavity; 21, lachrymal fossa. 
PROCESSES OF MAXILLA. 
The processes which, in their conjunction, make up a superior maxillary 
bone are four in number: the alveolar, Fig. 8 (3), the palate, Fig. 9 (10), 
the nasal, Fig. 8 (5), and the malar, Fig. 8 (12). 
Alveolar Process.-The alveolar process, wedged in, as seen in the DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
39 
diagram, between the malar and palate, constitutes the bulk of the bone. 
Looked at from below, this process is found excavated into cavities, or 
pits, corresponding with the character and number of the roots of the teeth ; 
these pits are termed alveoli, and, in the recent bone, are lined with peri- 
osteal tissue, which tissue is simply membrane acting as a bond of union 
between teeth and jaw. (See Extraction of Teeth.') In some bones the 
structure making up this process is exceedingly loose and spongy; in others 
it is condensed and cortical-like. After the loss of the teeth, it is removed 
through absorption; hence the approximation, in old people, of chin and nose. 
Fractures of this process, the result of falls, blows, or attempt at tooth extrac- 
tion, are quite common. (See Fractures of Jaw.) 
Close study is to be given by a student to this part of a maxilla. As im- 
plied, it is a distinctive tissue in the sense that teeth are bodies sui generis. It 
is certainly truly and wholly of relation and import with the dental apparatus, 
and, out of such connection, its diseases, apart from occasional lesions, are of 
dental relation. Epulic growths start in a large proportion of the cases 
from the dento-alveolar membrane. Odontocele has here its commonest 
seat. Scirrhous cancer, when found in the jaw, has in this process its 
favorite locality. Caries and necrosis, especially the former, are of more 
frequent relation with this particular process than with any of the others, or 
indeed with any of the other bones of the body. Neuralgic affections 
have here a frequent start-point, by reason of influences existing in the ex- 
traction of teeth or in changes associated with the process of absorption. 
The tuberosity of the bone is to be esteemed as the posterior extremity 
of the alveolar process, being, indeed, not infrequently excavated for the accom- 
modation of a wisdom-tooth. This tubercle, as implied in its name, is simply 
a bulb of bone ; it is quite vascular, and its relation to the posterior tooth 
subjects it to sources of irritation which not infrequently results in its inflam- 
mation, death, and exfoliation. 
Malar Process.-The malar process, seen projecting from the middle 
of the maxilla, Fig. 8 (12), is a rough, serrated facet for articulation with 
the malar, or cheek, bone. This process is, in front, somewhat concave; 
behind it has similar curvature; it forms part of a fossa which immediately 
underlies it, known as the zygomatic. A point of surgical interest con- 
nected with it exists in the character and line of the suture which unites the 
associate bones, this being the place of separation in removal of the maxillary. 
Two delicate nerves, branches of the trifacial, run through this process and 
may be a seat of neuralgia. 
Nasal Process.-The nasal process, Fig. 8 (5), well represented in 
the drawing, but practically appreciable only from study of the bone itself, 
is seen standing above the orbital surface. Rising from the anterior facial 
aspect, this process continues upward and somewhat backward, until it ends 
in a rough facet, which articulates the maxillary with the frontal and eth- 
moid bones, Fig. 8 (13), and assists in closing in the anterior ethmoidal cells. 40 
A SYSTEM OF ORAL SURGERY. 
Lined in the recent state with mucous membrane, which membrane is con- 
tinued into the cells of the ethmoidal and frontal bones, a moment's reflection 
recognizes the meaning of that sense of fulness so common about the 
anterior base of the cranium, when congestion exists in the nasal canals, as 
in case of taking cold. Externally, the face of the process is concave, thus 
assisting in carrying out the natural curve of the lateral aspect of the nose; 
numerous foramina are observed for the passage of vessels. The ten do 
oculi muscle has its attachment on this surface, while near, on the same 
plane, is a line giving origin to the levator labii superioris alaeque nasi and 
orbicularis palpebrarum muscles. Anteriorly, the border of the process is thin, 
and is serrated for articulation with the nasal bone. Posteriorly, it is thick, 
and hollowed into a groove for lodgement of the lachrymal sac and duct. When 
in position, in the articulated skull, this groove is found converted into a canal 
by annexation with the lachrymal bone. This canal, traced downward, is found 
to have somewhat of an hour-glass shape, being considerably contracted in the 
centre, and finally terminating at the inferior meatus in a bell-shaped opening. 
A little tubercle, the lachrymal, Fig. 1 (a), is seen where the anterior 
lip of the groove joins the orbital surface; this is a guide, directing the bis- 
toury of the surgeon into the canal, when operations for stricture are needed. 
Palatal Process.-This process, seen by turning the under surface of the 
bone towards the observer, starts out from the middle of the piece, and divides it 
into two unequal parts. Like to the orbital plate, it relates at right angles with 
the body of the jaw, and, when the maxilla is articulated, is seen to separate the 
nose from the mouth, constituting the floor of the first cavity and the roof of 
the second. Posteriorly, it is quite thin, and articulates with a process of the 
palate bone. Running forward, it grows thicker and heavier, and ends in the 
anterior nasal spine. Viewed on its nasal aspect it is slightly concave. Ex- 
ternally, it becomes merged into the body of the bone; internally or mesially, 
it rises into a ridge, which ridge is the one side of a groove receiving into 
articulation the vomer. A bristle passed through an opening in the thick 
part of the process shows the position of a canal, the anterior palatal, 
transmitting vessels of that name, which vessels find entrance into the oral 
cavity through the incisive foramen, seen just back of the centre tooth. Fig. 
9 (11). A nerve, the naso-palatine, having considerable surgical sig- 
nificance, enters the mouth at the orifice of this canal; it is not, however, 
transmitted by it, but has a canal of its own existing in the intermaxillary 
suture. The three marked points of surgical interest in this surface, or pro- 
cess, are-first, the fact of its forming the boundary between the mouth 
and nose ; a break in its continuity, and which, unfortunately, is not an in- 
frequent accident, relating with syphilis, throwing these two cavities into one; 
second, the nature and the relation of suture-harmonial, it is called-with 
the palatine process of the palate bone, this being the line of separation in 
ablation of the jaw ; third, the position of entrance of the naso-palatine nerve, 
paralysis of the parts supplied by this nerve being a frequent result of ill-applied DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
41 
pieces of dental apparatus. (See Suction Plates.} To these three is to be 
added a fourth : reference to the artery occupying the posterior palatine canal, 
an artery which is sometimes of considerable size, and which is easily cut by 
the slip of a lancet applied to the gum of a wisdom-tooth, or in the act of dividing 
the tendon of the flexor palati where this muscle curves around the hamular 
process. The other features observable on this aspect of the bone are without 
special surgical interest. 
SURFACES. 
The surfaces of a superior maxillary bone are five in number : the orbital, 
the zygomatic, the facial, the palatal, and the nasal. 
Orbital Surface.-The orbital surface, Fig. 1 (/)y in its articulative 
position, is here observed separate, Fig. 8 (4); it lies, as seen, at an almost 
direct right angle with the facial aspect of the bone. By reason of such 
relation it is recognized as forming a large part of the floor of the orbital 
cavity. Looked at from the cave of Highmore, it is seen to make the roof 
of that vault. When broken, or held against the light, the part is found to 
be little more than a scale in thickness. The infraorbital ridge, so called, 
is made by the bending downward of this orbital surface. Running along the 
free edge three distinct articular faces are to be seen: the outer, for the 
palate bone, the two inner for the orbital, or plane, plate of the ethmoid and 
lachrymal bones. Below the rim, or infraorbital border, is the orbital foramen, 
Fig. 8 (10). Passing a bristle into this opening, we find it directed to the 
groove on the orbital face, the infraorbital, led directly into by the foramen at 
that extremity, Fig. 8 (9). Changing the direction of the bristle by intro- 
ducing it into the canal from the groove, we learn it may take some other track, 
and not appear at the expected place,-namely, the orbital, or as it is more 
commonly distinguished, the infraorbital foramen. Searching for an explana- 
tion, we find the groove, soon after entering the ridge, as a canal, dividing into 
two channels, one of which passes to the face, as observed; the other entering 
the antrum, and transmitting across that cavity the nerves and vessels designed 
for the nutrition of the anterior teeth. The osseous boundary of the nose is 
seen to advantage in this drawing. It is a complete curve, and gives attach- 
ment by its continuous crest, or edge, to the cartilaginous wings. 
Zygomatic Surface.-The zygomatic surface, seen back of the malar 
process, enters into the formation of the fossa of that name. This surface is, 
to a degree, convex, and more or less rough. Dotting its face a number of 
foramina are observed; these are entrances to canals, known as the poste- 
rior dental, which are for the transmission of vessels to certain teeth ; to all 
situated back of the canines. At the lower part of this surface-that is, to the 
nasal aspect of the tuberosity-agroove, the posterior dental, is seen, and 
which, through an articulation with the palate bone, is converted into a canal, 
Fig. 8 (11). This groove, or canal, transmits vessels to the palatal face of the 
bone, and is found to terminate on the under side of the tuberosity. 42 
A SYSTEM OF ORAL SURGERY. 
Facial Surface.-The facial surface is fairly covered by muscles. From 
the second bicuspid tooth back to the tuberosity is a rough line to which is 
attached the trumpeter's, or buccinator, muscle (a similar line existing on the 
inferior maxilla). Above this first line, and below the malar process, certain 
fibres of the masseter are attached. Above the canine fossa is the origin of 
the levator anguli oris; while without this, toward the concavity of the nose, 
is the line for the compressor naris. In the incisive, or myrtiform, fossa is 
seen the origin of the depressor ala nasi muscle. (See, for position of these 
localities, the large diagrams.) 
Nasal Surface.-The nasal surface is the parts constituting the lateral 
boundary and floor of a naris. Above the inferior meatus, the space seen be- 
tween the floor of the nose and the inferior turbinated bone, Fig. 18 (21), is 
seen a crest for the attachment of that scroll. Still higher, on the nasal process, 
are the crests for union with the superior and middle scrolls. (See also 
Fig. 18.) The middle meatus (20), into which the antrum opens, is ob- 
served to be quite a large space, particularly when compared with the superior 
meatus (19), which is the slit lying between the upper and middle crests. The 
opening of the antrum, seen in the back part of the middle meatus, Fig. 3 (9), is 
portrayed of a natural size,-that is, natural to the disarticulated bone. In Fig. 
18 (26) it is shown of size in articulation. It is understood, however, through 
what has preceded, that in the articulated skull this opening is intruded on 
by various bones, which intrusion reduces the opening to an outlet not larger 
than an ordinary quill. The bones closing in this cavity, to. repeat, are the 
ethmoid, palate, and inferior turbinated. (See descriptions of these bones.) 
Articular Relations.-A superior maxillary bone articulates with 
nine others: by its nasal crest with the frontal, ethmoid, lachrymal, and 
nasal; by its malar process with the malar; at the intermaxillary suture with 
the opposite maxilla; by its palate process with the palate and vomer, and by 
the lower of its lateral crests with the inferior turbinated bone. 
Relation with Muscles.-Nine muscles have their origin from this 
bone: the orbicularis palpebrarum, the inferior oblique of orbit, the elevator 
of superior lip and wing of nose, the proper elevator of lip, the angular 
elevator, the compressor naris, the depressor of the ala, the masseter, and the 
buccinator. 
THE INFERIOR MAXILLARY BONE. 
The inferior maxilla, Fig. 11, the largest and strongest bone of the face, 
consists of a body (1), horseshoe in shape, and of two rami (2), joined to the 
body at right angles. The body, which is the anterior portion, is surmounted 
by a process of more or less spongy bone, excavated for the reception of 
the teeth ; this is the alveolar process. The basement portion of the body, or 
that part beneath the alveolar process, is made up of dense structure, and 
is so hard and resisting as to be able to withstand very considerable blows. 
The rami, curved and angular at the base, terminate above in two processes: 
the condyloid (7), for articulation with the glenoid cavity in the temporal DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
43 
bone, and the coronoid (8), for the attachment of the temporal muscle. The 
angle of relation of the perpendicular to the horizontal portion of the 
bone varies with age. In early infancy it is very obtuse; indeed, the two 
portions are nearly on the same plane. 
In adult life a right-angled relation is 
obtained, and this changes again to the 
obtuse as age advances and the teeth 
are lost. Taking advantage of a knowl- 
edge of these changes, the surgeon is 
enabled to correct, in young life, the 
great deformity of an unduly projecting 
lower jaw. (See Orthodontia.} 
Looking at the external face of 
the body of the bone, attention is first 
attracted by a prominent foramen situ- 
ated beneath the bicuspid teeth. This 
is the mental foramen (6), from 
it pass out, to be distributed to the lip 
and gum, the inferior dental artery and 
inferior dental nerve (see Fig. 13); the 
situation of the foramen represents the line of relation between the hard and 
spongy portions of the bone. It is at this opening that section of the nerve 
is occasionally made for severe and resisting labial neuralgia. A bristle passed 
into this foramen, and inclined backward, is directed along a canal at the base 
of the teeth, and emerges at a second foramen, the dental, situated on the 
inner face of the ramus. Passed forward, it enters a smaller canal, which 
continues under the central teeth, carrying to these organs branches of the 
nerve and artery. An oblique line-the external oblique, as it is called 
(the figure 1 is just below it)-fairly divides the surface of the body into two 
triangles. This line is for the attachment of muscles, and accommodates, in 
part, the buccinator, the depressor anguli oris, and the depressor labii inferi- 
oris. (See Muscles of Face.} In old persons, after falling of the teeth and 
absorption of the alveolar process, the line is found to run almost along the 
upper surface. All that portion of the bone which is above the ridge 
belongs to the facial region proper; all below it, to the cervical region. The 
centre vertical line, called the symphysis (3), represents the separation, or 
division, existing in the young bone, union of the two halves not occurring 
until about the end of the first year. The levator menti muscle has 
its origin from a fossa at the side of this line. The mental process, which is 
the tubercle at the base of the symphysis, is only a thickening of the part 
for the greater strength of the jaw. Viewed from above downward, the body 
of the bone is concave; looked at from behind forward it is convex. 
The external face of the ramus, or perpendicular portion, of the bone, 
exhibits a quadrilateral aspect, broken above by a notch, the semilunar (9), 
Fig. 11.-Inferior Maxillary 
Bone. 
1, body; 2, ramus; 3, symphysis; 4, base; 
5, angle; 6, mental foramen; 7, condyle; 8, 
coronoid process; 9, semilunar notch; 10, 
inferior dental foramen, the entrance of the 
corresponding canal; 11, alveolar border; 
12, incisor teeth; 13, canine tooth; 14, pre- 
molars ; 15, large molars. 44 
A SYSTEM OF ORAL SURGERY. 
which separates two projecting processes. The anterior of these processes (8), 
the coronoid, is a thin, flattened, triangular eminence, giving attachment to 
the masseter and temporal muscles. The posterior, the condyloid, process 
(7), is an oval projection, convex and smooth, with its face covered with articu- 
lar cartilage, and having its greatest width from side to side. This process 
articulates the bone with the temporal through an interarticular fibrous 
disk, and is occasionally the seat of fracture and luxation. 
The internal face of the bone presents the same general view as the 
external. 
A ridge, the mylo-hyoid, divides the body, by its obliquity, into two 
parts. To this ridge is attached, or rather from it has origin, a muscle bearing 
the same name. This muscle, with its fellow of the opposite side, forms the 
floor of the mouth, the two joining at the median line, so that looking at the 
line one sees exactly how much of the bone is within and how much without 
the oral cavity. Just below the line, about midway of the body of the bone, 
is seen a fossa, or depression, the submaxillary, for the accommodation 
of the gland of this name. The mesial line, or symphysis, presents on either 
side two tubercles, called the genial tubercles, to which are attached the genio- 
hyoglossi and the genio-hyoideus muscles. Outside of these tubercles, on 
either side, are two fossae for the lodgement of the sublingual glands ; 
these fossae are called by the name of the glands. It will be observed that as 
these fossae lie above the ridge, the lingual glands must be within the 
mouth, while the submaxillary fossa) being below it, those glands are 
without the cavity. One most important feature to remark is the rela- 
tion of the anterior border of the vertical portion of the bone to the molar 
teeth. It not infrequently happens that this border so nearly approximates 
the second molar that there is no room for the eruption of the third; formi- 
dable inflammations sometimes result from such a cause, the crown of the 
tooth being held down under the ramus. A marked feature of difference 
between the internal and external face of the ramus is the existence in the 
former of a large foramen, the posterior dental, for transmission into 
the canal alluded to, as passing beneath the teeth, of the inferior maxillary 
vessels and nerve. (Subfig. 10.) A groove, the mylo-hyoid, transmits to 
the muscle of the ridge an artery, which comes from the inferior maxillary 
just as it is about to enter its canal. Attached to the border and internal face 
of the coronoid process is the tendinous expansion of the temporal 
muscle, while to the face of the condyloid process is attached the ptery- 
goideus externus, the internal pterygoid being related to the angle. The 
semilunar depression, or notch, seen separating the two condyles, is 
crossed by the masseteric artery and nerve, while in its immediate proximity 
are the internal carotid and internal maxillary arteries. 
Fig. 12 affords a view of the inner face of this bone, as reference is had to 
the mylo-hyoid ridge, or line. All that portion of the jaw which is above this 
line, marked " Facial," is within the mouth, consequently is mucous lined; DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
45 
the part below, marked " Cervical," is without the oral cavity, therefore non- 
mucous. (See Inferior Maxilla in frontispiece.) 
Fig. 13 shows the alveolar region uncovered, the outer or cortical plate 
both of superior and inferior jaws being 
removed. In the drawing is to be ap- 
preciated the relation of the spongy, or 
alveolar, processes to body of the 
bones; also the relation of the roots 
of teeth to this process and to each 
other. In the lower jaw is exhibited 
the position of the dental canal 
occupied by its vessels, a square of 
plate being left to show the anterior 
mental foramen, and the manner of es- 
cape from the canal of its vessels. The 
stippled part is alveolar process ; 
the unstippled, bone proper. Alveolar 
process is to be accepted as related to the teeth rather than to the bone; it 
disappears on loss of the dental organs. 
Fig. 12.-Internal View of In- 
ferior Maxilla. 
Fig. 13. 
THE PALATE BONE. 
The palate bone, when in position, forms the back part of the hard 
palate, a portion of the floor and side of a naris, and a part of the orbital 
cavity. It also enters into the formation of three fossa;: the zygomatic, the 46 
A SYSTEM OF ORAL SURGERY. 
spheno-maxillary, and pterygoid. Like the inferior maxilla, the bone consists 
of two portions: one horizontal, the other at right angles with it, or vertical. 
(See Fig. 14.) The horizontal portion is irregularly quadrilateral, pre- 
senting two surfaces and four borders : the upper of the two surfaces is 
concave, and forms the back part of the floor of a naris; the lower, or under, 
surface is also concave, and forms the back of the hard palate. The suture 
of connection with the maxillary bone is always plainly seen; it is called 
palato-maxillary suture. (See Fig. 29, 2.) 
In glancing at a disarticulated palate bone, holding its posterior face in 
profile, it is seen to resemble markedly the letter L. Studying it from such 
Figs. 14, 15.-Palate Bone. 
Posterior view of the right palate bone. 
1, palate plate; 2, nasal plate; 3, pyramidal 
process; 4, articular border for the left palate 
bone; 5, palate spine; 6, ridge for junction 
with the turbinated bone; 7, spheno-palatine 
notch, between 8, the orbital, and 9, the sphe- 
noidal process; 10, groove for the internal 
pterygoid process of the sphenoid bone; 11, 
position of the posterior palatine foramen. 
Exterior view of the right palate bone. 
1, rough surface articulating with the superior 
maxillary bone, and diminishing the aperture 
of the maxillary sinus; 2, posterior palatine 
canal, completed by the tuberosity of the 
superior maxillary bone; 3, spheno-palatine 
notch; 4, 5, G, orbital process; 4, surface di- 
rected toward the pterygo-maxillary fossa; 5, 
orbital surface; 6, maxillary border; 7, sphe- 
noidal process; 8, pyramidal process. 
position in detail, we remark, first, the spine, situated at the base of the in- 
terpalatal suture, and which gives attachment to one of the motores uvulae 
muscles. (See Fig. 29,-the point back of 2.) Passing toward the vertical 
portion, the concave character of both nasal and palatine faces is observed, 
the former much more marked than the latter. This nasal concavity is seen 
to end at a crest, or ridge, on the vertical portion. This ridge is the posterior 
articular surface of the inferior turbinated bone; Fig. 14 (2) the space below it 
is a part of the inferior meatus. The base of the vertical portion is pyram- 
idal, and ends in a tuberosity called the pterygoid process, its articulation 
being with the pterygoid plates of the sphenoid bone. At the back part of this 
process are seen three grooves ; the middle one, wide and smooth, forms part of 
the pterygoid fossa, and gives attachment to the internal pterygoid muscle ; the 
two lateral are rough and uneven, and articulate with the anterior border of each 
pterygoid plate. 
Passing upward, a prominent feature is the sphenoid process, Fig. 14 (9). DESCRIPTIVE AND SURGICAL AN ATO MU' OF THE HEAD. 
47 
This is a comparatively thin plate, made up of an articular and non-articular 
surface, a groove and a notch. The articular surface associates the plate 
with the sphenoid bone ; the non-articular enters into the composition of the 
zygomatic fossa. The groove contributes to the formation of the pterygo-pala- 
tine canal; and the notch, closed in above by the orbital process, forms the greater 
part of the spheno-palatine foramen. This process also contributes, by 
one of its surfaces, to the lateral wall of the nasal fossa. 
The orbital process, Fig. 14 (8), resting on the sphenoidal, is composed of 
five plates, or surfaces, and includes a cavity. Of these processes, three are 
articular, two, free surfaces. The articular are the maxillary, the sphe- 
noidal, and the ethmoidal, associating the process with the bones named. The 
free surfaces are the orbital, forming a small part of the orbital cavity, and the 
zygomatic, entering into the composition of the zygomatic fossa. 
Looking on the inner face of the bone, we remark, first, the articular process, 
Fig. 14 (4). This process, or surface, associates the bone with its fellow of the 
opposite side; above, it forms, with its neighboring piece, a ridge receiving the 
vomer. The body of this face is seen to consist of two concavities, with a sepa- 
rating ridge (6). This ridge articulates the inferior turbinated bone ; the 
concavity above is part of the middle meatus; that below, part of the inferior 
meatus ; the ridge or crest is called the inferior turbinated crest. A second 
crest, situated at the upper boundary of the middle meatus, articulates the 
lower scroll of the ethmoid, or the middle turbinated bone. This is called the 
superior turbinated crest. Just below it is seen the now perfected notch in the 
sphenoidal process, the spheno-palatine foramen (7), for the transmission 
of the vessels and nerve of that name. Above the superior crest is seen the 
posterior part of the superior meatus, a horizontal groove, bounded above 
by the lower border of the ethmoidal face of the orbital process. 
The orbital process, seen from this side, presents three surfaces : the 
maxillary in front, the orbital above, and the ethmoidal internally. 
The lateral surfaces of the bone are almost entirely articular. That one 
looking forward associates in its full length with the superior maxillary bone; 
that looking backward, with the sphenoid, through its pterygoid processes. 
This very full articulation with these two bones leads the anatomist to speak of 
the palate bone as being wedged between, and supported by, them. 
Articulations.-The articulations of the palate bone are with seven 
others : the superior maxillary, the inferior and superior turbinated, the vomer, 
the sphenoid, the ethmoid, and its fellow of the opposite side. 
Muscles.-The muscles attached to the bone are the tensor palati, the 
motores uvulae, and the internal and external pterygoid. 
THE VOMER. 
The vomer, ploughshare-shaped, constitutes a portion of the septum 
of the nose. It articulates below with the interpalatine suture of the superior 
maxillae and palate bones ; above, with the perpendicular plate of the ethmoid; 48 
A SYSTEM OF ORAL SURGERY. 
by its base with the laminae and rostrum of the sphenoid bone; in front it 
associates with the triangular cartilage. Posteriorly it separates the nares. 
The naso-palatine groove, seen running from the base, forward and downward, 
toward the triangular cartilage, transmits the naso-palatine nerve to the inter- 
Fig. 16.-The Vomer. 
Fig. 17.-Articular Relations of Vomer. 
View of left side. 1,1, broad groove 
receiving the rostrum of the sphenoid 
bone; 2, 2, inferior border articulating 
with the palate plates of the superior 
maxillary and palate bones; 3, posterior 
border, the dividing line of the posterior 
nares; 4,4, groove border receiving a nar- 
row slip of cartilage, situated between the 
vomer and the nasal plate of the ethmoid 
bone; 5,5, border for the cartilaginous sep- 
tum of the nose ; 6, 6, nasal surface. 
palatine canal. Subfig. 13 of 
Fig. 17 affords accurate idea of 
the vomer as to shape and articu- 
lar relations. 
Occasionally it is the case that 
the vomer is found markedly 
bent to one side or the other, 
and this to such an extent as com- 
pletely to obliterate one of the 
nares, requiring an operation for relief. The bone is also subject to syphi- 
litic attacks, and frequently breaks down, allowing the arch of the nose to 
fall in. 
Articulation.-The articulation is seen to be with six bones: the two 
superior maxillary, the two palate, the sphenoid, and the ethmoid ; also with the 
cartilaginous septum ; this last is not shown in the cut; it occupies the position 
of the triangular break. 
Vertical section of the face, exhibiting the 
osseous nasal septum. 1, frontal bone; 2, frontal 
sinus; 3, nasal spine of the frontal bone; 4, nasal 
bone; 5, nasal spine of the superior maxillary bone; 
6, nasal process of the same bone; 7, border of the 
palate plate of the same; 8, incisive foramen; 9, left 
posterior naris; 10, palate plate of the palate bone; 
11, nasal plate of the ethmoid bone; 12, ethmoidal 
crest; 13, vomer; 14, left turbinated bone: 15, sphe- 
noidal sinus; 16, internal pterygoid process; 17, ex- 
ternal pterygoid process. 
TURBINATED BONES. 
Running across the lateral face of each nasal cavity are three scrolls, known 
as the turbinated bones, Fig. 18 (6, 7, 8). Of these scrolls, the two upper 
(6, 7) are simply processes, or portions of the ethmoid bone; the lower is a 
distinct piece ; it is called the inferior turbinated bone. 
Observing the relations of these scrolls, it is remarked that each curves 
over a portion of the sides of a naris. A space thus enclosed is called a DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
49 
meatus. The lower, or inferior, of these cavities (21) is bounded below by 
the floor of the nose ; above by an inferior turbinated bone. An opening seen 
about its middle is the outlet of a lachrymal canal. The middle meatus 
(20) is the space bounded 
below by the upper surface 
of an inferior scroll; above 
by the lower surface of a 
middle scroll. A foramen 
seen in this meatus is the 
outlet (26) of the antrum. 
The superior meatus (19) is 
the slit seen between two 
upper scrolls. 
The distinct, or inferior 
turbinated bone (8), is 
a thin, spongy scroll; it has 
a base of attachment the 
whole length of the lower 
crest seen on the nasal sur- 
faces of the maxillary and 
palate bones; the opposite, or 
inferior edge, is free, and lies 
in the middle of the inferior 
meatus. Viewed from its 
inner surface, the bone pre- 
sents a most irregular appear- 
ance, being perforated with 
numerous apertures, sulci, and 
grooves, for the accommoda- 
tion of arteries and veins. 
Two processes, the lach- 
rymal and the ethmoid, 
are seen to break the regu- 
larity of the upper convexity. The anterior-the lachrymal-articulates with 
the inferior angle of the lachrymal bone and with the nasal crest of the maxil- 
lary bone, thus assisting in forming the lachrymal canal. The posterior- 
the ethmoidal-articulates with the descending unciform process of the eth- 
moid bone. 
Turning the bone here, we see a third process, or division. This process 
is called the maxillary. It curves downward within the inferior meatus, 
assisting in filling up the antral orifice, and in its attachment steadies the 
bone firmly on the side of the naris. Externally, the general appearance of 
the bone is concave; internally, or looking toward the septum narium, it 
is convex. If the external surface were convex, and the processes absent, 
Fig. 18.-Position and Relations of Tur- 
binated Bones. 
VlEW OF THE OUTER WALL OF THE RIGHT NASAL FOSSA. 
1. frontal bone; 2, its orbital plate; 3, its nasal spine; 4, 
nasal bone; 5, ethmoid bone; 6, its upper turbinated 
process; 7, its lower turbinated process; 8, turbinated 
bone; 9, process of the lachrymal bone, within the posi- 
tion of which is the lachrymo-nasal duct; 10, nasal spine 
of the superior maxillary bone; 11, naso-palatine canal; 
12, palate plate of the superior maxillary bone ; 13, nasal 
process of the latter; 14, external pterygoid process; 15, 
internal pterygoid process; 16, nasal plate of the palate 
bone; 17, its palate plate; 18, posterior palatine foramen ; 
19, superior meatus of the nose; 20, middle meatus; 21, 
inferior meatus; 22, frontal sinus; 23, sphenoidal sinus; 
24, its communication with the upper back part of the 
nose; 25, spheno-palatine foramen; 26, orifice of the 
maxillary sinus. 50 
A SYSTEM OF ORAL SURGERY. 
the bone might very well be likened in shape to the Indian stone arrow- 
head. 
The turbinated bone is subject to specific inflammations, which, if not 
judiciously combated, are apt to end in necrosis. 
Articulation.-The bone articulates with four others: the ethmoid, the 
lachrymal, the maxillary, and the palate. 
Muscles.-No muscles are attached. 
THE ETHMOID BONE. 
A horizontal cribriform plate of bone, Fig. 19 (2), with a crest along its 
middle (3) ; a perpendicular plate dropping below into the nose from the centre 
of this first piece; two little oblong square boxes (1), hung on either side of 
the perpendicular plate, leaving the space of a 
narrow slit between the boxes on either side and 
the plate, and we have the complete idea of an 
ethmoid bone. Looking at the piece from above, 
we remark, first, the crest,-crista galli (3) it 
is called. It is to this the falx cerebri is attached. 
On either side of this crest is seen a depression 
occupied by a number of foramina. These de- 
pressions lodge the olfactory bulbs, and the 
foramina transmit to the nose the olfactory 
filaments, the three sets having corresponding 
foramina. A slit at the side of the crista galli 
transmits to the nose the nasal branch of the 
ophthalmic nerve. Looked at anteriorly, the 
crest is seen to terminate in two little horns, or 
wings; these articulate with depressions in the 
os frontis, and occasionally in a manner so imper- 
fect as to leave an opening, or foramen. When 
existing, this foramen accommodates a nasal 
vein, which passes upward, to terminate in the 
longitudinal sinus; the rupture of this vein, 
discharging the sinus, has saved many a life in 
congestive attacks of the brain. A plate, ex- 
hibited by the removal of one of the lateral masses, is simply a thin layer of 
bone. It is called perpendicular lamella, or nasal plate. This plate, 
Fig. 17 (11), descending in the middle line of the nose, assists the vomer in 
separating that cavity into its two lateral halves. In front, the lamella is 
received into a groove existing between the two nasal bones; below, it looks 
downward and forward, and affords attachment to the triangular cartilage; 
back of this it articulates with the vomer, and still farther back with the 
sphenoid. On each side of the plate are seen numerous grooves (Fig. 17) 
Fig. 19.-Ethmoid Bone. 
-General View. 
1, orbital surface of the lat- 
eral mass; 2, posterior extremity 
of the cribriform plate, which 
unites the lateral masses, and is 
depressed and perforated with 
numerous foramina on each side 
of the ethmoidal crest; 3, the two 
oblique processes in advance of 
the latter are ,the ethmoidal 
wings; 4, anterior extremity of 
the nasal plate; 5, the ethmoidal 
sinuses. DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
51 
leading from the foramina in the horizontal or cribriform plate ; these are 
channels receiving and shielding the inner olfactory filaments. 
The boxes, or lateral masses, are very loose and areolar-like in struct- 
ure; they constitute a series of cells (5). Disarticulated, many of these 
cells appear broken. When associated with the ethmoidal cells (Fig. 31) of 
the frontal bone, with the sphenoidal scrolls, with the orbital processes of the 
palate bones, and with the nasal processes of the maxillary' and palate bones, 
they are found to be complete. The relation of these cells, more or less 
directly, with the common nares, and the fact that they are lined by 
mucous membrane continued from these fossae, explain the sense of con- 
gestion and fulness known as 11 cold in the head." 
The outer surface, or face of the boxes (1), looks very much in color like 
the common clarified quill, is semi-translucent, is square in shape, and very 
smooth. Referring to the view of the skull (Fig. 1), this surface is seen enter- 
ing into the composition of the orbital cavity. 
The portion of the ethmoid which receives and articulates the process 
passing upward from the inferior turbinated bone is a hook-like projection 
from the under surface of these lateral masses. It is called the unciform 
process, and assists in narrowing the orifice of the antrum and supporting 
the masses. 
The internal surface of each lateral mass approaches the perpendicular plate. 
At the upper part is the narrow fissure, bounded by a scroll-like process on the 
surface, known as the superior meatus, Fig. 18 (above 5). The scroll 
(5) has received the name superior turbinated bone. Below this first 
Fig. 20. 
Fig. 21. 
Left side view of the ethmoid bone. 1 orbi- 
tal plate; 2, anterior ethmoidal sinuses; 3, the 
mesoturbinal; 4, uncinate process ; 5, ethmoidal 
crest; 6, alar process; 7, nasal plate; 8,9, position 
of the pre- and postethmoidal foramina. 
Inner view of the right ectethmoid. 1, 
cribriform plate; 2, the supraturbinal; 3, 
mesoturbinal; 4, supranasal meatus; 5, a 
shorter meatus occasionally present; 6, part 
of the ccecal pit. 
scroll, on the same surface, is a second. This second scroll (7) is called 
middle turbinated bone, and the space below it, between it and the inferior 
turbinated bone (20), is the middle, or supranasal, meatus. 52 
A SYSTEM OF ORAL SURGERY. 
In looking at an ethmoid bone in position, it is seen to be wedged in between 
the nasal, frontal, lachrymal, and maxillary bones in front, and the sphenoid be- 
hind ; below it is supported by the turbinated, vomer, and palate bones. Max- 
illary diseases find easy road to the base of the cranium through the nasal 
communication with the ethmoidal cells. Figs. 20 and 21, after Leidy, are in- 
serted as being admirable studies insuring easy understanding of the bone. 
THE SPHENOID BONE. 
The sphenoid bone, named from its wedge-like relations to other bones of 
the cranium, has been frequently and not inaptly compared in appearance to a 
" bat" with extended wings and unflexed legs. 
Fig. 22.-Sphenoid Bone.-Upper View. 
1, pituitary fossa; 2, olivary process; 3, declivity; 4, anterior clinoid process; 5, pos- 
terior clinoid process; 6, posterior border of the body; 7, cerebral surface of the great 
wing; 8, articular surface for the frontal bone; 9, articular border for the temporal bone; 
10, spinous process; 11, small wing; 12, border articulating with the orbital plate of the 
frontal bone; 13, border joining the ethmoid bone; 14, optic foramen; 15, sphenoidal 
foramen; 16, rotund foramen; 17, oval foramen; 18, spinous foramen; 19, groove for 
the internal carotid artery. 
Fig. 23.-Sphenoid Bonk.-Front View. 
1, 2, sphenoidal crest and rostrum for joining the nasal plate of the ethmoid bone and 
the vomer; 3, entrance of the sphenoidal sinuses; 4, small wing; 5, optic foramen piercing 
its base; 6, sphenoidal foramen ; 7, rotund foramen ; 8, orbital surface of the great wing; 
9, temporal surface of the same; 10, ridge separating the temporal and spheno-maxillary 
fossae; 11, position of the pterygo-palatine canal; 12, pterygoid canal; 13, internal ptery- 
goid process, ending in a hook; 14,15, external pterygoid process; 16, spinous process; 
17, oval foramen; 18, spinous foramen. 
In looking at a disarticulated bone (Figs. 22 and 23), we observe a central por- 
tion, or body; this body is irregularly square, and marked on all its surfaces DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
53 
with features which one at once infers to be possessed of anatomical signifi- 
cance. Extending laterally on either side from the body are two great 
wings, Figs. 22 (7) and 23 (8) ; these are made double by a foramen, called 
lacerated, or sphenoidal, Fig. 22 (15), and instead of being spoken of and 
described as a single pair, are mostly viewed as two pairs,-the larger portion 
being called the greater, the smaller the lesser wings. The legs, Fig. 
23 (13, 14, 15), falling from the base of the cranium, are found separated 
by a notch into two portions,-this separation being much more marked behind 
than in front: they have received the name of pterygoid processes. 
Superior Surface.-Beginning a study of the body from its superior, 
or cranial, surface, attention is first naturally attracted to a saddle-like de- 
pression, Fig. 22 (1), occupying a large portion of the face. This depression 
lodges a little body attached to the floor of the third ventricle, the pituitary 
body; hence it is called by many the pituitary depression, or fossa ; while 
from its resemblance to the Turkish saddle it is as frequently named sella 
turcica. A number of little pits seen on the floor of this fossa are foramina 
transmitting vessels of nutrition. On either side are two processes; these 
correspond to two others, terminating the plate of bone which represents the 
back of the saddle. The four, Fig. 22 (4, 5), have been compared to the 
posts of a bedstead, and are called clinoid processes. Passing forward, an 
olive-shaped eminence is next noticed, Fig. 22 (2),-the olivary process ; 
and directly in front of this, a groove, or oblong fossa. This groove has resting 
in it the commissure of the optic nerve, and hence is called the optic 
groove. Passing directly forward, we find the surface terminate in a spine, or 
projecting point; this point articulates the surface with the ethmoidal bone, 
Fig. 22 (13), hence called ethmoidal spine ; between this spine and the optic 
groove is a slight eminence falling off- on either side into a line of depression; 
these lines lodge the olfactory nerves. Two foramina, Fig. 22 (14), seen on 
this surface at either terminus of the optic groove, are called optic foramina; 
they transmit to the orbital cavities the optic nerves and ophthalmic arteries. 
From the back of the saddle the surface is seen to slope gradually downward; 
this concave plane lodges the medulla oblongata, and terminates at a line of 
union with the occipital bone, Fig. 22 (6). On either side is situated a 
tortuous depression, in which lie the internal carotid artery and the cavernous 
sinus. 
Anterior Surface.-Turning now to the anterior surface, there is 
first observed a rostrum, or beak, for articulation with the nasal, or perpen- 
dicular, Fig. 23 (1, 2), plate of the ethmoid. On either side of this beak are 
seen scrolls of bone, or rather lamellae,-the sphenoidal turbinated 
bones, as they are called. These lamellae (3) close imperfectly sinuses which 
are seen to hollow out the substance of the body, and which, in articulation, 
are found to communicate with the upper part of the nose, and frequently 
with the ethmoidal cells; being lined with the mucous membrane of the nares, 
and subjected consequently to sympathies of continuity. 54 
A SYSTEM OF ORAL SURGERY. 
Inferior Surface.-The inferior surface presents, first, the rostrum, 
or beak ; continued from the anterior face this spine is received into a groove, 
or fissure, in the vomer, Fig. 23 (1, 2). On either side are laminae of bone, 
which pass to the pterygoid processes; these plates, or laminae, are called 
vaginal processes. Close to the pterygoid process is seen a groove, 
which the sphenoidal process of the palate bone converts into a canal; this 
canal transmits the pterygo-palatine vessels and pharyngeal nerve. 
Posterior Surface.-The posterior surface exhibits simply a quadri- 
lateral sawed surface, union existing with the occipital at this point, which 
has required the saw for its separation. Because of such union it is common 
with many writers to consider the sphenoid and occipital as one piece, and to 
refer to them as the spheno-occipital bone. 
Greater Wings of Sphenoid Bone.-The wings, which may be 
next to claim attention, are called greater and lesser, the separation ex- 
isting at the lacerated foramen, Fig. 22 (15). The greater wings, Fig. 22 
(7), extend laterally, and assist largely in forming the floor of the fossa) which 
receive the middle lobes of the brain. Looked at from the encranial aspect, 
sight is first attracted by six foramina,-three on either side. The first of 
these is a round hole, and is called the foramen rotundum (16) ; it 
transmits from the brain to the superior maxillary bone the second branch of 
the fifth nerve. The second hole is oval in shape; hence called foramen 
ovale (17); it transmits the third, or inferior maxillary branch of the fifth. 
The third, the foramen spinosum (18), transmits the middle meningeal 
artery. A fourth foramen is occasionally found in the great wing,-the 
vesalli; when existing it is occupied by a small vein. The general floor 
of these wings is concave, and is marked with elevations and depressions for 
the accommodation of neighboring convolutions. 
Turning the bone (Fig. 23), these wings are seen to be made up of three 
surfaces: the encranial face, as just described; an external surface, occupying, 
when in articulation, a place in the base of the skull; and an orbital surface, 
Fig. 23 (8). 
The external surface (9) is irregularly convex, and is separated into 
two portions by a ridge (10) called the pterygoid. The superior of the two 
faces is seen entering into the composition of the temporal fossa for lodgement 
of the temporal muscle. The inferior face lies beneath the zygoma, and forms 
part of the fossa of this name. It gives attachment to the external pterygoid 
muscle. Running from the postero-lateral angle of the surface is seen a pro- 
longed spine; to this are attached the laxator tympani muscle and the internal 
lateral ligament of the lower jaw. 
The orbital face of the wing (8) assists in forming the outer boundary of 
the orbit; it is quadrilateral in form, smooth, and concave. Below, it has a 
somewhat rounded border, and enters into the formation of the spheno-maxil- 
lary fissure; internally, it assists in defining the sphenoidal fissure. At the 
lower edge of the inner border is a delicate spine, giving origin to one head of DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
55 
the external rectus muscle. Foramina seen on this face are called orbital 
foramina: they transmit small arteries. 
Lesser Wings.-The lesser wings, Fig. 22 (11), frequently de- 
scribed as the processes of Ingrassias, best seen on the encranial surface, extend 
outward, overlying at their apices the great wings. These processes are tri- 
angular in shape, and have their bases associated with the body of the bone. 
In articulation they complete the posterior boundary of the anterior fossm of 
the cranium, and are lodged in the separation of the front from the middle 
lobes of the brain known as the fissure of Sylvius. The fissure, or slit, which 
separates small from great wings, Fig. 22 (15), is called the lacerated, 
or sphenoidal, foramen. It transmits the first, or ophthalmic branch of 
the fifth nerve, the third, fourth, and sixth nerves, and the ophthalmic vein. 
The lesser wings are connected with the body by two footstalks (12, 14, 4), 
enclosing within them and assisting in forming the optic foramina. A process 
(4) seen jutting backward from the foramen is called the anterior clinoid 
process ; to it is attached the common tendon of the recti muscles of the 
eye. 
Pterygoid Processes.-The legs, or pterygoid processes, Fig. 23 (13, 
14,15), seen falling from the point of union of the great wings with the body, 
consist of two plates, separated behind by a deep notch, but united almost 
fully in front. The external plate is broad and curved; it forms part of the 
zygomatic fossa ; to it is attached the external pterygoid muscle. The 
internal face forms part of the pterygoid fossa, and gives origin to the in- 
ternal pterygoid. The internal plate is possessed of particular interest; it ends 
in a tubercle, or hook-like process, which is to be felt in the mouth just back of 
the wisdom-tooth; this is the hamular process; around it turns the tendon of 
the tensor palati muscle,-a tendon to be divided in the Fergusson operation 
for cure of cleft palate. The base of this internal plate forms a fossa, the 
scaphoid, from which originates the tensor muscle just alluded to. The 
outer surface of the plate forms the pterygoid fossa; the inner assists in 
marking the outer posterior boundary of the nares. 
The base of the pterygoid process, Fig. 23 (13), is quite broad, and in 
front gives support to Meckel's ganglion. The vidian canal passes 
through it. 
Articulation.-The sphenoid articulates with all the bones of the 
cranium ; as well with the two malar, the vomer, and the two palate bones of 
the face. 
Muscles.-The muscles to which the bone gives origin are the tem- 
poral, external and internal pterygoid, tensor palati, laxator tympani, levator 
palpebrae, the recti of the eye, and superior oblique of eye. 
Note.-The sphenoid is an important bone to understand, for the reason 
most particularly of its relation with the transmission of the three primary 
divisions of the trifacial nerve, and as well that it has to do conspicuously with 
the formation of parts in which oral surgery is particularly interested. It is 56 
A SYSTEM OF ORAL SURGERY. 
necessary that the student possess this bone both articulated and disarticulated. 
If study is directed here to the isolated trifacial nerve as exhibited in Fig. 13, 
and if the individual bone and skull are laid upon a table, the student, locating 
the ganglion of Gasser in the depression at the apex of the petrous portion of 
the temporal bone,-see this bone,-will find himself able easily to follow the 
divisions as they pass to and through the transmitting foramina. From these 
foramina he will wisely trace the succeeding divisions and subdivisions through 
all their osseous ramifications, informing himself, after such manner, as to 
where exactly the nerves are situated and how they are exposable in the living 
person. 
A particular and practical study is to be made of the location and boundaries 
of the spheno-maxillary and zygomatic fossae and of the spheno maxillary fissure. 
With such practical view in mind, advantage is gained by turning just now to 
the diagrams showing exsections of the branches of the nerve considered. (See 
Nerve Lesions Proper and their treatment by section.) If the student study 
the chapter referred to he will find appreciation afforded of the practical value 
of the anatomy he is called on to learn. 
THE NASAL BONE. 
Fig. 24 exhibits the face of a left nasal bone as it articulates with a 
fellow, which is its counterpart. The two occupy the quadrilateral space ex- 
isting between the two maxillary bones and the frontal, 
and form the prominence known as the nasal bridge. 
That these bones vary considerably in shape would be 
inferred from variations in the shape of the part as so 
frequently seen. Looked at from above downward, a 
nasal bone is observed to be concave, while viewed from 
side to side it is seen to be convex ; several light grooves 
are commonly noticed on the surface for the accommoda- 
tion of vessels; one, seen about the centre, transmits a 
small vein. 
The inner surface reverses relations with the outer,- 
being convex from above below, concave from side to side. 
Its only feature of interest is a groove for the lodgement 
of the nasal nerve. 
The borders of the bone are three articular and one 
free. The superior, serrated and somewhat narrow, fits 
in the frontal notch (see Fig. 1), forming the fronto-nasal articulation. The 
lateral border is bevelled, at the expense, above, of the internal plate, below, of 
the external, and fits with corresponding bevellings of the nasal processes of the 
maxillary bone. Internally, or mesially, the bone articulates with its fellow 
of the opposite side, being prolonged below into a crest, which forms a part of 
the nasal septum, and articulates with the nasal spine of the frontal above and 
the ethmoidal perpendicular plate below. The lower border (Subfig. 4) is free, 
Fig. 24. 
Nasal Bone. 
Anterior view of 
THE LEFT NASAL BONE. 
1, frontal border; 2, 
nasal border; 3, max- 
illary border; 4, lower 
border; 5, nasal fora- 
men. DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
57 
at least so far as any bony articulation is concerned; it gives attachment by a 
thin sharp edge to the lateral cartilage of the nose. A notch, seen at the centre 
of this border (4), transmits the nerve occupying the groove on the inner sur- 
face. 
The malar, or cheek, bones are to be likened to bony pads laid on either 
lateral aspect of the face for the purpose of influencing a general convexity. 
Each bone is irregularly quadrilateral, sup- 
ported above by articulation with the frontal, 
sphenoid, and superior maxillary bones; in 
front by the malar process of the maxil- 
lary ; posteriorly by the zygomatic process 
of the temporal. 
The bone presents two surfaces, four pro- 
cesses, and four borders. The external 
surface (Fig. 25), convex and smooth, pre- 
sents little of interest; the foramen (2), 
seen upon this face, is sometimes replaced 
by two or more; it is simply the orifice 
of a canal, transmitting unimportant vessels. 
The surface, in relationship, is mostly 
covered by the orbicularis palpebrarum 
muscle, while the zygomatici have origin 
from the lower and inner aspect. 
The internal face is concave, and assists in forming, above, the temporal 
fossa, below, the zygomatic. It yields partial origin to both the temporal and 
masseter muscles. 
Of the four processes, the orbital is the most important. Turning at 
right angles with the external face of the body, this process (5) assists in 
forming a portion of the outer wall of the orbit and orbital ridge. The 
frontal process (3) is thick and serrated ; it articulates with the external angu- 
lar process of the frontal bone. The maxillary process (6) is rough, tri- 
angular in shape, and attaches the bone in front. The zygomatic process 
(7) is sharp and flat, and forms part of the yoke overlying the ridge separating 
the zygomatic and the temporal fossae. 
The four borders are the orbital, maxillary, zygomatic, and temporal. 
These borders correspond with the relations named, being located by the same 
figures; they have no interest apart from the processes. 
THE MALAR BONE. 
Fig. 25.-Malar Bone. 
OUTER VIEW OF THE RIGHT MALAR 
bone. 1, external or facial surface; 2, 
malar foramen; 3, frontal process; 4, 5, 
orbital border; 6, maxillary border; 7, 
zygomatic process; 8, temporal border; 
9, inferior border. 
THE LACHRYMAL BONE. 
Looking at the diagram, or, much better, at an articulated skull, the lach- 
rymal bone is seen to occupy a position of some prominence in the com- 
position of the orbit. A ridge on its anterior surface divides it into two 58 
A SYSTEM OF ORAL SURGERY. 
parts: one part, called its orbital face (1) (bounded above by the orbital 
plane of the horizontal plate of the frontal bone; later- 
ally, by the os planum of the ethmoid; below, by the 
orbital surface of the maxillary bone), enters into the 
composition of the orbital cavity. The face, to the 
inner side of the ridge, is smooth and concave (7), 
and articulates with the nasal process of the maxil- 
lary bone, internally, and with the lachrymal process 
of the turbinated below; these three bones in their 
union form the ductus ad nasum, or lachrymal canal, 
which passage transmits the tears to the inferior 
meatus. 
The bone, by its internal, or nasal, surface, enters 
into the composition of the middle meatus, and 
assists in closing in the anterior ethmoidal cells. Like 
the external surface, this is divided into two faces, 
the line of division being a depression corresponding 
with the ridge on the opposite surface. 
Only one muscle has its attachment to this bone,-the tensor tarsi. 
Fig. 26.-Lachry- 
mal Bone. 
External view of the 
RIGHT LACHRYMAL BONE. 
1, orbital surface; 2, lachry- 
mal fossa; 3, small process 
bounding the latter inferi- 
orly; 4, frontal border; 5, 
ethmoidal border; 6, max- 
illary border; 7, process 
articulating with the tur- 
binated bone. 
The os hyoides is the bone situated on the anterior part of the neck between 
the chin and sternum. In shape it resembles somewhat an ordinary horseshoe. 
THE HYOID BONE. 
Fig. 27.-Hyoid Bone. 
Fig. 28. 
1, body; 2, greater horn; 3, lesser horn. 
It is held in place entirely by a 
series of antagonizing muscles, of 
which it gives attachment to some 
ten pairs. A glance at the bone 
divides it naturally into a body 
and four cornuae, or horns; 
the greater pair of these cornuae 
(2) extend widely over the lateral 
aspect of the neck, and give at- 
tachment, on either side, to the hyo-glossus, middle constrictor of the pharynx, 
and thyro-hyoid muscles, and, by a bulb constituting the extremity, to the 
thyro-hyoid ligament; these horns (2) serve as a guide to the surgeon in 
Antero-posterior section of the cranium, ex- 
hibiting the mode by which the connection of the 
different bones contributes to preserve its integrity. 
1, parietal bone; 2, frontal bone; 3, its orbital 
plate; 4, frontal sinus; 5, body of sphenoid bone; 
6, sphenoidal sinus; 7, occipital bone; 8, marginal 
ridge of the occipital foramen. DESCRIPTIVE AND SURGICAL ANATOMV OF THE HEAD. 
59 
seeking the position of the lingualis artery. The lesser cornuse (3) are 
simply two conical eminences, more or less prominent on different specimens. 
Starting out at the point of junction of the great horns with the body, 
these horns look upward toward the chin; they afford attachment to the 
stylo-hyoid ligaments. 
The body of the bone is irregularly quadrilateral in shape, convex in front, 
concave behind. A crucial ridge, the intermuscular, divides the front face 
into four fossae. This surface is devoted exclu- 
sively to the attachment of muscles; above, to the 
genio-hyoid and the genio-hyoglossus; below, to 
the stylo-hyoid, mylo-hyoid, and digastricus. The 
posterior surface is smooth and concave, and occu- 
pies a position just in front of the epiglottis, being 
separated from it above by some cellular tissue 
and a membrane called, because of its relationship, 
the thyro-hyoid. 
Fig. 29. 
View of the right half of the base of the skull. 1, 
palate plate of the superior maxillary bone; 2, palate plate of 
the palate bone; 3, vomer; 4, internal pterygoid process; 5, ex- 
ternal pterygoid process; 6, pyramidal process of the palate 
bone; 7, under surface of the great wing of the sphenoid bone; 
8, its temporal surface; 9, zygomatic arch; 10, zygomatic pro- 
cess of the malar bone; 11, zygomatic process of the temporal 
bone; 12, squamous portion of the temporal bone; 13, glenoid 
tubercle; 14, glenoid cavity; 15, vaginal process, its outer 
border constituting the auditory process; 16, styloid process; 
17, external auditory meatus; 18, mastoid process; 19, digastric 
groove; 20, basilar process of the occipital bone co-ossifled with 
the body of the sphenoid bone; 21, condyle; 22, occipital pro- 
tuberance : 23, superior, and 24, inferior semicircular ridges; 
25, occipital foramen; 26, incisive foramen; 27, posterior pala- 
tine foramen; 28, spheno-maxillary foramen; 29, posterior 
naris; 30, oval foramen; 31, spinous foramen; 32, lacerated 
foramen; 33, Eustachian tube; 34, carotid canal; 35, jugular 
foramen; 36, stylo-mastoid foramen; 37, 38, foramina for veins. 
Figs. 30 and 31 afford studies of the external and internal faces of the 
frontal bone. This bone (see Frontispiece 1) makes the forehead region 
of the face. It articulates, above, with the two parietal, and laterally 
with the great wing of the sphenoid and malar bones. Below, its relation 
is with the nasal, the superior maxillary, the lachrymal, the ethmoid, and the 
sphenoid bones. The frontal is composed of a vertical and horizontal portions. 
The first is the forehead proper, the second enters largely into the composition 
of the orbital cavity below and of the anterior cerebral fossa above. (See 
Frontispiece 3, also Fig. 28, 2, 3.) 
Vertical Portion, External View.-This portion is convex, both 
vertically and laterally. Viewed from below, it has as its base two curved 
THE FRONTAL BONE 60 
A SYSTEM OF ORAL SV ROE RY. 
arches, which form the supraorbital boundaries, the two being related cen- 
trally by a triangular continuation, the apex of which is supported upon 
the nasal bones and the nasal processes of the superior maxillary bones. 
Laterally, this vertical portion ends, on either side, by processes which articu- 
late with the malar bone and from this lateralize to a relation with the sphe- 
noid. (See Frontispiece.) A notch, seen at the inner fourth of the orbital 
ridge, Fig. 30 (6), transmits outward and upward the supraorbital vessels. 
Fig. 30. 
Fig. 31. 
External view of the frontal bone. 
1, position of the frontal eminence; 2, super- 
ciliary ridge; 3, supraorbital arch; 4, 5, ex- 
ternal and internal angular processes; 6, 
supraorbital notch or foramen; 7, glabella; 
8, temporal ridge; 9, nasal spine. 
Internal view of the frontal bone. 1, 
groove for the longitudinal sinus, narrowing 
below on the frontal crest, 2, in the eth- 
moidal notch; 3, superior dentated border, 
articulating with the parietal bones; 4, pos- 
terior border of the orbital plate 5, which 
joins the small wing of the sphenoid bone; 
6, irregular inner border of the same plate 
which covers the upper part of the ethmoidal 
sinuses; 7 points to the position of the eth- 
moidal foramina; 8, nasal spine; 9, thick 
rough border articulating with the great wing 
of the sphenoid bone; 10 refers to the black 
spot which indicates the position of a fossa 
for the pulley of the trochlearis muscle; to its 
outer side is the supraorbital notch; 11, in- 
ternal angular process, and entrance to the 
frontal sinus; 12, external angular process. 
The nasal spine (9) articulates in 
front with the nasal bones, behind 
with the ethmoid bone. The supra- 
orbital arch (3) terminates in the 
external angular, or malar, process. 
The frontal eminence (7) marks 
the position of the frontal sinus (see 
Fig. 1), a cavity of variable size situ- 
ated between the two plates of which this portion of the bone is composed. 
The central vertical line represents a suture which unites two parts of which 
the bone originally consists. What are called the frontal eminences find 
designation as to locality in Fig. 1. It is here, on either side, that ossification of 
the parts begins. The curved convex line separating the front from the lateral 
portion of the bone (8) is known as the temporal ridge ; to it is attached 
the temporal fascia. The part below this line constitutes a portion of the tem- 
poral fossa, wherein is lodged the muscle of this name. (See Temporal Muscle.') DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
61 
Vertical Portion, Internal View.-The diagram (Fig. 31) shows 
both internal vertical and horizontal portions of the bone. Features of interest 
related with the internal vertical portion are, first, a groove (1) for 
accommodation of the superior longitudinal sinus, which groove is seen to nar- 
row as it descends and to terminate at the frontal crest (2), where, made by 
relation with the ethmoid, is a foramen transmitting a vein from the nostril; 
the borders of this groove give attachment to the falx cerebri, which has 
its anterior termination at the crest; second, depressions for lodgement of the 
Pacchionian bodies ; third, concavities for support of the brain con- 
volutions ; and, fourth, grooves for arteries, particularly the one marked 
lowest in the cut, along which passes the middle meningeal. 
The horizontal, or orbital, portion, or plates, pass backward on either 
side to reach the lesser wings of the sphenoid bone, with which they conjoin, 
above, to form the anterior cerebral fossae, the under surface comprising largely 
the roof of the orbits. Centrally and externally, the plates are separated by 
the internal angular processes and entrance to frontal sinus. The half-cells 
seen on this face of the notch assist in completing, when the bone is articu- 
lated with the ethmoid, the cells of this name. Viewed encranially, or from 
above, the plates are seen fully separated by a notch called ethmoidal, the 
space receiving and articulating the cribriform portion of the ethmoid bone. 
The general surface of this superior aspect is convex, and is largely indented 
for reception of cerebral convolutions. The under surface is concave, in cor- 
respondence with the convexity of the upper face. At its outer part is a 
depression known as the lachrymal fossa, in which is lodged the lachrymal 
gland, while on the corresponding inner side is a depression for attachment 
of the pulley of superior oblique muscle. This surface is in relation with 
the ophthalmic nerve, the external rectus and superior oblique muscles, and 
with the lachrymal gland. 
Figs. 32 and 33 afford studies of the occipital bone. The first offers the 
external or posterior view; the second the internal or anterior view. 
The bone, as seen, is oval in form, is convex externally, concave inter- 
nally. While markedly of saucer-shape, it is seen that the inferior anterior 
extremity, the basilar process, Fig. 32 (11), is at almost complete right-angled 
relation with the posterior superior apex, Fig. 32 (above 3). 
Viewed externally and posteriorly, the bone shows transverse and vertical 
markings. The upper of the transverse lines, Fig. 32 (1), cross from 
side to side, offering a prominent projection at the centre (2), known as the 
external occipital protuberance, which projection affords attachment to 
the ligamentum nuchae. With the lines on either side, and with the 
spaces immediately beneath, are related, from centrally outwardly, the com- 
plexius, trapezius, occipito-frontalis, sterno-mastoid, and sple- 
nius capitis muscles. The lower of the lines, on either side (4), and 
THE OCCIPITAL BONE. 62 
A SYSTEM OF ORAL SURGERY. 
the space below afford origin to the recti capiti portion, major and 
minor, and to the oblique muscles. The crest (3) is the vertical line 
seen relating the protuberance with the foramen magnum. The superior 
angle of the bone, Fig. 32 (above 3), is seen in the articulated skull to relate 
with the posterior joining of the two parietal bones. A delayed completion 
of the process of ossification in this part, and in corresponding parts of the 
Fig. 33. 
Fio. 32. 
External view of the occipital bone. 
1, superior curved line; 2, external occipital 
protuberance; 3, occipital crest; 4, inferior 
curved line; 5, occipital foramen; 6, condyle; 
7, fossa behind the condyle, into which a 
venous foramen frequently opens; 8, position 
of condylar foramen; 9, jugular process; 10, 
notch contributing to form the jugular fora- 
men ; 11, basilar process. 
Internal view of the occipital bone. 
1, fossa for the cerebrum; 2, fossa for the cere- 
bellum ; 3, groove for the longitudinal sinus; 
4, ridge for the attachment of the cerebellar 
falx; 5, groove for the lateral sinus; 6, internal 
occipital protuberance; 7, occipital foramen; 
8, basilar process; 9,10, groove for the lateral 
sinus, descending on the jugular process to 
the jugular notch ; 11, border for the parietal 
bone; 12, border for the temporal bone; 13, 
position at which the ninth, tenth, and 
eleventh cerebral nerves pass through the 
jugular foramen ; 14, condylar foramen. 
parietal bones, is explanation of the posterior fontanels. Wormian 
bones, a name given supplemental osseous pieces found not infrequently in 
the skull, are more frequently met with in this than in any other locality of 
the head. This angle, when normal, is deeply serrated, presenting an 
appearance not unlike the irregular teeth of a rip saw. 
The foramen magnum (5, 7) is the large oval hole seen at the base 
of the bone uniting the body and basilar process. Passing through this hole, 
in the life-state, are the spinal cord and its meninges, the spinal acces- 
sory nerves, and vertebral arteries. Tubercles seen looking into 
the foramen from the sides of its anterior portion are for attachment of the 
cheek ligament. 
Condyles (6), seen at the sides of the foramen, articulate the occipi- 
tal with the atlas bone. These are convex elliptical-shaped projections, in- DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
63 
dining to proximity in front, and which, by reason of form in articulation 
with the associate atlas, permit of a rocking or bowing motion to the head. 
At the base of the condyle of either side are seen the posterior and anterior 
condyloid foramina; the first transmits a vein to the lateral sinus, the 
other the hypoglossal nerve. 
Jugular notch (10) is of semilunar shape. In articulation with a cor- 
responding part of the os temporis it forms the jugular foramen. This 
notch is the locality of termination of the sinuses of the dura mater. 
Jugular foramen, Fig. 33 (13), is bounded inwardly and laterally 
by the circumference of jugular notch, externally or outwardly by notch on 
side of petrous portion of temporal bone. It is not infrequently subdivided 
by spiculae of bone. It transmits the ninth, tenth, and eleventh nerves of 
its side, and forms the seat of communication between the lateral sinus and 
deep jugular vein. 
Basilar process (11) terminates the occipital inferiorly, articulating the 
bone in front with the sphenoid. In shape the part is triangular, the base 
corresponding with the anterior boundary of the foramen magnum and the 
position on either side of the anterior condyloid foramen. Articular rela- 
tion, along its whole length, is with the petrous portion of the temporal bone. 
In front and below it assists in forming the middle lacerated foramen. The 
pharyngeal spine is the ridge seen as the centre line of the external face 
of the process ; this gives attachment to the superior constrictor muscle of the 
pharynx and to its raphe, the depression to either side to the anterior recti capiti 
muscles, major and minor. The part is occasionally the seat of necrosis; to reach 
it incision through the soft palate is commonly, although not always, required. 
Internal surface of occipital bone (Fig. 33) shows crucial ridges 
connecting at a central prominence, known as the internal protuberance, 
this corresponding with the external; it designates the position of the torcular 
Herophili (6). The ridges locate the sinuses,-namely, superior longi- 
tudinal (3), the occipital (below 6), and the lateral (5). The accom- 
modation for these great venous channels is furnished by grooves. The falx 
cerebri and the tentorium cerebelli, which, in their splitting, form the 
sinuses, arch the grooves, being attached to either side. The great depres- 
sions (1, 2) locate beds occupied, the superior by the posterior lobes of the 
cerebrum, the inferior by the cerebellum. Subfigs. 9 and 10 show groove at 
which a lateral sinus terminates and a jugular vein begins. Subfig. 13 shows 
position of transmitted nerves. Subfig. 14 shows a condyloid foramen at its 
internal aspect. 
THE TEMPORAL BONE. 
This bone, looked at in its articular relation, is seen to be wedged between 
the parietal above and the occipital and sphenoid below and laterally. Anato- 
mists divide it, for descriptive purpose, into three parts,-the squamous, 
mastoid, and petrous portions. 64 
A SYSTEM OF ORAL SURGERY. 
External View.-The diagram (Fig. 34) represents a bone taken from 
the left side of a skull. The squamous portion is all the part superior 
to the zygomatic arch (4). 
The petrous portion is 
the part below the arch. The 
mastoid portion is the 
part making the projection 
backward of the bone (8). 
Zygomatic Portion.- 
Study of this face of the bone 
presents the zygoma (4), 
which is of surgical interest as 
being the frequent seat of fract- 
ure and depression. To this 
arch are attached, above, the 
temporal fascia; below, the 
masseter muscle. A tuber- 
cle, the preglenoid (6), makes 
a prominent middle feature; 
it is formed by the junction 
of roots, to be described, and 
gives attachment to the ex- 
ternal lateral ligament of the 
lower jaw. The zygoma 
arises by roots known as anterior, middle, and posterior; the first exists in the 
anterior boundary of the glenoid fossa (5); the second in the posterior 
boundary of this same fossa; the third is a continuation forward of the tem- 
poral ridge. (See Frontispiece 1.) Articulation of the zygoma is through its 
malar process with the malar bone. 
Squamous Portion.-This part (1) accommodates the temporal muscle, 
which fully occupies it. In front it is seen to articulate with the great wing 
of the os sphenoides by a line, the squamo-sphenoidal suture, which is almost 
vertical as to direction. Above, relation is with the parietal bone by means 
of a bevelled edge. Below, posteriorly, it rests upon the mastoid portion (2) 
of the common bone. 
Petrous Portion.-This is all that part of the temporal bone lying 
beneath the zygoma; it contains the principal points of interest related with 
it. This part is triangular in shape, affording at its base, as features of rela- 
tion, the external auditory foramen (12) and the mastoid process (8). 
Its apex (2) assists in bounding the middle lacerated foramen. (See 
Frontispiece 3.) Subfig. 5 marks the location of a fossa, the glenoid, which 
articulates the condyloid process of the inferior maxilla in front of the glenoid 
fissure (7), and the parotid gland back of it. Subfig. 13 represents the styloid 
process. 
Fig. 34 
External view of the temporal bone of the right 
side. 1, squama; 2, mastoid portion; 3, apex of the 
petrous portion; 4, zygomatie process; 5, glenoid fossa; 
6, preglenoid tubercle; 7, glenoid fissure; 8, mastoid 
process; 9, back part of digastric fossa; 10, mastoid 
foramen; 11, tympanic plate forming the vaginal and 
auditory processes; 12, auditory meatus; 13, styloid pro- 
cess ; 14, slight impression of the deep temporal artery. DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
65 
Mastoid Process.-The mastoid process (8) is a nipple-shaped 
prolongation of the bone downward. Externally it is rough for muscular 
attachments. Section shows it to be made up of cells. A groove lying 
inward of the process, the digastric fossa, gives origin to the posterior 
belly of the digastric muscle. (See succeeding page.) 
Internal View.-Looked at internally, while in articulation, the bone 
shows the squamous and petrous portions. The first is of concave aspect, 
and is marked by depressions 
and grooves for accommoda- 
tion of brain convolutions 
and vessels. The second 
shows two sides of a trian- 
gular-shaped prolongation 
inward, the base of which 
abuts the squama, the apex 
articulating with the body of 
the os sphenoides. Points 
of interest are as follows. 
(See Fig. 35.) Subfig. 12 
is the entrance to the audi- 
tory tube; the bones of au- 
dition being accommodated 
in the structure of this hill. 
11 marks location of termi- 
nation of lateral sinus, 
consequently position of jug- 
ular fossa. 10 is the mas- 
toid foramen. 9 is digas- 
tric fossa. 8 is mastoid 
process. 7 is groove for 
great meningeal artery. 6 is 
extremity of zygoma. 5 is 
place of articulation with the 
posterior inferior angle of 
parietal bone, and occupies a 
notch to the left of which is 
the mastoid process, seen on its encranial face. 4 exhibits character of bevelled 
edge characterizing the articular surface of squama. 3, together with neigh- 
boring figures, locates petrous portion, as seen internally. 2 shows character 
of articulating surface of mastoid process. 1 affords view of irregularities 
related with encranial face of the bone. 13 shows the styloid process. 14, a 
prominence locating the position of semicircular canal. 15, tegmen. 16, 
hiatus of facial canal. 17, a cleft that communicates with aqueduct of vesti- 
bule. 18, termination of carotid canal. 20, groove occupied by suprapetrosal 
Fig. 35. 
Internal view of the temporal bone of the left 
side. 1, squamous portion; 2, posterior border of the 
mastold.portion articulating with the occipital bone; 3, 
petrous portion; 4, bevelled edge, which overlaps the 
lower edge of the parietal bone; 5, notch between the 
squama and the mastoid portion, articulating with the 
posterior inferior angle of the parietal bone ; 6, end of the 
zygomatic process; 7, groove for the great meningeal ves- 
sels; 8, mastoid process; 9, digastric fossa; 10, mastoid 
foramen opening into the groove 11, for the lateral sinus; 
12, internal auditory meatus; 13, styloid process; 14, promi- 
nence produced by the supra-semicircular canal of the 
labyrinth; 15, tegmen ; 16, position of hiatus of the facial 
canal; 17, cleft which communicates with the aqueduct 
of the vestibule; 18, termination of the carotid canal; 19, 
Eustachian tube; 20, groove of the suprapetrosal sinus. 66 
A SYSTEM OF ORAL SURGERY. 
sinus. Subfig. 3 occupies a position supporting the ganglia of Casserio, or 
Gasser. 
Inferior, or Basilar, View.-This view considers exclusively the ex- 
ternal face of the petrous portion of the bone. As shown in the diagram, the 
mastoid process is next the observer; Subfig. 
20 locates the apex; 5 distinguishes the position 
of the zygomatic process. This third view 
of the bone shows the petrous portion to be a 
three-sided pyramid, the base of which is 
conjoined with, or abuts, the glenoid fossa. Be- 
ginning at the base, attention is to be directed to 
2, mastoid process, and 6, glenoid fossa. 
Glenoid Fossa.-The importance of this 
fossa in its relation with oral surgical operations 
demands for it special consideration. As seen both 
in the disarticulated and articulated bone, the 
cavity has, as boundaries, the eminentia articu- 
laris in front, the auditory osseous tube 
behind, the posterior peduncle of the zygoma 
externally, and the anterior peduncle in its 
extension internally. The parts named, while 
portions of a common bone, are appreciable sur- 
gically only in articular relation. That part of the 
common cavity in front of the Glaserian fis- 
sure (8) receives indirectly the condyloid pro- 
cess of the inferior maxilla, the sigmoid cavity 
of which last-named bone receives, in turn, the 
articular eminence, or anterior boundary of 
the fossa. The coronoid process of the jaw 
reaches forward into the zygomatic fossa and affords 
attachment to the tendons of the temporal mus- 
cle. The space back of the fissure (8) accommodates 
the parotid gland. The anterior boundary of 
the glenoid fossa is covered by cartilage, upon 
which glides back and forth the interarticular fibro- 
cartilage : the jaw is luxated when cartilage and 
condyle slip in front of the articular eminence. 
The Glaserian fissure (8), or, as it is not un- 
justly called, the squamo-tympanic suture, separates, as seen, the fossa into 
two divisions a trifle anterior to its exact middle. This break in the continuity 
of the part is with view to communication with the middle ear; the fissure trans- 
mits the levator tympani muscle and a minute artery, called tympanic, coming 
off from the internal maxillary. Internally, the slit, as seen, leads, by reason 
of a right-angled turn it makes, to the carotid foramen, through which passes 
Fig. 3G. 
INFERIOE VIEW OF THE LEFT 
TEMPORAL BONE. 1, SquamOUS 
portion; 2, mastoid portion; 
3, petrous portion; 4, border 
articulating with the great 
wing of the sphenoid bone; 
5, zygomatic process; 6, gle- 
noid fossa; 7, articular emi- 
nence; 8, glenoid fissure; 9, 
auditory meatus; 10, mastoid 
process; 11, digastric fossa; 
12, styloid process; 13, stylo- 
mastoid foramen; 14, jugular 
fossa ; 15, pit which communi- 
cates with the aqueduct of the 
cochlea; 16, position between 
which and the occipital bone 
the ninth, tenth, and eleventh 
cerebral nerves escape from 
the cavity of the cranium; 17, 
articular process; 18, vaginal 
process; 19, 20, entrance and 
exit of the carotid canal; 21, 
Eustachian tube; 22, mastoid 
foramen. DESCRIPTIVE AND SURGICAL ANATOMY OF THE HEAD. 
67 
the internal carotid artery; a proximity to be appreciated and remembered, 
as regard is had to operations involving the locality; among which perform- 
ances are section of the coronoid process in neurectomy of inferior maxillary 
nerve, and disarticulation of the condyle in removal of maxilla, which see. 
Meatus Auditorius Externus.-This opening of communication with 
the interior portion of the part of bone being considered has the glenoid fossa 
in front of it and the mastoid process behind. It is a short but spacious canal 
leading to the cavity of the tympanum, or middle ear, from which it is separated 
by the drum-head, or tympanal membrane. (See General Anatomy : Organ 
of Hearing.') 
Petrous Base Proper.-Beginning a study of the base proper, atten- 
tion is attracted first to its triangular shape ; the apex being inward, the 
base outward. The foramen, Fig. 36 (19), shows entrance of carotid canal. 
20 shows relation of apex to the middle lacerated foramen. 21 shows position 
of osseous attachment of Eustachian tube as this canal reaches from the 
pharynx to the ear. 17, an articular relation with occipital bone. 16, petro- 
occipital fissure, through which pass the ninth, tenth, and eleventh cerebral 
nerves. 15, foramen communicating with cochlear aqueduct. 14 is the jugu- 
lar fossa, the place of commencement of the deep jugular vein, which is under- 
stood as the continuation downward of a lateral sinus. 13, stylo-mastoid 
foramen, through which pass the facial nerve and stylo-mastoid artery. (See 
Facial Nerve.) 12 is the styloid process ; a prolongation of needle-like 
character ensheathed at its base by (18) the vaginal process. Before adult 
age the styloid spine is connected by cartilaginous relation with the occipital bone, 
-a relation which occasionally transfers it permanently to this seat; extremity 
of this spine gives attachment to the stylo-hyoid ligament. Muscles to which 
it affords origin are the stylo-hyoideus, the stylo-pharyngeus, and the stylo- 
glossus. 11 locates the digastric fossa. This fossa, which is of oblong 
shape, is bounded internally by the masto-occipital suture, externally by the 
mastoid process, posteriorly by the curved base of the nipple, and anteriorly by 
the stylo-mastoid foramen. The fossa shows to its inner side a groove, which is 
for transmission of the occipital artery. Close to where the fossa relates with 
the styloid process origin is afforded the posterior belly of the digastric muscle. 
(See Muscles.) 10, mastoid process ; this, as understood, is the nipple. 
It is divisible into an anterior and a posterior portion, the line of distinction 
being the continuation of the superior transverse ridge of the occipital bone, 
which at this point assumes a semicircular form. The process is small during 
infancy, but enlarges up to adult life; related muscles are the sterno-mastoid, 
the splenius capitis, and the trachelo-mastoid. Cells, of which the internal 
portion of this process is made up, communicate with the tympanum, and 
are not infrequently the seat of grave aural complications. 7 is articular emi- 
nence, being point of termination of anterior root of the zygoma. 
A student is here to turn to Frontispieces 2 and 3, where are to be seen, 
with proper distinctness (2), several features beside these considered,-namely, 68 
A SYSTEM OF ORAL SURGERY. 
seat of attachment of tensor tympani and levator palati muscles, Eustachian 
inlet, canal for Jacobson's nerve, cochlear aqueduct, foramina lacerum anterius 
and posterius, and canal for Arnold's nerve. Frontispiece 3, encranial face, 
shows, from apex outward, 1, groove for sixth cranial nerve; 2, foramen 
lacerum medius; 3, orifice of carotid canal; 4, depression for semilunar gan- 
glion ; 5, meatus auditor internus; 6, slit for attachment of dura mater; 7, 
groove for subpetrosal sinus; 8, foramen lacerum posterius; 9, vestibular 
aqueduct; and, 10, mastoid foramen. By having the frontispiece diagrams, 
the illustration of the disarticulated bones, the bones themselves, and the text, 
as found in works on anatomy, before him, a student will familiarize himself 
with this complicated part without difficulty. 
This bone is of little significance in oral surgery. The diagrams show it to be 
a square plate somewhat saucer-shaped, convex externally, concave internally. 
THE PARIETAL BONE. 
Fig. 37. 
Fig. 38. 
Outer view of the left parietal bone, 1, 
upper border; 2, bevelled lower border, which 
articulates with the squama of the temporal 
bone; 3, anterior border, joining the frontal 
bone; 4, occipital border; 5, temporal ridge; 6, 
venous foramen; 7, prolonged anterior inferior 
angle joining the summit of the great wing of 
the sphenoid bone; 8, posterior inferior angle 
articulating with the mastoid portion of the 
temporal bone. 
Inner view of the left parietal bone. 
1-4, borders corresponding with same numbers 
in former figure ; 5, groove for the longitudinal 
sinus, and, communicating with it, a venous 
foramen, 6; 7,8, anterior and posterior inferior 
angles; the groove on the latter accommodates 
the lateral sinus. The arborescent lines on the 
inner concave surface of the bone indicate 
grooves for the great meningeal vessels. 
External View.-Fig. 37 has, as its distinctive feature, a curved 
line constituting a ridge, the temporal (5), for attachment of the fascia cover- 
ing in the muscle of this name. 
Internal View.-Fig. 38 exhibits the encranial face of the bone, the 
individual feature of which is a groove, that quickly breaks up into lesser 
ones for accommodation of the great meningeal artery and its branches. CHAPTER IL 
THE MUSCLES OF EXPRESSION AND MASTICATION. 
All muscles met with about the face are with view to expression or mastica- 
tion. The cut exhibited is to be pronounced perfect as illustrative of a 
Fig. 39.-Muscles of the Face. 
Muscles of the head and neck. 1, 2, occipito-frontal muscle; 1, its frontal belly; 2, 
its occipital belly; 3, nasal pyramidal muscle; 4, superior, and 5, posterior auricular 
muscles; 6, palpebral orbicular muscle; 7, labio-nasal elevator; 8, elevator of the upper 
lip; 9, nasal compressor; 10,11, zygomatic muscles; 12, masseter muscle; 13, buccinator; 
14, depressor of the oral angle; 15, oral orbicular muscle; 16, elevator of the oral angle; 
17,18, depressor of the lower lip; 19, sterno-mastoid muscle; 20, trapezius; 21, posterior 
belly of the digastric and the stylo-hyoid muscle; 22, anterior belly of the former; 23, 
loop of fibrous tissue attaching the tendon of the digastric muscle to the hyoid bone ; 24, 
omo-hyoid muscle; 25, sterno-hyoid; 26, sterno-thyroid, seen to the outer side and behind 
the anterior belly of the omo-hyoid; 27, mylo-hyoid; 28, splenius; 29, elevator of the 
scapular angle; 30, 31, middle and anterior scalene muscles; 32, clavicle. 
finished dissection. The neck muscles added in the diagram are with view 
to afford appreciation of indirect relations. 
In studying the muscles of the face, it is to be observed that they ar- 
69 70 
A SYSTEM OF ORAL SURGERY. 
range themselves into groups. Thus, a group is seen that is composed 
strictly of elevators, another that is made up of depressors. Then groups that 
pertain to particular regions, as the nasal, superior maxillary, inferior maxillary, 
intermaxillary, etc. Surgically, however, information pertaining to the 
muscles is sufficiently elicited in comprehending their general plan and 
arrangement. 
The muscles proper of the face aro twenty-one in number, and are justly 
esteemed of a compound nature as regard is had to voluntary and in- 
voluntary action, being both under and independent of will. These muscles, 
for convenience of study, are divided into three groups,-namely, those of 
the forehead and eyes, called the fronto-palpebral group, those related with 
the nose, called the nasal group, and those associated with the lips, called 
the oral group. 
First Group.-The muscles of the first group, fronto-palpebral, 
are (see cut), respectively, the occipito-frontalis (1), the corrugator supercilii, 
the pyramidalis nasi (3), and the orbicularis palpebrarum (6), to which is 
added by some anatomists the auricular muscles (4, 5). 
Second Group.-The second group, the nasal, is made up of the 
compressor nasi (9), the dilator naris, a slip of a muscle commonly grouped 
with the mouth muscles (7), and the depressor ahe nasi (9). 
Third Group.-The muscles of the third group, oral, are, first, and 
prominently, the orbicularis oris (15), to which all the others are related ; after 
this, the levator labii superioris (8), connected with which is the slip formed 
by the levator nasi, the conjoined parts going under the common name of levator 
labii superioris alaeque nasi, the zygomatici, of which there are two on either 
side, called major and minor (10, 11), the levator anguli oris (16), the levator 
labii inferioris, not shown. All named are elevators. The depressors of the 
group are two in number, the depressor labii inferioris (17) and the depressor 
anguli oris (14). The remaining muscles of the group are (13) the buc- 
cinator, or trumpeter's, and, not shown in the cut, a slip, frequently a separate 
muscle, from the platysma myoides, attached to the upper angle of the mouth, 
called the risorius, or laughing muscle of Santorini. 
Blood-Supply.-The muscles of expression receive their supply of 
blood from tributaries of the external carotid,-namely, from the com- 
mon facial, the transverse facial, and the temporal arteries, these 
vessels anastomosing with branches of the internal maxillary. 
Nerve-Supply.-Of the first group, the occipito-frontalis is supplied, 
anteriorly, by the supraorbital and facial nerves, posteriorly, by the posterior 
auricular and small occipital nerves. Corrugator supercilii, by facial and supra- 
orbital nerves. Pyramidalis nasi, by facial nerve. Orbicularis palpebrarum, 
by facial and supraorbital nerves. The auricular muscles,-namely, attollens, 
attrahens and retrahens aurem,-the first by the small occipital, the second by 
the facial and auriculo-temporal, a branch of the motor inferior maxillary, and 
the last named by the posterior auricular branch of the facial. THE MUSCLES OF EXPRESSION AND MASTICATION. 
71 
Of the second group, all are supplied by the facial nerve. 
Of the third group, the orbicularis, the levator labii superioris, the levator 
anguli oris, and the zygomatici and risorius are supplied by the facial, the 
buccinator by the facial and by a branch, buccal, of the motor division of 
the inferior maxillary. 
Veins.-The veins returning the blood-supply of these muscles are the 
various branches of the temporo-maxillary and facial terminating in the 
jugulars. (See Veins.) 
Lymphatics.-The lymphatics, or absorbents, of the region are known 
as the superficial, or facial. , These accompany the veins, particularly the facial, 
pass through the buccal glands lying upon the surface of the buccinator 
muscle and connect with the submaxillary lymphatics. Cancer of the 
lip is almost certain to affect the submaxillary gland by reason of direct lym- 
phatic connection existing between the two. The lymphatic glands frequently 
take on a pathological condition, assuming tumorous form known as lymphoma. 
(See Lymphatics.) 
The muscles of the face have, as a superficial, or external, investment, the 
superficial fascia. This fascia is, in turn, so closely identified with the 
skin, particularly as the localities of lips and eyelids are concerned, as to be of 
little different import from the ordinary deep layer of this structure. The 
fascia extends over the parotid gland, and is continuous with that of the 
neck. In the hollow of the cheek it contains more or less fat, corresponding 
with plumpness or emaciation of the face. In the eyelids, and in the borders 
of the lips, no fat is present. Reference to Fig. 39 shows an antagonizing 
relation of the elevator, depressor, lateralizing, and orbicular muscles. All 
the former are inserted into the last named, thus affording the great variety 
as to motion of which it is found capable. On the other hand, the sphincter, 
or orbicular, when held as the fixed point, permits of expression directed the 
other way as relation is had with certain of the face muscles that are without 
osseous attachment. (See description following.) 
Occipito-frontalis.-This, which is a double muscle, having conjunction 
of its two parts through the occipital aponeurosis, relates alone with expres- 
sion, as its anterior, or frontal, portion is concerned. This portion is known as 
the frontal muscle, Fig. 39 (1). It covers the forehead and lies upon the 
fourth layer of the scalp; a layer of loose cellular tissue allowing of free 
motion in parts external to it. (See Scalp.) The muscle is a spread-out 
fleshy lamina, thin and delicate, which descends from its epicranial aponeurosis 
to relate with the orbicular of the eyebrows, the superciliary and the pyrami- 
dalis nasi muscles. 
Relation.-The relation of this anterior belly of the muscle with the skin 
is of such close character that movement of one implies motion in the other. 
Its form is quadrilateral. It associates with the orbicular • and corrugator 
RELATIONS OF MUSCLES OF EXPRESSION. 72 
A SYSTEM OF ORAL SURGERY. 
muscles through certain middle fibres, and with the nasal pyramidal through 
its internal fibres. 
Action.-Action of this muscle is to raise the eyebrows and parts about 
the root of the nose; also to corrugate the skin of the forehead. 
Corrugator Supercilii.-This muscle wrinkles the integument 
of the forehead vertically. It arises from the nasal aspect of the super- 
ciliary ridge, and reaches outward, upward, and external. Its attachment 
is with the subcorium and with the orbicularis palpebrarum muscle, a 
little external to a line drawn upward from the position of the supraorbital 
foramen. The shape of the muscle is that of a partially-opened fan. 
Relation.-Relation is, by outer surface, with the orbicularis palpebrarum 
and with the frontal muscles, and, by under surface, with the frontal bone. 
The supraorbital vessels pass between the muscle and bone. 
Action.-Action of this muscle is, as expressed, to corrugate the 
skin. 
Pyramidalis Nasi.-This is seldom more than a slip continued down- 
ward from the frontal muscle (3). It becomes tendinous upon the bridge of 
the nose, and is attached to the compressor nasi. The space left by the 
divergence of the slips on either side is filled by cellular tissue. 
Relation.-Relation is, by outer surface, with the skin, by under, with 
the frontal and nasal bones. 
Action.-Action of this muscle is to steady the frontal. 
Orbicularis Palpebrarum.-This is the sphincter muscle of the 
eyelids (6). Its principal office is to relate, or bring together, the free 
borders of the eyelids. A second office is to hold the lachrymal puncta 
in relation with the ball of the eye with view to removal of the tears. It is 
the winking muscle. Origin is from the internal angular process 
of the frontal bone, from the maxillary nasal process, and from the 
external surface of the palpebral tendon as this relates with the inner 
angle of the orbit. The muscle is a broad, delicate plane of elliptically-placed 
fibres. It covers the eyelids, reaches above the orbit to associate with 
the frontal and corrugator muscles and downward to be spread out beneath 
the skin of the cheek. The palpebral tendon is the white spot seen 
on stretching the eyelids outwardly. Its direction is transverse, and its situa- 
tion is immediately beneath the skin where the lids are attached to the nasal 
process in front of the lachrymal sac. This tendon is merely a thickened 
portion of the common fibrous membrane that attaches the tarsal cartilages 
to margin of the orbit. The palpebral tensor is best viewed as a slip 
of the orbicularis, situated behind the internal palpebral tendon, having os- 
seous attachment to the orbital face of the lachrymal bone. It crosses the 
lachrymal sac, covers the canal, and has a second attachment to the tarsal car- 
tilages. The levator palpebrte is a thin, triangular-shaped muscular slip, 
antagonistic to the sphincter action of the orbicularis, which arises by a tape- 
like slip from the orbital aspect of the lesser wing of the os sphenoides in THE MUSCLES OF EXPRESSION AND MASTICATION. 
73 
close superior relation with the optic foramen. Extending forward over the 
eye, it has insertion into the superior tarsal cartilage. 
Relation.-Relation of orbicularis palpebrarum is, by outer surface, with 
the superficial fascia, here almost completely part and parcel of the integu- 
ment proper of the lids; by deep surface, with an under layer of the fascia 
superficialis, with the frontalis and corrugator supercilii muscles, with which 
its fibres interlace, and with the supraorbital vessels, the lachrymal sac, the 
elevator muscles of the superior lip and nasal wing, and externally with the 
temporal fascia. 
Action.-Action of the orbicularis is exhibited in a voluntary closure of 
the eyelids and in involuntary winking. The tensor tarsi, palpebral tensor, 
as suggested, provides over securing passage of the lachrymal secretion into 
and through the puncta. The levator palpebra raises the superior lid. 
Compressor Naris.-This muscle (9), constituting, with its fellow, 
the compressor nasi, arises from the maxillary canine fossa, passes up- 
ward and mesially, and unites with its fellow of the opposite side. 
Relation.-Relation is, by under surface, with maxillary bone and lat- 
eral nasal cartilage; by outer surface, with the subcoreum; above with the 
pyramidal muscle, and below with tip and wing of nose. 
Action.-Action is to diminish the nasal aperture. 
Dilator Naris.-The attachment of this muscle is to the skin about 
the margin of the nostril. Origin is from a groove at the upper and back 
part of the wing. The fibres of the muscle, which are commonly indistinct, 
have connection with the subcutaneous areolar tissue. A layer, or slip, some- 
times named the anterior dilator, passes to insertion with the extreme tip 
of the nose. 
Relation.-Relation is, by outer surface, with the skin and underlying 
connective tissue ; by under surface, with its groove of origin, otherwise influ- 
enced by diversity of origin. 
Action.-Action is to open the orifice of the nostril. 
Depressor Alae Nasi.-Each of these muscles arises from the incisive 
fossa and the canine ridge of the maxilla; attachments being with the nasal 
septum and posterior border of the wing of the nose. 
Relation.-Relation is, by under surface, with bone; by outer surface, 
with mucous membrane of lip, with the naso-labial elevator, and with orbicu- 
laris oris. 
Action.-Action is to depress the septum and borders of the nose. 
Orbicularis Oris.-This prominent muscle, as shown in the cut (39), is 
elliptical in form, and constitutes in itself all the muscular substance found in 
the border and middle surfaces of the lips. Immediately around the free 
borders of the lips it takes the form of a rounded fasciculus of ring-like 
expression, which is so superficial as to be covered alone by the thin skin 
which here unites with the mucous membrane. At the angles and middle 
portion of the mouth the orbicularis gives attachment to various muscles; 74 
A SYSTEM OF ORAL SURGERY. 
at the middle portion above, and to either side of the mesian line, to the 
elevator of the lip and wing of nose, and to the levator proprius; at the angles, 
on either side, to the zygomatici, the levator anguli oris, the risorius, and the 
buccinator. The orbicularis consists of two planes of fibres, with the 
outermost, or facial, one of which the antagonizing muscles just named inter- 
lace. To this outer, or facial, plane certain fasciculi are also attached which 
give the muscle, and through it the lip, a partial fixation to the maxillary 
bone and to the nasal septum: these fasciculi, or slips, are known as the 
accessorii orbicularis superioris and inferioris and the naso-labi- 
alis. The depression, seen in the middle of the superior lip, marks a space 
existing between the two naso-labial slips as these relate with the lip and 
nasal septum. The superior accessory slips have bony fixation to the 
maxilla) opposite the incisor teeth ; arching outwardly they become continuous 
with the various muscles at the angle of the mouth. The inferior accessory 
slips arise from the lower jaw close to the cuspidati teeth; arching outwardly 
on either side they relate, like the superior, with the muscles of the oral 
angle. 
Relation.-Relation of the orbicularis oris is, by outer surface, with 
the integument with which it is almost inseparably related; by under surface, 
with the mucous membrane, from which it is separated by certain interposed 
labial glands and by the coronary vessels. 
Action.-Action is to contract the oral orifice. 
Levator Labii Superiorus Alaeque Nasi.-This is a delicate 
muscle of triangular shape having origin from the upper and outer part of 
the maxillary nasal process, from which its fasciculi descend to relate with the 
orbicularis of the lip and with the wing of the nose. Association of this 
muscle with the elevator proper of the lip causes some anatomists to deny its 
claim to distinct naming. If it is classed as one with the levator labii 
proprius, then a second origin is to be described, this latter muscle, or 
part, arising from the maxilla just below the infraorbital foramen (see cut, 
1), and uniting at place of relation with the orbicular. 
Relation.-Relation is, by outer surface, with integument and orbicularis 
palpebrarum ; by under surface, with the infraorbital vessels. 
Action.-Action is to lift superior lip and wing of nose. 
Zygomatici.-The zygomaticus major is composed of a series of slender 
fasciculi which have origin from the malar bone where it articulates with the 
zygoma, and which, descending, blend with the orbicular fibres and with those 
of the angular labial depression. The zygomaticus minor is an associate of 
the major; its origin is where the malar and maxillary bones articulate; its 
labial association is with the levator proprius as this relates with the orbicu- 
laris. (See cut.) 
Relation.-Relation of the first named is, by outer surface, with the in- 
tegument ; by under surface, with the bone of origin and with the masseter 
and buccinator muscles; of the second named, by outer surface, with the or- THE MUSCLES OF EXPRESSION AND MASTICATION. 
75 
bicular of the eyelid, and with the integument; by under surface, with the 
elevator of the oral angle. 
Action.-Action of both major and minor muscles is to assist as lifters. 
(See cut.) 
Levator Anguli Oris.-This muscle is situated deep in the face, being 
beneath the zygomatici and labial elevator. It arises from the upper part 
of the canine fossa and descends to the corner of the mouth, where its fibres 
blend with those of the orbicularis, zygomatici, and depressor of the oral angle. 
(See cut.) 
Relation.-Relation is, by outer surface, with the infraorbital vessels and 
the more superficially located muscles named above; by under surface, with 
the bone of origin, the buccinator muscle, and with the mucous membrane. 
Action.-Action is to lift and lateralize the angle of the mouth. 
Depressor Anguli Oris.-This muscle is of triangular form. Its 
origin is from the external oblique line of lower jaw; ascending, it attaches 
itself at the oral angle to the fibres of the orbicularis and buccinator. 
Relation.-Relation is, by outer surface, with the integument; by under 
surface, with mandible, and with the buccinator and depressor labial muscles. 
Action.-Action is to pull down and lateralize angle of mouth. 
Depressor Labii Inferioris.-This is of quadrilateral form. Its 
origin is from a line of the lower jaw which reaches from the symphysis to 
the mental foramen; ascending, its fibres pass to association with the orbicu- 
laris oris and with those of its fellow of the opposite side. 
Relation.-Relation is, by outer surface, with the integument; by under 
surface, with the mental vessels, glands, and mucous membrane. 
Action.-Action is to draw down the lower lip. 
Buccinator.-This muscle, known as the "trumpeter," is the most 
deeply situated of its group. It arises both from the superior and inferior 
maxillae, the place of origin in both jaws being a line marking the position of 
the apices of the roots of the molar teeth. A second origin is from the pterygo- 
maxillary ligament. From its origin the muscle advances forward toward the 
oral angle, its central fibres converging until, when the sphincter is reached, 
those of the lower plane decussate with those of the upper, the two sets cross- 
ing so that the lower are attached above and the upper below; the non- 
decussating fibres pass to make a central attachment. The buccinator is a 
muscle of much power, consequently of large fibre. A glance at the 
cut (39) affords excellent idea of it, and of its advance from place of double 
origin to association with the oral sphincter. 
Relation.-Relation is, by outer surface, with a layer of deep fascia with 
which it is invested, with superficial fascia and more or less fatty tissue, with 
the platysma myoides muscle, and with the skin; by under surface, with the 
buccal glands and with the mucous membrane lining the cheek. 
Action.-Action is of various signification. Being identified with actions 
relating to expression, mastication, and deglutition, this muscle is not unjustly 76 
A SYSTEM OF OH AL SURGERY. 
considered under three heads. As expression is concerned, it antagonizes a 
puffed-out cheek; in the act of mastication, it holds the food in contact with 
the grinding faces of the teeth; in the act of deglutition, it plays a part in 
directing a bolus backward toward the fauces. 
Risorius.-This is a slip arising out of the fascia overlying the masseter, 
otherwise it is given off from the platysma myoides. Attachment is at 
the angle of the mouth, in relation with the depressor anguli oris. 
Relation.-Relation is, by outer surface, with the integument; by under 
surface, with the platysma. 
Action.-Action is to draw the angle of the lips outward, as in the act 
of laughing. 
MUSCLES OF MASTICATION. 
The immediate muscles of mastication (see Figs. 40, 41, and 42) are the 
temporal, the masseter, the internal pterygoid, the external 
pterygoid, the genio-hyoid, and the digastric. The mediate, or indi- 
rect, muscles associated with the function are the sterno- and thyro- 
hyoid and the omo-hyoid. (See Anatomy.') 
Temporal Muscle.-This, as understood by the diagram, is a triangular- 
shaped muscle of extensive origin and restricted attachment. It arises from 
Fig. 40.-Temporal Muscle. 
the temporal ridge and fossa, consequently from a space that reaches from 
the angular process of the frontal bone to the posterior zygomatic footstalk. 
Its fibres converge and terminate in an aponeurosis, which envelops the full 
circumference of the coronoid process of the lower jaw. (See Fig. 40.) The 
belly, or fleshy portion, of the muscle is made up of a superficial and deep THE MUSCLES OF EXPRESSION AND MASTICATION. 
77 
portion. The first of these consists of an unimportant plane of fibres, the 
second constitutes the back and strength of the part. The aponeurosis, or 
tendon which relates the muscle with the coronoid process, is of firm character 
and most resistive of the knife; its situation is directly beneath the zygoma; 
it commonly associates with the masseter muscle. 
Relation.-Relation is, by its outer surface, with the temporal fascia ; 
this is a dense, shining aponeurosis closely covering the muscle, and attached 
below, by means of its division into two layers, to the outer and deep faces of 
the zygoma. Abscesses forming between it and the underlying muscle are 
directed below the yoke. External to this aponeurosis is another important 
structure,-the epicranial aponeurosis,-between which and the integument the 
superior and posterior auricular muscles are situated. By its under surface, 
with the temporal fossa, which it fully occupies, with the external pterygoid 
and buccinator muscles, and with the internal maxillary artery, particularly 
with the temporal branches. 
Action.-Action of the temporal muscle is to assist the masseter and 
internal pterygoid in relating the lower with the upper jaw. 
Masseter Muscle.-This is a 
quadrilateral-shaped muscle separated 
into parts known as superficial and 
deep, Fig. 41 (9). Its relation is 
with the malar process of the superior 
maxilla and with the anterior two- 
thirds of the zygomatic arch above 
and the lower half of the ramus and 
angle of the inferior maxilla below. 
The superficial portion, the 
heaviest but least muscular part, 
arises by a strong aponeurosis. The 
deep portion, the strongest, unites 
its fibres with this aponeurosis. (See 
Fig. 39, also Fig. 12.) The lifting 
"7 o 7 O 
power of this muscle is very great. 
Relation.-Relation is, by outer 
surface, with integument, orbicularis 
palpebrarum and zygomaticus major 
muscles, and with Steno duct, the 
transverse facial artery, and branches 
of the facial nerve, all of which cross 
it transversely ; by deep surface, with 
the buccinator and temporal muscles and with the ramus of the jaw. At its 
extreme anterior inferior border the facial artery is in contact with it. 
Action.-Action is to assist in the grinding and cutting of food. 
Pterygoideus Internus Muscle.-This is the quadrilateral-shaped 
Fig. 41.-Masseter and Ptery- 
goid Muscles. 
1, condyloid process; 2, angle of jaw; 3, base 
of jaw; 4, mental process; 5, portion of jaw 
below mylo-hyoid ridge; 6, mylo-hyoid mus- 
cle attached ; 7, inferior genial tubercles ; 8, 
superior genial tubercles; 9, masseter muscle; 
10, internal pterygoid muscle; 11, external 
pterygoid muscle. 78 
A SYSTEM OF ORAL SURGERY. 
muscle seen in the diagram, Fig. 41 (10), having attachment by abroad base 
at the angle of the lower jaw and reaching obliquely upward and forward 
to the inner surface of the external pterygoid plate, with which and the 
tuberosity of the palate bone it has relation of origin. 
Relation.-Relation is, by outer surface, with the ramus of the jaw, with 
the internal maxillary artery, with the internal lateral ligament, and with the 
superior dental vessels; by under surface, with the tensor palati and superior 
constrictor muscles. 
Action.-Action is to lift and hold the lower jaw in contact with the 
upper and to make protruding motion. 
Pterygoideus Externus Muscle.-This muscle, Fig. 41 (11), has 
origin by two heads separated by a cellular interval. The first, or upper, 
head is attached to the pterygoid ridge of the great wing of the sphenoid bone, 
the second, or lower, head is attached to the outer surface of the external ptery- 
goid plate. The central portion of the muscle is fleshy, the two extremities 
aponeurotic. Passing outward from place of origin attachment is (see Fig. 41) 
to a depression existing on the anterior face of the condyle, and t'o the temporo- 
maxillary interarticular fibro-cartilage. 
Relation.-Relation is, by outer surface, first, and most importantly, with 
the internal maxillary artery which crosses it, and, second, with the ramus of the 
jaw and with the tendon of the temporal muscle; by under surface, with the 
internal pterygoid muscle, the internal lateral ligament, the inferior maxillary 
nerve, and the middle meningeal artery. 
Action.-Action is to draw the lower jaw forward as expressed in the 
projection of the lower teeth beyond the upper. Alternation of movement of 
the pterygoidei, combined with the office of masseter and temporal muscles, 
results in trituration of the food. 
Digastric Muscle.-This muscle, commonly classed as an elevator of 
the hyoid bone, becomes, through fixation of that bone, a depressor of the 
lower jaw. It consists of two rounded fleshy portions connected by a 
fibrous aponeurosis. The posterior, the longer belly, arises from a groove 
upon the inner side of the mastoid process of the temporal bone. The ante- 
rior belly arises from the side of the symphysis of the lower jaw. At the 
aponeurotic intersection a slip furnished by the deep fascia of the neck makes 
a loop of association with the hyoid bone. 
Submaxillary Triangle.-The submaxillary triangle of the neck 
is formed by relation of the digastric with the bone of the lower jaw. This 
is an important region to be understood, as it is the location of the sub- 
maxillary gland and the not infrequent seat of abscess. Looking at the 
diagram (Fig. 42) this double-bellied muscle (1, 2) is seen in position, and in 
relation with the hyoid bone by means of its aponeurosis (3). This latter, which 
is the deep cervical fascia, or otherwise a thickened portion of it, divides 
when reaching the muscle into two leaves,-an anterior, which covers in the 
triangle externally, and a posterior, which closes it posteriorly. In this closed THE MUSCLES OF EXPRESSION AND MASTICATION. 
79 
cavity lies the gland, together with two others belonging to the common 
lymphatic system. (See Abscess of Submaxillary Gland.} 
Relation.-Relation is, by outer surface, with the platysma and sterno- 
mastoid muscles and with the parotid and submaxillary glands; by under 
surface, with the mylo-hyoid 
and other deep muscles of 
the region, and with the ex- 
ternal carotid, lingual and 
facial arteries, and the in- 
ternal jugular vein and 
hypoglossal nerve. 
Action.-Action is vari- 
ous, according as the hyoid 
or maxillary bone be the fixed 
point. When the former is 
steadied by the sterno-hyoid 
muscle the digastric becomes 
an opener of the mouth. (See 
Anatomy.} 
Genio-hyoid Muscle. 
-Subfig. 6 of the cut shows 
the position of this muscle, 
and affords idea of its mean- 
ing as a depressor of the lower 
jaw when the hyoid bone is 
fixed. It is a fleshy band 
arising from the inferior of 
the genial tubercle, from whence it descends to an insertion that is both tendi- 
nous and fleshy into the anterior and central part of the hyoid bone. 
Relation.-Relation is, by its outer surface, with the integuments; by 
its under and lateral surfaces, with the mylo-hyoid and with the genio-hyo- 
glossus. 
Action.-Action is the same, and much after like manner, with the di- 
gastric. 
Nerves.-The muscles proper of mastication are supplied from the motor 
branch of the inferior division of the fifth nerve. 
Blood-Supply.-This is from the offshooting branches of the external 
carotid; the temporal and internal maxillary principally. 
Fig. 42.-Front View of Muscles of Neck. 
Front view of the muscles of the neck. 1, posterior, 
and 2, anterior belly of the digastric; 3, its intermediate 
tendon attached to the hyoid bone and passing through 
the insertion of the stylo-hyoid muscle, 4; 5, mylo-hyoid; 
6, genio-hyoid; 7, stylo-glossal; 8, hyo-glossal; 9, styloid 
process; 10, stylo-pharyngeal; 11, sterno-mastoid; 12, its 
sternal origin; 13, its clavicular origin; 14, sterno-hyoid; 
15, sterno-thyroid; 16, thyro-hyoid; 17, 18, omo-hyoid; 
19, trapezius; 20, anterior scalenus; 21, middle scalenus 
muscle. CHAPTER III. 
ARTERIES AND VEINS OF FACIAL REGION. 
SUPERFICIAL AND DEEP 
Fig. 43 represents the heart, the circulatory centre. Reference to descrip- 
tive text locate the different parts. Subfigs. 10, 10, show manner of origin 
and relations of the primitive carotid arteries, from which, in turn, 
arise the principal vessels supplying the head. 
Fig. 43.-The Heart and Great Blood-Vessels, 
Front view of the heart and great blood-vessels. 1, right ventricle; 2, left ven- 
tricle ; 3, right auricle; 4, left auricle; 5, pulmonary artery, dividing into the right and 
left branches; 6, arch of the aorta; 7, remains of the ductus arteriosus; 8, descending 
aorta; 9, innominate artery; 10, common carotid arteries; 11, subclavian arteries; 12, 
superior cava: 13, right innominate vein, formed by the union of the right internal 
jugular and subclavian veins; 14, left innominate or transverse vein, formed like the 
preceding; 15, inferior cava, with the hepatic veins ; 16, left coronary artery ; 17, branch 
to the left auriculo-ventricular groove; 18, right coronary artery; 19, valvular sinuses of 
the pulmonary artery. 
Subfig. 12 locates a great vein, the vena cava, into which is emptied all 
the return current from the head, which current in turn is passed into the right 
auricular cavity. (See General Anatomy.') 
80 ARTERIES AND VEINS OF FACIAL REGION. 
81 
GENERAL VIEW OF HEAD CIRCULATION. 
The circulation of the head, as of other parts, consists of an afferent and 
efferent flux. The first is carried by arteries, the second is conveyed by 
veins. An intermediate system is the capillary. The aorta, the root 
artery which associates all others with the heart (6), arises from the left 
ventricle, and passing upward, gives off a branch known as innominate, 
which, in turn, divides into a right subclavian and primitive carotid. Changing 
to a transverse position, the aorta gives off, beside a subclavian, the left primi- 
tive carotid. These arteries and their branches-including two vessels of 
other origin, known as vertebral-furnish the supply of blood to the head. 
Veins returning the blood to the heart commence in all the peripheries of 
the parts as tributaries of the vena cava, line of flow being through the facial, 
the internal maxillary, the vertebral, and the jugular veins. 
Capillaries are the minute radicles of the afferent and efferent vessels 
related with seat of nutrition. 
ARTERIAL CIRCULATION OF FACIAL REGIONS. 
Carotid Arteries, Primitive and Collateral.-Fig. 44 exhibits 
the primitive carotid artery of left side as it rises above the clavicle into the 
neck. The beginning of the vessel is from the place of cut-off, as shown in 
Fig. 43 (10). 
The primitive carotids are to be recalled as having different origins: that of 
the right side from the innominate, Fig. 43 (9), that of the left from the arch 
of the aorta. 
The line of a primitive carotid artery as it runs up and across a neck 
is to be mapped out by a string extended from the mastoid process of a tem- 
poral bone to the sterno-clavicular articulation. The vessel, together with 
the deep jugular vein and pneumogastric nerve, lies enclosed in a common 
sheath, which sheath is obtained from the deep cervical fascia. At the base of 
the neck the two carotids approximate closely. Above, and external to 
them, are the remains of the thymus gland, the sterno-hyoid and the thyroid 
muscles, the left innominate vein, and the sternum. 
A common carotid artery, as it lies in the neck proper, rests upon the 
longus colli and rectus anticus major muscles. In front of it are integu- 
ment and fasciae, platysma, sterno-cleido-mastoid, sterno-hyoid and thyroid, 
and omo-hyoid muscles, descendens noni nerve, sterno-mastoid artery, superior 
and middle thyroid veins, and external jugular vein. To the external side 
are the pneumogastric nerve and deep jugular vein, which are enclosed by 
its sheath, Internally are trachea, thyroid gland, inferior thyroid artery, 
recurrent laryngeal nerve, sterno-thyroid and hyoid muscles, trachea, oesopha- 
gus, larynx, and pharynx. 82 
A SYSTEM OF ORAL SURGERY. 
PLACE OF DIVISION INTO EXTERNAL AND INTERNAL. 
At a point opposite and a little below the great horn of the hyoid bone (see 
Fig. 44) the primitive breaks into two divisions, known respectively as the 
external (3) carotid and internal (2) carotid arteries. Of these, the latter 
Fig. 44.-A Common Carotid, with its Divisions. 
Left common carotid dividing into the external and internal carotid arteries. 
1, common carotid artery ; 2, internal carotid; 3, external carotid ; 4, superior thyroid; 
5, lingual; 6, pharyngeal artery; 7, facial; 8, inferior palatine and tonsillar arteries; 9, 
submaxillary; 10, submental; 11, occipital; 12, posterior auricular; 13, parotid branches; 
14, internal maxillary; 15, temporal artery; 16, subclavian artery; 17, axillary; 18, ver- 
tebral artery; 19, thyroid axis; 20, inferior thyroid giving off the ascending cervical; 21, 
transverse cervical; 22, suprascapular; 23, internal mammary artery. 
ascends to the carotid foramen in the petrous portion of the temporal bone, 
where it disappears, to contribute, as seen in another illustration, to the forma- 
tion of the circle of Willis. 
EXTERNAL CAROTID ARTERY. 
The external of the divisions is the vessel contributing most directly to 
supply of the parts under consideration. This artery breaks up into twenty- 
two branches, and these, in turn, divide and subdivide until no locality is left 
unfurnished. The line of the artery, as seen in the diagram (Fig. 44) and 
one immediately succeeding, is directly upward until the temple is reached. ARTERIES AND VEINS OF FACIAL REGION. 
83 
A line locating it is drawn from the angle of the jaw to the sterno-clavicular 
articulation. 
Fig. 45. 
The external carotid artery and its branches. 1, right common carotid; 2, in- 
ternal carotid; 3, external carotid; 4, superior thyroid; 5, lingual; 6, facial; 7, sub- 
mental ; 8, inferior labial; 9, superior labial; 10, muscular branches; 11, lateral nasal 
artery; 12, angular artery; 13, occipital artery; 14, descending cervical; 15, muscular 
branch; 16, posterior auricular artery; 17, parotid branches; 18, internal maxillary; 19, 
temporal; 20, transverse facial; 21, anterior auricular; 22, supraorbital; 23, middle tem- 
poral; 24, anterior temporal; 25, posterior temporal artery. 
Branches of External Carotid.-The branches of the external 
carotid, direct and indirect, are as follows (see Fig. 45) : 
4. Superior thyroid. 
5. Lingual. 
6. Facial. 
7. Submental. 
8. Inferior labial. 
9. Superior labial. 
10. Muscular branches. 
11. Lateral nasal. 
12. Angular. 
13. Occipital. 
t 14. Descending cervical. 
15. Muscular branch. 
16. Posterior auricular. 
17. Parotid branches. 
18. Internal maxillary. 
19. Temporal. 
20. Transverse facial. 
21. Anterior auricular. 
22. Supraorbital. 
23. Middle temporal. 
24. Anterior temporal. 
25. Posterior temporal. 
Subfigures 
The division, as given, implies that the vessels named have their existence and 
supply in the external carotid. It is not the case, however, that commonly 84 
A SYSTEM OF ORAL SURGERY. 
other than eight come directly from what is named external carotid, the others, 
as a rule, being secondary offsets. The eight are, respectively,- 
1. Superior thyroid. 
2. Lingual. 
3. Facial. 
4. Internal maxillary. 
Passing medianly 
1. Occipital. 
2. Posterior auricular. 
Passing outwardly 
Passing upwardly 
1. Ascending pharyngeal 
2. Temporal. 
Superior Thyroid.-Branches five in number: 
1. Hyoid. 
2. Muscular. 
3. Superior laryngeal. 
4. Crico-thyroid. 
5. Terminal. 
Branches 
The superior thyroid is the first of the carotid branches (4). It 
crosses inward and downward. Its divisions, as named, signify its distribution. 
Surgical Anatomy.-The thyroid is the not infrequent seat of hem- 
orrhage in attempts at suicide by cutting the throat. In these cases the vessel 
is to be taken up and secured by ligature, the wound being enlarged for the 
purpose if found necessary. 
Lingual.-Branches four in number: 
1. Hyoid. 
2. Dorsalis linguae. 
3. Sublingual. 
4. Ranine. 
Branches 
The lingual is the second of the carotid branches (5). Its course is flexu- 
ously inward and upward. Its divisions designate the distribution. 
Surgical Anatomy.-Necessity for ligation of the lingual arise out 
of cut-throat, out of accident in operating for tongue-tie, and out of other 
wounds, or deep ulceration of tongue. The position of the vessel, as it crosses 
the neck to reach its destination, is immediately above, and on line with, the 
great cornua of the hyoid bone. It lies upon the middle constrictor muscle, 
and is covered by the hyo-glossus muscle and by the integuments. In cutting 
for it the surgeon makes his cut immediately above and on a line with the 
cornua. The incision is to divide skin, superficial fascia, and deep fascia. 
This performance exposes the hypoglossal nerve, which is on the same line 
with the artery and separated from it by the hyo-glossus muscle. Incision 
through the muscle lays bare the vessel, which may easily be lifted and ligated. ARTERIES AND VEINS OF FACIAL REGION. 
85 
Facial.-Branches ten in number, including muscular and cutaneous 
twigs: 
In the Neck 
1. Inferior palatine. 
2. Tonsillar. 
3. Submaxillary. 
4. Submental. 
5. Inferior and superior labial, or coronary. 
6. Nasal. 
7. Angular. 
On the Face 
The facial arises close to and above the lingual. Its course is flexuously 
inward and upward between the digastric and stylo-hyoid muscles above and 
the mylo-hyoid below. Reaching the angle of the lowe? jaw, it slips beneath, 
or passes through, the substance of submaxillary gland, from which, in turn, 
it reaches the notch in front of the masseter muscle, from which place it con- 
tinues, still in flexuous fashion, first to the angle of the mouth, next to wing 
and side of nose, terminating finally at the inner canthus under the name of 
angular. 
The tortuosity of the vessel increases with age. At the notch the artery is 
sufficiently superficial to have its pulsations distinctly felt. From this place to 
terminus it rests upon the buccinator, orbicular, superior labial elevators, and 
naso-labial elevator muscles. The covering of the artery is by integument 
alone, save at the angle of the mouth, where it passes beneath the platysma 
and zygomatic muscles. 
Surgical Anatomy.-Wounds of the face being of frequent occurrence, 
it is happily the case that hemorrhage is, as a rule, easily controlled by 
pressure made upon the vessel as it lies in the notch of the lower jaw (6), un- 
derstood as being immediately in front of the masseter muscle. The coro- 
nary vessels, inferior and superior labial (8, 9), are easily taken up by evert- 
ing the lip and passing a needle beneath them; their only covering being the 
mucous membrane. In hare-lip operations blood is saved by compressing 
the labial vessels to the outer sides of the cut. Pins inserted in the lip 
for approximation of cut surfaces are to reach deeply with view to making 
compression on the coronaries. Relation of the angular termination to the 
lachrymal sac makes care necessary in incision of the region with view 
to passing the stilette. The vessel is to the nasal side. 
Internal Maxillary.-Branches fourteen in number, divided into three 
sets,-namely, maxillary, pterygoid, and spheno-maxillary: 
1. Tympanic. 
2. Middle meningeal. 
3. Small meningeal. 
4. Inferior dental. 
Maxillary Branches 
r 1. Deep temporal. 
2. Pterygoid. 
3. Masseteric. 
- 4. Buccal. 
Pterygoid Branches ... . 86 
A SYSTEM OF ORAL SUROERY. 
1. Alveolar. 
2. Infraorbital. 
3. Post-palatine. 
4. Vidian. 
5. Pterygo-palatine. 
6. Spheno-palatine. 
Spheno-maxillary Branches 
The importance, and relation, of the internal maxillary artery as regard is 
had to performances in oral surgery make a close study of it desirable. The 
vessel, Fig. 46 (11), starts off from the external carotid artery in the sub- 
stance of, or more likely beneath, 
the parotid gland, through which it 
passes to the under surface of the 
lower jaw at seat of sigmoid notch, 
where it lies between the bone and 
internal lateral ligament. This is 
the first, or maxillary, part of its 
course. The second, or pterygoid, 
part is where it ascends obliquely 
upward to form the infraorbital (17) 
artery. The third, or spheno-max- 
illary, part is where it crosses be- 
tween the two heads of the ptery- 
goideus externus muscle to approach 
and enter the spheno-maxillary 
fossa. 
The artery, at its origin, is of 
considerable size, about three- 
fifths of an inch in circumference, 
and is, as to all its branches, so 
freely furnished with blood 
that wounds of the region are 
usually accompanied with free hem- 
orrhage. The artery supplies the 
deep region of the face, inclusive 
of ethmoidal sinuses, part of the 
pharynx, the dura mater, the an- 
trum of Highmore, and the nasal 
passages. 
Tympanic Branch.-The tympanic branch (12) arises, not infre- 
quently, in conjunction with the deep auricular. It ascends obliquely, 
entering the tympanum through the glenoid fissure. It anastomoses with the 
vidian and stylo-mastoid arteries. 
Middle Meningeal.-This branch supplies the dura mater, reaching its 
seat of distribution by passage through the foramen spinosum. Before enter- 
Fig. 46. 
Internal maxillary artery. 1, right com- 
mon carotid; 2, internal carotid; 3, external ca- 
rotid ; 4, superior thyroid; 5, lingual; 6. facial; 
7, occipital; 8, posterior auricular; 9, parotid 
branch; 10, temporal artery; 11, internal maxil- 
lary ; 12, tympanic; 13, the great and small me- 
ningeal arteries from a common branch; 14, in- 
ferior dental artery; 15, muscular branches; 16, 
superior maxillary, or alveolar, artery giving off 
the posterior dental arteries; 17, 18, infraorbital 
artery. ARTERIES AND VEINS OF FACIAL REGION. 
87 
ing the foramen it gives off the smaller meningeal artery. Within the cranium 
it furnishes a petrosal branch, which passes into and through the hiatus of the 
facial canal, anastomosing with the stylo-mastoid. 
Small, or Lesser, Meningeal.-This supplies the semilunar gan- 
glion of the fifth nerve, together with the brain-case of the middle fossa, and, 
limitedly, the dura mater; the parts being reached by passage through the 
oval foramen. Before entering this foramen the vessel sends twigs of supply 
to the soft palate and to the nasal fossa. 
Inferior Dental.-This branch (14) descends to enter the dental canal, 
commencing at the foramen on the inner face of the ramus of lower jaw. As 
it passes along the channel it gives off twigs to the teeth and bone. Its ter- 
mination is by division into two branches, one, the mental, emerging from the 
foramen of this name and furnishing a quota of supply to the chin, where it 
anastomoses with the inferior labial and submental arteries; the other, the in- 
cisive, continuing forward, through what is called the incisive canal, to supply 
the central lower teeth. Just before entering the posterior foramen a branch, 
called mylo-hyoid, is given off, which vessel, accompanied by the mylo-hyoid 
nerve, enters the groove of the same name, where it distributes, as twigs, to 
the under surface of the mylo-hyoid muscle. 
Deep Temporal.-This is a double branch, called, respectively, anterior 
and posterior. These supply the under surface of the temporal muscle and 
neighboring pericranium. The anterior of the branches anastomose with the 
lachrymal artery through perforations existing in the malar bone. 
Pterygoid.-Branches, fewer or greater in number, constitute the ptery- 
goid ; their supply goes to the pterygoid muscles. 
Masseteric.-This is a small branch furnishing blood to the masseter 
muscle. 
Buccal.-The buccal branch passes between the ramus of the jaw and the 
internal pterygoid muscle ; it supplies the buccinator and anastomoses with the 
facial artery. 
Alveolar.-This and the infraorbital (17, 18) arise out of the internal 
maxillary by a common root. The first descends upon the tuberosity of the 
superior maxilla until reaching the posterior dental canals, which it enters by 
division, one portion going to supply of the posterior teeth, the molars and bi- 
cuspidati, the other to supply of alveolar process and gums. The alveolar anas- 
tomoses well forward with the dental branch of infraorbital, forming thus a 
circle, which is to be esteemed of large consequence as the nutrition of the 
dental organism is concerned. 
Infraorbital.-This, the associate of the immediately preceding artery 
in the supply of the teeth, is seen (17) to enter the infraorbital canal, which 
it does in company with the superior maxillary nerve, along which canal, and 
out of which at infraorbital foramen, it passes to the supply of under eyelid and 
upper lip. In the canal the vessel gives off a branch, the anterior dental, which 
is the one anastomosing, as before referred to, with the posterior dental. This 88 
A SYSTEM OF ORAL SURGERY. 
branch supplies the anterior teeth, the incisors and cuspidati. Other branches 
are given off in the canal, some of which ascend and supply the inferior rectus 
and oblique muscles and the lachrymal gland; others descend to supply the 
mucous membrane of the antrum. Anastomosis is with the transverse facial, 
facial, buccal, and ophthalmic arteries. 
Descending Palatine.-This branch passes along the posterior palatine 
canal in company with nerves from Meckel's ganglion. It comes into the 
mouth at the posterior foramen and runs along a groove sufficiently forward to 
anastomose with the naso-palatine artery, which comes out of the incisive fossa. 
In its course it gives off branches which supply the hard palate, mucous mem- 
brane, palatal glands, and the gums. While in its canal the vessel gives off 
minute branches, which are distributed to the tonsils and nose. 
Vidian.-This branch passes to the supply of the upper part of the 
pharynx and the Eustachian tube, and not infrequently sends a small branch 
to the tympanum. Its passage is through the vidian canal in company with 
the vidian nerve. 
Pterygo-palatine.-This is an unimportant branch, passing backward 
through the pterygo-palatine canal accompanied by the pharyngeal nerve. Its 
distribution is about the pharynx and Eustachian tube. 
Spheno-palatine.-The nasal, or spheno-palatine, branch is the termi- 
nation proper of the internal maxillary. It enters the nose through the spheno- 
palatine foramen, an opening in the posterior part of the middle meatus, where 
it divides into two branches. The internal of these runs along the vomer until 
it meets the descending palatine artery, with which it anastomoses; it supplies 
all the parts entering into composition of the nasal septum. The external 
branch quickly breaks into a number which relate, in distribution, with the 
antrum, the ethmoidal and sphenoidal cells, and with the associated mucous 
membrane of these parts. 
Surgical Anatomy.-Operations on the bones of the face relate 
surgeon and internal maxillary artery. In section of the inferior max- 
illary nerve the accompanying artery, the inferior dental, is almost necessarily 
cut. To control a commonly resulting hemorrhage the plan is adopted of 
whittling a piece of pine stick to a point, and by thrusting this into the 
uncut portion of the canal compress the vessel against the bone. Error 
occurs sometimes, where, in this manipulation, the artery is thrust back instead 
of laterally ; death has resulted. 
Removal of sarcomata of the antrum are attended commonly with free 
bleeding; compresses soaked in styptics are used. 
Polypi of nasal origin may necessitate the cutting off of a blood-supply. 
It is to be remembered that the parts are supplied by the internal max- 
illary artery, and that in turn this vessel is an offshoot of the external 
carotid, which latter vessel can be ligated. 
Ablation in full of a superior maxilla breaks off the main branch of the 
internal maxillary, otherwise severs its branches. The performance requires ARTERIES AND VEINS OF FACIAL REGION. 
89 
to be quickly accomplished that a patient shall not bleed to death. The main 
vessel is to be ligated or compressed, the former preferably. 
This branch, Fig. 45 (13), has origin posteriorly. It is covered, as seen in 
diagram, by the sterno-cleido-mastoid muscle, and, more immediately, by the 
digastric and stylo-hyoid muscles and part of the parotid gland. As it reaches 
outward and upward it crosses the internal carotid artery and the vein and 
nerve associated with it,-namely, the deep jugular and vagus. Reaching the 
interval between the transverse process of the atlas vertebra and the mastoid 
process of the os temporis, it changes its course, turning horizontally backward. 
Its branches are,-1, muscular; 2, auricular; 3, inferior menin- 
geal; 4, princeps cervicis. The last named, the arteria princeps 
cervicis, commands attention by reason of being of an anastomotic relation 
which re-establishes the circulation where the external carotid is interfered 
with. The vessel is of moderate size, arising just beneath the splenius capitis 
muscle, which it supplies by an offshooting twig. From this origin it turns 
downward, passing beneath the complexius and semispinalis colli muscles, 
finally inosculating with the princeps profundus, a branch of the first 
intercostal. A student will find it of equal interest and profit to study 
this collateral circulation on the cadaver. 
OCCIPITAL ARTERY. 
POSTERIOR AURICULAR ARTERY. 
Origin of this branch of the external carotid is opposite the styloid process 
of temporal bone. Its branches are the stylo-mastoid and auricular. Both 
are alike unimportant to the oral surgeon. 
ASCENDING PHARYNGEAL ARTERY. 
This branch arises out of the crotch at which the division of the common 
carotid occurs. It is a long, delicate vessel reaching upward from its place of 
origin to the walls of the pharynx. Its branches consist of three sets,- 
1, prevertebral; 2, pharyngeal; 3, meningeal. The first are distributed to 
the longus colli and anterior rectus capitis muscles, to the lymphatic glands, 
and to the ganglia and nerves of the sympathetic system. Anastomose is with 
branches from the subclavian. These branches are, in a sense, supplemental 
of the princeps cervicis. The second, the pharyngeal, assists in the supply of 
the mucous membrane of the pharynx, the Eustachian tube, the soft palate, 
the levator palati muscle, and the tonsil gland. The third, the meningeal, 
passes through the posterior lacerated and the anterior condyloid foramina to 
supply the dura mater of brain. 
The temporal is a continuation upward and the termination of the ex- 
ternal carotid. It commences in the parotid gland, or beneath it, 
TEMPORAL ARTERY. 90 
A SYSTEM OF ORAL SURGERY. 
side by side with the internal maxillary, the location being the inter- 
space existing between the condyloid process of the inferior jaw and the 
external auditory meatus. Crossing the zygoma in its ascent it gives off the 
supraorbital (22), and a very little above this (23) the middle temporal; still 
higher the vessel divides into an anterior branch (24) and a posterior (25). 
The divisions and subdivisions of these branches are so fully displayed as to 
render addition to the text unnecessary. Attention is to be directed to trans- 
verse facial (20). 
Surgical Anatomy.-For this anatomy, accompanied with illustrations 
of operations required for exposure of arteries above described, see chapter on 
Ligation. 
INTERNAL CAROTID ARTERY. 
The internal of the primitive divisions of the common carotid artery as- 
cends almost vertically from place of origin to the carotid canal of the 
temporal bone, which it enters, passing to and along the cavernous groove 
until, reaching the position of the anterior clinoid process, it turns abruptly 
upward, pierces the dura mater, and terminates at the Sylvian fissure in an 
anterior and a posterior division, both of which enter into the composition of 
the circle of Willis. (See Fig. 47.) 
Glancing at the diagram (Fig. 45), the internal is seen to lie behind the 
external carotid and to be more directly overlain by the sterno-mastoid muscle 
than is its fellow. Passage of the vessel is behind, yet close to, the condy- 
loid process of the lower jaw, at which point it becomes lost to sight as to 
a superficial dissection. Back of the artery is the deep jugular vein, and 
enclosed in a common sheath with the two is the pneumogastric nerve. 
The vessel rests upon the anterior rectus capitis, and has the tonsil 
gland resting on it in turn at the inner side. Three muscles overlie and cross 
it,-the digastric, the stylo-hyoid, and stylo-pharyngeus. The hypoglossal 
and glosso-pharyngeal nerves and the pharyngeal branch of the pneumogastric 
lie forward, and externally, to it. 
Where the vessel lies in the carotid groove it is accompanied 
by a plexus of the sympathetic nervous system called after its name. 
A plexus of veins which communicates with the cavernous sinus above sepa- 
rates the artery from an underlying periosteum. 
The internal carotid is to be divided into four portions,-cervical, 
petrous, cavernous, and cranial. These divisions are expressive of 
the various localities occupied by the vessel and assist in the memorizing of 
relations. 
The cervical portion extends from place of origin of the vessel at seat 
of division of common carotid (see Fig. 45) to the carotid foramen. At seat 
of origin it is comparatively superficial, being external to the second division 
and covered above by skin, superficial and deep fasciae. The internal border 
of the sterno-cleido-mastoid muscle, while partially overlying it, is yet easily ARTERIES AND VEINS OF FACIAL REGION. 
91 
and simply pushed aside. As the vessel rises in the neck it passes deeper. 
Where it approximates the tonsil gland the two are in a relation suggestive 
of caution in the use of vulsellum for pulling the gland into the fenestra of a 
Fig. 47. 
Arteries of the interior of the cranium. 1, internal carotid arteries; 2, oph- 
thalmic artery; 3, posterior communicating arteries; 4, anterior cerebral arteries; 5, 
anterior communicating artery; 6, middle cerebral arteries; 7, lachrymal artery; 8, 
short ciliary arteries piercing the back part of the eyeball; 9, central retinal artery 
piercing the optic nerve to reach the interior of the eyeball; 10, muscular artery; 11, 
frontal and nasal arteries; 12, vertebral arteries; 13, posterior meningeal artery; 14, pos- 
terior spinal artery; 15, anterior spinal arteries conjoining in a single one; 16, inferior 
cerebellar arteries; 17, basilar artery formed by the union of the vertebrals; 18, internal 
auditory artery; 19, superior cerebellar artery; 20, posterior cerebral arteries. 
tonsillitome. Behind the jaw the artery is in relation with the condyle. The 
deep jugular vein, which accompanies, lies behind. It is rare that offshoots 
from the vessel relate with the cervical portion. 
The petrous portion relates with entrance and exit into and from the 
carotid canal, the locality of which is the petrous portion of the temporal 
bone; a tympanic branch is given off. 
The cavernous portion designates locality, as the artery lies in the 
sigmoid groove to the side of the body of the sphenoid bone. Branches given 
off are the arteria receptaculi, numerous twigs which supply the pituitary 
and Gasserian bodies and the walls of the cavernous and petrosal sinuses; the 
ophthalmic, which arises from the vessel just as it ceases to be of cavernous 92 
A SYSTEM OF ORAL SURGERY. 
location and passes to the eye in connection with the optic nerve; and the 
cerebral portion, which is the continuation of the vessel beyond a slit in 
the dura mater that admits it to the base of the brain, where it breaks up into 
terminal parts known as anterior cerebral, posterior communicating, middle 
cerebral, and anterior choroid arteries. (See Fig. 47, 4, 3, 6.) The last named 
is not marked, but has origin alongside of the posterior communicating. 
The ophthalmic, of cavernous portion, breaks up into twelve 
parts, seven of these being classed as an orbital group, five as an ocular 
group. The names of these are as follows: 
Lachrymal. 
Supraorbital. 
Posterior ethmoidal. 
Anterior ethmoidal. 
Palpebral. 
Frontal. 
Nasal. 
Orbital Group 
Muscular. 
Short ciliary. 
Anterior ciliary. 
Long ciliary. 
Retinal central. 
Ocular Group 
The parts to which these various branches are distributed find full locating 
in the naming. (See General Anatomy.') 
The cerebral branches are to find localization by reference to Fig. 47 
and the descriptive text. The anterior (4) arises at the inner extremity 
of the fissure of Sylvius, passes forward between the two anterior 
lobes of the brain to reach the front boundary of the corpus callosum, around 
which it curves, running backward to the posterior boundary, where it is lost 
through communication with the posterior cerebral artery of its side (20). 
The two anterior vessels communicate (5) shortly beyond their seat of origin. 
The supply from them is to the olfactory and optic nerves, to the under 
surface of the third ventricle, the anterior perforated spaces, the 
corpus callosum, and the inner faces of the hemispheres. 
The posterior communicating branch is of close relation with the 
anterior vessel. It runs, as seen (3), directly backward, communicating with 
and losing itself in (20) the posterior cerebral artery, which is a branch of the 
basilar. 
The middle branch (6) reaches outward obliquely along the fissure 
of Sylvius, at which locality it divides into branches which supply the pia 
mater, the middle cerebral lobe, and the small lobe at the extremity of the 
fissure. Other twigs enter the perforated space to supply the corpus cal- 
losum. 
Surgical Relations of Carotids proper.-Ligation of carotids 
proper is indicated where no other means exist of controlling hemor- 
rhage related with them. The performance is one easy of execution. In ARTERIES AND VEINS OF FACIAL REGION. 
93 
cut-throat, if time and circumstances permit, the vessels are to be taken up in 
the wound. In ordinary cases the superior cervical triangle is the seat of 
election. This triangle is that portion of the neck bounded above by the base 
of the lower jaw, posteriorly by the sterno-cleido-mastoid muscle, and inter- 
nally by the omo-hyoid muscle. The arteries here, primitive and primary 
divisions, lie comparatively superficial, being covered simply by skin, super- 
ficial and deep fasciae. Below the omo-hyoid, beside the integument and 
fasciae, the sterno-mastoid and sterno-thyroid and hyoid muscles overlie, and 
require to be separated in order that the primitive be reached. An interspace 
separating these muscles is easily made out by remarking the line of the fibres, 
those of the first-named muscle running obliquely upward and obliquely out- 
ward, those of the others passing directly vertical. 
In placing a ligature about a carotid it is necessary to bear in mind 
its immediately neighboring relations, which see. 
Position of patient is upon his back, with the side to be operated on up- 
ward. Incision to be from two to three inches in length, and made oblique to 
the line designative of locality. (See Ligation of Arteries.} 
VENOUS CIRCULATION OF THE HEAD AND NECK. 
Although veins commence where arteries terminate, study of them is most 
conveniently and satisfactorily made by beginning with the vena cavae, which 
vessels correspond with this system, as does the aorta with the arteries. 
Reference to Fig. 43 (12) shows the position and relation of the superior 
cava as it associates with the right auricle (3) of the heart. Into this vessel, 
which is between two and three inches in length and of nearly common 
diameter with the aorta, all the blood coming from the head is poured. Ob- 
serving the diagram, the cava is seen to be the result of junction of two 
vessels above it,-namely, the right innominate and transverse veins. 
To appreciate the venous circulation of the facial region it is necessary to 
study it in association with the circulation of the head at large. This circu- 
lation, which terminates at the superior vena cava as being the inferior and 
the receptive vessel of all above it, is to be divided, primarily, into superficial 
and deep, and, secondarily, into regions or groups. 
The superficial circulation comprises the veins of the temple, face, 
post-auricular, and occipital localities. 
The deep circulation embraces the vessels of the encranial and max- 
illary regions. 
Anastomosis fairly unites the two sets of vessels, making of the 
whole practically a common circulation. 
VENA CAVA SUPERIOR. 
The superior cava (Fig. 43) is a type of veins at large. It is tubular in 
form, although not absolutely cylindrical. It is made up of coats correspond- 94 
A SYSTEM OF ORAL SURGERY. 
ing imperfectly with those of the arteries,-first, internally, an epithelial 
layer; second, externally, an areolar fibrous sheath; and, third, mesially, a 
muscular layer, which last varies to such extent in veins at large that 
while, in the vena cava, the fibres are abundant, in a multitude of other 
veins, as those of the dura mater, the retina, the cancellous tissue of bones, 
etc., the layer is absolutely lacking, making the vessel to consist alone of an 
internal and external coats. Valves, common to most veins, are lacking in 
the vena cava. The office of a valve is to prevent reflux of the blood. 
Valves are not so abundant in the veins of the head as of parts of the body 
inferior to the heart, as, below, an office with them is to assist in supporting 
the column of blood. 
The veins immediately communicating with the superior cava are known as 
innominate. (See Fig. 43, 5, 6.) 
Innominate Veins.-The innominate veins are two in number,-right 
and left; the diagram exhibits them. Beginning, from above downward, 
is where the jugulars relate with the subclavian. Termination is at 
position of junction with the vena cava. Veins entering the innominate, be- 
sides those just named as forming them, are the vertebral, inferior thyroid, 
and mammary. The innominate are destitute of valves. 
Right.-The vein of the right side (5) is about an inch in length, and 
descends to the right of its corresponding artery. 
Left.-The left vein corresponds with what is usually described as the 
subclavian. It is some three inches in length. (See Subfig. 6.) 
Thoracic Ducts.-These ducts, which are carriers of chyle, are described 
variously as pouring their contents into the subclavian or innominate veins. 
The place of relation with the afferent circulation is directly alongside, or a 
little to the outer side, of the jugular veins. (See Lymphatics.} 
JUGULAR VEINS. 
Jugular veins are commonly classified as the external, internal, ante- 
rior, and posterior. The second named is of particular importance; the 
first named is to be cut or ligated with considerable impunity ; the other two 
are unimportant. The external and internal, to which attention is required, 
are made up of tributaries coming from regions above and lateral to them. 
As seen in the diagram, the deeper is the larger of the two. Its relations in 
the neck correspond closely with those of the primitive carotid artery, side by 
side with which it lies, enclosed in a common sheath. The external, or super- 
ficial, vessel is accommodated between the layers of the superficial fascia, being 
covered alone by platysma and integument. The latter not infrequently unites 
with the former in the common descent of the two toward the innominate 
vein. 
External Jugular.-The external jugular vein, Fig. 49, (13), has its 
tributaries in the vessels of the exterior of the cranium and those corre- ARTERIES AND VEINS OF FACIAL REGION. 
95 
spending with the circulation of the internal maxillary artery. The branches 
converging to form it are as follows: 8, anterior temporal vein ; 10, transverse 
facial; 12, posterior auricular; 11, internal maxillary; and 14, 15, certain 
superficial cervical veins known as anterior and posterior jugulars. The termi- 
nation of the vessel is in the innominate, otherwise in the deep jugular. The 
line of the vessel is from the angle of the jaw to the middle of the clavicle. 
It has two sets of valves, one of which, situated at place of termination, is 
imperfect, the other, higher up, is complete. To get from its superficial 
position to place of relation beneath the vessel pierces the deep fascia just 
above the clavicle. Commencement of the external jugular is in the 
substance of the parotid gland. 
FORMATIVE BRANCHES. 
Temporal.-This vein arises by two main branches,-anterior (8) and 
posterior (9). As seen in the diagram, the tributaries relate with the scalp 
at large, relation existing with the orbital angular vein and supraorbital in 
front and with the posterior auricular behind. Indirectly it has association, as 
seen, with the post- and suprascapular veins below. The temporal vein passes 
over the zygoma, but beneath the parotid, as it descends. A middle tem- 
Fig. 48.-Deep Venous Circulation of Facial Region. 
poral (4), derived from a plexus of the temporal fossa communicating with 
deep temporal veins, is a tributary; also certain auricular veins coming 
from a plexus about the pinna; also branches from the condyloid articular 
plexus. 96 
A SYSTEM OF ORAL SURGERY. 
Internal Maxillary.-Fig. 48 is illustrative of an admirable dissection 
showing the main branches of the internal maxillary vein, together with its 
relation to the ophthalmic vein (I) and the facial (II). The numerals III mark 
Fig. 49.-Veins of the Face. 
Veins of the head and neck. 1, frontal vein; 2, nasal vein; 3, 4, labial veins; 5, 
facial vein; 6, lingual vein; 7, internal jugular vein; 8, 9, posterior and anterior tem- 
poral veins; 10, transverse facial vein; 11, internal maxillary vein; 12, posterior auricular 
vein; 13, external jugular vein; 14, posterior, 15, anterior jugular veins, a, external 
carotid artery; &, sterno-mastoid muscle; c, trapezius; d, pectoral muscles; e, deltoid 
muscle. 
seat of and manner of relation of the vein with the jugular, a is the antrum 
of Highmore. The offshooting vessels find description in correspondence with 
arterial distribution of the parts. 
The internal, or deep, maxillary is, in its origin, a series of veins collecting ARTERIES AND VEINS OF FACIAL REGION. 
97 
the blood from the parts supplied by the internal maxillary artery and from 
adjacent localities. These various veins,-the middle meningeal, deep temporal, 
pterygoid, masseteric, buccal, and inferior dental,-forming the common trunk, 
empty into the external jugular, otherwise into the temporal. 
Internal Jugular.-This, as referred to, has its origin in the lateral and 
petrosal sinuses of the dura mater. (See Fig. 50.) As it descends it receives, 
as tributaries (Fig. 49), the 
pharyngeal, lingual (6), fa- 
cial (5), superior and middle 
thyroids, and the occipital. 
It empties into the innomi- 
nate vein. The valve is likely 
to be single. The vein in- 
creases in size at seat of con- 
fluence with the facial, but 
is found lessened in diame- 
ter near termination. 
At place of origin the 
jugular internus is situated 
back of its corresponding 
carotid artery. It rests 
upon the rectus capitis and 
lateralis muscles. It next 
passes to the side of the 
artery, being in close re- 
lation with the ninth and 
twelfth nerves. The vagus 
nerve is between it and the artery. On reaching the common carotid the 
vein lies to its outer side, the pneumogastric nerve continuing between the 
two. 
Facial Branch.-The facial (5), commencing at the inner angle of the 
orbit, is formed by the confluence of vessels from the supraorbital, palpebral, 
nasal, and angular regions. It commences its course downward and outward, 
passing beneath the zygomatic muscles, taking the superior and inferior lip 
veins, the buccal, and the masseteric; passes to the base of the jaw, receiving 
just below it the circulation from the submental, the inferior palatine, the sub- 
maxillary, and the ranine localities, and, finally, with a great branch, received 
from the temporo-maxillary vein, loses itself in the deep jugular. 
Thyroid Branches.-These collect the blood from the thyroid gland. 
Lingual Branch.-The radicles of this branch commence on the dorsum, 
sides, and under surface of the tongue. 
Pharyngeal Branch.-This has origin in a minute plexus at the back 
and sides of the pharynx; it receives twigs from the vidian and spheno-palatine 
veins. 
Fig. 50. 
Vertical section of the skull, exhibiting the sinuses 
of the dura. 1, superior longitudinal sinus; 2, termination 
of the superior cerebral veins; 3, inferior longitudinal 
sinus; 4, internal cerebral veins; 5, straight sinus; 6, 7, 
superior and inferior petrosal sinuses of the right side; 
8, right lateral sinus; 9, commencement of the left lateral 
sinus; 10, internal jugular vein, a, cerebral falx; &, ten- 
torium; c, cerebellar fossa; d, partition of the nose; e, 
frontal sinus; f, sphenoidal sinus. 98 
A SYSTEM OF ORAL SURGERY. 
Fig. 51, a dissection after Allen, showing in minute detail the temporo- 
maxillary vein and its tributaries, is to be accepted as being as nearly perfect 
as skill and time could make it. 
Fig. 51.-View of the Kegion of the Temple, etc., designed espe- 
cially TO SHOW THE TEMPORO-MAXILLARY VEIN AND ITS TRIBUTARIES. 
(After Allen.) 
A, temporal vein receiving the anterior and posterior temporals B, C; D, D, the internal 
maxillary veins, emptying into the temporal to form the temporo-maxillary vein; E, the 
middle temporal vein (slightly enlarged), to display which the deep temporal fascia over 
it has been removed ; F, the facial vein ; G, the supraorbital branch, uniting with the 
middle temporal vein; H, the inferior palpebral vein, uniting with the same; I, the mas- 
seteric vein; J, the parotid vein; K, the socia parotidis; L, the parotid duct; M, the ex- 
ternal jugular vein; N, the temporal vein. CHAPTER IV. 
LYMPHATIC VESSELS AND GLANDS OF THE HEAD. 
The lymphatics of the head are alike with all others of this system in that 
their office is to carryback into the circulation any excess of pabulum exuded 
by the capillaries. 
Fig. 52. 
Lymphatics of the head and neck. 1, facial lymphatics; 2, temporal lymphatics; 3, 
posterior auricular and occipital lymphatics; 4, cervical lymphatics; 5, the right lym- 
phatic duct; 6, internal jugular vein; 7, subclavian vein. 
The system consists of vessels and glands. The former are of great tenu- 
ity, being transparent to an extent that permits sight of their contents. They 
99 100 
A SYSTEM OF ORAL SURGERY. 
are beaded as to appearance, being interrupted in their course by constric- 
tions representing valves. The fluid carried by them is watery in appear- 
ance, hence its name, lympha, water. The glands of the system, named also 
conglobate, are bodies of varying size situated in the course of the vessels. 
A lymphatic vessel, before entering a lymphatic gland, breaks up into several 
branches which are known as afferent. The vessels, as they leave the gland, 
are called efferent. Fig. 52 affords clear idea of general appearance of the 
lymphatic system as it relates with the head. 
Lymph.-Examined with a microscope lymph is seen to differentiate itself 
into a clear liquid and corpuscles. The latter are most plentiful in the vessels 
as they emerge from the glands, signifying, as is to be inferred, that with these 
bodies is their source. Figs. 53, 54, exhibit lymph-corpuscles highly magni- 
fied. Lymphatics commonly accompany blood-vessels, and are to be esteemed, 
in office, as supplemental to veins, in that where the one fails the other 
may be expected to accomplish. Lymph resembles blood-plasma. 
Lymph-corpuscles, highly magnified. 1, 
corpuscle at rest; 2-10, in movement, ex- 
hibiting projections of the protoplasm called 
pseudo-pods; b, one which has assumed a 
stellate shape. 
Lymph-corpuscles, more highly magnified, 
and observed at the temperature of the body, 
exhibiting the changes of shape in move- 
ment. 
Vessels.-A lymphatic vessel differs from a vein as to its coats as does 
the vein from an artery. Arteries, veins, and lymphatics have three coats of 
similar signification,-namely, an external, fibro-cellular; a middle, muscular; 
and an internal, endothelial. In the lymphatic the coats combined are of such 
delicacy as to pass the system unobserved in an ordinary dissection. 
Lymphatic vessels commence in intricate plexuses in connection with 
the terminal radicles of the blood-vessels. Their course, like that of the veins, 
is toward the circulatory centre, all lymph being poured into the subclavian 
veins, thus reaching the heart fully mixed with the efferent flux. The ter- 
minal trunks of the lymphatic system are known as the thoracic and 
right lymphatic ducts. The first is the more prominent and longer, re- 
ceiving all the vessels from the left side of the body and those from the lower 
half of the right side. The latter is a tube about an inch in length and the ninth 
of an inch in diameter; it receives the lymph from the right side of the head. LYMPHATIC VESSELS AND GLANDS OF THE HEAD. 
101 
Glands.-The lymphatic glands are oval in shape, somewhat flattened, 
slightly reddish in color, and vary in size from a small seed to an almond. 
A gland consists of a cortical portion, or coat, of a light color and of an inner 
medullary part. It is invested with a capsule of fibro-connective tissue, 
which extends as a trabicular framework, accommodating in the interspaces the 
substance proper of the gland. (See General Anatomy.') Fig. 55 shows 
lymphatic vessel, laid open, and arrangement of its valves. 
Fig. 55. 
A lymphatic vessel, laid open, exhibiting the arrangement of its valves: magnified. 
Fig. 56 shows lymphatic afferent and efferent vessels, together with glandu- 
lar entrance and exit. 
Fig. 57 shows lymphatic gland in section. 
Fig. 56. 
Fig. 57. 
A small lymphatic gland, in section. «, the fibro- 
connective-tissue capsule; b, partitions of the same; 
d, nodules or follicles of lymphoid tissue of the cor- 
tex ; e, bars of the same tissue of the medulla; f, affe- 
rent vessels opening into lymph-spaces; c, g, efferent 
vessels converging to a single vessel, h, passing out at 
the hilus of the gland : magnified. 
Lymphatics of Head, Face, and 
Neck.-The lymphatics of the head ar- 
range themselves under the two divis- 
ions of superficial and deep. The first 
are a single set, the second double. 
Superficial Glands.-The superficial glands are classed as those of the 
cranium, those of the face, and those of the neck. 
Lymphatic gland and vessels. 1, 
lymphatic gland; 2, afferent vessels: 
3, efferent vessel. 102 
A SYSTEM OF ORAL SURGERY. 
Deep Glands.-The deep, like the superficial, relate with a threefold 
division. 
Superficial of Cranium.-These are few in number. They have loca- 
tion at the back of the head along the line of origin of occipito-frontalis muscle, 
extending outwardly to the neighborhood of the mastoid process, being found 
at the latter locality in greatest abundance. The vessels accompany the occipi- 
tal artery, gaining the cervical lymphatics indirectly through the medium of 
the auricular lymphatics. 
Superficial of Face.-These commence with what are termed by many 
the anterior cranial lymphatics. This temporal set accompany the ramifica- 
tions of the temporal artery, descending upon the lateral region of the face 
to relate with the parotid lymphatic glands, from which they proceed to the 
lymphatics of the neck. The superficial lymphatics of the face proper cover 
its entire surface, although the glands are not numerous. They are to be 
described as commencing with the frontal region, whence they accompany the 
arteries joining the facial vein, passing through the buccal glands upon the 
surface of the buccinator muscle, and finally joining the submaxillary glands. 
The vessels of this group relate lips and submaxillary region, hence explanation 
of affection of cervical glands in cancer of the lip. 
Superficial of Neck.-These are found on the line of the external 
jugular vein. They are continuous below with the axillary glands. Inter- 
mediate to origin and termination, they are most numerous in the interval 
between the clavicular attachment of the sterno-mastoid and the trapezius 
muscles. A few glands are met with on the sides of the larynx. 
Deep of Cranium.-The deep lymphatics of the cranium consist of 
two sets,-meningeal and cerebral. The first accompany the meningeal ves- 
sels, joining the deep cervical by escape through foramina at the base of the 
skull. The second commence between the arachnoid and pia mater and in 
the choroid plexuses of the lateral ventricles. They terminate in the deep 
cervical lymphatics by means of passage through cranial foramen. Their 
relation is with the carotid and vertebral arteries. 
Deep of Face.-The deep lymphatics of face associate as to origin with 
the Schneiderian membrane, the mucous membrane of mouth and pharynx, 
and the structures lying in the temporal and orbital fossae. They terminate 
in the deep parotid and cervical lymphatic glands. 
Deep of Neck.-These are numerous, of large size, and continuous as 
forming a chain which relate closely with the sheath holding carotid artery 
and vein. They lie along the pharynx, oesophagus, and trachea, and reach 
from the base of the skull to the chest, the lymphatics of which they join. 
Regions and Number of Glands.-Parotid region, four or five; 
mastoid region, four or five; submaxillary region, eight to ten; superficial 
cervical region, four to six; deep cervical region, twenty to thirty. CHAPTER V. 
THE FACIAL NERVE. 
Fig. 58.-Facial, or Motor, Nerve. 
1, trunk of the nerve emerging at the stylo-mastoid foramen; 2, its deep auricular 
branch ; 3, anastomosis of the latter with the great auricular nerve of the cervical plexus; 
4, 5, 6, branches to the contiguous muscles; 7, 8, branches of the facial to the digastric 
and stylo-hyoid muscles; 9, temporo-facial division of the nerve; 10, branch to the 
temple, anastomosing with the auriculo-temporal nerve; 11, temporal branches; 12, 
zygomatic branches; 13, infraorbital branches; 14,15, cervico-facial division of the facial 
nerve; 14, buccal branches; 16, inferior maxillary branches; 17, cervical branches; 18, 
auriculo-temporal nerve; 19, 20, terminal branches of the frontal nerve; 21, terminal 
branch of the lachrymal nerve; 22, external nasal nerve; 23, branch of the temporo- 
malar nerve; 24, terminal branch of the internal nasal nerve; 25, infraorbital nerves; 
26, anastomosis between the buccal branch of the inferior maxillary nerve and the 
buccal branches of the facial nerve; 27, terminal branches of the inferior dental nerve; 
28, great occipital nerve; 29,31, branches of the great auricular nerve; 30, small occipital 
nerve; 32, superficial cervical nerve, anastomosing with the facial nerve. 
103 104 
A SYSTEM OF ORAL SURGERY. 
The facial nerve, in the order of its emergence from the base of brain, is 
distinguished as the seventh. (See Fig. 58, 29.) It is also known as the 
portio dura, to demark it from a soft portion of a nerve with which it 
is connected, called portio mollis. As seen in its origin, it arises from 
a depression separating the olivary and restiform bodies of the medulla 
oblongata. 
Passing from seat of origin the nerve enters the internal auditory meatus. 
At the bottom of this meatus it leaves the auditory, or portio mollis, nerve, 
with which it has closely related,-a slip, the nerve of Wrisberg, portio inter 
dusam et mollem, as it is called, joining the two,-entering the facial, or Fallo- 
pian, canal, and, later, emerging from it through the foramen of outlet. The 
course of the nerve in the canal corresponds with its winding character. 
Nearing the foramen it makes an abrupt turn backward toward the supra- 
promontory of the tympanum, turning here downward and reseeking the 
orifice of exit. 
This nerve, as a direct associate of the trifacial, is one of large impor- 
tance in oral surgery. It is the nerve of motion to the face, the offices of 
expression being accomplished by means of it. It is subject to accidents 
arising out of operations performed upon the region, and for this reason is to 
have its position accurately located. 
The diagram shows the nerve (1) as emerging from the foramen of the 
facial canal-stylo-mastoid foramen-and appearing upon the face back of the 
lower jaw and just below the ear, where a short trunk is seen quickly to break 
up into three principal divisions, which, in their subdivisions, are distributed 
to the muscles at large of the face. The trunk enters the parotid gland and 
its divisions occur in this body. The divisions are known, respectively, as 
temporo-facial and cervico-facial. The joining of the various subdivisions 
constitutes what is called the parotid plexus. These subdivisions relate the 
facial with the fifth nerve, thus forming a circle of sensory motor character. 
(See Fig. 58.) 
The wide and important relations of the facial nerve are most easily appre- 
ciated if placed in tabulated form. 
FIRST, NERVES OF COMMUNICATION. 
1. In the Auditory Meatus With the auditory nerve. 
2. In the Facial Canal 
With the otic ganglion of fifth nerve. 
With the sympathetic. 
With the pneumogastric. 
With the glosso-pharyngeal. 
With the carotid plexus. 
With the great auricular. 
With the auriculo-temporal. 
3. At Place of Exit from Facial Canal, 
4. On the Face With the three divisions of fifth nerve. THE FACIAL NERVE. 
105 
SECOND, NERVES OF DISTRIBUTION. 
1. Within Facial Canal 
Tympanic. 
Chorda tympani. 
Posterior auricular. 
Digastric. 
Stylo-hyoid. 
2. At Stylo-mastoid Foramen .... 
Temporo-facial 
Temporal. 
Malar. 
Infraorbital. 
3. On the Face 
Cervico-facial . 
Supramaxillary. 
Inframaxillary. 
Cervical.*' 
Tympanic* Branch.-Supplies the stapedius muscle. Origin is 
opposite the pyramid. 
Chorda Tympani.-Constitutes the motor branch of submaxillary gan- 
glion. Supplies the lingual muscle. Communicates with the gustatory 
nerve. Origin is from the facial about a quarter of an inch back of exit 
from stylo-mastoid foramen. 
Posterior Auricular.-Communicates with the auricularis magnus. 
Supplies the posterior ear muscle and neighboring integument and the 
occipital portion of occipito-frontalis muscle. Origin is just back of the exit 
foramen. 
Digastric.-Communicates with the glosso-pharyngeal nerve. Sup- 
plies posterior fleshy portion of digastric muscle. 
Stylo-hyoid.-Communicates with carotid plexus. Supplies stylo- 
hyoid muscle. 
Temporal.-Communicates with auriculo-temporal branch of inferior 
maxillary, with the temporal branch of superior maxillary, and with the 
supraorbital branch of ophthalmic nerve. Supplies the integument and 
attrahens aurem muscle and the frontal portion of the occipito-frontalis muscle. 
Malar.-Communicates with lachrymal and supraorbital branches of oph- 
thalmic nerve, and with malar branches of superior maxillary nerve. Sup- 
plies the orbicularis palpebrarum and corrugator supercilii muscles. 
Infraorbital.-Communicates with the infratrochlear and nasal branches 
of ophthalmic and with the infraorbital branches of superior maxillary nerve. 
Supplies the zygomatic, the levator labi proprius, the nasal compressor and 
elevator, the levator anguli oris, the buccinator muscles, and the integument 
of the face. The infraorbital is made up of two branches. 
Cervico-facial.-Communicates with auricularis, with cervico-facial di- 
vision of the nerve, and with the inferior maxillary nerve through its buccal 
and inferior dental branches. Supplies orbicularis oris, buccinator, platysma, 
depressor anguli oris, and superior labial elevator muscles. 
* After Gray. CHAPTER VI. 
FIFTH PAIR OF NERVES. 
Fig. 59.-Outline Drawing exhibiting at a Common View the Distri- 
bution of the Fifth Pair of Nerves. 
This nerve, the largest of the cranial group, is chief in importance of its 
system to the oral surgeon. A student, in order to a proper comprehension 
106 FIFTH PAIR OF NERVES. 
107 
and appreciation, is to begin the study of it with origin and end with the 
terminal distributions. 
First, attention is to be directed to the outline drawing (Fig. 59) with view 
to obtaining idea of the general position and relation of the nerve. Beginning 
at the ganglion of Gasser, the direction of the three primary divisions- 
namely, the ophthalmic, the superior maxillary, and inferior max- 
illary branches-is to be impressed on the mind, while, as well, such other 
information is to be secured as lies with the picture. 
The immediately succeeding diagram (Fig. 60) is a study of origin and 
primary relation. The picture shows the base of a brain and the exit 
Fig. 60. 
Base of the brain. 1, frontal lobes of the cerebrum ; 2, temporal lobes; 3, occipital 
lobes; 4,5, anterior and posterior extremities of the great longitudinal fissure; 6, Sylvian 
fissure; 7, anterior perforated space; 8, infundibulum; 9, mammillary eminences; 10, 
posterior perforated space ; 11, crura of the cerebrum; 12, pons; 13, oblongata; 14, pyra- 
mid ; 14*, decussation of the pyramids; 15, olive; 16, restiform body; 17, hemispheres of 
the cerebellum; 18, vermis at the bottom of the valley separating the latter; 19, middle 
peduncle of the cerebellum; 20, floccule; 21, fissure which accommodates the olfactory 
lobe, 22; 23, bulb of the olfactory lobe; 24, optic commissure; 25, oculo-motor nerve; 26, 
trochlear nerve; 27, trifacial nerve;. 28, abducent nerve; 29, facial nerve; 30, auditory 
nerve; 31, glosso-pharyngeal nerve; 32, vagus nerve; 33, accessory nerve; 34, hypoglossal 
nerve. 
therefrom of the twelve cranial nerves. The origin of each nerve is accurately 
presented, and each set is to be located by relating figure and description. 
Figure 23 points out the position of the first, or olfactory, nerve, figure 108 
A SYSTEM OF ORAL SURGERY. 
27 the fifth, or trifacial, and figure 34 the twelfth, or hypoglossal, nerve. 
The remaining nine nerves are found placed between these named. 
The fifth nerve is, as appreciated, one of the cranial set,-that is, it 
comes off from that portion of the cerebro-spinal centre lying within the 
cranium, Fig. 60 (27). It is called the fifth, because this is its order of 
Fig. 61.-Trifacial Division and Ganglion. 
Trifacial nerve, the upper part of the orbit and temporal fossa removed. 1, semi- 
lunar ganglion; 2, ophthalmic nerve; 3, lachrymal nerve; 4, frontal nerve; 5. 6, its two 
principal branches; 7, a branch passing from the orbital above the pulley of the superior 
oblique muscle; 8, nasal nerve; 9, its external nasal branch ; 10, course of the internal 
nasal nerve from the orbit into the cranium and nose; 11,12,13, temporal branches of the 
inferior maxillary nerve; 14, commencement of the auriculo-temporal nerve; 15, greater 
petrosal nerve. I, olfactory nerve; II, optic nerves; UI, oculo-motor nerve; IV, pathetic 
nerve to the superior oblique muscle of the eye; V, trifacial nerve; its small root visible 
beneath the cut end of the large root, which forms the semilunar ganglion dividing into 
the ophthalmic, superior, and inferior maxillary nerves; VI, abducent nerve; VII, facial, 
included in a groove of the auditory nerve, VIII, both entering the auditory meatus; 
IX, glosso-pharyngeal, X, pneumogastric, and XI, accessory nerves emerging at the jugu- 
lar foramen; XII, hypoglossal nerve. 
emergence; called also trifacial, because it divides into three portions, 
which portions, in their divisions and subdivisions, are distributed respectively 
to the superior, middle, and inferior portions of the facial region; also " tri- 
geminus," a name derived from tri, three, geminus, twin, or double, sig- 
nifying literally three double, triple, referring to its threefold division. 
The fifth, trifacial, or trigeminus, is first discovered as a number of filaments, 
of which there are two distinct sets, coming off from the sides of the pons FIFTH PAIR OF NERVES. 
109 
Varolii, Fig. 60 (12) ; this is called the superficial origin of the nerve. The 
deep, or true, origin is to be traced into the substance of the pons far as the 
lateral tract of the medulla oblongata (13). These filaments of origin are 
called the roots of the nerve, and, being twofold, afford a likeness that 
exists between this particular encephalic nerve and those of the spinal cord. 
The fifth nerve is peculiar in being both compound and special,- 
that is to say, it supplies parts with filaments of sensation, with filaments of 
motion, and, through one of its branches, the " gustatory," with filaments 
which pertain to the sense of taste. It is the great sensitive nerve of the head 
and face ; the nerve of motion to the muscles of mastication ; a nerve of special 
sense to the anterior part of the tongue. (See Function of Nerve.') 
Immediately on the emergence of the roots from the points of their super- 
ficial origin, they pass through a slit-like opening in the dura mater at the apex 
of the petrous portion of the temporal bone. (See Fig. 61, 2.) Here the 
larger root, called the sensor, enters a ganglion, the Gasserian, or semilunar, 
lying in a fossa on the anterior face of this triangular apex. 
The ganglion of Gasser, or of Casserio, as is deemed by some to be its proper 
naming, is a small reddish-gray semilunar knot enveloping apparently the great, 
or posterior, root of the fifth nerve as it passes over the temporal apex; its 
size is about equal to that of an ordinary buckshot, although, from its flattened 
and crescentic form, the measurement from tip to tip of its horns would surpass 
somewhat the diameter of such a shot. The convex face of the ganglion looks 
forward. 
On emerging from this ganglion, the posterior root is found divided into 
three cords,-the three primary divisions of the sensitive portion. The 
first of these cords constitutes what is known as the ophthalmic nerve, or the 
ophthalmic portion, or division, of the fifth nerve. The second cord is the 
superior maxillary nerve, or superior maxillary division of the fifth. 
The third is the inferior maxillary nerve. 
The first of these nerves, or divisions, has its distribution over the orbito- 
frontal region. 
The second is distributed over the superior maxillary region. 
The third associates with the lesser, or motor root, which root first con- 
nects with it at the base of the skull, and finds its office in the inferior maxil- 
lary region. 
OPHTHALMIC NERVE. 
This division of the fifth passes from the Gasserian ganglion along the outer 
wall of the cavernous sinus, Fig. 61 (2), and enters the orbit through the 
sphenoidal fissure (see Sphenoid Bone) ; before entering, however, it breaks 
up into three branches. These branches supply the eyeball, the lachrymal 
gland, the mucous lining of the nose, and the muscles and integument of the 
forehead; they are named frontal, lachrymal, nasal. The ophthalmic is the 
smallest of the three divisions of the fifth; it is a flattened band not more 
than an inch in length, receiving, before breaking into its terminal branches, 110 
A SYSTEM OF ORAL SURGERY. 
filaments from the carotid plexus of the sympathetic, and giving off itself 
two or more filaments, which, with a branch from the fourth nerve, pass between 
the layers of the tentorium. (See Fig. 61.) 
Frontal Branch.-This is the largest of the divisions of the ophthal- 
mic, and is commonly regarded as the continuation of the nerve, Fig. 61 
(4). It lies in the orbit, above the levator palpebrse muscle, between it and 
the periosteum, dividing about midway of the cavity into two branches,- 
supratrochlear and supraorbital (5, 6). 
The supratrochlear branch (5) passes inward to the pulley of the 
superior oblique muscle, giving off here descending filaments which anastomose 
with similar trochlear filaments from the nasal nerve. A second or terminal 
branch passes from the orbit between the superior oblique and supraorbital 
foramen, ascends behind the corrugator supercilii and occipito-frontalis mus- 
cles, to both of which it distributes filaments, and is finally lost in the integu- 
ment of the forehead. 
The supraorbital branch, or division, of the frontal runs forward until 
it reaches the supraorbital foramen (6), when it passes out upon the forehead. 
In this situation it gives off a number of filaments to the upper eyelid, called 
palpebral. In its distribution over the forehead, it sends branches to the 
orbicularis palpebrarum, occipito-frontalis, and corrugator supercilii muscles, 
anastomosing in the first-named muscle with filaments of the facial nerve. 
Other two sets of terminal filaments supply: the first, the periosteum cover- 
ing the frontal and parietal bones; the second, the integument, so far back as 
the occiput. 
Lachrymal Branch.-This is the smallest of the three divisions of 
the ophthalmic (3). It is almost always accompanied by filaments from the 
fourth nerve. In the eye cavity it connects itself with the orbital branch 
of the second, or superior maxillary division of the fifth nerve. Its dis- 
tribution is to the lachrymal gland (see Fig. 61), the conjunctiva, and the 
integument of the upper eyelid, in which last situation it joins with filaments 
of the facial nerve. 
Nasal Branch.-This division (10) is intermediate in size between 
the frontal and lachrymal. Entering the cavity of the orbit between the two 
heads of the external rectus, it passes directly across the optic nerve to the 
anterior of the ethmoidal foramina (see Fig. 61); through this foramen it 
passes into the cavity of the cranium, where it traverses the shallow groove on 
the front of the cribriform plate of the ethmoidal bone, until arriving at the 
nasal slit it passes directly downward into the nose, terminating in two branches. 
Of these two branches, the external descends on the inner surface of 
the nasal bone, supplying the mucous membrane of its neighborhood; leaving 
the cavity at the juncture of the bone with the lateral cartilage, it passes, on 
the external part of the nose, to supply the integument of the lips and join 
with the facial nerve. The second branch, the internal, supplies the mucous 
membrane about the front of the septum. FIFTH PAIR OF NERVES. 
111 
In the orbital cavity three branches are given off by the nasal,-the 
ganglionic, ciliary, and infratrochlear. 
The ganglionic is a slender cord about half an inch in length; it is the 
sensor filament to the orbital, or ophthalmic, ganglion. (See Ganglia.^) 
The ciliary separates into branchlets, called long ciliary, to distinguish 
them from certain shorter branches, called also ciliary, given off from the 
ophthalmic ganglion. These branches are two or three in number ; they 
pierce the posterior face of the sclerotic in company with the short ciliary, 
and, passing between this coat and the choroid, are distributed to the ciliary 
muscle and iris. 
The infratrochlear branch is given off just as the main portion passes 
into the ethmoid foramen, joining, beneath the pulley of the superior oblique 
muscle, with a filament of the supratrochlear nerve; this branch continues to 
the inner angle of the orbit, where it is distributed to the orbicular muscle, 
the integument of the eyelid, and side of the nose, to the conjunctiva carun- 
cula lachrymalis and lachrymal sac. Let the diagram be closely studied. 
General Recapitulation.-The ophthalmic, or first, division of the 
fifth nerve supplies the tentorium, lachrymal gland, caruncula lachrymalis, 
lachrymal sac, ciliary muscle and iris, muscles of eyelid and forehead, integu- 
ment of forehead and nose, mucous membrane of eye and nose, and pericranium 
of frontal and parietal regions. 
SPECIAL RECAPITULATION. 
BRANCHES ALL SENSORY. 
PRIMARY DIVISION 
ULTIMATE DISTRIBUTION. 
1. Supratrochlear branches to infratrochlear muscle, to skin 
and conjunctiva of upper eyelid, to the palpebral orbicu- 
lar, corrugator, and frontal muscles, and to the skin of 
forehead. 
2. Supraorbital branches to skin of forehead, to frontal por- 
tion upper part of scalp, and to the pericranium. 
1. Frontal 
2. Lachrymal 
Branches to superior rectus muscle, to lachrymal gland, to 
upper eyelid, and to superior maxillary and facial nerves. 
Branches to mucous membrane underlying nasal bones, to 
skin of nose, to integument of upper lip, to facial nerve, 
to mucous membrane at front of septum narium, to oph- 
thalmic ganglion, to ciliary muscle and iris, to orbicular 
muscle and integument of eyelid, to caruncula lachry- 
malis, and to lachrymal sac. 
3. Nasal 
SUPERIOR MAXILLARY NERVE. 
This nerve, or division, arises, as a flattened band, from the middle of the 
Gasserian ganglion. It passes forward over the greater wing of the sphenoid 
bone, until, reaching the foramen rotundum, it leaves the cranium and 
presents itself in the spheno-maxillary fossa; from this fossa it passes, through 112 
A SYSTEM OF ORAL SURGERY. 
the spheno-maxillary fissure, to the orbital cavity, where, being lodged in the 
infraorbital canal, it continues forward to the points of its ultimate distribution. 
The diagram (Fig. 62) affords a most satisfactory showing of this division, its 
branches, and relations. 
Branches of Distribution.- i. In the Spheno-maxillary 
Fossa.-Three,-the orbital (1), the ganglionic (6), the posterior dental 
(2, 3.) 
The orbital enters, with the main branch of the nerve, the orbital cavity, 
and divides into two branches, temporal and malar. The temporal branch 
passes from the orbit through a foramen in the malar bone, and enters the 
Fig. 62.-Superior Maxillary Nerve. 
The external wall of the left orbit and of the superior maxillary bone re- 
moved. 1, superior maxillary nerve in its course through the infraorbital canal; 2, 3, 
posterior dental nerves; 4, anterior dental nerve; 5, anastomosis between the dental 
nerves; 6, spheno-palatine ganglion ; the branch from the superior maxillary nerve 
above is the commencement of the temporo-malar nerve; 7, pterygoid nerve ; 8, greater 
petrosal nerve joining the facial nerve; 9, deep petrous nerve joining the carotid plexus 
of the sympathetic; 10, abducent nerve with its communicating branches of the latter 
plexus; 11, superior cervical ganglion; 12, ascending branches to the carotid plexus; 
13, facial nerve; 14, glosso-pharyngeal nerve; 15, tympanic nerve; 16, branch to the 
carotid plexus; 17,18,19, branches to the round and oval windows and Eustachian tube; 
20, branch to the smaller petrosal nerve, 21. 
temporal fossa; it here perforates the temporal muscle and fascia, is dis- 
tributed to the integument covering the side of the head, and associates 
with the facial nerve, also with an ascending branch, auriculo-temporal, of the 
inferior maxillary. The malar branch leaves the orbit also through a fora- 
men in the malar bone, perforates the orbicularis palpebrarum muscle, and 
joins with a branch of the facial. (See diagram.) 
The ganglionic divides into two branches, which drop directly down into 
the spheno-palatine, or Meckel's ganglion; hence they are commonly known 
as the spheno-palatine branches. 
The posterior dental arises from the trunk just as it enters the orbit; 
it breaks up immediately into an anterior and a posterior portion. The first FIFTH PAIR OF NERVES. 
113 
supplies the gums and buccinator muscle; the second pierces the tuberosity 
of the maxillary bone, and, after forming a minute plexus above the alveolus, 
distributes filaments to each of the posterior teeth ; its termination is lost 
by union with the anterior dental nerve. 
2. In the Infraorbital Canal.-One,-the anterior dental (4). This 
branch is given off about midway of the canal. It enters a second canal exist- 
ing on the anterior face of the maxillary sinus, and curving backward, asso- 
ciates itself, as above alluded to, with the posterior dental; from the curve 
are given off filaments to the anterior teeth,-incisors, canines, and bicus- 
pidati. 
3. On the Face.-Three,-palpebral, nasal, labial. (See Fig. 59.) 
These are the terminal filaments, the division occurring as the nerve issues 
from the infraorbital foramen. The palpebral filaments ascend to supply 
the orbicularis palpebrarum muscle and the integument and conjunctiva of the 
lower eyelid; at the outer angle of the orbit they associate with the malar 
branch of the orbital and filaments of the facial nerve. The nasal filaments 
pass across the nose, supplying the muscles and integument of this region; 
they usually join at the tip with the nasal branch of the ophthalmic. The 
labial filaments pass downward beneath the levator labii superioris, and 
are distributed to the muscles and integument of the upper lip, to the mucous 
membrane of the mouth, and to the labial glands. The intricate plexus 
situated in the canine fossa is formed of filaments from the facial nerve 
associating with twigs of the trimaxillary division. 
General Recapitulation.-The superior maxillary nerve, or second 
division of the fifth, supplies the integument on the side of the head, 
Meckel's ganglion with its sensor filaments, the upper teeth, the antrum, 
orbicularis palpebrarum muscle, integument and conjunctiva of lower eyelid, 
muscles and integument of nose, muscles, integument, and mucous membrane 
of superior lip, and labial glands. 
SPECIAL RECAPITULATION. 
BRANCHES ALL SENSORY. 
PRIMARY DIVISION. 
ULTIMATE DISTRIBUTION. 
1. Orbital 
2. Ganglionic 
3. Posterior Dental . . . 
4. Anterior Dental . . . 
Branch to temporal region, and to malar region. 
Two branches to spheno-palatine ganglion. 
Branches to posterior superior teeth, and to gums. 
Branch to anterior teeth. 
Branches to orbicularis palpebrarum, to integument and to 
conjunctiva of lower eyelid, to malar branch of orbital, 
and to filaments of facial nerve. 
5. Palpebral 
6. Nasal 
Branches to muscles and integument of nose, and a branch 
of relation with ophthalmic nerve. 
7. Labial 
Branches to muscles and integument of upper lip, to mu- 
cous membrane of mouth, to labial glands, and to facial 
nerve. 114 
A SYSTEM OF ORAL SURGERY. 
INFEEIOR MAXILLARY NERVE. 
This nerve, or division, is the largest of the three, and constitutes, justly 
speaking, the only portion of the fifth nerve compound in character. The 
sensor portion is the third of the cords emerging from the Gasserian gan- 
Fig. 63.-Inferior Maxillary Nerve. 
Distribution of the inferior maxillary nerve. 1, muscular branch to the mas- 
seter muscle; 2,5,7, branches to the temporal muscle; 3, branch to the buccinator, anas- 
tomosing with one from the facial at 4; 6, external pterygoid muscle; 8, auriculo-temporal 
nerve; 9, branches to the temple; 10, branches to the ear; 11, its anastomosis with the 
facial: 12, lingual nerve; 13, branch to the mylo-hyoid muscle from the inferior dental 
nerve, 14; 15, branches to the teeth: 16, terminal branches to the lower lip and chin. 
glion : the motor portion is that lesser root alluded to as coming off from 
the pons Varolii: the special, gustatory, portion (12) is that seen in the 
diagram as passing to the inner side of the jaw; the sensor cord falls quickly 
into the oval foramen of the sphenoid bone, through which it passes from the 
cranium. The motor cord, which has passed forward beneath the Gasserian 
ganglion, unites with the sensor just as it emerges from this foramen. Here 
then is made, by this union, a single cord, the perfected, or compound in- 
ferior maxillary nerve,-a nerve made up of filaments of motion and filaments FIFTH PAIR OF NERVES. 
115 
of sensation. At the point of juncture of these two cords is found a little 
ganglion, the otic. (See Ganglia.') 
Immediately beneath the base of the skull this compound inferior max- 
illary nerve divides into two branches,-anterior and posterior. Into the 
anterior branch pass most of the motor filaments. 
The anterior branch breaks up into five divisions, and is distributed to 
the muscles of mastication. These divisions, or branches, receive names from 
the parts supplied by them ; they are the masseteric, buccal, deep temporal, 
and pterygoid. 
The posterior branch is the larger of the two divisions; it subdivides 
into three parts. These supply the inferior teeth, tongue, and auriculo-temporal 
region. Hence the branches are named inferior dental, lingual, and auriculo- 
temporal. 
Divisions of Anterior Branch-Masseteric.-This branch runs 
across the sigmoid notch of the inferior maxillary bone, enters the substance 
of the masseter muscle, and is distributed in it. In crossing the notch it oc- 
casionally gives off a filament to the articulation. 
Deep Temporal Branches.-These are two in number. They pass 
under the temporal muscle, and supply its deep surface. 
Buccal.-This branch pierces the external pterygoid muscle, passes be- 
neath the coronoid process of the jaw, pierces the fibres of the temporal 
muscle, and, reaching the buccinator, divides upon it into a superior and 
inferior branch. The superior supplies the upper part of the muscle and the 
integument; the inferior, the lower part of the muscle and its lining mucous 
membrane. 
Pterygoid Branches.-Two in number,-one supplying each pterygoid 
muscle. 
Divisions of Posterior Branch - Auriculo-temporal.- This 
branch passes out to the inner side of the temporo-maxillary articulation, 
turns upward in company with the temporal artery, and, on emerging with 
this vessel from beneath the parotid gland, divides into two branches. The 
posterior of the two supplies the attrahens auriculae, the pinna, and the 
neighboring integument. The anterior passes upward with the terminal 
branches of the artery, and is distributed to the temporal integument. 
Branches of communication exist between the auriculo-temporal nerve, the 
facial, and the otic ganglion. The articulation, the parotid gland, and the ex- 
ternal auditory meatus receive nerve endowment from the auriculo-temporal. 
Lingual, or Gustatory.-This branch is a nerve of special sense, 
presiding in part over the function of taste; its terminal filaments, as might 
be inferred, are distributed extensively to the papillae and mucous membrane 
of the tongue. Of the three sets of papillae, the filiform and fungiform, or 
those situated on the anterior two-thirds of the organ, receive the principal 
supply, the posterior, or great papillae, being endowed from the glosso-pha- 
ryngeal. On this account it was inferred that the gustatory presided over 116 
A SYSTEM OF ORAL SURGERY. 
taste only as the anterior two-thirds of the tongue was concerned; and this 
inference has been abundantly borne out by vivisection. (See Todd and 
Bowman's Physiology.) In the dissection, the gustatory branch is seen 
coming off just opposite the sigmoid notch. In company with the inferior 
dental nerve, or branch, it passes down along the inner side of the ramus, 
until, leaving the dental somewhat above the posterior dental foramen, it 
crosses obliquely to the side of ?he tongue, along which it pursues its way to 
its points of final termination, anastomosing at the tip of the organ with fila- 
ments of the hypoglossal. In its course it lies first beneath the external 
pterygoid muscle, crosses the internal pterygoid, rests upon the superior con- 
strictor of the pharynx, and passes over Wharton's duct, where it reaches the 
apex of the tongue. In its course, branches of communication are given off 
to the submaxillary ganglion and the hypoglossal nerve. 
Inferior Dental Nerve, or Branch.-This is the largest of the 
three divisions of the inferior maxillary nerve. Between its point' of origin 
and entrance into the dental canal it gives off a branch, the mylo-hyoid, dis- 
tributed to the mylo-hyoid and anterior belly of the digastric muscles. The 
main portion, after entering the posterior foramen of the dental canal, 
pursues its way beneath the teeth, giving, in its course, filaments to all these 
organs, terminating finally in a branch, the mental, which passes from the 
canal at the mental foramen, and has its distribution in the muscular and 
cutaneous substance of the inferior lip. 
General Recapitulation.-The inferior maxillary nerve, or third di- 
vision of the fifth, supplies the muscles of mastication, the auriculo-temporal 
region, the anterior two-thirds of the tongue, the mylo-hyoid and digastric 
muscles, the inferior teeth, and the muscles and skin of the lower lip. 
SPECIAL RECAPITULATION. 
BRANCHES SENSORY, MOTOR, AND SPECIAL, 
PRIMARY DIVISION. 
ULTIMATE DISTRIBUTION. 
1. Recurrent Nerve . . . 
2. Internal Pterygoid . . 
To great meningeal artery. 
To inner surface of pterygoid muscle. 
Branches to all the inferior teeth, to mylo-hyoid and digas- 
tric muscles, to the motor division of the common nerve, 
to the skin and mucous membrane of lower lip and chin, 
and to facial nerve. 
3 Inferior Dentai 
4. Deep Temporal 
To the under surface of temporal muscle. 
5. Buccal 
To plexus on outside of buccinator muscle, and to mucous 
membrane and skin of cheek. 
6. External Pterygoid. 
To pterygoid muscle. 
To great meningeal artery, to otic ganglion, to temporal 
artery, to facial nerve, to jaw-articulation, to skin of tem- 
poral region, and, again, to facial nerve. 
7. Auriculo-temporal. 
8. Lingual, or Gustatory 
To submaxillary ganglion, to hypoglossal nerve, to sublingual 
gland, to gum, and to the conical and fungiform papillae 
of tongue. FIFTH PAIR OF NERVES. 
117 
Associated with the fifth nerve are six ganglia: they are called Gasserian ; 
ophthalmic, lenticular, or ciliary (9) ; Meckel's, or spheno-palatine; naso-pala- 
tine, or ganglion of Cloquet (3) ; otic ; submaxillary. 
Ganglion of Gasser.-This ganglion, called as frequently the semi- 
lunar, from its shape, is found lying in a slight depression on the anterior 
face, near the apex of the petrous portion of the temporal bone. It receives 
the posterior or sensor cord of the fifth nerve, and transmits it divided into 
three parts. The ganglion receives filaments from the carotid plexus of 
the sympathetic, and gives off filaments to the tentorium cerebelli, and 
to the dura mater of the middle fossa of the cranium. 
Ophthalmic, Lenticular, or Ciliary Ganglion.-This ganglion, as 
implied in its name, is in the cavity of the orbit. It is a small, quadrangular, 
GANGLIA OF THE FIFTH PAIR OF NERVES. 
Fig. 64.-Ophthalmic Ganglion-the Outer Part ok the Eight Orbit 
REMOVED. 
1, optic nerve; 2, oculo-motor nerve; 3, branch to the superior straight and oblique 
muscles; 4, branch to the inferior oblique muscle; 5, abducent nerve to the external 
straight muscle; 6, trifacial nerve, its ganglion and three principal branches; 7, ophthal- 
mic nerve; 8, nasal nerve; 9, ophthalmic ganglion; 10, its communicating branch with 
the oculo-motor nerve; 11, its communicating branch with the ophthalmic nerve; 12, 
its communicating branch with the carotid plexus of the sympathetic; 13, the ciliary 
nerves; 14, frontal nerve. 
flattened body, not larger, generally, than the ordinary pin-head. It is situ- 
ated between the external rectus muscle and optic nerve, well enveloped in 
the mass of fat found occupying this portion of the cavity. Its branches of 
communication are derived, the first, or sensor, from the nasal; the second, or 
motor, from the third nerve; the third, or sympathetic, from the cavernous 
plexus. Its branches of distribution are the short ciliary nerves. These 
nerves (13), ten or twelve in number, arise from the anterior face of the gan- 
glion, being connected, as two sets of filaments, with the superior and inferior 
angles. The sets pass forward, one being above, the other below the optic nerve 
(13), until, reaching the sclerotic coat of the eye, they penetrate this organ, 
and are distributed to the ciliary muscle and iris. 
Meckel's Ganglion-Spheno-palatine.-This is the largest and 
most extensively connected of the cranial ganglia. Its position is in the 118 
A SYSTEM OF ORAL SURGERY. 
spheno-maxillary fossa, immediately in front of the vidian foramen. In shape 
it is triangular, and in color reddish-gray. Its branches of communica- 
tion are derived, the first, or sensor, from the superior maxillary nerve, which, 
as has been seen, gives to it two filaments while crossing the fossa. The 
Fig. 65.-View of the Spheno-palatine Ganglion and of the Outer 
Wall of the Left Nasal Cavity, and the Olfactory Nerve. 
1, olfactory nerve; 2, nasal branch of the ophthalmic nerve; 3, spheno-palatine gan- 
glion ; 4, 5, 6, palatine nerves; 7, branch to the nose; 8, nasal nerve to the outer wall of 
the nose; 9, nasal nerve to the inner wall; 10, pterygoid nerve; 11, facial nerve; 12, 
deep petrous nerve joining the carotid plexus; 13, the other branch of the pterygoid, 
is the larger petrosal nerve, which joins the facial. 
second, or motor, is derived from the facial nerve, or rather from the intumes- 
centia gangliformis of that nerve. This branch is known as the great petrosal 
nerve; it emerges from the Fallopian canal through the hiatus Fallopii, 
passes along the groove leading from this foramen, until, reaching the fora- 
men lacerum basis cranii, it pierces the cartilaginous substance, filling up this 
osseous break, and entering the vidian canal, associated with the carotid nerve, 
passes forward, under the name of vidian, to the ganglion. The third, or 
sympathetic, is derived from the carotid plexus through the vidian. 
The branches of distribution from this ganglion are numerous; they 
supply a portion of the orbital periosteum, the nares, the hard and soft palates, 
the half arches, the tonsil, the pharynx, etc. 
The ascending branches, two or three in number, enter the orbit 
through the spheno-maxillary fissure; they supply the periosteum. 
The descending branches, called palatine, are three in number; the 
anterior of these, or large palatine nerve, descends through the posterior pala- 
tine canal, passes along the groove on the hard palate, and is distributed to 
the gums, the mucous membrane, and palatine glands, anastomosing back of 
the incisor teeth with the naso-palatine nerve; while in the palatine canal 
filaments are given off which pass to the middle and inferior turbinated bones. FIFTH PAIR OF NERVES. 
119 
The middle branch, called external palatine nerve, descends through the 
same canal as the preceding; it distributes its filaments to the soft palate, 
to the uvula, and the tonsil. 
The posterior branch, called small palatine nerve, descends through the 
accessory palatine canal, and emerges back of the posterior palatine foramen. It 
is distributed to the levator palati muscle, to the soft palate, tonsil, and uvula. 
Coming off from the internal surface are two sets of branches; these are 
called superior nasal and naso-palatine. 
The superior nasal branches, four or five in number, enter the nasal 
fossa by the spheno-palatine foramen; they supply the mucous membrane of 
the superior portion of the fossa. 
The naso-palatine branch enters the fossa with the other nasal nerves, 
runs across the roof of the nose, until, reaching the septum, it descends be- 
tween the periosteum and mucous membrane to the anterior palatine foramen; 
passing through this canal, it unites with its fellow of the opposite side, and 
distributes its filaments to the mucous membrane about the incisive fossa. 
Fig. 66. 
The otic ganglion and its connections: view from within. 1, Internal pterygoid 
muscle; 2, palatal tensor muscle; 3, its tendon passing round the hook, 4, of the internal 
pterygoid process; 5, condyle of the jaw; 6, tympanic tensor muscle; 7, malleus; 8, 
tympanic membrane; 9, external carotid artery dividing into the temporal and internal 
maxillary arteries; 10, tympanic branch ; 11, great meningeal artery; 12, small menin- 
geal artery; 13, inferior dental artery; 14, third division of the semilunar ganglion of 
the trifacial nerve; 15, motor root of the latter; 16, lingual nerve; 17, inferior dental 
nerve; 18, auriculo-temporal nerve; 19, tympanic branch of the facial nerve joining the 
lingual nerve; 20, otic ganglion; 21, nerve to palatal tensor; 22, nerve to internal ptery- 
goid muscle; 23, branch to tympanic tensor; 24, small petrosal nerve; 25, communi- 
cating branch with the sympathetic nerve. 
Naso-palatine Ganglion, or Ganglion of Cloquet.-This is 
simply the small swelling situated in the incisive fossa, the result apparently 120 
A SYSTEM OF ORAL SVROERY. 
of the union of the naso-palatine nerves. The very name of ganglion is 
denied it by most writers. 
Otic Ganglion.-This is an oval flattened body (Fig. 66) of small size, 
lying on the sensor portion of the inferior maxillary nerve, immediately be- 
neath the oval foramen. Its branches of communication are : by sensor 
filaments with the auriculo-temporal nerve, by motor with the inferior maxil- 
lary nerve, and with the sympathetic by the plexus surrounding the middle 
meningeal artery. Branches of communication also exist with the glosso- 
pharyngeal, and through the medium of the lesser petrosal with the facial 
nerve. 
The branches of distribution are two in number: one to the tensor 
tympani and one to the tensor palati muscles. 
Submaxillary Ganglion.-This is a small-sized circular body situated 
upon the submaxillary gland. It is connected, through communicating 
branches, with the gustatory nerve, sensor; with the facial through the 
medium of the chorda tympani, motor; and with the sympathetic by fila- 
ments from the plexus of the nervi molies. 
The branches of distribution are five or six in number; these arise 
from the lower part of the ganglion, and supply the duct of the gland and 
mucous membrane of the floor of the mouth. 
Relations of the ganglia are to be understood as being mediate. 
Ganglia have as office intensification or modification of expression. The 
many associated with the fifth pair certify to its complexity of relation. 
FUNCTION OF THE FIFTH NERVE. 
The resemblance of the fifth to spinal nerves is now regarded by most 
writers as complete. 
The origin of the nerve is by two roots, the smaller being motor, the 
larger sensor. The origin is after such manner, otherwise the motor division, 
joining the inferior maxillary division of the sensor branches just external to 
the ganglion of Gasser, is to be esteemed as a pure spinal nerve. The judg- 
ment and studies of the author accept this motor branch as a spinal root of 
the common nerve. 
The nerve breaks up, in the Gasserian ganglion, as understood, into three 
branches. The first and second of these receive no filaments from the lesser 
root, and are, therefore, purely sensor. The third is compound by reason of 
relation with the anterior division of the spinal cord through such lesser root. 
The distribution of the first and second branches is to skin of forehead; 
to the lids, balls, and conjunctivae of eyes; to the temples, the ears, and sides 
of cheeks; to the nose, outside and inside; to the upper lip and its append- 
ages ; to the pulps and alveolo-dental periostea of teeth; to the dura mater. 
The distribution of the third division is to the muscles of mastication by 
its motor filaments; to the chin, the lower lip, the mucous membrane of mouth 
and tongue; to the pulps of inferior teeth, etc., by its sensory filaments. FIFTH PAIR OF NERVES. 
121 
In addition to the double function of a compound nerve, evidence worthy 
of acceptance connects the lingual branch of the third division with the 
special sense of taste, although it is to be noted that such office is attributed 
by equally good authority exclusively to filaments of the glosso-pharyngeal 
and chorda tympanic.* The intimate relation existing between the filaments 
of the nerves named serves without doubt to complicate inferences. The 
writer retains the old view,-namely, that gustatory office belongs to all these 
nerves; the fifth doing its office in relation with the anterior two-thirds of the 
tongue. 
It is in point here to refer to the fact that confusion exists as to the use 
of the terms taste and smell; the two being not so easy to keep separate. 
Taste, critically defined, relates to sensation arising out of touch upon the 
tongue, anterior pillars of fauces, and palate of acid, saline, bitter, and sweet 
substances. Smell applies to sensations produced in the nerves when in- 
tangible, but not less real, substances come in contact with filaments of the 
olfactory nerve: necessarily as well with filaments of the trifacial. 
The fifth nerve presides markedly over both salivary and oro-nasal mucus 
secretions. Excitement of its filaments increases these secretions; section 
being made of them, flow is diminished.^ In this connection, if in no other, 
the nerve is justly to be associated with both taste and smell, seeing that 
necessity exists for the intermediate agency of moisture, that such special 
functions exist at all. 
Inferences of office are to be derived from study of parts in a state of dis- 
ease. Pathological perversion of the fifth nerve shows marked separation of 
the two expressions of motility and sensibility according to the tract affected. 
Sensation and motion are alike destroyed only when disease of the nerve is 
general. In such state of general involvement it is common to find the eye- 
ball without sensibility; the muscles of mastication waste and become flabby ; 
tongue and mouth grow so unconscious of the presence of food that morsels 
remain in the cavity until decomposed; the nostrils oftentime afford no 
response to applications of the most pungent character. 
The fifth is to be accepted as a nerve of wide excito-motor capacity; it 
stimulates the facial nerve in all its offices; water dashed over parts supplied 
by it excites the respiratory tract. It too often produces distant neuralgia as 
the result of an aching tooth. 
The wide relation of this nerve is nowhere so markedly illustrated as during 
the dentitional period; convulsions, skin eruptions, diarrhoeas, indeed tetanus 
passing to a fatal termination, are all found in the category of its associations. 
(See Neuralgia.} 
* See a Text-Book on Physiology, by M. Foster, M.A., M.D., F.R.S., New York, 1881. 
Pp. 586-88. See also Principles of Human Physiology, by William Carpenter, M.D., etc. 
Henry C. Lea, Philadelphia, 1876. Pp. 620-55. 
f See Outlines of Physiology, by John Marshall, F.R.S., with additions by Francis Gurney 
Smith, M.D., p. 264. Henry C. Lea, Philadelphia, 1868. CHAPTER VIL 
THE MOUTH. 
Studying the mouth from the living subject, there is remarked, first, an 
entrance-way, or gate, consisting of two fleshy folds, the lips; separating 
these, the observer is met by a second portal, the teeth and gums; the space 
between these two entrances is called the hall, or vestibule; opening this inner 
gate-way, by depressing the lower jaw, the oral cavity proper, or mouth, is 
entered. 
The mouth is the commencement of the alimentary canal. It has 
as offices the reception of food, gustation, mastication, insalivation, and 
expression in sound; consequently must possess organs and agencies pertinent 
to these ends. The boundaries of the mouth are, in front, the teeth and 
gums; laterally, the teeth and gums; superiorly, the hard and soft palates; 
and below, the mylo-hyoid muscles covered by their overlying mucous mem- 
brane. 
Looking into this cavity, it is observed to be an oval archway, terminated 
posteriorly by a veil, or curtain. This curtain falls obliquely into the pharynx ; 
it has a central pendulum, and expands laterally in curves. The observer can 
see beneath this veil, or between it and the base, thereby recognizing the part 
viewed as simply the commencement of a something that is back of it, and 
of which it is appreciated as the entrance. Every part of the cavity is seen 
to be covered by a common membrane, which membrane is found to associate 
externally on the lips with the skin ; internally with the throat. This is 
mucous membrane; examination reveals it to be continuous from the lips to 
the outlet of the rectum. The teeth, thirty-two in number in the adult, are 
placed in two harmonizing or articulating arches, and are, in shape and char- 
acter, correspondent with omnivorous habits. Certain of these organs, the 
incisors, are so arranged as to cut, or incise. Certain others, the cus- 
pidati, or canines, are spear-shaped; these tear, or lacerate. Still others, the 
bicuspidati and molars, have broad and roughened surfaces; they act 
the part of grinders. The tongue, a muscular body, rests within the lower 
dental arch; its office is to preside over the labor of the teeth, to receive or 
reject articles to be comminuted, to place and retain food in position to be 
masticated, and, when ready to be swallowed, to roll up masses into a bolus, 
and pass this bolus into the pharynx. 
The roof of the mouth, beginning with the palatal faces of the teeth, is 
made up of hard and soft tissues. The hard portion is the flesh-covered 
122 THE MOUTH. 
123 
alveolar and palate processes of the superior maxillary bones and the palate 
processes of the palate bones. The soft part, as revealed by dissection, is a 
muscle-formed basement tissue covered with the common membrane. 
The uvula, the central pendulous termination of the soft palate, consists 
of two symmetrical muscles enclosed in a common envelope of mucous mem- 
brane. The office of this body is to act as an agent excitive of the act of 
deglutition. It draws the veil against the upper wall of the pharynx, thus 
closing the posterior nares during the process of swallowing. In the produc- 
tion of loud declamation and in the guttural forms of language, it is supposed 
to modify speech by lessening the pharyngo-nasal passage when it acts as an 
elevator; this elevating force being most exhibited in the highest ranges of 
the singing voice, and least in the lower keys. 
Looking for a short period into a mouth, jets of fluid are not unlikely ob- 
served as occasionally sent up from the anterior floor just back of the lower 
central teeth, also drops are observed issuing continuously from an orifice situ- 
ated on the cheek by the side of the superior second molar tooth. This fluid 
is the salivary secretion ; it comes from glands situated in the immediate neigh- 
borhood. Besides this salivary fluid, pearly drops are seen, more or less 
plainly, over the surface of the common mucous membrane. This last is 
mucus, and is the product of follicles, crypts, or glands related with the 
common membrane. (See Surgery of Uvula.') 
The mouth, then, we are to say, is made up of, and invites study of, 
lips, cheeks, gums, teeth, mucous membrane, tongue, hard and soft palate, and 
salivary glands; and if we accept, as indeed surgically we must, that the 
cavity begins with the lips and ends at the posterior wall of the pharynx, then 
we include in the study all the relations which exist between inlet and outlet. 
LIPS AND CHEEKS. 
Lips and cheeks, boundaries of the vestibule of the mouth, are alike in 
their composition, being, anatomically, part and parcel of each other. First, 
in a dissection, there is found a layer of skin on the outside and a layer of 
mucous membrane on the inside. Removing the skin, which here is thin as 
compared with that upon other parts of the body, a layer of cellular fascia is 
exposed, with which is found intermingled more or less fatty tissue. This, 
the superficial fascia, as it is called, differs from other fasciae of the same 
signification in not being distinct, or laminated. It is intimately connected 
with the skin on one side, and closely associated with muscles on the other. 
Removing this fascia, an apparently complex grouping of muscles is discov- 
ered,-the muscles of expression. (For full description of these, see chapter 
on Muscles.) 
The mucous membrane of the mouth belongs to that common layer known 
as the gastro-pneumonic. Commencing with the oral vestibule, it terminates 
at the anal outlet. At the base of the pharynx the initiative membrane gives 
MUCOUS MEMBRANE OF MOUTH. 124 
A SYSTEM OF ORAL SURGERY. 
off a prolongation which, passing into larynx and trachea, lines these tubes 
and is continuous with the inner surface of the terminal air-cells. The 
mucous lining found in the nose, the Eustachian tube, the antrum of High- 
more, the ethmoidal, sphenoidal, and frontal sinuses is of direct association 
with that found in the mouth. 
Viewed superficially, oral mucous membrane is a reddish soft 
tissue forming a lining to the cavity of the mouth. Considered analytically, 
it is found made up of pavement and underlying portions. The first of these 
is named epithelial layer, the second is called corium. 
Epithelial Layer.-Epithelium is the more evident of the two structures, 
as it is always found, while attenuation of the latter loses it frequently to 
sight; reference to cornea of eye, which is protected by mucous membrane, 
explains what is implied by absence of corium. Oral epithelium belongs to 
the stratified variety,-that is, the arrangement of the cells of its external 
layer is not dissimilar to the epiderm of skin, being laminated and held to- 
gether by an intermediate substance, to be referred to as inappreciable, which 
substance is to be esteemed as permitting absorption of fluids placed upon 
the part. The cell arrangement of the epithelium varies necessarily with the 
depth at which it is viewed. Broad and flat of scale at the surface, where its 
fluidic character is about lost by reason of a desquamation which is the law 
of its loss, it has a lower layer of cells which, by reason of the contained 
moisture, are columnar in form, while other cells, still deeper, are of polyhedral 
shape. 
Corium.-Corium is the cellular tissue underlying and supporting the 
epithelium. It is in this structure that are found the blood-vessels, glands, 
lymphatics, and nerves of the skin. This layer, as implied, varies greatly as 
to its characteristics. (See General Anatomy.') The thickness of the gums 
depends largely on excess of the corium, this structure, in this locality, being 
extensively existent, and serving the part of pads or cushions. Relation of it, 
below, is to the periosteum, a structure that is here largely cellular in character 
and of little division or difference from the corium proper. Softness as to the 
covering of a hard palate denotes free development of corium; on the other 
hand, hardness as to the covering implies cellular deficiency. 
Mucous Glands.-The mucous glands are of a racemose character, 
differing little in general characteristics from the tonsil glands. Their situation 
is the substance of the corium, and, as bony parts are concerned, as upon the 
hard palate, accommodation is found for them in the depressions marking these 
parts. A mucous gland secretes a pellucid fluid which serves to moisten the 
mucous surface. The labial mucous glands are found placed between the mucous 
membrane and orbicular muscle; the buccal, between the membrane and the 
buccinator muscle. 
Fraena.-The fraenum linguae, as well as the fraena of superior and inferior 
lips and of epiglottis, are simply folds of mucous membrane having corium in 
excess. THE MOUTH. 
125 
SECTIONAL DISSECTION OF THE MOUTH. 
The view (Fig. 67) represents a section made directly through the centre of 
the skull from before backward, and exhibits perfectly the character of the 
Fig. 67.-Sectional View of the Nose, Mouth, and Pharynx. 
Vertical section of the face and neck, through the median line antero-poste- 
R10RLY, EXPOSING TO VIEW THE NOSE, MOUTH, PHARYNX, AND LARYNX. 1, OVal Cartilage 
of the left nostril; 2, triangular cartilage; 3, line of separation between the two; 4, pro- 
longation of the oval cartilage along the column of the nose; 5, superior meatus of the 
nose; 6, middle meatus; 7, inferior meatus; 8, sphenoidal sinus; 9, posterior part of the 
left nasal cavity, communicating with the pharynx; 10, orifice of the Eustachian tube; 
11, upper extremity of the pharynx; 12, soft palate, ending below in the uvula; 13, in- 
terval of the mouth between the lips and jaws; 14, roof of the mouth, or hard palate; 
15, communication of the cavity of the mouth with the interval between the jaws and 
the cheek; 16, tongue; 17, fibrous partition in the median line of the latter; 18, genio- 
glossal muscle; 19, genio-hyoid muscle; 20, mylo-hyoid muscle; 21, anterior half arch 
of the palate; 22, posterior half arch of the palate; 23, tonsil; 24, 25, floor of the fauces; 
26, 27, pharynx; 28, cavity of the larynx; 29, ventricle of the larynx; 30, epiglottis; 31, 
hyoid bone; 32,33, thyroid cartilage; 34, thyro-hyoid membrane; 35, 36, cricoid cartilage; 
37, vocal membrane. 
mouth and its associations. Below is seen the tongue and its relations ; in 
front, to the genial tubercles; behind, to the epiglottis. Fossae between the 
root of the organ and the epiglottis, one on each side of a common centre, the 126 
A SYSTEM OF ORAL SURGERY. 
fraenum epiglottidis, are particularly worthy of note, as they are the not infre- 
quent receptacles for fish-bones and other foreign bodies, which give sometimes 
much trouble in their removal. The free surface of the tongue is seen to be 
convex, while the section reveals its common body to be triangular; the apex 
looks forward. 
The roof of the mouth, seen above, is remarked to be a quite thin plane, 
forming as well the floor of the nares. Its relation to the oral cavity is con- 
cave, but differs widely in various persons, being in some almost flat, in 
others very deep. The anterior portion, bony, will be recognized as being 
formed by the palatine processes of the maxillary and palate bones. The 
posterior part, soft, veil-like, and movable, is the velum, terminating in the 
uvula in the centre, just above and in front of the tip of the epiglottis. 
Laterally are two pillars, or half arches, called respectively the anterior and 
posterior pillars. The first of these-the one seen in the view as associating 
itself with the tongue-is formed by a projection of the palato-glossus 
muscle; the second, or posterior, is likewise the projection of a muscle, the 
palato-pharyngeus, passing from the veil to the pharynx. The fossa existing 
between these pillars lodges the tonsil gland. The hard portion of the oral 
roof, or nasal floor, is frequently the seat of necrosis; it will be remarked 
that only a very small loss of substance is required to associate the two cavi- 
ties. The oro-pharyngeal space, the space between the two arches, is bounded, 
above, by the margin of the palate; below, by the base of the tongue ; laterally, 
by the half arches and amygdalae. (See Diseases of the Pharynx.') 
Tonsils.-The tonsils (Figs. 67, 69) are glandular organs, situated one 
on either side of the oro-pharyngeal space, and between the palatal half 
arches formed by the palato-glossal fold in front and the palato-pharyngeal 
behind. These bodies are made up of many lobules, having many sulci lined 
by involutions of the common mucous membrane. They are not infrequently 
the seat of such hypertrophy as to make necessary their amputation, while in 
their sulci is apt to be lodged debris, which, in its retention and decomposition, 
becomes one of the sources of an unpleasant breath. Externally these bodies 
are in very close relation with the internal carotid arteries, a point necessary to 
be kept in remembrance in performing operations on them. A tonsil gland is, 
ordinarily, an inch in length by from one-half to three-quarters of an inch in 
breadth. In composition it consists of trabecular spaces accommodating ade- 
noid and lymphatic substance. The free surface is abundantly pitted, the in- 
tervening crypts holding a secretion found more or less glutinous. The yellow 
calcareous bodies seen so frequently upon the face of a tonsil gland are nothing 
more than collections of inspissated mucus. (See Tonsil Glands.) 
The relationship of a bolus of food with the pharynx, and with its direc- 
tion, over the chink of the glottis into the oesophagus, by the epiglottis, are 
clearly exhibited by the drawing. 
Tongue.-Dissection of the tongue reveals it to be a somewhat complex 
body, although made up in the great mass of its bulk by muscular sub- THE MOUTH. 
127 
stance. Attached to the inferior maxillary bone in front, and to the hyoid 
behind, it yet moves with freedom and latitude in either direction, afford- 
ing the idea that if it be muscular substance, it must be free muscle set upon 
fixed muscle, and this is practically the case, as is understood by studying a 
dissection. 
The muscular structure of the tongue (Fig. 68) is made up of five 
distinct pairs and certain non-attached fasciculi. The body, as its surface is 
concerned, is seen with a base looking backward into the pharynx, and a tip, 
which represents the apex of a pyramid. Beginning a study of the organ 
Fig. 68.-Side View of the Muscles of the Tongue 
1,2, stylo-glossal muscle; 3, lingual muscle; 4, upper part of the tongue; 5,6, hyo-glossal 
muscle; 7, genio-glossal muscle; 8, stylo-pharyngeal muscle; 9, genio-hyoid muscle; 10, 
11, median line of the mylo-hyoid muscles. 
with its relations to the hyoid bone, we observe, first, that from that 
bone arises a muscle, the hyo-glossus (6), which, passing almost directly up- 
ward, enters, with the stylo-glossus (1), the root of the body, and expands 
itself laterally and forward. Passing toward the centre of the bone, we 
remark a second muscle, the genio-hyo-glossus (7), which, having apparent 
origin from the genial tubercles, radiates downward and upward, attaching 
one of its wings to the os hyoides, the other spreading out to assist in the 
formation of the tongue. The stylo-glossus, the third muscle, arises from the 
styloid process of the temporal bone, passes downward and forward, and 
occupies, or makes up, either lateral aspect from the tip to the bone. The 
fourth, the lingualis (3), seen between the stylo-glossus and genio-hyo-glossus, 
passes from the tip to the base, having, indeed, some few of its fibres con- 
tinued to the os hyoides. The fifth, the palato-glossus, is the muscle of the 
anterior half arch; it assists in forming the base and side. The unattached 
fibres are certain longitudinal and transverse bands running through the sub- 128 
A SYSTEM OF ORAL SURGERY. 
stance of the organ. The tongue, as an agent of nutrition, is adapted most 
happily, through its muscular character, to preside over the act of mastication, 
and, this process completed, to transfer the comminuted mass back into the 
Fig. 69.-Upper Surface of the Tongue. 
1, 2, V-like row of the circumvallate papillae; 3, capitate papillae; 4,5, conical papillae; 
6, 6, floor of the fauces, with numerous simple follicular glands ; 7, tonsils; 8, summit 
of the epiglottis; 9, the middle glosso-epiglottic fraenum, with depressions on each side 
bounded externally by the lateral fraena. 
grasp of the pharyngeal constrictors. Its ability and variety of action are to 
be comprehended by a moment's observation of the dissection. 
Fig. 69, exhibiting the enlarged upper surface of the organ, discovers it 
covered with mucous membrane, dotted here and there with more or less 
regularly located papillae, of varying size and character. 
The mucous membrane envelops the tongue wherever the body has free 
surface. Above, it is dense, and affords support to the papillae; below, it is THE MOUTH. 
129 
exceedingly delicate, and is traceable through the ducts of the submaxillary 
and sublingual glands. 
Papillae.-The papillae, seen upon the dorsum, are cone-shaped projec- 
tions of homogeneous tissue, holding arteries, veins, and nerves in plexiform 
arrangement; they are located in three separate sets, each having distinctive 
features. 
The most posterior (1) are the largest, and occupy a position which very 
much resembles the letter V; they are to be likened to inverted cones, the 
Figs. 70, 71.-Papillje of Tongue. 
Diagram of the papillae of the tongue, moderately magnified. 1, capitate pa- 
pillae ; 2, conical papillae; 3, epithelium; 4, the same structure forming bunches of hair- 
like processes; 5, connective tissue. 
Papilla of the tongue, highly magnified. 1, conical papillae; 2, capitate papillae; 
3, simple papillae, occupying the intervals of the compound papillae; 4, epithelium as- 
cending from the conical papillae in hair-like processes; 5, isolated epithelial scales from 
the latter. 
apices resting in cup-shaped depressions of the mucous membrane, hence sur- 
rounded each by a valley. They are variously named the maximae or circum- 
vallatae. Of this class there are some fifteen. The elevated margins of the 
fossa surrounding these papillae are studded with secondary papillae. The 
structure of the bodies is accurately exhibited in the magnified drawing. 
The papillae fungiformes, or mediae (4, 5), are scattered somewhat irregu- 
larly over the sides and apex of the organ ; they are exceedingly vascular, and 
closely covered with secondary papillae; are broad and rounded on their free 
surfaces, narrow and pointed at their attachment to the tongue; their middle 
size and red color easily distinguish them. The magnified fungiform papillae 
are seen in the drawing. 130 
A SYSTEM OF ORAL SURGERY. 
The smallest, or filiform, papillae (3) follow somewhat in their arrange- 
ment the order of the maximae, being interspersed among the fungiformes. 
They are very minute, and covered so deeply with epithelium as to appear 
quite white; they are enveloped with secondary papillae, as exhibited in the 
figure. 
In the tongue, besides these papillae, numerous mucous glands are found; 
these bodies, scattered over the whole surface, secrete the ordinary mucus; 
they differ in no respect from mucous glands wherever situated. In the val- 
leys surrounding the maximae papillae they are found in larger number than 
in any other portion of the organ. 
A transverse section exhibits the tongue as composed of symmetrical halves, 
separated from each other by a fibrous septum, each half consisting, as seen, 
of muscular structure supplied with vessels and nerves, and having, in most 
cases, much interposed fat. 
The tongue, being an organ of both special and common sense, is furnished 
with nerves of like signification. Thus the papillae, at the apex and sides, 
are supplied with gustatory filaments from the third branch of the fifth 
nerve; the great papillae and base of the organ, from filaments of the glosso- 
pharyngeal ; the muscular structure, by the hypoglossal. 
The arteries of the tongue are the lingual, branches of the facial, and as- 
cending pharyngeal. The one of most signification is the first. This vessel, 
known in its continuation as the ranine, anastomoses with its fellow, just 
above the fraenum, on the under surface of the organ, and is liable to be 
cut in the operation for tongue-tie ; it is the second branch from the external 
carotid; it pursues a course parallel, for a short distance, with the great horn 
of the hyoid bone lying between it and the hypoglossal nerve. Wounds of 
the tongue occasionally make the artery at this point the seat of ligation. 
(See Ligation of Arteries.) 
Epiglottis.-The epiglottis, Fig. 67 (30), seen by depressing the dorsum, 
forms, practically, the base of the tongue; it is a cartilage supported in the 
centre by a bridle, the fraenum epiglottidis, and at either side by two duplications 
of the lingual mucous membrane, the glosso-epiglottic ligaments, or folds, as 
they are called; these boundaries form two lateral depressions, or fossae, fossae 
linguales, noticed as being so frequently the seat of the lodgement of foreign 
particles. (See Diseases of the Tongue.) 
Gums.-(See Diseases of the Gums.) 
Mucous Membrane.-Practically considered, the oral mucous mem- 
brane is to be viewed as commencing at the lips and terminating at the anus, 
so much is it in sympathy part with part. Anatomically, it is to be described 
as consisting of a plane of homogeneous tissue, underlaid by a vascular supply, 
the vessels being supported by and in cellular tissue, This basement mem- 
brane affords foundation to a covering of squamae, or scales, known as the epi- 
thelium, and covers in tissues or organs which have offices of a recrementitial 
nature. THE MOUTH. 
131 
The tissues, beside the vascular, which underlie the mucous membrane, 
are the nerves, the lymphatics, and the papillary structure. The epithelium, 
the covering layer, is singularly various in its character, being in some parts 
columnar, in others squamous, in still others ciliated. 
Commencing at the alveolar margin of the lower jaw, this membrane 
passes over the floor of the mouth, envelops the tongue on all its free surface, 
forming beneath, by its duplications, the fraenum linguae; from the back of 
the organ it is so reflected as to form the three glosso-epiglottic fraena; from 
this it lines the pharynx and larynx, and is then continued over the digestive 
and respiratory tracks, lining, in the latter, the very terminal vesicles. 
The mucous cysts, or follicles, so plentifully scattered over the oral mucous 
surface, have, as their office, the secretion of a limpid fluid, which is com- 
monly to be seen standing over the membrane as drops of cold sweat are 
observed on the forehead in typhoid conditions, the two, indeed, looking very 
similar. The constituents of mucus are water, the peculiar organic principle 
called mucosin, and alkaline salts. Mucous glands are variously named, 
according to their location, as glandulae labiales, buccales, etc. 
Columnar epithelium consists of rod-like particles, crowded closely to- 
gether, and bulged near the centre by a nucleus; this variety is found in 
the air-passages, on the intestinal villi, in the bile-duct, and elsewhere. The 
scaly is found in the alimentary tract, as low as the stomach. The glandular 
seems to be a constituent of all the glands, being made up of particles bulky 
and globular. Ciliated epithelium is the columnar variety clothed with 
secondary particles. 
SALIVARY GLANDS. 
The salivary glands are of the conglomerate order, and are very well rep- 
resented by an ordinary bunch of grapes. There is, first, a great number 
of lobules, each lobule being a miniature gland; from these come ducts, or 
channels of outlet, representing the grape-stems; these are all associated with 
a common branch or duct, which is the channel of outlet into the mouth. 
Parotid.-The parotid, the largest of the salivary glands, is situated in 
the hollow between the external ear and ramus of the inferior maxillary bone. 
Its weight varies considerably in different individuals, the mean being in the 
neighborhood of an ounce. The boundary of the gland above, is the zygoma ; 
below, a line carried directly across from the angle of the jaw to the sterno- 
mastoid muscle. Dissected from its bed, the organ is found quite deeply 
seated; it extends above into the glenoid fossa of the os temporis, occupying 
the portion situated back of the Glaserian fissure. Below, it rests upon the 
styloid process and muscles, extending forward to the space between the two 
pterygoid muscles. The gland is exceedingly vascular, having embedded in 
it the external carotid artery, which here divides into the temporal, internal 
maxillary, transverse facial, and posterior auricular. The temporo-maxillary 
vein also traverses the structure, while the deep jugular and the internal 
carotid artery lie very close to its inner surface; it is also pierced by the 132 
A SYSTEM OF ORAL SURGERY. 
facial and great auricular nerves. Externally, the gland is smooth, and has 
its lobes protected by a covering very similar in appearance to the pia mater 
of the brain. Upon this covering lie lymphatic bodies, the enlargement of 
which is often mistaken for disease of the gland itself. Covering the body 
are the parotid fascia, a reflection of the common deep fascia of the neck, the 
platysma myoides, fascia superficialis, and skin. The gland empties its secre- 
tion into the mouth through a duct known as that of Steno. This duct 
passes across the face between the superficial fascia and muscles, perforating 
the buccinator opposite the second molar of the upper jaw : a line, designating 
its position, and which is most important to be remembered, is drawn from 
the lobe of the ear to the middle of the upper lip. The duct is composed of 
firm and resisting tissue, is about the diameter of a crow-quill, and is some 
two inches in length ; it consists of three coats,-an external, or fibro-muscular, 
an internal, or mucous, lined with ciliated epithelial scales, and a middle, or 
cellular, coat. A glandular body, the associated parotid, is found related with 
Steno's duct; its location is just outside the perforation of the buccinator 
muscle by that tube. A tumor associated with the glandular bodies overlying 
the parotido-masseteric fascia is movable, one situated beneath the fascia is 
fixed. Tumefaction of the parotid itself shows at the angle of the jaw, other- 
wise inward toward the throat. 
Submaxillary.-The submaxillary, the second in size of the salivary 
glands, is situated beneath the lower jaw in the superior cervical, or submax- 
illary triangle. The gland is somewhat of the size and shape of an almond- 
hull, and has a weight of two or three drachms; it is completely enclosed in 
a triangular envelope, made by two leaves of the deep fascia attached below 
to the digastric tendon. Directly upon the gland, and within the envelope, 
are two lymphatic bodies, which are quite liable to take on inflammatory en- 
largement ; these glands I believe to be pretty constant, as I have examined 
many subjects for them, and mostly with the common result of finding them. 
The so-called extirpation of the submaxillary gland is, most generally, the 
removal of one of these bodies enlarged through inflammatory action; these 
ganglia may be surgically viewed as being strictly non-vascular, a ligature 
being seldom needed in operations upon them. The gland itself, on the con- 
trary, is very vascular, the facial artery passing frequently directly through 
its substance, or so closely connected with the lower surface as to compel the 
division of it, or some of its large branches, before the body can be raised 
from its bed; the lingualis also sends branches to it. The veins correspond 
with the arteries. The gland is closely in relation with the parotid, behind, 
and the lingual, in front, being separated from the first by the stylo-maxillary 
ligament, and from the latter by the mylo-hyoid muscle. The duct by which 
the gland conveys its secretion to the mouth is some two inches in length ; it 
passes between the mylo-hyoid and genio-hyoid muscles, and opens by the side 
of the fraenum linguae. It is the most common seat of ranula. It is called 
Wharton's duct. THE MOUTH. 
133 
Sublingual.-The sublingual is the smallest of the three glands; it rests 
directly beneath the mucous membrane, being between it and the mylo-hyoid 
muscle; its weight is about one drachm. The exact position of the gland, as 
it lies at the lateral aspect of the fraenum linguae, can be seen by raising the 
tip of the tongue ; its bulk will be noticed by elevating the mucous membrane, 
upon which its excretory ducts, some twenty in number, open; these ducts 
are named Rivini, and are to be distinguished from one or more, called the 
Bartholin, opening into or near Wharton's duct. The lingual gland, when 
diseased, may frequently by removed with very little hemorrhage. The author 
has extirpated it without using a single ligature. (See Oral Secretions.) 
TEMPORO-MAXILLARY ARTICULATION. 
The inferior maxillary bone articulates with the anterior portion of the 
glenoid cavity of the temporal, forming what is known as an arthrodial, or 
gliding, joint. The direct composition of this joint consists of the convex 
condyloid head of the maxillary bone,. the concave surface of the glenoid 
fossa, interarticular fibro-cartilage, a double synovial membrane, and a loose 
capsular ligament. (See Figs. 72, 73.) 
The double character of the glenoid fossa, with its fissure of division, its 
articulating eminence in front, and the cartilage-covered condyle of the max- 
Figs. 72, 73.-Vertical Section of Temporo-maxillary Articulation 
Vertical section of the articulation 
of the lower jaw. 1 is placed above the 
glenoid cavity; 2, glenoid cavity; 3, inter- 
articular cartilage dividing the joint into two 
cavities, 4 and 5; 6, an interarticular cartilage 
separated from a joint, to exhibit its form. 
External view of the temporo-maxil- 
lary articulation. 1, zygoma; 2, glenoid 
tubercle; 3, ramus of the inferior maxillary 
bone; 4, mastoid process; 5, external lateral 
ligament; 6, stylo-maxillary ligament, a pro- 
cess of the cervical fascia. 
illary bone, is best understood by looking at the diagrams, which a student is 
advised to study carefully. The view represents the parts in position and in 
physiological relation. Above is seen the glenoid cavity (2) ; below, the con- 
dyle of the inferior maxilla; separating the two is the interarticular fibro- 
cartilage (3), with a synovial, or lubricating, membrane lining each aspect of 
the joint; the back part of a common capsular ligament is also exhibited, 
which, if completed, would be seen enveloping the whole joint. Back of the 
section, the shaded cavity, bounded in front by the condyloid process of the 134 
A SYSTEM OF ORAL SURGERY. 
jaw, behind by the base of the nipple, and beneath by the styloid process, is 
that portion of the cavity which lodges the upper part of the parotid gland. 
The capsular ligament is an exceedingly loose sac, very much, indeed, 
like the capsule of the humero-scapular articulation; it is attached above to 
the circumference of the glenoid cavity, and in front to the articular root of 
the zygoma; below, it clasps the neck of the bone just beneath the head. 
The interarticular fibro-cartilage is an ovoid plate placed between 
the two bones. It is supported in its position by a more or less perfect 
circumferential attachment to the common capsule, the external lateral liga- 
ment, and to the tendon of the external pterygoid muscle; below, its face is 
concave, corresponding with the convexity of the condyle ; above, it is concave 
in front, convex behind, corresponding with the glenoid cavity proper and the 
eminentia articularis. In composition the circumference is markedly fibrous, 
shading off to a cartilaginous centre frequently quite soft and sometimes 
perforated. 
The synovial membranes, placed, as seen in the view, one above, 
the other below the interarticular fibro-cartilage, are the ordinary lubricating 
membranes of closed cavities; they may very well be likened to two simple 
bags with parietal attached faces. These bags secrete the synovia, a fluid 
which looks not unlike the white of an egg, but which is much more oily and 
resistive in its nature. 
From the spinous process, to be seen on the great wing of the sphenoid bone, 
a ligament, the internal lateral, descends to be attached to the inner face of 
the ramus. Behind, from the styloid process of the os temporis (6), a second, 
the stylo-maxillary, passes to be inserted just above the angle. 
The external lateral ligament is a short, somewhat triangular-shaped, band 
of fibrous tissue, having origin from the zygoma; passing obliquely down- 
ward and backward, and inserted about the neck of the condyle. Just below 
the head it lies in contact with the lateral aspect of the interarticular fibro- 
cartilage and assists in forming, or at least in thickening, the common cap- 
sule. Externally, it is quite superficial, being covered only by the integu- 
ments, except in instances where the upper border of the parotid gland 
spreads over it. The importance of the character of this articulation renders 
necessary its careful study by direct dissection. CHAPTER VIII. 
ANATOMY OF THE TEETH. 
The direct and associative lesions of the teeth being so many and so com- 
mon, study of oral diseases commences naturally with these organs. Here too 
begins the study of dentistry proper. 
A tooth is a body sui generis ; it resembles ivory, but is not that substance ; 
it is allied with bone, but is not osseous. 
Dissection of a tooth recognizes the presence of 
five constituents; these are : 
1. Pulp. 
2. Dentine. 
3. Enamel. 
4. Cementum, or Crusta Petrosa. 
5. Periodonteum. 
Fig. 74 shows the vertical section of a cuspid 
tooth. 1, cementum; 2, dentine; 3, enamel. The 
pulp is seen occupying the central cavity. The 
dotted envelope of the root represents the position 
of the cementum. The periodonteum is a fascia 
attached to the cementum. 
Pulp .-The pulp, exhibited here several times 
enlarged (Figs. 74, 75, 76), is a mass of delicate 
connective tissue, in which ramify the radicles of 
blood-vessels and nerve-filaments. It has no envelop- 
ing membrane proper, as will be understood in the 
study of odontogeny; it is the contracted original 
papilla, or tooth-germ. Through the vessels of this 
body the internal structure of a tooth is nourished; 
in its death the organ loses its translucency, becoming 
discolored and opaque,-being, indeed, devitalized, 
except as nourishment is received from the perio- 
donteum. The pulp of a tooth is so highly endowed with nerve-matter that 
the slightest touch suffices to provoke exquisite pain. 
Dentine.-The dentine, or dentinal portion of a tooth, is marked 2 in 
the diagram (Fig. 74). This substance is called, also, the ivory. While 
histological dispute exists as to the real constitution of the structure, a full 
surgical signification is found in accepting it as a fibro-calcareous stroma, 
Fig. 74. 
Vertical section of a cuspid 
tooth. 
135 136 
A SYSTEM OF ORAL SURGERY. 
tubular in character. The tubuli, commencing at the enamel membrane, 
the original tunica propria (see Dentition), approach the pulp, opening into 
the cavity by capillary mouths, and thus receive the halitus which is their 
nutrition. The tubuli of dentine are in some instances almost straight, 
at other times curvilinear. In the neighborhood of the enamel they are 
dichotomous and trichotomous. Figs. 77 and 78 show these varieties of 
tubes. Fig. 83 shows the tubes in transverse section. The diameter of 
a dentinal tubule is about the of an inch. (For mode of formation of 
dentine, see Dentition.^ 
Enamel.-No. 3, Fig. 74, exhibits the position and relation of the 
enamel as a cap to the crown portion of a tooth. This structure is almost 
Fig. 75. 
Fig. 76. 
Dental pulp, magnified. 
Nerves of dental pulp. 
entirely inorganic in its composition, containing but about two per cent, of 
animal, or living, matter; it is hard, flinty, brittle, and decreases in thickness 
as it passes from the cutting face to the neck of the tooth. In arrangement, 
Fig. 77. 
1, tubuli of dentine; 2, enamel. 
enamel is made up of a series of hexagonal fibres, having a double direction, 
by which each is strengthened by its fellow as it is crossed and recrossed, 
one set undulating outward, another crosswise. The nutrition of enamel is 
received through the tunica propria. (See Dentition.') ANATOMY OF THE TEETH. 
137 
Cementum, or Crusta Petrosa.-Fig. 78 (1) exhibits the relation of 
the cement as a sheathing to the fang. This structure so closely resembles 
Fig. 78. 
Vertical section of the fang of a canine tooth, exhibiting the structure of the 
dentine and cement. 1, inner extremities of the dentinal tubules; 2, outer extremities 
of the tubules, terminating in interspaces at the boundary of the dentine; 3, cement; 
4, lacunae like those of bone. Highly magnified. 
bone proper as to be liable to the diseases of that substance; it possesses all 
its chemical elements. A thick cementum contains well-marked Haversian 
Fig. 79. 
Fig. 80. 
Three enamel columns, highly magnified; 
exhibiting the six-sided prismatic and waving 
character. 
Section of enamel, highly magnified at 
right angles to the course of its columns; ex- 
hibiting the six-sided character of the latter. 
canals and Purkinjean corpuscles, or lakelets; vessels from the periodonteum 
are occasionally traced into its substance. (See manner of its formation in 
chapter on Dentition.) 
Periodonteum.-This is the analogue of the periosteum of the common 
osseous structures. It is a composition of fibro-cellular tissue, serving the 
double purpose of attaching the teeth to their alveoli and supporting the 
external vessels of nutrition. Originally it was simple mucous membrane 
forming the covering of the rudimentary jaw cartilage. At the neck of a 
tooth it is found dense and resisting; toward the apex it attenuates to soft- 
ness and delicacy. 
Interglobular Spaces.-Fig. 81 exhibits what are termed interglobular 
spaces, as seen in the dentine of certain teeth: these spaces possess much 
surgical interest, as it is to be presumed they represent an imperfect develop- 
ment, and thus explain the rapid breaking down of many teeth. In an 
excellent paper on this subject, by Dr. J. H. McQuillen,* that gentleman 
* Dental Cosmos, vol. viii. p. 113. 138 
A SYSTEM OF ORAL SURGERY. 
wisely remarks that it is well to direct attention to the fact that the existence 
of the spaces in teeth which have completed their growth must be regarded 
as an abnormal condition, predisposing such teeth to decay, and that when, 
Fig. 81. 
Fig. 82. 
Vertical section of a molar tooth, 
moderately magnified. 1, enamel, the lines 
of which indicate the arrangement of its 
columns; 2, dentine, the lines indicating 
the course of its tubules; 3, thin lamina of 
the dentine forming the wall of the pulp- 
cavity, the dots indicating the orifices of the 
dentinal tubules; 4, cement. 
Interglobular spaces. 
either by mechanical action, as by a fall or blow, or by the penetration of 
external caries, such spaces are reached, the disease here would run riot; 
hence the importance of care on the part of patients and operators to have 
the most minute cavities filled ; for though reached only 
through a microscopical opening, the result would be 
the same, while, if protected from the action of external 
influence or the exciting causes of decaythis predis- 
position might remain dormant for a lifetime. Refer- 
ence is here to be made to these spaces, as they furnish 
habitations to parasites. The cavities not infrequently 
communicate with one another, and are in turn com- 
municated with by breaks in the enamel. It is not 
uncommon to find them occupied by micrococci. (See 
Parasites.') 
Figs. 82 and 83 represent sections of molar teeth; 
they will assist in comprehension of the organs. It is 
very necessary to have accurate ideas concerning the relations of a pulp-cavity 
to the external parts of a tooth. Such understanding, to be of practical use, 
is to be gained only through examination of many teeth. What are called 
the cornuae, or horns, of pulps (extensions), are to be closely observed. 
Fig. 83. 
Transverse section 
OF A MOLAR TOOTH 
OF THE NATURAL SIZE. 
(The cut is made 
through the body of 
the tooth.) 1, dentine; 
2, enamel; 3, cavity. AX ATOM! OF THE TEETH. 
139 
Relation of the Teeth with the Jaw.-The teeth associate with 
the jaw through the intervention of a peculiar cellular bone described as the 
alveolar processes. (See Fig. 13.) This structure, as there seen, is hollowed 
into pits corresponding with the shape of the roots accommodated by them. 
In some persons it is very spongy, in others it closely resembles in density the 
cortical portion of bone; in proportion to this density teeth are found loosely 
or firmly fixed. It is a matter of experience that in proportion as this process 
is solid, teeth are found resistive of disease. 
Fifty-two teeth belong to the human species. These are divided into two 
sets. The first pertain to infancy ; the second associate with adult life. 
Fig. 84.-Deciduous Teeth oe the Left Side. (After T. Bell.) 
Deciduous teeth of the left side of the jaws. 1 and 2, incisors; 3, cuspidati 
4 and 5, molars. 
The first set, termed milk, deciduous, or temporary, consist of twenty teeth, 
-ten in either jaw: four central incisors, four lateral incisors, four cuspidati, 
and eight molars; the form and general characteristics are illustrated in 
Fig. 84. The second or permanent set are thirty-two in number,-sixteen 
in either jaw: four central incisors, four lateral incisors, four cuspidati, eight 
bicuspidati, eight molars, and four dentes sapiential. The derivations of these 
terms are as follows: incisores, from the Latin verb incido, to cut; cuspidati, 
from cuspis, a point; bicuspidati, from bi, two, and cuspis, point, having two 
points; molares, from mola, a mill; dentes sapientiae, teeth of wisdom, so 
called from being developed in mature life. 
Incisors.-Nos. 1 and 2 of Fig. 85 represent the incisor teeth of the 
upper jaw, and Nos. 1 and 2 of Fig. 86, the incisor teeth of the lower jaw: 
two centrals and two laterals. Labial aspect of crown is like frustrum of 
pyramid, or shovel-shaped, and slightly convex. Lingual surface, same 
shape, but slightly smaller, and concave. 
Laterally they are triangular, widest at neck, and represent the labial and 140 
A SYSTEM OF ORAL SURGERY. 
lingual surfaces gradually approaching one another until they unite to form 
the cutting edge. 
When first erupted, the cutting edges of these teeth terminate in three 
points, which points rapidly wear away in mastication. 
Enamel extends to greatest distance toward root on labial and lingual sur- 
faces, and terminates at neck in a curve, with convexity directed toward gum. 
On mesial and distal surfaces enamel does not extend up so high, and again 
terminates in curve line, but in this case with convexity toward cutting edge. 
In other words, outline of enamel corresponds to outline of festoon of gum. 
All of these teeth have single conical roots. 
Superior Centrals (Fig. 85,1).-Larger than laterals; about one-third 
wider, and usually a little longer. Their greater width at cutting edges than 
Fig. 85. 
Permanent teeth of superior jaw. 
at neck leaves spaces between themselves and fellows at latter point. Median 
side straighter and longer than distal; consequently a more acute angle at 
median corner than at distal. Lingual surface, which is concave, often termi- 
Fig. 8G. 
Permanent teeth of inferior jaw. 
nates near gum in a ridge, or prominence, called the basal ridge, or cingu- 
lum ; this is most frequently found and is most pronounced in laterals; it is 
a favorite spot for caries. 
Superior Laterals (Fig. 85, 2).-In every way smaller than centrals, 
but quite similar in general outline. Greater disproportion between width of 
cutting edge and neck than in centrals. Distal angle of crown more rounded ANATOMY OF THE TEETH. 
141 
than same angle of central. Median surface slightly concave, and distal more 
convex than in central. Basal pit more strongly marked, and hence more 
ready to decay. 
Lower Central Incisors (Fig. 86, 1).-Very much narrower than 
superior centrals; not much more than half the width at cutting edges. 
From before backward are very deep at neck; hence fangs are much flattened 
from side to side. Termination and outline of enamel at neck is similar to 
superior incisors, but there is neither basal ridge nor pit. 
Lower Laterals.-Unlike the superior laterals, these are larger than 
their adjoining centrals in every respect, but especially in length of root. 
Distal angle of cutting edge is not rounded off as in laterals of opposite jaw. 
Cuspidati-Eye-, Stomach-Teeth (Figs. 85, 86, 3).-Are thicker 
and stronger teeth than the incisors. Crowns are distinctly conical, with a 
slight bulging near middle of tooth; consequently they are (unlike the in- 
cisors) convex on lingual as well as on labial surface. Crown terminates in a 
blunt point, and the root is much longer than that of any of the other oral 
teeth. Slight ridge runs from cutting edge to neck on labial surface, dividing 
it into two unequal portions, of which the distal is the longer. This enables 
us to tell the side of the jaw to which it belongs. On lingual surface a slight 
median ridge runs from cusp to neck, sometimes terminating in a slight promi- 
nence or cingulum. Outline of enamel on lateral surfaces is more distinctly 
angular than in incisors, with angle pointing toward cusp. Section at neck 
shows root to be a rounded triangle in outline. Synonyme, eye-teeth. 
Inferior Cuspidati-Singular, Cuspidatus, Cuspus (Fig. 86, 
3).-Less pronounced in form than upper. Point more blunted, fang shorter, 
and lingual surface more distinctly convex. Synonyme, stomach-teeth. 
Bicuspidati-Singular, Bicuspidatus, Bicuspis (Figs. 85, 86, 
4, 5).-Eight in number, two on each side of upper and lower jaws. 
Superior Bicuspidati (Fig. 85, 4, 5).-Crown, as seen on grinding 
surface, is a rounded quadrilateral. Buccal side is larger than palatine, which 
latter is more distinctly circular than former. The mesial and distal sides are 
nearly plane surfaces, though slightly rounding toward the palatine side. 
They have two cusps, the external being larger and broader than the internal. 
A deep transverse fissure separates the cusps, and slight elevations border the 
anterior and posterior edges of the grinding surface. First bicuspis usually 
has its root bifurcated for about half its terminal length, and if not bifurcated, 
is deeply grooved. 
Second Bicuspidatus-Superior.-Differs from first in having 
cusps more nearly of a size, and in having an unbifurcated root. Root is, 
however, constricted in the middle, in the direction of its length. Like the 
canine, both bicuspidati have distal slope of cusp greater than medial. 
Inferior Bicuspidati (Fig.*86, 4, 5).-Are smaller than the upper, and 
differ considerably in shape. The buccal surface is much more convex, and 
dips strongly inward at the masticating surface. In the first bicuspis the 142 
A SYSTEM OF ORAL SURGERY. 
lingual cusp is so much shorter than the buccal as often to seem but rudi- 
mentary. Another distinguishing feature of first bicuspis is the joining of 
both cusps by a ridge of enamel instead of being separated by a fissure, as is 
the case with all the other bicuspidati. Roots of lower bicuspidati are rounder 
and less constricted than the upper,-more decidedly oval in outline. The 
second bicuspis is squarer and larger in all its dimensions than the first, with 
a higher inner cusp than its fellow. This inner cusp is often divided by a 
fissure. 
Molares-Molars; Singular, Molar.-Largest and strongest teeth. 
Have quadrilateral crowns, surmounted by several cusps and implanted by 
means of two or three roots. Twelve in number, named respectively First, 
Second, Third. The last commonly called "wisdom-teeth," dentes sapientiae. 
Superior Molars.-Crowns are rhomboidal in sectional outline. Buccal 
and lingual surfaces (more particularly the latter) are convex, while the proxi- 
mal surfaces are flattened. The angles connecting these sides are rounded; 
the mesio-palatine and the disto-buccal more markedly than the other two. 
The crown is surmounted by four cusps,-two buccal and two lingual,-which 
cusps are separated by fissures running between them. One main fissure ex- 
tends from the anterior to the posterior margin in an irregular line, while from 
this there branch off two others. One of these starts from the anterior part 
of the main fissure and runs obliquely backward and outward between the 
two buccal cusps, terminating on the buccal surface. The other branches off 
from the main fissure near its posterior terminus and runs obliquely forward 
and inward between the lingual cusps, and terminates on the lingual surface 
near the gum. Of the four cusps, the mesio-palatine is the largest. After it, 
in point of size, come respectively the mesio-buccal, the disto-buccal, and the 
disto-palatine. The crowns of the first and second molars differ but little 
from one another, but in the latter the two lingual cusps are sometimes united 
into one larger one, thus giving the lingual surface a more distinctly semi- 
circular outline. When they are not so blended the fissure dividing the lin- 
gual cusps will be found to be less pronounced in second than in first molar. 
The roots of these teeth are three in number,-two buccal and one palatine. 
Of the two buccal, the anterior is the larger, and stands out more prominently 
toward the cheek. Both are compressed laterally. The palatine fang is much 
larger than either of the others. It is round, long, and curved obliquely 
upward toward its fellows. Usually the three roots are separate and divergent. 
The enamel terminates in a nearly even line around the neck of the tooth. 
Inferior Molars.-First molar the largest. Has five cusps,-three on 
buccal and two on palatine surface,-visually separated by fissures. Of the 
three buccal cusps, the anterior is the largest and the posterior the smallest. 
The second molar has but four cusps, separated by a crucial fissure. One arm 
of this fissure generally extends to and ov^r the buccal surface between the 
cusps, and terminates near the gum in a small depression, where caries is apt 
soon to show itself. These teeth have usually but two roots, situated anteriorly ANATOMY OF THE TEETH. 
143 
and posteriorly. They are flattened and grooved, and the anterior is the 
broader and longer of the two. They are usually divergent and curved 
slightly backward. The roots of the second inferior molar differ from those 
of the first principally in their lying closer together and in their greater back- 
ward curvature. 
Third Molars-Dentes Sapientiae, Wisdom-Teeth.-In the 
upper jaw these teeth closely resemble the second molars. The two palatine 
cusps are always blended into one, and the three roots are usually confluent, 
Fig. 87. 
Lateral view of the upper and lower permanent teeth. 1, first incisors; 
2, canines; 3, first premolars; 4, middle molars. 
forming an abrupt tapering cone. The crown is the smallest of the three 
molars. Often it is abnormally small, almost rudimentary in character. In 
the lower jaw these teeth are considerably larger than the corresponding ones 
above, and are also usually larger than the superior second molars. They are 
very little, if any, smaller than the first lower molars, and greatly resemble 
these in crown, having five cusps similarly situated. They are usually two- 
rooted, but the roots are often confluent and curve strongly back toward angle 
of jaw. 
Recapitulation of Names.-The names of the teeth, expressed in the 
singular number, are, incisor, cuspidatus, bicuspidatus, molar, dens sapientiae. 
A tooth is divided into three parts: a crown, root or fang, and neck. The 
crown of a tooth is the exposed part; the fang, the part which associates it 
with the jaw; the neck is the intermediate part. In the language of dentistry 
the surfaces of the teeth are known as mesial, distal, labial, buccal, palatal, 
lingual, articulating, cutting. 144 
A SYSTEM OF ORAL SURGERY. 
Analysis of Dentine.- 
Phosphate of lime 62. 
Fluorate of lime 2. 
Carbonate of lime 5.5 
Phosphate of magnesia .... 1. 
Soda and muriate of soda 1.5 
Gelatin and water 28. 
Attention is to be directed to the variable density of the teeth ; consequently 
any individual analysis can only be an approximate. 
Analysis of Enamel.- 
Phosphate of lime 85.3 
Fluorate of lime 4. 
Carbonate of lime 7. 
Phosphate of magnesia 1.5 
Soda and muriate of soda 1. 
Animal matter and water 2. 
Analysis of Cementum.-The near approach of cementum to bone 
affords large proportions of organic matter,-twenty to thirty parts to the 
one hundred. A quantitative analysis of a given specimen yielded as follows : 
Phosphate of lime and fluoride of calcium 58.73 
Carbonate of lime 7.22 
Phosphate«of magnesia 0.99 
Salts 0.82 
Cartilage 31.31 
Fat 0.93 CHAPTER IX. 
DENTITION. 
By dentition is implied both the development and cutting of teeth. Origin 
of the term is with Latin words dens, a tooth; dentitio, to breed or pro- 
duce teeth. By some writers meaning is restricted to processes relating with 
eruption; others use it, and most 
properly, as it seems to the author, 
in the embracive sense here em- 
ployed. 
Teeth, together with alveolar pro- 
cess, develop upon the base proper of 
the jaws. The two relate. They 
come together and they go together. 
Teeth are bodies sui generis. 
Alveolar process, which con- 
stitutes the support of the teeth, is 
modified osseous tissue. 
Origin of the Teeth.-At a 
time beyond which it does not con- 
cern the surgical writer to go (about 
the sixth week of foetal life) the jaw 
-the lower will be the example- 
is a plane of simple rudimentary car- 
tilage ; a condition to be understood 
and appreciated by referring to the 
diagram (Fig. 88). This picture is, 
of course, an immensely magnified 
illustration, but it is to be accepted 
as exhibiting accurately the con- 
ditions represented. The letter F 
locates the position of the rudimen- 
tary cartilage about which, later, 
traces of ossific matter, II, show as a deposit. The dental papilla, D, here seen 
as assuming the crown-shape of a tooth, is first appreciated as an apparent con- 
densation of its neighboring mesoblastic-founded structure. While, however, 
it is, undeniably, of such foundation, it is so only in the sense that the whole 
jaw structure is mesoblastic; that is to say, the jawbone proper, the alveolar 
Fig. 88.-Section of Incisive Region 
of Lower Jaw. 
Section of the incisive region of lower 
jaw of human embryo. A, surface epithelium; 
B, epithelial cord; C, enamel membrane; D, den- 
tal pulp, covered by small cap of dentine; E, epi- 
thelial cord in which is developed permanent 
tooth; F, rudimentary cartilage of jaw; H, traces 
of ossific matter; I, section of the dental nerve. 
145 146 
A SYSTEM OF ORAL SURGERY. 
process, the gum, and the teeth are all one yet all different. A stands for mucous 
membrane. B represents what is denominated the " epithelial cord.'' Cstands 
for an appearance, related with tooth formation, known as "enamel membrane." 
E is a little sacculus, standing for condensed epithelium, having its meaning in 
a tooth-germ of the second set, which is within it. Zis the dental nerve. 
While the diagram shown is so admirable as an illustration, it is yet deceptive 
to the inexperienced by reason of the separation it makes between parts. 
Rudimentary cartilage, tooth-germ, and overlying mucous membrane are not 
differentiated as here shown, but relate primarily as exhibited in Subfig. 2, 
Fig. 89. This second figure is, of course, wholly diagrammatic, but it shows, 
after appreciative fashion, what is necessary to be understood,-namely, that 
there is a plane of rudimentary cartilage and a plane of mucous membrane, 
and that between these planes exist germs which later are to distinguish 
themselves from cartilage and membrane as teeth. 
The teeth are complex bodies, having to their construction a pulp, dentine, 
enamel, cementum, and periodonteum. Whence are these parts ? and how ? 
Before proceeding to a demonstration it is necessary to refer to differences 
that exist between the views of microscopists generally and those of the writer. 
Fig. 88, as it stands, represents accurately a relation of parts accepted both by 
microscopists and writer as expressive of tooth origin and development. Differ- 
ence lies with reading what is seen. Microscopic observers pronounce the crescent 
fold, shown at C, the maker of enamel. It is exhibited by them as an inver- 
sion of the mucous membrane, beginning as a dip from the surface and reaching 
little by little downward until it assumes the form shown when it begins to pour 
out enamel as a cap covering, mechanically, the tooth, D. Enamel is thus 
pronounced by the microscopic observers simply an adjunct to a tooth, with the 
origin and formation of which the tooth has no part. Enamel is pronounced 
by the microscopic observers one with epithelium, and in no sense one with 
dentine. The writer, on the contrary, pronounces the crescent the modifier 
of dental secretion, and not itself the maker of anything. He exhibits what 
the microscopists call an inversion as no inversion at all, but as simple thicken- 
ing expressive of a temporary nutritional activity; no dipping occurring from 
the surface, but inversion, if it is to be so called, confined to the rete mucosum. 
(See Fig. 94.) He exhibits enamel as formed, alike with dentine, by a tooth- 
pulp. He propounds that enamel is one with epithelium only in the sense that 
a common pulp secretion has been modified in being screened, as it were, by 
passage through epithelial tissue. 
Microscopists, in their inferences, deposit enamel from without inward ; that 
is to say, they place the first formed, consequently the oldest and hardest, 
layer in contact with the dentine, and the last formed, consequently the softest 
and most vital, in relation with parts farthest away from the dentine. Enamel 
is laid, by their theory, directly in contact with the dentine, no membrane of 
any kind intervening. Expressing all this differently, the microscopists furnish 
enamel, but they fail to provide means for its support and for the repair of that DENTITION. 
147 
continuous loss to which it is subject by reason of the process of mastication ; 
neither do their observations permit of notice being taken of the fact that 
while inverting the mucous membrane they as well invert, absolutely, the 
manner of its nutrition as this would be expressed in the formation and deposit 
of enamel, as viewed by them. It is to be added that they deny change in the 
enamel-being compelled by their theory to do so-after it is once formed. 
The inferences of the writer deposit enamel from inward without; that 
is to say, the oldest layer of enameloblasts are found farthest away from the 
dentine, and the newest, or softest, of them closest to it, just as in the case of 
epithelial scales the new and most vital are closest to a Malpighian structure 
out of which they practically arise, and by which they are both differentiated 
and nourished, and, when lost, replaced. 
The ordinary microscopic view of the enamel membrane leaves a tooth with- 
out its fibrous envelope, save as an undefined streak seen microscopically among 
the epithelium is drawn on for this purpose. The views of the writer find this 
membrane in the remains of a tunica reflexa, the lost portion of which is one 
with Nasmyth's membrane. 
Return is here made, by repetition, to place of beginning. In the early 
days of foetal existence the jaws are planes of rudimentary cartilage. These 
planes are overlaid by mucous membrane. Between the cartilage and the 
membrane the papillae known as dental germs are first met with. 
The period at which a dental germ is earliest seen is about the sixth week 
of intra-uterine life. At this period, a little sooner or later, such a germ is to 
be exposed by lifting the mucous covering from the basement cartilage. At 
all subsequent periods previous to eruption section through the overlying parts 
exhibits presence of germs. 
The alveolar process, with its many pits, is simply an osseo-spongy 
tissue, serving as a common envelope to the growing germs. In its origin it 
constitutes the primitive dental groove; a groove necessarily resulting from 
the growth of the process as, in its development, it borders on either side the 
germs. To appreciate the meaning of this groove, it is alone necessary to 
break out the septi in an adult jaw. What is here a big groove was once a 
little one. This groove is never, however, a ditch, or depression, except as 
such idea is conveyed by the pits and depth of an adult jaw, neither are 
alveolar process and body of bone one except as regard is had to relationship. 
Alveolar process is a provision associated with teeth; as dental germs develop 
so does it; when the teeth are lost so also does it disappear. Alveolar tissue 
grows around papillae; the dental pits signify obstruction. The papillae 
are not first met with in a groove; the groove being made, as understood, by 
the ridging on either side of developing alveolar process. 
Dental Germ.-A dental germ, a structure sui generis, is made up of a 
congeries of granular nuclei dispersed irregularly through a firm homogeneous 
blastema. It is not enclosed in a cell-wall, or membrane of its own; it is a 
hyaloid structure. 148 
A SYSTEM OF ORAL SURGERY. 
Tunica Propria.-A developing germ carries with it the overlying 
mucous membrane; the membrane hugging it closely. Here a student is to 
appreciate what is meant by observing Subfigs. 2 and 3, Fig. 89. This cover- 
ing, or envelope, constitutes, in time, a tunic; it is to be denominated coat 
first, or tunica propria. The relationship of this covering to a papilla is 
precisely that of parietal peritoneum to a knuckle of intestine in incarcerated 
or strangulated hernia. The shape of the coat is one with the papilla it en- 
capsules. 
While, after the manner just described, a tunic has been secured by a tooth- 
germ, it is recognized that the common mucous membrane has in no wise 
altered its relation to surrounding parts; it abuts closely all the circumfer- 
ence of a papilla; it is contracted, like an elastic substance about its base; it 
associates from this base with adjoining parts. 
Tunica Reflexa.-Corresponding with the growth of a papilla is that of 
its alveolar envelope. 
As such envelope is originally, and continuously, of submucous nature, being 
a bony organization, mecoblastic, arising out of cells existing between the 
mucous membrane and plate of jaw, among which cells the germ lies, it is to 
be recognized that as this increases about the germ, rising on either side of it, 
it necessarily carries around it a second coat, or tunic; tunica reflexa it is not 
unwarrantable to call it. Thus now stands the dental relation : a germ, origi- 
nally microscopic, has enlarged until it has become in shape and size the rep- 
resentative of a tooth; this germ is enveloped in a double sac; it is over- 
grown on all its circumference by tissue which later is to express itself as 
alveolar process and gum. 
Here again is difference between microscopists and writer, a difference which, 
if the former be right, leaves them nothing at all of a second layer to their enamel 
organ, while, as well, it takes from the writer his tunica reflexa, Nasmyth's 
membrane, and periodonteum, or, if not this, affords these parts with a defi- 
nition not nearly so well marked as after the manner contained in his own demon- 
stration. But just here is a way that the author feels sure is sooner or later to 
bring the microscopists and himself together. The microscopists will admit that 
a perfected tooth is supported by an alveolus made up of loose osseous structure. 
They will admit, as well, that this structure did not fall into its place suddenly, 
but that it gradually developed about the tooth it supports. If, accepting such 
universally well-known facts, they now go back to the period of encapsulation 
of a tooth, they will find the meaning of such encystment to lie with the de- 
velopment alluded to, and, as well, get appreciation of tunica reflexa, Nasmyth's 
membrane, and periodonteum. The encysting capsular tissue passing, as it 
does, through the proliferated mass of epithelium, called by microscopists the 
enamel membrane, necessarily cuts it in twain, thus separating a part above, 
called the cord, from a part below, called enamel membrane. All the part 
of the capsule below the neck of the tooth is to be periodonteum. All the 
part above is to give way and disappear before the erupting organ. The DENTITION. 
149 
face of this capsule is mucous membrane carried about the tooth by the 
developing alveolar process, and the circumvallation is rudimentary alveolar 
process. 
At this period the dental pulp, as the papilla is now to be called, having 
attained the size of the tooth-crown it represents, commences the formation 
of dentine ; in other words, the dentinoblastic stage has been reached. Before 
attainment of full size by the papilla, there existed between it and its sac proper 
a halitus. This halitus, now that the congeries of cytoblasts or nucleated 
granules have obtained their growth and secretive power, is replaced by a 
more highly endowed production, dentinoblastic, the work of matured cells. 
This secretion, or organization, constitutes the future dentine. Calcification 
is progressive with secretion. 
As this formation deepens within the mucous envelope, so the pulp contracts 
until, finally, it stops at that certain point which maintains within the tooth a 
canal, or cavity, and a vascular and nervous structure to occupy it,-this struct- 
ure, or pulp, being the contracted original papilla. The vessels of this papilla 
are analogous to those of the ordinary papillae of touch. 
Why this secretion, in its organization, should assume the position of the 
elongated tubular cells which pertain to the structure of dentine is not here 
to be discussed, it being enough for a present purpose to recognize the condi- 
tion, otherwise to express it as result of deposit of the calcific material out- 
side of the rod-like dentinoblastic fibrils, thus forming a sheath, as it were, to 
a rod that is later to be removed. 
Enamel.-The formation of dentine completed, covering of it with enamel 
begins; or rather this deposit is, to a degree, coincident with the dentinal for- 
mation. Secreted by the same pulp which forms the dentine, the same 
secretion, a portion finds its way through the primary sac. As it passes this 
sac, to be moulded against the second, it is modified by it; this, as understood, 
being mucous membrane, simply the modified mucous membrane, which was 
first seen as overlying the papilla. This sac of mucous membrane-tunica 
propria as it is properly termed-continues to exist between the two hard bodies, 
and receives and modifies, for the support of the enamel, the liquor sanguinis 
found in the dentinal tubules and intertubular structure. This tunica propria 
is the enamel membrane. It is to dentine and enamel exactly what Malpig- 
hian layer is to corium and epithelium. Its existence is not admitted by the 
microscopists. It is from this we receive impressions of pain when it becomes 
suddenly exposed by breaks in the continuity of enamel. 
In the process of tooth development, particularly at the stage when the hard 
structures are being formed, a grade of vascularity is present in relation with 
the two sacs, which seems quite to have deceived microscopic observers, as 
these persist in viewing such congested and thickened membranes as agents 
relating with the depositing of enamel, whereas, in reality, the external, the 
tunica reflexa, serves simply as a mould for the reception of this substance, 
and has its permanent office and meaning in the periodonteum, which mem- 150 
A SYSTEM OF ORAL SURGERY. 
brane a moment of reflection will show to be the persistent remainder of the 
tunic after the crown portion, Nasmyth's membrane, has been lost in eruption 
of the tooth, while the internal, the tunica propria, is, as suggested, one with 
the Malpighian office. Enamel is analogous with epithelium, in the sense that 
epithelium is analogous with corium. The only place where dentinal secre- 
tion comes into relation with, and under the influence of, epithelial correlation, 
is where it passes through the tunica propria, as has been described, into the 
moulding interspace existing between this and the tunica reflexa. A tooth 
at large is not a dermoid structure; the enamel of a tooth is dermoid to the 
extent and expression that its characteristic is received from, and is impressed 
by, an epithelial structure. 
Root-Growth.-The growth of the root of a tooth, as its dentine is 
concerned, has precisely the history of the body. Such growth is associated 
with pyramidal elongation of the pulp, which, pushing the crown upward, 
extends upon itself the enamel membrane and tunica reflexa. This elongation, 
with a greater vascularity and vitality assumed by it as approach is made to 
the basement vessels, modifies again the result obtained by the exudate passing 
through it from the dentinal pulp, the result being an approach to true bone 
in the production of cementum. Analogy is found in nails and in epiderm, 
structures of similar signification and origin. (See Cementum.^ 
Periodonteum.-The periodonteum, as suggested, is the modified ex- 
ternal sac, lost, of course, above the neck, as the tooth has emerged through it. 
Recapitulation.-The description given is a very simple and easily 
understood explanation of tooth-growth. The observations leading to the 
conclusions have been somewhat extensive, and the phenomena are certainly 
endorsed by general anatomical analogy. Let the conclusions be objected to, 
however, as undeniably they are by the physiologist, they are irrefutable as 
all surgical relations with the teeth are concerned. 
Diagrammatic Illustrations.-The tooth selected is an inferior central 
incisor. Subfig. 1 shows two lines; A represents mucous membrane 
overlying B, a plane of cartilage. 
Subfig. 2 shows, A, mucous membrane; C, basement cartilage; B 
illustrates the mucous membrane as it begins to be raised as an envelope- 
tunica propria-for the tooth-germ seen below it. 
Subfig. 3 is diagrammatic of the mucous envelope-tunica propria- 
as it invests the developed germ, no reference being made in the drawing to 
the developing alveolar walls. 
Subfig. 4 is diagrammatic of the idea of the manner of envelopment of 
germ by the second tunic,-tunica reflexa. It is understood that X X (B) 
is the growing alveolar walls, and that as this develops between the base bone 
and the covering of mucous membrane, it necessarily lifts the latter, but that 
in lifting it the tunica propria is not disturbed; hence a second tunic, having 
as its eventual office the meaning of a periodonteum,-i.e., a bond of rela- 
tionship between tooth and alveolus. The cut is to be understood as being DENTITION. 
151 
purely diagrammatic. A, mucous membrane; B, alveolar process ; C, tunica 
propria; D, base of jaw. 
Subfig. 5, also diagrammatic, is designed to afford idea of a tunica 
reflexa about completed. The relations of the parts in this cut need alone, 
in order to be exactly as in nature, that the two tunics be in relation with 
each other, separated only by an intervening halitus, and that similar rela- 
Fig. 89. 
tions exist between tunica propria and pulp. A, mucous membrane overlying 
gum-tissue, which tissue in its turn overlies X (B) alveolar process; C, de- 
veloping tunica reflexa, being part of the original plane of mucous membrane 
seen in Subfig. 1, and which here has been made to envelop the tooth-germ 
and its original tunic by reason of the developing alveolus of the germ repre- 
sented and of the other germs; D, tunica propria, got by the germ, as 
shown in Subfigs. 2, 3, and 4; E, base of jaw. 
Subfig. 6 shows similar relations as in 5, except that here the tooth-germ is 
withdrawn from its envelope, and the parts stand exposed, as would be shown 
by a transverse section. A and D, original mucous plane; B X> alveolar 
process; C, tunica reflexa, which tunic is eventually to constitute the perio- 
donteum ; the portion above, or that portion which relates with the tooth- 
crown, being lost because of the organ emerging through it in the act known 
as cutting;* D represents the inside of the tunica propria; the whole 
tunic, as shown, is persistent, the portion above the line constituting the 
enamel membrane, the portion below the line relating the cementum and 
dentine. From this tunic it is, as understood, that the enamel receives 
its whole nourishment; it acts also as a part-feeder of the cementum. 
Accepting the process of tooth development as here exhibited, it becomes 
understood that enamel has no special pulp as propounded by the histolo- 
gists. It is also understood that the structure calcifies from the outside inward, 
and not from the inside outward. It is, as well, seen that it is a vital tissue 
nourished exactly as are other parts. 
* Ligamentum Dentes.-The so-called ligamentum dentes is simply the thickened ring 
of the tunica reflexa, resultant of the remnant of the crown portion of this coat; part is 
absorbed, part contracts toward the root portion. 152 
A SYSTEM OF ORAL SURGERY. 
The description illustrates, as well, the manner and matter of periodonteal 
formation. It exhibits that a correct naming of that tissue would designate 
it alveolo-dental or alveolo-odonteal membrane. 
Nourishment of Enamel.-The enamel membrane is not strictly de- 
pendent on the common pulp for its nutrition. It has another source of 
supply,-namely, that received through the cemental portion of the tunica 
propria coming in its turn from the osseous-like circulation of the cementum 
derived from the periodonteum,-i.e., the persistent root portion of the tunica 
reflexa, the alveolo-dental membrane, and that gotten from twigs which come 
to it from apical vessels. (See Fig. 95.) 
Resume.-The attention of a student being directed to Fig. 90, a clearer 
understanding will not unlikely be secured by him of the subject considered, 
Fig. 90.-Relation between Dental Pulp, Dentine, Enamel, 
and Tunica Propria. 
Relation between dental pulp, dentine, enamel, and tunica propria. SD, dental 
pulp; D, dentine; E, to right side, enamel; E, to left side, position of tunica propria, or 
enamel membrane. PD is a point of uncovered dentine. 
as a practical significance is concerned. The diagram as here placed may stand 
for section of a cuspid tooth. Let SI) represent the dental pulp. D stands 
for the dentine. E locates the enamel. The line demarking dentine from DENTITION. 
153 
enamel, E, left side, expresses the position of the tunica propria, otherwise 
the enamel membrane, as this exists permanently between the parts, influ- 
encing, originally, the change of dentinoblasts into enameloblasts, and, later, 
furnishing the material of repair compensatory of a continuous wear and loss 
in the enamel. 
Fig. 91 furnishes another illustration of relation of dentine, tunica propria, 
and enamel. D, dentine; E, enamel; e, dividing line, tunica propria. 
Fig. 91.-Relation of Enamel, Tunica Propria, and Dentine. 
Relation of enamel, tunica propria, and dentine. D, dentine; E, enamel; e, the 
line running obliquely upward, tunica propria; a, a, a, a, dental fibres; c, d, so-called 
protoplasmic cavities. 
What is represented here-a, a, a, a-as dental fibres passing through the 
tunic into the enamel fibres and into protoplasmic cells is imperfect save as a 
higher power of the microscope is to distinguish the tunic as prolonged about 
the fibres, and that the cells are not so much protoplasmic cavities as they are 
likely to be what elsewhere in this volume is described as interglobular spaces 
having the meaning of arrested development, which see. 
Fig. 90, by its free illustration, corrects a confusion lying with the last, as 
in it the parts are more fully differentiated. SE, which here occupies the 
position and relation of the pulp, is not accurate for the purpose of a present 
demonstration, inasmuch as it represents a part that has undergone the pro- 
cess of calcification and has thus become part and parcel of the common dentinal 
mass. Were this pulp uncalcified-in other words, natural-it would show 
as a soft structure separated from its wall of dentine by a halitus. 
Fig. 92 represents a tooth-sac of the human embryo. Here the expressions 
of tooth development as set forth are perfectly exhibited. 1 stands for a dental 154 
A SYSTEM OF ORAL SURGERY. 
papilla arrived at a stage of odontoblastic (2) development. 3 stands for the 
forming dentinal tubules. 4 exhibits the enamel cap situated in the space 
between (5) the tunica propria and (6) the tunica reflexa. 7 is mucous 
membrane, much thickened by reason 
of great nutritional activity existing in 
immediately neighboring parts; it has 
come to overlie, as a third mucous layer, 
the papilla as exhibited in Subfig. 6, 
Fig. 89. 8 is elongation of tunica 
propria and tunica reflexa, as explained 
on page 148. The first, related with 
the root portion of the tooth, exists 
permanently between cement and den- 
tine, in like manner as above it relates 
dentine and enamel. The second con- 
tinues permanently to act as pericemen- 
tum. On eruption of the tooth the 
crown portion of this tunica reflexa 
becomes lost, being either absorbed by 
reason of pressure associated with the 
process of eruption, otherwise rubbed 
off in the act of mastication. This 
temporary top portion is known as Na- 
smyth's membrane, but it is to be rec- 
ognized as entirely one with an un- 
necessary portion of the pericementum.* 
Addenda, with Remarks.-The views of histologists at large regard- 
ing this matter of dentition are so tersely put by Dr. E. 0. Shakespeare in his 
introductory to Professor Allen's exhaustive " System of Anatomy," that it is 
deemed well to epitomize them for the benefit of students as regard is had to 
their further reading in the direction. 
" The first rudiments of the tooth," he says, " is met with early in embry- 
onic life, at a period when the connective tissue of the gum has scarcely ad- 
vanced in development beyond the state of fibrous mucous tissue. It is 
observed in the form of a club-shaped duplicature of the stratified epithelium 
of the gum." This, in the paper from which the quotation is made, is 
illustrated by a diagram (Fig. 29 Allen's System, here Fig. 93), which, as to 
its outlines, is without parallel in nature, as is clearly shown in Dr. Sudduth's 
work, where the club-shaped duplicature is demonstrated as a simple irregular 
proliferation of the lower cells of the rete mucosum, excited, as suggested in 
the text above, by a commencing tooth development, the excitation being one 
in character with the vascular perversion witnessed in association with eruption 
Fig. 92.-Tooth-sac of Human 
Embryo. 
Tooth-sac of human embryo. 1, dental 
papilla; 2, odontoblasts; 3, dentine; 4, en- 
amel; 5, tunica propria, or enamel mem- 
brane; 6, tunica reflexa, being below the 
periodonteum; 7, mucous membrane; 8, 
elongation of tunics. 
® Pericementum, periodonteum, or peridentium. DENTITION. 
155 
of the teeth through the gums. Precisely the same quality and character of 
proliferation relates with the development of hair-germs. " This epithelial 
infolding," Dr. Shakespeare goes on to say, 11 is the primary enamel-organ. 
Later, this club-shaped mass," he continues, 11 penetrates deeper and deeper 
into the connective tissue and increases greatly in thickness, at the same time 
changing its outline." The diagram referred to is here introduced fFitr. 93Y 
The change of outline in this club- 
shaped prolongation is shown in 
an immediately succeeding diagram 
(Fig. 30 of the same " System of 
Anatomy "), where a crescent form is 
assumed by its lower face, this face 
seeming, and as indeed is the case, 
to be moulding itself upon an ob- 
structing body inferior to it. This 
the text above explains as follows. 
The obstructing body is the now 
rapidly developing dental germ ; that 
which envelops it, in crescent fash- 
ion, is simple temporarily hypertro- 
phied mucous membrane tissue, the crescent form finding explanation in the 
comparative non-vagcularity of parts underlying the germ. Diagram, Fig. 94, 
from the work of Dr. Sudduth, explains, without necessity for many added words, 
what is meant bv the 11 excessivelv thickened mucous membranefor while 
Fig. 93.-Involution of Epithelium. 
(After Shakespeare.) 
Fcetal sheep. 1, dental groove; 2, palatal 
processes. 
Fig. 94.-Involution of Epithelium. (After Sudduth.) 
this illustration relates with a hair-germ, it relates not less exactly with a tooth- 
germ. Epithelium furnishes the sheath of a hair and the sheath of a tooth, 
but it furnishes neither hair-germ nor tooth-enamel. Looking at this last 156 
A SYSTEM OF ORAL SURGERY. 
microscopic picture the club-shaped prolongation is appreciated at its proper 
value. At first a diffused proliferation by reason of an increased vascular activity 
associated with the commencement of dental evolution, it disappears circum- 
ferentially as this activity subsides with advancement of the papilla, until later 
nothing remains of it but the crescent immediately about the germ, while still 
later nothing at all remains of it. 
Returning to the club-shaped extremity just discussed, Dr. Shakespeare goes 
on to say, " The extremity has now spread out and become indented by a slight 
elevation of the connective tissue which has begun to advance into it" (Fig. 
30 referred to). " This elevation is the first appearance" {perceptible) " of 
what will subsequently constitute the dentine and pulp of the tooth. The 
milk, or first teeth, are now in full process of development. A preparation for 
the growth of the permanent teeth is even at this stage often to be met with in 
the shape of an offshoot from the epithelial mass, already spoken of as the pri- 
mary enamel organ." Here is introduced in Professor Allen's book a 
diagram (Fig. 31) referred to by Dr. Shakespeare as follows: " The papilla has" 
(is seen) " grown into the enamel organ until the latter has become completely 
invaginated. The enamel organ covers the apex and sides of the tooth papilla 
like a cap, and it has been cut off from its former connection with the epithelial 
covering of the gum." (Explanation of these changes has been given in a pre- 
vious paragraph.) 11 This cap-shaped epithelial mass is termed the secondary 
enamel organ. Through the invagination of the epithelial mass consti- 
tuting the enamel organ, it results that the cap covering the papilla, when seen 
in section longitudinal to the long axis of the tooth, seems to be formed by 
three principal layers. The uppermost is composed of a single cone of cubical 
epithelium ; the lowest layer consists of a single row of long cylindrical cells; 
the middle layer is formed of more or less compressed and branched epithelial 
cells with a large amount of intercellular cement between them. They contain 
small oval or spherical nuclei, and, according to some authors, afford with the 
intercellular substance an example of mucous tissue. Klein denies to this 
layer any other than an epithelial constitution. 
" It is the lowest layer of long columnar, or prismatic, cells which ultimately 
furnishes the enamel of the tooth. The two upper layers gradually diminish 
in thickness, and finally form a thin epithelial covering, which is found upon 
the surface of the enamel when the tooth first makes its appearance above the 
gums (membrane of Nasmyth). 
" At first the lower layer of enamel-cells is separated from the papilla by a 
thin, elastic membrane, the remains of the basement membrane, upon which 
the epithelium of mucous membrane is implanted. Later, this disappears, 
when the enamel rests directly upon the dentine." 
(It is maintained in the text that a membrane continues to exist between 
dentine and enamel, the tunica propria, or enamel membrane.) 
Enamel.-" It is a mooted question," Dr. Shakespeare goes on to say, 
" whether the enamel of the tooth is secreted by the lower layer of columnar DENTITION. 
157 
cells or whether it is a product of a direct transformation of the cells them- 
selves." • 
Dentine.-"The dentine of the tooth," he adds, "is formed by the 
mediation of a double row of branched fusiform and columnar cells, which 
cover the pulp, or papilla." 
Cement.-"The dental cement, or bony incrustation of the dentine, in 
the root and neck of the tooth," he concludes, " is developed from the fibrous 
tissue of the dental processes, or alveolus. This tissue here has the structure 
and functions of the periosteum of the bone." 
Dr. Cryer, chief of clinic of Hospital of Oral Surgery, himself an able 
microscopist and a close observer, using a section prepared by Mr. Cole, of 
London, expresses himself as com- 
pelled to acknowledge that enamel is 
deposited, not primarily against, but 
farthest away from, the dentine. (See 
his monograph on " Development of 
Enamel.") 
Concluding with an addendum, 
Fig. 95, if carefully studied, affords 
demqpstration, after still other man- 
ner, of what has been advanced in the 
chapter regarding tooth development; 
the free spacing is with view to ex- 
hibit the different parts clearly. 
The block of alveolar process, 
shown on the left, is to be under- 
stood as relating with the line E, 
which is its mucous-lined face, hence 
the periodonteum. This line, in turn, 
is to be carried against E, the ce- 
mentum; and this, still in turn, is to 
be carried against B, the dentine. 
The parts being thus associated, the 
normal tooth stands justly represented. 
If a student, unfamiliar with such manner of diagramming, will take up his 
pencil and place the parts, here separated, in relation, as described in the text, 
he will undoubtedly secure fixed idea as to the author's views on dentition as 
these relate with the development and anatomy of a tooth. 
Fig. 95. 
A, dental pulp and its artery; B, dentine; 
C, tunica propria; D, enamel; E, periodon- 
teum ; F, cementum; G, canal in lower jaw; 
H, dental artery; J, branch of dental artery 
supplying periodonteum; K, branch of dental 
artery supplying tunica propria. 
Clinical Consideration of Dentition.-We pass here to a more 
directly clinical consideration of the subject: to the relation of the first and 
second dentitions. 
The first of the papillae of the deciduous teeth to make their appearance 
pertain to the anterior molars; after these are the germs of the canines and 158 
A SYSTEM OF ORAL SURGERY. 
incisors; last, the posterior molars. About the fourth month these papillae 
are all in their saccular envelopes, while forming behind the lids of the 
sacs are little crescentic depressions, called cavities of reserve, lined with 
mucous membrane, and containing the germs, or papillae, of the second set of 
teeth,-one to each deciduous germ. The first molar of the permanent set is 
markedly related to the deciduous, by having a common origin from and on 
the primitive dental plane. From sacs, secondary to the capsule of this tooth, 
spring the reserve cavities of the second and third molars of the second set. 
Order of Eruption of Temporary Teeth.-The eruption of the 
temporary set, although more or less irregular, ensues, as a rule, in the follow- 
ing order and time,-the lower teeth erupting first: Central incisors about 
the seventh month, lateral incisors about the eighth month, anterior 
molars about the thirteenth month, canines about the sixteenth 
month, and the posterior molars about the twenty-fourth month. The 
age intervening between the first and the last eruption is considered the 
critical period in infantile existence. (See chapter on Associative Lesions of 
First Dentition.') 
Calcification.-The calcification of permanent teeth commences, just 
before birth, with the anterior molars, proceeding forward, but terminating 
with the premolars at about the third year. This description does not^ how- 
ever, include the posterior molars, which are really the last to dentinify. 
Position of Permanent Germs.-The position of the permanent 
papillae, which at first are situated between the sacs of the deciduous and the 
gum, gradually recedes behind, falling deeper and deeper, at least relatively 
so, as the milk set elongate, until, on the completion of growth in the de- 
ciduous, the germs of the permanent set are found in the common alveoli at 
the apices of these cavities, occupying, indeed, almost the position and physi- 
ological relations of the original papillae. 
Antagonism of Permanent and Deciduous Teeth.-At this 
period, whenever it may be, and it varies of course with different individuals, 
a process of antagonism commences. It is intended that the new may advance 
and increase, that the old shall decline and diminish. The relative position of 
the two bodies is as follows : extending to the apices of the alveoli, and receiv- 
ing at these apices the principal vessels of nutrition, are the perfected roots of 
the first teeth. Crowding down into these alveoli, with nutritious vessels of 
their own, possessed with the high vitality of growing bodies, are the pulps of 
the second teeth. As these pulps enlarge, so is there a corresponding absorp- 
tion in the alveoli containing them, until, finally, through such process of 
absorption they have fallen directly beneath the roots of the first set. Of 
course a pressure has been equally exerted upon these roots, and, as a 
result, the nutrient vessels passing into the pulp-cavities, through the 
foramina at the apices, have been gradually obliterated. 
But do the pulps of the milk-teeth die? Not at all; or at least not neces- 
sarily. The neighboring vascularity is very great, the requirements of the DENTITION. 
159 
organs very small; a sufficient supply is received from the circulation in the 
dentine, as well as from the periodonteum, which, to the last, continues to 
close in the enlarging foramina. This, however, does occur: the absorbent, 
or destructive, system has been given the mastery ; little by little, day by day, 
month by month, portions of the roots of the first teeth disappear, while the 
crowns of the second advance and occupy the space gained, until at length, as 
is witnessed every day, the milk-teeth drop out of their cavities, minus root or 
roots, while the crowns of the permanent ones are seen in their places. 
Absorbed Deciduous Roots.-If here we take up a thrown-off 
tooth, we find that the pulp-chamber, or what remains of it, instead of having 
an almost complete bony envelope, as is the case in the perfect organ, has com- 
municated more and more largely, for 
a varying period, with the soft parts, 
guarding us, in such knowledge, 
against a manner of radical treatment 
in aching milk-teeth, at certain periods, 
which would be most applicable at 
others. (See Odontalgia.'} 
To judge of the condition of the 
foramina of the first teeth, the prac- 
titioner is to compare the organs 
with periods of eruption of the second, 
recognizing that the enlargement, or 
absorption, corresponds with such ad- 
vance in the permanent. 
The first teeth of the second set 
erupt entirely back of the temporary 
and in no way interfere with them. 
These are the anterior, or first, molars; they appear commonly at about the 
sixth year, seldom earlier, not infrequently from one to several months later; 
the sixth year, however, is the rule. The second teeth to appear are the 
central incisors,-the lower a little in advance of the upper,-about the seventh 
year; the third, the lateral incisors, at the eighth year; the fourth, the ante- 
rior premolars, at the ninth year; the fifth, the posterior premolars, at the 
tenth year; the sixth, the canines, or cuspidati, at the eleventh year; the 
seventh, the second molars, at the twelfth year; and the last, the third molars, 
or wisdom-teeth, at a period varying from the seventeenth to the twenty-fifth 
year,-most commonly, however, about the eighteenth year. 
Arrangement of Teeth.-The teeth, in their eruption, arrange them- 
selves after a physiological regularity in arches which have enlarged for their 
accommodation through a process of elongatory and interstitial growth. If 
development and functional harmony have not been interfered with, the fully- 
grown organs are found occupying in regular relations the two jaws, yielding 
perfect occlusion and articulation. (See Associative Lesions.') 
Fig. 96. 
First and second dentition, upper and lower 
maxillae. 160 
A SYSTEM OF ORAL SURGERY. 
Articulation of Teeth.-In examining an articulated skull (Frontis- 
piece 1), it is seen that the six upper front teeth close over and in front of 
those of the inferior jaw, while the external tubercles of the bicuspidati and 
molars of the lower jaw lodge in the sulci between the external and internal 
tubercles of those of the upper jaw ; thus, in the articulation, placing the 
tubercles of the upper teeth external to the outer tubercles of the lower. The 
central incisor of the upper jaw, because of its greater width, closes not only 
over the inferior central, but overrides the lateral. The superior lateral over- 
rides the cuspis; the cuspis its fellow and the first premolar. The premolars 
override their fellows and the anterior third of the first molar. The first 
molar opposes the anterior third of the second molar and the posterior two- 
thirds of the first. The second molar antagonizes the posterior two-thirds of 
the second molar and the anterior third of the wisdom-tooth. The wisdom- 
tooth of the upper jaw, being smaller than that of the lower, finds a required 
antagonism in the portion of its fellow left unoccupied by the second molar. 
Thus it is seen that no two teeth exclusively oppose each other,-an admirable 
provision, which not only guards as much as seems possible against loss of the 
organs from lack of articular relation, but secures the fullest results in the 
trituration of food. (For a diagram showing articular relations of the teeth, 
see chapter on Prosthetic Dentistry. See also Fig. 1.) 
Centre of Gravity.-Teeth in properly related jaws exhibit close ad- 
herence to the law of gravity; that is, pressure bearing upon a cutting or 
grinding face is carried through the line of the root as this relates with the 
curve of the jaws. Artificial dentures constructed unobservant of such law 
are sure to be failures by reason of tilting or unsteadiness. CHAPTER X. 
ASSOCIATIVE LESIONS OF FIRST DENTITION. 
The calculations of Dr. Arbuthnot that, at the period of dentition, one 
child in every ten has its life destroyed through the associative and influenced 
lesions of that age, may, perhaps, not be strictly in accordance with statistics 
at large; but the mortality is so alarmingly great that, to the general practi- 
tioner, no subject offers in its study more important and vital interests. Pro- 
fessor Camper is authority for the statement that out of 5989 infants admitted 
into foundling hospitals, only 884 were found alive at the end of the fifth 
year. 
Irritation.-In the first place, it is to be remarked that the process of 
dentition, while a physiological one, is yet, like that of utero-gestation, one 
of continuous irritation. Of the meaning of this word irritation, every 
surgeon and every physician has in his mind quite enough reminiscences. 
Irritation, then, is the matter of consideration in all of these associative 
lesions; if happily, in such cases, we could exactly appreciate and exactly 
control such irritations, we should of course abort, or resolve, the results. 
It is not, however, by any means to be esteemed that all infantile diseases 
are influenced by, or indeed even remotely associated with, dentition : mis- 
takes of such nature are quite too frequently made, and infants are tortured, 
and in many cases have the existing disease aggravated, by the lancing and 
cutting which follow. It is very true that irritation from this cause has not 
always an associated external local manifestation ; but such manifestation is 
much more frequently found present than absent,-at any rate, it is always 
to have its full share in the making up of a diagnosis. It will of course be 
taken for granted that dental irritation is influenced to a most marked 
extent, all other things being equal, by the slowness or rapidity of the evolu- 
tion of the teeth. Thus, such equality existing, we would not anticipate from 
the eruption of a single tooth the trouble of five or six, and such a difference 
in evolution is so common that it may be said of some children that they cut 
their teeth in mass, while with others it is a process of the greatest regularity 
and harmony. Again, the physical condition and age of the child are 
matters not without significance. A delicate infant suffers more, as a general 
thing, than a robust one; while premature dentitions are not unlikely, though 
not necessarily, attended with more danger than late ones. In taking into 
consideration the influences of this process, we are not to forget either the 
varying degrees of susceptibility manifested in different individuals, as thus 
161 162 
A SYSTEM OF ORAL SURGERY. 
we are led to appreciate the fact that judgment is not to be founded alone 
on the extent or degree of local manifestation. Some children are preter- 
naturally susceptible to stimuli, and these are not at all necessarily of the 
weak and feeble class; others, on the contrary, are so obtuse, even from 
earliest age, as to be very little influenced by any ordinary or common cause 
of irritation. 
To the experienced physician the appreciation of associated or abstract 
dental irritation should not be a matter of difficulty. He sees, and he does, 
what is to be done,-what only can be done; if the treatment fail, the fault 
resides not in the practice. In the first place, to understand dental irritation, 
one must be familiar with dental evolution ; this, of course, is the understand- 
ing of the physiology of the subject. We know the varying periods of erup- 
tion, and we are thus at once led very directly in our researches. If we find 
a source of offence, as manifested by a tumid, congested gum, we have only 
to pass a lancet down to the confined tooth, and, having done this, we are to 
expect and hope for relief from any trouble which has been engendered by 
the just liberated organ. If we look into the mouth, and see no manifesta- 
tions of offence, it is generally the case that dentition has nothing to do with 
a trouble which may have influenced the search,-not always, however, for it 
has been inferred that dentition may be a source of reflected trouble while 
itself presenting no local signs. Still, such cases are very rare, and, when 
existing, depend on great rapidity in evolution, either as a single tooth is 
concerned, or the simultaneous development of many. Several teeth, rapidly 
advancing at the same time, could very well be appreciated as a source of 
constitutional offence, not only as diverting in such direction an excess of the 
vital force, but also in local irritations induced in neighboring structures, and 
which might not at all be evident by any external signs. In these latter cases 
the physician can do nothing but increase, by indicated means, the ability of 
the system to endure the irritation; such means being more frequently found 
in tonics than in sedatives. In the weak, strict attention is to be given to 
diet, to exercise, and to cleanliness. The character of the clothing is also of 
much consequence. If the milk of the mother be not properly nutritious, 
other means are to be taken to nourish the child. Premature lancing is 
not a remedy. 
In cases where there seems simply an excess of irritability, such suscep- 
tibility is to be lowered by the withdrawal of everything capable of foster- 
ing it; this will pertain to the lodgement of the child, to its food, drink, 
clothing, exercise, etc., matters which should at once strike an observant 
practitioner. 
Disturbance provoked in the alimentary canal, and fever induced 
through the process of teething, when existing conjointly with acute disease, 
of whatever character, necessarily aggravate such disease, and increase by 
just that much the attending discomfort or danger; hence the recognized 
enlarged mortality in the exanthemata occurring at this period. ASSOCIATIVE LESIONS OF FIRST DENTITION. 
163 
DISEASES ASSOCIATED WITH DENTITION. 
The diseases, if they may be so called, directly associated with and depend- 
ent on abnormal dentition, and having, therefore, necessarily their cure more 
or less intimately associated with the correction of the primary lesions, are,- 
1. Localized Stomatitis. 
2. Irritative Fever. 
3. Diarrhoea. 
4. Spasms. 
5. Eruptions upon Skin, especially of Scalp and Face. 
LOCALIZED STOMATITIS. 
The first indication in this condition, dependent on advancing tooth eruption, 
consists, most likely, in a sense of titillation or itching,-as, before any local sign 
is visible, the child is found disposed to rub the parts with anything coming 
into its hands, seeming most comfortable when biting upon hard substances. 
Slavering is also associated with this stage. After a time, tumefaction 
of the gums is observed, and this inflammatory action circumscribes or extends 
itself on the same principle as the vaccine areola,-that is, as influenced by 
constitutional or local circumstances. If several teeth be attempting eruption 
at the same time, and these situated at opposite sides of the cavity, then the 
probability is that the inflammation will be a diffused one. If, on the 
contrary, the irritation be confined to a single tooth, and there be in the habits 
of the child no particular inflammatory tendency, then it may reasonably be 
anticipated that the area of congestion will be very circumscribed. The 
shape and extent of face in the erupting tooth do not seem to have as much 
to do with the amount of irritation as one would naturally infer should be the 
case. The author has certainly seen quite as much trouble from an erupting 
incisor as in the case of a four-cusped molar. Bad and degenerating inflam- 
mations are always associated with constitutional conditions. Thus in scrof- 
ulous children it is sometimes the case that a semi-gangrenous ulceration is 
the result of cutting a tooth which it is quite troublesome enough to manage; 
while in children of a mercurio-syphilitic cachexia such a condition 
will be even aggravated, the gums and continuity of mucous membrane look- 
ing as if it was impossible to keep the parts from breaking down into general 
ulceration. When tumefaction of the gum is dependent on tooth eruption, 
and the child is of healthy condition, a certain evidence is found in the glistening 
character of the swelling, the part immediately over the tooth or teeth looking 
stretched and feverish. This tense look is nearly always present, and may, under 
all circumstances, be esteemed an indication demanding the use of the lancet.* 
® Application of the tincture of belladonna to a gum thus congested is a source of relief. 
A full saturation of the bromide of potassium is also an agent of more or less comfort. The 
first is to be used with care, the last is harmless. Cocaine hydrochlorate, two grains to the 
ounce of water, is most reliable. 164 
A SYSTEM OF ORAL SURGERY. 
In unhealthy conditions this glistening is not commonly present, its absence 
being dependent on the flaccid, relaxed condition of the gum-tissue. Here, as 
implied, the congestion is of more diffused character; the part and associate 
parts are turgid and soft-looking. You esteem, in looking into the mouth, 
that scarification would be of service, but that it is demanded for a sense of 
general relief, rather than for a strictly acute local condition. Lancing, in the 
first of these cases, if properly performed, yields an almost instantaneously 
good result; in the second, such relief is gradual and most likely inconsid- 
erable. In the first, the cutting is all-sufficient to the cure; in the second, 
the constitutional indications make themselves felt as of most consequence. 
Lancing the Gum.-To lance the gum of a child, the surgeon seats 
himself directly in front of the nurse, the height of the knees of the two 
parties being arranged to correspond. The nurse is to take the child on her 
lap, supporting its whole body, excepting the shoulders and head, which are to 
rest upon the knees of the operator. In this position the nurse controls per- 
fectly the legs and arms of the infant, while the surgeon has complete command 
of its head, and can examine and operate upon its mouth at his convenience. 
The face of the child should look toward a window, or if night be the time of 
operation, artificial light is to be employed. 
A tooth is to be lanced in consideration of its shape. Thus, if it be any of 
the anterior four teeth, either of the upper or lower jaw, a single incision 
made sufficiently deep to feel the lancet strike upon the enamel is all that is 
required. This incision is to be made on the line of the cutting edge of the 
teeth. With the posterior teeth, the cuspidati being included among these, 
the crucial form of incision is demanded: such form will alone relieve the 
advancing cusp or cusps, and afford the result desired. 
The accompanying diagrams, after the elder Dr. J. W. White, admirably and 
fully illustrate the subject. Fig. 97 shows the single cusp of an eye-tooth 
Fig. 97. 
Fig. 98. 
Fig. 99. 
Fig. 100 
Fig. 101. 
making its way through the gum; Fig. 98 exhibits the proper manner of 
freeing such a tooth; Fig. 99 shows a gum made turgid by an advancing 
molar; Fig. 100 exhibits the first expression in eruption of this tooth ; Fig. 101 
illustrates a form of crucial incision required for the liberation of the circum- 
ferential and central portions of the organ. Observation of the diagrams 
affords illustration of the fact that gum-tissue may require lancing quite as 
much after as before a partial appearance of an advancing tooth. ASSOCIATIVE LESIONS OF FIRST DENTITION. 
165 
Hemorrhage in Lancing the Gum.-Concerning hemorrhage, it is 
not a common experience that any special danger is to be apprehended: a 
practitioner certainly seldom hesitates to lance the gums of a child on 
this score, and seldom meets with a case that gives any particular trouble. 
With ordinary patients, the loss of a little blood is rather to be desired than 
otherwise ; while if a hemorrhagic diathesis exists, the local application of tannic 
acid or of bayberry-powder will generally be found all-sufficient for control of 
the bleeding. A little cobweb, as found in the cellar, wet with borax-water, 
and then dipped in bayberry-powder, will in ninety cases out of the hundred 
control the hemorrhage when laid over the incision, the application to be 
secured by passing over it, if necessary, one layer of a delicate roller. Press- 
ure made by a finger and continued for some time is a means of control that 
will succeed nine times out of ten. Ice or hot water are reliable local styptics. 
A constitutional medicament, of good effect at times in these cases, is found 
in the Erigeron Canadense,-one drop of the tincture to be given in a 
little water, each minute, until the bleeding ceases, or until twenty or thirty 
are taken. Opium and lead act very happily in combination. The dose of 
each must of course be small. A very good formula is as follows: 
U Pulveris opii, gr. J; 
Plumbi acetatis, gr. j ; 
Aquae rosae, ^iij. 
Sig.-Tablespoonful to be taken each half hour, p. r. n. 
Tannic acid, in one-grain doses, given every two hours in a tablespoon- 
ful of water, is a haemostatic to be depended on. It is not to be used, however, 
save in cases attended with anxiety. Tincture of digitalis or of ergot act 
happily and reliably, by contracting the blood-vessels, when given internally. 
The dose of the former for a baby is two drops; of the latter, five drops; to 
be repeated in one or two hours, according to urgency. 
Another plan is to stuff the cut with a pledget of cotton which has been 
saturated with phenate of soda, or, better, which has been rolled in tannic 
acid. Still another consists in taking a stitch in the parts, drawing the lips 
of the wound tightly together. 
Touching a bleeding gum with Monsel's solutions, or with nitrate of 
silver, is a dangerous practice. The only alarming cases of hemorrhage ever 
seen by the author have been the resultant of these applications. It is true that 
such effects may rest rather with the operator than with the agents; but it is 
seldom that one seems to succeed in using the means with sufficient cleverness 
and localization. Monsel's salts are to be used in extreme cases only. Solu- 
tions and salts are apt to do harm rather than good; secondary hemor- 
rhages are common to them, and, when ensuing, are always of a character 
much more difficult to manage than the primary trouble. 
Another matter in this connection particularly worthy of note is the in- 
fluence on the hemorrhage through the sucking propensity of infants. This 166 
A SYSTEM OF ORAL SURGERY. 
is to be obviated by passing a roll of rubber or other convenient material 
across the mouth, and so confining it that, while it shall not fret the little 
patient, it will destroy the ability to make a vacuum. This manipulation is 
very simple and easy of accomplishment. The ordinary soft india-rubber 
ring may be cut in the middle; tie a piece of string or tape to each end, pass 
the rubber across the mouth, and fix the tapes on the back of the neck; an 
hour or two is commonly found sufficient to retain the apparatus. 
Associated Cachexia.-Cases of localized stomatitis, having associa- 
tion with the strumous, scorbutic, or syphilitic cachexia, require a treatment 
external to the cause exciting it; the child must be built up. Such an inflam- 
mation, passing quickly into an adynamic type, demands for its cure stimula- 
tion rather than depression. To express the requirements more explicitly, 
a local treatment is to be quieting, and perhaps refrigerating, while tonics, 
combined with the mineral acids, are demanded constitutionally. 
A child eight years of age, of marked scrofulous condition, tissues relaxed, 
abdomen pendent, was presented at one of the author's clinics, suffering with 
trouble in the oral cavity. Making an examination, the mucous membrane 
of the palate aspect of the superior jaw was found angry and uncomfortable- 
looking ; no tension at any point, but the whole membrane turgid, and yet 
flaccid-looking. In searching for the cause of trouble, the age of the patient 
directed a first attention to the position of the first bicuspid teeth, the lateral 
incisors being erupted and in position. Exploration with the lancet-the 
deciduous molars had been removed long before-revealed these teeth on 
either side, with the second bicuspids of the right side nearly ready to erupt. 
The ordinary crucial incisions were then made. In the case of a healthy 
child, this treatment would have been all-sufficient; with such a child as this, 
however, not so. Relief to some extent is certainly to be obtained from the 
incision ; but the congestion will continue, and, not unlikely, will grow 
worse, the parts seeming to lack the energy necessary to self-restoration. In 
this particular case, here noted merely as a type, the mouth was ordered to be 
washed three times each day with dilute brandy and aromatic sulphuric acid. 
Internally, lemonade was given every two hours, five drops of brandy being 
added to each wineglassful. Aromatic sulphuric acid acts very happily 
in these and similar cases, or nitro-muriatic acid may be administered in from 
two- to five-drop doses, three or four times a day. The acid phosphates are 
scarcely to be recommended too highly. The dose for an adult is a teaspoon- 
ful in a third of a goblet of water, three times a day; half hour after eating. 
The dose for a baby one year of age is the twelfth of a teaspoonful. Iron, 
combined with an acid, as in the Ferri Chloridi Tinctura, is an admirable 
medicine, given in from two- to eight-drop doses, three times a day. It is found 
also not infrequently necessary in these cases to bring the acid, in a more con- 
centrated form, directly to bear upon some obstinate point of ulceration ; this 
is done very readily by means of a pine stick or brush. Dip the tip into the 
acid used, and employ concentrated or dilute according to the requirements of ASSOCIATIVE LESIONS OF FIRST DENTITION. 
167 
a case. The acid nitrate of mercury so applied is found sometimes to act very 
happily. Deliquesced chloride of zinc may also be used. The zinc, fol- 
lowed by a brush of the officinal tincture of iodine, will sometimes induce 
granulation as if by magic; or tincture of iodine combined with creasote can 
be employed with good hope of success. Still another, and a most satisfactory 
application, is found in blue-stone; the part to be lightly smeared and immedi- 
ately brushed with water. 
In syphilitic stomatitis a specific treatment is to be conjoined with the 
supporting. A combination that may be directed with very satisfactory effect 
is as follows: 
U Hydrargyri chloridi corrosivi, gr. j; 
Potassii iodidi, 5j j 
Syrupi ferri pyrophosphatis, ^iv. M. 
Sig.-From a quarter to half a teaspoonful, according to age, three times a day. 
It not infrequently happens, however, that a treatment which may have 
preceded ours has been too free in the exhibition of mercurials ; here this 
medicine is not longer to be used, but, conjoined with a supporting treatment, 
we are to employ chlorate of potash : 
pt Potassii chloratis, §ss; 
Aquae, ^viij. M. 
Sig.-Teaspoonful, internally, four or six times a day ; the mouth to be washed with the 
same ad libitum. 
An admirable local application to the syphilitic sore mouth and throat is 
made by adding to a six-ounce infusion of white-oak bark two drachms of 
aromatic sulphuric acid and six grains of nitrate of silver, using, in case of a 
child, by means of a brush ; once a day is sufficient. 
In all adynamic conditions of childhood it is assumed to be a common ex- 
perience that no better treatment can be found than lies in the observance of 
general hygienic laws. Food is to be nourishing, frequently repeated, and 
never given to repletion. Fresh air and exercise are necessities. The 
child should sleep by itself, or, what, as it is concerned, is even better, it may 
sleep with some young person of more robust and healthy condition. The 
daily use of a salt-sheet bath, the water being tepid or cold, according to the 
ability of the patient to bear, is an invaluable adjunct to restoration; one of 
the best to be employed where used judiciously. Throw the wet sheet quickly 
about the person of the child, and rub until a fine glowing reaction sets in. 
In the use of this means, however, close attention is to be given to daily result. 
If reaction be not secured, but, on the contrary, the child grow cold, and 
the cutaneous capillaries contract unduly, then such bath is to be dis- 
continued ; or if cold water has been used, it is to be modified, even perhaps 
to absolute warmness. A good plan to adopt with this bath is to commence 
with milk-warm water and advance by gradations to cold; never overlooking 
the fact that warm water is to one person in the way of invigoration what 
cold is to another, and that it may be the warm water that is indicated. 168 
A SYSTEM OF ORAL SURGERY. 
Functions to be Noted.-All the functions of a child of scrofu- 
lous or syphilitic condition are to be carefully watched. If the bowels be 
habitually costive, as is frequently the case, olive oil of good quality may be 
administered q. s. This oil not only obviates such a condition, but acts as 
a most desirable article of nutrition. If given alone, a teaspoonful or dessert- 
spoonful, each day, administered at any convenient period, is generally found 
sufficient,-and, indeed, in many cases, too laxative. If the child be of an 
age to take the oil mixed with other food, much attention to the quantity 
employed will not be found of special consequence. A mineral water of 
great service in costiveness is prepared as follows: Take of magnesia 
sulphas one and one-half ounces; of aromatic sulphuric acid two drachms; of 
sulphate of iron sixteen grains; of water seven ounces. This is used by 
putting a teaspoonful during the day into the water drank by the child. In 
cases where the kidneys fail to eliminate with sufficient rapidity, small doses of 
sweet spirits of nitre are to be exhibited. Buchu, where there is undue irri- 
tability of the urinary apparatus, is found to apply very happily. A prescrip- 
tion affording good results is as follows: 
Take of buchu one ounce; add one and one-half pints of hot water, and 
simmer down to one pint; when cold, strain, and give in teaspoonful doses, 
four or six times a day, as may seem indicated. 
Liquorice powder, or pulverized rhubarb, in quantities of a few grains, 
afford an excellent laxative easily administered to children in syrups. 
State of Skin.-Attention is to be directed to the state of the skin. This 
tissue should feel soft, not relaxed; moist, but not wet, and reasonably oily; 
it is to be kept clean, but not washed too frequently with soap. Whisky or 
brandy, where stimulation seems indicated, may be added to the water 
with which a child is bathed; but a healthy skin is to be made rather from 
within outwardly than from without inwardly,-that is to say, a skin which 
does not properly perform its offices indicates, as a general thing, some de- 
rangement ulterior to itself, so that the local attention implied is never to be 
esteemed but as adjunct treatment. 
Angina.-Angina simplex, simple inflammation of the fauces, is not in- 
frequently dependent on irritations existing or having origin in the oral 
cavity. Here the trouble is one of continuity of structure, and its relief is 
found, of course, in cure of the exciting cause. Angina simplex is generally 
first made evident in difficulty of swallowing. Examination reveals the throat 
red and congested, the degree being influenced by the condition of the patient. 
Sometimes this congestion is so great as to make the act of deglutition an 
impossibility; even fluids taken into the throat are ejected through the nos- 
trils. The uvula occasionally is enlarged to an extent, as the result of effu- 
sion into its cellular structure, which seriously endangers the respiration of 
the patient, compelling, indeed, in many cases, the amputation of the organ. 
In some instances degenerating aphthous patches (angina aphthosa) appear 
upon various parts of the mucous membrane; these denote that the inflam- ASSOCIATIVE LESIONS OF FIRST DENTITION. 
169 
mation is adynamic in its type, and are always a matter of concern, just, in- 
deed, as a phagedenic chancre is a cause for more alarm than a simple sore, 
implying a degenerative tendency and absence of vital force. An aphthous 
ulcer is a patch of varying signification. It is the form of ulceration and 
exudation so frequently seen in weakly, broken-down women. Angina sim- 
plex, when dependent on any oral trouble, may be expected to retire on re- 
moval of the immediate cause. This, however, is not always the case, as is 
witnessed in the adynamic types, or in children of very full or sanguine 
temperament. 
Treatment.-In angina, treatment is to be pursued as implied in the 
indications. If the continuance of such inflammation depend on a surcharged 
condition of the vessels, general or local depletion is demanded. Three or 
four Swedish leeches, or twice as many American, may be put upon the 
upper part of the throat; the number to be graduated to the strength of the 
patient and the urgency of the case. A treatment preliminary to this, and 
one which in his own practice is always employed by the writer when the 
case is not especially urgent, consists in reducing the volume of blood by the 
administration either of diaphoretics or of the saline cathartics. Epsom 
salts, a teaspoonful in a wineglass of water, will carry much fluid from the 
blood of a young child; or the spirits of Mindererus-covering the patient 
warmly until diaphoresis is produced-given in teaspoonful doses, every ten 
minutes, is found sometimes to break up very quickly such inflammations. 
As a gargle, to be used half a dozen times a day, useful in every kind and 
condition of sore throat met with, phenol sodique is to be recommended in the 
proportion of a tablespoonful to an ordinary goblet of water. Hot pediluvia 
are not to be neglected; the feet and legs of the little patient, kept in hot 
water for the space of a quarter of an hour, will, in very many cases, be all- 
sufficient for a cure. A less speedy but frequently successful way of treating 
angina consists in diverting, as it were, the seat of irritation; for example, 
administering nitre, that it may be directed to the kidneys, or tartar emetic, 
that it may be thrown upon the skin. 
U Spiritus ammonias aromatici, 
Spiritus aetheris nitrosi, aa ^ss. M. 
Sig.-Give from five drops to a teaspoonful, according to age, every three or four hours.* 
The ammonia in the above prescription drives the congesting blood forward, 
while the nitre directs it toward the kidneys. 
An emetic will not infrequently break up a sthenic sore throat. In the 
case of children, syrup of ipecacuanha answers a good purpose. This may 
be given in doses varying from a half to a full teaspoonful, according to age, 
every ten or fifteen minutes, until the desired result of emesis be obtained. 
* Where teaspoonful doses of a medicine are given to the adult, five drops is the dose for a 
child one year old. 170 
A SYSTEM OF ORAL SURGERY. 
If, conjoined with the local inflammation, we have sympathizing by the 
system at large, as manifested in fever, febrifuges are to be employed. The 
following combination is found happily adapted to such indications: 
]£ Liquoris potassii citratis, ^iij ; 
Spiritus aetheris nitrosi, ^ss; 
Pulveris antimonii et potassii tartratis, 
Morphias acetatis, aa gr. j. M. 
Of this mixture the dose for an adult is a dessertspoonful every two 
hours; to an infant one year of age, from five to eight drops may be given, 
being diminished or increased according to effect. Overdoses produce sick 
stomach. 
Diet.-This is to be light, as in all sthenic inflammations. The child is 
to be limited to the breast; or if age or circumstances do not permit this, 
gum-water, or other light and unstimulating food, is to be employed,-that 
is to say, is to be employed while the grade of the inflammation is running 
upward. Ice-cream is an admirable food, particularly when eaten slowly 
and continuously. By continuously, however, is not meant that great quan- 
tities are to be taken, but that a reasonable portion be made to last as long 
as possible. Eaten in this way, the article is refrigerant, not only to the 
inflamed part over which it necessarily passes, but to the system at large, 
lowering the heat of the whole body, and thus quieting the disturbed circu- 
lation. High temperature is controlled by antipyrin, or, better, by laving the 
spine and stomach with alcohol; stopping every little while to dry the parts, 
repeating and re-repeating until coolness is secured. 
Chronic Angina.-Inflammation of the throat, running into a chronic 
condition, in children, may perhaps always be accepted as related with some 
constitutional disposition. In these cases the glandular bodies seem markedly 
the seat of trouble. Granulations are commonly prominent over the mucous 
membrane, this tissue being covered with a mucoid or muco-purulent secretion. 
Ulcers are very common, and not infrequently are of such degenerative ten- 
dency as to threaten the continuity of parts. A disagreeable association, con- 
nected nearly always with a neglected angina, is chronic enlargement of the 
tonsil glands ; the patient is constantly kept coughing and hawking. 
Operation is compelled in these cases, as every slight cold so swells up the 
bodies as to render respiration almost as difficult as in asthma. 
Tickling and Rawness of Throat.-The sense of tickling and raw- 
ness in the throat, in chronic angina, is another source of discomfort. This 
is induced, not infrequently, through the dryness of the membrane, and again, 
as result of the irritating nature of the secretions, or it may be dependent on 
ulceration. From whatever cause arising, nothing is found better adapted to 
its temporary relief than gum arabic or the jujube troches held in the mouth 
and allowed slowly to dissolve. A combination as follows brushed over the 
parts, or gargled, may be used ad libitum: ASSOCIATIVE LESIONS OF FIRST DENTITION. 
171 
R Tinctur® iodinii composite, gtt. xl; 
Acidi carbolici fluidi, gtt. vj ; 
Glycerin®, gj; 
Aquae, ^vij. M. 
Touching the part with the tincture of belladonna, with cocaine solution, 
two grains to the ounce of water, or with a saturated solution of bromide of 
potassium, is sometimes found to abort severity in these cases speedily. 
Difficulty in hearing is another frequent association of chronic angina,- 
the explanation being found in the inflammatory thickening of the Eusta- 
chian tube. Pain in the act of swallowing is the result of a lymph ex- 
udate in the submucous cellular tissue. This it is which gives the irregular 
thickening so observable about the posterior wall of the pharynx. 
Chronic Angina.-Chronic angina, if not dependent on any specific con- 
stitutional condition, is most rationally treated by stimulation, local or general, 
or both, as seems to be indicated. The ordinary domestic remedy of a red- 
pepper gargle, if judiciously used, not infrequently produces speedy cure. 
Unhappily, however, domestic medication is apt to be carried to excess, and 
thus adds to, in place of subverting, a disease. 
If a true uncomplicated chronic angina be present in a child,-and it will 
not do to deny that such cases exist,-let the patient be treated first with a 
lotion compounded as follows : 
Tincturse capsiei composita, ^ss 
Aquae, ^viij. M. 
If a few applications of this by gargling or brushing effect no change, let 
nitrate of silver be added, in proportion of one-half a grain to the ounce. If 
even this result not in a desired change, then it will be well to esteem that 
general medication is indicated. First we are to set about correcting any func- 
tional disturbances that may be present, and follow such correction with tonics. 
Muriated tincture of iron is an admirable tonic, where the system requires 
building up ; quinine, in the majority of cases, is happily given in addition. 
Tincturm ferri chloridi, 3iij > 
Quinise sulphatis, gr. x. M. 
Sig.-To be taken in from three- to ten-drop doses, according to age, in tablespoonful, or 
small wineglassful, of water, three times a day. 
Where treatment as here suggested fails, local alterative medicaments of 
the various classes are used,-alum-water, tincture of iodine, weak dilutions 
of creasote, acid nitrate of mercury, chloride of zinc, solutions of lead, etc. 
Constitutional vices are to receive a proper share of attention. It is to 
be assumed as the rule that children affected with chronic angina have the 
cause in some systemic disturbance. Scrofula is by far the most common 
of these vices. 
Scrofulous Angina.-A scrofulous child is liable to almost any descrip- 172 
A SYSTEM OF ORAL SURGERY. 
tion of physical degeneration. Now, scrofulous degeneration is rather a 
difficult thing to describe, the conditions being so diversified and varied. A 
child descended from consumptive parents is degenerate,-it is not 
amiss to say, is scrofulous. A scrofulous child has not necessarily always a 
special distinctive type as in general signification is hereafter described. Such a 
one, for example, may have white, delicate skin, tumid abdomen, non-compact, 
pouting lip, and a languid, listless gait. It may have every belonging of the 
most marked lymphatic temperament; or, on the other hand, a scrofulous 
patient may look as if possessed of all the characteristics of a vigorous constitu- 
tion. One does not know what better to do, in cases of this kind, than make 
a general observation of antecedent and present conditions and treat accord- 
ingly. Syphilis, it has been inferred by some writers, lies closely, or it may be 
in the distance, as the root of such conditions; but if this should be the case, 
a treatment anti-syphilitic is not necessarily implied. That peculiar vice may 
have lost itself in a general degenerative condition, just as an injury, which has 
of itself gotten well, may yet be the cause of broken health and physical ad- 
versity,-just, indeed, as phthisis may succeed syphilis, long since inferred to 
have been cured. In all such cases we can only hope, in the correction of ill 
conditions recognized as existing, to find the good required. We may phi- 
losophize and reason, but if nothing functionally wrong be perceived, we must 
have recourse to a somewhat empirical treatment, building, as we say, the 
patient up. In other words, there are no specific means of cure; therefore 
we resort to such general tonics as experience has demonstrated to be useful. 
Cod-liver oil, cream, mixture of spermaceti and milk, preparations of iron, 
infusions or tinctures of the bitter barks, as the Peruvian, serpentaria, gen- 
tian, etc., are medicines to be employed in these cases. 
IRRITATIVE FEVER. 
Fever resultant of the irritation of teething is a direction of infantile trouble 
very frequently demanding the attention of the physician. It may not be 
amiss, for the benefit of the student, to recall that by irritative fever is meant 
fever the result of something that produces over-excitement. This, it is true, 
would also be a definition of inflammatory fever, the two conditions being, as 
we understand, really one and the same, except in degree. Now, the irrita- 
tive fever of dentition is, as a rule, a rapid fever,-that is, it appears and dis- 
appears quickly; the lancing of a gum causing it very frequently to vanish 
almost instantly; not always, however, for it can readily be understood that 
such a disturbance of functional conditions could be excited as to make a 
return to an equilibrium less probable than the production of some organic 
lesion. 
All febrile, conditions in children of a sthenic type are attended with 
much restlessness; but the fever of dentition is markedly so accompanied. 
Muscular excitability is a prominent association; sleep is broken; thirst is 
great; appetite is impaired and irregular, the child taking the breast rather ASSOCIATIVE LESIONS OF FIRST DENTITION. 
173 
for the relief obtained from the moisture of the milk than from desire for 
food; the pulse is not infrequently driven to an incredible rapidity; the 
face is flushed and burning; the eyes are congested and protruded. Con- 
vulsions, and not infrequently death, mark the climax. 
The disturbance effected in the system is found in proportion to the local 
irritation, and to the age, constitution, and general condition of the patient. 
The marked mobility existing in the nervous structure of infants renders the 
brain peculiarly susceptible; it is therefore a most common association to find 
the feverish infant flighty, perhaps entirely out of its head; while if febrile 
disturbance, consequent upon dentition, supervene when other diseases are in 
progress, such diseases will be commonly much intensified. 
Diagnosis.-The diagnosis of dental irritative fever is not always easy, 
this simply because the fever is irritative, and not invariably inflammatory,- 
that is to say, the local disturbance is confined to the vis vitee, and does not 
involve, to a perceptible extent, the local vascular system. We look into the 
mouth, but see no swelling of the gums, no evidences of inflammation ; yet the 
trouble is there, and it may be that it is only by incision that the fever is to 
be controlled. Diagnosis must therefore necessarily not infrequently be of 
a differential character. To aid us in this, we not only consider the absence 
of other causes of irritation, but we have marked assistance in a knowledge of 
the varying periods of tooth eruption, and of the causes advancing or retarding 
such evolution. 
Where dental evolution is inferred to be the cause of a febrile manifestation, 
and incisions do not seem to be demanded, we are to resort to ordinary general 
treatment. Lemonade, prepared with crushed ice, is a grateful and refriger- 
ating febrifuge; the neutral mixture, freshly made, by adding carbonate or 
bicarbonate of potassa to lemon-juice, is another excellent medicine. This 
addition may be made to a full saturation. A refrigerating mixture, 
prepared as follows, may be prescribed, and administered pro re nata in tea- 
snoonful doses: 
U Liquoris potassii citratis, ^iij ; 
Potassii bromidi, 3j j 
Aquae, ^j. 
Much relief is commonly given by sponging the skin when it is very hot, 
using water and alcohol, or water and cologne, or water and vinegar. Bathing 
the wrists in alcohol, or in ice-water, is a means of great comfort. Bromide 
of potassium is an admirable preparation to administer in febrile conditions. 
To children it may be given, dissolved in ice-cold water, in doses of two to five 
grains or more to the tablespoonful. Tartar emetic, added to these doses in 
the proportion of the fortieth of a grain to each, assists the quieting influence. 
Where the pulse is much excited, and an infant is of sthenic condition, tinct- 
ure of veratrum viride may also be added, one drop to each dose; in the use 
of this last agent, however, the effect, as its action on the circulation is con- 
cerned, is to be watched with care; in some cases it reduces the pulse over- 174 
A SYSTEM OF ORAL SVROERY. 
rapidly. Emetics are highly valued by some. Cathartics may also be used 
to good purpose; sulphate or carbonate of magnesia being employed, as pre- 
ferred. 
When, in defiance of treatment, a fever of irritation continues, efforts are to 
be directed to effects that may be produced outside of the ordinary functional 
disturbances. The extension of inflammation by continuity, where, for 
example, severe and unyielding inflammation, resulting from dentition, exists, 
may produce pharyngitis, parotitis, bronchitis, pneumonitis, gastritis, or it may 
excite, to take on morbid action, the brain, the heart, the liver, or, indeed, 
any organ of the body. When such sequelae occur, we are to treat the parts 
involved, as in any common inflammation, just, indeed, as we have been treat- 
ing the unyielding fever, except that we feel the necessity to make such treat- 
ment more vigorous ; it may be that under such circumstances we will find the 
local or general abstraction of blood an absolute necessity. (See Venesection.') 
In these cases it is not to be forgotten, however, by the practitioner, that, 
conjoined with the original cause of inflammation, some other might exist; 
thus, a malarial influence may have been lying in abeyance, and needed but 
the depression, the result of the dental trouble, to allow of its asserting itself; 
or it may be that some half-corrected tendency to congestion is, by the excita- 
tion, entirely undone. Such associations are to be considered if treatment is 
to be successful. This excitation of morbid action is well demonstrated in the 
association, with dentition, of diarrhoea and the cutaneous eruptions ; while the 
treatment, wherever the secondary irritation shall exhibit itself, is recognized 
to have a common character. 
The alimentary mucous membrane being continuous from mouth to the 
anus, it will at once be recognized that a localized inflammation could render 
the whole tract irritable. It is thus that diarrhoea, or, indeed, more commonly 
all the symptoms of cholera infantum, associate with difficult tooth eruption, 
and it is thus that to cure a diarrhoea or an attack of cholera infantum we have 
so frequently only to cut down upon certain confined teeth or a tooth. I am 
led, however, to infer that it is quite too common a practice, during the 
time of dentition, to ascribe to this process not only every diarrhoea, but 
the numberless other functional irregularities which happen to occur at the 
period. Diarrhoea, or this combined with vomiting, has many causes apart 
from the influences of tooth eruption. 
Stomach of Infant.-The stomach of an infant may be likened 
to an enlarged portion of a common tube; not only this, but it is a vertical, 
or almost vertical, tube; hence a child overfed needs only to be inverted to 
have the milk run from the orifice of the tube. 
Alimentary Canal.-Again, the mucous membrane of the intestines of 
an infant is tender and susceptible; excess of food, or food not easy of diges- 
tion, irritates this membrane, and, by the relationship of tissue, excites to 
DIARRHCEA. ASSOCIATIVE LESIONS OF FIRST DENTITION. 
175 
action the middle coat of the tube, yielding discharge or diarrhoea. Crapu- 
lous diarrhcea may thus be somewhat continuous, for the reason that, un- 
assisted, the contractions fail to relieve the canal of the source of offence, and 
thus their continued efforts keep up the continued discharges. Worms 
irritating the canal are the frequent cause of diarrhcea. In hot weather we 
generally have an increase in diarrhcea cases; and not only is the irritation 
thus induced not limited to the intestinal tract proper, but the liver as 
markedly sympathizes; hence the frequency in these months of cholera in- 
fantum, the excess of bile being thrown both ways. Enteritis, from follicu- 
lar ulceration in typhoid conditions, may induce and keep up a diarrhoea 
in a child as it does in an adult. Tabes mesenterica is a cause of diar- 
rhoea in the scrofulous infant. Syphilis may ulcerate and irritate the intestinal 
tract, just as we so frequently see such irritation in the mouth. These allusions 
are sufficient to remind us that diarrhoea is not a disease, but only a symptom, 
and that, whether occurring in the dentitional or any other period, it may 
have, as its provocative, a great variety of sources, or lesions. When a diar- 
rhoea depends on a dental origin it is perhaps always a condition of vascular 
perversion, and is entirely direct in its nature; the erupting tooth or teeth 
inflame the mucous membrane of the mouth, and, by the continuity of tissue, 
the irritability extends itself over the intestinal portion of the structure. It 
is well to remember that in diarrhcea of this character there is much or little 
mucin, according to the state of the inflammation, and much casting off of 
epithelial scales ; but there is, of course, nothing diagnostic in such phenomena, 
because of their not being peculiar to a particular form, or character, of inflam- 
mation. We are to look at the mouth and at the throat; if there be a local 
condition of irritation and inflammation, and if the vascular derangement 
extend as far as we can follow it, we have reasonable grounds for inferring 
that in the teeth resides the origin of the trouble, particularly if, having 
examined the system at large, we fail to discover other lesions. The author 
does not desire to be understood as asserting that it is only in this way we 
have dental diarrhoea, for he well knows there is another way, and that is 
through the second of the legs of Bichat's tripod,-namely, deficient nerve 
force. He very well knows that there is an influenced innervation, and that, 
if the bowels of an infant be weaker than its lungs or its brain, such deranged 
innervation will there expand itself. He has seen the diarrhoea of such de- 
ranged innervation relieved almost instantly by an incision into a tooth- 
cyst, and yet there was no redness, no swelling, nor any other evidence of 
local excitability. These cases are, however, rare, and have their analogues 
in reflex spinal irritations. The diagnosis must necessarily be somewhat 
differential in character; yet, where a case is at all obscure and the circum- 
stances urgent, it is commendable practice to make incisions over the 
positions of teeth whose periods of eruption correspond most nearly with the 
time of operation. 
It is well, however, and indeed necessary, to remember that a mucous mem- 176 
A SYSTEM OF ORAL SURGERY. 
brane may be inflamed, in varying localities, without having intermediate san- 
guineous disturbance. Thus a stomatitis and an enteritis might be present 
at the same moment; the one depending on local dental disturbance, the other 
upon a cause or causes of entirely dissimilar nature. Now, in a case of this 
kind, having associative diarrhoea, it will plainly enough be seen that 
any treatment directed to the stomatitis would not (except as a similarity in 
practice might pertain to both troubles) affect the enteritis. To recognize 
these cases, antecedent conditions are to be inquired into. Colds or atmos- 
pheric vicissitudes will, most frequently perhaps, be found explanatory 
of the disturbances. The cutaneous circulation, as a result of some injudicious 
exposure, has been depressed, perhaps, and thus the enteritis has been forced 
upon a part having the least ability to resist an inrolling wave. In some 
infants, restless and nervous in their natures, a predisposition to enteric 
irritation seems inborn, the slightest disturbance reacting in this way ; it may 
not be that diarrhoea is the result, but the trouble exhibits itself in some 
evident way. 
Milk of Nurse.-The milk of a nurse is occasionally the source of a 
diarrhoea. Infusoria and crystalline substances are found frequently, on 
examination, in such milk. Here a cure is obtained only by change of diet,- 
good cow's milk, diluted or pure, according to the age of the infant, being 
the best substitute. Other causes of diarrhoea, to be considered in con- 
nection with a supposed but doubtful dental source, are debility, hepatic 
derangements, interfering with the venous circulation, an increased peri- 
staltic action through mental emotions, as anger or fright, a rheumatic or 
scrofulous diathesis, malarial influence, etc. 
Dental Irritation.-Diarrhoea from dental irritation, if inflammatory 
by continuity of relationship in the membrane, generally requires the lancet 
alone for its cure; the operator is to free the advancing tooth or teeth. If, 
however, on the removal of such cause, the effect does not subside, the invoked 
and persistent irritability is to be treated on such principles as commend them- 
selves. Sweet oil and paregoric, administered internally, are oftentimes found 
to act very happily. To each teaspoonful of the oil add from five to twenty 
drops of the opiate, according to the age of the little patient. Heating appli- 
cations to the abdomen are very useful; for example, a sinapism made as 
follows: 
Flour, ^ss; 
Mustard, 3j 5 
Ginger, $ij; 
Black pepper, £ss. 
Mix these together with a little vinegar, and retain against the skin until the part is well 
reddened. It is not at all necessary to blister the surface. 
Treatment.-A mode of treatment is to give small doses of Dover's 
powder, or, what is to be preferred, the liquor potassii citratis, in conjunction 
with minute doses of tartar emetic. ASSOCIATIVE LESIONS OF FIRST DENTITION. 
177 
R Spiritus aetheris nitrosi, ^ss; 
Liquoris potassii citratis, ^ij ; 
Antimonii et potassii tartratis, gr. M. 
Sig.-Give in ten- to fifteen-drop doses each two hours, and keep the patient cool. 
This combination serves to direct the irritability to the surface, and, by a 
relief thus afforded the affected part, not infrequently yields a cure. 
If the inflammation have anything of a sluggish or passive character, the 
spirit of Mindererus will act happily. Half-teaspoonful doses may be given 
every two or three hours. 
Diarrhoea from dental irritation, not inflammatory in character, is to be 
treated in consideration of its nervous relation; and just here is a condition 
in which the bromide of potassium is found to act most satisfactorily. This 
salt may be given in five-grain doses, dissolved in water ; or, if the practitioner 
do not like to commence, in the infant, with such a dose, he may try if less 
will answer his purpose, and increase pro re nata. Less than five grains, 
however, is not commonly found to do much good, unless, indeed, the child 
be very young. Spirit of Mindererus, sweet spirit of nitre, and the campho- 
rated tincture of opium also act satisfactorily in these cases. These are given 
in such proportions as seem indicated. An ordinary prescription would be as 
follows: 
U Spiritus Mindereri, §ij; 
Spiritus astheris nitrosi, §ss; 
Tincturae opii camphorates, Jij. M. 
Sig.-About twenty-five drops each two hours. 
The following combination is a valuable one when other sources of irrita- 
tion, not perhaps thoroughly appreciated, exist in conjunction with the dental 
trouble: 
R Hydrargyri chloridi mitis, gr. ij ; 
Pulveris opii, 
Pulveris ipecacuanhas, aa gr. j ; 
Magnesias carbonatis, gr. xij. 
Sig.-Divide into eight powders, and administer one after each operation, if profuse; 
otherwise, each two, three, or four hours, according to judgment. 
Where discharges are of watery character the following is to be depended 
on as possessed of almost specific virtue : 
R Bismuthi subnitratis, 
Myristicae pulveris, aa 3'j > 
Gretas preparata, Qij; 
Syrupi zingiberis, §iss. M. 
Sig.-Dose, teaspoonful every hour or two. Shake well. 
SPASMS. 
To appreciate the cause and condition of spasms and convulsions in early 
childhood, whether influenced or not by the excitements of dentition, one has 
but to consider the restless mobility of the cerebro-spinal system at such age. 178 
A SYSTEM OF ORAL SURGERY. 
If, at an early period of life, the gray matter of the spinal cord be examined, 
we are struck with its development when compared with the similar substance 
in the cerebral portion of the encephalic mass. To express ourselves differ- 
ently, the ganglion of excito-motor or reflex action we find to be much in ex- 
cess in its development, and not only so, but sensitive and susceptible, as its 
offices are concerned, to the last degree,-a result most likely of the necessity 
for the motion of growth and development existing in the members of a child. 
Such a system is to be compared to a tensely-strung instrument, responding to 
the slightest touch. 
The difference between a regular and irregular motion is the difference 
between an ability and disability of the cerebellar gray matter to perform 
its functions of co-ordination; the difference between a co-ordinated and 
an irregular motion is the difference of spasm ; and if we carry this to the 
disability of the cerebral mass to influence, it is the difference of convul- 
sion. 
Spasm Defined.-Spasm, then, may be defined as irritation, direct or in- 
direct, of the spinal cord or of its terminal outshoots, or nerves. This foundation- 
principle appreciated, a further consideration of the subject is not at all difficult. 
Very true it is, that there may be causes of disturbance not to be discovered ; 
but the results, and the meaning of these, are not thereby rendered obscure: 
it is only the cure that is to be delayed or denied. 
We are prepared, now, to recognize in what way dental evolution is a cause 
of spasm : it is precisely as it is a cause of diarrhoea, as it is a cause of fever; 
but the reflected irritation in the latter case expends itself on the muscular 
rather than on the mucous or vascular system. The cure, or the mode of 
cure, suggests itself: first, we are to remove the condition of irritation; sec- 
ond, if the parts do not quickly soothe and quiet themselves, we are to help. 
To meet a first indication we simply lance the gums. It is not thought that 
in these cases we are to be influenced entirely by local manifestations of con- 
gestion : we are to cut freely down upon teeth whose periods of eruption 
suggest them as being the source of offence. Take a pledget of cotton, and, 
saturating it with a solution of atropiae sulphas, one grain to the ounce of 
water, thrust it, by means of some delicate instrument, into the cut you have 
made. This is quite equal, at least as such a case is concerned, to the more 
common subcutaneous injection, and tends to quiet the disturbed nerve-fila- 
ments. Or the bromide of potassium, as before suggested, may be used; or, 
drying the gum with a napkin, the smallest possible quantity of the extract 
of belladonna may be rubbed over the part, or a point of nitrate of silver 
may be employed. If yet the spasms persist, some general effect on the 
nervous system at large is to be secured. Tinctures of valerian and gentian 
in equal parts, given in ten-drop doses, repeated pro re nata, will sometimes act 
most satisfactorily. If this should not answer, the bromide of potassium, inter- 
nally, may be employed. Tincture of belladonna is, in the author's experience, 
one of the best remedies for spasm. The bromide of potassium, cantharides, ASSOCIATIVE LESIONS OF FIRST DENTITION. 
179 
and camphor, as recommended by Dr. Chambers in epilepsy, constitute an 
admirable combination: 
Potassii bromidi, gr. iij ; 
Tincturae cantharidis, gtt. iij ; 
Misturae eamphorae, gtt. x. M. 
Sig.-Repeat this in a little water, p. r. n 
If, after proper trial of the above,-say a few hours,-the irritability fails 
to be subdued, the inference will be that our diagnosis has been a mistake, 
and that dentition has not been wholly, at least, in fault. 
At this point we see the necessity of glancing at other causes of irrita- 
tion which may exist. Many children incline to nervous disturbance from 
anaemia; this we know to be a quite common cause of such derangement. 
An anaemic condition might not of itself, in a special case, induce spasm, but 
assisted by conjunction with a second irritant, the two together could excite 
to the condition; and one removed, the other might yet very well resist a 
curative agent. A glance here shows us why the sedative has not effected a 
cure ; let us add iron to our prescription, and a very few more days will give 
a different result. Perhaps the condition of a child is just the reverse; in- 
stead of being anaemic, it is plethoric. Give to this child repeated doses of 
some suitable saline mixture, and conjoin with bromide of potassium quarter- 
grain doses of calomel; or, if you do not wish thus to medicate, diet closely 
for a few days,-give nothing but the breast, and this only in the daytime; 
or, if the period be that of second dentition, deprive it of all but vegetable 
food, with water for drink; a cure will most likely follow such treatment. 
Lack of good, fresh, pure air; unwholesome food; deficient or improper 
clothing; sleeping with debilitated persons; the milk of the nurse; articles 
of food not easy of digestion ; hepatic derangements ; worms in the alimentary 
canal; influences passed from mother to infant; and numberless similar 
conditions, are exciting and predisposing causes of spasm and convulsions; 
all demand, in every case, their share of consideration, if we are to be success- 
ful in treatment. 
Spasm resulting from the congestion of nerve-centres, however induced, is 
not infrequently tonic in its character; the child may lose all consciousness; 
it passes into the state that we call convulsion. In these cases results must 
be obtained immediately; we must relieve the overburdened part. How ? 
By derivation. Try first a hot foot-bath; let it be as hot as the skin will 
bear. Enclose the steam of the water so that it shall envelop all of the child 
but its head; compel the taking, if possible, of teaspoonful doses of the 
spiritus Mindereri. The steam, or the steam and mixture in conjunction, 
will soon compel profuse perspiration, and thus secure a double derivation. 
Such treatment will, most likely, relieve the congested part. If it should 
not answer the intention, then a vein may be opened, or leeches may be 
applied. The opening of a vein in such cases the author has had no occasion 
to resort to, but it is good practice, and is recommended by the best writers. 180 
A SYSTEM OF ORAL SURGERY. 
Hot pediluvia, and derivation by perspiration, will be found reliable. If, after 
consciousness is restored, the pulse continue rapid, with fulness, give one-drop 
doses of the tincture of veratrum viride, or relax the system generally by 
doses of tincture of lobelia or the syrup of ipecacuanha. Ten drops of either 
of these medicines, repeated as indicated, will very well answer the purpose. 
Keep the child now cool, and guard against every source of discomfort. 
An instructive and suggestive case where epilepsy had its irritant in dental 
irritation is described in the Medical Record by Dr. Nathaniel Field. The 
paper states that a small boy, about five years of age, while apparently in good 
health, was suddenly attacked with an epileptic fit, from which he soon re- 
covered. The parents were much surprised at the occurrence, and were un- 
able to account for it. About two weeks afterward he had another strong 
convulsion, lasting several minutes; but it passed off without any constitu- 
tional disturbance. No cause for the attack was discovered by the relater 
or other practitioners. In a day or two the fits returned, and were repeated at 
short intervals for about ten days, during which time it is asserted that he 
must have had a thousand. Every resource in the power of Dr. Field was 
exhausted, and three eminent medical professors examined the child from the 
crown of his head to the soles of his feet, but no local irritation was discovered. 
After carefully watching the commencement of the paroxysms, Dr. F. observed 
that the muscles of the left side of the face invariably began to twitch on the 
recurrence of a fit. After a convulsion had passed off, and while the child 
was in a state of unconsciousness, he raised the upper lip, and found the corona 
of the second canine tooth, instead of having caused by a just relation the 
absorption of the root of the deciduous tooth, had passed behind it, and had 
forced it through the alveolus and gum into the lip. The gum was now slit 
vertically and the old tooth removed. In less than an hour the convulsions 
began to subside, and before the day was over they had entirely gone, and 
never again appeared. 
Passive congestions are sometimes a cause of infantile spasms; these 
are not difficult to distinguish from the acute, or active, conditions, the languor 
and sluggishness markedly contrasting with the turgidity and fulness. Again, 
they are distinguished from the active state in their results, these being not 
immediate, but mediate. Passive congestions depend on some obstruction 
in the circulatory apparatus, and are, perhaps, more frequently associated with 
the chylopoietic than with any other system. Stagnations may also occur 
as a result of some interference with the respiratory office, or they may be 
the result of the action of some directly sedative poison. Wherever and how- 
ever they exist, they are to be removed, if possible, by meeting and combating 
the cause, which, of course, is the philosophy of cure. 
In cases of pure irritation, as Dr. George Wood happily puts it, besides 
removing the cause, it is proper to diminish the nervous susceptibility and to 
control the cerebral irritation by diffusing the excitement over the whole 
system. To meet the first indication, narcotics may be employed; and none ASSOCIATIVE LESIONS OF FIRST DENTITION. 
181 
is more efficacious than opium, which, to diminish its stimulant influence, 
may be combined in some instances with ipecacuanha. Hyoscyamus, lactu- 
carium, or conium may be substituted, if, on any account, thought preferable. 
But before resorting to these remedies, a practitioner must be very sure of 
his grounds. He must be quite convinced that it is nervous irritation, and 
not active congestion of the brain, that he encounters. The second indica- 
tion, above alluded to, is to be fulfilled by antispasmodics, administered by 
the mouth, the rectum, or the skin, and by the use of tonics, of which the 
metallics are deemed most efficient. Of these the oxide of zinc has perhaps 
enjoyed most reputation, though the chalybeates should be preferred in anaemic 
cases. Should the digestion be impaired, and the system at large feeble, 
the simple bitters or quinia might be preferable to the metallic tonics. These 
remedies are often combined in the same prescription. Thus, opium or hyos- 
cyamus, asafetida, and either oxide of zinc, carbonate of iron, sulphate of 
quinia, or extract of gentian or quassia, may very properly go together. The 
cold or shower bath, cautiously used, may also serve to strengthen the nervous 
system. Fresh air and nutritious diet of easy digestion are important. Any 
derangement in the hepatic secretions is to be carefully observed, and may be 
treated with minute doses of calomel, blue pill, or mercury with chalk. When 
the disease depends on intestinal spasm, advantage will often accrue from 
the use of laudanum, with asafetida or spirits of ammonia, by the mouth, the 
injection of musk into the rectum, the application of a mustard cataplasm, or 
blister, over the abdomen ; and if, as often happens, the bowels are distended 
with flatus, from the introduction of a catheter into the colon, and drawing off 
the air by means of a syringe. Should the disappearance of an eruption have 
preceded the convulsions, effort is to be made to restore it by friction with 
croton oil or other active irritant. In urgent cases a blister is to be produced, 
by means of a strong solution of ammonia, on the surface previously affected. 
In frequently recurring convulsions, resisting other measures, and threaten- 
ing life, the practitioner is justified in resorting to the exhibition of chloro- 
form ; this will often quickly quiet the spasms, and, if repeated with each 
return, may obviate the danger until the tendency is past. It has an advan- 
tage, moreover, over other narcotics, of not congesting the cerebral centres, 
though the danger of fatal prostration from its use is not to be forgotten.* 
Even when asphyxia or apparent death may have resulted from the con- 
vulsions, hope is not to be abandoned; but efforts made by artificial respira- 
tion to restore the functions of the lungs, and consequently that of the heart. 
Finally, on this subject, attention is to be directed to the connection between 
the troubles we are considering and the predispositions of hereditary nature, 
so often found in association; phimosis in the male infant is a not infrequent 
association. When these conditions exist, it is a necessity for success in treat- 
ment that they be considered and combated. 
* It is found safer to combine with it a portion of sulphuric ether. 182 
A SYSTEM OF ORAL SURGERY. 
ERUPTIONS UPON THE SKIN. 
That the skin of childhood should be the subject of irritation existing in 
various offending agents to which it is exposed is certainly only what is to be 
expected, and that variations in condition do most frequently occur is as true 
as that they are thus expected. 
Certain general considerations of the subject give us the key-note. 
Thus, in the beginning, a momentary thought directed to the great change 
which must result in the passage from intra- to extra-uterine life, would 
naturally lead to the anticipation of a cutaneous hyperaemic condition at once 
to be developed. In intra-uterine life we not only have the delicate and sus- 
ceptible skin lubricated with the soft, bland smegma, but pressure on any and 
every part is jealously guarded against by the surrounding amniotic fluid. A 
single minute, frequently, and the most irritative changes occur: the waters 
pass away, the uterus crowds and presses upon every part of the child, while 
the outside world, still less considerate, receives it on its birth, its atmosphere 
stimulating and irritating, its rough points jagging and abrading, while un- 
necessary and too frequently ill-advised appliances and applications add to the 
common discomfort. 
Cutaneous Hyperaemia.-Cutaneous hyperaemia-erythema, as it is 
generally called-is a child's primary skin-trouble. Such an erythema is cer- 
tainly nothing more nor less than the variegated blush of an over-stimulated 
circulation. Perhaps if the smegma were left undisturbed for a few hours, 
just as nature puts it over the body, or until the skin had become somewhat 
accustomed to its new atmosphere, such hyperaemia would be avoided; but as 
such excitability seems to do no immediate harm to the child, neither nurse 
nor mother are likely to be found satisfied with such an arrangement. But 
does this hyperaemia do no harm? Does it not provoke an excitability in 
the skin which would be better absent? Certainly children are most sus- 
ceptible to cutaneous impressions, as witnessed not only in colds so easily 
tak(*n, but by the variety of local manifestations, to the relief of which the 
practitioner is so frequently called. Dental irritations pertain to these 
troubles only as they act as excitants to the existing predisposition, or as they 
keep up an excitability which overmasters the corrective force natural to the 
vis vitae. 
Hyperaemia.-Hyperaemia running into an excess is inflammation. In- 
flammation of the skin finds a primary expression in the term Dermatitis. 
A dermatitis has secondary signification, as it presents peculiarities which lead 
us to look for reasons for such expressions. Thus, one inflammation in the 
skin is a simple sthenic increased vascularity, having the phenomena of red- 
ness, heat, pain, and swelling. A second is not regular and honest in its 
expressions, but throws out claw-like expansions, and looks dusky and threat- 
ening, throwing to the surface, here and there, blebs of serum. We distin- 
guish this second from the first by the subterm erysipelas, or erysipelatous ASSOCIATIVE LESIONS OF FIRST DENTITION. 
183 
inflammation. Then we have an inflammation which presents the pecu- 
liarity of studding the face of the skin with pustules, and this derangement 
we distinguish by the term pustulas or pustular inflammation. Another form 
covers the inflamed surface with vesicles; another throws out groups of 
nodules,-papular ; another circumscribes its redness to patches,-rashes; 
another presents raised or elevated wheals,-urticaria, etc. All have alike 
the primary signification of a perverted circulation, but differ in presenting 
distinctive phenomena, these marking differences in local or constitutional 
circumstances. 
Dental Irritation.-That dental irritation develops or creates the distinc- 
tive features in a skin-disease is not to be accepted. All that such irritation 
has to do with the matter is that it exhausts the system, just as any pain tires, 
and reduces, as remarked, the ability of the vital force to guard or protect 
itself against an enemy or enemies in waiting at the threshold. It does not 
make the enemy, it only lets him in by weakening the bars. 
That a skin-disease is thus introduced, and continued in an ability to resist 
applied medication, would seem to be true beyond the shadow of a doubt; 
and it is for such a reason that the consideration of dental irritation, in con- 
nection with infantile skin-diseases, is important; and yet this study, as the 
evolution of the teeth is concerned, differs in no wise from its study in rela- 
tion to stomatitis, diarrhoea, or spasm, as certainly any intelligent mind must 
at once appreciate. A general exposition of the subject is to be given in a 
few paragraphs. 
Skin-diseases belong to one of eight orders 
1. Pimples. 
2. Scales. 
3. Rashes*. 
4. Bullae. 
5. Pustules. 
6. Vesicles. 
7. Tubercles. 
8. Spots. 
1. Pimples-Papulae.-Small and pointed elevations of the cuticle, with 
an inflamed base,-very seldom containing fluid, seldom suppurating, and com- 
monly resolving as scurf. 
Three primary divisions of papules are made : strophulus, lichen, and prurigo. 
Secondary divisions.-Strophulus intertinctus. 
S. albidus, S. confertus, S. volaticus, S. candidus. 
Lichen simplex, L. pilaris, L. circumscriptus. 
L. agrius, L. lividus, L. tropicus. 
Prurigo mitis, P. formicans, P. senilis. 
P. pudendi muliebris. 184 
A SYSTEM OF ORAL SURGERY. 
2. Scales-Scaly Diseases-Squamae.-Scales or laminae form 
upon the skin. Scales are of various forms,-in some cases, as in pityriasis, 
resembling a scurf; in other cases, as in ichthyosis, being broad and flattened, 
and bearing likeness to fish-scales. To mark the various prominent differ- 
ences, four varieties are enumerated: Psoriasis, Lepra, Pityriasis, Ichthyosis. 
Subdivisions.-Lepra vulgaris, L. alphoides, L. nigricans. 
Psoriasis guttata, P. diffusa, P. gyrata. 
P. inveterata. 
Pityriasis capitis, P. rubra, P. versicolor, P. nigra. 
Ichthyosis simplex, I. cornea. 
3. Rashes-Exanthemata.-Irregular, variously figured patches, ap- 
pearing on various parts of the body, leaving interstices of a natural color, 
and terminating in exfoliations of the cuticle. The designation is generally 
limited to efflorescences originating in fevers, as, for example, measles and 
scarlet fever. 
Bateman, however, includes, and perhaps more philosophically, Erythema, 
Urticaria, and Purpura in the division. 
The first division is, then, according to Bateman, Rubeola, Scarlatina, Ur- 
ticaria, Purpura, Erythema. 
Subdivisions.-Rubeola vulgaris, Scarlatina simplex. 
S. anginosa, S. maligna, Urticaria febrilis, U. evanida. 
U. persistans, U. conferta, U. subcutanea. 
U. tuberosa, Purpura simplex, P. haemorrhagica. 
P. urticans, P. senilis, P. contagiosa, Erythema laeve. 
E. papulatum, E. tuberculatum, E. nodosum. 
4. Bullae.-A condition in which effusion occurs on the true skin, sepa- 
rating the cuticle in the form of blebs or blisters. An effusion developed by 
a blister comes justly in its consideration under this head, for it is surely not 
less a bleb because a blister has produced it. The difference between such 
a bleb and one resultant from an erysipelatous inflammation is that one has 
strictly a traumatic signification, while the second is a specific offence. Blebs or 
bullae have three primary classifications : Erysipelas, Pemphigus, Pompholyx. 
The subdivisions are into Erysipelas phlegmonodes, E. oedematodes, E. gan- 
graenosum, E. erraticum, Pompholyx benignus, P. dinuturus, P. solitarius. 
5. Pustules-Pustulae.-An inflammation of the skin, resulting in the 
formation of purulent matter, which accommodates itself by throwing up little 
circumscribed tumors. Whether one or many of these pustules rise on a 
common inflamed base depends on the fundamental or exciting cause; and 
because the conditions which produce pustular inflammation vary, so have we 
various names by which to distinguish and appreciate these causes. Five 
primary pustular inflammations exist: Impetigo, Porrigo, Ecthyma, Variola, 
Scabies. 
The subdivisions are numerous, depending on peculiarity of features. Im- 
petigo figurata, I. sparsa, I. erysipelatodes, I. scabida, I. rodens, Porrigo lar- ASSOCIATIVE LESIONS OF FIRST DENTITION. 
185 
valis, P. furfurans, P. lupinosa, P. scutulata, P. decalvans, P. favosa, Ecthyma 
vulgare, E. luridum, E. cachecticum, Variola, Scabies papuliformis, S. lym- 
phatica, S. purulenta, S. cachectica. 
6. Vesiculae-Vesicles.-Vesicles differ from pustules in containing 
lymph,-they look like little water pimples, although it is very frequently the 
case that the contained lymph is quite opaque; the end of a vesicle is by 
scurf or scab. There are seven primary varieties: Varicella, Vaccinia, 
Herpes, Rupia, Miliaria, Eczema, Aphtha. 
The subdivisions are Varicella lenticulus, V. conoidae, V. globate, Herpes 
phlyctaenodes, H. zoster, H. circinatus, H. labialis, H. praeputialis, H. iris, 
Rupia simplex, R. prominens, R. escharotica, Eczema solare, E. impetiginodes, 
E. rubrum, Aphtha lactantium, A. adultorum, A. anginosa. 
7. Tubercula-Tubercles.-These are small, hard, circumscribed 
tumors,-they may be fixed in a state of integrity, or they may be degenera- 
tive. There are nine kinds of these tumors,-or, to express it differently, 
there are nine distinctive differences: Phyma, Verruca, Molluscum, Vitiligo, 
Acne, Sycosis, Lupus, Elephantiasis, Framboesia. 
Among these, subdivisions seem necessary only with acne and sycosis. 
Thus, there are three peculiarities in acne, which are marked by the terms 
Simplex, Indurata, Rosacea. In sycosis, Sycosis menti and S. capillitii, 
designating the location of the tubercles. 
8. Macula-Spot - Mother-Mark - Freckles, or Ephelis- 
Naevus. 
These eight classifications, after Bateman, with his subdivisions, make out 
of skin-diseases all that concerns a present consideration of them. It is for 
the student to comprehend the primary divisions, as their pathological differ- 
ences are concerned; the radii, or subdivisions, will be found to take care of 
themselves. . Without an understanding of the general subject one could 
scarcely expect to appreciate any accidental or positive dental relations. The 
subdivisions will be remarked, on examination, to be simply as family sur- 
names distinguishing one child from another; it is true, of course, that there 
are peculiarities of character, just as each child is peculiar, and by such pecu- 
liarities are these modifications on the primary condition named. Now, it is 
not by any means common to associate all these conditions with dental irrita- 
tions ; yet it is certainly true that any one of them may have such association : 
therefore, if the student would understand one he must understand all. (See 
The Face and its Diseases ; see also works on Dermatology.) CHAPTER XL 
ANOMALIES OF SECOND DENTITION AND THEIR 
SURGICAL RELATIONS. 
Understanding and appreciating the characteristics and relations of a 
normal dentition, we are prepared to pass to the consideration of abnormal, 
or pathological, conditions. Such conditions are grouped under the head of 
anomalies. 
Anomalies in second dentition are classifiable under seven heads: 
1st. Teeth common to the age, but erupting external or internal to the arch. 
2d. Teeth denied space in the arch, because of natural or surgical interfer- 
ence with the process of maxillary enlargement. 
3d. Germs developing in positions where their product must remain 
encysted. 
4th. The production of supernumerary teeth. 
5th. Third dentitions. 
6th. Teeth the periodonteum of whose fangs associate with the periosteum 
of the maxillary sinus. 
7th. Germs with heterogeneous development. 
These seven conditions, then, because they differ from a just, or normal, 
dental evolution, we call anomalies. 
Anomaly First.-A tooth external or internal to the alveolar arch gives 
origin not infrequently to an ulcer or locates epithelioma. Close as is this 
primary to the secondary lesion, and evident as such relationship would seem 
to be, the writer has yet known ulcers of the tongue, lips, and cheeks 
treated for months-of course, without success-where it has never seemed 
to strike the practitioner that a tooth could have any association with the 
disease; indeed, in one case, where the patient was remotely connected with 
himself, death was the result of cancer located in the cheek from this very 
anomaly. Cases of like character are familiar to the experiences of every 
surgeon. 
Note.-Even where there is excess of room, the permanent teeth erupt 
not infrequently irregularly; indeed, this applies so directly to the inferior 
incisors that it may almost be said to be the rule rather than the exception. 
Unless, however, specially indicated, it is the best practice to leave such teeth 
to nature; they will almost always be found to come right of themselves. 
Such eruptions are to be classed with the anomalies only as derangement is 
marked and permanent. 
186 ANOMALIES OF SECOND DENTITION. 
187 
Anomaly Second.- Teeth denied space in the Arch.-This anomaly has 
perhaps the largest associative pathological connection. 
It is to be remarked that this lesion, if it is to be termed such, is more 
frequently the fault of the surgeon than of nature. If, for one moment, 
reference is made to physiological relations existing between first and second 
dentures, it will be found that it is within the province of surgery to prevent 
many ills that follow so frequently in this train, and this simply by doing little 
or, more commonly, nothing. 
The deciduous dental arch is filled, as we are all aware, completely by its 
ten teeth. The second, or permanent, set is to comprise in number sixteen, 
and each tooth certainly quite as large again as its predecessor. This increase 
in number and size of the teeth, it is evident, must be provided for in an en- 
largement of the alveolar arch. This provision is always attempted by 
nature in the process described by the physiologist as the elongatory. 
This process of maxillary enlargement is to be illustrated by consider- 
ing the ten milk-teeth as so many wedges placed in a springy arch. This arch 
it is designed to lengthen by additions to either end. If, now, these wedges 
should be removed before others were ready to take their place, it is evident 
that the elongation, being made at the ends, would, to a greater or less ex- 
tent, be counterbalanced by the springing together of the parts at the sites 
of the removed wedges. The process of maxillary, or rather alveolar, absorp- 
tion is truly represented by this retraction of an arch. In proportion to the 
number of deciduous teeth removed prematurely, will be the curtailment in 
size of the arch ; at least of its alveolar face. 
Let us, then, look at the results of such abridgment,-approximal caries 
of the teeth, periodonteal troubles, trismus, odontocele, necrosis, the violent 
inflammations attendant on the development of the dentes sapientiae, etc. 
Note.-If there be a pathological Pandora's box, it is certainly the lesion 
of an overcrowded maxillary arch. 
The condition of overcrowding is made evident to a practitioner the moment 
he looks into the mouth of his patient: the teeth are jammed into the most 
uncomfortable-looking positions; the deformity, however, mostly existing in 
the front of the mouth,-either the central incisors pverride, or the laterals 
are thrown back, or otherwise the cuspidati take a tusk position, standing out 
prominently from the arch, the bicuspidati occupying too anterior a location, 
approximating, indeed, not infrequently with the lateral incisors. 
Treatment.-To abort the ill consequences of such a contracted arch, ex- 
tract at as early a period as possible the first bicuspidatus of either side. 
This very simple operation will frequently secure not only against secondary 
lesions, but will occasionally correct the most annoying deformities. Let it 
be remembered, however, by the practitioner who prefers prophylactic to 
operative surgery, that on his treatment of the deciduous mouth depends, in 
a measure, the health and comfort of the adult. 
If the question be asked, What is to be done with the deciduous aching 188 
A SYSTEM OF ORAL SURGERY. 
tooth ? it is to be answered by saying that the cavity exposing the pulp should 
have been filled on appearance of the decay. This is a matter which no 
parent can afford to neglect. In the armamentum of the oral surgeon are 
plastic materials, easy and painless of introduction, which are to be depended 
on to accomplish the services required of them. 
Equal parts of chloroform and tincture of aconite, applied to an aching 
nerve on a delicate pellet of cotton, will sometimes instantaneously relieve 
this form of toothache. Hydrochlorate of cocaine, four grains to the ounce 
of water, constitutes an application worthy of being kept constantly at hand; 
it is applied by saturating a very small pellet of absorbent cotton and laying 
this with all delicacy upon the aching pulp. Another admirable application, 
used in the same way, is the atropise sulphas, in the proportion of one grain 
to the ounce of water. Still another-a means in universal use-is creasote. 
Other remedies are found in oil of cloves, in Goulard's extract, tincture of 
iodine, bismuthi subnitras in saturation, chloral hydrate, and tincture of ergot. 
Where inflammation exists no better means of alleviating an irritated pulp is 
to be found than the following, applied in the same manner as the cocaine: 
U Plumbi acetatis, gr. ij ; 
Tincturse opii, gtt. x; 
Aquae, ^i. M. 
Attention is to be directed to the necessity for washing away by use of warm 
water applied by means of a syringe any crumb or other particle that might 
happen to be in contact with the part. Also it is necessary to guard against 
a manner of using the cotton, as suggested above, that shall make pressure 
upon the pulp. 
An exposed pulp in the deciduous tooth is, however, so constantly subject 
to irritation, that every indication calls for its destruction. The necessity is 
unfortunate, but the demands are persistent, and the removal of the part 
seems the lesser of two evils between which a practitioner is compelled to 
choose. The application of arsenic, however, to such an exposed pulp has 
come to strike the experienced as questionable, and, as it is not a necessity, 
it will be found best perhaps to restrict the use of this agent to the perma- 
nent teeth. A deciduous pulp is to be destroyed by touching it a few times 
with a fully-saturated tincture of iodine, or with either of the Monsel's so- 
lutions of iron. (See chapter on Odontalgia.') Arsenical applications are, 
however, frequently employed, but unless a practitioner be conversant with 
the physiological change that occurs in the fangs of these teeth, he had 
better not risk this means; if, however, he feel prepared to employ such an 
escharotic, he can use no better formula than the following: 
U Acidi arseniosi, 
Morphia; acetatis, aa gr. x; 
Creasoti, q. s. to make a thick paste. ANOMALIES OF SECOND DENTITION. 
189 
This is a paste quite universally employed for destroying the pulps of adult 
teeth. To apply it to a milk-tooth, take a piece not larger than a pin's head, 
and dropping it lightly into the cavity, cover loosely with wax, or, preferably, 
with cotton saturated by gum sandarach ; the part is to be washed out with 
warm water after four or five hours; it is not well to leave such a preparation 
in a deciduous tooth over five hours; if absorption of the fang had advanced 
to any extent, even one might be too long. Employ it fearlessly in the adult 
mouth, only remembering that you deal with arsenic; but with the child too 
much caution is not to be exercised. London paste is peculiarly applicable in 
the cases here considered. (See, for formula, Index.) This is applied, of bulk 
corresponding to a large pin-head, directly in contact with the exposed pulp, 
which it destroys instantly; enveloping the tooth with a napkin is to precede 
its use. A means that works very well where the operator possesses delicate 
touch is the thrusting of a cauterant into the pulp by means of repeated 
thrusts made by a very fine needle. Removal of a deciduous pulp by the 
process of broaching, which see, is not judiciously to be practised. Pressure, 
in conjunction with pellets saturated with eucalyptus, or cajuput, or other con- 
gesting agents, is recommended by Dr. Flagg. 
The central incisors of the deciduous set of teeth should (a normal life 
continuing) last until the seventh year; the laterals until the eighth; the 
first deciduous molar until the ninth year; the second until the tenth; the 
deciduous cuspis until the eleventh; and let it be remembered that the most 
posterior molar teeth that are in the mouth at the sixth year are the first 
permanent molars, and that these teeth get their place in the jaw without 
displacing any of the deciduous. 
Note.-For an account of some of these secondary lesions, together with 
treatment, see future pages. 
Anomaly Third.-This anomaly is remarked by examination of the 
classes of teeth erupted. Teeth all appear in pairs, so that one is not likely 
to be deceived. The anomaly is not infrequently a result of interference 
with the development of the germ of the permanent through non-absorption 
of the root or roots of the deciduous teeth. 
Example.-A deciduous central incisor erupts-as a rule-about the 
seventh month, and is succeeded by the permanent at the seventh year. 
Now, the physiological relation existing between the two teeth is as follows. 
At the time when the deciduous has attained its full development the germ 
of the permanent is at its apex. (See Fig. 9G.) Retrograde metamor- 
phosis now commences in the fang of the deciduous, while, in an inverse 
ratio, the development of the permanent advances. It sometimes happens, 
however, that no process is set up for the taking away of the deciduous fangs, 
and, as a consequence, the crowns of the permanent are compelled to make 
places for themselves; this they generally do by emerging posterior to the 
deciduous; but, as can readily be imagined, odontocele, or encystment, is not 
infrequently a result. 190 
A SYSTEM OF ORAL SURGERY. 
Note.-Sometimes, long after the period at which second dentition is usually 
completed, the incisors, as would seem to be natural, are to be remarked, each 
occupying its respective alveolus. Yet here we may have odontocele. One 
of the teeth seen belongs to the milk set. This anomaly could, however, de- 
ceive only the very superficial observer, the difference in the classes of teeth 
being sufficiently marked. 
Because of this non-absorption of deciduous fangs, arrest in the develop- 
ment of the permanent occasionally occurs. It is really quite a nice point in 
practice to give advice in such cases; if extraction of the deciduous tooth be 
advised, and no permanent tooth come to replace it, the practitioner will be 
sure to get a good deal more censure than he deems himself deserving. There 
are a number of conditions to take into consideration in such a case, the 
most prominent of which is the existence or non-existence of the anomaly in 
a hereditary point of view. The author is acquainted with a family where 
continued integrity on the part of certain front deciduous teeth, conjoined 
with the non-appearance of the permanent, has been a striking peculiarity far 
back as the ancestors can be remembered. Ability to advise, in such cases, 
can be gained only by careful study of the laws of dentition and idiosyncrasies. 
Surgical Relations.-In an examination of any obscure tumor of the max- 
illary bones, look at the dental arch; if a deciduous tooth occupy the place 
of a permanent, or the permanent be lacking, not having been extracted, the 
existence of odontocele is reasonably inferred. 
Anomaly Fourth.-Supernumerary Teeth.-These teeth differ from 
all others in being doubly conoidal; this as a rule. It is, however, to be re- 
membered that exceptions exist. Harris mentions having seen teeth of this 
kind so resembling normal organs as " to make it impossible to distinguish 
which should be called the supernumeraryfew observers, however, have 
met with such decided exceptions. 
An encysted condition of these bodies obscures very much recognition of 
their existence. In diagnosing tumors of the mouth, we are to bear in mind 
that there are such odontoceles. The study of the evolution of these teeth is 
interesting, but concerns, of course, the physiological rather than the surgical 
writer. The place where they are met with is the roof of the mouth. 
Surgical Relations.-With the exception of the relation of supernumerary 
teeth to tumors, we have to deal with them only as they so strangely present 
themselves in the mouth. An example in this direction of practice may be 
given. A patient presents himself and tells you that 11 there is a piece of bone 
working out through his mouthand, truly, an examination will seem to 
verify the assertion. But there is a point which, if observed, will save the 
practitioner from being misled. Necrosis is always preceded by, and is asso- 
ciated with, tumidity of the gum. The eruption of a supernumerary tooth 
is very gradual, and, so far as the writer's experience goes, is seldom, if ever, 
attended with inflammation. To extract such teeth, wait until they have 
emerged to the base of the cone; or, if such waiting seems undesirable, care- ANOMALIES OF SECOND DENTITION. 
191 
fully force sharp-bladed forceps through the bone until the nibs grasp this 
base, then with a rotary motion they are easily to be pulled away. Their 
alveoli need no attention. 
Anomaly Fifth.- Third Dentitions.-We are not to be understood as 
referring here to that extra development sometimes occurring in young adult 
life, and yet the mention of the existence of such an anomaly is, perhaps, 
desirable. Thus, Columbus reports that one of his children had three rows 
of teeth. Valerius Maximus and Pliny relate similar facts. A son of Mith- 
ridates is said to have had two, and Hercules three. The author has never 
seen this anomaly, and inclines to think that its existence, in these modern 
times, is not coextensive with the ancient period. He certainly has had 
quite five hundred persons tell him that such and such tooth or teeth were 
the third of the class, but examination, in almost e^ery individual case, has 
satisfied him of a mistake; this anomaly has, however, surgically, little or no 
signification. 
Third dentitions, as here referred to, are those associated with advanced 
age. The student will recognize their physiology in classifying them with 
second sight, etc. The lesions of this anomaly are what might be termed 
associative,-that is, we are occasionally so deceived by them as to be led 
falsely to interpret engorgements, congestions, etc. 
A single case will illustrate the anomaly. An individual, aged sixty-five, 
applied to Dr. Chapin Harris, suffering with pain in the gums and jaw. No 
local lesion was discoverable. A tentative treatment was resorted to. The 
apparent disease went on, entirely uninfluenced by the experimental medica- 
tion, until at last it attained an intensity described as positively excruciating. 
In twenty-one days the mystery was explained by the eruption of a third set 
of teeth. The report of another case appeared, at the time of this writing, 
on the pages of various journals describing a new and full dentition in the 
person of a gentleman eighty years of age. 
Anomaly Sixth.-Association of the Odonto-periosteum with the Mem- 
brane of the Antrum of Highmore. 
It will be remembered that the easiest entrance to the maxillary sinus is 
through the palatine fang either of the second or the first molar tooth. It is, 
indeed, a very common thing to find the roots of these teeth perforating the 
cavity. Remembering this association of parts, it will be seen that many 
conditions, which may have been deemed obscure, are thus made very plain. 
Dr. Harris, who seemed a close observer in diseases of the mouth, went so far 
as to say that two cases, mentioned by Bell and Bordenave, were the only 
authenticated exceptions where abscess had originated in the antrum at any 
other point than that at which it had been penetrated by the root of a tooth. 
A case mentioned in Braithwaite, from the practice of a Mr. Louis Oxley, 
of London, illustrates most happily the relations of this lesion. A young 
woman, of rather strumous habit, complained of a dull, aching pain under 
the orbit. The pain lasted from three to four months, attended by a gradual 192 
A SYSTEM OF ORAL SU ROE RY. 
elevation of the orbital surface of the maxilla. The eye above this surface 
became at length so affected as entirely to lose its functions. At this stage 
of the case she was directed to use leeches and blisters behind the ears, and 
to employ drastic purges. After three months' blindness, the patient first 
perceived a discharge, from the right nasal fossa, of a thick, purulent fluid. 
This discharge, Mr. Oxley says, had existed eighteen months when he first 
saw the case. An examination of the mouth at once revealed the cause 0$ so 
much misery; the removal of three roots, in a state of periodontitis, was the 
simple means by which two most important organs regained their proper 
functions. 
The nasal opening of the maxillary sinus, it is known, is, in a healthy con- 
dition, almost closed by the duplicature of membrane lining the turbinated 
and neighboring bones; congestion of this membrane not infrequently closes 
the outlet entirely. Thus secretions accumulate, giving alarming and 
threatening disfigurements to the face. The weakest points in the osseous 
boundaries of this cavity are, the floor of the orbit, the hard palate, the tuber- 
osity of the bone, and the canine fossa. Any accumulation would necessarily 
be apt to vent itself at one of these four points, unless atresia of the duplicated 
membrane alluded to should occur, and which is not commonly the case. 
Note.-1The author's experience regarding acute abscess of the antrum is, 
that in the great majority of cases the pus seeks to vent itself through the 
floor of the cavity. After the inflammatory action has passed to the suppu- 
rative stage, a swelling will be noticed in the roof of the mouth at the side 
of the mesial line, corresponding to the diseased sinus: this is the abscess 
pointing, and, if left to itself, is sure to make an ugly opening. Such a 
result will be found particularly undesirable if there be any specific vice 
lingering in the system. But, wherever this abscess should tend to point, 
it is of course desirable to abort it. 
If the assertion of Harris be true, concerning the almost invariable dental 
origin of antral abscess trouble (and certainly experience confirms him), 
we turn naturally to the alveolar arch, seeking here the source of offence and 
defence. For a single moment, then, let attention be directed to a few dental 
lesions of a most practical character, without the ability to recognize which 
a practitioner will assuredly find himself at sea. 
Because, when turning to the dental arch, we find it entirely clear of teeth, 
and healthy-looking, we are not hastily to conclude that the primary lesion 
lies in some other direction. We are to remember that fangs of teeth are 
not infrequently broken off in an attempted extraction, and that when so 
broken, particularly if very deep in the socket, practitioners are not unapt to 
leave the pieces. Now, it is easy to understand that a fang so situated may 
be the source of extensive disease, and yet the gum over it be without break 
in its continuity, and perfectly healthy-looking. The relation, in such a case, 
of the fang is with the antrum,-the abscess need necessarily have no external 
sinus. Here an explorative incision along the gum down to the bone is to be ANOMALIES OF SECOND DENTITION. 
193 
made. If, happily, we come to a cavity, we will have hit on the origin of the 
trouble; if nothing be found, we have made but a simple incised wound, which 
left to itself heals in a few hours. 
Again, because the part may have its complement of teeth, and each tooth 
seem perfectly healthy, we are not to turn hastily away. There may be in 
one of these teeth a dead pulp. To satisfy ourselves on this point, we take up 
a delicate steel instrument and strike with it each tooth separately, directing 
the patient to note any difference in the sensations; if he start when a particu- 
lar tooth is struck, we have found the primary lesion. But still again the 
lesion may be here, and yet the patient not express the anticipated pain. A 
hand-mirror is now taken, and, placing the patient full in the sunlight, rays 
are to be reflected over the teeth, by putting the glass back of them. If 
in the arch there be a dead tooth, an opacity not belonging to its neigh- 
bors will show itself; this tooth is the offence; remove it, either by treatment 
or extraction. 
If a tooth have a plug of metal in it, take the filling out; the cavity will, 
not unlikely, be found to communicate with the pulp-chamber. 
Fig. 102. 
Anomaly Seventh.- Germs with Heterogeneous Development.-It 
occasionally happens that a dental germ, instead of arranging its parts accord- 
ing to the ordinary manner, assumes the most fantastic and heterogeneous com- 
plexion, yielding, indeed, such complexity as to ap- 
pearance that nothing but the microscope is found 
able to discover its true character. Out of this con- 
dition arise tumors, caries, necrosis, and other de- 
rangements. Fig. 102 shows the most simple ex- 
pression of heterogeneous development. The fusing 
of teeth after the manner here exhibited is so common 
as to be very familiar. Every variety has been met 
with from time to time. No confusion exists, how- 
ever, as recognition of tooth character is concerned. 
Fig. 103 is a marked departure from simple fusion. At the point 6 or- 
dinary tooth-roots are recognizable. At the summit of the mass, a, the 
appearance is cauliflower-like. 
Figs. 104 and 105 are other illustrations of heterogeneous development. 
Fig. 103. 194 
A SYSTEM OF ORAL SURGERY. 
Fig. 104. 
Fig. 104.-a, a', second grinding tooth of a horse, natural size, with considerable de- 
velopment of the roots, transformed|into two spheroidal swellings; b, b', portions of the 
maxillary bone sheathed in the tumor, and broken in its extraction; c, orifice conduct- 
ing to the interior <5f an intradental cavity; d, d, circular groove corresponding to the 
alveolar arch, and forming a sort of strangulation between the tuberosity a and the 
swelling e, which is underneath; f, inferior surface of the crown of the tooth. 
Fig. 105.-Microscope exami- 
nation of the tumor (300 diame- 
ters).-Represents part of a 
thin section of the tnmor 
shown in Fig. 104. The tumor 
was formed jointly by a hyper- 
trophy of the dental ivory and 
a hypertrophy or exostosis of 
the cement, the greatest part 
being formed of the substance 
of the cement, a, b represents 
the ivory in its canaliculi-not 
ramified in this section-and 
terminating near the union of 
the ivory and enamel; c, d, e 
exhibits the mammillated ar- 
rangement seen in the cement 
at certain points of the surface 
of union with the ivory or den- 
tine. This arrangement, often 
very elegant under the micro- 
scope, is also met with in the 
normal teeth, g, h, osteoblasts, 
or characteristic cavities of the 
cement. They are especially 
remarkable for their size in all the preparations taken from this piece, f, proper substance 
of the cement, or bone, in which the characteristic cavities are excavated. It is here, as 
always, homogeneous, little transparent, except when it is reduced to very thin lamina. 
Fig. 105. ANOMALIES OF SECOND DENTITION. 
195 
Figs. 106 and 107 afford further illustration. 
Fig. 106. 
Fig. 107. 
Fig. 106. - Intramaxillary bone 
bearing the two permanent incisors 
(a, a) superposed, and exhibiting an 
anomalous development. The al- 
veoli of the same infantile teeth, c, b, 
are partly destroyed; this section 
formed the deposit. 
Fig. 107.-Tumor of the ramus of 
an inferior maxillary bone, affected 
with mollifies ossium. At the surface 
are many openings of encysted ab- 
scesses; and the last molar, a, the 
crown of which extends slightly be- 
yond the alveolar edges, and is devel- 
oped in the thick part of the base of 
the coronoid apophysis; b is a second 
molar tooth. 
Fig. 108. 
Fig. 108.-Upper jaw of a horse; view of half of the palatine face, a, osseous cyst devel- 
oped in the interior and right side of the jaw ; it includes the tumor represented in Fig. 109; 
&, right canine, thrust backward and inward toward the medio-palatine line; d, alveolus 
of the left canine tooth; e, osseous perforation, conducting to the interior of the cyst. 196 
A SYSTEM OF ORAL SUROERY. 
Figs. 108, 109, and 110, after Forget, furnish still other examples 
Fig. 109. 
Fig. 110. 
Fig. 109.-Intramaxillary osseous tumor (natural size); it was contained in the cyst 
represented in Fig. 108. 
Fig. 110 (300 diameters).-Represents a part of the section of the mass shown in Fig. 
109. This tumor appears to be formed entirely of the cement or osseous substance sur- 
rounding the dental root. It is an exostosis of the dental cement, a, vascular cana- 
liculi of the osseous substance of the tumor (Havers's glands). The tumor is traversed 
by these as in the normal osseous substance,-only they are more rare, more scattered, 
and more irregularly distributed; b, osteoblasts disposed circularly, or nearly so, in a 
concentric manner around the Haversian canal, but less exact and evident than in the 
normal condition; c, the osseous substance, properly so called, in which the osteoblasts, 
or characteristic cavities of the osseous tissue, are excavated. 
For further illustration, see Odontomata. CHAPTER XII. 
THE TEETH AND THEIR DISEASES. 
CARIES. 
Caries of the teeth being a disease so destructive to comfort and to 
health, and withal so common as to possess its illustration in almost every 
human mouth, makes the subject felt as one claiming earnest investigation 
and attention. 
Caries of a tooth, most simply expressed, is corrosion of its substance: the 
disease may occur on any part of the surface of the crown or even on the 
root, but as a rule is found to originate on parts possessed of the least self- 
cleansing characteristics. Thus, it is most common to the sulci on the grind- 
ing faces of the molars and bicuspidati, to the posterior depressions met with 
so frequently in the superior incisor teeth, and to approximal faces of the 
teeth generally. 
Caries is a disease of chemico-vital relation, and is unfortunately most 
markedly of congenital association and predisposition; indeed, so true is this 
latter, that it is to be prognosed that the offspring of parents afflicted in this 
way will be affected in like manner, and that, on the other hand, the children 
of parents possessing good teeth will be favored in like manner. So constant 
is an analogy in the teeth of parents and child, that in most instances it ex- 
tends to the very shape and arrangement of the organs, deformity insuring 
deformity, regularity regularity. One parent alone may influence for good 
or for evil. 
Hereditary dental caries finds its explanation in likeness of condition, this 
being of local or constitutional signification, or more commonly a conjoining 
of these; such teeth being not only imperfect in development in one or more 
directions,-in shape, in deficiency of enamel-covering, in non-calcification as 
exhibited in the existence of interglobular spaces, in position, in tubular 
circulation, in nerve endowment,-but in an equal number of cases in lack of 
physiological harmony, either in surrounding secretions or in the offices of 
nutrition : any or all of these may be the conditions, as, indeed, resultant 
from them are all cases of caries. 
Healthy Dentures.-Health in the dental organism depends,- 
1. On circumstances associated with the original formation. 
2. On the shape of the teeth, their relation to each other, and their self- 
cleansing features. 
3. On constitutional conditions. 
197 198 
A SYSTEM OF ORAL SURGERY. 
4. On character of agents in contact with the teeth. 
5. On the absence of mechanical destructives, as salivary calculus, the 
bands of artificial dentures, etc. 
6. On accidental influences. 
Condition I.- On circumstances associated with the Original Formation. 
To appreciate the reasons explaining the inability on the part of certain 
dentures to fulfil the intentions of their creation, we are compelled to consider, 
not infrequently, influences and associations apparently far remote from them. 
That the student may be made familiar with the principles involved, without 
which, indeed, he might not otherwise than mechanically treat carious teeth, 
it is proposed to invite his attention to that study and understanding of the 
subject which practice will demonstrate as the exhibition of it in a clinical 
fulness. 
It is to be assumed, as a premise, that like begets like; therefore may un- 
healthy parents not fail to impress upon their offspring that which is of their 
own constitution. Of these impressions, some are readily appreciable ; others 
are obscure. As examples, we may refer to cachexiae, evident enough in their 
individuality as exhibited over the general system; again, to a transmission 
which illustrates itself alone in the direction of the teeth, the individual at 
large being otherwise healthy. These two type conditions exhibit themselves 
to every observer. 
Of the cachexiae pertaining markedly to the matter of our investigation, 
we have three,-scrofulosis, rickets, syphilis; cachexiae so widely associated 
with asthenic conditions, so adverse to the healthy performance-of the nutri- 
tional functions, that without an understanding of their expressions one might 
not hope to antidote their multitudinous sequelae. Because, therefore, of the 
marked importance of the cachexiae, viewed in hereditary association, the 
student is invited to complete, by reference to the proper works, the epitome 
here presented. 
DISTINCTIVE FEATURES IN TYPICAL CASES OF EACH 
CONDITION. 
Scrofulosis.-Temperament lymphatic; abdomen tumid ; complexion dark 
and pasty; lips and alae tumid; saliva stringy; breath insipid and offensive; 
mucous membrane markedly deficient in circulating activity, and much dis- 
posed to degenerative inflammatory action; lymphatics enlarged and promi- 
nent, especially those of the cervical and mesenteric regions, with great dis- 
position to suppuration; bones very loose and spongy in their areolar tissue, 
often fatty, breaking down on slight provocation into caries and necrosis; 
teeth, alike with the bones, deficient in inorganic material, loose in the char- 
acter of the intertubular structure, more or less deficient in the integrity of 
the enamel cap; the animal matter very susceptible to the irritating influences THE TEETH AND THEIR DISEASES. 
199 
of the unduly alkaline oral fluid; the pulp pabulum cacoplastic to an extent 
which almost completely stagnates the tubular circulation, thus antagonizing 
nutrition; conditions of dental health adverse without and within. 
Rickets.-Physical force deficient; habits sluggish; mentality small, with 
precocity; large head, more commonly broad than long; abdomen prominent 
and heavy; leanness; general debility, with indigestion; puffiness of the 
extremities; skin muddy; thinning of cranial bones, together with a plastic 
thickening of other flat bones and enlargement of the extremities of the long 
bones; tendency to aplastic infiltrations of the viscera; the teeth late in 
erupting, slightly attached to their alveoli, non-resistive of external offences, 
easily acted on by chemical agents, apt by slight causes to be pushed from 
their sockets. 
Syphilis and Mercurio-Syphilis.-Stagnant complexion ; leanness; 
atony of the skin and muscles; susceptibility to skin affections; poor and 
scanty hair; interstitial keratitis, with interlaminal corneal lymph effusions; 
stomatitis; tendency to iritis; the teeth more or less notched on their cutting 
edges, with pittings of the enamel; mucous membrane passively congested and 
easily breaking down into ulcers, which ulcers have pasty bottoms; seroplastic 
effusions into the submucous Schneiderian tissue, interfering with respiration, 
inducing in the patient constant snivelling; eruptions on the skin of a coppery- 
red color; periosteal indurations, with subperiosteal aplastic exudates; sup- 
puration of organs, as the liver, thymus, testes; caries and necrosis of bones, 
particularly the turbinated and the maxillae, and of the teeth. 
Scrofulosis-Scrofula-Lymphangitis.-This is a constitutional 
condition having its recognition in the cacoplastic conditions common to it 
and begotten of it, the manifestations of malnutrition being most frequently 
met with in the skin, mucous membrane, hip- and knee-joints, and in the 
lymphatic glands, which latter, in their suppuration, present most markedly 
the feature of a cheesy degeneration. These malconditions arise out of lym- 
phangitis, disturbing in turn tissue metamorphosis. 
Scrofula is commonly an inherited cachexia, but may, through depressing 
circumstances, be engrafted into any constitution. Bad and ill-nourishing or 
insufficient food, continued exposure to impure air, intemperance, excessive 
venery, mental anxiety, the effects of severe courses of medication, secondary 
effects of poisons,-these and similar causes may induce the cachexia. 
A marked scrofulous hereditary transmission has its expression in the type 
case given, but from this it is to be esteemed as shading into the greatest 
variety of aspect. Two primal expressions are clearly to be recognized. These 
are the fair and the dark; to be again subdivided into the fine and the coarse. 
The fine is the disease as existing and exhibiting itself in the sanguine tem- 
perament ; the coarse is the typical case, as exhibited in the sluggish lym- 200 
A SYSTEM OF ORAL SURGERY. 
phatic. It is well just here for the reader studying this disease from the 
stand-point of dental caries to exclude the fair variety, and to place it under 
the head of Tuberculosis,-a distinction in the conditions which one most 
practically recognizes as relation with the health of the teeth and general 
digestive apparatus is concerned; the typical form being markedly provocative 
of dental disease ; the fair variety exhibiting its manifestations in the viscera, 
and most particularly by deposits in the lungs, leaving the teeth quite exempt 
from any impression. Hence in persons affected with phthisis it is not un- 
common to find the most beautiful and perfect dentures. It is to be remem- 
bered, however, we are writing of predispositions, and not of manifestations 
from active or recent conditions; of impressions made on the teeth during 
the stage of formation and development, and not of impressions made by the 
acquired disease on teeth whose period of growth might have been associated 
with such vigorous and health-yielding life that the result is not to be easily 
overcome. 
Scrofulosis of the lymphatic type expresses that condition of a system in 
which morbid action results on the slightest provocation. Every part seems 
lax and incapable of self-sustenance. The slightest injury produces vascular 
perversion of a grade requiring for its control stimulation rather than depres- 
sion. In a word, it is a condition in which the vitalizing principle has no 
proper proportionable correspondence with the matter of the body. Hence 
the characteristic sluggishness,-the body is only half living, and was so born, 
-the parents, before it, lacking that fulness of force necessary to the vitaliza- 
tion of the offspring; no single tissue has been harmoniously constructed, 
the production being to an extent an abortion. 
Perhaps the student will possess himself of a clearer conception of scrofu- 
losis if we deny to it the name of a disease, and associate it alone with the 
idea of cachexia; and this, if we exclude from the relation tuberculosis, with 
its peculiar deposit, one inflicts no violence in doing. It is thus, from clinical 
observation, the writer has been led to consider it, and such understanding 
seems best to conduce to antagonizing its relations. We view the house as 
one ill built and of poor materials, and do what we can to remedy the de- 
ficiency. It is a condition in which attempts at specific treatment have little 
or no response: there is no special condition to combat. 
In conjoining the axioms that " excitement must terminate in exhaustion," 
and that 11 from nothing nothing comes," we may undeniably find the prece- 
dents and conditions of scrofulosis. In an animal body are so much matter 
and so much vitality. As the vis vitae may be abstracted from one part to 
minister to the excitation of some other part, so necessarily must both come to 
suffer: the latter from an over-stimulation which begets hypertrophic degener- 
ations, morbid plastic formations capable of organization, thus compelling 
alteration in physiological expression; the former from exhaustion through 
the absence of its correlating force, thus denying the changes necessary to the 
fulfilment of functional life,-breeding, of necessity, debility. THE TEETH AND THEIR DISEASES. 
201 
Over-stimulation, with its consequent prostration, finds examples in the 
intemperate, the venal, and the gluttonous. Children begotten of these, in the 
days of their depression, are apt to be possessed of evidences of the vices. 
Exhaustion, on the other hand, is found a primary condition, being a result 
of exposure to influences debilitating in themselves ; as, for example, to poisons, 
deprivation of proper food, insufficiency of clothing, to lack of cleanliness, 
being ill housed, unhealthy employment, continuous subjection to mental dis- 
quietude or oppression, excessive secretions and discharges, deprivation of 
light and sunshine, etc. We are to assume that the disease we study is not 
a materia peccans in the blood, but, as Billroth expresses it, " a debility of 
the organization." Dr. C. J. B. Williams, while admitting no distinction 
between scrofulosis and tuberculosis, yet describes the condition as " a degra- 
dation of the nutritive material from which old textures are renewed and 
new ones formed, in that in its origin it differs from the normal plasma or 
coagulable lymph, not in kind, but in degree of vitality and capacity of 
organization." 
What cacoplastic lymph is, we appreciate. What tubercle is, we do not 
know; the highest authorities, in such direction, are still at issue concerning 
not only its origin, but even its nature, and whether, therefore, tubercle is or is 
not an expression of struma, we are, in our present connection, not concerned 
to discuss.* Protoplasm, lymph, is the basal nutritive agent; plasma is 
not self-creating or of itself, but is a product of vital force acting on materials 
taken for the nourishment of the body. That organs be normal, protoplasm 
must be healthy. The diseased protoplasm of degraded parents-more par- 
ticularly, perhaps, that of the mother-may not afford that nourishment which 
is the proper life of a child; on the contrary, it associates its own degradation 
with all with which it may come in association. 
Following such line of view, it will be recognized that we may not have 
any marked distinction between scrofulosis and the hereditary manifestations 
of syphilis, of the mercurial vice, or of other parental adynamic transmis- 
sions ; and, therapeutically viewed, this premise we believe to be the proper 
one,-the principle of treatment being found the same,-this being tonic 
medication, and having no specificity to which it is to be directed. If, how- 
ever, special organs be specially affected, this would of necessity direct to 
them particular attention, and the treatment, as the part affected is con- 
cerned, would, in local requirements, differ,-as, for example, whether we 
might have to combat caries of the bone or caries of the teeth; the consti- 
tutional treatment may, however, only be the same, and, from such aspect, 
* Since originally publishing the above assertion concerning tubercle the author has 
pursued a course of investigation which makes him quite willing to here commit himself 
to the conviction that lymphatic stasis will eventually be recognized and admitted as the 
source of phthisis tuberculosis. Koch's bacillus is to a tuberculous lung exactly what the 
micrococcus is to a carious tooth, or what oidium albicans is to an aphthous ulcer. (See 
these subjects.) 202 
A SYSTEM OF ORAL SURGERY. 
what would be the cure of the one would necessarily tend to the same result 
in the other. Unfortunately, however, as the teeth are concerned, from the 
low grade of their vitality, and, consequently, the inactivity in their molecu- 
lar changes, counter-impressions are long in being made; therefore, in the 
constitutional caries of these organs, too much attention cannot be given to 
the local relations. The fluids of the mouth are, if adverse, to be neutralized 
to the required non-antagonism. Cleanliness is particularly to be insisted on, 
and all cavities are to be filled or filed away, as may seem indicated. 
Rachitis-Innutritio Ossium.-A constitutional disease, having its 
predisposition in hereditary transmission: characterized by non-solidification of 
the growing layers of bone, by the formation of medullary cavities in the older 
or more mature bones, thus rendering the bony laminae thin and brittle 
(Virchow), and by excess in the formation of phosphoric and lactic acids, 
with great excess of the earthy phosphates. 
It is not to be maintained that rickets is a constitutional disease, save in the 
sense of predisposition. Neither is it to be affirmed that it possesses a con- 
stancy of expression which allows of a common formulary for a description 
of its diagnostic signs; on the contrary, the expressions vary from the most 
simple manifestations of a disturbed nutrition to a specific alteration in the 
bones, which renders them, from lack of inorganic constituents, incapable of 
performing their functions. Indeed, it is probable that degrees of rickets 
may quite frequently present themselves and yet be overlooked. While, as 
suggested by Hillier, the secondary diseases, such as bronchitis, collapse of 
the lungs, atrophy, measles, whooping-cough, or convulsions, are recognized, 
the primary disease, which renders these secondary conditions fatal, is quite 
ignored. 
As rachitis is congenital, or as it associates itself with the dentitional 
periods, so are manifested the effects of the condition upon the health of the 
teeth,-these organs being delayed in their development, disposed to caries, 
and not infrequently of such loose relation to their sockets from aplastic 
softening of the peridental tissue as to be displaced by slight force: the perio- 
donteum, and also the pulp, may be affirmed to present evidences of the 
common amyloid degeneration as seen in the viscera, particularly in the liver 
and spleen. The delay in the cutting of the teeth is simply delay in 
development, the albuminoid pulp lacking organic force to secrete dentinal 
tissue; while, as is to be inferred, that which is made is of such imperfect 
organization, so mottled with uncalcified spots,-interglobular spaces,-as to 
be rendered quite incapable of resisting that excess of lactic acid found in the 
secretions coming in contact with it. 
History.-Rachitis is a disease having perhaps in all cases the association 
of hereditary predisposition, yet, like scrofulosis, existing in such variety of 
aspects and in such states of modification as to make it not easy of recog- 
nition through any constant signs. These modifications are of a twofold THE TEETH AND THEIR DISEASES. 
203 
nature. First, the character of the hereditary impression. Second, the 
associative surroundings and conditions of the patient. Sir William Jenner, 
whose lectures on the subject are worthy of all respect and attention, speaks 
of this disease as " without question the most common, the most important, 
and, in its effects, the most fatal of all that exclusively affect children." Hil- 
lier (Meigs and Pepper) presents a table showing the proportion borne by 
the number of cases of this disease to the total number of out-patients treated 
at the Hospital for Sick Children, London, from which calculation exhibits 
that of 128,656 children treated during thirteen years (1854-66) not less 
than 8419, or 6.5 per cent., were rachitic; and in some years the proportion 
of such patients rose as high as 9 per cent. In London hospitals and in the 
other great hospitals gathering in the poverty and degradation of any large 
city, such percentage does not strike us as at all a matter for surprise. It 
must be recognized, however, as is to be inferred from home observation, that 
such statistics designate the disease as included in its diversified phases. 
The cachectic state preceding the osseous manifestations of rickets is not 
generally to be noticed at birth, but develops commonly during the process of 
the first dentition, seldom appearing at a later period than during the time of 
the active stages of the second. The incubation precedes, however, the 
manifestations of the cachexia, residing, as we incline to believe, in an original 
molecular impression ; at least it is only thus that we find explanation of the 
organic impressions found in the structure of the deciduous dentine and 
enamel. 
The relation of rickets with scrofulosis is found in the pre-association of 
the two conditions. Thus, " Whatever tends to produce debility and anaemia 
in a mother, as too frequent pregnancies or prolonged lactation, renders it 
probable that her next-born children will be rickety." Jenner states 11 that 
it is very common for the first, or the two or three first-born children, to be 
free from any signs of rickets, and yet for every subsequent child to be 
ricketywhich he explains by the fact " that among the poor the parents 
are generally worse fed, worse clothed, and worse lodged the larger the num- 
ber of their children; and among the rich and poor alike, the larger the 
number of children, the more has the constitutional strength of the mother 
been taxed, and the more likely is she to have lost in general power." 
Predisposition in a child may be overbalanced by its prophylaxis. Thus, 
children of wealthy parents, even where the antecedents are very unfavorable, 
may escape the evident expressions of rickets as the result of hygienic an- 
tagonisms, just as adverse conditions are found to prove exciting causes to its 
development. It is indeed because the most characteristic expressions of this 
disease-namely, affections of the skeleton-are so influenced by outward 
circumstances, that eminent observers have in some instances come to deny 
its existence among the better classes; though this differs much from the 
statement of Jenner, who asserts that he has very often met with it among 
the children of the very wealthy. We think, however, that it is to be made 204 
A SYSTEM OF ORAL SURGERY. 
a cardinal point that the disease is not necessarily to exhibit its osseous com- 
plication to have existence, and that its prodroma are as much the condition 
(in abstractor as is the observable softening itself. 
The relation of rickets with hereditary syphilitic disease is affirmed by 
Vogel, who professes to base the deduction from wide clinical inquiry. Such 
relation is, however, denied by Sir William Jenner, the denial being founded 
mainly on the following facts: " The parent who infects his offspring (with 
syphilis) has usually contracted the syphilis before marriage, and the children 
first begotten after infection are those who suffer (from inherited syphilis); 
while, as a rule, it is only the younger children of a family that suffer from 
rickets." Sir William Jenner is also doubtful as to the health of the father 
affecting the child, but throws the weight of his influence in that scale which 
attributes the disease to insufficient nutrition ; thus suggesting the inference 
of the direction in which lies its prophylaxis, and as well endorsing, without 
intention, the oneness of cachexia. Mr. Lonsdale expresses himself as having 
invariably found " that in all rickety children the parents have had little or 
no milk for their supply, and have been obliged to feed them either partially 
or wholly with food other than their own milk. The mothers observe that 
the children never grew properly from the first, and it is mainly the improper 
nature of the supplementary food given by hand which impairs the health 
of the child." The rearing of the children of the poor in London is thus 
described by Sir William Jenner : 
For the first two or three days after birth their tender stomachs are 
deranged by brown sugar and butter, castor oil and dill-water, gruel and starch- 
water. As soon as the mother's milk flows, they are, when awake, kept con- 
stantly at the breast; and well for them if they are not again and again castor- 
oiled and dill-watered, and even treated with mercurials. After the first 
month, bread and water sweetened with brown sugar is given several times a 
day, and during the night the child is, when not too soundly asleep, constantly 
at the breast. As soon as the little ill-used creature can sit erect on its 
mother's arm, it has, at parents' meal-time, 11 a little of what we have,"-meat, 
potatoes, red herring, fried liver, bacon, pork, and even cheese and beer daily, 
and cakes, raw fruit, and trash of the most unwholesome quality as special 
treats, or as provocatives to eat, when its stomach rejects its ordinary diet. 
Then, instead of being weaned when from ten to twelve months old, the 
child is kept at the breast when the milk is worse than useless, to the injury 
of the mother's health, and to the damage of its after brothers and sisters, in 
the hope that thus keeping it at the breast may retard the next pregnancy. 
(Holmes.) 
According to M. Guerin, there will commonly be in rickets a period of at 
least six months before the practitioner may feel assured of the exact char- 
acter of the case, or fairly distinguish it from other diseases to which the 
prodroma are common. 
The incubative stage is characterized by irritations of a gastro-intestinal THE TEETH AND THEIR DISEASES. 
205 
character. The stools are irregular, being sometimes scanty, but more com- 
monly profuse, marked by absence of bile, not infrequently being of leaden 
color and most offensive in odor. Sometimes, however, and this more particu- 
larly in the beginning, the discharges are greenish, of a serous or watery con- 
sistence, with a smell which has been compared to that of rotten meat. The 
child is found to run down as from a chronic diarrhoea. 
A marked symptom soon supervening, and one which is not infrequently 
the first that suggests to the practitioner the peculiar nature of the disease, is 
profuse perspiration of the head. These perspirations weaken the child 
very rapidly, and, when in progress, the evidences of congestion are to be 
observed in all the neighboring vessels,-veins and arteries. 
Associated with this sweating, and more or less synchronous with it, is a 
general soreness of the body, the little patient in many cases lying motion- 
less for hours, rather than endure the discomfort of moving. Such soreness 
has always more or less connected with it a desire on the part of the child to 
be cool, even in winter; such patients seeming most comfortable when lying 
entirely uncovered,-a fact sufficiently demonstrated in hospital wards. 
The deformities of the head in rickets are thus distinguished by Sir 
William Jenner:* 
1. By thickening of the bones. This is usually most perceptible just 
outside the sutures, the situation of these being indicated by deep furrows. 
2. By the length of time the anterior fontanel remains open. In the 
healthy child, it closes completely before the expiration of the second year. 
In the rickety child, it is often open at that period. 
3. By the relative length of the antero-posterior diameter of the head. 
4. By the height, squareness, and projection of the forehead. The first two 
of these peculiarities of the rickety head are the result of the affection of the 
bones; the last two are chiefly due to disease of the cerebrum. 
The succeeding conditions are those which associate themselves with bone- 
disease. 
The process of dentition (Holmes) is invariably arrested or delayed; 
and if the teeth be formed, they soon decay, or they early fall from their 
sockets, the incisors frequently being lost before the second molars of the first 
set have made their way through the gums. So important is the knowledge 
to be derived from the progress of dentition, that Sir William Jenner lays 
down the following rule of practice: 
If a child pass over the ninth month without teeth, you should carefully 
inquire for the cause. It may be that an acute illness has retarded dentition. 
It may be (and this is infinitely the most common cause of late dentition) 
that the child is rickety. Fail not, then, when called to a child in whom the 
teeth are late in appearing, to look if it be rickety, for if you do fail to look 
for rickets, you will most likely attribute to the irritation of teething symp- 
* Medical Times and Gazette, 1860. See also Holmes's System of Surgery, vol. i. 206 
A SYSTEM OF ORAL SURGERY. 
toms which are the consequences of the rickety diathesis,-the late dentition 
in rickets being in itself merely a symptom of the general disorder. The rickety 
deformities may be very trifling, and yet the teeth considerably retarded in 
their development. 
The inorganic constituents of bone-the earthy phosphates-are sometimes 
found in great excess in the urine, a case being recorded by Mr. Solly where 
such excess was fourfold. It is perhaps, however, as frequently the case that 
the deficiency in lime-salts results from non-ingress of these materials, without 
change in the egress ; while a hypothesis founded on the observations of 
Marchand attributes the absence of the phosphates to their dissolution by 
lactic acid. This is effected, as inferred, by the lactic acid changing the car- 
bonate and phosphate of lime into the soluble lactate, which in this state 
is capable of being taken up and carried from the system; or, when not 
removed in this way, it might be possible for the organic basis of bone to be 
dissolved by the inflammatory neoplasia with a breaking down of the chalky 
substance, whose molecules might either be dissolved or carried away. 
In rachitis, according to Virchow, the bones are histologically formed, ex- 
cept that the bone-cartilage has no chalky salts,-or, at least, little in pro- 
portion to their requirements. Billroth directs attention to the effect of the 
dyscrasia upon dentition. The treatment he regards as of that general nature 
which pertains to the building up of the health of the patient. As food, it 
may not be well to use too freely of bread, potatoes, mush, or flatulent vege- 
tables, but the child is to partake freely of meat, eggs, milk, and all nitro- 
genous diet. Billroth, in discussing the use of preparations of lime, expresses 
a doubt as to any benefit that may arise from their employment, deeming it 
not impossible that rachitis is a disease of digestion in which such preparations 
may not be absorbed,-which view is indeed a common one among American 
physicians. 
A rachitic child should be daily bathed in salt water, lukewarm or 
cold, as seems most suitable; the dress is to be adapted to the season; and 
daily exercise, active or passive, is to be taken in the sunlight and open air. 
The use of cod-liver oil has the recommendation universally both of European 
and American practitioners. Vogel asserts that rickets is to be cured by the 
use of cod-liver oil alone. Rickety children tolerate the oil well, and are 
usually found to become fond of it. Iron and the vegetable tonics are almost 
always found useful; while beer or wine in limited quantities, graduated to the 
age and condition of the patient, is sometimes found to meet the indications 
most admirably. 
Syphilis.-Viewing the relations of this disease with the health of the 
teeth, we necessarily embrace, or, indeed, perhaps more fully treat of, the 
association of the mercurial poison than that of syphilis itself, inasmuch as the 
two are found so constantly combined that it may be esteemed a matter of some 
doubt if the single relation is ever met with in the hereditary aspect. I use THE TEETH AND THEIR DISEASES. 
207 
the term in the fullest sense of heredity, not embracing the cases in which a 
foetus receives inoculation in passing over an unhealed vaginal chancre, or 
where the father, having incipient secondary manifestations, extends such to 
the impregnating sperm. 
That the syphilitic poison impresses of itself the growing teeth is made 
evident by the very frequent imperfect development of these organs found 
in association with the disease. Allusion is made to the notching, the 
pitting, and the small size,-conditions which may fairly be presumed not 
to have special relation with the second of the poisons, inasmuch as this 
renders its expression in that general molecular depression which is seen in 
the lowered vitality of the parts at large, and which has been considered under 
the head of scrofulosis. 
The pittings in the enamel of the teeth, and the irregularities of the cutting 
faces, represent expressions believed generally to be found only in connection 
with hereditary syphilis, and which it seems proven may be transmitted to the 
third generation. These deformities are seen most generally in the second 
set alone ; the first are liable to early decay, but not so much to the malforma- 
tions. The impressions are confined commonly to the anterior six teeth, and 
vary from the most marked examples to scarcely perceptible irregularities of 
the cutting edges, or an occasional depression seen here and there upon the 
anterior face, or it may be the posterior,-most frequently, however, upon the 
anterior alone. Observation is found to greatly vary concerning the existence 
of any constancy in phenomenal expressions of the teeth in this relation.* 
® That the notchings found on teeth are not strictly associated with the vice of syphilis 
will clearly enough discover itself to an observer who takes the trouble to investigate. In 
one instance three children were exhibited at a clinic of the Oral Hospital dispensary service 
all having badly notched teeth, traceable unmistakably to attacks of measles occurring during 
the dentitional period. 
The alterations of teeth here considered are atrophic in nature, and are recognized as of 
different origin by close observers. Hutchison's syphilitic teeth pertain chiefly to pitted 
central incisors, the pits, breaks or sulci, disfiguring the cutting edge or closely adjoining 
parts. This observer has established a relation between these atrophies and chronic inflam- 
mation of the cornea. 
Atrophic change is most common to the six-year molars, and is here least traceable to any 
specific causa; the defect showing in general imperfection of the enamel and irregularity of 
faces, particularly the grinding surface. Color, too, is abnormal, yellow points and streaks 
intermingling with white of varying shade. The cusps of these teeth are too often found 
of foreign expression, resembling at times portions of a hard variety of yellow sandstone. 
That such atrophic condition relates itself with the bicuspidati is practically known to every 
practising dentist, these teeth being recognized proverbially as least resistive of aggression. 
Forms of atrophy related with the oral teeth are known as cup-shaped, sulciform, pitted, 
notched, and grooved. 
Cup-shaped atrophy is commonly met with in the labial faces of the incisors, although it 
is not peculiar to these; generally a number of pits exist, the bottoms of which may or may 
not be enamel-covered: carious evolution finds here most frequent start-points; the teeth 
are never of natural translucency, the color varying from a dead yellow to a dirty white. 
Sulciform atrophy is simply a variety of the cup-shaped; it consists in furrows, one or 
more running across the faces of teeth, commonly central and lateral incisors, occasionally 208 
A SYSTEM OF ORAL SURGERY. 
The diagnostic signs and conditions of acquired syphilis, it is to be taken 
for granted, are known to the reader. With these we have nothing to do, 
inasmuch as the influences here considered are those impressed in utero. 
The assumption is to be borne out that it is only in earliest infancy syphilis 
expresses itself with that distinctness which, outside of a history, renders its 
diagnosis reliable; and, further, that parents afflicted with the advanced 
tertiary stage of the disease do not transmit the disease with diagnostic 
individuality, but rather that in the term scrofulosis lies expression of the 
condition transmitted; that the condition of the syphilides is the state 
in which the transmission retains specificity,-the tertiary stage expressing 
the exhaustion of the disease in the molecular degeneration induced of it,- 
and that when transmitted in the secondary stage, its continuous course in 
the child is apt to be the same as in the parent. 
As a syphilitic impression made on the foetus is most closely allied with 
first or secondary manifestations, as these exist with the parent, so will the 
child exhibit rashes, or the graver expressions of inflammation of mucous 
surfaces. Thus, without perhaps proper attention to such data, it has 
become common to write of the mingling of secondary with tertiary mani- 
festations,-a mingling that does, without doubt, occasionally exist, owing 
to the general slighter resistive force of particular infants, just, indeed, as 
the same mingling of conditions is to be met with in the adult. 
The expressions of the transmission of uncomplicated syphilis show 
themselves commonly by the third week; although instances enough occur 
where the child is born with such evidences; or the little patient may live 
for a year without any sign of the disease exhibiting itself,-seldom longer, 
however. 
Hereditary syphilis differs of course from the acquired in having no primary 
stage. As the author's observations are concerned, the most common manifes- 
tation of the condition is found in that morbid congestive state of the Schnei- 
derian mucous membrane, which, as in a common cold, yields what the 
parents call snuffles, being universally attributed to the child's having a cold. 
Unfortunately, however, such colds do not tend to self-cure, but in very many 
instances, perhaps in a majority, produce changes in the nasal relations which 
result in a flatness of the bridge of the organ, bearing the sign throughout 
life, and which is justly to be esteemed as markedly diagnostic of the heredi- 
tary association. 
the cuspidati. The separation of these sulci, of which there are often three, more com- 
monly two, infrequently four, is by means of what looks like a ridge of pathological enamel. 
Instances occur where the sulci pursue a wavy course, or one that is oblique or vertical. 
The pitted, notched, and grooved varieties described by authors will be recognized as 
nothing different from expressions of forms described above. 
Objection is repeated to the fixing of heredity in syphilis out of the signs of the teeth. 
Any condition interfering with evolution at the dentitional period affords alike with syphilis 
acceptable explanation. THE TEETH AND THEIR DISEASES. 
209 
A child afflicted with this disease may, without doubt, be born plump and 
apparently vigorous; but such vigor proves evanescent. After a few days, 
or weeks, or, it may be, months, it begins to emaciate, the skin wrinkles 
from absorption of the underlying fat, the face shows discolorations, and a 
peculiar expression of premature age comes on: this expression of age is 
so marked and persistent that it will be found to characterize every child, 
young or old, afflicted with transmitted syphilis. The writer has this moment 
in memory the faces of a number of little girls who are in the habit of oc- 
casionally presenting themselves at his clinic, and, although the eldest is not 
over thirteen, they have, all of them, the expression of being advanced in 
years. This expression, it is to be remarked, is influenced by the character of 
their affection, those afflicted with bone-troubles being usually older-looking 
(in proportion to their years) than others presenting alone the skin-manifes- 
tations. 
Syphilis is a retarder of development, hence children so afflicted are com- 
monly stunted in stature, while dentition is much delayed. Fournier, in a 
paper on syphilitic teeth, lays stress on the disease as a modifier and an 
arrester of the growth of these organs,-a position in which he is undoubtedly 
right, only, however, in the sense that growth in all parts is modified and 
arrested by the vice. Demarquay relates a case where dentition delayed to 
the fourth year was attributed to syphilis. Many cases are on record where 
infants had not cut the inferior central incisors at the beginning of the second 
year. A point desired to be made is that notched, stunted, and otherwise 
deformed teeth are not necessarily what they are by reason of syphilis. 
The appearance of pemphigus soon after birth, associated with the ordinary 
early symptoms, is deemed by experienced observers very diagnostic. Inter- 
stitial keratitis with interlaminar lymph-effusions is associated alone with the 
hereditary form of syphilis,-iritis being an expression of the acquired form. 
In hereditary syphilis the manifestations are symmetrical; in the acquired 
form they are rarely so. The manifestations of the hereditary form run one 
into the other; those of the acquired tend to remain distinct. 
The Teeth and Nutrition.-From consideration of hereditary vices 
we pass to that aspect of the subject which treats of the relation of develop- 
ing teeth with nutritional instrumentalities. 
In viewing, from a systemic stand-point, the composition of the teeth, 
we have primarily to remark that the component parts are formed from and 
preserved by the chemico-vital relationship existing between blood and parts 
to be nourished. We recognize, and know, that in the fluid which we denomi- 
nate blood resides the element of nutrition, and that as this material is well 
or ill adapted to meet the requirements of the different tissues, so are these 
tissues found to be in varying states of health. We infer that blood rich in 
the elements of tooth-structure is capable of yielding good teeth, provided 
the process of assimilation resides to a proper extent in the part to be built 210 
A SYSTEM OF ORAL SURGERY. 
up and nourished; so that the study of caries, from the constitutional stand- 
point, consists in looking at the condition of the blood and the amount of 
vital force residing in the teeth themselves. 
A tooth in its composition is made up of cementum, dentine, enamel, and 
pulp substance. Excluding the pulp substance, we find, with some variation, 
the relative proportions of organic and inorganic matter to be as follows: 
Cenientum. 
Dentine. 
Enamel. 
Organic matter 
29.27 
28.70 
3.59 
Inorganic matter 
70.73 
71.30 
96.41 
The character of this inorganic material we find, by a more complete 
analysis, to be as follows: phosphate of lime, fluorate of lime, carbonate of 
lime, phosphate of magnesia, salts. 
The composition of healthy blood yields the following analysis: 
Water 780.15 
Fibrin 2.10 
Albumen 65.09 
Coloring matter 133.00 
Crystallizable fat 2.43 
Fluid fat 1.31 
Extractive matter 1.79 
Albumen in combination with soda 1.26 
Chlorides of sodium and potassium; carbonates, phosphates, and sul- 
phates of potash and soda 8.37 
Carbonates of lime and magnesia; phosphates of lime, magnesia, and 
iron; peroxide of iron 4.50 
1000.00 
In a healthy and normal condition of the human system we find always the 
existence of a relationship between the requirements and material of supply 
which should, and which does, afford proper tissue; where, then, such condi- 
tions exist, the teeth, ceteris paribus, are perfectly formed, and, as constitu- 
tional relations are concerned, are healthily preserved. 
In the study of the pathological conditions of these organs, we are to 
discover, if possible, wherein the harmony of demand and supply is or has 
been interfered with; and that we may look at the subject from the most 
comprehensive stand-point, we must study not only hereditary complications 
which may exist, but are to understand as well the direct relations of the 
developing organs. This brings us to the subject of nutrition proper,-a 
matter which refers the student to his works on Physiology.* 
* Prophylaxis is assuredly preferable to cure. It is the intention of this foot-note to call 
attention to nutrients and conditions out of which healthful dental organisms arise, and in 
which they preserve their resistive power. 
Alluding to American women and their early decay, James Paul, M.D., in the best paper 
on the subject ever met with by the author, laments the fact that even the progeny of other THE TEETH AND THEIR DISEASES. 
211 
Condition 2.- On the Shape of the Teeth, their Relation with each other, 
and their Self-cleansing Features.-On examining the two arches, Figs. Ill 
and 112, the observer will instantly be struck with the decided difference 
Fig. 111.-Superior Dental Arch. 
presented. In the first is represented a denture which, mechanically speaking, 
may be pronounced physiological, every tooth having a harmonious relation 
with its fellow, and each individual tooth being perfect in itself. 
continents coming to this show expressions of degradation, as the teeth are concerned, even 
in the very first generation. 
Admitting the too evident fact of the degradation as comparison is held with European 
and other races, the subject of cause presents itself with a relevancy not admitting of being 
passed over. 
The refusal of Europeans to drink of iced water is a matter familiar to the writer from 
personal observation, and not less common is knowledge of the inference drawn by that 
people that if Americans indulged less in iced refreshments their teeth would be propor- 
tionably better. That dental caries has not its existence, however, in cracking of enamel 
arising out of violent alterations in temperature needs but very little observation to decide. 
Caries, may, and assuredly does, show itself in sulci and fissures, but it is so frequently 
met with under the reverse circumstances as to declare the former not a necessity to its 
appearance. That alternations of extremes in cold and heat are after other manner in- 
jurious to the health of teeth is as truly and plainly evident as that the general health is 
thereby affected. 
Dental deterioration is accepted in these pages as being more commonly associated with 
constitutional weakness than with any of the various local causes, and the agreement of 
the writer with Dr. Paul is absolute as to this weakness having its existence in a deficiency 
of the inorganic or earthy constituents being taken into the system, most particularly in 
early life. Accepting such conclusion, the oral surgeon, as well as the general physician, 
necessarily agree that correction of the condition rests with such understanding of subjects 
involved as permits of reconciliation between demand and supply. 
Referring to the analyses, given in the text, of teeth and blood, Dr. Paul directs atten- 
tion to the very great proportion of certain earths that enter into the structure of the teeth 212 
A SYSTEM OF ORAL SURGERY. 
In the second of the diagrams the artist has exhibited imperfections which, 
in truthfulness to nature, have been extended to every individual tooth, even 
to the crowding and wedging of them which are so frequently remarked. 
Fig. 112.-Superior Dental Arch. 
Examining the molar teeth, the grinding faces are seen more or less pitted. 
These sulci are generally found uncovered at some point by enamel,-an imper- 
fection so common as to render them less resistive than their fellows; hence 
and the bones of man, the chief being the phosphate of lime; that in proportion as the 
definite earths are properly distributed so is the health both of bones and teeth. 
To be distributed a material must not only exist, but it must be in a channel of distribu- 
tion. The teeth require lime. The channel by which such requirement is supplied is the 
blood. It is necessary that the blood possess a proper quota of lime, that vessels of rela- 
tion with the teeth exist, and that the teeth are able to appropriate to the full satisfaction of 
a want. 
It is seen, as will be recognized, that if we take away from the blood the proportion 
of water, amounting to 780 parts, and the coloring matter, amounting to 133, we have 
left scarcely 90 parts of organic and earthy matter, the salts and earths forming upwards 
of a 10th,-the salts being in proportion to the earths as 4 to 1. It is here the subject 
opens from the stand-point of the derivations by the blood of the elements needed by the 
teeth. 
Having then shown the constituent portions of the bones and teeth to be in the blood, 
the next consideration is, whence are these constituent portions derived ? 
Out of deference for the industrious compiler and worker, and with a view of keeping 
the memory of a man in the minds of people his investigations benefit, Dr. Paul's analyses 
and conclusions are here appended precisely as they were presented in a paper read before 
the Medical Society of Mercer, New Jersey. 
Before entering on this subject further, wrote the lamented author, let us for a mo- 
ment take a broader and more comprehensive view of what must be most interesting to 
mothers, and of great consequence to the well-being of the infant generation, in a short 
time, in a very few years, to become in their turn the mothers and fathers of another gen- 
eration. 
The question then presents itself, what is the nourishment or food best adapted and neces- 
sary to the wants of an infant, that the foundation may be laid for a strong frame and 
vigorous constitution ? For here, we must recollect; is the starting-point in by far the ma- THE TEETH AND THEIR DISEASES. 
213 
caries is most frequent in this class. Particularly is this the case with the 
dentes sapientiae, an operculum of gum being too often found an added cause 
jority of instances. We know that in some cases disease is hereditary,-that the offspring 
unfortunately inherits from the parents constitutional defects; but we also know that more 
misery, suffering, and constitutional derangement are entailed on children by want of care 
and improper food in the first years of life, by which their hopes of health are blasted, and 
they are doomed to struggle through a weary life, to be hurried at last into a premature 
grave. 
Now, that the frame-that is, the bones, muscles, and other portions-of the infant may 
be fully developed, it is necessary that it should be supplied with nourishment containing 
all the constituents required for this important undertaking. And this nourishment, by 
the all-wise ordering of Providence, is contained in the milk secreted from the mother's 
bosom. 
The infant is entirely dependent on the nourishment derived from its mother, and nature 
has wisely ordained that the secretion from the mother is its very best food; for we find in 
the composition of milk-that is, healthy milk, derived from healthy blood-all those in- 
gredients we have hitherto traced as requisite in the formation of the bones and teeth, and 
not only these, but every constituent required for the life and growth of the individual; 
milk containing the albuminous, saccharine, oleaginous, saline, and earthy compounds 
requisite and necessary for the health, strength, and development of the infant child. 
An analysis of cow's milk gives the following proportions of the various constituents; 
that of human milk is not so elaborate, but contains the average of observations taken at 
fourteen different times from the same individual, by Simon. 
COW'S MILK, BY M. HAIDLEN 
Water 873.00 
Butter 30.00 
Casein 48.20 
Milk-sugar 43.90 
Phosphate of lime 2.31 
Phosphate of magnesia .42 
Phosphate of iron .07 
Chloride of potassium 1.44 
Chloride of sodium .24 
Soda in connection with casein .42 
1000. 
WOMAN'S MILK, BY SIMON. 
Water 883.6 
Butter 25.3 
Casein 34.3 
Milk, sugar, and extractive matter ..... 48.2 
Fixed salts 2.3 
1000. 
Maximum of 
14 observations. 
Minimum of 
14 observations. 
Butter 
.'.... 54.0 
8.0 
Casein 
45.2 
10.0 
Sugar and extractive matter 
62.4 
39.2 
Salts 
2.7 
1.6 
Now, although these amounts will no doubt vary, under every variety of circumstances, 
according to the health, exercise, passions, and food of the mother, yet they show that 
healthy milk contains all the requisites for the nourishment of the infant; but then it must 
be healthy milk, secreted from healthy blood, and that blood must derive these ingredients 
from the food consumed. 
Cow's milk differs from that of woman in the proportions of some of the constituents : it 
abounds more in butter, but particularly in casein, or cheese; and, on the other hand, 
human milk abounds more in the saccharine principle, or sugar of milk. Now, this points 
out a circumstance from which great benefit may be derived. It is of very frequent occur- 
rence that infants are deprived of the natural nourishment of the mother, and diverse 
opinions are given relative to the food of infants by persons who really know very little 
about the matter; one recommends a milk diet, another that the infant must be fed on 
starch and sugar. 
Now, to enable the infant to receive a nourishment in every respect similar to the mother, 
the knowledge of the various proportions which we obtain by chemical analysis enables us 214 
A SYSTEM OF ORAL SU ROE RY. 
of offence. To write any exact description of the irregularities of the faces 
of the molar teeth would be impossible, owing to the diversified aspects pre- 
to rectify and produce milk very analogous to human milk from that of the cow, by diluting 
it with water in the proportion of about half as much again; that is, to a pint of milk 
should be added half a pint of water that has been boiled, which will reduce the cheese 
principle to the proper proportion; add a small portion of cream to restore the proportion 
of butter, and then add sugar until the whole is distinctly sweetened, and we have a com- 
pound in every respect similar to the milk from the human breast. 
To understand the subject of nutrition, let us remember that food should, or must, embody 
two great principles: one to nourish, the other to give heat to the body. And food, when 
consumed, is applied to one or the other of these purposes. Now, in the process of diges- 
tion, the constituents of the food are separated, and arranged in three classes: 
1st. All that portion derived from animal food, eggs, the curd of milk, the gluten or 
adhesive portion of wheat and other grain, and whatever in animal or vegetable food can 
be rendered into albumen,-of which the best example that can be offered in illustration is 
the white of egg, which is in reality nearly pure albumen,-and the principle is therefore 
called albuminous. 
2d. All that portion of the food derived from vegetables, starch, sugar, etc., that can be 
converted into sugar in the process of digestion. This principle is therefore called sac- 
charine. 
3d. All the fat, butter, oil, etc., which, when deprived of the other substances, is left in 
the state of oil, and therefore called oleaginous. 
Now, of these three the albuminous is the nutrient, and the saccharine and oleaginous are 
the calorifacient, or heat-giving; and chemical analysis shows that they vary in composition. 
ALBUMINOUS. 
OLEAGINOUS. 
Eggs. 
Wheat. 
Mutton fat. 
Carbon 
55.000 
55.01 
78.996 
Hydrogen 
7.073 
7.23 
11.700 
Nitrogen 
Oxygen 1 
15.920 
15.92 
9.304 
Sulphur > 
Phosphorus ) 
22.007 
21.84 
SACCHARINE. 
Starch, 
Sugar 
Sugar 
Cane- 
arrow-root. 
from starch. 
of milk. 
sugar. 
Carbon 
44.40 
37.29 
40.00 
42.301 
Hydrogen 
6.18' 
6.84 
6.61 
6.384 
Oxygen 
49.42 
55.87 
52.93 
51.315 
It will be observed that the albuminous or nutrient differs from the saccharine and ole- 
aginous, in containing nitrogen, and sulphur and phosphorus, with carbon, hydrogen, and 
oxygen, while the latter contains only carbon, hydrogen, and oxygen,-nitrogen being re- 
quired in those compounds which give strength and formation to the frame. 
Now, the albuminous or nutritive, being that portion which affords nourishment to the 
body, contains those constituents required in the first place for the formation and giving 
strength to the different portions of the body, and, when fully developed, of repairing the 
general waste continually going on in the system, whether from the usual wear and tear, 
fractured bones, or the ravages of disease. And the saccharine and oleaginous-the calori- 
facient or heat-making-to keep up a continual supply of fuel, as it were, that the body may 
be kept of a regular and proper temperature; for all are no doubt aware that there is a con- 
tinual supply of carbon, or, in more simple language, of charcoal, required to keep up the 
natural temperature of the body; and what is not required for immediate use is stored away 
in the form of fat, to be called into action as occasion requires. 
We have seen in the analysis of milk that that fluid contains butter, cheese, and sugar; 
consequently we can understand how an infant can thrive so well upon it,-the cheese or THE TEETH AND THEIR DISEASES. 
215 
senting themselves. Sometimes such sulci are double, crossing each other at 
right angles. Frequently a single depression will separate the face into two 
casein* of the milk containing the nitrogenized or nutrient principle, which, together with 
the earths and salts contained in the milk, goes to form the bones, muscles, and the different 
tissues of the body,-the sugar, which, we have seen by the analysis, contains a large quan- 
tity of carbon in its composition, going to keep up the temperature of the infant, while the 
butter, in the nature of fat, is stored away in a healthy infant, filling up every vacant 
interstice, causing a roundness and plumpness, the pride and joy of the happy parent. 
Now, let us mark the difference of the babe that has been denied a milk diet, and is 
doomed by ignorance to be fed on starch and sugar. We will recollect that these two sub- 
stances are composed of carbon, hydrogen, and oxygen only. By a process of digestion 
which I need not here enter into, such food is converted into sugar, the carbon of which be- 
comes the fuel by which the temperature of the body is kept up; there being no principle 
in the food to give albumen, there is nothing taken into the stomach upon which the gastric 
fluid can expend its solvent powers; the infant is, therefore, much troubled with acid eructa- 
tions, and the stomach becomes weak and irritable. The want of the nutritive constituent 
of the food, and the earths and salts, etc., necessary and essential for the formation of the 
bones and teeth, show a lamentable deficiency in the child's development; and there being 
no fatty matter to be laid up, the body is emaciated, the countenance is ghastly, the flesh 
and integuments hang soft and flabby over the bones; no absolute disease can be detected; 
the child is ravenous and hungry, and the unfortunate babe descends to the tomb a spectre 
and an object of the most pitiful description. This is no fancy sketch, but one too often met 
with in the ordinary walks of professional life. And why is it so ? Simply because the 
composition of the human frame, the component parts of our food requisite to produce that 
frame, and the process of digestion and nutrition, are so little understood. 
We now advance from infancy to childhood; and this is a period when the greatest atten- 
tion is required in supplying nutriment to aid nature in the great work of developing the 
body. The child is now deprived of the maternal secretion, and dependent on food prepared 
for its use by the hand of man,-perhaps living in a city, and deprived of pure and whole- 
some milk from the cow. And we know there is a vast disproportion in the quality of milk 
when the cow is country-fed on the natural productions of the farm, and when city-fed on 
slops and grain, the refuse of the brewery. 
It is at this age that the great proportion of bony substances is deposited; those of the 
extremities are lengthened, become more compact and stronger, and the substance of the 
teeth is deposited in the cells of gelatinous tissue. How necessary is it, then, that this sub- 
ject should receive the utmost attention of parents ! It has hitherto been too much the cus- 
tom to leave all this, as belonging entirely to nature, as a thing we had nothing to do with. 
We have been too much in the habit of considering that nature furnished her own materials, 
and man had nothing to do with her operation. The potter cannot fashion the bowl with- 
out the clay, neither can bone be formed without earth : nature must be supplied with the 
material, which, although offered in the most incongruous forms, she has the power of de- 
composing, selecting from, and supplying for the various purposes required : one portion, as 
we have already stated, to act as fuel in keeping up the temperature; another portion she 
selects to add to the flesh, the muscle, skin, and different tissues; and the earths which are 
held in solution she carries away by vessels adapted for that purpose, and deposits them 
atom by atom, until they are so compressed, so strongly compacted together, as to become 
what we call solid bone,-and all this so wonderfully wrought that, as we have seen, small 
Analysis of 
casein from 
fresh milk. 
Albuminous substances found 
in whey after coagulation 
with an acid. 
Carbon 
54.825 
54.96 
Hydrogen 
7.153 
7.15 
Nitrogen 
15.628 
15.89 
Oxygen 1 
21.73 
Sulphur J 
22.394 
0.36 216 
A SYSTEM OF ORAL SURGERY. 
principal cusps, and, running over the side, will terminate in a pit. Still 
again a single deep sulcus will occupy the very centre of the grinding face, 
tubes are left in the hard, stony formations both of the bones and of the teeth, that nourish- 
ment may be supplied them, holding in solution the material of which they are composed, 
that the natural waste and decay may be replaced and injuries repaired. 
It is to this nutrition, and to the earthy matter of which the bones and teeth are com- 
posed, a deficiency of which is attended with results so deplorable, that I particularly wish 
to call attention. 
To what can we attribute the calamity which too often befalls the young ? I allude to 
distorted spines, where the bones composing the spine, instead of forming a column, allow- 
ing the body to be erect and dignified, are zigzag in their course, causing one shoulder to 
bulge out, and the opposite side to bend or double upon itself. This deformity has been 
long understood to arise from a deficiency of lime in the composition of the bones of the 
vertebras, allowing them to fall, press upon, and injure each other, destroying the beauty of 
the fabric and the health and comfort of the individual. 
Now, let us take a glance at the inhabitants of two countries, natives of which are no 
strangers on this continent. I take them as examples, because the food of the common 
people of those countries is well known to be of the most common kind. I allude to natives 
of Scotland and Ireland,-the principal food of one being oatmeal, and of the other potatoes. 
We have heard a great deal of the famishing poor of those countries, and particularly of 
the latter, of the misery and wretchedness seen in every hovel; and there cannot be a doubt 
that famine walked through the land when the blight and rot despoiled them of their potato 
crop, on which for so long a period they depended as the great article of food. Now, allow- 
ing all this,-allowing, in the best seasons, the chief article of subsistence has been potatoes 
for breakfast, dinner, and supper,-glad indeed many of them to get a little animal food 
once a week to dinner, or even far more seldom,-I now ask, what number, in the thousands 
of emigrants from that country who yearly arrive at our ports, are there that show a con- 
stitution weak, fragile, and wanting in physical strength ? Many, no doubt, arrive worn 
down by disease and suffering, and in the last stage of debility; but let them recover from 
that state, and the robust frame and healthy constitution will be again developed; the 
bones are strong, the teeth undecayed, and the muscular energy only wanting opportunity 
to display itself,-in fact, when we wish to denote strength in woman, we use the familiar 
phrase " strong as an Irishwoman," and all this from being reared on potatoes.* But then, 
if we examine the analysis of the potatoes, we shall find contained in 100 parts of dry 
potatoes,- 
Carbon 41.1 
Hydrogen 5.8 
Nitrogen 1 . „ - 
Oxygen j 
Ashes 5.0 
Here we see that potatoes not only contain the nutrient but the earthy constituents. 
But we have a stronger and more healthy race yet, from Scotland and the north of Ireland, 
who are generally descendants of the Scotch, and continue, in a great measure, the same 
means in rearing the young. Now, a principal-I will not say the principal-food of the 
youth of Scotland, high and low, rich and poor, except in the larger cities, among those who 
class themselves as more refined and more civilized, but who number few in proportion, 
* According to a memorial presented to the French minister, on the proportions of nutriment of the 
means of living, by Dr. Glaser, we find potatoes taking no mean rank. 
NUTRITIVE ELEMENTS. 
100 lbs. wheat bread contain 30 lbs. 
" flesh " 21 lbs. 
" fresh beans " 80 lbs. j 
" peas " 83 lbs. > casein and starch. 
" lentils " 94 lbs. J 
" potatoes " 25 lbs., albumen, starch, and sugar. 
" ='8 " albumen with sugar. THE TEETH AND THEIR DISEASES. 
217 
the four cusps being more or less associated and ranged round it, ring fashion. 
In still other cases, a multitude of pits will cover the surface. On a single 
face as many as fifteen have been counted. 
consists, for breakfast, at least, of oatmeal,-that is, porridge and milk; and milk, potatoes, 
and wheaten, oaten, or pease bread, or bannocks, at other times of the day. Animal food 
among the poor is a rarity, a meat dinner on Sunday only being common. Even among 
the youth of the better class, butcher's meat, or animal food, is by no means a principal 
article of subsistence. And I would particularly remark that Scotch oatmeal (the oatmeal 
generally used throughout Scotland) is coarse, and contains much of the bran which invests 
the oat,-containing, as it does, a large proportion of the earthy constituents required for 
the production of bone. Analysis of 100 parts of dried oats gives- 
Carbon 5.07 
Hydrogen 6.4 
Oxygen 36.7 
Nitrogen 2.2 
Ashes 4,0 
I may here casually remark, that the advantage to be derived from this wholesome food 
has not escaped the observation of Her Majesty Queen Victoria, who appears in the 
multiplicity of her public duties not to lose sight of the equally sacred duties of a mother; 
and we hear of her son, the heir to the crown of Great Britain, being as fond of his oatmeal 
porridge as the meanest peasant child in Scotland. 
I rather doubt if parents generally have given to this subject the attention to which it is 
entitled. I trust, however, that those who have followed me thus far may be impressed 
with its importance. We cannot shut our eyes to the complaint which so generally pre- 
vails of decayed teeth; and a moment's reflection will call to mind the number of the young 
and beautiful who are prematurely hurried to the tomb, ere yet the bud has expanded into 
the full-developed flower. Nay, comparing the two countries, the statistics of life and 
death communicate to us also the important fact, that while the greatest mortality shows 
itself in England in infancy and childhood, on this side the Atlantic it is found at a more 
mature age. 
Neither has the tendency of the physical organization of woman on this continent to 
degenerate escaped the observation of one of our greatest medical philosophers in this coun- 
try, who regards this retrogression as a national calamity, and impresses upon his students 
the importance of the subject, and the propriety of their attention in attempting to arrest 
it; and he particularly specifies the great object to be gained in the use of bran-bread made 
from unbolted flour. On this head I shall have more to say hereafter. 
With these observations, let us now direct our attention to what can be offered in remedy 
of this evil. 
We have already stated that in no country in the world are children more beautiful or 
more lovely,-healthy in complexion, quick, smart, and intelligent,-active, sprightly, and 
playful in their disposition. Now, in the period from infancy until the child becomes 
mature,-let us, at all events, say until thirteen or fourteen years, and even to a more 
advanced age,-there is a continued growth,-a continual deposition of organic and inor- 
ganic or earthy particles, which are required for the formation of bone, teeth, flesh, and 
every part of the human body. I have shown that the essential ingredients for these several 
formations are all found in the milk of the mother; consequently, so long as the infant is 
deriving nourishment from the mother, she ought to partake of good, wholesome, nourish- 
ing food, that the blood, deriving these principles from the food, may be able to supply 
them in turn to the milk from which it is secreted. So long, then, as the child is thus 
nourished, so long is it safe, and the rudiment or foundation of a robust frame is laid. And 
if we are to expect, in future life, the stalwart frame of man, or the enduring, firmly-knit, 
compact, and healthy physical constitution in woman, the organic and inorganic or earthy 
compounds of which that frame is composed must not be denied. Nature must be supplied, 
or nature will fail. 
It is not for me to dictate to any parent what shall be the food of his child: it is enough 218 
A SYSTEM OF ORAL SURGERY. 
The bicuspidati, for a similar reason, are markedly subject to be attacked. 
These teeth not only decay from their cutting face, but, because of a pecu- 
that I point out for his information what may be required to give what in common lan- 
guage is called " bone and sinew" to their offspring. It is necessary, then, that the food 
of children shall contain : 
1st. Aliment having the calorifacient or heat-sustaining principle. And this is contained 
in quite sufficient quantity in the usual food,-in milk, wheaten bread, potatoes, arrow-root, 
Indian corn (as mush, hominy, or corn-bread), in most vegetable matter, and in sugar. 
2d. Aliment containing the nutrient principle. And this is contained in animal food,- 
the lean of beast, bird, and fish,-in milk, eggs, wheat, rye, potatoes, beans, etc. 
And 3d. Aliment containing the inorganic or earthy constituents,-on which depends 
strength of frame, and from which are formed the bones and teeth of the individual. And 
these are contained in milk, eggs, animal food, and particularly in wheat, rye, oats, 
potatoes, etc.® 
Of the inorganic constituents contained in wheat (and the same may be said of the other 
cereal grains) I have already alluded to the benefit to be derived from using bread made of 
unbolted flour. On this subject allow me to refer to the difference of flour having much of 
the bran remaining, and superfine flour, or that in general use throughout this country, 
and on which Professor Johnston has made the following curious but practical observations. 
Examining wheat and flour, as to the amount of the nutrient or muscular matter, the fat- 
forming principle, and the bone and saline material, contained in grain in different states, 
he found- 
Muscular matter. 
Fat principle. 
Bone and salt. 
In 1000 lbs. of whole grain 
. . 156 lbs. 
25 lbs. 
170 lbs. 
" " fine flour . 
. . 130 " 
20 " 
60 " 
" " bran . . . . 
60 " 
700 " 
Taking the three substances together, according to Professor Johnston, of a thousand pounds, 
the three substances contain of the ingredients mentioned,- 
Of muscular matter 
Whole grain. 
156 lbs. 
Fine flour. 
130 lbs. 
Of bone material 
170 " 
60 " 
Of fat 
28 " 
20 " 
■ 
354 lbs. 
210 lbs. 
Accordingly, the whole grain is one-half more nutritious than fine flour, j" It also shows 
the very great proportion of bone material-that is, earthy constituents-contained in the 
bran; no less than 700 out of a thousand parts, or a little more than two-thirds of the whole. 
* On this subject, the author extracts the following from Carpenter's Physiology, p. 488: " These sub- 
stances are contained, more or less abundantly, in most articles generally used as food; and where they 
are deficient, the animal suffers in consequence, if they are not supplied in any other way. Thus, com- 
mon salt exists, in no inconsiderable quantity, in the flesh and fluids of animals, in milk and in eggs; 
it is not so abundant, however, in plants; and the deficiency is usually supplied to herbivorous animals 
by some other means. Phosphorus exists also in the yolk and white of the egg, and in milk; and it 
abounds not only in many animal substances used as food, but also (in the state of phosphate of lime or 
bone-earth) in the seeds of many plants, especially the grasses. In smaller quantities, it is found in the 
ashes of almost every plant. Sulphur is derived alike from vegetable and animal substances. It exists 
in flesh, eggs, and milk; also in the azotized compounds of plants; and (in the form of sulphate of lime) 
in most of the river- and spring-water that we drink. Iron is found in the yolk of egg and in milk, as 
well as in animal flesh; it also exists in small quantities in most vegetable substances used as food by 
man,-such as potatoes, cabbage, peas, cucumbers, mustard, etc. Lime is one of the most universally 
diffused of all mineral bodies; for there are few animal or vegetable substances in which it does not 
exist. It is most commonly taken in, among the higher animals, combined with phosphoric acid : in 
this state it exists largely in the seeds of most grasses, and especially in wheat-flour. If it were not for 
their deficiency of lime, some of the leguminous seeds (peas) would be more nutritious than wheaten 
flour; the proportion of azotized matter they contain being greater. A considerable quantity of lime 
exists, in the state of carbonate and sulphate, in all hard water." 
f Patent Office Report, 1847, p. 116. THE TEETH AND THEIR DISEASES. 
219 
liar flatness characteristic of their approximal planes, are more frequently 
affected upon the sides than even upon the grinding surface. 
Now, by reference to the same work, we find, in a communication from a Mr. Bentz, the 
diiference in weight of a barrel of flour without the bran, and when only the outer coating 
of the wheat is taken off. He says, " The weight of the bran or outer coating would, there- 
fore, in the common superfine flour, constitute the offal, weighing only 5| lbs. to the barrel 
of flour, while the ordinary weight of offal is from 65 to 70 lbs. to each barrel of flour; 
showing a gain of from 59J to 65 lbs. of wheat in every barrel of flour." Now, if we esti- 
mate the earthy constituents to be two-thirds of the offal or bran, we must consider that 
there is an actual loss of these important constituents, which might be reserved, in every 
barrel of flour, of 40 lbs. 
Again, if we estimate (according to the average of the consumption of flour to the amount 
of population, as one barrel to each individual) that every child shall consume annually 
only half a barrel of flour, then we find that by the use of the superfine flour, as commonly 
used in families, the child is deprived yearly of twenty pounds of those earthy substances 
which are required to form the bones and the teeth. When we speak of a child consuming 
half a barrel of flour annually, it appears a large quantity; but when we reduce the same 
to a daily allowance, we find that it is little more than 4 oz. or 4J oz.; and every parent must 
know that this would be a very small amount to limit children to. Yet we see how large a 
quantity of the bony material would be added if unbolted flour was used instead of the pres- 
ent superfine flour. I may here add that the oatmeal used in Scotland, already referred 
to, contains the bran or inorganic constituents, while the oatmeal used in England is 
deprived of it. Now, this is a great loss of the most valuable constituents in only one of 
the principal articles of the food of children; and if we allude to another article, which is 
largely used on this continent,-I mean Indian corn (and I may also add the fat of meat, 
both of which, children, if allowed, will partake of very freely),-we shall find that both 
of these abound more in the ealorifacient or heat-sustaining principle, and for the deposi- 
tion of fat, than the nutrient, and that they are quite deficient in the earthy material of 
lime,-that material on which so much depends the proper structure of the teeth. Analysis 
of Indian corn shows the following composition,-as taken from Mr. Salisbury's prize essay 
read at the New York Agricultural Society for 1849: 
Whole kernel: 
Starch 50.64 
Sugar and extractive 7.46 
Sugar. . .' 1.50 
Fibre . 6.28 
Matter separated from fibre 0.05 
Albumen 8.64 
Casein 1.70 
Gluten 4.56 
Oil 4.00 
Dextrine or gum 4.84 
Water 10.22 
99.89 
Ash of the kernel, constituting about two per cent.: 
Carbolic acid a trace. 
Silicic acid 1.450 
Sulphuric acid 0.206 
Phosphoric acid 50.955 
Phosphate of iron 4.355 
Lime 0.150 
Magnesia 16.530 
Potash 8.286 
Soda 10.908 
Chloride of soda 0.249 
Organic acid 3.400 
97.000 
This is a most elaborate analysis,-far more minute than any analysis we have had of 
any of the articles of food,-in fact, more minute than satisfactory; for the analysis of the 
whole kernel does not exhibit any amount of inorganic constituent; and when the whole 
is converted into ashes, we find that the lime only amounts to the one-sixth of one part in a 
hundred. Now, on inquiry, I find, on the authority of a very intelligent miller of this city, 
that in grinding corn the bran or thin skin of the grain is detained in forming it into corn- 
meal; consequently, it is deprived of even that portion more particularly containing the 
earthy constituents. This gentleman, in conversation, mentioned an important fact relative 
to this deficiency of lime in corn. To the best of my recollection, he observed, " This stands 
to reason; for, ten years ago, all the lower part of Jersey grew excellent corn, but would 
not grow wheat; but since the introduction of lime as a manure they have raised consider- 
able wheat crops." Now, the fact is, it is not the habit or food of this plant, even had lime 220 
A SYSTEM OF ORAL SURGERY. 
The next in the order of liability are the incisors of the upper jaw. 
Observation of the diagram exhibits a flatness on the palatine face of these 
been in the earth; and magnesia and the saline manures are recommended to the agricul- 
turist as best suited for its proper development. 
It is generally looked upon as invidious, and one is more likely to incur odium than to 
receive credit for saying one word against a food which stands so high in public estima- 
tion and is so universally used over this continent. Yet it must not for one moment be 
supposed that I condemn the use of Indian corn in its various forms of mush, hominy, 
bread, or pudding as an article of diet; far from it. But, containing, as it does, a large 
proportion of starch and fatty matter, rather a small proportion of the nutrient principle, 
and quite a deficiency of the inorganic or earthy constituents, I consider it as valuable, as a 
light diet, for heat-sustaining purposes only, and therefore a desirable adjunct to other food 
containing more nutriment and a due proportion of the earthy constituents. 
As an example or illustration of the want of the nutrient principle in corn or corn-meal, 
I may here allude to the effects I have seen in the West Indies, where, in a dearth of the 
ordinary provisions on which prisoners were fed, corn-meal was substituted; corn-meal and 
salted herrings, fish, etc., constituting their food. Now, the effect was that all the prisoners 
lost their natural strength; at the same time they became fat and bloated, inclining to 
dropsy. And this was not the effect of incarceration; for the prisoners were engaged in 
road-making, trimming fences, etc.,-consequently, in a healthy and exhilarating^ employ- 
ment. 
In reference to our domesticated animals, it may be asked, Why is corn so useful as an 
article of food to animals generally,-horses, hogs, sheep, etc. ? I have already shown that 
the overplus of the calorifacient food, after what may be required for sustaining the tem- 
perature, is stored away in the form of fat. Now, if we instance the horse, corn is gener- 
ally, if not always, given as an adjunct to his more usual food,-hay. And we find by an 
analysis that grass or hay contains not only the nutrient principle, but the inorganic con- 
stituents required in the formation of bone, etc. 
One hundred parts of dry hay contain- 
Carbon 45.8 
Hydrogen 5.0 
Oxygen 38.7 
Nitrogen* 1.5 
Ashesf 9.0 
Thus, the hay gives to the animal strength in bone and muscle, while the corn supplies 
additional heat-sustaining properties, and lays by, in the form of fat, the overplus as a 
reserve. The harder the horse is worked, the more corn he can bear; the great proportion 
of the carbon being carried off by the lungs, and the hydrogen and oxygen, as water, in 
exhalation and perspiration. But if the same quantity is given to a horse at rest, it over- 
loads him with fat, which in his case accumulates more internally, or around the internal 
organs, and will, in course of time, induce disease; while in the pig, under similar circum- 
stances, the fat is laid on externally, if I may so speak, giving the rich fat pork of our 
markets. And here I would again remark that no farmer would consider it necessary or 
essential to give corn to a young colt or horse, until required to work; nay, so careful is 
nature in appropriating just so much and no more of any constituent that may be required, 
that the food of the young horse should be more nutritious than heat-sustaining, and that 
there shall be no superfluity to store away fat, we find by analysis that the milk of the 
mare has little or no butter-in fact, only traces of it-in its composition.^ What a lesson 
* Fifteen pounds of such hay containing oz. 3.095 of nitrogen. 
f These ashes having a good proportion of lime. 
j Analysis of mare's milk: 
Water 896.3 
Butter traces. 
Casein 16.2 
Sugar of milk, extractive matters, and fixed salts 87.5 
1000. THE TEETH AND THEIR DISEASES. 
221 
teeth, which in many instances falls into a positive sulcus. These pits it is 
impossible to keep clean; hence an antagonism which results in caries. The 
surface most liable to suffer from caries is the approximal. This in 
many instances finds explanation in the constant abrasion here going on as 
the result of motion produced by the act of mastication, the enamel being 
literally worn or cracked away. In other instances, a species of pocket-like 
flatness is found near the necks, in which is lodged and retained the debris 
of diet. In still other instances, the dentine becomes deprived of its protecting 
enamel as the result of lateral pressure, such pressure being increased with 
the development of each new tooth; this applies most particularly when the 
relation of approximal contact is a limited one and not diffused over the face 
of the tooth at large. 
The inferior incisors and cuspidati are the teeth least disposed to 
decay. An explanation of such exception seems found in the shape of the 
organs and in their being fully surrounded by an antiseptic saliva. 
The wisdom-teeth, universally viewed as being most predisposed to caries, 
derive such tendency from a twofold direction. Developing at a period when 
in the animal economy is here given, and what a practical illustration of the requirements 
of the young of that and other animals ! 
Again, it may be contended that among the beautiful children we see on every hand, 
there is no want of those who are fat and hearty. It is not fat we want; it is bone and 
muscle, with so much fat only as shall give firmness to the flesh and plumpness to the 
figure. Fat, although it enters intimately into union with the other component parts of 
bone and muscle, cannot be transformed either into the inorganic constituents of bone or 
teeth, or into muscular fibre. These must be contained in the food consumed, in the first 
place, and thence transferred to the blood. 
How necessary, then, how important it is, if we expect to give strength and vigor to the 
constitution, that the food, in the first years of infancy and childhood, when the formative 
process is going on, should receive some further attention than has hitherto been given to 
it 1 and if our youth-if our young females-have hitherto been deprived of the necessary 
constituents for the full development of every portion of the body, can we wonder that a 
woman should be the delicate and fragile being she is, or that by the decay which assails 
the teeth in early life she should be deprived of an ornament of so much value ? If this 
state of things can be altered,-if the physical constitution of woman in America can be 
saved from further degeneracy,-a purpose may be effected of consequence even in a national 
point of view; for it is to the healthy and vigorous constitution of woman that we must 
look for a race of hardy, vigorous, and enterprising freemen. 
In conclusion, I would briefly state that this is a matter in which professional aid can 
avail little; it lies at the door and must be the work of parents generally. It is for them 
to understand the great value to be attached to the food on which their children subsist,- 
that it shall be wholesome and nutritious, and abounding in the earthy compounds so abso- 
lutely necessary to their proper development. If the chief articles of food have hitherto 
consisted of compounds made of superfine flour, corn-meal, and the fat of meat, let there be 
substituted in their stead bran-bread, milk, eggs, the lean of meat, and potatoes; let more 
attention be given to the nutrient quality of the food; let there be no deficiency of those 
articles containing the earthy material, that the bones and teeth shall not be deficient in 
those constituents so necessary in their composition and structure; and I should be inclined 
to hope that the evils which now exist will be lessened, and the physical organization of 
succeeding generations be equal to that of any nation upon the earth. 222 
A SYSTEM OF ORAL SURGERY. 
the formative force is losing vigor, these teeth are commonly deficient in the 
amount of that inorganic material which constitutes what might be called the 
mechanical resistance of the dental organs: in structure they are found, com- 
paratively speaking, loose, while their general resistive power is low; they 
might, indeed, be likened to the osteophytes which form after bone opera- 
tions, and which represent so imperfectly the tissue replaced, being found 
unable to resist antagonisms not at all injurious to properly-formed tissue. 
Again, as a local signification is concerned, these teeth, making their appear- 
ance at a period when all the others are formed, find so little room in the arch 
as to render the process of eruption difficult, slow, and in some cases impossi- 
ble ; hence not only is a chronic morbidity engendered, but the face of the 
tooth is in many instances so long overlaid by an unabsorbed operculum (see 
diagram) that a perfect pocket exists, constantly filled by ingesta. 
Condition 3.- Constitutional Relations.-This is the purely medical as- 
pect of the question: it considers the varying alterations in the individual as 
manifested in the changes of dental health,-whether such relation resides in 
altered nutrition of the organs or in the production of adverse associated ex- 
pressions. An example is furnished in the condition of utero-gestation, a 
second in dyspepsia, a third in the anaemic diseases. 
The common proverb, " for every child, a tooth," has passed into general 
acceptation : statistics demonstrate that women lose their teeth in a twofold 
proportion to men, and that child-bearing women lose them in a threefold pro- 
portion to single women. Teeth which, up to a period of pregnancy, never 
required attention, will, in some individuals, be attacked by a malignancy of 
carious action that quickly destroys a whole denture; such caries having the 
twofold signification of a perverted nutrition and antagonistic local action. 
An all-important question here presenting itself is the cure. To esteem 
this as residing in plugs of gold, and to so practice, is to find one's self resting 
upon a staff of reed. The matter, primarily, is solely one of nutrition; not 
that necessarily phosphate of lime or other special material is demanded; the 
patient may have of such agents quite enough, both for teeth and foetus; but 
the presence of agents of nutrition is not nutrition. Repair in living 
tissues resides in that function, as expressed by the physiologist, " by which 
nutritive matter, already elaborated by the various organic actions, loses its 
own nature and assumes that of the different living tissues, to repair their 
losses and support their strength." Here lies the indication : it is, to correct 
the morning sickness which compels the stomach to refuse its food; to keep 
cleansed an alimentary canal which, because of perverted secretions, is denied 
the office of its lacteals, the whole economy thereby, Tantalus-like, being 
starved, even with plenty around; it is to antagonize the perversions of appe- 
tite, which, refusing proper pabulum, craves substances injurious to the health 
at large; it is to control nervous irregularities. To express the requirements 
in one sentence, it is to secure, and to preserve to the system, that assimilative THE TEETH AND THEIR DISEASES. 
223 
force through which it may be enabled to add to its ordinary functional work 
the new labor demanded. 
Dyspepsia and Anaemia.-Dyspepsia and anaemia, as causes of dental 
caries, have the same general constitutional signification as found in the con- 
dition just referred to. To enter into a discussion of these relations would, 
as is seen, carry us necessarily over the grounds of general medicine,-a 
domain with which it has been taken for granted the reader is familiar. 
Condition 4.- Character of Agents in Contact with the Teeth.-The 
idea, as commonly held, that caries of the teeth depends exclusively on the exist- 
ence of free acids in the oral cavity, is, to the mind and experience of the 
writer, a proposition which needs but little observation to limit to very 
circumscribed boundaries. If any one hundred mouths be taken, having 
in them carious teeth, and the ordinary test of litmus-paper be made, four- 
fifths of them will be found neutral, if not alkaline. Alkalinity we would 
infer, then, to be a more common association of caries than acids; and of the 
truth of such position experiment will show that there can be little doubt. 
It is, however, a fact that the presence of any alkali may result in the for- 
mation of an eroding acid in a depression, or sulcus, and it does this precisely 
as the same effect results in decaying woody fibre,-namely, by enabling sub- 
stances to absorb oxygen which do not in themselves possess such power, or 
possess it to a very limited extent. Thus, perhaps in every mouth in which 
the fluids are alkaline, carbonic acid will be found in the debris of decaying 
teeth. (See Oral Fluids.') * 
Mucous Deposits.-Every one who has occasion to make observations 
in the mouth has met most frequently with that condition of the mucoid secre- 
tion in which this fluid is glairy and tenacious, alkaline to the test, and not 
* " No acids or soluble lime-salts are in the innermost decayed mass; hence no acetic, 
tartaric, or lactic acid has dissolved much of the lime-salts, because the acetates, lactates, 
etc., would not be found washed out completely from the decayed mass, but a small amount 
would still remain, which, being soluble, would be easily shown by oxalate of ammonia 
acid. 
" One large decay sliced up into several parts, and the slices analyzed, showed as follows: 
" First slice-Outermost, very gelatinous, soft layer,. 
"Water, 58 per cent.; organic, 26 per cent.; lime-salts, 16 per cent. 
" Or, omitting the water: Organic, 61 per cent.; inorganic, 39 per cent. 
"Second slice-Middle, water not determined, because no longer reliable. (The speci- 
men had become a little dry.) 
" Organic, 55.8 per cent.; inorganic, lime-salts, 44.2 per cent. 
"Third slice-Innermost, white, friable mass close to the healthy dentine; scraped out 
with a soft iron wire, and very crumbling. 
" Organic, 32.1 per cent.; lime-salts, 67.9 per cent. 
" This decay which was analyzed in these slices shows, therefore, from the outside, a uni- 
form advancement to the normal composition of the tooth. It shows that the lime-salts 
are removed, but not in any way which the acid theory demands. . . . The tooth is 
disorganized, the soft, friable white decay is no longer organized, though chemically differing 
only slightly from the tooth-substance."-Experiments by Prof. Charles Mayer, A.M. 224 
A SYSTEM OF ORAL SURGERY. 
infrequently offensive in odor,-a condition universally associated, when a 
habit, with dental caries, and, indeed, with general dyscrasia. Teeth in 
such a mouth are universally covered with a film, and this so persistent that 
the ordinary use of the brush fails to disperse it, while the common denti- 
frices have alone the signification of a temporary good. 
Relief in Acids.-Teeth so diseased find relief alone in acids, not only 
locally employed, but internally administered. A system secreting such mucus 
may be said to labor under the dyscrasia of super-alkaline poisoning, the agent 
having its point of exhibition most markedly in the mouth. It is really the 
condition of oral typh fever,-a typhoid condition expressing itself in 
this particular secretion, precisely as in other instances accident might have 
directed it to the degeneration of the glands of Peyer or of the liver. A 
poison is in the blood, and by means of the circulation is diffused throughout 
every part of the system; that it expends its force most markedly on certain 
parts is not unlike the expression of disease in general. If the blood of a 
patient laboring under this typh condition be examined under a microscope, it 
will be found that the normally-shaped red disks are diminished in 
number as compared with what are known to the pathologists as " the mela- 
nosed" corpuscles; that is to say, as expressed by Chambers, " the dying or 
dead disks, shrivelled and small, of a dark color, with black specks in them, 
and with gimped edges." 
Typh Poison.-But what is this typh poison? it may be asked. Un- 
fortunately, the nature and scope of the present volume limit an answer to the 
simple elements of one of the most interesting questions in medicine. By 
typh poison is meant a super-alkalinity of the blood which tends to dis- 
solve the blood-corpuscles and to defeat the ends of tissue-metamorphosis. 
This poison, according to its quantum, depresses to death, as seen too often in 
cases of typhoid fever, or it may expend itself in a simple deranged vitality, as 
witnessed in the stringy mucus now under consideration. How this poison 
enters the system necessarily provokes much discussion. That one of its in- 
roads, however, is by the stomach is not to be doubted, seeing that in epidemic 
typhoid fever an emetic at the beginning of an attack seldom fails to lessen 
the force and extent of the impression, such emetic seeming to act mechani- 
cally by emptying the stomach, thus preventing all the poison which had been 
received into that viscus from being taken up; while still again it is observed 
that, during the prevalence of such epidemics, those who smoke and chew 
tobacco, and thus eject their saliva, are least apt to be attacked. 
That, however, the typh poison maybe generated from within is scarcely 
to be doubted. In such chronic cases as associate with dental caries, this is 
the direction, no doubt, of the production; and yet the condition may reside 
in a subacidity, the alkalinity being what might in proper health be normal, 
but which is in excess from the deficiency of a neutralizing acid. Unable, 
however, to devote a greater space to the consideration of a question well 
worthy a chapter in itself, we leave the subject with this hasty glance, ex- THE TEETH AND THEIR DISEASES. 
225 
tracting the deduction that the prophylaxis of caries in this direction is found 
in the free use of acids. If to the mind of any one this may need confirma- 
tion, let a conclusion be drawn from any two cases of ordinary typhoid fever,- 
one being treated with alkaline medicines, the other with acids. In seven 
cases out of ten, the patients treated exclusively with the first will die; seven 
out of ten treated with acids will recover.* 
As a systemic medicament, let, therefore, the following be prescribed: 
JJ Acidi hydrochlorici diluti, gtt. x; 
Syrupi, 3ss; 
Aquae, ^j. M. 
Sig.-To be repeated from one to three times a day, as may seem required; or it might be 
that even five drops of the acid would be found sufficient for the requirements. In cases 
of typhoid fever, the author has administered as many as twenty-five drops to the dose, 
repeated every three hours for two weeks. 
Cider Vinegar.-Pure cider vinegar in tablespoonful doses taken in a 
little water three or four times a day is markedly antidotal; this particularly 
where the bowels are loose. 
Quiniae Sulphas.-Conjoined with an acid it will be found serviceable 
to employ the quiniae sulphas,-a grain pill once or twice a day, according to 
the length of time it is proposed to continue the medicine. A very good plan 
is to direct thirty pills: 
Quiniae sulphatis, gr. xxx; 
Ext. nucis vomicae, gr. viij; 
Extracti gentianae, 3j. M. 
Sig.-To be divided into pills No. xxx; one or more to be taken each day. 
As a mouth-wash, the following combination will be found applicable: 
U Tincturae eapsici composites, £ij ; 
Aquae Coloniae, ^ij; 
Spiritus vini, ^ij ; 
Tincturae quillai, ^iss; 
Tincturae gentianae compositae, ; 
Acidi acetici diluti, ^ss; 
Acidi carbolici fluidi, TCPij- M. 
Sig.-To be used by saturating a tooth-brush which has been first dipped in water. 
Disinfection.-Where much offensiveness in odor is associated with 
inspissated mucus, it may be necessary to use a gargle of the permanganate 
of potassa or of the aqua chlorinata. For the former, a very good proportion 
would be as follows : 
U Potassii permanganatis, gr. xv; 
Aquae, §viij. M. 
Sig.-Use as required. 
* This assertion is founded on observations made in daily attendance on quite a number 
of patients during an epidemic lasting nine months. 226 
A SYSTEM OF ORAL SURGERY. 
The latter is objectionable by reason of its disagreeable taste, and is, there- 
fore, seldom prescribed. 
Another excellent preparation for such disinfection is found in phenol 
sodique; indeed, by many, preference is given this article above most others. 
It is used diluted with water in such proportions as seem demanded to meet 
the indication of the special cases prescribed for,-ordinarily one part to 
twenty parts of water. Listerine finds many to recommend it, being agree- 
able to the taste and possessed of marked antiseptic Quality. 
The following combination may be used satisfactorily in any case of the 
character considered: 
U Tincturm capsici, £ij ; 
Tinctura? myrrhae, oj > 
Acidi carbolici fluidi, gtt. x; 
Spiritus frumenti, ^ij ; 
Aquae rosae, ^xj. M. 
Sig.-Use with tooth-brush or as simple mouth-wash. 
Seiler's antiseptic tablets furnish a cleansing and refreshing mouth-wash; 
one is dissolved in a glass of water. 
Acid Secretions.-That the common oral fluids are occasionally found 
of an acidity sufficiently strong to be injurious to the limy structure of the 
teeth is not, of course, to be denied. When such state exists, it is easily 
demonstrated by furnishing the patient with a few strips of litmus-paper, 
which are to be wet with the fluids of the mouth at varying periods of the 
twenty-four hours. The test of most signification is gotten in the morning 
upon rising, and before taking any fluid into the mouth. If such test reddens 
the paper for a series of mornings, an antacid indication would seem to be 
fairly established, and local prescriptions, something in combination like the 
following, are to be directed: 
U Aquae calcis, ^iv: 
Tincturae cinchonas, 
Tincturas pyrethri, aa, gj ; 
Tincturae quillai, ^ij; 
Potassii chloratis, 5j j 
Aquae chlorinatae, ^ij > 
Spiritus vini, ; 
Tincturae gaultheriae, q. s. M. 
Sig.-To be used with the tooth-brush. 
Or, 
U Potassii chloratis, ^ss; 
Aquas, ^iij ; 
Tincturae capsici composita;, o ij ; 
Aquae Coloniae, §j; 
Tincturae quillai, §iss; 
Olei limonis, vel verbenas, vel 
gaultheriae, q. s. M. 
Sig.-to be used with the tooth-brush, THE TEETH AND THEIR DISEASES. 
227 
Powders.-If it prove more convenient to employ powders, combinations 
like the following will be found to answer the required purpose: 
U Cretas praeparatae, 
Iridis Florentines pulveris, aa ^ss; 
Ossis sepiae pulveris, $ij; 
Olei limonis, q. s. M. 
Or, 
U Cincbone rubre pulveris, gij j 
Capsici pulveris, gr. x; 
Potassii ehloratis pulveris, oj > 
Pulveris aromatici, 3ij j 
Saponis castiliensis pulveris, ; 
Magnesie earbonatis, ^ss; 
Iridis Florentine pulveris, ^j. M. 
Or, 
U Cretae praeparatae, 
Iridis Florentines pulveris, 
Ossis sepiae pulveris, aa ^ss; 
Sacch. alb. pul., 
Carbo lig. pul., 
Pul. aromat., aa. 31. 
Conjoined Remedies.-Conjoined with local antacids, attention is 
demanded by the functional, or it may be organic, conditions producing the 
acids. Different derangements of the general health will exhibit different 
acids. Thus, in one mouth is to be found the uric, in another the lactic, 
in still another the nitrous, etc. These productions have their constitu- 
tional meaning and indications. As examples in such directions of practice, 
the presence of uric acid in the mouth, as in the urine, is apt to be found 
associated with deficiency in respiratory action and with circulatory sluggish- 
ness. Lactic acid in the saliva almost certainly indicates the condition of 
diabetes, although diabetes does not necessarily yield lactic acid to the saliva. 
Formic and acetic acids, found continuously in certain mouths, have been 
made to disappear quickly through treatment directed to an existing leukaemia. 
Parasites.-The parasitic theory of dental caries holds good only as 
fungi, animal or vegetable, are added causes of deterioration. Lodged in a 
cavity of a tooth of soft structure, these no doubt act the part of destructive 
agents, by insinuating themselves into the tubular and intertubular spaces, in- 
terfering with and counterbalancing the resistive efforts of dentinal consolida- 
tion, and serving as sponge-like bodies, to hold in contact with the parts agents 
alike injurious with themselves, lowering also the resistive vitality through an 
appropriation of nutritional pabulum. The matter of parasitic relation with 
dental caries, properly summed up by Dr. Miller, is appended as a foot-note.* 
* " 1. Decalcification of the enamel signifies total destruction of that tissue; of the dentine 
there remains after decalcification a tough, spongy mass, which becomes subject to the in- 
vasion of enormous numbers of fungi (leptothrix-threads, bacilli, micrococci, etc.). 
"2. The leptothrix-threads are found, with rare exceptions, only upon the surface, or in 228 
A SYSTEM OF ORAL SURGERY. 
To destroy these fungi, few agents are found more reliable than what is 
known as the dental carbolic acid soap. This soap should be used twice a 
day, one of these times being before retiring at night. Powders serve also 
an excellent purpose, removing the offence mechanically. Acid washes, as 
suggested, may also be prescribed. Dr. Aitkin, of Edinburgh, recommends 
the production in the mouth of sulphurous acid through a solution of the 
sodae sulphis ; his prescription being as follows : 
U Sodas sulphitis, Jj ; 
Aquae, f^j. 
In proportion as the secretions are acid, the salt is decomposed, the sul- 
phurous acid being set free. This disengaged acid will, it is affirmed, destroy 
oral parasites in twenty-four hours. 
Putrescent Caries.-In the case of a family of children where parasitic 
offence was associated most markedly with putrescent caries, a change quite 
wonderful in its character was produced by alternations of acid and alkaline 
washes. Either of these, by itself, failed utterly in any satisfactory result. 
The writer was led to infer, therefore, that two orders of fungi harmoniously 
existed,-the one impressible by acids, the other by alkalies; and the result 
of the treatment certainly seemed to verify the conclusion. The fluids of all 
the mouths were neutral. The Protococcus dentales, very minute 
organisms, are referred to by microscopists as being most frequently found in 
carious dentine, although it is not at all uncommon to meet in profusion the 
spirilla, amoebae, monads, etc. 
The following suggestive and instructive examinations, made by Dr. Joseph 
G. Richardson (author of the " Handbook of Medical Microscopy") on the 
first five patients coming into the office of the author after completion of the 
required arrangements, will be read with interest: 
Specimen I.-Patient, young lady. Mouth remarkably healthy-looking ; 
gums hard ; had lost no teeth; cavities very few in number; oral fluids 
neutral; teeth clean; no tartar or other collections, specimen examined being 
a particle of carious dentine. Examination with a one-twenty-fifth-inch ob- 
jective, giving with the No. 1 eye-piece a power of about twelve hundred 
the superficial layers of the softened dentine, and appear to take but a small part in the 
invasion. The bacilli, on the other hand, penetrate far into the dentine, even into the finest 
branches of the canaliculi. Micrococci penetrate farthest. 
" 3. In the separate tubules is frequently to be seen a gradual change from leptothrix- 
threads to long bacilli, from long to short bacilli, and from the latter to micrococci. 
"4. The fungi produce anatomical and pathological changes in the deeper layers, stop up 
the canaliculi, and necessarily lead sooner or later to death of the dentinal fibrils. The 
outer layers of dentine, thereby deprived of nourishment, die and fall a prey to putrefac- 
tive agents. 
" 5. The invasion of the fungi is always preceded by the extraction of the lime-salts. 
" 6. The fungi have not the power either to penetrate or to decalcify sound dentine, so that 
the infection of a perfectly sound tooth by a carious one seems to be excluded." THE TEETH AND THEIR DISEASES. 
229 
diameters, showed a multitude of bacteria and short leptothrix fila- 
ments, all, however, quite motionless. 
Specimen II.-Old lady. Teeth breaking down in every direction ; dif- 
fused collection of pasty debris ; gums soft and unhealthy-looking; epithelial 
cancer involving left half of lower lip, and passing around the commissure to 
upper lip; patient very deficient in vital force. Specimen examined was 
debris from the side of an inferior cuspis, against which rested the disease. 
It exhibited long bundles of leptothrix filaments, consisting of from five 
to fifty mycelial threads, each about one-ten-thousandth of an inch in 
diameter, and attaining sometimes the enormous length of one-tenth of an 
inch. These fibrous-looking bundles were interlaced and embedded in a large 
amount of granular stroma, apparently composed in great measure of bacteria 
and bacteridia, many of the former being seen in very active movement 
around the margins and in the interstices of the masses. 
Specimen III.-Patient, young lady. Mouth healthy-looking in the 
highest degree; had lost no teeth; very few cavities, and these all filled 
beautifully and perfectly with gold; fluids neutral; no tartar. Specimen ex- 
amined was a mere particle of debris found between the inferior central 
incisors. This showed great numbers of comparatively short leptothrix 
filaments, among whose interstices floated, in molecular (Brunoniao) move- 
ment, multitudes of bacteridia and nearly motionless bacteria. A few of these 
minute organisms manifested voluntary action, which continued in certain 
instances for at least thirty-six hours after removal from their parent mouth 
and immersion into a three-quarters per cent, salt solution. 
Specimen IV.-Boy with hare-lip. Oral fluids alkaline, stringy, and 
tenacious. Specimen examined was carious dentine from a lower molar. It 
showed immense numbers of bacteria, short leptothrix filaments, 
chains of spores, and occasionally a specimen of spirillum. These fungi were 
especially abundant around the margins of dentine scraped from the cavity; 
and, as they were not accompanied by salivary leucocytes, it is probable they 
did not proceed from the saliva, but had developed within the tooth. 
Specimen V.-A molar tooth with a large cavity in its side was ex- 
tracted from the mouth of fifth patient, a scrofulous lady, with most unprom- 
ising teeth, and, after being split open, was subjected to examination. A 
branch of the cavity, extending into one of the fangs, was found filled with 
a soft spongy mass, which, under the microscope, was seen to be composed of 
long interlacing filaments of leptothrix buccalis, such as were found in 
Specimen II., and to be swarming with bacteria. 
A portion of the cavity at the edge of the split surface was scraped clean, 
and thin sections of the still firm but diseased dentine were made with a 
strong sharp knife. These fragments, when examined with a power of twelve 
hundred, were seen to be associated with many bacteria and filaments of lep- 
tothrix, the latter of which seemed in several instances to occupy the dentinal 
tubules and to project from their fractured extremities. Although being then, 230 
A SYSTEM OF ORAL SURGERY. 
of course, without movement, it was difficult to say with absolute certainty 
that the structureless fibre-like bodies were actually portions of the vegetable 
growth. (See resume, on succeeding pages, concerning Acids and Parasites.) 
Electro-chemical Relations.-Every observer must have remarked 
how much more common caries is to moist than to dry mouths, and how much 
more frequent is the failure of an approximal plug at the base-wall of a tooth 
than elsewhere about its circumference. These conditions have been discussed 
by Mr. Kencely Bridgman, L.D.S., in a paper on the electro-chemical action 
of metallic substances upon the teeth, with an exhibition of experimental 
research which commends his views to respectful consideration. 
While investigating, says this observer, the action of voltaic electricity upon 
organic compounds, it was observed that all defects of metallic fillings 
in the teeth could be represented by results obtained out of the mouth. 
That decay might be, and probably was, a chemical action, every one was 
quite ready to admit; but how it could be electro-chemical did not appear to 
be in the slightest degree comprehended. The immediate effects of chemical 
action could easily be recognized as such ; but the previous electric condition 
giving rise to this chemical action required a somewhat intimate acquaintance 
with the laws of physical forces to render its presence appreciable; and, con- 
sequently, the only valuable portion of the theory has hitherto been left in 
abeyance. 
A basal experiment upon which the deductions of Mr. Bridgman are 
founded is as follows : 
A rod of absolutely pure zinc, three and a quarter inches long, after being 
thoroughly amalgamated with fresh distilled mercury and drained, and weigh- 
ing four hundred and eighty-seven grains, was placed half its length in cold 
dilute sulphuric acid, and the other half exposed to the atmosphere, in the 
same position as the ordinary plates of a battery. In a very short time 
bubbles of hydrogen made their appearance over the whole surface exposed 
to the acid, and after forty-eight hours the metal was found to have lost 
upward of ten grains in weight. This loss, however, was by far the least 
important part of the results obtained. The immersed portion of the metal 
had not been acted upon uniformly over its whole surface; but the action had 
been greatest at the surface of the liquid. At the same time the exposed 
portion had become covered with patches of crystalline sulphate of 
zinc, high and dry upon the projecting portion of the metal. Therefore, 
not only had chemical action been exerted between the metal and the acid 
and the water decomposed, but there was the additional evidence that the 
metal itself had become polarized. 
Associated with this first is the experiment by Faraday, copper being used 
instead of the amalgamated zinc, the color of the crystals and the coloring of 
the acid affording more conspicuous evidence of the results produced. 
A piece of stout copper wire being placed similarly in acid, the latter very 
soon gave signs, by the coloring it received, of the copper commencing to THE TEETH AND THEIR DISEASES. 
231 
undergo solution; and, after having been suffered to remain undisturbed for 
twenty days, it presented the appearance above the acid of a bushy rod, the 
portion exposed to the atmosphere becoming coated with a layer of 
minute and beautiful crystals of sulphate of copper, extending from near the 
top to within three-sixteenths of an inch of the liquid. At this intermediate 
portion a greater amount of chemical action had been induced, corroding the 
wire about half way through and forming a neck tapering upward. 
That the action which arises between the metal and the acid is due to 
polarization is evidenced by the following proceeding: " A similar piece of 
copper wire, wholly submerged in the acid, so as to entirely exclude any por- 
tion of the metal from coming in contact with the air, has remained for many 
months without imparting the slightest tinge of color to the liquid; but on 
suffering the fluid to evaporate, so as to bring the upper end of the metal 
near to its surface, the instant the slightest portion becomes exposed to the 
atmosphere chemical action immediately commences." There is thus, where 
no sufficient normal affinity exists between the metal and the liquid to effect 
the decomposition of water, a power imparted, by the metal being polarized 
by the atmosphere, which renders it then capable of accomplishing it. 
The atmosphere, says Mr. Bridgman, in its normal state being electro- 
positive, renders, by a well-known law of induction, bodies opposed to it 
electro-negative. The exposed end of the copper is, therefore, thus ren- 
dered electro-negative, and the acid, by the same rule, being electro-negative 
also, the immersed end of the metal becomes electro-positive. It is an estab- 
lished rule that bodies to be electro-decomposed must first be rendered 
electro-positive; and it is also a part of the same rule that bodies receiving an 
addition of matter must first be made electro-negative. Hence the exposed 
end of the metal has become negative and received the crystallization, while 
the immersed portion, being positive, has been acted upon accordingly. 
The appearance, however, of the crystallization upon what was at first the 
dry end of the metal requires particular attention. It is one of the special 
effects of electrolytic action that fluids pass to, and accumulate at, the 
negative pole. Obeying this law, the acid begins immediately to ascend and 
spread itself over the surface of the unimmersed end of the metal. But now 
we have another special provision, which demands the most careful and at- 
tentive consideration, as it constitutes the first step in the resulting chemical 
action. 
One metal placed in two dissimilar fluids, as the air and the acids, acquires 
the same condition that two dissimilar metals, or one metal non-homogeneous, 
assume when exposed to the air: each has become polarized, and rendered 
amenable to chemical action. Water, being a compound of gases chemically 
combined, can have its gases uncombined only by equal degree of force 
being antagonistic to them ; and consequently the decomposition of water must 
be preceded by some other arrangement. Now, the atmosphere being only a 
mixture of gases, or gases merely in a state of mechanical admixture, which 232 
A SYSTEM OF ORAL SURGERY. 
admits of their being readily separated on the slightest interference, supplies 
the initiatory steps by which decomposition can be effected. 
The first immediate effect upon a polarized metal is to drive the 
oxygen of the atmosphere to the positive end. Its combination with the 
metal, in oxidating or rusting it, is a chemical action determined by the 
electro-polar condition; and it has been established by Faraday and others 
that this chemical union is invariably accompanied by a development of elec- 
tricity, which in its turn can be made to produce electro-chemical results of an 
equal degree in another direction. 
The greater amount of action taking place at the neck of the copper wire 
will now be readily comprehended. The oxygen of the atmosphere has been 
driven toward the positive end of the metal; but its progress has been arrested 
by the acid surrounding it. The thin fibres, however, rising from its surface, 
being soon saturated with the oxygen, and presenting the latter in its most 
favorable form for acting upon the metal, facilitate its oxidation, and conse- 
quently accelerate its solution, and render the ascending acid saturated and 
ready for at once becoming a crystalline deposit, while little or no solution has 
been effected in the acid below. 
It must be kept in mind that an electric state is not a fixity, but is 
relative, and depending upon attendant circumstances. Thus, if the copper 
wire had been subsequently inverted, the immersed end, which is now positive, 
would then have been rendered negative, and vice versa ; or had the acid at 
any time been filled up to the top of the tube, the exposed portion only, 
however small that might be, would have remained negative, the surface of 
the liquid determining the line of demarcation between them. 
Let us now apply these facts to the mouth. The external epithelial layer 
of the gum is constantly throwing off its worn-out cells, and by this wasting 
process it determines its electro-positive state, while the crown of the tooth, 
as a continuation of the epidermal layer, partakes of the like condition. 
Were the teeth wholly and constantly submerged, and protected from the air, 
it is probable that, like the copper wire beneath the acid, they too might 
remain intact. But as the air is continuously passing into the mouth, or even 
through it in the act of breathing, they are thus, having one end exposed to 
the air and the other to the fluid moistening the gum, subject to the same 
polarizing influence as the metals. 
The negative portion of the polarized tooth being represented by the por- 
tion of the wire exposed to the atmosphere, it will be at once comprehended 
why tartar accumulates upon certain parts only of the teeth, and how it is 
enabled to creep over the surface and adhere with tenacity. 
In the case of the partly-submerged wire it has been shown that the prin- 
cipal amount of electro-chemical action takes place near the surface of the 
fluid, this point determining the line of demarcation. Hence in the mouth 
this line may be taken as the existing free edge of the gums. The moist- 
ure accumulating here, in the event of any electro-chemical action taking THE TEETH AND THEIR DISEASES. 
233 
place, it would necessarily be immediately above that line, and consequently 
the substance of the tooth directly above the gum would be attacked. We 
see this actually taking place in the peculiar decays so common at the exterior 
or anterior basal area of the molars, and also on the same part of the upper 
incisors. 
In the interstitial divisions, the moisture accumulates between the teeth 
by capillary attraction, and in connection with this we have approximal decay 
as one of the commonest forms occurring. The oxygen is attracted to the 
part, and produces the acid so invariably present, while by electrolysis 
the lime is abstracted and removed to another part, or carried away in solution. 
By such electrolysis, Mr. Bridgman thinks, every other phase and phenom- 
enon of decay is to be traced and explained. 
Viewing the matter strictly from the stand-point of a chemist, our author 
has overlooked vital resistive force. We trust we have, however, completed 
this lacking portion of his subject, and thus afforded him a required support 
in the chemico-vital aspect of his subject in which his foundation seems 
wanting. 
We may here follow Mr. Bridgman in his consideration of filling materials. 
In a prize essay, he says, I have shown that an amalgam filling in the side of 
a tooth having one edge near the gum generates acid at the latter point. 
This is due to polarization. A body of metal having its two ends or opposite 
sides exposed, under different circumstances, becomes polar, and in proportion 
as there is any substance to be acted upon by oxygen, so is the amount of 
chemical action regulated. Thus, a metallic plug in an approximal cavity, or 
in the external basal area of the molars, will have the cervical edge con- 
tinually wet, while the upper part may be comparatively dry; and hence will 
be assumed the two conditions as represented by the intermediate and exposed 
portion of the wire. It has often been lamented that, however carefully and 
well these fillings may have been done, there is the ever-recurring annoyance 
of finding, in a few years at the most, and not infrequently in a few months, 
that the sides of the plugs and baso-caval surface have become defective; 
showing that, although all the defects may have been removed in the first 
instance, the cause has been retained. 
With the entire range of metals and metallic compounds, it may be taken 
as a fact that from gold to copper and zinc it is only a question of degree, for 
the one cause affects them all more or less. In respect to this, gold is un- 
questionably the best by very far, as being one of the least oxidizable; 
but even with this, certain precautions are essential to success. The one indis- 
pensable condition is that there shall be no lodgement for moisture at any point 
of its circumference. The edge of the plug must be made perfect as 
possible, and no fissures communicating with it are to be suffered to remain ; 
for, if all be not right, electro-chemical action will be certain to recommence. 
With amalgams, such precautions are, if possible, even more important; 
but with these there are other points requiring attention. The composition 234 
A SYSTEM OF ORAL SURGERY. 
of amalgams is a subject which has never yet been systematically investigated, 
and those now in use differ considerably in character.* 
Zinc and copper, and their various alloys, with tin and silver, etc., form 
the hardest amalgams; while gold, silver, palladium, and platinum form only 
imperfect amalgams, which never acquire sufficient hardness to resist friction. 
In the latter, too, the mercury readily oxidizes and produces discoloration, 
while some of the former pass very quickly from oxidation to the acidifying 
stage, and thus soon reproduce the electro-chemical destruction of the dentine. 
There is another and more serious objection still to be urged against some 
of the more modern preparations. Amalgams hardening under a state of 
polarization assume, in some cases, a peculiar surface-crystallization, 
but almost invariably possess coarser crystals. 
I have exhibited, says Mr. Bridgman, two pieces of zinc which had been 
amalgamated and suffered to harden,-one under polarization, the other with- 
out it. With the polarized surface the metal had acquired a considerable 
amount of crystallization of a peculiar character, projecting above the level 
of its surface, together with a somewhat coarsely crystalline texture without; 
while that which had been allowed to harden without being polarized was 
much finer in texture, although distinctly crystalline. Two pieces of amal- 
gam, treated in a similar manner, showed the same corresponding results. 
In addition, both the polarized metals exhibited more discoloration than the 
unpolarized ones, and all showed that amount of roughness inconsistent with 
a perfect filling. 
Having thus traced the defects of metallic fillings, Mr. Bridgman proceeds 
to consider whether the objections are insuperable. 
There are two proceedings indicated, he remarks, as being desirable. The 
one is' to prevent polarization ; the other, to prevent the effects of polarization 
being reflected upon the dentine. The former is not by any means difficult, 
but it requires a thorough knowledge of the laws under which it takes place 
to adopt the provisions under all the different circumstances required. Insu- 
lation, however, is one of the means to be secured. This, too, is the end 
to be sought in protecting the dentine. Either gutta-percha, waxed tissue- 
paper, or allotropic sulphur-but, above all, the so-called os-stopping-forms 
an admirable lining for a cavity, where little success could be hoped for from 
an unprotected amalgam. It also compensates for the want of fineness in the 
texture of the metal. 
There is another point in connection with the electro-chemical action of 
metals upon the teeth discussed in the paper under consideration. Wherever 
a gold band comes in contact with the exposed dentine of a tooth, injury 
is commonly seen to ensue, and decay supervenes if the touched part be near 
the gum. This is assumed to be fully explained in the experiment with the 
copper wire. The gold, says the observer, may touch any part represented 
* See Plastics and Plastic Pillings. THE TEETH AND THEIR DISEASES. 
235 
by the blue sulphate, but at the intermediate portion-that is, that portion of 
the tooth just above the margin of the gum-it is fatal. 
Criticism on the deductions of the experiments is anticipated in a recog- 
nition of the fact that their author considers special cases alone, and does not 
lay down a general rule. That the condition of many mouths is fairly exposed 
seems entirely beyond doubt; and it must be admitted that Mr. Bridgman 
has given a very satisfactory expression to the chemical aspect of the subject 
of dental caries. (See chapter on Denudation.) 
Since attention was first called by the English experimentalist to the electro- 
chemical relations as a cause of dental caries, the American has taken hold 
of the matter with an earnestness that fills the dental journals with communi- 
cations on the subject. 
Medicines and Articles of Food.-That medicines, even the nitro- 
muriatic acid so frequently prescribed as an hepatic alterative, and the muri- 
ated tincture of iron used by almost every practitioner as a tonic, are not such 
sources of offence to the dental organs as is generally inferred, the author has 
come to be reasonably well satisfied. Prescribing both combinations with 
much frequency in his clinic as well as in private practice, he founds this 
conclusion on an extent of observation that would seem to render it entirely 
reliable. Not that the careless employment of such medicines is at all to be 
excused; but the inference is meant to be conveyed that caries associated with 
the periods of such prescriptions has explanation in the conditions prescribed 
for, rather than in the medicines prescribed. 
Administering Acids.-Acids are not best given through glass tubes, 
but, being sufficiently diluted, the draught, if such care be thought necessary, 
may be thrown into the back part of the mouth, and swallowed in a single 
muscular act, after which the teeth may be rinsed with water rendered slightly 
alkaline by the addition of a few drops of liquor ammonias. The system, 
however, which demands an acid medication will seldom find its dental organs 
injured by the reception of a share. Chalk, in place of the ammonia water, 
is suggested by Dr. J. D. White, he asserting that in this article acid medica- 
ments find their quickest and most reliable neutralization. 
Mercury.-Mercury, as a medicine, has no direct effect on the teeth,- 
its action having an intermediate signification ; neither have any of the potash 
preparations as ordinarily administered. 
Sugar.-Sugar, as usually employed, is not to be considered an agent 
deleterious to the teeth; locally it can act only through its conversion into 
acetous acid. A too free use of the agent, however, indirectly affects the 
teeth by debilitating the digestive functions in common with all other parts, 
diminishing, after such manner, the resistive force,-in other words, yielding 
malnutrition. 
Acids.-Vinegar, lemon-juice, the malic acid of apples, the 
tartaric of grapes, will all of them, in varying extent, decompose tooth- 
structure through affinity for the lime. When, however, their action is thus 236 
A SYSTEM OF ORAL SURGERY. 
injurious, the fact is easily recognizable by the patient in the loss of that 
polish noticeable on touching the organs with the tip of the tongue; or in 
the presence of the feeling familiar to every person, of " the teeth being on 
edge." 
It is not, however, to be affirmed or maintained that any of these articles, 
when brought in contact with the teeth under the circumstances of mastica- 
tion, with their speedy dilution by the oral fluids,-always proportioned to 
requirements,-are sources of disease to the parts. Prudence in the use of 
such things is, nevertheless, to be recommended to every person having teeth 
of loose structure,-soft, chalky teeth. (See Oral Fluids I) 
Fruits.-Of the dried fruits, raisins and figs may, it seems to the 
author, be denied with most reason ; they do, without doubt, rapidly corrode 
the teeth, and are excessively tenacious in their lodgement. That it is neces- 
sary to proscribe their use, except in the case of children, or where teeth are 
of soft structure, is, however, at least debatable. 
Sweet Spirits of Nitre.-The spiritus nitri dulcis,-a compound 
of the nitrate and carbonate of potassa, sulphuric acid, and alcohol,-freely 
used in the United States as a febrifuge, particularly in the case of children, 
is credited with being a frequent cause of dental caries. The diluted state in 
which the medicine is always administered may lead this inference to be 
received cum grano salis. 
Condition 5.- The Absence of Mechanical Destructives, as salivary cal- 
culi, the bands of artificial denture, etc. (See chapters on Salivary Calculus 
and Dentures.) 
Condition 6.-Accidental Influences.-Under the sixth head reference is 
first to be made to what may be termed the gymnastics of the teeth. These 
organs, like all others of the body, require to be used, and when denied the 
exercise of their function, deterioration universally follows. Illustration of 
this is markedly exhibited in slop-fed cows ; the teeth refused their accustomed 
task quickly becoming carious and loosened; also in the case of persons using 
alone one particular side of the dental arch,-the unused organs being soon 
enveloped in tartarized debris, and the gums becoming turgid and debased. 
This debasement is shown also in those who live on food which demands but 
little trituration. 
Risks.-The practice indulged in by many persons of breaking the 
harder shell nuts with the teeth is most reprehensible, cracking and split- 
ting the enamel, and thus exposing the more susceptible underlying dentine,- 
or, even where such accidents do not occur, exciting through shock a species 
of chronic inflammation which lowers the resistive force of the organs. 
Dental Operations.-Dental operations, as justly remarked by Dr. J. 
Taft in his work on " Operative Dentistry," performed at an improper time 
and in an improper manner, the vitality of the teeth being thus impaired, or THE TEETH AND THEIR DISEASES. 
237 
a diseased condition being established, are to be esteemed as exciting causes of 
caries. Often from injudicious use of the file extensive deterioration of 
the dentine supervenes, which is sometimes followed by death of the tooth and 
by disease of contiguous parts. Another cause enumerated in that volume is 
sudden transition from one extreme of temperature to another. 
Cleanliness.-Cleanliness is an essential to a healthy denture. 
Teeth should be cleansed after every meal; to this end a toothpick-always 
to be made of wood-is passed through the interspaces, and the mouth after- 
wards rinsed with water, or water to which has been added a few drops of 
alcohol or cologne. As a dentifrice, to be used when required,-which will, 
most likely, be once each day at least,-the following combination may be 
employed: 
U Ossis sepi® pulveris, 3'j > 
Cretae pr®parat®, ^ss; 
Coralli albi pulveris, 3b; 
Iridis Florentin® pulveris, ; 
Carbonis ligni pulveris, 3j 5 
Lapidis pumicei pulveris, 3b 5 
Olei limonis, q. s. 
Self-cleansing Mouth.-In a mouth self-cleansing, however, where 
there is little tendency to the accumulation and retention of debris, it would 
not, of course, be found necessary to have such excess of cutting ingredients. 
A modification of the prescription is therefore made: 
U Cretae praeparatae, ^ss; 
Ossis sepiae pulveris, 3ij j 
Iridis Florentinae pulveris, ; 
Cinchonae rubrae pulveris, 3j j 
Saponis albi pulveris, 3ij. M. 
Consideration of Causes.-In the treatment of any case of dental 
caries which may present itself, the careful practitioner first endeavors to 
satisfy himself of the causes, constitutional and local, influencing the 
diseased condition. Of the constitutional causes, all, as must be inferred, 
affect the integrity of the teeth which are deteriorative to the system at large. 
Unhappily for the dental organism, primary unhealthy impressions made upon 
the teeth, while in their formative, or pulpy, state, are apt to influence more 
or less their character for life, just as certain of the exanthemata,-variola, 
for instance,-occurring at this period, are so apt to impress permanent pittings 
upon the enamel. 
Unhealthy Parents.-Unhealthy parents, as has been suggested, can- 
not possibly beget healthy offspring. Here is a great primary antagonism. 
The teeth, however, are living and, consequently, changing bodies: particu- 
larly is this true, physiologically, of young teeth. Constitutional treatment 
may thus do service even as every molecule of tooth-structure is concerned. 
Such treatment would of course be longer in receiving apparent response, as 238 
A SYSTEM OF ORAL SURGERY. 
must be evident on considering the relative low vitality of these organs, than 
treatment directed to the production of an impression on the soft parts, or on 
common bone; yet, because a tooth is an organized body, because it has inner- 
vation and circulation, such treatment, to a greater or less extent, must have 
its influence. 
A first indication calls, therefore, for the consideration of causes interfering 
with the proper vitality of any denture coming under observation. Whether 
deteriorated hereditarily or otherwise, duty to the patient demands such con- 
sideration of the case. 
Heredity.-We will suppose a trouble to be hereditary. Here, if we 
can find in a patient the observable existence or continuance of habits of 
functional irregularity, or of animal habits common to the parent and which 
are to be esteemed of deteriorating import, our first attention is to be directed 
to a correction. The parent may have been specifically diseased, let us 
suppose, by his parent, and thus the bad teeth of both father and child lie in 
a venereal molecular impression. Here a predisposing cause would have come 
from and would be still residing in the transmitted condition. Granting, then, 
that such molecules, still living, are impressible, would not judgment direct a 
primary treatment to the production of an impression in such direction ? The 
writer has treated many a child, for skin and other disease, where the afflic- 
tion was a true hereditary venereal transmission, and he never thought 
of directing medication otherwise than in recognition of such a transmission ; 
and satisfied, as every medical man must be, that the circulatory fluid per- 
meates tooth-structure, he treats venereally deteriorated teeth on a common 
principle, and has found in the result that measure of success which has justi- 
fied the conclusions. In other words, he has prolonged the life and health of 
such organs, just as are prolonged the life and health of the patient upon 
whose molecules is impressed the fiat of the tubercles of phthisis. Such a 
treatment consists, however, not necessarily in administering specific or sup- 
posed specific remedies, but in viewing the system as laboring under depress- 
ing influences, either of a general or special local signification. This fact it 
is most important to recognize. 
Deteriorated Molecules.-A child, as we have studied, may have its 
molecules deteriorated by a transmitted mercurial impression, or a 
parent may have been an inebriate, and thus have debased his child in himself. 
The result of an excessive venery may have been transmitted. A mother, 
from lack of nourishing material, may have degenerated her offspring. These 
causes of transmitted ills-the appreciable ones-are many : all must recognize 
them. 
Improper Diet.-Improper diet, as has been suggested, is plainly 
enough a cause of bad teeth to the developing child. The state of health 
of such a developing child has its influence; indeed, so marked is this, that 
by an observation of teeth belonging to the various periods of life, one can 
easily trace constitutional variations; for just as at different periods the func- THE TEETH AND THEIR DISEASES. 
239 
tions of organic life were healthily or unhealthily performed, so we find the 
disturbances written in the character of teeth belonging to the period. More 
expressive even than this is the fact that the deciduous teeth mark, in the 
progress of their development, the health of the mother. 
That the teeth, in their formative state, partake of the healthy or unhealthy 
condition of the system at large, all observers admit. But here, unfortunately, 
the matter has been left, most practitioners acting on the premise that such 
impressions are never to be altered. At such a conclusion it is impossible not 
to express surprise. Who, in his own person or in the persons of friends, has 
not remarked the varying conditions of the health of the teeth? Up to 
the age of sixteen the writer was a martyr to toothache; yet about that period 
a change occurred, since which time he has had no trouble. Is it suggested 
that the teeth may have been filled ? True, they were; but certain of the 
small fillings came out years ago, and have never been replaced, yet the teeth 
are quite as good as those in which the operations remain. 
Similar instances exist in profusion, and yet the lesson seems unheeded. 
There is a constitutional treatment for the carious tooth, as there is for the 
carious maxilla, and from a common stand-point are the diseases of both to be 
viewed. It is not, of course, every case of a carious bone that demands sys- 
temic treatment, neither is it so with the teeth; the source of offence in the 
one, as in the other, may be strictly local in character; but ill success must 
ever attend that practitioner who has not the inclination to look for meaning 
of a lesion outside of things strictly local in signification. 
Resume concerning General Conditions.-Integrity of the teeth 
depends on two general conditions,-namely, inherent vital resistive power, 
and absence of irritating influences. A tooth may, in its vital relations, be 
just strong enough to resist external forces brought to bear against it, if in 
its construction there be no mechanical imperfection. It may, even with im- 
perfections, be able to resist temporary injurious impressions. The vitality 
of a tooth can be elevated as the vitality of a lung is increased. The study 
of the vitality of a tooth, and the study of its adverse influences, is the study 
of vitality and the expression of irritation anywhere. The treatment of dental 
caries is both medicinal and operative. 
Resume concerning Acids and Parasites.-The writer here directs 
special attention to a prominence given at the present time to the acid and 
germ theories of dental caries. In the present and in previous editions of 
this work notice has been taken of acid formations in the cavities of decaying 
teeth which are quite independent of an acid saliva, and suggestion made as 
to the importance of affording proper attention in the direction. Sugar is a 
common article of diet, and is as well a physiological formation arising out of 
the action of saliva upon starch, while fungi are found, as has been shown by 
our experiments, in every mouth. Here is explanation of a cause or condition 
of decalcification. 240 
A SYSTEM OF ORAL SURGERY. 
The study is of great importance, yet happily, developed as it already stands, 
it may be said that practically, surgically rather, we are masters of the situa- 
tion : creasote is the parasiticide for all dental fungi, while to destroy, and to 
prevent reaccumulation, seems, in this direction, all that can be done. Soft 
teeth, showing caries from any cause, have their destruction hastened, un- 
doubtedly, by reason of the habitat furnished in their large tubules for omni- 
present parasites, the fungi in turn sucking into themselves carbo-hydrates 
and continuously producing acids. Miller, if the writer understand him 
correctly, looks on these dental fungoids as analogous, morphologically, with 
the bacterium acidi lactici, which, " without the presence of oxygen, produces 
acid from sugar." Concern here, however, being with cause and effect, it is to 
be advanced, without necessity for engaging in controversy, that antacids and 
germicides are never to be overlooked as necessary preliminaries to the intro- 
duction of plugs into dental cavities.* Parasites, it is to be recognized, are every- 
where, and are ever on the alert seeking habitations suited to their respective 
wants. A carious tooth-cavity is invitive of a large variety, and such foreign 
matter is never present without, as understood, a more or less injurious signifi- 
cation. The subject is important and demands to be appreciated. To destroy 
fungiferous germs is an indication that is to receive attention after excavating 
and before placing plugs in teeth. (See chapter on Dental Therapeusis.} 
Agents acting as germicides stand in relation to each other as follows. 
The table is from Sternberg. 
1. Corrosive sublimate, one part in 2000 
2. Permanganate of potash, " " 833 
3. Iodine, " " 500 
4. Creasote, " " 200 
5. Sulphuric acid, " " 200 
6. Carbolic acid, " " 100 
7. Hydrochloric acid, " " 100 
8. Chloride of zinc, " " 50 
9. Tincture of chloride of iron, " " 25 
10. Salicylic acid (dissolved by sodas borate), " " 25 
By this table corrosive sublimate is found at the head of the list. An 
ordinary dose of this salt is the one-twelfth of a grain, so that it is seen that such 
a quantity dissolved in a tablespoonful of water may be used freely as a mouth- 
wash. Where the intention is to sterilize a cavity in a tooth prepared for filling, 
a solution of two grains to an ounce of water is to be employed. Wood crea- 
sote, used pure, is a valuable and entirely reliable germicide as the latter of the 
* See " Fermentation in the Human Mouth," by Dr. W. D. Miller, Berlin. Published by 
the New York Dental Journal Association. On this same subject excellent papers will be 
found published in the New England Journal of Dentistry, from the able pens of F. Searle, 
D.D.S., and Arthur S. Underwood, M.R.C.S., the latter appearing later in the Archives 
of Dentistry. Also see paper by Professor Leplace, of the Medico-Chirurgical College, 
delivered before the Odontological Society of Philadelphia, 1889. THE TEETH AND THEIR DISEASES. 
241 
two requirements are concerned. The table of Sternberg shows that the mer- 
curial bichloride is, as a sterilizing agent, twenty times the strength of carbolic 
acid and ten times that of creasote. 
Reference is here to be made to tobacco. The article is undeniably a 
preserver of the teeth, and its germicidal character is marked. Smoked it 
acts more powerfully as a parasiticide than when chewed. According to ex- 
periments made by Dr. Miller, the smoke from a Colorado Claro cigar was 
found able to sterilize a beef extract solution previously richly infected with 
carious fungi. 
In the accompanying table, for which indebtedness is due to the observation 
and research of Dr. W. D. Miller, of Berlin, the percentage is indicated of 
each antiseptic named which must be present in a sweetened saliva to prevent 
the appearance, within twenty-four hours, of an acid reaction, or in case of 
alkaline or acid antiseptics, to secure against the presence of the characteristic 
fungi in the same time. The table is intended to show the comparative 
strength of agents most commonly used. Dr. Miller determined by the use 
of the microscope the action of the antiseptics having an acid or alkaline re- 
action on fungi. 
Production 
OF ACID. 
(Development 
OF FUNGI.) 
Prevented. 
Retarded. 
Bichloride of mercury 
1-100,000 
1-500,000 
Nitrate of silver 
1- 50,000 
1-100,000 
Iodoform 
1- 5,000 
1- 10,000 
Naphthaline 
1- 4,000(?) 
1- 9,000 
Iodine 
1- 6,000 
1- 15,000 
Oil of mustard .............. 
1- 2,000 
1- 5,000 
Permanganate of potash 
1- 1,000 
1- 2,000 
Eucalyptus oil 
1,600 
Carbolic acid 
1,500 
1- 1,000 
Hydrochloric acid 
1,500 
1- 1,000 
Phenylic acid 
1,200 
1,500 
Liquid of agate cement 
1,250 
Lactic acid 
1,125 
1,250 
Carbonate of sodium 
1,100 
1,200 
Salicylic acid (concentrated alcoholic solution) . 
175 
1,125 
Alcohol 
110 
120 CHAPTER XIII. 
SURGICAL CONSIDERATION OF DENTAL CARIES. 
Caries of a tooth differs surgically from caries of bone proper in the fact 
of a too common inability to repair by any effort of nature the injury done 
through the destructive influences of the disease. Not but what such repair 
is attempted, and indeed oftentimes successfully accomplished, as witnessed in 
tubular consolidation, where power sufficient exists to perfect the attempt,- 
seen in the process generally spoken of as vitrifaction or eburnification, a 
mode of natural cure and resistance which no mechanical operation, however 
successfully performed, can equal. This process of secondary calcifica- 
tion, or eburnification, exhibits fully the circulatory relations associated with 
dental caries, for not otherwise than by such expression is it possible to explain 
the phenomena: it is, in every particular, a modified repetition of the ordi- 
nary lymph exudation and circumvallation seen in abscess, either of bone or 
soft parts. 
A tooth attacked in any part by caries expresses the stages and steps of the 
inflammatory process, inasmuch as at the first approach of the disturbing agent 
immediate alteration occurs in the circulation or nutrition of the part, the 
tubules being filled up and solidified, or such attempt inaugurated, by deposit 
of adventitious matter. Disease being thus resisted and retarded, it conquers 
only when stronger than the vital force which combats it. 
Such phenomena express to an observing mind the principles of the treat- 
ment of dental caries,-i.e., to relieve the part from the agent of offence, 
and to strengthen the resistive ability. 
Passing from the first of these principles, which has been considered on 
preceding pages with perhaps quite sufficient fulness, we proceed to the dis- 
cussion of the second. 
A tooth attacked at a given point by irritating agencies will, step by step, 
break and give way before the irritant; or, otherwise, will resist and antago- 
nize. Resistance implies assistance, which assistance may be either of 
nature, of art, or of both. Whatever shall tend so to consolidate or protect 
the parietes of a cavity as to render the parts impervious and insusceptible 
to external agents, will save the tooth. Such result is aimed to be secured 
through the removal of dead and dying dentine from a cavity, and provocation 
to tubular consolidation through the introduction of an agent exciting to the 
vascular system of the tooth; the chloride of zinc being among the best 
of such agents, and most conveniently employed in the preparation known as 
242 SURGICAL CONSIDERATION OF DENTAL CARIES. 
243 
oxychloride. (See Dental Therapeusis.} Zinc so introduced into a tooth 
will not infrequently be found followed by such inflammatory consolidation 
that parietes from being soft and of loose structure are seen to become solid 
and dense to an extent that makes them entirely self-protecting; they have 
become glass-like in hardness : this occurs, however, only where the vital force 
is able to respond to the excitation. The practitioner, aware of this fact, 
directs a medication to the assistance of an asthenic system laboring under 
advancing dental caries, precisely as, under similar circumstances, he endeavors 
to assist nature in the arrest of caries of bone. In the one case as in the 
other, thus only may he expect to get a cure. Such principle of treatment is 
so in accordance with the exhibitions of nature's expression, that no medically 
educated experience may doubt the indications. 
The cure of caries by filing finds its explanation precisely as ex- 
pressed in the employment of the zinc. The file cutting away the weak point, 
and exciting, through the exposure of the dentine, vascular response, struct- 
ural consolidation results, and thus external or offending agents are shut out, 
precisely on the same principle as a ball may become encysted in a bone and 
remain for years innocuous. 
Gold or other ordinary agents employed in filling act to an 
extent in the same way: these being, however, commonly non-irritating, or 
non-exciting, are not apt to be found associated with the same 
extent of change; in all reasonably vital teeth, however, such at- 
tempts at resistance are to be seen. A filling of metal represents, 
and, to a degree, stands in place of, tubular or structural consoli- 
dation. 
Fig. 113 represents a section of carious tooth from life, exhib- 
iting structural consolidation as shown in the black bounda- 
ries of the cavity. In this particular case, although the hole- 
being in a lower molar-was large enough to contain a pea, caries was held 
completely in abeyance, and had been so for years. The parietes of the part 
were as hard as flint. 
In the local treatment of dental caries, three indications exist: 
1. Neutralization of adverse oral fluids and the induction of a state of 
general health in the mouth. 
2. Medical treatment of the tooth. 
3. Mechanical treatment of the cavity. 
Fig. 113. 
Fluids of the Oral Cavity.-The normal condition of the oral fluids 
is neutral. A healthy saliva, in which practically is included the secre- 
tion of the mucous glands, as well as that brought into the mouth by the 
ductus salivarii, is an inodorous, tasteless, slightly viscid fluid, bland, unirri- 
tating, subject to changes as influenced by physiological impressions, affording 
at times an alkaline reaction, again being temporarily acid, sometimes sweet, 
and often, under the impressions of dry bodies, mucilaginous to a marked 244 
A SYSTEM OF ORAL SURGERY. 
extent, owing this last characteristic to excess of mucus,-a substance almost 
analogous to vegetable mucilage, having as a chief constituent an albuminoid 
compound, with the office of preserving the membranes moist and in a con- 
dition fitted to the performance of their functions.* 
* Messrs. Griffith and Henfrey, the able editors of the Micrographic Dictionary, state, 
when speaking of the oral cavity, " The mucous liquid of the mouth contains, in addition 
to detached epithelial cells, very transparent corpuscles about 1-2000 to 1-1500" in diameter, 
consisting of a delicate cell-wall, a nucleus, with a number of minute moving molecules. 
We have figured these among the test objects. (Plate I., Fig. 5.) They are called mucous 
or salivary corpuscles. Kolliker regards them as a form of exudation corpuscles; and this 
view is probably correct, for they may occur in the secretion of any mucous surface and 
have no special connection with the salivary glands; we have found them in myriads in 
the urine." 
Dr. Joseph G. Richardson, of this city, late Professor of Pathological Anatomy in the Uni- 
versity of Pennsylvania, claimed, however, to be the first to demonstrate their true nature 
and origin,-viz., that they are simply "migrating" white blood-corpuscles, which have be- 
come distended by the endosmosis of a fluid less dense than the liquor sanguinis. He 
remarks, " From my experiments as detailed in the same article, page 253, and briefly de- 
scribed on page 157 of this chapter, I conclude that 'tracing now the white blood-cor- 
puscle from its condition of irregular outline and amoebaform movement, as observed in 
serum and in heavy urine, when the circumambient fluid approaches the density of 1028, 
through its rounded form, with slightly more distinct nuclei, in the liquor puris and in 
urine of lower specific gravity, we find that immersed in a rarer liquid approximating to 
the mean density of the saliva (1005), it has an accurately spherical outline, is more than 
twice the magnitude, and contains a number of minute actively-moving molecules, thus 
exactly resembling in all sensible characters the true salivary corpuscles; and it therefore 
seems reasonably certain that the blood, under the appointed nervous influence, congesting 
the buccal mucous membrane and associated glands, moves slowly enough through their 
capillaries to allow some of its white globules to penetrate the walls of the vessels, as they 
do those of the frog's mesentery in Cohnheim's experiment ( Virchow's Archiv, Band xl. 
S. 38 et seq.), which, under the influence of the rarer saliva expanding them and setting 
free to move their contained molecules, constitute the bodies so long known to histologists 
as the corpuscles of the salivary fluid.' " (Vide Handbook of Medical Microscopy, p. 165.) 
The demonstration by Dr. Richardson is as follows: " Placing a drop of blood from the tip of 
my finger," says Dr. R., "upon a growing slide" (see Pennsylvania Hospital Reports, 1869), 
" I covered it with a thin glass and placed it upon the stage of the microscope. After find- 
ing a white blood-corpuscle showing well-marked granules, I raised the objective and 
arranged a fine filament of thread from the reservoir filled with fresh water to the upper 
edge of the cover, and a fragment of wet paper to the lower, according to the usual method 
for securing a constant current beneath the thin glass. On depressing the body of the 
instrument and bringing the corpuscle again into view, I found it still adhering to the sur- 
face of the cover, notwithstanding the torrent of red globules hurrying over the field; and 
as these became paler and less distinct by reason of the diminished density of the serum, 
the white cell first gradually expanded and displayed its delicate wall with two rounded 
nuclei, then, after acquiring the magnitude of about p^y^th an inch, it exhibited the 
rapid and incessant movement of its contained molecules, and, finally, when its diameter 
reached about the ^j^th °f an inch, it burst suddenly, discharging a portion of its contents, 
whose outbreak resembled that of a swarm of bees from a hive, and some particles of which, 
actively revolving as they went, swam off to the confines of the field. On repeating the 
observation and allowing some aniline solution to flow in with the water after the first few 
moments, the nuclei were strongly stained and beautifully distinct, although the move- 
ments of the molecules promptly ceased,-in this respect, as in all the others, showing a SURGICAL CONSIDERATION OF DENTAL CARIES. 
245 
Analysis of Fluids.-Analysis of the fluids bathing the teeth is to 
precede operations upon these organs. As acidity or alkalinity is concerned, 
such analysis is most easily made-demanding but a few days-by furnishing 
the patient with two strips of test-paper,-litmus, as it is called; paper 
colored with the dye of the plant Lichen roccella,-one piece being blue, as 
found in the shops; the other made red by subjecting it to the action of a 
weak acid, or for this latter purpose turmeric paper may be used. Having 
these pieces of test-paper, the patient is to wet them with salivary fluid, slip 
after slip, at varying periods of the twenty-four hours, particularly in the 
morning immediately on rising and before taking anything into the mouth. 
If persistently the result be acid or alkaline, as evidenced by the blue slips 
being turned red if the first condition exists, or the red slips of litmus being 
changed to blue, or the yellow of the turmeric to brown, if the action be 
alkaline, then is primarily indicated the necessity for antagonizing agents as 
suggested in the prescriptions presented a few pages back. 
S or des.-When sordes are found enveloping the teeth, or where the mucus 
is glairy, the condition manifested by such secretions is to find correction before 
any reasonable hope is to be indulged of saving the denture or of making me- 
chanical operations which may have in them any special import of good. (See 
Mucoid Saliva.} 
The restoration to a state of health of gums, turgid and congested from any 
cause, is to precede dental operations. Of such causes of ulitic troubles 
there are many. These will be found discussed in the chapter on Diseases of 
the Gums. In a word, attention to local or systemic indications is to pre- 
cede, or have association with, as judgment may determine, the operative 
requirements of existing cavities of decay. 
The physical history of a tooth to be treated demands consideration. 
Teeth so vary in character as to suggest their division into four classes. 
I. Teeth of the Sanguine and Allied Temperaments with 
Similar Hereditary Association.-These- teeth are white, shading 
into a cream tinge which deepens as it approaches the gum and as age ad- 
vances : the organs are uniform in dimensions and arrangement, are dense, 
and have a periodonteum of the most resisting character,-the associated 
alveolar process being condensed to a cortical-like extent; their relation with 
the jaw is so unyielding as not infrequently to suggest union of the parts. 
Such teeth, as justly remarked by Harris, indicate, " if not perfect health, at 
precise identity with the reactions afforded by the pus and the salivary corpuscles, as above 
described. It should be noted that a certain variable proportion of the white cells of the 
blood thus treated exhibited no moving molecules, and apparently consisted solely of nucleus 
and cell-wall." 
Since the above was in type, this doctrine seems to have been corroborated by further 
experiments of Dr. Richardson, in which salivary globules were again reduced to the size 
of the white cells of the blood, and their amoeboid movements restored under the influence 
of a three-quarters percent, solution of common salt. ( Vide paper on the "Structure of the 
White Blood-Corpuscles," Transactions of American Medical Association.) 246 
A SYSTEM OF ORAL SURGERY. 
least a state which bordered very closely on it at the time of their dentinifi- 
cation, and the possession by their proprietors of stomachs always willing to 
digest whatever the teeth are ready to masticate." 
II. Teeth having a Blue Shade.-These, without doubt, are much 
more common to females than to males. Constitutionally they indicate the 
lymphatic temperament. They are commonly super-sensitive, having a 
softness yet tenacity of structure that expresses disproportionate excess in 
animal matter; observation seems to endorse the conviction that such teeth 
are associated more or less in a hereditary history with struma. Certain it is, 
that to preserve them constant watchfulness is necessary, both as a systemic 
and a local aspect are concerned. 
III. Chalky Teeth.-Teeth of this class are not infrequently to be 
met with having so little mechanical resistance as to suggest their relation with 
plaster of Paris. As such teeth have in themselves no resistive force, an 
only hope of prolonging their existence lies in the antagonizing of agents 
injurious to them. Thus arises a necessity for that care on the part of a 
person so afflicted, which is to keep him informed continuously of the state 
of the oral fluids, or if such care be not consistent with the character of the 
individual, then are antacid agents to be kept in constant use. 
IV. Pearly Teeth-Teeth frequently found allied with the 
Tuberculous Predisposition.-Teeth of this class are commonly of 
great symmetry, being in harmony with the delicate conformation of the 
individual, and akin with the organization which has produced them. The 
inherent force of such organs is much in proportion with that of the 
common body. A treatment which tends to preserve them is that which 
increases the physical integrity of the individual at large. The author is not 
aware of a tendency to any peculiar local disease in them. The fluids of such 
mouths are commonly neutral. 
Teeth of the first and fourth classes seldom have indications for any required 
direct preparatory treatment. Teeth of the third class may only have imme- 
diate adverse associations antagonized. Teeth of the second class, however,- 
and these constitute four-fifths of all diseased teeth,-are benefited by direct 
local medication to a degree that is oftentimes found to be their salvation. 
(See chapter on Dental Therapeusis.') 
Soft, Moist Dentine.-A soft, moist dentine indicates non-resistance 
on the part of the immediate vital force (residing in the organ) to the ad- 
vancing disease. There is here little or no antagonizing structural consolida- 
tion. Can this be remedied? Without doubt, in perhaps the majority of 
cases; such remedy residing in stimulation of the dental pulp, and in affording 
to it a power of response. To secure such response implies combination with 
the local of general stimulation. As the first is concerned, it has been implied 
that no agent surpasses an aqueous solution of chloride of zinc as used com- 
bined with osteo-dentine. 
A soft, non-resisting tooth, in which such a temporary plug has been SURGICAL CONSIDERATION OF DENTAL CARIES. 
247 
used, will not infrequently in the course of a few months be found so hard 
that an ordinary excavator shall scarcely be able to make an impression on the 
dentine; indeed, in many cases, so thorough has been the calcification that no 
other treatment is found necessary; the caries has been cured, the dentine 
vitrified.* 
In the employment, however, of such stimulation, it is to be inferred that 
the nicest exercise of judgment is demanded. Quite as many teeth are de- 
stroyed as are saved by chloride of zinc fillings; perhaps the preponderance 
is to the first side; but this is the fault of a practice which overstimulates, 
provoking inflammation and suppuration where gentle excitation to a hyper- 
nutrition is alone demanded. A good rule to adopt is to feel one's way, 
recognizing always that the extent of local stimulation is to be commensurate 
with the ability of the pulp to respond; the object aimed at being to re-excite 
the formative capacity of the pulp, and thus oppose advancing disease by 
securing a calciferous barrier. 
Secondary Indications.-Secondary indications to be met preparatory 
to filling a carious tooth exist in a necessity for the destruction of any fungi that 
may be found in the cavity, the immediate antagonism of the carbonic or other 
acids, or any alkali temporarily present, and the saturation of the part with an 
antiseptic,-warm alcohol, followed by creasote, being about the best prepara- 
tions that may be used for the last purpose. By saturation is meant that the 
dentine be bathed in these fluids after the preparation of the part and imme- 
diately before the introduction of the filling. A person undergoing the 
process of having teeth filled should use freely as a rinse alcohol and water, 
combined in the proportion of one part of the first to four of the second. Or, 
where the refrigerating influences of the spirit are found irritating to the 
cavity, it may be replaced by the permanganate of potassa, one grain to the 
ounce of water. Iodoform is also justly lauded as an application to be made 
to the walls of a cavity just before the introduction of the filling. If the odor 
of this medicament be objectionable, it may be replaced with a weak solution 
of chloride of zinc; five grains to the ounce of water. 
Separation as a Prophylactic and Curative Agent.-Having 
in a chapter on operative dentistry referred to the use of the file from the 
mechanical stand-point, we have here to consider the instrument as a prophy- 
lactic and curative means. 
In the process of preparing approximal cavities for filling, it is seen that in 
very many cases-indeed, in a majority-the dentine of teeth has been 
exposed, and that afterward no steps have been taken for its protection. 
This absence of care arises out of the experience that such dentine left to 
* Vitrifaction, vitrified. The use of a term signifying glass-glass-like-would in such 
a case seem quite as permissible as its application to one of the humors of the eye, the con- 
dition being one of glass-like hardness and smoothness. Eburnification, or conversion into 
a substance resembling ivory, is another term used to express the same condition. 248 
A SYSTEM OF ORAL SURGERY. 
itself does not tend to decay, but that when the operation of filling has been 
accomplished with judgment and the proper delicacy, the tooth seems in quite 
as resistive a condition as before being denuded. 
Acting on the premises of such experience, it is to be commended not only 
that conditions of incipient caries be filed away, but also that in irregular 
dentures the irregularities which invite disease be treated-in prophylaxis- 
in like manner. Of the various operations performed upon the teeth, none, 
certainly, demands more experience than the one now being considered; or if 
experience is to be replaced, it may only be by a judgment which possesses 
the fullest recognition of the requirements. 
A Cardinal and a Second Principle.-It is to be borne in mind as 
a cardinal principle that, in prophylaxis, dentine is never to be uncovered 
except the surface exposed can be made self-cleansing; hence it is at once seen 
that certain positions of decay preclude this treatment; cavities, for example, 
occupying sulci upon the grinding faces of teeth. 
The second principle that is to possess its weight with the operator 
lies in the premise that separation is not to be practised upon teeth the confor- 
mation and relation of which deny continuance of the position in which the 
operator leaves them. This second might be considered but an iteration of 
the first premise if it were not so well known that filed teeth, unless wedged, 
tend to change position. Hence the judicious use of a file or disk considers 
not only a present, but a future. In Fig. 114 an illustration is given of what 
is meant. Observing the bicuspid and ap- 
proximating teeth in this diagram, it is seen 
that between the first and the second bicus- 
pidati the file has been passed directly 
through to the gum, the space being the 
same behind as in front, and at the necks as 
at the cutting edges; this is, as seen, a free 
and open space. Referring now to the molo- 
bicuspis relation, it is shown that these sur- 
faces, which have been filed in a precisely 
similar manner, have fallen together, and so 
fallen as clearly to exhibit the impossibility of keeping them cleansed unless 
by a care that very few persons are found to give to the organs. Teeth so 
filed are cut only to their injury, unless, indeed, it may be that, by the act of 
cutting, such response is excited from the pulp as to eventuate in a resistive 
consolidation of the structure,-a result that it would scarcely be wise to 
anticipate, being certainly possible, but scarcely probable. 
Eburnification, or vitrifaction, the process by which exposed and irritated 
dentine becomes self-protective, has been described on a preceding page. An 
operator, before resting anticipations of the cure of superficial caries on the 
file, is to appreciate well the responsive efforts with which the manipulations 
are likely to meet. 
Fig. 114. SURGICAL CONSIDERATION OF DENTAL CARIES. 
249 
Soft Teeth and the File.-Teeth of soft character are perhaps never 
found so tolerant of the file as are those of more solid structure, and when cut 
not infrequently give way as by a process of invisible ulceration, just, indeed, 
as caries in bone, while so commonly cured through the relief afforded from 
operative means, will be seen at times and under adverse systemic influences 
to have had the little force which existed in them destroyed by the operation. 
This is the case with teeth where the pulp life, instead of reacting, succumbs 
to the irritation. 
Appreciating these conditions influencing the use of the file, our study 
may lead to an observation of examples illustrative in the direction. 
As a first of such examples, attention is to be directed to surfaces of 
contact between teeth of the two dentures. A permanent tooth manifest- 
ing expressions of approximal change and being adjoined by a tooth of the 
first set, which tooth exhibits itself in the relation to be a cause of offence, 
may, if such first tooth be not too sensitive, find relief by filing directed ex- 
clusively to the latter organ. The use of the file is here and there oftentimes 
made available as the approximal relations of the six-year molar and second 
deciduous are concerned, or as are related the temporary cuspis and a perma- 
nent bicuspis, or, still again, as the permanent superior incisores centrales and 
milk laterales are seen to be sources of mutual injury. Milk-teeth, it is to be 
recognized, may not, however, always be filed with impunity: in very irritable 
temperaments spasms might very readily be found to result from such an 
operation. 
Referring now to the six superior anterior teeth of the permanent set, it is 
to be recognized that caries attacking the approximal surfaces is not an infre- 
quent condition, being excited, in part at least, as has been suggested, not 
only by the lodgement of detritus, but by a motion attendant on the mastica- 
tory act, which motion abrades or cracks the enamel of these surfaces. 
To Discover Incipient Caries.-To discover incipient caries of the 
approximal faces of teeth in the very earliest stage is a matter of no difficulty, 
a waxed thread passed into the interspaces exhibiting roughness of the surface, 
or a sharp excavator demonstrating the existence of a process of softening. 
Teeth so conditioned, if reasonably hard and of such shape as to permit of 
self-sustaining separation, may be cut with the prospect of a permanent cure. 
If, on the contrary, the structure be soft, and if the relation be such that con- 
tinued separation is not to be secured, then it must of necessity prove the better 
practice to depend, at a period somewhat later, on separation by means of wedges 
and the clearing out and filling of a cavity that may ensue. In the interim, 
however, the disease is to be held markedly in abeyance by means of waxed 
floss silk passed frequently, by polishing with soft powders used as for dress- 
ing fillings, and by attention to every condition which may be recognized as an 
agent of offence. 
In filing or disking away incipient caries, inclined surfaces are always to 
be the aim. Such surfaces secured and maintained, the parts from necessity 250 
A SYSTEM OF ORAL SURGERY. 
are made self-cleansing; the act of mastication itself is made a cleansing one. 
Especially is this so where the denuded surface has been burnished and polished 
with that care which is as indispensable as the plane itself. 
The Falling Together of Filed Teeth.-To prevent separated teeth 
from falling together, it is requisite to secure at some position surfaces of 
abutment; such surfaces, when possible, are to be maintained at the necks 
of the teeth. An abutting surface is, however, in itself an ill, but it is the 
smallest part of a common ill combated. When the absence of abutment 
of the teeth at the neck does not allow of the sustaining points being here 
secured, it may be proper first to press the organs asunder by means of a 
wedge of wood as directed in the chapter on filling, and, having thus the 
enamel in front intact, cut, by means of a safe-edged separating file of convex 
face, a V-space the base of which looks into the oral cavity. The wedge 
removed, and the teeth coming together, it is plainly seen that only the enamel- 
covered edges left in front may impinge. 
The objection to the employment of a file, prevalent among the com- 
munity, has arisen from the fact of the instrument being used with so little 
judgment: perversions, both pathological and artistic, rather than good results 
being witnessed as too frequently the result of its employment: hence in 
reasonable data has this prejudice had its origin. Such ill, however, resides 
no more in the instrument of itself than does discord in the keys of a piano, 
and nothing in required but an intelligent touch to disabuse the minds of 
people of such prejudice. 
Sensibility and the File.-That sensibility of dentine and irritation 
of the dental pulp are frequently witnessed in connection with filed teeth is a 
fact too common to be-denied. Indeed, many sets of teeth have been rendered 
permanently useless from such results; but here error in judgment has influ- 
enced the operation. Another objection urged against separating has been 
thought to lie in chronic ulitis engendered by the pressure of ingesta. Teeth 
treated as exhibited in diagram, Fig. 114, could but result in such conditions; 
but the fault here, as in the example above, lies with the operator. 
Fig. 115. 
Fig. 116. 
Examples of Filing.-Fig. 115 represents four incisor teeth carious on 
the meso-approximal (palatal) faces from which the disease has been cut. The 
diagram shows two ways of filing, a is a space made directly between the 
teeth, affecting alike the front and back faces, b is done by means of a disk, 
a diamond reamer, or a pyramid of corundum, and concerns the palatal face SURGICAL CONSIDERATION OF DENTAL CARIES. 
251 
alone, c is a form of separation sometimes found advisable: it removes the 
centre, leaving impinging points both at neck and cutting edge. In the 
filing a the impinging point is observed at the base of the teeth. 
Fig. 116 shows the front faces of the same teeth figured in Fig. 115. It 
will be observed that, as the centrals are concerned, the front face remains 
untouched. 
Bicuspid and molar teeth related as shown in Fig. 117, the impinging 
points situated as exhibited by the cross-lines, are to find self-cleansing sur- 
Fig. 117. 
Fig. 118. 
faces after the manner displayed in the succeeding cut (Fig. 118). To so 
alter the faces of these teeth, a disk of half-inch diameter is used (see Fig. 
119). Fig. 120, after T. T. Chupein, D.D.S., shows several teeth, molars and 
bicuspidati, which are filed in the treatment of approximal caries after a man- 
Fig. 119. 
Fig. 120. 
ner that is not too highly to be commended. When engaged in dental prac- 
tice it was ever the habit of the author to place approximal faces in relation 
as here shown. It is the only proper way to prepare such teeth for the recep- 
tion of plugs, as will surely be made evident to every practitioner by experi- 
ence. The original relation of these cavities to each other is appreciated by 
a glance at the diagram. (See, for criticism, Contour Work.) 
A diamond reamer devised and presented to the profession by William G. 
A. Bonwill, D.D.S., has a large circle of admirers. This instrument does its 
work with thoroughness and rapidity. The pros and cons of separation claim 
large attention at the hands of the experienced. This book is to be under- 
stood as endorsing or condemning the practice according to the circumstances 
of its performance. CHAPTER XIV. 
DENTAL THERAPEUSIS. 
A carious tooth is to be saved through the character rather than by the 
quality of a plug. The expression of gold is one of compatibility with den- 
tine ; that only. It is a substance wholly without therapeutic meaning, save 
as such meaning lies in an ability to protect an exposed weak surface against 
external agents of offence. Teeth made up of solid, resisting stroma are well 
treated if invariably filled with gold. Preference assuredly is to be given this 
metal in instance of every individual case, ceteris paribus, where a plug is to 
show. It is also to be given where elegance and purity of expression come at 
all into consideration. In a word, it is desired to have markedly understood 
that the teachings of this volume favor the employment of gold as a tooth- 
filling material whenever and wherever not contraindicated. It is as well 
desired to have plainly expressed the view that fully one-half the operative 
dentistry of the day differs in no respect from a jeweller's work. 
Criticism.-To be able to fill a tooth solidly and beautifully with gold, 
especially as contouring is concerned, is to have achieved a very creditable ac- 
complishment ; it is not, however, to have learned anything scientific. What 
is done is not half so difficult as things being accomplished every day by 
workmen who think nothing at all of what they do. 
Operative dentistry is not special surgery: it is art, not science. In 
this respect Oral Surgery is of little relation with dentistry; that art being 
viewed as a profession whole in itself. 
Gold Inert.-Whoever would treat and fill a carious tooth in relation 
with the laws of surgery is to treat and fill it in relation with indications. A 
filling of gold is an inert filling; it does nothing but stop a hole. Removal 
of a thoroughly well-made plug of gold, which has remained in relation 
with a cavity intact for many years, is not apt to exhibit change in the 
parietes of the cavity; the part remains as when brought in relation with the 
metal. 
Other materials brought in contact with the parietes of a cavity in a vital 
tooth are found on removal to show changes ; these have stopped holes, they 
have as well worked therapeutically. 
Therapy in Filling .Material.-A first consideration, as reference is 
had to selection of a tooth-filling material, may be instanced as referring to 
thermal conductivity. With some, with a great many teeth, such 
252 DENTAL THERAPEUSIS. 
253 
conductivity means nothing; with others, a great many others, it means 
inflammation of a pulp. 
Gold is the most marked among the tooth-filling materials as a conductor. 
Where irritation is contraindicated the metal is not judiciously to be used 
except in combinations. Where a cavity is large or a pulp nearly exposed 
non-conducting substances are to underlie plugs made of gold; otherwise 
plugs are to be made of other materials. 
Teeth are met with where use of gold is unsuitable because of its den- 
sity ; a soft tooth filled with cohesive gold, the mallet having been used, is 
oftentimes felt by the patient as possessed of a stuffed feeling; the discomfort 
being so great as to compel removal of the mass. 
The opposite of gold, conductivity being considered, is gutta-percha. Judg- 
ment plays the one against the other. 
Soft teeth are most surely to be saved by a prophylaxis that considers a 
re-excitation of the calcific power lying in the dental pulp. Agents used with 
this intent, named in the order of the excitant quality possessed, are chloride 
of zinc, copper, tin, silver. The first named demands exercise of judgment 
and experience for its proper use. 
Recalcification.-To recalcify a tooth means to harden it. To harden 
the parietes of a cavity of decay means to render the tooth resistive of ex- 
ternal influences. Calcification arises out of judicious stimulation of a pulp ; 
over-stimulation changes excitation to degeneration: defeats and perverts, 
consequently, the result of an intention. 
To judiciously use zinc chloride as a filling material is to possess 
measurement of the wants of the tooth to be filled. A majority of teeth can 
be recalcified. What, however, proves the equitable stimulation of one is over- 
stimulation to another. It is not to be denied that chloride of zinc has de- 
stroyed more pulps than it has calcified teeth. No rule resides in the manner 
of its use; proper employment of the agent lies in deductions arising out 
of experience,-and lies not, perhaps, elsewhere. 
In over-excitable teeth gutta-percha takes the place of the zinc chlo- 
ride ; or, in instances, the floor of a cavity may be covered with the gum or 
with a layer of oxide of zinc, and the zinc chloride placed upon this. Where 
gutta-percha is used the red variety is to be preferred. 
Gutta-Percha.-Where gutta-percha is selected as a material for a foun- 
dation it is not infrequently to have advantageously incorporated with it fine 
filings of copper; or, otherwise, dust of the metal may be spread over the 
floor of the cavity and the gum used to hold it in place. Tin filings and 
sheet-tin apply admirably in the same direction. 
Oxide of Tin.-Oxide of tin, found in connection with all tin plugs, is 
a reliable medicament as the calcific process is concerned. Teeth from which 
the finest made gold plugs fall away by reason of secondary decay are restored 
to integrity through the use of tin. As a rule, all children's first teeth, and 
all soft teeth, are filled safely where tin is the agent employed. In many cases 254 
A SYSTEM OF ORAL SVROERY. 
the removal of gold plugs and the refilling of the teeth with tin-foil results in 
the preservation of a denture. After recalcification the tin may be replaced 
with gold. 
Progress of Secondary Calcification.-The progress of secondary 
calcification is to be measured by the occasional removal of a therapeutical 
plug. If it be found, in such examination, that the process is not advancing 
with sufficient sureness or rapidity, opportunity is afforded to remedy the 
default in the application. 
Electrical Disturbance.-Electrical disturbance is to have considera- 
tion. Viewing the matter apart from unsettled theories, it is undeniably the 
fact that a plug made of gold or of amalgam, more particularly of the former, 
quickly becomes imperfect at a point where metal, gum, and tooth associate. 
Where, in filling such teeth, dryness was secured, the explanation of the 
deterioration is to be assumed as lying apart from defect in manipulation. 
Such teeth are saved by making a neck plug of gutta-percha or of tin. 
Amalgams.-Amalgams made with cadmium as a component, when used 
in a tooth, induce a condition of the pulp analogous to albuminoid degenera- 
tion. On the contrary, admixture being made with copper the result is so 
peculiarly tonic that subsequent years will not unlikely show the pulp con- 
tracted to a thread; this arising out of the physiological effort, made by the 
organ, at calcification. 
Parasiticides.-A concluding reference is to be directed to the use of 
agents acting as parasiticides. No tooth is prepared for any, save a zinc 
chloride, plug until a fungus-destroying application has been made to the 
cavity to be filled. Teeth of loose structure most particularly are infected 
with parasites. These parasites are to be eradicated, for it is these which 
conduce much to leakiness, which leakiness, in its turn, has related with it 
the meaning of tooth or plug decomposition ; such decomposition being 
resultant of a battery made by the juxtaposition of two solids and a fluid. 
Creasote as a Parasiticide.-As a dental parasiticide creasote con- 
spicuously recommends itself. It is to be used with every plugging material 
save those containing zinc chloride, this last being an agent of the same import. 
A cavity thoroughly saturated with creasote is rendered clear of all parasites. 
The author desires to emphasize the importance of saturating a cavity with 
creasote before introduction of the filling material. 
Corrosive Sublimate.-Objection, out of any reason, lying with the 
use of creasote in the mouth, corrosive sublimate, two grains to the ounce of 
water, may be employed. (See poisonous quality of.) CHAPTER XV. 
THE ORAL FLUIDS. 
The principal fluid found in the oral cavity is the saliva. Other fluids are 
those coming into it from without, those regurgitated into it from below, and 
the secretions from mucous and associated glands. The oral fluids have to do 
with dental caries. 
Saliva.-What is known as saliva is a commingled fluid secreted by three 
sets of glandular bodies,-namely, the parotid, the submaxillary, and the sub- 
lingual glands,-while another association of the fluid, as it is met with in the 
mouth, consists of a substance known as mucus, which is furnished, in vary- 
ing quantity, by follicular glands lodged in the oral and pharyngeal mucous 
membrane. To see this latter, wipe the roof of the mouth, when it shows 
itself as dewdrop-like particles standing over the surface. Other admixtures 
of the fluid consist of particles of articles of food, cast-off epithelial scales, 
animal and vegetable parasites; these latter commonly in great variety. 
Type of Salivary Gland.-The type of a salivary gland is seen in 
a bunch of grapes: the tube of outlet corresponds with the branch, the indi- 
vidual canals with the stem of the fruit, the secreting cells with the fruit 
itself. The development of a gland begins with the canal, this sending off 
bud-like processes which find accommodation in a cellular blastema; cells, 
canals, and blastema comprise the bulk of an organ. 
Analysis of Saliva.-Analysis of true saliva is more or less an 
unsatisfactory proceeding, owing to the difficulty of securing unmixed speci- 
mens. In 1000 parts ordinary analysis yields in the neighborhood of 990 
of water and 10 of solid matter. A formula made by Dr. Wright gives the 
solid matter at 11.90, as follows: ptyaline, 1.80; mucus (and epithelium), 
2.60 ; fatty matter, .50; albumen (with soda), 1.70; sulpho-cyanide of potas- 
sium, .90; alkaline and earthy salts, 3.20; loss, 1.20. Variation of from 7 to 
12 is suggested by Carpenter as allowable within the health range. The 
quantity secreted daily by the healthy average man he approximates 
at 18 ounces. 
Saliva is normal or abnormal; the first state relates with health, the second 
with pathological conditions; to appreciate the latter requires understanding 
of the former. 
Parotid Secretion.-The secretion of this gland has a specific gravity 
of about 1.006; it is without viscosity, according to late writers, and con- 
tains in solution carbonate of lime, together with traces of chloride of potassium, 
255 256 
A SYSTEM OF ORAL SURGERY. 
bicarbonate of soda, and sulpho-cyanide of potassium. Magitot gives 95 to 98 
parts of water to the 100 against 2 to 5 parts of the solid substances named. 
The parotids secrete alternately, and from the fact of their excessive de- 
velopment in ruminant animals are to be esteemed the lubricants of the oral 
cave. Meal or dry bread put into the mouth excite these glands to vigorous 
action. This fluid seems to be variously acid, alkaline, or neutral as 
times and circumstances relate with it; it may be inferred to be the second of 
these when the carbonate of lime deposits against the molar teeth in form of 
tartar. Innervation lies with the fifth and seventh nerves, explanation exist- 
ing in .this of the profuse salivation found so commonly associated with oral 
operations. Influence of mind on glandular secretion finds a striking ex- 
ample in the parotid, violent emotion suspending elimination; the Indian 
method of discovering a criminal by means of rice held in the mouth is 
familiar. 
Submaxillary Secretion.-The secretion of this gland is markedly 
in relation with the process of insalivation, as witnessed by the excitation of 
its action when sapid substances are tasted and its almost total suppression 
during periods of fasting. Experiments made by Claude Bernard show the 
excito-motor to lie with the gustatory and chorda tympani nerves. The 
fluid of this gland while very clear is yet very tenacious. Excess of ptya- 
line affords a coagulable appearance under the influence of cold. Animals 
making use of the viscid principle, as example is furnished in the ant-eater, 
have submaxillary glands of large proportion. The secretion, according to 
analyses made by Bidder, contains 3, in 100 parts, of organic, and about 5, 
in 100 parts, of inorganic matter. No sulpho-cyanide of potassium is found. 
Sublingual Secretion.-This differs but in degree from the secretion 
of the submaxillary gland. A viscidity characterizing it is owing to the 
presence of ptyaline, which is proportionately greater than in the other. 
Accessory Parotid.-This is an associate gland related with the duct of 
Steno; its secretion is thought generally to correspond with that of the 
immediately preceding, and with that of the submaxillary. 
Claude Bernard performed the following experiment, which affords clini- 
cal demonstration of the difference alluded to as existing in the composition of 
the secretion from the different glands. First he effected an entrance through 
external incision into the oesophagus of a horse, extracting the food bolus as 
it descended from the mouth ; weighing this, he found that it had increased 
in weight elevenfold as a result of the saliva it had absorbed. A succeeding 
step was to tie Wharton's duct, with the result of finding that it required 
forty-one minutes to masticate what before had taken but nine; while the 
mass, when withdrawn from the oesophagus, was coated with a glutinous 
mucoid fluid, the interior being dry and friable; the increase of weight 
was only about three and a half. 
Healthy Saliva.-Healthy saliva is a slightly opalescent fluid, somewhat 
glairy, commonly alkaline; the meaning of it in the animal economy is both THE ORAL FLUIDS. 
257 
excrementitial and recrementitial. Whether, however, the latter office pertains 
alone to deglutition, or to this and to digestion as reference is had to starchy 
matter, does not yet seem definitely to be settled. Perhaps physiology will 
eventually decide that the parotid secretion pertains to the first office, the 
syrupy product of the submaxillary and the ptyaline of the sublingual to the 
second. Carpenter expresses the conviction that the most important action 
of saliva relates to preparing food for chemical influences to which it is later 
to be subjected. 
The organic matter found in the parotid secretion is coagulable by heat, 
by nitric acid, and by the sulphate of magnesia. In the case of the sub- 
maxillary it is not so coagulable. The secretion of the sublingual is so 
viscous that it is with difficulty its density can be ascertained by the are- 
ometer ; it is not clouded by exposure to air, contrary to that of the other 
salivas. Healthy saliva is characterized by the presence of a limited number 
of corpuscles. (See foot-note in chapter on Dental Caries.') 
Abnormal Saliva.*-Attention is required to be given the oral secre- 
* In Magitot's instructive and interesting work treating of dental caries reference is 
made to laboratory experiments on human teeth with the sugars, lactic acid, butyric acid, 
malic acid, cider, carbonic acid, albumen and albuminoids, alum, oxalic acid, and the acid 
oxalates, acetic acid, tartaric acid, and acid tartrates, chloride of sodium and tannin. The 
experimenter directs attention to the fact that the teeth selected were from adults, and that 
they were perfectly sound, with the exception of a few taken intentionally showing a be- 
ginning more or less advanced of caries. In one group the teeth were absolutely free in 
the liquids; in the second they were completely coated with sealing-wax, having a single 
perforation over the enamel with a view of strictly localizing action of the liquid. These 
experiments are easily to be repeated by anybody; little, however, is gained from them as 
judgment is to be made up concerning vital teeth. 
Experiment 1.-Solution in water of cane-sugar, 1 to 3. Teeth placed and allowed to 
remain two years. Result: Teeth softened, blackened, enamel chalky, friable, and de- 
tached at several points, roots gelatinous. Certain of the teeth protected, except at single 
point, with coating of wax, showed at exposure alterations identical with the preceding. 
2. Same solution, with addition of a fragment of animal matter for the purpose of making 
fermentation more active. Result: Teeth so changed as to be unrecognizable. 
3. Same solution, with addition of a few drops of creasote, with view of retarding fer- 
mentation. Result: Teeth showed roots softened and brown without intense blackness of 
former experiment. 
4. A one-third solution of glucose placed in same condition, with addition of creasote. 
After two years, liquid had not changed in appearance. No alteration showed in the 
exposed teeth. 
5. Cold saturated aqueous solution of sugar and milk. After two years, fluid remained 
clear; no mouldiness or deposit; reaction perfectly neutral; no alteration in teeth. 
6. One-third solution in distilled water of cane-sugar filtered, and raised to the boiling- 
point, was placed in a flask and hermetically sealed in the flame, and left to itself for two 
years. A group of sound human teeth, weighed with the greatest care, had been previously 
introduced into the boiling liquid, and when weighed, after being washed and dried, proved 
to have undergone no loss nor any appreciable change. 
7. A solution of glucose under identical conditions gave the same negative results as to 
action on teeth. 
Lactic Acid.-1 gramme of acid to 1 litre of water (1 part to 1000). No change in 
teeth after two years of exposure. 258 
A SYSTEM OF ORAL SURGERY. 
tions during the continuance of general acute affections. Under the influence 
of pathologic conditions of this kind, pyrexiae, eruptive fevers, inflammatory 
2. Lactic acid 1 part, water 100 parts. Teeth exposed to this solution became gelatinous 
and reduced in volume; enamel chalky, friable, and changed to a brown color. 
Butyric Acid.-Solution, 1 part to 1000 of water. Enamel of exposed teeth green, white, 
chalky, opaque, and brittle. Roots were made penetrable by an excavator. 
2. Solution, 1 part to 100. Enamel removable without the least effort. General color 
yellowish. Roots softened throughout their extent and made flexible or gelatinous. 
Citric Acid.-Solution, 1 part to 1000 (1 gramme to 1 litre of water). Teeth exposed two 
years; were found enveloped in mammillated, whitish growths, composed of citrate of lime; 
deprived of enamel; roots softened; no special coloration. 
2. Solution, 1 part to 100. Teeth left exposed found completely deprived of enamel, the 
whole being converted into citrate of lime and deposited in bottom of glass. The teeth, 
thus reduced to their ivory and cement, had undergone no other apparent change, neither 
loss of substance; taken between the fingers they were found flexible, spongy, and gelat- 
inous. 
Malic Acid.-Solution, 1 part to 1000. Teeth exposed presented a complete opacity of 
the whole enamel layer, which was friable and chalky, but not removed from its position, 
nor detached from the surface of the dentine. 
2. Solution, 1 part to 100. Teeth presented same alteration in character with the pre- 
ceding, but with an intensity proportioned to strength of liquid. 
Cider.-Common Normandy cider used, acid malic. Injurious effect on teeth deduced 
from preceding experiments. 
Carbonic Acid.-Seltzer water used. 1 volume water to 5 of gas. Result: At the end 
of a week thin plates of ivory were found softened and flexible. Sound human teeth had 
undergone marked alteration in their substance, and a loss of weight to the amount of about 
a tenth; dentine of root could be pierced with a sharp instrument; enamel had become 
friable and chalky. 
2. A second experiment submitted preparations to a solution of carbonic acid exposed to 
the air,-that is, to equal volumes of gas and water. Result: Nil. 
Albumen and Albuminoids.-Solution composed of one litre of water to the white of two 
eggs well shaken in the liquid. Experiment lasted two years. Result: Teeth left freely 
exposed found to have undergone general and uniform softening; roots translucent; enamel 
friable and opaque. One tooth, protected with wax, except at a very resisting point of 
enamel, was found to show but slight alteration, this resembling the beginning of caries. 
Another tooth, exposed upon free edge deprived of enamel, showed softening of more pro- 
nounced character, which had resulted in formation of a cavity in the form of a deep cleft, 
with every characteristic of caries. 
Alum.-Solution, 10 grammes of alum in a litre of water. Experiment continued two 
years. Reaction clearly acid. Teeth left free in the solution not at all affected as to their 
roots. Enamel deprived of its glossy look, having become opaque; its disorganization was 
so complete as to offer the appearance and brittleness of chalk. 
Bi-oxalate of Potassa.-Solution, 1 part to 1000 of water. Result: Nil. 
2. Solution, 1 part to 100. Result: Enamel of teeth found opaque, friable, and easily 
reducible to powder. No change in eementum nor in dentine. 
Acetic Acid.-Solution of crystallizable acetic acid, 1 gramme to 1 litre of water (1 part 
to 1000). Experiment two years. Result: Nil. 
2. Solution identical with above, creasote being added. Result: Nil. 
3. Solution, 1 part to 100 (water 200 grammes, acetic acid 2 grammes). Experiment 
two years. Result: Teeth freely exposed exhibited, as the roots were involved, the altera- 
tions of softness, flexibility, yellow color; the roots being thinned lengthwise until of little 
greater circumference than common pins. Enamel undisturbed offered the curious appear- 
ance of crowns supported by pivots or pegs. THE ORAL FLUIDS. 
259 
diseases, phlegmasiae of glandular tissue, marsh fever, etc., Magitot most prac- 
tically and appreciatingly calls attention to the fact that there are produced 
by reflex action upon the mouth, immediate phenomena which are the 
suppression, more or less complete, of the salivary liquids, while at the same 
time the mucus is increased yet not less deteriorated. Glairy alkaline muco- 
saliva is a common associate of amygdalitis, acute or chronic, and is not infre- 
quently met with in general pharyngitis. A condition of this kind is assuredly 
adverse to the health of the dental organism, as the tenacious fluid not only 
bathes continuously the necks of the teeth, but invites and retains the debris 
of ingesta; to keep such a mouth cleansed is next to an impossibility. 
Sordes, a good name to apply to the incrustations about the teeth, is, un- 
deniably, a softener of enamel; removal of the incrustations, where of long 
existence, showing the parts of a dirty yellow, and altered as extent of cohe- 
sive force is concerned. Magitot attributes the dental change to the acid 
formed in the fermentation. 
Excess of Ptyaline.-Excess of ptyaline, combined as it always is with 
Tartaric Acid.-Solution, 1 part to 1000 (tartaric acid 1 gramme, water 1 litre). Result: 
Nil. 
2. Solution, 1 part to 100 (tartaric acid 2 grammes, water 200 grammes). Result: The 
teeth freely exposed showed no change on their crowns: the enamel was simply covered 
with a layer of crystals, but remained absolutely intact. The roots, without being generally 
softened, had yet undergone a real alteration in their substance; dentine had retained its 
color and translucency. 
3. Cream of tartar 1 gramme, water 200 grammes. Result: Nil. Magitot suggests that 
the peculiar action of the tartrates is to be regarded as a solution of the phosphates. As 
for the acid tartrates contained in wine, and especially in many kinds of fruits, it is to be 
esteemed as analogous to that of tartaric acid. 
Chloride of Sodium.-Solution, 1 part to 100 of water, with the addition of three drops 
of creasote. Experiment covering two years. Result: Teeth freely exposed underwent no 
alteration of their substance, except that they took on a darker color generally, which was 
intense at the roots. 
Tannin.-Solution, 1 part to 1000 (tannin of commerce 1 gramme, water 1 litre). Result: 
Nil. 
2. Solution, 1 part to 100 (tannin 2 grammes, water 200 grammes). Result: No effect on 
enamel; kept its polish, but was covered with a light deposit of a greenish coloring matter. 
Cementum showed marked softening; was easily penetrated by excavator; assumed a light 
brown color. 
In a r&sume, M. Magitot classifies as follows : 
1. Agents which act uniformly upon all the dental tissues; such are: the sugars by their 
products of fermentation; the lactic, butyric, citric, and malic acids; cider, carbonic acid, 
the products of putrefaction of albumen and albuminoid substances. 
2. Those which disorganize the enamel specially and exclusively, with formation of salts 
of lime, soluble especially in the acid liquors: alum, oxalic acid, and the acid oxalates. 
3. Those which act specially and exclusively on the dentine and cementum, with forma- 
tion of salts of lime, soluble especially in the acid liquors: acetic acid, tartaric acid, and the 
acid tartrates, tannin. 
4. The substances wholly without action on the teeth, as chloride of sodium, and gener- 
ally all other substances which may be met with in the buccal cavity soluble in water and 
the saliva with neutral or alkaline reaction. 260 
A SYSTEM OF ORAL SURGERY. 
perversion in follicular activity, furnishes the agent for cheesy deposits ; 
at the same time that which has affected the integrity of the secreting bodies 
has involved as well the health of the teeth. Caries, here, is simply a result 
of what may be called stasis in resistive force; if there were more acid, there 
would be more health ; a condition well expressed in typhoid fever, where pro- 
gressive deterioration in every direction finds its only check in the free use of 
agents which offset the super-alkalinity out of which the disease arises. (See 
Condition 4, chapter on Caries?) 
Unhealthy Saliva.-Salivary secretions, unhealthy in themselves by 
reason of a constitutional expression, are characterized by offensive!}ess of 
odor; to smear such saliva over a cold body, a common writing-slate being 
particularly adapted to the purpose, is to possess one's self quickly of percep- 
tion of an offence residing in the organic constituents. Such saliva is not 
wisely swallowed into the stomach without being disinfected. 
Saliva deteriorated by admixture with local sources of offence, as with the 
pus of abscess and ulcers, the detritus of decaying teeth, the chippings of 
tartar, the sordes of mercurial, typhoid, or scorb.utic deposits, is to find cor- 
rection by treatment directed to the offending cause. 
Saliva unduly Alkaline.-Saliva unduly alkaline is accompanied by 
excess in secretion; unduly acid, it is expressive of dyspeptic complications. 
Excess in salivary secretion is almost certain to be related with moist and 
decaying teeth ; limited secretion prognoses long life to the dental organism. 
A weak acid state of the oral fluids is infinitely preferable to a condition 
strongly alkaline,-the dental association being alone considered. 
Saliva unduly Acid.-Saliva unduly acid acts destructively on the lime- 
salts, of which the inorganic portion of a tooth is composed. Remedy lies in 
correction of the condition from the constitutional stand-point and in the pre- 
scribing of antacid washes. Acids sometimes found in the mouth, in 
association with saliva, are the acetic, carbonic, hydrochloric, nitric, sulphuric, 
malic, oxalic, lactic, citric, tartaric. 
Unduly alkaline saliva being expressive of sub-acidity of the blood, counter- 
medicaments are indicated. In this connection the author knows of no better 
treatment than is found in dilute hydrochloric acid prescribed in conjunction 
with sulphate of quinia and strychnia: 
U Quinise sulphatis, 
Strychnias sulphatis, gr. ss. 
Mix and make into pills No. xxx, using for the purpose extract of gentian. Of these pills 
one is to be taken three times a day. 
The acid is to be prescribed in fifteen-drop doses, repeated three times a 
day; the time of taking being intermediate to that of the first medicine. 
The parasites in such mouths find destruction through the evolution of sul- 
phurous acid after a manner suggested a few pages back; or, a bearable dilu- 
tion of chloride of zinc may be used as a wash: this last will destroy crypto- THE ORAL FLUIDS. 
261 
gamic fungus almost immediately. By treatment as just suggested the author 
has been instrumental in saving many a denture. 
Tests of Saliva.-The test for alkalinity consists of nothing more than 
the use of slips of turmeric paper employed at varying periods in the twenty- 
four hours : alkaline fluids turn this paper yellow. The conditions of alkaline 
oral fluids seem to depend on an excess of the phosphates of lime and 
soda. An ammoniacal smell in the saliva is indicative of danger to the system 
at large. In an alkaline diathesis the demand is for an excess of animal over 
vegetable food; this indication is not to be neglected. 
Acid conditions of the oral secretions find a simple test in the use of 
litmus paper ; this paper, which is blue, being turned red by contact with an 
acid. To secure therapeutical analysis of acid saliva, nothing more is required 
than that a given specimen be measured by its effect on lime-salts. To an in- 
definite quantity of the secretion is added a measured and weighed proportion 
of the salt; either phosphate, carbonate, or fluoride of lime being used. The 
saliva being evaporated after a given time, a sufficiently just estimate is to 
be made of its influence on the teeth; the resistance residing in vitality being 
taken into the account. 
Analyses of Acids.-Analyses of acids are made according to the ordi- 
nary provings of chemistry, which see. Sulphuric acid is to be presumed 
present where carious holes in teeth show a black surface. To directly test 
for this acid a solution of barium chloride is added to the saliva; if the acid 
be present a white precipitate deposits. This precipitate is not to be mistaken 
by reason of being insoluble either in acids or alkalies. 
Nitric Acid.-Nitric acid is peculiarly objectionable to tooth-structure; 
its presence in saliva is to be exposed by boiling with the suspected fluid some 
copper filings, red fumes being given off if the acid be present, and the liquid 
acquiring a blue color. Another test is to dip a piece of litmus paper in a 
weak solution of potash ; after this in the saliva ; if nitric acid be present the 
paper burns with deflagration. This last, however, is not so reliable a test as 
the former. 
Hydrochloric Acid.-Hydrochloric acid, objectionable in the mouth 
only when in excess, finds a simply applied test in nitrate of silver. To an 
indifferent quantity of the saliva a solution of the nitrate, sixty grains to the 
ounce of water, is added; if the acid be present its presence is shown by a 
white precipitate. This precipitate, which is a chloride of silver, is insoluble 
in nitric acid, but very soluble in caustic ammonia; it soon turns dark if left 
exposed to the atmosphere. 
Lactic Acid.-Lactic acid is an associate of gout, rheumatism, malarial 
fever, diabetes, and of general gastro-enteric derangements. A person, with 
decaying teeth, laboring under any one of these conditions is to have the oral 
fluids tested for the objectionable agent. The treatment is, of course, to be 
directed to the systemic vice. 
Accidental Substances.-Accidental substances found in the saliva 262 
A SYSTEM OF ORAL SURGERY. 
are uric acid, urea, urates, bile, milk, cholesterine, and albumen. The pres- 
ence of these is never disassociated from disturbance in the related organs or 
systems: treatment is to find direction accordingly. (See works on Practice 
of Medicine.) 
In prescribing for salivary conditions it is necessary that a practitioner dis- 
tinguish between local and systemic productions. Thus, for example, it is not 
difficult to understand that in a strongly alkaline mouth, with much soft 
caries present in the teeth, each cavity shall show an active corroding agent 
in the presence of sulphuric acid; this acid being evolved through the 
action of some existing agent on the albuminoid expression in which such soft 
teeth are rich. 
Carbonic Acid.-Carbonic acid serves as another illustration. This 
acid may be found existing in the fluids of the mouth to an extent markedly 
injurious to the teeth. Eight ounces troy is the medium quantity of carbon 
expired by a healthy man in the course of twenty-four hours. Indefinite is 
the amount that may be converted by the oral moisture into a corroding acid 
by the amount of oxygen therein intimately related with it. People inhabit- 
ing warm climates have better teeth than the residents of cold regions. 
The proportion of carbonic acid expired by the first is quite one-half less than 
of the other. Teeth decay in many instances very much faster in winter than 
in summer weather. Between 86° and 106° the carbonic acid set free in man 
is one-half less than when the thermometer marks the freezing-point. 
Conditions influencing Carbonic Exhalations.-Age, sex, de- 
velopment of body, state of health or disease influence carbonic exhalations. 
These relations are to be considered in connection with dental caries manifest- 
ing itself under the different conditions. 
Acid of Fruits.-The acid of fruits acts injuriously on very soft teeth 
alone. Where acids are freely used in this form frequent rinsings of the mouth 
with pure or medicated water will not be amiss. CHAPTER XVI. 
THE TEETH AND THEIR DISEASES. 
ODONTALGIA. 
Under this common head are to be studied the various pains in the teeth, 
however induced. The term comes from the two Greek roots, dSouq, a tooth, 
and az/o?, pain,-odontalgia, toothache, or pain in a tooth. 
The causes of toothache are to be classed under the following heads: 
1. Sensitive dentine. 
2. Direct or indirect exposure of the pulp to sources of irritation. 
3. A diseased state of the periodonteum. 
4. Confinement of pus and gas in a pulp-cavity. 
5. Granules of osteo-dentine in a pulp. 
6. Sympathy. 
7. Recession and absorption of the gum and alveolus. 
1. Sensitive Dentine.-Some teeth, immediately on the breaking down 
of the enamel and the consequent exposure of the dentine, become exceed- 
ingly sensitive; in other words, exhibit themselves as peculiarly susceptible to 
the influences of irritating agents. This impressibility is attempted to be 
explained by the most dissimilar hypotheses, few subjects connected with the 
teeth having elicited more discussion and controversy.* 
* An observation of the pulps of certain teeth which have been exposed to irritation in 
cavities unopened as well as open will exhibit the existence of fungoid excrescences. In 
experimentation it happened the author to open several teeth which had been partly destroyed 
by caries, the pulp-chamber, however, being intact; in two of these cases a magnifying- 
glass of very ordinary power exhibited thread-like excrescences of fibrilla-like appearance, 
passing in clusters from the surface of that portion of the body of the pulp adjoining the 
cavity of decay. These excrescences were in each instance of a pearly-white color, and 
might well have been likened to bundles of the delicate cobweb. It is suggested to the 
attention of the microscopist that it is possible that such excrescences passing into the 
tubular structure have been mistaken for nerve-fibrillae. Without qualification, however, 
the author believes that exception is to be taken to the doctrine that nerves pass from the 
pulp into the tubuli. It scarcely seems to need the microscope to demonstrate the correct- 
ness of such a demur. That fibrillae, however, are found in teeth of loose structure, being 
intertubular, may readily be received as a fact, but their origin is to be sought in the enamel 
membrane and not in the pulp. One explanation at least of sensitive dentine would seem 
to be found in the relation of the dentinal circulation to the pulp through the medium of the 
halitus of the chamber; this finds (at times) demonstration in the marked relief so commonly 
263 264 
A SYSTEM OF ORAL SURGERY. 
In organs thus sensitive, the operation of excavation is found occasionally 
so painful as to be quite unbearable, and is to be accomplished only through 
the employment of means that lessens such sensibility. Even sweets taken 
into the mouth, or cold or hot drinks, or acids, the latter particularly, will 
provoke pain in such teeth. Instances quite numerous exist where this 
dentinal sensibility is continuous, the pain being of a dull, annoying character 
existing quite independent of foreign agents of offence. In these latter cases 
the exciting cause is to be looked for in some irritative condition existing in 
the oral fluids: these may be too acid or too alkaline. Tests, however, 
are here easily made by the aid of litmus or turmeric paper. Specific remedies, 
accordingly, may have immediate employment; meaning by specific remedies 
whatever acts antagonistically to the agent of offence ; acids if the fluid be too 
alkaline, alkalies if it be too acid. 
As direct applications to teeth sensitive from the nature of their organi- 
zation, medicinal obtunders in great variety are suggested. Of these the 
most permanently effective is arsenic; this application, however, possesses 
an objection in ill results almost certain to accrue to the dental pulp which 
renders the use of it almost inadmissible; nevertheless, it is very frequently 
employed. 
Chloride of Zinc as an Obtunding Agent.-Chloride of zinc is a 
favorite preparation, and where used immediately preparatory to excavating 
a cavity is found commonly to answer most satisfactorily. In the employment 
of this agent, as in that of arsenic, care is to be exercised that such impression 
be not produced as shall unduly irritate the pulp. The application of the 
chloride of zinc is variously made. A common mode is to take a deliquesced 
preparation, dropping it, when it may conveniently be done, from the point of 
an instrument into the cavity, which cavity has been previously dried; the 
parts being protected from any inroad of moisture by means of napkin or dam. 
Another mode consists in employing a pellet of cotton saturated with the zinc. 
Still another manner, and the one to be preferred, is in using the 
crystals direct, a few of these being placed in a cavity and allowed to liquefy. 
This last plan is to be commended above the others. 
The almost immediate result of an application of zinc to a sensitive 
cavity is the production of quick, sharp pain ; this, however, commonly dis- 
appears in from one to two minutes, when, the sensibility being found ob- 
tunded by the action of the agent upon the superficies of the cavity, excava- 
tion may painlessly proceed to that extent of depth to which the salt has 
acted. Reapplications are to be made as found necessary, although it is to be 
recognized that the fewer one can get along with the better for the subsequent 
health of the pulp. 
gained through absorption from the cavity of all moisture, and the preservation of such 
■dryness during the process of cutting. That entire dryness in a dental carious cavity is 
among the best antidotes to sensibility has come to have such common practical recognition 
that a large class of experienced operators rely exclusively upon it. THE TEETH AND THEIR DISEASES. 
265 
Diluted Zinc.-Chloride of zinc in full strength obtunds immedi- 
ately the part to which it is applied ; diluted, it simply irritates and worries, 
increasing the very sensibility it is intended to destroy. Where the pain at- 
tendant on an application of the preparation is objectionable to the patient, it 
is to be in great part antagonized by a preliminary employment of a watery 
solution of cocaine; not less than eight grains to the ounce. 
Other Obtunding Agents.-Agents having no ulterior ill influence, 
and which frequently render all required service, are found in such prepara- 
tions as creasote, chloroform, an ethereal solution of the terchloride of gold, 
aconite, oil of cloves, London paste, nitrate of silver, glycerole of thymol 
used warm, etc. It is sometimes found that by sealing up in a cavity for one 
or two hours portions of sulphate of morphia, excavation may be accomplished 
with entire absence of pain. Cauterizing the cavity with a point of the nitrate 
of silver frequently answers the same end. A similar mode of treatment, the 
actual instead of a potential cauterant being used, is a suggestion by Dr. Stell- 
wagen, this operator employing a live coal secured by igniting the point of a 
hickory stick. A mixture of equal parts of tincture of aconite and a satu- 
rated solution of iodine is highly recommended as an excellent cauterant and 
obtunder. Still other obtunders are chloride of calcium, carbonate of potas- 
sium, and ethylate of sodium. A combination highly commended by Dr. 
Flagg is prepared by mixing up fifteen grains of carbonate of potassium with an 
ounce of glycerin; it is applied by means of a pointed stick or on a delicate 
pellet of cotton-wool. Another, a favorite application with many, is found in 
rubbing together equal proportions of sulphate of morphia and gum camphor. 
Still another is found in an eight-per-cent, solution of cocaine ; this finds 
much favor. The value of any of these agents is not, however, to be estimated 
without allowance for failures, a very little experience making evident the fact 
that what answers satisfactorily in one case proves of little effect in another. 
Sharp and Dull Burs.-A means of overcoming the difficulty which 
is perhaps more reliable than the employment of obtunding agents consists 
in using very sharp excavators or burs and by rapid motion making deep 
cuts which shall sweep the circumference of a cavity.* In acid mouths, 
* In a paper read before the Pennsylvania Odontologieal Society by Dr. Guilford, at- 
tention is called to the important fact that burs, used with the engine, are obtunders or 
producers of pain, according to their sharpness or dulness. The author alludes to the 
three forms manufactured,-the hand-cut, the stoned, and the machine-made; commending 
warmly the second, criticising severely the others. A dull bur he condemns as one that 
should never be used, and certainly the evolution of heat out of such an instrument in 
rapid motion might not be overlooked by the most careless. Recut burs are also exhibited 
as necessarily imperfect, for while a workman can sharpen them after a fashion, he cannot 
equalize the height of the teeth, some of which have been broken or been worn more than 
others. In order to enable his class at the Philadelphia Dental College to observe and dis- 
tinguish critically, Dr. Guilford has arranged an appliance and fitted it to the microscope 
in such a way as to bring a bur head into the field of vision, and there revolve it so that 
every point may be seen in a magnified form, as shown in the diagram. 
In examining the stoned bur (Fig. 121, Subfig. 1), the polished sides of the teeth and the 266 
A SYSTEM OF ORAL SURGERY. 
where the carious mass is mostly made up of semi-devitalized animal matter, 
such treatment commonly proves so satisfactory that on the removal of a 
clear and keen cutting-edges are to be noticed. Even the bottom of the furrows between the 
teeth is smooth and polished, enabling the bur thereby in the very best manner to clear itself 
in the act of cutting. This latter point is one not to be underestimated, for when a bur is 
in a condition to favor the retention of the debris in the furrows, these soon fill up and thus 
practically lessen the depth of the cutting-edges. The general appearance of the head of 
the stoned bur shows the care, skill, and labor necessary to its production. 
In direct contrast to this most perfect of cutting-tools, notice the ordinary bur (Subfig. 2). 
When this instrument is well made, the teeth will be of uniform height and shape, and it 
will be as perfect as the file can make it before tempering; but in the latter process, by 
Fig. 121.-Distinction between Sharp and Dull Burs 
Subfig. 1. 
Subfig. 2. 
Subfig. 3. 
Subfig. 4. 
Subfig. 5. 
the oxidizing of the metal, its entire surface is covered with scales, making it rough and 
irregular, where, before tempering, it was comparatively smooth. No doubt the file-marks, 
fine as they are, favor the retention of this scale upon the surface of the metal. It is 
perceived that not only are the furrows rough from this scale, but the cutting-edges are 
also made dull and uneven by it. It is easy to decide as to the relative value of the two 
instruments. 
In the recut bur (Subfig. 3), similarity is remarked to the new plain bur (Subfig. 2) so 
far as roughness from scale is concerned. Its teeth, however, are of unequal length, caused 
by some of them having been previously broken and their being filed to an edge in their 
present shape. This fact makes it one degree worse than the ordinary bur as a pain- 
producer. 
Attention is called to the worn bur (Subfig. 4). Some of its teeth are broken, while others 
are worn down so as to more closely resemble a burnisher than a cutting-tool. These worn 
and smooth edges, together with the irregularity of the teeth, make it an instrument that, 
by heating and thumping the tooth, would cause more pain and do less work than any 
other. It denounces itself as worthless. 
In the machine-cut bur (Subfig. 5), in addition to the scale, a general roughness, not only 
of the cutting-edge, but of every part of the furrow, is to be noticed. All its surfaces pre- 
sent the appearance of having been coarsely draw-filed. This is no doubt due to the rough 
face of the tool used in cutting them. It is als<* noticeable that pieces have been chipped THE TEETH AND THEIR DISEASES. 
267 
superficial horny layer all sensibility is found to have disappeared. The suc- 
cess of this manner of treatment does not, however, apply so happily in alka- 
line mouths or in the case of very hard teeth. Indeed, it may be said that 
with dense teeth zinc is the only agent yet known which invites any special 
reliance. Perfect dryness is to be associated with the cutting. Dry heat, 
or the chloride of calcium, applies. Dryness is depended on by many operators 
entirely and exclusively ; this is secured by means of bibulous paper conjoined 
with the use of a hot-air pump, which see. 
Sensibility of dentine is, at times, found dependent not on a strictly local- 
ized nor on a general hyperaesthesia, but on the existence of true inflammation. 
Here the indication suggests the treatment required for inflammation in gen- 
eral. Lead-water and laudanum applied freely on cotton-wool, both to cavity 
and surrounding parts, will commonly effect a speedy cure, particularly if 
aided by the use of cocaine, four grains of the hydrochlorate to the ounce 
of water, applied by means of brush. (See formula for Lead-Water and 
Laudanum.) 
Exposure of Pulp.-In directing medication to a sensitive cavity, it is 
necessary to distinguish between common sensibility and that depending on 
exposure of the dental pulp; note being made of the fact that the cornuae 
of this body are not infrequently met with making a very immediate approach 
to the surface. Such distinction, however, is generally easily enough made 
through the aid of an exploring instrument,-an excavator or nerve-plugger 
being used. If at any point there be exposure of the pulp, the touch of the 
or broken out of some of the cutting-edges. This is probably due to the hard temper of the 
bur and the lack of delicacy of the tool cutting it. Of the specimens shown in the diagram 
all are entirely new and have never been used, except, of course, the worn bur and the 
recut one; the latter has not been used since coming from the instrument-maker's hands. 
From examination of the diagram it is readily seen what qualities a bur should possess 
in order to commend itself to favor as a minister to a patient's comfort. In the first place, 
it is to be made of the best steel, and so treated as to give it the best qualities possible. 
Next, it is to be most carefully made, with keen, even, and regular cutting-edges, and per- 
fectly smooth furrows. It is to be well tempered and must be perfectly true. The tool- 
holder or hand-piece in which it is carried must also necessarily run perfectly true. 
In selecting burs an operator should use a magnifying-glass, in order the better to ex- 
amine the various points. Having succeeded in getting the proper quality and kind of burs, 
they are to be employed properly. For the excavating of living dentine a new and sharp 
bur is always to be used, lifting it frequently from the surface operated upon to prevent 
heating. The best results are generally obtained by running the bur rapidly. The tool is 
to be watched that it does not become clogged; an accident is less liable to occur, however, 
in a dry cavity than in a wet one. 
Another matter, hardly less important than sharpness in the bur, relates with the hand- 
piece that carries it. If this tool be not true, as pointed out by Dr. Guilford, the bur, in its 
revolution, will not describe a perfect circle, but, rather, an ellipse, by travelling in an 
eccentric way. The result of this would be that the head, in its motion, instead of touching 
the dentine all the while, as it should, would alternately touch and leave it, thus giving a 
series of raps or blows, productive of very decided pain. The operator might not be con- 
scious of these blows, but the patient would be, although, not unlikely, there might be 
ignorance as to the cause. 268 
A SYSTEM OF ORAL SURGERY. 
instrument cannot fail to distinguish it, as the pain induced by the contact is 
not found to apply to other parts of the cavity. 
Another condition of similar import exists where a cavity of decay so 
nearly approaches the pulp-chamber as to render each stroke of the instru- 
ment an agent of irritation. This condition is to be recognized in the depth 
of the common cavity, and in the tenderness being most associated with the 
deepest part. These cases require great delicacy in manipulation, as an in- 
advertent cut would most likely plunge into the substance of the pulp. 
Anaesthesia.-Etherization, as a means to enable an operator to excavate 
a sensitive tooth, is not infrequently, nor objectionably, resorted to; it certainly 
answers the purpose effectually, and where a patient is easily affected, as is 
occasionally found to be the case, a few inhalations inducing insensibility, 
there is no objection to its employment. Anaesthesia need not, of course, be 
carried to any profound extent. 
Subcutaneous Use of Morphia.-The administration, in hyper- 
sensitive cases, of morphia subcutaneously is a practice that an annoyed 
practitioner need not hesitate to adopt. To an adult from an eighth to a 
quarter of a grain, dissolved in ten or twelve drops of blood-warm water, 
may be given half an hour before commencing the excavation. Bromide 
of potassium answers also at times a reasonably reliable purpose; twenty- 
five grains to be given, by mouth, in a wineglass of water. Syrup of 
lactucarium is another agent not without virtue ; it is to be prescribed in 
tablespoonful doses. All of these means affect the local by diminishing the 
general sensibility. 
Sensitive Dentine and Odontalgia.-Viewing sensitive dentine as 
a cause of odontalgia, the operator finds his most satisfactory means of cure, 
as permanency is concerned, in the introduction of a filling into the cavity. 
A means resorted to, as a temporary treatment, is the excavation and pol- 
ishing of the surface. Still another means consists in cauterization, as above 
suggested, with the solid nitrate of silver, or the use of the various agents 
mentioned. A method-one highly commendable where the parts are 
very sensitive-consists in introducing into an unexcavated cavity a filling 
of oxychloride of zinc, the filling being allowed to remain three or four weeks, 
or even longer. Sensitive grooves, so often met with across the neck portion 
of the face of the teeth, are frequently happily obtunded by an occasional 
repetition of polishing the surface by means of a burnisher. ■ Such means, 
just here, is greatly to be preferred to the use of zinc. 
2. Direct or Indirect Exposure of the Pulp to Sources of 
Irritation.-Reference to the anatomy and relations of the dental pulp 
exhibits it as a body composed of the most delicate connective tissue, in which 
ramify nerves, arteries, and veins. This body is lodged in a bony cavity, 
sufficient only in size for its comfortable accommodation, and for the halitus, 
or fluid, which surrounds it. Any undue congestion will be perceived THE TEETH AND THEIR DISEASES. 
269 
therefore, at once, to result in a pressure, which, from the presence of nerve- 
matter, must cause acute suffering. 
A pulp need not, as suggested in connection with applications employed to 
obtund sensitive dentine, be fairly exposed to be the subject of irritation. 
Yielding Floors.-Cases not infrequently occur where the plate, or 
floor, of a cavity is so thin, and so altered in structure, that it yields or 
bends. In these instances the agencies of mastication may and do readily 
enough force the plate down upon the pulp. As a consequence of such 
pressure irritation and, not unlikely, inflammation results. 
Exposure of Pulp.-Irritation of a pulp is most apt, however, to be 
associated with exposure of the organ. Here everything entering the cavity 
is a source of offence, and the lesion is always plainly enough discover- 
able ; foreign particles coming in contact with such an exposed pulp give 
instant and perhaps excessive pain. This pain may quickly subside, or it may 
continue for hours or days; in the latter case, inflammation will be found 
to have established itself. 
A free and open break into a pulp-cavity is attended with much less pain 
in inflammation of the organ than are the limited exposures. In the first 
case, the swelling pulp has plenty of room, and consequently less pressure is 
exerted on the nerve-filaments. In the second, the protruding, congested 
organ becomes strangulated, and thus pain of an acute and severe character 
results. 
Treatment of Exposed Dental Pulp.-The treatment of an ex- 
posed pulp is of a twofold character,-palliative and radical. The first con- 
sists in the employment of soothing and quieting applications, and is employed 
principally for the relief of children. The second implies the destruction of 
the part; this being generally effected through the instrumentality of escha- 
rotic applications. To quiet an irritated pulp, attention is to be directed first 
to the removal of every source of offence. If the fluids of the mouth be irri- 
tative, the character of the condition must be appreciated and corrected. If 
foreign particles have found their way into a cavity of decay, they are to be 
carefully syringed away with warm water. Such attention may prove to be 
all that is needed. If not, and the excitability continue, recourse must be 
had to soothing applications: the tincture of hamamelis applied warm, or the 
oil of cloves, or creasote much diluted, or chloroform, aconite, and laudanum, 
in equal parts, will sometimes act very happily; particularly in such cases as 
depend on excitation unattended with inflammation. Where evidence of con- 
gestion, or vascular excitement of any grade, exists, lead-water and laudanum 
frequently acts like magic.* Persulphate of iron and tincture of iodine are 
found sometimes to serve very happily in similar conditions, constringing the 
* JJ Plumbi acetatis, gr. v; 
Tincturae opii, 3SS j 
Aquae, ^j. M. 
Sig.-Apply warm. 270 
A SYSTEM OF ORAL SURGERY. 
vessels, and thus breaking up, or aborting, as it were, the congestion. In the 
odontalgia of first dentition, it is well that parents be provided with some 
order of general prescription. A very good one is as follows, the obtunder 
to be applied by saturating a small piece of cotton and laying it loosely in the 
cavity: 
Creasoti, gtt. vj ; 
Tincturae iodinii, j 
Liquoris plumbi subacetatis, 3j > 
Chloroformi, 
Tincturae opii, aa 5ss. M. 
Such a prescription is suggested on the principle of Dewees's carminative, 
and is found apt to meet, in some one of its ingredients, the single or various 
indications that may be present. 
Cocaine is, without doubt, a valuable pain obtunder, and will, more than 
likely, be found to answer where the other fails; a good formula is as follows,- 
it may be marked " toothache drops 
|£ Cocaine hydrochloratis, gr. iv; 
Aquae rosae, ^j. M. 
Sig.-Apply to the aching pulp on softest cotton-wool delicately laid upon the part; also 
brush the surrounding gum with the medicine. 
Campho-phenique is a reliable application in this direction. 
Highly-Acute Pulpitis.-In severe inflammation of a pulp it may be 
necessary to conjoin with the directly local the indirect means of medication: 
blisters upon the nape of the neck frequently result in speedy relief; hot 
pediluvia; saline cathartic medicines, as the sulphate or carbonate of mag- 
nesia ; diaphoretics, as the spirits of Mindererus, or Dover's powder; or diu- 
retics, as the nitre preparations. An inflammation of the dental pulp, if not 
too far advanced, will almost invariably be broken up by the administration of 
from five to forty grains of bromide of potassium, the application of a mustard 
poultice to the back of the neck, and a hot foot-bath continued from twenty 
minutes to half an hour. Where there is relaxation of the vessels, tincture of 
digitalis or of ergot administered in conformity with the age of the child acts 
an admirable purpose. 
Sulphate of Atropia.-The atropiae sulphas is also to be relied on as a 
valuable agent in soothing, or obtunding, the pain of an irritated pulp. If 
severe inflammation have not supervened, and if the trouble be taken to 
syringe from the cavity any agent of offence, the instances will be found 
few indeed where this remedy will not afford almost immediate relief. 
U Atropiae sulphatis, gr. i ; 
Aquae destillatae, M. 
To be marked " poison" for safety, and to be applied precisely as the 
preceding combinations. THE TEETH AND THEIR DISEASES. 
271 
Irritating Fillings.-A cause of odontalgia from an irritated pulp fre- 
quently exists in the case of plugged teeth, from proximity to this organ of 
the material used in the filling. In these instances a constant irritation 
is kept up by thermal impressions induced by the presence of the metal. If 
inflammation supervene, the pain, because of the perfectly enclosed condition 
of the pulp, becomes of an acute throbbing and unbearable character ; 
relief is generally obtained by the removal of the filling; or, if that should 
not succeed, the pulp may be treated as shortly to be described. Where several 
teeth are in a state of irritation from such a cause, and confusion as to distinct 
location is thereby induced (as is not infrequently witnessed), the affected teeth 
can be made clearly to designate themselves by holding cold water in the 
mouth; or, what is even better, by touching each particular filling with some 
cold steel instrument. The increase in sensation will commonly be thus made 
very marked. An operator may frequently cure such teeth by removing the 
plug, and before reinserting it introducing between the filling and floor of the 
cavity some non-conducting substance,-a piece of ordinary quill, a particle 
of asbestos, a layer of gutta-percha, a portion of the Hill stopping, or a cap 
of platinum. Oxychloride of zinc prepared very dry is an admirable article 
to employ. 
Abrasion.-Still another source of irritation to the dental pulp is found 
in wearing down of the teeth. This is particularly observed in persons who 
use tobacco freely, or in such as have the upper and lower teeth directly articu- 
lating. Happily, however, in the generality of such cases, nature antag- 
onizes the external influence by depositing, in quantities as needed, secondary 
dentine within the pulp-cavity, at the same time contracting this organ, so that, 
in proportion as a tooth wears away on its cutting face, the pulp recedes, 
and casts out, for its protection, this secondary material. It is a beautiful 
and wonderful process of offence and defence, and commands unstinted 
admiration. 
Insufficiency of Reparative Activity.-In some cases, however, 
and these not a few, this reparative or protective power does not seem to 
exist; where this happens, the pulp, of course, soon becomes the subject of 
irritation. The writer has seen some of the severest cases of odontalgia result 
from such a cause. The only cure is found in the destruction of the pulp. 
To apply arsenical paste under such circumstances (see Radical Treat- 
ment of Pulp), there being no cavity of decay, it will be sufficient to lay it in 
the cup-shaped depression commonly existing on the cutting faces of such 
teeth (the result of the more rapid wearing of the inner dental structure than 
of the outer enamel wall), keeping it in place with a covering of wax. When 
possible, however, it is much better, and more speedy practice, to carefully 
drill an opening into the pulp-cavity, and with a delicate needle pick the 
arsenic directly into the organ. The death of the pulp secured, the part is to 
be removed from its cavity by means of a barbed broach, and its place 
supplied later with gold or other material. Another mode of devitalizing the 272 
A SYSTEM OF ORAL SURGERY. 
pulp of such a tooth will be found described in connection with the setting of 
pivot-teeth (which see). 
Metals and Moisture.-Improper union of metals in the filling of a 
tooth is another not infrequent source of irritation to the dental pulp. Tin- 
foil is sometimes placed in the bottom of a cavity, and the operation finished 
with gold. In many instances (depending not unlikely on lack of solidity in 
the overlying plug, thus admitting moisture, or in loose wet tooth-structure, 
which would amount to the same thing) this combination produces a galvanic 
action, which, if not corrected, will quickly enough destroy a pulp. It is, 
however, to be accepted that such relation of metals is not objectionable in 
dense teeth and dry relations. 
Oxychloride of Zinc.-Still another source of irritation is the employ- 
ment, in cavities more or less in proximity to the pulp, of the preparation later 
described as oxychloride, or tooth-bone ; the chloride of zinc used in excess in 
the compound will not infrequently, within a very few hours after its applica- 
tion, produce an inflammation in the parts almost, if not entirely, uncontrol- 
lable. Few preparations require to be used with more judgment. 
A tooth so irritated is to have the filling removed, and perhaps it will 
always be found the best practice to finish the death of the pulp as speedily 
as possible. As a reverse to this, it is to be recognized that the use of this 
material, as has been explained, will sometimes be provocative of just suffi- 
cient irritation to excite the secretion of secondary dentine, thus proving 
the best practice that could have been pursued. Experience is to direct the 
practice. 
Irritation in Pulps not Exposed.-A pulp may give every evidence 
of being in an irritated condition where the osseous integrity of the tooth 
is perfect, or seemingly so. Here the cause may be still strictly local; on the 
other hand, it may be constitutional. Blows received by a tooth often result 
in such irritation. Atmospheric changes sometimes account for the 
condition. Pieces of ice brought and retained in contact with teeth' of 
loose structure are the frequent source of such trouble. Cracks in the 
enamel, induced from whatever cause, and permitting the impression of ex- 
ternal influences upon the dentine, is another explanation. In a constitutional 
direction, rheumatism is, perhaps, the most frequent source; after this, 
gout. Reflex or radiated irritability is a frequent manifestation. This is, 
perhaps, most observable in the hysterical female. In these cases no special 
practice may be directed. It is only necessary to discover the cause of 
offence, wherever and however situated, and, if possible, remove it. In the 
odontalgia of gout, dependence is to be placed on the exhibition of col- 
chicum; twenty drops of the vinum colchici radicis, three or four times a 
day, according to the urgency of the symptoms, may be given. In rheuma- 
tism there is, perhaps, no better combination than the following; adminis- 
tration, in the plethoric, to be preceded by free purging with a saline 
cathartic: THE TEETH AND THEIR DISEASES. 
273 
U Potassii iodidi, ^ss; 
Tincturae colchici radicis, ^ss; 
Extracti belladonnas, gr. vj ; 
Tincturae guaiaci compositae, 
Aquae cinnamomi, aa ^vj. M. 
Sig.-To the adult give a dessertspoonful three times a day in a little water; if it act too 
freely on the bowels, add opium q. s. 
Salicylate of soda is a popular remedy of the day for rheumatism; a good 
formula is as follows : 
U Sodae salicylatis, 3U > 
Syrupi limonis, §ij; 
Aquae, ^v. M. 
Sig.-Dessertspoonful in a little water three times a day. 
Functional Derangement of Stomach.-Functional derangements 
of the stomach as the origin of reflex, or radiated, odontalgia, are to be con- 
sidered. Any one who has ever observed the relationship existing between 
the pneumogastric and the third nerve, as manifesting functional stomachic 
derangement in the enlargement of the pupil of the eye, will be at no loss to 
associate the fifth and the ninth nerve. Pure neuralgia, as the term has com- 
mon signification, is a very rare affection ; an aching nerve will generally be 
found to have some lesion outside of a so-estimated idiopathic condition, and 
the lesion can generally be discovered by closely looking after it. 
Passing now to a consideration of the same conditions as reference is had 
to a tooth requiring to be filled, we will be impressed with the intelligence 
and observation which have enveloped the subject with the light of a large 
common and reliable experience. 
We consider first the condition of a tooth with the pulp-chamber 
nearly exposed,-a very thin lamina of dentine existing between the two 
cavities. A pulp in this state and relation has, as the result of its subjection 
to irritating influences, one of three sequelae. It may maintain, just as it 
normally exists, its integrity unaffected by the association; second, it may 
accept just that extent of stimulation which re-excites the formative capacity, 
increasing the distance between it and external relations by a secretion consoli- 
dating the overlying dentinal structure, and not unlikely attaching a secondary 
deposit between itself and the original boundary of its cavity; third, it may 
succumb to the irritation. 
Of the probable result in all such cases, a reasonable experience enables 
the observing practitioner to form a fairly reliable estimate. To contend 
that all pulps in such relation are to be saved is to maintain a very foolish 
fallacy. A dental pulp is a part of the general organic life with which it is 
related, and will be seen to have residing in it the impressions of the system 
at large. Thus, a first observation necessarily considers the state of health 
in the individual who may be the patient. As is found equilibrium in ex- 274 
A SYSTEM OF ORAL SURGERY. 
citability, with normal nutritional functions, or otherwise degenerative ten- 
dencies, so will it prove the experience that attempts to save dental pulps are 
responded to or defied. 
Founding the practice to be pursued in each particular case on an experi- 
ence that shall come of observation, if indeed it be not already possessed 
by him whose judgment acts from the foundation of a knowledge of the 
principles governing all such matters, the practitioner determines either on 
destroying a pulp and removing it, or on attempt to preserve it. This latter 
conclusion is always to have the benefit of any doubt which may exist in 
the mind of the operator, as it is never to be overlooked that a destroyed 
pulp signifies necessarily a tooth with a diminished vitality, which dimi- 
nution makes it a body more or less foreign to the parts with which it is in 
association. 
Destruction of Dental Pulp.-The destruction of a pulp decided on, 
the operation is to be accomplished as follows: Quiet secured, and anaesthesia 
existing by reason of the presence of the morphia, or the action of cocaine, the 
operator uses, of what is known as nerve paste, a portion corresponding with the 
requirements of his case ; a piece larger than the ordinary pin-head being seldom 
needed. This paste is dropped gently into the deepest part of the cavity and 
overlaid with a pellet of cotton, which cotton is made protective against ex- 
ternal influences by means of a solution of gum sandarach, which is dropped 
upon it from the point of an instrument, otherwise the pellet is to be slightly 
touched to the solution previous to being put in place. A very little experi- 
ence will demonstrate that it is undesirable to have the cotton too fully 
saturated,-an objection sure to exist if care be not taken to avoid it. 
Should irritability and pain be present, these are,'if convenient and possible, 
subdued before application of the arsenic by means as suggested on a previous 
page. Formulas for nerve paste are variously given ; the original, and a most 
excellent one, is as follows : 
Acidi arseniosi, 
Morphias acetatis, aa gr. x ; 
Creasoti, q. s. 
Sig.-A thick paste to be made; rubbing to be continued an hour. 
Menthol and cocaine are additions finding great favor with many at the 
present time: 
U Acidi arseniosi, gr. x; 
Morphias acetatis, gr. v; 
Cocaine hydrochloratis, gr. iv; 
Olei mentholis, gtt. q. s. for paste. M. 
Campho-phenique, in place of the menthol, as in the immediately preceding 
prescription, is used and recommended by Dr. J. F. Flagg. 
Care in Use of Arsenic.-The length of time that arsenic is to be 
allowed to remain in a tooth is found to depend on the structure of the organ THE TEETH AND THEIR DISEASES. 
275 
and the amount of paste used. A proper amount of the medicament is 
just that quantity necessary to accomplish the destruction of a pulp, and 
which, in such destruction, finds itself antagonized. As such quantity is not, 
however, to have accurate measurement, it is found necessary to consider the 
structure of each particular tooth in which it is employed. When this struct- 
ure is solid and close, there exists little objection to allowing the preparation 
to take care of itself. Where, however, it is loose, organic matter being in 
excess,-a condition made satisfactorily evident by a few cuts with an exca- 
vator,-the effect of an application is to be watched with a judgment which 
comes, perhaps, only of observation. A period which approximates a rule 
as to the time arsenic is to be left in the adult tooth is fifteen hours, although 
nothing is more common than to allow it to remain for twenty-four. The 
danger in excess of time lies in the passage of the agent through the foramen 
and tubuli, affecting thus the periodonteum. 
Action of an Arsenical Destructive.-That the action of an ar- 
senical destructive on a pulp in a tooth of loose structure shall be as direct 
and speedy as possible, it is desirable practice-where the touch is sufficiently 
delicate to accomplish the act painlessly-to freely expose the organ before 
making an application. Such exposure effected, the paste may be at once 
pricked into the part by means of a very sharp-pointed needle. By 
such an operation a pulp is to be destroyed almost without pain, particularly if 
cocaine be previously used as an obtunder, and it may be removed from its 
cavity within a period of time not exceeding fifteen minutes. 
London Paste.-London paste, made by mixing equal quantities of 
caustic soda and quick-lime into a paste by means of a drop or two of water, 
if applied freely, and directly, to a pulp will destroy it instantly. Use of this 
is also happily preceded by the cocaine solution. 
Many other means are suggested for getting rid of a pulp. Among these 
a plan in favor with bridge-workers consists in pointing and flattening a cedar 
stick and in driving this by means of a quick blow between the organ and its 
tooth-wall; a cocaine application is to precede the performance. 
Atmospheric Influences.-However, and with whatever care and 
propriety, a pulp may be destroyed, there are seasons in which a good result 
is attained only after persistent effort long continued. Periods of influenza 
are particularly of such relation. 
Recognition of the death of a pulp is found in the absence of a previously- 
existing sensibility, as made manifest by the touch of the exploring instru- 
ment. Removal from its cavity is effected by means of the barbed broach. 
3. A Diseased State of the Periodonteum. (See Periodontitis 
and Alveolar Abscess.} 
4. Confinement of Pus and Gas in a Pulp-Cavity.-When 
the dental pulp dies, decomposition is likely to follow. As a result of such 276 
A SYSTEM OF ORAL SURGERY. 
lesion we have two sequences: either the decomposed matter is gradually 
absorbed into the dental tubuli, and thus disposed of, as made evident in 
the marked opacity of the tooth, or it becomes a source of great irritation and 
offence to the surrounding healthy structures, periodontitis being provoked, the 
evolution of gas forcing the matter unduly into, and in many cases entirely 
through, the foramen. If inflammation of the alveolo-dental membrane do 
not result, then the trouble induced becomes of the ordinary neuralgic char- 
acter, the living nerve-filament at the foramen, still more or less associated 
with its continuation ramifying in the dead pulp, taking on inflammation, and 
thus irritability not only of these special filaments results, but the whole tri- 
facial tract is apt to sympathize. Some of the most severe and unbearable 
neuralgias situated about the various parts of the head have been quickly 
cured by discovering and treating the cause in a confined dead pulp. 
A case recalled by notes furnishes an example. The patient, a professional 
man, had been completely lost to self-control, or reason, for a period of three 
days, from the effect of neuralgic pain running between the orbit and dura 
mater of the anterior portion of the cranial cavity. In this case not the 
slightest complaint was made of any of the teeth. Examining the mouth 
in search for a cause, discovery was made of a half-carious and evidently 
dead lower bicuspid tooth, but with no connection between the cavity of 
decay and that of the pulp. Communication was effected by means of a 
spear-shaped drill, and in a single instant the patient expressed himself as 
being cured. Relieved of the pain, he fell into a sound sleep, which con- 
tinued some fifteen hours; the next morning he went about his duties as 
usual. 
Reflex Trouble from Dead Pulp.-Any portion of the head, throat, 
or associate parts supplied by the fifth nerve, or, indeed, by its related nerves, 
may be the seat of reflex trouble from a dead pulp. Thus we have odonto- 
gastralgia, odonto-cephalalgia, odonto-cardialgia, etc.; even sciatica has been 
cured by the extraction of a diseased tooth. 
A common practice in all such cases is to remove the tooth, or other- 
wise, if it be desirable to save the organ, drill an opening into the pulp-cavity. 
The relief experienced is generally instantaneous. 
A tooth containing a dead pulp is distinguished by a loss of trans- 
lucency when compared with its fellows, or in an opacity, exhibited by reflect- 
ing upon it, by means of a hand-mirror, the rays of the sun. 
Illustration in Practice.-A case illustrative of practice in this direc- 
tion finds example in a patient under the care of the author at the date of 
writing this paragraph. Mrs. H., a lady of delicate organization, suffered for 
a whole week with severe pain situated in the alveolar region overlying the 
superior incisor teeth,-the teeth, however, seeming not at all implicated. In 
the beginning of the second week of the attack the lady first presented her- 
self, directing attention to an elongation of the right central tooth, but which 
elongation, according to the statement of the mother, had always existed. THE TEETH AND THEIR DISEASES. 
277 
Examination of the mouth showed not the slightest discoloration or inflam- 
mation about the gums. The lateral incisor, however, was recognized to be 
slightly loose,-this and the continuous pain being the only expressions of a 
pathological condition. Diagnosing the existence of a dead pulp in this tooth, 
the chamber was entered by means of a spear drill applied to the palatal face. 
On opening the cavity at least a teaspoonful of pus escaped into the mouth. 
A treatment pursued, which eventuated in a cure that allowed dismissal of the 
patient after a very few weeks, was as follows: The quantity of pus de- 
monstrating the existence of a reservoir outside the tooth, an incision 
was made through the gum at the apex of the root, thus exposing the bone; 
to this bone was next applied the point of a strong bistoury, which being 
pressed forward was felt to pass through a shell and enter a cavity; out of 
this cavity issued a second volume of pus. Examination of the cyst exhibited 
it as capable of accommodating all the fluid that had escaped, while, further- 
more, absorption was seen to be progressing toward the right naris, into which, 
without doubt, sooner or later, the abscess would have discharged itself. The 
cavity, after being washed out, was injected with the ordinary officinal tinct- 
ure of iodine, a tent of cotton being inserted to keep the opening in the soft 
parts patulous. On the third day the pulp-canal of the tooth was filled with 
gold to its apex, great care being taken that no portion of the metal should 
be thrust through the foramen, which foramen, without doubt, was enlarged. 
Little by little the cyst, which was daily injected with the iodine solution, 
grew smaller and smaller, until it was in the course of a month obliterated. 
The inflammation in this particular case was decidedly of a cold, or chronic, 
character. Had it been acute, the tooth would have been found too painful 
to fill with so short a period intervening between the time of attack and opera- 
tion. One sinus, however, is always enough in an alveolar abscess; if 
this exist in the gum there can be no objection to filling the tooth as soon as 
the sensibility of the organ admits of the operation being performed. 
Splitting of Teeth by Confined Gas.-The splitting of teeth from 
expansion of gas confined in a pulp-cavity seems a matter of record too 
authentic to be doubted. A case having peculiar interest in such direction, 
published by Dr. J. H. McQuillen, is to be found in the pages of the Dental 
Cosmos, vol. xiii. 
5. Granules of Osteo-dentine in a Pulp.-In rare cases there 
is found to exist an irritability of the dental pulp which exhausts itself in 
the formation of isolated granules of semi-bonelike character, which granules 
obtain lodgement in some portion of the organ, and become, in turn, a source 
of great offence to the parts, resulting indeed frequently in an odontalgia 
than which there are few severer forms. To diagnose this condition is an 
exceedingly difficult matter. The manner of doing it is by exclusion. The 
teeth in these cases present every appearance of the highest health: no dis- 
coloration, no soreness on pressure, commonly no local pain; this last mani- 278 
A SYSTEM OF ORAL SUROERF. 
festation being situated in some distant part, as the ear, the eye, the scalp, etc. 
Whether, however, the pain be localized or diffused, it is always expressed by 
the patient as being of a nature entirely unbearable; it is generally more or 
less paroxysmal in character, thus being mistaken for idiopathic neu- 
ralgia, and frequently so treated. A case illustrative is at present in mind. 
During a session of the University of Pennsylvania, a student in the medi- 
cal department suffered from neuralgia so severely as to have been entirely 
incapacitated for study for a period of some three weeks. During that time 
he had tried all the ordinary remedies which had suggested themselves, 
without finding the slightest relief. The pain varied between the tuberosity 
of the superior maxilla and the ear. The teeth, about the part, were entirely 
sound and healthy-looking; there was apparently no local lesion; while, on 
the other hand, the physique of the gentleman was not at all of the neuralgic 
type. The writer was at sea with the case, until, after a day or two, there 
came to his mind an instance of innodular calcification of the dental 
pulp once seen, where the patient had suffered in about a like manner. Now, 
while not prepared positively to affirm that here was a second case of such 
condition, permission was requested and obtained to pass an exploratory drill 
into the pulp-cavity of the wisdom-tooth. The result was the finding of the 
pulp filled with granules,-granules of secondary dentine, as they are 
technically termed. The extraction of the tooth was followed by immediate 
cessation of all pain, and the patient was able to go direct from the operation 
to lectures. 
A marked case, where the lesion gives direct local manifestation, the 
pain being seated directly in the affected tooth, exists in the person of a pro- 
fessional friend. The gentleman may be said to be affected with a diathesis 
in this direction. More beautiful teeth than he possesses, or, rather, did pos- 
sess, are seldom seen; and yet, one by one, they take on this condition, ex- 
citing such maddening pain that, regardless of everything, he flies to extrac- 
tion for relief. In this way, within the past few years, he has lost all those 
of the upper jaw. 
The treatment for this form of odontalgia consists in drilling into the 
body of the affected tooth, and securing thus a cavity of retention, applying 
the arsenious paste as has been directed. There are, however, cases in which, 
under these circumstances, it seems impossible to effect the destruction of the 
pulp. Here nothing is to be done but extract the tooth or teeth. 
The subject of the changes which may take place in the dental pulp, being 
the result either of age or other circumstances, commands, necessarily, the 
attention of the surgeon. Much as physiologists differ with regard to the 
precise method of dentinification, says Mr. R. T. Hulme, M.R.C.S., in an ad- 
mirable paper on the Calcification of the Dental Pulp, yet all are agreed that 
it takes place through the agency of the pulp, and that, commencing on the 
apex and external surface of the formative organ, it then proceeds inward 
until the tooth acquires its prescribed form and size, and the dentine has THE TEETH AND THEIR DISEASES. 
279 
attained its normal thickness.* When this is accomplished, the formation of 
the tooth is completed, and the same arrest of growth takes place as occurs 
in every part of the body at the adult period of life. If the person enjoy 
good health, and the tooth remain free from injury or disease, the organ may 
continue for some time without any appreciable alteration, in either the hard 
tissues which enter into its formation, or in the pulp itself. Sooner or later, 
however, as years go on, a change takes place in the character of the nutritive 
process throughout the body. The proportion which the fluids bore to the 
solids in early or middle life is diminished, nutrition is accomplished more 
slowly, and the composition of the various tissues undergoes a marked alter- 
ation. There is a general induration of the parts, and a tendency to the 
deposition of ossific matter; ligament is converted into cartilage, cartilage 
into bone, the coats of the blood-vessels are often impregnated with calcareous 
matter, and the cartilage of the ribs becomes ossified. If we turn our atten- 
tion to the teeth, or, more correctly speaking, to the dental pulps, we shall 
find that they also are liable to a similar alteration of structure. When a 
section is made through an old tooth, apart from the changes which are to be 
noticed in the color and transparency of certain portions of the original den- 
tine, the pulp-cavity will be seen to have been greatly encroached upon, and 
the entire mass of the tooth increased in thickness, The extent to which 
this filling up of the pulp-cavity can take place is shown 
in the accompanying drawings. Fig. 122 represents a 
section of a fully-developed molar in early life, when the 
tooth has attained its normal amount of growth; while 
Fig. 123 represents a similar section of a molar tooth 
taken from an elderly person, and in which the pulp- 
cavity has become diminished to the extent of fully 
one-half its original dimensions. This change in the 
cavity of the tooth can only have taken place through the agency of the 
pulp, which, after a period of repose, must have returned to its original func- 
tion of calcification, and have added fresh layers of dentine to the inner 
surface of the tooth. 
Changes of Condition.-The teeth, as suggested by Wedl, are dis- 
tinguished at different ages by a diminution of the pulp-cavity, an in- 
crease of thickness in the cementum, and a lessening of that of the enamel, 
and of the transparency of the three dental substances; by the edges and 
angles becoming blunted, and the surface assuming a yellow tinge, etc. These 
distinctions are most striking in the teeth of old men. In the pulps of teeth 
in this condition is to be noticed a considerable diminution in the quantity of 
blood, the color of that tissue often passing into a brownish yellow, from the 
quantity of pigment deposited in it. Earthy salts, assuming the outward form 
Fig. 122. 
Fig. 123. 
* Dentinification is not, as deemed by Mr. Hulme, calcification of the pulp itself, the pro- 
cess occurs in a secretion by the pulp. (See Dentition.) 280 
A SYSTEM OF ORAL SURGERY. 
of the botryoidal corpuscles met with in the pineal gland, occur on the inner sur- 
face of the pulp-cavity and of the dental canal, and also deposited in groups in 
the substance of the pulp. An increased number of layers of cementum 
will be observed, though these are often concealed by the opaque, brownish- 
yellow color of the inter-corpuscular substance. In thin sections, the dentine, 
sometimes throughout, sometimes only in isolated spots, appears less transparent 
than natural, and the dentinal tubes become less distinct, and occasionally dis- 
appear in the dark-gray or brownish-yellow substance. These partial opacities 
of the dentine are manifested, even to the naked eye, by a speckled appearance. 
The enamel presents dark, reddish-brown spots, and, as well as the dentine, 
appears to have lost some of its elasticity, and to have become more brittle. 
Teeth subjected to sources of local irritation are frequently-indeed, it is 
rather to be said, are commonly-found responsive in the way of self-attempt- 
ing deposits. This subject is discussed in connection with filling and filing 
teeth, which see. In Fig. 124, after Mr. Hulme, 
is exhibited a tooth which, as may be seen, has been 
worn into a groove at the neck; in the pulp-cavity, 
antagonizing the groove, is seen a deposit of second- 
ary dentine. 
Re-formative Efforts of the Dental 
Pulp.-The re-formative efforts of the dental pulp 
vary from conditions as shown in 
the diagrams to the complete con- 
version of its substance into a species 
of dentine, so that it is often found, 
on cutting open a tooth long sub- 
jected to irritating influences, that 
the cavity commonly existing is 
occupied by solid matter. 
Forms of Secondary Den- 
tine.-A form of secondary den- 
tine occasionally met with is shown 
in Fig. 125. This diagram repre- 
sents a specimen described by Mr. 
S. J. Salter, and presented by him 
to the attention of the Pathological 
Society of London. In this case, as is seen, the mass is attached to the 
chamber-wall of the tooth. 
The tooth, as mentioned in Mr. Hulme's paper, was a central incisor which 
had been extracted from a woman on account of severe neuralgic pains, obvi- 
ously connected with one of the central incisors of the upper jaw. The pain 
was described as of a gnawing character, abiding, but not constantly severe; 
frequently amounting to a mere consciousness of the presence of the tooth, 
and at other times sharp and darting. In the former condition it was confined 
Fig. 124. 
Fig. 125. THE TEETH AND THEIR DISEASES. 
281 
to the region of the tooth; in the latter, it flashed up the side of the face, 
and through all the branches of the superior maxillary division of the fifth 
nerve of that side. Sudden pressure, or a tap upon the tooth, or a marked 
change of temperature, produced a considerable augmentation of pain. The 
tooth itself was sound, to all external appearance; it was somewhat elongated 
beyond its fellow, and was very slightly loose. The gum surrounding it was 
red at the edge, and a little swollen. When the tooth was removed, no 
exostosis was discovered on it; and, with the exception of some small patches 
of half-organized lymph, it appeared quite healthy. 
On making a vertical section of the organ from side to side, a small pear- 
like excrescence of dentine was found growing from the side of the pulp- 
cavity, so as to encroach much upon it, and occupying for a short space more 
than half its diameter. It was of an oval form, its long axis corresponding 
to that of the tooth; in color less opaque, and yellower than the neighboring 
tissue. 
The structure was of that irregular character which has been previously 
described as occurring in secondary dentine, which has arisen from the wear- 
ing away of some part of the tooth's surface. The removal of the tooth 
was accompanied with a violent paroxysm of neuralgic agony, but was 
followed by a total cessation of pain, and the cure was permanent. 
Nodular Dentine.-Masses of dentine-nodular dentine, as it has 
been named by Mr. Salter-occupying positions in the substance of the pulp 
are to be met with as among the causes of odonto-neuralgia, as alluded to on 
a former page. These nodules may be single or multi- 
ple ; the author has in his possession specimens in which 
at least a dozen are to be found in the same pulp. These 
nodules differ markedly in form. Dr. J. F. Flagg, whose 
curiosity has prompted him to the preservation of a large 
number of specimens, makes an interesting classification. 
The author has to add a suggestion as to the fre- 
quency of their deposit where the syphilitic vice is 
present. 
Taking advantage of a cut at command (Fig. 126), a 
specimen is shown from the collection of Mr. Hulme, and 
which is thus described by that gentleman : 
Examination of Secondary Dentine Deposits.-The decay ex- 
tended to the pulp-cavity, and the median third of the crown was more or 
less affected by caries. The tooth was then broken open and the pulp ex- 
amined. It was of a pinkish color, and somewhat more vascular than usual. 
On endeavoring to withdraw the pulp from the cavity, at the part which was 
directly under the carious portion there was found a solid lump of osseous 
matter as large as a canary-seed, and something less than a grain in weight; it 
was not adherent to any part of the inner wall of the tooth. On examining 
the remainder of the pulp beneath the microscope after the addition of a solu- 
Fig. 126. 282 
A SYSTEM OF ORAL SURGERY. 
tion of caustic soda, it was seen to be thickly crowded with rounded masses 
of dentine, but more opaque and of a different character to the dentine glob- 
ules of Czermac. The drawing represents the appearance presented by this 
portion of the pulp. 
Odontalgia from Pulp-Calcification. - No form of odonto- 
neuralgia is more severe and persistent than this arising out of pulp- 
calcification, a direction in which it has happened the author to see among 
his clinic patients quite a number of cases. The diagnosis is perhaps always, 
as has been suggested, difficult, and at times only satisfactorily to be settled 
by the extraction of teeth presenting more or less evidence of complication. 
The condition is more frequent than generally supposed, and is to have 
consideration in all cases of obscure neuralgia. Many interesting illustrative 
cases could be quoted. (See Neuralgia.} 
6. Sympathy.-Sympathetic toothache is most frequently found associ- 
ated with teeth having a common period of eruption. Thus, if attention be 
called to an aching bicuspis, and examination discovers the tooth to be in 
healthy condition, we will commonly find the primary lesion in either of 
the three fellow-teeth. If it be the first or third molar, or any particular 
tooth, that seems to be aching, the real seat of pain may be found in an asso- 
ciate organ. This is the first and most common relation of sympathy. Other 
and indirect causes exist in various directions, the most constant of such 
associations being, first, with the ear, second, with the uterus. 
Radiated Gastro-Odontalgia.-That odonto-otalgia, cephalalgia, gas- 
tralgia,-indeed, any reflex or radiated pain having origin in the teeth, but 
expressing its manifestation in distant organs, and vice versa,-may exist, is 
at once to be appreciated in a recollection of anatomical associations ; abundant 
instances are on record illustrative of such relationship. Thus, as an example, 
allusion is to be made to a suggestive case reported by J. L. Suesserott, M.D., 
of Chambersburg. The patient, Mr. J. G., an old man seventy years of age, 
applied to me, says Dr. Suesserott, with the hope of being relieved of an in- 
tensely painful tic douloureux through the extraction of two or three fragments 
of roots of the superior incisor teeth, all the other teeth and roots of the upper 
jaw having been long before removed. 
The suffering of the patient at the time of this first visit is described as 
of extreme character, a breath of air, the slamming of a door, or even an 
allusion to his disease, being sufficient to produce violent paroxysms. The 
irritation, although reflected, as it afterward proved to be, appeared confined 
principally to the superior and middle branches of the par trigeminum of the 
left side. The suffering had been so intense and long-continued that there 
was considerable swelling and tenderness upon pressure along the course of 
all the ramifications of the fifth pair. 
Feeling the case, continues the description, to be a desperate one, although 
not suspecting the causa morbi, I determined on an active and energetic THE TEETH AND THEIR DISEASES. 
283 
course of treatment. Directing my efforts to the removal of the existing irri- 
tation, and I might also say inflammation, I established an issue on the back 
of the neck, which, together with blisters to his temples, produced a consid- 
erable amount of counter-irritation. The external use of aconitine, and 
the internal administration of the citrate of iron and quinine in full doses, 
produced a marked alleviation; but just at the time when hope was the 
brightest, another severe paroxysm would fill us with disappointment, and 
almost compel us to declare that there is no virtue in medicine. 
A period of two weeks having been uselessly expended, together with no 
small amount of medicine and patience, the patient, as I was dressing his 
issue, happened to remark that 11 his stomach was not in fault, for that he 
could digest without discom fort pieces of meat as large as he could swallow." 
Those who have anxiously watched over an interesting and difficult case can 
enter into my feelings of congratulation, for like Archimedes, I felt I might 
exclaim, Eureka! Remembering the old maxim, toile causam, cessat effectus, 
I directed my efforts to the improvement of the patient's manner of mastica- 
tion and to the directing of a proper character of food, with the result of a 
speedy cure of his trouble. 
As an example of reflection in an opposite direction, a case may be cited 
from an interesting paper read by Julius Chesebrough, D.D.S., before the 
American Dental Association. 
I have met, says this gentleman, a case wherein a fine-formed young woman 
suffered for a year after the birth of her child with pain in her teeth, alter- 
nately with that of the uterus. This case was one that had perplexed the 
physician in charge, and was presented to the medical -society for advice. 
Being called on, and a statement of the case made to me, I at once suggested 
that the uterine derangement was a reflection from the teeth, and that these 
organs were morbid ones. There was some doubt expressed as to this being a 
correct diagnosis of the case, for the patient had no toothache before her labor, 
and the pain in her mouth was since that event. Suggesting that examina- 
tion be made of the teeth, a visit was paid, with the result of finding decay 
in the four posterior molars. Three of these were extf-acted without giving 
much pain, but while extracting the fourth-the left superior-it seemed as 
if the woman was contracting within herself, and suffered intensely from 
uterine disturbance. After half an hour, however, she was entirely free from 
pain. 
A case even more directly the opposite of the first example is mentioned 
in this same paper, in which a patient suffering from continual pain in the 
stomach was cured only upon the accidental treatment of a carious tooth,- 
the pain ceasing immediately upon the application of arsenical paste to an 
exposed pulp. A second time the same patient is reported as presenting him- 
self,-the pain, which was of similar character and location as in the first 
instance, finding again immediate cure in the treatment of a second diseased 
tooth. In neither instance was discomfort referred to the mouth. 284 
A SYSTEM OF ORAL SVROERY. 
Odontalgia and Associated Disturbances.-Of odontalgic asso- 
ciations with the various viscera, cases in variety could be cited, while pains 
outside the splanchnic cavities, as in the hip-joint, etc., have found relief not 
infrequently only in an attention directed to the teeth. In the chapter on 
neuralgia the reader will find the subject abundantly illustrated. 
To understand the matter of radiation, or reflection, of pain, consideration 
is to be given to the anatomical associations of the nervous structure. This 
considers the cerebro-spinal and ganglionic systems, and refers the reader to 
his text-books on anatomy and physiology. 
7. Recession and Absorption of the Gum and Alveolus.- 
When, for any reason, the gum falls below the enamel cap, the periodonteum 
and cementum become exposed to various sources of irritation. The odon- 
talgia thus provoked is seldom, however, acute or severe in its character, but 
only dull and annoying. The practice in these cases is generally most unsatis- 
factory, resulting, sooner or later, in a necessity for extraction. If the reces- 
sion be associated with acute conditions or with the presence of agents of 
offence, treatment directed to meet the indications may result very well; but 
commonly such recession is slow and chronic, and admits of no remedy. Medi- 
caments to neutralize or correct irritative conditions in the oral fluid are some- 
times demanded, and answer a very good end. Of such neutralizing 
agents, acids or antacids are employed, according to the indications yielded 
by the test-papers; generally lime-water in the one direction, and very dilute 
citric acid in the other. 
Treatment of Absorbing Alveoli.-A treatment for absorption of 
the alveoli consists in scraping the absorbing bone, precisely as is done in 
osseous caries. This is to be accomplished without difficulty by introducing 
between the neck of the tooth and gum the common lathe-shaped excavator, 
which, upon reaching the alveolus, is made to cut away the surface surround- 
ing the tooth. Dr. Riggs, of Hartford, recommends instruments especially 
prepared for the purpose, but any kind which is capable of meeting the indi- 
cation answers the purpose of the suggestion. Such an operation has, in 
theory, much to commend it; in practice, however, the benefit accruing is not 
by any means all that is to be desired. To receive good results from freshen- 
ing the alveolar edges one is to do the operation only where indicated,-a selec- 
tion which it requires much experience to make. To freshen the bone, as a 
majority of the cases is concerned, is to expedite the falling of the teeth. 
Undue Density of Dental Tissue.-A character of recession of the 
gums from about the necks of the teeth, or, to express it better, a condition 
in which the teeth are raised in their sockets, and where a cure is impossible, 
is found as the result of a growing density in the structure, in which the 
equilibrium of circulation between these organs and surrounding parts becomes 
so deranged that they are as foreign bodies, and the recession really implies a 
filling up of the alveoli by an osseous deposit with the object, on nature's part, THE TEETH AND THEIR DISEASES. 
285 
of their removal. In these cases the teeth will seldom be seen affected by 
caries, being dense to an extent which is cognizable to the naked eye. 
Abuse of Dentifrices.-Recession arising from the employment of 
non-soluble dentifrices is frequently to be met with. Such condition is recog- 
nized from the history of the case, from the presence of particles of the sub- 
stance of offence, and from the disease seeming to implicate the gum alone. 
Such cases have their cure, in withdrawal from use of the injurious agent, in 
the free syringing of the part with a medicated water,-stimulation being 
required,-and in effecting the contraction of the turgid gums by free bleeding 
secured through occasional scarification. (See Pyorrhoea Alveolaris.) CHAPTER XVII. 
THE TEETH AND THEIR DISEASES. 
PERIODONTITIS. 
The importance of the condition known as Periodontitis demands for its 
consideration, in a work on Oral Surgery, a special chapter. 
Synonymes.-Periodontitis, peridentitis, pericementitis, dental periostitis, 
as the condition is variously designated, implies inflammation of the membrane 
associating the root of a tooth with its alveolus. (See Periodonteum.) 
Periodontitis, like inflammation in general, may exist either in a condition 
of activity or chronicity. 
Acute Periodontitis.-The active form is most frequently found as 
an expression of direct local irritation; the chronic, as a result of systemic 
influences. 
Acute, or active, periodontitis, if not resolved, or aborted, has a history 
which associates it with parulis. The inflammation commences com- 
monly with a dull, heavy gnawing in the parts affected : this is the signification 
of simple vascular excitement. As the grade of the trouble advances, pain 
increases with it. The tooth seems to the touch of the patient to project be- 
yond its fellows, and really does so. Occlusion of the jaws gives pain, which 
pain so grows in severity that the whole attention of the patient becomes 
directed eventually to the avoidance of contact. Finally, when not arrested, 
the action goes on to a suppurative condition,-the state of abscess; 
and the pus, discharging through a sinus which it creates for its convenience, 
-generally opening upon the gum opposite the diseased point,-establishes 
the condition of parulis. 
Chronic Periodontitis.-Chronic periodontitis-subacute, as it might 
with as much propriety be termed-has a history markedly distinguishing it 
from the sthenic form: its causes are manifold. Mercurial ulitis is per- 
haps the most frequent. Scorbutus is a common cause; being abundantly 
expressed in every neighborhood where much pork is eaten to the exclusion 
of a mixed diet. Many cases have origin from the exanthems: of such 
causes scarlatina seems the most provocative ; rubeola follows this in fre- 
quency. The phosphoric impression, as seen in connection with people 
working in match-factories, is a cause familiar to most surgeons. Neuralgic 
associations certainly beget irritability in the periodonteal tissue, and, in caco- 
plastic states of the blood, may degenerate the nutritional changes. Rheu- 
286 THE TEETH AND THEIR DISEASES. 
287 
matism and gout, as toxical conditions, are frequently found from 
clinical experimentation to be the irritants supporting a resisting periodontitis. 
Uterine reflections, those particularly from the menstrual relation, are 
other causes. Age is a common cause,-old people losing their teeth by a 
degenerative condition of this membrane, which allows the organs to drop 
out; or the same result is found frequently to coincide with tubular consoli- 
dation of the fangs, the excess of nutritional work thrown thus on the peri- 
odonteum exhausting finally the capability of the membrane. Tartar is a 
common and frequent cause of periodontitis. 
Chronic periodontitis-existing as a primary form-differs diagnostically 
from the acute condition in the absence of a sthenic expression. The tooth or 
teeth affected grow sore, tender, and elongated, but the progress is so 
slow as not to make the offence of sufficient import to the comfort of the 
patient as to invite any vigorous antagonism, the expression commonly being 
that associated with the chronicity so frequently succeeding the acute form ; 
the parts are recognized to be in the state of disease, but the condition is 
sufficiently bearable to be endured. 
Combined Conditions.-The acute and chronic forms of periodontitis 
find constantly a combined relation. Thus, the constitutional agencies are 
found capable of provoking the active condition, while local offences, as 
instanced in salivary calculus, conjoin not infrequently with the chronic state. 
Chronic periodontitis, except as associated with the acute form of the 
disease, is not found to tend to parulis, but when degenerating to the forma- 
tion of pus, has the discharge about the neck of the diseased tooth or teeth. 
Common Cause of Periodontitis.-The importance and frequency 
of periodontitis rendering the condition one most necessary to be thoroughly 
understood, advantage may be taken of the present and succeeding chapters 
to direct attention to the subject in a required detail. 
First and most commonly, it is seen that the acute form of the con- 
dition depends on preliminary disease in the dental pulp, that organ, being in 
a state of profound inflammation, affecting the periodonteum by its continuity 
of relationship, or otherwise being dead, proving the source of offence by its 
post-mortem changes and influences. In any and every case of acute peri- 
odontitis which presents itself, whether exhibiting the first expression of a 
scarcely noticeable uneasiness, or the tooth being so elongated and tender as 
to render the slightest touch unbearable, attention is to be directed to the 
condition of the pulp-cavity. If this, as is frequently the case, be found 
open, and the pulp dead or absent, then it is at once-no evidence of other 
vice, either constitutional or local, being seen-to be inferred that the trouble 
is that of a sthenic, free inflammation, demanding for its relief common 
antiphlogistic medication. 
Abortion of Common Cause.-Where a pulp-cavity is found closed, 
the tooth being undecayed, or otherwise having in it a filling, a first indica- 
tion directs an opening into the chamber, no hesitation being necessary, as in 288 
A SYSTEM OF ORAL SURGERY. 
perhaps all instances where a tooth has become thus tender to the touch, the 
pulp, if not actually dead, will be found in such a state of congestion that its 
destruction has been insured. If, however, it be desired to attempt an abortion 
both of the pulpitis and periodontitis, the plan suggested of uncovering the 
organ will be the wisest that is to be pursued, as thus depletion is to be prac- 
tised with the most immediate effect, and medicaments may find direct appli- 
cation. Instances, however, offer-and these are much the most numerous- 
where the periodontitis depends on a preliminary operation in which the pulp 
of the tooth has been purposely destroyed and removed, its place being occu- 
pied by metal,-as in what we are to study as a root-filling. Here it is not 
unlikely the trouble depends simply on an excess of work thrown upon the 
periodonteum from the abstraction of the pulp life; or it may be that the 
tooth is unable to endure the thermal changes resulting from the presence of 
the filling material; or perhaps some particle of the pulp was not removed, 
which, disintegrating and decomposing into its gaseous elements, has provoked 
the inflammation through pressure upon the parts about the foramen; or, still 
again, it may be that a slight twist of the cotton or gold, or whatever may 
have been used to fill the root, has been forced through the foramen. The 
consideration of a condition of this nature calls always for the 
exercise of individual judgment aside from ordinary rules. If a pulp-cavity 
has been well and scientifically treated, it would scarcely seem necessary or 
desirable to undo what has been done; as having been properly done, with 
all collaterals considered, it is not to be esteemed that undoing and doing over 
would improve matters. We would therefore naturally consider the periodon- 
titis as the lesion, and consider this alone. If, on the contrary, there be doubt 
as to the perfectness of the operation,-if there be reason to infer that any 
portion of the pulp remains in the cavity, or that a twist of the filling has 
passed the foramen,-then a first indication lies in such direction. 
Tartar as Cause.-Accumulation of tartar provoking periodontitis 
would not be difficult to distinguish, and the indication for its removal would 
be self-suggesting. 
False Occlusion as Cause.-False occlusion, another cause of peri- 
odontitis, calls alone for its appreciation to an observation which considers the 
common articulation. A tooth which, from any reason, strikes prema- 
turely, is certain to succumb to the irritation if the offence be continued 
for any length of time. In such relation, the condition of newly-placed 
fillings is to be considered. A plug is never to afford the feeling of special 
contact. When a filled tooth becomes sensitive in its periodonteum, attention 
is first wisely directed to its articular relations; should the metal be unduly 
prominent, it will, most likely, be at once remarked through an indentation 
seen upon its face. Should such indentation not exist, the surface may be 
rubbed over with a little pulverized pumice-stone, so as to deaden it: the con- 
tact of the opposing tooth, if now it unduly touch, will distinguish itself by 
a polish produced. THE TEETH AND THEIR DISEASES. 
289 
Teeth unduly occluding from false articulation are to find remedy in 
the file or disk, which is to cut away from the unaffected organs (or, if seem- 
ingly necessary, from the one which has expressed the irritation) such portion 
as shall remedy the defect. 
Escharotics as Cause.-Still another cause of periodonteal inflamma- 
tion, not infrequently met with, exists in accidents arising out of the use of 
escharotics, which, having been applied to a cavity for the destruc- 
tion of the dental pulp, have escaped and fallen around the neck 
of the tooth. A similar result has ensued from application of 
caustics to the gum for the arrestation of mucous oozing, or of 
hemorrhage. 
Rubber Rings.-Still again has such inflammation been pro- 
voked by ligatures used with the rubber dam, or by forgotten rings 
of rubber tubing or thread. In Fig. 127 is exhibited a ringed tooth, 
where the cause of a defying abscess was discovered only after extraction. The 
relation of ring and tooth here shown is just as when removed from the mouth. 
Little by little the ring had extracted the tooth. Another case of like signifi- 
cation, where a forgotten ring, used with view to correction of an irregularity, 
had resulted in necrosis of all the superior anterior teeth together with the 
alveoli, was shown by the author at a clinic of the Oral Hospital. The ring, in 
this instance, made its appearance, after the damage done by it, in a fistule that 
formed in the myrtiform fossa of the left side. Little by little it had passed 
the length of the root, delivering itself finally by contracting off the apex. 
Wedges as Cause.-Still another cause of periodontitis-one happily 
likely to be of very limited duration-is found in the process of wedging. All 
teeth are made more or less sore through this manipulation, and the soreness 
expresses inflammation. Such wedging, however, employed in the mouths of 
old persons, or with those of bad constitution, may well result in necessity for 
medication, aside from the removal of the cause exciting the trouble. 
Treatment of Periodontitis.-Taking it for granted that any and all 
existing sources of irritation have been removed, an acute periodonteal inflam- 
mation, taken in time, may in nine out of twelve cases be aborted as follows: 
Pass a lancet several times through the gum down to the alveolus; let the 
patient hold water in the mouth, so as to prevent the formation of clot, and 
provoke free bleeding; so soon as the vessels and capillaries have disgorged 
themselves, paint the parts with tincture of iodine. The philosophy of this 
treatment is sufficiently evident not to need explanation. 
A routine plan, followed commonly by satisfactory results in incipient peri- 
odontitis, is as follows: 
Place the feet of the patient in hot water. Apply just in front of the ear 
a fly-blister the size of a silver dime piece, and upon the nape of the neck a 
second the size of a silver dollar. Administer internally twenty-five grains 
of the bromide of potassium, having combined with it five drops of the 
tincture of veratrum viride,-this combination to be repeated in four 
Fig. 127. 290 
A SYSTEM OF ORAL SURGERY. 
hours, if relief be not sooner obtained. Lance the gums freely with a very 
sharp lancet, and afterward keep cotton applied saturated with tincture 
hamamelis, or this medicine combined with lead-water. Paint repeatedly 
with a cocaine solution. This treatment, if all local cause of offence has 
been removed, will seldom fail in securing a satisfactory result. It is found 
well to retain the feet in the hot water until a patient grows faint or breaks 
out into a perspiration. In the plethoric, in addition to the above course, 
half an ounce of the sulphate of magnesia may be given in a gobletful of 
water. 
Arterial Sedatives.-The employment of arterial sedatives in peri- 
odontitis, as in an inflammation of any other part, is to regard the condition of 
the pulse, such medicaments being alone indicated in sthenic conditions, and 
acting here with an efficiency and influence sometimes quite magical. Of 
such sedatives few seem possessed of the virtue of veratrum viride. I 
am well satisfied that it is in very many cases all that is needed in the treat- 
ment. Hydrate of chloral is another of this class of agents highly 
commending itself. That it, however, possesses sedative qualities dangerous 
in extent is scarcely to be doubted. To commence its exhibition in doses of 
not over seven grains is to err on the safe side. 
Leeches.-As adjuncts, leeches are occasionally employed with great bene- 
fit. If the inflammation be associated with the lower maxilla, these may be ap- 
plied below the jaw; or, if objection be not made by the patient, they may be 
used directly to the gum. Great care is required that they do not escape and 
get down the throat. Salt water kills them. 
Blisters.-A very simple plan of treating incipient periodontitis, one 
which will frequently be followed by immediate relief, consists in making a 
minute blister upon the gum overlying the affected root, through an ap- 
plication of a saturated solution of iodine. Lead-water and laudanum, as 
used so commonly in general surgical practice, is found a valuable refrigerant 
lotion to an inflamed periodonteum. It is applied on a pledget of cotton 
placed between the gum and cheek. A satisfactory combination is as follows: 
U Plumbi acetatis, 3SS > 
Tincturse opii, ^ss; 
Aquae, §vi. M. 
Dry Cups.--Another and a most admirable plan of treating incipient 
periodontitis consists in the application of dry cups to the side of the 
face; this plan can scarcely be too highly .commended ; the author always 
resorts to it, in conjunction with a free use of cocaine applied to the gum, 
before employing more severe means. To apply a dry cup a common wine- 
glass answers every purpose. (See Dry Cups in chapter on Inflammation.) 
Shields.-To protect an affected tooth from contact with its neighbors, 
resort is to be had to a cap placed over adjoining organs. To this end, gutta- 
percha is commonly employed, being easy and instantaneous of application, THE TEETH AND THEIR DISEASES. 
291 
requiring alone that a piece of the material about an inch square be softened 
in a flame and moulded over the parts, a mouthful of cold water hardening it 
into the required resistance. An instrument, however, more 
delicate, is found in a cap of silver, as devised by the late 
Dr. J. H. McQuillen. (See Fig. 128.) Such a cap is 
quickly made by the mechanical dentist, he requiring alone 
an impression of the tooth or teeth proposed to be covered, 
and which is secured in a moment by pressing about the 
parts a small lump of softened beeswax, which, after a few 
moments allowed for hardening, is carefully lifted. 
Stimulating Medicaments.-An acute periodontitis resisting the vari- 
ous means here suggested, the attack increasing in severity, the surgeon finds 
himself compelled to abandon antiphlogistics, the indication being to advance 
the condition to the suppurative point quickly as possible. To this end, 
heating and exciting medicaments are required; warm water is to be held in 
the mouth, or a weak dilution of the tincture of capsicum may be employed; 
about a teaspoonful to an ordinary-sized goblet of warm water will be found 
sufficiently stimulating. The domestic application of a roasted split fig 
to the gum increases the heat of the parts and invites suppuration to the sur- 
face on which it is used. Pepper bags are much in favor for the purpose and 
are widely used ; these are prepared by enclosing pepper between little squares 
of linen cloth. Pursuing a natural course, periodontitis ends in the formation 
of pus and the establishment of alveolo-dental abscess, which see. 
Analgesics.-In conjunction with the means suggested great service is 
gained by the free use of obtunding agents. Cocaine hydrochlorate, six grains 
to the ounce of water, has a most soothing and sedative effect when used upon 
inflamed parts. Aconite is another of such agents. Chloral hydrate is still 
another that may be commended; it is used in proportion of one drachm to 
the ounce of water. Others are watery solutions of lead and opium, hama- 
melis, hydrastis, carbolic acid, campho-phenique, spirits camphor, belladonna, 
bismuth, phenol-sodique. 
Sialagogues.-Attention is to be directed to benefit lying with the use 
of sialagogues. Cotton saturated with sulphuric ether and placed between the 
gum and cheek is oftentimes found to break up an incipient periodontitis by 
reason of profuse salivary discharge provoked. 
Fig. 128. 
Metal cap. CHAPTER XVIII. 
THE TEETH AND THEIR DISEASES. 
ALVEOLO-DENTAL ABSCESS. 
Periodontitis, or inflammation of the alveolo-dental membrane (consid- 
ered in the previous chapter), when not resolved, has as its other termination, 
as there suggested, alveolo-dental abscess. To this condition, as a distinct 
one, attention is now to be directed. 
Alveolar, or alveolo-dental, abscess has, of course, the general 
history of inflammation and suppuration wherever situated in the body, having 
nothing peculiar to its history, except as special features associate with the 
anatomical characteristics and influences of the part involved. It is a condition 
in which a tooth, diseased to the suppurative point in its enveloping membrane, 
or periodonteum, is discharging, through some convenient orifice of exit, pus 
secreted by or formed in such membrane. 
Local Features of Alveolar Abscess.-The local features of alve- 
olar abscess are to be fully described in a very few words. At the apex or 
somewhere about the root of the affected tooth a degenerative 
thickening of the membrane occurs,-pyogenic membrane, 
as it is termed. (Pig- 129.) This membrane, a diseased 
condition of the part, becomes shreddy and stringy, failing 
to organize the lymph constantly exuded or effused by it. The 
degeneration of this lymph is pus.* As such membrane grows 
thicker and softer, and such pus accumulates, it becomes evi- 
dent that space and vent are necessities; thus absorption, 
through the pressure of overlying parts, is effected, and the 
matter, sooner or later, influenced in the direction it takes by 
the vulnerability of surrounding parietes, finds egress, giving 
generally that peculiar fistule in the gum, known as parulis, 
or gum-boil. The morbid process exhibited in an in- 
flamed root-membrane consists in the accompaniment of 
the hyperaemia by a hyperplastic state of the tissue-cells, these cells increasing 
not only in number but in size. In this change it is that we find the expla- 
nation of the shreddy periodonteum seen more or less markedly upon 
all abscessed roots. 
Fig. 129. 
Shreddy sac of 
tooth abscess as 
met with in den- 
tal parulis. 
* See views of Recklinghausen and Cohnheim regarding the origin and meaning of pus. 
292 TEETH AND THEIR DISEASES. 
293 
Hyperaemia.-A recognizable hypersemia is not, however, a necessity for 
the excessive proliferation of connective-tissue cells; hence it is that epulic 
tumors frequently have origin in such hyperplasticity of the odonto-alveolar 
periosteum where expressions of vascular change have never been observed. 
Pus in a Cavity.-The formation and confinement of pus in a cavity so 
obstinately closed as the alveolus of a tooth must necessarily inflict the severest 
suffering, and such pain is so constant an attendant of the condition, and is of 
such almost unbearable character, that any means calculated to abort 
or limit its persistence is to be hailed as a boon ; it is to be taken for granted, 
judging from observation, that this is the severest form of odontalgia. The 
condition of throbbing pain, however, is confined to the period intervening 
between the accession of the acute inflammatory attack and escape of the pus; 
the period, properly speaking, of periodontitis,-a period lasting from two days 
to ten. Abscess fully formed, pain decreases to soreness. The treatment 
of the perfected alveolar abscess is very simple, at least as the indications are 
concerned; it consists simply in breaking up of the cyst and sac, and the 
excitation of an action sufficiently vigorous in character to fill with granulations, 
of organizable force, the fistule. Indications met, a practitioner can do nothing 
more. 
Prophylaxis of Alveolar Abscess.-The appreciation of the pro- 
phylaxis of alveolar abscess considers a treatment of the acute periodonteal 
trouble, of which the suppuration is seen to be only a result. This was con- 
sidered in the previous chapter, leaving here little to add, except that if such 
means as were there recommended fail in securing resolution, more formidable, 
if thought desirable, are to be brought into requisition.* 
Abortive Treatment.-As periodontitis is so frequently found abortable 
by scarifying the gums freely and deeply, and, after the congested vessels have 
relieved themselves, constringing the parts by applications of strong tincture of 
iodine, so parulis can very frequently be anticipated by the following trifling 
operation : With a sharp scalpel make a slight cut through the soft parts at the 
apex of the affected tooth. Next take up a spear-pointed drill and pierce the 
outer plate of the bone, thus entering the cavity in which the sac is being de- 
veloped. Break up the sac, and, by means of a delicate tent, keep the wound 
patulous for a few days. Judgment is demanded, however, as to the time 
when such puncture is to be made; it is to anticipate the moment at which 
pressure from accumulation of pus commences. Done previously to this, more 
harm than good results. 
Fig. 130 furnishes a correct idea of the cyst to be entered. A is a perfo- 
rating bit used with the engine; B is an ordinary steel probe. 
Objections to Fomentation.-Exception is to be taken to the com- 
mon practice of ordering warm fomentations to the face in incipient abscess; 
* More formidable would apply to the free use of diaphoretics, diuretics, cathartics, and 
venesection. 294 
A SYSTEM OF ORAL SURGERY. 
such practice is objectionable, resulting not infrequently in scars which much 
deform a patient. If the practitioner should not desire to adopt the operative 
Fig. 130. 
suggestion offered, let him direct the application of a roasted fig or raisin 
directly to the affected gum; either of these will do equally well the work of 
the poultice. Leeches, general bloodletting, vigorous antiphlogistic medica- 
tion, any and every means that promises resolution, may come between the 
periodontitis and the abscess if deemed desirable. 
Anomalies of Abscess.-The anomalies of alveolar abscess, if such 
a term be applicable to conditions not at all infrequent, may perhaps be best 
studied through the medium of examples. A few are selected from the prac- 
tice of the author and that of others. If, happily, they serve to throw light 
on any obscure case at present perplexing some inexperienced practitioner, the 
trouble of collecting them will be repaid. 
A few years ago the author saw, in consultation with a Dr. B. of this city, 
Mrs. , who had been afflicted with a running ulcer at the apex of the 
chin for four years. During this period the lady had been under the care of 
some five or six different practitioners, and had twice been operated upon for 
supposed disease of the bone. 
Suggesting that the origin and cause of this fistule might be found in some 
diseased tooth, assurance was given that these organs had been most carefully 
examined, and that there was not an unhealthy one in the mouth. 
A superficial exploration seemed to verify the truth of the assurance. Not 
satisfied, however, by such examination, experiment was commenced by striking 
with a steel instrument each tooth separately; the patient thought that in the 
left inferior lateral incisor she experienced a sensation differing from that felt 
in the others. 
Placing her now in the full sunlight, rays were reflected over the teeth by THE TEETH AND THEIR DISEASES. 
295 
means of a hand-mirror; this test demonstrated that the incisor alluded to 
had lost its pulp,-it showed a slight opacity. 
Now convinced that the disease was dental abscess, it was predicated on the 
demonstration that an opening made into the affected tooth would discover 
the death of its pulp; this was done, and the part found as anticipated. The 
offending organ was extracted, some necessary local attention given the sinus, 
and the patient was well in a week. 
Comment on this case scarcely seems necessary, and yet it may not be 
amiss to suggest the explanation of the deceptively healthy appearance of the 
dead tooth. 
Discoloration of Dead Teeth.-When the pulp of a tooth dies, dis- 
coloration of the enamel is a common result, this discoloration being caused 
from absorption of the dead matter by the tubuli of which dentine is made 
up. Occasionally, however, the opacity is so slight as to be scarcely percep- 
tible, this depending on the dense character of the tooth,-not infrequently 
the tubuli being so occluded as to destroy their capillarity: the dead pulp is 
therefore not taken up. A very vascular tooth, having a dead pulp in its 
cavity, will soon be turned almost black. A tooth in which the death of the 
pulp has been sudden discolors always more markedly than where it 
has been preceded by a chronic inflammation, explanation being found in 
the absence of that renewal of the process of calcification which in the chronic 
condition is apt to occlude the tubuli. 
A dead tooth, however, can always be distinguished by the tests given. 
The pathology of this case is to be summed up very briefly. The death of 
the pulp provoked periodonteal difficulty. The inflammation, uncombated, 
resulted in alveolar abscess. The pus, after inducing by its presence the 
absorption of the bone, dissected its way under the soft parts down to the 
apex of the chin, where it discharged itself,-the abscess passed into the 
chronic stage; the annoying and formidable fistulous ulcer was of course, 
because of its character, rendered incapable of being healed by any directly 
local treatment, or that not addressed to the true seat of the trouble. 
In another consultation the writer saw a Miss B., a young lady, nineteen 
years of age. In this patient, a fistule in the very centre of her hard 
palate had existed for some two years, giving rise to great uneasiness (as it 
had refused to yield to much treatment), a cancerous cachexia existing in the 
family. The denture in this mouth was also so complete as not to have 
attracted observation, every tooth being perfect, with the exception of a single 
molar, which had a small filling of gold on its grinding face. The filling in 
this tooth was removed, and the pulp found dead. Extraction was resorted 
to, and in three or four days all discharge had ceased. On the sixth day the 
patient was dismissed cured. 
Abscess venting upon Cheek.-It is not at all uncommon to find 
the sinus of an alveolar abscess venting itself somewhere on the cheek. This 
is too frequently the result of inviting the matter to the surface by warm 296 
A SYSTEM OF ORAL SURGERY. 
applications made to the side of the face. When pus thus seeks the surface 
it is to be vented from the inside should such procedure be prudent. Experi- 
ence exhibits, however, that little objection exists to an opening on the outside. 
Scar is not apt to result if nature's manner of cure be anticipated by use of 
the bistoury. Care is to be taken not to wound the facial artery or the 
duct of Steno. 
A case having likeness with the examples just quoted is recorded by Pro- 
fessor Harrison Allen: A young man in whom the roots of a lower wisdom- 
tooth had been prematurely filled was attacked with acute periodontitis, osteitis, 
and maxillary periostitis. This was sufficiently severe to excite inflammation in 
the loose connective tissue between the mylo-hyoid muscle and the jaw. An 
abscess followed here, and the pus gravitated to form a collection about the 
hyoid bone, and from that point passed upward upon the face in the line of 
the facial artery. The abscess in addition pressed directly upward against 
the floor of the mouth, and caused unilateral glossitis, from the mechanical 
effects of which upon the organs of respiration the patient died. The duration 
of the extra-maxillary complication was but four days. 
Abscess associated with Wisdom-Teeth.-Abscesses associated 
with the wisdom-teeth pass sometimes in the direction of the parotid region; 
in these cases it is not uncommon to find the orifice of the fistule as low down 
as the clavicle, the unyielding character of the parotid fascia-a continuation, 
as it will be remembered, of the deep cervical-compelling this lengthened 
dissection. The writer has seen and treated cases of this character. 
Abscess and Maxillary Sinus.-A form of alveolar abscess, which 
may lead to false diagnostic premises, exists in cases where, from a relation of 
a diseased fang with the maxillary sinus, the discharge empties itself into that 
cavity, to be in turn voided into the naris. (See Diseases of Antrum.') 
Osseous Cysts and Abscess.-Another, and very curious, result of 
alveolar abscess is the formation of osseous cysts on the side of the jaw; the 
pus, instead of inducing the ordinary absorption, is provided for by the ex- 
pansion of the outer plate of the bone. These cysts give little or no sense of 
fluctuation or crackling on pressure. There is no appearance of surrounding 
inflammation; the soft parts covering them do not differ in any respect from 
the adjoining tissue. Such cysts, or tumors, generally associate with teeth in 
which the pulps have been destroyed and the fangs filled with metal; they 
form sometimes very rapidly,-that is, when compared with solid tumors, for 
which they may be mistaken. The author has treated them where the cyst 
had enlarged to the size of a half hickory-nut in a few weeks. This rapid 
growth is particularly diagnostic. The easiest treatment of such cyst is, 
of course, the extraction of the offending tooth; but cure is to be obtained by 
opening them transversely and stuffing the cavity with lint saturated with 
tincture of iodine, or other stimulant; the cyst is thus obliterated, and the sac 
at the end of the fang destroyed, through the healthy reaction which the 
treatment excites. These cysts are not to be confounded with the sub- THE TEETH AND THEIR DISEASES. 
297 
periosteal exudates frequently found overlying the site of diseased roots. 
Diagnosis lies in the use of an exploring needle. 
Mr. Smith, in illustrating a lecture on alveolar abscess, notices the following 
cases: 
A few years ago, he says, a middle-aged man asked his opinion about a fistu- 
lous sore which opened on the middle of his whisker of the right cheek. Mr. 
Smith introduced a probe, and finding that it came in contact with the fang 
of the last molar tooth of the upper jaw, persuaded the patient to allow him 
to extract it, on the promise that he should be well in a few days. On the 
tenth day the gentleman wrote, by post, to say that the discharge ceased the 
day the tooth was extracted, and that at the time of writing he was perfectly 
well. 
He relates also the case of a young woman who came under his charge at 
the infirmary, with a fistulous sore in the fore part of the throat, within an 
inch of the sternum. It had been discharging upward of a year. On 
probing it, the instrument could be passed in the direction of the molar of 
the lower jaw on the left side. On inquiry, the patient said that eighteen 
months before she had a tooth drawn, but the fangs had been left in the jaw. 
Afterward an abscess formed, which descended lower and lower until it 
burst midway between the sternum and pomum Adami. Mr. Smith extracted 
the stump, the sinus still discharged for a week, then it got well without 
other treatment. 
Mr. Smith alludes also to a case where a horse had been condemned to the 
knacker's yard, as being afflicted with the glanders, having a foul, offensive 
discharge of purulent matter from the nostrils, and being in the last stage of 
emaciation. A veterinary surgeon, finding that it could not masticate its 
food, examined the mouth, and detecting a carious tooth in the upper jaw, 
extracted it. The discharge ceased; the horse soon began to thrive, and got 
well. A cat belonging to the author has furnished a similar experience. 
Mr. Fleischman {British Medical Journal) relates the following example: 
Miss Rose S., a little girl, aged five years, had been troubled about three 
months with a constant, though not profuse, discharge of slightly-purulent 
mucus from the right nostril; it appeared to be the sequel of a cold. The 
mucous membrane, so far as it could be examined, was healthy, and there 
were no indications of any morbid growth. She was ordered a strong in- 
jection of gallic acid, and took, concurrently, small doses of the sesquichloride 
of iron. The only advantage she derived was that the discharge lost its 
purulent character; in amount it remained about the same, though the treat- 
ment was long persevered in and other local astringents tried. I suspected, 
says Mr. Fleischman, there must be some undiscovered local irritation. Not 
being able, on careful examination, to find anything wrong in the nasal pas- 
sages, I looked to the condition of the teeth, and finding the right upper canine 
carious, removed it. The discharge was much lessened the next day, and 
in the course of one or two more disappeared altogether. Mr. Fleischman, 298 
A SYSTEM OF ORAL SURGERY. 
although he does not seem to see that his case is simply one of alveolar 
abscess, but offers it as a good illustration of reflected irritation, truly re- 
marks that it teaches us that the fans et origo mail is not always just where 
we might expect to find it. 
The Nares and Alveolo-Dental Abscess.-The author has had, in 
his own practice, a number of cases where the pus of an alveolar abscess dis- 
charged itself into a naris; but the disease, in every case met with where 
the sinus passed in such direction, was associated with central incisor teeth. 
It is, however, to be inferred that other of the teeth might relate fistules, 
with the posterior aspect of the nares, dripping their discharge behind the 
veil of the soft palate. Many such cases are on record. 
The Wisdom-Teeth and AlveolO-Dental Abscess.-Abscesses 
of this nature are not infrequently associated with the eruption of the wisdom- 
teeth. The arch being too small to accommodate the advancing organ, it 
becomes, as a matter of necessity, an agent of irritation ; inflammations of the 
most severe nature are thus oftentimes provoked, inducing, too commonly, 
trismus and abscess. (See Trismus Dentium.') Abscesses from this cause 
generally discharge about the neck of the tooth; they may, however, void 
themselves in other situations, as, for example, upon the face or neck. A 
case illustrative comes this moment to mind: Dr. D., a medical gentle- 
man, suffered for some time with heavy, dull pain in the right half of his 
lower jaw, attributed to two of his teeth, much decayed, which teeth, how- 
ever, had been treated and plugged. Inflammation of a severe character 
finally developed, and, in defiance of all treatment, ran on to abscess, which 
abscess discharged upon the neck. The pus voided, relief, of course, was 
obtained. The sinus, however, continued to discharge, and at the time of 
consultation the ulcer had become a source of much annoyance as well as 
deformity. This case had been examined by various friends of the gentleman, 
and, while all pronounced it alveolar abscess, all associated it with the treated 
teeth. The removal of a developing dens sapientse, a single cusp alone 
of which presented, caused the fistule to heal in a week. 
Duct of Steno and Abscess.-A complication sometimes met with 
in abscess discharging upon the cheek, and of which it is most important that 
note be taken, consists in a relation of the sinus with the duct of Steno. 
Within the past few years the writer has met with several cases of this nature, 
and by the operation required for salivary fistula has been enabled readily to 
cure them after the failure of every device not entertaining an appreciation 
of such condition. It is to be impressed that such fistulas deceive in the very 
limited salivary discharge, this fluid being easily overlooked in its relation 
with the pus; experience leads to the inference that the opening into the duct 
is not infrequently of the most diminutive calibre. Where such a case is 
recent, it is proper to attempt a cure through the granulative process, trusting 
by such means to cover in the break of the duct. To accomplish this, no 
better means is to be employed than daily touching the parts with tincture of THE TEETH AND THEIR DISEASES. 
299 
iodine or with crystals of the chloride of zinc, it being of course understood 
that the dental relation of the disease has been previously cured. If such 
treatment fail, and this will be found most likely, then an operation becomes 
necessary. (See Salivary Fistule.') 
Discharge of Abscess through Dental Foramen.-Dental ab- 
scess not infrequently exists where the discharge is exclusively through the 
foramen of the tooth, that orifice being enlarged. The gums in these cases 
may be unaffected, affording no signs of disease, the evidence of the lesion 
being perhaps alone in a peculiarly disagreeable taste experienced by the 
patient. To cure these discharges, it may be all-sufficient to throw the re- 
quired injection through the canal of the tooth; but, should this fail, the 
method of entering the cyst through the alveolus is to be tried. To so enter 
such a cyst, a very delicate trephine is employed, or, what commonly answers 
every purpose, a spear-shaped drill may be passed through the outer plate. 
Incising the gum over the apex, the drill is simply to be rotated into the cyst; 
precaution, however, is to be taken that none of the bony particles be 
allowed to remain, adding their quota of offence. This is guarded against by 
the free use of a syringe. 
False Abscess.-An alveolar discharge, which may be termed false 
abscess, is met with frequently in association with alveoli into which salivary 
calculus is intruding. In these cases no difficulty is experienced in the diag- 
nosis ; the discharge is seen about the necks of the affected teeth, the gum is 
more or less puffy, and the irritating deposit evident enough. To cure cases 
of this kind it is alone necessary to scale or cut away the offending agent, 
and, after making a few incisions through the congested and debased gum, 
stimulate the parts by such applications as seem indicated. Few medicaments 
are more reliable in this direction than the dilute aromatic sulphuric 
acid, or this combined in equal proportions with the tincture of capsicum. 
It is found, however, not infrequently the case that the deposit has so destroyed 
the sockets of the teeth that no cure is possible outside of extraction. (See 
Salivary Calculus.') 
Chronic Abscess.-Chronic alveolo-dental abscess, resisting local treat- 
ment, is to be viewed commonly as of constitutional association. In persons 
who are laboring under the effects of a mercurial poisoning the cases are found 
most resistive; indeed, in many instances, it is felt to be useless to make any 
attempt to save the affected teeth, the organs being absolutely thrust from 
their sockets and falling into the mouth. Where not too loose, however, the 
gums are to be incised every few days in a vertical direction, and attempts made 
to resolve the turgidity and puffiness by paintings of the tincture of iodine 
and capsicum, alternated with washes of chlorate of pdtassium and cologne. 
g. Potassii chloratis, ^ss; 
Aquae Colonae, ; 
Aquae, ^vij. M. 
Sig.-Use many times daily, 300 
A SYSTEM OF ORAL SURGERY. 
Internally the chlorate of potassium may be employed in doses of fifteen 
grains, repeated three times daily. 
U Potassii chloratis, ^iij; 
Aquae, S^iij. M. 
Sig.-Tablespoonful as a dose. 
Another prescription is as follows: 
U Tincturaa myrrhae et eapsicii composite, ^j. 
Sig.-To be used as a rinse in the proportion of 5 drops to of water. 
Rheumatic Diathesis.-The rheumatic diathesis is to be recognized 
as at least a predisposing cause of alveolo-dental abscess, and one which at 
times forces itself on attention in treatment of the condition. As this toxical 
influence is recognized as having affinity with periosteal tissue, so there is no 
reason to doubt that occasionally it is the resistive agent in the cure of such 
conditions. A similar view will also be found to hold good of the malarial 
poison, and, indeed, it very well may be, of all the other toxical expressions. 
Not that it is to be affirmed that such poisons have necessarily, in all instances, 
a direct relation, but that, being depressant to the system at large, they antag- 
onize that reparative influence, without which parts may not restore them- 
selves; precisely, if an illustration be needed, as a venereal ulcer, however 
proper and vigorous the local treatment, may refuse to be made well until 
systemic influences are considered and antagonized. 
Gout in Abscess.-Gout is another constitutional predisposition to 
chronicity in alveolo-dental abscess, just as it is a frequent excitant to pulpitis. 
An abscess which refuses to respond to any direct medication yields, with such 
predisposition, to a few doses of colchicum. Defying abscesses of this nature 
are oftentimes found to give way to the alterative influence of a week at the 
sea-shore, or a trip to the mountains. 
Discharge of Pus.-In chronic abscess the discharge must necessarily 
continue so long as the periodonteum remains in its pathological state. It is 
therefore always necessary in association with any systemic treatment 
which it may be desirable to adopt, to break up the local lesion. To ac- 
complish this, no better means is to be employed than tearing the sac to 
pieces by means of a delicate, temperless excavator passed through the sinus. 
After such breaking up, the part is to be syringed daily with an aqueous or 
vinous dilution of the ordinary officinal tincture of iodine,-about half and 
half being a good proportion. Another most excellent agent is found in the 
chloride of zinc. Of this salt, a solution of three grains to the ounce of 
water may be employed, a tent of cotton being saturated and carried into the 
cyst, or, charging with a few drops the ordinary hypodermic syringe, the fluid 
may be thrown into the cavity. Other local medicaments are found in nitrate 
of silver, sulphate of copper, tincture of capsicum, permanganate of potassium, 
in the passage of the electro-galvanic current, in carbolic acid, in creasote, THE TEETH AND THEIR DISEASES. 
301 
in alcohol, et hoc genus omne. The indication lies in the direction of stimu- 
lation and the use of germicides. 
Abscess Discharging through the Pulp-Canal.-Where an ab- 
scess discharges itself exclusively through the pulp-canal, the very best 
plan of treatment is to make a counter-opening in the gum and proceed as 
directed for the abortion of the acute stage of the disease, using, besides this 
means, injections and tents until all discharge ceases; or, if objection exist to 
this, threads of silk saturated with the medicament selected may be carried into 
the canal. Another and better mode than the use of the threads is, however, 
to introduce into the canal a plug of gutta-percha, in which a hole is to be 
made of a size just sufficient to receive the nozzle of a delicate syringe. 
Thus directed and controlled, injections may be forced through the foramen. 
Any treatment, however, except that by the counter-opening, is seldom found 
satisfactory. 
Counter-Outlet.-A tooth having such discharge through its canal, and 
thus incapable of bearing a filling, may have such filling retained without re- 
sponse by making a counter-outlet through the alveolar wall. Such a treat- 
ment is frequently adopted with much satisfaction, affording success in saving 
the tooth where, without the puncture through the gum and bone, the cavity 
would not have endured the plug for half an hour. 
Improper Canal Filling as Cause of Abscess.-An explanation 
of chronic alveolar abscess where no medication can possibly avail is found 
sometimes in a twist of gold which has been thrust through the foramen 
in the act of filling a root. The writer has several times met with this cause, 
although never fairly appreciating it until exhibited by the extracted tooth. 
An alveolo-dental abscess related with scrofulous children will not 
infrequently result in necrosis of the surrounding process. A case of this kind, 
coming quite lately under notice, resulted in the loss of quite half of the right 
superior maxilla; while a second case, occurring in a mercurialized man, 
destroyed the whole bone. 
Malarticulation.-A chronic abscess is not infrequently found re- 
sistive of treatment as result of the mechanical cause of a malarticulation, 
which keeps the affected tooth continuously worried. This is an offence for 
which we are always to examine, as it is readily induced by changes which may 
have occurred from the inflammatory associations. Any single tooth, however 
healthy, striking in articulation before its fellows, will become thereby dis- 
eased. This is often enough witnessed where, in filling teeth, the metal has not 
been sufficiently dressed down, and is thus unduly impinged upon; such teeth 
becoming sore to the touch, even to the result, when the cause is not appre- 
ciated and removed, of fretting the part into abscess. 
Abscess, associated with temporary teeth, is always to be looked 
on with concern, irritability and excitability of the young jaw being so great 
that any addition to the excitation of the dentitional period is found commonly 
to prove more than the force of the parts can antagonize, thus resulting not 302 
A SYSTEM OF ORAL SURGERY. 
infrequently in extensive disorganizations. Should the disease in the 
temporary tooth have association with any of the exanthems, the immediate 
removal of the organ is made a necessity. 
Indeed, these infantile abscesses, how- 
ever associated, are never to be allowed to 
run on, but, if not speedily responsive to 
medication, should be cured by extraction of 
the offending tooth or teeth. 
Imprisoned Teeth. - Alveolar ab- 
scesses arising out of imprisoned teeth are 
occasionally associated with much obscurity in 
the diagnosis. In this direction the consult- 
ing experience of the author has brought to 
his acquaintance many curious illustrations. 
Figs. 131 to 135 furnish examples of im- 
prisoned teeth. Fig. 131 shows a condition 
of abscess not infrequent; not only in this 
instance does the seat of degeneration relate 
to the malplaced tooth (a), but, being long 
uncombated, it has enlarged its boundaries to 
such extent as to destroy the buccal plate 
and alveoli of three neighboring teeth. In a case like this extraction of all 
the teeth involved is only in anticipation of a result sure to be achieved 
by nature. It is, indeed, not infrequently the case that health in the parts is 
Fig. 131. 
Fig. 132. 
to be recovered alone through a process of scraping the bone. Fig. 132 shows 
a cuspid tooth (c) lying in the palatal process, a malposition threatening ab- 
scess at all times (6, 6, antra ; a, a, line of palate). Fig. 133 exhibits a cuspis THE TEETH AND THEIR DISEASES. 
303 
(a) in process of self-liberation through means of abscess. Fig. 134 displays 
an eye-tooth (a, 6) freeing itself after a similar manner. 
Imprisoned teeth, related as above, are commonly to be located by means 
of a bistoury passed through the 
soft parts and bone, as required. 
Cases enough exist, however, where 
a sinus of discharge issues from a 
lesion of distant situation ; here de- 
pendence is to be placed on a steel 
probe; one that is sharp-pointed 
and that can be bent to suit. 
Illustrative Case. - The 
history of a case of alveolo-dental 
abscess very lately under the care 
of the author is as follows. The 
patient, a gentleman of leisure, re- 
marked a soreness that commenced 
in the neighborhood of the left 
naris. The discomfort increasing, he applied to his dentist, under an impres- 
sion that the trouble was connected with the root of an incisor tooth. This 
organ being faultless, and no other cause offering itself, the case was allowed 
to take its course. Two weeks 
later inflammatory disturbance 
had progressed to the extent of 
abscess. A week later still the 
gentleman was in bed with a 
vascular disturbance which in- 
volved the whole side of his 
face; the discharge reasonably 
profuse without abatement of 
discomfort. This condition ex- 
isted for a month, when fungoid 
proliferations projected abun- 
dantly from the now widely- 
extended mouth of the sinus, 
giving rise to a fear of malig- 
nancy. The trouble was cured 
by the discovery and removal 
of an imprisoned tooth lying 
upon the nasal floor. 
Another history is as 
follows. A lady consulted con- 
cerning a discharge from the alveolar ridge, which had continued two years. 
Neither pain nor soreness attended. Examination revealed the presence of 
Fig. 133. 
Fig. 134. 304 
A SYSTEM OF ORAL SURGERY. 
osseous caries, but no evidence of any dental origin of the trouble. On opera- 
tion for the removal of the diseased bone the antrum was reached; from this 
cavity there dropped an eye-tooth. 
Still another case is as follows. A young lawyer was afflicted with a 
swelling of the lower jaw, which long had given both himself and his physician 
much anxiety. Later on inflam- 
mation resulted in abscess. Fig. 
135 shows what was discovered 
in the process of search after a 
diagnosis : a, molar tooth ; &, cyst. 
Another illustration still 
is well exhibited by Fig. 136. 
The patient, a gentleman con- 
nected with the naval service, had 
labored for a period of two years 
under much concern as to the 
meaning of a growing discomfort 
situated at the angle of his jaws. 
This culminated finally in abscess, 
for which many examiners failed to find a cause. A probe passed along 
the sinus met with an obstruction that felt like healthy bone; nothing resem- 
bling the touch of enamel was to be appreciated. The case was under treat- 
Fig. 135 
Fig. 136. 
ment two weeks before it was recognized that the trouble lay in a tooth 
developed upside-down. A cure was finally secured by chipping away the 
process at the point a and working to the situation c twist after twist of 
cotton, the swelling of which finally lifted the organ from its bed. The sinus THE TEETH AND THEIR DISEASES. 
305 
led to the extreme tip of the root, this being the only part that was uncovered. 
The cut, although designed for other purpose, shows the position and relation 
of the tooth accurately. 
Pus, Protoplasmic Degeneration.-As a principle involved in the 
treatment of abscess, it is required simply that the practitioner esteem, with 
view to treatment, that pus is protoplasmic degeneration,-matter breaking 
down because of an inability to organize itself into self-supporting tissue. What- 
ever shall afford or add needed force must prove the cure of the degeneration. 
To this end all deteriorative local causes of offence are to be removed. If 
a tooth contain a dead pulp, such pulp is to be extirpated; if it unduly strike 
its neighbor, such false occlusion is to be remedied; if irritation be kept up 
by subjection of the membrane to foreign agents of offence, as a habit of biting 
improper articles, cracking nuts, untying knots, cutting threads, subjection of 
the parts to rapid and great alternations of heat and cold, as in the use of 
ices and hot drinks, these and any other causes of offence are to have con- 
sideration. 
General Indications.-General indications are to restore healthy in- 
nervation, circulation, secretion, and excretion by such medication, hygienic or 
otherwise, as shall tend to allay irritation, increase plasticity through tonicity, 
and restore normal action. To such an end, besides the local medication which 
shall be required, resort, as indicated, may be compelled to the employment of 
specifics, nervines, alteratives, astringents, and antiseptics. In one sentence, 
we are to recognize and appreciate the indications, local and general, and to 
meet them. When this has been done, and yet a cure is not secured, the only 
remaining question is between the extraction of the affected tooth or teeth 
and the risk of such consequences as osseous caries or necrosis. CHAPTER XIX. 
THE TEETH AND THEIR DISEASES. 
THE PULP-CHAMBER AND CANALS. 
At this point is properly to be studied the treatment of teeth containing 
dead pulps; the association of the condition with periodontitis and with 
alveolo-dental abscess being fresh in mind out of relation with the two imme- 
diately preceding chapters. 
A pulp dead, and intention being to save the tooth, appreciation is to be had 
of the means tending to such end. The performance is one of full surgical 
import, demanding both skill and physiological understanding. It is, indeed, 
within the memory of the present generation when a dead pulp was synony- 
mous with the loss of a tooth. Now, however, it has come, happily, to be 
recognized that such attendant loss is the exception,-observation eliciting the 
fact that the almost universally associated destructive sequelae depend on the 
presence of the putrid mass in the cavity rather than on the fact of death of 
the organ. Death of a pulp is recognized in loss of translucency by 
the tooth containing it. 
With such understanding, the first step in the treatment of the pulp- 
chamber and canal is found to consist in the thorough cleansing of them from 
substance which has become foreign. 
To Remove a Dead Pulp.-To remove a dead pulp, the operator com- 
mences by creating an opening into the chamber, or in enlarging to convenient 
size one that may already exist ;* this accomplished, it is not infrequently the 
case that the part may be caught and lifted away with a pair of delicate finger- 
forceps. A more common mode of procedure, however, consists in the em- 
ployment of a barbed broach ; this instrument being passed into the canal, 
and, when rotated, catching and twisting into its teeth the organ, its withdrawal 
brings with it necessarily the structure. Fig. 137 represents such a broach, a 
variety of blades being shown adapted to a common handle. 
In attempting to remove a pulp that may be entirely dead, it is occasionally 
found that considerable pain attends the operation. This pain arises out of the 
manipulations. A broach thrust directly upon a dead pulp will necessarily 
have the impression carried to the living structure still in relation with it at 
* While the present chapter finds proper place in relation with the studies which here 
immediately precede it, the student will be advantaged if he defer its reading until he has 
familiarized himself with the more ordinary performances of operative dentistry. 
306 THE TEETH AND THEIR DISEASES. 
307 
Fig. 137. 
Fig. 138.-Nerve Extractors 
the foramen of the canal. A proper plan is to enlarge the open- 
ing to such extent as allows the introduction of the instrument 
between the wall of the canal and the organ. Delicately insinuated 
in this manner, the rotation being commenced only when the instru- 
ment has reached the bottom of the canal, a pulp is commonly to 
be removed without even discomfort. 
Multiple-rooted Teeth.-In teeth having more than one 
root, it is generally found necessary first to extract the pulp of 
the chamber proper. This is to be effected through the use of a 
common excavator, simply cutting it away; the continuations occu- 
pying the canals are next withdrawn by the use of the broach, as 
described. 
Indication following Removal of a Dead Pulp.-An 
indication following immediately the removal of a dead pulp consists 
in such sealing of the emptied chamber and canals as shall 
prevent occupancy by foreign matter, whether from within or with- 
out. This embraces the process of preparation and filling,-a sub- 
ject to which attention may now be directed. 
Taking as a first example a tooth from which, after the arsenical 
application, the devitalized pulp has been removed, the operator is 
to consider that the surface of separation at the foramen of the 
tooth cures itself either by the process of immediate cicatriza- 
tion, or by granulative effort. Could assurance be entertained of 
the first result, then no better practice might be pursued than the 
immediate introduction of a permanent filling. As this may not, 
however, be the case, what is termed a test stopping is to be 
used. Disinfecting thoroughly the canal, or canals, as the tooth 
may be single or of several roots, using for such purpose plain 
water thrown forcibly into the cavities by means of a tooth-syringe, 
the test is to be made by preparing a delicate twist of cotton, which 
Nerve 
EXTRACT- 
OR, WITH 
HOLDER. 308 
A SYSTEM OF ORAL SUROERY. 
in length may double that of the tooth; this twist being moistened in a 
four-per-cent, aqueous solution of cocaine, in phenol-sodique, oil of cloves, or 
in glycerin, to which last menthol and iodoform in minute quantities are to 
be added. The cavity being made thoroughly dry by a free use of bibulous 
paper or by other means, the cotton is taken up with the point of a delicate 
root-plugger, and, being carried as deeply into the cavity as possible, fold after 
fold is forced upon the part first introduced until the space is solidly packed. 
The canal thus plugged, the chamber proper of the pulp and the common cavity 
of decay are to be filled either with white wax, with gutta-percha, or, what is 
found to answer most satisfactorily, a tuft of cotton which has been partly 
saturated with gum sandarach. (See Antiseptics.) 
Littlejohn's Flexible-shafted Bur.-This refined and admirable 
instrument, which consists of a bur of great delicacy attached to the extremity 
of a shaft of exceeding flexibility and strength, is found to follow a tortuous 
or irregular canal so entirely independently of any direction on the part of an 
operator as to completely obviate the possibility of drilling laterally through 
a root. The extreme apex of a canal is reached through its use without 
danger. 
A Temporary Canal Filling.-A manner of filling canals temporarily, 
which will commend itself, consists in employing the ordinary cotton wrapping 
twine of the grocer. A canal being cleansed, the thread, holding the antiseptic, 
is carried into the cavity, and packed precisely in the same way as the twist; 
an end being allowed to extend to the orifice of the common crown cavity, that 
thus the packing may be easily removed. 
Retention of Test Filling.-The length of time that a test filling is 
to be retained varies with almost every case. As a direction which may 
serve for a principle, it is to be remarked that when, after a single day, 
a closed cavity remains comfortable,-the patient affected by no consciousness 
of the presence of the tooth,-and when, on the withdrawal of the test, com- 
plete cleanliness is to be recognized in the absence of offensive odor, such a 
pulp-cavity is to be esteemed in condition to receive the permanent filling. 
Very often, however, it is found to happen that a test filling is so poorly en- 
dured that its presence for a single half-hour will develop symptoms 
of periodonteal irritability, the tooth becoming sore to the touch and sensitive 
to all impressions. Here we have nothing to do but remove the test and resort 
to required applications. Quiet restored, the cavity is to be loosely filled 
with cotton, or it may be left open, and allowed to rest until the irritability 
has subsided, when, a few days, or a week, having elapsed, the test filling is to 
be again tried. Campho-phenique finds here its best place. 
Continuous Irritability.-In cases where in single-rooted teeth irrita- 
bility is continuous, it is implied that a suppurating surface exists on the ex- 
ternal face of the root, and that the discharge, or oozing, finds its vent through 
the canal. In these cases, while the operator may, if he please, try stimulating 
injections forced through the foramen, trusting thus to find himself able to THE TEETH AND THEIR DISEASES. 
309 
break up the morbid action, a plan which is practised with much more satis- 
faction consists in the immediate permanent filling of the canal with gold, and 
the making of a counter-opening through the alveolus, such opening being 
kept patulous by the use of a tent of cotton. No better plan of treating a 
suppurating periodonteum is to be adopted than using injections through a 
counter-opening as thus made. 
Multi-rooted Teeth.-In the case of multi-rooted teeth resisting the 
test filling, trial is to be made until the particular fang diseased is discovered. 
Such information is quickly elicited by treating each canal separately. 
The treatment of an irritable root here offers itself for consideration. First, 
the cause of the irritability is to be appreciated. A common one 
exists in the unhealed condition of parts about the apical foramen. To jam 
against such a sore part cotton wet with creasote, carbolic acid, and perhaps 
rolled as well in iodoform, tannic acid, chalk, or other powdered substance, is 
to certainly increase a trouble it is the intention to avoid; doing too much is 
the fault. A well part does not need to be cured. An unhealed part, if pro- 
gressing favorably, needs simply to be let alone; the requirement of such a 
condition is protection, not medication. In place of filling such root or roots, 
as directed for ordinary cases, place as closely in contact with the sore part as 
possible particles of common zinc ointment; nothing is to be found that is 
more protective than this. A few days and the wound more than likely will 
be found cicatrized. 
A second common cause lies with irritability of periodonteal mem- 
brane, existing by reason of excess of nutritional work thrown on it. Here 
time alone can do good; nothing is to be done but wait; every extraneous 
source of irritation is to be avoided. 
A third cause lies with decomposing debris occupying the dentinal 
tubules; a source of trouble common enough to teeth of loose structure. 
Here indication points in the direction of antiseptics. Free and oft-repeated 
washings with water thrown forcibly into the canal by means of a syringe is 
a way to the end. Filling a canal with calcined magnesia, repeating the 
performance daily, is an admirable proceeding. Another means is found in 
a mixture of iodoform, yellow cinchona bark, and chalk powders; one part of 
the first, two of the second, and three of the third ; this, like the former, is 
used as a daily dressing until absolute cleanliness is secured. Still another 
medicament seen to be of value exists in a combination of zinci sulphas with 
bismuthi subnitras, the proportions being 3ss of the former to 3j of the latter; 
this is used precisely as the others. Creasote, carbolic acid, phenol-sodique, 
permanganate of potassium in solution, Watson's chlorinated water, iodoform 
rubbed up with glycerin, with oil of eucalyptus, or, with cacao butter, are 
alike agents used as disinfectants, and may be employed. Campho-phenique 
has commended itself particularly to the author. Peroxide of hydrogen is at 
the present time in common use by the best practitioners, being esteemed by 
many the most reliable of the agents of its class. 310 
A SYSTEM OF ORAL SURGERY. 
A canal thoroughly cleansed and an irritable one made quiet, common 
practice reapplies the test plug, and in this direction there is to be found 
nothing better than repetition of the cotton string or twist prepared and 
introduced dry as directed. 
Permanency of Quiet.-Assured permanency of quiet existing in a 
pulpless tooth, the filling of the root-canal is to follow, and is accomplished as 
follows. Take a sheet of gold (say, for illustration, No. 5); cut it into four 
strips. Take one of these strips, and, folding it once upon itself, run it into 
a spiral upon a broach or a common pin. Take now this spiral and carry it 
by means of a foil-carrier into the canal; if it has been solidly rolled, it may 
be forced at once quite to the apex of the cavity. Following the carrier with 
a root-plugger (Fig. 139), the spiral is condensed by forcing turn into turn, 
Fig. 139.-Nerve-Canal Pluggers. 
spy-glass fashion. Of the remaining pieces of foil, cylinders are to be made 
of such varying sizes as seem required for the operation. 
Gold in Root Filling.-Another method of using gold in root filling 
consists in taking a strip of heavy foil (say No. 20), and, cutting off a delicate 
thread, carrying it by a point to the apex of the canal. The plugger, fixing 
thus the initial extremity, is to be slightly withdrawn, and the thread, portion 
by portion, crimped upon itself until the canal is full. 
Cotton and Gold conjoined as a Canal Filling.-Still another 
manner of treating a canal, being that one which is most frequently practised, 
consists in filling first the apex of the canal with a twist of cotton which has 
been impregnated with creasote or oil of cloves. Upon this cotton gold is 
packed. To introduce the cotton, a twist is made, the initial extremity of 
which is to be of great tenuity. This initial end, or as near it as may be 
possible, is caught by the point of the root-plugger, and, being carried to the 
apex of the canal, the remainder of the twist is crimped upon it. Operators 
of repute are found whose commendation of the cotton plugs extends to the 
employment of the material for permanently filling the whole canal. Such 
free use, however, of so loose a material is not to be endorsed except for teeth THE TEETH AND THEIR DISEASES. 
311 
of solid structure. Gold is, without doubt, the very best material to be used 
in this direction, sealing as it does the cavity with an imperviousness which is 
the highest requirement in all such cases. A common fault with canal fillings 
of gold is that the operator fails in carrying the metal to the apex of the cavity 
or against the cotton, thus permitting the existence of a receptacle in which 
accidental deposits at once become foreign. This is worse than no filling. 
A canal being solidly full to the very foramen, any exudate that may occur 
must be associated necessarily with absorbent vessels which adjoin, no road of 
ingress into the tooth-canal being open. 
Gold forced beyond Foramen.-A source of disease equally to be 
guarded against exists in the accident of forcing a root filling into and beyond 
a foramen. This may occur only where the openings are enlarged, either 
because of natural condition or from absorption. Such an accident the prac- 
titioner is to guard against by informing himself as to the condition of 
the apex through exploration by a broach. If the part be normal, the sense 
of touch will discover a closed cavity; if abnormal, the instrument is felt im- 
pinging upon soft parts. The latter condition existing, the filling is influenced 
in the depth to which it is to be carried by a measurement secured by the 
broach. 
Enlarging a Canal.-Where it prove necessary to enlarge a canal, par- 
ticular care is to be exercised that the drill used shall not pass through the 
side of the root, this caution holding markedly as the first bicuspis is con- 
cerned, as it is in this tooth that a partial bifurcation of the fang renders the 
accident most likely to occur. Such a failure is almost certain to result in loss 
of the organ if not in graver lesions. This accident is fully guarded against 
by use of the Littlejohn flexible-shafted bur, which see. 
The Broach.-In the use of so delicate an instrument as a broach, great 
care is to be exercised that the steel does not become jammed in the canal,- 
perhaps, as has frequently been the case, in the foramen,-and, breaking, leave 
a cause of offence which may result, not alone in the loss of the tooth, but 
which, in more than a single instance, has caused loss of life from tetanus. 
Should such accident occur, every effort is to be made to remove the fragment; 
the desired result being generally attained by catching the piece in a wisp of 
dry cotton revolved about it by means of a second instrument. Where a broach 
has been caught and broken in the foramen, it may be found necessary to 
enlarge the opening by means of a spear drill,-a practice the necessity for 
which will be found unfortunate, as almost invariably does it result in necrosis 
of the root so treated. The magnet is another means of getting rid of a broken 
piece. Commonly it is to be caught and lifted away by finger forceps. 
Conduction and Non-conduction.-The conducting faculty of gold 
being well recognized, the value of a non-conducting substance placed between 
a plug in the canal and one that is to occupy the crown is appreciated. 
Teeth not so treated are subject to a source of continuous irritation to which 
many succumb; a chronic inflammation, resulting in necrosis, being not infre- 312 
A SYSTEM OF ORAL SURGERY. 
quently the result of varying thermal impressions. Founded on such experi- 
ence, the practice is pursued of filling the pulp-chamber proper-that is, the 
cavity out of which the canals run-with such preparations as the oxychloride 
of zinc, gutta-percha, Hill's stopping, etc. Lead is sometimes used: prefer- 
ence resides with the oxychloride of zinc. (See chapter on Filling Teeth.} 
Rest.-The canal and the pulp-chamber of a tooth filled, observation 
demonstrates the desirability of allowing a few days' rest to the organ before 
performing the crown operation; the cavity to be temporarily filled with a 
sandarach and creasoted cotton plug. 
Filling over Exposed Pulp.-So common has the practice become of 
attempting the performance of the filling of complicated cavities and, at the 
same time, the saving of pulps, that in the operation dental writers, in their 
multitudinous suggestions, are too frequently found forgetful of general prin- 
ciples which underlie necessarily all such character of manipulations. 
On a former page mention was made of three sequelae associated with ex- 
posure of the pulp. These three conditions are as naturally conjoined with 
the relation as is the immediate union of a wound with plastic blood, or non- 
union with the cacoplastic. Whether or not, therefore, it be worth while to 
attempt the saving of an exposed pulp is found to depend exclusively and 
strictly on the common condition of the individual. 
That the vitality of an exposed pulp may be preserved, and a tooth so 
affected be successfully treated and filled, is a fact attested by every-day 
record; but that such success is associated more closely with physiological 
relations than with mechanical skill requires only experience to become to 
every observer a self-evident fact. 
Assuming the existence of such conditions as justify the attempt to save 
an implicated pulp, attention is to be invited to methods of practice found by 
experience to be most applicable. 
Illustration.-Taking, as a first illustration, a case where the pulp should 
be scarcely uncovered, but be found overlaid by a layer of devitalized dentine, 
it has become the quite common practice to trust such layer to the offices of 
nature, allowing it to remain, rather than expose the pulp-chamber, trusting 
that through some means the foreign body may be taken care of,*-a desired 
result which frequently occurs, as case after case on record satisfactorily ex- 
hibits. In placing a filling, however, over such diseased dentine, it is desirable 
first to put the tissue in a state of neutrality; that is, tests are to be made for 
acid or alkaline conditions, and, if either state be found, it is to be antagonized ; 
fungi, an almost constant inhabitant of such devitalized dentine, are to be 
destroyed: in short, if an original condition is not to be restored, causes of 
change and disintegration are to be removed. A suggestion by Dr. James 
* A layer of devitalized dentine may be liquefied and absorbed, or it may become en- 
cysted; that is to say, between it and the pulp there may be deposited a layer of secondary 
dentine. THE TEETH AND THEIR DISEASES. 
313 
S. King relating with this condition will worthily command attention. Zinc 
and creasote, as used by him, act as a parasiticide.* 
Thin Plate of Dentine.-A plate of living dentine, be it ever so thin 
in the centre, but having circumferential relations sufficient for the maintenance 
of its vitality, is to be viewed as in a condition which, properly assisted, 
will tend to grow better rather than worse. 
A plate of dentine, on the contrary, with very limited parietal relations, 
will be found much more disposed to degenerate than to maintain or 
increase its resistive force. 
Cavities of decay opening into the pulp-chamber are treated in a variety of 
ways. Of the means adopted, the various modes employed may be studied 
with advantage; it being a common experience that the unsatisfactory and 
unreliable character of any or all of them tempts the practitioner to try each 
in its turn. 
Oxychloride of Zinc as a Pulp Capping.-A means enjoying large 
favor at the present time is the employment, as a capping, of the preparation 
described, in the chapter on tooth-filling material, as the oxychloride of zinc. 
It has, however, become a too common habit to treat of this substance as a 
specific in the direction, and with such false impression it is every day used 
by many with a recklessness which has no excuse. That oxychloride of zinc is 
an admirable agent in this direction, when employed with judicious care, is 
not to be denied; no substance introduced into a tooth seems to exert greater 
influence in the excitation of that action which produces secondary dentine; 
but, injudiciously employed, no compound more quickly provokes in the pulp 
antagonistic inflammatory action. 
In using oxychloride, it certainly is not to be understood that it may be 
plastered over an exposed pulp ad libitum ; on the contrary, if it is to be 
used with prospect of satisfactory result, every consideration is to be had to 
the delicate and susceptible nature of the organ treated. Oxychloride of zinc 
* In order to attain an average success in operations which have for their ultimate object 
the preservation of vitality in exposed tooth-pulps, says Dr. King, the first step to be taken 
is to provide the needed remedies and materials. In my practice these are few in number,- 
viz., wood creasote, zinc oxide, iodoform, paper treated in zinc chloride, and crystalline 
cement. A correct rule of practice in the treatment of exposed tooth-pulps is that all neces- 
sary preparations of the cavity of decay should be brought to a finish, with rubber dam in 
place, prior to placing within the cavity the materials intended for the protection of the pulp. 
In preparing the remedies and materials I have named for use in pulp treatment, my first 
move is to combine with wood creasote a portion of zinc oxide in amount sufficient to form 
a somewhat stiff paste. Then, the rubber dam being in place and the cavity properly pre- 
pared, I take a general view of the exposure and surroundings, in order to determine how 
large or how small I shall cut the fragment of paper for immediate use, the diameter of 
which should be such as to permit of an overlapping to some extent of the dentine that forms 
the border of the exposed orifice. Then on one side of the paper I put a small portion of 
creasote paste, and with a pair of delicately-pointed foil-pliers seize the paper, apply that 
side to the point of exposure, and in a gentle manner press the paper into the desired position 
in a manner that shall save from air-bubbles. 314 
A SYSTEM OF ORAL SURGERY. 
placed directly upon an exposed nerve can have good results only by an acci- 
dent which should just level the break in the continuity of the roof of the 
cavity, and which should have alone that most happy vascular response which 
tends to the formation of secondary dentine. These results are, however, 
precisely what is claimed as being the rule by supporters of the practice; the 
proof or disproof of the claim the student will, without doubt, incline at some 
time or other to make for himself. 
Oxychloride of Zinc as an Intermediate.-Oxychloride is recom- 
mended in this volume as an intermediate ; indeed, the experience of the author 
leads him to esteem it as the most valuable of the agents employed, and thus 
far does he fully agree with its enthusiastic admirers; but whether it is to be 
used with an excess of the chloride, or with this powerful excitant neutralized 
as much as possible by the inert oxide, depends entirely on the character of the 
tooth treated. Again, the preparation is not to be brought, in its plastic state, 
into direct contact with the pulp, but it is always the safer practice to have an 
interposed plate. As the material of such a plate, oiled paper may be used, or, 
what is still better, caps of platinum as prepared and sold at the dental depots. 
Fig. 140 shows such caps. 
Again, in the use of the agent it is the best plan to feel one's way; success 
will not infrequently be secured by letting the 
application, as first made, be so thin a deposit as 
may alone prove self-supporting. Upon such 
film, if no response be made, a second is to be 
placed, and upon this second a third; the cavity 
being finally filled complete, and thus allowed to remain until, from continued 
or accruing comfort, there is reason to infer that the pulp has entirely accom- 
modated itself to the new condition of things. 
Pain as Result of Application.-Perhaps always is it a result that 
pain, more or less severe, is experienced by a patient upon the introduction of 
zinc chloride; particularly is this found to be the case where the mixture has 
been prepared watery, or where a local anaesthetic or a cap has not preceded 
the application. When such pain continues longer than a few minutes, it 
is found the safer practice to remove for the time being the filling, otherwise 
it is necessary to call off the persistent irritability through means of counter- 
irritants applied to distant parts; also to diminish circulatory force by the exhi- 
bition internally of veratrum viride. Through the means named it is not 
infrequently a result that quiet is restored and the desired protective condi- 
tions secured. In the case of a pulp-chamber fairly exposed the process of 
capping particularly commends itself. 
Quill as a Capping.-A simple mode of capping an exposed pulp con- 
sists in taking a piece of clarified quill and, after cutting and scraping it into 
the required shape and thinness, laying it over the break, the circumference 
being supported by the surrounding hard parts. While held in place with a deli- 
cate instrument, it is to be fixed by a plug of oxychloride placed upon it, this 
Fig. 140. THE TEETH AND THEIR DISEASES. 
315 
material being afterward removed in part for the accommodation of the 
permanent filling. 
Oiled Silk as a Capping.-Still another manner of accomplishing the 
proposed protection is found in the use of a layer of oiled silk, or of vellum. 
These are most suitable as non-conducting qualities are considered, but are 
objectionable as permanency is concerned. 
Oxysulphate of Zinc.-Preference is given by a large and experienced 
class of operators to this combination as a pulp-capping medicament. It is non- 
irritating and markedly of antiphlogistic significance. Where irritation is con- 
traindicated it assuredly commends itself. The combination consists of oxide 
of zinc, which has been calcined, mixed with sulphate of zinc treated in like 
manner. The proportions vary according to requirements, commonly two 
parts of the first to one of the second. The prepared powder requires to be 
kept in a tightly-stoppered bottle. To make the mixture soluble glass may 
be used. The paste is to be as stiff as convenience of use allows. Where prop- 
erly handled the glass forms the powder into a coat of much resisting power. 
This coat, when set, is to be covered with a brushing of the glass. 
Other Preparations used for Capping.-Other preparations used 
for capping are oxyphosphate, lead, tin, asbestos, and the Hill stopping. A 
plan which many think to be commended by results consists in enclosing 
asbestos between layers of gold foil, arching the metal, thus stiffened, over 
the exposed pulp. 
Dr. Allport, of Chicago, a skilful dentist, has proposed-and professes to 
have practised with a success entirely satisfactory-the following delicate 
operation : Exposing fully the pulp, he takes out of the body of the organ a 
V-shaped piece, bringing afterward the lips together, and so retaining the 
apposition as to secure an immediate union. The necessity for such an opera- 
tion, however, may only occasionally apply. 
Orifices with Jagged Edges.-In the case of an uncovered pulp, 
with the orifice of the exposing cavity jagged, sharp, and irregular, necessity 
exists for such enlargement and dressing of the same as shall insure the organ 
-enlarging from time to time, because of functional office-from irritation 
and strangulation. To accomplish this dressing, it is desirable to constringe 
the pulp by such means as are found best to answer the end. Tannin in a 
menstruum of glycerin is a favorite in this direction. Alum water is an 
excellent application; tincture of nut-galls is another. The prick of a very 
sharp instrument, resulting as it does in depletion, is an admirable procedure. 
A very effective plan consists in conjoining with the local means hot foot- 
baths, calling the excess of blood away from the head; also the administra- 
tion of medicines which tend to diminish the propulsive force of the heart,- 
the tincture of veratrum viride, in five-drop doses, being perhaps the best 
of such agents. 
An orifice, as described, being enlarged and dressed, capping completes the 
operation. CHAPTER XX. 
DISCOLORED TEETH. 
A tooth of loose structure quickly becomes dark, and in instances almost 
black, on the death of its pulp. This opacity possesses a twofold explana- 
tion : First, death of pulp implies diminution in vital relations; out of this 
arises loss in translucency. Second, a dead pulp decomposes more or less 
quickly, becoming, in its liquefied condition, absorbed into the tubules. 
Impossible to restore Translucency in a Dead Tooth.-To 
restore translucency in a dead tooth is impossible; the organ can be whitened, 
never vitalized. 
When a tooth-pulp has died experience directs as a proper course to pursue 
that it be at once removed from its cavity, and that its place be occupied by 
a plug of gold, solidly impacted; such plug extending to the extreme end of 
the canal. 
A tooth already discolored, the pulp-canal is to be freely opened, and any 
remaining contents removed by means of a broach. Succeeding this is the 
use of a syringe. Repeated washings are to be employed. The fluid em- 
ployed may be either dilute chlorine water or peroxide of hydrogen. 
Checking advancing Discoloration. - A pulp-canal enlarged, 
cleansed, and the tubules saturated with chlorine water, a napkin or the dam 
is to be placed about the tooth, and a process of intra-tubular drying in- 
augurated. To effect such drying, pellet after pellet of bibulous paper is to be 
introduced until, as such means express it, all moisture is abstracted. Next 
the canal is to be packed with carbonate of magnesia. Thoroughly re- 
moving this, after a few minutes have passed, the hot-air syringe being used to 
blow it away, the extreme apex of the canal is plugged solidly and perma- 
nently with gold. By this plugging the bleaching process, if that be the mode 
of whitening adopted, is not at, a later time interfered with by reason of 
secondary discoloration. 
Bleaching.-Immediately on completion of an apex plug, and while the 
part is still enveloped in dam or napkin, a wisp of absorptive cotton is made 
to entangle as much as possible of common chloride of lime, which wisp is 
carried into the pulp-canal; the orifice being at once sealed. In the use of 
this material advantage is taken of the antiseptic virtue of the chlorine, but 
most particularly is it the object to suck out from the tubules of the tooth the 
putrescent moisture attracted by the affinity existing between itself and the 
preparation. Taking into consideration the caustic quality of the application, 
316 DISCOLORED TEETH. 
317 
judgment is required to be exercised as to the length of time it is to be 
left in a tooth. Where the dentine is loose in structure and full of moisture, 
the unsealing of the cavity after one or two minutes will show the cotton to 
be wet. Here it has been in quite long enough, perhaps too long. If, on 
the contrary, the cotton be found dry, the lime has not yet done its work, and 
the application is to be continued or renewed. 
Removal of a Bleaching Agent.-One or two employments of the 
lime having been made, a succeeding step considers its complete removal. This 
is generally accomplished by the clinging of the moisture to the cotton; not 
so fully, however, is this a result as to be entirely trustworthy; it is found 
desirable to use a syringe freely. 
The cavity again made dry as possible by means of Japanese bibulous paper, 
it is packed either with a fine article of English prepared chalk or with 
the carbonate of magnesia. This completes the operation for the day; the 
orifice being hermetically sealed. 
Zinc used in Place of Lime.-Zinc in place of lime is preferred by 
many. Having the cavity plugged at the apex, and under dam or napkin as 
before, pack into the canal as much oxide of zinc as it will hold. When full, 
seal the outlet quickly and retain for two or three hours. The application 
may be repeated daily until color is restored. In the interim the cavity 
of the tooth is to be protected by temporary plugging against external agents 
of offence. Crystals of chloride of zinc may be used in place of the oxide, 
but here an application is never to continue longer than from one to five 
minutes, and on removal of the caustic the cavity is to be thoroughly washed 
out and, after being dried, filled with chalk or magnesia. 
Bleachers.-A manner of bleaching, having in it little risk or danger, 
consists in free syringing with dilute chlorine water, and the use of chalk con- 
tinued for some few days, the preparation being renewed each twenty-four 
hours. A week having passed, an oxychloride plug, made by union of the 
aqueous solution of zinc chloride with a perfectly white preparation of oxide 
of zinc, the chloride being in excess, is introduced into the cavity and pro- 
tected until about two-thirds set. This imperfectness permits of an easy 
removal, which removal is to be succeeded by renewals of the plug. Repeti- 
tion results in whiteness. 
Chlorate of Potassium as a Bleacher.-Another bleacher is the 
familiar salt, chlorate of potassium: this is to be used without much regard to 
evil results. 
Labarraque's Solution.-Labarraque's solution, an aqueous chlorine 
preparation, permits of reasonable freedom in its employment; it is conveniently 
applied on a wisp of cotton, and the orifice of the cavity is to be sealed while it 
is in a tooth. Renewal of the application is to find directions in indications. 
Immediate Bleaching.-Immediate bleaching is secured by fitting a 
delicate canula tightly into the orifice of a tooth-canal, and forcing a stream 
of chlorine gas into the tubules. 318 
A SYSTEM OF ORAL SURGERY. 
In the use of chlorine preparations the facts are to be constantly in mind 
that the agent employed is a decomposer of organic substance; that it is 
of such chemical characteristic advantage is taken to get the hydrogen of 
organic combinations, consequently, in the case considered, the discolored 
element; that acting primarily on the most exposed material, which, in the 
instance of a discolored tooth, is the pulp-substance filling the tubuli, this is 
primarily removed or destroyed ; that a secondary action must be on the animal 
portion of the dentine; that necessarily secondary action is destructive to the 
integrity of a tooth, rendering it brittle and crumbling. 
Whitening.-Integrity of relation being disturbed by the use of chlorine 
preparations, the peculiar and marked harm arising out of their employment 
where caries has undermined the enamel of a tooth is evident enough. Taking 
as an example a front tooth where decay, running in from an approximal face, 
has decomposed much of the underlying substance, the injudiciousness of the 
use of chlorine needs not to be discussed. Whitening in this and similar 
cases is to be effected by removal of the discolored dentine and the replacing 
of it by oxychloride of a shade to suit. Here injurious result is to be obviated 
by complete neutralization of the chloride by the oxide of zinc; such 
neutralization rendering the filling entirely inert from a chemical stand-point. 
Free chlorine being no longer existent in it, the plug is one that has the 
meaning of color alone. 
A manner of whitening employed with fair satisfaction in particular 
cases consists in underlaying a plug of gold by a sheet of plaster of Paris. 
Another manner employs a mat of white paper, which, being put in place, 
is immediately overlaid by a second made of gold. Still another manner 
is to take a scale of porcelain and mould it as a support to the wall to be 
whitened; plaster or zinc chloride being used as the plastic. Another 
manner still shows a brushing of zinc or lead paint through the discolored 
face, the paint being covered by zinc phosphate, by soluble glass, or other 
plastic material. Preference is commonly given to the zinc chloride plastic. 
Haematin as a Discolorer.-Immediate discoloration of a tooth arises 
sometimes out of a pulpitis so severe as to rupture the red corpuscles of the 
blood, permitting thus escape of the haematin and its speedy absorption by the 
dentinal tubules. A tooth so disturbed is the subject of such discomfort to 
a patient that the practitioner is apt to be brought very quickly in contact 
with it. Treatment consists in opening at once into the pulp-cavity and 
by means of warm water thoroughly cleansing it. So almost certainly is the 
death of such a pulp assured that it will commonly be found the best practice 
to quiet by use of obtunders and afterward apply the arsenical paste; or, 
if the organ have been freely exposed, its destruction is to be instantaneously 
assured by means of London paste, a small portion of which, if laid directly 
in contact with it, kills the part in a moment. Subsequent treatment is as 
directed in previous cases. Haematic discoloration, having the expression of 
purpura, may take place slowly; the condition is very uncommon. DISCOLORED TEETH. 
319 
Dead Pulp as a Discolorer.-Discoloration being dependent 
on absorption of a liquefied dead pulp, or constituents of a pulp, it follows 
that inter- and intra-dentinal calcification are antagonistic to discoloration; 
hence, shadings of vascular excitement, existing to an extent promotive of 
calcareous expression in the dental pulp exudate, are prophylactic of absorption. 
Teeth naturally dense darken slowly or little at all. 
Whitening rather than Bleaching.-It is not amiss to add, as con- 
clusion of the subject, that experience leads to much stronger dependence 
being placed on processes of whitening than of bleaching; the first is entirely 
safe, the second not entirely without risk. CHAPTER XXL 
REPLANTATION, TRANSPLANTATION, AND IMPLAN- 
TATION OF TEETH. 
By replantation is meant the return of a tooth to its natural socket after 
extraction. 
By transplantation is meant the transference of a tooth from its original 
socket to one existing in another mouth. 
By implantation is meant making a socket in a mouth where none exists and 
placing a tooth in it. 
The initiative of these operations lies in experiments performed by John 
Hunter, in which that famous anatomist transferred teeth taken from the 
human mouth to slits made in the combs of cocks. These transferred teeth 
were found not only to become fixed and tolerated in their new position, but 
subsequent examination of the relation showed the parts to be attached after 
a manner not greatly dissimilar to that which exists between teeth and their 
natural alveoli. 
REPLANTATION. 
The frequency with which this operation has now been performed and the 
success attending it in the hands of capable practitioners justify the placing 
of it in the category of performances to be recognized and commended. 
It is to be assumed as a start-point that any healthy tooth can be 
lifted from a healthy socket and returned within reasonable time with an 
almost absolute certainty of reunion. Per contra, it is to be deduced 
that in proportion as parts are unhealthy probabilities of reunion are lessened. 
Mistakes in Extraction.-A wrong tooth being accidentally removed, 
the parts being healthy, it is to be returned to its socket immediately on the 
cessation of bleeding; this cessation to be expedited by means of cold or hot 
water held in the mouth. To retain the organ in place silk or thread ligatures 
will most likely be required. 
Teeth that have been extracted many hours are found capable of refasten- 
ing. Example : Some nineteen or twenty years back a young gentleman 
applied to the author about six o'clock of an evening with a view to having 
an impression taken for the purpose of replacing with an artificial substitute 
a central incisor that had been extracted very early in the morning of the 
same day. Inquiry elicited that the tooth had been removed by mistake. 
Replantation being proposed, the organ was found, after some search, in one 
320 REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
321 
of the pockets of the patient, being mixed up with keys, pieces of money, a 
knife, and the varied et ceteras of that receptacle, not to exclude the mention 
of a fair amount of dust. A first step was to throw the tooth into warm 
water, to which was added about ten per cent, of tinctura iodinii. A second 
was to remove the plasma, with which the socket was filled, and to touch the 
circumference with the iodine tincture. A third consisted in replacing the 
tooth in its alveolus and in binding it firmly as possible in place by means 
of silk ligatures. A fourth implied the combating of an active inflammation 
that showed itself by the next morning, and of a chronic form into which 
the first degenerated, the latter continuing its discharge of pus, in defiance 
both of local and constitutional stimulation, for a period of over two weeks. 
Result: The patient was last seen some twelve years after his accident; the 
tooth was then about as firmly implanted as its fellows. Very trifling change 
in color was present.* 
Dental Abscess.-Extraction and replantation of teeth for the cure of 
dental abscess has now long claimed attention. It is to be appreciated that a 
tooth is endowed with a threefold source of nutrition,-namely, pulp, tunica 
propria, and periodonteum ; that vitality is preserved commonly where the first 
of these has ceased its office; that necrosis certainly ensues where all three 
are dead. With such understanding it is recognized that a necrosed tooth is 
fit only for the first operation, not for the second. 
A tooth in a state of abscess is a tooth lacking pulp vitality; it is an organ 
chronically inflamed in its periodonteal structure. Chronic inflammation of 
a periodonteum implies disease of part, perhaps of all, that membrane. A 
tooth so diseased is found on extraction to have what is known as a pus-bag 
* A plan of retention suggested by Dr. Herbst is not less ingenious than suggestive; the 
accompanying cut shows it. First, a piece of rubber-dam material, oblong square in shape, 
with four holes punched in it. Second, this piece applied as exhibited; the lateral incisor 
is the replanted tooth. 
Fig. 141. 
Another manner of holding takes an ohlong strip of red base-plate gutta-percha that 
shall be of a form and size, when cut into shape, to reach and cover several neighboring 
teeth on either side of the one replanted. Softening this gum by use of warm water, it is 
laid over the arch and moulded back and front. Next, and while it is still soft, the teeth of 
the opposing jaw are closed against and slightly into it. Articulation being maintained, 
the splint is hardened by means of cold water thrown about it from a syringe. Finally, a 
strip bandage is applied with a view of preventing movement. 
In the use of means of retention delicacy of arrangement is a necessity. Added to this 
a mouth-wash, to be used several times a day, and which has seemed to the author never to 
be lacking in desirable effect, is made by mixing a teaspoonful of the tinctura capsicii et 
myrrhse with a goblet of water. 322 
A SYSTEM OF ORAL SURGERY. 
attached to its root. The cure of abscess implies removal of this pus-bag. 
In the chapter on alveolar abscess what is to be accepted as the most rational 
mode of treating that condition is to be found fully considered. 
In making up a prognosis as cure, by extraction and replantation, of an 
abscessed tooth is concerned, an important factor to be taken into considera- 
tion is the extent to which periodonteal denudation has progressed. The 
periodonteum is to be recognized as the only remaining source of supply to the 
tooth ; for in such a case the anastomotic circulation of the tunica propria which 
associates the other two is scarcely to be taken into account. If there be no 
periodonteum the replanted organ occupies a relation with its alveolus differing 
in the single respect from that which would be held by a plug of ivory or wood 
in that it is a something that once was in physiological harmony. The author 
is not prepared to deny that such harmony is of favorable import; it is not to 
be objected to, however, that the history of dead parts, or sequestra, exhibit 
them as things offensive to nature and which are commonly thrown off. It is 
a just deduction that a necrosed tooth is not suited for replantation. 
Example Case.-A tooth, in the mouth of a healthy person, having 
alone the extreme end of the fang in a state of abscess, the remainder of 
the periodonteum being in health, is in favorable condition for treatment by 
extraction and replantation. The process is as follows: 
1. The tooth is to be removed with all delicacy and care, and thrown at 
once into warm water which has been previously medicated with tincture of iodine, 
the socket, in the mean time, being stuffed with cotton or lint alike medicated. 
2. The pus-bag is to be removed from the root. If the underlying 
cementum be vital in appearance it is left undisturbed ; if it be dead, as shown 
by blackness or by evidence of absorption, it is to be cut away with as little 
disturbance to adjacent parts as possible. 
3. A third step considers treatment of the pulp-cavity. In a tooth where 
the apex of the root has been retained, the cavity is opened from the crown, 
and after being thoroughly washed out and profoundly disinfected it is filled 
solidly to the extreme end of the canal with gold. This being done it is 
ready for replantation. A root with a necrosed apex demands different 
treatment. The periodonteum is to be dissected back to an extent which shall 
insure the covering of the tip of the fang by it when the diseased part has 
been removed. Next, the pulp-canal is to be exposed from the apex portion 
of the tooth and filled with gold as in the first instance; great care to be 
taken in contouring, finishing, and polishing the apical extremity. The filling 
accomplished, the periodonteum is made to cover the gold; a delicate catgut 
ligature being used if necessary. 
4. The bony cavity, in which is accommodated the sac of a dental ab- 
scess, being lined by an adventitious membrane, a fourth step considers the 
destruction of such membrane. To accomplish this after the best surgical 
manner, the operator employs a delicate knife-scoop, passing it along the 
alveolus into the cyst, scraping the membrane away. Another, and a REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
323 
necessary plan of treating such cysts and membrane, where the tooth has 
been replaced, is to make an opening through the alveolar wall, using a drill 
in place of the scoop. The membrane being picked away, a twist of cotton 
saturated with iodine is to be introduced, thus furnishing a drain which serves 
to void any excess of exudation or, it may be, of pus. 
5. Relation of an extracted tooth and cavity is renewed by simply 
pushing the first into the second and confining it in place by tying to neighbor- 
ing teeth. At this stage in the operation it is that both danger and trouble 
are to be, not unlikely, encountered: danger from nervous relations which 
may, and has, resulted in tetanus; trouble from vascular perversion which 
over and again has made necessary the re-removal of the tooth, and which, 
unless skilfully looked after, may very possibly lose for a patient his jaw-bone. 
When a tooth is removed from its socket an immediate sequence is the 
filling up of the alveolus with lymph, which lymph, as a rule, progresses to 
speedy organization. When, on the contrary, any body, be it foreign or only 
semi-foreign, is put into the cavity, such lymph is not likely to organize, but, 
on the contrary, to degenerate into pus. Pus in a closed cavity means irrita- 
tion associated with much pain. The pathology of such a trouble is not 
involved by obscurity. 
Closing an Outlet.-A replanted tooth closes an outlet; one of two 
things surely follows. It may be, and often is, the case that lymph is poured 
out so plastic and coagulable in disposition that organization is effected without 
the formation of a single drop of pus; this is analogous to the healing of a 
wound by what is known as 11 first intentionit is not impossible that de- 
generation of so limited extent occurs that liquefaction is coincidently followed 
by absorption; this in like manner is fortunate and conduces to immediate 
cure. On the other hand, degeneration yields pus that finds vent for itself 
by the establishment of an alveolar fistule, otherwise it forces the replanted 
tooth from its socket. To obviate or overcome trouble residing in a collection 
of pus two means present themselves : one anticipates by operation the alveolar 
fistule, after a manner described; the second implies a drain-tube anchored in 
the canal while that cavity is being filled. 
Artificial Fistule.-To create a fistule in the bone nothing more is 
necessary than to pass a spear-pointed drill through gum and alveolar plate; 
keeping patulous the opening so made by means of a cotton twist as heretofore 
suggested. Than such manner of caring for the necessities of a cyst none 
other more surgical is to be adopted. The gum is first to be incised. 
Drain-Tubes.-Drain-tubes used in teeth need little description: they 
consist of channels of gold passing from apex to crown; being firmly built 
into the root-canal by means of cohesive gold. (See Pivoting.') 
Gold Apices.-A practice to be mentioned, one highly commended by 
respectable authority, consists in replacing with gold the removed apex of 
a tooth to be replanted, the contour to be a fac-simile as to length and cir- 
cumference of the original part. To do this one of two plans is to be 324 
A SYSTEM OF ORAL SUROERY. 
adopted: the part may be built out, as before suggested, cohesive gold being 
used, or, adopting the manner of capping crowns, a' similar gold cap may be 
applied to a root, the delicately-thinned edges being worked up to a slight dis- 
tance beneath the periodonteum. To hold such cap firmly in place it is to be 
attached to the drain-tube, or, if it be proposed to use the bone as a vent, the 
cap may have its fixedness secured by a pin soldered upon its cap face, which 
pin shall pass into the canal, being there retained by the root plug. (See Tin- 
gold.') 
TRANSPLANTATION. 
This refers to the use of the teeth of humans or brutes. Simple illustra- 
tion of transplantation considers the removal of a tooth from the mouth of 
one person and its immediate transference to that of another. This, ceteris 
paribus, differs little from replantation, and is a practice which assuredly will 
become widely practised as operators become confident and society grows 
aesthetic. 
The conditions necessary to success in this immediate expression of trans- 
plantation pertain to selection of teeth and to the health relations of the two 
individuals concerned in the transfer. Sale and price enter too into the 
consideration. One person disposes of charms to another. A surgeon takes 
the place of a broker. 
As an illustration, a defective central incisor may be instanced. One person 
has such a defective tooth, replacement of which he or she is very willing to 
pay for. A second person has a perfect organ which will gladly be parted 
with for a price. Two matters only remain: Is the tooth on sale of a form 
sufficiently in accord with the requirements? Is it free from objectionable 
associations? By objectionable associations is meant freedom from specific or 
local taint. 
A transfer being decided on, the parties meet the surgeon, who extracts 
first the defective tooth, and, when all bleeding has ceased, lifts the second 
from its socket, which, after immersion for a few minutes in a solution of 
carbolic acid, corrosive sublimate, or whatever antiseptic is selected (see page 
240), he plants in the new alveolus existing for its reception. Subsequent 
attention required relates with fixation by means of ligatures and to the com- 
bating of vascular perversion almost sure to be provoked. 
It may very well happen, however, that in the attempt to introduce the 
tooth into its new socket there is found lack of correspondence. This proves 
a complication, and lessens, in proportion to its demands for change in the tooth 
or socket, the chances of a successful result. The operator making himself 
acquainted with the unduly impinging relations has nothing to do but at once 
give up the case or otherwise proceed to trim the root or cavity to suit. Where 
such trimming is done upon the tooth its enveloping membrane is to be first 
lifted out of the way. 
Transplantation of brutes' teeth into human sockets is pro- 
fessed to have been accomplished with satisfactory results. The author has REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
325 
had no experience in this direction. The principle of procedure would differ, 
however, in no respect from that now understood. Able to accomplish the 
one, an operator would have no hesitation in passing to the other. 
Quoting from cases reported in the literature of the subject, it would seem 
to make little difference whether a root correspond or not with an 
alveolus. Thus, in one cited by M. Pietkiewietz, that surgeon claims to have 
extracted an anomalously related lower lateral incisor and to have successfully 
planted it in the alveolus of a lateral incisor removed from the upper jaw. In 
this instance the circumference of the root planted did not at all correspond, it 
is said, with the cavity in which it was placed, being very much smaller, while 
at the same time it was so out of proportion in length that a piece had to be 
cut off. Notwithstanding all this difference, perfect success is reported. 
Report of Cases.-Dr. David, a pupil with M. Pietkiewietz of M. 
Magitot, reports sixty-two cases, fifty-seven of which are claimed to have been 
successful. In these cases are found included varying ages in patients 
and all the variety of single- and multi-rooted teeth. Reasons for the opera- 
tions are named as follows: 1. For the adjustment of anomalies of direction. 
2. The treatment of caries where situation did not admit of the pulp being 
reached in order to destroy it, and the practising in situ of a satisfactory 
filling. 3. The treatment of that form of alveolo-dental abscess in which this 
affection is limited to the summit of the root. 4. Getting at a cavity in 
another tooth not otherwise to be reached. 
A singularity in this matter of tooth-planting relates to the length 
of time that an organ can be out of the mouth and yet preserve vitality, as mani- 
fested by later attachment to an alveolus into which it may be transferred. A 
case illustrative is reported in the Dental Cosmos, where a practitioner having 
removed a sound eye-tooth from the mouth of a lady in preparation for an 
artificial denture, planted it four weeks later in the jaw of a gentleman 
who had applied to him with the view of having a crown pivoted upon the 
root of a similar class tooth. In place of pivoting, the root was extracted by 
means of a screw instrument, and the lady's tooth inserted in the gentleman's 
jaw. " I opened," says the operator, " into the canal and pulp-chamber from 
the apex of the root, cutting off first from it the eighth of an inch, it being 
that much too long; reduced the size somewhat in the centre, it being a 
trifle larger than the root extracted, filled and placed it in position." Such 
a success is claimed for this particular transplantation that it is asserted that 
dentists were unable to distinguish the foreign from the natural organs. 
An advantage lying with root-canals filled after extraction of 
the teeth is the perfection with which the operation is to be accomplished. It 
is undeniably the case that canals treated after the ordinary manner are almost 
sure to be unoccupied about the extremity, thus affording a receptacle for 
decomposing fluid, which proves one of the severest sources of irritation 
to which a tooth can be subjected. Howsoever manipulated, a pulpless tooth- 
canal is put in its best condition when solidly and completely filled with gold. 326 
A SYSTEM OF ORAL SURGERY. 
If necessary to avoid thermal changes, such root filling is to be separated, as 
before suggested, from that required in the crown through employment of a 
layer of gutta-percha, oxychloride, or other intermediate. (See Root Filling.') 
A tooth replanted in restitution-that is, put back into a socket 
from which it has been removed-may be expected to become reasonably fast 
in the course of a week. If, in place of a cure that is continuous and pro- 
gressive, degenerative changes supervene, stimulation is to be resorted to. 
Cure here may be delayed for months. 
A tooth transplanted by transposition-that is, removed from 
one alveolus to another-will seldom unite with any degree of firmness before 
end of the second week. It will be found that such a tooth seldom or never 
perfectly harmonizes with its new relation. A cold taken, vascular perversion 
quickly distinguishes it. 
Tetanus.-Danger from tetanus is never for a single moment to be 
absent from the mind of an operator who attempts either replantation or trans- 
plantation. Nervous irritability is to meet with instant combatal; if it suc- 
cumb not quickly, the offending tooth is wisely taken from the socket. Tinct- 
ure of belladonna administered in doses of ten to fifteen drops each three or 
four hours is found the best remedy. Poisonous effects showing from the use 
of the medicine, an antidote is found in opium. 
IMPLANTATION. 
By implantation, as the term is commonly used, is meant the placing of 
teeth in an edentulous arch. The operation, most simply described, consists 
in uncovering a portion or portions of a jaw, cutting therein a cavity or 
cavities, and planting a corresponding tooth or teeth. As suggested on a 
former page, the origin of this operation lies with the experiment described as 
practised by the anatomist John Hunter, but to Dr. Younger, of San Fran- 
cisco, is to be given the credit, or discredit, as the matter may turn out, of 
propounding and endeavoring to demonstrate the desirability of making alveoli 
in jaws lacking teeth and furnishing them from foreign sources. Others 
whose names, through their work and published writings in the direction, 
have become familiar, are Dr. Curtis, of Syracuse, Dr. Kirk, of Philadelphia, 
and Dr. Ottolengui, of New York City. Practitioners who favor the per- 
formance seem growing in number. 
Implantation impresses the author as being an unsurgical pro- 
cedure ; one likely to result in so much more harm than good as to insure 
the practice being of short continuance. The reason for such opinion 
lies with the anatomical condition in which edentulous arches are found, with 
an ever-present rebellion on the part of a human body to the presence of for- 
eign material, and with the existence of an absorbing system ever attentive to 
its excrementitial duties. Whether, however, those who favor or disfavor the 
operation are to be found in the right seems best left to be determined by ex- 
perience and time. The first operation of implantation, as definition REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
327 
here distinguishes the performance from replantation and transplantation, is 
recorded by Dr. Younger as having been done by him on the 15th of June, 
1885. Since this first operation quite a little multitude are reported, the 
results given being various, as might be anticipated. 
Before entering on a description of manipulations related with the operation 
it is desirable to direct attention to the fact that alveolar process, and not jaw- 
bone proper, is the ossific material of relation with teeth, and that where this 
process is absent, as is the case in an edentulous jaw, implantation, if practised, 
places a tooth in connection with a part which is without natural affinity 
with it. 
Method of Procedure.-The objections of the author to the operation 
of implantation leaving him without direct personal experiences in the direc- 
tion, he compiles the present " method of procedure" principally from the 
works of those whose names are mentioned in a paragraph before,* taking 
these by reason of finding the full ground covered by them, both as to 
text and illustrations. 
A point emphasized by Dr. Younger is that "freshly-extracted teeth" are 
not indispensable to success; and just here, in a paper before the writer, is 
quotation of an operation practised by himself years long antedating Dr. 
Younger's work, where a tooth " was replanted after having been carried by 
the patient in his trousers-pocket among keys and small rubbish." This case 
demonstrates, however, not the value of implantation, but of replantation, for 
here was a socket, not artificially made in bone, but of original relation to the 
tooth replaced, and consisting as well of the original and unchanged alveolar 
process. The case but remotely relates with implantation. 
Preliminary Treatment of Tooth.-As is the case in the operations 
of replanting and transplanting, preliminary cleansing and filling of the pulp- 
cavity and canal of the tooth used is a necessity. Dr. Younger employs gutta- 
percha as a canal filling, except for the apex of the root, where a combination 
of gold and tin is preferred, the part being contoured by him and highly pol- 
ished.f Dr. Ottolengui speaks highly of the use of gutta-percha alone, sug- 
gesting in the connection a peculiar endurance of this material on the part of 
bone. A tooth to be implanted is to be subjected to aseptic treatment, to 
which end a bath is recommended made of mercuric iodide of potassium (1 gr. 
to gvj of water and 3j of alcohol, or of the bichloride of mercury (1 to 1000). 
By some operators moisture and sterilization of the tooth are considered factors 
not only important but absolutely necessary to success ; others, on the contrary, 
treat the matter as being of indifferent concern. B.eferring to a necessity for 
* Implantation of the Teeth of Man in the Jaws of Man, Rodrigue Ottolengui, M.D.S.; 
A Consideration of the Prevailing Theories of Repair in Implantation, G. L. Curtis, M.D., 
D.D.S, Brooklyn Medical Journal, February, 1889. Implantation of Human Teeth, E. C. 
Kirk, D.D.S. Discussion of the subject of Implantation of Teeth by the Pennsylvania State 
Dental Society, G. W. Weld, M.D., D.D.S. 
f See Tin-gold. 328 
A SYSTEM OF ORAL SURGERY. 
exercise of judgment in selection of cases and care in performance of the 
required manipulations, Dr. Kirk strikes a prominent note of the subject 
where, in his paper on implantation, he says, " It is to be borne in mind 
that a body foreign to the tissue is introduced; foreign, because devoid of 
vitality, and which may become an irritant of sufficient intensity to defeat 
the object in view, by inducing such a high state of inflammation as to cause 
suppuration, if not sloughing, or at least failure to unite. Our object is, 
therefore, to so control the vascular excitement that it shall not exceed at 
any time the degree necessary for repair of the wound and encapsulation of 
the root." 
Preparing the Cavity.-It is recommended that a hot solution of 
hydronaphthol (1 to 300) occupy a basin conveniently at hand, in which is to 
be placed all the drills, reamers, burs, bistouries, syringes, and sponge used 
in the operation. As often as a bur is changed, the assistant 
is to cleanse it of bone debris and blood and replace it in 
the hydronaphthol. As the operation of burring out a 
cavity progresses small pieces of sponge are to be used for 
taking up the bone-chips, and each piece, as used, is to be 
thrown away ; to this mode of cleansing syringing is added.* 
To expose the bone, Dr. Kirk employs a simple 
incision with view to securing adherence of the gum to the 
neck of the tooth, preceding his manipulation by injecting 
into the seat of operation, between the bone and periosteum, 
one-eighth of a grain of cocaine, which he finds to prove 
an absolute pain-obtunder in the case. Drs. Curtis and 
Ottolengui recommend removal of a section, the latter 
named using for the purpose a tubular knife devised by Dr. 
Rollins (Fig. 142). Dr. Younger is quoted as making a 
cross cut in the gum and dissecting back the four flaps. 
To Remove Periosteum.-To remove the peri- 
osteum Dr. Curtis uses an instrument called by him " the 
denuder." This consists of a hoe-shaped blade, the surfaces of which are 
keenly sharp. An ordinary dental chisel curved on the flat side represents for 
practical purpose such denuder. 
Instruments.-To cut out the cavity trephines (Fig. 143), reamers 
(Fig. 144), spiral knives (Fig. 145), and Ottolengui's combination instrument 
(Fig. 146) are used; all of which, as it seems to the writer, are to have a 
way made for them by a preliminary use of the familiar spear drill. 
Trephine.-Objection urged to the use of the trephine lies with non- 
removal by it of the core, the condition leaving the operator but little advanced 
in his work and compelling removal of the piece; manipulations that are both 
tedious and painful. 
Fig. 142. 
Rollins's Tubular 
Knife (to be used 
with the engine). 
* Ottolengui. REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
329 
Reamer Blades.-The reamer blades are pronounced both too fine and 
too coarse,-that is, they have too many blades and are harsh in lateral cut- 
ting, since the entire length of an edge is presented against the bone. 
Ottolengui's Bur.-The Ottolengui instrument, which impresses the 
author favorably, is made in sets of ten, and has its use described as follows 
Fig. 145. 
Fig. 143. 
Fig. 144. 
Fig. 146. 
Trephines. 
Younger's Reamers. 
Spiral Knives. 
Ottolengui's 
Combination 
Instrument. 
by its inventor: 11 It is provided with nine blades, of which only three reach 
the conical apex, thus insuring rapid forward drilling. The blades at the 
sides are subdivided into teeth, so that, though more rough in appearance, it 
really cuts cleaner than the Younger reamer in lateral work. . . . Holding 
a tooth as shown in Fig. 147 (X), I select an instrument," says Dr. Otto- 
lengui, 11 whose diameter equals that of the tooth at D, E, and set the collar* 
distant from the apex equal to A, C. This is carried into the bone and forms 
a cut, as shown at A, C, B (Fig. 147, Y). It is now known positively, first, 
that the socket is deep enough, and, 
second, that it is wide enough at the 
upper third to receive that portion of the 
tooth above the line D, E. The second 
instrument is chosen with reference to 
the diameter at F, G (Fig. 147, X), and 
is pressed into the socket as far as B. The 
result of this last is shown at D, E, F 
(Fig. 147, Y), and the tooth in place is 
seen at Fig. 147 (Z). In examining this 
last illustration the tooth and socket are seen to touch at four points only (sec- 
tionally viewed), but this is diagrammatical only. In the operation the second 
Fig. 147. 
* Collars shown on the trephines, spiral knives, and Ottolengui's instrument are with view 
to prevent too deep drilling; they are, of course, movable, and are set to correspond in 
length with the root of the tooth to be planted. 330 
A SYSTEM OF ORAL SURGERY. 
reamer is usually chosen a trifle too small, and the conical shape obtained by 
swaying the instrument and consequent lateral cutting." Dr. Ottolengui says 
that he has implanted, after the manner described, a tooth in a beef bone in 
three minutes, and that section has shown tooth and socket in close juxtaposi- 
tion throughout; also that he has planted a tooth in a jaw in six minutes 
which fitted so accurately as to need no splint for its retention. 
Anatomy of the Maxillae.-Criticism of the operation lies with the 
two immediately following diagrams (Figs. 148 and 149). Viewing the first 
Fig. 148. 
A, antrum; B, inferior meatus; C, anterior palatal canal; D, socket of central incisor. 
(Fig. 148), it is seen to represent a right superior jaw, the inner face of the 
bone being toward the observer. Here a full, and indeed a quite over- 
drawn, alveolar process is portrayed, whereas, in an edentulous mouth, save 
that extraction of the natural organs has but lately occurred, there is nothing 
of what is shown. Taking, as a special illustration, the " socket of central 
incisor" (see diagram), it is known to every anatomist that such 
exhibit is true only at moment of removal of the tooth which occupied it, 
and that from the week of such removal onward such socket diminishes 
little by little, until at length the amount of osseous structure left as a sepa- 
ration of mouth and nose may not be thicker than an ordinary blotting-pad. REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
331 
The same holds good, of course, to the process underlying the antrum, absorp 
tion of which removes the whole of the structure shown. 
Fig. 149. 
A, inferior dental foramen; B, dental canal; C, socket of third molar; D, second 
molar (filled new bone); E, first molar; F, second bicuspid; G, mental foramen; If, first 
bicuspid; I, cuspid; J, lateral incisor; K, central incisor. 
Fig. 149, representing the left half of a lower jaw with its lingual face 
removed, is equally deceptive, as a diagram, with the other. No such con- 
dition and existence of process as here shown is found in an edentulous jaw 
save as extraction has been most recent. To afford idea of what takes place 332 
A SYSTEM OF ORAL SURGERY. 
after removal of teeth Fig. 150 is introduced. In the two upper pictures are 
seen jaws possessed of their complement of teeth and alveolar process. In 
the lower one, teeth and process have disappeared. 
Dental Canal.-The canal holding 
the dental nerve and vessels, while situated 
in a normal mouth as shown in the dia- 
gram (Fig. 149), is so changed as to 
position in an edentulous jaw as to run 
almost immediately beneath the surface. 
The diagram shows quite an inch of struct- 
ure overlying the canal. The edentulous 
jaw reduces this, not infrequently, to the 
thickness of a piece of paper. 
Directions to make a retaining cavity 
away from adverse underlying or over- 
lying conditions are not easy to follow; 
indeed, in the case of an edentulous arch, 
of standing, is not possible; so it must 
impress that the nearer approach is made 
to what has been described as trans- 
plantation the more plausible and prom- 
ising is an operation. 
Implanted Teeth as Posts for Bridge-Work.-The confidence of 
operators as to response in implantation has tempted to the use of this means 
for the securing of posts with view to the fixation of bridge-work pieces. 
Fig. 150. 
Fig. 151. 
A, implanted tooth-post. 
Here very much more than an ordinary demand is made on the planted tooth, 
and, without exercise of large judgment and skill on the part of the manipulator, 
failure would seem to be inevitable. Apparently primary results are recorded, 
however, in the direction. Fig. 151 exhibits a case in the practice of Dr. REPLANTATION, TRANSPLANTATION, ETC., OF TEETH. 
333 
Curtis, where, in his need of a lateral support for a bridge, he implanted the 
bicuspid tooth (A), and which he reports as affording excellent and satisfactory 
service. The diagram shows the tooth six months after implantation, at which 
time it is represented as being more firmly fixed in its artificial socket than 
were either of the three adjoining naturally related organs. 
Theories concerning Reunion.-A first inference is that the peri- 
cementum of an implanted tooth becomes revivified. A second theory assumes 
that the socket contracts about the planted tooth and holds it in place mechan- 
ically. A third is that osseous material is deposited about the root of the tooth. 
A fourth is that true anchylosis occurs. 
Dr. Sudduth, whose persistent and effective work in the way of microscopical 
analyses entitles his opinion to weight, says, " As regards the method of attach- 
ment, there is no doubt at all but what it is at first one of encapsulation, 
and following that, if the vascular conditions are kept properly controlled, 
bony anchylosis may result. The pericemental attachment of the teeth 
serves as a cushion between the root of the tooth and the bone, which, in 
masticating, tends to soften the blow. In the case of an implanted tooth we 
have no such fibrous tissue between, and if it is a case of bony anchylosis, the 
bone and the tooth come directly in contact. There is a different condi- 
tion from that of a natural tooth,-a condition that can be detected by sound. 
If you tap with an instrument on an implanted tooth, it gives a hard resonant 
response that is not perceived when a natural tooth in its original condition is 
tapped in the same way. There is no intervening membrane between the 
tooth-root and the bone, and we are to infer that such tooth would be a weaker 
member than one undisturbed." 
Under the caption of "A Consideration of the Prevailing Theories 
of Repair," Dr. Curtis presents a series of illustrated studies* in which his 
observations exhibit that fixation in the case of implanted teeth is by true 
anchylosis. This showing accords with experiences recorded by others, 
and is not without plausibility. Later such new-formed bone, together with 
the root of the tooth, undergoes degenerative change. Just here is to be con- 
sidered that the plausibility referred to a few lines above relates with a character 
of union occurring possibly between bone proper and tooth, and not between alve- 
olar process and tooth, for it is not to be esteemed that this latter departs from 
what are its common characteristics. The anchylosis may not be a true union 
such as occurs so frequently in joints, and always in fracture cases where union 
results. It may be, and more than likely is, a condition where a reasonably 
profuse ossific deposit ferrules the tooth so perfectly as to make bone and tooth 
seem part and parcel of each other. In opposition to this view, however, Dr. 
Curtis seems to show that osteoblasts penetrate the cement. 
Absorption of Planted Roots.-Whether replanted, transplanted, or 
implanted, especially the two latter, loss of the tooth is found to result sooner 
* Brooklyn Medical Journal, February, 1888. 334 
A SYSTEM OF ORAL SURGERY. 
or later either as effect of abscess or of absorption. In a paper by Dr. Weld* 
we find this matter duly summed up in a series of speaking illustrations, types 
of which are here presented. Fig. 154 shows a tooth extracted and replaced, 
but after being used two years was again drawn. A is a large cavity formed 
by the absorption of the root after the tooth was replaced; B is a gold plug. 
Fig. 153 shows the tooth at date of first removal. Fig. 152 shows a tooth 
Fig. 152. 
Fig. 153. 
Fig. 154. 
Fig. 155 
Fig. 156. 
which had been extracted and replaced. After being worn five years the 
result was as shown. A exhibits extent of cavity, C, dentine; E, enamel. 
Figs. 155 and 156 are appearances shown by a tooth which had been ex- 
tracted and replaced. Regard here is not paid to the extent of lettering as 
given by Dr. Weld, the cuts being introduced simply with view to directing 
attention to changes exhibited. A lower molar tooth shown to the author by 
Mr. Heckard, a student of dentistry, which had been extracted from his own 
mouth, and after having a pus-bag removed from one of the roots was re- 
placed, answered an admirable purpose for nearly two years, when it suddenly 
became painful, and on being re-extracted was found minus the root from which 
the bag had been taken away. 
* Dental Cosmos. CHAPTER XXII. 
DENUDATION. 
This affection, at once appreciated by referring to the drawings, is, without 
doubt, one of the most deforming conditions to which the dental organs are 
subject. It is sometimes seen attacking every individual tooth ; at others, 
confining its ravages to very few. A common seat of the disease is 
where the gum festoons. Here may be seen a sulcus, or groove, passing from 
tooth to tooth, involving all those situated in the anterior part of the arch. 
Another form of the condition involves the cutting edges alone; while in 
still other cases the depressions are situated promiscuously over every portion 
of the teeth. 
The disease, commencing as a slight gutter, or break, in the enamel, pro- 
gresses with a varying degree of rapidity, moving sometimes with so slow a 
Figs. 157, 158.-Denudation. 
pace as scarcely to be measurable from year to year; in other instances, and 
these, unfortunately, much the most frequent, making constant attention 
necessary to the preservation of the organs. Occasionally the process begins 
at a number of points, and these, enlarging, finally coalesce, to the destruction 
not infrequently of all the anterior enamel wall. 
Diversity of Opinion concerning.-Concerning the cause or causes 
inducing this condition, much diversity of opinion exists. The present con- 
viction of the author is that the true explanation is enunciated in the electro- 
chemical experiments made by Mr. Kencely Bridgman (see Dental Caries'), 
and that in this direction will be found to lie not alone the cause, but the pro- 
phylaxis. As all that may be said on this subject is expressed in the experi- 
ments themselves, the careful attention of the reader is directed to them. True, 
it would seem to be that back of the immediately-acting cause must lie a pre- 
disposition ; here would seem to be the result of impressions made on the 
enamel at the period of its formation, and which deficiency the nutritive 
functions have failed to correct. It might, indeed, very well be that such 
enamel is entirely deficient in vital resistance, and thus subject to 
be acted on as any inorganic structure; being by electrolytic action simply 
dissolved. To combat such a condition, electrolysis must be negated. If the 
335 336 
A SYSTEM OF ORAL SURGERY. 
assumptions from the experiments of Mr. Bridgman, here made, and which seem 
to the author so rational, be accepted, the treatment of denudation lies with the 
antagonism of electro-chemical action ; this perhaps alone, as devitalized enamel 
might not be aided by vital antagonism. 
Treatment.-Treatment of denudation, in contrast with much 
theorizing, is confined markedly to combating by operative means the ravages 
inflicted, such means consisting in reaming out and filling the cavities with 
metal, as one after another may threaten from its extent and depth. 
ABRASION OF CUTTING FACES. 
Abrasion of the cutting face of the teeth from mechanical causes is a very 
common affliction, and a very unfortunate one. The articulation of the two 
dentures has much to do with the production of such a condition; indeed, 
everything, if we except an abnormal condition of enamel as found in certain 
teeth. Teeth that articulate scissor-fashion, the one set over or in front of 
the other, seldom suffer from this trouble. It is most markedly a result of 
direct articulation. 
Caused by Malarticulation.-Persons having the teeth thus articu- 
lated find these organs wearing shorter year by year; and were it not that, 
as this abrasion goes on, nature offsets the waste by internal repairs, throwing 
out layer after layer of secondary dentine, the dental pulps would be quickly 
enough exposed. 
Influence of Food.-The character of food used, while perhaps it would 
never yield this condition, yet, the predisposition in the articulation existing, 
assists without doubt in the destruction. Thus, it is remarked that chewers 
of tobacco, and sailors eating constantly of hard bread, are most subject to 
abrasion. This is strictly true, however, only as it applies to such as have the 
peculiarity of articulation mentioned, and with such the progress of abrasion 
is commonly very rapid. 
Treatment.-A means of relief in this condition, which, while fairly 
successful, is associated with more or less discomfort, consists in the adaptation 
to the posterior teeth of caps of metal. These caps take the strain of masti- 
cation, and thus protect the teeth. Another mode, but which is apt to excite 
inflammation, consists in cutting out cavities from the abrading faces of the 
teeth, and supplying the place of the removed dentine with plugs of gold. 
This latter plan has many advocates, and is highly commended by practitioners 
of experience and judgment. An indication is to increase the nutritional 
activity of the pulp.* (See Jackson's Gold Tips.) 
* It is not in accordance with the law of loss and repair to hold that dentine and enamel 
remain unchanged after once being formed. It is true that change here is of slow char- 
acter by reason of the limited amount of organic matter and the extreme hardness of the 
inorganic, nevertheless, repair, under such physiological conditions, corresponds with loss; 
were it not so the enamel on the cutting faces of all teeth would be lost in the first few years 
of life. (See Dentition.) CHAPTER XXIII. 
OPERATIVE DENTISTRY. 
INSTRUMENTS USED IN PREPARATION OF CAVITIES. 
We are here introduced to a department of Oral Surgery familiar under 
the name of operative dentistry,-a department which considers the me- 
chanical treatment of carious cavities and other physical defects found in 
relation with the teeth. 
Fig. 159 is reintroduced as illustrative of a perfect denture; to find a set 
of teeth so complete in construction and relation as exhibited in the diagram 
is an experience of exceeding rarity. Teeth so arranged, and free from 
irregularities, seldom decay. 
Fig. 159.-Superior Dental Arch. 
Fig. 160 represents what it may not be unjust to designate the typical 
American mouth. The imperfection of face of the organs illustrated, com- 
bined with overcrowding of the arch and deficiency in the inorganic con- 
stituents of the dentine and enamel, render such teeth the easy prey to disease. 
Cavities found in teeth are of every variety as regards size, shape, and loca- 
tion; dental art exposes, cleanses, and fills, with metal or other material, 
these cavities. Understanding of the instruments used, manner of preparing 
cavities, processes of making fillings, together with associative treatment re- 
quired in the conduct of cases, implies comprehension of operative dentistry. 
337 338 
A SYSTEM OF ORAL SURGERY, 
The subject opens with view of means employed for the exposure and ex- 
cavating of cavities; these means appropriate various instruments known as 
Fig. 160.-Superior Dental Arch. 
excavators, drills, the dental engine, chisels, files, saws, disks, separators, chip 
blower, and water-syringe. 
Fig. 161.-Hoe Excavators and Modifications, 
Excavators.-An excavator is an instrument designed to excavate, or 
clean out, a cavity. Excavators, while variously modified, are founded on two OPERATIVE DENTISTRY. 
339 
Fig. 162.-Hatchet Excavators and Modifications, 
Fig. 163.-Rose Drills and Spear Drills 340 
A SYSTEM OF ORAL SUROERY. 
elementary styles: one, hoe-like in shape, cuts as it is drawn toward the 
operator; the other, represented by the relation of the edge of the ordinary 
hatchet to its shaft or handle, cuts with lateral motion. 
Examination of the diagrams gives a general idea of these instruments. 
Unless, however, made of the finest steel, and shaped and tempered with 
the nicest appreciation and care, it is impossible to execute with them the re- 
quirements demanded. Excavators fit for the hand of an operator should be 
able to endure the test of an unturned edge when used to cut a cavity in a 
piece of ordinary ivory. 
Drills-Rose and Spear.-These express modifications of the ex- 
cavator. When properly tempered they cut with rapidity, and while clearing a 
cavity tend to give convenient shape for the retention of the filling; the spear 
drill is used also for the purpose of securing what are called retaining-points for 
plugs,-a matter to have consideration in connection with particular cavities. 
Drills, like excavators, are made with handle and point in one piece, or are 
fitted to separate handles, which handles may be made of steel, ebony, pearl, 
or more expensive material, to please the taste; the single piece is, however, 
commonly preferred, as being the most convenient form. To use this in- 
strument it is only necessary to rotate it between the thumb and finger, or, 
where pressure is found desirable, the palm of the hand is spared by receiving 
the butt of the drill in a socketed ring or thimble. Drills are also used 
associated with handles, which allow of application at any angle desired. Of 
such stocks there are quite a variety, the most simple of which is perhaps 
that known as Merry's. Fig. 164 exhibits this drill as ready for use. Fig. 
Fig. 164.-Merry's Drill, Ivory 
Handle. 
Fig. 165.-Bur Thimble. 
165 represents the bur thimble. This consists of an open ring for the middle 
or index finger, with a socket attached, in which the end of the handle of the 
drill rests: it saves the hand, while at the same time the instrument is rotated 
with more ease. 
Dental Engine.-A manner of using both excavator and drill now almost 
universal, being a great saver of both time and trouble, consists in the OPERATIVE DENTISTRY. 
341 
Fig. 166.-The White Dental Engine. 
Fig. 167.-The Bonwill Instru- 
ment. 342 
A SYSTEM OF ORAL SUROERY. 
adaptation of these instruments to, and the employment of what is known 
as, the dental engine. This machine, capable of producing several thousand 
revolutions of a mandrel in a minute, carrying at 
the same time a bit with such steadiness that motion 
is not observable, enables an operator to accom- 
plish his end with a certainty and precision to be ap- 
preciated only by him who is familiar with the work ; 
it is a great saver of time and trouble. 
Of these engines there are two general forms : one, 
known as White's, has its individuality in a flexi- 
ble shaft, the other, Bonwill's instrument, is con- 
structed after the type of a human arm. Several 
modifications on the two principles are in the market, 
each laying claim to peculiar and special virtues. 
A capability to act in any direction is given the 
hand-pieces of these engines by means of attach- 
ments. Fig. 168 represents a straight hand-piece; 
the action of it will be recognized by the mechanic. 
G, spindle, or bit-holder; D, sleeve-bearing, to 
which the front and rear portion of the casing are 
attached ; H, adjustable collar, by which any end- 
wise movement of the collar is taken up. The 
rose drill, seen in place, is fixed or loosened through 
means of the slot at its terminal end. The relation 
of this drill to the hand-piece is that occupied by 
the very great variety of instruments used in con- 
nection with the engine. Fig. 169 exhibits an attachment acting 
at an obtuse angle. A dental engine is to be looked on 
in the light of a duplicate hand possessed of an ability to work 
rapidly; it is not an instrument necessary to the accomplishment 
of dental operations.* 
Chisels.-Chisels used in dentistry are of great variety in 
form. Although not employed with a former freedom, their pur- 
pose being superseded in part by disks, they are yet found valu- 
able adjuncts to every operating-case. All cavities in the approximal faces 
Fig. 168. 
Fig. 169. 
* While Fig. 168 illustrates perfectly the action and meaning of a hand-piece, the at- 
tention of a student is to be directed to the existence of quite a variety as to forms 
and pretensions; the latest is known as the cone journal hand-piece. Dental catalogues, 
obtainable by application to the dental depots, keep one informed of the improvements, 
real and so called. Advantages claimed for the cone instrument are,- 
First. It has an absolutely secure and true bur-fastening. When locked, the bur and 
spindle become like one straight and solid piece. 
Second. The working parts are readily exposed for oiling, cleaning, or inspection, with- 
out disturbing the adjustment of the bearings of the spindle. 
Third. The bit can be changed while the engine is in motion, the spindle running as OPERATIVE DENTISTRY. 
343 
Fig. 170.-Some Forms of Chisels used in Dentistry. 
Fig. 171.-Jack's Double-End Enamel Chisels. 344 
A SYSTEM OF ORAL SURGERY. 
of teeth require for their proper exposure the employment of chisels or of 
something representing them. As the various forms possessed by the cutting 
faces of these instruments have evolved out of experience, so a very little use 
of them suffices to show an operator which are to be selected to meet a purpose. 
Fig. 170 shows styles and forms of chisels in ordinary use. A modifica- 
tion on these is known as Jack's double-end enamel cutters. Six 
instruments constitute a set of these last, such set being designed to furnish 
all the forms needed for freely cutting the enamel in separating teeth. Fig. 
171 exhibits these chisels. 
Other varieties of the same instrument are designed for opening fissures, 
making retaining-points, and also for enamel cutting wherever applicable. 
Fig. 172 shows chisels of this kind designed by Dr. Forbes and Dr. Jack. 
Nos. 1, 2, 3, 7, 8, and 9 are known as gouges. Nos. 4, 5, 6, 10, 11, and 12 
illustrate paraboloid chisels. 
A chisel of late device, the invention of Dr. E. P. Brown, is three-edged \ 
it is designed for opening fissures, trimming down walls of enamel, dressing 
the cervical parts of cavities, and to assist in removing calcareous deposits. 
Files.*-Fig. 173 represents a simple straight file, which is to be viewed 
free with the lock released as when the bur is clamped,-a very desirable feature, especially 
when a motor is used. 
Fourth. The facility with which one bit is substituted for another without changing the 
position of the hand-piece in the hand. 
Hand-pieces require continuous attention in order that they work properly. Rust is a 
difficulty. Blood or water when allowed to remain upon the bit quickly rusts it into solid 
attachment with the holder. Oil is a necessity. A hand-piece is to be taken apart at the 
end of each day's operations, and after being wiped thoroughly clean is to be lubricated with 
sewing-machine oil. Where a bit is found rusted, an easy plan to remove the incrustation 
is to rub with oil and lay by for a few days, after which a scouring of quick-lime restores the 
original brightness. Mercurial ointment is recommended as a protection against rust; to 
be used by coating instruments with a thin film. 
Absolute dryness is to be esteemed an essential in the preservation of instruments, no 
other care compensating for lack in this. 
A matter to be borne in mind in the use of all surgical tools is danger in carrying disease. 
As a guard in this direction disinfection is never wisely omitted. Such guard is found in the 
free use of very dilute carbolic acid. In the Hospital of Oral Surgery phgnol-sodique is used. 
* Files require to be kept very clean, not only as disinfection is concerned, but in order 
that they cut properly. At the conclusion of an operation it is well to throw such as have 
been used into a vessel containing soap-water, and after allowing them to remain for a few 
minutes to thoroughly cleanse by means of an ordinary nail-brush. 
Files are instruments which particularly demand fine tempering. Many makes or indi- 
vidual lots are, in this respect, absolutely worthless, either bending or breaking at the 
moment of application. Of the two faults the former is the worse. 
A perfectly-tempered file will accomplish an amount of work that is quite surprising; and 
when met with is to be treasured as a something that is not easily to be replaced. 
Considering the many makes of these instruments offered for sale and carrying large 
recommendation, it is to be suggested as a judicious plan that samples of the different kinds 
be tried with a view of the student possessing himself of the desired practical information. 
Manufacturers, with an idea to economy in the purchases, put up the straight files of different 
numbers in a common package. OPERATIVE DENTISTRY. 
345 
as the base from which all others digress. A file of such form will at once be 
accepted as well adapted to separating approximating surfaces; as, for example, 
the incisor teeth. Simple or, as they are more commonly called, separating, 
files are supplied of different gauges, some being not thicker than ordinary 
Fig. 172. 
Fig. 173.-Separating Files. 
writing-paper; the thickness and variation in size are shown by the 
cut. Nos. 00 to 4 and 6 have one safe side; Nos. 5, 7, and 8 are cut 
all over. 346 
A SYSTEM OF ORAL SURGERY. 
Files-flat, oval, blunt, and pointed-are in favor for separating quite as 
much as for purposes of plug-finishing. Fig. 174 shows such files. Made to 
succeed the straight in the disjoining of all teeth anterior to the molars, perfect 
attainment can be secured. Nos. 13 and 15 are good grades for beginners to 
employ. 
Fig. 174. 
Another general modification is shown in Fig. 175. The forms 
of this apply to the separation of molar teeth. A student is to 
select Nos. 78, 80, and 87. 
File-Carriers.-Carriers designed to render easier the use of 
files have been devised in great variety. The basal idea of such 
adjuncts is found in that one known as the Forbes carrier. The 
cut (Fig. 176) showing this carrier is half the size of the instru- 
ment. The files used are three inches in length and from one-eighth 
to three-sixteenths of an inch in width, and of various thicknesses 
and cuts. The shaft of the carrier extends through the handle, and 
can be adjusted at any point by a thumb-screw at the end. Files 
of shorter lengths can be used and held firmly. 
Miller's File-Carrier.-Fig. 177 shows a carrier designed by Dr. W. 
G. Miller, which is in much favor with operators. This appliance, with the 
different frames and heads shown, will hold and carry files and saws in any 
position desired for operations on the teeth. Frame No. 1 is jointed, so that 
the head can be passed on to the top of it and carry the file at any slope, as 
seen in No. 3. No. 1 head is also notched, so that, when in a direct line, the 
top of file drops in the notch, as seen in No. 2, which greatly adds to its rigidity 
in place. No. 2 frame carries the file or saw rigidly in a straight line, and also 
at an angle; besides which, its shape at one end allows the head to pass to the 
place shown in No. 3 and hold the frame at any slant desired. OPERATIVE DENTISTRY. 
347 
This carrier, with its three heads, as shown, admits of changing direction 
and slant very quickly. With either the No. 1 or No. 2 it is complete 
for use. The No. 3 is desirable for holding files to cross-cut and separate; 
Fig. 175. 
rigidity is gained by the bow-spring form of frame. A friction-block in the 
cavity of the head, between the frame and end of screw, insures very firm 
holding of the frames, so that they will not slip. 
Fig. 176.-Forbes's File-Carrier. 
Line's File-Carrier.-A still later design of file-carrier is one devised 
by Dr. J. Edward Line; a particular virtue lying with this instrument is that 
it enables an operator to utilize what would otherwise go to waste,-namely, 
the best part of broken files. This carrier, together with others, is met with 
figured in dental catalogues, which see.* 
Saws.-Saws for separating teeth are an outgrowth of the dental engine. 
Delicately handled by the experienced, they meet the indications with a degree 
of perfectness which, so far as molar teeth are concerned, make them favorites 
with all. These saws are circular in form. (See Fig. 178.) 
* To get an illustrated dental catalogue it is alone necessary to write to any dental depot. 348 
A SYSTEM OF ORAL SUROERY. 
Fig. 177.-Miller's File-Carrier. 
Clapp's Saw-Carrier.-This is a carrier hold- 
ing a knife-blade saw. It is found of much use in 
finishing plugs. 
Kaeber's Saw-Carrier.-This is a favorite 
frame used by many operators. Its use is one with the 
Clapp frame. 
Corundum Disks.-Disks made of corundum, 
Fig. 178.-Knife Edge. 
Fig. 179.-Side View 
of Disks. 
Fig. 180.-Disks of Corundum. 
used with the engine, are in general use as a means of 
separating teeth. Fig. 179 represents a side view of the 
instrument. To apply a disk of this brittle material OPERATIVE DENTISTRY. 
349 
requires a delicacy of manipulative tact to be gained alone out of experience. 
One unfamiliar with its use breaks the piece almost at the moment of applica- 
tion. Students are to master chisel and file before passing to disk and engine ; 
the latter are luxuries, not necessities, in practice. It is not to be overlooked 
that some of the best art work accomplished to-day is done by operators owning 
neither disks nor engine. 
The object both of saws and corundum disks is to overcome diffi- 
culties and disadvantages residing undeniably in the file and chisel for the 
purpose in view. This they do in an effectual manner. 
Advantages claimed for the corundum disks over other means now 
known for the purpose of separating are,-1st. By their use the requisite cut- 
tings are made in a manner least disagreeable and painful to the patient. 2d. 
The separated surfaces can be polished quickly and perfectly. 3d. The disjoin- 
ing is done with rapidity, as the disks readily grind away the hardest enamel. 
Other Means of Separating.-For other means of separating see 
Complicated Cavities. 
Drop-Tubes.-Drop-tubes are a necessity in the use of rapidly-revolving 
instruments. These, as shown in the cut, are little affairs constructed with 
Fig. 181.-Herrick's Fountain Drip-Point. 
a view to the continuous dripping of water; a very good one, conveniently 
manipulated with the finger, is a suggestion from the practice of Dr. F. Her- 
rick. It is not necessary to make attachment with the hand-piece, as here 
shown, although such a relation adds to the convenience of the operator. 
Chip-Blower.-A chip-blower is an ordinary air-syringe. Several kinds 
are made. They are used by hand or are attached to the engine. Hot or 
cold air is employed as desired. With most persons the chip-blower is 
replaced by a water-syringe. 
Water-Syringes.-A water-syringe is needed for the purpose of freeing 
a cavity of detritus accumulating 
from excavation. Manufacturers 
prepare these in great variety. One 
here figured answers every purpose, 
without being at all expensive. 
Concluding the subject here con- 
sidered, it is to be added that a student acts wisely who defers the employ- 
ment of a dental engine and its apparatus until he has educated his fingers to 
accomplish ends by simple means. 
Fig. 182.-Water-Syringe. 350 
A SYSTEM OF ORAL SURGERY. 
Exposure of Cavities.-To distinguish the existence and peculiarities 
of carious cavities, dental art employs, in its ordinary examinations, excavators, 
separators, probes, silk thread, and wedges of rubber and of wood. 
Cavities situated in the grinding faces of the bicuspidati and molars are 
discoverable to the most superficial examination, it being alone necessary to 
apply a sharp instrument to expose the soft character of the structure. Cavi- 
ties between teeth, if at all sizable, are distinguishable by insinuation of an 
excavator: where superficial, the passage of the silk thread will discover enamel 
deficiency. Rubber or wood wedges placed between suspected teeth dis- 
part the organs and admit of free exposure. A probe is useful as reference is 
had to a search after pin-point cavities; the instrument is to be of spring 
temper, and the point is to have the acuteness of a needle. Light is at all times 
a requisite; no better means of obtaining this is to be found than lies in the 
use of reflecting hand-mirrors, every variety and size of which are to be found 
at the depots. An ophthalmoscopic glass known as Anagnostakis's not only 
reflects powerfully but magnifies extensively.* Electric lights are in quite 
common use. 
The employment of cold water is found valuable in exposing the existence 
of a cavity, and as well in furnishing idea as to proximity of pulp; it is used 
by being thrown from a syringe over the suspected locality. The existence 
of cavities is to be inferred, ceteris paribus, where sweets or acids, hot or 
cold articles of diet, are found to disturb the comfort of the teeth. 
* For dental purposes this glass is reduced to a circumference of six inches, with a focal 
point of two inches. For concentration of light-rays, and for magnifying power, this 
mirror shows itself everything to be desired or that is required in the direction; human 
incisor teeth are made to approximate those of the horse in size. CHAPTER XXIV. 
OPERATIVE DENTISTRY. 
EXCAVATION, OR PREPARATION, OF CAVITY FOR FILLING. 
Having considered the kinds of instruments used in the process of pre- 
paring a cavity for its plug, or filling, we pass to the subject itself. 
Simple Cavities.-First we treat of simple cavities,-i.e., holes more or 
less round, situated in the grinding faces of molar teeth. Fig. 183 shows 
such cavities. 
Caries, as seen in the cut, varies as to the extent and character of the hole. 
In teeth of solid structure the orifice commonly represents the extent of cir- 
cumferential involvement. On the contrary, where 
tooth structure is loose and disposed to degeneration, 
a small orifice is not infrequently found leading 
to extensive underlying disorganization. To 
prepare such cavities for filling, an operator may 
use either excavator or drill; the most simple 
means, certainly the most expeditious, is found in 
the drill. Selecting a size suited to the opening, 
the operation consists simply in reaming out the hole, the single precaution 
being observed of having the common diameter of the outlet as large as the 
cavity. 
In cases where, after breaking through an entrance, a large cavity is found 
to exist, drill after drill of increasing sizes is to be employed, thus making such 
entrance correspond with the cavity being made within. Or, in such instances 
as present a resisting enamel, the orifice is most conveniently to be en- 
larged by use of a chisel. Selecting such chisel of suitable size, the oper- 
ator, little by little, chips away the operculum until the circumference of the 
diseased dentine is exposed; this accomplished, it remains only to refer to the 
drill or the excavator. In using a rose drill precaution is taken to avoid 
evolvement of discomforting heat ensuing from rapidity of rotation, which is 
done by careful drilling, or otherwise through the frequent dipping of the 
instrument in cold water, or still else by the use of a drop-tube. 
Fig. 184 represents cavities of a kind frequently found on the posterior 
face of incisor teeth. Such cavities correspond closely in their mode of 
preparation with those just described. A peculiarity occasionally observed 
exists in the tendency of a delicate line of disease to start from the bottom of 
Fig. 183. 
Simple cavities on grinding 
face of molars. 
351 352 
A SYSTEM OF ORAL SURGERY. 
the common cavity, making its way directly toward the pulp-chamber. Where 
such line is found, it is neither necessary nor desirable to associate it 
with the first cavity otherwise than by a reaming correspondent with its own 
diameter : should it be found to increase greatly 
in sensibility as it approaches the pulp, experi- 
ence has demonstrated that it is the best plan 
to allow a portion of the diseased dentine to 
remain; harm is not apt to ensue from its 
presence if it be disinfected and put in a state 
of neutrality. Rose drills are commonly 
used, to the exclusion of other instruments, in 
the preparation of these cavities, although the occasional convenience of the 
excavator is not to be denied. Great care is to be exercised in such cases, as, 
indeed, in all others, to have the orifice of the cavity sharply defined in its 
circumference; if it is strictly round so much the better, as thus the material 
used in filling can be made the more easily to associate harmoniously with it, 
such union being an absolute essential to the integrity of a plug. 
Fig. 184. 
Cavities on posterior face of 
incisors. 
Fig. 185. 
Fig. 186. 
Fig. 187. 
Cavities at neck-anterior 
face-of incisors. 
Cavities found in the midst 
of imperfect enamel. 
Cavities on buccal face of 
molars. 
Fig. 185 represents what is to be described as the third class of cavities ; 
these being very frequently met with in the position shown in the cut. A 
more common location, however, is on the buccal face of the molar teeth in 
a sulcus about midway of the face. (Fig. 187.) 
When a cavity is situated as seen in the drawing (Fig. 185), part of it 
being overlaid by the gum, it is found most convenient to remove a por- 
tion of the carious dentine by the use of an excavator, and to stuff the hole 
thus secured with a cotton filling, which cotton is to be allowed to project to 
some little extent; this filling, as it absorbs moisture and swells, naturally 
throws the gum from off the roof of the cavity, thus allowing the completion 
of the excavation as described in previous cases. The cotton is to remain in 
a cavity overnight. 
Fig. 186 represents a condition of imperfect enamel, in which is fre- 
quently found a number of pits : if examination, made with a sharp excavator, 
show the bottom of such pits to be enamel-covered, they need not be filled ; if, 
however, the point of the instrument is found to stick, or wedge, then it is best 
to ream out with a spear or rose drill and plug: not to treat such cavities is 
to allow caries to destroy the teeth. Unless of themselves running into each 
other, the cavities are not to be associated; situated on the buccal faces of the OPERATIVE DENTISTRY. 
353 
molars, such holes are to be reamed out with the rose drill. A complication 
found frequently to exist is where, starting from such a point, it may be in 
an abrasion near the neck of the tooth, 
the disease extends laterally, scooping 
out, as it were, a cavity (Fig. 188) : 
here the excavator is found most ap- 
plicable, while the employment of the 
chisel to uncover the caries is, not un- 
likely, made necessary. In excavating 
cavities of this aspect, it is common to make a slight undercut immediately 
beneath the enamel, this being useful for support of the filling. 
Fig. 188. 
Cavities on buccal face of molars. 
Complicated Cavities.-From cavities situated as described, we pass 
to a consideration of others so related as to demand for their exposure not 
only the exercise of considerable ingenuity, but such clinical data as shall 
show what extent of chiselling, filing, or pressure is permissible; not alone as 
the endurance of the teeth is concerned, but as reference is had to appearance 
and, where possible, to self-cleansing surfaces. 
Fig. 189. 
Carious denture. 
The denture seen in Fig. 189 is a type of many. On the left hand are 
shown teeth as involved by the caries when a patient presents himself. On 
the opposite side are represented the same cavities when made ready to receive 
the fillings. The second and third molars of left side, however, are utilized 
to exhibit cavities prepared for what are known as contour plugs. 
Approximal cavities are to be exposed by V-shaped filing.* This is 
* Most decided objection is made to such manner of exposure by a large class of operators, 
-a matter which will receive proper consideration in the paragraphs on contour filling. 354 
A SYSTEM OF ORAL SURGERY. 
a common rule, yet having exceptions, as hereafter to be explained. A 
central incisor tooth, decayed upon a surface concealed by its neighbor, the 
relation of the teeth being as exhibited in the diagram, the operation of ex- 
posure is commenced by passing a delicate separating file between the two 
teeth, a shoulder being left at the neck, which is to prevent the future falling 
together of the cut faces. Space for the play of the file being thus secured, 
the first instrument is replaced by a second, this latter being curved in its 
blade (Fig. 174, Nos. 10 to 14), and having a single cutting surface, which is 
slightly convex. 
Use of Convex File.-Using a convex file, it is plainly seen that it is 
only necessary to incline the free face against the tooth not to be cut, that an 
inclined plane looking inward shall be made upon the affected one. When 
the decay is common to both teeth, double filing is seen to make a V-cut with 
the base backward. Looking at the central incisor on the right of the dia- 
gram, the cavity (shown on the right incisor) is found placed on an inclined 
plane, all its parietes being exposed and easy to get at. This desirable ex- 
posure has been the result of the filing. The tooth, while widely separated 
from its fellow behind, affording plenty of room for operating, shows in front 
but the space made by the passage of the delicate straight file. This mode 
of separating applies to the six anterior teeth. 
Use of Chisel.-After making the primary cut, with a separating file, 
between the teeth from the front, it is a habit with many operators to rely 
for the back separation principally on the chisel. If handled delicately, 
there is perhaps little doubt that this instrument is found less disagreeable to 
patients, and, when used very sharp and of proper curvature, it assuredly will 
satisfactorily .accomplish the work: the file, however, is commonly employed 
to finish the separation, affording, as it does, a smoother surface than that left 
by the chisel. 
An approximal cavity, without complications, thus exposed (see central, 
lateral, and cuspid teeth in diagram), nothing remains but to treat it as the 
simple cavities before described,-that is, cut away the carious dentine and 
form the hole of a shape to retain the filling. Such excavating is generally 
done with hoe and hatchet instruments, the head of the patient being thrown 
backward. The rose and spear drills, however, 
are found at times convenient of use, particu- 
larly where the cavity, being of a saucer-shape, 
requires what are called retaining-points. 
Increase of Complication in Cavities.- 
The cavities just described, while departures from a 
simple type, are yet of such limited size as to have 
made little alteration in the front or back faces of the teeth. From the con- 
sideration of such we pass to a class represented in Fig. 190, where, as seen, 
the labial face is markedly affected. 
In examining these teeth with view to mechanical treatment, let the student 
Fig. 190. OPERATIVE DENTISTRY. 
355 
draw a transverse line midway between the cavities and the gum. From this 
first line let him drop vertically others which shall just include the carious 
breaks on the faces of the teeth. 
Where the cavities are no more extensive than exhibited in the diagram, it 
is found that the file, removing all between his lines, will yield no deformity, 
but afford, on the contrary, a space possessed of healthy look and not unbe- 
coming singularity. As a next step, let the convex-faced file be used, 
cutting wider the space posteriorly, so as to allow the cavity to be seen only 
from that surface. He has thus his cavities in the same position and relation 
as exist in the cases previously described. 
A second complication in such order of cavities is where the affected 
teeth are so related with each other and to the arch, and the holes of so exten- 
sive a character, as to make any alteration in the outlook impossible. Cases 
of this kind are found where caries has extended its ravages over half the 
anterior face of a tooth, or where a tooth has such position in the arch that 
what should be the approximal surface is found looking almost directly for- 
ward, the organ being twisted, as it were. Conditions of such expression are 
commonly treated by excavating in any manner found convenient, 
the original contour of the tooth being restored by the filling ; otherwise such 
teeth may be filed in front until resisting parietes to the cavities are found, 
and then treated precisely as in the case of the posterior V. Outlooks having 
the base of the V presenting forward are of course objectionable, but many 
teeth so treated-the fillings being of gold and highly finished-are far from 
unsightly. (See Contouring.') 
Another class of complications exists in teeth related as in Fig. 191, 
the central incisors being the organs consid- 
ered. In cases of this kind it is scarcely prob- 
able, by reason of the overriding, that either 
file, chisel, or disk will be found admissible; 
it is plainly seen that no expedient will 
apply to prevent the cut surfaces falling 
again together. In exposing the cavities in 
these cases,-if found, as is usual, on the covered surface,-the means employed 
is that of pressure, either a wedge of some soft wood or a section of tough 
rubber tubing being employed.* Of the two means, the immediate wedging 
by wood is found to produce least pain, a wedge of the proper size being 
driven delicately between the teeth until sufficient room to work at the cavity 
has been secured. Where the india-rubber is used, it is common to exert 
Fig. 191. 
* An instrument freely used with a view to disparting is known as "Jarvis's Sepa- 
rator." Two forms are shown by the cuts: of the first there are three sizes, Nos. 1, 2, and 
3, No. 1 being the largest. Nos. 4 and 5 show forms of compound signification; these are 
deemed particularly applicable to the incisor teeth, and are employed for the assistance 
rendered by them in the application of the rubber dam. For illustrations of many other 
forms of " Separators," see catalogues furnished on application by dental depots. 356 
A SYSTEM OF ORAL SURGERY. 
the pressure gradually, pieces of increasing size being introduced day after 
day until the desired separation is obtained. Objection to this latter means 
Fig. 192.-Jarvis's Separators 
No. 1. 
No. 2. 
No. 3. 
No. 4. 
No. 5. 
of separating teeth lies in a soreness provoked, the subsequent operation of 
filling being at times rendered so painful as to be nearly, if not quite, unbear- 
able. In using a wedge of wood, the separating, excavating, and filling 
are to be done at the same sitting. To introduce such a wedge, orange or 
pine being employed, it is found most convenient to cut it on the end of a 
stick of some length, nicking deeply at the base of the wedge. It is thus 
easily thrust by the hand between the teeth, or allows of the convenient ap- 
plication of the required blows from a mallet. When got into place, the 
wedge is cut or broken off at the neck. 
Referring again to the diagram, Fig. 191, another modification is found 
in the relation of the lateral incisor of the right side to the central. As in the 
case of the central with its fellow, this is seen also to override, but it differs 
from the first in possessing an impinging surface, continuing from cutting 
edge to neck. Teeth so related are to be separated, first, by a wedge in- 
troduced at the neck; and, second, space thus secured is to be increased by 
the file, the cutting, however, to be so directed as to leave at the neck an 
unfiled portion which shall prevent the parts falling again together after the 
removal of the wedge. To excavate and fill a cavity in such a situation would 
seem to be a very difficult matter, and, indeed, will be found so, unless the 
operator forces for himself sufficient space, and which in all instances is to be 
effected, wedges of wood or india-rubber and the file or disk being used as 
found necessary. It is to be accepted as a rule that file or disk is to be 
only used where after-changes are not to bring cut surfaces in contact. 
Still another modification is exhibited in Fig. 193. Here the soft 
parts are found somewhat receded, the necks of the teeth being exposed. In 
the approximal surface of each tooth near the gum is a cavity of deqay. To OPERATIVE DENTISTRY. 
357 
get at such a cavity, the space made by nature in the V-spaces seen in the 
diagram may be all-sufficient. If this should not be the case, then the 
wedge is employed, being driven midway between the cavity and the cutting 
Fig. 193. 
Fig. 194. 
edge. Such cavities being excavated and filled, the teeth are allowed to fall 
together. It must be seen that the misfortune of fillings so placed lies in 
absence of self-cleansing properties, compelling thus continual care for the 
preservation of the teeth. To obviate such objection, the use of reamer or 
chisel has been advocated, scooping out a V-space which is to extend from 
the neck to the cutting edge; treating such teeth, indeed, precisely as de- 
scribed with the uncomplicated cases,-a plan undoubtedly to be preferred 
where no lateral pressure exists to force the cut surfaces together. 
In Fig. 194, representing the six inferior anterior teeth, the same condi- 
tion is exhibited as shown in previous cut. Here cavities are frequently found 
in the interspaces. The plan of treatment is, of course, the same. 
Other modifications connected with the anterior teeth are not infrequently 
encountered, but with the general ideas here given the ingenious student will 
find in his own skill, after a little experience, all the directions required. 
Separating Teeth.-In deciding on a mode of separating teeth, a prac- 
titioner finds constant demand for the exercise of judgment. It is to be laid 
down as a rule that never more than two teeth are to be undergoing the process 
in the same mouth at the same time. When rubber is used, and it is 
an accepted and reliable means, it is proper practice to allow plenty of time 
for the operation ; from two to five days being the average required. When 
soreness arises no increase in the thickness of the rubber is to be made until 
the pain has subsided. Further, it is to be accepted that young teeth endure 
displacement better than old ones ; indeed, it seems to be a common conclusion 
that separation of the teeth in persons over forty years of age is to be made 
with safety by means of file or disk alone. (See Separating Instruments.') 
Modification of Excavators.-A modification of excavators, as ex- 
hibited in Fig. 195, will be found invaluable for excavating; indeed, than the 
forms 1, 2, 3, 5, and 6 none better are to be bought; these cannot be too 
highly commended, being recognized to apply to almost every form and position 
of cavity. 
Cavities in Bicuspid Teeth.-We pass now to bicuspid teeth. Fig. 
189 exhibits approximal decay of these organs involving both of the left side. 
Teeth presenting lateral cavities extending to the grinding face, as here seen, are 358 
A SYSTEM OF ORAL SURGERY. 
invariably found scooped out, the carious part being overhung by unsupported 
enamel. To fully uncover such cavities, no instrument applies better than the 
chisel; the operator simply cuts away the operculum, directing, where possible, 
Fig. 195. 
the greatest breadth of the cut inward ; such manner of exposure is expressed 
upon the opposite side of the diagram, where, as is seen, the cavities are fully 
opened upon the sides of inclined planes, while the anterior faces of the teeth 
are not at all disturbed, the cavities being put into a position and aspect in 
which they may be esteemed as simple and without complication. Contouring 
is here particularly to be considered. 
Complications in Cavity Relations.-A first complication in this 
direction is to be described as an approximal cavity associated with a second 
occupying a sulcus on the grinding face of a tooth. Here a plan pursued by 
many consists in exposing the first cavity, as just directed, and this accom- 
plished, preparing the second precisely as any simple crown hole. If the two 
be entirely separate, healthy dentine lying between, each is to be treated as a 
distinct cavity; if, on the contrary, there be found the slightest association, 
the two are joined by cutting out the septum which relates them. 
A second complication is found in the existence of that extent of 
decay which has so weakened the front or back wall of a tooth as to make the 
removal of the wall necessary. Such condition is unfortunate, as it renders 
the operation of filling more difficult,-except, indeed, to the experienced, 
who are able to adopt the plan of making a contour filling,-that is, building 
up with metal the part lost. To prepare such a tooth for its plug, the operator 
finds himself compelled to cut wherever the softening leads. This he does, 
using the chisel,-chipping away the weak parts little by little, desisting 
only when evidences of disease are passed. Commonly, teeth so decayed are 
found with pulps exposed; if this prove not the case in any particular in- 
stance, the question of how the required filling is to be retained becomes of 
essential consideration in the cutting of the cavity, the answer mostly existing OPERATIVE DENTISTRY. 
359 
in the formation of retaining-points. Retaining-points are slots cut out of 
the dentine, acting as places of anchorage ; fillings in such teeth being made- 
when gold is used-of that form of the metal known as cohesive; it being 
understood that gold so prepared can, with all facility, be attached piece to 
piece until any desired form is built up. (See Cohesive Gold.} 
Another complication, met with occasionally, consists in cavities meet- 
ing in the middle from either approximal surface. Such cavities are treated 
by cutting away the overlying grinding surface, thus making a common hole, 
which hole occupies, perhaps, the whole body of the tooth. Thus exposed, 
this common cavity is excavated and cleansed precisely as though it were, 
what indeed it has been made, a deep crown decay. (See Matrices.} Such 
a cavity necessitates contour work. 
The most common form of decay found in bicuspid teeth, the approximal 
excepted, is that situated in the sulcus between cusps. Where this is simple, 
it is prepared for filling by reaming it out at either extremity with a delicate 
spear drill, and connecting the two drill-holes by the employment of excavator, 
chisel, rose bur, or other convenient means. 
A modification on this single groove is frequently met with in a middle 
point of division that is entirely healthy. If such septum be of reasonable 
size, it may be allowed to remain, and each cavity be reamed out separately. 
When, however, the slightest doubt exists as to the integrity of this inter- 
mediate portion, it is the safer plan to remove it, thus making the two cavities 
one. 
We refer now again to diagram, Fig. 189, and observe the relation of the 
approximal faces of the first and second molars as seen on the left side. These 
teeth, while presenting at the angles a healthy aspect, are yet found to have 
cavities midway of this face,, which cavities, as thus situated, have only been 
discovered by the insinuated point of a delicate excavator, or, what is more 
likely, the passage of a silk thread. Referring now to the opposite side, the 
cavities are found prepared. The exposure has been accomplished by the use 
either of chisel, disk, or files. The cavities, before unseen, now exhibited 
upon the sides of the inclined planes, are recognized to have surfaces that 
allow fillings placed in them to be self-cleansing. 
Grinding Faces of the Bicuspidati.-Passing to the grinding faces 
of these same teeth, cavities of decay are seen running out over the lateral 
walls. The excavation of these is accomplished simply in following the sulci 
wherever they lead, bearing in mind that said excavation is to be of such 
character as provides for the retention of the filling ; that is, that at all aspects 
the cavity is to have a wall slightly concave. Sometimes, when much depth 
has been attained by that portion of the decay situated in the crown, and per- 
haps as well that upon the side,-the connecting sulcus being of slight signi- 
fication,-it is good practice to scoop out this intervening portion, without 
regard to the shape of the walls, and to carry the gold, arch-like, into and 
over it from one plug to the other. 360 
A SYSTEM OF ORAL SURGERY. 
Approximal Faces of Molars.-Referring now to the approximal 
faces of the second and third molars, left side, attempt has been made by the 
artist to represent cavities in these teeth prepared for contour fillings,-a plan 
of excavating all approximal cavities of any extent in the bicuspidati and 
molars growing rapidly in general favor, and certainly contributive to an 
ability to make beautiful operations. First, it is seen that a separating file or 
disk, slightly V-shaped, has been passed between the teeth. Next, the cavities 
have been excavated, being cut directly down from the crown surface, and 
have been so shaped that in putting in the metal the operator finds himself 
able to work directly from this crown surface. These teeth are so prepared 
that when filled the operation restores fully the portion lost. 
Excavating for Contour Filling.-The excavation of teeth-molars 
or others-for contour plugging is to find direction in experience. It is to be 
recognized that the idea and intention are to repeat in metal what has decayed 
or been cut away. In proportion as the part removed has been extensive, so 
is it to be recognized that proportionate difficulty will exist in securing fixed- 
ness for the plug. 
Contouring has undeniably become the common favorite plan of operation, 
and it is not less common to find separation denounced as being little 
less than one with the loss of a tooth so cut. The author, in his position of 
writer of a text-book, is not concerned to agree or disagree with the advocates 
of the two systems, finding his duty accomplished in leading a student forward 
step by step from the simple to the complex. 
General Rules for Excavating.-In excavating cavities of any class, 
certain general rules are to be observed and practised: 
1. A cavity is to have such exposure as affords room to introduce 
a filling properly. 
2. Walls are to be made as perpendicular as a case admits of, and 
the margin of a cavity is to be at right angles with the surrounding surface. 
3. The orifice of a cavity is to be without fissures or irregulari- 
ties wherever these may be avoided; it must have firm, decided margins, and 
must be supported solidly by underlying dentine. Roughness or brittleness in 
the edges of a cavity is most objectionable. 
4. In excavating a tooth, regard is to be had to the proximity 
of the pulp. This organ is not unnecessarily or carelessly to be exposed, nor 
to be too closely approached ; for if the first, the case is immediately changed 
from simple to complicated; if the latter, the pulp is apt eventually to become 
chronically inflamed, and to die as a result of the thermal irritation arising 
from the presence of the filling. It is not permissible to file or chisel or disk 
a tooth too freely, except where regard is had to density. A tooth of loose 
texture not infrequently has an irritation of the dentine and pulp provoked 
by the removal of even a slight portion of its enamel; on the contrary, one 
of dense structure is commonly to be cut with considerable impunity. 
5. In cavities having radii running from a common centre, OPERATIVE DENTISTRY. 
361 
which radii may not with propriety, on account of their extent, be included in a 
single round hole, care is to be observed that the extremities be rounded; 
never being allowed to retain their natural sharpness or fissure-like aspect. 
In the process of excavating teeth a practitioner finds it necessary to employ 
freely the water-syringe for washing away the debris. A mouth-mirror, used 
for casting additional rays of light, or for showing more conveniently the cavity 
at which one is working, is found of much service. 
Tact and Rules.-Tact yields the largest measure of .success in the pro- 
cess of preparing cavities. Rules, while well as a means for general direction, 
are always wisely laid aside by him who finds in his own ingenuity better 
means for accomplishing ends. A student gains much advantage in studying, 
and in excavating teeth out of the mouth, and such practice cannot be over- 
sufficiently commended to a learner.* 
Practice out of the Mouth.-Teeth to the number of sixteen, cor- 
responding as to classes and relation with a natural denture, are to be arranged 
in the form of an alveolar arch and supported by plaster of Paris built about 
them in the form of jaw-bone and gum. The delicacy of manipulation required 
not to break the plaster compels acquisition of a proper refinement as to touch. 
* If undue pain be suffered by a patient in the operation of removing carious dentine, 
obtunding agents are to be used. (See Sensitive Dentine.) 
Herbst's Obtunder.-An obtunder for sensitive dentine recommended by Dr. William 
Herbst has its description given as follows: It consists of chemically pure sulphuric acid 
saturated with hydrochlorate of cocaine. By stirring with a glass rod the salt will be perfectly 
dissolved. To this solution add sulphuric ether till supersaturated. It must be stirred gently 
with a glass rod until well mixed, but not shaken, as the latter might cause the bottle to 
burst unless the cork were driven out. The ether that is not taken up may be allowed to 
evaporate. A little of this preparation, applied to the sensitive dentine on a pledget of 
cotton, produces an excellent effect. When one layer of dentine is obtunded another appli- 
cation is to be made. It is not necessary to give proportions, as the solution of sulphuric 
acid and cocaine is a saturated one, and the ether added to supersaturation. The cocaine 
and ether obtund the momentary pain caused by the sulphuric acid. 
Nitrous Oxide Spray as an Obtunder.-Dr. Gr. L. Curtis demonstrates that a most 
satisfactory obtunder of sensitive dentine, if indeed one not wholly so, is found in the use 
of atomized nitrous oxide. (See, for manner of use, the chapter on Anaesthesia.) CHAPTER XXV. 
OPERATIVE DENTISTRY. 
RELATIONS OF MOISTURE. 
No tooth is likely to be filled perfectly that has not been operated upon 
under absolute exclusion of moisture. 
A tooth is protected against the salivary flow, and against moisture from 
the breath, through various means now to be considered. 
Dental Napkin.-A dental napkin is an oblong square of linen vary- 
ing in size to suit the idea of the operator ; dimensions found convenient are : 
length, twelve inches; breadth, three. In applying this napkin to the upper 
denture, it is folded upon itself in part obliquely, until one end is brought to 
a point. Beginning with this point, the linen is laid delicately and smoothly 
between the gum and cheek, being carried backward or forward according as 
the initial end may have been placed, until turned into the mouth at a con- 
venient distance from the organ to be operated upon, it is made thus to en- 
velop it, being supported on either side of the arch by the fingers of the 
operator's left hand. 
Napkin applied to Lower Denture.-Applied to a lower denture, 
the napkin is first folded upon itself into a ribbon shape of an inch in width ; 
second, the initial extremity is back-folded until a pad is made which corre- 
sponds in length to its width ; that is, being an inch each way. This pad is 
to be laid upon the floor of the mouth directly back of the incisor teeth, thus 
covering the orifices of the ducts of both the submaxillary and sublingual 
glands, which orifices it is the design to compress; from this point it is carried 
around the arch into the vestibule as required. 
To hold the floor pad firmly in place, as is demanded, various plans 
are adopted. A common one, where the tooth to be filled is upon the right 
side of the jaw, is for the operator himself to fix it by the thumb of the left 
hand, while the index finger is extended over the part occupying the vestibule. 
Where the tooth to be shielded is upon the left side, the index finger of the 
right hand of the patient is employed, the three remaining fingers being 
flexed out of the way beneath the chin. 
Flagg's Tongue-Holder.-As encroachment of the saliva constitutes 
about the most troublesome offence in dental operations, ingenuity has been 
extensively exercised for its control. Fig. 196 represents a tongue-holder 
devised by Dr. J. Foster Flagg. 
362 OPERA TIVE DENTISTR K. 
363 
It will be found that the use of this instrument insures additional facility 
to the operator, and maintains the tongue in position with comfort to the 
patient, causing neither fatigue nor unpleasant sensation, even removing desire 
to resist constraint. To apply it a fold of napkin, or a small piece of muslin, 
Fig. 196.-Flagg's Tongue-Holder. 
is placed under the tongue, and then covering that organ by back-folding the 
napkin, or by placing another small piece of the cloth upon it, the holder is 
put in position nearest the side where it is proposed to operate, and the patient 
is requested to retain it in place, using his right hand if the cavity be on the 
left side, and the left hand if the cavity be on the right side. The elbow is 
to rest upon the arm of the operating-chair. 
Morrison's Compressor.-Another instrument, a modification of an 
ingenious invention by Dr. Hawes, bears the name of Morrison's Compressor. 
(See Fig. 197.) The diagram fully illus- 
trates its working. The napkin being put 
in place beneath the tongue, is held by the 
bars of the curve, the cup receiving the 
chin, the ratchet-work approximating and 
holding the two parts in the required re- 
lation. A later instrument of this 
same character is one designed by P. T. 
Smith, D.D.S., the variation consisting in 
the sliding of the bar which supports the 
compress, and in an ability to change the 
position of the chin rest. A still later 
device is a porcelain compressor, the in- 
vention of Dr. Osborn, which highly com- 
mends itself. (See dental catalogues.) 
Dibble's Saliva-Pump.-Fig. 198 
represents a saliva-pump and tongue-holder 
combined, the invention of Dn Dibble. The object of this instrument is to 
facilitate the operation of filling teeth of the lower jaw by keeping the mouth 
free from saliva, and as a means of holding the tongue away from the parts; 
also as a means of propping the upper jaw, thus assisting the muscles which 
keep the mouth open. The application is readily understood in studying the 
illustration. , The instrument is composed of coin silver and hard rub- 
ber, the former heavily plated with gold. A designates the plate which keeps 
the tongue away from the teeth; B, the arm which supports the jaw ; (f the 
Fig. 197.-Morrison's Com- 
PRESSOB. 364 
A SYSTEM OF ORAL SURGERY. 
silver tube and base which fit over the jaw; D, the opening where the saliva 
enters the tube; E, the chamber that re- 
ceives the saliva : a vacuum is made in the 
saliva-chamber by the pressure of the bulb 
I, thereby causing the saliva to flow into 
the opening D; H, the opening where 
the saliva is discharged; G, the exhaust- 
valve. There are two mouth-pieces, one 
for the right side and one for the left side 
of the mouth. The instrument is readily cleaned inter- 
nally by drawing soap and water through it. It must 
not be laid down on its side after using until emptied of 
saliva. 
An automatic saliva ejector, known as Fisk's, is an 
elegant and convenient piece of apparatus in this same 
direction. 
McQuillen's Extension-Finger.-An instru- 
ment serving happily as an adjunct to the managing of 
a napkin by reason of facility furnished for holding in 
place pellets of spunk, bibulous paper, etc., is an extension- 
finger devised by the late Dr. J. H. McQuillen. This 
consists of a silver shield (see Fig. 199), to be worn upon 
the index finger, with a socket on the under surface, in 
Fig. 198.-Saliva-Pump. 
Fig. 199.-McQuillen's Extension-Finger, 
which a steel finger, B, fits. A number of these fingers, 
or bits, bent at different angles, accompany the shield, 
being adapted to meet various requirements. 
Taft's Thimble.-A second form of instrument 
having similar signification with that just described is 
known as Taft's Thimble and Extension. (See Fig. 
200.) This thimble is to be used upon the index or 
middle finger of the left hand. It is also employed to 
aid in fixing the napkin, paper, spunk, or whatever may 
be used to prevent the encroachment of saliva. The 
point of this instrument, like the first, can be extended 
into parts of the mouth where a finger, either on account 
of its diameter, or for want of length, cannot very well go. It is likewise OPERATIVE DENTISTRY. 
365 
found a convenience with which to reach over and draw the napkin firmly 
against the lingual side of the teeth. 
Rich's Duct-Com- 
pressor.-A form of com- 
pressor for the Stenonian 
duct, the invention of Dr. 
Rich, of New York, is rep- 
resented in Fig. 201. This 
forceps and spring assume 
Fig. 201.-Rich's Duct-Compressor 
Fig. 200.-Taft's Thimble 
to accomplish the closure of 
the duct more perfectly 
than any other appliance. 
The spring, used with a pad 
of bibulous paper, or with 
a napkin, prevents all flow 
of saliva, while the tip is 
free to yield to every mo- 
tion ; whereas with a wad 
of napkin in the cheek, the 
lip is tight, while very little 
motion frees the duct, allow- 
ing the saliva to flow. 
When in use, the re- 
curved ends of the forceps 
fit in the recess of the 
spring, closure of the han- 
dles of which expand it. Having placed the pad in position, exactly, opposite 
the second upper molar, release the grasp upon the handles, the spring will 366 
A SYSTEM OF ORAL SURGERY. 
close and the forceps be detached at once. An outer pad may be slipped 
under the spring afterward, if desirable. 
An operative plan of controlling the parotid secretions has been suggested, 
and perhaps to some extent practised, consisting in placing a temporary liga- 
ture about the ducts. This is certainly to be opposed as an unsurgical 
proceeding, and one which might most readily eventuate in stricture. 
Barnum's Rubber Dam.-Of the various appliances designed for 
the control of the salivary secretion, not one has met with so universal 
an approval as what is known as the coffer-dam of Barnum. This means 
consists in the use of a simple sheet of thin rubber, prepared and sold for the 
purpose, into which one or more minute holes are punched for the passage 
of certain teeth associated with a proposed operation. When properly applied, 
even a lower tooth may be protected from the saliva for a period of four or 
five hours, should such time be a requirement. 
In using the dam, the operator starts with the principle that a delicate 
round hole is to be made in a sheet of rubber; this is to be enlarged by pass- 
ing the tooth through it. The rubber contracting tightly grasps the organ, 
putting it in a water-tight dam. 
Applying this dam of Dr. Barnum to an isolated tooth, an inexperienced 
operator would be led to conclude that nothing in its way was left to be de- 
sired ; passing, however, to a case of complicated relation, he would err as far 
on the other side in inferring it to be without value. 
Application of Rubber Dam.-A sheet of rubber may be made to 
enclose one tooth, or several at the same time. We consider, first, relation 
with a single tooth ; this tooth being supposed to stand alone. 
The operator cuts a piece of dam material into a size and shape adapted to 
the want, into the centre of which he punches a small hole. He isolates his 
tooth by forcing it through this hole. This simple procedure constitutes the 
performance. 
Fig. 202.-Depressed Rubber Dam. 
Fig. 203. 
Fig. 204. 
Depressed Dam and Mirror.-In connection with a form of dam, 
known as depressed (Fig. 202 shows it), allusion is to be made to the use of 
a mirror for lighting purposes. Such a mirror is shown in Fig. 203. It is 
fixed in a required position by punching for it a hole in the rubber precisely 
as for a tooth. It is seldom used. 
Where ordinary sheet rubber is employed for making a dam, it will require, OPERATIVE DENTISTRY. 
367 
even when placed on an isolated tooth, to be fixed after a manner that shall 
prevent its slipping off. To such end a strand of common waxed silk is 
tied about the tooth above the sheet. A second suggestion is practised and 
taught by Clinical Professor Dorr. This operator first encloses the neck of 
the tooth to be operated upon by a waxed ligature, the ends of which he 
brings through the perforation in the rubber. This ligature serves not only 
to direct the dam into place, but being finally tied above fixes it firmly. 
Where a tooth to be placed in dam has immediate neighbors on either side, 
not less than three teeth require to be included in the sheet. Here the rub- 
ber is to be adjusted in the mouth, and by means of a soft pencil the position 
of each tooth is marked ; the sheet is then removed and the perforations made. 
The cut, Fig. 204, shows holes adapted in size for, 1, cuspidatus; 2, bicus- 
pidatus ; 3, molar. Perforations are made by means of a punch or by a heated 
blunt steel probe. 
Means for holding Rubber in Place.-The difficulty experi- 
enced in applying and keeping a rubber sheet in place as complicated loca- 
tions are concerned has called out much inventive tact,-first as to application, 
second as to retention. For placing a sheet about the teeth no instrument can 
equal human fingers. Education of fingers, then, stands as the highest ex- 
pression of tact. The principles of the application being understood, a stu- 
dent is to familiarize himself with the work through practice. An instrument, 
duplicating fingers, applicable particularly to forcing the rubber between back 
teeth, is shown by Fig. 205. 
Fig. 205.-Rubber-Dam Applier. 
Clamps.-Clamps to hold the rubber in place take the place of ligatures 
with many operators: these are little circles of metal made with the quality 
of a spring; slipped about a tooth they close tightly, and thus fix the sheet. 
Clamps are of many varieties to correspond with varying indications. Fig. 
20G affords idea of the instrument. 
Fig. 206. 
Fig. 207. 
Forms of Clamps.-A common form of clamp intended for incisor and 
bicuspid teeth is illustrated in Fig. 207. 368 
A SYSTEM OF ORAL SURGERY. 
Another form is a design by Dr. Hickman, and called after his name (Fig. 
208). Still another is known as Elliot's (Fig. 209). 
Fig. 208. 
Fig. 209. 
A clamp, Buckman's pattern, is shown applied, the rubber being in place, at 
the base of the three teeth. (Fig. 210.) 
Invention has quite exhausted itself within the past few years in designing 
tooth-clamps, as is seen in looking over dental journals, the pages of which 
are freely occupied by illustrations of the various in- 
struments. Ottolengui's set, consisting of two pair, 
shown applied (Fig. 211), are worthy of large com- 
mendation. How's Cervix Clamp (Fig. 212), de- 
signed " for holding back the gum from a cavity in 
the tooth-neck," has its application illustrated in the 
diagram. Johnson's Lever Clamp (Fig. 213) is " for 
use in filling cavities which extend under the gum- 
margins of incisor, cuspid, and bicuspid teeth." A 
tongue or clasp engages with the point of the tooth, and a gum-retractor 
projecting from the body of the clamp pushes the gum above the cervical 
margin of the cavity. The side of the clamp is elongated to form a lever, at 
the end of which is a loon throu<zh which an elastic lio-ature is passed. bein<r 
Fig. 210. 
Fig. 211. 
The Ottolengui Clamp applied. 
fastened around the patient's head or neck. The inventor claims that the clamp 
is easily adjusted and that the gum is not disturbed except at the point where 
the work is to be performed, where the clamp acts as a protector. The lever 
holds the lip out of the way,-a desideratum especially in operations on the 
lower teeth. The instrument is applied by means of the Universal Rubber- 
Dam Clamp Forceps. OPERATIVE DENTISTRY. 
369 
Palmer's Ring Clamp.-Palmer's Ring Clamp affords an example of 
ingenuity exercised to overcome difficulties in this direction. Figs. 214 and 215 
Fig. 212.-How's Cervix Clamp. 
Fig. 213.-Johnson's 
Lever Clamp. 
Fig. 214.-Palmer's 
Clamps. 
Fig. 215.-Palmer's Rings 
show clamps and rings. The device consists in the use of a ring constructed 
out of soft round wire. A cavity being exposed, by means of a wedge, if 
necessary, the dam is applied, and the ring, being bent to fit the tooth, is 
forced down upon it. A clamp is then applied to a neighboring tooth. 
Fig. 216. 
Subfig. 1, Fig. 216, represents a right inferior first molar tooth, in which 
four cavities are exposed,-one cervical, one posterior approximal, one crown, 
and one anterior approximal. The wire, which the 
clamps are shown as fixing in position, holds the rubber 
dam below the lower margin of the cervix cavity, and in 
this case extends as low down on the lingual as it is seen 
on the labial surface. Matrices are inserted between 
the posterior approximal surface of the second bicuspids 
and the first molar and between the first and second molars. The wire and 
matrices are held in place by the clamps as exhibited. Subfig. 2 repeats idea. 
Fig. 217. 370 
A SYSTEM OF ORAL SURGERY. 
Fig. 217 shows the means as 
applied to a tooth when standing 
alone, or to a third molar when 
the other teeth are all present. 
Barnes's Adjustable 
Clamp.-A student at the 
Philadelphia Dental College, Mr. 
Fig. 221. 
Fig. 218. 
W. H. McKerrol, has enlisted 
much interest on the part of his 
classmates in a clamp device of 
his preceptor, Dr. Barnes, which 
Fig. 219. 
is of most simple construction 
and made of so manageable a 
material as taggers' tin. Figs. 
219 and 220 show the clamp 
Fig. 22^. 
applied. In the hands of Mr. 
McKerrol it certainly works 
happily. 
" Take taggers' tin, 34 to 36, 
according to the case, English OPERATIVE DENTISTRY. 
371 
gauge, cut it into shape like Fig. 218, turn down the lip and bend the tin so 
as to pass between the teeth, and when in position take a pair of flat-nosed 
pliers and bring the two ends together ; next take the little oval-shaped washer 
(made of German silver with a punch and scissors), slip it over the two ends, 
bend them back, also bending the washer around the cutting edge of the tooth, 
which will support the clamp in position. Now with an instrument push the 
clamp up against the gum far as is necessary, as in Fig. 219. This will sup- 
port the dam and keep the gum from forcing itself into the cavity; the exca- 
vating may be done and the filling thoroughly finished before the clamp is 
removed, thus doing away with the laceration of the gums common in such 
cases." Dr. Barnes uses a strictly similar means for making matrices. The 
use of tin for these cases was originally suggested by Dr. Harvey, of Cleve- 
land, to whom proper credit is given by Dr. Barnes. 
Other Clamps.-Other admirable clamps are devices by E. L. Hunter, 
D.D.S., the Palmer set, Allan's set, Evans's, Lyder's, Barnes's, Holt's, Tees's, 
Longnecker's, Moore's, Bancroft's, and the St. Geo. Elliott's instruments, all 
of which are to be seen illustrated in the catalogues distributed by dealers in 
dental supplies. 
To put on Clamps.-Clamps are put on by aid of forceps, as explained 
in the demonstration afforded by Fig. 221. 
The sheet in place, as teeth are concerned, a matter to consider relates 
to that portion of the rubber outside the mouth. To keep this dependent, 
weights are attached by means of springs to the inferior free borders. Fig. 
Fig. 222. 
Fig. 223.-Rubber-Dam Holder, 
222 affords the idea. To hold it from the lips, springs are caught to the 
upper borders, these springs being related by a band of elastic braid passed 
around the head. This will be understood by reference to Fig. 223. 372 
A SYSTEM OF ORAL SUROERY. 
Application of Rubber to Special Cases.-Application of the 
rubber to special cases claims attention before leaving the subject: 
1. A cavity in the side of a tooth where the cervical wall is below 
the margin of the gum. 
To apply the sheet in a case like this the operator has recourse to cotton 
packing, which will convert the cavity into one of uncomplicated char- 
acter ; a few hours or a few days will suffice to accomplish this. A second 
plan is to ligate deftly into the required 
position a tuft of compressed sponge ; 
if so tightly tied as to render slipping impos- 
sible this will surely expose the neck. Still 
another plan is to throw about the tooth a 
ligature of loosely-twisted silk ; this is 
to be forced gradually about the neck of the 
organ until full exposure is secured; the 
rubber being made to cover this, a second 
ligature forces the sheet upon the first. 
To the last a weight is suspended holding 
the dam in place. A valuable aid in 
forcing gum tissue from about the neck of 
teeth is shown in Fig. 224. 
2. Teeth where the gum overlying a cavity is hard and immovable. 
Cut the gum away. 
3. Partly-developed teeth. The dam applies but poorly. Fill such 
teeth temporarily. 
4. Approximal cavities, the necks being beneath the gum. Wedge 
away the gum by means of soft pine. 
5. Conical teeth. Force the rubber below the base of the double cones. 
6. Cases where the rubber can be applied only at the expense of 
great pain to patient. Use other means. 
Coffer-Damming viewed Mechanically and Surgically.-Me- 
chanically viewed, the coffer-dam is perfect; surgically considered, no means 
employed in dental art is more abused. Where an application compels much 
forcing and bruising of the gum tissue, appliances of different character are 
always to have precedence. Expressed in other words, where the rubber is 
not to be applied without doing an injury to the parts it is best to do without 
its aid. 
The subject is concluded by a suggestion that in proportion to skill 
clamps are rejected ; ligatures answering every purpose of retention, and 
being preferable both because of inflicting less pain and less injury. Facility 
in using the rubber dam is to be found alone in practice. Fig. 225 affords idea 
of a dam as applied to certain of the front teeth. 
Direct drying of Cavity.-A cavity before prepared to receive the 
plug is to have a direct drying. To this end what is known as bibulous paper 
Fig. 224. OPERATIVE DENTISTRY. 
373 
is commonly used; other agents are pellets of old and fine linen, spunk, 
absorptive cotton, etc. 
A manner of drying much employed is the application of direct heat; such 
application is made by means of an air-syringe, the metal bulb of which has 
Fig. 225.-Rubber Dam applied. 
been held for a moment in a flame. Fig. 226, showing such instrument, will 
afford at a glance idea of the manner of its working. 
In filling a cavity on the approximal face of a tooth, it is necessary to 
consider a possible, oozing from parts immediately surrounding the neck. To 
control this-the rubber dam, napkin, or other means suggested failing-some 
Fig. 226.-Hot-Air Syringe. 
operators depend on pads of absorbing paper kept close to the parts; others 
use a wedge of soft pine, forcing it firmly against the gum; others throw a 
ligature of loose silk or a twist of cotton about the neck, working it out of 
the way of the cavity to be filled. Another mode yet-one, however, re- 
quiring care-lies in the use of cauterants, the agents used being nitrate of 
silver, a saturated solution of iodine, or, best of all, chloride of zinc. The 
mechanical means suggested are to have preference, certainly by the inexperi- 
enced, as no ulterior ill consequences are to be apprehended. CHAPTER XXVI. 
OPERATIVE DENTISTRY. 
MATERIALS USED IN FILLING TEETH. 
A cavity properly prepared, a succeeding step is the selection of a material 
with which to fill it. At our present view we treat of such material simply 
as it is found possessed of qualifications to meet mechanical requirements. 
Teeth are filled with a variety of agents; prominent among which are gold, 
tin, amalgam, oxychlorides, zinc phosphates, gutta-perchas. 
Not to depart from the intention of considering first the simple and by 
degrees passing to the complex, the plastics claim a first consideration. 
By a plastic is meant a material of putty-like consistence, which is put in 
its soft state into a tooth, and which quickly hardens. The last four articles 
named in a preceding paragraph are plastics. 
Amalgam.-This is the oldest of the plastics; it consists of hard metals 
in union with a solvent. The hard metals composing a tooth amalgam, com- 
monly silver and tin, are melted together and afterward filed up; the solvent 
is mercury. 
Difference between an Alloy and an Amalgam.-The technical 
difference between an alloy and an amalgam lies with the expression by the first 
of two or more metals combined by means of heat-fusion; the latter is combina- 
tion effected by use of mercury. 
Amalgam is furnished the market by a number of manufacturers ; the price 
is so low that few practitioners care to take the trouble of preparing it for 
themselves. It is recommended, however, that a student familiarize himself 
with the processes and principles of making. 
Townsend's Amalgam.-A standard amalgam, one as largely repu- 
diated in words as it is used in practice, is known as Townsend's formula. This 
preparation stands as the representative of all amalgams ; to appreciate 
this combination is to understand the meaning of a large number of modifica- 
tions on it; indeed, it is not going too far to say that all amalgams are simple, 
important, or unimportant variations on this one common formula. 
Townsend's Formula.-Townsend's amalgam, more properly to be 
called an alloy, is made as follows : Take of pure silver four ounces, of pure tin 
five ounces. Place the first, cut into small pieces, in a crucible quarter filled 
with borax, and when melted add the tin, and stir with a pipe-stem. Next 
pour the molten combination into an ingot, and when cooled, rasp into grains 
374 OPERATIVE DENTISTRY. 
375 
and bottle for use. A common coke or coal fire is sufficient to secure the 
fusion. 
Claims for Different Preparations.-Many manufacturers of amal- 
gam claim many virtues each for his particular preparation. The virtue of a 
tooth amalgam consists in absence of change, as to a tooth-plug made of it, 
either of shrinkage or expansion, and of an ability to maintain a clean, white 
surface and sharp edge. Amalgams obtaining a use more or less wide are 
known as Flagg's, Arrington's, Lawrence's, Weston's, Holmes's, Caulk's, 
Oliver's, and Johnson & Lund's. The Flagg Submarine Alloy sur- 
passes, perhaps, all other where sharpness and solidity of edge are required, 
and comes as near, certainly, to a " Universal Alloy" as has as yet been offered 
the specialty, although its inventor makes no such claim for it; asserting, on the 
contrary, that " it appears to be as impossible to make such an agent as it is 
to prepare a form of gold that shall prove equally acceptable in all cases." 
Weston's soft is admirably suited for use in children's first teeth, being 
easy of removal. Besides the usual combination of silver and tin, various 
other metals are finding their way into the amalgam plastic. Sharpness of 
edge is claimed for the Submarine Alloy by reason of the presence of gold 
entering into its composition. Copper as an element in amalgam plastic 
yields hardness as well as a curative virtue ; objection is blackness of surface 
apt to be begotten of it. Cadmium secures a putty-like mass, which seems 
to be the perfection of a working amalgam ; objection is its injurious effect on 
tooth-bone, and the dirty yellow of a sulphide quickly forming on plugs made 
of it. 
To afford idea as to additions made to the Townsend formula two analyses 
are presented : 
1. 
Silver 47.50 
Tin 47.50 
Copper 5.00 
Gold, a trace of a grain. 
2. 
Silver 38.50 
Tin 59.40 
Platinum .40 
Gold 60 
Cadmium 1.06 
It is common for practitioners at large to depend on a single amalgam; 
some selecting one kind, some another. Accomplished workers in the direc- 
tion use a variety ; five are noted and employed by Dr. J. F. Flagg: one, sub- 
marine ; two, usual; three, contouring; four, front tooth ; five, facing. Sub- 
marine amalgam has a formula as follows : silver 60 parts, tin 35 parts, copper 
5 parts. The variety denominated " Usual" is prepared by mixing one part 
of submarine with two parts of contour. " Contour" is, approximately, silver 
58 parts, tin 37 parts, gold 5 parts. " Front tooth" is a mix of one part con- 
tour with two parts facing. " Facing" is, approximately, tin 50 parts, silver 
30 parts, gold 6 parts, zinc 4 parts. (See Flagg's work on Plastics and 
Plastic Fillings.) 
Submarine.-The article called submarine is, in the experience of the 376 
A SYSTEM OF ORAL SURGERY. 
writer, quite preservative of tooth substance; objection to promiscuous use 
of it lies in a tendency to discoloration, both as plug mass and tooth are con- 
cerned. The use of this particular combination is to be recommended in the 
case of posterior soft teeth, and in instances where operations are not to be 
made without relation with the saliva. 
Usual.-The alloy termed "Usual" is for ordinary operations; front 
teeth excepted, this amalgam is esteemed to work with nice plasticity, to 
shrink but little, to hold good edge, and to discolor but triflingly. 
Contour.-This compound works with admirable plasticity, holds its white 
color exceedingly well, has great edge strength, and is quick setting. Its use 
is to build up broken teeth. 
Front Tooth.-" Front-tooth" alloy is deemed by many as possessing 
marked advantages as a means of preserving incisor teeth where non-inter- 
ference with whiteness is particularly indicated, and where difficulty exists in 
the way of using linings of oxychloride of zinc. This alloy is slow in setting 
and lacks in edge strength. 
Facing.-"Facing" alloy is most resistive of discoloration; its use is in 
situations exposed to sight. An incisor tooth having its labial wall wanting has 
been built up by means of this preparation so satisfactorily as not to invite 
objectionable attention.* 
Tin as an Important Factor in an Alloy.-Studying the composi- 
tion of an amalgam, the writer inclines to afford peculiar conspicuousness to 
the presence of tin, and favors the conviction that in proportion to the extent 
of use of this metal in the composition of a filling of the alloy class it is found 
most preservative of teeth. Copper added to tin favors still further conser- 
vation, and if it be true that addition of gold to such compound antagonizes 
tendency to discoloration, then amalgams are to be preferred which hold the 
articles named in proper measure. 
Silver.-Silver is necessary to hardness in an amalgam, and it is true that 
without such influence tin would lack solidity when in combination with mer- 
cury. Dr. Flagg favors silver particularly as the tooth-saver in an amalgam. 
Zinc.-Zinc as an ingredient in an alloy promises more than results yet 
obtained from its use; it will be found, therapeutically considered, to apply in 
* Chase's New Amalgam and Manner of. Preparation.-Melt forty pennyweights of 
pure silver; add to this thirty pennyweights of pure tin; stir, then add five pennyweights 
of antimony and five pennyweights of pure tears of zinc. When mixed, add thirty penny- 
weights of tin again; stir, and throw on the surface of the " melt" one-half ounce of bees- 
wax to burn off; and while burning pour the " melt" into the cup of a vulcanizing flask 
to cool. Cut it up with a very coarse file. Remove every particle of iron with a horseshoe 
magnet. This amalgam must be washed in alcohol while mixing with mercury. Squeeze 
it in dry buckskin. This amalgam is whiter for washing, and takes less mercury. Squeez- 
ing injures some amalgams; it does not hurt this. The amalgam pellets must be dry when 
placed in the cavity. This amalgam remains very white in the mouth. If all the tin is 
melted at once the antimony and zinc do not melt. If the antimony and zinc are put in 
the melted silver before the tin then the antimony and zinc burn up or oxidize. OPERATIVE DENTISTRY. 
377 
the case of all soft teeth where decomposition exists in vital rather than in 
chemical cause. 
Copper.-Copper, besides being curative or alterative, is accepted as a 
result of wide experimentation, to diminish shrinkage in an amalgam mass; 
on this latter score alone its presence in invaluable. 
Gold.-The presence of gold in an alloy has not impressed the writer as 
being of particular consequence one way or another; it is credited by Dr. 
Flagg, however, than whom there is no higher authority on the subject of 
amalgams, with increasing the rapidity in setting, imparting fine-grained plas- 
ticity, controlling maintenance of color, and securing desirable edge strength. 
Experiments made by Dr. C. S. Tomes would seem to establish the fact of a 
control of shrinkage by the metal. Other experiments exhibit gold as a 
retarder of setting. 
Platinum.-The metal platinum occupies a position not dissimilar to 
gold; just what it does or what it does not do seems rather undefined in the 
minds of alloy-workers; a view is projected that the virtue both of this metal 
and gold lies in some catalysis of action arising out of a relation with the 
other components of an amalgam mass; that is, if alloys are really found to 
be better because of such presence. 
Cadmium.-Cadmium is to be experimented with most cautiously; the 
opinion seems universal that the ingredient is hurtful to the health of tooth- 
bone. Crevicing at edges, softening ^.nd breaking up of the plug mass, are 
faults arising out of its presence. Teeth filled with amalgams containing 
special freedom of cadmium quickly become of a dirty yellow color, while at 
the same time the dentine rapidly softens by reason of decalcification. 
Edge Strength.-Edge strength in an alloy depends necessarily on the 
closeness of particles as such closeness is represented in a combination of 
metals. Silver, as a metal, has good edge strength, in that it is superior in 
such quality to tin ; it is not, however, equal to gold. Compatibility, on 
the other hand, is to be weighed in this connection, if it be true, as asserted by 
some alloy-makers, that copper, added to the mass, lessens notably edge 
strength. 
Plasticity.-This quality, as appreciated, depends, as to the length of 
time permitted for working the button mass, on the grade of metals of which 
the alloy is composed, the high-point melting metals compelling the quickest 
setting. 
Fusing-Point of Metals used in making Dental Alloys.- 
Gold, Aurum. Symbol Au 2016° F., specific gravity 19.3. ' 
Copper, Cuprum. Symbol Cu 2000° F., " " 8.8. 
Silver, Argentum. Symbol Ag 1873° F., " " 10.53. 
Zinc, Zincum. Symbol Zn 773° F., " " 6.8. 
Tin, Stannum. Symbol St 442° F., " " 7.3. 
Making an Alloy.-The Flagg method of making an alloy uses a 
Hessian, or sand, crucible. In this is first fused a very small portion of borax, 378 
A SYSTEM OF ORAL SURGERY. 
sufficient to coat the roughness upon the sides of the pot, loss by adhesion of 
the molten metal being thus prevented. A coke or coal fire affords the heat 
required. The borax being perfectly fused and the inner face of the crucible 
coated with it by means of a red-hot stirring- or smoothing-iron, the metals 
to be fused and commingled, previously cut up and mixed together, are poured 
into the pot and a sprinkling of borax thrown over them. Fusion is now 
secured, in which process the tin is found to melt first, the others, even most 
obstinate metals, quickly following, influenced, as thought by Dr. Flagg, by 
some catalytic influence residing with the molten tin. When entirely melted 
and mixed, the mass is to be poured quickly upon a broad, shallow matrice 
made of iron or soapstone. 
Cutting an Alloy.-The cutting of an alloy into grains is a matter 
deemed by Dr. Flagg worthy of large consideration, it being, as maintained 
by him, a troublesome and expensive process in proportion to the virtue of a 
melt. Thus, he says, a heavily-tinned, two-metal alloy can be cast into cylin- 
drical ingots and rasped into grains, or, better than this, it can be turned with 
rapidity and cheapness into shavings. A fine, heavily-silvered, four-metal 
mass, on the contrary, demands much labor, and is to be cut with the file 
exclusively. The ordinary vulcanite files are pronounced best for the cutting 
of all ordinary low-grade alloys, finer files being preferred by the workers for 
comminution of the higher qualities. 
Cleaning an Alloy.-Alloy filings are to be passed through a fine 
wire sieve with view of removing foreign particles. This done, a magnet is 
used with object of ridding the powder of steel filings. Remaining dust is 
best gotten clear of by gentle blowing. 
Aging Alloy.-It is maintained that alloys work better for being aged, 
those cut several weeks possessing advantage over the fresh cut. Experts, 
Dr. Flagg insists, can decide in a few minutes, approximately, how long an 
alloy has been cut, and, more than this, its quality, simply by making a mix. 
This operator offers it as his experience that 11 no really good alloy-such a 
one as will, when properly aged, rank well as amalgam under the ' setting,' 
' shrinkage,' ' edge strength,' and ' color'-is fit to work unless it have been 
cut for at least two months." Preference is given by Dr. Flagg to the amal- 
gams that have been cut double the length of time named. 
Influence of High Melting-Point in Metals on the Setting of 
Amalgam.-The setting of an amalgam mass being dependent on what is 
to be termed the cooling influence of a high on a low temperature metal, it is 
to be assumed that quick or slow setting is indicative of grade. 
Bulging, or Spheroiding.-An amalgam in which tin is of large 
admixture is found to spheroid very much more than where this low tempera- 
ture metal is replaced by a higher. This is accounted for by the rapid 
and rigid hardening of the high temperature metal mass in contrast with 
the lower, the latter setting slowly and being of softer and more yielding 
character. OPERATIVE DENTISTRY. 
379 
Qualitative testing of Amalgam Alloys.-Messrs. Eckfeldt and 
Du Bois, fellow-workers with Dr. Flagg in a long line of experiments done in 
this direction by the last named, give the following as simple qualitative tests: 
1. Tin.-Dissolve by the aid of gentle heat from ten to twenty grains 
of the alloy to be tested in a small quantity of nitric acid, say half an ounce. 
A first test is given by the shading of the solution. The tin present, remain- 
ing undissolved, will show itself in the form of a white precipitate. 
2. Gold.-Presence of gold is shown by the same solution, in effect pro- 
duced on the tin precipitate, this being changed from white to purple, varied 
in shade by the amount of the nobler metal present; less than one-half of one 
per cent, resulting in a decided purple. 
3. Platinum.-Presence of platinum, the same solution being observed, 
colors the tin precipitate a dirty blackish shade, while the partial dissolution 
of the platinum discolors the mixture at large. 
4. Copper.-Presence of copper in any considerable quantity colors the 
solution green. 
5. Silver.-To determine the presence of silver the solution referred to 
above is to have its fluid portion evaporated until full dryness obtains; then 
fluidize with distilled water and eliminate the oxide of tin by filtering. By 
now treating the filtrate with very dilute hydrochloric acid the silver will pre- 
cipitate as a chloride; flocculent and white. 
6. Cadmium.-The presence of cadmium is to be demonstrated by pouring 
over the filtrate a small quantity of ammonia, a yellow precipitate resulting. 
Ammonia showing as its result on the filtrate a blue color distinguishes the 
existence of copper. 
7. Zinc.-Boil down the filtrate from copper or from the mixed precipitate, 
as referred to, until nearly dry,-this with purpose of expelling the sul- 
phuretted hydrogen ; next add a little pure water and a solution of carbonate 
of soda. Presence of zinc is exhibited in a white carbonate that precipitates. 
Manner of using an Alloy.-Plugging alloy combinations, however 
composed, have a common manner of preparation for office use; this prepara- 
tion consisting in breaking up an ingot, as has been described, into grains or 
into shavings. Alloys possessing an excess of tin are best used in form of 
very coarse grains, hence are cut with coarse files, or are furnished as broken 
shavings. Alloys containing excess of silver, or having as an ingredient 
copper, gold, or platinum, are best cut with fine files, for reasons understood 
by the reader. Non-clogging of a fine file while cutting is being done 
will bear being repeated as a test to be remembered of the character of a 
good alloy. After being cut into grains an alloy, as referred to in a preceding 
paragraph, is to be carefully sifted and magnet picked ; the magnet to be passed 
and repassed until no more of the file particles are to be gathered. It is in- 
ferred of an alloy that mixes readily with a small relative proportion of mer- 
cury, when freshly cut, that it " will shrink notably, set slowly, bulge markedly, 
and have little or no edge strength." 380 
A SYSTEM OF ORAL SUROERY. 
Mercury.-Mercury, the solvent of alloys, is procurable in the proper 
purity at the shop of any chemist; the only need is that it be free from mix- 
ture with other metals,-a virtue that suggests the inadvisability of using the 
same portion with other than one mix. The proper quantity of quicksilver 
to employ with the different alloys is just that weight found to melt the mass 
into an apparently homogeneous ball. When too much mercury is allowed to 
remain with a plug, the mass refuses to harden; too little favors easy disinte- 
gration of a filling. Making the least quantity do by using heated instru- 
ments in the packing is not to be accepted as a desirable practice. 
Plug Mass.-An alloy when in solution with mercury is converted 
into an amalgam; here only is the latter term applicable, although out of 
deference to common habit the words are used in the chapter interchangeably. 
To make an amalgam mass, take a portion of an alloy, enough to correspond 
with the size of the cavity to be filled, place the grains in a mortar, add a small 
quantity of mercury, rub the two together by means of a pestle for a few 
moments, and the solid grains will be found to have disappeared. Add now 
to the mass secured a few drops of deliquesced chloride of zinc, and rub 
the whole together, using this last time a finger. As a result, the bottom of 
the vessel will be colored a dirty black, while the amalgam, robbed of its 
impurities, presents itself as a fluid ball of frost-white silver. The next step 
is to take the ball and, enveloping it in buckskin, cotton cloth, or linen stuff, 
press out, with forceps, the excess of mercury; the result is now a semi-solid 
material, which is the preparation to be used in the cavity of the tooth. 
Chloride of Zinc.-The employment of chloride of zinc as a purifying 
agent is not a necessity in the preparation of a plug mass, and may be omitted 
if the salt be not conveniently at hand; it is, however, a manner of treating 
the button deserving of high recommendation: a plug mass that has been 
frosted or washed with pure zinc will remain white much longer than if un- 
washed. This mode of cleansing amalgam was introduced many years back 
by the author, and seems to have passed into quite common use. After 
wiping away the black sediment-no water to be used-the mass is to be 
dried, absolutely, by means of bibulous or other moisture-absorbing paper ; 
such drying is to be insisted on, as it conduces markedly to the tenacity 
of the plug, through an influence on the process of crystallization. 
Remarks.-None of the agents employed in the operation of filling teeth 
has elicited so much discussion, pro and con, as amalgam. That it affects in- 
juriously the general health, as affirmed by many, is not perhaps to be accepted 
as true; assuredly the writer is not able to recall any decided instance of such 
result. No material is in more common use; thousands of teeth are filled 
with it every day, and it is not to be denied that cases enough offer where 
such a filling seems the only one that is practicable. It is claimed that if a 
tooth be properly prepared, and the material be carefully introduced, an amal- 
gam filling will last quite as long as one of gold. Assuredly in a multitude of 
instances it will preserve a tooth very much longer. OPERATIVE DENTISTRY. 
381 
Employment of Amalgam Necessitated.-The employment of 
amalgam seems necessitated in many cases in which gold cannot be used 
because of therapeutic reasons, and where tooth-bone or the gutta-percha 
preparations are not able to bear the demands of the act of mastication or 
the action of chemical antagonists. In the teeth of soldiers, where the 
convenience of the service, lack of manipulative skill on the part of the 
surgeon with gold or tin, or the habits of most of the patients would render 
the use of foils scarcely admissible, amalgam certainly recommends itself. 
Explanation of Bad Repute.-An explanation, in part, of a bad 
repute in which amalgam is held by many is to be found in poor manipula- 
tion. Being easy of preparation and of introduction into cavities, the use of 
the article has begotten great carelessness in its employment. A carious 
cavity in which amalgam is used is to receive not less attention in 
the way of perfect cleansing than where gold is proposed to be employed; 
quite as good reasons obtain for the perfect drying of it. 
Manner of Introducing.-Another matter is the manner of intro- 
ducing amalgam fillings. Experiments have clearly shown that it is 
not enough to smear the mass into a hole: it is to be packed in. Expert 
operators use a tap-blow, working piece upon piece in a manner not unlike 
that employed in consolidating cohesive gold. Without such care an amalgam 
plug leaks everywhere and is necessarily worthless.* 
Plug Mass.-Returning to the subject of the plug mass, attention is 
to be directed to a marked improvement on the manner of making a mix intro- 
duced in connection with the use of his Submarine Alloy by Dr. Flagg; this 
consisting of relation through weight of alloy and solvent. In preparing this 
amalgam a proportion found by Dr. Flagg to result in absolute harmony lies in 
five parts of alloy to six of mercury; the union of the two being complete, 
the mass desirably plastic, and no mercury to be pressed out. To save the 
trouble of weighing the proportions in each plug mass the exact relative 
weights are found to be obtained when the alloy is put in a scale which is 
weighed down by the plate of the opposite side by as much quicksilver as 
gives a declension of forty-five degrees. Absolute harmony of measure 
between an alloy and its mercurial solvent is to be accepted as representing 
absolute antagonism; the mercury being rendered inert. Alloys demand the 
solvent according to grade : Townsend's will antagonize and be antagonized 
by 36 per cent.; Lawrence's consumes 41 per cent.; Johnson & Lund's 39J 
per cent.; Arrington's takes 36 per cent. The solvent, as seen, is demanded 
in proportion as the metals used in the alloy are of high melting grade under 
ordinary heat. Particular stress is desired to be laid on this matter of measure 
for measure ; it is worthy of being worked out in the instance of every lot of 
* A young practitioner cannot do better than inform himself of the relative solidity and 
porosity of the amalgam plugs he makes by packing different specimens of the ma- 
terial in glass tubes and pouring over the same aniline alcohol: leakage will be found the 
rule. 382 
A SYSTEM OF ORAL SURGERY. 
alloy made or purchased. Where an alloy is regular in its proportions, and 
the age is known, the trouble of weighing individual specimens is spared. 
Kneading the Mass.-An alloy being amalgamated, the mass 
is taken from the mortar and gently kneaded into smoothness by a 
finger of one hand in the palm of the other. This apparently simple 
performance requires delicacy of touch, otherwise the practitioner, in 
place of securing a button of putty-like softness, may find himself 
holding nothing but a portion of dust. A button of amalgam is 
to be kept warm and pliable until ready for use by being held 
between the ring finger and palm of left hand. It is good practice 
to varnish the bottom of a cavity before introduction of a plug. (See 
chapter on Therapeusis for other suggestions.) 
Fig. 227.-Amalgam Cups. 
Fig. 228.-File Flat. 
Instruments for working Amalgams. - Special instru- 
ments add to convenience in working amalgams. Cup tools (Fig. 
227) are used as a conveyance by many in carrying the paste to the 
cavity. Another means which equally secures against dropping the 
mass into the mouth is found in the use of a file cut flat. (Fig. 228.) 
Amalgam demanding to be packed, instruments corresponding some- 
what with those used in working cohesive gold are required; the 
Fig. 229.-Amalgam Pluggers. 
faces are to be serrated, but the cuts must be very dull. A set here shown 
(Fig. 229) highly commends itself. OPERATIVE DENTISTRY. 
383 
No. 1.-For filling undercuts generally. 
Nos. 2 and 3.-For crown and buccal cavities in upper and lower molars. 
Nos. 4 and 5.-V-shaped fissure pluggers for filling anterior and posterior 
V-shaped fissures in molars and bicuspidati. 
Nos. 6 and 7.-Right and left V-shaped fissure pluggers for right and left 
V-shaped cavities in molars and bicuspidati. 
Nos. 8 and 9.-Adapted for working in anterior and posterior approximal 
cavities, and specially useful in removing excess of amalgam when finishing. 
No. 10.-For commencing a filling in the cervical portion of an approximal 
cavity. 
Nos. 11 and 12.-Burnishers, applicable to a great variety of cases. 
Another-a most valuable set-is the device of Dr. D. D. Smith. 
Illustration in Amalgam Practice.-We take as an illustration in 
making an amalgam plug an irregular cavity, dipping in part beneath the 
gum; situate upon the side of an inferior molar. Rubber dam or napkin in 
place, the plastic mass, kept pliable by being held in the warmth of the palm, 
as directed, is taken up by cup or file flat, preferably the latter, and, being 
carried to the bottom of the cavity, is condensed by tap-blows, particle after 
particle being added until the hole is full. To finish, a match-stick bevelled 
to a feather edge removes the excess, and a little later, according to time of 
setting of the amalgam, a reapplication of the stick affords a clean, white, 
smooth surface not at all unsightly. This manner of finishing applies 
strictly with the Submarine Alloy. With other amalgams advantage is some- 
times gained by polishing and burnishing precisely as is done in making a 
gold plug. The observing will remark, in the case, absolute necessity for a 
preliminary treatment which shall fully and fairly expose the base of the 
cavity,-a matter that necessarily compels the use of cotton plugs preliminarily 
continued for hours or it may be days. 
A second illustration may consider a cavity upon the grinding face of 
a deciduous molar. To operate for children is at all times a tedious process. 
The demands are for easy and rapid execution. The cavity cleansed, engine 
or hand drill being used, the amalgam-a soft variety being selected-is packed 
precisely as in the previous case, except, indeed, as frequently enough happens, 
the restlessness of the child prevents. Under such circumstances instruments 
known as the " Arrington set" accomplish the work speedily. 
The use of amalgam obtains at the present day so largely that it has 
become hardly less common to use the article with the anterior than with pos- 
terior teeth. Here most decidedly is it to be esteemed that circumstances are to 
control the practice. Undeniably is it the case that front teeth are met with 
afflicted with such seat and character of decay that question narrows itself at 
once to extraction or to filling with an alloy. An incisor or cuspid tooth, for 
example, broken to the point of disfigurement, and of a frailness denying suf- 
ficient promise from the use of gold, and being of root character denying 
thoughts of pivoting, finds a contouring advantage from the use of amalgam 384 
A SYSTEM OF ORAL SURGERY. 
of an indicated character which seems to be almost everything that could be 
desired. (See Cap Crowns.) Amalgam, again, applies as ease and facility 
in working are concerned. With care and time any kind of a case may be 
entered on with assurance as to a satisfactory outcoming. A bicuspid tooth, 
with but a trifle of its inner wall remaining intact, is to be started below with 
the submarine variety of standard alloy, built into form with " standard 
proper," and, if desirable, faced with the zinc variety, the operation being 
found invaluable by its possessor. Certainly, as the experience of the writer 
is concerned, he finds himself able to refer to cases treated in the manner 
suggested where not only satisfaction but pride was felt in the accomplish- 
ment. 
Large cavities in teeth, associated with a limit of dollars in pocket, find 
great good in the direction of alloys; a plug of amalgam is to be preferred 
commonly to a plate tooth where not contraindicated by effect on appearance. 
Amalgam is to be accorded its advantage, as relation is held with dental 
workers at large; few can fill teeth perfectly with gold; a judicious use of 
alloy is to be accomplished by almost any one who will take time to try. 
Objections urged to Use of Amalgam.-Objections to the use of 
amalgam relate markedly, if not exclusively, to immediate local conditions. 
As a rule, all the preparations discolor; some more, some less. Teeth in 
which the material is used lose very much of their translucency, darken, and 
sometimes blacken. A second fault relates with porosity of surface ; this being 
influenced markedly by the character of alloy employed, but it is so common, 
perhaps with all, as to compel recognition. Relation with galvanic electricity 
is another objection ; where an amalgam-filled tooth has a gold band placed about 
it, galvanic action is not unlikely to result,-a condition adverse to the health 
of tooth-bone and markedly irritative of the pulp. As here the irritation of 
the pulp is concerned, the effect is obviated by removing the plug and inter- 
posing between it and the bottom of the cavity a layer of oxychloride of zinc 
introduced dry as possible, or else using a portion of gutta-percha. Other 
means applied to the same end are found in varnishes, slips of adhesive plaster, 
layers of quill scraped very thin, oiled silk, etc. To antagonize effects 
on the tooth-bone is a less easy matter. Here it is recommended that the 
polish of the gold be removed by subjecting it to the action of a flame, and 
that, if the face of the plug be bright, it be smeared with a coating of an amal- 
gam that tends to rapid and persistent blackening. Wrapping a spring with 
silk thread is a means,-a dirty one, however. Still another is found in mer- 
cury-coating the inside of the clasp,-that is, touching it with a film of the 
metal. A method that is to be tried with a certain extent of good effect 
consists in the free use of alkaline mouth-washes. 
Putrescency of Pulp.-Putrescency of pulp, so frequently found in 
conjunction with amalgam fillings, is to find explanation most commonly in a 
chronic inflammation that has resulted in death of the organ, the cause being 
extent of decay and size of plug mass rather than character of material. The OPERATIVE DENTISTRY. 
385 
same explanation applies to conditions of periostitis, ulitis, osteitis, caries, and 
necrosis of bone as found in connection with amalgam. 
Temporary Salivation.-Temporary salivation (not of systemic mean- 
ing) is in rare instances attributed to the presence of amalgam in the teeth; 
such ptyalism is found quite as frequently associated with newly-placed gold 
or other plugs; it is very common as a sequel to surgical performances done 
on the jaws. 
Bad Taste in the Mouth.-Bad taste in the mouth is another of the 
implied objections to amalgam; it is worthy of consideration here whether 
lack of cleanliness rather than influences of the alloy is not the root of an 
explanation. Amalgam fillings in approximal relation are not infrequently so 
indifferently placed as to form receptacles for the accumulation of debris ; the 
writer has met with many such cases. 
Systemic Complications.-Systemic complications in relation with 
amalgams are unknown to the author; it is not impossible that idiosyncrasy 
exists in the direction, but assuredly the cases must be rare where observation 
extending over thirty years has failed in showing a single instance. 
Place for, and Use of, Amalgam.- The place for, and the use of, 
amalgam is to be decided by the judgment of an operator, and in proportion 
as such judgment is good or bad so is a patient served or abused. Amalgam 
is unsightly when compared with gold, consequently, as an aesthetical 
aspect of the question is concerned, it is not suited to exposed situations. 
Solid and highly-burnished plugs of gold bespeak cleanliness and an idea of 
purity never associated with an alloy, hence gold-filled teeth are of healthier 
appearance than are the amalgam-filled. Impression of refinement and of 
delicacy as conveyed by teeth golden strikes all; amalgam lacks in afford- 
ing social classification; it impresses disagreeably. We place our individual 
opinion in a single line by saying that gold, when not contraindicated, is the 
material with which human teeth are always to be filled. Saying this, we 
are to be understood as recognizing the existence of conditions constantly 
being met with where gold is flatly unable, however well worked, to preserve 
teeth. 
The subject is concluded with a few appended formulae which analyses 
show as so approximative of the originals as to render them strictly reliable 
either as studies or for use. 
Townsend's. 
Silver 42.00 
Tin 58.00 
Copper, none. 
Gold, none. 
Walker's. 
Silver . ■ 30.50 
Tin 69.00 
Platinum 50 
Gold, none. 
Arrington's. 
Silver 42.50 
Tin 57.50 
Townsend's Improved. 
Silver 43.00 
Tin 57.00 
Gold, none. 386 
A SYSTEM OF ORAL SURGERY. 
Lawrence's. 
Silver 47.50 
Tin 47.50 
Copper 5.00 
Gold, a trace ...... of a grain. 
Johnson & Lund's. 
Silver 38.50 
Tin 59.40 
Platinum 40 
Gold 1.06* 
Gutta-Percha.'-Like amalgams, various preparations of gutta-percha are 
used in dental art for the purpose of stopping carious teeth. Two varieties 
are white and red; of these there are sub-varieties, having their distinctive 
features either in the temperature at which they become plastic or by reason 
of admixture with other substances. 
* Chemistry of Amalgams.-To some extent most metals are capable of combining with 
each other in definite proportions. Their chemical affinity is for the most part very feeble 
and easily disturbed. The more unlike metals the more stable their compounds. 
Amalgams, as understood, are alloys containing mercury. Combinations of mercury 
with other metals result in a liquid or varying solid, according to the proportions. Heat 
decomposes all amalgams. In ordinary use iron and platinum are the only metals which 
can be brought in contact with mercury without being corroded by it; however, quicksilver 
adheres to platinum. It is found that if a little amalgam of sodium be added to metallic 
mercury it gives to it the power of adhering much more readily to other metals; it will 
even adhere to iron. 
By experiment it has been found that the following definite proportions can be obtained : 
Amalgam of Iron, FeHg. 
" " Silver, AgHg. 
" " Lead, Pl2Hg. 
" " Zinc, Zn2Hg. 
" " Copper, CnIIg. 
" " Platinum, PtHg2. 
There is a native amalgam of silver found associated with mercurial and silver ores, 
AgHg2, in dodecahedral crystals. Beautiful crystals of amalgam of silver, having the 
composition Ag2Hg3, are to be obtained by dissolving 400 grains of nitrate of silver in 40 
measured ounces of water, adding 160 minims of concentrated nitric acid and 1840 grains 
of mercury; after a few days crystals of from two to three inches in length will be de- 
posited. 
As an illustration of proportions in amalgam one or two formulae may be cited: 1. To 
promote the action of electric machines, mercury 6 parts, zinc 1 part, tin 1 part. 2. For 
the silvering of glass, mercury 1 part, tin 4 parts. 
Mercury combines very readily with bismuth. Heat a mixture of 497 parts of bismuth, 
310 of lead, 177 of tin, 100 of mercury. This makes an amalgam solid at ordinary tem- 
perature, melts at 171.5° F., and solidifies at 140° F. This is often used in injecting delicate 
anatomical preparations. 
Whenever mercury is combined with potassium and sodium there is always a disengage- 
ment of heat; the resulting amalgams have a pasty consistence, and decompose water. 
Tin, lead, and mercury, when heated together and left to cool slowly, yield a solid crys- 
talline amalgam of definite constitution. 
Gold unites peculiarly with mercury; even a large quantity of gold does not affect its 
fluidity. Where mercury is saturated with gold the result is a mass of waxy consistence. 
When 1 part of gold is dissolved in 1000 of mercury, the combination being pressed 
through chamois leather and the residue treated with dilute nitric acid at a moderate heat, 
there is obtained a solid amalgam, AugHg, in shining, four-sided prisms which retain 
lustre in the'air. 
There is also a ternary combination of hydrogen, mercury, and nitrogen. OPERATIVE DENTISTRY. 
387 
Compatibility with tooth-bone is markedly characteristic of gutta- 
percha. The article assuredly has an advantage over the metals in that it is purely 
a non-conductor of thermal changes. While gutta-percha is in a tooth-cavity 
there is no interference with nature's process of recalcification, even if there 
be little excitation of the act. Were it not because of an inability to resist 
the wear of mastication, and the not very aesthetic appearance, no plug would 
surpass one made of gutta-percha as a tooth preserver. 
Gutta-percha is resistive in proportion as it is tough and of high 
softening point. In proportion to such resistiveness, it is adapted to the 
office of a tooth-plugging material. 
Brittleness in gutta-percha expresses porosity, the cause being an 
over-admixture with foreign inorganic substances, such as oxide of zinc, silex, 
quick-lime, etc.; on this account, if on no other, a brittle preparation is to be 
refused. Great attention is being paid at the present time to the manufacture 
of the material. To secure the best quality, one is to apply to a reputable 
and experienced maker, or, what is still better, test each purchase for himself 
by means of a spirit-lamp and water-box. Stickiness in a specimen, when hot, 
is one of its greatest virtues.* 
Hill's Stopping.-Combinations with gutta-percha are illustrated in a 
* Test of Quality.-Dental preparations of gutta-percha are reasonably to be divided into 
grades, these grades referring to degrees of solidity. The form of preparation most in use 
is procured from the depots under the name of base plate; of this there is much that is very 
good for the purpose of filling teeth and plenty that is not so good. Base plate, lacking 
admixture with other substances, is valuable in proportion to its possession of a high soften- 
ing power; this refers more especially to preparations made particularly for plugging pur- 
poses. Plasticity of gutta-percha, and of its dental combinations, is secured at a temperature 
varying from 112° to 235° F. Easy plasticity is attained at the expense of durability; it 
expresses over-softness. Resistance to softening implies over-combination with inorganic 
substances, which is quite as inimical to satisfactory results as is over-softness. The best 
gutta-percha for filling teeth lies in a quality that approaches 180° F. and is unmixed with 
other material. 
The grade of a gutta-percha is measured, as the unmixed variety is concerned, by using a 
flat boiler, or any convenient means representing one, and after laying the specimen to be 
tested upon it, heating the water by use of a spirit-lamp; a thermometer bulb related to the 
water of the cup or boiler shows the extent of heat. Plasticity obtained below 150° F. is not 
acceptable for surface plugs, but is found useful in filling canals. Plasticity standing at 
180° F. allows of the making of a plug which, while not as resisting as the mixed gutta- 
perchas of higher grade, is eminently conducive to tooth preservation. 
Dry testing, a manner that has to be used with the mixed varieties, the grade of which 
is above the boiling-point of water, is to be esteemed as injurious to the specimen; hence a 
conclusion that grades of gutta-percha requiring to be softened by means of hot plates are 
not apt to prove serviceable. It is not, however, to be understood that the material may 
not be softened after this latter method without injury, but it seems to be a quite common 
experience that it is likely to get burned or otherwise deteriorated. 
To dry test gutta-percha, take a specimen and lay it upon a metal or, preferably, a por- 
celain plate, apply now the flame of a spirit-lamp from the under surface, and bring the 
heat up in the most gradual manner. The proper place for the relation of flame with plate 
is the farthest possible point away-from the plastic. To apply heat immediately beneath a 
specimen is almost certainly to bubble or burn it. 388 
A SYSTEM OF ORAL SURGERY. 
very familiar tooth-plugging material, known as Hill's stopping. In this agent 
the gutta-percha has worked into it, presumedly, definite proportions of quick- 
lime, felspar, or other inorganic material. As a substance for filling children's 
teeth the stopping is in much favor. It is also used freely in adult teeth of 
frail character. 
Use of Gutta-Percha in Seasons of Dental Metamorphosis. 
-Gutta-percha, alone or in combination, recommends itself in that multitude 
of cases where patients are undergoing what might be called a season of dental 
metamorphosis. These seasons are familiar to every observing practitioner 
of the dental art. A set of teeth, good for previous years, suddenly, and 
without observable change in the constitution, takes on decay. To fill such 
teeth with expensive material is to incur great cost to the patient, with a cer- 
tainty as well to the operator that what is done will prove of little avail; that 
it will require quickly to be done over. Such failure certainly comes to the 
dentist who fails to appreciate that his operations are directed alone to effect, 
not to cause. The inexpensiveness, the easy manner of introduction, and the 
quickness with which gutta-percha is to be removed from teeth and replaced, 
render the material one of pre-eminence for selection in such cases. 
Red Gutta-Percha.-Red gutta-percha has seemed to the writer to 
possess virtue as a tooth conservator not enjoyed by the white. The latter, 
however, is commonly selected to be used with front teeth for the reason that 
it calls less attention to the defect. To prepare the first, it is desirable to heat 
and soften it by aid of hot water. Any convenient means to this end may 
be adopted, it being understood that the material is not to come in immediate 
relation with the moisture. A metal cup filled with water, the cover serving 
as a plate to hold the plastic, a ring and stand to support this cup, a spirit- 
lamp for purpose of heat, constitute an admirable apparatus. White gutta- 
percha is made ready for the tooth by exposing it, upon a plate of tin, 
silver, or mica, to the action of a flame acting on it from beneath. (See foot- 
note.) 
Instruments used with Gutta-Percha.-Special instruments are 
required for a proper use of gutta-percha. Of many different patterns, prefer- 
ence would not unjustly be given the D. D. Smith set. (Fig. 230.) These 
instruments are employed by the deviser for all kinds of plastics; they are 
here commended particularly in connection with the material under considera- 
tion. Nos. 1, 2, and 3 have smooth heads. Nos. 4 to 9 are dully serrated. 
No. 6 is for distal cavities in molars and bicuspidati. Nos. 10 and 11 are 
spatulas for carrying and inserting the material, and used also as burnishers. 
No. 12 finds its exclusive use for mesial and distal cavities. No. 13 is a cut- 
ting instrument for trimming excess of plug from cervical margins. 
Introduction of Material.-A cavity made ready, the operator takes 
up the selected instrument, and gently warming it by means of his spirit-lamp 
or, preferably, by contact with a heated plate, lifts with it the desired portion 
of plug mass. Here much difference exists in practice. With some operators OPERATIVE DENTISTRY. 
389 
Fig. 230.-Smith's Plastic Fillers. 
the method is to take small portions and work them piece after piece 
into the cavity, aiming all the while after a stickiness of surface that 
shall insure adherence with the walls of the tooth and coherence of 
particle with particle. Others, on the contrary, aim at securing a 
mass of such size that when put in the cavity it shall just fill the 
hole, leaving little or no excess to be trimmed. 
Stickiness.-Sticking of the mass to the instrument is guarded 
against through use of an oiled pad to which the points or bulbs are 
touched. Taking up the piece at the point of a probe and applying 
it by such means to the locality where it is proposed to be fixed, and 
while steadying it to pack with a plugger, is an excellent manner of 
manipulation. 
Cooling and Hardening.-A cavity filled, the operator is to 
wait, before dressing the plug, for its cooling and hardening; or, 
as is thought well by many, cold water may be held in the mouth, 
which quickly compels this end. To attempt the dressing of a gutta- 
percha plug before it has become hard is certainly to pull it from the 
marginal walls of the excavation, and thus render it useless. When 
hard the material is freely cut, heated instruments being used, with- 
out risk to its relations as a plug. Cutting away surplusage 
from a filling is done by means of knife-edged blades shaped as shown 
in No. 13, Fig. 230. A blade requires to be heated to that tempera- 
ture which expresses the plasticity of the specimen being worked. 
Cutting is always done by drawing toward the circumference of a 
cavity with a view of insuring against a drag of the gutta-percha in 
a wrong direction. 
Gutta-percha is supplied by manufacturers for tooth-filling pur- 
poses in the various forms of squares, blocks, pellets, and disks. 
Oxychloride of Zinc.-Oxychloride of zinc is a plastic made by mix- 
ing dry oxide of zinc into a watery solution of chloride of zinc. As met with 390 
A SYSTEM OF ORAL SURGERY. 
in the dental depots it consists of a powder and fluid, occupying different 
bottles. 
Of this plastic the variety offered is greater even than that of the amal- 
gams. A single formula affords not only an idea of the composition of all, 
but, as well, a recipe which secures a preparation equal perhaps to any. 
Formula for Oxychloride of Zinc.-For the powder, simple French 
oxide of zinc. 
For the fluid, aquae, 5vi; zinci chloridi, $j, or, by fully saturating muriatic 
acid with metallic zinc. After mixing water and zinc chloride or the muriatic 
acid and metallic zinc, much heat being evolved, the bottle is to be loosely stop- 
pered. After a number of shakings the contents of the vessel are to be al- 
lowed to settle, when the clear liquid is poured off by filtration. The solution 
is to stand uncorked twenty-four hours. 
Shading.-An oxychloride plug, when prepared as above, is absolutely 
white, or so nearly colorless as not to accord with any tooth in which it 
may be desired to use it. Shade to suit is secured by addition to the 
powder of scraped slate or, preferably, in the judgment of others, by ochre. 
Another element, used in many preparations with a view of increasing hard- 
ness of surface, is borax. Still others are felspar, flint, silex, titanium, 
aluminium. • 
Mixing Plug Mass.-Taking zinc oxychloride of any formula,-that is, 
taking from a bottle which contains dry oxide of zinc and from another hold- 
ing a watery solution of chloride of zinc,-the preparation of a mass for tooth- 
plugging purposes is nothing more complex than making a mixture of powder 
and fluid upon a glass slab, using for the purpose a knife-blade or an ivory or 
a platinum spatula; the consistence is to be that of fresh putty. 
Use in Frail Teeth.-For use in frail and poor teeth oxychloride has 
much to commend it. It will support a weak tooth and harden a soft one. 
It will whiten one that is dark and purify one that is foul. There is a multi- 
tude of cases in which no filling material but this will save a tooth. It is a 
therapeutical filling; it does very much more than stop a hole. Not under- 
stood or properly managed, it becomes quickly an agent of evil. 
Viewed Mechanically.-Viewed mechanically, an oxychloride of zinc 
filling is made very much the same as one of amalgam. It is not, however, 
necessary to tap-blow it. Preparing the paste, which, for therapeutic reasons, 
is to be mixed thick or thin, the operator lifts upon an instrument a portion 
corresponding in size with about a fourth of the cavity to be filled; this he 
introduces, obtunding the pain which almost instantly follows, and at the same 
time forcing the material into all the irregularities of the hole by means of a 
pledget of bibulous paper used as a ball in the grasp of a pair of finger forceps. 
This use of bibulous paper with the first portion is never to be omitted by a 
student, otherwise the price paid for his neglect may be the loss of the tooth 
upon which he operates. The paper takes up any excess of the chloride, which 
is a powerful irritant. OPERATIVE DENTISTRY. 
391 
Freedom from Moisture.-Of the different filling materials used in 
dental art, none requires more absolute freedom from moisture, both at time of 
making a plug and the setting of it, than an oxychloride. It is seldom, how- 
ever, that the trouble of coffer-damming a tooth is required. The material 
being easy and quick of introduction, a napkin, aided by a free use of bibulous 
paper, is all that is commonly found necessary. 
Expediting Setting.-A plug in place, setting is to be expedited by 
pressure with an absorptive pad. Once solidified, protection against the fluids 
of the mouth is secured by dropping upon the filling from the point of an ex- 
cavator a solution of gutta-percha, which is to be made by dissolving that gum 
in chloroform. A skin of the material thus secured remains intact for a 
period varying from several hours to many days. 
As Foundation for Gold.-A secondary mechanical use for this oxy- 
chloride is found in employing it as a foundation for metal fillings. A great 
cavity partly filled with the paste is of better promise than where metal alone 
is used; this applies in every instance where such a combination does not in- 
terfere with ability to anchor metals solidly. Still another good service is 
rendered by the material as a facer of amalgam plugs in anterior teeth. An- 
other use is as a capper of nearly exposed pulps. Cements of this class are 
prepared particularly for the special purpose; they set quickly and may be 
used so creamy as to be poured into a cavity. One such preparation, known 
as " Foundation Cement," hardens sufficiently in from two to five minutes to 
allow of packing gold or other filling material upon it. 
Temporary Nature.-An oxychloride of zinc filling is not to be es- 
teemed otherwise than of temporary signification. Two years is quite as long 
as an exposed plug of this class may be expected to last. The material con- 
tinues longest in mouths that are acid. The manner of its disappearance is by 
crumbling and wearing. 
A zinc filling, when thoroughly dry, will take a polish by being burnished 
gently with heated talc; unfortunately, such polish quickly disappears, con- 
sequently is of little service. 
As a Support to Frail Walls.-Oxychloride is invaluable as a means 
of strengthening the weak walls of dental cavities. An incisor or other tooth, 
for example, having the dentine almost completely decayed away from the cir- 
cumferential enamel walls is fortified satisfactorily by a lining of oxychloride, 
and is then to be filled with gold without danger of fracture. As a hardener 
of chalky teeth its value is well known ; soft and septic organs are always to 
have a filling of gold preceded by one of oxychloride. Caries rarely progresses 
in presence of immediate contact of the part with oxychloride. (See chapter 
on Filling Teeth.) 
Zinc Phosphates.-The zinc phosphates closely resemble the oxychlo- 
rides in common appearance and manner of working. 
A phosphate-of-zinc filling is made by mixing glacial phosphoric acid and 392 
A SYSTEM OF ORAL SURGERY. 
basic oxide of zinc in proportions affording a mass of putty-like consistency. 
The common time of setting is two minutes. 
Difference as to Material.-Difference in the quality of this stopping 
is assumed to be influenced more by the quality of the materials named than 
by admixtures with other agents; many samples, both of acid and base, being 
so imperfectly made as to be worthless for purposes of cement. The trouble 
and uncertainty of preparing the syrup render purchase, rather than attempt 
at making, desirable.* 
Phosphoric Acid less an Irritant than Chloride of Zinc.- 
Phosphoric acid being less an irritant than chloride of zinc, fillings made with 
it are less dangerous, necessarily, as well less therapeutic, than those made of 
the oxychlorides. A claim for superiority on the part of a phosphate-of-zinc 
plug lies in the direction of hardness. 
Varieties.-Forms of phosphate filling material in the market which 
have attained to most prominence are Flagg's, Peirce's, Fletcher's, Weston's, 
Poulson's. 
It is to be mentioned that there are in the depots varieties of cement for 
which claim is made that they are something besides either of these just 
named. One, Guillois's preparation, is known to the commercial world in 
the form of imitation coral sleeve-buttons, shirt-studs, etc. Another, Wes- 
ton's Insoluble, has prominent claims put forth with it. Both preparations 
possess worthy endorsement. 
Cement Plombe.-Still other articles of the kind are the " Cement 
Plombe" and the "White Enamel Stopping" of Oehlecker. The 
former finds many to recommend it; the latter has an advancing reputation. 
Directions for manner of use accompany the preparations. 
From the employment of oxide of zinc as a base, manufacturers of zinc 
phosphates are passing to the employment of the nitrate; this latter is found 
to secure a greatly-increased stableness in the compound. 
The syrup used in kneading the powder of fillings of this class is to be 
fresh and of specific character ; when old it is over-thick or otherwise rendered 
useless by being found separated into fluid and sediment. 
Lasting Capability.-A filling made of zinc phosphate will commonly 
last from one to three years. Before introducing it a cavity is to be varnished. 
It is a good tilling for the front deciduous teeth. Use of it applies satisfactorily 
in the setting of crowns and attaching bridge-work. 
* A formula by Dr. C. N. Peirce for the making of zinc phosphate is as follows: "Place 
oxide of zinc in a clay or black-lead crucible and keep over a fire until it has been reduced in 
bulk fully one-third and has a good yellow color. Pulverize this result in a mortar of iron 
or Wedgwood until fine enough to pass through bolting-cloth of about No. 80. This affords 
the powder ready for use. To make the syrup, the best, and a perfectly clear, glacial phos- 
phoric acid is dissolved in pure water and subjected to boiling until the syrup consistency is 
obtained. If the syrup is boiled too much it is useless by reason of crystallizing on cooling; 
if too little, a filling made by its use crumbles." OPERATIVE DENTISTRY. 
393 
Manner of working Zinc Phosphate.-The plug mass is made by 
taking equal parts of powder and syrup and working the former into the latter 
through use of a spatula used quickly and after a smearing manner. When a 
ball of proper size and consistency is secured it is taken up as a whole and 
forced into the cavity to be filled, which cavity is to stand properly prepared 
as to dryness, and otherwise, for its reception. A plug mass introduced after 
such manner compels care that no bubble of air be retained in the cavity. If 
a hole be very large it is recommended to make two or three mixes. Fully 
a quarter-hour may be allowed for setting before inaugurating the process of 
finishing, which performance differs nothing from that practised with amalgam 
or zinc chloride. Completion of the operation is with a coating of varnish 
that shall suffice to protect the face of the plug for several hours. 
Tests of a Good Material.-The tests of a reliable zinc phosphate 
filling, according to Dr. Flagg, whose experience is scarcely equalled by any 
other dentist, are as follows: 
1. Decided force required to take the mass from a spatula. 
2. That it roll into pellet form without adhesion to the fingers. 
3. That it glaze in one or two minutes, and rebound if dropped upon wood, 
glass, or porcelain. 
4. That in five minutes it yield a porcelain-like sound if tapped gently upon 
the cutting edges of the teeth. 
5. That in ten or fifteen minutes it be resistant if bitten upon, or, if break- 
ing, do so with a clean, sharp fracture. 
6. That in a half-hour it be without taste, save as to a slight astringency, and 
be capable of taking a fine and persistent burnish. 
Tin as a Filling Material.-Tin is furnished in form of foil. In color 
this foil is like the metal as met with in commerce. As a filling material quality 
is in accord with purity. When freed from alloys, tin furnishes the dentist 
with an agent which serves a wide purpose,-much less wide, however, than 
previous to the introduction of gutta-percha and the chloride plastics. As the 
use of metals is concerned, tin is undeniably, in case of soft teeth, eminently 
superior to gold as a preservative. It is easy of introduction into a cavity, 
and, as compared with the nobler metal, pre-eminently easy of a required 
consolidation. 
Tin is prepared in sheets of various numbers, these numbers giving the 
thickness of the leaf. From Nos. 4 to 10 are commonly used; higher num- 
bers are 14, 18, 20, the latter being the highest. 
For Use in Children's Teeth.-For use in children's first teeth, 
particularly the molars, tin foil is an admirable article; certainly in every way 
preferable as irritative qualities are concerned, the metal being peculiarly in 
accord with tooth-substance. 
Tin foil is used precisely as gold foil; both soft and cohesive forms of it 
are in the market. (See Gold.') 394 
A SYSTEM OF ORAL SURGERY. 
Plastic Tin.-Plastic tin is a preparation of the metal which is used by 
amalgamating with mercury, employing for the purpose 48 parts of the latter 
to 100 of the former. It is not to be washed nor squeezed ; neither 
is alcohol to be used ; but it is to find its cleansing through the aid of zinc pre- 
cisely as directed in the case of amalgam. This preparation makes a solid 
cohesive plug, and one that is decidedly therapeutical. It is claimed that it has 
only one-fourth the conducting power of gold, and that on a scale of 100 it 
stands 40 degrees nearer to tooth-substance than the latter metal. 
Tin-gold.-Another preparation of tin is known as stannous gold. This 
material comes prepared in the form of heavy, coarse sheets. It is used pre- 
cisely as cohesive foil, and works with a plasticity not much inferior to amalgam. 
All preparations the base of which is tin deserve consideration at the hands 
of the operating dentist. (See Tin-Gold.') 
Herbst's Glass Filling.- Filling teeth with glass is a practice advo- 
cated by Mr. Herbst, of Germany, and is to be described as follows. Two 
kinds of glass are powdered and mixed. One of these is lamp-shade glass,- 
not the cylinders used for gas, as these blacken in the burning,-the other is 
the flask used for cocaine or chloroform. These are separately pulverized in 
a clean agate or porcelain mortar, and, after being thoroughly dried, put up in 
bottles. Cavities in which the glass plugs are to be used are not, at first, 
to be undercut, but so excavated that accurate impressions of them may 
be secured. An artificial tooth of the exact shade required is to be selected, 
which shall serve as a guide to the color of a filling to be made. It is 
recommended to mix and wet eighty parts of the milk glass with one 
part of the brown. Models made from the impressions secured are to be 
soaked with clean water, and when thoroughly saturated are to be two-thirds 
filled with the glass mixture, a brush being used for the purpose. The models 
and glass are now dried by use of linen cloth and afterward laid upon an iron 
plate and heated. A succeeding process places them upon a soldering coal, 
where the glass is to be melted by means of a single-cell Bunsen burner, care 
being exercised that the models be first well heated without being made white. 
When coolness obtains, the color, as the fuse comes out, is compared with the 
shade-tooth, and, if not satisfactory, the glass is remelted, white or brown 
being thrown into the flux as is indicated. Color obtained, a final step is the 
introduction of the piece into the cavity originally prepared for it. To effect 
this the hole is deepened a trifle so as to let the plug down, and undercuts are 
made within the circumference of the margin of the cavity. The glass plug 
is now laid in its place and cemented by a plastic. This plan in no way com- 
mends itself save as it may possibly prove the forerunner to a something better 
to come out of it. The writer possesses six specimens of the work. 
Gold as a Material for Filling Teeth.-We come now to gold, a 
material which is to be accepted as holding the position par excellence as a 
material for filling teeth,-certainly a material which yields the most artistic OPERATIVE DENTISTRY. 
395 
and beautiful results, outranking, in such respects, all preparations used in 
operative dentistry. 
Gold is prepared for the hands of the dentist at the present time in such 
variety as to form, and with such view as to fitness, as indications are con- 
cerned, that in reality the operator finds much of his work anticipated. 
Soft and Cohesive Gold.-A division of gold is into soft and cohe- 
sive ; the first has a kid-like character and is worked by a process of wedging ; 
the second is sticky: plugs are made of it through a process of cold welding. 
Variety as to Form.-Varieties of gold, as to forms prepared for 
dental use, are sheets, mats, pellets, cylinders, blocks, ribbons, twists. These 
are forms fitting the material for the table of the operator; they are prepared 
both from the soft and plastic gold. A preparation looking not unlike golden 
sponge, and known as Watt's Crystal Gold, is popular; the working of it 
differs nothing, however, from that of the kinds now to be described. 
Sheets.-A sheet is gold in the form of leaf: it comes to the dentist in 
books marked variously from Nos. 4 to 240. Number designates the weight 
of a leaf. High numbers express heavy foils; they are comparatively infre- 
quently used. Low numbers distinguish the preparations most easily worked. 
From Nos. 4 to 8 are commonly selected. Leaf gold is soft, or non-cohesive, 
cohesive, and semi-cohesive. 
Mats.-A mat consists of a square made by folding leaf gold into a strip, 
and afterward cutting it into sections. 
Pellets.-A pellet is made by compressing a mat into ball form. 
Cylinders.-A cylinder is a form of gold secured by rolling a strip about 
a broach or common pin. 
Blocks.-A block differs from a mat only as thickness is concerned; it is 
made in the same way. 
Ribbons.-A ribbon is leaf gold folded upon itself until a desired width 
is obtained. 
Twists.-A twist is a ribbon coiled upon itself. 
All these forms are furnished by manufacturers. Fig. 231 represents cylin- 
Fig. 231.-Cylinders. 
Fig. 232.-Mats and Blocks. 
ders prepared of various lengths and diameter. Those known as Peck's are 
loosely wrapped, and can be used, if desired, as pellets. Fig. 232 shows forms 
for mats and blocks. CHAPTER XXVII 
OPERATIVE DENTISTRY. 
FILLING TEETH. 
Filling Teeth with Gold-Non-Cohesive.-Appreciation of the 
matter of filling teeth with gold is best reached by beginning with the most 
simple and ordinary mechanical expression of the subject. Referring to indi- 
vidual cavities, which shall serve as studies to direct the ingenious hand, atten- 
tion is first given to such uncomplicated forms as are represented by round 
holes,-cavities alluded to as being common to the crowns and sides of the 
molar teeth and to the posterior faces of the incisors. To fill a cavity of this 
class, the use of metal rolled into cylinder form naturally suggests itself. 
Selecting, or making, such cylinder of a size that will reach the bottom and 
extend beyond the margin of a hole proposed to be 
filled, it is, after being placed, to be laterally expanded 
by a wedge-plugger carried through its centre, or other- 
wise is condensed in mass against the wall of the cavity. 
The space thus secured is to be filled by a second cylin- 
der of convenient size, the wedging to be repeated, and 
the introduction of cylinder after cylinder to follow, 
until no more can be introduced. (See Fig. 233.) 
Mats.-Mats are found, in the beginning of an 
operation, to conveniently replace the cylinder where 
crown cavities are large and of more or less irregular 
form, as in Fig. 234. These are used precisely as the 
latter, being carried into position by means of the foil- 
carrier, and condensed carefully and accurately against 
the immediately neighboring wall. Other mats, follow- 
ing the first, are to be arranged around the cavity, thus 
making, as it were, a gold tube into which cylinder after 
cylinder, as before directed, is wedged, or, one plate 
may be condensed against its fellow until in this way 
the cavity is full. Wedging throws apart laterally, thus insuring 
marginal solidity to a plug; it is the master principle of making perfect opera- 
tions. Soft gold is commonly used. The idea of wedging is fully illustrated 
in wood-splitting, Fig. 235. 
Ribbon.-Filling a cavity with the ribbon, although highly extolled by 
many, is now an almost obsolete practice; it is associated with much more 
Fig. 233. 
Cylinders and mats in 
the act of being intro- 
duced into a crown 
cavity. 
396 OPERATIVE DENTISTRY. 
397 
trouble than relates with the use either of cylinder or mat. 
To manipulate gold so prepared, the operator, after carrying 
the initial extremity to the bottom of a cavity and fixing 
it by any convenient means,-generally by holding it with an 
Fig. 236.- 
Foil-Carrier. 
Fig. 235. 
Fig. 234. 
Mats in place. 
The principle of wedging. 
instrument held in the left hand, or confiding the task to an 
assistant,-folds upon this first layer after layer, making the 
bend at such distance above the orifice of the cavity as con- 
siders the condensation to which, later, the metal is to be 
subjected, and which, if properly done, is to afford a solid 
surface that shall not be sunk below the margin when the 
necessary filling and polishing shall have been completed. 
Twist and Rope.-Twists, or ropes, are used precisely 
as the ribbon, fold after fold being bent and carried into a 
cavity until no more will be received. It is more common to 
confine the use of the rope to small cavities, such as 
are found on the approximal faces of anterior teeth, although 
operators are met with who employ gold in this form exclu- 
sively. 
Secondary Cavity.-A modification on the use of 
ribbon and rope, as just described, consists in wedging the 
centre during the progress of the filling. The operator first 
gets his cavity loosely filled; then, leaving the rope as related 
with the last fold, he wedges the gold against the parietes. 
The secondary cavity thus made is then filled by turning the 
rope into it precisely as in the first instance, the lateral pressure 
securing solidity. 
Another study, which will serve as the demonstration of a 
second class of fillings made of non-cohesive gold, relates to 
cavities in anterior teeth, approximal faces. As the 
filling of all such cavities is on a common principle, we will 
take the superior incisor, Fig. 189, right side, as seen prepared. 398 
A SYSTEM OF ORAL SURGERY. 
Filling a Tooth by means described.-To fill this tooth,-being 
made ready as understood,-the operator takes a leaf of gold, preparing with 
it, besides a rope, a number of mats. These mats he arranges upon his tray or 
table, having various sizes in such convenient rotation that, without search, he 
is able to pick up each as required. The rope is to be cut into small pieces. The 
material thus made ready, the next requirements are the necessary instruments. 
Fig. 237 exhibits a set of pluggers designed by Dr. W. G. Redman. Pos- 
Fig. 237. 
sessing these instruments, an operator will find himself able to readily intro- 
duce and pack cylinders, mats, and ropes in the various cavities to which they 
are found adapted. The cuts represent thirty of the most approved points. 
They can be procured with handles to suit. A half-inch ivory or ebony handle 
is recommended. Nos. 1 to 7 (serrated-foot instruments) are lateral condensers 
for all cavities. Nos. 8 to 11 (smooth-foot instruments) are used in the same 
cavities and in the same manner, but not until the cavities are nearly full. Nos. 
12 to 24 are all approximal condensers. No. 25 is for anterior approximal 
cavities, molars and bicuspids. No. 26 is for posterior approximal cavities, 
molars and bicuspids. Nos. 27 and 28 are for crown cavities, upper molars 
and bicuspids. Nos. 29 and 30 are for crown cavities, lower molars and 
bicuspids. OPERATIVE DENTISTRY. 
399 
The operator takes up with his foil-carrier a mat of gold of a size suited to 
an easy introduction into the cavity. This mat it is designed to place firmly 
against the neck surface. To so direct and place it, any of the instruments, 
Nos. 7, 11, 27, or 28, may be employed. The first piece in position, a second 
is to follow, being introduced in like manner and consolidated against the first. 
Sometimes, particularly where the labial wall of a cavity is delicate, it is best 
to lay the second mat against such wall, obtaining thus increased security 
against fracture. Mat after mat is now added until the cavity is full; or, if 
preferred, the cut rope may be used, piece after piece being carried and 
wedged into place. 
Plan.-Another plan of using mats in cavities of this character 
consists in first lining the circumference with them and afterward wedging the 
cut rope into the centre. 
Plan.-Still another plan that is found at times convenient consists in 
placing one mat against the neck wall and a second in that portion of the 
cavity nearest the cutting edge of the tooth, wedging next the cut rope, or 
other mats, between these. 
Plan.-Another plan still is found in using a twist or rope of gold, as 
directed in the case of crown cavities, turning into the hole layer after layer, 
until no more can be introduced. This formerly was the almost universal 
practice; being now, however, almost as universally replaced by cohesive foil 
manipulation,-a manner of working gold shortly to be described. 
In operating on a cavity of such position as has just been considered, the 
head of the patient is to be thrown back, the mouth looking upward. 
The operator stands at the right side of the chair, while the fingers of the 
left hand support the tooth and adjacent parts. 
Another Study in Filling.-Passing to still another study, we con- 
sider anterior approximal surfaces of the bicuspidati and molars. Referring 
to «the diagram, Fig. 189, it is seen that such cavities, when properly exposed, 
are converted through such outlook into a very simple form. To fill them 
it is only necessary to employ the mechanical means given. Commonly the 
operator commences with a mat which he fixes against the cervical wall, 
laying one after another of these over the first one, until the cavity is full. 
Where the cylinder is employed, the manner of introduction and consolidation 
is precisely the same. In large cavities of this position it is found an excellent 
plan to bound first the cervical and lateral walls with mats, and afterward 
to wedge cylinders or mats within this golden cavity. 
Difficulties of Access.-Posterior approximal faces are commonly much 
more difficult to fill than anterior. Such difficulty, however, is found markedly 
influenced by the preparation of the cavity and the state of the boundaries of 
the mouth to be operated in. A deep narrow arch with the oral orifice small 
and tense, and strong buccal muscular tissue, and with the patient unable or 
unwilling to assist by keeping the mouth open, will worry the most skilful and 
experienced. On the contrary, in the wide mouth of free and lax orifice, little 400 
A SYSTEM OF ORAL SURGERY. 
more trouble is experienced than in the case of anterior faces. Such cavities 
are filled with the non-cohesive gold precisely as are the anterior. 
Matrices.-The use of matrices in the construction of a temporary wall 
for the conversion of approximal cavities into simple holes has long been a 
favorite means employed by many persons. A very easy and always conven- 
ient way of making a matrice, and one which the author has employed in hun- 
dreds of cases with satisfactory success, consists in breaking off a section of an 
ordinary separating file having a free or uncut surface, and slipping it between 
the two teeth, wedging it in place. This, as must be seen, is not by any 
means a complete wall, but it will be found to answer an excellent end; need- 
ing, indeed, to be seconded only by a reasonably skilful touch to fulfil suf- 
ficiently the indications. Such a matrice is most conveniently used if the 
temper be first removed. 
Another mode of making a matrice applicable to an approximal in- 
clined plane consists in taking a delicate strip of silver, and after cutting and 
filing so that it shall half cover the cavity, being bulged, however, just over 
it, wedging it by means of splints of boxwood into place. This manipulation 
forms, as is seen, a limited last wall, but such wall is quite sufficient to answer 
the ends. 
The Loop M atrice.-A matrice known as the " Loop" is a device of much 
service. A set of these consists (see Fig. 238) of eight thin, flexible steel bars 
Fig. 238.-Loop Matrices. 
and a milled thumb-screw. The bars have heads on each end, with eyes, in one 
of which a thread is cut to fit the thumb-screw. To use, select the proper 
size for the case in hand, pass the head with the smooth hole over the thumb- 
screw, bend the screwed head around, and screw to place on the tooth. 
The Jack Matrice.-A character of matrice invented by Louis Jack, 
D.D.S., has attained deserved popularity; reference to Figs. 239 and 240 
affords idea of its construction. When cavities are of such extent as to 
much complicate the process of introducing and fixing gold, these matrices, 
out of what is to be termed their permanent and full character, are found not 
only to spare the operator much fatigue, but to assist materially in giving form 
and solidity to a plug. OPERATIVE DENTISTRY. 
401 
Fig. 239 shows the surface of a matrice that is placed next the cavity; it 
will be observed to correspond with the natural shape of the part to be re- 
stored. This face is file-cut or coarsely draw-filed. Fig. 240 shows reverse 
face, which is in most cases plane and smooth, excepting at the section c, 
Fig. 239. 
Fig. 240. 
Fig. 241. 
which is file-cut. It is often, according to the experience of the inventor, de- 
sirable to have this side in two surfaces; one, section a, parallel with the plane 
parts of the face, and from this point inclining to a thin edge. A very de- 
sirable form is to have section c bent backward to follow the incline of the 
proximate tooth beneath the gum ; h d show square cuts made to accord with 
the plier-ends shown in Fig. 241. 
Guilford's Matrices.-Fig. 242 shows matrices designed and used by 
Fig. 242. 
Guilford's Matrices, and manner of use. 
Dr. Guilford, of the Philadelphia Dental College, together with manner of 
application. The diagrams so fully exhibit the complete matter as to render 
description entirely unnecessary. 402 
A SYSTEM OF ORAL SURGERY. 
Matrices in large variety are kept on sale by the dealers, while the adver- 
tising pages of dental journals are well supplied with 
illustrations of them. One among the latest is a device 
by Dr. Miller, of Altoona, which for simplicity and effec- 
tiveness commends itself highly. The instrument, to- 
gether with manner of application, are shown in Fig. 243. 
The piece is made of steel, rolled thin, and shaped like 
the " spring cotters" used by machinists. The strip of 
steel, about an eighth of an inch wide, is bent so as to 
bring the ends together, the bend being formed into a 
circle, as shown in the cut. 
Application of Matrice.-To apply a matrice, it is necessary first to 
secure space either through pressure or, preferably, by means of file or disk. 
As well is it necessary to the performance of a preservative operation that 
before wedging a matrice in position the edges of a cavity, as well as the cavity 
itself, be so prepared that no obstruction exist to an easy reaching of every 
part. 
Employing the Jack matrice, selection is to be made of one correspond- 
ing in curve, size, and thickness with the requirements of a case under 
treatment. For small cavities it is recommended by the inventor that the 
drying be first done, the napkins or dam applied, and a hard 
rope of bibulous paper pressed against the gum, followed by 
the matrice. Fig. 244 represents the appearance of the 
parts at this stage, except the wedges, which are not shown. 
When the cavity is now examined, it will be found to pre- 
sent an open mouth, formed by its curved lower edge of 
enamel and by the boundary of the matrice, through which funnel-shaped 
opening every part of the space is easily seen and directly touchable. The 
case is now ready for the reception of gold. 
Fig. 245 represents a transverse section of two cases at a point immediately 
above the grinding surface, which exhibits the outline of the form of the 
cavity and finished surface of the gold. 
Referring again to the diagram, Fig. 189, attention is directed to the filling 
of the very irregular crown cavities represented, two of which are shown 
running, upon the first molar, into the lateral walls. In 
filling such cavities, the operation is to be accomplished 
without much difficulty by introducing first into either ex- 
tremity (which has been prepared as described) cylinders or 
mats of gold, and, after securing the fixedness of these, 
packing subsequent mats or twist-pellets one after the other, 
until the line of association is full. It is, however, in instances of this kind 
that the use of the cohesive gold is felt to be almost a necessity. 
Working gold so prepared and understood, one would scarcely be likely to 
depend on the mode just described. (See Cohesive Gold.) 
Fig. 243. - Mil- 
ler's Matrice. 
Fig. 244. 
Fig. 245. OPERATIVE DENTISTRY. 
403 
A last study that seems necessary to be made in connection with the exclu- 
sive use of the non-cohesive gold is to be directed to the cavity seen in the 
crown face of the wisdom-tooth, Fig. 189, right side. This cavity has a 
complex relation, only, however, from the fact that it is seen to be half 
covered by an operculum of gum tissue. In filling such a cavity (or, indeed, 
rather would it pertain to the preparation of the cavity) it is found necessary 
to uncover the parts; to accomplish this, a tuft of cotton or sponge is to be 
thrust between the tooth and operculum, which tuft, in the process of swell- 
ing, will sometimes remedy the trouble by pushing the gum beyond the pos- 
terior wall of the tooth, around which it may have gathered. If the operator 
be not successful in this performance he is to cut the part away, using scissors 
or a bistoury. 
Cohesive Gold.-Two leaves or portions of that preparation of gold 
known as cohesive, when pressed together with a moderate degree of force, 
will cohere so strictly as not to permit of subsequent separation. 
Using Cohesive Gold.-To fill a tooth with cohesive foil, absolute 
dryness is essential to even a comparative success. To make ready such 
gold for use, if not bought sufficiently prepared, it is desirable that the operator 
first wash his fingers with alcohol: this cleans and dries them thoroughly. 
The foil is now to be cut according to the number used, being folded loosely 
into twists or cut into strips. Confining one's self to what is known as No. 5,- 
that is, a leaf of this number of grains in weight.-the manner of procedure 
is first to fold the full leaf ribbon fashion, making the folds very loose and 
about an inch in breadth; afterward lightly twist it upon itself. In making 
the twist, it would seem that nothing is more necessary than that the bright 
crisp and polish of the foil be not broken, while to avoid so breaking it requires 
only the exercise of a very little care. The twists are to be cut into pellets. 
Heavy Foils.-Heavier foils-those ranging from 20 to 120-are com- 
monly used cut into little oblong squares, a delicate strip being first taken 
from a leaf and this strip subdivided into pieces of a size suited to the cavity 
to be filled. These heavy numbers are, however, confined mostly to use on 
the surface of a filling the bulk of which has been made by the lighter foils, 
or otherwise are employed for filling the root-canals, which see. 
Cohesive Gold and Atmospheric Influences.-Cohesive gold 
exposed to the atmosphere or to association with phosphorus or sulphuretted 
hydrogen gas, loses always more or less of its quality. To restore lost cohe- 
siveness, it is the practice to anneal the leaf, doing this either by laying it 
upon a heated plate or by passing it through the flame of a spirit-lamp. The 
amount of heat to which foil is to be subjected is found to vary considerably. 
A satisfactory test of cohesiveness is found in touch ; a plan is to pass 
the twist through the flame, and then touch to it a finger: if it stick, it is to 
be considered sufficiently annealed; if it do not stick, greater heat is required. 
A practice with many is to heat every twist to a cherry-red at the moment of 
introducing it into the cavity; and while such a rule may be found generally 404 
A SYSTEM OF ORAL SURGERY. 
applicable, many lots of foil are met with which the treatment assuredly ruins. 
A rule to be observed in every case is not to burn the gold and not to heat it 
to an extent which destroys its softness. A foil that is not made cohesive by 
a heat which varies from that which shall simply dry it to that which exhibits 
the cherry-red can never be made so by any such means; it is faulty. 
Annealing.-It is not to be understood that cohesive foil always requires 
annealing at the hands of an operator. Many makes are perfect in this respect 
as received from the makers, it being alone necessary to keep the books in a 
strictly dry place, and enclosed, when not being used, in the envelopes which 
accompany them. 
Sun-Rays as an Annealer.-Placing foil in the rays of the sun trans- 
mitted through glass, as an ordinary window, is a reasonably satisfactory way 
of annealing. In cool weather concentrated sunshine answers every purpose 
where the gold is good. 
Instruments for working Cohesive Gold. - Instruments with 
which cohesive gold is worked differ from those employed with the soft foil 
in being serrated. In the production of such tools the most accomplished 
skill has exerted itself, both in the way of devising forms and in securing 
temper. Instruments when too deeply serrated cut the gold; when too 
smooth they fail to assist the natural cohesiveness by addition of the quality 
of interdigitation. Attention, however, is to be directed to the fact that there 
are operators of repute who deny the necessity for sdtrations, and even, indeed, 
the desirability of using instruments so prepared, believing that cohesive gold 
is to be worked with better results by smooth-faced and highly-polished 
pluggers. At still another extreme, needle-points are used. 
To afford the student every advantage which is to be gained without actual 
manipulative trial, cuts are inserted representing the instruments of serrated 
character most in esteem by the experienced dentists of the country. It is 
to be found, perhaps, that in the use of these, as with the use of the various 
kinds of gold, familiarity constitutes the best recommendation. 
Atkinson's Pluggers.-Fig. 246 exhibits perfectly the features of a 
set of pluggers, comprising fifty-nine instruments, designed by William H. 
Atkinson, M.D., of New York City, and known by his name. Although in- 
tended to be used with the mallet,-a process yet to be described,-these 
instruments are found adapted to hand-pressure. Lately, however, as has 
been reported to the writer, this set, long among the most celebrated, has been 
renounced by the designer, in a preference for smooth-faced pluggers. Much 
reputation attaches to them with the best practitioners; a too great depth in 
the serrations is an objection that has been urged. A set of these instruments, 
consisting of twenty-four pieces, selected from the full complement, is found 
to answer the purposes of most operators. 
Accompanying the pluggers is a set of burnishers of designs corresponding 
with requirements. Fig. 247 exhibits these burnishers. 
Butler's System.-A system of pluggers, composed of sixteen pieces, OPERATIVE DENTISTRY. 
405 
Fig. 246.-The Atkinson Pluggers. 
designed by C. R. Butler, M.D., is represented in Fig. 248. These are in 
great favor with a wide circle of operators. The serrations, as seen in the 
cuts, are very fine. 406 
A SYSTEM OF ORAL SUROERY. 
Fig. 247.-Burnishers 
D. D. Smith's Set.-Still another form-a "student's set," as 
it is called (Fig. 249)-consists of selections and modifications made 
Fig. 248.-The Butler Pattern. 
by Dr. D. D. Smith, and which are used by many of the class in the 
Philadelphia Dental College. These instruments are alike adapted to 
malleting and hand-plugging, and for use with soft or cohesive gold. 
The set has a wide reputation. 
Abbott's Pattern.-Another set, and which is the last that space 
permits to be shown, is exhibited in Fig. 250. These are known as 
the Abbott pattern. Like the others, they have many admirers ; the 
forms of the points will certainly not soon be surpassed. It seems 
scarcely possible that an indication could present in shape or situation 
of a cavity that some one or other of these would not reach. 
Other pluggers, well known and widely used, are sets known as 
Jack's, Ellis's, Goodwillie's, Forbes's, Darby's, and Head's. It is well, OPERATIVE DENTISTRY. 
407 
when visiting dental depots, to examine the many pro- 
nounced improvements constantly being issued, and to 
purchase accordingly. Students do well to buy care- 
Fig. 249.-The Smith Pattern. 
fully at the beginning; experience proving the most 
reliable supplier of wants. 
A tray of instruments recommended to students of 
the Philadelphia Dental College by a late professor, to 
be used after graduation, is made up as follows: 
This style Handles, Nos. 1, 2, 3, 4,5,15. 
This style Handles, Nos. 13,14,15. 
This stylo Handins, Nos. ft, 7, ft, 0,10 11 1$. 
Operating-Case of Philadelphia Dental College. 
7 Head's excavators, Nos. 4, 7, 12, 17, 18, 20, and 21. 
1 Palmer's nerve instruments, each Nos. 2 and 3. 
1 " " " No. 5. 
1 " " " No. 15. 
4 auger drills, two No. 3, 8, and 6. 
2 retaining-point drills, Nos. 1 and 2. 
8 wheel-burs, Nos. 1, 3, 5, 7, 12, 15, 18, and 9. 
7 round burs, Nos. 1, 2, 3, 4, 7, 9, and 12. 
1 cone head, odd No. 6. 
1 Goodwillie's excavator, No. 32. 
2^ dozen standard excavator hatchets, Nos. 16,15,14,12, 10, 9, 
50, 49, 47, 99, 81, 82, 85, and 86. 
2^ dozen standard excavator hoes, Nos. 27, 28, 91, 75, 78, 79, 80, 
57, 58, 59, and 60. 
2^ dozen standard excavator scoops, Nos. 65, 66, 67, and 68. 
7 i inch f. c. pluggers, N. Y., Nos. 127, 128, 101, 1, 4, 9, and 99. 
| dozen S. S. W.'s small scalers, Nos. 1 and 8. 
5 J inch f. c. burnishers, S. S. W.'s, Nos. 8, 6, and 2; Darby's, 
Nos. 31 and 32. 
4 J inch f. c. pluggers : Ellis's, Nos. 10,11,12, and Darby's, No. 3. 
1 universal porte polisher. 
1 box corundum points. 
1 long-handle wood magnifying mouth-mirror. 
1 Cogswell rubber-dam holder. 
1 i inch f. c. rubber-dam punch. 
1 glass syringe, silver-plated mountings, with one curved pipe. 
1 J inch f. o. plugger, bayonet-shaped, no number. 
2 J inch f. c. scalers, R. L. Stellwagen's pattern. 408 
A SYSTEM OF ORAL SURGERY. 
1 § inch bayonet-shape condenser. 
1 octagon-handle plain steel small scaler, No. 5. 
1 set of six Jack's chisels, single-bladed, heavy handle. 
1 lead mallet in gas-pipe, nickel-plated. 
i dozen five-sided drills, three-faced. 
1 set of ten mallet-pluggers. Nos. 1, 3, 4, 5, 6, 7, 8, and 9, of the set of mallet-pluggers 
for sponge gold, No. 2 of Ellis's pluggers, and Atkinson's No. 32. 
Fig. 250.-The Abbott Pattern. 
i dozen Froid's separating files, Nos. 00 and 8, cut three sides. 
8 Murphy's files, Nos. 12, 20, 14, 33, 40, 41, 42, and 19. 
3 " " Nos. 54, 99, and 100. 
2 " " No. 81, R. and L. 
2 Scotch stones. 
1 box each pumice and polishing putty. 
J dozen square-handle probes, one foil-carrier and plugger combined. 
1 abscess lancet. 
1 student's large morocco case. 
3 trays and instruments fitted. OPERATIVE DENTISTRY. 
409 
A set of instruments, as designated above, is recognized as full and complete 
for the purposes of filling teeth.* 
Fillings of Cohesive Gold.-Fillings of cohesive gold are made either 
by hand-pressure or by the use of a mallet. Where the latter means is em- 
ployed, experience certainly demonstrates the necessity for shallower serrations 
in the instruments. Mallet filling consists simply in condensing the gold 
by repeated taps from a hammer made of wood, lead, tin, or steel, applied to 
the head of the plugger. To employ a hand mallet, an assistant is commonly 
deemed necessary, although not by any means an indispensable adjunct, the 
* The following are the instruments recommended by a present clinical professor to stu- 
dents entering the dispensary department of the Philadelphia Dental College. The cost of 
the whole is $27.31. 
4 New York pluggers, Nos. 22, 23, 37, and 50. 
2 J inch file-cut pluggers, Nos. 9 and 28. 
3 Smith's pluggers, Nos. 14, 15, and 16. 
4 Flagg's filling instruments, Nos. 1, 5, 7, and 12. 
1 double-end amalgam plugger (nickel-plated). 
1 octagon-handle wheel bur, No. 5. 
1 " " round bur, No. 7. 
1 " " cone bur, No. 8. 
1 " " inverted cone bur, No. 2. 
1 " " retaining-point drill (round). 
8 " " excavators, Nos. 5, 6, 7, 9, 28, 74, 141, and 142. 
1 " " Head's excavator, No. 11. 
2 plug-finishing burs, Nos. 2 and 7. 
1 D. D. Smith's approximal trimmer, No. 1 (blue). 
2 Chappell's scalers, Nos. 1 and 3. 
1 Abbott's small scaler, No. 2. 
2 J inch file-cut chisels, Nos. 2 and 8. 
2 Arrington's nerve instruments, Nos. 2 and 13. 
3 Palmer's nerve instruments, Nos. 1, 15, and 20. 
1 rubber syringe (with silver pipe). 
1 chip syringe. 
1 steel mallet. 
1 wedge cutter (nickel-plated). 
1 rubber-dam holder (with buffalo guard). 
1 Arkansas stone. 
1 ebony-handle mouth-mirror. 
1 ebony-handle gum lancet, No. 1. 
1 pair college pliers. 
1 pair foil scissors. 
1 dozen nerve broaches (assorted). 
1 bundle orange-wood. 
1 ounce spunk. 
} quire Japanese bibulous paper. 
1 skein gilling twine. 
1 dozen emery strips. 
i dozen separating files. 
1 mortar and pestle. 
1 bottle sandarach varnish (with brush). 
1 bottle nerve paste. 410 
A SYSTEM OF ORAL SURGERY. 
operator being quite able to manipulate both plugger and mallet. Fig. 251 
represents the size of mallets ordinarily used. No. 1 is made of metal,-lead, 
preferably; No. 2 is made of lignum-vitae. 
Fig. 251.-Plugging Mallets 
Practical Experiment.-Provided with some selection of the serrated 
pluggers, the operation of fixing and packing cohesive gold, whether foil or 
crystal, may very well be practised to its appreciation by employing the perfectly - 
clean surface of a metal dollar, either silver or gold being used. 
First, that a hold be secured, the operator washes the coin thoroughly with 
sulphuric ether, and follows this by making a series of deep cross-scratches 
over a portion of the surface selected for the attachment of the foil. Taking 
up now with the serrated point a pellet of gold which has been prepared, it 
is laid upon the scratches, and by a very few manipulative touches is solidly 
attached to the coin. The building up of a cone to any desired height is 
simply a repetition of these attachments. Appreciating through such practice 
the principle on which a plug of cohesive gold is to be constructed, the 
experience is to be quickly enlarged by passing to the filling of simple crown 
cavities in teeth. 
Simple Crown Cavity.-To fill a simple crown cavity with cohesive 
gold, the operator (after adoption of such means as insures to the end of the 
operation against the inroad of saliva) takes up a piece of metal of such size 
as, being packed solidly in the bottom of the cavity, shall give it fixedness; 
upon this first piece after piece is to be attached, precisely as in the case of 
the coin. If the mallet be used, each second or third layer is to be condensed OPERATIVE DENTISTRY. 
411 
by its aid, although it is a habit with many operators to mallet every pellet,- 
a plan only permissible where the shallowest serrations are used, such frequent 
blows, where the instruments are at all deeply cut, quickly destroying the 
integrity of the plug. 
Another mode of fixing the first piece of gold in such a cavity is to 
make at some convenient spot what is called a retaining-point: this is simply 
a slight undercut or slot. The first piece being worked into this slot, the 
remainder of the filling is attached to it. 
A much more convenient, and certainly more expeditious, way of filling 
such a cavity is found in wedging into it the gold prepared as cylinders, mats, 
or the cut twist. When no more can possibly be thus introduced, the metal 
is to be hand-packed or malleted into solidity, foil, worked after the cohesive 
manner, being attached wherever a place invites addition, thus building up 
the required face. 
Complicated Cavity.-As another study in the use of cohesive foil, 
reference may be made to the cavities seen upon the grinding faces of molar 
teeth, Fig. 189, running over into the lateral surface. With the cavity pre- 
pared as described, the operator commenced by fixing in either extremity a 
pellet of gold. This being solidly malleted into place, pellet after pellet is 
attached upon it, until the irregular, sulcus-like place is filled. 
Approximal Cavities.-We pass now to the approximal cavities-ex- 
hibited in the same figure-in the anterior teeth. Taking, as an example, the 
incisor tooth: the operation is commenced with a pellet of gold carefully and 
delicately worked into an undercut; the remainder of the plug, as before 
directed, is attached to this. A plan, however, which is exceedingly easy and 
convenient as to execution consists in first laying a mat, precisely as suggested 
in the use of uncohesive foil, against the neck wall of the cavity ; this is to be 
of such size that when consolidated into place its relation with the boundaries 
of the cavity makes it self-supporting. Against and into this wall of gold the 
cohesive pellets are worked with such serrated instruments as are found most 
conveniently to apply. 
Plan.-A third plan of filling such cavities consists in rolling into balls 
three suitable-sized twists of cohesive foil. Taking up the first ball, it is carried 
to the neck wall and there partially condensed. The second ball is now placed 
in that part of the cavity which adjoins the cutting edge; the third ball is 
wedged between the first and the second, and the mass is condensed by the 
serrated pluggers against the labial wall. Having thus a support of gold im- 
movably fixed by its relations with the neck and base of the cavity, pellets are 
taken up, piece by piece, and worked into it until the cavity is full. 
Plan.-Still another plan, practised, after a little experience, with all 
satisfaction, consists in taking a single ball, prepared as just described, and, 
after carrying into place against the neck wall, holding it in position by means 
of any convenient instrument until it is condensed and a sufficient addition 
made to render the mass self-supporting. 412 
A SYSTEM OF ORAL SURGERY. 
Plan.-Yet another plan is found in the employment of the matrice. 
This, as before suggested, is to be extemporized out of almost anything. A 
very simple mode consists in casting first a ligature of heavy, well-waxed silk 
about the neck of the tooth. Between the tooth and its neighbor a piece of 
soft silver is next thrust and wedged into place by a slip of match-wood. 
Into the cavity thus formed the initial of the plug is placed. A temporary 
matrice of this nature is also provided by the introduction between the teeth 
of a lath-shaped plugger, the initial gold being supported by the instrument 
until fixed and condensed. 
Heavy Foils.-Heavy foils, even those as high as No. 120, are used by 
some operators in filling front teeth, it being claimed for gold so prepared that 
from being rolled instead of beaten it is rendered softer and more cohesive. 
Such metal, after being cut into delicate strips, is attached across the surface 
of the cavity, retaining-points being first prepared and filled. 
Bicuspid Teeth.-Cavities in bicuspid teeth, approximal surfaces, are 
filled according as they may have been excavated. Where the V-cut has 
thrown the hole into an upward outlook,-that is, has given it more or less 
the aspect of a common crown cavity,-no special suggestions are required to 
be added to directions already understood. In the contour fillings, how- 
ever, each case possesses its own peculiar indications. In preparing 
a bicuspid tooth for such a contour filling it is to be remembered 
that the cavity is cut from the grinding face, the tooth being, as 
it were, scooped out. This necessarily makes an open, free cavity, 
which requires some special means of support for the first piece 
of gold introduced. To obtain this support, it is found con- 
venient to take advantage of an undercut, such point of fixed- 
ness being secured at any convenient spot about the base of the 
cavity. Experience avoids intruding on the neighborhood of the 
pulp-canal. A first piece being by this means attached, the remainder of the 
plug is built upon it, the gold in mass becoming finally self-supporting as the 
cavity is packed. The use of a matrice is here found most conducive to con- 
venience and success. (Fig. 252.) 
Plan.-A second means of filling such cavities, and one which is found 
easier of accomplishment by the inexperienced, consists in using a series of 
blocks or mats. After making a slight retaining undercut around the parietes 
of the cavity, a first piece is laid against the neck surface and loosely condensed 
into place. A second and third are next placed against the lateral walls, these 
also being loosely pressed into the undercuts. A fourth, fifth, and sixth, as 
required, are now wedged into the centre, each wedge, as will be seen, tending 
more and more to consolidate and fix the first layers. Securing thus fixedness 
for the gold, the whole is to be carefully hand-worked or malleted solidly 
against the bottom; the upper part of the cavity (exposed by the condensa- 
tion) is filled by working cohesive pellets into the anchored portion of the 
plug, precisely as in the case first described. 
Fig. 252. 
Cavity cut 
from grind- 
ing surface. OPERA TIVE DENTISTR K 
413 
Filling Lower Teeth.-In filling lower teeth, it is common for an 
operator to be behind his patient, standing at such elevation as enables him 
to lean over the head or shoulder. Such a position is found to add immensely 
to convenience in manipulating. Another posture, practised and preferred 
by many, is to stand at the side, precisely as in operating upon the upper teeth, 
-a position that is found to answer a very good end where cavities to be oper- 
ated upon occupy the buccal face of the teeth, but which certainly cannot be 
compared for convenience to the first position for crown or approximal cavities. 
In manipulating upon a cavity in any part of the mouth, advantage is of 
course taken of the various movements permitted by an operating-chair or a 
head-rest. 
Gold Crowns.'-Building up with gold the entire lost crown of a tooth 
is an operation frequently practised by expert workers with cohesive gold. 
Such operations, however, are too often to be viewed rather as exhibitions of 
nice smithery than as proper and judicious surgical performances, it being ex- 
ceptional that the root built upon does not rebel against the treatment pursued ; 
besides, the gold cap crown happily replaces such manipulation. To practise 
operations of this class, the gold receives its fixedness either by anchorage in the 
pulp-canal-the pulp having been removed, of course-or through means of 
gold screws roughened to attach and hold the metal worked into and about 
them. A plan that may be adopted with satisfaction is to ream out the root- 
cavity precisely as for the accommodation of the tube of gold so frequently 
employed for the reception of artificial crowns, as in the process of pivoting. 
(See Pivot Teeth.} Into the canal, so prepared, is inserted a screw, which 
is to have close relation with it near the apex only. The screw is now built 
solidly into the canal, furnishing a support for the crown which the operator 
builds upon and about it. 
In the case of molar teeth, the practice has been pursued of drilling sev- 
eral holes into the circumference of the surface to be built upon, making 
these act the part of slots for the fixing of bases of gold, or for the introduc- 
tion of supports. Little gold retaining-screws known as Mack's answer 
here an admirable end. 
Contour Filling.-By contour filling is meant the building up of a carious 
or broken tooth into its original form after a general manner as just described. 
To do extensive contouring, gold being used, requires much endurance on the 
part of patient, tooth, and operator. The practice, to be satisfactory, is to be 
measured by great good judgment. To do substantial contour work requires 
the perfection of operative dental skill; its understanding and practice is 
therefore to be commended to the student from an educational stand-point. 
Preparation for Contouring.-A tooth prepared for contouring is to 
stand with a cavity perfectly cleansed and of such form that every part is 
easily accessible by gold and pluggers. The walls are to be regular as pos- 
sible, neither rounded nor absolutely sharp, while every edge is to be firm and 
resisting. 414 
A SYSTEM OF ORAL SURGERY. 
The tooth properly secured from moisture, even from that of the breath, 
an operation of contouring is commenced by anchoring immovably a first piece 
of gold in a retaining-slot prepared for it. (Fig. 265.) Then, piece by piece, 
the plug is built upon this into the required form. The manner of progress 
and performance, as suggested, is precisely that which one may familiarize 
himself with by practice on a gold or silver piece of money, and after such 
manner it is always to be first attempted. 
Illustrations from Marshall Webb.-Fig. 253, after the late Dr. 
Marshall Webb, one of the most skilful of gold-workers, shows central incisor 
teeth prepared for contouring upon the pala- 
tal surface, the back and lateral faces of the 
organs being almost entirely lost. It is to be 
observed that absolute distinctness of outline 
distinguishes every point of the margins. 
Fig. 254, also after Dr. Webb, shows, 
on one side, cavities made ready for contour 
plugs; on the other, plugs introduced and 
finished. The incisor affords an idea of the completion of the operation, as 
one tooth is concerned, of that for which the cavity is seen prepared in the 
immediately preceding diagram. In the cut, c shows a groove made in the 
dentine, along each wall of the cavity; a and b show manner of treating fis- 
sures related with a main cavity; d shows a retaining-point. Upon the oppo- 
site side, f exhibits contouring to correspond with the anatomy of the tooth; 
Fig. 253. 
Fig. 254. 
g, the relation of two approximating gold surfaces, the metal being in con- 
tact,-a feature of approximal plugging insisted on by Dr. Webb,-shows 
also the strictly-defined surfaces of enamel as it should relate with gold; 
defines as well the original contour of the part. This same cut exhibits con- 
touring of an approximal cavity in a lateral incisor. Also, a plug in the grind- 
ing face of a bicuspis defined as the metal should show in a perfect operation. OPERATIVE DENTISTRY. 
415 
Fig. 255 exhibits a praiseworthy case of contouring done by Dr. Webb; it 
serves as an example of what is to be accomplished in this direction by skill 
and patience: a, b, d, f, g, and h show pulpless teeth; y, a whole crown 
Fig. 255. 
restored with gold; a. f, and A, almost entire gold crowns; the teeth b and d 
support the gold crown faced with porcelain, c; and fully one-fourth of the 
crown of each of these is restored with gold, as is also that of e, the pulp of 
which is living. 
Studies from Dr. Weld.-Figs. 256 and 257, after Dr. Weld, of 
New York, show studies where breaks extend on the continuity of the faces 
Fig. 256. 
Fig. 257. 
Fig. 258. 
Fig. 259. 
Fig. 260. 
of the teeth, which breaks are to be assumed, for our purpose, to affect both 
labial and palatal walls. To properly contour such teeth requires simply that 
they be cut and built up, as shown in Fig. 258. 
Another illustration is furnished in Fig. 259; here the teeth affected are 
second bicuspis and first molar. Fig. 260 affords idea of the requirements. 
A case commanding much skill is shown by Fig. 263. This exhibits incisor 
teeth decayed largely about their mesial faces. The procedure, securing result 
shown, lies in obtaining proper retaining-points, keeping the organ, while 
under operation, free from moisture, and, precisely as accomplished on the 416 
A SYSTEM OF ORAL SURGERY. 
metal piece, building layer to layer until the lost parts are restored. Rubber 
damming is an essential. 
Contour Work in Progress.-Figs. 261 and 262 show contour work 
in progress. First, attention finds itself directed to shape of the cavity. Second, 
Fig. 261 
Fig. 262, 
Fig. 263. 
Fig. 264. 
it is observed that in one the gold (6) is being built of convex form; in the 
other the manner is concave. To the former mode is given the preference. 
The instrument with which the work is being done is p ; the line of impaction 
is a . 
Plan.-Fig. 264, representing a bicuspis and molar, shows cavities which, 
to allow of the ends of contour work, are to have the 
grinding faces cut away until vertical walls exist. 
Teeth like these, being excavated as shown, and free 
from caries, are wisely filled with oxychloride, and 
when this has set secondary planes are prepared in 
the added material, the margins corresponding exactly 
with the enamel line. Such procedure affords a 
strength which it must be seen would be lost in 
cutting away the healthy operculum: the suggesting 
of an oxychloride lining implies, of course, that it be 
the case that the cavities are larger within than is 
measured by the margins; the zinc extends to the 
vertical plane. 
Plan.-Fig. 265 shows side view of a cuspis crown 
almost destroyed by caries. The tooth is prepared for contouring,-nothing 
having been cut away that could be saved. Retaining-points, as seen, 
are slotted out in the dentine. In each of these slots is a twist of gold, the 
initial end of which is assumed to be firmly anchored. Upon these anchorages 
the original form of the tooth is to be restored. 
Contouring is done by hand or by mallet, preferably by the latter, as 
through such instrumental means the work is accomplished more easily and 
decidedly more firmly. 
Automatic Mallets.-Automatic mallets used in contouring are of 
three general forms: 1. Hand mallet, working by means of internal springs; 
Fig. 266 shows such an instrument. In use it is grasped by its hard-rubber 
Fig. 265. Fig. 266. 
OPERATIVE DENTISTRY. 
417 
Fig. 267.-Electro-Magnetic 
Mallet. 418 
A SYSTEM OF ORAL SURGERY. 
case, somewhat after the manner of holding a lead-pencil, 
the point of the plugging instrument being directed against 
the filling to be impacted. Pushing the case toward the 
point exposes the end of the plunger to the stroke of its 
hammer; the trigger-latch holds the hammer while the 
case is drawn from it, until the latch, which works on a 
pivot, is forced past the lug, when the full strength of the 
blow is delivered upon the plunger, which transmits it to 
the plugging-point. The force of the blow is regu- 
lated by the milled screw over the spring; loosening the 
screw diminishes, and tightening it increases, the force. 
When desired, the instrument is to be used as a hand- 
plugger simply by placing the forefinger on the spring- 
button at the lower end of the hard-rubber case, which 
acts as a stop to the plunger. 
2. Electro-Magnetic Mallet.-Fig. 267 shows 
the electro-magnetic mallet, an invention by Wm. G. A. 
Bonwill, D.D.S. The instrument is run commonly by the 
aid of a Bunsen four-cell battery. It is deemed very com- 
plete by those familiar with its use. Its blows, regulated 
in force to suit, are given with a lightning-like rapidity. 
This inventor has also given to the profession a mallet to 
be used with the dental engine which fully commends 
itself. 3. A mallet also to be used in connection with 
the dental engine. This is an invention by the veteran 
teacher and accomplished mechanician and chemist, Thomas 
Buckingham, M.D. The instrument has secured a large 
number of admirers. Fig. 268 exhibits it. The number 
of impactions to the minute of which the machine is capa- 
ble is said to be eighteen hundred. The use of it is ex- 
ceedingly simple, requiring for the motion only that the 
bit be slipped into the hand-piece of an engine. 
Holmes's Mallet.-Still another mallet is the device 
of Dr. Holmes; this also is worthy of equal commenda- 
tion with the others; it is delicate in construction and in 
every way effective ; practical workers praise it highly. 
With gold adapted to the end, and 
with absolute freedom from moisture, 
an operator, possessed of the requisite 
skill, requires only patience to carry 
the building process to any extent. It 
is to be suggested, however, that if at 
any stage in the performance the mass 
in process of building is found to 
Fig. 268.-Buck- 
ingham Mallet. OPERATIVE DENTISTRY. 
419 
move, nothing better is to be done, as a rule, than begin again from the 
foundation. Still another suggestion considers the possibility of flooding. If 
this threaten at any point of the procedure, the half-accomplished work is to 
be at once burnished, to be recommenced, when dryness is secured, where left 
off. To resecure a proper surface, it is only necessary to scratch the gold and 
wash with ether. The use of the dam obviates commonly this accident. 
Herbst, or Rotation, Method.-The fundamental idea of this sys- 
tem is to transform all cavities to be filled into central. Commence an opera- 
tion by fixing several cylinders of a size proportioned to the hole to be filled 
with a common plugger, and then take No. 2, or 3, or 4, of the pluggers 
shown in Fig. 269, and by a slow rotation polish the gold against the walls. 
If the metal do not stick directly, put in more cylinders with the plugger, 
and recommence condensation by use of the burnisher. On this first layer of 
gold a second one is to be made to-adhere; but the polished surface prevents, 
and here No. 5 finds employment in quick rotation and interrupted touches 
until the polish is gone. (I may here remark that the gold is condensed by 
this rotation, and without pressure, in a very remarkable way.) For large 
fillings, No. 5 is to have proportionate points,* which, if too fine, will make 
holes in the gold, and the pressure is to be intermittent, in order to avoid the 
development of heat, which would be painful and irritating to the pulp. 
Metal instruments gild by use, and will not then work without tearing out 
the gold; but this inconvenience is to be prevented by occasionally rubbing 
them while in rotation upon a piece of tin. Agate may replace the steel. 
The filling of the cavity is continued in the way above described. 
Fig. 269. 
" Let us now," says Dr. G. C. Claudius, who describes the method, " take 
the case of two incisors with lateral cavities approximating one another. The 
two cavities, prepared as usual, are treated as if one, and the gold is at the same 
time introduced into both cavities, fixing some cylinders in the four corners by 
rotation of the proper burnishers, and condensation with No. 5, until they are 
filled, so that there appears to be a single mass, of gold. No. 18 is then pushed 
with regular rotation between the teeth until the mass is quite separated, so 
that thin files, and disks, and tapes may be employed in finishing the fillings. 
* In the cuts, Nos. 6, 7, and 8 are proportionate modifications of No. 5. 420 
A SYSTEM OF ORAL SURGERY. 
" In filling similar cavities between the second bicuspis and first molar, after 
they are properly prepared, place a matrice and fill one cavity with shellac to 
retain it and distribute the resistance, and then fill the other like a central 
cavity, beginning at the cervical border, and, pressing especially against the 
matrice at that point, work toward and finish at the middle of the crown. 
Having filled the first one, remove the shellac and fill the other in the same 
way." Rotation and the pressure do not produce heat,-at least not more 
than seems to render the gold more cohesive. 
Finishing a Plug.-From the consideration of the introduction of a 
plug, we pass to the processes of finishing. These consist in condensing the 
surface thoroughly, in filing the mass into such shape and relation as accord 
with articulation and other requirements, and in giving the gold a jewelry 
polish. 
To accomplish these ends, an operator needs condensers, files, disks, bur- 
nishers, hard and rotten-stone, rouge, strips of tape or of wash-leather, pieces 
of wood, etc.,-that is to say, he will find useful any means which conduce to 
the ends. As condensing instruments are concerned, they find representation 
in pluggers with the serrations filed off. Much pressure, however, being 
brought oftentimes to bear upon such instruments, especially where the mallet 
is not used, the manufacturer in preparing them considers the requirements, 
and by so much enlarges the size of the shank over that of the pluggers. 
Fig. 270.-Finishing Files. 
Files used in finishing are prepared in the greatest possible variety. The 
separating files, figured on a foregoing page, are indispensable for use on the 
front teeth. Fig. 270 represents forms of files that are found useful in almost OPERATIVE DENTISTRY. 
421 
every position. Fig. 271 exhibits files prepared in the bur form. These 
latter have application in the cutting down of crown plugs, and accomplish 
Fig. 271.-Bur and Wheel Files 
their work with a nicety and finish which seem to prove them perfect; the 
figure shows also the handle. These bur files, of which there are every 
possible variety, when worked by the engine, are revolved with a velocity 
which enables them quickly to cut into shape the hardest-made plug, Dr. Bon- 
will claiming for his instrument a rotatory power of several thousand to the 
minute. 
Burnishing Instruments.-Burnishing instruments are found of many 
patterns, the designs corresponding with requirements. Fig. 272 represents a 
Fig. 272.-Set of Burnishers. 
set of these tools intended for hand use, which will be recognized by the ex- 
perienced to comprise all the forms for which there is real necessity. Indeed, 
it would be quite possible to do without Nos. 1, 3, 5, and 7. Such a set cost- 
ing, however, not over six dollars, the outlay for the whole is soon found to be 422 
A SYSTEM OF ORAL SURGERY. 
covered by the extra convenience. No burnishing instrument except that made 
from the very finest steel is worth possessing. The use of a burnisher is 
both to condense and polish the face of a filling. It is used in connection 
with the file, the plug mass being alternately filed and planished. The forms 
figured are prepared for use by both hand and engine. 
Porte Polishers.-Among other instruments found convenient, if not 
absolutely necessary, in the process of finishing plugs, are porte polishers. 
Fig. 273 represents a set of three. These carriers, made for the hand, enable the 
Fig. 273.-Porte Polishers. 
operator to fix splints of wood, upon which he carries pumice- or rotten-stone, 
at any angle found convenient in working. The use of pumice-stone so applied 
represents the finest file, and is found of the highest import in securing a proper 
surface. A hand porte polisher of satisfactory yet inexpensive character is 
made by soldering together at right angles two tubes of silver or of tin of a 
size fitted to support a handle of wood and a splint. As a polisher, an 
arrangement invented by Dr. Bonwill, to connect with the engine, having a 
reciprocal motion, is quite the perfection of manipulation. Circular heads 
of wood revolved by the engine after the manner of a common bur, save much 
time and trouble. 
Corundum Disks.-Corundum disks, and other appliances of that ma- 
terial, are invaluable for plug-finishing purposes. Fig. 274 exhibits a set of 
finishing-points devised by Dr. A. L. Northrop, to be used with the engine. 
Hard Stone.-Hard stone, Arkansas, Hindostan, and Scotch, are to be 
had mounted on engine mandrels. These serve a valuable purpose. They 
are represented in Fig. 275, and their use is understood at a glance. 
Corundum Tape.-Tape, covered with corundum, or used by wetting 
and attaching pumice-stone to the surface, is required in many cases of 
finishing. 
Corrugated Disks.--Corrugated disks, used for carrying powders, is 
another means yielding convenience to the practitioner. Fig. 276 shows such 
a disk. 
Wood Points.-Wood polishing-points, above referred to, illustrated in OPERATIVE DENTISTRY. 
423 
Fig. 277, are necessary to the fine finish of a filling. Pumice, emery, 
rouge, and rotten-stone are used with them. 
Fig. 274.-Corundum Points, Set of 12. 
Condensing a Surface.-A 
cavity being filled with gold, it is felt 
a necessity to secure a surface of suf- 
ficient polish to resist the absorption 
of moisture before the removal of the 
napkin or dam. This is effected with 
the burnisher, a polish being at once 
taken, provided the gold has been 
solidly packed. Should polish not be taken, then the operator is to go over the 
Fig. 275. 424 
A SYSTEM OF ORAL SURGERY. 
surface again and again with the condenser, using either hand-pressure or, 
preferably, the mallet. The manipulations of burnishing and condensing in 
alternation are to be repeated until the protecting polish is secured. 
Fig. 276. 
Fig. 277. 
Condensation of a Filling.-Condensation of a filling is most con- 
veniently obtained through aid of a mallet. The blows struck are at first to 
be very light, that thus unequal consolidation be avoided ; it is best that at 
the commencement the instrument be directed about the circumference of 
the plug, the centre being gradually approached, the operator thus avoiding 
the drawing of the metal from the parietes,-an important matter, as a very 
little experience does not fail to show. Having made such condensation of 
the surface, it is to be followed by the burnisher or file, as seems indicated. 
It is always important to avoid overhanging of the walls by the gold; this 
implies that a cavity be not overfull. In crown fillings, such overfulness is a 
not uncommon fault. Where it is seen to exist, a bur file is to follow the 
burnisher. The face of a crown plug should, when finished, be concave, cor- 
responding with the aspect of the surface of which it forms a part. In se- 
curing such relation of parts, the filling will always be found of more resisting 
surface if the cutting down has been done little by little, the burnisher being 
used very frequently as such cutting goes on. Final finish is given to a plug 
by the alternate use of the burnisher and the porte polisher, pumice or 
Arkansas stone being first used, and after this rotten-stone, crocus, or 
rouge. Through such means the surface of a plug may be made as solid and 
polished as though it were of molten metal. 
Finishing Approximal Surfaces.-In finishing approximal fillings, 
wherever situated, it is desirable to give such plane to the surface as shall render 
it self-cleansing; this is secured most simply by making the metal correspond 
reasonably with the V-shaped cuts which have been advised: in the anterior 
teeth this is effected with all convenience by the use of a convex sepa- 
rating file, as seen in Fig. 174. Treating posterior teeth, an operator will 
select from his case any files that are suitable and easy of manipulation ; 
among the forms exhibited in Fig. 175 he will be likely to find himself suited. 
Cuts made in the V-shape are not void of objection. It is not infrequently 
the case that particles of food, instead of passing quickly and cleanly over 
such a surface, tend to pack in the interspace, thus being a source of discom- 
fort to the patient, and at times provocative of a species of chronic ulitis. OPERATIVE DENTISTRY. 
425 
Such jamming is, however, oftentimes the result of the manner of filing,- 
a matter which soon comes to be corrected by a growing experience. In place 
of such packing of the ingesta being an objection, it is with force argued by 
many that it is a positive good, compelling, through the discomfort induced, an 
attention to cleanliness which it is the object of the space to insure. 
Polishing and finishing a Filling.-An approximal plug filed into 
the required relation, the polishing and finishing follow, as with the crown plug. 
Strips or points of wood, corundum tape, or strips of wash-leather wet and 
dipped into pulverized pumice, or twists of ordinary candle-wick used in a 
similar manner, are found valuable adjuncts, securing a fineness of surface 
which cannot, without a much greater amount of labor, be had through the 
instrumentality of partly-worn files. Strips are used by simply drawing them 
back and forth over a surface to be smoothed. Rotten-stone or rouge, 
or the peroxide of tin, is employed upon strips and wood points for the finish ; 
the first named is to have the preference. 
Dressing Contour Fillings.-In dressing contour fillings, regard is 
not to be denied to self-cleansing properties as related with the planes. Such 
plugs are to be filed into a shape corresponding with the natural irregularities 
of the tooth. That they may render prolonged service, they must have such rela- 
tion as shall enable them to bear the strain endured by the original parts. The 
process of finishing is the same in principle as that employed in ordinary 
cases. In shaping the articulating face it is necessary, however, that special 
regard be given to the contact of the opposing tooth or teeth,-a matter which 
frequently demands much time and care. In shaping contour fillings, it is 
generally found convenient to use the Arkansas or similar stone, rubbing thus 
from the gold every scratch or indentation. Finish, it is to be remembered, 
is the expression of stability and resistance in a contour filling. It is only a 
solid and reliable filling that is capable of receiving a fine finish. 
Principles governing Filling Teeth.-In concluding the subject of 
filling the decayed crowns of teeth with gold, a student is reminded that the 
principles which govern are, that all difficult cavities are to be converted 
into those of simple form ; and that space is always to be secured, 
either by the file, chisel, or pressure, that shall afford the required room for 
manipulation. It is to be added that a fault, as the preservative virtue of gold 
is concerned, exists in a tendency of the tooth to re-decay which shows itself 
at the neck-wall; that is, at that boundary which immediately adjoins the gum. 
A gold plug being satisfactorily good, with the exception of the defect alluded 
to, it is now accepted as good practice to cut away the secondary caries and to 
fill the newly-made cavity with copper amalgam. Explanation of the benefit 
existing in the relation of the two materials is suggested as follows by Dr. 
Register: " The combination is to be supposed to form a galvano-plastic which 
decomposes irritating acids, which would otherwise attack the lime-salts of the 
tooth. A primary battery of acids attached to a secondary one of metals will 426 
A SYSTEM OF ORAL SUROERY. 
deplete itself in charging the latter, and then will, in part, flow back until 
drawn off and used by interruption; and this flow continues back and forth 
each time, becoming less and less, until the current ceases and an equilibrium 
is established." Gutta-percha is a reliable agent in the direction of the same 
indication. If a patient can be watched, preference is to be given it. (See 
chapter on Dental Therapeusis.} 
Plugs made of Cohesive Gold Defective.-It is to be suggested 
by way of addendum that plugs made of cohesive gold may be defective, as 
the whole mass is concerned, by reason of a marginal defect not sufficiently 
great to admit at the imperfect spot the point of a cambric needle. This is 
ever to be borne in mind during the process of packing; it is always to have 
consideration when comparing the relative values of the two forms of gold, 
cohesive and non-cohesive, as a filling material. 
Tin-Gold.-The combination known as tin-gold, first introduced to the 
specialty, so far as is known to the author, by Dr. Abbot, of Berlin, is nothing 
more complicated than strips of No. 4 tin and gold laid together and used 
precisely as one would fill with non-cohesive gold. The strips are to be related 
by being folded mat-fashion, twisted loosely as a rope, or rolled into a ball. 
(See Filling with Non-cohesive Gold.") 
This combination is highly recommended for children's teeth and for all teeth 
that are soft and chalky ; also in cases where a pulp is nearly exposed or where 
semi-devitalized dentine exists that it may be objectionable to remove. A 
filling of this kind, when first inserted, is little harder than tin, but out of a 
catalysis lying with chemico-physical causes it becomes after a little while so 
hard that mastication has little effect on it. Unlike amalgam, the combination 
does not discolor the dentine. Herbst's method (which see) may be employed 
in the use of this material. Witzel's plan is also recommended. Objections, 
to be inferred as existing in the direction of electrical possibilities in the use 
of the combination, are said not to apply. 
Operating-Chair.-The chair upon which a patient sits while having 
teeth filled is to be of such height that it shall bring the'head on a level with 
the breast of an operator. To this end there is great variety in construction. 
Where economy is to be consulted rather than elegance, a head-rest, the in- 
vention of C. C. White, D.D.S., is found most useful. This rest makes its 
own fastening to almost any chair, sofa, lounge, or settee. It has full move- 
ment in all directions on a scale for a tall person or for a child, and is securely 
fastened by turning a single thumb-screw. The accompanying cut represents 
the instrument applied to a common office-chair. The dotted lines show its 
movement. Weight, four and a half pounds. Chairs of much elegance in 
construction, designed both for ornamentation and use, are to be seen in the 
catalogues of the dental depots. 
Conveniences.-Upon an operator's tray there should always be found, OPERA TIVE DENTISTR K 
427 
apart from the ordinary operating instruments, pellets of bibulous paper and 
twists of absorbing cotton, a bottle of Monsel's solution, either of the per- 
sulphate or chloride of iron, with view of controlling trifling hemorrhages, a 
Fig. 278.-White's Head-Rest. 
bottle of creasote, cocaine of an eight-per-cent, solution, for use in obtunding 
sensibility of the gum, sticks of soft pine wood, cologne, brandy, tannic acid, 
oil of cloves, and chloroform for the same end as the cocaine, ether for the 
purpose of provoking speedy salivation, belladonna and morphia with a view 
of controlling or arresting a too free flow of oral fluid (these to be used only 
by the experienced), ammonia as an excitant or for blistering purposes, rubber 
rings, floss silk, a small cupping-glass, undeliquesced crystals of chloride of 
zinc, alcohol, a tongue-depressor, and a magnifying mirror. CHAPTER XXVIII. 
OPERATIVE DENTISTRY. 
THE EXTRACTION OF TEETH. 
Indications for extraction are,- 
1. Dead and Loose Teeth.-Teeth, or roots of teeth, which have 
lost their vitality, and which have become so much loosened as to be agents 
of offence and injury to surrounding parts. 
2. Teeth being thrown off.-Posterior teeth which, from absence 
of antagonizing teeth, are rising from their alveoli, and, through the displace- 
ment, have become a source of pain or inconvenience. 
3. Teeth having Fungoid Excrescences.-Teeth having fungoid 
excrescences growing from the pulp-cavity, not responding happily to curatives. 
4. Teeth afflicted with Incurable Abscess.-Teeth having asso- 
ciated with them incurable abscesses, threatening complications. 
5. Teeth unduly Crowded and Wedged.-Teeth, particularly 
the premolars, so crowded and wedged into the arch as to contribute to undue 
lateral pressure. 
6. Teeth unduly sympathetically involved.-Posterior teeth in- 
ferred to contain nodules of osteo-dentine, being themselves painful, or involved 
with sympathetic neuralgia. 
7. Teeth associated with Antral Disease.-Teeth recognized as 
associated with antral disease. 
8. Teeth worn to the Gums.-Teeth which are worn down to the 
pulp-cavities, or so close upon the gums as to render mastication painful, and 
where periodonteal irritability renders the application of artificial crowns ob- 
jectionable. 
9. Teeth without Usefulness.-Teeth so badly affected by caries- 
being painful or offensive-as to afford no prospect of usefulness. 
10. Roots interfering with Comfort.-All roots of teeth about 
which the gums are congested and debased. All roots which are sources of 
unrelievable pain or discomfort. All roots in which badly-putrescent decay 
is progressing. 
Removal of a Tooth.-The removal of a tooth is an easy or difficult 
matter according as the principle involved in the operation is clearly or ob- 
scurely appreciated. In the adult mouth there are thirty-two teeth, and these, as 
the study of their extraction is concerned, are comprehended under six classes. 
428 OPERATIVE DENTISTRY. 
429 
The first class embraces the eight central and lateral incisors, teeth with 
cone-like roots, and accommodated in alveoli representing hollow cones. 
The second class embraces the cuspidati, represented by the partly- 
flattened cone. 
The third class embraces the bicuspidati, represented by the flattened 
cone. 
The fourth class embraces the superior first and second molars, teeth 
having three roots,-two external cone roots, situated antero-posteriorly, with 
Fig. 279.-Permanent Teeth of Upper Jaw. 
Fig. 280.-Permanent Teeth oe Lower Jaw. 
Figs. 279,280, diagram of teeth.-1, 2, incisors; 3,4,5, bicuspidati, or small molars; 6, 7,8, large 
molars, or grinders. 
the interspaces looking toward the cheek, and the third, generally a flattened 
root, looking toward the palatine arch. 
The fifth class embraces the inferior first and second molars, teeth 
having two roots, one looking anteriorly, the other posteriorly; the interspace 
looking outward and inward. 
The sixth class embraces the four wisdom-teeth. These are single-rooted, 
as a rule, with a curve looking backward. 
Extraction of Teeth considered by Classes. 
Teeth of First Class.-To extract a tooth of the first class, the ap- 
plication of the force is required in a twofold direction, rotary, and downward 
or upward as the case may be. 
Teeth of Second Class.-To extract a tooth of the second class, the 430 
A SYSTEM OF ORAL SURGERY. 
force is required in a threefold direction, downward or upward, lateral and 
rotary. 
Teeth of Third Class.-To extract a tooth of the third class, upward 
or downward, and lateral, or inward and outward, as one loosens a nail. 
Teeth of Fourth Class.-To extract a tooth of the fourth class, the 
same application of the force; one-half of such a tooth is, however, to be ex- 
tracted at a time,-that is, we first break the attachment of either the inner or 
outer roots, and feeling these yield, the force is instantly brought to bear upon 
the other. In extracting teeth of this class after such manner, much care is 
necessary in guarding against a too great extent of lateral motion; otherwise 
the roots, instead of yielding, will be found to break, thus complicating matters 
very seriously. 
Teeth of Fifth Class.-Teeth of the fifth class require the lateral and 
direct application of the force; they are to be gently rocked inward and out- 
ward until felt to yield, when they are at once to be lifted from their sockets. 
Teeth of Sixth Class.-Teeth of the sixth class are to be carried back- 
ward and upward, or downward, in the line of the axis of their single curved 
root. Such applications will make easy an extraction that might otherwise 
be attended with much risk. 
INSTRUMENTS. 
Instruments used for extracting teeth are now made in consideration of the 
anatomical peculiarities of the organs for which they are intended. The better 
class are nickel-plated, to insure against rust, and are of such temper, as the 
character of the steel is concerned, that they will retain the outline and sharp- 
ness of blades through much service. No forceps but those of this quality 
Fig. 281.-Upper Incisor. 
Fig. 282.-Upper Lateral Incisor. 
are worthy of purchase. We now describe, together with manner of use, 
such as have most commended themselves. OPERATIVE DENTISTRY. 
431 
Incisor Forceps.-Figs. 281 to 285 represent forceps designed for the 
extraction of the incisor teeth. Referring to Figs. 279, 280, Nos. 1 and 2, 
or, what is practically much better, examining the organs themselves, the 
Fig. 283.-Lower Incisor, Hawk-Bill. 
Fig. 284.-Lower Incisor and Bicuspid por Either Side. 
Fig. 285.-Hawtk-Bill, Lower Incisor and Crowded Teeth 
reader will perceive that these teeth fully represent, as has been stated, double 
cones, the bases abutting just beneath the free margin of the gum. To secure 
a fixed, unyielding hold of a body so shaped, it would strike the intelligence of 
any operator that the forceps should be so constructed as to accommodate the 
width of the base, yet at the same time grasp firmly the retreating cones. 
Turning here the examination to the forceps, these indications are found 
fully met. The fenestra, made when the blades are closed, forms an ellipse, 
the widest part of which agrees with the base of the teeth. The apices corre- 
spond so in form with the cones, and the concavities of the blades so adapt 
themselves, that, applying the instruments, they are found fitted to the teeth 
with the nicest accuracy; indeed, as suited to the purpose, nothing seems left 
to desire. 
Forceps for Superior Incisors.-Fig. 281, upper incisor, is a straight 
forceps, designed for the superior incisors, and which, where the under jaw is 432 
A SYSTEM OF ORAL SURGERY. 
well withdrawn, answers very well for the cuspidati. The roots of the incisor 
teeth are understood to be rounded uones, having corresponding alveoli. These 
teeth are, perhaps, the most easily extracted of any in the jaws. Thrusting the 
blades well beyond the neck of the tooth, the curve in the handle receiving the 
little finger, and looking toward the body of the patient, having the head rest- 
ing either in the support of the ordinary dental chair or against the chest of 
the operator, whose left arm is to be thrown around it to secure fixedness (and 
which position applies to all the upper teeth), a force is to be exerted which, 
while drawing downward, rotates or twists the organ from its socket. If, how- 
ever, the resistance prove too great for a single twist,-which, in heavy jaws, 
is almost certain to be the case,-then the motion is to be reversed, the direc- 
tion of the twist being alternated until the tooth is felt to yield, when, without 
further effort, it may be drawn from its socket. 
Fig. 286.-Upper and Lower Root, Half Curved. 
Fig. 287.-Lower Root, Full Curved. 
Fig. 288.-Upper and Lower Bicuspid, Half Curved. 
Fig. 289.-Upper Back Root (universal). 
Forceps for Superior Laterals.-Fig. 282 represents a forceps de- 
signed for the upper lateral incisors. The ellipse is seen to differ a trifle from OPERATIVE DENTISTRY. 
433 
that of the preceding instrument; this adapts it to a corresponding difference 
in the tooth. It differs principally, however, in having the blades made nar- 
rower. The application of this forceps is precisely the same as that employed 
in the case of the central. 
Forceps for Inferior Incisors.-Figs. 283 to 289 represent forceps, 
all of which are found adapted to the inferior incisors, central and lateral, to 
the cuspidati, and the bicuspidati. 
When extracting these teeth, the operator may stand either in front of his 
patient, or (a position more commonly preferred) he may seat the patient 
upon a low chair, leaning over his head, or over the right or left shoulder, 
as found most convenient. 
Special Forceps.-Fig. 289 is a forceps particularly adapted to the ex- 
traction of the inferior incisor teeth. Grasping the tooth by forcing the blades 
as far down as possible, keeping them confined closely to the organ, that thus 
they may be directed between the tooth and its alveolus, the rounded root of 
the central may generally with much ease be broken from its attachments by 
an upward and rotary movement. If, however, with a very reasonable exer- 
tion of force so applied it is not felt to yield, the strain is not to be increased 
to a risk of breaking the tooth, but a lateral motion inward and outward may 
be tried, or this conjoined with the rotary. This root being sometimes con- 
siderably flattened, makes such lateral motion necessary. If very narrow or 
crowded, the forceps represented by Fig. 290 may be used. In removing the 
inferior lateral incisors the rotary movement is to be employed, which may 
Fig. 290.-Half Curved, Narrow Beak, for Crowded Teeth. 
have combined with it slight lateral motion, although this latter will not be 
found of much import, unless in exceptional cases, where the roots happen to 
be markedly flattened. The bicuspidati all have flat roots, and, so far as the 
conditions of extraction are concerned, are to be viewed as possessing but a 
single root. These teeth are removed just as a nail is worked from a board 
into which it has been loosely driven,-a motion inward and outward quickly 
breaking the attachment. The position of operator and patient is the same 
as just suggested. 
Forceps for Ten Anterior Upper Teeth.-Fig. 291 designates a 
forceps adapted equally well to the ten anterior upper teeth. It may justly 
be termed a faultless instrument. The writer certainly gives it the preference 
over all that he has seen used for the purposes intended; indeed, he inclines 
to think that with it any tooth in the mouth could be extracted in an emer- 434 
A SYSTEM OF ORAL SURGERY. 
gency. Applying this instrument to any one of these ten anterior teeth, it is 
seen to be possessed of most satisfactory adaptation, the curve in the blades 
and handles clearing the lower lip to an extent affording the greatest freedom 
Fig. 291.-Upper Bicuspid and Canine. 
in motion, while the support curve in the handle prevents the possibility of 
change in the grasp. 
Root of Cuspidatus.-The root of a cuspidatus is perhaps the most 
firmly fixed in its alveolus of all the teeth of the jaw. Occupying as it does 
the position of a key-stone to an arch, to extract it requires both strength and 
skill. In shape, the root is found to be a partly-rounded, partly-flattened 
cone; its alveolus, of course, corresponds. In length it is greater than the 
adjoining teeth,-in many instances to the extent of a third,-and, while 
generally straight, is yet frequently to be met with having an apex curved at 
varying angles, such curvature, however, being confined to the extreme end. 
To extract this tooth, the organ is grasped by working the blades of the 
forceps as much below the edge of the process as possible, and, while a firm 
compressing force is maintained, the tooth is gradually rotated, and also worked 
inward and outward. If, after a moment, it should be felt to yield, and yet, 
while moving with more or less freedom in its socket, seem to be held by some 
attachment, the operator is to cease his efforts, that he may satisfy himself 
that the loosening resides not in a fractured alveolar process nor in a retaining 
flap of gum. If neither of these complications exists, he may again seize the 
tooth, and, understanding that the retention depends on curvature of the fang, 
attempt to get it away by finding, through various movements, the direction 
which affords the least resistance. This discovered, the organ is to be worked 
out even at the risk of fracturing the curved apex. No tooth requires to 
be more thoroughly and deeply lanced than the canine. 
Forceps for Bicuspid and Cuspid Teeth.-Figs. 292 to 294 are 
instruments devised by different operators for the extraction of the bicuspidati 
and cuspidati. These forceps are remarked to vary considerably in shape. 
Fig. 294 is one found to have most frequent application, being useful alike in 
the superior and the inferior jaw Unless it is designed to furnish a case with 
all the numbers, this may with most satisfaction be selected. Fig. 295 is an 
excellent instrument, particularly applicable to the lower jaw when the teeth 
are set well back and the commissure is small and unyielding. OPERATIVE DENTISTRY. 
435 
Forceps for Superior Molar Teeth.-Figs. 296 to 298 represent 
forceps designed for the extraction of the superior molar teeth. On examin- 
Fig. 292.-Upper Bicuspid and Incisor. 
Fig. 293.-Lower Bicuspid and Canine. 
Fig. 294.-Lower Bicuspid, Safety. 
ing the blades of any of these instruments, the outer will be seen to run to a 
nib at its centre, while the inner is plain. These correspond with the anatomi- 
cal indications of the teeth upon which they are to be used, as is seen by glancing 
at Figs. 279, 280, Nos. 6 and 7. To apply these forceps, the triangular blade 
must correspond with the outer face of the tooth. Having the instrument well 
in position, which, it will be recognized, places the point of the outer blade in 
Fig. 295.-Upper Bicuspid, Safety. 
the interspace made by the bifurcation of the buccal roots, and the concave 
plain inner blade against the palatine root, the force is to be so applied as to 
break the attachments at separate motions; this is easily accomplished by the 436 
A SYSTEM OF ORAL SURGERY. 
process of rocking the tooth outward and inward. Lateral movement is 
not to be great, that fracture be avoided. The position of operator and 
patient is as before designated for other upper teeth. 
Fig. 296.-Upper Molar, Right and Left (Harris's). 
Anomalous Roots.-It is not always the case, however, that these teeth 
are found as represented in the drawing. Sometimes as many as five roots 
exist, and these so diverging as to render the removal of all of them, without 
fracture, a very difficult matter, perhaps, indeed, impossible, particularly if the 
jaw be heavy and the alveolar process dense. At other times it will be seen 
Fig. 297.-Upper Molar, Right and Left. 
that the roots have commingled, forming an irregular conical fang. This latter 
condition facilitates, of course, extraction. Another expression not infrequently 
met with is a convergence of the apices of the roots, these so grasping the 
enclosed process that, in the coming away of the tooth, either the fangs must 
spring to such extent as to permit the passage, or this piece of bone must 
come away with it. OPERATIVE DENTISTRY. 
437 
Teeth out of the Arch.-Again, it is sometimes seen that a molar 
tooth-although this is much more common to the bicuspidati-stands to the 
Fig. 298.-Upper Molar, Right and Left. 
inside of the arch, being wedged, as it were, out of its place. Here the rock- 
ing motion is necessarily modified. The tooth is first, with gentle yet steady 
force, to be carried inward, then back to the point of departure. This is to 
be repeated until the attachments are broken. Cases also present, but they 
are very rare, where a tooth desired to be removed is more or less overlaid by 
its fellows. Here it will most likely be necessary to resort to the use of the 
file, or recourse may be had to wedging away the opponent teeth by means of 
slips of india-rubber worked, while held on the stretch, between the teeth. 
Such wedges, after being retained for a few hours, will not infrequently be 
found to have secured room quite sufficient for the passage. Where undue 
crowding is seen to depend on approximal caries of the tooth to be extracted, 
it will be all-sufficient to chisel away the part intruded upon. 
Forceps to be used on Upper Molar of Both Sides.-Instru- 
ment Fig. 299 is of such construction as permits its application to the superior 
Fig. 299.-Upper Molar, for Either Side. 
molars of either side. It is not, of course, an anatomical forceps, but when 
the teeth to be extracted are solid and resistive as to structure it answers its 
end tolerably well. It is not, however, to be commended. 
Maynard, or Cow-Horn, Forceps for Superior Molar Teeth. 
--Fig. 300. These are instruments, in pairs, designed for the extraction of 438 
A SYSTEM OF ORAL SURGERY. 
the superior molar teeth. They are known as the Maynard, or cow-horn. 
Than these forceps, it would seem that none could be devised meeting more 
happily the anatomical requirements of Class IV. 
Fig. 300.-Upper Molar, Right and Left, Cow-Horn, with or without 
Hook on Handle. 
The outer beak, horn-shaped, is designed to enter the interspace between 
the buccal roots; the inner-flat, square of blade, and grooved-adapts itself 
accurately and firmly to the palatine fang. 
To apply these forceps, the operator stands to the right of his patient, 
precisely as in the case of teeth of the first three classes, the left arm passing 
around the head, the fingers of the left hand holding the lip out of place. 
In using the Maynard forceps, care must be taken to thrust the point of the 
horn directly into the interspace, otherwise the operator would have no hold 
on the tooth; this being in position, the flat blade is carried along the pala- 
tine fang as high as possible. A few rocks of the tooth inward and outward, 
combined with a direct force in the line of its long axis, and it will be found 
to give way. 
Combination Forceps for Superior Molar Teeth.-Fig. 301 is 
Fig. 301.-Upper Molar, Cow-Horn, Either Side. 
an instrument of similar construction, differing, however, in an arrangement 
of blade-curvature which permits of its application to the teeth of either side. OPERATIVE DENTISTRY. 
439 
Fig. 302 is a forceps intended for the lower molars and the dentes sapientiae 
of either side. The molars of the inferior jaw are two-rooted (see Figs. 279, 
280), with the interspace looking outward and inward. Examining the instru- 
ment, it is seen that the blades terminate in sharp, central nibs, the design of 
Fig. 302.-Lower Molar, Either Side (Harris's). 
such points being to fit as accurately as possible the depressions made by the 
division. When the crown of a tooth is strong and resisting, or where a 
loose process permits of a hold which carries the nibs well into the inter- 
space, this instrument is to be used most satisfactorily. Where, however, 
the crown is much decayed, and consequently frail, the cow-horn forceps 
next to be described are found better adapted. 
Harris's Wisdom-Tooth Forceps.-The wisdom-teeth of the lower 
jaw have the single curved root corresponding with the upper, bending here 
toward the rami of the jaw. Instrument Fig. 302 allows of the proper ap- 
plication of the force demanded for their extraction; they are to be lifted up- 
ward and backward. Wisdom-teeth crowded under the rami, and thereby 
unable properly to erupt, not infrequently become the occasion of grave 
lesions. (For instances of such complication, together with mode of treat- 
ment, see Alveolar Abscess.} 
Cow-Horn Forceps for Lower Molars.-Fig. 303 is the lower cow- 
horn forceps. This instrument, designed to be used in the extraction of the 
lower molars, is one of the most effective in the collection. To employ it, care 
Fig. 303.-Lower Cow^-Horn Forceps. 
is taken so to apply the points that the closure of the handle forces them into 
the interspace. Referring to Fig. 280, this interspace is seen to correspond with 
the exact centre of the buccal and lingual faces of the tooth, and, examining 
its relation with the alveolar process, it is seen to be on a level with the border. 
When the blades of the instrument are in position, it will be recognized that 
the points are to occupy this interspace; thus the pressure is exerted from 440 
A SYSTEM OF ORAL SUROERY. 
below, and not at all upon the walls of the crown, affording, in this respect, 
such advantage that extent of decay or brittleness amounts to very little. 
The lifting power and leverage of this forceps are of such character that it 
frequently happens that closing the handle loosens the tooth. 
When, however, this does not occur, the organ is to be rocked until the con- 
nection is felt to break. Examining a tooth held in the grasp of this instru- 
ment, the points of the blades are found met in the interspace. Before 
applying the force it is well always to have the points thrust as deeply as 
possible below the free edge of the gum. When such precaution is not taken, 
and the sharp points do not reach the interspace, they are almost certain to 
produce fracture. This instrument is, of course, not applicable where 
caries has proceeded to such an extent as to have separated the roots. Figs. 
304 and 305 are the cow-horn forceps in pairs: the shape of the handles, and 
the curve for the rest of the little finger, add much to convenience of employ- 
ment. Together, they make a very efficient set for lower molars. 
Fig. 304.-Lower Molar, Cow-Horn, Kight Side. 
Fig. 305.-Lower Molar, Cow-Horn, Left Side. 
Wolverton's Forceps.-Fig. 306 is a forceps designed for the inferior 
molars; it is known as Wolverton's instrument. It is preferred by many as 
combining the advantages of the Maynard and Harris. 
Hutchinson's Lower Molar Forceps.-Fig. 307 is a lower molar 
forceps. In a deep mouth, or where the tooth to be extracted is much con- 
cealed by one anterior to it, the curve of the blade is found to render great 
service. Admirers of the instrument commend it particularly for the shape 
of the fenestra. 
Booth's Claw-Forceps.-A forceps for the extraction of lower molars 
constructed with a double-clawed face, the device of Dr. Booth, of Iowa, highly OPERATIVE DENTISTRY. 
441 
commends itself; a second pair, clawed on the palatal blade and cow-horned for 
the buccal interspace, applies to upper molars. 
Fig. 306.-Lower Molar, Either Side (Wolverton's). 
Fig. 307.-Lower Molar (Hutchinson's). 
Forceps for Superior Wisdom-Teeth.-Fig. 308 designates forceps 
for dentes sapientiae of upper jaw, either side. As a rule, these teeth are 
found to have but a single root. This, in shape, is conoidal, with a curve 
which directs the apex toward the tuberosity of the bone. To remove them 
with least effort and risk, this curve of the root is always to be considered; 
requiring the extraction to be in the line of its axis. To accomplish such a 
requirement, the crown of the tooth, after being grasped in the beak of the 
instrument, is to be directed backward. This rolls the organ wheel-fashion, 
Fig. 308.-Upper Dentes Sapienti^e, for Either Side, with or without 
Hook. 
as it were, from its socket. The forceps Fig. 307 is adapted for the removal 
of these teeth when they are small. 
Bifurcating Roots.-It happens, however, that in many instances the 
superior wisdom-teeth have three, or even more, bifurcating fangs; when this 442 
A SYSTEM OF ORAL SURGERY. 
is the case, it is quickly to be recognized by an undue resistance offered to the 
employed force, and its direction. No rule can here be given outside of that 
which applies to the neighboring molars: the operator, if the irregularity be 
peculiar, feels his way by testing for the aspect of least resistance. 
Phy sick's Forceps.-Fig. 309 represents a forceps designed by the 
late Professor Physick for the extraction of wisdom-teeth. The instrument 
Fig. 309.-Physick's Dentes Sapientije, Either Side. 
is seen to represent a double inclined plane, and, in consideration of the neces- 
sity for throwing these teeth backward, is designed to be applied between the 
tooth to be extracted and the one directly anterior to it. The closure of the 
handle is expected to throw the organ from its socket. 
In the case of wisdom-teeth possessed of several roots, as referred to in a 
preceding paragraph, these roots, instead of being inclined in a common axis, 
being spread irregularly in various directions, it is plain that the instrument 
would not apply, and that, more than this, it is entirely incapable of being 
used in the direction. Another difficulty in the way of its use lies in injury 
apt to be inflicted on the anterior, or fulcrum, tooth; this not infrequently 
having the enamel so crushed and broken as to expose the more susceptible 
dentine, and thus lead to caries. Still another objection lies in the contusion 
inflicted on the periodonteum, this membrane being occasionally so injured as 
to result in severe inflammation. 
Key Instrument.-The ordinary key instrument, when lightly and 
delicately made, answers a very admirable purpose with this class of teeth. 
The roots being generally quite short, there is little of the common danger of 
alveolar fracture, and being but lightly set in their sockets, and easily yielding, 
the application of but very trifling force is required. 
To use the Key.-In using a key, the fulcrum is to be placed on the 
inner face and well back upon the tooth, the claw being upon the opposite face 
and well in front; this application allows of the proper direction of the force, 
and admits of the easy and natural removal of the organ. 
Elevators.-Still another instrument employed in the extraction of these 
teeth is the elevator. 
To use the Elevator.-To apply this means, the grooved face is laid 
against the antero-lateral aspect of the tooth, and the blade being carried down 
to the process, the hand is depressed so that the free edge alone impinges; the 
tooth is then pushed outward and backward from its socket. When wisdom- 
teeth are but ordinarily adherent, this is a reliable instrument for their re- 
moval care, however, is necessary that it shall not slip from the tooth and OPERATIVE DENTISTRY. 
443 
inflict injury on the neighboring soft parts. Elevator No. 5 (Fig. 310) is the 
one most commonly employed. 
Fig. 310.-Elevators used in Extracting Teeth 
Forceps for Lower Wisdom-Teeth.-Another instrument yet is 
Fig. 311: long of shank, and with blades curved at right angles with the 
handle, it answers an excellent purpose in the case of the inferior wisdom- 
teeth. 
Fig. 311.-Lower Dentes Sapient!.®, Either Side. 
Fulcrum Forceps.-These instruments, of which seven constitute a 
set, act on the principle of the key and elevator. A glance at their construc- 
tion will exhibit the mode of application. That when skilfully used they are 444 
A SYSTEM OF ORAL SUROERY. 
capable of meeting many emergencies, is not to be doubted. The forceps of 
this class here figured are the invention of Dr. E. M. Jones, of Richmond, 
Fig. 312.-Upper Incisors, Cuspids, and Bicuspids, for Either Side of 
the Mouth. 
Fig. 313.-Lower Incisors, Cuspids, and Bicuspids. (Two pairs, one for the 
right and one for the left side of the mouth.) 
Fig. 314.-Lower Molar. (Two pairs, one for the right and one for the left 
side of the mouth.) 
Virginia. Another instrument of the same general character, which, in re- 
spect to the fulcrum, highly commends itself, is the invention of Dr. H. H. 
Perrine, of Maryland. 
Modifications of the Key.-All forceps of this class are modifications 
of the key of Garengeot and of the elevator, and, in the deserved commenda- 
tion they receive, serve to exhibit the virtue of the instruments they represent. 
The key, so long and so almost completely abandoned, should not be without 
its place in an operating-case. With a variety of claws to fulfil the diver- 
sified indications, and with skill and care in the adjustment of the fulcrum, it OPERATIVE DENTISTRY. 
445 
is a most valuable addition. An advantage possessed, however, by the 
fulcrum forceps, is easier adaptation of the claw, together with a more direct 
oversight during the act of extraction. In applying either this forceps or the 
Fig. 315.-Upper Molar. (Two pairs, one for the right and one for the left 
side of the mouth.) 
key, it is necessary to force the blade as deeply as possible along the root of 
the tooth, and so to arrange the pad that the pressure upon the soft parts shall 
be as little injurious as possible. Bruising and crushing the gums are the 
objections. 
Concerning the fulcrum forceps, much commendation has been re- 
ceived,-gentlemen of experience considering them an essential to a satisfactory 
success in this direction of practice. 
Hurd's Forceps.-A comparativelyrecent device in the way of forceps 
is an invention by Dr. Hurd. Five instruments constitute the full require- 
ments of an outfit. The introduction of a spring which drops the tooth is 
a valuable addition. The set cannot be overhighly commended. 
Extraction of Fractured Teeth and Roots of Teeth.-It not 
infrequently happens that, in attempts to extract teeth, fractures result; and 
such fractures must, of course, present the greatest variety of aspect, and 
require various resources for the removal of the parts left. 
Fractures of the first, second, and third classes present the same common 
features, and are to claim a first attention. Fig. 316 represents the alveolar 
line and the various relations held to this line, or free border, by fractured 
teeth or roots. 
Illustration.-A fractured tooth, as represented by No. 1 in Fig. 316, is 
placed in no worse condition for easy extraction than before the occurrence of 
the accident. The same forceps and the same manner of its application apply. 
Illustration.-No. 2 represents a slight modification of the same con- 
dition. The one forceps and the one application still, however, apply. It 
is advisable, if the tooth be at all brittle, to work the blades of the instru- 
ment well beneath the alveolus. This affords greater support and yields 
increased security. 
Illustration.-No. 3 represents a bicuspid tooth with the crown half 
broken away. In such a case, if the remaining portion be not at all brittle, 
and if the process be soft and spongy, the forceps, as described, having well- 446 
A SYSTEM OF ORAL SU RO ER Y. 
sharpened blades, may again be tried, working them well beneath the festoon, 
and securing all the hold possible on the root. If fracture again occur, which 
Fig. 316.-Relation of Fracture Roots to Alveolar Line. 
is very likely, simulating Nos. 4 and 5, the cutting forceps may have to 
be employed. 
To use Cutting Forceps.-To use a cutting forceps, make, with a 
scalpel or other blade, an incision on either side of the root through the soft 
parts directly down to the process; these cuts must correspond with the exact 
centre line of the root. The forceps is now to be applied scissors-fashion, cut- 
ting directly through the bone. Being thus brought in contact with the root, 
and grasping it perhaps full half its length, the removal is a simple matter. 
Fig. 317.-Inferior Combined Root-Incising, Separating, and Elevating 
Forceps. (Dr. T. C. Stellwagen's Pattern.) 
Fig. 318.-Superior Combined Root-Incising, Separating, and Elevating 
Forceps. (Dr. T. C. Stellwagen's Pattern.) 
Trial with Elevator to precede Cutting.-Some operators prefer 
to precede the cutting forceps with trial of the elevator, and this instrument, 
in many cases, certainly does the work very well. OPERATIVE DENTISTRY 
447 
In the application of the cutting forceps, it not infrequently happens that, 
from want of care, the blades, instead of coming directly upon the root, slip 
to the back or front of it. In these cases the fang may generally be easily 
enough picked out with the ordinary root forceps. A 
form of cutting instrument used by many, consisting of 
a double curved blade, avoids this accident, but it is to 
be objected to on account of the wound it makes. 
Illustration.-Roots represented in Fig. 316, Nos. 
4, 5, 6, and 7, are removed on a common principle. The 
first attempt is to be made with the elevator: laying the 
groove of this instrument closely against the root, its 
sharpened knife-like edge is insinuated between the fang 
and process, being worked down as far as possible. The 
handle is now carried obliquely to the line of the root, 
and thus, using a careful oscillatory motion, the piece is 
forced from its bed. It is very well known, however, 
that with a dense, heavy alveolar process this instrument 
cannot be made to operate so happily, it being next to 
impossible to insinuate it between the bone and tooth. 
Under these circumstances, another instrument, the screw 
(Fig. 319), may be brought into requisition. 
Dental Screw.-The screw is designed to operate 
upon a tooth-root as the spiral does upon a cork. Well 
tempered, and very sharp, it is introduced into the 
pulp-canal, and slowly and gently turned until it has taken 
a firm hold. A simple direct movement, and the root is 
brought away. 
It may happen, however, that no hold sufficiently 
fixed for the extraction is to be obtained with the in- 
strument. When this is the case, it is to be laid aside 
and the always reliable cutting forceps brought 
into requisition. If preferred, however, the screw can 
be bored into the tooth until fracture is produced, and 
this will sometimes enable us quite easily to pick away 
the splinters; particularly will this be found the case 
when the line of the fracture divides the root in its 
length. 
Dubs's and Hullihen's Compound Forceps. 
-Forceps known as Dubs's and Hullihen's represent the 
combination of the screw with the forceps. In the Hullihen instrument the 
screw is designed more especially to afford support, preventing the blades from 
crushing the root. In Dubs's forceps the spring trigger corresponds with 
the two forces, affording thus not only support, but allowing the extracting 
power to be divided between the two means. 
Fig. 319.-The 
Screw. 448 
A SYSTEM OF ORAL SURGERY. 
Use of Compound Forceps.-In using these instruments (their em- 
ployment being confined to the single-root teeth), the shank holding the screw 
is to be confined in the grasp of the blades, and, thus controlled, it is to be 
Fig. 320.-Dubs's Screw Forceps. 
1, conical screw with square ratchet shaft; 2, beaks of forceps, grooved inside; 3, 
socket with square hole to receive shaft; 4, spring trigger by which the screw can be 
detached at pleasure at any given point. 
screwed into the pulp-cavity: a proper hold secured, the blades are to be 
expanded, and thrust, as in the ordinary application, about the root, which is 
then extracted secundum artem. 
In many instances, however, the immediate employment of the 
screw is found impracticable, owing to the shape of the canal or the 
Fig. 321.-Hullihen's Screw Forceps. 
density of the dentine: in these cases the fang may be reamed out of its 
bed, which manipulation is accomplished without effort by the use of drill and 
engine. 
Removal of Molar- and Wisdom-Teeth Roots.-Roots of the 
molar and wisdom teeth, superior and inferior, are removed on a common 
principle. In the use of the elevator, a very happy result is not infrequently 
secured by applying the blade to the inner face of the root, carrying the shank 
across the mouth, and making a fulcrum of some convenient opposite tooth. 
Where the roots of a molar tooth are so firmly fixed as to seem incapable 
of removal with the application of an ordinary amount of force, it is better to 
divide them. This is easily done with the cutting forceps, and after the sepa- 
ration each root may be picked out singly, and generally with comparative ease. 
Beaked Forceps.-Forceps of delicate beak are much in favor for the 
extraction of roots of teeth; indeed, it is a common practice to exhaust their OPERATIVE DENTISTRY. 
449 
capability before resorting to other means. Figs. 322 to 327 exhibit different 
forms of such forceps. Figs. 322 and 323 are to have the preference,-these 
being quite capable of performing the work of the others. 
Fig. 322.-Upper Front Root, Straight. 
Fig. 323.-Upper and Lower Root, Half Curved. 
Fig. 324.-Lower Root, Full Curved. 
Fig. 325.-Bayonet-Shaped Root. 
Fig. 326.-Half Curved, Long Beak, Alveolus. 
Sub-Alveolar Forceps.-Mention is to be made of what is denomi- 
nated the sub-alveolar, thin-pointed forceps used in the extraction of roots. 
Where an alveolus is of loose structure, this instrument accomplishes its 
purpose admirably. 450 
A SYSTEM OF ORAL SUROERY. 
Deformed Teeth.-Understanding the principles on which teeth of 
ordinary character are extracted, the practitioner will need but little instruction 
so far as anomalies are concerned. 
Fig. 327.-Lower Molar Root (with Crowns). 
Illustration in Extraction of Deformed Roots.-In Fig. 328, 
Nos. 1, 2, 3, 4, and 5 represent five anomalies, and these may very well stand 
for the class. In removing such teeth from the mouth, the matter of greatest 
importance is to recognize them. Now, while this cannot in all cases be done 
so as to appreciate exactly the condition of the roots, yet we may always feel 
that some impediment to the removal exists; and this, after all, is the most 
Fig. 328.-Anomalies 
important matter, as it influences the amount of force used, which, too 
freely rendered, might result in fracture of the bone, or still greater injury to 
surrounding parts. 
A tooth, as represented in No. i, will generally yield in its roots so 
as to pass the intermediate piece of process. If it do not yield, then this wedge 
of bone will fracture and be brought away. Such fracture, however, results 
in no harm, and is to be deemed of little consequence. 
One, as represented by No. 2, having a great curve in the root, is 
made incapable of passage, unless, after being loosened, it is carried outward 
in the direction of the axis of the curve. In this way it is easily removed. 
The character of the curve is recognized by the resistance offered when the 
tooth is inclined in certain positions, and by the absence of such resistance 
when it is directed in the proper line. The attempt to extract such a tooth 
by simple force would result either in fracture at the curve, in lifting out a 
neighboring tooth, or in fracture, more or less extensive, of the alveolar 
process. 
No. 3 represents exostosis of a root. A fang so enlarged will not pass 
through the process unless the bone be very open in its structure. Such OPERATIVE DENTISTRY. 
451 
a tooth may be made quite loose, but, while it moves freely enough in its 
socket, it is felt to be held by something abnormal. To free such a root it 
is only necessary to use the cutting forceps, or, what is preferable, to take the 
ordinary small surgical chisel or, still better, an engine-drill and cut 
away sufficient of the process to admit of the passage. This little operation 
is easy of accomplishment, and must prove adequate to the end. 
No. 4 represents a form of twin teeth. The two must be removed 
together, which may be difficult or the reverse according to the character of 
the process. It is well, before making the effort to extract, to free the process 
from the teeth as thoroughly as possible : this is done by a sharp and flat 
elevator or by use of the chisel or drill. 
No. 5 represents a second form of twin growth, the result of original 
germ union. If the offshooting bulb be situated within and covered by the 
process, it is to be treated as if it were a case of exostosis of the fang. These 
germ unions are exceedingly rare, and one might not be met with in a lifetime. 
Among other curious examples of anomalous teeth to be seen in the Mu- 
seum of the Philadelphia Dental College is one exhibited by Fig. 329. A 
Fig. 329. 
Fig. 330. 
practical feature in the anomaly concerns the extraction. This was effected 
with less trouble than might be supposed. In the attempt to remove the 
one standing upright, it soon appeared that there was something wrong, and 
the effort to extract was suspended and a thorough examination made. In 
the second attempt, the force was very cautiously applied, in order to find 
what direction the tooth would take. It yielded most to an inward motion, 
and by a continued effort in this direction the removal was secured with 
only a slight fracture of the lingual border of the alveolus. 
The second specimen (Fig. 330) is a union of three of the anterior 
teeth. This mass would extract as a single tooth. 
Anomalies out of Rule.-An anomaly is, of course, a condition out- 
side of rule. A practitioner familiar with normal tooth anatomy will find 
little difficulty in dealing with exceptions; the plan is to feel one's way to a 
result. Lance well in all cases. CHAPTER XXIX. 
OPERATIVE DENTISTRY. 
GENERAL REMARKS ON EXTRACTION. 
The relationship of the teeth with the jaws is through the medium of a 
cellular process known as the alveolar. Each tooth is lodged in an alveolus 
or alveoli corresponding to the number and character of its roots: thus, the 
central and lateral incisors, the cuspidati, and the bicuspidati, having each 
but one root, have each but one alveolus.* 
The molar teeth of the superior jaw have three roots, consequently a three- 
fold relation to the alveolar process. 
The molar teeth of the inferior jaw have two roots and two alveoli. 
The wisdom-teeth have, as a rule, a single short curved and stumpy root, 
consequently a similar alveolus. 
Association of Teeth with Alveoli.-The association of the teeth 
with their alveoli is through the medium of a fibro-cellular tissue; this mem- 
brane is coarse and resisting about the free edge of the bone, loose and cellular 
as it gets deeper. A properly-shaped lancet may be made to excise the 
coarse fibres; consequently, the operation of extraction is always to be pre- 
ceded by that of thorough lancing. In this way much of the strength of the 
relationship of a tooth with its socket is to be overcome. 
Influence of Associate Relation with Extraction.-A tooth is 
extracted with difficulty or easily as influenced by the character of its periodon- 
teum, and the loose or firm structure of its alveolus. 
Fracture attending Extraction.-A limited fracture of the alveolar 
process is not generally found to be a matter of much consequence. If an ex- 
tensive break should associate with an extraction, the tooth and bone may be 
laid carefully back in place, and treated as any common fracture; or, if this 
do not seem desirable, the fractured piece may be dissected from the soft parts, 
and the wound treated on general principles. Sometimes, when too much 
force is injudiciously used, a fracture may occur, including several teeth. In 
such accidents the circumstances of each particular case are to direct the prac- 
titioner ; they are ugly and generally unnecessary troubles, and not apt to occur 
where proper care is exercised. Meeting with such an accident, effort is to be 
made to reunite the parts; failing in this, there is no resource but to dissect 
* The student will here turn to the chapter on the " Surgical Anatomy of the Mouth and 
Face" and make himself acquainted with the nature and meaning of the alveolar process. 
452 OPERATIVE DENTISTRY. 
453 
away the piece, or otherwise wait on nature for a process of expulsion; dis- 
secting it away is the preferable plan. 
Laceration of Gum.-Laceration of the gum is an accident frequently 
associated with the careless extraction of teeth. Such laceration may be trifling 
or it may be serious; it is always to be guarded against by attention to proper 
lancing. A small piece of gum torn by a tooth as it comes away had best be 
removed; left in the mouth, it is a source of annoyance, and reflects, in the 
mind of the patient, on the practitioner. Large strips are to be carefully laid 
back in place and secured by one or more stitches, by a plate, or by other 
convenient means of retention. 
Paralysis following Extraction.-The writer is familiar directly and 
indirectly with the existence of this complication. Cause is injury of a nerve, 
avoidable or unavoidable. Effect is felt commonly at seat of peripheral termi- 
nation. In the way of treatment nothing is to be done but wait, provided 
spicula of bone or a portion of tooth-root be not present to disturb. Time 
cures the trouble invariably. 
Hemorrhage after Extraction.-Hemorrhage after extraction is in- 
fluenced by two circumstances : the state of the parts and the predisposition 
of the patient. An ordinary tooth extraction is followed by bleeding lasting 
but a very few minutes. In extraction for periodonteal trouble this bleeding 
is sometimes profuse. Such hemorrhage, however, if at all reasonable, is not to 
be interfered with ; it expedites the cure of the case wonderfully, relieving, as 
it does, the general congestion of the parts. 
Hemorrhage of Local Signification.-Undue hemorrhage, of local 
signification, is found to depend either on non-contractility in the foraminal 
and circumferential vessels, or on excessive vascularity in the alveolar walls. 
Where the bleeding is from an artery, it is more or less per saltern; where 
venous or capillary, it is continuous. Hemorrhage of constitutional 
expression is associated with the defibrinating condition, or with hereditary 
predisposition. Anaemia as a cause is perhaps the most common of the sys- 
temic vices ; next to this is to be ranked a typhoid state; after this, pur- 
pura. Plethora conjoined with laxity of the tissues is another of the 
constitutional causes. Vicarious relationship is a condition met with sometimes. 
Hemorrhagic Diathesis.-In cases where a hemorrhagic diathesis 
exists, alveolar hemorrhage is not infrequently of profuse character, making 
necessary energetic treatment for its cure. Two cases, occurring with the 
author in the persons of a father and son, may illustrate such direction of 
practice. 
Illustrative Example.-Mr. B., aged nineteen, applied to his dentist for 
the removal of the second superior molar of the right side. The operation over, 
the bleeding seemed not excessive, and the patient was dismissed as usual. On 
the same day, in the latter part of the afternoon, bleeding recommenced ; Mon- 
sel's solution of the persulphate of iron was employed, and the patient dismissed. 
During the night hemorrhage recurred, and the family physician was sent 454 
A SYSTEM OF ORAL SURGERY. 
for; the solution of iron was re-employed, and a temporary arrest again se- 
cured. The next day the bleeding reappeared, and nitrate of silver was applied 
in the alveolus. This controlled the hemorrhage until the succeeding day, 
when it again appeared ; and so off and on over a period of eight days. At 
this time the case was first seen in consultation, the patient being unable to 
swallow any other than liquid food, owing to the swelling of the fauces and of 
the oesophagus, from the effects of an over-free use of the silver nitrate. 
In examining the case, the cavity was found filled with a half-coagulated 
clot, which was taken away, thus discovering that the bleeding came not 
alone from the socket of the tooth, but from about the margins which had 
been ulcerated and degraded by the various applications. Hemorrhage was 
entirely capillary. 
Treatment of Case.-In a treatment which resulted in the immediate 
control of this case, the following course was pursued : First, an impression in 
wax was taken of the roof of the mouth, inclusive of the bleeding part. From 
this impression a model was made, to which was struck a silver plate. (See 
Prosthetic Dentistry.') This task accomplished, which consumed about two 
hours, the bleeding cavity was solidly packed with alum-saturated lint, the lint 
projecting and overlying the ulcerated margin. Over and upon this was now 
placed the accurately fitting and compressing plate. Upon the plate, raised 
to the common level of the adjacent teeth, was laid a fold of linen: the lower 
jaw was next closed upon this compress and kept in position by a bandage. 
Tincture of erigeron canadense was administered, and the feet of the patient 
were placed in hot water. Hemorrhage ceased entirely in the course of an 
hour, and did not recur. 
Second Example.-Mr. B., the father of this young gentleman, aged 
perhaps fifty, suffered five days from hemorrhage, under the following cir- 
cumstances: A wisdom-tooth of the left upper jaw troubling him because of 
its great looseness, he applied to his dentist for its removal. Not deeming it 
necessary or desirable to cut the gum, the practitioner extracted the tooth 
without the preliminary step of lancing, and in the act was so unfortunate as 
to tear away a small strip. Hemorrhage was immediate, and more or less 
continuous. Monsel's solution being prescribed by his physician, it was em- 
ployed, but with somewhat the same result as in the son's case. On the 
evening of the fifth day the case was first seen by the writer. The patient 
was much weakened from the excessive discharge, and was exceedingly fright- 
ened and nervous. The clots washed away, it was discovered that the blood 
oozed from the torn gum, and not at all from the tooth-socket. Erigeron in 
drop doses, repeated every minute, was directed, and a tuft of alum-saturated 
cotton was ligated against the wound. The hemorrhage ceased entirely within 
ten minutes, and did not recur. As an assurance, wine of iron was prescribed, 
which the patient continued to take to the amount of four ounces. 
Erigeron Canadense as an Haemostatic.-Tincture of erigeron 
canadense, in cases of this character, seems to be a reasonably reliable haemo- OPERATIVE DENTISTRY. 
455 
static; not entirely so, however, as it is frequently prescribed where it fails to 
exert the slightest influence. Wine of ergot may take its place. 
Hemorrhage dependent on the Typhoid Condition.-Hemor- 
rhage dependent on the typhoid condition is to be treated with most success 
by conjoining with the local medication the internal administration of acids, 
than which none seem to answer so good and reliable a purpose as the dilute 
hydrochloric, in doses of fifteen drops in a wineglass of water, repeated each 
four hours. Cider vinegar freely used is an admirable medicine in the direc- 
tion. Purpura, as a predisposition, demands its own peculiar class 
of remedies. Anaemia is best treated for immediate ends with the 
tincture of the chloride of iron. Vicarious hemorrhage requires 
an attention which shall consider restoration of a lost harmony. Whatever 
the systemic vice, appreciation of the requirements and the meeting of the 
indications constitute an important direction in the treatment. 
Use of Cardiac Sedatives.-Depressing the action of the heart is, 
under almost all circumstances, a valuable means for the arrest of hemorrhage. 
To this end the tincture of veratrum viride is always given with satisfac- 
tion ; the dose is five drops for an adult, given in a tablespoonful of water. 
Conjoined with this, and indeed in many instances quite capable of taking its 
place, is the hot foot-bath,-the depression to be continued until the patient 
shall either grow faint or break out into profuse perspiration. 
Lead and Opium.-Lead and opium prescribed in conjunction form a 
reliable haemostatic; two grains of the first to one of the latter may be given 
every two or four hours, according to the urgency of the case. 
Rest as a Means.-Rest is a reliable means of cure. A patient is to 
be kept quiet, both as motion and anxiety are concerned. 
Signification of Local Treatment.-Local treatment of dental 
hemorrhage has the threefold signification of mechanical, vital, and chemical. 
The first considers means which, through compression or clot, shall confine 
the blood to its vessels; plugging the alveolus is a common practice in this 
direction; the plug to be of almost any convenient material, as raw cotton, 
or shreds of lint made by scraping linen. When hemorrhage is per 
saltern, a splint of soft pine wood, shaved to a point corresponding with the 
apex of the alveolus, being carried and retained in place, will almost of a cer- 
tainty control the hemorrhage. Plates of metal or of gutta-percha, so moulded 
as accurately to close the cavity, thus favoring the formation of a clot, are 
frequently employed with success. Spider-web as a clot-holder is another 
means, the web being packed into the cavity and there retained. Com- 
pressed sponge is still another of the mechanical means. This last, when 
thinly coated with wax and of delicate point, is to be carried to the very apex 
of a cavity, and, when forced into itself and maintained in position by an 
overlying compress, constitutes one of the most reliable of this character of 
agents. Preference, however, is to be given to a delicate strip of old 
and soft linen packed into a bleeding alveolus after full saturation with phenol- 456 
A SYSTEM OF ORAL SUROERY. 
sodique or tannic acid ; such packing, when tightly made and the pledget kept 
firmly in place by means of a compressing pad, has never failed in the hands 
of the writer. The packing, however, is to be carefully done. The strip is 
crimped on itself, the initial extremity being first carried to the extreme end 
of the socket. Gallic acid, five-drop doses, may be conjoined. 
Clotting Agents.-Of the medicinal agents having the signification of 
forming a clot, preference is to be given tannic acid. The persulphate of iron, 
a preparation much used in general practice, is to be denied application in the 
mouth. Without doubt a clot is formed more speedily and solidly with 
this agent than with the tannin, but the danger from secondary hemorrhage 
overbalances all its virtues. A tannin clot is not soluble by the blood, and 
needs but support to possess all required attributes. 
Astringents and Stimulants.-Of the astringents and stimulants, 
acting by exciting responsive force in the tissues to which they are applied, 
and controlling hemorrhage through contractility, we have alum, zinc, lead, 
red pepper, iodine, turpentine, and most of the dilute mineral acids; of these 
preference is to be given to a dilute tincture of capsicum. 
Alum as a Haemostatic.-Alum, in full saturation with water, is a 
reliable haemostatic, and, when properly supported by a mechanical adjunct, 
is seldom found to fail; it is injurious to enamel, on which account it is not 
to be used without care. 
Chemical Astringents.-Of agents acting chemically to the control 
of hemorrhage, mention is to be made of catechu and kino among the vege- 
tables, and nitrate of silver among the metals; the latter, however, is an 
objectionable preparation, because of the destruction of tissue so common to 
its employment, except when used in dilution. 
Actual Cautery.-All ordinary means failing for the arrest of an alveolar 
hemorrhage, the actual cautery is to be applied. A control thus secured, how- 
ever, is to be seconded by anti-hemorrhagics of internal expression, as it is 
frequently found to be the case that separation of the slough made by this 
means re-excites the original trouble. Ergot is indicated. 
Compression.-Compression made to a bleeding alveolus is to be mod- 
erate, not severe ; and when made, and the hemorrhage controlled thereby, the 
packing is not to be hastily removed; a good rule is to wait for expression of 
suppuration. 
Luxation of the Inferior Maxilla.-Occasionally, in tooth extraction, 
as a result, perhaps, of sudden movement, or of an abnormal laxity of the 
ligaments of the temporo-maxillary articulation, the condyloid process falls for- 
ward over its glenoid boundary. The patient is thus rendered unable to close 
the mouth, and is said to labor under luxation. (See chapter on Luxation.) 
Local Anaesthetics in the Extraction of Teeth.-The employ- 
ment of various local agents to secure exemption from pain in the operation 
of extraction has of late commanded so much attention that no chapter treat- 
ing of the subject would be complete without reference to them. OPERATIVE DENTISTRY. 
457 
Bags of Ice.-The most simple and elementary application in this direc- 
tion is found in enclosing in a piece of bladder, or other convenient skin, a 
small portion of pounded ice and salt, and enveloping, for a few moments, the 
part to be operated on. To secure the effect most conveniently of such a 
process of refrigeration, various instruments have been devised, but none, so 
far as the application of the ice and salt is concerned, have been found to 
answer any better purpose than the bladder or skin enclosure. Such skins 
should consist of two little bags, one to rest upon the outer, the other upon 
the inner side of the gum. To prevent pain from the application of the cold, 
the bags are to be brought gradually in contact with the gums; or, what 
answers a similar purpose, the application may be preceded by ice-cold water 
held in the mouth for a few moments. 
Refrigerating Apparatus.-An apparatus designed and manufac- 
tured by Messrs. Horne & Thornwaite, of London, is said to answer a very 
good purpose, and is thus described: 
A required amount of water is cooled down, by means of ice and salt, to 
about zero, in a vessel called a refrigerator. To this vessel is attached another, 
called a graduator, containing warm water at about 100° F., and so constructed 
as to allow the slow admixture of its contents with the chilled water in the 
refrigerator, and thus produce a gradual diminishing temperature, for the pur- 
pose of preventing sudden shock and pain to the teeth, which a direct applica- 
tion of cold would inevitably cause. A tube conveys this graduated current 
into a terminal portion constructed of very fine membrane, which adapts itself 
to the form of the gums, and wholly surrounds the tooth to be extracted. 
The fluid then passes away through an exit tube. In this manner a constant 
current of cold, at a decreasing temperature, is made to pass over the part, 
abstracting therefrom all heat, and consequently all feeling. 
Aconite as an Anaesthetic.-The concentrated tincture of aconite is 
a useful local anaesthetic, but one that is to be used with a great degree of 
caution. If a portion of this tincture be applied to one-half the lip, sensibility 
is likely to be found so interfered with that a goblet placed to the part feels 
as if broken. 
Chloroform and Laudanum.-A mixture of chloroform and lauda- 
num in equal parts is lauded by some. To apply this, it is only necessary to 
saturate a tuft of cotton and lay it against the tooth to be extracted. 
Strong Iodine Tincture.-Another means, serving to attract the atten- 
tion of the patient from the operation, consists in painting the gum heavily 
with tincture of iodine. After such painting, people are often heard to say 
that the pain has been much ameliorated. 
Electro-galvanism.-Electro-galvanism claimed at one time a large 
share of attention. The application of this consists in attaching one pole of 
a battery to the forceps, while the other is held in the hand of the patient; a 
gentle current is next let on, during the passage of which the tooth is ex- 
tracted. This mode of effecting local anaesthesia is still practised by many ; 458 
A SYSTEM OE ORAL SURGERY. 
but the writer has to say that in his hands and in the hands of experienced 
friends it has proved a failure. It is not to be denied that in certain 
cases it does seem somewhat to obtund sensibility, but in the majority of 
instances it either does no good at all, or adds the discomfort of shock to the 
pain of the operation. 
Ether and Rhigolene Spray.-The use of the spray of ether or of 
rhigolene is a not entirely unreliable means for the production of local anaes- 
thesia ; certainly one reasonably acceptable when employed for operations of 
limited extent about soft parts, but as to an availability in tooth extraction 
experience has not so fully endorsed it. With these agents as thus locally 
applied, incisions, in the way of the removal of sebaceous and other super- 
ficial tumors, the opening of abscesses, carbuncles, and similar operations, are 
assuredly to be made with fair satisfaction; but in their application to the 
teeth the obtunding of the sensibility has not by any means been so marked, 
and particularly has this been found the case where rhigolene was used. 
Evaporating Ether.-The process of freezing a part through the known 
refrigerant power of evaporating ether seems first to have suggested itself to 
Dr. Richardson, of London. An instrument invented by this gentleman for 
the accomplishment of such an end is here exhibited, forms of bellows for 
both hand and foot being represented (Figs. 331 and 332). 
Fig. 331.-Spray Apparatus-Hand-Instrument 
For the spraying of any plain surface, a simple straight tube is all that is 
necessary. For the teeth, the double sprayer, as seen in the drawing, is used; 
with this instrument a continuous vapor is cast upon both the outer and inner 
face of the gum, congelation being rapidly induced. OPERATIVE DENTISTRY. 
459 
In using the hand-instrument the operator should not himself work the 
pump. A very few moments' compression of the ball renders the hand shaky 
and unmanageable. 
Fig. 332.-Spray Apparatus-Foot-Instrument. 
Upon this instrument of Dr. Richardson's many modifications have already 
been made. Of these, one by Messrs. Codman & Shurtleff, of Boston, has 
perhaps attracted most attention. It certainly seems to divide the ether more 
infinitesimally, thus insuring complete vaporization; but it has a weak point, 
in that the tube frequently freezes or chokes up,-an accident that does not 
occur with the Richardson apparatus. 460 
A SYSTEM OF ORAL SURGERY. 
Objection to Cold.-An objection urged to the use of extreme cold, as 
above induced, is injury done to the soft parts. That such objection is valid 
seems, however, not to be satisfactorily proven ; if anything, parts thus operated 
upon unite better and with less inflammatory reaction than obtains where the 
spray is not used. 
Hydrocarbon.-Rhigolene, or hydrocarbon, manufactured from coal-oil, 
and much vaunted by some, has not proven so satisfactory as ether. It cer- 
tainly freezes a part more quickly than this latter agent, but the anaesthesia is 
not so complete. 
Cocaine.-This newest of the local anaesthetics finds many to commend 
its use emphatically. To be of service, as extraction of teeth is concerned, it 
is to be injected into the periodonteum by means of a hypodermic syringe. 
The amount to be used is from one-eighth to one-fourth of a grain dissolved 
in ten drops of water. Professor Poinset, of Paris, recommends the following 
formula : Liquid vaseline and arachis oil, of each, fifty centigrammes ; of pure 
cocaine, five centigrammes. The cocaine is to be dissolved by placing it in a 
hot-water bath. 
Nitrous Oxide.-Liquid nitrous oxide, atomized by means of an in- 
strument specially designed for the purpose, is likely to command much 
attention in the near future. (See Local Anesthetics.) CHAPTER XXX. 
OPERATIVE DENTISTRY. 
CAP-CROWNING, THE PIVOTING PROCESSES, AND BRIDGE- 
WORK. 
Cap-crowning, the pivoting processes, and bridge-work belong with a re- 
lated class of operations that are to be studied and appreciated as parts of a 
common performance. 
Broken teeth, when not contoured after a manner that has been de- 
scribed, are to be repaired by substitution in the way of a metal cap, by a pivot- 
ing operation, or by addition of scales or faces of porcelain. Bridge-work is 
an enlargement of the aspects of such accomplishments, being a combination 
of the plans. 
Metal Cap-Crowns.-A metal crown is a hollow cap, as illustrated in 
Fig. 333, made to represent as accurately as the skill of an operator permits 
the part to be covered or replaced. Capping was initiated, and led to, by 
experiences growing out of manipulations related with pivot- 
ing, but, as the views and performances of the present 
day are concerned, is to take precedence, for purposes ol 
instruction, where progressive advance into and through the 
practice of tooth restitution is the object of a demonstration. 
Likeness to Enamel-Cap.-A tooth-cap, in its most 
simple expression, is a reproduction in gold of the enamel-cap. 
and is to be accepted as perfect in proportion with its likeness in fit to such 
natural covering. 
Making and applying a Cap-Crown.-A simple cap-crown is made 
of metal, commonly gold, and is so to fit and be related with a part to be hooded 
that while it shall not be subject to displacement in the act of mastication it 
yet may be removable without unnecessary trouble should uncovering of the 
part be a necessity. 
After whatever manner a cap is to be made, consideration of a case begins 
with recognition and appreciation of the facts, first, that the root is healthy, 
and, second, that enough of it stand above the gum; otherwise, that it is capable 
of being made so to present as to permit of its being firmly encircled. Such 
conditions existing, the inexperienced will proceed wisely if, as a beginning, he 
take an impression of the part and secure an articulation; details commonly 
omitted, however, by the experienced. 
Fig. 333.- 
Cap-Crowns 
461 462 
A SYSTEM OF ORAL SURGERY. 
An impression is taken by softening a piece of common beeswax and 
moulding it over the part. An articulation is secured by shutting the 
teeth together upon this wax, thus getting the relation in which the artificial 
crown is to stand to teeth biting upon it. To make this bite practical, plaster- 
of-Paris paste is run over both surfaces of the wax, and associated back of it. 
When dry, separation by section is to be made in such manner as shall 
preserve the relative positions of bite and root. The space left between is 
that to be occupied by the proposed new crown. (See Plaster Articulator.) 
A succeeding step is to take a strip of flat gold, and, laying it upon a piece 
of lead, strike with a punch into its centre; this secures resemblance to the 
front face of an anterior tooth. Next anneal, and bend the sides round the 
root. When this is satisfactorily accomplished, solder the ends together. 
The articulating pieces are now to be put together, and the superior face of 
the tube so made as to be filed into a shape that permits proper closure with 
the tooth antagonizing. To finish, fit a crown surface to correspond with 
the face of the articulating tooth and with the filed surface of the tube; the 
soldering together of the two completes the operation. 
The above directions apply especially to restoration of teeth anterior to the 
molars. To fit a crown to a 
molar base, the operator com- 
mences by striking up in a 
piece of lead a crown-face, 
which, being ready, a suc- 
ceeding step encircles the 
root of the tooth with a deli- 
cate gold band of width cor- 
responding with the tooth; 
crown and band are now 
soldered together, and the 
work is done. Fig. 334 illustrates one of several manners of relating crowns 
and roots, and shows as well three forms of crowns. 
Crown-Surface, how made.-The crown-surface, or, more justly 
expressed, the articulating face of a cap-crown, is made either by shaping out 
the cusps by use of a file or, preferably, striking them up by means of a die. 
To make a die it is alone necessary to get an impression in wax of such 
surface or surfaces as may be selected, into which water-mixed plaster of Paris 
is run. When this hardens the wax is trimmed away so as to expose the 
face. Next a sand mould is made from this plaster model and used for casting 
a zinc die. In turn this die is partially buried in sand, the face being left 
exposed, and lead is poured over it. The die and counter-die thus secured 
serves for swaging the faces. (See Making Casts.) 
Fig. 334. 
To apply a crown, if the root stand but little above the free surface of 
the gum, it is found necessary, in order not to irritate the tissue, that it be OPERATIVE DENTISTRY. 
463 
forced away from tne tootn; this is conveniently accomplished by using an 
ordinary gum lancet, or more expeditiously, by tying tightly about it a strand 
of twine and then forcing the gum away by use of the instrument exhibited 
by Fig. 224. Still another manner lies with the very temporary use of a 
rubber ring slipped about the neck of the tooth. Free use of cocaine, in a 
solution of eight grains to an ounce of water, proved so effectual in the case 
of the writer in such a performance as to permit the driving of a gold crown 
between root and gum without giving him the slightest pain. Next the cavity 
of the root is fully cleaned, as for the ordinary process of filling with a plastic. 
One or more pins, as deemed necessary (see Fig. 334), are now placed in the 
cavity, and secured in a desired position by means of gutta-percha, oxychloride 
or oxyphosphate of zinc. The same material being next filled into the artificial 
crown, relation of the parts is to be made during the state of plasticity. Ger- 
man os artifidel is highly commended for making the relation. 
A means of fixing a gold crown where the root is decayed upon either 
side or in the centre nearly to the alveolar process is to be practised with 
much success after the following plan: Cut down until a 
firm base is secured; trim and put the rough edges in good 
condition; next separate the gum from the neck of the 
root low down as the alveolar process; fit and solder the 
band, and proceed as before to secure a crown. The arti- 
ficial part made ready, the operator reams out the pulp- 
cavity or cavities, and, fixing in these headed screws, grafts 
his crown as before described. Fig. 335, after a cut by Dr. 
E. S. Talbot, affords idea of the manipulations. 
Fig. 336 shows a grooving bur engine-bit and illustrations of its work, 
designed for the making of grooves in the walls of the root-canals. It is to 
be seen that the instrument plays an important part 
in securing fixedness for a piece. " The grooves are 
made by sweeping the bur, while in motion, around 
the walls of the canal, which should be made large 
enough to permit the bur end to reach the bottom 
of the cavity. Two or three grooves, as may be de- 
sired, can be cut in thin roots with safety, one size 
of the bur answering for all cavities. The canal is 
then filled, as before described, with gutta-percha, 
oxychloride, amalgam, or other plastic, and before it 
sets the barbed pin of the crown is inserted, with 
the effect, as will be appreciated, of forcing the mate- 
rial into the grooves." 
Bing's Method.-A manner of capping a broken tooth with gold 
is the device of Dr. Bing, of Paris. The operation is accomplished as illus- 
trated in the series of accompanying drawings (Fig. 337). 1 shows molar 
teeth badly decayed and broken. These teeth are first to be excavated as for 
Fig. 335. 
Fig. 336. - Grooving 
Bur Engine-Bit. 464 
A SYSTEM OF ORAL SURGERY. 
ordinary plugging, the parietes of the cavities being made smooth and solid 
Next an impression is taken in wax, out of which a die is obtained. Upon this 
die caps are to be struck up. A succeed- 
ing step tries these caps over the teeth, 
finishing them to suit (2). A next step 
solders rings to the bottom of them, as 
seen in 3. Teeth and caps ready, the 
cavities of both are filled with gutta- 
percha, and, being related, a warm iron 
applied to the surface of the caps melts 
the two together. Cold water is now 
used, and, the gutta-percha being made 
resistive, the operation is finished by 
burnishing the edges of the gold about 
the parietes of the teeth. 
Among the devices in the direction 
considered is a crown made by Dr. M. 
Reyner, of New York City, which car- 
ries with it strong self-recommendation, 
seeing that almost any cap can be fitted 
to almost any root by the simple means 
of manipulating the metal by finger-pressure. A cap of this design differs 
from other caps in possessing the ductile softness which belongs to pure gold, 
in being very thin at the gum edge, and in being so cut that, by overwrapping, 
form is secured as desired. A crown being accurately fitted is lifted from the 
root it is to cap, the slits are soldered, and the roof added. Strength of walls 
is secured by use of solder or other metal. 
Dr. M. H. Crver, proceeding on a plan somewhat similar to the above, pre- 
pares and fits a gold crown in a very short time; often 
in less than half an hour. 
Starr's Root Reducers.-Where a root is found 
to require reducing, or trimming, 
instruments designed by Dr. R. 
Walter Starr serve the require- 
ments effectually. A glance at the 
associated diagrams imparts sufficient 
explanation. " The shoulder keeps 
the instrument on the root and limits 
the penetration of the spur, which, 
by its knife edge, scrapes the side of 
the root, Fig. 339 (1), so that it 
may easily and quickly be given the shape of Fig. 339 (2), or any similar 
form. They are made right and left; the straight pair, Fig. 338 (1 and 2), 
for use on the superior roots anterior to the molars, and the curved pair, Fig. 
Fig. 337. 
Fig. 338.-Starr's 
Root-Trimmers. 
Fig. 339.-Root 
and its Reduc- 
tion. OPERATIVE DENTISTRY. 
465 
338 (3 and 4), for use in all the other natural roots. It is evident that a 
crown could not be slipped closely over a tooth fashioned as Fig. 339 (1), 
while alteration, as shown in Fig. 339 (2), provides the requirement. (See 
Ferruling.) 
Digression.-Here digression is made with view to introduction of the 
subject of pivoting, the complicated performances in cap-crowning being 
best placed when following appreciation and understanding of this matter. 
Indeed, the manipulations are so related, that to separate them, as a study, is 
to leave either subject incomplete. 
Pivot Teeth.-A pivot tooth is a porcelain crown attached to 
a natural root. We commence with the simplest expression of 
the subject. 
A pivot tooth is a crown of porcelain having a hole in its centre 
for the accommodation of a piece of rounded wood or metal; this 
wood or metal fits •a hole of corresponding size reamed into the 
root of a tooth; the joining of the two, crown and root, consti- 
tutes the operation of pivoting. Fig. 340 shows a crown and root 
associated. Pivot teeth of every form, kind, and character are 
to be procured at the dental depots, and found figured in the 
catalogues. Capping, facing, and bridge-work have origin in the process of 
pivoting. 
A case presenting itself as a pivoting operation will commonly be found in 
the condition of a half-destroyed crown with the pulp dead, or it may be 
only semi-devitalized. The latter condition of the pulp found to exist, a first 
step resides in its full destruction. To accomplish this, as little disturbance 
as possible is to be provoked. If the organ be exposed, the best plan to 
pursue is to prick into it, with any convenient needle-pointed instrument, 
arsenic and morphia, equal parts of which have been rubbed up in creasote. 
(See Nerve Pasted This is accomplished without pain, particularly if the 
performance is preceded by an application of cocaine, and is a simple opera- 
tion, to be done by any person who possesses sufficient delicacy of touch. 
A pulp so treated limits irritation to the closest confines. When the pricking 
instrument is felt to strike against the foramen of the root and sensibility is 
lost, it is only necessary to introduce a barbed broach,-being careful to keep 
close to the tooth-wall, and by a few turns in the canal the mangled pulp is 
caught and withdrawn. 
Consideration of Pulp.-Tn a broken tooth where the cavity of decay 
does not expose the pulp, such exposure is to be made by delicate manipula- 
tion with drill or excavator; otherwise the case is treated by the introduction 
of an arsenical preparation into the existing cavity, and the sealing up 
of the same for a period varying from twelve to twenty-four hours, according 
to the density of the tooth. A piece of the pulp paste the size of an ordinary 
pin-head is commonly found sufficient to destroy a pulp. The part killed, the 
crown of the tooth is to be cut off as now to be described. Previous refer- 
Fig. 340. 466 
A SYSTEM OF ORAL SU ROE RY. 
ence, however, is to be made to accidents, not uncommon, which may have 
caused the fracture of a perfectly-healthy tooth. If in such cases the shock, 
as is not unlikely, has excited pulpitis, and, it may be, periodontitis, a first 
attention is to be directed to the resolution of such conditions; no immediate 
attempt is to be made to destroy the pulp, unless indeed it be exposed, when 
it is to be pricked as before described; but a local vigorous antiphlogistic 
treatment is to be instituted and continued until the practitioner is satisfied 
that resolution is not to be effected. Accepting resolution, on the other hand, 
as secured, the broken tooth is allowed to remain strictly at rest until all 
irritability has subsided, when a spear drill is to be used for the production of 
a receiving cavity, into which the arsenious paste is to be applied as before 
directed. Another way to employ the paste with such broken teeth is to build 
about the edges of the fracture a ring of gutta-percha, this to be accom- 
plished by trailing a solution which has been made by dissolving parings of 
the plastic with chloroform; the solvent, quickly evaporating, leaves the 
gutta-percha firmly adherent to the parts upon which it has been laid. Within 
a ring thus secured the paste is to be laid and covered by the same solution. 
Teeth, from the accident of fracture, are sometimes made so sensitive as to 
render it impossible to use the drill. The means just suggested meet the 
indication. 
If gutta-percha be found not to adhere with sufficient tenacity by this 
method, it will be necessary to excavate a groove in the face of the organ, 
and, after thoroughly drying the parts, build on, piece by piece, the ring of 
" Hill's Stopping," or red gutta-percha, when the paste may be placed in 
position and covered with a portion of the same material. 
Pulp Nodules.-Sometimes it happens that nodules of secondary 
dentine exist in the pulp, interfering with the absorption of the arsenic; in 
such cases it is commonly found necessary to repeat the application a number 
of times, or else expose the organ and prick it. Resistance to arsenical 
applications is quite diagnostic of the presence of pulp-stones. (See 
chapter on Odontalgia.} 
Where a tooth is decayed or broken away, or the operation may be practised 
on one that is unbroken, a plan employed by many practitioners for reaching 
the pulp is through use of a corundum disk, cutting with this saw-like body 
transversely across the tooth at a point where the crown approximates the neck, 
and securing, after this manner, a deep cut both on outer and inner face. 
These cuts are used to direct an excising forceps, with which the crown is next 
instantaneously cut off. The pulp is here made to stand exposed at its greatest 
diameter, and if it has not been killed by the shock of the excision such result 
is obtained by pointing a piece of orange stick, which, with a sharp, quick blow 
from a mallet, is driven to the apex of the canal; being first placed between 
the pulp and its wall. A strong solution of cocaine is always to be used. 
Excising Forceps.-To cut the crown of a tooth from its root, the first 
instrument required is the excising forceps ; wisely preceded, however, as sug- OPERATIVE DENTISTRY. 
467 
gested in the paragraph above, by the diamond disk, unless it be the case 
that the walls to be cut away are frail and of little resistance, when the forceps 
singly meets every indication. The forceps alone being used, the excision is 
Fig. 341.-Excising Forceps. 
done little by little until the the neck is uncovered, thus avoiding shock. This 
extent of performance being accomplished, it is prudent to give the part a rest 
of a day or two; it is a safe plan, although certainly not in all cases, or indeed 
even in the majority, a necessity. 
Crown Saw.-In place of the forceps some operators prefer the saw for 
excising a crown; this will not, as a rule, be found so convenient of employ- 
ment, and is more apt to provoke inflammatory response. It is not amiss, 
however, to have such an instrument, as occasionally it is found useful. 
Fig. 342.-Saw for Excising Crown. 
Pivot File.- Following the excising forceps is the pivot file. This in- 
strument, being half round, cuts a concave face on the neck of the root, which 
aspect of face is seen to correspond with the accommodation required by the 
neck face of the artificial crown, which, as it comes from the depot, and is 
used, is convex. 
In filing down a natural root, a judicious gentleness is to be combined 
with a necessary despatch. The file first used is to be sharp, so as to 
accomplish the required work with the least irritation, and should be used 
until the gum is fairly reached; the sharp file is then to be exchanged for 
one comparatively dull, with which the now concave face of the root is to 
be smoothed until marked bleeding occurs from the abraded gum. The object 
of this abrasion is to insure an accurate covering of the joint between root 
and pivot tooth by means of new granulation-tissue. It is sometimes, though 
very rarely, the case, that with previously-irritated roots this preparatory 
operation is profitably divided into several sittings, meanwhile an antiphlo- 
gistic treatment is to be pursued; but the cutting with the dull file which 
is to take off the root below the gum is to be the step immediately preceding 
the attachment of the new crown, otherwise the soft tissue is found to fall 
over the root and partially cover its surface. 468 
A SYSTEM OF ORAL SURGERY. 
During the process of cutting down a natural crown, or, to make a rule, 
we may say at that stage which is to employ the dull file, the preparation of 
the canal is to claim attention. To effect the requirements here de- 
manded, rose, or bur, drills of various sizes are employed, 
commencing with one received into the natural canal, and in- 
creasing, seriatim, until a sufficient diameter is secured, such 
diameter being in correspondence with the size of the pivot 
used. The depth to which a canal may be reamed, and also 
the diameter, depend upon the size and density of the root; 
a rule applicable to all cases cannot be given: it is to be 
accepted as necessary, however, that sufficient circumference 
and depth be secured to insure the retention of the pivot; 
half the length of a root may commonly be reamed with 
impunity. 
Clearing the Canal.-The process of reaming com- 
pleted, a delicate spear drill is to be passed into the con- 
tinuation of the canal, and the parts cleansed to the apex. 
This secondary canal is then to be filled with gold (see 
Filling Pulp-CanaT) ; when accomplished, the root is ready 
for the crown. 
Dental Engine.-The introduction of the engine 
has done much to simplify the preparation of roots for re- 
ception of artificial crowns. Instead of the hand-file, burs 
of corundum, barrel-shaped, used with the engine, are now 
freely and largely employed by the experienced. These burs 
accomplish the concaving of a root with absolute accuracy 
and certainly with great despatch. Drills for slotting and 
reaming are also used. 
Selection of Crown.-The selection of a crown for a 
root considers, first, shade, or color,-this refers to corre- 
spondence with neighboring teeth ; second, shape and adapta- 
bility,-this being recognition of form. By having in one's 
possession a few hundred artificial crowns, it is quite possible 
to find among them many of such perfect match as to render 
the slightest alteration unnecessary. Third, it is requisite 
to have the pivot canal in the crown and that in the root so 
in correspondence that when jointure is made the two shall 
occupy a proper relation. To be satisfied of such proper 
relation of parts, the crown and root are to be put together 
for the moment with a pivot of round match-stick. It is 
suggested, and practised by some, that where there is lack of natural cor- 
respondence in the canal of the root, a required direction shall be given by 
the drill: this, however, is to be condemned as bad practice; it is much better 
to seek a new crown. 
1 ig. 343. 
impunity. OPERATIVE DENTISTRY. 
469 
Accuracy of Fit.-It is necessary to have accurate adaptation of crown 
and root; to secure this may require some grinding of the crown; and to 
Fig. 344.-Hand-Lathe. 
Fig. 345.-Foot-Lathe. 
know just where and how to grind makes it 
necessary that touching points be recognized. 
Such information is to be secured by 
coating the surface with a film of wax ; put- 
ting parts so coated together, the wax over- 
lying the points implicated will, of course, 
be indented and displaced. A plan even 
better is, immediately upon having a root 
prepared, to take an impression of it and the 
contiguous teeth in wax (see Taking Im- 
pressions), and, having made a model of 
plaster of Paris, fit the crown to it. 
Hand-Lathe.-To grind the natural 
tooth, a stick of corundum is used by many. 
Such a stick is to be procured at the fur- 
nishing depots for a few cents. A better, 
by reason of being more speedy, means is 
found in the employment of a lathe or the 
engine. Of lathes used for dental purposes 
the greatest variety is offered; the smallest 
hand-lathe, however, is found suf- 
ficient to meet requirements. Fig. 
344 represents such a one: it may 
be attached temporarily to any stand 
conveniently at hand. This lathe is 
entirely noiseless. Having neither 
cog-wheels nor belt, it is free from 
oil, dirt, and the trouble of adjust- 
ment. The motive power is commu- 
nicated by friction gained by covering 
the small wheel, or pulley, with a rubber ring which comes in contact with 
the inner surface of the driving-wheel. The driving-wheel is six and a half 470 
A SYSTEM OF ORAL SURGERY. 
inches in diameter; the small wheel, two inches in diameter; and the weight 
of the lathe is two and three-quarters pounds. 
Foot-Lathe.-A form of lathe which, being worked by the foot, leaves 
both hands at liberty, is represented in Fig. 345. Such a lathe is in many 
respects preferable to the first; it is certainly more convenient to the operator. 
This lathe has a movable column and table, and is capable of being elevated 
eight inches; forms are made to accommodate users in either a sitting or a 
standing posture. 
Grinding Instruments.-As grinding instruments, wheels of corun- 
dum are used on these lathes; the operator is to provide himself with five or 
six of varying sizes. 
Character of Pivots.-Pivots are made either of wood or metal. They 
are called variously pivots, posts, and dowels. A wood pivot is made of thor- 
oughly-seasoned and firmly-compressed hickory: a box of such pivot-sticks, 
which may be purchased at a depot at a cost of twenty-five cents, will set 
hundreds of teeth; it is best thus to provide one's self. To use a wood 
pivot, the operator commences by securing the exact length required; this 
he learns with least trouble from his temporary fixture of match-stick. One 
end of this pivot is now fitted into the crown, the other being of a size cor- 
responding with the canal in the root. Everything being thus prepared, it 
only remains to put the two together and the operation is complete.* 
Faulty Articulation.-Occasionally, however, it is found that, in defi- 
ance of the nicest care which may have been exercised, there is slight fault 
in the articulation of the cutting edge of the new crown with the cor- 
responding tooth of the other jaw ; this is commonly easily remedied by filing 
away the impinging point on the natural tooth, or, using the corundum-stick, 
it may be taken from the artificial crown. 
Inflammatory Complication.-A second and more serious com- 
plication is periodonteal inflammation, the root becoming sore and painful. 
If such inflammation supervene, all mechanical manipulations are to cease at 
once and the parts are to be treated until recovered. 
Metal Pivot Case.-Metal pivots are variously used. A common plan, 
and a safe practice, is to make a delicate tube of gold of such size as permits 
its introduction into a drilled opening of the root (which opening, in these 
cases, is to be somewhat larger than is required for wooden pin pivoting, and 
is to be bell-mouthed), leaving sufficient space between tube and cavity for a 
packing of cohesive gold ; a wire fitted into the tube prevents its compression 
during the packing. The tube being fixed in place, the wire is withdrawn, 
and the tube refilled either with wood or gutta-percha, to prevent its injury, 
and the face of gold filed concave as though it were tooth structure; this 
leaves only a ring of cementum exposed, thus securing, by reason of the dura- 
bility of this substance, a permanent and desirable result. Next, an impression 
* Wood pivots are now almost entirely replaced by metal. OPERATIVE DENTISTRY. 
471 
being taken in wax, a plaster cast is made, and from this, in turn, metal dies. 
A thin plate of gold is now struck between these dies, which is to fit accu- 
rately the face of the root, being filed to the exact shape of the face and out- 
lines of circumference. Following, the plate of gold-the cap having a hole 
drilled through its centre corresponding with the tube in the canal-being laid 
in place, a piece of gold pivot wire is passed through it into its place in the 
tube, and secured with a small piece of adhesive wax. Cap and pin are now 
removed, are invested in plaster of Paris, and the two soldered firmly together. 
The tooth to be used here is what is known as a plate tooth,-a tooth 
having pins of platinum in its back. Selecting one of this class to suit the case, 
the cap and pivot are slipped into place, and the crown, being held in the ex- 
act position required, is fixed by a particle of wax. The whole piece thus 
cemented together is now removed from the mouth; this last is accom- 
plished by inserting the blade of an excavator beneath the plate, and thus 
lifting it. The tooth is next backed with a plate of gold having holes punched 
for the passage of pins. Backing, tooth, and cap are now soldered together, 
and the fixture stands complete, requiring only to be cleaned and introduced 
into the tube. If all is as desired, the gold pivot is then to be tapped laterally 
very gently with a pivoting hammer, when it will be found, upon introduction, 
to remain with all necessary firmness. This is one of several methods of 
pivoting employed by Dr. Flagg. A tooth set after such manner is removed 
and replaced with little trouble. 
Screw Receiver.-An improvement, as it is thought by some, on the 
plan just described consists in converting the tube into a screw receiver by 
means of a thread cut by a screw-tap about its inner face; this screw, fixed 
in its place, is to be levelled with the face of the root as in the former instance, 
and the operation completed as already described. (See Hows Crowns.) 
Canals out of Correspondence.-In roots having canals out of cor- 
respondence with the position demanded for the new body, the mode of using 
caps for the attachment of the crown affords all that can be desired, inasmuch 
as when teeth are thus pivoted correspondence between the cavities of root and 
crown is of no importance. 
Carious Roots.-A condition endorsing fully the employment of the 
tube is found in roots somewhat decayed. Here, the part being in place, after 
excavation of the canal, as in any case of caries, the seat of disease is occupied 
by gold placed on the principle of ordinary plugging. 
Combination Pivoting.-A manner of pivoting which is a combination 
of the plans described consists in passing through the centre of a wood pivot, 
which pivot has been drilled for the purpose, a second one of gold wire; such 
wire is found materially to strengthen the wood, and is thought by many to be 
the most desirable support that can be employed. 
Vulcanized Pivot.-Still another plan is the employment of what is 
known as the vulcanized pivot. This process is as follows. The root being 
prepared by tubing as previously described, a wire of length sufficient to pro- 472 
A SYSTEM OF ORAL SURGERY. 
trade one-eighth of an inch or more beyond this tubing is flattened at one end 
and inserted into the tube; next a tooth (usually one made for vulcanite plate 
purposes) is fitted to suit and placed in position; wire and tooth being joined 
with adhesive wax. The wax cold, the adherent tooth and pin are care- 
fully withdrawn. Moulds are next made of plaster, as for vulcanite-work, 
the wax is removed, vulcanizable rubber is introduced in its place, and 
the pin and tooth are united by the vulcanizing process. This is a very neat, 
easy, and, as thought by many, an altogether desirable operation. 
Mack's Screws.-A means of setting a pivot tooth founded on the ease 
with which the Mack screws can be worked, and applicable particularly to bi- 
cuspid and molar teeth, consists in inserting into the filed face of the root three 
or more of the screws, and, having a tooth prepared for the purpose, of a box- 
like character, the chamber is filled with cement plombe, or any of the oxy- 
chloride or, preferably, oxyphosphate preparations, and while the material is 
soft the tooth is put into place, being retained by the fingers until the cement 
hardens about the pins. A box tooth may easily be made by soldering a 
metal chamber to the pins of an ordinary plate tooth. 
Another plan, pertaining, however, only to the treatment of a root where 
this has been weakened by decay, consists in first making proper excavation 
of the diseased dentine and replacing it with oxychloride or with amalgam. 
The material used having set, a pivot canal is reamed in its centre, and the 
operation completed by the use of the wood or wire-wooded pivot. 
Flagg's Method.-A second method of pivoting anterior teeth employed 
by Dr. Flagg is as follows: Select an ordinary plain plate tooth to suit. 
Grind and bevel the neck face. For the pin use platinum wire No. 14, U. S. 
gauge. Hammer this flat at end,-tooth end. Through this flattened end 
punch holes for tooth-pins. Rivet into union tooth and wire by means of the 
pins, and complete by soldering.* To attach to the root the artificial piece thus 
made ready, the operator barbs the pin and drills out the canal bell-muzzle 
fashion. Next dryness is to be secured, and the barbed wire being thrust into 
the root (the crown being related exactly as desired), a quick-setting amalgam 
is packed until not only the canal is solidly filled, but a posterior face built to 
the tooth. 
Dennet's Plan.-A method of setting a plate tooth on a root, and giving 
an additional support by a rim of gold, is practised by Dr. H. E. Dennet. His 
plan is as follows : 
First cut off the crown ; then tunnel out the root, by enlarging the pulp- 
cavity, making it very large at the orifice, smaller as it goes in, and cutting 
retaining-points at proper places. Solder a platinum pivot to a suitable plate 
* Soldering is a process accomplished by means of blow-pipe and a metal cement; in 
this case pure gold is used. Lay upon charcoal and partially embed in sand and plaster. 
Next smear the parts to be united with a cream of borax. Place in this cream small pieces 
of gold, and direct over the embedment, by means of a gas blow-pipe, the flame from a 
spirit-lamp until the metal melt and run. Parr's flux is better than borax. OPERATIVE DENTISTRY. 
473 
tooth, the pivot being large where it is soldered, and a gradual taper bring- 
ing it nearly to a point; then make it barbed or rough, so that it will not 
pull out after the crown is set. 
Having prepared the root and the tooth, put on the rubber dam; fill the 
root to the point where the end of the pivot is to meet it; put on the tooth 
and fill around the pivot (turning the tooth in and out, 
and laterally, as convenience requires, the pivot being 
easily bent without danger of break- 
ing) ; build out to the natural form of 
the tooth, using first soft gold, then 
that which is partly cohesive, then co- 
hesive. 
Tooth-pivoting is finding marked 
impetus through the inventive efforts 
of W. G. A. Bonwill, D.D.S., Mar- 
shall Webb, D.D.S., M. H. Cryer, 
M.D., Dr. Gates, and others. Fig. 346 shows a pivot operation as practised 
by the first of the operators named. The principle consists in fixing a barbed, 
screw-headed pivot of platinum into a root-canal, using for the purpose of fixa- 
tion a preparation of amalgam; the crown, previously fitted to the root, is 
placed upon this pivot and retained immovably in place by means of a gold 
nut. Fig. 347 exhibits the components of the operation separated. 
Bonwill's Second Method.-A second method of this same practi- 
tioner, adapted particularly to the posterior teeth, bicuspidati and molars, one 
preferred by him, consists, radically, in a filling of amalgam capped with porce- 
lain. Fig. 348 furnishes the idea. In the diagram sections of bicuspid and 
molar roots are shown into which are impacted the platinum barbed pins. 
Fig. 347. 
Fig. 346. 
Fig. 348. 
Sections are also shown of crowns made hollow, an opening existing through the 
face surface. Placing one of these peculiarly-constructed crowns over a root 
surface prepared to receive it by reason of a coating of amalgam, it will be seen 
that to make a perfect joint and strong bond of union the operator needs alone 474 
A SYSTEM OF ORAL SUROERY. 
to proceed by filling in at the crown opening a continuation of the amalgam 
already begun over the face of the roots. (See succeeding paragraphs.) 
Amalgam a Discolorer.-Amalgam being a discolorer, attention is to 
be directed, in the use of this means, to a necessity for nice discrimination in 
the matter of shade. 
In the immediately preceding cuts the cases shown relate, all alike, with the 
supposition of a dead pulp; the canal or canals being the place of anchorage. 
A reverse to this is expressed in Fig. 349, which shows, perfectly outlined, a 
mode of procedure in living roots; a procedure not, however, to be 
endorsed or recommended as its employment by the inexperienced 
is concerned. 
Pivoting to correct Irregularity.-The adaptation of 
a plan bf pivoting to the correction of deforming irregularity 
finds illustration in Fig. 
350. Here, as will be in- 
ferred, the natural crowns 
are first to be cut off and 
the pulps destroyed. Next, 
plate teeth are to be backed 
with stays of gold, the 
metal reaching to the loca- 
tion of the different roots 
and being fitted to them. 
From this point the pro- 
cedure finds modification, as in the illustration, save that the manner of fixing 
is by means of nut and screw. Fig. 351 shows forked screw-driver. The 
plan is commendable, the pulps being first destroyed and the canals used for 
the pivot. 
Fig. 349. 
Fig. 350. 
Fig. 351. 
Fixation by Slots.-Still another manner, closely corresponding with 
other methods to be described, is shown in Fig. 352. Here slots are cut 
which receive amalgam fillings. The diagram fully illustrates the manner of 
putting on the crown. A, molar; B, bicuspis ; C, lateral incisor. The root 
plug, as seen, continues through the crown ; posts may be used or left out. 
Porcelain Facing.-A porcelain face is a scale or full tooth surface of 
the material used for correcting a dental deficiency. Fig. 353 furnishes an 
illustration. The How crown (which see) belongs to this variety, A crown, 
b, is fitted to a root; a represents an open tube which has been soldered to plati- 
num pins. On either side grooves are seen, cut by means of a corundum disk OPERATIVE DENTISTRY. 
475 
into the substance of the porcelain. This crown, consisting of an ordinary 
plate tooth, is made to take the place of a lost tooth-face by closing the tube, 
Fig. 352. 
Fig. 353. 
slipping it over a pin fixed in the root, and building up the back surface in 
cohesive gold. 
Fig. 354 shows another class of operations. The centre drawing 
exhibits a square of porcelain built into a broken tooth-face, being retained in 
its position by means of a pivot combined with a circumferential rim of gold 
worked, after the cohesive plan, into place by the impacting qualities of an 
automatic mallet. 
Fig. 354. 
Side and front view of the 
piece of porcelain. 
Labial surface, with porce- 
lain in position. 
Diagram giving side view, 
with porcelain in place. 
A very pretty, and as well a reasonably commendable, performance 
in this direction relates with incisor teeth, where, for example, the mesial 
angles of, say, the two centrals are broken away. Here, after cutting a square 
into the two faces, or, if preferred, curving the surfaces, scales, having pins 
burnt into them, are nicely ground, and are related with these surfaces so as 
to constitute an accurate fit, and restore as well the lost contour. Next, an 
impression being taken, dies are prepared and delicate backings are fitted to 
the teeth. Succeeding this, the scales are put in place, and being attached by 
means of the pins to the backings,-soldered,-the contrivance is fixed by 
drilling countersunk holes through the backings, making slots in the teeth, 
and in uniting the two by rivets made of cohesive gold. Much judgment is 
demanded, however, in the employment of this means, while none but the 
most skilful need attempt it. 
Rambo's Porcelain Facing.-Subfigs. 1 to 10 (Fig. 355) illustrate 
operations in porcelain facing, all of which explain themselves. Dr. S. D. 
Eambo, whose practice furnishes the drawings, fills the extreme end of the 476 
A SYSTEM OF ORAL SURGERY. 
pulp-canals with lead. The facings used are simply cut artificial plate teeth, 
selected with Regard to shade and fitness. A piece or pieces being ground into 
Fig. 355 
absolute adaptation, the pins are backed with plati- 
num, the backing being held in place by splitting 
the pins. Next, the canal of the tooth to be fitted 
is reamed out, the apex being filled with lead, as 
suggested. The canal thus made ready, a platinum 
wire is loosely placed, and so bent as to accord with 
the backing of the porcelain, the porcelain being in 
the exact position required. The parts properly re- 
lated (a space the thickness of an 00 file is suggested 
as proper to be left between facing and tooth), pin 
and backing are joined by means of a piece of wax, 
and being lifted away, are embedded in plaster and sand, and soldered together 
with pure gold. Next, the canal is dried by means of a hot-air syringe, when 
the platinum pin, being well enveloped in heated gutta-percha or with 
oxychloride, is thrust into the cavity to which it had been fitted. Later, the 
plastic is cut from about the joint to the extent of about two lines, and that 
material is replaced with gold. 
No. 4 represents a central incisor with parallel break of crown. No 5 shows 
piece of porcelain tooth pivoted and made ready for the repair. No. 6 is a 
side view of the restored crown. Nos. 7 and 8 show operations where nearly 
the full crowns have been restored. Nos. 9 and 10 show a 
bicuspid and a molar tooth where portions of the crowns are 
replaced with porcelain. If, in these cases, the pulp lies dead, 
it is recommended to pivot as in the previous examples, and 
fill in with plastic and gold; but if the pulp be vital, the 
porcelain is to be fitted with a view to its sole retention by a 
circumferential packing of gold. (See Herbst's Method.') 
An improvement, so considered, on the above 
manner of fixing a tooth to the backing-a manner tending 
to prevent breakage of the porcelain face-consists in cut- 
ting, with a disk of corundum, a groove along each side and across the cut- 
ting face of the tooth and another (a) between the pins. A wire to connect 
Fig. 356. OPERATIVE DENTISTRY. 
477 
the barbs is now laid in the groove and soldered in place as shown by cut, 
Fig. 356. 
Harrower's Method of Porcelain Facing.-A simple, durable, 
and exceedingly efficacious restoration of contour, a device of Dr. A. B. Har- 
rower, is accomplished without the use of a pivot in this wise: A plate tooth 
is selected of the proper shade, size, and type and fitted so that the line of 
apposition with the root is concealed by the festoon of the gum. A piece of 
platinum, about No. 30 gauge, has holes punched for the tooth-pins, is placed 
in position, and the pins bent over or split to secure it. Next a band of plati- 
num, about No. 32 or No. 34, is fitted around the part of the tooth remaining 
and the whole invested and soldered. In setting, the tooth is properly under- 
cut, a little very thin amalgam is rubbed on the inside of the band, the tooth 
placed in position, and the band burnished firmly into adaptation with the 
back of the tooth; the space between the tooth and facing is then filled with 
an ordinary mix of amalgam. This method is peculiarly applicable to bicuspids 
which have lost the buccal face, but which 
have the palatal one remaining. It can also 
be applied to incisors and cuspids, and its use 
does not necessitate devitalization of the pulp. 
It serves to insure years of usefulness before 
crowning, and if the supporting portion of the 
tooth ever give way, the root can then be 
crowned in the ordinary way. There are 
many of these restorations which have been 
in use for years, and the percentage of failures through accident has been 
far below that of ordinary crown-work. Fig. 357-a case from practice-illus- 
trates the method described. In this instance the restoration relates with a 
cuspis, the anterior face of which is entirely gone. 
Diamonds in Teeth.-The placing of diamonds in the front 
faces of the teeth as ornaments has been accomplished with a great deal of 
satisfaction to the possessors. To do this, using cohesive gold, little more 
skill is required than in making common crown plugs. 
Plastic Facings.-The use of the plastics as a facing material, in the 
repair of deficient labial walls, attracts a good deal of attention. A zinc 
amalgam accomplishes this work excellently well. (See Amalgams.} In 
such a situation the material keeps peculiarly clean, the moving lips acting as 
a constant cleanser and polisher. A happy manner of making a facing con- 
sists in building up the deficient part with a tough, sharp-edged amalgam, and 
while it is in the act of setting cutting away this material on the face surface 
until none is left except a delicate rim leading to an undercut. When setting 
is accomplished the place of the removed amalgam is to be occupied by facing 
alloy. With skill, and patience to secure shade, a tooth may be faced after 
this manner to the satisfaction of all concerned. When the less dense plastic 
fails it is renewed with little trouble. 
Fig. 357. 478 
A SYSTEM OF ORAL SURGERY. 
Another manner of facing relates with the use of oxychloride or oxy- 
phosphate as a material. This preparation is not very permanent, as is under- 
stood, but then it is easy and convenient of reapplication. A tooth defective 
on its anterior face is improved wonderfully in appearance by a skilful em- 
ployment of oxychloride. 
Examples illustrating facing with the plastics would need to be given 
alone in connection with the preparation of special cavities. To become 
accomplished in such directions a student must give much time to practical 
studies made out of the mouth.* 
Ferruling.-A manner of attaching an artificial crown to a natural root 
is done by means of a gold ferrule. This is a suggestion by Dr. Buttner, of 
New York ; the procedure as discussed by the inventor is as follows. Counter- 
reamers with counter-pins to level the root, and trephines with centre pins to 
turn a shoulder on the exposed end of the root, are used. 
The instruments prepare the root as required, hence nothing prevents 
applying ferruling, which is recognized in mechanics as the most accurate 
and reliable system for combining two parts. 
The ferrule used is of stiff plate gold, struck up on steel dies. It is a single 
piece of gold, closed at one end with a pivot soldered in its centre. The 
accuracy and strength of a ferrule constructed in this manner insures double 
the strength needed. 
The first step in the practical application of the method is to enlarge 
the pulp-canal with one of the drills. The next is to level the root by aid 
of the counter-reamer, the centre pin of which fits the hole in the root. 
The trephine is used to turn a round shoulder on the exposed end of the 
root. This completes the preparation of the root. An accurately-fitting 
straight wire is now inserted into the canal, and an impression taken; the 
impression cup is to be open opposite the root so as to allow the wire to pro- 
trude through impression material and cup. Next withdraw the wire, then 
remove the impression from the mouth, and return the wire to its hole in the 
impression. 
* As an addendum concerning the use of plastics, more properly in place, however, in 
the article relating to the use of amalgam for tooth-plugging purposes, the author calls 
attention to an ingenious carrier of the alloy designed to take the place of cup and file-flat; 
see Figs. 227 and 228. The apparatus consists of a tube attached to the end of a shank, 
which tube, being filled with amalgam, is carried to the cavity to be occupied; arrived at 
which it is emptied, and the material partially packed into the cavity by a simple act of 
pressure which calls a spring into motion. Two or three forms are to be found figured in 
dental catalogues. 
Dental Catalogues.-For the benefit of students it is to be mentioned that dental 
catalogues, to which reference is frequently made in this work, are book-like issues, to be 
obtained free of charge by addressing a postal to any of the various dental depots. These 
contain drawings and descriptions of all instruments used in dentistry, and by means of 
them the practitioner keeps himself informed as to new devices, while a text-book is spared 
the necessity for using them over-freely. OPERATIVE DENTISTRY. 
479 
A set of brass root models accompany the set of instruments, which cor- 
respond with the trephine and gold caps in size. These represent the pre- 
pared end of the root on the plaster model, and serve to guide the gold cap 
in being placed on the model. One of these models, corresponding in size 
with the trephine used, is placed over the pin in the impression; now the 
model is pressed in plaster of Paris. 
In removing the impression material from the model, the root model is 
found accurately in place of the root, representing the prepared root end. 
The corresponding gold cap is now placed on the root model, a porcelain 
crown prepared for the cap, and waxed into the same in such a way as to 
cover the gold in front. The united parts are now withdrawn from the 
model, embedded in plaster and sand, and are soldered and finished. 
Bonwill's General Views.-Dr. Bonwill has given such exhaustive 
attention to the study of dental mechanics that any conclusion offered by him 
is worthy of being well weighed and considered. Concerning the all-porcelain 
crown substitution that practitioner writes, 11 My experiments commenced in 
1871, the object being to give to dentistry a porcelain tooth that would meet 
any requirements" in the direction here considered. 
Dr. Bonwill's first experiment was with a perforated crown of a construction 
to admit of the application of a nut to the top of a threaded screw which, 
previous to the placing of a crown, had been solidly anchored in the root by 
means of gold foil. This he speaks of as not found satisfactory by reason of 
inability to fix the post solidly and permanently. Taking the place of the 
gold, amalgam was next used, improvement being found in this means, but 
practicable, as deemed by the inventor, only to skilful mechanicians. Amalgam 
is now abandoned by Dr. Bonwill for attaching molar crowns to roots, red or 
white gutta-percha being used instead. 
11 To meet the issue" the nut was abandoned, the hollow crown being sub- 
stituted for the drilled one. The meaning of this is to be appreciated in the 
Bonwill operation described, which see. 
Means for Escape of Gas.-Next in importance to the crown is the 
adaptability and signification of a post. It is wisely suggested by Dr. Bonwill 
that cases are met with where it is not desirable to fill the apical extremity of 
a canal, but that vent be left for escape of gas, not only as such non-filling is 
concerned, but as to a continuous line through a tap-hole. A dowel, flat on 
either side, secures fixedness as to non-turning, and if made like the post 
used with a Logan crown but extending to the exposed face of the tooth, 
secures effectually a desired communication with the locality where gas is 
found. To make sure of continuity in such vent-hole being preserved it is 
well suggested by Dr. Bonwill that, during the process of packing the amal- 
gam, a fine annealed nerve-broach is to be retained in the canal desired to be 
established. 
Objection to Use of Amalgam.-Objection urged against the use of 
amalgam as to a too great plasticity applies, in the estimation of Dr. Bonwill, 480 
A SYSTEM OF ORAL SURGERY. 
only where the ordinary preparation is used. " Using a proper amalgam, he 
writes, " I have never had to replace a single case." 
Discoloration from Use of Amalgam.-It is suggested that when 
amalgam is used the shade of the crown is to be lighter than where a white 
cement is employed, as " the opacity of the former adds a blue tinge to the 
porcelain." 
Use of a Collar.-An injury which he thinks is done to the peridental 
membrane by even the narrowest band justifies, in Dr. Bonwill's estimation, 
its almost universal condemnation. But few, he contends, are at all well fitted, 
and aside from all else, there is interference with the gingival secretion. 
Excising the Crown.-Dr. Bonwill's method of excising a crown con- 
sists in using a half-inch disk to cut through the labial and palatal faces, follow- 
ing this with a spear drill, which he passes through the tooth from groove to 
groove, and running these finally into one by means of a fissure drill. 
Shape of Root.-Concerning shape of root, Dr. Bonwill concludes out 
of his experience that the face is to be concave or convex. 
Posts, or Pins.-He commends the use of pins composed of a combi- 
nation of metals, which, while offering the greatest strength, " allows the mer- 
cury in the filling to amalgamate the surface without injury to the substance. 
Serrations," he says, " increase the size of the post, are obstructive to its pas- 
sage through the amalgam, weaken, and make it more liable to break." 
Crown-Adjuster.-Referring to the difficulty of getting an artificial 
crown into its place as to a final adjustment, Dr. Bonwill commends the use 
of a device of his own which he calls an adjuster. This finds its representa- 
tion and purpose in a V-cut, as the front teeth are concerned, made in a very 
hard cork. The extremity of Dr. Bon- 
will's adjuster is made of rubber, which is 
self-adapting to the various forms of teeth. 
(See dental catalogues.) 
Pivoting in Absence of Root.- 
Pivoting, or, to better express it, anchor- 
ing, may be done even in absence of root. 
A drawing, after Marshall Webb, Fig. 358, 
illustrates the procedure. First, suitable 
cavities are to be formed in the approxi- 
mating faces of the two teeth adjoining 
the toothless space to be filled. An im- 
pression of the parts is next to be taken, 
and a plain porcelain crown selected of a form and shade corresponding with 
requirements. This tooth is to be backed, which backing is to extend about 
one and one-half lines from each side of the crown for insertion in cavities pre- 
pared in the adjoining teeth. To these wings barbs are to be soldered for 
introduction into the pulp-canals. A next step considers an impression of 
the parts which secures the ability to prepare a delicate cast of gold accurately 
Fig. 358. OPERATIVE DENTISTRY. 
481 
fitting the gum upon which the porcelain tooth is to rest. Everything thus 
made ready, the parts are respectively placed in position, and secured in rela- 
tion by means of a piece of wax. Being next carefully lifted from the mouth, 
all are included in a matrice and soldered. The operation is completed and 
made permanent through fixing the barbs by means of fillings made of cohe- 
sive gold. To secure temporary fixedness for his pins, Dr. Webb 
uses first a packing of oxychloride, subsequently cutting most of this away, 
replacing it with gold. 
Grafting Crowns.-What is termed "grafting crowns" is an operation 
attracting at the present time considerable attention. The principle of the 
performance is one with the accomplishments that have been considered. To 
illustrate it reference may be made to a mouth where the first and second 
molars, say of the upper right side, have been lost. The abutting, or adjoin- 
ing, teeth-that is, the second bicuspis anteriorly and the wisdom-teeth pos- 
teriorly-are to be supposed to have cavities in their approximal faces, the 
first in the distal, the latter in the mesial, face. An operator preparing these 
cavities for plugs of amalgam, concludes to use them as abutments to a bridge 
of the plastic, which he builds in the intervening space, moulding and shaping 
it nicely to fit the gum and to articulate with the teeth of the inferior jaw. 
Grafting is nothing different from replacing amalgam with teeth. 
Different manners are practised in securing the organs. One way consists 
in taking crowns that represent fully the teeth to be replaced. These crowns 
possess double longitudinal perforations for the accommodation of a stiff gold 
wire which is to occupy them, stringing as it were the teeth together. Before 
being placed on this double string the base of the crowns are to be ground into 
accurate fit with the gum upon which they are to rest, and as well so fitted as 
to fill the space to be occupied, leaving, however, room for the necessary 
side, or anchoring, attachments. The manner of relating will be understood by 
glancing at Fig. 358. To the extremities of the horizontally-placed wire of 
either side vertically-placed roughened gold wires, or wings, are soldered, and 
these, as understood, are accurately fitted and plugged into cavities existing or 
prepared for their reception in the adjoining teeth. Another mode consists in 
attaching the crowns to a delicate plate, fitted through impression and swag- 
ing (see Prosthetic Dentistry') to the face of the gum, precisely as ordinary 
plate teeth are manipulated, and in turn relating the fixture with the natural 
teeth, as understood. This latter is ordinary bridge-work. 
Darby Crown.-Related as to manner of setting with Dr. Flagg's first- 
described method of pivoting is an operation as practised by Dr. Edmund Darby. 
This is employed where caries has progressed too far to admit of the use of 
a band. Dr. Darby fits and burnishes a piece of platinum over the end of a 
root, into which metal he punches a hole for reception of a dowel. Disk and 
dowel being related, he places the parts in position and takes an impression. 
From this point his manner of procedure is identical with the Richmond- 
Sheffield manipulations, which see. 482 
A SYSTEM OF ORAL SURGERY. 
Stowell Crown.-In this crown employment is made of cap and 
dowel, as in the Darby operation; in place, however, of an enamel facing a 
countersunk tooth is used. It is an intention to fuse gold into the depression. 
The tooth is invested in plaster and heated until a piece of twenty-carat gold 
that has been laid upon it shall so fuse as to permit of being spatted down. 
This gold is later ground to fit the cap, and at the same time it is bevelled at 
the distal surface to allow of soldering. The parts being properly related and 
again invested, are soldered and thus ready for fixation. 
Parmley Brown Crown.-This is a porcelain tooth having a post 
fused into it. Being related to a root by the grinding of the latter, it is set 
after a manner not dissimilar to the Bonwill method. 
Dewey Crown.-Claim made for this crown relates with perfectness 
and simplicity. The crown is of porcelain, with a bore running through 
it of sufficient size to admit the post, being countersunk on coronal surface. 
The post is made of platinum and iridium, is hollow, and is so cut away near 
the end enclosed by the root as to prevent its turning or withdrawal after 
being cemented in the canal. The neck end is threaded internally with view 
of receiving a retaining-screw. Dr. Dewey's directions for setting are as 
follows: 
Grind root at outer and inner side so as to make the end slightly convex. 
Enlarge nerve-canal to such depth as required to sustain crown, and only large 
enough to admit post, having bore of equal diameter the entire length. If 
the root is much hollowed out with decay, fill first with amalgam and drill 
hole in that for the post. Cut your post the required length. If the tooth 
is a bicuspis, have the post the thickness of retaining screw-head short of 
bite, bend post to proper alignment, cut strip of pure gold or platinum plate, 
No. 30, large enough to little more than cover end of root, punch a hole in 
centre of same diameter as post. The post being in root, put plate on post 
and burnish down to root until its outline is imprinted on the plate. Place 
now a little wax around post above plate and press tightly down on root, after 
which remove, invest, and solder together post and plate. Trim plate to wear 
outline of root, replace, and again burnish until it fit the root accurately; then 
trim to edge of root, thus securing a capped post that fits the stump perfectly. 
Next select crown, preferably larger than the case requires, grind base end 
until, when placed on post, it fits down on crown side of cap perfectly, allow- 
ing post to project through crown so as to be flush with lower edge of coun- 
tersink. If the crown be larger than the root it will project over sides of cap. 
Here grind down to plate and polish, giving a perfect contour of the natural 
tooth, nor leaving any overhanging portions where food or foreign matter may 
lodge. The grinding of the crown is done with little trying in the patient's 
mouth, for if it fit the post and cap, all the parts go to place without trouble. 
Here things are in readiness to put the crown in place. To practise this 
dry the root, which is to have the apex stopped after the usual manner. 
Fill the bore in the root with any suitable cement mixed to the consistency of OPERATIVE DENTISTRY. 
483 
thin cream, insert post, and push home, the post going to the bottom of the 
bore and not filling under as it would do if the post were solid and thus 
raising the cap from the stump, but letting the surplus cement enter the 
hollow post, allowing it, as suggested, to go to the bottom of the bore, bring- 
ing the cap down tight on the root with only enough cement under it to seal 
up the joint. This cement being hardened a little, mix more thin cement and 
spread on cap and post, put on crown, and press to place, turning in retaining- 
screw and covering with cement. 
Should a crown so set become broken, claim is advanced that it can be 
replaced without disturbing the post or root simply by turning out the retain- 
ing-screw and grinding another crown to fit cap and post. Dr. Dewey and 
the admirers of the crown claim a latitude for setting this crown as great or 
greater than lying with any of the various other forms offered. First, it can 
be set as above; secondly, it can easily be converted into a band crown when- 
ever it may seem desirable by fitting the band and placing the already fitted 
cap on it and soldering together, forming an accurately-fitting cap with 
rim ; thirdly, it may be ground to fit the root end without any intervening 
plate. 
Richmond Gold Crown and Method of Mounting. - A full 
description of the manipulations related with ordinary cap-crowning after 
the Richmond-Sheffield method is here presented as described to him by 
one of the author's students* who had been engaged in Dr. Richmond's 
laboratory. 
Begin by cutting the walls of a tooth to be crowned so as to make them 
parallel with sides, or, better yet, of barrel-shape, or, in still other words, prop- 
erly receptive of a gold band which is subsequently to be placed over the 
root. (See Starr's operation, Fig. 339.) The band is made in the following 
manner: Take a strip of crown metal, or gold plate, 26 to 28 gauge, twenty-two- 
carat gold, and from three to four lines in width, bend this around the neck 
of the root. Mark the point of contact and cut off. Next reduce slightly in 
length so as to allow for imperfect adaptation to the root. Solder with twenty- 
carat gold solder. 
The band is now dressed with files so as to conform with the prepared end 
of the root and with the alveolar process. This completes the band. 
A succeeding step is to transform the band that has been made into a cap, 
which is done by soldering a piece of gold (No. 32) and platinum (No. 36 to 
40 gauge) tightly within its circumference. 
After accomplishing this extent of manipulation the facing selected for 
the crown is ground to fit the bevelled cap, then is backed with platinum, No. 
30 to 32 gauge, and then waxed to the cap in proper position, appreciation of 
which is obtained through an articulating model, or the crown may be waxed 
on in the mouth; the latter way giving the more satisfactory results. 
* George C. Hubbell, P.D.C., Class 1889-90. 484 
A SYSTEM OF ORAL SURGERY. 
The crown is now invested, heated up very carefully, and soldered with 
eighteen-carat gold solder. It is next dressed off and polished, being then 
ready to be put in place. 
Kirk's Method.-This is an all-porcelain crown to relate with a frail 
single-root tooth. For holding the parts together Dr. Kirk depends on a 
screw-dowel and a gold ferrule, the double means being aided by employment 
of a strong cement. The method of setting consists in first preparing the root 
by a judicious closing of the apical foramen; gold or gutta-percha being em- 
ployed, as seems indicated. Quiet being insured, the part of canal for ac- 
commodation of the dowel is cleared of all softened dentine and next undercut 
or roughened by use of a wheel-bur. Following this is employment of a How 
drill-top, with which a thread is cut in the dentine of the neck portion of the 
root; the depth being from the sixteenth to the eighth of an inch ; just sufficient 
to engage the dowel, dependence for anchorage being placed mainly upon the 
cement lining. Next a collar, made of twenty-two-carat gold, No. 30, prepared 
and related after the common manner (which see), is driven about the neck of 
the root until it disappears below the gum; the thirty-second of an inch being 
the distance suggested by Dr. Kirk. This collar is cut narrow, so as to show 
little, on the labial side, and left broad as possible, so as to afford support, on 
the palatal side. When this ring has been satisfactorily adapted, a Foster 
crown, which stands fitted to the root by previous grinding and preparation, 
is adjusted to place. It will be recognized that the relation between tooth 
and collar requires to be close as possible, so that the crown, if smaller than 
the ring, would not answer, while one larger requires simply to be ground 
down. A Foster crown is one having a hole through it passing from base 
to cutting surface. (See, for idea, Fig. 346.) Crown, collar, and root being 
satisfactorily related and the matter of articulation looked after, a gold screw, 
with a head similar to the ordinary gimlet-pointed wood screw, is passed through 
the opening in the crown and passed up by means of a driver to its place against 
the gold that fills the apex of the canal. Adjustment being found or made 
satisfactory, screw and crown are removed and the different parts-i.e., screw, 
collar, and canal-thoroughly dried. The root-canal is now filled with slow- 
setting oxyphosphate of zinc, mixed rather thin. As concluding steps the 
crown is forced down into position, encircled by the collar, when the gold screw 
is passed through the crown-hole and screwed quickly through the plastic zinc 
into place. The excess of root filling is, of course, crowded out about the screw, 
whence it is allowed to remain until fully set. Being later cut away so as to 
expose the screw-head lying in its countersunk cavity, anchorage is obtained 
for a gold filling by cutting a groove about the base of the screw and intro- 
ducing such plug. 
Meriam's Method.-The crown devised by Dr. Meriam bears somewhat 
close likeness to the familiar English tube-teeth. The tube, or hole, in this 
crown comes directly through to the crown-face except in the instance of the 
anterior teeth, where the opening is below the cutting edge. These crowns OPERATIVE DENTISTRY. 
485 
may be set as described in connection with the Kirk tooth. Dr. Meriam sug- 
gests that if collar and crown be related before being put into place upon the 
root by melting a little sulphur inside the collar so that it shall flow into an 
undercut made about the crown, that the so-ringed tooth may be attached to a 
root properly dovetailed with all security, without necessity for use of a 
post.* Criticism as to this last-named detail is to suggest the easy breakage 
of such hold unless, indeed, a relation of the parts is perfect. 
How System.-The How system, like the preceding, is largely em- 
ployed in dentistry. The crown devised by Dr. How and his manner of 
mounting are to be differentiated and as well fully understood by reference to 
and study of the accompanying diagram. To relate crown and root 
this system employs a screw-post, the thread of which is supplemented by one 
of receptive signification cut in the tooth. The crown is perforated as to 
bicuspidati and molars and reamed out on the palatal face in the case of the 
front teeth. The screw-cuts of the posts used bear close likeness to those of a 
common wood screw, having been obtained by rolling and not through dies, 
advantage as to this manner lying, as assumed, with a greater uniformity and 
smoothness of surface secured. 
Accepting, with Dr. How, that a root proposed to have a crown grafted 
upon it is in a healthy state, and that it is fitted for the purpose, a first step 
measures the depth of pulp-canal, which is done by use of a root-plugger 
(Fig. 359, No. 1). Such measurement obtained, a second instrument of bur- 
like extremity (No, 2) is lifted and passed through a gauge (No. 3), out of 
the smaller end of which it is made to project, the last referred to acting the 
part of a shoulder and preventing drilling of the canal, which is the intention, 
from being carried beyond, or unduly near, the apical foramen. Conditions 
being favorable (see Root Filling), the apical extremity is solidly filled with 
gold, or if objection seem to stand against so radical a performance, gutta- 
percha or a sterilized cotton twist may be used. 
A succeeding step cuts off the root-crown down to the gum margin by 
means of an excising forceps and a round file (see Figs. 341, 343), continuing 
such cutting by means of a barrel-bur until the labial aspect of the face is 
fairly under the gum. 
" Set gauge (No. 3) on a drill (No. 2) to one-half the gauged depth of the 
canal, and drill to that depth. Set the twist drill (No. 4) in its chuck (No. 5) 
to project the same length as the drill, and turning the chuck with thumb and 
finger, drill the root to exactly that depth. Enlarge the mouth of canal one- 
sixteenth of an inch deep all around to near the margin of the root, using 
square-end fissure-bur (No. 59), and then with oval (No. 94) undercut a groove 
at sides and lingually, as shown in Fig. E. If the rubber dam is to be used 
for a gold or plastic backing, put it now over the root with Ottolengui's root- 
clamp, also over the adjacent teeth, and thoroughly dry the canal. Set the 
* See paper in Dental Cosmos, August, 1886. 486 
A SYSTEM OF ORAL SURGERY. 
tap (No. 6) in its chuck (No. 8) a trifle less in length than the drill, oil the 
tap, and carefully tap to the gauge depth. Insert the post in its chuck (No. 8) 
to the exact gauge of the tap, and turn the thumb-screw down hard on the 
end of the post; then screw the post into the root, release the thumb-screw, 
unscrew the chuck a half turn, bend the post until the chuck stands in centre 
line with the adjoining teeth, and unscrew the chuck. Slit the rubber back 
from adjacent teeth, tucking the flaps out of the way, so that occlusion may 
be tried, and the post excised and ground off until the teeth close clear of the 
post. Try the crown on the post, and with an F disk, dry, grind the rib 
between the neck-pins until the crown is labially flush with the root margin, 
cutting a little at a time until exactly flush. Take the crown and place the 
mandrel (No. 9) between the pins just as the post is to be, and with the pliers 
(No. 10) bend the pins carefully over the mandrel, cutting them off if too 
long to be pinched in on the mandrel at the sides, observing that the pin 
nearest the cutting edge is first to be turned, and the opposite pin bent below it 
on the mandrel, and so with the others. (See lower Fig. E.) Slip the crown 
over the post, try occlusion, and with the post-chuck bend the post until the 
crown is properly aligned with the teeth; then with a stump corundum wheel 
(No. 3) grind the neck of the crown to a close labial fit with the root, fitting 
only the portion to be concealed by the gum, leaving narrow gaps at the sides 
to be filled by the backing between crown and root (No. 13). Grind cutting 
edge for relation to the other teeth, being sure that opposing tooth does not 
strike crown, or post, or pins. Fix crown on post by pinching the pins into 
the screw-threads of the post with special pliers (No. 10 or 11). Finally, 
pack the backing of gold, or cement, or amalgam, or-for temporary backing 
while treating abscess-gutta-percha into all the crevices around the post and 
behind and under the pins, and between the crown and the root; contour and 
finish thoroughly, so that no ledge or other imperfection can be found. 
" No. 14 shows in vertical mid-section an incisor crown mounted, the black- 
ened portions of the backing defining the locking-hold of the backing on the 
post, the crown-pins, and the root recess. 
" No. 25 shows in perspective a cuspid crown ready to be slipped over its 
post, and also a cuspid crown ready for its post in the bicuspid root, which 
has its lingual cusp remaining, and the lower of the tooth diagrams shows the 
crowns on their posts awaiting the contour backing. 
" In mounting a crown on the bicuspid root (No. 25), the chucks will not 
usually pass the natural cusp, and hence both the drill and the tap must pro- 
ject the cusp's length in addition to the gauge length. Observe also if the 
space between the tap and the cusp is wider than the thickness of a crown- 
pin, and if not, cut the cusp vertically with a large fissure-bur so that the 
space shall be wide enough, before setting the post, else the bent pins will not 
pass between the post and cusp. Grind the rib quite down to the floor of the 
crown; and if the occlusion necessitates grinding the crown so as to destroy 
one pair of pins, invest the crown, and solder the pins at the lap. OPERATIVE DENTISTRY. 
487 
" When it is desired to contour the backing of a cuspid crown to form an 
inner cusp, or to adapt a cuspid or incisor crown for masticating uses, the pins 
Fig. 359.-The How System. 488 
A SYSTEM OF ORAL SURGERY. 
may be twisted together over the mandrel, and again twisted tightly over the 
post as in No. 13 ; but in some cases it may be better to bend the neck-pins 
instead of twisting them. In all cases the bent pins are to be pinched quite 
hard over the mandrel and post, so that the serrations of the pliers will 
roughen the pins to prevent their being pulled through the backing, which 
should also be condensed around the pins and post. 
" If the root be not ready for permanent mounting, use a tubular post, or, 
in the absence of a threaded tube, back temporarily with wax, rubber, or gutta- 
percha, awaiting the next sitting, when the crown may be taken off, the post 
unscrewed, and the remedy applied. Thus the root may be alternately medi- 
cated and mounted until ready for the permanent crown. 
" When the root is much decayed, the bottom of the cone-shaped cavity 
may be drilled and tapped to the depth of a sixteenth of an inch, and the 
post, thus anchored, may be further secured by cement in the grooved walls 
of the cavity and around the post." 
It is claimed that " these crowns afford unusual facility for mounting 
by any of the well-known methods of inserting the post, after soldering it to 
the crown. They are also adapted for use in celluloid- and rubber-work, 
especially in cases of single teeth. The several long pins, having their ends 
bent with pliers at a sharp angle, may be so arranged as to both strengthen 
the shank of the plate and hold the crown very firmly in position." 
No. 12 is a carrier with which amalgam, gutta-percha, cement, or other 
root-filling material may be held in close relation with a cavity, with a view to 
convenience in packing.* 
Dovetail Tooth-Crown.-These crowns, as appreciated, are designed 
for the roots of bicuspids and molars only, and the process of mounting them 
may be very briefly described, with reference to the accompanying illustrations. 
" Fig. 360 shows the roots of an inferior molar after the apical portions have 
been filled, the neck recessed, the canals drilled and tapped, and two How screw- 
Fig. 360. 
Fig. 361. 
Fig. 362. 
Fig. 363. 
Fig. 364 
Fig. 365. 
posts firmly fixed therein, the ends of the posts having been pinched toward 
each other by means of a pair of pliers, so that they will go through the cen- 
tral opening in the crown (Fig. 361). This opening is of a dovetail form, as 
shown in cross-section by Fig. 362, where the crown is seen in place over the 
* See paper in Dental Cosmos, June, 1886. OPERATIVE DENTISTRY. 
489 
posts on the root. It is thus made obvious that the crown may easily be put 
on and off the root in the process of fitting the crown-neck to the root-neck, 
and also that, for occlusion, it may be ground low on any or on all of its sides, 
Fig. 366. 
Fig. 367. 
Fig. 370. 
Fig. 368. 
Fig. 369. 
without destroying the dovetail function of the cen- 
tral cavity. When the fitting is completed, and the 
crown cut so short as to be one-thirty-second of an 
inch distant from the occluding tooth, amalgam is 
packed into the neck recess, around the posts, and 
thinly over the cervical margin of the root, the crown 
put in place, and, with thumb pressure, firmly seated. 
Then test the occlusion, and complete the operation 
by packing amalgam into the crown opening, which 
will permit the forcing of the amalgam in all direc- 
tions, to insure a firm base for the crown and its 
secure dovetail attachment to the posts, as is clearly 
shown by Fig. 362. 
" The bicuspid crown (Figs. 363 and 364) is simi- 
larly mounted, as may be seen in Fig. 365, cross- 
section ; the same crown and root being shown in 
contour by Fig. 366. In some instances this bicuspid 
crown may, like the Foster crown, be secured by a 
headed screw, as shown in Fig. 367. The root having 
been drilled and tapped and recessed, and the crown 
properly fitted and articulated, the screw is put 
through the crown, amalgam packed in the crown-groove and around the screw, 
which is then inserted in the root, and the crown pressed hard into its place. 
The screw is then turned into the position shown in Fig. 367, thus compress- 490 
A SYSTEM OF ORAL SUROERY. 
ing the amalgam or cement in both recess and groove, after which the screw- 
head may be covered with amalgam, cement, or gold as desired. 
" As a preferable mode, however, the screw-post may first be fixed in the 
root, the crown adjusted over the post, amalgam packed on the root and around 
the post, the crown seated firmly, more amalgam packed in the crown cavity 
around the post, and then a nut screwed on the post, as shown in Fig. 368. 
In all the sectional cuts cement, amalgam, or gutta-percha is to be understood 
as filling the cavities in the conjoined roots and crowns. 
" Fig. 369 shows in contour a dovetailed crown mounted on a superior 
molar root in the manner shown by Fig. 362. It is obvious that the crown 
of Fig. 362 might be ground quite down to the post ends, and yet be firmly 
held by the dovetail sides of the central cavity." Fig. 370 shows features 
related with the How crown and setting, appreciable out of the text. 
Logan's Crown and System.-With the information of which the 
student is now possessed he is prepared to appreciate modifications on the 
Fig. 371. 
Fig. 372. 
Fig. 373. 
Fig. 375. 
Fig. 376 
manner of setting crowns of any kind. Figs. 371 and 
372 show a Logan crown as fixed and related to a supe- 
rior molar. Figs. 373 and 374 exhibit the same as applied 
to a lower molar. These crowns are of large repute with 
dentists, are extensively employed, are to be procured in every variety as to 
size and shape from dealers in dental goods, and are certainly among the easiest 
to set of the various kinds found on sale. Fig. 375 shows a split post and its 
adaptation to a bifurcated bicuspid root, as shown in Fig. 376; it also affords 
full idea of the crown. 
Logan's Method.-Entering on a study of this system and employing 
illustrations and description furnished, Fig. 377 shows a superior right cen- 
tral root, an end appearance of the same, and a Logan crown, front view. 
Fig. 378 exhibits, at a right angle to the plane of the first figure, the same 
root, its end, and the Logan crown, side view. In both figures the pulp-canal 
is supposed to have been first drilled to a gauged depth with an engine twist- 
drill, No. 151, and then enlarged by means of a fissure-bur, No. 70, to the 
tapering form shown; the walls being subsequently grooved with an oval bur, 
No. 90. The enlarged section, Fig. 379, shows the crown adjusted on the 
root by means of cement or gutta-percha, which surrounds the post and fills 
all the spaces in the root and crown. Fig. 380 shows the completed crown. OPERATIVE DENTISTRY. 
491 
Fig. 381 exhibits a bifurcated bicuspid root, its end appearance, and a Logan 
crown adjusted to the root, and Fig. 382 illustrates the best manner of bending 
the post. 
In the light of the preceding descriptions the figures offered in illustration 
present clearly to the mind's eye of an expert the essential features of the 
new Logan crown and the method of mount- 
ing it; yet further explanation with reference 
to the figures will perhaps prove serviceable to 
Fig. 377. 
Fig. 378. 
Fig. 379. 
Fig. 380. 
Fig. 381. 
Fig. 382. 
the student and as well to those who may not be familiar with all the details 
of root-crowning. 
Measuring Root.-In every instance where a root is deemed ready to 
receive its filling, it is first to be measured through its canal from the cervical 
opening to the apical foramen, and this may be done accurately with a gauge 
adjustable on a delicate canal explorer (Fig. 383).* The same device serves 
to measure the distance from the apex to which the canal is then to be filled 
(Fig. 384). It also gauges the depth to which the drill may be carried. The 
proper degree of enlargement from the bottom of the drilled hole will, of course, 
depend on the observed size and character of the root. Every dentist should 
familiarize himself with generic tooth-forms, so that when the length of an 
incisor, cuspid, or other tooth-root is known, he can so nearly determine its 
hidden outlines as to form with precision a corresponding enlargement of the 
pulp-canal such as is shown by the several cuts. The suitable preparation of 
the bifurcated roots of some bicuspidati and of all molars is a matter involving 
difficulties of an unusual character and requiring good judgment. The feasi- 
bility of splitting the post of a Logan crown to adapt it to the bifurcated root 
of a bicuspid is shown by Figs. 375 and 376. This example directs attention 
to the peculiar shape of the new post, in which there is effected such a distri- 
bution of its metal that its greatest strength is in the line of the greatest stress 
that will in use be brought to bear on the crown, while the least metal is found 
at the point of the least strain; the applied part of the post being in outline 
* Harrower's Method of gauging Depth of Canal.-A tiny piece of rubber dam is 
slipped on a probe or broach. The instrument being carried into the canal, the rubber slips 
to the proper point of itself and is held there. 492 
A SYSTEM OF ORAL SURGERY. 
nearly correspondent to that of the root itself. The pulp-canal is likewise 
conformably enlarged to receive the largest and stiffest post which the size 
and shape of the root will permit. 
Fitting Crown.-The fitting of a Logan crown to a root is best done by 
the use of a wet stump wheel in the engine hand-piece,-a method which affords 
the greatest facility for the slight touches required to abrade the 
thin cervical borders of the crown, which may by this means be 
done without encroachment on the post. 
Recess for Amalgam.-By the old method of adapting pivot 
teeth to roots, the close fitting of the crown precluded the employment 
of a plastic holder, because its thinness over the surface of the joint 
made the packing liable to break loose under the shock and strain of 
use. The recess in the Logan crown is assumed to obviate this de- 
fect by providing a receptacle for a considerable interior body of 
cement that will be deep enough to be self-sustaining internally, and 
yet allow the peripheral portions of the root and crown to approach 
Fig. 383. 
Fig. 384. 
Fig. 385. 
Fig. 386. 
Fig. 387. 
Fig. 388. 
each other so closely that, though only a film of packing remain, it will still 
be strong enough to insure the persistent tightness of the joint. This annular 
boss, if formed of amalgam, also adds strength in some cases to the mount. 
Natural Crown.-When enough of the natural crown remains, it is well 
to leave standing some of the palatal portion, and cut the root under the gum 
margin at only the labial part, as shown by Fig. 385. Thus the labial joining 
of the root and crown will be concealed, and the other parts of the joint will 
be accessible for finishing and keeping clean. (See Fig. 386.) The Logan 
crown may be ground until a large part shall have been removed for adap- 
tation to the occluding tooth or teeth without seriously impairing its strength. 
(See Fig. 387.) This crown also in such cases maintains the translu- 
cency which is one of its peculiar excellencies, owing to its solid porcelain 
body, and the absence of a metallic backing or an interior largely filled with 
cement or amalgam. 
Distal Root.-The distal buccal root of the natural superior molar is 
nearly always too small to receive a post of any useful diameter, and therefore OPERATIVE DENTISTRY. 
493 
the Logan superior molar crown has but two posts, which, like those of the in- 
ferior molar crown, are square, and thus may be easily barbed, as may also 
the ribbed posts of the crowns for the anterior tooth-roots. These posts are 
large enough in all the Logan crowns to answer in any given case, and can of 
course be easily reduced to suit thin or short roots. 
Gutta-Percha.-Any of the cements or amalgams may be 
used in fixing these crowns, but good gutta-percha, softened at a low heat 
and quickly wrapped around the heated crown-post, which is at once seated in 
the root, forms the best mounting medium, and has the great advantage of 
permitting a readjustment, or if need be the ready removal of the crown by 
grasping it with a pair of hot pliers or forceps, and holding it until the gutta- 
percha is sufficiently softened. 
Combination Holder.-An excellent combination for some cases is ac- 
complished by fitting a narrow seamless gold collar over the neck of a root 
Fig. 389. 
Fig. 390. 
Fig. 391. 
Fig. 392. 
prepared like that of Fig. 386, and then adjust- 
ing and mounting in the manner described a 
Logan crown, with the result shown by Fig. 
388. 
This collar combination is available in very dif- 
ficult cases, as, for instance, when a root is decayed 
far beneath the gum, as seen in Fig. 389. Such 
an operation when completed would appear in ver- 
tical section like Fig. 390, and a view in perspec- 
tive would resemble Fig. 391. The collar is also 
very useful whenever the root and crown are not 
flush and smooth at every point, as, if possible, 
they should always be made. 
Dryness a Necessity.-In all cases it is 
of great importance that the root be thoroughly 
dried with alcohol, or ether and hot air, in 
order that the cement or gutta-percha may if 
possible adhere to the walls of the root to exclude moisture and insure the 
stability of the crown ; the stiff post of which will successfully resist any 
normal strain, as is made obvious by the enlarged views which in Fig. 392 494 
A SYSTEM OF ORAL SURGERY. 
exhibit the structure and relative capacity for resistance inherent in this form 
of post.* 
Gates's Crown and Method.-We reach here Gates's latest improved 
crown and manner of mounting. As a study this system commends itself to 
the consideration of practitioner and student, inasmuch as it shows itself an 
outcome of what has gone before both as ideas and devices on the part of 
inventors are concerned.f 
Method.-Referring to the drawings for its illustration (Fig. 393), 
the line a, a, Fig. 1, shows the anatomical outline and a strong defensive 
angle of the end of a tooth-root, while the dotted line b, b indicates the 
modification necessary to make this angle available as a crown-seat,-a ledge, 
c, Figs. 1 and 2, being formed at the outer base against which the crown may 
solidly abut. This ledge is meant to neutralize the inclined plane which would 
otherwise imperil the crown ; and as the crown-seat represents a trifle less than 
a right angle, the plane is assumed to supplement the support afforded by the 
ledge, with the result of affording a crown-seat. 
To make Crown-Seat.-To make this crown-seat there are provided 
a facing-wheel (Fig. 3) and a gauge (Figs. 4 and 5), which are exact and 
practical in application because each has a supplemental form, which enables 
one plane to be finished before the other is begun. The facing-wheel is file- 
cut upon its front face. Its diameter covers one face of the crown-seat, which 
it quickly and definitely forms while firmly sustained by a self-centring point 
(e, Fig. 3), which, separately made, has been hermetically sealed into its mandrel; 
and as this centring point cuts only on its front face (/, Fig. 3), which is also 
its largest diameter, the wheel is thereby confined to the selected, position, 
while free to adjust the plane of the crown-seat to any inclination desired. 
Gauge.-The gauge, made of sheet metal, represents a kind of skele- 
ton of the body and the outer lobe only of the crown,-the body of the lobe 
being represented by a circular crib (y, Figs. 4 and 5), over which its outer 
face, h, rests as a hinged cover. The natural crown having been reduced to 
the line of the gum, and the enamel removed, this gauge is applied against 
the end and labial face of the root while forming the outer face of the crown- 
seat by the facing-wheel. The occlusion with the opposite jaw, the mouth 
being closed, determines at once the length and position of the crown required ; 
and, by uncovering the crib in testing to be sure of its proper contact, this 
outer and determining face of the crown-seat is carefully formed, the contour 
of the gauge proving its position correct. We have thus an unfailing guide, 
a direct open view, and a thoroughly-controlled, painless, and effective instru- 
ment for overcoming, and right at the start, the paramount and, by the old 
method, most formidable difficulties of crown-setting,-viz., obtaining the cor- 
rect position and the proper adaptation. 
* Description of setting by Dr. W. Storer How. 
f Method compiled from description furnished by the inventor. OPERATIVE DENTISTRY. 
495 
Fig. 393.-The Gates Crown and Method. 
Fig. 1 
Fig. a 
Fig 3. 
F^ig. G. 
Fig. 4 
Fig.3 
Fig • & 
Fig. 7. 
Fig. 9 496 
A SYSTEM OF ORAL SURGERY. 
Face-Extension Wheel.-The supplemental or face-extension wheel 
(Fig. 6) is of similar diameter to the facing-wheel, but cuts only on its pe- 
ripheral face. Resting flat on the plane already formed, it simply extends 
that face of the crown-seat as far up under the free edge of the gum as the 
selected crown requires. Of this form there may be a pair, cutting right and 
left. 
Supplemental Gauge.-The supplemental gauge (Fig. 7) is an oval 
band or crib bent edgewise to the standard angle. Guided by the outer face, 
this determines the correct position of the inner face of the crown-seat, which 
is formed by a facing-wheel in the right-angle attachment. 
Coronal End of Crown-Seat.-It will be observed that the coronal 
end of the crown-seat extends beyond the enamel line at the ridge. This, 
like that at the ledge, is a useful variation from the saddle-shaped anatomical 
outline of the root, as it projects a solid line of support of unexampled height 
into the centre of the crown. It is slightly trimmed at each end to admit its 
reception between the lateral wings (a', Fig. 9) of the crown so provided. But 
the crown of itself requires no trimming. It represents the standard 
of joint as suited to the crown-seat. Dr. Gates, as its inventor, suggests both 
an economic and an artistic advantage in having at hand perfectly-adjusted 
crowns in porcelain. 
Staple as Bond between Body and Root.-An important feature 
also embodied in this crown consists in employing a staple as the bond between 
the crown and the root. Entering the inner face of the crown, its loop is 
bent backward and embedded in the porcelain toward the outer face, as shown 
at i, Fig. 8, thus securing the most powerful combination with the crown-seat. 
This arrangement provides an open passage directly through the crown and 
the pulp-canal while the crown is in place upon the root, and affords facilities 
for the attainment of highly-important purposes. 
Consideration of a Possible Pathological Condition.-Instead 
of having the approach to the pulp-canal sealed with impenetrable porcelain, 
it is assuredly a manifest advantage to have opportunity to reopen in case of 
pathological conditions not apparent at the time of closing; and the open 
passage is of still greater importance at the time of setting the crown, for it 
permits the centre of the canal to remain open and undisturbed until the treat- 
ment can be made under favorable circumstances. Thus, instead of wasting 
time at the start in a difficult diagnosis of the case, the crown-seat is at once 
formed, the canal enlarged, and the crown set on gutta-percha, the presence 
of a slender pin embedded therethrough leaving the canal open when with- 
drawn ; and on removing the crown at a subsequent sitting the treatment is 
made with every advantage of free access, an open view, and the opportunity 
to make deliberately whatever tests may be necessary. 
Advantage of Open Passage.-This open passage also makes avail- 
able an important discovery touching the material employed in the setting. 
Gutta-percha having shown unusual tenacity and power of resistance as a thin OPERATIVE DENTISTRY. 
497 
layer between this crown and its crown-seat, requires only the assistance of a 
firmly-embedded staple to make it serve as a permanent setting; but to 
embed the staple properly, subsequent and direct access is essential. The con- 
venience and simplicity of such an adjustment are apparent. A thin layer of 
gutta-percha adapted to the base of the crown is warmed and impressed on 
to the crown-seat, which, being moist, allows the crown to withdraw the gutta- 
percha as an impression. The excess at the border and immediately around 
the staple being trimmed away, it is warmed and replaced until the crown 
practically rests against the crown-seat. At this point, if the mounting is to 
be temporary, two slender sticks of gutta-percha are warmed and pressed 
within and upon the opposite edges of the staple and embedding also a small 
ordinary pin between them. The point of this pin, made blunt, will be slightly 
in advance of the gutta-percha when inserted into the canal, and the gutta- 
percha should be at least an eighth of an inch in advance of the ends of the 
staple, so that, in condensing, it may obtain firm contact with the sides and 
retaining-points of the canal. The canal and root having been well dried, the 
loosening and withdrawing of the pin will leave the case in a safe and suc- 
cessful condition. But the permanent placing is still more simple, as, when 
the gutta-percha has been adjusted to the base of the crown and the root 
dried, nothing remains but to partly fill the canal with a soft mix of amalgam, 
carry the crown to place after warming, and finish by thoroughly introducing 
very dry amalgam until mercury will no longer appear. In making this per- 
manent closing of the canal the insertion and withdrawal of a slender steel 
pin, reaching almost to the foramen, will leave a closed tube if desired in the 
amalgam for more convenient approach in case of necessity. 
Amalgam as a Setting Agent.-It is here to be stated that amalgam 
is perfectly adapted for setting this crown, as a soft mix placed between the 
crown and crown-seat permits the crown to go fully and easily to place, leaving 
only a mere film between, the excess of mercury being withdrawn at the same 
time with that in the canal; and the only part of the joint facing outward- 
namely, the ledge-is easily provided with a fender, excluding the amalgam, 
so as to appear, if at all, only as a fine line of gold. 
Gutta-Percha as a Holder.-The convenience, entire concealment, 
and stanch character of gutta-percha, as a cement between two solid surfaces 
otherwise sustained in close apposition, allows of the dispensing with amalgam 
in this operation, and adds one more to the laurels of this invaluable material. 
Reaming the Canal.-Reaming the canal is preferably deferred by Dr. 
Gates until the crown-seat is formed, as any improved position desirable to be 
given the crown will require ordinarily only a slight corresponding change in 
the position of the staple at the mouth of the canal, without resort to bending ; 
and since the dislodging force against the crown, hitherto borne by the post, 
is here sustained by the crown-seat with its reserve of force, we can widen 
laterally, or make such other shaping of the pulp-canal as suits any purpose 
of advanced ideas. 498 
A SYSTEM OF ORAL SURGERY. 
Determination of Position of Crown-Seat.-But the question 
will be asked, How shall the position of the crown-seat be determined when 
the end of the root is far decayed or already cut into concave shape ? Simply 
by inserting into the pulp-canal, temporarily, a pivot of orange wood, the outer 
end of which, cut to a wedge shape, will give support to the centring bur of 
the facing-wheel. In such cases, after the crown, set for a few days upon these 
partial outlines with a slight excess of gutta-percha, has pressed the morbid 
gum back to its normal condition, a section of corrugated tubing having its 
outer end likewise cut to wedge shape is to be permanently set into the en- 
larged canal by means of amalgam, which is then simply built out far enough 
to restore the crown-seat. As all tendency to split seems to be interrupted by 
this simple arrangement, it is obvious that roots may in this manner be saved 
otherwise impossible of preservation. 
Adaptation to Bridge-Work.-Lastly, this facility of the open canal 
offers, accepting the experience of Dr. Gates, a unique advantage for bridge- 
work. All banding is set aside and a strong, simple, and removable attach- 
ment is made to this crown. A lingual gold face set into the crown its own 
thickness (y, Fig. 8), including a short hood at the cutting end, is easily secured 
by a suitable screw (Z, Fig. 8), provided with a platinum counterpart previously 
embedded in the amalgam of the pulp-canal. 
How's Improved Crown and Setting.-Dr. How, whose ingenuity 
is in constant exercise with view to the production of improvements in dental 
and oral apparatus, furnishes the accompanying description and series of illus- 
trations of his latest work in the direction of crowns and setting. As suggested 
by the deviser, this new matter of his is one of extreme simplicity and quite 
capable of being practised by any person ordinarily proficient in the kind of 
work required. In Dr. How's opinion this new manner of mounting entirely 
obviates the difficulty of obtaining a close fit of a post in a root so that it can- 
not be turned in the socket by a rotating strain on the crown. Alluding to 
this too-familiar defect, he reminds us that square, oval, triangular, and parallelo- 
grammatic posts have been employed with that object in view, and because of 
the great difficulty of forming in the root suitable sockets for those angular 
and straight-sided posts, it has been the practice to provide tubes correspond- 
ing in cross-section to the posts, and by first setting the tubes in the roots, to 
insure the fitting of such posts in those sockets. The provision of tubes, the 
fitting of them, and the fastening of them in the roots has, however, as is well 
recalled by Dr. How, been the occasion of much delay, expense, trouble, 
weakening of the teeth by reason of the necessarily large bore required for 
the tube, and of various other incidental perplexities that, taken together, have 
hindered frequent resort to that method. 
Manner of Setting.-Setting, after the manner of this new device, is as 
follows: Cut and polish the end and edges of the root exactly and thoroughly. 
Select a piece of straight round wire of suitable size, say No. 17, and preferably 
of iridio-platinum. With a drill (preferably a twist) that has been tested in a OPERATIVE DENTISTRY. 
499 
piece of bone and found to make a hole that the wire will exactly fit, drill the 
tooth-root to the proper gauged depth (Fig. 394). Then with a fissure-bur, 
No. 55-j or 66-J, carefully cut a longitudinal groove in the side of the root- 
bore equal to about the length and thickness of the cutting part of the fissure- 
bur. Fig. 395 is a sectional and an end view of the root so prepared. Take a 
short piece of small platinum wire, say No. 22, fix it on the post with binding 
wire, as in Fig. 396, flatten a common pin as thin as a hammer will make it, 
dip but the point of the pin in thin borax paste and touch only the contact line 
of the two wires with the borax. Put the least bit of gold plate, or pure gold, 
or fine gold solder on the outer end of the post, hold in the flame of a Bunsen 
burner, and neatly unite the two wires without running any solder over their 
Fig. 394. 
Fig. 395. 
Fig. 396. 
Fig. 397. 
Fig. 398. 
Fig. 399. 
sides. This feathered post should be found to fit closely the grooved 
socket, as in Fig. 397, resist every effort to rotate it, and yet permit withdrawal 
by a direct pull. A thin platinum plate may be then fitted on the root end, a 
plate tooth backed, adjusted, and hard-waxed on the plate and to the feather 
wire, the end of which is to be left free, as in Fig. 398, so that it may be 
grasped by pliers to withdraw the crown and the plate without disturbance, 
for investment and soldering in the usual way. Fig. 399 shows the completed 
crown, after mounting with sandarach varnish, hot resin, copal varnish, or very 
thin cement. In favorable cases, under skilled hands, using exact instruments, 
the feathered post-crown will fit nearly moisture-tight, and the varnish will 
make it quite so. 
It is entirely practicable to fit the plain wire post to the simple round 
socket, to fit the root-plate, to back and adjust the crown, and to remove and 
solder all together as usual; then reinvest the crown in plaster and marble- 
dust, leaving the post exposed. To this solder the feather of small wire, 
locating it so that its seat will be in the widest part of the canal. Then put 
it on the root, mark with a pencil the place it is to occupy, and with 
the fissure-bur cut the groove for it, which may be filed slightly to give 
it a wedge shape, and by frequent trials, with careful corresponding cuttings 
of the groove with the bur, be made at least to go to its seat so tightly as to 
be secure against dislodgement in use. 
It will be noticed that the post is materially strengthened by the 500 
A SYSTEM OF ORAL SURGERY. 
feather, which reinforces it in the line of resistance to outward thrust during 
the acts of incising or grinding with the crown. 
Special Cases.-Special cases where the root is small and short, as in 
Fig. 400, and the crown subjected to hard usage by the deep underbite of the 
opposite tooth, will be well met by the feathered post, which affords the 
maximum strength of crown attachments with the least possible removal of 
root-substance. 
Whenever the root end is somewhat decayed the feather seat 
may be cut at the soundest part. In greatly-wasted cases the root may be 
Fig. 400. 
Fig. 401 
Fig. 402. 
Fig. 403. 
collared, filled, and the filling drilled and prepared as first described. If the 
canal is unusually large, as in Fig. 401, a narrow strip of plate may be bent 
around the post and pinched close upon it. A suitable clamp will hold the 
plate ends together while they and the plate are being soldered on the post. 
The piece is then filed to the shape shown in Fig. 402. Before drilling the 
root it is well to cut a trial piece of bone, and with a large round common 
bur and an inverted cone-bur form the enlargement of the socket. A fissure- 
bur is to follow, cutting the groove for the feather. A better way is to 
make a countersink drill that will at once and truly cut both the socket and its 
enlargement at the same time. Fig. 403 shows in section the finished crown. 
Fig. 404. 
Fig. 405. 
Fig. 406. 
Fig. 407. 
In some instances a wedge-shaped seat may be burred and cut square 
by a file, as in Fig. 404. The feather is then to be made of a piece of plate 
and soldered to the wire (Fig. 405), the operation preparatory to removal for 0FE7M77KE DENTISTRY. 
501 
investment being shown by Fig. 406. The completed and mounted crown is 
illustrated in Fig. 407. 
Use of Tapering Post.-It may sometimes occur that a tapering post 
is desirable. Such an one is shown straight in Fig. 408 and bent inwardly, 
as in Fig. 409, to suit some requirements of adjustment. The How four-pin 
crown (Fig. 410) may be readily adjusted on the feathered post by bending 
the long pins around it, as in Fig. 411, and be then removed, invested, con- 
Fig. 408. 
Fig. 409. 
Fig. 410. 
Fig. 411. 
Fig. 412. 
Fig. 413. 
toured with porcelain body and enamel, and baked in the Parker-Stoddard 
furnace, with the excellent result shown in Fig. 412, the mounted crown 
resembling that seen in Fig. 413. 
It would be easy to multiply modifications and applications of the 
feathered post device, which has its familiar counterparts in many mechanical 
structures, but is novel in its adaptation to dentistry. Like all such simple 
things, it occasions surprise that it should not have been previously used. 
An undeniable advantage is that the ordinary dentist, by means and materials 
within common reach, may employ this post as a readily-recognized improve- 
ment on the well-known methods of mounting tooth-crowns. 
BRIDGE-WORK. 
Here the student finds himself fairly and fully introduced to the subject of 
bridge-work, or, as the performance is as frequently termed, crown-extension 
work. 
Bridge, or Crown-Extension, Work.-As implied in the naming, 
bridge-work means spanning. A bridge may span from supporting abutments 
on opposite sides of a space or it may have intermediate support or supports. 
The studies already made will be found to cover, in a general way, the ground 
of the practice, leaving here to be considered simply matters of detail. 
Necessity for the Possession of Skill and Understanding.- 
Only a skilful handworker may hope to succeed in the refinements of bridging, 
and only a surgically-educated one is justified in attempting the performances. 
Bridging affords good example of the common relativity lying with things as 
distinction exists between what is good and what is bad. (See Addendum.) 502 
A SYSTEM OF ORAL SURGERY. 
Introductory of the Subject.-Fig. 414 is happily introductory of 
details to be considered. It shows a mouth where crowns and roots of four 
incisor teeth have been lost, but where the roots of the cuspidati remain. 
Here it is an intention to supply the missing organs by means of a dental 
bridge,-that is, a bridge composed of teeth so related and fixed as to take 
the place of what has been lost. Observation of the figure exhibits the roots 
of two eye-teeth prepared in proper manner for the reception of pivots. The 
proposition is to pivot crowns to these roots, which pivoted crowns are to 
serve in turn as abutments to a proposed bridge. (See, for the proper prepara- 
tion of roots, previous paragraphs; also Root Filling.') 
Figs. 415 and 416 show sections of one of the two roots the faces of which 
stand exposed in Fig. 414. Fig. 417 is a porcelain-faced crown ready for set- 
Fig. 414. 
Fig. 415. 
Fig. 416. 
Fig. 417. 
ting as an abutment of the bridge. Appreciation of all is possessed in what is 
fully exhibited up to this point. 
Illustrative of a Bridge.-Fig. 418 shows a bridge of teeth prepared 
for the requirements existing with Fig. 414, and Fig. 419 represents the 
bridge anchored in the root-abutments. Looking at the first of these two 
latter diagrams, it is seen that pivot eye-teeth have been prepared to relate 
with the roots shown in Fig. 414, the manner of relation being much like that 
described as ferruling. To the circles of gold a metal bridge has been attached, 
to which metal, in turn, teeth are soldered after a manner required. 
Fig. 418. 
Fig. 419. 
The making and articulating of a Bridge.-To make and to ar- 
ticulate such bridge as shown, or dental bridges of any kind, a first step, as is 
now undoubtedly understood, relates with preparation of the anchoring roots or OPERATIVE DENTISTRY. 
503 
crowns. In the case of roots, as shown in the illustration, the performance is 
without difficulty. The immediately succeeding step consists in taking an 
accurate impression of the parts in plaster, wax, or other selected material, 
and in making from this a plaster model together with an articular bite of the 
opposing jaw. Model and bite secured, the completion of the work is little 
more than a process of grinding, filing, and soldering, with which every dentist 
is inferred to be familiar. (For taking impressions, bites, etc., see chapter on 
the subjects.) 
The character of bridge shown above is not necessarily an irremovable fixture, 
for it must impress the ingenious that the Flagg method of fixation is 
little less applicable here than elsewhere. (See Flagg's Method.') 
Studies in Bridge-Work.-Figs. 420 and 421 are introduced as 
studies. The case is one offering unusual difficulties, and is illustrated and 
described by Dr. R. Walter Starr, in whose practice it occurs. In the first 
diagram an eye and a molar tooth are seen in section that exposes pivots 
which hold a bridge. From this bridge, which spans the intervening space, 
posts are seen standing up, to which posts backed teeth are to be soldered. 
The second figure (421) shows the denture completed and in place. 
Removable Bridge Denture.-The forward overhang of the inferior 
right second molar tooth, as seen, was, says Dr. Starr, so excessive that an 
impression could hardly be taken, even piecemeal, until with corundum wheels 
Fig. 420.-Removable Bridge-Work. 
A, telescoping cap; B, cap; C, bridge of teeth. 
and points the sides of the tooth had been made parallel, or rather slightly 
tapering, to form a truncated cone, with the neck as a base. The molar was 
alive and sound, but the crown was gone from the pulpless cuspis, which was 
suitably shaped by means of a peculiar root-trimmer. (See Fig. 338.) 504 
A SYSTEM OF ORAL SURGERY. 
An impression was then taken, the cast from which is illustrated by Fig. 
420. A seamless gold collar was, by means of a slightly-tapering mandrel, 
made to exactly fit the tapered natural molar, the lower edge of the collar cut 
to conform to the gingival margin, a cap piece of gold plate soldered to the 
top edge of the collar, and a hole drilled through the centre of the completed 
cap (A, Fig. 420). Care was taken to so fit and proportion the cap that it 
would require finally pretty hard driving to send it home on the tooth ; but first 
there was fitted to the cap a telescoping seamless collar, on which was 
soldered a gold plate, with cusps, to form a molar crown, as shown in Fig. 420. 
The molar was then thoroughly dried, slightly painted with agate cement, and 
the cap, A, driven hard down with a flat pine stick held upon it and struck 
with a mallet; the hole in the cap enabling me to see when the cap was quite 
Fig. 421.-Removable Bridge-Work. 
down. The cuspis was then likewise fitted with a seamless gold collar, the top 
edge of which was given a roof shape, as seen above the root in Fig. 420. A 
piece of gold received a corresponding roof shape, had a short section of gold 
tubing soldered into it, anti was trimmed to the outline of the collar, beside 
which (7?, Fig. 420) its form is seen, and to which it was subsequently soldered, 
after suitable investment to keep the parts in proper place. The root- 
canal had been previously prepared to receive the tube, which, with its roofed 
cap, was with stick and mallet driven hard down over the root. A piece of 
gold wire exactly fitting the tube had a roof-shaped piece of properly-perforated 
gold plate slipped over it into position on the root; became fixed in such rela- 
tion by a drop of melted hard wax; * was removed, invested, soldered, and 
finished in such shape that, excepting the hollowness, it looked like the tube 
and cap (2?, Fig. 420). 
The relations of the occluding teeth had, of course, been determined by 
an articulating model, and by means of it a series of seamless gold collars and 
cusp-crowns were adjusted on a thin platinum plate fitted on the cast between 
the cuspis and second molar and the collars soldered to the plate. The truss 
* Hard wax, a mixture of rosin with beeswax. OPERATIVE DENTISTRY. 
505 
thus formed received an appropriate finish by the rounding and smoothing of 
its basal borders. A plain plate cuspis was backed with gold plate and fitted 
on the roof plate, to which, after determining its proper occlusion, it was 
secured by hard wax, removed, invested, and soldered. It was then put into 
the tube on the root, the telescoping cap A put over the molar, the truss put 
in position in the mouth, and the whole covered with sand and plaster. 
Securing thus absolute integrity and fixedness as to a relation of the dif- 
ferent parts, they were immovably connected. Fig. 421 shows the bridge and 
teeth related and in place. 
Figs. 422 and 423, which are entirely self-explaining, show specimens of 
removable bridge-work. 
Richmond's Work.-Fig. 424 exhibits an entirely-soldered denture. 
Dr. Richmond (to whom seems to belong the credit of reintroducing, if not 
Fig. 422.-Removable Bridge-Work. 
Fig. 423.-Removable 
Bridge-Work. 
inventing, the gold-cap crown, certainly a boon to humanity) has his manner 
of constructing a piece, as here shown, described as follows: 
He employs a zinc die made from a cast of the anchor tooth with its cap 
on. He makes of crown metal (platinum faced with gold) a collar somewhat 
smaller than the tooth-cap and deep enough 
to reach from the gum to about a sixteenth 
of an inch above the cap. He then drives 
the die into the collar so far that the extra 
sixteenth of an inch can be hammered over 
and burnished down on the die end to form 
a flanged collar. Outside of this, in the 
same manner, he forms another flanged col- 
lar, and then solders the two together, thus 
obtaining a close-fitting, stiff collar that will 
not stretch in being telescoped on and off the anchorage, and which is kept by 
the flange from being forced too far over the tooth-cap. The illustration shows 
Fig. 424.-Illustration in 
Bridge-Work. 506 
A SYSTEM OF ORAL SURGERY. 
his post and roof device, and is so expressive as to make enlargement in the 
way of description superfluous. 
Curtis's Bridge.-Not to unnecessarily .or unprofitably occupy either 
the time of the student or the pages of this volume, passage is here made to 
the Curtis bridge, the principal use of which is in cases where the pier teeth 
do not stand parallel with each other, and where, in the language of Dr. 
Curtis, "it is desirable to attach a bridge without cutting off one or more of 
the teeth or dressing down the sides until the surfaces next to the bridge 
become parallel, as is necessary when a permanent bridge is used." 
By this method, as will be understood in a study of the diagrams accom- 
panying, cap-crowns are first fitted to the teeth between which the bridge is 
to be placed and their cusps correctly articulated. This done, an impression 
is obtained after any of the ordinary methods. (See Taking Impressions.} 
Dr. Curtis selects for his own use plaster, placing it about the crowns and 
filling the space between them and reaching above the masticating surfaces, 
when the jaws are closed and articulation secured. The plaster being set, the 
mouth is opened and the mass removed. If broken in the removal, which is 
almost a necessity, the parts are carefully placed in position and secured by 
means of wax. This model is now put in an articulator (see Articulators} 
and the relation of parts secured after permanent fashion. Dr. Curtis's de- 
scription of his manner of procedure from this point is as follows: 
The bridge is constructed by taking suitable porcelain facings, grinding and 
backing them until the space is properly filled. The solid gold cusps are now 
ground to articulate with the antagonizing teeth and are attached to the facings 
by means of wax. Next the bridge is removed and encased in marble-dust 
and plaster, which being done the cusps are soldered to the backings, only 
sufficient solder being used to prevent movement of the cusps. The sockets, 
like A, Fig. 425, which are made of thin gold, are now placed in position and 
held by means of y?ua>wax, when the entire piece, again encased as before, 
the ends of the sockets projecting beyond the cusp surface of the bridge, are 
embedded in the plaster. The wax is next melted out and the sockets sol- 
dered into place. After being allowed to cool, the projecting parts of the 
sockets are cut away until the bridge fits perfectly between the crowns. The 
soldered surface is now ground away to the proper fulness, and the whole 
piece rendered quite smooth or ready for polishing (C, Fig. 426). Arms 
like B, Fig. 425, are now placed in the sockets and so cut off that a perfect 
adjustment with the crown is obtained. It is found that the arms are wider 
than the sockets are deep, this width allowing them to project one-sixteenth 
of an inch or more. The bridge is now secured in position by means of a 
drop of wax placed at the junction of the porcelain surface and the cast. 
Next the palatal face of the cast is varnished, after which soft plaster and 
marble-dust is placed over it until it is raised on a level with the masti- 
cating surface, when it is to be allowed to harden. Next carefully remove the 
bridge and replace the arms in position as marked in the plaster, and retain OPERATIVE DENTISTRY. 
507 
them by means of additional plaster or steel springs, and solder them to the 
crowns, first placing in the joint sufficient flux-wax so that in the process of 
soldering the arms will be perfectly united to the crown, which requires a very 
small quantity of solder. The case is now ready to finish. 
Fit.-If the adjustment of arm and socket be perfect, the structure will 
be found to fit so snugly that it is with considerable effort that the bridge 
can be removed. With everything in readiness for cementing, the crowns 
are quickly forced into position, the bridge carried to place, and the cement 
allowed to harden. 
Removal of Bridge.-Should there be necessary, in the articulation, 
any alteration that cannot be met by grinding off the cusps of the antagonizing 
teeth, the bridge can readily be removed without disturbing the crowns. 
Fig. 426. 
Fig. 425. 
Arm.-The arm B, Fig. 425, is made of a strip of clasp-metal, No. 
16- gauge in thickness, and of any desired width or length. The strip is 
placed in a slot like B, Fig. 427, and the projecting end hammered to form 
a solid head as shown. A longer or shorter arm may be formed in the slot 
F, wherein the adjustable limit G may be set to limit the length of the arm 
while the hammered head is being formed. A piece of twenty-carat gold 
plate, No. 33 gauge, is cut to the size and shape of Fig. 428, and by means 
of a former (K, Fig. 427) is forced into a suitable slot. The place of the 
former K is then taken by the arm B, Fig. 425, and the part H, Fig. 427, 
bent and delicately hammered over the head of the arm. The socket so 
formed is then removed, soldered from the outside, and finished as at A, to 
exactly fit the arm B, Fig. 425. 
It is obvious by recurring to Fig. 426 that the bridge C, D may be readily 
detached for the purposes of cleansing or repair. 
Porcelain Facings on Living Teeth.-There is not infrequent 
occasion for putting caps with porcelain facings on living teeth. To do this 
Dr. Curtis cuts any one of the oral teeth to a sharp wedge shape, fits a thin 
gold cap, selects a thin facing, punches the cap and solders the pins on the 
inside of the cap, fills the cap and covers the facing with plaster and marble- 508 
A SYSTEM OF ORAL SURGERY. 
dust, and contours the back with solder. Fig. 429 illustrates the operation 
after the cap-facing has been cemented over the crown. Fig. 430 shows in 
Fig. 427. 
Fig. 428. 
Fig. 429. 
Fig. 430. 
section and perspective a living molar gold-capped, having solid gold cusps, 
and provided with porcelain facing on its buccal and lingual sides. 
Brown's Porcelain Bridge-Work.-It is now five years since Dr. 
E. Parmley Brown devised and made public his system of all-porcelain bridges, 
and the interim seems to have been spent by him in so improving his invention 
that it is to be assumed as standing to-day in its perfection. It is claimed for 
this manner of bridging, by very many practitioners, that it is justly to succeed 
and replace other processes of its kind as permanent fixtures are concerned 
by reason of advantages lying with it in the directions of cleanliness, strength, 
and comfort. 
Composition of Bridge.-The porcelain bridge is composed of porce- 
lain teeth, with a metal bar of platino-iridium baked invisibly into and 
through the centre of the piece. The construction is attached to the natu- 
ral teeth or roots, the cervical portion being a broad, concave surface, 
which presses tightly against the gum, thereby gaining considerable extra sup- 
port, and preventing the accumulation of food impurities beneath the bridge. 
In no case is any so-called self-cleansing space left beneath the bridge; 
such space being, as almost every practitioner knows, simply a cavity in which 
detritus lodges. The gum, by reason of absence of irritating agents, keeps 
in a perfectly-healthy condition, and adjusts itself normally around the necks 
of the teeth, festooning them, and insuring absence of ingesta from beneath 
the denture. 
No Occasion to excise Teeth or devitalize Pulps.-It is never 
necessary, as is claimed, with this system to excise a natural tooth, and only 
in very rare cases is it deemed advisable to devitalize a pulp that a pin may be 
extended into its canal as a means of attaining extra strength. 
Manner of Attachment.-The porcelain bridge is attached to the 
natural teeth (living or dead) by means of gold or amalgam fillings placed OPERATIVE DENTISTRY. 
509 
therein, unless there be roots to which it may be attached preferably, in which 
case porcelain or gold crowns are used for the purpose. Such crowned roots 
may constitute the " piers" at either end of the bridge, or they may be taken 
advantage of as extra means of support at any point along the span, whether 
the piers are crowns or natural teeth. When the attachments are to be made 
in fillings in living teeth, the projecting ends of the bar are extended and 
formed so as to be anchored or embedded in such fillings ; when in fillings in 
dead teeth, such ends are turned at right angles to be extended into the root- 
canals ; when to anterior roots by means of porcelain crowns, the said crowns 
are made an integral part of the bridge, being united with porcelain to their 
approximating artificial teeth, and having the platino-iridium bar extended 
into them and bent at right angles in their centres, and thence extended 
through the cervical portions, in the form of root-pins; when to posterior 
roots by means of gold crowns, the projecting ends of the bar are extended 
through holes, made to take them, in the approximal surfaces of said crowns, 
and either simply embedded in cement therein, or bent at right angles and 
thence extended into the root-canals, this depending upon whether the pulp be 
living or dead. These modes of attachment may be used, of course, in any com- 
bination, as the case may indicate. Porcelain or gold crowns may be adopted 
at any supports happening to exist along the span of a bridge; the porcelain 
crowns as explained, and the gold crowns by having the bar of the bridge 
extended through them, from side to side, through holes made to take it. 
Where gold crowns are used, the porcelain teeth are first baked on the bar, 
and they and the gold crowns separately fitted; then the holes are made in 
the approximal surfaces of the crowns, and slits cut from the cervical edges 
up into the said holes. The bar is then forced through these slits into the 
holes made to receive it, the slits soldered, and the crowns set with cement 
when the bridge is attached. When natural teeth, too sound to be indicated 
for crowning, instead of roots to which such crowns are attached, stand any- 
where along the span of a bridge, the bar is extended through gold or amal- 
gam fillings therein, and is said to be 11 saddled" across the same. 
Extension of Wings.-From any one of the above-described attach- 
ments one or two teeth may safely be " winged," or extended on an opposite 
end. The third or second molar, or both, may often be replaced after such 
manner; and sometimes a single tooth is preferably " winged" on. where one 
of its approximating natural teeth is sound, and it is not advisable to cut into 
it. Several cases where the first bicuspids have been thus winged to the 
second have been shown by the inventor of this bridge system, they having 
been satisfactorily useful for from three to five years. The leverage is too 
great for more than one tooth to be " winged" on, unless the bridge is ex- 
tended for some distance on the opposite side of the li pier," that a sufficient 
balance be effected. Where such a tooth or teeth cannot be " winged" from 
a " pier," a cavity, for the reason just stated, must be cut in the sound ap- 
proximating tooth; it need, however, only be very small, and the end is 510 
A SYSTEM OF ORAL SURGERY. 
assumed to justify the means. In the majority of cases, however, cavities 
are likely to be found on the approximal surfaces of teeth adjoining spaces 
from which the associate organs have been lost. 
Method of making Porcelain Bridge.-The method of making 
the porcelain bridge is simple. The bar is first fitted to the model, cavities 
having been cut in the plaster pier teeth (where there are such), as they are 
to be made in the corresponding natural teeth, the bar being extended into 
these. The bar must be of very heavy platino-iridium wire,-square,-which 
is made for the purpose, and is to be most carefully hammered and bent into 
the requisite shape, so as to come in the centres of the porcelain teeth, equi- 
distant from the cervical and the masticating surfaces. Ordinary plate teeth 
are then fitted in place, preferably with straight pins for anterior ones, be- 
tween which pins slots or grooves are ground by means of a thin corundum 
wheel, which grooves are to extend from behind just so far into the teeth that 
the bar, when fitted into them, will be in the centre of the completed denture ; 
then the teeth are fitted upon the bar in their proper relation to the gum, the 
antagonizing teeth, and to each other, and, in anterior teeth, the straight pins 
are bent over the bar, serving to hold them firmly upon the same during 
manipulation. 
No Occasion for Use of Pins.-The pins are of little or no use in 
posterior teeth, and are preferably ground away before the groove is cut. The 
teeth being fitted on the bar, the porcelain body, mixed just so that it will not 
run, is applied with a spatula, only a small quantity, preferably, just around 
the bar, until after the first baking. Such a small quantity placed around 
the bar shrinks better during the baking into the spaces between the metal 
and the teeth and unites them better than would a large quantity, which 
would shrink toward the centre of the greatest bulk, and often away from the 
bar. 
Baking.-Experience alone can give success in the baking. The various 
bodies require different degrees of heat and, as well, difference as to time in the 
furnace. Bodies must also be selected with reference to the teeth used. The 
American bodies cannot be combined with the English teeth, as the latter fuse 
with much less heat than the former. For the ordinary American teeth, the 
Allen, Tees, or Close body works admirably. The muffle for the baking must 
be at a white heat, but never so hot that the case disappears entirely from 
view. An old-fashioned continuous-gum furnace is to be used where gas 
cannot be had; but where such means is at command, the inventor of this 
porcelain system thinks that a Verrier, or Stoddard, or hand furnace is to be 
preferred, as such eliminate all dust and dirt and can be heated to the desired 
temperature quickly and precisely when wanted, and can be kept at such 
temperature as long as needful without trouble. 
First Baking.-The bridge being prepared for a first baking, as de- 
scribed, it is to be thoroughly dried out over a flame, and is best placed, as the 
inventor has found, on a bed of broken crystal quartz or silex. Thus placed, OPERATIVE DENTISTRY. 
511 
the slide is slowly put in the muffle, and if the heat be high enough is to 
have the first baking in from five to seven minutes. In the more extensive 
cases it is sometimes found best to suspend the denture on suitable racks of 
platinum, which may be made of wire properly bent, or, if there be one or 
more root-pins, the denture may be held on the slide by having the pins 
extended into holes drilled in the slide for the purpose. 
Test for the Baking.-A test for the baking is that the new body is 
opaque in the furnace until baked, while the teeth are beautifully translucent 
from the first. When baked the case is slowly allowed to cool, then fitted 
again on the model and the remainder of the body applied. The body must 
be packed solidly against the plaster gum and carved to imitate the natural 
teeth, a camel's-hair pencil being used at last to brush away any particles, 
especially from the faces of the teeth. The case is again placed in the fur- 
nace and baked as before, only a little longer. If gum is to be added, it 
must subsequently be applied and the case baked a third time; or if any 
cracks or checks are found, caused by the shrinkage or too sudden cooling, 
after the second baking, it is to be repeated. If the new body has been 
made glossy like the enamel of the faces of the teeth, the case has been 
overbaked-vitrified-and is easily broken. The new body should be dull, 
and if enamel be not applied-and its application is not necessary-it can 
be ground perfectly smooth on corundum wheels, when extra fine touches 
of form can be given, and can at last be highly polished on belt wheels and 
moose-hide polishers with pumice. It is then ready to be inserted. 
Attachments.-If the attachments are to be made by means of porcelain 
crowns, it is simply necessary to fit the crowns (which are integral parts of 
the bridge, having been baked with it) to the roots in the usual manner 
and cement them in place. The joint should always be well up under the free 
margin of the gum, and the pin extended even to the end of the root-canal. 
The form of crown and pin invented by Dr. Brown doubtless gives the best 
results in combination with these bridges. The crowns themselves can often 
be used in the making of the bridges instead of plate teeth. If the attach- 
ments are made by means of gold crowns, the bar is fitted in holes in their 
approximal sides, as described, and all are cemented on as in ordinary gold 
crown work. The Evans or Rynear seamless gold crown are claimed to be 
the best for this as for other crown work. If the attachments are by gold or 
amalgam fillings, the process is more complicated and difficult, especially if 
one pier be a crown while the other is a natural tooth with a gold filling, 
perhaps with one crown or more, or a " saddle" filling somewhere along the 
span. 
Materials used for Anchoring.-Gold is to be used for anchoring 
these bridges in the great majority of cases,-in all cases anterior to the 
bicuspid teeth,-while amalgam answers very well in the posterior teeth, 
especially in large molars, everything being favorable. The bridge being 
fitted in such cases, a piece of the thinnest rubber dam is applied and the 512 
A SYSTEM OF ORAL SURGERY. 
filling commenced, whatsoever it may be. With amalgam the performance is 
comparatively simple, as this may be forced under the bars and only needs to 
be held immovably until it has set. With gold the cavities are to be prepared 
to the very best of the operator's ability, fine undercuts, extra large retaining- 
pits, and perfect margins being made. 
Preparatory to fixing Bridge.-The cavities are to be lined or 
11 boxed" with gold and the cervical margins finished before the bridge is put 
finally in place; if too much gold be packed at any point, it can easily be 
removed with a bur. If both extremities are to be anchored in fillings, both 
cavities are boxed, as described, after which the bridge is pressed in place, 
forcing the thin rubber dam tightly against the gum everywhere. The fillings 
are next completed and the dam pulled from beneath the bridge. If, how- 
ever, only one extremity is to be thus anchored, while the other is to be 
attached by means of a crown, or if one or more crowns are to be placed along 
the span, the single cavity is boxed with gold, as described, and round holes 
are cut in the dam over the roots (everything being kept dry with bibulous 
paper), the crowns cemented on as in ordinary cases, and the single filling 
completed. The crowns are carefully held in place during the filling while 
the cement is setting. If the bar is to be run through a gold filling into a 
nerve-canal at one extremity of a bridge, the filling is " boxed" in, as described, 
the opening into the canal being left free, or burred out after the 11 boxing," as 
desired, and the root-pin fastened therein, preferably with gutta-percha, as the 
fluids of the mouth might in time work in along the sides of the bar and 
dissolve out oxyphosphate, if that were employed. Care is to be taken to 
have all cavities in which bridges are anchored lined with gold, nor is the 
bar to touch the dentine, as fluids might intrude, as just stated, and destroy 
the tooth. Objection is raised by many that gold fillings cannot be made to 
sustain such bridges,-an objection that holds unless such plugs be made in 
the best possible manner; this being done, it is claimed by Dr. Brown that 
they can support extensive bridges, and have done so for years. 
The inventor believes that gold cannot be packed to hold such bridges 
unless the electric mallet and heavy rolled gold are employed. He uses 
Rowan's Nos. 30 and GO, and considers it superior to all others. He has 
shown cases from time to time, before various societies, which have worn 
for varying periods up to five years. At the First District Society's (New 
York) anniversary meeting, in 1890, he presented a lady patient with four 
bridges in her upper jaw that had been worn over a year; these consisted 
of two separate laterals anchored in gold fillings and the two first bicuspids 
and first molar on either side anchored anteriorly in gold fillings in the canines 
and posteriorly in gold crowns in the second molars. At the same meeting 
he introduced a dentist who had worn for over four years a first bicuspis 
attached to the second bicuspis by the " winging" method. The cases were 
much remarked, especially the former ones, they being perfectly strong and 
cleanly, the gum hugging the cervical portions of the artificial teeth and OPERATIVE DENTISTRY. 
513 
festooning between them as perfectly as around and between natural teeth, the 
bridges, to all appearances, growing out of the gum. 
Wherever any old-fashioned gold bridge can be properly or improperly 
inserted a porcelain bridge may take its place; and although successfully used 
by Dr. Brown in all varieties of cases, up to full dentures on four roots, it 
seems especially applicable in cases where one, two, or three teeth are missing, 
and where it would be culpable to sacrifice sound teeth for the insertion of 
any kind of a bridge. 
Seamless Collars.-These are made of No. 30 gold (American gauge). 
They are collars, or bands, of sizes corresponding to the general circumference 
of necks of teeth about which they are to be fitted. In width they measure, 
as prepared and sold at the depots, from one-tenth to three-tenths of an inch. 
Fig. 431.-Mandrels of Various Sizes. Caps, applied and exposed. 
Hammer with Peen. Pliers used. 
It is to be appreciated that they stand as ready-made appliances applicable to 
all kinds of crown- and bridge-work, and particularly to that form of the latter 
which has been described as detachable. These collars, as they are procured 
in sets from the manufacturers, are of telescopic signification ; that is to 
say, they fit into or upon each other, so that a root, proposed to be banded, 514 
A SYSTEM OF ORAL SURGERY. 
being smaller than what is necessary to the circumference of the crown, a suc- 
ceeding size of band is telescoped over it. 
Reducing-Plates and other Instruments.-Accompanying these 
collars are a reducing-plate, or contractor, a hammer, with steel face and horn 
peen, a pair of collar pliers, and mandrels. The use of a contractor, which 
consists of gauge-holes corresponding in shape to the mandrels, insures re- 
duction in size of a collar at the edges without buckling. The pliers are of a 
construction adapted to the work, one beak being concave, the other convex, 
and the hammer is of like signification. The idea and meaning of these 
seamless crowns or bands, standing always ready for immediate use as they do, 
lies with recognition of the comparative conformation of the necks of teeth of 
different classes; hence it proved no difficult task to prepare the few required 
corresponding mandrels which enable an operator to spread or to contract bands 
so that they shall fit any teeth. 
To secure Measure and Shape of Root.-To secure measure 
and shape of a root-neck a wire, No. 26 American gauge, is fitted accurately 
Fig. 432.-Wired Root. 
Fig. 434.-Mandrel 
Fig. 433.-Lead Plate 
about it, as the part stands prepared to receive the collar. Fig. 432. This ring 
of wire is laid upon a lead plate and a piece of flat metal being placed over it, 
is driven into its soft anvil, Fig. 433. The wire being removed from the lead 
leaves an exact impression of the part to be fitted, provided the manipulations 
have been carefully accomplished. The collar is now contoured to fit the im- 
pression,-a performance easy of accomplishment by means of a selected man- 
drel, which, as understood, is of a shape correspondent with the ring-mark to 
be fitted; this mark, in its turn, being correspondent with the tooth-neck. 
Exceptional cases presenting, the shape made by the mandrel is to be 
modified, as required, by use of a pair of flat-nose pliers. A little examina- 
tion will exhibit the matter as of marked simplicity. Fig. 434 shows a 
mandrel upon which a band is manipulated and stretched. OPERATIVE DENTISTRY. 
515 
Evans's System of Seamless Gold Contour Crowns.-This 
system expresses a " practical tabulation" of gold crowns, and affords what 
seems to the writer an understanding of the subject that can only be accepted, 
considering what has preceded, as fairly exhaustive of the matter and wholly 
satisfactory. 
In presenting his system before the New York Odontological Society, Dr. 
Evans,* the deviser, criticises the method of constructing all-gold crowns as 
these are commonly employed as being difficult and laborious, and, as a rule, 
showing results anything but artistic. He objects, also, to the time employed 
and expense incurred in the construction of them. He feels that his own 
system overcomes these faults. These crowns, Dr. Evans suggests, present a 
surface of metal which is uniform in grade and color and which will not tar- 
nish, each crown being made quite thin, of one piece of fine gold, and con- 
sequently entirely seamless. An advantage, as suggested by the inventor, 
is that they admit of any necessary alteration of shape to suit special require- 
ments of a case in hand. Easy and quick adjustment, also that but ordinary 
skill is required for the work, are other virtues claimed. 
These crowns are made for the bicuspidati and molars only. There are sixty- 
four sizes, gauged by the dimensions of occluding surfaces. Most of these 
sizes are made with three forms of cervix,-small, medium, and large,-and a 
few having only the small and medium cervices. The total number of forms in 
the system is one hundred and eighty-three, so that, according to Dr. Evans, 
the most suitable crown for a given form is to be selected at once without 
difficulty. The forms are as follows : 
Superior bisuspids with occluding surfaces corresponding in shape to the 
form shown in Fig. 435, nine sizes; each of which is made with three forms 
of the cervix or collar section, small, medium, and large (Fig. 436). 
Fig. 435. 
Fig. 436. 
Fig. 437. 
Fig. 438. 
Superior bicuspids with occluding surfaces like Fig. 437, five sizes; each 
with two forms of cervix, small and medium (Fig. 438). 
Inferior first bicuspids with occluding surfaces like Fig. 439, seven sizes; 
each with three forms of cervix (Fig. 440). 
Inferior second bicuspids with occluding surfaces like Fig. 441, seven sizes ; 
each with three forms of cervix (Fig. 442). 
* Dr. George Evans. His description is here given. 516 
A SYSTEM OF ORAL SURGERY. 
Superior molars, right side, with occluding surfaces like Fig. 443, five sizes; 
each with three forms of cervix (Fig. 444). 
Superior molars, left side, with corresponding occluding surfaces; same sizes 
and cervix forms. 
Fig. 439. 
Fig. 440. 
Fig. 441. 
Fig. 442. 
Fig. 443. 
Fig. 444. 
Fig. 445. 
Fig. 446. 
Fig. 447. 
Fig. 448. 
Superior second molars, right side, with occluding surfaces like Fig. 445, 
seven sizes. The five largest sizes are made with three forms of cervix (Fig. 
446) ; the two small sizes with two. 
Superior second molars, left side, corresponding in sizes of occluding surface 
and cervix form. 
Inferior molars, right side, with occluding surfaces like Fig. 447, six sizes; 
each with three cervix forms (Fig. 448). ' 
Inferior molars, left side, to correspond. OPERATIVE DENTISTRY. 
517 
Dr. Evans directs attention to the fact and advantage that in the bicus- 
pids the same form serves for either side, while for the molars complementary 
forms are required. These generic styles practically include many more, as they 
are readily altered to suit special cases. In many instances, inferior second bi- 
cuspid crowns can be used for first bicuspids, superior second molars for first 
molars ; the smaller sizes of both upper and lower molars answer very well 
for third molars. 
Method of inserting Seamless Gold Contour Crowns.-For 
the purpose of illustration, Dr. Evans takes a superior first molar, with nearly 
all of the natural crown in position. 
Preparation of the Natural Crown or Root.-The hygienic re- 
quirements having been attended to, an immediately succeeding step is the 
proper shaping of the tooth or root. Smooth, level, parallel sides 
facilitate the adjustment of the gold crown, the collar section of which must 
be accurately adapted. To this end the root and so much of the natural 
crown as remains are trimmed with files, corundum disks, and wheels until 
the planes are as nearly as possible longitudinally parallel. At the approximal 
sides sufficient of the tooth-substance is to be cut away to allow a free space 
between the artificial crown and the adjoining teeth at the cervical portion for 
the gum septa. If less than one-half the length of the natural crown remains, 
it is to be built up, or a post inserted to afford a secure support for the 
artificial crown. Posts of iridio-platinum or silver wire, with their points 
fitted and cemented in the root-canals, will serve to support the crown or 
furnish a hold for the amalgam (Figs. 449 and 450). 
Fig. 449. 
Fig. 450. 
Fig. 451. 
Fig. 452. 
Restoring by Amalgam.-When the natural tooth is decayed beyond 
the gum margin, it should be restored with amalgam (Fig. 451) so as to per- 
mit the part to be properly shaped as before described. It is understood that 
when amalgam is used for such purposes it is to be allowed to set before the 
adjustment of the crown is proceeded with. 
In the typical case taken for illustration, the natural crown when prepared 
for the reception of its gold adjunct appears as shown in Fig. 452, A. The next 
step is the selection of the proper crown for the case. 
How to select a Suitable Crown.-The dimensions of the crown 
required, from the anterior to the posterior sides of the occluding surface, are 
first obtained by measurement with a piece of card-board or thin copper plate, 518 
A SYSTEM OF ORAL SURGERY. 
cut as shown at A, Fig. 452. The measurements can be taken direct from 
the mouth or from a plaster cast made from an accurate impression of the 
entire arch. With these measurements as a guide, the proper-sized occluding 
surface is readily found by comparison with the dimensions of the various 
crowns as shown on the chart (C, Fig. 453). The size of cervix required 
can be determined by measuring from the labial to the palatal, and from the 
mesial to the distal sides of the root, as shown at A and B, Fig. 454, and 
then again comparing with the sizes given in the chart, as seen at A and B, 
Fig. 453. The same plan is applied in taking measurements of the bicuspids. 
(See A and B, Fig. 455.) 
Measuring Cervix of Root to be crowned.-Another way of 
determining the size of cervix required is by measuring the cervix of the root 
to be crowned with a piece of fine wire, and then applying it to the forms of 
Fig. 453. 
Fig. 454. 
Fig. 455. 
the crowns or to their representations on the chart. Experts in crown-work 
can usually determine this point by the eye alone. In making the selection it 
is to be borne in mind that the cervix of the gold crown is, prefer- 
ably, to be smaller than the root it is to encircle rather than larger, as it 
can always be easily expanded, while to contract it is difficult. It is not 
essential that the curve of the collar shall correspond with that of the 
tooth. The gold will readily take the proper shape as the crown is adjusted. 
Fitting the Crown.-The crown having been selected, it is slipped 
over the end of the prepared tooth and gently pressed or worked toward the 
gum-margin. The collar portion assumes the shape of the root during this 
operation. When the edge of the collar meets the gum-margin (A, Fig. 456), 
a line, B, parallel to the gum-line is marked on the gold with a sharp-pointed 
instrument. The crown is then removed and the edge trimmed parallel to 
this mark (A, Fig. 457) with small curved scissors, taking off a little at a 
time and trying the crown as the work proceeds, until the edge of the gold OPERATIVE DENTISTRY. 
519 
meets the gum evenly at all points. The edge of the gold is then bevelled and 
polished, and the crown readjusted and pressed up under the margin of the 
gum, when, if the occlusion be correct, a burnisher is passed around the cer- 
vical portion and the collar planed accurately to the root. 
Enlarging Collar.-If the collar of the crown need enlargement, it is 
easily and most properly accomplished with expanding forceps (Fig. 458), the 
points of which should be introduced at first just within the edge and the 
gold spread sufficiently to allow it to fit over the end of the natural crown or 
root, the process of expansion being gradually continued as the crown is 
brought into position. By proceeding in this manner too great expansion is 
avoided. If the entire crown require enlargement, it 
is best done by softening a mass of gutta-percha, of 
about the same size as the crown, upon the closed 
ends of a pair of expanding or clamp forceps, which 
are heated for the purpose. The forceps points, 
armed with the gutta-percha, are then introduced 
inside the collar of the crown, which should be mois- 
Fig. 458. 
Fig. 459. 
Fig. 460. 
tened to prevent adhesion. The gutta-percha is next withdrawn, hardened in 
cold water, and cut through the centre between the points of the forceps. 
This makes practically an expanding sectional mandrel, with which the neck 
of the crown can be enlarged in the direction (Fig. 459) in which the points 
of the forceps were first inserted. 
Shaping Collar or Side of Crown.-The shape of a portion of the 
collar or side of a crown can be altered by slipping it over the point of an 
anvil, or the end of a pair of expanding forceps, or of a small round-handled 
instrument held in a vise, and then tapping the part to be altered with the 
flat end of a riveting hammer. The crown is to be frequently annealed 
during any of these operations. 
Examining the Occlusion.-Before the crown is pressed up to its 
apparently proper position, the occlusion is to be examined and calculations 
carefully made to obviate any defects of articulation, which can be readily cor- 
rected at this stage by proper manipulation of the crown. Any necessary 520 
A SYSTEM OF ORAL SURGERY. 
change in the form of the occluding surface can usually be made, with the 
crown in position on the tooth, by means of an instrument tapped by the 
mallet; or by removing the crown and burnishing the part; or by holding the 
crown between the thumb and forefinger, with the edge of the collar resting 
on the side of the next finger, which, when necessary, can be protected with 
a napkin, and tapping the gold with the point of the riveting hammer (Fig. 
460). The sides can be depressed by changing the position of the crown and 
using the flat face of the hammer. 
Strengthening the Crown.-These crowns are purposely made thin 
to facilitate their adjustment and necessary alterations in shape; but any 
desired strength or stiffness is to be imparted to them without liability of melt- 
ing the gold forming the sides,-a difficulty which has been urged against their 
use. The strengthening material is always to 'be placed upon the inside. 
Where the cusps or occluding surface requires filling in or thickening, it is 
safely and easily accomplished by the proper use of prepared gold solder 
filings. These prepared filings are made from a thick piece of solder grasped in 
a vise, by use of a clean flat-plate file. The filings are allowed to fall into a box 
or upon a sheet of paper, and a magnet is passed through them to remove any 
minute particles of steel detached from the file. To five parts of the filings 
is added one part of Parr's prepared flux or of finely-vitrified borax. Solder 
prepared in this way is not only useful for strengthening crowns, but in fine 
soldering work of all descriptions it is much to be preferred to solder cut in 
small pieces, as the fine particles separately take up the heat and fuse more 
easily. The flow of the solder is also under better control. 
Packing the Prepared Filings.-The prepared filings are carried in 
a dry state with a spoon-shaped excavator, and packed in position in the cusps 
or placed on any desired spot. The crown is then held in the flame of an 
alcohol lamp and slowly heated to a cherry red, this being sufficient to fuse 
the filings, which will attach exactly where they have been placed. During 
the process the crown is to be grasped on one side, at the extreme edge of 
the collar, between the points of small tweezers, and held in such position as 
to present a full view of the inside. The melting of the solder is thus instantly 
noted, when the crown is to be quickly removed from the frame. If it is 
desired to strengthen the sides of the crown also, the surface of the interior 
is first dampened with a piece of cotton moistened with water, and a quantity 
of solder filings are placed in the cavity and shaken around against the sides. 
A portion of these will adhere evenly all over the damp surface. The sur- 
plus is then dropped out. The quantity required in the cusps being placed 
in position, and heat applied as described, the solder will fuse evenly over the 
surface of the gold without melting the sides or materially changing the 
general form of the interior of the crown. 
Trimming away Excess of Solder.-If it be found that too much 
solder has been applied at any part, it can be trimmed and smoothed with a 
small corundum point. Flux or oxidation may be quickly removed by heating OPERATIVE DENTISTRY. 
521 
the crown to a dull red and immersing it in acid. These crowns can be filled 
in an easy and inexpensive manner by packing the lower section with amalgam 
from which the mercury has been well pressed. In a crown so filled, where 
there are no antagonizing teeth, the result is the same as though the inside 
of the occluding surface was filled with gold; but if antagonizing teeth are 
present, the surface will in the course of time probably wear through in places 
and expose the amalgam. 
Suggestion of Insecurity.-If the tooth be short and the occlusion 
of a character requiring the reduction of the collar to such degree as to 
suggest insecurity when the crown is cemented, a headed or barbed pin which 
will anchor in the natural crown or root is to be soldered in the centre of 
the gold crown, as shown in Fig. 461. This is done by passing the pin 
through a hole drilled in the occluding surface of the gold crown, which is 
then adjusted in the mouth, removed, invested, and the pin soldered from the 
Fig. 461. 
Fig. 462. 
outside. If the pin is tapered and fitted tightly to the hole, the soldering can 
be accomplished without investing by holding crown and pin, with the solder 
in position, in a blue flame. 
The polishing of the crown is best done with pumice and moose-hide points 
on the engine, and with whiting and brush-wheels on the lathe. 
Cementation.-The seamless gold contour crowns are to be inserted 
only with oxyphosphate cement. A vent-hole is to be put in the deepest 
fissure of the occluding surface of the crown for the escape of air and surplus 
cement. As the collars of the crowns can be very closely adapted, the vent- 
hole had better be made early in the operation of adjustment, to facilitate the 
removal of the crown by the admission of air. 
During or just after the setting of the cement the collar is to be bur- 
nished close to the sides of the root by passing a burnisher around under the 
gum margin. 
Fig. 462 represents the typical crown cemented in position. 
Addendum.-This chapter, extended as it is to much length by reason 
of the importance of the subjects considered, is yet not to be concluded with- 
out reference to surgical associations which are found often enough to stand 
in contrast with and opposition to the mechanism discussed. A matter to 
be borne in mind by an operator is that he works on living and not on 
dead parts, and that these parts are of so different a relation and susceptibility 
to what he does, that whereas in some individuals there is little or perhaps 
no response in way of rebellion, in others consequences even so formidable 522 
A SYSTEM OF ORAL SUROERY. 
as death of a patient may result, to leave without mention the extensive 
disorganizations of bone-tissue that are not by any means infrequent. A 
consideration of temperament and of local or constitutional adverse 
conditions is to antedate always such a class of performances as here find their 
consideration concluded. An objection prominently urged, to the effect that 
a rim of gold extended below the gum surface is a source of offence to the 
parts, is well and fully demonstrated not to hold as the great majority of cases 
are concerned. The author has made close examination in this direction, and 
has become satisfied that, save in exceptional cases, trouble arises, not out of 
the nature of the appliance, but out of fault in construction, fit, or application. 
Whether a bridge is best fixed or removable is to be decided as to special 
cases by the judgment of the operator, and such judgment can have no other 
proper foundation than experience. Malodor, which relates with another ob- 
jection urged against bridge-work, lies not with the nature of the construction, 
but either with fault as to performance by the operator or lack of cleanliness 
on the part of a wearer. CHAPTER XXXI. 
OPERATIVE DENTISTRY. 
IRREGULARITIES OF THE TEETH. 
ORTHODONTIA. 
Teeth irregularly related to the common arch are, under favorable con- 
ditions, capable of having the malposition corrected without ill results. 
Conditions to be appreciated.-Conditions to be appreciated are, 
1st, general and local health; 2d, age of patient; 3d, nature of alveolar 
process. 
Temperament and Dyscrasia.-A patient of extreme nervous tem- 
perament, or one laboring under a dyscrasia, is scarcely a proper subject for 
the endurance of details necessary for the correction of misplaced teeth: the 
latter, by reason of a degenerating inflammatory action almost certain to be 
provoked ; the former, because of nervous excitability aroused, which involves 
a risk to the health at large of greater import than any local good to be 
attained. 
Sex to have Consideration.-The age of fourteen, or thereabouts, is 
a critical period in the life of the female, and addition to the natural irritability 
is not to be made without full measure being taken of the power of endurance. 
The boy has no such special period, and requires alone to have his 
case considered from the stand-point of general health. Attention is not, 
however, to overlook the mental state of a student being overworked at 
school. Another matter in connection with sex refers to the ability of the 
male to conceal a dental defect by means of the moustache,-a means lacking in 
the female ; nor is it to be left from the consideration that regularity and beauty 
of features are of infinitely more importance, by reason of a variety of causes, 
to the latter than to the former. 
Influence of Age.-A patient over twenty-five years of age may, as a 
rule, be deemed to have attained a solidity and fixedness of stature which 
cause the risk of change to overbalance the promise of good. The period 
intervening between twelve and seventeen years of age is found by experience 
to be the time of election for this class of operations. 
Character of Alveolar Process.-An alveolar process of loose struct- 
ure is more capable of affording response to a mechanical impression than is 
one of solid character. In the first, a tooth may be quickly changed in its 
523 524 
A SYSTEM OF ORAL SURGERY. 
position ; in the second, not only is more time required, but great increase in 
the moving force. 
Importance of retaining Deciduous Teeth.-Treatment which 
pertains to regularity and harmony in the second denture commences with the 
first; the rule being that a deciduous tooth is not to be extracted, save by 
compulsion, until a successor is ready to take its place. (See Anomalies of 
Dentition.} 
Change induced in Alveoli.-A tooth is to be changed in its position 
by the application of force drawing in the required- direction. The physio- 
logical changes induced in the alveolar process are, first, absorption of the 
parietes of that aspect of plate pressed upon ; second, the exudation and 
organization of plasma in the part relieved. Change too rapidly effected ex- 
cites inflammation, or otherwise draws the tooth from its cavity; haste in the 
correction of an irregularity is never safe. 
Consideration of Results.-Operation, or application, for the correc- 
tion of a dental irregularity is not to be commenced until not only probabilities, 
but possibilities, have been fully weighed. If end be not fairly seen from 
beginning, it is the part of wisdom to let a case alone. Possibilities consider, 
among other things, the likelihood of a patient to assist or obstruct the prac- 
titioner. 
Causes of Irregularity.-These exist in the two directions of heredity 
and acquired. Certain families manifest dental peculiarities which distin- 
guish them from generation to generation. It is not an unfair hypothesis 
that the intermarriage of persons possessing on the one side small 
arches and on the other large teeth is a possible, not to say a probable, cause. 
Foetal enervation is another cause that has been suggested. Syphilitic 
impression transmitted from parents is a cause. In a local direction pre- 
mature extraction of the milk-teeth and alike undue retention of 
them are to be esteemed as causes. Nasal obstruction as to respiration 
favors the throwing inward of the lateral aspects of the superior maxillary 
arch by reason of attempted assistance on the part of the buccinator muscle. 
Thumb-sucking is a familiar cause. Nipple-sucking continued un- 
duly tends to antagonize the natural convexity of the upper jaw, thus favoring 
direct occlusion of the permanent anterior teeth. 
Complexity in Apparatus signifies Lack of Skill.-In ortho- 
dontia, as in every other department of art, familiarity simplifies practice. To 
move teeth, but few means are really requisite. Complexities in appliances 
commonly signify lack of skill. 
Conditions to consider.-A full consideration of the associations of 
a case is to precede operation upon it. Such consideration embraces, first, 
age. As a rule, it is not found good practice to attempt the moving of an 
undeveloped tooth, the parts being too susceptible and irritable. (See Denti- 
tion.} Second, condition. Not only are dyscrasic and nervous conditions 
adverse to operation, but the more immediate expressions are to be taken into OPERATIVE DENTISTRY. 
525 
account. Teeth, from the shape and direction of their crowns, are sometimes 
to be recognized as possessed of peculiarities of fangs which, in a proposed 
change, must compel the piercing of the alveoli. Again, teeth of bulky 
crown may have stumpy roots of such limited relation to their alveoli that 
very slight traction will drag them from their sockets. A tooth out of the 
arch may be a supernumerary; it may in every respect simulate the true teeth 
and yet not belong to the denture. Here, to avoid error, it is alone neces- 
sary to possess proper familiarity with the characteristics of the common den- 
ture. Mention as well is to be made of retained deciduous teeth which deny 
proper place in the arch to their successors. The writer has often met with 
such retentions in persons of advanced years. 
Recognition of Irregularity.-It is scarcely necessary to say that 
recognition of an irregularity depends on appreciation of the normal denture ; 
nor does it seem important to say what constitutes a natural arrangement of 
the organs, as this, save as to rare exceptional cases, is familiar even to the 
laity at large. The exceptional cases, as known to oral surgery, relate with 
retained deciduous teeth, to the encystment of the eye-teeth, and with super- 
numerary teeth. 
Expression as influenced by the Teeth.-Man being omnivore, it 
is necessary that he present the combined expression of carnivore and herbiv- 
ore. Loss of eye-teeth is interference with the first of these, and absence of 
lateral incisors insures disappearance of the peaceful expression belonging to 
the second. It is of importance, therefore, that these classes of teeth be 
never interfered with, save from extreme necessity. 
V-shaped Arch.-A V-shaped deep arch offers one of the greatest 
difficulties with which oral surgery has to contend in the way of correction of 
dental irregularities. As a rule, mouths of this condition are of such relation 
with absence of vital force that an operator is wise in letting them alone, save 
from compulsion. 
Interference to be deprecated.-The inferior anterior teeth of the 
second set are found in nearly all instances, in the earlier stages of the eruptive 
act, more or less irregular in the manner of their relation; but, if not unduly 
crowded from narrowness of the arch, it is an exception to the rule where they 
do not prove self-correcting. Also is it found the case that in nearly every 
instance where accommodating space exists, irregularly-developing teeth, wher- 
ever situated, will of themselves seek proper position. Early interference 
is therefore, because of such natural tendency to self-correction, to 
be deprecated, except where it is evident that mechanical impediments render 
such self-correction impossible. A single example may illustrate. Suppose 
a case where the superior central incisors develop with their cutting faces so 
inclining inward that in occlusion of the jaws the inferior teeth close over 
the labial surfaces: here it must be seen that time, instead of serving to 
diminish the deformity, will only increase it. In such a condition, correction 
as immediate as possible is desirable; judgment must direct the means and 526 
A SYSTEM OF ORAL SUROERY. 
the manner; the superior teeth should certainly be placed outside of the 
inferior. If this be done without provoking inflammatory resistance, however 
accomplished, the means employed have necessarily been judicious. (See 
illustrative cases.) Instances, again, are met where certain teeth have com- 
pletely changed position: a lateral incisor appearing in the situation of the 
central, the central occupying the place of the lateral. Ilere there is no cor- 
rection possible, except it be found in transplantation, in the pivoting process, 
or in extraction of the teeth and their rearrangement upon a plate. 
Teeth held in False Position.-Teeth irregular to the arch, being 
held in the false position only by pressure from articulating teeth, find 
easy correction; forced into proper place, the same teeth which continued the 
deformity will prove the instruments of permanency to the new relation. 
Character of Correcting Apparatus.-Apparatus used for correcting 
irregularities are to be as delicate as regard to a necessary strength will allow : 
they are to permit of ready change of form or relation to suit the constantly 
varying requirements of cases; the construction and application are to be as 
simple as practicable, that thus, as much as possible, the assistance of the 
patient be engaged; they are to be easy of removal and replacement, that 
thus a necessary cleanliness be maintained. 
Relation of Means to Necks of Teeth.-In the relation of plates 
to the necks of teeth, care is to be exercised that unduly sharp edges shall not 
cut the enamel; while in the employment of rubber rings, now in common 
use, attention is demanded to the avoidance of injury to the gums so apt to 
ensue from the sliding of the ring,-a result easily avoided by placing between 
the gum and ring a thread of waxed silk tightly tied around the tooth. 
Support of Changed Teeth.-Teeth changed in position, through 
mechanical means, are to have support in the new location until the required 
alteration is effected in their alveoli. This support is commonly seen to be 
given by nature: as, for example, where a tooth being inside of the arch 
and so retained by overlying teeth, being forced outside, is equally compelled 
to retain the new place by the pressure of the same teeth. In all cases, how- 
ever, where circumstances deny natural support, advantage is to be taken of 
mechanical appliances; such appliances being found in ligatures, metal bands, 
or plates. 
With appreciation, now assumed as obtained by the student, of the sim- 
plicity of the principles underlying the practice of orthodontia, illustrative 
cases in practice are here to be offered as studies, while, as well, they are to 
prove helpful hints to the practitioner. 
Illustrative Cases.-Fig. 463 exhibits a cast taken from the living 
mouth, in which, as is seen, the bicuspidati and lateral incisors approximate. 
Age of patient, fifteen years. 
Studying this case, it becomes recognized that a required space is absent,- 
namely, that for the accommodation of the cuspis of either side. At eight OPERATIVE DENTISTRY. 
527 
years of age the incisor found its place ; at nine years, the bicuspis. Most 
important was it that the space occupied by the deciduous cuspis should be 
preserved by the retention of that tooth until the eleventh year, the period 
of eruption for the permanent. Not preserved, the room naturally became 
occupied by adjacent teeth ; hence irregularity was inevitable; unless, indeed, 
Fig. 463. 
it should have happened that the second cuspis remained unerupted,-a 
matter which must always necessarily occasion more concern than even a 
deformity. This irregularity is the one most frequently met with ; a student 
will wisely study it closely before advancing, seeing that it stands for the point 
of departure. 
Considerations to relate with Treatment of the Case illus- 
trated.-If an arch so presenting exhibit the proper articulation, practice 
lies between the removal of the projecting cuspidati and that of the immedi- 
ately adjoining bicuspidati. (See succeeding paragraphs.) 
Regard for Facial Expression.-As facial expression is concerned, 
it is to be remembered that much of character resides in the eye-teeth. Many 
mouths from which these teeth have been removed show a flat, expressionless 
appearance most undesirable. Again, it is found that these teeth serve as 
key-stones to the arch; hence it frequently follows that secondary 
irregularity associates with their removal. 
Where a mouth with overriding eye-teeth possesses proper articulation, 
-that is, where the superior incisors fully override the inferior; where the 
bicuspidati resemble in their labial outlines the cuspidati, and their approxi- 
mation with the lateral incisors is complete and regular; where the cuspidati 
are situated well forward, and not over the bicuspidati, or even over the inter- 
spaces ; where the patient is advanced in years, the process having become 
fixed in its relations,-it is, in a case of this kind, the proper practice to 
extract the eye-teeth. On the contrary, where the patient is young, 
where the articulation is harmonious, where the projecting teeth are situated 
over the interspace, or, still better, posterior to it; where the bicuspidati do 
not simulate in appearance the cuspidati; the practice proper to pursue con- 
sists in removing the underlying premolars. 
Development of Teeth forward.-Experience exhibits that the 
developing tendency of the teeth is always in a forward direction; the ex- 528 
A SYSTEM OF ORAL SURGERY. 
traction of a first molar, therefore,-a plan often recommended for the correc- 
tion of this irregularity,-does not favor to any extent the accommodation of 
the cuspis; the second bicuspis will not fall back into the space made. On 
the contrary, a second irregularity is favored in the immediately manifested 
inclination of the second molar forward, thus breaking the harmony of the 
posterior articulation. The preservation of the first molar teeth is of great 
importance to the process of dentition. It is a misfortune where they have 
been neglected. 
Where overriding is Slight.-A third condition of this special de- 
formity is met with where it is evident that the slightest curtailment of the 
superior arch would destroy the harmony in articulation,-that is, the over- 
riding is so slight that the extraction of two teeth would likely result in the 
opposing organs closing directly upon each other, or perhaps, indeed, in the 
inferior teeth closing outside. Two lines of practice here offer: the 
bicuspidati may be removed, as before directed, and by the employment of an 
occipito-mental elastic sling, exhibited and described on a succeeding page, 
the inferior arch may be retracted; or the superior arch may be enlarged 
through the aid of instrumental assistance to an extent that shall afford the 
required space; or, still again, equality may be maintained by the extraction 
of corresponding bicuspidati from the lower jaw. 
Appliances used in the Correction of Irregularities.-Of ap- 
pliances used in the correction of irregularities, every variety is to be met 
with. The operator will always, however, find himself best served in employ- 
ing the most simple means capable of meeting indications. 
White's Apparatus.-Fig. 464 represents an apparatus devised by Dr. 
J. D. White, the office of its mechanism being the enlargement of the whole 
superior arch and the consequent accommodation of any outlying tooth or 
teeth. Taking an impres- 
sion of the jaw, a plate, in 
shape as shown, A, is made; 
this plate, separated into 
two parts, has its association 
preserved by a spiral spring, 
C, so arranged as to lie di- 
rectly back of the teeth, 
being thus as much out of 
the way as possible. B, B 
represent crib bands for 
attachment to the first or 
second molar teeth, as may 
seem advisable. D, a hinge, joins the parts in front,-a device, however, 
which, for the purpose now considered, is to be replaced with advantage by 
any arrangement admitting of lateral separation on the line of division. It 
Fig. 464. OPERATIVE DENTISTRY. 
529 
is to be recognized that in the tendency of the spring to straighten itself the 
plate is separated, outward pressure being thus exerted against each tooth. 
Westcott's Appliance.-A second appliance, having similar import, 
shown in Fig. 465, is a device by Dr. A. Westcott. This apparatus possesses 
in its construction the ability to move outwardly any tooth or teeth requiring 
change of position. The instrument may be thus described: First, a double 
clasp (A, A), these clasps connected by a straight bar made of tubular wire. 
This tube has a screw cut in its inside the 
whole length, and is soldered to one pair of 
the double clasps; the other pair of clasps 
are soldered to a wire which screws into 
the tube, the object being to lengthen or 
shorten the bar at pleasure. Next a flat 
piece (C, C) of sufficient width for hinge- 
joints is soldered to the bar. To these are 
connected by hinge-joints (F, F, F, F) a 
series of tubes (D, D, D, D), each having a screw cut on the inside, these 
receiving and accommodating an equal number of spurs (E, E, E, E). 
These spurs, as is recognized, screw back and forth as may be desired, and 
are therefore capable of pushing (in time) any tooth from its socket. 
Such an apparatus prepared, the clasps are slipped about the teeth for 
which they have been adapted, and, slight depressions being reamed upon 
the posterior faces of such teeth as it is designed to move, the spurs are 
screwed forward, the point of each thrusting upon the depression prepared 
for it. 
Examining the construction of this piece of mechanism, its peculiar adapt- 
ability to the end designed must certainly strike any one. A single weak 
point is the reamings used as supports to the spurs,-an objection which 
may, however, in many instances, be obviated by directing them between a 
double ligature of gilling or bookbinder's twine. 
The moving of the teeth accomplished, the apparatus is at once to be 
removed, the parts being maintained in their new position by fitting a plate 
covering the whole roof of the mouth, so constructed as to act like a wedge 
in its relation to the common arch. Fig. 478 exhibits such a retaining 
plate. 
Still another means of enlarging an arch so as to afford room for outlying 
cuspidati consists in adapting to the lower denture an accurately-fitting en- 
velope of metal, from the articulating face of which pass upward and inward 
springy flat spurs, against which, in the act of occlusion, the superior teeth 
close, thus being directed outward, and to such extent spreading the parts. 
A spur is not, of course, to strike either of the eye-teeth. 
Coffin's System.-Coffin's system differs nothing in principle from that 
employed by Dr. White; its distinguishing feature depending on the principle 
of permitting a relative motion, or maintaining a particular controllable re- 
Fig. 465. 530 
A SYSTEM OF ORAL SURGERY. 
action, between two semi-independent parts, usually its symmetrical halves. 
The system is highly regarded and widely used. 
The general form of Mr. Coffin's apparatus, as described by him- 
self, consists of a thin vulcanite plate capping or clasping some or all of the 
bicuspidati and molars, and fitting the lingual surfaces of anterior teeth, but 
divided along the median line (as shown in Fig. 464) into two distinct halves, 
connected, however, by a slight steel wire, so disposed that, while guiding and 
limiting their relative motion, its tension exerted between them may be per- 
fectly determined and varied in direction and magnitude. Perfection of the 
model is insisted on, as an entire plate may fit well and securely, and yet both 
halves be so loose when divided as to be useless ; while, on the other hand, the 
halves of a split plate may be easily fitted, which, before division, could 
not possibly be inserted. 
Dispartment.-As a means of dispartment, Mr. Coffin recommends piano- 
forte wire of a diameter varying between three- and four-hundredths of an 
inch. The extremities of this wire being buried in the lateral plates and 
bowed like the spring C in Fig. 464, the character and nature of the ten- 
sion becomes self-demonstrable. A modification of the bow suggested as 
an upper general expander is a three- or five-curve serpentine figure, like a 
rounded capital W. 
Use of Steel Wire.-The experience gained of steel wire, says Mr. 
Coffin, referring to his own practice, has led to its almost exclusive adop- 
tion for ordinary regulating purposes, as spring levers acting directly on the 
teeth, for pulling, pushing, or rotating; and, being permanently fixed to the 
plate, their convenience, adjustability, and many adaptations are remarkable. 
Combined with a split plate, they are found to replace, with advantage, screws, 
inclined planes, wedges, levers, and ligatures, in their many local uses, and, 
moreover, are practicable where nothing else can be applied. 
As a Separator.-The means just described is recommended equally as 
a widener of the inferior arch, and on trial is found to work satisfactorily. It 
is also recommended by its deviser as a means of securing room for the treat- 
ment of approximal cavities, it being maintained that less discomfort relates 
with such manner of dispartment than associates with simple wedges of wood 
or rubber even, as in the latter way the separation of two teeth is implied. 
A Second Study.-Passing here to another study, a case may be pre- 
sented where, with room in the arch, the lateral incisors maintain a posterior 
position. Fig. 466 exhibits such a condition. 
McQuillen's Bar.-This is an irregularity capable of quick correction, 
as exemplified in the use of the bar (Fig. 467). This bar, being adapted to 
the labial face of the teeth, is held in position by silk ligatures bound tightly 
to the misplaced teeth. A great improvement on the silk, however, as has 
been shown by Dr. J. H. McQuillen, consists in the substitution of india- 
rubber rings, applied, as will be understood by referring to the diagram, OPERATIVE DENTISTRY. 
531 
by being slipped into the holes through file cuts made upon the face of the 
bar. 
Rubber Rings and Ligatures. Flagg's Method.-Another study 
is presented in Fig. 468. Here, it is seen, a central incisor is out of the arch. 
Fig. 466. 
Fig. 467. 
To correct this deformity a very common and very satisfactory practice is that 
exhibited. This consists in an india-rubber ring thrown about the projecting 
tooth, being stretched back until it reaches a bicuspis, around which it is 
placed. In thus employing the elastic ring, it will not infrequently be found 
that undue strain is exerted upon the base tooth, making it quickly very sore. 
Fig. 468. 
In these cases the ring is to be changed to other teeth, or assistance may be 
rendered by relieving the first tooth of an excess in strain by dividing the 
work by means of a ligature carried to some back tooth. 
Extraction of Crowding Teeth.-Fig. 469 exhibits another de- 
formity. Here, as is seen, irregularity exists in both arches. The treatment 
consists in removing all the second bicuspidati, above and below, and throwing 
india-rubber tubing ligatures around the six-year molar and the left inferior 
first bicuspis and cuspis, drawing the. two latter backward into the arch, at the 532 
A SYSTEM OF ORAL SVRGERY. 
same time passing a silk ligature around the lower incisors (Fig. 470) in such 
manner as to force into position an overlapping central. In the upper jaw a 
plate (not a necessity) may be adapted to the palate, secured by silk ligatures 
Fig. 469, 
to the first permanent molars. Pins are to be placed in the plate in such 
manner as to allow of the attachment of two elastic bands, which are secured 
by silk threads to the central incisors (Fig. 471), drawing thus upon the mesial 
face. Other bands are so arranged as to draw upon each lateral angle of the 
centrals, passing between these and the laterals from their palatine faces, and 
running along the labial and buccal faces to the first molar of either side. 
Tubing is now to be thrown around the remaining superior bicuspis of 
either side and the molar, for the purpose of approximating these teeth, thus 
Fig. 470. 
Fig. 471. 
affording space for the proper placing of the irregular centrals. By this 
arrangement nine ligatures will be exercising traction at the same time, gradu- 
ally and beautifully performing their work of correction. With the view of 
preventing periodonteal irritation from becoming periodontitis, both local and 
constitutional treatment may be required. OPERATIVE DENTISTRY. 
533 
Bar and Band Operation.-A simple manner of turning incisors, re- 
lated as shown in Fig. 471, is to lay across the labial faces a simple bar, which 
is attached by means of elastic to a second, which, when in place, will pass 
across the mouth from bicuspis to bicuspis. 
Fig. 472. 
Undue Projection of Lower Anterior Teeth.-Another study, to 
which attention is to be directed as being a quite common condition, resides in 
that articulation in which the anterior teeth of the superior jaw, in place of 
overriding the inferior, close directly upon them. This manner of bite, when 
found in elderly persons, is not to be remedied by any change in the position 
of the teeth, but by the adoption of some mechanical device which shall 
relieve the organs of the abrading influence to which they are subjected, and 
which, unrelieved, will wear them to the gums. Fig. 472 shows normality. 
Antagonizing Direct Occlusion.-To treat such a malarticulation 
three modes have been employed: one consisting of a metal cap enclosing 
the molar teeth, this keeping the anterior organs 
apart and taking the strain of mastication; sec- 
ond, a cap to be worn over the front teeth while 
eating (Fig. 473); and, third, the cutting of 
cavities in the antagonizing faces of the abrading 
teeth and building thereon faces of gold. 
Consideration of Underhung Jaw.- 
Fig. 474 exhibits the malarticulation known as 
" underhung,"-the teeth of the lower arch closing beyond the upper. To 
correct this deformity, different operators employ different means. A first 
consideration is as to the nature and cause of the condition. 
Protrusion of the inferior teeth may exist in a variety of reasons. The jaw 
itself may be elongated, the angle being too obtuse for the age. The body of 
the lower jaw may be out of proportion to the upper. The teeth themselves 
may unduly spread or evert. The fault may be in the superior denture. 
Fig. 473.-Cap for Front 
Teeth. 534 
A SYSTEM OF ORAL SURGERY. 
Anatomico-Physiological Consideration.-An anatomico-physio- 
logical examination of the inferior maxilla exhibits a body and ramus whose 
Fig. 474. 
angle of relation varies with the age of the patient, or some other influencing 
circumstance. At a very obtuse angle in young life, it passes to the 
right angle in adult life, to fall again into obtuseness on the approach of old 
age and the loss of the teeth. The three 
illustrations (Fig. 475) represent these 
varying conditions,-the first, the infant 
bone, being very obtuse; the second, the 
adult, being at a right-angled relation; the 
third, the bones of an edentulous old per- 
son, having the ramus almost on a plane 
with the body. 
Occipito - Mental Sling. - In a 
young patient having a protruded under 
jaw, the size of the upper and the posi- 
tion of the teeth being normal, advantage 
is to be taken of the natural tendency of 
the parts to retire ; a sling,-the occipito- 
mental,-the straps being of elastic mate- 
rial, is to be used, as represented in Fig. 
476. A sling of this kind, properly made 
and applied, will be found to exert such 
constant pressure on the angle, forcing, as 
it does, the body backward, that not infrequently a very few months will 
suffice to correct such a malarticulation, and this without discomfort or the 
possibility of ill consequences. 
Fig. 475. OPERATIVE DENTISTRY. 
535 
Fault being with Upper Jaw.-Where fault resides in the superior 
arch, the jaw itself being small, or the teeth being possessed of inlooking 
cutting faces, the appliance represented in Fig. 471 may be used, or the en- 
velope, with the flat spurs, may be employed, as directed for use upon the 
lower denture (Catalan's inclined plane). 
Fig. 476.-Occipito-Mental Sling. 
Kingsley's Method.-A mode of treating a case of malarticulation 
such as is exhibited in Fig. 474 is as follows: Pull back lower jaw by means 
of occipito-mental sling (Fig. 476). Wedge upper arch as shown in Fig. 
479. To retain advantage gained by wedges, apply plate as shown in Fig. 
478. 
Fig. 477 shows a result obtained, after this manner of operating, in twenty 
days by Dr. N. W. Kingsley. 
Extraction in Treatment of Protruding Lower Jaw.-A very 
simple, and not infrequently effectual, mode of correcting the deformity of 536 
A SYSTEM OF ORAL SURGERY. 
protruding lower teeth in young patients, applicable particularly where the 
organs close directly against the upper, consists in removing from the inferior 
Fig. 477. 
arch the first bicuspidatus of either side, and advising the cultivation by the 
patient of a habit of pushing the chin backward; or the latter purpose will 
be answered by using the occipito-mental sling during meal-time. 
Redman's Plate.-Among the various appliances which ingenuity has 
suggested for the treatment of dental irregularities is a plate (Fig. 478) devised 
by Dr. Redman, of Cincinnati. This is a 
rubber cap fitting accurately the palatine 
arch and carried across the anterior face of 
the teeth, having thus, as is seen, a most 
secure relation. Where it is desired to 
move a particular tooth, the plate is 
cut away in the direction which it is desired 
the tooth shall take, pressure being brought 
to bear from the opposite point by wedges 
of wood forced through holes in the plate. 
Antagonism Lying with Articu- 
lation.-In correcting irregularities of 
the teeth it is always necessary to bear in mind an antagonism which may 
exist to the moving force as relation is had to articulation. A tooth bound in 
place by one overlying it is to be moved only through relief from the existing 
pressure. To insure such relief it is found necessary, in almost all cases, 
so to cap neighboring teeth as to compel a space between the two arches,- 
such space to be preserved until the tooth is changed to its new position, when 
the removal of the cap and the restoration of the articular bite will, in many 
Fig. 478. OPERATIVE DENTISTRY. 
537 
instances, prove the best means that can be adopted for securing permanency 
to the change. 
Fig. 479. 
Wrench and Screw.-Fig. 480 represents a principle found most use- 
ful in a great variety of cases of dental irregularities. An example of its 
application may be given as follows: 
Illustrative Case.- Two central, incisors turned upon their axes and 
overlapping; arch narrow and crowded.-To turn teeth so situated, a first 
necessity is room. To secure this room the arch must be widened. Exami- 
nation of the instrument exhibits double 
collars for resting against teeth on opposite 
sides of the arch ; these collars are attached 
to screw-cut tubes 1,2, which tubes are as- 
sociated by a common screw, 3. Desiring 
to widen the arch and thus afford facility 
for manipulating the crowded incisors, the collars are placed against the inner 
faces of the teeth designed to be moved, when, by means of a wrench, the 
screw is turned, the arms being extended day by day as circumstances permit. 
The desired space thus secured, a plate is fitted to insure retention of the teeth 
in the new position, when the twisted teeth may be turned into proper position, 
by means shown in Fig. 471. 
Illustrative Case.-Illustrating the u^ of this means in another in- 
stance, reference may be made to lateral incisors, or other teeth fallen within 
the arch and overlaid by their fellows. Here application of the enlarging 
force is directed after the same manner. When the proper room has been 
secured, the misplaced tooth or teeth may with all facility be drawn into place 
by the labial plate and elastic ring as before described,-a manipulation which 
would be impossible without the previous expansion. 
Fig. 480. 538 
A SYSTEM OF ORAL SUROERY. 
Illustrative Case from Kingsley.-Fig. 481, after a cut by Dr. N. 
W. Kingsley, exhibits a case of protruding jaw treated as follows: First, a 
vulcanite plate with jack-screws, across the mouth against the bicuspidati, as 
Fig. 481. 
Fig. 482. 
shown in Fig. 482, the plate being split to allow of expansion under pressure. 
Second, a bar with elastic band acting upon the front anterior face of the arch, 
Fig. 483. The rectification was made in just five weeks. 
Farrar's System.-A system of regulating, claiming attention through 
the efforts of J. N. Farrar, 
M.D., is known as the positive. 
Not entirely new, this system 
yet claims a study that shall 
fully appreciate it from the fact 
that it embraces its subject 
from a philosophical stand-point. 
The student who familiarizes 
himself with the positive sys- 
tem, even though he may not 
be disposed to accept all its 
practice, will find that he is 
master of the situation. 
Physiological versus Pathological Changes.-In regulating 
teeth the positive system accepts the dividing line between the production of 
physiological and pathological changes in the tissues of the jaw to lie within 
a movement of the teeth acted upon, allowing a variation which shall cover 
all cases, not exceeding one-two-hundred-and-fortieth or one-one-hundred-and- 
sixtieth of an inch each twelve hours; the application of the force to be inter- 
mittent, not a continuous motion. 
Motive-Power employed.-For motive-power, movement of the screw 
is accepted as expressive of the positive, the drum and belt as typical of the 
probable. For measurement, the action of a screw is recognized as unerringly 
calculable, the slippings of a belt over a drum as incalculable. Regulating 
Fig. 483. OPERATIVE DENTISTRY. 
539 
apparatus constructed purely on the screw principle are capable of intermittent 
motion. Elastics and springs are necessarily of continuous action. 
Special Instruments used.-Instruments used in the positive system 
by Dr. Farrar are simple when appreciated* They consist really of two pieces, 
-i.e., a band to encircle the tooth or teeth to be moved, and a screw to act 
on this band. Teeth being various in shape and position, the band requires, 
of course, to have other than a single meaning. Fig. 484 shows the band in 
its varieties. 
Fig. 484. 
Exhibit.-No. 1 is the box wrench, with lever. The separate parts A, B, 
and C, of which it is composed, are shown for a better understanding of it. 
Nos. 2 and 3 are the bar and loop wrenches, the bar prolonged at both ends 
being the only difference in them. 
No. 4 is the rotating loop, used to turn teeth in their sockets. 
The lugs, or ears, shown on all these bands and loops, are to be bent into 
fissures of the crowns of teeth to prevent them from slipping too far on the 
necks, and so irritating the gums, or causing misdirection of the screw-power. 
First Consideration.-A first matter in this system considers the 
application of a band to be acted upon, and which in turn is to act upon the 
tooth it encircles. Fig. 485 will supply the idea to a mechanical mind. 
Rotation.-The cut represents rotation. The nut T, when tightened, 
draws the bolt through the bar U, and being attached to the band-clamp V on 
the opposite side of the tooth, causes 
it to rotate, and at the same time fall 
backward if desired. Should, how- 
ever, this latter movement be unde- 
sirable, it may be prevented by a 
little screw, W, passing through a 
threaded hole in the bar U, which, impinging against some point (or not), as 
shown, holds the tooth in position. Should it be necessary, this screw may 
be made an assistant rotator ; but a proper shaping of the bar by bending or 
filing will generally be sufficient for this purpose. 
An Application of the Farrar Method.-Fig 486 shows the appli- 
cation of positive movement to a cuspid tooth out of the arch anteriorly and 
somewhat overriding the lateral. The requirements are, 1, to drag the mis- 
placed organ backward ; 2, to pull it into the line of arch. C, left side of 
cut, and C, right side, exhibit bands or clamps placed about teeth as supports 
Fig. 485. 540 
A SYSTEM OF ORAL SURGERY. 
from which traction is to be exerted; these same bands are also shown sepa- 
rated from the teeth. In front, encircling the eye-tooth C, is a similar band. Q 
shows bolts and nuts ; B is a wrench ; S is direction. The design explains itself. 
Fig. 486. 
Illustrative Applications.-Figs. 487 to 493, after Dr. Farrar, 
exhibit ideal cases of application. In the diagrams, the arrows indicate the 
direction of the movement of the teeth 
operated upon. 
Fig. 487 illustrates a form of 
apparatus which acts upon the teeth 
collectively, also by means of a band 
(rn) extending along the outer surfaces, 
and which is made to force against the 
teeth to be moved by tightening of 
bolts which pass through smooth-bored 
nuts (t, t) soldered to the ends of the 
band (m), and which enter threaded 
nuts soldered to anchor-bands (A, c) 
secured around the back teeth as shown. 
The band m is to be prevented from ^impinging on the front gum by passing 
through the eye of a clamp-band, 0, secured to a front tooth, or, better still, 
by having a T (Fig. 488) soldered to the inside, so that the 
top of the T shall rest on the lingual surfaces of the central 
incisors. 
Fig. 489 illustrates a case of the lower jaw having 
the incisors in the posterior position, and which are being 
forced forward and into position by a compound variety of jack-screw devices. 
This appliance does*its work by pushing against a bar situated immediately 
behind the teeth to be moved. 
Fig. 487. 
Fig. 488. OPERATIVE DENTISTRY. 
541 
■ The jack-screws are secured posteriorly to anchor-clamp bands (c, c) around 
two of the back teeth by a hook or rivet-hinge joint (e), and anteriorly into 
little pits made in the bar (/) by countersinks or cups soldered to it. 
Fig. 489. 
Fig. 490 represents a device made up of the same form of bar (a) 
behind the teeth, to be moved as illustrated in Fig. 491, but which is made 
to force the incisor teeth forward by attachment to little bolts (d, d) which 
pass through a bridge-bar (6), which is tightened by nuts on the front sides. 
Fig. 491 illustrates a device in the form of a drag- or swivel-jack («Z) 
in the act of drawing upon to move a cuspid (/) tooth by forces based at the 
Fig. 490. 
Fig. 491. 
opposite side of the mouth (c, c). The cut so clearly shows its construction 
that it needs no further explanation. 
Fig. 492 represents the application of a spindle jack-screw (c) in posi- 
tion to force outwardly the two upper lateral incisors (a, 6), which have 
erupted in the posterior position. 542 
A SYSTEM OF ORAL SURGERY. 
Fig. 493 exhibits the application of a compound jack-screw (/) made 
of the spindle and fish-tail varieties combined. The spindle-points should 
Fig. 492. 
rest in pits, made in the teeth by a drill, or in cups or pits made in or upon 
a clamp-band secured around the tooth, d and e refer to direction. 
Danger from swallowing Small Pieces.-To avoid the swallow- 
ing of small pieces of regulating apparatus which may get loose, they are to be 
secured to some convenient teeth by threads, as shown in Figs. 492 and 493. 
Fig. 493. 
As to other Methods.-The author has made a careful study of many 
methods with which he is familiar, but concludes that they are not wisely to 
be introduced into this volume for the reason that one and all of them repre- 
sent modifications on plans which are here offered. A student, or practitioner, 
making himself familiar with the principles related with the correction of 
irregular dentures will modify his treatment with any case, and is necessarily 
and wisely to be left, in such respect, to his own discretion and judgment. 
Among the names of gentlemen associated with exhibit of large ingenuity in 
the direction of orthodontia, and who offer ideas of different kinds in that direc- 
tion, are to be mentioned Drs. Guilford, Patrick, W. E. Magill, B. S. Byrnes, 
E. S. Talbot, and E. H. Angle. All these have published their experiences, and OPERATIVE DENTISTRY. 
543 
their writings are to be obtained by addressing the publishers of dental jour- 
nals, or themselves directly, in care of any dental depot. 
Harm over Good.-In conclusion, it is to be added that the health of 
a multitude of mouths has been ruined and patients rendered uncomfortable 
for life by ill-advised attempts in the direction here considered. To do nothing 
unless the way to an end is clearly, fully, and practically perceived, is a rule 
of practice from which the experienced practitioner never departs. (See, for 
surgical expression of this subject, chapters on Anomalies of Dentition and 
their Relations, on Alveolar Abscess, and on the Odontomata.} It is also to 
be added that irregularities are to be corrected by brains rather than by appli- 
ances of metal and rubber, and that a practitioner who fails in finding with 
the illustrations and descriptions here given very much more of apparatus than 
he requires is to look for the fault in himself and not in these pages. CHAPTER XXXII. 
PROSTHETIC DENTISTRY. 
Prosthetic dentistry treats of the replacement of lost natural teeth by 
artificial ones set upon a plate. It is what is generally known as mechanical 
dentistry. 
A full set of artificial teeth is called a denture. A plate having one or 
several teeth attached is commonly called a piece. 
Preparation of Mouth.-The preparation of a mouth for the recep- 
tion of a plate implies that the operator consider in the relations of each case 
the hygienic, mechanical, and artistic considerations therewith necessarily as- 
sociated : one mouth, the lips being long ; the process full; the arch markedly 
concave, and of some depth; the gums solid and resisting; the submucous 
structure neither deficient nor excessive; the teeth all absent, or such as may 
remain having harmonious relation; temperament lymphatic,-such a mouth 
the merest tyro will accommodate. On the contrary, lips short; process 
absorbed to a line; arch flat; gums irregularly flaccid and hard; teeth all 
gone, or, where some remain, inharmonious to a common articular relation; 
temperament nervous,-such a mouth the most skilful will scarcely serve to 
satisfy. 
Teeth standing Alone and Roots of Teeth.-A mouth before 
prepared to receive a denture, full or partial, is to be free from all roots which 
may have association with the parts to be occupied; teeth irregular to the 
arch, and thus the source of deficient symmetry, or such as may interfere with 
a successful fitting of the artificial piece, or such as may be diseased and lack- 
ing in promise,-these are to receive attention and judgment. As a rule, a 
plate is not to rest upon a root, healthy or unhealthy. The retention of an 
isolated tooth in the dental arch (all the others having been lost), however 
healthy and symmetrical, except it be in a position where a plate is not to go 
back of it, will be apt to antagonize the merits of any denture, however per- 
fect its construction. Soft teeth are not to be clasped. A cachectic 
mucous membrane is to be covered alone with a gold plate which has 
been alloyed with platinum, the baser materials being irritative. A turgid 
congested membrane is not capable of affording an impression which 
will allow a denture to be useful. Scorbutus, ptyalism, all unhealthy condi- 
tions are to find correction before an impression is taken. Clasp teeth are 
to be freed from tartar, and (except when the denture is to be temporary) 
alveoli are to be absorbed. 
544 PROSTHETIC DENTISTRY. 
545 
Taking an Impression.-The first step in the construction of an arti- 
ficial denture or piece is the taking of an impression, or measure. This con- 
sists simply in filling a tray (of which every size and variety is supplied at 
the depots) with softened wax, plaster, 
or other impression material, and press- 
ing it over the parts to be modelled.* 
Trays.-Trays are of two general 
forms, the one being designed for the 
superior arch, the other for the in- 
ferior. 
In selecting one for use in any special 
case, regard is to be had to the require- 
ments. First, such a tray is to be em- 
ployed as shall admit of easy passage 
through the labial commissure. If an 
arch be deep in its palatal aspect, the 
one used will require to have marked 
convexity; otherwise a common cup 
may be made to answer equally well for deep or shallow arches by means of a 
false bottom. For application to the lower arch, a deep or narrow rim is 
demanded, as the alveolar process may happen to be prominent or the reverse. 
In many mouths the site of the original process is found to have entirely dis- 
appeared, leaving a perfectly 
flat surface that will require a 
tray without any flange. 
A tray is to be large 
enough to embrace the al- 
veolar arch, leaving a space 
between gum and rim of about 
a quarter of an inch; it is to 
be deep enough to include the 
tubers of the upper jaw, or to 
touch the rami of the lower. 
If teeth long and promi- 
nent stand in either jaw, particularly the anterior in the lower, as is very 
common, it Aay be found more convenient to use a tray so cut as to admit of 
such teeth passing through it (Fig. 496) ; this, however, is not a necessity, 
and not always even a convenience. 
Modified Trays.-Modifications on these common trays are numerous; 
few practitioners, however, recognize sufficient merit in them to feel their 
Fig. 494.-Tray for Superior Jaw. 
Fig. 495.-Tray for Inferior Jaw. 
* A case presenting where irritability is so great as to cause retching and sick stomach is 
commonly to be corrected by means of a gargle made by mixing two drachms of bromide 
of potassium with an ounce of water. Another plan is to prepare the parts by practice of 
irritation, anticipating the impression by at least a week. 546 
A SYSTEM OF ORAL SURGERY. 
consequence, finding rather in skill, the result of practice, that which meets 
the various requirements. An impression, good as requisite, has been taken 
with a piece of shingle whittled for the 
occasion; but the hand that secured 
the cast was experienced. The author 
has never, in his own practice, em- 
ployed other than the character of 
trays here shown, and takes it for 
granted that his trouble in getting 
satisfactory impressions has been about 
of a common experience with others. 
As suggested, however, it is well to 
employ for the palatal arch the tray 
with a false bottom. Any one 
can make such false bottoms for him- 
self by replacing with pieces of tin or 
other metal, bent into shape, the centre 
which is to be cut from the tray. Having a number of these bottoms (which 
are to be somewhat larger than the piece removed), an operator finds himself 
requiring very few cups; half a dozen, or certainly a dozen, will be sufficient. 
This false bottom may be duplicated by building the centre of a tray to the 
required height by means of wax or plaster. 
Fig. 496.-Tray for Passage of 
Teeth. 
Impression Materials.-Materials adapted for taking impressions are 
wax, plaster of Paris, gutta-percha, and modelling compound, either being 
used alone or in combinations. The inexperienced is to begin with wax, as 
this is most simple and easy of manipulation, and at the same time quite 
capable of meeting all indications. 
White Wax.-Two kinds of wax are employed, the white and the 
yellow; of these, the white is, on some accounts, to be preferred. It will 
take a sharper impression, and has not its shape so readily deranged. An ob- 
jection, however, is a lack of plasticity as compared with the yellow, much 
more time and trouble being required to prepare it for the tray, while corre- 
sponding increase in pressure is demanded to force it into place,-the latter 
being a matter of importance where there is excess of the submucous cellular 
tissue. 
Yellow Wax.-Yellow wax, when pure, will, under all ordinary circum- 
stances, afford a satisfactory impression. To soften it to a required con- 
sistency, which is about that of dough, it is only necessary to work it at the 
fire, or by a spirit-lamp, or in hot water. Having selected a tray and ob- 
served the requirements of a special case,-that is, having considered the 
matters of depth of mouth, position of remaining teeth, and character of 
mucous membrane, whether this latter be hard or soft, yielding or unyielding, 
-the wax is piled into the tray, being heaped in the middle if the mouth be PROSTHETIC DENTISTRY. 
547 
deep, smooth, and flattened, on the contrary if it be shallow; the wax to be 
very soft if the membrane be flaccid, of greater consistence if it be firm. 
Position of Operator when taking Impression.-The operator, 
if to take an impression of the upper jaw, stands behind, leaning over the head 
of the patient; if of the lower, a position is assumed in front and to the 
right. 
Manipulation.-Tray and wax being in the mouth, observation is de- 
manded to see if such correspondence of relation exist as will allow of the cup 
being carried into place. If care be not exercised in this direction, it will 
frequently be found that the cup is not far enough back in the mouth, or 
perhaps it is too far back, or too much to one or the other of the sides, so 
that, as this last is concerned, in pressing it into place, the sharp edge of 
some portion of the ridge comes down upon the gum, producing not only 
much pain, but rendering the impression good for nothing. A proper corre- 
spondence existing, it only remains to press the tray gently and steadily upon 
the arch, throwing the lip off should it interfere,-a manipulation, this last, 
easily accomplished by running a finger between lip and wax. A tray is never 
to be rocked into place, but rather carried with all steadiness until it is felt 
to be fixed and firm. Such bearing obtained and preserved, a finger of the 
operator is to press the wax around the external face of the alveolar process, 
and where the false bottom has been used this is to be forced into the roof of 
the mouth. If the impression be of the lower jaw, the wax is to be pushed 
with the finger against the internal face of the process as well as against the 
external. Before removing an impression of wax from the mouth, it is to be 
allowed to remain a few minutes to harden. If, in the withdrawal, suction is 
recognized, the impression will almost certainly prove a good one. A tray is 
held most steadily in the mouth by being supported on either side. 
Breaking Suction.-Some operators, skilful in the use of wax as an 
impression material, find it necessary to employ a strand of silk or thread run 
through the material just before introducing it into the mouth, that, after 
securing the cast, they may get it away by letting in air through withdrawal 
of the string; the accuracy of the fit they obtain resulting in a suction so 
powerful as to make it difficult to get away the tray without derangement of 
the plastic. 
Before taking an Impression.-Before taking an impression, a 
mouth is to be cleared of saliva and mucus. This is most conveniently ac- 
complished through rinsing with water and cologne, a teaspoonful of the latter 
to half a goblet of the former, or, if more convenient, the cologne may be 
replaced with alcohol. Where irritability exists, a rinse of bromide of 
potassium is to be used, or a brushing of cocaine. 
Hardening the Wax.-It is occasionally found recommended that im- 
mediately upon withdrawal of a wax impression from the mouth it be plunged 
into ice-water, or otherwise that it be laid upon ice. This is a practice 
scarcely to be endorsed, the varying thickness of the wax rendering some 548 
A SYSTEM OF ORAL SURGERY. 
change not unlikely. Unless hurry exist, it is best to leave the cast to the 
state of the atmosphere. 
Sulphate of Lime-Plaster of Paris.-Plaster of Paris mixed with 
water into a paste, or batter, is very widely employed as an agent for taking 
impressions. Plaster, to be useful for such purpose, must be of the very 
best quality; this implies that it has been well calcined and thoroughly 
pulverized. 
Using Plaster of Paris.-To employ plaster, as an impression material, 
the operator selects a tray, and, filling it with the plaster batter, it is passed 
into the mouth in such manner that bubbles of air shall not be caught in the 
depth of the arch,-that is, the pressure which carries the mass into place is 
to be exerted gradually from the front backward. 
Employing the material for the upper arch, cups or trays, as 
portrayed in Fig. 494, are commonly used. These cups are made of britannia 
and are easily forced into any change of form required. A plan preferred, 
however, by many, consists in first taking an impression in wax, precisely as has 
been directed. This secured, the surface of impression is indifferently cut away, 
simply with the view of securing what might be termed a fairly-fitting wax 
tray. Into this is now poured the plaster batter, and the whole is reintro- 
duced into the mouth. Put batter first in concavity of arch where very deep. 
Employing plaster for the lower arch, the tray as shown in Fig. 
495, uncut, is found entirely applicable. The requisites of a tray holding the 
plaster batter are, depth of flange sufficient to invest the alveolar face to an 
extent required to be covered by the paste, and a relation to the arch which 
insures the plaster reaching every position of the part to be modelled. 
Getting the Impression.-To take an impression in plaster, a patient 
is to be seated upon a low chair, and the head inclined forward at an angle 
sufficient to prevent the falling of particles back into the throat. The bat- 
ter is to be of a consistency which does not allow it to run from the 
tray, nor, on the other hand, is it to be so stiff and hard that it may not take 
the desired cast. The time required for setting is about three minutes ; 
it may be shorter or it may be longer,-this depending on the character of the 
plaster used. The proper time for the removal from the mouth of 
a plaster impression is designated by the sharp, abrupt break to be seen by 
fracturing any inconsiderable and unimportant fragment, or by testing such 
portion as may be left in the mixing vessel. The matter of the time for re- 
moval is of very marked importance ; should the batter not have set, the im- 
pression is of course worthless. Should it, on the contrary, have become too 
solid, it may bring a portion of the mucous membrane with it; particularly 
in the case of the superior arch. Plaster known in the market as " superfine" 
is the best. 
Slow-Setting Plaster.-Plaster that is slow in setting finds the defect 
removed by the addition of a small portion of common table salt, or, what is 
thought by some to be better, the sulphate of potassium. PROSTHETIC DENTISTRY. 
549 
Adaptation to Edentulous Arches.-Plaster of Paris as an agent 
for taking impressions finds its most convenient application to edentulous 
arches; that it is to be used, however, with all success for partial sets of teeth 
is daily demonstrated. 
Used for Partial Impressions.-To take a partial impression it is 
found convenient to have a tray with a false flange. After the batter has 
set, this flange is to be withdrawn, the bottom part of the tray being sepa- 
rated from the mass by means of the point of a knife-blade. Next, the 
impression is broken into pieces, each fragment being removed carefully 
and preserved. When all are away, each piece is coaptated with its fellow, 
thus restoring the cast. A second mode of taking a partial impression is 
found in the use of a wax cast; the cup thus detached, the wax is quickly 
and easily removed from the plaster ; the exposed cast is now broken and 
treated as before described. Occasionally, indeed frequently, it happens that, 
if the proper moment be secured, a plaster cast, even although it enclose 
several teeth, may be removed with reasonable facility without occasion for 
the fracturing as suggested. It is a point with many operators to try and 
save themselves the trouble arising out of breakage, and with a reasonable 
experience this is oftentimes to be accomplished. 
Modelling Compound as an Impression Agent.-This is a prep- 
aration composed of French damar, Venice turpentine, talc, coloring matter, 
and aromatics. As an impression material it is sharp and of firm fixation. 
The manner of use is the same as for wax. 
Gutta-Percha for taking Impressions.-This material, used alone, 
has never impressed the author as an agent of sufficient merit to warrant, in 
this direction, any special commendation. It is not only troublesome to 
manipulate, but from its tendency to undue hardening, as influenced by 
circumstances, is tedious to look after; it does not compare with either 
the wax or the plaster. As an agent of admixture with wax, however, it 
is at times found a not unsatisfactory adjunct, insuring, as it does, an ac- 
curacy and sharpness in outline which is the highest recommendation of an 
impression. Gutta-percha alone, or in combination with wax, is used pre- 
cisely the same as the pure wax, being softened by moist or dry heat, 
placed in the cup, and thus applied. When the gutta-percha alone is used, 
trouble may be experienced in getting it from the mouth, particularly in cases 
where teeth stand in an irregular relation to one another in the arch. Where 
it sticks beyond the power of withdrawal hot water is to be held in the 
mouth. 
The Model.-An impression of the mouth secured, a succeeding step is 
the making of a model. This model is to be a fac-simile of the parts taken 
in the impression, and is made in a very few moments, as follows: If the 
impression be of wax, or gutta-percha, or of the mixture of wax and gutta- 
percha, or modelling compound (see Fig. 497), the surface is to be thoroughly 
smeared with oil, the tray is placed upon a table, a strip of paper, or lead, or 550 
A SYSTEM OF ORAL SURGERY. 
waxed cloth-any convenient thing, being of a length sufficient to encircle 
the circumference of the impression, and of a width not less than one and a 
half inches-is to be placed around the tray, forming thus a temporary cup, 
the bottom of which is the impression. (See, for idea, Fig. 498.) Taking 
Fig. 497.-Impression ready to 
receive Plaster Batter. 
Fig. 498.-Rim to support 
Batter. 
now plaster of Paris sufficient in quantity to fill this cup, it is mixed with 
water into a batter of the consistency of very thick cream, and in this state 
it is poured, with care, beginning at one corner, into the cup. When set 
solid, which will require two or three hours, the strip is to be taken away, the 
tray removed by heating it slightly, and the wax, being further warmed and 
softened, is picked off little by little, any convenient instrument being used, 
an ordinary pocket-knife answering the purpose quite as well as anything else. 
This model is the cast to which the mechanician works ; it is a perfect likeness 
of the mouth to which the teeth are to be fitted. 
Plaster Impression and Plaster Model.-In the case of a plaster 
impression the manipulations for securing the model differ somewhat from the 
above. The impression is first to be thinly varnished, and when dry is to be 
oiled, and the cream batter poured as before. When solid, the plaster im- 
pression is to be broken by the taps of a mallet, and thus, in pieces, lifted 
away. Another plan is to put the cast and impression in water, where the 
impression, by reason of its greater dryness, will absorb the fluid and expand 
more rapidly than the cast, so that it can be lifted away without injuring the 
model, and in many cases saving the impression for secondary use in case 
accident should render this desirable. 
Insurance against Chipping.-To insure a plaster model against 
chipping it is commonly coated with shellac varnish ; this is accomplished by 
repeated brushings, one coat being dry before another is applied. Where it 
is important to insure much resistance on the part of a model, it is a practice 
adopted by many to boil it for about half an hour in a strong solution of 
alum; the officinal, or potassa-alum, is the variety used. PROSTHETIC DENTISTRY. 
551 
THE DENTURE. 
At this point is to be considered the mechanical performance of making a 
denture. The student whose purpose it is to practise dental art exclusively 
will wisely supplement the instructions now to be given by much work in the 
laboratory. Out of such practice he will find himself master of the require- 
ments. (See succeeding chapter.) 
Procedure as related with the Practice of an Oral Surgeon. 
-The procedure of an oral surgeon in this connection is as follows: Taking 
the model which he has made, he transfers it to the hands of a mechanical 
dentist, being judicious in selecting one who possesses an art appreciation of 
his work. This latter now makes what is known as a trial plate,-a plate 
made to prove the correctness of the impression,-which, being delivered to 
the surgeon, is placed in the mouth, and, if found right, receives the articu- 
lation. To make a trial plate is nothing more difficult, however, than 
taking a piece of sheet gutta-percha or modelling composition and, warming it 
into ductility, spread it over the face of the model. Sheet-lead, wax, or any 
convenient means may be used. One is to be moulded and trimmed into 
shape in five minutes. 
Plates used for Dentures.-Plates used for a denture are of two 
kinds,-those attached by clasps, or bands, which pass around certain teeth, 
and those which depend on atmospheric pressure for support. Whether the 
one or the other of these is to be employed depends entirely on the state of 
the mouth. Where all the teeth are gone, there is, of course, but the 
single resource: the plate must be made to cover the full arch, and, if the 
case is for the superior jaw, a cavity occupying the centre of the palatine 
face is commonly made in it. Where certain teeth are present, these being 
of good shape to support bands, and of vigorous health and solid structure, 
it may prove a matter of comfort to the patient to take advantage of such 
means to give him a plate which allows exposure to a greater extent of 
mucous membrane,-a matter of little consequence to the comfort of the 
lymphatic temperament, but of much concern to the nervous. 
Plate holding by Atmospheric Pressure.-The matter of holding 
a plate by means of atmospheric pressure demands both experience and thought. 
The usual manner consists in cutting from heavy sheet-lead a half-moon-shaped 
piece, which piece is moulded upon the palatine face of the plaster .model, with 
a view of securing a similar elevation in the zinc cast to be made from it, and 
a counter-depression in the lead mould prepared upon this latter. As will be 
inferred, a metal plate struck between such casts would contain a cavity cor- 
responding in shape and depth with the piece of sheet-lead. If a denture 
plate be celluloid or gutta-percha, the moulding of the plastic over the pre- 
pared face of the plaster model secures the same cavity. (See making plates.) 
Shape of Palatine Arch.-The shape and characteristics of a palate 
have much to do with success in suction cavities. The best kind of a palate 552 
A SYSTEM OF ORAL SURGERY. 
is one that is reasonably deep and not too soft. Sometimes it is found 
desirable to use no vacuum plate, but to cover the oral roof fully and accu- 
rately. On the other hand, cases are met where the plate is to relate solely 
with the alveolar arch, the suction cavity occupying the whole hard palate. 
Leather-Sucker Cavities.-Cavities made on the principle of the 
leather sucker, a plaything familiar to every school-boy, are favorites with 
many; these being used alone or as adjuncts to the kinds described. A form 
of these is known as the Beer's disk. Attached to a plate prepared with 
a cavity, it requires alone to be pressed against the roof of the mouth in order 
to hold. Being made of pure gum, consequently being soft, any rocking 
occurring with the plate does not detach it. The manner of holding is abso- 
lutely that of the leather sucker, while it differs nothing in form from that 
toy, being round, saucer-shaped, with its middle occupied by a rivet instead 
of by a string, which rivet relates disk and plate.* 
Clifford's Disk.-A disk of this same meaning has been shown the 
author by Mr. I. E. Clifford, of Windermere, England; it differs, however, 
from the Beer instrument in being circularly corrugated, some on one, others 
on both faces. This disk, attached to a plate after the manner of the Ameri- 
can device, catches the oral roof with considerable tenacity. The pieces 
corrugated on both surfaces adhere alike, on pressure, to plate and arch of 
palate. 
Cavities not Necessary.-It is coming more and more into fashion to 
discard the vacuum cavity entirely, it being found that a perfectly-fitting plate 
furnishes its own support. 
Use of Spiral Springs.-A manner of supporting dentures, now almost 
obsolete, consists in the use of spiral springs. 
Articulation.-Articulation considers bite,-that is, it is necessary to 
know how the natural teeth stand in order that the artificial shall be in 
harmony with them. To secure articulation the procedure is as follows: 
For the Partial Denture.-We take, as the most simple illustration, a 
plate upon which is to be placed a partial denture, say the six central teeth of 
the upper jaw. Try the plate in its place, and see if a fit has been secured. 
Fit is adaptability. Every part of a plate is to rest evenly and solidly upon its 
* " Some members of the profession consider the disk a valuable invention for extremely 
difficult cases, but not necessary in the majority of mouths. In this they are seriously 
mistaken, for it is really of great utility in almost every case, and all who are compelled to 
wear artificial teeth should have the benefit of it. The large majority of plates made with 
the ordinary 'suction chamber' are likely to tilt during mastication, thereby admitting air 
beneath them and destroying the vacuum, and very often they are thrown down in cough- 
ing, sneezing, etc., to the great annoyance and embarrassment of the wearers. With the 
disk attachment it is impossible to dislodge a set of teeth by any movement of the mouth, 
and the wearer has a sense of security and satisfaction which cannot be enjoyed with a set 
made by the old method. We therefore claim that a set of artificial teeth is unfinished 
unless it has this improvement, which adds so much to the comfort of the patient."-From 
advertisement of inventor. PROSTHETIC DENTISTRY. 
553 
base. If bands have been used, these are to enclose with the nicest accuracy 
the special teeth to which they are related; they are to hug the teeth. 
Where atmospheric pressure is the means of support, the relation of parts is 
to be so intimate that withdrawal of air from beneath the plate-effected 
through suction by the tongue-causes it to adhere to the parts with more or 
less tenacity. 
Satisfied as to the adaptability of the plate, a succeeding step 
consists in softening a piece of beeswax precisely as was done for the wax 
impression, and, moulding this upon that part of the plate to be occupied by 
the new teeth, the patient is directed to close his mouth. This, as is seen, 
bites the lower teeth into the wax, thus affording knowledge of how the 
artificial teeth are to be set; leaning the head far back insures against false 
bite. Associated with this step is the trimming of the wax, while in the 
mouth, into what shall seem the required length of the new teeth; also the 
wax overlying that portion of the plate which covers the external face of 
the alveolar ridge is to be so trimmed and moulded as to give proper contour, 
or expression, to the overlying lip. In such partial cases, however, it is not 
at all a necessity that anything more be done by the surgeon than secure the 
bite as directed. The mechanician, if at all an artist, has every required 
guide in the surrounding relations; the trimming and modelling he can do to 
suit himself. What is called a shade is required, however, by him; this is 
secured by matching in color the natural by an artificial tooth, of which 
latter the surgeon is to have at his command quite a number.* 
For the Full Half-Denture.-A full half-denture implies the complete 
set either of the upper or the lower arch. We consider first the upper. Try 
the plate in the mouth to test its adaptability. If this be satisfactory, let 
the patient close the teeth of the lower jaw upon it. This affords informa- 
tion as to a general line at which these teeth will strike the plate. Take now 
the plate from the mouth, and build upon it a rim of wax of a height which, 
when in the mouth, will represent the required length of the new teeth. 
Such height is readily distinguished by trimming the wax little by little, 
until, in the various movements of the lips, as in talking, laughing, etc., it is 
seen to afford the promise of a natural expression. This secured, let the 
patient make a line of the impression of his lower teeth by slightly biting 
into the wax. Next the support of the lip is to have consideration. This 
pertains of course to the gum portion of the teeth. To afford here the requi- 
site information to the artist, it is only necessary to model the wax until the 
external parts are seen to have proper expression. This modelling is done by 
building upon the flange of the plate a rim of wax of such form and shape 
as are proved to be right by the impression produced on the contour of the 
* Shade Teeth.-The proprietors of dental depots give to proper applicants rings to which 
are attached shade teeth in full variety. These teeth are numbered, so that to secure just 
what is wanted requires alone the sending of a number. The arrangement is as complete as 
it is satisfactory. 554 
A SYSTEM OF ORAL SURGERY. 
lip. (See, for illustration, Figs. 499 and 502.) Accompanied by its shade 
tooth, the articulation is now ready to be again transferred. 
An articulation of the full lower denture is to be secured in a manner 
precisely similar to that practised with the superior. 
Fig. 499.-Plate waxed and ready 
for Bite. 
Fig. 500.-Plates prepared for 
Upper and Lower Dentures. 
For the Articulation of a Complete Denture.-A complete den- 
ture implies a set of teeth full above and below. Having the plates made 
ready (Fig. 500 shows the two plates), the surgeon first places them, each 
in its proper place, and causes the patient to close the mouth that thereby 
some general idea of the relation of the parts be obtained. Measuring now 
the size of the lips that an idea be afforded of the required length of the new 
teeth, rims of wax are built upon the two plates precisely as before explained. 
Fig. 501.-Upper Plate waxed, 
affording idea of Requirement in 
same Direction of Lower Plate. 
Fig. 502.-Lower Plate waxed, 
showing Requirement of Upper 
Plate. 
This accomplished, each plate is to be placed in position and the relations 
studied; the lip is to be properly contoured, the wax is to represent the 
proper length of the new teeth, and the arches are to have such relations 
with each other that the tongue is accommodated with the room required for 
untrammelled movement; likewise is it to be observed that the line at which 
the rim of wax rests upon each plate is calculated to throw the centre of PROSTHETIC DENTISTRY. 
555 
gravity of the new teeth on a bearing which antagonizes any tendency in the 
plate to tilt. This last, however, the mechanical dentist should himself know 
all about; it is not a necessity that the surgeon particularly heed it; it is of 
chief consequence, however, that such balance be secured. Finally, the 
plates, with their rims, having been accommodated, each to its special require- 
ments, the two are put at the same time in place in the mouth. This done, 
the patient is directed to close naturally the jaw, and as now the rims of wax 
meet and adhere to each other, the natural bite, or articulation, is secured. 
The operator next, with a knife or other convenient instrument, marks from 
plate to plate upon the united rims of wax a line which represents the exact 
centre of the mouth, and besides this central mark two others, one on either 
side. The plates may now, in their united condition, be lifted from the 
mouth, and are ready for another transfer. If, however, it happen, as indeed 
is not unlikely, that in removing the plates they have separated, it makes but 
little difference, as by the lines which have been cut they are at any moment 
to be replaced in the original position. 
Peculiarities as to Articular Relations.-Peculiarities in articular 
relations occasionally occur, the management of which requires experience to 
make easy. As an example, reference may be made to a condition in which 
teeth remaining in both the upper and lower arches hold such relation that in 
bringing the jaws together they pass each other, allowing those of either 
arch to strike the gum of its antagonist. Proper articular relation here re- 
sides in so arranging the artificial teeth that bite is restored to the original 
plane. In other words, in the arrangement of the wax the closure of the 
jaw is to show the impression upon it on that plane which would be natural, 
should the irregularly-placed teeth strike instead of passing each other. 
False Bites.-In an attempt to procure almost any but the most simple 
of articulations, the operator finds himself annoyed by false bites, the patient 
closing his mouth in every way but the right one. Particularly does experience 
show this to be a result where special pains are taken to instruct a sitter as to 
the manner of closure. A proper bite, it is to be recognized, is the natural 
one. After arranging the wax, tell the patient to close the mouth. Having 
thus obtained an articulation, take the piece out and after a few minutes 
replace it, procuring now a second bite. Should the two correspond, inference 
is in favor of correctness. Should, however, different impressions be made 
upon the wax at the different bites, one or the other must necessarily be 
wrong; the test is to be repeated until satisfaction is secured. The manner 
suggested a few paragraphs back, of having the patient lean the head far back 
while biting, seems to be the best corrective of false bite yet tried. 
Articulating a Full Denture in the Mouth.-When an articula- 
tion, or bite, as just described, is faultless, the relations of an artificial denture 
should be equally perfect. It very frequently happens, however, that, from 
fault either in the surgeon or the artist, the desired and absolutely necessary 
perfectness of articulation does not exist, certain teeth being seen to strike 556 
A SYSTEM OF ORAL SURGERY. 
unduly, thus denying a common occlusion; or it may be that the cusps are 
found wrongly placed as regard is had to their articulating neighbors. 
Illustration, as a Study, of Articular Relation.-To appreciate 
the character of a proper articulation, the student will refer to Fig. 503. 
Integrity and mechanical adaptability in articulation are essentials to useful- 
ness and comfort. Artificial teeth which do not strike properly can never be 
serviceable or easy to the wearer. When, therefore, a finished denture is 
Fig. 503.-Articulation. 
found to be so far out of the way in this direction as not to permit of a satis- 
factory correction, the very best thing to do is to have the piece made over. 
Such a necessity must come more or less frequently to the inexperienced; 
each mistake, however, has in it the compensation of a lesson more instructive 
than a dozen successes. 
Faulty Articulation the Rule.-Artificial dentures slightly faulty in 
articulation constitute the rule rather than the exception. Relief here is found 
in recognizing the false touching points and by the use of the corundum stick, 
or preferably the wheel, cutting such points away. 
Appreciation of Articulation.-Closing his own natural teeth, one 
recognizes solidity and regularity of occlusion. This is the secret of articula- 
tion. No tooth is to touch before its fellow ; bite is to be common : an upper 
relates with two lower teeth, the dentes sapientiae excepted. 
Addenda.-Working to an articulation which has been furnished him 
(Fig. 505), the mechanical dentist attaches the teeth to his plate in general 
correspondence with such articulation. That it may be proven he returns it 
to the surgeon, prepared as designed by him, to be placed in the mouth. The 
teeth, however, in place of being solidly attached to a plate, are merely moulded 
into wax. Taking this denture, one who would convert the manufacture into 
an art proceeding places the set in the mouth, and, with aid of taste, he twists, 
turns, and alters special form and general contour until relation with physiog- PROSTHETIC DENTISTRY. 
557 
nomical requirements is complete. The stones figured in connection with the 
insertion of pivot teeth are requisite in the work. 
Arranged and ground to suit, the case is handed back to the mechani- 
cian, who, without in any way changing what has been done, proceeds to finish 
the operation; which being accomplished, it is again returned to the surgeon 
to be fitted into the mouth as just described. 
Prosthetic dentistry, viewed as art work, is possessed of great 
interest. 2Esthetically considered, it is a restorer of youth to age, comfort to 
discomfort. As work it soon comes to command great interest at the hands 
of him who engages in it. (See Vulcanite and Celluloid.') 
Artificial Denture relates many Indications.-An artificial 
denture is to relate many indications: it is to fit a mouth so as to be worn 
with comfort; it is to articulate after such manner as shall serve all the pur- 
poses of mastication; it is to restore lost expression. 
Few Dental Artists.-Makers of artificial dentures are many, dental 
artists are few. It is possible, with appliances now at command, to replace 
lost teeth and symmetry with such perfectness as to deceive the closest observer. 
Every case is a special study; there is no rule of setting teeth that will apply 
to any two mouths. An artist may spend many hours not less pleasantly than 
profitably in physiognomically adapting a set of teeth to the mouth of a patient 
under charge. Adaptation consists in an appreciation of relations. This 
adaptation is to be practised at that stage of denture-making which precedes 
the fastening of teeth to a plate. The secret lies in arrangement. 
Illustrations in Arrangement.-In the laboratory of the mechanical 
dentist is an instrument known as an articulator; Fig. 504 represents one 
form ; a great variety existing. That he may be certain of having a reliable 
model of the articular relation of the jaws to work by, the denture-maker uses 
this apparatus, fixing the 
plates in their apposed posi- 
tions by attaching them, 
each in its place, to the 
wings. These wings, before 
removal of the intervening 
wax which holds the plates 
in relation, are secured by 
means which allow of no 
change in position, so that 
on taking away of the wax 
the worker has assurance 
that relations are absolutely 
maintained, and that as the 
teeth are attached to his 
plates, so will they surely show in the mouth. Articulators have, as a rule, a 
joint which permits of a motion corresponding with that of the lower jaw, 
Fig. 504. 558 
A SYSTEM OF ORAL SURGERY. 
adding much to the convenience and facility of the dentist as he works at and 
studies his case. 
Moffitt's Anatomical Articulator.-This articulator is described by 
its inventor as having its movements correspondent with those of the natural 
jaws, the arrangement of the lower to the upper plate being such that any 
false position of the bite is to be corrected, and at the same time the arc of 
the circle of the lower jaw in relation to the upper is secured as in the mouth, 
thus assuring a correct articulation without necessity for grinding the teeth 
after they are mounted. It is adapted to either partial or full cases. 
Plaster Articulator.-The student, by looking at Fig. 505, will be led 
to infer that articular relation is to be secured without the aid of appliances 
as just referred to, although he is to understand that such pieces of apparatus 
are useful, time-saving, and costless to an extent that renders the possession 
most desirable. The plaster relation, as shown in the diagram, is made by 
taking a bite after the manner directed. Carefully lifting the associated den- 
tures from the mouth, the portion represented by the lower plate is laid upon 
a piece of oiled paper, when wax is 
softened and arched over the inter- 
space of the arch and beyond it. This 
wax reaches to the underlying paper 
and covers in the back of the two 
related arches. Gutter of plate and 
the wax being now oiled, a batter of 
plaster is poured which is to extend 
one-quarter of an inch above the rim 
of the denture and reach over the 
wax arch down to the paper. It is 
to reach beyond the wax at least an 
inch and a half. When this cast has 
become thoroughly dry, it is to 
be lifted from the table and reversed. 
The flat or paper face of the cast is 
now bisected to half its depth by 
grooves. Following the manner pur- 
sued before, plate, wax, and plaster are thoroughly oiled and batter is again 
poured. This last being afforded time to dry, easy separation of the two models 
is allowed by reason of the oil. The whole is now to be trimmed into form as 
shown by the cut. The grooves in the one model and the prominences upon 
the other insure preservation of the articular relations of the two plates. 
Articulations for half-dentures are made after a like manner. 
Space required to be filled.-The plates being attached, as ex- 
plained, to the articulator, and the bite-wax removed, it is evident that a 
model as exhibited (Fig. 505) would exist, and that the space between the 
two plates is that which requires to be correctly filled by the artificial teeth. 
Fig. 505. 
Arches in articular relation. PROSTHETIC DENTISTRY. 
559 
Unset Teeth.-Fig. 506 illustrates a set of teeth as furnished for setting 
by the manufacturer.* As here shown they reach the hands of the mechani- 
cal dentist, whose business it is to set or prepare them for the mouth. Fig. 
Fig. 506. 
Fig. 507. 
507 shows this same set of teeth prepared for the mouth. As exhibited in 
the diagram, this denture appears handsome and finished. If so set for a 
patient about twenty-five or thirty years of age, possessed of great regularity 
of features and freshness of complexion, the arrangement might prove perfect. 
Fig. 508. 
Fig. 509 
TEsthetical Arrangement of Teeth.-We pass to a step in aesthet- 
ics. Fig. 508 shows this same set of teeth triflingly altered in outlook by a 
cutting of the articulating faces expressive of abrasion. Fig. 509 shows these 
abraded teeth irregularly related in the setting. Fig. 510 retains the same 
* This form of teeth is prepared and adapted for the celluloid base. Plate teeth, designed 
for ordinary soldering, are without roots. 560 
A SYSTEM OF ORAL SURGERY. 
particular teeth irregularly set, a bicuspis being left out of the arch. Fig. 511 
is a palatal view of the same case. Fig. 512, still the same teeth, is expres- 
sive ; it shows a very common condition of recession in the gums. Great 
Fig. 510. 
effect in the way of naturalness is gained in imitating this recession. Fig. 513 
is a side view of the same denture. 
These illustrations, copied from studies by Warrington Evans, M.D.,* have 
the meaning of changes made to meet varying indications associated with 
features, age, etc. Seeing what results are to be obtained out of a single set 
of teeth, an operator will be led to infer that, with so great a variety before 
him as is to be found in a dental depot, he may effect anything within his 
inclination. 
Fig. 511. 
Contouring a Face.-What are known as plumpers consist simply in 
what has been alluded to as contours, made by additions to the base of a 
denture; the object is expression. Plumpers are commonly associated with 
* Since the issue of the immediately previous edition of this work the author has received 
a letter from a gentleman in South America claiming credit with Dr. Evans for arrangement 
of the studies here shown. He hereby acknowledges the receipt of said letter, and has to 
regret that having mislaid it prevents his giving the writer's name. PROSTHETIC DENTISTRY. 
561 
the cheek portion of the base. To make them nothing more is necessary than 
to thicken this base by added material. Contouring is first to be accomplished 
during the process of articulation, the operator adding layer after layer of 
Fig. 512. 
wax until a desired restoration of form is achieved. It is in the experience 
of the author to have secured such results in this direction that a toothless 
woman of seventy has found herself able, through a judicious use of rouge, 
to compete with a sister forty years younger. An instance is familiar in which 
a mechanical dentist of celebrity in the art furnishes in his own person such 
Fig. 513. 
an illustration of the capabilities of contouring that with teeth and plumpers 
out of his mouth he becomes instantly metamorphosed from a man full, appar- 
ently, of life and vigor, looking not a day over fifty, to one old and decrepit, 
whose age might be anywhere between ninety and a hundred. 
A contour obtained by wax, it remains simply for the operator to pass the 
piece over to the mechanical dentist, who reproduces it in metal, in vulcanite, 
celluloid, or in whatever material it may be decided to use. 
A full study of oral aesthetics is best made, and indeed is to be made only, 
in a study of faces. CHAPTER XXXIII. 
PROSTHETIC DENTISTRY. 
LABORATORY. 
A laboratory, to be used, on occasion, for the contrivance and construction 
of mechanical apparatus, is a source of great convenience both to a general and 
a special surgeon. 
Mechanical Wants in Oral Surgery.-The laboratory wants of an 
oral surgeon are comprised in the needs of a mechanical dentist, and these 
needs are to be found neither extensive nor expensive. 
Dental Supplies.-The extent and perfection of dental supplies as 
furnished, in the present day, by manufacturers of these goods, leave room 
for but a minimum of work to be done in the laboratory. Even so far back 
as thirty years the writer, whose business was then that of a dentist, found 
himself quite, and not particularly inconveniently, able to prepare for his 
patrons sets of artificial teeth which, in his own estimation, compare for ser- 
vice, appearance, and comfort with the dentures of the present time. 
It is to-day well known to him that some dentists, depending on the con- 
veniences furnished by the depots, construct dentures for the mouth and do 
all other required work, having little else to show as a workshop than a table 
with a drawer in it, a stool to sit upon while working, and a shelf or two for 
convenience in holding things. In these cases a kitchen stove furnishes the 
requirement for melting the die metals, and a brick or stone in the back yard 
fulfils the sufficient purposes of an anvil upon which swaging is done. 
Illustration.-On an occasion the author, having an impression of a 
mouth in wax which he had taken by means of a strip of board whittled for 
the purpose, prepared, after the manner described in the preceding chapter, a 
plaster model. This he carried to a blacksmith-shop, and finding an old 
tin cup, the bottom of which he knocked out, he quickly made a mould out 
of some black sand, which he wet and kneaded for the purpose. Taking now 
a piece of zinc furnished by the smith, he melted and poured it into the mould, 
thus supplying the required metal duplicate of the plaster. A succeeding 
step made the necessary lead counter-cast, this performance consisting of 
nothing more than taking the first, or zinc, die and laying it upon the table, 
placing the cup about it, and filling up to the alveolar base with sand, melting 
the lead and pouring it over the exposed face of the zinc. Knocking the 
two apart, a die and counter-die were possessed. 
A silver plate being the next requirement, an ordinary metal dollar was 
annealed in the fire of the smith's furnace and hammered into a required 
562 PROSTHETIC DENTISTRY. 
563 
thinness upon his anvil. This was next swaged between the dies, and later 
cut and filed to fit the plaster model. Trying this plate in the mouth, and 
finding it fit, an articular bite was obtained (see previous 
chapter), and to this was fitted a set of gum teeth, ordered and 
received from a dental depot, the work being done by means 
of a stick of corundum (Fig. 514). 
To back the teeth the pieces of silver remaining were used, 
while portions of the same metal, combined with brass in pro- 
portion of two-thirds of the first to one-third of the latter 
metal (see Solder^ were melted together upon a piece of char- 
coal by means of a common blow-pipe acting on an alcohol 
flame, and, having cooled, was beaten out into a thinness that 
allowed of its being cut into small pieces. Borax, used in 
soldering, was furnished by the blacksmith. 
The maker of this set of teeth saw the denture twelve years 
later in most satisfactory use. 
Some of the most skilful and competent dentists known to 
the writer do their mechanical work at desks which, when not 
in use, serve as pieces of furniture not at all out of place in 
well-appointed and handsomely-furnished operating-parlors. 
General instruments used in a laboratory relate with working 
vulcanite and celluloid and metal, the first two needing common 
means, the last, tools of a different kind. 
Tools used for Vulcanite- and Celluloid-Work.- 
The following, with prices appended, afford idea of the sim- 
plicity and cheapness of an outfit of this nature: 
Fig. 514.- 
Corundum 
Stick. 
6 britannia impression cups, uppers, Nos. 2, 3, and 12; lowers, 
Nos. 15, 18, and 19 $1.70 
2 vulcanite scrapers, Nos. 12 and 13 .50 
1 Kingsley scraper, No. 6 .30 
1 corundum wheel, No. 2, round edge, mounted on chuck . . .29 
1 « " " " 5, J-inch, mounted on chuck .... .41 
1 " " " 5, f-inch, fine grit, mounted on chuck .45 
1 vulcanite flask 1.00 
1 wrench for flask .10 
1 articulator, plain line (or No. 2, $2.00) .90 
1 alcohol lamp, No. 1 or 2 .40 
1 wax spatula, No. 2 .40 
1 plaster spatula, 4-inch .25 
1 plaster knife .15 
1 vulcanite file, double end, half round . .28 
1 brush wheel, No. 30 .44 
1 stiff brush wheel, No. 5 .18 
1 large felt cone .40 
1 pair calipers .25 
1 plate brush (stiff), 4 rows .45 
1 vulcanizing apparatus . 10.00 564 
A SYSTEM OF ORAL SURGERY. 
Tools used for Metal-Work.-The following, also having prices 
appended, are the ordinary tools required in doing metal-work related with 
oral apparatus: 
1 pair plate shears $1.25 
1 " wire nippers .80 
1 " round-nose pliers, 4|-inch .40 
1 " flat-nose pliers, 4^-inch ; .40 
1 " plate nippers 2.75 
1 plate punch for rivet-holes 2.25 
1 riveting hammer .70 
1 half-round file, 5-inch .35 
1 flat file, 3J-inch ' .18 
1 brush wheel, No. 2 .15 
1 double-end plate burnisher .75 
1 horn mallet for swaging plates .38 
1 pair solder tweezers .10 
1 Scotch stone .08 
1 blow-pipe for mouth .50 
(See Laboratory Furnishing.) 
Enlarged Conveniences.-So much pleasure is to be found in a work- 
shop, and besides this so much profit and convenience, that such an establish- 
ment is never found else than a good investment. 
Fitting up a Workshop.-First, a solid bench supplied with 
drawers, and particularly with one having 
a bellied leather apron for catching 
and holding the precious metals, is fitted 
firmly in front of a win- 
dow. Into this bench, 
and overlying the leather 
drawer, which is to be 
so constructed as to pull 
out beyond it, is to be 
mortised a block bev- 
elled off at an angle, its 
use being for filing pur- 
poses. The next conven- 
ience is a vise with 
jaws capable of being dis- 
parted some four inches; 
this is attached by its 
screw to the bench. A 
small anvil, set in lead 
with view to deadening 
sound and breaking the 
concussion, is found most useful. A sand-box, holding half a peck of 
moulder's sand, is a requirement. Another box, found indispensable, is one 
Fig. 515.-Shop Furnace. 
Fig. 516.-Foot- 
Lathe. PROSTHETIC DENTISTRY. 
565 
for plaster, and this may be supported above a small barrel, the intention 
of which is to hold the cuttings from casts, and other laboratory refuse. A 
furnace is an invaluable adjunct; this can vary as to character, according 
to the purse, from a simple low open-topped stove to one of the various 
apparatus specially prepared and used for the purpose. A blow-pipe. 
Fig. 517.-Lamp burning 
Fig. 518 -Lamp burning Al 
cohol or Kerosene. 
operated by a foot-bellows, by steam, or by compressed air, is a valuable 
adjunct. Of such instruments the depots offer quite a variety. (See dental 
catalogues.) A foot- or hand-lathe, preferably the former (Fig. 516), 
furnishes the means for grinding teeth and doing, after an easy fashion, 
much other work. For use with this are required circular saws, wheels 
made of corundum, polishing brushes, cones of soft and hard woods, and 
other et c^teras as wants make themselves felt. A rolling-mill is a 
convenience, but hardly a necessity, as it is quite as easy and economical to 
Fig. 519.-Rivet Punch. 
buy plate-stuff as to prepare it. Other requirements are beeswax, rosin, 
an alcohol-burning lamp (Fig. 517), a lamp with large wick for burning oil 
(Fig. 518), otherwise, and preferably, means for attachment with a gas-supply, 
hammers of sizes and shapes varying from that used for swaging plate to 566 
A SYSTEM OF ORAL SURGERY. 
the small one employed in riveting, sheet-lead for mapping out plates and 
shaping suction cavities, a pair of scales for weighing out proportions, a mortar, 
pestle, and spatula for making mixes of various kinds, a slate upon which to 
rub up borax used in soldering, and a plate punch (Fig. 519). Other matters 
adding to convenience will be found to accumulate. 
General Consideration connected with the doing of Vulcan- 
ite-, Celluloid-, and Metal-Work.-Possessed of the advantages of 
a laboratory furnished as suggested, an oral surgeon may find it convenient on 
occasions to supplement with his own the fingers of the mechanical dentist or 
general surgical mechanician. To such end general instructions are appended 
in the shape of chapters treating on the subjects of dental vulcanite-, celluloid-, 
and metal-work, together with the construction of obturators,-matters which, 
when understood, afford the skill to do almost any kind of laboratory-work. 
Soldering and Appliances.-Here, as being a convenient place, 
reference may be made to the matter of soldering. 
Proper Use of Blow-Pipe.-The proper use of a blow-pipe requires 
to be understood. Flame (see Fig. 520) is divisible 
into a reducing and an oxidizing portion. The first 
named (b, b') is the blue, or hydrocarbon, portion; the 
second named (c, c', e) is the yellow, or pure carbon, 
portion. The first is a heat flame; the second oxidizes. 
Attempt being made to run solder by directing the yel- 
low portion of a flame upon it, the metal is burned or 
oxidized. The blue flame melts the metal. An experi- 
ment, demonstrative of what is meant, is to be made by 
taking a common lead shot and 
directing upon it the yellow por- 
tion of a flame, when the lead is 
found quickly oxidized, or con- 
verted into litharge. The flame 
being here changed to the blue and 
this directed upon the powder re- 
sultant of the yellow flame, the 
litharge is resolved back into lead 
proper. 
Bunsen Burner.-Where 
purity, or absence of soot, com- 
bined with great heating capability, 
is a desideratum as to flame, ad- 
vantage is gained in use of the 
Bunsen burner. Here the carbon 
is completely burned out by reason of being brought into contact with a suffi- 
ciency of oxygen to insure its absolute combustion. Fig. 521 shows such a 
Fig. 520. 
Fig. 521.-Bunsen 
Burner. 
Showing relation 
OF BLUE AND YELLOW 
flame. a, obscure 
cone; b, b', blue flame; 
c, c'> e> yellow flame; 
d, d', base of blue flame. PROSTHETIC DENTISTRY. 
567 
burner. Gas, as seen, flows in from the bottom. At air, on either side, it is 
combined with oxygen, which is drawn into the line of the ascending gas, 
which, as understood, is a mixture of hydrogen with various hydrocarbons 
and a small portion of carbon monoxide. Soot deposited by a gas-flame has 
the significance of incomplete combustion. 
Fig. 522.-Fletcher's Radial Burner. 
Fletcher's Radial Burner.-In connection with the Bunsen burner 
reference is to be made to Fletcher's radial burner,-an apparatus for the use 
of gas in soldering dentures which impresses the writer as being beyond over- 
commendation. Fig. 522 shows this burner. To use it a piece of common 
rubber relates it with the gas-supply. A denture to be soldered, or other 
heating-up to be done, the thing, whatever it may be, is laid within the circle, 
when, the gas being turned on and ignited, it is instantly enveloped in blue 
Fig. 523.-Fletcher's Blow-Pipe. 
flame. Adding to this means the use of a second Bunsen flame directed by 
what is known as Fletcher's blow-pipe (see Fig. 523), an experimenter finds 
himself able to get a heat that will fuse continuous-gum material. 
Mellotte's Soldering Appliances.-As the fruit of study and ex- 
perimentation, Dr. Mellotte has greatly improved soldering appliances. The 
usefulness and completeness of his means are at once apparent. Directions 
accompany the apparatus. Gas is used. 568 
A SYSTEM OF ORAL SUROERY. 
Mellotte's Gas Blow-Pipe.-The gas-supply is received through the 
valved tube by connecting it, with rubber tubing, to the gas-bracket. The 
spring valve which regulates the supply of gas may be set, by means of the 
thumb-screw and jam-nut, to any flame desired. When used as a hand blow- 
pipe the best way to hold it is with the third finger through the ring as shown 
in Fig. 524. It can also be used with the foot-bellows when a more powerful 
blast is required, or with nitrous oxide to produce an oxyhydrogen flame. 
Fig. 524.-Mellotte's Gas Blow-Pipe. 
Mellotte's Blow-Pipe Pad.-Fig. 525 shows the blow-pipe pad. It 
is about four and one-half inches in diameter, and is made of wound asbestos 
tape surrounded by a metal band supplied with loops at regular distances apart 
for the reception of the handle hooks or spring clamps. The construction of 
Fig. 525. 
Fig. 526. 
Fig. 527. 
the pad, which is reversible, makes it a perfect cushion, into which pins can be 
readily thrust to hold small articles while being soldered. One face is plane 
for soldering, the other has a depression for the melting-cup. Fig. 525 shows 
the plane face with the removable rim (also of asbestos) for confining the heat, PROSTHETIC DENTISTRY. 
569 
and Fig. 526 shows the reverse face with cup and ingot-mould attached. The 
ingot-mould has three matrices of different shapes and 
sizes. Fig. 527 shows the handle. 
Treadle Blow-Pipes.-Fig. 528 is introduced 
with view of affording idea of modifications of the blow- 
pipe found in the market. The two shown are some- 
what old as to pattern, but continue to be largely used. 
Fig. 529.-Mouth 
Blow-Pipes. 
Fig. 528.-Treadle Blow-Pipes. 
Simple Means.-What, however, is shown in the 
Fletcher and Mellotte appliances is done by most dentists 
by means of a mouth blow-pipe (Fig. 529) and a piece 
of common charcoal upon which to lay the set of teeth 
or other thing that is to be soldered. 
Soldering : how learned.-Soldering is to be 
learned by use of the mouth blow-pipe. A process of 
breathing is to be acquired that permits the throwing 
of a continuous blast. The appliances shown do away, 
of course, with the necessity for wind from the lungs, but 
they are not to be employed until the simpler manner 
is understood. CHAPTER XXXIV. 
PROSTHETIC DENTISTRY. 
THE MATERIALS VULCANITE AND CELLULOID. 
Manipulations with the materials vulcanite and celluloid are so exceed- 
ingly interesting, and, at the same time, so easy of being understood and 
accomplished, that the present chapter is introduced for the instruction of 
such as wish to enter upon the practice, either with a view to profit, con- 
venience, or entertainment. 
Vulcanizing Process.-By vulcanizing is meant the conversion of a 
plastic material into a base of such solidity that it can be used for the attach- 
ment and support of artificial teeth, for obturators, and for a variety of similar 
purposes within the requirements of oral surgery. Vulcanite is a composition 
bought prepared at the depots; its components are india-rubber, sulphur, and 
sulphuret of mercury. It comes in form of sheets. 
Dental Plates as an Example.-The author describes here the 
manner of making a denture, the example applying to the working of the 
material for any other purpose. First, an impression of a mouth is taken, and 
an articulation secured precisely as described in a previous chapter, except 
that the test plate, on which the bite is re- 
ceived, is preferably made of wax for a 
reason shortly to be understood, and that 
also a layer of tin foil be made to underlie 
this wax as direct relation with the model 
is concerned. Teeth used are specially pre- 
pared for the purpose. Fig. 530 shows the 
peculiarity. 
Let it be accepted that the worker has a 
set of teeth arranged as required, which 
teeth have their fixation by reason of tem- 
porary attachment to a base plate of wax, 
which wax, in its turn, rests upon a layer 
of tin foil: teeth and base rest in turn upon 
the plaster model. The wax of the base is required to be trimmed and formed 
so that it shall represent accurately a base of vulcanite which is to take its place. 
The thickness of the wax is to vary according to position, and to requirements 
in general, from the twelfth to the twentieth of an inch. It is to be added 
Fig. 530.-Teeth used with 
Vulcanite; Front and Side 
Views. 
570 PROSTHETIC DENTISTRY. 
571 
that the joints between the gums are demanded to be as close as accuracy can 
make them. 
To replace Wax Base with Vulcanite.-To replace the wax 
base with one of vulcanite the operation is as follows: Fig. 531 represents 
a moulding-flask, composed, as will be understood, of two horse-hoof-shaped 
cups. Into the lower one of these cups a thin batter of plaster is poured, 
when the model, holding the wax plate and teeth, is sunk in this batter until 
the base of the alveolar margin is on a level with the rim. (Points to observe 
relate to cutting away the base of the model so that it shall allow of the mar- 
Fig. 531. 
gin occupying the relation to rim alluded to, and as well the immersing of the 
model in water so that it shall not too hastily and unduly soak the fluid from 
the batter.) The model and batter becoming united through the setting of 
the latter, the worker trims up smoothly so that expression of model, teeth, 
the hardened batter, and the flask are as shown in Fig. 531. Here it is 
necessary to consider what is termed the draw, or separation ; that is to say, 
that as it is the intention to cover in this whole surface with batter-plaster, 
and that later this covering is to be lifted away, regard must be had to so 
placing the model that as little interference as possible exists in the way of 
the separation. Under, or receding, spaces are to be brought out as nearly 
as permissible to the level by means of plaster. 
Varnishing and Oiling.-The draw provided for, a succeeding step 
varnishes or oils the whole exposed surface, as seen in Fig. 531, and, after 
placing the top portion of the flask, minus its cover (see same figure), fills up 
with thin batter; being most careful to avoid bubbles and to see that no in- 
terstice be left unoccupied. Next the cover is placed and the screw (see same 
figure) applied. Convenience is found in washing the batter-covered flask 
before the plaster has entirely set about the outside. 
Separating Flask.-The plaster within the flask being allowed to rest 
until it has become quite hard, the parts are separated (a matter insured by 
the precautions described), and the wax base plate is delicately picked away. 
Fig. 532 shows the expression resulting; the model is in the portion of flask 
to the left; the teeth, together with the space secured by removal of the wax, 
are in that to the right. 
Antagonizing Defects.-As it is the intention in an immediately suc- 
ceeding step to occupy the wax-space with vulcanite, and as the backs of the 572 
A SYSTEM OF ORAL SURGERY. 
ground teeth abut on this space, it is recognized that imperfection in the 
grinding would necessarily permit the fluid gum, when brought under press- 
ure, to insinuate itself into and between the spaces, thus destroying wholly 
Fig. 532. 
the appearance of perfect jointure necessary to exist in a finished denture 
Assuming, however, that inexperience, or undue haste in performance, shows 
the jointures at this stage as imperfect, the operator may, to an extent, an- 
tagonize the defect by insinuating dry plaster, touched with water, into the 
fissures; or, as is recommended by some experts, soluble glass may be painted 
into them ; the manipulator being careful to clean every part, save the fissures, 
of the foreign material. 
Turning again to Fig. 532, diagram of right side, the palatal reverse of the 
left is seen. Surrounding the palate, and corresponding with the curvature 
of the alveolar arch, the backs of the artificial teeth are seen, at least that 
portion of the backs which exposes gums and pins. Outside of the extreme 
tops of the gum a curved dig-out in the plaster is observed, the intention of 
this being to make room for that portion of gum-rim always seen on the 
boundary of a denture. The transverse cuts observed in the plaster are made 
with a view of accommodating surplusage, when the soft gum comes later to 
be crowded into the place of the removed wax. 
Packing the Vulcanite.-Packing the vulcanite, for which the parts 
are now found ready, is accomplished by using gum made soft through means 
of a steam-heated surface. This gum, cut into strips for convenience of use, 
the first piece being of a size that shall cover the palatine surface, is laid upon 
the plate, the matrice being subjected at the same time to similar heat, and, 
when the flask has become warm and the gum is softened, the latter is taken 
up by any convenient means, and is packed into every part of the locality 
formerly occupied by the wax. An excess of this gum is allowed to be pro- 
vided for by the transverse cuts, should it prove more than can be received. 
Here attention is to be bestowed on the experience that too little gum is 
the spoiling of the piece, too much is alike its destruction; the-last owing 
to the undue pressure required to move it from the matrice ; and most particu- 
larly does this apply where said transverse cuts are lacking in accord with 
requirements. 
Forcing the Paste.-The packing completed, and the cups of the com- 
mon flask being put together and the screws or clamp applied (a temperature PROSTHETIC DENTISTRY. 
573 
of 212° Fahrenheit being maintained), the parts are screwed up as closely as 
is to be accomplished by aid of a wrench. This screwing process forces most 
fully the contained pasty mass into every locality, the excess escaping into the 
transverse cuts. 
Vulcanizing Instruments.-The last performance introduces the 
vulcanizer. Of these instruments, as of the flasks, there is a wide variety; 
the one shown in the cut (Fig. 533) is quite equal, though perhaps in no way 
superior, to the many competitors found in the dental depots. A vulcanizer is 
Fig. 533. 
Fig. 534 
an apparatus made up of a boiler and a furnace. In the one shown the boiler, 
surmounted by a thermometer, constitutes an upper half, the lower half is a 
furnace. Furnace-power measures an ability to raise the temperature to 326° 
Fahrenheit, the means employed being gas, alcohol, or kerosene. Fig. 534 
shows gas, and alcohol, or kerosene, arrangements. The boiler is rimmed in- 
ternally about half an inch above the bottom, the object being support of the 
flask and accommodation of a few ounces of water. 
Consideration of Temperature.-The water being in place at the 
bottom of the vulcanizer, and being brought up to a temperature corresponding 
with that of the flask and contents, the latter are laid upon the rim, and the 
lid of the boiler screwed into place. Now begins the process of vulcanizing. 
Slowly the temperature is increased, it being a rule with many to expend an 
hour in obtaining 310° Fahrenheit, and a second to advance it 10 other 
degrees; this last secured, and being held for five minutes, vulcanizing is to 
be accepted as accomplished. In college laboratories it is not common to 
spend more than a single hour in vulcanizing; the temperature being gradu- 
ally brought up to 326° Fahrenheit without an intervening waiting. 
Cooling to be Gradual.-Cooling is to be gradual; a desirable plan is 
to leave things undisturbed until the flask can be handled without discomfort 574 
A SYSTEM OF ORAL SURGERY. 
to the fingers. The plaster, together with its embedment, being allowed to 
stand a few hours after removal from the flask, is found to grow entirely 
crumbly, and is easily broken away from the denture; to remove it, tap the 
edges of the flask. 
Concluding Steps.-The gum vulcanized, or turned into a plate of 
horn-like consistency, concluding steps refer to finishing the denture for the 
mouth. These performances relate to getting clear of all superfluous material, 
to thinning and shaping the piece into fitness and comeliness, and to compel- 
ling a polish of the inferior surface and sides of plate, which is good in pro- 
portion as it is glass-like. Instruments employed are scrapers, files, sand-paper, 
rotten-stone, oxide of zinc, pumice, cone-burs.-any means found at hand and 
convenient. Spring calipers are necessary to measurement of the thickness 
of plate. 
Chemical Meaning of Dental Plate.-The conversion of the com- 
pound gum known as vulcanite into the hard substance distinguished as dental 
plate is of chemical meaning, and relates with a catalysis arising out of an 
intensified union of sulphur and caoutchouc produced through high heat; the 
difference as to softness pr hardness being influenced entirely by that degree 
of temperature in which union is effected. 
Vulcanite Plates from a Medical Stand-point.-A concluding 
reference is to be made to the employment of the material from a medical 
stand-point. Ill effect upon the mucous face of the mouth is at times a result 
of the use of vulcanite plates, which effect is commonly attributed to the action 
of the vermilion, or sulphuret of mercury. The writer has given considerable 
attention practically to the subject, and desires to offer it as a conviction that 
trouble, exceptional cases perhaps excluded, will be found to rest in the fact 
that the material, being a non-conductor, heats the parts, particularly 
as the locality of the suction cavity is concerned, thus engendering a passing 
inflammation, which is the nature of the offence. A vulcanite denture for 
this reason is not wisely kept in the mouth during sleeping hours. 
Black Vulcanite preferred to the Red.-Black vulcanite is pre- 
ferred by many operators to the red. Here the gum is absolutely free from the 
coloring matter,-i.e., the sulphuret of mercury. The process of preparing 
this form of the material is preferably by dry heat, moisture changing it to a 
dirty-brown color. The time required for vulcanizing is seldom less than five 
hours. Black base plates take a brilliant and durable polish. Objection to 
the preparation lies in an exposure of it when in the mouth, not at all times 
to be avoided. 
CELLULOID. 
Celluloid is a pink-colored material, semi-brittle in consistency, possessed of 
greater conducting property than vulcanite, wholesome in nature, solid to an 
extent that denies soakage into it of fluids, and capable of being made into 
plates, buttons, etc., of ivory-like coolness and characteristics; its composi- 
tion is gun-cotton, camphor, and collodion. PROSTHETIC DENTISTRY. 
575 
Making a Celluloid Denture.-The making of a celluloid denture 
finds exact correspondence with vulcanite-work until the stage of packing is 
reached. Here, instead of the warmed strips and heated flask, what is called 
a blank is taken (a blank being a mould of celluloid as furnished by the manu- 
facturers, bearing fair resemblance to the ordinary denture plate), selection 
being made of a size corresponding nearly as may be to the requirements in 
the final plate. The teeth and base exposed, as seen in Fig. 532, the blank is 
laid loosely in its situation, and the other section of flask placed in position.* 
Next the flask, with its contents, is placed inside the boiler, and the screw 
(plunger it is commonly called) is turned sufficiently to lightly compress it. 
Consideration of the boiler refers us here to apparatus to be used, and of such 
Fig. 535. 
instruments, as of the vulcanizer, manufacturers offer a considerable variety. 
Fig. 535 shows a New Mode Heater, an apparatus operated with moist or dry 
heat, and applicable alike to celluloid and rubber. The circular base, resting 
* Celluloid flasks differ from those used in vulcanite, being heavier in structure and pro- 
vided with rods and grooves on the sides of the sections, in place of screws, as in the rubber 
flask, for the purpose of guiding the sections into position during the process of moulding. 576 
A SYSTEM OF ORAL SURGERY. 
upon the floor, is the gas-heating arrangement. The door, in the boiler 
portion, is a framed glass, permitting inspection of the flask-room. The 
screw-caps, four in number, three small and one large, seen on top, have their 
meaning understood by casting a glance at Fig. 536. To the right is a safety- 
valve. The left affords accommodation for a thermometer. 
New Mode Heater.-Fig. 536 is a sectional view of working parts of 
the apparatus, and affords, in its correctness, a full lesson of the manipulations 
to be described. The instrument, in its invention, is the outgrowth of what 
Fig. 536.-Sectional View of New Mode Heater. 
is esteemed by many the just view, that perfect work, both as celluloid and 
vulcanite are concerned, is to be made only in a dry chamber, and that where 
a high degree of heat is used, such as is essential in the manipulation of cellu- 
loid, the temperature must be kept uniform until the task is completed, and is 
not then to be allowed to change suddenly. 
The blank, in place as described (occupying the loosely-screwed flask seen 
here under the screws within the boiler), it is the design and indication to 
begin its pressure only when a temperature has been obtained which is to be 
just below the burning-point; this is about 320° Fahrenheit. It is common 
practice, however, to commence to turn the nuts when the blank becomes duc- 
tile enough to yield before a strength found in the fingers and thumb : about 
212°. The mode of making pressure is understood in noticing that 
screws I, H, I bear upon the top of the flask, and that compression is com- PROSTHETIC DENTISTRY. 
577 
plete only when the divisions meet at the centre line. The screw-caps K, K, 
K, L are used with a view of making the screw-holes steam-tight where moist- 
ure is depended on for the heating principle. 
Observing the diagram, 0, 0 shows a compartment separated from 
the flask- or packing-chamber; this is the water- and steam-box. Into this 
box put sufficient water to reach line A, and commence making steam by light- 
ing the gas-furnace. Temperature, as it advances, is measured by the ther- 
mometer, C, in which connection it is to be noticed that the mercury-bath, B, 
is to be kept supplied with quicksilver (or what is found to answer equally 
well, iron filings) to an extent that covers the bulb. D is a screw-plug through 
which a compound steam-faucet works. E is a gum-nut for tightening the 
packing of the steam-valve. F is stem of valve. G is a cap with a minute 
aperture, as seen, at one side. No probability of explosion lies with the 
apparatus. 
Continuing to force the flask together, little by little as the temperature rises 
to the required average, the process is to be considered complete only when 
absolute apposition is secured, after which the furnace flame is extinguished 
and the case treated precisely as was the vulcanite. 
An inexpensive apparatus replacing the one just described consists of 
a cylinder of iron large enough to hold a flask, glycerin being employed as 
the vehicle for the conveyance of heat. To use this means prepare and flask 
case. Next fix in clamp pertaining to the instrument, and, after placing the 
glycerin,-sufficient to envelop the flask,-put into cylinder. A subsequent 
step relates with the boiling of the fluid and compression of the blank. This 
apparatus presents, unfortunately, objection in the waste of time necessary to 
the preservation of a required cleanliness. 
Repairing Celluloid Dentures.-Breaks in celluloid dentures are 
repaired in the Philadelphia Dental College, under Dr. Cryer's plan, after the 
following very simple fashion: Remove all portions of broken tooth from the 
plate, taking care not to disturb the outlines of the socket. Select another 
of proper size and shade to replace the lost one. (If the tooth be numbered, 
a considerable part of the trouble of selection is saved by taking the number 
of the mould from the reverse impression in the plate, or from the broken 
pieces.) Having set the new organ partly in its place, hold it steadily over 
the flame of an alcohol lamp, carefully guarding the celluloid from contact 
with the flame. In a few seconds it will grow warm, and its heat will soften 
the plastic sufficiently to allow the placing of it in proper position. The at- 
tachment will cause, of course, a slight bulge, or raised spot, to appear in the 
celluloid opposite the oral aspect of the root of the tooth. Invest in plaster, 
in the deeper section of the flask, covering the whole plate and the teeth, 
except the small portion of the celluloid raised in pressing the tooth into 
place. Complete the investment, part the flask, and dry the case, after which 
insert a piece of rather thick writing-paper or heavy tin foil over the raised 
spot, and place in the oven. Heat up to the usual temperature for moulding 578 
A SYSTEM OF ORAL SURGERY. 
and close the flask. When the case is cold the tooth will be found firmly 
fixed in its position, and there will be no mark to show that the plate had 
been repaired. In case a small portion of the celluloid is chipped away from 
the front of the socket,-enough only to expose the end of the root when 
in position,-drop a little wax upon the vacant spot, after placing the tooth, and 
carve to the shape desired. Without removing the wax, invest and mould as 
before described. The wax will pass off into the plaster, and its place will be 
supplied by the celluloid, of which there is usually enough to permit the 
flowing of the minute quantity required without damage. 
If there be a similar deficiency on the inside of the plate, exposing the pins 
of the tooth, drop wax into the vacancy, and proceed as before, except that 
in this case the wax is to be removed when the investment is made, and the 
bit of writing-paper or tin foil is to be placed just below instead of over the 
pins, so as to force the flowing of the celluloid to cover them. 
Herbst's Method of repairing.-For repairing rubber plates quickly, 
Dr. Herbst is quoted as drilling two holes about the thickness of the ordinary 
mandrel into the rubber plate, in a direction to correspond to a dovetail. 
These holes he fills with a round piece of celluloid, letting it extend some- 
what upon the labial surface of the teeth. Then the tooth to be set is warmed, 
held over an alcohol lamp, and as soon as the celluloid softens upon its outer 
surface it is pressed into position and held there until cold. A tooth replaced 
in this manner is thought by the deviser of the plan to serve almost as well 
as though it were repaired by vulcanizing. It can be set in a very few 
minutes. 
Detaching Teeth from Celluloid Plates.-To detach a tooth from 
a celluloid plate, hold the outside surface of the one to be removed in the 
flame of a lamp until the heat softens slightly the plastic about the pins, when 
it may be taken off without trouble, and it will come away clean, without 
any of the celluloid adhering to the metal. Do not move the plate back and 
forth through the flame, else others than the desired tooth may be loosened, or 
articulation may be interfered with. There is little danger of cracking a heated 
tooth so long as the flame does not come in contact with the pins. 
Celluloid for Purpose of Continuous-Gum Work.-The writer 
inclines to the conviction that continuous-gum work will, later on, be accom- 
plished exclusively by means of celluloid. The agent allows easy imitation of 
the natural part, is tenacious in its hold of teeth and plate, denies all inter- 
spaces, and is, in itself, clean and sightly. Continuous-gum work is, undeni- 
ably, the highest accomplishment in artistic dentistry; each tooth is available 
for placing in any position desired, and for study, as expression is concerned. 
Objection to such dentures, as the ordinary manner of making them out of 
porcelain is concerned, relates with weight, absence of elasticity, and expense 
in repairing accidents 
Directions for Working.-The following are directions applying to the 
new mode continuous gum, vulcanite being used as a base : PROSTHETIC DENTISTRY. 
579 
Employing teeth made expressly for continuous-gum or celluloid work 
(Fig. 506 shows such), set them up in wax after the usual manner, leaving 
the front, or outside, of the roots exposed. Cut a thin strip of the wax, 
warm, and attach it to the upper edge of the portion of the wax plate 
representing the gum, forming a rim which extends all around the outer 
margin. Finish the palatine surface 
to the form desired, invest in the flask 
in the usual manner, remove the wax, 
pack with rubber, and vulcanize. When 
removed from the flask, the case will 
present the appearance shown in Fig. 
537, the front or outside of the roots 
being exposed and the narrow under- 
cut rim extending all around, leaving 
a space with retaining-grooves between 
the teeth, for forming a gum of cellu- 
loid, looking very much as though the substance of the plate had been gouged 
out for the purpose. The vulcanite plate is now completed, with the teeth 
firmly attached to it. 
To put on the Gum.-To put on the gum, fill up the groove with 
paraffin and wax (this compound, not being sticky, does not adhere to the 
instrument, and is therefore most easily carved to the form desired) until all 
the space inside the rim, including the retaining-grooves between the necks of 
the teeth, is occupied. After the wax has hardened, which may be hastened 
by placing in cold water, carve it into the desired form of gum. The wax 
may be made very smooth by throwing about it the flame of a spirit-lamp with 
the aid of a blow-pipe, taking 
care not to destroy the outline 
of the carved gum. Cover the 
wax with heavy tin foil, bur- 
nishing it lightly, but smoothly, 
to the wax. 
Reinvesting the Piece. 
-Invest the piece again in the 
following manner: Place the 
plate in one section of the flask 
with the teeth upward, and 
raised at the front at a greater 
ar less angle, as may be neces- 
sary, so that when the invest- 
ment is completed the upper part of the flask may be removed without drag- 
ging. Embed in plaster to the rim, and pour batter over the palatine surface, 
covering the crowns, and taking care to fill the interstices between the necks 
of the teeth, but leaving their outer surfaces exposed. After the invest- 
Fig. 537.-Case ready for Gum. 
Fig. 538.-Celluloid Blank Rim. 580 
A SYSTEM OF ORAL SURGERY. 
ment sets, pour more plaster around the inner edge of the flask ring, form- 
ing a ridge, leaving a groove or space between it and the plate. (See Fig. 532.) 
Complete the investment, and remove the wax from the groove and interstices 
between the roots of the teeth by pouring boiling water over it. Having 
selected a celluloid blank of proper size, saw off the outer rim; in other 
words, make a semicircular rim; warm this rim of celluloid in boiling water, 
and with the hand and a cloth press it closely about the teeth, and hold it to 
its place until stiff; it will then remain there until the two parts of the flask 
are entered upon the guide-pins. Join these two parts of the flask together and 
place the investment in the oven of the machine, having previously heated up 
the chamber. When the temperature of 280° Fahrenheit is reached the flask 
may be closed. As soon as this is accomplished the case is ready to be removed 
from the oven and placed in a clamp to cool. 
Removal of Plate.-When entirely cold remove the plate. The tin 
foil will adhere to it, but can readily be removed by inserting the point of a 
knife under the edge and pulling it off. A surface produced by the above 
method presents a smooth, polished gum, but if the tin foil used be " stippled" 
a striking resemblance to the natural part is produced. The adjoining edges 
of the celluloid and rubber will be found perfectly united, each preserving a 
sharp outline. 
Celluloid Gum upon Metal Base.-A second manner of making 
continuous gum out of celluloid relates to its use on metal bases. First an 
impression of a mouth is taken, 
and a plate of silver, gold, or plati- 
num is prepared.* This plate is 
tried, and, if found to fit, teeth 
like those shown in Fig. 506 are 
arranged on wax after a manner 
that secures both articulation and 
physiognomical adaptability. The 
piece, as it thus stands, is handed 
back to the dentist, who sets the 
case up in plaster, backs the teeth 
with metal, and solders the parts indifferently together. Taking the denture 
as now prepared, it is again tried in the mouth, a gum structure having been 
built out of wax about and around the teeth. This stage introduces the cel- 
luloid pack, which is accomplished and the piece finished precisely as described 
in preceding paragraphs. Fig. 539 shows a metal plate with stippled celluloid 
gum attachment. 
Fig. 539.-Metal Plate with Cellu- 
loid Gum. 
* Refer to description as to taking impressions and making metal plates, on page 544. CHAPTER XXXV. 
PROSTHETIC DENTISTRY. 
ARTIFICIAL DENTURES UPON GOLD OR SILVER BASE. 
The chapter introductory of prosthetic dentistry having treated of the 
manner of getting impressions of a mouth to be fitted with a plate, and as 
well the manner of securing the articulation, or bite, it is the purpose of the 
present one to show the way of making a metal denture. 
Test Plate.-By a test plate is meant a construction demonstrative of 
the measure of correspondence, of a model that has been made, with the mouth 
which it represents. An impression, either in wax or plaster of Paris, having 
been taken and a model secured from it after the manner described (see page 
544), a piece of sheet-lead is moulded over its face, and, being trimmed to 
represent the plate that is to replace it, is tried in the mouth. If this fit 
accurately it proves the model to be right, and the process may advance to 
construction of the base plate. 
To make a Base Plate.-A base plate, either of gold or silver, is 
made as follows: Take a moulding-flask, which is a simple rim of iron or tin 
somewhat wider and deeper than the 
plaster model, and put it around the 
model which has been laid upon a 
table, or moulding-board, with its face 
looking upward. Next fill up the flask 
with moulder's sand or marble-dust, 
preferably the latter, that has been pre- 
viously wet and tempered. Pack this 
reasonably solid, beginning with the portion first put in and concluding with 
that which covers the face of the model and completes the filling of the flask. 
This done, reverse the flask and, having screwed a delicate gimlet into the 
base of the model, a piece of wood having been placed in the batter at time 
of pouring for that purpose, give a few gentle taps, when the model may be 
lifted from the sand without disturbing in the least the impression. This 
completes the mould. 
Making the Die.-A die is most commonly and conveniently made by 
use of zinc. A ladle-one not used for other purpose-is employed for the 
melting. To pour the fluid metal it is desirable to begin at one corner of the 
mould and to flow gradually and gently until the face portion is covered. 
Fig. 540.-Moulding-Flasks. 
581 582 
A SYSTEM OF ORAL SURGERY. 
The fluid mass fully solidified, it may be dug from the sand and thrown into 
water. 
Testing Accuracy of Die.-To test the die the lead trial plate is to 
be employed. It is not likely that this will rest in place as upon the plaster 
model, explanation lying with drawing of sand about the alveolar border, 
which has, of course, added an excess of zinc. This excess is to be cut from 
wherever the test plate shows that it exists. The trial, or test, plate, fitting 
the zinc as it does the plaster and mouth, manipulation is to pass forward to 
the counter-die. It will impress the student that his lead test plate is to be 
handled with exceeding care that risk of bending it be avoided. 
Making the Counter-Die.-A counter-die is made out of lead, and 
this also is to be melted in a ladle that is used for no 
other purpose. Take the zinc die and lay it, back 
down, upon the moulding-board or table. Fill below 
and around with sand, lining the circumference of the 
flask, and covering all the zinc cast save its face and 
alveolar border, A, B, C. This done, pour the lead over 
the exposed zinc. The casts, when cold, are easily 
knocked apart by use of a hammer. (See Fig. 541). 
Making Die direct from Impression.-A 
student, having informed himself as to the method of 
making a die after the common manner, is now to learn that one may be made 
by pouring the melted zinc directly into an impression. Such an impression 
is taken by means of a mixture composed of equal parts of ground silex and 
plaster of Paris. It is to be understood that the impression is to be fully dry 
before attempting the casting. 
Measuring the Plate.-A succeeding step flattens and spreads the lead 
trial plate upon the metal to be used for the permanent plate and maps out 
its form, leaving, however, some little latitude, as to size, in consideration of 
a possibility that the swaging may not occur entirely satisfactorily. Metal 
shears are used to cut out the piece. 
Annealing.-A plate, before being ready for swaging, is to be annealed. 
By this is meant that it be heated to redness with view to softening. This is 
commonly accomplished by laying the metal on a piece of charcoal and direct, 
ing a strong flame upon it by means of the mouth blow-pipe. 
Swaging the Plate.-The plate being softened, it is next taken and 
laid upon the zinc cast, and, after being forced with fingers and pliers indif- 
ferently into place, the lead counter-cast is laid on top of it. A reverse now 
being made,-that is, the lead being turned below,-it is laid upon the anvil 
and with well-directed blows from a heavy hammer zinc and lead are forced 
together, the gold, or silver, as the case may be, being between them. Such 
first swaging but partially accomplishing the proposed end, the plate is re- 
annealed and again subjected to the dies. This manipulation, if found neces- 
sary, is repeated until fit is obtained. 
Fig. 541.-Illustra- 
tion of Text. PROSTHETIC DENTISTRY. 
583 
Pickling.-The next step is known as pickling, or taking off a fire-coat 
that has associated with the annealing; this is nothing more than subjecting 
the plate for a greater or lesser length of time, commonly half an hour, to 
an acid bath consisting of equal parts of sulphuric acid and water. Removal 
of the fire-coat is not necessary at this stage of construction, although com- 
monly practised. Where time is a consideration, the pickle is to be heated 
or even boiled. A strong solution of alum is not infrequently employed in 
place of the acid. Where this is used it must always be boiling hot. After 
removal from its bath the plate is to be thoroughly washed. If the acid has 
been used, it is desirable to add a little soda to the water. 
Filing and Fitting the Plate.-A plate, as thus struck up, requires 
what may be termed refining,-that is, it is to be filed and fitted to the plaster 
model, and later to the mouth, after a manner that implies accuracy of adapta- 
tion. It is not to rock. It is not to reach back beyond the line of the hard 
palate. In its flange, which encircles the alveolar process, it is not to intrude 
on the alveolo-labial mucous membrane. It is to prove of a fit that allows of 
all air being sucked from beneath it, this being witnessed in the solidity of its 
holding as a result of atmospheric pressure. Fig. 548 (which see) shows a 
plate for superior arch fitted and ready to have the bite taken. The raised 
centre is a vacuum cavity, which has been secured by placing a corresponding 
piece of lead upon the plaster model before the sand-mould was made. 
Taking the Bite.-See, for the taking of bite, or articulation, both as 
complete and partial dentures are concerned, page 553. 
Kind of Teeth to be used.-Teeth in every variety are supplied by 
the manufacturer at a price which renders it waste of time to attempt to pro- 
duce them for one's self. Single and gum teeth are used with metal plates. 
The first are much the easier to relate with the base, and have their use con- 
fined commonly to what is understood as a temporary denture,-i.e., a piece 
designed to serve for a time that corresponds with the absorption of the 
alveolar process. The second, teeth having gum structure attached, require 
Fig. 542.-Plain 'Teeth. 
much grinding in order that they may conform to a plate and to aesthetic 
requirements. Fig. 542 shows plain teeth ; Fig. 543 shows gum teeth. Gum 
teeth are to be bought singly or in blocks. Whether one or the other of the 584 
A SYSTEM OF ORAL SURGERY. 
kinds shall best meet the wants of a case depends on circumstances. Exposure 
of the joints is, of course, decidedly objectionable ; hence, ordinarily, the fewer 
of these the better. Every plate 
tooth is furnished with a back- 
ing in the shape of platinum pins, 
commonly two to each tooth, the 
intention of these being to allow 
of a metal attachment or stay. 
(See subsequent description.) 
To secure Kind of Teeth 
to be used.-Persons doing 
dental work commonly keep on 
hand a variety of sets of teeth 
from which to make their selec- 
tions. Where this is not the case, it is alone necessary to send a waxed plate 
and its plaster cast, together with the articulating model and a shade tooth, to 
some neighboring dental depot, where experienced hands quickly determine 
and send back what is required. (See Fig. 499.) 
Grinding and Fitting Teeth.-This is one of the refinements of 
dental art, and the number who attain proficiency in it is not large. To grind 
a set of teeth means to fit them not only to the plate and to each other, but 
to attain to such conformity with the physiognomy of the person in whose 
mouth the denture is to be placed as to render teeth and face of common 
likeness. The grinding appurtenance is a corundum wheel revolved on the 
mandrel of a hand- or foot-lathe, much the most preferably by the latter. 
(See page 564.) The worker, having his articulation, is able to see exactly 
where and how the artificial teeth are to be set in order to show aesthetically 
and to relate properly with the associate denture. This is an art that is to be 
learned by practice alone. The objects to be attained demand time and earnest 
care. Where gum teeth are the kind used, the jointing is perfect only when 
scarcely distinguishable. No tooth or point of a tooth is to touch before its 
fellows. Teeth are to be neither too long nor too short, nor too broad nor 
too narrow. They are to stand regular or irregular as required by conform- 
ity with the expression of her or him in whose mouth they are to be worn. 
Besides fitting, as the approximation of the external gum-face is regarded, 
the necks of the teeth are required to rest solidly against the plate. 
Centre of Gravity.-Centre of gravity considers support given by a 
tooth when pressure is brought to bear upon its grinding surface. If this 
pressure is carried after a manner that brings it to the inner surface of the 
alveolar arch, the denture holds up; if, on the contrary, it falls to the buccal 
side, the piece tilts. 
The subjects of gravity and relation are to command much atten- 
tion. Perfect dentures are expressed in equilateral triangles, as illustrated 
in Fig. 544. The lower is the lesser arch. The superior teeth close over 
Fig. 543.-Gum Teeth in Blocks or 
Sections. PROSTHETIC DENTISTRY. 
585 
Fig. 544. 
Arches ok the superior and inferior jaws. A-B shows the width of the base 
or hinge of the jaw; A-C and B-Cshow the length of the line from the condyloid 
process to the centre of the curve of the inferior Incisors. 586 
A SYSTEM OF OH AL SURGERY. 
and in front of the inferior. Study of the figure exhibits the teeth as in- 
clining circularly and inward, wherein lies what is meant by centre of gravity. 
Quoting from Dr. E. S. Starr, whose patience has supplied the illustrations: 
The centres of the tips of the anterior superior teeth are in the arc of a 
circle, the centre of which is found by measuring from between the centrals 
along the median line of the mouth a distance equal to the combined widths 
of the superior central, lateral, and cuspid, taken at the lines of greatest 
breadth. A line, at right angles to the median line of the head, through the 
centre of this circle, which is known as the circle of the mouth, will pass 
through the centres of the second bicuspids; and a similar line, parallel to the 
first, through the posterior periphery of the circle, will pass through the pos- 
terior edges of the second molars. 
The cuspis and the anterior buccal cusp of the first molar form, respec- 
tively, the primary and secondary springs of the superior arch; that is, they 
mark decided changes in its direction. In Fig. 544 the superior central, 
lateral, and cuspis lie in the arc of the circle of the mouth. At the cuspis 
the direction changes; the buccal faces of the teeth between the cuspis and 
the anterior buccal cusp of the first molar lie in a straight line. At this 
latter point, which is usually prominent, the arch is again deflected slightly 
inward. 
In the inferior jaw there is no secondary spring of the arch. The four 
incisors are more nearly in a straight line than their corresponding teeth in 
the superior jaw. The direction changes sharply at the cuspis, and thence 
forms a continuous, gentle curve along the buccal faces of the teeth, though 
the lingual faces of the posterior teeth approach very closely to a straight line. 
(These latter points do not appear in Fig. 544, as the teeth were drawn in 
position to give a perspective instead of an exact face-view.) 
Quoting the observations of Dr. Bonwill: In ninety-five per cent, of cases 
the superior jaw projects beyond the inferior, the depth of the underbite 
varying from three-eighths to one-sixteenth of an inch, and in not more than 
five per cent, of articulations do the incisors come directly together. The 
ramus has a definite curvature, and the depth of the underbite and the length 
of the cusps of the bicuspids and molars correspond therewith. The teeth in 
the arch posterior to the cuspids are almost directly in a straight line toward 
the centre of the condyles. 
The substantial correctness of these conclusions are to be accepted. 
Peculiarities of Bite and Peculiar Teeth.-Fig. 545, with its 
subfigs. 1 to 8, are introduced with view of assisting a student in selecting 
teeth. The bite is seen to differ with each pair. In the first of the series 
the artificial tooth is shown as receiving the natural organ by direct superior 
contact. In the last one the bite is upon the base of the artificial tooth. In- 
termediate expressions are shown by the remainder of the series. These bites 
are not selections made by the operator, but are in conformity with natural 
requirements. It is to be appreciated that there are such requirements, and PROSTHETIC DENTISTRY. 
587 
that, as well, teeth are specially made to meet them. The illustrations con- 
stitute a study not to be left by a student until appreciated. The perfect bite 
is with No. 3 of the series. 
Fig. 545. 
Casing the Teeth.-By casing the teeth is meant the investment of a 
denture in a mixture of plaster and sand, or plaster and marble-dust. Having 
the grinding and articulating done to suit, a denture is lifted from the plaster 
model and laid in a batter of plaster and sand, this batter being built about 
and a trifle above, and overhanging, the teeth. When this batter has become 
thoroughly dry, and not before, the wax, into which the teeth are stuck, is 
picked away little by little, until, being all away, the palatal, or pin, faces of 
the teeth stand fully exposed. It is to be remarked that where a subsequent 
soldering is to be done solely by means of a mouth blow-pipe the batter is 
wisely associated with the face of a block of charcoal, this allowing of conven- 
ient handling, and assisting in the heating process. Where, on the other hand, 
the heating up is to be commenced, and perhaps concluded, in a furnace, batter 
and denture are to stand alone. The casing is always to have scattered through 
it pieces of wire, as these control cracking and prevent the teeth being drawn 
out of position. Filaments of asbestos interspersed in the batter is to be 588 
A SYSTEM OF ORAL SURGERY. 
commended with view to control of cracking. Fig. 546 shows a set of teeth 
incased, and affords accuracy of idea as to what is implied in the description. 
The diagram exhibits the plate lying upon the batter and this material built 
Fig. 546.-Denture incased in Batter. 
about the outer faces of the teeth, the pins of the inner faces showing through 
the stays or backings. The right side shows two molar teeth, the batter 
having been cut away with view of affording idea of the position of wire 
recommended to be introduced to guard against fracture. The left side shows 
backed teeth put back in place and supported by fresh batter put about the 
articulating faces. 
Backing the Teeth.-The diagram introduces to the backing or staying 
of the teeth. To do this a strip of metal, the same kind as the plate, but of 
heavier gauge, is taken, and, being laid against any selected tooth, it is filed at 
its base to exactly and closely fit the plate. Next the face corresponding to the 
tooth is smeared with wax and, while rested in place upon the plate, is pressed 
against the pins. The points of impression are now punched (see Fig. 519), 
and the tooth being lifted with all care from its casing, so as to disturb the 
plaster as little as possible, the metal is cut off and fitted to it, this fitting con- 
sisting simply in passing the pins through the corresponding holes that have 
been made and fastening by use of a rivet-hammer. The backings are, of 
course, to be nicely bevelled and finished before being riveted to the teeth. 
When all the set have been backed each tooth is to be put into its place and 
held by means of some fresh batter applied so as just to cover the articulating 
edges, yet in no way to intrude upon the seat of riveting. PROSTHETIC DENTISTRY. 
589 
Soldering the Denture.-The experienced manipulator commences by 
scraping the various places where he wants his solder to flow. Next a piece 
of borax is made to yield a cream by being rubbed up with water upon 
a slate. The solder to be used* is now cut into delicate strips or pieces, 
and, being washed in the cream, is laid against the surfaces over and upon 
which it is to be flowed, which surfaces have been brushed with the same 
cream. 
Parr's Flux.-The use of borax, however, is to be happily replaced by 
Parr's flux. This is a preparation that is furnished in form of powder. Use 
of it consists simply in dusting a trifle upon solder and plate. It brightens the 
parts as it melts, thus doing away with occasion to scrape the seat over which 
the solder is to run. Its effects are simply wonderful as a flux, and, being 
once used, a worker would not be likely to return to use of the borax. 
Flux united with Wax.-Another use to which this flux is put unites 
it with wax. Parts to be soldered are to be stuck together by wax mixed 
with the powder, the solder being stuck into it. The wax when melted by 
the flame evaporates, leaving the flux to act on plate and solder exactly as 
though no wax had been present. 
Heating up a piece of work requires that the process be advanced with 
much care in order to avoid cracking the teeth, heat too quickly and freely 
applied being almost sure to do this. Heating is not only to be gradual, but 
regular and harmonious as the mass is concerned. This, of course, would be 
the case where a furnace is used, but where a blow-pipe is depended on the 
reverse is apt to occur. The flame is never to be directed on particular points 
save when it is seen that the flow is about to take place. Soldering accom- 
plished,-and this is certainly the pons asinorum of the whole process of 
denture-making,-the incasement is to be allowed to cool slowly, the batter 
* Solders.- Solders are best bought. The following are formulae : 
Silver Solder. 
1. Fine silver 3 parts. 
Brass 1 part. 
2. The old silver three-cent piece. 
Pure gold 6 dwts. 
Fine silver 1 dwt. 
Roset copper 2 parts. 
4. To one pennyweight of clippings from a 
gold plate to be soldered add three 
grains of cadmium. Excess of cadmium 
will burn a hole through the plate. 
Running of the alloy is attended with 
evaporation of the cadmium, so that 
a denture, when soldered, contains none 
of it. 
5. For use on a twenty-carat gold plate use 
a twenty-carat solder. Advantage of 
using so high a grade of solder in the 
original work is that it allows of re- 
pairing by use of a lower grade without 
danger. 
Gold Solder. 
1. Gold coin 28 parts. 
Silver coin 6 " 
Brass . . 2 " 
2. Gold plate 34 parts. 
Silver coin 7 " 
Copper 1 part. 
Brass 1 " 
3. To solder a gold plate not less than twenty 
carats fine, the following is recom- 
mended : 590 
A SYSTEM OF ORAL SURGERY. 
being broken or soaked away from the teeth only when all heat has departed. 
Pickling, as before described, completes this step of the work.* 
Finishing the Denture.-The nature of this work will be appreciated 
without particular description. Scrapers and bur-headed files are used to trim 
away redundant solder. All scratches are smoothed out and the general sur- 
face of the plate is equally polished with a burnishing iron. Revolving or 
the ordinary watchmaker's brushes are used for the purpose of carrying rotten- 
stone, rouge, or such other material of this nature as may be employed. It 
will be appreciated that trouble in finishing corresponds with carelessness or 
inefficiency in soldering. Yet, however carefully soldering may have been done, 
the smoothing, polishing, and planing of a denture demand much time for their 
accomplishment. Arkansas, Scotch, or water of Ayr stone lends assistance in 
the work of finishing, and where there are many or deep scratches the per- 
formance is expedited by use of fine sand-paper. Finishing is generally 
concluded with rouge or whiting. 
Fitting the Plate to the Mouth.-This is one with articulation, which 
see. However accurately and judiciously articulation may have been made 
with the models, it is more than likely that certain greater or lesser changes 
are required to render the bite practically correct when the artificial and natu- 
ral teeth are brought into relation. Placing the denture in the mouth, the 
teeth are closed upon each other. If occlusion occur principally upon 
one side, the denture will be tipped and fall. If impingement exist inter- 
mediately,-that is, if a point here and another there around the arch strike 
out of a common articular relation,-a sense of lack as to solidity will express 
itself to both mechanician and wearer. Correction is made by grinding as 
required. * It happens, however, in instances, that articulation is 
so nearly correct as to render the unduly impinging parts undistinguishable 
by the eye. Here it is a common plan to have the bite made upon a piece of 
interposed carbonized paper. The places indented mark the localities requiring 
to be ground. 
Interlocking of cusps is to have consideration. Where this exists the 
gliding, grinding motion of the lower jaw is interfered with. To remedy it 
commonly requires but a few light touches of the stone. 
Biting the cheek is common to newly-placed dentures, explanation lying 
with contraction of muscles allowed by absence of proper support from the 
natural teeth. The condition corrects itself commonly after a few days; if 
not, it becomes necessary to see if the centre of gravity of the artificial teeth 
be right. (See Centre of Gravity.') 
Cutting the labial or buccal fraena, or undue pressure made along 
the alveolar border, is a not uncommon defect with a newly-placed plate. The 
depth of the vestibule varying with most mouths, this being influenced by the 
* A pickle made of hydrochloric acid is preferred by some over the sulphuric for fine 
gold-work. PROSTHETIC DENTISTRY. 
591 
state of absorption of the process, it follows that while some plates may have 
the alveolar flange very wide, others must have it correspondingly narrow. 
The flange being unduly wide or close fitting, the file quickly corrects the evil. 
Intrusion of plate on soft palate, the metal reaching so far back 
as to cross the border of the hard palate, requires that the part be shortened; 
otherwise the denture is continually being thrown down. 
Defect in suction may rest with plate or wearer. Where fault is in the 
first direction, lack as to accuracy of fit is to be inferred, and correction is not 
unlikely to be made through free use of the planishing iron. Where it is in 
the second of the directions, the wearer is to be trained in the required manip- 
ulations. 
Gagging and retching from wearing a plate is commonly of short 
duration where the denture fit fairly well and does not reach too far back 
in the mouth. The latter of the directions is the first to be looked after. 
Rinsing the mouth and throat with a saturated solution of bromide of 
potassium is a valuable means of control. 
Pain resulting from over-suction is to be obviated by rounding some- 
what the edges of the vacuum-cavity, which examination will show not to have 
been sufficiently bevelled. (See Vacuum Plates.') 
Paralysis of oral roof related with the wearing of a denture has its 
meaning in pressure made on the palatine nerve; the edge of the vacuum- 
chamber presses it. Cure is in filing away, or in rounding, the point of 
pressure or in shifting position of chamber. 
Expression in denture is the marring or making of a wearer's face. 
Every countenance has its individuality, and no two sets of teeth are to be 
made exactly alike. Expression, however, is a matter to be attended to when 
teeth are upon the wax and when change of any and every character implies 
nothing more than pushing in this direction or in that, or in twisting, as may 
seem desirable. The cardinal point to consider is the omnivorous meaning of 
the human teeth. Herbivorae and carnivorae are expressed, as man is con- 
cerned, in the character and relation of later incisor and cuspid teeth. Absence 
of the first and prominence of the second result in an expression of ferocity. 
The condition reversed, an appearance of tameness associates. Regularity 
of setting is to be avoided where a face is irregular, as, the contrary existing, 
regularity of setting is the indication. A stumpy, heavy man will find corre- 
spondence with himself in short and broad teeth, as, on the other hand, a tall 
and frail lady has her want met in teeth of corresponding length and delicacy. 
Where the lower teeth are worn partly away the artificial teeth 
of the upper denture are to be ground into correspondence. Natural teeth 
being twisted in the arch, or of irregular relation, compel reasonable corre- 
spondence on the part of the foreign organs. Gums showing unduly is 
as often a seeming as a real fault; the wearer is not used to his teeth. More 
than this, the denture goes up as the process absorbs, so that it is often the 
case that gums showing over-prominently at time of insertion cease to show at 592 
A SYSTEM OF ORAL SURGERY. 
all after a few months. Plain teeth ground to fit the gum are at times 
objected to by reason of not relating closely enough with the flesh ; this 
objection also commonly cures itself by a few days' wearing of the plate. 
Remarks.-The description given of making a denture and fixing it in 
the mouth shows the performance to be quite akin with the simpler work of 
a jeweller. A principle of construction, however, has only been given, but, 
so far as it goes, it applies to every kind and variety of metal-base dentures 
that is made, and to understand, and to be able to practise, what has been de- 
scribed is to be able, sooner or later, with growing experience, to pass to any 
complication that may possibly offer, as, for example, the construction of 
obturators and vela. 
The set of teeth just constructed, on paper, might possess, or 
be without, a vacuum-chamber; nothing particularly was said about this. No 
reference was made to a rim bordering the flange, in presence or absence of 
which is refinement and cleanliness or crudeness and filthiness. The teeth 
might have been single or in sections; this was not considered. In short, the 
single idea of the description relates with making a set of teeth,-sans any- 
thing but being a set of teeth. 
Rimming.-By rimming is implied supplying the free border of the 
flange with a facing in the way of a narrow band of very thin metal, which 
is so soldered to this free edge that as 
it reaches downward on the external 
alveolar face of the flange it stands 
off from it, leaving sufficient space 
for accommodation of the gum base, 
which is so ground as to slip into the 
groove. The ordinary letter re- 
versed affords idea of the cross-sec- 
tion of such groove, or it is to be ap- 
preciated in referring to the rim of a 
watch-case as this receives the crystal. 
In finishing the denture the delicate 
and yielding rim is planished tightly against the gum. This performance, as 
appreciated, conceals entirely the base of the continuous gum, just as the 
watch-rim covers and conceals the circumference of the glass, and yields a 
refined, clean, and beautiful finish to the parts. Fig. 547 shows a plate so 
rimmed. 
Means for holding Plates in Place.-Dental plates are held in 
place by means of atmospheric pressure, spiral springs, or bands. The first 
and last named are the common manners, the intermediate is obsolete. Besides 
these, gravity, or weight, is to be named in connection with fixation of lower 
denture. 
Atmospheric Pressure.-Fig. 548 shows a plate ready to have the 
rim and teeth attached, which exhibits upon its palatine face what is known 
Fig. 547.-Showing an Upper Plate 
with Rim. PROSTHETIC DENTISTRY. 
593 
as a vacuum-chamber. This chamber has the meaning of a space preserved 
between the metal and roof of mouth, and is intended to be of such accurate 
adaptation to the soft parts, as its circum- 
ference is concerned, that the air may be 
readily drawn out by tongue-suction. To 
secure the vacuum-chamber in a 
plate, nothing more is necessary, as has 
been suggested, than to take a piece of 
sheet-lead of a thickness and shape corre- 
sponding with the required cavity. This 
piece is fastened by means of varnish, or 
a thin coating of wax, upon the centre of the oral roof of the plaster model 
before making the sand mould. It follows that the mould contains a corre- 
sponding depression, and that when the zinc is poured it corresponds in 
turn with the elevation placed upon the plaster model, and still further, that 
when the lead counter-die is run over the zinc it, in turn, holds a correspond- 
ing depression. The striking of a plate between a die and counter-die so 
related makes, of course, the chamber seen in the diagram. Wax, in 
place of the lead plate, is used by many to make the vacuum elevation 
upon the plaster model. This is nothing more than pressing a softened piece 
into the locality and trimming to suit.* Holding of a plate by means of atmos- 
pheric pressure is secured, and, as thought by many, preferably, by a plain 
plate njade to fit the mouth with such accuracy that no air can remain beneath 
it. Springs will be considered in connection with partial denture, which see. 
Preparing a Plaster Model for the Mould.-In order that a plaster 
model may be withdrawn readily from the sand it is necessary so to trim and 
bevel it that a somewhat pyramidal shape obtain. It is also of service to 
smooth it in every part by the use of a thin coating of sandarach or shellac 
varnish ; these last being made by dissolving a quarter of a pound of the gum in 
half a pint of alcohol. Preparing the model means freedom from indentations 
or undercuts, or from any kind of a depression or irregularity that will inter- 
fere with drawing it from the mould. Some mouths, for example, have a less 
circumference above than around the free border of the alveolar process. 
Here, of course, the border, in being drawn through the lesser circumference, 
would break away the sand, thus rendering the mould worthless. Obviation 
is here made by so filling the depression with wax as to complete the general 
pyramidal form. 
Much difference exists, as regards this pyramidal aspect, between an 
edentulous model and one occupied by scattered teeth. In the latter case 
great care is necessitated, the knife and wax being called into constant requisi- 
Fig. 548.-Vacuum-Chamber. 
* A variety of chamber-making instruments are to be found on sale, among which is the 
Gilbert chased suction-cavity. The lead or wax, as described, meet, however, the indica- 
tions entirely. 594 
A SYSTEM OF ORAL SURGERY. 
tion. Directions for trimming and filling up are complete in attention called 
to the necessity for securing a draw. 
Rugae seen upon the roof of the mouth are to find exact corre- 
spondence upon the models, both plaster and zinc. That this be insured, the 
impression being perfect, the varnish coating is to be very thin. Where the 
sandarach is lumpy or thick, and is so used, it is almost a certainty that the 
depressions between the folds become filled up. Shellac is counted by many 
the better varnish to employ. 
Full Cases. Upper and Lower Dentures.-The making of a full 
upper and lower denture differs in nothing from the descriptions given as to 
making a single set, except that the construction of the two cases goes on syn- 
chronously. This necessity for working the two plates together lies with the 
importance of insuring proper articular relations. (See page 554.) 
Partial Sets of Teeth.-Fig. 549 shows a partial denture designed to 
replace teeth lost from the lower jaw. A case made after this fashion depends 
Fig. 549.-Partial Den- 
ture. 
Fig. 550.-Plate cut out ready for 
Swaging. 
on accuracy of adaptation for support. How partial cases are prepared is to 
be understood by studying Fig. 550. The places cut out of this plate stand 
for teeth remaining in the mouth. Such a piece of metal is easily secured by 
means of a lead test plate. A piece of tea-chest lead is laid upon the plaster 
model, and being moulded over the palate and forced into the interspaces, is 
cut to the exact shape and character required for the permanent plate. Such 
a test plate being secured, it remains simply to lay it upon the metal intended 
for the permanent plate and to mark this latter so that it can be correctly cut 
and filed out.* 
Manner of holding Partial Dentures.-Partial dentures are held 
in place in the mouth by means of bands clasped about the natural teeth ; 
otherwise by suction. 
Bands.-Gold alloyed with platinum furnishes the best band. To fit 
such band to a tooth it is first to be adapted to the model. This, where a 
* What are known as rat-tail and half-round files are used. Curved metal shears do the 
cutting. PROSTHETIC DENTISTRY. 
595 
tooth abuts the one to be clasped, implies necessity for separation,-a process 
first to be effected on the plaster and later with the natural teeth. To separate 
teeth of model, or the natural organs, the performance is as described on page 
357, which see. Bands require to be fitted with the nicest ac- 
curacy. They are to rest directly upon the gum, but are not to cut into it. 
They are to clasp the tooth, but are not to relate with it as a spring. A band 
is to be of a width that prevents cutting the tooth. It is not, however, to be 
wide enough to risk a lateral drag upon the organ in the act of mastication. 
Relation with Plate.-One or more bands being fitted about the teeth, 
a succeeding step considers the relation of it or them with the plate. This, as 
appreciated by a glance at the illustrative diagrams, implies simply the cutting 
away of the band aspect of the plate until the two parts harmoniously relate. 
The closer the fit the less trouble in the succeeding step of soldering. 
Fig. 551.-Partial Plate. 
Fig. 552.-Partial Plate. 
Making Partial Plates.-Figs. 551, 552, 553, 554 show partial plates. 
These explain themselves. Impressions, models, dies, and counter-dies are 596 
A ^SYSTEM OF ORAL SURGERY. 
Fig. 553.-Partial Plate. 
Fig. 554.-Partial Plate. 
Fig. 555.-A Reinforced Plate. PROSTHETIC DENTISTRY. 
597 
obtained and made precisely as described in connection with whole dentures. 
Fig. 551 shows a plate supported by a molar and cuspid teeth. In the case 
of the former tooth, A, separation has been made to allow of application of 
the band. Fig. 552 shows a plate, B, B, banded to bicuspid teeth. J. is a 
support. Fig. 553 exhibits a denture held up by attachment to a molar and 
two bicuspid teeth. Fig. 554 shows a lower set of teeth the anterior sup- 
port of which is secured by stays, A, A, passed between the lateral incisors and 
eye-teeth; bands, not yet in place, are to girdle the molars. Fig. 555 shows 
a lower plate which has been strengthened in front by what is called a 
reinforcing piece. This second, or overlying, plate is struck up precisely 
as the one it is designed to strengthen, and the two are to be soldered 
together. 
CONTINUOUS-GUM WORK. 
What is known as continuous-gum work finds illustration in referring to 
vulcanite and celluloid dentures. Fig. 556, taken from the section on vul- 
canite, is here reintroduced with view to showing the common likeness in a 
set of teeth standing ready, the one for 
application of a vulcanite or celluloid 
gum, the other for the mineral gum 
preparation. 
In the case of the vulcanite the base 
plate is of common material with the 
gum. In that of continuous-gum work 
the plate is made of platinum, and this 
is done precisely as in making the plate 
of silver or gold, as has been described, 
save that in making the flange it is to 
be of a width that allows it to be turned upon itself with view of acting as 
its own rim. To effect this last easily, the plaster cast is trimmed, at direct 
right angle with the alveolar process, at that circumference which expresses 
the depth required for the flange. This is re-expressed, of course, in the 
metal dies. Enough surface is to be allowed in cutting out the platinum to 
cover this right-angled expression of the flange. It is later to be turned into 
such rim-like aspect upon itself that when the body has been put on and 
burned it can be planished into place over and upon the gum. In the first, 
no primary or individual backing is required. In the second, the teeth are 
backed with platinum and soldered to this backing with pure gold,-a perform- 
ance that requires furnace heat in conjunction with the blow-pipe. The back- 
ings, however, in this latter case, are applied with no view of securing solidity 
for the teeth, but merely with intention of holding them for convenient appli- 
cation of the gum. The unsolid character of this backing, there being but 
a single pin (see Fig. 557), admits of the teeth being twisted and inclined in 
Fig. 556. 598 
A SYSTEM OF ORAL SURGERY. 
any direction as demanded for aesthetic effect. Another character of backing 
that obtains, however, with some manufacturers of this class of denture con- 
sists of a continuous strip fitted to plate and pins and soldered in mass. This 
will undoubtedly increase strength, but it interferes with securing facial 
expression, except in the hands of the fully experienced. An amateur is cer- 
tainly not to begin with this latter form of work. 
Fig. 557.-View of Teeth used 
with Continuous-Gum Work, show- 
ing Grooves and Single Pin. 
Fig. 558.-Continuous-Gum 
Teeth without Grooves. 
As with the continuous-gum work, it matters not that the teeth be ground 
or, in this instance, stayed with any degree of nicety, as plate and teeth are 
to be covered and concealed by succeeding work. It is well, however, that 
every tooth have a rest upon the plate. 
Incasing.-Dentures of continuous-gum work are made ready for 
backing and soldering precisely as are the common plate sets, except that 
experience shows the advisability of displacing the sand of the batter mass 
by calcined silex. Great thickness of the batter mass is not desirable, 
as it interferes with ready heating. It is, however, to be heavy enough 
not to break readily, and the writer is to urge, what he found his own 
experience, as to benefit derived, at second baking, from a free use of the 
binding wire. The wax is to be removed as directed in connection with 
plate teeth. 
Asbestos, Sand, and Plaster as the Investing Batter.-Dr. 
Moffitt, whose experience renders him a most acceptable and reliable authority, 
objects to the use of wire, replacing its purpose by a virtue lying with a com- 
bination in equal parts of asbestos, sand, and plaster. He recommends this to 
the students of the college in which he is demonstrator as constituting the 
most trustworthy investment. 
Soldering.-Pure gold, or a gold and platinum alloy, is to be used in 
soldering continuous-gum work, for the double reason that the lower melting- 
point of inferior solders would prevent their standing the heat required in 
baking or fusing the gum, while, as well, they would prove discolorers of the 
material. 
Pickling.-With view of a required absolute removal of borax or other 
foreign material from about the teeth and plate, it is found best to bring 
the pickle to a boiling-point. Much washing with clean water is to follow the 
acid bath. PROSTHETIC DENTISTRY. 
599 
Defects.-Excess of solder is to be carefully scraped or cut away. If 
a tooth, or teeth, be found incompletely soldered, it is the safest plan to 
reincase and repeat the performance. As this, however, doubles the risk 
of cracking the teeth or encountering other accident, it is a not uncommon 
or inexcusable means to depend on the rivet-hammer for the required 
fastening. 
Testing for Warping.-Manipulation carried to this point, a succeed- 
ing step is to return to the model with view of information as to accidental 
change of any kind that may have resulted. Platinum being ductile, a 
planish er is commonly found sufficient for the correction of any derangement 
that may be found. 
Scratching the Plate.-The plate being upon the die, a sharp graver 
or common knife-blade is made to cut freely that surface to be covered with 
the gum material. This is with view of affording hold at the time of fusion. 
Building the Gum.-Referring here to Fig. 556, understanding is 
secured as to what is meant by building the gum. Few things are more 
simple or easy of accomplishment. Given the material (which see), and it 
being appreciated that the object is to obtain likeness with the natural gum 
as to contour, relation with necks of the teeth, the forming of festoons, and 
besides these, to the more thorough holding and fixation of the teeth, the 
operator begins by mixing his material for the body, as it is called,-so called 
to distinguish it from gum, or facing, material,-which is done by using a 
glass or porcelain plate and uniting the powder and water in a proportion that 
yields an easily-working, plastic mass. This ready, the laying on is com- 
menced by use of a small portion of this body, almost watery in consistence, 
brushed over the plate and about the teeth with view of insuring its attach- 
ment. This is followed by packing,-a process that begins by working the 
material between and about the roots of the teeth as they abut the plate, 
stopping occasionally to settle the mass by shaking or jarring. This jarring 
extracts, of course, much of the excess of water, and this is to be dried off 
by use of pads of bibulous paper. 
Experience decides against completing the body of the gum for a 
first firing, but elects to do it to the extent of about one-quarter of what 
is required. The paste is to be smeared, as a thin coating as well, over the 
external face of the plate or over that part of it which it is proposed to cover. 
When the body has become reasonably dry, a fine saw is to be passed between 
each of the teeth, the material to be removed, not only just here, but back 
and front, until the plate is exposed. This saves the teeth from being drawn 
out of place as shrinkage is inclined toward them, while cracking is antago- 
nized. The process carried thus far, all body material is to be carefully re- 
moved from about the crowns of the teeth or other parts where its fusing 
would be undesirable, when, the denture being gradually dried, first through 
atmospheric influences and afterward in a stove, it is to be subjected to a first 
baking. 600 
A SYSTEM OF ORAL SURGERY. 
Baking Continuous Gum-Furnaces.-To bake, or burn, continu- 
ous-gum body a furnace capable of affording a temperature of not less than 
2400° Fahrenheit is required. Such furnaces are of two general forms,-1, 
coke burners ; 2, gas burners. Of the first, one known as White's and another 
as Teese's occupy prominent and recognized places. Verrier's furnace is a 
favorite with many. Of really wonderful character, however, as to compactness, 
cleanliness, and efficiency, accepting that it will do the work as described and 
certified to by its inventors, is an apparatus, lately put on the market in the 
shape of a gas burner, known as the Parker furnace (Fig. 561). 
Fig. 559.-The White Furnace. 
Fig. 560 -The Teese Furnace 
The Parker Improved Gas Furnace.*-In offering this furnace 
to the profession, the inventors, Drs. A. H. Parker and A. H. Stoddard, feel, 
as they assert, that it supplies a long-felt want. Many, as suggested by them, 
have been deterred from entering the field of tooth-carving, porcelain-filling, 
and continuous-gum work by reason of the association with so many diffi- 
culties. In this furnace the greatest possible simplicity seems to have been 
attained. The reduction in size over other gas furnaces reduces the time of 
baking to the minimum (requiring with ordinary good quality of city gas at 
* Whoever the maker, and whatever the kind of furnace employed, the apparatus is to 
be capable not only of affording, but of maintaining for a sufficient length of time the 
maximum of heat needed. The coke furnaces named do this readily, and it is claimed for 
the gas instrument that it is equally reliable and manageable. The manner of working the 
latter is appreciated by a glance at the diagram. PROSTHETIC DENTISTRY. 
601 
fair pressure from ten to twelve minutes to fuse continuous gum or the hardest 
porcelain). The quantity of gas consumed is also reduced to a minimum, and 
the air-blast is furnished by an ordinary foot-bellows. The furnace is four 
and one-half inches in diameter and about six inches high. It is made of 
Russia iron with fire-clay interior. The top is dome-shaped and made entirely 
of fire-clay, as is also the tray. It is held by a bracket attached to the wall, 
and may be swung out of the way when not in use. The burner and bracket 
are bronzed and nickelled, making the furnace a neat as well as a useful addi- 
tion to the operating-room and laboratory. It is so constructed that there is 
perfect combustion, thus preventing " gasing" and disagreeable odors. It is 
Fig. 561.-The Parker Furnace. 
suitable for the largest continuous-gum cases, carved work, porcelain fillings, 
or inlays, and is particularly useful for heating up cases and soldering and 
fusing metals. 
Charging a Coke Furnace.-Charging a coke furnace is of large 
consequence as to result. First, shavings and kindling are to be introduced 
to an amount capable of igniting a body of small pieces of coke that is to 
reach half-way up to the muffle. The kindling being burned out so as to 
allow settling of the coke, the full charge is prepared by filling the furnace 
with pieces selected or prepared for the purpose,-pieces not larger than a 
walnut being employed, and care taken that the whole surrounding neighbor- 
hood of the muffle is closely packed. It is especially desirable, and indeed 
necessary, that the under surface and sides of the muffle be packed,-this for 
the double purpose of supporting the slide and securing the greatest heat 
where most needed. The denture is to be placed only when the required 
maximum of heat has been obtained. 
Baking.-By baking is meant fusing the body material. The denture, 602 
A SYSTEM OF ORAL SUROERY. 
as it stands now ready, is taken from the stove where it has been heated and 
is introduced, slowly and gradually, face forward, into the muffle. When in 
place, at the centre, the top is to be closed and the piece allowed to remain 
that length of time that suffices for the fusion. This time, as understood 
from what has been said above, is relative. Five to fifteen minutes is the varia- 
tion according to the baking, whether a first, a second, or a third, the former 
requiring the least, the last the most time. A plan is to remove at the end of 
five minutes an eye-hole that belongs to the trap, and, after protecting the 
eyes with glasses, look in and see whether or not fusion has commenced. For 
the first baking semi-vitrifaction is alone required. 
Cracking.-When a denture is removed from the furnace after a first 
baking the body is almost sure to be found cracked. Here recommences the 
process of building. These cracks are filled up with freshly-mixed material, 
the whole process of gum-building, contouring, and plumpering being now 
completed, except that consideration is to be given to the thickness of gum- 
shading that is to be subsequently added. The second baking corresponds 
with the first as to all details, save that here the fusing is carried a step 
forward. 
Putting on the Gum.-Before applying the gum enamel the denture 
is again to be tried both upon the plaster model and in the mouth. It is the 
object here to notice if a required correspondence exist,-that is, if the lips 
and cheeks find proper support and contour. Excess is to be ground away. 
Deficiency is to be made up. It is well if at this time articulation be looked 
after. If, after the second burning, large cracks are found, there is nothing 
to do but reapply body and rebake ; if, on the contrary, the cracks be small, 
they may be filled up with the gum enamel. To apply the gum is akin with 
painting upon porcelain. The material, mixed with water, precisely as in the 
case of the body, is painted on by means of a brush. The thickness to which 
it is applied should correspond to No. 22 of a gauge plate. 
The gum, like to the body, and for the same reason, requiring a 
double baking, it is not necessary at the first one to carry the heat or process 
to a full fusing-point. The second and final baking is to be preceded by the 
strictest attention to enamelling. Cracks or particles chipped off in the pre- 
vious baking are to be fully repaired. Where shade is at fault it is to be 
modified. It is upon this second baking of the gum that aesthetic success or 
failure depends. The process is to be watched with closest attention through 
the trap-hole, and the piece is to be removed at that exact moment when the 
material is seen to vitrify and settle. Removal of this highly-heated mass 
being a matter of large consequence, the denture is to find proper annealing 
by being transferred to a heated muffle which stands prepared for the purpose 
and in which it is to remain until entirely cool. 
Material used for Continuous-Gum Work.-The idea of con- 
tinuous-gum work rests with the possibilities of fusing a silicious composition 
upon a plate and about teeth possessed of a higher melting-point. The origin PR OS THE TIC DENTISTR F. 
603 
of this work is with France, but it has remained with America to carry it to 
its present perfection. As suggested, the performance is of simple character, 
yet much practice is required before the moulding and baking manipulations 
can be brought to a satisfactory result. As is seen, the steps preliminary 
to applying the gum scarcely differ at all from the doing of ordinary plate- 
work. 
Body Material.-Body material is of various formulae, and practi- 
tioners who, through repeated trials and failures, have hit on a happy working 
compound are commonly not over-communicative as to what they have found 
out. Among formulae which have become common property the following 
may be given. If worked properly little fault is to be found with them. 
Dr. Hunter, whose working agents are silex, fused spar, calcined borax, caustic 
potash, and asbestos, gives the following formulae : 
Flux.-Of silex take eight ounces, of calcined borax four ounces, and of 
caustic potash one ounce. To grind these together a wedgwood mortar is 
used, the potash being first ground to a fine powder and the other materials 
added little by little. Next a Hessian crucible is lined with pure kaolin, and 
the powder being put into it, this, covered with a slab of fire-clay, is put into 
a strong fire made of coke and there retained until the contents are fused into 
a translucent glass. Being poured out, it is broken and ground when cold, 
being made fine enough to pass through an ordinary bolting sieve. 
Granulated Body.-Of spar take three ounces, of silex one and one- 
half ounces, of kaolin one-half ounce ; these to be completely fused. Powder 
together until fine enough to pass through a No. 50 sieve. Repass what has 
passed the sieve through a No. 10 bolting cloth. 
Body.-Of flux take one ounce, of asbestos two ounces. Grind finely 
together, securing a complete intermixture. Add of the granulated body one 
and one-half ounces and mix loosely. 
Moffitt's Body Formula.-The following is Dr. Moffitt's latest im- 
proved formula as furnished by him to the students of his college. It is to 
be accepted as surpassed by none other.* 
No. I.-Take eight parts of fine ground silex, twelve parts of fine ground 
spar, eighty grains of titanium. Mix. Fuse on a slide in muffle of furnace. 
Grind to pass through bolting cloth No. 15. 
Flux-No. 2.-Take of silex, ground fine, ten parts; calcined borax, 
three parts; caustic potassa, one part. Mix. Fuse in a tray, lined with a 
batter of silex, in muffle of furnace. Grind fine, and keep for use. 
To make continuous-gum body, take of No. 1 three parts, No. 2 
one part. Mix thoroughly. 
Enamels.-These, like the bodies, are of varying composition. The 
Hunter formula is a good one by reason of its fusing-point. Of flux, as 
given, and of fused spar, take of each one ounce, and of English rose-red from 
* Demonstrator of Mechanical Dentistry in Philadelphia Dental College. 604 
A SYSTEM OF ORAL SURGERY. 
thirty to fifty grains according to shade required. Grind these very fine and 
fuse together in a crucible. The mass obtained is to be coarsely powdered 
for use. 
Moffitt's Formula-Purple of Cassius.-Of pure gold take twenty- 
four grains, of silver two hundred and forty grains, of tin ten grains. 
Melt the gold and silver in a clean sand crucible, after which add the tin; 
keep well covered with borax, granulate by pouring in water in a wooden vessel, 
and repeat the melting and granulating three or four times. Collect the par- 
ticles, place in a suitable glass vessel with two parts C. P. nitric acid and one 
part water, and heat on sand-bath. After it is dissolved pour off the acid and 
wash the precipitate with hot water; repeat the washing until there is no acid 
reaction, dry, and keep for use. 
To make Gum Frit.-Take of the purple of Cassius ten grains, of 
flux No. 2 twelve pennyweights, of spar twenty-five pennyweights. Grind 
this combination from six to ten hours in a mortar, after which pack it in 
a tray lined with a batter of silex and covered with a piece of fire-clay slide. 
Fuse in muffle, after which grind and fuse on slide, which will develop the 
color. 
To make the gum enamel from this, take, say, two parts frit to one 
of flux No. 2, or more or less of flux as may be required to produce the 
shade of color desired. 
Caution against Metallic Admixture.-In all these manipulations 
the greatest care is to be observed that no metallic substances, such as iron, 
zinc, lead, etc., come in contact with the materials. 
Suggestion.-Unless one be much inclined to laboratory-work, and dis- 
posed to give to its details a required attention, advantage will be found in 
having the bodying and burning of continuous-gum-work dentures done by 
persons whose business is confined to such matters. Neither risk nor prob- 
ability of being disappointed as to result associates with carrying the progress 
of a set of teeth of this kind to the point shown in Fig. 556, as up to this stage 
almost any amateur can do it. Bodying and baking are also easy enough, 
only that experience is required. Still, with the convenience afforded for ex- 
perimentation by the Parker furnace the whole matter is amusement rather 
than work. Experience so masters details as to this work that adepts, like 
the writer's accomplished chief of clinic, Dr. Cryer, seldom make more than 
three burnings, two for body and one for gum. Men of this class smile at 
the suggestions of difficulties associated with the work, esteeming it hardly 
otherwise than as amusement. Dr. Moffitt's burnings are commonly two in 
number. 
Objections to Mineral Continuous-Gum Work.-It is heavy 
and consequently cumbersome. Occlusion of the dentures yields an offensive 
rattle. Risk and cost associate with repairing. 
Recommendation.-Absolute cleanliness. Continuity of face of gum. 
^Esthetic and physiognomical setting that may be given the teeth. PROSTHETIC DENTISTRY. 
605 
Cast aluminium-work, as produced by an economical and simple method, 
after many experiments, is thus described by Dr. Moffitt. 
A suitable flask of iron, with tube, or gate, for pouring the metal therein, 
is required. The model from the impression and the investment are to be 
made of equal parts, by measure, of ground silex and plaster. The form of 
plate, or whatever work is to be done, is modelled in pure paraffin. The 
gates should be made of the same, and arranged as for pouring any fusible 
metal. Heat the flask until the paraffin runs and burns out, when it will be 
ready to receive the molten aluminium, which melt in a sand crucible,-Hessian ; 
keep covered with paraffin. As aluminium has a great affinity for oxygen, 
some flux must be used to protect it. Paraffin is found to answer the pur- 
pose. After the mould or flask is heated to the temperature required to melt 
the metal, pour it, taking care to have it well covered with paraffin, and press 
it with a suitable plunger into the mould; the result will be a perfect casting 
of the plate or parts made in the flask. Aluminium shrinks to such an extent 
as to render the casting of it on gum teeth, or sections, impracticable, though 
plates for mounting these sections by means of vulcanized rubber, casting to 
plain teeth, and making bridge-work are practical, producing light and durable 
dentures. 
MOFFITT'S ALUMINIUM DENTURES. CHAPTER XXXVI. 
PROSTHETIC DENTISTRY. 
OBTURATORS. 
Breaks in the continuity of the palate surface of the mouth, congenital 
or acquired, are treated by operation, or otherwise through the use of obtu- 
rators and vela. The present chapter considers the mechanical means. 
Definition of Term.-The instrument, or plate, called an obturator, 
gets its name from the Latin verb obturo, and signifies a something that shall 
close or stop up an entrance or break. 
Vela.-Obturators correcting breaks of the soft portion of the palate, 
being mobile in construction, are not improperly designated vela,-artificial 
vela. 
Where used.-Obturators are used in the treatment of palatine defects 
where operative surgical means do not apply. 
Designed to meet Various Indications.-As obturators are in- 
struments designed to meet the most varying indications, so necessarily are 
they apparatus of great variety in construction. The simplest of them is 
nothing more than a plate of metal or rubber covering a break in the hard 
palate; it differs but little from the support of an ordinary denture. An 
obturator having the meaning of a velum is an attempted duplicate of missing 
part in the movable, or soft, palate; it is designed not only to fill a break, but 
to assist in functional performance. 
Simple Obturator.-A simple obturator holds the same relative posi- 
tion to one at the other extreme that is held by the Physick-Desault leg- 
box to the most complex of apparatus used in the treatment of fractures of 
the extremities. The simple is expressive of a principle; varieties express 
modification on the principle. A practitioner understanding the basal idea is 
at no loss to appreciate the genius of the instrument in its application to all 
kinds of cases. 
Consideration of Requirements.-A patient presents himself, let 
us suppose, suffering under a deficiency in the hard palate. We examine the 
condition, and find the walls of the break so heavily and solidly indurated as 
at once to perceive that any attempt to pare and bring them together would 
be futile. Palato-plasty naturally suggests itself, but observation of the sur- 
rounding parts convinces that the risks are too great for a good promised. 
Such is a case that not infrequently offers itself to the surgeon's judgment. 
606 PROSTHETIC DENTISTRY. 
607 
Dieffenbach, whose name is so honorably associated with oral operations, evi- 
dently found himself much embarrassed with just such conditions,-cases 
here to be presented as the easiest of remedy by use of an obturator. To 
correct such defect the German surgeon suggested a stud of india-rubber. 
Two pieces of rubber the thickness of pasteboard are cut, being somewhat 
larger than the opening to be closed, and between these is placed a small round 
piece ; the whole is then securely fastened together by means of waxed thread : 
one of these pieces is intended to rest on the posterior, the other on the ante- 
rior surface of the opening; the small middle piece is for the intermediate 
space. 
A moment's reflection will exhibit the inconveniences as well as the more 
striking faults of such an appliance. The rubber, unless vulcanized (and, to 
be so applied, it cannot be vulcanized), soon becomes offensive. It acts as a 
continual source of irritation, particularly as the posterior base of the cleft is 
concerned. The centre piece, which, to hold the parts with any degree 
of steadiness, must fit the opening with reasonable accuracy, soon, because 
of the presence of moisture and heat, expands, thus enlarging the canal. 
The apparatus is as well very inconvenient to remove for the purpose of 
cleansing, which cleansing it demands daily. 
Means that Enlarge an Aperture.-A case amply illustrative of 
the inefficiency of this mode of combating palatine defects, and, indeed, of 
the absolute harm resulting from it, is recorded by Dr. J. H. McQuillen. The 
patient, who had an opening in the palate, the result of syphilis, was treated 
by Dr. Daniel Neall, who employed, in the first instance, india-rubber as a 
substance from which to construct an obturator. This was cut somewhat in a 
button shape, being large above and below, and contracted in the centre, thus 
constituting an apparatus which was retained in position by resting on the 
parts of the nares surrounding the orifice. After this had been worn a week 
or two, the patient returned, when it was found quite loose and the orifice 
somewhat enlarged, the rubber having acted as a source of irritation and in- 
duced absorption. Another apparatus was formed from the same material, 
and, after being worn a week, the orifice was found larger than at the previous 
meeting. The rubber was also found considerably affected by the fluids of 
the mouth. Satisfied that it would not answer the purpose intended, this 
material was abandoned, and a simple obturator of silver constructed, this 
covering both orifice and roof of the mouth. It was found to fulfil every 
indication. 
Cotton as an Obturator.-There is another, a somewhat domestic, 
treatment for these defects which may be alluded to in passing. This con- 
sists in stuffing the break with cotton or wool. The material, unfortunately, 
not infrequently escapes into the throat, or, passing into the nares, it has some- 
times produced ozaena by lodging in a meatus, quite extensive necrosis of the 
turbinated bones having been provoked in this way. The practice is not 
without marked danger. 608 
A SYSTEM OF ORAL SURGERY. 
Specific Disease as Cause of Break.-A case of a different class, 
yet belonging to the same category so far as treatment is concerned, invites, in 
connection with the consideration of simple obturators, a moment's attention. 
This is the existence of a cleft or break associated with subacute or chronic 
disease,-cases not fit, of course, for operation. 
Some time since, Mr. , a French teacher of this city, had necrosis of 
the palatine arch, the result of venereal disease; the sequestrum that came 
away was quite large, producing a break in the continuity of the hard palate 
at least an inch in diameter, freely exposing, of course, the nares. A result 
was, as might be anticipated, that his vocation as a teacher had at once to be 
relinquished. 
This case was seen, in consultation with the attending physician, about a 
month after the patient had resigned a situation which he held in one of our 
principal private schools, and upon which, up to this time, he had mainly 
depended for his income. The necessities of the man were immediate; 
operation for the restoration of his speech was out of the question. The 
writer had the happiness of relieving this patient of his trouble so perfectly, by 
the use of an obturator, that every time he has since been met he laughingly 
asserts that he speaks better English than before his accident. It is certainly 
true that he speaks quite as well. 
Simple Plate.-An obturator for a case like this consists simply of a 
metal plate that fits accurately every part of the hard palate. Such a plate is 
to set with the greatest nicety, and is to be held in place either by bands placed 
around certain of the teeth, or by means of atmospheric pressure. The first 
plan of fastening is to be employed when disease is associated with the cleft. 
The latter is well adapted when the break is not too large, and where all disease 
has long passed away. To make such an obturator, first take an ordinary 
impression-cup, such as is employed in taking casts of the mouth for teeth. 
This cup is filled with beeswax, softened to the consistency of dough. Thus 
prepared, the operator takes his position behind the patient. The cup is now 
to be introduced carefully into the mouth, and carried just so far back as will 
allow of the teeth being included within the arch, or rim. This accom- 
plished, cup and wax, in a body, are to be pressed firmly up into the roof of 
the mouth, and the wax worked around the necks of the teeth and about 
the alveolar border. The patient holding his mouth very wide open, the 
mass is to be removed even more carefully than it was inserted. This ma- 
nipulation, if properly executed, gives the exact impression of the palate. 
The next step is to make a model. To do this, take the impression just 
obtained, and, surrounding it with a rim of paper, the rim to be, say, one 
and a half inches in height, stir into water the common calcined plaster- 
sulphate of lime-until a very thick paste is obtained. This paste is poured 
into the impression, and should be enough in quantity to fill from the wax, 
which lies at the bottom, up to the top of the rim. The model thus made 
is not to be disturbed for three or four hours; it must have time to set. PROSTHETIC DENTISTRY. 
609 
The next step in the operation is to remove, from about the plaster cast 
just made, the paper and wax. This is accomplished, first, by heating gently 
the cup in which the wax lies, which permits of its easy removal; and next 
by carefully trimming from about the necks of the teeth, by means of a knife- 
blade kept constantly warm, the wax which so closely surrounds and embeds 
them ; in this way it is all safely to be taken away. The paper is, of course, 
simply torn off. Comparing the face of the model thus made with the 
mouth from which the impression has been taken, we find a common likeness 
to the minutest particular. 
Arching the Palate.-As the model expresses the break in the arch, and 
it is the intention to restore this arch to its original contour, so is it at this 
point in the procedure that the step is to be taken which insures such result. 
This step is easily accomplished by taking a little ball of warm wax and filling 
with it the hole or break in the model. The natural concavity of the arch is 
in this way restored. Of course this is not at all difficult, nor is there any 
guesswork about it, as we have the inclinations of all the surrounding parts 
to guide us, and all we have to do is simply to model this wax to the proper 
curve. The cast is finished by bevelling the portion which rested against the 
paper; this bevelling to be so done that the greatest diameter of the model 
shall be its base, the object of the shape being to permit of easy drawing of 
the model if a sand cast be made. 
This completes the model to which an obturator is to be made. 
Making Dies.-A next step is the preparation of dies.* These are to 
be made, one of zinc, the other of lead; and the process of getting up such 
casts is precisely the same as has been described. 
Repetition.-Procure a moulding-flask or a circle of tin: a common tin 
cup, with the bottom broken out, answers the purpose well enough. Lay the 
model you have prepared upon the table, the palate face looking up. Now 
place the circle of tin over it, and with some moulder's sand, very fine, which 
you have previously moistened and tempered, cover in the model, packing and 
filling the circle completely. Now turn the circle, or cup, so that the base of 
the cast looks up. Next a penknife-blade or a small gimlet is to be inserted 
into a square of wood previously inserted into the plaster, and by striking it 
several light taps the cast will be loosened. It is now to be lifted from the 
sand. Thus we have a mould for a metal casting. The next step is the 
making of such a cast. To do this we have only to melt, in any convenient 
vessel, one or two pounds of common zinc and pour it slowly into the mould. 
This done, let the whole remain undisturbed until cold. 
Model of Palate in Metal.-Thus, it is seen, we have prepared, with 
little or no labor, a correct model of the palate in metal. It is to this zinc 
* A surgeon being the operator, the model, or even the impression, may be handed to a 
mechanical dentist, who makes the obturator ready to put in place, without further trouble 
to the practitioner. 610 
A SYSTEM OF ORAL SURGERY. 
model we are to fit and adapt our obturator. Now, this latter process is easy 
or difficult, according as one goes about it. One method is to take ham- 
mer, files, and pliers, and cut, file, and mallet until the adaptation is secured. 
Such a task is almost as hard as was the cleaning of the Augean stables; 
besides, it is next to an impossibility to accomplish the work properly. A 
second plan, and one which is as easy, simple, and interesting as the 
other is difficult, perplexing, and annoying, consists in making a counter- 
model in lead, between which and the model, or male cast, as it is called, the 
palate, or obturator, is struck up. This counter-model is very easily made, as 
follows: 
To make a Counter-Model.-Take the zinc die and lay it upon a 
table, with the face or palate surface looking up; place about it the cup, or 
circle, precisely as in the case of the plaster model. Now, with the sand 
moistened as before, fill up the cup covering in the die, packing the sand as 
solidly as possible. Next, without disturbing the cup as it rests upon the 
table, take a knife and dig away the sand until the face of the die is exposed, 
together with a reasonable space between zinc and cup. You are now prepared 
to make the counter-model. Take a vessel (not the one in which the zinc 
was melted) and place in it two or more pounds of lead; when fluid, pour 
this over the face of the zinc die, filling up to the very top the cavity which 
you have dug out in the sand. When the lead has become cool, remove the 
castings from the sand, and with a hammer knock the two apart. 
To make the Obturator.-To make an obturator by means of dies 
thus obtained, the procedure is as follows: A piece of thin sheet-lead is forced 
with the fingers over the face of the zinc die, and with a sharp and delicate- 
bladed knife this lead is cut so as to cover accurately the hard palate, being 
festooned so as to adapt itself accurately about the necks of all the teeth. 
This palate of lead, being nicely and correctly fitted to the parts, is taken off 
the die and carefully spread. Next it is laid on a piece of gold or silver plate, 
and the outlines distinctly marked; using a pair of cutting forceps, the shape 
of the lead is repeated in this second piece of metal. A next step is the 
process of annealing, or softening the metal, so that it shall be as malleable as 
possible. This consists in subjecting it to a red heat, which may be done in 
any convenient manner. The mechanical dentist lays the piece upon charcoal, 
and throws over it, by means of a blow-pipe, the flame from his alcohol solder- 
ing lamp. Another manner is to lay it upon hot coals. 
Conforming a Plate to Die.-The metal being annealed, it is taken 
up and so bent with pliers as to fit the die tolerably; it is not, however, at all 
necessary, in this procedure, to give one's self much trouble. Next take up 
the counter-die and lay it carefully over the zinc,-the plate being between 
the two. Employing a heavy hammer, the dies are now driven together. In 
this step of the operation it is desirable that the worker feel his way,-that is, 
hit the zinc model a few slight taps, and then, taking the two apart, see if the 
plate is going as required. If all be right, the casts are to be driven into each PROSTHETIC DENTISTRY. 
611 
other with reasonable force. If, on the contrary, the metal is not taking a 
proper direction, it must be properly inclined by means of the pliers. To 
complete the finish of the plate itself, the festoons, which are to embrace the 
necks of the teeth, are to be cleanly cut out by means of a round file; polish- 
ing completes the manipulation. 
Plate completed.-Thus we have an obturator finished. If now it 
be placed in the mouth, we shall see that we have restored the arch, by our 
contrivance, to its original condition, at least so far as purposes of speech and 
mastication are concerned. 
Nothing now remains but to secure the piece firmly to its place. This 
brings us to the consideration of modifications of the instrument. 
Modification of the Obturator.-If a patient, for whom had been 
made such an obturator as that the manufacture of which has just been de- 
scribed, had certain good sound teeth, we might proceed to fix the piece in 
the mouth as follows. Going back to the plaster model, we would fit around 
such teeth as might seem best adapted to the purpose delicate bands of metal, 
-gold is always to be preferred; these bands should fit the teeth with accu- 
racy, and are to be fixed to their places while the obturator is lying on the 
model. Next take particles of wax, and stick the plate and bands together. 
Now carefully lift all from the model and set in plaster. This last manipu- 
lation is accomplished by laying the piece on charcoal and pouring over it, 
the wax alone excepted, the creamy plaster before alluded to. When this 
plaster sets, the wax is to be delicately picked away, and thus are exposed 
small portions both of plate and bands. These parts are to be soldered to- 
gether. 
This last process completes the piece for the mouth. In placing it in posi- 
tion, we have only to slip the bands over the teeth to find it held with all 
security. 
Another plan of fixing the apparatus to the mouth is by means 
of atmospheric pressure. To accomplish this, a cavity is made in the piece. 
This is done by placing on the plaster model, before making the castings from 
it, a piece of wax ; its shape may represent, in diameter and thickness, the 
ordinary half-dime. Or perhaps we cannot find a surface on the arch for a 
suction of such size and shape; if so, it may be lessened, or the shape modified 
so as to suit the case; what is wanted is a cavity in the plate, the size and 
location are not of special consequence. Such a piece of wax will, of course, 
be represented by zinc in the casting, and by depression in the counter-cast. 
In forcing the plate between the dies, the portion represented by the wax is 
thrown up; thus, when the plate is in the mouth, a cavity is formed. The 
instrument is held, in this case, by making an air-pump, as it were, of the 
tongue, and sucking the air from the cavity. Obturators are seen thus 
dependent on atmospheric pressure for fixedness, held so tightly that it re- 
quires considerable force to effect their removal. The principle is the same 
as that employed for holding artificial dentures in place. The modus operandi 612 
A SYSTEM OF ORAL SURGERY. 
will be perfectly understood at a glance by looking at any set of teeth made 
for the superior jaw.* f 
Another modification of the obturator is that in which the piece 
is held to its place by a bulb, or rim which passes into the cavity of the break. 
This adapts the instrument to such cases as have neither teeth for clasps nor 
site for suction; where disease has destroyed the whole of the hard palate, 
leaving alone, as boundaries of the cleft, the alveolar processes and velum. 
Such an obturator and the character of cleft for which it is adapted are 
happily and truthfully exhibited in the accompanying drawings. Fig. 562 
represents the mouth, Fig. 563 
the obturator. This case, and 
others which represent various 
modifications of the apparatus, 
are from life, having occurred in 
the practice of different dentists.^ 
Fig. 562. 
Fig. 563. 
Illustrative Case.-The first case, as seen in Fig. 562, from the prac- 
tice of Dr. McGrath & Son, was that of a female over fifty years of age. In 
this instance the fissure was confined to the hard palate and was undoubtedly 
the result of syphilis. Of the history of the case, all that could be obtained 
was derived from answers to indirect questions which were put to her. The 
gentlemen learned that the defect was the result of a disease which commenced 
as sore throat and continued its ravages for over three years before it was ar- 
rested ; this, together with the appearance of the pharynx and uvula,-these 
being covered with cicatrices, the result of old ulcers,-left them without any 
doubt as to the true nature of the complaint. The parts which had been de- 
* Plates, whole or partial, for the support of artificial teeth, are made and fixed as here 
described. For repetition, after different manner, of the description, see page 544. 
f Report by George T. Barker, D.D.S. PROSTHETIC DENTISTRY. 
613 
stroyed during the progress of the disease were the palate bones and the pala- 
tine processes of the superior maxillaries (making an opening into the nose 
nearly two inches in length and one inch in breadth), the turbinated bones 
with the exception of the middle one on the left side (which is represented in 
the cut as projecting from the side of the cavity), and the vomer, producing an 
enormous irregularly-shaped cavity, extending as high up as the nasal bones, 
which latter, however, bore no traces of ever having been affected by the dis- 
ease. The patient, in order to prevent the passage of the food into the cavity 
during mastication, had been in the habit of filling the opening with a fold 
of muslin, which answered the purpose to a certain extent; the velum was 
entire; she also had lost all the teeth of the upper jaw. 
The kind of obturator employed in this case was simple and un- 
complicated in its mechanism (Fig. 563). A plate was made to fit accurately to 
the alveolar ridge, extending about one-eighth of an inch beyond the posterior 
margin of the opening; also passing in to a distance of nearly an inch, and 
fitting as closely as possible to the anterior and lateral sides of the cavity. The 
object of this latter arrangement was to render the piece firm in its position. 
From the posterior margin of the opening, and extending forward about half 
the length of the alveolar ridge, was a fold of mucous membrane projecting in- 
ward and upward, over this margin ; that portion of the plate which was oppo- 
site to it was bent. This, together with the suction obtained by the plate 
fitting closely to the alveolar ridge, enabled the wearer to keep it in its place. 
The opening was then covered by soldering to this a second piece of plate, so 
fashioned as to represent as nearly as possible the form of the lost palate. 
The object in not extending the plate into the cavity on the posterior edge 
of the opening was to prevent a lodgement for the nasal secretions, which by 
their accumulation would prove offensive to the patient. The artificial teeth 
were then fastened in their proper position, and the apparatus was complete. 
This obturator the patient had been wearing for about three months; it re- 
mained in place and fulfilled the office of mastication as well as any ordinary 
suction plate in a mouth where no defect of the palate exists. 
Illustrative Case.-The second case (Fig. 564) was also that of a female, 
but the fissure was confined to the soft palate. This, as in the former case, was 
the result of syphilis. The break extended from the posterior opening of the 
nares through the velum looking backward, and was nearly an inch in breadth. 
The uvula was entirely gone, as well as the lateral half-arches, and along with 
them the palato-pharyngei and constrictores isthmi faucium muscles. In this 
case deglutition was impaired to a great extent; the food would get into the 
nares, and the fluids would also pass into the nasal cavities and out through 
their anterior openings. The disease had not confined itself to the palate, 
but, extending to the nose, had destroyed its internal structure, as well as 
portions of the nasal bones, to such an extent as materially to change the 
external shape of the organ. The obturator (Fig. 565) constructed for this 
case was of one piece, and made to cover the hard palate completely, extend- 614 
A SYSTEM OF ORAL SURGERY. 
mg from the central incisors to the posterior wall of the pharynx, and pass- 
ing a short distance beyond the edges of the opening on each side. The 
plate was made to press firmly against that portion of the soft palate which 
remained, yet not so firmly as to 
be the cause of irritation, the edges 
of the plate being slightly bent 
downward for the same reason ; the 
object being to prevent the possi- 
bility of the soft narts beiner drawn 
Fig. 564. 
Fig. 565. 
above the palate, which would afford a communication with the nares. The 
posterior edge of the obturator was bent downward at a right angle with the 
body of the palate, and curved so as to form, with the posterior wall of the 
pharynx, an oval opening sufficiently large to permit the patient to breathe 
freely through the nostrils. In the act of deglutition, the muscles would con- 
tract and press against this portion of the plate, thereby cutting off the com- 
munication with the nares. To this plate were attached three artificial teeth,- 
two lateral incisors and one molar,-the whole being retained in position by 
means of clasps around the teeth. 
This obturator the patient had been wearing a little over two months, and, 
like the former one, it had proved successful, deglutition being restored and 
speech considerably improved. 
Illustrative Cases.-The practice of Dr. T. L. Buckingham, formerly 
Professor of Chemistry in the Pennsylvania College of Dental Surgery, offers 
the following cases: 
The first case is that of a gentleman who had an opening through the 
hard palate, in the centre of the arch, about as large as a ten-cent piece. This PROSTHETIC DENTISTRY. 
615 
patient had worn an obturator with a sponge attached to it, made in the 
following manner: A plate was modelled to fit the roof of the mouth, and a 
piece of sponge was sewed upon the palatine surface, to fill the break and 
hold the plate in its place. Objections to this obturator were that the 
opening became enlarged from the absorption occasioned by the pressure of 
the sponge upon the sides of the cavity; the sponge would also become 
very offensive, requiring frequent removal. In this case a plate was struck 
to fit the mouth, and attached to the teeth by means of clasps. This simple 
appliance answers better than any other that had been made for him. 
The second case is that of a gentleman who had an opening into the 
left antrum, at the point where the second bicuspis and the first molar had 
been, but on the outer surface of the alveolar ridge, or rather seat of original 
ridge,-for the alveolus was entirely absorbed opposite the opening, which 
was about half an inch in length by a quarter in width. The nasal bones 
were diseased, which caused an almost intolerable odor. 
There was made for this case a small obturator to close the opening. This 
was left open at the top, to allow the placing in it of a small portion of chloride 
of lime, the intention being to correct, if possible, the offensive smell. The 
patient did not live long enough, however, to give it a fair trial. Dr. Bucking- 
ham remarks that while any of the chloride of lime remained in the obturator 
there was no unpleasant smell; but, unfortunately for the experiment, the 
Fig. 566. 
gentleman had lost nearly all the sense of smell, and therefore could not tell 
when the agent had evaporated. The obturator was held in position, to a 
great degree, by a plate and teeth, to which it was attached. 616 
A SYSTEM OF ORAL SURGERY. 
In the two preceding cases voice was not altered when the appliances were 
in the mouth. 
The third case is that of a gentleman who on a previous occasion had a 
tumor removed which covered a portion of the posterior surface of the hard 
and the anterior surface of the soft palate. The surgeon, in the ablation, had 
divided the velum and uvula, so that the case resembled a congenital de- 
formity. The attempt had been made twice to bring the soft parts together 
by surgical operations, both of which failed. Fig. 566 exhibits the appear- 
ance of the parts very clearly,-the letters A and B showing the thickened 
muscles as they hung down on the sides of the pharynx. 
For this case an obturator was constructed (Fig. 567), the plate of which 
covered the whole of the roof of the mouth, with a bulb attached, to extend up 
into the posterior nares and well 
back toward the posterior walls of 
the pharynx, leaving but a small 
space between the two. This ob- 
turator enabled the patient to eat 
and drink with convenience ; with- 
out the instrument in place food 
would pass into the nares and occa- 
sion much trouble. It also greatly 
assisted the voice, as many of his 
words could not be understood when it was not worn,-articulation was with 
great distinctness when it was in the mouth. Dr. Buckingham remarked that 
he had been more successful in restoring speech in this case than in any 
other he had treated, and attributes it to the fact that the person, having once 
had perfect voice, was always endeavoring to speak as he had formerly done. 
In the congenital cases patients do not, he inclines to think, try to overcome 
the difficulty. 
The fourth case is that of a lady with an opening in the anterior part of 
the hard palate, a little larger than a ten-cent piece, and also a second small 
one exposing the left antrum. All the teeth in the superior arch had been 
long removed, and absorption of the alveolar process, opposite the smaller 
opening, had progressed to such an extent as to present at that point a deep 
depression; the remaining part of the alveolar ridge had not been absorbed 
more than is usual where the teeth have been lost. 
Fig. 568 shows the appearance of the different parts, C representing the 
smaller opening and D the larger one; between these two points is the 
depression referred to. 
This lady had never worn any mechanical appliance, but had been in the 
habit of closing the larger opening with loose cotton or pieces of linen. With- 
out having it filled, she could scarcely be understood when speaking. For 
this case there was made, first, a plain plate to extend over both the openings, 
but not into them ; upon this plate, at the point where the process had been 
Fig. 567. PROSTHETIC DENTISTRY. 
617 
absorbed, wax was arranged so as to restore the alveolar ridge to its natural 
fulness. By using the plate with the wax attached for a mould, metallic dies 
were obtained. A second 
plate was then made to fit 
over that part of the first 
one which was covered by 
the wax; these two plates 
being next soldered together. 
The object in forming a 
double plate was to fill up that 
part where absorption had 
taken place, so that the plate 
when worn would resemble 
the roof of the mouth, and 
not be deeper on one side 
than on the other. 
This obturator was very 
successful; the voice was 
much improved, the patient 
was able to eat and drink as 
well as persons ordinarily can who use upper sets of teeth; and, what was 
more remarkable, she could wear the piece without springs, or any assistance 
whatever, to retain it in position. 
A fifth case by this same practitioner relates to a gunshot wound. 
A gentleman was handling a gun loaded with buckshot, when it was dis- 
charged in his hands. The gun being pointed toward his head at the time, 
the load struck him at the angle made by the ramus and body of the inferior 
maxilla on the right side, passing upward and outward on the opposite side of 
the face. The only way the patient could eat or drink was to lie on his back 
and let the food run down his throat. 
The teeth in the upper jaw were all gone, excepting the left second molar 
and dens sapientiae ; both antra were fully exposed, the remainder of the mouth 
being left almost flat. The lower jaw-bone was wanting on the right side, 
from the second bicuspis back, and also the condyloid process; about three- 
quarters of an inch of the coronoid remained, which was drawn in so as to 
partially cover the roof of the mouth. The molar teeth were lost on the left, 
and also all on the right side from the symphysis. In taking hold of the lower 
jaw it could be moved either backward, forward, or laterally, to a considerable 
distance. 
Figs. 56g and 570 show this case,-the letters A and B are the 
openings in the antra, and C the end of the lower jaw-bone. The distance 
between the points A and C, with the mouth closed, was just two inches. 
The gentleman had been wearing a partial upper set of teeth which had 
been attached to the molars, but the clasps of the artificial work had loosened 
Fig. 568. 618 
A SYSTEM OF ORAL SURGERY. 
these, and it was therefore necessary to replace the piece with a set that could 
be supported in some other way. 
This was found a difficult case to treat. One of the obstacles encountered 
was the obtaining of a correct impression. To accomplish this the antra were 
Fig. 569. 
Fig. 570. 
first filled with loose cotton, to prevent the material used from passing into 
them; next as good a wax impression of both the upper and lower jaws as 
could be got was taken; from these cups were improvised, to be used in 
securing the plaster moulds. There was found very little difficulty in obtain- 
ing an impression of the upper jaw with plaster (the antra being filled with 
cotton as before), but it was far more difficult to secure a good one of the 
lower jaw. The distance from the points of the teeth down to the point 
marked C, as shown in Fig. 569, was so great that when any material was 
forced down to take the impression, removal was almost impossible without 
alteration that rendered it valueless. After several trials a fair one was 
secured with plaster. This, however, had to be broken before its withdrawal 
from the mouth; but, by carefully putting the pieces together, an answerable 
mould was obtained. 
Next a plate to extend over the roof of the mouth and cover both the cavi- 
ties opening into the antra was made; on this plate wax was arranged, bring- 
ing it down to where the alveolar ridge should have been; then, from a metal 
cast was struck another plate to fit over the first; these were soldered together, 
and upon them were placed single gum teeth as would have been done had 
there been no more absorption than is usually found in upper cases. 
There was nothing peculiar in the formation of the lower teeth, except that 
these had to be very long on the right side (for this a block was made), and 
the plate not allowed to extend farther back than to the position once occupied PROSTHETIC DENTISTRY. 
619 
by the second bicuspis. The under teeth were put in more for the purpose 
of attaching springs for the support of the upper than for use. 
What success attended this case the operator was not able to report, as the 
gentleman left the city immediately upon the insertion, and has not been seen 
since. 
Vulcanite for Obturators.-Vulcanite is the material now almost uni- 
versally used for making obturators. Advantages claimed are : its cheapness, 
its lightness, its capability of being moulded into the most irregular positions, 
and its resemblance in color and feel to the natural parts. Objection is its 
liability to become offensive. The manipulation of the material is so easy, as 
has been shown, that the surgeon attempting the manufacture from it of sur- 
gical appliances gives himself a source of recreation rather than work. To 
make an obturator from vulcanite, an impression of the mouth is taken in wax, 
and from this a plaster jnodel is made precisely as before described. Gutta- 
percha is now moulded over this model to the form required. Plaster is next 
run over this first model, the gutta-percha plate being between. The model 
and counter-model thus made are separated, and the place of the original plate 
is supplied with vulcanite. The models are now put together, and the vul- 
canite between subjected to pressure. The whole, with a few ounces of water 
added, is then placed in a vulcanizer, and the temperature is raised to about 
325° Fahrenheit. When taken from its steam-bath the plate is found as hard 
as bone. A finishing process consists in the polishing of the piece; this last 
is a simple manipulation, and requires only one or two files, a scraper, a bur- 
nisher, and some patience. (See previous chapter.) 
Desirabode's Obturator.-M. Desirabode, a French surgeon, proposes 
a palatal obturator for congenital fissure, by which he thinks the sides of the 
alveolar border may be so approximated as to favor a union of the separated 
parts. This consists of a platinum plate fitted to the vault of the palate and 
bent upon the alveolar borders in such a manner as to maintain the whole 
pressure. It is fastened to the teeth by means of three clasps soldered to each 
side, so as to cap the canines, the bicuspidati, and two of the molars. After 
the plate with these appendages has been well adapted, it is to be divided from 
before backward along the median line, and a piece removed from either side, 
so that the two edges are separated about half an inch. The two parts are 
now united by means of a thick and resisting band of caoutchouc, made fast 
by riveting. Thus united, the piece forms a smaller obturator than the plate 
before it was divided, so that it can only be applied by putting the caoutchouc 
on the stretch, which is effected by means of two sticks so contrived as to 
force the plates asunder. After the piece is properly adjusted, these sticks are 
removed, when, by the contraction of the caoutchouc, the sides of the alveolar 
borders are gradually approximated. 
This contrivance of Desirabode looks very plausible, but, unfortunately, all 
experience is against its employment. 
In the first place, to correct a fissure in the hard palate by pressure implies 620 
A SYSTEM OF ORAL SUROERY. 
the very earliest use of force. A child is five or six years old before its first 
dentition is properly completed; and even at this period one would not dare 
apply any such apparatus, because of the physiological process of absorp- 
tion, which has already commenced in certain of the teeth. Then if, on the 
contrary, he meant his instrument to apply to a more advanced period, he 
would have to wait until at least the sixteenth year, as'before this age the 
fangs of the anterior molars are not perfected. The bones by this time have, 
as a matter of course, become much less amenable to treatment. And again, 
even besides this, as the author knows from practical experience, his apparatus 
would in less than a week's time produce such ulitic and periosteal trouble that 
no human being would, or could, bear the continuance of the pressure ; or, 
even admitting there should be found a patient resisting enough to endure 
the treatment, the apparatus would have its usefulness destroyed in less than 
two weeks by the teeth, to which it was attached, coming away. In other 
words, the instrument is useless, because the teeth, being the weaker and 
more yielding, would give way first. 
Complicated Instrument.-The late Dr. E. Wildman, an able me- 
chanical dentist, kindly furnished a description and cuts of a case which, as 
a study, will repay attention. 
The obturator in this instance 
holds in place an artificial nose, 
which in turn holds it in place. 
The description of manufacture 
affords the principle of construct- 
ing all such character of work. 
Fig. 571 conveys an idea of 
the external appearance of the 
patient, but not fully, as the 
whole upper lip was cicatrized, 
and the left cheek depressed 
near the border of the cavity. 
In May, 1863, a young man, 
aged twenty-six years, presented 
himself to Dr. Wildman for the 
purpose of having an appliance 
made to repair a loss sustained 
by disease. Upon removing the 
black patch which he wore upon 
his face, and the cotton with 
which the cavity was filled 
(without the latter he could 
not articulate a word), it was found that the entire external nose was gone,- 
that the nasal bones, the nasal processes of the superior maxillae, also a large 
portion of their palatine processes, the approximal parts of the palatine pro- 
Fig. 571.-The Face without Nose. PROSTHETIC DENTISTRY. 
621 
cesses of the palatine, and the turbinated bones, had been destroyed. The 
soft palate, the uvula, and the tonsils were uninjured. In looking into the 
nasal cavity, the walls of the antrum on the left side were found deficient, 
and ends of the roots of the incisors exposed and decayed. The tongue was 
visible through the opening in the palatine arch. The size and shape of this 
orifice are represented by the outer central line in Fig. 572. 
Although desirable, it was deemed unsafe to remove the diseased roots, 
owing to the yielding nature of the superior maxillary bones. The disease 
Fig. 572.-Internal View of Superior Arch 
appeared to be arrested, and the parts in a sufficiently healthy condition to 
warrant the application of the substitute; and time has verified this, as, with 
the exception of the exfoliation of a small scale from one of the superior 
maxilla, no change has taken place up to this date. 
A first step in the operation for remedy was to procure an impression 
that would secure a perfect model of all the parts involved, and their surround- 
ings, in their relative positions. For this purpose plaster was first used, but, 
its employment being found precluded by the acrid secretions in the nasal 
cavity, wax and paraffin were substituted. Owing to the rigidity of the upper 
lip, Dr. Wildman was unable to employ the ordinary impression-cup with 
success, and found himself obliged to take a rough impression of the palatine 
arch, from which a cast was made, and a metallic tray swaged. 
A sufficient amount of paraffin and wax being thrown into warm water, and 
an assistant aiding to keep the mixture at the proper temperature, the mode of 
procedure was as follows: A proper quantity of the compound was placed in 
the cup, introduced into the mouth, and pressed up firmly against the arch; 622 
A SYSTEM OF ORAL SURGERY. 
the portion forced into the palatine fissure was at the same time pressed with the 
finger, introduced through the nasal cavity, so that it should give an accurate 
impression of the region. A groove was then cut in this to serve as a 
key, and, after oiling it, a piece of the compound was introduced through the 
orifice of the nasal cavity, and passed down to make the impression of the 
floor of the nasal cavity. When sufficiently hard, it was carefully removed, 
the upper surface trimmed, placed in cold water to secure its greatest firm- 
ness, then introduced into the cavity, and pressed into its proper position. 
The metallic cup containing the impression of the palatine arch was then re- 
moved. The next step was to take an impression of the sides of the cavity, 
then the top, using a curved wooden spatula to press the compound in proper 
position, being careful to mark or key the parts that came in contact, and 
have their surfaces oiled, to prevent adhesion; and also that the pieces should 
be thinner in front than in their posterior parts, so that when the four pieces 
forming the impression of the base, sides, and top were in their propor po- 
sition, they would leave a tapering cavity, with its largest diameter at the 
front orifice. Into this orifice was forced a plug, or cone of the compound, 
filling it completely; in the front of this piece were inserted pieces of 
match-sticks, to cause it to adhere to the next piece, or mask. The head 
was now thrown back to nearly a horizontal position, wet tissue-paper was 
placed over the eyebrows and lashes, the face oiled, and plaster mixed 
thick was batted on with a brush. When set, this was removed, drawing 
with it the central plug or cone; the different parts were then carefully 
removed, and thrown into cold water to give them a consistency that would 
bear handling without danger of injury. On this central cone all the parts 
were placed in their proper position, and the impression of the palatine arch 
was adjusted in its proper place. From this a plaster model was made, 
giving the upper part of the face, cavities, palatine arch, all correctly in 
their relative positions. 
Different Substances used for making an Artificial Nose.- 
Of the different substances-leather, wood, wax, metal enamelled, and por- 
celain-used for making artificial noses, Dr. Wildman gave the preference to 
hard rubber in this case, on account of its rigidity, strength, lightness, and 
less liability to injury by accident.* 
To prevent derangement, it was necessary to make the appliance as 
simple as possible; it consisted of two pieces: the external nose, septum, and 
floor of the nasal cavity constituted one, having a projection passing downward 
into the palatine fissure, as represented in Figs. 572 and 573, A; and the 
other, the obturator B, Fig. 574, with a projection rising upward into the 
palatine fissure. These projections were made hollow, so that when the two 
parts were placed together, as in Fig. 573, there would be a cavity or box 
wherein the attachments could be placed. 
* Celluloid yields a more natural appearance than does rubber. PROSTHETIC DENTISTRY. 
623 
Paraffin and Wax as Models.-Models were made of the compound 
of paraffin and wax, which were strengthened in the weaker parts by embedding 
small strips of metal in their substance to give sufficient firmness to admit of 
Figs. 573, 574.-Nose with Attachments. 
the necessary handling without injury. The combined parts were then applied 
to the patient, and the nose trimmed so as to harmonize with his features. 
These were next embedded in plaster in the usual manner for vulcanite-work, 
with the exception that a stout curved wire passed through the artificial nasal 
cavities, extending beyond their borders, to give strength to the rods of plaster 
forming these cavities in the matrice, and thus to prevent their fracture in 
packing. 
This appliance was vulcanized four hours, consuming one hour in 
attaining 280° Fahrenheit, at which point it was held one hour, and occupying 
the third hour in elevating the temperature to 320°, where it was retained 
one hour. The work was rather overdone, but not so much as to injure it. 
The two pieces were retained, in position by a staple and slide- 
bolt. In the recess of the part of the floor of the nasal cavity projecting 
into the palatine fissure (J., Fig. 573) was inserted a gold staple. In the 
recess of the projection of the obturator passing into the palatine fissure 
(71, Fig. 574) were the gold catch and shield of the slide-bolt. The object 
of this shield was to prevent any foreign substances entering the slot and 
obstructing the movements of the bolt, also to give a base of support to the 
catch. The rectangular upright of the catch was soldered to the shield, passed 
through it and a longitudinal slot in B, and securely fastened to a rubber slide 
inlaid longitudinally, and moving freely in the lingual surface of the obturator. 624 
A SYSTEM OF ORAL SUROERF. 
On the anterior end of this slide was a small rounded projection, which enabled 
the patient, when the two parts of the appliance were placed in their proper 
position, with the point of a finger introduced into the mouth, to force the 
slide backward, thereby to pass the catch into the staple and firmly secure the 
apparatus, or, by drawing the slide forward, detach the parts when desirable 
to remove them. 
Securing Likeness to Flesh.-The external nose was painted with 
an oil color, to give it as nearly a 
flesh tint as possible, although this 
is not wholly attainable upon an 
opaque ground. Flesh being trans- 
lucent, a true imitation can only be 
made upon a translucent ground. 
The apparatus was introduced 
on June 30, 1863, giving to the 
patient great satisfaction and com- 
fort. His appearance was much 
improved, as may be judged by 
comparing Fig. 571 with Fig. 575, 
both being engraved from photo- 
graphs. The man breathes freely 
through the nose, and speaks with 
ease ; the only imperfection in his 
speech is a nasal twang, and this 
is less now than when the instru- 
ment was first applied. The ob- 
turator at first extended too far 
back, and caused some irritation 
of the velum: this defect was 
readily remedied. 
Defects.-The operation proved entirely satisfactory, with two excep- 
tions : first, the color of the nose was not as natural as desirable, for the reason 
already stated; second, in deglutition and speech, when the tongue pressed 
forcibly against the posterior part of the obturator, an unpleasant vibratory 
movement of the apex of the nose was noticeable. This could have been 
remedied by an elastic attachment coupling the two parts of the apparatus, 
but this mode was objectionable by reason of its producing constant pressure 
upon the delicate parts, and thereby endangering absorption. A safer plan 
was adopted by inserting a small steel pin in the nose as near as possible to 
its apex, to which was attached the bridge of a pair of spectacle-frames, these 
being retained in position by an elastic cord attached to the bows and passing 
around the head. This arrangement answered the double purpose of counter- 
acting the vibratory movement and concealing the upper part of the joint 
where the nose came in contact with the face. 
Fig. 575.-The Face with Nose. PROSTHETIC DENTISTRY. 
625 
This apparatus is worn at the present date (twenty-four years later) with 
ease and comfort by the patient; at least was so worn when the man was last 
seen by the writer. 
Fig. 576. 
Fig. 577. 
Study in Mechanical Appliances.-Fig. 576 is introduced as a 
study in mechanical appliances. This diagram represents a patient in the 
practice of the author as first seen by him. 
Fig. 577, although not taken from life, is yet wonderfully correct as a like- 
ness after treatment of the lip by operation. 
Fig. 578 is from a photograph taken after treatment of the case was com- 
nleted bv adantation of an artificial nose, which, with the assistance of the 
ingenious surgical artist, Mr. Kemble, was 
prepared for the lady. In this case the 
piece was temporarily employed in antici- 
Fig. 578. 
Fig. 579. 
pation of a more promising condition of the general health for restoration of 
the organ by operation. The effect in life is, or was, quite as good as shown 
in the photograph. The patient has now not been seen for several years. 
Fig. 579 represents an artificial nose, together with a common manner of 626 
A SYSTEM OF ORAL SUROERY. 
holding such a piece in place. In employing springs A, A, as here shown, 
great care is to be exercised that pressure be so applied as to insure if possible 
against an irritation which is apt to result either in inflammation or absorption 
of the tissues, thus in a double direction rendering the piece useless. Better, 
however, than the upper spring for fixing the piece is the use of a pair of 
spectacles; these, through the employment of an elastic band passed around 
the head, not only prevent all motion on the part of the artificial nose, but also 
conceal the line of break. The author is satisfied that the use of spectacles is 
the best means of fixation yet devised. 
Springs in Relation with Whiskers and Moustache.-In gen- 
tlemen wearing whiskers and moustache, the lower spring is also to be replaced 
by means of a delicate silver wire painted the color of the beard, and kept 
tense by relation of the two ends through an elastic bandage, concealed by 
the hair as it passes around the head. 
Origin of Obturators.-Obturators for the mouth, although employed 
by the ancient Greeks, and by every succeeding generation of civilized men, 
seem to have attained to a reasonable completeness only in our own age. 
Before the time of Ambrose Pare, the appliances were all of a temporary 
nature, if we except mention of one suggested by Petronius, in the sixteenth 
century, although whether that surgeon ever really made such a plate as he 
described we are not informed. To Pare, however, we are indebted for a 
written description of the metal obturator, crude, without doubt, but em- 
bracing the principles of the present instruments. Made, says this author, 
like unto a dish in figure, and on the upper surface, which shall be toward 
the hair, a little sponge must be fastened, which, when it is moistened with 
the moisture distilling from the brain, will become swollen and puffed, so that 
it will fill the concavity of the palate, that the artificial palate cannot fall 
down, but stand fast and firm as if it stood of itself. 
Garangeot's Obturator.-Garangeot, in 1715, made an advance on the 
idea of Pare,-although, it must be admitted, a very slight one. He describes 
his instrument as having a stem in the form of a screw, upon which ran a 
nut. To make use of it, he cut a piece of sponge in the form of a hemi- 
sphere, with a flat surface; through this sponge the stem was passed, the nut 
holding it in place. When about to introduce it, he wet the sponge, then 
squeezed it dry, and forced it through the aperture, or break. 
Snell's Instrument.-After the period of Garangeot, no special advance 
seems to have been made until 1828, when obturators were constructed by a 
Mr. Snell, prepared on casts, which were correct representations, or impressions 
of the special cases. In a monograph published by this surgeon, he says, My 
method of constructing an obturator is with a gold plate, accurately fitted to 
the roof of the mouth, extending backward to the os palati, or extremity of the 
hard palate; a part of the plate, about an inch in length, being carried 
through the fissure. To that part of the plate, which answers to the nasal 
fossae, are soldered two plates, meeting in the centre and carried upward PROSTHETIC DENTISTRY. 
627 
through the fissure to the top of the remaining portion of the bones, to which it 
should be exactly adapted, and made to the natural shape of the nasal palatine 
floor: thus the fluids of the mouth will be carried backward into the fauces. 
A piece of prepared elastic gum is next attached to the posterior part of the 
plate where the natural soft palate commences, extending downward on each 
side as low as the remaining part of the uvula, and grooved at its lateral edges 
to receive the fissured portions of the velum ; a movable velum is placed in the 
posterior centre of the elastic gum. That these may partake of the natural 
movements of the parts during deglutition, a sponge is affixed behind them, 
one end of which is attached to the posterior and anterior surfaces of the 
principal plate, and the other end rests gently against the posterior face of the 
india-rubber; this keeps it always in close apposition with the edges of the 
fissure during deglutition. 
It is requisite to mention, he says, that the elastic gum should be placed in 
a gold frame, and not merely fastened to the posterior part of the plate, as it 
would shrink by remaining in the mouth. The frame should pass round its 
edges only, leaving the centre open. 
VELA. 
Defects in the Soft Palate.-Coming to the present period, attention 
is interested in efforts made to compensate, through mechanical means, defects 
in the soft palate. The indication here is twofold: 1. To cover the break 
after such manner that food and drink shall be shut off from the nares and 
directed toward the throat. 2. To furnish ability for speech. 
Fig. 580. 
Fig. 581. 
Palatine surface. 
Nasal surface. 
An obturator meeting the first of these indications reasonably well consists 
in an attachment to a metal plate of a flexible continuation made of rubber. 
Figs. 580 and 581 show the two surfaces of such a velum, and aflbrd under- 
standing of its construction. 
Obturators, here most justly called vela, designed to accomplish the second 628 
A SYSTEM OF ORAL SURGERY. 
end, introduce the practitioner, in a study of them, to the complexities of 
prosthesis. Fortunately, the study leads in turn toward absolute simplicity. 
Steam's Velum.-In 1845, Mr. Stearn conceived the idea of a velum 
which should take the place of parts wanting in a soft palate, and be made 
movable by the parietes with which it was related. This appliance, as made 
by the gentleman, consisted of a gold plate fitted to the hard palate, having 
attached to it, by means of two spiral springs, an artificial velum of elastic 
rubber, composed of a body, wings, and grooved edges, to receive the margin 
of the cleft. 
Kingsley's Velum.-Succeeding Mr. Stearn is Dr. Norman Kings- 
ley, of New York City, a practitioner who has been an enthusiastic worker in 
the direction for years. To follow and appreciate the steps taken in the direc- 
tion by this operator is to inform one's self very fully as to the principles of 
the practice. 
Fig. 582 shows a case with which Dr. Kingsley commenced experi- 
mentation. The patient was a lady; the defect congenital. As is seen, the 
Fig. 582. 
break passes completely through both hard and soft palates. Indications 
directed an obturator and velum combined. 
In the cut is exposed the perverted anatomy of the parts: A is the dis- 
articulated vomer; B, B are the turbinate bones; C, C show the separated 
halves of the uvula, and afford an accurate idea of extent of deficiency in the 
soft palate. PROSTHETIC DENTISTRY. 
629 
In my desire, writes Dr. Kingsley, to benefit this patient, I re-read all 
the literature I could find on the subject, with but little satisfaction, and 
ended in making a plate of vulcanite, of which Fig. 583 is an illustration. 
This obturator was worn for a few days with entire comfort, when my patient 
Fig. 583. 
informed me that she had accidentally learned that there was a gentleman in 
the city engaged in manufacturing pursuits who had made a plate for himself 
which was a great success. Calling on the gentleman, Dr. Kingsley expresses 
his great surprise in finding him to be the veritable Mr. Stearn whose name, 
in connection with the invention of the artificial velum, is cited in previous 
paragraphs.* 
Mr. Stearn and Dr. Kingsley entered conjointly on the manufacture of a 
second apparatus. Fig. 584 shows the result of the work. 
Fig. 584. 
This velum proving unsatisfactory to Dr. Kingsley, believing, as he ex- 
presses himself, that one produced more after the manner in which a dentist 
would manipulate must do better, a second impression was secured (this being 
taken in plaster), and from it a model made. Upon this model a pattern was 
formed in gutta-percha, which, in turn, was copied in vulcanite. This 
vulcanite model was carefully finished, and steps taken to make a mould in 
which to vulcanize duplicates of soft or elastic rubber. In this manipula- 
tion Dr. Kingsley claims to have been the first to use type metal, the mould 
* Desirabode, Snell, and Seracombe, as will be recognized, are not lacking in claim to a 
share in the conception of the possibilities of artificial vela. 630 
A SYSTEM OF ORAL SURGERY. 
used by Mr. Stearn being of wood. The instrument made is shown in 
Fig. 585. 
Alluding to the two pieces, Dr. Kingsley suggests that the only 
advantage in the one constructed by himself lay in a nicer adaptability. 
Fig. 585. 
Improving on his original plate, Dr. Kingsley exhibits his second 
case, made in 1863. Figs. 586 and 587 show the oral and nasal surfaces. 
A, A, A represent the groove which corresponded to the border of the fissure. 
E, E show processes which lapped on to the floor of the nares and assisted 
in its support. C is the central flap, as used in the Stearn palate, and G, G 
are the two bows, or springs, of rubber which sustained it. In swallowing, 
Fig. 586. 
Fig. 587. 
the sides, B, B, approached each other, sliding under the flap C. This instru- 
ment was made of soft rubber in a type-metal mould, the mould itself being 
an intricate affair; but the instrument was simple in its application, and was of 
as much benefit in articulation as anything which has been produced since. PROSTHETIC DENTISTRY. 
631 
Objection to this apparatus, felt by Dr. Kingsley himself not less than 
by others, lay in its complexity, the instrument being both costly and liable to 
get out of order. Here was an incentive to renewed effort. In 1864 a model 
was made of an instrument strictly original. The change consisted in aban- 
donment of the triple form of construction, doing away with the central slip, 
the flaps, and all gold and other springs. These arrangements, it will be 
recognized, were in the former appliance to provide for the movements of 
the divided uvula and adjacent remnant of palate. The complexity is not 
hard to appreciate. Figs. 588 and 589 show the new instrument. 
Fig. 588. 
Fig. 589. 
Out of his experience Dr. Kingsley remarks of this last con- 
struction : For fifteen years I have used this form, and applied it in hundreds 
of cases of congenital fissure, and have made no improvement beyond simpli- 
fying the method of production. I know of no other form, or attempt at 
making an elastic velum, which fulfils the functions that this one does; nor 
do I believe it possible to make a flexible, yielding instrument which shall be 
of so universal application in any other form or by any other method. 
In the cut (Fig. 588) D expresses the wings and A the posterior part of the 
velum; Fig. 589 shows an unattached instrument. Viewed in situ and dis- 
tinct, the arrangement is easily appreciated. The hole in the front face of 
either velum is a means for attaching the piece to any arrangement required 
anterior to it. 
Suersen's Velum.-Passing from the Kingsley experiments, refer- 
ence is to be made to the velum and to the labors of William Suersen, Doctor 
of Surgery, a dentist practising his profession in Berlin. By this gentleman 
we have had advanced a new principle in the mechanism of speech. 
To pronounce distinctly it is necessary, he says, that the cavity of the mouth 
be separated from that of the nose by muscular interruption. That inter- 632 
A SYSTEM OF ORAL SU ROE RY. 
ruption is, under normal conditions, effected, on the one hand, by the velum 
palati, on the other by a muscle which has not, in such connection, received 
the attention merited,-namely, the constrictor pharyngeus superioris. This 
latter muscle contracts itself during the utterance of every letter pronounced 
without the nasal sound, just as the levator palati does. The constrictive 
muscle contracts the pharyngeal cave, the wall bulging. On the action of this 
muscle is based the system of the new velum. 
The palate, constructed in all its parts of caoutchouc, consists of a plate 
suitably attached to existing teeth, this being made as an obturator if indi- 
cations exist in that direction. Where a fissure is related alone with the 
velum, this palate expands at the part into a process, or apophysis broad 
enough to compensate for the loss of the missing part. This process, or en- 
largement, is at the same time of such thickness as to keep up contact be- 
tween the high edges constituting the sides of the apophysis and the two 
halves of the velum, even when the levator palati is active. To insure this 
contact in motion of the parts, the high edges do not rise straight, but ob- 
liquely, toward the outside. The lower surface of the apophysis, turned 
toward the mouth, lies on about an equal level with the velum, if the latter 
be raised by the lifting muscle. When, however, the levator is not in action, 
the velum loosely depending, the back part of the artificial palate lies over it. 
This back part fills up, accordingly, the pharyngeal cave, and in such manner 
as not to impede the entrance of air into the cavity of the nose when the 
pharyngeus constrictor superioris is inactive. Thus the patient can, without 
impediment, breathe through the nose. But as soon as the constrictor con- 
tracts the cavum pharyngo-palatinum, this happening with the pronunciation 
of every letter, m and n excepted, the muscle reclines against the vertical 
back surface of the instrument. By this operation the air-current is pre- 
vented from entering the cavity of the nose and is compelled to take its way 
through the mouth, utterance being thus freed of nasal sound. To the ex- 
istence of the vertical surfaces, and consequently to the thickness of that part 
of the apparatus which fills up the fissure in the soft palate and the cavum 
pharyngo-palatinum, special importance is to be attached. But for the thick- 
ness, the levator palati, when it rises upward, would not remain in contact 
with the side-edges of the instrument, nor would the pharyngeal constrictor 
be able to effect a sufficient termination if the portion of the obturator 
nearest it consisted only of a thin plate. 
Suersen's Velum simple and not unsatisfactory. - The 
author has to remark his reasonable satisfaction with the Suersen design. 
Nothing yet made surpasses it for service, and for adaptability to require- 
ments. It is his own plan, however, to make the portion covering the hard 
palate out of metal and to attach to this a velum, or box portion, constructed 
from celluloid. 
Booth's Velum.-Reference in connection with this form of obturator 
is deservedly to be made to what may prove an addition designed by Dr. PROSTHETIC DENTISTRY. 
633 
Booth, of Iowa, in the shape of a box, or velum, portion related by means 
of a stop-hinge, and controlled in its upward movement by a delicate spring. 
The promise of this instrument has much impressed the writer. It has 
certainly all required latitude of ascent and fall, and there is nothing to get 
out of order. To appreciate the construction of this obturator, it is only 
necessary to imagine a common plate fitted to the hard portion of the palate, 
to which a box, shaped something like the last phalanx of an index-finger, is 
attached by a hinge of a character that prevents the part descending below 
the curvature of the arch, yet moving freely upward, except as such freedom 
of movement is controlled by a spring riveted at its fixed extremity to the 
nasal aspect of the common plate, and reaching back to the box. 
In a specimen of this design exhibited to the writer by its inventor, the 
roof-plate on one side was fixed by means of a groove slipped about the palatal 
process; a means of fixation not so desirable, it would seem, as the employ- 
ment of the ordinary denture arch. 
Baker's Velum.-Not dissimilar as to general design and idea from the 
Booth instrument is an obturator made by Henry A. Baker, D.D.S.; like the 
last described, it is a modification of the Suersen instrument. Cuts here intro- 
duced afford idea both of the Booth and Baker apparatus. 
Fig. 590, A, shows a gold or rubber plate fitted to the hard portion of the 
palate, its support being in clasps about the necks of certain teeth, as shown 
in the festoons. F is the velum proper; it is of chestnut shape and extends 
backward and downward, filling up completely the space between the sepa- 
Fig. 590. 
rated parts, and being so embraced by the muscles and so restorative of the 
absent curvature that the movements of the palatal remnants reacquire, as 
nearly as may be, the meaning of original function. 
Dr. Baker describes his velum as consisting of polished hard rubber, 
gold, or platinum. B, B exhibits hinge attachment to allow of part lifting 
and falling in concert with constricting muscles. C is a delicate platinized 
gold spring, which, bridging the joint and resting on the velum at E with a 634 
A SYSTEM OF ORAL SURGERY. 
slight downward pressure, serves to keep the latter in contact with the levator 
muscles when in action, thus giving them control of the appliance. 
Turning here a glance at Fig. 591, the apparatus is seen in position. 
Fig. 591. 
A, the plate; B, the stop, preventing downward motion when the muscles are in a 
relaxed condition; C, the artificial velum; D, D, muscles lying under it; the dotted 
lines show the appliance rests upon the muscles. 
Fig. 592. 
E, E, the artificial velum thrown up by the muscles as in all sounds requiring closure 
of the nasal passages; F, the superior constrictor muscle advanced to meet it; G, the 
tongue, raised, pressing hard against the appliance, as in pronouncing the letter k or g; 
A, the plate; B, the hinge-joint and stop; C, the spring resting on the velum. 
Baker's Velum in Transverse Section.-Attention is next di- 
rected to Fig. 592, which shows transverse section of Dr. Baker's obturator 
and of the natural parts to which it holds relation. PROSTHETIC DENTISTRY. 
635 
Fig. 593 exhibits expression of velum and associate parts when out of office. 
Referring to the curvature, marked difference is seen as contrasted with Fig. 
592. In the latter nasal respiration is shut off, in this it is uninterfered with. 
The letters refer alike in both diagrams to the same parts. 
Fig. 593. 
Showing muscles relaxed and the velum at rest, thus affording free passage for nasal 
sounds and respiration. 
To secure Lightness.-A valuable hint in connection with the velum 
or bulb portion of this obturator relates to making it hollow, so that weight 
shall not interfere with the necessary, or desired, movement. Manufacturers 
of rubber balls secure the result as follows : Take the vulcanite rubber in the 
soft state, and cut the sheets so that when joined the desired form is secured; 
then a little water (alcohol is added by Dr. Baker) is dropped into the cavity, 
the edges are sealed, and the piece vulcanized in the usual way. The steam 
produced by the water and alcohol inside creates sufficient pressure to keep 
the walls distended. 
A well-founded claim for this obturator relates with assistance rendered 
the levator muscles of the palate, as the action of these contributes to freedom 
in speech. With all sounds requiring closure of the nasal passage the bulb 
is lifted (see Fig. 593, D) by the levator muscles, which muscles find their 
ability to act through the bridge-like relation with those of the velum (Fig. 
592, D, C, D), nothing interfering with the action except the insignificant 
resistance offered by the slight spring (Fig. 590, C). The thickness of the 
velum, or bulb, relates its posterior surface in apposition with the superior 
constrictor muscle, F, thereby affording, in the pronunciation of the gutturals, 
firmer resistance to the tongue, C, than is to be obtained with a thin obtu- 
rator. By reason of the presence of the hinge, B, the above movements are 
rendered so free and easy that there is no tendency to displacement of the 
plate. If a nasal sound immediately follow a guttural, the descent of the 
velum is rendered certain and timely by means of the spring. 636 
A SYSTEM OF ORAL SUROERY. 
Facial Masks.-A mask is an obturator or cover designed to conceal 
facial defects. Fig. 576 furnishes a good illustration of a defect suited for 
the mask ; it being accepted that the case admits of no correction by operation. 
Principle of the Mask.-The principle of the mask is that of the 
common false-face ; difference lying in quality and adaptability of construction. 
Masks Complete or Partial.-Masks are complete or partial. The 
full piece covers the whole face; limited pieces apply to a part or parts. 
To make a Mask.-To make a mask that shall fit perfectly and restore 
as completely as possible the lost contour, the surgeon commences by restoring 
to the face in wax the lacking parts; this he does as perfectly as his artistic 
skill admits of. Harmony of features secured by such temporary means, a 
succeeding step is the taking of a mould, or impression. To take such cast, 
plaster being used, all hair of the region is to be shaved away; otherwise 
closely flattened to the face through the free use of bandoline. This accom- 
plished, a succeeding step provides means of breathing. Next is the getting 
of the mould. To secure this plaster batter is mixed in quantity and con- 
sistency that shall cover the face, yet not flow. The patient being now supine, 
and the parts thoroughly oiled, the batter is moulded upon the region; care 
being taken to accomplish the intention perfectly. 
When set, or hard, the mould is carefully to be lifted from the face 
and laid away for at least twenty-four hours. If, in the act of removal, dif- 
ficulty be experienced in raising the plaster, the piece is to be broken and 
lifted in parts. 
A succeeding step refers to the proper cast of the face ; it being rec- 
ognized that the impression just taken is but a form in which this other is 
made. 
The mould proper being arranged and built about so as to lie in the 
bottom of a cup, it is first varnished, and, after being dried, it is very com- 
pletely oiled. A second batter of plaster being mixed,-this time in the form 
of a thick cream,-the cup is filled by a pouring which commences and retains 
place at the lower portion of the mould. The batter is to rise gradually over 
the face surface, that absence of air-bubbles and absolute continuity of surface 
be secured. 
Allowing time to elapse sufficient for the setting of the cast, a few 
hammer-taps against the mould suffice for the separating of the parts. A 
model thus secured represents perfectly the countenance from which it has 
been taken. 
To fit a Mask.-To fit a mask to this model, the whole or part being 
considered, a procedure is as follows: Taking the face (Fig. 576) as the block, 
and accepting the cast to have provided it with nose and lip, the operator com- 
mences by moulding over the restored parts a layer of absorbent paper, which 
performance he accomplishes by a free use of water. With this layer of paper 
he represents nose and lip, taking great pains that the boundary edges shall 
rest against their neighboring parts with the nicest accuracy. The paper being dry and hard, he proceeds to mould upon it either gutta- 
percha, other paper, or a sufficient number of layers of cotton stuff saturated 
with paste to accomplish the purpose of the requirements. This done, the 
proper contour of the free surface of the lip and the nasal openings having 
been considered, succeeding steps relate to varnishing the piece, and to the 
manner of fixing it in place. In the case of a female such fixation is no easy 
matter; spectacles and flesh-colored string offer the best solution of the problem. 
The brush of an artist is necessary to give the final covering and color. 
Burne's Mask.-In this direction of practice an interesting example 
has been detailed to the author by Dr. Alfred Burne, of Australia; the patient 
being a medical gentleman and personal friend of the operator. The deformity 
in the case involved the superior maxillary region, bounded above by the 
transverse suture, below by the lower lip, extending from either oral angle 
backward and upward in curved lines to the temporo-maxillary articulations. 
Having found, said Dr. Burne, that my own face corresponded in form and 
size with that of my patient, I had an impression taken of it. From this 
mould I made a cast, upon which, in turn, a mask was constructed. The 
completion of this mask showing it to be too large, I had a second impression 
moulded; this time also of my own face. Another mask was now made, this 
time being moulded into the mould, no cast being made. The fit secured is 
described as being so perfect and in every respect so satisfactory that whereas 
the gentleman never before its application ventured abroad without close con- 
cealment, he is now found mingling in society generally. 
Steps of Manufacture.-The steps of manufacture and fixation of the 
mask are given as follows: After the impression was hard it was thoroughly 
smeared with cosmoline; common paste flour and warm glue, eight parts of 
the former to one of the latter, were in turn laid over the cosmoline. Next, 
a piece of fine linen was taken, and by dint of much patience it was worked 
into the irregularities of the mould, the task being accomplished minus a single 
wrinkle. This being allowed time to dry, the glue-paste was in turn brushed 
over it, this receiving still in its turn a layer of blotting-paper. Again dry, 
again was repeated the layer of paste and paper. 
Sufficient thickness obtained, the mask was removed from the mould and 
padded and trimmed to suit the face of the patient. The piece was completed 
by cutting out holes for the eyes and nostrils, adapting eyebrows and moustache 
to match hair and beard, and a final artistic painting of it. 
Fixation to Face secured.-Fixation to the face was after the fol- 
lowing manner: When in place the mask extended from the line of the hair 
upon the forehead to contact with the inferior lip below, from the ear upon 
one side to that upon the other. Above and at the sides the hair was brushed 
over the edges, concealing these fairly well. Midway-that is, over the bridge 
of the nose-spectacles were fixed which passed around the ears with a spring. 
The artificial moustache mingled with a beard which concealed elastic flesh- 
colored strings passing among the hair around the head. 
PROSTHETIC DENTISTRY. 
637 638 
A SYSTEM OF ORAL SURGERY 
With the aid of the diagrams shown in the chapter, and with comprehen- 
sion of the principles on which obturators and vela are constructed, the student 
or practitioner will surely be at no loss to continue experiments in the direc- 
tion. The field is one inviting wide and generous competition. It is to be 
added, however, in conclusion, as regard is had to the mouth cases, that the 
experience of the writer favors treatment of palatine defects by operation in 
all instances where such means applies. It is to be suggested, at the same 
time, that failures are, and will not unlikely continue to be, multitudinous. 
In a succeeding chapter the matter and manner of surgical operations upon 
the parts will be found fully considered. CHAPTER XXXVII. 
PYORRHCEA ALVEOLARIS. 
The term pyorrhoea alveolaris, meaning a pus-flowing alveolus, is correctly 
applied only to a condition where pus is exuding from about the necks of the 
teeth. 
Features and Causes.-Features and causes of this condition vary 
greatly. A practical illustration of impressive character is gotten by envelop- 
ing tightly the neck of a tooth by an india-rubber ring and allowing it to 
remain until suppuration is established. (See Fig. 127.) Anything that 
tends to induce degenerative disturbance of a tooth-pit is to be esteemed cause 
of the condition considered. 
Salivary Calculus and Serumic Deposits as Cause.-Salivary 
calculus and serumic deposits, the latter various as to expressions, but always 
a resultant of degenerative conditions of the mucous crypts surrounding the 
necks of teeth, are to be instanced as the most common causes. (See illus- 
trative case, page 289). 
Lack of Articular Antagonism in the Teeth.-Teeth when not 
antagonized are exfoliated as a result of deposits made in their sockets, this 
process occasionally progressing with such rapidity as to be accompanied with 
considerable degeneration of tissue and flow of pus; commonly, however, no 
pus is present. 
Undue Antagonism.-A tooth striking for any reason before its fellows 
soon expresses evidence of the existing irritation, and, if not relieved, takes on 
peridental inflammation which may end in suppuration, the pus venting itself 
from about the neck of the tooth. 
Insoluble Dentifrices.-Still another cause of crypt and peridental 
inflammation lies with the continued use of insoluble articles for teeth- 
cleaning purposes. Destruction of functional office on the part of the follicles 
lining the gum-pit-a result of senile changes-is so common a cause 
as to be equally familiar to the laity and the profession. 
Plugs in Necks of Teeth.-A plug in the neck of a tooth, unless well 
and judiciously placed, arouses inflammation and pus discharge. 
Denture Clasps.-Clasps employed for fixing artificial teeth prove often 
enough the cause of pyorrhoea alveolaris. 
Caustic Agents.-A case of alveolar pyorrhoea where a profuse pus dis- 
charge related with tooth exfoliation had its meaning in an application of 
chloride of zinc, made with view to control a hemorrhage of the gum. 
639 640 
A SYSTEM OF ORAL SURGERY. 
Sordes.-Deposits relating with an overuse of salt meat and the absence 
of vegetable diet is a cause of pyorrhoea very familiar to medical practitioners 
in country districts. (See Diseases of Gums.) 
Scurvy.-This condition is quite analogous with the former, and is most 
familiar in the persons of sailors who have made long voyages under circum- 
stances of deprivation. (See Diseases of Gums.) 
Mercurial Medicines.-Degeneration of the gum-pits and alveoli from 
abuse of mercury, attended with loosening of the teeth and free discharge of 
pus, is among the familiar experiences in surgery. (See Diseases of Gums.) 
Lack of Use of the Dental Apparatus.-A dental apparatus not 
used results in peridental degeneration, as made familiar in the case of swill- 
fed cows. 
Epulic Growths.-An epulo-carcinomatous tumor sooner or later de- 
generates, yielding pus. Necrosis gives much pus. 
General Debility.-This, while infrequent, is yet a cause to be borne 
in mind. The teeth loosen and drop out. 
In recognition of definition and causes pyorrhoea alveolaris resolves itself 
into a matter wholly of cause and effect and exhibits that it is no special dis- 
ease. Excuse for giving it the distinctiveness of a chapter is to 
be found alone in compulsory recognition of the fact that prominence in the 
way of its being some individual thing is accorded it quite universally by the 
younger members of the specialty, in whose interest this book is more par- 
ticularly composed. 
Treatment.-This demarks and distinguishes itself, as is expressed in 
meeting the various indications. Taking the first of the causes named in 
this paper,-namely, a collection of tartar about the necks of teeth,-the in- 
dication is to remove such collection. In turn taking one after another of the 
other causes enumerated, the indication is to treat such cause or causes. 
That practical and immediate application be made in the matter of meeting 
indications and as well of scientifically appreciating causes, the student is to 
pass to the immediately succeeding chapter treating of salivary calculus, and 
from which he is to continue to the one that follows it treating of the 
gums and their diseases. These various details studied, little will remain to 
be learned about the subject. A typical case may introduce the chapters. 
Typical Case-Serumic Tartar.-In a paper exceptionally prac- 
tical and embracive of its subject, read before the New Jersey State Den- 
tal Society by George S. Allan, D.D.S., this gentleman, adopting the views 
of Dr. Black regarding what is denominated by him serumic tartar, offers 
a case in the direction treated of in the present chapter that is so entirely 
typical of what is commonly understood and spoken of as pyor- 
rhoea alveolaris that it well deserves to have permanent record. Fig. 594 
represents the teeth of the patient, a gentleman, as they existed in the year 
1874. Fig. 595 shows the same mouth as seen one year later. Fig. 596 ex- 
hibits the affected tooth, as remaining permanently elongated, after treatment. PYORRHCEA ALVE0LAR1S. 
641 
Fig. 597 is expressive of the mouth after cutting down of the diseased incisor 
with view to correspondence with its fellow. Dr. Allan's description of his 
case affords the following compilation of it. 
In June, 1874, the teeth were perfectly regular in the mouth of a gentle- 
man aged thirty-five or thirty-six, and also in a healthy condition. Soon after 
that, the front teeth were felt as 
if crowding or pressing tightly 
together, and in the autumn 
of the same year, and during 
the winter, the left central 
pushed against the right and 
finally commenced to overlap 
it. (See Fig. 594.) In the 
spring of 1875 the mouth was 
very much in the condition as 
that shown by Fig. 595, which is a front view. On examination a pocket 
was found on the lingual face of the right central, extending nearly to the 
apex of the root. On the left central a pocket had extended quite to the 
apex of the root, and had cut off the pulp where it enters the apical foramen. 
The lateral was dead. A careful exam- 
ination, made by putting some cotton in 
the pocket two or three days in suc- 
cession and pressing the gum back, 
brought to sight a dark shade, indi- 
cating serumal tartar of the scaly 
character. The thickening of the 
membrane on the inner surface of the 
tooth had crowded it to the right and 
outward. If that pocket, suggests Dr. 
Allan, had been discovered in time, and the thin scale of serumal tartar been 
removed, the deplorable condition of affairs never would have been brought 
about, and the patient would have continued to possess his teeth in a sound 
and healthy condition. 
The treatment pursued by 
Dr. Allan consisted, first, in 
the use of scalers to remove 
the tartar, followed by the 
application of peroxide of 
hydrogen. For a month or 
six weeks the pockets were 
treated once or twice a week. 
At the end of that time the teeth which were quite loose when treatment was 
commenced-the lateral being very loose-were in a much firmer condition, 
showing that the tumefaction of the peridental membrane had been bettered. 
Fig. 594. 
Fig. 595. 
Fig. 596. 642 
A SYSTEM OF ORAL SURGERY. 
When success was attained in removing the tartar and quieting the inflamma- 
tion, effort was inaugurated to move the tooth around to the left, and to pull 
it in. Fig. 596 shows the condition of the mouth when the movement of 
this tooth was completed. As seen, it has been pushed out of the socket to 
one-eighth of an inch. For two months trial by various methods was mad& 
to get it up in the jaw, but with so little success as to compel shortening of 
it by grinding off the cutting 
edge. The lateral was treated 
by removing the dead pulp 
and filling the pulp-chamber. 
The last cut (Fig. 597) shows 
the condition of the teeth as 
Dr. Allan describes them at 
the present time. The left 
central, which was, as sug- 
gested, quite loose at the commencement of the operation and out of place, 
is referred to as being now firm as the right central, every indication existing 
that the disease is completely cured. 
This case is presented by Dr. Allan as illustrative of the effect of 
serumal tartar of the thin and scaly character. The suggestive conclusion 
of Dr. Allan's paper is as follows: If a sound and firm tooth in the mouth of 
a man of thirty-six years can be pushed completely out of its place inside of 
eight months by swelling of the peridental membrane, induced by tartar, 
it shows the necessity of an early and correct diagnosis and prompt and 
thorough treatment. Referring back to his case, Dr. Allan says there is no 
new deposit of bone whatever. The parts around the tooth have assumed a 
normal condition, and the pocket remains as when treatment was commenced. 
Expressive of Serumic Deposits.-It is familiar that in certain sys- 
temic conditions-in scurvy and ptyalism, for example-the crypt-glands lose 
their integrity, and either fail to secrete at all, or otherwise discharge a fluid 
that is quickly destructive of peridental integrity. A condition of 
not dissimilar significance is observed in scrofulous children in case of the 
Meibomian glands, where the secretion, in place of properly lubricating the 
edges of the eyelids, stick them together. It is assuredly not to be doubted 
for a single moment that conditions exist, solely local as to significance, as de- 
scribed by Dr. Black and Dr. Allan. Where, from any cause, the crypt-glands 
are wanting, or deficient, as to their functional office, the crypts may not re- 
main clean, but are intruded on by ingesta that meet with no obstructing 
fluid to wash them away. Deterioration of the glands may be of a character 
that favors the deposit of an inspissated fluid, the watery portion of which 
evaporating, leaves as residuum what is understood by Dr. Black as serumic 
tartar, a name quite as expressive of the deposit as any other that might be 
used. There is little doubt as to this deposit being a habitation for 
parasites, hence indication for the use of germicides. Diagnostic signs and 
Fig. 597. PYORRHCEA ALVEOLARIS. 
643 
symptoms of such a typical case as is here proposed to be presented are most 
correctly given by Dr. Allan as follows: 
Diagnostic Symptoms.-First, and most prominent, of the symptoms 
is the loosening of the teeth. This may or may not be accompanied by a re- 
cession of the gums, but most frequently is. The condition may come on 
gradually and be unaccompanied by pain, or it may make rapid progress and 
cause more or less soreness and inconvenience. A careless patient would, more 
than likely, have his attention first drawn to the trouble by noticing that one or 
more teeth felt lame or were tender to the touch, or when eating, but at other 
times were quiet and gave no annoyance. On placing one of his fingers, as 
he naturally would, on the offending member, he would find it had lost some 
of its firmness and was shaky in its socket. When recession of the gums is 
the prominent feature, it will be noticed that on one face of the tooth 
the root is unduly exposed, the gum having disappeared, but the tooth need 
not of necessity feel loose, being held in place by healthy tissues on the re- 
maining portions, and may be still further steadied by its neighbors on either 
side. This is a second symptom. A third symptom appears in a softened, 
tumefied gum, one that bleeds easily and has a dark purplish color. A fourth 
symptom would be a bad breath and a disagreeable taste in the mouth. A 
slight discharge of pus from around the affected tooth, or teeth, might account 
for this taste and odor, but not of necessity. All these symptoms may occur 
simultaneously, or any two of them may exist without the third. They all 
belong to the final stages of the trouble, and precede, without treatment, a 
limited time only the final loss of the teeth affected. It will be noticed that 
allusion is simply made to a discharge of pus as a probable incident mani- 
festing itself in the later stages. It is not a prominent indication to go by. 
A practitioner who looks for pus as aid in his diagnosis oftentimes will look 
in vain, and still the disease be making rapid progress. The presence of pus 
comes only as a sequence to inflammation, and can be counted on only as one 
of its signs and indications. It does not represent the disease any 
more than the interest on a debt represents its principal or what it was for. 
Symptoms continued.-In the second class of symptoms, those that 
require both skill and knowledge for their appreciation, belong a much larger 
group of symptoms, and really the most important to be considered, for they 
lie at the very basis of proper diagnosis and treatment, and as prevention is 
more valuable than either of these, their due consideration is most important. 
To this second group belong the following: 1, the gum over the 
affected tooth will have a slightly darker color than is natural, and, probably, 
will have fallen slightly away from the root; 2, an instrument can be passed 
up between the gum and teeth beyond the normal distance, which is about 
one-sixteenth or one-eighth of an inch ; 3, the depth will vary at different 
points more than it ought to; 4, the border of the alveolar process will be felt 
by an exploring instrument at one or more points; 5, the neck of the tooth 
will be unduly sensitive, showing the presence of some irritating agent, and 644 
A SYSTEM OF ORAL SURGERY. 
will be rough and uneven under the margin of the gum; 6, a whitish, milky 
exudation can be pressed from between the gum and the tooth, not at all, 
however, like pus, simulating it neither in color nor consistency. 
Fig. 598 shows the dissection of a case similar in every respect 
to the typical example described. The gum here was retracted and of light 
purplish color, and the tooth was elongated exactly as 
shown in the case of the incisor (Fig. 595). There 
was no pus, only a gleet-like oozing from about 
the tooth, which tooth was loose. Exploration, made 
with a lathe-shaped excavator, showed partial loss 
of the labial face of the alveolar process, affording 
to the touch impression of its being fringed by 
proliferated peridental tissue. Section of the gum 
and laying back of the flaps, as shown in the cut, 
afforded what is seen in the diagram. A is the 
neck-line of the tooth. B is the proliferated and 
degenerated periodonteum. C'is the alveolar process 
thinned and absorbed irregularly to the extent shown. 
D is the flap of gum. 
Absence of Tartar.-In this case the uncovered neck portion of the 
tooth had no tartar of any description on it, but was clean and reasonably white. 
Treatment pursued consisted in cutting away all the exposed periodonteum and 
in freshening, by means of a bone-drill, the absorbing process. The flaps were 
laid back in place and held by three stitches. The patient used as a rinse, 
three times a day, a stimulant wash made by adding a teaspoonful of the 
tinctura capsici et myrrhae to two-thirds of a gobletful of water. Cases of 
this kind are so common as to be familiar to every practitioner. As a rule, a 
tooth so affected is lost sooner or later. 
Resume.-The student is to understand that the term pyorrhoea 
alveolaris has come to quite general adoption where the intention is to 
express loosening of the teeth. He is to understand that it is not restricted 
to loosening associated with presence of pus. He is to appreciate that the 
loosening is a resultant of various causes, consequently that appreciation of 
the subject lies not elsewhere than with recognition of these causes. 
Typical Case.-The case given as typical illustrates the most common 
expression of the lesion and phenomena as these are met with in practice. 
Serumic tartar, or deposit, is accepted by the writer of these pages as a 
good term to use, inasmuch as no better one offers itself. It is not meant to 
accept, however, that there is a tartar in any way analogous to salivary cal- 
culus ; the latter is another condition entirely, as will be understood in a study 
of the immediately succeeding chapter. Fig. 598 is absolutely, correctly, 
and fully illustrative of a typical case of so-called pyorrhoea alveolaris. Just 
what it is that inaugurates the lesion is Appreciable in a study of the gums 
and their diseases, which see. 
Fig. 598. 
Gum turned aside, show- 
ingunderlying condition in 
a case of pyorrhoea alveo- 
laris (so called). CHAPTER XXXVIII. 
SALIVARY CALCULUS. 
Salivary calculus, or tartar, as it is commonly called, is that lime-like 
material so often seen collected upon the necks of the teeth. Observation 
elicits the fact that the primary seat of deposit is about the posterior 
or lingual faces of the inferior incisors and the buccal aspect of the superior 
molars. As in these situations exist the outlets of the salivary secretions, 
an inference is that from these secretions comes, in part at least, the deposit. 
Analysis of Saliva. 
W ater. 
Ptyalin. 
Fat. 
Chloride of sodium. 
Chloride of potassium. 
Phosphate of lime. 
Sulpho-cyanide of potassium. 
Analysis of Salivary Calculus. 
Carbonate of lime. 
Phosphate of lime. 
Fat. 
Mucus. 
Accidental matter. 
Sluggish Salivary Secretions.-When the salivary secretions are 
sluggish, the inorganic material, not being held in solution until fairly ejected 
into the mouth, becomes deposited about the roughened and inviting surfaces 
of immediately neighboring teeth. A nucleus once formed, aggregation goes 
on until serious secondary lesions are apt to result. 
Effects of Salivary Calculus.-The first and most marked effect of 
salivary calculus is upon the teeth themselves; beginning about one face, it 
soon involves the whole organ, and if undisturbed, envelops, sooner or later, 
in an imperfect sheath, the whole denture. A mouth so filled with tartar is 
not only disgusting, but necessarily is in an unhealthy condition. Salivary 
calculus soon destroys the integrity of the teeth. It does this by its 
effects on the secretory crypts about their necks and by compelling a gradual 
diminution in the periosteal supply; that membrane receding little by little as 
the foreign body encroaches on it. As a result of such abstraction of nutri- 
tion, the tooth soon dies, and is exfoliated like any other sequestrum; tooth 
after tooth necrosing, and each month or year one or more dropping from its 
socket. When the presence of tartar provokes a condition in the neck-pit of a 
tooth that results in pus a condition of pyorrhoea alveolaris obtains. 
Anomalous Condition.-Not infrequently there may be seen stand- 
ing, isolated and alone, on some portion of the dental arch,-most fre- 
quently, however, either on the anterior portion of the inferior arch, or the 
645 646 
A SYSTEM OF ORAL SURGERY. 
posterior portion of the superior,-a yellowish-looking tumor, which might 
not inaptly be compared to a shell-bark covered with inspissated mucus. Some- 
times this tumor * will be found quite firm in its position, seeming, indeed, 
as if it might have sprung from the socket of some long-ago-extracted tooth ; 
at other times you will be able to move it quite freely, as if it had a fleshy pe- 
duncle. Such tumors give to the mouth a most disagreeable appearance, are 
oftentimes insufferably offensive, and so detrimental to health that five or six 
grains of their substance, given to a small animal, will not infrequently cause 
its death. The composition of the collections consists of phosphate and 
carbonate of lime, epithelial scales, inspissated mucus, and the various detritus 
of a cavity devoted to mastication. The nucleus of the growth is of course a 
tooth. The manner of formation is too evident to need description. The 
author has removed these calculi, where the nucleus had become so encysted, 
from crown to apex, that no trace of it was to be discovered without dividing 
the mass. Where, however, the encystment has advanced to this extent, the 
body is about ready to drop from the mouth. A calculus of this kind has 
been met with where the six lower front teeth were encysted, making as 
strange and anomalous a looking mass as could be well imagined. 
Calculi in Steno's Duct.-Salivary calculi develop, as may be inferred, 
in other parts of the mouth. Thus, they are occasionally found just within the 
orifice of the duct of Steno ; the calculus, in such a case, bulging out from the 
cheek against the second molar tooth of the upper jaw. The formation of such 
a deposit in this situation does not necessarily imply the closure of the orifice of 
the duct; it forms when the gland is working sluggishly. The secretion, not 
being in sufficient abundance to hold the lime of the saliva in solution until it 
is ejected from the duct, that substance falls upon the floor of the duct, and, 
lodging, results in the offence. 
Sublingual Calculi.-An instance is recalled where a mass of this cal- 
careous matter, fully the size of the largest almond, seemed to be growing from 
all that portion of the sublingual region anterior to the gland of that name; 
one-half the tumor looked as if it might be below the level of the floor of the 
mouth, the mucous membrane enveloping the mass with a ragged and an ul- 
cerated fringe, the condition presenting a strange and threatening look; 
there was no apparent direct association between the tumor and the neighbor- 
ing teeth, and it was as firmly fixed as though it might be a growth springing 
from neighboring bone. Yet this was a salivary calculus and nothing else, the 
only question being as to its cause and fixedness. 
Looking about the mouth, it was perceived that the patient had certain 
artificial teeth on the left side of the arch; these teeth were all coated with 
tartar, and so associated thereby with the natural teeth as to be only distin- 
guishable by that difference in the translucency so immediately noticeable by 
any one experienced in such direction. Knowing well that it is a plan with 
* See the author's definition of tumor. SALIVARY CALCULUS. 
647 
some dentists to secure such teeth by passing a strong gold wire across the 
mouth, and which wire hot infrequently buries itself within the mucous mem- 
brane, thereby occasionally becoming concealed, it was inferred that such a 
fixture would be found the nucleus of the calculus, and accordingly examina- 
tion was so directed. This was commenced by cutting away the tartar-mass 
from about the artificial teeth, and, as anticipated, a band was revealed; next 
was sought the concealed attachment of the opposite side, and this being dis- 
covered and exposed, the two ends were forced from the teeth which they 
clasped, and thus artificial teeth, wire, and calculus were lifted from the mouth 
in a body. 
The site of the calculus, as may be inferred, presented a cup-shaped 
ulcerated depression, and was quite angry-looking. 
The only after-treatment consisted in the use of an astringent wash. 
The ulceration healed kindly in a very few days. 
It is to be suggested that the existence of such calculi is not an infrequent 
cause of dyspeptic and other alimentary troubles. The writer has in 
mind the memory of a case of dyspeptic consumption very illustrative. The 
patient, a lady, had in her mouth but a single tooth, and this for years had 
been so embedded in calculus as to resemble a half-rotted shell-bark rather than 
a tooth,-the breath was made insufferable by it. This offensive mass was 
removed, and the recovery made by the patient was really magical in its 
rapidity. 
Such calculi are to be removed in any convenient manner: they may be 
pulled away, broken in pieces, or, when loose, may be cut from the gum; the 
operation being entirely a mechanical one, and of course very simple. 
Removal of Calculi in Ducts and Glands.-Calculi situated in 
the salivary ducts are to be removed, either by enlarging the orifices of 
the ducts and crushing the stones, or by cutting down upon them at a con- 
venient point. When so cut upon, the wound does not commonly require any 
after-attention. 
The existence of salivary concretions in the ducts, particularly the Whar- 
tonian, is not at all infrequent; indeed, they are occasionally to be met with 
in the substance of the glands themselves. A specimen, extracted from 
the submaxillary gland, had its diagnosis in a continuous issue of pus 
from the tubal outlet. A second instance is on record where the glands of 
either side were found stuffed with calculi. When situated in the ducts, the 
sense of touch, exhibiting the hardness and irregularity of the body, will not 
infrequently afford recognition of the condition. Where, however, the en- 
veloping tissues have become infiltrated and thickened, a diagnosis by such 
means is rendered obscure, and is perhaps to be secured only by passing into 
the tumor the blade of a delicate bistoury or the point of an exploring 
needle. 
Calculus in Substance of Submaxillary Gland.-In the case of 
a calculus in the substance of the submaxillary gland, met with by the author, 648 
A SYSTEM OF ORAL SURGERY. 
a happy cure was effected by working the stone to a presentation upon the 
floor of the mouth, the purpose being accomplished by depressing the chin 
upon the neck and thrusting the gland from without upward. Knowledge of 
the exact position thus secured, a single cut, passing through the mucous 
membrane and mylo-hyoideus muscle into the substance of the gland, reached 
the body, which, with some little trouble, was secured in the grasp of the for- 
ceps and lifted away. This calculus was, in size, about the circumference of 
a hazel-nut. The wound made by the incision healed completely after a week, 
and the patient had no further trouble. It is a feature to be added that in 
this case the facial artery had been obliterated as a result of the long-continued 
pressure. 
Unique Example.-An interesting and most suggestive case in this 
direction has the following record : 
Mrs. B., a lady, sixty-nine years of age, residing in West Philadelphia, 
applied to the author, being directed by some unknown professional friend, 
concerning a tumor of the mouth, from an inflamed condition of which she 
was at the time enduring much suffering. 
Ocular inspection revealed the following condition: a tumor, very 
scirrhus-like, hard, lobulated, and angry-looking, occupied all that portion 
of the floor of the mouth to the right of the mesial line; general inflammation 
existed of the whole oral cavity, to such extent as to make mastication too pain- 
ful to be practised, and to render deglutition very difficult. All the teeth in the 
neighborhood were loose and occupied irregular positions,-the result evidently 
of a hyperplastic condition of the alveolo-dental membranes. The superficial 
cervical glands, especially those of the submaxillary region, showed sympathy 
to a considerable extent; while the submaxillary gland itself was so enlarged 
as to render it sufficiently prominent to be easily mapped out. 
The patient seeming unable to talk of anything save her present great 
distress, which she described as " cutting, tearing, burning," the case was dis- 
missed for the day, after prescribing for the immediate discomfort,-namely, 
the ordering of leeches, aperients combined with Dover's powder, astringent 
local applications, etc. 
Two days after the patient was again seen. The general inflammation was 
resolving very rapidly, while the mental equilibrium was quite restored. 
This disease had been pronounced cancer by several gentlemen, and 
advice given that no application of any kind be made; that the patient 
should not even permit the tumor to be handled for further examination. 
Under such impression as to its character, the lady had given up all hope of 
relief. 
The history of the case is as follows : 
Eighteen years before, while engaged in milking an intractable cow, a kick 
was received under the chin, so severe in character as to compel a confine- 
ment to bed for over two weeks. This trouble passed through, the parts soon 
recovered their natural tone, and she seemed as well as ever. SALIVARY CALCULUS. 
649 
A little more than nine months had passed, however, when the patient was 
made conscious of occasional slight inflammatory attacks about the region of 
the sublingual gland. These attacks continued to grow in frequency and 
extent, terminating, to use her own language, " by a something which looked 
like a whitish worm coming from somewheres into her mouth." This 
worm, she said, " was always the assurance of temporary immediate relief." 
The trouble continued to recur for over a year, when a tumor began to 
develop in the parts. The inflammatory attacks now decreased in number, 
but increased in severity,-the patient noticing that after each inflammation 
the size of the original enlargement was augmented. 
The case ran on after this manner for a period of several years. It 
was remarked, however, nearly ten years back, that the tumor had ceased to 
enlarge from the inflammatory attacks, having at that time gained the size 
of a pullet's egg, and neither increasing nor decreasing up to the time of 
examination. Reference is made, of course, to the tumor in a quiescent state, 
for each succeeding inflammation swelled all the parts, tumor included, tem- 
porarily, more than the one which had preceded it. 
The patient's general health was quite good; there was no constitutional 
evidence to be perceived of a cachexia. 
Now, while the history of this tumor, in its local features, was in many 
points the history of cancer, yet, considering the affection of the gland- 
duct, which, as indicated by the story of the worm, evidently had association 
with the tumor ; considering the inflammatory attacks to which the parts had 
been so frequently subjected, and which had resolved harmlessly; considering 
the length of time the tumor had existed, without passing or tending to pass 
to the ulcerative stage, it seemed necessarily decided that the tumor was of 
local signification, certainly not a cancer. 
What, then, was it? The trouble commenced evidently as inspissated 
ranula. A conviction, founded on the history, was, that it was still a ranula. 
Not ranula as derivatively we understand the meaning of that word, but 
ranula as pathologically the term has association with the salivary ducts. 
What the contents of such cyst, if cyst there was, might be, the writer did 
not feel prepared absolutely to decide. 
Acting on the strength of this conclusion, it was suggested to the patient 
that a bistoury be exploratively passed through the parts. This, however, 
met with a decided negative,-the refusal not being, perhaps, at all strange, 
considering the assurance that Mrs. B. had so often received that any attempt 
to operate would be her death-warrant. 
Failing in several other efforts at persuasion, the case was later dismissed. 
About a month after, prompted by curiosity, Mrs. B. was visited. There 
was now not the slightest evidence of inflammation about the parts. The 
tumor was about the size of a pullet's egg, hard almost as stone, and dis- 
tinctly divisible into three lobes. The patient stated that, with the excep- 
tion of an occasional sharp pain, she felt at the time little or no inconvenience. 650 
A SYSTEM OF ORAL SURGERY. 
At this visit, more than ever satisfied as to a diagnosis, an exploration was 
re-urged, but refused as before. 
On a Saturday morning was called to see the patient. She was suffering 
from another of the inflammatory attacks; the most severe yet experienced. 
Examination discovered the tumor swollen to such an extent as to throw the 
tongue over into the left cheek. Mastication had been impossible for three 
or four days, while the ability to swallow was being very rapidly lost; yet, 
with all this inflammation, there seemed no tendency to the formation of 
abscess. 
Placing the old lady in an arm-chair, before the window, the mouth was 
got under control, and, before she was aware of the intention, a bistoury was 
passed directly through the body of the tumor; the knife grated over a 
hard substance. 
After a time spent in making peace, greatly assisted by the assurance given 
of the discovery which was to result in her immediate cure, the foreign body 
was dissected away. This, as anticipated, proved to be a salivary calculus. 
The specimen was presented to the pathological museum of the Philadelphia 
Hospital, and is, perhaps, one of the largest, if not the largest, of such calculi 
on record. 
The pathology of such a lesion is at once appreciated : the formation 
of the calculus in this region was merely secondary to the occlusion of the 
mouth of a gland-duct. 
Dr. J. J. Woodward, the eminent microscopist, who made an analysis of 
a portion of the calculus, informed the writer that he found it composed 
almost exclusively of the phosphate of lime, only a very small trace of the 
carbonate being perceptible. 
Saw Mrs. B., for the last time, one month later. All induration had so 
completely disappeared that it would have been difficult for one who had not 
seen the case to say from which side of the mouth the tumor had been 
removed; not the slightest expression of disease being visible. 
Interesting Case.-A case of calculus, interesting from its rarity, has 
been presented to the attention of the French Academy of Sciences, in which 
a concretion was removed from a sublingual duct of an infant but three 
weeks old. The history of the case is thus given. On the , a poor 
woman called upon Dr. Burdel, complaining that the child could not take the 
breast, which she attributed to its being tongue-tied. Upon examination, Dr. 
Burdel did not discover any string or ligament of undue shortness, but found 
the sublingual gland so excessively developed as to raise the tongue considerably 
from the cavity in which it lies. He soon discovered, by touching the tumor 
with his little finger, that it contained a hard substance. Slight pressure 
brought to light the extremity of a calculus, ending in a fine point, and, after 
some unsuccessful attempts, he succeeded finally, without making an incision, 
in extracting it. The calculus is described as being of egg-shape, but ending, 
as already stated, in a fine point. Its size was that of a grain of wheat, its SALIVARY CALCULUS. 
651 
color yellow, its surface granulous, wrinkled, and formed of a number of 
minute cones or paps, cemented together at their bases. This is an instance 
of a salivary calculus formed before the birth, when the saliva, according to 
Dr. Cloquet, is but little charged with salts. An analysis of the concretion 
exhibited it as being composed almost exclusively of tribasic phosphate of 
lime and a small fraction of nitrogenous organic matter, which must have 
been mucus from the salivary duct. 
Tartar, as seen upon the teeth, varies markedly in color and consistence, 
being sometimes so hard and closely adherent as to seem almost a part of the 
organs. In other instances it is found soft, and of so flaky a nature that 
the slightest effort suffices to break it away in bulk. A character of tartar 
is found allied with the mucoid, or typh, condition, being of pasty consistence, 
having, perhaps, a truer expression of its significance in the term sordes, 
being composed of detritus, combined with inspissated mucus; this is a true 
serumic tartar or deposit. 
Color.-In color, tartar varies from a dirty white to positive black, the 
shade depending on the temperament of the individual, yet being necessarily 
much influenced by personal habits. In the sanguineo-bilious, tendency to 
the deposit of flaky brown tartar is very marked. This deposit is the truest 
expression of salivary calculus, being composed almost exclusively of constitu- 
ents of the saliva. In these cases the fluid is always alkaline, analysis showing 
deficiency as to carbonic acid. The green stain met with so commonly 
upon the teeth of young people is esteemed by many a cryptogam. Other 
discolorations, as the black found with tobacco-chewers, the gray of the 
pregnant woman, stains of medicines, as iron, nitrate of silver, etc., are to 
be placed and reckoned after a required manner. 
Fungi.-United with all tartar are fungi. Here, as suggested by Herr 
Schrott, do the infusoria find convenient habitation, remaining the longest 
time, attaining their highest age, dying, and leaving their limy remnants to 
interlace with epithelial scales, parasites, remains of food, slime, and secretions 
of saliva, forming in this manner the tartar of the teeth. 
That all tartar is not salivary calculus is made evident enough by 
minute examination. The deposit about the teeth of the scorbutic is in great 
part from the mucous glands situated in the mucous membrane enveloping 
the necks of the organs. Again, in mouths abounding in parasites, micro- 
scopic analysis shows plainly enough analogy with the coral reef. Hence it is 
that analyses of this supposed common material are found so markedly and 
decidedly to differ. 
Treatment.-The treatment of the ordinary collections of tartar about 
the teeth is very simple, and is to be made very effectual. Various cutting 
and scraping instruments, very well understood by glancing at the engravings, 
Fig. 599, are used in the process of removal. The operation consists simply 
in scraping away the mass (scaling, it is termed), being careful not to scratch 
the enamel, and afterward thoroughly polishing the teeth,-using for the 652 
A SYSTEM OF ORAL SURGERY. 
purpose, first, pulverized pumice, afterward the ordinary burnishing instru- 
ments.* 
To prevent re-collection, cleanliness is a first requirement: the use 
of acid washes, carbolic acid soap, or dentifrices, is to be directed, as may seem 
Fig. 599.-Instruments employed in removing Tartar from Teeth. 
to the judgment of the practitioner indicated, while the action of the glands is 
to be increased by the use either of local or constitutional sialagogues. Or, if 
in any individual case the advisability of such prescriptions seem debatable, 
then pumice-stone, finely pulverized, may be used with a good stiff brush ; or, 
what will be found a still better plan, the patient may, every few days, 
standing before a mirror, use the grit on a piece of soft pine or orange stick. 
Salivary calculus, lodged about the teeth, has been thought to produce 
caries and necrosis of the alveolar processes. The author does not, how- 
ever, remember in his own practice ever to have seen such a result. It is 
true that the process is not infrequently exposed, but here the teeth drop out, 
the calculus falls away with them, and thus the power for evil ends. A 
spongy and scorbutic character of gum-tissue, and consequent hemorrhage, 
are, however, very common associations; but a practitioner sees at once that 
the cure is in his hands. 
Acids in Treatment of Calculus.-The use of acids, highly com- 
mended by some as a conclusion to the operation of scaling, is by no means 
an objectionable practice. Not only does an acid, judiciously applied, cleanse 
the teeth thoroughly, but it also destroys infusoria which are themselves, as 
we have seen, tartar; and it serves as a stimulus to the deteriorated and 
generally spongy neighboring soft parts. Of acids which may be used for 
this purpose, none have advantage over the aromatic sulphuric, this being em- 
ployed pure or diluted, according to the nature of the teeth to which it is ap- 
plied and the work proposed to be done with it. Acid is most conveniently 
* A set of instruments devised by Dr. Riggs, of Hartford, Connecticut, has a wide use 
in the treatment of calculus collections. How's set of scalers is a favorite. Circular brushes, 
used with the engine, carry powders more or less fine which cleanse and polish rapidly. SALIVARY CALCULUS. 
653 
used at the end of a pine stick, the detritus left by the scaler being softened 
and dissolved by it. Ulterior ill effects are neutralized by frequent rinsing 
with ammoniated water. The objection that an acid will dissolve the lime- 
salts of teeth has as little weight as that a scaler will cut enamel, or that 
calomel will salivate. 
Parasiticides.-The use of germicides in mouths where tartar collects 
is necessary as the health of the teeth and as decent cleanliness are concerned. 
(See Germicides.) 
Revolving Brushes.-See, for illustration of these, the catalogues of 
the dental depots. 
Serumic Deposit.-See Pyorrhoea Alveolaris. CHAPTER XXXIX. 
THE GUMS AND THEIR DISEASES. 
The gums are simply an amount of fibro-cartilaginous tissue (the fibrous 
element predominating) placed upon the alveolar process and about the necks 
of the teeth as protecting cushions. The mucous membrane, which covers 
the common surface of these cushions, is reflected around the necks of the 
dental organs and is continuous with the periodonteum. 
Gums, Healthy State of.-The gums, in a healthy state, are remark- 
able for their insensibility, bearing, with very little or no response, the pressure 
and irritation to which, in the process of mastication, they are so continuously 
subjected. The mucous membrane, of which this tissue is largely made up, 
is very heavy and thick as compared with its continuity in other parts of the 
alimentary canal, and is underlaid by a net-work of vessels, which leads it 
to be esteemed of considerable vascularity as reference is had to operations 
involving it. 
Inflammation, the Disease of.-Inflammation is the disease of the 
gums ; but such perverted vascular action, here, as everywhere else, has quite 
a variety of significations. These significations are- 
1. Accumulations of tartar. 
2. Periodontitis. 
3. Mercurial impression. 
4. Scurvy. 
5. Syphilis. 
6. Dead or loose teeth. 
7. Overcrowded condition of the dental arch. 
8. Use of improper dentifrices and brushes. 
9. Improperly-inserted artificial teeth. 
10. Malignant impressions. 
11. Anomalous conditions.-Neuralgia. (See Neuralgia.') 
A comprehension of the diseases of the gums is found in the appreciation 
of these various conditions or influences. 
1. Accumulations of Tartar.-Salivary calculus, a deposit from the 
saliva, combined with the various oral detritus, when attached about the necks 
of the teeth, becomes necessarily a source of offence, provoking inflammatory 
action, the grade of which is marked by the general condition of the indi- 
vidual. The most common type of inflammation thus induced is the chronic 
654 THE GUMS AND THEIR DISEASES. 
655 
degenerative. The tartar, pressing upon the gums and insinuating itself about 
and around the necks of the teeth, soon interferes to such extent with the 
proper circulation in the part as to yield the puffy, turgid condition so familiar 
in most of the cases. The mucous follicles associated with the dental pits 
have, of course, their secretive ability soon destroyed, and thus nothing pre- 
vents the insinuation of particles into these pits, and a consequent increase in 
the agency of offence. This irritation, uncombated, gradually progresses until 
the teeth become loosened and fall out, when, carrying with them the tartar, 
the parts recover. 
Green and Black Discoloration.-All deposits, however, existing 
under the common name of tartar, or salivary calculus, do not have such a 
destructive history. Thus, it is very common to observe a greenish discolora- 
tion of cryptogamic significance upon the teeth of the robust and uncleanly, 
and as well upon the teeth of children, which, so far as is observed, seldom 
results in any particular harm: it is aesthetically offensive, no doubt, and is 
credited by many with being a corroder of enamel. It not unlikely is this 
latter in the sense that a creeping wall-adhering vine is a consumer of the 
mortar. Another kind, the black, seldom exists but in very limited amount, 
and rarely or never does greater ill than slightly irritating the festoon; its 
situation is commonly the lingual face of the inferior teeth. It does happen, 
however, that this description of tartar, or something very analogous to it, is 
sometimes provoked, as it were, in depraved constitutions, to extensive deposit; 
it is a kind of mixture or agglutination related with sordes. The gums, very 
much depraved from a constitutional influence, are irritated not infrequently 
by this deposit into a state very little short of gangrene; the breath is made 
offensive, and the oral fluids, by admixture with the offensive mass, are ren- 
dered entirely unfit to be received by the stomach. The first two conditions 
of these stains, or deposits, if attempted to be removed with instruments or 
by means of pumice-stone, offer great resistance, but, as has been dis- 
covered by Dr. Dorr, a preliminary touching with tincture of iodine 
softens them most happily. 
Yellow Tartar.-Yellow tartar, the deposit of the bilious and allied 
temperaments, is the kind most generally met with, and, as a rule, is most 
destructive to the integrity of the alveoli and gums. It is not at all uncom- 
mon to find this deposit of such extent as to enclose in a common mass half a 
dozen or more teeth, while its power of insinuation and destruction is so great 
that, before attention may have been directed to the process, the pits will be 
found destroyed and the teeth ready to drop from the mouth. The writer 
has, in his own practice, frequently been consulted in these cases, where 
nothing was of any avail but the removal of the implicated teeth. This de- 
scription of calculus is evidently a direct deposit from the saliva, its situation 
corresponding with the location of the salivary orifices. It is found associated 
with a sluggish condition of the secretive action of the glands, and its reliable 
prophylaxis rests with their stimulation. This tartar has a rough, dry 656 
A SYSTEM OF ORAL SURGERY. 
surface, and is generally easy of removal; flaking away in masses at the 
slightest touch of the instrument. The effect of its presence upon 
the gum is to force it away from the teeth, or rather, it might be more 
correct to say, to lift the teeth from the gums and their alveoli, destroying 
entirely any relation of attachment between the parts. The gums themselves, 
under its irritating influence, become puffy and soft, and so tender occasionally 
as to render, in many cases, unbearable the ordinary pressure exerted in masti- 
cation, so that the patient is compelled to subsist exclusively on soft food, 
or to employ other than nature's process of comminution. (See chapter on 
Salivary Calculus.') 
2. Periodontitis.-Ulitis arising out of periodontitis is not at all difficult 
to distinguish; it corresponds in character with the primary lesions in being 
acute or chronic. If a tooth be acutely inflamed in its periodonteum, it is 
sore to the touch, and elongated. If it be chronically inflamed, it is loose 
or discolored. Inflammation in the gum is simply an inflammation of con- 
tinuity. If the patient be in good health, the action is circumscribed; if the 
reverse, it will of course influence. To treat such an inflammation, the health 
of the tooth or teeth is to be restored. An inflamed periodonteum is com- 
monly associated with a dead pulp; this is the first source of offence for which 
the practitioner looks. If such a condition be found, and no cavity of com- 
munication exist with the pulp-canal, it will, in nine cases out of ten, only be 
necessary to make such communication, and the trouble quickly disappears. 
Tartar is the frequent source of chronic periodontitis. Fish-bones, or other 
foreign bodies, forced into the membrane in mastication, excite inflammation. 
Acute periodonto-ulitis uncontrolled ends in parulis, and from 
such acute termination is very apt to pass to chronicity. Chronic ulitis 
presents the condition of continued turgescence, soreness, loose teeth or fangs ; 
suppuration frequently occurs at the seat of the original abscess, and some- 
times from the affected alveolar pits. Its cure, like that of the acute con- 
dition, resides in a treatment directed to the teeth. (See Periodontitis and 
Alveolar Abscess.) 
3. Mercurial Impression.-Mercury first yields decided evidence of 
its action by producing in the mouth a metallic taste, complained of as cop- 
pery. A little time, and this taste is accompanied with some increase in the 
quantity of the saliva; still later the festoons of the gums are found congest- 
ing, commencing generally about the necks of the lower central teeth. Suc- 
ceeding this congestion we have the dull whiteness indicating the change in 
the epithelial tissue (a form of aphthae). There now follow the elongation of 
the teeth, increased salivary flow, stiffness of the gums, enlargement of the 
tongue, foul breath, etc. The effects which mercury is to produce 
on the mouth, or system at large, depend on the quantity administered 
and the susceptibility of the individual. The writer has exhibited the medi- 
cine in quantities of from fifteen to twenty grains in the course of three days 
without being able to perceive any local action ; while, on the contrary, he has THE GUMS AND THEIR DISEASES. 
657 
known five grains so to swell the tongue that it required much effort to pre- 
vent the patient being smothered. Children from five to ten years of age 
seem markedly susceptible. Some time back there was removed at the Oral 
Hospital the whole of the left half of the body of a lower jaw, dead from 
but some three grains of calomel, as averred by the practitioner who admin- 
istered the medicine. The patient was seven years of age. Mercurial 
ulitis, when confined alone to these parts, signifies but slight effect on 
the part of the action of the agent; and immediate cessation in its employ- 
ment will generally result in disappearance of the effects. If this should 
not, however, prove to be the case, nothing better is to be done than to 
scarify the gums and paint them with tincture of iodine, the medicament to 
be graduated to each particular case, say, as a rule, half and half of the 
officinal tincture and water. Chlorate of potassium as a wash, and used 
internally, is also to be employed. To an adult, ten grains of the salt, dis- 
solved in a tablespoonful of water, may be given four or five times a day. 
As a local application, one drachm to the ounce of water is a very good 
strength. The bowels are to be kept in a lax condition by the administration 
of Seidlitz powders or other saline cathartics. Where mercurial ulitis 
passes to that stage which results in a breaking down of the tissue (and this 
is sometimes the case where even adjacent parts are not markedly affected), the 
treatment required is more imperative, and pertains, as a rule, quite as much 
to the constitution at large as to the mouth itself. Locally, the fetor will 
urgently demand attention; and one of the best means to correct this 
is found in the use of a solution of the permanganate of potassium, such solu- 
tion varying in strength from two to ten grains to the ounce of water. Consti- 
tutionally, vigorous tonic medicaments are required,-not the least important 
of which are the iron and bark preparations. If hemorrhage intervene, 
it may be necessary to employ opium and lead internally; or, as suggested in 
another part of this work, tincture of erigeron Canadense, in doses of one 
or two drops, repeated frequently until such bleeding is controlled. Locally, 
cobweb saturated in alum-water may be used; laid carefully upon a bleeding 
part, and retained in position, it is seldom found to fail. Monsel's salts 
are not to be used. The tendency in extreme cases toward sloughing 
is a matter constantly to be borne in mind. When the tumefaction is very 
great and the tissue indolent-looking, the parts are to be incised and iodine 
applied; both remedies, however, are to be used with judgment and caution. 
The author has known gums in this condition which might perhaps have been 
recovered, sloughed in mass by applications of strong tincture of iodine. 
Always let the incisions be few at first, and the officinal tincture at least two- 
thirds diluted with alcohol or water. Aromatic sulphuric acid as a 
wash is a happy local remedy in these depressions: it may be mixed with 
water until the acid taste is comfortably bearable,-about §i to gvi of water. 
A combination for local use, occasionally employed with much benefit, is 
composed as follows: 658 
A SYSTEM OF ORAL SURGERY. 
Potassii chloratis, ^ss; 
Sodee biboratis, 
Aluminis pulveris, aa 3'j > 
Potassii permanganatis, gr. xxv; 
Aquae Colonise, 5 j ; 
Tincturae cinchonae, ^ij; 
Tincturae myrrhae, 5 j; 
Tincturae capsici, 3 j J 
Tincturae krameriae, 
Aquae, ^viij. M. 
Boro-glyceride, as furnished by the shops, diluted with ten parts of 
water, the two being thoroughly combined by means of a syringe, otherwise by 
free shaking, is an efficient application. The preparation may simply be held 
in the mouth or may be used by means of a brush; five or six times a day is 
not too often for its employment.* 
Tannic acid is a reliable and, perhaps, the most commonly employed 
means. To apply it nothing more is necessary than to dip a wetted finger in 
the powder and by such means smear it over, or rub it into, the bleeding 
part. 
Tinctura Capsici et Myrrhae.-There is a preparation of capsicum 
and myrrh, officinally known as Tinctura Capsici et Myrrhae, which is used in 
this same direction with the most satisfactory of results by adding to it water 
until the latter fluid is changed in color to a bluish-white. A direction com- 
monly given to patients in connection with this medicine is to take a goblet 
of water and add to it drop after drop of the combination until the shade 
required is secured, then to retain a mouthful for a few moments before eject- 
ing it; this to be repeated several times a day.f 
Sloughing.-If, in defiance of all that is done, the parts slough, one of 
three things occurs: the disease will seem to have exhausted itself, and the 
adjoining parts, after a little rest, give evidence of recovery; or the bone fol- 
lows the ulcerative action, and sloughs as did the soft parts; or the patient 
dies from irritation and exhaustion. (For treatment of Caries and Necrosis, 
see other pages.) 
4. Scurvy.-Scurvy proper, such as decimated the legions of Louis the 
Ninth, and in later days was so frequently the scourge of protracted sea- 
voyages, is a condition which modern science and judgment have so combated 
that it may be trusted that few will meet with or have occasion to treat it. 
Modified forms of the disease are still, however, prevalent enough, and exist 
with features which vary from simple indolent ulitis to general purpura. 
* Boro-glyceride is prepared by mixing 62 parts of boracic acid with 92 parts of glycerin. 
The mixture is a stiff paste. Fifty times its weight in water prepares it for common use. 
The combination is markedly antiseptic. 
f The formula is,- 
Capsicum, ; 
Myrrh, ^iv; 
Alcohol, Oij. THE GUMS AND THEIR DISEASES. 
659 
Puffiness of the gums, scorbutic in nature, is fairly judged from its 
dull, purple aspect, independent of its varying constitutional conditions. This 
venous congestion compares pathologically with the effusions of purpura proper. 
It would not, however, be at all truthful, nor in accordance with the facts, to 
describe any particular train of constitutional conditions as constantly asso- 
ciated with the scorbutic sore mouth, as met with in ordinary practice, and 
for the reason that nothing else of the disease may appear but the local mani- 
festation. That it is a constitutional affection, and not a local disease, 
is proven by the fact of absence of any source of local irritation, and by the 
further fact of its constant presence in the mouth, let the disease possess what- 
ever other manifestations it may. Dr. Foltz, U.S.N., in a report made by him 
on the scurvy which appeared in the blockading fleet of the Gulf of Mexico, 
states that lassitude and indisposition to muscular energy, noted 
so frequently by authors as prodroma, were not among the symptoms which 
ushered in the disease, and that there was great activity, and not infrequently 
cheerfulness, good appetite, and sound sleep at night, after the teeth were 
loosened, the gums ulcerated, the limbs oedematous and discolored ; and when 
at last the patient gave way, it was not an indisposition to corporal exertion, 
but an actual disability. Authors, however they differ in their de- 
scriptions of the various cases that have come under observation, are all 
agreed that scurvy results from the absence of fresh fruits and vegetables, or 
of juices, necessary to furnish some principle required in the blood, which 
principle is not, in such absence, otherwise obtained. In the treatise pub- 
lished by Dr. Hamilton on Military Surgery, the author says, " In regard to 
the pathology of scurvy, the belief prevails that it is due essentially to 
the absence of certain staminal principles from the blood, and especially potash. 
It appears to be a pretty well ascertained fact that all, or nearly all, of those 
remedies which have been employed successfully in the prevention or cure of 
scurvy contain potash. Potatoes, cabbage, celery, lettuce, lime-, lemon-, 
and orange-juice contain it in large quantity, unless their salts have been 
expressed by the application of heat, as in boiling, or other modes of cooking. 
Lime-, lemon-, and orange-juice contain nearly one grain of potash to every 
ounce. One ounce of potatoes yields one grain and a half, while one 
ounce of rice yields only .005 of a grain. The substitution of rice in an 
English work-house for an equal amount by weight of potatoes was followed 
in a short time by scurvy." In the ordinary scurvy of the gums, 
which every practitioner is aware presents itself most frequently in the very 
early spring, when the old vegetables have been pretty well exhausted and 
fresh ones have not begun to grow, it is a common experience to discover that 
the patients have existed almost exclusively on salt meats; hence it is much 
the most frequently met with in the poorer class of farm-laborers. The gums 
in these cases are of a purple color, turgid, the dental pits discharging pus, 
the teeth loosened, the breath offensive, but the face not by any means pale, 
nor the habits languid; indeed, there is little or nothing to signify that the 660 
A SYSTEM OF ORAL SURGERY. 
local manifestation is a systemic offspring. When the condition is extreme, 
it is not uncommon to have fungoid growths springing from the edges and 
depths of the dental pits. (See Pyorrhoea Alveolaris.') 
Treatment.-It will be found good practice to treat these conditions 
locally, as directed in mercurial ulitis. Constitutionally, however, different 
indications are to be met; a something possessed by a vegetable and acid diet 
is required by the blood. Without stopping to discuss the question whether 
this something may or may not be potash, we act on the empirical conviction, 
and at once direct such diet. Then the depressed or perverted life-force is to 
be elevated or relieved, and to this end nothing can equal the sheet-bath, taken 
with water moderately warm and moderately salt. Saturating the sheet, it is 
quickly thrown around the body, and the patient or an assistant rubs the cloth 
over the flesh until the whole person is in a ruddy glow. This is repeated each 
morning immediately on rising. As medicine, the vegetable acids 
are to be freely used. Lemonade is perhaps quite as good as anything 
that can be given. A combination which has some celebrity is known as 
Turner's antidote ; it consists of 3ij of nitrate of potassa, mixed in gviij 
of acetic acid, administered in tablespoonful doses three times a day. Con- 
joined with general medication, local attention is required by the teeth and 
gums. (See chapter on Salivary Calculus.^ 
5. Syphilis.-Syphilitic ulitis the writer infers, from his individual expe- 
rience and observation, to be an inflammation, not of the gum-tissue proper, 
but simply of its mucous envelope; or, on the other hand, it is an inflamma- 
tion commencing in the periosteum, and secondarily affecting the gum-tissue. 
He does not recall a case of pure uncomplicated syphilitic ulitis; while few 
conditions are more common than mercurio-syphilitic ulitis 
and osteo-ulitis of syphilitic origin. The appreciation of such lesions is, of 
course, not at all difficult; the history alone is sufficient to give a diagnosis, 
while to the experienced eye a moment's glance is enough to reveal the prece- 
dents. If the inflammation be confined to the mucous membrane, the full 
extent of its surface will be more or less affected, its color will be a dull red. 
it will be more or less tender to the touch, and most likely ulcerated. If, on 
the contrary, the bone or its periosteum be the primary seat of trouble, the 
gum may simply be thrown up by the effusion beneath it; or if it happen 
that the gum itself has become inflamed, the action seems inclining to local- 
ize itself as much as possible. This, however, depends on the state of the 
parts beneath and on the treatment that is being pursued. If the condition 
be one of pure uncomplicated venereal ostitis, the excitement in the gum is 
found localized to the immediately overlying parts ; but if there have been a 
mercurial treatment, any extent of complication may show itself. The treat- 
ment in these cases is founded on existing conditions. 
6. Dead or Loose Teeth.-Pulpless teeth affect secondarily the gum 
structure through continuity with the inflamed periodonteum. A tooth peri- 
odontally inflamed is always sore to the touch, is more or less elongated, THE GUMS AND THEIR DISEASES. 
661 
and is discolored. A ulitis connected with such diseased tooth or teeth is 
plainly discoverable by the absence of other sources of irritation; relief 
follows, of course, the cure of the primary lesion. 
7. Overcrowded Condition of the Dental Arch.-See chapter on 
Anomalies of Dentition. 
8. Use of Improper Dentifrices and Brushes.-Many gums are 
subjected to continuous irritation and inflammation from the use of agents 
in the way of dentifrices, brushes, or other dental applications, which, either 
chemically, vitally, or mechanically, predispose and conduce to deterioration. 
Perhaps in the whole range of practice there is, in no single instance, less 
attention given to the requirements of the various cases than is manifested in 
the prescribing of tooth-cleansing powders and washes. Charcoal, a favorite 
agent with many, while excellent in its place, is one of the most frequently 
abused of these remedies. Very common is it to find, after a few weeks or 
months of the use of the material, the gums becoming pitted with black 
spots about the necks of the teeth and loosening from them. This is a result 
of the insolubility of the agent in the fluids of the crypts; gradually, but 
surely, it finds its way into the mucous pits, and not being either washed out 
or dissolved by the secretion, it quickly destroys the integrity of the relation; 
hence follow chronic periodontitis and the eventual loss of teeth,-the mass of 
gum-tissue sympathizing during the whole period, resulting in chronic ulitis. 
Dentifrices mechanically and otherwise Irritating. - Pul- 
verized coral and pumice are other agents mechanically destructive, although 
in their places very good, and, as will be remarked, recommended. Castile 
and other soaps, too freely used, degenerate the gum-tissue by the action 
of their alkalinity; a constant use of such agents is quite certain to be 
attended by puffiness and chronic turgidity of the parts, by degenerated 
mucous discharges, and by an offensive breath. Acids, on the other hand, 
employed of too full strength, inflame and irritate the gums, and put the teeth 
on edge by dissolving more or less of their lime-salts. A ulitis arising out 
of the irritation of acid agents differs, however, from that produced by those 
which are alkaline, in being of a free, generous, acute, or, at worst, subacute 
nature, easy of control, and much more injurious to the teeth than to the 
gums themselves. Irritation of the gums commonly associates also with injury 
to the teeth. 
Creasote as an Irritant.-A very common cause of ulitis in persons 
with carious teeth results from the too free use of creasote. This agent, used 
pure, is a powerful irritant, and has been the cause of some of the most 
severe acute inflammations. Seen early, the cases exhibit the direct effect of 
the agent in the escharotic result that has been produced on the mucous mem- 
brane,-the part being white, pasty, and sloughing. Outside of the imme- 
diate local use of oil or butter, if it be inferred that free creasote remains 
about the mouth, such cases are to be treated on common principles. A case 
occurred, some time back, in the writer's practice, where a girl, with the in- 662 
A SYSTEM OF ORAL SU ROE RY. 
tention of committing suicide, swallowed two drachms of the agent. Called 
immediately, an emetic was used; the first thing at hand, namely, the soap on 
her wash-stand, being employed, and this was followed by making her swallow 
half a pound of common table-butter. No particular bad results occurred : 
the patient's mouth, oesophagus, and stomach were sore for three days, but 
after this she seemed about as usual.* 
Chloride of Zinc as an Irritant.-Chloride of zinc, used in the 
mixing of the oxychloride plugs, is another of the causes of ulitis. The 
action of this may be of a twofold character: either directly upon the gum- 
tissue, as by its careless use it may have been allowed to come in contact with 
this structure, or through a periodontitis excited by the action of the agent on 
the dental pulp. From abuse of this material many cases have occurred in 
which large portions of the gums are destroyed; and not infrequently the 
action extends to the alveolar process, necrosing the sockets of the teeth. 
Undressed Plugs as the Source of Irritation.-A cause of chronic 
ulitis, occasionally met with, exists in an undressed plug, in a wedge of gold, 
or in metal or other material forced into the dental pit while in the act of 
filling a tooth on its approximal face. A matter of this kind is apt to be 
overlooked by a general practitioner ; hence an unappreciated stubbornness in 
his case. When ulitis is circumscribed, and the centre of the trouble seems 
to be a tooth filled on an approximal surface, attention may first be directed 
to the possibility of such a condition. To satisfy himself, let the physician 
take a strand of common ligature silk, and, passing it between the teeth, feel 
if it run freely about the necks ; if it catch, the probability is that the trouble 
has been discovered. Remedy is found in dressing away by means of a file 
the bulging portion of gold, or otherwise removing what may be found. 
Arsenical Paste as Cause of Ulitis.-The employment of arseni- 
cal paste with view to the destruction of the dental pulp is a frequent source 
of ulitis. In the use of this means, it is well to seal the preparation in the 
cavity with a particle of wax, or, where this is not admissible (and there are 
certainly cases where to do it is impossible), then a tuft of cotton, saturated 
with gum sandarach, is placed over it, and protected for a few moments until 
it hardens. (See Odontalgia.^ In inflammation from this cause the local 
use of sesquioxide of iron has been recommended; but no good results come 
from it, the harm being established before the patient applies. Syringing the 
* Antidote to Creasote Poisoning.-Dr. Theodore Husemann opposes the use of fixed 
oils, glycerin, and similar demulcents in cases of poisoning by carbolic acid or creasote, 
but recommends, based upon experiments with rabbits made by himself and Ummethun, 
the saccharate of lime, the alkaline earth combining with the carbolic acid to form a non- 
irritating salt. Lime-water is less adapted to this purpose, owing to the sparing solubility 
of lime in water, and the large quantity of lime-water required for neutralizing the poison. 
Precipitated carbonate of lime does not combine with carbolic acid, but may be employed 
in case the saccharate of lime should not be procurable at once; the carbonate appears to 
act merely mechanically by absorbing the poison, and thus delaying its ill effects; suffi- 
cient time is thereby afforded to prepare the saccharate.-Journal of Applied Chemistry. THE GUMS AND THEIR DISEASES. 
663 
parts thoroughly, and a treatment directed on general principles, is all that 
can be done. 
Overstiff Tooth-Brushes.-Brushes used in cleansing the teeth are 
frequently a source of offence from their excessive stiffness, tearing really the 
epithelium, at each cleansing, from the mucous membrane; the patient com- 
plains of the soreness and bleeding of the gums every time the teeth are 
brushed, yet fails to recognize himself as producer of the trouble. 
9. Improperly-inserted Artificial Teeth.-Ulitis, resulting in fun- 
goid degeneration, and in troublesome chronic conditions, is frequently wit- 
nessed as a result of ill-adapted dentures and of ill-adapted material employed 
in their construction. Teeth inserted on plates held in position by clasps, or 
bands, attached to unsuitable teeth, are a prolific source of offence. Where 
the bearings of a plate are not accurate, the bands cut into the gums and fret 
and irritate them until, in the end, the teeth to which the clasps are attached 
are loosened, and the part passes to a chronic degeneracy, puffing up, and 
losing much of its vitality, otherwise a hypertrophied ring of the tissue, 
hard and callous, surrounds the diseased tooth, and serves as a sort of pro- 
tection to the adjoining parts. A case comes to mind in which a lady, wear- 
ing an upper set of teeth, supported partially by atmospheric pressure and 
partly by a band passing around the only natural tooth in her mouth, had 
provoked, in this socket, an epulic growth of such threatening character that, 
failing to cure it by ordinary means, an operation was advised as the only 
hope of saving her life. In Mr. Heath's Jacksonian prize essay, drawings 
are given of certain papular hypertrophies (thought by the author to be 
quite rare specimens) on the oral mucous membrane. These hypertrophies the 
author has frequently seen on the surface beneath the cavities of suction 
plates; they look like enlarged and indurated fungiform papillae. Another 
form of such hypertrophy is induration of the membrane lying be- 
neath the cavity ; the parts are raised by sub-effusions, which organize 
and become almost as hard as cartilage. Still another form is the rugose,- 
several wheals running across the space; these indurations never degenerate 
or do any particular harm. In some instances they remain permanent after 
the removal of the offence; but, as a rule, are found to disappear in a few 
months after a plate is taken away. 
Hypertrophy of the Gum-Tissue.-Hypertrophy of the gum in 
mass results occasionally from the mechanical irritation of dental plates. At 
the time of writing this page a case was being treated in the person of a lady 
suffering under such an enlargement; the trouble was in the upper gums, these 
seemed like thickened masses of gristle, and proved about as insensible as 
does this substance to medicinal impression. 
Vulcanite as an Irritant.-Vulcanite, a material much employed in 
the construction of dental plates, is, to many mouths, a source of unbearable 
offence. The cases that come under observation are all alike,-soft, flabby, 
relaxed, congested, and very sluggish in recuperation, the gum-tissue seeming 664 
A SYSTEM OF ORAL SURGERY. 
to be softened from surface to base. Acid and astringent lotions are 
adapted to the cure. The material called celluloid is to have preference over 
the former substance. 
Silver as an Irritant.-Silver is another material that it would perhaps 
be as well to dispense with in the construction of dental appliances; also gold 
too much alloyed with copper, running down, as it is sometimes found, to 
fourteen carats. 
10 and 11. Other Conditions to be considered.-In other parts of 
this work occasion is taken to treat, under what are deemed to be proper heads, 
various conditions, commonly associated under the general appellation of gum 
diseases. These diseases are of various expression; they associate with acci- 
dents, with idiosyncrasies, and with cachexia; examples are furnished in the 
epulic tumors, and in sympathetic disturbances. 
Congestion as measured by the Teeth.-Observation of Fig. 600 
exhibits a congestion which has swollen the gums and tissues of the hard 
palate to an extent that conceals almost 
completely three posterior teeth which re- 
main in the parts. The patient from whose 
mouth the drawing was made had worn a 
plate of vulcanite nine months; the parts 
were a dusky red,-flabby, relaxed, and ex- 
ceedingly indolent. There was no particular 
pain,-simply a soreness, together with a 
tenderness on pressure, which tenderness 
had increased gradually until the removal of 
the piece became a necessity. The cause of 
irritation from such a plate is variously as- 
cribed : the most probable is the exclusion 
of atmospheric air, and a consequent heating which follows. To cure such 
cases it is found, in most instances, a necessity to remove the denture, after 
which stimulating and astringent washes are to be prescribed. 
A very excellent combination is as follows: 
Fig. 600.-V iew of Gums 
INFLAMED BY VULCANITE 
R Aquas Colonise, gj; 
Tinctures capsici composites, 5j; 
Sodae biboratis, 3j > 
Tincturae cinchona?, 
Tinctures pyrethri, aa ; 
Aquas, ^vj. M. 
Borate of Zinc.-A second application, which justly receives much com- 
mendation, is borate of zinc, gi to water Oi. Use as a rinse. 
Borate of Potassa.-Borate of potassa and water in like proportions 
with that immediately preceding affords also a reliable lotion. 
Subiodide of Bismuth.-Where an alterative is indicated, an excel- 
lent and tasteless ointment is made out of the subiodide of bismuth. THE GUMS AND THEIR DISEASES. 
665 
Cases of Hypertrophy.-Cases of hypertrophy from ill-fitting clasps 
or ill-adapted plates are not infrequently met with ; sometimes such an indura- 
tion will be found circumscribing a single tooth to an extent that half con- 
ceals it, the band being accommodated in a space existing between the gum 
and tooth. The author has known such cases give much concern by the 
obstinacy of their persistence after the removal of the cause of offence; but 
such anxiety is seldom well founded, for even should the induration remain it 
will exhibit no tendency to degenerate. In the treatment it is only necessary 
to remove the offending agent and leave the case to nature. As general 
hypertrophy of the gums is concerned, illustration may be made 
by referring to a case at present under treatment. The patient, a lady in fine 
health, middle-aged, wears a plate of gold containing seven scattered teeth. 
Wherever this plate bears upon the gum, the parts are enlarged, indurated, 
and scirrhus-like. If it were not for the absence of associate expressions of 
carcinoma, one might very readily infer the presence of such disease. The 
explanation of such induration is to be found in an imperfect adaptation of 
the denture, conjoined, perhaps, with a cachexia. The treatment has been 
the very simple one of advising the patient not to wear the plate, nor any 
other, until a cure is obtained. No medication has been deemed necessary. 
Hypertrophy associated with Vacuum-Chambers.-Still an- 
other class of cases exists in the hypertrophy of the mucous membrane lying 
beneath the surface of sharp-edged cut-out suction cavities. Sometimes this 
surface is found simply thickened and hardened; at other times it is seen 
broken into deep fissures; still again it is observed studded with papillae, fungi- 
form in character, and not infrequently possessed of a tendency to hemorrhage. 
Cases are met with where serious results threaten, yet seldom ensue. In one 
known instance necrosis of the underlying bone exposed the nares. 
Treatment.-This is generally to be tentative ; the plate is to be removed, 
or at least the suction cavity must be. If the parts do not recover after such 
removal of the offence, it may be found desirable 
to touch with zinc, iodine, or capsicum. If caries 
or necrosis ensue, such conditions are to be treated 
as referred to in the chapters on these diseases. 
Example of General Ulitic Hypertro- 
phy.-Fig. 601 exhibits a form of general hyper- 
trophy of the gum structure occasionally met with. 
Such condition is oftentimes found to be but an 
expression of unobserved local agents of offence, 
upon the removal of which the overgrowth disap- 
pears. Where, on the contrary, it is seen to be an 
expression of constitutional condition, the related 
vice is to be corrected. The best local treatment consists in frequent incisions 
through the parts and the application of tincture of iodine. Removal of the 
overgrowth by the knife is seldom, if ever, found to be compensating. 
Fig. 601. - View of 
Case of General 
Hypertrophy. 666 
A SYSTEM OF ORAL SU ROE RY. 
Fig. 601, showing the underlying condition of a case of chronic ulitis, is a 
type of a not uncommon condition, and has a great variety of meanings. The 
principal cause of a recession, seen to have taken place, is found, according to 
experience, in the accumulation 
of small quantities of tartar just 
below the free edge of the gums. 
A second cause, and a very 
prominent one, lies in a solidifi- 
cation of the tooth-structure,- 
the equilibrium of circulation 
existing between the tooth-pulp, 
periodonteum, and gum being 
thus disturbed. Causes strictly 
local, however, need only give 
concern as they affect the ap- 
pearance of the parts and the 
health of the teeth ; they are 
susceptible of remedy, requiring 
only attention and the proper 
skill. It will be readily inferred, 
however, from what has been 
said on previous pages, that local 
lesions are not alone to blame for such conditions. In forming a judg- 
ment, says Mr. Bell, upon cases of this description, and even upon those 
in which the loss of substance is associated with more or less of diseased 
action, it is necessary to recollect that the teeth in old age are 
removed by this identical process,-namely, the destruction of their support 
by the absorption of the gums and alveolar processes; and as this step toward 
general decay commences at very different periods in different constitutions, it 
may, doubtless, in many cases, even in persons not beyond the middle period 
of life, be considered as an indication of a sort of premature old age, or an 
anticipation at least of senile decay, so far as regards these parts of the body. 
Depressed Conditions of the Life-Force.-In depressed condi- 
tions of the life-force, as witnessed in the habitual drinker and debauchee, 
such recession is generally found conjoined with suppuration, and affects all the 
parts alike ; the gums are turgid, sluggish-looking, and more or less purple; the 
mucous membrane lining the mouth and throat is of a dirty red ; the tremor and 
prostration of the system at large show the constitutional nature of the offence. 
Anaemic Conditions.-Another form of this recession is associated 
with the sickly and weak; here the part is lighter than in health, is shriv- 
elled and shrunken, clasping the neck of the tooth tightly and closely,- 
seeming, indeed, shrinking within itself. These cases are always anaemic, 
being found usually in the female sex, or in males inclining to phthisis. 
Everything that tends to induce such a condition is to be regarded as a pre- 
Fig. 602.-View of Chronic Ulitis, with 
Recession. THE GUMS AND THEIR DISEASES. 
667 
disposing cause; such are bilious and inflammatory fevers, the excessive use 
of mercurial medicines, the venereal virus, anything occasioning deterioration 
of the fluids of the body. Persons of cachectic habit are far more subject to 
the condition, and generally in its worse forms, than individuals in the enjoy- 
ment of good health. Because of the truthfulness of such assumption it is 
seen that the condition is an occasion of warning. In the writer's experience, 
he has not infrequently had occasion to recognize in recession of the gums a 
first expression of declining health. 
Treatment.-This is of course to be directed to cause. Where it is 
found to be of a strictly local nature, excellent effects are secured by scarify- 
ing the affected parts three or four times a week, and touching them lightly 
with chloride of zinc: a solution in strength of about gr. xx to water 3 j. 
Sometimes the edges may be pared and brought together with a 
single stitch; this little operation, however, only applies where the tissues are 
reasonably loose and fairly healthy, and the recession is V-shaped. Compound 
tincture of capsicum is an excellent provocative of granulations; iodine also 
acts happily. The parts are always to be scarified to allow such applications 
to be of any use. The various washes recommended are, of course, serviceable 
or not, according as they are adapted to indications: of these, the stimulating 
and astringent will be found most frequently useful. Where the teeth are 
thus exposed without apparent lesion, either of a local or a general nature, the 
trouble is to be deemed incurable. 
Congenital Union of Gums.-Dr. W. S. Carter reports the following 
anomalous case, which, with a few others, is presented as an interesting study 
in this direction of oral troubles: Mrs. W. was delivered, after an easy 
labor at full term, of a living male child. The infant was perfectly quiet for 
a few moments after its birth, and then spasmodic respiratory efforts were 
made. Thinking the throat might be obstructed by mucus, endeavor was 
made, using the finger, to remove it. The digit passed readily between the 
lips, but could get no farther than the gums, which both to sight and touch 
were found firmly united. As it was necessary to act promptly, the tissue 
uniting the parts was divided. This tissue appeared to be about as thick as 
the gums, and was cartilaginous, extending as far back on either side as the 
angle of the bone. Notwithstanding a free division, which enabled the child 
to breathe with more facility, the jaw remained immovable. After letting 
the patient rest a few hours, it was decided to use force to secure separation, 
and make a further careful exploration. This exploration showed a tough 
membrane, one-eighth of an inch in thickness, passing from the palate bone 
above, and inserted into the lower gum. Upon the division of this and the 
use of some little traction, the mouth was opened. In two weeks the gums 
had healed, the child took nourishment readily, and did well. 
Conjoined Malformations.-Other malformations also existed in this 
case: viz., the fingers and toes were webbed, and the ears were in rather a 
rudimentary condition,-the integument passing from the head over the 668 
A SYSTEM OF ORAL SUROERY. 
anterior surface of the upper third of each of these. When the mother was 
about three months pregnant, her son, about six years of age, had a severe 
convulsion, the jaws being spasmodically closed. She was alone at the time, 
and her terror was excessive ; and, indeed, since then, during all the remaining 
months of her pregnancy, the frightful scene, she states, had scarcely ever been 
absent from her mind. 
Unique Case.-We have delayed, remarks the editor in whose journal 
this interesting communication appears, for some weeks the publication of Dr. 
Carter's extraordinary case, in order that we might, if possible, find recorded 
some similar cases or case; but after a diligent search we have been utterly 
disappointed. Even Saint-Hilaire, to whose study of the various anomalies 
of organization science is so greatly indebted, fails us in presenting any 
analogous instance. 
Anomalies associated with Inferior rather than with Supe- 
rior Orifices.-While almost anyone of the external openings of the body 
may be imperforate, continues the record, yet this condition much oftener 
affects the inferior than the superior orifices: e.g., closure of the anus as a 
congenital condition is more frequently met with than closure of the eyelids, 
closure of the vagina than of the external auditory meatus. 
Congenital Adhesions about the Mouth.-In regard to congenital 
adhesions of the mouth hitherto described, they have been from adherence, 
sometimes complete, in other instances partial, of the lips. Even this mal- 
formation the illustrious Boyer spoke of as a possibility, never having seen it; 
but Velpeau discovered that Haller had pointed out its occurrence in the 
human species and also in the inferior animals, that Schenkius had met with 
cases upon which he had to operate, and that Desgenettes had seen a seven 
months' foetus with imperforate mouth. 
Imperforate Nares.-In Saint-Hilaire's work, chapter iii., Des Anoma- 
lies par Continuity des Parties ordinairement disjointes, section i., Des Anoma- 
lies par Imperforation, will be found the following, which may be of some 
interest in connection with Dr. Carter's report: The imperforation of the nares 
is much less frequent than that of the eyelids; nevertheless, Littre and Jean 
Bianchi have seen it in subjects in whom other irregularities also were found, 
and Oberteuffer has also several times observed the same condition. 
Conjoined Closure of Nares and Mouth.-In a case mentioned 
by Littr^, the closure of the nares was complicated with closure of the mouth, 
the skin passing over both apertures, an anomaly of still less frequent occur- 
rence. The closure of the mouth has also been seen where the nares were 
unobstructed, but these cases presented various other deviations also. 
Maternal Impressions.-As to the possible influence of the sudden 
and severe terror to which the mother was subjected, which Dr. Carter men- 
tions, in causing the malformation, it probably is better neither to affirm nor 
still less to deny. Certain it is that the tendency of the observant and 
thoughtful in our profession is not to reject as " old wives' fables" all that is THE GUMS AND THEIR DISEASES. 
669 
told of the very strong influence of maternal impressions upon the foetus, 
fables which have so long found such general credence with mothers and with 
the public. Those who are interested in the study of this question will find 
an admirable and philosophic discussion of it, by Dr. Alfred Meadows, in the 
seventh volume of the London Obstetrical Society's Transactions. It occurs 
in connection with the report of a case of Monstrosity given by Dr. M., the 
mother attributing the deformities of her offspring to the fact that during the 
earlier weeks of her pregnancy she was greatly horrified by being shown some 
of Aristotle's plates, in which were exhibited deformities resembling this and 
specimens of other monstrosities.- Western Journal of Medicine. 
Stomatitis and Pharyngitis Leucaemica.-In Virchow's Archives, 
Dr. F. Mosier relates the case of a male forty years old, and previously of 
sound health, in whom, in the course of some fifteen months, there took place 
gradually a swelling of the glands on both sides of the throat, attended with 
inflammation of the mucous membrane of the mouth and pharynx, with flac- 
cidity of and hemorrhage from the gums, followed by swelling of the axillary 
and inguinal glands, and finally of the liver and spleen. There was now an 
evident increase in the white particles of the blood. In the case described, 
the only etiological agent to which the morbid phenomena it presented could 
be referred was inordinate exertion of mind and body. The condition of the 
throat was of especial interest. Its mucous membrane was red and swollen, 
and over its surface there were spread numerous medullary elevations having 
a smooth, shining appearance. Both tonsils were enlarged, and their surfaces 
presented the appearance of a congeries of large, dense medullary knots. The 
secretions of the surface of the mouth and larynx and of the salivary glands 
were greatly increased by talking. After a thorough rinsing of the mouth, 
its secretions gave an acid reaction. The patient had not suffered previously 
from any disease of the mouth or throat. The person was attacked with this 
only after the lymphatic glands of the neck had become enlarged, and, at first, 
with their increase or diminution the throat affection became worse or better. 
Finally, under the use of quinia and iron, remedies which exerted a beneficial 
influence on the entire morbid phenomena, recovery resulted. Dr. M. believes 
that the form of stomatitis and pharyngitis here described is a specific dis- 
ease resulting from a leucaemic dyscrasy. The inflammation of the mouth, 
which in its symptoms had a close resemblance to scorbutic stomatitis, was 
probably caused by an irritation due to some morbid chemical product in the 
blood and the secretions of the lymphatic glands, by which, also, according to 
Dr. M., is to be explained the affection of the mouth met with in cases of 
diabetes, the nature of which is still, however, unknown. 
Blue Line in Saturnine Affections, and its Pathognomonic 
Value. (Archives de Medecine Navale, and Gazette Hebdomadaire.}-Dr. 
Falot refutes the authors who believe that the blue line along the gums is 
formed by an accidental deposit on the buccal mucous membrane of lead fur- 
nished by dust contained in the air or food, or still more in fluids that have 670 
A SYSTEM OF ORAL SURGERY. 
been adulterated or accidentally charged. According to M. Grisolle, among 
others, the blue line is the livery of the lead-worker, not a symptom 
of poisoning, but a simple deposit, and a sign of the worker's occupation. Dr. 
Falot quotes the observations of Beau, Barlow, Gregory, Smith, and Lecoq, 
all of whom observed the blue line in patients undergoing an internal treat- 
ment with pills of subcarbonate or acetate of lead; and he gives, in addition, 
the reports of some cases of his own, which were gathered in an epidemic of 
colic in a ship's crew at the Gaboon, the cause of which was lead-poisoning. 
Finally, after having established by experiment the impossibility of re- 
producing the blue line artificially by touching the gums correspond- 
ing to the incisor and canine teeth of the lower jaw with a brush dipped in 
acetate of lead, and after having proved that oxygenated water, and water 
sharpened by sulphuric acid, the ordinary reagents of lead, had no influence 
upon the blue line when it is plainly established, Dr. Falot proves that the 
line is the result of an elimination of the lead, and indicates by its 
manifestation that the lead, carried along by the circulation, comes to be de- 
posited in the tissue of the gums, where it forms a combination which reveals 
its presence by a more or less intense blue coloration. Dr. Falot finishes his 
contribution by representing the blue line as a sign of penetration of lead into 
the economy, and he derives the important conclusion for forensic medicine, 
that its presence may denote lead-poisoning, although an analysis of the viscera 
may not have revealed the smallest trace of the metal. 
Lead Line depending on Deposit of Black Pigment.-It will 
be remembered that a few years ago Dr. Hilton Fagge described, in an inter- 
esting paper, the microscopical characters of the lead line on the gums, and its 
dependence on the deposit of black pigment in and around the capillary loops. 
The same facts were described, almost at the same time, by M. Cras in the 
Archives de Medecine Navale (February, 1875, and May, 1876), and further 
observations by him were submitted recently to the Soci^te de Chirurgie. He 
has examined the line in portions excised from the gums of many patients, and 
found that it was easy to demonstrate the presence of lead in all the capillaries 
by the action of chromic acid. This stains the whole gum of a yellowish color, 
but the capillaries are distinctly marked by a much deeper tint, in consequence 
of the formation of chromate of lead. If now the section be washed in distilled 
water, and treated with sulphide of sodium, the black tint of the capillaries is 
rapidly reproduced. Examination with high magnifying powers 
shows that the pigment is for the most part in the interior of the capillaries. 
M. Cras asserts that this line is not the only effect of lead upon the 
gums, and he describes another change antecedent to the lead line, and more 
constant, which he terms " saturnine gingivitis." The gums have two 
aspects,-the one free in the mouth covered with epithelium, the other ad- 
herent to the teeth and periosteum. These two surfaces unite at the narrow 
festooned border, which the epithelium covers as far as the place at which the 
gum adheres to the neck of the tooth by its periosteal surface. The inter- THE GUMS AND THEIR DISEASES. 
671 
dental processes, which fill up the furrow between the gums and the teeth, 
present two surfaces adherent to the teeth. The capillary circulation of 
the gum is constituted by two plexuses : the one superficial, papil- 
lary, with fine vessels; the other, deep and periosteal. It is always the peri- 
osteal plexus which is the seat of the deposit of lead; the papillary plexus is 
normal. He asserts that every lead line is accompanied by a detachment of 
the gum from the tooth. On separating the loosened edge of the gum by a 
needle, a drop of pus, retained between the gum and the tooth, often escapes. 
The excision of the edge of the gum for examination is easy and painless, the 
interdental processes being especially convenient for the purpose. It will be 
seen, if the periosteal aspect be removed, that there, in the section, the line is 
replaced by a dotted area due to the black infiltration of the capillary loops. 
Thus the line which is visible on the outer aspect of the gums is only the 
edge of the layer of blackened capillaries on the periosteal surface. The 
mechanism of the production of the line is, according to M. Cras, 
as follows: First, by the chronic inflammation of the gum, the edge is sepa- 
rated, and in the space between the gum and the tooth organic matters accu- 
mulate. The sulphuretted hydrogen disengaged during the decomposition of 
these organic substances passes, as soon as produced, into the walls of the 
capillaries, and, acting in them on the metal brought by the blood, a deposit of 
sulphide of lead takes place in the capillary net-work. The gingivitis and 
deposit extending around the tooth often lead to serious consequences,-re- 
traction of the gum, abscess, etc. The production of this change is variable. 
The presence of tartar unquestionably assists its production. M. Magitot at 
the same meeting contested the opinion of M. Cras as to the seat of the de- 
posit, asserting that it is placed invariably in the deeper layers of the epithe- 
lium of the gum, adjacent to the Malpighian layer of the mucous membrane, 
not in the capillary net-work; and urged that the deposit depends on the 
elimination of the lead by the saliva, and was precipitated by the effect of the 
sulphur in the tartar of the teeth.* 
Osteo-Gingivitis Gangrsenosa Neonatorum.-Klementowsky de- 
scribes under this name three very similar cases, the first he ever met with 
during twenty years' practice among children in the Foundling Hospital at 
Moscow. Case I. A boy aged six days, well nourished, healthy, was taken 
ill, with high fever and an erysipelatous flush on the right cheek. The 
following day the latter had disappeared, but an (edematous dark swelling had 
appeared on the gums of the right upper jaw. Toward night two teeth broke 
through the swelling and fell out; the swelling diminished in size; ulceration 
set in four days later, and the child died. At the necropsy gangrene of the 
upper jaw and pyaemia were found. Case II. A girl aged one month and a 
half, badly nourished, had high temperature and a small gangrenous abscess 
on the gums of the upper jaw on the left side. On the second day a tooth 
* London Lancet. 672 
A SYSTEM OF ORAL SURGERY. 
broke through the abscess and fell out, the swelling diminished, the tempera- 
ture rose, and a gangrenous abscess formed on the right side of the upper jaw. 
On the fourth day it began to heal; on the fifth peritonitis set in; and on 
the sixth the child died. The necropsy revealed purulent gingivitis, with ul- 
cerations and diffuse purulent peritonitis. Case III. A boy aged thirty-eight 
days, well nourished, had gastric catarrh a short time ago. There was high 
temperature, with a purple swelling of the size of a nut on the gums, corre- 
sponding to the right upper eye-tooth. On the second day a tooth pierced the 
tumor and fell out; it was replaced by a dentiform granulation surrounded by 
necrotic tissue. On the third day the swelling and granulation diminished and 
suppuration set in. The wound healed during the following days; but on the 
fourth the temperature again rose, and a hard reddish swelling appeared on the 
left side of the gums, corresponding to the upper molar teeth. No pus escaped 
on incision. During the following days necrosis set in, the swelling beginning 
from the edges of the incision, gradually exposing the tooth and the bone in 
the alveolus. There were fetid suppuration and a gangrenous perforating ab- 
scess of the left cheek. Death occurred on the forty-seventh day. At the 
necropsy it was found that the two posterior thirds of the left half of the upper 
jaw had become one gangrenous cavity, the periosteum was detached from the 
zygomatic arch, and the latter was necrotic.* 
Proliferative Gingivitis in Pregnancy, or Frog-Spawn Gum. 
-Since the publication of former editions of this work it has come in the 
way of the author to see several remarkable illustrations in this direction. 
That inflammation of the gums, showing a frog-spawn appearance, is not an 
infrequent associate of pregnancy is a familiar fact to every practising physi- 
cian. It is not so familiar, however, that epulic growths, bearing close 
likeness to cancerous tumors, occasionally start with and continue throughout 
the whole period of utero-gestation. In one such case the disappearance alone 
of the growth after birth of the child served to satisfy that the condition was 
not malignant. In the particular instance alluded to a fungous mass quite the 
size of a hickory-nut occupied the right side of the upper jaw, giving much 
pain, and bleeding at the slightest touch. Another case presented a tumor, 
fibro-cellular in appearance, occupying a space on the gums of the left upper 
jaw, extending from the cuspid tooth to the molar. These tumefactions are 
most likely to be met with in women whose health is not very robust. They 
appear most commonly from the fourth to the sixth month of 
pregnancy, and disappear from the second to the fourth after delivery. As an 
application, nothing as a palliative has as yet been found better than the 
following formula: 
U Zinci sulphatis, gr. xii; 
Chloral hydratis, gr. xv; 
Aquas, ^iv. M. 
Sig.-The part to be touched three times daily by means of a camel-hair brush. 
* London Medical Record. THE GUMS AND THEIR DISEASES. 
673 
Radical Treatment.-As a radical application, a preparation consisting 
of equal parts of caustic soda and quick-lime may be employed; this is used 
by mixing the powder into paste form with alcohol or water; a portion laid 
against the tumor will quickly slough it away. Upon return of the growth 
the cauterant is to be reapplied. 
Gangrene of Gums following the Exanthems and other Dis- 
eases.-Any acute disease tending to impair the general health may be fol- 
lowed by, or have associated with it, ulceration or gangrene of the gums. 
Measles is the most common condition. The incipient ulcer ex- 
presses markedly the degenerative condition, the bottom of it being dirty and 
pasty looking. The treatment required pertains both to the constitution at 
large and to the immediate locality. Acid tonics commonly act admirably. 
The bowels are to be kept soluble, the skin clean and in a stimulated condi- 
tion. Exercise in the open air, either passive or active, is to be insisted on. 
The sleeping room is to be kept well ventilated; the bed is not to be of 
feathers ; the covering not too abundant.* 
Tonicity.-A medicament of valuable tonic import in all such cases is 
prepared as follows: Take of red Peruvian bark one ounce, of Virginia snake- 
root half an ounce; put these into one and one-half pints of warm water, 
simmer to one pint, when cold strain and add one pint of Lisbon wine. The 
dose for a child is a tablespoonful three times a day; for an adult double this 
quantity. As a local remedy reliance is to be placed on the aromatic 
sulphuric acid diluted and used as a general mouth-wash, or applied, by 
means of a brush, full strength, to the ulcers. 
Tincture of calendula, made stimulating by the addition of compound 
tincture of capsicum, furnishes an admirable wash when diluted one-half with 
water. Tar-water, to which has been added indicated proportion of carbolic 
acid, is a trustworthy agent, f A rinse composed as follows is to be rec- 
ommended : Carbolic acid, twelve drops; compound tincture of iodine, 
eighty drops; glycerin, two ounces; water, fourteen ounces. Touching 
with tincture of iodine is to be practised. Phenol-sodique is found a 
reliable cleansing agent; it is to be used in the strength of a tablespoonful to 
a goblet of water. Campho-phenique, brushed pure over the parts, commends 
itself. 
Oidium Albicans.-Upon most sores in the mouths of ill-nourished 
subjects are to be found cryptogamic spores shooting out thread-like 
plants. These spores are not the disease, but parasites finding habitation 
among the sores. To destroy them creasote or chloride of zinc, diluted, or in 
full strength, as indicated, may be employed. Cleanliness is a neces- 
* A mineral-water that acts admirably as an aperient is to be made as follows: Take of 
sulphate of magnesia, ^iss; of aromatic sulphuric acid, Jij; of sulphate of iron, gr. xv; 
of water, §vii. Of this combination put a tablespoonful in a goblet of water and drink 
half an hour before breakfast. 
f Tar-water, one pint; fluid carbolic acid, mixed with an ounce of glycerin, one drachm. 674 
A SYSTEM OF ORAL SURGERY. 
sity. Phenol-sodique, or the carbolized tar-water, mixed with the water used 
to wash the parts is found of profit. (See Aphthae,.') 
Calcified Dentinal Tubules.-A cause of chronic ulitis not yet men- 
tioned lies in that calcification of the tubular material of one or more teeth 
by which equipoise of vital relation is interfered with. In this condition the 
tooth-structure is found so solidified as to have its circulation disturbed to an 
extent which makes of the organ a foreign body. The receding and atrophied 
gum is expressive of nature's attempt at elimination. There is no cure outside 
of extraction. The common practice is to let such a tooth or teeth alone until 
it, or they, drop out of the mouth or become the source of discomfort. CHAPTER XL. 
THE APHTHAE. 
Aphthae is a term which every reader must have remarked to be associated 
(like the word epulis) with some degree of confusion. 
Derivation of Term.-In the Greek, from which the name is derived, 
there are two verbs with the same spelling,-an-w. The meaning of the one 
is 11 to set on firethat of the other, to " bind to" or to " fasten upon." 
Ulcers of Various Signification found in the Mouth.-The 
mouth presents ulcers, or sores, of various signification,-some are charac- 
terized by pain of a burning, inflammatory character; others, chronic, or 
cold in nature, furnish an inviting soil to a very persistent and almost omni- 
present parasite,-the oidium,-this fungus fastening upon and binding such 
sores in its necklace-like embrace. It has thus very naturally occurred that 
pathologists, seeking an expressive term by which to designate these varying 
conditions, differently employed the common name as it happened to them to 
observe or adopt the one or the other of the roots from which the nomenclature 
is derived. That such uses of the dissimilar verbs on the part of various 
authors must have been made, is necessary to be inferred to explain the differ- 
ences which distinguish descriptions. With such examples of liberty, inten- 
tional or unintentional, the author is to be excused in presenting to his readers 
the subject after his own manner and views. For the reasons of the double 
derivation, and for others which will be presented, the term aphthae cannot, in 
justice and pathological signification, be applied to a particular species of sore, 
but must, as a noun of multitude, apply to a class,-which class has many 
species. Thus we accept, as explained and dismissed, the various questions of 
ulceration or non-ulceration, exudation or non-exudation, the oidium or no 
fungi. 
Type of the Aphthae.-The type of the aphthae is as follows: An 
aphtha or aphthous patch is a degenerate sore, to be seen, under varying cir- 
cumstances, upon the mucous surface of the mouth, the fauces, the oesophagus, 
and, quite likely, upon any part of the alimentary canal, and perhaps also 
upon the respiratory tract. The most common seat of this patch is the uvula ; 
next to this the lower lip ; next the tongue. The sore varies in size, from the 
smallest point to a confluent mass which may cover a large surface; looks 
pasty or exudative, is generally oblong in shape, and varies in color from the 
misty white of hoar-frost to the dirty yellow of scrofulous pus. As most 
frequently seen, such a patch is one of several similar sores. This, as de- 
675 676 
A SYSTEM OF ORAL SURGERY. 
scribed, is a typical case. From it we are prepared to pass to the general 
view of the subject. 
Aphtha one with Canker.-An aphtha is a canker; nothing more, 
nothing less. Thrush, follicular inflammation, cancrum oris, gangraena oris, 
are all species of a cancroid class, of the class aphthae. 
Analysis.-What, then, is the class aphthae ?* The modern microscopist 
exhibits and describes aphthae as patches of a fungoid excrescence,-the 
oidium albicans. A pot of paste, a papered wall, a section of apple or other 
fruit, the leather back of a book or chair, exposed to a confined atmosphere, 
hot and moist, quickly produces, or rather gives attachment to, the oidium. 
Oidium Albicans not Aphtha.-Oidium albicans is not aphtha; 
neither is it the expression of a particular lesion. It is a fungous growth, ac- 
cidentally associated with a soil and circumstances favorable to it as a habitat.f 
The class aphthae is, without, the expression of a cachexia, and is not likely 
to be merely a local disease. Neither is it possible for the fungus to be 
peculiar to a sore, as a something specific, any more than it is peculiar to the 
paste, the fruit, or the book. It must depend in the one instance, as in the 
other, on an accidental association. This accident, in the case of the sore, 
would seem to be the absence of a sufficient vitality to enable a part to resist 
the "fastening upon itself" of ever-present germs. The microscopist has, 
in his examinations and conclusions, accepted the accident and overlooked 
the disease. 
Thrush.-Thrush, or muguet, one of the species, is an erythematic in- 
flammation, degenerating after a few days into a condition of curdy exudation. 
The inflamed surface, after a longer or shorter time, presents small whitish 
points ; these coalesce, forming exudate patches. These patches vary in color. 
As they remain moist and clear, they are considered with least apprehension; 
as they grow dry and brown, they are found possessed of dangerous import. 
Exhibit of Aphthae through Dissection.-Dissections of the ca- 
daver have exhibited aphthae not only upon the oesophageal mucous membrane, 
® The term is here employed as a noun of multitude. 
j- Parasite fungi (Hogg on the Microscope)-vegetable blights, as they are commonly 
called-have of late years become objects of earnest attention on account of the enormous 
damage done to our growing crops, and also of the many curious facts in their history 
which have been brought to light. Oidium is a common mildew. 
It appears that at particular periods of the year the atmosphere is, so to speak, more 
fully charged with the various spores of fungi than it is at others. In 1854 the Rev. Lord 
Godolphin Osborne, during the cholera visitation, exposed prepared slips of glass over 
cesspools, gully-holes, etc., near the dwellings where the disease appeared, and caught what 
he termed aerozoa,-chiefly minute spores and germs of fungi. 
From this same year (1854) to the present time we have amused ourselves by catching 
these floating atoms, and, so far as we can judge, they are found everywhere, and in and 
on every conceivable thing, if we only look closely enough for them. Even the open mouth 
is an excellent trap. Of this there is ample evidence, since we find on the delicate mem- 
brane lining the mouth of the sucking, crying infant, and on the diphtheritic sore throat 
of the adult, the destructive plant oidium albicans. THE APHTHAE. 
677 
but also on other parts of the alimentary canal. They have not as yet been 
met with upon the respiratory tract; but there is no good reason why they 
should not have here a like existence. 
Heat and Fever.-In an acute attack of thrush, the mouth is hot and 
the general condition feverish. Milder cases, or those of easy progress, may, 
and do, seem-so far as observable constitutional sympathy is concerned-to 
have only a local signification. 
Double Signification of Thrush.-But, if thrush be a distinct dis- 
ease, could it be possessed of a double signification ? Could it at one time be 
strictly local, at another systemic ? Thrush is common to children prema- 
turely born or to those nursed by unhealthy women. It is a disease which 
belongs to hot, moist climates and to the situations of uncleanly hospitals; in 
fact, to any condition recognized to be depressive of the life-force; it is, in 
short, a systemic adynamic expression, seated on a mucous surface. That it 
differs from carbuncle or cancrum oris would not seem to be the case in fact, 
but only in degree. Thrush is, in other words, one expression of a common 
condition,-a species, not a class. 
Follicular Inflammation.-Follicular inflammation-another form of 
stomatitis very likely to be asthenic-is a term used to signify that the ab- 
normal vascular change is seated in the mucous crypts, or follicles. In passing 
the finger over a surface so inflamed, the.studded irregularity produced by the 
engorgement of the glands is plainly evident. As such inflammation pro- 
gresses, the bodies become recognized by the eye as papular eminences standing 
out from a common erythematic surface. In color they are of a varying red, 
such variations in shade expressing the constitutional conditions. 
Termination of Follicular Inflammation.-Follicular inflamma- 
tion terminates either by resolution or ulceration : when in the latter way, 
the follicles soften in the centre, suppurate, and show a bottom filled with a 
whitish, pasty mass. When in this condition, they are the aphthae of M. 
Billard. 
Relation with Dentition.-Follicular inflammation appears most fre- 
quently in the infant during the dentitional period,-an explanation existing 
in a quickly and easily recognized combination of a predisposition and an 
excitant. In its most simple form,-that is, where there is no marked dys- 
crasia, or where the excitant is not of sufficient intensity to irritate to any 
extent,-the lancing of the gums, or the application of cooling local remedies, 
may be sufficient to combat or control the manifestations. Where, on the 
other hand, the conditions predisposing to the disease exist in a state of 
balance, as it were, with the natural resistive forces, the addition of a second 
depressant influence, as that resulting from the irritation of dental develop- 
ment, may very well be understood as giving the mastery to an agent or 
condition otherwise controlled or held fully in check. Thus we explain to 
ourselves both the real and apparent connection of dental irritation with the 
aphthae. 678 
A SYSTEM OF ORAL SURGERY. 
Confluent Form.-From a simple form, or the inflammation of isolated 
follicles, the condition, in some ill states of the general system, becomes con- 
fluent, such extreme form being most frequently noticed in connection with 
the typhoid exanthems, or in company with destructive organic diseases. In 
confluent follicular inflammation a prognosis can only be justly made when 
every associate and collateral influence has been appreciated. The condition 
will nearly always be found an occasion for anxiety. 
Cancrum Oris.-Cancrum oris, a species of stomatitis, generally accorded 
a special classification, differs in no wise from that just considered, except in 
being more localized; as if the force of an influence had concentrated rather 
than diffused itself. The complaint known by this name is an asthenic de- 
generating ulcer. In appearance the sore differs from what has been given 
the special definition of aphthae by most writers only in being more depraved 
and threatening. It has the same pasty bottom of varying shades of 
white, the same association of pain, the same variation in persistence. Like 
other aphthae, cancrum oris seems to be, and is, associated with dyscrasia, 
appearing most commonly in the infants of ill-conditioned charities, in the ill 
housed and poorly fed,-having, in all systemic associations, the precise history 
of the conditions alluded to as thrush and glandular inflammation. This form 
of stomatitis, although confined to no exact locality, is yet most com- 
monly met with on the cheeks or gums. It may commence with a phage- 
denic expression, and very quickly destroy the patient; or a slight vesicle 
or pustule may first appear, to be followed by varying inflammatory associa- 
tions, precisely as if some local poison was the source of the trouble. 
History of Cancrum Oris.-The history of cancrum oris differs from 
that of other cancroid affections only in degree. This is fully proven in the 
facts that it is associated with the same causes; that any ordinary canker sore 
is capable of taking on an ulcerative action; that the fungus oidium is quite 
as common to the seat of this as the other affections. In fact, every analogy 
will demonstrate that the relation is like that which associates the phagedenic 
with the simple venereal sore, being a difference of degree and not of cause, 
or character. 
Gangraena Oris.-Gangraena oris, sloughing phagedaena, is another ex- 
pression, or species, of the common class. It may commence as an acute 
inflammation, quickly deteriorating; as a species of fatty degeneration of the 
epithelial tissue; as a submucous effusion; or as an eschar which falls from 
its relations with a rapidity that leaves us at a loss for an explanation, except 
on the inference that the materies morbi have had the most special concentra- 
tion. The eschar, formed sooner or later, is ashy in color, or a deadish brown, 
while the still living parts, particularly the external cheek, if this location 
should be the seat of the ulcer, has an erysipelatous blush,-semi-livid and 
threatening in appearance. 
Associate of the Dentitional Period.-Gangraena oris is markedly 
a disease of the dentitional period, occurring in ill-fed, ill-clothed, or ill- THE APHTHAE. 
679 
housed children. The constitutional nature of this affection is 
conspicuous. It is a general febrile or inflammatory disturbance, con- 
centrating its intensity upon some part of the oral cavity, invited or directed, 
not unlikely, by an irritability existing thereabout. Foundation for this in- 
ference lies in the fact that in nearly every case are to be found inflammatory 
complications; such associated inflammations being most frequently met with 
in the lung-tissue. It is be taken for granted that the oral concentration 
modifies the impression showing in the other part. 
Support to Parasites.-Gangraena oris, where it does not quickly 
separate its eschar, affords support to parasitic fungi-the oidium albicans. 
Variability of the Condition.-Oral gangrene varies, as will be in- 
ferred, in degree. When commencing as a single canker sore, or epithelial 
degeneration, and showing no complications, it is to be treated as the follicular, 
or other of the simple species. Concentrated, or in its malignant form, it de- 
stroys life without affording the physician any extended chance to combat it. 
In reasonably healthy children gangrene is very uncommon, the ordinary 
canker being generally the worst manifestation. In children exhausted under 
the exanthems, in a class maltreated with mercury, or those laboring under a 
syphilitic degeneration, the marked, or destructive, type exhibits itself. 
Habitation of the Fungi.-The decomposition of mucus, or the 
debris remaining from food, when lodged upon an aphthous sore, forms the 
best nidus for the development of fungi; it is, as it were, a soil; and it is un- 
deniable that epithelial scales in varying states of abnormal degeneration, in- 
spissated mucus, and particles of decomposed food are general to all such 
sores. Thus, in sickly children, the fungoid association is most common from 
the fact of the weakened energy of the parts afflicted; this, favoring decom- 
position and the retention of the debris in the cavity of the mouth, and con- 
sequently producing the required soil or habitat of the oidium. In foundling 
hospitals, where the sucking-bottle is used, the spores of fungus find, through 
such vehicle, an easy passage to the mouth, being, indeed, incontestably in 
this way located and developed. In the nursing infant of an uncleanly 
mother, the accumulation and retention of the milk will, with favoring at- 
mospheric influences, quickly develop fungi. It is the fungus and not aphthae 
that is contagious, as must be plainly seen ; hence one can but wonder at the 
disputes of Guersant, Billard, Valleix, Duges, and others. 
Review.-Having thus expressed his own views of aphthae, committing 
himself to the admission that he fails to distinguish it as any special disease, 
the author may, with greater justice to so important a subject, present the 
opinions of others whose extended observations and judgment have long held 
them in the light and position of authority. Trousseau and Delpech both 
describe the aphthae as being sores with the materies morbi deposited beneath 
the epithelium. Bamberger (^Krankheiten der Mund und Mundhbhle) con- 
troverts these views, and explains the presence of the soormasse by the fact 
that it has insinuated itself between, among, and below the epithelial particles. 680 
A SYSTEM OF ORAL SURGERY. 
If we take, says Professor Bamberger, the soormasse, and place it under the 
microscope, we find it made up almost exclusively of epithelial scales, old and 
young, the debris of the food, and of inspissated mucus, which last is prob- 
ably only a condition of epithelial formation. The color of the mass is not 
to be hastily judged, as this might have been influenced by the debris of the 
mouth. Upon the sores, however, very quickly appears a peculiar or- 
ganization, which consists of round and oval spores which stick to one another, 
and in this way form a more or less ramifying series of threads. The longer 
the sore continues the more marked is its penetration by these threads or 
spores. This new organization, or fungus, can never, however, originate or 
be generated by the organism itself, but is always the result of germs coming 
from outside sources. It is not peculiar to a particular sore, though it occurs 
most frequently on those of a certain order. Besides the two constituent 
parts, epithelial scales and fungus, there appears sometimes a third constituent, 
in the form of granules or granulated matter. From this, continues Pro- 
fessor Bamberger, we see that aphthae cannot be counted among the products 
of inflammational and exudational processes, as so frequently considered; the 
microscope has failed to discover an exudational appearance: also there are 
wanting the anatomical and clinical appearances of inflammation. True, it 
may be that it is found in association with a catarrh, but this is an accident, 
just as one may not say that the diarrhoea so frequently found in connection 
with the sore in the infant is the cause of the sore, as he might not say that 
the sore is the cause of the diarrhoea. There is, in aphthae, no ulceration, 
the soormasse being capable of being peeled from the surface. 
Infants' Sore Mouth.-Professor Dewees thus refers to the aphthae as 
exhibited in the infant: 
This complaint is generally called the baby's sore mouth: it consists of a 
greater or less number of white vesicles on the inside of the cavity. It very 
generally begins on the inner part of the lower lip or corners of the mouth, 
and much resembles a small coagulum of milk. From this point it some- 
times spreads itself very rapidly over the inside of the cheeks, tongue, and 
gums; and, at others, it will appear in the same form, and at the same time, 
on several portions of the mouth; as inner portions of the cheeks, etc. The 
French, especially M. Billard, make it a different disease from what they term 
" muguet," but, from a careful examination of the two diseases, I believe 
them to be the same, differing only in intensity. I think we have not the 
disease which he terms " muguet," or I do not understand his description ; so 
far as I have been able to compare them, they are identical. The difference 
may consist in the modification which a hospital gives it; if there 
be a difference, I think it must be owing to this cause. When this efflores- 
cence is extensive, the child slavers very much, and is frequently embarrassed 
in its sucking; it cries, and evidently betrays that it is in pain; it is very 
restless and very thirsty, as it evinces by its frequent stirrings, and its disposi- 
tion to be continued at the breast. The eruption in its mildest form is THE APHTHAE. 
681 
very white, and looks as if a stratum of milky coagulum were spread over 
the mouth. It sometimes confines itself to the centre of the cheeks, at others 
to the lower lip, or one side of the tongue. In its severe forms the ap- 
pearance of the eruption is of a dark-brownish, color or extremely red, 
owing, most probably, to minute portions of blood; but both are evidently 
grades of the same affection, changed either by mismanagement, constitution, 
or the force of the remote cause. 
Affection Symptomatic.-This affection is thought to be altogether 
of a symptomatic kind, or very rarely idiopathic. It is almost uniformly 
preceded by a deranged condition of the stomach and alimentary canal, and 
always, we believe, by some disturbances of the stomach itself. The brain 
always shows signs of participating in this complaint, as there is almost always 
an unusual inclination to sleep, though the child is frequently disturbed in its 
nap by some internal irritation, perhaps of the bowels themselves. This dis- 
position to sleep is so well known to nurses that they will frequently tell 
you " the child is sleeping for a sore mouth." The bowels are often teased 
by watery, acrid stools, of a greenish color; their discharge is frequently at- 
tended with the eruption of much wind, and, to judge from the noise, it 
would be supposed there was a very large discharge of faeces, though, upon 
examination, it is found to be very sparing. 
Condition of Alimentary Canal.-The alvine discharges are fre- 
quently very acrid, so much so, sometimes, as to excoriate the verge of the 
anus and nates very severely, especially when due attention is not paid to 
cleanliness or to the frequent changing of the diaper. This, however, never 
takes place until the condition is pretty well advanced. It is generally, in 
instances of this kind, fairly spread over the mouth, and always shows a violent 
disease. The stomach is also sometimes much deranged; vomiting the 
milk very soon after it is received into it, in the form of a dense curd, 
mixed with a porraceous mucous substance. If the milk be not voided 
by vomiting, the stomach constantly discharges, by eructations, a gas with a 
very sour smell. The child, when the disease is severe, soon becomes 
debilitated, and rapidly emaciates; it is almost constantly harassed by 
severe colics and profuse diarrhoea; its stomach will scarcely retain the 
little it can swallow; the oesophagus sometimes becomes so loaded with 
aphthae that it can no longer transmit the small quantity which is reluctantly 
admitted into the mouth; and the child dies, either from the exhaustion con- 
sequent upon the profuseness of the discharges from its bowels, or from inani- 
tion. It is a popular belief that this aphthous efflorescence passes from 
the mouth through the whole tract of the alimentary canal to the very termi- 
nation of the rectum; and the excoriation at this part is offered as evidence 
of the fact. Whether this be true or not we do not know, for we are not in 
possession of any facts from dissection which decide the point. We once 
examined a body which certainly died from aphthae, the examination of which 
would by no means tend to confirm this common belief. A child, on the 682 
A SYSTEM OF ORAL SURGERY. 
tenth day after birth, was observed to have a number of white spots upon 
several different portions of its mouth, which rapidly spread over its whole 
surface. It had the usual premonitory and accompanying symptoms, which 
increased daily in severity, in spite of every effort to oppose them. It was a 
feeble, weakly child, of a consumptive, feeble mother. Its sufferings were 
very great, though under some control from laudanum, so long as this could 
be taken by the mouth or retained by injections. Coat after coat of 
aphthae was thrown off, and each new crop appeared to be more abundant 
and less amenable to remedies, until at last, at the end of two weeks of severe 
suffering, the poor infant could not swallow a drop of the thinnest fluid. 
Injections of bark and mutton-tea, in conformity with popular opinion, were 
resorted to, but all in vain; the child, in a few days more, died from absolute 
starvation, or, at least, the catastrophe was certainly hurried by the impossi- 
bility of receiving nourishment. We examined the body after death, 
finding the whole tract of the oesophagus literally blocked up with an aph- 
thous incrustation, to the cardia, and there it suddenly stopped. The inner 
coat of the stomach bore some marks of inflammation, as did several portions 
of the intestines; but not a trace of aphthae could be discovered below the 
place just mentioned. This case would, therefore, create a doubt whether 
this affection besieges any other parts of the body than those just stated,- 
namely, the mouth, posterior fauces, and the oesophagus to the cardia,-since, 
perhaps, none could have been of greater severity; but it is with us a solitary 
case, and should not be received for too much. Dr. Heberden says, The 
aphthae are supposed not only to infest the mouth and fauces, but to be con- 
tinued down through the whole intestinal canal. In two who died of lingering 
fever, and whose mouths were covered with aphthae, which hung in rags all 
over it, there was not the least trace of them that could be found in dissection 
beyond the fauces.* The excoriations about the anus can certainly be ac- 
counted for without the presence of aphthae to produce them; in bad cases 
the stools are always extremely acrid, and the parts over which they constantly 
pass and spread are, at such a tender age, very delicate, and very readily 
excited to inflammation. Dr. Good seems to admit, without hesitation, 
the transmission of aphthae through the intestinal canal; for he says, without 
reserve, the fauces become next affected, and it descends thence through the 
oesophagus into the stomach, and travels in a continuous line through the 
entire course of the intestines to the rectum, the faeces being often loaded 
with aphthous sloughs.f 
Not to take too much for Granted.-We are afraid there is too 
much taken for granted in this account; we know of no decided evidence of 
the fact, nor does Dr. Good name any authority for the statement. The case 
* Commentaries, p. 31. "It is well known, too, that in small-pox no pustules are traced 
beyond the pharynx and larynx, even in the most severe cases, when the mouth and tongue 
are thickly covered with the eruption."-Tiveedie's Illustrations, p. 65. 
f Study of Medicine, vol. ii. p. 391. THE APHTHAE. 
683 
alluded to was certainly one of death from aphthae; but in it the aphthous 
efflorescence stopped at the cardia. Is it probable that any child could sur- 
vive this affection did it travel the whole course of the intestinal canal? We 
think not; yet aphthae is rarely a dangerous disease in infancy. Dr. Good's 
description of this affection would certainly lead to the conclusion that it is 
the ordinary march of the disease to pass through the bowels and manifest 
itself at the verge of the anus. This point is far from being settled in the 
minds of pathologists: even the French are far from having ascertained it 
with certainty: it is true M. Billard says he has seen evidences of it in the 
large and small intestines, as well as the stomach; but there is no mention of 
it lower than the ileum. Now, this cannot be so; since it is in violent and 
long-protracted cases alone that the anus discovers any signs of irritation from 
this cause, which would not be the case were Dr. Good's account correct. 
Aphthae communicating itself by a Specific Contagion.- 
Dr. Good and others suppose that aphthae communicates itself by a specific 
contagion,* and give as evidence the excoriations of the nurse's nipples. We 
do not hesitate to believe there is a discharge from these little pustules which 
may be highly acrimonious to the denuded skin ; but we think this is perfectly 
innoxious to a sound one. We have never seen sore nipples produced by 
aphthae where the skin of these organs was perfectly sound. That they 
aggravate the tenderness and inflammation, when the parts are tender and 
abraded, is to be accepted without hesitation. Any other acrid substance 
would do the same thing. There is no occasion to have recourse to belief in 
a specific contagion. 
Complaint occasionally Epidemic.-That this complaint, con- 
tinues this writer, is occasionally epidemic there is every reason to believe; 
and this circumstance, among some others to be mentioned, renders the opinion 
so commonly credited (of its being a sympathetic affection) very questionable. 
We have always considered aphthae as arising from some peculiar condition 
of the stomach; but, from some late cases and more mature reflection, we 
think it may be otherwise. Our reasons for doubt are,- 
1. We have recently seen this affection in two cases where the stomach and 
bowels were in the most perfect order before the eruption, but became dis- 
turbed a little during the progress of the disease. 
2. That this complaint has been very often removed by topical applications 
alone, where the efflorescence has been very considerable, and where there was 
no remedy of any kind addressed to the stomach and bowels.f 
3. That we do not uniformly see this complaint where there has existed 
great disorder of both stomach and bowels, these being of a permanent kind. 
4. That, however the stomach and bowels may be disturbed by acidity or 
other inconvenience, or however long these may continue, if the child has had 
* M. Billard declares it not to be contagious. 
f Query.-Is, then, the unconquerable diarrhoea, sometimes present, a mere accident, or 
would it not be more easy to account for it by the presence of aphthae ? 684 
A SYSTEM OF ORAL SUROERY. 
this complaint, it is not renewed, though the individual is not exempt from a 
second attack, like measles or small-pox ; for, in certain chronic affections, they 
may be again visited by aphthae. 
5. That this affection is sometimes epidemic, as stated above ; for Dr. Good 
informs us that not only all the children of the same family, however cau- 
tiously separated from one another, but many of those of the same neighbor- 
hood, have been known, at times, to suffer from it simultaneously. (Vol. ii. 
p. 391.) 
6. That this disease is almost always ushered in by some cerebral affection, 
as great drowsiness or wakefulness; the first is by far the most common. 
7. That other portions of mucous membranes are liable to the same kind 
of eruption, without the condition of stomach or bowels being instrumental 
in its production ; for we have seen it most plentiful within the labia pudendi, 
as well as on the internal face of the prepuce. 
Sympathetic Origin of Aphthae questioned.-These facts have 
made us lately question the sympathetic origin of aphthae: yet we admit they 
are not altogether conclusive in our own mind; but we thought it proper to 
suggest the possibility of its being an idiopathic disease of the mucous 
membrane. 
Affection not confined to Early Infancy.-This affection is 
not confined to early infancy; it shows itself in the more advanced periods of 
childhood, and from that to any period of human life. It is sure to attend 
the last stages of almost every long-protracted disease, especially those which 
may have wasting discharges, such as phthisis pulmonalis, dysentery, or diar- 
rhoea ; and when it does appear, it is almost sure to be a fatal harbinger. 
Not essentially accompanied with Fever.-This disease is not 
essentially accompanied with fever; if it accompany any chance affection which 
is attended by fever, we do not find it to heighten the existing one. 
Weakly Children Obnoxious.-Weakly children, and especially those 
born before their full period, are more obnoxious to this complaint than the 
robust and those who have tarried to their full time in the uterus: the chil- 
dren of weakly women, and particularly those who make bad nurses from 
scarcity of milk, or from its not being of a sufficiently nutritious quality, are 
more disposed to this affection than the children of hale women, who have 
plenty of nourishment of good quality. The children fed much upon fari- 
naceous substances are especially exposed to the attack of this disease, par- 
ticularly when their food is sweetened with brown sugar or molasses. 
Jourdain on Aphthae.-In the work of M. Jourdain " On the Surgical 
Diseases of the Mouth" is a chapter on aphthae, so unlike all that precedes it, 
as connected with modern pathology, that the reader finds himself inclining to 
think the book owes the presence of the chapter to the translator rather than 
to the author. The term aphthae, says this work, is used alike by ancients 
and moderns, but in quite a different acceptation. The former define aphthae 
as superficial malignant ulcers, attended with heat, occurring especially in THE APHTHAE. 
685 
infants, and not confined to the mucous membrane of the mouth. It is at 
the present day universally applied to those whitish pustules which appear on 
the mucous membrane of the mouth, and sometimes of the adjoining parts. 
Inattention to this difference has led many to apply to the latter disease a 
treatment based upon the definition of the ancients, whereas the two are pal- 
pably different. Aphthae have been regarded as ulcers ; but ulceration implies 
solution of continuity, whereas in true aphthae there is no erosion or 
decrease of substance, but, on the contrary, an increase; desquamation 
of the aphthous crust leaves no trace of cicatrization. Theorists speak of 
white, red, and black aphthae, according to the nature of the generating 
humor; but during a long practice we have never seen them of any other 
color than white, whitish, or, especially when of an unfavorable character, 
ash-colored. They commence by small white spots, usually on the 
uvula, thence spreading, sometimes over the veil of the palate, sometimes 
over the tongue, gums, and inside of the lips and cheek. Often they spread 
still farther into the pharynx and oesophagus. Of their extension beyond this 
we cannot, of course, have the evidence of sight; but we have other and un- 
equivocal symptoms, which prevent us from regarding as an absurdity the idea 
of their presence in the oesophagus, stomach, and smaller intestines; as, for 
instance, in the difficulty of breathing and deglutition ; also in the appearance 
of the discharges from the stomach and bowels, so frequent in aphthous 
disease. 
Confusion as to Etiology.-The description of aphthae is easier than 
their etiology. We maintain that they depend in all cases upon the same 
cause, differing, indeed, in degree of intensity, but never in its nature. We 
therefore differ from those who assign one cause in adults and another in 
infants. Nor can we agree with the many who make them to arise from ex- 
cess of serum or of acid in the milk or nourishment given to the infant. 
The depleting, purging, and starving treatment based upon this hypothesis is 
most pernicious; moreover, experience tells us that this very acidity or astrin- 
gency of aliment will frequently cure aphthous eruptions, or prevent them 
from coming to maturity; and a serous flux, determining to the mouth, has 
caused the complete disappearance of existing aphthae. 
On the Origin.-What, then, is the true origin of this disease? We 
believe it to be found in the existence of a slow and imperfect crisis, and to 
arise from a sulphurous humor generated in the larger vessels, and determin- 
ing to such parts as are, by position or structure, most impressible. Observe 
for a moment the circumstances and character of aphthae. In all fevers in 
the young and in the vigorous, their appearance in ever preceded by a crisis 
more or less distinct, and, according to the violence of the primary disease, 
marked by more or less severe symptoms. In one case nature struggles suc- 
cessfully with the acrimonious morbific principle, a favorable crisis occurs, and 
an aphthous eruption brings great relief to the patient; in another case this 
morbific principle is too abundant, obstinate, or malignant,-no crisis occurs, 686 
A SYSTEM OF ORAL SURGERY. 
-no aphthae,-nature succumbs, and the patient dies. Again, we have 
aphthse through the critical transfer of morbid action from some more or 
less vital and important organ. In some cases the change proves salutary; in 
others there is a reaction, the aphthae disappear, and if the vis vitae, be not 
destroyed, it is often greatly endangered. 
Relation with Crisis.-Aphthae rarely occur in a perfect and favorable 
crisis, but, rather, as we have before said, in those which are slow and imper- 
fect, such as are met with in a great number of diseases. Thus we find some 
aphthous eruptions of not only days', but weeks' and months' continuance. 
When, for instance, necessary evacuations have been neglected in the onset 
of disease, and a cachectic plethora has supervened, the cure is slow and 
incomplete without the occurrence of aphthae. Diuretics and gentle 
enemas aid the recovery; bloodletting and purgatives retard it: the 
aphthae disappear after fulfilling their sanative purpose, and the patient feels 
perfectly relieved. Experience, however, shows that the danger is not quite 
over : some lurking matter may take fresh increase, give rise to new aphthae, 
in default of other means of escape from the system, and greatly endanger 
life; this may happen twice, or thrice, or oftener. 
Differences as to Causes or Antecedents.-The causes or ante- 
cedent symptoms of aphtha) may be mild, and recovery take place without 
any or with very simple treatment; or they may be severe and lamentable, 
ending in suffocation, delirium, or obstinate diarrhoea. This difference we 
find explained by the varying state of the humors: at one time being crude, 
and by consequence irritating, at another time matured or concocted, by which 
process of concoction the more hurtful principles are expelled,-a process aided 
in some inexplicable manner by the continued circulation of the animal spirits. 
Thus it happens that the aphthae of seventh-day crises are usually more 
unfavorable than those which follow crises of a latter date, when the morbid 
matter has had time to undergo a thorough concoction. Although aphthae 
are most generally preceded by febrile miasmata, they are not neces- 
sarily so. Cases are seen, both among adults and infants, in which they have 
been neither preceded nor attended by fever. In infants we may properly 
suspect impurity of the mother's blood. Certain evacuants have been found 
more hurtful than beneficial in the treatment of aphtha). This comes from 
the forgetfulness of the excellent advice of Hippocrates, who tells us to have 
regard, in the choice of depleting agents, to the channels of evacuation which 
nature points out in any given case. Now, the vessels concerned in the 
critical discharge of an aphthous eruption are the lymphatic rather than 
the venous or arterial. Therefore to the changes of the lymphatic fluid, 
rather than to those of the blood, is our attention to be mainly directed in 
the management of this disease. We have frequent evidence of serous or 
lymphatic engorgement at the outset of aphthous eruptions: in the 
fever, stupor, and restlessness during sleep,-indicating a fulness of the head 
and an acrimony of the humors. THE APHTHAE. 
687 
Influence as to Climate and Living.-Aphthae are more common 
in certain countries than in others, which explains the almost total silence of 
some writers respecting them. This depends upon difference in climate and 
mode of living. In warm countries their course is rapid, from the increased 
perspiratory action of the skin. But in colder latitudes, where the food is 
coarser, the habit of body denser, and the humors thicker, their progress is 
slower, because the secretions of the system generally are more liable to ob- 
struction. In these countries, especially, all discharges which tend to arrest 
perspiration, such as henforrhoidal, intestinal, or uterine, whether occurring 
spontaneously or artificially provoked, are very unfavorable in the treatment 
of aphthae. On the contrary, a copious cutaneous or urinary secretion forms 
often a favorable crisis. This agrees with the doctrine that aphthae are essen- 
tially serous, and most readily cured by a free discharge of serum or lymph. 
The cause of endemics we leave others to explain; each country bears in its 
womb the seeds of its own diseases, and also the means for their cure. 
External agencies may cause aphthae, not, as the ancients supposed, by their 
direct action on the mouth, but indirectly, through the mass of the circulating 
fluids. 
Diagnosis Easy.-The diagnosis of aphthae is easy; not so the correct 
interpretation of their premonitory symptoms. Painful deglutition, dryness 
of the mouth, a thick, husky voice, heat of the stomach, with rumbling 
noises, disturbed, unrefreshing sleep,-these often precede aphthous eruptions. 
Urinary symptoms are not to be relied upon, though often useful in 
prognosis after the appearance of the eruption. In the different forms 
of fever the obstinacy of the disease is often a precursory symptom ; when, 
notwithstanding the intestinal, urinary, and other evacuations, there still exist 
great depression and embarrassment of the vital functions, the appear- 
ance of aphthae will often in a single night bring calm and relief to the patient, 
as experience has abundantly testified. The physician should follow nature's 
hint, and seek to aid in the cure of the disease through the same channels. 
The above symptoms, be it understood, are by no means necessarily followed 
by aphthous eruptions. 
Caution as to Prognosis.-We should be careful in our prognosis: 
where the system is not weakened, the pre-existing morbid matter well con- 
cocted, or the extent of the eruption limited to the palate, we may anticipate 
a favorable issue. But if the patient be in a reduced and weakened condi- 
tion, the morbid matter crude, or the aphthae covering the entire membrane 
of the mouth and pharynx, the disease is much more to be feared. Again, 
suppression or derangement of the menstrual flux is unfavorable, 
from its tendency to draw the eruption from the place where alone it can 
properly mature. Profuse alvine or hemorrhoidal discharges are also hurtful; 
also any catarrhal attack falling upon the throat, causing the sudden disap- 
pearance of the aphthae. Aphthae occurring in diseases at the onset of which 
there was insufficient evacuation, are grave and dangerous. The disease may 688 
A SYSTEM OF ORAL SURGERY. 
occur in persons of either sex, and be of tedious duration; but when the 
appetite returns, not only is the food highly relished, but it gives, by its new 
nourishment, relief and salutary benefit. 
Wood on the Aphthae.-The term aphthae, says Professor Wood, in 
his "Practice of Medicine," vol. i. p. 501, was employed by the ancients 
to signify various inflammatory affections of the mucous membrane of the 
mouth. Willan proposed to restrict it to a peculiar vesicular 
eruption upon the membrane, but committed the error of confounding with 
this affection the thrush of early infancy. The two complaints are quite dis- 
tinct, and should not be similarly designated. Aphthae, in compliance with 
very general custom, is extended to all those small ulcers, with whitish 
surface, which so frequently appear in the mouth, whatever may be their 
origin. The most frequent source of aphthae is probably the vesicu- 
lar eruption occasionally present in erythema. The vesicle is small, oval, or 
roundish, white or pearl-colored, and consists of a transparent serous fluid 
under the elevated epithelium. In a few days the epithelium breaks, the 
serum escapes, and a small ulcer forms, more or less painful, with a whitish 
bottom, and usually a red circle of inflammation around it. The vesicles 
are sometimes distinct and scattered, sometimes numerous and confluent. The 
distinct variety, though painful, is a light affection, continuing in general only 
a few days or a week, and is usually confined to the mouth. It produces 
little or no constitutional disorder, though it may be associated with 
fever and gastric irritation as an effect. It attacks equally children and adults, 
but is said to be very common in early infancy. In adults it is frequently 
occasioned by the irritation of decayed teeth. The confluent variety is 
much more severe and obstinate. This frequently extends into the fauces of 
the pharynx, and is said to reach even the intestinal canal, though it may be 
doubted whether the affection of the stomach and bowels is identical with that 
of the mouth. 
Muguet of French Writers.-The French fail in distinguish- 
ing, with Professor Wood, the difference between the pultaceous inflammation 
of thrush, or muguet, and the aphthae, calling muguet the " aphthes des 
enfans." They recognize also that there are variations in the expressions of 
the condition, making a distinction between the muguet Benin ou discret, and 
the confluent, muguet matin ou confluent. 
Classed as Follicular Inflammation. - In Clymer's Aitken's 
" Science and Practice of Medicine" the subject is thus alluded to: Follicular 
inflammation of the mouth, follicular stomatitis, aphthous stomatitis, or aphthae 
of the mouth, is a disease which usually commences as a simple stomatitis ; but 
very soon small, round, transparent, grayish or white vesicles appear, and at 
the base of each is an elevated marginal ring, which is pale and firm. Fluid 
soon escapes from the ruptured vesicle; an ulcer forms, which spreads, bounded 
by a red circle and an elevated border. In some forms of the affection micro- 
scopical parasitic plants appear. THE APHTHA. 
689 
Treatment.-If we are content to view aphthae simply as a fungous sore, 
originating from and maintained by the presence of a parasite,-the oidium 
albicans,-we would find a most admirable application in carbolic acid; ad- 
mitting that the parasite had an external relation only. If, however, these 
spores come from within and are exudational, such local treatment would be 
of very temporary service. 
Viewing the Fungus as an Accidental Parasite.-Viewing the 
fungus simply as an accidental parasite external in its relations, attention is 
demanded primarily to the necessity for cleanliness, and the avoidance of all 
localities and circumstances favoring the development of fungi. Carbolic 
acid, acid nitrate of mercury, sulphuric acid, nitrate of silver, or chloride of 
zinc, will be found destructive to the parasite, and, of necessity, if the cir- 
cumstances are changed, equal to the production of a permanent improvement 
in the appearance of the part; that is to say, the application is equal to the 
removal of the envelope or cover of the disease, but, except by a happy ac- 
cident, will not beneficially affect the underlying condition, or the disease 
proper. 
Compelled to consider Constitutional Associations.-In the 
treatment of aphthae, the practitioner finds himself compelled, at the very 
outstart, to consider constitutional associations. Occurring in connection with 
acute diseases, it is generally the case that the local expression is found to 
disappear with the condition exciting it. Thus, in febrile attacks attended 
with stomatitis, remedies are directed to causes inducing such attacks; as the 
functions become harmonized, the expressions of the irregularity disappear. 
Appearing in Connection with Dyscrasic Conditions.- 
Aphthae, whatever the form, appearing in connection with the dyscrasic dis- 
eases, give to the practitioner anxiety and trouble. In anticipation of what 
is to be done, he is not to forget that a task before him is the removal, or, 
at least, the amelioration, of the constitutional disease. If this should be 
syphilitic, tubercular, or cancerous, the magnitude of the task is evident: 
hence it is that patients are allowed so frequently and so unnecessarily to 
find themselves subjected to a series of disappointments. 
Manifesting in Cancroid Lesions.-Acute aphthae, as manifested 
in cancrum oris, gangraena oris, and follicular inflammation, demand not in- 
frequently the most attentive local treatment. This treatment has, however, 
nothing particularly special in it, and, without doubt, must be appreciated 
from the general expressions of the subject. Alterative and bracing applica- 
tions are such as would naturally commend themselves. Sulphate of 
copper, in proportions varying from five to thirty grains to the ounce of 
water, is an excellent stimulant. Iron and quinine in combination are 
used to great advantage,-twenty-five grains of the latter to one drachm of 
the muriated tincture. A powder made by combining equal parts of 
red bark, chalk, and tannic acid is frequently found very serviceable. Solu- 
tions of alum, and the tinctures of capsicum and myrrh, are useful in 690 
A SYSTEM OF ORAL SURGERY. 
their places ; also borax, oxalate of cerium, powdered chlorate of potassium, sul- 
phate of iron, etc. Hydrochloric acid, applied by means of a feather or 
small brush, causes less pain than might be supposed, and is thought by many 
to be the very best local application that may be employed. 
Irritable Condition.-Where the parts seem angry and irritable, or 
phagedenic, the more soothing means, combined with these alteratives, are to 
be employed; starch, gum, and slippery-elm water being found in such direc- 
tions very serviceable. Tincture of hamamelis, much diluted, is a good 
preparation. Another is the phenate of soda. It is to be understood 
that while the principles which govern the treatment of the aphthae are 
common to the species, the applications must vary to meet varying local indi- 
cations. The ordinary white sores, for example, need little more in the way 
of such direct treatment than the continued application to them of some of 
the agents mentioned; which one is best, or, indeed, what would be best, we 
could not well say, unless considering a particular case. The local treat- 
ment is not, however, in any of these cases urgent, and it is the general experi- 
ence that a practitioner finds himself trying first one thing and then another; 
indeed, it is unfortunately too common that one is soon brought to the convic- 
tion that any local application is unreliable,-not that a sore cannot be made to 
disappear, but that to-day, to-morrow, or next week, another comes to take its 
place. Canker sores seem periodic in some persons; they come with- 
out perceptible cause other than what seems a persistent constitutional condi- 
tion, defy all treatment, and finally disappear of their own accord. 
Thrush and its Demands.-Of the special conditions, thrush demands 
that the bowels be kept free from costiveness,-oil, the saline cathartics, or 
aloes being employed as indicated. Where fever attends the local manifesta- 
tion, it is well to prescribe neutral mixture made by fully saturating 
lemon-juice with the carbonate of potassa; or, if more agreeable to the patient, 
ordinary lemonade may be drunk. In diarrhoea, which is so frequent an 
attendant on thrush, some such combination as the following may be used: 
U Hydrargyri cum creta, 
Pulveris opii, 
Pulveris ipecacuanhas, aa gr. j ; 
Magnesias carbonatis, gr. xij. M. 
Ft. chart. No. xii. 
Of these powders, the infant may take one, mixed in molasses or other 
vehicle, every two hours, until the discharge is checked, or until the twelve 
are taken. In diarrhoea with green discharges it may be sufficient to use 
the magnesia alone; or lime-water, which is more convenient of exhibition, 
may suffice for the correction of the acidity: this latter can be rendered pal- 
atable by adding to it some of the aromatic waters. A combination, for 
a knowledge of which the author is indebted to his friend Professor Penrose, 
and which it would seem could scarcely be replaced by a better, is as follows: THE APHTHA. 
691 
U Bismuthi subnitratis, 
Myristic® pulveris, aa 3ij 5 
Cretae preparat®, > 
Syrupi zingiberis, ^iss. M.® Shake well. . 
Sig.- Dose, from twenty-five drops to a teaspoonful, according to age, repeated every two 
hours. 
Cases associated with Intestinal Disturbance.-In cases as- 
sociated with much intestinal disturbance, it will in most instances be found 
satisfactory practice to combine laudanum or paregoric with olive or castor 
oil, administering in such doses as accord with the age of the patient. A 
child one year of age may take three drops of laudanum or twenty of 
paregoric, combined with a teaspoonful of the oil; for an adult a dose would 
be twenty-five or thirty drops of laudanum to a tablespoonful of the oil. It 
is also found useful to drink freely of the demulcent waters, marshmallow and 
gum arabic being among the best of these. In debility,-and this is by far 
the most frequent of the conditions,-combinations of iron and bark, con- 
joined with the most nutritious articles of diet, will be found indicated: fer- 
rated elixir of cinchona is a pleasant and very reliable preparation, and is 
freely taken by children. The dose for an adult is one teaspoonful, repeated 
three or four times a day; to an infant a year old, ten drops may be given. 
Concerning Diet.-If the patient be beyond the age of infancy, it will 
be found that rich food is advantageously received; juicy beef, oysters, malt 
liquor, wine, etc., being freely allowed. In the infant, the character of the 
milk of the mother is to be examined : in many cases it will be 
found needful to furnish a different nurse, or, otherwise, wean the child. 
Many cases of persistent thrush in the infant have quickly disappeared on 
a change of nurses. 
Gangraena Oris.-Gangraena oris, the most degenerative and destructive 
of the aphthae, requires persistent vigor in the treatment, both as regards 
systemic and local conditions. Sulphate of quinia and the muriated tincture 
of iron are, in the first direction, most to be relied on. This condition occurs 
most frequently between the periods of first and second dentition, and is, 
without doubt, more common to the miasmatic than to other regions, except- 
ing always the location of ill-kept and ill-ventilated charities. Gangraena oris 
may have a local excitant, but it is never without a constitutional pre- 
disposition. It may commence as a simple sore, gradually degenerating, or, 
as in carbuncle, destruction may reside in the primary impression. A com- 
mon form of sloughing stomatitis is its appearance as a whitish or 
ash-colored eschar situated upon the gums, lips, or cheeks. This eschar 
quickly falls out, being followed by degeneration of the associate parts; the 
breath becomes offensive, the saliva flows as in ptyalism, while, to add to the dis- 
* The author is assured that his readers will recognize the obligation he places them 
under in directing attention to this palatable combination. As a medicine for the ordinary 
watery diarrhoea of summer, both in the infant and adult, it is seldom found to disappoint 
in affording speedily the desired cure. 692 
A SYSTEM OF ORAL SURGERY. 
comfort, the ulcer pours out an acrid, corrosive fluid, which not only excoriates 
the mouth, but provokes extension of the mortification. If not checked, the 
ulceration extends to the bone, quickly involving it in the general destruction, 
and bringing on the condition of necrosis,-necrosis infantilis, as the disease 
is, unfortunately, so frequently compelled to be named. 
Treatment of Gangraena Oris.-The treatment of gangraena oris is 
precisely that of a carbuncle. The practice is to endeavor to circumscribe 
the action by sloughing out the affected part with the aid of caustic; tonic 
stimulation of the general system associates. Where possible, all functional 
disturbances are controlled, and for the relief of the local sore such soothing 
means are used as seem indicated. The very best caustic for these and similar 
cases is found in the London paste,-i.e., equal parts of caustic soda and quick- 
lime made into a thick dough at time of application by mixing with water or 
alcohol. CHAPTER XLL 
WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
Wounds of the mouth and associate parts have, of course, the significance 
of wounds in general. Thus, some are of an incised chsrracter, being slits 
or incisions made, accidentally or purposely, by sharp-edged instruments. 
Some are lacerated, contused, or torn, being made by dull and blunted 
instruments; some are punctured, a result of injury by pointed but not 
sharp instruments; some are penetrating, as when the offending agent 
passes through the lip or cheek into the vestibule. A wound may be of a 
compound, or complicated, nature, as, for example, in the case of blows or 
falls, where, while the lip or cheek is cut or contused, lesions relate at the 
same time with the teeth or jaw ; gunshot injuries, lacerating, or simply punct- 
uring the soft parts, comminuting the hard; bites of rabid animals, intro- 
ducing a virus; syphilitic inoculations, etc., illustrate compound wounds. 
Complications may also be considered as embracing hemorrhage and shock as 
primary associations; inflammation, with its varied phenomena, erysipelas, 
pyaemia, tetanus, etc., as secondary associations. 
First Indication.-Every wound presents a first indication. If an indi- 
vidual receive a hurt which covers the injured part with earth or other foreign 
substance, such substance is to be washed or taken away as a primary step. 
If hemorrhage be the feature, arteries are to be ligated, or other necessary 
means taken to control the bleeding. If shock be present, this is the most 
immediate feature, and is first to be combated. If a rabid or poisonous 
animal has inflicted the wound, the destruction of the virus is a first indication. 
Foreign Particles.-To remove foreign matter, no better means is to 
be employed than simple sponge and water. Holding a basin beneath the 
injured part, squeeze water upon it from the sponge; if the particles be not 
washed away with the agent closely applied, let it be lifted and the water 
allowed t$ fall from a distance. It is not, as a rule, at all necessary to rub a 
sponge directly over the surface of a wound. Bodies which are not to be 
washed away, no matter what their character,-splinters, shot, balls, particles 
of powder, spiculae of bone, etc.,-are to be removed with forceps, scoop, or 
other convenient means, -the rule being to allow nothing to remain that may 
interfere with the process of repair. 
Hemorrhage.-A first matter to consider in hemorrhage is its character. 
Is it arterial, venous, or capillary ? An arterial hemorrhage is known by 
its scarlet color, and by issuing from the wound in jets. Hemorrhage of 
693 694 
A SYSTEM OF ORAL SURGERY. 
venous character is dark, and has a gradual and regular flow. Capillary 
hemorrhage is an oozing. Arterial hemorrhage may require that the bleeding 
vessel be ligated. To do this, it is only necessary to sponge away the blood 
until the part is to be plainly seen; it is then to be taken hold of by the for- 
ceps, or caught by the tenaculum, and a strand of waxed silk thrown around 
it. In tying this silk, one must be careful that he does not break his strand 
at either side of the knot; also that the tightening shall be sufficient to cut 
the middle and inner coats of the vessel. To prevent tearing the artery 
from its bed by the breaking of the ligature, the rule of holding the thumbs 
upon the strands close to either side is to be observed. After ligating a 
vessel, one encbof the thread is to be cut off and the other brought from 
between the edges of the wound; this allows of easy future removal of the 
knot. (See legation of Arteries.') 
Torsion.-Torsion of a bleeding artery is a favorite mode of treatment 
with many surgeons. The end of the vessel is to be caught by the forceps 
and twisted. The author of the mode suggests that torsion be continued 
until the end is twisted off. 
Acupressure.-Acupressure is another and a very common method of 
treatment. A steel or gold needle is passed beneath the vessel in such manner 
as to tightly compress it against neighboring parts. 
Use of Pad.-Pressure by pad and bandage, when a hemorrhage about 
the face will not yield to simpler means, is a very satisfactory way of treat- 
ment, and one very reliable. All the vessels of the face region rest upon 
a bony floor, and all of them, at certain points, are sufficiently superficial 
for the purpose of compression,-the facial, at the notch in the inferior 
maxilla, in front of its angle; the temporal, just in front of the ear above 
the zygomatic process; the supraorbital, at 
the notch in the orbit; the infraorbital, at 
the foramen below the border. (See Surgical 
Anatomy.) 
Knotted Bandage.-A bandage of com- 
mon application for any of these vessels is the 
crossed, or knotted, circular. A glance at the 
drawing (Fig. 603) will afford understanding of 
the manner of its employment. 
Cold or Hot Water.-It is, however, very 
seldom that any of these operations are necessary 
for the arrestation of hemorrhage about the face 
or mouth. Cold or hot water thrown over the 
bleeding part from a sponge causes generally 
such contraction, both of vessels and tissues, as to control the bleeding quickly 
enough. If water alone do not answer the purpose, let as much alum be 
added as the water will dissolve. If even this should not suffice, a syringe 
may be used, throwing a jet from a distance directly upon the bleeding 
Fig. 603. - Crossed, or 
Knotted, Bandage. WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
695 
part; this last will seldom disappoint. Monsel's salts, so warmly lauded 
for their styptic qualities, have exhibited to the writer more ill results than he 
has ever met with from any dozen other articles. If employed at all, the 
bleeding points alone are to be touched; but of one thing any one using them 
may be assured: if the application do not control the hemorrhage instantly 
and permanently, he will have greatly increased his trouble. 
Venous or Capillary Hemorrhage.-A hemorrhage that is venous 
or capillary seldom requires more than the application of cold water and pressure. 
If this or an alum conjunction, or preferably phenol-sodique, fail, astringent 
medicines are to be administered internally. Of the anti-hemorrhagic medi- 
caments, tincture of the erigeron Canadense, one drop in a teaspoonful of 
water each minute, may be tried. This dose seems like a very small one, but 
a larger always appears to do harm rather than good. Opium and lead are to 
be used with much satisfaction, one grain of the former to two of the latter; 
three or four of such pills may be administered at intervals of from one to 
six hours for each. Tincture of ergot is reliable. 
SHOCK. 
Definition of Shock.-Depression generally attends, to a greater or 
less extent, the reception of wounds. Surgery divides shock into primary 
and secondary, or that which is immediate upon the reception of an injury 
and that which exhibits itself at some later period. Shock is prostra- 
tion : this may be simply of a nervous nature, implying functional disturb- 
ance ; or it may be organic, testifying to injury of a vital part; it may, again, 
have the twofold relation. In the author's experience he has found few things 
more important to observe than the differences between real and apparent 
shock. One person, heavy and lymphatic of temperament, receives an injury 
mortal in its character, and yet, as immediate or primary shock is concerned, 
shows less evidence of such injury than may some other of a different nature 
who is suddenly called to look on his wound. Mistakes in judgment of 
these limited expressions may readily influence a practice most adverse to the 
good of a person prescribed for. 
Interference with Function.-Shock means interference with func- 
tion. Interference with function arising out of the direct destruction of a 
part is not to be recovered from,-that is, if the part destroyed be necessary to 
the functions constituting life. Interference with function extended over a 
lengthened period is dangerous in proportion to the continuance of the period. 
Functional disturbance, individual or general, arising out of simple shock, may 
reasonably be expected quickly to correct itself. 
Characterized by varying Expressions.-Shock is characterized 
by expressions varying all the way from tremor to collapse. Expressions of 
primary shock are paleness, trembling, faintness, sickness of stomach, giddi- 
ness, palpitation of heart, cold sweating, loss of office in sphincter and other 
muscles, disordered respiration, glassiness of eyes. 696 
A SYSTEM OF ORAL SURGERY. 
Primary Shock.-Primary, or immediate, shock has seldom the dan- 
gerous meaning of that which comes on in the later course of an accident. 
An intermediate condition, consecutive shock, not infrequently met with, 
is without dangerous import, as it implies simply a mental recognition just 
arrived at by the patient of a situation in which he finds himself. Insidious, 
or secondary, shock is never to be absent from a surgeon's mind when injury 
is about the head region. Here the import refers likely to injury done the 
vascular system; the ill consequences arising out of hemorrhages or effusions. 
Many a blow ending fatally, received upon the head, has had as the primary 
expression nothing more than a slight bewilderment almost instantly recovered 
from. 
Deceptive Character.-A patient, being the recipient of a grave 
injury, yet showing little concern, either bodily or mentally, as to the harm 
received, is to be watched with anxiety. Here, as is frequently enough found 
the case, the system is in a state of stun. It has received a hurt which has 
destroyed or greatly interfered with sensibility. Gradual change shows in an 
icterode skin, in an albuminoid expression of the immediate subcutaneous 
tissues, cold extremities, a weak but laboring pulse, occasional long-drawn 
sighs, progressive prostration. 
Relation of Shock with Visceral System.-To appreciate the 
subject of shock is to recognize its relations with the nervous, the vascular, 
and the common visceral systems. The first finds a familiar illustration in the 
effects of self-given blows over the locality of the solar plexus. The second 
is to be appreciated in watching the changes common to one undergoing the 
operation of venesection. Collapse, belonging to the third, is but an in- 
tensified expression of a history associated with splanchnic inflammations. 
Fright as cause of Shock.-Accepting the above expressions of rela- 
tionship, diagnosis and prognosis are divested of confusion. A person may 
die, persons have died, from nervous shock arising out of extraction of a tooth. 
Quite a number of instances are on record where similar fright in anticipation 
of taking an anaesthetic has resulted fatally. The trepidation associated in 
many persons with injury connected with surgical performances is infinitely 
of more evil import than the hurt itself. Some persons faint at the first spurt 
of blood from an opened vein, others require to be kept in an upright position 
and the vessel largely incised that they be depressed at all. 
Idiosyncrasy.-Idiosyncrasy is to be taken into account; a warrior 
shows paleness at sight of a coflin, a strong woman grows hysterical at ap- 
proach of a mouse. Some particular child goes into spasms on putting a 
forkful of cabbage into its stomach. 
To treat Shock.-To treat shock is to deal with varying conditions. 
Medicines required vary all the way from an assuring word to a dose of am- 
monia. A danger is from overdoing. In ordinary depression the abeyance 
in action tends naturally to over-excitation in the reaction. A patient doing 
well is to be let alone. Stimulation is not the indication ; rather, indeed, WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
697 
would it be the better practice to exhibit depressants as reaction shows itself, 
wholesome fear being entertained of over-excitation. A best plan is to do 
nothing until indications make themselves clearly felt. 
Indications.-Shock of simple, but prolonged, character demands the 
treatment given a fainting fit,-namely, recumbency as to position, fanned air, 
the dress loosened, cold water gently sprinkled or otherwise dashed vigorously 
over the face, smelling-salts to the nostril. If continuing, in defiance of the 
employment of these means, recourse is to be had to swift blowing into the 
ear, the dropping of a few minims of raw liquor into the throat, or, in the 
absence of this, the use of ice-cold water. An excellent adjunct lies in the 
application of sinapisms; in this direction immediate result is to be derived 
from the use of pure chloroform poured over a handkerchief which has been 
folded into a small square, the application to be to the praecordial region, or 
otherwise to the calves of the legs ; the agent is to be so covered that its vapor 
shall not reach the nostrils of the patient. 
Use of an Emetic.-Prolonged shock having associated with the 
symptoms a continued retching is commonly to find its best treatment in the 
administration of an emetic; particularly is such a treatment indicated if it 
be known that a hearty meal has immediately preceded the accident; retching 
is almost invariably found associated with an ability to swallow. 
Anodynes.-Anodynes are not infrequently indicated after shock. An 
excellent and reliable combination consists of tinctures of valerian and gentian 
in equal parts; the dose varies from a drachm to a half-ounce. Another ex- 
cellent means is found in a combination of bromide of potassium and veratrum 
viride ; as a dose for an adult from twenty to forty grains of the first, four to 
eight drops of the second, may be administered in a wineglass of water. In 
injuries having associated with them fear of secondary hemorrhage or effusion, 
opium conjoined with lead is to be employed; the dose is one grain of the 
former to two of the latter, repeated as occasion requires. 
Combating Visceral Determination.-Tendency to visceral deter- 
mination is to be combated by cups, wet or dry; by hot foot-baths; by medi- 
cines directing the circulation to organs the most remote from the particular 
one threatened. 
VIRUS. 
Primary Indication.-If a rabid dog, or other animal, bite the part 
being considered, or any part,-if a poisonous snake strike its fang, or if the 
loose kiss of a chancrous lip inoculate,-a first indication is to get clear of the 
poison. How ? It is now very generally accepted that, as the first is con- 
cerned, the immediate application of the stick nitrate of silver to the 
part wounded will neutralize the poison, or that, at any rate, it will alter the 
status of the hurt to an extent which results in a slough and the prevention 
of absorption. If an escharotic be not at hand (and this, at the moment, 
would be not unlikely), such a wound may be cut away. Suction is also an 
admirable prophylactic. The danger to the person sucking such a wound 698 
A SYSTEM OF ORAL SURGERY. 
would be trifling; danger, at all, depending on a casual abrasion that might 
at the time be present about the mouth or lips. Excision of bitten parts 
is frequently practised. The writer recalls an occasion on which, several years 
back, an enraged rattlesnake escaped from an experimenter, striking its fangs 
into a colored assistant standing by. Without a moment's hesitation, the 
gentleman excised the part: no harm came of the matter. Tiding a patient 
over the depression of rattlesnake-poison by the stimulus and specific effects 
of whiskey has received so many confirmations as to reliability as to have 
become a matter of common knowledge. As the removal of hurts received 
from dogs, supposed rabid, is concerned, the author has, on several occasions, 
practised excision with entirely satisfactory result. Without exception, how- 
ever, the wounds had been received through intervening substances, and such 
substances may have prevented the introduction of any poison. Syphilitic 
virus is best destroyed by use of London paste. 
HEALING WOUNDS. 
How Wounds heal.-Primary indications met in relation with a wound, 
a second relates to healing it. Every break in continuity heals by granulation. 
The difference between a healing by first intention, as it is termed, and a heal- 
ing by second intention is only a difference in degree. An incised wunod, 
delicately and accurately approximated, unites with so little new inter-tissue 
that observers quote cases where no line of difference was discernible even under 
the microscope. A healing by second intention, so called, may require so much 
material to fill a gap that the new, or cicatricial, substance is observable at a 
great distance ; frequently witnessed in scars from burns. An indication, then, 
of the utmost importance to be met in wounds about the face, is the avoidance 
of a necessity for new tissue. To meet such indication, every wound is to have 
its parts as nearly and as neatly approximated as possible, and the associated 
vascularity controlled. 
Methods of Treating.-How wounds are best put together is a matter 
which is always eliciting discussion. Common methods are by stitches, plasters, 
and compresses. An incised wound, of limited extent, about the cheek, 
seldom needs more than a strip of adhesive plaster thrown across it. If 
such a wound occupy the position of the lips, and complete separation has been 
made, adhesive plaster will not, perhaps, be found sufficient for the purpose. 
To insure the best result, a stitch is to be used, and increased support given 
by placing lateral compresses at the sides of the wound, relating these by a 
turn of the circular bandage; or it may be found that, after the stitch, the 
adhesive strips will answer the purpose. Pins, with a figure-of-eight turn 
about them, make a very nice, reliable, and accurate adaptation, and, if not 
kept in too long, leave very little scar. 
Silver or Lead Wire.-A mode of approximation, which is found 
very satisfactory, consists in using a suture of silver wire, and bringing the 
edges of the wound together, as directed in cleft palate. An objection, how- WOUNDS OF THE MOUTH AND ASSOCIATE PAETS. 
699 
ever, it must be admitted, to all pins and stitches, lies in the fact of new 
wounds being made,-an irritation being begotten by the presence of the 
foreign body, which is very apt to provoke more or less suppuration, thus 
making other scars, as is witnessed so frequently in operations performed for 
harelip; it may therefore be set forth as the best practice, that a means which 
breaks the flesh is to be avoided, if any other can be made to answer. Silver 
or lead wire is preferred to the waxed silk only from the fact that these metallic 
agents seem to irritate less, and are, therefore, not so likely to make points of 
suppuration, and consequently scars. 
Time to remove Pins or Stitches.-When pins or stitches are 
used, they are to be left in place only so long as is absolutely necessary; the 
time will, of course, depend much on circumstances. If an incised wound do 
as well as it may, twenty to seventy hours will usually be found sufficient for 
the union, while instances enough exist where, in that time, the process of 
repair seems scarcely to have commenced. A very good way of obtaining 
information is to sponge the wound, and to be instructed by the line of ap- 
proximation : if this continue to show its incised nature, the pins are not to be 
disturbed; if, on the contrary, it is a fleshy line of comparative solidity, the 
pins are to be removed,-the parts will hold. 
How to remove Pins or Ligatures.-The withdrawal of a pin 
or ligature is a matter demanding delicacy of manipulation. It is frequently, 
and indeed generally, the case, that more or less blood-rust collects, making 
the removal a matter of such difficulty that, unless precaution be taken to 
scrape away such rust before making the attempt, disturbance of the cicatrix 
is inevitable. In the withdrawal of a pin, an important matter is the rota- 
tion of it; such rotation facilitates the getting away wonderfully. Metallic 
ligatures are generally disturbing on removal; the proper plan to take them 
away is to cut the wire at the side of the knot opposite that on 
which it seems desirable to withdraw it; the end is then to be carefully 
straightened, so as to place it on a line with the part through which it is to 
be pulled from the wound; support is to be given the cicatrix by a 
finger applied on either side, when, with a rotatory movement, the wire is 
taken away. In the use of the pin and figure-of-eight, a very excellent plan 
is, on the removal of the pin, to allow the blood-matted silk to re- 
main glued to the wound; it serves to hold the parts together, and is 
entirely void of any offence as a source of irritation. 
Use of Plasters.-When plasters are used, it is a necessity to have all 
hairs shaved away and the parts perfectly dry. The ordinary adhesive, composed 
of resin and lead plaster, and kept on sale by every druggist, is perhaps open 
to as little objection as any. It is to be applied in strips of convenient length 
and breadth, and rendered sticky by holding, for a moment, the back of the 
strip in contact with a vessel of hot water. There are skins, however, which 
this plaster irritates and inflames; when cases of the kind are encountered, it 
is well to employ an isinglass plaster. This latter is applied by moistening 700 
A SYSTEM OF ORAL SURGERY. 
the glazed surface with water. In the use of plasters, it is a good rule to 
allow a space between each strip : this not only keeps the wound exposed to 
observation, but permits of easy drainage. The only exception to this rule is 
found in small cuts where it is thought desirable to use collodion. This 
mixture of gun-cotton and ether is applied either directly over a cut-first 
nicely approximating the edges, and holding the parts together until the 
ether has evaporated-or indirectly through the agency of saturated slips of 
gauze or other convenient material. 
Removal of a Plaster.-The removal of a plaster is to be effected by 
drawing the strip from either side toward the wound ; such a removal being 
accomplished without any strain upon the cicatrix, the line of union being, of 
course, supported by the thumb and forefinger of the other hand. If a 
wound seems to be doing well under plaster, there need be no special haste in 
the removal. It is usually the case, however, that such a dressing will not 
continue to do service longer than two or three days. In simple incised 
injuries, this is generally all that is needed, but in lacerated wounds, dressings 
are demanded an indefinite length of time, and require continued renewal. 
In reapplying a dressing of adhesive strips, a good plan is to displace and 
replace one at a time. In this connection attention is to be directed to a 
plaster prepared by Meade, of New York City; the author has never 
met with any that at all equals it; no heat is necessary to its application. 
Complicated Wounds-Illustrative Cases.-The history of a 
few cases may, perhaps, best serve to illustrate practice in the direction here 
considered. 
Case I.-Little girl, of remarkably perfect temperament,-temperament- 
less, it might be said,-about four years of age, brought into the office with 
a gash in the lower lip and the six anterior teeth knocked directly back; 
considerable hemorrhage. 
Treatment.-Checked the hemorrhage, and cleaned the parts by the free 
use of cold water applied through the syringe.; pushed the teeth back into 
their unfractured alveoli, and retained them in place by laying a delicate roller 
over them, fixing it beneath the chin. A single stitch of waxed silk was 
placed in the wound of the lip. The case was dismissed for the day, with 
directions to keep the parts refrigerated through a continuous application of 
cold water. 
Second day.-Same treatment continued, the band over the teeth being 
replaced by a fresh one. 
Third day.-Wound in the lip healed sufficiently to remove the ligature. 
Teeth somewhat tightened ; very little inflammation; continued the bandage, 
but left off the application of the water. 
Fourth day.-Removed the bandage. Teeth very sore, but doing well, 
and quite fast. 
Eighth day.-Patient dismissed; some soreness still in the teeth, but need- 
ing only time to bring them to full health. WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
701 
This case was seen three months after the accident; there was no discolor- 
ation of the teeth, and not the slightest evidence that any harm had ever been 
done them. 
Case II.-Child, six years of age. Four front inferior teeth knocked 
loose by a blow from a ball; some contusion of the lip, but no break in the 
continuity ; very little bleeding. 
Treatment.-Removed the injured teeth; absorption of the sockets 
having progressed to a considerable extent, applied to the lips dressing of cold 
water; case well enough to dismiss next day. 
Case III.-Little boy, five years of age, fell upon a curb-stone, fracturing 
the superior alveolar process. Examination revealed six teeth movable in 
mass, the fracture extending from tuberosity of right side to canine fossa of 
left. The accident occurred nine hours before recourse to treatment. 
Condition.-Child feverish and restless; pulse much excited; soft parts 
about the seat of fracture considerably swollen, and so tender as to cause the 
patient to scream when the lip was touched. 
Treatment.-A Seidlitz powder; hot pediluvia; the mouth syringed 
with cold water; iced lemonade ad lib.; spts. Mindereri, 5ij, gr. acetate 
of morphia. This was the treatment on the afternoon and night of accident. 
Second day.-Hot pediluvia ; iced lemonade, made of crushed ice ; mustard 
poultice at back of neck. 
Third day.-Swelling of gums very much abated. Fed the child freely 
with spoon food, then brought the fractured part to its place by reducing to 
proper articulation with lower teeth, and retaining in position by means of the 
yard strip modification of the Barton bandage; a fairly comfortable day was 
passed. In the evening the bandage was loosened, the child again fed, the 
bandage retightened, patient put to bed. A comfortable night was enjoyed. 
Fourth day.-Doing very well. On loosening the bandage there was very 
little tendency in the fractured part to move of itself; child fed with soup food ; 
mouth well syringed with cold water; bandage reapplied. Patient played 
about the room most of the day, taking lemonade and rice-gruel very fre- 
quently ; the fluid being placed within the lips and sucked between the teeth. 
From fifth to tenth day did little more than continue the treatment of the 
fourth. 
Eleventh day.-Removed the bandage. Fracture fairly solid ; able to hold 
of itself; liquid food continued ; no other treatment. 
Fifteenth day.-Patient began to eat solid food ; passing on, without further 
treatment, to a good cure. 
Case IV.-Little girl, three years of age, markedly scrofulous; lip cut 
through ; fracture of process of central, lateral incisor, and cuspid teeth of 
left side inferior maxilla; cutting edges of teeth thrown backward. 
Treatment.-The wound in the lip being quite extensive, a harelip pin 
was inserted, and the parts pushed together and held with a figure-of-eight. 
The fractured process was restored to position, and retained by tying one 702 
A SYSTEM OF ORAL SURGERY. 
end of a strand of waxed floss silk around the last molar tooth of the injured 
side, bringing it forward, passing it between the first molar and cuspis of the 
fractured part, back of the three teeth of the broken process, then out between 
the central incisors, and back to the first molar, where it was tied. This liga- 
ture supported the part in its place very well. The ferrated elixir of bark, in 
doses of twenty-five drops, directed to be taken three times a day. 
Second day.-Wound in the lip doing tolerably well; seat of fracture look- 
ing puffy and asthenic. Very weak solution of compound tincture of capsicum 
ordered to be thrown, ter die, over the part. 
Third day.-Looking worse; ligature cutting into the gums; patient re- 
fusing both solid and soft food. Took away the ligature ; tempted the appetite 
with ice-cream and jellies; scarified the puffy gum. 
Fourth day.-Matter oozing from about seat of fracture; etherized the 
child; dissected down to the broken piece, and removed it. 
Sixth day.-Very much improved; wound healing fairly; continued to 
syringe with the dilute capsicum compound. 
Eighth day.-Case well enough to be dismissed. The pin in the lip had 
been removed on the third day. The wound gaped some little; but the 
removal was a necessity, on account of irritation produced by its presence; 
support was given by an adhesive strip. After the taking away of the pin, 
and the part being stimulated with capsicum, it healed very rapidly. 
Case V.-M. L., an iceman, aged perhaps thirty-five, brought into the 
office immediately after having been kicked on the mouth by a vicious mule. 
Patient very pale and faint. Examination revealed comminuted fractures of 
the alveolar process of both jaws, with the teeth knocked into every position. 
Treatment.-First, stimulation with a little brandy. The patient revived. 
Incisions on either side of the teeth were made down to the bone, and some 
eight pieces removed, with the teeth associated. No hemorrhage of conse- 
quence attended the operation, and in the course of three or four days the 
man was going about his business,-no treatment outside of the free use of 
cold water having been indicated or employed. 
Case VI.-C. H., struck over the angle of the jaw by a minie-ball, which 
ploughed across the face, completely dividing the cheek, and grooving the 
right nasal ala. A first treatment, employed on the field where the injury 
was received, consisted in associating the several parts with a series of inter- 
rupted sutures, and the application of a poorly-adapted bandage. In this con- 
dition the patient was sent several days' journey, to a hospital in which the 
writer happened at the time to be employed. A first observation of the case 
exhibited an immense wound, stitches all torn out; superior maxillary bone 
exposed, with groove cut into it; suppuration profuse; patient irritable and 
feverish, and much exhausted. 
Treatment.-The weather being oppressively hot, a large basin of water 
was brought, in which the head and face were thoroughly, yet tenderly, 
washed. The matted hair was combed out and arranged. This refreshed the WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
703 
man very much. Examination of the wound was commenced. On the groove 
in the bone was found no splinter, nor other indication adverse to the direct 
and immediate overlying of it by the soft parts. Attention to the line of 
wound in the flesh exhibited that the slough, which must necessarily have 
ensued from the passage of the ball, had been completed, and that a process of 
repair was attempting to inaugurate itself. Indications being very plain, 
the whole of the cut and suppurating surface was slightly stimulated by an ap- 
plication of dilute tincture of iodine, and then carefully moulded into place and 
approximated. The maintenance of this apposition was accomplished by fit- 
ting a compress to the cheek, and also below the wound, and, by means of a 
bandage, carefully lifting and supporting it; no stitches, pins, or plasters being 
employed. The success in way of adaptation of parts was perfect, the whole 
line of the wound being exposed, permitting full and frequent examination. 
In two weeks the parts had united so firmly as to allow of the removal of 
the compress and bandage. The only medication employed consisted in the 
administration of an occasional Seidlitz powder, and a glass of porter daily, 
together with repeated applications to the wound of the dilute iodine, one 
part of the officinal tincture to four of water. 
Case VII.-Little girl fell over the shafts of a wagon, cutting, in some 
unaccountable way, her tongue directly in twain, for the distance of an inch 
down the middle. Hemorrhage was very profuse, requiring the ligation of 
a vessel. This wound was united by two stitches of the interrupted suture 
passed deep in the substance of the organ; cold water directed to be held in 
the mouth quite continuously, for the first day; patient fed on ice-cream and 
jelly. Third day, stitches removed, union complete, ligature loosened, and 
was pulled away on the seventh day. 
Case VIII.-Brigadier-General D., standing upon an outlook, was struck 
by a sharp-shooter, the ball passing through the right ramus of the lower jaw, 
shattering the bone, passing forward across and through the tongue, emerging 
from and splintering the body of the bone on the left side. The treatment 
pursued upon the field had been to check an alarming hemorrhage from the 
region of entrance of the ball by stuffing the wound with charpie saturated 
with Monsel's solution of iron, throwing a bandage over this, and hurrying 
the case to the hospital. 
Condition on Entrance.-Patient arrived, and was put under the 
author's care about eleven o'clock at night; complained, by writing on a 
slate, of great thirst, with entire inability to swallow, and of the painful effort 
required to breathe; had not been able to drink since the injury, which 
happened two days before. 
Treatment.-Examination revealed marked displacement of the middle 
piece of the fractured bone. This, with the tongue, being pulled backward by 
the hyoid attachment of the genio-hyoglossal muscles, sufficed to explain part 
of the difficulty in respiration and deglutition. The tongue itself, however, 
was much swollen, and had a ball wound through its base. Two primary 704 
A SYSTEM OF ORAL SURGERY. 
indications thus presented: to restore the body of the bone and tongue to 
position, and to reduce the swelling in the soft parts. The external wounds 
were for secondary consideration : the patient had to breathe and had to be 
nourished. The mouth was first well syringed with cold water, which was 
found most refreshing by the patient; the bone was then brought forward, 
the inferior teeth in front of the superior; the jaws were closed, and held 
together by a delicate bandage, the middle fragment being thus retained even 
in front of its natural position, and pulling the tongue forward with it. This 
accomplished, the patient was propped up in an arm-chair and his feet im- 
mersed in hot water, the application being continued until every vein and 
capillary was engorged. A local abstraction of blood was not thought 
desirable, as he had already lost as much as he could well spare. The result of 
such a primary treatment was, that in half an hour the sufferer was able to 
swallow spoonfuls of lemonade. This drink, cold as it could be made, was 
continued during most of the night, serving by its refreshment to give much 
comfort, and by its refrigeration to abate the vascular excitement. About 
four o'clock in the morning the patient fell into a disturbed sleep, which 
continued until eight. At nine o'clock the tongue was examined by sep- 
arating the lips and looking at it through spaces which existed between the 
teeth ; the swelling and turgidity had very much diminished. The feet were 
again placed in hot water, and the blood held in the inferior parts until a sense 
of faintness was experienced. This gave increased relief. Immediate danger 
averted, attention was directed to the state of the external injuries and the 
line of passage of the ball. The wound at the external angle of the jaw was 
found to occupy quite a space in the parotid fossa, the ball having evidently 
been received as the general had turned his head to address some one behind 
him. The gap was stuffed with charpie, this being now a black and 
blood-infiltrated mass; it had evidently been thrust hard and solidly into the 
wound, and had swelled to double its former size, displacing the parts to a very 
marked extent. This plug being found firmly fixed, it was left to be removed 
or not, as circumstances should seem to direct, at a future time. The wound 
of exit was larger than might have been expected, spiculae of bone having 
considerably torn the parts; from it were removed several small splinters. 
A probe, passed into this opening, revealed the line of the wound running 
through the base of the tongue obliquely across the mouth. The treatment 
consisted in a free use of permanganate of potassium and water. The patient 
passed the day in a fair degree of comfort. Sudden secondary hem- 
orrhage being the next thing to fear, it was determined, on the third day, to 
remove the plug; this was accomplished only after a full hour of labor, the 
charpie having wedged itself into every imaginable space, the removal being 
effected by the very free use of milk-warm water and the most gentle traction 
with forceps and scalpel handle. The withdrawal was attended with consider- 
able pain, but without the loss of a single drop of blood. The relief afforded 
from the sense of pressure was so very great as to change the whole WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
705 
appearance of the injured man, he now breathing and taking his beef-essence 
with great freedom. The appearance of the wound was really very promising, 
attempts at granulation being quite evident, while nothing especially threaten- 
ing was to be observed. The day after this dressing, the patient, in opposition 
to advice or commands, insisted on being passed to his family in Washington. 
All the dangers of hemorrhage were exposed and explained to him, but he 
was possessed of a single idea,-getting home. At five o'clock in the afternoon, 
being continued in charge of a surgeon who had been sent with him from the 
field, he was driven to the steamer plying between Fortress Monroe and 
Baltimore. At midnight, while on the Chesapeake, profuse bleeding came 
on, which was controlled, as best it might be, by masses of ice held continu- 
ously to the wound. The patient died the next day at a hospital on the 
wharf in Baltimore, under what exact circumstances was not learned; most 
likely from exhaustion. 
Case IX.-J. B., middle-aged man, gash, from a blow, lacerating the 
cheek, opening the duct of Steno. 
Treatment.-With a heavy-eyed needle carried a loop from the bottom 
of the wound to the inside of the cheek: the silk, which was very loose, 
conducted the saliva into the mouth. Brought the external wound together 
by strips of resin plaster; no other treatment required, save an occasional 
dressing. In a week the loop had sloughed through into the mouth, pre- 
serving completely the track for the secretion, and the process of granulation 
had advanced almost to the stage of cure in the external wound. No after- 
trouble. 
Case X.-C. A., young gentleman, twenty years of age, deep punctured 
cut in the floor of the mouth just to left of middle line, made by the slipping 
of an elevator in the attempt to remove root of upper canine tooth. No 
hemorrhage, or immediate bad sign of any kind; patient very much fright- 
ened. Accident had occurred two days before first seeing the case; part very 
sore and tender ; inflammation limited. 
Treatment.-Directed arnica-water for relief of the soreness; nothing 
else indicated or required; the wound healed rapidly and kindly. 
Case XI.-Cut received by young lady, exposing and incising mylo-hyoid 
artery of left side in the groove; hemorrhage very great and persistent. 
Treatment.-Upright position; tinct. erigeron as directed; strong alum 
solution held to the part on tufts of cotton ; afterward thrown with the syringe ; 
ice to the part, etc. No result on the bleeding. The patient becoming affected 
from loss of blood, the wound was enlarged, the vessel picked out with the 
Liston forceps and tied. This, of course, controlled the hemorrhage. A 
comfortable recovery was made. 
Case XII.-Mr. C. Performed operation on the cheek for a peculiar 
erectile growth; cut well into the sub-tissue, making quite a deep wound, just 
as if the part had been scooped out. 
Treatment.-Cold-water dressing; waited on nature to fill up wound 706 
A SYSTEM OF ORAL SURGERY. 
with granulations; nothing else required, nothing done; the case progressed 
to a satisfactory cure, excepting that a raised scar remained. 
Case XIII.-Young man, shot through the cheek; the mouth being 
open, fortunately, at the time, the ball passed out, doing no further damage; 
no hemorrhage. 
Treatment.-Applied cloths wrung out in cold water, for the purpose 
of controlling vascular action; nothing else done; wound suppurated until 
the compressed and devitalized tissues were sloughed ; then kindly granulated, 
the patient being entirely well in a month. 
Case XIV.-Patient, young lady. In an attempt to extract the first 
molar tooth of right upper jaw a flap of gum had been torn, extending around 
the mouth to the left second bicuspis; this flap had been hanging loose some 
three hours before the patient presented herself. 
Treatment.-Cut the piece off, and depended on granulations from the 
wounded surface for the filling up; patient comfortable next day; entirely 
well in a week; no other treatment of any kind required. 
Case XV.-Boy, twelve years of age; playing with powder contained in 
a bottle it unfortunately exploded, throwing the glass and burning grains into 
his face. When first seen-, an hour after the accident, the patient was in the 
greatest distress; the eyes were completely closed, lashes entirely destroyed, 
hair singed, face raw and bleeding, pulse rapid, and very irritable. 
Treatment.-First, Seidlitz powder, with half-grain of opium; second, 
removal of such pieces of glass as could be readily picked away with the 
forceps; third, cold-water dressing. In an hour the patient was fairly com- 
fortable ; at the end of which time a second half-grain of opium was 
administered. 
Second day.-Face very sore, but no burning pain; picked away several 
small pieces of glass and a number of the powder-grains. Continued cold- 
water dressing. 
Third day.-Reactive inflammation evidently aborted; water dressings 
dispensed with ; used in place 
Olei lini, 
Aquae calcis, aa q. s. 
With this the surface was protected from the atmosphere until it cicatrized, 
-a period of two weeks. During the time of cure some little attention was 
given to the diet, the patient for the first day craving principally ice-cream, 
which answered very well, and served to allay a slight tendency to irritative 
fever which existed; the latter four days of the first week stimulating articles 
of food were interdicted; after this he ate what he liked. 
Case XVI.-Patient, young gentleman. Struck, while on a gunning 
excursion, by a buckshot, which passed through the lower lip, burying itself 
in the bone. Patient not seen until the next day; lip too much swollen to 
permit of examination. WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
707 
Treatment.-Cold-water dressing to the lip. Mag. sulph., §ss, internally. 
Third day.-No diminution in swelling ; slight erysipelatous blush ; brushed 
the parts with the following combination : 
g Tincturae ferri chloridi, j ; 
Quiniae sulphatis, gr. xxx; 
Tincturae cinchonae, Sij. M.s 
In one hour the blush had disappeared. 
Fourth day.-Inflammation, with the swelling, disappearing very rapidly. 
Sixth day.-Probed the wound; discovered the shot lying near the root 
of the first bicuspid tooth ; dissected away the gum from the inside, and with 
a very small curved gouge picked the lead away. 
Seventh day.-Inflammation back again, confined, however, rather to the 
inside of the mouth; reapplied the cold-water dressing, and directed a Seidlitz 
powder. 
Eighth day.-Better ; inflammation rapidly yielding ; a little pus escaping 
from the shot track in the bone. 
Tenth to thirteenth day.-Track of wound in the bone suppurating con- 
siderably ; tinct. iodine used. 
Fourteenth day.-Discharge diminishing ; iodine continued. 
Sixteenth day.-Discharge entirely ceased ; patient dismissed. 
Case XVII.-Patrick T., laborer. While engaged in blasting rocks the 
patient was struck with great force, just below the orbit, by a flying fragment, 
lacerating in a frightful manner the soft parts of the face, breaking and knock- 
ing into the naris the left nasal bone, and severely concussing the maxillary. 
No hemorrhage ; heavy shock. 
Treatment.-The patient being a strong, plethoric man, reaction was 
allowed to establish itself, which it did completely only after the lapse of sev- 
eral hours. Cold-water dressings were, however, at once applied to the parts, 
every deduction favoring the inference of severe inflammation. The accident 
occurred in the morning. At seven in the evening a pine stick, whittled, to 
make its introduction easy, was coated over the end by dipping it in melted 
wax, and with this, insinuated into the nostril, the depressed nasal bone was 
thrust out into place, position being maintained by a tuft of wax-coated cotton, 
having attached a string for its withdrawal. 
Examination of the injured face and maxillary bone revealed contusion and 
injury to such an extent as to make it evident that the process of cure must 
be that of exfoliation, sloughing, and repair by granulation; the only treat- 
ment was the expectant, and this was a simple water dressing. 
Second day.-Most decided reaction. Mag. sulph., §ss, administered in a 
glass of water ; water dressing, medicated with lead and laudanum ; the formula 
being as follows: 
* Ointment of the oxide of zinc may first be tried. 708 
A SYSTEM OF ORAL SURGERY. 
U Plumbi acetatis, 5'j > 
Tincturae opii, ^ij; 
Aquae, ^xxx. M. 
Cloths wet with this lotion kept constantly upon the cheek. 
Third day.-Inflammation abating, but patient complaining of feeling hot 
and generally miserable. Lemonade ordered as a febrifuge, to be made by 
expressing the juice of an ordinary lemon into a goblet, sweetening, and filling 
up the glass with ice broken into a coarse powder. To be allowed ad libitum. 
Fifth day.-Wound suppurating; fever all gone; dressing changed back 
to simple water; waxed cotton changed in nostril,-the replacement giving 
much pain. 
From fifth to tenth day.-Water dressing continued; portion of external 
plate of the bone apparently dying; periosteum evidently destroyed. 
Eleventh day.-Stimulation commenced; parts wet three or four times a 
day with the following : 
U Aluminis pulveris, 3'j J 
Tincturae capsici compositae, ^ss; 
Aquae, §xvj. M. 
Fifteenth day.-Granulations being thrown out from around the edges of 
the wound; parts brought as closely together as possible, and retained with 
adhesive strips; nasal fracture doing very well. 
Twenty-fifth day.-Wound of face entirely healed, with the exception of a 
small place in the centre, which, when examined with the probe, discovered 
a sinus leading to diseased bone. 
Thirty-fourth day.-Piece of bone presented at the sinus; enlarged the 
opening, and withdrew a sequestrum rather larger than an ordinary finger- 
nail. Examination with the probe, after the removal, gave the fleshy feel 
indicative of repair. Case dismissed on the thirty-sixth day. 
Case XVIII.-Young man, struck on the side of the face, in a street- 
brawl, with a slung-shot; face severely cut and contused; outer boundary of 
the antrum driven backward into the cavity; not fractured, apparently, but 
bent inward. 
Treatment.-Cold-water dressing,-no other application for the first 
three days. After this, the patient being compelled to go out to his work, 
adhesive strips were employed; repair progressed rapidly, without a single 
adverse manifestation. The depressed plate of the sinus gave no trouble, 
soon accommodating itself to its new position; all sense of soreness leaving 
it by the end of the second week. External wound cicatrized in twenty 
days. 
Case XIX.-A young man slipped while standing on a stall in a market- 
house ; falling forward and downward upon one of the hooks, the point entered 
his mouth, broke off three of his upper teeth, perforated his hard palate, and 
passed into the right nostril. WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
709 
Treatment.-Seen first one hour after the accident. Pain in the broken 
teeth unbearably severe. Examination discovered the engorged pulps entirely 
exposed and bulging from their cavities. A probe introduced through the 
wound in the palate passed readily into the nares, giving little or no pain. 
No fracture of the bone, save a few trifling spiculae about the circumference 
of the puncture. The roots of the broken teeth were at once extracted, and 
the case, for the time, left to nature. 
Second day.-No necessity for any interference; some soreness, but no 
actual pain. 
Third day.-Nothing required to be done. 
Fourth day.-Three trifling pieces of bone discharged into the mouth. 
Seventh day.-Wound granulating very satisfactorily. 
Fifteenth day.-Nature unable, evidently, to quite fill up the opening; 
assisted by scarifying the circumference of the wound and touching with 
tincture of iodine. 
Seventeenth, twentieth, and twenty-second days.-Scarified and touched 
with iodine. 
Twenty-fourth day.-Opening completely closed. Case dismissed. 
Case XX.-Gentleman. While striking the iron handle of a chisel in 
the act of opening a box, a small piece flew off from the hammer, burying 
itself in the malar process of superior maxillary bone. 
Treatment.-With probe, searched in the wound for the foreign body; 
found it in position as described, with very oblique track through soft parts. 
Introduced a sharp steel instrument, and, after some trouble, succeeded in 
working the piece loose ; could not, however, get hold of it with forceps 
without such manipulation as would evidently enough contuse the parts. 
Introduced a director down to the body, and cut to it; removing it in this 
way without effort. Closed wound with two delicate sutures, and applied 
cold-water dressing. In three or four days the parts were entirely well, not 
the slightest suppuration having occurred,-no noticeable scar. 
Case XXI.-A little boy, Harry H., while playing with a wooden paddle 
which had been made for use in rendering lard, slipped while having one end 
of it in the mouth, the weight of his body carrying the stick through the soft 
palate, making a complete separation between the veil and hard parts. This 
patient was first seen three days after the injury. No inflammation of con- 
sequence existed. 
Treatment.-Etherizing the child, the parts were stitched together by 
means of interrupted sutures of silver wire, the approximation being main- 
tained by perforated shots clamped over the threads. Only a very limited union 
was secured, the two most important stitches sloughing out. On the fourth 
day from the introduction of the first stitches, those which had been lost were 
replaced, which last, by the eighth day, also sloughed out, yielding no increase 
in extent of the union, but happily being associated with such extent of 
granular face to the wound that, when the veil was pressed upward, it met 710 
A SYSTEM OF ORAL SURGERY. 
the part from which it had been torn. An impression of the mouth was now 
taken with very soft wax. From this a model was secured, to which a silver 
plate was struck. This plate enveloped the back teeth of the upper jaw, but 
was cut to fit the palatal faces of the anterior. Impressions were next obtained 
of the inferior teeth, and caps made for the molars. Putting next plate and 
caps in place, they were related by means of wax, and the apparatus thus asso- 
ciated lifted carefully from the mouth, the piece being completed by soldering 
the parts together. Thus prepared, the apparatus was put in the mouth, 
and the two jaws held in relation by means of the author's strip bandage. 
In two weeks union was sufficiently firm to permit the removal of the splint. 
Case XXII.-Stout Irish lad, twelve years of age, shot in the face by a 
playmate. In this case the pistol was in the hands of a smaller boy, the 
muzzle being directed obliquely upward. The ball, which was a good-sized 
minie, struck the centre of the nose, and, as it passed upward on the line of 
its projection, was deflected at an angle of about eighty degrees by an in- 
fluence exerted by the nasal bones, against which it struck. This boy was 
first seen on the second day after the accident. No inflammation, no evidence 
of shock, indeed, no anything that would lead to the inference of an accident 
of gravity; even the wound of entrance was scabbed over, looking nothing 
different from an insignificant sore. 
Treatment.-Breaking away the scab, search was made for the course of 
the ball by means of the ordinary silver probe. As the instrument reached 
the nasal bones, the condition of deflection was recognized. Examining next 
the mouth of the patient, a solid projection was observed at the line of union 
of the palate plates of the maxillary and palate bones. Inferring this to be 
the missile, an incision was made through the soft parts; this exposed, how- 
ever, not the ball, but a fractured portion of bone. Removing this, the lead, 
much flattened, was found immediately above it, being wedged in the site from 
which it had forced the bone. The boy seemed to require no treatment, and 
therefore received none. In no way had he a bad symptom. 
Case XXIII.-Michael M., car-driver. Separation from its maxillary 
attachment of left nasal bone. Deformity very marked; the whole nose 
looking as if it had been thrust upon one side of the face. 
Treatment.-The parts being very much inflamed, application of the 
lotion of lead-water and laudanum was ordered, and continued until the con- 
dition was fully combated; two days being required to secure such desired 
result. Using now the handle of an ordinary scalpel, the displaced bone 
was lifted into position, and was retained by making a flattened roll of the 
common adhesive plaster,-the unspread side out; this, being dipped in olive- 
oil, was directed into place, and retained for a week by a ligature which kept 
it well in position by passing over each ear. At the end of this period the 
roll was withdrawn and the parts left to nature. A perfect cure resulted. 
Case XXIV.-From Langenbeck. Head of patient was caught between 
a locomotive and its tender. The eyelids were torn away from the orbit, and WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
711 
a deep wound ran down from the inner canthus to the upper lip. A probe 
could be passed into the antrum : not a trace of the eyeball could be found ; 
while in the orbit was a bluish-black pulsating mass. The nasal bones com- 
minuted. Patient conscious, but sleepy; pulse slow; violent pain on right 
side of head. A week afterward, as head symptoms disappeared and the 
extravasated blood had been somewhat absorbed, a closer scrutiny could be 
made. The eyeball was discovered to have escaped into the antrum from the 
orbit by a hole in the orbital margin of the upper jaw, big enough to admit 
the finger easily,-the axis of the eye standing vertical, the cornea down- 
ward. 
The fragments of bone were adjusted as well as possible, and the eyeball 
replaced in the orbit. It was uninjured, and vision was perfect. 
About ten weeks after, by two blepharoplastic operations, the eyelids were 
brought into tolerably good condition. They could be closed, and usually so 
remained, but could be opened enough to expose the cornea and permit sight. 
The globe was, however, perfectly immovable. About five months after the 
injury ulceration and suppuration of the cornea occurred, and the globe 
atrophied. 
Case XXV.-A painter, engaged at some work in the line of his trade, 
fell from the roof of a three-story house to the street, striking against the rail 
of a car-track, producing, besides other fractures, compound comminution of 
the inferior jaw. The writer first saw this man at the Pennsylvania Hospital, 
several months after the accident. Despite the judicious care he had received, 
full half the centre of the body of the bone had been lost, the angles being 
pulled together by action of the mylo-hyoid muscles, the fragments having 
united just above the hyoid bone. A more lamentable condition it would be 
hard to imagine. The tongue, of course, was permanently fallen back into 
the throat. The treatment of the case being kindly transferred to the clinic of 
Oral Surgery by the surgeons of the hospital, attempt to restore the articular 
relations of the portions of lower jaw remaining was commenced by separating 
the united angle, using for this purpose the cutting forceps. This accom- 
plished, reunion was prevented and a false joint secured through the inter- 
position of a tuft of sponge kept in place several weeks. The parts recovered 
to a healthy condition, a succeeding step pertained to the restoration of rela- 
tions. This was accomplished by means of metal plates made to fit accurately 
the lingual faces of that portion of the jaw remaining on either side. Passing 
across the floor of the mouth, acting upon the plate of either side, was a swivel 
screw. Elongation of this screw forced the parts into position. 
Articular relations restored, a succeeding step was the securing of a wax 
impression of the parts representing the hiatus, or lost segment, of the jaw. 
From this impression a model was made in plaster, from which in turn there 
was prepared a silver jaw, with teeth attached. This jaw, or segment, when 
slipped into place, restored and preserved the contour most satisfactorily. 
When last seen the patient looked not unlike people in general, and was using 712 
A SYSTEM OF ORAL SURGERY. 
his artificial jaw and teeth to the required end of enunciation and mastication. 
(See, for illustration, Fractures.} 
INJURIES OF THE SOFT PALATE. 
Injuries of the soft palate are to be treated from the stand-point of princi- 
ples rather than by special rule. If an artery be jetting, torsion rather than 
ligation will be the recourse, the latter being an operation very difficult, com- 
monly, of accomplishment. Tannic acid is a reliable local styptic in this 
direction, yet the use of it is to be avoided where possible because of require- 
ments in the way of healing. Where a patient is of an intelligent age, gar- 
gling with iced water is oftentimes found sufficient for the control of quite 
free hemorrhage. A serre-fine, having a string attached to avoid accident 
in the way of swallowing, may be found serviceable ; this only, however, where 
the throat is not irritable. The writer has used, in an emergency, a hemo- 
static forceps, keeping it in place a whole day. Stitching together 
breaks in the soft palate requires the use of curved needles, as pictured in 
the chapter on Palatine Defects, and the manner of using the needles is the 
same as there described. Tension is to be relieved alone by myotomy, but 
the necessity is unfortunate, as additional cuts tend to degenerate the parts. 
Cutting is to be avoided where possible. Movement is best antagonized by 
the wearing of a plate. Inflammation being always in these cases of 
aplastic meaning, rinses of diluted tinctura myrrhae et capsici are to be 
employed,-the medicament, an ounce, water, a pint. Erysipelas is to be 
treated with the mistura quiniae et cinchonas et ferri chloridi. (See Ery- 
sipelas Mixture.') It is necessary to deny a patient solid food in cases only 
where a plate is not worn. Degeneration of edges of a wound is com- 
mon. Touching with tincture of iodine is to be endorsed. Where a wound 
is of such character as to deny approximation of the edges, granular activity 
may be aroused and depended upon by use of this tincture; the plate as a 
support is, however, a necessity. The edges of a wound are kept raw by 
daily light touches of iodine used in the form of a saturated solution. 
Dangerous swelling of the uvula is to be treated by amputation of 
the tip of the organ, thus draining the cellular tissue of which it is so promi- 
nently composed. (See Uvula and its Diseases.) 
BURNS AND SCALDS. 
Burns and scalds imply injury done by heat. The former is a result of 
contact with hot solid bodies, whether through radiation, flame, or immediate 
touch. The latter results out of a relation with heated fluids; these being 
water, alcohol, ether, oil, or steam. 
Classification.-Burns and scalds classify themselves as simple and 
complicated, or according to extent of injury. 1. An impression made, either 
by dry or moist heat, including that of the sun, which has acted as an irritant WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
713 
to the surface of the skin. Result: simple erythema terminating speedily in 
delitescence. 2. Irritation resulting in inflammation. Result: vesication, the 
vesicles curing themselves by desiccation or suppuration. 3. Cauterization of 
tissues. Result: sloughing by dry eschar or demarcation. 
First Indication.-The first indication in burn or scald relates with 
shock; this, in proportion to the injury received, is commonly more severe 
than from other forms of casualties. It is a matter to be closely appreciated. 
(See Shock.} 
First Application.-As immediate application in burn, the one com- 
monly most conveniently at hand is cold water. In ordinary cases no means 
insures so great an amount of comfort as fine handkerchiefs spread over the 
face and kept continuously wet. Such an application continued from one to 
two hours, or until it ceases to be comfortable, will almost surely relieve a 
patient of the agony attending on a burn. Where sanguineous reaction 
threaten, acetate of lead may be added to the water. 
Prognosis.-Vascular disturbance aborted or modified, a second step in 
treatment refers to prognosis. A burn or scald, superficial in its nature, may 
reasonably be expected to resolve itself without greater loss than the epiderm, 
and without scar. Where a burn has involved the skin proper, tardiness of 
cure and resulting deformity will be in proportion to the injury received. 
Lost skin is replaced by scar-tissue. In scar-tissue is deformity. Depth of 
destruction implies extent of eschar. 
Superficial Burns.-Where a burn is superficial, aim lies in the direc- 
tion of immediate resolution of the induced vascular perversion. The treat- 
ment is: first, cold water; second, soothing unguents. The epiderm is not 
to be removed in surface burns. Where effusion occurs the vesicles are to be 
drained by pricks with a needle; otherwise blebs and serum may be left to 
take care of themselves. 
To protect a Burned Part from the Air.-To protect burnt skin 
against the irritating effects of the air, it is highly recommended by some to 
paint the part heavily with gum-water and to form a coating by dusting into 
this subnitrate of bismuth. Common white paint is also highly com- 
mended. A varnish, lasting the necessary length of time, is prepared by 
mixing into tinctures of iron and cinchona a sufficient quantity of sulphate 
of quinia to thicken the fluid. Carron oil, a remedy much used in Scot- 
land, consists of lime-water and linseed oil in equal parts. Carded cotton 
is a common and valued domestic remedy. The new preparations of petro- 
leum, vaseline and cosmoline, are coming into much favor for use in 
superficial scalds or burns. A soothing application is found in a starch 
poultice. Scrapings of potato, apples, and carrot are good reme- 
dies. Fresh-gathered plantain leaves furnish a very satisfactory dressing. 
Earth, in the form of dry powder, dusted over the part, is highly com- 
mended by Dr. Addinell Hewson. Cod-liver oil is a good although an 
offensive means. As an immediate application to relieve pain much com- 714 
A SYSTEM OF ORAL SURGERY. 
mendation has been given from various sources to an admixture with water 
of the bicarbonate of sodium. In the experience of the writer no applications 
surpass the hamamelis or the benzoated oxide of zinc ointments. 
Deep Burns.-Deep burns, implying eschar, or slough, are treated pri- 
marily as the previous class. Inflammatory disturbance being modified, sec- 
Fig. 604. 
Burn of neck; showing contraction; remedy lying alone in operation 
ondary indications refer to anticipated loss of tissue. Parts entirely dead are 
wisely cut away; partly dead, being injured beyond possibility of restoration, 
poultices hasten a line of demarcation. 
Poultices.-A good and comforting poultice is made of bread and milk 
or of ground flaxseed and water: whether to be applied cold or warm is best 
determined by the feelings of a patient. If vascular disturbance be present 
to an undesirable extent, great good is derived by admixture with the mass of 
lead-water and laudanum. 
Plumbi acetatis, 5j ; 
Tincturse opii, ; 
Aquae, Oi. M. 
Sig.-The poultice to be thinned with this fluid. 
Stimulating Unguent.-Where passivity or tardiness of condition in- 
tervene, the poultice is wisely replaced with a stimulating unguent. In this 
direction Kentish's salve, mixed in equal parts with oxide of zinc ointment, 
highly recommends itself. In the way of fluid applications tincture of mari- 
gold is found serviceable; also almond or olive oil in which has been infused WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 
715 
the fruit Momordica balsamina (balsam apple), also glycerin to which has 
been added a fourth part of red ointment. 
Tinctura Capsici et Myrrhae.-Where passivity approaches dead- 
ness, the compound tincture of capsicum, used pure or dilute, is indicated. 
Water is employed for dilution. 
Bismuth and Iodoform.-An admirable and most satisfactory means 
of dressing a reasonably indolent ulcer resulting from burn consists of the 
free and continuous use of subnitrate of bismuth and iodoform combined in 
equal parts. The powder is dusted over the parts, a dredging-box being used. 
lodoform-Poisoning.-It is necessary to guard against iodoform- 
poisoning. A patient so affected turns a dark yellow. 
Erysipelas Threatening.-Where erysipelas threatens, absolute re- 
liance is to be placed on the following combination, the application to be 
renewed each one or two hours, or oftener if found necessary; it cannot be 
repeated too frequently so long as the shiny blush and tension persist. (See 
Erysipelas.} 
Tincturae ferri chloridi, ; 
Tincturae cinchonae, 3 ij > 
Quiniae sulphatis, £j. 
Sloughing.-A sloughing part is to be kept both stimulated and disin- 
fected. To this end carbolized fluids may be used ; or, if the part be irritable, 
phenol-sodique answers a better purpose. Tar-water, to which has been added 
required proportions of the aqua chlorinata and tincture of capsicum, is found 
serviceable.* Still another application is the permanganate of potassium; a 
solution being made of five grains to the ounce of water. 
Loss from Eschar.-Where an eschar is large, a succeeding indication 
refers to the prevention of scar. Two means here apply: mechanical fixation 
and skin-grafting. From the first little good is to be expected. The second 
is seldom wisely omitted. 
Skin-Grafts and Epiderm.-Skin-grafting includes planting the sur- 
face of a wound with points of skin removed from well parts, or from the 
bodies of other people, and the transference of flaps, having temporary rela- 
tion by pedicle to neighboring parts, into seats made vacant by falling sloughs. 
The latter means promises greatest benefit. Scrapings of epiderm ap- 
plied as a dressing to a non-healing ulcer affords, at times, a most satisfactory 
result. (See Plastic Operations.} 
Operation for Removal of Scar-Tissue.-In operating for the 
relief of deformity from scar-tissue regard is to be had to the time interven- 
ing between date of proposed operation and that of reception of the injury. 
It is well to let months, if not years, elapse, except indeed the performance be 
* Tar-water, one pint; 
Chlorine-water, one ounce; 
Tincture of capsicum, one ounce. 716 
A SYSTEM OF ORAL SUROERY. 
attempted at the time of accident; a matter the consideration of which 
should imply the possession of a wide experience. No objection holds, how- 
ever, to the immediate use of skin-grafts. To receive such grafts the ulcer 
is to be in a condition developing healthy granulations. 
Removal of Scars.-As a medicinal means acting on scar-tissue the 
following combination will be found of some use. The application is by 
means of lint soaked in the solution. Kneading the part is of service while 
using it. 
|{ Soda? boratis, ^iss; 
Acidi salicylici, gr. xij ; 
Glycerini, 3iij; 
Aquae rosae, ^vi. M. 
Pathology of Severe Burns.-Dr. Oscar Silbermann, of Breslau, 
studying the clinical and pathological signs of the destruction of numerous 
red blood-corpuscles, found by his experiments, according to the Lancet, here 
quoted : 1. That after extensive burns of the skin the red blood-corpuscles 
alter their form and lose their power of resistance to heat, drying, compression, 
and staining. 2. In consequence of these alterations numerous thromboses 
in the arterioles and capillaries, especially in the finer branches of the pulmonary 
artery, occur, leading to stasis in different organs,-e.g., lungs, kidneys, stom- 
ach, bowels, liver, spleen, skin, and brain. 3. The large deviation of the pul- 
monary capillary circulation produces a considerable impediment to the empty- 
ing of the right heart and serious venous congestion, as well as dangerous 
arterial anaemia. 4. This state, coupled with the above-mentioned symptoms, 
leads to bleeding and parenchymatous alterations in the affected organs. 5. 
The interference with the circulation also produces dyspnoea, a small pulse, 
angina, eclampsia, and anuria, as well as a remarkably low temperature. CHAPTER XLII. 
THE TONSIL GLANDS. 
The tonsil glands, situated on either side of the oro-pharyngeal space, be- 
tween the half arches, are readily exposed by depressing the tongue through 
the medium of any convenient means. An instrument made especially for 
the purpose, called a " depressor," is found well adapted to the purpose.* 
Character of Tonsil Glands.-The tonsils, glandular organs, de- 
scribed by Virchow as analogue of the lymphatic glands, are made up of 
many lobules, congeries of mucous follicles, with intervening sulci lined by 
involutions of the common mucous membrane. Inflammation, simple or acute, 
and chronic or morbid, is the disease of these bodies. With the first are 
associated the various features of vascular perversion, passing from the most 
transient of congestions to the most threatening of swellings. 
Simple Tonsillitis.-Simple tonsillitis-angina tonsillaris-amygdalitis 
-is an inflammation of the substance of the gland. Looking into the mouth, 
the bodies, one or both, are seen unduly colored and swollen. If the inflam- 
mation be of any severity as to grade, the patient experiences pain and diffi- 
culty in swallowing, together with a sense of dryness, heat, and fever in the 
mouth and pharynx; and these discomforts, influenced by the character of 
the attack, may progress until it become impossible to swallow, and in many 
cases exceedingly difficult to breathe. 
Treatment.-The discomfort, and possible danger, render effective treat- 
ment a matter of consequence. First, and most important, dry cups are 
to be applied to the sides of the neck below the mastoid process. Second, 
recourse is had to the use of gargles. Third, a solution of cocaine, four 
grains to the ounce of water, is to be brushed over the part three or four times 
daily, or as often as the pain returns. As a gargle, found useful in such cases, 
-or rather as an application to hold in contact with the parts, for the act of 
gargling may be impossible,-the following will be employed with satisfaction : 
Ji Sodse biboratis, 3i'j > 
Potassii chloratis, 3j > 
Tincturae capsici, 3j; 
Tincturae myrrhae, 
Aquae, viij. M. 
* It is a singular fact that depression of the tongue is commonly most easily secured by 
simply laying the depressor upon it. When force is employed, the organ, in many cases, 
resists, spasmodically crowding against the roof of the mouth. Directing a patient to in- 
spire commonly exposes the tonsils. 
717 718 
A SYSTEM OF ORAL SURGERY. 
Another is as follows; care to be taken not to swallow any of it: 
R Plumbi acetatis, 5j ; 
Tincturae opii, ; 
Aquae, Ojss. M. 
A third medicament, highly esteemed by many, consists in a combina- 
tion of tannin and glycerin, the application being made to the parts with a 
brush. 
Sulphate of Copper.-Another practice, which the author has found 
happily applicable, consists in first brushing the parts with a solution of sul- 
phate of copper, ten grains to the ounce of water, and afterward using a com- 
pound iodine and carbolic acid gargle. 
U Tincturae iodinii composite, gtt. Ixxx; 
Acidi carbolici fluidi, gtt. xij ; 
Glycerini, ^ij; 
Aquae, ^xiv. M. 
Cocaine Hydrochlorate.-There are few more comforting or alterative 
applications than cocaine brushed over the parts. The strength is to be six 
grains to the ounce of water. Repeat every four hours. Cocaine shows 
itself not less a resolver of inflammation than an obtundent of pain. 
Turpentine and Chlorate of Potassium as a Specific.-An 
application for the treatment of acute tonsillitis, recommended by I. H. Pea- 
body, M.D., as a specific, is as follows: Take of oil of turpentine 5ij, of pul- 
verized chlorate of potassium a like quantity, of white sugar and gum-arabic gss 
each, of water §v. These are to be mixed, and being well shaken and united, 
the patient is to slowly swallow a teaspoonful each hour or two until relieved. 
The writer's experience has not been satisfactory with it. 
Phenol-Sodique.-Phenol-sodique diluted with water, in proportion of 
a tablespoonful of the former to a gobletful of the latter, affords a grateful 
gargle in acute tonsillitis. In very many cases the use of this combination is 
all-sufficient to a cure. In ulcerative conditions its employment is to be 
advised. 
Tincture of Belladonna.-Tincture of belladonna has lately received 
much commendation as a remedy in acute tonsillitis, being administered in 
from two- to fifteen-drop doses, repeated every two hours until the patient is 
relieved, or until contraindicated, either as dryness in the throat is induced, or 
as the pupils exhibit enlargement. Local applications are also highly endorsed, 
the medicine, it being affirmed, having the same action whether applied 
directly or given internally,-that is, diminishing the calibre of capil- 
laries by its action on the vaso-motor system of nerves. Still another means, 
one described as specific, consists in the use of aconite tincture; five drops THE TONSIL GLANDS. 
719 
first to be administered, to adult, to be succeeded by two drops each two or 
three hours, if found necessary.* 
Gargarysma Guaiaci Composita.-A mixture prescribed as a stand- 
ard remedy at the Philadelphia Polyclinic, known in the House Pharmacopoeia 
as the gargarysma guaiaci composita, and which is highly recommended by Dr. 
Cohen, is made by mixing two fluidrachms each of the ammoniated tincture of 
guaiac and compound tincture of cinchona with six fluidrachms of clarified 
honey ; all are shaken together until the sides of the containing vessel are well 
greased. A solution consisting of eighty grains of chlorate of potassium in suffi- 
cient water to make four ounces is then gradually 
added, the shaking being continued. Without care 
the resin will be precipitated (a matter to be remedied 
by first dissolving it in alcohol). This mixture is used 
freely as a gargle at intervals of from half an hour to 
three hours. No harm will result from swallowing 
a portion. 
Sympathetic Inflammations. - Sympa- 
thetic inflammation of the tonsil glands is not in- 
frequent. Among the most common of such rela- 
tions, and where a treatment must of necessity 
consider the influencing lesion, are croup, scarlet 
fever, measles, diphtheria, typhoid fever, and syphilis. 
Glancing at the diagram, Fig. 605, which exhibits the glands in a state of 
partial engorgement, it is plainly seen that the isthmus, the oro-pharyngeal 
space, would be closed in proportion to enlargement; hence difficulty experi- 
enced in deglutition and respiration. Tonsillitis ends either in resolution or 
suppuration. 
Incipient Condition.-When the inflammation is met with in its in- 
cipiency, attempts are at once made to resolve it by use of antiphlogistic reme- 
dies. Free scarification of the glands is occasionally resorted to with 
satisfactory result. Dry cups to the neck, as recommended, are invaluable; 
used in time these will abort almost every attack.f Leeches applied ex- 
ternally between the angle of the jaw and the sterno-cleido-mastoid muscle, 
-to be used only, however, with the vigorous and plethoric,-and blisters, 
Fig. 605.-The Tonsil 
Glands. 
* Caution.-The tincture of the leaves is one-half the strength of the tincture of the root; 
the medicine is to be used with caution.-See Dispensatory. 
f Dry cupping is conveniently done by using a small wineglass; applying this by means 
of a lighted wisp of paper, which paper has been touched to alcohol. The wisp lying in 
the bottom of the glass is fired by a match, and while blazing the rim of the vessel is 
quickly put to the skin. Suction cups are more conveniently used by the inexperienced; 
these are worked either by a piston or by a rubber ball attached to the glass. The artificial 
leech is another convenient means. Wet cupping implies the use of a scarificator after 
blood has been drawn to the surface by means of the dry cup and the reapplication of the 
dry cup after the skin has been cut. The illustrations explain themselves. Fig. 606, rubber- 
ball cup; Fig. 607, air-pump cup; Fig. 608, scarificator; and Fig. 609, artificial leech. 720 
A SYSTEM OF ORAL SURGERY. 
directed to the nape of the neck, will be found of the greatest service. Hot 
foot-baths, continued until the veins of the legs are engorged, or until dia- 
phoresis results, or the patient grows faint, constitute a satisfactory and reli- 
able means of relief. If the inflammation have advanced to a point where 
the system at large sympathizes, as exhibited by the presence of fever, hope 
is still to be entertained of recovery by resolution. In these cases it is found 
Fig 609. 
Fig. 607. 
Fig. 606. 
Fig. 608. 
Cupping-glass, with 
elastic ball. 
Cupping-glass, with 
stop-cock and air- 
pump. 
Scarificator. 
Kolbe's artifi- 
cial leech. 
good practice to place the patient.over a basin of steaming water, and with 
the form enveloped up to the very mouth in blankets, secure diaphoresis by a 
plentiful exhibition of the spiritus Mindereri,-a tablespoonful every ten 
minutes, for the adult, until free perspiration is produced. This performance, 
if the patient be robust, may be succeeded by a saline cathartic. As a local 
treatment, much satisfaction is to be derived from lemonade, made by crush- 
ing ice in a towel or napkin; the small particles thus acidulated are to be 
taken little by little into the mouth, and allowed gradually to dissolve. 
Another application is found in a gargle of flaxseed tea, in which chlorate of 
potassium has been dissolved. Tartar emetic, or the tincture of veratrum 
viride, administered internally, is of much use in controlling the circulation. 
A most useful and reliable combination, where vascular disturbance runs high 
and the system is irritable, is as follows : 
R Liquoris potassii citratis, ^iij ; 
Spiritus aetheris nitrosi, ^ss; 
Tincturae veratri viridis, gtt. xxv; 
Antimonii et potassii tartratis, gr. ss. M. 
Sig.-From 5j to ^ss, according to age and requirements; in water. THE TONSIL GLANDS. 
721 
Swelling of Uvula.-In most cases of tonsillitis where inflammation 
is excessive, the uvula is found participating; swelling of this body occur- 
ring, through serous effusions, not infrequently to such extent as to threaten 
suffocation, the bulbous tip of the organ dropping into the chink of the 
glottis. In these cases it may be proper first to try an application of the 
tincture of iodine ; but should this fail,-which, in the experience of 
the author, will most likely be found the case,-immediate resort is to 
be had, through use of curved scissors, to section of the mucous sac 
holding the effusion; such a cut will cause the swelling to disappear quickly 
through drainage. Circumstances sometimes arise where an opening into the 
larynx or the trachea affords the only chance to a patient for his life. (See 
Uvula and its Diseases^) 
Suppuration.-Where, in defiance of all treatment, a tonsillitis, what- 
ever its significance, determines toward suppuration, and difficulty of breath- 
ing exists, the best thing to do is to hasten the process as rapidly as possible, 
providing always that the attendant swelling be not too formidably extensive. 
The latter condition existing, nothing better is to be done than make incisions. 
Where the "swelling is not extensive or threatening, a gargle of flaxseed tea 
will be found soothing to the parts and encouraging to the formation of pus, 
and may be used with all freedom. 
Formation of Pus.-Where pus has formed in a gland, it is a proper 
practice to void it with the knife as soon as recognized. This is to be done 
with most safety by using an ordinary tenotome. 
Caution as to Loss of Blood.-In inflammation of the tonsil glands 
occurring in the weak and depressed, the abstraction of blood is seldom, if 
ever, advisable; too much care cannot be exercised in this direction. 
Constitutional Expressions.-Acute tonsillitis is accompanied by 
increase of temperature, the change being not infrequently as much as six 
degrees Fahrenheit. The tongue is coated, the bowels constipated, occasion- 
ally there is delirium, often much wandering of thought, the urine is dimin- 
ished in quantity and is of increased specific gravity, the chlorides are 
deficient. One- to two-grain doses of antipyrin repeated every three to four 
hours apply. Sweet spirits of nitre is found reliable. Tincture of digitalis 
in ten-drop doses for the adult decreases the heart's action through effect on 
the inhibitory nerve of that organ. Where a patient is of full habit advan- 
tage is found in tablespoonful doses of spirit of Mindererus repeated until 
profound diaphoresis results. 
Possible Conditions.-In a true appreciation of inflammatory disturb- 
ance of the region studied, it requires not to be overlooked that the arches 
themselves-namely, the palato-glossal and palato-pharyngeal folds-may be 
the seats of lesion; swellings occasionally occurring as the result of sub- 
mucous effusion to an extent that throws these parts as an envelope over the 
gland. Remembrance not being borne of this fact, much confusion would 
exist when such condition is met with. Diagnosis is secured, first, by recog- 722 
A SYSTEM OF ORAL SURGERY. 
nition of the smooth mucous face of the swelling; second, through means of 
a probe exposing the line of separation between the folds. 
Inflammation of Infra-tonsillar Glands.-Another expression 
relates to inflammation associated with a number of glandular bodies situated 
between the tonsils and base of the tongue,-infra-tonsillar glands, as it has 
been proposed to call them. While not very subject to perversion, the writer 
has yet met with them in an inflamed state where great discomfort was pro- 
duced in deglutition. Treatment is the same as for common tonsillitis. 
Herpes as a Lesion.-An infrequent disease of the tonsil, yet not suf- 
ficiently uncommon to deny it mention, is known as herpes. This is a vesic- 
ular affection very familiar to the dermatologist, as it shows itself upon the 
skin surface of the body. Herpes makes its appearance in the form of little 
vesicles studding the surface of the gland, the body being of a scarlet-red 
color, and swelled to an extent that throws it well out into the oro-pharyngeal 
space. Maceration of the epithelium quickly converts the vesicles into open 
abrasions, which, in turn, cover themselves with an exudate that gives to them 
the expression of aphthae. Characteristic symptoms are burning 
sensations in the throat, combined with sharp pain darting toward the ear. 
Care is to be taken that the condition considered be not confused with diph- 
theria. The treatment of herpes relates with the use of gentle laxa- 
tives, together with the employment of gargles, as directed in follicular 
pharyngitis. If febrile expression be marked, strong lemonade is found of 
service. Where the regions of the spinal column, the breast, and the abdo- 
men are found with elevated temperature, the parts are to be laved with 
alcohol until cool. No specific treatment is demanded. 
Hypertrophy.-Hypertrophy, or chronic enlargement, of the tonsils is 
a condition most common to scrofulous children, and pertains, consequently, to 
early life, being, indeed, rare after puberty and perhaps never seen in old age: 
of the multitude of patients operated upon for the relief of this affection, few 
have been over thirteen years of age. The enlarged or hypertrophied tonsil 
differs very much in consistence and character in different cases, being 
in one patient indurated and smooth, in another spongy and lobulated. In 
color equal variety is presented, varying in appearance 
from the scarlet of an arterial injection to the dull 
blue of a passive venous stagnation. One of the in- 
conveniences associated with enlarged tonsils is the 
effort required in respiration, particularly during sleep. 
Another is interference with hearing, pressure 
upon the Eustachian tube frequently occluding that 
passage, particularly when the patient takes cold. 
Speech is interfered with: to sing softly and finely 
with the tonsils enlarged is impossible. Tonsillar hypertrophy being a sys- 
temic expression rather than a strictly local disease, very little true benefit 
Fig. 610.-Hypertro 
phied Tonsil. THE TONSIL GLANDS. 
723 
has been derived from the employment of the great variety of direct remedies 
which from time to time are recommended. A patient so afflicted is to be 
treated from the constitutional stand-point; and to this end noth- 
ing is found more conducive to good than cold salt-water bathing; indeed, as 
a rule, more attention will be found required in the direction of diet, clothing, 
exercise, and general mode of life than to the administration of medicine. 
Where, however, medication seems demanded, it is to be directed to the cor- 
rection of any observable constitutional defect or irregularity. Iodine and its 
preparations are not always, by any means, indicated; and not infrequently 
their exhibition, by a further debasement of the vital powers, does more harm 
than good. It does not seem possible to lay down rules that shall apply to 
the constitutional treatment of such cases, except so far as to suggest atten- 
tion to all the functions, and to the general tonic medication mostly, if not 
always, demanded. 
Remedies used in Treatment.-Among remedies professed to be 
possessed of specific signification, used for enlarged tonsils, sulphate of 
potassium holds the most prominent posi- 
tion. This preparation, given in doses of 
from five to fifteen grains, continued for a 
month or six weeks, will, without doubt, in 
some cases, cause the hypertrophy to disap- 
pear. It is usual to combine with it rhubarb 
and some of the aromatics, sufficient to in- 
sure laxity of the bowels. 
Diatheses as influencing Treat- 
ment.-Where enlargement of the tonsils 
associates with the rheumatic or gouty dia- 
thesis, colchicum is to be prescribed: to be 
taken internally, and applied externally as 
an alterative in combination with the lini- 
mentum saponis. The use of colchicum in 
such direction was originally introduced into English practice by a Mr. Harvey, 
he being led to his conclusions by observing the relationship of the contents 
of the tonsillar follicles with the concretions found in the joints of the rheu- 
matic and gouty.* 
Acetate of Zinc as a Systemic Remedy.-Another remedy, having 
the commendation which associates with frequent successful response, and par- 
ticularly applicable where the condition is coincident with scarlatina, 
is found in the acetate of zinc: it is prescribed from 9j to 5j in from gvj to 
Fig. 611. - Hypertrophied 
Tonsil laid open. 
* Foul Breath.-Foul breath, so frequently associated with the soft variety of tonsillar 
hypertrophy, arises from degeneration of the sebaceous secretion retained within the crypts, 
and from inspissated mucus that covers the glands. The phenate of soda, chlorine-water, 
or a solution of the permanganate of potassium, either of these being combined with diluted 
tincture of capsicum, will be found satisfactory for the purpose of temporary relief. 724 
A SYSTEM OF ORAL SURGERY. 
gviij of water and glycerin, given in tablespoonful doses every four hours, 
or in the acute, severe cases oftener. It is well to retain it for a moment in 
contact with the tonsils before swallowing. 
Local Treatment.-The local treatment of hypertrophied tonsil glands 
resolves itself into the threefold direction of the use of alteratives, destruction 
by cauterization, and amputation. Of the first of these means the iodide of 
zinc holds, perhaps, the most prominent position. It is used in solution of 
from ten to thirty grains, being applied with a brush two or three times in 
the twenty-four hours; or, as the treatment advances, it may be applied pure, 
-that is, as it deliquesces when exposed to the atmosphere. Pressure by 
the finger, frequently repeated, punctures with the point of a bistoury, 
gargles of capsicum,-means of such character may be tried, as judgment 
shall make preference for one or the other. It is to be regretted, however, 
that the promise by such mode of treatment is not the most satisfactory; and 
it is always to be borne in mind that if such agents are found to do good even 
by controlling the enlargement, it may be prudent to rest satisfied, as advancing 
age will generally be found to afford correction of the trouble. 
Use of London Paste.-A second mode of treatment-that by cau- 
terant destruction-may be said to have been made familiar by A. Rup- 
paner, M.D., of New York. A practice introduced by that gentleman, and 
whose successes have been verified in a large number of cases by the author in 
his own experience, consists in the use of the London paste recommended by 
Dr. Morell Mackenzie. The following are the directions given for the prepa- 
ration and use of this paste: A quantity of equal parts of finely-pulver- 
ized and well-mixed caustic soda and unslacked lime is kept on 
hand. When an application is to be made to the tonsils, a little of the powder 
is put into a small porcelain cup; a few drops of absolute alcohol, which is 
kept near at hand, are added; the two are carefully mixed with a glass rod, 
when the paste is ready for use. Care must, however, be taken that it be of 
the proper consistency. If too thin, it is apt to find its way to parts which 
ought not to be touched; if too thick or lumpy, the paste will not readily 
stick, and little pieces might be swallowed. 
To Apply the Paste.-To apply the paste, the patient is to be placed 
in the position for laryngoscopy. The tongue is then to be depressed with 
the spatula, and the paste applied to the enlarged surface for two or three 
seconds. The action of the escharotic upon the tonsil is rapid. The mucous 
membrane almost instantly assumes a deep flesh color, and presently a dark, 
blackish spot is seen streaked with blood. The following day the tonsil is 
covered with a whitish-yellow eschar. The inconsiderable amount of suffering 
produced by this cauterant is noticeable. Children pay scarcely any attention 
to the pain, or make light of it. At the longest, the discomfort lasts only 
two or three minutes. Subsequent applications are accompanied with less, if 
any, inconvenience. A cocaine application may precede the cauterant 
if it seem desirable. THE TONSIL GLANDS. 
725 
Time Required.-The operation is repeated every six days. The num- 
ber of touchings required will depend on the nature of the ease. Our author 
reports one hundred and twenty-three treated in this manner: the minimum 
number of applications of the paste, in any instance, was six ; the maxi- 
mum, fourteen. The good results obtained from the use of this paste are 
not exaggerated by Dr. Ruppaner. Still, the experience of the author 
makes him unwilling to agree that such mode of cure is to dispense 
entirely with the use of the knife. Over-commendation, however, cannot 
be given the process: it is above praise. It will disappoint nobody who 
properly practises the manipulation. In place of the glass rod the writer 
employs the cup of an ordinary director. The practitioner, experienced 
or inexperienced in the use of the knife, may put full confidence in London 
paste. 
Digression.-It is not out of place, perhaps, to refer to the possibilities 
of this London paste. Applied to a seed wart, the body drops away almost 
instantly. It is so little provocative of vascular response that the writer has 
made frequent use of it in the treatment of endometritic vegetations, using it 
freely over the whole inner face of the womb. Sloughs of the uterine os are 
quickly and safely made with it. In the treatment of chancres, familiarity 
with its virtues will quickly accord it the first place.* 
Rumbold's Treatment by Injection.-Dr. Rumbold, of St. Louis, 
Missouri (Medical Archives), claims to have treated successfully a number of 
cases of enlarged tonsils by means of hypodermic injections, using an iodine 
combination (R-lodinii, gr. ij ; potassii iodidi, Qij ; aquae, §j). A slight 
inflammation-one, however, which soon subsides-is reported as following 
the injection. From twelve to seventeen applications-ordinarily two a week 
-were found sufficient to reduce the gland to its normal condition. An 
advantage claimed for this mode of treatment is that it saves the substance 
and function of the gland. 
Amputation of Gland.-Amputation of an enlarged tonsil is to be 
effected either with a bistoury or the tonsillotome, the latter instrument being 
that which most recommends itself. Figs. 612 and 613 exhibit forms of such 
instrument. The principle of a tonsillotome is that of the guillotine. Of 
these instruments there are a variety, a single mode of operation being com- 
mon, however, to all of them. The construction embraces, first, a fenestra, 
to encircle the gland; second, a slide-pin, to catch and hold the organ; and, 
third, a triangular blade, for the excision. Of these instruments, some cut 
by having the knife drawn backward ; this is the manner of that known as the 
Fahnestock blade. Others, as the Physick, have the motion forward. 
An improvement lately made on the Physick instrument, by Mr. Kolbe, 
* In a conversation held by the author with Dr. Morell Mackenzie, he learned with sur- 
prise of the substitution by that gentleman of the galvano-cauterant for the London paste. 
In his own experience preference remains with the latter. 726 
A SYSTEM OF ORAL SURGERY. 
consists in an addition of automatic fingers and ringed lever-handles. To use 
this instrument it is only necessary to carry the fenestra over the gland, when, 
by the simple closure of the handles, the fingers grasp and pull the gland 
under the blade, which, in a synchronous movement, cuts it off. Another 
Fig. 612.-Physick's Tonsillotome 
Fig. 613.-Kolbe's Tonsillotome 
valuable instrument in this direction is known as the Billings tonsillotome. 
Mr. Kolbe gives this device preference over his own, pronouncing it indis- 
putably the very best of the class. 
To Apply a Tonsillotome.-To apply the tonsillotome to the gland 
of the right side, the surgeon finds his greatest convenience in leaning over 
the thrown-back head of the patient. In using it for the left side, there is 
no better manner than to rest in front of the patient upon the right knee, 
thus placing the fenestra with facility, and, if the Kolbe instrument be used, 
holding it, while the handles are manipulated by an assistant. In using any 
of the slide-pin instruments, both pin and blade are best worked by the 
assistant, the surgeon both fixing and retaining the fenestra exactly where it 
is desired that the section shall be made. 
Use of a Volsella.-In using the ordinary tonsillotome, occasion is 
not infrequently found for the employment of means which shall allow of the 
gland being enveloped by the fenestra. When such difficulty is met, it com- THE TONSIL GLANDS. 
727 
plicates the operation to some extent, yet is easily overcome through the use 
of a volsella, the gland by this means being caught and dragged within the 
ring. Where hemorrhage is anticipated, a tonsillotome is well replaced by an 
ecraseur; better still by the London paste. 
Use of Bistoury.-The use of the bistoury as a means for amputation 
of a tonsil gland is only to be endorsed when in most experienced and skilful 
hands; results of the gravest nature might very readily arise through some 
unexpected and unanticipated movement on the part of a patient,-risk 
entirely avoided in the use of the other instrument. 
Operating on Young Children.-In operations on young children 
with the tonsillotome, it is found best to employ ether, restlessness interfering 
with the proper introduction of the instrument. After the excision of one 
tonsil the child is to have its head immediately thrown forward, that the blood 
may not pass into the throat. As soon as hemorrhage has stopped, the anaes- 
thetic is to be readministered, and the section repeated upon the opposite 
side. 
Questions as to Double Operation.-Questions, however, will arise 
as to the advisability of the double operation at the same sitting,-questions 
of shock, of hemorrhage, of inflammatory sequelae, of idiosyncrasy. The 
experience of the author favors decidedly two operations, the first to 
be in every respect recovered from before the second is attempted,-not, how- 
ever, that it is meant to imply that such care and caution are always necessary, 
or that indeed the single operation is his own constant practice ; it is suggested 
as that attended with least risk. 
Means in Anticipation of Inflammation.-Many surgeons, im- 
mediately after this operation, and in many instances before it, administer, in 
anticipation of inflammatory trouble, a full dose of sulphate of magnesia. 
It is also thought well by many to protect the incised parts against the irri- 
tating influence of atmospheric changes by a confinement of several days in 
an even temperature. It may be accepted, however, that if the weather be 
moderately mild, it will be found sufficient to keep the parts lubricated by a 
coating of gum acacia, or of marsh-mallow confection, secured by 
simply holding the agent in the mouth until it dissolve. 
Hemorrhage not Common.-Hemorrhage of marked character, after 
the operation, is not common; instances occur, however, where the tonsillar 
artery has to be compressed, twisted, tied, or grasped by a hemostatic forceps; 
but, as a rule, there is no trouble from this source which a simple gargle of 
alum-water is not quite sufficient to overcome. 
Ulceration as an Associate Condition.-Of other surgical condi- 
tions associated with the amygdalae, ulceration is, without doubt, the most 
common. Of the non-specific ulcers, all will be recognized to have the ex- 
pression as described under the head of 11 The Aphthae," which see. Specific 
ulcers are of two kinds, the venereal and the cancerous. A diagnosis of the 
former is readily to be made from the expressions found associated in other 728 
A SYSTEM OF ORAL SU ROE RY. 
parts of the mouth.* The cancerous ulcer, being of the epithelial 
variety, is to be recognized in the papilliform character of the granulation, 
with which its surface is always found studded. The treatment of the first is 
to be that directed to the cure of the influencing disease. (See Ulcers.} That 
of the second may only be founded on the most careful weighing of the cir- 
cumstances of each case. Should such disease be recognized in its true 
character, when very circumscribed and non-infiltrated, it is justifiable to ex- 
tirpate the gland. If not appreciated until the neighboring mucous membrane 
manifests its sympathy, an operation would be worse than useless. It has 
happened to the author to be consulted in several cases of epithelioma of the 
tonsil glands, but he has not seen one which warranted operation. 
Complete Extirpation of Tonsil.-Complete extirpation of the 
gland, when indicated for a cancerous manifestation, is best practised by a 
procedure directed from the external parts. An operation so performed is 
recorded by Dr. Cheever, of Boston. In this case two incisions were made: 
one commencing within the angle of the jaw, and directed downward on a 
line parallel with the sterno-cleido-mastoideus; the second forward, along the 
base of the jaw. The dissection in this case revealed, first, an enlarged lym- 
phatic gland, which was removed; second, the digastric, stylo hyoid, and 
stylo-glossus muscles, these being cut and pushed aside; and, third, the supe- 
rior pharyngeal constrictor, the fibres of which were disparted, thus allowing 
the finger to reach and retract the gland. Twelve ligatures controlled the 
hemorrhage of the operation, and the patient is reported as having recovered 
completely in a month. Extirpation of the gland from within the mouth has 
been successfully accomplished by both European and American surgeons. 
In a gland well solidified by the scirrhous expression, and possessed of a well- 
defined base, a catgut or wire ecraseur might be used with satisfaction. 
Cystic Disease.-The formation of a cyst or cysts within the gland is 
of rare occurrence. In his own immediate practice the author has as yet 
never seen a case. Virchow, in his volume on tumors, mentions them, how- 
ever, as being of not infrequent occurrence. The treatment demanded is of 
* Syphilitic Affections of the Tonsils.-" The syphilitic affections of the tonsils are 
difficult to diagnose, since even in relative good health considerable swelling, fissuring, 
partial loss, excoriations, follicular abscesses, and cicatrices may frequently affect these 
organs and yet remain unnoticed. The crypts of the tonsils sometimes form extensive 
fistulous passages, thus constituting a persistent cause of altered secretion and of increased 
sensibility. If the hypertrophied tonsils are not removed, the surgeon should at least 
slit up these fistulous canals or cauterize them to a sufficient depth. Of the ordinary caus- 
tics, Professor Sigmund prefers to nitrate of silver or bichloride of mercury the Vienna 
paste, immediately after the application of which the cauterized spot is to be washed with 
vinegar and water. Concentrated tincture of iodine may also be applied to ulcers with 
good results. Tannin is used principally as a wash after the use of caustics, or as a retain- 
ing agent after brushing over the parts with tincture of iodine. All these applications, how- 
ever, may be spared if the surgeon at once removes the hypertrophied tonsils, the most 
certain means of alleviating and cutting short the course of syphilis in these organs."-■ 
Schmidt's Jahrbucher. THE TONSIL GLANDS. 
729 
such simple nature as applies to abscess or ranula. Should a cyst prove of 
malignant character, little harm results from mistaking it for, and treating 
it as, one of simple form: it will necessarily prove fatal. The diagnosis of a 
cystic tonsil is to be made by touch. 
Abscess.-Abscess of strumous signification is frequently met with in 
the tonsil glands. These abscesses belong to the cold or chronic variety, 
being oftentimes two or three months in maturing, seldom attended with 
pain, and imparting to the overlying structure a dull white appearance, very 
characteristic. Such abscesses are to be treated from a constitutional as well 
as from a local stand-point. As a gargle, to be used several times a day, 
no medicament seems to equal the compound tincture of capsicum ; 5ij to 
$viij of water being employed.* Internally, cod-liver oil, combined with a 
chalybeate, is found of the greatest service, and may be prescribed with large 
freedom. Scrofulous abscess related with the body of a tonsil 
gland commonly approaches the surface in the shape of a yellowish bulb; if 
not breaking readily the pus is to be voided by employment of a blade that is 
to be wrapped, leaving the point alone exposed. A gargle of admirable and 
reliable character, to be used for correction of the offensive odor relating with 
such abscess, is found in phenol-sodique; a tablespoonful to a goblet of water. 
Syphilitic Affections.-Syphilitic affections of the tonsil glands exist 
generally by reason of an extension of the manifestations from the soft palate. 
The bodies may exhibit simply a tumidity, the congestion showing as a dark 
coppery red, or they may possess ulcerated surfaces, or they may be studded 
with condylomata. (See Uvula and its Diseases.} 
Anomalous Case.-An anomalous case of tonsillar abscess having 
the following history was treated and cured by the author some few years 
back. The patient, a young married woman, was troubled by a swelling that 
made its appearance on the side of her neck just below the ear. After some 
three months, the enlargement extending down her neck, an abscess formed 
and discharged itself just above the clavicle. This abscess was under treat- 
ment by her medical adviser for over two years, injections of different kinds 
being used daily. Examination for diagnosis was commenced by the use of a 
long and very soft silver probe, which, after repeated attempts to trace the 
track of the fistula, was finally brought in contact with a tonsil gland. Cure 
was immediate on the removal of the body, this being effected by an ecraseur- 
like operation from the inside. No hemorrhage of consequence attended the 
ablation, great care being taken to avoid the internal carotid artery. 
* Tinctura capsici et myrrhae. CHAPTER XLIIL 
BRONCHOTOMY. 
LARYNGOTOMY, TRACHEOTOMY, THYROTOMY, INTUBATION. 
Study is here to pass to operations required to be done upon the upper 
air-passages. 
Bronchotomy.-These operations, the common object of which is fur- 
nishing a supply of air to the lungs, are known under the common name of 
bronchotomy ; subdivisions are laryngotomy, tracheotomy, thy- 
rotomy, and intubation. The three former require use of the knife, the 
last is done without it. Occasions demanding this class of opera- 
tions lie with inflammatory swellings and exudates associated with the larynx, 
with the intrusion of adventitious growths, and with the presence of foreign 
bodies either in the air-passages or oesophagus. All of them being con- 
ditions of emergency, a practitioner of surgery is to be prepared to meet their 
sudden demands. 
The immediate and marked necessity existing with a person so 
afflicted as to make necessary any of the above-named class of operations 
allows it to be well remarked that there is no condition giving rise to symp- 
toms of greater distress or of more urgent appeal, or, as extravasations are 
concerned, of less certain relief by medical means. Trousseau, impressed 
with the inadequateness of medication in these moments of danger, taught 
and urged the importance of early resort to tracheotomy,-an urgency keenly 
appreciated by all who have been witness to the struggles of children afflicted 
with diphtheritic exudates to get breath, and of the almost necessarily fatal 
result of the diminished oxygenation of the blood resulting from such lack of 
aeration. 
ILLUSTRATIVE ANATOMY. 
The operations named, while not at all difficult of performance, demand for 
their appreciation accurate knowledge of the anatomy of the parts involved. 
Fig. 614, being a view of the air-tubes, is introduced as a study; the 
descriptive text is wholly explanatory. The parts, as here shown, are to be 
understood as being entirely uncovered. The first of the two pictures, A, is 
a front view of the larynx, trachea, and bronchial tubes. The second, B, is 
a back view of the same parts, the bronchial tubes, however, not being con- 
tinued. Observation, as the first of the two diagrams is concerned, is to be 
730 BRONCHOTOMY. 
731 
directed particularly to the centre line of the larynx, to the crico-thyroid 
membrane, 4, to the cricoid cartilage, 5, to the cartilaginous rings of the 
trachea, 7, 8, and to the membrane separating them, 9. The figures 10, 11 
Fig. 614.-View of the Air-Tvbes 
A. Larynx, trachea, and bronchial tubes, viewed in front. 1, hyoid bone; 2, 
thyro-hyoid membrane; 3, thyroid cartilage; 4, crico-thyroid membrane; 5, cricoid 
cartilage; 6, trachea; 7, 8, two cartilaginous rings; 9, membrane which separates them; 
10, right bronchus and its divisions; 11, left bronchus. 
B. Larynx, trachea, and commencement of bronchial tubes, viewed from be- 
hind. 1, upper opening of larynx; 2, 3, lateral grooves of larynx; 4, fibrous membrane 
of trachea, interspersed with small glands, beneath which are seen, 5, muscular fibres ; 
beneath this last are, 6,7, small fibrous bands; 8, mucous membrane seen between them. 
distinguish the right and left bronchi. Note is to be made of the direction 
of the two tubes. The left, by reason of being more directly in line of con- 
tinuation of the trachea, receives small foreign bodies accidentally drawn into 
this passage. 
Fig. 615 is a picture of the parts shown in preceding diagram, here associ- 
ated with conspicuous and important overlying relation. It is of vital con- 
sequence that the positions of D, the aorta, and of B, C, the innominate and 
carotid arteries, be accurately appreciated. To cut into either of the three, 
when in the act of incising the trachea, would be fatal to the patient. A, the 
trachea, is here seen to be overlaid by an inferior thyroid artery, B, an ana- 
tomical condition too common to be esteemed an anomaly, as it exists in one 732 
A SYSTEM OF ORAL SURGERY. 
out of every four cases. F, the thyroid gland, is a factor of large consequence 
both in tracheotomy and in laryngo-tracheotomy. It is necessary, in the latter 
operation, to divide this body in its centre line, while, in the former, the same 
necessity exists save where a long neck allows it to escape or permits of its 
being pushed out of the way. The centre line is known as the isthmus. This 
isthmus separates the two lobes of which the gland is composed. To divide 
it safely a double ligature is passed between it and the trachea, and one of 
these being tightly tied to either side, division is made between them. H is 
the thyroid cartilage; the operation of thyrotomy is the dividing of the 
common box in its middle line. G is the crico-thyroid membrane; this is to 
claim close examination, as it is the seat of laryngotomy. Note is to be made 
of K, the superior thyroid artery, a vessel that runs, more frequently than 
otherwise, directly across the membrane. The inferior thyroid artery is accom- 
panied by from two to four veins that occupy the centre line of the trachea. 
Fig. 615. 
Fig. 616. 
A, trachea; F, thyroid gland, its 
isthmus occupying the exact centre 
line; H, thyroid cartilage; O, crico- 
thyroid membrane; I, hyoid bone; 
J, thyro-hyoid muscles; D, aorta; 
C, carotid artery; B, innominate 
artery; E, inferior thyroid artery; 
K, middle branch thyroid artery. 
Front view of the muscles of the neck. 1, poste- 
rior, and 2, anterior belly of the digastric; 3, its inter- 
mediate tendon attached to the hyoid bone and passing 
through the insertion of the stylo-hyoid muscle, 4; 5, 
mylo-hyoid; 6, genio-hyoid; 7, stylo-glossal; 8, hyo- 
glossal; 9, styloid process; 10, stylo-pharyngeal; 11, 
sterno-mastoid; 12, its sternal origin; 13, its clavicular 
origin; 14, sterno-hyoid; 15, sterno-thyroid; 16, thyro- 
hyoid ; 17, 18, omo-hyoid; 19, trapezius; 20, anterior 
scalenus; 21, middle scalenus muscle. 
Fig. 616 shows perfectly the parts overlying the exhibits of the immedi- 
ately preceding diagram, just as it, in turn, was of relation with the first one. 
That the necessary understanding of the anatomical relations here shown be 
most easily obtained a slight expose has been made of the sternal extremity of 
the trachea. The muscles-14, the sterno-hyoid, and 15, the sterno-thyroid- 
are common to either side, the four directly overlying the trachea and meeting BRONCHOTOMY. 
733 
at its exact centre line. In exposure of the tube these muscles require to be 
displaced, and this is done by getting between them at the line named and 
pulling them, by means of retractors, to either side. Such displacement being 
made, the parts figured in the preceding cut are exposed to view. 
The parts overlying this last dissection are the integuments, consisting of 
deep and superficial fasciae and skin. There are no vessels in either of the 
layers that interfere with free incision. 
LARYNGOTOMY. 
Occasions are found to offer where, in acute tonsillar disease, in other throat 
affections, and in the sudden accidental impaction of a bolus of meat at table, 
the surgeon, called in an emergency, is compelled to a speedy operation in 
order to save life. For such possibilities a judicious practitioner fully pro- 
vides himself. 
Suffocation Evident.-When convinced that a patient is not other- 
wise to be relieved, suffocation being evident, a surgeon is, without hesitation, 
to thrust a bistoury directly through the crico-thyroid membrane. This opera- 
tion, which is that of laryngotomy, is one of simple character, if no 
superior thyroid artery cross the part. If the membrane be properly dis- 
parted after the cut is made, and kept so, either by the introduction of a tube 
Fig. 617.-Tracheal Retractors. 
or by hooks of wire, which pass around the neck, the patient will likely 
experience immediate relief. When the artery crosses the mem- 
brane, and has been cut, blood is to be prevented from entering the lungs 
Fig. 618.-Mackenzie's Dilator. 
by leaning the person forward, the face downward; the vessel is then to be 
secured in the most convenient manner; with ligature if possible. Fig. 617 
shows hooks used, and Fig. 618 shows Mackenzie's dilator. Forceps apply 734 
A SYSTEM OF ORAL SURGERY. 
for temporary use (Fig. 619). When the offence demanding the operation is 
removed, the cut is allowed to heal, which it commonly does without giving 
any trouble. Where moments are not 
chief factors in this operation, time is 
to be taken to separate the sterno-hyoid 
muscles which overlie the membrane. 
A vertical incision through the integu- 
ments, about an inch in length, is to be 
made. The membrane itself is divided 
first transversely, afterward, if intro- 
duction of a tube be necessary, verti- 
cally. The vertical cut being made converts the performance into what is 
known as laryngo-tracheotomy. A student is to examine the parts on the 
cadaver. 
Fig. 619.-Tracheal Forceps. 
TRACHEOTOMY. 
Tracheotomy, an operation often found compulsory in such connection, 
while seemingly complex, is yet not difficult of accomplishment; at least the 
author has found himself able to perform it on the living subject without 
assistance. 
Fig. 620. 
Manner of Operation.-Having a patient upon his back, with the 
neck extended, an incision is made directly in the middle line: this incision 
may be quite short, and is to be commenced immediately below the cricoid BRONCHOTOMY. 
735 
cartilage. Dividing skin, superficial fascia, and the delicate layer of the deep 
fascia, the muscles running from the sternum to the os hyoides and thyroid 
cartilage are met with. Seeking an interspace that separates these, they are 
thrust and held to either side,-easily done by using the handle of a knife and 
retractors. The thyroid plexus of veins is now brought into view, and this is 
to be carried aside or ligated, as seems most convenient. The isthmus of the 
thyroid gland (Fig. 615), if found in the way, is pulled upward, or, if neces- 
sity exist by reason of a very short neck, the double ligature is passed, and 
being secured on either side, the bridge is divided between. These manipu- 
lations bring into view the trachea with its rings. Steadying the tube, after 
scraping the selected seat, by use of a tenaculum, pulling it at the same 
time upward, one, two, or three rings are to be incised. 
Incision to be kept Open.-The operation accomplished, the incision 
is to be kept open by use of wire loops (Fig. 617), or, what is much to be 
preferred, introduce a canula and maintain it in place by a strap of tape. 
(Subfig. 6, Plate I.; see also Fig. 624.) 
Fig. 621.-Tracheal Tubes. 
Inferior Thyroid Artery.-In performing the operation, it is neces- 
sary to bear in mind that occasionally the inferior thyroid artery (Fig. 615, E} 
is found lying upon the trachea, directly in its middle line. When this vessel 
is met with, it becomes necessary to throw a ligature around it. Observations 
in the dissecting-room would lead to the inference of the presence of the 
artery in this position in about one out of four cases. 
Superior Thyroid Artery.-A superior thyroid artery may be out of 
exact place, or an anomalous distribution might be met with. In an instance 
occurring at the Hospital of Oral Surgery, much anxiety was induced in a 
case by reason of hemorrhage arising out of an anomalous position supposed 
to be related with the vessel just named. The patient in this case was a man 
seventy years of age, where an operation was made necessary by a rapidly- 
growing tumor enveloping the larynx. 736 
A SYSTEM OF ORAL SU ROE RY. 
Thymus Gland as a Complication.-A complication occasionally 
met with in tracheotomy exists in the intrusion of a prominent thymus gland. 
In one particular operation done by the writer on the person of a child the 
body named swelled with such prominence into the wound as to convey a 
momentary impression that the tissue to be dealt with was the lung. After 
some manipulation the gland was gotten rid of by being crowded beneath the 
manubrium of the sternum. In the subsequent treatment of the case it gave 
no trouble. 
Surgical Study.-With a view to convenient reference Plate I. is 
inserted. The anatomy of the parts involved, together with the several feat- 
ures of a tracheal operation, are so perfectly repeated as to render the hints 
afforded invaluable. Regarding the tube, seen in place, with its retaining tape 
bands (Subfig. 6), it requires to be remarked that, as furnished by the manu- 
facturer, this is a double canula, the object of the inner tube being to permit 
of easy cleansing. The author being possessed of considerable experience in 
the direction of these operations, advances it as his opinion that this inner 
tube is seldom a convenience but,often an obstruction. By reason of occupy- 
ing a space within the outer tube it will readily be recognized as interfering to 
an extent with free breathing. By reason of this same interference it in- 
vites the clogging it is intended to correct. In removing it, in cases 
where secretions are tenacious, the first tube is occasionally withdrawn; a 
matter, this last, of little consequence in the later treatment of a case, but 
demoralizing to a patient when occurring immediately after an operation. To 
remove the secretions a mechanical plan suggested originally to the 
author by Dr. Cohen will not soon be superseded; this consists in the use of 
a common wire brush such as is employed by smokers to clean their pipes; 
thrusting this into the canula, a single, quickly-made, turn catches among the 
bristles the sticky glutinous mass, 
bringing it cleanly away. These 
little brushes, made on the end of 
a strand of wire, are to be bought 
in tobacco stores. The brush ap- 
plies only when the secretions are 
fresh. 
Use of Canula.-A canula 
is to correspond in diameter with 
the trachea into which it is to be 
introduced. The common length 
of the instrument is one and one- 
half inches. The windpipe opened, a tube is most conveniently intro- 
duced by means of a rubber bougie (Fig. 622), the point of this leading the 
way, the tube following on the principle of a trocar and canula. The tube 
being in the trachea, the bougie is to be quickly withdrawn, it being recog- 
nized that while it is in the patient is unable to breathe. 
Fig. 622.-Bougie leading Canula. BRONCHOTOMY. 
737 
Necessity of Absolute Exposure of Trachea.-A point of large 
practical importance in operations of this kind pertains to absolute exposure 
of the trachea before incision. Covering the tube is a sheath of cellu- 
lar tissue ; if this sheath be simply incised, without being scraped fully 
Fig. 623.-Trachea exposed. 
Fig. 624. - Canula tied in 
Place. 
and completely away from the circumference of the canula, a result sure to 
follow is emphysema. From neglect of a matter so simply accomplished 
the earlier experiences of the writer confounded him more than once with 
windy expansions puffing out the integuments of the whole breast region. A 
trachea properly exposed for opening is 
shown in Fig. 623. Hurry is not well 
save where compulsory. Fig. 624 shows 
canula tied in place. 
Occasions arise where the use of for- 
ceps become necessary for enlarging the 
opening. The form exhibited in Fig. 
625 applies. 
Moisture to relieve Dryness of Trachea and Bronchi.-A 
source of inexpressible comfort to a patient who has undergone the operation 
of tracheotomy is found in relieving the bronchial dryness, and the 
irritability arising out of the new manner of respiration, by means of fre- 
quent atomizing of water or other grateful fluids. The practice is deemed 
a necessity by the writer to the successful carrying through of his cases. To 
this end a steam atomizer is to be kept quite continuously at work, the vapor 
being directed to the neighborhood of the patient, care being taken not to 
wet him. In the absence of the steam apparatus an ordinary cologne sprayer is 
Fig. 625.-Tracheal Forceps. 738 
A SYSTEM OF ORAL SURGERY. 
made to take its place. Fluids found grateful are tincture of hamamelis, 
tar-water and glycerin, phenol-sodique much diluted, and very weak chlorine- 
water. Steam applied by the spout of a kettle of boiling water 
affords great relief to a patient; the application at first to be repeated every 
hour or two. Close attention is to be paid to clogging of the tube, 
sure to occur where not combated by moisture. The writer has been hurriedly 
called from his bed at midnight to find a patient running frantically about a 
room gasping for breath, examination revealing a tube so clogged with tena- 
cious mucus as almost entirely to obliterate its calibre. Such a case is relieved 
by supporting the canula in place by means of a finger placed against either 
wing, in using steam freely, and, most important, in picking away 
the glutinous mass by means of an ordinary hoe-form dental excavator. 
A tube, after having been in place two or three weeks, may be taken out and 
replaced without difficulty or risk. Here it is cleaned without trouble, a 
patient, if an adult, being able to do it for himself. Until, however, the time 
has arrived to dispense with a tube entirely a patient is to be warned against 
keeping one out too long, as in a single hour changes may occur rendering it 
impossible for other than the surgeon to replace it, compelling at times use of 
the knife for enlargement of the opening. 
This is the operation of opening the larynx, a performance occasionally made 
necessary by reason of papillotomata growing within its cavity. To gain access 
to this part requires simply the separation of the two thyroid cartilages, the 
division being made in the mesian line. Loss of voice is almost sure to attend. 
(See Diseases of Pharynx.') 
THYROTOMY. 
INTUBATION. 
Intubation, as a means to take the place of tracheotomy, is a device by Dr. 
Joseph O'Dwyer, of New York. This means consists of an appliance in the 
shape of a properly-adapted tube, designed to reach the trachea by being 
passed, per road of the mouth, into and through the larynx. Unlike trache- 
otomy, its applicability is restricted to cases of membranous exudation, but, 
like it, has its beneficial use limited, as exudates are concerned, to cases where 
the deposit is confined to the larynx. 
Instruments used in the Operation of Intubation.-The in- 
struments of Dr. O'Dwyer are six in number,-namely, a gag to keep the 
mouth open, a laryngeal tube, an obturator, or plunger, a depositor, a with- 
drawer, and a scale. 
Gag.-The gag (Fig. 626, Subfig. 2) explains itself. It has the simple, 
single purpose of holding the jaws apart. It is open to an objection that its 
handles are directed downward, which permits of easy displacement of the 
instrument should the child so throw its head about as to have a shoulder 
strike against them. Kolbe's screw and jaw instrument is a better one. Wax- BRONCHOTOMY. 
739 
ham s forceps, the handles of which are directed backward, is given prefer- 
ence by operators of experience. The author has found it quite as conven- 
ient to do without a gag of any kind, as the retching that associates with the 
performance insures an open mouth. 
Laryngeal Tube.-Subfig. 5 shows one of these tubes. They are con- 
structed either of platinum, silver, or gold. In length they measure variously. 
They are partly flattened, being enlarged at the pharyngeal extremity to allow 
of their resting easily upon the rima glottidis and to insure against slipping into 
the windpipe. Their smoothness and polish are perfect that irritation may be 
guarded against. The metal is thin so that the opening shall be large as 
possible. 
Fig. 626. 
Obturator.-The instrument called an obturator, or plunger, otherwise 
the carrier, is a length of steel a little longer than a tube with which it is 
designed to work (shown in outline within the tube). It is divided into a 
shank and an inferior and superior extremity. The shank, which is round, is 
in two parts, these parts being related by a hinge-joint at the junction of the 
upper and middle thirds. The inferior extremity is shaped as a director, 
being rounded like the extremity of a bougie. The superior part is flattened 
and perforated by a screw-cut hole. 
Depositor.-The upper instrument is a depositor. This, as seen in 
the cut, is fixed to the obturator, the piece remarked as occupying the 
canal of the tube above which it projects. The instrument is of ingenious and 
peculiar construction. Primarily it is a shank of steel attached to a handle, 740 
A SYSTEM OF ORAL SURGERY. 
the shank being curved anteriorly and ending in a screw. Secondarily, it is 
a tube of imbricated construction, ending in a fork-like extremity. The tube 
covers, and moves over, the shank, being slid by means of a push-button seen 
upon the upper surface of the handle. 
Withdrawer.-Subfig. 3 shows the withdrawer, or extractor. The cut 
exhibits the instrument when, the spring being pressed, the jaws are disparted. 
The spring unpressed, the jaws relate so as to constitute a delicate director-like 
extremity of a diameter somewhat less than that of the opening in the tube. 
Measure.-Subfig. 4 shows a measure that accompanies the case. The 
numbers on the scale indicate the years for which corresponding tubes are 
suitable. For instance, the smallest tube when applied to the scale will reach 
to the first line, marked 1, and is intended to be used up to the age of twelve 
or fifteen months; the size marked 2 is suitable for the next year, 3 and 4 for 
these years, and so on. When the proper tube is selected for the case to be 
operated on, a fine thread is passed through a small hole seen near its anterior 
angle, which is left long enough to hang out of the mouth, its object being to 
remove the tube should it be found to have passed into the oesophagus instead 
of the larynx. Five tubes of different measure, having corresponding obtu- 
rators, are furnished with each case. 
Doing the Operation.-The introducer is first screwed to the obturator, 
and this, in turn, is pushed into a tube selected to be used. Looking at Fig. 
626 the relation is appreciated. The little round head which projects out of 
the opening it occupies is the upper extremity of the obturator. The part 
immediately above it is the screw extremity of the introducer. The two are 
shown screwed together. The obturator is of a shape so correspondent with 
the tube that when in place it carries its burden reliably, insuring against the 
possibility of the tube slipping or turning. The rounded lower extremity of 
the tube is the projecting bougie-like end of the obturator. Notice is to be 
taken of the fork-like extremity of the imbricated cover of the introducer, 
the purpose of which is to throw the laryngeal tube off the obturator when 
the latter has been placed. 
Introducing the Tube.-The usual method is to have the child wrapped 
in a blanket and held in the arms of an attendant. The latter sits in a 
straight-backed chair with the patient upon his lap. The aid of an assistant 
is required, who throws the head of the infant slightly back and holds it 
firmly between his hands. The mouth is commonly held open by a gag. The 
index-finger of the left hand of the surgeon is introduced into the mouth, and 
is carried over the tongue, and draws forward the epiglottis. Using this finger 
as a guide, the tube, being fixed to the introducer, as seen in the diagram, is 
carried into the chink of the glottis and pushed down and off, this last being 
accomplished by pushing forward the button governing the imbricated cover 
and fork. In movement of the child, or in its gasping or swallowing, the 
tube may be carried over the glottis into the oesophagus. To prevent its 
being swallowed a ligature has been passed through a small opening in its BRONCHOTOMY. 
741 
flange, by which it can be kept under control until the operator is certain that 
it is in the larynx. Entrance of the tube into the air-passage is indicated by 
a metallic sound as the air and mucus are forced through it. 
Spasm and Cough.-A child in whose larynx a tube has been placed 
frequently coughs quite violently for a few minutes after deposit of the body. 
The mucus being cleared out, however, and the presence of the tube becoming 
familiar, it gets quiet and, not infrequently, sinks into a peaceful sleep. 
Time for wearing the Tube.-A tube is to be worn until all symp- 
toms of exudation and febrile conditions have disappeared. The time required 
varies, some patients being able to do without it in two days, others being 
compelled to continue its use for so long a period as three weeks. 
Feeding after Intubation.-Nothing is to be given a patient by the 
mouth for three hours after introduction of a tube, it being necessary to favor 
the pharynx that it may become accustomed to the presence of the metal. 
Difficulties in Feeding.-In the exceptional cases where fluids are 
not readily taken on account of trickling through the tube, the patient is to 
be placed upon an inclined plane, the head being the lowest part. Deglutition 
in such position is found easily accomplished. 
Experiences.-Dr. Montgomery, of the Medico-Chirurgical College, 
Philadelphia, has done intubation in fifty-one cases with twenty-one recov- 
eries. These cases are described as having been seen in all stages of the dis- 
ease from its incipiency to a moribund condition. Two of the patients died 
before the canula could be introduced. The doctor advises out of his experi- 
ence that the tube be inserted as soon as there is evidence of want of com- 
plete inflation of the lungs, as shown by the substernal depression during 
inspiration. In cases of a feeble and exhausted heart from long-continued 
efforts at respiration, he insists that a patient is not to be lifted up, as the mere 
changes of position may be sufficient to induce heart-failure. Dr. Shimwell, 
a colaborer with the writer in the Oral Hospital, reports twenty-six cases with 
twelve recoveries. 
Withdrawal of the Tube.-This, save to the expert, is the most 
trying part of the operation,-not that it is difficult, but because of antag- 
onism offered by the patients, particularly in the case of children. Appre- 
ciation of the withdrawer affords understanding of the performance. The 
mouth is opened, the finger placed as in introduction, and the probe-shaped 
jaws engaged in the opening. Pressure upon the spring opens these jaws, as 
seen in the diagram, and by a hold thus secured the tube is lifted from its 
place. The performance requires to be done very quickly. 
Remarks.-Intubation, while possessed of advantages over tracheotomy, 
inasmuch as it does away with the use of the knife, is yet inferior to it in 
that the tube is difficult to rid of the mucus that necessarily adheres to instru- 
ments of its kind so placed. A reader turning to the subject of cleansing 
and clearing tracheal tubes, as referred to on a previous page, will find full 
appreciation of the matter without further reference being here made to it. It 742 
A SYSTEM OF ORAL SURGERY. 
is to be added, however, that the laryngeal tube is not so apt to clog as the 
tracheal instrument, for the reason that the air has been warmed and moist- 
ened in its passage through mouth and nose; nevertheless the difficulty lies as 
an objection, for a clot suddenly stopping such a tube, death might result. 
Unsuccessful operations of the class considered find a too common ex- 
planation in reference to Fig. 627. Where the performance is in consideration 
Fig. 627. - Extension of 
Exudate from Trachea into 
Bronchi. 
Fig. 629.-Epithelioma 
of Larynx. 
Fig. 628. - Epithe 
lioma of Larynx. 
of diphtheritic exudate, introduction of a tube is useless if the deposit be below 
a point that can be reached. The author assumes to suggest that careful 
stethoscopic examination will reveal with sufficient accuracy for the purpose 
here implied the boundary of such exudate. Ordinary physical signs of ex- 
tension downward of the membrane are found in an increasing pulse and 
advancing symptoms of asphyxia. In proliferating laryngeal growths the 
operation of tracheotomy becomes a necessity. The writer has had many 
most satisfactory temporary results in cases of this kind, the patient gradually 
dying from the constitutional effect of the disease rather than from smother- 
ing. Figs. 628 and 629 illustrate the conditions. Plate I CHAPTER XLIV. 
THE TONGUE AND ITS DISEASES. 
Expressions of the tongue indicative of systemic conditions are not to be 
confounded with lesions of the organ itself. 
Tongue a Sentinel of Medical Diseases.-Of medical diseases 
the part has long been esteemed a reliable sentinel. As an index, pointing, 
through sympathy, to a wide range of morbid affections, physicians have 
learned through experience to confide in it as among the most useful of guides. 
Meanings expressed by Changes in the Tongue.-Changes in 
the tongue, associated with systemic derangement, relate to size, form, color, 
temperature, moisture, taste, motion, and coating. Increase in bulk, 
recognized, while very moderate, by lateral indentation made by pressure upon 
the teeth, affords not infrequently the first sign of salivation. Pointing, or 
elongation, is expressive of irritation in the alimentary canal and of deter- 
mination of blood to that region. A shrunken tongue is met with where 
atony exists in the digestive organs. Color varies from white to livid: 
whiteness indicates anaemia; floridity implies either inflammation of the 
stomach or an unduly arterialized state of the blood;. redness relates with 
vascular excitement, particularly as associated with the alimentary canal; 
lividity signifies prostration. Temperature is influenced by that of the 
body at large: heat denotes fever; coldness implies diminution in vital force. 
Moisture, or its absence, is highly significant: a moist tongue in sickness is 
a good sign; dryness implies congestion or otherwise that force is failing. 
Taste, or its absence, depends on derangement of the tongue's surface; the 
cause is commonly found in a coating covering the surface of the organ. 
Motion affords important indications: inability to control the part implies 
prostration or cerebral complications; loss of motion on one side points to 
hemiplegia. Coating is a principal element in tongue diagnosis: a furred 
condition signifies fever; allied with disease this fur distinguishes itself from 
that habitual to certain persons by resistance to local means employed for its 
removal; a white, uniform fur, accompanied with moisture, indicates an open, 
active febrile condition without complications; short and tenacious, showing 
through the coating a florid base, a typhoid condition is indicated; yellowish 
fur implies bilious disorder; a brown or black coating implies blood-poisoning, 
and as well diminution of vitality. 
Illustrations-Diabetes Mellitus.-Tongue dry, generally red, ab- 
normally clean and fissured; sometimes covered with a whitish and dry coat; 
743 744 
A SYSTEM OF ORAL SURGERY. 
sometimes streaks of fur appear in a longitudinal direction along the dorsum ; 
sometimes covered with rough papillae; sometimes sticky to the touch. 
Abscess of Liver.-Tongue covers itself with a coat grayish-yellow in 
color. 
Congestion of Spleen.-Tongue sometimes as if transparent; is pale, 
commonly thinly coated with a whitish fur. 
Diarrhoea.-Tongue dry and stiff. 
Atonic Dyspepsia.-Tongue flabby, broad, pale, and enlarged. 
Enteric Fever.-Tongue rough, fissured, and dry, indicating ulceration 
of the Peyer glands. 
Malarial Poisoning.-Tongue coated down its middle with a dirty- 
brown fur thinning toward the tip, where the color of the papillae is to be seen 
through it; edges flattened, pinkish in color, and traversed by sharp lines 
conveying an impression of puckering, or corrugation. 
LOCAL, OR SURGICAL, LESIONS. 
The local, or surgical, injuries and diseases of the tongue are many. These 
lesions are of twofold relation: direct, as reference is had to some immediate 
cause demanding local attention only; indirect, as constitutional offence is the 
predisposing or exciting agent requiring to be antagonized. 
Examples of Local Lesions.-Local injuries find examples in ulcers 
caused by jagged and projecting teeth, in cuts and contusions from falls or 
blows, in bites inflicted by one's self, in insect stings, in burns, scalds, the 
incautious or accidental mastication of acrid and irritating substances, etc. 
Local diseases are to be illustrated by reference to hypertrophy, atrophy, erec- 
tile, papillary, fatty, and benign cystic tumors, to chancres, to nerve-lesions 
constituting neuralgia, etc. 
Localization of Diseased Action.-In his admirable monograph, 
" Studies in the Facial Region," Dr. Harrison Allen divides the subject most 
happily, as it seems to the writer, into four portions: (a) diseases confined to 
or appearing on the mucous or epithelial surface; (6) those appearing in the 
submucous or muscular tissues; (c) diseases of the anterior two-thirds of the 
dorsum, as contrasted with the posterior third; (<Z) diseases as influenced by 
symmetry. 
(a) Psoriasis, ichthyosis, keloid, furring, papillary, hypertrophy, epithelioma, 
fissure. 
(6) Syphilitic gumma, fibrous tumors, tubercular deposits. 
(c) Ulcers of local expression, bites, stings, burns, fatty tumors, cancer. 
(d) Hypertrophy, atrophy. 
Tongue diseases of systemic relation are venereal manifestations, scrofulous 
ulcerations, carcinoma. Changes arising from emotional influences are wit- 
nessed. 
Local Injuries.-Local injuries imply a treatment as directed by indica- 
tions. Where a cause of offence is seen to be present, the first thing is the THE TONGUE AND ITS DISEASES. 
745 
removal of such cause; this refers to the extraction of irritating teeth and 
roots of teeth, to the withdrawing of splinters, the removal of masses of cal- 
culus, the antagonizing of acrid agents, etc. 
Glossitis.-Inflammation arising out of falls, blows, the accidental biting 
of the parts, burns, and scalds are to be treated on common principles. Ordi- 
nary hurt done to the tongue is commonly quickly cured by the remedial 
power of nature. For the relief of trouble arising out of sting by an insect 
a mould of mud, or an alkaline solution, applied to the part constitutes a 
specific application. Burns and scalds are wisely left to nature, except where 
the saliva is found unduly acid; correction of this condition resides in the use 
of lime-water. Cuts are to be sewed with stitches of the interrupted suture, 
note of the point being made that such stitches are to be taken deeply. A 
manner of treating a cut when it is lengthwise consists in slipping around the 
organ a wide rubber ring. Vincent suggests the use of a roller, which, bind- 
ing the maxillae together, compels the tongue to lie in place within the lower 
jaw. The experience of the author commends the suture. 
Syphilitic Lesions.-The most frequent disease met with about the 
tongue is syphilis. Syphilitic ulcers, the commonest of the manifestations, 
successors to the gumma, appear on any part of the organ, but are most fre- 
quently met with on the sides and upper surface, particularly upon the dorsum. 
Such ulcers are almost invariably accompanied by associations pointing to their 
origin,-psoriasis on the body, nodes, falling of the hair, lymphatic induration 
of the posterior cervical glands, etc. A syphilitic ulcer on the tongue has the 
appearance of chancre, hard or soft: such are to be seen where the ulcera- 
tion is quite deep and the edges heavily indurated. Again, a form is met 
with bearing likeness to soft chancre, there being neither excavation nor 
induration ; we nevertheless know, from the associations, and from the peculiar 
characteristic appearance of the surroundings, that the ulcer is venereal. 
Induration and Hypertrophy.-A second form of syphilitic disease 
of the tongue is observed in the induration and hypertrophy of circumscribed 
patches of mucous membrane. The induration in these cases is so markedly 
localized that, were it not for their varying locations,-being always, how- 
ever, on the dorsum,-one might readily believe them to be enlarged vallate 
papillae; the patches are quite as large as a dime piece, are elevated, and are 
as isolated as a fungiform wart. The author has seen two such patches on the 
dorsum of a tongue, and at the same time a large ulcer on its under surface. 
Cracks and Fissures.-Cracks and fissures are other syphilitic indi- 
cations met with on the tongue. It may happen in some instances that these 
fissures are so deep as to seem to divide the organ into a number of parts; 
they always, so far as the author has observed, run lengthwise. These fissures 
are at times unbearably sore, denying the patient comfort either in eating or 
at rest. (See a succeeding paragraph.) 
General Thickening.-Indurations of the mucous membrane of the 
sides of the tongue from this cause are occasionally observed, or it may be 746 
A SYSTEM OF ORAL SURGERY. 
that a general thickening exists, or indeed that the whole organ is indurated. 
In this latter condition the disease has sometimes been mistaken for can- 
cer ; but such an error could arise only from a failure to observe the associa- 
tions of the case.* 
Red Patches, Bald Tongue, and Condylomata.-Sometimes 
the dorsum presents red patches, the result, evidently, of a loss of the epithe- 
lial covering. These patches show papillae but are not ulcerated. They are 
painfully sensitive to hot or cold impressions. The condition is to be met 
with where the dorsum seems literally skinned. By those familiar with the 
diagnostic description of the tubercular ulcer as insisted on by M. Tielert, it 
will be seen that with such a condition his premises become to a marked 
degree confused. Bald tongue, recognized in the existence of smooth, glossy 
* Syphiloma (Gummata Syphilitica) of the Tongue.-Dr. Neumann, of Vienna (Allge- 
meine Wiener Medizinische Zeitung and Half- Yearly Abstract).-The dorsum of the tongue, 
as is well known, is frequently at its centre or lateral portions, more rarely at the root of 
the organ, the seat of infiltrations,-the so-called syphilitic gummatous tumors, the size, 
superficial aspect, and progress of which undergo many variations. These tumors, which 
are of firm consistency, are seated partly under the mucous membrane, partly in the mus- 
cular tissue of the tongue, and are developed from small infiltrations of the size of a pea to 
prominent nodules as large as a bean or hazel-nut, or even larger. The growth sometimes 
extends laterally, so as to form level patches; in cases of this kind a greater part of the 
tongue, especially its edges, feels thickened, infiltrated, and hard as cartilage. In this affec- 
tion the mucous membrane covering the growth is either smooth or covered by numerous 
papillary growths, which occupy a large portion of the tongue in the form of broad-based 
watery formations, or the surface of the dorsum may be traversed by shallow furrows, or by 
deep fissures crossing in various directions,-rhagades; or, again, if the mucous membrane 
be irritated by the sharp edge of a decayed tooth, it may present superficial patches of 
gangrenous tissue. 
The 'whole volume of the tongue is increased to a considerable extent. Finally, the dis- 
ease may proceed by softening of the nodules to a more or less extensive and deep loss of 
substance, in consequence of which the tongue on the affected side presents large cavities, 
which, when the loss of substance has affected the root of the tongue, exert a considerable 
influence upon the consonance of the speech. The movements of the tongue, also, as in 
speaking, masticating, and swallowing, cause much pain. These new formations, consisting 
partly of granulation tissue and partly of connective tissue,-which tissue, in its further 
development, becomes either soft and jelly-like, or is converted into adipose tissue, and 
forms dry yellow lumps,-were described by Robin and E. Wagner as syphiloma. They 
present granular cell contents, and their cells and nuclei lie in peculiar hollow spaces,- 
alveolar formation. 
In cases of this kind one has to distinguish the infiltration of syphilis from that of cancer. 
Hardness, rapid growth, painfulness, and an uneven surface are, indeed, symptoms which 
speak more for cancer than for syphilis; the existence, however, of a sharply-defined loss 
of substance, and the presence on the dorsum of the tongue of warty or condylomatous 
growth, are indicative of gummatous deposit. In cancerous growths of the size of syphilitic 
gummata, the submaxillary glands would certainly be enlarged. In doubtful cases the diag- 
nosis might be determined by means of the microscope. In some cases the distinction may 
be indicated by the course taken by the disease. In syphilitic gummata the breaking down 
of the tumor commences deeply, and proceeds to the surface; in cancer the opposite takes 
place; loss of substance commences superficially, and gradually extends to the centre of the 
growth. THE TONGUE AND ITS DISEASES. 
747 
patches entirely disassociated with fur, is an expression of specific psoriasis. 
Condylomata of the posterior portion of the tongue are not uncommon. 
These are wart-like granular masses crowded at times together, at other times 
separate ; they are most frequently met with in the mouths of smokers afflicted 
with systemic syphilis. (See Use of Papayotin.') 
Syphilitic Psoriasis Contagious.-To Professor Sigmund we are 
indebted for knowledge of the fact that the raw ulcerations on the sides of 
the tongue called syphilitic psoriasis are very contagious, a diseased 
child poisoning a nurse, and a diseased nurse poisoning a child by chewing its 
food first in her own mouth. 
Treatment of Syphilis in the Tongue.-The treatment of syphilis 
in the tongue has, with one special exception, the twofold signification of con- 
stitutional and local,-the exception being that of chancre. It has without 
doubt occurred that a man has gotten a chancre upon his tongue. Mercury, 
in some of its various forms, seems to be looked on by most practitioners as 
having in this direction something specific in its nature; without doubt, how- 
ever, it is a greatly abused medicine, and should be used with more caution 
and judgment than generally characterize its exhibition. A chancre is to be 
burned out,-London paste being employed. 
Tongue Ulcers Secondary as to Signification.-Where ulcers or 
other manifestations upon a tongue are secondary in signification, and mercury 
has not been used upon the case, it is marvellous how at times, under its in- 
fluence, such manifestations can be made to disappear. How this medicine is 
to be used is perhaps best left to be directed by the apparent requirements of 
individual cases. Of one thing, however, we may be sure : its best effects are 
not to be obtained by salivating the patient. Mercury in the form of the 
bichloride is a favorite preparation; it is to be given in doses of the tenth to 
the twentieth of a grain dissolved in water or the syrup of sarsaparilla, three 
times a day. The hydrargyrum cum creta, combined with Dover's pow- 
der, is a combination which is used with benefit where dryness and other 
lack of function is found in the skin. Impression by inunction is still 
another mode of exhibiting the medicine. A lump of mercurial ointment, 
the size of a large pea, may be rubbed into the inner face of the thighs night 
and morning. Calomel in quarter-grain doses, combined with small quan- 
tities of sugar to render it palatable, may be given every two or three hours, 
until the patient remark the coppery taste. Blue pill, in five-grain doses, 
answers very well if there be hepatic disturbance, as manifested by gastric 
derangement and sick headache. 
Bichloride of Mercury. - Of the various mercurial preparations, 
preference will be found to reside with the bichloride: in this form the im- 
pression of the medicine is gradually secured. If necessary, it may be given 
continuously for a month. 
Tonics in Combination with Mercury.-It is a common experi- 
ence that tonics combined with the mercurial are generally found indicated,- 748 
A SYSTEM OF ORAL SURGERY. 
a something to counteract the degenerative tendency which appears to reside 
in every dose of mercury administered. Iron, quinine, gentian, and the red 
bark are excellent preparations. A prescription found to be a very good one 
is as follows: 
R Hydrargyri chloridi corrosivi, gr. vi; 
Tincturae cinchonas composite, ^vj. M. 
Sig.-A teaspoonful three times a day. 
Pyrophosphate of Iron.-A second, admirable in cases associated with 
nervous disturbance, is the combination with the mercurial of the pyrophos- 
phate of iron: 
U Hydrargyri chloridi corrosivi, gr. vj ; 
Syrupi ferri pyrophosphatis, ^vj. M. 
Sig.-A teaspoonful three times a day; after meals. 
Process of Cure one of Repair.-In syphilitic disease of the tongue, 
tertiary in its type, mercury will seldom be found admissible; the system is 
broken down : the process of cure is to be one of repair. These are the 
patients for the sea-shore and the hill-side. You will not get them well if 
you do not build them up. 
Iodide of Potassium.-Conjoined with tonic medication in these cases, 
very experienced authorities commend, for its alterative influence, the use of 
the iodide of potassium. Where it is thought desirable to use this medicine, 
ten grains as a dose for the adult may be given three times a day. It is most 
conveniently exhibited in water, or, if taste is to be consulted, in the syrup 
of sarsaparilla. 
Tertiary Condition and Mercury.-Tertiary symptoms, as M. 
Ricord observes, do not inevitably occur in the course of syphilis, but they 
are very likely to do so if the treatment of the primary and secondary symp- 
toms be not conducted with the greatest care. As soon as the tertiary period 
has set in, mercury is to be abandoned and iodide of potassium given. 
Nay, further, as mercury taken in time may prevent or retard secondary 
symptoms, and so may be regarded as prophylactic against them, so may 
iodide of potassium be esteemed as prophylactic against tertiary symptoms; 
and therefore M. Ricord, from the premises of his great experience, teaches 
that to render the treatment of secondary syphilis complete and rational, it 
should always be followed by the exhibition of iodide of potassium. This 
substance is, however, not only useless when employed against secondary 
symptoms and those of transition, but very often hurtful; yet when seconda- 
ries have been of long standing, it may produce beneficial effects; it is also 
useful as an adjuvant of mercury in those affections which in some degree lie 
between the secondary and strictly tertiary manifestations; and, finally, it is 
indispensable for combating the symptoms of a decided tertiary nature. In 
order to become well acquainted with the proper manner of administering the THE TONGUE AND ITS DISEASES. 
749 
iodide of potassium, we should take the trouble of studying its effects, inde- 
pendently of its curative action. First let us see how it acts on the 
skin. It may produce on the cutaneous surface diverse psydracious and 
acnoid eruptions. The pustules are generally surrounded by a vividly red 
areola, and the usual seat of these eruptions is below the umbilical region, 
as the nates, thighs, etc., whereas the common acne (not to mention its other 
characters) is mostly situated in the upper half of the body. To these pecu- 
liarities, it may be added that the pustules will fall in immediately the admin- 
istration of the iodide is interrupted. Exanthemata, impetigo, and lichen are 
very apt to be produced by the use of this salt; and what we ought espe- 
cially to keep in mind is, that ecchymosis and purpura in the inferior ex- 
tremities are sometimes caused by the action of the iodide of potassium. The 
effects of the latter on mucous membranes should also be carefully observed. 
It may cause inflammation of the conjunctiva; the submucous cellular tissue 
gets infiltrated and puffed up; the eyelids turn red and oedematous, and, 
when the inflammation and effusion are not arrested, the internal parts of 
the eye become involved in the affection, and photophobia is the result 
of this state of things. The normal mucous secretion is always a little in- 
creased, but it does not take the muco-purulent character, as in the case of 
catarrhal ophthalmia. Coryza, of a more or less severe nature, often exists 
at the same time; it is preceded and accompanied by headache and a pretty 
abundant mucous secretion; but this coryza never reaches the suppurative 
state; it seldom produces more than a catarrho-serous flux. These affections 
never give rise to any fever, and they disappear as soon as the iodide is given 
up. This coryza is an accident which we should not overlook; for it is of 
importance to avoid it when we have to treat a tertiary affection of the nasal 
fossae. As for the effect of the iodide on the intestinal canal, I have to state 
that persons enjoying good health can bear very large doses of it; I have 
given as much as fifteen drachms a day. M. Puche has often given ten 
drachms per diem, after commencing with six; and it has been noticed that 
it improves the appetite of the persons who use it. With some patients a 
certain pleurodynic sensation, corresponding to the cardiac extremity of the 
stomach, is felt after its ingestion; but it never causes vomiting. The sub- 
mucous cellular tissue of the stomach may, by the use of this iodide, undergo 
the same modifications to which we have noticed the conjunctiva to be sub- 
ject; a sort of hyper-secretion and intestinal ptyalism takes place, and much 
of the fluid which ought to have been secreted by the skin is rejected by 
the mouth. This liquid has a slight taste of iodine; it is not fetid in the 
least; the gums are not swollen, and there is no fetor in the breath, as hap- 
pens in mercurial ptyalism. The same effect may be produced on the other 
portions of the intestinal canal; the patients are then seized with abundant 
serous diarrhoea. The iodine is eliminated from the system by the kidneys; 
half an hour after the ingestion of it its presence may be ascertained in the 
urine; and it should be remembered that the presence of iodine in the blood 750 
A SYSTEM OF ORAL SURGERY. 
increases the renal secretion. I have even observed a case of polydipsia 
which went on as long as the iodide was used, but disappeared when the 
latter was discontinued, gradually springing up again as the use of the salt 
was resumed. 
Effects of Iodide of Potassium.-The effects of the iodide of 
potassium on the circulation are of a sedative kind; it diminishes the number 
of arterial pulsations, and lowers their force, but they may regain their normal 
standard if the remedy act beneficially on the system ; the same arterial energy 
may also reappear when the iodide causes a slight phlegmasia. This salt is 
somewhat antiplastic; for it has rather a tendency to liquefy the blood, and 
may even produce the peculiar hemorrhages of purpura. When the effect 
of the iodide on the nervous system is carefully watched, it is found to cause 
a certain excitement of the nervous centres, followed by a little uncertainty in 
the movements and in the intelligence.* 
Donovan's Solution.-A combination much employed by Sir Astley 
Cooper, in cases where the iodide of potassium did not seem to favor the 
patient, was the liquor arsenici et hydrargyri hydriodatis,-Donovan's solution ; 
the dose is from five to fifteen drops thrice daily. 
Local Treatment of Venereal Tongue Affections.-Concerning 
the local treatment of the venereal affections of the tongue, with which, in a 
work like this, we would seem to have most to do, little is to be added outside 
of the suggestions offered in the previous paragraphs. The treatment has 
principally to be constitutional in character: direct medication is perhaps to 
be esteemed simply as palliative. 
Lactuca Sativa and Hemlock.-As a local application of a common 
signification, lactuca sativa five ounces, honey one ounce and a half, and alum 
one drachm and a half, is a favorite with Ricord. Another consists of a de- 
coction of hemlock, six ounces and a half, to bichloride of mercury, three 
grains. The use of acids applied to the ulcers in cases where the dyscrasia 
has been corrected or nearly so is to be recommended. It is surprising with 
what rapidity a syphilitic ulcer will frequently respond to occasional touches 
of almost any of the mineral acids. 
Quinia and Iron.-In a bad case of mucous tubercles the author once 
treated, he got his patient well by daily salt baths and the local use of a paint 
composed of sulphate of quinia and iron; twenty-five grains of the former 
to two drachms of the muriated tincture forming the combination. The 
tubercles were painted twice a day for two months. 
Borax.-Borax is a soothing application; it may be rubbed with water 
into a cream, and applied ad libitum. Boro-glyceride diluted with eight parts 
of water furnishes an admirable application. 
Specific Treatment.-A species of local specific, to be used on the 
part and rinsed away after a few moments, is composed as follows: 
* Ricord. THE TONGUE AND ITS DISEASES. 
751 
R Aquae destillatae, 3ixss; 
Ferri perohloridi, 
Acidi acetiei, 
Acidi hydrochloric!, aa 3j. M. 
Sig.-This may be repeated three times a day. 
Use of Knife.-Fissures and fistulae are sometimes, in their chronic 
form, to be cauterized, nitric acid, pure or dilute, being used for the purpose. 
In a case of long-standing fissure of the tongue, the author on one occasion 
cut out the bordering induration, the patient making a rapid recovery. 
Papayotin in Treatment of Fissure.-In treatment of fissure of 
the tongue and of the raw red tongue, Professor Schwimmer recommends 
papayotin as a curative agent of surpassing character for good. His formula 
and manner of application are as follows: 
Ji Papayotin, .05 to 1.0 (8 to 16 gr.); 
Aquae destillatae, 
Glycerini, aa 5.0 (80iq,). 
Sig.-The solution to be applied with a camel's-hair brush two to six times a day after the 
parts have been previously well dried.® 
Zinc Chloride.-Chloride of zinc, twenty grains to the ounce of water, 
is found a useful application in chronic syphilitic conditions, whether of ulcer, 
fistula, or fissure. Cocaine is found both comforting and healing. 
Mucous Lesions resultant of Smoking and Drinking.-In 
smokers, and in persons addicted to strong drinks, or with such as feed on 
irritating diet, the lips, cheeks, tongue, and especially the fauces, as pointed 
out by Dr. Charles Drysdale, and as has frequently been observed by the 
author, become the seat of interminable eruptions of mucous syphilitic lesions. 
These habits are not to be indulged by persons afflicted with the general dis- 
* Fissures of the Tongue.-In some people, especially where gastric disturbances are 
present, the tongue suddenly becomes fissured all over, without, however, becoming coated, 
changing its color, or losing its moisture. Professor Schwimmer ( Wiener Med. Woch., 10, 
1886) had the opportunity to experiment on some cases at his clinic. Although he tried chromic 
acid, which had been recommended by Vidal, and though he applied iodoform, which Dr. 
Unna, a dermatologist of Hamburg, had greatly praised, in none of his cases did the tongues 
evince any improvement. If anything they became worse, especially under iodoform. As 
the patients were greatly annoyed by this morbid state of their tongues, Professor Schwim- 
mer tried a series of remedies in the hope to bring about some alteration, but utterly 
in vain; even Kaposi's treatment with nitrate of silver was useless. Some improvement 
was noticed after the applications of soda solutions, and the lactic acid, first employed by 
Schiff, gave the patients decided relief, and the latter in one case almost established a cure. 
Finally, Schiff used papayotin, and the result was surprising. In every case an ameliora- 
tion was at once noticed, and within a few weeks a perfect cure was obtained. The effect 
is not a macerating one, as one would think from the action of the drug on digestion, but 
it ACTS BY STOPPING THE PAIN IN THE PARTS DEPRIVED OF THEIR EPITHELIUM, AND CAUSES A 
RENEWAL OF THE LATTER. 
In twenty-five cases, many of which were of many years' duration, a complete and perma- 
nent cure was established in all with the exception of one, where a syphilitic dyscrasia existed, 
but where specific treatment brought about no result either. But even in this case a great 
amelioration was obtained. 752 
A SYSTEM OF ORAL SURGERY. 
ease. Smoking is to be discontinued at once by a syphilitic patient who would 
avoid oral and throat complications. 
Tongue enlarged from abuse of Mercury.-Mercurial enlarge- 
ment and induration of the tongue are conditions frequently demanding 
treatment. One of the first effects of mercury is often seen in the markings 
made upon the sides of this organ by an otherwise not observed swelling which 
has crowded it against the teeth. A tongue, tumefied by the impression made 
by the medicine, may become so enlarged as to fill the whole mouth. One par- 
ticular case is just here recalled, where, to prevent the patient from being 
smothered, the writer was compelled to string the part and drag it forward 
over the lower jaw, fixing it until relief could be otherwise secured. 
Ulcers from use of Mercury.-Mercurial ulceration of the organ is 
another of the offences of that medicine. Such ulcerations are in appearance 
indolent and yet irritable, and are associated with similar conditions of the 
gums, and with salivation: the diagnosis is plainly marked. 
Rational Treatment of Mercurial Conditions.-The rational 
treatment of mercurial conditions refers to the correction of local impressions, 
together with elimination of the agent from, and support applied to, the 
system at large. In rapid swellings of the tongue it may be found necessary 
to resort to the use of leeches combined with most marked derivation. Such 
treatment, combined, if the circulation be sthenic, with some arterial depres- 
sant, as aconite, or veratrum, will commonly relieve from immediate danger. 
Unless, however, the ptyalism has been acutely excited, and the subject be 
strong and vigorous, the means of cure employed will be succeeded by much 
lassitude and depression; such result is, however, a necessity, and the treat- 
ment will, perhaps, have saved a life. Local medication in cases of this 
kind is simply palliative and soothing. Lactuca sativa and honey, recommended 
in the syphilitic sore mouth, is an excellent gargle. Sage-tea combined to 
a full saturation with chlorate of potassium, is another agreeable application. 
Common table-tea is very grateful to a patient. In combination with these, 
or any similar demulcent gargle, great relief is to be afforded by the free 
exhibition, internally, of bromide of potassium: 
U Potassii bromidi, §ss; 
Aqiiae, §viij. M. 
Sig.-Tablespoonful repeated occasionally as the patient is found nervous. Twenty 
grains, as here directed, may be prescribed three times a day at the least. The author 
has given eighty at a single dose. 
Antagonizing Mercurial Impression.-The acute conditions of a 
mercurial glossitis combated, the practitioner will find it desirable to attend to 
the general requirements of the case. The system is to be protected against 
further impressions of the offending agent, while at the same time it is gener- 
ally found that a present support is demanded. Chlorate of potassium, the 
antagonist of the mercurials, has now obtained in this direction an almost THE TONGUE AND ITS DISEASES. 
753 
universal use: it is to be administered in full saturation, in tablespoonful doses, 
three or four times a day. A very good way to prescribe this salt is to order 
two ounces placed in an eight-ounce bottle, the vessel to be kept filled with 
water until all the salt is dissolved. As each dose is taken, the patient replaces 
it with fresh water. 
Direct Applications.-In the treatment of mercurial ulcers the local 
applications suggested have been various. Bismuth, red bark, and borax, in 
equal proportions, act sometimes happily. Chlorate of potassium, tannic acid, 
and iodoform form an excellent combination. Solutions of sulphate of copper 
or of zinc, ten grains to the ounce of water, are cleansing and stimulating ap- 
plications. Iron, opium, chalk powder, aromatic powder, are all, in their turn 
and place, useful. If phagedaena intervene or threaten, the potassio- 
tartrate of iron, as recommended by Ricord in the similar ulcers of 
syphilis, is not to be omitted: this may be used in the strength of thirty 
grains to the ounce. It is also to be administered internally in doses varying 
from five to ten grains repeated every two hours. 
Chronic Phagedaena.-Chronic phagedaena, which in some degree 
associates itself more or less frequently with mercurial ulcers, is best treated 
by potential cauterants. Of these, a favorite is creasote ; this is to be applied 
with care, however, as it may provoke secondary inflammation. Carbolic acid 
is a useful article, and sometimes proves very reliable. Nitric and hydrochloric 
acids are highly commended by many practitioners ; when applied, every recess 
of a sore is to be burned, and this is to be repeated daily until healthy granu- 
lations appear. Phenol-sodique, used full strength, is an admirable application. 
Scirrhus.-Of the third form of constitutional impressions, scirrhous 
carcinoma may now invite consideration. The scirrhus of the tongue, from 
the circumstances of its association and position, is to be deemed a necessarily 
dangerous, if not fatal, disease. Scirrhus in other parts may be cured; that 
is to say, being removed, it may not reappear in the part of removal,-although 
the disease is seldom, if indeed ever, permanently combated. That scirrhous 
carcinoma is not, however, at least in its incipiency, so formidable an expres- 
sion as the encephaloid, seems to be the universal impression : there is a fixed- 
ness, an apparent isolation, about it which always invites operation. Situ- 
ated in the tongue, such isolation is, however, unfortunately, not so 
marked as when found in many other parts: the disease appears here as an 
induration rather than as what might be termed a lump, and this induration 
has not, commonly, a definite boundary ; hence, if it be removed by operation, 
one is at a loss to say whether such removal has been complete. A carcino- 
matous scirrhus is to be distinguished from scirrhus of local significa- 
tion,-first, by its resistance to treatment; and, second, by the peculiar darting, 
lancinating pains which, sooner or later, always appear in it; these pains are 
markedly diagnostic. Again, a scirrhous carcinoma is apt to have a heredi- 
tary history: a generation may have escaped, but it is apt to be discovered 
somewhere in the family. 754 
A SYSTEM OF ORAL SURGERY. 
Local Medication.-Cauterizing a carcinomatous scirrhus is worse than 
useless. If such a lesion be not widely cut away, it is better, a hundred times 
better, to let it alone. Many a tumor of this class that would have remained 
dormant for years has been excited to destructive malignancy by over-officious 
meddling with it. If a practitioner do not know the character of a tumefac- 
tion upon a tongue, he cannot act more wisely than in letting it alone until 
continued observation has secured to him the proper diagnosis. 
Fungus Haematodes.-At a period very various as to time, a scirrhous 
carcinoma ulcerates. If the tumor have attained any size, fungous granula- 
tions sprout forth, giving that expression known as fungus haematodes ; 
if, on the contrary, the tumor ulcerate while small, it is irregular, puck- 
ered, everted in its edges or elevated, and covered with abundant granula- 
tions : the discharge may be thin and sanious, or purulent, the latter character 
being, however, rare: it differs from the syphilitic sore in its granulative 
bottom. 
Histology of Scirrhous Carcinoma.-A section of scirrhous carci- 
noma presents a stroma dense, abundant, and closely meshed. A fibrous 
structure is always more or less marked, particu- 
larly in its occult state, such structure assimilating 
both the white and yellow tissues, being perhaps 
really these tissues. A diagnostic sign is a pecu- 
liar creak or cry given under the knife. Another 
is a shrinkage or contraction in the centre of a 
section. Still another is a creamy juice, which 
may often be scraped from it. 
Heteroclitic Cells.-In looking micro- 
scopically at a slice of scirrhous carcinoma, the 
areolae existing in the stroma are found filled with 
granules, nuclei, and nucleated cells. These cells 
being of diversified form and common to no tissue, 
the term heteroclitic is justly applied to them. 
The appearance of such a section is exhibited in 
the engraving (Fig. 630). 
Commences on Sides of Tongue.-As scirrhous carcinoma com- 
monly begins upon the sides of the tongue, jagged and sharp teeth irritating 
the parts may be supposed to have some influence in its localization; such 
teeth, under all circumstances, are to be removed or smoothly dressed. (See 
Epithelioma, which is now most commonly affirmed to be the same expres- 
sion of the cancer vice as this considered.) 
Manners of Treatment.-In the treatment of scirrhus of the tongue 
by amputation, several modes are employed. One, that of the French school, 
is by means of an instrument known as the ecraseur of Chassaignac. This is 
simply a delicate chain arranged from a handle, which little by little crushes 
off the part. Another mode, that of strangulation, consists in the introduc- 
Fig. 630. 
A microscopic view of the 
cancer-cells filling the inter- 
stices among the bundles of the 
fibro-cellular tissue. Magnified 
about two hundred times. 
(After Paget.) THE TONGUE AND ITS DISEASES. 
755 
tion of circumscribing ligatures, which, being drawn tightly, cut off all 
circulation from the diseased part, thus compelling its separation. Another 
means of treatment widely employed, and in instances recommended by very 
high authority, consists in the use of caustic remedies ; of these there 
is a great variety,-arsenic, however, forming the base of most of them. 
No remedies require to be used with more judgment and caution. If the 
practitioner desire to try a caustic, the author's experience would suggest 
chloride of zinc: 
Zinci chloridi, 
Aluminis pulveris, aa gr. v; 
Acidi tannici, gr. ij ; 
Ferri persulphatis, gr. iij ; 
Glycerini, q. s. for a paste. M. 
To apply Chloride of Zinc.-To apply this paste, draw the tongue 
forward, hold, and dry it carefully in a napkin. Lay some crystals of zinc 
on the part, and cover over with the paste. This may be allowed to remain 
as long as the tongue can be kept dry. Finally, wash the debris away, and 
the application is completed. 
Glossitis.-It may happen, after such an application, that severe general 
glossitis will supervene ; this is unfortunate, and implies that harm rather than 
good has been done. In making a caustic impression under such circum- 
stances, the parts are to be cpickly killed, not excited nor provoked. 
Galvano-Cauterant.-The galvano-cauterant, a means suggested origi- 
nally by Heider, and lately made quite practical by Hilton, is thought by 
many to be greatly preferable to the potential cauterants; this consists of a 
long, delicate bladed forceps transmitting copper wires, which, being applied 
to the part to be acted upon, are heated to whiteness by the galvanic current, 
and destroy it instantly. 
Injection of Persulphate of Iron.-Injection of persulphate of iron 
is still another means employed and commended. The writer's experience 
with the agent has not led him to look on it as a specific. 
Maisonneuve's Arrows.-The arrows of Maisonneuve, points tipped 
with chloride of zinc, may be used by those who do not fear a resulting inflam- 
mation. Two, three, or more of these arrows are made to circumscribe a 
tumor, precisely as practised by that surgeon in his operations upon the mam- 
mary gland. 
Caution enjoined.-The author desires to emphasize caution as to 
meddling over-ofliciously with cancer of the tongue, affirming, without hesita- 
tion, that, as a rule, very much more harm than good attends attempts 
at radical treatment. A case if not favorable by reason of concentration is 
best let alone. Chlorate of potassium finely pulverized and kept applied 
retards the progress of the disease. 
Epithelioma.-Except as the lower lip is concerned, in no situation is 
epithelioma of cancerous expression more frequently met with than upon the 756 
A SYSTEM OF ORAL SURGERY. 
tongue. Situated at the sides and along the fraenum, the disease is commonly 
first noticed as an irregular puckered patch of more or less hardness, and 
almost from the very beginning has associated with it a characteristic pain. 
More frequently than otherwise, instead of one patch, a sufficiently close 
observation will discover the affected side studded,-a matter which is not 
long in being made evident enough to the patient. After a time, differing in 
individuals, these patches sprout forth the giant granulations so characteristic 
of the disease, the surface of the sore becoming foul and ragged, and inclining 
to spread over neighboring parts. In some cases the disease exists as an in- 
filtration, involving the full side of the tongue originally affected, but not 
likely passing the raphe. 
Dormant Condition.-In no cases of disease does there seem to exist 
greater reluctance on the part of a general practitioner to the admission of 
the existence of a fatal malady than in that of epithelioma of the tongue; 
and this perhaps is not to be wondered at, seeing that not infrequently an 
ulcer of such signification will lie in a dormant condition for a period of sev- 
eral months, looking to the inexperienced scarcely so formidable as a syphilitic 
sore. These are the cases for operation. 
Confounded with Syphilis.-Cancerous epithelioma, so frequently 
confounded with syphilis, is to be distinguished from the latter expression not 
only by its location, but with most assurance by its appearance: the first being 
characterized by isolated giant granulation of rough surface, the latter 
by a soft, pasty base. The two are really very unlike, and should deceive 
no one: even the primary chancre sometimes found here bears no resemblance 
to epithelial carcinoma. 
Progress.-The progress of lingual epithelioma is of most distressing 
character; the organ enlarges and stiffens, mastication and deglutition become 
functions of difficult and painful performance, the saliva dribbles constantly 
over the chin, and the patient finally perishes from exhaustion. 
Extremes in Treatment.-Cancerous epithelioma of the tongue must 
either have attempted with it the most radical extirpation or be soothed into 
quiet and into such abeyance as is possible to be obtained. Of the latter means, 
advantage has been taken of a partial paralysis, securing immunity from pain 
through section of the lingual nerve; while it has also been deemed that much 
control over the progress of the disease is to be secured bj> ligation of the 
lingual artery of the affected side. 
Local Obtunders of Pain.-In the practice of the author, where, in 
certain cases, operative means of any class have not been thought advisable, 
the patients have expressed themselves as receiving great relief from the local 
employment, by means of an atomizer, of the following combination: 
U Acidi carbolici fluidi, 5j ; 
Sodse sulphitis, ; 
Aquae, ^x. THE TONGUE AND ITS DISEASES. 
757 
Boro-glyceride.-Boro-glyceride, one ounce to eight of water, a little 
phenol-sodique being added, furnishes an agreeable wash. 
Citric Acid.-Citric acid, in the proportion of four grains to four hun- 
dred of water, applied to a sore on scrapings of old and fine linen, affords 
much comfort. 
Cocaine.-Cocaine, ten to fifteen grains to the ounce of water, is to find 
cautious employment. Its use is commonly attended with much comfort. 
Systemic Obtunders of Pain.-When it becomes evident that there 
is no cure for a patient morphia may be used ad libitum. Commencing with 
a quarter-grain three times a day, limit is reached only with control of pain. 
Ten grains in divided doses have been taken during twenty-four hours. 
Acetate acts better than the sulphate. Atropia, in doses of of a grain, 
is to be taken three times a day. The bi-meconate of morphia, pre- 
pared in solution of laudanum strength, is a good preparation to use before 
pain becomes over-severe. The dose is one to two teaspoonfuls. (See 
Laudanum.') 
Location of Tongue Cancer.-Lingual epithelioma most frequently 
makes its appearance either at the side of the base of the organ or under its 
tip. Frequently, however, where jagged teeth exist in the arch, it may arise 
as an abrasion, the location being without doubt influenced by the irritant. 
Such a lesion is not apt to be appreciated in its true character until its refusal 
to heal is noticed, after extraction of the offending tooth. Still another cause 
of localization in this direction arises from a malarticulation of the posterior 
teeth, the tongue on each occlusion being caught and fretted. The peculiar 
articulation referred to is to be seen when the molars of both jaws incline 
inward, striking above at the buccal angle and leaving a space with the base 
looking inward. The author has frequently had under his care cases of epi- 
thelioma which apparently had been thus located.* 
* SYPHILITIC AND CARCINOMATOUS LINGUAL ULCERS 
syphilitic. 
Age.-Any time after puberty; most com- 
mon to smokers. 
Situation.-Most commonly upon dorsum; 
more frequently than supposed at sides. 
Form.-Edges defined; surface excavated 
and pasty. 
Pain.-A simple soreness. 
Progress.-Of tardy action; stationary; 
responds to anti-syphilitic treatment. 
Glands.-Post-cervical nearly always en- 
larged ; immediately neighboring glands not 
necessarily. 
History.-Primary and secondary syph- 
ilis. 
CARCINOMATOUS. 
Age.-Seldom until after fifty. 
Situation.-Most commonly at the sides, 
and encroaching speedily upon floor of mouth. 
Form.-Edges reasonably defined, everted, 
hard; bottom granular and of active expres- 
sion. 
Pain.-Specific; burning, cutting, darting. 
Progress.-Continuous; often rapid; no 
response to treatment. 
Glands.-Post-cervical not affected; sub- 
lingual and submaxillary commonly hard- 
ened and enlarged. 
History.-Likely none; possibly heredi- 
tary connection; not improbably local irri- 
tation from jagged teeth. 758 
A SYSTEM OF ORAL SURGERY. 
Epithelial and Scirrhous Cancer.-The oneness of scirrhous and 
cancerous epithelioma of the tongue is beyond dispute; that is, as a common 
specific nature is concerned ; histological differences, when existing, have the 
meaning in anatomical relations. The treatment differs certainly in nothing: 
a cancer locating itself in the tongue implies a fatal result. 
Tobacco Tongue.-Inveterate smokers and chewers of tobacco are not 
unapt to be found with a tongue that is somewhat enlarged, dry, and fissured, 
and yellowish-brown in color. Complaints on the part of patients refer to 
stiffness, to harshness of surface, and to diminished motion. 
White Tongue-Tape-Worm.-A condition of the organ where 
the extreme tip and edges maintain a natural appearance while the centre is 
a dead white has been met with by the writer as the result of presence in the 
alimentary canal of a tape-worm. 
Tubercle.-Tubercle, to the apprehension of the writer, signifies a cata- 
lytic result arising out of lymphangitis; this, whether the tubercle be found 
in the tongue or in the lungs. Lymphatic obstruction implies stasis in tissue 
metamorphosis; out of this, or associated with it, is the materia peccans. 
Lymphangitis is not common to the region of the tongue, consequently tuber- 
cle is as rare to the situation as it is common 
to the lungs. That it exists occasionally, how- 
ever, has been fully illustrated in the studies 
of Langham. Tubercle of the tongue tends 
to self-cure through abscess. Where 
abscess terminates in an indolent ulcer, iodine 
or light touches of the actual cautery may be 
used.* 
Cystic Tumors.-Cystic tumors of the 
tongue, while not frequent, are yet not suf- 
ficiently rare to make allusion to them un- 
necessary. That known as meliceris is round, free from pain, and filled with 
a glutinous, honey-like substance. A peculiarity of this cyst is the fungiform 
character of its bottom, this portion looking pyogenic. A second order of 
Fig. 631.-Cystic Tumor of 
Tongue. 
* Manifestations of Local or Surgical Tuberculosis.-An interesting r^sum^ of local 
tubercular manifestations is made by R. Volkmann. 1. Lupus, found generally in persons 
without a hereditary predisposition. 2. The tuberculous ulcerations of the skin, formerly 
described as scrofulous, and most frequent in the young. 3. Primary tuberculous abscess of 
intermuscular, periosteal, or pararticular connective tissue, mostly the result of bone lesion, 
which is frequently overlooked. 4. Primary tuberculosis of the connective tissue, generally 
in the panniculus adiposus of young children. These are the gommes tuberculeuses appearing 
in the shape of numerous flat, small nodules, which soon break down. 5. Tuberculous abscess, 
which is characterized by a distinct lining membrane and the absence of involvement of the 
surrounding tissue. 6. Tuberculosis of the tongue, presenting in the shape of ulcers, 
sometimes torpid, sometimes fungous, at other times forming deeper-seated nodules, which 
soften at the centre. The solitary tuberculous ulcer of the tongue, with fungous 
growth and indurated edges, may easily be mistaken for cancer. In two cases the tongue 
was found covered with superficial ulcers, the intervening tissue being dotted with miliary THE TONGUE AND ITS DISEASES. 
759 
cysts contains lymph, sometimes fairly colloid in consistence and appearance, 
at other times flaky, tubercular, or, it may be, puriform.* 
tubercles. 7. Tuberculosis of the palate and pharynx, found almost exclusively about the 
age of puberty. The lesion consists of flat, confluent ulcers, with yellow base, spreading 
from the palatine arch to the posterior wall of the pharynx and the posterior surface of 
the velum. The extensive contractions and adhesions of the velum and upper part of the 
pharynx are more frequently the result of tubercle than syphilis. In its severer form the 
latter may produce defects of the palate. 8. Ozaena tuberculosis. 9. Tuberculosis of the lips. 
Treatment of local tuberculous manifestations by the use of acid phosphate has 
the commendation of Kolischer, of Vienna. Solutions used by him are as follows: 
First Solution. 
Neutral phosphate of lime, gr. Ixxv; 
Distilled water, gi, Sivss. 
Then add phosphoric acid enough to make a perfect solution. Filter, and add 
Dilute phosphoric acid, Tqjx; 
Distilled water, enough to make giij, 5i. 
This solution is used for parenchymatous injections, and for washing the sores and 
abscesses. 
Second Solution. 
Neutral phosphate of calcium, giss; 
Distilled water, enough to make Oi. 
Add phosphoric acid to make a perfect solution. Filter, and add 
Dilute phosphoric acid, gij to giv; 
Distilled water, enough to make Oi. 
Kolischer's experiences in the use of his formulae are not without warning as to care 
necessary to be exercised in the employment of these means. Inflammatory fever is alluded 
to as being apt to set in after the parenchymatous injections. (Annual of Universal Medical 
Sciences.) 
* There is a disease of the tongue which I have seen every now and then, and which I 
am sure is very often mistaken for cancer, though it is of a different nature. It is a cura- 
ble disease, although it looks like a malignant one in many respects. The first thing of 
which the patient complains is enlargement of the tongue, with some pain. On examina- 
tion, you find a tumor in one part of it, not very well defined, nor with any distinct margin. 
It is a softish tumor, and increases in size, and perhaps a second appears in a different part 
of the tongue, and that increases also. There may be three or four of these soft, elastic 
tumors, with no very defined margins, in various parts of the tongue. This is the first 
stage of the disease. 
In the second stage there is a small formation of matter in one of these tumors,-a 
little abscess, which breaks externally, discharging two or three drops of pus. When the 
abscess has burst it does not heal, but another forms in one of the other tumors. These 
abscesses may assume the form of ulcers, and the ulcers have a particular appearance. In 
the first instance it is a very narrow streak of ulceration, but on introducing a probe you 
find that the ulcer is the external orifice to a sort of fissure in the tongue. The probe 
passes in obliquely: the tongue is, as it were, undermined by the ulcer, a flap of the sub- 
stance of the tongue being over it. 
The disease now becomes more painful, and at last the ulcers may spread externally. 
In some instances they occupy a very considerable portion of the surface of the tongue, but 
generally they burrow internally, and do not spread much toward the surface. This is a 
very distressing state of things, and a man may remain in this state for a long time. The 760 
A SYSTEM OF ORAL SURGERY. 
Hypertrophy of Circumvallate Papilla.-A form of cystic tumor, 
being a cystiform hypertrophy of a circumvallate papilla, is met with occasion- 
ally on the back part of the dorsum. These tumors have been known to 
attain the size of a walnut. To the touch they are quite solid, the walls being 
greatly indurated. If satisfied that there is no malignant association, the prac- 
titioner may puncture the sac and introduce a tent. Iodine is to be used both 
externally and by injection. Ranular cysts, frequently described as lingual 
cysts, are classified by themselves. (See Ranula.') 
Acute Glossitis.-Acute inflammation of the tongue, whether of idio- 
pathic or of traumatic character, is always to be looked on with concern. The 
causes inducing the condition are various. 
Viewed as a distinct lesion,-and this view, no matter what the 
cause, will ever force itself on the attention of the practitioner when called 
to a case,-urgent necessity is always felt for a treatment that shall abort or 
resolve the phenomena as quickly as possible. It is true that all glossal in- 
flammations are not dangerous; but it is the case that all inspire with a sense 
of danger. 
Acute glossitis, idiopathic in form, commonly begins with a sense of 
enlargement and stiffness of some part of the organ, generally the anterior 
glands of the neck do not become affected, nor does the general health suffer, except from 
the difficulty of swallowing food. This is one inconvenience experienced by the patient; 
and he also labors under a difficulty of articulation. The tongue, from its enlarged state, 
may become stiff, not sufficiently pliable for the purposes of speech, and the patient either 
speaks thick or lisps. 
In some instances the disease may be relieved by a course of sarsaparilla, with small 
doses of bichloride of mercury. A strong decoction of sarsaparilla, with from a quarter to 
half a grain of bichloride of mercury, may be taken in the course of the day. Of course, 
if there be anything wrong in the general health, you should endeavor to get that corrected 
and attend especially to the state of the bowels and the secretion of the liver. If the se- 
cretions of the digestive organs be unhealthy, a dose of senna and salts may be given every 
other morning, and blue pill every other night. When the patient is brought into this 
state, one remedy, as I have said, is sarsaparilla with bichloride of mercury; but, accord- 
ing to my experience, this is not the best remedy. The remedy best adapted for these cases 
is a solution of arsenic. Give the patient five minims three times daily, in a draught, 
gradually increasing the dose to ten minims. It should be taken in full doses, so -that it 
may begin to produce some of its poisonous effects on the system. When it begins to act 
as a poison, it will show itself in various ways. Sometimes there is a sense of heat, a 
burning pain in the rectum; sometimes griping, purging, and sickness, and nervous trem- 
blings. A patient who is taking arsenic, especially in pretty large doses, ought to be care- 
fully watched. At first you may see him every two or three days, and then every day; and 
as soon as the arsenic begins to operate as a poison, leave it off. When this effect is pro- 
duced, the disease of the tongue generally gets well; but at any rate leave off the arsenic, 
and the poisoning will not go too far; it will do no harm. If, after a time, you find that 
the disease is relieved, but not entirely cured, you may try another course of arsenic. 
Perhaps it may take a considerable time to get the tongue quite well. Sarsaparilla, with 
the bichloride of mercury, may be given at one time; and at another, arsenic. You cannot 
give either of these remedies forever, and indeed the arsenic can only be given for a very 
limited period; but it is astonishing what bad tongues of this description I have seen get 
well under these modes of treatment, especially under the use of arsenic.-Brodie. THE TONGUE AND ITS DISEASES. 
761 
part; this soon becomes red, painful, and perceptibly swollen. At this stage 
the condition may rest, and after some little time begin to decline. On the 
other hand, a single hour may witness the spread of the inflammation to an 
extent which threatens, or perhaps produces, suffocation. In still other in- 
stances advance is gradual; the general circulation sympathizing, the pulse 
grows rapid and irritable, the skin becomes hot, to decline, however, to the 
cold sweating stage; suppuration or perhaps gangrene terminates the action.* 
* Glossitis, Acute.-"Michael M., aged thirty-six years, employed as a boatman by the 
Barrow Navigation Company, presented himself at the Meath Street Dispensary, Dublin, 
on the 14th of January, 1871. His appearance was characteristic of the affection from 
which he suffered. His countenance was anxious, the tongue protruded between the teeth, 
his speech was thick, or what might be termed the glossitic speech; his breathing was dis- 
tressed. On inquiry, he (Mr. Croly) ascertained that the man had got a severe wetting some 
days previously, and had his feet also immersed in water. He shivered, and felt a soreness 
at the root of the tongue. He had not been taking any medicine, and up to the time of 
severe wetting was in robust health. In addition to the symptoms detailed, he had a drib- 
bling of saliva from the mouth, with headache and dysphagia. The pain in the tongue, as 
the disease advanced, was described by him as of a stinging nature. On examination, he 
found the tongue covered with a white exudation, like a false membrane. The organ was 
large, protruded, and exquisitely tender to the touch. The sublingual space was infiltrated 
and chemosed, and the fringe beneath the tongue resembled a cock's comb. The tonsillitic 
regions were natural, and bore pressure without causing any uneasiness. He got the patient 
to open his mouth sufficiently to enable him to introduce his little finger, and the man winced 
when he depressed his tongue. He observed that the palate and tonsillitic regions, as seen 
internally, were not in the slightest degree altered. He considered from the patient's general 
symptoms, and the infiltrated condition of the tongue, caused by the exudation of lymph in 
addition to the engorgement with blood and serum, that no time should be lost in giving 
him relief by the knife. He accordingly introduced a sharp-pointed bistoury far back, and 
made a free incision at each side, parallel with the raphe. The wounds gaped and bled 
freely, and the patient's speech became suddenly better. He next punctured freely the 
chemosed sublingual space. A warm bath and a purgative draught were prescribed, and he 
warned the man against cold, and recommended him to come into hospital, but he declined. 
On the following day he called at the dispensary, and was much improved. The tongue was 
still tender to the touch, but the symptoms were so much relieved that, notwithstanding his 
advice to the contrary, he returned by boat to the country that evening, and he had heard 
nothing of him since. The notps of the next case to which he would call their attention 
were sent to him by Dr. Barry, of Kanturk. He visited a man, aged forty, whose respira- 
tion, articulation, and deglutition were very painfully affected. His tongue protruded be- 
tween his teeth, and was so engorged as to fill all the space up in the palate; and the tissues 
from the chin to the larynx were infiltrated. With some difficulty, Dr. Barry introduced a 
long and narrow bistoury on the flat, and, having turned the blade on its edge, he made two 
longitudinal incisions parallel to the raphe, with instantaneous relief. There was a copious 
flow of blood, which relieved the danger of impending suffocation, and the patient recovered 
in a few days, and was now in good health. The notes of the following three cases were 
kindly given to him by Dr. Leeper, of Keady. Dr. Leeper called the cases 'Glossitis.' 
The first was followed by an attack of delirium tremens, and after that by diffuse inflamma- 
tion of the left leg. Mr. , of full habit of body, a free liver, of intemperate habits, 
dined at a club with seven friends on New Year's eve. He left the hot dining-room late, and 
drove home, a distance of six miles, the night being bitterly cold and frosty. Next morning 
he awoke with sore throat, some difficulty of swallowing, and had a dry, parched, and swollen 
tongue. These symptoms rapidly increased, and Dr. Leeper was asked to see him at ten 
o'clock A.M. The tongue was then greatly swollen, filling up the mouth, and protruding an 762 
A SYSTEM OF ORAL SURGERY. 
Danger of Severe Glossitis.-The dangerous character of a severe 
glossitis demands energetic treatment. Leeches direct to the organ, or, better, 
inch between the teeth. It was of a dark-brown, almost mahogany, color. The sublingual 
glands were swollen, and the sublingual spaces filled up to a level with the incisors. The 
submaxillary glands were not much affected. It was impossible to see either the tonsils or 
fauces; but the roof of the mouth was covered with red erythematous patches. When the 
tongue was well moistened he could swallow and speak without much difficulty. Six leeches 
were applied to the under surface of the tongue and sublingual space. They rapidly filled 
themselves, and from the bites there was a very considerable flow of blood, which gave imme- 
diate relief. Before two hours he could keep the tongue in the mouth, and swallow with 
ease. Dr. Leeper considered that the leeching, purging, and sudden withdrawal of his accus- 
tomed stimulant and food brought on an attack of delirium tremens. The next case was 
one of acute glossitis, treated by free incisions on the dorsum of the tongue. P. R., a farm- 
laborer, was attending a corn-mill, getting oatmeal prepared. When there, he assisted the 
kilnman in turning the oats when drying, got into a profuse perspiration, and soon afterward 
exposed himself, on a cold, biting day in March, and was chilled. This was followed by 
swelling of the tongue, and difficulty of swallowing. Dr. Leeper saw him the next day. 
The tongue was greatly swollen,-especially at the back part; there was an abundant flow 
of saliva from the mouth, and the surface of the tongue was covered with a dirty-white, 
creamy-looking paste. He was speaking thick, and said he would soon choke if not relieved. 
There was no enlargement of the tonsils or the submaxillary glands. Dr. Leeper made with 
a lancet, the only instrument he had with him, two incisions on the dorsum of the tongue, 
parallel to the raphe. There was a discharge of four or five ounces of blood and serum from 
these incisions. He received a message next day to say that the man was much worse, and 
on visiting him found the tongue more swollen, protruding from the mouth, and that deglu- 
tition and speech were more difficult than on the day before. He introduced a sharp-pointed 
bistoury, and made two long and pretty deep incisions on the dorsum from the base to the 
tip of the tongue. These bled profusely, and gave immediate relief, and the next day the 
patient could swallow without difficulty, but the speech was thick. His recovery from this 
time was rapid. In the third of Dr. Leeper's cases, the patient was forty-five years of age. 
After exposure to cold he complained of pain and deafness in the right ear, and these were 
soon followed by difficulty in speaking. These symptoms, after having lasted upward of a 
fortnight, were succeeded by rapid swelling of the right side of the tongue. When Dr. 
Leeper saw him, there was a profuse flow of saliva, so much so, that he thought he must be 
laboring under the influence of mercury; but there was no mercurial fetor, nor were the 
gums affected. The right side of the tongue was as much affected as it could be, but the left 
was not engaged. The tonsils were not enlarged ; neither the salivary nor the submaxillary 
glands were swollen. The root of the tongue was hard and swollen. Any attempt to swal- 
low was followed by a squirt through the nose and mouth, with coughing. It seemed as if 
the epiglottis could not act, and that the fluid passed into the larynx. Some milk was in- 
jected (by means of a large elastic catheter attached to an elastic bag) into the oesophagus. 
He sometimes succeeded in swallowing, but the attempt far oftener failed, and was very dis- 
tressing to him. Dr. Leeper made a free incision, on the dorsum, from the back to the tip 
of the tongue on the right side, but the discharge of blood was inconsiderable, less than he 
could have supposed from the extent of the incision. Fomentations with hot chamomile-tea 
were used and kept in the mouth, and his health supported as well as possible with milk and 
beef-tea. Next day he was worse, and Dr. Leeper made a still deeper and more extensive 
incision on the right side of the tongue. There was no discharge of blood or serum, at least 
not more than two ounces, and no relief from it. Mr. Young, of Monaghan, saw the patient 
the next day, and advised leeches to the side and under surface of the tongue. These in- 
duced profuse bleeding, which was kept up by cold water in the mouth, Dr. Young thinking 
that cold water promoted bleeding from leech-bites better than hot. The swelling of the 
tongue subsided at once after the leeching, but the right side of it remained thicker and THE TONGUE AND ITS DISEASES. 
763 
beneath the jaw, bleeding from the arm, catharsis, diaphoresis,-any or all of 
these means are successively to be brought into requisition. A plan of treat- 
ment, as reliable as any in character, is as follows: place on the back of the 
neck a cataplasm of mustard and red pepper; put the feet in water, as hot as 
can be endured; give a full dose of sulphate of magnesia. If' now the dis- 
ease be not held in check, wrap the patient in shawls or blankets and admin- 
ister spirits of Mindererus until full diaphoresis is secured. If even yet control 
be not secured, let ten, twenty, or thirty American leeches, or a third of the 
number of Swedish, be placed beneath the jaw. If the action be still uncon- 
quered, blood pro re nata is to be taken from the arm, and the tongue itself 
freely incised. If yet the swelling go on, and suffocation is threatened, laryn- 
gotomy or tracheotomy becomes a necessity.* (See these operations.) 
harder than the left, and the man's speaking was still difficult and imperfect. Mr. Croly 
proceeded to say that it was superfluous to go into the subject more fully, as it had been 
already discussed at a previous meeting. He would only state that he thought the case he 
had detailed was a very well-marked case of idiopathic glossitis. The man working on a 
river and getting a severe wetting, not taking any mercury, the tongue becoming greatly 
swollen, the characteristic voice, the absence of any tonsillitic inflammation,-all these 
features showed that it was a typical case of idiopathic glossitis. 
" Mr. Richardson said he had a case of this kind a short time ago in the Adelaide Hos- 
pital. There was rapid swelling of the right side of the tongue and chemosis of the floor of 
the mouth. In that case he not only made an incision from the base to the point of the 
tongue, along the dorsum, but he also made a few punctures in the chemosis on the floor of 
the mouth, and the man was well in a few days. An exfoliation of mucous membrane fol- 
lowed, which, however, did not interfere with recovery. As there was some doubt regarding 
the period at which the treatment by long incisions was introduced, he wished to state that 
he had found in the Memoirs of the French Academy of Surgery several cases of this kind 
recorded. In one of these cases, published by De la Motte in 1725, the tongue became greatly 
swollen in less than five hours. It soon filled the mouth, and protruded from between the 
teeth. Bleedings from the jugular vein, arm, and foot were performed without relief, but a 
rapid cure followed three deep incisions along the dorsum, extending from base to apex. 
The patient could speak in an hour after the incisions were made. In another case, that 
occurred in 1744, rapid swelling of one side of the tongue took place in a woman; respira- 
tion was obstructed, and deglutition impossible. It was cured by one long, deep incision. 
Louis mentions a ease that occurred in the military hospital at Metz in the year 1740. The 
tongue became spontaneously swollen. Alexander Benedictus, who published the case, men- 
tioned that M. Casteras, the senior physician of the hospital, directed him to scarify the 
tongue lightly. This, however, was not sufficient, and the patient died in two days in con- 
sequence of the swelling. As Louis truly observes, life might have been saved by a couple 
of deep incisions along the dorsum of the tongue." 
® "Mr. J. Z. Laurence exhibited before the North London Medical Society the tongue of 
a woman who had died of acute inflammation of the organ. She had been under Mr. Lau- 
rence's care for acute rheumatism, when, on the evening of the 5th November, he was called 
to her, and found her sitting up in the bed, with a countenance expressive of the greatest 
anxiety, her face pale and bedewed with sweat; she breathed at long intervals, and labori- 
ously; pulse 130. The cause of this was evident; she could not open her mouth to speak, 
for a swelling of the left half of the tongue, which was red, dry, and glassy. On the night 
of the 2d and 3d she had had severe rigors. Mr. Laurence at once made three free incisions 
into the tongue, and about half a pint of blood escaped. About two hours after the bleeding 
had ceased, the submaxillary region began to swell, twelve leeches were applied, and on the 
following morning the right half of the tongue began to swell, and by the afternoon it had 764 
A SYSTEM OF ORAL SURGERY. 
Abscess.-In depraved and tainted conditions of the system, abscesses, 
of what might be called a cold character, occasionally form among the deeper 
muscles of the tongue; such abscesses are not necessarily associated with any 
marked inflammatory phenomena, but may have attention first directed toward 
them by the swelling which appears on the under surface. 
Treatment.-The proper treatment is found in voiding the matter through 
puncture as soon as fluctuation is perceived; otherwise it has happened that 
the pus has dissected its way down the neck, pointing in front of the hyoid 
bone, creating much derangement, and threatening even a fatal result. Treat 
these cases by local stimulating injections and the internal administration of 
tonic medicines. Acute abscess is one of the terminations of glossitis. (See 
foot-note for illustration.)* 
attained full as great a size as the left. With this was a corresponding engorgement of the 
tissues about the jaw; the local depletion had had very little effect in reducing the swelling 
of the left side of the tongue; generally she was worse; rigors now came on, and the pulse 
intermitted three or four beats. Mr. Quain saw her, and proposed incising the right half of 
the tongue, but both patient and friends objected. Mr. Laurence saw her the last time alive 
the same night; her surface was deadly cold; pulse not perceptible at the wrist, yet, strangely 
enough, the respiration went on tranquilly, though feebly. Mr. Laurence at once perceived 
that she was dying of slow asphyxia, and that her only chance was in tracheotomy ; this was 
proposed with more impressive force than a surgeon almost dare do. She and her husband 
doggedly refused. Next morning she was dead. 
"Autopsy.-No organic disease was discoverable. The whole of the tongue was swollen, 
pale, and soft from maceration in a puro-serous fluid, which infiltrated the substance. The 
superior aperture of the larynx was greatly narrowed by serous effusion; the rima glottidis 
to a less extent; below this point the whole of the trachea was perfectly unobstructed; the 
submaxillary region and anterior triangles of the neck were infiltrated with a serous fluid, 
which, among the suprahyoid muscles, had assumed a purulent aspect. The lungs were 
singularly healthy; the heart, kidneys, and bladder presented no signs of disease. 
" From the above facts, it follows that tracheotomy would in all probability have saved 
the woman's life; and Mr. Laurence believes he proposed it at the proper time. It is true 
there was, throughout the case, not one fit of suffocation. On the contrary, she died choked 
in the most gradual conceivable manner; and were he to meet with another case, he would 
not defer the operation until the patient was in his last gasp, as was too commonly the case, 
but resort to it as soon as he saw the patient sinking, previous measures not having ameli- 
orated his condition. A curious pathological fact, which Mr. Laurence noticed and pointed 
out to Mr. Phillips, who attended the case with him, was the successive and separate inva- 
sion of the two halves of the tongue by the inflammatory action, offering a remarkable 
instance of the dependence of pathological changes on the anatomical distribution of the 
blood-vessels." 
* The following suggestive case of abscess of the tongue, ending fatally from hemorrhage, 
is related by Mr. Ward, being presented before the London Medical Society: 
" E. T., aged seven, was born with a slight red enlargement in the centre of the tongue. 
No inconvenience or difficulty in the ordinary motions of the tongue, or in swallowing, had 
ever been experienced; the general health had always been good. In the night of Septem- 
ber 27, having been in her usual health at bedtime, she was attacked with pain and swell- 
ing under the chin and both sides of the lower jaw; slept very little, and the following 
morning had pain in the tongue, with great difficulty in speaking, or swallowing anything 
but liquids. She had an aperient powder at night, and the lower jaw was fomented fre- 
quently. In this state she continued for two or three days, and was visited by me on October 
1, when the following appearances were noted: Face flushed; eyes very bright; counte- THE TONGUE AND ITS DISEASES. 
765 
Neuralgia of the Tongue.-The only neuralgia of the tongue which 
seems special and peculiar to the organ has its seat about the extreme tip; the 
nance anxious; great swelling, redness, and extreme tenderness of the parts under the 
lower jaw; very slight swelling of the tongue itself, which is covered with a thick, brown 
fur; is unable to open the mouth wide, or move the tongue beyond the teeth, or to speak, 
and has great pain in the mouth; pulse very quick and sharp; great heat of skin, and 
thirst urgent; bowels confined. Ordered eight leeches to be applied under the chin; to take, 
at bedtime, four grains of calomel; James's powder and sugar, of each three grains; a saline 
mixture, containing a scruple of nitrate of potash; one tablespoonful every three or four hours. 
"October 2. Slept more last night than since first attacked; fever great; pain slightly re- 
lieved ; swelling and redness less; mouth nearly closed; was able to swallow the powder in 
jelly, but refuses the mixture, of which very little has been taken; bowels freely relieved, 
evacuations dark and offensive; to take calomel and James's powder, of each three grains, 
and jalap, five grains, at bedtime; use a chloride-of-soda gargle, warm, to the mouth, by 
means of a syringe. Fluids taken in the mouth return by the nose. 
"4th. Less fever; rests better at night; difficulty in swallowing or speaking the same; 
can open the mouth sufficiently to allow the tongue to be seen, which is nearly fixed, very 
little swollen, and still thickly coated; the breath extremely fetid; external redness and 
swelling still considerable; the tenderness great; pulse soft, quick, and weak; the bowels 
act freely; was able to pass my finger into the mouth; under each side of the tongue dis- 
tinct fluctuation can be felt; while pressing on the left side the lining membrane gave way, 
and was followed by a profuse discharge of fetid pus, mixed with blood; the point of the 
finger passed easily to the depth of the first joint, under the tongue, giving the sensation of 
a large pulp-cavity; the tongue not very tender, can be moved from side to side by means 
of a small teaspoon, but not voluntarily. Apply strong poppy fomentation frequently, and 
linseed poultice; continue the chloride-of-soda gargle under the tongue, with the syringe, 
and take, of a mixture consisting of six grains of quinine, a teaspoonful every four hours; 
give a little port wine and water frequently, and milk or thin arrow-root for drink. 
" 6th. The pain less since the use of the poppy fomentation, generally sleeping for some 
hours after using it; the discharge of pus and saliva very copious and offensive; lies with 
the head on the left side to allow the free exit of the discharge, otherwise the mouth is con- 
stantly filled; fever less, as also the swelling and tenderness; redness gone; great debility 
and considerable wasting of the body already; can swallow fluid, and is eager for the wine; 
very little quinine has been taken; bowels act twice a day; can open the mouth wider, but 
is still unable to protrude the tongue, which is cleaner and moister; on slightly raising it 
by the handle of a spoon, a large jagged opening may be seen on the left under side of the 
lower jaw, from which, by gentle pressure under the chin, a profuse discharge of thick pus 
wells up, of which I pressed out at least two ounces; pulse soft and weak. Continue the 
external applications; apply the chloride-of-soda gargle frequently to the mouth and under 
the tongue, with the syringe; take a mixture consisting of two ounces and a half of decoc- 
tion of bark, syrup of orange-peel, and tincture of bark, of each two drachms, a fourth part 
three times a day; continue the wine, and give strong beef-tea and arrow-root frequently. 
" 9th. Altogether improved; discharge less, but still fetid; takes fluid nourishment fre- 
quently, and the wine; the general swelling and the tenderness reduced; more on the left 
side under the jaw than the right, and is unable to protrude the tongue farther. Continue 
all the applications and the mixture. 
"11th. Has not rested so well the last two nights, and has had more pain, particularly 
on the right side, which is more swollen and very tender, the left side being almost in its 
natural state; the discharge has been profuse, but thinner; the tongue is moist and clean; 
not very tender, but less movable; the opening under the left side of the tongue smaller; 
fever returned; has constant hacking cough; not able to swallow so well, or to speak so as 
to be understood. Apply six leeches under right side of lower jaw; continue the fomenta- 
tions and poultices; also, bark mixture and port wine. 766 
A SYSTEM OF ORAL SURGERY. 
pain, which is very irregular in its coming and going, is of the most acute 
character, seeming indeed as if the organ might be in the grasp of red-hot 
pincers. This neuralgia is most frequently encountered in the persons of 
middle-aged men. Vanzetti, for the cure of such a trouble, has recom- 
mended and practised the operation of section of the lingual nerve,-accom- 
plished by first drawing the tongue forward and to one side, and exposing 
the nerve, through incision of the mucous membrane on the border of the 
internal pterygoid muscle. An excellent obtunder is found in the combination 
suggested in the paragraph on Epithelioma. Lingual neuralgias originating in 
" 12th. Has slept very little from the frequent coughing, which tires her very much; dis- 
charge from the mouth less and thinner, but still fetid; emaciation extreme; has changed 
the position of lying to the right side-; left angle of the mouth drawn down; the swelling 
and tenderness on the right side very much increased since yesterday; feels soft; is more 
prominent in the centre, and appears.pointing here; the finger in the mouth can detect 
very distinct fluctuation under the tongue, which is thickly coated and very tender; takes 
very little nourishment, only a teaspoonful at a time : prefers wine to other things. Con- 
tinue the fomentations and poultices. 
"13th. Has had a bad night; is very irritable and feverish; mouth nearly closed; unable 
to examine the tongue; the swelling about the same; the right cheek and under side of 
the jaw of a dusky red color, and very shining; so tender that she has again changed the 
position; lying on the left side; cough less; pulse very small and weak; takes scarcely 
anything; discharge more copious, thicker, and slightly tinged with blood; it now appears 
to come from the right side. In the evening, while coughing, a large gush of blood took 
place from the mouth, mixed with pus, and flowed freely for more than ten minutes. By 
applying ice internally and externally (which I had directed to be in readiness), the hem- 
orrhage was arrested. A cold lotion was applied externally, and an alum gargle frequently 
to the mouth. 
"14th. Has slept very little; unable to lie down, from the constant discharge of fetid 
pus and saliva from the mouth; the swelling of the right cheek and side of the jaw less; 
very tender, of a dull, yellowish color; able to open the mouth so as to examine the tongue, 
which does not appear enlarged; no power of moving it herself; is thickly coated with a 
dark fur, and when pressed upon, a profuse discharge of thick pus fills the mouth imme- 
diately; no return of the hemorrhage; is very pale and faint; pulse very small and weak ; 
has taken more nourishment since last night than for some days before, such as port wine, 
isinglass in milk, beef-tea, jelly, etc. Continue the lotion and alum gargle to the mouth 
with a syringe. At half-past seven p.m., in the act of swallowing a small piece of bread 
and butter, profuse hemorrhage occurred from the mouth, and more than a pint of blood 
was lost before it was again arrested by the free application of ice; it was of a bright 
arterial color. She became faint, and expired at nine p.m. 
" On the day following I made a post-mortem examination of the parts affected. The 
parotid, submaxillary glands, and other parts, having been brought into view, were found 
(on the right side) so much softened, decomposed, and mixed with coagulated blood and 
pus as to be recognized with difficulty, and it was impossible to trace from what vessel the 
hemorrhage proceeded, such was the destruction of the parts. On the left side, the glands 
were of a greenish color, very much softened, and bathed in pus. A probe passed readily 
by the side of the jaw into the mouth. I divided the trachea just above the sternum, and 
dissected the larynx and tongue carefully out. The morbid state of the tongue is shown in 
the preparation before the society." 
In the discussion which ensued, the case was considered a very remarkable one. The 
remarks had reference chiefly to the cause of the disease, respecting which various opinions 
were expressed. THE TONGUE AND ITS DISEASES. 
767 
the offence of jagged teeth have their origin too evident to need comment. 
The causes of many cases seem beyond finding out. (See Neuralgia.') 
Epithelial Desquamation-Raw Tongue.-Cases are not infre- 
quently met with where the dorsal face of the tip of the organ seems to 
have entirely lost its mucous covering, the papillae showing prominently as 
raw points and being exceedingly sensitive and painful. Cocaine solution fol- 
lowed by applications of benzoated oxide of zinc ointment constitutes the 
most satisfactory treatment. (See Use of Papayotin.) 
Effusions.-The tongue is occasionally the seat of formidable congestions 
or effusions. The writer has known an inflamed tongue so swell in a single 
hour as almost to prevent respiration. The organ, when enlargement in- 
creases to an extent which threatens suffocation, looks so vascular that one 
hesitates to use the knife. The practice is to incise freely,-cut deeply from 
behind forward, on each side of the median line, avoiding, however, in the 
depth of the cut, the ranine arteries. A wound thus made will bleed for a 
time freely, even alarmingly; but the common experience is that such cuts soon 
close, and are devoid of danger. Velpeau has recommended the opening of the 
ranine veins in congestion. Leeches may also be applied direct to the tongue. 
Erysipelas.-A formidable danger in the tongue is the presence of ery- 
sipelas : this may be idiopathic, but is most frequently traumatic, operations 
about the jaws being, occasionally, provocative of the condition. The treat- 
ment of erysipelas in the tongue is the same as treatment of the condition 
elsewhere. Iron and quinia, internally and locally, are to be freely employed. 
If this be not found effective, then make incisions. The practitioner is, how- 
ever, never to forget to extend his observations over any functional disturb- 
ances which may exist. (See Erysipelas.) 
Bites of Insects.-The most severe and threatening glossitis ever met 
with by the author was the result of the sting of a wasp, the insect being 
taken into the mouth while the patient was eating blackberries. The tongue 
in these accidents is apt to swell enormously, but, happily, tends to a rapid 
self-cure. If a case be seen immediately, no better application is to be em- 
ployed than common mud ; phenol-sodique is a favorite preparation : later, we 
can only treat such an inflammation like any other of the sthenic type. It is 
well, however, to remember that the swelling in these cases is from effusion 
rather than a congestion ; incisions, if necessary, are always to be made freely. 
Iodine, in these instances, sometimes acts happily ; paint the tongue thoroughly, 
and hold cold water in the mouth. If, unfortunately, erysipelas supervene, 
the iron and quinia combination is at once to be resorted to.* In these cases 
* Tincturae ferri ehloridi, ; 
Quiniae sulphatis, 5j > 
Tincturae cinchonae, 3U to oss- M. 
The author believes that this combination, as a local application, is an approach to, if it 
is not indeed an absolute specific in erysipelas. It will be noticed that the proportions of 
the combination as here given differ from that on a preceding page: this relates to appli- 
cation of the mixture as location is concerned. 768 
A SYSTEM OF ORAL SUROERY. 
the pain becomes excessive, the parts may assume a livid hue, and there 
seems to be a decided tendency to gangrene; particularly does this occur in 
depraved and broken-down persons. Free incisions are never to be neglected: 
the degraded expression of the erysipelas depends upon the separation of the 
molecules-if the expression may be used-from their base of supply; the 
incisions, draining the organ, allow contraction of the parts, and thus restore 
the circulatory relationship. 
Injury from Teeth.-In ulcers or tumefactions of the tongue provoked 
by irritating teeth, it is seldom necessary to do more than remove the source 
of offence. Cases occur, however, where some after-treatment is demanded, 
the provoked ulcer being indolent, or, in some instances, even semi-gangrenous. 
For all such sores, one of the best washes to be used is water changed in color 
to a milky blue by the addition of the compound tincture of capsicum. Where 
a part is simply indurated and not ulcerated, presenting no evident cause, it 
is better, for a time at least, to leave the case to nature. The writer's rule is, 
never to interfere with a non-explainable induration except from necessity. 
In all these cases injudicious meddling is bad practice. 
Erectile Tumors.-Of this character of lingual tumors the author has 
met thus far with some five cases. Of these, the most marked was in the 
person of a babe nine months of age, for whose relief an operation was suc- 
cessfully performed at the hospital clinic. This tumor, which was congenital, 
occupied the whole anterior third of the tongue, protruded from and filled up 
the oral fissure to a considerable extent, was of a dark-red or purple color, en- 
larged very much when the child cried, was soft and fluctuating, and through 
manipulation could be made temporarily to almost disappear. 
Treatment by Operation.-A mode of operation which in two weeks 
resulted in a perfect cure consisted in first strangulating the mass with a 
double ligature, and, after three days, effecting separation through the instru- 
mentality of a wire ecraseur. 
The principle of the treatment of erectile tumors of the tongue is that 
common to this class of tumors wherever found. (See Erectile Tumors.') 
Fatty Tumors.-These, like the erectile, are uncommon. A peculiar 
case met with by the author exhibited the growth looking like a mass of very 
smooth fat, overlaid by the mucous membrane: the situation was the inferior 
left surface of the organ. As the patient spoke, the tumor would bulge out 
over his lower teeth, presenting a most unsightly appearance. 
Metastatic Disease.-An example herewith given explains, without 
other remarks, a character of trouble rare, yet sometimes met with, upon the 
tongue. We may recognize in the disappearance and reappearance of the 
various exanthems an explanation of the condition. I have been consulted, 
says Mr. Wm. McClure, in a paper read before the Harveian Society, by a 
young married lady for rather a curious affection. She informs me that her 
tongue becomes occasionally bestudded with small ulcerations, and, afterward, 
when these get well, the palm of her left hand becomes affected with a sort of THE TONGUE AND ITS DISEASES. 
769 
psoriasis palmaris. The tongue is at present quite well, but the palm of her 
hand is covered with the eruption. When this gets better, however, she 
expects her tongue to become again the seat of disease, for thus they have 
alternated for a considerable time past,-she says about two years. The chief 
reason for which she consults me at present, however, is that she has gout in 
one of her feet. I believe that the whole series of her complaints depends 
on some derangement of the digestive organs, though that is not made very 
apparent by external symptoms. I gave her an alterative pill and a tonic 
mixture, combined with colchicum and an alkali. The gout has already dis- 
appeared, and even the hand is much improved. As soon as the gout was 
got rid of, I substituted for the tonic mixture-in which, as I have just said, 
were wine of colchicum and carbonate of soda-a mixture composed of the 
extract of sarsaparilla combined with the iodide of potassium. As a local 
application to her hand I prescribed an ointment composed of pure iodine, 
iodide of potassium, and hog's lard; but this was found, upon trial, to give 
her so much pain, and produced so much irritation, that I was forced to 
abandon its use after a few days' trial. For it I substituted the following 
ointment,-viz., white oxide of mercury four grains, and extract of conium a 
drachm, rubbed up with seven drachms of prepared hog's lard. This oint- 
ment was ordered to be rubbed into the palm of her hand every day, both 
morning and evening. Besides these remedies, local and general, she took 
occasionally an alterative and aperient pill, made up of blue mass and the 
compound extract of colocynth. The consequence has been that after a 
month's steady use of the remedies the hand has become quite well, the skin 
being now, for the first time these two years, soft, white, flexible, smooth, and 
completely free from itching, heat, and every unpleasant appearance and feel- 
ing. Nor has the tongue as yet shown any tendency to alternate disease, as 
before; so that we have reason to hope-the constitution having been set to 
rights by the means employed-the former chain of morbid sympathy between 
the distant organs of which we have been speaking, and by which a metastasis 
of the psoriasis, from the one to the other alternately, took place so often, 
for so long a time, has been at last broken and destroyed, permitting both to 
remain in their healthy condition. 
Urticaria.-Urticaria, a very common skin-trouble, has similar metastatic 
relation. In a case encountered a wheal would appear either upon the cheek 
or the tongue whenever ice-cream was eaten. 
Hypertrophy.-This condition has been met with and described by vari- 
ous writers.* Hypertrophy may be complete, involving the whole organ, or 
* A case is related by Zacchias, of a male infant well made except that the tongue pro- 
jected three fingers' breadth from the mouth: the child could suck, and it lived until the age 
of fourteen months. Bertholin mentions a case of linguae portentosa magnitude, where a 
male infant was born with the tongue out of its mouth as large as a filbert: as the child 
grew its tongue enlarged to the size of a calf's heart. A case is recorded by Dr. Humphrey 
of a child, eleven years of age, whose tongue from the upper lip to its tip measured three 770 
A SYSTEM OF ORAL SURGERY. 
the enlargement may pertain to particular tissues alone. A case is described 
by Mr. Paget, involving the muscular substance exclusively, the primitive 
fasciculi being found to divide in a dichotomous manner. The epithelium is 
another of the tissues most frequently found affected, instances being on record 
where this structure has thickened so as to resemble a coat of mail. Granular 
hypertrophy, a condition of enlargement of the papillary structure, is some- 
times seen in the form of a mass of warty excrescences covering the whole 
body of the tongue; at other times it is confined to some portions more or 
less limited in extent. 
Treatment of Lingual Hypertrophy.-The treatment of hyper- 
trophied tongue is to be governed by the circumstances and character of each 
particular case. In epithelial hypertrophy the best results seem to have been 
secured through the use of arsenic,-from the thirtieth to the twentieth of a 
grain administered three times a day, its effect being carefully noted. Dono- 
van's solution, the liquor arsenici et hydrargyri hydriodatis, given in five- 
drop doses, has been highly commended; also the solution of Lugol, given in 
the same quantity. These doses are for adults. In a true hypertrophy of 
the organ,-prolapsus, as it is frequently miscalled,-that is, where the body 
has enlarged as a result of congenital impressions, medicinal appliances are of 
little service. This disease is markedly one of young life, commencing 
generally very soon after birth, and progressing tardily but surely until death 
or an operation gives relief. Unaccountable though it may seem, hypertrophy 
is confined almost exclusively to female children,-this sex being affected in 
the proportion of five to one of the other. As may be inferred, hypertrophy 
of the tongue presents various degrees of enlargement; cases are on record 
where the organ has hung from the mouth, resting upon the breast. In the 
instance of elephantiasis, the mucous membrane looks more like the bark 
of a tree than anything else, being rough, dry, and crusted. In the treat- 
ment of hypertrophy we consider the character of the trouble from the aspects 
of activity and chronicity. Where the first of these exists, most is to be 
hoped for from medication; where the latter obtains, little is to be expected 
except from operation. Compression, recommended by Lasser and 
endorsed by Professor Syme, it may not be amiss to try before proceeding to 
excision or ablation; but the treatment will certainly be found to have much 
more of failure than of success in it. The author at one time had at his clinic 
a boy in whom congenital hypertrophy had enlarged one side of the tongue to 
a bulk fully double that of the other; compression had no effect whatever. 
Ablation of redundancy was accomplished by cutting away a V-shaped piece, 
as shown in Fig. 4, Plate II. The manner of relating the parts after the sec- 
tion is explained in Fig. 5 of same plate. 
and a half inches; from the under lip to its tip, one and a half inches; from the angle of 
the mouth round the sides and tip to the opposite angle, six and a half inches. The circum- 
ference of the widest part, which was about the middle of the protruded portion, measured 
six and a half inches circular measurement.-Holmes. THE TONGUE AND ITS DISEASES. 
771 
Atrophy.-As the opposite to hypertrophy, reference is to be made to a 
condition sometimes, though infrequently, met with, of atrophy. A case 
described by Dupuytren found its explanation in a post-mortem, which re- 
vealed the presence of hydatids at the base of the cerebellum ; one of these 
parasites, wedging itself into the anterior condyloid foramen, had compressed 
the lingual nerve and thus obliterated its function. Paget has reported a case 
arising out of pressure, by a piece of dead bone near the anterior condyloid 
foramen, on the hypoglossal nerve. Allan refers to a third instance where a 
physician in opening an abscess, which had formed beneath the jaw, is sup- 
posed to have severed the nerve, as from the time of operation deflection and 
atrophy of the corresponding half of the tongue were observed; these were 
found to continue twenty-five years later. A case reported by W. Fairlie 
Clark details the particulars of atrophy of the organ, confined to its anterior 
two-thirds, where the lesion seemed to lie in carcinoma of the breast. 
Errors of Nutrition.-Errors of nutrition being the cause of asymmetri- 
cal conditions, it is to be appreciated that deficiency may be to such extent as 
insures loss of the organ. A case quoted by Dr. Allan refers to a male aged 
seventy-eight, who suffered from neuralgia of the occiput. The patient com- 
plained at the same time of dysphagia and excessive flow of saliva. By the 
eighteenth day the tongue became flabby, insensible, and began to mortify. 
By the thirty-first day a line of demarcation had formed, which included 
the right half of the tongue and the tip of the left half. The patient re- 
covered. 
Papilloma.-A papilloma of the tongue, as commonly met with, bears 
close resemblance to a common seed wart. A very simple and easily practised 
method of removing such a growth consists in drying the parts by means 
of napkin or rubber dam, and making an application of the London paste. 
A second means is found in transfixing the base by means of a curved 
needle and strangulating the pedicle. Papillomata, if unduly vascular, are 
to be looked on with concern ; a common seat is the side of the organ well 
back. They are met with as large as a phalanx of the little finger. 
Venous Tumors.-A case treated by the writer showed a bulbous vein 
not much less in size than an ordinary hickory-nut; cure was effected through 
strangulation. Varicosity of the veins of the tongue is a sign directing 
attention to possible apoplexy. 
Arterial Naevi.-Growths of this nature are most frequently met with 
about the tip ; treatment is by ligature. (See Nwvi.') 
Cartilaginous Tumors.-Cases of enchondroma are reported as being 
met with. These growths must be very rare; the author has never seen one. 
Treatment would be by excision. 
Immobile Tongue.-Immobility arises out of inflammatory changes 
attended with plastic deposits. The condition is uncommon except in connec- 
tion with carcinoma, and, to a degree, with syphilis. The cure employs sorbe- 
facients, aided, as the second of the causes is concerned, by a specific. 772 
A SYSTEM OF ORAL SURGERY. 
Operations practised upon the Tongue.-From medical necessity, 
or from accident, it sometimes becomes necessary to amputate a part or even 
the whole of the tongue. Surprising as it may seem, such amputations, even 
when of the complete organ, interfere very little with speech, and do not 
entirely obliterate the sense of taste. Mr. Nunneley, an English surgeon, 
lately exhibited to the Pathological Society of London a patient from whom 
he had removed the whole of the organ, this being affected by a submental 
opening, the patient, a man aged thirty-five, recovering without a bad symptom. 
The disease, which had existed sixteen or eighteen months, became worse eight 
weeks before the operation, and, from the pain and difficulty of speaking, the 
impossibility of mastication, and the difficulty of deglutition, was fast wearing 
the patient out. When shown to the society, the man had regained strength 
and flesh ; indeed, said that he felt as well as ever : he talked with distinctness, 
and swallowed with facility. 
A second interesting case is reported by the late James Syme, 
F.R.S.E., Surgeon-in-Ordinary to the Queen in Scotland, and Professor of 
Clinical Surgery in the University of Edinburgh. About twelve months 
ago, says Mr. Syme, I communicated a case in which the tongue had been 
completely removed by excision, on account of extensive disease that threat- 
ened to prove fatal by preventing the admission of nourishment. This ac- 
count was necessarily limited to the operation and its immediate effects, as 
sufficient time had not elapsed for determining whether or not the relief 
afforded would prove permanent, or how far the powers of deglutition, articu- 
lation, and taste would be restored. After his return home to Manchester, 
the patient sent me favorable reports of his progress, but certainly not such 
as to convey any adequate idea of the improvement that had taken place 
since he came under my care. He was then emaciated and bent down by 
long-continued suffering, unable to articulate, so as to require a slate and 
pencil for expressing his wishes, and swallowing even fluids with such extreme 
difficulty as to feel on the point of starvation. My surprise may, therefore, 
be imagined when, on the 10th of September last, he unexpectedly made his 
appearance, erect and vigorous, and seeing that I did not recognize him, an- 
nounced his name in a loud, clear voice. The feeling thus excited was not 
lessened by learning that, while travelling in the Highlands, he had dined at 
tables-d'hote and entered into conversation without betraying the deficiency 
under which he labored. Very much astonished by a result so much better 
than could have been anticipated, I requested a number of my medical friends 
to join me in examining the state of matters. Professor Goodsir and Mr. 
Nasmyth having satisfied themselves that no vestige of the tongue remained, 
various observations were made with regard to articulation and other functions 
of the absent organ ; and Mr. Annandale afterward instituted a more particular 
inquiry, of which he has given me the following report: " The lips and jaw- 
bone, where divided, were soundly united without any deformity. The open- 
ing between the mouth and pharynx was much diminished in size and irregular THE TONGUE AND ITS DISEASES. 
773 
in shape from contraction of the fauces'and soft palate, which were drawn 
downward and forward more to the right than the left side, from the mucous 
membrane at that part having participated in the disease and been removed 
along with the tongue. Mr. W. says that he can swallow as well as ever, pro- 
vided that the food is either finely divided or fluid. He is also able to masti- 
cate solid substances, although difficulty is sometimes experienced from their 
getting into awkward parts of the mouth. In ordinary speech his words are 
wonderfully clear and distinct, and he can sing without any difficulty. All 
the vowels and words composed of them are articulated perfectly, and also the 
following consonants: B, C, F, H, K, L, M, N, P, Q, R, V, W. D is pro- 
nounced ' dthe,' J ' the,' G like ' sjee,' S is a lisp. His taste is impaired, but 
still enables him to distinguish different articles and their respective qualities, 
as grouse from partridge, bitters from sweets, good beer from bad beer, etc. 
He has remarked that the seat of sensation lies somewhere in the throat, since 
there is no recognition of taste previous to the act of swallowing; and in 
order to ascertain the truth on this point more precisely, the following experi- 
ments were made: 
" 1. A strong solution of salt was applied by means of a camel's-hair 
brush to the fauces, palate, floor of the mouth, lips, and inner surface of the 
cheek, with the result of something being felt in the mouth, but no idea 
formed as to its nature. 
"2. About a quarter of a teaspoonful of finely-powdered sugar was 
placed on the floor of the mouth, and, having been allowed to remain there a 
few seconds, was then brought thoroughly into contact with every part of the 
cavity without any recognition of its nature; but when a little water was 
added and swallowed, the taste was immediately perceived. 
" 3. The same experiment was repeated with another substance (salt), and 
with the same result." 
It has long been known that large portions of the tongue may be re- 
moved without destroying or materially impairing the power 
of articulation ; but I am not aware of any case on record in which it 
has remained so perfect after complete removal of the organ.* Of the facts 
* Complete extirpation of the tongue has now been practised with success by a number 
of surgeons, among them by Fiddes, Heath, Nunneley, Annandale, Rizzoli, and Sedillot. 
Excision of Tongue.-The removal of the entire tongue is altogether a modern surgical 
operation. Though, for time out of mind, greater or less portions of the tongue have been 
removed by cutting instruments, escharotics, actual cautery, or ligatures, the importance of 
the organ in deglutition and articulation, the difficulty of reaching its base, and especially 
the fear of not being able to arrest the hemorrhage, owing to the depth of the wound, the 
size of the arteries, and their near origin from the carotids, have not unreasonably deterred 
attempts at more than partial amputation of it. I believe it was Mr. Syme who first sug- 
gested an operation for its entire removal, and performed it in the presence of many mem- 
bers of the Association, when its meeting was held in Edinburgh. Unfortunately, that 
patient, as well as a second, died a few days after the operation; and a solemn warning was 
published by Mr. Syme, who declared that the operation was so serious that further at- 
tempts were not justifiable, as no one could recover from it. Subsequently, I believe, in a 774 
A SYSTEM OF ORAL SURGERY. 
above mentioned, continues Mr. Annandale, the one that seems most curious is 
the connection between taste and deglutition; from which it appears that the 
latter is essential for the full perception of the former. If the pleasure of 
taste could be perfectly gratified by mastication without deglutition, there 
would be no limit to the consumption of food; but the instinctive desire to 
swallow an agreeable morsel affords a check to any such abuse. 
Mr. Paget reports the following case : 
Hypertrophy and Prolapsus.-On the 20th of February a little 
girl, about three years of age, was brought into the operating theatre of St. 
Bartholomew's Hospital with hypertrophy and prolapsus of the tongue, which 
commenced when she was some six months old. It now protruded nearly two 
inches, and hung downward, completely filling the circle of the lips; its end 
was dry, and excoriated with hardened epithelium, a sort of crust having 
formed of the size of a shilling; several of the papillae also were enlarged, 
and in places gave to the tongue a warty or granular appearance. The lower 
jaw had already begun to be deformed, and expanded downward and outward; 
the teeth were gradually separating from one another in the mental portion of 
the jaw, and there was dripping of saliva. An examination of the tongue 
by Mr. Paget showed that the organ was truly hypertrophied ; the part not 
prolapsed completely filled the cavity of the mouth. Chloroform was care- 
fully given to the child, and the chain of an ^craseur was passed around 
the tongue within the mouth, the jaws being kept open by a metal gag. The 
chain was slowly drawn home, and the prolapsed and hypertrophied portion 
was detached with little or no bleeding. On examination of the piece re- 
moved, its structure was found to be similar to that of the natural organ, both 
in texture and color : it was simply a redundancy of growth from hypertrophy. 
The subsequent progress of the case was reported as most satisfactory, a good 
recovery being recorded. 
Speedy Union in Partial Amputations.-Partial amputations of 
the tongue have been very frequent. Union, in many of the cases, is very 
rapid and perfect. In one instance, that of a child, where a kind of a flap 
operation was made by the writer, reliable union resulted in a single day. 
third case, Mr. Syme was, by a like proceeding, rewarded with success; and Mr. Fiddes, in 
Jamaica, and Dr. G. Buchanan, in Glasgow, have also succeeded by the plan laid down by 
Mr. Syme. However, believing that the severity of the operation depended far more upon 
the method of proceeding than upon the mere removal of the tongue itself, I devised what 
I hoped would prove to be a less formidable one, and which experience has proved to be so. 
Up to the present time I have removed the entire tongue nineteen times, and Dr. Fenwick, 
of Montreal, has done the same operation once, without any untoward symptom following 
in a single instance. In most cases the patient has not required any after-treatment, being 
able to sit up the following day, and in ten days to be considered well. In the majority of 
operations not a drachm of blood has been lost. In two cases only has there been any hem- 
orrhage, and in those not more than half an ounce of blood was lost. In one a point of hot 
wire, and in the other a ligature, at once arrested the bleeding. The little constitutional 
disturbance which follows this operation is surprising; indeed, in the majority of cases 
there is none.-Thomas Nunneley, F.R.C.S. THE TONGUE AND ITS DISEASES. 
775 
Means used in Amputation.-Amputation of the tongue, complete 
or partial, is practised with ligature, knife, or ecraseur. The author, from his 
own experience, gives the preference to the last means. 
Operations.-For a surgical study of the tongue, and the operations 
practised upon the organ, the reader will turn to Plate II. 
Subfig. I, in plate, is a front view of the anatomical relations of the 
parts about the fauces, as shown with the mouth wide open. 1, the dorsum 
of the tongue; 2, 3, the tonsils; 4, the uvula; 5, the anterior half arch; 6, 
the posterior half arch, with the tonsil between it and 5 ; 7, the soft palate. 
Subfig. 2 represents a side view of a vertical section of the mouth and 
tongue, showing the relations of the vessels and nerves of the tongue. 1, the 
lingual artery ; 2, its sublingual branch,-the veins accompanying the arteries ; 
3, the hypoglossal nerve; 4, the ranine terminations of the lingual vessels. 
Subfig. 3 represents the situation and associations of a disease com- 
pelling amputation of a section of the tongue. The lines 1, 2, 3 form a V, 
which is to circumscribe the growth; it should, however, have been placed 
much farther back. 
Subfig. 4 exhibits the operation of excising the tongue, as practised 
with scissors. When the knife is used the sections are similarly made. If, 
in such an operation, the hemorrhage be threatening, it is better to ligate 
quickly the vessels of one side before making a section of the other; this 
suggestion, however, only holds good when the bleeding orifices are freely 
exposed and can be reached without effort or difficulty. 
Subfig. 5 shows the preceding operation completed, and the flaps united 
by ligatures. 1, 2 represent the sutures; wire, pins, or waxed silk may be 
used. Let them be left in only long enough to secure the union; this, if no 
undue inflammation supervene, will be accomplished in from twenty-four to 
forty-eight hours. 
Sub fig. 6 is the lingua vitula, or lingual hypertrophy. The particular 
case here represented was a patient of Dr. Harris, of Philadelphia, and the 
operation was the first performed in the United States. The case is thus 
described by Professor Henry H. Smith in his 11 System of Surgery": 
Harris's First Operation.-The patient, aged nineteen, had the 
tongue enlarged at birth. A short time previous to the operation it projected 
beyond the upper incisors at least three inches. Its circumference was six 
inches, and its vertical thickness one inch and a half; it filled up the jaws so 
completely that it was necessary to have the food cut into small pieces and 
introduced at the side of the tongue. The operation practised by Dr. Harris 
was accomplished as follows : The tongue being elevated, a strong ligature was 
passed through its tip so as to control its movements. The under surface was 
then dissected from the floor of the mouth about three-fourths of an inch 
behind the anterior part of the jaw, and a strong, straight bistoury introduced 
into the organ at a point where the dissection terminated, whence it was 
pushed through between the median line and the left ranine artery, and, being 776 
A SYSTEM OF ORAL SURGERY. 
drawn laterally and forward, was made to cut a flap, which terminated near 
the first bicuspid tooth. The left ranine artery being then secured with a 
ligature, the bistoury was again introduced in a corresponding position on the 
right side, and the opposite, or right flap, made in a similar manner. The 
artery of this side being now secured, and the space intervening, or central 
portion, divided by strong scissors, the incisions, or flaps, resembled the letter 
V, and, being approximated by these interrupted sutures, made a pointed, 
well-formed tongue of the ordinary length. A year subsequently the patient 
articulated distinctly, and continued relieved of all deformity. 
Harris's Second Case.-In another case, somewhat similar to this, 
under the care of the same surgeon, a ligature was applied to the enlarged 
portion, in order to cause it to slough off; but the irritation, Professor Smith 
informs us, was so great that Dr. Harris found himself subsequently com- 
pelled to amputate the end of the tongue with a catling. In this patient the 
organ protruded four inches; its circumference was over six inches, and its 
vertical thickness nearly two inches. 
Addenda.-Other figures upon the plate show manner of excising the 
tonsil glands, the bistoury and tonsillotome being used. 
Treatment of a Resisting Ulcer by Ligature.-Fig. 632 rep- 
resents a condition of resisting ulcer, together with a manner of treatment 
Fig. 632.-Amputation by Strangulation, 
by strangulation. With such ulcers and such manner of treatment the author 
has had quite a large experience, but, as before remarked, he gives the prefer- 
ence to the ecraseur. A mode of using the ligature, more convenient than 
that exhibited in the diagram, and quite as effectual, consists in the passage 
of the double thread, exactly as is represented in this case by the threads oc- 
cupying the middle position; separating this double ligature, it may be made 
to circumscribe any portion of the tongue simply by the passage of pins: as, 
for example, if in the places of the first and second threads, as shown, pins 
were placed, it must be seen that by separating the double middle ligatures 
and casting them back of the pins, the part included would be precisely the 
same as found here with the six ligatures. By such use of the double liga- 
tures the author has amputated full half the tongue twice within four months. THE TONGUE AND ITS DISEASES. 
777 
Such a mode of employing the double ligature, not alone for the tongue, but 
in any other situation, is shown in Fig. 633. 
Ecraseur.-Fig. 634 exhibits the ecraseur of the inventor of the in- 
strument, the French surgeon M. Chassaignac. Of the two forms shown, 
the one to the right will be found most to commend itself, the direction of 
the chain being best controlled by it. To use the Ecraseur, it is simply neces- 
sary to arrange the chain back of the part to be amputated, the handle being 
Fig. 634.-Chassaignac's Ecraseur. 
Fig. 633. - Mode 
OF EMPLOYING THE 
Double Ligature. 
Fig. 635. - 
Ligature Ex- 
TEMPORANEE. 
next slowly worked, whereupon the chain, little by little, is retracted, until 
finally-the time should seldom be less than a quarter of an hour-the portion 
of tissue drops off, without, quite as likely as not, the loss of a single drop 
of blood. Such bloodless ablations of the tongue are occasionally performed 
by the author before his class. 
Annealed Wire.-As a substitute for the chain of the Chassaignac in- 
strument, a common annealed wire is used by many with satisfactory success. 
The use of such a wire is highly commended by M. Maisonneuve, of Paris, 
who has published a memoir on what he terms the 11 ligature extemporan^e." 
Fig. 635 exhibits this ecraseur, and.the mode of its application. A screw 
like that of Graefe's serre-noeud, or any other convenient means, may be 
employed to tighten the wire. A very convenient instrument of such char- 
acter is manufactured at a trifling price by Mr. Kolbe, of Philadelphia, and is 
to be procured of most surgical cutlers. With such form of Ecraseur, the 
author bas succeeded in amputating, without trouble, fully two-thirds of the 
organ. 778 
A SYSTEM OF ORAL SURGERY. 
Illustrations of Ablations.-Ablation of the tongue in part by means 
of the ecraseur is fully demonstrated by Figs. 636 and 637. In the first of 
the cuts is exhibited the manner of applying the instrument, which, as seen, has 
been threaded, or attached, to the eye of a silver probe, the probe following 
Fig. 637. 
Fig. 636. 
Application of Gcraseur with a view to 
limited section. 
Two Ecraseurs used in making sections. 
the thrust of a bistoury and being in place before the knife is withdrawn. 
In the second of the cuts, two chains, belonging to different ecraseurs, are 
seen ready fixed for the strangulation ; the retraction of the chains within the 
handles cuts the piece out; the loop held by the finger in this diagram is a 
replacement of the tenaculum seen in the other; either being used alike with 
the common purpose of securing control of the organ. 
Regnoli's Operation.-Ablation of the tongue in full, an operation that 
has attracted considerable attention, is variously practised. A mode known 
as that of Regnoli, shown in Fig. 638, consists in opening into the oral cavity 
from the neck, and, by means of a loop in the tip, drawing the organ down- 
ward. To open into the cavity by this plan, the operator commences by 
making a curvilinear incision corresponding to the arch of the jaw, extending 
nearly from angle to angle. Joining this first incision is a second of vertical 
direction, extending to the hyoid bone. The flaps are next to be reflected, 
and, after incising the lingual muscles from the bone, the tongue is caught by 
the tip and drawn out of the mouth. Control of the organ being thus secured, 
the knife or ^craseur is employed to make the separation. THE TONGUE AND ITS DISEASES. 
779 
Syme's Operation.-A second manner of operation is that which was 
practised by Mr. Syme. This is shown in Fig. 639, and is as follows. A first 
incision, carried down to the hyoid bone, divides the lower lip in its exact 
median line. Next the maxilla is separated, by means of a saw, at the 
Fig. 638.-Regnoli's Operation. 
Fig. 639.-Syme's Operation. 
symphysis; this may or may not necessitate the removal of the two front 
teeth. Placing the finger as a guide beneath the tongue, the surgeon next 
incises the mucous membrane, together with the muscular attachments. At 
this stage attention is to be given to hemorrhage. The tongue, as shown, is 
to be drawn forward and the amputation made by the ecraseur. 
Results.-Statistics favor the Regnoli operation rather than that by Mr. 
Syme; the section of the jaw made by the latter complicates to a marked 
extent the process of cure. 
Nunneley's Operation.-Still another operation, one practised by 
Mr. Nunneley, of Leeds, has 
yielded a success most sat- 
isfactory, since of nineteen 
cases in which this surgeon 
has operated, removing the 
whole or a large portion of 
the tongue, every one sur- 
vived the performance. The 
manipulations, as practised by 
Mr. Nunneley, consist in a 
slight incision,-a puncture, 
indeed, made in the exact 
middle line of the throat, a 
little nearer the base of the 
jaw than the hyoid bone, the 
bistoury being passed upward until it emerges at the fraenum. Through this 
Fig. 640.-Nunneley's Operation. 780 
A SYSTEM OF ORAL SURGERY. 
wound is drawn up the chain of the ecraseur, the loop being cast about the 
base of the tongue. Next, with a volsella, or by any other convenient means, 
the organ is pulled outward and upward. To control and secure the loop of 
the chain about the base, two strong 
curved pins are passed from below, 
through the tongue, to the base; the 
loop thus controlled, ablation is made 
as in the previous cases. (See Fig. 
640.) 
Paget's Operation. - A 
fourth process is that practised by 
Mr. Paget. Separating first the gen- 
eral attachments of the genio-hyo- 
glossal muscles, this surgeon dissects 
along the floor of the mouth, thus 
liberating the tongue, whereupon the 
organ is caught, drawn forward, and 
removed with the ecraseur. (See 
Fig. 641.) 
Limited Ablations.-In limited ablations, the surgeon, not having at 
his command the ecraseur, may use with satisfaction the ligature as illustrated 
a few pages back. A point of importance, however, to consider in the use 
of this means, is the danger of cutting out the string; it is really a nice point 
to draw it tight enough, yet not too tight. The author has seen a ligature 
cut through a tongue almost with the facility of a knife, complicating matters 
most seriously by the hemorrhage which followed. Another matter is corre- 
spondence in size of the thread with the needle used. A needle larger than 
the thread which is to occupy the line of its passage will not infrequently 
have its use associated with an oozing of blood, so persistent as to compel the 
repetition of an operation. 
Hemorrhage and the Ecraseur.-In the use of an Ecraseur the 
surgeon will also not infrequently find himself confronted by hemorrhage, and 
particularly is such a result to be anticipated where abundance of time is not 
allowed for the ablation: the rule with this instrument should be, " make 
haste slowly." 
Billroth's Operation.-Billroth's method of amputating the tongue, a 
method in favor with many surgeons, begins with the ligation of both lingual 
arteries, the vessels being reached by a curved incision upon the submaxillary 
region of the neck, which starts below the anterior border of the masseter 
muscle, is carried down to a level with the hyoid bone, and is extended from 
this to the locality of the genial tubercles. The cut passes through the in- 
teguments, exposing and opening the envelope of the submaxillary gland, 
which body is pushed out of the way, and an incision made through the hyo- 
glossus muscle, the vessel being exposed and lifted in a triangle formed above 
Fig. 641.-Paget's Operation. THE TONGUE AND ITS DISEASES. 
781 
by the hypoglossal nerve and below by the converging bellies of the digastric 
muscle. The arteries secured, and the circulation thus shut off from the 
tongue, the jaws are widely separated by means of a convenient gag, following 
which a strong ligature is passed through the organ, and looped, with a view 
of securing control. Ablation here commences, a pair of stout and sharp 
scissors being used. First the fraenum is divided. Next a blade of the in- 
strument is thrust through the hole thus made, below the mucous membrane 
relating the tongue and floor of mouth, which membrane is divided back to 
the epiglottis. A succeeding step disparts the hyoid muscular attachments 
from before backward, following which the organ is freed and lifted from its 
bed. Only limited bleeding attends the operation, a compress of sponge 
being found sufficient for its control. Nutrition is effected for five or six 
days after the operation by means of an india-rubber tube passed through a 
nostril into the oesophagus. 
Whitehead's Operation.-Whitehead's operation differs from the one 
just described in that the English surgeon does not preliminarily ligate the 
lingual vessels. 
Possible Sequelae. - Hemorrhage, shock, inflammatory perversions, 
and septicaemia are the dangers associated with operations upon the tongue, 
which dangers the prudent surgeon guards against by every precaution known 
to his science. After an operation of magnitude upon this organ, it is always 
prophylactic practice to prescribe veratrum viride, bromide of potassium, and 
morphia; while, as a local detergent, nothing better can be used than the 
ph^nol-sodique, in proportion of a dessertspoonful to a goblet of water, tinc- 
tura capsici et myrrhse being added to the extent of a teaspoonful if suppura- 
tion follow, or, if acute inflammation supervene, this conjoined with the fluid 
extract of hamamelis Virginicus or lead-water and laudanum. 
TONGUE-TIE. 
The condition denominated tongue-tie is frequently met with in young chil- 
dren, and, indeed, occasionally in the adult. Tongue-tie is simply a shortening 
or curtailment of the anterior mucous fraenum. A tongue that cannot be 
projected beyond the teeth, and which, in the attempt at projection, has its tip 
turn downward, is tied. A tongue so fixed cannot perform its offices com- 
fortably and naturally. Upon examining the mouth of a person thus afflicted, 
the tip of the organ is not infrequently found set to the floor of the mouth, 
incapable, indeed, of any movement. This, however, is an extreme case, the 
usual condition being simply curtailment of ordinary motion. 
Adventitious and Congenital.-Tongue-tie is of two kinds, adven- 
titious and congenital. Of the first, that arising from ulceration is the most 
common. A person having a bad ulcer under the tongue, particularly if on 
the side of the fraenum, is almost sure to have the fold shortened as the result 
of cicatrization. 782 
A SYSTEM OF ORAL SURGERY. 
A second expression of this first form is one described by Professor 
Dewees; exceedingly rare, but necessary to note. 
Dewees's Membrane.-There is found, says Dr. Dewees, attached to 
the fraenum of the tongues of new-born children a nearly transparent, whitish 
membrane, which pursues the bridle through its whole course, continues beyond 
the point where it stops, and terminates near the extremity of the organ itself; 
so that the tongue is tied down, as it were, to its proper bed. 
Inability of Child to Suckle.-In consequence of this disposition of 
the fraenum the child cannot elevate the tongue nor protrude it be- 
yond the lips, and in attempts to suck cannot apply it with sufficient force or 
certainty to the nipple to make a complete exhaustion ; therefore it sucks but 
imperfectly, and the act is accompanied by a clucking kind of noise. When- 
ever this is observed the mouth should be examined, and it will almost always 
be found in the condition just described, but not necessarily, as there may be 
clucking without this membrane; but the membrane, we believe, is never 
without the clucking. This membrane is easily discovered by pro- 
voking the child to cry or by elevating the point of the tongue by the ex- 
tremity of the little finger. In making the attempt to raise the tongue the 
child is almost sure to cry; and then this tissue is readily discovered, as it is 
put fully upon the stretch. 
To Remedy the Defect.-The defect is easily remedied, being cor- 
rected in the following manner: Let the child be laid across the lap of the 
nurse, with its face toward a proper light, the operator standing behind the 
head so that he does not intercept the light. The chin of the child must be 
gently depressed by the forefinger of the nurse. When it is thus lowered the 
little finger of the left hand of the surgeon is to be insinuated between the 
side of the tongue, near its tip, and the inner corresponding portion of the 
jaw, until it can lift up the point of the tongue, which being done, the mem- 
brane is immediately brought into view and put upon the stretch; or, should 
the child now begin to cry, as it almost always does, the operator can easily 
place his finger under the tongue and keep this false fraenum tense, while by a 
single stroke directly across it by a sharp gum-lancet he divides it to the true 
fraenum ; the operation is then finished. We have never known it necessary 
to repeat this operation. The incision through the membrane never yields 
more than a small drop of blood; no hemorrhage can ensue, as the tissue is 
but very slightly vascular. 
Third Adventitious Form.-A third of the adventitious forms, oc- 
curring in the adult, is the result of induration of the fraenum. This is 
occasionally venereal in character, or it may be cancerous. In these cases the 
band gradually thickens until the motion of the tongue is markedly impaired. 
The cancerous is distinguished in its incipiency from the venereal disease by 
the greater pain associated with the movements of the parts; in the first the 
pain is acute and sharp, in the second it is soreness rather than pain. If the 
induration be malignant the parts may be excised, still better, let alone, the THE TONGUE AND ITS DISEASES. 
783 
hope of cure being very slight; if venereal, a specific treatment conjoined 
with such general and local combinations as may seem demanded by the 
circumstances of the case is to be pursued. The practitioner is to avoid over- 
irritation. 
Congenital Tongue-Tie.-Congenital tongue-tie is quickly appreciated 
by lifting the tip of the organ. These cases differ very much, the fraenum 
being observed at times to run as in the normal course, except that it is much 
shortened. In other instances the fold passes forward almost to the apex. It 
may be free or tight. If the first, it forms a septum between the lateral 
aspects of the floor of the mouth, but is not otherwise inconvenient; if the 
latter, it ties the tongue more or less closely. 
Cutting the Fraenum.-The relief of a congenital tie consists in nick- 
ing, or cutting, the contracted fraenum. This operation, although of the 
simplest nature, requires to be performed with some care. A fraenum too 
freely cut permits of the tongue being pulled quite far back into the fauces; 
cases are on record where suffocation has nearly resulted from such accident. 
Again, it is not to be forgotten that the ranine vessels inosculate just in front 
of the fraenum on the under surface of the organ, and that they might very 
easily be divided in an operation. Many children have lost their lives from 
such an accident. 
A proper operation consists in making a simple nick midway between 
the tongue and the floor of the mouth ; a rupture of the parts thus effected, 
the motions of the tongue will quickly secure all the latitude required. 
Should an operation unfortunately open a vessel, the best practice would be to 
secure it with a ligature; but this is not always easy of accomplishment, the 
artery retracting within its loose sheath. An instrument devised by M. Petit 
to control such a hemorrhage consists of a piece of ivory, cut fork-shape, the 
prongs, of which there are two, passing on either side of the fraenum, the 
short handle resting against the inside of the jaw. To apply this instrument 
introduce against the bleeding vessel a tuft of lint saturated with alum-water 
or other astringent, then place the fork about it and secure it by pressing it 
down with the tongue, over and around which and the jaw a roller is to be 
thrown. A much better means, however, would be the use of the Morrison 
Compressor, which see. Guersent, in his 11 Surgical Diseases of Children," 
recommends the serre-fine, or the retention, for a time, of agaric against the 
part. Another means, where the wounded vessel is not too far retracted to 
be caught, is the employment of torsion. The use of nitrate of silver or of 
Monsel's salts in these cases cannot be too forcibly discountenanced, the 
injury done by either to the tender parts making secondary hemorrhage 
almost a certainty. The position of the lingual vessels in danger from opera- 
tion for tongue-tie is seen by reference to Plate II. Fig. 2. 
Swallowing the Tongue.-Swallowing the tongue, as it is called, is a 
disagreeable accident, and may occur without section of the fraenum. Dr. 
Dewees mentions one case in which a child became choked several times a 784 
A SYSTEM OF ORAL SURGERY. 
day from such a recession. This case was always, however, relieved by the 
nurse, who would press the organ down with the handle of a spoon and then 
draw it forward. 
Fig. 642. 
Fig. 643 
Position for fingers. 
Division of the fraenum while held 
up by director. 
Fig. 643 shows the fraenum exposed and held by means of the nick in a 
director. Elate II 
Ulma/b fc Sons CHAPTER XLV. 
THE UVULA AND ITS DISEASES. 
Surgical anatomy recognizes the uvula as muscle enclosed in a bag of 
mucous membrane, the connection between the two being a varying amount 
of loosely related cellular tissue. 
Enlargement of Uvula.-The frequent and only common local dis- 
ease of the uvula refers to enlargement of the organ. Enlargement is by 
reason of relaxation, by cellular engorgement, by hypertrophy, by neoplastic 
associations. 
Elongation of Uvula.-Persons of lax tissues are not unapt to possess 
a uvula of such undue length that serious irritation of the fauces is provoked, 
phthisis pulmonalis being too often a consequence. Examination of the 
condition reveals a pale, relaxed apex, the distinction between muscle and 
membrane being very marked. 
Serous Infiltration.-Enlargement by cellular engorgement finds ex- 
planation in serous infiltration. The writer has encountered cases where, in a 
single hour, the organ has swelled to the size of a shell-bark, and where im- 
mediate relief was necessary to the saving of life. Cases of this kind relate 
with laxity of tissue associated with acute inflammatory attacks, although, as 
a reverse to this, instances are met with where tonicity is the characteristic of 
the individual at large. The organ, when this condition exists, has much the 
appearance, and certainly all the characteristics, of a water-bag. 
Bifid Uvula.-This is a not infrequent condition, the soft palate being 
otherwise perfect. If correction be thought desirable the approximating 
surfaces are to be pared and sutured. 
True Hypertrophy.-Hypertrophy, as an uncomplicated condition, is 
not at all common, and when met with, has its meaning in organization of 
plastic lymph exuded between muscle and envelope. The subjective symptoms 
are described by the patient as a lump in the throat and interference with 
swallowing. 
Neoplasms.-Neoplasms refer to new formations of cancerous relation, 
and are always of secondary signification, the disease extending to this from 
neighboring parts; the signs are pre-existence of the vice, local enlargement, 
hardening, nodulation, specific pain, progressive degeneration. 
Fibrous and Fatty Tumors.-Tumors, analogous to those so often 
produced in the lobes of women's ears by the wearing of rings, are occasion- 
ally found pendent from the tip of the uvula. Fatty growths are also alluded 
785 786 
to as having been met with. Defined cysts are described as of occasional 
occurrence. 
Treatment.-Treatment of uvular disease is according to indications. 
When the organ is simply relaxed, the mucous bag being the tissue involved, 
no cure equals amputation of the redundant part. To accomplish this the 
A SYSTEM OF ORAL SURGERY. 
Fig. 644. 
author now universally employs the plan of empaling the tip upon a tenaculum 
(Fig. 644), and incising with scissors curved flatwise. The use of a tenaculum 
for fixation and control is superior to all other means. In the case of chil- 
dren ether is to be given, and the mouth held apart by a Kolbe or other gag. 
Fig. 645 shows a form of scissors much used; the teeth have the intention of 
Fig. 645.-Uvula Scissors. 
catching and holding the excised part; its use does not apply in connection 
with the tenaculum. 
Amputation for Serous Effusion.-Enlargement from serous effu- 
sion demands effective treatment. Iodine, muriate of ammonia, and other 
sorbefacients are recommended, yet are tried only to be found unreliable. 
Every cell of the connective tissue communicating the one with the other, 
accommodating the serum, it is alone necessary, in order instantly to drain the 
tumor, to snip off the apex, otherwise to slit the uvula; preference to be given 
the first of the operations. THE UVULA AND ITS DISEASES. 
787 
Sorbefacients for Hypertrophic Enlargement.-Hypertrophic 
enlargement of the uvula is treated by the use of sorbefacients, and by press- 
ure applied through the daily use of forceps faced with rubber; fifteen minutes 
are required for the latter purpose, the handles of the instrument being re- 
tained in the grasp of the operator's hand. A second manner of exerting 
pressure employs a rubber ring, applying it by means of forceps not unlike 
those used with the rubber dam. To avoid accident, a string is attached to 
the ring, which string is brought out of the mouth, and may be attached to a 
button-hole. Still another plan employs collodion; the uvula, after being 
dried by means of bibulous paper, is thoroughly coated, the performance being 
repeated several times daily. If the lower half alone be involved, amputation 
is the remedy. 
Simple fibromata, lipomata, and cysts may be cut away even to the extent 
of removal, along with them, if necessary, of the whole uvula. 
Syphilis of Uvula.-Expressions of systemic syphilis are seen upon 
the uvula in form of tumidity, of ulcerations, and of condylomata. Diagnosis 
lies in history of the case. Cases now and then occur in the mouths of 
smokers where the organ is covered with a mass of warts, and, not unlikely, a 
similar studding of the whole immediate neighborhood. The origin can lie 
in heredity. Condylomata, as met with about the uvula, may be reasonably 
clean, although always irritable-looking. They show commonly a semi-dry, 
dark-red face. They interfere markedly with deglutition. The writer has 
met with them as the only evident sign of the constitutional affection. Treat- 
ment is to be both of systemic and local signification. In the former direction 
the protiodide of mercury, from a half to a whole grain, put up in the form 
of pill, is to be given thrice daily. Locally the parts are to be painted three 
times a day with the erysipelas mixture, which see. If the parts are sensi- 
tive it will be necessary to increase the proportion of cinchona tincture. A 
camel's-hair brush is convenient for making the application. 
Condylomata.-Condylomata of the fauces differ nothing from the vege- 
tations seen about the anus, penis, and scrotum, except as to location. Where 
the growths are offensive as to discharges, phenol-sodique, diluted, furnishes a 
correcting gargle. Bismuth in the form of subnitrate, having mixed with it 
iodoform in the proportion of ten grains to the drachm, furnishes a good 
drying powder, used by being blown from a glass tube over the parts. Boracic 
acid, as an addition, is employed with profit in many cases. 
Corrosive Sublimate as an Application.-Brushing the vegeta- 
tions with a solution of corrosive sublimate (gr. iij to water 3j) is curative. Zinc 
sulphate (gr. ij to rose-water §i) is an agreeable and comforting medicament. 
Cleanliness Essential.-Continued attention and cleanliness are essen- 
tial, recurrence of the condition being the rule in all neglected cases. Drinking 
spirits is to be prohibited. 
Use of Tobacco.-The use of cigars, and particularly of cigarettes, is to 
be interdicted in all cases where symptoms of constitutional syphilis show 788 
A SYSTEM OF ORAL SURGERY. 
themselves. The use of tobacco in such form invites attack of the soft palate, 
uvula, and pharynx. 
Irritation.-All irritations associated with pathological conditions of the 
uvula find much relief through brushing with a solution of cocaine (gr. vij 
to water gj). 
The following combination, the suggestion of M. Nonin, is quite an efficient 
sedative; it is used as the preceding: 
U Morphias hydroehloratis, gr. iv; 
Potassii bromidi, $j; 
Tincturae cocae, 5b > 
Grlycerini, ^iss. M. 
Restrictions.-As one of the offices of the uvula is to convey the mucus 
and saliva about the base of tongue and epiglottis, acting thus as an agent of 
lubrication to these parts, it is objected that ablation of the organ results in 
a dryness of the parts more irritating than the offence removed. Objection 
is also advanced that as the uvula possesses the function of holding the soft 
palate tense and firm in the median line against the pharynx during the act of 
deglutition, thus preventing the passage of fluid or of solid substances toward 
the nose, amputation of it must result in serious inconvenience. As loudness 
in speech is concerned, the organ is credited with exercising much influence 
through its capacity as a levator or shortener; this as the muscular portion is 
involved. Speech, according to Sir Duncan Gibbs's experiments, is modulated 
by the soft palate and uvula, and the motor power of the latter is unquestion- 
ably exerted, he maintains, in pronouncing the letters K, Q, and X, with their 
associations, more especially in the gutturals of the various languages. Con- 
cerning these objections the writer has to note a clinical experience which in 
no way endorses them. Caution in performing operations of the kind on the 
persons of public singers or speakers is, however, not unwisely considered and 
practised. 
Hemorrhage from Amputation.-Hemorrhage from amputation of 
the uvula is seldom found to require attention. The author has operated a 
great number of times, and never, except in a single instance, met with bleed- 
ing to an extent demanding treatment; in this one case it yielded to a gargle 
of alum-water. A feeling of rawness associated with the excision, and 
which is the principal complaint, will be found corrected through the use of 
crystals of gum-arabic held in the mouth, or, if preferred, marsh-mallow or 
jujube paste may be used ; solid food is to be excluded from the diet for a short 
time. CHAPTER XLVI. 
DISEASES OF THE FLOOR OF THE MOUTH. 
Encircling the tip and sides of the tongue is a space bounded externally 
by the inner face of the maxillary alveolar process, which space constitutes 
the lower boundary of the mouth, its floor being the mylo-hyoid muscle, its 
carpet a plane of mucous membrane. Anteriorly this space is divided into 
two parts by the fraenum linguae. Floor and carpet are separated by cellular 
tissue which might not inaptly be likened to a single layer of wadding related 
by one face to the first, by the other to the second, structure. 
Embedded in this cellular tissue are the sublingual glands, together 
with their vessels of outlet. Passing through it are the Whartonian ducts. 
Lying beneath the floor of the region are the submaxillary glands. A large 
vein crosses it. The most common of the diseases of this locality, as the 
author has met with them, is tumefaction arising out of sympathetic disturb- 
ances ; notably, alveolo-dental inflammations. Cases are encountered where 
the mucous membrane is so thrown upward, as a result of effusion into the 
underlying cellular tissue, as to assume a place on a level with the teeth. In 
glossitis such infiltrations are not infrequently of an extent that throws the 
membrane as a partial envelope about the sides of the tongue. Treatment is 
to be directed to the primary lesion. 
The second most common disease arises out of obstruction in the 
salivary ducts. The trouble shows itself either as a raised roundish line 
running from an inflamed point beneath the tip of the tongue, as a cystoma, 
or as a tumor, lesser or greater in size, of stony hardness. The swelling 
known as frog-belly ranula is an example of recent salivary obstruction. 
Ranula.-The term, not a good one, is retained because of the familiar 
position it holds in surgical nomenclature. The subject is one easily compre- 
hended. A ranula is the analogue of a sebaceous tumor, being 
simply a cyst of retention; a collection, the result of the closure of a tube of 
outlet. The tumor thus designated is found principally beneath the tongue ; 
it is a swelling varying in size and in expression according to the circumstances 
of its existence, at times being observed when not larger than a pea, at others 
so great in bulk as to throw the tongue back into the fauces. Ranulae are 
occasionally met with which fill the whole oral cavity; such dimensions, how- 
ever, are uncommon. 
Illustration.-If we were to tie or otherwise obstruct one of the tubes 
just alluded to, it would be natural to expect that the secretion accumulating 
789 790 
A SYSTEM OF ORAL SURGERY. 
back of the ligature would expand and bulge out the duct into the form of a 
tumor. This is really the very simple history of the formation of a ranula. 
Resemblance.-Ranula, thus provoked and formed, varies as much in 
appearance and character as in size. In one case it looks and feels almost pre- 
cisely like the belly of a frog, the enveloping cyst being thin and attenu- 
ated. In other instances the walls are thick. The contents present varying 
characteristics, being watery, semi-solid, or solid even to the hardness of stone. 
Commonly it consists of a yellow albuminous-like substance, which, for evacua- 
tion, requires pressure upon the tumor after an incision has been made. 
Watery Contents.-A ranula, the contents of which are watery, implies, 
as a rule, that the disease has been of short existence, the fluid being simply 
the secretion from the gland unchanged in character. In the ranula of semi- 
solid consistence an explanation is found in the partial absorption of the more 
fluid portion, leaving an inspissated mass. In the solid ranula the encystment 
is the common salivary calculus,-being precisely the same as is seen upon 
the sides of the teeth, except in the absence of the common detritus of the 
mouth. Such a ranula as the last is found to be of long standing; absorp- 
tion of the watery part has gone on until what remains is the limy portion 
of the secretion. 
Thin Cysts.-A thin cyst implies a rapidly-formed tumor unattended by 
vascular excitement, the envelope being a simple attenuation of the walls of 
the duct and overlying parts. This form of ranula very frequently ruptures, 
and thus effects a self-cure. Cysts, thickened and hard, imply tumors of 
slower growth and the association of vascular changes resulting in the effusion 
within the cyst-wall, and the organization of a greater or less amount of lymph. 
Cysts thus thickened may compose the bulk of ranulae, the cavities being 
small in comparison. 
Character of Trouble.-A ranula gives trouble from its size and loca- 
tion, seldom or never degenerating. It does not seem true, either, that harm 
results to digestion from the loss of the secretion,-such loss, indeed, being more 
apparent than real, the associate glands performing excess of work. A ranula 
attaining great size would necessarily intrude upon all the surrounding parts, 
thereby provoking secondary lesions which might very well prove of more 
serious character and consequence than the original disease; thus, cases are 
on record where the teeth have been forced from their sockets, where large 
ulcers have formed against the inner face of the lower jaw, where necrosis of 
extensive character has been provoked, etc. 
Treatment.-This, in principle, consists simply in opening the tumor, 
evacuating its contents, and so conducting cure of the wound that it shall 
not entirely close, securing and preserving in this way an orifice of exit for 
the secretion. 
In the frog-belly tumor it is found sufficient to catch up with tenacu- 
lum or forceps a portion of the sac, and with the scissors or bistoury cut it 
off; the edges of the wound then to be cauterized, and the case left to nature. DISEASES OF THE FLOOR OF THE MOUTH. 
791 
In the thickened cysts an operation as just suggested might not be 
easy to accomplish. In such a case take a strand of ligature wire (silver is 
to be preferred), double it upon itself half a dozen times, to the extent of the 
supposed thickness of the sac of the tumor to be operated upon. Take next 
the continuation of the length of the wire, and closely, yet spirally, bind with 
it the thickness just secured by the half-dozen reflections. Next take a curved 
needle, and thread the wire to it. Now pass it through the tumor, entering 
at the centre. When the thickened part of the wire-which is to be bulbed 
by a perforated shot compressed on its extremity-is brought in contact with 
the cyst, an incision is to be made just large enough to allow the passage; 
pull it now in until checked by the shot; fix the needle-end so as to retain 
the thickened part in place, and the operative part of the proceeding is 
completed. 
A second mode, founded on the same principle of drainage, consists in 
taking a delicate rubber tube and, after cutting through its walls a number 
of outlets, passing it through the tumor. To retain it in place, the extrem- 
ities are tied together, having an opening made between the ligature and the 
tumor. If, when making the little section in the tumor for the passage of 
the wire or tube, the contents should not at once escape, they are to be pressed 
or syringed out. If the parts seem particularly indolent, there is no objec- 
tion to the introduction of a stimulating injection. The presence of the 
drain will, however, in ordinary cases prove sufficiently provocative of a 
desired inflammatory action. Iodine, in tincture, may be used externally 
over the face of the tumor. 
Ranulae holding Calculi.-In a ranula holding a calculus nothing is 
to be done without the knife, except, indeed, in certain occasional instances 
where the orifice of a duct has become patulous and the stone can be seen or 
felt. In these latter cases the operator may succeed in drilling or breaking 
the mass in pieces, and thus securing its removal. It is much easier, how- 
ever, even here, to incise down to the stone and take it away. (See, for in- 
teresting case, chapter on Salivary Calculus.') 
Differential Diagnosis.-All cysts or tumors found beneath the tongue 
are not, however, to be esteemed as of the character just described. Inflam- 
mation of the sublingual gland is not infrecpiently met with, and the tume- 
faction is, at times, so considerable as to very closely simulate ranula. Cysts 
within the substance of the gland, not salivary in character, are other of the 
conditions encountered, and these more closely imitate the ordinary ranula 
than the first, particularly when the cyst is simple. Papillary indurations are 
sometimes met with in the same situation. 
Lipoma.-Lipoma simulating ranula is found occasionally referred to.* 
* Lipoma simulating Ranula.-Mr. F. Churchill exhibited a specimen of lipoma 
simulating ranula. He said this tumor was removed from under the tongue of an old man 
eighty-six years of age. The specimen is unique, so far as the Society is concerned. I 
have been unable to find in the Transactions any records of a lipomatous tumor removed 792 
A SYSTEM OF ORAL SU ROE RY. 
Writers, prominent among whom is M. Marrant Baker, are found, who incline 
to doubt the common relation of the ranulae with the salivary 
ducts, but upon such premises, as must appear to any one who shall see 
much of the disease, that the arguments advanced carry no weight: the true 
ranulae arise from salivary lesions influencing the relations of the discharge: 
tumors of kindred position may have the signification of muciparous cysts, or 
may be expressive of a systemic vice. Because a tumor is beneath the tongue 
it is not necessarily a ranula. 
Superficial and Deep Ranulae.-Ranulae are found superficially 
seated, or deep, according to the part affected and the location of the lesion; 
thus, ranulae associated with the tubal outlets of the sublingual gland are 
always entirely superficial, because the part affected is covered only by the 
from this situation, and there is no such tumor in the Museum of the College of Surgeons. 
Mr. Liston refers to the removal of fatty tumors under the tongue in his work on Practical 
Surgery. Mr. Pollock removed a fatty tumor from below the jaw of a lady forty years of 
age, enveloping the mylo-hyoid muscle; but in this case the intrinsic muscles of the tongue 
do not appear to have been encroached upon by the tumor. In several cases, hardened, 
putty-like masses have been removed from a ranular cyst, as also phosphatic concretions. 
During the last session of the Society, Mr. Warren Tay exhibited four or five butter-like 
masses, which he had removed from a ranular cyst, but " under the microscope no definite 
structure could be detected in them. Entangled in the substance composing the masses were 
some cells and portions of cells looking like debris of epithelium." Dr. Meymott Tidy, after 
a careful chemical analysis, " was disposed to regard the bulk of the deposit as adipose." The 
history of the case was as follows: II. T., aged eighty-six, was admitted to the Westminster 
General Dispensary, under the care of my colleague, Dr. Waite, who treated him for eczema 
rubrum of the leg. After consultation with Dr. Waite as to the nature of the tumor beneath 
the tongue, supposing it to be a ranula, I suggested that it should be removed in the usual 
way. He stated that on several occasions fluid had issued from the tumor, after which it 
was distinctly smaller. The incisive teeth in the lower jaw were intact, and situated just 
behind these was a movable (apparently pedunculated) tumor, about the size of a walnut, 
covered by the smooth, glistening mucous membrane of the floor of the mouth. The tumor 
was also, in part, covered by the sublingual gland; it was soft and yielding, and I was 
under the impression that I could detect fluctuation. The distended mucous membrane was 
being chafed by contact with the sharp edge of the teeth during mastication. The old man 
had noticed the swelling for twenty-two years. It had gradually increased up to the present 
time. During the past twelve months, however, it had given him pain, in consequence of 
chafing against the teeth; he much feared that it was a cancer. From its size it had also 
interfered with mastication, and acted as a serious impediment to his speech. Having re- 
moved a portion of the anterior wall of the tumor, I proceeded to turn out the contents, 
but found, underlying the mucous membrane, a bright, glistening mass, resembling a cyst- 
wall ; this was seized with a pair of clutch-forceps and drawn forward, a small portion of it 
being removed, but still no fluid escaped. I proceeded then to separate the adhesions to 
the mucous membrane with the spoon end of a director, but the deep connections were too 
firm to separate in this way; the finger also failed to enucleate the mass. The tumor was 
forcibly drawn forward, and these deep attachments cautiously divided with the knife. In 
this way the tumor, which was lobulated, and enveloping (probably) the genio-hyoglossi 
muscles, was removed. Exploring the cavity afterward, I could feel the sharp borders of 
the vertical muscles, and I was satisfied that the growth had been entirely removed. There 
was very little hemorrhage after the operation, and the cavity had completely closed in the 
course of a week.-Proceedings of the Pathological Society. DISEASES OF THE FLOOR OF THE MOUTH. 
793 
mucous membrane. Obstruction of the duct of Wharton at its orifice 
yields also a superficial tumor, lying as it does between the mucous membrane 
and the mylo-hyoid muscle; occurring, however, 
beneath that muscle, the tumor resulting is deep- 
seated. 
Temporary and Permanent Significa- 
tion.-Ranulae are of temporary or of permanent 
signification : thus, where only a limited obstruc- 
tion exists, a tumor may form suddenly during the 
excess of secretion at periods of mastication, to 
drain gradually away as the superexcitation passes 
off. Cases are met with where, as the result of 
accidental inflammatory conditions, the outlets be- 
come obstructed from neighboring exudates, the 
tumor disappearing as the exudates are absorbed. 
Tube not necessarily closed in Ran- 
ula.-The existence of true ranula does not neces- 
sarily imply that the tube affected is absolutely 
closed: a ranula may exist where observation dis- 
covers the canal patulous and the secretion dis- 
charging ; here an explanation is found in well-known similar stricture as met 
with in the relation of the bladder and its urethral canal, urine constantly 
dribbling from the meatus, yet the patient suffering from retention; or, again, 
a probe may be passed with all ease into the orifice of a salivary duct, yet a true 
tumor of retention exist,-here, as referred to, a stricture being deep-seated. 
Indolent Enlargement of Sublingual Gland.-The sublingual 
gland itself is occasionally the seat of an inflammatory enlargement which 
protrudes a tumor upon the floor of the mouth. These enlargements are not 
infrequently of most indolent character, as many as five or six months being 
required to resolve them. The submaxillary, however, seems to be the gland 
most disposed to take on such condition, the tumefaction thus produced being 
without rather than within the mouth, although it occasionally happens that 
it is first observed by the patient as a swelling on the inner side of the jaw. 
Illustrations in Ranula-Case i.-A gentleman having a tumor 
the size of a hen's egg, situated upon the floor of the mouth, applied to the 
author, having been assured that his disease was cancer and that nothing could 
be done. The growth seemed semi-solid, and was fixed to the underlying parts 
with great firmness; the vault of the swelling was smooth and non-vascular ; 
darting pains associated with it. 
Examination of the centre of the tumor made by means of a syringe and 
large aspirating needle afforded the diagnosis of ranula. Cure was secured by 
Fig. 646. 
Superficial ranula, showing 
seton introduced.* 
* This is but a single expression of the superficial ranulee. One treated by the author- 
being a double tumor-presented the appearance of the whole floor of the mouth raised to 
a level with the teeth. 794 
A SYSTEM OF ORAL SURGERY. 
section of the cyst and complete cauterization of its inner face. The walls 
of the sac were quite a quarter of an inch in thickness; the contents were 
semi-fatty. 
Case 2.-Some time back, at the Imperial Society of Surgeons there 
were exhibited by M. Paulet two salivary calculi found by him in Wharton's 
duct. In connection with the presentation was reported the unique fact-for 
such it was thought to be-that the submaxillary glands of both sides were 
found stuffed with stones. See, in this connection, case of Mrs. B., described 
in chapter on Salivary Calculus. 
Case 3.- Obstruction of both Submaxillary Glands. December 17, 
1847, John C. Lyons, aged twenty, Benton Centre, Yates County, consulted 
Dr. Hamilton. He stated that in the latter part of July, while harvesting, 
the weather being very warm, he discovered in the morning a soreness under 
his tongue upon the left side, and before night he found there was a tumor 
at this point. This was oblong and about half an inch in length. His 
physician, Dr. Wolcott, opened it the following day, and it discharged a glairy 
matter. Since then it had been opened four times; but, a few days before 
calling on Dr. H., he discovered that there was a swelling on the opposite 
side, externally, in the region of the submaxillary gland. When seen by Dr. 
H. the gland was of the size of a pullet's egg, oblong, not painful or tender. 
It was increasing in size, but he noticed that it was larger in cold and damp 
weather. His health was good. He was advised to submit to a low diet, 
take physic, and apply externally the tincture of iodine. Patient was never 
seen again, and the result is unknown. During the winter of 1847 and 1848 
two similar cases of enlargement of the submaxillary gland were presented in 
Dr. Hamilton's surgical clinic, at the Buffalo Medical College, one of which 
had resulted in an external salivary fistula. 
Muciparous Cysts.-The third most common affection met with about 
the floor of the mouth relates with muciparous cysts. The meaning of such 
cysts is obstruction in outlets of mucous glands. Diagnosis lies in limited 
size and in the superficiality of situation. Treatment consists in puncture 
and cauterization. 
Enlargement of Sublingual Folds.-Cysts apparently non-mucous 
are met with in the region, the contents of which are various: cheesy, pul- 
taceous, jelly-like. The sebaceous form has been most frequently described; 
one of these cysts seen by the writer was as large as a pullet's egg. A condi- 
tion, simulating a cystic tumor, treated by W. Fairlie Clark, had its meaning 
in the symmetrical enlargement of the sublingual folds; the trouble arising 
out of irritation caused by a carious tooth. The tumor is described as being 
of a horseshoe shape and surrounding the free portion of the tongue. 
Fleischman's Synovial Sac.-The fourth in classification, as fre- 
quency is concerned, are cysts simulating ranula; that term being restricted to 
tumors arising out of obstructions in salivary ducts. The seat of such cysts 
is Fleischman's synovial sac,-a bursa closely adjoining the outer side of the DISEASES OF THE FLOOR OF THE MOUTH. 
795 
genio-hyoglossus muscle, beneath the mucous membrane. Cases of this kind 
are frequently mistaken for the true ranula?. An interesting example was 
lately reported to the Pathological Society of Philadelphia by Professor J. G. 
Richardson, where the sac was filled with seed-like bodies similar to those met 
with in bursae of the wrist-joint. 
Convinced by personal experience that this form of cyst is not uncommon, 
the author is led to infer that the bursa described by Fleischman is very much 
more constant as to presence than generally admitted. Diagnosis of this special 
cyst is forwarded in remembering that the tumor is to be felt upon the neck 
adjacent to the middle line. A post-mortem made of such a cyst by a Dr. 
Muller, of Moscow, showed a cavernous tumor the size of a pigeon's egg, the 
contents of which were a clear, transparent fluid. The subject was an infant. 
Epithelioma.-Epithelioma of the floor of the mouth commences as a 
primary affection at or near the lingual fraenum, otherwise it is an extension 
of the disease from the side of the tongue or gum. 
Venous Aneurism.-Venous aneurism, or naevus, of the location, has 
been met with in the author's practice but in a single instance. The case was 
successfully treated by exciting inflammation in the growth. (See succeeding 
chapter.) CHAPTER XLVIL 
HYGROMATA OF THE NECK. 
A class of cysts indirectly associated with the oral floor may at this point 
claim attention. 
Bursae of Front of Neck.-The front of the neck holds several bursae. 
The first of these, commencing from above, is known as Fleischman's. 
The second is situated between the thyro-hyoid membrane and the poste- 
rior face of the hyoid bone. The third has its location between the skin 
and pomum Adami; this last is sometimes double. Any of these cysts may 
become the seat of a hygroma, the contents of which may be either clear and 
viscid, or sanguineous and grumous. Any one of them may furnish location 
for a true ranular deposit. 
Example of Ranula situated in Front of Neck.-Fig. 647 
represents a case and operation, occurring in the practice of the author, having 
Fig. 647. 
the following history. First, it was noticed by the patient that the parts 
beneath the chin began to soften and broaden, and that gradually freedom 
of motion in the jaw was lost, while a slight sense of difficulty was ex- 
perienced in speech, as the result of stiffness about the tongue, the floor of 
the mouth being quite indurated. In the course of four months, a tumor, 
evidently cystic, and fully the size of an ordinary orange, occupied the front 
of the neck, but was happily concealed by a long and heavy beard worn by 
the patient. 
796 HYGROMATA OF THE NECK. 
797 
Presenting himself for a cure, a diagnosis as to the general nature of the 
tumor was secured through the aid of an exploring-needle; this valuable in- 
strument demonstrating not only that the tumefaction was cystiform, but 
affording an idea of the contents. 
Manner of Treatment.-Treating the tumor as a cyst of immediate 
signification, a bistoury, making a reasonable incision, was passed into the 
most pendent part; the contents, a mass of lymph-like fluid, filling a large 
goblet, issued as a continuous rope; in color and in consistence this would 
have been well likened to thin calves-foot jelly. The cavity having been thor- 
oughly washed with warm alum-water, compresses were carefully adjusted to 
the parts and sustained by a strip bandage. In two weeks, and without any 
trouble, the incision had united, and the cyst seemed permanently obliterated. 
One month later the patient again presented himself. The tumor was re- 
forming : the sac apparently had not been obliterated; already it was the size 
of a walnut. A few days later a second operation was performed pre- 
cisely as in the first instance; the contents of the cyst differed, however, at 
least in color, having the same colloid consistence, but being blood-red. After 
the incision, and after evacuating the cavity, determined on obliterating the 
cyst, it was treated with the officinal tincture of iodine, and stuffed loosely 
with cotton. This time a cure was obtained; but the swelling, associated 
with the inflammation produced by the injection, was so great that it was 
only with the aid of leeches, and by a free use of cathartic and diaphoretic 
medicines, combined with the closest attention, extending over four days, that 
the man's life was saved ; for two whole days the patient was unable to 
swallow even teaspoonful measures of water, and breathed only with the 
greatest difficulty. 
This tumor was evidently enough a hygroma, the starting-point of the 
lesion being, as inferred, in a sublingual gland. It might be suggested that, 
had it been associated with this gland, the swelling would have exhibited 
itself more in the mouth. A reason for inferring that it was so associated lay 
in the fact that a blunt probe passed into the cavity could readily be felt in 
the position of the left of these bodies in the mouth. 
The preceding history is one of the illustrations offered in the chapter on 
Ranula, published in the first edition of this book ; it was written four months 
after performance of the operation, every evidence existing as to the com- 
pleteness of a cure. 
As a coincidence, it occurred that, on the very day the perfected proofs of 
a succeeding edition were put into the writer's hands (the form being struck 
off), this patient again presented himself, the neck exhibiting evidence of a 
return of the tumor. 
Now was determined on, and practised, an operation which shows the case 
in its most instructive light. 
As illustrated in the diagram, a crucial incision was made, exposing, in 798 
A SYSTEM OF ORAL SU RO FRY. 
the retraction of the flaps, the common deep fascia of the neck, which fascia 
constituted the floor of the cyst, and was, in appearance and consistence, 
apparently natural. 
Passing into a sinus in this deep fascia, and emerging from the mouth, the 
reader observes a probe. The orifice of this sinus was very small, and was 
only seen after the parts had been thoroughly cleansed; the track was ex- 
ceedingly tortuous, and was not passed until after several attempts, and only at 
last by an experimental bending of the probe. 
On reaching the floor of the mouth, it was evident enough that the instru- 
ment struck the sublingual gland, as without effort that body could be thrust 
upward from its bed. To thus elevate and dissect out the organ, which was 
done, was a matter of no difficulty. 
To complete the operation, the walls of the cyst were slightly cauterized 
with the solid stick of nitrate of silver, the flaps laid in place, and secured 
with the necessary stitches of interrupted suture; adhesion was secured by 
compresses continued in place over a month. 
Examination of the removed gland discovered upon its under surface a 
break in the continuity, evidently pathological and of long standing; thus was 
demonstrated the salivary character of the tumor. Little by little the secre- 
tion had worked a passage downward, securing, by slow progress, an adven- 
titious tissue, or walled sinus. 
Looked at from the cervical base, one would naturally have viewed the 
sinus as being made by a prolongation of the fascia, so precisely did it look 
as though a tubular cul-de-sac had elongated itself until it had met and asso- 
ciated itself with the base of the gland. 
The question of the location of this tumor is not without a special interest. 
Does it not prove the existence of a supra-hyoid bursa, described by some 
anatomists and searched for in vain by many others ? If such bursa had not, 
in this particular case at least, an existence, how shall we explain so naturally 
the presence of the perfect cyst which formed the tumor ? 
A second point of interest lies in the fact of reaching the gland described 
in the first diagnosis made months before. This, it would seem, could only 
have been the result of a rare accident, which on that occasion directed the 
probe into the sinus, and gave to the parts such favorable position as made 
the passage a direct one. 
This case, viewed from the stand point of fistula, is one of great interest 
and instructiveness: had the tumor been allowed to enlarge and attenuate 
the walls, and thus to rupture, it is evident that the case would have be- 
come one of salivary fistula proper. 
Case of Hygroma.-An example of hygroma, very suggestive as a 
study, is recorded in Bell's " Principles of Surgery." The attention of the 
reader is directed to it. 
The case was that of a young woman of Berwick, whose native peculiarity 
of accent had received a singular aggravation by such an uncouth obliquity HYGROMATA OF THE NECK. 
799 
and imperfect motion of the tongue as conveyed the notion of her attempting 
to chew and turn each vocable with her tongue before she proceeded to swal- 
low, in place of uttering it. This was produced by a tumor of very great size, 
and of an appearance so peculiar as plainly to denote its character. It con- 
sisted of a vast collection of matter in the sublingual gland; and as that 
gland is covered by the whole thickness of the tongue within, and by the 
mylo-hyoid muscle without, and is bounded by the line of the jaw-bone, it 
had the following singularities of character. It could not be distinguished as 
a tumor, but had rather the appearance of a general tumefaction of the lower 
part of the face, jaw, and neck, such as often accompanies severe toothache or 
mumps. On laying the hand upon the outside of the neck, below the lower 
jaw-bone, it was found filled with a swelling, apparently solid, but so little 
convex or circumscribed as to resemble in no degree a tumor of any particu- 
lar gland, and yet so limited and so firm as not at all to simulate the general 
enlargement proceeding from periodontitis. On introducing the finger into 
the mouth, the tongue was found raised, turned edge uppermost, and pressed 
entirely toward the left side of the mouth, the external tumor being upon the 
right side. On pressing the fingers very firmly down by the side of the 
tongue, and reaching from without, one could sensibly perceive not so prop- 
erly a fluctuation as an elasticity, which implied the presence of a fluid; the 
tumor seemed elastic like a foot-ball, but with a degree of tension which made 
it appear almost solid. It was by comparing a variety of circumstances, es- 
pecially the original place and slow growth of the tumor, that the surgeon con- 
fidently referred it to the sublingual gland. The patient being placed in a 
chair, a fine bleeding-lancet was struck deep into the growth by the side of the 
fraenum of the tongue, when, from the firm compression of the surrounding 
parts, the matter, though too gross to pass freely through such an opening, 
was spewed out from the orifice, in a manner expressly resembling that in 
which yellow paint is squeezed from the bladder upon a painter's palette. It 
was of a deep saffron color, thicker than mustard, mixed like gruel with 
seed-like particles, and exceedingly fetid. Next day the point of a probe- 
pointed bistoury was introduced into the orifice made by the lancet, when 
thick yellow mucus flowed freely, or was raked out with the points of the 
fingers and the handle of the bistoury, the tongue descending to its natural 
level. 
So tense and apparently fixed was this tumor, in consequence of the com- 
pression by so many surrounding muscles, that it was at one time mistaken 
for a solid and strumous swelling. 
It is found, in all such cases, a matter of some importance, especially in 
girls, to anticipate the outward suppuration of any sacculated tumor, by 
puncturing it, though to a great depth within the mouth and under the 
tongue, and equally necessary to be at pains in preserving the opening and 
obliterating the sac: a slight misconduct in this respect occasions much dis- 
tress to the patient and much superfluous labor to the surgeon. 800 
A SYSTEM OF ORAL SURGERY. 
Deep-seated Ranula.-An expression of deep-seated ranula is ex- 
hibited in Fig. 648. Cases of this kind are met with where the swelling is 
associated exclusively with the submaxillary region ; more commonly the tumor 
shows alike within and without the mouth. Abscess of the gland, the pus 
Fig. 648.-Deep-seated Ranula. 
being confined between the triangular leaves of its fascia, is distinguished from 
hygroma by its history; the one being an inflammatory disease, the other not. 
Hygromata of the neck, in no way related with ranula, are frequently to 
be met with. The writer has dissected out such cysts of sizes varying from 
that of a hickory-nut to that of a cocoanut. In a case operated on by him 
before the class of the Oral Hospital the tumor was almost the size of the 
patient's head. It reached from the jaw above to the clavicles below and 
extended correspondingly laterally. The patient, a young artist of great 
promise, died a month later of a galloping consumption. CHAPTER XLVIIL 
DISEASES OF THE PHARYNX. 
The pharynx is the pouch entered on passing through the oro-pharyngeal 
space. Its boundaries are as follows : above, the base of the skull; posteriorly 
and laterally, the constrictor muscles; anteriorly, the plane of the opening 
which associates it with the mouth. 
Communications with Pharynx.-The pouch communicates with 
seven associate parts; namely, with the mouth, the larynx, the oesophagus, 
the two nares, the two Eustachian tubes. 
Dissection of Pharynx.-Dissection of the pharynx exhibits it as a 
muco-musculo-aponeurotic bag held open by attachment above to the petrous 
Fig. 649. 
Fig. 650. 
Fig. 649. Side view of pharynx and its muscles. 1, trachea; 2, cricoid cartilage; 
3, vocal membrane; 4, 6, thyroid bone; 7, stylo-hyoid ligaments; 8, oesophagus; 9, in- 
feriorconstrictor; 10, middle constrictor; 11, superior constrictor; 12, portion of stylo- 
pharyngeal muscle ; 13, upper extremity of pharynx; 14, pterygoid-maxillary ligament; 
15, buccinator muscle; 16, oral orbicular muscle; 17, mylo-hyoid muscle. 
Fig. 650. Posterior view of the muscles of pharynx. 1, vertical section trans- 
versely of the base of the skull just in advance of the cervical vertebree; 2, 3, posterior 
border and angle of lower jaw; 4, internal pterygoid muscle; 5, styloid process, giving 
attachment to, 6, stylo-pharyngeal muscle: 7, pharynx; 8, inferior constrictor of the 
pharynx; 9, middle constrictor; 10, superior constrictor. 
portion of the temporal bone, and laterally to this same bone, to the pterygoid 
processes of the sphenoid, the pterygo-maxillary ligaments, the angle of the 
lower jaw, the hyoid bone, and to the larynx. The base, or framework of the 
801 802 
A SYSTEM OF ORAL SURGERY. 
pouch, is an aponeurosis. This is a fibrous structure internal to the muscular 
layers; thick above, where it is attached to the skull, thin below, where it 
proximates the apex. The muscles are ten in number; these being fairly 
separable into five pairs. Figs. 649 and 650 show and name these muscles; 
affording as well appreciation of the posterior and lateral relations of the 
pouch. Fig. 67 shows an inside view of the pharynx. The mucous 
lining, seen in the last-named diagram, is soft and brownish-red. The 
epithelium covering it is of the columnar ciliated variety above; below it 
resembles that of the mouth in being squamous. Membrane and under- 
lying parts are related by much submucous tissue in which are embedded 
a large number of glands, these being of the racemose and follicular varieties. 
The blood-vessels of the pharynx are derived indirectly from the internal 
maxillary and thyroid arteries. The nerves issue from the glosso-pharyn- 
geal, the pneumogastric, and from the sympathetic system. 
Oro- and Naso-Pharynx.-The pharynx is partly divided into an 
upper and a lower portion by the soft palate which extends incompletely 
across it. The part above the velum is termed the naso-pharynx; its imme- 
diate relation is with the nose. The part below is named the oro-pharynx; 
its association is with the mouth. 
Soft Palate.-The soft palate, or veil, is a musculo-membranous curtain 
concerned in the processes of deglutition and speech. It may not inaptly be 
described as a fold of the common oral mucous membrane extending backward 
for some distance from the ledge of the hard palate, then turning upon itself, 
after dropping a pouch-the uvula-and passing forward to line the nares. 
Between these layers, relating with each other at a medium raphe, are five 
pairs of muscles. These muscles are elevators, depressors, lateralizers. A 
special pair-azygos uvulae-arise from the spine of the conjoined palate 
bones and extend into the uvula pouch. 
Diseases of Pharynx.-The diseases of the pharynx relate to the 
mucous membrane and elements of the submucous tissue. Affections of the 
muscular and aponeurotic structures are uncommon. 
Pharyngitis.-Pharyngitis, active, passive, or chronic, is the pathological 
condition most frequently met with. The aspect of phases presented in in- 
flammation of the parts depends partly on the nature of the cause, partly on 
the state of health of the patient. 
Angina Simplex.-Angina simplex, common sore throat, inflammation 
arising out of taking cold, is ushered in by a sense of irritation about the 
throat which later progresses to a condition of huskiness in voice and pain in 
swallowing. Examination reveals a swollen state of the parts, a bright-red 
color, velvety appearance of the surface, a uvula more or less elongated and 
oedematous. Result: commonly resolution; sometimes laryngitis, trachitis, 
oesophagitis, and inflammation of Eustachian tube by extension through con- 
tinuity. Treatment: feet in hot water, dry cups to neck, saline cathartics, 
refrigerant diaphoretics or diuretics, a gargle composed of one grain each of DISEASES OF THE PHARYNX. 
803 
hydrate of chloral and sulphate of zinc to the ounce of water. A medicine found 
frequently to break up at once a sore throat consists of twenty to forty grains 
of bromide of potassium combined with five drops of tincture of veratrum 
viride and one-quarter of a grain of elaterium; the whole to be taken in a 
wineglass of water on going to bed. Ph^nol-sodique, a tablespoonful to a 
goblet of water, is an admirable gargle in all conditions of sore throat; in 
diphtheria it is reasonably specific, while the use of it is to be recommended 
prophylactically wherever this disease is prevalent. 
Ulceration and Gangrene.-In ill constitutional conditions pharyn- 
gitis may rapidly advance to a state of ulceration or even gangrene. Indica- 
tions here direct special systemic medication. In diphtheria the congested 
pharyngeal membrane is commonly covered with patches of exudate which 
have extended from the palato-pharyngeal fold, requiring a special local as 
well as systemic medication; local remedies are tincture of iron and chlorine- 
water, these being alternately applied by means of mop, brush, or atomizer, 
every one, two, or three hours according to urgency. Constitutional remedies 
are found in the direction of the chalybeates and preparations of bark. (See 
works on Practice of Medicine.) 
Follicular Inflammation.-Follicular inflammation of the pharynx 
limits itself chiefly to the crypts; these, however, commonly ulcerate and 
cause a very great deal of pain and nervous disturbance, although not com- 
monly exciting the febrile condition. A continuous desire to hawk or spit is 
the first sign of follicular inflammation. Examination of the throat reveals 
the pouch reddened and studded with oval granular patches lying within 
areolae of congested tissue. The patches are the diseased follicles. The 
summit of each presents a whitish translucent appearance which is apt quickly 
to change to the condition of ulceration. Where the general health is unim- 
paired this ulceration is found to be the point at which turn is taken toward 
cure; the sores healing commonly within a few days. In bad states of the 
system the ulcers oftentimes exist for a long time; taking on a chronicity and 
an indolency which render them the source of much distress. 
Treatment of Follicular Inflammation.-Treatment of follicular 
inflammation differs nothing, as the active, or first, stage is concerned, from 
that employed for angina simplex. Becoming chronic, the ulcers remaining 
stationary or enlarging, local and general stimulation is indicated; the former 
particularly. As a gargle no medicine surpasses the tinctura capsici et myrrhae 
used in dilution; enough being dropped into water to change the color of this 
fluid to a bluish-white. Chloride of zinc in the proportion of two grains of 
the salt to an ounce of water is another valuable means. Still another is 
found in a formula as follows: 
U Acidi carbolici fluidi, gtt. xii; 
Tincturae calendulas, ^iv; 
Aquae, Oj. M. 
Sig.-Gargle frequently. 804 
A SYSTEM OF ORAL SUROERY. 
Dilute chlorine-water-Watson's formula (see Dublin Pharma- 
copoeia)-is an invaluable application in association with stimulants; being 
used with the atomizer. In diphtheritic sore throat this remedy plays an 
invaluable part as a solvent of the exudate and a preventive of blood-poisoning. 
In the estimation of the writer it approaches a specific. 
Other means of treating ulcers in follicular pharyngitis refer to 
touching them with solid caustic or alterative preparations: agents of this 
class are nitrate of silver, sulphate of copper, alum, etc. 
Pharyngitis Sicca.-Pharyngitis sicca, atrophic pharyngitis, senile in- 
flammation of the pharynx, is an atrophic condition esteemed commonly as 
associated with age or as the ultimate of chronic pharyngeal or naso-pharyn- 
geal catarrh, or as a state dependent on constant contact with dust or other 
foreign agents of offence. A case of this nature, at one time under care of 
the writer, in the person of a gentleman aged eighty, presented the single dis- 
agreeable symptom of dryness, this being so great and persistent as to neces- 
sitate the continuous use of glycerin as a lubricant. Dr. E. L. Shurly, of 
Detroit, in an able monograph on the subject, lays stress on systemic condi- 
tions influencing and keeping up the condition ; these being functional or or- 
ganic derangements of the stomach and allied parts, rheumatism, enfeeblement 
of the circulatory apparatus, etc. 
The principle of treatment lies in accepting the expression of local 
paralysis. Means of relief or cure refer to the correction of systemic defects, 
particularly as nervous derangement is concerned, and in the employment of 
local lubricants and stimulants. The use of a constant electric current as 
applied through a Grenet battery is credited with some virtue by Dr. Shurly. 
The prominent feature in the diagnosis refers, in the estimation of the writer, 
to interference with the nerve-supply of the parts; the sympathetic system 
being most apt to be found at fault. In this connection, and as well in rela- 
tion with all local expressions of enervation, the author finds that great reli- 
ance is to be placed on the use of Volta's pile, applied by taking pieces of 
sheet-zinc and copper and securing galvanic action by placing between the two 
a strip of woollen cloth saturated with cider vinegar. 
Herpes.-This disease, as an affection of the pharynx, is exceedingly 
rare, particularly as exhibit of it in the vesicular stage is concerned. Ulcers 
result from the breaking down of the vesicles, but these are commonly found 
to yield quickly a cure to required systemic or local treatment. (See Herpatic 
Tonsillitis.) 
Effusions.-Effusions into the submucous tissue of the pharynx are fre- 
quently met with. These are semi-plastic in character, and tend to limit 
themselves to one side of a vertical line, principally to the right side as met 
with in the experience of the writer. When extensive, the membrane is 
thrown forward to an extent that sometimes interferes markedly with degluti- 
tion. If not resolved, such effusion may result in abscess. Primary treat- 
ment is by local stimulation. If pus form, speedy vent is to be given it. DISEASES OF THE PHARYNX. 
805 
Post-Pharyngeal Abscess.-Retro- or post-pharyngeal abscess is a 
form of disease differing from that just alluded to alone in situation, the 
effusion and pus being situated between the pouch and vertebrae. The sub- 
jects of it are generally children of scrofulous habits; the cause, acute 
pharyngitis or disease of vertebral column. Diagnosis refers to subjective and 
objective symptoms. The abscess being situated high up, the bulging of the 
pouch is plainly to be seen. When the position is low down, judgment is to 
be formed by the seat and nature of obstruction. A diffused abscess may 
baffle the most experienced. The condition is always to be looked on as seri- 
ous, being of constitutional import. Treatment consists in venting the pus as 
soon as discovered, and in ministering to the patient supporting cordials and 
tonic medicines. Iron and cod-liver oil are always indicated. 
Specific Conditions.-Syphilitic ulcers of the pharynx, while not 
common, except as relation is had with the soft palate, are yet not sufficiently 
infrequent to deny them notice in connection with diseases of the part. The 
affection is among the earliest of the series of secondary phenomena. Syphi- 
litic erythema is very much more common to the pharyngeal walls than are 
ulcers; indeed, it is to be asserted that any secondary or tertiary expression 
manifesting itself about the tonsils, uvula, or palate will have associated with 
it this blush of the pouch. 
Syphilitic ulcers of the pharynx differ nothing in appearance and character 
from such sores when affecting mucous surfaces generally. There are two 
varieties, the superficial and the excavated. Superficial sores are commonly 
multiple ; they simulate abrasions, showing, in many cases, no other expression 
than that of lost epithelium; in others, being of ragged, or, it may be, of 
undermined edge. Sometimes the sore assumes a serpiginous form. An 
excavated one is the analogue of a Hunterian chancre. It is deep, has a 
pasty bottom, and is indurated. 
Tubercles.-Specific tubercles are occasionally met with in this location; 
these are irregular elevations of the mucous membrane, generally of oval form 
and of whitish color. To the touch they are not unlike chancres. When 
becoming confluent, as is sometimes the case, the degenerated surface may 
break down with the result of an open ulcer of the second class as above 
viewed. 
Diagnosis.-Diagnosis of venereal affections of the throat relates to color 
of the parts,-which is that of copper,-to the peculiar feel, and to coexist- 
ence of the disease in the system at large. 
Treatment.-Treatment concerns itself with prescribing, first, for the 
vice at large ; second, for local indications. 
An anti-venereal of satisfactory import in secondary syphilis is a formula 
as follows: 
U Hydrargyri chloridi corrosivi, gr. ij; 
Potassii iodidi, 5ij; 
Syrupi sarsaparillse, §viij. M. 
Sig.-Dose, tablespoonful three times a day. 806 
A SYSTEM OF ORAL SURGERY. 
Where the disease is of tertiary form it is usually found well to 
omit the mercurial, replacing it with a medicine of anti-scrofulous significa- 
tion : cod-liver oil, having combined with it the hypophosphites of iron, lime, 
and soda, may be used with profit. 
Local treatment differs little from that employed on chancre of the 
penis. If the sore be of the superficial variety it may be all-sufficient to 
touch it lightly with a dilute mineral acid. Nitrate of silver, in stick or solu- 
tion, is an admirable remedy. Acid nitrate of mercury, diluted in eight or 
ten parts of water, is highly commended, being brushed over sore and neighbor- 
ing parts once each day. Phenol-sodique, diluted one-half with water, is never 
found otherwise than useful. This last remedy not being at hand, an admira- 
ble substitute is found in common tar-water, made by stirring a tablespoonful 
of tar in a goblet of water, adding to this carbolic acid to suit indications. 
Where the sore is of excavated 
character it may be touched 
moderately with the London 
paste, or, what answers an ad- 
mirable purpose, crystals of zinc 
chloride may be laid in the 
part and allowed to deliquesce, 
care being taken that the fluid 
do not run over adjoining 
localities, and that as soon as 
permissible it be mopped from 
the ulcer with bibulous paper. 
Plethoric persons require de- 
pression ; the anaemic are to be 
stimulated. 
Nebulization of Fluids.-Fig. 651 shows a nebulizer of fluids, known 
as " the American," which is invaluable for use in throat affections. Formulae 
employed are to meet indications. Two for chronic rhinorrhoea, which for 
cleansing and alterative character equal any others, are as follows: 
Fig. 651.-Nebulizer. 
Acidi carbolici cryst., grs. v; 
Liquoris iodini (Lugol), 3iij; 
Aquae menth. pip., 3SSJ 
Glycerini pura, Siijss. M. 
U Acidi carbolici cryst., grs. v; 
01. eubebae, 
01. eucalypti, 
01. menth. pip., 
01. caryophylli, aa gtt. x; 
Fl. cosmolini vel vaselini, q. s. ad ^j. M 
Wounds.-Wounds of the pharynx demand attention in consideration of 
indications. A case treated by the author, where the pouch was opened just DISEASES OF THE PHARYNX. 
807 
above the larynx in an attempt at suicide, resulted in permanent aphonia. In 
a second case of injury to the region a stick in the hands of a boy passed 
through the posterior wall and struck against the vertebral column. The 
recovery was without a bad sign, soothing gargles being alone used. 
Gun- or pistol-shot wounds are the commonest injury to the region. 
Primary indications relate with the removal of the missile, the control of 
hemorrhage, and the recovery from shock. Treatment of the hurt implies 
little more than the directing of fluid food and the prescribing of antiphlo- 
gistic lotions. 
An ugly complication of wounds perforating the mucous membrane of the 
pouch is emphysema of the neck ; the areolar tissue of the region some- 
times becoming so much distended as to be a cause for much alarm; the 
swelling not at all times disappearing with a rapidity to be desired. 
Incised wounds of the pharynx are to be closed with stitches of the 
interrupted suture where such stitching is conveniently to be accomplished; 
the ends of the ligatures are to be cut off close to the knots so that, when 
ulcerated free, the thread may fall into the throat. Thread of catgut replaces 
happily that of silk. The staphylorraphy needles apply, which see. 
Stricture.-This condition, as affecting the pharynx, has never been met 
with by the author except as associated with carcinoma. 
Globus Hystericus.-This condition, familiar under the name of 11 a 
lump in the throat," is troublesome but never dangerous. Being an hysterical 
affection, it finds a good treatment in the use of assafoetida pills. 
Spasm.-(Esophageal spasm, productive of temporary stricture, may be 
caused by irritation arising out of an elongated uvula; such probable cause is 
always to be looked after where the condition is met with. Accidental injuries 
are recorded as causes even in cases where years have passed since the hurt. 
Treatment in the case of uvular elongation lies in amputation of this organ. 
Spasmodic states require the bromides. In a case noted before the New York 
Clinical Society, Dr. Delavan cured the patient by ten-grain doses of bromide 
of potassium administered in a little water three times a day. (See Uvula 
and its Diseases.') 
Imperforate Pharynx.-Cases of imperforate pharynx, as relation is 
had with the oesophagus, are on record. If met with, a practitioner could do 
nothing apart from a practice directed by common experience derived in 
analogous directions. A case that was under the care of the writer showed 
an imperforate condition of the naso-pharyngeal opening, ulceration of the 
nasal surface of the velum having attached that part immovably to the region 
above it. No opening existed between nose and pouch. 
Neoplasms.-Cancer of the pharynx proper is rare. A case in the 
Hospital of Oral Surgery showed the sac so completely occupied by a sar- 
coma growing into it from the maxillary sinus that the patient was unable 
to pass any but the most fluid food. Another case in the same hospital 
exhibited the soft palate so involved that a pendent mass completely filled the 808 
A SYSTEM OF ORAL SURGERY. 
oro-pharyngeal orifice, extending back to the posterior wall, interfering not 
only with deglutition but with respiration. Cancer occurring directly in con- 
nection with the pharyngeal walls is apt to start in the submucous cellular 
tissue close to the oesophageal locality. A first expression is in the form of an 
infiltration which is apt to afford primarily idea of cold having been taken. 
Stricture arising out of the condition is incurable; operation is only a pro- 
longation of misery sure to end fatally. (See Tumors.} 
Fibromata.-Fibromata, of which mention is to be found in connection 
with the soft palate, are always to be associated with doubtful prognosis. 
Fungiform papillomata, except where of pronounced venereal character, are 
not unjustly to be regarded with like concern. 
Polypi.-Polypi falling from the naso-pharyngeal space back of and below 
the velum are not infrequent. These are to be caught from the oral opening 
and twisted off. A second means of evulsion employs a wire ecraseur passed 
through the nostril. (See Polypi.} 
Uvula.-Tumor of the uvula, caused by infiltration or hypertrophy, may 
be of such bulk as to interfere with respiration by descending into the laryn- 
geal opening. Treatment is by amputation or sorbefacients. (See Uvula and 
its Diseases.} 
Irremovable Causes.-Irremovable causes of interference with the 
pharyngeal openings, either of larynx or oesophagus, are to find all correc- 
tion possible in the operation of tracheotomy or oesophagotomy. (See 
Tracheotomy.) 
Foreign Bodies.-Pertinent to this direction of our study is a refer- 
ence to the probability of foreign bodies lodging about the parts considered. 
First: artificial teeth and plates. Pivot teeth falling from their sockets are 
commonly swallowed; no harm results where the pivot remains in the root. 
A tooth of this class carrying with it into the intestines a pivot of wood or 
metal is not disassociated with danger existing in the possibility of perfora- 
tion. A guard is found in feeding the patient largely on mush with 
a view to distending the intestinal tract as much as possible. 
A plate commonly lodges about the orifice of the oesophagus or de- 
scends into that tube. On one occasion the writer was called to an accident 
Fig. 652.-Bond's (Esophagus Forceps. 
of such nature where a piece having three teeth attached and measuring an 
inch across had worked along full half-way down the canal. Removal was 
effected with very little difficulty by use of forceps as here shown, Fig. 652. DISEASES OF THE PHARYNX. 
809 
A plate lodged in the apex of the pharynx is to be felt with the 
finger, and, if no forceps be at hand, is not infrequently to be dislodged and 
thrown from the mouth through the production of emesis. 
A plate in the oesophagus is commonly to be located by pain induced 
from pressure made over its seat. 
Bones swallowed in eating may be stayed 
in the oesophagus. An instance of this kind under 
observation by the author showed the obstruction fixed 
at the cardiac orifice of the stomach ; the body could 
not be made to descend and it seemed alike impossible 
to withdraw it. Manipulation with long forceps con- 
tinued, at varying intervals, over two or three days, 
resulted in catching the piece at a proper axis and 
getting it out. (Esophagitis followed, but quickly 
resolved itself. 
Spasm.-One of the very immediate results of 
the presence of a body impacted in the apex of the 
pharynx is spasm, this being at times so severe and 
persistent as to smother the patient quickly if relief 
be not afforded. Opening of the crico-thyroid mem- 
brane is the indication; to be followed by trache- 
otomy, if necessary. If chloroform be at hand it may 
be employed with hope of relief from the effects of 
the stricture. Moments are, however, as hours. 
Fish-Bones and Bristles.-Fish-bones, bris- 
tles from a tooth-brush, and similar small particles, 
are the not infrequent causes of great suffering from 
lodgement in the throat. The first place to look for all 
such bodies is in the lingual sulci found on either side 
of the fraenum epiglottis; failing in discovery here, 
examination is to be directed backward. Small bones 
incapable of being dislodged are to be rendered flexi- 
ble by the free use of acids. 
Probangs.-Instruments used in search of such 
bodies, known as bristle probangs, are exhibited in 
Figs. 653 and 654. As will be recognized, these 
probangs fold the bristles on introduction into the 
oesophagus, spreading them out, thus searching the 
circumference of the tube, on withdrawal. 
Swallowing a Pin.-The swallowing of a pin 
is a not infrequent event; the writer has occasionally 
been called to these accidents without finding the body; in no case has there 
been any serious result. 
Swallowing a Fish-Hook.-A fish-hook attached to its line has been 
Figs. 653, 654.-Bris- 
tle Probangs. 810 
A SYSTEM OF ORAL SURGERY. 
swallowed into the oesophagus where withdrawal was effected by means of a 
lead ball perforated and slipped over the string. Extending the twine and 
allowing the ball to drop, a dislodgement was secured and the hook brought up, 
its point being caught in the metal. 
Soft Bodies impacted.-Soft bodies in the oesophagus, if at all im- 
pacted, are to be helped to their destination by means of a bougie or flexible 
probe. Fig. 655 represents such a probe having bulbs of varying size; these 
Fig. 655.-(Esophageal Bougie. 
are used also in strictures of the oesophagus. Rodies in the trachea will 
almost certainly require for their removal opening of that tube. 
Feeling not Evidence of Presence.-In considering the subject of 
foreign bodies about the throat it is always to be borne in mind that feeling is 
not evidence of presence. Lives have been destroyed in efforts to dislodge 
bodies which dissection showed to be absent. It is in the experience of the 
author to have a patient maintain for days the existence of presence where 
certainty existed as to absence. 
Cutting a Blood-Vessel.-Sharp and jagged bodies in the oesophagus 
may occasion speedy death by being forced through a blood-vessel, or, if 
remaining some length of time, a similar result may be brought about through 
ulceration. 
NASO-PHARYNGOSCOPY. 
Examination of the naso-pharynx is made by employing the means known 
as posterior rhinoscopy. Rhinoscopy is the manipulation designed by Czermak 
for exposure and illumination of the naso-pharyngeal space. 
Rhinoscopy.-A rhinoscope differs nothing from the mouth mirror used 
in dentistry. Adjuncts used with the mirror are: 1, the flame of an argand 
burner; 2, a glass of concave face. 
To make a naso-pharyngoscopic examination implies lighting up of 
the space together with an ability to see into it when looking directly into the 
mouth. 
Recognizing the double requirement of reflecting a flame and catching 
an image, the operation is ordinarily commenced by placing a light to the 
back and side of the patient. This light is variously modified to suit 
the convenience or views of the surgeon. Tobold, Voltolini, Czermak, DISEASES OF THE PHARYNX. 
811 
Morell Mackenzie have each devised apparatus. (See works on the 
Laryngoscope.) 
A simple means of illumination consists of an argand flame en- 
veloped by a cone made of tin, which cone is so fenestrated as to allow of its 
being slipped in a horizontal direction over the glass; the base of this cone is 
a concave circular mirror; the apex, which is cut off so as to give a diameter 
of two inches, is open. The instrument stands upon a pedestal, which raises 
and lowers to suit examinations made standing or sitting. 
Light and patient in relation, a succeeding step considers reflection 
of the flame. To accomplish this the operator uses a concave mirror; this 
being employed attached to the forehead, or otherwise held. Catching the 
ray upon this glass it is appreciated that it can be directed at will. 
Step three refers to the employment of the throat mirror. Here is the 
difficulty of the operation. A deep velum associated with irritability of the 
region seriously complicates the matter, rendering, indeed, in occasional in- 
stances, the performance an impossibility. A short velum and an unirritable 
throat favor in every way the examination, exposure of the parts being secured 
without even discomfort to the patient. 
Fig. 656.-Use of the Laryngoscope by Sunlight. 
A throat lined with tenacious glairy secretions is to be pre- 
liminarily treated by gargles of Watson's chlorine-water diluted to suit require- 
ments. An irritable throat may be partially schooled into hebetude through 
frequent handling, or by use of a potassium bromide gargle. 812 
A SYSTEM OF ORAL SURGERY. 
Illustrative Practice.-Fig. 656 exhibits the relations and manner of 
laryngoscopic and rhinoscopic examinations. The cut is fully self-explanatory. 
Fig. 659 shows an image of the nose 
as seen in posterior rhinoscopy. Fig. 
657 exhibits the laryngeal image. 
Electric Illuminator.-The con- 
spicuousness of separate mention is made 
of this illuminator because of special 
merit; the design is by J. S. Dicken, 
L.D.S., of Southport, England; intro- 
duction of the light into America was 
by M. H. Cryer, M.D. Employment of 
the instrument relates alike with mouth, 
throat, and naso-pharyngeal surgery. It 
illumines perfectly. A too frequent absence of battery conveniences is the 
single offset. 
Referring to the diagram, complete understanding of the apparatus is re- 
ceived in recognizing that it consists simply of an ordinary mouth, or laryngeal, 
mirror, to the handle of which is attached a circular glass lantern holding the 
platinum points of an electric light. Associate fixtures refer to transmission 
Fig. 657.-Laryngeal Image. 
Fig. 658. 
Description of diagram.-C C, an ordinary mouth mirror, or laryngoscope. A B, two 
binding-posts. D E, a small Swan's electric lamp. H H, two wires running in grooves 
along the handle C, from A B, to a silver sleeve, G, made in two sections, insulated from 
each other, in which the lamp is held. E, a brass plate on each side of the insulated 
portion of the lamp; from these plates run the platinum wire into the lamp D and back 
when the lamp is held in the sleeve, and the wires of a battery, consisting of two Bun- 
sen's cells, attached at A and B; the current is then formed from A to sleeve G on one 
side, connecting with E through the platinum wire, back again to E and G on the other 
side, thence to B, or vice versa. F is a silver shield and reflector combined, highly pol- 
ished, to protect the cheeks or any portion of the mouth coming in contact with the 
instrument. 
of wires from battery, to reflection, and to lifting and protecting surrounding 
parts. The heat evolved is so trifling that the writer has allowed the uvula 
to rest against the lantern, the patient being unconscious of the fact; it is yet 
sufficient to keep the glass entirely free from moisture however long it be 
continued in the mouth. The use of this mirror does away, of course, with 
the means for illumination shown in the preceding diagram. 
Dental practice is perfectly served by this illuminator of Mr. Dicken's. Placed 
back of the teeth, these organs are rendered nearly transparent. Pulp-canals 
can be seen almost to their apices. DISEASES OF THE PHARYNX. 
813 
Different Instruments.-In connection with Mr. Dicken's apparatus 
attention is directed to Trouve's polyscope, an instrument differing nothing at 
all in principle from the former, but not comparable with it in adaptability to 
oral requirements, the light in the latter being exposed in a porcelain saucer. 
An illuminator of similar signification is a design by Mr. Margetson, a surgeon 
of Dewsbury, England. This gentleman uses carbon filaments varying in size 
from one by half an inch to one-eighth by one-quarter inch. Mr. Stern, of 
the Swan Electric Company, has brought out an instrument of this same 
class, while others, notably a construction by Messrs. Queen & Co., opticians, 
of Philadelphia, and one by the S. S. White Dental Manufacturing Company, 
are prominent. 
Depression of Tongue and Relaxation of Uvula.-To employ 
a rhinoscope requires depression of the tongue and relaxation of the velum. 
The first is accomplished by means of an instrument known as the depressor; 
the handle of a spoon practically represents this. The second is secured by 
directing the patient to breathe entirely through the nostrils; in which act 
the veil falls toward the tongue. 
Rhinoscope to be Warm.-A common rhinoscope is to be intro- 
duced warm; this with the double purpose of avoiding moisture upon its face 
and sparing irritation to the throat. 
M anner of Introducing.-Everything being ready the glass is passed 
gently into the pharynx, the face being directed at a proper angle toward the 
space to be examined. Upon this glass is received the light reflected by the 
head mirror; to be cast by it in turn into the naso-pharynx ; and still in turn 
to give to the eye of the looker an image of the part illuminated by it. Prac- 
tice is required to afford proficiency. Dicken's instrument is complete in itself. 
Picture seen.-What will be seen in naso-pharyngoscopy depends on 
the manipulative tact of the surgeon. What should be seen, the parts being 
healthy, is beautifully outlined in the accompanying diagram. 
Fig. 659. (After Cohen.) 
1, septum; 2, free space of nasal passage; 3, superior meatus; 4, middle meatus; 5, 
superior turbinated bone; 6, middle turbinated bone; 7, inferior turbinated bone; 8, 
position of the opening into Eustachian tube; 9, fossa of Rosenmuller; 10, lateral wall 
of pharynx; 11, superior wall of pharynx; 12, posterior surface of velum. CHAPTER XLIX. 
PALATINE DEFECTS, AND THEIR TREATMENT BY 
OPERATION. 
In the treatment of palatine defects, the first consideration refers necessarily 
to cause and condition. Thus, it is found that such defects or deficiencies 
may, by influencing circumstances, require treatment so modified or changed 
as to seem, in cases apparently similar, quite at variance with each other. 
For example, take two perforations exposing the nares; one congenital, the 
other the result of disease. In the first of these cases any operation or appli- 
ance which would seem to promise relief might be adopted; in the second we 
might justly pause at any interference. No one would attempt staphylorraphy 
on a patient laboring under acute syphilis, or where a mercurial course had 
so broken down the crasis of the blood as to make a union by the first 
intention impossible, or even doubtful. No more would one be justified in 
attempting this or any other of the operations of expediency, with the consti- 
tutional conditions adverse to success, than he would be justified in avoiding 
the responsibility where such influencing associations were favorable. 
Cleft Palate.-The condition known as cleft palate, to which we at once 
pass, must, from its exceeding frequency, be the first to claim attention. A 
cleft may be partial or complete; that is, there may be a simple lengthwise 
division in that portion of the mouth known as the soft palate, or the cleft 
may be so extensive as to extend from the uvula to the lip, a fissure sepa- 
rating both hard and soft parts. The first of these conditions is found 
sometimes as the result of disease; the latter is always congenital. Fissures 
produced by syphilis are constantly treated where there are breaks both in 
the bone and in the soft palate, but never where there is a coexistent one in 
the continuity of the lip. 
Fissure of the hard palate, a result of disease, differs from the con- 
genital form in a particular which would scarcely allow of the surgeon's being 
deceived. A fissure the result of disease exhibits an irregular break in the 
continuity of one or both palatine processes; a fissure having congenital origin 
exhibits the deficiency harmonious to the line of contiguity; that is, to the 
palatine raphe. 
Let first be considered the condition and treatment of a congenital 
cleft. A child is born, toward whose mouth attention is directed either by 
the nasal character of the cry, or, a little later, by inability to take the breast 
properly; or the condition is marked, perhaps, by the break continuing 
through the lip, giving the deformity known as harelip. 
814 PALATINE DEFECTS-TREATMENT BY OPERATION. 
815 
When a child is thus unfortunate and the attention of the surgeon 
is called to the case, a single question presents itself,-namely, how is the 
deformity to be corrected ? If suffered to continue, every day increases the 
difficulty of the cure,-that is, as the most formidable part of the operation is 
involved,-while if its correction be at once attempted, the prospect of complete 
success is very great. 
Fissure of the hard palate has generally been deemed irremediable 
as operative means are concerned, and the surgeon has been taught to consider 
his whole duty done in describing to the parents the mechanical method 
which in after-life is to conceal and correct the defect of his patient. Now, 
in this connection will be presented a remedial surgery which is as practicable 
and feasible as any other of the operations of expediency, and perhaps one 
is justified in going so much further as to say that the modes of procedure 
will be found much more promising than the majority of such operations. 
Through the proper application of mechanical allied with the more strictly 
surgical means, the writer has not infrequently succeeded in effecting changes 
in the young maxillary bones, a simple description of which might cause his 
veracity to be doubted ; yet this ability to effect such changes becomes very 
evident if for a single moment we pause to consider the difference between 
the composition of the young and that of an old bone. Young bone, or bone 
at birth, as is well known, is almost if not quite half made up of animal ma- 
terial ; while in the osseous structure of the adult there is excess in the inor- 
ganic or unyielding material representing from seventy-five to perhaps quite 
eighty-five per cent, of the substance of the part. 
To illustrate more familiarly this yielding constituent of young 
bone, reference may be made to the old experiment of maceration in dilute 
muriatic acid. We know that if a rib-bone be subjected to the action of this 
acid for one or two weeks, we may tie it like a whip-cord. This is done 
simply by reducing an old bone to the condition of a young one. As has 
been shown in the chapter on dental irregularities, one may take an inferior 
maxilla, even in a child of fifteen years, where the projection of the chin is so 
great as to produce deformity, and with a properly-constructed vertico-mental 
elastic sling can, in a period varying from three weeks to as many years, so 
change the angle as to do away entirely with the deformity. One may take 
the projecting myrtiform border, and through the instrumentality of the 
occipito-alveolar sling compel it in quite a short period to a natural relation. 
On this known yielding character of young bone operations for the correction 
of congenital fissures of the hard palate are founded. 
A congenital fissure of the hard palate may be corrected instantly, 
or the cure is to be effected slowly. The first of these procedures is applicable 
to such cases as present but a limited separation of the bones; the latter, when 
the break has considerable width. 
Operative Procedure for Immediate Cure of Congenital 
Fissure.-The operative procedure for immediate cure is as follows: an 816 
A SYSTEM OF ORAL SURGERY. 
instrument, a modification of the Hoey clamp, ordinary arterial compressor, 
or a Hainsby compress, is to be made by so arranging the pads that they shall 
apply to the sides of the jaws and allow of the force being so directed that the 
pads can be approximated without undue facial pressure. The clamp of Hoey, 
it will be seen, needs alteration only so far as the pads are concerned, and is 
quite easy of adjustment to this purpose. 
The instrument ready (the infant being in proper condition), the 
operator commences by paring the soft parts and bone on both sides of the 
fissure, beginning on the approximal faces of the palate bones, and cutting 
forward to the alveolar face of the chasm. This part of the operation com- 
pleted, the little patient is to be allowed to rest until the bleeding ceases. A 
succeeding step is to re-etherize and apply the compressor; the curved pads 
to embrace the buccal faces of the alveolar arch. By now gradually turning 
the screw of the instrument, the yielding bones are brought together. The 
next and last step in the operation is to retain the parts in position by the use 
of compresses placed upon and below the malar bones, and secured by adhesive 
strips applied as in the occipito-labial cravat of Mayo. 
It may be urged against these manipulations that they are for- 
midable and entirely too heroic; that fractures may result, etc. On these 
points the surgeon must decide for himself. If carefully performed, the 
operation is not dangerous; fracture of the bone, even if it occur, is of little 
consequence, the parts having to be kept, as it were, in splints, consequently 
the treatment of the one would be the treatment of the other. The marked 
risk is from inflammation that may be provoked; but a surgeon not infre- 
quently has to run far greater for even a less result. 
Another mode of securing the same end is as follows: take a 
circle of india-rubber tubing, the circumference of which shall be about one- 
third or one-half that of the child's head; next prepare two firm compresses, 
of a size adapted to the case under treatment; place these pads, or com- 
presses, one on either cheek, in such position as will give them their rest on 
the buccal faces of the alveolar border, and secure them in place by one or 
more delicate strips of adhesive plaster; next take up the ring of rubber and 
pass it over the pads and around the cervico-labial diameter of the head. 
Resting upon the compresses, the ring will exert, as is seen, a gradual 
pressure, serving to push the bones toward a common centre, this centre 
being the mesial line of the palatine arch. This process is a gradual one; 
but, if the patient be young, it will be likely to succeed; the only real objec- 
tion to the manipulation is the constant care necessary to prevent excoriation 
of the tender skin. 
Paring or Cauterizing Mucous Surface.-When, by this pro- 
cedure, the bony parietes have been brought into contact, the operation, as 
the hard palate is concerned, is completed by simply paring or cauterizing 
the adjacent mucous surfaces. If the bones have been brought very close 
together, the granulations will bridge the slight remaining chasm. PALATINE DEFECTS-TREATMENT BY OPERATION. 
817 
In either of these operations it is seen that the break, both in 
the soft palate and in the lip, is not remedied. It is well not to attempt 
operation on the face until the patient has entirely recovered from the fore- 
going treatment. It may at such time be performed, and, if done according to 
rules given, will secure a lip so perfect that, in adult life, little or perhaps no 
mark of the manipulation will exist. The operation for the cleft in the soft 
palate is to be left to a period later in life, for reasons alluded to presently. 
These suggestions for the cure of cleft in the hard palate were, it was 
thought by the writer, original with himself;-though it is of slight conse- 
quence who invents an operation, so that it be good; but in the periscopic 
department of the Dental Cosmos is to be found the following extract, taken 
from the Australian Medical Record and Dublin Medical Press, which shows 
that the performance was conceived by another. The extract is a short one, 
and so d propos to the matter that it may be presented entire: 
Pressure in the Treatment of Cleft Palate.-I am not aware, says 
the author, that the subject of using pressure in treating fissure of the palate 
has been before suggested. I am inclined to think that it has not; for when 
the plan first presented itself to my mind, in 1851, I carefully examined 
French, German, English, and American works to see whether it had. I was 
first led to try it on the dead body of a child, which had died three weeks 
after birth. The fissure was longitudinal, and large enough to admit the 
extremity of the little finger; fissure of the lip also existed. By means of 
a pair of clamps, the sides of the fissure were brought readily in contact, with- 
out any fracture or displacement of the bones; the only fault was that the 
gums of the upper jaw were within those of the lower; but nature would 
modify this as the living child grew up; the use of pressure on the lower 
jaw would remove a great deal of this deformity; of course the amount of 
deformity would depend on the size of the fissure in the palate. I several 
times repeated the experiments on young dogs, removing a piece of the palate 
bone by means of Hey's saw, and then applying the pressure. The animals 
did well. 
The operation should be performed as early as possible 
after birth, when the bones are in their softest condition. The following is 
the plan which I would suggest: the edges of the fissure having been pared, 
the superior maxillary bones are to be embraced by a horseshoe-shaped clamp, 
with a shelf on its lower border to receive the gums and prevent it slipping. 
It should be padded with india-rubber or some other material, to save the 
germs of the teeth from being injured. The clamp should work on a joint, 
and possess arms. It may be said to resemble a large pair of pincers with 
horseshoe-shaped blades. A screw may be attached at the extremities of the 
handles, for the purpose of bringing the blades in contact, or the hands may 
be used: the former would be, I think, preferable, as the force could be ap- 
plied gradually, and not be likely to be carried too far. It may also be 
employed in grown-up children, when the bones are so widely separated as to 818 
A SYSTEM OF ORAL SURGERY. 
render it difficult to get soft parts enough to close the opening, but in a 
gradual manner and at intervals more or less prolonged, according to the 
amount of pain it excites. If it were used suddenly it might produce in- 
flammation, and subsequently abscess, which would be troublesome to treat. 
From the foregoing it will, I hope, be understood that the younger the child 
the safer the operation is likely to prove, and that even in grown-up children 
it may be adopted, with precaution, with decided benefit. 
The pads and the ledge to rest the teeth upon are to be made to slide 
in the sides of the clamp: the former, that the pressure may be directed on 
any part of the bones; the latter, that the edges of the teeth may rest on it, 
without the pressure being directed either too high or too low, but at the 
point where the palate bone joins the superior maxillary. 
Closing Break in Hard Palate by Operative Procedure.- 
Fig. 660 shows the steps of an operative procedure for closing breaks in the 
hard palate, which is not unworthy close consideration. First, an incision 
is to be made through the soft parts upon either 
side, midway between the fissure and alveolar 
ridge. From the line of this incision the peri- 
osteum is to be dissected inward or outward, as 
found most convenient. Or, as preferred by 
some, the strip seen between the two lines in the 
diagram may be cut away. Next, using a spear- 
drill, a series of closely-related holes are made 
through the bony parts which the previous steps 
have exposed. (The writer employs a circular- 
saw, revolved by the engine.) A concluding 
process pares the edges of the fissure, intro- 
duces two wires through soft parts and bone, 
applies a wedge instrument, as shown in the cut, 
and forces the edges into contact. Granulations springing up in the seats of 
the lateral separations quickly fill up the breaks, thus completing a cure. 
Cleft of Velum.-We pass now to the consideration of treatment of 
fissure in the soft palate. The operation, done for the cure of this deformity, 
is known as staphylorraphy, a term derived from two Greek words, signifying 
suture of the uvula. As generally practised, it is rather difficult of perform- 
ance, and so frequently unsuccessful that surgeons seem disposed to avoid the 
responsibility of it. It is proposed here to suggest for consideration a new 
mode, which renders the manipulations as easy of accomplishment as by the 
old one they are tedious and difficult. 
Preparation of Patient for Operation.-For weeks before it is de- 
signed to perform staphylorraphy, preparations are made for it by subjecting the 
parts to such daily manipulations as shall educate to forbearance the natural 
sensibility of the throat. In the absence of such preliminary manipulation, 
Fig. 660. PALATINE DEFECTS-TREATMENT BY OPERATION. 
819 
the retchings and spasmodic twitchings are such as to render a proper perform- 
ance of the operation, without the use of an anaesthetic, almost an impossibility. 
With such education, the parts are found to assume, in a reasonable time, 
quite a stoical indifference to even severe irritants. This forbearance is 
secured by roughly fingering the velum daily. Some surgeons are in the 
habit of daily tickling the parts with a fine brush; this answers a very good 
purpose. A very admirable idea, and a most successful one, is to have made 
an obturator,* which shall extend back to the palate border, or nearly to it. 
This is to be placed in the mouth, and, as soon as the irritability produced by 
it is so far overcome as to permit of its permanent retention, the bands attached 
to it are clasped firmly about the necks of the teeth, and it is worn continu- 
ously for one or two months. When the parts have thus submitted to the 
presence of an obturator, they will be found quite ready for an operation. 
On the evening before the day of performance a saline cathartic 
is to be given the patient, particularly if he be robust and strong. In oper- 
ating on a depressed and anaemic person, the deficiency in vital force is to 
be first considered and, so far as possible, corrected. If such attention be 
neglected, failure is almost certain to result; the parts will not 
unite. Exercise in the open air, generous living, iron tonics are to be 
prescribed. To sum up in a single sentence, preliminary treatment is to meet 
the indications of each particular case. If, for example, one should operate 
on a scorbutic patient, or on a patient disposed to purpura, without correcting 
such dyscrasia he would be no more likely to get union of the parts brought 
together than in an operation done on the cadaver. 
Surgical Anatomy of Soft Palate.-The surgical anatomy of the 
region is to be fully understood. So much of success depends on a thorough 
knowledge of the muscular relation to the cleft that such acquaintance gives 
a success where otherwise failure would be sure to result. This anatomy we 
may look at before taking up the steps of the operation. 
To get a correct idea of the soft palate, we commence the study 
by first carefully examining the parts on the living subject. When we look 
into a mouth, we see an arch, stretching from every portion of the alveolar 
ridge inward and backward toward the pharynx, terminating in a tongue or 
uvula, pendent in a vertical direction from its centre. One-half of this arch 
is seen to be fixed, the other-the posterior half-in almost constant motion. 
If now the finger be called into service, the fixed part is found to corre- 
spond with the boundaries of the palatine faces of the maxillary and palate 
bones; that is, for a certain extent the parts are felt to be solid, as if the 
finger passed over an arch of bone which might be covered alone by mucous 
membrane; and this is, in fact, about the case. The finger traverses the 
anterior bony border of the mouth, or the hard palate. As now the finger is 
passed backward, it falls over a hard ridge upon parts that are soft and yield- 
* A description of this instrument and of its proper use will be found on page 606. 820 
A SYSTEM OF ORAL SURGERY. 
ing; the hard ridge is the posterior face of the palate bone, and terminates 
the hard palate. The part upon which the finger has fallen is the veil, or soft 
palate, the part observed to be movable. This is the region in which occurs 
the rent, or cleft, for the cure of which is demanded the operation about to 
be considered. 
The mobility of this part, which pertains to its function, depends, 
as will be anticipated, on an associated muscular structure. To study properly 
this structure, which it is all-important to understand and appreciate practi- 
cally, the student is to take up a scalpel and pass to the cadaver; it is, perhaps, 
only by dissecting that a really satisfactory idea of these muscles is to be se- 
cured,-that is, as pertains to that kind of knowledge which gives confidence 
when one comes to perform operations upon the part. 
The external coat, or covering, which is seen in every mouth, living 
or dead, is the mucous membrane,-simply the continuation of that which 
covers the hard palate; but while in the case of this part the underlying 
structure of this hard palate is found osseous, in the soft palate the deep tissue 
is made up exclusively of muscular substance,-at least as a surgical anatomy 
is concerned, or as it serves the present purpose to study it. 
Commencing with the mesial line, one can dissect out the attach- 
ment of five muscles, each of which is of course duplicated on the opposite 
side, and each of which has such relation to a mesial line that, in case of cleft, 
or split, it serves more or less to draw away the parts postero-laterally. 
These muscles, mentioned in the order of their significance to 
such lateral displacement, and consequently in their relation to the operation 
of staphylorraphy, are the tensor palati, palato glossus, levator palati, palato- 
pharyngeus, and motor uvula?. Of all these structures the tensor palati plays 
the most important part, and is therefore entitled to the first consideration. 
This muscle arises from the scaphoid fossa at the root of the internal ptery- 
goid plate, from the anterior surface of the Eustachian tube, and from the 
spinous process of the sphenoid bone. If the student carry his finger (in his 
own mouth) back to the wisdom-tooth of the superior jaw, and let it drop 
over and back of this organ, it will fall on the tuberosity of the maxillary 
bone; carry it now half an inch farther back, and it will come to a second 
prominence; this is the hamular process of the pterygoid plate of the sphenoid 
bone. The tensor palati muscle descends from the origin of which we have 
just informed ourselves, and, meeting this hamular process, it winds-as a 
tendon-around it, and then, by a fan-like expansion, spreads itself into the 
substance of the soft palate. Its action is evident: it expands the palate 
laterally. 
Removal of Strain.-To perform successfully the operation for cleft 
palate, it is perhaps desirable, in every case, that the strain made by this 
muscle be taken off. A moment's reflection will show that the action of the 
muscle, in case of a cleft, would, when the parts are brought together, be 
much increased over its natural capability, not only because it would be put PALATINE DEFECTS-TREATMENT BY OPERATION. 
821 
considerably on the stretch, but also because such stretch would, more than 
likely, excite to spasmodic contraction. The muscle, of course, is then to be 
divided: as well here as anywhere else may be considered the easiest point 
at which such preliminary operation is to be done. 
Tensor Palati Muscle.-It is to be remarked that the muscle is found 
winding-as a tendon-around the hamular process. It winds from the back, 
outwardly, inward, and forward, so that just in front of the process, between 
it and the tuberosity, is the place at which its section may be best accom- 
plished ; there are here no important vessels to be wounded, if we except the 
posterior palatine artery and nerve, and these hug the base of the tuberosity 
so closely that it would have to be a very badly-managed knife that would 
interfere with either of them. The cut is to be a little oblique. The inter- 
ference with function, as in most cases of myotomy or tenotomy, is, of course, 
but temporary. The action of the muscle will be found recovered quite as 
soon as the cleft operation is ready for it. 
Palato-glossus Muscle.-The next most important muscle is the 
palato-glossus; this is simply the anterior half-arch, the constrictor isthmii 
faucium. It arises, as will be seen, from the soft palate on either side of the 
uvula, and. passing outward, is inserted into the sides of the tongue, blending 
with the fibres of the stylo-glossus muscle. 
Palato-pharyngeus Muscle.-The palato-pharyngeus arises from the 
soft palate by an expanded fasciculus, and, passing outward, goes to be in- 
serted into the posterior borders of the thyroid cartilage. The two muscles 
constitute the posterior half-arches. Section of the palato-pharyngeus and 
the palato-glossus is to be made through the substance of the muscles, and is 
accomplished simply by nicking, somewhat deeply, the arches, four cuts, one 
to each arch. These nicks are best made with curved scissors. 
Levator Palati Muscle.-The levator palati muscle arises from the 
petrous portion of the temporal bone, passes into the interior of the pharynx, 
and then descends obliquely downward and inward, spreading its fibres out 
over the posterior surfaces of the soft palate as far as the raphe. 
Azygos Uvulae Muscle.-The action of the fifth and last muscle, the 
azygos uvulae, it is perhaps not absolutely necessary to consider, its influence, 
for separation of the wound, being very trifling. 
Section of Levator Palati Muscle.-Section of the levator palati 
is thought to be easiest of performance after a manner suggested by Mr. 
Pollock. This gentleman first puts the flap on stretch, and then, with a 
double-edged knife, makes an incision through the soft palate just on the 
inner side of the hamular process. The handle is now alternately elevated 
and depressed, a sweeping cut being made along the posterior surface of the 
soft palate. 
Other Anatomical Elements.-The other anatomical elements of 
the soft palate are glandular structures, vessels, nerves, etc., all associated, 
more or less intimately, by connective tissues; but these need not be particu- 822 
A SYSTEM OF ORAL SURGERY. 
larly referred to, as one could not well dissect out the muscles without 
necessarily familiarizing himself with them. Thus, then, we understand the 
surgical anatomy proper of the parts,-the anatomy as it has relation to cleft 
palate. 
Operation : by whom first practised.-The operation of staphy- 
lorraphy was first practised by a dentist of Paris,-La Monier. It has for its 
object the bringing together of the separated portions of a cleft soft palate 
and the retention of the parts in apposition until nature shall unite them. 
Stages of Operation.-The operation consists of four different stages, 
with an object to be attained by each stage: 
1st. The paring of the edges of the cleft. 
2d. The introduction of ligatures. 
3d. The bringing together of the freshened edges, and fixing the ligatures. 
4th. The relief of any tension on the ligatures that may attend the ap- 
proximation of the parts. 
These are the steps or stages, and to accomplish them various means and 
instruments have been devised,-some good, some bad, some indifferent. The 
reader curious in such matters will find an admirable and most instructive 
chapter on the subject in a System of Surgery, published in 1851, by Pro- 
fessor H. H. Smith. In the chapter therein devoted to staphylorraphy is given 
a synopsis of the operations as practised by surgeons whose names have been 
and are particularly associated with the subject. 
An epitome may be made of this chapter by noticing that the operation 
first suggested by La Monier, in 1764, was revived by Graefe, of Berlin, in 
1817, but first methodized and published, with the rules for its accomplish- 
ment, by Roux, of Paris, about 1819. In 1820 a nearly similar operation was 
performed by Dr. John C. Warren, of Boston, he being at that time ignorant 
of the views or operations of other surgeons. In many respects the steps 
proposed by Drs. Roux and Warren correspond, though the means suggested 
by Dr. Warren are simpler, the operation of the lattei' being generally re- 
garded as the basis of the various modifications that have since perfected the 
proceeding. 
Roux's Operation.-The instruments prepared by Roux for performing 
the operation are alluded to as being sufficiently complicated. To execute the 
manipulations, that surgeon seated his patient before a strong light, the head 
being thrown back and supported against the chest of an assistant, the mouth 
kept wide open by means of a cork placed between the molar teeth. The 
operator then placed himself in front, and, with forceps held in the left hand, 
seized the right lip of the fissure. With his right hand armed with a needle- 
holder, he next introduced the point of a needle from before backward behind 
the uvula, in order to traverse the flap from behind forward, at three or four 
lines from the free edge of the fissure. The needle, being thrust in as far as 
its head, was then freed from the holder and seized at its point by forceps, 
which drew it, and the ligature, through into the mouth. After permitting PALATINE DEFECTS-TREATMENT BY OPERATION. 
823 
a few minutes of rest to the patient, the same manoeuvre was practised on the 
left side of the fissure with the other needle of the same ligature, the two 
ends of which were thus brought out of the mouth. In passing these liga- 
tures, M. Roux commenced with the lowest, next passed to the highest, and 
ended with the middle. 
The next step in the operation of Roux was to freshen the edges of the 
fissure. This he accomplished by seizing the margins, as before, with his 
forceps, and paring from behind forward. To tie the ligatures, he commenced 
by knotting the middle one with the fingers, and, after making a simple tie, 
confiding it to an assistant, who held it with an instrument termed by the 
French a serre-noeud (knot-tier) ; he then passed on to the second ligature, 
and from that to the first, drawing them tighter than was necessary to ap- 
proximate the edges of the wound, in order to prevent any separation. Eating, 
drinking, and speaking were interdicted the patient for from two to three days, 
the ligature being removed on the third or fourth day, excepting the lowest 
one, which was allowed to remain twenty-four hours longer than the other. 
Warren's Operation.-Dr. John C. Warren performed the operation 
as follows: The patient being well supported and secured, a piece of wood, 
an inch wide, a little curved at the end, and with a handle to be held by an 
assistant, was placed on the molar teeth of one side to keep the mouth open. 
A sharp-pointed curved bistoury was then thrust through the top of the 
palate, above the angles of the fissure, and carried down on one edge of the 
cleft to its extremity, and the same was done on the opposite side, so as to cut 
out a piece in the form of a letter V, including about a line from each edge. 
Next a hook, or curved needle, fastened in a handle, with an eye on its ex- 
tremity, and a movable point, armed with a triple thread of strong silk, was 
passed doubled into the mouth through the fissure behind the palate, and the 
latter pierced by it one-third the length of the fissure from the upper angle 
of the wound, so as to include about three lines of the edge of the soft palate. 
The eye, with the ligature, being seen, was seized with a common hook and 
drawn out. The eyed hook was then drawn back, turned behind the palate, 
and the other edge transfixed in a similar manner. A second and a third 
stitch were now passed in a similar manner, the third being as near as possible 
to the lower end of the fissure. Then, seizing the upper ligature with the 
finger, the knot was tied without using a serre-noeud, and placed on one side 
of the wound in order to prevent its pressing on the fissure, the other being 
tied in like manner, and the fissure closed. 
After the first operation of Dr. Warren, Dr. A. H. Stevens, of New York, 
in September, 1826 (see North American Medical Journal, vol. iii. p. 233), 
operated successfully, by first inserting the ligatures and then paring the 
edges. 
In 1827, Dr. Mettauer, of Virginia, operated for staphylorraphy, and in 
1837 published an excellent essay. Dr. M. employed leaden ligatures. (See 
American Journal of the Medical Sciences, vol. xxi. p. 309.) 824 
A SYSTEM OF ORAL SURGERY. 
Allusions are made in the chapter to other operators and operations; but 
as they are all only modifications of the methods of Roux and Warren, it is 
not necessary to refer to them. 
Several years back the author had in his possession a monograph on the 
subject of staphylorraphy from the pen of the late Professor Mutter. He regrets 
that he cannot now lay hands upon it. Dr. Miitter was much interested in 
the operation, and his pamphlet abounded in cases illustrating his success in 
the direction. 
Fergusson's Operation.-To Sir William Fergusson, of England, more 
than to any other man, are we perhaps indebted for a scientific appreciation of 
the requirements in staphylorraphy. The cutting and sewing parts of the opera- 
tion are simple mechanical manipulations, which are of consequence only as 
they tax the ingenuity of an operator. The proper surgical understanding of 
the subject consists, as we are prepared to see, in an acquaintance with the 
muscular relations of the parts. These relations we have just studied. To 
Mr. Fergusson belongs the credit of first making the demonstrations. It is 
very true that before his time incisions in the soft parts had been advised. 
Roux, Dieffenbach, Mettauer, Liston, and Warren all practised them where 
difficulty was met with in approximating the fissure ; but the sections made by 
them, as remarked by Mr. Fergusson, seem to have been without reference to 
the anatomy of the parts, and, as a consequence, rendered success somewhat a 
matter of accident. The operation of Mr. Fergusson, as the paring and bring- 
ing of the fissured parts together are concerned, is much the same as that 
practised by Dr. Warren. He pares the cleft before inserting his sutures, and 
his knots are made about as are Dr. Warren's. 
Difficulties.-In looking over the history of staphylorraphy, the reader 
will be struck with the likeness in complaints, the three principal of which 
seem to be the difficulty in tying the ligatures, their great tendency to slough 
out after they are once nicely secured, and the concealment of the parts dur- 
ing operation both because of deficiency in light and the accumulation of 
the viscid muco-saliva which in mouths thus affected is secreted in great 
abundance. 
Position in Front of Patient.-Now, in the direction of operations in 
and about the oral cavity, the writer has had an experience which will, perhaps, 
justify him in asserting that there is an easier and more philosophical mode of 
performing the operation of staphylorraphy than has yet been described. To 
sit in front of a patient and operate in the mouth is most unhandy. The 
surgeon is in his own light; besides, it is certainly much more difficult to 
operate sitting than standing: motion is cramped, freedom is interfered with. 
To perform on the mouth of a patient, when the surgeon is seated in front, 
renders an assistant necessary, whose office it is to manage the head. This 
has a twofold objection. In the first place, the assistant cannot follow in all 
those little changes which are so necessary to success. He does not see 
quickly the shiftings and turnings which so help in the manipulations. PALATINE DEFECTS-TREATMENT BY OPERATION. 
825 
Again, one is more naturally ambidextral when the arms are supported than 
when they are unsupported. In operating sitting in front of a patient, the 
surgeon must work at arm's length ; he has nothing to steady him,-no guard 
which shields against any sudden awkward movement on the part of either 
assistant or patient. 
To make a knot deep in a canal, such as the mouth or the vagina, is not 
easy. To fix a ligature by compressing something upon it is very simple. 
Silk an Irritant.-Silk is not unapt to act as an irritant to human tissue, 
silver or lead is less worrying; therefore, where it is desirable to retain a liga- 
ture for several days or weeks, without irritation, metal is best adapted to the 
end. 
Instruments perfectly suited to a performance greatly simplify it. 
Predicating an operation on these self-evident truths, the following manner 
is commended as being the best and easiest mode of manipulating. Where 
once practised it will take precedence of all other modes. 
Instruments required.-The instruments required are those belong- 
ing to the ordinary vesico-vaginal case,-a long-handled knife, needles and 
needle-carrier, shot-carrier and compressor, tenaculum, cutting forceps, silver 
or lead wire, the perforated flat shot of McLean, and mop-sticks. Better in- 
struments than these for the operation of staphylorraphy will not soon be de- 
vised. The instruments arranged on a tray in the order in which they are to 
be used, the patient, having had the steps of the operation explained to him, 
-for much is expected from him,-is seated on a chair having a movable 
head-rest: it is well if this rest move in a ball-and-socket joint; at any rate, 
it must be movable backward and forward. The ordinary dental chair answers 
the purpose admirably. When the head is placed on this rest, the mouth will 
be found to look directly upward. The surgeon now takes his position back 
of the patient, standing on a footstool of such height that his breast shall 
be brought on a level with the head. If the reader be disposed, he can 
thus seat a friend, and, taking a position back of him, by leaning over his 
head he will find that when the mouth is opened he not only has a per- 
fect view of a thoroughly-lighted cavity, but by leaning against him, and 
passing his arms around the head so as to bring the hands to the mouth, he 
will perceive that, besides having his own arms so steadied as to allow of the 
easiest manipulation, he has the movements of the sitter completely under 
control. 
Relative Position.-This relative position of the surgeon to his patient 
gives not only the advantages enumerated, but places him out of the way of 
ejective spasms. If saliva and blood accumulate about the parts, he can and 
will, almost unconsciously, and certainly without effort, so turn the head that, 
while he does not at all interfere with his own manipulations, he throws the 
fluid into some more convenient part of the mouth. This is to be done so 
readily that each step of the operation may be accomplished without the an- 
noyance and delay experienced in using the mop. Certainly, a patient so 826 
A SYSTEM OF ORAL SURGERY. 
held cannot make any movement too quickly or too unexpectedly for the 
surgeon. True, he might be so obstreperous that the operation could not be 
accomplished; but he could not make any change which the knife of the 
operator would not intuitively follow, and therefore accidental harm could not 
be done. 
First Step.-Patient and surgeon being in position, a tenaculum is taken 
up and carried through the very point of the cleft pendulum, or, if preferred, 
the forceps may be used. (See Fig. 661.) The part is then put on stretch, 
and a paring (as shown in the diagram) of about a line is taken from the 
whole of that side, cutting from behind forward. The manipulation is re- 
peated on the opposite side. The 
first stage completed, very dilute 
compound tincture of capsicum, 5j 
to gxvj of water, or water medi- 
cated with potash, or ammonia, is 
given the patient, with which to 
gargle and wash the mouth. These 
cleanse the part admirably, besides 
acting as healthy stimulants. 
Second Step.-The bleeding 
arrested and the patient a little re- 
covered, the second step, that of 
passing the ligature, is to be prac- 
tised. Take up one of the curved 
needles, Fig. 662, and, threading it 
with the silver wire, thrust it 
through one side of the cleft, about 
three lines from the margin and 
about half an inch from the apex 
of the cleft or hard palate. After 
passing it to this point the wire is unthreaded by means of an excavator. 
This accomplished, the needle is withdrawn, rethreaded, and carried after a 
like manner through the opposite side; the two ends are next brought from 
the mouth and their relaxation secured by one or two twists. This completes 
Fig. 661. 
The author's operation as described. A is the 
curved needle; B is the wire thread; C is an or- 
dinary dental excavator used in unthreading 
the eye; D is the knife paring the cleft; E is 
tenaculum or forceps putting the part on stretch. 
Fig. 662.-The Author's Curved Needles. 
the first ligature. A second is now passed half an inch farther on, also a 
third, or more, as may seem needed. The manipulations required are of 
course the same as for the first. This completes the second stage, and the PALATINE DEFECTS-TREATMENT BY OPERATION. 
827 
patient is allowed to rest as before. If he need to wash his mouth, which is 
very much more than likely, the surgeon must look carefully after the 
ligatures. 
Third Step.-The third step, or approximation of the edges, is next to 
be accomplished. Take up the shot-carrier, and, slipping through its fenestra 
the twisted ends of the last ligature introduced, push the carrier down the 
wires, and it is found that as it approaches the palate the edges of the cleft 
approximate. This will always be found to be the case with the ligature 
nearest the uvula : the parts are closed very easily. Now slip off the carrier 
and take up one of the perforated shot; put this on the wires, and with the 
carrier force it down to the palate. Holding this in place, which is done by 
simply laying the wire against the carrier and shifting a finger over it, take 
up with the right hand the forceps, and compress the shot tightly upon the 
strands. The parts up to this ligature will now be found nicely approximated 
and fixed. This completed, repeat the operation on the second ligature. 
This, however, may be found impossible, without greatly overstraining the 
parts and risking the tearing out of the wire. 
Undue Tension.-If this be the case, the operator at once desists from 
the attempt, and makes the section as described of the tensor palati muscles 
on either side. Now most likely the parts will come together conformably: 
if so, fix them with the shot as before; if, however, an approximation has 
not yet been secured, nick the anterior half-arch; and if this do not suffice, 
cut the posterior and as well the levator palati muscle; the ligature may then 
be fixed, and, as well, those still farther front. Each shot firmly compressed, 
the wires are to be cut off as closely as possible. Thus the third and fourth 
steps of the operation are completed, and nothing remains but to enjoin on the 
patient reasonable quiet. In this rest lies half the secret of success: the 
patient should move warily for two or three days; certainly he should not be 
permitted any food that would demand for its comminution the slightest effort 
at mastication. He is to be directed to allow the liquids taken to trickle 
down his throat, rather than attempt to swallow them. These restrictions 
need not, however, be made quite so stringent if in the operation myotomy of 
the half-arches has been employed. 
Ligatures to Remain.-In the old mode of performing the operation, 
it was found necessary after the first day or two to remove the ligatures, 
because of their tendency to slough out: the use of silver wire obviates this 
necessity to a great extent, as the metal seems to provoke little inflammation. 
These ligatures may therefore, if they seem useful, be allowed to remain a 
whole week. This non-irritating quality of metal ligatures is so marked that 
they have been seen, when applied to varicose veins, as firmly fixed after four 
months as on the day of application. This is the feature which adapts such 
ligature-material so admirably to staphylorraphy. 
Wounds to be left to Nature.-The wounds made in dividing the 
muscles may be left to nature. If the patient be in condition for the principal 828 
A SYSTEM OF ORAL SURGERY. 
operation, he is in a condition which does away with any necessity for care in 
trifling flesh-wounds; if, however, trouble should arise in such a direction, the 
practice is that which applies to similar wounds, however made. 
Likeness of Operation.-It is seen that the manipulations here sug- 
gested for the cure of cleft palate are precisely the same as those practised in 
vesico-vaginal fistula, and that the instruments adapted to the one operation 
are exactly suited for the other. 
The position in operating, together with the employment of perforated 
shot and carrier, were first suggested and practised by the author twenty-five 
years back.* 
Needles and Carrier.-Needles as shown in Fig. 663, and a carrier as 
seen in Fig. 664, may be used where more convenient means are not at hand. 
The author is not sure but that some of his most successful operations have 
been accomplished by use of the instru- 
ments here shown. The shortest of the 
needles exhibited is the one most commonly 
used. The common hemostatic forceps 
makes a good carrier. 
Fig. 663.-Curved Needles. 
Fig. 664.-Needle-Carrier. 
Combined Needle and Carrier.-Fig. 665 shows an eyed needle that 
serves its purpose after a tolerably convenient manner. The needle, as appre- 
ciated, is unthreaded of one of its strands after being passed, and then with- 
drawn, thus unthreading itself of the second. A great improvement is found 
Fig. 665.-Combined Needle and Carrier. 
in use of needle and carrier as separate pieces, the former being held by a 
drill-hole in the latter, so that when it is passed through one edge of the cleft 
it may be pulled through and be readjusted to the carrier for use on the oppo- 
site side of cleft. 
From this consideration of cleft palate proper, we now pass to the study of 
other defects of the parts. 
* These manipulations were first practised in 1861, and were described in papers pub- 
lished by the author in the Medical and Surgical Reporter of Philadelphia. PALATINE DEFECTS-TREATMENT BY OPERATION. 
829 
Holes in the Palate.-Breaks in the continuity of the palate may be 
treated in two ways: either by an operation strictly surgical, as reference is 
had to the use of the knife; or by means which are to be denominated 
surgico-mechanical. If the knife is to be exclusively used, we have simply 
to pare the edges of the break, and then get the parts in apposition as best 
we can. Herein consists, however, the difficulty of such operations; and the 
tact and knowledge of the surgeon will prove his best guides. If the breaks 
are in the soft palate, any resistance that may be met with is to be overcome 
precisely as in staphylorraphy : let the surgeon consider what muscle or muscles 
oppose him, and divide them as before suggested ; or, if myotomy seem scarcely 
necessary, he can in all probability accomplish his purpose by making lateral 
slits through the mucous membrane alone, or otherwise he may go a little 
deeper, making a kind of semi-myotomy. 
Break Small.-If the break be small, one ligature will perhaps be all 
that is necessary to secure the approximation of the pared edges; this suture 
is to be made and fixed precisely as in the previous operation. If more than 
one seem indicated, of course more are to be employed. 
Surgical Treatment of Defects of Hard Palate.-Defects in the 
hard palate are also amenable to surgical skill: they may be remedied by the 
use of the knife and stimulating local applications, or, if these fail, an artificial 
palate, properly constructed, will so admirably supply the deficiency that the 
patient is rendered almost as well off as his fellows. (See Obturators.') 
Bridging Chasms.-Using the knife alone, most successful results are 
frequently attained by first paring the edges of the break and afterward dis- 
secting the parts freely from the bone. This mode of operating is suited to 
such hard palates as have a thick, soft mucous membrane. Through this 
manner of manipulating, and with such character of mucous membrane, quite 
wide chasms may be spanned. 
With such mucous membrane, plastic operations are found to answer very 
well. It is quite easy to get a flap without disturbing the periosteum, and 
such a flap may be twisted on its pedicle without any special interference with 
its function. The pedicle, however, should be as wide as possible, remembering 
that the circulation pertains to the basement membrane alone. An objection, 
however, to such operations in the mouth is the difficulty that attends the 
fixing of the flap in its new place. 
Dieffenbach's Treatment.-The next mode of relieving these defects 
which may be alluded to is that originally suggested by Dieffenbach. This 
surgeon commends the pencilling of the edges of the break with tincture of 
cantharides, hoping thereby to excite granulation to an extent that shall fill up 
the cleft. The use of nitric acid is advised in the same direction. 
Break Large.-Now, while this does very well for small holes, it seldom 
succeeds with the larger. The granulations, having nothing to support them, 
break down before connecting in the middle. 
This defect in the treatment is to be remedied, and success almost war- 830 
A SYSTEM OF ORAL SURGERY. 
ranted, by the following modification: make a simple obturator, or artificial 
roof; after fitting this so as to cover accurately every portion of the hard 
palate, it is to be removed and the cleft pared; next touch the parts with 
cantharides, nitric acid, or tincture of iodine,-the latter is preferred by the 
writer. The plate is now to be replaced, and will be found to act most com- 
pletely as a support to the granulations which form. The process of freshen- 
ing the edges is, of course, to be frequently repeated; but after the first paring 
the cuts may be made from the circle on, and not around, the cavity. 
Uranoplasty-Warren's Operation.-To Dr. J. Mason Warren 
seems justly due the credit of the conception of this operation. His plan 
of manipulation is as follows: Incisions are first made on either side of the 
Fig. 666. 
Instruments for raising soft tissues from hard palate-two patterns. 
cleft down to the submucous cellular tissue, being midway between the borders 
of the break and the alveolar processes, these incisions extending back to the 
extent of the break. Next, using a double-edged knife, these flaps are dis- 
sected toward the cleft, and, falling, are united in the middle line. Another 
plau practised by this surgeon consists in dissecting the mucous membrane 
from the edges of the cleft toward the alveolar processes, and, as they are thus 
made loose and pendulous, uniting them along the centre line. 
Langenbeck's Modification of Warren's Operation.-A modi- 
fication by Langenbeck on the operation of Warren consists in including in 
the dissection the periosteum, thus taking advantage of the osteogenetic 
qualities of that membrane to secure the filling of the break by a deposit of 
bone. 
Use of Gag.-The use of a gag to keep the jaws separated, both in the 
operation of staphylorraphy and in that of uranoplasty, will be found to add 
to convenience in the operation. The instrument of Kolbe, shown in Fig. 
667, the author occasionally uses with much satisfaction. A means, how- 
ever, more commonly employed is known as Whitehead's Gag and Tongue- 
Depressor ; this consists of two curved bars, one supporting either jaw, kept 
separated by a ratchet lever; to the lower bar being attached the tongue- 
holder. A modification of this gag (or, more properly speaking, of the Smith 
gag, which is much like it), made by Dr. Louis Elsberg,* of New York, is 
preferred by many. See, for idea of this form, the Mears gag, Fig. 668. 
* A sponge-holder of most convenient form and construction, and of great service in 
operations about the mouth, is known as Elsberg's sponge-forceps. PALATINE DEFECTS-TREATMENT BE OPERATION. 
831 
Another form of gag is a very simple, but yet quite effective, apparatus 
devised by Dr. Goodwillie, shown in Fig. 669; this consists of two arms 
Fig. 667.-Screw Lever. 
Fig. 668.-Mears's Gag. 
Fig 669. 
covered with elastic rubber, with a central screw which increases or diminishes 
the length of the piece as required. Gags of this class require, however, to 
be held in by the finger of an assistant. 
Still another form of this instrument is one devised by John Wood, of 
King's College Hospital, and which was used exclusively by Sir William Fer- 
gusson in his operations about the mouth; this consists of a double bar 
having rests for the support of the teeth, and which are separated on a 
principle precisely the same as that employed with the bivalve speculum. 
Uncertainty, and Dissatisfaction, as to Results.-In con- 
cluding the subject of treatment of cleft palate by operation, reference is to 
be made to uncertainty in way of success both as regards result of manipula- 
tions and improvement in speech. Cases operated on by the writer have proved 
to the fullest degree satisfactory; a greater number have ended in failure. 
Where the remnants of a velum are plentiful, and the patient is in health, 
operation promises most, and is to be recommended. Where, on the contrary, 
the parts are scanty, and these scanty parts fixed, little good is found in trying 
anything outside of mechanical means. 
Section of the velum, as shown in Fig. 5 of illustrative plate, is only to 
be practised when impossible to be avoided. As a result of such section, 
a tumidity of the parts is almost certain to show itself, which proves very 
adverse to union of the pared edges. 
Fig. 1 (see plate) shows the operation of Roux. 832 
A SYSTEM OF ORAL SURGERY. 
Fig. 2 shows paring of edges of cleft. 
Fig. 3 shows the operation of Warren; the knife freshening the edges of 
the fissure from above downward; the forceps steadying the margin so as to 
favor its regular incision. 
Fig. 4 shows manner of introducing sutures, Physick's forceps and a curved 
needle being used. 
Fig. 5 shows Dieffenbach's operation of staphyloplasty. In this case silk 
has been used and ties made. 
With the understanding now secured of the mouth, the pharynx, and their 
diseases and deformities, we may carry our observations from above forward 
through the nose. 
Mechanical Treatment of Cleft Palate.-See Obturators. Plate III 
Hbnan Sc Sons CHAPTER L. 
THE NOSE AND ITS DISEASES. 
The nose is a symmetrical organ, occupying the exact centre of the facial 
region. Looked at from below it is seen to be divided into two cavities, or 
canals, by means of a vertical septum. These canals are called nostrils, or 
nares (naris, singular) ; they constitute the nasal fossae. 
Fig. 670.-View of Nasal Septum. 
1, cartilage of the partition; 2, its junction with the nasal plate of the ethmoid bone; 
3, its junction with the nasal bones; 4, margin of continuation with the upper lateral 
cartilage; 5, fibrous membrane connecting the cartilage of the partition with the lower 
cartilage; 6, inner portion of the left lower lateral cartilage; 7, anterior border of the 
vomer; 8, an accessory cartilage; 9, prolongation of the cartilage of the partition in a 
groove between the vomer and nasal plate of the ethmoid bone; 10, naso-palatine canal 
of the right side opening into the anterior palatine foramen; 11, palatine process, osseous 
floor of nose. 
Surgical Anatomy of Internal Nose.-By the nasal fossa) is meant 
the whole inside of the nose. By a nasal fossa is understood either lateral 
cavity; the one being separated from the other by means of a division com- 
posed of bone and cartilage, known as the septum narium. Fig. 670, repre- 
senting a vertical section of the nose, the septum being left in position and 
833 834 
A SYSTEM OF ORAL SURGERY. 
relation, affords accurate understanding of the middle boundary, the immedi- 
ately succeeding picture showing the aspect of lateral boundary. 
Deviation of and Breaks in Septum.-A feature in surgical 
anatomy regarding the septum refers to its occasional deviation toward one or 
the other of the sides of the common cavity and to a possible perforation. 
Sometimes deviation is found so great as to entirely occlude a naris, while 
breaks of congenital character, related commonly with the line of union of 
vomer and ethmoidal lamella, have been seen of a size sufficient to admit the 
passage of a finger. 
Vault of Nose.-The vault of the nose is supported, posteriorly, by the 
vomer and by the nasal plate of the ethmoid ; anteriorly, by a cartilage. The 
Fig. 671.-Inside of Nose. (After Leidy.} 
Outer wall of the left nasal cavity. 1, superior turbinated process; 2, superior 
meatus; 3, inferior turbinated process; 4, middle meatus: 5, portion of the turbinated 
process of the ethmoid bone removed to show the orifice of communication (6) with the 
anterior ethmoidal sinuses; 7, communication with the frontal sinus; 8, left frontal 
sinus; 9, part of the unsymmetrical partition which separates the frontal sinuses; 10, 
turbinated bone; 11, inferior meatus ; 12, lachrymo-nasal duct exposed by removing a 
portion of the bones; 13, its termination; 14, edge of the upper lateral cartilage; 15, outer 
part of the left nostril; 17, cut edge of the partition; 18, inner portion of the left lower 
lateral cartilage; 19, sphenoidal sinus; 20, its orifice; 21, pharynx; 22, orifice of the 
Eustachian tube.* 
vomer is a single bone, ploughshare-like in shape. Above, it articulates with 
the rostrum of the os sphenoideum; below, with the crest formed by the 
conjunction of the palate processes of the maxillae. The nasal plate of the 
ethmoid is simply a prolongation of the vertical lamina of that bone; it con- 
* The student will do well here to turn back to the special descriptions found on pages 
47 to 52, inclusive of both. THE NOSE AND ITS DISEASES. 
835 
stitutes one-third of the partition. Posteriorly it articulates with the sphe- 
noidal crest, inferiorly with the vomer, superiorly with the nasal process of 
the frontal bone. The cartilage constitutes the anterior portion of the divis- 
ion ; its connection above is with two lateral cartilages, associated with the 
free edges of the nasal bones and nasal processes of the superior maxillae, pos- 
teriorly with the vomer and ethmoidal nasal plate, and inferiorly with the 
vomer. (See cut.) 
Inside Anatomy of Nose.-The inside anatomy of the nose, nasal 
cavity, or fossa, is to be thoroughly appreciated through a study of Fig. 671. 
It is also to be suggested that, with aid of a pencil and this diagram, a stu- 
dent shall draw figures of nasal polypi in position and relation, thus affording 
to himself thorough comprehension of a most important subject. (See also 
Fig. 681.) 
Communications with Nasal Fossa.-The communication of a 
nasal fossa is with six cavities: above, with the frontal sinus, the relation 
being by means of the ethmoidal cells; behind, with the sphenoidal sinus; 
laterally, with the antrum of Highmore and the posterior ethmoidal sinus. 
The first of these communications is related with the middle meatus; the 
second and fourth with the superior meatus; the third with the middle meatus. 
Communication also exists between the nose and orbital cavity through nasal 
duct. 
Meatuses.-Each nasal fossa is of like form and characteristics. The 
irregularities seen upon the outer wall are resultant of the turbinated scrolls. 
These represent the meatuses, of which there are three,-superior, middle, 
and inferior. The common covering is mucous membrane.* 
Superior and Inferior Canals.-Each fossa is physiologically divisible 
into a superior and an inferior canal: an upper, which relates with the olfac- 
tory region (olfactory channel) ; a lower, which pertains to respiration (respi- 
ratory channel, Schneiderian region). The septum, described by Meyer as 
the agger nasi, is simply a duplication, or fold, of mucous membrane prolonged 
anteriorly upon the middle turbinated bone. Division of the common naris 
is made by action of the compressor naris muscle. 
Functions of Nose.-The functions of the nose divide it into four 
different aspects (Watson): 1, a sense organ; 2, a respiratory apparatus; 3, 
as part of the face and of the mechanism of expression; 4, as part of the 
vocal mechanism. 
Surgical Points.-Surgically studied, regard is to be paid,-1, to the 
cavities and irregularities arising out of the presence of the scrolls; 2, the 
regularity or irregularity of the septum ; 3, the peculiar thickness and softness 
of the mucous membrane lining the olfactory channel when compared with 
that found in the Schneiderian region ; 4, association with the sinuses and orbit. 
* Asymmetry of the nares relates with deflection in the septum, or is a natural inequality. 
Congenital interference in respiration has not by any means its constant cause in deviation 
of the partition. 836 
A SYSTEM OF ORAL SURGERY. 
Diseases of the Nose.-Diseases of the internal nose, named in the 
order of their frequency, are,- 
1. Simple Nasal Catarrh. 
2. Hemorrhage. 
3. Ulcers. 
4. Polypi. 
5. Nasal Abscess. 
6. Exostosis. 
7. Conditions associated with Ozaena. 
8. Neoplasms. 
9. Hypertrophy of Nasal Mucous Membrane. 
10. Deviations of Septum. 
11. Gonorrhoea. 
12. Chancre. 
13. Imperforate Nares. 
14. Foreign Bodies in Associate Sinuses. 
1. Simple Nasal Catarrh.-Simple nasal catarrh is the so-called " cold 
in the headthe meaning of it lies in vascular perversion congesting the 
mucous membrane of the nose, particularly that portion associated with the 
olfactory channel. Fulness felt in the front and base of the fore- 
head region finds explanation in the continuation of this membrane 
which lines the frontal and ethmoidal sinuses. 
Sneezing.-Bald-headed people are peculiarly subject to nasal catarrh 
attended with much sneezing. Prophylaxis is found in wearing a silk skull- 
cap. 
Treatment.-Treatment of simple nasal catarrh lies in applications directed 
to the production of resolution. Such applications consist in hot foot-baths, 
and in the inducing of free catharsis, diaphoresis, or diuresis. From five to 
ten grains of sulphate of quinia given in a single dose is a favorite re- 
solvent with many physicians. Dover's powder, ten grains at bedtime, 
is a valuable means for immediate cure. A large dose of sulphate of magnesia 
dissolved in a goblet of water is an admirable remedy; to be taken at bedtime. 
A means in the second direction is found in tablespoonful doses of spirits of 
Mindererus repeated each fifteen minutes until free sweating is induced. 
Spirits of nitric ether is a reliable medicine in the third direction; the dose is 
a teaspoonful repeated each two hours. A combination used freely by the 
author, being prescribed, indeed, in nearly all cases which he is called to treat, 
is as follows: 
Liquoris potassii citratis, §iij ; 
Spiritus aetheris nitrosi, ^ss; 
Antimonii et potassii tartratis, 
Morphiae acetatis, aa gr. j. M. 
Sig.-Dose, from a dessertspoonful to a tablespoonful, repeated every two, three, or four 
hours according to urgency. THE NOSE AND ITS DISEASES. 
837 
Bromide of Potassium.-An admirable plan to pursue with a view of 
breaking up a cold in the head consists in prescribing from twenty to forty 
grains of bromide of potassium in conjunction with five drops of tincture of 
veratrum viride; the two to be combined in a wineglass of water. To be 
repeated, if found necessary, after four or five hours. A home remedy 
which comes in as a serviceable adjunct consists in covering the nose with slices 
of the fat of ham. Ointment of the oxide of zinc may take the place of the 
ham fat. Cocaine solution applied to the mucous surface is admirably cura- 
tive. Vaseline is to be highly commended. 
Erysipelas.-Inflammation showing itself upon awing of the nose with- 
out evident cause, the probability of erysipelas is always to have consideration. 
Attention is also to be directed to an alar irritability and enlargement apt to 
be met with during epidemic or endemic periods of mumps. The first con- 
dition, if it show any expression of flush, is to be painted with the erysipelas 
mixture, which see. The second is well treated if covered by cotton batting 
kept wet by diluted phenol-sodique. Small alar abscesses are best treated by 
Deshler's salve. (See Erysipelas.} 
2. Hemorrhage.-Nasal hemorrhage is direct or indirect; the first re- 
ferring to a lesion of the fossa, the second being related with the sinuses of 
the dura mater, and with constitutional conditions. A division made by 
Watson* is: 1st, the traumatic, or lesional; 2d, the plethoric, or active; and, 
3d, the adynamic, or passive. 
Lesional Epistaxis.-Lesional epistaxis arises out of erosions and ex- 
ternal injuries ; the first may have the expression of a polypus, of an ulcer, or, 
viewing it as traumatic, may result from accidental injury to the part. The 
second is commonly associated with fracture of some portion of the osseous 
parietes of the part, compound in character, the opening being internal. 
Plethoric Epistaxis.-Plethoric, or active, epistaxis is the hemorrhage 
so commonly met with in growing children of robust constitution ; the expres- 
sion is that of relief to over-full vessels. In the apoplectic it means rupture 
of a vein associating the brain sinuses with the nose; it is here to be looked 
on as a safety-valve, and, unless excessive, no attempt is to be made to 
control it. 
Passive Epistaxis.-Passive epistaxis occurs in the depressed and ill- 
' conditioned ; it is not usually preceded by precursory molimen. The condition 
of defibrinization as existing in the typhoid condition is a common antecedent. 
Scurvy and purpura, as noted by Watson, are other associations. The blood 
coming from this kind of hemorrhage is dark, serous, and lacks in coagulable 
quality. 
Traumatic Epistaxis.-Traumatic nasal hemorrhage is commonly left 
to take care of itself. When excessive, the bleeding point or space is to be 
looked for, and, if discovered, direct pressure is to be applied by means of a 
* Diseases of the Nose. 838 
A SYSTEM OF ORAL SURGERY. 
ball of lint-cloth which has been saturated with alum-water or, preferably, 
with dilute gallic acid. The search implies anterior rhinoscopy, which see. 
Treatment of Epistaxis.-Where the immediate seat of flow in 
traumatic epistaxis is not to be discovered the treatment is to be upon general 
principles. Holding the hands high above the head, after the manner of 
Negrier, while the bleeding nostril is compressed, will oftentimes control the 
bleeding. Ice-cold water drawn into the nares is a favorite means. Upright 
position. Hot foot-baths. Ice to nape of neck. Strong solutions of lead, 
or of phSnol-sodique, snuffed up the canal. Ice applied upon the external 
face of nose. Hot or ice bags to the spine (Chapman) with a view to stimu- 
lating the sympathetic ganglia. Tannic acid thrust into the nostril. Any 
of these means may be tried, or all of them successively. To use tannic acid 
or other powder, the Hibbard blower or the Kolbe insufflator may be used. 
(See, for illustration of these, pages found in this chapter.) A common glass 
tube filled with the powder answers a reliable purpose by being passed into 
the nostril and the medicine then blown out 
Plugging Nares.-Ordinary practice failing, the practitioner is driven 
to operative measures; these imply the employment either of a Cooper Rose 
gum-tube or Belloc's canula. The former instrument has never been used 
by the writer, but strikes him favorably; a description of it by Watson is as 
follows: It consists of a gum elastic tube about five inches long, with lateral 
perforations near the end, and covered with thin caoutchouc membrane in the 
form of a spirally-twisted bag for the last three or four inches of its length. 
The cavity of the bag can be injected with air or water from the gum-elastic 
tube, the end of which has fitted to it a piece of india-rubber tube for the 
purpose of connecting it with a syringe. This instrument is used by folding 
smoothly the membranous bag over the contained tube, and, after oiling, 
passing it along the floor of the naris until the pharynx is reached. The 
bag is now to be inflated, its inflation, before and behind, serving to close 
completely both apertures. 
Belloc's Canula.-Belloc's canula, exhibited in the cut, is a means 
familiar to practitioners at large. To use this instrument the curled spring 
Fig. 672.-Belloc's Canula. (See, for application, Fig. 673.) 
is withdrawn, and the instrument, being warmed and oiled, is passed along 
the floor of the nose .until seen in the pharynx. A succeeding step forces 
the spring forward, which, as is recognized, must throw it into the mouth. THE NOSE AND ITS DISEASES. 
839 
The eye is now double-threaded, the terminal end being retained without the 
mouth, the initial portion being carried through the nostril by retraction of 
the spring and withdrawal of the canula. To the mouth end of the string 
there is now attached a plug sufficient in size to occlude fully the posterior 
naris. This plug is now drawn into place, being directed by a finger of the 
surgeon ; its impaction against the outlet of the opening being secured by a 
Fig. 673.-Manner of using Canula. 
second plug forced into the anterior naris and held in place by tying about it 
the double strand of which the common string is composed. This manipula- 
tion controls hemorrhage by clotting the blood in the canal. Removal of the 
plugs is to be effected with great care. For convenience in removing the 
posterior plug it is common to tie about it at time of introduction a second 
ligature, which remains in the mouth, being fixed to the initial end related 
with the anterior plug, during time of treatment. 
Use of Tampon.-The use of the tampon, as here described, is attended 
with danger, both as to delay in its employment and results arising out of its 
use. The first refers to a procrastination in plugging, which has allowed the 
patient to become exsanguined beyond the ability of the system to recover. 
The second relates with irritative fever and to pyaemic conditions begotten of 
the confined and decomposing blood in the naris. This last involves lack ot 
judgment, or otherwise carelessness on the part of the surgeon. In placing 
the anterior plug the knot retaining it is to be of a character easily untied. 
On the second day this plug is to be carefully lifted and the cavity syringed 
with permanganate of potassium or, preferably, phenol-sodique; disinfection 
attained, the plug is put back in place, to remain until the following day, when 
it most likely can be dispensed with. The immediately succeeding day 
permits, most commonly, of the removal of the posterior plug. The with- 
drawal of the string through the clot is always a matter of concern as regard 
is had to the possibility of re-exciting the bleeding. Both as pertains to 840 
A SYSTEM OF ORAL SURGERY. 
secondary hemorrhage and disinfection the writer has learned to rest strongly 
on the phenol-sodique. 
Constitutional Conditions.-Nasal hemorrhage of active or plethoric 
character requires, in instances, a very immediate attention to constitutional 
conditions. Over-fulness of the stomach, and costiveness, are common asso- 
ciations. Nasal hemorrhage immediately after a hearty meal is apt to find 
quick cure in the production of free emesis. Costiveness is wisely treated by 
the administration of purgatives. Bleeding from the arm is a means of cure 
sometimes found a necessity in the hemorrhage of plethora. An important 
matter in the after-treatment relates with diet. Rare meats and much stimu- 
lating food are to be avoided. 
Relaxation of Vessels.-Nasal hemorrhage of passive signification 
implies lack of resistive force on the part of the containing vessels, not excess 
in the propulsive power of the heart. A case of this kind shows a lymphatic 
temperament, atheromatous vessels, otherwise debility from disease or improper 
living. A case some years back under the observation of the author, the 
patient being a young man, had its origin fairly in excess of candy eating; it 
seemed as though a finger might be punched into the tissues at any point. 
Persons ill fed, syphilitic, or scrofulous are subjects of passive hemorrhage. 
Out of thirty cases of diphtheria in an epidemic at the Stafford Infirmary 
(Watson) twelve were lost from passive hemorrhage. Wine of ergot in 
teaspoonful doses may be used. Tincture of digitalis in ten-drop doses, 
repeated every three or four hours, applies. 
Vicarious Epistaxis.-Epistaxis of vicarious meaning is not to be 
meddled with without appreciation of exciting conditions. Common rela- 
tions are with piles and with the menstrual period in women. The writer 
had under his professional care for over ten years a lady who, whenever 
she missed the regular monthly menstruation, bled from either the lungs or 
nose. 
Hemorrhagic Diathesis.-Epistaxis associated with the hemorrhagic 
diathesis finds its best treatment in the occasional use of quinine, iron, strych- 
nia, and hydrochloric acid. The condition is commonly that of super-alkalinity 
of the blood combined with vaso-motor debility. The free use of pure cider 
vinegar with the food is to be recommended. 
3. Ulcers.-Ulcers of the nose are of traumatic, scrofulous, syphilitic, or 
cancerous origin. 
Traumatic and Adenoid Ulcers.-A traumatic ulcer implies injury 
done to the part by some accidental source of offence. A not infrequent cause 
of such condition, as met with in early childhood, has its existence in foreign 
bodies that have been thrust into the nostril. In congenital breaks of the 
hard palate ulcers of the Schneiderian nasal region are not uncommon, portions 
of articles taken as food lodging and proving sources of irritation. The 
escape of cotton plugs which have been inserted into the anterior nares is to 
be credited for much offence in this direction. Adenoid vegetation is THE NOSE AND ITS DISEASES. 
841 
another cause ; the location of this ulcer, for so it may be esteemed, is toward, 
and in, the naso-pharyngeal region; posterior rhinoscopy discovers it. 
Treatment of ulcers of local signification arises out of the indi- 
cations of each particular case; cure is commonly found in removing a source 
of offence. In the adenoid vegetations a nasal curette, dull or sharp, may be 
used. A plan of treatment more commonly preferred consists in locating the 
lesion and making daily applications to it of a powder composed of equal 
parts of iodoform and subnitrate of bismuth. Injections of zinc 
sulphate and chloral hydrate, in the proportion of two grains of each to one 
and a half ounces of water, are never out of place in nasal ulcerations. 
Adenoid vegetations, unrecognized, become the source of perma- 
nent injury and deformity. The child, not able to breathe through the nostrils, 
uses the mouth entirely for such purpose, this resulting in the falling of the 
lower jaw and the production of a vacant expression. Diagnosis as to these 
growths is usually made without difficulty by means of a finger passed forward 
from behind the soft palate. In an excellent paper on these vegetations written 
by Franklin H. Hooper, M.D., Dr. Chatellier,* of Paris, is quoted as calling 
especial attention to deformities of the bones of the head and face 
consequent on obstructed nasal respiration. He suggests that the air-cavities, 
as the frontal, sphenoidal, and ethmoidal sinuses, and the antrum of Highmore, 
being normally in communication with the air, cease to develop when the cir- 
culation through the nose is interfered with, and hence the dimensions of the 
face become altered. The lower jaw, which follows its normal development, 
often projects beyond the upper, which is contracted in front, the upper lip 
being drawn up, while the hard palate, from the constant atmospheric pressure 
within the mouth, is pushed upward, terminating in a sharp angle like the 
Gothic arch. Dr. Hooper thinks there is a definite relation between these 
adenoid growths and the V-shaped palatine arch, which has 
never been appreciated in considering the acquired cause of irregularity of 
the teeth in children. In my experience, he says, the high-arch palate is always 
present in typical cases of this complaint. Moreover, I believe it to be one of 
the earliest mechanical results of obstructed nasal breathing. Mouth-breathing 
being unavoidable in these cases, the constant pressure of the air inside the 
buccal cavity gradually, but surely, forces the hard palate upward. 
Figures are presented in Dr. Hooper's paper, taken from the casts of 
typical cases, proposing to show that from a simple vaulting of the hard palate 
in the very young, trouble may go on and lead to marked deformity of the 
jaw and great irregularity of the teeth. The central incisors are assumed to 
suffer most, being in some instances rotated to such degree as to stand at 
almost a right angle to the jaw. Many a child, Dr. Hooper thinks, has had 
one or more healthy molars extracted, and has worn for years ingenious me- 
chanical devices for correcting a crowded and irregular denture, while atmos- 
* Des Tumeurs Adenoides du Pharynx. Paris, 1886. 842 
A SYSTEM OF ORAL SURGERY. 
pheric pressure was constantly working against the efforts of the dentist. 
Whereas, if the growth had been first removed, the labor would have been 
shortened and lessened, since, by establishing free nasal breathing, the undue 
atmospheric pressure would have been removed from the inside of the mouth. 
Scrofulous Ulcers.-Scrofulous ulcers are most frequently met with 
in yellow persons ; diagnosis lies in collateral associations. It is perhaps 
never the case that a scrofulous ulcer of the nose is disassociated with an easily 
distinguishable dyscrasia. As a rule, phthisis pulmonalis is found to exist. 
Scrofulous, tuberculous, or lymphatic ulcers, as sores of this class are indiffer- 
ently to be termed, seldom, if ever, extend their ravages beyond the submucous 
tissue. A common location is the septum. A good local application in treat- 
ment of them is found in the formula last given. Another is tinctura calen- 
dulae. Still another, particularly useful if odor be present, is phenol-sodique 
much diluted. Where marked indolency exists the compound tincture of 
capsicum, used in the proportion of five drops to a tablespoonful of water, 
answers an admirable purpose. As constitutional medicaments, unskimmed 
milk, cod-liver oil, and iodine in limited quantity are to be used. No better 
course of treatment is to be prescribed for a person afflicted with, or tending 
toward, tubercle than the following: A sheet-bath, prepared with Turk's 
Island salt, immediately on rising in the morning; the act to be accomplished 
within a minute. Succeeding this is to be a self-rubbing of the skin until the 
surface is aglow. After this a goblet of milk containing a raw egg together 
with a tablespoonful of brandy. This to be followed by a walk ; breakfast 
finishing the performance. In the case of a patient weakened from disease 
the milk and egg are to be taken fifteen minutes before getting out of bed; 
bath and rubbing are to be given by a nurse; the tablespoonful of liquor 
concludes the breakfast; exercise may be passive. 
Strumous Rhinorrhoea.-Strumous rhinorrhoea and ulceration as a 
disease of childhood is found in connection with hereditary taint, and in a dys- 
crasia related, as in the previous recital, with disease of the lymphatic system. 
The ulcers are of the pasty variety, the discharge commonly somewhat offensive. 
Obstruction of the nostrils exists in a swelling of the mucous lining and in 
the formation of yellowish scabs. Attention is to be directed, in connection 
with strumous ulceration of the nose, to a congestive infiltration of the mem- 
brane covering the inferior turbinated bone, which oftentimes results in a 
pouch-like projection of that tissue from the nostril, which, while it obstructs 
respiration, so simulates polypus in appearance as not infrequently to beget 
mistakes in diagnosis. 
Treatment of Scrofulous Ulcers.-Treatment of scrofulous ulcers 
in children differs nothing from that just suggested. Importance is attributed 
by some to frequent removal of the scab, this being recommended to be done 
twice a day. To accomplish such removal glycerin and water in equal pro- 
portions combined with carbolic acid, one part of the last to sixty or eighty 
of the first, is highly commended by Watson ; application is made with a THE NOSE AND ITS DISEASES. 
843 
camel's-hair brush. A means used by the writer is cod-liver oil; this softens 
the scab nicely. Still another admirable local application is found in benzoated 
zinc ointment, to which have been added small quantities of iodoform; two 
grains of the latter to one drachm of the former. Where a general passive 
congestion of the parts exists the injection of zinc and chloral, noticed a few 
paragraphs back, will be found of great service. 
Syphilitic Ulcers.-Syphilitic ulcers are, in like manner with the 
scrofulous, recognizable by associations. A syphilitic ulcer is a dangerous 
sore; once started its ravage might not be stayed until mucous membrane, 
cartilages, and bone-structure are involved in a common destruction. The 
starting-point of this ulcer, excepting when of primary meaning, is commonly, 
if not exclusively, in the form of a gumma. The symptom first noticed is 
interference with free nasal respiration; a later sign is a thin muco-purulent 
discharge of offensive character; still later, greenish, slimy clots are formed 
and thrown off. Ulcers associated with the tertiary form are most formidable. 
Principles of Treatment.-Correct treatment is founded on general 
principles : the disease is syphilis, syphilis requires to be prescribed for; the 
local expression is a rhinorrhoea, or coryza, associated with ulceration; local 
expressions demand exhaustive attention. 
Septic Discharges.-The offensive, and indeed poisonous, nature of 
the discharge relating with syphilitic coryza renders cleanliness a matter of 
special consideration. Nostrils so diseased are to be washed, disinfectants 
being used, several times daily. This is accomplished by a douche bath pre- 
pared by adding to the zinc-chloral water a required quantity of phenol-sodique 
or Watson's chlorine-water ; this last much diluted. 
Application to be Direct.-Application to ulcers is to be direct. 
To discover the seat of such ulcers anterior rhinoscopy is employed, which 
see. Syphilitic ulcers of the nose are treated the same as those found in the 
mouth or pharynx, which see. 
Neuro-paralytic Ulcers.-Ulcers of this class are to be looked for 
in conditions of paresis of the fifth nerve. Treatment is in stimulation. Use 
strychnia internally in doses of one-fiftieth of a grain three times a day. 
Scorbutic Ulcers.-These are undoubtedly to be met with situated 
within and about the nostrils. Diagnosis and treatment refer to the general 
condition. (See Scurvy.} 
Glanders.-This is an ulcer of contagion. The period of incubation is 
commonly twenty-four hours. The primary nasal expression is a discharge 
of thick yellowish fluid streaked here and there with blood. The disease is 
almost necessarily fatal. (See works on Practice of Medicine.) 
Cancer.-Cancerous ulcers of the nose are of fatal signification. They are 
recognizable in the giant granulations studding the surface. No cure is known. 
Treatment considers free excision of the part involved. (See Epithelioma.} 
Exanthems.-Nasal ulcers associated with the ordinary exanthems of 
childhood find proper treatment in that which considers the disease at large. 844 
A SYSTEM OF ORAL SURGERY. 
The same is to be remarked of diphtheritic ulcers. Local treatment of the 
first class consists alone in the employment of simple soothing unguents or 
fluids. Ulcers of the last kind require that the exudate forming over them 
be both dissolved and disinfected. Watson's chlorine-water will be found 
invaluable. 
4. Polypi.-Polypus is the fourth most common disease of the internal 
nose. All polypi are to be looked on with concern as reference is had to a 
possible malignancy. Two general forms are met with: the gelatinoid and 
fibrous. 
Gelatinoid Polypi.-A gelatinoid polypus resembles closely, in color 
and general appearance, a common oyster; it is moist, translucent, occasionally 
jelly-like, infrequently fairly solid. Shape varies to a degree that places it 
out of the way of comparison, although, as a rule, the growth is pedunculated. 
" Pyriform" is the expression for form commonly used by writers. 
Origin of Growth.-The origin of this growth is almost invariably 
from the middle turbinated bone, while yet it is quite well known that it may 
spring from any part of the cavity, the nasal septum not excepted. Origin is 
single or multiple, one or several occupying a naris. Gelatinoid polypus, 
looked on as a mucous tumor, is to be esteemed as a hypertrophy of that 
structure, otherwise as a submucous development carrying and attenuating 
the membrane; a variety is undoubtedly modified adenomata. Papillomata 
is a variety made by certain writers. 
Moisture and Polypi.-The hygrometric character of a gelatinoid 
polypus finds explanation in its structure; this is cellulo-fibrous, the meshes 
being filled with a sero-albuminous fluid. The growth is commonly much 
affected by the state of the atmosphere, being smallest in dry, largest in wet 
weather. 
Treatment.-Treatment of mucous polypi is by desiccation, evulsion, 
abscission, the electric cauterant, and the use of potential cauterants. The 
first is to be tried with the smaller varieties. In this direction a powder 
Fig. 674.-Kolbe's Powder Insufflator. 
composed of tannin and iodoform, in equal parts, is to be recommended; 
application is made by means of a glass tube charged with the medicine, this 
being blown over the growth. A second means employs an insufflator com- 
posed of bellows and tube: Kolbe's instrument (Fig. 674) is a good one. 
Strong alum- or lead-water, as an injection, is found to afford much comfort; 
it is to be used two or three times a day. THE NOSE AND ITS DISEASES. 
845 
Hibbard's Powder Blower.-This apparatus is to be commended; 
it works perfectly, and as the powder is contained in a glass bottle, it is always 
easy to see how much you have in the blower. It is more readily filled than 
Fig. 675.-Hibbard's Powder Blower. 
any other, much more economical, and the powder does not absorb the odor 
of the rubber. The powder does not issue en masse, but in a nebulous cloud, 
and is exactly regulated by the pressure used. 
Evulsion.-Cure by evulsion, tearing away, or by strangulating is most 
relied on; to this end a polyptrite, or double canula, is used. Fig. 676 shows 
Fig. 676.-The Areling-Hodge Polyptrite. 
Fig. 677.-Gooch's Double Canula. 
a modification on Hodge's modification of Areling's polyptrite. This 
instrument, though best fitted for use in another location, is yet found at times 
to act well in the nostril. Fig. 677 represents Gooch's double canula 
applied. 846 
A SYSTEM OF ORAL SURGERY. 
Torsion Forceps.-Still another instrument, one the writer would 
recommend, is shown in Fig. 678. An advantage consists in the forceps 
having the grasping part connected by three joints; thus, in seizing a tumor 
Fig. 678.-Torsion Forceps 
the points cannot slip or twist laterally; the leverage is also increased, while 
the strain on the fingers is diminished. Another instrument still is that illus- 
trated in Fig. 679. This, where the pedicle is tough and resisting, plays a 
most satisfactory part. 
Use of Snare or Forceps.-To use the snare or forceps requires that 
the operator possess himself of an accurate knowledge of the position of the 
base of the tumor; using the 
loop, the wire is to be placed 
by means of a notched guide; 
the forceps employed, the 
pedicle is to be grasped im- 
mediately adjoining the part 
from which the growth origi- 
nates. A polypus associated with the posterior nares, or naso-pharynx, falling 
backward into the throat, is to be caught from below and twisted off, other- 
wise it may have its pedicle encircled by a double wire passed through the 
nostril, being extended until it can be caught in the pharynx and slipped over 
the tumor. In ablating a polypus after this latter manner it is desirable to 
save the mass from slipping into the apex of the pouch through means of a 
ligature passed through it previous to the strangulation. 
Cauterization of Base.-After removal of one of these polypi the 
base, where possible, is to be deeply cauterized with London paste, chromic 
acid, or other agent. The preference of the writer is for the paste. 
Fibrous Polypi.-Fibrous polypi, unlike the form just described, which 
is rarely met with in the young, is a condition associated with all periods of 
life. It is less common than the gelatinoid, is rarely multiple, and, unless 
markedly pedunculated, is to be esteemed of threatening import. The com- 
position of these growths consists of fibres intricately arranged, among which 
arterial and venous vessels, possessed of brittle coats, freely circulate. Micro- 
scopic examination too often distinguishes a sarcomatous element. 
Peduncle.-Fibrous polypi of pedunculated base are to be snared or 
twisted precisely as the gelatinoid. Where the base is broad experience has 
shown the futility of all but the most radical of operations. Great care is 
to be exercised in distinguishing these growths, that they be not confounded 
with others coming from the base of the skull. 
Fig. 679.-Polypus Forceps. THE NOSE AND ITS DISEASES. 
847 
Diagnosis.-Diagnosis of simple fibrous polypi lies in notice of obstruc- 
tion caused in the breathing, either in inspiration, expiration, or both, and in the 
movable nature of the tumor, as well as in its complexion, which differs from 
the gelatinoid in being of flesh-like appearance. The sarcomatous form of 
polypus is commonly of rapid growth, quickly making its presence recognized 
upon the external face. Frog-face, as it is called, deformity growing out 
of lateralization of polypus, is diagrammed in left side of cut.* (Fig- 680.) 
Fig. 680.-Frog-Face. 
Fig. 681. 
Polypus related with turbinated bone. 
Fig- 682. 
illustrations of removal of polypi with the 
forceps, and with the canula and loop. 
Sarcomatous Polypi.-Polypi of the sarcomatous variety are found 
little amenable to treatment, even the most radical removal seldom affording 
any but a temporary relief, although this last seems the only thing to do, save 
the policy of doing nothing be adopted. Injections of ergot, of iron, of 
different acids, are not, as has been suggested, of questionable advantage ; they 
are injurious to the greatest extent. The galvanic ecraseur is alike objection- 
* A cartilaginous tumor associated with the septum nasi or lateral cartilage finds repre- 
sentation in the tumor seen on right side. 848 
A SYSTEM OF ORAL SURGERY. 
able, except with the markedly pedunculated growths,-a form of polypi seldom, 
if ever, found in association with the sarcoma cell. 
Extirpation.-Extirpation of sarcomatous polypi, if determined on, is 
practised variously. When situated well back in the naso-pharyngeal region, 
Fig. 683. 
Removal of polypus by means of forceps and finger. 
the origin being from the base of the skull, Langenbeck's procedure 
may be imitated; this consists in a depression of the upper jaw. The writer 
has, on several occasions, succeeded most satisfactorily in operations performed 
in the naso-pharyngeal space by slitting the soft palate. Nelaton, the French 
surgeon, records performances practised by dividing both soft and hard palates. 
To do the operation of Nelaton, an incision is commenced in the soft 
parts and carried through mucous membrane and periosteum of the hard 
palate. Next the periosteum is carefully raised, a triangular exposure being 
made of the bone. A succeeding manipulation removes the bone to an extent 
necessary to reach the tumor. 
Button-Hole in Velum.-Where a polypus of the naso-pharynx is 
not large, yet of a nature not to be excised from the nares, the 11 palatine 
button-hole" of Manne may be made. This " hole" consists of a simple sec- 
tion through the velum, leaving the uvula intact. 
Langenbeck's Operation.-The operation of Langenbeck is done as 
follows: 1. An incision commenced at the base of the nasal ala and carried 
outward until it reaches midway of the zygomatic arch. 2. A second incision 
beginning at the centre of the root of the nose directed just below the inferior 
margin of the orbit, continuing over the frontal process of the malar bone 
until it meets the first at an obtuse angle. Beginning now at the apex of the 
triangle seen to be included in the incisions, the flap is dissected from its bed. 
Succeeding this, section is made of the periosteum in the line of the cuts, 
while the masseter is lifted from its malar origin. Using now the circular-saw 
of the surgical engine (though Langenbeck employs a narrow blade), the bone THE NOSE AND ITS DISEASES. 
849 
is to be cut horizontally from behind forward, leaving intact the nasal process. 
Using the engine-saw, no occasion exists to introduce the finger into the pos- 
terior nares as a guide, the position of the cutting edge of the saw being 
instantly recognized in the cessation of obstruction. The bone thus freed, 
except as regard is had to its relation with the central line of the face and its 
covering of soft parts, is to be pried out of its bed by a lever inserted between 
it and the os malare. The tumor, thus exposed, being removed, the bone and 
overlying parts are restored to their original location. 
Intracranial Disease.-Fibrous polypi are secondarily dangerous as 
the cause of intracranial disease, being an excitant of coma, convulsions, 
abscess, chorea, asthma, emphysema, and cerebral affections. 
5. Nasal Abscess.-As met with in the practice of the writer, nasal 
abscess has its seat most commonly in the septum. Cause is so persistently a 
strumous diathesis as to imply, for such cachexia, consideration in every case. 
Patients are almost invariably of the yellow class. Diagnosis is found in pro- 
trusion from the nares of a fluctuating sac. Treatment is both constitutional 
and local. The first is as heretofore directed; the second implies venting of 
the accumulated pus and the injection of stimulating lotions. 
6. Exostosis.-Referring to Fig. 670, and observing the situations of 
junction of nasal plate of ethmoid bone with the vomer and of the latter with 
the central line of base of nose, the common situations of nasal exostosis are 
appreciated. That found in association with the first of the locations is spongy 
rather than hard, that in relation with the second is not infrequently of ivory 
solidity. 
The exostosis found in association with the articular line of vomer and 
ethmoidal lamella is apt to be of ridge-like shape, and is quite as likely as 
otherwise to have cavities interspersed filled with cartilaginous matter; rarely 
with gelatinous or with fibrous matter. The situation of this exostosis inter- 
feres with the sense of smell and, as well, not infrequently, with free breathing, 
also with discharges from the neighboring sinuses. It may grow rapidly, or, 
after gaining a certain unimportant size, may remain dormant for years. 
Ivory Exostosis.-Ivory exostosis shows itself most commonly in the 
form of one or of several hillocks of varying size having a base or bases in- 
clined to correspond with the palato-vomer articulation; that is to say, infer- 
ence is afforded that origin is from the line of such articular relation by 
reason of this obliquity of base. 
Antral Exostosis.-Exostoses growing to great proportions originate 
at times within the antrum and encroach upon a naris. One of this order 
lately operated upon by the writer occupied the entire site of an upper maxilla 
and obliterated completely the nostril of its side. (See Exostosis of Antrum.') 
Sphenoidal Exostosis.-Cases occur where the posterior nares become 
completely obliterated by reason of exostosis originating in the body of the 
sphenoid bone. Operations on this bone require, of course, to be conducted 
with great care and skill. (See a succeeding paragraph.) 850 
A SYSTEM OF ORAL SV ROE RY. 
Treatment.-If it be thought well or necessary to operate upon nasal 
exostoses, no means that can be employed make any approach, as adaptability 
of instrumentation to ends is concerned, to burs revolved by the surgical 
engine. Figs. 144 and 163 show forms of burs used by the writer. 
Use of Burs.-The use of burs is to be submucous, an operative per- 
formance easily practised by perforating and undercutting the membrane, em- 
ploying for the purpose a delicate double-edged bistoury. The entering points 
of nasal burs are best when uncut and polished. In the use of the bur de- 
pendence is strictly upon the sense of touch, the eye being unable to see the 
situation of operation. Practice is necessary, which practice is to be obtained 
by manipulation upon the cadaver and by using the burs in connection with 
such different substances as bone, cancellous and cortical, ivory, cartilage, 
periosteum, and mucous membrane. The teeth of nasal burs are to 
be short, otherwise the soft parts will be caught and whirled into shreds. 
Short teeth, while cutting bone, slip over flesh. (See Surgical Engine.) 
Exostosis of Body of Sphenoid Bone.-A lady, living in North 
Carolina, was brought to the writer's clinic by her physician, Dr. Malden, 
whose naso-pharynx was filled so completely by an osseous tumor as to entirely 
prevent respiration by the nose. This tumor, which had been growing four 
years, was quite the size of an ordinary hickory-nut, was without pain, or 
observable inflammatory accompaniment, and had its sole inconvenience by 
reason of its position. An operation, in which the whole of the body of the 
sphenoid, with the exception of the superior surface, was removed, was prac- 
tised as follows: First a cut, an inch in length, was made in the line of the 
raphe of the soft palate. The growth being thus exposed, a succeeding step 
peeled the osseous mass of its mucous covering. Following this revolving 
burs were used. The performance, which necessarily had to be accomplished 
with great care and delicacy, occupied less than an hour. Recovery was 
speedy and the result in every way satisfactory.. 
OZAENA. 
7. Conditions, Direct and Indirect, associated with Ozaena. 
-Ozaena is an opprobrium of surgical practice. By some it is esteemed and 
treated as a parasitic disease; by others as an expression of a dyscrasia. At 
the head of the first of these schools is Dr. Massei, an Italian. Treatment 
advised by that gentleman is as follows: a. Gradual dilatation of the oblit- 
erated nasal passages by means of elastic bougies. 6. Cleaning and disinfection 
of the diseased regions by a very weak solution of salicylic acid (one part to 
five hundred parts of water), applied by means of a syringe, c. Modifying 
local medication, by blowing calomel powder through a nasal speculum on the 
ulcerated surfaces. This author insists that there is always an arrest in the 
process of healing at a certain period, but advises strongly not to give up the 
treatment, but to continue it patiently until total cure is obtained. Dr. 
Frankel ( Virchow's Archiv, vol. Ixxxv.) gives a number of cases which he THE NOSE AND ITS DISEASES. 
851 
thinks will confirm the views of those who believe that ozaena always owes its 
origin to a dyscrasia,-two of his patients were phthisical, two syphilitic,-but 
he does not believe, though admitting the frequent coincidence of ozaena with 
pharyngitis sicca, that the diseases are in causal connection with each other. 
To understand ozaena is to appreciate a circle of associations. The 
accompanying study is presented for the instruction of the student and the 
consideration of practitioners. 
Indefinite Character of the Term.-The term ozaena, like that of 
epulis, is a somewhat indefinite one, and is to be first viewed from the stand- 
point of its common significance. 
Ozaena is from the Greek 6^, signifying " stench," and the term is, 
therefore, in reality, applicable to any ill-smelling condition. By universal 
consent, however, it has been restricted in its application to foul expressions 
about the nares and associate parts, accompanied with offensive discharge. 
The study of ozaena, then, it will be seen, is, necessarily, a study of 
various conditions, and these conditions, experience will show, are 
classifiable under the following heads: 
1. Accumulation and degeneration of the common antral secretion. 
2. Degenerated pus from tooth-abscess discharging into the antrum, and 
from this appearing in the nose. 
3. Ulceration of the mucous membrane of the antrum. 
4. Deteriorated secretions from constitutional causes. 
5. Caries of the osseous walls of the antrum. 
6. Ulceration of the mucous membrane of the nares. 
7. Caries and necrosis of the osseous boundaries of the nares. 
8. Lodgement and retention of foreign bodies. 
Accumulation and Degeneration of the Common Antral 
Secretion.-The first of these conditions is most frequently observed in 
connection with an ordinary cold in the head. The outlet of the antrum, 
it will be remembered, is by an opening about the size of a goose-quill into 
the middle meatus, which opening is circumscribed by mucous membrane, 
and which membrane, as the result of congestion, can very readily occlude 
this outlet; the parts being in this condition, it may happen that the pent-up 
mucus degenerates and decomposes, so that, on the subsidence of the swelling, 
the escaping discharge presents an offensive odor. To diagnose this character 
of ozaena, it is only necessary to connect it with the preceding inflammation, 
with the absence of specific conditions, and with the readiness with which it 
yields to simple treatment. Of course there would have been a preliminary 
feeling of the sense of congestion on the part of the patient; he would have 
had, to express it most simply, a cold in the head, and this cold, with its 
accompaniment of dryness and constriction, would have grown worse, until, 
with the appearance of the discharge, relief would have been experienced,- 
the discharge implying the passing away of the congestion and the restoration 
of a normal circulation and secretion. 852 
A SYSTEM OF ORAL SUROERY. 
To cure this form of ozaena requires very little treatment,-indeed, 
in most cases no treatment at all. The author is in the habit, when the dis- 
charge continues longer than two or three days, of directing the sniffing up 
the nostril of the affected side some such combination as the following: 
R JStheris sulphurici, ; 
Tincturae iodinii, ^ij ; 
Olei juniperi, 3j- M. 
If this fail to check the discharge, such constitutional treatment as 
seems indicated is to be directed. Patients in whom such drain exists belong 
to one of two classes, the plethoric or the antemic. With the first, the treat- 
ment demanded is depletory; a dose or two of sulphate of magnesia will gen- 
erally be all that is demanded ; although in a few instances it is found necessary 
to bleed from the veins. With the second class-and this is by far the more 
numerous-the mucous membrane of the part is found fallen into a condition 
analogous to the urethritis of chronic gonorrhoea; in these cases tonics are 
at once to be resorted to; the common combination of iron and quinia is 
perhaps the best that can be prescribed : 
U Tincturse ferri chloridi, ; 
Quiniae sulphatis, 3j. M. 
Sig.-Fifteen drops in water every three hours. 
Fetid Discharges depending on Tooth-Abscesses. - Fetid 
discharges depending on tooth-abscesses-abscesses which vent into the an- 
trum-find their cure, as a rule, immediately on the extraction of the diseased 
organ. If this prove not to be the case in any special instance, then injec- 
tions are to be made through the tooth alveolus. Iodine is an admirable 
base for all such injections. It is desirable practice to control the odor with 
the permanganate of potassium : 
Potassii permanganatis, 3ss-j 
Aquae, M. 
Sig.-Inject as occasion requires. 
It would most likely be quite sufficient to use the disinfectant three times 
a day. After it the following may be thrown in: 
R Tincturae iodinii, ; 
Glycerini, £j ; 
Acidi tannici, 5SS> 
Aquae Coloniae, ; 
Aquae destillate, ^iij. M. 
Or, 
U Tineturae capsiei composite, ^ss; 
Aquas rosas, §viij. M. 
Or, 
Argenti nitratis, gr. xxx: 
Aquas, ^vj. M. Or, 
THE NOSE AND ITS DISEASES. 
853 
R Vini opii, ; 
Vini aromatici, ; 
Aquae, ^vj. M. 
Indeed, any stimulant preparation may be resorted to, although experience 
favors particularly the use of iodine. 
Ulceration of the Mucous Membrane of the Antrum.-Ozaena 
from ulceration of the mucous membrane of the antrum is not a condition of 
frequent occurrence; without doubt this is the case where no specific disease, 
as syphilis, scrofula, or scurvy, exists, so that, meeting with such ozeena, we 
naturally at once revert to the constitutional condition. To discover an ulcer 
within the antrum is a matter for diagnosis by exclusion, and thus to expose 
it is not at all a difficult matter. If there be no diseased teeth or teeth-roots, 
no nasal ulceration, no antral dropsy, no acute preliminary conditions; if the 
fetid matter flow most freely when the suspected antrum overlies its nasal 
outlet, then we will generally be right in inferring an ulcer of the antrum; 
but an ulcer in the antrum is not necessarily a cause of ozaena. To give this 
fetid odor, it must be an unhealthy ulcer, by which is meant that it tends to 
degenerate its granulations, rather than to organize them. An ulcer, says Mr. 
Cooper, may be defined to be " a granulating surface, secreting matter;" and 
this is certainly true of most ulcers, particularly if we replace the term secret- 
ing with the term making; for the matter given off is nothing but degenerated 
lymph-corpuscles, to which the parts lacked strength to give force of organiza- 
tion. A healthy ulcer is to be seen in any accidental sore tending to 
rapid self-cure; there is in these cases little or perhaps no pus, for the reason 
that every particle of the exuded lymph of repair has in it vitality sufficient 
for its organization. An unhealthy ulcer, on the contrary,-and by such 
an ulcer we mean an adynamic one,-gives off more or less matter; it throws 
out its reparative lymph just as does the healthy one, but the viability of such 
lymph differs materially from the exudation of the former ulcer. Thus, ac- 
cording to the nature and character of such degeneration, we have the pro- 
duced pus: ichorous, a thin, watery, acrid discharge; scrofulous, a cheesy, 
curd-like pus; sanious, a thin, sizy discharge; glutinous and viscid, as in 
sordes, etc. 
Now, whether any or all of these kinds of pus give the fetor of ozaena 
depends on circumstances, not the least important of which is the state of the 
atmosphere and the condition of cleanliness preserved. Laudable pus, issuing 
from a healthy wound, will, in hot weather, become quite offensive in a very 
short time, as is, unfortunately, too freely illustrated in hospital practice. 
Certain ulcers are, however, in themselves offensive. Every one has 
had occasion to observe, at some time or other, the disgusting odor arising 
from the saliva of particular persons,-constitutional ozmna it may with most 
propriety be termed. The writer recalls, even to this day, a certain school- 
master, the stench of whose spittle, employed to rub sums from his slate 854 
A SYSTEM OF ORAL SURGERY. 
always made him sick. This kind of saliva, and this odorous ulcer, belong to 
the alkaline class of people. Give such persons acid: they always need it; 
there is no exception. 
A simple ulcer of the sinus-that is, one not associated with osseous 
diseases-is to be treated in the twofold direction of its constitutional and 
local requirements. To treat an ulcer scientifically, calls for an understand- 
ing of the conditions on which ulcers in general depend; and as ulcers of 
various signification so frequently present themselves about the mouth and 
throat, it is not a digression to make a hasty review of so enlarged and 
important a subject. 
Nature of Ulceration.-Ulceration is the absorption or the breaking 
down of some constituent part of the body. Its great cause is inflammation. 
Inflammation is always preceded and excited by irritation. The term irrita- 
tion is a comprehensive one, and covers every source of offence to which the 
human body is subject. Thus, one man has an ulcer, the result of an inflam- 
mation excited and perhaps kept up by the presence of some foreign body, as, 
for example, a ball, a splinter of wood, a particle of dust, etc. A second man 
has an ulcer, the result of a localized inflammation, predisposed by the pres- 
ence within his system of some specific taint. These ulcers, a glance would 
exhibit, must vary widely in their character, and even more so in treatment 
demanded for their cure. Thus it is that we speak of, and think about, 
ulcers in the way of their signification. We have simple purulent 
ulcers, venereal ulcers, scrofulous ulcers, scorbutic, varicose, and cancerous 
ulcers; the character of each being expressed by its adjectival prefix. A 
simple purulent ulcer is a sore, the result of some local accident, and is, 
most likely, self-curing; a venereal ulcer is one excited and kept alive by 
the presence in the system of the venereal poison ; the scrofulous, scorbu- 
tic, and cancerous alike depend on dyscrasic conditions; the varicose on 
certain obstructions in the venous system, etc. To secure a cure in the first 
of these classes of ulcers, nothing more is necessary than to protect them from 
adverse influences. A varicose ulcer, to be cured, must be converted into 
a simple one by treatment directed to the trouble in the circulation; a can- 
cerous, scorbutic, or scrofulous ulcer is only to be permanently cured by ob- 
literating the cachexia. There is nothing obscure in the appreciation of these 
facts; the difficulty is in meeting the indications. Ulcers, it is true, are 
presented under a great variety of names; but these variations have reference 
only to differences in expression. Thus, a carious ulcer implies that the con- 
dition is dependent on the presence of dead or dying bone ; a callous ulcer 
is one having indurated circumference; a fungous ulcer is one where the 
granulations of repair are in excess; a sinuous ulcer is one constituting 
the orifice of a canal leading to a deeper than the manifested disease; an irri- 
table ulcer is one that, from internal or external causes, has become tender 
and excitable ; a phagedenic ulcer is one that tends to take on gangrenous 
action ; a sordid ulcer is one discharging a dirty-looking glutinous matter; THE NOSE AND ITS DISEASES. 
855 
and so on, each of the many appellations being simply expressions of dis- 
tinctive peculiarities. Now, one man, having syphilis, gets a rheumatism 
in his joints ; another an ulcer on his tibia. In these two cases the important 
features of treatment are alike: both patients must have antisyphilitic medi- 
cation ; local applications are simply adjuncts. An ulcer, simple in its 
character, situated over or upon some part in frequent motion, is apt to 
assume the irritable aspect; an ulcer the result of an idiopathic influence, if 
occurring on a person of weak or typhoid condition, is almost certain to 
assume the chronic or indolent form; an ulcer engrafted by external cause 
on a depraved constitution is always more or less influenced by the vice, and 
such vice is to be considered in its treatment; and so, whatever the extent of 
the review, this wide collateral relationship keeps itself in the foreground. 
Ulcers of Antrum.-To return to ulcers in the antrum. We are pre- 
pared to recognize that such sores may be of various signification, and may, 
for their cure, demand a various character of treatment. So far as odor is 
concerned, all will alike be benefited by a primary treatment of cleanliness 
and antiseptic injections. To correct the fetor in a chronic case, it gen- 
erally becomes a necessity either to trephine the canine fossa or to extract one 
of the underlying teeth and get into the cavity through its alveolus: the latter 
mode is decidedly to be preferred. A plan, however, that may be tried, con- 
sists in keeping a tuft of cotton or fine sponge in the nostril, and frequently 
saturating it by the sniffing into it of an antiseptic. The entrance into the 
cavity, however, through the alveolus of a tooth is one of the simplest pro- 
cedures in surgery, demanding only that the operator shall recognize the posi- 
tion of the sinus as influenced by the shape of the jaw. Any spear-shaped 
instrument will answer to make the opening: to keep it patulous, it is only 
necessary to introduce, after each operation or injection, a tent of cotton or 
sponge. As a medicament, the following combination may be employed: 
U Acidi carbolici, gtt. xx; 
Glycerini, ^ss; 
Acidi tannici, gr. v; 
Aquae, ^vj. M. 
Or, 
R Spiritus vini, ; 
Creasoti, gtt. x; 
Aquae, ^vj. M. 
Or, as suggested on a previous page, the permanganate of potassium 
in the proportion of from two to ten grains to the ounce of water, as indicated. 
Phenol-sodique, combining as it does antiseptic and alterative virtues, 
is one of the very best injections that may be employed in these cases. It is 
used diluted, as required. 
Associated with such antiseptic treatment, and which is to be 
used in every case of ozoena, whatever its origin, we connect the specific or 856 
A SYSTEM OF ORAL SURGERY. 
peculiar treatment demanded by each special case,-the appreciation of which 
treatment presupposes and necessitates the understanding of therapeusis in 
general, and can conform to no special rule. 
Specific Treatment.-It is true that for certain diseases certain reme- 
dies have come, perhaps unadvisedly, to stand too much in the light of specifics. 
Thus, in syphilis, the inercurials are depended on ; so that, having an ulcer 
of such origin to treat, a medicine ordinarily prescribed is as follows: 
li Syrupi ferri pyrophosphatis, 5vj; 
Hydrargyri chloridi corrosivi, gr. iv. M. 
Sig.-A teaspoonful three times a day. 
Or, 
Hydrargyri iodidi, gr. ij; 
Potassii iodidi, j 
Syrupi sarsaparillae composite, §viij. M. 
Sig.-A tablespoonful three times a day. 
Mercury.-Mercury is to be considered as an active force, striking at the 
condition of syphilis, destroying it; and while it is very well thus to kill such 
a condition, it is quite as well to remember that the harm of the agent em- 
ployed requires to be constantly met and antagonized. This is done by keeping 
up and supporting the system, so that it will commonly be found that syphilitic 
ulcers require, quite as much as a specific medication, wholesome food, fresh 
air, proper exercise, judicious bathing,-in short, the employment of every 
means that tends to the maintenance of general health. 
Mercurial Ulcer of Antrum.-In the mercurial ulcer of the antrum 
-which is far more common than the syphilitic-the general and local use 
of the chlorate of potassium is found to act very well. The medicine, dissolved 
in water, may be given in doses of ten grains, repeated four or five times a 
day ; the injection is not to be less in strength than a saturated solution. The 
mercurial character of an ulcer is discovered by association of a local lesion 
with an existing dyscrasia. 
Diagnosis of Scrofulous Ulcers.-Scrofulous ulcers are judged by 
the appearance of the sore, the nature of the discharge, and the existence of 
depression in the patient at large. A scrofulous subject, while not always 
bearing the clearest general evidences of the disease, usually has some one or 
more features that will allow of it being distinguished. Common features 
associated with scrofula may be enumerated as follows: the first manifestation 
occurs generally, not always, at the period of milk dentition, the symptoms 
being irregular appetite, an ill-smelling inspissated mucus, and swelling of the 
superficial glands of the neck. Continued manifestations advance with age, 
presenting subcutaneous lymph effusion, particularly about the calves of the 
legs and the outside of the thighs; various eruptions, inflammation and sup- 
puration of joints, especially those of the hip, knee, and thumb; a flaccid, 
enlarged condition of the tonsil glands, susceptibility to atmospheric changes, 
inability to endure physical fatigue, impoverishment of the blood, general THE NOSE AND ITS DISEASES. 
857 
asthenia. Scrofulous subjects are generally languid in their movements and 
without much impressibility ; not always this last, however, for it is well known 
that many precocious and bright persons end their effulgence in phthisis. In 
short, the history of scrofula may be viewed as the history of phthisis: it 
matters little as a principle is concerned whether tubercle deposits itself in 
the lung or in the ganglia, or whether there be or be not a deficiency in the 
developing force. 
Unhealthy Appearance of Scrofulous Ulcers.-Scrofulous ulcers 
are unhealthy in appearance, being covered with a dirty-yellowish aplastic 
matter, irregular about their edges, generally bluish or purple, more or less 
undermined, and discharging an ichorous, flaky pus. Local stimulation meets 
with little or no response, and, for the reason of the general deficiency in 
vitality, the parts around are usually indurated from interstitial deposits, 
chronically congested, and looking altogether indolent and ill-conditioned. 
Treatment of Scrofulous Ulcers.-The treatment of scrofulous as 
well as of the commonly called tuberculous ulceration is (in our present knowl- 
edge of the disease) simply a treatment of building up. Unacquainted with 
any special materia peccans,* we direct our aim so to lift up the life-force that 
a sufficient inherent vitality may be developed to throw off or master the de- 
pressing influence. Exercise, tonic medicaments, cold bathing, salt and moun- 
tain air, rare or raw meats, generous liquors,-all are useful means to such an 
end. Iodide of potassium has long had a reputation in this condition, 
although, as the author inclines to think, unjustly. In his own practice he 
employs both it and barium cautiously. Iodide of iron, syrup of the phos- 
phates, cod-liver oil, and phosphoric acid are indicated. The individual experi- 
ence of the author is, that wrapping one's self in a wet sheet on getting out of 
bed, and securing vigorous reaction by a good hand-rubbing, and, after such 
operation, drinking a fresh-laid egg drowned in good brandy or whiskey, is better 
than any medicine proper yet prescribed. Something, however, is always done 
for the local expression of disease, if for no other reason, from force of habit. 
A practitioner may use with these ulcers any of the applications referred to a 
few pages back, and any one of them is about as good as another. 
Syphilitic Ozaena.-Syphilitic ozaena from ulceration of the antral 
mucous membrane must be, as has been remarked, an exceedingly infrequent 
affection. Not so, however, with ulceration from such cause in the nares; 
such a condition is quite common. When a practitioner has a case in which 
dirty, clotty scabs are constantly being received into the handkerchief, and 
much offensive sanies is discharged from the nose, he may feel well satisfied 
that he has a case of syphilitic ulceration, and particularly is he to rest satisfied 
in his diagnosis if evidence of the disease exist in other parts of the body. 
Syphilitic ulceration of the nose has frequently been confounded with a com- 
mencing polypus; but the conditions are so dissimilar that only a culpable 
* See authors views on tubercle. 858 
A SYSTEM OF ORAL SURGERY. 
carelessness could fail to distinguish them. In the first there are the fetid 
discharge, and the association with the anterior train of accidents ; a scab soon 
comes away, and a temporary cessation of the obstruction ensues. In the 
latter the obstruction is apt to be gradual and continuous; there are no fetid 
clots, and no anterior accidents of association : blowing the nose, in the one 
case, most likely relieves for the moment; in the second, it throws forward 
the polypus so that we can see and feel it. In this differentiation the hygro- 
matous changes are, however, to have consideration. 
Gumma.-Syphilitic ulcers within the nose, commencing commonly as 
gumma, attack equally any location, and possess the most unfortunate ten- 
dency to extend to neighboring parts, so that, if not successfully combated, in a 
very short time the bony framework is involved, thus producing the deformities 
so common. 
Sense of Congestion.-A patient with a syphilitic ulcer developing 
in his nose complains first of a feeling of congestion. Diagnosis is arrived at 
by observation of associations. A few weeks later he is troubled with a dis- 
charge ; this, at first, is very slightly, and perhaps not at all, offensive. Soon, 
however, odor is remarked, and the discharge, which continues to increase, 
frequently becomes so profuse that twenty or thirty pocket-handkerchiefs are 
necessary for daily use. Occasionally, and sometimes very frequently, dirty, 
gluey clots or scabs come away, and the ulcer, if seen, is noticed to present a 
reasonably healthy look,-something, for example, as a chancre would look 
when only half destroyed and casting off its slough. If uncombated and uncon- 
quered, the ulcer extends deeper and deeper, until the bone is reached, which, 
in its turn, succumbs, yielding caries, or, more likely, necrosis. Arrived at 
this stage, the condition is formidable; not at all infrequently, in defiance of 
every effort, more or less deformity results. 
Forced Expirations Diagnostic.-An ulcer situated in the anterior 
part of a naris is indicated by the forced expirations of the patient. Situ- 
ated well back, he relieves himself by strained inspirations ; occasionally, how- 
ever, in the very beginning, the mucous membrane becomes so thickened and 
engorged that the passage of air through the tube is almost shut off: in these 
cases excessive restlessness is found associated. 
Bones Primarily Diseased.-It is not by any means always the 
case that nasal osteitis is secondary to gumma; on the contrary, cases are fre- 
quent enough where the bone becomes primarily diseased and where the ulcer 
is simply an associated lesion. Syphilitic osteitis very frequently ends in ne- 
crosis, and more particularly is this likely to be the case where the turbinated 
bones are the ones affected. The vomer, however, is the bone most fre- 
quently necrosed in syphilis,-that is to say, is the most frequently 
attacked. This is brought about in three ways: first, from a primary ulcera- 
tion of its mucous covering ; secondly, by the deposition of submucous tuber- 
cles ; thirdly, by the direct affection of the bone. Next to the vomer the 
inferior turbinated sympathizes most in syphilitic affections. When osteitis THE NOSE AND ITS DISEASES. 
859 
attacks the vomer or any other bone, efforts are to be directed to the resolu- 
tion of the inflammation. To secure this end resort is had to such local 
means as seem indicated by the peculiar features of the case. The treatment 
would be that applicable to inflammation anywhere; it is to be influenced by 
the temperament of the patient and the stage of the disease. Locally we 
have at this time nothing to do with its specific character: we have simply to 
treat a perverted condition of the circulation of the part. Constitutionally, 
however, its origin is to attract closest scrutiny, and, in connection with the 
local remedies employed, anti-venereals are to be depended on as strong 
supports. 
Diagnosis of Inflammation of Nasal Boundaries.-Diagnosis 
of inflammation of the nasal boundaries is not difficult to make out. When 
the vomer is the bone attacked, the patient suffers from sharp spasms, referred 
to the root of the nose; he has headache, always increased by the recumbent 
position. If the inflammation exist in the anterior part of the cavity, pressure 
on the cartilage increases the pain. 
Expressions of Bones affected.-The nasal bones, when affected, 
exhibit an overlying congested skin, gumma; pressure on the bridge is re- 
sponded to by much pain ; the lachrymal secretions are affected, and not infre- 
quently, because of the congestion in the ductus ad nasum, run over the 
cheek. The turbinated bones, when they are the seat of the inflammation, 
yield a soreness to the lateral aspects of the canal, and respond quickly to 
pressure exerted thereon. 
Prognosis.-Whichever of these bones may be affected, the prognosis, 
as ozaena is concerned, is the same in signification. If the inflammation be 
not arrested, necrosis or caries, partial or complete, results. Soon a discharge 
makes its appearance, disgustingly foul if the case be one of necrosis, and 
more or less offensive, and mixed with osseous particles, if it be caries. 
Anti-Venereal Treatment.-Anti-venereal treatment is a process of 
strengthening. One cannot hope to arrest syphilis in any other way, when 
it has passed to its tertiary manifestations. Limit and circumscribe the local 
inflammation as much as possible. To do this stimulants act a better part than 
depressants. An excellent local medicament is a combination of iron, iodine, 
quinine, and glycerin: 
U Tincturae ferri chloridi, 3j > 
Quiniae sulphatis, gr. xxv; 
Tincturae iodinii, 
Glycerini, aa ; 
Aquae, ^iv. M. 
Sig.-Inject, or brush over and about the parts, three times a day. 
Iron and Quinia.-Give iron and quinia internally. It is scarcely 
probable that a patient having syphilitic necrosis needs a mercurial course; 
indeed, it is much more likely that he has already been so over-drugged with 
this medicine that his trouble is mercurio-syphilitic, rather than syphilitic 860 
A SYSTEM OF ORAL SU ROE RY. 
alone. Any use of the agent in such a case is almost certain to prove an 
abuse of it. Chlorate of potassium is to be recommended and freely pre- 
scribed in these tertiary conditions; it may be given in doses of from ten to 
twenty grains dissolved in water. Good rare roast beef, poultry, a daily glass 
of malt liquor, boat-rowing, wrestling, horseback-riding, systematic bathing,- 
these are reliable means, and may elevate the vital forces to an ability, per 
vias naturales, to throw off the disease. It is confessedly hard to cure 
syphilis when it has fully taken hold of a system ; when it inflames a bone, 
particularly a small one, the patient is fortunate if he escape without the com- 
plete destruction of the part. 
Necrosis.-Necrosis, partial or complete, entails, of course, the existence 
of a sequestrum ; and the getting away of this dead part implies very generally 
the cure of the ozaena. Particularly is this the case when the death is limited 
to a single bone, or piece. To get away this piece is, then, one of the most 
important features in treatment. How is it to be done ? Simply wait until 
the probe reveals that it is loose; if it cannot be taken away through the 
orifice of the sinus it has itself created, it is only necessary to enlarge in any 
convenient manner such sinus, and then lift it out. If, after the removal of 
such dead bone, the discharge be found to continue, yet modified as to char- 
acter and odor, necessity exists for stimulation. Iodine, or iodine and 
iron, or the combination with tannin and glycerin, is employed, as seems 
indicated. It may be, however, that neither the discharge nor the odor de- 
creases ; in such cases the practitioner is seldom wrong in inferring that more 
dead or dying bone is in the nose; the treatment first employed is to be re- 
newed. When tertiary syphilis has associated with it severe nocturnal pains, 
great relief is frequently secured from the administration of the iodide of 
potassium, particularly if combined with minute doses of phosphorus,-say 
five drops of the diluted phosphoric acid ; it is to be remembered, how- 
ever, that because of the relationship of the potash with the mucous mem- 
brane, it is the case that in many persons even very small doses will excite 
much irritability in the air-passages, thus seeming to increase instead of allay- 
ing the trouble. With such patients we must diminish the dose of the iodide 
pro re nata. 
To Procure Rest.-Bromide of potassium is now frequently employed 
to procure rest and tranquillity. It is commonly prescribed in doses of ten 
grains; but forty or fifty will be found the better dose. It is best given in a 
little water just as the patient is about to get into bed. 
LODGEMENT AND RETENTION OF FOREIGN BODIES. 
In the use of cotton or sponge about the nares, care is to be taken that 
the pellets do not escape attention and become lodged in the passages. Some 
of the most offensive and resisting discharges occasionally have their cause in 
this direction. Rhinolites-calculi varying in size from that of a pea to 
that of a pigeon's egg-sometimes form in the canals and, by inducing ulcera- THE NOSE AND ITS DISEASES. 
861 
tion and collecting detritus, come to be a source of ozaena. Peas, rags, but- 
tons, and sundry other articles are not infrequently found in the nares, thrust 
there by children of experimental proclivities: any of which may, of course, 
become a source of offence. 
Removal of Foreign Bodies.-The removal of foreign bodies from 
the nares is always to be effected as speedily and with as little injury to the 
parts as possible. A plan that may first be tried is to place the patient in a 
strong light and search the parts with very delicate forceps: if the body can 
be seen, it may thus generally be removed. Another plan consists in giving 
Fig. 684.-Scoop for removing Foreign Bodies from the Nose. 
a pinch of snuff and compressing the unobstructed nostril; the effort of 
sneezing will not infrequently throw the body a considerable distance. Still 
another plan is to compress the unobstructed nostril and blow into the mouth. 
An annealed wire, bent into the form of a loop and passed over the lodgement, 
is very frequently employed with satisfactory success ; a flexible, blunt, double 
hook is also used with advantage. A syringe is sometimes found beneficial, 
the obstruction being washed back into the throat. 
Douche Bath.-The convenience of the douche bath in ozaena is ac- 
knowledged. Thudichum's apparatus* highly commends itself in such direc- 
tion. Another means of great service is the rubber bulb atomizer : this 
is used by the patient without effort or trouble of any kind, and carries the 
spray to every part of the nostril. This latter instrument may be charged 
with a solution of permanganate of potassium, with chlorine-water, or with 
other disinfectant, and may be kept about the person, ready for use at any re- 
quired moment. In cases which emit much fetor, employment of this means 
will avoid many seasons of mortification. 
Syphilitic Coryza in Infants.-Syphilitic coryza in infants, charac- 
terized by snuffling and by difficulty in holding the breast, is not infrequently 
associated with offensive discharge. Here the excessive delicacy of the affected 
membrane is not to be overlooked. While it is a necessity to keep the parts 
well cleansed, it is not permissible to employ any but the gentlest of medica- 
ments. Borax-water associated with a little glycerin is a nice preparation, 
* Washing out the Nose.-Some years ago it was discovered by Professor Weber, of 
Halle, that when one side of the nasal cavity is entirely filled through one nostril with fluid 
by hydrostatic pressure, while the patient is breathing through the mouth, the soft palate 
completely closes the choanae, and does not permit any fluid to pass into the pharynx, while 
the fluid easily passes into the other cavity, mostly round and over the posterior edge of the 
septum narium, and escapes from the other open nostril, after having touched every part of 
the first half of the cavity of the nose, and a great part-certainly the lower and median 
canals-of the second half.-Thudichum: Polypus in the Nose, and Ozsena. 862 
A SYSTEM OF ORAL SURGERY. 
or a weak solution of the phenate of soda may be used satisfactorily. Fissures 
of the membrane are to be touched with dilute chloride of zinc, or with iodine 
ointment made very weak. 
Anterior Rhinoscopy.-The employment of the rhinoscope in rhinor- 
rhoea or ozama is to be commended as of great value in making a diagnosis. 
Anterior rhinoscopy is performed most simply by using two delicate ivory 
spatulas and placing the patient in the full sunlight. Or, placing his back to 
a bright gas-flame, a stream of rays is thrown up the nostril by means of a 
reflector. A mode of anterior illumination frequently employed by the author 
consists in extending the ala, and passing the light through a silvered speculum. 
Metz's Nasal Reflector.-The nasal reflector of Metz differs from 
the ivory blades in being made of highly-polished metal. A speculum known 
as Duplay's anterior is the analogue of the common bivalve vaginal instrument, 
the valves being separated by means 
of a screw. No instrument is so 
commonly used for making nose ex- 
aminations as the common bivalve 
ear speculum. 
Frankel's Speculum. - An- 
other instrument, known as Fran- 
kel's, working admirably in exposure 
of the anterior nares, is shown in 
Fig. 685 ; application of this specu- 
lum is explained by the cut. 
Fig. 686.-Tobold's Illuminating 
Apparatus. 
Fig. 685.-Frankel's Nasal 
Speculum. 
Use of Sunlight.-Certainly, in anterior rhinoscopy, it is not to be 
doubted that sunlight surpasses all other sources of illumination. In cloudy 
weather, besides the means explained in connection with posterior rhinoscopy, 
-which see,-use is to be made of artificial light. 
Tobold's Apparatus.-As a means of artificial illumination Tobold's 
apparatus carries in itself much recommendation. Fig. 686 exhibits the THE NOSE AND ITS DISEASES. 
863 
instrument, affording at the same time idea of its use. Besides this device 
many of various forms and attributes have been invented by specialists, and 
are to be met with at the stores of instrument-makers. 
Fig. 687.-Posterior Rhinoscopy by Artificial Light. 
Other Specula.-Other specula to be named in this connection are 
Dicken's electric illuminator, Trouve's polyscope, Margetson's lamp, and 
devices by Mr. Stern and by Dr. Starr, of the S. S. White Company. 
Fig. 688.-Rhinoscopic Examination of Naso-Pharynx 
Manner of making a Posterior Rhinoscopy.-Fig. 687 shows the 
manner of making a posterior rhinoscopy by means of what is known as the 
Johnson method. The diagram carries its own explanation. 864 
A SYSTEM OF ORAL SURGERY. 
By neoplasm is meant a new formation. By a new formation is commonly 
implied cancer. To put this in other words, any growth of the nose 
not having identification in a history is to be looked on with 
doubt as relation is had with benignancy. Treatment of neoplasms of the 
nose is not apt to yield satisfactory results. (See Fibrous Polypi.) 
8. NEOPLASMS. 
9. HYPERTROPHY OF NASAL MUCOUS MEMBRANE. 
A nasal condition allied with persons of the scrofulous diathesis, being most 
commonly met with in children, shows a tumorous projection of reddish 
appearance projecting from one or both nares. This protuberance is liable to 
be mistaken for polypus, from which it differs in being a hypertrophy of the 
mucous membrane. To distinguish the one growth from the other requires 
the use of a probe. This means enables the practitioner to see and feel the 
seat and character of origin as these relate with the inferior turbinated bone. 
Treatment pertains to the employment of both local and constitutional 
means. The writer finds good service rendered by a saturated solution of 
sulphate of copper, the part being lightly brushed every other day. Dry 
cups upon the face near to the nose may be used. Occasional scarification 
of the part, where the growth is of spongy nature, and the application of 
iodine ointment is good practice. The systemic functions are to be care- 
fully regulated. Leeches are to be used where activity of action prevails. 
(See Scrofulous Conditions.') 
10. DEVIATIONS OF SEPTUM. 
Deviation of septum to one side or the other is a source of great discomfort. 
If a patient be young a means of correction frequently found beneficial con- 
sists in the continuous use of a pledget, saturated with glycerin, introduced 
and retained in place between the central and alar cartilages, or straightening 
forceps may be used. Where, however, a sufferer has reached adult years 
the knife is likely to prove the only remedy; the projecting part being shaved 
away. (See Fracture, page 867.) 
Bougies.-Bougies used for correcting nasal stenosis are easily and quickly 
made of common wax or of the vulcanite base plate used in dentistry. To 
make either requires simply the softening, by dry or moist heat, of the material 
and the moulding of flattened cylinders. These cylinders are to correspond, 
of course, with the cavity to be occupied and maintained. A cylinder is 
always to be well oiled before being passed into place. Where one sticks, on 
attempt at removal, oil is to be thrown about it by means of a syringe. Oper- 
ation for imperforate nostril consists commonly of little or of nothing 
more than cutting through the closed part. Thorough appreciation of the 
nature of a closure is to precede operation upon it. THE NOSE AND ITS DISEASES. 
865 
11. GONORRHOEA. 
Gonorrhoea of nares is an occasional condition met with as the result of a 
lack of care on the part of persons afflicted after the ordinary manner with 
this disease; the virus having been carried to the parts by unwashed fingers. 
Treatment is that used for the penis,-namely, emollient applications in the 
primary, or acute, stage; specific and stimulating remedies in the secondary, or 
suppurative, stage. A combination used by the author with much satisfaction 
as a curative of the disease considered is as follows: 
R Zinci chloridi, gr. iv; 
Chloral hydratis, gr. vi; 
Aquae destillatae, ^iv. M. 
Sig.-To be injected into penis or nostril three times a day. 
As an application in the first stages of nasal gonorrhoea sulphate of 
zinc in the proportion of three grains to the ounce of water may be used. 
Common tea as prepared for the table is a good wash. When much inflam- 
mation is present lead-water and laudanum are to be employed: 
B Plumbi acetatis, 3j; 
Tiucturaa opii, ; 
Aquae, Oj. M. 
Subnitrate of bismuth is a favorite injection and commonly affords 
much satisfaction in its use : 
U Bismuthi subnitratis, ^ss; 
Aquae, ^viij. M. 
Sig.-Shake before using. 
12. CHANCRE. 
Chancre of the nose, resulting in like manner with gonorrhoea from impure 
contact, is most satisfactorily treated by the use of London paste, which see. 
The specific character of the sore destroyed, it is healed through applications 
of emollients; an ointment of the oxide of zinc is a good application. Boro- 
glyceride, diluted with three measures of water and applied by means of a 
camel's-hair brush, is found of healing import. Should doubt exist as to the 
complete destruction of the specificness, lint saturated with phenol-sodique is 
to be kept in contact with the part until healed, or, should this be found not 
to agree with it, iodine ointment, mixed in proportion of four parts to one of 
oleate of cocaine, and one of cosmoline, is to be tried. Black or yellow wash 
is a common application. Indolency of action finds stimulation in employ- 
ment of the tinctura capsici et myrrhae compositae diluted to meet indications. 866 
A SYSTEM OF ORAL SU ROE RY. 
13. IMPERFORATE NARES. 
This, while an extremely rare condition, is yet sometimes met with as a con- 
genital defect. Treatment is by operation, the directions for the performance 
being peculiar to each case. Experience and judgment are required that more 
harm than good shall not result. Where incision alone is employed, bougies 
play an important part in the cure. (See Bougies.') 
Balls and other foreign inanimate substances may lodge in the frontal sinus, 
resulting in abscess which discharges through the nose. Of animated objects, 
many illustrations are to be found recorded where persons have disgorged cater- 
pillars and other worms after having experienced discomfort in the region of 
the sinus, pointing to it as a seat of habitation by the parasites. M. Saint- 
Pierre instances six cases of deposits of fly-larvae : in one of these more than 
three hundred were washed out by means of injections, the patient dying 
eighteen days later from invasion by the worms of neighboring parts. Dr. 
Raoure, of Nismes, records the case of a woman attacked with fever and 
violent headache, which, in spite of remedies, made continual progress. About 
the fourth or fifth day she began sneezing, and expelled some small white 
worms. The headache diminished as the parasites came away. Seventy-two 
were expelled in the course of a few hours, and the patient found herself well.* 
Fly-Larvae.-During the war of the American rebellion the author, who 
for some time was on surgical duty at the Fortress Monroe hospital, in a hot 
summer, had wide opportunity for witnessing the destructive inroads of the 
fly-larvae: these were literally everywhere; the stump of an amputation 
guarded to the extreme of caution and of prophylactic and antiseptic care 
would sometimes be found filled with maggots at the stage of a first dressing; 
petroleum and chloroform proved the best remedies. Insufflation of snuff is 
recommended as a parasiticide where maggots are located in the nose or sinus. 
Justification exists for trephining the frontal sinus. 
Diagnosing Nasal Parasites.-A means of diagnosing nasal parasites 
consists in the free employment of the syringe, salt water being used; detec- 
tion of a worm is proof of presence. General signs refer to uneasiness in the 
region, pain more or less constant, sometimes localized, sometimes darting about 
in various directions; spells of fainting, an aura starting from the region of 
the frontal sinus; vertigo, mania. 
14. FOREIGN BODIES IN ASSOCIATE SINUSES. 
EXTERNAL NOSE. 
Surgical conditions of the external nose relate with tumors, epithelio- 
matous ulcers, injuries, and loss of substance. 
Tumors.-Tumors are infrequent; they are embraced by the sebaceous, 
cartilaginous, and neoplastic. The first are readily treated through an incision 
* Diseases of the Nose, Watson. THE NOSE AND ITS DISEASES. 
867 
which permits of enucleation; the second, through extirpation ; the third, if 
it be deemed advisable in any particular case to touch them, are to be thor- 
oughly and widely removed by the knife, and are to be replaced by flaps moved 
from places distant as possible. Skin-grafts taken from other persons apply. 
(See Rhino-Scleroma, also Acne Rosacea.) 
Ulcerations.-The writer desires to be impressive in the suggestion that 
ulcers appearing upon the external nose without explainable cause, proving at 
the same time resistive to simple means of cure and showing giant granu- 
lations, are to be looked upon as epithelial cancer, and considered accordingly. 
(See Lupus of Face.) 
Caustic Applications.-Treatment of epithelial nasal sores by caustics 
implies commonly the death of the patient. Removal of the sore and sur- 
rounding parts by use of the knife, and replacement by healthy tissue trans- 
ferred from neighboring, or, preferably, from distant, parts as suggested in a para- 
graph above, insures a cure. This means of remedy the writer claims as a 
discovery made twenty years back from the date of this writing, he having 
lost no case of epithelial cancer in the interim where such operation could be 
perfectly practised. (See Epithelioma.) 
Fracture.-Fracture of the nasal osseous arch is a not uncommon accident. 
Diagnosis lies in history of injury, in crepitation, and in character of deformity. 
A broken nose expresses one of two conditions : depression arising 
out of a bending of the anterior or cartilaginous portion, otherwise irregularity 
in position, and crepitation of the nasal bones. 
Fig. 689. 
Adams's forceps for straightening nasal septum. 
Treatment refers alike to the combating of an inflammation sure to 
associate with the accident, and to the setting and retaining in place of the 
distorted parts. 
Displacement of Septum.-Where displacement is in the septum 
nasi, broad and flat-faced forceps apply to the restoration of symmetry; glycerin- 
saturated pellets being applied to preserve the posi- 
tion. An instrument used in English surgery consists 
of two smooth-faced triangular blades hinged at the 
middle, somewhat like a pair of scissors, these plates 
corresponding with the arch of the nose when con- 
sidered from the inside. The thrusting of these blades 
into the nostrils restores symmetry; the blades are made to lie flat against the 
broken or twisted septum on either side, and to grasp it between them, thus 
Fig. 690. 
Adams's screw plates for 
holding septum straight. 868 
A SYSTEM OF ORAL SURGERY. 
holding and being held. Change of the blades is secured through means of 
a screw working external to the joint. (See Figs. 689 and 690.) 
Displacement of Nasal Bone.-Displacement of the nasal bone 
is much the most comfortably combated by external means, internal appliances 
being endurable by the very phlegmatic only. A practice employed by the 
writer consists in the use of a splint of gutta-percha, moulded over the part after 
setting the fracture. To make such a splint it is alone necessary to warm the 
material until a consistency of dough is secured; it is then moulded over the 
region without effort on the part of the surgeon or pain on that of the patient: 
suffered to remain two or three minutes, it is found sufficiently hard to be 
removed without change of form, when, to complete the hardening process, it 
is dropped into cold water. Retention of the fixture is secured by placing 
over it a strip of adhesive plaster. Soft cotton wool or other pad is to 
underlie the splint. Campho-phenique rubbed gently over the part two or 
three times a day relieves of pain and soreness. 
Mechanical Support.-Gutta-percha not being at hand, an admirable 
substitute is found in a piece of common pasteboard softened in hot water. 
Complications.-Complication in nasal fractures is the rule rather than 
the exception. The relation of the arch to the ethmoid bone not infrequently 
results in fatal injury to the brain by the driving upward of the crista galli. 
The nasal bones are sometimes torn from their place, being so comminuted as 
to render replacement impracticable, if not impossible. Wounds of the soft 
parts are at times extensive and formidable, requiring much placing and 
stitching. Separation of the nasal cartilages is not an uncommon event. 
Principle of Cure.-The principle of cure in all complications consists 
in putting displaced parts into position, and combating vascular perversions. 
LOSS OF SUBSTANCE. 
Rhinoplasty.-Defects of the nose, requiring relief through plastic 
operations, vary markedly in character: thus, the parts may be completely 
lost, or only one ala may be absent; a break in the continuity exist, as shown 
in Fig. 691, or with the loss of one side may be conjoined a misshaped and 
sunken condition of the opposite, as seen in Fig. 693; nose and lip may both 
be wanting, as exhibited in Fig. 576; or, as is often seen, V-shaped breaks 
may exist in the continuity of the free surface of one or other of the alae. 
Methods in Rhinoplasty.-Four general features associate with the 
operations of rhinoplasty,-namely, the Italian, the German, the Indian, and 
the English method. 
Tagliacozzi's Method.-The Italian method is that known as the opera- 
tion of Tagliacozzi. This is practised by marking upon the inner and middle 
portion of the integuments of the arm two longitudinal lines four inches at 
least in length by three and a half in breadth ; the flap thus outlined is raised, 
and, while allowed to remain attached at either end, is separated its length Plate IV 
IHman, & Saits THE NOSE AND ITS DISEASES. 
869 
from the underlying parts by well-oiled linen or sheet-lead passed beneath it. 
Allowed thus relation until it become thickened and indurated,-a period of 
some two weeks,-the one end is detached, and the oblong flap, being pared 
into shape, is stitched to the face, which has been prepared for its reception. 
Von Graefe's Method.-The German method, being a modification of 
the preceding, made by Professor Von Graefe, of Berlin, consists in the per- 
formance of the whole operation at a single sitting. This plan, while advanta- 
geous as regards the comfort of the patient, yet fails to secure that thickness 
of substance in the flap which was the object with Tagliacozzi in subjecting 
it to such long-continued irritation; also the shrinkage has to occur in the 
part, as a nose, rather than as integument. 
Indian Method.-The Indian manner, the one most generally practised, 
consists in taking the flap for the bridge and alae from the forehead, and the 
columna from the lip. 
English Method.-The English operation, devised and first practised 
by Professor Syme, of Edinburgh, consists in taking flaps from the cheek, as 
is shown for one ala, in Fig. 693. In this operation the columna is also to be 
obtained from the lip. 
Fig. 5, Plate IV., exhibits the flap, as made after the manner of Taglia- 
cozzi ; also the manner of attachment to the face, together with the means 
practised by that surgeon to fix the forearm over the head. 
Fig. 4 of the plate shows the Indian operation ; the general V-shape of the 
flap, conjoined with the strip for the columna, is recognized in the ulcer on 
the forehead; the flap, rotated on its pedicle, is seen to be raised in its new 
position into the shape of the nose by bougies introduced into the nostril- 
spaces. 
Studies.-Fig. 691 exhibits a case in which the alae and cartilaginous 
septum of the nose have been lost. In this case the defect is proposed to be 
remedied by material taken from the forehead, after the Indian method. First, 
the size and shape of the new wings are dotted out with ink, as shown. To so 
map out the organ it becomes necessary, first, to have a complete idea of what 
is needed; this is obtained by using a thin sheet of gutta-percha, which, on 
being warmed, may be moulded as desired. Obtaining thus a measure, the 
material is spread out upon the forehead, as shown in the cut. It now remains 
to freshen the circumference of the parts to be restored, and, dissecting the 
flap from the forehead, plenty being allowed for shrinkage, twist it upon the 
pedicle, which of course is allowed to remain, and by means of ligatures fix it 
in the new position.* 
The separation of the pedicle is to be practised only after full relationship 
of circulation is established in the newly-related parts,-a period varying from 
ten days to as many weeks. 
* A manner of relating the parts, devised by the elder Paneoast, is known as the tongue- 
and-groove suture: this consists in associating two surfaces by means of convex and con- 
cave faces. 870 
A SYSTEM OF ORAL SURGERY. 
Convex position of a new nose and maintenance of the orifice are to be 
secured by tubes of silver, worn for several months. Fig. 692 shows a 
frequent result of such a rhinoplastic operation. 
Fig. 691. 
Fig. 692 
Fig. 693, being a case from the practice of Professor D. Hayes Agnew, in 
which the author had the pleasure to assist that gentleman, exhibits the loss 
of fully one-half the nose. In this instance it is perceived that, besides the 
absence of the ala, the remaining nostril, as the result of a cicatricial depres- 
sion at the bridge, has been made to look unduly outward, the organ being 
converted into a very decided pug. Two indications are here seen to exist: 
first, the body of the nose is to be let down ; secondly, a new ala is to be made. 
Turning now to the lines of incisions, it is perceived how these indications 
were attempted to be met. Across the bridge is seen the first cut made; this 
incision, with a little dissecting, allowed the part to drop as required ; secondly, 
commencing upon the nasal prominence, as remarked in the diagram, an in- 
cision was brought down, and, after extending a very short distance, was made 
to assume a triangular form, thus affording a pyramidal slip to occupy the 
space necessarily resulting from the dropping of the nose; thirdly, continuing 
the line of incision, the cut was carried into the substance of the cheek, as 
shown in the drawing, the form of flap created being in accordance with the 
wants of the part to be restored; fourthly, the edge of the nose was fresh- 
ened, and the triangular flap seen below was dissected to its base. All being 
thus made ready, the alar flap was brought into place and attached, while the 
inferior one was forced outward to help fill up the space left vacant by the 
removal of the irregular apex of the alar flap. 
Fig. 694 shows an alar loss replaced by section cut from upper lip. The 
performance, as shown in the cut, is self-explanatory. 
Fig. 695 exhibits an operation similar to that shown in Fig. 691, the new THE NOSE AND ITS DISEASES. 
871 
nose being here seen stitched in place, and the wound on the forehead ap- 
proximated. 
Fig. 693. 
Fig. 694. 
Fig. 695. 
Fig. 696, exhibits a facial loss of substance, together with a proposed mode 
of correction. 
Fig. 697 exhibits the flap, as made in Fig. 696, in place, with the wound 
of the forehead approximated, the various pins and stitches required being 
shown. 
Fig. 696. 
Fig. 697. 
Fig. 698 shows an operation practised on the nose of a fellow-practitioner 
by the writer. In this case an epithelial degeneration had resisted a number 
of ordinary scraping and cutting operations, but succumbed absolutely to one 
done as shown. The flap is from the cheek. 
Fig. 699 shows flaps cut from cheeks. Fig. 700 shows these flaps carried 
and stitched into place. 
Fig. 701 exhibits an operation practised for loss of substance upon dorsum 
of nose. Care is to be taken to secure a full blood-supply for the flaps. 872 
A SYSTEM OF ORAL SURGERY. 
PLATE V. 
RHINOPLASTIC AND CHEILOPLASTIC OPERATIONS. 
Fig. 1.-Appearance of John Glover prior to the operations of cheiloplasty and rhinoplasty. 
Fig. 2.-View of his face with the chin depressed. The mouth, being contracted into a rigid 
orifice, was enlarged laterally by the stomato-plastic operation of Dieffenbach for 
atresia oris, after which two flaps were made, as marked in the lines upon the 
cheeks, so as to form the upper lip. 
Fig. 3.-Appearance of his face after this operation, showing the position of the sutures 
and the improvement in the mouth. 
Fig. 4.-Shows the steps of the rhinoplastic operation performed upon him subsequently. 
The edges of the nasal cavity being freshened by a grooved incision, the outline 
of the new nose was marked on the forehead before cutting the flap. The dots 
indicate the position of the sutures. 
Fig. 5.-The wound in the forehead being closed by the harelip sutures, the flap was re- 
verted, and attached in the groove on the edge of the nasal cavity by three 
stitches of the interrupted suture, which were tied over little rolls of adhesive 
plaster, after Graefe's method. The edge of the septum is also attached to the 
upper lip. The twist in the pedicle is seen in the root of the nose. 
Fig. 6.-An accurate likeness of John Glover, sixteen months after the operation. 
Fig. 699. 
Fig. 698. 
Fig. 700. 
Fig. 701. Plate V 
ILbnan . THE NOSE AND ITS DISEASES. 
873 
Plate V. is one representing a combined performance in rhino-cheiloplasty, 
with the original appearance of the patient, the steps of an operation devised 
and executed by the elder Professor Pancoast, and the result obtained as ex- 
hibited by an accurate likeness of the patient taken sixteen months after the 
cure. 
History of the Case.-The recital of this example, having the advan- 
tage of illustration, will serve as a type and study of similar cases. A man 
aged fifty-three had lost all the soft part of the nose and the whole of his 
upper lip, from the commissures of the mouth to the canine fossa of each 
side, as well as the septum narium and the turbinated bones; the cavities of 
the antra Highmoriana and of the sphenoidal sinuses being exposed. His 
appearance with his mouth closed is shown in Fig. 1 of the plate. The 
mouth, when opened, presented a rigid circular orifice three-fourths of an inch 
in diameter. 
Operation.-The mouth being widened after Dieffenbach's method (see 
description on a preceding page), the free surface of the gum was freshened, 
and an incision made obliquely upward and outward for a quarter of an inch 
from the point where the gum was covered by integuments, and from the end 
of this another cut was made for about the same distance, nearly parallel with 
the incisions for widening the mouth, but inclined a little downward. The 
cheeks being now loosened from the gum and malar bone by incisions on the 
side of the mouth, the flap of skin and subcutaneous fatty matter were raised 
from the surface of the muscle by beginning the dissection at the angle next 
the nose, Plate V., Fig. 2. 
The arterial branches, divided in cutting, having been twisted, the flaps 
were drawn downward and forward over the raw surface of the gum, and 
fastened together with the harelip suture, Plate V., Fig. 3, the inner edge 
of the rotated flaps being thus united in the middle line of the lip. The face 
was dressed with lint wet with lead-water and laudanum. The patient 
recovered in about two months. The nose was subsequently formed as fol- 
lows : 
The hair being shaved from the temple and forehead, the nasal orifices 
closed with lint to prevent the entrance of blood, and the patient lying down 
with the head supported by a pillow, a flap was raised from the forehead, as 
shown in Plate V., Fig. 4, the skin being divided at a single sweep of the 
knife, the blade of which was inclined outward so as to cut a bevelled edge. 
The apex of the flap, which was about five-eighths of an inch wide, rested 
between the eyebrows, and the tongue-like portion which was to form the 
columna nasi extended up into the scalp. The base of the flap was nearly 
three inches wide, in order to allow for its subsequent contraction. The flap, 
after being dissected up, was then turned down on the left side and wrapped 
in linen, while the wound in the forehead was closed by four interrupted 
sutures, after which the flap was applied to the freshened edges of the new 
lip and gums, the whole being held in position by the plastic suture before 874 
A SYSTEM OF ORAL SURGERY. 
described, and tied over rolls of adhesive plaster, as in Graefe's method, 
Plate V., Fig. 5. Union having occurred, the pedicle of the flap was divided, 
five weeks subsequently, by passing a director under it, after which it was 
smoothly fitted down to the roots of the ossa nasi, in a cavity which was 
made for its reception by excising a portion of the subjacent 
integuments. By the twelfth day union was perfect, and 
the patient left the hospital so much improved that, sixteen 
months subsequently, his likeness was taken, as represented 
on Plate V., Fig. 6.-H. H. Smith. 
An Easily-Corrected Case.-Fig. 702 exhibits a 
case which was of much interest to the author, inasmuch as 
the defect deformed the face of a fine-looking person, and 
had twice been attempted to be cured by a plastic section 
from the cheek ; the flap in both instances having sloughed. 
Examining the diagram, an irregular V-shaped break is seen 
to exist in the right ala; this had been produced by the im- 
proper application of caustics for the cure of a supposed 
cancer. The character of operation seen in the diagram 
yielded a most satisfactory result; this consisting in the 
employment of a double V-incision, conjoined with a second 
loosening of the ala at its external inferior angle from the cheeks; these cuts 
made, the ala was slipped toward the mesial line and fixed in its new position 
by a pin. Passing now to the comparatively lax nostril, a delicate harelip pin 
was passed through the apices of the two lesser triangles, and by means of the 
figure-of-eight ligature these apices were brought into contact, thus necessarily 
securing a proper curvature to the free border of the nostril. 
Falling of the Top of the Nose.-Loss of the cartilaginous portion 
of the septum narium, a not infrequent sequel of syphilis, results in a sinking 
of the nasal tip, a matter productive of great deformity. A case of this kind 
treated at the Oral Hospital by simply cutting loose the attachments and afford- 
ing a required support by means of a properly-adapted silver tube gave a fairly 
satisfactory result. 
Referring to Plate IV., Fig. i, is seen the front view of a patient 
operated on by Dr. Watson, in the New York City Hospital, for the relief of 
a large ulcer, accompanied with syphilitic caries of the frontal bone; the ulcer 
is represented with thickened and inverted edges, and as retaining a portion 
of the diseased bone. A fistulous orifice is also described as existing at the 
upper border of each orbit, with another in the left temple, through which 
pus escaped freely. The superior eyebrows and eyelids are shown as slightly 
elevated and deformed by the adventitious adhesions existing around the fistulae. 
Fig. 2 represents the lines of incision practised for obtaining the 
flap-tissue to cover this ulcer, together with the approximation secured, and 
the appearance of sutures in place. 
Fig. 3 exhibits the benefit resulting from the operation. 
Fig. 702. THE NOSE AND ITS DISEASES. 
875 
Another manner of treating a facial ulcer, or indeed any ulcer, consists in 
the transplantation of particles of skin, as referred to on a previous page. 
These islands serve as points of cicatrization, and not infrequently succeed 
most happily in covering an ulcer, and in limiting to marked extent the 
boundaries of a cicatrix.* 
Loss of Tip of Nose.-An accident occasionally met 
with by persons who indulge in street-brawls consists in the 
loss of the tip of the nose by the teeth of an antagonist. 
Fig. 703 affords idea of the appearance of the part after 
such injury. 
To treat a case of the kind implies, first, con- 
sideration of the state of the lesion. The incisor teeth of 
people differ very markedly, being in some of such knife-like 
edge that a bite made by them would really represent the 
ordinary incised wound, and might be expected to heal with 
little or no slough; on the other hand, there are teeth, known 
ordinarily as double, where the surface is so broad and jagged that sloughing 
to a greater or less extent would necessarily associate with an injury done by 
them. 
Replacing a Part.-In the case of a portion of nose bitten off, it is good 
practice, if the piece be quickly found and is not too much injured, to stitch 
Fig. 703. 
* Study of Transplantation.-The study of the subject of transplantation of tissue has 
recently received fresh impetus from the experiments which have been made in the direction 
of attempts to compel independent islands of skin to unite with and live upon an ulcerated 
surface without the support of a pedicle. The nutrition of such a piece of transplanted skin, 
and, in fact, the immediate union of any transplanted flap, necessitates the rapid passage of 
vessels across the intervening space and the production of but little intermediate tissue. 
The formation of new blood-vessels in tissue is a subject so wonderful that it is well 
worthy of careful study. At some point on an existing vessel the wall dilates; a pouch is 
formed; it deepens, and a blind canal results. At the same time, at a point not far distant 
from the first, a similar action is going on,-one diverticulum projects backward, the other 
forward, each taking its course in the direction of the new tissue to be nourished or formed; 
they extend, meet; the intervening walls which closed their ends are removed, and a con- 
tinuous arch is formed, through which the blood freely courses. Thus at every place these 
little offshoots or arms, microscopic in size, unite with similar ones from the same or adjoin- 
ing vessels, until multitudes of small arches and natural anastomoses are formed, and nutri- 
tion is accomplished, every step being taken with precision, regularity, and dispatch. Thus 
marvellous are the actions constantly taking place in our bodies to subserve the process of 
repair; and although man's capacity for the reproduction of lost tissue is infinitely less than 
that of lower beings, yet all of us must frequently be astonished at the extent of reparative 
power exhibited by him. As we descend the scale to creatures incapable of self-defence, self- 
preservation, the provision for the sustenance of existence becomes more marked, until, in 
protozoa, self-mutilation is but a common occurrence in case of danger, repair being so active 
that a short time suffices to replace any member which may thus have been cut off. Man, 
endowed with powers of reasoning and defence, requires such provisions to a correspond- 
ingly less degree, and in him we find that repair exists in its least expression. Still, with 
our advancing knowledge, we may hope to assist nature even in this process, as exampled, 
for instance, in the reproduction of bone from preserved periosteum.-From Clinical Lecture 
by the author in the Hospital of Oral Surgery. 876 
A SYSTEM OF ORAL SURGERY. 
and bind it in position. Nothing can be lost by doing this, and a happy re- 
pair may possibly be secured. Should such result not ensue, the loss is to be 
replaced by modifications of some of the various operations suggested. Or, 
most conveniently, it is to be done from a flap secured from the lip as shown 
in the diagram; this flap, shaped to fit the part, is twisted on its pedicle, and 
attached after the usual manner. The gap left is simply an expression of 
harelip, and is to be so treated. (See Operations for Harelip.') 
From the studies and illustrations offered, it is to be taken for granted that 
the ingenuity of a practitioner, directed by the hints afforded, will enable him 
to meet such varying indications as may from time to time be encountered. 
The subject is very interesting, and will repay attention given it. 
Fig. 704. 
Fig. 705. 
Use of nasal douche. (See foot-note, page 861.) 
Naso-pharyngeal syringe 
with spray-nozzle; also 
nozzle for anterior nares. CHAPTER LI. 
DISEASES OF THE FACE. 
The most common diseases of the face arrange themselves under a derma- 
tological signification. A division is into affections of the epiderm, of the 
corium, of the epiderm et corium, of the sebaceous glands, of the sweat- 
glands, of the connective tissue, and of the blood-vessels. A subdivision is 
into immediate and mediate diseases. 
Immediate Disease.-By immediate disease is meant anatomico-physi- 
ological perversion resulting in lesion of a part involved. Illustration: 
Sebaceous tumor arising out of duct occlusion. 
Mediate Disease.-By mediate disease is meant lesion originating in 
an indirect source of perversion. Illustration : Syphiloderma existing in con- 
stitutional condition. 
Immediate diseases associated with the facial epiderm are callositas, cornu 
cutaneum, lichen pilaris, vitiligo, naevus pigmentosus, lentigo, chloasma. 
Immediate diseases associated with the facial corium are naevus pilosus, 
scleroderma, dermatolysis, elephantiasis, atrophy, morphoea, framboesia. 
Immediate diseases associated with the epiderm et corium are verruca and 
ichthyosis. 
Immediate diseases of the sebaceous glands are seborrhoea, comedo, milium, 
molluscum sebaceum, sebaceous tumors. 
Immediate diseases of the sweat-glands are hyperidrosis, chromidrosis, ani- 
drosis, sudamina. 
Immediate diseases of the connective tissue are keloid, molluscum fibrosum, 
xanthoma, rhino-scleroma. 
Immediate diseases of the blood-vessels are nawus vasculosus and telan- 
giectasis. 
Mediate affections of the facial skin are the various manifestations of 
scrofula, of syphilis, of the exanthems, of the cancer vice. 
EPIDERM. 
Callositas.-A callus finds its best illustration in the horny hand of a 
workingman ; it consists simply of hypertrophied epiderm. Callus upon the 
face is as rare as are indurating causes to the region. Splints used in jaw- 
fractures may excite the condition. 
Treatment.-Remove the cause. 
Cornu Cutaneum.-A cutaneous horn is a hyperplastic growth of the 
deeper strata of the mucous layer of the epidermis. These excrescences 
877 878 
A SYSTEM OF ORAL SUROERY. 
vary much in size, but are alike in being largest at the base and of laminated, 
roughened appearance. Rare at all, they are yet rarer in the young than in 
the aged. A cutaneous horn, when developed, is to be accepted as differing 
little, if at all, from the horns of the lower animals. Microscopic examina- 
tions show the prolongation to be made up of small columns, or rods, so 
blended by an intermediate plasm organization as to present the appearance 
of a homogeneous mass. The arrangement of the epidermic scales is after the 
Fig. 706. 
Fig. 707. 
Horns growing from the nose and face. 
Section of a horn, showing its laminae. 
imbricated manner. A specimen in the British Museum is eleven inches in 
length. A case recorded in American practice describes the horn as measuring 
fourteen inches in circumference, and branching into three divisions. (See 
Figs. 706, 707.) 
Treatment.-The radical cure of a cutaneous horn is achieved by extir- 
pation of the mass and cauterization of the base. 
Lichen Pilaris.-This is a hypertrophic affection, characterized by the 
formation of pin-head-sized, conical, whitish, solid epidermic elevations seated 
about the apertures of the hair-follicles. The lesion is liable to be mis- 
taken for cutis anserina, that familiar condition known as goose-flesh, from 
which it differs, however, in being of a non-acute character; it may also be 
confounded with miliary syphiloderm when this is in the desquamative stage, 
but difference lies in a related history. The course of the disease is chronic; 
it has no associated itching; it is often related with ichthyosis. 
Treatment.-Cosmoline and lanolin are found serviceable. The latter, 
or glycerin, may be medicated with the compound tincture of iodine and 
carbolic acid. Either serves a good purpose. Dermatologists recommend the 
free use of warm or vapor baths. DISEASES OF THE FACE. 
879 
Vitiligo.-This is a rather rare affection ; it is commonly known as white, 
or bald, spot. Its origin is in pigmentary perversion. As met with upon the 
face, the lesion consists of round, oval, or irregular patches of blanched skin, 
which patches commence as points, or dots. 
A diagnostic feature is the abrupt line at which the whiteness terminates, 
no matter what the shape of the patch. A second feature in recognition 
refers to an areola, never absent; this areola is most distinct at the line of 
its internal surface, and fades gradually away into the surrounding skin. In 
the black race the disease is more common than in the white; piebald negroes 
are met with frequently. When congenital, the condition is to be accepted as 
permanent; the acquired lesion is occasionally found to disappear spontane- 
ously. Microscopic examination shows deficiency of pigment in the white 
spots with excess in the surrounding areola. The condition may readily be 
confounded with phenomena showing in Addison's disease,-a lesion 
of the supra-renal capsules of the kidneys almost necessarily fatal. Differenti- 
ation is to be made through study of the latter. 
Treatment.-This is to be directed, if any attempt at cure be made, to 
the correction of adverse constitutional conditions. Hebra recommends the 
removal of the areola. Duhring refers to the propriety of treating the hyper- 
trophy, rather than the atrophy, of the pigment. Balmanno Squire associates 
little worth with any means. Where unseeming deformity exists it has im- 
pressed the writer that advantage might be gained by a judicious coloring of 
the part with skin-red india-ink. 
Naevus Pigmentosus.-A circumscribed deposit of pigment without 
alteration in bulk or feel of the surface is called naevus pigmentosus. Such 
naevi may be simple or multiple. The face is a common situation. Naevus 
pigmentosus is indifferently illustrated by a patch of dark-blue india-ink 
which a boy pricks into his hand. Simple flat pigmentary naevi are almost 
always acquired. (See, for illustrations, Naevus Pilosus and Vasculosus.') 
Treatment.-A pigment stain may be removed, when not too extensive, 
by a dissection extending to the structure of the corium. Another plan em- 
ploys caustics. Still another, frequently found successful by the author, con- 
sists in occasional prickings up of the epiderm through use of a needle. The 
location of the pigment cells and granules being in the mucous layer of the 
epidermis, any treatment employed is to reach that layer. 
Lentigo.-This is the common freckle. It is found to consist of normal 
pigment deposited at points in excess. Most common to childhood, it is yet 
met with at all ages. It is not necessarily confined to parts exposed to the 
sun, for which reason its pathology is somewhat obscure. 
Treatment.-See Chloasma. 
Chloasma.-This is a pigmentary affection, exhibiting itself as a smooth, 
yellowish, brownish, or reddish-brown defined patch. It differs from lentigo, 
or the common freckle, in appearance, as form and size are concerned. 
Chloasmata are of both immediate and mediate meaning, arising, in the first 880 
A SYSTEM OF ORAL SUROERY. 
case, out of direct sources of irritation, as exposure to the sun, the action of 
chemicals, scratching in skin affections, etc.; in the second, being symptom- 
atic. Chloasma uterinum is specially noted. A second illustration is found 
in Addison's disease. In the first of these symptomatic expressions the 
whole face may be occupied by a diffused, blotchy discoloration resembling 
a mask ; more commonly it shows itself as one or several patches about 
the forehead. Pregnancy is still another of recognized causes. In non- 
pregnant women its association is mostly with dysmenorrhoea, chlorosis, 
anaemia, and hysteria. The seat of the affection is the mucous layer of the 
epiderm. The lesion consists essentially in an increased deposit of normal 
pigment. 
Treatment.-This is directed, first, to removal of cause. To destroy 
the pigment various lotions and ointments are used. Favorite among such 
preparations is an application of corrosive sublimate, from one to three grains 
of the salt to an ounce of water. Ointments are made with sulphur, zinc, 
ammoniated mercury, subnitrate of bismuth, etc. Acetic acid in solution is 
commended by Squire. 
CORIUM. 
Naevus Pilosus.-Hair mole differs from the macula described in con- 
nection with the epiderm in being of deeper origin and relation. The same 
distinction applies to the flabby hypertrophies known as toads or toad-marks. 
Hair, or mouse, moles are exceedingly common to the face. They vary in 
size from that of a small shot to a hand's breadth. Their relation with the 
skin is that of comparative flatness. In occasional instances they are met 
with raised from the surface quite a finger's width. The hair covering them 
is found to differ in almost every case; the term fur expresses fairly well the 
appearance. 
Treatment.-The inert and lifeless character of most of these growths 
defy all curative means except the knife, ligature, or cauterant. 
Scleroderma.-Leather skin, as this affection has been not inaptly 
termed, is a hard, fixed condition of the corium, unaccompanied by either 
constitutional disturbance or expressions of local vascular change. The affected 
part is neither raised above nor depressed below the ordinary skin surface; 
neither is the lesion expressed by a defined line of demarcation, the hardness 
shading off into the normal skin. The author has never met with a case. 
Professor Duhring, who enjoyed opportunities of observing the disease at the 
clinic of Hebra, in Vienna, has described it to the writer as commencing by 
an apparently simple induration of the integument, which goes on until the 
part becomes almost as hard as wood or stone. The color of the skin is re- 
ferred to as varying considerably, more or less pigmentation being present; a 
waxy appearance is alluded to as occasionally showing itself. The disease, 
according to the experience of the Vienna clinic, may appear at any period 
of life, but is most rarely encountered in youth. Women are more frequently DISEASES OF THE FACE. 
881 
affected than men. From studies made by such eminent dermatologists as 
Kaposi, Auspitz, and others, it is to be accepted that the condition consists in 
a lymph stasis occurring in the cutis. Kaposi suggests by way of explanation, 
in consequence of the thickening of the lymph, which results, not from local 
cause, but out of a general abnormal state of the nutritive process, that this 
stagnates in the interstices of the tissue, which, according to the views as to 
the commencement of lymph-passages, are considered to be lymph-spaces. 
Hence the rigid infiltration of the cutis. A return to health of the parts 
would imply that circulation of the lymph has been restored. Stagnation 
continuing, connective tissue comes to be formed in excess, this structure 
growing at the same time denser and denser. The interstices of the tissue 
become more and more narrowed. The whole structure diminishes as to 
juiciness, at the same time retracting and shrinking. Diagnosis is expressed 
as lying in the solidified, rigid, bard, more or less pigmented condition of the 
integument, apparently unaltered in structure. 
Treatment.-Practitioners familiar with the disease agree that little is 
to be done. Galvanization is recommended by Fieber. Constitutional reme- 
dies that have been most used are iron, arsenic, cod-liver oil, and iodine. 
Dermatolysis.-Fig. 708 shows a marked case of this rare disease in 
the person of a young man aged eighteen years, recommended to the author 
for consultation by Dr. A. R. Begun, of Iowa 
The condition consists in a hypertrophy 
of the integuments apt to extend to the 
sublying structure, the characteristics of 
which are a laxity and pliability suggestive, 
to the touch, of adipose tissue. The sur- 
face is commonly rugose, is apt to assume 
the form of folds, and is generally more 
or less pigmented. Difference in views 
exist as to the features of the disease. 
Cooke describes it as an affection not 
making its appearance until after puberty. 
Hebra and Kaposi write of it as 
of purely congenital origin. Duhring 
classes it with molluscum fibrosum, and 
implies that it may appear either as a 
congenital or an acquired affection. The 
example here presented made its appearance when the patient was in his third 
year, and the hypertrophy has continued to advance to the present time. 
A remarkable case of this disease occurring in the practice of Nelaton 
showed a huge fold extending, in the form of a cloak, from the neck to the 
buttocks. 
Treatment.-The knife offers the only present known means of relief, 
yet applying, unfortunately, to a very few instances. In a case somewhat 
Fig. 708. 882 
A SYSTEM OF ORAL SURGERY. 
similar to the photograph shown, the author excised the redundant skin with 
considerable satisfaction both to the patient and himself. 
Hypertrophy of Mucous Surface of Lip.-A condition related with 
the mucous surface of lip is of similar significance with example shown in 
immediately preceding cut. Few deformities are 
more offensive. In speaking or laughing the 
inside of the lip everts itself, falling outwardly. 
Treatment.-Excision is the only remedy. 
Fig. 709 shows the lesion. 
Unilateral Atrophy.-A disease of the 
cutis, the reverse of that just considered, is 
known as atrophy (atrophia cutis propria). The 
affection of unilateral facial atrophy is expres- 
sive of arrest in development. The skin of 
the side involved presents a shrunken, yellowish, lardaceous aspect. Struc- 
tural alterations exist without actual loss of substance. The condition is one 
of undergrowth, as dermatolysis is one of overgrowth. 
Treatment.-No line of medication affords any promise. The lesion may, 
however, incline to improve of itself. A case familiar to the author verifies this. 
Elephantiasis.-Repeated attacks of erysipelas about the face not infre- 
quently result in a cutaneous hypertrophy not dissimilar in appearance and 
characteristics to elephantiasis Arabum. The parts become swollen, pit on 
pressure, are pigmented, are sometimes rough, sometimes smooth, at times 
scaly, in instances ulcerated. The condition, as met with upon the face, is 
undoubtedly a lymphatic disease; a stasis in this circulation the judgment of 
the writer would denominate it. Practically it differs little, except in origin, 
from dermatolysis; indeed, such likeness has struck both Hebra and Kaposi 
with a force that has led these able authorities to denominate the last-named 
disease elephantiasis telangiectodes. Diagnosis lies in origin, in history, and 
in the appearance of the enlargement; this last having the characteristics of 
parts chronically inflamed and semi-solidly indurated. 
Treatment.-If met with while at all possessed of active expression no 
treatment is found so efficacious as a combination of muriated tincture of 
iron, tincture of cinchona, and sulphate of quinia applied locally. The writer 
recommends a mixture made of these medicines as absolutely specific in facial 
erysipelas; application to the parts being often enough repeated. Specificness 
in the inflammation being destroyed, succeeding steps consider the use of 
sorbefacients and softening cataplasms. A very satisfactory course to pursue 
consists in daily rubbing into the induration an embrocation consisting of equal 
parts of tincture of iodine, tar, and olive oil; following this with a poultice, 
made very light, medicated with a chloral solution ; this last being in the pro- 
portion of five grains of the salt to an ounce of water. 
As an adjunct of great value, where the induration is heavy and resisting, 
bandaging, judiciously done, deserves to command much attention. 
Fig. 709. DISEASES OF THE FACE. 
883 
Morph cea.-This disease, a synonyme of which is "the keloid of Addi- 
son," is a condition characterized by much variety in expression. As ordi- 
narily seen it consists of irregularly rounded or elongate pinkish or purplish 
patches circumscribed by an areola made up of minute capillaries. In its 
early stage a patch may be slightly elevated above the surrounding plane, 
later it is on a level, when of long standing it is likely to be depressed. The 
surface is usually smooth and shining, looking sometimes as if polished ; other- 
wise it may show a dry, shrivelled appearance.* In the early stages minute 
and anastomosing blood-vessels are not infrequently seen ramifying over the 
affected part. Pigmentation is rarely absent. As a rule, subjective symptoms 
are lacking; occasionally itching and tingling pain are present. Common seats 
of morphoea patches are the regions holding the tracts of the fifth nerve. 
Duhring and Hutchinson, who have closely studied the pathology of the dis- 
ease, agree in pronouncing it a trophoneurosis. 
Treatment.-Arsenic continued in small doses over a period of months 
promises most. Iron and cod-liver oil are thought highly of by some prac- 
titioners. Prognosis is not encouraging. 
Frambcesia.-This is an endemic disease peculiar to South America and 
the West Indies; known in the region of its occurrence as yaws. Drs. Mil- 
roy and Imray, of Dominica ; Dr. Bowerbank, of Jamaica; Mr. Hutchinson 
and Dr. Ward, of Peru, describe the cutaneous symptoms as consisting of 
various-sized reddish papules, tubercles, and tumors which are usually present 
in all stages of development. These begin as pin-head-sized, hard, red points, 
and enlarge gradually to the size of cherries. As they grow they incline to 
become flat on their summits and to be studded with yellow points; they grow 
soft in consistence, and are apt to break down and ulcerate, discharging a thin, 
fetid, yellowish fluid. The lesions, although roundish and semi-globular, may 
be of any shape; at times they coalesce, forming a patch of a vegetating, or 
fungoid, nature. Dr. Imray likens a yaw to a piece of coarse cotton wick, a 
quarter of an inch, more or less, in diameter, dipped into a dirty yellow fluid 
and stuck upon the face in a dirty, scabby, brownish setting. The author has 
met with a single case of the disease. 
Treatment.-Dr. Imray pronounces a treatment most effective which 
employs the local use of carbolic acid solution or a weak nitrate of mercury 
ointment combined with the internal use of tonics. Cleanliness, hygiene, and 
good food are alluded to as essentials. 
EPIDERM ET CORIUM. 
Verruca.-Warts are excrescences familiar to everybody. The significa- 
tion of a wart is that of papillary hypertrophy. Five varieties are known 
to dermatology,-namely, verruca vulgaris, v. plana, v. filiformis, v. digitata, v. 
* Duhring graphically likens one of its expressions to a piece of bacon which has been cut 
out and laid in the skin. 884 
A SYSTEM OF ORAL SURGERY. 
acuminata. The first is the form seen upon the hands and is not common to 
the face; a split pea thrust beneath the epiderm would fairly represent it. 
The second is of flat aspect, being frequently met with about the cheeks of 
elderly persons ; in structure these are more or less sebaceous ; elevation above 
the skin is slight; size is about that of a small finger-nail. The third variety 
is commonly found upon the lower eyelid; the wart consists of a single thread- 
like projection of slightly conical form. The fourth form is allied with the 
second, differing from it in possessing a surface broken up into rugae, or claws. 
The fifth affects the face at points where skin is in contact with mucous mem- 
brane ; acuminated well expresses the appearance of its surface. A common 
name of the variety is moist, or cauliflower, wart. 
A wart situated upon the side of the nose is not unwisely looked on with 
concern. Degeneration is not uncommon. When a growth assumes a vascu- 
lar aspect about its base a judicious rule of practice is, not to irritate. Re- 
move thoroughly with the knife or ligature. 
Treatment.-Ordinary warts are removed by means of ligature or, 
preferably, by caustics. In the fungiform varieties an application of London 
paste destroys one almost instantly. A thread wart is quickly got rid of by 
use of scissors. Flat warts are to be dissected out, or may be transfixed and 
strangulated. 
Ichthyosis.-Fish-skin is a condition sometimes met with upon the face 
expressive of excessive proliferation of the epidermic scales combined with 
hypertrophy of the papilla of the corium. A space, greater or lesser in extent, 
shows itself covered with fish-like scales. A variety is distinguished as xero- 
derma ; here there is simple dryness with furfuraceous exfoliation. A second 
phase has the designation of ichthyosis corium ; this shows a greatly-thickened 
derm, the parts being hardened and fissured. Ichthyosis is unaccompanied 
either by redness in the skin or sensibility. Diseases with which it might 
possibly be confounded are psoriasis and pityriasis.* 
Treatment.-This is palliative rather than curative. Scales are to be 
removed and the part kept continuously anointed with cosmoline. Ointments 
of the alkaline carbonates are recommended. Where the scales tend to ad- 
here closely a blister serves an admirable end. Cod-liver oil and arsenic are to 
be employed internally. 
SEBACEOUS GLANDS. 
Seborrhcea.-This is an expression of functional derangement on the 
part of the oil-glands, showing, over the region affected, an excess of sebum. 
* A condition met with upon the inside of the cheeks where the surface is checkered and 
scale-like seems not unjustly classifiable with ichthyoid expressions; it is not, however, a 
congenital disease, and not infrequently yields, after some resistance, to iodide of potassium, 
administered in ten-grain doses thrice daily. Leucoplakia Buccalis vel Alveolaris, 
which expresses itself in white irregular lines or patches upon the inside of cheek or upon 
the gum, is to be looked on and treated with concern. It is best combated when let alone. 
Cancer of epitheliomatous form is always to be feared as a likely associate of these conditions. DISEASES OF THE FACE. 
885 
As the face is concerned the localities particularly involved are the forehead 
and nose. Two varieties of the disease are s. oleosa and s. sicca. The first of 
these exhibits a coating of oil, the second a covering of dirty, greasy scales. 
Looked at as it exists upon the forehead of the young, the asthenic character 
of the condition is clearly recognized in the patulous mouth of the ducts and 
in the general sluggishness of the parts involved. 
Treatment.-This is both local and general, the first being stimulating, 
the second tonic. A local application used satisfactorily by the author consists 
of equal parts of zinc, tar, and iodine ointments. Dusting the parts with 
flour of sulphur is good. Hebra has introduced and highly commends a wash 
composed as follows: 
Ji Saponis viridis, ^viij 
Spts. vini, ^iv. M. 
Eau de luce, a liquid soap made by mixing oil of amber and balsam of 
Gilead with water of ammonia, commends itself. Duhring claims good results 
from a combination of red oxide of mercury and vaseline, five grains of the 
first to an ounce of the second. 
Cold salt-baths taken in conjunction with iron medicaments afford the best 
systemic results. The face, before being vigorously rubbed after the bath, is, 
advantageously, to have a second washing with cologne or alcohol. 
Comedo.-This, like the immediately preceding, is a disease of the seba- 
ceous glands. It is the familiar pimples, containing as their centre a black 
point, seen over the faces of young people of both sexes. The affection 
implies indolent distention of the sebaceous outlets, and indicates absence of 
vigor in the oil-glands. The so-called worm squeezed from a comedo is, of 
course, nothing but the accumulated sebum. Comedo is distinguished from 
acne by the absence of inflammatory associations, and from milium by a non- 
presence in the latter of the characteristic black point. 
Treatment.-Comedos are treated by expressing the contents of the 
ducts and employing stimulant remedies. Tar ointment having rubbed up 
with it a little oil of cloves is an excellent application. As with seborrhoea, 
advantage arises out of local invigorating influences. To wash the face in 
salt water and afterward rub with a coarse towel until a glow is produced is 
commendable practice. 
Milium.-A milium is a distended oil-duct, the orifice of which has 
become obliterated. Milia are mostly seen about the eyelids, where they 
appear as papilliform whitish elevations, covered alone, seemingly, by the 
epidermis. 
Treatment.-The pathology appreciated, it is seen that treatment of a 
milium differs from that of comedo in requiring incision of a sac. 
Molluscum Sebaceum.-This is a little tumor arising, perhaps, out of 
sebaceous perversion, having the face as one of its localities. In color it is 
whitish or pinkish. Its size varies from that of a pin-head to that of a cherry. 886 
A SYSTEM OF ORAL SURGERY. 
A glistening appearance is characteristic. Sometimes the expression is dead 
white. The condition, as known to the writer, is without constitutional relation. 
Duhring associates its existence with the ill-nourished and neglected. Virchow 
does not accept the relation of this tumor as being with the oil-glands, but 
regards it as a hyperplastic formation of the cells lining a hair-follicle. Others 
are led to esteem the disease as associated with the rete mucosum. 
Treatment.-Incision, expression of the contents, and cauterization are 
the means of cure employed. Ligation sometimes applies most happily. The 
necessity for cauterization supports Virchow's view. 
Sebaceous Tumors.-As a result of some unremembered cause, or in 
the absence of recognizable explanation, the orifice of one or more of the 
ducts of the sebaceous glands becomes obstructed; the secretion continuing 
and having no outlet, necessarily accumulates; hence the gradual expansion of 
the duct and formation of a tumor. As this tumor enlarges, it becomes more 
and more solid, the result of the absorption, or, if not this, at any rate the dis- 
appearance, of its more liquid contents, until finally, by the touch, it is found 
springy and elastic. A section of such tumor exhibits a delicate cyst-wall or 
envelope, and cheesy or semi-cheesy contents. The cyst is seen to lie among 
the integuments as distinctly as a walnut within its hull. 
Sebaceous tumors are found of sizes varying from that of a hazel-nut 
to that of a foetal head ; they are generally spheroidal in shape, but frequently, 
because of influences exerted by neighboring parts, or by reason of semi- 
patulous ducts, become changed, even to a lobulated character. 
The diagnosis of a sebaceous enlargement is generally not at all difficult; 
the tumor rolls under the touch, can be circumscribed by the grasp, and has 
a detached feel, as if confined to its place alone by the skin. The tissues en- 
veloping it are perfectly healthy, while however large it may be, no evidences 
are given of constitutional association. Exceptions, however, exist to this 
simplicity in some special cases, as, for example, where the presence of the 
tumor has excited inflammation in the surrounding parts, where attachments 
have formed, where an attenuated skin has ulcerated, or where the contents of 
the cyst have degenerated. 
Treatment.-Sebaceous growths are most easily gotten clear of by 
operation. In a majority of cases it is only necessary to make a sufficient 
cut in the skin, and the tumor can be enucleated, just as the crystalline lens 
is removed in the operation for hard cataract. 
In other cases it is necessary to incise the tumor through its centre down 
to the base; this divides the cyst, or sac, each portion of which is to be dis- 
sected away. In instances of moderate or of large growths it is the practice 
to commence with an elliptical incision, making the skin removed corre- 
spond with the requirements of the parts after the tumor shall have been 
taken away. In doing this it will be found better to have too much than too 
little integument: even very redundant flaps are seen to accommodate them- 
selves to the parts beneath. DISEASES OF THE FACE. 
887 
The contents of sebaceous tumors, while uniform in character, vary 
greatly not only in consistence but in appearance. Yet, whatever the expres- 
sion, the springy, elastic character, as touch is concerned, is preserved. These 
tumors, while frequently multiple when appearing upon the scalp, in which 
position they are known as the common wen, seldom appear but as single upon 
the face. 
Where the contents of a sebaceous cyst has completely softened the condi- 
tion is not unlikely to be mistaken by the inexperienced for cold abscess, and 
treated by simple puncture ; the result being, of course, 
unsatisfactory ; refilling being the rule. A cyst having 
fluid contents is cured by being cut in half, and after- 
ward dissected from its bed, as suggested in a pre- 
ceding paragraph. Some practitioners, with a view to 
avoiding the dissection, simply lay the cyst open and 
stuff with lint saturated by tincture of iodine, the inten- 
tion being to obliterate through inflammatory action. 
Sebaceous tumors have little vascularity, the 
supply of vessels being confined to the sac, which, as 
will be inferred, is the attenuated duct and glandular 
substance. Little or no pain attends their development. 
The enlargement is entirely devoid of danger, as 
tendency to malignant degeneration is concerned. To 
prevent the possibility of return on the part of a re- 
moved sebaceous tumor, particular care is to be observed that no particle of 
the sac be allowed to remain. Cauterization is not required, nor is it permis- 
sible. 
Fig. 710. 
Small sebaceous tumor, 
showing its sacculated 
condition. 
SWEAT-GLANDS. 
Hyperidrosis.-This affection finds its diagnosis in greatly-increased 
perspiration. The condition relates with both systemic and local disease; is 
of acute or passive signification. General sweating is identified with febrile 
maladies; it arises also out of a high atmospheric temperature. Local sweat- 
ing signifies abnormality on the part of the sudoriparous glands of the region 
implicated; it is a special condition. When associated with the face hyperi- 
drosis confines itself markedly to the forehead. 
Treatment.-Inferring the cause of local hyperidrosis to lie in deficient 
innervation, out of which arises passive congestion of the sudoriparous plexus, 
faradization commends itself as an application to be repeated daily for weeks, 
and after that, interruptedly for months. Stimulation excited by the use of 
dry handkerchiefs which have been wrung out in salt water is a promising 
remedy if continued long enough. Astringents and alteratives apply. In 
the first direction alcohol medicated with tannic acid is to be commended; in 
the latter few means are found of more satisfactory import than a combina- 
tion of chlorate of potassium, sulphate of zinc, and hydrate of chloral: 888 
A SYSTEM OF ORAL SURGERY. 
U Potassii chloratis, ^ss; 
Zinci sulphatis, gr. xxiv; 
Chloral hydratis, gr. xv; 
Aquae rosae, ^viij. M. 
Sig.-To be applied pro re nata. 
Chromidrosis.-This is an affection of the sweat-glands, emotional and 
vicarious of signification, in which a watery fluid, variously colored, is seen to 
issue directly from the tubal outlets. At the present time the writer has 
under observation a lady of marked hemorrhagic diathesis where these glands, 
on the intervention of an hysterical attack, will sometimes throw out a fluid 
of venous darkness. Causes are idiosyncrasy, chlorosis, irregularity in the 
menstrual relations, nervous prostration. 
Treatment.-This is to be directed to any derangement seen to exist, 
and to a general building up of the constitution. 
Anidrosis.-This condition is the opposite of that just considered. It 
may occur as an idiopathic condition, but is most commonly an associate of 
chronic skin affections. Dry face is met with occasionally in very thin-skinned 
persons, where moisture is absent in the hottest weather. 
Treatment.-This is directed by the circumstances of each particular 
case. Where the cause is not recognizable nothing is to be done outside of 
administering nerve tonics. 
Sudamina.-This affection occurs in hot weather and during the con- 
tinuance of such diseases as typhoid and typhus fevers, phthisis, and rheu- 
matism ; its subjects are alone thin-skinned people; commonly women. The 
characteristics of the lesions are crowded, transparent vesicles, pin-head in 
size, raised somewhat above the level of the skin and felt as elevations. The 
vesicles never run together nor become puriform. Pathology of the condi- 
tion is explained in an excess of secretion over discharging ability of the 
tubal outlets. Sudaminse disappear with the occasion excitive of the condi- 
tion. 
Treatment.-This affection being received as an expression of debility, 
remedy lies in the direction of stimulation. 
CONNECTIVE TISSUE. 
Keloid.-Keloide, the French term, signifying a disease resembling scir- 
rhus, is the name given to one of the most peculiar and individualized of skin 
affections. This condition, first described by Alibert, is characterized by 
nodules, or more generally wheals, scattered irregularly over the body,- 
usually, however, confined to the breast, arms, neck, and face. It occurs in 
both sexes, may appear at any time of life, and is more common to the black 
than to the white race. 
Keloid is a disease of the corium and subcutaneous cellular 
tissue. That it is an atonic condition is to be inferred from the fact that 
in every individual case in which the author has met with it there appeared DISEASES OF THE FACE. 
889 
to be present a scrofulous association. This, however, is a feature not referred 
to by dermatologists. 
As to the exciting causes of keloid, writers on skin diseases express no 
opinion: it is traumatic and it is idiopathic; it appears upon a skin which 
before has seemed entirely healthy, and it springs up in the cicatricial tissue 
of a wound. The cicatrices of bad burns from dry heat very frequently so 
simulate this disease that one might be readily mistaken for the other. Ke- 
loid certainly constitutes a diathesis: the writer has seen it develop after a 
Fig. 711.-Keloid of Neck. 
simple puncture which opened a boil, while others have remarked it appearing 
in the cicatrices of small-pox, after scarification in cupping, after vaccination, 
blistering, etc. Processes, or roots, pass into neighboring parts, thus extending 
the disease. The excrescences, to the touch, are hard, semi-elastic, and rough ; 
the color differs from that of the surrounding region,-varying as do the cica- 
trices of burns. According to some observers, the parts itch and are more or 
less uncomfortable. Complaints of any peculiar sensation are seldom heard, 
however, except as the location of some wheal may interfere by its stiffness 
with free motion. 
Keloid is an imperfect fibrous development, a species of cellular 
fibroma. Warren, of Boston, has demonstrated the origin of the disease to 
be in the walls of the blood-vessels, numberless cells accumulating and in time 
becoming converted into dense connective tissue. Microscopic studies made 
by Langhans, Kaposi, and others exclude from connection with the lesion both 
the epiderm and papillae. 
Treatment.-This has, in every instance, proved so unsatisfactory that 
surgeons are agreed in the practice of letting the deformity alone: even the 
knife is useless, or worse than useless; if a nodule or wheal be removed, one, 
or perhaps half a dozen, will spring up in its place. Where the tumors in- 890 
A SYSTEM OF ORAL SURGERY. 
terfere much with motion, they may be lubricated with glycerin, lanolin, 
or oil, but otherwise nothing is to be accomplished: the only comforting 
reflection for the patient is that keloid seldom, if ever, kills. 
Molluscum Fibrosum.-This is a connective-tissue proliferation ex- 
hibiting itself as multiple, sessile, or pedunculated tumors varying in size from 
a common pea to that of an egg; the situation is immediately beneath the 
skin or it may be in the skin itself. Appearing occasionally single, it not in- 
frequently multiplies itself by hundreds. When single the measurement is 
not unapt to be that of an olive or a small pear, the shape corresponding with 
that of the latter-named fruit; existing in numbers, the growths are seldom 
larger than a pea or cherry, and are not unlikely to be dome-shaped. 
Section of a tumor differs with its age and size; all, however, show a 
white fibrous stroma from which, on pressure, a yellowish exudate may be 
pressed. A marked clinical difference between this tumor and the mol- 
luscum sebaceum lies in the oneness of the latter with associated parts; this 
is not to be expressed. Old growths frequently show much vascularity about 
the base. These have a twofold termination : they become arrested in develop- 
ment after attaining a certain size and remain through life, or they ulcerate 
and become troublesome sores. The latter is uncommon. 
Treatment.-This relates strictly with operative proceedings; common 
manners of extirpation are by means of knife and ligature. 
Xanthoma.-This is a common affection, seen most frequently upon and 
below the under eyelid, and upon the region of the malar bone. It is a connec- 
tive-tissue new growth, yellowish or saffron in color, irregular in form, showing 
itself in the two forms of tubercle and an inlaid patch or streak. In a case 
long under observation of the writer, the characteristics are saffron-colored, 
distinctly-demarked strips, running horizontally along either eyelid, together 
with a number of tumor-like bodies situated between the lower orbital border 
and position of infraorbital canal. The patient is a lady possessed of dark and 
somewhat delicate skin ; the general health being perfect. Microscopic ex- 
amination of a patch removed from an upper eyelid by Professor Duhring 
showed a structure related with the corium consisting of connective tissue, 
which, to use the words of the examiner, " had undergone fatty degeneration, 
oil-globules and fat being present." This result agrees with that obtained by 
Tilbury Fox and others. 
Treatment.-If not deforming, these strips and tubercles are best let 
alone. Excision is the only remedy. 
Rhino-scleroma.-This is an exceedingly infrequent affection. It is de- 
scribed by Duhring, who possesses the experience of having seen two cases in 
Europe, as a circumscribed, irregularly-shaped, flattened, tubercular, remarkably 
hard and dense cellular new growth, having its seat about the region of the 
nose. Beginning as an induration, or hypertrophy, of the nasal alae, the dis- 
ease extends to the septum and from that down the lip. Upon pressure 
the growth shows elasticity, it is free of all acute inflammatory expression, DISEASES OF THE FACE. 
891 
the color of the skin is unchanged, or, if not so, only slightly pigmented a 
reddish or brown. The line of demarcation is diagnostically distinct. 
Kaposi, who, together with Geber and Mikulicz, has microscopically studied 
the affection, remarks a surprise begotten by cutting into the growth at the 
ease with which a blade passes through it as comparison is made with the 
hardness to touch ; that observer describes a section as showing the epidermis 
and rete as normal, the papillae being filled with cells closely packed, the cellu- 
lar infiltration, here and there, extending deeply into the corium, which struct- 
ure is uniformly dense throughout, the vascular stratum and the papillae being 
especially crammed with cells. Kaposi associates the disease with the small- 
cell sarcoma; Geber and Mikulicz consider it as a chronic inflammatory 
process. 
Treatment.-If allowed to run its course, rhino-scleroma is found to 
eventuate in occlusion of the nostrils. Caustics are recommended, but the 
inference drawn by the writer from a clinical examination of the cases treated 
at foreign clinics begets a very positive conviction that a remedy proper to 
use has not yet been discovered. Prognosis is most unfavorable. No case is 
known to have occurred in the United States. 
CARTILAGINOUS TISSUE. 
Enchondromata.-Cartilaginous tumors are not infrequent to the face, 
and are divisible into two kinds,-namely, into the enchondroses, which 
originate in permanent cartilages, as those of the eyelids and nose, and en- 
chondromata, which are found to exist independent of a cartilaginous base ; 
the former are the more common. 
The enchondroses correspond in histological character with the cartilage in 
which one originates, particularly while small or before forming mediate rela- 
tions. The enchondromata of non-cartilaginous base are more likely to be of 
compound signification, often recurring after removal, and not infrequently 
terminating fatally by reason of cancer complications. The seat of the en- 
chondroses, as the face is concerned, is about the eyelids, the nose, and the 
locality of the temporo-maxillary articulation. The enchondromata are met 
with most frequently in the parotid and submaxillary glands ; occasionally 
they are encountered in connection with the muscles of expression. 
A cartilaginous tumor stands clinically as a cross between the osseous and 
fibrous growth; to the touch it is smooth, hard, and elastic. The enchon- 
droses are reasonably solidly fixed, the enchondromata can be lifted, and they 
roll more or less under the finger. Both forms, as implied, the latter, how- 
ever, particularly, may undergo change; the most common of which changes 
is in the direction of osseous and calcareous admixtures. Cysts are very fre- 
quently found in this connection, and their presence is to be looked on with 
concern as possessed of relation with malignancy. Cartilaginous developments 
vary, not infrequently, with age and parts, being at times gummy, at other times, 
or in places, having the solidity of a sturgeon's nose. 892 
A SYSTEM OF ORAL SURGERY. 
BLOOD-VESSELS. 
Angeioma-Naevus Vasculosus.-A vascular naevus is a disease of 
the blood-vessels ; arterioles, venules, or capillaries being individually or collec- 
tively involved. Varieties of the condition show many aspects; extremes are flat 
discoloration and extensive tumors. Under the designation are included the 
naevi materni, mother-marks ; also, jtlstly, the acquired lesion, telangiectasis. 
Mother-Mark.-A mother-mark is commonly a small reddish or brown- 
ish flat or raised defect situated upon the face or other part of the body. 
Such a mark is various as to size and characteristics, being, in instances, a mere 
point, in other cases, as in that known as the port-wine stain, covering a large 
surface. 
Although to the eye such lesions do not in all instances appear vascular, 
they certainly differ only in degree from the telangiectases, being commonly 
capillary hypertrophies, as is sufficiently witnessed when wounds occur in 
them. That such vascularity does not, however, shade off into the adjoining 
tissue is sufficiently well recognized ; on the contrary, the connection is very 
limited. Such marks are supplied by two or three large vessels, the 
hypertrophy of whose radicles may, for practical purposes, be viewed as con- 
stituting the disease; hence, in operating on them, if the incisions be made 
wide of the growth, there is no more than ordinary hemorrhage,-only one or 
two vessels, if any, requiring the ligature. 
Arterial Tumor.-This is a form of the erectile growths which has an 
individuality, inasmuch as it consists of a congeries of vascular twigs held 
together by the more or less imperfect remains of the associated skin or cel- 
lular tissue. That it is not, as has been suggested, an aneurism, but rather 
a simple enlargement of terminal vessels, is proven by the fact that such en- 
largement accompanies the vessels of supply for a greater or less distance; 
that it differs, however, from the naevi just described, few are prepared to 
admit. It is, perhaps, a formidable naevus, nothing more, both being, in 
varying degrees, erectile tumors. 
These growths, while in many instances referable to local injuries, are in 
most cases fairly presumed to be of congenital character. It is quite true 
that they may appear late in life, yet the impress has existed not unlikely, 
although it may have been in the form of a point not larger than a pin-head, 
and may have entirely escaped attention. 
Variability as to Growth.-The growth of such tumors is markedly 
variable. The writer has met with them where twenty years seemed scarcely 
to have changed their character, while in other instances a single week has ex- 
hibited alarming progress. In some cases the attenuation of the coats of the 
vessels is so great that one might well imagine he can see the flow of the blood, 
while in other instances hypertrophy of the associate tissues is so marked as 
comparatively to solidify the part. In color also, as will be inferred, the 
arterial tumors are found to vary, the shading being influenced by the con- DISEASES OF THE FACE. 
893 
ducting facility of the associate veins. Pulsation exists in many of the 
growths, and is synchronous with ventricular systole. To the touch the 
tumors are soft and doughy, almost disappearing under pressure, yet filling up 
the moment such pressure is removed. Form is without absolute definition, 
the outline being modified by circumstances of which we know nothing. A 
marked diagnostic sign is the effect produced on the size by the condi- 
tion of the circulation. Veratrum viride, or aconite, by lowering the action 
of the heart, will almost cause those of moderate bulk to disappear. Even 
the quietude of sleep and of recumbency markedly affects them. Passion, on 
the other hand, excitement, or any mental emotion disturbing the pulse, causes 
them to enlarge, even in some instances to bursting, such enlargement being 
most pronounced in cases where a state of atrophy characterizes the con- 
nective tissue. The common danger from these tumors is ulceration, 
which, in many instances, resulting in severe hemorrhage, has gradually, yet 
sometimes suddenly, exhausted the patient. 
Extreme Illustrative Case.-A case of arterial naevus, the largest 
ever treated, or indeed ever seen, by the author, is perfectly shown in Fig. 
712. The patient, a negro baby from Maryland, was brought to Professor 
D. Hayes Agnew, who, for the service of the oral clinic, kindly placed the 
Fig. 713.-Venous Naevus. 
Fig 712.-Arterial Njevus. 
child in that department. The growth, as exhibited in the cut, involved the 
full side of the face and looked as if it might give way at any moment. The 
whole substance of the cheek was involved, the mucous membrane excepted. 
The tumor is shown uncovered, its base being transfixed by two needles. A 
complete cure was made. (See page 896.) 
Venous Tumor.-This is another form of the erectile growths, dif- 
fering, however, from the one just described, in the fact that the venous 
rather than the arterial twigs are in a state of enlargement. A description 
of the one is a description of the other, save in the matters of color and pul- 
sation, the latter being generally dark, almost to a dull purple or grayish- 894 
A SYSTEM OF ORAL SURGERY. 
black, and of course deficient in movement. Like the arterial, the venous 
tumors are sometimes slow of growth, at other times rapid; they appear 
without assignable cause other than the congenital impression. 
Fig. 714 shows a form of naevus, or, as it is more commonly called, venous 
varix, which is met with in varying facial locations not infrequently by the 
writer. The condition, as will be appreciated, consists of a congeries of en- 
larged veins. A common seat of the affection is the cheek, where, the over- 
Fig. 714. 
lying skin becoming more or less atrophied, the appearance presented is that 
of a divisioned sac filled with darkish-blue blood. 
Fig. 715, being a case illustrated by the elder Pancoast, represents a large 
naevus met with upon the lip of a black man. It was successfully removed 
by acupressure, after a manner shown in the cut. 
Illustrative Case.-A case of naevus possessed of marked interest, 
treated by the writer, existed in the person of a white baby, the right half of 
whose lower lip was a vascular mass, the disease extending well into the 
cheek. The condition was congenital, the naevus having enlarged, however, 
very much and rapidly after birth. The lesion was happily gotten rid of 
through use of red-hot needles, introduced every few weeks with view to 
provoking obliterating inflammatory deposits. After a few years every sign 
of the lesion had disappeared (See page 900.) 
Capillary Naevi Maculae.-A capillary naevus may involve the deep 
structures or it may be of superficial import; the signification of it lies in the DISEASES OF THE FACE. 
895 
capillary tissue. Under this head are to be classed not only small and unim- 
portant phases of the disease, but tumors which threaten life. 
Fig. 715. 
Port-Wine Stain.-This is a naevus of such marked and peculiar ex- 
pression, and withal so common, as to merit special naming. In color a reddish- 
purple, the extent of parts deformed by it varies from an aspect known as 
araneus (epides clavus) to the whole side of the face and neck, the patient 
looking as if stained by dark wine. So superficial is this discoloration that a 
touch of the finger will cause its temporary disappearance. 
Treatment.-Naevi are treated on a common principle: by ablation with 
the knife, by strangulation, by starvation, by compression, by injection, by 
electrolysis, and by the application of caustic remedies. 
Excision is chiefly confined to small tumors, this being the 
easiest and quickest way of getting clear of them. The general experience 
to cut as wide of the growth as convenient is the principal rule to bear in 
mind. As the vessels of supply are cut, an assistant compresses them with 
thumb or finger ; and while such vessels are frequently very formidable-looking, 
yet it may happen that when the tumor is entirely away not a single ligature 
will be required. Should the hemorrhage not cease, it will be found con- 
venient practice to ligate. 
Removal of a growth effected, and the bleeding controlled, nothing remains 
but to close a wound, that may have been made, with a few stitches of the 
interrupted suture, and to support it with adhesive strips. 896 
A SYSTEM OF ORAL SURGERY. 
Strangulation as a Means of Cure.-Strangulation is a means of 
treatment familiar to every practitioner. Such manner of cure implies trans- 
fixion of the base of the naevus and the application of ligatures that shall cut 
off the circulation. Simple strangulation uses one or more curved needles and 
a strand of waxed silk ; skin is included in the strangulated circle. A step 
more complicated cuts around the disease, the incision passing through the 
skin ; this circular channel receives pins and ligature. Another operation 
(Fig. 712) demands uncovering of a tumor that skin may be secured or saved 
to cover in the part from which a naevus has been removed. In the case of 
the child portrayed four flaps were commanded by means of a crucial incision. 
The mass thus exposed, it was worked into as ball-like an aspect as possible, 
fingers and the handle of a knife being used to tear the adhesions. When 
hemorrhage could no longer be controlled by ligatures, two large curved 
needles were passed, as shown in the cut, and strangulation effected by means 
of several strands of gilling twine twisted together and well waxed. The 
pedicle controlled by a single tie of the ligature, the vascular fungus was 
freely depleted by deep pricks from a lancet. This last step allowed such a knot 
to be made as turned the tumor quickly black by reason of absolute shutting 
away of all circulation. To render the case as suggestive as possible, it is to 
be stated that union of the base of the growth with its vital bed was prevented 
by interposing layers of linen saturated with an antiseptic. Four days later 
the now degenerating and offensive mass was lifted away and the flaps, which 
had changed surprisingly little, were laid down and delicately stitched and 
compressed into place. Recovery was without a complication. Four years 
later, the baby, grown into a rugged child, was brought to see the operator, 
scarcely a scar designating the locality of the formidable performance. 
Subcutaneous Strangulation.-Still another class of strangulation 
refers to the manipulation practised subcutaneously. Cases demanding this 
operation have the disease situated beneath the skin, circumstances existing 
which contraindicate an uncovering. In these instances, not always satisfac- 
tory as to results, a threaded needle is passed over one surface of the pedicle 
and brought under the other by being returned through the opening of exit, 
the needle finally emerging at the point of entrance. The principle is that 
employed in the treatment of varicocele. 
Arrangement of Ligatures.-The strangulation of naevi requires not 
infrequently the exercise of considerable ingenuity in the arranging of ligatures. 
Figs. 716 and 717 exhibit complexities in transfixion, and will serve as hints 
to practice. 
Compression as a Means of Cure.-Compression applies to pressure, 
however made. Take a piece of ivory, metal, or other convenient material, 
adapt it to the part, and confine by means of bandage or adhesive strips. 
This mode of cure is rarely applicable, being used only over bony surfaces and 
where a tumor is quite small. A practice which in one instance, where the 
tumor was situated upon the finger, answered a satisfactory purpose, consisted DISEASES OF THE FACE. 
897 
in the daily application of tincture of iodine four times the officinal strength, 
together with the use of an india-rubber ring.- Collodion, daily applied, is 
recommended with similar intent. 
Use of Injections.-Injections have some few advocates: of agents 
thus used, the principal are iodine, Monsel's solution of iron, nitric acid, and 
Fig. 716. 
Fig. 717. 
Diagram of tumor with 
its base transfixed by a 
number of threads. 
Diagram of tumor with its 
base transfixed by threads at 
right angles to one another. 
creasote. Such mode of treatment is always, however, attended with more or 
less risk, and is not to be commended. The practitioner disposed to try the 
plan has only to use the ordinary subcutaneous syringe, break up, with its 
point, the structure of the tumor or some portion of it, and follow with the 
injection. Several cases of death are on record from this manner of treat- 
ment ; the danger lying in emboli. , 
Caustic Remedies.-Caustic remedies, used to destroy naevi, are of 
various kinds,-Vienna paste is a wide favorite; this is the potassa cum calce 
of the Pharmacopoeia; it is used by continuing an application from ten to 
twenty minutes, following it with an emollient poultice. London paste, com- 
posed of equal parts of quick-lime and caustic soda, replaces this in the esti- 
mation of the author; it is used by being mixed into a thick paste with water 
or alcohol. 
Blistering Collodion.-Another method is to paint the part with blis- 
tering collodion, and, after the cuticle is raised, apply crystals of the chloride 
of zinc. An application recommended by Richardson, of England, is the 
ethylate of sodium used upon the nib of a quill pen. 
Treatment of Slough.-In the application of any caustic, trouble, 
more or less severe, is always to be apprehended from a resulting inflammation ; 
this every patient, or the friends, are to be made to understand, as it is impos- 
sible to know just how a case may come out. After the use of a caustic, 
and the slough of a part, the resulting wound is to be treated as a simple 
ulcer. 
Starvation as a Means of Treatment.-Starvation is still another 
method of treating the erectile growths. This consists simply in finding the 898 
A SYSTEM OF ORAL SURGERY. 
vessel or vessels of supply, and cutting off the circulation by ligation; this 
mode has many advocates, and is certainly a good one where the arteries are 
in a position to be surely recognized and conveniently operated upon. 
Seton employed for Cure.-The seton is still another mode. This 
is introduced by threading a needle with tape or other material, and passing it 
beneath the growth. The seton, whatever the material used, is to be as large 
as the needle which carries it, preferably larger ; thus, by the pressure secured, 
guarding against hemorrhage. 
Some General Considerations.-In considering the treatment of 
naevi, it is not to be forgotten that there are cases which, if left to themselves 
long enough, might effect self-cure. Young children afflicted with naevus are 
hurried to the surgeon, under an impression that the disease must necessarily 
spread, and that therefore the sooner an operation is done the better. Such 
haste is not always found necessary, nor even prudent. For a short time 
after birth a naevus may continue to grow,-for several weeks, perhaps; then 
it may cease to enlarge. If it be of a simple cutaneous variety, it may 
become the seat of ulceration ; this may spread, but it will destroy the naevus. 
In other instances, a naevus, after growing to a considerable size, will become 
the seat of atrophy,-will dwindle, shrink, and degenerate, until little or 
nothing of it is left. 
Electrolysis in Treatment.-Treatment of the vascular naevi by the 
galvano-cauterant is at present in much esteem. Dr. Maas, of Breslau, has 
collected in the Archiv fur Klinische Chirurgie (vol. xii.) the histories of 
one hundred and twelve cases of naevi treated by this method. The results 
were as follows: Capillary naevus-cured, 32 ; improved, 1; result unknown, 
1. Cavernous or venous naevus-cured, 72 ; improved, 8 ; result unknown, 
1; died, 3. Arterial or racemose naevus-cured, 2 ; improved, 1. Naevus 
combined with other tumors-cured, 6; improved, 1; result unknown, 2. 
This surgeon deduces from the examination of his cases the conclusion that 
the galvanic cautery is followed by the best results, and is much safer than 
the injection of perchloride of iron or other coagulating fluid. It 
would, however, be wrong to say positively that the remedy is indicated in all 
cases of naevi. As Virchow has well remarked, the physician is to take the 
circumstances of each lesion into consideration. The battery used in the 
cases referred to is that of Middeldorpf. 
Repeated Operation Necessary.-In the use of the means of elec- 
trolysis, a difficulty encountered arises out of the experience that occlusion of 
one venule or other radicle seems to have but little influence on its neighbors, 
thus necessitating repeated operations until the electrolytic action has directly 
influenced almost each individual vessel. Moreover, since galvano-puncture 
thus cauterizes the tissues as well as coagulates the blood, it is evident that a 
slough must ensue, provided the superficial portion be much affected; and if 
such an occurrence must take place, with its consequent cicatrix, it is prefer- 
able to have it occasioned by the more speedy action of a ligature. The DISEASES OF THE FACE. 
899 
slough of galvano-puncture is, however, perfectly devoid of hemorrhage, since 
it is tardy in its separation, and remarkable for its extreme dryness. 
Limitation of Objection to Means.-These objections to the use 
of this means apply only to cases which are superficial, or where the skin is 
implicated. In subcutaneous naevi the operation possesses the advantage of 
being safer and more certain than injection, and in cases where no slough is 
necessitated the scar of an excision or ligation is avoided,-that is, provided 
insulated needles are employed. A Bunsen or other battery may be used, the 
number of needles varying with the size of the tumor; but in all cases care 
is to be taken not to carry the action beyond the whitish hue indicative of 
cauterization. In regard to the introduction of gas into the circulation by 
this method, little danger is to be apprehended, notwithstanding the opinions 
of Rutherford and other able writers on electro-therapeutics. In cases of 
huge naevi or vascular tumors, the practice is to be pursued with advantage, 
especially when excision is hazardous.* 
Treatment by Tearing.-A method of treating naevi practised and 
highly commended by certain English surgeons is that of " piecemeal" removal, 
-i.e., tearing the mass away fragment by fragment, the object being to prevent 
hemorrhage, on the same principle as in torsion of arteries. 
Use of Red-Hot Needle.-The repeated use of a needle, heated to 
redness by means of an alcohol-lamp, thrust a sufficient number of times and 
on a sufficient number of occasions into a naevus is a means that has yielded 
great satisfaction in the practice of the author. This applies particularly to 
naevi involving the skin under circumstances not permitting excision of the 
* Electrolysis.-Drs. Beard and Rockwell, in the Medical Record for July 15, 1872, 
publish some of their results in the use of electricity in surgery: 
In the treatment of erectile or vascular tumors, they claim for electrolysis the following 
advantages over the knife or other methods : there is no hemorrhage; there is no scar; by 
proper management, the effect produced is solely upon the blood in the tumor; the operation 
is easily performed. 
In proof of this they adduce cases. 
1. A child aged eight months, with an erectile tumor in the cheek. Four needles intro- 
duced for eight minutes. A clot was produced, which was wholly absorbed in four months. 
2. A large tumor in the back, in a weakly child aged one year. Same operation. 
Result unsatisfactory, as some ulceration followed, and the tumor remained. 
3. A child aged fifteen months, with a tumor near the angle of the mouth. Four needles 
introduced for ten minutes. In four months the tumor had disappeared, and no scar was 
left. 
4. A subcutaneous erectile tumor at the inner angle of the eye, in a child aged sixteen 
months. Three needles introduced for twenty minutes. Some sloughing occurred after- 
ward, and deformity was left. The authors think too strong a current was used, and for too 
long a time. 
5. A child aged eight weeks, with a naevus on the neck, just below the chin. One needle 
introduced and a sponge electrode applied externally for four minutes. Two and a half 
months afterward there were signs of reappearance of the growth. 
6. Bronchocele of four years' standing, in a girl aged fourteen years. External gal- 
vanization twice a week for two months failed. Needles introduced; in four months, after 
about twenty applications, a great decrease in size in the tumor. 900 
A SYSTEM OF ORAL SURGERY. 
parts. The case of the white baby with naevus of lower lip and cheek, 
alluded to on page 894, furnishes an example. In that case heated needles 
were used each one, two, or three weeks for some four months, the child being 
etherized on each occasion. Cure of a complete type resulted, and little 
trouble was experienced either by child, operator, or nurse. 
Treatment of Port-Wine Naevi.-Port-wine naevi are treated by 
ligation of supplying vessels, by the formation of points of issue, or by cross- 
sections. In a case of naevus of this character, involving a whole cheek, a 
second and isolated mark being related with the scalp of the temporal region, 
cure of both resulted from an inflammation provoked in the latter. The cross- 
sections proposed by Squire consist of a series of obliquely-directed cuts cross- 
ing each other at right angles, so as to divide a surface into many small squares ; 
the operation to be repeated in one or two weeks if found necessary. 
MEDIATE AFFECTIONS. 
Scrofuloderma.-All facial skin affections traceable to scrofulosis are, 
clinically, to be denominated scrofulodermata. These affections vary in 
characteristics and find in the classifications of the dermatologists arrange- 
ment after different order. Treatment being, however, of a common expres- 
sion, the disease is proved thereby individual. 
Diagnostic features in the scrofulodermata relate with history and 
certain common features. Out of lymphatic stasis, and a consequent arresta- 
tion in tissue metamorphosis, arise all scrofulous manifestations, let the forms 
be what they may. The disease may be inherited or acquired. Inheritance 
is more common than acquirement. Causes related with inheritance are syphi- 
lis, intermarriage of near blood-relations, impoverishment of tissue. Condi- 
tions pertaining to acquirement are insufficient or bad blood, lack of proper 
cleanliness, want of protection against atmospheric changes, malarial influences, 
living in sunless and damp rooms, depressing associations. 
Accepting a common type of local manifestation for de- 
scription, we consider an indolent swelling, much in general appearance like 
the syphilitic gumma, which shows itself upon the face, remaining for a long 
time stationary, breaking down, not unlikely, eventually into an ulcer. The 
meaning of the process from beginning to ending is in tissue stasis, by which 
is meant, repeating for emphasis our definition, interference with, and arresta- 
tion of, nutritional activity. 
The commonest expression of scrofuloderma is that so fre- 
quently met with upon the sides of the neck and beneath the chin. Here the 
condition of stasis is most appreciable, the organs primarily involved being the 
lymphatic glands. The breaking down of a gland, and of its overlying tissue, 
is a direct phase of the lesion. 
A scrofulous ulcer is usually of uneven, undermined, ragged 
edge, has a bottom covered with a flaky deposit among which indolent granu- 
lations of a palish red show themselves, gives off a curdy pus, is not unlikely DISEASES OF THE FACE. 
901 
found incrusted with scabs, and is painless. Diagnostic concomitants are 
coryza, otorrhoea, palpebral conjunctivitis. 
Treatment.-Cure of the scrofulodermata lies in a medication directed 
to the lymphatic system. Toward this end nothing, in the estimation and ex- 
perience of the author, equals " roughing it,"-salt baths taken as directed at 
page 167, deep breathing induced by running up-hill, the temporary drink- 
ing of alcohol, working in a horse-stable or in a butcher's yard, arousing the 
system to vigorous action and feeding it with pure air as found among moun- 
tains or by the sea-shore. Medicines used are iron, iodine, arsenic, nux 
vomica, cod-liver oil. Local applications are benzoated zinc ointment, tinct- 
ure of calendula, tar cerate, solutions of iodine, mercurial preparations. 
Syphiloderma.-By the syphilodermata are meant all skin manifesta- 
tions arising out of the syphilitic vice. These are met with in the forms of 
macules, papules, pustules, tubercles. The forms succeed one another, or, 
what is more likely, are met with upon the same surface at the same time. 
Like the scrofulodermata, the syphilodermata find diagnosis in history 
and in local peculiarities. The syphilides are always preceded by a 
primary stage of the disease. Appearing upon the face the form is almost 
constantly that of erythematosum. The blush is persistently copper-color. 
No pain, itching, or other subjective symptoms are present, except at times 
when the patient finds himself over-warm in bed. 
Facial Tubercles.-Facial syphilitic tuberculosis, a condition allied with 
tertiary manifestations, consists of one or several prominences varying in size 
from a split pea to a finger-point, hard and resisting to the touch, rounded and 
conical in form, copper-colored, usually of smooth and glistening surface. 
Progress in development is slow, several weeks commonly elapsing between 
time of appearance and suppuration. A resulting ulcer is differentiated from 
one of scrofulous nature in not being undermined nor ragged. 
Gumma of Forehead.-Gumma is markedly peculiar to the forehead 
as the facial region is concerned; two, seldom over three, are found together. 
A gumma is in shape and size not unlike the dorsum of the middle phalanx 
of a finger; more rounded perhaps. Cases, however, are recorded where the 
size of a hen's egg has obtained. The skin is more or less involved, is of a 
coppery purple, and looks apparently toward pointing. Consistence of tumor 
is that of tough dough ; at times it is quite elastic, sometimes markedly 
fluctuating. 
A gumma tends to break down; skin, cellular tissue, and deeper 
structures giving way before it. The ulcer resulting is of perpendicular edges 
and abrupt as related with associate parts. In place of disintegrating a gumma 
may disappear by absorption. 
Other Forms of Syphiloderma.-Other forms of the syphilodermata 
are the papular, large, small, and lenticular, these being of dry and moist 
varieties; the vesicular; the pigmental; the pustular, these being of the 
acuminated and miliary kinds ; last, those pertaining to hsereditarium infantile. 902 
A SYSTEM OF ORAL SURGERY. 
Treatment.-All syphilitic manifestations are prescribed for on the prin- 
ciple of specificness; the antidote is mercury. A recipe directed toward the 
constitutional condition most frequently used in the practice of the author 
is as follows: 
U Hydrargyri biclijoridi, gr. ij ; 
Potassii iodidi, 5ij 5 
Syrupi sarsaparillae, ^viij. M. 
Sig.-Dose, tablespoonful three times a day. 
If judiciously directed, this combination may be continued, if found neces- 
sary, over a period of weeks without touching the gums. In sickly subjects 
it is well to combine it with a bark tonic. (See Treatment of Syphilis of 
Tongue.) Locally, a syphilitic ulcer is to be treated in considera- 
tion of whatever may be the peculiar indications. Much benefit generally 
ensues from touches of caustic application, chloride of zinc, acid nitrate of 
mercury, London paste, and iodine being valuable remedies in this direc- 
tion. It is a habit with the writer to apply the cauterant and afterward to 
keep the part packed with absorbent cotton or, preferably, lint saturated 
with a solution, made to meet indications, of tar-water, glycerin, and carbolic 
acid. 
A syphilitic tubercle, papule or gumma, met with in the non-ulcerous 
stage, commands effort for its cure by absorption. The recipe given above is 
almost surely curative. 
Parasites.-Certain skin affections exist in the presence of parasites; of 
such parasites there are two general forms, animal and vegetable. 
Animal Parasites.-The animal parasites are 
the acarus scabiei, or itch-mite; the pediculus capitis, 
or louse; the acarus folliculorum, or gland insect; the 
pilex irritans, or common flea; the pimex lectularius, 
or bed-bug; the pulex penetrans, or sand flea; the 
filaria medinensis, or Guinea-worm ; and others of 
unimportant relation. 
Vegetable Parasites. - Vegetable parasites 
are the achorion Schbnleinii, the fungus giving rise to 
tinea favosa; the trichophyton, out of which arise 
three diseases,-namely, tinea circinata, tinea tonsu- 
rans, and tinea sycosis; the microsporon furfur, the 
fungus of tinea versicolor. Tinese is a generic term, 
signifying vegetable fungoid disease. 
Origin of Parasitic Diseases.-The origin of parasitic diseases is 
accident or want of cleanliness. All of them are contagious. The course 
is chronic. Medication lies in the employment of parasiticides. Cure is 
assurable. 
Facial Parasitic Diseases.-Parasitic diseases met with upon the 
Fig. 718. 
Illustration of a parasitic 
growth, oidium albicans. DISEASES OF THE FACE. 
903 
face, named in the order of their frequency, are tinea sycosis and tinea 
circinata. 
Tinea Sycosis.-This is the familiar " barber's itch." Itcommences 
as a reddish, slightly scaly patch, followed in a week or two by desquamation 
and induration. The hairs of the part involved grow dry, loose, and brittle, 
showing points of pustulation about the follicles. From this condition the 
course of the disease is rapid, the skin becoming nodulated, and the deeper 
parts indurated. The surface, which has assumed a deep reddish color, be- 
comes pustular, scabs of offensive appearance forming over the parts. A 
crust removed, the sore beneath shows a granulated face not unlike that of a 
broken fig: whence the name sycosis. The lesion generally involves the whole 
of the region of the lower jaw. 
Treatment.-The cause lying in the trichophyton fungus, the seat of 
which is the hair-follicles, treatment is necessarily specific. The practitioner, 
distinguishing the condition from that of sycosis non-parasitica,-a matter not 
difficult, as this latter confines itself markedly to the hair-follicles, implicating 
the surrounding skin but comparatively triflingly,-remedies known as parasiti- 
cides are selected. An application destructive of the particular fungus consid- 
ered is the yellow sulphate of mercury, an ointment being used com- 
posed of fifteen grains to an ounce of simple cerate or of Cosmoline. The 
bichloride is another mercurial of great value; one to two grains to the ounce 
of water as indicated. Still another remedy, one much employed, is sulphurous 
acid, one part to three of water. 
A point is the manner of application : crusts are to be removed by 
means of poulticing. Hairs at all loose are pulled away. Shearing is to be 
practised to all the extent possible. Absolute cleanliness is to be preserved. 
Using an ointment, the medicine is to be gently but thoroughly rubbed into the 
parts. Employing a lotion, contact is to be continued for at least half an hour. 
Cure is slow ; relapse frequent: treatment is to be persevered in for a long time. 
Diagnostic Expressions of a Peculiar Tinea.-Some dozen cases 
of a disease appearing upon the face, met with by the author, which is to be 
classified with the tinea, possess the following clinical features. There ap- 
pears first an induration about the size of an almond; this, after a time, 
turns a purplish-red and softens; affording fluctuation, it yet yields no pus 
when opened, but is seen to be composed of a watermelon-like stroma. Still 
later the original tumor lessens, but in proportion as it diminishes a second 
arises to take its place. The history of this second is that of the first, and 
so one after another come and go indefinitely. Relation of the hairs with the 
condition is that of tinea in every particular. The author has found these 
tumors invariably respond either to creasote daily brushed lightly over 
them, or a solution of corrosive sublimate, two grains to the ounce of water. 
The latter to be applied several times a day. 
Tinea Circinata.-Ringworm is a not unfamiliar condition. Its char- 
acteristics are one or several circular patches of varying size, commonly not 904 
A SYSTEM OF ORAL SURGERY. 
larger than a twenty-cent piece, occasionally the size of a hand, appearing 
upon any part of the body. 
Acne Rosacea.-Fig. 719 illustrates a not unfamiliar condition known 
as acne rosacea. This is an inflammatory lesion of the face, more particularly 
of the nose, characterized by simple 
redness, by dilatation of the blood- 
vessels, or by these conjoined with 
hypertrophy and acne according to 
the stage of the disease. 
Stage first is a more or less 
diffused hypermmia of the part with- 
out enlargement. The expression is 
that of passive congestion. The part 
has lost some of its natural warmth, 
and is commonly of more or less 
greasy appearance and feel. This 
stage may continue with little change 
for years; it is the condition of 
rosacea. 
Stage second shows the blood- 
vessels prominent and tortuous. Pap- 
ules and pustules establish themselves. 
Acne is now located. 
Third stage signifies progression of the combined rosacea and acne. 
Both blood-vessels and papules enlarge. The condition may remain of a size 
as shown in the illustration, or it may enlarge to the size of a fist.* 
Etiology.-It is pointed out by Hebra that the disease in women occurs 
more than likely at two periods of life,-namely, in early womanhood and 
again at the climacteric time, being, in both instances, attended by menstrual 
disorder. Related with the first period the trouble is not apt to be severe, 
seeming to be purely sebaceous in its significance. At the second period 
it is of severer form, the vascular system being more involved. It is the 
case, however, that women are seldom, if ever, afflicted to the same extent 
as men. 
Spirituous liquors are presumed cause of the condition in drinkers, as it 
is universally conceded that such indulgence may originate it. Here it is 
known as the " brandy nose." Free users of port wine are almost sure to 
show certain of the conditions of the affliction. 
Treatment.-This considers, primarily, possible causes. As local reme- 
dies found to be serviceable, Anderson uses hypochloride of sulphur mixed 
with rumex ointment, made as follows: Rumex root, nine ounces ; lard, six 
Fig. 719.-Acne Rosacea. 
* Duhring, in the Photographic Review of Medicine and Surgery, exhibits such a case of 
hypertrophy. DISEASES OF THE FACE. 
905 
ounces; yellow wax, one ounce; water, q.s. Wash and bruise the roots; 
boil for two hours and strain ; evaporate to four ounces; add gradually to the 
lard and wax previously melted, and keep stirring until cold.* Neumann 
recommends mercurial plaster. The writer's favorite means consists in paint- 
ing the part until black with the erysipelas mixture, which see, and following 
this by cloths spread with lanolin and zinc ointment, equal parts. 
Prognosis.-This is favorable as to the first stage; unfavorable as to the 
second. 
* Duhring. CHAPTER LIL 
LUPUS. 
There are two general expressions of lupus: one of these, seen most 
commonly in the adult, is known as lupus erythematosus; the other, met 
with more frequently in the young, is designated lupus vulgaris. 
Lupus Erythematosus.-The characteristic of this condition is an 
irregular, yet more or less roundish, dry sore, appearing upon the face, having 
its situation most commonly either about the bridge or ala of the nose, or 
Fig. 720.-Lupus Erythematosus. 
over the location of the infraorbital foramen, the surface being covered with 
adherent scales. Lupus presenting itself in this form is commonly of most 
chronic condition; if untreated, not being irritated through caustic applica- 
tion nor by scratching or picking off the scabs, it may remain a lifetime in 
the state described. 
Manner of Beginning.-This expression of lupus begins in one of 
two ways: first, and most commonly, as a dry patch toward which attention is 
directed by the formation of scales; second, as several unepitheliated, isolated 
patches, which later enlarge and coalesce, forming in this way one large patch, 
or, it may be, two or three. 
The scales of lupus erythematosus show in their abundance that 
the disease is a cellular new growth ; also, out of a grayish or yellowish 
906 LUPUS. 
907 
aspect sometimes pertaining to them, that it is associated with the sebaceous 
glands. 
Views of Dermatologists as to Origin.-Hebra, because of this 
last-named association, and for the reason that the origin of the disease is not 
infrequently that of seborrhoea, inclined to give it the name of seborrhoea 
congestiva. Kaposi and Thin show that the sweat-glands as well as the seba- 
ceous may be the seat of the disease; while, according to Duhring, to Geber, 
and to Stroganow, all the structures and every layer of the skin may be the 
centre of the morbid process. 
Lupus Vulgaris.-Expressive synonymes for this condition are, wolf- 
gnaw, corroding tetter, malignant herpes. 
Fig. 721.-Lupus Vulgaris. 
Manner of Beginning.-This expression of lupus begins in one of 
several ways: as a papule, as a tubercle, or as a flat infiltration. That, like 
the form just considered, it is not a condition of scrofulosis exclusively is 
proven by the fact of its exceeding rarity when compared with that condition, 
statistics of the American Dermatological Association showing but 42 out of 
16,863 cases of skin diseases reported. 
Parasitic Theory.-Koch demonstrates the presence of a bacillus in 
lupus not distinguishable from that found in phthisis pulmonalis, hence his 
claim that the condition is of parasitic origin,-a claim energetically contested 
by others, who maintain a tuberculous origin for the lesion. 
Commencing in papular form, lupus vulgaris is first observed as a 
number of points situated beneath the epiderm, these being of a reddish or 
brownish color, and associated by intervening tissue not entirely without in- 
duration ; a variety is the verrucous, or scaly wart, form. 908 
A SYSTEM OF ORAL SURGERY. 
Lupus tuberculosus is the disease in the shape of one or several tuber- 
cles ; this is a stage progressive on the first, or, tubercle may be a primary 
expression. 
Infiltrating lupus begins as an effusion among the sub-epidermic struct- 
ures, the corium being the commonest seat: a synonyme for this expression 
is lupus hypertrophicus. 
Progressive History.-However commencing, the history of lupus 
vulgaris is that of progressive ulceration. First, from the breaking down of 
papule, wart, tubercle, or infiltration, a sore of resistive, angry, and threaten- 
ing appearance shows itself; this may not be larger than a pin-head, or it may 
not be smaller than a silver dollar. A peculiarity about the sore is absence 
of indication. In its origin a lupus ulcer aims to cover itself with a scab; 
this grows out of a plastic exudate which concretes into a yellowish or dirty 
grayish crust. Extension of the ulcer is from the circumference of this crust, 
fresh pustules or, not unlikely, blebs appearing, forming, as it were, new nidi 
of the disease. 
Direction of Extension.-Extension is also in the direction of the 
deep structures; a lupus commencing upon the side of the nose not infre- 
quently destroys not only all surrounding parts of the face, but erodes the 
osseous structure beneath until the arch is completely destroyed. (See Fig. 
721.) 
Dermatologists apportion the disease to the poor, the scrofulous, and the 
uncleanly. The author has seen a fair share of cases, and it is his testimony, 
unhesitatingly written, that the class of people affected are likely to be just 
the reverse of these. 
Pathological Anatomy of Lesion.-The pathological anatomy of 
the lesion is interesting but not pertinent clinically. The subject has been 
elaborately studied by the European histologists, but nothing germane to a 
scientific treatment has come of the studies. What the writer learns from 
these investigations only serves the more to confirm him in a conviction of 
the likeness of the condition-certainly of lupus vulgaris-with cancer. Using 
a low-power microscope, Kaposi exposes a recent nodule to consist of various- 
sized, roundish, nest-like masses of neoplasm distributed through the lower 
part of the corium. Lang, Thoma, and Friedlander present varying results 
as influenced by the stages of the diseased part studied by them. Schiippel 
lays stress on the existence of giant cells containing numerous refractive 
nuclei, deemed by Thin, who has examined them exhaustively, to consist of 
diseased blood-vessels. Duhring, grouping the studies, pronounces the etiology 
of the disease obscure, but persistently refuses to identify it with carcinoma; 
he favors, but does not commit himself to, the scrofulous origin. 
Lupus erythematosus separates itself from lupus vulgaris in that 
it is not accompanied by ulceration, and that it confines itself to the surface 
of the skin ; also in its relation with age. 
Tertiary syphilitic ulcers are not unlike the erosions of lupus vul- LUPUS. 
909 
garis; distinguishing marks lie in histories of the two conditions, and absence, 
in the latter, of an offensiveness as to odor so characteristic of the former. 
Acne rosacea is still another disease of resemblance ; distinction lies in 
the pustules of acne, in the dilated vessels, and in the ro^e-red of color when 
compared with the purple of lupus. In assuming a cancer origin for lupus 
vulgaris the author is not to be understood as confounding it with forms of 
the lesion possessed of familiar description. What is meant to be implied is 
existence of close likeness as to clinical histories. Acne rosacea finds a familiar 
illustration in Fig. 719. 
Treatment.-This aims to be alterative. Absence of knowledge of cause 
denies any but empirical practice. Attention is to be given to any systemic 
derangement that exists. Local remedies relate with iodinej iodide of potas- 
sium, the mercurials, sulphur, carbolic acid, zinc, chloral hydrate, bismuth, 
and similar preparations. Tar has been found serviceable. A mixture com- 
posed of equal parts of oil of cade, alcohol, and soft soap is recommended. 
Hebra favors the use of iodine, alone or in combination with glycerin, painted 
over the part until a scab is formed. Cutting away of the surface by means 
of a curette is endorsed by many. Multiple scarification is recommended by 
Volkmann. Burning with the ordinary sun-glass has been tried. The treat- 
ment employed by the author is the same as used by him in cancerous epi- 
thelioma, which see. CHAPTER LUI. 
EPITHELIOMA. 
Epithelioma as a term, when properly applied, is expressive of a variety 
of conditions: A cutaneous horn, an epidermic neoplasm, a subcutaneous 
scirrhoma are alike justly to be grouped under the single name. They are 
epitheliomata. 
Definition of Term.-Epithelioma means relation with epithelial tissue, 
-that, and nothing more. Pathological signification of any special condition 
compels the prefix to the substantive of an adjective. 
The present chapter deals with cancerous epithelioma. 
Cancerous Epithelioma.-By cancerous epithelioma is meant perver- 
sions, related with epithelial structure, arising out of the cancer vice. Cancer 
is the terra incognita of surgery. A question of large clinical import relates 
with the origin of the disease. Is carcinoma primarily of local origin ? Is a 
local manifestation simply an expression of a vice lying back of it ? These 
questions wait solution. An English school contends for a primary consti- 
tutional meaning. The German, and an American school, the latter headed 
notably by the distinguished histologist, J. J. Woodward, late of the Surgeon- 
General's Department at Washington, maintain the origin to be local. Ac- 
cepting the latter authorities to be right, cure of cancer is found in immediate 
recognition and abortion of a local manifestation. The difference between the 
two views is separation between life and death,-a specific remaining undis- 
covered. 
Local Significance.-A cancer sore accepted as holding similar relation 
to the constitutional condition as is held by a chancre to systemic syphilis, 
treatment of the two becomes identical. Immediate recognition and destruc- 
tion of a chancre is the abortion of syphilis; to possess a diagnostic acumen 
capable of distinguishing the incipiency of cancer is to hold in one's hands 
the means of cure. 
Certain experiences of the author, had within the past seventeen years, have 
introduced into his mind some doubt as to the humoral theory. He has cured 
epithelioma diagnosed to be cancerous. He is led to think that skin cancer, 
if taken in time, is to be aborted precisely as is syphilis. 
Carcinoma and Epithelioma.-Granting the success assumed: Are 
carcinoma and epithelial cancer the same disease ? This dispute is gotten 
clear of in the exclusion which characterizes the diagnostic data of the chapter. 
All epitheliomata are not carcinoma. Some epitheliomata are necessarily car- 
910 EPITHELIOMA. 
911 
cinomatous, for the reason that exclusion shows they can be nothing else. 
Cancerous epithelioma is what has been successfully treated by a practice later 
to be described. 
Diagnosis.-The author of this work, in absence of better data, defines 
and treats as cancerous epithelioma every lesion upon the face that the process 
of exclusion cannot determine to be something else. (See Tumors.) 
Varying Attributes.-Whether primarily of local or of systemic 
expression, cancer, like syphilis and scrofulosis, is a vice of varying attri- 
butes, being, in some cases, mild and tractable, in others, strong and uncom- 
batable. 
Self-Classification.-An epithelioma, possessed of a history, classifies 
itself. In absence of history, or of likeness with known benign affections, a 
practitioner places, compulsorily, a disease before him with the neoplasms. 
Accepting the reader as one able to distinguish a self-explainable condition, 
we proceed to a study of cancer seated in the skin of the face. 
Histogenesis.-Viewing first the histogenesis, the idea is to be con- 
veyed that, out of an impression made by the vice considered, abnormal 
epithelial evolution results. The vice intensifying, local expression enlarges; 
being in abeyance, change is at rest; being dead, cure takes the place of 
destruction. 
Time of Life and Seat of.-Cancerous epithelioma seldom shows 
itself before middle life. It is more common to man than to woman. Its 
seat of predilection is the face, markedly the lower lip. Exceptionally it is 
met with in the superior lip. It is rarely seen multiple. 
Forms of.-Three general forms of origin characterize the condition; 
these are the superficial, the infiltrated, and the papillary. A form of 
epithelial cancer met with by the writer first showed itself as a series of 
delicate blebs in front of the ear, these being surrounded by a net-work of 
enlarged capillaries. 
Flat Variety.-The superficial, or flat, variety presents itself as an 
irritation of the epiderm which assumes the form of scales, or of a grouping 
of papules, or of an inflamed sebaceous outlet. (See Lupus.) 
Infiltrated Variety.-The infiltrated variety is illustrated in the indu- 
rations begotten of chronic inflammation. Difference lies in absence of cause 
to explain the effusion. Another beginning of this diversity is in the form 
of indurated points, which later enlarge and coalesce until considerable surface 
is covered. This surface may be raised, but is more commonly as if bound 
and held down by the associated connective tissue. 
Fungiferous Variety.-The third form varies greatly, being in in- 
stances not dissimilar to the common wart, again presenting a cauliflower-like 
excrescence. 
Papillary Form.-Commencing in the skin proper, epithelial cancer is 
apt to assume the papillary shape. Upon a mucous surface it is most com- 
monly met with as an ulcer; at juncture of skin and mucous membrane it is 912 
A SYSTEM OF ORAL SURGERY. 
seen in either of these states. All warts of vascular type, all pigmental and 
other naevi, all single and defined scaly patches, all persistent and unexplain- 
able indurations, all cracks and fissures refusing to heal, are to be looked on 
with concern as of possible relation with the cancer vice. 
Microscopic Character.-In microscopic character epithelial cancer 
differs somewhat with location and stage of the disease. Primarily and 
characteristically it is made up of proliferation in epithelial cells, which cells 
range themselves in groups, and are found pushing their way into adjacent 
parts. These differ but little from the ordinary cell of the part implicated; 
when young they are round and succulent; when old they are caudate or 
elongated. Not infrequently they degenerate, undergoing a fatty metamor- 
phosis. 
Likeness to Split Turnip.-The cut surface of an epithelial cancerous 
tumor shows a face not unlike that of a split turnip; it is hard, white, suc- 
culent. 
Granulative Expression.-An epithelial cancerous ulcer is fissured, 
vascular, and proliferating; its face is covered with giant granulations. 
Significance lying with Epithelium.-Epithelial cancer is not 
debarred by depth of surface, the signification lying in the presence of epithe- 
lium. Parts histologically connected with skin or mucous surfaces, wherever 
situated, as, for example, the liver, pancreas, frontal sinus, vermiform appendix, 
being attacked by cancer, would or would not show the epithelial expression 
according to tissue implicated. Parts histologically disconnected, as the sub- 
cutaneous connective tissue, find involvement in contiguity of structure. 
Gland-like Ingrowths.-Epithelial growths, as suggested by Billroth, 
" gland-like ingrowths," might be inferred not infrequently to diffuse into 
the spaces between the connective-tissue bundles, where lymph circulates, for 
there the structure offers least resistance. These are the tubes and cylinders 
which Koster thinks he has proved lie solely in the lymphatic vessels. 
Epithelial Pearls.-The epithelial pearls, described by histologists, are 
a result of a globular union of cells of the flat variety ; their development 
being, most likely, as has been suggested by Billroth, from the increasing 
division of a number of conglomerate cells, the peripheral layer being flattened 
by pressure against not very distensible surrounding parts. 
Treatment.-This, as will be inferred, is much at odds and ends. The 
humoral theory being that commonly accepted for the epithelial, as for all 
other forms of cancer, and nothing in the direction of a specific being known, 
practice has been purely empirical. To avoid doing harm has had more of 
significance in it than has hope of affording cure. In every case in which 
the author is at all in doubt, the treatment adopted by him is that of a sooth- 
ing nature. Cerate of oxide of zinc, thickened with oxalate of cerium, does 
no ill if no good; the combination is judiciously directed on occasion of a 
first interview. To feel one's way is the meaning of prescribing by exclusion ; 
a placebo affords time for the making up of a conclusion. EPITHELIOMA. 
913 
Use of Caustics.-Caustics hold prominent place in the practice of the 
day. If used at all, there is to be no half-way measure in the application. 
Nothing is so provocative of malignancy in the cancer vice as the application 
of a means not fully and completely radical as an extirpative destruction is 
concerned. Caustics used to destroy epithelial lesions are of various kinds; 
the Vienna paste is widely preferred; this is the potassa cum calce of the 
Pharmacopoeia. It is employed by retaining an application in place from ten 
to twenty minutes, succeeding it with an emollient poultice. Landolfi's caustic 
is as follows: 
g Bromin. chlorid., 3 parts; 
Zinci, 2 parts; 
Antimon., 1 part; 
Pulv. rad. glycyrrh., 1 part. M. 
Still another is called Fell's : 
U Pulv. rad. sanguinar. Canaden., ; 
Zinci chloridi, 30; 
Aquae, f§ij. M. 
A thick paste is formed. 
Mackey's Cauterant.-A cauterant used by Dr. Mackey, of Edinburgh, 
consists of four parts of corrosive sublimate combined with thirty of glycerin. 
This makes a paint which is allowed to remain in contact with the part four 
hours; the application being followed by a warm-water dressing; the eschar 
sloughs in from three to six days. 
The author desires to express great personal fears of any and all cauterants; 
repeating, and laying decided stress on, the injunction " to use with 
radical freedom or not use at all." 
Resorcin.-Resorcin is reported as being used with excellent results in 
the treatment of cancerous growths upon the face. An ointment is to be 
made composed of half and half of resorcin and vaseline. This ointment 
forms eschars which fall off satisfactorily. The ulcers are to be dressed with 
iodoform or vaseline. 
Nitrate of Silver.-The employment of nitrate of silver cannot be too 
emphatically denounced. In no instance, when used with a cauterant in- 
tention, does it do anything but harm. Special mention is made of this last- 
named application for the reason that the practice of touching unfamiliar 
sores with it is so very common. 
Conditions inviting Operation.-Epithelioma appearing in tumor 
form upon, or in the substance of, the lower lip, invites removal by the knife 
in proportion as a condition of concentration is expressed by hardness and 
non-infiltration. Fig. 722 shows such a tumor. In the instance illustrated, 
the lesion, together with almost the whole of the lip, was removed by a 
triangular-shaped section. Such section is the common manner of ablating 
these growths; to promise anything, a wide margin is to be cut away. 914 
A SYSTEM OF ORAL SURGERY. 
Illustrative Case.-Fig. 723 shows one aspect of a case having the 
following history: Col. W., merchant. Epithelioma involving, when first 
seen, lip, tongue, and cheeks,-state hopeless. The disease in this instance 
began as a minute tubercle just over the genial bodies of the inferior maxilla; 
Fig. 723. 
Fig. 722. 
little was thought about it, and it received attention only when found ulcer- 
ating, such attention consisting in the application of caustics. Aggravated by 
the treatment, the ulcer commenced to spread rapidly, defying, when too late 
understood, every means employed for its arrest. Shortly after coming under 
care of the author, the lip fell off in mass, the root of the tongue became 
indurated to such extent as to interfere with both respiration and degluti- 
tion, and the sufferer, who had been a fine robust man, died from prostration. 
In this instance the patient had, for many years, been in the habit of holding 
the tip of his cigar between the tongue and floor of the mouth. Many 
persons, however, so hold cigars without cancerous disease resulting. 
Illustrative Case.-Fig. 724, being from life, has the following history : 
M. G., aged about twenty-one, farmer by occupation, was sent for consultation 
by Dr. Edward Townsend, whose dental patient 
he was. Dr. Townsend, while treating a bicuspid 
tooth, remarked at the neck a slight ulceration, 
which lesion, appearing of little consequence, 
commanded scarcely more than a passing thought. 
Attempting, however, at a later period, a cure, 
the obstinacy of the sore excited his suspicions, 
and, being unwilling to assume the trouble of 
the case, he directed the patient to the writer's 
care. Examination made on first meeting the 
case exhibited a small ulcer on the left superior 
gum between the bicuspid teeth, in size about 
half as large as the silver three-cent piece, 
jagged, covered with a whitish gummy secretion, and apparently superficial. 
The passage of a sharp probe through the centre of the ulcer revealed carious, 
Fig. 724.-View of Case 
AS FIRST SEEN. EPITHELIOMA. 
915 
softened, and periosteally denuded bone. Impressed with the character of the 
ulceration, yet unwilling while there might be an unrefuted doubt, however 
slight, to depress the patient by informing him of the nature of his disease, 
he was placed under ordinary treatment for a period of two weeks, at the end 
of which time, finding the experience in treatment to agree with that of Dr. 
Townsend, his condition was laid before him, immediate resection of the 
affected and adjoining parts being advised. Refusing to submit, the patient 
desired consultation, and in turn the advice of every prominent surgeon in the 
city was obtained. Opinions differing, he, by advice, submitted himself to 
various proposed remedies, being treated two weeks by one gentleman, eight 
weeks by a second, and nine by a third, the disease progressing, though slowly, 
all these weeks. At the end of this time operation was again proposed and 
insisted on, the gentleman being informed of the necessarily increased magni- 
tude of the portion of bone and soft parts to be removed ; on his still refusing, 
further responsibility in the case was declined. The patient making the 
author a visit at a later period, the ulceration was found involving the Ste- 
nonian duct and extending from the symphysis to the tuberosity of the bone. 
At this visit he was told of the utter hopelessness of any operation for his 
relief, the disease being too extensive. From this time until his death, which 
happened in a few months, he was in the hands of different advertising im- 
postors. Whether or not an early operation would have saved the person 
from his doom one may not say, but from a reasonable experience in the 
direction, it is to be asserted that without the performance of such proposed 
operation he had no possible chance. 
Illustrative Case.-Fig. 725 is from a photograph. It shows a patient 
under care of the author six months after the commencement of an infiltrating 
epitheliomatous cancer ; three months later 
death ensued from exhaustion. In this 
instance the first trouble from the disease 
was in stiffness of the lower lip; a very 
short time after papillary protuberances 
showed themselves; these, in instances, 
coalesced, forming the more prominent of 
the tumors seen. The infiltration ex- 
tended rapidly to neighboring parts, the 
neck becoming indurated; a choked disk 
showed itself to ophthalmoscopic illumina- 
tion. Vascularity was excessive. In this 
case the choked disk, and as well the entire 
condition, contraindicated the trial of any direct means of cure. The patient 
died without attempt being made to save him. 
Treatment of cancerous epithelioma by injection of bromine is commended 
by Dr. Wynn Williams. A patient exhibited by this practitioner to the Ob- 
stetrical Society of London was a person nearly the whole of whose lower lip 
Fig. 725. 916 
A SYSTEM OF ORAL SUROERY. 
had been removed for epithelioma eighteen months previously. The disease 
shortly appearing in the cicatrix, the growth was successfully treated by two 
injections of bromine, twenty drops to a drachm of spirit. There was 
later no appearance of any return. 
Injections of glacial acetic acid and of Monsel's solution of iron, both 
of which have been highly recommended, have been submitted by the author 
to exhaustive tests. No good results ensued. 
Treatment by the Knife.-Treatment by the knife consists in com- 
plete ablation of the diseased mass. Unless an extirpation can be thorough, 
there is no excuse for attempting an operation. 
Medicines used.-Tn the numberless cases of epithelioma where the 
most superficial observer would recognize, out of reason of an existing infil- 
tration, the impropriety of attempt at cure by operation, it becomes a necessity 
to support the strength and contribute to the comfort of the patient. Here 
medicines found most antagonistic to the disease are indicated. Of such local 
means the author would highly recommend the daily use, by means of an 
atomizer, of the following combination : 
R Glycerini, gj : 
Acidi carbolici, 3j 5 
Sodae sulphitis, ; 
Aquae, ^x. M. 
Not only will this preparation be found affording much relief from pain, 
and to be softening and soothing, but it has seemed to the author possessed of 
marked influence in way of retarding the progress of the disease. It may 
also be administered internally in teaspoonful doses. 
Hydrastis Canadensis.-The American drug hydrastis Canadensis, 
used in lotion, is highly commended by Dr. Edwin Payne, of London, for its 
pain-obtunding character and for its power in keeping the surface in a healthy 
condition and free from offensive odor. The strength prescribed is a drachm 
of the tincture to eight ounces of water. In this connection phenol-sodique 
is to be mentioned; the author has tried no remedy that seems more grateful 
to a patient: it is not only an obtunder but a most reliable disinfectant. It is 
employed diluted pro re nata with water. 
Vallet's Mass.-Vallet's mass, administered in doses of from five to 
ten grains a day, is highly recommended by Professor H. H. Smith. One 
case, as an example, is mentioned by this surgeon, where, his having been con- 
sulted with a view to operating, and having declined on account of the rapid 
advance of the disease, he suggested the use of the medicine, conjoined with 
the application of the powdered carbonate to the sore, and the patient lived 
eight years without the sore having made any very great progress. 
Ammonio-Chloride of Iron.-Justamond, of London, also favored 
the internal use of iron, and was in the habit of giving from sixty to one EPITHELIOMA. 
917 
hundred and twenty grains of the ammonio-chloride a day. Dr. Carmichael, 
of Dublin, expressed himself as deriving much benefit from washing cancerous 
ulcerations with a solution of sulphate of iron. 
Chloride of Zinc.-Chloride of zinc in solution is, in this direction, a 
favorite preparation : the power of this salt to arrest phagedenic action is re- 
markable; it is peculiarly alterative. Judiciously applied to any indolent, 
irritable, or bad ulcer, it will be found to influence markedly to a change for 
the better. Concerning the use of this agent in cancer, we have many com- 
mendations, particularly from European surgeons; but, as can be very readily 
apprehended, nowhere in the range of its application is more judgment re- 
quired for a judicious employment than here, for it is a cauterant, a stimulant, 
an antiseptic, and an alterative. Dr. Zuerine, of Vienna, relates a case of can- 
cerous ulceration of the septum nasi which threatened to destroy the whole 
nose; one grain and a half of the chloride of zinc, he says, were dissolved in 
one ounce of distilled water, and, the scab being removed, the ulcer was 
pencilled over several times a day with the solution ; at the end of a fortnight 
a healthy granulating surface was found underneath the thick crust which 
covered the sore, and this crust being occasionally removed, and the solution 
reapplied, cicatrization was complete in five weeks. 
Tuson on Use of Chlorine.-Mr. Tuson has published some cases to 
show the value of certain preparations of chlorine in cancerous affections. In 
one that he refers to there was an extensive cancerous disease of the right 
breast and neck, which was treated unsuccessfully for a long time, till a paste 
was used, made of one part of chloride of zinc to three of flour; this was 
well mixed, and moistened with water, and then applied over the ulcerated 
part. The zinc was also given internally ; half a grain was ordered in a wine- 
glassful of caraway-water every morning. The chloride of zinc paste was 
used twice, and when the second slough separated, the ulcerated surface healed 
kindly. The cancerous deposition continued for some time, and the dose of 
the metal was increased to three-quarters of a grain and continued for three 
months. The improvement, although very striking, was not permanent, as 
the patient suffered a relapse which ended fatally. The case, however, was 
sufficient to show that the treatment had made considerable impression on the 
disease, and especially in healing the open cancer, which Mr. Tuson had found 
to be the result in several other cases. 
Necessity for Opiates.-The great suffering associated with carcinoma 
makes necessary the free use of opiates, both locally and internally. Stramo- 
nium, belladonna, aconite, hamamelis, opium and its preparations, are highly 
recommended. As much as twenty grains of sulphate of morphia have been 
administered during the course of a single twenty-four hours in certain ex- 
ceptional cases. Injection by the subcutaneous method, where morphia is to 
be long continued, is now generally resorted to. Batley's solution answers well 
for this manner of use. For continuous stomachic administration of the 
opiate preparations, preference is to be given to the bi-meconate of morphia; 918 
A SYSTEM OF ORAL SURGERY. 
the officinal strength of this medicine, prepared in solution, is that of laudanum, 
twenty-five drops representing one grain of opium. 
Morphia as commonly used.-While commending the use of mor- 
phia hypodermically, the author, with practitioners at large, is made to feel 
that the medicine is to be so prescribed as to be more or less at command of the 
patient. To such end the liquor morphias sulphatis is supplied. The strength of 
this is one grain of sulphate of morphia to the ounce of water. Patients com- 
mence with a teaspoonful as a dose, but are commonly found to advance shortly 
to a tablespoonful, the latter dose answering so long as the pain continues at all 
moderate. Sickness of the stomach, an almost universal attendant on the use 
of morphia, is controlled by use of sulphate of atropia, the dose of which is 
to be the one-hundred-and-twenty-fifth of a grain. This last may be added 
to the morphia solution, as is always done when the syringe is employed, or it 
may be prescribed in tablet form ; one tablet to be taken with each quarter 
grain of the hypnotic. The medicines antidote each other. 
Supervention of Erysipelas.-A complication sometimes occurring 
with epithelioma about the mouth is the supervention of erysipelas. A pe- 
culiarity of these cases is that the inflammation does not exhibit its specific 
complexion, but a patient is found looking as if in a few hours his disease had 
made more progress than before in months, or perhaps in years. The best 
treatment the author has found for such a complication consists in the use of 
what on a previous page has been alluded to as almost a specific, the propor- 
tions being varied to suit cases: 
Ji Tincturas ferri chloridi, ; 
Quiniae sulphatis, 3j; 
Tincturae cinchonas, 5ij to §ss. M. 
Sig.-To be brushed over the parts every hour. 
Salivation.-Another complication occasionally met with is the existence 
of salivation. The author once had as a patient a lady who was compelled to 
keep a wash-bowl constantly upon her lap: the water literally flowed from her 
mouth. (See Dribbling.') 
Caution as to Treatment.-In doubtful cases, as will bear to be re- 
peated, great caution is demanded that a practitioner do not more harm than 
good. A safe rule is to do nothing unless one knows exactly what to do. 
More patients have the fatal termination accelerated than retarded by attempts 
at cure of epithelial cancer. That which is the treatment of lupus erythema- 
tosus in its milder aspects is here good practice to pursue in doubtful cases. 
The affected part may be sprinkled with iodized starch, ten grains of iodine to 
an ounce of finely-pulverized starch. Another most excellent powder is com- 
posed of subnitrate of bismuth, calomel, and oxide of zinc in equal parts. 
Still another is found in lycopodium. Tar and zinc ointments in like propor- 
tions constitute an excellent application. Sulphur proves at times serviceable. 
Iodide of potassium and iodine, of each half a scruple, mixed up with a EPITHELIOMA. 
919 
drachm of glycerin, is highly recommended by Anderson. Duhring, in the 
treatment of lupus erythematosus, thinks favorably of an ointment made by 
mixing up with an ounce of simple cerate from a scruple to a drachm of 
chrysophanic or pyrogallic acid. 
Chlorate of Potassium.-The author has found much service in the 
free employment of this salt in a finely-pulverized form. The powder is 
furnished the patient, and he is directed to apply it freely. Use of it is 
highly commended. 
Bacilli Theory.-If cancerous epithelioma, as maintained by some, 
originates in presence of a bacillus, the use of a solution of bichloride of 
mercury, one grain to the ounce of water, is to be recommended. 
Treatment by Erosion.-Treatment of strictly surface cancer may 
try the method of erosion by the curette as practised with much satisfaction 
in surface lupus; recommended for this last by Auspitz, of Germany, and by 
Wigglesworth, of our own country. 
Author's Treatment.-The author concludes the chapter by re- 
serving a place of prominent signification for a treatment referred to at 
commencement of the chapter and to which special attention is directed,-a 
treatment which, in every individual instance where he has found the opera- 
tion practicable, has resulted in cure. It is desired to lay stress on the 
suggestion that it is the most promising means of treatment yet tried. The 
practice is founded on an inferred catalysis resulting from bringing in contact 
and into vital apposition tissues differently re- 
lated. That is to say, a patient laboring under 
epithelial cancer of the face is to have the 
disease thoroughly and widely removed by the 
knife, and the seat of the ablated part occupied 
by structure brought from neighboring or dis- 
tant parts. Cases of epithelial cancer occur, 
however, in positions where plastic operations 
are impossible. In all such instances it has 
become a favorite practice with the writer to 
scrape upon the face of the sore, at each dress- 
ing, epiderm taken from his own person or from 
that of a bystander. The scales found most 
catalytic are those nearest the derm. Dr. Cryer 
has introduced curryings from the horse. The 
part of the animal from which the epiderm is 
taken is to be first thoroughly washed. 
Illustrative Case.-Fig. 726 exhibits an 
operation practised by the writer for the relief 
of an epithelial ulceration involving the full lower eyelid and a limited portion 
of the upper. The study of this operation illustrates a class in the direction. 
First, as seen in the diagram, the diseased structure is fully removed through 
Fig. 726. 920 
A SYSTEM OF ORAL SURGERY. 
incision associated with the uninvolved surrounding parts. Second, the hemor- 
rhage being entirely controlled, a flap to replace the lost part was made, as 
shown in the inferior lines; this flap being raised was carried upward, the 
convex portion being associated with the concave break resulting from the 
section of the upper lid,-the slightly concave portion representing the supe- 
rior line of the lower lid. The triangular portion, seen in the diagram to 
exist at the side of the ala between the two incisions, was next dissected from 
its apex toward its base, and being directed below what, in the diagram, is 
seen to be the inferior flap, was thus brought into relation with healthier 
influences, while a similar good was secured for the new eyelid, in making it 
of tissue which had not been in immediate juxtaposition with the diseased part 
removed. 
The position of this cancer is seen to be of most unpromising relation. 
The operation was done in 1869. There has been no return. 
In 1875 an epithelioma situated on the side of the nose of a nephew of 
the gentleman whose case is referred to above, was treated by a flap trans- 
ferred from the hair-line of the forehead. Cure remained complete when the 
patient was last heard from several years later. 
Fig. 727.-Flap Operation in Treatment of Carcinoma. 
Illustrative Case.-An operation of extensive transplantation was 
made by the author at the Hospital of Oral Surgery, where the disease 
involved both eyelids, the contents of the orbit, including the eye, the nasal 
arch, and the cribriform plate of the ethmoid bone, all the parts named being EPITHELIOMA. 
921 
removed, and their places occupied by a flap taken from over the scapula, its 
pedicle being at the mastoid process of the os temporis. Being fitted into its 
new place, this pedicle was crucially incised 
where it overlay the circumference of the 
orbit, and the flaps thus secured were turned 
into this cavity. Unfortunately, some slough- 
ing occurred which interfered with the aes- 
thetic results of the performance ; but aside 
from this a good was secured which de- 
layed the progress of the disease for over a 
year. 
This case was not a practicable one as 
to prospect of permanent cure, the disease 
being of too complicated ramification and 
relation. Repeating the performance, two 
flaps would be made; one to be taken from 
the neck, the other from the forehead. The 
sloughing in the case was adverse to a fair 
trial of the influence in cases of such magnitude, but further tests are en- 
couraged by the result obtained. (Fig. 727.) 
Fig. 728. 
Fig. 729 
Illustrative Case.-Fig. 728 shows steps of an operation performed 
upon the person of a lady who had submitted to three previous ablations of a 922 
A SYSTEM OF ORAL SURGERY. 
diagnosed epithelial cancer situated as shown in Subfig. 1, the disease in each 
case by its immediate return preventing the healing of the wound made. The 
lines marked upon the side of the face designate the part removed. Subfig. 2 
marks a flap of replacement. Nine years have elapsed; cure remains perfect. 
Illustrative Case.-Fig. 729 shows an operation where a flap of re- 
placement is taken from a distant part. The cut explains the details. The 
cap seen upon the head, and the rollers attached to the wrist, are to the end 
of securing fixation of the hand to the face. Union secured, the pedicle is 
to be cut. Three days suffices for the hand to be retained in the position 
shown. This case being one pertaining to the practice of the Hospital of 
Oral Surgery, a clinical report of the procedure made at the time, and pub- 
lished, is appended as a foot-note, with the idea of affording a lesson to 
students.* 
* The gentleman before us has an epithelioma involving his lower lip where that part 
relates with the cheek. Already has the condition been treated after the ordinary manner 
of operating, and already has the disease returned. It is a peculiar satisfaction to approach 
a case of this kind with a confidence inspired of success. I have told the patient I will cure 
him, and I am assured out of my experience that I will. 
What I propose to do is,-first, cut away the ulcer from its base; second, replace the part 
removed by a flap taken from the hypothenar eminence of the left hand. The gentleman, 
himself as much interested in the operation as I am, proposes to endure the cutting without 
an anaesthetic: he wants to understand the matter. I refer you to him as an example 
encouraging to men pursuing an object under difficulties. 
» ♦ 
We are now ready for the operation, and to the features of it I particularly commend 
your attention. 
First, I remove the portion of face upon which the disease has fixed itself. I do this by 
means of an elliptic-shaped cut. . . . This is now done, and I show you clearly exposed 
the depressed anguli oris muscle. The parts, as you see, are extra-vascular; this they 
always are where cancer is present: vascularity is diagnostic. Three vessels are bleeding 
with a freedom which requires the use of ligatures. We tie them and dry the parts. This 
done, we wait for the process of glazing. 
The courage of the gentleman not being abated by this first step of the operation, we 
pass to the second. Having the hand firmly held, I repeat the incision by ellipse along 
the hypothenar eminence. Observe, however, I do not cut the piece entirely away from its 
attachments, as upon the face. I leave a pedicle: this with a view of temporarily feeding 
the ellipse. To cut about the hand is excessively painful. Our patient is without feeling, 
or, what amounts to about the same thing, is possessed of endurance stronger than pain. 
If, however, he can stand this work, assuredly we can; the courage is not at all in cutting, 
but in submitting to be cut. 
The third step implies the stitching of the flap from the hand into the place prepared 
for it upon the face. This is a feat not without difficulty. First, I place over the vault of 
the head a cap made to fit accurately. Next I attach a double bandage about the wrist of 
the hand operated upon. I now close with stitches of the interrupted suture the wound of 
the hand, leaving the flap pendent. Lifting the hand to the head and directing the palm 
to the side of the face, observe with what nicety I find myself able to adapt part to part. 
You wondered, perhaps, why I cut so long a pedicle. Had I not done that, I could never, 
as you must see, have accomplished the stitching now attempted. . . . The stitching is now 
finished to my entire satisfaction. 
The hand is next to be attached immovably to the side of the face. This with the means 
prepared is no difficult matter. I pass one roller obliquely over the vault and a second 
your attention. EPITHELIOMA. 
923 
Commendation of Plan in Treatment of Lupus.-The author 
commends the same plan of treatment for the radical cure of lupus. 
beneath the chin. I now proceed after the manner of a double Barton bandage,-a style of 
dressing with which you are all familiar. 
The hand and wrist firmly fixed, a succeeding step is the support of the elbow and fore- 
arm. A simple manner of accomplishing this is to button the patient's vest over the parts. 
A second plan-one I shall adopt this morning-is found in the use of the third roller of 
the Velpeau bandage. This done, nothing remains but to hope for the life of the flap and 
to separate it from the hand at the proper time,-a period that will vary from forty-eight to 
seventy-eight hours. 
Restlessness and irritability being associates of plastic operations, sedatives are indicated. 
In the present instance I will wait, however. The strength of resistance possessed by our 
patient may be proof against irritability. Opiates, where they do no good, always do harm; 
never use them unnecessarily. If restlessness supervene, I will prescribe thirty-grain doses 
of bromide of potassium. If the pulse run up, I will conjoin with this five-drop doses of 
tincture of veratrum viride. If fever show itself, I will direct tablespoonful doses of a 
formula as follows: 
R Liguoris potassii citratis, 3 i i j; 
Spiritus aetheris nitrosi, 3ss; 
Antimonii et potassii tartratis, 
Morphias acetatis, aa gr. j. 
Sulphate of morphia you all know as the great sedative; with it you can quiet to any 
degree, even down to the stillness of death itself. The dose is from one-eighth to half a 
grain repeated pro re nata. Many surgeons recommend that immediately after all opera- 
tions of consequence a one-grain pill of morphia be given. If the medicine be exhibited 
in a vehicle of judgment, the prescription proves no bad one. 
In doing plastic operations, where immediate union is the tummum bonum, never use 
chloroform. Chloroform interferes with the process of glazing, and without the glaze the 
promise is little. 
Another matter to look after in operations of the kind just done is maceration. Between 
the palm of the hand and the face I will lay a piece of old and soft linen. Maceration 
comes on very rapidly where the weather is warm enough to excite perspiration. From 
lack of such simple care as is expressed in the use of this little strip of cloth many other- 
wise perfect operations have proved blank failures. Do not overlook the fact that a flap 
does its utmost in preserving its vitality; never put unnecessary work on it. 
A flap doing well is to be let alone. Think not to make a well thing better. Where a 
diminishing vitality is seen, as shown by a flap growing dark, dry heat and other stimulants 
are to be employed : not only local but constitutional stimulants. 
Preparation of a patient for a plastic operation is a matter not to be left unconsidered- 
A plethoric man is to be reduced, an anaemic one built up. With the first the lancet, or 
preferably, as a rule, sulphate of magnesia is to be used; the latter demands iron, gentian, 
and similar tonics. 
Another very important-indeed, in a sense, all-important-matter associates with plastic 
surgery,-namely, calculation. Never do a new or untried operation on a living face until 
after you have done it on a dead one, or, if this last be impracticable, do it upon a paper 
face. I have seen in my time a surgeon standing utterly confounded in the presence of a 
large class, a gTeat wound before him, a flap and pedicle too short to fill up; nothing fitting. 
Make a blunder of that kind once, and you will never get over it; it will be found to have 
undermined your confidence, and without that quality a surgeon is nothing. 
[Note.-The flap was separated from the hand forty-eight hours after the operation. 
Two weeks later the patient was shown to the class, the union and relation of the parts being 
complete. The wound in the hand was getting well rapidly, part of this latter cure being 
necessarily by granulative action. The scar upon the face promises to be almost unobserv- 
able after a very short time.] 924 
A SYSTEM OF ORAL SV ROE RY. 
Controlling Progress of Disease.-The following combination 
seems to control the progress of carcinoma: iodoformi, gr. x; olei eucalypti, 
Fig. 730. 
Microscopic view of a section of a squamous epithelioma. The cells are seen to be 
massed in isolated groups. On the left side are the pearly bodies showing a concentric 
or laminated arrangement. (After Formad.) 
gtt. xx; ung. aquae rosae, oj. Belladonna ointment applied about the circum- 
ference of a sore is obtunding. In inflammatory accidents the accompanying 
endorses itself: plumbi acetatis, 5j J tinct. opii, j ; aquae ferventis. Oj. 
Apply by means of a baker's-bread poultice. CHAPTER LIV. 
OPERATIONS UPON THE LIPS AND CHEEK. 
Harelip.-This defect consists in a break, single or double, in the con- 
tinuity of the lip. The deficiency in its typal form is almost precisely similar 
to that existing naturally in the hare and rabbit, from which resemblance it has 
taken its name. When congenital, it is always found associated with the 
superior lip. 
Significance of Operation.-A general idea of the operation for the 
relief of harelip, and indeed the one which comprises the principles of the 
cure, is, that the margins of the cleft, or break, be pared, be brought together, 
and held in apposition until nature shall secure a union. There are, however, 
nice surgico-artistic associations which are to be studied in connection with 
such principles of operation. Cutting manipulations upon the face, and espe- 
cially about the lips, claim more than ordinary skill and judgment. Such 
skill and judgment the practitioner is to be prepared to exercise, if not for 
humanity's sake, at least for that of his own credit and reputation. As truly 
remarked by the skilful surgeon, Mr. Skey, " on the more or less perfect 
result of such operations depend the appearance and expression of the patient 
for life." Surely, just so far as an operator shall beautify or mar is the com- 
fort of the patient, as well as his own satisfaction, influenced. 
General Considerations.-A proper and comprehensive study of hare- 
lip divides itself into three subjects of special signification : 
1st. The time of life best suited to the operation. 
2d. The condition of the patient. 
3d. The mode of operating. 
In making up the sum of an operation, a surgeon is to consider, regard- 
less of the age of the patient, the amount of shock such operation is to give, 
and the ability of the patient to bear it. This at once brings up the char- 
acter of the defect, and the amount of manipulative proceeding necessary to 
a cure. A bad double cleft would inflict a greater amount of pain than 
a simple single one, consequently would inflict a shock double or treble in 
measure. Now, every man, woman, and child in the world has a certain 
amount of physique, and no more. The experience and physiological knowl- 
edge of the surgeon should enable him to weigh this life-force. He must 
decide, in the first place, whether or not his patient be equal in such force 
to the demands of a proposed operation. He must consider the condition 
of the patient. This brings up the second of the special propositions, or 
925 926 
A SYSTEM OF ORAL SURGERY. 
stand-points, from which the operation is to be studied. The possession of 
a capable physique does not imply that life-force has not, like the tide, 
its ebb and flow. A child may have proper development, yet at the time 
when presented for operation may labor under temporary depres- 
sion, the result, perhaps, of functional disturbances. One, for example, just 
convalescent from cholera infantum, or just recovered from some of the ex- 
anthemata, would certainly not be so fit a subject for cutting as though it had 
not suffered; it may have borne the demands made upon it very well, and 
come out of the ordeal looking strong; but then it is the last feather that 
breaks the camel's back; the physique that endured bravely the one demand 
may not have a residue of force on hand that will just then meet another. 
Give such a system time; get it back to the condition in which the first de- 
mand found it, and you then have it certainly capable of the same resist- 
ance and of the same endurance. Again, a patient may not be up to the 
required tone, and yet circumstances render a speedy operation desirable. 
We can assist nature. Exercise, fresh air, and proper food will do 
much. The last may imply that the milk of the mother, if the child be 
nursing, is exchanged for that of a nurse. Who has not examined the milk 
of a mother or wet-nurse and found it greatly deficient in some important con- 
stituent? The author has seen babes growing weaker and more puny day 
by day; has seen physicians baffled because they could find no one portion of 
the economy less healthy than another. He has seen the microscopist take 
the milk on which such a babe has been feeding, and, looking at it through his 
glasses, find large quantities of cholesterin. A change of milk has 
effected an immediate change in the health of the child. A babe may have 
fibrinous blood to excess, tending to undue circulatory excitement, or the 
lymph which such blood would exude might be so corpuscular in character 
that a wound would at once take on suppurative action. Either condition is 
adverse to an operation. We have, however, alteratives for the one and tonics 
for the other. A seemingly strong child can be in a typhoid state, and a blush- 
ing cheek may be but the effect of hectic or excitement; typhoid blood has, 
comparatively, no fibrin. If you were to perform an operation on a patient 
so conditioned, you would be sure to have a failure for your pains. The 
writer has had under care children in just such a typhoid state ; the 
pulse would be bounding and the face always flushed: such quick pulse and 
flush are, however, resultant of this very deficiency in blood. A child may be 
cutting its teeth, yet this does not necessarily contraindicate an operation. 
It is not every child that has convulsions and kindred troubles with the cut- 
ting of teeth ; many an infant goes through the whole process of dentition 
without cause on which to ground a sob. If a child cutting teeth be brought 
to the surgeon, with an operation for harelip to be performed, and there 
be associated with the dentition no general or special local disturbance, why 
should he not proceed, cxteris paribus, at once to operate? There are no 
objections to so doing. OPERATIONS UPON THE LIPS AND CHEEK. 
927 
Period of Selection for Operation.-The author, who has operated 
on such number and conditions of harelip cases as to afford confidence in his 
experiences, prefers that period which precedes the eruption of the first teeth. 
In babes of such age he has frequently been able to remove the first pin in 
twenty-four hours, and the remainder at the end of the second day. Any 
time between the eighth week and the sixth month is to be esteemed a period 
of selection. Operations have been performed by him after the thirtieth year. 
Operation.-The next consideration is the performance itself,-the 
modifications of the one principal operation, and the variety of clefts in- 
fluencing modifications. 
A basis operation is best represented by a simple V-cleft, having the 
mesial line of the lip as its centre,-the indication being to restore such lip to 
a normal contour. (See Fig. 731.) On examination, we find that a normal lip 
has no break in its continuity; we find what may be termed the centre of the 
lip represented at its free margin by a pro- 
jection of more or less graceful curve. We 
find, extending from this free margin up to 
the septum nasi, and bounded laterally by the 
alae, a fossa,-the fossa labialis. From this 
fossa we find the lip on either side spreading 
itself out to be lost in the cheek. To meet 
the indications of this case we are to 
remedy the break in the continuity, create a 
mesial projection, and give to the centre a 
fossa. To fulfil such indications requires a study of the conditions from a 
surgico-artistic stand-point. We want, first, to correct the cleft. This in itself 
is easy of accomplishment; we have only to pare the edges and sew, or pin, 
the raw surfaces together. In viewing this first step a little more closely, we 
perceive that a common V-paring from the edges of the V-break would defeat 
our purpose in securing either a centre fossa or a mesial projection; the mode 
of bringing the parts together would put on the stretch such fibres of the 
orbicular muscle as are associated with the margin of the lip, while all that 
portion farther up would be comparatively relaxed; thus our fossa would be 
a promontory and our soft median swell a stretched mucous membrane. 
Such an operation would, then, in meeting the first indication, defeat the two 
others. We must, therefore, instead of the V-cut, seek a better; for on the 
way in which we pare our edges depends the fulfilment of the three indica- 
tions. An ellipse suggests itself, and such a paring will, measurably, meet 
our wants. 1st. It enables the edges of the cleft to be brought together. 
2d. The centre of the ellipse is its transverse greatest diameter, and this centre 
is the centre of the lip. When we bring together this most widely separated 
part, it necessarily projects the most yielding surface, and such surface is the 
free symphysis of the lip ; thus the second indication is met. 3d. The greatest 
stretch on the muscle is in the site of the myrtiform fossa, with a necessary 
Fig. 731.-V-Incision in the 
Operation for Harelip. 928 
A SYSTEM OF ORAL SURGERY. 
relaxation above and below; and thus the last indication is met; for, as the 
result of such a condition of the parts, we have a fossa formed and a promon- 
tory at the free mesial line. 
Remarks.-The paring of a cleft is always to be constant in the one 
feature of being V-shaped, as reference is had to the base of the V looking 
toward the throat; this allows for excess in the retraction of the skin over 
the mucous membrane. If this precaution be neglected, a difficulty is likely 
to be experienced in the gaping of the cutaneous portion of the wound. 
Means for Retaining Paring in Apposition.-The subject of 
retaining the parts in apposition, with regard to suture material, has elicited 
much controversy. The ordinary operation is as follows. After the edges of 
the cleft have been pared, a needle threaded with the ordinary waxed silk is 
taken up and passed through the free margins of the lip, the parts being 
brought together. This insures satisfactory approximation at this point. 
Next three ordinary steel pins are passed at equidistant points on the lip,- 
they are to go, in depth, at least half its thickness; these pins are to enter 
and emerge at least five lines on each side of the fissure. Silk ligature stuff, 
in the shape of the figure-of-eight, is now to be passed about and around these 
pins. (See Plate VI., Fig. 5.) Adhesive strips are next passed over the 
pins, a slit being made for their accommodation; the object of these strips is 
to press tissue toward the wound, preventing, through such support, undue 
tension. If blood oozes and clots upon the ligature, it is favorable rather 
than otherwise, as it adds to the support of the parts. After two or three 
days the pins are carefully removed by a rotatory motion; the ligature 
material and adhesive strips are allowed to remain from four days to a week 
longer. 
Regarding Removal of Pins.-While two or three days is the 
ordinary time for retention of pins, it is the practice of the writer to get clear 
of them as quickly as possible. There is seldom any risk in removing those that 
are intermediate to the one at the free border of the lip and the one next to 
the nose on the second day,-that is, at the end of twenty-four hours. With- 
drawing them by rotation means that a finger forceps be made to span a pin so 
as to support the track of union, and that its head be caught by a stronger 
instrument and turned to and fro. Inattention to this trifling detail has 
been the means of undoing many good operations, the extent of union being, 
of course, very slight. 
Affording Support.-Support is furnished by use of adhesive plaster, 
preference being given to that made by Mead, which is the most reliable the 
author has ever used. At the seat of operation an elliptical piece is to be 
cut out so that sight of what is going on is secured. The lower border 
of the plaster is to reach a trifle below the free surface of the lip, so as to 
keep nipple or spoon from worrying the cut apart. While removing pins and 
applying plaster, support is always to be carefully given the cheeks by pressing 
them toward the middle line of the face. Plate VI 
lUmeui 3c Sons OPERATIONS UPON THE LIPS AND CHEEK. 
929 
Necessity for Dryness.-Experience will quickly discover to an 
operator necessity for keeping the part operated on as dry as possible. Such 
dryness is favored by the ellipse existing in the plaster. An old and fine 
linen handkerchief serves admirable purpose as a mop. Iodoform may be 
dusted in small quantity over the part, or, preferably, iodized subnitrate of 
bismuth. 
Agnew's Wire Suture.-Various means have been suggested to be 
employed in lieu of the pin and figure-of-eight dressing, objection to such dress- 
ing certainly existing in ulceration apt to associate with the pressure induced 
by swelling. Professor Agnew uses silver wire. He simply sews the parts 
together with a greater or less number of interrupted sutures. He thinks 
such sutures possess great advantages over the pins. 
Hidden Suture.-Another means of bringing the parts together which 
has been suggested, consists in the employment of the interrupted suture of 
silk used from the under surface of the lip. In such use of the hidden 
suture nice approximation and support are to be given the face of the wound. 
Rubber-Ring Suture.-Dr. Washington Atlee has suggested a suture 
which differs from the ordinary pin and figure-of-eight only in that he em- 
ploys rings of india-rubber, which are stretched over the pins. This suture 
for many purposes must prove an admirable addition to the armamentarium 
chirurgicum ; but in harelip operations it has no advantage over the ordinary 
figure-of-eight, inasmuch as the same strain, if not a greater, is exerted upon the 
points at which the rubber is supported by the pins. The merit claimed for 
this suture is, that whether a part swell or remain normal, the compressing 
force continues the same. 
Sheet-Lead Plate Suture.-A mode of securing apposition of the 
parts, which will be found very satisfactory, is to take three, four, or more 
threads of silver wire,-the fewer you can get along with the better,-the 
gauge being the most delicate that can be procured ; pass these and let them 
emerge at lines which shall very nearly correspond with the commissure of 
the lips. Next take a strip of common sheet-lead and, cutting it to an 
appropriate size, make in it as many little holes as you have threads to either 
side ; pass the threads through these holes, and compress on each a Me Leon 
button,-i e., a simple flat shot having a hole through its centre. Now, 
with the fingers, nicely approximate the wound. This satisfactorily accom- 
plished, draw up the wires and fix them on a second piece of sheet-lead, as in 
the first instance. If the centre, which is the line of the wound, tend to 
bulge forward, a delicate compress is to be placed over it, and bound to its 
place by an adhesive strip. The advantages of this dressing are, that it may 
be retained for weeks, if necessary ; it is entirely unirritating ; the wound is 
exposed to examination ; and, more than all this, the threads, being unirri- 
tating and very slight, when taken away leave no scars. 
Hainsby's Compressor.-A still happier dressing, but one which can 
be applied only on such patients as have reached the age of intelligence, or 930 
A SYSTEM OF ORAL SURGERY. 
where the services of a skilled nurse is employed, is a modification on Dewar's 
dressing. Hainsby's compressor-this being the modification-may be likened 
to the ordinary double hernia truss. It consists simply of a spring which 
passes around the head, having a 
small pad at each extremity. The 
piece is of such circle and character 
as to bring the pads to the labial 
commissures. The instrument is held 
in position by any convenient means. 
Dewar holds it by what might be 
termed a fronto-sagitto-lambdoidal 
sling. The process of dressing with 
this instrument is as follows. After 
making the paring of the cleft, 
cleanse the parts well with cold water 
(controlling hemorrhage by pressure 
on the facial arteries) ; next take a 
strand of the common silk ligature 
material, and nicely approximate the 
free edges of the lip, passing the 
needle on the under side. The next 
step is the application of the com- 
pressor. With the thumb and finger 
force the tissue of the cheeks toward the mesial line of the lip,-this approxi- 
mates perfectly the edges of the wound; replace your fingers by the com- 
pressor, and the parts are held in situ. If the approximation of the wound 
thus made should not be satisfactory, secondary compresses of linen are to be 
placed more immediately about the cut, and fixed by a delicate roller. The 
advantages of this dressing will be at once apparent. There are no pins or 
ligatures used, consequently there is nothing to interfere with direct union ; 
there are no punctures made in the skin ; of course there is no risk of having 
any but the single linear scar, and even this, if direct union be secured, must 
be slight indeed. The parts can be examined at any time without important 
interference with the apparatus.* 
Hemorrhage from Coronary Arteries.-In some individuals the 
coronary arteries are quite large. To suppress the hemorrhage from these 
vessels, dependence is generally placed on the pressure exerted in bringing 
together the edges of the wound. If such pressure fail to answer, or if some 
dressing is preferred that will not make it, light ligatures may be thrown 
around the arteries, one end to be cut off, the other to be brought out at the 
Fig. 732.-Hainsby's Compressor. 
* This description does not, as is seen, accord fully with the diagram, the pin and figure- 
of-eight being shown. The drawing has been utilized to show the feature of the ordinary 
dressing. In depending on a Hainsby compressor, much skill and a continuous oversight 
of the case are required. OPERATIONS UPON THE LIPS AND CHEEK. 
931 
back part of the wound. Ligatures, however, are best avoided where pos- 
sible, as they interfere with immediate union. 
Compression of Facial Arteries.-A better means than resort to 
the ligature is found in compression of the facial arteries. Such compression 
needs to be kept up but for a short time, as the smaller vessels soon con- 
tract. Hainsby's compress controls the hemorrhage by its pressure on the 
coronary arteries, and its action may be very readily imitated with a common 
roller. 
Linear Cicatrix.-There is a feature associated with the formation of 
the linear cicatrix, and the unsightly notch which so commonly deform hare- 
lip patients, that is not enough considered, being of a consequence to merit 
the closest scrutiny. Is it the fault of nature or the fault of the surgeon that 
the operation gives any cicatrix at all ? Cicatricial tissue-tissu inodulaire, as 
Delpech more happily terms it-means accidental tissue,-new tissue formed 
from granulations. The existence of inodular tissue implies, as it is greater 
or less in amount, that a wound has healed either by primary or secondary 
adhesion, and certainly not by what Mr. Hunter terms union by first intention, 
or what Mr. Paget calls immediate union. If a wound be made to unite by 
first intention, there cannot possibly be any observable inodular tissue, or scar, 
because so little new tissue has been formed, blood-vessels and nerves have 
been brought into perfect contact, and the harmony of the parts has been so 
completely restored that after a few weeks the closest observation fails to dis- 
cover the seat of accident. Familiar examples of such union exist in the 
slight cuts we are constantly giving ourselves with the razor, the cuts we get 
about the fingers, etc. Some years back the author removed from the parotid 
region of a young man a tumor fully the size of a hen's egg. The flaps were 
adjusted with the greatest care, and held in place by compresses of old and 
fine linen. Ten weeks after the operation the union was found to be so 
immediate that it was impossible to say where the cut had been made.* 
* Mr. Paget mentions very large wounds that not infrequently heal in this perfect manner. 
One case, that of a lady who had been operated on for scirrhus of the mammary gland, may 
be specially alluded to. Speaking of the operation, he says,- 
" The flaps, which were very large, had been carefully laid down, strapped with isinglass 
plaster, and well tended. After death, which occurred in three weeks, from erysipelas and 
phlebitis, I cut off- the edges of the wound with the subjacent parts, expecting to find the 
evidences of union by organized lymph or, possibly, blood; but neither existed; and the 
state of the parts cannot be better described than by saying that scarcely the least indication 
remained of either the place where the flap of skin was laid on the fascia, or the means by 
which they were united. It was not possible to distinguish the relation which these parts 
held to each other from that which naturally exists between subcutaneous fat and the fat 
beneath it. There was no unnatural adhesion; but the subcutaneous fat which did lie over 
the mammary gland was now connected with the fascia over the pectoral muscle. The parts 
were altered in their relations, but not in their structure. I could find," continues Mr. Paget, 
" small points of induration where, I suspect, ligatures had been tied, or where, possibly, some 
slight inflammation had been otherwise excited; and one small abscess existed under the 
lower flap. But, with the most careful microscopic examination, I could discover no lymph 932 
A SYSTEM OF ORAL SURGERY. 
Union of Wound.-The union of a wound, either by adhesion or by 
granulation, implies a certain amount of inflammatory action, and the exuda- 
tion and organization of lymph. This is the way in which harelip operations 
are healed, and this is why we have the linear cicatrix; and not only the 
cicatrix, but, according as the union has simulated or departed from the 
immediate type, we have necessarily a small or a great notch. 
Cicatricial Notch.-But how is the notch formed? The explanation 
is simple enough; but it is not that generally given; at least, this will be 
assumed. The notch is the result of the natural contraction which belongs to 
fibrous tissue, of which fibrous tissue the cicatrix is formed; and if we ob- 
serve, it will be found that where this linear inodular tissue exists in excess, a 
large notch is always associated with it. If proof be needed that out of such 
contraction is the notch, we have only to remark that in cases of large cica- 
trices destruction of symmetry in all surrounding parts invariably occurs; 
contraction puckers, as it were, the whole part. When a linear cicatrix is very 
limited, the notch is correspondingly small. These conditions could not so 
uniformly exist associated, if it were the manner of the paring exclusively 
that gave the notch, and not the contraction, as described. 
Healing by First Intention.-The nearer approach to a union by first 
intention can be secured in harelip operations the better will be the result. 
But can we not get immediate union in full ? This would imply that we have 
artery to artery, vein to vein, nerve to nerve. Well, the artery is a prominent 
point of reference, and the relations of surroundings parts are in perfect 
unison. If we can get the mouths of the two arteries together, will not all 
other vessels assume, by compulsion, inosculation? We may try for this, at 
any rate; such care will necessarily insure the very nicest approximation of 
parts, and, if what is termed immediate union cannot be obtained, there is at 
least secured to the patient, by such care, the smallest possible scar. To insure 
perfect union, a wound should never be approximated until all hemorrhage has 
ceased and the raw surface becomes glazed with a film of lymph. 
Illustrative Case.-Fig. 733 represents a modification on the ordinary 
operation for simple harelip which the author has now performed many times, 
and always with the most satisfactory success. This operation, as is seen, 
differs from that shown in the preceding figure in having the parings utilized 
in place of being cut away. Studying the diagram, it is seen that the parings, 
being commenced at the nasal septum, have been cut to the free border of 
the lip, from which, supported by their attachment, they hang. From the 
septum to the apices of the flaps it is seen that raw surfaces approximate : the 
parts in this condition are now brought and retained in apposition, the pendent 
or exudation corpuscles, and only a small quantity of what looked like the debris of such 
oil particles or corpuscles of blood as might have been between the cut surfaces when the 
flaps were laid down. In short," says Mr. Paget, " this was union by first intention } it was 
immediate, at once in respect of the absence of any intermediate substance placed between 
the wounded surfaces, and in respect of the speed with which it was accomplished." OPERATIONS UPON THE LIPS AND CHEEK. 
933 
portion being trimmed to that shape which considers the labial swell. This 
operation performed properly, a notch cannot result. 
Illustrative Case.-A second modification on the basal operation is 
shown in Fig. 734. Here, as is seen, one side of the break (the left) is most 
extensively pared, the section taking off quite a portion of the free border of 
the lip. Upon the opposite side, however, the paring is compensatory. Study 
Fig. 733. 
Fig. 734, 
of the section will exhibit that the flap of the right side of the face restores 
the removed part on the left, affording, at the same time, complete continuity 
of the free border of the lip at the mesial line. 
Complications.-The first modification of the simple mesial cleft, which 
has been described as a type, is where the break is to the one side or other 
of the labial centre, this centre constituting one of the lateral boundaries. 
This character of cleft, particularly as the left side is concerned, is by far 
the most common form; indeed, it is to be denominated the type proper of 
harelip. 
In operating on a case of single break, laterally related, as thus described, 
certain variations, as must be seen, are demanded. Employing the ellipse, 
it is recognized that the labial prominence would necessarily be thrown out of 
that exact central position which is its place. The same defect would reside 
in uniform pendent parings. To meet the objections, using the ellipse, a 
modification, as practised by Malgaigne, is employed. The surgeon makes 
the one side of a simple V-cut upon the outer flap; upon the mesial is prac- 
tised the ellipse. The bringing together of two surfaces so related throws 
down, as is seen, the free border of the mesial flap. 
Levis's Operation.-A modification on the operation of the French sur- 
geon, suggested by Dr. Richard Levis, consists in making a double V on the 
mesial flap. Entering the knife just below the nostril, a first incision pares 
the flap ; a second removes from this surface a small V-shaped piece, having its 
apex looking toward the cheek. In bringing the parts together, which is done 
by inserting a pin at the apex of the second V and passing it through the 934 
A SYSTEM OF ORAL SURGERY. 
opposite flap, it is seen that the free border of the mesial flap is alike bulged 
downward. 
Better, however, than the operations either of Malgaigne or of Dr. Levis, 
is the modification where the paring from the mesial flap, being made heavier 
than its fellow, places the desired prominence in its right position. 
Illustrative Cases.-Figs. 735, 736, 737, 738, and 739 are introduced 
for the benefit of students, as they exhibit modifications on the performance 
described which must prove profitable in their suggestiveness. 
Fig. 735. 
Fig. 736 
Double Harelip. - Another variety in harelip, and the next most 
common, is that in which the break is double,-that is, the single break is 
divided into two parts by a teat which starts out from the apex of the cleft; 
this teat is seldom more than half the width of the lip. Fig. 740 exhibits 
very satisfactorily an example of the most simple of such double breaks. A 
second is shown in Plate VI., Fig. 4. For the correction of this defect vari- 
ous means are resorted to. Some surgeons cut out the teat, thus converting 
Fig. 737. 
Fig. 738. 
the double into a single break, making the basis cleft as described. Others, 
on the contrary, after paring all the four sides, tease and strain the centre 
piece or teat until they get it on a level with the rest of the lip. Both opera- 
tions are objectionable. The first takes away an unnecessary amount of sub- 
stance from the lip, thus giving a tense, stretched appearance to the part, 
while from the second manipulation, the natural resiliency which belongs to 
most tissue compels a character of notch or central depression almost as un- OPERATIONS UPON THE LIPS AND CHEEK. 
935 
sightly as the original deformity. In this simple form of double harelip it is 
found the most satisfactory operation to pare the lateral flaps in the form as 
shown in Fig. 733, while the centre teat should be pared into the V-form, the 
Fig. 739. 
Fig. 740. 
base being to the septum narium ; all the parts will thus be found capable of 
a neat approximation, the teat doing its share more or less in filling up the 
break. The approximation is to be made in the manner described. 
Second Form.-A second form of double harelip is that in which 
alveolar process is associated with the teat. This is termed complicated hare- 
lip. The portion of process projecting into the cleft is generally an inter- 
maxillary formation, and holds the germs or developed incisor teeth. The 
correction of this defect implies a somewhat formidable operation. The first 
step consists in dissecting the lip well from its reflection over the process, 
should attachment exist. Next the gum is separated thoroughly from the 
projecting bone, which bone the third step in the operation removes down to 
the natural curvature of the parts, this last being effected either by means of 
revolving saw, chisel, or cutting forceps. If in this third step of the opera- 
tion the anterior palatine artery be wounded, the resulting hemorrhage is 
controlled either by taking up the vessel or by touching it with one of the 
astringents; or, if neither of these means suffices for the arrestation, the artery 
may be touched with a red-hot cauterant needle, or, better, may be plugged 
with a point of pine stick. The bone removed, the flaps of gum are to be 
laid back in the cavity, where they will remain sufficiently approximated with- 
out the employment of sutures. The operation upon the lip may now be 
performed at once in any of the manners described; or, if the force of the 
patient be too much exhausted, it may be left for a future period. 
These are the two principal forms of double harelip. An 
appreciation of the operations required for their cure will enable the surgeon 
to meet satisfactorily any modifications that may present on either of them; 
and these modifications, it is to be suggested, are constantly occurring. 
Operation for Double Harelip.-Reference is first to be made to 
an uncomplicated double harelip, where the centre piece, or teat, is found so 
large and square as fairly to divide the lip into three parts. See Fig. 740. 936 
A SYSTEM OF ORAL SURGERY. 
Here the mesial line of the lip is found in the centre piece; it suggests itself, 
therefore, to any one, that either side of the cleft is to be treated as a separate 
harelip,-that is, the whole manipulation is to be done at the one sitting and 
there are to be symmetrical parings made of either cleft. In such a case we 
have also to take into account the concavity made on either side of the fissure, 
as reference is had to the influence exerted on the free margin of the lip; for 
here, of course, no swell is required. Whether, again, in these really double 
cases, we would first operate on the one side, and, when that is cured, on the 
other, is a matter to be decided by the judgment of the operator. Many 
surgeons prefer to correct the whole de- 
formity at once. If it be decided to do this, 
the operation deviates from the principles laid 
down only as regard is had to approximating 
the parts; If the centre piece be small, it 
is found the most satisfactory practice to pass 
the pins, wire, or whatever suture material is 
used, directly from one lateral flap, on through 
the centre piece, to and through the other, 
thus uniting all the parts by a common suture. 
If, on the contrary, a centre piece be 
broad and well covered by skin, the greatest 
good is found in using two sets of ligatures. As regards the single or double 
operation, the author is influenced by the width of the middle piece, the tense- 
ness or laxity of the tissue of the lip, and the endurance and condition of the 
patient. Fig 741 affords full idea of the manner of doing this operation. 
Incisor Teeth projected into the Cleft.-A modification of the 
double harelip is one in which there is a projection, into the cleft, of the 
incisor teeth; the alveolar process itself being sufficiently normal to allow of 
non-interference with it. This modification is commonly met with in the 
adult, or at least after second dentition. The projection of the teeth is the 
natural result of the lack of external support from the labial deficiency; the 
tongue has actually pushed them outwardly. In a case of this kind, a pre- 
liminary operation is the removal of the teeth. If, now, six months be allowed 
to intervene before attempting the operation on the lip, the alveoli of the ex- 
tracted organs will be found to have receded, through absorption, quite the 
eighth of an inch. The second operation is then to be done secundum artem. 
This waiting on the process of absorption will be found to conduce to success- 
ful result. 
Pushing the Teeth Back.-A still better, though a more tedious, 
mode of correcting such deformity is by first bringing the projecting teeth 
back to their normal place in the arch, through the agency of elastic ligatures. 
This is a perfectly feasible operation, and not at all difficult of performance. 
By such a preliminary procedure we not only get the teeth out of the way, 
but save to the patient these valuable organs. To make and apply such a 
Fig. 741 OPERATIONS UPON THE LIPS AND CHEEK. 
937 
ligature, we have only to take a slip of common india-rubber and attach at 
each end a loop of silk. We next place these loops over certain of the molars, 
it is entirely immaterial which; the centre, or rubber part, is then stretched 
forward and laid over the labial faces of the teeth to be pulled back. It is 
astonishing how quickly and powerfully such a force acts upon them. In two 
or three weeks, at most, the organs are brought into their proper line. To 
secure them in situ, and prevent their being again pushed forward, we have 
only to keep them ligatured in any convenient manner until the operation on 
the lip is made and union secured. (See Correction of Irregularities.') 
Alveolar Process projected into the Cleft.-Cleft of the lip, as 
previously remarked, is common to perhaps a majority of the cases of cleft of 
the hard palate. It has always been deemed very important in these cases 
that an operation on the lip be performed as early as possible; it favors 
approximation in the bony cleft. In these cases the manipulation 
differs from that suited to an ordinary one only when there is projection of 
one or both alveolar prominences into the break. (See Cleft Palate.) In 
such instances, if the intrusion be very marked,-that is, so much so as to 
prevent the bringing together of the lips,-nothing better is to be done than 
cut away the parts. This, however, is always to be avoided where possible: 
first, because thus we destroy the germs of the teeth ; and, secondly, because 
if by any means union of the lip can be gotten, the parts in their develop- 
ment will come mutually to accommodate themselves to each other. In such 
cases it is recommended by some authors that endeavor be made to bend back 
these juttings of bone, turning them in toward the mesial line. Where 
this can be done, it answers a very admirable purpose. It is seldom, however, 
found practicable. Still another mode-after the method suggested for 
the complete relief of this character of cleft-consists in the employment of 
the fronto-occipito-labial elastic sling. This sling is to be so applied as to pull 
from the occiput upon the projecting process. It will certainly fulfil the in- 
dications if time be allowed; but its employment is attended with so much 
inconvenience and discomfort as seldom to be continued after one or two days. 
Association of Centre Slip and Nasal Septum.-Cases of double 
harelip not infrequently occur where the centre slip is so associated with the 
septum of the nose as to make the parts seem as one; if there was not the 
loss of material from the lip, the septum would bear being described as in a 
state of hypertrophy. Again, the lost part from the lip is sometimes found 
attached to the very tip of the nose, giving to the patient somewhat the ap- 
pearance of laboring under lipoma. These, together with all the anomalies in 
this direction, are first to be studied, as regards their cure, from the artistic 
stand-point. The surgeon knows where and what he can afford to cut; he 
judges what nature will do in the case; it only remains for him to consider 
well his incisions, where he shall make them, and what is to be the aesthetic 
result, before the operation is attempted. 
A useful study is found in the examination of examples. If 938 
A SYSTEM OF ORAL SURGERY. 
one familiarize himself with all kinds of cases, and if-what is commonly 
found more at command-he represent the morbid anatomy in india-rubber, 
and thus devises and tries experimental operations, he finds the subject of 
harelip grow simple enough. 
Addendum.-In operating for harelip, always first dissect the lip 
well off from its attachment to the gum. 
In paring the fissures, the young surgeon is much more apt to remove too 
little than too much. 
In paring out the apex of the cleft, be sure to freshen perfectly the extreme 
point of such apex. This is oftentimes neglected, and an ugly pucker is the 
result. 
The paring for harelip is, perhaps, best made on a wooden spatula. 
Few instruments are really required in this operation. A bistoury and 
forceps, or tenaculum, together with such coaptating means as it is designed to 
employ, will answer the purpose well enough. 
Position of Surgeon and Patient.-A mode of operating on the 
infant is for the surgeon to seat himself face to face with an assistant. The 
child being etherized, the surgeon lays its body over his own knees, the head 
being supported by the helper. On incision being made upon one side, 
the assistant grasps the lip between the thumb and finger, compressing the 
coronary artery. When the vessel of the opposite side is cut, he secures this. 
Both are steadily held until the operator is ready to coaptate the wound. 
In operating on the adult, it is found convenient to stand behind the 
patient; such a chair being used, and the head being placed in such position, 
as recommended in the operation of staphylorraphy. 
Another very convenient manner is to sit in front of the patient, the head 
being supported against the breast of an assistant. 
The common manner in hospital practice is to lay the patient, baby or adult, 
upon the operating-table. 
Gauze and Collodion as a Plaster.-Silk gauze and collodion are 
used by some surgeons; this, like to the ellipse made in the Mead dressing, 
leaves the wound exposed to inspection, and is a light and reasonably effective 
dressing. 
Projection of Intermaxillary Bone.-Fig. 742 is a dissection show- 
ing the nature and character of an intermaxillary projection. Where such 
bone interferes with the ability to obliterate a cleft, it is plainly proper practice 
to cut it away. 
Intermaxillary Complications.-Figs. 743, 744, 745, and 746, 
which are strictly true to cases constantly being met with, exhibit aspects of in- 
termaxillary complication. Wherever such intermediate projections are found 
unyielding, and may not be utilized, the author pursues the practice of ampu- 
tation ; this converts the case at once into simple harelip, with the complica- 
STUDIES IN COMPLICATED HARELIP. OPERATIONS UPON THE LIPS AND CHEEK. 
939 
tion, however, of a very great loss of substance from the centre; this cannot 
be helped; and if the parts be found too widely apart to be brought together, 
Fig. 742. 
Fig. 743. 
Fig. 744. 
as directed in the ordinary cases, the surgeon is compelled to resort to the 
cheeks for the required material. (See Making Upper Lip.} 
Door-Knob Deformity.-Fig. 747, being from life, represents the ap- 
pearance of a child operated on by the author at one of his clinics. In this 
babe complete cleft existed not only in the lip, but in both hard and soft palates, 
while pendent from the nasal septum was a mass half cartilage, half bone, 
which, as shown in the drawing, was the complete representation, in shape, of 
Fig. 745. 
Fig. 746. 
a door-knob. In examining the case, it will be seen that the removal of the 
pendent mass is to be effected by section of the pedicle. This was done, ex- 
posing the cleft in the lip, which, as recognized, was very extensive. To make 
raw and bring the boundaries of the cleft in apposition was now the indication. 
This was met after the manner of utilizing the parings. The strain on the 
pins being very great, extra support was given by placing a delicate compress 940 
A SYSTEM OF ORAL SURGERY. 
on either side and dragging all the lateral aspects of the parts toward the mesial 
line by means of adhesive strips. 
In this instance traction on the pins necessitated their removal 
earlier than was desirable; but moderate union was found to have been secured 
Fig. 747. 
at the free border of the lip,-that is, with the parings. Taking advantage 
of this, support was kept up by means of an extemporized Hainsby's compress, 
and after two weeks the cleft was found obliterated, having been filled up by 
granulation. 
This case is selected as an example, because it is an instance where nothing 
better could have been done than the operation practised, the child not having 
force to endure a more complicated means of treatment. It was not 
desirable to have a cure by granulation; but it was better than 
taking risks overbalancing the good to be secured. 
Fig. 3, Plate VI., exhibits the manner of placing a pin. 
Fig. 5' exhibits three pins in place, the points being cut off, and the parts 
retained in apposition by means of the figure-of-eight. 
Fig. 6 exhibits the dressing of a simple, uncomplicated double harelip. 
Pins.-Until very familiar with the operation, it is advised that in approx- 
imating flaps the ordinary steel or gold pin be used. Such means, while 
having the objections noticed, will yet be found of ready, easy, and convenient 
application. The author, after trial of many proposed and highly-commended 
means, finds in common steel pins his usual resource. 
Relation of Head of Pin to Line of Cut.-In passing a pin, it is 
to be carried forward until within about three lines of the head, while the 
point of the opposite side is to be cut off. 
Caution regarding Strain.-In casting the figure-of-eight, no more 
strain is to be employed than suffices to hold the denuded surfaces in contact; 
more than this is almost sure to result in strangulation of the compressed 
parts, a consequent ulceration marking the line of the pins. Cotton twine 
is to be used. OPERATIONS UPON THE LIPS AND CHEEK. 
941 
Pins are always to be removed as quickly as parts are found sufficiently 
self-supporting, their presence interfering necessarily with the process of 
union. 
Fig. 748. 
In withdrawing a pin, support is demanded by the lip. A rude removal is 
apt to tear asunder the delicate granulations. 
Fig. 748 exhibits the twisted or harelip suture, together with the manner 
of making it. CHAPTER LV. 
OPERATIONS UPON THE LIPS AND CHEEK. 
Operations required to be done upon the lips and cheek are of large 
variety and of such different expression and significance that familiarity with 
the performances resides alone with an appreciation of common principles 
governing one and all of them alike. 
Atresia Oris.-As the result of disease or of accident, persons occa- 
sionally suffer from contraction of the orifice of the mouth,-a most un- 
happy condition, both as regards appearance and comfort. Such contractions 
are represented in Plate VI., Figs. 7, 8, and 9. 
Dieffenbach, of Berlin, who interested himself very much in the surgery 
of the mouth, suggested and practised for the relief of these deformities an 
operation which, with slight and unimportant modifications, is the one still 
generally employed. 
Operation after Dieffenbach.-Dieffenbach's operation is performed 
on the following principles: Map out with pen and ink on the tissues such 
lines and angles as meet approbation of what the proper mouth should be. 
These lines are, of course, to be in conjunction with the existing orifice, or 
commissure, wherever or however situated,-that is, the relation of the exist- 
ing orifice must be studied as it is to have association with the cuts to be 
made. Thus, glancing at Fig. 7, we at once appreciate the necessity for 
enlarging the mouth by sections equilateral to the centre, as certainly it is 
apparent enough that only by such a form of incision-represented by a line 
-could we secure the end at which we aim. Fig. 8, on the contrary, would 
demand an operation exclusively lateral; for here the mouth at its right side 
is as perfect as one would hope to make it. Fig. 9 presents a complication on 
these simple conditions. This complication might be multiplied almost in- 
definitely ; for who may say in what condition a wound or other injury shall 
leave a part ? At any rate, the surgeon is to be prepared to meet all kinds 
of modifications. The three figures give, however, as just an idea of the 
mechanico-surgical indications of such cases as any other that might be drawn. 
Figs. 7 and 8 are from life; 9 is one made up to represent a not unlikely 
aspect.* It exhibits, as is seen, a combination of a cicatrix and harelip. 
In this last case is suggested of itself the necessity for a double operation. 
The mouth is to be made smaller before it would be at all proper to attempt 
making it larger. We must first perform a harelip operation. Imagine 
942 
* Fig. 9 is not correct to the text: add to it the defect in Fig. 1, and it will be right. OPERATIONS UPON THE LIPS AND CHEEK. 
943 
this done, and then, further, the condition in which such operation would 
leave the orifice. If we refer to the drawing, we see that the opening is 
now at what is fairly the right angle of the mouth; and an operation for 
the making of a proper commissure, if there were no hare or cleft lip, would 
be precisely the same lateral incision as that indicated in Case 8. But then 
it is to be remarked that, after the first operation was performed, the orifice 
would not be, as now, at the proper right angle. The bringing of the cleft 
together would pull it naturally toward the mesial line. Thus, then, it is 
made a cross between 7 and 8 ; it is not like 7, because it is not exactly in 
the mesial line, and it would not be like 8, because it has been drawn from 
the proper right angle toward the mesial line. Here, then, the complication 
has materially changed the indications of the principal operation. The in- 
cisions are to be bilateral, yet not equally so as reference is had to the false 
commissural centre, but only as reference would be made, say, to the septum 
narium or to any other fixed mesial line proper. The space between the cen- 
tral incisor teeth would be a good mesial centre to adopt. 
These features well considered, the surgeon takes up a pair of sharp-pointed 
scissors, and, passing a finger of the left hand into the mouth, enters one 
blade down through the tissue toward the finger, sparing alone in the punct- 
ure the mucous membrane; the blade is now pushed forward toward the 
mesial line, and the tissues incised, as indicated by the superior right lateral 
half of the ellipse represented by the line in Fig. 7. The blade is now rein- 
troduced at the previous point of entrance, and the cut made on the inferior 
lip precisely as was done above. Next is dissected out the triangular piece. 
These incisions are repeated on the opposite side. A succeeding step con- 
siders the cutting of the mucous membrane. This is done simply by dividing 
it down the centre to within two or three lines of the angle of the wound; it 
is then to be brought over the raw surfaces and attached by means of the 
interrupted suture to the skin. 
This mode of re-establishing the oral orifice is deemed to be the best that 
can be employed. 
Mechanical Modification.-A modification on the manner of Dieffen- 
bach, which the author would suggest, and which he is confident will be found 
to add to the good results, is an association with the surgical means of a 
mechanical appliance. 
After the operation, as described, has been performed, and time has been 
given for union of the reflected mucous membrane, let such an appliance as 
is here figured (mouth-stretcher, it might be called, Fig. 749) be prepared, and 
slip it between the lips. This stretcher represents a properly-shaped mouth ; 
the lips in the whole of their circumferences are caught and held by the gutter 
of the apparatus, and thus not only is the healing influenced to a desired 
shape, but undue cicatricial contraction is prevented. 
If it be objected that such an instrument looks ungainly in the mouth, 
the reply is that after the first week or two there would exist no occasion for 944 
A SYSTEM OF ORAL SURGERY. 
its constant wearing; it might be entirely dispensed with during the day and 
be worn alone at night. Use of it is to be continued, however, for at least 
six months, if cure is to be perfected. An advantage yielded by such an appli- 
ance to a bungling operator lies in the fact that it naturally corrects any imper- 
Fig. 749. 
fection in his manipulations, the character of the apparatus compelling the 
regular healing of the wound. Indeed, the writer is not sure but that in 
this way a proper mouth might be made if the strictly surgical part consisted 
only in a simple incision to enlarge the parts to a proper capacity; for in the 
operation it cannot be said that the reflection of the mucous membrane is an 
absolute necessity; whether that membrane should be carried over the cut 
surface or not, we would very soon have it clothed with such tissue, or at 
least with that found sufficiently analogous to fairly represent it. The great 
difficulty in all these cases, as has been remarked by Dr. Mutter, arises from 
the constant tendency to contraction manifested by the cicatrix, which oc- 
casionally goes on to such an extent that the orifice of the mouth is almost 
closed. At the first examination of such a deformity, the remedy which seems 
to promise most success, says Dr. Miitter, is mechanical dilatation. Unfortu- 
nately, this is productive of but temporary relief, and has never, I believe, 
effected a permanent cure. Next to this method comes incision of the com- 
missures. We might naturally expect such a course to be sufficient to effect 
the ends desired, and in all probability this would be the case, could we by 
any means prevent reunion of the edges of our incisions. But this, it would 
appear from statements of the best authorities, has hitherto been impossible; 
for, notwithstanding introduction of tents, leaves of sheet-lead, cerate cloth, 
etc., between the lips of the wounds, adhesions, more or less complete, are 
sure to take place. 
The instrument here suggested will master indications which the appliances 
heretofore used have not been able to meet. A tent, or cerate cloth, or strip 
of easily-yielding sheet-lead cannot resist the great contractile force exist- 
ing in these conditions; something fixed and immovable is required. One 
would not be willing to trust to a less resisting body than the catheter, after 
urethral section. It might be asked, " What need of such appliances, if Dief- 
fenbach's operation will effect a cure ?" Unfortunately, Dieffenbach's manip- 
ulations cannot in all cases be carried out. If the mucous membrane, for 
example, participate in the lesion, the operation cannot be successfully per- OPERATIONS UPON THE LIPS AND CHEEK. 
945 
formed. Or who can say that flaps of mucous membrane, however nicely 
approximated with the skin, will unite? There are several things which 
are apt to come between the surgeon and success. There are, at least, cases 
which Dieffenbach's nice operation will not cure. 
Preliminary Performance.-A preliminary performance, having the 
object of obviating the tendency to closure of the mouth, consists in first 
passing through the tissues, at the proposed sites of the angles of the lips, 
setons of delicate india-rubber tubing. These are to remain in place until the 
orifices are cicatrized, precisely as in the case of the ringed ear. No trouble 
is experienced after this in preserving the mouth as formed. 
Studies.-Plastic operations about the lips are embraced under the gen- 
eral name of cheiloplasty; those upon the cheeks are termed genio- 
plastic. 
The necessity for such operations arises from various causes, not the least 
frequent of which are sections made by the knife of the surgeon. Reference 
to ■ Plate VII. exhibits five cases: the first resulting from salivation, the 
second from an ulcer, the third, fourth, and fifth due to operations for the 
removal of cancer. 
Operation after Mutter.-The first of these (Fig. 1) is described as 
having been a shocking deformity. The operation for its relief was performed 
by Professor Mutter, the practice being as follows. Having first extracted 
the useless teeth of the upper jaw, which would have prevented the proper 
adjustment of the flaps, or induced their ulceration, the edges of the ulcer 
were freshened, and the integuments detached from the side of the jaw. Two 
incisions, one above and one below the break, as seen in the figure, were made, 
so as to form four flaps. These were now allowed to fall together, and were 
united in the line of the teeth as far forward as the natural angle of the 
mouth. The result was entirely satisfactory. 
In studying this case the reader will remark that while the mode of 
section, or making the flaps, most happily meets the indications as filling up 
the seat of the original lost tissue is concerned, yet this is only done by making 
two other defects, one above, the other below. Such defects prove, however, 
in healthy tissue, of no great consequence; granulations, quickly springing 
from the whole circumference of such wounds, supply the lost tissue: indeed, 
in the author's experience he has found that, as a rule, the tendency in these 
fresh parts is to so rapid a repair and cicatrization that frequently the line 
of the artificial union is torn apart. 
Fig. 1 may be studied from another stand-point. In a case 
operated on, very similar to the drawing, where the neighboring tissues were 
loose and free in character, the writer secured an admirable result by simply 
dissecting the parts from the bone, freshening the edges, and uniting them by 
the ordinary harelip pin, supporting the whole with straps of adhesive plaster 
passed from beneath the jaw to the side of the head. The parts at first looked 
much stretched, but soon accommodated themselves. 946 
A SYSTEM OF ORAL SURGERY. 
Operation after Tagliacotius.-Still another mode of performing 
such operations is after the manner of Tagliacotius. Freshening the edges as 
before, map out, by means of a piece of card-paper, the size of a flap required 
to fill up the gap ; next lay this upon the arm, and, dissecting from the integu- 
ments its size, supported by a pedicle, fix it in the break by means of stitches 
of the interrupted suture. To do this, the arm is to be brought over the 
head, and thus supported until union is secured, when the pedicle is to be de- 
tached, and the parts trimmed to suit. 
Operation after Mott.-Subfig. 2, constituting a second study, repre- 
sents an operation performed by Mott for the relief of an anchylosis of the 
jaw dependent on cicatrization of the mouth, together with the restoration of 
a part of the cheek. 1 exhibits cicatrix arising from an ulcer. This was 
entirely excised, leaving an opening in the cheek. 2, tongue-shaped flap cut 
to fill up the opening, this being rotated upon its base. 
Operation after Pancoast.-Subfig. 3 represents an operation per- 
formed by Professor Pancoast for the removal of an extensive cancer and the 
formation of a new lower lip. The disease is shown circumscribed by a 
curvilinear cut. A vertical incision in the median line of the chin extended 
from the cut nearly to the os hyoides, and another, which was horizontal and 
parallel to the base of the lower jaw, formed four flaps. The angles of the 
flaps being removed, the upper (1, 2) were raised to the proper level, and 
united by the twisted suture on the median line, when the lower (3, 4) were 
also united on the median line so as to cover the front of the chin. 
Operation after Chopart.-Subfig. 4 represents a similar case, treated 
by the operation of Chopart. The lines give the idea of the incisions. 2, 
4 circumscribe the disease. 1, 5, 3, 6 show vertical cuts. The diseased 
part, all above 2, 4, being removed, the integuments are loosened from the 
lower jaw and simply lifted, being retained in the new position by harelip 
pins, or by other convenient means. This operation occasionally answers very 
well. In certain instances, however, where, for example, it has been necessary 
to stretch the parts, much cicatricial evulsion is apt to occur. 
Operation after Lallemand.-Subfig. 5 represents the same position 
of the disease, treated after the manner of Lallemand. 1, the remaining 
portion of the lip, which is to be drawn over to the angle of the mouth at 2. 
A flap, formed of the integuments of the neck, having been dissected off, is 
shown as being partially rotated on its base and about to be carried up to 
cover the deficiency. The wound on the neck may either be approximated at 
its edges or be left to heal by granulation. 
Operation after Malgaigne.-In epithelial cancers quite as large as 
those represented in Figs. 3 and 4, the author has succeeded in making perfect 
operations by practising the manipulation of Malgaigne. This consists in re- 
moving the diseased mass by a simple V-incision; the angles of the mouth 
are next enlarged by horizontal cuts, and the V drawn together and united in 
the middle line of the face. In the cases alluded to a pin was always placed Plate VII 
Slim an, X' Sons OPERATIONS UPON THE LIPS AND CHEEK. 
947 
at each corner of the mouth; as the result of this, some little puckering is 
produced, but, in return, it eases the strain on the middle line, and itself 
disappears after a very few months.* 
* The lower lip, from its conspicuousness, its utility in articulation, and also in the pre- 
vention of an involuntary and incessant flow of saliva, forms a very important portion of 
the face. Unfortunately, it is exceedingly prone to diseases of various kinds, especially 
tumors and ulcers, requiring for their relief the removal of the whole, or a portion, of the 
organ involved. It would be worse than useless to enter into a description of all the oper- 
ations that have been devised to remedy its loss, but a brief sketch of the most novel and 
important may prove useful stnd interesting to those not familiar with this department of 
plastic surgery. 
Chopart's Operation.-This operation consists in making, on each side of the diseased 
tissue, a perpendicular incision, extending from the margin of the lip to a point below the 
base of the lower jaw. Dissecting up the flap enclosed between the incisions, he carefully 
removed from its upper margin all the affected tissue, either by a transverse or a curvilinear 
cut. Then, pulling upon what remained of the flap, he brought its upper edge to the level 
of the margin of the natural lip, and there retained it by suture, straps, and placing the 
head of the patient in such a manner as to prevent all strain upon the part. This method, 
though apparently simple and easy of execution, does not generally answer, in consequence 
of the subsequent contraction of the tissue. 
Horn's or Roonhuysen's Operation.-If the part to be removed be small, the common 
V-shaped incision is sufficient, and the parts may be brought together as in the operation 
for harelip; but where the mass is large, this process is sure to diminish the orifice of the 
mouth and thus give rise to deformity and inconvenience. To obviate all this difficulty, it 
was proposed by Horn to detach the adjacent parts by free dissection from the maxillary 
bones, which would of course afford more material for the lip. The objection to this method 
is, that in many cases the orifice of the mouth is rendered so small as to be almost useless, 
besides presenting great deformity. 
Operation of Dupuytren.-This, in ordinary cases, is nothing more than cutting away 
by a semi-elliptical incision all the diseased tissue. Granulations spring up from the margin 
of the healthy skin, occupy in part the place of the original lip, and conceal to a certain 
extent the deformity. It is only in mild cases, however, that such a measure could succeed. 
Celsian Operation.-Having carefully removed the diseased part by a V-shaped incision, 
he proposed to divide the tissue remaining horizontally, carrying the cuts as far into the 
cheek on each side as might be deemed necessary, after the manner of Horn; but in order 
to take off the strain from the flaps, he made a semilunar incision in the cheek, just beyond 
the base of each. This enabled him to bring the parts together without difficulty ; and the 
only objection to this operation is the danger of wounding the larger vessels, nerves, and 
ducts of the cheek, in making the semilunar incisions. 
Operation of M. Serres.-If the disease, as is sometimes the case, be confined to the 
integuments and subjacent muscles, leaving the mucous lining of the lip sound, Serres cuts 
away only the affected part, and then turns the mucous membrane over the margin of what 
is subsequently to form the lip. A few stitches are sufficient to hold it in place, and, as 
union by the first intention usually occurs, a very natural and useful organ may thus be 
made. This method, however, will only answer in cases of superficial and recent disease. 
Operation of T. W. Roux.-After removing the affected tissues, and forming suitable 
flaps of the adjacent parts, M. Roux takes away with the saw or cutting instruments the 
prominent centre of the maxillary bones, so as to make room for the proper and easy ad- 
justment of the integuments intended to replace the organ destroyed. The operation is 
barbarous, because unnecessarily severe. 
Operation of P. Roux.-Professor Roux, determined to surpass his namesake, saws out 
an inch or more of the bone, and then, by drawing the lateral flaps toward each other, 
diminishes the breadth of that part of the face involved in the disease. Then, detaching 948 
A SYSTEM OF ORAL SURGERY. 
Fig. 75° exhibits conditions met with almost every day. 
Such ulcerations, being esteemed of cancerous signification, are commonly 
treated by excision. Taking as example the two shown in the diagram, the 
the flaps, he draws them across the opening in the bone, and the sutures which hold the soft 
parts are generally sufficient to hold the bones in their proper places. 
Operation of Mr. Morgan.-This consists in first removing the entire lip by a semilunar 
incision, the concavity of which is uppermost; and, second, in making an incision also 
curvilinear and parallel to, and about an inch or more below, the first. The skin included 
between the two is then carefully detached, except at its extremities, and lifted into the 
place occupied by the diseased lip. 
Operation of M. Blasius.-M. Blasius has performed a very simple operation when the 
tumor was large; and, according to his statement, with decided success. After removing 
the diseased mass by a common V-shaped incision, he next divided the integuments along 
the base of the lower jaw by two incisions, which commenced at the entering angle of the 
V, and extended an inch or more in the direction specified. Lifting the flaps, he made 
them occupy the place of the original lips. 
Operation of Dieffenbach.-This surgeon has recommended an operation apparently 
hazardous and severe. The following is his description : 
Having pared away the useless remains of the former diseased lip, or separated the 
cicatrized margin, a horizontal incision, about two inches long, is carried from either angle 
of the mouth outward, through the cheeks, so as to throw the mouth widely open. The 
length of these incisions must be regulated according to the width of the mouth; or, as a 
general rule, the combined incisions must somewhat exceed in length the breadth of the 
upper lip. From the outer point of each of these another incision is next carried obliquely 
downward and toward the median line; the section in this case likewise extending through 
the whole thickness of the cheek. Thus, by means of the first operation for paring the 
cicatrix, and by the succeeding horizontal and vertical incision, a flap will be prepared on 
either side to replace the defective lip: this flap is of a quadrangular form, and maintains 
a connection of more than one inch wide with the soft parts covering the tissue of the 
lower jaw. It may be useful further to separate the mucous membrane at its attachment 
to the gums, to allow of the more ready traction of the flaps. 
The severe injury inflicted on the facial nerve, the large arteries and veins, and possibly 
the parotid duct, has rendered this operation anything but popular. 
Operation of Liston.-This consists in first removing the diseased mass by a horizontal 
and two perpendicular cuts, or by one curvilinear in shape; and, second, in detaching a 
flap from the chin and neck, twisting it on its pedicle, placing it in the seat of the original 
lip, and there retaining it by suture. After adhesion has taken place, the pedicle is divided, 
and a wedge-shaped piece removed so as to allow the flap to be laid down smoothly. This 
method, it is obvious, is frequently applied to the restoration of other parts, and will 
answer here exceedingly well in many cases. Dr. Mutter, however, prefers the following 
operation, "as there is less scar, and less risk of sloughing of the flaps." 
Dr. Mutter's Operation.-Having first removed the diseased mass by a semi-elliptical 
incision, two slightly-curved incisions are carried from the centre of this line, downward 
and outward, to the base of the inferior maxillary bone. Then, from the terminal ex- 
tremities of these incisions, two others are carried upward and outward along the base of 
the lower jaw until they reach a point opposite the initial and terminal points of the 
original semilunar incision. Two quadrangular flaps are thus marked out, and immediately 
detached from the subjacent bones. These flaps are then raised and placed in the position 
originally occupied by the lower lip, and then united to each other at the median line, and 
also by their lower thirds to the triangular piece of integument (as between the two lines 
which started from the centre of the semi-elliptical incision), by means of the twisted 
suture. By the elevation of these flaps a raw surface is left on each side to heal by the 
modelling process or by granulation.-Matter. OPERATIONS UPON THE LIPS AND CHEEK. 
949 
manner of removal is portrayed in the circumscribing lines, the remark being 
to add, however, that such lines are to be twice or thrice as widely separated 
from the lesion. The after-treatment consists simply in approximating the 
Fig. 750. 
parts by the use of the pin and figure-of-eight; adhesive strips being used or 
not, as may be found indicated. 
Removal and Restoration of Lower Lip.-Fig. 751 exhibits dis- 
ease involving the entire lower lip and compelling its removal. To accomplish 
the necessary end-namely, to ablate the lesion and restore the lip-various 
means are employed. (See foot-note.) By the diagram are shown the out- 
lines of an operation known as Serres's. In this mode it is seen that the 
tissues of the cheeks are utilized. Fig. 752 shows the disease removed and 
the wounds dressed. A marked objection to this operation is inability 
to gain such character of lower lip as shall control the direction of the saliva 
Fig. 751. 
Fig. 752. 
or permit of true and full approximation with the superior lip. In looking 
at the restoration, the reader is to observe the manner adopted of covering 
the same surface of the free border by stitching to the skin the mucous 
membrane. 
Fig. 753 exhibits a lower lip removed, and lines of incision practised by 
Mutter for the restoration of the lost part from the chin. Fig. 754 shows 
the flaps dissected and raised into place, the triangular spaces being left to 
heal by granulation. 
A modification made by the author on the sections of Mutter-cuts of 
which are shown in a clinical report published in the Medical and Surgical 950 
A SYSTEM OF ORAL SURGERY. 
Reporter-consists in carrying the vertical lines beneath the jaw, so that the 
flaps when put in place show but the single central line upon the face. By 
this modification not only are observable scars avoided, but the lip is not apt 
Fig. 753. 
Fig. 754. 
to be shortened by the cicatrization ; indeed, it is possible by such manner of 
cutting to obliterate the triangular breaks left in the operation shown, the 
yielding integuments of the neck being made to close the breaks. 
Fro. 755. 
The transplantation of particles of skin, now an accepted means, 
may be practised in the Mutter plan: this consists in snipping from sound OPERATIONS UPON THE LIPS AND CHEEK. 
951 
parts small pieces, and by careful application uniting them with the uncovered 
surface of the triangles. 
Removal and Restoration of Parts of Upper and Lower 
Lips.-Fig. 755 exhibits an operation practised by the author for the removal 
and restoration of parts of both the upper and lower lips. 
At the angle of the mouth is seen the lesion designed to be removed, cir- 
cumscribed by lines which fully include it; all tissues within these lines are 
ablated. Commencing now at the angle of the wound in the mesial centre, an 
incision is carried downward beneath the jaw, and outwardly-as shown in 
the diagram-as far as the line of the facial artery ;* this flap being next 
dissected from its base, is lifted until it meets the free border of the natural 
half of the lip ; to this it is pinned. The angle seen back of the mesial in- 
cision will be recognized as receiving accommodation in the second angle in 
the upper lip; this relationship limits the size of the commissure on the side, 
which limitation, however, is to be corrected by a subsequent operation 
practised after the manner of Dieffenbach. 
Remedy for disease thus situated is of frequent necessity. The 
operation shown is one that may be practised with entire satisfaction. With 
various required modifications the author has repeated it many times. 
Removal and Restoration of Upper Lip.-Fig. 756 exhibits lines 
of section demanded for the restoration of a lost upper lip. The case here 
Fig. 756. 
shown represents a case in which the author found himself compelled to re- 
move the upper lip on account of the rare affection, as here located, of epi- 
thelial cancer. Imagining the lip away, the reader will perceive that lateral 
flaps dissected from the cheek, as shown in the diagram, must admit neces- 
sarily of being brought down and stitched together in the place of the lost part; 
* Mistake has been made by the artist in not giving width enough to the flap: it is to be 
one-eighth in excess of the part removed. 952 
A SYSTEM OF ORAL SURGERY. 
the points nearest the eyes being joined immediately below the nose at the 
central line, and the inferior points and extended lines of cut forming the 
centre and free surface of the new lip. 
Fig. 757. 
Fig. 758. 
Loss of Nose and Upper Lip.-Fig. 757, demonstrative of thesame 
operation, as the making of a lip is concerned, shows the face of a patient 
when first presenting for treatment. 
Showing Restored Lip.-Fig. 758 exhibits the appearance of the face 
immediately after the completion of an operation for a new lip, practised pre- 
Fig. 759, 
Fig. 760. 
cisely as shown by the lines marked upon the face of Fig. 756. The triangu- 
lar space, left necessarily on each cheek, as must be appreciated by a study of 
the drawing, on the left side is shown obliterated by compelling the cheek to OPERATIONS UPON THE LIPS AND CHEEK. 
953 
override the space. On the right side it has been allowed to remain. The 
artist, however, should have represented this space by a dark rather than by a 
light surface. 
Fig. 759 shows what is known as the Dieffenbach operation for removal and 
restoration of an upper lip. The inferred diseased part, d, being ablated, an 
incision, b, is carried upward, outward, and downward, as seen. Fig. 760 
Fig. 761. 
Fig. 762. 
exhibits b carried to the place of d ; the line on either side, with its double 
dots, representing the seats of flaps after approximation. 
Operation after Leidillot.-Another manner of making an upper lip 
is known as Leidillot's. Fig. 761 shows the lines of incision. Fig. 762 the 
flaps in place. 
Deformity existing in Paralysis.-The lady represented in Fig. 763 
applied to the author for relief from the deformity exhibited, the irregularity 
of features being dependent on injury done the facial nerve in an inflammation 
and necrosis of the temporal bone from accident met with in childhood. 
Paralysis was complete; not the slightest power existed in the muscles of the 
affected side. 
The desire of the patient was for a symmetrical mouth and face; the ques- 
tion was, the accomplishment of such an end. 
Treatment.-A case of this kind is treated strictly from an operative 
stand-point. The indications are threefold : 
1st. To reduce the flabby redundancy of the paralyzed cheek. 
2d. To give comeliness and regularity to the mouth. 
3d. To antagonize the muscular action (when in play) of the vital side. 
In this case these indications were attempted to be met by means as follows : 
A study was made of the cheek, and what was deemed to be the redundant 
tissue was included in an ellipse drawn with a lead-pencil, one of the apices 
being at the middle of the nose, the other at the angle of the lower jaw,-such 
direction of the ellipse being with a purpose of raising the angle of the mouth. 954 
A SYSTEM OF ORAL SURGERY. 
Satisfied that the removal would be found rightly placed to meet the first two 
indications, the part was cut out. In the operation the facial artery was the 
only vessel which needed a ligature, and even this ejected no more blood than 
does an ordinary coronary. 
To bring the parts together three harelip pins were used, and so 
direct and immediate was the union, somewhat surprisingly, that it was found 
Fig. 763. 
permissible to dispense with two of them on the following day; the third, the 
middle one, was left in until the fourth day, but this not, seemingly, from 
necessity. The ligature, a strand of ordinary silk, remained firm for three 
weeks, and was finally taken away only by the use of a traction quite as great 
as would have sufficed for its removal the moment after it was placed about 
the vessel. 
The result of this procedure is exhibited in Fig. 764. With the 
features in a state of rest, nothing more, it would seem, could be desired. 
Artificial Muscle.-The third indication, however, showed itself a most 
important one. Emotion of the face altered this mechanical harmony of the 
parts, and exhibited the non-vitality of the side operated upon ; that is to say, 
in laughter, for example, the superior and lateral levators would pull up the 
well angle, with no corresponding action on the diseased side. This was, of 
course, a matter which had been originally considered. The indication was 
met with remarkable success, as follows: A piece of rubber tubing four inches 
long, possessed of an elastic power adapted to the requirements of the case, 
was attached by one of its ends to a hair-pin (the ordinary pin used by ladies OPERATIONS UPON THE LIPS AND CHEEK. 
955 
in dressing the hair). With its other end was united a piece of strong, but 
delicate, gill-net string, and this, in turn, was connected with a small strip of 
flesh-colored court-plaster. 
The application of this piece of mechanism-an artificial muscle, let us call 
it-was made as follows: The plaster was softened and applied to the dead 
side of the face, as far back upon the cheek as would answer the purpose. 
Fig. 764. 
The lady, standing before her glass, would excite the displacing muscles into 
play, and antagonize them by drawing slightly backward 'the dead side by 
means of an artificial muscle, holding a required tension by the pin fixed into 
one of the coils of her hair, the rubber lying entirely concealed by such coil. 
When applied, only the plaster could be seen, the string being hidden by the 
hair. 
This rubber muscle answered its purpose admirably. The fear that the 
plaster would irritate, and perhaps ulcerate, the skin seems to have been 
without foundation. At any rate, this held good for six months of use, which 
was as long as the case was under observation, the lady living in a distant 
city. Should this accident have supervened, it was evident that, after a very 
few days of experience, a habit might be attained of accomplishing the same 
object by the use of the fingers applied in such manner as not to elicit at- 
tention. 
This operation-the only one of the kind done by the writer-gave results 
which warrant its repetition. It is recognized, however, that a continued and 
proper employment of the artificial muscle is a necessity, otherwise the use of 
a finger, as suggested. 956 
A SYSTEM OF ORAL SURGERY. 
Cicatrices from Burns.-Plastic operations practised for the relief of 
cicatricial deformities must always be of special signification. Of such cica- 
trices there are of course an endless variety, and it may only be that each case 
shall command a special operation. 
Cicatricial tissue, always the result of suppurative inflammatory action, is 
a species of imperfect fibrous formation, dull white in color, hard, its fibres 
running in every direction and possessed of a contractility which, in many 
instances, requires years for exhaustion. In vital force this structure is of 
low organization, peculiarly susceptible to degenerating influences, rarely, if 
ever, developing to full likeness with its associated parts. 
The surgeon on treating a cicatrix will find himself wisely influenced in 
heeding the maxims of Dupuytren : 
Maxims of Dupuytren.-1. Never attempt the correction of a de- 
formity until months, and in many instances years, have passed after its 
production. 
2. Never operate unless certain of obtaining a larger cicatrix than that 
which is wished to be removed. 
3. Be certain that the operation can restore the parts to their shape. 
Dermoplasty, as this operation is called, is never to be undertaken without 
full consideration of the shock to be entailed by the cutting and suppuration, 
and the ability of the patient to endure such a shock (see page 695). In re- 
moving a cicatrix, it is to be recognized that not only may a prolonged dis- 
section be necessitated, but the cutting is not at all unlikely to be of the 
most hazardous nature, requiring on the part of the surgeon not only an 
accurate knowledge of the anatomy of the parts involved, but a patience 
and a manipulative skill which are by no means a common possession. 
Danger from Erysipelas.-A secondary danger associated with these 
operations lies in the supervention of erysipelas,-a contingency to be guarded 
against by that preliminary attention which has taken into consideration every 
functional irregularity which can have a tendency to lower the resistive force 
of the individual locally or at large.* 
Size of Flap.-A flap is always to be at least from a quarter to a third 
larger than the cicatrix to be replaced; such increased size will be found 
necessary to counterbalance shrinkage. 
Cutting and Laying a Flap.-A flap is always to be taken from the 
nearest healthy neighboring part. It is to have the widest pedicle the cir- 
* Erysipelas would seem to be a parasitic disease; the fungi finding habitation in a part 
incapable of self-defence. Repetition of the formula for a medicament always used by the 
author is made: 
U Tinctures ferri chloridi, ; 
Tinctures cinchonas, £ij; 
Quinias sulphatis, 5j- M. 
Sig.-Apply thoroughly hourly by means of a brush until blush and tension disappear. 
Decrease or increase tinctura cinchonas according to delicacy of skin. OPERATIONS UPON THE LIPS AND CHEEK. 
957 
cumstances of the case will permit, and is not to be laid in its new situation 
until all hemorrhage has been fully suppressed and both flap and base are 
covered with a film of plasm. In fixing a flap, unnecessary stitches are to be 
avoided, while compression of the most gentle nature is to be used in holding 
the parts in apposition. 
Dressing a Plastic Operation.-No dressing except of the simplest 
character is to be employed after an operation; the surgeon is to take it for 
granted that no complication will arise and that the union is to be immediate 
and full; should, however, such results not accrue, then indications are to be 
met as they arise. 
Treatment of Wound left by Transfer of Flap.-Concerning 
the wound left by the transfer of the flap, this is best treated in the endeavor 
to close it by the overdrawing of neighboring parts ; with large surfaces, how- 
ever, where the practice may not avail, the process of skin-grafting is had 
recourse to; this, while not so reliable as is to be desired, serves at times a 
satisfactory end. For further illustrations in plastic surgery see chapter on 
Epithelioma. CHAPTER LVL 
LIGATION OF ARTERIES. 
Appreciation of surgical performances upon the vessels of the neck and 
head is to relate with accurate understanding of circulation in the parts; this 
understanding to embrace appreciation of anastomosis. 
Fig. 765.-Arterial Circulation oe Neck. 
Left common carotid dividing into the external and internal carotid arteries. 
1, common carotid artery; 2, internal carotid; 3, external carotid; 4, superior thyroid; 
5, lingual; 6, pharyngeal artery; 7, facial; 8, inferior palatine and tonsillar arteries; 9, 
submaxillary; 10, submental; 11, occipital; 12, posterior auricular; 13, parotid branches; 
14, internal maxillary; 15, temporal artery; 16, subclavian artery; 17, axillary; 18, ver- 
tebral artery; 19, thyroid axis; 20, inferior thyroid giving off the ascending cervical; 21, 
transverse cervical; 22, suprascapular; 23, internal mammary artery. 
Figs. 765 and 766 are here reintroduced with view of setting before the 
student, in juxtaposition with Fig. 767, the general and anastomotic circula- 
tion of the head and neck. 
Preliminary Study.-Preliminary study of ligation consists in making 
one's self familiar not only with the lines locating vessels, but, quite as im- 
958 LIGATION OF ARTERIES. 
959 
portantly, with the seats and nature of anastomotic relations. The diagrams 
here presented are to be accepted as sources of reliable reference. 
Study in Anastomosis.-A student beginning the study of the 
diagram with the arch of the aorta, perceives it to give out, on the right side, 
as he faces it, first the common carotid artery, and, outside of this, the sub- 
Fig. 766.-Arterial Circulation of Head. 
The external carotid artery and its branches. 1, right common carotid; 2, in- 
ternal carotid; 3, external carotid; 4, superior thyroid; 5, lingual; 6, facial; 7, sub- 
mental; 8, inferior labial; 9, superior labial; 10, muscular branches; 11, lateral nasal 
artery; 12, angular artery; 13, occipital artery; 14, descending cervical; 15, muscular 
branch; 16, posterior auricular artery; 17, parotid branches; 18, internal maxillary; 19, 
temporal; 20, transverse facial; 21, anterior auricular; 22, supraorbital; 23, middle tem- 
poral ; 24, anterior temporal; 25, posterior temporal artery. 
clavian, from which, in turn, come off, first, the vertebral artery, and, second, 
the thyroid axis, this latter, in the threefold division that it makes, giving 
off, with other two, the inferior thyroid artery. Turning to a view of the 
opposite side, a difference is seen to exist in that the two vessels first named are 
offshoots of what is known as the innominate artery; the subclavian, in its 
turn, affording, besides the vertebral and thyroid axis, certain others unshown 
on the opposite side, but of course existing there,-namely, the long internal 
mammary, the superior intercostal, and profunda cervicis. 
Anastomosis of Internal Carotid Arteries.-Beginning with the 
primitive carotid arteries of either side, these are seen ascending until they 
break up into what have been studied as external and internal carotids. (See 960 
A SYSTEM OF ORAL SURGERY. 
Figs. 765 and 766.) Tracing the course of the internal of these, which, 
however, as seen in a dissection, lies first to the external side, it is found to 
pass deeply into the neck and to enter the carotid canal, emerging from which, 
within the brain-case, it enters into the formation of the circle of Willis, 
anastomosing with its fellow-carotid, which has come from the opposite side 
Fig. 767.-Anatomical Circulation of Arterial System of Head 
and Neck. 
Internal maxillary artery. 1, right common carotid; 2, internal carotid; 3, ex- 
ternal carotid; 4, superior thyroid; 5, lingual; 6, facial; 7, occipital; 8, posterior auricu- 
lar: 9, parotid branch; 10, temporal.artery; 11, internal maxillary; 12, tympanic; 13, 
the great and small meningeal arteries from a common branch; 14, inferior dental 
artery; 15, muscular branches; 16, superior maxillary, or alveolar, artery giving off the 
posterior dental arteries; 17,18, infraorbital artery. 
of the neck, by means of two communicating vessels, the posterior of which is 
seen in the diagram. 
Basilar Anastomosis.-Passing here to the vertebral arteries of the 
two sides, these are seen ascending and entering the cranium through the 
foramen magnum, the two running together above this, forming the basilar 
artery. This basilar vessel divides into two branches, known as the posterior 
cerebral, which, in turn, give off two vessels, the posterior communicating, 
which join the posterior communicating of the two carotids, thus making two 
other anastomoses. 
Cervical Anastomosis.-Returning here to the external carotid artery, 
this vessel is seen to give off, among other branches, the occipital, which, in 
its turn, gives off a descending vessel, the princeps cervicis; this, in turn, LIGATION OF ARTERIES. 
961 
meets, and anastomoses with, the profunda cervicis, an artery which has origin 
from the first intercostal. (See the diagram.) 
Thyroid Axis Anastomosis.-Looking at the left side of the dia- 
gram as it faces us, but which, it is to be remembered, is the right side of the 
Fig. 768.-A Study in Anastomosis 
Circle of Willis 
Basilar artery 
Occipital artery 
External carotid artery 
Princeps cervicis artery 
Primitive carotid artery 
Vertebral artery 
Thyroid anastomosis 
Princeps profunda artery 
subject, the axis, known as thyroid, is seen arising out of the subclavian and 
dividing into three parts. The one seen ascending is the inferior thyroid 
artery, this, as observed, ascends upon the neck, dividing, in its turn, into 
other branches, one of which communicates with its fellow of the opposite 
side, while a second reaches upward to anastomose with a corresponding de- 
scending branch of the superior thyroid, which vessel, as understood, is a 
branch from the external carotid. 962 
A SYSTEM OF ORAL SURGERY. 
Thoracic Anastomosis.-From the under surface of the subclavian 
are seen coming off the long internal mammary and the first superior inter- 
costal arteries. These vessels communicate with the descending aorta, as 
shown in the diagram. 
Pelvic Anastomosis.-The extreme inferior vessels of the diagram 
represent the deep epigastric; this and the mammary anastomose. 
Review.-Occlusion of a primitive carotid artery of one side (see string 
placed about the vessel) finds compensation by the anastomosis existing 
between the external carotid and subclavian vessels as these relate through 
the profunda and princeps cervicis, and as well through anastomosing thyroid 
branches, as seen in the diagram ; also through the circle of Willis by the 
branches coming off from the basilar; this, in turn, from the subclavians 
through the vertebrals. Occlusion of an external carotid is compensated by 
the same general arrangement. If the vessel be ligated below the superior 
thyroid (see diagram), the circulation to parts above is continued through 
anastomosis of this last-named vessel with the inferior thyroid and with its 
fellow of the opposite side. If ligation be practised above the thyroid, the 
subclavian supplies the blood, the passage being (see diagram) through the 
profunda cervicis into the princeps cervicis, and from this through the occipital 
into the carotid above seat of occlusion. In instances of limited stenosis of 
the aorta just below the arch, the intercostals-seen in the diagram in relation 
with the subclavian and internal mammary-are found to enlarge in attempt 
at compensation,-an attempt attended by success if the obstruction be not too 
great. This diagram is to be closely studied. It is a dissection 
that is invaluable as a guide in selection of seat of a ligation.* 
Facial Anastomosis.-Fig. 766 affords appreciation of facial anasto- 
mosis. Beginning from below, first, by coronaries, inferior and superior; sec- 
ond, by transverse nasal; third, by angular. Upon the forehead relation exists 
with the temporal, midway of the cheek with the transverse facial, in the 
deep structures with the internal maxillary artery. 
Internal Maxillary Anastomosis.-Section of the inferior maxillary 
nerve, after the manner of removing coronoid process of inferior maxilla, im- 
plies, almost necessarily, ligation of the internal maxillary artery between its 
offshooting fourteen branches and the carotid out of which it arises. These 
branches anastomose freely with radicles coming from other vessels, so that 
the ligation of the root-vessel results in no interference with the nutrition of 
parts supplied by its division. (See Fig. 767, together with legend and text.) 
Lines for Locating Vessels.-The arteries of the face, external and 
deep, arise out of the external carotid. The external carotid is one of the 
two terminal divisions of the common carotid. A line laid upon the neck, 
* This beautiful dissection is the work of Henry Albert Reeves, F.R.C.S., author of the 
book " Human Morphology." The present writer has repeated it on many occasions. It is 
absolutely accurate. LIGATION OF ARTERIES. 
963 
from the sterno-clavicular articulation to the mastoid process of the temporal 
bone, marks the position of the common vessel in the length of its course 
from emergence above the clavicle to termination opposite hyoid bone. (Refer 
to Fig. 765.) A line drawn from a point of meeting with the first, opposite 
hyoid bone, to angle of lower jaw, locates the situation of external carotid. 
(Refer to same Fig., also to Fig. 766.) A line starting from the notch upon 
the face of lower jaw anterior to masseter muscle, being carried to internal 
canthus of eye of the same side, distinguishes the course of facial artery. 
(Refer to same Figs.) 
External Carotid Artery.-The external carotid artery breaks up in 
the substance of the parotid gland into the internal maxillary, the temporal, 
and the posterior auricular. (Fig. 766.) The first (Subfig. 18) passes the 
head of the jaw and supplies all the deep parts of the face. The second 
(Subfig. 19) has its pulsations felt just in front of the ear; it continues upward, 
supplying the temporal region and side of forehead. The third (Subfig. 16) 
runs back of the ear, assisting to vascularize the posterior auricular locality. 
Lingual Artery.-Associated with the surgical signification of the region 
is the lingual artery ; this is the second branch (Fig. 765, Subfig. 5) of the ex- 
ternal carotid. It supplies the tongue, and is the not infrequent seat of ligation. 
Venous System of Face.-Arterial blood having passed through the 
capillary system is returned to the common circulation by office of the veins. 
A dissection of the facial venous system, one of the best the author has ever 
seen, is introduced as a study in Fig. 51, which see. 
Arrestation of Hemorrhage.-Where ligation is found necessary for 
the arrestation of hemorrhage, the vessel indicated for operation is that one 
most directly associated with the lesion. 
Ligation of Facial Artery.-Wounds of the face, when not other- 
wise controllable, compel ligation of the facial artery of the injured side. 
Feeling for the anterior border of the masseter muscle, the finger is allowed 
to drop until resting upon the notch (see Fig. 766, Subfig. 6) occupied by the 
artery in its passage over the jaw. Position discovered, a pencil-mark, half 
an inch in length, is made to designate the direction of the vessel. An 
incision, one inch in length, is cut oblique to this line. The artery is reached 
by incising skin, the subcutaneous and adipose tissue, platysma myoid muscle, 
and deep fascia. Along the outer border of the facial runs an associate vein, 
which is not to be included in the ligature. 
Ligation of Temporal Artery.-The seat of selection for ligation of 
the temporal (see Fig. 766, Subfig. 19) is immediately above the zygoma, 
the white line upon which Subfig. 22 is placed, and one-quarter-of an inch 
in front of the cartilage of the ear. The vessel lies quite superficial, being 
covered alone by the integuments. Its pulsations are to be felt, and constitute 
a reliable guide in the operation. A feature of obstruction is met with in the 
resisting character of a connective tissue which ties the vessel closely to its 
bed; this tissue is to be torn carefully by means of a director. Not in- 964 
A SYSTEM OF ORAL SURGERY. 
frequently one or more lymphatic glands are found in the line of incision; 
these are to be pushed aside, or, if found unduly in the way, may be dissected 
out. On the ear side of the artery runs its vein, while both anteriorly and 
posteriorly are seen nerves (branches of the facial and inferior maxillary), all 
of which are to be excluded in passage of the thread. 
Ligation of Occipital Artery.-The occipital is a vessel of consid- 
erable import coming off from the external carotid just opposite the facial. 
(See Fig. 766, Subfig. 13, and Fig. 767, Subfig. 7.) Ligated in the 
scalp, which is the seat of selection (Fig. 769), an incision two inches in 
length, which commences at the mastoid process, is carried outwardly in the 
direction of the occipital protuberance. The operation is more involved 
than the two preceding. The layers to be gone through are skin, subcu- 
taneous tissue, some fibres of the sterno-cleido-mastoid muscle, the splenius 
and complexus. Reaching thus the locality of the artery, search is made for 
the vessel by means of a finger introduced into the wound which feels for its 
pulsation. Casting of the ligature implies the avoidance of accompanying 
vein, and, most importantly, of the large mastoid vessels which in this 
neighborhood join the occipital vein, forming communication with the lateral 
sinuses of the dura mater. The student not possessed of the advantages of 
Fig. 769. 
direct observation on the cadaver, is to study closely, and in connection, the 
three diagrams noted. (See description of the course of artery and its cover- 
ings, on page 89.) 
Ligatures in Position.-Fig. 769 shows, besides the lines of incision 
described, the ligatures in position. 
Thyroid Artery.-The superior thyroid artery (Fig. 766, Subfig. 4) is 
the occasional seat of ligation in attempts at cure of goitre. To reach it the LIGATION OF ARTERIES. 
965 
incision is employed that exposes the external carotid, of which it is the first 
branch. This latter vessel reached, the operator feels for the bifurcation and 
from this slides the finger upward. The first offshoot passing inward is the 
artery of which he is in search. The ligature is not to be nearer the carotid 
than an inch. The position and relations of the thyroid gland and the 
manner in which the vessel reaches it is fully shown in Fig. 771. The letter 
I marks the position of the gland. The cut is to be looked at from its left side. 
Fig. 770. 
Relations of the lingual artery. H, hyoid bone; h, its great horn ; M, the body 
of the lower jaw; M', its angle; sh, oh, th, insertions, into the body and horn of the 
hyoid bone, of the sterno-hyoid, omo-hyoid, and thyro-hyoid muscles; ph, the inferior 
constrictor muscle of the pharynx; sm, the submaxillary gland drawn over the jaw, 
with (/) the facial artery and vein; je, the external jugular drawn aside, along with 
the sterno-cleido muscle; d, the digastric muscle perforating the stylo-hyoid, and looped 
down to the great horn of the hyoid bone by its fibrous pulley, d'; hyp, hypoglossal 
nerve running alongside the lingual vein, and disappearing under (mh) the mylo-hyoid 
muscle ; I, the lingual artery passing beneath (hy) the hyoglossus muscle; t, the superior 
thyroid artery; f, the facial artery, behind which lies the external carotid; ci, the in- 
ternal carotid artery; ji, the internal jugular vein, into which are seen emptying the 
facial, the lingual, and the superior thyroid tributaries. The white stars mark the point 
where the artery is cut from, as described in the text. 
Lingual Artery.-Wounds and diseases of the tongue make necessary, 
occasionally, the ligation of the lingualis. To do this operation requires much 
skill and thorough anatomical knowledge of the parts. The seat of selection 
(see Figs. 765 and 766, and particularly 770) is where the vessel runs 
beneath the hyoglossus muscle, immediately above the greater cornua of the 
hyoid bone. Feeling for the extension of the bone (Fig. 770, letter A), the 
cutting is commenced by an incision running toward the mesian line of the 
neck, from the anterior border of the sterno-cleido-mastoideus parallel with, 
and just above, the cornua, h. The tissues to be gone through are the skin, 966 
A SYSTEM OF ORAL SURGERY. 
platysma myoid muscle, superficial fascia, deep fascia. Arrived at this depth, 
the hypoglossal nerve, accompanied by the lingual vein (Fig. 770, hyp), is 
found directly in the line of the cut, overlying the hyoglossus muscle. 
Supporting these vessels and covering the artery is the muscle (hy) named. 
This is to be incised; a director being used. 
Fig. 770 is introduced as a guide to the performance of the operation, 
which, confessedly, is a difficult one. The author has repeated the dissection 
a great number of times. The exhibit made of parts and of their relation 
is surgically accurate. One having the picture before him at time of doing 
the ligation can hardly go wrong. 
A hemorrhage uncontrolled by any one of the ligations described, a suc- 
ceeding recourse is to the external carotid; this failing, in turn, the primitive, 
or common, carotid is to be tied. 
Ligation of External Carotid Artery.-The patient being placed 
upon his back, with the head extended, an incision is made obliquely over 
the line of the vessel as located. (Fig. 765, Subfig 3.) The incision is to be 
one and one-half inches in length. (See Fig. 771.) The overlying tissues con- 
sist of skin, platysma myoides, superficial fascia, deep fascia. Section of this 
last exposes more or less connective tissue in which lies the sheathed vessel. 
The facial and lingual veins, and commonly one or more lymphatic glands, are 
in close association. The artery is crossed by the hypoglossal nerve and by 
the digastric and stylo-hyoid muscles. Close to its outer border lie the in- 
ternal carotid artery and deep jugular vein. (See Fig. 771, letter V.) The 
situation of the part being quite deep, much dexterity is required in manipu- 
lating about it. The place at which the ligature is to be tied is to be as far 
removed from seat of bifurcation as possible. Put too near, hemorrhage of 
the most serious character is likely to occur on the coming away of the thread. 
A remove of less than one and one-half inches is not admissible. The farther 
away from the bifurcation the operation is done the greater is the promise of 
safety and good result. The ligature is to be passed between the two carotids, 
-that is, from without inward. Before tying, the surgeon is to see that the 
vessel alone is surrounded. 
Ligation of Primitive Carotid Artery.-Study of the topographical 
anatomy of the neck shows it first as an oblong square. The boundaries of 
this square, surgically made, are, below, the clavicle; above, the base of the 
lower jaw, together with a line continued from its angle back to the mastoid 
process of the temporal bone; anteriorly, the mesian line of the neck; and 
posteriorly, the border of the trapezius muscle. This square is divided 
primarily into an anterior and posterior triangle by reason of the oblique 
crossing of the sterno-cleido-mastoid muscle, the line of which, as understood 
(Fig. 39, Subfig. 19), is from the mastoid process to the sterno-clavicular articu- 
lation. These triangles are known, in surgical language, respectively, as the 
anterior and posterior cervical triangles. The first of these has its base above 
and its apex below, the boundaries being, in front, the mesian line; behind, the LIGATION OF ARTERIES. 
967 
anterior border of the sterno-eleido muscle; superiorly, the base of the lower 
jaw; and inferiorly, strictly, a half-inch space to the outer side of the centre 
of the sternum. The second has its base below and its apex above, the boun- 
daries being, in front, the posterior border of the sterno-eleido muscle; behind, 
the anterior border of trapezius muscle; superiorly, strictly, a half-inch to 
posterior side of mastoid process; and inferiorly, all that portion of the clavicle 
lying to the outer side of the sterno-eleido-mastoid muscle. In the first is in- 
cluded the submaxillary triangle, and in the second, the subclavian. (See, as a 
study, Fig. 39.) A second muscle, passing obliquely in a reverse direction, the 
omo-hyoid (Fig. 39, Subfig. 24), subdivides the two triangles seen to be made 
by the passage of the former muscle into four, these being known as the an- 
terior inferior and superior and the posterior inferior and superior cervical 
triangles. The primitive carotid is ligated in either of the anterior triangles; 
in the superior preferably. Appreciation of the forms and positions of the 
triangles is gained by a study of Fig. 39. The picture shows perfectly the 
different triangles, and a student is not to leave it until fully informed on the 
subject. The legend locates the different muscles. 
In Superior Triangle.-The patient in position as described in connec- 
tion with the external carotid, an incision from one to two inches in length is 
made upon the line designated. Overlying tissues are skin, platysma 
myoides, superficial fascia, deep fascia, sheath of vessel. Upon the sheath is the 
descendens noni nerve ; within it are the artery, the pneumogastric 
nerve, and deep jugular vein. Opening the sheath exposes the artery. 
In Inferior Triangle.-Position of patient is the same. The line of 
incision approaches the trachea along with the anterior border of sterno-eleido 
muscle. Overlying structures are skin, platysma myoides, superficial 
fascia, deep fascia. In place of coming here, as in the previous dissection, 
upon the sheath of the vessel, after cutting through the integument mus- 
cular structure is met with; this structure is, on the outside, the sterno- 
cleido-mastoideus; on the inside, the sterno-hyoid and thyroid muscles. (See 
Fig. 39.) To get at the artery requires separation of these muscles at the 
interspace, retractors being used to hold them out of the way. Exposure of 
the sheath reveals an anatomy as before described. The passage of the needle 
in both operations is to be from behind forward, great care being taken 
that neither nerve nor vein be included in the ligature. 
Dissection.-Fig. 765 is a reliable study made from a most careful dis- 
section. The exposure shows most fully the relational anatomy of external 
carotid artery and that of the superior cervical triangle, as reference is had to 
seat of election for ligating primitive carotid. The anterior inferior shows 
upper boundary of that triangle as made by the crossing of the omo-hyoid 
muscle, also outer and inner boundaries as made by sterno-eleido and sterno- 
hyoid and thyroid muscles. 
Fig. 771 enlarges the dissection shown in Fig. 765. Combination of the 
two affords an anatomy which furnishes a sufficient guide to the performance 968 
A SYSTEM OF ORAL SURGERY. 
of the ligation. In the latter diagram is seen the relation of artery and vein, 
the first being in front, the latter behind. The pneumogastric nerve lies 
between and beneath the two. The little nerve seen passing between e and I 
is the descendens noni. It comes off, as further shown, from the hypoglossal, 
seen crossing above. Great care is necessary, in passing a ligature, that the 
vagus nerve be not included. The descendens noni, as understood, is met 
with outside and upon the sheath. 
Submaxillary Triangle.-While not related with ligations except as 
removal of the gland makes this performance necessary, in case of the facial, 
Fig. 771.-Dissection exposing the Anterior Superior and Inferior 
Cervical Triangles and the Submaxillary Triangle. 
V, internal jugular vein with its tributaries, the facial, the lingual, and pharyngeal; 
p, parotid gland; h, os hyoides to which is attached the stylo-hyoid muscle, through 
which is seen running the tendon of the digastric, under which passes the hypoglossal 
nerve after crossing the external carotid; a, hook raising the submaxillary gland in 
order to expose contiguous parts; c, thyroid gland. 
it is not out of place just here to consider a region so important to the oral 
surgeon. This triangle, which has found in it the submaxillary gland and 
portions both of the duct of Wharton and the facial artery, has its boundary 
above in all that inner face of the lower jaw lying beneath the mylo-hyoid 
ridge; below, it is bounded both in front and behind by the two bellies of the 
digastric muscle. The apex lies with the tendinous intersection of the muscle 
named. The boundaries given show the base to be above and the apex below. 
Practically Viewed.-Practically viewed, the triangle is to be esteemed 
a closed box, the bottom of which is a leaf reaching from behind the digastric LIGATION OF ARTERIES. 
969 
muscle to the jaw from the common deep cervical fascia, and the lid of which 
is of similar significance as a second leaf extended in front is concerned. In 
this box lies the gland, the not infrequent seat of abscess and of other diseases 
which render necessary opening into the cavity. Removal of the gland com- 
pels a ligature placed about the facial artery. To ligate the vessel in this 
cavity is a matter, however, requiring no skill, as removal of the gland has 
divided and exposed it. The artery lies at the bottom of the box,-a matter 
which insures confidence where the bistoury is used to open an abscess of the 
locality. Abscess, or accumulations of fluid of any kind, in the cavity is 
differentiated out of the triangular form that it takes by reason of the shape 
of the part in which it is confined. Fig. 771 exposes the triangle. The 
facial artery is seen running into it. The hook, a, holds up the submaxillary 
gland. The parotid gland, seen to the right and above the submaxillary, is 
recognized as being separated from it by the posterior belly of the digastric 
muscle. 
Anterior Inferior Triangle.-Studying this triangle, as exhibited in 
dissection (Fig. 771), its base is seen to be the mesian line of the neck, or at 
least the outer border of the sterno-hyoid and sterno-thyroid muscles as seen 
in the cut next the line of the 
skin; its superior boundary, 
the omo-hyoid muscle, seen 
in the dissection descending 
obliquely outward ; its inferior 
boundary, the sterno-cleido- 
mastoideus, seen drawn upon 
by the hooks. The apex is 
outward, and is made by the 
crossing of the omo-hyoid and 
sterno - cleido muscles. The 
muscular structure alluded to 
as being met with is seen in 
the diagram to be the oblique sterno-cleido-mastoideus and the straight sterno- 
hyoid and sterno-thyroid. To get at the artery these muscles are to be sepa- 
rated, while to recognize the line of separation requires only that attention 
be directed to the running of the fibres. Oblique fibres being met with, the dis- 
Fig. 772.-Manner of tying Ligatures. 
Fig. 773.-Tenaculum for taking up Artery. 
section is to reach inward ; vertical fibres being seen, the knife is to go inward. 
(For study of ligation of occipital, infra-, and supraorbital arteries, see Nerve 
Exposures') CHAPTER LVII. 
THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
The antrum of Highmore, or maxillary sinus, the cavity being called in- 
differently by either of these names, is a cave existing in the superior maxil- 
lary bone, having the threefold office of rounding the cheek, of warming 
air with purpose of modifying that passing along the respiratory passage to 
the lungs, and of adding to a lubricant of the pituitary mucous membrane so 
necessary to the offices of olfaction and respiration. 
Concerning its Diseases.-Many years spent in a direction of prac- 
tice which affords opportunity for observation, combined with a scope of view 
which necessarily offers to one who is himself a hospital surgeon and a fre- 
quent visitor at hospitals, combine to impress the writer with the truthfulness 
and propriety of a conclusion, that the immediate diseases of the antrum are, 
for the most part, simple in character, easy of diagnosis, and, as a rule, not at 
all difficult of treatment. Indeed, for the purpose of general study, one 
would not be entirely without justification in asserting that there are but two 
sources of trouble to be found in this cavity: the first, and prominent, being 
lesions secondary to the diseases of the teeth; the second, the lesions common 
to mucous membranes, wherever situated. Certain it is that the great ma- 
jority emanate from the first of these directions; while the atonic conditions, 
represented by the dropsies, the puruloid secretions, the mucous engorge- 
ments, and the ulcerations, are in no wise different from ordinary mucoid 
affections, except as modifications are made by situation; the last being con- 
clusively proven by the fact that what is the cure of the one is the cure of the 
other. 
Surgical Anatomy of Antrum.-Fig. 774 is for use as a reference 
and for surgical study. The antrum, as here seen, occupies the interior of 
a superior maxilla. The diagram shows the cavity of the left side of face 
as it stands exposed by removal of its outer wall. It is a more or less irregular 
sinus, and extends, not infrequently, slightly into the malar bone, and in rare 
exceptions occupies the whole of its body. 
The cavity has its first describer in Nathaniel Highmore (1651). Appearance 
of the sinus is with the sixth month of foetal life, and its increase of size ac- 
cords with the development of the individual. It diminishes with age, or 
decreases in size if the teeth be lost, not otherwise. It is naturally larger in 
the male than in the female, corresponding thus with the commonly greater 
osseous structure of the former. A female possessed of larger jaw-bones 
970 THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
971 
than a male reverses the condition. No definite size is to be recorded for the 
sinus. Examples occur where capability exists of holding so much as one and 
a half fluidounces. The rule is half this quantity. The shape of the cavity 
is irregularly triangular. Thickness and thinness of walls correspond with age, 
sex, and circumstances. In 
women who have lost their 
teeth the boundaries are 
sometimes found almost 
paper-like as to lack of 
resistance, the blade of a 
knife being able to pene- 
trate from any part. 
Regard is to be had to the 
probable existence of septi, 
which are found at times 
to divide the cavity into 
compartments. The mu- 
cous membrane lining the 
cavity is to be inferred as 
being of the ciliated vari- 
ety, as after such arrange- 
ment the fluid finds its 
place of egress at the 
middle meatus. Breaks 
relating the oral cavity 
and antrum allow falling 
in of the cheeks if the 
vestibule be inflated. 
Outlet of Cavity.- 
Subfig. 20 of cut shows 
the opening of the antrum 
into the middle meatus of 
the nose. Seen, as here, 
divested of soft parts, it shows as being about the size of a goose-quill. Three 
other bones unite with the maxillary to form the nasal boundary of the antrum 
and to diminish its outlet. These are,-1, the lachrymal, by its descending 
process (Subfig. 20) ; 2, the inferior turbinated, by its maxillary process 
(Subfig. 17); and 3, the palate, by its external rough surface (Subfig. 19). 
(See Anatomy of Bones.') This outlet, when lined by mucous membrane and 
its sublying connective tissue, is reduced in size to the circumference of a 
crow-quill. The mucous lining of the antrum is continuous with that 
of the nostril and is always in sympathy with it in catarrhal affections. The 
opening is a way of ingress and egress for tumors originating in the nose or 
sinus, the boundary bones quickly giving way in presence of such affections. 
Fig. 774. 
Left side of face, with the outer walls of the 
ANTRUM REMOVED, SHOWING MAXILLA IN RELATION WITH 
NEIGHBORING BONES, AND THE INNER FACE AND BOUNDA- 
RIES of the sinus. 1, frontal orbital plate; 2, frontal sinus; 
3, lachrymal bone; 4, ethmoid bone; 5, 6, ethmoidal fora- 
mina ; 7, sphenoid bone; 8, optic foramen; 9, palate bone; 
10, spheno-palatine foramen; 11, rotund foramen; 12, ptery- 
goid canal; 13, pterygo-palatine canal; 14, termination of 
the spheno-maxillary fossa in the posterior palatine canal; 
15, posterior dental canal; 16, inner wall of antrum formed 
by the maxilla; 17, turbinated bone; 18, uncinate process of 
the ethmoid; 19, palate bone; 20, descending process of the 
lachrymal, behind which is the opening of the antrum into 
the nasal cavity; 21, lachrymal fossa. 972 
A SYSTEM OF ORAL SURGERY. 
Relation with Spheno-maxillary Fossa.-Another complication 
relates with the spheno-maxillary fossa (Subfig. 14). Sarcoma originating 
in the antrum, commonly, quickly pushes its way through the tuberous 
boundary filling up this cavity and extends, in turn, to the zygomatic fossa, 
involving from this the regions about the soft palate. 
Relation with Lachrymal Fossa.-The position of the lachrymal 
fossa is exposed by Subfig. 21. This fossa has, as its continuation, a tube, the 
ductus ad nasum, that associates it with the lower nasal meatus. The two 
constitute the receptacle of, and overflow for, the tears. Referring to Subfig. 
20, the position of the lachrymal process is seen. This is an exceedingly thin 
plate of bone, and constitutes the only separation of the tear-canal and antrum. 
Engorgements of the cavity may break into this canal, while soft sarcomatous 
growths are sure to soften and destroy the plate and crowd upward into the 
fossa. 
Relation with Orbital Cavity.-The orbital plate of a superior 
maxilla (see Fig. 9, Subfig. 4) is one with the roof of the antrum and the 
floor of the orbit. It is a thin, triangular-shaped plate of bone, easy of 
absorption or displacement. Abscess of the antrum, having associated with it 
closure of the outlet, discharges, not infrequently, through this plate, causing 
formidable eye complications. Tumors throw it up, forcing the eye upon the 
cheek. The orbital face of this plate is the occasional seat of sarcoma. It is 
the experience of the author that this disease, when commencing here, is of less 
threatening import than when originating in the antrum. Its progress is 
certainly much less rapid. 
Possible Anomalies.-While accepting that in the two directions of 
diseases of teeth and diseases common to mucous membranes at large lie the 
chief sources of antral trouble, it is not by any means to be understood that 
the subject is unworthy investigation outside of such considerations; on the 
contrary, there are found recorded more than one account of diseases of the 
cavity which, to the author, at least, are as anomalous in principle as they 
are in description, and which he can only explain to himself on the ungenerous 
supposition that the authors have drawn on their descriptive powers, other- 
wise that the antrum has some strange anomalies. 
Sequelae as Lesions.-Again, as a class coming between these uncom- 
mon and the common affections, it follows, not at all indirectly, that there exist 
sequelae of certain of the exanthemata which have a special and peculiar 
affinity for this cavity; while, in syphilis, it may be the case that the very 
first event in the secondary train exhibits itself in a disturbance of the sinus. 
That this latter, however, is rare, observation certifies. Indeed, syphilitic 
troubles of the antrum are so infrequent, even in the tertiary stage of that 
affection, that experience will lead to the inference that the cavity never takes 
on the disease unless when, from continuity of structure, it has the trouble 
absolutely forced on it, this either from its relationship with the hard palate THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
973 
in the oral direction, or with the turbinated bones in a nasal; for, while the 
practitioner will surely hear complaints, yet, if he investigate the cause of 
trouble, he will find that mercurial inflammation of periodonteal membranes is 
the source of offence, rather than the specific condition. Clumsily-per- 
formed surgical operations are also occasional causes of morbid condi- 
tions being set up in the cavity, which, when forerunning, would of course be 
so evident as to force the consideration of them on the attention,-the most 
common of them being the breaking of the fangs of teeth in attempts to 
extract these organs. (See Tumors.) 
A required preliminary appreciation of the surgical anatomy and associations 
of the antrum being possessed, attention is to be directed to the lesions of the 
part, and these the writer will describe exactly, and alone, as he personally 
knows them. 
Diseased Teeth as Lesions.-In the chapter treating on Anomalies 
of Dentition, attention is directed to the close relationship of the fangs of 
several of the teeth with the floor of the antrum, and to the fact that it is not 
uncommon to find these fangs-particularly the palatine of the second molar 
-penetrating the sinus, thus associating their membranes, and furnishing a 
contiguity if not a continuity of structure. In the same chapter attention is 
also called to diseases and conditions of the alveolar border as apt secondarily 
to affect the antrum; means of diagnosis and treatment being suggested. 
Dento-alveolo-antral Abscess.-The common tooth abscess is the 
common disease of the antrum, and a discharge found running from the 
nostril of a side affected is of entire significance with that discharging from 
the familiar gumboil; difference lying alone with place of discharge; a parulis 
venting itself upon the face of the gum, the antral abscess into that cavity. 
Treatment of both cases is precisely alike. (See, for full understand- 
ing of this, the chapter on Alveolar Ahscessi) 
Illustrative Case I.-A lady having had the pulp of a second bicuspid 
tooth treated with the ordinary arsenical paste and the canal filled, was 
troubled almost immediately after the completion of the performance by peri- 
dental inflammation which, defying all that was done with view to resolution, 
passed to suppuration. The pus, instead, however, of finding vent in the 
ordinary situation upon the gum, made its way into the antrum, becoming here 
a source of irritation, which quickly made itself evident by a sense of pain 
and general discomfort that followed, and the sympathetic phenomena that 
showed upon the face. Removal of the tooth was followed by a free discharge 
of matter and the speedy subsidence of trouble. Examination made with a 
probe showed the antrum in this case to reach unduly forward. Differentia- 
tion between resolution and abscess lay in the quick cessation of pain, resultant 
of the abscess discharging into the sinus, and the appearance of the antral sequel. 
Illustrative Case II.-A young man applied to the writer for treat- 
ment of what had been diagnosticated purulent nasal catarrh. Examination 974 
A SYSTEM OF ORAL SURGERY. 
showed almost entire naturalness in the Schneiderian membrane, nor was there 
any interference with the respiratory office of the canal. Inquiry elicited 
that the discharge was worse at night, the pus being found upon the person and 
the pillow in the morning. A look into the mouth discovered a dead second 
molar tooth, yet one of which no coinplaint was made. This tooth being 
opened by means of a spear drill, the patient was able to suck pus into the 
mouth freely. Extraction revealed communication between all three of the 
roots and the antrum. Syringing the parts for a few days with very dilute 
iodine tincture was the simple and only treatment used. 
Illustrative Case III.-Patient, a lady sixty years of age. The face 
of the gum underlying the antrum along the alveolar border was congested, 
purplish, and cystiform after the manner of an indolent abscess that has dis- 
charged itself. Employment of the probe discovered free association with the 
antrum, whence the pus evidently came. Treatment consisted in an 
exploratory incision that freely opened the abscess and which exposed carious 
bone in abundance. Necessity for removal of this being evident, an engine- 
bur was used. A result was the finding of a tooth-root. This person had 
worn artificial teeth for years, during which time this root had laid in an en- 
cysted, quiescent state, giving no trouble. The writer has met with many simi- 
lar cases. No attempt was made in this case to close the sinus, nor did it close. 
The patient continues to syringe it daily. 
Illustrative Case IV.-Patient, a gentleman fifty-two years old. 
Swelling below the eye, which quickly extended over the side of the face, was 
consequent on exposure to a heavy wind. In defiance of the most energetic 
treatment of an antiphlogistic nature, both locally and constitutionally directed, 
an abscess formed which was vented within the mouth. The presence of 
much carious bone exposing itself to the probe, the engine-bur was freely 
used, and in the cutting an eye-tooth was discovered having its location in the 
nasal process. This tooth, which was the predisposing cause of the trouble, 
was removed and a cure quickly followed. In this, as in the preceding case, 
artificial teeth had been worn for years. 
Note.-In cases, like the last two, where effects, as originally observed, are 
out of proportion to an apparent cause, the progress of the case will discover, 
almost certainly, an abeyant lesion. 
Illustrative Case V.-Indolent Tumor on the Right Cheek.- 
A woman had an indolent tumor on the right cheek, about the size of a pigeon's 
egg, occasioning much disfigurement, but altering the color of the skin very 
slightly. The patient had often suffered violent toothache on this side, and, 
though young, had few teeth remaining, and these all carious; otherwise she 
was in very good health. The tumor was prominent toward the cheek, palate, 
and nostril, yielded on pressure, and gave a slight noise as it returned to its 
position. 
The symptoms caused the practitioner to suspect the existence of some 
fluid, which it was necessary to evacuate and follow with suitable injections. THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
975 
For this purpose, the cheek was drawn aside, and an incision made into the 
bone above the gum, with a bistoury, enlarging it before and backward, till a 
sufficient opening was obtained, from which escaped an inodorous mucous 
fluid. The bone was at no point denuded of its periosteum. The wound was 
dressed with a pledget of lint saturated with spirits of wine, and the next 
day the patient was better. On the third day she was feverish, the sinus was 
swollen and painful, and the discharge acrid and fetid. These symptoms were 
controlled by proper remedies, and, after twenty-four days, the walls of the 
sinus were nearly restored to their normal condition. 
The canine tooth of this side being very obliquely situated, it was thought 
proper to extract it, and thereupon followed an escape, through its socket, of 
fluid contained in the sinus, though the tooth itself seemed perfectly sound. 
Through this orifice injections were made. The opening made in the exter- 
nal wall healed promptly, without any exfoliation ; in six months the tumor 
entirely disappeared, and the patient was cured. (From Baron Haller's 
Collection of Medico-Chirurgical Theses.) 
The translator of the above case, in commenting upon the treatment, 
pointedly remarks, " One cannot fail to see the uncertainty, not to say ob- 
scurity, of the treatment adopted. Though all the teeth were carious, and 
their extraction plainly indicated, an incision in the external wall of the 
antrum, or, more correctly, its destruction, was determined on. The result is 
seen in the symptoms which supervened on the third day, which were, per- 
haps, hastened by the spirits of wine. We have here a canine tooth quite 
displaced and involved in the tumor; yet it was long before the idea of its 
extraction occurred, though the subsequent discharge, through its socket, 
proved how advisable it would have been at the commencement of the treat- 
ment. In this way the time of cure might have been shortened by half." 
Illustrative Case VI.-Distention with Softening of the 
External Walls of the Sinus.-In , says the same surgeon, I was 
consulted in the case of a large tumor of the right cheek. The external wall 
was much distended and softened, and yielded to pressure, upon the removal of 
which it gave a sound resembling the crushing of an egg-shell. The nose was 
turned to one side,-the nostril was obstructed,-yet the patient suffered no 
pain, and the skin, though distended, preserved its natural color. On examina- 
tion of the mouth, I found that the crowns of the bicuspidati and molars were 
destroyed by caries, which induced me to advise the extraction of their per- 
sistent fangs ; the patient consenting, this was immediately done. The shock 
occasioned by the removal of each of the fangs caused a portion of fluid to 
escape from the sinus through the natural opening: it was thin, reddish, 
saline, and inodorous, and, in all, about three spoonfuls. The tumor could 
now be made to disappear by pressure, but would again return to its full size. 
Pressure caused no escape of fluid through the nasal, and but slight through 
the alveolar, opening, which latter was at the bottom of the first molar socket 
and large enough to admit the finger. 976 
A SYSTEM OF ORAL SURGERY. 
The internal membrane of the sinus was entire, except at the alveolar open- 
ing : through this I made injections of warm water, strengthened with a little 
gently alterative fluid. The next day I injected the sinus repeatedly with 
a decoction of agrimony * and honey of roses, meanwhile not neglecting ex- 
ternal compression. In fifteen days the parts returned to their natural con- 
dition, all crepitation of the bone ceased, and the discharge was very slight. 
I now had recourse to stimulating solutions. On the second day the discharge 
had ceased and the alveolar opening was reduced to a mere fissure, and in a 
month from the extraction of the teeth the patient was fully restored. 
Illustrative Case VII.-Periodonteal Abscess affecting the 
Antrum.-A patient was brought to the author who, for more than three 
months, had suffered with a tumor, like the last, on the right side. The 
maxillary cavity was distended to a level with the orbital margin ; the nose 
was turned to one side, and the vault of the palate was remarkably prominent. 
The treatment pursued consisted in removing the fangs of the first two molars, 
the crowns having been destroyed by caries, which fangs seemed to be the im- 
mediate cause of the disease. Next, the opening at the bottom of one of the 
sockets was enlarged, and through this there escaped a large quantity of a 
serous inodorous fluid. Pressure upon the palate and external wall caused 
this fluid to pass through both the alveolar and the nasal openings: this com- 
pression, together with suitable injections, soon terminated the disease. 
The teeth on the left side being in bad condition, their removal was urged; 
but to this the patient would not consent. In three months she came back 
with a precisely similar swelling of this side, which, having the same cause, 
was cured in the same manner. 
Illustrative Case VIII.-The following interesting and instructive 
case is from the practice of Dr. J. D. White, and was reported for the Dental 
Cosmos by his son, Horace Meredith White, M.D.: 
Mr. S., aged twenty years, light complexion, peculiar whiteness of the skin, 
-a characteristic of the family,-had been complaining for some time of a 
fetid discharge from the right nostril; of heat, and a sense of tension, in the 
right superior maxilla. 
He applied to his physician, who gave him a wash, with the belief that 
the parts would speedily return to their normal condition, the practitioner 
supposing the affection to be merely an increased discharge depending on a 
slight local hypermmia, the result, perhaps, of the bad state of the weather 
* A mild tonic and astringent. An injection of more character would be as follows: 
R Glycerini, ; 
Tinctur® opii camphorat®, ^ij ; 
Aqu® Coloni®, giv. M. 
One still better is,- 
Tinctur® eapsici et myrrh re composite, $ij ; 
Acidi carbolici, gtt. vi; 
Aquae, ^viij. M. THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
977 
at the time. The parts, however, did not recover; the discharge became 
much more fetid, and evidently was principally composed of unhealthy pus, 
though it was not as copious as it had been previously; the pain was not 
severe, but the heat of the parts more elevated, and the sense of tension in- 
creased. The patient was irritable and pale; the heat of the body was above 
the average temperature. This was the condition of the sufferer when he 
came under the care of Dr. White. 
Upon examining the anterior naris, nothing was to be discovered to account 
for the discharge; the mucous membrane being a little inflamed, but not suffi- 
ciently so to explain it. A diseased state of the antrum was suspected, and 
the mouth was looked at to ascertain if diseased teeth could be the cause. 
The second molar, upper jaw, right side, was unsound. Part of the crown 
was decayed away; the bulbous portion of the nerve, and the filaments of the 
buccal roots, were dead, but that part in the palatine root was living, and oc- 
casioned the patient pain. A little arsenical paste was applied to destroy it. 
No sign of alveolar abscess was present in this or any other tooth. The next 
day the nerve in the palatine fang was removed without trouble; a careful 
inspection was now made, and important information received. On examining 
the right nostril by means of the speculum, a little pus was seen in the middle 
meatus. The patient was requested to incline the head toward the left side; 
he did so, and on looking at the parts again, a large amount of pus was found. 
This, together with the facts stated already, and that there was no other 
assignable cause of the discharge, was deemed sufficient to establish the 
diagnosis,-abscess of the antrum, caused probably by the unsound second 
molar tooth. 
Extraction was advised and submitted to. On the removal of the tooth no 
pus escaped. A probe was introduced into the alveolus previously occupied 
by one of the buccal roots, and readily passed on into the antrum; matter 
followed the withdrawal of the instrument. 
The cure was completed on general principles. 
Dr. White concludes the description of his case by remarking a coincidence 
which it will not be at all amiss to repeat here,-a coincidence which must 
have been very alarming to the patient. The gentleman had repeatedly 
visited a horse belonging to his father, which had a profuse discharge from 
the nose, thought to be glanders. The date of the horse's malady was prior 
to that of the patient, and, of course, an inference as to infection was not 
unnatural. 
ANTRAL DISEASES COMMON TO MUCOUS MEMBRANE. 
Dropsy of the Antrum.-This, which is only another name for mucous 
engorgement, is not infrequently the result of a reflected chronic periodonteal 
inflammation, not, however, periodonteal abscess, as illustrated in preceding 
paragraphs. In such cases we have the analogue of a similar inflammation 
in the cavity of the mouth: the membrane becomes puffy and thickened, the 978 
A SYSTEM OF ORAL SURGERY. 
mucous secretions grow inspissated, and the natural opening of the sinus 
(simply through this thickening of the mucous membranes, the folds of which 
are the natural outlet of the cavity) is found obliterated. Egress being closed, 
the result is not difficult to surmise: if atresia of the occluding membranes 
should not occur, and no correct surgical assistance be afforded, there must, of 
course, result either the gradual attenuation of the weakest portion of the 
parietes of the cavity, or the setting up of active and severe inflammation. 
If, on the contrary, the natural outlet has a partial restoration, it is not at all 
unlikely that a troublesome and, if misunderstood, tedious and unmanageable 
puruloid discharge will ensue ; this being the result of a continuance of the cause 
of trouble. Recalling illustrative examples from his own practice, the writer 
remembers particularly the case of a child who, previously to coming under 
care, had been treated nearly two years for the occasional discharge of muco- 
purulent matter from the left nostril; the subject was of bad temperament, 
being a cross of the bilio-lymphatic. This patient was relieved in a single 
week, the treatment being directed wholly to the dental arch, if a course of salt 
sheet-baths-continued long after the local cure, and which had been directed 
in consideration of the relaxed condition of her general system-be excepted. 
Temperament and General Condition.-The relation of tempera- 
ment and general condition is to be closely considered in connection with dis- 
eases of the antrum : it is, of course, far from being every one who is troubled 
with a bad tooth, the fangs of which penetrate the cavity, who has secondary 
disease of that cavity as a result. The author had some years ago under 
treatment a patient suffering from necrosis of the whole roof of the mouth, 
the result of a syphilitic cachexia, the exciting cause of the local trouble 
being an incisor tooth anomalously developed. This tooth, the extreme point 
of which presented just back of the incisive foramen, had been mistaken by 
a practitioner for the point of a sequestrum, and, being worked and cut at, 
periostitis had developed; and when the dead bone, which was the result, 
came away, both antra were necessarily exposed.* 
View of Purulency.-A purulent condition of the secretions of the 
antrum is to be viewed as one considers a gonorrhoeal discharge; indeed, Mr. 
Bell, the English author, has, not at all unjustly, referred to the conditions as 
being similar, " both diseases," he says, " consisting equally of an altered 
secretion,-in the one, of the pituitary membrane, and in the other, of the 
muscular lining of the urethra, which in neither instance possesses any of the 
characteristics of abscess, though the matter in both is purulent." Certainly, 
if we allow for some differences, as influenced by cause and location, the de- 
scription of the one answers very well for the other. In both there is the 
same perverted secretion, the same molecular change, the same sthenic and 
asthenic modifications. As a gonorrhoeal discharge is always preceded by 
certain inflammatory conditions, and as, after the subsidence of the acute 
* The lost process is now replaced by an obturator. THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
979 
attack, the discharge may long continue profuse, and of pus form, or, on the 
contrary, may decline to a scarcely perceptible minimum in the shape of gleet, 
so, in antral purulency, we have the antecedent inflammation, and may have 
the profuse or limited secretion. In antral diseases, however, as is readily to 
be inferred, very much depends on the nature and associations of the secretion. 
A profuse discharge, with closure of the orifice of the sinus, must necessarily 
entail untoward consequences: the walls of the cavity will attenuate until 
(unless surgically relieved) the weakest point gives way, the rupture being 
most apt to occur either into the orbit or the mouth. Not infrequently, how- 
ever, this weakest portion seems to be the canine fossa; the opening has also 
occurred at the tuberosity. The author's experience leads to the inference 
that the hard palate is by far the most common point at which such matter 
seeks egress. The tumor will be seen bulging from one side of the mesial 
line, the swelling advancing more or less rapidly, until fluctuation becomes 
distinct. A diagnostic sign of this class of tumors is, that the internal 
boundary is apt to be quite abrupt, and that it does not pass the line of the 
mesial division. The establishment of a fistula relieves at once the sense of 
distention, and, if such sinus has opened at a convenient place, as within the 
mouth, the patient feels disposed to congratulate himself on having come to a 
sufficient cure. Unfortunately, in the majority of cases this satisfaction is of 
short continuance ; for, independently of the fact that the disease at once 
takes on chronicity, making the sufferer an object of disgust to those with 
whom he is brought into immediate contact,-the fetor of the discharge, 
under some circumstances, being really unbearable,-the undue retention of 
the secretion within the cavity is a source of such irritation to the parts that 
not infrequently the most serious lesions result. In some instances-happily, 
rare-all the bones of the face are destroyed. 
Cause of Retained Secretions.-The causes influencing retention of 
these secretions are twofold: First, an external wound is apt to heal, and to 
continue impervious until increase of the collection induces sufficient pressure 
to cause absorption, as in any case of abscess. In the second place, the 
passage is blocked up by flocculi within the cavity. 
Puruloid secretion in the antrum may, from the onset, be of so 
limited a character that, like secretions in certain of the ovarian cysts, years 
pass before marked inconvenience results. The writer is acquainted with a 
case, that of Mr. C., late a merchant of Philadelphia, in whom, after five 
years of great mental and physical suffering, a disease of the antrum, supposed 
to be malignant, was found to be nothing but simple muco-puruloid engorge- 
ment depending on a dead tooth. In this case the trouble had commenced 
with a feeling of heaviness and oppression in the body of the jaw; the parts 
had gradually enlarged until finally there was distention of the cheek to the 
size of a large fist, the eye being thrown entirely out of position from the 
rising of the roof of the antrum. Much treatment had been given the case, 
without the slightest benefit accruing. No attention, however, had been 980 
A SYSTEM OF ORAL SURGERY. 
directed to the dental arch,-the teeth, although the patient was sixty years of 
age, being apparently in perfect condition. The result of this case was the 
diagnosis, on the part of a surgeon to whom he finally applied, of a dead 
pulp in one of the bicuspid teeth. The organ, although as healthy-looking, 
to common observation, as any of its fellows, responded to the stroke of an 
instrument in the manner described in the chapter on alveolar abscess ; the 
tooth was extracted, and in six months the health of the patient was perfectly 
restored. A circumstance connected with the extraction offers 
an example of practice of which it is well not to lose sight. The practitioner 
informed the reciter that he expected to find associated with the tooth-fang a 
pyogenic membrane, and to have the extraction followed by a gush of pus, in 
both of whieh expectations he was disappointed. The fang was clean, and 
the blood which followed the operation had nothing peculiar about it. Not to 
be thus balked, a probe was passed up the alveolus of the extracted tooth, 
which, meeting a resisting yet yielding body, was thrust onward in the direction 
of the antrum; the withdrawal was followed by profuse discharge. Such a 
resisting body may be simply flocculi or it may be the mucous membrane 
proper to the parts: most likely it would be found the latter, for we are to 
remember that it is not alveolar or antral abscess with which, in these cases, 
we are dealing, but simply what might be termed a mucitis, and, of course, a 
break in the continuity of the membrane is not necessarily to be inferred. 
The practitioner, in this case, only approximated to the exact condition ; he 
thought, evidently, that the trouble was tooth-abscess discharging itself into 
the sinus, whereas (while the treatment was perfectly adapted to the require- 
ments) the case was one of simple mucous or muco-puruloid engorgement, the 
result of reflected irritation. 
Diagnosis of Muco-puruloid Engorgement.-The diagnosis of 
mucoid or puruloid engorgement of the antrum is not, as a rule, difficult to 
make out. At first there is inflammation, and this, as has been suggested, is 
found most likely to have origin with the teeth. As the trouble advances, 
the patient complains of a sense of heaviness about the body of the cheek. 
If the secretion be active, there is much pain, sometimes sharp in character, 
but more frequently heavy and unbearably dull. In all chronic periodonteal 
inflammation we have this same character of pain, but then it differs from 
that of engorgement in being confined to the alveolar arch ; in this latter 
trouble the greatest distress is found associated with the floor of the 
orbit, which, as will be remembered, makes the roof of the antrum. At 
length, as the secretions accumulate, the parietes of the cavity begin to 
attenuate and expand. The tumor now forming may be distinguished from 
others,-first, by the history of the case; second, by dryness of the naris of 
the affected side, the result of the closure of the orifice of the antrum ; third, 
by the gradual and regular enlargement; fourth, by the non-association of 
the integuments of the cheek; and, fifth, by a fluctuation which it will 
finally yield. THE ANTBUM OF HIGHMORE AND ITS DISEASES. 
981 
Neuralgia associated with Engorgement.-Neuralgia express- 
ing itself in relation with the supra- and infraorbital nerves is frequently 
met with as a result of puruloid engorgement of the antrum. In this con- 
nection attention is to be directed to the fact of occasional absence of any sign 
pointing to existence of the condition, the mucous membrane of the neighbor- 
hood appearing perfectly healthy, the patient making complaint of the pain 
alone. A number of cases comes to the mind of the author where diagnosis 
was arrived at purely by exclusion and where verification was obtained only 
through the passing of a spear drill. 
Treatment of Antral Purulency.-To treat successfully such a 
disease, we have only to search out the source of offence, and, where it is 
possible, remove it. If this should prove to be a tooth, we may, if necessary, 
secondarily treat the antrum through the alveolus. Where the offence is 
thus of strictly local origin, we shall find little more needed than the daily 
employment of some stimulating application, such as diluted tincture of 
iodine, zinc sulphate, or a carbolized solution. Where the acrid character 
of the retained secretion has provoked degenerating ulcers, the very happiest 
effects are to be obtained from injections of chloride of zinc: E Zinci 
sulphatis, 5j 5 aquae, Oj. 
If, on the contrary, such bad conditions of the antrum be associated 
with constitutional causes, it need not be suggested that these are to 
have a required attention. In these latter cases, where the cure inclines to be 
tardy, complete relief is to be given a patient, locally, by making an opening 
into the cavity and keeping it patulous by means of a cotton tent; this, 
combined with the daily use of such injections as may seem indicated, yields 
great satisfaction. 
Caution in regard to Necessity for keeping Antrum Open- 
Antral Break not to be Closed.-It is here to be remarked as a 
matter that the author finds of prominent consequence, that the antrum once 
fairly and fully opened in the floor region, a practitioner is not to attempt 
its closure. As a rule, it will not close, and the experience of the writer 
impresses him that closure, as a rule almost without exception, is the worst 
thing that can happen. Once fairly exposed by a break in its floor, an 
antrum never again physiologically voids itself through the nose, the reason 
for this being that the ciliated expression and meaning of the antral mucous 
membrane has lost its office as a result of the disease that caused the open- 
ing. It will be appreciated, however, that breaks occur not attended with 
this destruction of office, as, for instance, opening made into it by tooth 
extraction where a root has penetrated the cavity, or where small pieces of 
the floor of the sinus have been torn away in tooth extractions. In these 
examples we are to accept that the cavity proper has not been interfered 
with, the mucous lining having remained undisturbed. It is not intended to 
deny that cases of absolute openings of the antrum come to cure by closure, 
but a practitioner is never to do else than leave such possibility to nature. 982 
A SYSTEM OF ORAL SURGERY. 
Treatment by the author is confined to putting the mucous lining in 
a healthy state, and his treatment is precisely one with that, both as to local 
and constitutional significance, which is used for the cure of an urethral gleet. 
What, in any way, is good for one is good for the other. A bougie is no more 
necessary for the urethral passage than is a probe for keeping open and free 
the false passage leading into the antrum. The following is a prescription not 
better for the cure of one of the cases than for the other: 
Ji Chloral hydratis, 
Zinci sulphatis, aa gr. xii; 
Aquae, §xii. M. 
Sig.-Inject three times daily. 
As a common and continuous wash, however, to be used where the inten- 
tions are cleanliness and healthfulness, the author finds nothing better than the 
tinctura capsici et myrrhae, employed in the proportion of a teaspoonful to a 
goblet of water. 
Injections and Injecting.-Attention to the manner of syringing an 
antrum is a matter of sufficient importance to claim consideration. A syringe 
employed by the author holds one and a half ounces of water, and is of corre- 
sponding power as to ejecting capacity. Fluid thrown into the antrum in 
driblets does little good in the way of cleansing if the contents happen to be 
thick. The want is a stream that will carry everything along with itself into 
the nose, otherwise that will return by the road of the syringe into the mouth. 
Fig. 776. 
Fig. 775. 
Farrar's curved safety-tube. 
Sectional view of the antral chamber, showing position 
of the spray-tube during operation. 
Where an opening into the antrum is simply large enough to admit the nozzle 
of a syringe, and where the nasal outlet of the cavity is closed, syringing is 
converted into aspiration by the act of withdrawing the piston. Repetition 
of these correlative acts soon cleanses the part, when medication is to follow. 
Another plan lies in the possession of a nozzle divided into two chambers, after 
the manner of catheters used for washing out the bladder. Still another is THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
983 
to disconnect nozzle and syringe, letting the fluid run back by the way it 
entered. 
Fluids disagreeable or injurious to neighboring well parts are best used by 
means of an atomizer. Figs. 775 and 776 show-and afford idea of use- 
tubes devised by Dr. Farrar. 
Antral Drainage-Tubes.-A piece of common rubber tubing used in 
an antral break answers every purpose of a drainage-tube save as to conveni- 
ence. Silver or vulcanite is commonly employed. To make either of the 
latter it is best to take an impression 
and work by it. First there is struck 
up by means of dies, if silver be used, 
a saddle to cover the break. Next an 
open tube is to be made that is to be 
long enough to reach into the antrum. 
Following this a hole is to be cut in the 
saddle corresponding with the canal of 
the tube, and the two soldered together, 
which completes the making. If vul- 
canite be used, the gum is moulded and 
afterward hardened, as explained in the 
chapter treating of this material. Fig. 777 shows a tube ready to be used ; 
a patient quickly learns to place and replace such an instrument. Care is to be 
taken that the piece be sufficiently firmly placed not to slip out and fall into 
the throat. 
Purulent Formations connected with the Antrum.-While, 
says Dr. Richardson, we cannot trace out the nature of that condition of 
the blood which gives rise to purulent formations, we are informed by ob- 
servation of the external conditions which foster it. We learn that the pus- 
producing disposition is an indication of deterioration of blood. We see that 
when the system is enfeebled, whether by diathesis hereditarily supplied, as by 
the strumous diathesis,-whether by epidemic influences, or whether by de- 
privation of nitrogenous food, or the inhalation of bad air,-that under these 
circumstances the tendency to purulent formations in local structures is 
marked, and that, in extreme instances of the kind named, the act of sup- 
puration may take its absolute origin from blood thus depressed. Hence we 
have reduced almost to a principle in medicine the saying that suppurative ten- 
dency is a sign of an impaired or vitiated nutrition. Hence, also, we 
reason in speculative argument, that pus is lymph transformed into a lower form 
of organization, and we adduce, in evidence of this view, that the purulent fluid 
is incapable of organic construction, and that in animals in which the respiration, 
the circulation, and the animal temperature are more than ordinarily active, the 
formation of pus, even in an open wound, is an occurrence almost unknown. 
These remarks, from a lecture by Dr. Richardson, cannot fail to be sugges- 
tive ; they have, indeed, much meaning; the student reader, however, is to be 
Fig. 777.-Antral Drainage- 
Tube. 984 
A SYSTEM OF ORAL SURGERY. 
reminded that their signification is limited. Puruloid conditions are, 
without doubt, and as the rule, perhaps, indicative of asthenia; but it would 
be very wrong to jump from such data to the conclusion that every puruloid 
disease requires treatment from a constitutional stand-point; and particularly 
will this hold good as suppuration of the antrum is concerned. 
Treatment on Principle.-All diseases are to be treated on principle. 
M. Ricord, as many readers will remember, has a favorite prescription for 
gonorrhoeal purulency, which runs as follows: 
U Pulveris cubebas, ^vj ; 
Ferri carbonatis, ^iij. M. 
Now, anybody can understand that such a combination would naturally act 
well on a debilitated system ; it is, perhaps, a happy prescription for half the 
roues of Paris. Where applicable, it would, as appreciated, answer as well 
for a puruloid antrum. The author recalls treating a gentleman for a gon- 
orrhoeal difficulty, which had been contracted almost immediately after getting 
over an attack of syphilis. This patient was medicated locally over six weeks, 
a defying discharge constantly increasing in quantity. At the expiration of 
that period he was put on copaiba, tincture of iron, and quinia, and sent to 
the sea-side for a few days. The discharge began quickly to diminish, and 
after the eighth day disappeared entirely. A success of this kind would not, 
however, lead to the inference that every man afflicted with a purulent dis- 
charge is to be treated with tonic stimulants. On the contrary, though large 
opportunity has been enjoyed by the writer in prescribing for this condition, 
-gonorrhoea,-it is seldom that indications have seemed to call for anything 
more than a strictly local treatment; at any rate, to such treatment the dis- 
ease has been found quickly to succumb. 
Local and Constitutional Significance.-On a previous page it was 
suggested that puruloid conditions of the antrum had origin chiefly from two 
directions : first, from diseased teeth; second, from constitutional disturbance. 
It was also desired to convey the inference that where the fault is markedly 
in the first of the directions, the practitioner would err on the right side if, in 
his consideration of the case, he should incline to look on the tooth only in 
the light of an exciting cause, searching farther for what might be a predis- 
posing condition. It is, however, to be inferred that lesion of the cavity may 
exist, while yet constitutional condition has nothing at all to do with the 
matter, and is not to be taken into account in the treatment. As a line in 
practice running between the two states, allusion is to be made to the fact that 
cases are met with where inference of constitutional association seems most 
marked, and yet where patients are quickly cured without resort to other than 
local treatment. These are the kind of cases in which the medical man is to 
feel his way: if he be an observer, it is not likely that more than a week will 
pass without his arriving at a just conclusion. THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
985 
Cause in Nasal Catarrh.-Coming now to the investigation of cases 
where the cause is found in predisposing or associate local conditions, we have 
to refer back to the general features of disease as manifested on mucous mem- 
branes. The most common, and indeed not infrequent, cause of engorgement 
of the antrum-particularly mucous engorgement-is simple catarrh of 
the Schneiderian membrane. The patient takes a cold, the excitement expends 
itself about the nares; by simple continuity of structure the lining membrane 
of the sinus becomes vascularly excited ; perhaps the duplication at the orifice, 
because of greater nearness to the central ring of inflammation, becomes con- 
gested to such extent as to close the opening: thus we have the elements for 
retention, and the mucus thus confined will, if not vented, sooner or later act 
as such a source of irritation that it becomes to the membrane of the cavity 
almost precisely what the virus of gonorrhoea becomes to the same character 
of membrane lining the urethra. Trouble from this cause is, however, 
generally so slight, and so quickly over, that it is seldom prominently marked, 
either to patient or practitioner. 
Increase of Mucus.-The symptoms designating this condition are, 
first, simple vascular excitement of the membrane lining the nares, accompanied 
with increase of mucus. 
Decrease of Mucus.-As the grade of inflammatory action advances to 
complete congestion, the excess of mucus associated with the immediately pre- 
ceding stage is succeeded by a most uncomfortable deficiency in the secretion. 
Significance of Nasal Dryness.-Dryness is associated with all 
nasal inflammations of advanced grade, but when the trouble is to implicate 
the antrum it is even specially marked. A single moment's consideration of 
the parts affords explanation. The nares are the natural outlets for the antral 
secretions; in ordinary Schneiderian catarrh the extensive secretory surfaces 
of the antra are comparatively unaffected, consequently the secretion is suf- 
ficient as to quantity and character to lubricate the passages to a greater or 
less extent. When, however, the grade of inflammation is of a degree that 
congests the duplicatures of membrane which form the nasal outlets, then, be- 
cause of the retention of the mucus, the extreme dryness is induced. This 
excessive dryness may be said, therefore, to offer the first diagnostic sign of 
antral engorgement from simple catarrh. From this point the disease advances 
or declines. If it decline, the trouble will have proved of such trifling in- 
convenience as scarcely to have attracted attention. If, on the contiary, 
it advance, the patient is soon made conscious of the engorgement by a 
sense of growing heaviness in the cheek, this being attended by soreness of 
a dull, sluggish character. The progress of the disease, from this condition, 
is precisely the same as that described as accruing from dental lesions. 
Treatment.-This is to be conducted on general principles. Where the 
trouble is met in its incipient stage, it will, perhaps, be found unnecessary to do 
more than administer a saline cathartic; or, what is found most satisfactory 
treatment, to give the patient at bedtime one-sixth or one-quarter of a grain 986 
A SYSTEM OF ORAL SURGERY. 
of sulphate of morphia dissolved in an ounce of the liquor ammonias acetatis. 
This latter treatment is seldom found to fail in breaking up a limited con- 
gestion. Dover's powder, ten grains on going to bed, is common treatment. 
Where, however, the disease has advanced to engorgement, and the antrum 
is found to be enlarging, it may be necessary, in order to insure against more 
serious lesions, that treatment be directed immediately to the cavity. To ac- 
complish this a trephine is to be used on the canine fossa, or, the second molar 
tooth may be extracted, and penetration of the cavity effected through the 
alveolus of its palatine fang; by either of these ways such medication as may 
seem indicated is readily employed. For a cure it is seldom necessary to do 
more than keep the wound patulous, leaving the rest to nature. 
Teeth found in the Antrum.-Non-erupted teeth are the not infre- 
quent cause of cystiform enlargement of the antrum. An antrum diseased 
from such cause shows the condition of a slow-growing tumor. To the touch, 
felt from the position of the canine fossa, it is variously elastic. To the sight 
it is entirely without inflammatory significance. The use of a strong and 
pointed bistoury discovers both the cyst and character of its vault. This roof 
is sometimes composed of fairly thick bone demanding some little force for its 
perforation. More commonly it is of cartilaginous expression and is cut with- 
out difficulty. The free contents of such cysts are of the consistence of the 
albumen of eggs. In color the fluid is light yellow. 
Treatment.-Treatment consists in dissecting off the soft parts, from the 
inside, and using heavy and sharp curved scissors to cut away the vault. If 
the part be too bony for such cutting, the author uses a bur revolved by the 
engine. In absence of this latter means the chisel and mallet, or bone-forceps, 
may be employed. Teeth found in such cysts are, of course, to be removed. 
They are confined to no part of the cavity. At one of the late clinics of the 
writer four teeth were met with by him: one, an eye-tooth, projected down- 
ward from the nasal process; a second, a central incisor, lay lengthwise along 
the floor of the sinus, being partly secondarily encysted; the third and fourth 
were undeveloped molars; one occupied the position of the tuberosity, its 
crown projecting into the cavity, the other looked as if growing inward from 
the nose. In another case lately shown to his class two teeth were seen to 
have reversed their positions absolutely, eruption being into the antrum. 
After operation the treatment consists wholly in keeping the parts clean. The 
cavity never obliterates itself, but it never, in a physiological sense, recovers its 
office. 
Furuncular Epidemics.-It will be found the experience of every 
one who has observed in the direction, that during the existence of furuncular 
epidemics, mucous and purulent engorgements of the antrum are more than 
usually common. This is not strange, if we consider the epidemic condition 
in the light of an exciting cause alone; for in no single instance where his 
attention has been called in such direction has the writer been unable to dis- 
cover a predisposing cause in a dead or diseased tooth. The same state THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
987 
of things exists in regions where the intermitten ts are endemic. All the 
odontalgias and cephalalgias of the country are apt to be quotidian, tertian, 
or quartan. Furuncle is a condition associated, it would seem, with some 
derangement of the digestive or cutaneous functions. When epidemic, it 
would be in proof that a condition exists adverse to the performance of cer- 
tain physiological functions. With the existence of a predisposing cause of 
disease about the antrum, it is not at all strange that the addition thereto of 
an exciting cause should increase at once the effect of the irritant even to 
the production of acute disease; and this, in truth, is the case : the patient 
escapes the purulency of boils, but he has purulency of the antrum. 
Treatment.-This need scarcely be referred to: it consists, first, in re- 
moving the source of local irritation ; secondly, in combating the constitutional 
disturbance. 
Scorbutus.-This diathesis, as may be inferred, predisposes to antral 
purulency and ulceration. To understand the local condition thus induced, it 
is only necessary to examine the gums in an individual so afflicted. The state 
of the antrum is akin to that of the mouth. Treatment, to be successful, 
must be from the constitutional stand-point. If injection of the cavity be 
indicated, it is to be gotten at as before directed, or a canula can be passed 
into it through the natural opening in the middle meatus: the latter is, how- 
ever, difficult, and therefore liable to objection. A delicate trephine used 
upon the wall of the canine fossa is the preferable way. 
The exanthemata are said to associate, not infrequently, their sequelse 
with this cavity. Treatment thus demanded could need no special considera- 
tion : it would be a treatment founded on general principles. 
Mercurial Diathesis.-Reference has been made to troubles of the 
cavity thus provoked. Mercury holds a double pathological relation to the 
antrum ; it predisposes from its constitutional relations, and actively and 
locally excites, through the periosteal inflammation it induces in the alveoli of 
the teeth. (The same is to be remarked of the condition known as scurvy.) 
Treatment.-The indications here are twofold. Resolve, if possible, 
the inflammation about the teeth (see chapter on Periodontitis), and eliminate 
the mercury from the system. Chlorate of potassium and the common muriate 
of soda, administered in ten-grain doses three times a day, are found valuable 
medicines in the direction. 
Syphilis.-This is a disease which it might be inferred would have 
affinity for such mucous-lined surfaces as the antrum. Now, the author's may 
be a singular experience, but, in contradiction of many who have written 
on the subject, he must say that, with the wide scope afforded by such a 
hospital as that of Blockley (in which, for over a year, he gave the study of 
the venereal disease a very close attention), he was unable to find a single case 
of disease of the antrum which could with justice be attributed to the vice. 
As remarked on a previous page, instances are met with where the origin has 
been traced in such a direction; and it will not do to deny that, in some 988 
A SYSTEM OF ORAL SURGERY. 
cases, it has been justly so traced; but, in every example seen, the mercury 
administered for the cure of the syphilis seemed to have much more to do 
with the condition than any dyscrasia induced by the virus. 
Illustration in Anomaly.-Among what are to be termed anomalous 
cases of antral disease, mention is to be made with benefit, perhaps, of one 
presented at the author's clinics, the child being under charge of Dr. Cruise. 
Patient, infant, two weeks old. Six days after birth the attention of the 
mother was called to an uncommon restlessness, which quickly associated 
with a growing swelling of the right side of the face, the eyelid being soon 
closed from oedema. Examining the case closely, discovery was made of a 
distending antrum, every portion of the common wall gradually bulging. 
Pressure upon the roof of the mouth, with counter-support to the cheek, 
caused a slight ejection of bloody pus from the nose. Diagnosis secured, a 
bistoury was passed through the attenuated, softened wall of the canine fossa, 
the withdrawal of the blade being followed by much pus and blood. 
The treatment of the case, continued by Dr. Cruise, consisted in the fre- 
quent injection of black tea, of a strength as prepared for the table. Several 
spiculae of bone came away, leaving the little patient, after two or three weeks, 
in what might be termed a common state of health. No injury was known 
to have happened this child in its passage through the pelvic straits. The 
mother was quite hearty; the father, however, was scrofulous. Three still- 
births had preceded the present live one. 
In this connection mention is to be made of examples which occasionally come 
under the writer's observation where patients long treated for nasal discharge 
without relief are recommended by their physicians for antral examination, this 
cavity giving not the slightest sign of being affected and seeming in every way 
to be healthy. Over and again the base wall of the sinus, although overlain 
by gum structure showing not the slightest evidence of congestion, has been 
found quite as thin as ordinary writing-paper, and on the knife-blade being 
made to perforate it large quantities of pus, laudable or otherwise, would escape; 
while treatment, changed in application from nose to sinus, would afford speedy 
cure of all complaint. On the other hand, the fact is not to be overlooked that 
antral catarrh, so diagnosed, is oftentimes nasal catarrh, and that in order to 
obtain cure medication is to be directed to the nose. 
Mention is to be made of a throbbing of the fluid seen occasionally as- 
sociated with an antral break ; this is caused by proximity of an artery, or, 
infrequently, by an aneurism located within the cavity. 
Mechanical Diseases of the Antrum.-Cases of what are termed 
mechanical diseases of the antrum will be encountered by every surgeon in the 
persons of those who, having met with the accident of limited exposure of the 
cavity, are in the habit of wearing plugs of cotton, wax, or wood in the 
break, which plugs escape into the cavity. The treatment required is, 
of course, the simple one of getting away the foreign body,-a matter, how- 
ever, not always easy to accomplish. THE ANTRUM OF HIGHMORE AND ITS DISEASES. 
989 
Tumors of the Antrum.-Tumors originating in the antrum are al- 
most invariably of sarcomatous nature. It is an exception to the rule where 
they are not fatal within two years. A first evidence of the existence of such 
a growth is commonly manifested by closure of nostril of the affected side. 
A second is likely to be found in a swelling of the cheek just below the eye. 
A third is projection of the canine fossa, combined with a throwing down of 
the roof of the mouth. Surrounding bone, in presence of giant-cell sarcoma, 
softens and gives up its integrity with rapidity. In cases of antral sarcoma 
it is useless to operate except in the very early stages of the disease, and even 
here, except the ablation include the whole maxilla. To operate with less 
thoroughness is one with adding fuel to a flame. Tumors found in the 
antrum wanting in the sarcoma-cell, being exclusively of ordinary fibrous ex- 
pression, begin, ordinarily, in the periosteum upon the outside of the maxilla, 
and absorb their way, through pressure, into the sinus. Cartilaginous tumors 
have been met with by the writer, but they are exceptionally rare. En- 
cephaloid tumors are likely to be, primarily, of orbital origin, otherwise they 
develop in the tear-canal of the bone. (See Tumors. See also Nasal Polypi 
growing into Antrum.') 
ABSCESS OF FRONTAL SINUS. 
In connection with diseases of the antrum, reference is to be made to abscess 
occurring occasionally in the frontal sinus. Trouble within this cavity is rare. 
In a case met with by the writer during the war of the Rebellion, maggots had 
developed from the larvae of flies. The pain was unbearable. Trephining 
was resorted to. Three cases of abscess are recorded by Bosthen under the 
head of empyema. 
Case I.-Woman, aged fifty-six. The disease began with constant head- 
ache, at times extremely violent, and then accompanied with vomiting. The 
patient also suffered with violent fits of sneezing. A swelling gradually 
formed at the inner angle of the right eye, dislocating it downward, outward, 
and a little forward. This swelling commenced in the middle line of the frontal 
region, and extended toward the root of the nose and back into the orbit as 
far as the finger could reach. It fluctuated under pressure, was covered with 
normal skin, and was somewhat tender to touch. Exploratory puncture showed 
that it was full of purulent matter. This was evacuated, after which the eye- 
ball speedily returned to its normal position. 
Case II.-In this case there was no dislocation of the eye. The tumor 
had developed itself with constant violent headache, which had been preceded 
by violent attacks of sneezing. 
Case III.-In this case the prominent part of the tumor was in the orbit, 
and accompanied by dislocation of the eye. An incision was made into the 
parts covering the swelling, which was then punctured and several spoonfuls 
of tough, yellow matter evacuated. A drainage-tube was introduced, and 
antiseptic treatment adopted. CHAPTER LVIII. 
SALIVARY FISTULA. 
By a salivary fistule is meant a break in the continuity of structure, either 
of a salivary gland itself or in its tube of outlet, through which break the 
secretion is poured over external parts rather than passing into the mouth to 
fulfil its recrementitial offices. 
Causes.-The causes of salivary fistulas are various. In children, cancrum 
oris has frequently so sloughed away portions of the cheek as to produce the 
most intractable sinuses, necessitating, indeed, plastic operations for their cure. 
Wounds of lacerated character, and burns, are other causes of such fistulas. 
Abscesses, osseous and dental, venting through the cheek and involving in 
their course the Stenonian duct, are origins met with by the author several 
times. Epithelial cancer eroding the cheek is a condition encountered. Saliva- 
tion, once a most common cause, is fortunately now infrequent. Surgical op- 
erations exposing the glands or ducts are to be enumerated among causes. 
Subcutaneous Ulceration of Gland.-A rare cause of salivary 
fistule met with by the author on two different occasions, the diagnoses of 
which were verified by removal of the organ, consists in an apparent sub- 
cutaneous ulceration of several lobules of the gland, the secretion being thus 
continuously discharged in small quantity and 
forming hygromata. In one of these instances 
-detailed in the section on Ranula-an adven- 
titious sinus led the secretion from the sublin- 
gual gland to the supra-hyoid bursa, forming a 
cyst as large as the fist. 
Fig. 778 exhibits a fistule upon the cheek, 
the break being into the duct of Steno near its 
outlet. On the same diagram is shown a second, 
situated just above the angle of the jaw. This 
latter represents the condition as connected with 
the gland proper. 
Cure of Salivary Fistule.-The cure 
of salivary fistule is found in restoring by any 
capable means the original tube of passage. 
Test for the Fluid.-Where the salivary discharge is limited, in pro- 
portion to the amount of pus being discharged from a sinus, diagnosis is not 
Fig. 778.-Salivary Fis- 
TULE-FROM LlFK. 
990 SALIVARY FISTULAE. 
991 
always easy m the absence of an acceptable test. The following, which is given 
by the Polyclinic, is reliable : 
Bring a drop of the suspected fluid into contact with a drop of the tincture 
of chloride of iron, on a white surface; if the discharge contain saliva it will 
give a pink color, thus indicating the presence of the sulpho-cyanide of potas- 
sium, an ingredient of normal saliva. 
Fistulae are treated by cauterization and by operation. The first 
manner has its application particularly in exposure of the substance of a gland, 
and in most instances invites to a trial which is to precede operative measures. 
Cauterization.-A mode of cauterization, which has the commendation 
of many successful cases reported, consists in pointing a stick of nitrate ol 
silver, and forcing it through the track of the sinus down to the gland. 
When a sinus is straight, and the caustic may thus be made to reach the place 
of disease in the organ, the practice is to be commended. In the tortuous 
track, however, such means does not apply; the line may be closed, but, the 
surface of secretion being unobliterated, the accumulating secretion needs but 
a very short time to re-establish its channel. Fistulae of irregular track, con- 
nected with the glands, are, with most 
hope of success, treated by injection. In- 
jections may be saturated solutions, if 
deemed necessary, and are to be either of 
the nitrate of silver, of chloride of zinc, 
or of iodine. 
Operative Means.-Of the opera- 
tive means resorted to for the cure of 
salivary fistulae quite a variety have been 
practised. A common manner, and one 
most easily accomplished, applicable par- 
ticularly to breaks in the continuity of the 
Stenonian duct, consists in taking a strand 
of well-waxed ligature silk, threaded at 
each end to straight or curved needles, as 
preferred. Seeking the bottom of the 
fistule, the first needle is thrust through 
the cheek into the vestibule and brought 
out at the orifice of the mouth; the 
second is now passed to the bottom of 
the fistule precisely as the first, and is 
also thrust through into the vestibule, but 
leaving some little tissue between its exit 
and the line of the first. The two ends being out of the mouth, a single knot 
is made, drawing it close up to the mucous surface of the cheek, strangulating 
the contained tissue. The strangulation, however, is not absolutely necessary, 
many surgeons, indeed, preferring the knot loose, and to have the new passage 
Fig. 779. 
Agnew's method of treating salivary fis- 
tule. The cheek is represented as everted, 
showing the orifice of the duct of Steno, 
and the seton deposited between the duct 
and outside of the cheek, with its two 
ends brought out at the corner of the 
mouth. As the threads cut their way out 
by absorption, the duct is detached from 
the external opening in the cheek. 992 
A SYSTEM OF ORAL SURGERY. 
resultant simply from the presence of the silk. With such a new passage 
formed, the original fistule will frequently tend to close. Particularly is this 
found to be the case where it has been so made as to afford easier exit for the 
fluid than does the fistule. 
Horner's Operation.-A second plan of operation is one devised by 
the late Professor Horner, of the University of Pennsylvania, and is that 
preferred and practised by many surgeons. Employing a punch, a simple 
incision is first made from the surface of the cheek down to the line and posi- 
tion of the duct; placing now a wooden spatula against the mucous aspect of 
the part, the instrument is directed to the bottom of the superficial wound 
made by the knife, and then pushed through to the wood, thus, as is seen, 
cutting out a section of the tissue and affording a track to the discharge. 
The external incision is next closed, and attempt made to secure immediate 
union. 
Operations devised and practised by the Author.-As a study 
in a class of cases oftentimes found quite defying, the following may be 
offered: 
The patient, a gentleman of excellent constitution and in easy circumstances, 
suffering from a carious dens sapientiae, had sought relief in its extraction. 
The dentist had, however, the misfortune to break the tooth, and was unable 
to remove the fang. From the irritation which resulted, conjoined with that 
residing in the broken and inflamed root, caries of the bone was induced; this, 
in its turn, inflamed the cheek, and an abscess formed which opened externally, 
involving in its passage the duct of Steno, thus producing fistule. The con- 
dition of the patient was as follows: the natural outlet of the gland continued 
patulous; consequently, to the comfort of the case, much of the secretion 
found its way into the mouth. Enough of the fluid escaped, however, through 
the artificial channel to keep the cheek constantly bathed with saliva and pus, 
the orifice being continuously covered with a large, but soft, pasty, and im- 
perfect, scab. Of course, so long as the channel passed saliva it was impossible 
for nature to close it. 
In this case-which had been under the treatment of different surgeons 
for over two years-three weeks, lacking three days, were required for the 
cure. First, examination was directed to the condition of the underlying 
parts. The caries of the bone being found cured, the depth and course of 
the sinus were discovered by the use of an ordinary silver probe. This fis- 
tule was enlarged by the introduction, repeated for several days, of a tent of 
twisted cotton. At the end of this period a slender, straight-bladed bistoury 
was passed directly through the cheek into the mouth. An eyed probe was 
next threaded with a cotton tent (Fig. 780), large and thick at the 
part which was to occupy the inner half of the thickness of the cheek, deli- 
cate and as thread-like as it could be made where it was to be lodged in the 
external track of the fistule. By the aid of the probe this tent was carried 
through the cheek, and was then fixed in position by a little slip of adhesive SALIVARY FISTULYE. 
993 
plaster, attaching it to the cheek. The cotton, being kept clean and disin- 
fected by daily syringing, was retained in position one week, the swelling of 
the inner bulky portion having by this time resulted in the formation of quite 
a channel, with a corresponding diminution in the diameter of the fistule. 
At this stage it was replaced by a wire seton 
(Fig. 781), made by taking the most delicate of 
ligature iron wire, and coiling it upon itself a num- 
ber of times to half the thickness of the cheek, a 
single strand continuing the length designed to 
occupy the line of the fistule. To replace the one 
with the other it was only necessary to attach them 
by an intermediate strand of silk : as one was with- 
drawn, the other took its place. This wire seton 
was thus inserted, and was held in place by per- 
forated shots clamped on each extremity. In one 
week the external, or original fistule, had closed so as to hug the wire, the 
discharge being entirely into the mouth. The seton was now withdrawn, and 
on the next day complete closure was found to have resulted. The case was 
dismissed cured, and has remained so.* 
A fistule of the parotid gland proper, failing to close upon cauterization, is 
to be treated precisely as the case just detailed. In place, however, of the pyra- 
midal coil, a rope of wire is used, three or more strands being twisted together; 
the track leading to the mouth is to be the shortest that can be selected. 
Destruction of Gland.-The capability of pressure to produce absorp- 
tion of an underlying part is well known, and this means may be employed 
where a fistule is situated far back. An oblong pad is to be laid over the 
gland, and moderate compression, made by use of a double bandage, is to be 
kept up so long as the discharge continues. 
Probing the Duct.-The surgeon, on meeting with a case of uncompli- 
cated fistule, is to make the attempt, before resorting to more troublesome 
means, to restore a patulous condition of the obstructed duct. This he does 
by a free use of probes, passing these, of gradually increasing size, from the 
orifice to termination in the gland. The turning of the canal over the bucci- 
nator muscle offers the only complication, but this is overcome by exercise of 
a little patience. 
Foreign Bodies in the Canal.-Foreign bodies in the canal are the 
not infrequent cause of fistule. The author removed, some time back, from 
the Stenonian duct of a patient in the Oral Hospital, a splint of broom-corn 
measuring over an inch in length. Earthy concretions, when met with, are 
to be crushed, otherwise removed by an incision made upon them from the 
mucous surface. 
Fig. 780. 
Fig. 781. 
* The cross line upon both cotton and wire tents marks the proper size for use. The 
single strand associated with the base of the wire twist has been overlooked by the artist. 994 
A SYSTEM OF ORAL SURGERY. 
Pseudo-Fistule.-A case of pseudo-abscess of the parotid gland which 
had resisted long-continued attempts to cure it was discovered by the writer to 
have its meaning in a molar tooth which lay upon the ramus of the jaw 
immediately beneath the gland. The sinus had continued to discharge for 
over four years. Discovery of the tooth was by means of a probe so bent as 
to follow a tortuous channel. Enlargement of the track, accomplished by free 
use of cotton tents, followed by extraction of the tooth, resulted in immediate 
cure. 
Dribbling.-This condition associates with deficiencies of the oral boun- 
daries. Cure is by operation.* (For studies, see Plastic Surgery.} 
* Dribbling.-Patients are infrequently seen where constant dribbling, or at least con- 
stant desire or necessity to spit, exists. Persons so afflicted are met with who are debarred 
society, and who are an offence to themselves and to their families. Examination reveals 
that this dribbling is not generally associated with the salivary glands, but that it is excess 
of secretion on the part of the mucous bodies. Cathartics given such patients show a 
glairy mucous discharge suggesting the existence of worms, yet exhibition of anthelmin- 
tics fails in supporting the suggestion. Treatment is by tonics directed to the mucous tissue. 
Pilocarpine hypodermically used is a late application highly lauded: dose, gr. 1-60. Wine 
of ergot in occasional teaspoonful doses is found useful. Any systemic derangement existing 
is to receive attention. CHAPTER LIX. 
CARIES OF THE MAXILLAE. 
Caries of bone, practically viewed, is a disease very analogous to ulcera- 
tion in the soft parts, and is possessed of the threefold expression of simple, 
strumous, and specific. As the jaws are concerned, the condition is confined 
almost exclusively to the superior bones. The causes which act as provoca- 
tives are, of course, various; yet dead teeth and roots of teeth are found far 
to preponderate. 
Diagnostic Expressions.-Caries of the jaw presents commonly, yet 
it may be in aggravated form, the external features which characterize the 
ordinary alveolar abscess, whether in its acute or chronic state. This, however, 
would be inferred, such lesion being so commonly its origin. When the attack 
is acute in its nature, ulitis or periostitis will always be found associated with 
it. If the disease originate as a pure osteitis, then the gum, in turn, quickly 
sympathizes; if, on the contrary, the inflammation arise from a tooth, perio- 
dontitis will distinguish the offending agent. In all inflammations about these 
parts, whatever their character and cause, the abortive treatment cannot too 
quickly be attempted. From failure to attack such perversions with sufficient 
vigor, the whole bone is sometimes destroyed. 
Examination through Touch.-Caries once established, a diagnosis 
is made easy through the instrumentality of touch. One or more fistulous 
openings will be found to exist in the gum, or it may be in some neighboring 
part, the orifices of which are surrounded usually by fungous granulations; 
it is only necessary to carry a probe through these sinuses to find the bone 
riddled, honey-comb-like, and easy to break down, either as the surface is im- 
plicated or as, in the strumous expression of the disease, the deeper parts 
are involved. In such examinations it is always found advantageous to re- 
place the ordinary probe with a common dental excavator, as otherwise, from 
the less accurate touch attained through the first instrument, it is possible to 
mistake the denuded bone of ordinary alveolar abscess for the more formidable 
and extensive disease, thus being misled as to treatment. In carrying the 
instrument through the opening of an alveolar abscess, it is remarked that the 
bone is bared; but the touch differs from that peculiar to caries in the fact 
of this uncovered bone being hard and resisting. Not always, however; for 
it has just been remarked that periodontitis and dental abscesses are the most 
common causes of osteitis and caries. Reference is here made to the pure, un- 
complicated cases of alveolar abscess only. As a rule, when a sharp instrument 
995 996 
A SYSTEM OF ORAL SURGERY. 
can be made to pass readily into the substance of the bone, and to break it 
down, caries is present. If, on the contrary, the bone be solid and resisting, 
even although denuded, caries does not exist. Carious bone is frequently, 
however, found associated with exuberant granulations, which deceive when 
the probe used is not of sufficient sharpness readily to penetrate the fungus. 
As a rule, no harm is seen to result in boldly thrusting knife or probe through 
soft parts inferred to mark benign maxillary disease. 
Variations in Phenomena.-An osteitis, however provoked, does not 
by any means necessarily run into osseous ulceration, any more than ulcera- 
tion is necessarily a result of an inflammation in the soft parts. There are, 
however, certain conditions which markedly predispose to such degenerations; 
of these the strumous is without doubt the most common. The bones of 
scrofulous subjects break down easily, also those of persons who have received 
the mercurial impression. Cancerous caries of the upper jaw is not infre- 
quently met with; while, aside from such lesions, it seems to be true that, in 
persons of the most robust and vigorous health, a slight cause has been suffi- 
cient to develop the disease. A case recalled (a very expressive one) will serve 
to illustrate the probability. 
Illustrative Case.-In the autumn of 1867 a gentleman from a distant 
State visited Philadelphia for the purpose of having an opinion concerning a 
fistule that existed over the apex of the right upper lateral incisor tooth, and 
which had long resisted the ordinary applications and injections used by his 
professional adviser at home. This fistule had originated from the tooth 
named,-a dead one,-and was considered simply an alveolar abscess, the only 
question thought to be involved being the loss of an organ which the patient 
was most desirous to save. The gentleman coming first under the care of a 
personal friend, opportunity was afforded the writer to see him in consultation, 
when examination revealed a softened, honey-comb-like condition not only of 
the right, but also, partially, of the left jaw, necessitating an operation of very 
extensive character as the removal of bone was concerned. In this case 
nothing wrong was recognized with the general health of the patient, he 
being young and of more than commonly vigorous habits. The primary 
lesion here was, without doubt, the dead lateral incisor. Why this should 
have provoked such extensive trouble one is at a loss to say. In this par- 
ticular instance, as in other cases, the disease was developed and advanced 
without any very marked acute manifestations, a not uncommon feature in 
caries, and one which is of much importance to be borne in mind. A whole 
jaw may be softened and destroyed, while the patient rests under 
the impression that he has no lesion beyond cure through the loss of a tooth. 
Cases of this kind are occasionally met with, where the adviser and advised 
have been alike deceived. 
Conditions that Modify.-The slowness or the rapidity with which 
caries of the jaw progresses is influenced by individual conditions. Thus, in 
the periods of dentition the disease will commonly be found to make rapid CARIES OF THE MAXILLAE. 
997 
progress, unless, indeed, the vital forces are very resistive; while in the 
mercurially-weakened bone caries seems sometimes analogous to simple dis- 
integration, as if, indeed, the particles had lost the power of cohesion. 
Affinity of Caries for Cellular Bone.-The peculiar affinity exist- 
ing between this disease and the cellular tissue of the bones leads to the 
inference that it is more common to persons whose skeletons are loose and 
spongy in character than to the reverse class; and this is markedly true: 
hence strumous children are very subject to caries, as is so often witnessed in 
their articular complaints. In many subjects the condition seems to be that 
of a semi-fatty decomposition, the animal portion of the bone becoming quite 
soft and greasy; indeed, even the osseous particles thrown off present the same 
aspect. The relationship of the disease with tubercular deposits is so fully 
established in the minds of many that they incline to the conviction that such 
tubercle is present at all points of the manifestation of caries. That this is 
not fully true is proven by examples such as have been presented. That 
constitutional causes have, however, quite as much to do with the development 
of caries as have local injuries is made sufficiently evident in the immunity 
of the numberless persons who have been brought, without ill result, under 
the influences of similar local sources of irritation. 
Inflammation preceding Ulceration.-It has been suggested that 
caries may exhibit itself in various ways. Yet, however and whatever the 
manifestation, an osteitis-chronic or acute-must precede the ulceration. 
The great majority of cases about the jaws have nothing to distinguish them, 
in their incipiency, from ordinary periodontitis; and it is by far most fre- 
quently the case that the acute attack has been long past before this peculiar 
ulceration is developed, it seeming to be that the resistive power of the bone 
is gradually worn out by the presence of chronicity ; the inflamed tooth has 
died, and its devitalization is the source of offence. Nearly every case of caries 
of the jaws met with could have been aborted by the timely removal of a 
certain tooth or teeth,-not, of course, all, but that great majority which have 
dental irritation as the exciting cause. 
Clinical Peculiarities presented by Carious Bone.-A carious 
bone presents clinical peculiarities according to the duration of the disease and 
the several phases of the cause inducing it. If seen early, there is to be 
observed simply the increased vascularity and congestion of the inflammation 
A little later, and a cacoplastic exudate occupies the cells, which cells, in their 
turn, have become enlarged, and their walls decalcified; these, still later, com- 
mence gradually to break down, together with the semi-organized lymph exuded 
into them ; in proportion as such exudation has been, and is, extensive, and 
the breaking down is rapid, the caries may be said to be dry or moist. Such 
exudation and degeneration are markedly exhibited in many cases of hip-dis- 
ease, or in white swelling of the knee-joint, where the discharge may amount 
to quite as much as a pint a day. On now looking at the bone, we find it 
riddled with irregular cavities, many or all of which are lined by a sort of 998 
A SYSTEM OF ORAL SURGERY. 
imperfect secretory surface, or perhaps it would be more correct to say, a 
glazing of semi-organized exudate corpuscles.* If the disease is to involve 
the whole bone, such will be its general condition. If, however, there reside 
in the part the vital force capable of resisting the lesion, then from the central 
point of the disease outward a change will be observed in the character of 
the lymph exuded. The farther we get from the centre the more bland and 
healthy is the exudate; while the complete filling up of the cells (structural 
consolidation) exhibits the wall of protection present in circumscribed healthy 
inflammation of the soft parts. It is to be observed, however, that this pro- 
* Virchow on Caries.-The whole essence of caries consists in this: the bone breaks 
up in its territories, the individual corpuscles undergo new developmental changes (granula- 
tion and suppuration), and remnants composed of the oldest basis-substance remain in the 
form of small, thin shreds in the midst of the soft substance. In ossification (in cartilage) 
there is a portion of the original intercellular substance of the cartilage cells (secondary 
cells) which, though it belongs to the group as a whole, yet when these, in the course of 
ossification, are transformed into a number of isolated bone-cells, becomes, comparatively 
speaking, almost entirely independent of those cells individually (which have their own 
immediate intercellular substance to attend to, and from most of which it must be separated 
by a considerable interval), and therefore escapes the changes which befall them. It is this 
portion which remains behind in caries, while the secondary intercellular substance perishes. 
In other processes, however, which run a more chronic course (in cancer, for example), 
everything is destroyed. 
At the moment a periosteal tissue quits the surface of a bone, and the vessels are drawn 
out from the cortex in inflammatory condition, we see, not as in normal bone, mere threads, 
but little plugs, thicker masses of substance; and if they have been entirely drawn out, 
there remains a disproportionately large hole, much more extensive than it would be under 
normal circumstances. On examining one of these plugs, you will find that around the 
vessel a certain quantity of soft tissue lies, the cellular elements which are in a state of 
fatty degeneration. At the spot where the vessel has been drawn out the surface does not 
appear even, as in normal bone, but rough and porous, and when placed under the micro- 
scope, you remark those excavations, those peculiar holes, which correspond to the liquefying 
bone-territories. If it be asked, therefore, in what way bone becomes porous in the early 
stage of caries, it may be said that the porosity is certainly not due to the formation of 
exudation, seeing that for these there is no room, inasmuch as the vessels within the medul- 
lary canals are in immediate contact with the osseous tissue. On the contrary, the substance 
of the bone in the cellular territories liquefies, vacuities form, which are first filled with a 
soft substance, composed of a slightly streaky connective tissue with fattily-degenerated 
cells. If round about a medullary canal the territory of one bone-corpuscle after another 
liquefies, you will, after a time, find the canal bounded on all sides by a lacunar structure. 
In the middle of it, the vessel conveying the blood still remains, but the substance around 
about it is not bone or exudation, but degenerate tissue. The whole process is a degenerative 
osteitis, in which the osseous tissue changes its structure, loses its chemical and morphological 
characters, and so becomes a soft tissue which no longer contains lime. The tissue which 
fills the resulting vacuity in the bone may vary extremely according to circumstances, con- 
sisting in one case of a fattily-degenerating and disintegrating substance (the bone-corpuscles 
perishing), and in another of a substance rich in cells, and containing numerous young cells; 
this latter is formed by the division and proliferation of the bone-corpuscles, and the newly- 
produced substance is very analogous to marrow. Under certain circumstances this substance 
may grow to such an extent that-if we may again borrow our illustration from the surface 
of the bone where a vessel sinks in-the young medullary matter sprouts out by the side of 
the vessel, and appears as a little knob filling one of the pits in the surface. This we call 
granulation. CARIES OF THE MAXILLA. 
999 
tecting wall is most apt to give way before the advance of the trouble,-seem- 
ing to retard but not to check it. In other words, nature seems seldom able, 
unassisted, to complete a line of demarcation, as witnessed in necrosis. 
Treatment.-To do all that can be done in these cases is not at all diffi- 
cult. If inflammation of the bone exist in an acute stage, it is to be treated 
on general principles: cathartics, diaphoretics, counter-irritants, hot pediluvia, 
leeches, dry or wet cups, the general abstraction of blood,-any or all of these 
means being brought into requisition, the practitioner being influenced alone 
by the resistance of his case. If a tooth, irritated in its enveloping mem- 
brane, be the cause of the inflammation, as is most frequently the case, such 
tooth is to be removed or treated. Generally, in such an inflammation, it is 
found sufficient to scarify the gums, give a hot foot-bath, apply a blister to 
the back of the neck, and administer a saline cathartic. If such a course 
should not abort the trouble, then three or four Swedish leeches are to be 
applied directly to the inflamed part, this being easily accomplished by intro- 
ducing a napkin back of the middle of the roof of the mouth. If even this 
should not succeed, and the patient be plethoric, blood is to be taken from 
the arm. Dry cups are invaluable. (See Treatment of Inflammation.') 
Necessity for Constitutional Support.-It is, however, frequently 
the case that even what may be viewed as the acute stage will be found of 
an asthenic type. In these cases, tonics conjoined with local depletion are 
demanded: iron, quinia, beef-essence, cod-liver oil, etc., being indicated. If, 
when a case be first seen, the caries has become established, the acute action 
having ended, as recognized by the existence of fistulse, the honey-comb, etc., 
vigorous tonic medication, conjoined with stimulating injections, is to be used. 
Of such injections, the tincture of iodine, carbolic acid, compound tincture of 
capsicum, and chloride of zinc will be found as promising as any. Of the 
tonics, a common experience gives a preference to the chalybeates. It is not, 
however, from the medication alone that a cure is to be expected. In caries 
nature seems unable to throw off the incubus of the disease; and the cases are 
rare indeed where relief by operative means is not found imperatively de- 
manded. Such operative means, to be of profit, however, are to be well con- 
sidered.* 
* Miller on Caries.-Prevention is obviously the paramount indication. With this 
view, if symptoms of interstitial absorption be present, our attention will be directed to the 
arrest of this by counter-irritation and constitutional care. If a simple abscess or ulcer 
occurs on the surface of bone, it will be our object to effect the healing of this as rapidly as 
possible, in order to prevent degeneration. When mere osteitis is present and demands our 
aid, we shall treat it actively yet warily: actively, in order to arrest the inflammatory pro- 
cess ere yet the untoward results of suppuration or ulceration have occurred; warily, avoid- 
ing exhaustion of the system, and still more the poisoning of it by excess of mercurial and 
other active antiphlogistics; careful not to induce a state favorable to the occurrence of de- 
struction in bone. And seeing that caries is usually so much connected with taint of system, 
our attention will be directed throughout toward constitutional care in connection with both 
prevention and cure. 
When caries has occurred, the indications of local treatment are abundantly simple. 1000 
A SYSTEM OF ORAL SURGERY. 
Use of Surgical Engine and Burs.-To operate for caries of the 
jaws the author now employs universally the surgical engine and stoned rose 
burs. The rapidity and painlessness with which such operations can be per- 
formed must be witnessed to be appreciated. One not possessed of an engine 
gets along very well, however, with two or three delicate chisels, a scalpel, and 
a syringe. Taking the fistule for a guide in an operation, the bone is exposed 
by a simple incision. Next, with chisels curved on the flat side, the softened 
structure is, little by little, cut away. 
Necessary to follow the Disease.-The extent to which caries is 
occasionally found to have progressed is a matter of surprise. One can do no 
better than follow the softened bone, wherever it lead. The author very 
frequently, in this way, has been led from an apparent simple beginning to 
remove nearly or quite all of the upper jaw. Danger from hemorrhage 
affords no special occasion of anxiety ; indeed, cases are few in which the in- 
We are to take away the two portions which are incapable of healthy effort,-the intersti- 
tially absorbed as well as the truly ulcerous; leaving a solid foundation of normal texture, 
not only capable of, but already engaged in, the business of efficient repair. Afterward, 
the part is to be treated as a simple ulcer; our anxious care being directed to speedy yet 
efficient and certain closure, lest renewed degeneration supervene; not resting satisfied with 
a blue, elevated, soft, and spongy cicatrix, but insisting on the establishment of one which 
is firm, white, depressed,-plainly incorporated with the bone. 
For effecting the removal, cutting instruments are infinitely preferable to escharotics, 
in all situations where excision is practicable. But, as a general rule, no operation of any 
kind should be performed on the bone unless the adjacent and superimposed soft parts are 
in a quiet state. They may be undergoing the acute inflammatory process; they may be 
the seat of acute suppuration, of acute ulceration, or of both; and removal of a portion of 
bone, embedded in such soft parts, is almost certain not only to prove futile as a means of 
cure, but actually to aggravate and extend disease. The then carious portion of bone may 
be taken away, but ulceration instead of reparation is certain to ensue; and by rapid 
degeneration the carious condition is renewed; or a more general and intense osteitis is 
kindled, and the partial caries is merged in general necrosis. And even supposing none 
of these untoward events to occur, still the time of operation were inexpedient, as causing 
an unnecessary and therefore unwarrantable amount of secondary inflammation. 
The soft parts being already quiet, or having become so under suitable treatment, free 
incision is made through them, so as effectually to expose the diseased portion of bone,- 
previously tolerably well explored by judicious use of the probe. The extent of the 
doomed parts having been satisfactorily ascertained, their thorough removal is then to be 
accomplished. 
Escharotics are employed in some cases; as, for example, when a patient resolutely ob- 
jects to any other mode of removal. Or when cutting instruments have been used, and 
yet a border of suspicious character remains, the extinction of such a suspected part may 
sometimes be conveniently enough intrusted to cauterization. The actual cautery may be 
applied, but unwisely. It effects too much. The carious part is at once and satisfactorily 
killed; but, as in all severe burns, the texture immediately surrounding the eschar, though 
escaping with life, has its vitality very much impaired, and is more prone to disintegration 
than to repair. The potential cautery is infinitely preferable. It destroys the diseased 
part just as effectually, though, perhaps, with less rapidity, and at the same time the im- 
mediately adjoining parts do not in any wise suffer, but at once institute a healthful line 
of demarcation for removal of the dead part, and are well able to commence, at the same 
time, a sthenic action of repair. CARIES OF THE MAXILLA. 
1001 
jection of alum-water or phenol-sodique is not found all-sufficient for its control. 
When healthy bone is reached in an operation, it is distinguished from the 
carious by both touch and sight. Under the steel the first is hard and 
springy, the latter soft and brittle; passing, with the instrument, from the 
diseased to the healthy tissue, one could not fail to remark a difference. To 
the sight, healthy bone is white and vascular; carious bone is dark and non- 
vascular, or it is a deadish white, or oleaginous. A very observable difference 
between caries and necrosis consists in the absence, in the former, of the odor 
associated with the latter,-caries running its whole course without necessarily 
giving the slightest annoyance from this cause; at least, where proper 
cleanliness is observed. 
Use of Syringe.-The use of the syringe, after an operation for caries, 
is of the greatest moment; the capacity is not to be less than one gill, 
and every particle of detritus is to be carefully washed away. In the after- 
treatment, this instrument will also be found to perform good service,- 
repeated washings with proper medicaments being very conducive to a 
cure. 
Acid Treatment.-The use of sulphuric acid in the treatment of caries, 
designed to unite with the base of the phosphatic salts of the bone, and thus 
remove it, introduced into practice by George Pollock, F.R.C.S., surgeon to 
St. George's Hospital, has justly attracted much attention. Used in that 
state, in which nature, possessed of the requisite resistive force, has compelled 
the line of demarcation, and needs only the assistance of relief from the dead 
tissue, sulphuric acid employed in a required strength will undoubtedly dis- 
solve such dead bone and thus allow a cure. Again, employed as a local 
stimulant, it exerts most excellent influence, exciting into action, and seeming 
to afford support to all the abeyant force of the parts. Still again, used as an 
antiseptic, its effects are very beneficial, assisting in keeping the parts fresh 
and clean. 
Dissolving Dead Bone.-In using sulphuric acid with a view to the 
solution of dead bone, one part of the officinal is to be diluted with eight of 
water; or, if preferred, the aromatic acid may be used pure. Mr. Pollock 
himself uses this latter, at first diluted with equal parts of water, and then 
more and more nearly pure, pencilling the surface which he exposes by turn- 
ing aside the soft parts. When the acid is employed simply as a stimulant 
or antiseptic, the circumstances of each case will govern the strength of the 
application. 
Aromatic sulphuric acid is used undiluted by the writer, being applied and 
retained against the part to be dissolved on tufts of cotton wool fully saturated. 
No harm results to the soft parts. 
Caustic Potash Treatment.-The employment of caustic potash for 
destroying quickly disintegrating bone has the recommendation of no less 
eminent authority than Dr. Fitzgerald, of Dublin. When tested, however, 
by the side of sulphuric acid, it is to be agreed that there is no comparison. 1002 
A SYSTEM OF ORAL SU ROE RY. 
With the former agent, secondary injuries may associate; with the latter, 
nothing but good is to be anticipated.* 
Illustrative Case I.-Mary B., girl of weakly constitution with caries 
of inferior maxilla involving the body of the bone from the second bicuspis of 
one side to the first molar of the other, the teeth being in place, but very 
loose, three sinuses existing in the gum overlying the disease, which sinuses 
were in constant discharge. Examination with a sharp-pointed steel probe 
exhibited the bone as so honey-comb-like that the instrument could be pushed 
through it without difficulty. 
Treatment and Result.-Patient kept on a chalybeate tonic for three 
weeks, then operated upon before hospital class. Desirous of testing the 
reparative powers, a cut, uniting several sinuses, was made below the apices of 
the roots of the teeth, and with delicate gouges the softened bone was scraped 
away, allowing the teeth to remain supported almost exclusively by the gum. 
After the operation the parts suppurated from the superficies of the bone 
more or less for three months, the left cuspis being thrown off by a slough of 
the immediately overlying gum. At the end of this period an osteophytic 
sequestrum was exfoliated, after which the wound closed, the teeth gradually 
* Pollock on Use of Acid.-Acid does not affect or injure the soft tissues when used in 
the diluted form; acting chemically on the diseased bone alone. It does not affect the living 
bone, and its application is seldom followed by any great degree of pain. 
That, in the diluted form, it will only act on dead or diseased bone, and not on healthy 
bone, is a point of very considerable practical importance, and is the great advantage sul- 
phuric acid possesses as an application, under the circumstances quoted, over the use of the 
gouge, or of the actual cautery, or of caustic potash. The following experiments, conducted 
at my request by Mr. Henry M. Noad, lately my clinical clerk, satisfactorily prove the cor- 
rectness of this statement. 
Portions of dead, diseased, and healthy bone were selected and subjected to the action 
of sulphuric acid, viz.: 
1. Dead bone, 10 grains. 
2. Diseased bone, 10 grains. 
3. Healthy bone, middle age, 10 grains. 
4. Healthy bone, old age, 10 grains. 
Exposed to the action of a mixture of sulphuric acid and water, one part in four, for three 
days, at a temperature of 100°, the following were the results: 
1. Dead bone: Phosphate of lime, 2 gr.; carbonate of lime, 3.30 gr.; dissolved in the 
mixture. 
2. Diseased bone: Phosphate of lime, 2 gr.; carbonate of lime, 1.3 gr.; dissolved in 
the mixture. 
3 and 4. In both specimens of healthy bone no action took place. 
The process of disintegration or dissolution, with the commencement of healthy granu- 
lation from the surface of the living bone, may be observed simultaneously progressing, in 
any exposed surface of dead or dying bone to which the acid may have been applied. 
When its action and effects are compared with those of the gouge, the bruising which is 
necessarily produced by the use of the latter, the pain and frequent subsequent inflamma- 
tion, and, even under the most favorable circumstances, the time required for the rough 
lacerated surface to recover itself, throw off its small bruised fragments, and become covered 
with granulations, the treatment by sulphuric acid will be found far preferable. CARIES OF THE MAXILLA. 
1003 
became firm, and a cure, with the teeth preserved, was happily secured. Lo- 
cally, sulphuric acid alternated with the chloride of zinc was used. System- 
ically, advantage was endeavored to be taken of all tonic influences: exercise 
in the open air and sunshine, salt-water sheet-baths, juicy undercooked meat, 
the compound tincture of gentian as an appetizer, etc. 
The use of sulphuric acid in caries, acting to the chemical de- 
composition of bone, may readily be conceived as possessed of much good 
import; indeed, it may very well be recognized as possessed in itself of power 
sufficient to a cure, doing chemically that which the gouge or bur does 
mechanically. The strength in which an acid is to be used depends entirely 
on the effect desired to be accomplished. If employed in the anticipation of 
decomposing carious bone, the undiluted aromatic sulphuric is never found 
over-strong. Personally, the author has frequently made a test strength much 
greater,-using, indeed, the officinal ordinary sulphuric acid,-taking, however, 
the precaution to make direct applications by means of a stick brush. Where 
acid is used merely as a stimulant, the aromatic is to be preferred and is to be 
used diluted pro re nata. 
Illustrative Case II.-French lady, about twenty-three years of age; 
caries of base of alveolus of right cuspis of superior jaw, involving the pala- 
tine process, with discharge beneath the covering of the hard palate; two 
tumors, one the size of a hickory-nut, the other that of a hazel-nut, existing. 
Treatment.-First opened the sacs, giving vent to the accumulated pus, 
the bone being found denuded to quite the size of a dime piece. Once each 
day, for the period of two weeks, the sacs were injected with commercial sul- 
phuric acid and water, one part of the first to twelve of the second. At the 
end of this time the cure was complete, granulations after the sixth day being 
recognized as covering the exposed bone. 
In this second case, observation elicited the fact that the acid acted just 
as any other stimulant would have done. Iodine or zinc might have been 
used with precisely similar result,-power existing in the natural force of the 
patient to overcome the destructive condition, requiring only the aid of slight 
stimulation. 
Illustrative Case III.-Merchant from New York City, caries of both 
palate plates of superior maxillae. In this case, while two sinuses existed, the 
mucous envelope of the hard palate was found separated from its bony base, 
forming a tumor which half filled up the mouth. Examination revealed the 
palatine processes riddled with holes. This was a character of case most 
admirably suited to acid treatment, and which was recommended. A diagnosis 
of different character afterward offered in another city resulted, however, in 
resection of the jaws,-a performance as unnecessary as the diagnosis was 
faulty, and from which operation the author is under the impression the 
patient died. 
Illustrative Case IV.-A very delicate lady, about twenty years of 
age; caries arising from presence of a lateral incisor tooth containing a dead 1004 
A SYSTEM OF ORAL SURGERY. 
pulp. When this patient first presented herself, no external evidence of 
disease existed, except that implying chronic inflammation of the membrane 
surrounding the root of the tooth, the organ being loose, slightly elongated, 
and sore; the gum, however, over the apex of the root was healthy-looking. 
Treatment directed to the cure was commenced by drilling an opening into the 
pulp-chamber, through the palatine face of the tooth; the cavity entered, a 
discharge of pus was the result. A succeeding step was an exploration of the 
parts about the apex of the root, effected by passing a sharp steel probe 
through the soft tissues. The probe, meeting bone, was thrust forward, 
revealing a cavity the size of a hazel-nut, the parietes of which were found 
spongy and disintegrating. This cause, condition, and character of 
caries are most frequently met with in the upper jaw. Treatment of the 
case, which resulted in a cure in ten days, was as follows: 
The pulp-chamber was thoroughly washed out with water medicated with 
creasote. The length and circumference of the pulp-canal were measured, 
and a delicate pyramidal cylinder of gold was passed and consolidated to the 
apex. This manipulation was not, however, a necessity, but had reference to 
the preservation of the future usefulness and color of the tooth. This ac- 
complished, the parietes of the carious cyst were well broken up by means of 
a sharp excavator, and the detritus removed through the aid of a syringe. 
Injections of sulphuric acid and water, one part of the first to eight of the 
second, were now used for ten successive mornings, when the cyst was found 
filled with organizable material, and the cure was esteemed complete. 
Since penning the above illustrations, which pertain to preceding editions 
of this work, the author has operated on many cases of caries. There seems 
nothing to add except to commend aromatic sulphuric acid, employed pure, 
and freely, and to endorse the surgical engine and -its appendages as 
being worthy to take the place of all operative means in common use. CHAPTER LX. 
NECROSIS. 
Necrosis, signifying death of bone, while a lesion common to both the 
superior and inferior maxillae, exhibits decided preference for the latter, attack- 
ing it, as the author is led to infer from the experience of his own practice, 
in twenty cases to five of the former. The disease offers a twofold primary 
expression. It commences either as a general osteitis : stasis of the circulation 
quickly antagonizing nutrition, thus killing the bone outright; or, as com- 
monly witnessed, in periosteal disease, the membrane affected being the 
periosteum proper, or, as recognized in a majority of instances, in the alveolo- 
dental tissue,-periodonteum. In such primary membranous associations, 
the nutrient structures named are found dead, otherwise are seen to be sepa- 
rated from the bone by a degenerating plastic exudate.* In such inflamma- 
tions and separations, it is to be inferred that the layer of bone immediately 
adjacent to the membrane would be the first affected; this is so truly the case 
that timely incisions and the combating of the inflammation are most influen- 
tial in the limitation of the disease,-this being markedly exhibited in the 
periodonteal inflammation. The superior jaw, however, is much more liable 
to take on a general inflammation than the inferior; but the higher vascu- 
larity and resistive force of that part seem to enable it to resist the destructive 
action and to limit the area overwhelmed.^ 
* Necrosis and Hypertrophy.-In necrosis confined to part of a bone, the increase in 
the vascularity of the parts is apt, especially in young persons, to result in hypertrophy of 
the remainder. 
f Significance of Necrosis.-Necrosis signifies death, and, as the human body at large 
is concerned, death relieves the surgeon of his duties. Partial death, because of the relation 
of a lifeless to vital parts, and because the changes of separating the dead from the living 
differ as to the situation and circumstances of parts, demands a close and very practical 
consideration on the part of a practitioner. 
Separation and Exfoliation.-A particular portion of bone being deprived of its nutri- 
tion, attempt at separation and exfoliation is an immediate consequence. The phenomenal 
expression of throwing off a portion of dead bone and as well the destroying of an offending 
part is found in the inflammatory act. Circumvallation is the rule as to slough and seques- 
trum. To appreciate the process, it is only necessary to consider the blood supply to a part 
interrupted by an effusion of lymph, which lymph proceeds to coagulation, and which con- 
solidation compresses little by little the vessels, until finally obliterating them. In traumatic 
sequestrum-i.e., where a piece of bone is broken from its bed-the signification is the same, 
the clinical difference being that in this latter case the nutritive interference is by reason of 
laceration of the vessels. Purulency is an associate of exfoliation. To appreciate this con- 
sists in a recognition of a mass of circumferential exudate unable to do more than partially 
1005 1006 
A SYSTEM OF ORAL SURGERY. 
Consideration of Inflammatory Conditions.-Inflammation of the 
jaws, whether osteal or periosteal, is primarily to be treated on general 
principles. If acute in character, which is generally the condition, local 
antiphlogosis is the immediate and prominent indication. It is the custom of 
the writer to use dry cups freely, applying these to the side of the face and 
back of neck. Another manner is to use the cups for the face alone, applying 
to the neck a fly-blister four inches square. This blister, after being in place 
organize itself, falling back quickly into a degeneration expressive of pus, pus being nothing 
else than abortions of granulation-corpuscles. Purulency is the act of floating. A dead 
part is lifted or floated by means of pus. Pus continues to form so long as a dead part 
remains in contact with a living seat. 
Pyogenic Membrane.-A pyogenic membrane is a sheet of granular lymph making 
effort to organize itself. A pyogenic membrane ceases to be the moment sufficient power 
accomplishes the act of organization. A pyogenic membrane does not secrete. Pus is not 
a secretion, but a degeneration. 
Line of Demarcation.-Demarcation is a line expressive of a surface of separation: all 
in front of this surface is the sequestrum; all back of it is vital. To demark a part is an 
act related with varying time and systemic energy. The process may extend over months 
or it may accomplish its end in a very few weeks. Nine months is the ordinary time re- 
quired for exfoliating a lower jaw. 
Sequestrum.-A sequestrum prevented by the circumstances of situation from being 
thrown off becomes enveloped by a case of new bone. This is found markedly with the 
instance of the inferior maxilla, it being, as a rule, necessary to break through a case in 
order to get at the dead part. 
Osteophytes.-Osteophytes are expressive of attempts at ossification. As a rule, osteo- 
phyte after osteophyte dies before sufficiency of force is found to complete organization. At 
a certain stage in the processes of exfoliation and repair osteophytes are to be met with 
irregularly interspersed throughout the affected region, and too often are found converted 
into loosened sequestra, which require to be removed. 
Osteogenetic Agencies.-Periosteum, as well as bone itself, constitute the osteogenetic 
agencies. Both are no sooner relieved of the incubus of a dead part than evidences of 
repair are exhibited. Both exude and organize bone pabulum, both enter the work as 
repairers of damage. 
Exfoliation and Repair.-The student familiar with the processes of exfoliation and 
repair, as flesh lesions are considered, has nothing different to learn as concerns bone surgery. 
There is first, as the result of injury, extravasation into the cellular structure, into the 
cortical substance perhaps, and certainly beneath the periosteum. As a result of such 
extravasation, nutrition is entirely cut off from the lymph-surrounded island. The death 
of the island following, the most immediate layers of lymph degenerate, thus affording pus, 
which is the eliminating or rather the extruding agent. Repair of bone and of soft parts 
are the same, save as difference of tissue is concerned. 
Granulation Material.-Granulation material, incapable of organization, needs assist- 
ance in the shape of stimulation. Cleanliness is an essential, and dead osteophytes are to be 
picked or washed away as soon as discovered. 
Use of Aromatic Sulphuric Acid.-As an injection acting peculiarly happily where osteo- 
phyte degeneration exists, no agent known to the writer acts so happily as aromatic sulphuric 
acid, the strength used varying with the indications; equal parts of the acid and water is an 
ordinary injection, or the medicine may be used on cotton, a cavity being loosely stuffed. 
Tinctura Capsici et Myrrhs.-A second stimulant and antiseptic of most satisfactory 
response is found in a combination of capsicum and myrrh (the tinctura capsici et myrrhae 
of the Pharmacopoeia). This is used diluted with water, the proper strength being expressed 
by a bluish-white color. NECROSIS. 
1007 
seven hours, is to be replaced by a poultice made of flaxseed meal or of bread 
and milk. The result of this treatment is the flow of a large quantity of 
serum, which is, happily, the frequent means of relieving the congested 
vessels of the inflamed locality. Conjoined with the local means the hot 
foot-bath and a saline cathartic are to be recommended. A constitutional 
medication on which much reliance is to be placed is found in a combination 
of tincture of veratrum viride and bromide of potassium, the 
dose of the first being, for an adult, five drops, and of the second, twenty to 
forty grains. The object of the combination is to reduce the pulse and quiet 
the nervous irritability. The first of the two medicines named is a powerful 
agent and is to be used with caution. It is not well to reduce a heart-beat 
much below what is normal to it. In administering it the state of the pulse 
is to measure the dose and the interim of its exhibition. The second of the 
agents is to be esteemed harmless. A quick pulse is not to be mistaken for a 
full one. Veratrum viride applies alone to the latter. The former is likely 
to find its correction in ten-drop doses of digitalis administered from three to 
five times daily. (See Inflammation.') 
The means just suggested failing, the parts are to be well scarified, or 
leeches may be applied, or blood taken from the arm. Diaphoresis can be 
employed. In short, antiphlogistics of any and every nature, promising con- 
trol of the excitement, may be pressed into service. If all fail, and pus 
form, vent cannot too soon be given that fluid. When, on the contrary, an 
inflammation is chronic and asthenic in character, as marked in 
the puffy, debased character of the parts exhibited in the dyscrasic, there will 
exist, with the necessity for free scarification, a demand for local stimulating 
douches and the administration of tonics. Of the supporting medicines 
applicable to these cases, the very best is found in the union of sulphate of 
quinia with the muriated tincture of iron. A combination very frequently 
employed is as follows: 
R Tincturae ferri chloridi, ; 
Quiniae sulphatis, 3j- M. 
Sig.-Fifteen drops in water four times a day for an adult. 
Osteitis as a Primary Condition.-Osteitis, as a primary expression, 
exhibits its most intractable cases in the periods connected with dentition, 
whether first or second; the irritability being increased and kept up by the 
excitability associated with this process. Hence the care necessary to guard 
against any increase in the vascularity natural to such age. The trouble 
aroused, nothing can be done, however, beyond using such treatment as applies 
to ordinary cases; except, indeed, it will be found that there exists a greater 
necessity for the use of sedative medicaments. 
Principal Indication.-In directing treatment to a condition of osteitis 
or periostitis, as relation is had with necrosis, an indication of principal signi- 
fication lies in the discovery, and removal when possible, of the exciting cause 
or causes. That such causes may have proper and definite appreciation, we 1008 
A SYSTEM OF ORAL SU RO FRY. 
proceed to the division and study of the subject as clinically it presents its 
diversified phases and aspects. 
Causes, in order of Frequency.-In the order of frequency in 
which maxillary necrosis is met with, the following table may be accepted and 
studied: 
1. Dental necrosis. 
2. Alveolar necrosis. 
3. Necrosis from lack of room for eruption of wisdom-tooth. 
4. Syphilitic necrosis. 
5. Mercurial necrosis. 
6. Necrosis from injuries. 
7. Exanthematous necrosis. 
8. Phosphor-necrosis. 
DENTAL NECROSIS 
Dental necrosis-death of a tooth or teeth-may claim a first attention as 
being the most common of all the troubles of the ossa corporis. 
Nutrition of Supply of Teeth.-A tooth has a threefold source of 
vitality,-an internal, or tubular, secured from its pulp; a middle related with 
the vessels of the tunica propria; and an external arising out of its perio- 
donteum. The destruction of the internal circulation, through the killing of 
the pulp and filling the root-canal with metal, is so common an occurrence as to 
be familiar to almost every one. By the majority of teeth, if properly treated, 
such destruction of one source of the nutritional supply seems to be sustained 
without much apparent inconvenience. The treatment consists, as we 
have learned, in extracting from the cavity every particle of dead pulp, and so 
filling the chamber with gold or other material as to prevent the introduc- 
tion of more irritating matter. (See Treatment of Pulp-Cavity.') Where 
teeth, however, are not properly treated, or where there is great suscepti- 
bility in the system to vascular perversion, the destruction of the pulp results 
in an extension of irritative action to the periodonteal membrane, yielding the 
lesion known as periodontitis; this, if not aborted, terminates in the death of 
the tooth. A dead tooth is not, however, fortunately, treated in all cases by 
the system, or even in the majority of cases, in so summary a manner as a 
piece of dead bone. As a rule, there exists a wonderful forbearance on the 
part of nature to its presence, and the organ may be retained in its cavity and 
made to serve useful purpose for a long time. True, it is discolored, and 
provided there be no decomposing pulp in the canal, in proportion to this 
discoloration may the degree of degeneration be judged. A tooth lowers 
in the scale of vitality in degrees. It may be deteriorated as the 
death of part of its pulp is concerned, or as the death of all of it is implied, 
or as regards the whole or any part of its enveloping membranes. When 
both pulp and membranes are dead, the tooth, of necessity, must be dead with 
them; and in proportion to their destruction, so is its destruction. NECROSIS. 
1009 
Refinements in Tooth-Nutrition.-Fig. 782 is introduced with a 
view of exhibiting the refinements in tooth-nutrition, and the possibility of a 
retention of vitality on the part of 
an organ, its pulp and periodonteum 
being dead. Glancing at the dia- 
gram, it will be seen that the dental 
artery gives off three branches, the 
first passing through the apical fora- 
men, to be distributed to the pulp, 
the second going to the tunica pro- 
pria, the third supplying the perio- 
donteum. (See Tunica Reflexa.} 
It seems quite possible that one or 
two of these branches might be ob- 
literated, the third remaining intact, 
and, accepting this third as the vessel 
distributed to the tunica propria, it 
can be understood that, though seem- 
ingly deprived of nutrition, the tooth- 
structure is yet not without pabulum. 
Irritable Systems. - Some 
systems are so irritable that any 
amount of skill fails to make the 
mouth retain a tooth in which simply 
the pulp is dead. Others, on the 
contrary, are so unimpressible that half the teeth in an arch might be utterly 
necrosed, and yet no complaint be made. The author once, as an experiment, 
replaced in the mouth a central incisor tooth which had been extracted twelve 
hours before, and although it had been carried in the pocket, enveloped in 
the usual collection of dust, tobacco, keys, knife, etc., the whole intervening 
time, it was kept in its socket until the parts became reconciled. Many years 
have since passed, and it seemed, when last seen, as useful as in its palmiest 
days. The repetition of this experiment is now common. (See chapter on 
Replantation.} 
Caries as Cause of Dental Necrosis.-The irritation, inflammation, 
and death of a tooth are generally the result of caries which exposes its pulp. 
The first stage in the destructive process is the death of this part ;* here it 
may end, the pulp sloughing off at the foramen, the periodonteum and middle 
membrane assuming the full duties of nutrition. If this be not the case, the 
membranes become involved; if these too die, the tooth is dead. A dead or 
partly dead tooth is recognized by its loss of translucency, the opacity varying 
from the slightest discoloration to complete blackness. 
Fig. 782. 
ALVEOLAR 
PROCESS.' 
A, dental pulp and its artery; B, dentine; C, 
tunica propria; D, enamel; E, periodonteum; 
F, cementum ; G, canal in lower jaw; H, dental 
artery; J, branch of dental artery supplying 
periodonteum; K, branch of dental artery sup- 
plying tunica propria. 
* The pulp of a tooth is composed of most delicate connective tissue, in which ramify the 
vessels and nerve. By some it is described as a ganglion. (See Figs. 75 and 76.) 1010 
A SYSTEM OF ORAL SURGERY. 
Significance of Tunica Propria.-The writer is not aware that 
clinical significance has before been called to the vascular relation of the tunica 
propria. Analogy with such circulation is found in the response existing in 
the anastomosis of vessels of pericranium, diploe, and dura mater. It seems 
not at all doubtful that the threefold circulation related with tooth- 
structure finds its meaning in the law of compensation. Assuredly it would 
be the case that a tooth deprived of pulp and periodonteal supply would have 
little chance for life, yet, as a principle of nutrition is concerned, it assuredly 
would have a chance, and perhaps the agency we consider is of greater 
consequence than a first thought would incline to give it. Because an 
artery entering a foramen is occluded, it does not at all follow that an im- 
mediately adjoining one meet with the same fate. A glance at the diagram 
shows that the vessels of the tunica propria have nothing to do with another, 
or others, intended for the periodonteum. The spiral lines represent the 
vessels or their equivalents. 
Haversian System of Cementum.-The diagram shows another 
feature in tooth-nutrition. Referring to, and considering the vascularity of, 
the alveolar process, it is not difficult to appreciate that a tooth can be nour- 
ished, even though the maxillary artery itself be dead. Vessels pass from the 
process into the periodonteum, and this blood can be passed, in turn, through 
the Haversian system of the cementum into the tunica propria, and from this 
tunic dentine and enamel may be fed. 
Death of Tooth not necessarily associated with Caries.- 
A dead tooth is not, however, necessarily associated with caries. Inflamma- 
tion, resulting in its destruction, may be induced by atmospheric changes, 
by blows, etc. This is to be recognized, so that by reason of the absence of 
decay a diagnosis be not obscured. 
Exfoliation of Dead Tooth.-A dead tooth is thrown off in one of 
two ways: either by chronic or by acute action. When by acute means, 
violent inflammation is set up in all the surrounding parts, the tooth is elon- 
gated and loosened, much pus is discharged, and eventually the organ drops 
from its socket; this accomplished, the trouble commonly subsides. In chronic 
exfoliation, the parts indurate, one or more sinuses form as in ordinary abscess, 
all the region about the tooth is thickened and rough, as if some ugly disease 
were in process of development, the enamel grows dark, perhaps black. The 
tooth does not get loose, but is apt to frighten into its removal. If such ex- 
traction be not resorted to, the lesion involves the bone, and tooth and alveolus 
become eventually cast off as a common sequestrum. Another, and more 
chronic form, consists in the gradual absorption from about the roots of a 
dead tooth of its alveolar process. This is most frequent with old persons, 
although not by any means so confined. This form of exfoliation is usually 
very slow in its progress, extending sometimes over a period of several years. 
Cases, however, frequently present-confined to young persons-where several 
teeth are cast off in this manner within a few months. NECROSIS. 
1011 
Death of Teeth from Structural Consolidation.-Teeth some- 
times die as the result of structural consolidation. This never occurs but in 
what are recognized as dense teeth, and is seldom found associated with caries. 
Such teeth loosen day by day, and finally-it may be after a period of years 
-drop from their cavities. The condition is seen seldom but in old persons, 
or in those beyond middle age. To arrest this trouble seems impossible. 
No treatment appears to do any good. 
ALVEOLAR NECROSIS. 
The membrane enveloping the root of a tooth is associated, as a nutritional 
vehicle, with its alveolus; hence it is commonly termed 11 alveolo-dental mem- 
brane." As the result of such relationship of structure, an inflammation 
originating in a tooth extends to the surrounding bone, and, according to its 
severity, affects the parts involved; hence portions of alveolus, overwhelmed 
by the force of an attack, sometimes die and sequester. This form of necro- 
sis, while very common, would perhaps, with proper treatment, seldom occur. 
(See Fig. 782.) 
Resultant of Arsenical Applications.-The dentist, for the pur- 
pose of destroying a pulp, applies an arsenical mixture. This is placed in a 
cavity of decay, and covered with cotton or wax. It happens, however, occa- 
sionally, that from carelessness in application, or out of difficulty in retention, 
the paste oozes around the neck of the tooth, and thus acts on parts not 
intended. In this way alveolar necrosis is sometimes induced; the portion 
destroyed is seldom, however, very considerable, and generally exfoliates in 
from two to four weeks. The local application of the sesquioxide of iron has 
been thought by some to exert a happy effect, applied immediately on the 
discovery of the accident. Repeated syringings are not to be neglected. 
A case, occurring in the person of a physician, was some years ago treated 
by the author, where arsenic had been sealed in a tooth-canal having a drill- 
hole through it communicating with the alveolus. As a result, all the bone 
forming the envelope of the tooth was destroyed and came away. 
Chloride of Zinc Applications as a Cause.-Alveolar necrosis is 
sometimes induced by the application of chloride of zinc (used as an obtunder 
of dentinal sensibility, and also for the purpose of controlling the slight 
hemorrhages caused by the slipping of instruments in the operation of filling). 
The first result of contact is of course on the gum, inflaming and engorging 
it, the effect upon the bone being secondary. Nothing better than the 
ordinary antiphlogistic applications can be employed. The action here is 
much more tardy than in the destruction induced by arsenic; the sequestrum 
is seldom very considerable, the alveolus perhaps of a single tooth. The 
action of nature in the separation is always to be awaited. 
Anomalous Causes.-Cases which, for want of classification, may be 
termed anomalous, sometimes occur. An instance will illustrate. I. B., 
an Irish laborer, consulted for pain in the two inferior incisor teeth. No 1012 
A SYSTEM OF ORAL SURGERY. 
caries, no periosteal inflammation, nothing indicating disease, was observable. 
The pain increased day by day, until at the end of the second week the two 
teeth and their alveoli had become detached, and were dissected from the gum. 
This case is one of a very few of the kind that have been met with, and may 
well be termed anomalous. The pulps of such teeth are not found dead if 
examined at the time, as under ordinary circumstances one would expect to 
see them. There is no soreness on pressure, and, strangest of all, the absence 
of every phenomenon of inflammation. The practitioner in these cases is to 
be guided by such indications as he may be able to seize on. A case illustra- 
tive in the direction is at this time of writing under the care of the author. 
The patient, a young and delicate lady, applied with complaint of the gum 
related with left lower cuspis being swollen and falling away from the tooth. 
Apparent cause was wanting. A treatment resorted to was local depletion 
secured by incisions, conjoined with alternating stimulating washes. No pain, 
no diminution in the vital translucency of the tooth. After a week the puffi- 
ness of gum was found extended to the festoons of all the central teeth, while 
at the seat of origin the distal alveolar septum was felt to be denuded. A 
week later a limited portion of this septum came away and the gum is now 
recovering its health. (See Pyorrhoea Alveolaris.) 
Ill-directed Dental Performances.-Reference is here to be made 
to the fact of entire destruction of the thickness of the jaw, arising out of ill- 
directed dental performances. In a case quoted from the author's note-book, 
an operator in drilling out a root had allowed the instrument to pass, not only 
out of the apical foramen, but to enter the dental canal, where both nerve and 
artery had been wounded. As a result osteitis set up, which eventuated in a 
sequestrum one and a half inches in length, involving the entire continuity of 
the bone. Cases of this kind, formerly not uncommon, are happily decreasing 
in frequency. 
Principles of Treatment.-Principles of treatment consider, outside 
of medication as commonly directed to such cases, the relation of the extremi- 
ties after separation of the sequestrum. To insure preservation, or restoration, 
of continuity, cotton is to be worked between periosteum and bone, and the 
part kept cleansed and stimulated by free use of the tinctura capsici et 
myrrhas.* As a rule, an envelope of bone extending around the sequestrum, 
and associating the living parts, is to be secured. The author has had a 
number of happy experiences in this direction. 
Securing a Bridge.-The importance of retaining articular relationship, 
thus insuring against deformity, in all cases where a section of the full width 
of the gum is destroyed by necrosis is too evident to need illustration. In 
a case referred to in the text the periosteum was separated from the dying 
bone by means of pledgets of cotton daily applied; disinfection and cleanli- 
ness being adjuvants esteemed of the greatest importance. As the process of 
$ A teaspoonful to a wineglass of water ; stronger if indicated. NECROSIS. 
1013 
necrosis and separation went on a bridge of bone was being formed by the 
periosteum joining and supporting the two extremities of healthy gum. As 
exfoliation and the bridge conjointly advanced the cotton stuffing was dimin- 
ished, cleansing by injection being, however, is no wise abated. Three months 
from date of origin separation of the dead part was absolute, the sequestrum 
being allowed to remain for another month with a view to security as solidity 
in the bridge was concerned and also to permit of an easier removal. Result 
in the case is a jaw not at all disturbed as to shape, while the filling up of the 
break is so complete that a dentist would not find himself able to distinguish 
the condition as different from that ordinary alveolaris absorption which 
occurs after tooth extraction. 
NECROSIS FROM LACK OF ROOM FOR ERUPTION OF WISDOM- 
TOOTH. 
This is found most commonly associated with the lower jaw. The close re- 
lationship of the second molar with the ramus frequently makes the egress 
of the advancing wisdom-tooth an impossibility; hence an irritation resulting 
in inflammation. The serious extension of the trouble to the bone is always, 
however, preceded by more or less trismus and difficulty in deglutition; thus 
every chance is given for an anticipating surgical relief. This form of necro- 
sis is to be looked for between the seventeenth and twenty-fifth years. The 
extraction of the second molar allows the wisdom-tooth to fall forward, thus 
remedying the irritation and effecting a cure. These cases, if rightly treated, 
are as simple and harmless as they are found severe and prostrating if left to 
chance or if improperly managed. Extract the second molar tooth, 
and do not attempt the removal of the offending one,-that is, if such ex- 
traction threaten difficulty. 
Advent of Wisdom-Tooth.-The advent of the wisdom-teeth is very 
often accompanied by painful and distressing symptoms, that may be protracted 
through many months, or it may be even years, unless relieved by surgical 
interference. These circumstances arise from the position occupied by these 
organs, so close to the joint of the lower jaw, where the mucous membrane 
is reflected from the gum to the cheek and fauces, combined with the very 
common condition that the jaw is not sufficiently elongated backward to allow 
them to range in the horizontal series with the other teeth. This mechanical 
difficulty not only prevents the proper evolution of the teeth, holding them 
back in their bony bed, but it often perverts their direction of growth and 
dislocates them. Annoying and very painful as are often the symptoms at- 
tendant on difficult cutting and misplacement of the upper wisdom-teeth, they 
are trivial in comparison with those which occur in similar conditions of the 
lower.-Salter. 
Impaction of Wisdom-Tooth.-Necrosis arising out of impaction 
of a wisdom-tooth is associated, as a rule, with inflammatory phenomena and 
with false anchylosis of severe type. The trouble begins commonly with a 1014 
A SYSTEM OF ORAL SURGERY. 
sense of stiffness about the articulation, which is quickly accompanied by 
swelling and pain. Enlargement of the face is in the sense of induration, 
the hardness being sometimes scarcely less than that of a board. Diagnosis 
associates with the age of the patient and with relation of the second molar 
tooth to the ramus of the jaw. The dens sapientiae erupt at a varying period 
between the seventeenth and twenty-fifth year. A second molar jammed 
directly against the ramus leaves no room for a succeeding eruption. Examin- 
ing a mouth in which this trouble exists, it is not unlikely that a pearly point 
is seen back of the developed denture, no room at all existing for accommoda- 
tion of the rest of the crown. Unrelieved, such a case is almost certain to 
develop an osteitis of a grade in severity that will quickly advance to the sup- 
purative stage, which result implies death of parts, small or great in extent. 
Mal-eruption of Wisdom-Tooth.-Condition of mal-eruption in 
the wisdom-teeth is another cause of necrosis. It occasionally happens that 
the long axis is in horizontal relation with the body of the bone, and hence 
eruption cannot take place, while pressure exerted against the immediately 
neighboring tooth excites an irritative condition of all the teeth of the side. 
Burrowing of Pus.-Burrowing of pus in connection with imprisoned 
wisdom-teeth is a familiar condition. An inflammation sets up, and lymph 
becomes deposited sub- and supra-periosteally, not unlikely as well in the cel- 
lular structure of the cheek. Degeneration following, pus burrows and makes 
openings, which are a source of much distress and not unlikely of deforming 
scars. Cases of this kind demand, primarily and imperatively, that room be 
made in the deficient arch, and to secure this it is seldom the case that any- 
thing else is to be done than extract the twelve-year molar. Just here, how- 
ever, arises a question where the six-year organ is decayed, the other being good. 
Will extraction of the former meet the indication ? If the inflammation be 
of high grade and threatening, the question is to be answered negatively. If, 
on the contrary, irritability rather than marked vascular perversion exist, the 
reply may be affirmative. Where the wisdom-tooth itself can be drawn, such 
removal is to take precedence as a line of practice. 
Cause removed, subsequent steps of treatment in these cases relate with the 
use of sorbefacients and the healing of any sinuses that may have formed. 
(See chapters on Periodontitis and on Alveolo-Dental Abscess.') 
Exfoliation of Laminae.-Exfoliations of laminae of bone are very 
common after the operation of extraction of teeth. Such scales vary in size 
from the dimension of a pin-head to that of a finger-nail. They seldom 
require particular attention, coming away, generally without pain or trouble, 
of themselves. 
SYPHILITIC NECROSIS. 
The hard palate, the turbinated bones, and the external plate of the cranial 
vault seem particularly liable to suffer from attacks of this specific disease, the 
venereal ulcer of the overlying soft parts, as of the structure of the soft palate, NECROSIS. 
1015 
being observed as among the common constitutional expressions. That this 
ulcer is, however, strictly venereal one is oftentimes led to doubt; certain it 
is that it appears and exists with 
greatest virulence where mer- 
cury has been used with un- 
necessary freedom. Venereal 
ulcers of the mouth are of two 
kinds: the superficial, and 
the ordinary ulcer of necrosis. 
The superficial ulcer is 
met with both upon the hard 
and soft palates, but is much 
more common to the latter. 
This ulcer-like the chancre- 
varies in size and character, 
being sometimes small and very 
amenable to treatment, at others 
large, resisting, and phagedenic. 
The second form is resultant 
of underlying bone disease,-a 
matter quickly appreciated by 
use of a sharp steel probe. 
Treatment of Syphilitic Ulcer.-Treatment of venereal lesions of the 
kind considered is to be conducted on general principles; few surgical conditions 
require nicer general judgment or more attententive care ; it is, really, to blow 
hot to-day and cold to-morrow, and vice versa. As a rule, such ulcers are 
oblong in form, from an eighth of an inch to an inch or more in length; 
more or less excavated, the cavity being filled with a dirty-white semi-solid 
paste. The truest practical comprehension of the lesions is found, as the 
experience of the author leads him to infer, in looking at them as one 
looks at scorbutus. Met with in the scalp, the history is most likely that of 
gumma. 
Local Applications.-Touching locally with the acid nitrate of mer- 
cury, with the nitrate of silver, with blue-stone, with London paste, or with 
a mixture of equal parts of iodine and creasote, not infrequently causes such 
sores speedily to assume healthy action. A wash for the mouth that is used 
in no case without advantage is made of twelve drops of fluid carbolic acid, 
eighty drops of compound tincture of iodine, two grains of corrosive sublimate, 
five grains of hydrochlorate of cocaine, and fourteen ounces of water. 
Internal Remedies.-A case will seldom be met with where the in- 
ternal exhibition of a mineral acid does not seem in some degree useful; par- 
ticularly is this found the case where a phagedenic tendency exists. Whatever 
remedies be employed, the venereal basis of the trouble is always to be kept in 
mind. Syrup of the pyrophosphate of iron, conjoined with minute doses of 
Fig. 783. 
Diagram illustrative of a bone surface broken and 
in process of being broken up into sequestra. The 
picture is particularly expressive: it shows appear- 
ance of the conditions perfectly. (After Agnew.) 1016 
A SYSTEM OF ORAL SURGERY. 
corrosive sublimate and iodide of potassium, will, under certain conditions, 
compel such ulcers to disappear as if by magic; or a combination which may 
be employed commonly with a happy effect is as follows: 
U Hydrargyri chloridi corrosivi, gr. ij; 
Potassii iodidi, $ij; 
Syrupi hypophosphitis, 5 ij ; 
Syrupi sarsaparilla composita, ^vi. M. 
Sig.-Tablespoonful three times a day. 
Ulcer of Necrosis.-The ulcer of necrosis, looking like the preceding, 
differs from it in having the pasty mass, which constitutes the apparent bottom, 
associated with dead or dying bone beneath. The ulcer in this case is not the 
trouble to be cured,-indeed, could not be cured while the underlying disease 
exists. Ulcers of this class,'being an attendant condition, are always, of course, 
situated over bone, generally about the maxillary and palate sutures; they are 
preceded by an engorged and tumid state of the parts in which they are 
situated, indicative of the osseous trouble beneath. The character of this 
tumidity is a matter of much concern, as in proportion to its solidity will be 
found, generally, the extent of destruction in the soft parts; the variability of 
such destruction is seldom, however, in proportion to the disease below. The 
author has seen a whole palatine process die while the indicative ulcer has 
not been larger than the eighth of an inch in circumference; on the contrary, 
the smallest sequestrum will sometimes be found associated with the largest 
ulceration. 
Incision as Remedy.-Incision into and through this tumid engorge- 
ment is always found satisfactory practice. The cuts, however, are to be 
made, not carelessly, but with judgment; always taking into consideration the 
vitality of the part. Such incisions, if made through the periosteum, will 
frequently be found to exercise quite a controlling influence on the osteitis, 
just as in cases of ordinary inflammation; the effect upon the soft parts is 
always good. The treatment which should succeed the incisions is only to be 
determined by the circumstances of each particular case; not infrequently it 
will be found amply sufficient to keep the parts well cleansed, and await the 
coming away of the sequestrum ; never, however, forgetting to meet the con- 
stitutional indication. In other cases, as when, for example, the phage- 
denic type is assumed, the most vigorous and well-directed local treatment 
is necessitated. When cases are first seen in the open ulcerated condition, 
semi-indolent, as is frequently the case, no treatment seems superior to pack- 
ing the sore with cotton saturated with creasote and iodine, with ph^nol- 
sodique, or with dilute aromatic sulphuric acid. Cases have come to the 
writer for treatment where the bone would be found exposed to the size of a 
silver three-cent piece, and where all the consequences of a large opening into 
the nares were to be apprehended, yet, by such applications, repeated every 
other day, allowing the cotton to remain in the ulcer the intervening time, in NECROSIS. 
1017 
the course of two weeks the denuded bone would be entirely granulated over, 
and the parts remain permanently cured. * 
Correction of Breaks into Nose by Use of Obturator.- 
Breaks occurring in the hard palate, associating the oral cavity with the 
nares, are easily remedied by a covering of gold or silver plate. An impres- 
sion of the full roof of the mouth is taken in wax; into this is poured plaster 
in a cream form; to the cast thus procured is fitted the plate of metal, sup- 
ported by the teeth, or by atmospheric pressure, precisely as in the case of a 
plate for the attachment of teeth. Any reasonably ingenious mechanical 
dentist can meet the indications. (See Obturators.') 
Freshening and Stimulating Edges of Ulcer.-In breaks of the 
soft palate a simple wad of cotton may be temporarily used with a considerable 
degree of satisfaction. Astonishing results in the way of diminishing or closing 
breaks, both in the hard and the soft palates, are not infrequently secured 
by freshening the edges and touching every second or third day with iodine, 
zinc, dilute sulphuric acid, or the compound tincture of capsicum. Great care 
is, however, to be exercised in this practice not to over-stimulate, very trouble- 
some degenerating inflammations being sometimes a result. 
Recurrence of Ulcer.-An ugly feature in a syphilitic ulcer is its 
tendency to recur: a palate, looking healthy to-day, will assume to-morrow an 
indolent relaxed type, becoming semi-yellowish ; some point or other will take 
on a fatty look, and in a few hours break down into an ulcer. This may recur 
a dozen times; explanation lying in the systemic condition. Such recurrence 
of ulceration may extend over a period of six or eight months, in defiance of 
the most careful attention. The author has certainly found it so in his own 
practice, and believes it to be a common experience. The salt bath is 
found in these cases invaluable, affording, as it does, increased vitality. 
We are indebted to Professor Sigmund, of Vienna, for an appreciation of 
syphilitic manifestations occurring where there is associated with the disease 
nothing of the ordinary history. Syphilis of the mucous membrane of the 
mouth and jaws * is recognized as a secondary or tertiary form of the disease 
commencing in the genitals or region of the anus. Those cases, on the other 
hand, are rare in which syphilis most undoubtedly, or with a probability 
amounting almost to a certainty, occurs as a primitive affection of the oral 
mucous membrane, especially the lips, and thence extends to the general 
system. Professor Sigmund, long ago, called attention to the increasing fre- 
quency of affections of the lips of primitive syphilitic forms,-indurations, 
papulae, ulceration,-and this opinion has been confirmed by subsequent ex- 
perience in his own private hospital practice. This observation has, in addi- 
tion to its importance with regard to pathology and treatment, a deep social 
significance. During a given time seventy-three cases of these primary affec- 
tions of the lips came under the notice of Professor Sigmund. Of these, 
* Wiener Med. Wochenschrift. 1018 
A SYSTEM OF ORAL SURGERY. 
thirty-two were presented at the hospital, and forty-one in private practice. 
These seventy-three cases of syphilitic affections of the lips occurred out of 
5551 patients. The disease was observed much more frequently in the upper 
than in the lower lip. The most frequent explanations as to the cause of its 
having been contracted were, in males, smoking, and the use of certain tools, 
and in women, the rubbing of a spoon against the upper lip, and also the 
habit of holding between the lips thin, sharp, and pointed instruments, such 
as are used in sewing, arranging flowers, drawing, painting, working in card- 
board, and similar occupations. It is worthy of remark that these affections 
of the lips occur in all ranks of society. Professor Sigmund passes over the 
special etiological reports appertaining to these affections, as they are in many 
cases doubtful. Labio-genital coitus could be clearly proved in some cases, 
and in others contagion by means of paint-brushes, tobacco-pipes, drinking- 
vessels, etc., was made out. The syphilitic affections of special importance to 
the practitioner are those produced through kissing. Any method of trans- 
ferring syphilis to a healthy individual from one previously affected at an 
earlier or later period, but evidently, and to a superficial observer, cured of 
the disease, is of the greatest importance; and even these methods have, ac- 
cording to Sigmund's experience, occurred with great frequency, and form a 
very noteworthy, but often neglected, mode of origin of the affection. 
Interesting cases of specific inoculation by kissing are recorded in consid- 
erable number in American medical publications. The author has treated 
quite his share of such cases. Children should not be allowed to be promis- 
cuously kissed. The habit is full of dangerous possibilities. 
MERCURIAL NECROSIS. 
Osteitis, and exfoliation from the undue use of the mercurials, are so common 
as to have come under the notice of almost every physician. These cases have 
generally a history that is regular and distinctive in progress. First there is 
observed by the patient, while the medicine is being taken, a coppery or me- 
tallic taste. Quickly associated with this is an enlargement of the 
tongue, recognized through the indentations made by the teeth as the organ 
encroaches on these bodies. The next stage is puffiness remarked about 
the necks of the teeth, commencing generally with the inferior incisors; the 
congestion of the oral mucous membrane, which soon extends over the entire 
cavity, produces a sense of dryness, and not infrequently of burning; the 
tumefaction, which has now become general about the necks of the teeth, 
assumes a livid color, and presents a grayish, oedematous surface, which ex- 
tends more or less widely throughout the mouth ; the inflammation, attended 
with cacoplastic exudate, next intrudes on the alveolo-dental membrane, and the 
teeth soon become so loose as readily to be lifted from their cavities, and when 
so thrown off are found covered with the sticky, grayish lymph in abundance. 
Uncombated, the effect of the metal passes rapidly to the al- 
veolar processes, this tissue seeming to undergo a process of liquefaction and NECROSIS. 
1019 
absorption. Necrosis, when it ensues, may be partial or complete. Many 
interesting cases of such condition have come under the notice of the author, 
some of which will be found alluded to in other parts of this volume. Chil- 
dren, during the dentitional period, are found most in danger of mercurial 
necrosis, the parts seeming preternaturally susceptible,-a result, without 
doubt, of the excitement related with dental genesis. When the mercurial- 
poisoning is conjoined with a scrofulous condition, the ravages are 
found most marked. The writer has known a single two-grain dose of calo- 
mel given a child of this cachexia kill half the lower jaw. Inflammation 
accompanying mercurial necrosis is apt, from its sloughing tendency, so to 
destroy neighboring soft parts that not infrequently the mouth is permanently 
closed, requiring for relief plastic operations of the most difficult and compli- 
cated character; and, unfortunately, even these proceedings are not always 
able to restore to the patient the lost offices of parts. (See Atresia Oris.) 
State of Salivation.-The state of salivation, so characteristic of the 
mercurial-poisoning, comes on at varying periods, the susceptibility being in- 
fluenced by different conditions: the increase of saliva also changes from 
that which shall scarcely elicit attention to a secretion which may keep the 
mouth of a patient constantly over a vessel. Persons are occasionally met with 
who will be salivated by the simple smell of a mercurial; there are others, on 
the contrary, who appear almost unimpressible. It would seem to be a just 
experience that mercury, as a rule, is not wisely given to teething children or 
to scrofulous subjects, and assuredly it can never in any case be productive of 
good to push the medicine, let little or much be demanded, beyond that point 
at which its effects are observed on the festoons of the gums. 
Scarification and Use of Iodine.-In the treatment of mercurial 
ulitis (which see) attention has been called to a practice by free scarification 
and the local use of iodine. Many cases of threatened necrosis have by these 
means been aborted; but very great care is to be exercised that a low vital 
force be not still further depressed. 
Medication that applies to ulitis applies also to osteitis. 
Sequestra to be detached by Nature.-In the special treatment 
of the mercurial, as of any other sequestrum, it is to be looked on as a matter 
of importance that the dead piece be detached by nature alone, assisted by the 
surgeon only as in other paragraphs described. Particularly does this seem 
important in the young jaw, as thus it may happen that we shall not disturb, 
unnecessarily, the germs of developing teeth. Much stress has been 
laid by some practitioners on the preservation of such teeth as are associated 
with the sequestrum, and advice given that incisions be made through the soft 
parts which shall allow the bone to be drawn away from the loosened organs. 
Such treatment can certainly only apply to very few and peculiar cases. As 
a rule of practice, the author is confident it will be found of little signification. 
Ill odor and putrescence associated with mercurial necrosis are to be 
antagonized by the free use of antiseptic injections. 1020 
A SYSTEM OF ORAL SURGERY. 
NECROSIS FROM INJURIES. 
Accidental injuries received by the jaws are not infrequent causes of necro- 
sis. Having such origin, the recognition and comprehension of the condition 
are but the apprehension of the common pathological expression. Traumatic 
influences capable of provoking an osteitis or periostitis which may result in 
necrosis, can be independent of external wound ; depending entirely on con- 
cussion. The treatment of such a case is the treatment of inflammation 
anywhere. Death of the bone, in whole or in part, resulting, the case has the 
common history of necrosis. 
EXANTHEMATOUS NECROSIS. 
As a result of the exanthemata, it occasionally, though fortunately infre- 
quently, happens that a subacute inflammation of the jaw occurs, resulting in 
limited or, it may be, in extensive necrosis of the part affected. To this form 
of disease, as the recognition of its associations is concerned, attention seems 
first to have been directed by S. James A. Salter, of Guy's Hospital, who 
records twenty-three cases as being met with in the associated population of 
that institution. The author in his own practice has seen quite a number of 
examples. 
Illustrative Case.-The accompanying cut is from a photograph of 
pieces, constituting the full half of the lower jaw, removed from the mouth 
of a German boy six years of age, the bone being 
in the museum of the Hospital of Oral Surgery. 
The earlier history of this case could only be pro- 
cured to the extent of learning that some time after 
an attack of measles the child commenced to com- 
plain of a sore mouth, the gums swelling as in an 
attack of periodontitis, the swelling after a few 
weeks being followed by a continuous discharge 
of pus, which the parents stated had been troubling the child for several 
months; could not say whether it might be two or four. When first pre- 
sented at the clinical service, the boy was so emaciated that little hope was 
entertained of saving his life; but after having been placed on vigorous tonic 
medication for two weeks, taking iron and quinine, drinking beer, using salt 
baths, and having the parts almost hourly syringed, thus washing away the 
offensive semi-putrid pus in place of allowing it as before to pass to the 
stomach, and at the same time using local means of a stimulating nature, the 
reaction was of the most promising character, and invited and endorsed the 
attempt to remove the sequestrum. 
Making at a second clinic thorough examination, it was evident that 
the body of the bone in mass was dead, and that not the slightest attempt had 
been made toward the formation of any new osseous structure. In this in- 
stance, all proper attempt was made to excite the production of osteophytes, 
Fig. 784.-Sequestrum 
after Measles. NECROSIS. 
1021 
the necrosed structure only being removed when to leave it longer in its bed 
would have been to risk life. 
The removal of the sequestrum in this case resulted in a consider- 
able immediate deformity, but which, after two years, had so completely dis- 
appeared as to be scarcely observed, while the natural motions of the jaw 
seemed quite as good as with other children. 
In a second case, the disease attacked the upper jaw, resulting in a repe- 
tition of small inflammatory sequestra, together with the crowns of the unde- 
veloped bicuspidati of the side affected; the trouble continuing, in defiance of 
medication, for over a year, and yielding finally only to a summer spent by 
the patient among the mountains. 
Treatment on General Principles.-In the treatment of such cases, 
nothing special seems demanded, unless it is that we be able to recognize and 
administer the specific for the peculiar poison. Lacking such knowledge, the 
cure is to be conducted on general principles: great cleanliness, conjoined with 
stimulating and antiseptic injections, constitutes the principal local demand; 
while systemically, the patient is to be supported under the drain which, to a 
greater or less extent, always attends the process of exfoliation. 
In cases of slight signification, where the exfoliated part involves 
the edge of the alveolar process only, so little attention is demanded as to deny 
the surgeon, not unlikely, even opportunity to see the condition. 
PHOSPHOR-NECROSIS. 
This is a term applied to that lesion of the maxillary bones dependent on 
phosphorus-poisoning, being a disease peculiar to workmen in match-factories, 
and confined here almost exclusively to such as are engaged in the processes 
of dipping and packing. 
Manner of Affection.-How phosphorus affects the maxillary bones, 
whether from a systemic or a purely local relation, continues to excite discus- 
sion. That persons possessed of carious teeth are alone affected seems suffi- 
ciently verified; while, on the other hand, as shown first by Dr. Letheby, of 
London, phosphorus has a systemic relation, as exhibited by its detection in 
excess in the urine of the poisoned patients. Von Bibra and Geist, holding 
to the theory of a local contamination, direct attention to the fact 
that " toothache invariably precedes the more severe affection," that a carious 
state of some tooth or teeth is a " sine qua non," and that 11 so long as the 
teeth remain good the affection does not show itself." Lorinser, who was the 
first to describe the phosphorus-disease, holds to the analogy of the affec- 
tion with mercurial-poisoning,-a view which the experience of the 
author of this volume leads him to sympathize with, although it is not to be 
denied that it is in opposition to that which at the present time is generally 
held; this common view being that phosphorous oxide, in a low form, finds a 
way to the periosteum through the dental pulp-canal, producing, as a result, 
the peculiar and specific inflammation. 1022 
A SYSTEM OF ORAL SURGERY. 
Prodromata.-A jaw, however, fretted and vascularly excited by teeth 
in a state of disease, would naturally be expected to be in a more susceptible 
condition than one strictly healthy ; hence it may very well be that such special 
susceptibility can explain the attack, the natural resistive force of the part being 
to such extent lowered. Such supposition certainly tends to add force to the 
views of Dr. Lorinser, " that the fumes act by infecting the blood, laying the 
primary foundation for a disease which remains dormant until an exciting cause 
fixes the spot for the outbreak." In proof of his inference, attention is 
directed to the peculiar sallow skin, combined with a dull expression, together 
with the gastric derangements, which are prodromous to the local affection ; 
expressions which the author has observed as characterizing his own patients. 
In certain Nuremberg cases, however, mentioned by Von Bibra and Geist, 
these prodroma were not only lacking, but, on the contrary, the majority 
were seen to be of healthy, florid complexions, which some retained to the 
last stage of the disease. Let the true expression of the condition be as it 
may, a prophylactic to be commended always to workers in phosphorus is 
found in that continuous attention to the mouth and teeth which insures 
absolute cleanliness, combined with the immediate filling of every tooth as 
it may become carious, thus preventing exposure of the pulp. A second 
prophylactic is one suggested by Mr. Salter (see Holmes), who expresses the 
belief that by keeping the atmosphere of the factories ammoniuretted, and 
thus neutralizing the acid vapor, few, if any, cases of the disease would 
occur. 
Graham's Respirator.-Still another means having general commen- 
dation is found in the employment of a respirator, of which perhaps the best 
is that devised by Mr. Graham for persons exposed to carbonic acid vapor. 
This consists of a mixture, in equal bulk, of fresh-slacked lime and sulphate 
of soda, worked into a cushion, through which it shall be easy to breathe. 
Carbonate of magnesia, used in teaspoonful doses twice each day, and applied 
with all freedom locally, will be found of great service in antagonizing the 
acid. 
First Signs.-Outside of the association of the patient with phosphorus, 
there is nothing which, to an ordinary observer, would distinguish the in- 
cipient condition of this loathsome disease from a case of chronic periodontitis. 
The first sign of a commencing phosphor-necrosis is found commonly in one 
or more teeth becoming sore to the touch, feeling, on occlusion, as if raised 
in their sockets; in a short time the surrounding gum begins to swell; in the 
character of this swelling is the first distinctive sign. It is not the acute, 
firm, inflammatory swelling of periodontitis, or of traumatic osteitis, but from 
the beginning has a puffy, debased, and degenerating look. One feels as if 
he might hesitate in adopting any very decided antiphlogistic treatment, or, 
indeed, in employing any other than an expectant one. 
Seat of Predilection.-Phosphorus acts on both the upper and the 
lower jaw-bone, but seems to have a decided predilection for the latter; as NECROSIS. 
1023 
twelve to nine, perhaps. Of twenty-two cases reported by Dr. Lorinser, nine 
were of the upper jaw, twelve of the lower, and one in which both were 
affected. Of fifteen cases occurring in Nuremberg, five were in the upper, 
nine in the lower, and one in both. Of eight cases recorded by Dr. Neumann, 
three were of the upper jaw, four of the lower, and one of both. 
History of Phosphor-Necrosis.-The history of a case of phosphor- 
necrosis is to be epitomized as follows: A degenerative inflammation com- 
mences in the alveolo-dental membrane, or in the substance of the bone; the 
author inclines most strongly to the belief of its commencement in the latter. 
The degeneration of this bone progresses until its enveloping periosteum- 
which remains unaffected as its vitality is concerned-separates from it. The 
bone dies in bulk, or in part. In the lower jaw, the body alone commonly 
dies, the rami remaining unaffected. In the upper, one cannot well infer 
where the demarcation will occur. During the process of dying, 
the periosteum, particularly in the lower jaw, is most active in the reproduc- 
tion of new bone, of osteophytes, so called; this new material exhibiting 
markedly its endeavors to envelop and replace the old. The separation of 
the dead from the living bone, in the lower jaw, when the dead part is at 
all extensive, is found to occupy a period of from seven to nine 
months. It is attended with the formation of many sinuses, both in the 
mouth and about the neck, and is very exhaustive to the patient, on account 
both of the great suppurative drain and of the nauseating character of the 
discharge. All the soft parts associated with the affected jaw, the periosteum 
perhaps excepted, sympathize warmly during the process of decomposition 
and separation, looking, indeed, as if very badly affected with scurvy. At 
the period above alluded to, exfoliation being complete, the surgeon may re- 
move, with little effort, the sequestrum; the sinuses then heal, and the parts 
may recover with as little deformity as attends the extraction of the teeth and 
the ordinary absorption of the alveolar process. 
This will be found a common history of the disease. The 
author has seen and treated quite a number of cases, and it is thus that it has 
presented itself to his observation. It is to be added that the teeth, influ- 
enced by the advancing disease, loosen one by one, so as to make necessary 
their removal long before the bone is ready to come away. 
Pathological Porosity.-In phosphor-necrosis the death of the bone 
seems to be a result of pathological porosity, the loosening and expansion of 
the structure proving antagonistic to its nutrition; as vitality diminishes, so, 
as the result of a cacoplastic exudate, the periosteum is found to separate 
itself, such exudation explaining, in its degeneration, the characteristic abun- 
dance of fetid pus. Indeed, it is to be seen, almost from the earliest affection 
of the bone, that the periosteum is aroused to efforts for self-protection; so 
marked is this in many instances that attempts at the formation of new bone, 
made by separating the periosteum from the dead tissue, result in numberless 1024 
A SYSTEM OF ORAL SURGERY. 
osteophytes, if indeed a perfect wall be not secured. The writer has seen not 
infrequently the whole floor of the mouth, back to the base of the tongue, 
occupied by such new bone. 
Osteophytes in Inverse Proportion to Pus.-As is to be readily 
recognized, the tendency of this exudate to degeneration is marked; thus, the 
osteophytes are found in inverse proportion to the quantity of pus. These 
osteophytes, in characteristics, are seen also to be greatly influenced by a 
treatment employed in a case: in the beginning they are, it is to be inferred, 
uniform; from such uniformity we see them as slender shreds, in masses, and 
indeed in every irregularity of form and feature; decidedly disposed also are 
they to break down and disappear, and this particularly where extreme clean- 
liness is not observed, or the system at large is left without the support of 
tonic medication. It is, indeed, simply the common history of lymph degen- 
eration,-an inability on the part of the plasm to the maintenance of a self- 
supporting organization. 
Condition of Complexion.-A dull, dirty-yellow complexion is almost 
universally associated with phosphor-necrosis; this has been variously attributed 
to dyscrasia, to the pain, the impeded ingestion, and to the immense drain 
made on the system in the progress of the exfoliative process. The most rea- 
sonable hypothesis is that all these causes are alike implicated. Certain it is, 
that to get a patient clear of such complexion, all require to be considered in 
a treatment. 
Tendency to Burrowing of Pus.-The tendency to the burrowing 
of pus in acute phosphor-necrosis is remarkable, and to a great extent such 
burrowing will occur in defiance of treatment. If the lower jaw be the seat 
of the disease, the sinuses will riddle the neck ; if the upper, the antrum tends 
to receive the pus, while in grave cases the matter not infrequently finds its 
way to the ear and to the mastoid cells of the temporal bone. 
Salivation a Marked Characteristic.-Salivation is another of the 
marked characteristics of the condition. The author has had patients who 
were compelled to have a handkerchief constantly at the mouth to receive the 
drainage. Another source of discomfort resides in vomiting: particularly 
does this tend to occur in the morning; the result of the pus swallowed during 
the night. Fever, diminution of appetite, and derangement of the bowels 
follow the progress of the disease, and, if not vigorously combated, are apt to 
end in an inanition fatal to the patient. 
Likeness of Sequestra to Rotten Sponge.-The sequestra of 
phosphor-necrosis in the lower jaw look somewhat like pieces of rotten 
sponge, being almost as light and porous; this arises from the suppuration and 
discharge of the primary exudate which was the cause of the original enlarge- 
ment: the organic material being all discharged, nothing remains but the 
cell-riddled, inorganic structure.* 
* White Liver.-Persons dying from phosphor-necrosis show a liver almost entirely white 
as to color. NECROSIS. 
1025 
Treatment.-The treatment pursued in phosphor-necrosis is to consist in 
the employment of means that shall circumscribe as much as possible the 
disease, that shall hasten the process of limited death and the accruing sep- 
Fig. 785.-Phosphor-Necrosis Sequestrum. 
aration, and that shall support the patient under the drain to which he is 
necessarily subjected. 
Condition of Incipiency.-When a case presents in its incipiency,- 
that is, simulating a developing periodontitis,-we commence the local treatment 
just as we would that of the tooth lesion. If the inflammation have about it 
anything of a healthy acuteness, we limit as much as possible all external irri- 
tation, by softening in a gas-flame or by the stove a piece of gutta-percha, and 
moulding it over some opposite organ, or tooth farthest removed from the seat 
of disease; a mouthful of cold water hardens this cap, and thus occlusion 
against the sore tooth or teeth is prevented. A dose of Epsom salts or other 
saline cathartic is ordered, and a sinapism is applied to the back of the neck. 
A hot pediluvium is found to act sometimes very happily as a derivative; or a 
diaphoretic, such as the spirits of Mindererus, may serve a very good end. 
Depletion by leeches, however, has never seemed to the author to be an indica- 
tion : the affection has its foundation in asthenia. 
Secondary Condition.-If we first see the case-and this is most apt 
to occur-when a discharge has made passage for itself by opening through 
the gum at the neck of a certain tooth or teeth, we immediately make a free 
incision through the soft parts down upon the bone, and syringe thoroughly 
with some medicated water, stimulating or antiseptic, or both, as indicated. 
Having the parts well cleansed, the wound which has been made is stuffed 
with cotton or sponge saturated with aromatic sulphuric acid. This is re- 
peated the next day and the next, until, particularly as the syringing is con- 
cerned, it may be absolutely necessary to repeat it a dozen or twenty times per 
diem, the progress of the disease being so marked by discharge and offensive- 
ness. As day by day the cotton or sponge stuffing is renewed, it is insinuated 1026 
A SYSTEM OF ORAL SURGERY. 
gently between the separating periosteum and bone. This manipulation will 
be found to hasten the separation wonderfully; it may abort the disease. 
Separating Periosteum and Bone.-It might here be asked, per- 
haps, by some one, Is not this process of working off the periosteum an un- 
surgical proceeding, compelling an extension of the destruction beyond that 
which would have been a result if the bone was let alone ? The author can 
only answer from his own experience in different modes of treatment, and say 
that he is perfectly satisfied that this is not the case, and that the result is for 
the good of the patient in every way: the portion of bone destined to die has 
the destruction markedly hastened; the sooner the death the sooner the 
separation ; the sooner the separation the less the exhaustion. 
Stimulant and Antiseptic Washes.-The compound tincture of 
capsicum, a dessertspoonful to a goblet of water, with an addition of the 
fluosilicate of sodium, three to five grains to the ounce, is an excellent in- 
jection. Dilute phenol-sodique is in high favor. Cold water, with a little 
salt and magnesia dissolved in it, can be used ad libitum. 
Dressing Sinuses.-The sinuses which are so apt to form upon the 
neck, in defiance of all treatment, and which greatly annoy by their discharge, 
are most comfortably treated with dressings of patent lint. Once formed, it 
is a waste of time to attempt the healing of them: they will get well only 
when the source of offence in the dead bone is away. 
Time of Separation of Sequestra.-It has been remarked that the 
sequestrum is limited in the lower jaw to the body of the bone, the horizontal 
portion, the demarcation occurring at the angle. This, in the majority of 
instances, will be seen to be the case, particularly if the treatment has been 
properly directed. Seven months has been found, in the practice of the 
writer, the minimum required for the course of the disease, nine months the 
more common time, and fifteen the maximum, although this latter does not 
accord with German experience, cases being reported of two years and a half 
standing. 
Supporting the System.-The drain during most of this time is im- 
mense, the patient requiring generous tonics and substantial fare. Atten- 
tion to repair of wear and tear is, perhaps, of greater consequence than any 
local treatment; certainly, if one could not have both, his chances would 
be best with the former. Both are to be esteemed of vital consequence. To 
commence, however, with the ordinary medicinal tonics is ill-advised. One 
cannot well keep on with them, and by employing such means in the begin- 
ning of the disease their powerful assistance is lost at a time when every help 
is found weak enough at the best. Good underdone roast beef is enough for 
the first two or three months; then addition is to be made of generous malt 
liquors, together with the salt bath. The latter portion of the time demands 
iron, quinine, brandy. 
Hemorrhage.-The hemorrhages, sometimes profuse, are held in check 
by exhibitions, once or twice weekly, of teaspoonful doses of wine of ergot. NECROSIS. 
1027 
Gallic acid in doses of ten to fifteen drops, used as occasion requires, is a 
favorite means with many. Erigeron Canadense is to be recommended. 
Packing the seat of bleeding with cotton that has been rolled in tannic acid 
is to be depended on. Phenol-sodique, used pure and applied by means of a 
sponge-packing, is reliable. 
To know when a Sequestrum is ready to come away.-The 
period at which a sequestrum is ready to come away can only be known 
by repeated examinations, the proper treatment being to wait always until 
exfoliation is complete, be such time longer or shorter. Nothing is gained 
by expediting the removal through operative proceedings, as by breaking away 
the bone, using the chain-saw, etc., while the risk to life, out of danger of septi- 
caemia, is very considerable. To wait patiently, keeping the system equal 
to the demand on it, is the surgeon's highest duty; to do more is to do harm. 
Bone to be removed from the Inside.-The removal of the bone 
may always be effected from the inside; it does not seem that an outside 
incision could ever be found necessary. If the opening along the gum, 
obtained in the treatment, be not great enough, it is easily enlarged to any 
desired extent. 
Preliminary to removing Body of Lower Jaw.-A step pre- 
liminary to the removal of the body of the lower jaw is its division at the 
symphysis. This is easily accomplished by means of a straight-cutting forceps, 
or still better by the engine and drill. It is better to cut little by little, 
from above downward, than to crush through the bone with a single cut; it 
does not hurt nor shock nearly so much. The operation with the drill pains 
little or none, never demanding the patient to be etherized. 
Tooth Forceps used for taking away Bone.-To take away the 
bone, no instrument is found better than ordinary tooth forceps, such as is in 
common use for the extraction of the inferior incisors and bicuspidati. With 
such forceps, complete control of the part is secured, and the removal, as a 
general thing, is easily effected. 
Grasp of Sequestrum by overlying Soft Parts.-A trouble fre- 
quently encountered, and one which, unappreciated, proves confusing and 
deceptive, consists in the grasping of the sequestrum, when extensive, by 
lateral overlying tissues,-not new bone, but indurated soft parts. The 
writer recalls a case which he once had under treatment, where, the dead bone 
being thus held, a practitioner had been waiting for the separation a period of 
over two years, being deceived entirely as to the relation of the part. To 
satisfy one's self as to the condition, pass a small hook under the bone, and 
lift: if it yield, the sequestrum is only thus held, and is with safety to be 
pulled through; if, on the contrary, it be firm and unyielding, it is to be 
let alone, separation not yet having occurred. If the bone seem grasped 
by the contracting soft tissue, the easiest plan of removal is found in the 
introduction between the parts of pellets of cotton; these quickly swell, and 
thus effect loosening. 1028 
A SYSTEM OF ORAL SURGERY. 
Excess of New Bone about Floor of Mouth.-In the reproduc- 
tion of new bone, which, at the period for the removal of the old, should be 
found to have obtained such character as to keep up perfectly the shape of 
the parts, the observer will be struck with the excess deposited along the 
middle line of the mouth ; it seems, oftentimes, as if the floor was a mass of 
bone,-which, indeed, it really is. It is not found necessary, however, to do 
anything with this excess, nature taking all proper care of it. 
Phosphor-Necrosis attacking Upper Jaw.-Phosphor-necrosis 
attacking the upper jaw seems not so much to be dreaded as that associated 
with the lower. It is seldom so formidable in its nature or so destructive in 
its progress, the disease in these parts being sometimes found to run its whole 
course with an entire absence of acute action. A portion of bone dies, and 
the surrounding soft parts seem utterly indifferent. One would scarcely 
know anything abnormal was going on, were it not for the indication given in 
the loosening of the teeth; these drop out somewhat as they would out of a 
dried skull, while the soft parts eventually present the appearance of shrinking 
away from the bone, which structure becomes fully exposed,-as dry and life- 
less, apparently, as a portion of dead wood. This, however, is, of course, not 
the common history. The inflammatory action is of the same type as that 
associated with the disease in the lower jaw, but more limited in extent and 
consequence, and much more susceptible to remedial measures. A bad feature 
consists in a marked tendency to recurrence of the trouble; but this, perhaps, 
will mostly be found within the control of the surgeon. The removal of a 
sequestrum is here a trifling matter, comparatively little effort allowing delivery 
of the piece. 
At a Medical Congress in Zurich, Switzerland, Professor Billroth, in citing 
his experience with phosphor-necrosis, remarked that in attacking the upper 
jaw it seemed to act with greater and more destructive force than on the 
lower, and was more unmanageable. 
The author does not know how to reconcile this difference in clinical obser- 
vation, unless an explanation is to be found in an implied greater tendency 
to return which exists on the part of the disease when situated in the upper 
jaw. In the lower jaw, the full part that is to die seems impressed from the 
beginning,-that is to say, a certain portion seems predestined, and it dies, 
likely, in defiance of all that surgery can do. Not that the evidence of the 
disease is general over all the involved part from the beginning; on the con- 
trary, the incipient stage is markedly localized; but then, day by day and 
week by week, the trouble extends over the apparently predetermined or 
preimpressed part. When the death occurs, it is a single death; and when 
the piece is cast off, there is not apt to be any renewal of the trouble. The 
sequestrum of the upper jaw, on the contrary, is generally small, 
some portion, most likely, of the alveolar process; but unless the treat- 
ment is of a most supporting and specific kind, it is apt to repeat itself again 
and again; but your treatment is responded to here, and for this reason, with NECROSIS. 
1029 
care and attention, the extent of destruction is comparatively under control. 
If it be found more unmanageable in Zurich, then the means would not seem 
to be so well adapted to the end as those employed here, otherwise the circum- 
stances are different. 
Resection to be Condemned.-Again, at the same Congress resec- 
tions are strongly commended. To be so endorsed, they must, of course, have 
been found to answer a good purpose. 
The patients who have their jaws re- 
sected for phosphor-necrosis disease in 
this country generally die, or, if hap- 
pily they escape death, they do not find 
their disease cured without an inflam- 
matory sequestrum at last. 
The picture (Fig. 786), taken from 
life, represents a patient as he ap- 
peared with the disease five months 
in progress. At the end of eight 
months the writer removed the jaw 
at the articulation: the loss was very 
fully repaired at the date of operation, 
the parts having excellent motion. 
Deformity related with Resection.-An important objection to 
the operation of resection, even were the question of life not involved, is the 
great resulting deformity. Let nature take her course, and of such deformity 
there may be little or none. A patient was a gentleman for whom the 
author removed-or rather from whose mouth nature cast out-the whole 
body of the inferior maxilla, and no one could tell whether it had been a case 
of necrosis or of simple extraction of all the inferior teeth, with the consequent 
alveolar absorption, so perfect has been the repair in accordance with the 
destruction. The objection that this new bone keeps up the 
trouble, by becoming involved in the diseased action, is not according to the 
experience of the writer. If it become implicated it would seem to imply 
that it has not been properly cared for. Careful and properly-repeated 
syringings with water medicated with iodine or capsicum will protect it. This 
experience does not, however, include the isolated osteophytes; these do with- 
out doubt incline to degeneration and decomposition, but by care the many 
may be stimulated to a self-supporting combination to which the periosteum 
becomes what it was to the bone exfoliated. 
No Repair of Upper Jaw.-It is certainly most unfortunate that in 
the case of the upper jaw no osseous repair seems attempted, but it is not the 
experience of the author that the horrible deformities mentioned by various 
writers are at all common. Local and systemic stimulation combined with a 
tonic treatment insures more or less attempt at support by the surrounding 
parts through means of an exudate which assumes a fibro-cartilaginous aspect, 
Fig. 786.-Appearance of Patient 
with Phosphor-Necrosis. 1030 
A SYSTEM OF ORAL SURGERY. 
and which takes on itself the duties of the structure lost, to very good pur- 
pose. 
Vigorous Reparative Action in Case of Lower Jaw.-In loss 
of structure in the lower jaw the most vigorous efforts are seen to exist on 
the part of the periosteum almost from the beginning to reproduce the im- 
pressed part, disproving to such extent, as it would seem, the deduction of 
Dr. Geist, that the phosphorostitis is secondary to periostitis, for assuredly is 
it the case that under no circumstances of excitation does that tissue exhibit 
higher vitality. That this secondary deposit differs from the original bone, in 
possessing an excess of organic structure, implies perhaps only that the 
deficiency in inorganic substance has its explanation in the presence of the 
corroding acid of the disease. That the capsule of new bone is so frequently 
found to atrophy may have similar explanation with the primary osteophytic 
degenerations, requiring, if not a local, yet a constitutional care. A sug- 
gestion made by Mr. Salter that the new bone be supplied with function by 
using it as soon as possible as a base for artificial teeth may be found to have 
in it much practical import. CHAPTER LXI. 
DISLOCATION OF THE INFERIOR MAXILLA. 
The frequency of this accident, the terror it excites, and the harm result- 
ing when it is not properly cared for, give an importance to the subject that 
renders appreciation of it a matter of necessity. 
Forms of Submaxillary Displacement.-There are four forms of 
submaxillary displacement: complete dislocation, incomplete, bilateral, and 
unilateral. 
Complete Form. - In the 
first of these, one or both condy- 
loid processes have slipped fully out 
of the glenoid fossae and rest en- 
tirely in front of the articulating 
eminence, as exhibited in the view. 
Second Form.-In the sec- 
ond, the condyles rest upon their in- 
terarticular fibro-cartilages, directly 
over the articulating eminence, and 
will remain fixed, or may fall back- 
ward or forward as directed by acci- 
dent, not being retained in their 
position, as is frequently thought, 
by the coronoid processes being hooked under the malar bones, but resting, 
as it were, upon points with complete balance in the muscular structures. 
Third Form.-This relates with the two described and means that the 
two sides are equally involved. 
Fourth Form.-A unilateral dislocation relates to one side. 
Diagnosis of Luxation.-The diagnosis of a luxation is an exceedingly 
simple matter. An open mouth, with inability to close it, the lower jaw thrust 
forward in a straight line or otherwise turned to the right or the left, accord- 
ing to the accident, indicates a luxation of bilateral or unilateral character. 
Exciting Causes.-The exciting causes of dislocation are various: laugh- 
ing, yawning, vomiting, putting large bodies into the mouth, blows received 
upon the chin from above downward, or in front, while the mouth is open; 
the extracting of teeth, or extending the jaws widely for the convenient filling 
of them, etc. The first case ever met with by the author occurred with a 
middle-aged man while he was laughing immoderately. 
Fig. 787.-Complete Dislocation 
of Jaw. 
1031 1032 
A SYSTEM OF ORAL SURGERY. 
Predisposing Causes.-A predisposing cause of the accident resides 
in a general or a special laxity of the articular connections: thus, all are ac- 
quainted with persons who without effort will dislocate a finger or a toe. Rare 
instances exist where the operation of removing teeth is almost certain to be 
attended with unilateral luxation unless a mento-occipital sling be used. 
Condition of Parts in Jaw Luxation.-What is the condition of 
parts in this luxation ? By placing the finger immediately in front of the 
tragus of the ear when the mouth is closed, and carrying it forward along the 
zygoma, the surface is felt to be a plane. If the finger be kept on the surface, 
and the mouth opened, it drops into a fossa. This is the glenoid fossa ; the 
concave rim above is the border of the cavity ; the rounded prominence below 
is the condyle of the lower jaw. Placing the maxilla of the cadaver in this 
position, and dissecting down to the articulation, the condyle is seen slipped 
forward, resting upon the interarticular fibro-cartilage; the fossa has been 
partially vacated, and the bone lies against the articulating eminence. If now 
the condyle be dragged downward and forward over the eminence, the glenoid 
cavity will be found completely vacated, and unless by manipulation, the condyle 
cannot be restored. Laying back now the soft parts, the cavity in front of the 
tragus is remarked greatly increased, the finger falling into the unoccupied fossa. 
(An added diagnostic sign is found in increased depth and size of the fossa in 
front of the ear: this it is desirable to remember, as a fracture of the neck might 
simulate a luxation.) Returning to the examination, we see that to reduce the 
luxation it is necessary to depress the head of the bone below the level of the 
articulating eminence, which, being back of the condyle, serves to fix it in its 
abnormal position, as originally it was the means of its retention in place. The 
capsular ligament is not usually found torn in a jaw dislocation, but stretched 
and elongated. The lateral ligaments do not seem particularly interfered with, 
and impress an observer as having little influence in the matter one way or 
another. The temporal muscle shows itself stretched and dragged forward, 
but is seldom lacerated. The pterygoid and masseter muscles are relaxed. 
Luxation more Common to Women than Men.-Luxation is 
of more frequent occurrence in women than in men, is uncommon in children, 
and is rare in the robust. When such condition has existed for a long time, 
there seems to be a tendency on the part of nature to make a compromise; the 
jaw will gradually recover considerable of the lost motion. Cases are met with 
where patients seem able to masticate without the least trouble. The original 
contour of the face is never, however, entirely restored. 
Unreduced Luxations.-A luxation of the lower jaw, like that of 
any other bone, if left unreduced, even for a very few days, is found difficult to 
correct; the muscles contract, the condyle settles itself in its new position, 
lymph is effused and coagulates, the general aspect and relations of the joint be- 
come changed. A patient so situated is not, however, to be left unassisted, or 
to the relief afforded by nature. A satisfactory practice in cases of this kind, 
where a luxation cannot be immediately reduced, is found in wedging corks DISLOCATION OF THE INFERIOR MAXILLA. 
1033 
between the teeth, forcing the back part of the jaws as far asunder as possible, 
and then with a properly-directed compress and bandage approximating the 
anterior teeth, and at the same time forcing the lower jaw backward. This 
manipulation, assisted by the employment of sorbefacients, results, not infre- 
quently, in a removal of the semi-organized lymph and a consequent ability on 
the part of the bone to reoccupy its original cavity. 
Reducible after Long Periods.-Reduction of a luxated jaw has 
been accomplished so long as ninety-eight days after occurrence of the 
accident. 
Subluxations Common.-Subluxations are of common occurrence, 
particularly among weak women of easy and luxurious lives. In England 
attention was first directed to the condition by Sir Astley Cooper; in this 
country it certainly has needed no particular one to discover it,-a proof, per- 
haps, of the physical superiority of English over American ladies. This con- 
dition depends, evidently enough, on laxity of the ligaments, and on the weak- 
ness of the muscles of the part. In yawning, or not infrequently in ordinary 
mastication, the condyle will slip forward on the articulating eminence, and, 
for a moment, the mouth cannot be closed, requiring, in many cases, the as- 
sistance of the hand to shut it. Existing in weakness, a permanent cure is 
to be looked for only as a higher and stancher vitality is secured. Such weak- 
ness and condition are to be treated by cold bathing, tonic medicaments, 
exercise, etc. In the case of a lady liable to the luxation, and who was made 
very nervous by its occurrence, the accident was entirely guarded against by 
her wearing the occipito-mental caps and bands. The writer was once 
consulted by a person who was awakened almost every night by a peculiar 
and unbearable pain attendant on such slipping of the condyle during the 
relaxation of sleep. 
Luxations and Fractures.-Dislocations associated with fracture are, 
happily, of rare occurrence. Delamotte records a case where, in the person 
of a girl, double luxation existed with fracture of the body of the bone. 
Another is mentioned by Roberts, where the body was broken in front of the 
right ramus, and the condyle dislocated outward. A third case (Heath) is 
reported in the Dublin Medical Gazette; it occurred in a boy of eight, 
who suffered a fracture at the symphysis, with dislocation of the left condyle 
upward and backward. There was bleeding from the ear, and the chin was 
much retracted and turned to the left; the mouth was open, but could be 
closed, and it was then observed that the lower molars overlapped the upper, 
but that the lower incisors were at least one inch behind the upper. Reduction 
was easily effected, and the case did well. 
Congenital Luxations.-Luxations are sometimes congenital. The 
first case of this kind was noticed by Mr. Robert Smith, of Dublin, who gives 
with minuteness the results of his dissection. The patient, an idiot from 
infancy, died at the age of thirty-eight. The displacement existed on the 
right side, which was remarkably deformed, having a singularly hollow ap- 1034 
A SYSTEM OF ORAL SURGERY. 
pearance, which strikingly contrasted with that of the sound one, which was 
unusually full and plump. The extremity of the finger could be readily 
pressed between the posterior margin of the jaw and the auditory canal, owing, 
as was found on examination, to the absence of the condyle of the bone, 
which was, in fact, greatly atrophied nearly as far forward as the ramus proper. 
There was no interarticular cartilage nor distinct capsular ligament, and the 
masseter, pterygoid, and temporal muscles were much wasted. The temporal, 
malar, superior maxillary, and sphenoid bones were imperfectly developed, and 
the glenoid cavity existed merely in a rudimentary state. 
Treatment of Luxation.-By referring to Fig. 787, it will be plainly 
evident that the reduction of a disarticulated condyle consists in getting it 
back of the eminentia articularis. How best to do this is the question. 
1st. Wrap the thumbs in delicate napkins, seat the patient on a strong chair, 
and, standing behind him, rest his head against your person; place now the 
protected thumbs upon his inferior molar teeth, and with main strength force 
the jaw directly downward and a little backward; the moment you have de- 
pressed the articulating face of the condyle, it will be felt to be dragged into 
place. The amount of force required to do this depends on the 
muscular tone of the individual. In some 
cases the reduction is effected almost before 
you are aware of having exerted any press- 
ure ; in others it cannot be secured with- 
out the assistance of mechanical appliances. 
Fig. 789. - Vertico-Mental 
Sling or Cap. 
Fig. 788. 
2d. Failing to reduce a luxation standing behind a patient, reverse the 
position, resting the head against an assistant. 
3d. Take corks, one or two, according as the luxation is single or double, 
force them between the wisdom-teeth of the upper and the lower jaw as firmly 
and fixedly as possible; now gradually push the chin forward and upward, 
using either the hands or a tourniquet applied around the head. DISLOCATION OF THE INFERIOR MAXILLA. 
1035 
4th. Take a piece of wood about a foot m length, place one end upon the 
molar teeth of the luxated side, making a fulcrum of the molar teeth of the 
upper jaw of the opposite side, and elevate the end held in the hand. If 
the luxation be double, reduce one side at a time. In the use of this lever, 
the results are most easily secured by resting the centre of the piece of wood 
upon the teeth of the side to be reduced, carrying the end downward. 
Stromeyer's Forceps.-The forceps invented by Stromeyer yields a 
powerful leverage. This consists of two blades so expanded at the extremities 
as to fit, as well as may be, the dental arches, these blades being covered with 
leather; a spring between the handles throws them apart, thus closing the 
blades. Reduction is attempted in two ways. One way is so introducing 
the padded blades that each shall rest upon its proper tooth or teeth,-the 
third and second molars,-the handles are grasped in the hands of the operator 
and gradually brought together; when the blades have thus been so far 
separated as to lead to the inference that the face of the condyle is below the 
level of the obstructing eminence, the jaw is to be pushed forcibly backward 
into its place by an assistant. The other way is using a screw and nut 
which passes between the blades: a delicate wrench fits the nut, and through 
its instrumentality the handles are gradually screwed together, separating, of 
course, the blades. The manipulation of pushing back the jaw, Stromeyer sug- 
gests, is to be effected at the same moment with the sudden closing of the blades. 
Kolbe's Mouth-Opener.-Better than the Stromeyer forceps is the 
instrument shown in Fig. 790. With this it is easy to secure the required 
depression, when the condyle, 
not unlikely, is found to slip 
into place of its own accord. 
Nelaton's Method.- 
Still another manner is that 
known as Nelaton's. To prac- 
tise this, the patient is seated 
upon a common chair, and the 
surgeon, standing behind, fixes 
his thumbs upon the nape of the neck, while with his fingers he pushes the jaw 
forward and downward by pressure exerted upon the angular prominences. 
Use of Anaesthetics.-In recent cases the anaesthetic agents may not 
be required, although there is seldom objection to their employment. In cases, 
however, of any standing, or in muscular persons, it often happens that it is 
impossible to succeed in the reduction without the aid of relaxing agents; 
while, again, the formation of adhesions are found to make attempts at 
reduction both painful and formidable. 
After-Treatment.-A luxation having been reduced, it becomes neces- 
sary to give support to the parts, and insure for a time against the possibility of 
the mouth being too widely opened. This is most conveniently insured through 
the use of a vertico-mental sling made with elastic straps. (See Fig. 789.) 
Fig. 790. CHAPTER LXIL 
FRACTURES OF THE MAXILLARY BONES. 
Fractures of the maxillary bones are to be divided into two classes, 
simple and complicated. The first relates with such cases as are without ex- 
ternal or associated injury, implying a single break in the continuity of the 
bone. The second embraces all conditions associated with comminution of 
the bone, with external lesions, injury to vessels, to teeth,-in short, to any 
relation which alters the fracture from one of a simple to one of a compound 
character. 
Lower Jaw most Liable to Fracture.-The inferior maxilla, from 
the exposure of its position, from its shape, and from its office, is more liable 
to the accident of fracture than is the superior, the lesion being commonly 
the result of blows, falls, kicks, etc. These fractures are found associated, 
in the majority of cases, outside of gunshot injuries, with the body of the 
Fig. 792. 
Fig. 791. 
Simple fracture through the body of the 
lower jaw near the mental foramen. 
Compound fracture of the lower jaw. 
jaw, the rami escaping, from the fact that a force brought to bear upon them 
slips the articulation more easily than it breaks the bone. 
Weak Line of Lower Jaw.-In most inferior maxillae a weak point 
exists in the line of the roots of the canine teeth; hence here is the most 
frequent seat of fracture. This, however, as will be inferred, applies to an 
unbroken dental arch. When teeth have been lost, and the process absorbed, 
the situation of this weak part is changed. In gunshot injuries, accidents 
from the passage of a wheel over a jaw, or similar applications of force, 
fractures occur at the seat of such applications, and follow no rule. 
Fractures likely to be Compound.-It is singularly the case that 
most fractures of the body of the lower jaw are compound, the opening exist- 
1036 FRACTURES OF THE MAXILLARY BONES. 
1037 
ing on the lingual aspect; this is a result of the easy lacerability of the gum- 
tissue, combined with a quick displacement inward of the fractured part. 
This exposure of the bone seems, in many mouths, to be of little consequence. 
In others it is quite the reverse, the saliva thus allowed to come in contact 
with the structure degenerating and deteriorating it. 
Character of Fractures influenced by Causes.-Fractures from 
blows of the fist, or from similar concentrated forces, are apt to be single; 
from falls, they are not unlikely to prove multiple; from kicks of animals, 
comminuted. A common cause of fracture, familiar to every dentist, is found 
in the extraction of teeth having large and bifurcating roots; luckily, how- 
ever, such breaks are not of serious nature, being confined to the alveolar 
process, although cases are on record where the accident has been so extensive 
and severe as to cost the life of a patient. Complete division in the continuity 
is, however, rare, very few cases having occurred. 
Openness of Symptoms.-The symptoms denotive of fracture in this 
bone are seldom or never obscure. There are, first, the mobility at the break, 
and the crepitation; second, loss of harmony in the line of the teeth. If the 
fracture be multiple, irregularities are produced in the general contour of the 
arch, and in the articulation. If the freed portion be the anterior or chin 
part, it will be dragged downward and backward by the action of the genio- 
hyoid, genio-hyoglossus, and digastric muscles. If it be at the line of the 
cuspid tooth and at the upper portion of the ramus, the fragment will be dis- 
placed inward by the action of the mylo-hyoideus, upward by the action of 
the masseteric, and forward by the action of the external pterygoideus. If 
the fracture be single, and beneath the attachment of the masseter, crepitation 
will be present, but little displacement. If the neck of the bone be broken, 
the body is dragged forward by the action of the external pterygoideus; while 
much pain will attend the movements of the jaw. 
Uneasiness, soreness, inability to masticate, inflammatory phenomena, inter- 
ference with speaking and swallowing, associate with and characterize jaw 
fracture. 
In short, the history of a broken jaw is the history of fracture anywhere 
else, allowing for differences in office. 
Fractures of Upper Jaw.-Fractures of the superior maxilla are 
quite infrequent, and when occurring, except from extraordinary causes, de- 
mand little attention outside of that which pertains to the injury as a contu- 
sion. Of such fractures the author has treated a number which surprises 
him in the count, considering the rarity of the accident; in no instance, out- 
side of the alveolar breaks, has he met with a displacement requiring special 
apparatus for its cure. Indeed, the cellular character of these bones, and the 
existence of the antra, permit of such yielding that depression of the sub- 
stance forms commonly the displacement; hence the associated frequency of 
caries with such accidents, the vitality of the part being lowered or destroyed. 
It is not, however, to be understood that derangement does not occur; the 1038 
A SYSTEM OF ORAL SUROERY. 
force of an injury may be great enough, as cases are on record to show, to 
luxate the bones in mass. 
Illustrative Case.-In Mr. Heath's work is the record of a case 
taken from the Chirurgical Treatise of Richard Wiseman, which is a marked 
example of such displacement. The patient was a lad eight years old, who 
had received a blow on the middle of the face so severe that he appeared at 
first to be dead, and afterward lay in prolonged coma. When, says Mr. 
Wiseman, I first saw the boy he presented a strange aspect, having his face 
driven in, his lower jaw projecting forward. I knew not where to find any 
purchase, or how to make any extension. But after a time he became sensible, 
and was persuaded to open his mouth. I saw then that the bones of the 
palate were driven so far back that it was impossible to pass my fingers behind 
them, as I had intended; and the extension could be made in no other way. 
I extemporized a retractor curved at its extremity, which I engaged behind 
the palate, and having carried it a little upward, used it to draw the bone 
forward, which I did without any difficulty; but I had hardly withdrawn the 
instrument when the fractured portions went back again. I then contented 
myself with dressing the face with an astringent cerate. I likewise prescribed 
bleeding, and some hours afterward I had an instrument better constructed to 
reduce the large mass of displaced bone to its proper position. I had it held 
by the child's hand, by that of its mother or of an assistant, each for a certain 
time. Nothing else was done. Thus, by our united attention, the tonicity of 
the parts was maintained, callus was developed, and in proportion as this last 
became solidified the parts grew stronger, the face assumed a good appearance, 
-certainly better than could have been hoped for after such marked displace- 
ment. The child was entirely cured. 
Illustrative Case.-A case in the Westminster Hospital, of a frightful 
deformity produced by the passage of a wagon-wheel over the face of a man 
who fell in the street, may be alluded to. Here the bones were completely 
shattered, and the maxillae torn from one another, death being instantaneous. 
A case is also recorded, admitted into the same hospital, the accident resulting 
from the overturning of a cab upon the face of its occupant, who at the 
moment was leaning out of the window to direct the driver. Here, in addi- 
tion to a fracture of the lower jaw, a little to the left of the median line, the 
nasal bones were broken, both malars were loosened and separated from their 
attachments, and the left bone was fractured, as also the external angular pro- 
cess of the os frontis. Though not positively ascertained, the vomer was no 
doubt fractured, and probably the vertical plate of the ethmoid. The case is re- 
ported by Dr. Fyfes. It was remarkable, says this gentleman, to observe how 
movable the bones of the face were. On watching the profile of the patient 
while he was in the act of swallowing food, the whole of the hard parts could 
be seen to move up and down into the fixed part of the skull, as the different 
portions were brought into motion. It appeared as if the integuments alone re- 
tained them in position. It was a curious feature that notwithstanding the FRACTURES OF THE MAXILLARY BONES. 
1039 
very extensive injury done, and the violent character of the force, not a single 
tooth was fractured or misplaced. The patient is reported as having made a 
perfect recovery. 
Illustrative Case.-A case of similar signification, which the kind- 
ness of Professor Agnew enables me to illustrate, is shown in Fig. 793. The 
patient, a lad, who had been caught between the bumpers of two railroad cars, 
was brought to the hospital, the whole face being disjointed from the head. 
The upper jaws were greatly 
comminuted, the inferior max- 
illa was broken in four places, 
and a number of ragged wounds 
involved the soft parts of the 
face. Notwithstanding this ex- 
tensive mutilation, Dr. Agnew 
speaks of all the upper frag- 
ments as uniting, a portion of 
the lower only becoming ne- 
crosed and requiring to be re- 
moved. The drawing shows 
the appearance of the patient 
after recovery. 
Illustrative Case. - A 
case of complicated fracture, 
treated by the author in con- 
junction with the service of the 
Pennsylvania Hospital, has the 
following history: 
The patient, a painter, while 
passing over the roof of a 
house, had the misfortune to 
slip, falling all the way to the street. As a result, besides fractures of both 
legs and arms, the superior and inferior jaws were broken into many pieces. 
Comminution being very great, a number of splinters were necessarily re- 
moved ; this, as the lower maxilla was concerned, allowed the lateral remnants 
to fall together, the symphysis of junction being midway between its former 
position and the hyoid bone. 
The patient being recovered, this adventitious jointure was incised and the 
parts separated by means of a jack-screw; some three weeks being required 
to accomplish the task. Being held in place, an impression of the parts was 
secured in wax from which was finally prepared the section shown (Fig. 794). 
This, slipped into the hiatus, restored most happily the continuity; the 
great deformity being corrected and the patient eating with almost his ordinary 
comfort. Teeth in place in the upper jaw conceal the defects in that arch. 
(See Wounds of Mouth and Associate Partsi) 
Fig. 793. 1040 
A SYSTEM OF ORAL SURGERY. 
Bands as Means of Retention and Support.-In a case of this 
kind it is exceptional where bands are not demanded for the purpose of holding 
a section, such as described, in place. These bands are to be made of platin- 
ized gold, and it is mostly necessary 
to encircle two or three teeth. It is 
the case, however, that the use of 
bands can be dispensed with through 
employment of a loaded plate. At 
best the cases are likely to be found 
troublesome both to surgeon and 
wearer. (See chapter on Exsections 
of Lower Jaw.} 
Gunshot Injuries.-Of gun- 
shot injuries the writer has had op- 
portunity to see many and marked 
examples. In comminuted fractures 
it is his practice to pick away 
such pieces as are completely de- 
tached, but to leave and mould in 
place, when feasible, all others. He 
has never met with the trouble of 
uncontrollable hemorrhage, and generally has found the reparative energy 
sufficient to unite parts much broken. In Circular No. VI. of the Surgeon- 
General's Department, secondary hemorrhage is noted as the principal source 
of fatality in the cases: 1579 fractures of the facial bones are reported; of 
these 891 recovered, 171 died,-the terminations of 517 cases were left un- 
accounted for. 
Fig. 794. 
TREATMENT OF FRACTURES OF JAW. 
The treatment of a fractured jaw involves the indications to be met, and 
the mode or modes of meeting them. These indications and modes vary, 
of course, with almost every individual case. For a simple fracture of the 
inferior maxilla, or, indeed, for most compound fractures, the common paste- 
board or gutta-percha splint is generally found sufficient and reasonably satis- 
factory. 
Pasteboard or Gutta-Percha Splint.-To make this splint,- 
which constitutes the basal idea of dressings for jaw fractures,-take a piece 
of binder's board, or gutta-percha, and cut it as shown in letter A, Fig. 795. 
The board thus shaped is soaked in hot water until it becomes soft. The 
fracture is then set, the jaws approximated, and the splint moulded into shape 
and position over the parts. Letter B shows the mould. To accomplish this 
last it is only necessary to lay the centre of the board beneath the chin, one- 
half projecting; the wings are next brought up and pressed about the cheeks ; 
next the projecting portion of the board is laid against and around the chin FRACTURES OF THE MAXILLARY BONES. 
1041 
and sides of the face. This makes a complete cap, fitting accurately the re- 
gion, and, when dry, it is uniform and unyielding. So simple is this matter 
and so easily are the parts 
held in place that the author 
frequently uses the ordinary 
postal-card as a splint. 
Gutta-Percha as a 
Splint. - A manner of 
splinting, as perfect as it is 
simple, and which, as the 
author's practice is con- 
cerned, commonly relieves 
him of all trouble, as com- 
plicated apparatus are con- 
cerned, consists in putting 
into dough form ordinary 
gutta-percha (used in den- 
tistry for the purpose of 
taking impressions), by means of hot water, and, after setting the fracture, 
model out a rim corresponding with the jaw, and allow the patient to bite into 
it. If delicately and properly done, no excess of material being allowed, this 
holds the parts firmly, and may be allowed to remain, without being disturbed, 
Fig. 795.-Barton's Bandage. 
A, shape of the piece of pasteboard or gutta-percha for 
the chin; B, the same moulded to the part,-the ends, 1,1, 
being turned upward, and the sides, 2, 2, turned from 
before backward. 
Fig. 796.-French Dressing for 
Fracture of the Lower Jaw. 
Fig. 797.-Hamilton's Dressing for 
Fracture of the Lower Jaw. 
for two or more weeks, or even, indeed, until splinting is no longer a necessity. 
After the first week, a patient wearing this splint may be allowed to rest him- 
self frequently by opening and shutting the mouth. 1042 
A SYSTEM OF ORAL SURGERY. 
French Apparatus.-Fig. 796 shows a dressing much used in France. 
Hamilton's Dressing.-Fig. 797 exhibits Dr. Hamilton's manner of 
putting up fracture of lower jaw, 
Simple Form of Interdental Splint.-A perfect double interdental 
splint (see succeeding paragraphs) is to be made in a few moments by means 
of gutta-percha, the mouth being held open at any angle desired. Such a 
splint is made by simply placing the material, in required bulk, between the 
jaws on both sides and allowing the patient to settle the teeth into the masses 
to that extent which preserves the necessary opening in front. A sponge, 
wet with cold water, hardens the splint instantly. Fig. 805 affords the idea, 
the middle portion being supposed absent. 
Barton's Jaw Bandage.-To hold splints in position, a bandage is to 
be applied. The most simple is a modification of Barton's, which suggested 
itself to the author several years back, and which has since been used by him 
with much satisfaction. The Barton bandage, so generally employed in fract- 
ures of the lower jaw, consists of a roller six yards in length and from one 
and a half to two inches in width,-following in this latter respect the taste 
and idea of the operator. To apply this dressing, place the initial extremity 
behind the left ear; carry it around the side of the head, over the opposite 
parietal bone; cross to the right over the neighborhood of the fronto-parietal 
suture ; carry down beneath the chin ; carry up on the opposite side; cross on 
the forehead; carry around the left parietal bone, and meet the beginning of 
the roller at the occipital prominence, or a little below it. Repeat the turns 
until the roller is exhausted. 
Gibson's Jaw Bandage.-Gibson's bandage, used in the same and 
similar fractures, employed mostly when the break occurs at the angle, consists 
of three distinct turns. First. Place the initial extremity in front of the 
ear ; carry beneath the chin; pass up on opposite side, and meet the begin- 
ning by passing over the fronto-parietal region far enough back to prevent 
slipping ; repeat this turn three times. Second. Reverse in front of and a little 
above the ear, and make three turns around the circumference of the vault. 
Third. End the third of these last turns at the occiput, and carry three times 
around the occipito-mental circumference. This is also a six-yard roller. 
Author's Modification of Barton's Bandage.-The modification 
of Barton's bandage, known by the author's name, is applied as follows: Take 
a strip of roller material, one and one-half or two inches wide, one and one- 
half yards in length. Standing behind the patient, rest the chin on the centre 
of this strip ; carry the ends up, cross on the forehead, carry around the sides 
of the cranium, cross again at the occiput; carry forward, and tie, or otherwise 
fix, in front of the chin. 
In the application of this dressing or strip, if the parts about the jaws be 
tender, it is better to make the termination somewhere on the side of the neck. 
To effect this, it is only necessary to place the chin, when first resting the strip, 
nearer to one or the other of its ends. This bandage is shown in Fig. 799. FRACTURES OF THE MAXILLARY BONES. 
1043 
Interdental Splints.-A second method of dressing a fracture, appli- 
cable to both simple and complicated cases, one which allows the mouth to be 
partially open, consists in getting accurate impressions of the parts (see Pros- 
Fig. 799.-The Author's Bandage. 
Fig. 798. - Gibson's 
Bandage. 
thetic Dentistry'), and in making two plates, one to fit the upper teeth, and in 
part the roof of the mouth, the other to cap a certain convenient number of 
the lower teeth. After setting the fracture, and using temporary means to 
hold the parts accurately in position, these plates are put in position, and 
attached to each other by means of pieces of wax. A succeeding step is to 
remove the parts, as they have been related, from the mouth, to set them in 
plaster and sand, and to solder the three pieces together. This done, the con- 
struction is replaced, and the teeth closed into the metal sockets. The strip 
bandage being applied, the dressing is completed. This mode of treat- 
ing a fracture of the lower jaw the author thought original with himself, 
but has found it employed by Mr. Liston, of England, some twenty-five years 
or more back, a splint entirely similar having been constructed for that sur- 
geon by Mr. Nasmyth at least five years before the idea suggested itself to 
his own mind. 
Complicated Cases.-In any ordinary fracture of the lower jaw the 
mode of dressing described will be found to meet all indications. In complicated 
injuries it has been the common experience that rules are of little consequence ; 
a surgeon finds himself governed and directed by the peculiarities of each 
case, and is thrown entirely on his own judgment and ingenuity. 
Bean's Splint.-A splint devised by Dr. Bean, of Georgia, and used 
during the war of the Rebellion, among the Confederate troops, is, seemingly, 
much regarded in the Southern United States. This apparatus consists simply 
of a piece of light wood, four and a half inches in length, three-sixteenths of 
an inch in thickness, and one inch and a half in width in the middle, tapering 
to seven-eighths of an inch, and round at the ends, to each of which is attached 
a metallic side piece four or five inches in length and from three-quarters to 1044 
A SYSTEM OF ORAL SURGERY. 
one inch in width; also a shallow cup, fitting the apex of the chin. Associated 
with these side pieces are temporal straps, made of stout cloth, and secured 
by a strong cord at the base of each piece. 
A bandage, occipito-frontal, is composed of a band passing around 
the head from the forehead to the occipital protuberance, and secured by a 
buckle, one inch to the right of the median line behind, of another strap 
secured to the band in front and behind, and a third, extending from the tem- 
poral buckles on either side and secured to the middle strap at the point of 
crossing. Figs. 800 and 801 show this splint. 
Fig. 801.-Bean's Splint applied. 
Fig. 800.-Interdental Splint. 
Sudduth's Splint.-A mento-dental splint, the invention of Dr. W. X. 
Sudduth, editor of the International Dental Journal, is shown in Fig. 802. 
This apparatus carries its own commendation, and no doubt will come into 
wide use by such as have the ingenuity to make and the tact to manage it. 
The especial points claimed for the instrument are,-1st. That it is universal 
in its application. 2d. That by its use a perfect articulation is insured (upon 
recovery). 3d. Cleanliness. 4th. Comfort in wearing. 5th. Ease of ad- 
justment. 6th. Absolute firmness, so that no crepitation of fractured ends of 
jaw can occur at the posterior portion of the splint. This is insured by the 
arms of the ratchet-clamp extending nearly to the rear of the splint. This 
last point has not been touched by any other device. Also, the attaching of 
the clamp to the sides of the cups allows the jaws to move nearly approximate, 
insuring comfort to the wearer. 
Directions for Use.-Adjust the fractured portions of the inferior 
jaw, and take impression in wax of the maxillm (upper and lower). Fill 
impressions with plaster. Place the cast of the upper teeth thus obtained in 
the superior portion of an articulator. Break the cast of inferior maxilla at 
sueh points as correspond to the fractures of the jaw (if you have not been 
able to secure an impression that will articulate its cast, which in all proba- FRACTURES OF THE MAXILLARY BONES. 
1045 
bility you will not). Articulate the fractured portions with the cast of superior 
maxilla. When you have the articulation correct, cement the fractured por- 
tions by the addition of fresh plaster to the breaks. Next warm some im- 
pression compound and place in 
the upper tray of splint. Next 
press the articulated cast of in- 
ferior maxilla into the impression 
material, thereby getting an im- 
pression of the jaw as it should 
be to articulate with the superior. 
Insert the cup into the mouth, 
and carefully work the natural 
teeth into the impressions made 
for them by the cast. Adjust 
the clamps and the lower cup, 
placing a little plaster in this 
last in order to fill up any ine- 
qualities in the jaw not met 
by it, thus making a perfect 
splint that holds the teeth above 
and the lower portion of the in- 
ferior maxilla below. If it be 
found that the circulation of the facial artery is interfered with, a groove can 
be cut in the plaster in lower cup to accommodate the vessel. 
Failure of Fractures to Unite.-It is sometimes the case that from 
comminution, or other causes, fractures of the inferior maxilla, like fractures 
of other bones, fail to unite. In treating these cases the practitioner finds 
each one possessed of special indications. If necrosis exist, exfoliation of the 
sequestrum is to be awaited. If the vital force seems at fault, this is to be 
stimulated and elevated. If it occur that the ends of the fragments have 
become rounded, and perhaps tipped with a species of cartilage, operative 
means are demanded,-such means varying with circumstances. One plan, 
considering this last condition, much approved, is to pass through the parts a 
seton, composed of several strands of wire, to be removed thread by thread, 
as inflammation requires to be modified. Or, in place of the wire, other 
material, as silk, twine, tape, etc., may be used. An operation consists in 
boring one or more holes through each of the fragments, and the tying of 
them together with sutures of wire. Resection is a means successfully em- 
ployed by many. Irritating the ends by rubbing the fragments together, thus 
provoking the desired inflammatory action, is still another plan. 
Nutrition as related with Ununited Fracture.-Attention to 
the circumstances of a patient suffering from ununited fracture is important. 
A case exhibited at one of the clinics of Professor Henry H. Smith was 
plainly enough due to the individual having confined himself exclusively to a 
Fig. 802.-Sudduth's Mento-Dental 
Splint. 1046 
A SYSTEM OF ORAL SURGERY. 
diet of potatoes,-such food, in this case at least, being insufficient to accom- 
plish the repair. 
Treatment of Complications on General Principles.-Compli- 
cations, whatever their character, are to be treated on general principles. It 
is impossible to direct any special course, for the reason that such conditions 
are constant to no rule. Hemorrhages of moment, so frequently alluded to, 
have not been met with by the author. Those occurring are nearly always 
secondary in character, and it is well, where possible, to treat them in antici- 
pation. For example, an injury which has lacerated the facial artery would 
perhaps yield little or no hemorrhage at the time of accident; yet as the 
process of sloughing should expose the sound part of the vessel, hemorrhage 
might be profuse and alarming enough. In these and corresponding cases 
circumstances, in special instances, justify one in searching for the ends and 
ligating them, otherwise cutting down upon them. (See Ligation of 
Arteries.') Injuries to the dental organs are to receive due attention: it is 
not by any means every loosened tooth that is to be removed, nor every 
displaced one that is to be looked on as lost to usefulness. The proper plan 
is to wait on nature's indication. The practice of the writer is to remove no 
important tooth or teeth under circumstances of accident until shown by the 
extent of suppuration or by a threatening appearance of the parts that reten- 
tion is impossible. As a means of support to loosened teeth, apparatus of 
the least irritating nature is to be employed. 
Where Teeth are Broken.-In cases where teeth are broken off, 
parts of the roots remaining in the gum, indications demand the removal of 
the crowns should these be hanging attached to the gums. It is desirable 
also that the roots be removed, but this, as a rule, it seems impossible to 
accomplish, so that nothing better is to be done than to combat the associated 
inflammation and wait. Acute manifestations having been mastered, the 
most satisfactory results possible to be secured are found in the use of the 
tinctura myrrhas et capsici; teaspoonful to half-goblet of water; gargle 
frequently. Fractures occurring about the neck of the inferior jaw are to 
have the displacements corrected by the application of such compresses as are 
found to answer the purpose, no matter how closely such applications follow 
any special rules, nor how far they depart from them. The author does not 
remember ever to have treated, in the course of his professional life, two 
fractures precisely in the same way. (See Inflammation.') 
Complications in Breaks of Superior Jaw.-In breaks of the 
superior jaw, complications, while rare, are still more anomalous. Thus, a 
case is recalled where it was necessary to remove the whole alveolar process 
of both maxillae, the accident being resultant of a kick received from a mule. 
In this case the patient was a man broken down by drink and dissipation. A 
process was anticipated which was sure to have resulted, but which, to have 
been accomplished per vias natura/es, would have cost the patient weeks of 
suffering, not unlikely life. The writer has seen a case of fracture of the FRACTURES OF THE MAXILLARY BONES. 
1047 
right upper jaw, where the alveolar process (the fractured part) hung at least 
a quarter of an inch below the common level. In this case the part was 
moulded into its place and supported by a simple strip passing across the jaw 
and fixed a little beyond the fronto-parietal suture. In three days the piece 
became self-supporting, and in two weeks the patient was eating comparatively 
solid food. 
Gunshot injuries of the face and jaw are of every conceivable variety. 
The surgeon does primarily, in such cases, what he can, and leaves the rest 
to nature. (See Obturators.') 
With Hamilton, the author has to remark that it is impossible to discuss 
in detail the varieties of accidents to which the complicated structures of the 
face are exposed from balls or other missiles. Certain general rules are, 
however, to be observed. For instance, as suggested by that surgeon, mis- 
siles entering and lodging in the face are to be extracted as speedily as 
possible ; and, whenever it is practicable, they are to be removed through 
the mouth. If permitted to remain, they expose to the danger of secondary 
hemorrhage, and increase chances of subsequent disfigurement. 
Fragments of Bone to be replaced.-Loose fragments of bone are 
to be replaced, unless much detached from the flesh and periosteum, experi- 
ence proving that these unite in most cases with facility. 
Skin not to be removed.-No piece of skin that is torn up is to be 
removed unless it be absolutely dead; it is to be laid back carefully in place, 
and retained either by a few delicate sutures or by some, gentle means of 
support. Tight ligatures and firm straps of adhesive plaster, being apt to 
bind the tissues and destroy their little remaining vitality, are not to be 
employed. The best means of supporting a fragment of skin in place, in 
many cases, is to lay upon it a thin piece of lint smeared with cerate, and 
over this a pledget of cotton-batting, securing the whole with adhesive plaster 
or a roller. 
Plastic Operations.-As soon as the inflammation and consequent 
induration have completely disappeared, but not before, it will be proper to 
make the final plastic operations. 
Controlling and Combating Inflammation.-An addendum to 
these suggestions of Dr. Hamilton is to be made by directing attention to the 
necessity of controlling and combating inflammation. To this end cold water 
is freely used locally, saturated cloths being renewed as the temperature is 
elevated ; or the water may be medicated ; acetate of lead and laudanum being 
generally employed. An admirable antiphlogistic application is prepared by 
adding to Oj of water 5ij of the former and gij of the latter. If a patient 
be robust and plethoric, it is, in most cases, advisable to assist local treatment 
by cathartics,-sulphate of magnesia or the ordinary Seidlitz powder being 
prescribed. 
Secondary Breaking.-Imperfectly-treated fractures not infrequently 
induce so much discomfort as to warrant secondary breaks. As an illustration, 1048 
A SYSTEM OF ORAL SURGERY. 
the following case may be cited: T. H., an employ^ on the Camden and 
Amboy Railroad, received a double fracture of the inferior jaw by being in 
some way jammed between two cars,-one break being on the line separating 
the second and third molar teeth, the other, the line of the cuspis root of the 
same side. A treatment resorted to in a hospital to which he had been carried 
failed in retaining the intermediate part in place, so that, on uniting, the teeth 
lay flatwise, presenting the buccal as an articulating surface. 
Deciding on the propriety of an attempted correction, the bone was re- 
broken through the imperfectly-solidified callus, and the depressed portion, 
being raised into position, was retained by a silver splint,-this splint being 
made and applied as described and illustrated. (Fig. 803.) As a conse- 
quence of the injury inflicted, several pieces of the callus necrosed and came 
Fig. 803.-The Interdental Splint. 
away; but the daily injection of a much-diluted tincture of capsicum and 
myrrh resulted in such solidification of the parts in their new position as to 
permit, after a couple of months, of the disuse of the splint,-terminating in 
a cure most satisfactory to all concerned. 
Description.-The bone being rebroken, the fragment was raised into 
position, and while held by the tongue of the patient upon the inside and the 
fingers of an assistant upon the outside, an impression in wax of the whole 
lower arch was secured. From this mould a silver plate, C, was prepared,* 
which fitted accurately the lower arch when the disjoined piece was in position. 
A succeeding step secured a wax mould of the upper jaw, from which model 
* For manner of making see Prosthetic Dentistry ; also Obturators. FRACTURES OF THE MAXILLARY BONES. 
1049 
a second plate, H, was made. This plate, as seen, covers the side but not the 
front teeth; it covers as well the roof of the mouth. 
The two plates ready, a succeeding step placed them in position, exactly as 
seen in the diagram. The jaws being separated to an extent permitting of the 
convenient passage of food, relation was secured temporarily through the use 
of adhesive wax thrust against and between the plates on either side in the 
spaces existing between E G and D F. The plates thus related were lifted 
from the mouth and, being placed in a plaster investment, were soldered together 
at the seats of the wax application. Afterward cleaned by being dropped 
into a dilute sulphuric acid bath, the fire coat being thus removed, they were 
polished with pumice- and rotten-stone. The fracture was now again set and 
the piece put in position. The patient went at once about his business and in 
six weeks was well. This splint is the one referred to a few paragraphs back. 
To hold it in place, or rather to secure fixed relation of the jaws with it, the 
bandage already described and figured is to be used. 
Interdental Splints Invaluable and Reliable.-As a means of 
dressing in any complicated jaw fracture the interdental splint is as invalua- 
ble and reliable as it is simple of construction and easy of application. The 
screws passing between the teeth - shown in the cut-are seldom found 
necessary. A bandage, applied tightly enough, prevents all motion. It is to 
be understood that the edge of the plate seen below the superior incisor teeth 
is so shown in the cut with a view of exhibiting its relation with the palatal 
faces of these organs; when in place this edge rests upon the gum adjoining 
the necks of the teeth. 
Vulcanizable Rubber as a Material for Interdental Splints.- 
Interdental splints are now, in America at least, more frequently made of 
rubber than of metal; this presumably because of the easier working of that 
material. Metal, however, is, in the estimation of the author, most decidedly 
to have preference; gold to be used, if the patient be rich enough to bear the 
expense. Silver, when fire-gilded, is an admirable substitute. 
Fig. 804.-Dental Splint. 
Fig. 805.-Interdental Splint 
Gutta-Percha Splint.-Fig. 804 exhibits a splint made of gutta- 
percha, which is most simply done by warming base plate and moulding it over 
a cast secured from a wax impression obtained as has been described. Being 1050 
A SYSTEM OF ORAL SURGERY. 
hardened by the use of cold water, and trimmed, such a splint is prepared and 
applied in a little time. A represents alveoli accommodating the teeth. Fig. 
805, after model by Dr. Gunning, shows an interdental splint, made of vul- 
canized rubber, fitting both jaws. 
Vulcanizing a Rubber Splint.-Where more than ordinary fixation 
is required it is necessary to vulcanize. Rubber so prepared affords the hold- 
ing quality of metal and would equal it were it not for an objectionable bulk. 
(See Process of Vulcanizing.') 
An interdental splint of satisfactory character, and entirely general in 
application, is to be prepared and applied as follows: Make a curved tin chan- 
nel corresponding to any inferior jaw that may be selected. Upon the base 
of this first set and attach second channels made to correspond loosely with the 
molar regions of the superior jaw. Putting the three in place, attach them 
by means of wax, the jaws being separated to the width of a finger. Remove 
carefully from the mouth and solder. Make several of these to correspond 
reasonably with the varying curvatures of different arches. To apply, fill 
the channels with softened rubber base plate, set the fracture, and, placing 
the apparatus in correspondence with the arches, let the patient bite into the 
gum until the plates are reached. Instantly bandage to prevent movement, 
and, this accomplished, harden the material by cold water held in the mouth. 
This apparatus proves as satisfactory as it is seen to be simple. 
Angle's Manner of Fixation.-Three classes of cases into which 
Dr. Angle divides maxillary fractures, with illustrations given by him in each, 
enable his plan and appliances to be fully understood. 
Illustration in Class I.-N. P., a lady twenty-one years of age, was 
admitted to St. Anthony's Hospital suffering from simple fracture of the 
lower jaw extending through the symphysis, terminating in front between the 
central and lateral incisor teeth on the left side, as shown in Fig. 806. The 
treatment practised was as follows: 
The faces of the fractured bone were 
placed in their proper position and 
temporarily secured by lacing the 
teeth with silk ligatures. Next bands 
of very thin German silver were made 
to encircle and accurately fit the cus- 
pid teeth. A small tube of German 
silver, one-half inch in length, was 
soldered to each band and in exact 
alignment. A piece of wire accu- 
rately fitting the bore of these tubes, bent at right angles at one end, and 
having a screw cut upon the other end, was slipped through each tube and 
secured therein by adjusting a nut on the screw. The bands were cemented 
in position upon the teeth, as shown in the diagram, by means of oxy- 
phosphate cement. 
Fig. 806. FRACTURES OF THE MAXILLARY BONES. 
1051 
After the cement had become thoroughly set, the nut was tightened until 
the fractured ends of the bone were drawn snugly together. 
The appliance was worn without displacement or trouble for twenty-one 
days, when it was removed, the parts being firmly united. It is to be added 
that during the time the apparatus was in the mouth, so firmly was the 
jaw supported, the patient suffered little, if any, inconvenience. After the 
third day she partook regularly of her meals, using the teeth freely, but of 
course avoided over-hard particles of food. The appliance being removed, a 
careful impression of the jaw was taken, a model made, and the construction 
transferred to it with view of furnishing the illustration here shown. The 
lower part of the jaw is of course diagrammatic. 
The bands, tubes, wires, screws, and nuts used in the case described are some 
of the fixtures. known as the 11 Angle Regulating and Retaining Appliances," 
devised and employed for the purpose of correcting irregularities of the teeth. 
The set complete is shown in Fig. 807. The pieces may be made by any 
ingenious dentist, or procured from any dealer in dental goods. 
Fig. 807. 
Illustration in Class II.-The treatment for cases of the second 
class is to be understood from the description in the following instance: On 
July 4,1889, W. F., aged forty-five, was admitted to the Minneapolis City Hos- 
pital. A blow from a policeman's club had produced two simple fractures of 
the inferior maxilla. The first was an oblique break of the right side, begin- 
ning with the alveolus of the second bicuspis, extending downward and back- 
ward, involving the socket of the first molar, knocking out the second bicuspis, 
and greatly loosening the first molar. The second molar had been lost years 
before, while the third, as well as the remaining teeth, were much abraded 
and loosened by salivary calculus, thus making the application of the appli- 
ance described in Class I. impossible. The second lesion was situated on the 
opposite side high up in the ramus. Because of a swollen condition of the 
parts the exact line of fracture could not be detected, but the movement of 
the parts of the bone and the great pain occasioned thereby were unmistakable 1052 
A SYSTEM OF ORAL SURGERY. 
evidence of the breaks. The patient, as in all such cases, was unable to close 
the jaws. The parts on the right side were widely separated, the anterior piece 
being much depressed by reason of the contraction of the digastric muscle, 
while the posterior piece was firmly drawn up, the molar teeth occluding. 
The following is the treatment used: Bands were made to encircle all four 
of the cuspid teeth, they being the most firmly attached in their sockets. The 
fractured ends of the bone were placed in accurate apposition, the lower jaw 
being closed carefully. Shutting the lower upon the upper teeth required so 
great a force and occasioned so much pain that anaesthetizing the patient 
became necessary. Points on the bands for the necessary attachments being 
carefully noted, these bands were slipped off the teeth and little pipes (shown 
at D, Fig. 807) soldered at such points, after which the bands were cemented 
in their proper positions upon the teeth, and two small traction screw wires, 
the same as shown at B, Fig. 807, were slipped into the pipes. The jaws were 
closed and the nuts tightened on the screws, until the parts were drawn firmly 
together, and each tooth occupied its exact position in occluding with its fellow 
of the opposite jaw. Both fractures were then examined, the parts being 
found in proper apposition. 
The appearance presented 
is shown in Fig. 808. 
During an attack of 
coughing in the night fol- 
lowing, one of the bands 
was wrenched loose, but 
was replaced the next day 
without trouble. No fur- 
ther accident occurred. The 
patient readily took nour- 
ishment through the spaces 
between the teeth. The 
fractured jaw was firmly supported to exclusion of the least motion for twenty- 
two days, when the appliance was removed, showing excellent results. 
Illustration in Class III.-December 28, T. B. was admitted to 
the Dental Infirmary of the University of Minnesota, suffering from the 
effects of a blow received on the left side of the jaw from a cant-hook while 
working in a lumber camp in Wisconsin, which produced fracture of the jaw 
in two places. The first break was on the left side, beginning between the 
first and second bicuspids and extending downward and backward so far as to 
involve the lower part of the anterior root of the first molar. The second 
was on the right side directly through the angle of the jaw. These fract- 
ures had occurred thirty-two days previous to admission of the patient into 
the infirmary, during which time nothing had been done to reduce the dis- 
placements. He reported that he had called on a physician, who, supposing 
the trouble to be merely an abscessed tooth, had lanced the gum with view 
Fig. 808. FRACTURES OF THE MAXILLARY BONES. 
1053 
of reducing the swelling. Later, the man had called on a dentist in a neigh- 
boring town, who also failed to recognize the fracture, and who had extracted 
both bicuspids in the hope of giving relief. 
On examination, considerable swelling was found in the region of the injury 
on the left side. The patient was unable to close his mouth by reason of a 
piece of the fractured bone that was drawn down by the contraction of the 
depressor muscles. A false joint had also become established. The parts 
could be moved freely without causing pain. 
At the seat of fracture of the right side there was little or no displacement; 
swelling was also slight. The patient was anaesthetized. The ends of the 
bones were rubbed forcibly together with the view of breaking up the false 
attachments and stimulating activity in repair. 
The disjoined parts were next placed in a required apposition, and the 
mouth closed, great care being taken to articulate the teeth of the injured jaw 
in correct relation with those of the upper. 
The broken jaw was now firmly fixed in its 
corrected position after a manner similar to that 
described in Class II., only that the method was 
improved on by employing clasp-bands, as shown 
in Fig. 809. 
No cement was used, and, instead of the screws, small metallic buttons were 
soldered to the sides of the bands (as shown in the cut), around which were 
wrapped, in the form of the figure 8, fine binding wire as shown in Fig. 810. 
Four bands were made to encircle the four cuspid teeth. Those shown in 
the cut, on the molar teeth, were not used, but are here exhibited for the purpose 
Fig. 809. 
Fig. 810. 
of illustrating their use in cases that might occur. At the end of seventeen 
days, as Dr. Angle reports, the bands were removed and the patient dis- 
charged, the parts being firmly united. 1054 
A SYSTEM OF ORAL SURGERY. 
It may be urged, suggests Dr. Angle, as an argument against this method, 
that the teeth being closed and the jaws being firmly bound together, the 
patient would be unable to take sufficient nourishment. This, however, 
proves ill-founded, as it rarely happens that a patient is without some 
teeth missing, thereby leaving abundance of space for the passage of liquid 
foods; and even if all are sound and in position, it is recognized that 
there is plenty of space between them, particularly between the upper and 
lower incisors, and behind the molars, for taking all the food necessary. Of 
course in such rare cases much more time is required in taking such nour- 
ishment, but this obstacle is greatly compensated for, as I am led to esteem, 
by points of advantage in favor of the manner of dressing, such as cleanliness 
and comfort as comparison exists with bulky and awkward appliances. Third, 
reference is to be made to the extreme simplicity of the apparatus, this enabling 
any one with ordinary mechanical ability, when provided with a set of clamp- 
bands, to easily and quickly set and fix all ordinary cases of fracture. And 
last, the certainty of correct results; this, I think, furnishing sufficient reason 
for all who are interested in this branch of surgery to give the plan a trial. 
Class III., comprising fractures of edentulous jaws, are fortunately very 
rare. The method of treatment proposed by Dr. Angle is similar in principle 
to that already illustrated in Class I., only, in place of the teeth, small bone 
hooks are used, cavities suitable for their reception being drilled on each 
side of the fracture comparing in position to the original sockets of the teeth, 
or the same as if implanting teeth were intended; only the cavities thus made 
are not to be so large or deep. The holes are to be drilled obliquely to corre- 
spond to the course taken by the hooks. Practitioners familiar with Mal- 
gaigne's hooks as employed in fractures of the patella will appreciate the 
character of performance as proposed in treatment of this third class. 
FRACTURE OF HYOID BONE. 
A fracture of the hyoid bone, when in condition for surgical treatment, is 
generally resultant of a grasp and compression of the part by the hand of an 
antagonist in a quarrel. It is sometimes caused by a fall. Muscular spasm 
may also cause it. 
Diagnosis.-Where a neck is fat it may not be possible to distinguish 
the condition through touch, so that one can infer the existence of a fracture 
only by associate signs. These signs are, first and prominently, pain in 
moving the lower jaw and tongue. Second, a possible crepitus distinguish- 
able by the patient, and by the surgeon, when the act of swallowing is per- 
formed. If there be no associate injury,-an unlikely happening,-a diagnostic 
sign lies with the entire freedom from pain which associates with maintenance 
of absolute quiet in the part. A sense of suffocation, often present 
by reason of inflammatory sequelae that affect the larynx, is a grave sign. 
Ecchymosis shows itself always sooner or later in the overlying skin. FRACTURES OF THE MAXILLARY BONES. 
1055 
Secondary Accidents.-A horn of the bone may be driven into the 
larynx or other neighboring part, necessitating cutting down upon the part for 
its removal. Necrosis of a separated piece of the bone is a possible 
condition to be borne in mind: here abscess forms sooner or later. Removal 
of such a sequestrum is commonly wisely anticipated by an operation. 
Treatment.-This is likely to be very little apart from that which con- 
siders maintenance of quiet in the part and the use of antiphlogistics and 
sedatives. It will prove well to support the patient for the first few days by 
enemata, interdicting entirely swallowing or speaking. The head is to rest in 
its natural relation with the neck upon a pillow so arranged as to afford most 
comfort. No muscle of the bone serves to displacement except the middle 
pharyngeal constrictor, and this has motion only in the act of deglutition. 
After three or four days swallowing may be gradually practised. 
FRACTURES OF THE CARTILAGES OF THE TRACHEA AND 
LARYNX. 
Fractures of the trachea or larynx are accidents of rare event, owing to the 
resiliency of these parts, occurring, likely, only where by reason of age the 
parts have undergone a greater or lesser degree of ossification.* The larynx 
is the more common seat of fracture as the two parts are concerned, the pro- 
portion being nearly three to one. 
Causes.-Causes are the same as those of the hyoid bone. 
Diagnosis.-Commonly there is a sense of suffocation attended by ex- 
pectoration of bloody sputa. Emphysematous swelling of the neck and chest 
is apt to be a prominent sign, this particularly if a break of importance has 
been made in the continuity of the mucous lining of the tube. Dyspnoea is, 
perhaps, never absent. The tongue swells to an extent that not infrequently 
projects it from the mouth. Dyspnoea, as an immediate attendant of the 
accident, if unattended with hemorrhage, implies displacement of the broken 
part into the air-passage. Where it comes on later it is to be attributed to 
swelling or effusion. So serious is this accident that the fatal cases are in the 
proportion of eighty to one hundred. 
Treatment.-As with the foregoing condition, quiet, as absolute as 
possible, is to be maintained. Leeches or cups are to be used if inflammation 
supervene. Feeding is to be as much as possible for the first week by enemata. 
Where dyspnoea reaches the danger-point tracheotomy is to be em- 
ployed. The position of the patient's head upon the pillow is to be that 
which allows of easiest breathing. Where great excitability is present mor- 
phia is to be used freely subcutaneously. So important is tracheotomy 
in connection with fracture of the trachea that it is doubted by some that 
recovery has ever been made without it. 
* In contrast with this, Dr. William Hunt, in a paper published by him in the American 
Journal of Medical Sciences for April, 1886, records twenty-nine cases, five of which 
occurred in childhood, and fifteen in persons under fifty years of age. 1056 
A SYSTEM OF ORAL SUROERY. 
FRACTURES OF SKULL AND TREPHINING. 
The operation of cutting a section out of the skull, or trephining, as it is 
technically called, forces itself at times as a necessity demanding speedy atten- 
tion on the part of a surgeon. The requirement, in cases of accident, lies 
with the removal of a portion of bone that has been driven upon the brain. 
The operation is also done where extravasations of blood or pus exist and 
where cerebral tumors have developed. It is also practised in treatment 
of epilepsy where circumstances point to a brain injury of limited area and 
this area is fully recognizable. Punctured fractures also demand this 
operation, as shown in Fig. 811, where a ball has perforated the bone and re- 
quires to be removed, or where, as in Fig. 812, a foreign body of other kind, 
Fig. 812. 
Fig. 813, 
Fro. 811.-Punctured 
Bullet-Wound of 
Skull. 
as, in this instance, an arrow (Fig. 813) has half cut its way through the 
bone, doing injury to underlying parts that will, more than likely, require 
uncovering for purposes of treatment. 
Trephines.-Trephines are of different sizes. Figs. 814 and 815 ex- 
hibit a large and a small one of the conical variety. Another form is cylinder- 
shaped. 
Trephining.-The operation of trephining is performed by laying the 
circle of the instrument upon the part to be cut, which part is to be the solid 
portion of the bone in immediate relation with a depressed piece to be elevated, 
or, in case of simply opening upon the brain, it is the seat selected for making 
the exposure. The trephine thus located, fixation is secured by pushing 
down the pointed blade, shown in the cuts, and fastening it by means of the 
screw seen upon the shank. This blade insures the saw against slipping. As 
soon, however, as a circular groove is cut, the blade is retracted. Trephining, 
from this point, is simply a performance of boring by means of a cir- 
cular-saw. To guard against accident, the instrument, as it cuts toward the FRACTURES OF THE MAXILLARY BONES. 
1057 
brain, is frequently removed and the depth attained by it is measured by use 
of a toothpick. It is necessary to use a brush for cleaning away the bone 
dust. The point of the toothpick enables the operator to know when the 
dura mater has been reached. Fig. 816 shows the performance in progress. 
Fig. 816.-Operation of Trephining. 
Figs. 814, 815.-Conical Trephines 
Here, as seen, there has first been made a flap, which flap includes all 
the covering of the bone except the periosteum. When the seat of selection 
has been made and the flap raised, a knife is swept around the trephine and, 
by means of a raspatory, the membrane is scraped away. The dark circle of 
the exposure in the cut represents a portion of bone that is depressed, and to 
elevate which is the purpose of the operation. The trephine, as seen, is 
fixed partly upon the solid bone, the intention being to secure a space, 
with a solid abutment, that will permit introduction beneath the depressed bone 
of an elevator and the use of this as a lever for prying the bone into position. 
Dura Mater.-The dura mater is never to be opened except from neces- 
sity. In treatment of depressed fractures this necessity is not likely ever to 
exist. 
Cranial Topography.-It is desirable to avoid, in the operation of 
trephining, the positions of the longitudinal and lateral sinuses and the torcular 
Herophili. 
Use of Surgical Engine.-The surgical engine as a means of opera- 
tion in conditions here considered does its work with speed and certainty. A 
trephine, to be used with a mandrel, has been devised by Dr. John Roberts, 
but the writer finds himself entirely at home with the performance in the use 
of the ordinary bur. In cutting down to the meninges after this manner it is 
of course necessary to dress very delicately and carefully the borders of the 
bone, but this is a matter of simple performance. A circular bur, cutting by 1058 
A SYSTEM OF ORAL SURGERY. 
its face, used by the author in removing the os coccyx, accomplishes the end 
perfectly. In absence of such bur a curved chisel may be used. Fig. 818 
shows an elevator, and Fig. 819 a modified form of Hey's saw, these being 
instruments that belong to the ordinary trephining case, and found at times of 
Fig. 818.-Elevator. 
Fig. 819.-Hey's Saw. 
Fig. 817. 
A button of bone taken from 
the head of an epileptic, show- 
ing comminution of the inter- 
nal table; removal followed by 
cure. (After Agnew.) 
great use, the first to lift the depressed bone, the other to cut away little 
points. Of course where, as in hospital practice, the surgical engine is at 
command, the saw here shown would be replaced by the circular instrument 
used with the engine. (See Surgical Engine and its Appliances.') CHAPTER LXIII. 
EXSECTIONS OF THE MAXILLARY BONES. 
The history of experimental surgery on the bones of the face constitutes 
one of the most interesting of the chapters in surgery. The formation about 
and within these bones of such tumors as seemed to make desirable their 
removal, necessarily directed, from a comparatively early period, the attention 
of surgeons to the feasibility, propriety, and promises of such operations. 
Observation of Accidents.-It is not at all unreasonable to infer that 
surgery gained its first lesson in this direction by observing, in the results of 
accidents, how extensive could be an injury done to the parts without fatal, or, 
indeed, even threatening consequences. 
First and Succeeding Operations.-As early as 1693, Acoluthus, 
a surgeon of Breslau, attempted the removal of a portion of the upper jaw 
for a tumor, in which operation he succeeded very satisfactorily. Jourdan, 
according to his translator, removed, at various times during his century, por- 
tions of the jaw. Dr. Ephraim McDowell, of Kentucky, the originator of 
ovariotomy, did in his time a number of bold operations in this direction. To 
Dr. Jameson, an American surgeon, belongs the credit, however, of having 
made the first complete exsection, or removal of the upper jaw, this having 
been done in 1820, although to Lizars, of Edinburgh, belongs the higher 
credit of having first suggested the possibility and advantage of the operation. 
In 1824, Dr. David Rodgers, of New York, exsected both superior maxillae. 
Later, this performance was repeated by Lizars, and in the same year by 
Gensoul, of France. After this the operation may be considered as having 
become commonly recognized, surgeons of ability performing the various 
sections throughout England and France, and especially in the United States. 
Improvement as to Operating.-While the operation of exsection 
has been frequently performed, it cannot but surprise the surgeon of to-day 
to notice how slowly its lessons were learned. At present it is practised with 
little preliminary caution, being esteemed a matter that is to be attempted with 
trifling danger to the patient, and even without much damage to the appearance. 
Formerly, and, indeed, not very far back, it was considered necessary to ligate 
the primitive carotid artery as a preliminary step; and when, as experience 
advanced, this was seen not to be a necessity, the actual cauterants were held 
in readiness,-a means of controlling the hemorrhage which, much to the 
detriment of a happy cure, obtains, unfortunately, in some regions even to the 
present day. 
1059 1060 
A SYSTEM OF ORAL SURGERY. 
Meaning of Ill Results.-Exsections of the maxillary bones are prac- 
tised for various diseases, the principal of which are the malignant tumors. 
That such exsections are so often reported as resulting unfavorably, has ex- 
planation, not in shock, or in local injury done, but in the fact that the disease 
for which the operations have been performed is in itself fatal. 
Nature's Correction of Deformity.-In looking, after an interval 
of months, and, in cases, of years, at individuals on whose jaws the author 
has personally performed exsections, he has been astonished at the correction, 
on the part of nature, of deformity. The little German boy, alluded to in 
the chapter on Necrosis, as having lost the left half of the inferior maxilla, 
without at the time any reproduction occurring, looks to-day as though no such 
loss had occurred; his face is exactly as it was before the operation, and, so 
far as may be judged, the ability to masticate, allowing for the loss of the 
teeth on that side, is about as good as ever. This, however, is an uncommon 
case, the result, without doubt, of the youth of the patient. A young lady 
allowed herself to be exhibited by the author to a few gentlemen during a 
meeting of the dental profession of New England, held at Providence (1883), 
from whose person he had removed, a year before, the right superior maxilla 
in its entirety. A denture made for the case by her dentist, Dr. Buckland, 
of Woonsocket, which differed little from an ordinary tooth-plate, corrected 
the loss so absolutely as appearance was concerned, that every external evidence 
of an operation was absent. The bone had been removed from the inside. 
Importance of Periosteum.-Ollier, by his experiments upon the 
osteogenetic properties of the periosteum, has done good service to oral sur- 
gery. It is now a common practice in exsections to spare and save all this 
tissue possible. In the chapter on Necrosis the author has alluded to his own 
success in this direction, having replaced entirely (now several times), with 
the exception of the alveolar process and teeth, the whole of the lower jaw; 
the process adopted being that of of enucleation. 
Periosteum not to be saved if Unhealthy.-It is not to be over- 
looked, however, that the seeds of a disease, so to speak, may be left in a part 
by an attempted preservation of periosteal tissue. This fact is always, in all 
classes of exsection, to be borne prominently in mind: periosteal 
tissue is not to be saved unless healthy. 
Preliminary to Exsection.-To make a complete exsection of either 
maxilla implies, ordinarily, a preliminary uncovering of the affected bone. 
The incisions to such ends are necessarily various, being influenced by the 
condition of the parts beneath. 
Uncovering the Bone not always Necessary.-Exposure is not, 
however, always necessary. Professor Horner, as exhibited in Plate VIII., 
has removed the upper jaw of the left side without preliminary incision ; and 
in several favorable cases the writer has himself succeeded, even without diffi- 
culty, in doing the same thing. In the case of tumors of magnitude sub- 
integumental operations are not, however, to be commended. A wound, or EXSECTIONS OF THE MAXILLAE F BONES. 
1061 
incision, made to expose such tumors, may be united by the first intention, 
leaving little or no scar, while certainly the exposure obtained through such 
incision compensates by the liberty and rapidity of movement allowed in the 
subsequent steps of an operation. 
Horner's Operation.-Subfig. 1, Plate VIII., exhibits the mouth of a 
patient of the late Dr. Horner, immediately after the removal of the superior 
maxillary bone without external incision. Subfig. 2 is a side view of the bone 
removed, and Subfig. 3 is the likeness of the patient taken three years after the 
exsection. The operation, as practised by Dr. Horner, is thus described 
by his son-in-law, Professor Henry Smith : Having determined to avoid cutting 
through the cheek, as commonly practised, the patient was seated in a chair, 
with his head well supported, and partially etherized. The assistant, hold- 
ing the man's head, then raised the angle of the mouth on the left side,* 
and held it widely open, while the upper lip and cheek were dissected from 
the superior maxilla as far back as possible, in a line parallel with the superior 
margin of the buccinator muscle. The two incisor teeth on the left side being 
next drawn, the corresponding alveoli were cut through in the middle line by 
a narrow saw, which worked its way from the mouth into the left nostril; 
next a pair of strong hawk-bill scissors, such as are used by gardeners for 
lopping off twigs, took out the two vacated alveoli at a clip. 
A thin, flat, well-tempered knife, with a strong, round handle, was 
now stuck through the roof of the mouth into the nose, at the junction of the 
palatine processes of the palate and superior maxillary bones (posterior middle 
palate suture), so as to cut forward and separate the maxillary bones from 
each other in the middle, when the narrow saw was again used to cut through 
the root of the nasal process of the maxillary bone, and strong scissors, curved 
on the flat side, made to cut through the orbitar plate at its margin, the inci- 
sion being carried back to the pterygoid process of the sphenoid, around and 
below the malar bone. 
The base of the soft palate being next separated by a short triangular 
knife, curved on the flat side, so as to leave the part associated with the palate 
bone, a few touches of the knife freed the remaining attachments. 
The pterygoid process, malar bone, and the orbitar plate of the maxilla 
were not disturbed. The tumor,-which was a scirrhoma,-besides its bony 
connection, was also attached to the posterior part of the cheek and to the 
external pterygoid muscle. The gouge and scissors, however, sufficed to re- 
move every part that could be detached. 
The bleeding was profuse, especially from what was believed to be the 
posterior palatine artery, but the vessel was readily secured by means of a 
ligature and Physick's needle. A few other ligatures, together with the use 
of charpie, arrested the remainder of the hemorrhage. 
Ordinary Operation for Removal of Superior Maxilla.-The 
* The figure, by an error, is made to show the operation, on the right side. 1062 
A SYSTEM OF ORAL SURGERY. 
ordinary operation for the removal of the superior maxillary bone may now be 
described in detail.* 
If the disease for which such an operation is to be performed be a tumor 
of moderate dimensions, say scirrhus, as in Professor Horner's case,-which 
tumor seldom attains to large size,-the uncovering of the part is effected by 
dividing the superior lip in the middle line, carrying the incision upward 
along the base of the ala of the diseased side to the inner canthus, and from 
this outwardly by a curved line with its convexity looking downward made 
midway of the lower eyelid. The flap thus secured, which is triangular, is 
dissected off as far as the malo-maxillary articulation. Next remove the 
central teeth, or, it may be, that extraction of one is sufficient, and, with a 
scalpel, make an incision along the middle line of the hard palate as far back 
as the palato-maxillary articulation. Make next, at right angles with this 
Fig. 820.-Excision of the Upper Maxilla. Instruments applied to 
Parts requiring Division. 
incision, a second, which is to extend to the tuberosity of the bone; the cut to 
be as nearly as possible on the line of the articulation named. Examining at 
this stage a skull,-which it is never amiss to have by,f-take up a Hey or a 
* Double Tracheal Canula.-An arrangement in the shape of a double tracheal canula 
has been introduced into German surgery, and has received much encomium; this, of course, 
necessitates the preliminary operation of tracheotomy. The canula being put in place, the 
breathing of the patient is said to be in no way interfered with by the hemorrhage, thus 
permitting the exsection to be made without that haste generally found so necessary. A 
later design of tube enters the trachea from the mouth. The author uses neither. 
f In a review of the first edition of this book, " Diseases and Surgery of the Mouth, 
Jaws, and Associate Parts," fault was found by a critic with this suggestion. To some, 
such reminders may not be necessary; the author, however, has always found them ser- 
viceable as immediate hints for delicate and accurate manipulations. With a patient 
etherized, there can be no objection to the presence of such models. EXSECTIONS OF THE MAXILLARY BONES. 
1063 
metacarpal saw, and, with delicacy and accuracy, cut across the nasal process, 
leaving, if possible, the orbital plate. Next, with the same saw, cut across 
the maxillo-malar articulation; this completes the two upper sections. The 
third, the intermaxillary, is quickly effected by introducing within the nostril 
one blade of the large cutting forceps, the other being placed on the line of 
the articulation within the mouth, as far back as the point of union with the 
palate bone; the incision is now made, and the separation, as cutting is con- 
cerned, is completed. Take now a pair of Lion forceps, and seizing the bone, 
twist it from its bed. Fig. 820 shows an uncovered superior maxilla, with 
forceps and saw in the act of making separations. 
Use of Circular-Saws.-In place of the instruments shown in the cut 
the author now employs, in nearly all his cases, a circular-saw, revolved by 
the surgical engine. This latter means, while accomplishing the object neither 
more effectually nor quickly, is yet attended by such diminution in 
shock, and of injury to associated parts, that no hesitation exists in 
according decided preference to it. 
Attention required by Hemorrhage.-Immediately succeeding the 
removal of the bone is a required attention to the hemorrhage. It may be 
that twenty arteries will jet their blood into the face of the operator, or, on 
the contrary, only two or three may require artificial means for their control. 
One need not be over-hasty or timid about this bleeding. Neither is he to 
be over-easy or too confident. The circumstances pertaining to the arresta- 
tion of such hemorrhage are most influenced by the nature of a tumor occu- 
pying the bone; a sarcoma being of great vascular relation, a fibroma only 
very moderately so. The author, depending first, and most prominently, on 
ligation, resorts at once, on failure of this, to packing. 
Packing for Control of Hemorrhage.-Packing has the double sig- 
nification of stanching the bleeding and affording support to the overlying in- 
tegument which is to rest upon it. Using first a square, this is to be fully 
saturated with phenol-sodique, and may, if deemed necessary, be covered with 
iodoform and tannic acid combined in equal parts, when it is laid in the bot- 
tom of the wound. Next a long strip of linen is soaked with oil, and the 
cavity is solidly filled; the end of the strip being so placed as to be easily 
found when removal is demanded. 
Objection to Use of Sponge.-Where a hemorrhage is threatening, 
resort to the use of sponge as a packing may be found compulsory. 
It is certainly a means to be quoted as absolutely reliable. Ob- 
jection to its use exists, however, in the difficulty of getting it away. It 
seems to become part of the location in which it is packed. If not removed 
in a few days its odor is unbearably offensive. If pulled away fatal 
secondary bleeding may result. It is to be pronounced the best and yet 
the worst of packing. The writer, where compelled to its use, gets it away by 
use of curved scissors, cutting off piece after piece. Suppuration does 
not loosen sponge as it does other packing material, the reason being 1064 
A SYSTEM OF ORAL SURGERY. 
that granulations grow into the meshes. Nowhere in the range of surgical 
practice is the employment of germicidal disinfectants so imperative as here. 
Professor La Place uses, and warmly recommends, a strip of cheese-cloth, which 
is first to be rolled in iodoform. An improvement would seem to be with using 
the antiseptic on the initial extremity and soaking the remainder in oil. 
The hemorrhage controlled and sub-integumental support considered, the flap 
is laid carefully into place and closely, but not tightly, approximated by a 
sufficient number of stitches of the interrupted suture. It is generally the 
best plan to first put a pin or stitch in the lip, thus insuring correct relation 
at that most important point. 
Phenol-Sodique as a Dressing.-As a dressing, in this, as in all 
his operations, the author uses phenol-sodique freely, cloths kept wet with it 
overlying the part. Should high inflammation supervene, the following com- 
bination is to be employed: 
R Plumbi acetatis, ^ij > 
Tincturae opii, ^ij; 
Aquae, Oj. M. 
Pad and Strip not to be allowed to Dry.-Concerning the pad 
and strip inside, it is found the best practice not to allow them to dry from 
the time of their first introduction. This is to be prevented by repeated 
syringing with phenol-sodique and water, half and half. 
Removal of Stitches.-Stitches used in approximating the external 
wound are to be removed as soon as possible: three or four days generally 
allows of such removal. It is well to cut them cautiously, taking away inter- 
mediate ones. 
Withdrawal of Packing.-The withdrawal of the packing is to be 
effected leisurely; indeed, the idea is to consider it as a tent, to be thrown 
out as the wound granulates and fills up below. The plan of the author is to 
withdraw a very little portion each day, cutting off the part extracted by 
means of sharp scissors. 
Many cases occur where the external incision here suggested might not be 
the best one, and, indeed, where it might not be sufficient to uncover the dis- 
ease. Certain surgeons prefer to expose the bone by an incision, commencing 
at the angle of the mouth, and passing obliquely in front of the Stenonian 
duct to the centre of the malar bone, throwing thus the flap upward and 
inward from below. Another mode is to use both these incisions upon the 
same subject,-a necessary proceeding, in many cases, where the tumor is large. 
Fergusson's Operation.-Sir William Fergusson, who during his 
years of practice was particularly successful in oral surgery, in remarks after 
an operation for the removal of disease affecting the alveolus and antrum, 
made some important and interesting suggestions, having reference generally 
to the exposure of such parts prior to the removal of the actual disease. He 
said that formerly, and even now, some surgeons divided the integument of EXSECTIONS OF THE MAXILLARY BONES. 
1065 
the cheek, lip, etc., trying to get at the disease from various points: that one 
method he pursued with advantage (as in a case of removal of malignant dis- 
ease of the upper jaw) was to divide the upper lip in the median line, and 
then by carrying the incision on one or both sides, as the circumstances of 
the case required it, into the nose, to dissect back the upper lip, ala nasi, and 
cheek, and thus expose the parts freely, avoid the deformity of scar on the 
cheek, or, to use his own words, 11 to leave as few marks of the surgeon's 
doings on the face as possible." In a case before him at the time the remarks 
were made,-a young woman,-he was able to remove the disease without in- 
terfering with the lip. It affected the alveolar ridge of the right side, ex- 
tending from the second incisor to the second molar, and was continued into 
the antrum; but whether it first arose in the sinus, or in the alveolus, he did 
not know. Mr. Fergusson attributed the success attending this 
method of removal, in a great measure, to the instrument he used,-viz., 
a pair of clipping forceps. He first clipped away the alveolar ridge, and then 
attacked the portion of disease situated in the neighborhood; by this means 
freely laying open the antrum and nostril. 
He alluded to a case in which Mr. Bow- 
man successfully removed a large tumor 
from the cavity extending into the mouth, 
without dividing the lips. 
Such a mode of uncovering a tumor of 
limited size is admirable: the section will 
be found to make a large exposure, but the 
scar left is scarcely to be remarked. 
Operation for Removal of both 
Superior Maxillae.-It has never fallen 
to the lot of the author to exsect, or to see 
removed, both maxillary bones at one opera- 
tion. Several such performances are, how- 
ever, on record ; and from among them may 
be selected that of Heyfelder, as being the 
one most practicable and easy of accom- 
plishment. 
Heyfelder's Operation for Removal of both Superior Max- 
illae.-The patient is to be seated in a chair, with his head supported by an 
assistant, or, better, he may lie down. An incision is made on each side of 
the face, from the external angle of the eye to the labial commissure; the in- 
cluded parts are now reflected upward toward the forehead until the infra- 
orbital ridges are exposed. This uncovers the whole of both bones. The 
chain-saw (see Fig. 830) is now passed through the spheno-maxillary 
fissures, the malar bones are divided, the maxillae separated from the ossa nasi, 
and the vomer and thinner bones are cut with strong scissors. These steps 
complete the separation, when the bones are to be pried from the cavities with 
Fig. 821.-Lion Forceps. 1066 
A SYSTEM OF ORAL SURGERY. 
elevators or twisted away with the lion forceps of Liston. The result of an 
operation thus performed by the deviser himself is described as follows: Very 
little blood was lost, torsion and compression sufficing to arrest the hemor- 
rhage. Two hours afterward the edges of the wound, from the angles of 
the eyes to the corners of the mouth, were united by twenty-six stitches of 
the interrupted suture; cold lotions were applied: there was no reaction or 
swelling, and the patient could swallow water and broth. Four days subse- 
Fig. 822.-Cutting-Bone Scissors. 
quently the wound had nearly healed by the first intention, and in six weeks 
the patient was exhibited to the Medical Society of Erlachen. At this time 
there was no deformity of the features: a fissure, thirteen lines long and 
three wide, was seen along the median line of his mouth; the soft palate and 
uvula were in their natural place; deglutition was free; the nose had assumed 
its original form and direction. The face, which, before the operation, was 
like that of a monkey, again possessed a human expression; a firm and solid 
tissue replacing the extirpated parts. 
Tumors back of the Maxillae-Osteoplastic Section.-For 
the removal of a class of tumors not otherwise removable, having origin back 
of the superior maxilla, the means known as the osteoplastic section of the 
jaw is employed. This operation consists in detaching the bone from 
its relations, except at one side, and then forcing it in the direction of the 
attached part,-that is, turning it out of place. The tumor is removed, and, 
after controlling the hemorrhage, the jaw is replaced. Langenbeck, the 
deviser of the manipulations, after exposing the bone, as in the ordinary per- 
formance, passes the saw through the maxillo-malar articulation, along the 
orbital angle, and then without further section turns, if possible, the bone 
toward the mesian aspect; if this may not be done, he then makes section of 
the palatine raph6. 
Cheever's Modification of Langenbeck's Operation.-As a 
modification of Langenbeck's operation, Dr. Cheever, a Boston surgeon, 
separates the nasal and malar attachments, leaving in relation the palatine, 
thus throwing the bone downward. EXSECTIONS OF THE MAXILLARY BONES. 
1067 
Nasal and Naso-pharyngeal Polypi.-In the removal of large 
and threatening nasal and naso-pharyngeal polypi, osteoplastic operations of 
the most severe character find commendation in the greater risk they are 
designed to avoid. 
Getting at Tumors situated at Base of Skull by splitting 
Soft Palate.-A mode of getting at such tumors, when they spring from 
the spheno-occipital base, and one which has now been practised by the writer 
on a number of occasions, consists in splitting the soft palate, and by a ligature 
passed through the apex of either flap drawing the veil aside. 
Ollier's Operation.-Still another mode, one used by Ollier, applying 
more particularly where tumors are situated well back in the nares, consists in 
making a U-incision over the bridge and along the sides of the nose, having 
the apex looking toward the forehead; the flap, which is the nose, is now 
turned downward. Should space enough for the manipulations needed be not 
thus obtained, Ollier uncovers by a second incision the maxillae, and saws away 
such portions of the bones as may be found necessary. (See Polypi.) 
Figs. 6, 7, and 8, Plate VIII., exhibit various steps in section and removal 
of the inferior maxilla. 
Complete section of the lower jaw is one of the most disfiguring and com- 
fort-destroying operations that is practised on the living being, and is never 
to be performed without the existence of a well-recognized or proven 
necessity. Section of the alveolar process is not a difficult matter, and is 
generally easily accomplished without external wound, the lips being held out 
of the way by such a mouth-stretcher as is used in the performance of dental 
operations. 
Keeping the Mouth Open.-Fig. 823 shows a form of mouth-stretcher 
commonly employed. A second form, one devised by Dr. Goodwillie, is shown 
in Fig. 824. This latter instrument takes up less room, and on that account 
is, in many cases, to have preference over the former. Quite as good as any 
is the common retractor found in every surgeon's operating-case. Still another, 
and a most excellent one, is known as Doyle's. 
Section of the Lip.-In instances where section of the lip may be 
thought desirable, as when the practitioner, from inexperience, is not able to 
accomplish ablation without such uncovering, various cuts are proposed. These 
are to be fully appreciated by the studies presented. Subfig. 8, Plate VIII., 
represents exposure of the mental portion of the bone. The flaps, 1, 2, are 
made by a single vertical incision through the median line of the lower lip, 
crossed by a second at right angles at the base of the jaw, extending on either 
side, laterally, as far as the bone is required to be removed. 
Exposure of Left Half of Lower Jaw.-Subfig. 7 represents 
an exposure of the whole left half of the jaw. To accomplish this, make a 
first incision in the median line to the under border of the bone. From this 
EXSECTION OF INFERIOR MAXILLA. 1068 
A SYSTEM OF ORAL SURGERY. 
carry a second under the jaw-although along it-to the temporo-maxillary 
articulation. Dissect now the flap upward. In the horizontal cut here made 
it will be perceived that the facial artery is divided; this is a large vessel, and 
Fig. 828.-Mouth-Stretcher applied. 
requires a ligature. It will be found the better practice to tie both ends 
before proceeding to the operation upon the bone. The coronary artery, cut 
in the vertical incision, will often compel a ligature. 
Fig. 824. 
Exposure in full of Body of Jaw.-Subfig. 6 exhibits an exposure 
of the whole body of the bone. This is accomplished, as seen in the drawing, 
by a simple horizontal incision along the base of the jaw, being carried from 
angle to angle, and the flap, including the mouth entire, thrown up ; or it may 
be secured by joining the horizontal to a vertical incision made from the angle 
of the mouth; or, as in Subfig. 8, by the median, vertical, and horizontal in- Hate VIII 
Ulman & Sons EXSECTIONS OF THE MAXILLARY BONES. 
1069 
cisions. These sections understood, any required modification will suggest 
itself. 
Barton's Operation.-Subfigs. 4, 5, and 6 represent an operation prac- 
tised by Dr. J. Rhea Barton: Subfig. 4 exhibits the tumor, which is seen to 
be of great bulk, being described as having complete possession of the mouth, 
forcing the tongue into the pharynx, and stretching the jaws widely apart. 
It also rose up outside the superior maxillary bone, protruding the lips, cheek, 
and neck on the left side. 
Finding, by examination, that the base of the bone might be left with promise, 
Dr. Barton made the exsection as exhibited by the lines in Subfig. 5. This 
was accomplished by sawing horizontally from without inward, commencing 
at the middle line below the canal, and extending the section bilaterally. 
The removal of the bone, in this particular operation, gave no hemorrhage 
that required attention. The flaps being replaced and stitched, the patient 
was well in a month. 
Dupuytren's Operation.-Complete section of the jaw, as exhibited 
in Subfig. 8, after the practice of Dupuytren and many successors, destroys 
forever the articulation of the jaws, and interferes not only with mastication, 
but seriously with deglutition and speech. Exposing the bone as directed, 
the section is most easily made with either the Hey, metacarpal, chain-, or 
circular-saw. Before, however, shaving from the bone its inner attachments, 
a loop of waxed silk, or silver wire, is to be passed through the tip of the 
tongue, that this organ may be prevented from being drawn back into the 
pharynx by the hyo-glossi muscles. 
Removal of One-Half Maxilla.-Subfig. 7 exhibits the removal of 
one-half the maxilla. Exposing the bone as directed, extract one or more of the 
centre teeth ; next, from without inward, saw through the bone, or, if preferred, 
use a chain-saw, carrying it around the part by the aid of a curved needle. 
Catching now the bone in the grasp of the forceps, or using the fingers, 
detach the inner soft parts, turning it outward and downward. Arriving, in 
the dissection, at the coronoid process, the temporal tendon is to be detached 
by a chisel-shaped knife, care being taken not to wound the maxillary artery 
or internal carotid. The process freed, the condyle can be twisted from its 
ligaments, or, better still, twisted and at the same time cut away. This opera- 
tion, apparently so formidable, the author has succeeded in doing without 
external incision. With the section of the soft parts, as represented in the 
figure, it is not nearly so difficult as might be supposed. A diseased bone is 
not commonly more troublesome to disarticulate than is a sound one. 
History of Maxillary Resections.-Professor Smith, in his " System 
of Surgery," gives the credit to Dr. George McClellan of having been the first 
to attempt more than a limited section of the inferior maxilla,-this surgeon, 
in 1823, having removed all the parts anterior to the angles. In this, how- 
ever, he was preceded by Deadrick, of Tennessee, who, in 1812, made an 
exsection which extended from the symphysis to the angle. Professor Mott, 1070 
A SYSTEM OF ORAL SURGERY. 
of New York, also made an operation similar to Deadrick's, in 1821. Dr. 
Ackley, of Cleveland, Ohio, is reported as having, in 1850, removed the bone 
entire. In Europe, priority of the operation performed first by Deadrick is 
awarded to Dupuytren. Mott, according to Professor Smith, disarticulated 
the bone,-Deadrick and Dupuytren did not. Professor Mott thought it 
necessary to ligate the primitive carotid artery a few days before making 
his exsection,-a step long since proved to be uncalled for. 
Deadrick's Operation.-The performance of Dr. Deadrick, deservedly 
famous for its priority, was done on the person of a lad fourteen years of age. 
The operation was for the removal of a cartilaginous tumor on the left side 
of the jaw, which tumor filled up nearly the whole of the mouth, causing the 
greatest difficulty in swallowing, and, at times, even in breathing. To accom- 
plish his exsection, Dr. Deadrick commenced an incision under the zygomatic 
process, and carried it across the tumor, downward and forward, to nearly an 
inch beyond the middle of the chin. From the centre of this first incision, 
and consequently at right angles with it, a cut was extended a short distance 
upon the neck; the flaps thus secured were dissected from the diseased mass, 
and the bone next sawed off at the angle and symphysis. The flaps were laid 
back in the usual way, the boy making a speedy recovery. 
Illustrative Operation.-The author's manner of exposing the lower 
jaw and removing sections from it will be understood by reference to the 
illustrations given. 
Case I.-Operation in this case was required for a cysto-sarcoma which 
extended from the first molar tooth of the left side to the first bicuspis of the 
Fig. 825. 
Fig. 826. 
right. Patient, a young lady, seventeen years of age. Tumor had been 
twice removed by internal section, quickly recurring in both instances. 
An exsection from which the lady quickly recovered, and which leaves her 
to-day (thirteen years having passed) without disfigurement of any kind, was EXSECTIONS OF THE MAXILLARY BONES. 
1071 
done as follows: An incision, commenced at the free border of the lip, was 
carried directly in the vertical line until it passed beneath the chin. Next 
the neck tissue was drawn upward until it rested upon the jaw; it was then 
incised outwardly upon either side, as shown in the cut. The bone thus ex- 
posed was sawn with great delicacy from side to side, a rim being left to pre- 
serve the convexity of the chin. The tumor removed, a succeeding step 
replaced the soft parts and stitched them in position. On completion of the 
cure, which was very rapid, an artificial substitute for the lost teeth and por- 
tion of jaw removed was made by her dentist, Dr. Gilmore, which, together 
with the immediate union of the lip wound, have placed the patient in as 
good a position, as appearance is concerned, as before the operation. 
Illustrative Operation.-Fig. 827 exhibits an operation performed 
now many times by the author both before the class of the Philadelphia Hos- 
Fig. 827. 
pital of Oral Surgery and in private practice. As is seen, the instrument used 
is a circular-saw revolved by an engine. The removal of bone after a manner 
that retains the continuity, consequently preserves the contour of the face, is 
understood by observing the dotted line. 
The manner of making a section of the lower jaw, as here shown, is one 
always to be selected when circumstances permit. The circular-saw is not, of 
course, a necessity for accomplishment of the performance, but it is a help 
only to be appreciated by a surgeon familiar with its use. In the absence 
of an engine, Hey's saw is to be used. An exsection thus made leaves no 
deformity. 
Fig. 828, taken from the practice of the writer, shows the use of engine 
and saw used on front of lower jaw. 
Fig. 829, shows manner of applying circular-saw in removal of small epulic 
growths. The diagrams explain themselves. 1072 
A SYSTEM OF ORAL SURGERY. 
Obstruction by Undeveloped Teeth.-In doing operations upon 
the jaw-bones consideration is demanded for any undeveloped teeth that may 
happen to be present. To cut through a tooth with the Hey saw is im- 
possible. It is difficult, and in cases 
cannot be done where the circular 
instrument and engine are used. 
Caution is to be observed as refer- 
ence is had to making the horizontal 
cut as near the base of the jaw 
as safety permits. 
Fig. 828. 
Fig. 829. 
Chain-Saw, Use of.-The chain-saw has long been in use where the 
purpose is to remove a complete section of the lower jaw. Fig. 830 shows 
such a saw with its handles attached. To use this chain one of the handles 
is taken off, and attachment is made to an eyed 
probe, which, having had a way made for it by a 
bistoury, is carried about the inside of the jaw and 
pulls the chain after it. Reattachment of the handle 
affords the surgeon capability to cut through the 
bone. An idea of the manner of cutting is afforded 
by Fig. 831. 
Surgical Engine.-A surgical engine differs 
from the instrument used in dentistry proper princi- 
pally as power is concerned. The invention is by 
Wm. G. A. Bonwill, D.D.S., and the introducing 
of it into general surgical practice is claimed with 
much satisfaction by the writer. 
The reader, by referring to the cut (Fig. 832), 
will obtain correct understanding of the apparatus, 
and of the tools used with it. While a dental 
engine is worked with the foot, or by an electric, steam, or water motor, and 
possesses but a single driving-wheel, the surgical machine is driven by means 
of a hand-crank, and is intensified in motion by the addition of a cog adjunct, 
or it may receive its motive power from a street electric wire. The shaft of 
Fig. 830.-Chain-Saw. EXSECTIONS OF THE MAXILLARY BONES. 
1073 
Fig. 831.-Chain-Saw in Use. 
Fig. 832.-Surgical Engine and Appliances. 1074 
A SYSTEM OF ORAL SURGERY. 
the latter is always of arm fashion ; the cable of the former, as at present 
constructed, being too weak to accomplish other than operations demanding 
little mechanical power. 
The middle pieces in the engraving show a circular-saw, of which 
kind of saw there are diameters measuring from a half-inch to four inches, 
together with different sizes and forms of burs, and a drill. These are the prin- 
cipal instruments used with the engine, and they possess the capability, indi- 
vidually and collectively, of doing a great variety of service. The burs and 
drill vary as to forms. The contrivance seen to the left is a reciprocal saw ; it 
possesses a latitude of motion to the extent of one-quarter of an inch, and runs 
back and forth with an unrecognizable rapidity; its use applies in exsections. 
Surgical Engine in Oral Practice.-In oral practice the surgical 
engine is a convenience above praise. By means of the capability furnished 
by the apparatus operations of magnitude and danger are accomplished with 
all ease and at greatly-diminished risk. Instruments are used with the engine 
precisely as one handles a pen; saw, bur, or drill slipping, by means of a 
shank, into a hand-piece, or handle, and made to perform revolutions to the 
extent of several thousand to the minute, while, at time of greatest movement, 
a thumb and two fingers controls the cutting tool with all the facility of an 
act in drawing. (See, for illustrations in practice, various diagrams showing 
operations.) 
Preventing Deformity after Complete Section of the Jaw.- 
It is not necessary, as will be found referred to in another place, to remove, 
but in exceptional cases, a complete section of the lower jaw, for the 
reason that tumors are so vigorously resisted by the jaw-bone proper and 
confined to the alveolar process. Where, however, the jaw proper is involved, 
nothing better is to be done than cut the part completely out. In a case of 
this kind impressions of both upper and lower jaws are to be taken before 
performance of the operation. When the plaster models are run, a full plate 
is to be made, first, for the upper one, which, if there be no teeth, is to differ in 
nothing from an ordinary denture plate, as described on page 551. If there 
be teeth, this plate is to cover those of the sides, but is to go back of the front 
ones, leaving these exposed. The lower jaw is to have caps made to cover 
the parts not involved by the tumor. Plate and caps ready, all are put in 
place, and, while articularly related by the patient shutting his mouth, are 
attached to each other by means of wax. Being lifted out of the mouth, they 
are permanently soldered together. The operation being done, the apparatus 
is put into the mouth, the teeth of the two sides of the lower jaw are forced 
into their respective caps, and a Barton bandage is made to hold the parts 
closely and solidly in relation. This apparatus is to be worn until healing is 
complete, when it is to be replaced by a denture occupying the seat of the 
removed bone. 
In the edentulous jaw artificial teeth may be attached to the plate, 
these serving to keep the jaws apart, and to hold the ends with added fixity. EXSECTIONS OF THE MAXILLARY BONES. 
1075 
Fig. 833 affords idea of plates with teeth so prepared and in place. The 
observer is to accept that a complete section of the jaw, involving all its 
mental portion, has been made, and that 
the upper denture and the caps for the 
parts of the lower jaw remaining are in 
place. The lower caps and the upper 
plate are soldered together back of the 
teeth. 
Continuing the Faces of the 
Teeth.-It will be appreciated by the 
reader who has made himself familiar 
with the chapter treating of Bridge, 
or Crown Extension, Work that 
the mental chasm could be easily faced 
with teeth by using the two side caps as 
abutments, or supports, and throwing a 
bridge across. Fig. 834 may be offered as illustrative of one manner of 
making such an intermediate portion. The block of teeth here shown, 
Fig. 833. 
Fig. 834. 
consisting of a molar and the bicuspidati, are to be accepted as standing 
for central teeth. Any convenient manner of relating a central and the 
side sections is to be employed. Reference is to be made with profit in the 
connection to Figs. 794 and 803. CHAPTER LXIV. 
ANCHYLOSIS OF THE JAW. 
Anchylosis of the jaw (ayxuko^, crooked), trismus to gnash), 
finds its general nature and characteristics exhibited in the condition as seen 
in the common articular system. A special study is therefore to be benefi- 
cially preceded by a limited review of the subject at large. 
Definition of Term.-By anchylosis is meant stiffness in an articula- 
tion, such stiffness varying from an expression of simple inconvenience to ab- 
solute immobility. The terms true and false, complete and incomplete, are 
employed to express two common groups under which a variety of forms are 
classed; the first being applied to a state of fixedness in the joint, the second 
where more or less motion exists. A clinical division, one the practical utility 
of which every practitioner is soon found to recognize, relates with the lesion 
as reference is had to an intra- or extra-articular character; that is, whether 
the disease be within, or without, the joint. 
Intra-Articular Anchylosis. - Intra-articular anchylosis implies 
change in the immediate articular relations,-arthritic inflammatory action 
leading to plastic effusion, which effusion has necessarily a varying history. 
Imprimis, a stiff joint may depend on a simple synovitis. It may associate, 
again, with lengthened disuse of the joint, as compelled in fracture-treatment, 
such fixedness acting as the abstraction of the natural stimulus of the part 
found in its motion, thus resulting in a dryness which becomes in time the 
excitant of an inflammatory exudate, with tendency to organization favored by 
the immobility. Intra-arthritic inflammatory lesion has the history of common 
inflammatory action, and is to have consideration from such common stand- 
point. (See chapter on Inflammation.') 
Extra - Articular Anchylosis.-Extra-articular anchylosis implies 
change in parts externally associated with a joint. 
Character and Nature of Lesion.-In any inflammation, a matter 
which first calls for consideration is the character and nature of the disturbance. 
Such a consideration applies particularly to arthritis; for whether the action 
arises from local or constitutional cause makes great difference in a prognosis 
that one may incline to offer. 
Local Significance.-Local arthritis is explained by any cause of local 
character that may be discovered to have provoked the lesion ; of such offences 
we may instance blows, luxations, fractures, immediately neighboring lesions, 
and the presence of inter-articular bodies. 
1076 ANCHYLOSIS OF THE JAW. 
1077 
Constitutional Significance.-Arthritis of constitutional relation 
finds its diagnosis in the absence of local sources of offence, and in the pres- 
ence of cachexia: scrofulosis, syphilis, rheumatism, gout, cancer, and the sang 
calcine. Rheumatic, gouty, and scrofulous arthrosia are familiar exhibitions 
in such direction. 
Complicated Arthritis.-This refers to a provocation into action, by 
some direct irritant, of an abeyant cachexia. Enough instances of such 
complications are found in the hip-diseases of children arising from falls, and 
of cancers located through immediate injuries. 
Double Diagnostic Significance.-Inflammation in a joint has pri- 
marily a double diagnostic signification of concern to the surgeon ; that is, it 
may involve the joint proper, the bones, cartilages, and synovial membrane; 
or it may be confined to the latter exclusively. 
Synovitis Proper.-In synovitis proper, the prognosis is much more 
favorable than in true arthritis, provided the attack be acute in character and 
the treatment timely. Synovitis, in its incipiency, is attended by excess in the 
natural secretion of the membrane ; such excess, by producing overfulness of 
the articular cavity, interfering markedly with freedom of motion. Passing 
into a chronic state, the neighboring parts are soon involved, and what is to 
be the result depends as much on the circumstances of the case as on the care 
and skill employed in the treatment. Effusions, in synovitis, are readily dis- 
tinguished : the serous, associated with all the phenomena of acute inflam- 
mation, the parts being red, heated, painful, elastic, and fluctuating; the 
plastic appearing after the acute action has passed; this being dull, doughy, 
and pitting, and divested of active associations. 
Subacute Synovitis.-An attack of synovitis may be, and indeed 
commonly is, subacute in character ; that is, it may be a long while in develop- 
ing itself, and this even when it is the result of local injury. The first symp- 
tom attracting notice is apt to be a sense of stiffness after rest, this being most 
observed in the morning; succeeding this is pain, with the stiffness prolonging 
and fixing itself; swelling will now perhaps be first observed, the heat of the 
part increasing with the distention ; suffered to progress, suppuration of the 
membrane may be the result, and with it the complete destruction of the 
joint. A better and, happily, more frequent result is found in a cure of the 
inflammation through the exudative process, such exudation seeming to 
afford the necessary relief to the over-distended vessels. With such a 
result obtaining, the care of the surgeon becomes directed alone to the 
exudate; absorption is to be compelled, and, through passive motion and 
the judicious employment of the sorbefacients, the plastic lymph is not to 
be allowed to associate its bands with parts that shall afford it the capability 
of organization. 
Acute Synovitis.-Acute synovitis, if disassociated with cachexia, may 
commonly be quickly resolved into a subacute condition; to obtain such 
result, however, treatment is to be directed with much judgment; if purely 1078 
A SYSTEM OF ORAL SURGERY. 
local, the attention required will most likely be one vigorously antiphlogistic ; * 
if conjoined with cachexia, local sedation is to have associated with it a con- 
stitutional specific medication, or, stimulation and invigoration may be indicated. 
A common treatment for an acutely-inflamed joint, whatever the parts involved, 
may be laid down as follows: Put the feet and legs of the patient in water, 
as hot as can be borne ; administer a full saline cathartic, or a diaphoretic; 
apply a lead-water and laudanum lotion to the inflamed part; bleed with the 
lancet, or locally by leeches ; depress the circulatory force by the administra- 
tion of arterial sedatives, aconite or veratrum viride, and restrict to a low diet; 
use counter-irritants; any or all of these means being employed according to 
the indications of the case, an exception to the use of the pediluvium existing 
in inflammation of the inferior joints. An inflammation, once having its acute- 
ness broken, is often happily terminated by painting the parts with the tinct- 
ure of iodine, or with the muriated tincture of iron combined with quinine 
and the tincture of cinchona, as recommended on another page for erysipelas, 
and afterward, if deemed necessary, enveloping the part in the lead-water and 
laudanum lotion. Where structural change is feared as the result of effusions, 
a mercurial may be administered and pushed to the least perceptible evidence 
of its impression. It is seldom the case, however, that a result is not better 
without than with this last: it is not to be doubted that through the inju- 
dicious use of mercury many joints have been depressed to suppuration which, 
without it, would have escaped. 
Suppuration in a Joint.-When, in defiance of treatment, suppura- 
tion occurs in a joint, the pus formed is to be got clear of as speedily as possi- 
ble. To effect this, aspiration is to be resorted to. It is at this stage that 
stimulation is directed with prospects of good results. Yet what is to be the 
precise nature and extent of such medication is not so easy to suggest, each 
case having, most likely, some special indication. The principle of the means, 
however, is to be found in anything that shall arouse the parts to a higher 
and healthier grade of action : embrocations, hot or cold douches, strapping, 
painting as before suggested, passive motion, or even, it might very well be, 
injections into the joint itself,-a means, this last, that might save an articu- 
lation where all others should fail. 
Specific Indications.-Synovitis of systemic origin demands that the 
treatment consider the specific indication. If syphilitic, gouty, rheumatic, or 
strumous, medicines which experience characterizes as most antagonistic to the 
particular condition are to be conjoined with the local means. Thus, while giving 
every attention to the affected joint, we direct a medication to the cause at large. 
Arthritis.-By arthritis is meant the inflammation of the common 
structures of the joint; here the danger of ill results is proportionally 
greater than synovitis, as extent of parts is involved. An arthritic inflamma- 
* A cure almost magical in the rapidity with which it results is sometimes secured by 
cauterizing the surface with the solid nitrate of silver. ANCHYLOSIS OF THE JAW. 
1079 
tion may be general, involving all the components of a joint, and of such se- 
verity of grade as to run quickly into suppuration and destruction of the parts ; 
on the contrary, it may prove so slight as to amount to nothing more grave 
than a temporary congestion resolvable by a few hours of rest and sedation. 
Between these two extremes are found all the phenomenal associations of 
inflammatory action. An arthritis, in the fulness of its history, is thus to be 
described: First, a sense of stiffness in the joint, with increasing uneasiness, 
-the stage of simple vascular excitement. Second, the development of the 
sense of heat, the parts swelling and becoming intensely painful on the slight- 
est motion,-the stage of active congestion. Third, fixed engorgement, the 
pain persistent and of a heavy character, skin a dull red or white, according 
as the inflammation may or may not have travelled to the surface,-the stage 
of stagnation. Fourth, the destruction and breaking down of the involved 
parts,-necrosis, as evidenced in morbus coxarius,-the stage of suppuration 
and devitalization. Fifth, hectic fever from exhaustion, or pyaemia from pus- 
poisoning. Sixth, death. 
Treatment of Arthritis Proper.-The treatment of arthritis proper 
is precisely that indicated and employed in synovitis. To limit and control 
inflammatory action is the principle of the cure. The vigor with which such 
a treatment is to be directed depends, of course, on the indications of each 
special case, these presenting, as suggested, every shade of character. If an 
inflammation, in defiance of the immediate antagonists employed for its control, 
pass onward in its grade to the effusion of lymph, as recognized by the doughy, 
pitting character of surrounding parts, then the danger of anchylosis, on the 
one hand, or of the degeneration of this agent into pus, on the other, is the 
matter which presses for attention and concern. Passive motion of the 
gentlest character is to be resorted to, together with the employment locally of 
sorbefacients, combined with such general medication as the particular case 
may appear to demand. If a mercurial seems essential, the practitioner will 
seldom find himself at fault in combining a tonic with it. This will most 
certainly be found to hold true in all cases associated with asthenia. The 
character of cases in which it would seem to the writer's judgment that mer- 
curials are admissible, and, indeed, in some instances, positively necessary, is 
where the trouble occurs with the robust and vigorous. In cases of this class 
their good effects are occasionally markedly observed; but even here, if em- 
ployed too freely, the harm done quickly overbalances the good. When a 
mercurial is used, the effects produced are to be watched with the closest at- 
tention, and never is it to be inferred that, because good results are observed 
from the gentlest of ptyalisms, pushing the medicine will expedite a cure. 
No greater error than this can arise; a result is not unapt to be pus, and de- 
struction of the joint. Another matter, not to be overlooked in the employ- 
ment of the medicine, is its cumulative nature. A man may take a mercurial 
for a week or a month without apparent effect, when suddenly most profuse 
ptyalism exhibits itself. 1080 
A SYSTEM OF ORAL SURGERY. 
Rheumatoid Arthritis.-For a medical paper treating most fully on 
this condition, the reader is referred to Reynolds's " System of Medicine." 
TRISMUS. 
This term has its application alone to the anchylosis of the temporo-maxillary 
articulation ; it expresses the simple locking or fixing of the jaw. As there 
are many causes or conditions involved in such locking, so, of course, are there 
conjoined terms expressive of such different lesions: trismus traumaticus, in- 
cluding tetanus,-the locked jaw from wounds and other local external injuries ; 
trismus dentium, arising from associative dental lesions; trismus nascentium, or 
trismus neonatorum,-infantile tetanus. In strictness of application, the term 
trismus is used, however, only for gnashing, spasmodic, or nervous lockjaw, and 
is without true expression or meaning when applied to other forms. It might 
be best viewed as referring to the medical rather than to the surgical aspect 
of the lesion. 
TETANUS, 
from recvo, to stretch, is a disorder of the nervous system, presenting its 
manifestations in spasms, and affecting in nearly every instance the muscles of 
mastication, thus producing gnashing, or, it may be, locking of the jaw. 
Tetanus is decidedly a nervous disease, and is primarily confined to the true 
spinal system, being produced in some individuals by the most trifling injuries, 
many cases being on record where the simple extraction of a tooth has sufficed 
to provoke it. A bath, unduly prolonged, produced it in one of the 
author's surgical students. The terms opisthotonos, emprosthotonos, and 
pleurosthotonos are employed, together with trismus, to designate the groups of 
muscles implicated in the derangement. 
Division into Traumatic and Idiopathic.-Tetanus is divided into 
traumatic and idiopathic, and into acute and chronic : the first following 
wounds and other injuries, the second arising without assignable cause. The 
first form is usually acute in character; the latter is likely to be chronic, and, 
to the extent of its chronicity, amenable and responsive to treatment. 
Predisposing Causes.-As predisposing causes of tetanus, the experi. 
ence and observations of Baron Larrey would seem to give cold and dampness 
prominent positions. Dr. Kane, in his " Arctic Explorations," alludes to the 
death of two of his men from tetanic spasms, after being exposed to intense 
cold. Extreme heat is certainly another of such predisposing causes, tetanus 
being as common in very hot as in very cold temperatures, both extremes 
acting, most likely, by provoking centric nervous irritation. 
Symptoms.-Tetanus, although sometimes coming on suddenly, has more 
commonly a premonitional history. Instances are recorded where the spasms 
have arisen almost simultaneously with the reception of a wound. Such cases 
are, however, exceedingly rare, and indicate a predisposition which renders 
the disease almost necessarily fatal. On the other hand, it is exceedingly ANCHYLOSIS OF THE JAW. 
1081 
common to find the condition remaining in abeyance until the external wound 
has completely healed. A case of this latter character came under the author's 
observation some time back, where a lady, while searching in a barn for 
eggs, accidentally ran a rusty nail into her knee, not, however, involving the 
articulation. Four days after the reception of the injury, the break being 
fairly healed, emprosthotonos supervened ; yet the spasms quickly disappeared 
on opening the wound with a bistoury and the introduction into it of a 
delicate tent, thus compelling a filling up of the parts from the bottom. The 
irritation of a nerve radicle by its being caught and compressed in a cicatrix 
is a reasonable explanation of neuralgia and tetanus supervening on the heal- 
ing of a punctured or lacerated wound, and seems to have had an example 
in this case. 
Prodroma.-Commonly, tetanus exhibits its approach, as suggested, in a 
gradual manner. Attention is first directed to a sense of general malaise; 
then stiffness of the movements of the lower jaw supervenes, as though the 
muscles were exhausted. This stiffness, increasing to soreness, extends to the 
muscles of the neck. The mouth becomes dry and sore ; mastication 
grows painful, and swallowing difficult, a sense of spasm and suffocation 
resulting when these offices are attempted. Eventually the masseters, tem- 
porals, and pterygoid muscles become stiffened and bulging; the orbicularis 
puckered and contracted; the eyelids are closely approximated; the zygo- 
matici are liable to become fixed, thus giving a peculiar expression known as 
the Risus Sardonicus. Following these symptoms, almost any of the 
voluntary muscles may become implicated, the abdominal group, particularly 
the recti, corrugating and knotting themselves. Colicky symptoms soon 
supervene, induced by spasms of the muscular coat of the bowels ; or difficulty 
in respiration may arise, from spasms of the diaphragm. Opisthotonos, em- 
prosthotonos, pleurosthotonos, or, it may be, a most unyielding trismus now 
develops, according as the force of the irritant may select special groups of 
the muscular system on which to expend itself. That tetanus does not impli- 
cate the ganglia of special sense, but is confined to the spinal cord, medulla 
oblongata, and cerebellum, is demonstrated in a clearness of the intellect which 
continues during the attack. 
State of the Bowels in Tetanus.-The bowels, in tetanus, are com- 
monly found obstinately constipated, depending on the general derangement of 
the alimentary canal; and motion, when it does obtain, is commonly accom- 
panied with fetor of a most offensive character and of great persistence. The 
bladder may be closed by spasm of the muscular fibres of its neck, or these 
may be so relaxed that complete incontinence exists. The tongue, when 
involved, tends to be thrust forward, and is thus often lacerated in the spas- 
modic occlusions of the teeth. 
Duration of Disease.-Acute tetanus seldom has a greater duration 
than four days, the patient perishing either from asphyxia in a spasm, or 
otherwise from exhaustion. Chronic tetanus, on the contrary, runs on day 1082 
A SYSTEM OF ORAL SURGERY. 
after day, most frequently eventuating favorably. One is impressed with the 
sense of a battle, in which nature, properly supported, may reasonably be 
expected to win. 
Pathology of Disease.-Because of the absence of definite pathological 
lesions, more or less diversity of opinion exists concerning the conditions of 
this disease. Sporadic or traumatic cases, where tetanus has shortly super- 
vened upon injury to a nerve, naturally direct attention in such direction. 
Investigations into nerve-relations, however, prove so unsatisfactory that there 
seems now quite a tendency to revive the humeral origin, a view maintained 
with all earnestness by Rose, and favored by both Billroth and Dr. Richardson, 
the latter suggesting that it may eventually prove to be the result of the 
absorption of some septic material. In the disease, says this author, 
the poison, in my opinion, is first developed in the wound as the result of 
decomposition. Thence carried into the circulation, the new substance, with- 
out any necessary increase of its own parts, excites a zymosis, ending in the 
production of an alkaloidal or alkaline body, which has all the power of ex- 
citing the symptoms of spasm as much as strychnine itself. Billroth inclines to 
ally the condition with the infectious phlogistic. It is known, he says, that, 
by blood-poisoning with strychnia, severe spasms, and with alcohol, 
psychical disturbances (drunkenness), may be induced; hence it is very pos- 
sible that this disease may result from poisoning with a peculiar substance, only 
very rarely formed in wounds, and thence absorbed. 
Spinal Medulla.-The symptoms of tetanus indicate irritation of the 
spinal medulla. Rokitansky describes, from autopsies made by him, evidences 
of vascular relations of this substance as exhibited in the development of 
young connective cells. Other observers, however, have failed to find these 
expressions. 
Generation of an Animal Poison.-The reviewer of the article 
Tetanus in Reynolds's " System of Medicine" (see British and Foreign Medico- 
Chirurgical Review, vol. xiii.) says, The author does not attempt to trace any 
connection between the acknowledged causes, cold and damp and wounds, and 
the production of such a fearful consequence in only a few cases. With re- 
gard to its relation to hydrophobia and analogy of the latter to that of snake- 
bites, may not the connecting link between chilled wounds and spasmodic par- 
oxysms be an animal poison generated in the wound during the process of 
healing ? and being an animal poison, therefore poisonous in extremely-minute 
doses? and being an animal poison, therefore latent in the system for long 
periods ? and being an animal poison, therefore specially fatal to the nervous 
system? The greater tendency in punctured and closed wounds to cause 
tetanus is very suggestive of the needle-like serpent's fang, and the frequent 
triviality of the dog's bite, which are more deadly the less blood flows. 
Holmes on Tetanus.-Holmes (in his chapter on Tetanus; see vol. i. 
p. 330), after a review of the morbid anatomy, as referred to by various ob- 
servers, remarks the obscurity in which the pathology is involved. Some, he ANCHYLOSIS OF THE J A IK 
1083 
says, are heard to affirm tetanus to be an irritation of a peculiar kind, affecting 
the excito-motory apparatus; that the irritating cause may be excentric at the 
extremity of, or in the course of, the afferent spinal nerve, or it may be centric 
within the spinal canal itself. Some consider it to be an exaltation of the 
polarity of the cord and medulla. Others, again, maintain it to be identical 
with inflammation of the spinal cord and medulla oblongata, and adduce cases 
of inflammation of such structures as inducing symptoms of tetanus. 
Principles of Treatment.-If the difficulty of ascertaining patho- 
logical conditions, on which all rational indications of cure should be based, 
says Dr. Copland, be so great in this malady as not to have hitherto been 
overcome, can it be a matter of surprise that the means which have been re- 
sorted to, by both physicians and surgeons, in its treatment, have been most 
opposite in their effects, the most different in their nature, and in every respect 
most empirical and uncertain ? In this state of our knowledge it would be 
better to leave nature to her unaided efforts, to observe closely and accurately 
what is the true procession of changes and of *their manifestations, and to 
ascertain the seats and the extent of lesion as soon after death as may be 
attempted with propriety. 
Common External Means employed in Treatment.-The 
treatment that has most commonly suggested itself seems to be that of anaes- 
thesia ; opium and chloroform being much depended on. Of the 
former medicine as many as twenty or more grains have been used in the 
course of a day, or a correspondence in the subcutaneous use of morphia. 
The greatest gain in treatment seems to be to prolong the disease into chro- 
nicity, thus wearing out, as it were, the force of the active cause. Billroth 
refers to the use of warm potash baths, and the application of strong irritants 
along the spine, large blisters, moxae, but does not feel that experience 
tends to endorse any of them. On the contrary, referring more particularly 
to the chronic cases, he suggests that the patient be allowed to remain as 
quiet as possible, guarded against all injurious influences, especially from 
physical or mental excitement; the general aim of the treatment, he thinks, 
being to alleviate the acute course and make it more chronic, as this adds to 
the hope of recovery. 
Common Internal Means.-Of the internal means that have been 
employed, almost every class and description of remedy has been tried, with- 
out, as yet, any result in the way of a specific or an approach in such direc- 
tion. Alteratives, in the shape of the varied preparations of mercury, 
large doses of fixed alkalies, solutions of arsenic, etc.; diuretics, in 
the form of tincture of cantharides, oil of turpentine, given in frequent and 
large doses so as to irritate the urinary passages or to occasion bloody urine; 
sedatives, such as digitalis, tobacco, nicotina, hydrocyanic acid, aconitina; 
anodynes and narcotics, as opium, morphia, belladonna, colchicum, canna- 
bis indica, ether and chloroform internally and by inhalation ; stimulants and 
antispasmodics, including musk, ammoniacum, camphor, turpentine, as- 1084 
A SYSTEM OF ORAL SURGERY. 
safoetida, castor, wine, and other stimulants; tonics, such as quinine, bark, 
strychnia, iron, zinc, etc.; hygienics and dietetics, as support, milk-diet, 
etc.; injections into the veins of solutions of opium, stramonium, etc.; tracheot- 
omy and laryngotomy. The Calabar bean in sufficient doses to paralyze 
the voluntary muscles has been affirmed to be attended with marked success, 
although it has, on the other hand, failed very frequently. (See Alfred 
Poland, Holmes's 11 System of Surgery.") The writer directs attention to bel- 
ladonna as a remedy with which he has cured tetanus. The dose of the 
tincture as employed by him is half a teaspoonful repeated pro re nata. 
Woorara Treatment.-The treatment of tetanus by woorara has of 
late excited some attention, mainly through the work of Mr. Morgan. Ac- 
cording to Demme, this most powerful poison has out of twenty cases resulted 
in eight cures. It is recommended by Spencer Wells, Broca, Chassaignac, 
and others; the dose is given as from one-eighth to one-half grain to an 
adult. To one not familiar with the action of woorara, it would seem neces- 
sary to recommend great caution in its employment. Most interesting experi- 
ments have been performed with the agent upon the lower animals, particularly 
a series in 1858 by Dr. J. J. Woodward. 
Calabar Bean.-The use of the Calabar bean has come to be much re- 
lied on in the United States. Eighteen cases are reported by Dr. Eben Watson 
in which this medicine was used, yielding ten recoveries. The dose varies 
with the effect produced in controlling the spasms. The action seems to be 
that of a direct sedative to the spinal cord, patients, while under its influence, 
commonly taking food with ease. One grain may be commenced with as a 
dose, increasing the quantity as seems warranted. 
Hydrate of Chloral and Croton-Chloral. - The preparations 
hydrate of chloral and croton-chloral have in them considerable promise in 
this direction. A peculiar action from the latter of these agents is found, in 
that at first a high degree of anaesthesia is produced in the head, while sensi- 
bility in other parts of the body remains intact. In a stage that succeeds the 
spinal cord loses its function, and reflex excitability is everywhere extin- 
guished. During this condition, pulse and respiration remain unchanged. 
A third stage, which is induced by large doses, is characterized by paralysis 
of the medulla oblongata, and death. Animals may, however, be kept alive 
by artificial respiration, because the function of the heart is not interfered 
with; while the ultimate effect of hydrate of chloral is to paralyze the heart. 
Local Means.-The local treatment to which recourse has been had in 
tetanus consists in laying open wounds, their thorough cleansing, and the 
free use of antiseptics; division of nerves, the application of counter-irri- 
tants, the employment of sedatives, ice-bags to the spine, cold and warm 
shower-baths, electricity, attention to inflamed and suppurating wounds. The 
author is confident that he saved himself from advance of the disease, where 
tetanic? symptoms developed as a result of a nail run into the foot, by holding 
the part during a whole night in a basin' containing three parts of phenol- ANCHYLOSIS OF THE JAW. 
1085 
sodique to one part of water. The shooting pains, which were very severe, 
disappeared entirely after a couple of hours. 
TRISMUS NASCENTIUM-LOCKJAW IN NEW-BORN CHILDREN. 
The frequency of this condition, and its fatality to a particular order of in- 
fantile life, make its study one of interest and importance to the practitioner. 
It is decidedly a disease associated with the period of the desiccation and phe- 
nomenal change occurring with the cord and umbilicus, and is found confined, 
therefore, to the time related with these changes,-never happening before 
the second day after birth, and seldom after the fourteenth. 
Relation with Excito-motor System.-The condition under con- 
sideration has its expression and association exclusively with the nervous sys- 
tem of organic life,-the excito-motor. That trismus nascentium is therefore 
a special disease is an idea not to be entertained for a single moment; it is 
simply tetanus occurring from generally evident causes in the newly-born, and 
is to have the consideration and treatment of the disease as found anywhere 
else. Wherever the nervous system of organic life exists in over-sensitive 
development, and wherever it is excited from any cause to excess of expression 
or action, there, also, is found the danger of trismus. Hence in infants of 
the negro race, and particularly those born of parents of less than average 
intelligence and resident in hot climates, the condition is found to prevail most 
widely. In the southern section of the United States, and in the West Indies, 
the mortality of infantile deaths from this single cause is estimated by some 
observers at not less than twenty-five per cent.; while it is affirmed that in 
the equatorial regions of South America in some years more than half the 
infants born fall victims to this disease. In an epidemic form in which it 
is found to appear occasionally, the mortality of certain neighborhoods has 
amounted to four-fifths of the births. 
Not confined to Hot Latitudes.-That trismus nascentium is not 
confined, however, to the hot latitudes is to be inferred, not only from the 
report of many cases elsewhere, but from its oneness with tetanus proper. 
According to Dr. Holland, it is very prevalent on the southern coast of Iceland, 
also at St. Kilda, one of the western islands of the Scottish coast. In Elbing, 
Prussia, cases are announced as frequently occurring, thirty- seven being recorded 
from 1863 to 1865 in a population of two thousand seven hundred. In Dublin 
the disease has prevailed so alarmingly that at one time, for a limited period, 
nineteen-twentieths of the infantile deaths occurring in the Lying-in Hospital 
of that city were from this cause, the death-rate being one to every sixth child 
born. Being attributed to ill ventilation and the absence of proper hygienic 
requirements, attention was at once directed to these prophylactics, with the 
result of decreasing the rate to one in nineteen. 
Symptoms.-Like the manifestations of the disease as exhibited in the 
adult, the prodromous period may be deficient in signs sufficiently 1086 
A SYSTEM OF ORAL SURGERY. 
marked to attract ordinary observation. The child may seem restless and 
more excitable than usual, but this is apt to be attributed to any other than 
the true cause. A few hours, or perhaps days, intervene, when the infant, 
apparently anxious for the nipple, is found unable to take hold of it. This, 
together with an occasional smothered cry, as if the child were in distress, 
first brings it under the notice of the physician. If now the jaws be ex- 
amined, more or less rigidity is found to exist, the masseter muscles 
seeming the ones principally affected. From these the expression may 
extend to any others, and does so, not unlikely, in a very few hours; or it 
may be that the first manifestation of muscular involvement is exhibited in 
spasm, the jaw being shut with a snap which has, in instances, partially 
amputated the tongue; or the spasm may affect some muscle of the limbs or 
trunk. Such commencement of the active stage of the disease is, however, 
infrequent. 
Fully-developed Stage.-In the fully-developed stage of infantile 
trismus the spasms are found quite frequent. The agitation of the child is 
very great. The smothered scream which it emits is peculiarly painful,- 
itself spasmodic in character from affection of the respiratory muscles. The 
little sufferer foams at the mouth; the fists are tightly clinched; the feet are 
flexed upon the ankles, with the great toe abducted ; the head is drawn back 
by the cervical muscles; the surface grows livid, the infant dying in the 
paroxysm, or, otherwise, either receiving respite in which relaxation ensues, or 
sinking into death through coma. The duration of the disease is 
commonly about two days; but cases are recorded where death has not 
occurred until the third week of the attack. 
Causes.-First, there may be assumed to be a predisposition (though this 
need not of necessity exist), such predisposition being impressed on the child 
in utero by the hot and foul air and common filthiness of habit which, from 
its inception, have attended it in the person of the parent who has borne it: 
this finding proof in the fact that as the condition of parents has been im- 
proved, so has trismus diminished, the disease seeking its habitat almost ex- 
clusively amidst the squalor and poverty of the lowest and least intelligent 
classes. Other predisposing causes are found in any and all relations of 
depressing character. Thus, hot, moist days, followed by cold nights, have 
been sufficiently recognized to be among the most efficient of the predisposing 
causes, the explanation being found in the interruption of the functions of the 
skin. Miasma, no doubt, contributes its quota through its depressing action 
on the nervous system,-tetanus being associated with the period of reaction. 
Marion Sims on Cause of Trismus Nascentium.-In papers 
published by Dr. J. Marion Sims, this practitioner advances the view that the 
cause of trismus nascentium lies in a pressure exerted on the medulla oblongata 
and the nerves originating from it, produced by displacement of the cranial 
bones, and especially the occipital, such displacement occurring in the parturi- 
tive effort, and capable of being corrected; but, that the cases observed by ANCHYLOSIS OF THE J A JK 
1087 
him were exceptional, and not common, seems clear enough by the universal 
denial of his premises, following observations elicited by the publication of 
his views. 
Association with Umbilical Cord.-Whatever, then, may be a 
predisposing cause of infantile trismus, the chief exciting one is found in 
association with the umbilical cord; and first this associates with the tying 
and excision of it. A cord cut with a dull blade is put into a condition 
of irritability, which, reacting on a highly-predisposed system, might readily 
bring on an immediate attack of spasm. An ill-strangulated cord is to be 
classed as the second of the offending causes. A common habit with 
midwives, among the poorer classes, is to wrap the part with packthread. 
This is not only an inadequate protection against hemorrhage, as in his 
experience the writer has several times had occasion to witness, but it is irri- 
tating even in the remote aspect of its relation with the general system, and 
may readily arouse the abeyant irritability, The umbilical vessels separate 
from the body, physiologically speaking, as does the stem from the ripe fruit. 
When such is not the character of the disjunction, the conditions are to be 
expressed as pathological, being associated with more or less inflammation, 
ulceration, and local irritation. The ordinary period required for the separa- 
tion of a funis is from three to six days. During this time the parts should 
be kept enveloped in a fold of antiseptic linen, prepared as a dressing by 
snipping a piece out of the centre after the manner of a Maltese cross; the 
cord to be passed through this hole, and thus, by its envelopment, separated 
from contact with the person of the child. Tn hot climates, such dressing, 
combined with excess in use of antiseptics, is the more necessary, as the danger 
is to be guarded against of having the parts serve as a habitat for the deposit 
of larvae,-a not infrequent cause in itself of tetanus. 
Treatment.-From the constitutional stand-point, nothing more may be 
done than is to be inferred from the directions given in general tetanus. 
Anodynes, antispasmodics, anaesthetics, and alteratives may be tried ad libitum, 
but the result will amount to very little if any unappreciated or unremoved 
cause exists in the way of local irritation. Attention is therefore to have 
a first direction to the umbilical region, and such attention, if thus given 
in the incipient stage, will not infrequently result in aborting the attack. If 
an ill-incised cord be found, let a fresh and clean cut be made at once nearer 
the body. If the cord be indifferently strangulated, remove the ligature im- 
mediately, and replace with a well-waxed silk thread, or otherwise place the 
new ligature nearer the body. If separation be not progressing with its usual 
physiological harmony, treatment will be needed as indicated. Cleanliness 
is to be strictly enjoined, and vascular action is to be stimulated or de- 
pressed, as required,-not as indicated by the pulse, for this in tetanus affords 
very little guidance, but, as implied, at the seat of local offence. Among 
negroes, as remarked by Dr. James S. Baily, whose opportunities for obser- 
vation seem to have been extensive, the uncleanliness and unsuitableness of 1088 
A SYSTEM OF ORAL SURGERY. 
the umbilical dressings are by far the most common of the exciting causes of 
the disease. Among these people are found infants not only fetid with the 
ammoniacal smell of the urine with which they are wet from morning until 
night, but are loaded with faecal matter, so thoroughly saturating the appen- 
dage of the funis as to render its drying impossible. In consequence of the 
sphacelated condition of the cord, it gives off the material of death and decay, 
which, being deposited in direct contact with the active absorbents, must 
necessarily act as a fearful causation. This gentleman, who, during a resi- 
dence in Texas, was able to collect and make notes of two hundred cases, 
tells us that in his experience he has never observed a case of lockjaw when 
due regard was paid to proper instructions in reference to the management 
and dressing of the umbilicus. Tumefaction and redness without 
suppuration are always, he thinks, expressions to excite apprehension, and 
are to receive immediate attention. Quoting a Mrs. 0., a lady living on the 
Brazos, in Texas, observation is directed to the value of a mush poultice ap- 
plied to the navel immediately after birth, to be continued until the falling off 
of the cord, or while any signs of inflammation exist, the lady asserting that 
with such practice employed with her own servants she has never lost a case. 
This, however, evidently applies to the use of the poultice as a prophylactic, 
-a direction, indeed, in which the physician finds his advice most useful. 
An antiseptic mixed with such a poultice would certainly add to its effective- 
ness. 
In the chapter on Dental Anomalies was studied the process of maxillary 
enlargement, and it is understood how that process is, in part, counterbalanced 
by an untimely extraction of the deciduous teeth. It was further shown how 
certain derangements of the dental organs are a common, if not a necessary, 
sequence to such abridgment of the arch ; and, among other ill effects, refer- 
ence was made to the impossibility of a natural and healthy evolution of the 
wisdom-teeth, and to conditions favoring periodonteal inflammation. In this 
section we are to consider lockjaw as it has a signification exclusively surgico- 
dental. 
Dental Significance. - Such dental signification, however, will be 
recognized, it is apprehended, outside of tetanic conditions proper, as having 
widest relationship to the lesion, and, indeed, if experience has not been un- 
commonly one-sided, it will be found to have the very closest relationship ; in 
every twenty cases of local trismus, eighteen have, as the primary lesion, peri- 
odontitis, in some of its varied forms. 
Lesions relating with a Retracted Dental Arch.-We con- 
sidered the retraction of the dental arch. (See chapter on Anomalies of 
Dentition.') We will now look at such lesions as this retraction engenders,- 
lesions pertaining to the subject under consideration. The troubles of an in- 
dividual afflicted with a contracted dental arch are most apt to begin at about 
the fifteenth or sixteenth year of age. If you look into such a mouth you 
TRISMUS PENTIUM. ANCHYLOSIS OF THE JAW. 
1089 
find the teeth crowded into most uncomfortable-looking positions. The last 
molar of the lower jaw you will see, quite likely, jammed into the ramus; 
while the same tooth of the superior jaw is found occupying the very extreme 
of the tuberosity of the bone. At this period, unless, fortunately, the teeth 
are possessed of uncommon resistance, they will be found breaking down from 
approximal caries; while, as the result of such caries, combined with the 
crowded condition of the fangs, the alveolo-dental membranes enter into a sub- 
inflammatory state, and become as ready to take on acute disease as is tinder 
to respond to a spark. If, then, interference with the elongatory process has 
been such as to yield these troubles when only twenty-eight teeth have erupted, 
it is plain that the development of the four dentes sapientise must proportion- 
ally add to the difficulties. Only by appreciating the character of such trouble 
can we fit ourselves to abort its lesions. These lesions are periodontitis, 
alveolar abscess, stomatitis, osteitis, caries, necrosis, trismus. 
Relief afforded by Extraction.-In the chapter on Anomalies, it 
was remarked that all dental troubles arising from retraction and diminution 
of the maxillary arch are to be guarded against by a timely extraction of certain 
of the permanent teeth ; and from this we are to infer that a lesion arising 
from an advancing wisdom-tooth is also to be provided for on the same prin- 
ciple,-namely, by extracting the second molar, thus securing a required 
alveolus. 
These pathological conditions, and the remedial and prophylactic indi- 
cations so plainly written over them, it would seem impossible to over- 
look because of their very simplicity ; that they are overlooked, however, is too 
evident, from the many secondary associate lesions which the surgeon finds 
himself constantly called on to treat. 
Periodonteal Trouble.-The view has been advanced that the majority 
of the cases of trismus are found to have, as the primary irritant, some peri- 
odonteal trouble. Of course this is to be understood as not including trismus 
neonatorum, or any trismus traumaticus, the lesion of which is of different 
signification and self-evident. A child might get a severe burn on the cheek, 
and trismus be a result of the innodular tissue, which would close up the break 
in the continuity. Anchylosis might exist, the sequence to articular disease, as 
we have studied. Traumatic tetanus affecting the muscles of the jaw has, as 
we know, a primary cause combined with peculiar nervous disturbances, which 
would give the diagnosis. But it is to the numberless cases of so-called 
idiopathic trismus that allusion is made, and to the cases of trismus 
which have evidently a local signification alone; this signification not being 
evident, or otherwise being associated with so many complications as not to be 
distinguishable. 
Unappreciated Causes.-Reports of case after case of unappreciated 
local trismus come to our attention,-of the lesion being referred to this cause 
and the other cause,-the treatment being as various as the diagnoses. Many 
of the inferences thus presented are, without doubt, just and acceptable; but 1090 
A SYSTEM OF ORAL SURGERY. 
it is to be offered as a reliable experience that where, personally, the author 
has had the opportunity of seeing such examples as would seem to be their 
parallel, he has mostly been able to point out some dental disturbance, simple 
or obscure, constituting the primary lesion. 
Illustrative Practice.-In the epitome of Braithwaite, vol. ii. p. 191, 
is a case, the diagnosis and treatment of which will serve as an example. 
Dr. S., the practitioner who reports it, ascribes the trismus to a complication 
of inflammatory and nervous derangements. Now, while the inference may 
be wrong, yet from the history, and from the age of his patient, the writer 
would have expected, had he seen the case with the gentleman, to have been 
able to show that an ulcerated sore throat, to which Dr. S. alludes, had its 
primary lesion in a trouble of the alveolo-dental membrane; the reader, how- 
ever, can draw his own inference. The case is compared with one from the 
author's practice. 
The patient, twenty-five years of age, unmarried, had for years been sub- 
ject to attacks of suppurating sore throat, in which the jaws often became 
nearly immovable for two or three days before the discharge of matter. In 
1826 she had a severe attack, from which resulted complete lockjaw, accom- 
panied with hysterical symptoms, which attack yielded, after six weeks of 
treatment, so far that she could put a teaspoon in her mouth. After nearly a 
year, the jaw again became completely fixed, without accompanying sore throat, 
and the same treatment, with galvanism, was tried without effect. Although 
unequivocally connected with hysteria, there was reason to think, from the 
inflammatory action with which the disease set in, that the affection was not 
purely spasmodic, but was kept up by the rigidity of the muscles closing the 
jaw produced by inflammation; in consequence of which the antagonistic 
muscles had become inadequate to the effort of opening the mouth under the 
mere influence of volition. 
It was this view of the case which made Dr. S. think it more reasonable, in 
making trial of the needles, to insert them into the muscles opening the jaw, 
in the expectation of exciting them to such a contraction as might overcome 
the rigidity of their antagonists. On each of the two following days two 
needles were inserted, one on each side of the mesial line between the chin 
and the hyoid bone, the effect being short, convulsive efforts. The teeth 
began to grate on each other, and the jaw was drawn from side to side, not by 
single alternate attractions, but by severe convulsive movements on one side, 
followed by a nearly equal number toward the other side, interrupted occa- 
sionally by a momentary opening of the mouth to the extent of about two 
fingers'-breadth. The convulsions continued after the needles were with- 
drawn ; ceased and became renewed again after a few minutes, and returned 
spontaneously in the evening on both occasions. Some increase of voluntary 
power over the jaw followed both applications of the remedy. After each 
trial of the acupuncture some improvement was observable; but, as the spon- 
taneous convulsion was almost always followed by a slight loss of motion, the ANCHYLOSIS OF THE JAW. 
1091 
progress made was slow. The needles were usually inserted to the depth of 
half an inch, and sometimes to the depth of an inch. The acupuncture, 
together with leeches, was used for ten days, by which time the patient could 
open the mouth two fingers'-breadth and chew soft substances. She then 
went into the country for five weeks, by which she derived great benefit; 
but, being exposed to cold and wet on her return, had another severe attack, 
the consequence of which was the loss of much of the voluntary power over 
the muscles of the jaw. The needles were again resorted to, with the same 
effect as before ; but the pain produced by the spasms was greater, and lasted 
longer, while the spontaneous convulsions recurred several times in the even- 
ings after each of the first trials. As leeching did not succeed in mitigating 
these convulsions, the temporal artery was opened with the desired result, and 
with the effect at the same time of restoring, to a considerable extent, the 
sight of the right eye, which she almost lost with the first attack of lockjaw. 
A second abstraction of blood from the same vessel diminished the force of the 
attack so much as to permit the acupuncture to be used twice a day. Nine 
days after the renewal of the operation the jaw had recovered its natural 
extent of motion. The aphonia, which had come on at the same time as 
the affection of the eye, was completely cured by a smart shock of elec- 
tricity. 
Illustrative Practice.-The case referred to as from the author's ex- 
perience occurred in the practice of a friend, relation with it being through 
consultation. Its history is as follows : 
For a period of several years the patient, Mary C., twenty-four years of 
age, had been troubled with attacks of sore mouth and throat whenever she 
unduly exposed herself; these attacks had always associated with them partial 
loss of voice and general excitation of her whole nervous system, while her 
jaws were invariably stiffened to a greater or less extent, according to the 
severity of the attack. On each of these occasions she had depended for 
relief on domestic treatment or on homoeopathy. At the period, however, 
of her coming under the care of Dr. W., she was suffering from such severe 
trouble as to have decided her usual attendant into dismissing the case. The 
jaw had remained so firmly locked for a period of six weeks that it was with 
difficulty a knife-blade could be introduced between the teeth. This particular 
spell had come on as usual; but the patient said there was something about 
it which made her think that her teeth were implicated; she could not say 
what tooth or teeth, but thought it was one or more in the lower jaw. 
Now, whatever was to be discovered as the primary lesion in the case, its 
surgical feature, as it presented itself, was an extra-capsular mass of coagu- 
lated lymph deposited about the temporo-maxillary articulation, which over- 
balanced the influence of the depressor muscles, holding the parts, of course, 
in a state of false anchylosis. 
The patient was asked if, when these attacks came on, her face had not 
always swelled more or less. She said that it had. She was further asked 1092 
A SYSTEM OF ORAL SURGERY. 
if the cheek had not always a stiff, hard feeling in it, which wore away 
gradually after such attacks. It was so, she said. 
Dr. W. coinciding that the speediest way of overcoming the trismus was 
by mechanically breaking up the adhesions, a pine stick about a foot in length 
was procured, tapering, wedge-shape, from an inch and a half base. The 
thinnest portion of this wedge was, after much trouble, passed between and 
across the dental arches, and, after being forced a little farther on, the stick 
was turned on its axis, the adhesions yielding before the strain. Thus the 
mouth was opened at least an inch, and we were enabled to explore the cavity 
in search for the lesion on which the trouble depended. 
So far this case will be seen to simulate closely that of Dr. S.'s: sore throat, 
aphonia, hysteria. 
Now, here we found all the trouble emanating from a wisdom-tooth pro- 
jecting, as it were, from the very angle of the jaw, and half covered by an 
operculum of gum drooping over on it from the ramus. The tooth, of course, 
we at once removed. The patient was then dismissed for the day, a sorbefacient 
being directed for external application. 
The next afternoon, at four o'clock,-no inflammation having supervened,- 
we completed, by our mechanical appliance, the unlocking of the jaw. In a 
week the patient was well. She has since had no return of her spells, and 
will not have. 
Parallelism between these two cases will be recognized; but should the 
reader disagree, study of them will not be without its profit. 
Illustrative Practice.-One of the most severe examples of inflamma- 
tion of the mouth, throat, and face, combined with a bad trismus, ever seen 
by the author, was in the person of a medical student in the office of a Dr. C., 
of this city,-the primary lesion being such a half-erupted wisdom-tooth as 
has been alluded to as being found in the preceding case. This gentleman, 
when first seen, had been suffering for two or three weeks. The oper- 
culum of gum had been split up on two different occasions. Antiphlo- 
gistics in every form had been resorted to. The patient consulted under the 
anticipation that nothing was to save him from necrosis of the angle of the 
bone. 
We gave this man one and a half pounds of ether; it seemed impossible to 
get him into an anaesthetic condition, so great was his physical suffering. 
Prying the mouth open, just sufficient to introduce the key of Garengeot, 
the offending tooth was extracted after much trouble. In three days the man 
was attending to his studies. 
Partly-erupted Wisdom-Tooth.-This peculiar lesion of a half- 
erupted wisdom-tooth may well claim more than a passing attention. Many a 
practitioner has been so deceived by the anomaly as to have been led widely 
astray in the study of his cases. Where the condition exists, it is to be 
noticed, on looking into the mouth, that only the anterior face of the tooth 
has fairly erupted, the other two-thirds being overlaid by the integuments of ANCHYLOSIS OF THE JAW. 
1093 
the ramus. You infer that the development is not yet perfected, and conse- 
quently it does not even occur to you to associate disease with the parts; but 
this tooth, a single cusp only of which is through the gum, may have caries 
extending into its pulp-cavity, or it may be the seat of aggravated periodon- 
titis. It is the common impression that wisdom-teeth decay early; that they 
are not a substantial class 
of teeth. The fact is that 
four-fifths of these organs 
which decay so soon have 
been destroyed by 
this operculum of 
gum. The explanation 
is very evident. The 
decomposing epithelial 
scales, and other debris 
of the mouth, combine 
in the acidity engendered of their disintegration to corrode the structure of 
the tooth, thus quickly destroying its integrity. The writer is sure that he 
has seen more than a thousand cases illustrative of this fact; and if any prac- 
titioner will take the trouble to dissect off 
the fleshy lid-the proper treatment, by the 
way-and examine with a delicate probe 
the sulci of such teeth, he will find caries 
in nine cases out of twelve.* 
Illustratio n.-The diagram (Fig. 
836), after a drawing by Dr. James Tru- 
man, affords idea of this class of lesions. 
Here a chiselling away of the outer alveolar 
plate exhibits a wisdom-tooth developed in 
a horizontal relation with the body of the 
lower jaw. This position is exceedingly 
common, while removal is attended with 
great difficulty. Extraction, or room, being 
a necessity when inflammation is set up, it is the practice of the author to free 
the organ by means of a spear-drill passed around it, otherwise to secure the 
desired room by removing the second molar. A tooth situated as seen in the 
Fig. 835.-Operculum-excising Forceps. 
Fig. 836. 
* Forceps for excising Operculum overlying Wisdom-Tooth.-The lesion of an oper- 
culum wholly or partially covering a half-erupted wisdom-tooth is one presenting very 
frequently to practitioners. The indication in every one of these cases is removal of the 
fleshy projection. To accomplish this a punch forceps furnished by Ash, of London, and in- 
troduced into this country by Dr. Sheppard, of Boston, offers itself as better adapted to the 
purpose than any other means familiar to the writer. This forceps consists of a blade the 
shape and size of the operculum, which blade is slipped between the flesh and the grinding 
face of the tooth. Closure of the handles catches the flesh in a fenestra, fully and cleanly 
and instantaneously excising it. (See Fig, 835.) 1094 
A SYSTEM OF ORAL SURGERY. 
cut would show no single point through the gum. From quarter- to half- 
erupted wisdom-teeth are met with in many mouths. They may or may not 
give trouble. (See Alveolar Abscess and Neuralgia.') 
Secondary Relations of Partly-erupted Wisdom-Teeth.- 
The lesion described will at once be recognized to have important secondary 
relations. For example, the writer has been consulted time and again by 
persons who have been sufferers for a considerable period from what has been 
pronounced and treated as neuralgia. Their teeth had not escaped observa- 
tion, but had, on the contrary, been examined and pronounced sound. There 
has been found, however, in such mouths, not infrequently, this operculum of 
gum overlying the wisdom-tooth. This has been dissected off, exposing com- 
pound caries. Such teeth have been extracted and the patients have been 
instantly relieved of their odonto-neuralgia. 
Inflammation arising out of Opercula.-Again, these fleshy cups, 
catching, and holding in contact with the soft parts, insoluble particles, as 
often found mixed with the food, will provoke periostitis, or even osteitis of 
the angle and ramus of the jaw. The writer has seen most alarming inflam- 
matory attacks thus aroused. The tooth in these cases, as is somewhere else 
remarked, will always be found responsive to the stroke of an instrument. 
Its periodonteum being inflamed, experience directs that the organ be at once 
extracted. Such extraction, however, is occasionally among the almost im- 
possible things. A tooth so affected will not infrequently have but a point 
not larger than the head of a pin erupted. In these cases the best thing to 
be done is to take out the adjoining molar; this relieves the pressure 
on the ramus of the jaw, and gives room for the posterior tooth. It com- 
monly yields a cure. Trismus, depending on such lesion, is not 
infrequently the only external evidence yielded of the existence of the con- 
dition. The jaw stiffens and relaxes, as an odontalgia comes and goes. In 
such ephemeral cases it is not at all unlikely that the locking is exclusively a 
nervous action, or reflected irritation, slight and ephemeral local inflammatory 
action being the irritant. 
Consideration of Wisdom-Teeth.-Wisdom-teeth erupt from the 
seventeenth to the thirty-fifth year ; commonly, however, at about the eighteenth 
year. 
Some years ago the author treated a case of extreme trismus, recital of the 
history of which is to prove profitable by reason of being a very common one: 
The patient, David B., a farmer, after doing a hard day's work, and being 
much overheated, threw himself down at early evening, in a cool out-house, 
to rest. Here he fell asleep, not waking until near midnight. The next day 
he felt a soreness in the left superior alveolar arch, which soreness increased 
for two or three days ; after which it deserted the teeth and passed to the 
antrum. Then commenced a swelling in the integuments of the face, which 
advanced until it shut up the left eye. The jaws began to stiffen, and ended, 
after three or four days, in complete immobility. ANCHYLOSIS OF THE JAW. 
1095 
Lockjaw existing Nine Weeks.-The call to the case was after the 
lockjaw had existed nine weeks, the patient having barely been able to support 
life by putting his mouth into a basin filled with soup, and sucking the nutri- 
ment between his teeth. During this time he had been seen by seven different 
practitioners, no one of whom had seemed to appreciate the case, or, what per- 
haps is more probable, none of whom had been willing to assume the trouble 
of it. The patient had not told any of these gentlemen about the soreness 
first felt in his teeth, and no one of them had ever questioned him in the 
direction; his single complaint was of a great weight about the cheek. 
Extension of Inflammation.-The diagnosis of the case was, pri- 
marily, periodontitis. This inflammation, by a double continuity of structure, 
had extended into the maxillary sinus, and to the integuments of the face. 
The inflammation of the antrum had been sufficiently severe to result in 
abscess: abscess of the alveolo-dental membrane, and of the lining membrane 
of the cavity. The inflammation of the face had resulted in an exudation of 
lymph, which lymph in a state of coagulation was the cause of the trismus. 
Flow of Pus from Antrum following Tooth Extraction.-A 
first effort was directed to getting into the antrum, which it was felt assured was 
filled with pus,-a matter that was accomplished by prying out a second molar 
tooth with an elevator; pushing it into the mouth (from which, with some 
trouble, it was afterward gotten out); the extraction was followed by profuse 
discharge. The patient described the relief as being immense. This par- 
ticular tooth was removed, not because it was more carious than its fellows, 
but because it was somewhat loose, and thus gave evidence of the diseased 
condition of its roots. Again, it is through the alveolus of the palatine fang 
of this tooth that we find our easiest and best road to the antrum; in this 
case, as is recognized, the fang communicated with the cavity. 
Persistency of Anchylosis.-On the day succeeding the evacuation 
of the abscess, the patient expressed himself as entirely free from pain, his 
only trouble being the anchylosis, which had not, as yet, relaxed in the least. 
To the touch, all the parts about the articular extremity of the inferior 
maxilla seemed completely indurated. Hesitation existed as to attempting 
the breaking up of the parts mechanically, fearing injury to the important 
vessels which are associated with the head of this bone,-the maxillary nerve 
and internal maxillary artery. The induration was of course extra-capsular, 
and of sufficient extent to have bound the jaw from the glenoid cavity to the 
anterior border of the masseter muscle; passive motion was resorted to, but 
employed very gently. Blisters and sorbefacients were depended on. The 
case progressed very slowly, the patient having to come to the office every day 
for half a month; at the end of this time, but after removing other diseased 
teeth from his mouth, he was dismissed cured. 
Question as to the Advisability of breaking up Fixation.- 
When one is called to a case of trismus of any standing, the anchylosis being 
the result of inflammatory action, question may arise as to the propriety of 1096 
A SYSTEM OF ORAL SURGERY. 
mechanically breaking up the adhesions. The condyloid extremity of the 
maxillary bone is assuredly not the stanchest part of the body, and there are 
anatomical relations which it would not be at all pleasant to disturb: these 
things are for the surgeon to consider. So far as the writer, individually, is 
concerned, he now uses mechanical force in all cases that come under his care, 
premising, of course, that the condition is one where, from inflammation, the 
trismus depends on effused lymph. He is willing to run a risk for the great 
and immediate good yielded; some considerable experience in this direction 
assuring him that such risk is materially influenced by the manipulations. 
Of course it is not meant to recommend that attempt be made to open 
the mouth to its greatest capacity with a single turn of a lever employed, 
although there are cases where such practice would be very commendable. 
The author has so opened the mouth many a time, but not in cases of long 
standing. Generally, the force is to be applied with gentleness,-gain a little 
one day, and a little the next; it takes but a very short time to open a mouth 
in this way; besides, if your force be applied with such judgment as not to 
provoke vascular response, you will arouse to co-operation the absorbent 
system, the excitement acting as a stimulus to it, and it will be found to do 
its part vigorously. 
Trismus resulting from the Pivoting Process.-A person will 
not infrequently be attacked with trismus after the dental operation of insert- 
ing a pivot tooth. Here the lesion is more than likely inflammatory in 
character, and the treatment is to be directed accordingly; the root of the 
tooth is in a state of periodontitis. Cases of pure tetanus, however, have 
had origin in such an operation. Where the lesion is inflammatory, the parts 
are sore and tender to the touch. 
Trismus after Plugging Teeth.-A person will sometimes be attacked 
with trismus after the plugging of a tooth with metal; the attack comes on 
suddenly ; it is a reflex nervous action, and is always to be esteemed of danger- 
ous import. The conducting facility of the metal irritates the nerve periphery 
in the pulp; this irritation is referred to the spinal cord, and thence reflected 
to the muscles of mastication. To prove the existence of such a lesion, direct 
the patient to hold cold water in contact with the organ. 
To treat a case of this kind, remove the metal; when the irritation has 
subsided, be sure that, before refilling, a non-conducting substance be placed 
between the plug and floor of the cavity; or, because of the thinness of the 
bony septum, it may be desirable to destroy the pulp. 
Different Metals in the same Tooth.-Spasmodic trismus, very 
persistent, may result from the employment of different metals in the operation 
of a single tooth-plugging; galvanic action being a consequence, and the nerve 
subjected to a most harassing irritation. To test for this trouble, increase the 
action by holding silver and zinc against the plug. This test, however, will 
irritate any supersensitive pulp into a state of excitement, and is an admirable 
search-warrant for obscure lesions of the organ. The treatment consists, of ANCHYLOSIS OF THE JAW. 
1097 
course, in the removal of the plug, and the medication, if required, of the 
irritated pulp. 
So over many pages might be extended the consideration of dental lesions 
in connection with trismus. Enough, however, has been written, it is pre- 
sumed, to direct proper attention to the subject. 
Recapitulation.-To recapitulate: It is suggested that many of the 
cases of so-called idiopathic or obscure trismus will be found to depend on 
conditions associated with the dental arch. 
That to insure permanent relief, the treatment must include the primary 
lesion. 
That such primary lesions as are described in the chapter on Anomalies 
are always distinguishable. 
That where it is desirable to extract an offending wisdom-tooth, and such 
extraction seems too difficult to attempt, the removal of the tooth immediately 
anterior to it will, as a rule, meet the indications. 
That the immobility of the jaw, where acute inflammatory action exists, is 
to be treated on general antiphlogistic or phlogistic principles, according as it 
seems probable or improbable that the inflammation may be resolved. 
That when the acute action has passed, adhesions are to be broken up by 
mechanical force carefully applied. 
That mechanico-dental lesions are not to be overlooked, but are to be 
searched for, and discovered secundum artem. 
TRISMUS TRAUMATICUS. 
This is that anchylosis, true or false, intra- or extra-articular, dependent on 
local injury. Blows inducing inflammation are among the common causes; a 
not infrequent origin, one difficult to combat, resides in severe burns; sloughs 
from the undue use of mercurials are to be named; in short, enumeration 
might instance any lesion in which the locked jaw associates with conditions 
of local signification attended with solutions or irregularities in the continuity 
of the structures. A case treated by the writer in his practice, the patient 
being a boy twelve years of age, had the anchylosis dependent on false 
articulation, the result of injury done the glenoid fossa three years before by a 
blow upon the chin. The force of this blow being carried to the joint, a 
chronic inflammation had resulted in a filling up of the cavity to a level with 
the articular eminence ; while, in this particular situation, a species of irregular 
cavity had formed, which partially accommodated the condyle, permitting, 
however, dislocation whenever the jaw was opened beyond a certain point. 
In this case a fair cure was obtained by a tri-weekly manipulation of the bone, 
which resulted in a better-adapted fossa through compelled absorption. To 
procure such motion as seemed demanded, frequent luxations resulted, 
causing at first not infrequently some trouble in the reduction. This patient 
was advised to watch any tendency to contraction which might appear, 
and to keep it counterbalanced by rolling corks between his teeth,-an ex- 1098 
A SYSTEM OF ORAL SURGERY. 
cellent means, by the way, where the expense of an instrument prevents its 
purchase. 
Simple Means for opening the Jaw.-The use of common bottle- 
corks as a means of overcoming false anchylosis is attended with satisfactory 
success. Beginning an operation with one of a diameter to be readily intro- 
duced, increasing sizes are to be rolled, one after the other, between the teeth, 
into place. Timid children who resist the screw will permit the use of corks. 
Illustrative Practice.-At a clinic some years ago, a young man pre- 
sented himself with the lower jaw so fixed that only by profoundly etherizing 
him was it possible to pass the blade of a common table-knife between his 
teeth. This condition, which had existed for two years, had resulted from a 
blow received on the cheek, involving, in an inflammatory fixedness, the mas- 
seter muscle. This case was treated by subcutaneous section of the muscle, 
associated with the daily use of the screw. Through the use of this instru- 
ment there was no doubt of his being kept comfortable ; he was directed to 
employ it daily, and never to allow the jaws to deny the introduction of two 
fingers. Eventually such modification of the contracted muscle resulted that 
a fair cure was obtained. The section of the muscle in this case had of course 
but the meaning of affording the use of the second and true means of cure,- 
namely, the daily stretching of the part. 
Kolbe's Mouth-Opener.-Fig. 837 represents the instrument em- 
ployed in the stretching process, and which was furnished the patient for 
daily use: it is one devised or modified by the ingenious 
cutler to the Hospital of Oral Surgery clinic, Mr. Kolbe, 
and surpasses any other form with which the writer is 
acquainted. By simply turning the handle, the blades, as 
seen in the drawing, are gradually separated. The power 
residing in this instrument is sufficiently great to break 
up any anchylosis, true or false ; a jaw is easily to be 
broken by it. A necessary addition to the instrument that 
makes itself felt is a transverse bar in the handle to afford 
a more convenient application of the force. The appara- 
. tus is to be recommended as the best in use; it will fulfil 
the requirements of any case to which such application of 
force is indicated, while the most careless patient may be 
intrusted to use it on his own jaws. 
Cases of False Anchylosis.-Cases of false 
anchylosis are most frequently found extra- rather than 
intra-articular; or where the condition has existed for a 
long time, say for a year, then it is reasonably to be in- 
ferred that the two conditions combine,-that is, that portion of the articular 
cavity which is not used has been modified by nutritional changes. Wherever 
the lesion of a false anchylosis is situated, the philosophy of its relief consists 
in the practice of passive motion,-it is really only another expression of the 
Fig. 837 ANCHYLOSIS OF THE JAW. 
1099 
mode of cure of urethral stricture; operation may be necessitated, but it is 
only to be practised in cases of urgent necessity. 
Forms of Gags or Openers.-Besides the instrument commended, 
various others have been devised for the purpose of passive motion. Figs. 
838 and 839 show forms. Fig. 838 is that known as the wedge of 
Scultetus. Fig. 839 is a modification, as 
is seen, of such instrument: neither of these 
deserve mention as compared with that de- 
vised by Mr. Kolbe. 
Trismus the Result of Mercu- 
rials.-In sections of the country where 
the mercurials are freely used, anchylosis as 
a result of sloughing is not uncommon; it is 
frequently found in these cases that the mu- 
cous aspect of the cheeks has been converted 
into a dense, unyielding fibro-cellular cicatrix, 
which cicatrix resists all attempts on the part 
of the depressor muscles to antagonize it. In 
cases of this kind, instrumental aid applies 
most happily, and, if properly and judiciously 
persisted in, will eventuate in a reasonably 
satisfactory relief. 
Means for cutting Cicatrices.-A form of instrumentation applying 
in this direction finds its suggestion in the deep, yet perfectly-healed, cuts 
existing in the mouths of patients who have worn for considerable time dental 
plates which impinge unduly about the vestibular base. Acting on such hint, 
an impression of the parts is taken, and an apparatus constructed, possessed 
of dull edges, which press continuously and increasingly upon the cicatrix 
where it relates the cheek and gum sur- 
faces. This plate is to be worn for months. 
Success in securing permanent division of 
the cicatrix by this means is sometimes 
very satisfactory. 
Buckland's Cicatrix Cutter.- 
Fig. 840 represents an instrument of this 
class, the mutual device of the author and 
of Dr. E. B. Buckland, a student at the 
time attending the Philadelphia Dental 
College, by the latter of whom it was made. It consists, as seen, of two 
wings constructed of vulcanite and separated by pieces of watch-spring. The 
uprights, of which there are three, have the single office of steadying the 
wings. The clamps, seen to the left, are with a view of holding the wings 
together until fixed in place in the mouth. They fit in the holes seen. This 
instrument accomplishes its intention with fair satisfaction. 
Fig. 838. 
Fig. 839. 
Fig. 840. 1100 
A SYSTEM OF ORAL SURGERY. 
Inadvisability of using the Knife externally.-Cutting the face 
open with a view of getting at the cicatrices is an operation to be avoided 
where possible. Fig. 841 shows a mouth so cut, where, after the structure 
had been removed and the teeth separated, an interdental splint, with attached 
vestibular wings, made from celluloid, has been inserted. Here are met the 
double indications of holding the jaws apart and preventing reunion of the 
cicatrix to the gums. In theory the manipulations work beautifully, not so 
well, however, in practice, objection 
existing in a degenerative action 
which is found most apt to interfere 
with union of the cut cheek. In- 
struction exists in the diagram, as it 
exhibits the relation of the inter- 
dental splint. Where it is possible 
to get such apparatus in place by 
separating the cicatrix from the gum 
without external incision, the per- 
formance cannot be too highly 
commended. If attempt is to be 
made, the surgeon incises freely 
above and below, and, after forcing 
the teeth apart by means of a Kolbe 
gag, he moulds softened gutta-percha 
between the teeth and into the vesti- 
bule, hardening this by use of ice- 
water. Celluloid requires to be pre- 
pared upon an impression, a difficulty in procuring which stands in the way 
of the use of the agent. When, however, a mouth can be so opened as to 
permit of the introduction of impression cups and material, a vestibulo-inter- 
dental splint of this material is the least irritating of the different kinds used 
in the direction. 
Modelling Compound not to be used.-The use of modelling 
compound, as employed in dentistry, is not permissible in the direction here 
considered. As an agent ductile under a low degree of moist heat it peculiarly 
commends itself, but it is not in the mouth more than a day when it begins 
to crumble and lose its supportive power. 
Bridges of Bone.-Another expression of anchylosis is found in bridges 
of bone associating neighboring parts, commonly the edges of the glenoid 
cavity, with the neck of the lower jaw, or it may be that the relation is 
between two maxillary bones. These bridges are not infrequently to be 
broken and their absorption secured through dilatation conjoined with passive 
motion and the use of sorbefacients. In no cases, however, is it more desira- 
ble to guard against inflammatory results, and therefore such procedure is to 
be conducted with the same care as obtains in breaking up anchylosis in the 
Fig. 841. ANCHYLOSIS OF THE JAW. 
1101 
knee- or elbow-joints, a principle being to make haste slowly ; fracture of 
the neck may readily attend rough manipulation. Should such fracture occur, 
the desirability of making a false joint is to have consideration. If a diagnosis 
exhibit complete fixedness of the head of the bone by an osseous relation, then 
nothing better is to be attempted than the creation of such false joints, union 
of the parts being prevented by passive motion, and inflammation combated 
through antiphlogistics. Cases offer where the only possible prospect of relief 
exists in the production of such a false joint by operation directed particularly 
to that end. The author has met with success by excising from the posterior 
part of the body of the bone a V-shaped piece. A flap raised, the engine 
quickly removes the section. Saw or bur is used; the latter preferably. 
Anchylosis depending on Superficial Cicatrices.-In such con- 
ditions of anchylosis as depend strictly on superficial cicatrices, the propriety 
is always to be considered of a plastic operation, which, removing the deformed 
tissue, shall replace it with that which is normal, secured from some convenient 
part in the immediate neighborhood. If the cicatrix to be replaced be small, 
adjoining portions of the cheek may furnish the required material; if, on the 
contrary, it be large, the neck will have to be depended on, or it may seem 
preferable to employ the Italian method of taking a flap from the arm. The 
principle of the operation consists in mapping out on the part from which the 
flap is to be taken such extent and shape of surface as shall replace that 
designed to be removed. The cicatrix being dissected out, and all bleeding 
checked, the flap, as marked, is raised, leaving it attached alone by its pedicle ; 
and when hemorrhage in this also has been controlled, and the surfaces begin 
to glaze, it is carefully to be turned on the pedicle into its new position, and, 
being fixed by stitches, is to receive the attention required by wounds in 
general. The space left by the removal of the part is to be drawn together 
by stitches, adhesive strips, or other convenient means. Before undertaking 
a plastic operation, however, nothing is more necessary than to possess an ap- 
preciation of the reparative and nutritional powers of the patient. To operate 
on a person in a typhoid state, or on one the plasticity of whose blood is de- 
stroyed by the influences of syphilis, scrofulosis, scorbutus, or mercurialization, 
would be simply to court failure. (See Plastic Surgery.) 
Resume.-Concluding this consideration of fixedness in the jaw, a 
resume of the subject exhibits as causes of the condition,- 
1st. Spasm ; the treatment being of constitutional consideration. 
2d. Anchylosis by muscular induration ; the treatment being by 
local medicaments, combined with the employment of the dilator. 
3d. Osseous anchylosis ; the treatment being the breaking up by 
section or otherwise, if permissible, of the bony bridges. 
4th. Cicatricial anchylosis ; the treatment being by dilatation and by 
plastic operations. CHAPTER LXV. 
NEURALGIA. 
The term neuralgia is from the Greek roots veupov, a 11 nerve," and afyo^, 
" pain." It signifies an effect, not a cause; or if this definition be not an 
absolutely correct one, the exceptions to the rule it would form are exceed- 
ingly few. For such reasons it is, as commonly employed, a meaningless term, 
expressing idea of a condition about as indefinitely as the word suppuration 
conveys idea of the meaning of inflammation. 
Definition.-Neuralgia, as the appellation has definite application, refers 
to paroxysmal pains, localized or metastatic, presenting no manifestation of 
any lesion at the seat of complaint outside of the single phenomenon of 
pain. 
Character of Pain.-The pain of neuralgia is mostly, although not 
exclusively, acute in character, is confined to the tract or to the periphery of a 
certain nerve, remits, or more commonly fully intermits, and is accompanied 
with tenderness of the part involved only when an accidental associate lesion 
may exist, or when an irritation is so severe or has been so long continued as 
to have reacted on the neighboring vascular system. 
Diagnosis.-When, then, a practitioner has his attention directed to a 
seat of pain without apparent lesion, the matter of first importance is an ap- 
preciation of cause. To say that such a one has neuralgia, and to treat him with 
nervines, is to say just nothing, and certainly is to do nothing in the way of 
good except, indeed, by accident. A first duty is to search for cause, and, if 
discoverable, to remove it, if this be possible. Now, the causes of neuralgia 
are, as farther on is to be shown, sometimes very evident, and very easy of 
removal; and it will be seen, from illustrations offered, that one, from lack of 
observation, may utterly fail in giving a relief very easily and naturally afforded 
by another. Correctly speaking, every pain is a neuralgia. It is 
quite proper to say rheumatic neuralgia or gouty neuralgia. The suggestion 
affords a lesson in diagnosis. Rheumatism is always accompanied with 
vascular perversion ; the pain is not distinctly localized, but is diffused over 
a part involved; as a general thing it is a soreness rather than sharp, acute, 
concentrated pain. Movement aggravates this soreness, changes in tem- 
perature affect it; it is not paroxysmal, although it maybe, and generally 
is, remitting; in short, it has a history, and this history is not difficult to read. 
Gout exists in heredity and in over-generous living. It is decidedly inflam- 
matory in its local manifestations. It attacks in preference small joints. It 
1102 NEURALGIA. 
1103 
is accompanied by oedema, by congestion, and by enlargement of the veins. 
If it prove metastatic, the seat of transfer presents like vascular phenomena 
with the original inflammation. The cause to be removed in rheumatic 
neuralgia is rheumatism, in gouty neuralgia it is the gout. 
Neuralgia a Disease.-But is there not a condition-a disease-which 
is, or might be, termed neuralgia?*-as, for example, gout is a disease with 
an individuality, or rheumatism is a disease. If, without being influenced by 
other than his own observations, the writer were to answer the question, he 
should say decidedly there is not; and his reasons for the denial would lie in 
the fact that in one way or another he has become conversant with many cases 
which have stubbornly resisted a long course of treatment founded on an 
abstract neuralgic theory, but which have rapidly and readily yielded on the 
discovery and removal of some lesion of which the pain proved to be simply a 
sympathetic connection,-as, for instance, otalgia, hemicrania, or even sciatica, 
from an exposed tooth-pulp, from a splinter of foreign substance, or from the 
pressure of an exostosis. It is certainly true that there is a class of persons 
who might be termed neuralgic; these do not belong strictly to what is called 
the nervous temperament, but are the anaemic and prostrated. A plethoric 
temperament disposes to inflammation, but plethora is not inflammation; it 
is only a predisposition; the nervous temperament is only a predisposition. 
It cannot be denied that cases called neuralgia, and treated without ideas of 
specific lesion, do very frequently get well; but has not the indication been 
accidentally met, just as with Dewees's carminative a restless child is often 
prescribed for and cured, no definite idea of the ailment being entertained,-a 
single medicine possessing the requirement of various conditions? 
Neuralgia a Phenomenon.-If neuralgia, then, be simply a pheno- 
menon,-simply the expression of an immediate or distant lesion,-scientific 
preliminary treatment lies in search after cause. But is cause always evident ? 
Not certainly to our present acquirements. Cause, nevertheless, exists, and, 
failing to discover it, a practitioner is compelled to desert principles and treat 
experimentally. 
Predisposing Causes of Pain-Radiation.-Are there predisposing 
causes of pain-radiation ? Undoubtedly. These may, and always are to, re- 
ceive a proper degree of attention, as, in antagonizing them, it may prove to 
be the case that the proper lesion is not in itself of sufficient importance to 
* Posterior Root of Spinal Nerve the Seat of Neuralgia.-Dr. Anstie, whose mono- 
graph on Neuralgia has attracted much attention, as well as criticism for and against, ad- 
vances and defends the position that as regards both the seat of what must be the essential 
part of the morbid process, and the general nature of the process itself, we must possess 
very definite information indeed. In the beginning of his third chapter he says, I expect 
to convince most readers that the essential seat of every true neuralgia is the posterior root 
of the spinal nerve in which the pain is felt, and that the essential condition of the tissue of 
that nerve-root is atrophy, which is usually non-inflammatory in origin. There can be no 
doubt that such condition is to be met with as an explanation of peripheral pain; but such 
a condition is merely one cause of the neuralgise. 1104 
A SYSTEM OF ORAL SURGERY. 
inaugurate or maintain a neuralgia. Thus, of predisposing causes, a damp, 
cold atmosphere is to be named, fatigue, over-excitement, excess in drinking, 
poor diet, the too free use of coffee or tea, loss of sleep, costiveness, diarrhoea, 
-in short, anything which interferes with the easy and proper performance 
of functional life. 
Malaria as Cause of Neuralgia.-In miasmatic neighborhoods neu- 
ralgia frequently assumes a periodic type, influenced evidently by the malaria. 
It is without doubt true that the exhibition of quinine will and does, not in- 
frequently, cure such cases. Whether such cure is because the medicine con- 
trols the full and complete cause of the trouble, or only removes an exciting 
cause in the absence of which nature gains the mastery, need not be discussed, 
it being a matter of certainty that it is by no means always the case that in 
the destruction of periodicity pain is removed. 
Syphilis as Cause.-Syphilis is another of the exciting causes of neu- 
ralgia. Patients have sometimes great pain in diseased teeth, which can be 
held completely under control, although not cured, by iodide of potassium. 
The pain undoubtedly is from the teeth, as with a subsequent removal of these 
organs the trouble disappears. 
Catarrh as Cause.-An interesting paper prepared by Dr. A. G. Hobbs, 
of Atlanta, Georgia, considers headaches and browaches caused by pressure from 
nasal hypertrophies or foreign bodies, together with reflex pains that have for 
their origin pressure in the nasal cavities, whether they be located in the fore- 
head, the temples, across the bridge of the nose, or over the cheek bones. 
That such reflex pains do occur, and have for their cause pressure in the nasal 
cavities, Dr. Hobbs suggests, was known long ago. If they were only, he goes 
on to say, occasional or of short duration, they might not demand much at- 
tention ; but in many cases the pains are more persistent than the neuralgise 
from any other cause, and they many times produce a more profound impres- 
sion upon the general system, as indicated by a sense of lassitude, a haggard 
expression, a malassimilation, and a decided loss of weight. In his own note- 
book of the last three years he finds, bearing upon the comparative frequency 
of catarrhal and ocular neuralgias, fifty-four cases under the combined headings : 
Catarrhal neuralgia, ocular headache, and catarrhal and ocular neuralgia 
combined; thirty-six cases occur under the first caption, fourteen cases under 
the second, and four cases under the third. 
Epitome.-To epitomize the subject is to find the view that in a state of 
health the nervous system represents a poised balance: it is neither excited 
nor depressed; it works in entire harmony with its requirements. Apply a 
source of irritation, and this harmony is interfered with. According to the 
amount and extent of irritation, so the amount and extent of derangement. 
Life, happily says Bichat, rests upon a tripod of innervation, respiration, cir- 
culation. What affects one of these legs affects the life. To appreciate the 
phenomenon of neuralgia is to appreciate relations,-is to search over the 
economy until wherever a lesion exists it is exposed and comprehended. NEURALGIA. 
1105 
If after such manner of studying diagnosis a first view be directed 
to the nervous system, we look for a lesion in that part which, by the expres- 
sion of pain, seems most markedly implicated. The most decided cases of 
neuralgia are, without doubt, odontalgic. A tooth decays until the cavity 
containing the delicate nerve is exposed; the neuralgia has the simple, single 
signification of a direct irritation. Exostosis of a tooth-root presses on nerves 
ramifying in an alveolo-dental membrane; the signification is similar. 
Conditions.-Let reference be made to a neuralgia occurring in a part 
after amputation. Is cause not most frequently found in the squeezing and 
pinching of a nerve caught in the cicatrix ? Is it not the same history where 
tumors grow about and press upon some nerve-periphery ? May there not be 
instanced neuromatous expansions found in stumps, evidently enough sources 
of pain ? Let a different view be considered. Are there idiopathic inflam- 
mations of nerve-substance ? Do nerves in themselves degenerate and ulcerate ? 
The subject may be looked at from a still wider stand-point. There is no 
doubt that a pure nervous irritation of the system at large can exist. There 
is certainly an individuality living in this system. It has a mode of action of 
its own, and this action, as remarked by Dr. Wood, is susceptible of exaltation, 
depression, or deprivation in itself, and from the influences of its own peculiar 
agents. But can or do these vicissitudes express themselves ever, or even 
occasionally, in sharp neuralgic pains ? Connected with the digestive function 
we have often nausea and vomiting; with the secretory, disorder of the liver 
and kidneys; with the respiratory, hurried and otherwise irregular breathing; 
with the circulatory, a frequent and agitated, though seldom full or energetic, 
pulse. As the offices of the brain, suggests Professor Wood, are 
various, so also must be the signs of its excessive excitation. Irritation in the 
brain obeys the general laws of that morbid affection. If moderate, it exalts 
the healthy functions without otherwise altering them; if stronger, it more or 
less degenerates the functions; in great excess, it entirely changes or abolishes 
them. Thus, sensation and perception may be rendered simply more acute, 
or may be deranged, producing vertigo, pain, and every variety of disorder 
in vision, hearing, touch, etc., from buzzing in the ears, unnatural coloring of 
objects, a sense of tingling, formication, etc., to complete hallucination. The 
intellectual faculties and the emotions may be excited into increased vigor, or 
may be completely perverted, as in delirium and insanity. The general over- 
seeing faculty of the braip may be simply stimulated to increased vigilance, 
to a more ready and rapid response to all the intimations of its dependent 
functions; or it may be thrown into excessive disorder, evinced by restless- 
ness, jactitation, obstinate sleeplessness, etc. The motor faculty may merely 
impart increased activity and energy to the muscles under the influence of 
the will; or it may throw off more or less completely subordination to that 
principle, and give rise to every variety of spasm and convulsion. Finally, 
all the functions above referred to may be overwhelmed by an excess of irri- 
tation, and more or less completely lost in stupor and coma. This is nerve- 1106 
A SYSTEM OF ORAL SURGERY. 
irritation, from causes or influences which reside in, or in association with, 
the system, and to be considered alone in connection with the system.* 
Conditions.-Reactions of vascular perversion on the nervous system 
are to be considered. Coup de soleil and apoplexy may be esteemed opposite 
conditions in such reactions. How frequently have all the phenomena of 
partial compression-headache, giddiness, buzzing in the ears, disordered vision, 
tingling, formication, numbness, drowsiness, mental confusion, spasms, convul- 
sions, etc.-been quickly resolved and removed by the accidental rupture of a 
nasal vein having communication with a meningeal sinus I And how happily, 
when similar conditions have come on from long-continued chlorosis, has a 
course of iron relieved them ! Every portion of the encephalic mass, every 
portion of its continuation in the spinal canal, every nerve-periphery, requires 
a certain amount and a certain character of blood to keep it in proper equi- 
librium and nutrition. Too much blood, and too nutritious, and we have 
derangement from over-stimulation ; too little, and too poor, we have it from 
lack of pressure, lack of nourishment, and, in many cases, from effusions. 
Conditions.-Derangements in respiration act as predisposing causes 
to neuralgia. A patient who labors under an inability to aerate his blood, 
whatever the cause, fails to relieve that fluid of certain poisonous qualities, 
which, of necessity, sooner or later disturbs the nervous economy. 
Conditions.-Anything and everything, in short, it is to be said, that 
acts as a depressant in the vital economy, whether by over-stimulation or by 
under-nutrition, is to be thought of, and considered, in neural derange- 
ments : over-study, sexual excess, indigestion, hepatic and nephritic diseases, 
repression of the cutaneous circulation, the depressing passions, as fear, grief, 
melancholy; the employment of sedative poisons, as opium, tobacco, chloro- 
form ; living in an atmosphere impregnated with irrespirable gases,-any of 
these may assist some otherwise incapable lesion in determining an attack of 
neuralgia. 
Conditions.-Definite note is to be made of the fact that poison long 
continued proves so great a depressant of the vital economy that, though a 
lesion be fully and undeniably exposed and removed, secondary relations are 
apt to show themselves, which prove, not infrequently, of worse offence than 
the first. The writer directs particular attention to the clinical fact that sooner 
or later, after the cure of some special, severe, and long-continued neuralgia, 
the general health is found to become deranged, Jhis derangement showing 
itself as of common systemic import, otherwise as associated directly with 
some vital organ. 
Conditions.-The most extreme case of nervous mania that has ever 
come under the observation of the writer, this being accompanied with general 
hyperaesthesia and local neuralgia, was in the person of a carter, addicted to 
excessive smoking. For three days this man was uncontrollable by any but 
* Practice of Medicine, George B. Wood, M.D. NEURALGIA. 
1107 
physical restraint; at the end of which period a short interval of sleep and 
quiet were secured by placing between his lips a pipe of the strongest 
tobacco. The patient was finally cured by making the section of a nerve, and 
treating him with tobacco and sedatives, just as one treats delirium tremens 
with whiskey and narcotics. In this case there can be no doubt that the local 
neuralgia was goaded to its intensity by the perverted condition of the general 
nervous system. Similar cases associate with the improper use of opium, and 
with the abuse of the sexual instincts. 
Conditions.-In cases of persons long habituated to the use of opiates 
as a relief in neuralgic pain, operations which have considered and which have 
truly relieved the system of a lesion of offence are not apt to be followed 
by the immediate relief anticipated. Here is a point in which clinical obser- 
vation agrees with deductions of Dr. Anstie, that pain involves a lowering of 
function; on the other hand, it is not unreasonable to suggest that the con- 
dition is one of hyperaesthesia. Pain is of both conditions, and is to have 
such appreciation if it is to have cure. 
Conditions.-The first of the propositions quoted finds demonstration, 
plain enough, in the exhibitions of the inebriate, who manifests the first symp- 
toms of delirium only on the deprivation of the wonted stimulus, his aberra- 
tion having the meaning of exhaustion consequent on over-stimulation, as 
shown in what might be termed the synthetical proof of the primary demand 
for stimulation. 
Conditions.-From his own practice the author might cite many inter- 
esting cases illustrative of the difficulty of affording ease to a patient addicted 
to, and long dependent on, opiates, even where the original disease un- 
doubtedly has been cured,-as, for example, in such instances as the removal 
of cicatrices or of foreign bodies; these cases, however, are not at all in proof 
of neuralgia being a disease in itself, the reverse rather; pain being the ex- 
pression of exhaustion consequent on long-continued over-stimulation. No 
direct lesion remains in such instances to be considered. Cure lies in getting 
back a lost equipoise. Exactly what this lost equilibrium may be called is 
entirely immaterial. Let it be named vaso-motor paralysis, as desig- 
nated by Dr. Anstie, and let it be said that the paralysis is a direct extension 
of the original morbid process from the sensory root to the motor, affecting 
the original fibres in the latter, which are destined to control the calibre of 
the ocular and facial vessels. Granting the premise of neuralgia being an 
expression of the presence of an irritant, or accepting the hypothesis of Anstie 
as to its being a condition of diminished vitality, it must certainly be felt that 
the hypodermic injection of morphia,-of obtunding agents,-so continuously 
practised and recommended, has in it only the virtue of covering a wound 
temporarily from sight and calling it well; indeed, it is much worse than this; 
it is exhausting more completely that which is already weak; it is making 
neuralgia; it is treating effect, taking no heed of that which is the cause of 
effect. 1108 
A SYSTEM OF ORAL SUROERY. 
Use of Opiates.-It is not designed to convey an idea, however, that 
opiates are unjustifiably used in neuralgic conditions; pain in itself is, as has 
been suggested, a cause of exhaustion, and it may prove the lesser of two evils 
to moderate or annul pain. But opiates are to be employed as adjuncts. 
When a practitioner finds himself forced to rely upon such medicaments, the 
confession is extorted commonly that he knows solidly nothing of what he is 
treating. 
Neuralgia an Effect.-It is to be accepted, then, as the proposition of 
this chapter that neuralgia has its existence in a lesion. As a corollary it is 
deduced that treatment of neuralgia is treatment of a lesion. Lesions result- 
ing in neuralgia are of every possible kind and situation. The illustrations 
appended have the meaning of propositions in diagnosis. 
1. Tooth and Uterus.-Miss A., unmarried, thirty-five years of age; 
neuralgia situated in a bicuspid tooth of lower jaw; pain of nine weeks' 
standing; unbearably severe. 
Treatment.-Tooth, being carious and of little value, removed. No 
benefit. Examination directed to all the teeth of the mouth showed no 
associate lesion in any of them. Search for cause, extended over the system 
at large, discovered an ulcer upon the inner face of uterine fundus. The 
cure of this ulcer resulted in cure of the jaw pain. Later, this same patient 
applied to the writer for treatment of a defect in refraction ; this defect being 
so great as to require for its correction glasses ground as follows: 
Ji Right eye 4- 48 = c X 60 ax 35. 
Left eye 4- 32 = prism 4 ax 0 = c 4 48 ax 145. 
The lenses, constructed to order, worked so perfectly as to elicit from the 
patient the remark that she had never before seen the world as it is. Six 
months later they ceased to work at all; the lady being returned for con- 
sultation by her physician under an impression that she was going blind. 
Satisfied as to the correctness of the glasses, attention was at once redirected 
to the uterus, ordinary sponge tents being used for the exposure. The ulcer 
was back. Cure of it corrected the amblyopia. 
2. Tooth and Eye.-Mr. , thirty years of age; mydriasis and pain 
of two years' standing. Cause, in this case, lay in an encystment of a cuspid 
tooth. Cure, which was so immediate as to be almost complete before the 
patient left the office, was found in breaking up the cyst and taking away 
the enclosed organ. 
3. Ear and Maxillary Region.-An exostosis the size of a split pea, 
found in the external auditory meatus, was proved, by its removal, to be the 
cause of a facial neuralgia that had resisted a course of treatment continued 
over ten years. 
4. Tooth and Ear.-Patient, a medical student. Otalgia of five weeks' 
standing. No expression of local cause. Examination directed to the teeth NEURALGIA. 
1109 
discovered a nodule in the pulp of the most immediately neighboring dens 
sapientiae. Instantaneous cure resulted from extraction of the tooth. 
5. Tooth and Ear.-Patient, a professor of otology. Pain and ringing 
in the ear constant. Cause found in an undecayed wisdom-tooth which 
nature was making an effort to throw off. Extraction was succeeded by 
immediate cure. 
6. Antrum and Forehead.-The writer has met with a number of cases 
where severe neuralgia of the supra- and infraorbital regions were found to have 
as cause lesions of the antrum where not the slightest sign of disease in this 
cavity showed itself, yet where trephining was attended by copious discharge 
of pus, laudable or otherwise. In some instances the purulency has been 
found associated with a denuded floor, the bone requiring to be burred away; 
in others the condition showed itself as ordinary catarrh and yielded speedily 
to injections of stimulant germicides, of which corrosive sublimate in the 
proportion of half a grain to the ounce of water, a teaspoonful of which mixture 
is thrown in after a thorough washing out of the part, is to be recommended. 
Permanganate of potassium, five grains to the ounce of water, is a second suitable 
medicament. Still another is the aromatic sulphuric acid used half and half 
with water. Another one still is the boro-glyceride, a teaspoonful to water 
3iij- Listerine is an agreeable and useful injection ; it is to be diluted five 
or six times with water. Phenol-sodique in the proportion of a tablespoonful 
to the goblet of water is found equally antiseptic and curative. 
7. Maxillary Nerves and Head.-Mrs. B., wife of an undertaker, suf- 
fered for a long time from periodic attacks of pain about the face and head. 
This person, exceedingly quiet and retiring, spent most of her life in sunless 
rooms surrounded by the melancholy paraphernalia pertaining to the business 
of her husband. She was anaemic, and of poor general health and spirits. 
Although she had certain bad teeth, yet the pain from which she suffered had 
never seemed associated with them; indeed, so insensible were these organs 
to ordinary agents of irritation, that a diagnosis was founded alone on her 
general condition and surroundings, and remedies applied entirely in such 
direction. Tonics were administered, window-shutters unbowed, exercise and 
amusement, conjoined with generous living, were advised ; even with this 
entire change the patient failed to improve, but, on the contrary, grew worse. 
The diagnosis thus discovered at fault, the bad teeth were extracted ; still the 
condition persisted, the pain increasing. The patient was now treated for over 
a year, the Pharmacopoeia being exhausted in her case. Called in consul- 
tation, and acting on the belief of the existence of a special lesion in all 
such cases, the author determined, with the concurrence of the gentleman in 
attendance, to make a most careful exploration of her whole system. At 
this period the pain had assumed, and continued, the impression of an iron 
clamp about the head, terminating beneath the chin, which clamp seemed 
daily contracting itself. The terror and pain of this impression had become 
so great as to convert the woman almost into a lunatic. On inquiry, it was 1110 
A SYSTEM OF ORAL SURGERY. 
found that her internal organs had been most carefully examined, and inferred 
not to be in fault. Investigations, therefore, were commenced externally. 
First, was there any remaining tooth or teeth implicated ? The organs were 
examined for caries, for pulpitis, for nodules, for necrosis, for exposed ce- 
mentum. The teeth were in no wise involved. Next the spinal cord was 
explored and, through its expressions, the encephalic mass; organically, the 
trouble could not be found reflex from these points. Every articulation, the 
line of every artery, vein, and nerve was looked at so far as these could be 
followed. Every observation and fact which might throw light on the case 
were considered without success, as any discovery of an exciting cause was 
concerned. Finally return was made to the oral cavity. The teeth which had 
been extracted the year before were the molars and premolars of the left 
superior jaw. Might there not possibly have been just the smallest particle 
of one of these teeth left in its socket ? Pressure was being made in the 
canine fossa, when the patient made slight complaint; it was the only point 
that had yielded difference in sensation. Now, what was this sensation, 
and what did it mean ? It was not pain of which the patient complained, 
not discomfort; it was simply difference of sensation. It was a point, how- 
ever, which had yielded expression. It was in the line of the diagnosis to 
infer that here existed something,-the lesion, perhaps, of which we were in 
search. Acting on this hint, an exploratory trephine of the antrum was 
made. This discovered that branches from the infraorbital nerve, running 
across the cavity, had enlarged to the size of knitting-needles. These enlarged 
nerves, of which there were two, were cut away. The patient was immedi- 
ately relieved, and, although fifteen years have passed, she has had no recur- 
rence of her neuralgia. 
8. Tooth and Scalp.-Patient, a young lady, who shortened a summer 
and fall campaign to come to Philadelphia for advice concerning neuralgia of 
the face, and of the ear and scalp. She described her agony as being some- 
times so great that she could get only from chloroform but a very temporary re- 
lief ; she had been taking tonics and opiates throughout the summer; had no 
pain in any of her teeth, although on the upper jaw was a pulpless molar. 
Examining her mouth, attention was attracted to a peculiar overriding of the 
second bicuspid tooth of the lower jaw by the first molar; the employment 
of a delicate curved probe revealed caries of the first of these teeth exposing 
the pulp ; the tooth was extracted, and the distant and apparently dissociated 
neuralgia instantly disappeared. 
A tendency to nervous irritability which exists in this patient may very 
well be re-aroused by the presence of the upper pulpless molar; if this should 
prove to be the case, she is advised to have it extracted. 
9. Supernumerary and Non-Erupted Teeth.-Too much stress is 
not to be laid on the possibility of these relations with obscure neuralgia of 
the trigeminus. The writer has met with cases where no means known to 
him outside of exploratory incisions could have revealed the lesions. In one NEURALGIA. 
1111 
instance a tooth was found in the antrum. A second discovered a molar de- 
veloped in the condyloid process of the inferior maxilla. Quite a number 
have been brought to light in the palatine process. It is the case that non- 
developed or retained teeth will occupy positions in the jaws for years without 
giving trouble, yet later become sources of offence. In all obscure cases where 
localization of pain is complained of the practice of search by means of a bis- 
toury or of an exploring needle is to be recommended. 
A tooth is recognized by touch upon the enamel. Cure associates with ex- 
traction. Where a tooth is deeply and solidly impacted, spear-drills used with 
the engine are necessary to the removal. Non-erupted wisdom-teeth are particu- 
larly to be looked after. In the chapter on Anchylosis of the Jaw (which 
see) this matter has illustration. A wisdom-tooth, horizontal to the body of 
the lower gum, is seen lying directly upon the dental nerve. (For relations of 
diseases of the teeth to neuralgia, see chapter on Odontalgia.^ 
10. Urine and Nervous System.-During a mid-day meeting of 
the class of the Oral Hospital, convened for the purpose of experimentation in 
analyses of human fluids, the urine of one of the students, a martyr to neu- 
ralgia, was offered for examination, the heat test of which exhibited an opales- 
cence quickly passing to the showing of an (apparently) albuminous deposit 
startling as to quantity. The addition of nitric acid dissipated instantly both 
opalescence and threads, proving the coagulum to be not albumen, but lime 
salts, and directing attention to the immense waste going on in the nervous 
system as a possible, not to say probable, cause of the young gentleman's 
disease. As this person had his case under examination from time of en- 
tering the school, a year and a half, without having come either to cure or 
to a satisfactory understanding of his condition, he was put at once on the 
syrup of the hypophosphites with a view of finding correlative proof, if such 
existed, as to inferences arising out of the condition of his secretion. The 
specific gravity of the specimen was 1030.* 
11. Inferior Maxillary Nerve and Face.-Lesions of the inferior 
maxillary nerve, where it lies in the maxillary canal, are assuredly more com- 
mon than is generally supposed. Diagnosis of such lesions lies in the fact 
that pain, however it may shift about, is distinctly referable to the locality, and 
to evidence as afforded by a certain obscure tumidity never, perhaps, entirely 
absent. As a rule, the origin of these lesions is to be traced to some perio- 
dontal affection, although not infrequently direct injury has been inflicted on 
the nerve by an unskilfully-executed dental performance. It is to be men- 
tioned in this connection that cases seem to exist where a peripheral nerve 
of one side of the jaw passes to the other side, and where the mylo-hyoid 
nerve penetrates the bone and associates with the maxillary. At the present 
moment of writing there is a patient in the Oral Hospital whose inferior max- 
* This person is still under care of the writer, not being cured nor his case understood. 
Cause of his trouble seems to be beyond finding out. 1112 
A SYSTEM OF ORAL SURGERY. 
illary nerve was removed a week back from mental to dental foramen; from 
the time of coming from under ether influence, to the present moment, the man 
suffers as profoundly as ever from pain in that side of the lip supplied by the 
nerve removed. 
Nerves of Gum.-Reference is also to be made in this connection to a 
neuralgia of the lower jaw, which close examination shows to be associated 
strictly with the gums. Here is to be borne in mind that the part is supplied 
by branches accompanying the gustatory nerve, and that consequently the 
trouble is not-save accidentally-to be reached by a section that considers 
the dental nerve. The writer has in his experience verified this in cases where 
the dental nerve has been removed from the whole length of the canal, yet 
where cure has been secured only by a second section made near the oval 
foramen, and which included the mylo-hyoid and lingual. Attention is to be 
particularly directed to this complication. 
Neuralgia of Gums and Tip of Tongue.-Neuralgia, situated in 
the gum tissue, invites, in a search of its cause, to a consideration of the fol- 
lowing: The gums of the lower jaw are supplied by branches of the gustatory 
or lingual. This is a branch of the third division of the fifth, and comes off 
from that nerve just above the inferior dental branch ; communicating, not 
infrequently, with this last-named just before it enters the posterior dental for- 
amen to be distributed to the teeth. The lingual, in its continuation, supplies the 
tip of the tongue, at which point it associates with filaments from the hypo- 
glossal. The tip of the tongue is a frequent seat of paroxysmal neuralgia 
of an almost unbearable type. 
Experience has yielded the lesson that neuralgia situated in the 
substance of the lower gum is not to be cured by section of the dental nerve, 
unless, indeed, it happen that the pain is reflected from a lesion related with 
this nerve. Neuralgia of this situation and of the tip of tongue demands con- 
sideration of possibilities associated with the lingual nerve and with the hypo- 
glossal,-not overlooking, at the same time, probabilities connected with more 
distant anastomosis. Sectioh of the lingual nerve at the base of skull is made 
by means of same operation practised for dental. 
12. Foot and Knee.-One of the most impressive cases of neuralgia ever 
treated by the author has the following history. A Mr. B., serving in the 
war of the Rebellion, received, as near as memory serves to recall the case, 
three gunshot wounds,-one in which a small minie-ball passed through the 
tarsal bones, a second into the arm, a third lodged in the chest; the exact 
locations of the two latter are not distinctly recalled, as they did not associate 
with the case. After dismissal from the service, and after being engaged for 
a long period in the occupation of a carter, the patient commenced to suffer 
pain in the knee-joint and down the back of the leg, this pain increasing 
during a period of months to such extent as to require a constant watch being 
kept to prevent suicide. The author feels justified in asserting that seldom 
is witnessed greater expression of agony in a human being than was the NEURALGIA. 
1113 
almost constant condition of this man. Spending two months in observation 
and clinical study of the case, a conclusion eventually forced itself upon 
the mind that associated with the track of the ball through the foot existed 
some lesion of the dorsalis pedis nerve. Not that at this point there was 
pain, tenderness, or indeed expression of any kind, but a diagnosis by exclu- 
sion seemed to locate the trouble here: the author mentions particularly the 
absence of all signs, because he could find no one to second his conclusions or 
to endorse a proposition to make section of the nerve above the ankle. The 
nerve, however, was exposed and the length of an inch removed. From the 
moment of the operation the patient was entirely free from his neuralgia, 
although tenderness about the knee upon pressure continued for some little 
time, while the superficial portions overlying both malleoli sloughed and re- 
mained in an ulcerating condition over three months. 
Dental surgery affords countless instances of immediate pain-radia- 
tion. This radiation commonly relates to teeth having a common period of 
eruption, a diseased bicuspis of one side expressing itself in a healthy bicuspis 
of the other, a molar in a molar, etc. 
It is to be accepted that a diseased tooth may express itself in almost 
any part of the body; on the other hand, that disease in any part of the body 
may express its discomfort through a tooth. (See Odontalgia.} 
Treatment.-The idea is advanced that there is seldom or never what 
is termed idiopathic neuralgia but that pain is always a symptom. It is un- 
fortunately the case that too often as practitioners we discover weakness 
in search after cause, and thus find ourselves unable to treat a case scientifi- 
cally, being driven to empiricism. Even yet, however, medicine is able to 
render more than an accidental service; and the principle on which treatment 
is founded is that of soothing and quieting, either as applications refer to the 
system at large, or to a particular part involved. Sedatives, where there is 
general nervous disturbance, independent, so far as we discover, of other 
derangements, are found sometimes to act very happily. The tinctures of 
valerian and gentian in equal proportion, given in tablespoonful doses, make 
a fine combination. Bromide of potassium, where it seems necessary to keep 
up a continuous impression, is given with advantage in doses of ten grains, 
dissolved in a wineglass of water, from two to ten times a day. If adminis- 
tered, however, in a paroxysm, forty to sixty grains are found not too much, 
and it is sometimes well to combine with this small doses of opium or morphia. 
R Potassii bromidi, gr. xx; 
Morphiae acetatis, gr. I to J, according to severity of pain; 
Aquae, ^j. M. 
Sig.-The dose to be repeated in five or six hours, if required. 
Valerianate of Zinc.-Valerianate of zinc is a favorite preparation; 
it may be made into pills with conserve of rose, or any preferred vehicle, each 
pill to contain from one-half to a full Jgrain, to be given twice or thrice a day. 1114 
A SYSTEM OF ORAL SURGERY. 
Tincture Cannabis Indica.-Tincture of Indian hemp is prescribed 
in doses of five drops, repeated three times a day. 
Calomel. Tincture of Benzoin.-Where there is disturbance of 
the visceral health, it has been found occasionally successful to produce rapid 
but moderate salivation. Compound tincture of benzoin administered in fif- 
teen-drop doses three times a day acts happily in those wandering abdominal 
pains which sometimes put at fault in way of explanation. 
Aconite.-Aconite, made into quarter-grain pills, and administered cau- 
tiously, three or four times a day, is recommended. No preparation of this 
medicine approaches in efficiency aconitia as offered in the pure alkaloid form 
by Duquesnel's formula. No matter how severe the pain it is likely to 
be controlled. Great care is, however, necessary in the administra- 
tion. Dose is from to of a grain. The author's manner of pre- 
scribing is as follows: 
Ji Aconitae (Duquesnel's). 
Druggist will furnish fifty granules, as prepared by Schieflelin, each of which shall con- 
tain the one-two-hundred-and-fortieth part of a grain (gr. Of these the patient is to 
take one every two hours until numbness is felt or pain is found relieved. 
Note to be put on Label.-Overdose is to be antidoted by application of mustard over 
stomach, by hot baths, and by injection of oil of turpentine in the proportion of two table- 
spoonfuls to a pint of water. 
The care used as to direction is to avoid possibility of accident. 
It is found the case, however, that a patient soon learns to use the medicine 
with a satisfactory freedom. 
Tincture Veratrum Viride.-Tincture of veratrum viride, in con- 
ditions of undue circulatory excitement, exhibited in five-drop doses until 
such excitement is subdued, will sometimes quickly relieve the pain. 
Tincture of Digitalis.-Where a pulse is quick and the patient is of 
high temperature, tincture of digitalis given in ten-drop doses every three 
hours in a small wineglass of water acts at times as a specific. 
Colchicum.-Colchicum, where there is a supposed gouty association, is 
always wisely employed. The wine of the root is the best preparation. 
Specific Formula.-In rheumatic neuralgia, or pain associated with a 
rheumatic condition, the following formula is found very reliable ; certainly so, 
if some other existing lesion be not too antagonistic : 
Ji Potassii iodidi, ^ss; 
Extracti belladonnae, gr. vj ; 
Vini colchici radicis, §ss; 
Tineturae guaiaci ammoniatse, ^vj ; 
Aquae cinnamomi, ^vj. M. 
Sig.-A tablespoonful to be taken in a wineglass of water three times a day; if it purge, 
five drops of laudanum is to be added to each dose. 
Salicylate of Sodium.-A favorite preparation with many is the sali- 
cylate of sodium administered in doses of ten grains in water and lemon syrup 
three times a day. NEURALGIA. 
1115 
Arsenic.-Arsenic is frequently used with benefit. It may be exhibited 
in granules of the twentieth of a grain three times a day. It acts well in 
cutaneous neuralgia. 
Donovan's Solution.-Donovan's solution-the liq. hydrarg. arsen, et 
iod.-is a favorite with many practitioners. Dose, five drops three times a day ; 
avoiding salivation. This is an alterative, having a variety of significations. 
Exolgine.-Eight cases are reported in the British Medical Journal 
where exolgine was administered successfully in treatment of facial neuralgia. 
Gelsemium Sempervirens.-Gelsemium sempervirens in doses of 
from ten to twenty drops, repeated every hour until relief is obtained, or until 
giddiness or dimness of vision occur, is highly recommended in cases involving 
the teeth and the alveolar structures of the jaws. Dr. T. L. Lallerstedt con- 
siders gelsemium to be almost a specific for facial neuralgia, if used freely. 
He generally orders the fluid extract in twenty-drop doses every two hours, 
until the physiological effects are produced or relief is obtained. In cases 
of severe frontal headache he frequently prescribes forty grains of bromide of 
potassium with twenty drops fluid extract of gelsemium, to be taken every 
hour in a full glass of water. 
Tonics.-In all cases associated with lassitude and anaemia, the following 
is to be prescribed with benefit: 
U Elixirii gentianae ferrates, ^vj. 
Sig.-Teaspoonful four times a day. 
Or, 
Tincturae ferri chloridi, ; 
Quiniae sulphatis, 3j- M. 
Sig.-Fifteen to twenty drops three to four times a day, in water, 
Or, 
U Syrupi ferri pyrophosphatis, ; 
Quinise sulphatis, M. 
Sig.-Teaspoonful four times daily. 
Opium and Ether.-Opium and ether, given in full doses before a 
paroxysm, with ten or fifteen grains of quinine administered after the pain 
has ceased, will commonly make an impression, and frequently abridge the 
next attack. Success is claimed for the exhibition of opium to the production 
of narcotism. Such treatment is only, however, commendable as an occasional 
expedient. 
Muriate of Ammonia.-Muriate of ammonia, in doses of half a 
drachm three or four times a day, has been given with advantage; a soothing 
effect is produced by placing a lump of the salt on a burning coal, thus im- 
pregnating the atmosphere of a room. 
Oil of Turpentine.-Oil of turpentine is frequently applauded by Eng- 
lish practitioners. It is to be given in doses of from one-half to a full drachm. 
Chloroform and Camphor.-Chloroform, or chloroform combined 
with camphor, is recommended. A formula used by Dr. George B. Wood is 
as follows: 1116 
A SYSTEM OF ORAL SVROERY. 
Ji Chloroformi, f^ij; 
Camphor®, 3j. 
Sig.-Mix with the yolk of an egg and ^vj of water, and direct a tablespoonful to betaken 
every half-hour, every hour, or every two hours, according to the urgency of the case, until 
relief is obtained, or some decided effects are experienced from the medicines, either on the 
stomach or brain. Chloral hydrate, in ten-grain doses, may replace this, commonly happily 
in the case of the plethoric with strong hearts. 
Vermifuges.-Vermifuge medicines are frequently prescribed with bene- 
fit, particularly in the case of children, parasites frequently keeping up an 
irritation, although presenting no definite signs. Of these medicines, one of 
the very best is the combination of spigelia and senna: 
Jjt Syrupi spigelise et senn®, ^iv. 
Sig.-Teaspoonful doses three times a day. Four ounces will commonly be found enough 
to destroy any worms which may be present in the intestines, or to show error in diagnosis. 
Cathartics.-Cathartics are generally indicated in spasmodic attacks of 
neuralgia; especially is this the case when there is costiveness, furred tongue, 
sick headache or stomach, giddiness, etc. It is generally satisfactory practice 
to precede the purgation with a few quarter-grain doses of calomel. The 
character of the purgative is to be influenced by the condition of the patient. 
Sulphate of magnesia is generally found applicable. The compound cathartic 
pill is mostly found objectionable. The ordinary Seidlitz powder, repeated 
three or four times within the day, is a very happy and really refreshing medi- 
cine. If it should do no good, it certainly will do no harm. 
Strychnine.-Strychnine is an empirical anti-neuralgic medicine of much 
reputation. It may be prescribed in quantities of two grains, divided into 
eighty pills, one to be taken three times a day. 
Rauque's Liniment.-Of local remedies there is a great variety. A 
formula long celebrated under the name of Rauque's liniment is as follows: 
U Extracti belladonnas, ^ij ; 
Etheris, ; 
Aquae lauro-eerasi, ^ij. M. 
Sig.-Let it be rubbed on the part and saturated flannel be applied. 
Morphia used Endermically.-The endermic application of morphia 
is a common practice. The medicine may be used on a blistered surface, or 
be injected subcutaneously. To make the injection, it is only necessary to 
thrust the needle-point of the syringe into the rete mucosum, or it may be 
passed completely beneath the skin into the underlying cellular structure. 
Hot and Moist Applications.-Hot and moist applications are gener- 
ally found of much service in quieting pain,-the part to be enveloped in old 
and loose flannel, and evaporation prevented by an investment with oiled silk 
or other material. 
Snuff and Quinine.-In affections of the fifth pair, Dr. Richab, of 
Strasburg, attributes great good to one grain of quinine and two of common NEURALGIA. 
1117 
snuff, introduced into the nostril of the painful side. It is said in many cases 
" to act like a charm." 
Common Table Salt.-Table salt finely pulverized and snuffed into 
the nostril of the affected side will at times cure instantly, as temporary relief 
from pain is concerned. 
Meigs's Ether Treatment.-Professor Charles Meigs introduced, 
several years back, a plan of treatment with sulphuric ether, which yields at times 
great temporary relief. He confused the nerve-currents by taking a piece of 
sponge saturated with ether, and, by a continuous but irregular round, touching, 
here and there, different neighboring surfaces, until the pain would disappear. 
If, for example, it was in the forehead, he would touch over the supra-orbital 
nerve, over the infra-orbital, over the anterior dental, over the facial, over the 
cervical,-alternating the touches to these parts for a period varying from 
five minutes to half an hour. In most cases the pain is, for the time, relieved. 
Creasote.-Creasote, much diluted in simple cerate, is sometimes found 
very useful as a local obtunder,-five drops of creasote to an ounce of cerate or 
lard ; to be rubbed over the affected part, little by little, until relief is obtained. 
Kirby's Liniment.-Dr. Kirby directs a liniment made of one drachm 
of tincture of aconite to seven of fresh palm oil, or with two ounces of camphor 
liniment,-a half-drachm of the former, or double the quantity of the latter, 
-to be rubbed in twice or thrice a day, according to its effects. It must be 
watched, however, as the medicine is cumulative; if its poisonous effects 
appear, stimulants are to be given. 
Grave's Plaster.-Dr. Grave's neuralgic plaster is compounded as 
follows: 
R Pulveris opii, 3 b ; 
Camphorse, 3SS 1 
Picis Burgundic®, q. s. M. 
Sig.-Stupe the parts with warm water before applying it. 
Cazenave's Pomade.-Cazenave's pomade is thus made 
Chloroformi, 3j ; 
Potassii cyanidi, 3ijss j 
Adipis, giij; 
Ger® alb®, q. s. M. 
Sig.-Rub into the part a piece of the ointment the size of a pigeon's egg, and cover with 
oil-skin. 
Hydrate of Chloral.-Hydrate of chloral in the proportion of gss to 
^viii of water furnishes an admirable local obtunder. 
Salicylic Acid.-Professor Nussbaum lays great stress on the use of 
salicylic acid, speaking of it as a specific in tic douloureux. His prescription 
is as follows: 
U Acidi salicylici, gr. iij J; 
Sodii salicylatis, gr. xxxij. M. 
Within twenty-four hours the patient takes from four to six of such pow- 
ders. The author has had good results in his trials of the means. 1118 
A SYSTEM OF ORAL SURGERY. 
Salicylate of Cocaine.-Schneider (Allg. Med. CtrL-Zig.} relates 
the case of a woman in her third attack of neuralgia of the second and 
third branches of the trigeminus. The first attack, five years before, had 
been treated successfully with large doses of quinine. The second attack 
lasted almost six months; quinine was of no avail, but the pain gradually dis- 
appeared under the use of morphine and iron. The third attack had continued 
four weeks when Schneider injected salicylate of cocaine experimentally. The 
effect was extraordinary; six grains of the salicylate, injected into the cheek, 
caused the pain to disappear entirely, and occasioned a general feeling of well- 
being wholly free from any unpleasant collateral phenomena. The injection 
itself was painless and did not give rise to irritation. The patient was enabled 
to sleep at night, although before the pain had been most severe at that time. 
Eight such injections were given in the course of six days, and after that 
there was no pain except at the site of the injections, which was overcome by 
three applications of galvanism with the anode applied to the seat of the pain 
and the cathode to the back of the neck. 
Ear-Drops.-A writer in the American Practitioner recommends drop- 
ping into the meatus auditorius from four to ten drops of the following mixt- 
ure, remarking it to be " very rare, with the use of this liquid, that relief is 
not to obtained in a few minutes, and the patient asleep in half an hour, 
whatever may have been the severity of the pains." 
Extract! opii, 
Extracti belladonnas, 
Extracti stramonii, aa pars j ; 
Aquae pruni Virginiani, partes xij. M. 
If it should happen, says this writer, that at the end of eight or ten 
minutes the pain does not yield to the remedy (which sometimes happens 
when the quantity used has been too small, or when we have to treat a neu- 
ralgia which has already required the use of narcotics in any way), it is neces- 
sary to use a second dose, at least equal to the first. 
Alluding to the extemporaneous character of the preparation, it is suggested 
that it may be preserved, if care be taken to keep it cool, by pouring on its 
surface from two to four drops of sweet almond oil. 
Napheys's Recipes.-Among the recipes found in Dr. Napheys's 
" Modern Therapeutics," which have been selected from the prescriptions of 
eminent practitioners, are the following, which may not be without service to 
many readers: 
William Aitken, M.D., Edinburgh: 
When the neuralgia is superficial, compresses steeped in the 
following solution : 
Ji Atropiae sulphatis, gr. v; 
Aquas destillatas, f^iij. M. 
Sig.-Renew the compresses several times in twenty-four hours, continue them for at least 
an hour each time, covering them with oil-skin to prevent evaporation. Bad for the eyes. NEURALGIA. 
1119 
Brown-S^quard 
R Extracti belladonnas, gr. 
Extract! stramonii, gr. |; 
Extracti cannabis Indicae, gr. J ; 
Extracti aconiti, gr. ; 
Extracti hyoscyami, gr. §; 
Extracti conii, gr. j ; 
Pulveris glycyrrhizae, q. s. M. 
Sig.-For one pill. To be used with care, and not over four a day. 
Dr. Da Costa 
R Aconitiae, gr. ij ; 
Veratriae, gr. xv; 
Glycerini, fjij ; 
Cerati adipis, Jvj. M. 
Sig.-To be rubbed over the painful part, care being taken to see that there is no abrasion 
of the skin. 
Dr. William Hammond: 
R Extract! belladonnas, gr. v. 
Sig.-Divide into twenty pills. One three times a day. 
Liniment of Guy's Hospital: 
R Liquoris plumbi subacetatis, 
Tincturae opii, 
Meilis, aa $ij; 
Confectionis rosae, ^j. M. 
Fiat linimentum. 
London Hospital 
R Tincturae aconiti, 
Linimenti saponis, aa f^j. M. 
Sig.-To be used as an anodyne liniment. 
A liniment recommended by Dr. Napheys as an elegant sedative is as 
follows: 
R Atropiae sulphatis, gr. viij; 
Morphias sulphatis, gr. xvj ; 
Aconitiae, gr. ij; 
Acidi sulphurici diluti, t^v; 
Alcoholis, f^ss; 
Olei olivae, q. s. ad f^iv. M. 
Or, if a stimulant be also desired: 
R Chloroformi, f^ss; 
Spiritus terebinthinae, f^j; 
Camphorae, 5j; 
Olei lavandulae, H^xx; 
Olei olivae, q. s. ad f^vj. M. 
Sig.-The first four ingredients are to be mixed before adding the oil, and the liniment to 
be well shaken before being applied. 1120 
A SYSTEM OF ORAL SUROERY. 
Dr. Felix von Niemeyer, University of Tubingen: 
R Extracti hyoscyami, 
Zinci oxidi, aa ^ij. M. 
Sig.-Divide into eleven pills. Begin with one pill morning and evening, and increase to 
twenty or thirty of them daily. These, known as the Meglin pills, have a good reputation 
in Germany. 
Ludlow's Formula.-The late Dr. D. J. L. Ludlow recommended the 
following formula with large confidence. It is used by rubbing into the painful 
part a piece the size of an ordinary pea. 
U Atropise sulphatis, gr. ss; 
Aconitise, gr. iss; 
Olei tiglii, gtt. ij ; 
Ung. petrolii, $ij. M. 
Compression of Arteries.-One of the most intractable of the neu- 
ralgias of the scalp ever met with in the practice of the author yielded to 
compression of the facial arteries. 
Massage.-Methodical rubbing, massage, of a neuralgic seat is recom- 
mended by Dr. S. Weir Mitchell. 
In a case, noted by that author, of contusion of the ulnar nerve subject to 
intense neuralgia, the nerve being hardened and enlarged, tender, and endur- 
ing no application of electricity, the pain was relieved by hypodermic injec- 
tions ; but after using many remedies, and at last the actual cautery over the 
nerve-trunk without altering its size or tenderness, slow and careful manipu- 
lation was tried to test if it could be enabled to bear pressure. After a course 
of gentle friction, lasting half an hour, the object was attained, three sittings 
enabling the parts to be rubbed and even kneaded quite roughly. 
Unique Case.-A case of neuralgia of seventeen weeks' standing, the 
seat of pain being the lumbar muscles, was instantly cured by the author on 
relieving the pregnant uterus found caught by the promontory of the sacrum. 
The patient, when met, was found propped on all sides by pillows, not having 
been able for the period named to touch a foot to the floor. Correction of the 
misplaced womb allowed her at once to go about as usual. 
Errors in Refraction and Posterior Conus as Causes of Neu- 
ralgia.-The author concludes this chapter by directing attention to the seem- 
ing impossibility of explaining many neuralgic cases, while at the same time he 
leaves the inference to exist by reason of what has been said in the text that 
ability to diagnose is strictly proportional with the acquirements of a practitioner. 
He holds it a necessity that ophthalmology be understood by an oral surgeon 
with the minuteness of specialism. In this last direction it will be found that 
cases enough offer where nothing but the correction of errors in refraction is 
found capable to the cure of what is truly a sympathetic disturbance. Posterior 
conus, the remnant of some previously-existing glaucoma, is a condition the 
possibility of which is always to have consideration in search after obscure cause 
of facial neuralgia, a discovery of which demands use of the ophthalmoscope. CHAPTER LXVI. 
NERVE LESIONS PROPER AND THEIR TREATMENT BY 
SECTION. 
Neuralgia arising out of disease of a nerve incurable by medical means 
finds remedy in removal of the affected part; otherwise, by section made 
between the seat of lesion and sensorium. (See Neuralgia.') 
Fig. 842. 
Refer for general description to page 114. 
INFERIOR MAXILLARY NERVE. 
Fig. 842 shows the location of the inferior maxillary nerve (14) as lying in 
the jaw and crossing the zygomatic fossa, together with the gustatory (12), the 
auriculo-temporal (10), the mylo-hyoid (13), the dental (15), and the mental 
(16). Other branches shown in the diagram belong to the motor root, and 
1121 1122 
A SYSTEM OF ORAL SURGERY. 
are, of course, not of concern in a present consideration. The part removed, 
to secure exposure in the maxilla, is the external plate. The old ways of 
operating on this nerve have been surely succeeded, as the writer cannot 
help but feel, by operations soon to be described. 
Author's Operation. First Manner.-Having a patient seated in 
a reclining chair with the body thrown back at an angle of about fifty degrees, 
the side of the face to be operated on being turned toward the light, the opera- 
tor feels for the notch upon the jaw, over which runs the facial artery. The 
vessel found, its position is marked by a line corresponding with its direction. 
Next a second line is made upon the neck parallel with the plane of the lower 
jaw and immediately beneath it. A succeeding step draws this line upward 
until it rests upon the body of the bone, when, the finger-nail guarding the 
artery, an incision, reaching 
to the bone, is cut as far for- 
ward as the position of the 
cuspid tooth. The wound 
thus made is separated by re- 
tractors, and search is made 
for the anterior, or mental, 
foramen. This hole exposed 
and the terminal position of 
the nerve thereby accurately 
ascertained, a succeeding step 
lifts the roof from the canal 
in which the nerve lies. This 
last manipulation is accom- 
plished in one of two ways. 
Using a raspatory to scrape 
away the periosteum, the oper- 
ator employs a circular-saw 
revolved by the engine, or, he 
may gain the same end with 
chisel and mallet. 
Adopting the first means, 
the saw is put in rapid mo- 
tion, and two lines, corre- 
sponding to the width of the 
canal, are made, as shown in 
the cut, from the circular 
black opening in front, representing the foramen, as far back as it is desired 
to go. These lines are joined posteriorly by a trephine-cut. The roof of the 
canal, as will be understood, has thus been freed, and it only remains to lift it 
away; the vessels and nerve lying freely exposed by the operation to the eye 
of the surgeon. 
Fig. 843.-The Author's Operation for Ex- 
posure of Inferior Maxillary Nerve. NERVE LESIONS PROPER-TREATMENT BY SECTION. 
1123 
A modification of the above-described operation consists in employing a bur. 
The bone being denuded of its periosteum, and the foramen exposed, the 
canal is opened by burring away its roof. This latter performance is easier of 
accomplishment by the inexperienced than is the former; the exposure of the 
nerve can be made equally perfect. 
Author's Second Manner.-The second manner employs a sharp 
chisel, the lines shown in the diagram being cut with that instrument propelled 
by blows from a mallet. 
Exposure thus secured, the cord is lifted and severed; otherwise 
treated as indicated. 
Where bleeding results from the cutting of the dental artery it is 
readily controlled by the use of a pledget of sponge thrust into the canal, or, 
what is better, by the use of a match-stick whittled into a wedge shape and 
forced between the artery and side of canal. If the sponge be used it is to 
have a strong string attached for convenience of subsequent removal. 
Dressing the Wound.-The immediate operation done, a succeeding 
step rounds the two edges of bone, and, after well washing the parts with a 
view of getting away all debris, closes the external wound, which, when the 
stitching is complete, is found to be upon the neck and in a situation that 
shows no scar. 
The author assumes that the diagram serves fully to familiarize the surgeon 
with the manipulations, and further that the operation is of a character to 
show and speak for itself. 
Section of Inferior Maxillary Nerve at Oval Foramen.-The 
author has devised and highly commends the following manner of exposure 
(see Fig. 844). Open into the nerve-canal in the inferior maxilla as shown 
in the lower part of the diagram. Pick up the nerve on a tenaculum and cut 
it. Seize next with bull-dog forceps, as shown, and, preserving the continuity, 
bur along the line of nerve and canal until the dental foramen is reached. 
Enlarge the foramen, using bur and engine. At this point in the operation 
when enlargement of the foramen has been made and free passage upward 
secured (see square opening showing in bone), the nerve is slipped through a 
fenestra, as seen, which is pushed up as far as it will go. When the base of 
the skull is reached, and the nerve is seen to stand clear, a pair of eye-scissors 
or the blade of a tenotome, as shown, completes the section. 
If not thought necessary to open the canal in front of the 
masseter muscle, a line vertical with the posterior border of the ramus may be 
cut. The isolation of the nerve, after the dental foramen is enlarged, is seen 
to carry the instrument of the operator between the external and internal 
pterygoid muscles. (See Fig. 842.) 
The enlargement of the dental foramen does not interfere with 
either the health or the offices of the condyloid or coronoid processes, while it 
exposes the nerve quite as freely, as exhibited in the diagram, as when these 
bodies and as well a portion of the ramus have been removed. 1124 
A SYSTEM OF ORAL SURGERY. 
Referring to the diagram, the anatomy as well as the operation are 
to be clearly appreciated. The opening in the bone shows the nerve up to 
the point of emergence from the oval foramen; this foramen showing just 
Fig. 844. 
back of the fenestra. Crossing the instrument externally is the internal max- 
illary artery, the position and relation of which are plainly seen in the diagram. 
Running parallel with it (see Fig. 842) is the gustatory nerve. In the opera- 
tion, as here shown, the nerve, after being cut, is passed, exactly as before, 
through the fenestrated instrument exhibited, and by means of which it is 
isolated up to the base of the skull. The knife used to cut it is very small 
and of sickle shape. To cut the lingual nerve implies simply the use of a 
hook with which to pick it out, or the knife may be used as described in 
the immediately succeeding operation. 
Neuralgic pain persistently located in the lower lip, one side 
or the other of the mesian line, is oftentimes successfully treated by section of 
the affected nerve at its exit from the mental foramen. The operation is ac- 
complished by sinking a bistoury to the proper depth adjoining the second 
bicuspid tooth and shaving the bone as far forward as the cuspis. When NERVE LESIONS PROPER-TREATMENT BY SECTION. 
1125 
the pain returns as result of reunion of nerve the performance is to be 
repeated. 
Operation by Removal of Coronoid Process.-The author has 
now on many occasions done neurectomy of the inferior maxillary nerve most 
satisfactorily after the following manner, the cord being cut where it emerges 
at the oval foramen and its whole length pulled from the dental canal. Make 
an incision that reaches from the zygomatic arch, commencing at the point 
where the yoke overlies the coronoid process, curvilinearly downward to a 
point a little above the line of the duct of Steno.* Cut directly down upon 
the bone. Open the wound by means of retractors and clear the process of 
the masseter muscle. Control hemorrhage by use of ligature or styptics, 
preferably the former. Scrape periosteum from coronoid process and saw the 
bone. The part being free, pry it out of its place, and, by use of forceps, lift 
and twist it. Carefully cut away attachment of temporal muscle. The bone 
being away, ligate internal maxillary artery. This done, use blunt hook in 
search after nerve, the line of which is obliquely upward and downward from 
oval foramen to posterior dental canal. The nerve being caught upon the 
hook, it is to be lifted until a finger can be gotten under it, when, with a 
motion that draws from below, it is pulled out of the dental canal. Next 
slip the nerve through a fenestra,-see right-hand instrument, Fig. 844,- 
which push toward base of skull until place of division of nerve into gusta- 
tory and auriculo-temporal is reached. Take next a curved blade, as seen in 
diagram. If the neurectomy is to be of the inferior maxillary nerve alone, 
the cut is made below the fenestra precisely as in the previously-described 
operation and as shown in Fig. 844. If, on the contrary, the excision is to in- 
clude the gustatory and auriculo-temporal nerves, the blade is to be placed 
above the fenestra and the cut made only when the knife has reached the bone. 
SUPERIOR MAXILLARY NERVE. 
Section of the branches of the second portion of the nerve is made at 
various points as indicated by various conditions. Fig. 845 shows a neuroma 
diagnosed by the writer as existing upon the under surface 
of the nasal arch. In this case the neuralgia was of twenty 
years' standing. Fig. 846 exhibits the steps of an opera- 
tion which exposed and removed the bone with which the 
tumor was related ; the circular-saw and engine were used. 
Branches External to Infraorbital Foramen. 
-Neuralgia of parts supplied by branches external to the 
infraorbital may find relief by section made at the foramen. 
Innervation from Branches within Infraorbital Canal.- 
Parts innervated by branches coming from the canal demand section of the 
Fig. 845. 
* Line of Steno's Duct.-Transversely from the tip of the lobe of the ear to a point in 
the superior lip midway between its free border and the nose. 1126 
A SYSTEM OF ORAL SURGERY. 
nerve within that channel. To expose the part the operator commences by 
dissecting a flap from over the region of the antrum. The anterior wall of 
that cavity is next trephined. A succeeding step chisels away that portion of 
the orbital floor which makes the inferior boundary of the canal. The nerve, 
now laid bare, is to be incised. The section can be made from the 
inside of the mouth by trephining. 
Fig. 846. 
Nerve Lesions of the Maxillary Sinus.-Nerve lesions existing in 
the maxillary sinus are exposed by dissecting the overlying parts within the 
mouth and trephining. Illustration 7 in the previous chapter is an example 
of a lesion so situated and treated. 
Criticism on Operations.-Cases of neuralgia occur, where pain is so 
diffused over the track of the second division of the fifth nerve, and where 
the suffering of a patient is so intolerable, as absolutely to force the surgeon 
into operation even in the absence of a perfectly-reliable diagnosis, and when 
it is felt that no section outside of the main branch may promise any good. 
In these instances, the results too frequently prove the worse than uselessness 
of what has been done; too often does continuous pain, transferred to some 
other part, show that the lesion is still back of the seat of operation. The 
author does not, however, condemn these operations: desperate evils call for 
desperate remedies. He would only enjoin that it be well understood that a NER VE LESIONS PR OP ER- TRE A TMENT B Y SECTION. 
1127 
desperate remedy is not to be unnecessarily employed, and that no man is to 
undertake the section of the superior maxillary nerve until assured that he has 
mastered all that can be known of his case. 
Carnochan's Operation for Neurectomy of Second Branch 
of Trifacial Nerve.-The exposure of the second branch of the fifth 
nerve was first practised in this country by Dr. Carnochan, of New York, and 
the plan originally adopted by that surgeon for the exposure is the same, with 
unimportant modifications, as is still employed. 
Commencing this operation, a Y-shaped or simple curvilinear flap 
exposes the anterior wall of the antrum. A trephine, as large as may be used, 
is now made to cut out the wall. The posterior boundary thus exposed, a 
second trephine, necessarily somewhat smaller than the first, removes a section 
of this. The spheno-maxillary fossa thus exposed, the nerve is found and 
isolated from its surroundings and as much of it excised as may conveniently 
be effected. If, in the opening made through the antrum, space enough has 
not been secured by the trephine, the operator finds himself compelled to 
remove, by means of chisels and cutting pliers, the lower boundary of the 
infra-orbital canal; this will be found to enlarge the working space considerably. 
In seeking in the fossa for the nerve, too much delicacy cannot 
be exercised, as above all things it is desirable to have, if possible, a healing 
of the parts without degeneration or destruction of the tissues. 
A mode of exposing the antral wall, affording greater convenience 
in the succeeding steps of the operation, consists in dividing the lip and cheek 
by an incision leading directly from the labial commissure to the malar bone: 
two flaps are thus created, one being directed inward, the other outward. 
Langenbeck's Operation.-An operation devised by Langenbeck for 
section of this nerve, being, however, one that is scarcely likely to meet with 
much favor, consists in the use of a stout tenotome, which is thrust, with its 
point directed downward and backward, immediately beneath the external 
palpebral ligament, being kept in close contact with the outer wall of the orbit 
until it reaches the spheno-maxillary fissure, this being recognized in the ces- 
sation of resistance. The edge of the knife is now turned so as to shave the 
surface of the bone, the nerve being cut by a sawing motion as it enters the 
orbital canal. A cut opening the canal is now to be made through the floor 
of the orbit, and with a hook the nerve is to be caught and pulled from its 
bed. 
Pancoast's Operation.-The elder Pancoast's operation for exposure 
of the second and third branches of the trifacial is performed as follows: 
First, as exhibited in Fig. 847, a trap-like flap is made across the ramus of 
the lower jaw. This being raised and reflected, the masseter muscle is shaved 
from its attachment and the coronoid process exposed; this process is next 
sawed off at its root, and, having detached from it the temporal muscle, is 
removed; the muscle being thrust upward out of the way. This series of 
manipulations exposes the zygomatic fossa, across which, but overlaid with some 1128 
A SYSTEM OF ORAL SURGERY. 
fatty tissue, passes the internal maxillary artery, which a succeeding step picks 
out and ligates. The next use of the knife is found in detaching from the 
great ala of the sphenoid bone the ex- 
ternal head of the pterygoid muscle ; this 
accomplished, any soft parts found in the 
way are to be pushed aside with the finger, 
after which attention is to be given to 
stanching the hemorrhage and oozing. 
The parts thus exposed and dried, the 
nerves of the spheno-maxillary fossa are 
plainly visible, and may be exsected by 
using a pair of curved scissors. 
Author's Operation.-An opera- 
tion practised by the author for making 
section of the second branch of the fifth 
nerve immediately as it emerges from the 
foramen rotundum, being a manner supe- 
rior to, and easier of accomplishment, as 
he thinks, than either of the others described, is as follows: Place the patient 
on a pallet and etherize. Next expose the anterior face of the antrum by 
a trap cut in the cheek, which trap is to open toward the eye, and is to 
hold the branches of the infraorbital nerve, which nerve is to be dissected 
out of the flap and held in the grasp of a forceps out of the way. Hemor- 
rhage being controlled by ligatures, styptics, or other means, the face of the 
antrum is cut away by use of bur (Fig. 848) revolved by the surgical engine. 
With the nerve secured, as directed, for a guide, the floor of the infra-orbital 
canal is cut away, and the nerve followed to and along the floor of the orbit. 
The posterior wall of the antrum reached, the bur is passed backward through 
it; the nerve still being preserved intact. A succeeding step removes, by 
means of the bur, such extent of posterior wall as exposes the spheno-palatine 
fissure. At this point the branches relating Meckel's ganglion are met. Here 
the fenestrated instrument (Fig. 844), has the nerve slipped through it, and 
being pushed back until meeting the obstruction, the curved blade (Fig. 844), 
is, in turn, directed back of it, and over the Meckel branches, when, the fora- 
men being reached, the nerve is cut off. In performance of this operation, 
great care is required to avoid cutting the nerve prematurely by the rapidly- 
revolving bur. The figure shows the stage of operation when the bur has 
cut out the floor of the orbit. 
Study of Fig. 848.-The diagram shows, first, the external opening 
made into the antrum. Second, the nerve dissected out of the flap and con- 
trolled in the grasp of locked forceps. Third, the nerve where internally it 
lies upon the floor of the orbital cavity. Fourth, its position in spheno-pala- 
tine fissure. Fifth, the fenestrated instrument, the circle of which is lost to 
sight, together with the nerve in the obscurity that conceals the round fora- 
Fig.847. NERVE LESIONS PROPER-TREATMENT BY SECTION. 
1129 
men. The shadow beneath the nerve represents the line of the 
bur where the orbital floor has been cut away, which cutting permits of the 
nerve falling into the antrum. The posterior antral opening is made beneath 
the orbit, so it is to be understood that in the operation the director would 
not be seen in the orbit, as shown in the cut, but below it, in the antrum, the 
nerve having been dropped to this latter position, as described. 
Fig. 848.-Author's Operation for Exsection of Superior Maxillary 
Nerve at Base of Skull, using Engine and Bur. 
Study of Skull.-If, turning from the cut, the student will take up a 
skull, he will find that the spheno-maxillary fissure, seen by the side of the 
optic foramen at the apex of the orbit, leads directly to the round foramen, 
and that by means of a fenestrated hook he could isolate a nerve from its as- 
sociations and then reach the base of the cranium. 
Referring to the author's operation for exposing the zygo- 
matic fossa and its nerves, it is seen that the same exposure can be followed 
to the spheno-maxillary fissure. It implies simply detachment of heads of 
pterygoid muscles. (See Fig. 842.) 
Clean Cut required in Neurectomy.-A nerve-section is to possess 
the feature of a cut absolutely clean. Section made after any manner, or by 
means of a form of instrumentation that gives a fringed or frayed expression, 
is apt to be associated with bad results. An experiment original with, and 
performed each session before the class of the Oral Hospital by, Dr. M. H. 
Cryer, is worthy of close consideration. Two insulated wires, extending the 1130 
A SYSTEM OF ORAL SURGERY. 
length of one of the lecture-rooms, are related with a bell and a battery. 
Making a clean cut of one or both of these wires crosswise, contact elicits no 
response by the bell. Scraping the wires, so as to interfere with the insula- 
tion, touch results in vigorous ringing, continued so long as contact and non- 
insulation exist. Relating the experiment with nerve fasciculi 
deprived by accident of the insulating neurilemma, inference is drawn that 
cause of pain exists, under all circumstances, in absence of insulation, and 
that it is to be recovered from only when nature or the physician cures such a 
defect. It is argued that in inflammation neurilemma is destroyed, allowing 
contact of immediately-related fasciculi, hence continued worrying of the sen- 
sorium, as a principle, if not similar with, yet analogous to continued ringing of 
the bell. As corroborative of the experiment, a case some years ago 
offered in the clinic of the hospital service, where a median nerve, much frayed, 
and imprisoned in a cicatrix, afflicting the patient with persistent pain, had 
cure of complete character resulting from dissecting out and sharply incising 
the cord crosswise some little distance from the frayed end. Accepting contact, 
as here alluded to, as an explanation of pain, interest in the subject invites to 
examination in every individual case as to probabilities and possibilities in this 
direction. 
Exposure of other Nerves of Head.-For exposure of other 
nerves of the region under consideration, see succeeding chapter. CHAPTER LXVIL 
EXPOSURE OF NERVES.-NERVE LESIONS PROPER 
AND THEIR TREATMENT BY STRETCHING. 
Study of the preceding two chapters has prepared the reader to pass to a 
consideration of the present one. The study is that of nerve-stretching, but 
it embraces, necessarily, exposure. The two are here conjoined with view of 
economy in space. 
Definition.-By nerve-stretching is implied the exposure of a painful 
nerve, the lifting of it from its bed, and the pulling of it. The performance 
was introduced as a surgical operation some twelve years back by Nussbaum, 
and, by reason of an occasional success found in the practice, has established 
for itself a position which attracts a certain amount of attention. 
Scientific Meaning of Operation.-Nerve-stretching, when practised, 
is to find its endorsement wholly in diagnosis. To do the operation simply on 
the data of statistics is to engage in an unjustifiable procedure. The scientific 
meaning of the performance lies in breaking up areas of obstruction existing 
somewhere along the line of a nerve-cord, and not in the fallacy that, by 
stretching, a transmitting capacity is lessened, or that new impressions are 
made on the centre of origin. As illustrative, reference is to be made to 
an example of lesion of anterior tibial nerve referred to on page 1113. It 
happened in this case that an absolute cure of several years' standing 
was but comparatively lately replaced by a recurrence of the old pain, and, 
on application of the patient, arrangements had been about completed for 
repetition of the exsection. Apart from sympathy for the sufferer, much 
interest was excited in the mind of the writer, as he regarded the condition 
as identical with inflammatory obstruction, and one where stretching-i.e., 
breaking up adhesions-was the indication, a conclusion which he expected 
the operation fully to endorse. A few days before the one set apart for the 
meeting, the patient, while descending some stairs leading from a chamber, 
caught his toes in an irregularity of the carpet, which accident compelled his 
foot to extreme extension, throwing the man forward on his face. A draggy 
snap is reported as being both heard and felt. There has not been a twinge 
of pain felt since. 
Extra- and Intra-Lesions.-Nerve-stretching, to be effective, must 
associate with extra- and not with intra-lesions. Where a distinction is recog- 
nizable, good will be found attending operations practised in relation with the 
first, evil when in connection with the second. The author is compelled to 
1131 1132 
A SYSTEM OF ORAL SURGERY. 
recognize out of his experience that a great many cases of neuralgia indicate 
a requirement for nerve-stretching. Unfortunately, in a majority of the cases, 
the reading of the indication is very difficult. The writer has to admit mis- 
takes or failures, as it may be thought well to distinguish them, which furnish 
him with sufficient reasons to recognize his lack of personal judgment in the 
direction. No diagnoses are more difficult, as a rule, to make out, than those 
that relate with neuralgia. 
Recognition of Seat of Lesion.-Exposure of the main branch of 
a nerve, some radicle of which is the part involved in a plastic effusion, and 
the stretching of this main branch, is not at all the indication. Recognition of 
the exact seat of lesion is to go before operation, and the exposure of the part 
involved is to be not farther away from the obstruction than permits the 
lesion being acted on by the force exerted; this applies particularly to nerves 
running at obtuse and at right-angled relations. 
Nerves, like arteries, are exposed according to directions furnished 
by the anatomy of a part. 
INFRAORBITAL NERVE. 
The infraorbital is the main continuation of the superior maxillary division 
of the trifacial nerve; its entrance upon the face is from the infraorbital 
canal; the direction of change at the foramen is at a right angle; seat of 
lesion exists not infrequently at the orifice of this canal, being resultant of 
blows or other injury received upon the face. (Fig. 849.) The letters OP 
and L point out the radicles of the nerve and the muscles upon which they lie. 
Referring to Fig. 58 as a study, the student will recognize the nerve as 
breaking up, immediately on exit from the foramen, into three sets of radicles, 
which supply respectively the palpebral, nasal, and labial localities; conse- 
quently pain met with in these regions is plausibly referred to as being related 
with the sensorium by the cord found at the foramen, and an inference is 
most likely to be indulged that exposure at such point affords command of the 
lesion. Here it is necessary to look beyond and consider that in the infra- 
orbital canal a branch is given off which supplies the anterior teeth, and that 
farther back a second branch is given off by the main nerve innervating the 
bicuspidati and molars,-situations much more likely to afford lesions than 
either of those first named. (Turn also to Figs. 13 and 59.) 
To expose the Infraorbital Nerve.-To expose the infraorbital 
nerve at its exit from the facial foramen, it is the practice of the author to 
feel for the depression, using the pulp of the little finger, and, when found, 
dissecting carefully to it by means of a single incision carried in the direction 
of the lip. The body exposed, a tenaculum is passed beneath it and the 
stretching accomplished, or the nerve may be excised, as preferred. 
Agnew's Method by Flap.-A means of exposing the infraorbital 
nerve, suggested by Professor Agnew, is shown in Fig. 849. Although the 
author disagrees with his valued and learned friend as to a necessity for more NERVE LESIONS PROPER-TREATMENT BY STRETCHING. 
1133 
than a single cut where the object is simply stretching, he yet regards the 
experience, out of which the recommendation comes, sufficiently to know that 
his readers will find profit in study of the diagram. 
SUPRAORBITAL NERVE. 
The supraorbital is the continuation of the ophthalmic division of the fifth 
nerve; its branchlets supply the upper eyelid, the orbicularis palpebrarum, 
occipito-frontalis, and corrugator supercilii muscles, also the periosteum of 
Fig. 849. 
Fig. 850. 
Exposure of infraorbital nerve. 
Exposure of supraorbital nerve. 
frontal and parietal bones. Neuralgic phenomena are frequent associations 
with it. Diagnosis is apt to be very confused. The appearance of this nerve 
upon the forehead is at the supraorbital notch. It lies, as its trunk is con- 
cerned, upon the periosteum, being covered by skin, fascia, fibres of occipito- 
frontalis and corrugator supercilii muscles. Exposure is effected by means of 
a cut corresponding with the curve of the eyebrow. The operation is one 
very easy of performance. Direction of cut, and anatomy of relation, are 
shown clearly in Fig. 850. 
INFERIOR MAXILLARY NERVE. 
This nerve, which has its ultimate distribution to the muscular and cuta- 
neous portions of the lower lip, emerges from the dental canal of the inferior 
maxilla at the mental foramen. (See, for study, Figs. 58 and 59; also page 1122.) 
Auricularis Magnus Nerve.-Fig. 851 exhibits an exposure of the 
part. This nerve, a branch of the superficial cervical plexus, which supplies 
the auricle and the parts about the mastoid process, is found least covered 
at a point about half an inch posterior to the lowest point of the lobe of the 
ear. (See, for study, Fig. 58, Subfigs. 2, 3, 29, 31.) Fig. 852, A, shows a 
manner of exposure ; a single curvilinear incision corresponding with the line 
of the lobe as it ascends to join the tragus. 1134 
A SYSTEM OF ORAL SURGERY. 
Great Occipital Nerve.-Fig. 853 exhibits location and relation of 
occipital nerve and artery. OA, artery ; N, nerve. The occipital is a branch 
Fig. 851. 
Auricularis magnus nerve exposed. 
of the cervical; it supplies the integument of the scalp as far forward as the 
vertex. 
Gustatory, or Lingual, Nerve.-See Vanzetti's operation, page 766 
also see page 1122. 
Fig. 853. 
Fig. 85'2. 
Line of incision for exposing auricular and 
occipital nerves. 
Exposure of occipital nerve and artery. 
Auriculo-temporal Nerve.-Severe neuralgias relate occasionally 
with the auriculo-temporal division of the inferior maxillary nerve; exposure 
and section or stretching are performances of easy accomplishment. 
The seat of selection for operation is immediately above the zygoma. (See NERVE LESIONS PROPER-TREATMENT BY STRETCHING. 
1135 
Fig. 63, Subfig. 8.) The nerve ascends in company with the temporal artery 
lying on a plane with this vessel and between it and the tragus. An incision 
made for the exposure is to be one and a half inches in length, is to be cut a 
trifle oblique to the line of the nerve, and is to divide the integuments and the 
prolongation upward of the parotid fascia. Where exsection is the intention 
fully an inch of the cord should be removed. To stretch the nerve an opening 
is made through the cellular tissue in which it lies, by means of which an 
aneurismal, broad-faced, needle may be employed for the lifting. The writer 
has found occasion to expose the nerve in several instances. A trifle of caution 
is necessary to avoid cutting the artery. Care is to be observed that a branch 
be not mistaken for the main cord; the size of the latter corresponds with the 
common cotton twine used by grocers. (See Ligation of Temporal Artery.} CHAPTER LXVIII. 
TUMORS OF THE MOUTH AND FACE AND THEIR 
CLASSIFICATION. 
In the following pages the author proposes, after proper reflection, and after 
making himself entirely familiar with the views and observations of the latest 
writers, German, English, and American, to present to his readers the subject 
of tumors, precisely as in his own clinical service he meets with, classifies, and 
treats the lesions. He assumes, to a certain extent, a disregard of the arrange- 
ment of others, because one here adopted seems to him to introduce and 
evolve the subject, not only rationally, but with a clearness and simplicity 
which permits of easy and full clinical understanding of it, while at the 
same time it limits in no way the examinations and inquiries of the most 
inquisitive histologist. 
Definition.-The surgical expression "tumor" is a term having origin in 
the Latin verb tumeo, to "swell;" it applies necessarily to any enlarge- 
ment of a part, no matter where such enlargement is met with or from what 
cause it arises. 
Variety as to Signification.-The definition given is to be fully ap- 
preciated by a student before proceeding a step farther. The pregnant woman, 
being large, has a tumor. A person being struck upon the eyelids, and having 
these appendages swollen, has a tumor. In the word is implied enlargement, 
nothing else. The term and idea enlargement are to be impressed. 
The word tumor is generic. It covers every swelling that has appeared or 
that ever will appear. The significance of what it covers varies from that 
which has meaning in some accidental and, it may be, evanescent functional 
derangement-as, for example, a foot oedematous from exhausting exercise, 
an abdomen swollen from accumulated flatus, a duct expanded from obstruc- 
tion of its outlet-to that character of an outgrowth which is without ex- 
planation in itself or in any immediate physiological or anatomical perversion, 
-a something which, by exclusion, is to be classified as an expression of a 
mediate, or systemic, antecedent. Illustrating by extremes, a pimple on the 
face, being an enlargement, is a tumor, an ovarian cyst weighing seventy 
pounds is a tumor, a cancerous fungus hsematodes is a tumor. 
Clinical and Histological Study of Tumors.-A study of tumors, 
to be exhaustive, is to be pursued from a twofold stand-point,-clinical and 
histological. The first has to do with that classification of the conditions 
which directs the practice demanded. The second analyzes under the micro- 
1136 TUMORS OF THE MOUTH AND FACE-CLASSIFICATION. 
1137 
scope the histogeny of a growth, and describes the expressions of its minute 
anatomy. A pimple and an ovarian cyst, while one and the same in that both 
are enlargements,-tumors,-are yet, when clinically considered, as far apart 
as are the antipodes. 
Division of Tumors into Two Classes.-Clinically, experience 
fairly demonstrates that a rational primary distinction of tumors is found by 
separating them into two classes. One class embraces every lesion that 
possesses a local self-explanation, as, for example, the swollen eye appendages, 
the pregnant woman, the flatus-expanded stomach, a sebaceous tumor, a ranula, 
a hernia, a hydrocele. Such tumors are purely and wholly of local sig- 
nificance. The other class comprises all that remainder, the ex- 
planation of which lies outside of local conditions; examples in this latter 
direction being recognized in the nodes of syphilis, the degenerating glandular 
enlargements of tuberculosis, the many expressions of cancer. 
Two Classes.-The weight and importance of the author's study 
of tumors lie with this separation of them into two classes. Starting with 
such manner of primary division, any tumor, ever to be met with, is to be 
differentiated and put in its proper place, as to diagnosis, through the process 
of exclusion. Certainly if a swelling be not of local significance it is of con- 
stitutional meaning. This division into two classes offers then, as its primary 
differentiation, the single question as to whether a tumor that is being con- 
sidered is of local or systemic expression. 
Significance.-All tumors of the first class are, in themselves, of a neces- 
sity, benign. All tumors of the second class are to be viewed, not in them- 
selves, but in a dyscrasia of which they are simply phenomena. 
Indications.-Tumors of the first class, having only a local significance, 
demand only a local treatment; tumors of the second class, having, save in 
the accident of the habitat, no local significance, but being of constitutional 
meaning, receive scientific treatment only through remedy directed to the vice 
in which they exist. 
Homologous.-Tumors of the first class are to be termed homologous, 
indicating by the term, not likeness to associated tissue as exhibited by some 
of the neoplasiae, but that a tumor is wholly part and parcel of a location in 
which it exists. 
Heterologous.-Tumors of the second class are to be distinguished as 
heterologous, the expression indicating neoplasia, no matter what the likeness; 
a something which is more or less foreign to a part in which it is found. 
Clinical Illustration in Differential Diagnosis.-A patient having 
a tumor in his groin presents himself to a surgeon. What is the nature of 
the tumor ? It may be a hernia; an undescended testicle ; a hydrocele of 
the spermatic cord; an inflamed lymphatic gland. It may have the constitu- 
tional meaning of a syphilitic or of a tuberculous bubo. It may be an ex- 
pression of cancer. To satisfy himself as to the nature of the particular 
condition represented, a practitioner may only proceed as follows. First, 1138 
A SYSTEM OF ORAL SURGERY. 
he must recall the anatomy of the part. In the groin of the 
human male is a canal,-the inguinal. This canal is entered by a ring from 
the abdominal cavity, and has an outlet through a second existing in the 
aponeurosis of the external oblique muscle. In this canal lie, enveloped in a 
sheath, the spermatic vessels. This canal constitutes the passage transmitting 
the testicle from the abdomen to the scrotum ; the entrance to it may permit 
of the insinuation of a knuckle of omentum or of intestine. In this inguinal 
region exist a number of lymphatic glands. This, then, is the surgical an- 
atomy, and these are the data. Is the tumor a hernia ? There is no impulse 
on cough ; no doughy feel; no diminution in size when the patient lies down ; 
no ability to thrust the tumor into the abdomen; no enlargement of either 
inguinal ring. In absence of such diagnostic signs the tumor is not a hernia. 
Is it an undescended testicle ? The testicle is to be felt in its place in the 
scrotum. The tumor is not an undescended testicle. Is it hydrocele of the 
spermatic cord ? There is no fluctuation on percussion ; no ability to change 
the position; no fluid as test is made with an exploring needle or aspirator. 
It is not hydrocele. Is it an inflamed gland of a local inflammatory signifi- 
cance, as, for instance, a lesion existing in a hurt ? There is absence of his- 
tory. The tumor, then, is not of local or immediate significance; this, it 
would seem, the explorer must know to a certainty. By exclusion, then, 
such tumor is exhibited as belonging to the second class. A single question re- 
mains. What is the nature of the tumor ?-that is, What is the vice represented 
by it? Of these vices there are three, syphilis, tuberculosis, cancer. 
The two former have histories. The last is an arcanum. If the knowl- 
edge of the surgeon enable him to exclude the first two his diagnosis is made, 
-the tumor before him is cancer. 
Example.-At a comparatively late hospital clinic there appeared before 
the class of the author five patients. These patients, suffering alike from swol- 
len, enlarged cheeks, were ranged side by side for diagnosis. Patient one 
was found to have the tumefaction dependent on a periodontitis ; patient two 
was laboring under caries of the jaw, originating from a dead tooth-root; pa- 
tient three suffered from necrosis, the result of injury; patient four had 
a lymph effusion consequent on a fracture; patient five, with very limited 
swelling of the cheek, associated with enlargement of the maxilla, presented 
in his case no local explanation; out of exclusion the lesion, in the 
last case, pronounced itself cancer. The first four patients, their lesions 
being self-explaining, were quickly made well; the last-whose case was with- 
out an accounting explanation-died, and died from that condition which, in 
its developed state, was by all called carcinoma. 
Judgment out of Exclusion.-With the premises of the preceding 
pages assumed and accepted, it is to be understood that any tumor, 
wherever situated, being without a history which explains it, is to be called, 
and treated as, cancer. But here at once may seem to rise insurmountable 
objections to such classification. It may be urged, for example, that a fibroma, TUMORS OF THE MOUTH AND FACE-CLASSIFICATION. 
1139 
that does not destroy life, has no more explanation of its origin than has an 
encephaloma, which in a single year runs to a fatal end. Such objection, 
however, influences only the histologist; the clinician recognizes no practical 
difference between the conditions: they are, he assumes, expressions of a 
common vice. But the one kills, the other does not. If this be urged, the 
objection will be admitted; but it has an explanation which is easily made 
evident. There is, we say, but one non-self-explaining vice; this vice puts on 
various phases. These phases are influenced by the malignancy of the crasis, 
or by relation with the condition of the individual into whose system the 
malady has found ingress. This we may illustrate by an example. Four 
men go from a healthy to a malarious district; all live in the same house, and 
all impregnate their systems with the same poison. In a week one succumbs 
to a quotidian fever; in two weeks the second has a tertian ; in three weeks 
the third dies from a congestive chill; while the fourth, preserved by an 
inherent resistive force, antagonizes the miasma entirely. Thus also in the 
cancer vice: one man, either from the concentration of the virus, or from 
the absence of antagonizing power, dies quickly from a medullary expression ; 
while another maintains a tumor for years, in the expression of simple fibroma, 
succumbing finally in the battle by reason of some accident out of which his 
resistive force becomes diminished, affording thus mastery to the abeyant vice ; 
the fibroma quickly degrading into that which the microscope distinguishes 
from it as sarcoma. 
Tumors Benign or Malignant.-The premise, then, is assumed, that 
any and every tumor which cannot be proved to be benign is to be deemed ma- 
lignant. A self-explaining tumor expresses its nature and indicates its 
name; a non-explaining tumor demands from us no special regard for 
the distinctions of nomenclature, except as in an adjectival way the distinctions 
classify, for convenience in description, what are to be regarded as varying 
expressions of a common disease. (See Fibroma.} 
Simplicity in Clinical Distinction.-Urging the conviction that in 
the preceding few and very simple rules lie the fulness of a proper clinical 
distinction of tumors, applicable to any and all cases, the student may now, 
without the chance of becoming confused, proceed to acquaint himself with 
the growths pertaining to the parts which it is the special object of this volume 
to study. Before doing this, however, a comprehensive discussion of distinc- 
tions at large is to engage his attention.* 
* But it is to be asked whether or not, outside of the negation of the self-explaining 
tumors, there is not a something that may distinguish cancer? If there be, the author 
knows nothing about it. The negation has, however, a wide meaning. According as a 
man knows of a certainty what is not cancer, his inference as to the existence of that con- 
dition becomes reliable and valuable: he calls that cancer which he proves to be 
NOTHING ELSE. 
But is there not some special histological expression which characterizes cancer,-some 
peculiar heteroclitic cell ? Once it was thought so; but nowit is known that certain cau- 
date cells, deemed a few years back entirely diagnostic, are also found in foetal connective 1140 
A SYSTEM OF ORAL SURGERY. 
1. Relationship.-Homologous tumors tend, as would be inferred, to pre- 
serve isolation and individuality; a malignant growth, on the contrary, repre- 
senting, as it is here assumed to do, simply the nidus of a vice, is seen to tend 
to infiltration and to a commingling with adjacent tissues. 
2. Homologous tumors progress regularly, are apt to remain 
stationary after attaining some certain size, as in an odontocele; or they may 
degenerate and slough, as seen frequently in the sebaceous growths. In 
structure, homologous tumors are akin with the parts in which they are found ; 
they do not possess other than a single formative capacity. Treatment of 
them is purely local. The tumors of a vice, on the contrary, have, 
as a rule, the evidences of their systemic character associated with them. 
They are not amenable to a local treatment: if one be removed, a second 
comes to take its place, appearing either in the site of removal or in some 
other locality.* The cure of a vice tumor resides either in the use 
of a specific, antidoting the poison of the vice, or in affording such increase 
of the natural resisting force that the destructive tendency is retarded or 
overcome. To make illustration of what is meant by this last, let it be 
instanced that a syphilitic node is curable by mercury and not by a knife. 
3. Homologous tumors are commonly single, or, if multiple,- 
sebaceous cysts, for example,-are confined to a common tissue and a common 
association. Vice tumors exhibit their constitutional relation in the tendency 
to reproduction, not only in a special part, but in different tissues. 
4. Homologous tumors, if painful, express common pain. 
Vice tumors inflict a character of suffering peculiar to themselves. 
1. Simple Inflammatory Tumors.-A simple inflammatory tumor 
refers to a swelling (which is of varying nature), associated with an inflamma- 
tion ; thus, it may depend on simple excess of blood in a part, or on effusion 
of serum or of lymph. 
Example.-A patient presented himself at the oral clinic with an ery- 
sipelatous blush upon the left cheek. Two days later the part enlarged 
rapidly and largely presented the appearance of abscess. Puncture with a 
bistoury was followed by the escape of at least three ounces of blood and the 
immediate subsidence of the tumefaction. 
Influence of Inflammation on a Part.-Vascular excitement, of a 
grade which brings a perverted circulation under cognizance as an established 
inflammation, never increases the dimensions of a part through excess of 
nutritive or formative action; on the contrary, the nutrition of an inflamed 
tissue. Heteroclitic cells afford information to diagnosis from location and combinations 
alone. The histological aspects assumed by a cancerous tumor originate out of relation. 
No SPECIAL CELL EXISTS. 
* This is attempted to be explained by Virchow on the principle influencing syphilitic 
absorption, or rather, to express him more critically, by embolism. In this connection a 
view of many is to be presented holding the conviction that cancer is, primarily, a purely 
local disease and that it is aborted by a speedy and radical local extirpation. TUMORS OF THE MOUTH AND FACE-CLASSIFICATION. 
1141 
part is always diminished, this being amply demonstrated by a disorganization 
which has in it the meaning of suppuration. Even, however, in cases where 
resolution occurs, the tissues are always left relaxed and degenerate, and in 
themselves are, without doubt, of less consistence by weight or bulk than 
before the attack. 
Effusions in Inflammation.-It is, as well understood, a charac- 
teristic of vessels involved in inflammatory action to relieve their distention 
through effusion, and thus, as such effused material may be serum, fibro-serum, 
blood, or lymph, tumefaction is produced, which tumefaction is persistent or 
otherwise according to character and associations. While a part is enlarged 
by reason of the presence of such effused matter a tumor is present,-i.e., the 
parts are in a st;ate of tumefaction, or swelling. 
Watery Effusions.-Concerning the first,-the simple, unmixed 
watery effusions,-these are found most frequently associated with low degrees 
of inflammation, as in certain articular affections, in encephalocele, hydrocele, 
etc. In such effusions there can be no tendency either to coagulation or to 
organization: a tumor is formed, but it is simply a water-bag. 
Fibro-serous Effusions.-Fibro-serum, or serum holding fibrin, has 
in it an organizing force proportioned to the quantity of fibrin contained, 
approaching to such extent the nature and character of lymph. Such fibro- 
serum is seen, on withdrawal from the body, to differ from serum proper in 
the ability it possesses to assume a jelly-like consistence, and to show the fibre- 
cell, as exhibited in peritoneal and pleural effusions. Fortunately, however, 
while excluded from the air, fibro-serum seldom manifests any tendency to 
coagulate, thus remaining as susceptible to the action of the absorbents as 
the more simple effusion.* 
Lymph Effusions.-Lymph, another of the exudates of an engorged 
vessel, finds its most practical expression when viewed as the agent of nutri- 
tion ; it is that pabulum in which reside the elements of life, and is in a state 
of constant relation with every part of the organism. Only as the result of 
over-pressure or engorgement, however, is it likely to be found in excess in 
any one part; but when so found it compels a tumefaction, measured by the 
undue amount present. (See Office of Lymphatic System, page 99.) 
Variety in Lymph Effusions.-Between lymph and the vitalizing 
principle-the vis vitee-there exists a marked affinity, so that circumstances 
must be adverse indeed where exuded lymph does not tend to organization. 
Corpuscular lymph, as a kind is sometimes termed, is a physiological mis- 
nomer,-difference lies in degeneration, not in primary character: thus, while 
lymph exuded by a vigorous system tends always to organization, exuded 
in a specifically-diseased person, or in one deficient in the vital element, the 
recognition of cause for degeneration is sufficient explanation of the variety 
* Fibro-serum is the liquor-sanguinis of Babington, the plasma of Schultz, the mucago, 
or mucilage, of Harvey. 1142 
A SYSTEM OF ORAL SURGERY. 
considered. Corpuscular lymph is protoplasm the grade of organization of 
which fails to rise to a plane of proper development. A common admixture 
of the two varieties is evidence enough of oneness. 
Lymph Tumors.-Lymph tumors have associated with them a three- 
fold sequelae; they are 
absorbed ; or they organ- 
ize ; or they degenerate 
and are gotten clear of 
in suppuration: or the 
three conditions may co- 
exist, part of the lymph 
being absorbed, part being 
thrown off, and a portion 
affiliating itself with the 
surrounding parts. 
2. Hypertrophic 
Tumors. - Hyper- 
trophy is an expression 
of unbalanced nutrition, 
-i.e., a part developed 
in excess of its fellow- 
parts. Hypertrophic tu- 
mors differ from all others 
by conformity with regions with which they are associated. So marked 
and characteristic is this that it is only through comparison with neighboring 
parts that such enlargement is to be measured. Hypertrophy may ensue from 
the opposite conditions of excessive supply 
or of diminished waste. The enlarged 
biceps muscle of a blacksmith, and the 
gastrocnemii of the ballet-dancer, are illus- 
trations of hypertrophy from supernutri- 
tion. Enlarged glands from tuberculosis 
are not unjustly to be instanced as illustra- 
tions of the second condition.* Over- 
growth of fat-forming tumors may be 
placed in this direction. 
3. Tumors which result from 
Interference with Function.-The 
appreciation of this class of tumors, of which there are a great number, 
is commonly without confusion or difficulty. It is, of course, required that 
the observer draw his inferences from the data of anatomical and physiological 
Fig. 854.-Hypertrophic Tumor of Fatty 
Significance. 
Fig. 855.-Hypertrophic Tumor 
of Fatty Significance. 
* Lymphangitis and Tuberculosis Identical.-The meaning of scrofulous induration 
lies in stasis of tissue metamorphosis, the direct cause being lymphatic obstruction. Lym- 
phangitis and tuberculosis are identical. TUMORS OF THE MOUTH AND FACE-CLASSIFICATION. 
1143 
knowledge. The deficient spinal canal gives the protruding meninges, the 
fluid of the subarachnoidean space filling the fluctuating cyst. (See, for illus- 
tration, Fig. 887.) Obstructed sebaceous ducts yield wens. Relaxed veins 
afford varices. Occlusion of the antral foramen compels engorgement of that 
cavity. An umbilicus, unclosed, or its boundaries attenuated, hernia follows. 
A tooth out of the dental arch, yet developing within the structure of the 
bone, odontocele exists. So of all this class of tumors, similar simple and 
single signification is found. 
Histological Distinctions.-A classification of tumors, employed by 
writers generally, is founded on histological anatomy. The philosophy of 
such classification finds confusion, if not condemnation, in changes constantly 
occurring. These namings are good, bad, and indifferent, in the phases of 
neoplasms, and in the fact that the clinical history of the conditions demon- 
strates expressions to be phenomenal, just as, though in more marked degree, 
the expressions of vascular perversion which we denominate inflammation are 
phenomenal. Histological definitions are not, however, without great useful- 
ness and interest; indeed, it is here the science of the subject lies. 
Tumors, as histologically classified, are as follows: 
Cystoma Cystic. 
Enchondroma .... Cartilaginous. 
Fibroma Fibrous. 
Lipoma Fatty. 
Osteoma ' Osseous. 
Dentinoma Dentinal. 
Haematoma Blood. 
Eneephaloma .... Brain-like. 
Scirrhoma Marble-like. 
Melanoma Like black pigment. 
Myxoma Mucus-like. 
Adenoma Glandular. 
Angeioma Vascular. 
Sarcoma ..... Fleshy. 
Neuroma Nerve-like. 
Hygroma Water-like. 
Steatoma Lard-like. 
Myeloma Marrow-like. 
Meliceroma Honey-like. 
Atheroma Gruel-like. 
Chloroma Like green pigment. 
Histological and Clinical Classification.-No conflict exists be- 
tween the histological classification as here offered and the clinical one used by 
the present author, as surely the reflection of a single moment will show. An 
angeioma, to make illustration, may be homologous or heterologous. A 
haematoma may be benign or malignant. It will serve the purpose of a study 
to analyze, in illustration, some of the terms. 
Analysis of Names.-We say, for example, of a certain tumor, that 
it is a cystoma. Using this descriptive expression, we imply by it a cystiform 
character of the growth spoken of,-this, and nothing more. The 
tumor may readily enough be what we have called homologous; for should it 
be in a jaw-bone, and should we make examination, we might remark the 
absence of certain teeth from the arch affected, and, on chiselling off the vault 
of the enlargement, might find the lost teeth as an explanation of the growth : 
the cyst would be a self-explaining odontocele. Again, examining a maxillary 
cyst, we might not find teeth absent from the arch, nor any of these organs 1144 
A SYSTEM OF ORAL SURGERY. 
diseased, nor 'anything of local significance bearing on an explanation of the 
condition; accurate inspection, founded on a thorough knowledge of the 
parts, revealing no cause why a cyst should have developed in such a place 
and at such a time. Here the most experienced surgeon has but a single 
resource. He must act on the premise that the condition is an expression of 
constitutional meaning. In his investigation he passes, under the circum- 
stances, to examination of vices possessed of a history. Discovering still 
nothing, he has left him alone but assumption of the condition of cancer. 
Certainly he has been able to secure nothing outside of such assumption. If 
he treat not his case as cancer he is without data for treating 
it as anything else. 
Take a third condition of cyst,-a cyst in the substance of the lip. 
Is a particular cyst that is being considered a self-explaining condition, or does 
it express a vice? In the substance of the lip are secreting glands of 
three characters, mucous, sebaceous, and sudoriparous; each of these, 
for the purpose of clinical study, is to be described as a secreting cyst-like 
body with a patulous tube running from it to a free surface, through which 
tube is constantly being discharged the fluid formed in the gland. Suppose 
now any one of these tubes accidentally occluded, and we find ourselves led 
at once to apprehension of a diagnosis. Should a labial cyst be mucous 
in its character, it will be a soft, more or less elastic, tumor, will be situ- 
ated upon the oral aspect of the lip, and, if explored by the needle, will yield 
a characteristic discharge. Should it, on the contrary, be of a sebaceous 
nature, it will be related with the external tissue, will roll loosely under the 
touch, and, if explored, will exhibit cheese-like contents. The sudoripa- 
rous cyst is, of course, of very rare occurrence; if existing, it also would 
lie in the external tissue, and would be found to have walls much more elastic 
than either of the others. A cyst is sometimes found in the lip dependent 
on dental abscess. A case is at this moment in the mind of the writer where 
such a cyst as here alluded to was of eleven years' standing; during all that 
period the tumor had not been of less size than an ordinary shellbark-nut. 
The sac was found very thick, and the surface ulcerated. A treatment, which 
consisted simply in the extraction of two dead teeth, resulted in the entire 
disappearance of it.* 
Other Synonymes of the Word Tumor.-We pass to other of 
these synonymes. Let us take the terms scirrhoma, myxoma, encephaloma, 
myeloma: these are names given to tumors because of peculiari- 
ties in structure. The clinical placing of them, however, is the practical 
matter. Whatever name the histologist employs for the designation of a 
tumor, whatever may be the histogeny of a growth, if no local or common 
systemic vice explanatory of presence exist, its place is with cancer. Here 
* Hydatid Cyst.-The hydatid, being a cyst of parasitic origin, is not introduced. Such 
a cyst, being an accident, as it were, can be conformed to no rule. Diagnosis is through 
aspiration or recognition of fremitus. TUMORS OF THE MOUTH AND FACE-CLASSIFICATION. 
1145 
only may it be placed as treatment is concerned. Such a tumor is to be cut 
away or let alone. This is the sum of its treatment. 
Scirrhoma.-Scirrhoma is a term employed to designate solidity, hard- 
ness. Influenced by the associations of a part in which it is found, by its 
own character, or by some peculiarity or idiosyncrasy of the individual, scir- 
rhoma exhibits itself as a hard body; remove this body, and not unlikely the 
return of the disease-particularly if appearing in another locality-is in the 
form of a brain-like substance,-encephaloma; or that might come, which, 
cut into, would exude a mucus-like substance, and we might call it a myxoma ; 
or perhaps a section would exhibit marrow-like contents,-myeloma; or there 
might be a cyst with gruel-like contents,-atheroma. Or, diffused through- 
out the substance of any of these differently-appearing conditions, there 
might be a black coloring-matter,-then we might name the tumor a mela- 
noma ; should the pigment be of a green shade, we would call it chloroma; 
or should we at the first time see the tumor in a state of fungous proliferation, 
we should call it a fungous haematodes. Yet, with all these various syno- 
nymes, we would mean, in truth, but a single thing; and, to clinically classify, 
in contrast with histological naming, any or all of these phases we would need 
but a basal term,-that is, taking it for granted that the tumor was without 
local or common vice explanation. The basal term is cancer. The tumor 
would be cancer, while it would as well be the other things; one form of the 
other things. 
Value of Histological Distinctions.-In such exposition of names, 
which are seen to be simply expressive of types,-synonymes we may with 
all propriety call them,-any confusion must certainly be found dispelled. 
These various terms, as employed in writing, are, however, as has been sug- 
gested, of great assistance in expression; it is only necessary to bear in mind 
that their meaning and relation are adjectival. 
We pass here to a study of oral tumors proper. CHAPTER LXIX. 
THE TUMORS OF THE MOUTH. 
THE EPULIDES. 
Tumors of the mouth most frequently met with are those seen growing 
upon the gums, and known as the epulic. These growths are, in almost all 
instances, first to be observed making their way from about the neck of some 
particular tooth, pushing out, apparently, from the socket, being found to 
originate from the odonto-periosteal membrane. 
Definition.-As the epulides, like other tumors, classify themselves into 
self-explaining and non-explaining, the term epulis, still in quite common use, 
is without proper signification when employed as a noun substantive. It is 
derived from the Greek words and ouAa, signifying " upon the gumit 
is to be accepted as distinctive of situation only, so that, in using it, one ex- 
presses simply that a growth spoken of is upon the part classically designated. 
Histological and Clinical Classification of the Epulides.- 
Histologically expressed, the epulic tumors are to be arranged as follows: 
epulo-fungoid, epulo-erectile, epulo-fibroid, epulo-fibro-recurring, epulo-sarco- 
matous, epulo-myeloid, epulo-myxomatous, etc. Clinically classified, we have 
to concern ourselves only with benignancy or malignancy, as thus alone we are 
led to a required treatment. 
Benignancy and Malignancy.-The single epulic tumor which may 
with certainty be known as benign is the pulp-fungoid. A second form, 
which is usually found so, is the erectile. Any of the epulides which does 
not exhibit itself as one or the other of these forms is to be deemed can- 
cerous, and treated with the latitude given to cancer. No other inference 
insures the best good to the patient. 
A pulp-fungoid growth is self-explaining. An erectile tumor is fairly so 
from analogy with the common vascular naevi: it is, in fact, a naevus. Besides 
these two, no other of the epulides possesses explanation of their presence or of 
their development. The epulo-pulp-fungoid growths demand a treatment pecu- 
liar to themselves; so, also, do the erectile. All the other epulides are to be 
treated on a common principle. From such data, which may be accepted as 
solidly reliable, the surgeon is led to perceive that an appreciation of the first 
two insures clinical understanding of all the other conditions. That is, 
knowing two, he knows all the rest. 
Epulo-Pulp-Fungoid Tumor.-By an epulo-pulp-fungoid tumor 
is meant a fungoid growth of an exposed degenerating tooth-pulp. This 
1146 THE TUMORS OF THE MOUTH. 
1147 
tumor is as common as it is simple, harmless, and familiar. It is certainly 
to be seen in a thousand cases to one of any other form of epulic growths. 
The fungoid-pulp tumor is met with under the various aspects exhibited in 
Fig. 856. As forms one and two are concerned it is hardly epulic, being of 
sole relation with a tooth ; but as it departs from such relation, as witnessed in 
examples three and four of the diagram, it is anatomically epulic; hence the 
propriety of not confusing the matter by separating the classification adopted. 
Study of Pulp-Fungoid Tumors.-Referring back to Figs. 75, 76, 
and description, the dental pulp is recognized as a stroma of delicate connec- 
tive tissue, in which stroma ramify blood-capillaries and nerve-fibrillae; this 
structure occupies the cavity of a tooth, and is liable, through the accidents of 
decay or fracture of its containing organ, to become exposed. When so 
exposed, it is not unlikely to undergo fungoid degeneration. 
Diagram One.-Fig. 856, Subfig. 1, is an outline drawing representing 
the walls of a tooth-root enveloping its pulp, which pulp, slightly fungous, 
Fig. 856.-Epulo- or Dental-Fungoid Tumor 
projects a trifle above the level of its cavity. In molar roots, the crown being 
gone, such form of pulp tumor is very common. No difficulty exists in its 
recognition, as the boundary-walls of the cavity are plainly to be observed. 
Diagram Two.-A form of pulp-fungoid growth, a trifle complicated, is 
exhibited in Subfig. 2. Here, as is seen, the fungus is of such extent as to 
overlie the boundaries of its cavity ; any confusion is avoided, however, by 
thrusting the mass aside, when its character is at once made evident. 
Diagram Three.-Subfig. 3 represents another condition. Here the 
mass has increased to such extent that it not only conceals the cavity, but it 
rests upon the surrounding gum, to which, not unlikely, it will be found to 
have formed attachments. 
Diagram Four.-Still another form is exhibited in Subfig. 4. Here a 
tooth-root may be below the border of its socket. No pulp projects from, nor 
is seen upon the face of, the canal; a break exists, however, upon one side of 
the root, out of which grows the fungous mass. Such a growth, little by 
little, insures the absorption of the alveolus on the side at which it projects, 
and rising, finally, above the free face of the gum, exhibits a condition well 
calculated to mislead. This tumor is readily distinguishable from 
the odonto-periosteal growths by the nature of the proliferations, 
these being of a livid asthenic appearance, not common to any other of the 
epulides. This last form of tumor is not at all frequent; it depends for its 1148 
A SYSTEM OF ORAL SURGERY. 
existence on such a break in the continuity of a tooth-root as seldom occurs. 
It is to be remembered, however, that a decay commencing at the free surface 
may run along the root of a tooth, and that out of this track the fungus may 
project. 
Complicated Form.-A form of epulides simulating, as location is 
concerned, the pulp-fungus, is exhibited in Fig. 857. In this instance the 
tumor, while seen to arise from the pulp-cavity of the fang, when traced, is 
found to be an outgrowth of that aspect of the odonto-alveolar membrane 
Fig. 857.-Odonto-periosteal Growth 
SIMULATING PULP-FUNGOID. 
Fig. 858.-Ulitic Tumor. 
which adjoins the bone; the growth, as seen in the diagram, has passed 
through an opening in the root, and has progressed, as shown by the dotted 
lines, until, reaching the margin, it becomes exposed and proliferated. It is, 
as understood, in no sense a pulp-fungoid growth, yet is easily to be so 
mistaken. The form is rare. To mistake it for the ordinary pulp-fungus 
would be to err necessarily in the treatment, the four conditions represented 
in Fig. 856 requiring either the destruction of the fungus by means of cauteri- 
zation, or the extraction of the affected fang; while this last necessitates re- 
moval of a portion of jaw found implicated. 
Complicated Form.-Still another form of epulic tumor* consists, as 
exhibited in Fig. 858, of an ulitic outgrowth, the result of irritating influences 
associated with double approximal dental caries; the gum-tissue, semi-strangu- 
lated, rises and fills the cavities. A similar expression of tumefaction is not 
infrequently met with in the interspace existing between teeth in which the 
V-cut has been improperly made ; indeed, these growths are encountered 
where they have not only completely filled such interspace, but so projected 
above the grinding face of the teeth as to be injured at every occlusion of the 
organs. The treatment consists either in extracting one of the approxi- 
mating teeth, in so altering the relation of the necks of the teeth as to obviate 
the strangulation, or, after cutting away the mass, and by means of cotton 
wedges forcing the structure entirely clear of the cavity, in restoring, by con- 
tour filling placed in the cavities, the original relation of the parts. A tem- 
porary curative consists in keeping the sites of projection stuffed with 
plugs of cotton saturated with gum sandarach. 
* This, from its simplicity, is to be classed with the pulp-fungoid, as it is equally self- 
explaining. THE TUMORS OF THE MOUTH. 
1149 
Reviewing the tumors just described, it is seen that, with a single excep- 
tion,-that shown in Fig. 857,-all are very simple and equally self-explaining. 
Epulo-erectile Tumor.-This is a vascular growth, the analogue of 
the common naevi; it is associated, generally, with the capillary system, and 
has its character marked by its variation in size and appearance as influenced 
by the conditions of the circulatory system at large,-excitement increasing 
its turgescence, quiet reducing it. Active in a general appearance, epulo- 
erectile tumors present, however, decided features of variation. Thus some 
represent a congeries of vessels which would seem to need the merest 
scratch to result in profuse hemorrhage; others carry likeness with the tissue 
of the corpus cavernosum penis, the cellular stroma being thinned into a series 
of communicating cells, which are found congested or otherwise, as circum- 
stances control; others are not infrequently quite solid, simulating 
fibrous structure: this depending on some vascular perversion which has pro- 
duced excess of the fibro-cellular element; indeed, it sometimes happens that 
spontaneous cure is effected through solidification, and the surgeon, acting on 
such a hint, employs the process as one of his means of cure. Of the various 
forms of epulo-erectile tumors, the spongoid is by far the most com- 
mon,-is, indeed, to be placed as the type; stimulation of the circulation 
will fill it at times to bursting; pressure may almost completely empty it. 
Arterial, Venous, and Capillary Epulides.-Whether an erectile 
tumor come under the definition of arterial, venous, or capillary, depends 
simply on the vessels most involved. A term, aneurism by anasto- 
mosis, applied to these growths by John Bell, has its foundation in that 
variety in which the arterioles are implicated. This species, when congested, 
presents the scarlet hue, and, if accidentally wounded, is troublesome, as con- 
trol of hemorrhage is concerned. The venous variety is made up of a 
congeries of venules: the tumor is dark and commonly sluggish in aspect. 
The capillary form is intermediate between the arterial and the venous, 
and constitutes the spongoid form. The underlying bone of the erectile 
epulides will almost invariably be found involved, being softened and spongy. 
Erectile tumors sometimes, though rarely, make their first appearance as a red 
pimple upon the gum, growing in a polypoid form until they may attain the 
size of a cherry. 
Treatment of Erectile Growths.-Tumors of this class, where 
the bone is involved, can be cured only by a section which includes that 
structure. A diagnosis is easily secured by passing an exploring needle 
through the soft tissue: if the bone be implicated, the needle is found to enter 
the structure freely, and may be moved about among the loose stroma; if it 
do not pierce the bone, and the tumor be at all pedunculated, it may be stran- 
gulated ; or, even where the base is broad, the ligature may yet be used, trans- 
fixing first with one or more needles for the proper directing of the thread. 
A second mode of treatment, applicable when the bone is not 
involved, is by injection ; the ordinary hypodermic syringe being employed, 1150 
A SYSTEM OF ORAL SURGERY. 
charged with one of Monsel's solutions of iron, with a very concentrated 
tincture of iodine, or with the glacial acetic acid. Any substance that will 
coagulate the blood may be used, and not infrequently is found to answer a 
satisfactory end. The employment of this means of cure is not, however, 
unattended with risk from emboli. Still another method consists in the 
application of caustics, such as chloride of zinc, Vienna paste, the 
London paste, or the strong mineral acids. An anxiety, however, that must 
always accompany the employment of these agents is the fear of hemorrhage 
on the casting of the slough; and such anxiety is so well grounded that 
experience soon teaches that the means of cure is applicable only in the least 
vascular of the growths. 
Seton as Means of Cure.-The seton, as an agent, finds not infre- 
quently happy service in the erectile epulides. The needle used is that em- 
ployed by the surgeon in passing ordinary ligature silk. The seton may be 
soaked, or not, in some caustic solution ; the thread is always to be the thickest 
that the eye of the needle will admit, in this way insuring the occlusion of 
the transfixed vessels and guarding against bleeding. When hemorrhage as- 
sociates itself with such transfixion, tannic acid is to be drawn into the wound 
by coating the seton and moving it gently backward and forward. Should 
this not control the bleeding, a knitting-needle heated to whiteness may be 
thrust through the wound, or the saturated tincture of iodine be injected. 
On two or three occasions the author has found himself enabled to control 
such a hemorrhage by casting a ligature around the parts, as best might be 
done, thus cutting off the circulation ; indeed, the practitioner, using the seton, 
will on some occasions find the employment of a strangulating ligature 
forced on him. Such hemorrhages are, however, very infrequent, and may 
not be met with in one out of a hundred cases. They are most commonly 
associated with the arterial variety of tumor. 
Electrolysis.-Electrolysis is a means of treatment employed not un- 
satisfactorily by many practitioners (see Treatment of Neevif and is highly 
lauded in its application; the object should be the coagulation of the blood, 
rather than a cauterization of the stroma of the tumor. Although destruction 
is preferred by many as the best service of electrolysis, it is to be recognized 
that the mode of using the agent suggested has the advantage, inasmuch as it 
is a certain assurance against hemorrhage. 
Piecemeal Removal.-A practice of " piecemeal removal" has been 
introduced into English surgery. This consists in teasing or tearing or twist- 
ing away fragment after fragment. The object is to avoid hemorrhage, as by 
torsion of arteries. This is a practice, however, which the inexperienced will 
do well to avoid; not but that, in certain cases, it is a good plan of treatment, 
but frequently it has troublesome associations, not the least of which is active 
hemorrhage. 
Use of Serres-fines.-Still another treatment, employed where a tumor 
has no association with the bone, is the application of the serres-fines: these THE TUMORS OF THE MOUTH. 
1151 
are spring-wire forceps; they are to be made of a size proportioned to the re- 
quirements, and are to be clamped over the mass. In using these clamps, 
regard is to be had to the nature of the serrations, these being used deep or 
shallow according to the vascularity of the part to be grasped; the pressure 
of these clamps will not infrequently result in a coagulative and inflammatory 
action, which proves the cure of the tumor. 
Use of Pressure.-An application somewhat on the principle of the 
serres-fines is the employment of pressure. The parts having first been 
emptied by forcing out the blood, a well-adjusted compress is to be bound 
tightly over the tumor, and retained in place continuously for several days: 
this treatment, when the growth is small, will often effect a cure. The princi- 
ple is one with employment of finger-pressure on vessels aneurismally enlarged. 
An admirable plan of securing a desired pressure is to take an impression of 
the jaw on which the tumor is situated, and, obtaining thus a model, make a 
plate precisely as for an artificial denture, having bands, to hold it firmly in 
place, fitted to clasp neighboring teeth. By placing a layer of cotton-wool 
over the tumor and compressing it with the plate, pressure of a very effective 
type is to be secured. Advantage is gained by employing astringents in con- 
junction with the plate; saturating the wool with a diluted preparation of 
Monsel's solution of the persulphate of iron answers a very good 
purpose. Tannic acid may be used. 
Local Significance of Erectile Epulides.-The erectile forms of 
the epulides, while not so clearly explainable as the pulp-fungoid, are yet to be 
esteemed as of local significance and of innocent type. An analysis of 
an erectile growth exhibits it as a tuft of vascular tissue. In 
it the practitioner is to recognize vascular anatomical perversion. 
Epulides of the Second Class.-From the consideration of the 
epulides of self-explainable character we proceed to that of other forms, all 
of which experience assures us are best esteemed, and most wisely treated 
when accepted, as belonging to the second class. The author so treats them 
because, while they may not all express the cancer vice, he cannot prove that 
they do not. By treating them with the latitude given to carcinoma, nothing 
detrimental to an innocent growth is done, but everything in the way 
of cure possible (with our present knowledge) should the disease be malig- 
nant. This practice the writer himself shall continue to pursue-finding in 
it the commendation lying with experience-until the typical something is 
discovered which shall allow him to know a cancer in all its expressions, just 
as, to-day, one might not easily be deceived in a hernia or in a ranula. 
Epulides not Self-explaining.-We pass here to a consideration which 
includes every epulic tumor, apart from those already described, as met with in 
the mouth. Histologically, these several growths are to be classed as myeloid, 
sarcoid, myxoid, fibroid, etc.; clinically, we are not interested in giving them 
any name at all; the single concern with our classification being 
as to self-explainability or non-explainability. With the epulides the author 1152 
A SYSTEM OF ORAL SURGERY. 
has had much to do; he may be pardoned in suggesting that in the direction 
few have had, perhaps, wider opportunities for observation; as the result of 
such an experience, he believes that he advances the highest truth, and that 
which will be found to redound to the greatest good of patients, when he 
teaches that a growth is to be called, viewed, and treated as 
cancer which cannot be proved not to be cancer.* 
Cancer to be treated in Consideration of Condition.-Cancer 
is treated from the aspect of a twofold expression belonging to the condition. 
When infiltrated,-that is, when parts adjacent to a tumor are in marked 
sympathy, being engorged and shading dimly into healthy structure ; when 
glands are indurated and dyscrasia is marked ; then, not knowing any anti- 
dote to the virus, a surgeon can do nothing for a patient. When, on the 
contrary, a cancer lesion is strictly localized, when a tumefaction does 
not shade gradually away, but possesses a strict individuality, like, for ex- 
ample, the concentric fibroma, then let it be epulic, or of whatever situation, 
ablation is endorsed, on the principle of assistance rendered to a some- 
thing which offers expression of attempt to help itself. 
Practice pertaining to an Epulic Tumor.-Accepting the premise, 
we find in the character of an epulic tumor the practice pertaining to it. 
Indecision or confusion is without occasion for existence. 
Illustrative Cases.-Presenting Figs. 859 and 860 as illustrations of 
some of the various expressions of the epulides, attention is to be directed to a 
description of the cases, together with the practice adopted, and the results. 
Case, Fig. 859.-Some time back, Mrs. T., the sister of a medical friend, 
was brought by the brother to the office of the writer for consultation on a 
tumor (about the size of an ordinary pea) growing from the alveolus of an 
upper molar tooth. This tumor was thought, on a first sight, to belong to the 
class pulp-fungoid. There was a broken palatine fang in the jaw, but so deep 
as to be only fairly discernible to the probe. The origin of the growth could 
not be seen, only inferred. By separating carefully the alveolus from the 
fang, the root, after some little trouble, was gotten from its bed. The little 
tumor proved to be an outgrowth of the periodonteal membrane, and not an ex- 
crescence from the pulp; in character it was distinctly and decidedly fibrous: 
it was, then, histologically to be classified as an epulo-fibroid tumor. It 
did not look like a growth from the periodonteum, but rather as if its origin 
was in the crusta petrosa, and as if it had carried the membrane before it, 
somewhat as the infundibuliform fascia is made a tunic to a descending intes- 
* Remarks.-The author sees, of course, that here are involved the learning, experience, 
and judgment of an observer. But with all grades of intelligence he must perceive his 
position equally to hold. A man can handle and treat a matter only as he compre- 
hends it; it is the fatal misfortune of all cancer-afflicted patients that the highest intelli- 
gence has not yet arrived at the apprehension of what cancer is. It is a great misfortune 
for a patient to fall into the hands of a man who does not know-to the extent of the known 
-what is not cancer. THE TUMORS OF THE MOUTH. 
1153 
tine in an oblique inguinal hernia. The removal of the fang brought the 
growth cleanly away. Of course, no scraping or cutting of the parts was 
Fig. 859 
Epulic Tumors 
Fig. 860. 
Fig. 861. 
Fig. 862. 
Fig. 863. 
Fig. 864. 
necessary; the growth was evidently an emanation of the dental aspect of 
the periodonteum, and had in no way involved its alveolar association. The 1154 
A SYSTEM OF ORAL SURGERY. 
case is, perhaps, unique. No treatment of any kind outside of the 
removal of the tooth was employed. The patient remains cured. 
Case, Fig. 860-Epulo-erectile Tumor.-Mrs. J. presented herself 
with a livid, threatening-looking tumor, the size of a hickory-nut, occupying 
the left alveolar face of the upper jaw, the growth extending from the lateral 
incisor tooth back to near the tuberosity. This tumor diminished in size 
during sleep, and increased at the time of any excitement which tended to 
accelerate the circulation; sometimes it seemed like a solid body, at other 
times like a spongy mass; it was evidently erectile in its nature, the analogue 
of an ordinary naevus. It was an epulo-erectile tumor. Separating the 
growth from the gum, its association with the periosteum was plainly 
evident; the probe revealed involvement, as well, of the neighboring bone. 
An operation, which resulted in cure, was performed as follows. The lip 
being held out of the way by an assistant, an incision was made, extending from 
the central incisor tooth of the affected side back to the tuberosity, a similar 
cut being carried back on the palatine face of the tumor to the place of begin- 
ning ; these cuts passed freely through the soft parts down to the bone, and 
circumscribed the tumor, with a reasonable margin to spare. The central 
incisor was next extracted, and, with the ordinary cutting-forceps, section was 
made through its alveolus, extending almost to the labio-nasal angle. A second 
pair of forceps was now taken up, and, by two cuts, the width of its blades, 
the involved bone was removed; the section extending, as is evident, from 
the situation of the left central incisor tooth to the tuberosity. Consider- 
able hemorrhage attended the operation, although the section was well out- 
side of the vessels involved; three ligatures being required. Treatment by 
excision of the bone was here necessitated from the implication of this 
structure. 
After-Treatment.-The lady being of very full habit and of markedly 
sanguine temperament, magnesia sulph. gss was ordered the evening of the 
operation. As an opiate, morph, sulph. gr. ss. 
Condition on Day after Operation.-Marked inflammatory action, 
attended with considerable swelling of the tissues of the face. Prescribed,- 
U Plumbi acetatis, $ij ; 
Tincturae opii, ^ij; 
Aquae, ^xvj. M. 
Ordered a cloth wet with this preparation to be kept continuously upon the 
part. 
Condition on Third Day.-Inflammation increasing; eyes completely 
closed from the great oedema of the lids ; mag. sulph. re-ordered, together with 
hot pediluvia; eyelids heavily painted with tincture of iodine. 
Condition on Fourth Day.-Erysipelas set in, the face looking like 
a glistening red ball; patient restless, nervous, and frightened; painted the THE TUMORS OF THE MOUTH. 
1155 
whole face with tincture of iodine, officinal strength; the lead-water and 
laudanum continued ; iron and quinine internally.* 
U Tincturae ferri chloridi, 3iij; 
Quiniae sulphatis, gr. xxv. M. 
Sig.-Fifteen drops in water every three hours. 
Also a diaphoretic: 
Liquoris ammoniae acetatis, ^ij. 
Sig.-Tablespoonful every ten minutes until the induction of profuse perspiration. 
Condition on Sixth Day.-Erysipelas evidently yielding; iron and 
quinine; painting with iodine; lead-water and laudanum continued. 
Condition on Seventh Day.-Much improved; the erysipelatous 
redness gone; skin wrinkling; patient can see a little from one eye; con- 
tinued the painting with the iodine, and the application of the lead-water 
lotion. 
Condition on Ninth Day.-Inflammation all gone; patient quite 
comfortable; the exposed bone covered with a thin layer of healthy granula- 
tions ; case progressing well. 
Condition on Twelfth Day.-Patient attending to household duties ; 
mouth of course very tender, but advancing rapidly toward a cure. 
Condition on Twenty-fifth Day.-Patient may be called well; 
needs no further attention. 
To complete the case, artificial teeth have been inserted, the plate being 
made to fill up the place of the lost bone. No one would suppose, in looking 
at the lady, that she had lost such a portion of the jaw. She remains well. 
Case, Figs. 861 and 862-Recurring Epulo-fibrous Tumor. 
-These two views, from life, represent the case of a young lady as an epulic 
tumor appeared when first operated on, and as it reappeared and was re-operated 
on some four months after the first time. 
Consideration of Case.-The patient, nineteen years of age, and of 
much more than ordinary personal attraction, applied for treatment of the 
growth as represented in the first view. The necessity for an operation 
* Parasitic Relation of Erysipelas.-The author, recognizing a parasitic relation, if 
not origin, of erysipelatous inflammations, employs now always for local use the combina- 
tion recommended of iron, quinia, and cinchona. The application is a specific. 
Micrococci of Erysipelas.-The micrococci of erysipelas have been demonstrated by Feh- 
leisen (of Bergmann's Berlin clinic). A patient had been inoculated forty-five hours pre- 
viously, and when showed displayed a typical erysipelas. The micrococci which had been 
here implanted were the product of more than thirty generations cultivated on gelatin, and 
could be considered entirely free from extraneous matter or germs. Of eight thus inocu- 
lated, only one failed to show typical results. The last trial in April was just as successful 
as the first during the previous August, and with the same culture. The one person on 
whom the experiment failed had suffered from an idiopathic attack but a short time before. 
-Annals of Anatomy and Surgery. 1156 
A SYSTEM OF ORAL SURGERY. 
having been explained, the following suggestions were made. First, that a 
section be cut which should remove simply the tumor and the alveolar process 
connected with it. If this should succeed, no deformity would result. If 
the growth reappeared, a second operation to be performed, this to ablate 
the bone proper, except a simple rim of continuity. Third, if this, too, 
failed, then complete section of the jaw to be made; this, of course, would be 
deforming, but it would be the only resource. 
The first operation was performed (Fig. 865, section above Subfig. 
5); the bone outside the section looked healthy, and gave every promise of a 
satisfactory result. In two weeks healthy granulations 
had covered the part, and in one month the patient 
was dismissed cured. The following March-the 
operation having been done in December-a small 
tubercle appeared in the centre of the site of the 
original tumor, and in the course of three weeks half 
a dozen new lobules had sprung up. The second 
operation, as proposed, was now done (same Fig., 
section below Subfig.), the continuity and natural arch of the bone being pre- 
served unbroken. This was successful. The patient remains perfectly well. 
The site of the removed bone is occupied by artificial teeth ; not the slightest 
deformity is to be observed.* 
Case after Liston-Fig. 863.-This figure exhibits a case operated 
on by the celebrated English surgeon Mr. Liston. The following is a sum- 
mary of it, given by that gentleman in a paper on " The Tumors of the 
Jaws." 
The patient had labored under the disease for eight years, 
and had been subjected to a partial removal of the growth when of incon- 
siderable size. The tumor was of fibrous nature as regards its disposition, 
form, and intimate structure. It differed somewhat, however, in outward 
appearance, in consequence of its exposed situation. The growth sprang 
originally from the gums and sockets of the incisors and canine teeth of the 
left side; at an early period it protruded from the mouth, unconfined and un- 
influenced by the pressure of the lips or cheek. It had assumed a most for- 
midable size and appearance, concealed the palate and pharynx, and gave rise 
to great inconvenience and suffering. The surface had been broken by ulcer- 
ation, but on close inspection of the projecting part, and of that covered by 
the cheek, it was found to possess a firm consistence, and to present a peculiar 
botryoidal arrangement of its parts. 
An operation proved successful. 
Illustrative Case.-Mrs. S., of Camden, New Jersey; epulo-fibroma of 
left superior jaw. This growth was the size of a large walnut; it was of some 
eighteen months' standing; the bulging of the cheek quite deformed the 
Fig. 865. 
Section of bone as first and 
afterward made. 
* Twenty years have elapsed. THE TUMORS OF THE MOUTH. 
1157 
patient. Lady had been confined with her fourth child five weeks before 
presenting herself. 
Operation.-This was performed three weeks later. The tumor, or all 
that portion of it which was free of the bone, together with a margin of sur- 
rounding healthy tissue, was cleanly excised with the scalpel. This step ex- 
posed the bone, which was found carious. This diseased bone was removed 
by the use of a gouge, little by little being cut away until healthy structure 
was reached. The surgeon recognizes such healthy structure by 
its feel under the instrument and by its appearance; healthy living bone being 
white and studded with minute bleeding points. Hemorrhage, during the 
operation, was considerable, but was controlled, without ligature, by throwing 
alum-water into the wound from an ordinary syringe. The bur and sur- 
gical engine, had they been at hand, would have done the work on the 
bone more expeditiously. 
After-Treatment.-Very little required; a wash of the permanganate of 
potassium, five grains to the ounce of water, was used as a disinfectant, there 
being for a few days a somewhat disagreeable odor from a decomposing blood- 
clot, which it was not thought desirable to pull away. No antiphlogistic or 
systemic treatment of any kind was required, not a bad symptom having ap- 
peared, the patient being entirely well three weeks after the day of operation. 
In this case the floor of the antrum was removed and the cavity wholly ex- 
posed. At the completion of the cure the break was closed in. 
Illustrative Case.-Mrs. T., of Philadelphia. Tumor of four years' 
standing; loose in structure, occupying one-half of the roof of the mouth, 
giving a most disgusting and threatening appearance. The growth had first 
appeared between the bicuspid and first molar teeth, and at the time of presen- 
tation had entirely destroyed the inner alveolar plate of the portion of jaw 
with which it was associated. In raising the mass from its bed, all the 
underlying palatine process, so far as could be seen, was found diseased. 
Operation.-This consisted in cutting away with the scalpel as much of 
the growth as possible, and completing the manipulation on the bone by use 
of the gouge. The hemorrhage was very profuse, the use of a compress being 
necessary for its arrestation, and this effected only after several hours. 
After-Treatment.-Very little required ; some over-inflammatory action 
showed itself, which quickly and readily yielded to low diet for a few days, 
and a single dose of sulphate of magnesia. In three weeks the case was in 
condition to be dismissed. 
Remarks.-These special illustrations of the class epulides, all of them 
being, with the exception of the third, without the pale of our first classifica- 
tion, are given because they serve to show that there is an order of fibrous 
tumors; or, on the other hand, an antagonizing condition of the system, which, 
fully appreciated, would afford to the surgeon an ability to prognose the result 
of operations on them with the same certainty as in the removal of a pulp- 
fungoid. To be able to distinguish this class, or species, or condition, would 1158 
A SYSTEM OF ORAL SURGERY. 
certainly signify a step gained,-one of the many to be made, without doubt, 
by those who shall come after us. But such ability to distinguish does not 
yet exist. We may infer, but we are not certain. No treatment is known 
but that of radical ablation. Full appreciation of what is implied 
is secured in an attempt to demark a fibro-recurring from a sarcomatous tumor. 
The matter of a distinctive cell comes to be recognized as a thing of secondary 
importance. A simple fibroma returning after removal is a fibro-recurring 
tumor, and a fibro-recurring tumor is certain, sooner or later, to show the 
caudate or round cell of sarcoma. CHAPTER LXX. 
THE TUMORS OF THE MOUTH. 
OSTEOMA AND SUBACUTE INFLAMMATORY TUMORS. 
Passage is here made to a consideration of exostosis and the subacute in- 
flammatory tumors. 
Definition.-Osteomata are tumors composed of bone. The term osteoma 
is derived from the Greek words ef, " out of," and oareov, a " boneit denotes 
an osseous tumor which forms on the surface of bones, or in their cavities; 
the first is called exostosis, the latter enostosis. An osteoma may be 
independent of bone, having its relation with cartilage. 
Varieties of Ostosis.-The following varieties have been named: 
Ivory exostosis, that which is ivory-like ; lamina exostosis, that which is made 
up of distinct fibres or layers ; spongy exostosis, that which is like the spongy 
tissue of bone. 
Hyperostosis.-Hyperostosis is precisely the same thing as exostosis, 
both being hypertrophies. Inflammatory osseous tumors are hyperostoses. 
Because, however, there are great differences in the expressions of these con- 
ditions, they may be written of under special heads. 
Exostosis.-Exostosis, as commonly met with in the mouth, is strictly 
benign. It is generally recognizable by its extreme slowness of growth, the 
entire absence of pain,-except when it meets with some peculiar obstruction, 
-and its freedom from disease in surrounding parts. It does not tend 
markedly to ulceration, and does not, except mechanically, affect the regions 
even most directly associated with it. 
True exostosis has its origin in local irritation, perhaps always. It 
is true that reference is made by authors to an ossific diathesis, but, as is 
significantly remarked by Miller, a skeleton so susceptible is prone rather to 
the more common inflammatory products of caries, abscesses, ulcers, and 
necrosis. That local irritation is the chief cause of exostosis is satisfac- 
torily proven by reference to parts most subject to the lesion. The teeth, for 
example, are found affected in a thousand instances to one of any other bone, 
and certainly no bones are so constantly found in an irritated condition. The 
term bone is used, the reader being reminded that the portion of a tooth 
which takes on this morbid action, the cementum, is, in a surgical sense, 
one with that structure. 
Non-specific Exostosis.-Non-specific exostosis, occurring on any 
portion of the maxillae removed from the alveolar borders, is an exceedingly 
1159 1160 
A SYSTEM OF ORAL SURGERY. 
infrequent disease. With every opportunity for observation, the author is 
surprised at the small number of cases met with by him ; and these, with a 
very few exceptions, have been of little consequence. 
Around the base of the alveolar processes, however, and par- 
ticularly on the lingual aspect of the lower jaw, the affection, in a minor form, 
is exceedingly common, the enlargements varying from the size of a small 
shot to that of a rifle-ball. As pathological relations are concerned, the 
growths seem of little consequence; the treatment is, commonly, the very simple 
one of letting them alone. 
Operation demanded.-It is not improbable, though, that cases may 
occur upon which operations will be demanded. The mode of procedure is 
simply to lay off the soft parts from the tumor, and with a chisel or bur, 
preferably the latter, cut away the mass ; there is no hemorrhage or other trouble 
attendant on the operation. (See Hyperostosis.') 
Exostosis Dentium.-Exostosis of the fangs of the teeth-exostosis 
dentium-finds location in the cemental structure of the organs; for while 
the writer has seen two or three cases where the crowns of the teeth were 
enlarged, as if from a species of hypertrophy, yet these were so anomalous 
that the growth is to be described as associated exclusively with the fangs; 
and even here it is found, in the majority of instances, confined more or less 
closely to the apex, growing, bulb-like, as it were, about the end of the root. 
Diagnosis of Exostosis Dentium.-The diagnosis of exostosis in 
these situations is not always without confusion. The most frequent pathog- 
nomonic feature is a sense of continued uneasiness about the parts, this not 
amounting to pain, but serving as a constant reminder of the presence of the 
tooth. The organ itself may or may not be carious. Pressure, or the stroke 
of an instrument, does not, in ordinary cases, either increase or diminish the 
soreness; the sense of fulness about the parts is particularly observed where 
the absorption of the alveolus is not proportionately active with the exostosis. 
In these latter cases the extremest symptoms of neuralgia are not 
infrequently produced, and, if not comprehended, are of course treated with- 
out avail. 
Anomalous Case.-One of the most remarkable cases of dental ex- 
ostosis on record is related by Mr. Fox. The subject was a young lady, who, 
at the time she sought the professional aid and advice of this practitioner, 
had suffered so severely and so long that the palpebrae of one eye had been 
closed for nearly two months, and the secretion of saliva had for some time 
been so copious as to flow from the mouth whenever opened. The patient 
had tried every medicine recommended by the ablest professional advisers, 
without deriving any permanent benefit, and was only relieved by the extrac- 
tion of every one of her teeth, all of them being exostosed as to the roots. 
The surgeon may infer from the mention of this case that he is likely 
to meet with many gradations of the trouble. Such inference is right. Cure 
is found in the removal of the affected member or members. This is easily THE TUMORS OF THE MOUTH. 
1161 
accomplished by ordinary process of extraction, or, if not after this manner, 
then by the aid of a pair of cutting-forceps, or by means of an engine drill. 
Warty Teeth.-In this association reference is to be made to an anoma- 
lous development of teeth-germs to which the term warty has been applied. 
On another page this aspect of dentigerous cysts has been discussed. The 
rarity of these warty teeth permits few the opportunity of seeing them. 
Among recorded examples familiar to the writer are four by S. J. A. Salter, 
one by Mr. John Tomes, two by Wedl, two by M. Oudet, two by M. Forget, 
and one by Mr. Harrison. To teeth of such anomalous development M. 
Broces has applied a name that has now come into somewhat general use,- 
namely, odontomata. These, with all propriety and clinical justice, he 
has classified into circumscribed and diffused,-the first including all masses 
in which recognition of the tooth exists; the second, where it is lost in an 
anatomical confusion of the structures. The odon- 
toma described from the practice of M. Forget, on a 
succeeding page, constitutes what, in the previous edi- 
tion of this book, was classed by the author as the 
most remarkable example of the condition on record; 
but since the issue of such edition he duplicates 
it exactly in the case of a gentleman from Rhode 
Island treated by him at the Oral Hospital. Fig. 866 
is an example of warty teeth. 
Salter's Enamel Nodule.-A form of dental exostosis termed by 
Mr. Salter the enamel nodule exhibits a pearl-like protuberance growing from 
a tooth. Excrescences of this kind are considered to be essentially sub- 
merged cusps, being composed of a cone of dentine enveloped by a cap of 
enamel. 
Rare Case.-As an illustration of extreme dental hypertrophy, com- 
bined with the existence of an enamel nodule, attention may be directed to a 
specimen belonging to the Philadelphia Dental College; exhibited in Fig. 867. 
This mass is two and a half inches in length by two and 
five-eighths inches in circumference; it was associated 
with the roots of a left superior molar, and was extracted 
from the mouth of a laborer by Dr. S. H. Whitman, of 
Newport, Perry County, Pennsylvania. 
In examining this specimen, it is observed that 
to the right of the palatine root, and connected with it, 
is a portion of enamel; being an outgrowth, as has been 
inferred, either of a wisdom or of a supernumerary tooth, 
-most likely, however, a production of the tunica propria 
of the tooth itself. Mr. Salter describes such cusps as 
being clothed with a pulp,-the enamel pulp. 
Microscopical Section.-A microscopical section of this growth is 
shown (Fig. 868) and described by Dr. J. H. McQuillen, through whom the 
Fig. 866.-Odontoma. 
Fig. 867. 1162 
A SYSTEM OF ORAL SUROERY. 
specimen was received as a donation to the museum: A first or outer 
section presents lacunae and canaliculi characteristic of cementum. A 
second or inner section differs somewhat from the first in having in 
addition to what is there seen certain spaces of no definite shape, and appar- 
ently being the blending of a number of the lacunae. In a third section the 
lakes are quite numerous, and the canaliculi 
starting from them are of considerable length, 
and pursue a tortuous or curved direction, 
resembling very much the appearance and 
course taken by the dentinal tubuli in sec- 
ondary dentine. Fig. 868 is from a draw- 
ing of one of the preparations as seen under 
the microscope. A few canals (cut trans- 
versely), evidently existing for the passage of 
blood-vessels, are observed (but no Haver- 
sian canals, as in bone), with the lacunae and 
canaliculi arranged in concentric layers around 
them. 
Specific Exostoses.-In the venereal, scorbutic, and tubercular hyper- 
trophies or exostoses of the maxillary bones, the features of the common dis- 
ease become quickly evident in the local trouble; so remarkably so, indeed, 
that no one would be likely to misunderstand the condition, presupposing 
the general disease to be understood. The growths are rapid, painful, 
and, happily, almost always more or less amenable to constitutional treatment. 
Difference between Scrofulous and Venereal Forms of Ex- 
ostoses.-Scrofulous and scorbutic tumors differ from the venereal in being 
more loose and spongy in structure, and, in consequence, more apt to run into 
abscess, being possessed, as it were, of elements for their own destruction. 
The lesion is commonly heralded by deep-seated, dull pains, which precede by 
some time the visible enlargement of the part. After the tumefactive 
process sets in, it goes on, if uncombated, until the parietes of the bone 
are completely disparted. Associated with this enlargement is an unhealthy 
condition of the soft parts. As the disease advances, the centre of 
the tumor softens, while the character of pain changes, becoming sharp and 
throbbing. As pus forms, sinuses are created, and thus ulcerations occur on 
the face of the tumor. Enlargement of the maxillae from these causes 
is, however, very uncommon, and is to escape being confounded with cancer 
only by observation of the association with the disease at large. 
Treatment of Specific Exostosis.-The treatment of inflammatory 
tumors of these and similar types is to be conducted in consideration of their 
twofold requirements. The systemic influences are to be corrected, while, 
as a rule, they will be found to succumb locally to the treatment commonly 
directed against similar lesions of the soft parts. Great confidence is to be 
entertained in the use of tents and stimulating injections. 
Fig. 868. THE TUMORS OF THE MOUTH. 
1163 
Non-specific Exostosis.-There is a simple inflammatory tumefac- 
tion of the maxilla sometimes met with, which, without exercise of caution, 
is to be mistaken for specific exostosis. It is, however, to be distinguished by 
the rapidity of the formation and by the greater soreness attendant on it; it 
comes as a cold in the head, or on the chest, comes,-without, in the majority 
of cases, the patient being able to assign any cause,-and it is found soon to 
give way to antiphlogistics. This tumefaction is extra- rather than intra-max- 
illary; it is simply a periosteal exudate, and has no constitutional as- 
sociation. 
Spongy Exostosis.-In this connection, attention is to be directed to a 
form of tumor that is very common to the mouth, which, clinically, is classible 
with the exostoses. Allusion is made to an apparent expansion of bone fre- 
quently found in association with a strumous diathesis, and invariably 
in connection with periodonteally-diseased teeth or roots of teeth. These 
tumors have a common history. The nerve of a tooth dies, and the 
periodonteum takes on a chronic irritative condition, or perhaps a tooth has 
been fractured in attempts at extraction, and the root, or some portion of it, 
has been left in the socket. After a time, sooner or later, a slight swelling, 
apparently of the gum, is observed. This may readily be taken for a chronic 
alveolar abscess; there is no pain, however, associated with the enlargement, 
which is soon seen to differ from abscess in the slowness of its evolution; 
it is also hard, being unyielding under pressure. As such a case is watched 
month after month, it is seen to grow gradually, giving the impression of an 
expansion of the bone under the gum, although, as we understand, there are 
no special or marked signs of such cystiform expression. If an exploring 
needle be passed into the tumor, the sensation is that of cutting through 
spongy bone; and this, indeed, is the condition, dissection revealing that the 
cancellated structure has taken on hypertrophic action. It is such spongy 
enlargement that bulges out the overlying parts and makes the tumor. The 
author has treated quite a number of these growths, invariably in connection 
with the inferior jaw. He does not think they are often to be found in the 
superior, such chronic conditions being in the latter relation more apt to 
induce caries, which disease is known to be as uncommon to the lower as it 
is common to the upper jaw. These tumors either remain fixed in character, 
after growing to the size of half a walnut, or, in very bad subjects, they 
degenerate into abscess, and, discharging thus the offending body, correct 
themselves. Such spontaneous cure is, however, not common. 
Treatment of Spongy Exostosis.-The surgical treatment of the 
growths considered is both simple and effectual. It is enough, commonly, to 
remove the tooth or root, particularly if, in connection with such removal, the 
socket be kept open for a few weeks by use of a tent of cotton or sponge. A 
certain method of cure consists in cutting away the enlarged mass with 
a bur or gouge: this is easily accomplished by using the opening made in 
the extraction of the tooth as a means of ingress to the mass ; the disease can, 1164 
A SYSTEM OF ORAL SUROERY. 
in this way, be taken out, particle by particle, without external incision, and with 
a wound not larger than that made by the preliminary extraction. After such 
operation the parts are to be well syringed, and the tent kept in the tooth- 
socket, to insure granulations from the circumference of the wound. Cure is 
likely to be complete in two or three weeks. The writer has such cases under 
treatment almost continually. 
Obscurity in Diagnosis.-In this connection attention is to be directed 
to an obscurity which sometimes exists in the diagnostic relationship of diseased 
teeth,-that is, no teeth or roots of teeth seem to be present. A sufficiently 
close observation, however, will always detect in the neighborhood a fistulous 
opening ; it may be very minute, but it is seldom, if ever, absent. If a probe 
be passed into the orifice, it will lead to the offending agent. 
HYPEROSTOSIS. 
In connection with the simple tumors, reference is now to be made to 
general facial hyperostosis sometimes existing. In a work published 
by Mr. Heath, being a Jacksonian prize essay of the Royal College of Sur- 
geons, England, the following illustrative diagram and description of a case 
ire given: 
Illustrative Case.-The patient, when about forty-five years of age, 
and apparently in perfect health, was exposed to a cold wind; immediately 
after which he perceived an itching and heat in the eyes, a swelling of the 
face rapidly supervening. A small tumor formed just below the inner angle 
of each eye, which burst, and after twelve weeks the man was able to resume 
his employment. He suffered from inflammatory attacks in the growth, with 
much pain in the head on more than one 
occasion. He consulted many medical men ; 
but no treatment relieved the disease nor 
retarded the growth of the enlargements, 
which increased slowly and were of stony 
hardness. The eyes were projected from the 
orbits by reason of the tumors. The right 
one inflamed and burst. The left one was 
accidentally ruptured by a blow. The patient 
lived to be over sixty years of age, and 
died of apoplexy, having been occasionally 
maniacal during the last two years of life. 
The portrait is taken from the work of Mr. 
Howship (" Practical Observations on Sur- 
gery"). The skull of the patient is pre- 
served in the College of Surgeons, and shows, as might be anticipated from 
the portrait, two large masses of almost exactly symmetrical form and arrange- 
ment, which have partially coalesced in the median line. The tumors are as 
hard as ivory, and consist of very close, cancellous structure. They project 
Fig. 869.-Hyperostosis. THE TUMORS OF THE MOUTH. 
1165 
more than three inches from the face, and an inch beyond the malar bones 
on each side. The man attributed the growths to repeated blows received on 
the face in fighting. 
Illustrative Case.-The skull of a Peruvian (3093, College of Sur- 
geons, London) is also alluded to by the same author. In this case the lesion 
is of a more diffused character, all the bones of the face, as well as the frontal 
and the adjacent parts of the sphenoid and parietal, being enlarged and 
thickened in a remarkable manner. The nasal fossae and orbits are nearly 
closed, the superior maxillary bones having grown into great knobbed and 
tubercular masses, in which their original form can hardly be discovered. The 
hard palate is similarly diseased. The lower jaw is enormously enlarged at 
its right angle, and in the greater part of its right half it measures upward 
of five inches in circumference ; all but three of its alveoli are closed up. A 
section of the lower jaw shows that its interior is composed of an almost 
uniformly hard and compact, but finely porous, bone. There is no history 
attached to the specimen. 
Duplicate Case.-The writer is able to offer a duplicate case to Mr. 
Heath's in the person of a middle-aged gentleman, related with his own prac- 
tice, where the facial bones of the right side, the inferior maxilla excepted, 
are enlarged fully a third beyond the normal size, while the posterior left 
third of the frontal, the whole of the parietal and temporal bones of the 
same side are hypertrophied to an extent that shows as a great deformity. 
Cause here is with injury done to the head. The patient seemingly suffers no 
inconvenience. 
Hyperostosis one with Exostosis or Enostosis.-Hyperostosis 
is simply exostosis or enostosis. It is analogous to hypertrophy of the soft 
parts, and has a similar meaning. As can be very well understood, varieties 
in form and character present themselves. These growths are sometimes as- 
sociated exclusively with the face of a bone, as in the ordinary exostosis. In 
these cases the periosteum may separate the two bodies. In 
other instances there is hypertrophy of the bone proper. The condition is 
one of disease only as there is a lack of correspondence in other parts. Any 
section of a hyperostosed bone exhibits the peculiar features of bone-sub- 
stance ; it may be, as is often seen, that the cellular substance is compressed 
and much altered, but there is the distinction to be observed between it and a 
cortical boundary, and the analysis remains the same,-that is, as the constit- 
uent parts are concerned. When these hypertrophies associate exclusively 
with the medullary canal, as in long bones, they obliterate or diminish the 
cavity, and, if of sufficient size, expand the external parts into a tumor, 
greater or less in size. 
History.-The history of any form of hyperostosis is the history of cer- 
tain of the phenomena of inflammation; there is, from some cause or other, 
irritation attended with vascular changes, the effusion of plastic matter being 
associated with osseous transformation. What this source of irritation is, and 1166 
A SYSTEM OF ORAL SU ROE RY. 
how to control it, are matters which necessarily invite the attention of the 
surgeon. Reference has been made on a preceding page to the hypertrophies 
of the specific conditions; such enlargements are easy enough to understand, 
even if not so easy to remove, but the hyperostoses here considered are not 
of such character, but of local signification; hence a local source of offence is 
not to be sought for in vain, as, for example, in Mr. Howship's case, where 
the osteitis was justly attributed to blows received in fighting, and in my own, 
where the man had been thrown against a post in a mill. The inflammatory 
thickening of bone, alluded to a few pages back in connection with diseased 
teeth-roots, is but another illustration of the results of local irritation. 
Rates of Growth.-That the hyperostoses are to be viewed, and in 
every way treated, as simple overgrowths, is certainly well exhibited by Mr. 
Quekett, who, submitting to microscopic examination portions of all the osseous 
tumors in the Royal College of Surgeons, confirms the position in all particu- 
lars. The rates of the growths of such tumors are influenced 
by individual susceptibilities or peculiarities. There is certainly in this respect 
the greatest possible difference. In the 11 Osteographia" of Mr. Cheselden there 
is an engraving of an osseous tumor surrounding the head of a tibia, which 
measures exactly one yard in circumference. An imposing growth of like 
character is also figured in Mr. Paget's " Surgical Pathology." 
In this latter case, as Professor Clark describes the tumor, the hardest parts 
have neither Haversian canals nor lacunae. In the less hard parts the canals 
are very large, and the lacunae are not arranged in circles around them; 
the lakes being everywhere of irregular or distorted form. 
Remarkable Specimen.-A remarkable specimen of an osseous tumor 
of the left upper maxilla (Fig. 870), from the " Traits de Pathologic Externe," 
found in the Musee Dupuytren, is described in 
Mr. Heath's essay as being limited behind by the 
pterygoid process, internally by the intermaxil- 
lary suture, above and externally by the malar 
bone. The tumor encroaches considerably upon 
the cavity of the mouth, and reaches back as far 
as the front of the spine. Its form is bilobed, and 
in the deep sulcus between is to be seen a molar 
tooth. All the other teeth of the jaw have dis- 
appeared, and there is no trace of alveoli. The 
left orbit and the nasal fossa are not sensibly 
diminished in size, but the cavity of the mouth is 
almost entirely occupied by the posterior lobe of 
the tumor. The lower jaw has, in this case, 
undergone several remarkable alterations. It must at first have combated the 
growth and produced the deep sulcus between the lobes ; but in its turn the 
tumor has reacted on the jaw with the following effect: it has caused a double 
luxation, the left condyle resting against the root of the zygoma, and the 
Fig. 870.-Osseous Tumor. THE TUMORS OF THE MOUTH. 
1167 
glenoid cavity being filled with soft material. The teeth of the left side have 
disappeared, and absorption of part of the coronoid and the whole of the al- 
veolar process has taken place, so that only the base of this part of the bone 
is left. The outer surface of the growth is smooth, and presents numerous 
vascular grooves of good size; at many points it is perforated with holes. 
The vascularity of the other bones of the face does not appear to be aug- 
mented. 
Tuberculated Specimen.-In Guy's Hospital Reports a case is 
described by Mr. Hilton in which a tumor similar in signification to the one 
just referred to spontaneously separated from the face. The patient was a 
man aged thirty-six, who, twenty-three years before Mr. Hilton saw him, 
noticed a pimple below the left eye, close to the nose, which he irritated, and 
from that spot the tumor appears to have originated. The disease, in its 
growth, displaced the eyeball, giving rise to excruciating pain, which subsided 
on the bursting of the ball. It began to loosen by a process of ulceration 
around its margin six years before it fell out, which event was unattended by 
bleeding or pain. The tumor weighed fourteen and three-quarters ounces. 
It was tuberculated externally, and an irregular cavity existed 
at the posterior part. A section presented a very hard, polished surface, 
resembling ivory, and exhibited lines in concentric curves, enlarging as they 
were traced from the posterior part. The huge cavity left by the separation 
was bounded below by the floor of the nose and antrum, above by the frontal 
and ethmoid bones, internally by the septum nasi, and externally by the orbit, 
which last had been considerably encroached upon by the growth. 
Enlargement of Whole Side of Face.-Among several rare and 
interesting cases in this direction, described by Mr. Hilton, particular mention 
is to be made of that of a lad, William Mars, born with a general enlarge- 
ment of the whole left side of the face,-cheek, jaw, teeth, tongue. As the 
boy grew, so in a relative proportion did the side enlarge. The exact mesian 
line of distinction was curious to observe : the left half of the tongue was 
quite one-third larger than the right, the papillae likewise showing the dis- 
tinction. Commencing with the left central, the teeth were also one-third 
larger than their fellows of the opposite side. The ears, as well, differed in size. 
No sense of discomfort was experienced by the patient. This congenital 
peculiarity was confined strictly to the head, all other parts being in cor- 
respondence. 
The cut of a case of osseous hypertrophy-being the exact 
duplicate of an impression in plaster in the cabinet of the Hospital of Oral 
Surgery, taken by a practitioner of a distant county, in whose own mouth the 
tumor exists-was kindly sent the writer by D. H. Goodwillie, M.D., of New 
York, the following description accompanying : 
Osseous Tumor of the Right Superior Maxilla.-Mrs. B., 
aged forty-four years, has always enjoyed good health. About six years ago 
she noticed that the alveolus of the right superior jaw began to enlarge, 1168 
A SYSTEM OF ORAL SURGERY. 
and has gradually increased to time of this communication. In size and shape 
the growth resembles a hen's egg, the large end presenting posteriorly. It 
extends antero-posteriorly from the right superior canine to the internal ptery- 
Fig. 871.-Hyperostosis of Tuberosity of Maxilla. 
goid process, laterally from near the centre of the palate to the maxillo-malar 
fossa, forward to the canine fossa, and, to a slight degree, into the antrum of 
Highmore. 
The mucous membrane over the surface of the tumor is de- 
scribed as being lighter in color than normal; this, no doubt, is due to the ten- 
sion on it by the parts below. On the face of the enlargement could be seen 
the fangs of the first and second molars. The canine and bicuspidati were not 
decayed. First bicuspis and canine retained their normal position in the jaw, 
but their crowns were somewhat buried in the tumor. The crown of the 
second bicuspis could be seen above the surface of the tumor, but the whole 
tooth was raised out of its natural position and thrown inward about half 
an inch. One of the roots of a molar was lying longitudinally in the soft 
parts on the surface. 
Patient has experienced no pain, nor discharge from the mouth or 
nose, during the long period of growth; from its apparent firm texture, to- 
gether with the excellent health the lady has always enjoyed, there appears no 
doubt of its benignant character. 
Pathological Appearances.-On making a section of the tumor 
through the longitudinal direction of the teeth, the following was to be 
seen : At the apex of the second molar tooth there was a small, soft cyst, THE TUMORS OF THE MOUTH. 
1169 
containing some pus, and for a short distance surrounding this the bone ap- 
peared quite cancellated, but the rest of the tumor was quite dense in structure. 
The pulp of the canine and of first bicuspis had still some vitality, but that of 
the second bicuspis was dead. The pulp-chambers were decreased in size by 
a deposit of osteo-dentine 
upon their walls. Slight 
hypertrophy of the cemen- 
tum existed around the fangs. 
A large nerve entered the 
growth on its buccal side. 
A microscopical examina- 
tion of this tumor, made by 
Dr. J. W. S. Arnold (see his 
drawing, Fig. 872), shows 
cancellated tissue almost en- 
tirely ; the outer edge being 
a thin layer of more compact 
bony tissue. In the spongy 
part is a small amount of 
soft marrow, containing the 
usual constituents of foetal 
marrow,-i.e., medulla-cells, 
and myeloplaxes with oil- 
globules. 
Commonness of Hypertrophy of Maxillary Tuberosity.- 
Exostosis, or, more correctly speaking, hypertrophy, of the tuberosity of the 
maxillary bone, the condition shown in Fig. 871, is a quite frequent affection, 
being associated, as the author infers, with the continuous excitability en- 
gendered in this part by that elongatory process which terminates only in 
adult life. The propriety of operating upon these cases is to be determined 
by the individual conditions. The majority of such tumors are safely to be 
let alone, as they exhibit little or no disposition to change from year to year. 
The author has met with neuralgia of such severity associated with these 
hypertrophies that only through section of the affected part could relief from 
suffering be secured. 
Neoplasm, which is not uncommon to this locality, is not to 
be confounded with the exostosis considered. The former is a condition much 
more related with the gum-tissue than with the bone. Use of an exploring 
needle quickly determines the difference. In the case of the exostosis the 
gum is natural and healthy-looking. In the instance of the neoplasm it is 
more or less purple as to color and of angry aspect. 
Fig. 872. CHAPTER LXXI. 
THE TUMORS OF THE MOUTH. 
SELF-EXPLAINING CYSTIC TUMORS. 
The self-explaining osteo-cystic tumors of the jaws are, all of them, dental: 
of this the author is now fairly satisfied. Exceptions may exist, but, judging 
from his experience, they are rare. The cysts are to be described as being of 
two kinds, simple and compound. The first, the simple, are mere expansions 
of the outer plate of the bones,-wind-bags, the old writers called them, the 
expansion having associated with it a corresponding absorption of the cancel- 
lous structure. The second class, the compound, are to be described as cysts 
differing from the first in that their contents are of more or less confusing 
expression. Whether, however, simple or compound, dental lesions are to 
be looked for as cause, or origin. 
Simple Cyst.-All writers on surgery have remarked the existence, 
in the mouth, of this form of tumor,-a simple expansion of the bone, with 
varying fluid or gaseous contents. Different authors differently describe and 
name them. The term spina ventosa is, perhaps, about the most un- 
meaning that has been applied. As the author knows them, their history may 
be written as follows: there is first remarked on the side of the jaw, either 
superior or inferior (no preference seems to exist), a slight flattened enlarge- 
ment ; this increases slowly, until the swelling reaches the size of half a 
hickory-nut; they are seldom seen larger. No pain attends the growth, and, 
outside of the mental disquietude induced, no functional or other disturbance 
associates. The slowness of growth is such that it may require from one to 
three years to reach the size alluded to. This tardiness, absence of pain, and 
constitutional disturbance form marked diagnostic signs. Another sign, one 
on which most writers lay stress, is the giving forth, on pressure, of a parch- 
ment-like crackling; with this last the author seems to have had a pecu- 
liar experience, for while he has treated quite his share of such cases, it has 
not been his experience to find such crackling sound in any one of them,-that 
is, in any one of the small cysts here alluded to; and while of course it would 
ill become any individual to assert that such a crackling is never heard, yet it 
is to be impressed that the sign is not by any means a constant indication, 
consequently is not to be given a heed demanded for it. The gum covering 
such cysts is always perfectly normal,-no congestion, nothing indicating im- 
plication ; a matter important to observe, as, should the diagnosis be in any 
wise obscured, the practitioner has at least the satisfaction of feeling a tolerable 
1170 THE TUMORS OF THE MOUTH. 
1171 
assurance as to the benign character of the lesion as well as of its non-acute 
character. 
Diagnostic Illustration.-Fig. 873 expresses the meaning of the cysts 
here under consideration. The case shown is from life. The vault having 
been removed, the cause and contents of a cyst, 
the representative of its kind, is shown in the 
denuded root of a twisted lateral incisor tooth. 
Location.-Of the number of cysts of this 
class treated by the author, every one has been 
situated in the outer or vestibular walls of the 
bones. Why they should have been so located, 
or indeed whether it is always the case that they 
are so found, he does not know. An individual 
experience alone is offered. 
Manner of Treating.-A diagnosis made 
out, correction is simple. A common treatment, 
and one generally practised, because of its little 
trouble, is to make a crucial incision through the 
body of the tumor and stuff the cavity with lint 
saturated with the tincture of iodine: this, if the 
cause has been appreciated and removed,-that is, if the involved tooth, or 
piece of root, has been extracted,-will invariably cause the base to throw out 
granulations, and thus obliterate the cyst. 
Another mode, not infrequently resorted to, is to dissect from 
the tumor, in flap-form, the overlying gum, and, with a chisel, or the bur of 
an engine, cut away the vault of the cyst. The parts are next carefully 
syringed and the flap laid back. This latter operation requires much more 
time, more skill, and gives more pain than the other. The first is not nearly 
so objectionable to the patient, and is equally effectual. 
Cutting off Root and Replanting.-Where a patient is healthy 
and a tooth implicated is important, the organ may be carefully extracted with 
view to its replantation, a course as follows being pursued. First, throw the 
tooth into a vessel containing one part of tincture of iodine to four parts of 
distilled water. Second, open into the cyst by crucial incision and delicately 
scrape or bur its parietes. Third, syringe the cyst so thoroughly that no 
debris remains. Fourth, measure the alveolus of the extracted tooth and cut 
off the tooth so that its length corresponds with the depth of the socket as it 
remains. Fifth, throw the tooth back into the iodine solution, and with cotton 
saturated with iodine tincture and alcohol, half and half, stuff the cavity. 
Sixth, clean out the canal of the tooth and fill with gold, making a new but 
diminished apex, to which is to be given a perfect finish. Seventh, replace 
the tooth in its socket and hold after convenient manner. Eighth, inject the 
cyst daily until filled up, using the dilute tinctura capsici et myrrhae. (See 
Replantation.') 
Fig. 873. - Diagnostic 
Illustration. 1172 
A SYSTEM OF ORAL SUROERY. 
Illustrative Case.-Mrs. C., aged about twenty-one, applied to the 
author for treatment of a tumor occupying the canine fossa of the left superior 
maxillary bone. The growth had been eighteen months in progress; was 
about the size of half a walnut; was solid to the touch, painless, and entirely 
healthy-looking; the disquietude of the patient was purely mental, her mother 
having died from scirrhous cancer. 
Diagnosis.-Simple cyst. 
Treatment.-Crucial incisions were made with some little difficulty ; 
several delicate septi of bone, which the cuts revealed, were broken up; the 
cyst was injected for the first three days with weak stimulating liquors. No 
inflammation developing, tufts of cotton were saturated with tincture of 
iodine, and the cysts stuffed with them. In one week the site of the cavity 
was occupied by healthy granulations ; in three weeks the patient was entirely 
cured, and left the city for her home in an adjoining State. 
Illustrative Case.-A German woman applied with a cystic tumor, 
similar to the above; it was certainly as unyielding as solid bone. This tumor 
was treated by making a crucial incision through the soft parts alone; the 
flaps were then dissected off, and the cyst, being exposed, was cut away with 
a chisel-shaped instrument. The flaps fell naturally into the cavity, and were 
left, even without a stitch, to take care of themselves. The cure was complete 
in about a week. In both these cases dental disease was no doubt the original 
cause. 
Fig. 874. 
Illustration of Second Class.-Fig. 874 shows the external, and Fig. 
875 the uncovered appearance of a cystoma successfully removed by the 
author at one of the clinics of the Philadelphia Hospital of Oral Surgery. THE TUMORS OF THE MOUTH. 
1173 
This tumor had been some two years in progress of development. It pre- 
sented certainly a threatening appearance and was variously diagnosed by 
different surgeons. The 
origin was in a diseased 
wisdom-tooth. In the ex- 
tirpation it was found to 
involve all the body of the 
bone extending from the 
cuspid tooth to the sigmoid 
notch. Internally were sev- 
eral septi. The feature of 
the cyst was that of osteo- 
enchondroma. The patient 
recovered without a bad 
sign and remains well. The 
flesh-like surface of the 
cyst is absolutely from na- 
ture. 
Odontocele Proper.-An odontocele proper is exhibited in Fig. 876. 
In the diagram a large tumor cystic in character is recognized to have existed 
in the body of the lower jaw, as seen in laying off the vault c, the exciting 
lesion of which, b, a tooth-crown, is remarked lying in the cavity. 
Diagnosis seldom a 
Matter of Difficulty.- 
The diagnosis of an odonto- 
cele is seldom a matter of 
difficulty. The illustration 
here presented is the subject 
in its simplest expression; 
from this the lesion varies 
to the complex dentigerous 
tumor, an example of which 
is to be presented on suc- 
ceeding pages. 
An odontocele may 
show itself in any part 
of the ossa maxillae, 
and, what is of consequence 
to remember, may have, as 
the lesion of departure, a 
supernumerary tooth. 
The absence of a tooth or teeth from the arch, through non- 
development, conjoined with the presence of a non-vascular tumor, affords 
inference of the existence of odontocele. 
Fig. 875. 
Fig. 876. 1174 
A SYSTEM OF ORAL SURGERY. 
Employment of Exploring Needles.-In the case of supernumer- 
ary teeth, or of doubt as to the presence of a tooth or teeth in a cyst inferred to 
be odontocele, an exploring needle is to be used ; this, striking the glossy, slip- 
pery enamel, if a tooth be in the cyst, exposes the condition. 
Illustrative Case.-A young lady, aged sixteen, presented herself, 
having a tumor, intra-maxillary, evidently, occupying the anterior left side of 
the hard palate. Her condition was as follows. She had never had a tooth 
of the permanent set extracted, yet she lacked, to make up the complement 
common to her age, the canine of the affected side. The tumor was, of 
course, an odontocele, or at least so great was the probability of this being its 
character, considering the absence of the tooth from the dental arch, that any 
surgeon would have felt himself justified in founding a proposed operation on 
such conviction. An exploring needle verified the conclusion.* 
Illustrative Case.-A few years back the following interesting case of 
odontocele came under observation of the author. The patient, desiring a set 
of artificial teeth, had, about a year previous, all the teeth of the upper jaw 
extracted, and, as is customary (not desiring to wear a temporary denture), 
had been dismissed for a period of some four months to await alveolar absorp- 
tion. At the end of this time the impression of his mouth had been taken, 
the parts being in healthy condition. The teeth were made, placed in position, 
and worn with entire comfort for a period of a year. 
About eight weeks before presenting himself, these artificial teeth had been 
found getting loose, as if from some projection at the right border of the 
myrtiform fossa. Applying to his dentist, surprise was expressed at the oc- 
currence, and advice given that developments be awaited. At this period 
the gums were more or less congested, and were putting on quite an angry 
appearance; a few days later a fistule formed. His adviser, confident that 
no portion of the roots of any of the teeth had been left in the jaw, now 
dismissed the man, advising him to seek surgical assistance. In this condition 
he came under the observation of the author. 
The case now presented the following features : much engorgement 
of all that portion of the gum and lip covering the incisive and canine fossae, 
which engorgement extended in a triangular direction to the inner canthus 
of the right eye ; also much soreness on pressure over all the affected parts, 
the fistule discharging thin and occasionally bloody pus. 
Examination with a probe gave the impression that it struck against the 
root of a tooth, which would certainly have influenced the making up of 
the diagnosis if experience had not suggested that no tooth could, under ordi- 
nary circumstances, have a fang extending such a length. 
Deducing from the conditions present the imperative necessity for an ex- 
ploration, and the patient willingly acceding to the conclusion, the following 
* Refer, for proper appreciation of the subject, to chapter on Anomalies of Second 
Dentition. THE TUMORS OF THE MOUTH. 
1175 
course was pursued. The lip being pulled away, a pointed and somewhat 
delicate-bladed bistoury was passed from the superior fleshy boundary of the 
canine fossa to the inner canthus. The cut passed not only through the soft 
parts, but sunk readily into the bone. A first flap was now dissected pos- 
teriorly from the dead mass ; a second was bounded mesially by the nasal bone, 
ala, and left prominence of the myrtiform fossa. The blood being sponged 
away, there was discovered, lying in the very centre of the carious bone, a 
cuspid tooth of ordinary size and development, the apex being in immediate 
relation with the floor of the orbit. 
That this tumor had existed for a long time is, of course, not to be doubted, 
but it had attracted the attention of the patient only on the setting up of acute 
inflammatory action. This inflammation soon destroyed the integrity of the 
vault of the cyst; hence the softened, carious state in which it was found. 
The interest associated with the lesion lies in the absence of all the teeth by 
extraction, and the consequent loss of data for a diagnosis. A tumor precisely 
similar is described by Dupuytren. 
Illustrative Case.-A case of odontocele, deserving to be put forward 
as illustrative, occurred in the practice of Dr. David Roberts, treatment being 
conducted by the writer in consultation with that gentleman. 
Mr. T., a person of wealth and leisure, wearing a partial set of artificial 
teeth, noticed that the four natural incisors of the superior jaw were loosen- 
ing. This trouble increased until the living teeth were about to drop out. 
Anticipative of that accident the organs were extracted. Following the re- 
moval exuberant granulations filled, and projected from, the cavities. Ex- 
amination with a probe revealed the bone to be in a condition of caries. 
Development showed the expression of fungus haematodes. Diagnosis 
being in abeyance, the concern felt was very great. 
The meaning of the case turned out to lie in an encysted canine 
tooth of uncommon size, occupying a position in the floor of the nasal fossa 
midway between the anterior and posterior openings. The writer, in an ex- 
perience of thirty years, has met with no case more confusing. A diagnosis 
was secured only by cutting away the carious bone on the supposition of an 
existing local lesion; this supposition arising out of absence of dyscrasic ex- 
pression. 
Supernumerary Teeth.-Osteo-dental tumors dependent on the devel- 
opment of supernumerary teeth are not uncommon; they are generally easily 
recognized from their size and position, being seldom larger than an or- 
dinary pea, and mostly situated in some part of the palatine processes of 
the superior maxilla. Any obscurity, however, is readily dispersed by thrust- 
ing a bistoury into them, or, as suggested, using an exploring needle. The 
dental surgeon, particularly, would remark, from the sense of touch, the 
nature of the contents. 
Osteo-dental tumors not infrequently have as their cause 
undeveloped teeth. Some time ago the author saw a couple of bicus- 1176 
A SYSTEM OF ORAL SURGERY. 
pid crowns, evidently long dead, which had been removed from one of these 
oral compound cysts. 
Such osteo-dental tumors, then, as just illustrated, may be viewed as the 
most simple of these compound cysts. Another class, the complex osteo- 
dental, may now claim attention. 
Complex Osteo-dental Tumors.-Taking advantage of illustrative 
cuts kindly furnished by writers and publishers, two cases are shown which 
cover the ground of a required study perfectly; both being anomalous, indeed 
almost unique. Fig. 877 shows an odontoma, or tooth-tumor, in position. 
Fig. 877.-An Odontoma. 
The outer, enveloping, plate has been removed with view to the exposure. 
This growth, looking in its. bed, k, e, so unlike dental structure, and not less 
so when isolated, b, is yet easily demonstrated by microscopic section to be an 
expression of odontocele, or, better expressed, to be an odontoma. 
On the top of the tumor, as is seen, is a portion of the enamel of the 
crown of a tooth, a, very much like a half-decayed deciduous molar. The 
part below this shows rough on the surface, and seems dense in structure, 
with the exception of a concave surface on the bottom of the tumor, which is 
found quite porous. Sticking out from this surface a number of spines are 
seen, between which are minute openings in the centre of the tumor for the 
passage of vessels. 
Alongside of this were two other concave surfaces, not so deep, but dense 
and somewhat smooth, produced by the cusps of a molar tooth found below 
the tumor at this point. These cusps were probably a part of the first per- 
manent molar, and the tumor was composed of the elements of the last 
deciduous molar. No other teeth were found. THE TUMORS OF THE MOUTH. 
1177 
On making a section of the tumor, there were seen columns or 
spiculae running from the circumference to the centre, forming quite a net- 
work, in which the pulp was held, so that, instead of there being one pulp- 
chamber, there were many. 
Fig. 878, drawn from a section of this tumor, made by Drs. Goodwillie and 
Arnold, represents the dental tissues in their deranged and distorted condition. 
The internal structure is seen to be very much fenestrated. (See legend.) 
Fig. 878. 
a, a represent the enamel at the top of the tumor penetrating into fissures, or depres- 
sions, in the mass below. 
b, b. Here is represented the dentine; passing from the centre in two directions,-in 
one instance passing between two layers of enamel, and in the other between enamel 
and cement. 
C. The cement is here seen, recognized by the presence of lacunee. 
/, f, f represent the fenestrae, once occupied by the dental pulp. Around some of 
these may be seen distorted dental tubuli. 
Cystoma of Maxillary Ramus.-Fig. 879 illustrates a condition of 
cystoma occurring in the ramus of the lower jaw. As seen, the disease has 
its location in the cellular intermediate structure of the bone, the boundary 
tables being widely disparted. A case of this character is familiar to the 
writer, where a cyst enlarged to the size of the patient's head. The patient, 
who refused an operation, died, after several years, apparently of exhaustion. 
Complete removal of all the parts involved is commonly the only remedy. If, 
in any particular case, it seem well, the practice may be tried of burring and 
stuffing the cyst. Mistake is not to confound the simple with the sarcomatous 
cyst. The latter, unless radically treated, is to be let alone. 
Anomalous Case.-A curious case, diagrammed for the Dental Cosmos 
by Dr. C. N. Peirce, the tumor having been ablated by Dr. A. B. Eastman, 1178 
A SYSTEM OF ORAL SURGERY. 
of Wellsboro', Pennsylvania, will command interest. In the preceding chapter 
reference is made to a condition evidently of similar signification, but another 
periodonteal proliferation, or hypertrophy, so 
extensive as that here shown is not familiar 
to the author as being on record. Histologi- 
cally the growth is described as not being very 
widely differentiated. Its upper part, or that 
portion which surrounded and almost buried 
the crown of the tooth and which presented a 
somewhat granular appearance, is delineated 
as being composed largely of a proliferation 
of impacted epithelial cells so dense that quite 
an effort was required to separate them suffi- 
ciently for an accurate examination. 
Fig. 879. - Cystoma of 
Ramus. 
Fig. 880. 
The lower part of the tumor, or that division which was entirely 
within the walls of the alveolar process, was still more dense, forming a struct- 
ure hard and leathery in appearance; like the upper part, it was composed of 
epithelial cells, with a tendency to a linear arrangement containing various 
amorphous patches of the salts of lime, showing quite an effort at calcification, 
-a condition occasionally presenting itself in the periodental membrane 
without causing much deviation from normal appearance of function. 
The feature of interest lies in the fact that the envelope is part 
of the tooth. Periodonteal thickenings are not at all rare ; the writer has seen 
cases counting by hundreds; but accepting that here shown as photographically 
correct, it is exceptional. It is only, however, in a special sense that the 
condition is to be allied with the odontomata. 
Forget's Rare Case.-An odontoma, the most heterologous example 
found illustrated in surgical literature, corresponding with one made familiar 
to many students by reason of the patient being treated in the Oral Hospital 
by the writer, was presented, together with a prize essay thereon, by M. For- 
get to the French Academy. Fig. 881 shows the tumor as it lay in the 
section of jaw removed. The commencement of the disease was by pain, at 
first intermittent, afterward continuous and acute. When the patient was 
seven years of age, two small, healthy molars were extracted, under the im- 
pression that they were preventing the evolution of the second teeth. The 
operation gave great relief, and the pain ceased. Shortly afterward a small, THE TUMORS OF THE MOUTH. 
1179 
round, hard tumor appeared on the external face of the jaw, near the alveoli 
of the teeth that had been removed. The growth caused no suffer- 
ing to the patient, and made no sensible progress for a period of eight years. 
After this the left side of the jaw be- 
came tumefied, and the bone, in the lan- 
guage of the patient, broadened and 
rounded. He also observed, at this time, 
that the large molars, which were regu- 
larly developed on the right side, were 
wanting to the diseased part. 
This morbid enlargement was 
accompanied by frequent fluxions of 
the gums, cheek, and whole left side of 
the face. The recurrence of this per- 
version was attended with great pain, 
and caused an increased tumefaction in 
the soft parts to such an extent that the 
difference between the sides of the face 
became absolute deformity. 
Later, a violent inflammation 
occurred in the base of the jaw and the 
cervico-maxillary region. Antiphlogistic 
treatment was employed, two applications 
of leeches were made, and the inflam- 
matory symptoms decreased, and, fifteen 
days afterward, purulent matter formed. 
The thick part of the cheek opened spon- 
taneously, allowing the issue of a large quantity of fetid pus. The opening 
of the abscess became fistulous, the surrounding tissues then detached, and 
the bone under them was naked for a very considerable extent. 
Description of Case.-The case is thus described in the memoir. The 
disease appears externally in a considerable tumefaction of the left cheek, which 
is more than three times its natural size, and the tumor has caused a very 
marked eccentric development of the corresponding maxillary bone. 
When the patient opens his mouth, which he does without effort, 
the whole left side of the bone is seen to resemble a large turkey egg, the 
base of the jaw being confounded, without appreciable line of demarcation, 
with the internal and external faces, which describe a very considerable curve. 
The tumor is uniform, without depressions or any irregular swellings 
upon the surface. It does not yield to pressure, and no part of it gives that 
sound of crepitation which is characteristic of attenuation of the osseous 
tissues. The external swelling hides the superior and lateral parts of the 
neck; the enlargement of the bone has forced the tongue from its true direc- 
tion, and the floor of the mouth has been driven from the left to the right. 
Fig. 881. 1180 
A SYSTEM OF ORAL SURGERY. 
The alveolar ridge, singularly enlarged, contains none of the 
grinding teeth, except the first bicuspis, which stands regularly in its socket. 
The tissue of the gums is dark red and unusually thick and hard. In a cir- 
cumscribed spot, about the size of a twenty-centime piece, the tissue is broken, 
and exhibits an unequal, wrinkled, grayish surface which gives a dry sound 
when struck with a metal, as if the crown of a tooth were hidden in the cavity. 
Fistulous Openings.-In order to complete the symptomatic descrip- 
tion, it is added that there are many ossifluent fistulous openings at the base 
of the tumor, and much hypertrophy and hardening of the submaxillary 
lymphatic ganglia. 
Functional Disorders.-The functional disorders arising from the 
pathological condition, at first very slight, are noticed at this stage as in- 
creasing every day : embarrassment of vocal utterance, mastication painful and 
incomplete, deglutition effected with difficulty, and respiration much impeded 
every time inflammation is renewed in the tumor; lastly, the patient suffering 
from two serious inconveniences,-one, the very marked deformity of the face ; 
the other, the incessant flow of fetid pus, proceeding from the complicated 
fistulas of the osteo-dental caries.* 
* Anatomical Examination of Tumor.-With the surrounding soft parts, the tumor is 
described as being an exact ovoid. The tissues, adhering to its external face, were found 
marked with many fistular passages, ending at inflamed and ulcerous points of osseous 
structure. This tissue was thin, soft, and depressible, and perforated by two orifices leading 
into the interior of the cyst, from which exuded a purulent, viscid, reddish liquid. A stylet 
introduced into one of these passages was stopped by a hard body, which, under percus- 
sion, sounded like a compact tissue deprived of its periosteum. This object was reached 
by dissecting off the gums, which, condensed into a thick bed, formed a sort of operculum 
for the upper part, completing the cyst in which the morbid product was situated. The 
dissection exhibited that the jaw from the ramus to the premolar had been changed into a 
cavity containing a compact, saxiform, ovoid mass, the size of a large egg, grayish, un- 
equal surface, studded with small tubercles, surrounded by a bed of enamel, and completely 
buried in the thick part of the bone. (See Fig. 881.) 
Next, the tumor was divided along its axis into two unequal parts, each confined to the 
corresponding half of the osseous cyst that was comprised in the division. This revealed 
the composition of the tumor: it was formed of a smooth, glossy, compact, homogeneous, 
ivory-like tissue, of a whitish-brown color. In the centre of it a kind of regular disposi- 
tion of its elements is described as existing, discernible by the naked eye. (See Figs. 882 
and 883.) 
Between the tumor and the wall of the cyst was a thick, fibro-cellular tissue, free on the 
side of the former, where it covered the whole intra-maxillary portion, and was joined to 
the latter by filamental prolongations of a cellulo-vascular appearance, these being attached 
to the numerous openings that covered the face of the cyst. The external surface of this 
membrane was bathed with a muco-purulent liquid, smelling like dental caries. 
At the base and anterior extremity of the tumor an indentation is described fitting the 
crown of a large molar that stood between it and the maxillary bone. (See Fig. 883, 6.) 
A portion of the same tooth caused a slight elevation on the external face of the jaw. (Fig. 
882, c.) M. Forget also describes the tooth encountered in the operation. (Fig. 882, d.) 
Its location, as will be seen, is directly beneath the alveolus of the first molar, which is 
standing in its true position. (Fig. 882, e.) 
All the teeth, with the exception of the last two molars, it will thus be seen, were found, THE TUMORS OF THE MOUTH. 
1181 
Duality of Anatomical and Pathological Lesion.-M. Forget, 
in presenting his case to the French Academy, remarked that it was a duality 
Fig. 882. 
of anatomical and pathological lesion, so rare that, after the strictest research, 
he was led to believe it unexampled in the human species. 
and the space appropriated for them was filled by the tumor. What, then, queried M. 
Forget, could have become of these two great molars ? It could not be, he argued, that the 
bulbs, compressed from their very origin, had disappeared without leaving a single vestige 
of their existence. The numerous instances, he held, that had occurred of the simulta- 
neous development of teeth and anomalous productions in the very centre of the maxilla 
would not allow him to think of accepting such an explanation. In all the analogous cases 
that had fallen under his observation, the teeth were of the ordinary dimensions, and com- 
plete in number, although removed from their normal position, and sometimes buried even 
in the morbid substance itself. 1182 
A SYSTEM OF ORAL SURGERY. 
Accepting this, we have here, side by side, extremes. Under 
Fig. 884. 
standing each, there is not likely to come anything between that we may not 
be able readily to explain. 
Let us now, that we may fully comprehend such a class of cases, pursue the study of this 
particular one. 
Fig. 881 represents the left half of the body of the inferior maxillary bone, hollowed into 
a large cavity, containing an ivory-like bony tumor. 
d. Side view of the alveolar edge. 
a. Orifice of the dental canal upon the surface of the resection of the bone in the con- 
tinuity of the ramus. 
b. Plane of the cut in front, showing the second small molar which was found in it. 
c. Crown of the first molar, in regular position. 
Figs. 882 and 883.-The two halves of the anatomic section, divided according to its axis 
(osseous cyst, and included tumor). 
Fig. 882.-c. Crown of great molar, seen through a notch in the outer wall of the cyst. 
d. Second small molar. 
e. First small molar. 
a and b. Points of the same wall, perforated by the prolongation of the tumor. 
f. Summit of the most elevated of these. 
Fig. 883.-a. Interior aspect of the tumor. 
b. Great molar inverted. 
c andcL Cellulo-fibrous membrane, interposed between the osseous cyst and tumor. 
Fig- 884.-Microscopical appearance. THE TUMORS OF THE MOUTH. 
1183 
Dental Germ in Abnormal Position.-A dental germ assuming or 
compelled to an abnormal position may have various sequelae. It may make 
a mal-eruption ; it may remain encysted ; it may die after partial development; 
or it may present heterogeneously. 
Heterogeneous Development.-We have, then, but to consider 
heterogeneous development, and we have mastered the pathology of the lesion 
and all its various phases. 
Dissection of Tooth.-First, let us dissect a tooth,-for the parts of 
a tooth are the parts of such tumor. A tooth is made up of enamel, dentine, 
cementum, pulp-substance, periodonteum, and tunica propria. 
Enamel of the Teeth.-Cortex strata, adamantina dentium; crusta 
dentium adamantina; substantia vitrea. 
The enamel of a tooth is that portion which caps the crown. In 
structure it is fibrous ; its fibres radiating from externally inwardly. 
In microscopic structure, the enamel (Owen) consists of long and 
slender, solid, prismatic, for the most part hexagonal, fibres of phosphate, 
carbonate, and fluorate of lime, which are essentially the contents of extremely- 
delicate membranous tubes. 
Dentine.-Os dentis, substantia ossea ebur dentis. This is the portion 
of the tooth between the pulp and the cementum and between the pulp and 
the enamel, the tunica propria intervening. It makes up the great body of 
the organ. Dentine is composed of numberless tubules, these being 
not smaller than the one-four-thousandth of an inch in diameter; their course 
is waving, each tubule having several curves resembling, according to Retzius, 
the Greek letter '7. " Professor Retzius confirms the observation of Muller, 
that the tubes contain an organic earthy matter in granular 
masses, which disappears under the action of dilute muriatic acid. The 
cells, and the small tubes which radiate from them, also contain earthy mat- 
ter, as in bone. They are naturally white and opaque, but, after maceration 
in dilute muriatic acid, become colorless and transparent." 
Chemically, dentine differs from enamel principally in the ab- 
sence of the fluorate of lime. 
Cementum-Crusta Petrosa.-The cementum of a tooth is that 
portion which invests the fangs. In character it corresponds quite closely to 
the osseous structures. The microscope demonstrates clearly the existence of 
Haversian canals, and the so-called corpuscles of Purkinje, or, as 
Robin prefers to term them, osteoblasts. 
Osteoblasts.-In growing teeth, with fangs not fully formed, the cement 
is so thin that the Purkinjean cells are not visible; it looks like a fine mem- 
brane, and has been described as the periosteum of the fangs, but it increases 
in thickness with the age of the tooth, and is the seat and origin of what are 
called exostoses of the fangs, which are wholly composed of it. It is the 
presence of this osseous substance, suggests Professor Owen, which renders 
possible many well-known experiments of which the human teeth have been 1184 
A SYSTEM OF ORAL SURGERY. 
the subject; such as their transplantation and adhesion into the combs of 
cocks, and the establishment of a vascular connection between the tooth and 
the comb, etc. Under every modification, the cement is the most 
highly organized and most vascular of the hard dental tissues, and its 
chief use is to form the bond of vital union between the denser constituents 
of the tooth and the bone in which the tooth is implanted. 
Dental Pulp.-The pulp is that vascular, reddish-gray, highly-sensitive 
substance occupying the cavity of the tooth. It is made up of delicate 
connective tissue, in which ramify the dental nerve, artery, and vein.* When, 
says Mr. Nasmyth, the internal structures of a dental pulp are examined, the 
number of minute cells which present themselves in a vascular form is re- 
markable ; they seem, indeed, to constitute the principal portion of its bulk. 
Mr. Nasmyth describes them as " varying in size, from the smallest microscopic 
appearance to one-eighth of an inch in diameter ; and as being disposed in 
different layers throughout the body of the pulp." This tissue is highly en- 
dowed, and, perhaps, more liable than any other portion of the body to take 
on morbid action; fungoid degeneration is, perhaps, its second most common 
disease. 
Periodonteal Membrane.-This is the pericementum of the tooth. 
Anatomically and physiologically it differs little from this general class of 
membranes. Pathologically, it may be remarked as being more susceptible to 
disease, and more disposed to assume quickly acute perversions. For example, 
inflammation of the periodonteal membrane is easily provoked, and, once in- 
flamed, the part is ever after surprisingly prone to reassume morbid action. 
(See Dentition.') 
Perversion in Tooth Development.-Familiar with tooth composi- 
tion, we turn to Fig. 884, and trace a perversion of development in the 
structures,-see them forming a tumor, strictly dental, yet to the last degree 
anomalous and abnormal. 
We refer here to the microscopic examination of M. Forget's 
odontoma, made and noted by Professor Ch. Robin, Fig. 884 (400 
diameters). This figure represents a portion of a slight cut made into the 
tumor represented in Fig. 883, a. The preparation is taken from near the 
free edge, or the irregularly-mammillated surface of the tumor. The latter 
is formed principally of the ivory or dentine, easily recognized upon the thin 
section by its very fine tubes, disposed in parallels, or nearly so, through part 
of their extent (Fig. 884, e). 
These tubes, radiating more or less regularly from the little depressions or 
cavities observable in the mass of the tumor (Fig. 883, a), very near to each 
other through part of their extent, become more rare, fine, and ramified as 
* Exception is taken by so eminent an observer as Dr. Atkinson, to tbe existence of 
vessels proper within the pulp. This gentleman, whose learning and keen sense of obser- 
vation commend his inferences to the professional reader, prefers to consider the nutrition 
as of capillary signification. THE TUMORS OF THE MOUTH. 
1185 
they approach the surfaces of the dental tumor (Fig. 884, d^fy and end in 
a very sharp point toward the lines of junction between the ivory and the 
enamel (a, b, c), and the cement (/, g, A). The presence of the ivory, which 
forms the greater part of the tumor, demonstrates its dental nature very 
clearly. 
Enamel.-Another important particular is the presence of the enamel on 
the surface of the tumor, where it in some measure covers the irregularities 
with a varnish which moulds itself upon them in order to penetrate more or 
less deeply into the fissures or depressions that divide the growth superficially 
into lobes. 
This bed of enamel varies in thickness from microscopic dimensions to a 
millimetre (.03937 inch), or near it, and is as irregular in places on the 
lower or adhering face as it is on the free surface, which the microscope alone 
allows to be seen. The portion of the section of the tumor that is 
here delineated (Fig. 884) is taken at the level of one of the points 
where the enamel (a, 6) in a manner penetrates (c) into the body of the ivory 
mass of which the tumor is principally formed. 
The enamel is easily recognized by its narrow prisms, from six- to eight- 
thousandths of a millimetre in width, which are in immediate juxtaposition 
(Fig. 884, a, b~). The figure shows them inclined, as by the accidents of the 
cuts in making the section. When the cut is perpendicular, or nearly so, to 
their greatest axis, their prismatic form, with five or six faces, is easily seen; 
this is shown in the neighborhood of 6, Fig. 884. 
Cement.-In the depth of the fissures, and here and there in the mass of 
the tumor, near its surface, and especially that part of the surface hidden in 
the adventitious cavity of the maxillary bone, the microscope discovers some 
trails or beds of variable thinness, formed entirely of the substance of the 
cement (Fig. 884, y). 
The cement is enclosed between masses of ivory, and is con- 
solidated by the immediate contact (Fig. 884) with the masses between which 
it lies. It extends itself in places with the surface of the tumor to the 
neighborhood of, and even to contact with, the enamel. The section repre- 
sented in the plate is taken at a point that shows this arrangement (Fig. 884, 
f, g, hy There are, besides, thin pieces of cement extending far forward into 
the body of the tumor. 
The cement is known to be no other than the osseous sub- 
stance. The figure before us exhibits the characteristic elements belonging 
to it. These are the microscopic cavities, called osteoblasts, or, incorrectly, 
osseous corpuscles, for they are excavations. The air that fills the dry bone 
makes these cavities appear black under the microscope (Fig. 884, y); but in 
the fresh state they are full of liquid, and are pale and more difficult to observe 
than in the dry pieces. 
These cavities, which are in breadth and length from one- 
to three-hundredths of a millimetre, are always of very irregular 1186 
A SYSTEM OF ORAL SURGERY. 
shape, on account of the presence of the fine tubes that start from all their 
peripheries and traverse even the substance interposed between the osteoblasts. 
The best-joined pieces show that these little canals are subdivided two or three 
times, and are then inosculated with those of neighboring osteoblasts. The 
portion of cement shown in the plate does not exhibit this arrangement, which 
was visible, nevertheless, in the parts close to it. 
The cuts in the tumor exhibit, moreover, little openings, that are 
either full of a grayish or brown pus, or empty. These small orifices are from 
two- to six-tenths millimetre and upward in width, and from about one to two 
millimetres apart. The microscope shows that these orifices accompany the nar- 
row, irregular cavities, sometimes in the form of elongated conduits, hollowed 
out of the ivory through which they pass. The instrument shows also that 
the tubes of the latter start from these cavities to radiate toward the surface 
of the tumor, in the same manner as those of the ivory in the normal tooth 
start from the natural cavity of the dental pulp. These narrow, irregular 
cavities, more or less elongated, traverse the mass of the growth, and some of 
them even reach within a few millimetres of the surface. 
These cavities are, in reality, nothing more than the pulp-canals of 
this morbid product, either rugous from desiccation, or still containing some 
remnant of the dried organ in the form of a brownish or grayish powder. 
Recapitulation.-The result of the observations of the case is thus 
epitomized by M. Forget: 
1st. An original union of the follicles of the last two molars, followed by 
an intimate union of them, caused by phlegmasial or other action. 
2d. Under the same morbid influence, the excess of vitality in the organic 
elements of the follicles has produced hypersecretion of an ivory-like osseus 
substance. 
3d. That the irregular aggregation and diffusion of these constitutes the 
pathological growth. 
4th and lastly. Its growth has formed in the cyst, and it has maintained 
therein a permanent inflammation which has disorganized the osseous tissue 
and altered the structure of the adjacent soft parts to such an extent that a 
radical operation is necessary. 
Common Likeness in Anomalous Incongruities.-Many curious 
illustrative instances might be mentioned of anomalous incongruities in dental 
evolution ; but, as we are prepared to understand, all are to be found the same 
in character,-enamel, dentine, cementum, pulp-structure ; arrangement only 
would differ. A practitioner using his eyes, or assisted by the microscope, is 
to be able to pronounce concerning any of them. 
Ordinary Dental and Malignant Osteoid Tumors.-Ability to 
distinguish a dental from a malignant osteoid tumor must certainly prove a 
source of much satisfaction; for, as M. Forget has remarked, if intervention 
cannot be too radical in an instance of cancer, it is certain, on the contrary, THE TUMORS OF THE MOUTH. 
1187 
that more caution and moderation are desirable when it is a question of a 
lesion which is essentially local and of a benignant nature, and allows the 
surgical operation to be restricted to the precise limits of the lesion, without 
its being necessary to provide against an improbable repetition by encroaching 
upon the osseous tissues that border it, thus subjecting the patient to a mutila- 
tion which might not be justified. 
Data.-1. There are twenty teeth in the deciduous denture, which twenty 
are to be replaced by thirty-two, each of which is to be at least twice the size 
of its predecessor. 
2. A contracted maxilla, having no accommodation for certain teeth, 
the germs of which are in the jaw, gives us, among other lesions, irregularity 
in dental evolution. 
3. Irregularity in evolution yields morbid conditions, as described, 
which conditions are influenced, not unlikely, by peculiarities of the general 
organization and by manner of interference with development. 
4. An overcrowded arch will surely yield periodonteal and other 
minor troubles, and may produce lesions of grave character. The extraction 
of the bicuspid teeth of the permanent set is therefore to be practised, when- 
ever time makes evident the existence of contraction on the part of an arch. 
5. Dental tumors vary from simple cystic growths to such perverse 
and anomalous evolutions that the microscope alone is capable of explaining 
them. 
6. A dental tumor is an abnormal growth, having its point of 
departure and development in irregularity of tooth evolution. 
7. Dental tumors are benign; operations for their cure promise all 
success, and are to be practised in exclusive consideration of the disease as it 
locally exists. 
8. The existence of a dental tumor is to be inferred, caeteris 
paribus, in case of deficiency and derangement in the dental arch. 
Preservation of Continuity.-The extent of very large cysts, as these 
are occasionally found in the lower jaw, involves in a treatment consideration 
of preservation of continuity in the parts. Complete section of the bone is 
to be practised only as an absolute necessity. If removal of a cyst is to 
risk breaking the continuity of the jaw, the lower being referred to, 
either at time of operation, or subsequently, through exfoliation, an impres- 
sion of the whole dentine, upper and lower, is taken in wax and a double 
plate made and so arranged (see Fractures') that, being put in place after the 
operation and the jaws bound together for one or two weeks, accident is 
guarded against. Such splinting, as understood, corresponds fully 
with the interdental form in fracture dressing. Cysts of the extent 
here referred to involve the bone not infrequently to such extent that 
when fully cut away the continuity necessarily is broken, or so nearly so that 
the ordinary motions of the jaw will break it. An interdental splint, as ap- 
preciated, meets the indication perfectly. No matter where the cyst is situated, 1188 
A SYSTEM OF ORAL SURGERY. 
arrangement of the lower cap or caps and the soldering of these, in articular 
relation to the upper plate, secures and holds harmony of the relation in the 
jaw operated upon. 
Application of Interdental Splints.-If a tumor to be operated 
on involve the centre portion of the lower jaw, impressions in wax are taken 
of the parts on either side back of the seat of operation. A plaster and metal 
model and dies being obtained from these impressions (see Prosthetic Den- 
tistry)^ caps are swaged to fit the teeth. A succeeding step secures an im- 
pression of the upper jaw and makes a plate to fit it. Plate and caps being 
made, the pieces are put in place in the mouth, and while so placed are stuck 
together by means of wax. The patient now gently and cautiously opens the 
mouth so as not to disturb the relation, and the attached parts, being carefully 
lifted away, are laid upon a piece of charcoal and invested in a mixture of 
sand and plaster after a manner that leaves the localities of the wax uncovered. 
The manufacture of the splint is completed by soldering upper plate and caps 
together. 
Taking as other examples other situations as the seats of opera- 
tion, it is understood that corresponding changes as to the caps is the simple 
requirement. Where a c^st occupies a situation that leaves no teeth back of 
a section that is necessitated, a single cap on the opposite side meets every re- 
quirement. 
Application.-A plate made, and ready to be put in place, the tumerous 
expansion is to be cut away and the appliance located. 
Stuffing Cysts.-Cysts of limited size are ordinarily treated by crucial 
incision and packing, as before described. 
Departure from Homologousness.-Cysts may have a self-explain- 
ing origin, yet, from the presence of a systemic vice, depart from homologous- 
ness. As heteroclitic contents are met with, so will be found want of success 
in attempts at cure by the granulative process. The septi alluded to as seen 
so frequently in the simple cyst will be found at times replaced by what is 
known as the soft multilocular stroma. Again, the cavity will be found filled 
with a pulpy, liver-colored turgid mass. It is the experience of the author 
that exactly in that degree in which these cysts depart from simplicity, do 
they afford evidence of the change by the sympathy expressed in the overly- 
ing mucous membrane. (See Cystosarcoma.) 
Hypothesis of Cause.-In accounting for the formation of the ordinary 
odontocele, the hypothesis has been advanced that the condition is due to a 
morbid secretion into and enlargement of the capsule of the enamel organ; 
this, however, is certainly not the explanation, as the true enamel membrane 
-the tunica propria-is always found in a normal relation and position. That 
an effusion might have occurred between the enamel and its matricial mem- 
brane-the tunica reflexa-is barely probable, though possible; the enamel of 
the crowns of the encysted teeth being commonly too perfect to warrant in- 
ference of interference of any kind in the process of development. THE TUMORS OF THE MOUTH. 
1189 
Teeth most frequently found Encysted.-The teeth most fre- 
quently found encysted are the cuspidati ; this would be inferred from the 
relation of these organs. After the eye-teeth, the next in frequency are the 
dentes sapientiae. According to the observations of Dr. Bolles, the sexes 
show the condition in nearly equal degree. Most of the instances collated 
are noticed as having occurred between the ages of ten and forty. The prac- 
titioner named records but a single case where the patient was under ten years 
of age. Nine cases were met with in persons whose ages varied between ten 
and twenty. Three cases are noted where the ages were between thirty and 
forty. Between forty and fifty, none. Between fifty and seventy, three. The 
duration of his cases was from four months to thirty years. 
Dentigerous Cysts and Successional Teeth.-Dentigerous cysts 
of the character here referred to are, as would be inferred, related with the 
permanent (or as they would in this connection be better named, the succes- 
sional) teeth. One or two exceptions, however, are related: one from the 
practice of Mr. Alexander Edwards, of Edinburgh, being in the person of a 
young man in whose upper jaw, just below the orbit, a tumor had developed. 
This tumor consisted of exostosis from the maxilla, combined with a bony 
cyst, containing a tooth which was pronounced by Professor Goodsir to be a 
temporary molar. 
Of the various preparations in existence of cyst of the jaws, 
the largest with which the author is familiar is one in the Museum of St. 
George's Hospital. This is an immense tumor which rested upon the clavicle 
when the head of the patient was thrown as far back as possible. It is to be 
found figured in Holmes's " System of Surgery," vol. iv. 
p. 459. An example in the author's practice showed a 
cyst eight inches in diameter. 
Cystiform Antra.-Fig. 885 shows a cystic 
tumor, or, rather, a form of expansion of the walls of 
the antrum, as occasionally met with. The cyst repre- 
sented in the view occurred in the person of a young 
gentleman some twenty years of age, from whose jaw 
it was successfully removed, the soft parts being ex- 
posed by pulling outward and upward the angle of 
the mouth; the wall of the cyst, about the thickness 
of ordinary parchment, was cut away with a chisel. The 
cavity was without contents of any kind. After the 
removal of the vault, the soft parts were permitted to 
fall into the sinus. No deformity resulted, and no trouble has since been 
experienced. The size of the tumor was that of an ordinary orange. 
Tenacity of the Antrum, functionally considered.-An in- 
teresting feature in this character of cases is found in the tenacity on the 
part of the antrum, after operation, to maintain its office. The author has 
tried his best to obliterate a sinus by compelling granular activity about its 
Fig. 885. - Antral 
Cyst. 1190 
A SYSTEM OF ORAL SURGERY. 
walls, but so long as he has been enabled to watch cases (and in one instance 
seven months elapsed before the overlying tissues so covered in the part as 
to conceal it from free observation), in none of them has he been able to 
satisfy himself as to what was the subsequent condition of the part. His 
impression is, however, that the mucous membrane maintains itself, and 
that a species of cavity continues to exist. (See Antrum.) 
Hydrops Antra.-Hydrops antra is another form of cystiform enlarge- 
ment of this cavity. The dilatation in these cases is gradual and painless, 
and when the bone becomes expanded to any considerable extent, fluctuation 
is commonly apparent, the vault of the cyst readily yielding to pressure. If 
obscurity exist, it is to be dispelled by the use of an exploring needle. It 
sometimes happens in these cases that the floor of the orbit becomes the 
yielding-point, or it may be the canine fossa, the tuberosity, or the hard 
palate; the latter boundary, however, according to common observation, is the 
most frequent seat of the enlargement, forming a tumor within the mouth. 
Intra-antral Cyst.-Hydrops antra depends, in many cases, on the 
formation of a cyst within the cavity. In others it is to be recognized as a 
simple mucous engorgement, the natural outlet into the meatus being, from 
some cause or other, obliterated. A very expressive illustration of the first 
of these conditions was ex- 
hibited in a specimen taken 
some eight years back by the 
writer from the antrum of a 
young man. In this case the 
cyst seemed to spring from the 
root of the second molar tooth, 
or from its immediate neigh- 
borhood ; the mucous mem- 
brane being dissected up, and 
covering the cyst as a kind of 
reflex tunic. Although this 
particular tumor was not large 
enough to exhibit external evi- 
dence of its existence, yet there 
are no reasons for inferring 
that more extensive tumefac- 
tion would not eventually have resulted. A case of interest in this direction 
is recorded in the practice of Dr. Chase, of Iowa City, who reports it in the 
Dental Cosmos, accomnanvine the account with a diagram.* 
Fig. 886.-Secondary Cyst of the Antrum. 
1, root of second bicuspid attached to alveolus; 2. 
neck of tooth and border of alveolus; 3, walls of 
antrum, palatal side; 4, centre of crown of tooth; 5, 
tumor; 6, tartar, covering the cavity of decay. The 
buccal aspect of the tooth was similar in appearance 
to the palatal surface which is seen in the engraving. 
* Description of Case.-An Irishwoman, aged forty years, came to have the right first 
upper molar extracted. I found her teeth in a bad condition generally : they were decayed 
and loose, and the gums congested. This particular tooth was decayed and very loose. On 
pressing it, the alveolus seemed to move with the tooth. Adjoining it in front was the 
root of the second bicuspid,-the crown gone. THE TUMORS OF THE MOUTH. 
1191 
Multiple Antral Cysts.-M. Giraldes refers to multiple cysts of the 
antrum ranging in size from a pea to that of a pigeon's egg. These cysts he 
describes as being found filled with a fluid, sero-albuminous, thin or glairy, 
and differing in color in different cases, being brown, yellow, or blood-shade. 
To the suppuration of them is attributed the occasional resistance of abscess 
to treatment. These cysts this author believes to be quite common, and that 
they are the explanation of many of the enlargements encountered. Their 
origin he locates in morbid changes of the mucous glands.* 
Meningocele.-A cystoma, meningocele, of grave nature-a self-ex- 
plaining cyst of an entirely different nature from any referred to-is shown 
in Fig. 887. The tumor expresses a congenital deficiency in the occipital 
bone, and exists in a protrusion of the meninges of the brain. An operation 
being rendered necessary in this special case, shown by reason of rapid in- 
crease in the size of the cyst, attempt was made by the author to strangulate 
As the woman was of that class which makes no attempt to preserve the teeth, I extracted 
the molar without hesitation. She had told me that her "jaw" had ached for three or four 
months previous to this time. On applying the forceps, the beaks readily passed under the 
gums without lancing, and the tooth, much to my surprise, came away with a very slight 
application of force. But this surprise was not equal to my astonishment when I saw what 
I had brought away with the tooth,-namely, a large quantity of alveolar substance, the 
bicuspid root, and a fibrous connective-tissue tumor, nearly an inch in diameter, attached 
to the tooth, and enclosing two of the roots, namely, the posterior buccal and the palatine 
root. 
The tumor, after being in alcohol three days, was nearly white, and had shrunken to 
one-third its original size. On cutting it open, it was found filled with a solid structure. 
The consistence was that of tubercle, or pressed cheese-curd; the color, light yellow, tinged 
in most parts with red. 
The roots within the tumor were nearly free, and covered with their periosteum, which 
had thickened into a loose, spongy mass, extending even to the base of the body of the 
tooth. The appearance was like that of roots involved in an alveolar abscess. The walls of 
the tumor were not composed of detached dental periosteum. There were apparently two 
coats, the outer fibrous, like periosteum; the inner a mucous one, like the lining of the 
nasal cavity. 
The pathology of the case, as inferred by Dr. Chase, is that the tooth decayed to the pulp- 
cavity, and that the pulp, after repeated inflammatory attacks, died. Putrefaction occurred, 
provoking periodontitis; after a while suppuration ensued, and the disease became chronic. 
The periodonteum became thickened and spongy, and continued irritation caused a prolifera- 
tion of connective-tissue corpuscles, thus eventuating, finally, in the formation of the cyst. 
This inference is, probably, the true explanation of the tumor. The trouble, however, 
seems to have been seated primarily upon the bicuspid and not upon the molar roots, in- 
volving the latter secondarily. This tumor, although it did not possess the contents of the 
one operated on by the author, has a similar pathological signification: it constitutes an 
INSTRUCTIVE EXAMPLE. 
In cases of this kind it will be seen at a glance that, however patulous the natural out- 
let might be, the contents of the tumor could not by such means find egress. In the second 
character of cases, the contents are just within the cavity, but the engorgement of the tis- 
sue bounding the outlet has closed the foramen. A case described in the chapter on Dis- 
eases of the Antrum exhibits the dangerous and destructive effects of such accumulations 
when unappreciated and untreated. 
* Recherches sur les Kystes muqueux du Sinus maxillaire. 1192 
A SYSTEM OF ORAL SURGERY. 
it at the pedicle by means of subcutaneous ligation. No shock or immediate 
ill result attended the accomplishment, but on the fourth day coma gradually 
came on, in which condition the child 
died three days later, without, ap- 
parently, having experienced the least 
pain. Age of babe, ten months. 
Aneurismal Cyst. - Lately a 
patient presented himself to the writer 
having an immense cystiform enlarge- 
ment of the lower jaw. The tumor 
was quite the size of a foetal head. 
Examination revealed an aneurism. 
Aneurism is to be treated by 
the fully experienced alone. 
A cut made into such a cyst would 
result seriously, and, not unlikely, 
fatally. Mistake being made, the cyst 
should be instantly opened with a freedom that would permit of the cavity 
being solidly packed, otherwise the internal maxillary or external carotid artery 
should be ligated. (See Ligation of Arteries.} 
Osteo-enchondroma.-Fig. 874 exhibits the external appearance of 
an osteo-enchondroma operated upon at the Hospital of Oral Surgery. Fig. 
875 shows the cyst uncovered. In this case the trouble originated about the 
roots of certain diseased posterior teeth. The tumor is, of course, classifiable 
with the cystomata, as it is referred to under that head. It belonged to the 
self-explaining growths, although obscure until its cause was exposed by opera- 
tion. Treatment consisted in removing the vault and scraping out the floor. 
Recovery was rapid. 
Hydatid Cysts.-A tumor occupying the extreme end of the self-ex- 
plainable growths is found in the hydatid cystoma. Here the origin, not being 
in a perversion peculiar to a part, is not without confusion in the way of diag- 
nosis. The tumor is to be placed, howeVer, in remarking the absence of all 
signs which relate it with common vice expression, and in observing that, 
unlike cancer, there is absence of vascular change, and as well no disposition 
to invade neighboring parts. Local diagnostic signs lie in a peculiar resiliency 
and in the not infrequent presence of a fremitus. The treatment of a 
hydatid cystoma is by radical removal with the knife, otherwise by absorbable 
parasiticides, or by the injection of like agents. (See chapter on Hygromata 
of Neck.} 
Fig. 887.-Meningocele (from a 
patient in tbe author's clinic). CHAPTER LXXIL 
THE TUMORS OF THE MOUTH. 
TUMORS NOT EXPLAINABLE IN LOCAL CONDITIONS. 
Assuming the student as being now appreciative of the principle on which 
all tumors belonging to the first division of our classification are diagnosable, 
we pass to that of the second. 
Constitutional Import of Tumors.-As all lesions of the first class 
have their meaning in purely local derangements, after a like signification all 
growths of the second division are found of constitutional import. That is 
to say, repeating the basal principle of the arrangement, there are two 
kinds of tumors ; only two kinds : 1, tumors arising out of local 
causes; 2, tumors arising out of constitutional causes. 
Differentiation of Tumors of Constitutional Import.-There 
is one constitutional cause of tumors that is an arcanum,-namely, cancer. 
Nobody knows anything as to the cause of cancer. Besides this one there 
are other constitutional causes of tumors. These others are understandable 
and appreciable ; examples lie with the manifestations of syphilis, of scrofulosis, 
of scorbutus, of gout. 
Making a Diagnosis.-Accepting a tumor to be of constitutional im- 
port, diagnosis proceeds on the ground of getting accurate conception 
of the lesion through a process of exclusion. 1. In what systemic vice 
does the condition^ exist ? 2. If no appreciable vice exist,-that is, if the 
patient be neither syphilitic, scrofulous, gouty, scorbutic, nor rheumatic,- 
diagnosis finds itself fallen back upon the only thing left,-namely, cancer. 
Study of Cancer.-We pass to the study of cancer. 
Every tumor is a cancer that is not something else. Learn- 
ing and experience are capable of distinguishing the "some- 
thing else.'' 
Another aspect of diagnosis relates with treatment. All self-explainable 
tumors, whether of local or of systemic signification, possess in themselves 
the meaning and manner of their treatment; all such tumors are combatable 
on a purely scientific basis: cause is understood, cause is managed. 
Tumors not self-explainable are treatable on an unscientific basis 
alone; nothing being appreciated as to their cause, nothing is to be done for 
them, save mechanically. To let such tumors be, otherwise to cut them away, 
is all that surgery has yet learned. 
1193 1194 
A SYSTEM OF ORAL SURGERY. 
Extremes.-For purposes of scientific treatment the most simple of the 
fibromata occupy common ground with the most complex of the encephalo- 
mata. Tumors which are of a common manner of treatment belong under a 
common head. Deduction : Fibroma and encephaloma, having a single and 
common manner of treatment, are-as treatment, at least, is concerned- 
identical. 
Histologically : Tumors found to run into each other, no absolute line 
of demarcation existing between the extreme of the one and the commence- 
ment of the other, are to be classed under a common head. Simple fibroma 
and recurring fibroma cannot be demarked, as the extremes of the two are 
concerned. Recurring fibroma cannot be demarked from sarcoma. 
Sarcoma cannot be demarked from encephaloma. Deduction: 
The most simple of fibromata differ from the most complex of encephalomata 
alone in features of expression. The family is a common one. The 
reader interested in the subject will wisely at this point observe and study 
closely the diagrams introduced illustrative of distinctions in the neoplasms as 
taught by the microscopist, but he is to hold in his mind differences which 
exist between histological and clinical definitions. 
Histological Classification.-In a record of 307 cases of tumors of 
the jaws made by Professor C. Weber, the histological varieties noted are as 
follows: Carcinoma, 133 ; sarcoma, 84 ; osteoma, 32 ; cystoma, 20 ; fibroma, 
17 ; enchondroma, 8, gelatinoid polyps, 7 ; melanotic sarcoma and carcinoma, 
5; angeioma, 1. 
Clinical Classification.-The tumors named in the histological classi- 
fication arrange themselves primarily, clinically, into two sets, or kinds, or 
conditions. First, one set that bear with them self-explanation; that is to 
say, a dentigerous cyst tells us all about what it 
is, so likewise does an angeioma carry its own 
history. Taking these two of the several named 
above, a practitioner knows that he knows 
exactly what he is dealing with. Second, 
the other set, naming as examples carci- 
noma and sarcoma. Here a practitioner, if he 
be of any experience, knows that he does not 
know what he is dealing with. He knows 
nothing about what to do for such tumors except 
that he cut them out or let them alone. Indi- 
rectly, however, a histological classification is to 
be accepted, as thus with most convenience data 
are found for a study, the understanding of 
which is of great service, and certainly of large 
interest. 
Fibrous Tumors-Fibroma.-Tumors of this kind are composed 
of firm, interlaced fibrous tissue; are, to the touch, hard, yet to an extent 
Fig. 888.-Fibrous Tumor 
over Parotid Gland. THE TUMORS OF THE MOUTH. 
1195 
elastic. Such growths spring from the periosteal tissue. When unmoulded, 
as where springing from a free surface, they are superficially lobed, and, as 
a rule, are ovoid in form. In color, they are a faintly yellowish-white, pure 
white, or a very pale red. Tn arrangement, the fibres are of concentric, ec- 
centric, or of irregular relation. The first form is known as concentric; 
the expression of the fibres is that of concentrating toward a centre. The 
Fig. 889.-Microscopic Appearance op Fibroma. 
second form is known as eccentric; the fibre expression is that of con- 
verging from a centre. The third form is known as fibro-cellular, or the 
fibro-plastic of Lebert; the fibres are of irregular admixture with free and 
plentiful cellular tissue. 
Diagnosis.2-The diagnosis of the first form of the fibromata, the 
concentric, lies with the isolation of the growth ; with its elastic hardness; 
with the perfectly-healthy and non-implicated appearance of the associate parts ; 
with the absence of pain ; and with the tardy growth. Such a tumor is to be 
removed with reasonable assurance of its non-return. 
2. Diagnosis of the second form of the fibromata, the eccentric, 
finds it in such close alliance with the first that no one may doubt the intimate 
relationship of the two. This tumor, or rather this expression of a common 
tumor, departs in various degree from the concentric development, seeming, in 
this respect, to be seeking freer and wider relation. 
Diagnosis of the third form of the fibromata, the fibro-cellular, 
finds a tumor neither so hard nor elastic as the two preceding, nor is it of 
such concentrated expression. This form is what Rindfleisch terms a " con- 
nective-tissue growth." It is the fibro-recurring tumor. Its stroma is much 
freer as to extent of cellular tissue than are the others of its class. 
3. Myomata of Virchow.-Advancing one step farther in the ap- 1196 
A SYSTEM OF ORAL SURGERY. 
preciation of tumors of fibromatous expression, we meet with those spindle- 
shaped cells which induced Virchow to give to the class the name of myoma, 
and which, when possessed of more marked characteristics, constitute the 
fibro-sarcoma of Rokitansky. This is truly the fibro-recurring tumor, 
an expression of which Mr. Miller speaks-see his " Principles of Surgery"- 
as of a tumor ill defined, one which it may be doubted if it be not more 
properly classed when placed with the malignant condition, seeing it is 
found prone to return, after excision, with singular obstinacy. 
Fig. 890.-Microscopic Appearance of Fibro-recurring Tumor. 
Beginning of Confusion.-The fibro-cellular tumor - fibro-plastic, 
fibro-recurring, myoma, fibro-sarcoma-presents alterations of structure, from 
which, at a point of some confusion, it passes into classification as sarcoma. 
Sarcoma.-The sarcomata are so called from presenting on section a 
fleshy look. A sarcoma is what Billroth designates a tumor consisting of 
tissue belonging to the developmental series of connective-tissue substance 
(connective tissue, cartilage, bone, muscles, and nerves), which, as a rule, 
does not go on to the formation of a perfect structure, but to peculiar degen- 
erations of the developmental form ; in other words, it is an expression of im- 
perfect fibroma. Rindfleisch distinguishes the sarcomata into 
the round-celled sarcoma, the spindle-celled sarcoma, and the fibroma.* These 
* The granulation-like round-celled sarcoma (sarcoma globo-cellulare simplex) in its 
textural and structural relations is allied to the model of the tissue of granulations. To 
the naked eye, a yellowish or reddish, thoroughly homogeneous, elastically-soft mass, at 
times extraordinarily like the roe of fishes, presents itself from the cut surface; by scraping THE TUMORS OF THE MOUTH. 
1197 
tumors grow to an immense size. Fig. 891 shows a not infrequent clinical 
expression of the disease 
Unexplainable Tumors expressive of Arrest of Develop- 
ment.-Tumors denominated in this chapter neoplasms are coming to be 
commonly accepted as conditions expressive of arrest in development,-a con- 
clusion which is no doubt just enough, yet which does not touch the cause in 
which the arrest has its meaning. 
Myeloid of Paget.-Another expression of this tumor is that classified 
and described by Mr. Paget as the myeloid, 
-so called from its resemblance to marrow,- 
an expression so lacking in persistent indi- 
viduality that, even according to the classifier 
himself, the features vary from simple semi- 
fibrous, semi-marrow-like structure to those 
so heteroclitic that they " seem to merge into 
the medullary." A myeloid, as suggested 
by the English surgeon, like a fibrous tumor, 
may be enclosed either in a bone whose walls 
are expanded round it, or, more rarely, it is 
closely set upon the surface of a bone con- 
fused with its periosteum. The sketches of 
fibromata pictured in the " Surgery" of that 
author are readily to be received as illustrative 
of myeloid. 
These two kinds of growths are equally 
common to superior and inferior jaws. 
Enclosed Myeloid.-A myeloid enclosed in bone affords a tumor ovoid 
in shape, well defined, and found, not infrequently, invested with a distinct 
capsule. Situated externally, it is apt to be lobulated and of irregular roundish 
form. Mr. Paget describes the growths as feeling like uniformly compact 
masses, but in different instances variously consistent. The most character- 
Fig. 891.-A Clinical Ex- 
pression of Sarcoma. 
with a knife-blade, we can obtain a scanty amount of juice, which is almost entirely clear, 
or contains but few cells. The cells are small, round, and possess comparatively large 
nuclei, of sharp contour, and provided with nucleoli. The protoplasm, as a rule, is present 
only in small amount, therewith entirely naked; we must have recourse to hardening the 
tumor and coloring it with carmine, in order to make it generally distinct, and to convince 
ourselves that a cell-body actually belongs to each of the apparently free nuclei. 
The structure of round-celled sarcoma deviates only in a quantitative relation from the 
structure of granulations. The vessels in part are wider, thicker walled; where these, 
however, break up into capillaries, they are just as delicate, frequently only built of a 
simple cell-layer, such as we saw in the vessels of granulations. The interspaces between 
the vessels are everywhere uniformly filled by the round cells and the scanty, soft, and 
formless basis-substance of the germinal tissue. In rare cases one observes a higher organ- 
ization of the whole, which reminds of the papillosities of granulations,-namely, a radiated 
striation and a decided disposition of the mass of the tumor for cleaving in radiating 
directions. 1198 
A SYSTEM OF ORAL SURGERY. 
istic examples are firm, and (if by the name we may imply such a charac- 
ter as that of the muscular substance of a mammalian heart) they may be 
called fleshy. Others are softer, in several gradations, to the consistence of 
size gelatin, or to that of a section of granulations. Even the firmer are 
brittle, easily crushed or broken ; they are not tough, nor very elastic, like the 
ordinary fibro-cellular or fibrous tumors, neither are they grumous nor pulpy, 
neither do they show a fibrous nor granular structure on their cut or broken 
surfaces ; these tumors are smooth, uniform, shining, compact, succulent, with a 
yellowish, not a creamy fluid. A peculiar appearance is commonly given to them 
by the cut surface presenting blotches of dark or livid crimson, or of a brownish 
or a brighter blood color, or of a pale pink, or of all these tints mingled on 
the grayish-white or greenish basis-color. (In a foot-note, Mr. Paget quotes 
from Lebert, who says the greenish-yellow color they may show depends on a 
peculiar fat, xanthose.) The tumors may all be pale, or have only a few 
points of ruddy blotching, or the cut surface may be nearly all suffused, or 
even the whole substance may have a dull modena or crimson tinge, like the 
ruddy color of a heart, or that of the parenchyma of a spleen. Many of what 
have been named spleen-like tumors of the jaws are of this kind. The color 
they present is not due merely to blood in them; some of it is appropriate to 
their texture, as is that of the spleen or that of granulations, and it may be 
quickly and completely bleached with alcohol. 
Microscopic Appearance of Myeloid Growths.-The following 
are the histological appearances pronounced peculiar to the myeloid growth, 
being imitated in no other morbid structure : 
1. Cells of oval, lanceolate, or angular shape, or elongated and 
attenuated like fibre-cells, or caudate cells having dimly-dotted contents, with 
a single nucleus and nucleolus. 
2. Free nuclei, such as may have escaped from the cells, and, among 
these, some that appear enlarged and elliptical, or variously angular, or are 
elongated toward the same shapes as the lanceolate and caudate cells, and 
seem as if they were assuming the character of cells. 
3. The most peculiar form: large, round, oval, or flask-shaped, 
or irregular cells or cell-like masses, or thin disks of clear or dimly- 
granular substance, measuring from one-three-hundredth to one-thousandth 
of an inch in diameter, and containing two to ten or more oval, clear, and 
nucleated nuclei. 
Corpuscles such as these, irregularly and in diverse proportions embedded 
in a dimly-granular substance, make up the mass of a myeloid tumor. They 
may be mingled with molecular matter, or the mass they compose may be 
traversed with filaments or with bundles of fibro-cellular tissue and blood- 
vessels, but their essential features (and especially those of the many-nucleated 
corpuscles) are rarely observed. 
Many varieties of aspect (as remarked by Mr. Paget in his histologi- 
cal studies) may thus be observed in myeloid tumors, and beyond these they THE TUMORS OF THE MOUTH. 
1199 
may even be so changed that the microscope is essential to their diagnosis. 
After they partially ossify, well-formed cancellous bone being developed in 
them, cysts, also filled with bloody or serous fluids, are to be found occupying 
much of their volume, or even almost excluding the solid texture. 
Fig. 892.-Microscopic Appearance of Myeloid,-i e., of Sarcoma. 
This author notes a case in which he amputated the leg of a woman, 
twenty-four years old, for what was supposed to be a cancerous tumor growing 
within the head of the tibia. She had pain in the part for eighteen months, 
and increasing swelling for ten months, and it was plain that the bone was 
expanded and wasted around some soft growth within. 
On section, after removal, the head of the tibia, including its articular face, 
appeared expanded into a rounded cyst or sac about three and a half inches 
in diameter, the walls of which were formed by its flexible bone and perios- 
teum, and by the articular cartilages above; within there was little more than 
a few bands or columns of bone, among a disorderly collection of cysts filled 
with blood, or blood-colored serous fluids. The walls of most of the cysts 
were thin and pellucid; those of others were thicker, soft, and brownish - 
yellow, like the substance of some medullary cancers, a likeness to which was 
yet more marked in a small solid portion of tumor, which, though very firm, 
and looking fibrous, was pure white and brain-like. 1200 
A SYSTEM OF ORAL SURGERY. 
No one, Mr. Paget says, who examined this disease with the naked eye 
alone, felt any doubt that it was an example of medullary cancer, 
with cysts abundantly formed in it. But, on minute investigation, 
none but the elements of the myeloid tumors could be discovered; these, 
copiously embedded in a dimly-granular substance, appeared to form the sub- 
stance of the cyst-walls, and of whatever solid material existed between them. 
The white brain-like mass was apparently composed of similar elements in a 
state of advanced fatty degeneration, but neither in it nor in any other part 
could be found a semblance of cancer-cell. 
No mention is made of the return of the disease; it would 
seem that, in the present state of our knowledge of cancer-growths, it would 
have been no difficult matter to class such a tumor with the malignant. Not 
consuming time in a discussion of the subject, it is evident that even so able 
an observer as Mr. Paget was not at all clear with his case. 
An epitome of the myeloid may thus be presented: 
They are a class of fleshy tumors called by M. Lebert fibro-plastic, 
because, he says, they are made up of fibre-cells. They are called myeloid 
by Mr. Paget, because he thinks they resemble marrow much more than 
they do fibrous tissue. 
In character, they vary from simple semi-fibrous, semi-marrow-like 
structures to those so heteroclitic that they seem to merge into the medullary. 
Their favorite seat seems to be about the bones, either intra or extra. 
They are growths which usually occur singly ; they are most frequent 
in youth, and very rare after middle age; they generally grow slowly and 
without pain, and usually commence without any known cause, such as injury 
or hereditary disposition. 
According to Mr. Paget's observations, they rarely, except in portions, 
become osseous; they have no proneness to ulcerate or protrude; they 
seem to bear even considerable injury without becoming exuberant; they may 
shrink or cease to grow; they are not apt to recur after complete removal, 
nor have they in general any features of malignant disease. These observa- 
tions as they relate to non-return of the disease after ablation of the tumor 
are the reverse of the writer's experience. 
Since penning the above the author has accidentally fallen on a classifica- 
tion of the tumors of the upper jaw, made by Mr. Hancock. After alluding 
to various classes, he says, In addition to these, Mr. Paget adds what he terms 
myeloid tumors of the part; but while the examples he quotes resemble on 
the one hand so much the fibrous, on the other the medullary tumors, their 
true character, whether innocent or malignant, is so very doubtful that I 
should hesitate in admitting them as a distinct class. 
Epitome.-Fibrous tumors proper, and the fibro-plastic, have general 
features in common,-that is, they belong to the expression of sarcomatous 
growth ; but then in a histological sense they have such differences that an 
epitome, at least, of their history should be reviewed by us. THE TUMORS OF THE MOUTH. 
1201 
In instances, as first described, fibrous tumors are seen under the micro- 
scope to have a concentric development: this species is slowest of growth, is 
least malignant, never attaining any great size. 
In other instances, as described secondly, the fibres converge, 
kind reaches toward the heteroclitic. 
The class described thirdly attain the largest size; the fibres interlace 
in a most complicated and irregular manner. This kind may be said to have 
reached the heteroclitic. Dr. Humphrey speaks of examples showing nodules 
which he compares to a conglomerate gland; the tumor being made up of 
small masses closely compressed, having an uneven, knotty outline. 
Braithwaite on the Fibromata.-Fibrous tumors affecting the bones 
(Braithwaite) are usually found upon those of a spongy nature, upon the ends 
of the long bones, the phalanges, pelvis, and in the jaws. So far, says the 
author, as I have met with them, they are confined to the exterior of the 
lower jaw, growing from the periosteum and creeping along the surface of 
the bone in such a manner as to prove almost to a certainty that they originate 
in some morbid condition of the periosteal fibres. The bone underneath 
these tumors may suffer absorption in consequence of the pressure pro- 
duced, but does not seem to be affected in any other way. The growths appear 
upon the maxillary bone more frequently than upon any other part of the 
skeleton. On the lower jaw they spread along the ramus, encir- 
cling it beneath and on the sides, so that the bone is almost concealed by the 
tumor. In some instances they form within the substance of the 
jaw, probably from the alveolo-dental membrane, and as they increase, the 
walls of the bone become spread out over them. They grow up around the 
teeth, and when they project into the mouth may be soft and fungous.* 
In some instances the fibrous tumors of the jaws exhibit 
a semi-cartilaginous structure, and now and then fibres or plates of bone are 
formed in various parts of them. The progress of the disease is well illus- 
trated by a series of maxillary tumors in the College of Surgeons, London, 
from the museum of the late Mr. Liston. These preparations serve to show 
how necessary it is to bear in mind the mode of growth of periosteal fibrous 
tumors of the jaws, because from their disposition to creep along the surface 
of the bone, whether it be an endosteum or periosteum, they are liable to re- 
turn after removal, unless the immediately adjacent as well as affected parts 
be excised. The histories attached to the specimens teach that very large 
fibrous tumors, both of the upper and lower maxillae, together with the bones 
on which, or in which, they grow, may be successfully removed. 
Cysto-sarcoma.-A cysto-sarcoma, as implied by the prefix, is a tumor 
of only semi-solidity. Its interior, or stroma, is made up of cysts and fleshy 
substance. These cysts within a cyst are original formations, and not of 
This 
* Presenting this phase, the tumor is classed with the epulic, but it will be seen that on 
this account there need be no confusion. An epulic tumor may be fibromatous. 1202 
A SYSTEM OF ORAL SURGERY. 
secondary character,-that is, they are not the result of molecular disintegra- 
tion. They are lined sacs, having a distinct secretory membrane. 
Miller describes the contents as widely differing, which difference every sur- 
geon must have observed: They are more or less fluid, as noted by him, 
sometimes a clear gluey liquid, sometimes a gelatinous, pale mass of semi- 
solid consistence, elastic, and projecting beyond the level of the cut cyst on a 
section being made; sometimes a solid, consisting of a fibrous deposit, or- 
ganized very imperfectly, if at all; sometimes of a pulpy consistence, as in 
many encysted tumors; sometimes, but more rarely, a dark fluid, like printers' 
ink, is contained; sometimes blood is mingled with the contents, either in the 
solid or in the coagulated form. 
Approach to Self-explainable Cystomata.-The very nearest ap- 
proach made by cysto-sarcomata to the self-explainable cysts is in that class 
very well named the " cysto-succulent." These are sarcomatous tumors, 
the stroma of which is made up of very loose fibro-cellular tissue. They 
might well, in their contents, be likened to a watermelon, solid enough on 
section, but compressible to a few shreds. The fibrous contents of the stroma 
are, however, always a distinguishing sign. These tumors are very rare, and 
particularly so about the bony structures. 
Cysto-sarcoma Phyllodes.-Muller describes a variety of cyst of 
sarcomatous growth, which he calls cysto-sarcoma phyllodes. The tumor 
forms a large firm mass, with a more or less uneven surface. The fibrous 
substance, which constitutes a greater part of it, is of a grayish-white color, 
extremely hard, and as firm as fibro-cartilage. Large portions of the growth 
are made up entirely of this mass, but in some parts are cavities or clefts, not 
lined with a distinct membrane (an exception to the rule in cystic tumors). 
These cavities contain but little fluid, for either their parietes, which are hard, 
like fibro-cartilage, and finely polished, lie in close apposition with each other, or 
a number of firm, irregular laminae sprout from the mass and form the walls of 
the fissures, or excrescences of foliated or wart-like form spring from the 
bottom of the cavities and fill up the interior. These excrescences are per- 
fectly smooth on their surfaces, and never contain cysts or cells. The laminae 
lie very irregularly, and project into the cavities and fissures like the folds of 
the psalterium in the interior of the third stomach of ruminant animals. 
Sometimes the laminae are but small, and the warty excrescences from the 
cysts are very large, while in other instances both are greatly developed. 
Enchondromata.-Cartilaginous, or the enchondromatous, tumors of 
Muller are, for all practical purposes, to be classified with the sarcomatous; 
for while it might demand some little stretch of the imagination to convert a 
cartilage into a fleshy mass, and while certainly it is not intended to say, or to 
be understood as suggesting, that the two are histologically even of remote 
connection, yet surgically the species are very much alike,-that is, both 
are little amenable to the action of sorbefacients, and both are better treated 
by the knife than in any other way. THE TUMORS OF THE MOUTH. 
1203 
Cause of Formation of Osteo-sarcomatous Tumors.-As we 
understand the osteo-sarcomatous tumors proper to be outgrowths associated 
commonly with periosteal membranes, so we are led naturally to ask ourselves 
as to the cause of their formation. This may be conceived to be of twofold 
relation: first, as a result of local irritation; second, as a relation of constitu- 
tional condition; and, still again, we may combine the two, laying the predis- 
posing cause on the one, the exciting on the other. This, as appreciated, 
conveys, however, little knowledge of the matter. 
The attention of the author was once directed by William Gibson, late 
Professor of Surgery in the University of Pennsylvania, to a case markedly 
illustrative of this latter condition. An old gentleman, Mr. F., seventy years 
of age, was struck on the cheek by a stone. Soon he had growing from the site 
of the injury a tumor, diagnosed by Professor Gibson as osteo-sarcoma. The 
growth of the body was so rapid and so formidable as to incline the professor 
to view it as of intimate relationship with malignancy. Later, the patient died 
from it. No one in this day would doubt the cancerous character of such a 
tumor. 
Rapid Growth of a Tumor.-When osteo-sarcoma takes on this 
rapid growth, its malignancy is not to be doubted; when the development is 
slow and regular, and particularly if the origin can be traced to some local 
irritant, extirpation may be expected to result in at least temporary relief. 
Changes relating with Sarcomatous Tumors.-As regards 
changes common to sarcomatous tumors, these may be considered under the 
heads of softening, suppuration, and malignant degeneration. 
Softening.-Softening, as described by Dr. Humphrey, appears to take 
place in two ways: First, as a chronic process, affecting some circum- 
scribed portion of the tumor, which is usually at or near the centre. The 
change is observed to commence with a slight discoloration, a yellowish or 
dark tinge, which is followed by loosening or by incipient disintegration of 
the structure; at the same time a line of demarcation is formed around the 
altered portion, which portion becomes separated, like a sequestrum, from the 
surrounding mass. Both the detached part and the cavity are at first rough 
and thready on their opposed surfaces; the former undergoes still further 
disintegration and solution, becoming broken up into a number of smaller 
fragments, these floating about in a dark, dirty, turbid fluid, and likely ulti- 
mately disappearing. The process of destruction may go on in the 
adjacent portion of the tumor, enlarging the central cavity till the whole is 
reduced to a fluid or a semi-fluid mass, walled in by the capsule of the tumor, 
which now stands in the relation of a cyst-wall to the disorganized contents. 
In some cases the softening operation is completed without extend- 
ing the circumference, the ragged processes hanging into the interior of the 
cavity being removed. The excavation acquires a smooth lining, and looks 
like a simple cyst lying in the centre of the tumor. A second mode in 
which softening takes place is more rapid and diffused, the whole or the 1204 
A SYSTEM OF ORAL SURGERY. 
greater portion of the tumor being affected at once. The change commences 
with the infiltration into the mass of a serous fluid, whereby its texture is 
loosened and its components separated; at the same time the tissue of the 
growth is softened, and interstitial absorption is set up in it. 
As the result of these processes combined, a tumor is soon broken up 
into detached fragments, and reduced to a diffluent pulp, or it may be com- 
pletely liquefied. These changes, Dr. Humphrey suggests, are occasioned 
by some altered nutrition analogous to inflammation ; they may be induced by 
Fig. 893.-Osteo-sarco- 
matous Tumor. 
Fig. 894.-Cysto-sarcoma. 
some accidental cause, as an injury; nevertheless they are not necessarily 
attended with any constitutional disturbance at all corresponding with the 
extensive destruction which is in progress. 
Suppuration.-This is very rare; it may begin internally, or may pro- 
gress from without inward. 
The tumor represented in Fig. 893, taken from the person of an old woman, 
commenced in the imperfect antral periosteum, and progressed four years 
before causing death. In character it was fibro-plastic, with here and there 
osseous masses. 
Fig. 89-1 represents a cysto-sarcoma. It is a section of the diseased 
lower jaw of a man aged about thirty. Death occurred within a year, from 
return of the growth after operation. 
Histoid Mixed Tumors.-The tumors described as fibro-sarcomata 
possess their appellation from a distinctiveness of tissue which characterizes 
them in their purest expression from each aspect. In the histoid mixed, two 
or more elements are found conjoined, thus, as is seen, confusing necessarily- 
not a clinical, but the histological-classification. When, as has been 
queried by Rindfleiscb, besides distinct lipomatous constituents, distinct chon- 
dromatous features are found ; when sarcoma nodes and nodules are deposited 
in an enchondroma, we do not know whether we should name the thing en- 
chondroma lipomatodes, or lipoma cartilagineum, or sarcoma cartilagineum, 
or chondroma sarcomatosum. This embarrassment recurs with the THE TUMORS OF THE MOUTH. 
1205 
question as to the clinical character of the sort of tumor, the prognosis, etc. 
The histoid mixed tumors will, in the mouth, be found more common 
than the pure histoid; their nature and character are to be appreciated from 
what has preceded. 
Scirrhus.-Although the very rarest of the expressions of the cancer vice 
as met with inside the mouth, except as relation with the tongue is concerned 
in shape of epithelioma, yet, as a form of dyscrasia, clinical attention will 
occasionally be directed to the condition. Scirrhus is a disease of adult 
life, rarely appearing before the age of forty, and even then seeming, in its 
isolation, a something concentrating itself for purposes of operative relief. 
Commencing in the gum or alveoli, and secondarily affecting the bone, scirrhus 
appears as a small nodule, incompressible, having indeed a lead-like feel. 
What is to be its progress depends pre-eminently on circumstances. The 
author has at the present time under charge, and has had for several years, 
a scirrhous tumor associated with the periosteum immediately beneath the 
left malar bone ; this tumor grows neither larger nor smaller, being held in 
abeyance either by the lightness of the dyscrasia or-what amounts to pre- 
cisely the same thing-by the resistive powers of an antagonizing life-force. 
A second case is a lady, still under observation, from whose under lip, seven 
years back, was removed a tumor yielding the microscopic expression of scir- 
rhus carcinoma, and with whom there has been no return of the disease. 
Features of Advancing Development.-As a scirrhus advances in 
its development, there associates with it a lancinating character of pain par- 
ticularly diagnostic, the presence of which is commonly admitted to decide any 
existing doubt. Still advancing, the overlying structures become impli- 
cated, the skin contracts and adheres, and soon shows an increased vascularity ; 
later in its progress the tumor puts on the 
character of a pointing abscess, or ulcerates 
with a lupoid expression, or it cracks; finally 
the telangiectatic expression is assumed, ex- 
uberant granulations springing forth, giving to 
the patient the disgusting and depraving asso- 
ciations of the fungus haematodes, soon 
wearing out vitality. 
Multiplication of the Scirrhomata. 
-The meaning of the multiplication of scir- 
rhomata is one of the most interesting, as it 
is certainly one of the most important, mat- 
ters of surgery. First appearing as a solitary 
nodule, the tendency in the condition to in- 
crease its expressions is a sufficiently recog- 
nized fact. After the removal of a single scirrhous nodule, the recurrence, if 
it take place, is apt to be in the form of numerous secondary papules, or else 
with a medullary expression. Fig. 895 exhibits photographically this 
Fig. 895. 1206 
A SYSTEM OF ORAL SURGERY. 
disease as it made its reappearance over the mammary region of a lady from 
whose axilla the author had removed a scirrhous gland. 
Duration of Scirrhus.-Concerning duration, scirrhus is apt to com- 
plete its history in from twenty to forty months, although, as has been re- 
marked, cases may remain in abeyance for many years. If a scirrhus let a 
patient alone a judicious practice is to let it alone. 
Fig. 896 
A microscopic view of the cells of hard cancer, showing their varied shapes, with the 
numerous free nuclei, as seen in scirrhus of the breast. Magnified 500 diameters. (After 
Paget.) 
Appearance shown by Section.-Section of an amputated malignant 
scirrhus shows a concave surface, deemed to be diagnostic of malignancy; it 
is smooth, being indeed very similar to the section of a fresh turnip; scraping 
the surface affords what is commonly called the cancer-juice, the microscopic 
cell aspects of which are portrayed in Fig. 896. 
Eig. 897.-Microscopic Appearance of Scirrhus Carcinoma 
Cells.-It will be seen from the great variety of feature exhibited in these 
cells that there is here no characteristic cancer-cell. Judgment of such THE TUMORS OF THE MOUTH. 
1207 
growths is to be founded on the common heteroclitic expression. Fig. 
897 shows a section of a scirrhus taken from the centre of a cancer of this form 
undergoing atrophic changes. A common shape of the cells seen is the 
caudate. 
Encephaloma.-To the mind and experience of the writer, encepha- 
loma expresses the very fulness of the meaning of malignancy. It is crasis, 
which, either through its own force, or through non-resistance on the part of 
the patient, overwhelms and quickly destroys; all tissues melt before it, for 
none seem able to combat it. Early ulceration and the protrusion of fungus 
hsematodes form the common history of encephaloma, the cases being excep- 
tional where a patient survives the first appearance of the disease over two 
years. 
Fig. 898.-An Encephaloid Tumor. 
Pure encephaloma of the jaws has, in its inception, nothing to dis- 
tinguish it from the most simple of sarcomata; once started, however, the 
greater activity of the expression exhibits itself, showing futility of treatment; 
particularly does this find illustration in the infiltrated appearance of 
surrounding parts. If the idea of cutting has suggested itself, it is quickly 
enough abandoned by reason of the absence of any distinct line of demarca- 
tion. One is made to feel that in the lack of a specific he is powerless for 
good. 
Not Encapsuled.-Encephaloma does not seem to the author justly 
described-certainly not at all so from the clinical stand-point-when an im- 
pression is conveyed as to its encapsuled character, for never perhaps is it the 
case that the heteroclitic expression is confined inside of any capsule, cells, 
differing from the normal tissue, being found infiltrated not only throughout 1208 
A SYSTEM OF ORAL SURGERY. 
the substance of such capsule, but also through all the neighboring parts. 
Presence of capsule is apt to signify absence of malignancy. 
Fig. 899.-An Encephaloid Expression of Cancer in a Young Child. 
Illustrative Case.-Fig. 900 shows a case that was in a Philadelphia 
Hospital at the time of writing, which has the following history. Four 
Fig. 900.-Encephaloid Tumor. 
months back the patient, a boy thirteen years of age, was attacked with pains 
in the jaw, his face and general condition being, apparently, in every other THE TUMORS OF THE MOUTH. 
1209 
respect normal. Examination, made by his physician, revealed a molar tooth 
considerably carious, which tooth was extracted under the impression that 
it might be the cause of the discomfort. The socket, in place of filling up 
after the ordinary manner, threw out a fungous mass, disease being then dis- 
covered in association with the antrum of Highmore. From the day of the 
extraction to the one in which this paragraph was written proliferation ran 
riot. As seen in the diagram, the whole side of the face was projected, the 
eye of the affected region had gone blind, the nostril was filled with the 
growth, which shows from it, while the oral cavity was so completely crammed 
that scarcely more than breathing-room remained. The patient, as will be in- 
ferred, was in a state of inanition, and this quickly eventuated in death. Micro- 
scopic examination revealed the histological expression of the tumor as that of 
encephaloma. No other form of carcinoma advances so rapidly. The writer 
attended a consultation on the case, the conclusion being adverse to an operation. 
Illustrative Case.-Fig. 901 exhibits the case of a child six years of 
age, brought to the Hospital of Oral Surgery, where the growth was of the 
usual rapid extension, and attended with the pain and expression of dys- 
crasia, so characteristic of encephaloma. The neoplasm, as seen, was about 
the size of the head itself. To the touch it was semi-elastic; it was marked 
by veins of large size irregularly distributed over the surface. Progress was 
as regular as it was rapid. Patient 
died two months after being exhibited 
at the clinic. 
Fig. 901. 
Fig. 902.-A Carcinomatous 
Growth. 
Illustrative Cases.-Figs. 902, 903, and 904 are illustrations taken 
from life of cancerous tumors. All of them are neoplasms in the sense of 
being new formations. A section of any one of these growths would not 
unlikely show, under microscopic enlargement, cells of sarcomatous character, 
or, if not these, then those expressive of the encephaloid condition. Whether 
one kind or the other is of no practical meaning to the classification here 1210 
A SYSTEM OF ORAL SURGERY. 
adopted. The tumors are neoplasms. Their presence is without explana- 
tion. The diagnosis is carcinoma.* 
Fig. 903.-A Carcinomatous Growth. 
Fig. 904.-A Carcinomatous Growth. 
Fig 905.-Microscopic Appearance of Encephaloid Cancer, 
Appearance of Encephaloid Tumor shown on Section.- 
Section of an encephaloid tumor, as is to be inferred, presents varying ex- 
* The author expresses his sense of obligation to Dr. Servais, of Anvers, for photographs 
of cases received through Dr. F. Shain. THE TUMORS OF THE MOUTH. 
1211 
pression: it is sometimes quite brain-like, or it may, as it shades into less 
malignancy, simulate scirrhus; occasionally it will be colored, such coloring 
being the pigment-granules of melanosis,-melanoid cancer. 
Fig. 906. 
Fig. 907. 
Fig. 908. 
Fig. 906.-A microscopic view of the nuclei of soft medullary carcinoma embedded in 
a molecular basis substance or stroma without cancer-cells. Magnified 500 diameters. 
(After Paget.) 
Fig. 907.-A representation of various fully-developed cells and nuclei of medullary 
carcinoma, as seen under the microscope. Magnified 500 diameters. Some of them are 
larger than the average, others more peculiarly slender, elongated, strip-like, or caudate 
cells, with a darkly-dotted granular nuclei. (After Paget.) 
Fig. 908.-A representation of the dotted nuclei of medullary carcinoma of the breast. 
Magnified 500 diameters. (After Paget.) 
Fig. 909. 
Fig. 910. 
Fig. 911. 
Fig. 909.-A representation of the clustered nuclei of medullary cancer, composed 
almost exclusively of round, shaded nuclei, with three or four shining particles, 
arranged in groups or clusters of five to twenty or more. Magnified about 400 diam- 
eters. ('After Paget.) 
Fig. 910.-A representation of the caudate and variously elongated cells of a firm 
medullary cancer. Magnified 450 diameters. (After Paget.) 
Fig. 911.-Small elongated cells and nuclei with a nucleus of the ordinaiy shape, 
from a firm medullary cancer. Magnified 500 diameters. (After Paget.) 
GOITRE, OR BRONCHOCELE. 
The condition known as goitre consists in an enlargement of the thyroid 
gland. It may be of double significance as it affects the two lobes of the 
body, or single as one side alone is involved. The nature of the growth may 
be solid or cystiform. Goitre is a chronic affection and shows itself much 
more common to women than to men. The localities in which it is most 
abundantly found are valleys related with high mountains. Thus 
it is a familiar disease of the Alp regions of Europe and not unfamiliar in 1212 
A SYSTEM OF ORAL SURGERY. 
the mountainous parts of the United States. Low and moist flats inter- 
mediate to altitudes are peculiarly favorable to its development, this depend- 
ing, as is inferred, on the relation of moisture and of calcareous water. The 
Fig. 912. 
Fig. 913.-Symmetrical 
Goitre. 
disease is associated with adult life. It seldom makes its appearance before 
the fifteenth or eighteenth year. The tumor varies from a scarcely observable 
increase over the natural size to an enlargement that may equal the infant 
head. The growth of a goitre is mostly very slow except in instances 
of the cystiform variety, when it may quite reverse this. Generally there 
is neither pain nor interference with free breathing. Section of a recent 
goitre shows, most commonly, a stroma of 
more or less cellular character, which is found 
to contain a varying amount of a glutinous 
fluid. Old tumors of this class lose, to a 
marked extent, this loose nature, becoming at 
times semi-cartilaginous and calcareous. The 
cystiform variety may show as a single cavity, 
but is most apt to be made up of a multitude of 
little cysts filled with an oleo-watery substance. 
Diagnosis.-The differentiation of goitre from other growths of its 
locality lies with the rising and falling of the tumor with the trachea, to which 
it is attached, when the act of swallowing is performed. 
Treatment.-This is most unsatisfactory. One manner, consisting in 
starving the tumor by ligating the thyroid arteries, has been recommended, 
but is practised with little success. Extirpation is to be attempted only 
when it happens that breathing is interfered with and the patient is in danger 
of smothering. Free leeching, followed by the application of sorbefacients, 
is a manner that has the support of much commendation. Gross lays most 
stress on the rubbing in twice a day of a mixture composed of equal parts of 
Fig. 914.-Cystic Goitre. THE TUMORS OF THE MOUTH. 
1213 
iodine and camphorated mercurial ointment. The intra-paren- 
chymatous injection of tincture of iodine, introduced, many years back, by 
Suton, of Rheims, carries much endorsement. Three points important to be 
considered are suggested by Terrillon. One is that absolute antisepsis be 
secured ; a result attained by keeping the needle of the syringe in boiling water 
for so long a time as five minutes before it is used, and by washing the seat 
of the injection with a bichloride or other antiseptic solution. The second 
refers to absolute penetration of the tumor before throwing the injection 
from the syringe. The third considers the avoidance of veins; a matter that 
necessitates, particularly with fat persons, the taking and holding of a full 
breath, as this swells out the superficial jugulars. After introducing the 
needle Terrillon injects slowly, at his first performance, half a gramme of the 
pure tincture. If this be well borne, he repeats, after an interval of five days, 
using a syringeful. This medication is repeated so long as it seems useful or 
prudent to the operator. The object of such treatment being to secure atony 
of the part, the place of injection is to vary with each application, so that all 
parts of the gland be brought under the influence of the medicine. Tapping 
a cystic goitre is found to be inadvisable. Electrolysis, highly recom- 
mended by many, has not proved of the slightest use in the practice of the 
writer. Injections, whether of iodine or anything else, are not unattended 
with danger, so that an operator is to feel his way cautiously. What- 
ever may be tried or done, little enough good will be the likely result. 
ILLUSTRATIVE CASES OF TUMORS AT LARGE. 
Plate IX., introduced as a clinical study, represents the appearance and 
position of some of the various tumors met with about the neck. All of these 
are extreme cases as size is concerned. 
Description of Plate.-Fig. i.-A large cystoma of the right 
parotid region, caused by the development of a sebaceous follicle in con- 
sequence of a blow upon the part. Commencing as a lump the size of a nut, 
this tumor gradually increased to nearly the size of the head ; gave exit at one 
time to sebaceous matter ; had a broad base ; was nearly immovable; had the 
veins enlarged upon its surface, and showed a small ulceration in front, from 
which fetid, acrid, and bloody sanies had escaped. As the tumor enlarged, 
the jaw became closed, sensation of the face diminished, and there were all the 
other symptoms due to pressure on the vessels and nerves of the part. The 
tumor differs in appearance from scirrhus of the parotid gland in its size and 
period of development. It was readily removed, and is represented as an 
example of one of the class of growths of the parotid region not involving 
the parotid gland. (After Auvert.') 
Fig. 2.-Large adenoid tumor of the neck dependent on degeneration 
of the lymphatic glands of the neck. Arising as a small swelling caused by 
an enlarged gland below the angle of the jaw, it gradually increased until it 
occupied the entire side of the neck, involving many glands, and reaching 1214 
A SYSTEM OF ORAL SURGERY. 
from above and behind the ear to below the clavicle, so as to turn the head 
to the opposite side. Its appearance was that of an irregularly-lobulated mass; 
it was unaccompanied by pain, was perfectly firm and hard, and gave no sense 
of fluctuation at any point. Under the use of chloroform it was successfully 
removed by Mott. (After Mott.} 
Fig- 3.-Appearance of an immense adipose or lipomatous tumor 
of the neck. This tumor was not painful; had no pulsation ; was formed of 
numerous large lobes, with the superficial veins distended over them, and was 
attached to the neck by a large pedicle which extended from the angle of the 
lower jaw on the right side down to the sterno-clavicular articulation, its 
weight being so great that the patient could hardly retain the erect position. 
The tumor was found to be covered by a strong capsule formed of the sur- 
rounding cellular tissue, and to have originated in a hypertrophy of the sur- 
rounding adipose tissue. (After Auvert.} 
Fig- 4--A large cystoma of the left parotid and submaxillary regions, 
which to the touch was semi-elastic, unequally lobulated, and due to a chronic 
irritation of one of the sebaceous follicles, the duct of which had become 
closed, and thus caused a retention and degeneration of its secretion. (After 
Auvert.} Plate IX CHAPTER LXXIII. 
MEDICAL DIAGNOSIS. 
BEING PRELIMINARY TO THE STUDY OF ANAESTHETICS AND 
ANAESTHESIA, AND APPRECIATIVE OF DISEASE IN GENERAL. 
By diagnosis is meant recognition of the origin and meaning of disease. 
Definition of Disease.-When, from any reason, part or the whole 
of the system of an individual is out of equipoise, being disturbed, the person 
is not in a state of ease, but is in a condition that requires a word of 
exact opposite signification to express it. Such a word is the preposition 
dis. Using this word the converse is designated. A man-to make example 
as to converse-not being honorable he is called dis-honorable, or not being 
honest his deficiency is expressed in the term dis-honest. Making similar 
use of the preposition, medical nomenclature expresses the condition of a man 
who is not in a state of ease as being that of dis-ease. 
Disease a Generic Term.-Disease is a generic term : it tells nothing 
of diagnosis, it expresses simply and alone, yet embracingly, general condition,- 
i.e., an individual is not in a state of ease by reason of the existence of, 
or presence with him of, a something that irritates or worries,-a dis. 
Foundation of Diagnosis.-Foundation of diagnosis lies with appre- 
ciation of the word dis. Search after dis, or dis-ease, means search after 
cause. Discovery of cause implies ability to recognize what is not natural out 
of understanding of what is natural. It is not natural for teeth to have holes 
in them ; a practitionei' who knows that perfect teeth are without holes per- 
ceives and recognizes, in the presence of a hole, a dis when he meets with 
such defect. It is not natural to carry a cinder about in an eye; when this 
organ is found inflamed and suffering, he who exposes and removes the offence 
shows himself, as the particular case is concerned, both diagnostician and physi- 
cian. Between the elbow and shoulder anatomy gives no joint; when, then, 
dis-ease expresses itself in this locality and examination exposes false, or 
unnatural, mobility, comprehension is gained that the dis and a fracture are 
one. Rapid breathing may mean pneumonia, or it may mean asthma. Whether 
it imply the one or the other, or some one or other of a dozen varying con- 
ditions, the rapid breathing expresses the irritative state,-a dis is most evident. 
If the condition be pneumonia, it is not asthma; if asthma, it is not pneu- 
monia. To distinguish the one from the other requires simply knowledge of 
a kind that has appreciated the hole, the cinder, and the mobility. Lung 
1215 1216 
A SYSTEM OF ORAL SURGERY. 
structure is seen and felt, however, by use of the ear,-by auscultation, as the 
act is termed. A kidney, situated deep back of the lumbar muscles, may be 
in process of degeneration, dis is present over the system at large, every- 
where, perhaps, except at the seat of lesion ; there is headache, loss of memory, 
the lungs are sore, the heart labors, the muscles deny their wonted elasticity, 
strength wanes. If the cause, or meaning, of the dis be not discovered and re- 
moved, death will surely follow. To discover is to use means familiar to 
medical science. The offence is not, however, to be seen with an unassisted 
eye, to be touched with a finger, nor to be heard by the ear. Here a micro- 
scope applies, or the practitioner, relying for his requirement on a knowledge 
of normal urine, resorts to urinometer, to test-tubes, to flame, to nitric acid, 
or to other appreciated agents. Chill and fever are other expressions of dis. 
What cause is it that means the dis as this is expressed in chill and fever? 
Doctorly acumen finds itself able to answer the question, and, more than this, 
to remove, with a few grains of an antiperiodic medicine, the cause of the 
trouble, and thus rub out, as it were, the dis. 
Ability to Diagnose Proportional with Knowledge.-Ability 
to diagnose is proportional with knowledge. What an eye sees it sees. With 
not less certainty does judgment understand what it comprehends. Under- 
standing is resultant of experience. Thought and experience are one. There 
can be no thought where there is no experience. Nothing different from an 
unmarked slate is a self upon which no experiences are inscribed. Knowledge 
and experience being one, it follows necessarily that power to diagnose accrues 
out of observation, and that only a worker and looker may be a diagnostician. 
He who is without learning as to a subject does wisely when he turns a dis 
to where more knowledge exists than he finds in himself. To appreciate is to 
comprehend. To comprehend is to be able to say exactly what a thing is. 
Exclusion is something different. Diagnosis is not infrequently a 
matter of exclusion. By this is meant finding one's self able to say what a 
thing is by being certain as to what it is not. 
Study of Diagnosis.-Study of diagnosis is the study of many things; 
among them, of anatomy. It learns where, naturally, there are holes and 
where there are no holes ; where there are joints and where there are no joints. 
It is a study of physiology ; it inquires into sulci, into joint movements, 
into the functional meaning of uriniferous tubules. It is cognition ; it 
measures the cavity of a pot by means of the very circumference that hides ; 
it deduces unknown from known ; it pushes ghost from behind substance. A 
practitioner is not to hope to be useful in other measure than as he is learned ; 
while to become learned implies simply that he keep himself in the way of 
experiences. 
Suggestions in Diagnosis.-The author directs the attention of the 
reader to the chapter on Tumors as a study in diagnosis. In most of the 
examples offered in that chapter the relationship and significance of growths 
are fixed by comparison, and by anatomical or physiological exclusions. Un- MEDICAL DIAGNOSIS. 
1217 
deniably, it is to be seen that in places the distinctions are entirely without 
confusion ; that diagnosis asserts itself. As undeniably is it the case that in 
places distinctions are not without confusion; with the neoplasms, for ex- 
ample. A point to be made is this: Where a writer knows absolutely, 
there he is clear; where he does not know, he is not clear. It takes very 
little learning to appreciate all about a pulp-fungoid tumor, but, as carcinoma 
is concerned, the clinician has not yet appeared who shows himself able to 
explain the reason for presence of such a growth. Where there are definition 
and clearness in this chapter on Tumors, it means learning; where definition 
and clearness are lacking, it implies ignorance. The lesson to the student is 
this: To know a matter is to understand it. To understand a matter is to 
work at it, and at its environment, until nothing remains to be learned. 
As tumors are concerned, understanding is complete only when cause is 
appreciated. 
Diagnosis a Matter both of Principle and Detail.-Diagnosis is 
a matter both of principle and detail; the first to come first, the second to 
follow. Making here another illlustration, one that, like the former, is to be 
referred to by the student without change of book, attention is directed to 
the subject of inflammation. Every inflammation is one with 
a perversion of the circulation, and every perversion of the circulation 
has certain associate phenomena which are general to a common condition. 
Following this, every inflammation has phenomena peculiar to special relation 
of the condition. First, a student is to acquaint himself with the common 
phenomena; second, he is to inform himself of relations which modify such 
common phenomena. A phenomenon of inflammation, to make an example, 
is swelling. A swelling about the skin is almost invariably an expression of 
relief. A swelling about the mucous lining of a trachea means, not relief, but 
too often death. Reason for the difference exists. To understand such 
difference implies that one make himself acquainted with a relational anatomy 
of the parts. A papilla, assuming a hypertrophic expression, turns into a 
wart. What'is a papilla? An engorged antrum will, not unlikely, throw the 
eye out of its socket. What is the connection of an antrum with an eye ? 
To expand the fauces with air is to learn by sound whether or not the drum 
of an ear be ruptured. What is the relation of a throat and the drum of an 
ear? To see copper-colored blotches over a man's face is to discover whether 
he has a chancre covered by his pantaloons or by the lapse of years. What 
is the kinship between blotches and sore ? To hear a person complain of his 
hair coming out by the handful is to get a suspicion. A surgeon learns of 
distant things by sight of near things,-of exposures, as manifested by rheu- 
matism ; of sybaritic living, as shown by gout. A missing, unextracted, tooth 
explains an odontocele. Irritation about the head of a penis directs attention 
to the possibility of stone in the bladder. Petechial spots upon the abdomen 
or chest tell of irritation of the glands of Peyer. Color of the skin shows 
distinction between diphtheria and scarlatina. A cornea that is the segment 1218 
A SYSTEM OF ORAL SURGERY. 
of a cylinder, and not of a sphere, gives understanding of astigmatism. In 
short, things tell of themselves, tell commonly everything about them- 
selves. To read narrowly or widely, little or much, is with a man's self. 
Treatment founded on Diagnosis.-Diagnosis secured in any given 
case, treatment that is founded on a simple principle follows: holes are filled, 
cinders are lifted away, broken bones are set and splintered, congestions are 
resolved, spasms relaxed, poisons antidoted, errors in refraction corrected. 
Complexity is resolved into simplicity through understanding; to see into a 
pot requires never anything but to know how to lift its lid. 
PHYSICAL CONDITION. 
By physical condition is meant the state of parts, or the condition of the 
whole, of a body. 
External and Internal.-For purposes of diag- 
nosis the body is conveniently divided into external and 
internal. The first expresses parts familiar to ordinary 
observation ; the second considers regions hid away from 
other than cultivated perceptions. The first is classi- 
fied as surgical diagnosis ; the second is known as 
medical diagnosis. 
Surgical Diagnosis.-Appreciation of surgical 
dis-ease lies with observation that is to be made by 
simple employment of the common senses ; that is 
to say, the unassisted organs are able to recognize a 
thing requiring to be recognized ; the thing is seeable, 
touchable, tastable, smellable, or hearable, after a com- 
mon every-day manner. This is known as physical 
diagnosis. 
Medical Diagnosis.-Appreciation of medical 
dis-ease lies alone with educated senses ; a thing 
requiring to be recognized is not to be seen, touched, 
tasted, smelled, or heard after the common every-day 
manner ; secondary means are required. To see the 
circulation of the brain an ophthalmoscope is necessary. 
Measure of temperature demands a clinical thermometer. 
To learn of a degenerating kidney compels the use of 
microscope and test-tubes. To appreciate lesions of 
heart or lungs implies education of touch and ear. 
Process of Exclusion.-Perfection in medi- 
cal diagnosis is reached only where ability resides to 
discover an unknown through the known. An infant, 
too young for speech, is brought for examination. Here 
there is no recital of symptoms; there is no pointing 
out of a seat of pain ; no story of prodromata. Dependence, in such a case, 
Fig. 915. 
Clinical thermometer, 
used for taking tempera- 
ture of the human body 
by placing it beneath 
the tongue. MEDICAL DIAGNOSIS. 
1219 
is wholly on a reading lying with the process here considered. Examina- 
tion is to commence and proceed seriatim. If it begin with the supposition 
of a broken finger, it passes to the possibility of a dislocated joint. Find- 
ing neither of these conditions to be the meaning of the dis, nor discover- 
ing, after a like manner of examination, anything wrong with the external 
parts of the body, passage is made to the viscera, these being interrogated 
one by one in like manner with the external parts; giving, not unlikely, a re- 
quired answer only when the last has been reached. To be able, as suggested, 
to say what a thing is by being able to say what it is not, is to be possessed 
of fulness in the way of diagnostic acumen. He who is unable so to ask and 
answer questions is not a diagnostician. 
Consideration of Common Expressions.-A humpback is known 
by its lack of likeness to a straight back. A hot skin is recognized by com- 
parison made with a cool one. A moist surface is measured by the dry body. 
Direct eyes distinguish those that are crossed. Irregularity in action of the 
bowels is determined out of understanding of what is regular action. To 
know that something is wrong with heart, lungs, liver, or other viscus lies with 
knowing that things are not all right with it. Studies in diagnosis may have 
foundation alone in understanding of anatomy and physiology ; in other words, 
in understanding of what constitute natural conditions. 
DIAGNOSIS AS APPLYING TO ANESTHESIA AND ANES- 
THETICS. 
In what follows it is, of course, assumed that the reader is informed in 
anatomy and physiology, otherwise that he studies these subjects synchronously 
with the volume in hand. 
Requirements of an Anaesthetist.-No person is justified in as- 
suming the office and duties of an anaesthetist who is not fairly masterful in 
the direction of medical diagnosis. 
Tripod of Life.-Life, as suggested by Bichat, is like to the pot 
held in place and supported by a tripod. The supports of life are circu- 
lation, respiration, innervation. Break, deficiency, or interference 
with the three, or with any one of them, causes the fabric to totter or fall. 
One assuming the role of an anaesthetist is to understand how to make diag- 
noses as to any and all physical conditions. 
DISEASES OF THE HEART. 
The heart, as the centre of the circulatory system, may be the first of the 
organs to claim attention. A heart is perfect if a circulation is perfect. 
A perfect heart, as an imperfect one, is to be known by signs and sounds 
characteristic, unmistakably, of difference as to conditions. Study of the 
heart, from the stand-point of physical diagnosis, begins with getting appre- 
ciation of the normal organ. A student determined to master the subject of 1220 
A SYSTEM OF ORAL SURGERY. 
anaesthesia begins, not with anaesthetic agents, but with study in the direction 
of physical diagnosis. 
Beginning of study of the heart lies with appreciation of size, posi- 
tion, movements, and sounds. Size of heart corresponds with the fist of 
its owner. Position of heart is oblique in the chest, the base being di- 
rected upward and backward to the right, and corresponding, in front, or ex- 
ternally, to the interspace between the second and third ribs, and behind, or 
internally, to the interval between the fifth and eighth dorsal vertebrae; its 
apex reaches downward and to the left, corresponding to the interspace sepa- 
rating the fifth and sixth ribs ; being two inches below the nipple and one inch 
to its inner side. Measuring the position of the heart in relation 
with the centre line of the sternum, it is found, in its correspondence with 
this centre, to reach three inches to the left and one and one-half inches to 
the right. The heart increases in size as influenced by conditions of exercise 
and vigor. The apex may correspond with the centre of the sixth rib or it may 
be even lower than this, yet not be abnormal. (See, for illustration, Fig. 918.) 
Locating the heart and mapping its size is easily done through 
the three means of educated sight, touch, and hearing. In lean persons, the 
apex impulse, as the space between the fifth and sixth ribs is struck, is to be 
seen plainly. This impulse measures, to the eye, the length of the organ. 
Percussion, as an instrument, enables a diagnostician to bound the cir- 
cumference of the heart perfectly, the manner consisting simply in the use of 
two fingers, one of which is laid upon the region at any position and tapped 
upon by the other. As percussional relation is concerned, the heart is to be 
esteemed as lying in a basin made by the enveloping lungs, difference in 
sound, as the two organs are struck, differentiates the sought line of circum- 
ference. While the stroke is over the heart the sound is dull, as though the 
blow strikes a solid body ; when over the lung it is changed instantly to the 
resonant. This distinction is so evident that a pencil line may be made to 
show the line of demarcation. Hearing as a means refers to locating 
certain sounds. The apex beat is always to be heard in a healthy heart. 
This sound distinguishes its position. The base may be located by the ear 
as the valvular sounds are heard. Systole and diastole are always distinct, 
and are to be recognized plainly and clearly while the ear is over the heart 
region or even far distant. 
Systole and Diastole as furnishing Information of Condi- 
tion of Heart.-Systole and diastole, or contraction and dilatation, afford 
definite understanding, not only of the power residing with a heart, but of the 
state of its valves. To appreciate abnormal sounds, understanding is first to be 
possessed of those that are normal. Study begins with recognition of 
natural conditions. The impulses of a heart, meaning by this the beat, 
numbers about seventy to the minute in the male adult and seventy-five in 
the female. In the young it is more frequent. The impulses of a foetal heart 
are one hundred and forty to one hundred and fifty in number to the minute. MEDICAL DIAGNOSIS. 
1221 
At birth the number is one hundred and twenty. At ten years of age the heart 
beats ninety times to the minute.* 
Recognition of the force of the heart is secured by the making of 
many examinations. Measure of this force, as it applies to an individual, is 
gotten by comparing it with the muscular power of the same person. In- 
creasing force of blows means, commonly, hypertrophy. Decrease signi- 
fies atrophy, dilatation, or fatty degeneration. 
Sounds heard in Stenosis and Anaemia.-A whir, heard in the 
systole, or first sound of a heart, implies stenosis, otherwise it means anaemia. 
Separation of the two is made in recognition of the condition of the patient. 
A full-blooded rheumatic person, possessed of the whir, is sure to have its 
meaning in thickening of the valves. The poor-blooded and weakly have it, 
not unlikely, in thin and watery blood. The former condition is dangerous, 
and, indeed, commonly fatal, in time. The latter is removable by a course 
of iron. 
Sound of Regurgitation.-Regurgitation relates with the second 
sound, or diastole. The meaning of it lies with non-closure of a valve which 
allows blood to be sucked back from a superior part as a ventricle expands. 
To hear the sound of regurgitation is to learn of the imperfect state of a valve 
or of valves. The valve affected may be either the auriculo-ventricular or the 
semilunar. Practically, as use of the anaesthetics is concerned, the particular 
part diseased is of little import. It is quite possible, however, and indeed 
not difficult, to locate distinctly the lesion. 
Locating Lesion of Tricuspid Valve.-The tricuspid is the three- 
leaved valve situated in the right auriculo-ventricular opening. Its position, 
as correspondence is had with an external point upon the chest, is the locality 
of junction of the third rib and sternum. To hear most distinctly the sound 
made by this valve the ear is commonly placed at the corresponding side of 
the ensiform appendix. The writer, for himself, prefers to listen for it at 
place of location. 
Locating Lesion of Mitral Valve.-The mitral, or bicuspid, is the 
two-leaved valve occupying the auriculo-ventricular opening of the left side. 
The situation of the valve is opposite to and back of the tricuspid. To locate 
its sounds the ear is commonly placed at the interspace separating the fifth and 
six ribs and at the seat of junction of the ribs with their cartilages. 
Locating Lesion of Semilunar Valves of Pulmonary Artery. 
-The semilunar, or three-leaved, valves relating the right ventricle and pul- 
monary artery are situated beneath the middle of the sternum on a line re- 
lating the third ribs of the opposite sides. To best hear their sounds the ear 
* Study of Pulse.-Distinction is to be made between the pulse, or beat, of the heart and 
the pulse of the arteries. A normal arterial pulse is rhythmic, each stroke having equal 
force. Variations on the regularity are expressed in the dicrotic pulse, in the intermittent 
pulse, the thready, the gaseous, the filiform, the hard, the jerking, the quick, the small, the 
wiry, and the tremulous pulse. (See works on the Practice of Medicine.) 1222 
A SYSTEM OF ORAL SURGERY. 
is placed at the second intercostal space close to the sternum; left side of 
patient. 
Locating Lesion of Semilunar Valves of the Aorta.-The 
valves of the aorta have their nearest approach to the surface on the patient's 
right side at a point corresponding with the second intercostal space. The 
ear best catches the sounds by being placed at this space. 
Studies of the Heart.-The studies here introduced, Figs. 916 and 
917, are with view of affording immediate reference as to localization of lesions. 
To Mr. Gray, the English anatomist, to whom the perfect work of these 
drawings is to be credited, the medical world owes a debt of gratitude. 
Hypertrophy of the heart is a chronic enlargement of the organ dis- 
tinguished, diagnostically, by extended area of dulness on percussion, the 
characteristic of the condition being excess of growth in the walls, accom- 
panied, if the cause, as is 
most commonly the case, be 
stenosis, with enlargement of 
the cavities ; attended, on the 
contrary, if the cause lie not 
with stenosis, not unlikely, 
with diminution of the cavi- 
ties, a result of intrusion on 
them of the thickening pari- 
etes. All four of the cham- 
bers may be the seat of 
hypertrophy; this, however, 
a possibility, not a proba- 
bility. Commonly, the hyper- 
trophy is confined to the 
left ventricle, this being 
naturally the thickest and 
heaviest of the cavities, and, 
by reason of relation with the 
systemic circulation, having 
the most work to do. Diag- 
nosis of hypertrophy of the 
left ventricle is easy in pres- 
ence of the increased force of 
stroke. Diagnosis of hyper- 
trophy of the right ventricle is not so evident by reason of its being of less 
expression than the left. Enlargement of the auricles of either side are 
not always easy to distinguish. Signs more or less distinctly marked in all 
cases of cardiac hypertrophy are floridity of face, a full, strong pulse, eyes 
HYPERTROPHY OF THE HEART 
Fig. 91B.-Studies of the Heart. MEDICAL DIAGNOSIS. 
1223 
bright and prominent, and throbbing carotids. Headaches, giddiness, ring- 
ing in the ears, shortness of breath, a sense of weight about the epigastrium, 
may or may not be present. Except when exercise has much excited the 
action of the heart, it is not likely to trouble its possessor in the way of pain, 
Fig. 917.-Studies of the Heart. 
palpitation, or irregular action. Marked physical signs are found in 
a fulness or projection of the region immediately overlying the heart, and 
in the apex stroke, which reaches downward and inward in proportion to the 
increase of size, the latter position existing in the increased weight of the 
organ. The area of dulness being most evident on the right side points to 
lesion of the right ventricle, being on the left the ventricle of that side will be 
judged as the diseased one. Dyspnoea points to affection of the right side, 
the cause lying with an over-freedom of circulation compelled in the lungs. 
Lack of increase and possible diminution in the pulse are also diagnostic of 
the right side being the seat of disturbance. Lesion of the left side, as sug- 
gested, is expressive and free in diagnostic signs: a hammer-like stroke, full 
and distended arteries, congested mucous surfaces, dry cough. 1224 
A SYSTEM OF ORAL SURGERY. 
Association of Hypertrophy with Kidney Disease.-Bright's 
disease, particularly a form of it where the circulation of the kidney is inter- 
fered with,-the contracting form,-is a not unlikely associate of hypertrophy 
of the left ventricle ; is, indeed, a not unlikely cause of it. Ability to diagnos- 
ticate Bright's disease is to be possessed by the anaesthetist. (See Kidney 
Diseases in works on the Practice of Medicine.) Obstruction of the circu- 
lation in any organ may prove the exciting cause of hypertrophy. 
Common Cause of Hypertrophy.-The common cause of ventricular 
hypertrophy is stenosis, or a narrowing of the outlet of the cavity. The 
most common cause, in turn, of such narrowing lies with the disease rheuma- 
tism,-a condition possessed of marked inclination to inflame the endocardium, 
this, in its turn, tending to thickening of the valves. Valves indurated and 
thickened interfere necessarily with free passage of the blood, hence hyper- 
trophy arising out of increased effort made by the muscles of the organ to force 
the blood through the diminished aperture. Rheumatism existing, 
attention is always to be directed to the heart as being more than probably the 
seat of a lesion. 
Obliteration of Pericardial Sac as Cause of Hypertrophy.- 
Pericarditis, or inflammation of the pericardial sac, resulting in adherence of 
the two layers, is but an infrequent cause of hypertrophy. Relation of cause 
and effect lies with excessive action provoked on the part of the heart. 
Males more Subject to Hypertrophy than Females.-The 
more vigorous means of exercise used on the part of the male, the tendency 
to indulgence in venereal excesses, the use of tobacco, coffee, and other func- 
tional disturbing causes, render men much the more frequent subjects of the 
lesion as comparison is with the other sex. 
DILATATION OF THE HEART. 
This condition signifies a yielding of the parietes of the heart, consequently 
is the reverse of hypertrophy. Its location is commonly the right ventricle, 
and its cause, most generally, is in obstruction lying with the circulation of 
the lungs. The physical signs in dilatation are almost the reverse of those 
expressing hypertrophy. The beat of the heart, instead of being vigorous, 
sharp, and hammer-like, is dragging, prolonged, feeble, and fluttering. In place 
of a bounding pulse there is debility in flow combined with marked tendency to 
venous congestions. Dropsy is likely to be an attendant. The liver is gorged 
and indolent. The bowels are constipated. Chilly sensations interfere with 
the comfortable warmth of the patient. The intellect becomes dull and in- 
active. The pulse is slow and feeble. The kidneys fail in proper action, 
albumen not infrequently showing in the urine. 
Area of dulness on percussion may be the same in dilatation as in 
hypertrophy; it contrasts with the latter, however, by a sense of deadness or 
absence of ring as percussion is made. Experience differentiates the two with- 
out difficulty. The natural sounds of the heart vary with different conditions MEDICAL DIAGNOSIS. 
1225 
of dilatation. Where the walls have attempted no compensation, but 
are thinned as well as expanded, the systolic murmur may possess the clear- 
ness of the ring of a bell. Where, as is not infrequently the condition, dis- 
organization associates with the expansion, clearness is replaced by a contrasting 
dulness. 
Murmur Present or Absent as Circumstances Influence.-If 
the blood be watery, or if valvular obstruction exist, the latter being the likely 
condition and cause of the dilatation, then whir or regurgitation, or both, will be 
heard. These conditions being absent, none but the ordinary sounds are heard. 
Expression of Weakness.-Whatever sounds may be present or 
absent, evidence of the condition is never wanting as these pertain to languor 
of action both as the heart itself and the circulation at large are concerned. 
FATTY HEART. 
Fatty degeneration of the heart is a condition not difficult to- confound, 
diagnostically, with dilatation. Percussing such a state of the organ, one case 
may yield increased area of dulness, while another affords no sign in the 
direction. 
Definition.-By fatty heart is meant a condition of the organ expressed 
in softness and flabbiness, the muscular fibres being atrophied and changed 
into fat. A heart that has undergone, or that is undergoing, fatty degener- 
ation may show no change to the eye, yet, in presence of the microscope, be 
little less than an oleaginous mass. 
Judgment of Existence of Condition through Inspection.- 
A fatty heart has associated with it, necessarily, feebleness of sound, impulse, 
and circulation. The condition is to be suspected when more or less oppres- 
sion in breathing is found combined with cold extremities. Other diagnostic 
signs are giddiness when suddenly changing from a supine to an upright 
position, losing the breath easily, rapid and labored respiration attendant 
on moderate effort, fatty or oily condition of the skin, existence of the arcus 
senilis, atheromatous degeneration found elsewhere, general wasting 
disease. While percussion may yield no information, both palpation and 
auscultation are instructive. A hand laid upon the chest discovers the weak- 
ness in absence of the apex impulse. To the ear the sounds are mixed, are 
irregular, and lack in distinctness. 
Antecedents.-Old age. The gouty condition.* Degenerative changes 
in the blood affecting nutrition. Repeated hemorrhages. Pernicious anaemia, 
chlorosis, poisoning by phosphorus f or acids. Heredity ; cause being here 
a tendency to early degeneration of the muscular fibre. Sex ; men being 
much more disposed to the disease than women. Sedentary habits ; the 
* Gout and Angina Pectoris.-The relation of gout with angina pectoris is familiar. 
f Phosphorus-Poisoning.-In a case recorded by Habersham, fatty degeneration was found 
to occur on the fifth day after a five-grain dose. 1226 
A SYSTEM OF ORAL SURGERY. 
indolent high liver being inclined to muscular atony. Febrile condition ; 
it occurs to a lesser or greater extent in seventeen cases in the hundred of 
typhoid fever; in diphtheria forty cases to the hundred ; in small-pox, erysipelas, 
and puerperal fever it is a frequent associate. Parrot found it present in 
about one-fourth of fifty-four fatal cases of measles. 
Alcoholism is a cause ; free drinkers are apt to have their blood 
loaded with fat. Ether and chloroform dispose the users to fatty 
degeneration. 
Diagnostic Symptoms.-Besides the symptoms enumerated, which 
are not specifically diagnostic by reason of being common to other conditions 
as well as to this being considered, dyspnoea is to be referred to as the one 
most commonly present. This interference with breathing varies from an 
occasional sigh to what is known as the Cheyne-Stokes respiration, 
this latter being a form of ascending and descending inspiration where the 
breathing is at first rapid and intense, and later slow and feeble; the condition 
is of recurring character, the interval being marked by an almost entire 
cessation of the respiratory act. Dyspnoea is not, however, to be identified as 
of exclusive association with fatty heart. It is not unfamiliar to the practi- 
tioner in connection with both valvular disease and dilatation, while many 
instances are recorded of its connection with nerve lesions, with atheroma of 
the aorta, with exhaustive hemorrhage, and with tumor of the brain. The 
probable cause of it, as first suggested by Walshe, lies in diminished sensi- 
bility in the respiratory centre. Fatty degeneration of the muscular fibres of 
the heart is not one with deposits about and around the organ. In the latter 
condition the beat is regular and harmonious, even if more or less concealed or 
masked. In the former, as understood, rhythm is lacking or absent, and the 
circulation at large is labored and deficient. 
Pericardial Effusion.-Effusion into the sac surrounding the heart is 
to be considered in relation with the diagnostic signs attendant on dilatation 
and fatty degeneration because of a reasonable likeness in the conditions. 
Water in the pericardial sac obscures impulse and sound. It is at times 
the case, as familiar in the experience of the writer, that the beat of the 
heart is almost lost in a smothered sound, while impulse, as distinguishable by 
palpation over the apex, is entirely wanting. One unfamiliar with the con- 
dition could readily be deceived into a conviction of atrophy of the organ. 
Diagnostic Signs.-Signs and antecedents differentiating the condition 
lie, first and prominently, in the direction of percussion. While, in dilatation, 
the area of dulness is square, in pericardial dropsy it is pyramidal, the apex 
of the pyramid being downward and obliquely lateral in correspondence with 
the shape of the sac. Second, there is the history of a case to be taken into 
consideration. Pericardial dropsy has associated with it an inflammatory 
antecedent, and this, during the progress of a case, has some time or other 
afforded the friction-sound. It is also the case that in this condition, the 
effusion not being too extensive, the valvular sounds are little interfered with MEDICAL DIAGNOSIS. 
1227 
by reason of remaining uncovered by the fluid, this, by gravity, falling to the 
bottom of the cavity. It is as well the case that there is neither venous con- 
gestion nor dropsy in other situations; conditions common to dilatation. Cough, 
and interference with respiration, may be present, but neither are likely to be 
conspicuous as in the instance of the dilatation and fatty degeneration. Da 
Costa calls attention to a condition, an example of which has never been met 
with by the author, where there occurs an accumulation of blood in the 
cavities of the heart. Here, as described by him, and as would be in- 
ferred out of an appreciation of the condition, the heart works after a labored 
and irregular manner, being at times strong and weak ; dyspnoea is present, 
together with venous congestion of the face. Cause lies with lesions com- 
pelling cardiac engorgement, as inflammation of the endocardium, or pneumonia. 
It is well remarked by the same authority that there is no reason why dilata- 
tion and fatty degeneration should not produce it. 
VALVULAR AFFECTIONS. 
Appreciation of valvular affections being a matter that requires not only 
cultivation of ear but refinement as to anatomical knowledge, attention will 
wisely be given by the student to the diagram here introduced (Fig. 918), 
and from which passage should be made to dissection of a bullock's heart. 
Definition.-By valvular affection is implied lesion of one or more of 
the cardiac valves, yielding to the ear a murmur, or blowing sound. 
Location of Valves.-Referring to the diagram, Subfigs. 6, 7, and 8 
point out a cardiac valve. The particular one shown by these figs, is the tri- 
cuspid, its situation being in the right auriculo-ventricular opening. Another 
valve, being of similar expression and significance, is the mitral, or bicuspid, 
the situation of this being the left auriculo-ventricular opening. Subfig. 12 
locates one of two semilunar valves ; the situation of the one here shown being 
at the orifice of the pulmonary artery, the other is at the beginning of the 
aorta. 
Use of the Valves.-Study of the diagram shows the ventricles to have,, 
as their floor, (1) a series of irregularly-related carneous, or fleshy, columns. 
Certain of these rise into prominence as papillary muscles (9, 9), to which 
tendinous cords are attached, which cords, as seen in the diagram, pass upward 
to a valve (6, 7, 8), and are lost in its substance. The valves with which 
these cords arc related,-the tricuspid and mitral,-situated, as understood, in 
the auriculo ventricular openings, open downward, or into the ventricles. In 
systole these valves are tightly closed, by reason of the relaxation of the cords, 
and the volume of blood forced against them as the ventricles contract to 
empty themselves into the pulmonary vessel and aorta, the valves of which 
open the other way. In diastole the valves are open by reason of the ex- 
pansion of the ventricles and the rush of blood from the direction of the 
auricles. In the diagram the exposed right ventricle is shown in a state of 
dilatation. The condition is that of diastole. In this state of the living 1228 
A SYSTEM OF ORAL SURGERY. 
heart, the cavity is full of blood which has rushed into it through the 
gate-way of the tricuspid valve which its act of dilatation opened. The open- 
ing has been effected by recession of the papillary muscles from the valve 
Fig. 918. 
View of the heart, with the anterior portions of the ventricles removed. 
1, interior of the right ventricle, exhibiting its carneous columns; 2, left ventricle; 3, 
right auricle; 4. left auricle; 5, aorta; 6, 7, 8, divisions of the tricuspid valve; 9, papil- 
lary muscles attached by tendinous cords to the tricuspid valve; 10, mitral valve; 11, 
pulmonary artery laid open; 12, one of the semilunar valves; the other two are seen 
in section on each side of the former; 13, sinus or dilatation of the artery behind one 
of the semilunar valves. 
against which they lay when the cavity was contracted, or in its state of systole. 
Further study of the diagram exposes the condition of systole. The contrac- 
tion of the ventricle loosens, necessarily, the tendinous cords, which, in. turn, 
liberate the valves. The blood is to be forced somewhere. It shuts itself off 
in the direction of the auricles by reason of pushing against and closing the 
doors leading in these directions. A way of egress, and the only way, is above, 
through the semilunar valves, which are opened by reason of the same force 
that shuts the others ; these opening outwardly. 
Healthy Valvular Action.-Healthy valvular action is appreciated, 
in understanding of the anatomy of the parts, to relate with unobstructed and 
uninterfered-with valvular action. The sounds designative of such action are 
easily made familiar, it being alone necessary to listen for them in a number of MEDICAL DIAGNOSIS. 
1229 
individual cases in order that the listener assure himself that what he hears 
is physiological and not pathological. Students should examine each other in 
turn by classes. Valves being located and their sounds estimated, an observer 
is prepared to pronounce as to health, or absence of it, in any individual heart, 
even though he be without understanding of pathological conditions. 
It is appreciated that, in order to prevent passage of the blood in an 
opposite direction to that in which it is designed to go, the valves must shut 
tightly. This, in a healthy state, is what they do. In systole the valves, 
occupying the openings which relate auricles and ventricles, close accurately, 
for here it is the meaning of the action to drive the blood into other parts. 
On the contrary, it is in this motion that the superior valves open, that which 
opens them being simple pressure from below. In diastole, on the other 
hand, it is the purpose to receive into a ventricle the blood from an auricle. 
Here, were it not for the semilunar valves, the blood would be sucked from 
auricles, pulmonary vessel, and aorta alike, but the closing of them prevents 
supply from the two latter directions. The sound heard in the shutting is 
distinctly sharp and abrupt; the result of the striking of the Aurantian 
bodies. 
Unhealthy Valvular Action.-Unhealthy valvular action will be 
appreciated as existing in a non-perfect working of the valves. Where the 
auriculo-ventricular valves are not tight there is a backward flow into the 
auricles at time of systole. Where the semilunar are imperfect there is a 
sucking of blood from the pulmonary vessel and aorta into the ventricles at 
time of diastole. This reversed flow is known as regurgitation. 
Endocardium.-The endocardium is the lining membrane of the cavi- 
ties of the heart and the cover of the valves. It is a serous membrane, con- 
sequently when inflamed the exudate thrown out by it is of plastic nature. 
Deposit of this material about the valves is cause of their imperfection. 
A valve thickened and stiffened through deposit and organization of lymph 
cannot accurately perform its function, hence regurgitation, hence also 
stenosis. 
Regurgitation.-The condition of regurgitation is expressed to the ear 
by a murmur. When the flow is upward into the auricles the sound is heard 
at time of impulse, or systole. When it is downward from the pulmonary 
vessel or aorta it is heard at time of dilatation, or diastole. 
Stenosis.-Stenosis, or narrowing of the pulmonary or aortic orifice, 
makes itself known to the ear by a whirring, or blowing, sound, this being 
acute or dull according to the measurement of the contraction. The condition 
is infrequent to the pulmonary valves but not at all uncommon to those of 
the aorta; it is of both congenital and acquired origin. 
Results and Conditions of Regurgitation and Stenosis.-As 
resultant of auriculo-ventricular regurgitation the auricles incline little by 
little to give way in dilatation, while the right ventricle, being the intermediate 
part, is apt to take on hypertrophy. The nature of the sound conveyed to the 1230 
A SYSTEM OF ORAL SURGERY. 
ear is smooth or rasping according to the character of the lymph deposit about 
the valve. Where it is the latter, consequences are more threatening, as clot 
could be formed or an embolus given to the circulation. Cough and dyspnoea 
are attendant on auriculo-ventricular regurgitation by reason of congestive 
conditions induced in the lungs. Stenosis, interfering, as it does, with the 
propulsion of the blood upward, is certain to be accompanied by ventricular 
hypertrophy, the meaning of this lying with effort made by the part to over- 
come the obstruction. Dilatation of the ventricles may easily prove the source 
of regurgitation, cause lying not with plastic changes in the valves, but with 
the altered condition of the ventricles which denies them proper closure. 
Regurgitation into the auricles has as an almost invariable associate distention 
of the veins of the neck, this being one of the diagnostic signs, while, not 
infrequently, there is pulsation. Stenosis is characterized by the 
symptoms of the condition of which it is the cause,-namely, hypertrophy. 
(See Hypertrophy.') There is here, however, little or no pain. Objective 
symptoms, noticeable by the patient, lie with excessive palpitation, very trouble- 
some, sometimes, at night, with vertigo, with dry cough, and with epigastric 
oppression after a full meal. A striking feature is that the impulse stroke 
of the heart is extended over several intercostal spaces. Where there is 
great severity of palpitation, dilatation will be found combined with the 
hypertrophy. 
Aortic Aneurism.-The writer has given ether conveniently and safely 
where aortic aneurism existed to the capacity of a quart measure. Here 
diagnosis is difficult. Aneurism situated in parts distant from the heart are 
recognizable in a murmur, conspicuously present, which is not unlike the pur- 
ring sound made by a cat. When closely related, as in aortic aneurism, all 
sound may be wanting, otherwise so concealed and covered by those of the 
heart as to be lost to the car. Signs pointing to the presence of 
distention of the aorta are somewhat akin with several related with 
stenosis. There is, not unlikely, ventricular hypertrophy, a result of inter- 
ference with the free egress of the blood from the heart. The arteries of the 
neck are rigid and stiff. A prominent sign is interference with breathing, 
slight physical effort making this labored and quick. Other signs, accidental 
or incidental in their character, relate with pressure on adjoining parts. If 
the part be a subclavian artery, pulsation in the two wrists are found to differ. 
If the cesophagus be intruded upon, there is likely to be difficulty in swallow- 
ing. Pressure upon a carotid results in giddiness of the head, dulness, flashes 
of light before the eyes, and engorgement of the veins of the neck. Pressure 
upon the ascending laryngeal nerve compels aphonia. Double beating, as 
though the chest contained two hearts, is diagnostic. Pressure by a solid 
tumor may simulate all the conditions named, but distinction exists between 
this and aneurism in the pulsation of the latter. It is the case, however, that 
a solid tumor may pulsate, or seem to. Here the growth overlies a thing 
that pulsates. The distinction, from this aspect, is not always easy to make MEDICAL DIAGNOSIS. 
1231 
out. Tt is also the case that the stenosis which relates with ventricular hyper- 
trophy may produce pulsation in the aorta, while it is familiar that a collection 
of fluid in the chest may transmit the cardiac impulse. The flow in the pul- 
monary artery is to be heard where a lung is so consolidated as to present 
an abrupt obstruction, while it is not impossible to have the ear deceived by 
reason of a peculiar beat found at times in connection with the circulation in 
the thyroid gland. Balfour calls attention to deception found infrequently 
associated with a malposition of the aorta due to rickets, while Da 
Costa refers to the dilated auricle, the walls of which are at the same time 
hypertrophied, as giving rise to a movement separate from that of the beat 
of the ventricle. Hydatid cysts are variously referred to as having been 
found in connection with the heart, and it is to be inferred that a large one, 
having the fremitus marked, could easily be mistaken for aneurism. Rey- 
nolds, in his chapter on the entozoa, gives many interesting and instruc- 
tive quotations in this direction. In connection with these growths there may 
occur effusions of serum and lymph into the pericardium,-a matter which adds 
to confusion in diagnosis. Aneurism of the coronary artery is not to 
be left out of the account, although so rare a condition as to be referred to as 
a museum curiosity. In the St. Bartholomew Hospital Reports there is 
recorded the case of a boy, aged seven years, who had died with scarlatinal 
dropsy, pneumonia, and meningitis, where three aneurisms were found bulging 
out from the space occupied by this vessel. 
Emphysema of the lungs is a possible cause of aneurism of the pul- 
monary artery. Narrowing of the mitral orifices, holding, as it would, 
the blood in the lungs and reacting consequently on the pulmonary artery, 
might readily enough be a cause of aneurismal enlargement to this vessel. 
Cause of Aneurism.-Cause, as a factor in the production of aneurism, 
is of an importance requiring consideration. While, as non-splanchnic parts 
are concerned, cause may lie with overstrain, yet the idiopathic condition, 
that which we consider, is due, more commonly than otherwise, to atheroma- 
tous and ossific degeneration, the vessels losing their resistive character, and 
yielding, little by little, to the continued strain of the circulation bearing upon 
them. Atheroma existing in the blood-vessels about the heart may, quite 
as readily, affect those of the brain, hence a possibility of sudden rup- 
ture involving parts, possessed of fatal significance when the circulation is 
excited, as in the primary stages of an ether exhibition. 
Kinds of Aneurisms.-Aneurisms are divisible into forms known as the 
sacculated, diffused, and fusiform. The first is the true aneurism; 
its expression is that of an artery dilated and enlarged in its circumference, 
yet having its area strictly defined. The second is the false aneurism ; its 
parietes, or boundaries, are whatever structure happens to circumscribe the 
blood. A common expression of this form of arterial tumor is where certain 
adventitious tissue that has formed, envelope-fashion, about an enlarging vessel, 
receives and holds the blood when the walls of the artery have thinned and 1232 
A SYSTEM OF ORAL SURGERY. 
let it escape. The third is a true aneurism, inasmuch as the blood is con- 
fined by the parietes of the artery ; but the character of it, as expressed by the 
name, is, in form, like an elongated cylinder,-an irregular one, however,- 
approximating, at times, the state of bead-like dilatation, or it may be that one 
side of the vessel is alone found expanded. 
Phantom Aneurism.-This is one of the conditions of possibility. 
Cause lies with a temporary relaxation, or giving way, of the muscular coat of 
an artery,-a result, more than likely, of vaso-motor paralysis. Enlargement of 
the blood-vessels of the cheek in blush is illustrative. 
Displaced Heart.-A heart may be displaced, even to the extent of 
being on the side of the chest opposite its ordinary location, and yet exist in 
what is to be esteemed a physiological state. The manner of fixation of the 
organ by its root-vessels, and its entire freedom as to all other parts, allows of 
large mobility, while its relation with parts so disposed to change of size as 
the stomach and liver renders its limited displacement a matter of every-day 
occurrence. A worried heart, the result of flattening of the stomach existing 
in indigestion, is a familiar occurrence. A collection of fluid in the pericar- 
dium tilts the apex of the heart upward. Finding it pushed to the right side 
renders probable the existence of pneumothorax or a pleuritic effusion on the 
left side. Emphysema is a cause of lateral displacement. A contracted or 
cirrhosed lung may invite it over by reason of the vacuum afforded. 
Displacement invites Attention to Cause.-The first condition 
named is likely to be of congenital meaning; not necessarily so, however, as a 
cirrhosed lung on the one side and an emphysematous organ on the other could 
result in such effect. Fluid in the pericardium would have an associate history 
of pericarditis. Pneumothorax exposes itself to auscultation. Pleuritic effu- 
sion has a preliminary of pleurisy. The associate conditions, rather than the 
position of the heart, are matters concerned in the diagnosis. 
Heart-Sound in Anaemia.-In a watery state of the blood a 
whirring sound is heard at time of systole that so resembles the condition of 
stenosis as to prove very deceptive, not only to the inexperienced, but, at times, 
to others of large observation. The cause of this murmur is indeed not dis- 
similar as to its meaning to the lesion named, for while there is nothing the 
matter with the size of the opening, there is with the volume of the blood, 
this being of an excess that puts it out of correspondence with the ring it has 
to flow through. The heart, in this condition of affairs, beats rapidly, and 
more or less in an excited and labored manner. Breathing is apt to be 
hurried. A murmur-this being transmitted from the heart-is present in 
both the carotid and subclavian arteries and in the veins of the neck. 
Differential diagnosis resides, as the writer thinks, in a softness of 
the blowing sound existing with the anaemic whir as comparison is made with 
the blow of stenosis. To so refine on the matter it becomes necessary, how- 
ever, to have the ear or stethoscope directly in contact with the skin of the 
patient. Happily, however, diagnosis resides not alone in sounds appreciated MEDICAL DIAGNOSIS. 
1233 
by the ear. Condition and history are drawn on. A person being plethoric 
and rheumatic, true stenosis is to be predicated. Being, on the other hand, 
anaemic and nervous, absence of contraction is implied. 
Tobacco Heart.-All clinicians are familiar with the tobacco heart, and 
this, particularly, as it associates with the young and the free users of cigarettes. 
Here defect lies not with sounds, but in irregularity of action, cause 
existing with enervation. Palpitation and irregularity of this char- 
acter compelled to long continuance are apt to change the functional into an 
organic disturbance, the overacting muscles taking on a hypertrophic condi- 
tion. Similar character of disturbance lies with masturbation and with excess 
in ordinary sexual indulgence. 
Exophthalmic Goitre.-This lesion, another name for which is 
Graves's disease, consists in an inordinate action on the part of the heart 
leading to organic change, to swelling of the thyroid gland, and to a staring 
prominence of the eyeballs. It is attributed, plausibly, to an affection of the 
cervical sympathetic nerve, origin of such disturbance lying, not improbably, 
with uterine conditions or with discoverable or undiscoverable neuralgic ante- 
cedents. Certain it is that the trouble is more common to the female than 
the male, while the class of those affected comprises the hysterical and weakly. 
Exophthalmic goitre is distinguished from the common variety by presence of 
the eye and heart symptoms, as well as by a pulsating murmur. 
Resume.-Resume of what has been written concerning the organic 
diseases of the heart shows the subject as divisible into,- 
1. Conditions changing Walls and, likely, Cavities . 
Hypertrophy. 
Dilatation. 
Fatty degeneration. 
Atrophy. 
Aneurism. 
Entozoon. 
2. Conditions related with the Walls 
3. Conditions associated with the Valves 
Stenosis. 
Regurgitation. 
Besides these, which are all of the diseases of the heart that relate with 
particular intent to the anaesthetist, other very interesting directions of study 
offer themselves, prominent among which is a relation that exists at times 
between the auricles by reason of an unclosed oval foramen. The possi- 
bility of the existence of acute disease of the heart of a patient 
presenting for surgical services is never to be out of mind. Any such condi- 
tion has associated with it pain at the cardiac region, disturbance of the 
circulation, and possible changes in the sounds of the organ. 
Confusions.-The blowing sounds of bronchial breathing-see Diseases 
of the Lungs-and the murmurs associated with stenosis and anaemia may 
readily be confounded, by the inexperienced, if pains be not taken to separate 
the first from the latter by having the patient hold the breath while examina- 
tion is being made; this differentiates the source of the sounds absolutely. 1234 
A SYSTEM OF ORAL SUROERY. 
Rasping of the heart, existing in conditions of pericarditis, is differ- 
entiated after a similar manner from a pleural rasping existing in inflammation 
of the pleura. Without such temporary cessation of breathing it is at times 
impossible to say whether a sound heard lies with roughening of the pericardial 
or pleural sac. 
Attention is also to be directed to a necessity for absence of articles of 
dress intermediate to the skin of the patient and the ear of an auscultator. 
If obscurity, or refinement as to a matter to be diagnosed, exists, the writer 
insists on removal of all articles of dress from the chest. Students of a late 
class at the Oral Hospital will recall a mistake imposed on all the members 
where the blow of an apparent stenosis was later shown to exist in the rubbing 
together in the respiratory acts of two surfaces of starched linen. 
DISEASES OF THE LUNGS. 
As preliminary to a consideration of the diseases of the lungs as these 
relate with the employment of anaesthetic agents, it is deemed well to introduce 
certain diagrams with view both to foundational study and ready reference. 
Fig. 919. 
Anterior view of the lungs. The chest and pleural cavities laid open. 1, anterior 
mediastinum; 2, superior mediastinum ; 3, 4, 5, superior, middle, and inferior lobes of 
the right lung; 6, 7, interlobular fissures; 8, 9, superior and inferior lobes of the left 
lung; 10, interlobular fissure; 11, notch of the left lung; 12, pericardium enclosing the 
heart; 13, diaphragm; 14, seventh rib. 
Front View of Lungs in Position and Relation.-Fig. 919, a 
drawing, after Leidy, affords a front view of the chest, the pleural sacs of the 
two sides being laid open with view to exposure of the lungs. 
Character of Lungs.-The lungs are bodies of sponge-like nature, the 
office of which is the aeration of blood. To accomplish such office, which MEDICAL DIAGNOSIS. 
1235 
means the taking in of oxygen and the giving out of carbonic acid gas, 
requires that they be permeable by air, that the blood be brought in contact 
with this air, and that a condition exists which permits of the functional office 
of endosmosis and exosmosis. The lung of the right side is seen to be the 
larger of the two and to consist of three lobes. That of the left side consists 
of two lobes, the absent one corresponding to room occupied by the heart. 
The position of the lungs is to the right and left of a median space. The 
middle space is known as the mediastinum,-a common space that is sub- 
divided, anatomically, into three mediastina, known respectively as anterior, 
middle, and posterior. The middle one accommodates the heart. 
Pleural Sac.-The lungs are confined each in a sac of its own, this sac 
being a serous membrane of double layer affording and holding an interposed 
lubricant. The portion of this sac forming the external covering of a lung is 
known as pleura pulmonalis. The reflected part-namely, that which lines the 
ribs-is called the pleura costalis. The cavity is known as the pleural cavity, 
and is the seat of the dropsy in pericardial effusions. The two layers, falling 
Fig. 920.-A Transverse Section of the Thorax, showing the Relative 
Position of the Viscera and the Reflections of the Pleurae. 
into direct contact with each other, and being smeared with a plastic exudate 
as is common in pericarditis, is what yields the grating and rasping sound, and 
the sharp pain which denies a full breath, in attacks of pleurisy. 1236 
A SYSTEM OF ORAL SURGERY. 
Shape and Relation of Lungs.-The lungs are reasonably pyramidal 
in shape, the bases corresponding with the diaphragm, the apices with the two 
sides of the root of the neck. Each lung is supported in its position by its 
root, this consisting of the bronchus and of the artery and veins which go in 
and out of it. The first of these relate it with the atmosphere, the latter with 
the right ventricle and the left auricle of the heart. Fig. 920 shows lungs 
and heart in relation, also the pleura and pleural cavities. (After Gray.} 
Composition of Lung.-The composition of a lung is of the simplest 
possible character. To understand it one has simply to imagine an ordinary 
grape from which the pulp has been removed, its place being occupied by air. 
First there is the grape, this standing for a single air-cell. Next is the stem 
coming from the grape and passing into the common stem of the bunch; this 
corresponds with a bronchiole. Next is the stem passing into the vine; this 
represents the trachea. Let now the grape-skin be enveloped in turn by a 
film of blood-vessels and a whole lung is fully described; for though it be 
made up of a billion cells, each one is like the other and every one is like that 
described. In turn as there are many bunches of grapes on a 
vine, so in a lung there are many lobules. Fig. 921 is an exhibit of this 
anatomy. The diagram shows two lobules. 1 is the stem or bronchiole; this 
becomes finally, by its relation, one with the trachea, admitting air to the cell. 
5 is a branch of the pulmonary artery, which brings to the cell the blood 
that requires to exchange its carbonic acid gas for oxygen ; 5 is also desig- 
Fig. 922 
Diagram of two primary lobules of 
the lungs, magnified. 1, bronchiole; 2, 
a pair of primary lobules connected by 
fibro-connective tissue; 3, intercellular 
air-passages; 4, air-cells; 5, branches of 
the pulmonary artery and vein. 
native of a pulmonary vein, which 
receives the purified blood and 
conducts it to the left auricle that 
it may reach the systemic round. 
Pulmonary artery and veins con- 
stitute the film of blood-vessels. Fig. 922, after Leidy, magnified sixty 
diameters, shows the vascular film as this surrounds the air-cells. 
Trabeculae.-The trabecuhe of a lung are septi of one of its external 
Capillary nets of the air-cells of the lung, 
magnified 60 diameters. MEDICAL DIAGNOSIS. 
1237 
coverings which permeate a lobe passing between and giving support to the 
lobules. It is an elastic coat, and serves to compress the air-cells in the respira- 
tory act so as to empty them. The size of an air-cell is from the TLy to the 
2-^^ of an inch. 
Understanding and appreciation of the anatomy and meaning of the lungs 
lead to recognition of the fact that a lung which is capable of filling itself 
naturally with air and of emptying itself is in a healthy state; vice versa, that 
a lung that is not capable of filling itself naturally with air or of emptying 
itself is not in a healthy state. The state of fulness is to be designated by 
the technical word pneumatosis; the second, that of emptiness, is expressed 
in the word apneumatosis. 
Pneumatosis.-This term expresses 11 distention by wind." A healthy 
lung receiving its complement of air and having all its vesicles distended ex- 
presses the state of pneumatosis. In this state the acts of respiration, or 
inbreathing and outbreathing, are perfectly performed, the performance being 
represented by a murmur, or sound, known as the vesicular or respiratory 
sound. 
Apneumatosis.-This term reverses the expression pneumatosis, signi- 
fying that a complement of air is not being received and that the vesicles do 
not wholly participate in the respiratory acts. This lack is recognizable in 
absence of the vesicular or respiratory murmur. 
PHYSICAL DIAGNOSIS-AUSCULTATION. 
Respiratory, or Vesicular, Murmur.-The first and prominent 
means of appreciating the condition of a lung lies with presence or absence of 
the vesicular murmur. Where this murmur is present with a lung it makes 
itself evident to an ear placed upon the chest by a sound that is best likened 
to that made by a gentle wind as it passes among thick-set leaves. This sound 
is of double character: the first being made by the air as it rushes into the 
vesicles, the second as it goes out of them. These two acts are named vari- 
ously inspiration and expiration. The first represents the inbreathing, the 
second the outbreathing. Placing one's ear against a chest and hearing no 
murmur, or but limited murmur, affords knowledge of the absence of perfect- 
ness. Such information is in no sense appreciation of detail, but it is one with 
consciousness that a lung is not right. The student who is to become masterful 
in the study of thoracic diagnosis is to practise auscultation upon the 
healthy chest until the sounds are fully and entirely evident to him in every 
direction. Possessed of such appreciation, he is prepared to pass to examinations 
in the pathological direction. 
Illustration.-Fig. 923 is a perfect illustration of the opposite con- 
ditions of pneumatosis and apneumatosis. The upper half of the 
lung is seen to consist of multitudinous air-cells, while the lower part expresses 
consolidation. A case like this would give to the ear the vesicular murmur 1238 
A SYSTEM OF ORAL SURGERY. 
above, while below nothing would be heard. To percussion resonance would 
be given above and flatness below. This diagram is to be thoroughly studied 
and appreciated, as there lies with it the principles related with the diagnosis 
of lung affections at large. 
The stethoscope in auscultation is to be commended for use by the 
uncultivated ear. A stethoscope is an instrument possessed of some variety 
as to device and form, but having the like object of intensifying sound. 
Fig. 923.-A Lung, the Upper Half of 
which is Normal, the Lower Half being 
Consolidated. {After Da Costa ) 
Fio. 924.-Ordinary 
Stethoscope. 
Fig. 924, which shows an ordinary instrument of this class, affords an idea of 
its meaning and construction. Stethoscopes possessed of double ear-tubes are 
preferred by many. An instrument of this class, known as Alison's, is of 
differential significance: it has two ear- and two chest-pieces. Its intention 
is to furnish two contrasting sounds at the same moment. Hawksley's 
stethoscope is composed on the principles of the sounding-board used in per- 
cussing for stone; it is highly regarded by many. The writer seldom employs 
a stethoscope of any kind, finding most dependence to be placed on his un- 
assisted ear laid directly upon a chest. 
Percussion.-By percussing is meant sounding the lungs. This manner 
of reaching diseases was introduced by Avenbrugger, who had noticed the 
difference in sounds as emitted by the hollow and solid parts of the human 
body when struck. This manner was that of direct percussion, or striking a 
part by means of the fingers or a mallet. The plan of to-day is that of Piorry. 
This is known as the mediate. It consists of placing a body between the 
part struck and the part striking. This " mediate" may be a piece of wood MEDICA L DIA G NOSIS. 
1239 
or ivory or other substance. Commonly, by reason of being most convenient 
and efficient, it is a finger of the left hand of the operator. In a condition 
of pneumatosis the sound obtained is clear, resonant, or ringing ; 
the sound emitted by a muffled drum approaches its expression. In a con- 
dition of apneumatosis the sound is dull, flat, heavy. To place a 
finger of the left hand upon a thick book and to strike this with a finger of 
the right is to get a fair idea of it. Percussion must be practised to become 
a familiar means of diagnosis. 
Palpation.-By palpation is meant laying on of the hands. A man being 
blindfolded, but having his hands spread over the two sides of a chest, could 
tell whether or not they moved in consonance with each other, or in consonance 
with the condition of pneumatosis. Apneumatosis would express itself to 
palpation by absence of movement. Touch distinguishes soreness. If acute 
it may remark the presence of fluids or vibrations as made in vocal fremitus. 
In pleural effusions it distinguishes the bulged intercostal spaces. This means 
is, however, only reliable and important when used accessorily. 
Inspection.-This is observation of a part by the eye. By sight, as 
well as by touch, the extent of rise and fall in a chest is to be measured, and 
as well the existence or absence of elevations and depressions, also general 
shape, and likeness or unlikeness with common conditions. A chest that has 
little variation in its rise and fall 'during the respiratory acts denotes one of 
two conditions, both being the contraries of a healthful condition : the lungs are 
partially solidified or they are emphysematous. One side of a chest 
seen to be flat or its opposite projected expresses atrophy or hypertrophy. 
Intercostal spaces being concave or convex signify difference between absence 
and presence of fluid in the pericardial sac. 
DIFFERENTIATION BETWEEN SOUNDS IN HEALTH AND 
DISEASE. 
Study of the respiratory sounds is to begin with the trachea, pass downward 
to the bronchi, and terminate with the vesicular substance of the lungs. 
Tracheal Sound.-The sound given to an ear placed over a larynx or 
trachea is not dissimilar to the whir heard in limited cardiac stenosis. 
It is different, however, in being prolonged, and in having its interval, or break, 
of longer duration, as expressed in change of act from inspiration to expira- 
tion. The sound obtainable by blowing through a tube having a smooth face 
and a diameter of half an inch affords idea of it. It is a smooth sound. 
Bronchial Sound.-The bronchial sound is best made familiar, in the 
estimation of the writer, by repeated examinations made upon a person whose 
lungs are almost entirely gone or solidified. There is here little or no diffi- 
culty in separating from it the associate slight vesicular murmur remaining, or 
any pathological sound. Appreciation of natural bronchial sound is of largest 
importance, as surely no one can approach understandingly a study of pleural 
pathology, being unfamiliar with it. This sound, as would be inferred, is a 1240 
A SYSTEM OF ORAL SURGERY. 
modified tracheal blow, being softer by reason of depth of parts and the heavier 
covering of them. It is modified also as the sound pertains to many tubes 
which are related with the making of it. In health it is smooth, undisturbed, 
and continues as regards the inspiratory act. It is most distinct and least 
modified near the roots of the lungs by reason of the fewness of the tubes, 
and it alters from this as the circumferences are approached. In lean persons 
the sound is heard fairly well between the scapula and vertebral column. 
Respiratory, or Vesicular, Sound.-This is a murmur made by the 
air as it passes in and out of the vesicles composing a lung. It is heard 
most distinctly, and definedly, in inspiration. In expiration it is more pro- 
longed and softer. A healthy lung gives to the cultivated ear the respiratory 
murmur in all its parts, and absence of it from any given locality is to be ac- 
cepted as indicative of special attention required to be given such part. The 
respiratory murmur being heard, in its proportional relation, in the different 
situations, one listening, with anaesthetic purpose, may pass the organ as 
being without concern for him. Greatest distinctness and volume of the 
murmur considered lies with the upper lobes. In women who compress the 
waist tightly it is necessarily more than ordinarily indistinct below because of 
such compression, or for the reason that the organ has been crowded into the 
higher region. A person leaning forward, the vesicular murmur is to be recog- 
nized plainly just below the angles of the scapula. The erect position, and 
the arms thrown back, afford the sound clearly and purely defined at the outer 
aspect of the nipples. The writer makes it here a point to contend that a 
refined ear separates the bronchial and vesicular sounds for a considerable 
distance beyond the roots of the lungs. In far-advanced phthisis pulmonalis 
the bronchial are not unlikely to be the only sounds heard. 
RALES OR RHONCHI. 
Rales is a term applied to bronchial sounds as modified by disease; these 
are of two general kinds, dry and moist. 
Dry Rale.-By a dry rale is meant a sound resultant of the narrowing 
of a bronchial tube. It is here evident that appreciation of such sound is 
obtainable nowhere else than in understanding of the calibre of the natural 
murmur belonging to the tube of a location in its condition. The narrowing 
of a bronchial tube may express the state of the long urethral stricture 
(see Fig. 925), or it may exist, as is most commonly the case, in an inspissated 
mucus clinging tenaciously to the circumference of the tube. Dry rales are 
termed sonorous or sibilant, difference dependent on diameters of con- 
stricted parts. Reference to the pipes of an organ makes plain what is meant. 
Dry rales dependent on presence of mucus are apt to be changed as to position 
or broken up entirely by the act of coughing, hence such act has in it the 
meaning of attempt at relief by nature. Dry rales not relieved or changed as 
to position by the act of coughing imply inflammatory constriction, as shown 
in the diagram. MEDICAL DIAGNOSIS. 
1241 
Moist Rale.-The same diagram exhibits the meaning of a moist rale. 
Here the sound is bubbling or crepitant, this dependent on the form assumed 
by a fluid that occupies the tube. Where the form is that of drops (see dia- 
gram), the rale is of bubbling character, and this may be of heavy or light 
Fig. 925.-Illustrative of Text describing Dry and 
Moist Rales. {After Da Costa.} 
expression according as the drops are large or small. The crepitant rale 
has the meaning of an easily-yielding fluid giving way in presence of passing 
air. The crepitant rale is mostly confined to the air-cells, but not necessarily 
so. It is heard only in inspiration. (See Pneumonia.} 
Cavernous Rale.-This is a sound associated with the existence of a 
cavity in the lungs,-a sound that is sometimes so pronounced as to be best 
defined by the word bubbling. (See Phthisis Pulmonalis.} 
Crackling Rale.-This, like the former, belongs with the moist variety. 
Both the crackling and crepitant rales are attributed by able and compe- 
tent observers to the common cause of air forcing its way into parts, and sepa- 
rating them, which parts have been lightly agglutinated by deposits of plastic 
expression. The crepitant rale is found first, and most distinctly, about the 
lobules; it is the primary distinctive sign of pneumonia. The 
crackling rale is related with tuberculosis, hence its common primary seat is 
the apices of the lungs. 1242 
A SYSTEM OF ORAL SURGERY. 
PLEURAL FRICTION. 
By pleural friction is meant the rubbing together of the pleura pulmonalis 
and costalis. The pleura, as understood, is a double sac which first surrounds 
a lung and is then reflected to the ribs. As further understood, this sac is the 
lubricating membrane of the lung, permitting and aiding in its free and con- 
tinuous movement. When the pleural secretion is normal the two parts of the 
common sac move easily and noiselessly on each other; when, on the contrary, 
an inflammation supervenes, as in pleurisy, the parts are dry, hence a friction, 
or rubbing sound. There is also a crepitant sound pertaining to this condition. 
This, by reason of its oneness in character with that yielding the crepitant rale, 
is not always easily distinguished from the latter. A highly-sensitive ear will 
likely differentiate it by reason of its more superficial position, but it is never 
amiss to aid the hearing in such cases by means of a compress so firmly applied 
as to restrain the movement of the ribs. This last is accomplished either by 
means of the hands or by a single layer of cheese-cloth bandage stuff. Press- 
ure being applied, the sound, if pleural, ceases; if it be vesicular it continues. 
VOCAL FREMITUS AND RESONANCE. 
Vocal fremitus, which means the sounds of the voice as felt in the vibra- 
tions of the chest, seems to the writer to be less relied on as years pass as a 
means of diagnosis. 
Vocal Resonance.-The ear being laid against the healthy bare chest 
of a speaking person, the listener hears nothing by which he finds himself able 
satisfactorily to associate voice and lung unless the speaker be of heavy voice, 
or of diseased condition. In the case of the heavy-voiced person, a certain 
vibration is heard, which is what is known as vocal resonance. This resonance 
relates with the vesicular tissue. 
Bronchophony.-When the vesicular tissue is consolidated out of any 
reason, vocal resonance becomes more marked. The sound lies here with 
relation of such resonance with the bronchial tubes and with absence of ob- 
struction of the sound in a passage outward. Bronchophony has a variety of 
expressions as modified by diseased conditions. The term pectoriloquy is 
applied to it where the resonance is resultant of a cavity in the substance of a 
lung. Where such cavity is of a size to yield a sharp metallic sound the word 
amorphic is used. The cavernous, sepulchral, or cracked metal 
voice is present where the walls of a cavity are of sufficient extent and solidity 
to echo the speech: in such condition words are sometimes to be heard as of 
distinct enunciation. 
The term aegophony is used to express a modification in bronchophony 
where the voice reaches the ear as a bleat. The cause of this bleat lies with 
a layer of fluid which both compresses the lung and modifies the sound to 
the ear. MEDIC A L DIA GNOSIS. 
1243 
PATHOLOGICAL CONDITIONS. 
Pathological expressions are, from the stand-point of a foregoing preparation 
and understanding, easy of recognition and appreciation. A primary division, 
as before suggested, is into the conditions of pneumatosis and apneumatosis. 
n n 
Conditions of Pneumatosis 
Vesicular emphysema. 
Extra-vesicular emphysema. 
Atrophy. 
Collapse. 
Pleural effusion. 
Hypertrophy of heart. 
(Edema. 
Congestion. 
Hemorrhage. 
Induration. 
Pneumonic consolidation. 
Lymphatic stasis. 
Phthisis. 
Cirrhosis. 
Cancer and allied deposits. 
Hydatids. 
Conditions of A pneumatosis 
CONDITIONS OF PNEUMATOSIS. 
Emphysema.-Emphysema is a condition of a lung where the cells have 
become enlarged and expanded, or where rupture has occurred and the air 
passes into the intervesicular or interlobular cellular tissue. The first is the 
true, or vesicular; the latter, the false, or extra-vesicular emphysema. 
Cause.-Anything that puts an intra-vesicular strain on a lung. 
Diagnosis.-Prominent chest, dyspnoea, expiratory act prolonged and 
labored, high resonance on percussion, feeble inspiratory act. 
Atrophy.-Atrophy is a condition where a lung shrivels and lessens in 
size. 
Cause.-Senile or other change. 
Diagnosis.-Sunken chest, combined with diminution in the respiratory 
sound and absence of pathological signs. Where the condition affects one 
lung alone, as might occur from an obstruction of the nutritive circulation 
lying with atheroma, physical differentiation would lie marked with difference 
of measurement on the two sides. 
Collapse.-Collapse is a condition where a lung has lost its functional 
meaning by reason of a something that interferes with its aeriform circulation, 
the organ itself not being diseased. 
Cause.-Cause is of various significance. A wound opening the pleural 
sac would cause it, provided the air had free entrance and indifferent exit. 
Similar significance lies with a rupture of the covering, the air having here 
CONDITIONS OF APNEUMATOSIS. 1244 
A SYSTEM OF ORAL SURGERY. 
similar, if a reversed, entrance into the sac. Pleural effusion is a common 
cause. Gradual stoppage of the bronchial tube of the side explains the 
presence of the condition in given cases. Here escape of air fails to find 
compensation in a return, allowing little by little contraction, or collapse 
of the cells. A cause for this is found sometimes in syphilitic gummata. 
Extreme weakness is a cause. The writer has seen a man die by reason of 
simple inability to overcome by the inspiratory act the contractility of the air- 
cells. 
Diagnosis.-Sunken, or a gradually sinking, chest, dulness on percussion, 
no vesicular murmur, increase in the number of the respiratory acts, recognition 
of presence of causes, dyspnoea. 
Pleural Effusion-Hydrothorax.-Pleural effusion is a condition 
expressive secondarily of apneumatosis by reason of the preceding condition 
of collapse induced by it. By the term is commonly meant an exosmosis of 
the serum of the blood into the pleural cavity. The pleura being a serous 
membrane, its exudate is most generally of a plastic nature, hence the partial 
gluing together of the layers and the friction or rubbing sound given the ear. 
Besides serum and fibro-serum, collections of pus and of blood are to be met 
with in the cavity. 
Cause.-The most common cause is pleuritis. Other causes lie with dis- 
ease of the heart, liver, or kidneys. In the case of pus or blood, cause may 
lie with abscess originating in adjoining parts and opening into the cavity, and 
with the rupture of vessels. 
Diagnosis.-Pleural effusion related with the acute local condition of 
pleuritis has its meaning exhibited in an associate history. It is here restricted 
probably to one side by reason of the pleurisy being more likely single than 
double. Where an inflammation has its meaning in lymphangitis, or, as this 
is most commonly termed, tuberculosis, the effusion will most likely affect the 
cavities equally. Hydrothorax, or common dropsy, has its analogue 
in abdominal ascites; the circulation, obstructed in neighboring parts, finds in 
the pleural cavity a convenient place to relieve itself of the water that is over- 
distending its vessels. In dropsy of this latter import the collection is always 
thin. Percussion sounds are dull, vesicular murmur is deficient or absent, 
intercostal spaces are bulged. Pleural effusions are distinguished from 
an enlarged liver or spleen in change of area of percussional dulness 
during the respiratory acts. The organs named, being enlarged, intrude 
naturally upon the room normally occupied by the lungs, and thus yield flat- 
ness of sound where naturally there is resonance. Mistake is avoided in ob- 
serving that this area of flatness lifts or falls with the acts of expiration as to 
the first and of inspiration as to the other. 
Hypertrophy of Heart.-This condition, which has been studied, re- 
lates with the lungs through compression of their substance by reason of enlarge- 
ment of the viscus ; otherwise, by pathological relation arising out of and exist- 
ing in changes begotten in the circulation. (See Hypertrophy of the Heart.') MEDICAL DIAGNOSIS. 
1245 
CEdema.-(Edema is a condition of the lungs allied with pleural effusion. 
Here, however, effusion is within and not without. (Edema of a lung is one, 
in its common pathological significance, with oedema wherever situated. Its 
meaning is a deposit of water. 
Cause.-CEdema occurring on one side will be found to have its meaning 
in local obstruction. If persistent, the cause is likely to exist in a lympho- 
matous tumor that is making pressure on a vein. Where the condition is 
double it implies a mediastinal tumor, otherwise thin and watery blood. 
Bright's disease may be the cause. 
Diagnosis.-Percussion is affected according to extent of effusion. Aus- 
cultation yields like variable results. Cough and dyspnoea are prominently 
present. Where the cause lies with an anaemic state of the blood, weakness, 
lassitude, and whiteness in the patient show it. Disease of the kidney reveals 
itself to manipulative tests easily employed. Prominent, and of first impor- 
tance, is the test for albumen. If obstruction to the circulation lie with 
the heart, auscultation is at no loss to define the character of it. 
Congestion.-This condition will not unlikely be found in any given 
case of similar meaning as to cause with oedema; that is, when it is not of 
acute significance. The latter being the case, it is to be considered and 
studied under the head of pneumonia. 
Hemorrhage.-This condition is too familiar to need special description 
as to its common phenomena. The technical name is haemoptysis. 
Cause.-Cause is various. It may be idiopathic. The writer has in his 
practice two patients who infrequently suffer from lung-hemorrhage, and who 
have so suffered, one of them, for thirty years. In the female, hemorrhage 
of the lung may be of vicarious nature. It is, however, commonly the case 
that haemoptysis has the meaning of grave organic change going on in a lung, 
and so it is esteemed, not unjustly, a close forerunner of consumption. 
Diagnosis.-Differentiation is to be made between blood coming from the 
mouth, the nose, and the lung. Bleeding of the mouth is commonly associ- 
ated with the dental crypts. It never flows as a stream, but rather as an 
oozing, requiring, not unlikely, that the part be sucked to yield it. Where 
a result of a congested uvula, or pharynx, the eye takes in such origin at a 
glance. Epistaxis, or nose-bleeding, is of continuous flow, while it lasts, 
or if not this, it remits. In color it is dark. No cough is produced by it so 
long as the head of the person is inclined forward. In bleeding from the 
lung the color of the blood is florid, it comes more or less commonly by the 
mouthful, is salty to the taste, produces coughing, and is demoralizing to 
the patient in a sense that is not found accompanying the other forms 
named. 
The relation of such hemorrhage with apneumatosis is in its con- 
sequences and meaning rather than in its immediate status with auscultation, 
this, at the time, affording conspicuous illustration of what has been described 
as the bubbling rale. 1246 
A SYSTEM OF ORAL SURGERY. 
Induration.-By this condition is meant what is commonly described 
under the names of splenization and hepatization. As the subject 
concerns studies pertaining to the present volume, it takes in the remainder of 
the classification here proposed,-namely, pneumonic consolidation, lymphatic 
stasis, phthisis pulmonalis, cirrhosis, cancer, and allied deposits and hydatids. 
Cause.-The conditions named express variety as to cause. 
Diagnosis.-This condition, as a common one, is not at all difficult of 
appreciation. Percussion is dull, auscultation finds no vesicular murmur. 
Other signs are shortness of breath, rapid respiration, a quick and irritable 
pulse, possible, and, not unlikely, associate disease of the heart in the way of 
hypertrophy, or dilatation, of the right ventricle. One lung alone is likely to 
be affected if the patient be able to move about. Both lungs could not be 
affected to an extent involving obliteration of the expressions lying with per- 
cussion and auscultation without a necessarily fatal result. In some conditions, 
as in cirrhosis, contraction of the chest-walls and intercostal spaces are present; 
in other conditions, as in sarcoma, the intercostal spaces are likely to be bulged 
and the chest expanded. 
Differentiation.-While the conditions named offer their immediate di- 
agnostic signs in common, the histories are as varying as are the names. By 
pneumonic consolidation is meant consolidation lying with inflamma- 
tory sequences as associated with a state of acute pneumonia. (See works on 
the Practice of Medicine.) By lymphatic stasis is meant that inter- 
ference with the law of nutritious supply and appropriation through which 
there accumulates in the lung an excess of plasma which, in its secondary sig- 
nificance, is the cause and meaning of phthisis. 
By phthisis is meant a labored and chronic form of lung inflammation 
existing in the presence of a lymph stasis where this material degenerates and 
breaks down, affording habitation for an omnipresent parasite known as the 
tubercle bacillus, and producing, through catalysis, an inflammatory product, 
pronounced tubercle. 
By cirrhosis is meant contraction of, or growth of, the intra-trabecular 
tissue. A name applied to the condition by Da Costa is fibroid phthisis. 
A section of a whole cirrhosed lung shows the functional character of the 
organ to have been obliterated by changes in the interlobular boundaries where 
excess of fibrous tissue has developed to an extent that has compressed and 
obliterated the enclosed vesicles. Cirrhosis is evidently a disease existing in 
external irritation, the lung being acted upon to the production of offensive 
barriers in the presence of the dust of mills or coal-pits in a manner not dis- 
similar to what is found with the liver in excess of spirit stimulants. 
By cancer is meant a neoplasm originating in the lung or thoracic 
cavity. The disease is rare, and is to be differentiated from other conditions 
that eventuate in consolidation alone by and through the process of exclusion. 
Percussion grows in dulness. Auscultation loses the murmurs little by little 
until the whole are gone. Cough is dry and distressing, dyspnoea is most MEDICAL DIAGNOSIS. 
1247 
painful. What sputa there is has a red color, and is more or less of jelly-like 
appearance. Pain is constant and of oppressive character. There is a sense of 
fulness in the side of the chest affected that is not felt in phthisis. Unlike a 
result obtained from paracentesis where fluid is present in the thoracic cavity, 
the needle returns filled with a grumous mass, as is known to the personal 
experience of the writer. 
By hydatids is meant a cyst which is made up of a little multitude of 
lesser cysts, these little cysts having the meaning each of a hydatid. By a 
hydatid is implied an entozoon whose habitation is a vesicle filled with a water- 
like fluid. A collection of these little water-bags makes what is called the 
hydatid tumor. If the writer judge by his own experience the disease is rare. 
He has met with it in a ligament of the liver, but never, personally, in the 
lung. The peculiar diagnostic sound lies with a fremitus that might easily 
be confounded with the pur of aneurism. CHAPTER LXXIV. 
ANESTHESIA AND ANESTHETICS. 
By anaesthesia is meant the opposite to aesthesia. The term is derived 
from the Greek privative ay and the word alffOdvo/iat. By the root-word, or 
substantive, is implied " feeling." The privative an placed before this root- 
word converses its meaning and implies lack of feeling. The anaesthetic con- 
dition lies with absence of feeling, or sensation. Anaesthetics are agents that 
deprive of feeling, or sensation. 
History.-Knowledge of anaesthesia extends back to an unknown period. 
A prominent instance of its employment is found in the case of Socrates, who, 
after drinking the poison-cup of prepared hemlock, directs attention to the 
effect of the medicine in the growing numbness of his limbs. Modern anaes- 
thesia begins with M. Girardin, who in 1828 writes " concerning the inhala- 
tion of gases that produce insensibility." In 1844 came the observation of 
Horace Wells, that a person under the influence of inhaled nitrous oxide could 
be hurt without suffering from the ordinarily accompanying sensation of pain. 
Agents used.-Agents that obtund, or deaden, are classed under two 
general heads,-namely, local anaesthetics, anodynes, or analgesics, and general, 
or systemic, anaesthetics. 
Manner of Use.-Agents of the first-named class are applied and act 
locally. Agents of the second class are breathed into the lungs, thrown up 
the rectum, taken by the mouth, or injected hypodermatically. 
Agents acting locally. 
1. Camphor. 
2. Chloral hydrate. 
3. Camphor and chloral. 
4. Laudanum. 
5. Phenol-sodique. 
6. Camphorated phenol. 
7. Carbolic acid. 
8. Campho-phenique. 
9. Arnica. 
10. Aconite. 
11. Chloroform. 
12. Oil of eucalyptus. 
13. Menthol. 
14. Rhigolene. 
15. Ether. 
16. Nitrous oxide. 
17. Cocaine. 
18. Oleate of cocaine. 
19. Bromide of potassium. 
20. Iodine. 
21. Hamamelis. 
22. Creasote. 
23. Morphia. 
Agents acting systemically. 
1. Spirits. 
2. Sulphuric ether. 
3. Chloroform. 
4. Nitrous oxide. 
5. Bromide of ethyl. 
6. Hydrobromic ether. 
7. Mandrake. 
8. Morphia. 
1248 ANESTHESIA AND ANESTHETICS. 
1249 
GENERAL CONSIDERATIONS. 
The local use of anaesthetic agents is commonly accepted as being without 
danger or risk. To use anaesthetic agents systemically implies risks to be 
taken wisely by him only who is well informed as to a circle embraced by the 
matter. 
Local Use.-By local use is meant the immediate application of an 
agent to a part to be deadened. Examples : Wetting a cloth with lauda- 
num and wrapping it about a painful finger; brushing a mucous surface with 
a cocaine solution; spraying an evaporant upon a part and thus deadening by 
drying it. 
Systemic Use.-By systemic use is meant affecting a painful part, or a 
part to be operated upon, secondarily, through an impression made primarily 
on the system at large. Examples : Anaesthetizing a person by use of 
alcohol; impregnating the blood with the vapor of ether, chloroform, nitrous 
oxide, or agent of similar significance, through breathing. 
Intermediate Use.-By intermediate use is meant local application 
made with view to affect the system at large secondarily. Examples : 
Morphia used upon a blister, or injected beneath the skin; suppositories 
inserted in canals. 
DIFFERENCE AS TO ACTION. 
A purely local impression has the meaning of a concentrated 
and little-diffused effect made by a medicine on the sentient nerve-radicals of 
a part. Such applications are without danger for the double reason of the 
concentration and the speedy recovery; this, as any effect is to be considered 
in relation with the general system. Attention is not, however, to lose sight 
of possible ill local results, as, for instance, chilling a part by use of evaporants 
to an extent denying reaction. 
The local agents are divisible into those that contract and those 
that relax the capillaries of a part acted upon. The first finds illustration in 
cocaine, the second in eucalyptol. Anaesthetics acting after the first manner 
are without associate pain in the reaction, for the reason that they hold the 
vessels in a state of contraction which is of gradual disappearance. Those of 
the second class inflict the discomfort of reactionary engorgement. 
Anaesthetics systemically used place all vital action more or less in 
abeyance. The condition is that of interference with nature's manner of co- 
ordination and direction. It expresses comparative states of life and death in 
a common individual. It implies that if some certain part or parts is, or are, 
not up to a required resistive point, that such part or parts may succumb, 
resulting in the death of the individual. Different people are differently 
affected. Cases of nervous prostration arising out of fear and ending fatally 
are of common record. Pneumonia is not an infrequent result of ether 
exhibition in the case of young children. Absolute heart-failure and instan- 1250 
A SYSTEM OF ORAL SURGERY. 
taneous death is sufficiently common in chloroform narcosis to necessitate such 
possibility being kept constantly in mind. Stenosis of any of the openings of 
the heart stands as a threatener of severest consequences where a circulation 
is over-excited by use of ether. Unsuspected kidney lesions are deemed by 
many as a source of concern. Wherever and whatever a danger, its effects, 
in anaesthetic conditions of systemic import, are to be met, if at all, on the 
instant, time being allowed neither for consultation nor reflection. 
The intermediate anaesthetics,-namely, endermic and suppositorial 
applications,-while not without danger, as with the local agents proper, are 
yet safe as to use when compared with the wholly systemic means. Action 
being slow, time is afforded for antagonism. 
Camphor.-Camphor as an anodyne of local significance has the com- 
mendation lying with long and continuous employment. It is used in the 
form of spirit, gum camphor being dissolved in alcohol to the extent of a 
saturated solution.* To apply it consists simply in rubbing it into a painful 
part. It is in large demand in form of camphorated soap liniment in con- 
dition of strain, fracture, or similar injury. (For nature of, see Dispensatory.) 
Chloral Hydrate.-Chloral hydrate is used in form of a solution the 
strength of which is to be ten to twenty grains of the salt to an ounce of water. 
It is applied on charpie or cotton. (For nature of, see Dispensatory.) 
Camphor and Chloral Hydrate.-Chloral hydrate and camphor put 
together in equal parts combine to produce a liquid that seems to more than 
double the anodyne effect of either agent singly. Repeated applications of 
this mixture to an irritated and inflamed part produce not only an anaesthetic, 
but a resolving influence. 
Laudanum.-Laudanum, or tincture of opium, comes next in the order 
of analgesics of skin significance. This is one with the use of opium and 
morphia, and is to include them, each twenty-five drops of the tincture being 
equal to one grain of the opium, which, in its turn, equals a grain of the 
morphia by every seven grains. Laudanum, when mixed with lead-water and 
applied by cloth or poultice to an inflamed and painful part, is one of the most 
obtunding and curative means known to surgery; its employment is universal. 
A formula in general use is as follows: 
AGENTS ACTING UPON THE SKIN. 
U Tincturse opii, ^ij ; 
Plumbi acetatis, 3'j j 
Aquse, Oij. M. 
Where used with a poultice the mush is to be made thick with view of 
holding much of the fluid, which thins it. 
Phenol-Sodique.-This is a preparation the virtues of which, both as 
* A saturated solution is made by supplying the alcohol with all that it will dissolve. ANAESTHESIA AND ANESTHETICS. 
1251 
an analgesic and antiseptic has brought it into wide use. It is made by 
neutralizing phenic acid with soda. The writer has long made free use of this 
phenate of soda in his clinical service, and finds little call for anything better in 
the way of a dressing after operations. It is the only germicide he finds occasion 
to employ, and it is seldom that any other obtundent is required. Another 
virtue lies with its antiphlogistic character. Diluted one-half with water, and 
applied as a free dressing,-that is, in a manner that admits of free evapora- 
tion,-its effect on an inflamed part is similar to that exerted by lead-water and 
laudanum. It acts adversely in about one out of five hundred cases, pro- 
ducing blisters and increasing all bad symptoms that may be present. 
Camphorated Phenol.-This is a preparation made officinal in the 
new edition of the United States Dispensatory. The name explains the com- 
bination. Its quality and action are akin with campho-phenique, which see. 
Carbolic Acid.-Carbolic acid, diluted with water, or mixed with other 
agents, plays an important part as an analgesic. If used pure it burns a part 
with a cauterant effect. If, on the contrary, it be properly weakened, it warms, 
soothes, and obtunds. As a dressing to surgical wounds it is a corrective of 
putrefactive change, a germicide, and an alterative. Too freely used, even 
locally, it may poison, evidences of which are exhibited by sick stomach, giddy 
head, and a falling temperature. These conditions intervening, an application 
out of which they arise is to be removed immediately, and, if necessary, car- 
diac stimulants are to be administered; a little wine, whiskey, or ammonia is 
as good as anything else. Used as a local anaesthetic, one part of the pure 
carbolic acid is mixed with twenty-five parts of water. Petroline forms a 
good vehicle, five drops of the acid being mixed with half an ounce of the 
unguent. (See Dispensatory.) 
Campho-Phenique.-This preparation, which is a combination of 
camphor and carbolic acid, made, after one manner, by mixing the two agents 
to the extent of half and half, is a local anaesthetic of most reliable character. 
Used when pain results from strain or other direct injury, its anodyne effects 
are most gratifying. It may be rubbed freely into a painful part or applied 
by means of a cloth. In an open, aching, offensive tooth-canal it has no 
superior as an obtundent. 
Arnica.-Tincture of arnica is among the most familiar of the analgesics. 
It is used like the above. (See Dispensatory.) 
Aconite.-Aconite is a well-known obtunder. A practitioner, in using 
it, is to have in mind its formidable nature. Effect is on the circulation, 
the heart weakening under its influence, the extremities growing cold, the 
skin clammy. Antidote lies with stimulation. The preparation of 
aconite commonly used for a local effect is the tincture of the root. An 
unguent, convenient of use, is made by rubbing up two grains of aconitia, 
which is the active principle, with a drachm each of zinc ointment and lanolin. 
Where a strong and high pulse associates with a local disturbance requiring 
the use of an obtunder, aconite may be administered in conjunction inter- 1252 
A SYSTEM OF ORAL SURGERY. 
nally. The dose of the tincture of the root is from three to five drops, that 
of the tincture of the leaves from five to ten drops. (See Dispensatory.) 
Chloroform.-Few agents of local application are more effectual in 
relieving non-inflammatory pain than is chloroform. To apply it a fine hand- 
kerchief is folded into a square of the size desired, and this, being saturated 
with the agent, is laid upon the painful part and immediately covered by a 
folded towel. The burning impression resulting is severe, but it is commonly 
effectual in affording the relief desired. If a blister result, it may be dressed 
with any of the petroleum unguents. A few days commonly suffice for it to 
get well. (See chapter on General Anesthetics.} 
Oil of Eucalyptus.-This oil is indifferently soothing to a skin sur- 
face. Its principal use lies in affording protection against atmospheric influ- 
ence where a part is peculiarly irritable by reason of thinned or lost epiderm. 
Combined in equal parts with the benzoated oxide of zinc ointment, it affords 
a good dressing for a burn that is giving pain. It is antiseptic. (See Dis- 
pensatory.) 
Menthol.-This, while recommended as a local anodyne, is of little effect 
used externally, save in combination with other means; it is a camphorated 
peppermint; veratria combines happily with it. A good formula is as follows : 
U Mentholis, 
Veratria;, aa grs. xxx 
Lanolini, §ss. M. 
This ointment is to be used with moderate care on account of the dangerous 
nature of the veratria. A piece the size of a pea may be rubbed into a pain- 
ful external location. Menthol is used by many in form of stick or 
plaster. 
Rhigolene.-See chapter on Extraction of Teeth. 
Ether used locally.-See chapter on Extraction of Teeth. 
Nitrous Oxide.-Nitrous oxide, applied as a spray under high pressure 
as obtained from a cylinder containing the agent in liquefied form, is just now 
being offered to the profession as a likely means of affording desired immu- 
nity from pain during the accomplishment of minor surgical performances. 
Dr. Gr. L. Curtis, with whom this idea originated, uses an atomizing tube of 
great delicacy, and succeeds, in a little while, in obtaining any extent of 
refrigeration desired. It has been used by its advocate in the clinic of the 
writer, but its virtues have not been made, as yet, sufficiently evident to give it 
the mention of recommendation in a text-book. The recognized fact, as re- 
ferred to by Dr. Curtis in a paper at this moment in the hands of the author, 
that moisture is essential to sensation, and that a tissue deprived of its moist- 
ure is dead to sensation, points the way to the situation. No doubt will lie as 
to the production of dryness by this means. A number of successful cases 
related with the excavating of sensitive dental cavities is recorded in the paper, 
and associated with them is the experience that the parts operated on re- ANESTHESIA AND ANESTHETICS. 
1253 
covered sensibility after from three to ten minutes. A principal claim made 
for the means at this time is that it controls the sensibility referred to during 
the time of operating on it. Any dentist using nitrous oxide and owning a 
fine atomizing apparatus can try the experiment for himself by detaching the 
sprayer and relating it with the cylinder. 
AGENTS ACTING UPON THE MUCOUS MEMBRANE. 
Cocaine.-Pre-eminent in the direction here considered, by reason of 
being the most reliable of its class, is the salt cocaine. There is little doubt 
but that cocaine, when applied in solution of the proper strength, will induce 
a more reliable local anaesthesia than any other of the agents of its class yet 
discovered. To use it nothing more is necessary than to mix the salt with 
water and brush it over a part to be anaesthetized. The brushing commonly 
requires to be repeated three or four times. Ill effects, as found reported in 
various journals, have not been met with in a single instance by the writer, 
although he uses it in his clinical service with large freedom. It is an ad- 
mirable obtundent of an aching tooth-pulp, and in cases of periodontitis, if re- 
peatedly applied to the outside and inside gums, it will not only relieve of the 
severe pain, but do more than almost any other means toward resolving the 
inflammation. The writer inclines to think that any case of periodontitis can 
be aborted by use of cocaine, if taken in its incipiency, provided the offending 
cause has been removed. (See Injection of Cocainej 
Tendency of a Solution to undergo Decomposition.-Owing 
to the fact that solutions of cocaine very soon undergo decomposition, it is of 
importance that they be prepared extemporaneously. For this purpose cocaine 
muriate tablets especially commend themselves. These tablets are commonly 
of two sizes, containing one and one-eighth and two and one-fourth grains of 
cocaine hydrochlorate. For preparing a two-per-cent, solution, all that is ne- 
cessary to do is to dissolve one of the one-and-one-eighth-grain tablets in one 
fluidrachm of distilled water; for a four-per-cent, solution, a two-and-one- 
fourth-grain tablet is to be employed, or two of the smaller size may be sub- 
stituted therefor. Anhydrous cocaine hydrochlorate, free from hy- 
grine or other decomposition products, should alone be employed in the man- 
ufacture of the tablets, in order that a trustworthy preparation be assured.* 
This alkaloid having come into such general use in oral surgery, a knowledge of 
its chemical properties, and the nature of certain objectionable constituents with 
which the commercial article is occasionally contaminated, is worthy of con- 
sideration. 
Formula C7H21NO4. Of the various salts of cocaine, the hydrochlorate 
is the one most generally employed. This salt crystallizes from alcoholic solu- 
tion in short, firm prisms in anhydrous condition. Aqueous solutions yield 
* The writer uses with entire satisfaction a tablet prepared by Parke, Davis & Co. One 
is dissolved at time of use and any remainder of the fluid is thrown away. 1254 
A SYSTEM OF ORAL SURGERY. 
long satin-like needles, containing two molecules of water, or a little more than 
ten per cent, of their weight. The quantity of water of crystallization found in 
the commercial salt is, however, quite variable,-so much so that it is advisable 
to employ only the anhydrous salt, the potency of which, if it be chemically 
pure, can be depended on. It should dissolve in less than its own weight of 
water and yield a colorless solution, having a neutral or very faintly acid re- 
action. It should be freely soluble in alcohol, be of a pure white appearance, 
and without odor. Physiologically it may be recognized by its anaesthetic or 
numbing action on the mucous membrane of the mouth or tongue and by its 
mydriatic action on the eye. 
Dr. F. Giesel states that if one c.c. of cocaine hydrochlorate is dissolved in 
one or two drops of water, and about one c.c. of the three-per-cent, solution 
of potassium permanganate added, a violet precipitate is produced, at ordinary 
temperature, containing but a trace of manganese binoxide, and when boiled 
no odor of bitter almond is perceptible. 
An amorphous cocaine hydrochlorate, when heated with perman- 
ganate solution, gives off an odor of bitter almond oil. Giesel states that 
this odor is due to impurities of the leaves and not from decomposition 
products of cocaine. Other investigators, however, have shown that pure 
benzoyl-ecgonine, when treated in the same way, reduces permanganate, and 
on heating gives off the characteristic odor of bitter-almond oil. This is an 
important test, as it readily detects the presence of the amorphous salt, which 
is objectionable owing to its irritant action. 
A ten-per-cent, solution of the -amorphous hydrochlorate causes 
irritation of the conjunctiva and a dimming of the cornea, followed next day 
by the appearance of an ulcer. Hyperaemia of the palpebral conjunctiva is 
generally produced. A mixture of cocaine and of its decomposition products is 
capable of causing similar objectionable conditions, hence the importance of 
employing the pure crystals which fully respond to the foregoing tests of 
reliability. 
Oleate of Cocaine.-This form of a cocaine preparation is in much 
favor with many practitioners. Dr. Turnbull recommends its use in case of 
burns, and quotes a formula: R Cocaine oleat., gr. vijss to xvss; lanolinii, gv; 
olei olivae, gr. xxxi. (See Injection of Cocaine.) 
Bromide of Potassium.-This salt is a reasonable anaesthetic when 
used to mucous surfaces in the proportion of a drachm of the salt to an ounce 
of water. It is used in oral cases simply by holding it in the mouth. 
Carbolic Acid.-This when used for the mouth is to be freely diluted. 
It may be combined with the bromide mixture alluded to above, in proportion 
of one drop of the fluid acid to the ounce. The addition of a little glycerin 
softens the mixture. Repetition of use is to be very frequent in order to secure 
comforting effect. 
Menthol.-The use of menthol for the oral mucous surface is in some 
favor. The care necessary in using it pertains to making a watery solution ANaESTHESIA AND ANaESTHETICS. 
1255 
that shall be agreeable to the mouth. In conditions of passive inflammation, 
attended with pain, where the indication is in the direction of stimulation, 
menthol is happily combined with cocaine and used by means of a brush. 
Enough of it is to be added to the cocaine solution after being prepared to 
render the application stimulating. A single grain put into an ounce of 
water renders it almost unbearably hot. As a gargle or rinse one grain of 
menthol dissolved in half a goblet of water is sufficient. It may be used in 
conjunction with the bromide of potassium mixture. The salt masks pain by 
reason of the burning it produces, and not through any anaesthetic effect 
residing with it. 
Iodine.-The ordinary officinal tincture of iodine painted upon a mucous 
surface is found reasonably analgesic. 
Hamamelis.-A fluid extract of hamamelis virginica is found, when 
diluted with four to six parts of water, to prove a most soothing gargle and 
rinse. It is applied full strength to an aching part. 
Chloral Hydrate.-This salt is markedly anodyne to a mucous surface 
when brushed over it in a solution of ten grains to the ounce of water. 
Creasote.-This oil combined with lanolin, in proportion of one part of 
the first to six of the latter, if rubbed over a painful gum is commonly found 
to afford a degree of relief. 
INTERMEDIATE USE OF OBTUNDING AGENTS. 
By the intermediate use of anaesthetic-producing agents is meant their 
employment endermically, hypodermatically, and by suppository. 
Endermically.-By endermically is meant the use of a medicine applied 
upon a blistered surface. By hypodermatically is understood an injection 
made, by means of a syringe, beneath the skin. By a suppository is implied 
medicine put up in a stiff cerate after a form that admits of its convenient 
introduction into the rectum. 
Morphia endermically.-To apply morphia a blister is first made, 
and upon removal of the epiderm from a quarter to half a grain of the sulphate 
is sprinkled over the sore. 
The accompanying combination, the formula for which is by Dr. A. N. 
Denton, is an excellent endermic application to be used in cases of facial 
neuralgia: 
Olei camphorae, f^ij ; 
Pulveris opii, 3* > 
Potassii nitratis, gr. xv. M. 
Sig.-To be well mixed in a mortar. 
Morphia hypodermatically.-The dose is from an eighth to a quar- 
ter of a grain, ordinarily. Morphia comes prepared for this manner of use in 
tablets. A tablet is broken up and put into a teaspoon containing ten drops of 
water that has been boiled. If the fragments be not quickly dissolved, the 1256 
A SYSTEM OF ORAL SURGERY. 
water is to be rewarmed by holding the teaspoon for a moment over a flame. 
The syringe being charged, and absence of air insured by pushing the piston 
sufficiently forward to force out a drop of the fluid, the needle is thrust obliquely 
beneath the skin, care being taken to avoid a vein, 
and the contents are slowly and carefully ejected. 
A convenient manner of introducing the needle 
is found in pinching up the skin between a thumb 
and finger. Morphia administered after this man- 
ner acts one-half more quickly and powerfully than 
when given by mouth. 
Atropia Antidotal to Morphia Sick 
Stomach.-To guard against the sickness of 
stomach which is the so constant associate of 
morphia, it is usual to add the of a grain of 
sulphate of atropia. This medicine comes mixed, 
almost universally, with the tablets. Morphia and 
atropia are antidotal to each other, and are so used 
in cases of poisoning by either. 
Cocaine hypodermatically.-In oral sur- 
gery, cocaine, in doses of from the one-eighth to a 
whole grain dissolved in ten drops of water, is used 
by being thrown into the substance of the gums or 
adjacent soft parts. For tooth-extraction it is in- 
jected into the periodonteum. Professor Poinsot, 
of Paris, uses as an injecting vehicle liquid vaseline and arachis oil, claiming 
thus the ability to more distinctly localize the action of the cocaine; his formula 
is ten grains each of the two oils and one grain of pure cocaine. The cocaine is 
dissolved by placing it in a warm bath before adding it to the oils. Dr. Poinsot 
makes his injections slowly, and in the case of multiple-rooted teeth 
makes a number of them. The bleached appearance of the gum resulting from 
the injection is his rule for knowing when enough of the salt has been used. 
He waits for six or eight minutes after the injection for complete anaesthesia, 
determining the condition by pricking the part with a knife. 
Corning's Method.-To secure a distinctly local effect, Dr. Corning 
applies a moderately tight rubber bandage with view of locating the veins. 
He next renders the limb bloodless by means of an Esmarch bandage, and in- 
jects in spots, embracive of a proposed area, a one-per-cent, solution.* This 
procedure is warmly commended by a number of surgeons. To hold the local 
effect, and to prevent access to the general circulation, a tourniquet is used when 
practicable. The injections are distributed over a seat of selection by means 
of massage. When an operation is done, the tourniquet, or other constrict- 
ing means that may have been used, is gradually loosened so as to allow of 
Fig. 926.-Hypodermic 
Syringe. 
* Five grains of the salt to the ounce of water. ANESTHESIA AND ANESTHETICS. 
1257 
mingling of the cocaine with the general circulation only after the most gradual 
manner. 
Accidents related with the Hypodermic Use of Cocaine.- 
These are of association with the nervous system as general accidents are 
concerned, and with necrosis and similar molecular disintegration as to local 
accidents. The latter are deemed avoidable by Dr. Hugenschmidt, where 
proper antiseptic precautions are taken. His recommendation, which is to be 
endorsed, is free washing of a part with a solution of bichloride of mer- 
cury a few minutes before performance of an operation, and the boiling, for at 
least five minutes, of the water in which the cocaine is to be dissolved. Iodo- 
form and iodol are recommended as antiseptics to be used in the case of scrofu- 
lous patients. 
General accidents, while all of direct influence exerted by the salt on the 
nervous system, are yet phenomenonally, or secondarily, expressed by the heart 
and lungs, otherwise by hysteria or in diminution of animal heat. Dr. Hugen- 
schmidt has a paragraph in a paper written by him on the subject which 
covers the ground with thoroughness. It is as follows: 
. Cardiac and pulmonary symptoms present themselves at the same time. 
They are an acceleration and irregularity of the cardiac rhythm, palpitations, 
and irregularity and interference in the respiratory movements; respiration 
becomes difficult, catching, and even stops momentarily. 
Cardiac symptoms are due to an influence of the drug on the pneu- 
mogastric nerve, which is the cardiac inhibitor. 
Respiratory symptoms are due to an action on the pneumomedullar 
centre, and also to an interference with the sensibility of the pulmonary sur- 
face, preventing the pulmonary reflex. We observe, when the patient is in a 
state of semi-lethargy, that he stops breathing for a few seconds, but im- 
mediately takes a long breath if he is told to do so; hence volition or will is 
not interfered with: only the pulmonary surface sensibility is partially ob- 
tunded. 
The calorific symptom consists in a lowering of the peripheral tem- 
perature, and is due to a stimulating action on the vaso-constrictor filaments 
of the great sympathetic nerve, which, by producing a contraction of the 
arterioles, diminishes the quantity of blood supplied to the cutaneous surface. 
The brain symptoms which present are: a strange feeling in the head, 
a sensation of emptiness; the patient complains of vertigo, blurring of vision, 
everything dances before his eyes; he looks frightened, his face is pale, per- 
spiration appears on the forehead, he feels that he is going to faint, and then 
passes into that semi-lethargic state observed in opium-poisoning: this indi- 
cates an action of the drug on the cerebrum ; the production of cerebral 
anaemia. This is sustained by the fact that plethoric persons are least 
apt to present nervous symptoms after the administration of the drug. Again, 
if we produce a physiological cerebral congestion before injecting the drug, 
the toxic symptoms will not appear. Moreover, if to a person who presents 1258 
A SYSTEM OF ORAL SURGERY. 
all the symptoms of cerebral congestion we inject cocaine, these symptoms 
will disappear. 
Preliminary Precautions.-It is to be inferred that as the plethoric 
are least affected adversely by the use of cocaine, action of the drug on the 
anaemic would prove conversely. To avoid accident with the latter class it 
is not amiss to use some agreeable stimulant a quarter or half an hour before 
making an injection. Wine or whiskey is commonly employed. It is never 
well to hasten an injection. The entire confidence of a patient is to be won. 
Absence of nervousness is at least one-half of the safety of a case. 
Treatment of Accidents.-This is to accord with the indications. 
In all cases the patient is to be placed in the supine condition. No treatment 
is of more satisfactory result than that of soothing and assuring. If the heart 
be much disturbed, as witnessed in a hasty and irregular beat, the administra- 
tion of ten drops of tincture of belladonna in a tablespoonful of brandy will 
likely quickly overcome the irritability and restore the equilibrium. This same 
treatment applies to the cold extremities. Where the expression is hysterical 
a teaspoonful each of tinctures of valerian and gentian administered in about 
an ounce of wine is commonly found to give a desired result. Assafoetida in 
pill form or tincture is a reliable medicine to prescribe. A one-grain pill may 
be repeated in half an hour if required. Profound collapse is best treated by 
the injection, hypodermically, of whiskey, or of spirits of ammonia much 
diluted. 
Valerianate of Ammonia.-A practitioner in the habit of using 
cocaine freely will find advantage and sense of security in having a small 
quantity of this salt at ready command. The dose is from two to eight grains 
dissolved in water. It is markedly antidotal of nervous irregularities attended 
with depression. 
SUPPOSITORIES. 
The use of suppositories is often enough necessitated in oral surgical prac- 
tice. Their application is by rectum in the male, and by rectum or vagina in the 
female. Where not designed to act directly on the bowel the use of them is 
to quiet restlessness and induce sleep. Medicines used after this form are 
morphia, first and prominently; in conjunction with this, or alone, hyoscyamus, 
opium, belladonna, and assafoetida. 
Formulae.- 
1. U Morphias sulphatis, gr. ijss; 
Extracti belladonnas, gr. ijss; 
Extract! hyoscyami, gr. xxx ; 
Butyri theobromse, q. s. M. 
Sig.-Make into ten suppositories. One to be used on going to bed. 
The above is a favorite formula long used with entire satisfaction by the 
writer in his practice. The morphia may be doubled in quantity if found 
necessary. ANAESTHESIA AND ANAESTHETICS. 
1259 
2. Extracti hyoscyami, 
Extracti belladonnas, gr. v; 
Butyri theobromae, q. s. M. 
Sis.-Make into twenty suppositories. Relieves pain without constipating. 
3. Pulveris opii, gr. xv; 
Butyri theobromae, q. s. M. 
Sig.-Make twelve suppositories. To be used to insure rest and sleep where pain and 
restlessness are present. 
4. U Assafoetidas, gr. xvi; 
Extracti belladonnas, gr. ij; 
Extract! hyoscyami, gr. xx. M. 
Sig.-Make into ten suppositories. CHAPTER LXXV. 
ANESTHESIA AND ANESTHETICS- Continued. 
Obtunding agents used ordinarily in the sense implied by the heading of 
the chapter are alcohol, sulphuric ether, chloroform, nitrous oxide, and bro- 
mide of ethyl. 
Alcohol.-See Ether. 
Ether, History of.-Ether, or oxide of ethyl, is the discovery, made 
in 1540, of a German physician named Valerius Cordus. The name given it 
by this person was oleum vitreoli dulce. The name ether was first used by 
Frobensius in 1730. 
Manner of Preparation.-When equal weights of rectified spirits 
and oil of vitriol are mixed in a retort, the latter being connected with a 
good condensing arrangement, and the liquid heated to ebullition, a colorless 
and highly-volatile fluid, long known under the name of ether, or sulphuric 
ether, distils over. The process must be stopped as soon as the contents of 
the retort blacken and froth, otherwise the product will be contaminated with 
other substances which then make their appearance. The ether obtained 
may be mixed with a little caustic potash, and redistilled by a very gentle 
heat. 
Physical Characteristics.-Pure ether is a colorless, transparent, 
fragrant liquid, very thin and mobile. Its specific gravity at 60° is about 
720 ; it boils at 96° under the pressure of the atmosphere, and bears, without 
freezing, the severest cold. When dropped on the hand, it occasions a sharp 
sensation, from its rapid volatilization. Ether is very combustible; it burns 
with a white flame, generating water and carbonic acid. Although the sub- 
stance is among the lightest of fluids, its vapor is very heavy, having a den- 
sity of 2.586. A light is never to be placed below ether. Mixed with oxygen 
gas and fired by the electric spark, or otherwise, ether explodes with the utmost 
violence. Preserved in an imperfectly-stopped vessel, it absorbs oxygen and 
becomes sour, from the production of acetic acid. This attraction for oxygen 
is increased by elevation of temperature.-Fownes. 
Jackson's Formula.-Dr. Jackson's formula for the preparation of 
ether for anaesthetic purposes is, we believe, as follows: Procuring the 
strongest and purest rectified sulphuric ether,-that just described,-wash it 
well, to get clear of any acids; then decant from the water, drying it with 
chloride of calcium, to free it of any water that might otherwise remain from 
the washing. 
1260 ANESTHESIA AND ANESTHETICS. 
1261 
This, however, is but a single formula for the anaesthetic ether. Different 
chemists arrive at the same end through different processes. The surgeon 
should buy of a reliable druggist rather than attempt the preparation for 
himself. 
To exhibit ether successfully, four essentials seem necessary: 
1st. That the ether be very pure. 
2d. That the vehicle upon which, or with which, the agent is exhibited, 
be of such character that full volume of atmospheric air is allowed to pass 
with the ether into the lungs. 
3d. That the vapor of the ether be properly diluted, given for the first few 
inspirations comparatively weak, and increased in strength as the glottis, air- 
passages, and lungs are found able to receive it. 
4th. That insensibility be produced as quickly as the system will bear, as 
evinced by obvious signs. 
Instruments employed in Administering.-A cone-shaped, 
close sponge is a good means for administering ether. This possesses 
every advantage, except that of economy in the exhibition.* Another means 
CONDITIONS NECESSARY TO SUCCESSFUL USE 
Fig. 927. 
of simple expression is found in the familiar straw cuff. This allows of a 
free circulation of air. A sponge is put into its lesser end to hold the anaes- 
thetic. A towel done up in the form of a cone is the common 
means employed, out of reason of its convenience and effectiveness, at most 
hospital clinics. Among various contrivances used more or less widely are 
apparatus known as the Ormsby, the Hawksley, the Hearn, the Barr, the 
Johnston, and the Allis inhalers. The writer is familiar with a great many, 
but sees no advantages possessed over a common cone of towelling. The 
* Fig. 927 represents an instrument devised by the writer thirty years back; he has 
been able to find nothing better. As seen, it is simply a common cone, open at both ends. 
A is the mouth-piece enveloped by a napkin, E; B is a valve for escape of respired air; C 
implies a sponge placed within the cone with a view of holding ether; D is to furnish air 
(which necessarily must pass through C) for inspiration. A tinner will make the apparatus 
in a few minutes. 1262 
A SYSTEM OF ORAL SURGERY. 
Allis instrument, Fig. 929, consists of a frame filled with ribs of cotton 
stuff, upon which the ether is poured with view to rapid evaporation. A 
mouth-piece covering in the frame concentrates the agent for breathing pur- 
poses. 
Time required to induce Ether Anaesthesia.-From two to 
five minutes is found the average period necessary to produce the full effect 
Fig. 928.-Towel done up 
as a Cone. 
Fig. 929.-Allis's Inhaler. 
of perfect sleep ; though cases present themselves where double and quadruple 
this time is required, and where, indeed, it may be necessary to combine with 
the ether the more powerful agent, chloroform, or even, indeed, to employ 
pure chloroform. 
Necessity for Vigorous Employment.-Ether acts well in pro- 
portion to vigorousness of employment. Rapidity of breathing, not the quan- 
tity of the agent respired, is the secret of easy and quick narcotism. It is 
quite possible to get out of one part of an anaesthetic an effect to secure which 
ten are commonly used; not only this, but every relation is of healthier and 
more agreeable character. 
Effects of Over-Dilution with Air.-Over-dilution, and a conse- 
quent protracted inhalation, is the cause of excitement which supervenes in 
the experience of many practitioners, while it so rarely shows itself in that of 
others. In these cases a patient is made drunk; drunk in the first degree, 
but not, as remarked by Mr. Snow, dead drunk, the condition required for 
surgical purposes.* 
Supervening Excitement.-It is to be noticed in passing, that one of 
the objections of the opponents of ether lies at this door,-this supervening 
state of excitement instead of that of stupor. The fault is not with the 
agent, but with the operator. 
* The reliable experience and judgment of Mr. Snow are here offered in conjunction with 
those of the writer. ANESTHESIA AND ANESTHETICS. 
1263 
Action of Ether and Spirits the same.-The idea is to be conveyed 
that the effects of sulphuric ether and of the common alcoholic bever- 
ages are the same. The results of the latter are too well known to require 
description. There is, first, the state of exhilaration, which gradually changes 
to complete stupefaction or narcotism; the second condition the result 
probably of narcotism of the brain. Just so acts ether, yet passing through 
its various stages more quickly, the effects of its being poured in a continuous 
and undiluted stream upon the heart and brain. Ether is no sooner absorbed 
than the blood charged with it passes to the left side of the heart, and imme- 
diately thereafter is circulated through the coronary vessels, the carotid and 
vertebral arteries, and thus pervades the tissue of all parts of the heart, as 
well as of every portion of the brain. A writer, in an influential dissertation, 
presents an example in thiswise: Suppose, to take an extreme illustration, 
that the blood was as capable of absorbing as much ether as water can com- 
bine with, or one-tenth its own weight. If, then, we suppose the blood in the 
lungs was impregnated to this extent, it would be applied in that state to the 
heart and brain ; whereas, if the blood in the stomachic vessels was impreg- 
nated to the same extent with ether, it would, before reaching the liver, have 
mingled with more than its own mass of pure blood from the splenic and 
mesenteric veins. The tenth would then become a twentieth, and, on the 
blood leaving the liver and joining the larger current of the inferior cava, the 
twentieth would become a fiftieth or sixtieth; a further dilution would take 
place at the confluence with the superior cava, so that the current, on reaching 
the heart and brain, instead of containing one-tenth part of absorbed ether, 
could not contain as much as one-hundredth. When, therefore, the same 
quantity of ether, or any absorbable substance, is taken up from the lungs and 
from the stomach, it must, in the former case, be applied to the tissue of the 
heart and brain in a state of concentration at least ten times greater than 
the latter, and will therefore act on these organs with more suddenness and 
energy. 
Difference in Time of Effect of Alcohol and Ether.-The 
evanescence of the influence of ether, as compared with that of alcohol, is 
explained by a momentary consideration of the different manner of absorption. 
During the inhalation of ether, as is understood, the charged blood is 
specially applied to the heart and brain, while that circulating in 
the lower parts of the body contains a much smaller proportion of it. Now, 
on stopping the inhalation, the blood in the heart and brain speedily passes 
off by the veins, and is succeeded by that which is comparatively pure coming 
from the lower regions of the body, and so the narcotic symptoms disappear. 
It is far otherwise when alcohol is absorbed from the stomach, for the whole 
mass of blood must be impregnated with it before a highly-charged fluid can 
be applied to the heart and brain ; and then the effect continues for many 
hours, till the alcohol has been thrown out of the system by the lungs and 
skin. With respect to ether, it must not be supposed that on the subsidence 1264 
A SYSTEM OF ORAL SURGERY. 
of the narcotism it disappears from the body; for it is merely weakened in 
its effects by being diffused over the whole mass of blood. This is obvious, 
from the smell of the breath for many hours, and from its frequently causing 
copious perspiration. 
Influence of Familiarity.-Does not the question here suggest itself, 
If the effects of ether and of the common alcoholic beverages be so nearly 
alike, why any dread of the one and entire fearlessness with the other? 
Would not the answer seem to be something of this kind? Men when 
etherized are as dead drunk ; our eyes are accustomed to seeing them only 
partly drunk. In this state they excite amusement; in the state of profound 
drunkenness they have always aroused our fears for their recovery. Associa- 
tions have great weight. 
The immediate and obvious effect of ether on one to whom it is 
administered in anaesthetic dose is almost too familiar to justify the use of a 
paragraph for its description. First, there is commonly exhilaration, this 
shading gradually into stupor. Second, and finally, there is narcotism, which 
differs much as to the time that it lasts; one person recovering almost 
instantly on the cessation of the exhibition of the agent, another continuing 
drowsy, or, it may be, remaining in the deadness of profound sleep for several 
hours. Loss of smell introduces the first stage. 
The progressive effects of the agent as relation is had with the 
various nerve-centres are markedly shown in the course of an etherization. 
A first effect is on the intellectual faculties, these being, 1, stimulated; 2, 
degraded; 3, negated. Second, the influence shows itself in relation with 
the spinal cord; on the anterior column first, motion being affected, soon 
temporarily destroyed, successively on the posterior segment; sensation, little 
by little, being obliterated. The point of danger is intermediate to brain 
and cord,-namely, the medulla oblongata, the respiratory centre. So long as 
an ether patient breathes undisturbedly there is no necessity for apprehension. 
Disturbance of respiration is a signal for caution. 
General Harmlessness of Ether.-Throwing out of immediate 
consideration the idiosyncrasies, let us for a moment consider the question of 
the general harmless exhibition of the agent. 
The safest means may be made a source of ill. As the intruder on the 
physical laws of his organism must suffer the consequences of ignorance or of 
temerity, so may any agent, however good, become an evil by its abuse. As 
the drinking of alcoholic beverages can be carried to a point beyond which 
the life-principle will not react, just so, and as the warmest supporters of the 
anaesthetics would have impressed, may ether be made an instrument of 
irreparable injury, blasting and destroying where it was designed to refresh 
and save. 
Absolute Rules for the Exhibition of Ether not possible.- 
To lay down certain reliable rules, applicable in all cases, for the process of 
etherization, is an impossibility. The presentment of conditions in various ANESTHESIA AND ANESTHETICS. 
1265 
individuals differs so materially, that it would be charlatanism to act on any 
but rules resulting in a general knowledge of the agent and a comprehension 
of physiological laws and pathological alternations. One person, as Mr. Snow 
has remarked, shall become impassible as the subject on the dissecting-table; 
another talks incoherently or mirthfully, replies to questions, or obeys direc- 
tions ; others utter exclamations of pain, which they afterward retain no 
reminiscence of having felt; others again declare that they have suffered pain, 
but felt themselves powerless for its expression. Finally, in the exceptional 
few, ungovernable violent or convulsive action takes place, quite adverse to 
the performance of any delicate surgical operation. With some an utter 
oblivion is induced; while others, though undergoing all the apparent torture 
of a prolonged dissection, are revelling in the realms of memory and in the 
fields of imagination. M. Jobart and other observers have attempted to lay 
down three distinct stages in the effects of the agent, according to the 
prolongation of the etherization. 1. That of incoherence, agitation, or 
delirium, as the case may be. 2. Acceleration of the pulse, with loss 
of sensibility and loss of power. 3. Exhaustion and coldness of the 
surface. The matter, wisely argues Mr. Snow, cannot thus be methodically 
stated, for it is quite certain that any of these conditions may be induced, in 
different individuals, by very various doses of ether; while others, again, are 
susceptible of only the first degree, to appearances, and yet enjoy an immunity 
from suffering during operations. Even the quickened condition of the pulse 
and respiration, and that almost universally employed criterion, the insensibility 
of the pupil, may deceive in the supposed impression produced. 
Flourens's Experiments.-A number of the French Academicians 
instituted some years back a series of experiments on animals, for the purpose 
of determining the mode and order in which the various portions of the cere- 
bro-spinal system were influenced during inhalation. The following are some 
of the conclusions arrived at as stated by the veteran vivisector, Baron 
Flourens: The action of ether on the nervous centres follows 
in a given course. It acts, first, on the cerebral lobes, disturbing the in- 
tellect. It acts, secondly, on the cerebellum, deranging the equilibrium of the 
movements of the animal. Thirdly, it acts on the medulla spinalis, in which 
it extinguishes, successively, the motor and sensory principles; and, lastly, it 
acts on the medulla oblongata, where arrived, life becomes extinct. 
Agent and Administration.-To produce the best effects of sulphuric 
ether, it is of the first consequence that an entirely reliable article be employed. 
Not only this, but that the agent be employed heroically, yet persuasively. In 
the Hospital of Oral Surgery, where ether is used almost exclusively, and 
under circumstances the most trying to such agents, it will be testified that 
trouble of any kind has yet to be experienced. A patient is assured, 
not forced. The ether is administered in full doses, not in driblets. In- 
struction is given to make full inspirations; persons are not allowed simply to 
sniff and smell. The effect of a bad article of ether is not only to 1266 
A SYSTEM OF ORAL SURGERY. 
deny anaesthesia, but to provoke sick stomach, headache, and derangement 
generally. 
Quantity required.-Concerning the quantity required, this is a matter 
special to each patient. Persons are met with-trusting and confiding people 
of lax fibre-upon whom a single inhalation will produce the anaesthetic im- 
pression. A different class-the vigorous and lusty, of untrusting nature- 
will consume it as some men do spirituous liquors. The writer has given a 
whole pound before getting the primary impression. 
Criterion of Condition.-The criterion in ether exhibition relates, as 
the state of narcotism is concerned, to the effect of touch upon the eyelashes 
or eye; these insensible, an operation may be proceeded with. The point 
of danger, as has been suggested, relates with respiration. Easy breath- 
ing is assurance of safety. 
Respiration.-Respiration is not, however, to be misjudged. In some 
persons a peculiar repugnance to the agent exists. Others find much mo- 
mentary irritability of the air-passages induced. Cure of both is found in 
dropping a few minims of chloroform upon the sponge. 
Sick Stomach.-Sick stomach, another not infrequent associate, finds 
treatment, alike with cough, in a drop of chloroform, the agent being mingled 
with a spoonful of water, and drunk. Another specific is coffee. Dr. Stiles, 
of Conshohocken, a practitioner of experience, assumes failure of this latter 
remedy to be uncommon; he prescribes it in small, but strong, doses. Car- 
bonic acid is a grateful means of relief. A spice-plaster placed over the 
stomach will seldom disappoint. Creasote is another cure; the dose and man- 
ner of administering is the same as that of chloroform. 
Prevention being better than cure, it is alone necessary to insure 
against sick stomach that food be abstained from for two or three hours pre- 
ceding the exhibition. When such sickness supervenes, the emesis is preceded 
for a few moments by a growing paleness of the surface, and, not unlikely, by 
the breaking out of a clammy sweat. The inspissated mucus that clogs 
the throat in these cases is to be cleaned out by means of a mop, or by a finger 
wrapped in a fold of old and soft linen. 
Continuance of the Anaesthetic State.-As to the question of the 
continuance of a patient in the anaesthetic condition, it is the practice of the 
author, and that of the Oral Hospital, to make the time just as short as pos- 
sible ; that is to say, as the continuance of the agent is concerned. If an 
operation to be performed may be completed in five, fen, or fifteen minutes, it 
is not good policy to prolong it, and with it the continued administration of 
the ether, to a half or a full hour. That there is, however, any imperative or 
absolute necessity to hurry through an ether case is not at all implied. The 
author has kept a patient profoundly under ether for two and 
a half hours ; and in obstetrical practice half or a whole day of intermit- 
ting anmsthesia is not at ail infrequent. It is contended only that it is neither 
desirable nor prudent to unnecessarily prolong the condition. Where, how- ANESTHESIA AND ANESTHETICS. 
1267 
ever, such lengthened action is demanded, it is to be secured, not by keep- 
ing the saturated sponge constantly applied over the air-passages, but by using 
the agent at such intervening periods as may be necessary to preserve its 
effect. 
Temperature in Relation with Exhibition of Ether.-The con- 
dition of the temperature, as might be inferred, has much to do with pro- 
longing or shortening the time commonly considered necessary to place a patient 
in a state of sleep. Mr. Snow obtained, from experiments, the following 
results: 
One hundred cubic inches of air, saturated with the vapor of ether, at a 
temperature of 
44° contains 27.0 cubic inches of vapor. 
54° " 34.3 " " 
64° " 43.3 " " 
74° " 53.6 " "■ 
84° " 66.6 " " 
Being doubled by a rise of only thirty degrees; or, in other words, if at a 
temperature of 84° Fahrenheit we employ two or two and a half minutes in 
affecting a person to the state desired, at a temperature thirty degrees lower 
we would require from four and a half to six minutes to obtain the same 
result. 
Concerning the Idiosyncrasies.-Concerning the idiosyncrasies, the 
author offers his own experience by saying that he has never yet met 
with a person who might not take ether, or ether in combination with chloro- 
form. The London Medical Gazette considers its use inadmissible where 
there is a tendency to apoplexy or epilepsy, and also in plethoric 
individuals. Another intelligent source says that persons presenting the 
slightest signs of being cataleptic should be viewed as idiocratical. Per- 
sons under the influence of liquor, it is generally thought, are to be 
esteemed for the time as not fit subjects. In conversation with the elder 
Dr. Flagg, had several years back, that experienced man implied that he 
believed in no idiosyncrasies, except it might be a very high, nervous tem- 
perament; that he had administered ether to the infant of thirty-six hours 
and to persons in extreme old age, had given it to the robust and the weak, 
the plethoric and the consumptive; had used it in all stages of pregnancy, 
except that known as quickening; might also exhibit it here, but would feel 
called on to exercise more than ordinary care. Seeming idiosyncrasies could 
generally, he thought, be explained by an examination of the operator's igno- 
rance of the agent. The faith of that gentleman in the safety of the use of 
ether was so great that he remarked he would not hesitate to use it where 
there had been, or was, aneurism of the aorta. The opinion of Dr. Flagg 
concerning the non-existence of idiosyncrasies is to be taken before that of 
most persons, either of this country or Europe. His opportunities for obser- 
vation were not surpassed, up to his time, by those of any other physician, 1268 
A SYSTEM OF ORAL SURGERY. 
and perhaps equalled by few. A work published by him in 1854, long before 
his retirement from practice, has not, up to the present day, been advanced 
on, and is an heirloom to be valued by those to whom his industry has left it. 
The experiences of the author coincide with those of the gentle- 
man quoted. He has administered ether under every possible variety of cir- 
cumstances as to age, condition, time, and apparent idiosyncrasies, and has 
never met with any cause for anxiety. In the labor of childbirth ether 
is absolutely temporary euthanasia. The author, speaking out of an experi- 
ence arising from a connection of several years, in the earlier portion of his 
life, with a large obstetrical clinic, bears witness to the entire absence of any 
objection to the free employment of the agent in this direction. The indica- 
tion is to have the ether at the mouth in full strength at the commence- 
ment of a pain. Two or three inhalations suffice for each contraction. 
Etherization by Rectum.-Etherization by the rectal method is a 
mode of anaesthesia lately introduced, which, if found to be safe and reliable, 
will prove of great advantage in oral operations. To use ether in this manner, 
an india-rubber tube the size of a finger is introduced into the bowel and 
attached to a bottle containing the agent, which vessel is plunged into water 
heated to about 120° Fahrenheit; soon the ether boils, the vapor passing into 
the intestine. The stages of anaesthesia are the same as when the exhibition 
is after the ordinary manner. 
CHLOROFORM. 
From the consideration of sulphuric ether we pass to an investigation of 
the character and merits of the terchloride of formyl, or chloroform. This 
agent is, without doubt, the most powerful and reliable of the anaesthetics; 
but, unfortunately, it possesses qualities which render it not infrequently fatal 
to life, and therefore make it of less value than the one just considered. No 
person is to employ chloroform who is not prepared to meet 
formidable emergencies. 
History.-Chloroform is the terchloride of formyl (CHC13). Its dis- 
covery was simultaneous by Guthrie, Liebig, and Soubeiran, in the year 1831. 
It was first used by Professor Simpson, of Edinburgh, as an anaesthetic in the 
year 1847. 
Preparation of Chloroform.-To procure chloroform, the chemist 
takes of chlorinated lime, say (to take a common formula), lb. iv; rectified 
spirits, Oss; water, Ox; chloride of calcium, broken in pieces, 5j. Put the 
lime, first mixed with water, into a retort, and add the spirits, so that the 
mixture may fill only the third part of the vessel. Then heat them in a sand- 
bath, and as soon as ebullition begins withdraw the heat as quickly as possible, 
lest the glass be broken by the sudden increase. Let the liquor distil into the 
receiver so long as there is nothing that subsides; the heat being reapplied 
if necessary. To the distilled liquid add a quarter of the water, and shake 
them all well together. Carefully separate the heavier portion, which falls, ANESTHESIA AND ANESTHETICS. 
1269 
and add the chloride to it; frequently shake them for an hour. Lastly, let 
the liquid distil again from a glass retort into a glass receiver. 
Appearance of Chloroform.-In appearance chloroform resembles 
the freshest water of the mountain-spring. To the taste it is hot and very 
sweet; to the nostril it has much the odor of the common strawberry. When 
dropped upon linen it evaporates very quickly, leaving, if pure, no stain or 
sign behind. In weight it is quite one-half heavier than water, and, as its 
vapor is concerned, it is four times as dense as atmospheric air. 
Some Tests of Purity.-The smell of chloroform is esteemed by Mr. 
Snow one of the best tests of purity and identity. If a disagreeable scent 
remain on the hand after the evaporation, the chloroform has probably been 
made from impure spirits, or even from wood or acetone, and is therefore unfit 
for medicinal purposes. When dropped on the skin it should quickly 
evaporate, leaving not the least odor or moisture behind. When chloroform 
becomes decomposed from any cause, it acquires a greenish-yellow color, and 
gives off chlorine and hydrochloric acid, so that the alteration is at once appar- 
ent. When it is pure, it has no reaction on test-paper, but is quite 
neutral. The best wTay, according to the writer quoted, to detect a small quan- 
tity of hydrochloric acid in it, is to moisten a slip of blue litmus paper 
with distilled water, and hold it just within the neck of the bottle, exposed to 
the vapor. If sulphuric acid be present, it may be discovered by agitating 
the chloroform with distilled water and adding nitrate of baryta. 
Degraded by Admixture with Alcohol.-Chloroform is degraded 
by admixture with alcohol, and this can be done without making any perceptible 
change in its appearance : its specific gravity, however, is thereby lowered. Ac- 
cording to M. Mialhe, the foreign presence is most easily detected by add- 
ing to the suspected fluid a small quantity of water, when a milky opacity results. 
Action on Heart.-Chloroform, as the heart's action is concerned, is a 
powerful sedative. In nearly if not quite all the fatal cases resulting from its 
administration, cardiac syncope has been the cause of death ; and in a very 
small minority of the cases indeed has there been any evident interference 
with the process of respiration. This latter fact is always to be held in strict- 
est remembrance when exhibiting the agent. In oral surgery, where it is 
desirable to secure the profoundest and most prolonged primary impression, 
chloroform, if it were without danger, would be the anaesthetic most indicated 
and required. Indeed, in the writer's practice he finds many cases where he 
does not seem able to get along without it, using the agent in association 
with either brandy or ether. Because its use is so frequently neces- 
sary, the oral surgeon is to make himself as familiar as possible with all that 
concerns its defects as well as its virtues. 
Quantity required to be used.-Experiments have demonstrated 
that eighteen minims of chloroform is the average quantity necessary to put 
an adult in a condition of insensibility,-that is to say, this amount is to be 
absorbed and carried to the nerve-centres. 1270 
A SYSTEM OF ORAL SURGERY. 
Danger of Limited Admixture with Air.-It has also been 
shown that chloroform vapor has the effect of suddenly arresting the action 
of the heart, when it is mixed with the respired air to the extent of eight or 
ten per cent, or upward. With these two lessons appreciated, it is seen that 
the matter and manner of the exhibition of the agent have much to do with 
the result: not everything, however, as it is undeniable that fatal accidents 
occur in the best and most skilful hands. 
Absorption and Respiration.-Eighteen minims, according to Mr. 
Snow, are to be absorbed from thirty-six breathed; allowing thus that one- 
half is lost in expiration. But atmospheric conditions, as in the case of ether, 
has much to do with the taking up of quantity. The following table com- 
prises experiments in this direction. At a temperature of 40° Fahrenheit, one 
hundred cubic inches of air will take up but seven cubic inches of the vapor. 
At 45° 8 cubic inches, 
50° 9 " 
55° 11 " 
60° 14 " 
65° 19 " 
At 70° 24 cubic inches. 
75° 29 " 
80° 36 " 
85° 44 " 
90° 55 " 
This table exhibits the fact that anaesthesia by the use of chloroform must 
come on at varying periods, and that therefore no judgment of its proper 
exhibition is to be derived in the direction. Again, outside of these atmos- 
pheric associations, the manner of the exhibition has much to do with the 
minims inspired. Where, for example, the agent is exhibited poured upon a 
single layer of linen (as upon a handkerchief laid over the face), quite as 
much is lost in the surrounding atmosphere as is inhaled into the lungs. 
Cardiac Syncope.-Recognizing the danger as arising from the direc- 
tion of cardiac syncope, advantage is to be taken of means antagonistic to 
such depression. In bloodletting, it is known that such a condition is much 
the most readily brought about when the operation is performed on the patient 
standing, and when the primary impression is made most marked through a 
large exit for the blood. In states of depression arising from whatever 
cause, either of physical or mental disturbance, such tendency is increased. 
A surgeon always hesitates to bleed a depressed patient; or, if such bleeding 
seem a necessity, supporting means are employed and continued in conjunction 
with the depletion. Advantage is taken also of all collateral indications, as, 
for example, position, the patient lying down, the head being placed, perhaps, 
on a lower plane than the body, the orifice of exit being made very small; 
intermissions in the flow of the blood, stimulants, as the pre-exhibition of 
brandy or wine, kind and encouraging assurances, etc. The depressing effect 
of fear on the heart's action is never to be lost sight of in the admin- 
istration of chloroform. How many patients faint even while preliminary 
arrangements in anticipation of an operation are going forward ! indeed, how 
many are the cases on record of death from such fright! It would seem, ANESTHESIA AND ANESTHETICS. 
1271 
then, that one would never be justified in administering chloroform to a 
patient laboring under marked depression; at least such is the author's con- 
viction, and on such impression he has always acted. All persons, or nearly 
all, approach a surgical performance with a certain amount of trepidation, but 
such fear may, in the majority of cases, be dispelled; or if this be impossible, 
then a preliminary artificial courage is to be given by the use of champagne 
or other stimulant; or, cerebral consciousness may be confused by the inhala- 
tion of a few drachms of ether. 
Chloroform may be given in a Sitting Position.-The objection 
that chloroform is not to be given a patient in a sitting posture does not seem 
to hold entirely good. In oral surgery this is a common necessary position; 
and the agent is thus administered in hundreds of cases without ill result. 
A difference in the character of cardiac syncope is here to be 
recognized. The paralysis may arise from two sources, and exhibit, as the 
state of the heart is concerned, quite different appearances; that is, there is a 
syncope of anaemia and a syncope of narcotism. Now, while there is between 
these two conditions much relationship, as the question of a vital propulsive 
force is concerned, yet there are also certain differences, of which, as surgeons, 
we are to take advantage. Paralysis of the heart occurs when, from any 
reason, the organ is deprived of the effect of its natural stimulus, the blood: 
this is the syncope, or paralysis, of anaemia. It occurs again when, through 
the action of a common or a specific narcotic, its muscular fibres are relaxed 
and deadened. The two causes may exist and act in conjunction. Chloroform 
is a specific narcotic as the heart is concerned ; at least this is the 
deduction from post-mortems made in the fatal cases of its exhibition. In 
anaemia, syncope is partly a mechanical production; the patient, in a standing 
position, faints, as the result of gravity counterbalancing the natural distribu- 
tion of the blood. In narcotic syncope, position is, perhaps, of little con- 
sequence, at least as the action of the producing cause is, of itself, concerned. 
The question, then, of sitting or of lying, as the exhibition is concerned, 
resolves itself into a consideration of the state of the general health of a 
patient: if there be deficiency either in quality or in amount of the vital fluid, 
then the erect or even semi-erect station is not to obtain. If, on the contrary, 
a patient does not present such conditions, then it would seem that there is no 
special danger in the position. 
Prefatory Stimulation.-Prefatory stimulation, if not contraindicated, 
is happily employed in conjunction with chloroform. A tablespoonful or more 
of brandy given to a patient some five or ten minutes before exhibition of the 
agent will frequently support the natural action of the heart through a pro- 
longed operation, and thus antagonize the common source of alarm. 
Sulphate of strychnia, gr. to acts as a cardiac stimulant. 
Where a heart is acting over-quickly as result of deficiency of control by the 
inhibitory nerve, tincture of digitalis in ten-drop dose furnishes the 
desired correction. 1272 
A SYSTEM OF ORAL SURGERY. 
Ether conjoined with Chloroform.-In his own practice the author 
never likes to use chloroform save in conjunction with ether; not mixing 
them, as in a common practice, but alternating, as the case seems to 
require or allow. Thus, employing the cone, the process is commenced by 
pouring within it a quantity of ether, when it is gradually, and yet as rapidly 
as possible, brought to cover the mouth and nostrils. If now the pulse 
rapidly increase, or even remain fixed and steady, and particularly if undue 
cerebral excitability manifest itself, ten or twenty drops of chloro- 
form are dropped upon the sponge. This is found to quiet the patient almost 
instantly. From this point the surgeon proceeds, using chloroform or ether, 
according to the result to be secured. If an operation be one of simple char- 
acter and of quick performance, as the extraction of teeth, or the making of a 
puncture or incision, then it is not wise to risk anything with chloroform. 
If, on the contrary, it be some difficult and tedious case about the mouth, 
where, after commencing, the operator cannot well stop to readminister the 
anaesthetic, the risk of the excess of chloroform may be taken for the pro- 
longed effect yielded and the greater profundity of impression secured. The 
use of a sphygmograph is a reasonable safeguard in the use of chloroform, 
as it marks the force and extent of the pulse with absolute accuracy. This 
instrument, being related with a superficial artery, shows the rhythm. Least 
disturbance is seen to lie with the bromide of ethyl, most with chloroform, 
intermediate with ether. (See Combination 1, 2, 3.) 
Manner of Exhibition as influencing Result.-The manner of 
the exhibition of the agent has, as one would infer, much influence as result is 
concerned. Thus, of the various apparatus that have from time to time been 
devised to assist in the use of chloroform many are deserving of no better 
name than life-traps; and in this connection one naturally finds himself 
wondering at the character of contrivances which, particularly in the earlier 
history of chloroform, were employed, even by the ablest men, in experiments 
directed to the testing of the general safety and results of the agent. One 
cannot read of the white mice, guinea-pigs, cats, and bell-jars of these 
pioneers without wondering that it should never have occurred to the experi- 
menters that animals might as readily die from lack of proper respirable air as 
from effects of an anaesthetic agent that was being tried. 
Necessity for Free Admixture with Air.-In using chloroform, 
it is most desirable that there be the fullest admixture of air; with this 
intention the sponge is used, first softening it with warm water, which water 
is to be well squeezed away. The respiration should be easy and natural, and 
the patient fully en rapport with the operator. He should be given to under- 
stand that anaesthesia is but a gentle and harmless sleep, and that one is to 
enter on it as he does on natural slumber. If such confidence be secured, 
there will be found little trouble in producing narcotism. Another plan of 
using the agent, and one which has many advocates, is to let fall drop after 
drop upon a napkin, laid loosely over the air-passages. The tin cone shown ANESTHESIA AND ANESTHETICS. 
1273 
will not disappoint. However employed, the principal indication is to 
have the agent in proper dilution and combination with atmospheric air; this 
secured, any mode of inhalation must be a proper one. Insensibility, as 
wisely remarked by Mr. Snow, is not caused so much by giving a dose as by 
performing a process. Nature, continues this gentleman, supplies but one 
mixture of diluted oxygen, from which each creature draws as much as it 
requires ; and so, in causing narcotism by inhalation, if a proper mixture of 
vapor and air be supplied, each patient will gradually inhale the requisite 
quantity of the former to cause insensibility, according to his size and strength. 
It is desirable to vary the proportions of vapor and air, but 
rather according to the purpose one has in view, whether medicinal, obstetric, 
or surgical, than on account of the age or strength of the patient; for the 
respiratory process bears such a relation to the latter circumstances as to cause 
each person to draw his own proper dose from a similar atmosphere in a 
suitable time. 
Induction of Insensibility varying with Patient.-The induc- 
tion of insensibility varies with the individual, or rather, it is to be suggested, 
with classes of individuals. One class will breathe quietly and slowly, until 
unconsciousness supervenes as if by a natural sleep: persons of this kind are 
of the lymphatic temperament. The nervo-sanguine or bilious class are apt 
to become restive and frightened, and require a great amount of care and atten- 
tion, being the most difficult to impress, but of less dangerous import than the 
former class. The true and full nervous man, while timid and frightened, is 
yet apt to be impressed by a very few inhalations. There is one question that 
here arises in regard to an exhibition of timidity. When a patient be- 
comes excited, shall the chloroformization go on? Yes, is to be answered, 
if such exhibition be associated with mental disturbance produced by the 
agent; for here it is not as the condition previously named, but is rather an 
hallucination. These patients are to be forced rapidly beyond the state of 
excitement. Here is the point in which the production of anaesthesia de- 
mands skill, courage, and judgment. Over and over again incompetent oper- 
ators worry poor creatures into most wretched conditions simply by fearing to 
pass the Rubicon of excitement. If assured that all is right (and such as- 
surance is to be derived from noting closely the circulation), we are to get 
over this intermediate excitable stage as quickly as possible, and get 
over it by concentrating the chloroform. Patients laboring under such ex- 
citability will, often enough, assure you that they feel that another inhalation 
will kill them ; that it is impossible to breathe; that the heart is laboring 
under woful depression; with many complaints of like character. Such 
speeches are mostly to be taken cum grano satis ; the practitioner is to judge 
for himself. Danger is, however, at the bedside; let it not be overlooked. 
Chloroform is more treacherous than is Mephistopheles. 
Condition of Narcotism.-Before an operation of magnitude is com- 
menced, it behooves a surgeon to assure himself that his patient is in the proper 1274 
A SYSTEM OF ORAL SURGERY. 
anaesthetic condition. Entire paralysis of the muscles of animal life is com- 
monly received as indicative of such a state,-this being manifested in the 
lifeless falling of an arm when raised. But this is not strictly reliable, as, to 
obtund sensation, the posterior column of the spinal cord, as we are aware, is to 
be affected, while loss of motion implies anaesthesia of the anterior only. So 
quickly, however, does the action of the agent pass from the one to the other 
of these parts, that this sign is found to be one most convenient of acceptance. 
Three Degrees of Narcotism.-Three degrees of narcotism are 
described. The first includes all the effects of chloroform that exist while a 
patient retains a perfect consciousness of where he is and what is occurring. 
In the second there is no longer correct consciousness; the mental functions 
are impaired, but not necessarily suspended. In the third there are no longer 
any voluntary motions. 
Snow on Circumstances which influence Effects of Chlo- 
roform.-The circumstances which influence or modify the effects of chlo- 
roform are thus considered by Mr. Snow, than whom, perhaps, there is no 
one whose observations have been of a more extended or thorough nature; 
although it is not to be overlooked that he was so enthusiastic in his direction 
that perhaps, in some instances at least, his prejudices may have somewhat 
influenced his judgment. The writer puts it on record that he discounte- 
nances the employment of chloroform. He never uses it, save under com- 
pulsion, and fears always while he uses. He never administers it 
without the conjunction of a prophylactic,-ether or brandy. 
I arrived at the conclusion, says Mr. Snow, after much careful observation, 
that chloroform might be given with safety and advantage in every case in 
which the patient requires, and is in a condition to undergo, a surgical opera- 
tion. And having acted on this conclusion for several years, I have found no 
reason to change it. It is desirable, however, to pay attention to every cir- 
cumstance connected with the health and constitution of the patient before 
exhibiting chloroform, as many of these circumstances influence its effects. 
The conclusions arising out of Mr. Snow's experience concerning circum- 
stances of exhibition are thus to be epitomized. Those of the writer 
accord with them. 
Age of Patient.-The age of a patient has considerable influence in 
modifying the effects of chloroform. It acts very favorably on children. 
These sometimes oppose the inhalation of it so long as they are conscious, but 
it does not occasion the rigidity and struggling, after unconsciousness, which 
are sometimes met with in the adult. Anaesthesia is generally induced in 
children with a less amount of narcotism of the nervous centres than in 
grown persons. 
The effects of chloroform are produced more rapidly, and also sub- 
side more quickly, in children than in adults, owing, no doubt, to the 
speedier breathing and circulation. It often happens, however, that when the 
insensibility has been kept up for some time, say twenty minutes or half an ANESTHESIA AND ANESTHETICS. 
1275 
hour, in a child, it is followed by a natural sleep of a few hours' duration, 
provided there be no painful wound or other cause to prevent the sleep. It is 
worthy of remark that none of the accidents from chloroform which have 
been recorded have occurred to young children. 
There is nothing peculiar in the effect of chloroform upon people ad- 
vanced in years, except that its influence subsides tardily, on account of 
the slower breathing and circulation. 
Strength or Debility.-The comparative strength or debility of a 
patient has considerable influence on the way in which chloroform acts. 
Usually the more feeble the person, whether from illness or any other cause, 
the more quietly does he become insensible; while if he be strong and robust 
there is very likely to be mental excitement in the second degree of narcotism, 
and rigidity of the muscles, and probably struggling, in the third degree. 
Patients in a state of debility resemble children, not only in coming quietly 
and easily under the influence, but also in the circumstance that the common 
sensibility is suspended with less narcotism of the nervous centres than is 
generally required in robust people. Children, and persons in a state of 
weakness, have usually an acute sensibility which causes them to suffer pain 
from very slight injuries, but this sensibility is more easily suspended by 
chloroform than the less acute sensibility of the robust. 
Hysterical People.-Patients who are subject to hysteria have some- 
times symptoms of the complaint, such as sobbing, crying, or laughing, as 
soon as consciousness is suspended, or even impaired, by the chloroform; but 
these symptoms can always be subdued by proceeding with the inhalation.* 
In some persons who are subject to hysteria the breathing becomes exces- 
sively deep and rapid while inhaling chloroform.'}' This usually occurs just 
as the patient is becoming unconscious, but in a few cases even earlier, and 
the subject is aware of the impulse to breathe in this manner. After this 
kind of hysterical breathing has lasted a little time, the individual generally 
rests nearly a minute without breathing at all, after which the respiration is 
likely to become natural. Chloroform is to be given very sparingly during the 
violent breathing, or else withdrawn altogether for a moment or two. 
* Chloroform in Hysteria.-Chloroform in hysteria is one of the most valuable medi- 
cines of the Materia Medica, while, on the contrary, sulphuric ether is most decidedly ob- 
jectionable to such patients. The writer has treated females afflicted in this way where 
ether had been used by the pound with no other effect, seemingly, than increasing, intensi- 
fying, and prolonging the paroxysm; yet with a very few inhalations of chloroform has 
had the pleasure of seeing the persons fall into the most natural slumber, and after resting 
quietly for hours, the sleep prolonged, perhaps, as sometimes has seemed indicated, by 
occasional repetition of the inhalation, has again and again seen them awake perfectly 
recovered. 
f Mr. Snow, in his paragraph, remarks the supervening of this condition after the first 
few inhalations, but, according to the writer's experience, it is as uncommon when chloro- 
form is used as it is common in the employment of ether. When, in administering ether, 
the slightest signs of hysteria are seen either in male or female, control is to be secured by 
replacing the ether with chloroform. 1276 
A SYSTEM OF ORAL SURGERY. 
Condition of Pregnancy.-It is not generally thought that there is 
anything in this condition objectionable to the use of chloroform. 
Menstrual Period.-This time is certainly not to be preferred or 
selected as an occasion for chloroform exhibition, yet there is nothing at all 
in it adverse to the administration. The controlling effect of the agent over 
hysterical symptoms has just been remarked, and such irritability of the 
system is a peculiarity of the state. Indeed, it is very common that the 
hysterically-inclined female is compelled to resort to chloroform, particularly 
in conditions of dysmenorrhoea. 
Diseases of the Lungs.-Affections of the lungs may readily cause 
difficulty and delay in the administration of chloroform, as the vapor is liable 
to excite coughing when the mucous membrane of the air-passages is irritable. 
The inconvenience is, however, confined to the time of inhalation, for the 
cough is generally relieved afterward. 
This difficulty, as observed not only by Mr. Snow and Dr. Turnbull, but 
by nearly all writers on anaesthesia, is found to be almost, if indeed not 
entirely, obviated by preceding the exhibition with a tablespoonful of 
thick mucilage of gum acacia, the patient allowing it to lose itself 
gradually over the mucous surfaces. 
I have given, says Mr. Snow, chloroform for surgical purposes in many cases 
where phthisis was present, and in several patients who have suffered 
from haemoptysis, and have not seen any ill effects from its use. Chloroform 
is, indeed, often inhaled with advantage to relieve cough in consumption. 
The instances of chronic bronchitis in which the agent is administered for 
relief of the condition and for operations are still more numerous. 
Disease of the Heart.-The practitioner quoted does not seem timid 
regarding a weak heart. There is a very general impression, he says, that the 
use of chloroform is unsafe when disease of the heart exists, more particularly 
fatty degeneration of that organ. This belief has been encouraged by the 
circumstance that the affection has been present in a few of both the real and 
alleged deaths from the agent, and also by the fact that, in the accidents that 
have really been due to chloroform, the heart has been the organ on which it 
has exerted its fatal influence. When we come to investigate these cases, how- 
ever, we shall find reason, he goes on to say, to conclude that the heart has 
probably been diseased in quite as great a proportion of the patients who have 
taken chloroform without ill effects as of those who have succumbed under its 
influence. As regards my own practice, Mr. Snow says, the only case in which 
death could in any degree be attributed to the chloroform was one in which 
there was extreme fatty degeneration of the heart; but, on the other 
hand, I have given chloroform in numerous cases without ill effect where the 
symptoms of this, as well as of other affections, were present in a marked 
degree. Indeed, I have never declined to give chloroform to a 
patient requiring a surgical operation, whatever might be his condition, as I 
early arrived at the conclusion that this agent, when carefully administered, ANESTHESIA AND ANESTHETICS. 
1277 
causes less disturbance of the heart and circulation than does severe pain. 
Wherever, he continues, I have had opportunity of seeing an operation per- 
formed without chloroform, I have carefully examined the pulse, and although 
none of these seen have been of a very severe nature, I have found the circu- 
lation to be much more disturbed than it would have been by the agent care- 
fully administered. The pulse, in most of the cases, has been exceedingly 
frequent during the operation, and in some instances it has intermitted to an 
unusual extent. 
In one case, Mr. Snow says, I had an opportunity of witnessing a similar 
operation on the same patient, first without chloroform, and afterward 
under its influence. In the first, which was lithotrity, I began to feel the 
pulse just when the patient saw the lithotrite about to be introduced. It was 
120 in the minute. As soon as the instrument was in the bladder the pulse 
increased to 144, and immediately afterward it became uneven, irregular, and 
intermitting. I could not count more than three or four beats at a time; and 
occasionally, when the pain seemed greatest, and the man was straining and 
holding his breath, the pulse was altogether absent for four or five seconds. 
In order to ascertain whether the loss of beat at the wrist might not depend 
on the pressure of the muscles of the arms, caused by grasping the table, I 
applied my ear to the chest, and found that there was no sound what- 
ever to be heard during the intervals when the beat was impercep- 
tible. It was evident that the patient held his breath till the right cavities of 
the heart became so distended as to stop the action of the organ till the respi- 
ration returned. The man did not complain or cry out during the operation. 
A week afterward the lithotrity was repeated, but on this occasion I ad- 
ministered chloroform. The pulse was 120 in the minute when the patient 
began to inhale the anaesthetic, but it became slower as he was made uncon- 
scious, and it was regular during the operation. It was. only toward the end 
of the performance, when the effect of the agent was allowed to diminish, and 
when the man began to strain a little, though not yet conscious, that the 
pulse intermitted slightly, passing over a single beat occasionally. There 
were none of the long intermissions observed on the former occasion. 
It is very evident, he continues, that if the above-mentioned patient had 
been the subject of any affection of the heart which weakened or em- 
barrassed its action, he would have run a much greater risk from the pain 
of the first operation than from the inhalation of the chloroform in the 
second one. 
In a few of the patients having the arcus senilis of the cornea, a 
weak, intermitting, or irregular pulse, and other signs of fatty degeneration of 
the heart, there have been a feeling of faintness and a tendency to syncope as 
the effects of the chloroform were subsiding, especially when the opera- 
tion had been performed in the sitting position ; but these symp- 
toms have soon subsided, in all cases I have met with, on placing the patient 
horizontally, with, or without, the help of a little ammonia to the nostrils. 1278 
A SYSTEM OF ORAL SURGERY. 
Criticism on Overconfidence.-The writer has had his own experi- 
ence in the use of anaesthetics quite equal to that of surgeons at large. He 
has quoted Mr. Snow in order that such side of the subject have presentation. 
He here offers another side in resuggesting that the word treachery is synony- 
mous with chloroform. Deaths are reported as occurring from its use of so 
instantaneous a character that time was scarcely allowed to turn. However 
imposing and authoritative the testimony favoring the exhibition of chloroform 
where organic heart derangements of any kind exist, the writer puts in his 
own word of warning. He considers the agent full of risk. 
Recovery from Anaesthesia.-The exhibitions made by patients in 
recovering from anaesthesia are various. Some come out of the state with a 
start as if suddenly awakening from sleep, seeming for a few moments to be 
bewildered. Others are possessed of full consciousness, but are entirely ob- 
livious to the operation that has been performed. Still others, and this is the 
most desirable result, continue in a gentle sleep which may last for one or 
several hours. Hysterical laughing or extravagance as to general words and 
actions characterize another class. Respiration, in case of ether, and the 
heart's action, in case of chloroform, continuing regular, no anxiety is to 
be felt. 
Cerebral Diseases.-Affections of the head, accepting this same 
authority, offer no obstacle to the administration of chloroform. I have given 
chloroform, says Mr. Snow, to several patients who had suffered previously 
from an attack of apoplexy ; some of them still retained the paralysis resulting 
from the attack, but the exhibition has not been attended or followed by ill 
effects in any of the cases. 
The following interesting and very instructive case is mentioned in this 
direction: 
The 31st of October was a day appointed by Mr. Fergusson to perform 
lithotrity on a gentleman seventy-eight years of age, who had a phosphatic 
calculus in his bladder. He was a patient of Mr. Propert, and Mr. Fergus- 
son had removed a similar calculus by lithotrity, and I had given him chloro- 
form at each of the operations, and it was arranged that he should have it 
on the present occasion. Mr. Propert informed Mr. Fergusson and myself 
on our arrival that his patient had, the night before, an attack resembling 
apoplexy; he had been insensible; the breathing had been stertorous, the 
pupils dilated, and the face very red and congested. Mr. Propert had caused 
him to be cupped to fourteen ounces, and had given him twenty grains of 
calomel in the course of the night, and in the morning he was as usual, and 
remained so at the time of our visit. We considered the case with his 
attendant, and, as there were no reasons for postponing the operation, it was 
determined that the man should inhale the chloroform rather than be sub- 
jected to pain. The vapor acted very favorably : he recovered his conscious- 
ness a few minutes after the crushing, and expressed himself as feeling quite 
well. ANESTHESIA AND ANESTHETICS. 
1279 
Chloroform in Insanity and in Delirium Tremens.-Chloro- 
form acts on insane patients just as it does on others ; when the effects subside 
they are in the same state of mind as before. Mr. Snow remarks the sus- 
piciousness of the insane, but gives his experience where teeth have been 
extracted and other operations performed which it would have been impossible 
to accomplish in the same individual without resorting to inhalation. The 
employment of chloroform in the delirium of mania a potu has, 
through the experiments of Dr. Ely McClellan, of the United States Army, 
been brought into wide notice, and commands much attention, the success of 
this gentleman being verified by practitioners in every part of the country. 
Given in drachm doses, pro re nata, chloroform seems to 
break the paroxysm completely, causing the patient to fall into a 
profound sleep, from which, after eight or ten hours, he awakes, commonly 
entirely relieved. In these cases the chloroform is to be taken into the 
stomach, however, not breathed. 
This consideration of chloroform may be closed by remarking, 
as alluded to in the commencement of the chapter, that the agent, if one 
feel justified in using it, is far to be preferred in oral surgery to ether; a 
profound impression created by chloroform will not infrequently continue 
through quite a prolonged operation; or, if it be necessary to renew the 
inhalation, the desired impression is generally secured with great rapidity. 
Performances about the mouth, unlike most other surgical services, require to 
be executed with rapidity; therefore it is a necessity to be as little interfered 
with as possible: an impression, apparently very profound, made with ether, 
is apt to be broken in the very first shock of an oral operation. This first 
step may be of a character starting, in some instances, frightful hemorrhage, 
and which is to be combated only at the completion of the service. To have 
a patient pass from control at such moment, and under such circumstances, 
is sometimes a matter of serious concern. If one has not used chloroform up 
to this time, and the article be at hand, it is apt to be given the patient in a 
quite free manner. 
Accidents happening with the Skilful.-The author in this chapter 
has used in many instances the strong authoritative experiences of Mr. Snow. 
He is not disposed to enter on any dispute as to these experiences; person- 
ally, however, he is afraid to use chloroform except in conjunction with ether; 
and while such fear may not be solidly grounded, yet, as it exists, he cannot 
do otherwise than give expression to it. At this day it were certainly idle to 
deny that many deaths-a great many-have resulted from the use of chloro- 
form ; and a large proportion of these accidents have happened in the hands 
of eminent and skilful men, and where every possible scientific precaution 
had been taken. 
Accidents not Traceable to Overdose of Chloroform.-Again, 
the accidents have seldom, if ever, been traceable to an overdose of the agent; 
the deaths have never occurred from narcotism, but from a direct and unfore- 1280 
A SYSTEM OF ORAL SURGERY. 
seen paralysis of the heart. The author has not overlooked the fact that 
fatal results happening while chloroform was being used might not be owing 
to the agent. Certainly there are cases enough on record justifying such a 
conclusion,-cases with which every surgeon must be familiar; but, on the 
other hand, there are instances of such doubt, or perhaps it is better to say, 
of such certainty, that one may incline to err on the side of discretion. 
Restoration of the Abeyant Circulation.-Treatment of chloro- 
form narcosis relates with restoration of the abeyant circulation. To this end 
a cloth wrung out in cold water is to be slashed over the chest. Inhalations 
of ether may be given. The head is to be placed on a lower level than the 
body. Artificial respiration is to be maintained. Tickling the 
nostril is a favorite means. 
Influence of Oil of Turpentine on Chloroform.-In the Vier- 
te/jahresschrift fur Gericht. Med., Dr. Wachsmuth, of Berlin, makes the 
important statement that if one-fifth part of oil of turpentine be added to 
chloroform, the latter can be administered to the fullest anaesthesia without 
the slightest risk, as the turpentine prevents, by its stimulating properties, the 
pulmonic paralysis, which he accepts as being the proximate cause of death in 
fatal chloroform narcosis. 
Inverting a Patient.-Apparent death from chloroform has found 
remedy in turning the patient for a few moments head downward. The 
author has had occasion to practise this, and it has proved successful; it 
applies as well to ether syncope; it is known as Nelaton's method. 
Artificial Respiration.-Artificial respiration, continued for from half 
to a full hour, is on record as proving restorative. 
Use of Nitrite of Amyl.-Nitrite of amyl, ten drops poured on a 
cloth and applied to the nostril, is an antidote. 
Pulling Forward the Tongue, and other Means.-Look to the 
tongue; if this be fallen back pull it forward. Give fresh air. Fan the 
patient. Use smart strokes of a battery. Dash cold water over the face. 
Rub briskly the extremities. Blow in the ear. Insert a lump of ice in the 
rectum. (See Possible Accidents.) 
NITROUS OXIDE GAS. 
The frequency with which this agent is now used, and the immunity from 
accident endorsing its employment, has begotten acquaintance with and con- 
fidence in it on the part of the people at large. Application of it is with 
minor and quickly-performed operations. Dentistry proper, as it relates to 
tooth extraction, is particularly served by it. 
History.-Nitrous oxide gas owes its discovery to Priestley, 1776. Credit 
for its use as a pain-obtunding agent is due to both Sir Humphrey Davy and 
Dr. Horace Wells; to the latter particularly. 
Manner of Preparation.-The gas is secured simply by boiling nitrate 
of ammonia and collecting the vapor evolved in the process. ANESTHESIA AND ANESTHETICS. 
1281 
Apparatus used.-Fig. 930 shows a nitrous oxide gas apparatus. It 
consists, as seen, of a stove and retort, three bottles connected by means of 
pipes and tubing, and a holder and receiver. 
Fig. 930. 
To make the gas an operator provides himself with a quantity of pure 
nitrate of ammonia (a pound produces thirty gallons of the vapor). This he 
tests by a procedure as follows : A teaspoonful is placed in half a goblet of dis- 
tilled water. If admixtures containing chlorine be present the fluid will be 
rendered milky; if, on the contrary, the salt be pure the water will remain un- 1282 
A SYSTEM OF ORAL SURGERY. 
changed. Being found unadulterated, the required quantity-measured 
by the amount of gas needed, one pound to each thirty gallons-is 
placed in the retort* and heat applied through a sand-holder in which the 
retort rests, until the fusing-point be attained, 250° Fahrenheit. The salt 
melted, heat is to be increased to the boiling-point, 460° Fahrenheit. If now 
the gas be disengaged and commences to pass over with freeness, the temper- 
ature is to be maintained, otherwise it is to be advanced, the maximum being 
482° Fahrenheit. Heat higher than this is productive of a poisonous element. 
Washing.-The bottles employed are for the purpose of cleansing, or 
washing, the gas. Bottle 1 is furnished with a pipe having a hole-riddled 
terminus, the external end being associated with the retort by medium of rub- 
ber tubing ; it may or may not contain a little water,-never enough, however, 
to be in contact with the tube. The office of this first bottle is simply to 
catch the drip. Bottle 2 is partly filled with water : beside that fluid it com- 
monly has put into it three or four ounces of sulphate of iron or copperas. 
Bottle 3 is to have a stick of caustic potash placed in it, this as a guard against 
the possibility of chlorine being present. The contents of the wash-bottles 
are to be renewed after each running. Before starting the distillation 
it is desirable to prove the existence of communication between retort and re- 
ceiver. To do this it is only necessary to blow in the retort end of the con- 
necting tubing: the passage being found unobstructed, the water in the middle 
and third bottles is made to bubble. 
Collecting.-To collect and preserve the gas implies a receiver. The 
one shown in the cut is highly commended by users of it. Connected with 
bottle 3 a tube, having a stop-cock, is seen. This conductor relates with the 
cylinder at a point above the surface of water with which the fixed portion, or 
holder, is filled. Forced through this pipe the gas enters the receptacle, the 
weighted and balanced receiver accommodating the collection. It is now 
ready for use. 
Fig. 931. 
Dispensing.-This is by means of the outlet marked inhaler. A rubber 
bag receiving the gas, it may be disconnected and carried anywhere. To ad- 
* The fused or granulated salt is to be preferred. ANESTHESIA AND ANESTHETICS. 
1283 
minister the agent, a mouth-piece (Fig. 931) is associated with the contents of 
the bag by means of a spigoted tube. 
Liquefied Nitrous Oxide.-Nitrous oxide gas subjected to extreme 
cold and pressure is to be condensed, in strong iron cylinders, to the form of a 
liquid. Fig. 932 shows such a cylinder in the shape of a not unsightly piece of 
office furniture. One of these, holding one hundred gallons of the gas, weighs 
Fig. 932. 
just ten pounds. With paper wrapped about it one would carry this shell 
in his hand without attracting a passing glance. The surgeon's case, a 
package containing the liquid, and conveniences for exhibiting it is a most 
handy, economical, and convenient arrangement for the use of general prac- 
titioners. 
Fresh Gas Better than Old.-Fresh gas is to be accepted as being 
better than old. Twenty days is esteemed by many the maximum time that 
the agent is to be allowed to stand over water. Differing, in this respect, as 
the antipodes, from ether and chloroform, nitrous oxide gas is to be given to 
the absolute exclusion of air. Bearded men require to this end the application 1284 
A SYSTEM OF ORAL SURGERY. 
of a hood. No condition or idiosyncrasy absolutely contraindicative of the 
use of the agent is admitted. 
Interruptions to Exhibition.-Spasm of the glottis and syncope are the 
commonest of the interruptions. In both cases immediate attention is required 
to the tongue; the organ to be seized with a dry napkin and drawn forward. 
In spasm, the placing of the tongue, combined with a few inhalations of air, is 
sufficient for relief. In syncope, the patient is put in a reclining position; 
fresh air is freely admitted; water is dashed against the face; smelling salts 
or ammonia fortior is applied to the nose; the ear is blown into or the nostril 
tickled. 
Conditions demanding Caution.-Conditions demanding caution 
are plethora, hypertrophy, fatty degeneration and valvular obstruction of the 
heart, temporary or permanent systemic depression, as existing, the first, in 
the over-fatigued, the second, in drunkards. 
Action of Nitrous Oxide.-While the agents previously described 
relax the muscular system, nitrous oxide gas stiffens it. Hence the necessity 
for a prop placed between the teeth as a preliminary to inspiration. Respired 
in association with a modicum of air the agent produces exhilaration ; received 
absolutely pure, such state of excitement is commonly too quickly passed to 
be noticeable; particularly is this the case where complete rapport exists be- 
tween patient and operator. Insensibility is quickly induced and as quickly 
passes away. Judgment of the effect of the gas is derived from observing 
the mucous surfaces. Danger lies with venous congestion. 
Bonwill's Method of Rapid Breathing in Connection with 
Use of Nitrous Oxide.-Referring to reliable experiments made in Pro- 
fessor Botkin's laboratory, at St. Petersburg,-see foot-note,-it seems to be a 
fair inference that danger lying with insufficient oxidation of the blood as 
related with the use of nitrous oxide gas might be in part, if indeed not 
wholly, antagonized by preceding the inhalation with rapid breathing, as 
recommended by Dr. Bonwill. (See a succeeding paragraph.)* 
* From a series of experiments made in Professor Botkin's laboratory in St. Petersburg, 
Dr. S. Klikowitsch ( Virchow's Archiv, xliv. 2) draws the following conclusions: 
1. Nitrous oxide gas is incapable of supporting respiration in animals and plants, and, 
like other indifferent gases, leads to death from asphyxia. The asphyxia produced by this 
gas, however, presents points of contrast to the asphyxia produced by other means. 
2. Nitrous oxide gas produces no chemical or morphological changes in the blood of 
animals, but is dissolved in it and again eliminated, according to physical laws, without 
apparently being broken up into nitrogen and oxygen. 
3. Anaesthesia with laughing gas is so closely associated with insufficient oxidation of the 
blood that it cannot be regarded as absolutely without danger, especially in diseases of the 
heart, lungs, or blood-vessels. 
4. The association of laughing gas with twenty per cent, of oxygen completely removes 
the possibility of asphyxia, and produces a number of results capable of therapeutic 
application. 
5. Under the influence of the mixture of laughing gas and twenty per cent, of oxygen, in the 
majority of healthy subjects, the heart's pulsations are increased, the pulse-wave diminished, ANESTHESIA AND ANESTHETICS. 
1285 
ETHYL BROMIDE. 
A process employed by Dr. Lawrence Wolff to secure this agent is as follows: 
Twenty-four ounces of bromide potassii, coarsely powdered, are conjoined with 
a mixture of sixty-four of sulphuric acid and thirty-two of water. After cool- 
ing, sixteen fluidounces of alcohol (95 per cent.) are added, the whole placed 
in a large flask contained in a sand-bath and connected with a Liebig's con- 
denser. The temperature is now raised to about 200° Fahrenheit and main- 
tained thereabout until reaction shall have ceased, and the ethyl, which has been 
gathering rapidly in a receiver, shall no longer come over. To know of this, 
about an ounce of water is put in the receiver before commencing the opera- 
tion. The evolution has stopped when no further sinking to the under surface 
of the water is observed. The ethyl bromide so obtained will amount to 
twenty ounces, and is to be shaken with a solution of potassium bicarbonate, 
subsequently washed with water, and purified by redistillation. 
Hydrobromic Ether.-Hydrobromic ether, as ethyl bromide is fre- 
quently termed, is employed in surgery by many, professedly with much 
satisfaction. The occurrence of several accidents has, however, somewhat 
modified the estimate of its safety, and induced a spirit of caution as to its 
acceptance. This anaesthetic is a colorless liquid possessed of an agreeable 
odor and pungent taste. It mixes perfectly in all proportions with ether, but 
sparingly with water. The action of the agent, from an anaesthetic stand- 
point, is even more quickly exerted than is that of chloroform. The manner 
of its use is the same as for ether, a sponge, napkin, or inhaler being employed. 
Recovery is more rapid than from the two agents just named. According to 
experiments by Dr. Laurence Turnbull, to whom the profession stands indebted 
for a knowledge of the anaesthetic quality of the preparation, the shortest 
time required to place a patient under its influence is thirty seconds; the 
longest, five minutes; average, ninety seconds. In the experiments, the 
smallest quantity used was that taken into the lungs by two inhalations 
from a sprinkled handkerchief; the largest was two ounces. Out of twenty- 
one cases, sickness of stomach, with vomiting, occurred in three, hysterical ex- 
citement in two, prostration in one. 
Bonwill's Method of Rapid Breathing.-An anaesthetic effect, as 
has been shown by Dr. W. G. A. Bonwill, is produced when rapid and full 
breathing is indulged in for a few minutes. What may prove the result of 
greater familiarity with the means the writer is not prepared to say. That a 
and the respiratory movements decreased in number and increased in depth; these effects 
pass off in from three to five minutes. 
6. In six cases of weak heart action the above gaseous mixture produced no unfavorable 
results; on the other hand, the pulse was decreased in frequency and increased in strength. 
These effects lasted from one to two hours. 
7. In cases of disturbed respiratory innervation the mixture of laughing gas and oxygen 
regulated the respiratory rhythm and rapidly removed the subjective and objective signs of 
insufficient oxidation of the blood. 1286 
A SYSTEM OF ORAL SURGERY. 
condition is produced which allows of puncture being painlessly made he 
knows from observation. A feature undoubtedly lying in the practice is the 
diminished quantity of an ordinary anaesthetic required where this process has 
preceded, and is continued, with the exhibition. A danger connected with 
the performance seems, to the experiments and experience of the writer, to 
lie in the direction of venous congestion of the brain,-a conclusion to which 
exception, however, is taken by physiologists whose opinions worthily com- 
mand wide respect. Greater familiarity, and wider experimentation, with the 
means may demonstrate the existence in it of a boon not surpassed by the 
other great discoveries in anaesthesia. 
Medicines used by Hypodermatic Injection.-" Gemischte nar- 
kose" (mixed narcosis) is a term introduced by Thiersch, of Leipsic, to express 
a relation of means by which insensibility to pain is secured without entire 
abolition of consciousness. The means consists in the hypodermatic employ- 
ment of morphia by an anticipation of some five minutes of chloroformization. 
This manner, while most recommendable, is yet not justly to be credited to the 
German surgeon; the author has been familiar with it assuredly for the last 
twenty years, certainly wrote about it in connection with jaw operations quite 
that long ago. Advantage residing in the practice is that a semi-conscious- 
ness may be maintained which insures against the passage of blood into the 
larynx at the same time that it serves as a prophylactic to shock. 
Sulphate of morphia used in conjunction with sulphate of atropia con- 
stitutes an admirable injection. The dose will vary from the eighth to a half 
grain of the first, and from the one-hundredth to the seventieth of a grain of the 
second. To prepare the combination for use it is to be mixed with from seven 
to ten drops of pure water. The spoon containing the solution is to be held 
over a flame for a single moment that a blood-heat of the fluid be secured. 
Chloroform, subcutaneously injected, is an excellent obtunder. 
In sciatica, ten drops, injected deep among the gluteal muscles, is efficacious 
in breaking up an attack. The remedy and manner of use are indicated 
in obscure neuralgias generally. 
STUDIES. 
POSSIBLE ACCIDENTS IN RELATION WITH THE USE OF 
ANAESTHETIC AGENTS. 
Conditions of apnoea and asphyxia supervene at times to an alarming and 
possibly fatal extent. The first relates with the use of ether, the second with 
chloroform. The first implies either nervous spasm or affection of the res- 
piratory centres, the second, paralysis of the heart. 
Apnoea.-This is a primitive word signifying " not to breathe the sub- 
stantive is breathing, or to breathe. When the condition supervenes in 
connection with the use of an anaesthetic agent, and precedes diminution of 
the heart's action, it means, as suggested, spasm ; otherwise anaesthesia of the ANESTHESIA AND ANESTHETICS. 
1287 
medulla oblongata. That it may mean clonic spasm unattended by any 
twisting or change on the part of a patient is known to the writer out of personal 
experience. There comes a sudden constriction of the chest-walls as though 
an incasement of iron had suddenly been thrown about them. To breathe 
through rib movement is impossible, while so little motion remains with the 
diaphragm as to impress the sufferer, if he be conscious, that death is close 
at hand. Where the apnoea resides with anaesthesia of the medulla the occur- 
rence is comparatively gradual. As a rule, much of the agent has been inspired 
and the stages preceding affection of this part have been passed one by one 
and should have been observed. The medulla being approached, the breathing 
becomes stertorous, or it may be, if the patient is not very vital, that it simply 
diminishes as to force and extent, until, if the condition be not appreciated, 
cessation results. Breathing being one with oxygenation and decarbonization 
of the blood, it is to be appreciated that ether given after a manner that 
excludes air is necessarily dangerous. Ether is always to be passed into 
the lungs in conjunction with a volume of atmospheric air. When, during 
an ether exhibition, the patient froth unduly at the mouth and the lips turn 
toward a blue and the face a dusky brown, danger is near and the administra- 
tion is to stop immediately. 
Asphyxia.-This word is another of primitive significance, meaning 11 not 
to beatits substantive is beating, or to beat. When, through the 
use of chloroform, the heart has been paralyzed, asphyxia precedes apnoea. In 
affection of the heart through use of this anaesthetic agent there is always 
momentary warning in a dead-blue color or shade to be observed upon 
the lip. If this sign be unobserved or unheeded death will surely follow 
closely. The sign always precedes the result. A chloroformist of 
experience never has his eye away from the lip while performing his office. 
A surgeon who is to operate in a case is never to conduct the anaesthesia 
if chloroform be the agent used. There is a reverse side as to the use of 
chloroform,-a side where danger seems to lie, not with over- but with under- 
use of the agent; thus it is maintained by Dr. Brunton that if a patient be 
not thoroughly under the influence of chloroform, irritation of the trifacial 
nerve is attended with the result of slowing and finally stopping the heart's 
action through its association with the pneumogastric nerve. Another danger 
lying with chloroform is in the direction of what may be called its cumulative 
effect; danger, as suggested by Dr. Turnbull, lies with increase in the number 
of carbon atoms, so that while wood-spirit (methyl alcohol), with but a single 
atom of carbon, is transient and slight in its effects, those of fusel oil (pentyl 
alcohol), which has five atoms of carbon, are prolonged and severe. 
Ether being a stimulant of the circulation and chloroform a depressant, it 
follows necessarily that the two may have distinctive places; such places to be 
allotted them out of understanding and appreciation of physical conditions. 
ETHER AND CHLOROFORM COMPARED. 1288 
A SYSTEM OF ORAL SURGERY. 
Children and the Aged.-Because of the vigor lying with the circula- 
tion of children and the converse of this as to the aged, chloroform is com- 
paratively a safe agent with the former, and ether with the latter. 
Organic Diseases and Chloroform.-Stanley Carl, thirty years of 
age, who for some years had bedn a lion-tamer and trainer at Forepaugh's 
Circus, died at the Medico-Chirurgical Hospital while under the influence 
of chloroform which he had taken preparatory to a minor surgical operation. 
Every effort known to science was made to resuscitate him as soon as it was 
discovered that he was sinking. Dr. Formad, the coroner's physician, found 
in his post-mortem that the man had been suffering from liver and kidney 
troubles, and also from fatty degeneration of the heart.* 
Sex.-Sanam and Turnbull find their observations agree as to the greater 
frequency of death in case of the male. In a record of ninety-nine deaths, 
seventy were men and twenty-nine women. 
Quantity of Chloroform employed.-In cases collected by the 
author named, and recorded in his book, one person died after inhaling but 
a very few drops, a second after fifteen to twenty drops had been used, a third 
had inspired forty drops. In eight cases death followed the inhalation of a 
teaspoonful of the fluid. Twelve died from the use of two teaspoonfuls. In 
other cases the amount used had varied from half an ounce to a full one. 
Erichsen, who inclines to believe that the rate of mortality has increased since 
the introduction of anaesthetics into surgical practice, attributes the most 
dangerous condition to an overloading of the blood by urea as result- 
ant of renal disease. He advises that close observation be made of 
the state of the kidneys. He is in accord with the writer in recognizing that 
surgical performances do not terminate as readily and happily when done 
under chloroform narcosis as under ether or without either. 
Stenosis, Hypertrophy, Dilatation, and Ether.-Ether being a 
stimulant of the circulation, its use is to be preceded in cases of stenosis and 
hypertrophy by a dose of five drops of tincture of the veratrum viride ; the 
same applies to fatty degeneration of the heart, except it be the case that 
the force of beat reveals itself to auscultation as being sufficiently low not to be 
disturbed by the exhilaration. The practitioner, cognizant of the state of a 
heart in the conditions named, will readily enough appreciate the possibility of 
rupture when the organ is aroused to excessive action. The existence of the 
arcus senilis is significant of atheromatous arteries and ruptures. (See 
Medical Diagnosis?) 
Emphysema and Ether.-The pulmonary return circulation being 
dependent, in part, on the diminution of the lungs in the expiratory act, it 
appears that congestion is a not impossible result of excessive systolic action 
on the part of a right ventricle. Veratrum or aconite applies here. 
* See Turnbull on Artificial Anaesthesia. ANAESTHESIA AND ANAESTHETICS. 
1289 
Stenosis, Hypertrophy, Dilatation, and Chloroform.-In the 
use of chloroform in these conditions heart-failure results as the direct effect of 
the agent. 
Emphysema and Chloroform.-Here congestion of the lung may 
exist in inability of the pulmonic veins to return the blood to the left auricle, 
the left ventricle being unable to properly and timely empty itself. 
COMBATING DANGEROUS SYMPTOMS. 
Ether.-So long as a person who may be taking ether inhales quietly or 
without effort,-that is, without evidence of dyspnoea,-no anxiety is to be 
felt; the criterion of condition is the respiration, not the pulse. 
Such manner of breathing changing to the sighing respiration, attention 
is immediately to be given it. As a rule, the indication rests with 
withholding the agent for a few moments. This failing, effort is to be made 
to arouse the patient,-a matter commonly easily effected by a few drops of 
water sprinkled upon the face. Ammonia may be held to the nostril; atropia, 
the of a grain dissolved in ten drops of water, or whiskey, to the extent 
of from ten to twenty drops undiluted, may be hypodermically injected. Gal- 
vanism is a favorite means : the positive pole is to be applied to the back of the 
neck and the negative to the centre of the diaphragm; the current is to inter- 
mit. A method known as Hereopath's places the positive pole at the nostrils. 
Inflation is a resource. A strong person, after exhausting his own lungs of 
the residual air, takes hold of the nose of the patient and, while compressing 
this, forces a volume of air through the mouth into the lungs. Expiration is 
made to follow by means of pressure made upon the sides of the chest. 
These acts are repeated some twenty-five times to the minute, being continued 
until the patient recovers or is dead. Attention is always to be directed to 
the tongue to see that it has not fallen back.* Collapse from shock is 
always to have grave consideration. The confidence of a patient is the 
greatest assurance in this direction. While a person is passing from conscious- 
ness to unconsciousness, the hand of the operator is always to rest upon his 
person and words of cheer are to be spoken in the ear. 
Chloroform.-Nelaton's method of inversion is most reliable. This 
method lifts the person by his heels and holds him for a moment or two head 
downward. This failing, there is no resort except to what are known as the 
"ready methods" of Silvester or Marshall Hall. 
Silvester's Method.-The patient is turned upon his back and a roll 
of clothing or other convenient article is placed under his shoulders. The sur- 
geon, standing over the person's head, seizes the elbows and slowly lifts them 
above and to either side of the face until he can make them touch each other. 
Next, they are carried down against the chest, which they are made firmly to 
* Dr. Howard, of London, claims that the best way to raise the epiglottis is not 
by pulling the tongue forward, but by extending the head and neck.-Turnbull. 1290 
A SYSTEM OF ORAL SURGERY. 
compress. The movement is to correspond more or less closely with the ordi- 
nary acts of respiration, beiog neither too fast nor too slow. This plan is said 
Fig. 933.-Silvester's Method of Artificial Respiration. 
First Motion. 
Fig. 934.-Silvester's Method of Artificial Respiration. 
Second Motion. 
to be capable of displacing from forty to fifty cubic inches of air at each move- 
ment. Figs. 933 and 934 exhibit the positions of patient and surgeon and 
the processes. ANESTHESIA AND ANESTHETICS. 
1291 
Marshall Hall's Method.-This method reverses somewhat the 
manner of Silvester. The patient is placed upon his chest, his head being 
supported by his own right arm, which is flexed so as to come under the fore- 
head. This position allows the tongue to fall forward. A roll is now placed 
so as to occupy the position of the lower part of the sternum and the patient 
is rolled back and forth from front to side. This plan, while excellent in the 
case of a person lifted from the water, with surcharged lungs, compares in 
no way with the Silvester method in anaesthetic resuscitation. 
Howard's Method.-This consists in laying a patient upon his breast, 
with a support under both chest and abdomen, and making pressure upon the 
back. This, which is the first position, is used in cases of drowning. The 
portion of the method that applies to anaesthetic resuscitation is found in 
turning the person upon his back, a roll being placed beneath, and the lifting 
of the arms by an assistant, after the Silvester method, while the surgeon, 
being in front and below, compresses the chest with his hands. 
ALCOHOL. 
CHLOROFORM. 
ETHER. 
The mixture familiarly known as I, 2, 3, made up of alcohol, chloroform, 
and ether, in the proportions of one part of the first, two of the second, and 
three of the third, is coming into wide favor. The student, inferred as 
now being familiar with the qualities and action of the three agents, is 
able to appreciate the virtue of the combination. So fully is the immediate 
depressing effect of the chloroform antagonized by the immediate stim- 
ulating action of the ether, while, secondarily, so antagonistic are the alcohol 
and chloroform as to a not uncommon cumulative influence associated with 
the use of the latter, that it would seem as if nothing is left to be considered. 
The commendation is not, however, to be without qualification as to possible 
idiosyncrasies. CHAPTER LXXVI. 
INFLAMMATION. 
The author adds to the volume a chapter on the subject of inflammation,- 
a chapter which is to find apology for its appearance in a work of the present 
character in consideration of being addressed solely to students, and in further 
consideration of the importance of the theme. 
Understanding of Inflammation one with Understanding 
of Surgery.-Understanding of the subject of inflammation is one with 
understanding of surgery. No man has ever yet attained to over-knowledge 
of inflammation. Many practitioners fail wholly in apprehending the impor- 
tance of it. A study of inflammation involves primarily a comprehension of 
principles. To appreciate principles is to secure understanding of phenomena 
as these arise out of what is to be termed their nomenon. The present thesis, 
written in the most simple words at the author's command, and after a manner 
aiming to be demonstrative, is commended as designed to present the topic 
in an aspect which relates it with every-day practice. An analyzer starts 
on the study of inflammation properly only when he has arrived at 
recognition of the fact that it is the very corner-stone of that building which 
is expressive of the full meaning of a physician's life. Without a knowledge 
of the subject of inflammation no practitioner can be successful. Possessed 
of such knowledge, obscurity converts itself into simplicity. 
DEFINITION OF INFLAMMATION. 
By inflammation, as the term is commonly and truly defined, is meant a 
condition of a part where the circulation of the blood is in excess, and where, 
as the result of such excess, there is modification of the physiological, or 
healthy, state, this having associated with it the phenomenal expressions of 
redness, heat, pain, and swelling. 
CAUSE OF INFLAMMATION. 
The cause of inflammation lies with disturbance resultant of the presence 
of an irritant of either local or systemic import. The condition is to be 
accepted as an effort being made by nature to eliminate, or get clear of, an 
agent of offence. 
PERVERSION OF CIRCULATION. 
While there is never an inflammation where there is no perversion of the 
circulation, there may be a perversion of circulation where there is no inflam- 
mation. 
1292 INFLAM MA TION. 
1293 
By perversion of the circulation is implied derangement in that harmonious 
distribution of blood to the organism at large, through which harmony every 
individual part has its proper share, and has no more than this share. 
DEFINITION OF PERVERSION. 
EXAMPLES IN PERVERSION. 
A philosophical onlook at the subject of inflammation considers it never 
otherwise than from the aspect of perversion of the circulation. If start be 
made with recognizing and accepting a pulse beating seventy times a minute 
as being indicative of a natural circulation, it follows that a pulse beating one 
hundred and forty times to the minute is indicative of an unnatural circula- 
tion ; it follows, as well, that a pulse beating seventy-one times to the minute 
is a circulation out of equilibrium to the extent of one beat. 
A leg that may be partly frozen, the part being, not red, heated, painful, nor 
swollen, but, on the contrary, white, cold, numb, and contracted, is in a state 
of perverted circulation, but is not in a state of inflammation. On the other 
hand, the leg being not frozen, but surcharged with blood, its parts being red, 
heated, painful, and swollen, is in a condition of inflammation, while it is ne- 
cessarily at the same time in a state of perverted circulation. 
STUDY OF INFLAMMATION. 
Study of inflammation is seen to be one with study of perversion of cir- 
culation. In any and every case of perversion of the circulation there is 
disturbance of the equilibrium. It follows, per se, that treatment of disturb- 
ance is one with effort to restore equilibrium. A student is not wisely to 
commence by perplexing and confounding himself with inquiring into the 
refinement of this and that sign related with conditions described as simple 
vascular excitement, active congestion, and stagnation ; his primary and im- 
mediate concern is with the equilibrium of the circulation. It is not difficult 
to count a pulse nor to say of a part, it is over-hot or it is over-cold. Able 
thus to count, and say, it demands no special effort to conclude that a discovered 
disturbance of equilibrium lies with some cause. Existence of cause being 
accepted, a conclusion naturally follows that restoration of equilibrium lies 
with discovery of and removal of cause. 
These few and simple principles accepted, and thoroughly understood and 
appreciated, advance is to be made toward the aspect of perversion of the cir- 
culation, which, because of conditions and signs associated with it, is called 
inflammation. 
Inflammation caused by Presence of an Irritant.-Inflammation 
never exists but by reason of the presence of an irritant. 
By an irritant is meant anything that worries. Examples of irritants 
are to be instanced in referring to a splinter pricking the finger, to an exposed 
tooth-pulp fretted by crumbs or other foreign particles coming in contact with it, 1294 
A SYSTEM OF ORAL SURGERY. 
to a broken jaw, to a burn, to a ball shot into the flesh, to virus mingled with 
the circulation; in short, to anything of whatever nature that after any form 
or any method interferes with the natural condition of a part or of parts. 
Fig. 935. 
Fig. 936. 
Capillaries enlarged and made varicose from blood engorgement 
in inflammation. 
Appreciation of Irritants.-A splinter in the finger is to be seen, not 
unlikely, by the unassisted eye. A ball in the flesh is commonly to be located 
by the touch of a probe. Irritants, on the other hand, may be of a meaning, 
and be involved in an obscurity, that the widest examination to be made, in 
the light of modern science, fails to get comprehension of them. I NFL A MM A T10N. 
1295 
Result of Presence of Irritant.-An irritant not removed by being 
picked or lifted away, or by being antagonized by means of medicine, or after 
Fig. 937.-Uninflamed Wing of a Bat. 
Fig. 938.-Inflamed Wing of a Bat. 
other required fashion, is always attempted to be combated by nature, and it 
is the processes of this combat which medical science de- 
nominates inflammation. 
Local and General Disturbance.-An irritant of strictly local 
signification arouses local phenomena, while one of general import, as, for 1296 
A SYSTEM OF ORAL SURGERY. 
example, syphilis, is seen to be expressive of disturbance throughout the system 
at large. 
Inflammatory Effort.-Wherever and whatever the irritant, nature 
will surely make an effort to rid herself of it. Inflammation is to be under- 
stood as nature's effort to circumvent and to get clear of an offending body 
It is therefore to be looked on as a means of cure and not of hurt. 
Local inflammation differs nothing in principle from general inflammation. 
In both there is perversion of harmony in the circulation, both aim to cir- 
cumvent an offending agent, both show an excitement in the circulatory fluid 
expressive of aggressive attack on something. 
Illustrative Demonstration.-To understand, practically, the meaning 
of inflammation, the student will consider that he watches with the writer a 
case possessed of purely local signification. First, it is seen that an agent of 
offence has fixed itself in the flesh. Let us assume this agent to be a lead 
ball. No sooner has such an agent intruded than the sensorium, having gained 
cognizance of the fact, calls on the circulatory system for defence. This 
system inaugurates an inflammatory attack; that is to say, it takes on itself 
the office of isolating the ball from surrounding parts by pouring around it 
a mass of lymph. This lymph is an ingredient, or component, of the blood. 
It would not be at all amiss to liken it to the white of eggs. It is first a thin 
fluid, but later coagulates and becomes 
hard. In its solidification it compresses 
all blood-vessels which it envelops, thus 
cutting off nutrition from the parts in- 
filtrated. These parts, dying, slough 
away, and carry with them the offending 
agent in a stream of pus significant of 
the death. (Fig. 939.) 
Inflammatory Act.-The inflam- 
matory act is described commonly as 
consisting of the stages of simple vas- 
cular excitement, active congestion, stag- 
nation, suppuration. These terms have 
no other significance than that a condi- 
tion inaugurates where excess of blood 
begins to run toward a part (simple 
vascular excitement), that it in- 
creases as to amount until the part is 
engorged (active congestion), that later the part has become so filled that 
circulation can no longer go on (stagnation), and that still later out of the 
stagnation has come the death of the part (suppuration). 
It is seen that by the term suppuration is meant simply the breaking down 
of tissue by reason of absence of nutrition, and that such breaking down 
implies a lake, greater or less in extent, of pus (suppuration and pus being 
Fig. 939. 
Diagram showing process of circumval- 
lation. The centre shows the foreign body. 
The lines represent vessels. Circumscrib- 
ing the irritant, compressing the arteries, 
and shading dimly away is the lymph. INFLAMMA TION. 
1297 
synonymous), which pus is a means to float an offence away; a common boil 
is illustrative. A boil exists by reason of some particle that, to be 
gotten rid of, must be circumvallated and finally floated off. (See diagram.) 
Repair is an inflammatory act. The meaning of this is to resupply a 
part lost in the pus lake. It means simply that such lymph as remains begins 
to organize, explanation of this existing in the fact that it is beyond that line 
of compression from which the circulation was cut off. The lymph organizing 
is vitalized ; granulation after granulation springs out, until finally the destroyed 
part is renewed. The whole performance, as must be appreciated, is expressive 
of healthy effort, and is not to be interfered with, except for reasons. (See 
diagram, which shows the expression of circumvallation.) 
Inflammation of Systemic Import.-Inflammation of systemic 
import is illustrated in what is known as " taking cold." An individual 
exposes the whole or part of the superficies of his body to the action of a cold 
atmosphere. Cold contracts the capillaries of the skin. As a result of the 
contraction blood is driven from without inward. Here is interference with 
equilibrium. There is too much blood among the viscera, too little with the 
integuments. The derangement implies perversion of the circula- 
tion. The perversion of the circulation is inflammation. A man who has a 
cold is, in a sense, in a state of inflammation. 
Systemic Irritants.-A third and last illustration is found in consider- 
ing irritants which mingle with the blood at large, proving a source of offence 
that shows perversion at many points. To express this most simply we are 
justly to accept that emboli, significant of a vice, are caught at varying locali- 
ties, and that the perversions seen at these points are expressive of the phe- 
nomena of attempted circumvallation and expulsion. Syphilis stands as a 
prominent representative of the blood vices. 
Appreciating the meaning of inflammation, it is understood 
that whenever the condition is met with in practice a primary question relates 
with purpose and intention. In the case of a ball, not to be removed other- 
wise than through natural effort, it is assuredly desirable not to antago- 
nize, but to forward and assist nature's means. It is, however, to be con- 
sidered that circumstances alter cases, and that while, on principle, the ball 
should be floated away, yet because of relation of a part with vital organs, it 
may be a necessity to limit the action of disturbance all that is possible, or 
even, indeed, to abort it altogether. 
In perversion of the circulation arising out of taking cold, it is always 
an indication to remedy the derangement as speedily as possible. 
In perversions existing by reason of presence of irritating agencies in the 
blood, treatment is to be as immediate as may be. 
LOCAL TREATMENT OF INFLAMMATION. 
Inflammation meaning disturbance of equilibrium in the circulation, it 
follows that to restore equilibrium is to resolve inflammation. 1298 
A SYSTEM OF ORAL SURGERY. 
Whatever means tend to restore a lost equilibrium in the cir- 
culation is the proper and scientific treatment of inflammation. 
Primary Indication.-First, an inflammation being understood never to 
exist but in the presence of an irritant, attention to the irritant is a primary 
indication. A splinter in the flesh is to be lifted away if possible, a ball or a 
diseased tooth is to be extracted, a broken jaw is to be set and quieted, a 
virus of specific nature is to be antagonized by specific remedies, influences of 
cold are to be corrected by repairing broken windows or assuming protective 
clothing. 
An irritant removed, it is commonly the case that inflammation 
cures itself; that is to say, the cause of disturbance in equilibrium being 
away, equilibrium comes back. 
Secondary Indication.-When, upon the removal of an irritant, an 
inflammation does not resolve itself, or when reason exists for modifying or 
aborting an inflammation, means are at once to be employed which tend to 
disgorge over-full parts, restoring the excess to parts under-full. 
Over-full parts are in a state of distention. They are so because the 
office of contractility has been put in abeyance by reason of the unnatural 
afflux of blood. To relieve this distention implies simply removal of the 
cause. The cause away, the vessels regain of themselves their normal calibre, 
accommodating consequently only that amount of blood natural to the circu- 
lation of the part. The amount of blood natural to a part circulating in 
this part, it follows that no inflammation is present; if it existed it has been 
resolved. 
Getting Blood away from a Part.-Great variety in means and 
manner relates as regard is had to getting blood away from a region. If too 
much blood exist in a part above the lower limbs, a plan is to immerse feet 
and ankles in warm water; warm water relaxes. Feet placed in warm water 
are found quickly to grow red, to become engorged; really to assume the in- 
flammatory condition. The excess of blood called to the part as the result of 
the relaxation invites from the seat of primary congestion such excess as has 
in it the meaning of the distention. Relieved of the distention the part re- 
covers its contractility, and is thus found cured. The feet, by reason of being 
in a condition of perfect health, are seen to be able to take care of themselves 
and to drive the excess of blood from the capillaries, the process of self-relief 
commencing quickly after the removal of the irritant,-i.e., the relaxing water. 
The blood returning from the feet cannot throw the excess back on the seat of 
original engorgement, provided time and condition have allowed the part to 
recover its tone. When tone has not been recovered the inflammation is not 
found cured, and the foot-baths are to be repeated and other means of relief 
added, otherwise the other means employed alone.* 
* Inhibitory Nerves.-A student will find large profit just here in a physiological study 
of the inhibitory nerves. INFLA MM A TION. 
1299 
Dry Cups.-Dry cups are an admirable agency of derivation. As- 
suming, for example's sake, that an inflammation is related with the enveloping 
membrane of a tooth, by the placing of a dry cup upon the cheek and a second 
on the back of the neck, relief to the part is apt quickly to follow the abstrac- 
tion of blood, the change of position in the fluid being witnessed in the red 
and engorged swellings formed under the cups.* The suction-cup is a means 
of convenient application. (Fig. 940.) 
Wet Cups.-Wet cupping is another plan. This relieves by running 
blood out of a part. In the plethoric the means commends itself, in the 
anaemic it is oftentimes of double propriety. To wet cup, a dry cup is 
first applied. When this has en- 
gorged the part, the blades of a 
scarificator are stuck into the part 
and the cup reapplied as before. 
The suction quickly fills the vessel 
with blood. (See, for scarificator, 
Fig. 608.) f 
Use of Leeches.-The use 
of leeches is another manner. Two 
kinds are used in practice, the 
Swedish and American. A Swedish 
leech sucks half an ounce of blood, 
the American a less, but an unde- 
termined, quantity; the former is 
to be preferred. To apply the 
worms it is usually necessary to 
hold them against a part by means 
of a wineglass or goblet. Where 
leeches refuse to bite sweetened water may be smeared 
over the part. Another plan is to prick the skin until a 
few drops of blood are obtained, this being spread after the same manner as 
the sweetened water. The use of what is known as the artificial leech saves 
much trouble where it is of convenient application. It is a suction instru- 
ment. (Fig. 941.) 
Use of Fly-Blisters.-Abstraction of water from the blood by use of 
Fig. 940.-Suction- 
Cup. 
Fig. 941. - Arti- 
ficial Leech. 
* Dry Cupping.-To dry cup means simply to take a common wine or other glass and to 
put in it a wisp of paper saturated with alcohol. When ready to attach,-that is, having one 
edge of the rim resting against the skin,-a lighted match is applied and the full circumfer- 
ence instantly pressed to the skin. To remove a cup, the integument is pressed from the 
outside away from the rim. 
f Another manner of wet cupping is in the use of a fleam, or lancet. A cup being ap- 
plied after the dry manner, and excess of blood brought to the part, the point of a knife may 
be stuck into the skin in a number of places and the dry cup reapplied. Here the vacuum 
made draws the blood from the wound, filling the cup. Surrounding parts are of course 
relieved of the excess, contractility being thus secured. 1300 
A SYSTEM OF ORAL SURGERY. 
a fly-blister is a means applicable to underlying inflammation,-of a joint, for 
example. Take of the fly-plaster, as prepared by druggists, a square or strip 
of size required and place upon the skin above the diseased part. This is 
allowed to remain from eight to twelve hours, according to susceptibility of 
the tissue. On being removed it is to be replaced by a poultice of bread and 
milk, which poultice is kept on until it is seen that much serum occupies the 
space between the epiderm and true skin. The object being to drain, the 
bleb is pricked with a needle and the poultice reapplied, pricking and poultice 
to be continued so long as water comes, or until indications are met. 
Venesection.-In inflammations of threatening import involving vital 
parts, bleeding from a vein is a practice which cannot be over-commended. A 
vessel commonly selected for the operation is one at the bend of the 
arm that does not occupy the centre line; this line being the position of the 
brachial artery, which, in the region, is separated from the veins by the thickness 
only of the bicipital aponeurosis. To open a vein the operator commences 
by placing a constricting band between the proposed seat of performance and 
the heart. Fig. 942 shows the anatomy of the parts. The crossed vessel is 
the brachial artery. The bicipital aponeurosis is seen passing between vein 
Fig. 942.-A Study. 
Fig. 943.-Thumb Lancet. 
Fig. 944.-Spring Lancet. 
Arrangement of veins, bra- 
chial artery, nerves, and bi- 
cipital aponeurosis at the bend 
of the arm. 
and artery; it is hardly thicker than foreign post writing-paper. The blood 
being dammed back in the locality through means of the constriction, and the 
veins swelling to a greatly-increased diameter, it remains simply to open the 
one selected, by means of an oblique incision; a curved bistoury of sharp INFLAMMATION. 
1301 
point being employed, otherwise a lancet, thumb or spring, as portrayed by 
Figs. 943 and 944; the first much preferably to the second. If an open vein 
refuse to .bleed, the fist of the patient is to be opened and shut many times. 
If this fail, it is more than likely that the overlying skin interferes with the 
egress, or that a freer cut is required to be made in the vein. 
To Check the Flow of Blood.-To check bleeding from a vessel 
the band is to be taken away, and a compressor, retained by a figure-of-eight 
bandage, is to be bound upon the wound. 
Antiphlogistic Applications.-In parts suffering from inflammation 
where exposure is immediate and direct, as, for example, a cheek, the neck, or 
ear, medicines known as antiphlogistics apply. Antiphlogistic remedies act 
after two manners: 1, constricting the capillaries, thereby driving the blood 
out of them; 2, sedating the nerve irritability of a locality, thus relieving 
the vessels of a fret that worries and goads them. In the direction of the 
first, means are alcohol, phtmol-sodique, cold water, hot water, and medicated 
water, so applied as to permit of rapid evaporation. A medicated water 
known to surgical practice the world over is as follows: 
U Plumbi aeetatis, 3ij > 
Tincturae opii, §ij; 
Aquae, Oij. M. 
This is applied by means of cloths kept constantly wet, or mixed into poul- 
tices of bread-crumbs. Where abscess is inevitable, perhaps 
desirable, yet where at the same time necessity exists for limiting as much 
as possible the inflammatory area, it is the practice of the writer to apply 
flaxseed poultices, moderately cool, every portion of which, except the part 
immediately overlying the centre which it is desired to break down, being fully 
saturated with the lotion; the centre being warm as well as unmedicated. 
Phenol-Sodique.-This agent, which is of valuable signification in the 
direction, is used by means of pieces of cloth saturated with the preparation, 
one-half diluted with water, and kept applied to the part. Phenol is antiphlo- 
gistic and antiseptic; it applies particularly in hospital practice where reason 
exists to fear the influence of septic conditions; it is markedly sedative. The 
writer always uses phenol in his surgical operations, depending on it wholly 
for what is called Listerism. 
Hydrochlorate of Ammonia as a Sorbefacient.-Hydrochlorate 
of ammonia in proportion of 3iij to Oiv is a good sorbefacient antiphlogistic, 
applicable particularly where, in the inflammatory act, an undesirable quantity 
of lymph-the circumvallating material-has been thrown out. It is not 
so good, however, as is lead-water and laudanum preceded by paintings of 
tincture of iodine. 
Goulard's Extract.-Goulard's extract is a favorite antiphlogistic. To 
use it a mixture is made in proportion of §ij to water Oj. It is placed by 
means of saturated cloths. 1302 
A SYSTEM OF ORAL SURGERY. 
Hamamelis Virginica.-As applications acting from the stand-point 
of sedation, reference is to be made to tincture of hamamelis virginica, to be 
much diluted with water; to laudanum conjoined with an equal proportion of 
sweet oil; to moist plantain leaves; to decoction of poppies or of hops; to 
steam. All these are applied with reference to keeping the parts unexposed 
during an interim of necessary changing. 
Rest as a Factor.-Rest is to be numbered as among the important 
features in treatment of an inflamed part: a broken arm is to be splinted; 
capping of neighboring teeth applies where periodontitis exists; a diseased 
stomach is to be spared to all possible extent in its functional work; a lung 
affected, the fewer respirations the better. 
Veratrum Viride and Bromide of Potassium.-Every inflam- 
mation implies disturbance alike of the nervous with the circulatory system. 
In every inflammation it may be necessary to direct remedies to the quieting 
of both systems. Considering as a type that perversion of the circulation 
which arises out of " taking cold," few combinations act more curatively than 
a mixture of tincture of veratrum viride and the bromide of potas- 
sium ; the first affecting directly the circulation, the second the brain. A 
formula is as follows : 
U Tincturae veratri viridi, gtt. xx; 
Potassii bromidi, ; 
Aquae, ^ij. M. 
Sig.- A tablespoonful to be taken on going to bed, and to be repeated twice or thrice the 
succeeding day, if found necessary. 
Dover's Powder.-A second valuable medicine in this same direction 
is found in Dover's powder : 
U Pulveris ipecacuanhas et opii, gr. xl. 
Chart. No. iv. 
Sig.-One to be taken at bedtime, and repeated twice or thrice next day, if required. 
Febrile Condition.-A free pulse, hot skin, and general febrile dis- 
turbance are treated happily by tablespoonful doses of the following mixture, 
repeated each three or four hours, according to urgency: 
R Liquoris potassii citratis, ^iij; 
Spiritus aetheris dulci, 3SS j 
Antimonii et potassii tartratis, gr. ss; 
Morphias acetatis, gr. j. M. 
Epsom salts is an admirable anti-inflammatory agent of constitutional 
expression; it reduces the volume of blood by reason of producing watery 
stools; the dose is a tablespoonful dissolved in a full goblet of water. IN FL A MM A TION. 
1303 
Another agent of this same class is elaterium : 
U Extracti elateri, gr. j. 
Ft. pil. No. viii. 
Sig.-One to be given every two hours until copious watery evacuations are secured. 
Another means, one acting as a diaphoretic, the spiritus Mindereri, 
is a favorite with the writer: 
U Liquoris ammonias acetatis, ^iv. 
Sig.-Put the patient in bed, cover with blankets, and give in tablespoonful doses every 
fifteen minutes until profuse perspiration is secured. 
Domestic Mode of Sweating.-Still another manner of sweating 
serum from blood is to place a patient upon a cane-seat chair beneath which a 
bucket of water, kept steaming by means of hot bricks, has been put; the 
patient to be supplied freely with hot drinks and wrapped about with a 
blanket which extends to the floor, enveloping the bucket. Care is required in 
taking a person from such a steam-bath ; he is to be rubbed dry by means of 
towels used beneath the blanket, and is to be exposed for the shortest possible 
time while a change of clothing is being made. 
Diet as an Element in Treatment.-Diet is an element in the 
treatment of inflammation ; articles that never hurt are tea and dry toast. 
Water-ice, ice-cream, and acidulated drinks are found both refreshing and 
profitable. 
Cooling the Surface of Body.-Where much heat of surface exists, 
no means familiar to the author equals sponging with pure alcohol. 
Generally it is the case that in febrile disturbance the regions of the spine, 
thorax, and abdomen are burning. A plan that commonly yields inexpressible 
relief consists in a few minutes of bathing with the alcohol, then drying by 
means of a soft towel; the bathing and drying to be repeated until the parts 
are entirely cool and remain so. The writer uses his hand in place of a 
sponge. Placing the hands and wrists of a febrile patient in ice-water is an 
admirable means of refrigeration, the cooled blood being carried from the parts 
over the general system. Tincture of digitalis, acting as an inhibitory, 
controls and quiets the pulse markedly. The dose is ten drops of the tincture, 
repeated every three or four hours. 
Diuretics.-Diuretics commend themselves where a derangement is of 
such trifling import that it is justifiable to treat the patient without confine- 
ment to the house; in common colds, for example. Sweet spirits of 
nitre is a favorite preparation in this direction; the dose is a teaspoonful, 
repeated three times a day. Spirit of Mindererus, referred to above, is much 
employed by the author. As intended to act upon the kidneys the dose is a 
dessertspoonful, the external parts of the body being kept cool, so that its 
action shall not tend to the skin. 1304 
A SYSTEM OF ORAL SURGERY. 
Narcotics.-Opium and its preparations, used with a view to the narcotic 
quality, seems, to the experience of the writer, to be ill-advised practice. In 
the Oral Hospital the medicine is never given but in emergencies. Like 
with the use of chloroform, employed as an anaesthetic, inflammatory condi- 
tions seem impressed with characteristics of depression. It may be, and 
undoubtedly is, occasionally necessary to employ full doses of opium, but such 
necessity is a matter to modify anticipations of a generous cure. 
Where inflammation associates with wounds, or exists in other causes, and 
where sedation is an indication, no medicine surpasses, if it equals, the potas- 
sium bromide. As a dose this may be pressed from thirty grains to one 
and a half drachms. A practice with the writer is to order a mixture con- 
taining ninety grains, and to exhibit this in three equal parts, if found 
required, at intervening periods of four hours. It is to be observed that 
the medicine is not to be taken until external circumstances favor the falling 
asleep of the patient. 
Hyoscyamus and Belladonna.-Hyoscyamus and belladonna com- 
bined in a suppository commonly act favorably. 
Extracti hyoscyami, gr. xx; 
Extracti belladonnas, gr. ijss. 
The proportions are to be mixed up with cacao butter and divided into ten 
suppositories. The application is by rectum; one three times a day. In 
connection with this combination morphia has seemed to the author to be 
least objectionable; one-quarter of a grain of the sulphate added to each 
suppository induces speedy sleep ; half a grain, if pain be great, as, for 
example, in phlegmasia of the skin or cellular tissue, in rheumatic or gouty 
inflammation, is not at all an overdose. In visceral inflammation, where 
control of movement is a necessity, there is nothing that seems able to do the 
work of opium. Being the only medicine to be used, it is best given in full 
doses. The writer has frequently met with conditions of irritable bladder 
where, to prevent the patient from being worn out, morphia had to be given; 
this, however, as must be appreciated, from the fact only of an inability to 
learn of and to treat the direct cause of the trouble. In conditions of pleuritis 
and of inflammation of the lungs morphia applies, and is to be employed 
where extreme irritability is not otherwise to be subdued. 
Specific Inflammation.-Specific inflammation having existence by 
reason of the presence of a source of irritation specific in its nature, a treatment 
required is to be with special signification; the poison, or agent of 
offence, is to be antagonized. Syphilis is a specific agent of offence 
that shows many expressions. Here, local conditions are to be met on the 
grounds of common indications; but, associated with these common means, 
medicine specifically antagonistic to the virus is not to be omitted. The 
medicine required is mercury,-an agent found too often not less full 
of evil than of good. The writer, deducing from the experiences of many I NFL A MM A TION. 
1305 
years, recommends the bichloride. Where employed at all judiciously he 
has yet to fault the preparation in a single instance. His own usual prescrip- 
tion is as before given. (See page 902.) 
R Hydrargyri bichloridi, gr. ij; 
Potassii iodidi, 3ij > 
Aquae, §iij. M. 
Sig.-Teaspoonful three times a day, before or after meals, as found least objectionable. 
Iodide of Potassium.-In all conditions of syphilis, primary, second- 
ary, and tertiary, it is the practice of the author to give this combination in 
connection with whatever local remedies it seems necessary to employ; the 
iodide of potassium, if not useful in the first and second of the stages, is cer- 
tainly not likely to be found hurtful, if judiciously prescribed. On the contrary, 
it has always seemed to add activity and curative virtue to the mercurial. 
Malarial Complication.-In perversions of the circulation arising out 
of malarial poisoning the antidote is quinine. In acute attacks, where the 
disturbance associates with certain periods of the day, as in the instance of 
quotidian intermittent, the specific is to be employed only in the interim of 
attacks. Ten grains of quinia sulphatis, given in divided doses when the 
fever has passed off and before the chill comes on, being repeated during 
from two to half a dozen interims, destroys the cause of the disturbance, conse- 
quently cures the evil. In conditions of malarial disturbance, where the 
cause is not of sufficient force to produce paroxysms, yet induces the state 
of malaise, no specific means better than the following is to be employed. 
Take of powdered red Peruvian bark (cinchona rubra) one ounce, of 
powdered Virginia snakeroot (serpentaria Virginiana) half an ounce, put 
the two together into one and one-half pints of water, simmer to one pint; 
when cold, strain, and add one pint of Lisbon or other red wine having 
an alcoholic strength of not less than twelve per cent. The dose is a wine- 
glass, containing two tablespoonfuls, before meals. 
Specificity residing with Iron.-The specificity of diphtheritic in- 
flammation, as of ordinary erysipelas, demands iron; this to be used externally 
and internally. In treatment of this inflammation it is a practice of the 
writer, resultant of his experience in the direction, to administer from five to 
twenty drops of the muriated tincture of iron every three hours, and to apply 
to the throat the iron, quinia, and cinchona mixture (see Erysipelas), by 
means of a camel's-hair brush, at least six times a day. With a view to dis- 
solving the exudate as it forms, free local use is made of Watson's chlo- 
rine water, full strength, used with the brush, or, when the deposit has 
reached the trachea, by means of a hand or steam atomizer. It is to be 
recommended that the steam atomizer keep the atmosphere quite continuously 
impregnated with chlorine. With this as the specific treatment, aided by ad- 
juncts of a character suited to indications as they may offer, the writer finds 
himself able to claim a reasonable share of success in the direction. 1306 
A SYSTEM OF ORAL SU ROE RY. 
Scrofulous Inflammation.-Scrofulous inflammations demand special 
attention to the general lymphatic indolency which begets them. Treat- 
ment is tonic; salt sheet-baths, milk, drank in quantities of two quarts a 
day, cod-liver oil, ferrated wines, exercise, rough and exhilarating as it can be 
borne. In scrofulosis the perversions are always of indolent 
expression ; no acute symptoms show themselves. As a local application to 
glands and parts indurating, the following combination is to be employed with 
much satisfaction: 
g Tincturaa ferri chloridi, ; 
Tincturae iodinii, ^ss; 
Quiniaa sulphatis, 3ss; 
Tincturae cinchonas, SU- M. 
Sig.-To be painted over the part thrice daily. 
Activity and Chronicity in Inflammation.-Inflammation is to 
be considered from the stand-points of activity and chronicity. Active, or 
acute, inflammation signifies response, to the presence of an irritant, that runs 
a rapid course. It would not, perhaps, be easy to provide a better illustration 
of acute inflammatory action than is exhibited in the common boil. The phe- 
nomena are open, free, and follow each other successively, if not interfered 
with. 
Indications in Active Inflammation.-Indications in active in- 
flammation are always of an antiphlogistic nature. The force of the heart's 
action is to be lowered. The pores of the skin are to be relaxed and opened. 
The bowels are to be softened. Cool applications are to be made to the part 
affected. 
Indications in Chronic Inflammation.-Chronic inflammation, 
on the contrary, is expressive of exhaustion and of sluggishness. It is that 
condition too often encountered on the subsidence of acute attacks where the 
irritability of parts seems worn out, where capillaries are over-full of blood, 
yet unable to contract upon and expel it. It is a condition where everything 
is in abeyance, growing neither worse nor better. It is a state where demand 
exists for external help, and this help pertains not to depression, but to stim- 
ulation. The indication is for supply of lacking force. To accomplish the 
requirement demands the unloading of capillaries, and the putting into the 
parts of such activity as shall enable them to recover and preserve the lost 
equilibrium. An expression of chronic inflammation very familiar to the 
oral surgeon is seen in scorbutic gums. The parts are spongy, turgid with 
blood, are purplish-red in color, are fallen away from the teeth, about which 
organs pus is exuding; they look as if mortification was to terminate the con- 
dition.* Ulcerations occurring in scrofulosis and in syphilis furnish other 
illustrations. In neither of the latter lesions is there any sign that is open 
and generous. Everything is indolent and expressive of degeneration. 
* This is one of the conditions of pyorrhcea alveolaris. I NFL A MM A TION. 
1307 
To unload capillaries passively or chronically congested, 
depletion is almost always a necessity. Certainly the radicles cannot recover 
normality unless relieved of blood. This unloading is commonly to be accom- 
plished by pricks or slits, made by means of a bistoury.* When deple- 
tion is obtained, a valuable succeeding performance consists 
in free painting with a sorbefacient of stimulating attributes. Of such 
medicines there is nothing superior, if indeed equal, to the ordinary officinal 
tincture of iodine. This tincture not only excites, but it favors attempt 
at renewed action by arousing the lymphatics to removal of lymph and sero- 
lymph effusions with which such parts are found burdened. Aromatic 
sulphuric acid in dilution is an alterative stimulant of happy signification. 
Another, one of great virtue, is the tinctura capsici et myrrhae, used 
pure, applied'by means of a brush, otherwise diluted with water to meet indi- 
cations. It is seldom that, in the practice of the author, this last is not 
pressed into service at some stage of the treatment of chronic inflammation. 
Mercury is to be commended when employed with discretion by the experi- 
enced. It is a remover of indurations, but is an agent capable of an evil 
far excelling any good that it may do. Tincture of erigeron is an expressive 
stimulant. Still another is the compound tincture of benzoin. 
Where it is desired to constringe, and at the same time to cover a surface, an 
admirable medical varnish is made by thickening muriated tincture of 
iron with sulphate of quinia. Touches with chloride of zinc or with 
nitrate of silver are sometimes found of valuable import in chronic conditions. 
A most excellent means for renewing vitality in a part is found in Volta's 
pile. To make this requires simply strips or squares of sheet-zinc and cop- 
per, between which is placed a piece of cloth kept wet with cider vinegar; 
care is to be exercised that it do not blister. 
General Tonicity-Sheet Salt-Bath.-Conjoined with local cure, 
chronicity, where of any extent of signification, requires systemic considera- 
tion. This is to be always a treatment of building up, and it varies neces- 
sarily with the disease and circumstances of a patient. A means of 
general import for good is found in the sheet salt-bath. To apply this, 
Turk's Island salt is put into a small tub of water (enough being added to 
give it the taste of the sea), and in this a coarse sheet is placed. The bath thus 
made ready, the patient steps into the tub, and the sheet being thrown quickly 
about him, he is rubbed, or rubs himself, until the skin is aglow. In the use 
of this bath regard is to be had to the immediate effect. If, instead of a glow, 
the patient comes from under the manipulations cold, depressed, the surface in 
the condition of goose-flesh, the cold water is to be changed for hot, or, the 
bath being taken in the morning, a goblet of milk in which a tablespoonful of 
* Pancoast's Antiphlogistic Touch.-Professor Pancoast, a hospital colleague of the 
writer, has devised what he calls an antiphlogistic knife, which he uses for the antiphlo- 
gistic touch. It is not unlike a tenotome, but is of spear-shape. Cuts or punctures can 
be made with it almost without pain to a patient. 1308 
A SYSTEM OF ORAL SURGERY. 
whiskey or brandy, together with the yolk of an egg, have been placed, may 
be drank a quarter of an hour before getting out of bed. Milk is an ad- 
mirable medicine ; two quarts may commonly be taken in the course of 
a day with benefit. Oils and oleaginous foods are indicated in every 
case of tuberculosis. Hill-sides and the sea-shore, and roughing it where air 
is pure and water good, are means not wisely neglected when a condition of 
depression is serious. Attention to habits is of consequence ; excesses of any 
kind bear to be inquired into. 
Massage.-Massage is a means tending to restoration of lost general ex- 
citability most worthy of careful study. To massage a person means 
simply to rub and to knead his flesh. Few better methods of dispersing in- 
durations exist than is found in this practice. An induration is to be rubbed 
toward more vital parts. The acts of massage relate with both' the vascular 
and lymphatic systems, meeting thus two indications at the same time. 
A feature of chronic inflammation annoying and defying 
as to treatment relates with an inability shown by parts to retain advantages 
apparently secured. This is to be estimated in the treatment of a case, that 
discouragement do not ensue. A part will hold its own when fully recovered 
from depression, not sooner. 
Chronic inflammation associated with joints favors plastic 
effusion, apt to result in false, or possibly in true, anchylosis. Related with 
the lymphatics, scrofulosis or tuberculosis ensues; if existing with the viscera, 
adhesions form; if in the tonsils, hypertrophy is developed; in mucous 
membranes, sub-infiltrations and strictures follow. 
Suppuration.-By suppuration is meant nothing different than that nu- 
trition in a part, showing the phenomenon, is incapable of perfecting itself, 
consequently that food elements brought to the locality, in place of accom- 
plishing the process of organization, proceed a certain space in the direction, 
then undergo degeneration and roll away in the shape of pus-corpuscles. 
Redness, Heat, Pain, Swelling, Functional Disorder.-Red- 
ness in an inflamed part signifies coloration by the excess of blood that 
is in it. Color varies. In syphilitic inflammation it is like to copper. 
In erysipelas it is a glistening red. In the skin, and associated with mucous 
membranes, being of non-specific character, it is scarlet. Affecting the iris, 
it is commonly brick-colored. In scrofulosis it is not unlikely to be a 
yellowish-purple. When gangrene is threatened the color is gray, brown, or a 
brownish-black. 
Heat.-Heat signifies increased nutritional activity. It relates also with 
friction existing in an accelerated circulation. 
Pain.-Pain is a factor not fully comprehended. That it is not an un- 
mitigated evil is proven in the fact of its acting as a Warner, affording under- 
standing of the condition of diseased parts. Pain begins with a perversion, 
and accompanies it until the suppurative act is reached, when it gradually 
subsides. In an inflammation it is commonly greatest at the central point of INFLAMMATION. 
1309 
obstruction, and shades off proportionally with the clearing of the circulation. 
Pain exists with the nerve radicles, consequently the phenomenon is to be 
studied in relation with the nervous system. To pinch is to produce pain. 
Nerves related with inflamed parts are pinched by the effusions. Pain, like 
color, varies : associated with serous membranes it is sharp, with mucous 
membranes it is dull, in cellular tissue it is throbbing, in the bones it is 
gnawing, in the testicles it is sickening, in the urethra it is scalding, 
in the kidneys, spleen, liver, and lungs it is a heaviness or soreness, in gout 
it is twinging, in rheumatism it is constricting. 
Pain is proportional with the temperament and irritability of a patient. 
The lymphatic person suffers little, the nervous one much. That long con- 
tinuance of pain wears out vitality is not to be doubted. Pain, when in ex- 
cess, is to be narcotized. Being bearable, without too great discomfort, it may 
be left to its office of sentinel, affording information as to a patient's condition. 
To narcotize pain is not necessarily to be in the line of cure 
of a case. To cure a case, however, is to be certainly rid of pain. 
Pain is not the associate of inflammation alone. There is the 
pain of spasm, the pain of neuralgia, the pain of colic, the pain of anaemia, 
the pain existing in the functional disturbance of organs, growing pains, 
reflected pains. 
In inflammations of vital organs the sudden cessation of severe 
pain where no opiate has been used is a sign of threatening import, implying 
too often that mortification has set in. 
Morphia is the most reliable of pain-obtunding agencies. 
A standard preparation is the liquor morphias sulphatis; the admixture is a 
grain of the salt to an ounce of water; the dose, from a tea- to a tablespoonful, 
according to urgency. The liquor morphiae bi-meconate is another 
admirable mixture; the strength is to be that of laudanum ; the dose, twenty- 
five to fifty drops. Paregoric (tinctura opii camphoratas) is used with in- 
fants; the dose is five drops for each year. Morphia, hypodermically 
injected, is in universal favor: a quarter of a grain is dissolved in ten drops 
of blood-warm water, and by aid of a needle-pointed syringe is thrown beneath 
the skin. Dover's powder is an admirable medicine as an opiate; being 
a combination of ipecacuanha with opium, it is not less antiphlogistic than 
narcotic. In common colds, having painful associations, few agents are found 
superior to ten-grain doses of this preparation. Other formulae of the medi- 
cine are known as vinum opii, acetum opii, confectio opii, extractum opii, 
morphiae acetas, etc. 
Swelling.-Enlargement of an inflamed part has its meaning in simple 
engorgement, in effusions, and in expressions of hypertrophy. In every in- 
flammation there is, primarily, excess of blood in a part; necessarily, measure- 
ment is increased. Effusions are of two kinds, serum and lymph : the 
first is a condition of a simple oozing from attenuated blood-vessels of the 
water of the blood; the second is a vital act, and expresses intentions looking 1310 
A SYSTEM OF ORAL SURGERY. 
toward the act described as circumvallation. A watery effusion is elastic to 
the touch, and by manipulation is quickly to be pressed from a part into which 
it has flowed. A plastic infiltration, on the contrary, is of dough-like con- 
sistency, and is not to be gotten rid of without much trouble. Swelling is 
beneficial or the reverse. It is the former where the effusion has relieved the 
tension in blood-vessels and permits of a restoration of contractility; it is the 
latter where it is of a character choking and interfering with the functions of 
a vital organ. Hypertrophy means overgrowth; the liver, the spleen, and the 
heart furnish too frequently examples. 
Functional Disorder.-By functional disorder is meant matters of local 
and of general import. All organs show exhilaration of function in the con- 
dition of simple vascular excitement. On " taking cold," excess in the circu- 
lation being directed to the nostrils, " cold in the head," as it is termed,- 
increase in the secretion of the Schneiderian membrane,-is familiar in the 
" running of the nose." Vascular excitement, progressing to the condition of 
congestion, function is diminished, not unlikely temporarily suspended. Sus- 
ceptibility is increased ; parts that are almost without feeling when in 
health become vividly sensitive to impressions when inflamed. Special senses 
are modified ; the ear, the tongue, the tactile papillae, the eye, all show derange- 
ment influenced by the circumstances of each particular case. In the instance 
of the kidneys, an acute congestion may quickly result in uraemic poisoning 
by reason of suppression,-a most dangerous condition, that, happily, is to be 
quickly and easily remedied by means of dry or wet cups used about the 
loins. Enlargement of the prostate gland results in retention of the con- 
tents of the bladder,-an accident less formidable than the immediately pre- 
ceding, but scarcely less alarming. Congestion of the lungs afflicts with 
dyspnoea, the intervesicular circulation being of an extent that compresses 
the cells. Irritability of the general circulation, if at all excessive, results 
in fever. Changes in nutrition necessarily relate with inflammation ; this for 
the reason of variation in quantity of blood brought to a part. In simple 
vascular excitement, nutrition, as suggested, is increased; this solely for the 
reason that free feeding and ability to appropriate exist. On the contrary, 
where congestion is present, that cell-action, in which resides nutrition, is 
antagonized; the work of assimilation cannot go on in presence of crowding. 
Changes in the Blood.-Besides nutritional changes, alteration shows 
in the circulatory fluid itself. Examining the contained blood of vessels 
related with an inflamed part, great increase is found in the number of the 
white, or pabulum-carrying, corpuscles, while at the same time the tendency of 
these bodies is to secure place about the sides of the vessel, the red corpuscles 
being crowded, not only toward the centre, but also closely packed together 
by the flat sides of the disks, after the manner of a rouleau of gold coin. 
The meaning of the excess in the white corpuscles, which is not relative, but 
real, is appreciated in referring to their meaning as the circumvallating agency. 
The fibrin of irritated blood is increased commonly several per cent.; change INFLAMMA TION. 
1311 
being at times as great as from ten to twelve per cent, over the ordinary 
amount of two and a half. The clotting of inflamed blood is slower than 
with the healthy fluid; this exists by reason of the close relation of the red 
corpuscles, the fibrin and the white 
bodies separating and not being caught 
and held in the coagulum. The 
huffy coat so characteristic in the 
blood of inflammation has its exist- 
ence in the union of the white cor- 
puscles and fibrin, contraction on the 
part of the latter agent explaining 
what is known as the cup,-i.e., the 
sunk centre and the elevated circum- 
ference of the clot, or crassamentum. 
Swelling and Hypertrophy. 
-Swelling and hypertrophy as asso- 
ciated with vascular perversion will be 
recognized as being antipodal. Swell- 
ing has its meaning, as has been de- 
scribed, in the simple increase of blood 
in a part, otherwise in effusions of 
serum or of lymph. Hypertrophy 
means growth; illustration is fur- 
nished in the second direction by the increased development of the biceps 
muscles of a boxer, and of the gastrocnemii of a ballet-dancer. 
Paradox of Congestion.-Evolved by the illustration just offered, 
attention is referred to a question as to the identity of excess of blood in a 
part with inflammation. Reference is to be made to the fact that erectile tis- 
sues engorge normally, and that, out of the application of a constricting bandage, 
much blood is dammed up in a part. Confusion as to this seeming paradox 
is avoided on the part of a student by his bearing in mind the subject of 
office, or meaning, as this refers to determination of blood to a part. If some 
words more explanatory seem needed, reference may be made to engorgement 
of the penis. Here irritation precedes the afflux not less surely than presence 
of a splinter invites excess to a finger; but the irritant is of a mental char- 
acter. The removal of such an irritant resides with the act of seminal emis- 
sion, otherwise with the passing away of a libidinous thought. An irritant is 
not less real by reason of being mental. 
Repair.-Inflammation not terminated by resolution, destruction of a part 
involved necessarily follows. Repair, like to destruction, is an inflammatory 
phenomenon. Referring to diagram (Fig. 939), it is understood that destruc- 
tion exists through compression by lymph. It is as well explained that 
lymph is the pabulum out of which structure is built, and that it needs alone 
relation with the circulation to establish it in vital meaning. An over-com- 
Fig. 945. 
Positions occupied in inflammation by blood- 
corpuscles; in the centre are the red, outside 
are the white. 1312 
A SYSTEM OF ORAL SURGERY. 
pressed part being sloughed away, all that remainder of the circumvallating 
lymph free of such over-compression begins to organize, and in the act accom- 
modates extension of blood-vessels, which, in turn, supply to the new surface 
more lymph, which lymph repeats the acts of an underlying portion until, in 
repetition, a cavity is filled. 
Lymph, as now understood, breaks down in the form of pus, or it or- 
ganizes, or it is absorbed finding its way back into the blood whence it came. 
The subject of lymph invites to and furnishes wide and curious study. 
Much objection is urged by pathologists to accepting it as a fluid exuded by 
the blood-vessels. It is a common 
view that cell proliferation, or seg- 
mentation by existing cells, is the 
meaning of repair after suppurative 
destruction. Cohnheim considers and 
teaches the identity of lymph and 
white blood-corpuscles. As seen by 
the clinical observer, lymph is an 
opalish-white plastic substance, differ- 
ing little, when first exuded, either as 
appearance or apparent characteristics 
are concerned, from ordinary albu- 
men. Continued to be watched, ten- 
dency in the fluid to coagulation is 
observed, which coagulation, or solidi- 
fying, increases until a part occupied 
by an effusion may come to feel hard 
as a board. The writer, not at all unwilling to commit himself, offers it as his 
view that the material called lymph is a combined expression of the natural 
succulency residing in parts, in addition with fibrin, albumen, salts, a certain 
amount of water, and an indefinite number of white corpuscles coming direct 
from arterial radicles. (See Lymphatic Vessels.) 
To affirm that tissues are built out of lymph is not at all to dispute the 
doctrine of Virchow as to cell segmentation. Organization of lymph means 
very much the same as what is meant by an egg mass, as out of this is built 
by the germinal spot a chick. 
Fig. 946. 
Nutritional pabulum exuding through the 
walls of vessels. CHAPTER LXXVIL 
ERYSIPELAS. 
Erysipelas is a form of inflammation so distinctive, and so formidable 
when mismanaged, as to demand for its appreciation a special study. 
Diagnosis.-This lies with a shiny blush and tension of skin associating 
with, or developing upon, a surface that has been the locality of a surgical 
operation. 
Idiopathic.-Cases offer where, no operation having been done, inflamma- 
tion of the skin and deeper parts appears without appreciable cause. These 
cases are almost invariably of erysipelatous character and require to be so 
considered and treated. 
Tendency to spread.-The term erysipelas signifies red skin, other- 
wise, tendency to spread, which latter is a distinctive feature of the condition 
and wherein most frequently lies the danger. A common name for the disease 
is St. Anthony's fire. 
Expressions vary.-The expressions of erysipelas are apt to vary with 
the state of health and surroundings of a patient; hence a division of forms, 
commonly made by authors, into simple, phlegmonous, oedematous, and erratic. 
Simple Erysipelas.-By simple erysipelas is meant an open, uncompli- 
cated expression limiting itself to the skin. The signs are a glistening, bright 
redness, a stiff feeling in the part, and, not infrequently, a burning or tingling 
pain. Sometimes there are little vesicles, but more frequently none. Swelling 
is inconsiderable. Constitutional disturbance is slight or absent. This is that 
form of the disease met with frequently in the treatment of ordinary inflam- 
mation existing in a traumatic origin. Termination is by furfuraceous 
desquamation of the epiderm. Resolution is commonly secured at the ex- 
pense of little anxiety or trouble. Age is alike subject to it with youth. 
Treatment.-The author finds a specific which has never yet failed 
him in the following formula: 
Ji Tincturae ferri chloridi, gj ; 
Tincturae cinchonae, 3'j J 
Quiniae sulphatis, 3j- M. 
This preparation is used by means of a camel's-hair brush, being painted 
freely over the part every hour, half-hour, or fifteen minutes until a black 
coating is secured and the skin loses its tension and begins to wrinkle. The 
erysipelas is to be accepted as conquered only when the redness ceases 
1313 1314 
A SYSTEM OF ORAL SURGERY. 
to show through the application. It is well not to be hasty in discontinuing 
the painting. In a rough, thick skin the cinchona may be lessened in 
quantity. In the delicate skin of a lady or an infant it is to be increased. 
If, in association with the simple form of erysipelas, there 
be found derangements of the system at large, such derangements are to be 
corrected precisely as under ordinary circumstances. 
Costiveness.-Costiveness, recent or habitual, finds correction according 
to indications. Plethoric people are always wisely purged by means of Epsom 
salts; a dose, to be taken at bedtime, is a heaping tablespoonful to a full gob- 
let of water. Where torpidity of the liver exists, as manifested in headache, 
sick stomach, or an icterode skin, calomel is wisely employed. The writer 
finds most satisfaction in the use of this medicine by exhibiting it in quarter- 
grain doses every two hours until two grains are taken: 
R Hydrargyri chloridi mitis, gr. ij ; 
Saechari albi, gr. x. M. 
Sig.-To be taken by being dropped upon the tongue, 
Purging Weakly People.-Weakly people are best purged by means 
of castor oil; the dose is a tablespoonful, to be repeated after four or five 
hours, if necessary by reason of the first not acting. 
Habitual costiveness is happily treated by a combination of nux 
vomica and podophyllin: 
R Tincturae nucis vomicae, ; 
Podophyllini, gr. iss. M. 
Sig.-Five drops before meals. (See Artificial Mineral- Water, per Index.) 
Cleanliness.-Cleanliness as to personal relations and surroundings is to 
receive proper attention. Wherever erysipelas is present, an impure atmos- 
phere is not to be left without the disinfecting influence to be found in the 
use of an atomizer and an antiseptic. Phenol-sodique is to be recommended 
as a fluid to atomize; a good proportion is dilution with equal parts of water. 
Phlegmonous Erysipelas.-This second differs from the first form in 
that it involves parts beneath the skin, producing a cellulitis which terminates 
over-frequently in suppuration and not unlikely in gangrene. Here the color 
shown upon the skin is apt to be a dusky red. Swelling is extensive. Pain is 
severe. Blebs, filled with sero-lymph, or it may be with blood, appear over 
the part. Tension is prominent. The system sympathizes to the extent of 
manifesting a febrile disturbance which quickly inaugurates a typhoid 
condition. Abscesses which involve all associated parts are common. 
Cause would not seem to lie with difference in origin, but with 
influencing circumstances as these relate with improper treatment, with 
peculiar susceptibility, or with debility. Phlegmonous erysipelas is much 
more common to hospital than to private practice and to the epidemic 
than to the sporadic cases. ERYSIPELAS. 
1315 
Treatment.-Primarily, the iron, cinchona, and quinine mixture exter- 
nally, with iron and quinine internally: 
U Tincturae ferri chloridi, ; 
Quiniae sulphatis, 3j- M. 
Sig.-Twenty drops to be taken in a wineglass of water every three hours. 
Constitutional Support.-Constitutional support from a food stand- 
point is of the greatest consequence in phlegmonous erysipelas. Grated beef is 
valuable. Eggs beaten up with brandy may be used with reasonable freedom. 
A free use of milk is good. The bowels and the condition of other excretory 
organs must be kept under careful observation. Depletion of any kind is not 
permissible. 
Tension and Free Incisions.-Tension of a part affected is of con- 
cern, and is to be relieved by free incisions. Pus is to be afforded free 
drainage. Injections of stimulating antiseptics are to be used freely, and 
for which purpose the following formulae are favorites with the writer: 
R Potassii permanganatis, gr. xxx; 
Tincturae myrrhse et capsici, ; 
Aquae, ^x. M. 
R Acidi sulphurici aromatici, ; 
Aquae, ^x. M. 
g PhSnol-sodique, ^ij; 
Tincturas capsici, ^ss; 
Aquas, ^x. M. 
Chloral hydratis, gr. xx ; 
Zinci sulphatis, gr. xv; 
Aquae, ^x. M. 
Phlegmonous erysipelas showing in parts-simply lymph effusion without 
tendency to tension or to suppuration-is to be painted freely with the iron 
formula and afterward kept moist by a wrapping of very thin poultice, 
applied hot. Stupes of poppy-water, thickened with glycerin, is a 
comforting application. 
Relation with Poisoned Wounds.-Cellular erysipelas is associated 
commonly with poisoned wounds, hence where local specifics apply these are 
to be used. 
Danger from septicaemia is to be constantly in the mind of the prac- 
titioner. Washing such wounds, on general principles, with pure phenol- 
sodique is employment of a means than which the writer knows none more 
reliable. 
Aconite.-Tincture of the root of aconite, given in one-drop doses, with 
an interval of two or three hours, is admirable practice on a rising pulse, while 1316 
A SYSTEM OF ORAL SURGERY. 
increase of temperature is to be combated with two-grain pills of sulphate 
of quinine, with one-grain doses of antipyrin, or with ten-drop doses of tinct- 
ure of digitalis, used at the same intervals. The author prefers digitalis. 
Lemonade is refreshing, and seems useful. 
Erysipelatous Lymphangitis.-Erysipelas involving the lymphatics 
or the veins (erysipelatous phlebitis) is to receive vigorous combatal. The 
latter is particularly dangerous by reason of clots apt to be formed in the vessel, 
thus furnishing the means for embolism. Sign of the disease in both 
cases exists in red lines showing upon the course of the vessels. For 
treatment the author relies on the iron mixture. Equal parts of extract of 
belladonna and glycerin constitute an application highly endorsed. Cold is 
never admissible. 
Erysipelas attacking the throat offers a dangerous condition. The 
possibility of a necessity for the operation of tracheotomy is to be kept in 
mind. The iron mixture is here commended as the most reliable medicine 
that can be employed; a modification of the formula as given is to be made 
by increasing the measure of tincture of cinchona sufficient to prevent blister- 
ing ; equal parts of the two fluids make the mixture about right. 
Attempting to limit the progress of an advancing erysipelatous inflammation 
by means of a line made with nitrate of silver is commonly without result for 
good or for evil. 
Cause of Erysipelas.-While much is spoken and written on this 
subject, it is quite sufficient to say,-certainly so from a clinical stand-point,- 
that it is to be considered of such relation with constitutional conditions that 
indications point always to correction of whatever is found amiss. Locally, 
it is to be accepted that a germ has found habitation and is expressing its 
presence after its own peculiar manner. The specific action found to lie with 
the iron, quinine, and cinchona mixture is assumed to be of relation with this 
special germ. The mixture is here a special germicide. CHAPTER LXXVIIL 
ANTISEPSIS. 
To appreciate properly the significance of an antiseptic, the student is to 
consider the derivation of the term,-namely, a^rt, against, and to 
putrefy. The term 11 to putrefy" is synonymous with the term " to decom- 
pose,"-i.e., with sepsis. In other words, it is synonymous with the self- 
breaking up of an organic body; consequently, the use of an antiseptic 
is with a view to the prevention of such breaking up. A deodorant or a 
disinfectant is not to be confounded with an antiseptic. The 
first is simply a coverer-up, a masker, of odor; the second exerts an influence 
which antagonizes conditions out of which odor arises. 
Double Effect of Sepsis.-The effect of sepsis is of double signifi- 
cation ; it is a local irritant, a systemic poison. The former is analogous with 
irritants at large. The latter is a result of the absorption of a product of 
putrefaction. Septic infection, if it differ at all from septic poisoning, means 
the effect produced on the circulation by the deteriorating action of an agent 
which has so altered the degree of vitality that general resistance is injured 
to an extent which distinguishes an affected from a healthy body. 
Healthy and Unhealthy Pabulum.-Healthy nutritional pabulum 
being a necessity for healthy molecular activity, it follows that the presence 
of any agent deteriorative of such pabulum is adverse to health in the human 
organism. Here is the principle and, at the same time, the indication of 
practice ; septic conditions are to be antagonized. It is to be recognized 
that septic expressions vary. To employ for the purposes of a surgical opera- 
tion a table upon which a dissection has been made, is to insure erysipelas to 
the patient. Small-pox breeds similar disease in others. Exposed drainage of 
excrement is a cause of typhoid fever. Epidemics relate with the presence 
of specific germs in the atmosphere. Endemic disease is of similar mean- 
ing. The emphasis of antisepsis lies with the destruction of germs. 
Consequently, what is antiseptic to one cause is not necessarily 
so to causes at large. To use specifics scientifically is to acquaint one's 
self with the virtue of the germicides; not only with a comparative strength 
lying in the different agents, but with the adaptability of each to a specific 
end. Here is markedly exhibited the difference between antisepsis and deo- 
dorization. It is the office of the former to destroy the cause of an offensive 
smell. The meaning of the latter, as before suggested, is to cover up the 
smell. 
1317 1318 
A SYSTEM OF ORAL SURGERY. 
Germ Theory.-Over-signification is not to be given the germ theory. 
Habitations generally imply inhabitants. Change in the human body is quite 
as apt to precede as to succeed parasites. Bacilli, to make illustration, are 
not the cause of pulmonary phthisis, but the phthisis affords place 
for the bacilli. On the contrary, it is not to be doubted that cholera lives 
in a spore, or that small-pox is bred from without. 
Koch's Bacillus.-The claim of Koch that he has found a peculiar 
bacteria in putrefaction is certainly not intended to be understood by him as 
meaning that in the absence of the parasite there would be no degeneration. 
During the wrar of the Rebellion, the author, in the heated July term of 
1863, was never surprised to see the flaps of an amputation bored by maggots 
on the third, and not infrequently on the second, day after the removal of a 
limb ; here was habitation and flies were everywhere: they would deposit the 
larvae in defiance of all precautions. Germs once finding such fitting dwelling- 
place, multiplication is expressive of intensification of disease; hence anti- 
putrescents and germicides are of a not dissimilar meaning in a multitude of 
instances. 
Listerism.-Listerism is a term come into quite common use, signifying 
germicidal cleanliness. Operations done under this method imply the use of 
carbolized or other spray made to surround the seat of a performance, and the 
hands as well as the instruments of the operator. To such end phenol- 
sodique is used in the Oral Hospital, commonly much diluted with water, and 
applied, not by the atomizer, but simply by means of a sponge. Listerism 
has meaning only where there is filth and germ life; but as it is quite impossi- 
ble to declare the presence of absolute cleanliness, it can certainly be no other 
than good practice to reap a possible advantage out of so simple a means as 
resides in an easily-applied spray or wash. Practically, the writer affirms of 
advantage lying with Listerism. He commends cleanliness, as nearly abso- 
lute as possible, in the instance of any and every operation done on a human 
body, but the germ theory, as propounded by the bacteriologists, is an extreme 
with which his experiences fail to conform. 
Stimulants Identical with Antiseptics.-Stimulants are often 
enough identical with antiseptics, as where the end is served of preventing 
degeneration; example is given by referring to changes made in indolent 
ulcers through a touch of tincture of capsicum or of iodine. 
Zinc Chloride as an Antiputrefactive.-Antiputrefaction after 
another principle is secured in the use of zinc chloride. A proportion of this 
salt-forty grains or thereabout to the ounce of water-penetrates tissues, 
coagulating the albuminoid material, thus preventing change; this is under- 
stood by coagulating the albumen of one egg by heat and leaving a second one 
exposed without being boiled. 
Use of Aromatic Sulphuric Acid.-An excellent antiputrescent is 
found in aromatic sulphuric acid. 
Corrosive Sublimate.-One at the present time attracting wide atten- ANTISEPSIS. 
1319 
tion is corrosive sublimate. As the mouth fluids are concerned, experiments 
made by Dr. Miller, of Berlin, seem to show that, if to one hundred thou- 
sand parts of sweetened saliva one part of the mercurial bichloride be added, 
the solution is found preserved from acidity for a space of twenty-four 
hours.* 
Corrosive sublimate is at present the most popular antiseptic in use. 
Chalk.-Common chalk is to be esteemed an antiseptic where it takes up 
offensive debris and discharges. 
Charcoal, Bismuth, and Iodoform.-As an antiseptic and deodor- 
ant, a combination of marked virtue is found in pulverized charcoal twenty 
parts, subnitrate of bismuth five parts, iodoform one part. 
Peroxide of Hydrogen.-This has come to wide use in dental surgery 
proper. It is a colorless fluid having little taste or odor. Claim is made for 
it as a parasiticide of reliable character; that its action on indolent parts is of 
alterative nature, and that therefore its use is particularly applicable in cases 
'of alveolar abscess; and that no better purifier of the breath is to be found 
where the cause is local to the mouth. As a dressing for canals from which 
putrescent pulps have been removed it is in great favor. 
Parasiticides are to be measured out of experimentation and perhaps out of 
no other method. The writer has illustrated and determined by hundreds of 
observations that a mixture of iron, cinchona, and quinine, locally applied, is 
an absolute specific in cutaneous erysipelas. This result could exist only in a 
germicidal action; hence to discover and to enjoy familiarity with the fungus 
of erysipelas is to possess knowledge of cause, effect, and antidote. Crea- 
sote is destructive to teeth parasites, sulphur to the itch insect, 
iodine to the pediculus capitas, santonine to lumbricoidal worms. Here in 
like manner are illustrations which a student is to consider in order that the 
subject be comprehended. 
The simple washing of a wound with water and soap is an anti- 
septic performance, albeit it is neither a chemical nor a specific one; it simply 
removes or floats off. 
If an indication be to cover a sore, thus shielding it from possible un- 
known germs, Monsel's persulphate of iron may be laid heavily upon 
the part and its clot protected by a solution of the corrosive sublimate. 
Sinuses giving out offensive excreta are happily disinfected by 
the use of permanganate of potassium, five grains to the ounce of water, or 
by diluted phenol-sodique, a tablespoonful to a goblet of water. Where an 
alterative is indicated, iodine in tincture, or aromatic sulphuric acid, or nitrate 
of silver may be used with profit; the last is employed in a strength of one 
grain to the ounce of water. 
As understood, phosphor-necrosis is attended by the most disgusting of dis- 
charges. It is a matter of great importance to keep such eliminations continu- 
* This is an experiment that students will do well to repeat; results will be suggestive. 1320 
A SYSTEM OF ORAL SURGERY. 
ously deodorized and disinfected, as it is found impossible to prevent their 
passage into the stomach. 
An antiseptic highly lauded by Dr. Richard Levis consists in tablets of the 
potassio-mercuric iodide so prepared that one dissolved in a pint of 
water furnishes a solution. Dr. Levis sets much value also on the use 
of hydro-naphthol. 
Aseptol, a liquid of a rose color, is an antiseptic introduced by Mr. 
Serran. It is without disagreeable odor and is three times the strength of 
carbolic acid. 
Fluosilicate of soda is used widely. Iodoform, used alone, or in con- 
junction with subnitrate of bismuth and boracic acid, is unsurpassed by other 
agents or combinations. 
Styrone is a late addition to the antiseptic list. The origin of this is 
from liquid storax and balsam of Peru. The preparation is non-poisonous 
and is of agreeable odor. It is applied to open wounds mixed with equal 
parts of olive oil. Ulcerating cancerous growths are sprayed with a mixture 
made of equal parts of the preparation, of glycerin, and distilled water. 
Prominent dentists give it endorsement as a satisfactory dressing in carious 
cavities and especially in ill-smelling pulp-canals. 
Micro-organisms are divisible into five classes, which are known, respec- 
tively, as,- 
1. The Micrococci. 
2. The Diplococci. 
3. The Streptococci. 
4. The Staphylococci. 
5. The Bacilli. 
A micro-organism is called micrococcus, A, when it shows as a 
single dot. When two of these dots, or points, relate, the term diplococci, 
A, is used. Where the dots lengthen into a string, the name given is strep- 
tococci, A. Staphylococci applies, A, when the dots are found grouped. 
Bacilli, C, are expressed by rod-like forms.* 
It will be seen that this classification may be accepted as differentiating 
fairly only as growth and arrangement are concerned. This agrees nearly 
with the views of Billroth, but differs from those of Cohn, who contends for 
variety not only as to forms, but as well individually. In the diagram, B 
shows bacteria, oval or rod-shaped bodies the length of which exceed their 
breadth. D represents a corkscrew form of growth termed, by reason of 
their shape, spirilla. 
Micro-organisms are, undoubtedly, the active agents in fermentation 
and decomposition. The yeast-plant lightens the dough and the bloom of the 
FORMS OF MICRO-ORGANISMS 
* The classification of Professor La Place, Pathologist to the Medico-Chirurgical Hospital. ANTISEPSIS. 
1321 
grape-skin ferments the wine. The streptococcus, which is the expression of 
micro-organisms found in connection with erysipelas, is assumed as the cause 
of extension of this disease, as witnessed in hospitals, on the ground that if a 
Fig. 947.-The Forms of Micro-organisms. 
culture be made of the parasite, and this be applied to the skin, it will repro- 
duce itself,-that is to say, it will develop the condition in the new situation. 
A word is to be added in conclusion. The writer has treated and 
handled many cases of erysipelas, but has never found himself inoculated. 
There is an inference in such immunity that seems not unfair, 
-namely, microbes are not one with disease, but are as accidents in the line 
of the phenomena of disease. They are inhabitants found in a habitation 
prepared for them. It is not, however, to be doubted that the presence of 
anything foreign to a part is the source of change as to a natural condition, 
and it is, therefore, safe practice to exclude from a wound, where possible, any 
and all agents not of natural relation with it, hence the almost universal ac- 
ceptance of the germ theory and adoption of the use of germicides. (See 
Oidium Albicans, pp. 676 and 679; see, also, p. 228.) INDEX. 
A. 
Abbott's pluggers, 408. 
Ablation and restoration of lower lip, 949. 
of upper lip, 951. 
of jaw, 775. 
of tongue, 777. 
Nunneley's operation for, 779. 
Paget's operation for, 780. 
Regnoli's operation for, 778. 
Syme's operation for, 779. 
Abortion of alveolar abscess, 293. 
Abrasion of teeth, 336. 
caused by malarticulation, 336. 
treatment of, 336. 
Abscess, 292. 
abortion of, 293. 
alveolar, 292. 
associated with temporary teeth, 301. 
with wisdom-teeth, 298. 
caused by imprisoned teeth, 302. 
complicated by opening into Steno's 
duct, 298. 
dental, 292. 
of antrum, 191, 970. 
of liver, indicated by tongue, 744. 
of tongue, 764. 
of tonsil gland, 729. 
relation of, with imprisoned teeth, 302. 
treatment of, 293. 
Absolute ether, 1260. 
Absorbable parasiticides, 227. 
Absorbed deciduous roots, 159. 
Absorption and recession of gum and alveo- 
lus, 284. 
treatment of, 284. 
of alveolar plate in dental abscess, 292. 
of alveoli, 284. 
of dead pulp into dental tubules, 295. 
of gums, 284. 
of replanted roots, 333. 
Abutments at neck of teeth, 250, 356. 
Abutting teeth, 357. 
Accessory parotid gland, 132, 256. 
Accidental injuries to face, 693. 
substances found in saliva, 260. 
Accidents in root-filling, 311. 
in tooth-extraction, 452. 
Accumulation and degeneration of antral 
secretions, 977. 
Acetic acid in ether, 1260. 
Acid in treatment of osseous caries, 1001. 
of salivary calculus, 652. 
of typhoid fever, 224. 
nitrate of mercury in treatment of ul- 
cers, 1015. 
Acid oral secretions, 226, 235. 
acetic, 261. 
carbonic, 260. 
citric, 260. 
hydrochlorate, 261. 
lactic, 227, 260. 
malic, 260. 
nitric, 227, 260. 
oxalic, 260. 
sulphuric, 260. 
tartaric, 260. 
uric, 227. 
Acids, administering, 235. 
and the teeth, 235. 
cure by, 224. 
in treatment of dental caries, 224. 
Acne rosacea, 904, 909. 
Aconite as a local anaesthetic, 457. 
in toothache, 265. 
Action of ether on nerve-centres, 1264. 
of nitrous oxide, 1284. 
Active inflammation, 1293. 
Actual cautery in dental hemorrhage, 456. 
in sensitive dentine, 265. 
Acupressure in hemorrhage, 694. 
Acute aphtha, 675. 
glossitis, 760. 
periodontitis, 286. 
synovitis, 1077. 
Adams's forceps for straightening nasal Sep 
turn, 867. 
Adaptation in dentures, 556. 
Addison's disease and vitiligo, 879. 
Adenoid tumors, 1143. 
vegetations, 841. 
Adenoma, 1143. 
Adhesion of the gums, 667. 
Administering acids, 235. 
Administration of ether, 1261. 
Advent of wisdom-teeth, 1013. 
Adventitious tongue-tie, 781. 
Adynamic stomatitis in infants, 163. 
JEgophony, 1242. 
Aesthetic aspect of amalgam, 383. 
Age and dental irregularities, 523. 
in dentition, 145. 
in orthodontia, 523. 
in relation to orthodontia, 523. 
relation of, to scirrhoma, 1205. 
to use of chloroform, 1288. 
Agents excitative of dental caries, 223. 
of calcification, 278. 
in contact with the teeth, 198, 223. 
Aging an alloy, 378. 
Agnew on harelip, 929. 
on salivary fistule, 991. 
1323 1324 
INDEX. 
Air and diet in dentition, 167. 
tubes, view of, 737. 
Albumen, albuminoids, and teeth, 202. 
in saliva, 255. 
Albuminoid degeneration and cadmium, 375. 
Alcohol and sulphuric ether, 1263, 1291. 
in febrile conditions, 173, 1303. 
sponging in inflammation, 1303. 
Alimentary canal during dentition, 174. 
in aphthae, 680. 
Alkalinity and dental caries, 198. 
Allan's typical case of pyorrhoea alveolaris, 
640. 
Alloy, aging, 378. 
cleaning, 378. 
cutting, 378. 
dental, 377. 
manner of using, 379. 
Allport's operation on dental pulp, 315. 
Alteratives in tetanus, 1083. 
Alum and the teeth, 456. 
in dental hemorrhage, 456. 
Aluminium dentures, 605. 
Alveolar abscess, 292. 
abortion of, 293. 
anomalies of, 294. 
arising out of imprisoned teeth, 302. 
chronic conditions of, 299. 
discharging into nostril, 298. 
gout an associate of, 300. 
illustrative cases of, 295. 
meaning of, 292. 
objections to use of warm fomentations 
in, 293. 
opening into Steno's duct, 298. 
prophylaxis of, 293. 
rheumatic diathesis a predisposing cause, 
300. 
Alveolar artery, 87. 
exostosis, 1160. 
necrosis, 1011. 
Alveolar process, 32, 38, 45, 145. 
and extraction of teeth, 447. 
development of, 14 7. 
fractures of, 445, 1036. 
in orthodontia, 523. 
necrosis of. 1011. 
projecting into cleft of palate, 937. 
Alveoli of teeth, 32. 
Alveolo-dental abscess, 292. 
periosteum, 292. 
odouteal membrane, 152. 
Amalgam, 374. 
Arrington's, 375. 
cadmium in, 375. 
Caulk's, 375. 
cause of failure as a tooth-filling ma- 
terial, 381. 
Chase's, 376. 
chemistry of, 386. 
chloride of zinc as a cleanser of, 380. 
composition of, 374. 
contour, 376. 
copper in, 377. 
cupped carriers for handling, 382. 
different preparations of material, 375. 
discoloration of teeth caused by use of, 
384. 
facing, 376. 
file flats for handling, 382. 
Amalgam, front-tooth, 376. 
gold as an element of, 377. 
Holmes's, 375. 
illustration in working, 383. 
indications for use of, 385. 
instruments used for, 382. 
Johnson A Lund's, 375. 
Lawrence's, 375. 
Oliver's, 375. 
platinum as an ingredient of, 377. 
pluggers, Arrington's, 382. 
silver in, 379. 
standard alloy, 375. 
submarine, 375. 
Sullivan's, 375. 
therapeusis of, 382. 
Townsend's, 374. 
use of, necessitated, 381. 
usual, 375. 
Weston's 375. 
American leeches, 986. 
in angina, 169. 
Ammonia in angina, 169. 
Ammonio-chloride of iron in epithelioma, 
916. 
Amputation of tongue, 777. 
Billroth's method, 780. 
by strangulation, 777. 
by the ecraseur, 777. 
Nunneley's method, 779. 
Paget's method, 780. 
Regnolis method, 778. 
Syme's method, 779. 
Whitehead's method, 781. 
of tonsil gland, 725. 
instruments used for, 725. 
Billings's tonsillotome, 726. 
Kolbe's tonsillotome, 726. 
of uvula, 786. 
Amygdalitis, 717. 
acidulated ice in treatment of, 720. 
dry cupping in treatment of, 717. 
herpes in association with, 722. 
hot foot-bath in treatment of, 720. 
leeches in treatment of, 719. 
medicated gargles in treatment of, 717. 
phenomenal expressions of, 717. 
pus forming in gland, 721. 
spirit of Mindererus in treatment of, 
720. 
veratrum viride in treatment of, 720. 
Anaemia and dental caries, 223. 
and hemorrhage, 455. 
as a cause of dental hemorrhage, 453. 
Anaesthesia and anaesthetics, 1248. 
and alcohol, 1260. 
and sensitive dentine, 265. 
by agents acting upon the skin, 125. 
upon the mucous membrane, 1253. 
by chloroform, 1268. 
by ether, 1260. 
by ethyl bromide, 1285. 
by local means, 1248. 
by nitrous oxide gas, 1280. 
by rapid respiration, 1284. 
by rhigolene, 458. 
by subcutaneous medication, 1286. 
general, 1260. 
in jaw luxation, 1035. 
local, 456. INDEX. 
1325 
Anagnostakis's magnifying-glass, 350. 
Analogy of teeth in parent and child, 238. 
Analyses of amalgam, 386. 
Analysis of blood, 210. 
of cementum, 144. 
of dentine, 144. 
of enamel, 144. 
of Indian corn, 220. 
of milk, 213. 
of potatoes, 216. 
of saliva, 255, 645. 
of salivary calculus, 645. 
of the oral fluids, 245. 
of tooth-substance, 144. 
Anastomosis of arteries, 959. 
Anatomy in nerve operations, 1121, 1131. 
of bend of arm, 1300. 
of facial region, 27. 
of internal nose, 833. 
of soft palate, 819. 
of the teeth, 135. 
Anchorage slots, 475. 
Anchor-clamp bands, 507. 
Anchylosis of the jaw, 1076. 
complication, 1077. 
definition, 1076. 
inflammation a cause of, 1076. 
lockjaw in new-born children, 1085. 
rheumatoid, 1077. 
tetanus, 1080. 
trismus, 1080. 
dentium, 1088. 
nascentium, 1085. 
Aneurism, aortic, 1230. 
kinds of, 1231. 
Angeioma, 892. 
Angina, 168. 
aphthosa, 168. 
cathartics in, 169. 
diet in, 170. 
emetics in, 169. 
hot foot-baths in, 169. 
simplex, 168. 
tonsillaris, 717. 
treatment of, 169. 
Angle of lower jaw at varying ages, 534. 
Angle's jaw dressing, 1050. 
regulating and retaining appliances, 
1051. 
Angular artery, 83. 
Anidrosis, 888. 
Animal parasites, 902. 
Annealing gold foil, 404. 
silver and gold plate, 582. 
Anodynes in shock, 697. 
Anomalies in alveolar abscess, 294. 
in second dentition, 186. 
in situation of salivary calculi, 648. 
Anomalous case of antral disease, 972. 
of exostosis, 1160. 
of jaw fracture, 1038. 
of necrosis, 1011. 
of salivary calculus, 648. 
teeth in relation with extraction, 436. 
tonsillar abscess, 729. 
Anstie on neuralgia, 1103. 
Antagonism of deciduous and permanent 
teeth, 158. 
Antecedents of aphthae, 687. 
Anterior nares, 833. 
Anterior palatine canal, 40. 
pillars of oro-pharyngeal space, 126. 
rhinoscopy, 862. 
Antero-posterior section of cranium, 58. 
Antiphlogistic prescription, 1301. 
remedies, 1301. 
Antisepsis, 1317. 
germ theory, 1318. 
Koch's bacillus, 1318. 
Listerism, 1318. 
micro-organisms, 1320. 
Antiseptic injections in mercurial necrosis, 
1019. 
Antral diseases common to mucous .mem- 
brane, 977. 
drainage-tubes, 983. 
outlet, 37. 
ulcers, 853. 
Antrum of Highmore, 37, 851, 856, 970. 
abscess of, 973. 
cystiform, 974, 1189. 
diseases of, 970. 
distention and softening of walls, 975. 
drainage-tubes, 983. 
dropsy of, 977, 1190. 
injections and injecting, 982. 
multiple cysts of, 1191. 
necessity for keeping breaks open, 981. 
ozaena of, 855. 
puruloid secretion of, 979. 
relation of anomalous dentition with, 970, 
986. 
of furuncular epidemics with, 986. 
of scorbutus with, 987. 
of syphilis with, 987. 
tooth-hills in, 37. 
ulcers of, 855. 
Aortic aneurisms, 1230. 
Aperient mineral-water, 673. 
Apex plugs in tooth-bleaching, 316. 
Aphthae, the, 675. 
Bamberger's views of, 679. 
Delpech's views of, 679. 
Dewees's views of, 680. 
Good's views of, 682. 
Jourdain's views of, 684. 
Trousseau's views of, 679. 
Wood's views of, 688. 
Apneumatosis, 1237. 
Aponeurosis of pharynx, 801. 
Apparatus used in correction of dental ir- 
regularities, 528. 
(Farrar's) in orthodontia, 539. 
in preparing nitrous oxide gas, 1280. 
Appearance of dead teeth, 276. 
Appliances used in correction of dental ir- 
regularities, 528. 
Application of dental napkin, 362. 
of rubber dam, 366. 
Approximal dental cavities, 353. 
and the rubber dam, 372. 
tooth plugs, 424. 
Approximation of wounds, 698. 
Arbuthnot on infant mortality, 161. 
Arches of the superior and inferior jaws, 
585. 
Arkansas stone, 424. 
Aromatic sulphuric acid in mercurial diseases, 
657. 
in treatment of osseous caries, 1001. 1326 
INDEX. 
Arrangement of artificial teeth, 556. 
of gold for filling teeth, 395. 
of teeth, 158. 
of teeth in dental arches, 556. 
Arrest of development a cause of tumors, 
1197. 
Arrestation of hemorrhage, 963. 
Arrested dentition in rickets, 199. 
Arrows of Maisonneuve, 755. 
Arrow-wounds of skull, 1056. 
Arsenic as a pulp devitalizer, 275. 
pulp nodules interfering with action of, 
466. 
relation of, with necrosis, 1011. 
Arsenical paste, 275. 
in sensitive dentine, 264. 
Art treatment of dental caries, 337. 
Arterial anastomoses, 959. 
hemorrhage, 693. 
after tooth extraction, 453. 
naevi of tongue, 771. 
sedatives and periodontitis, 290. 
tumors, 892. 
Arteries and veins of facial regions, 80. 
ascending pharyngeal, 89. 
circle of Willis, 90. 
facial, 85. 
internal carotid, 90. 
lingual 84. 
occipital, 89. 
of neck, 82. 
of tongue, 130. 
posterior auricular, 84. 
superior thyroid, 84. 
temporal, 89. 
Artery, lingual, 84. 
Arthritis, 1079. 
complicated, 1077. 
from constitutional disease, 1077. 
from local cause, 1076. z 
rheumatic, 1077. 
Arthrodia, 35. 
Articulation, 556. 
of complete denture, 554. 
of full half-denture, 553. 
of head bones, 35. 
of inferior maxilla, 43. 
of nasal bone, 33. 
of palate bone, 47. 
of partial denture, 553. 
of superior maxilla, 42. 
of teeth, 160. 
of temporo-maxillary, 133. 
of turbinated bone, 49. 
of vomer bone, 48. 
proper bite, 555. 
sutural, of head, 35. 
test bite, 555. 
Artificial dentures, 544. 
as a cause of ulitis, 663. 
nose, 623. 
pivot crowns, Bing's, 463. 
Bonwill's 473. 
Gates's, 473. 
Talbot's, 463. 
support of lip and cheek, 928. 
teeth, 544. 
tooth-crowns, 461. 
vela, 616. 
Artistic dentistry, 544. 
Aseptol ns an antiseptic,1320. 
Association of teeth with alveoli, 145, 452. 
Associative lesions of first dentition, 161. 
of second dentition, 186. 
diarrhoea, 174. 
eruptions upon skin, 183. 
irritation, 161. 
irritative fever, 172. 
localized stomatitis, 163. 
spasms, 177. 
Asthenia and purulency, 984. 
Astigmatism, 1108, 1120. 
Astringents in dental hemorrhage, 453. 
Asymmetrical condition of tongue, 771. 
Atkinson's burnishers, 406. 
pluggers, 404. 
Atlee's elastic suture, 929. 
Atmospheric changes a cause of pulpitis, 272. 
of gelatinoid polypi, 844. 
of tetanus, 1080. 
pressure in dentures, 551, 592. 
relations with chloroform, 1269. 
with ether, 1260. 
Atomizers, 458. 
foot-instrument, 459. 
hand-instrument, 458. 
Atonic dyspepsia and tongue, 743. 
Atresia oris, 942. 
Dieffenbach's operation for, 942. 
Mutter's operation for, 945. 
Atrophic change in teeth, 198. 
Atrophy of tongue, 771. 
Atropia antidotal to morphia, 1256. 
in neuralgia, 1118, 1120. 
in odontalgia, 270. 
Auditory outlet, 34. 
Auricu'aris magnus, exposure of, 1134. 
Auriculo-temporal nerve, 115. 
Auscultation, 1237. 
Author's inhaling instrument, 1261. 
jaw bandage, 1042. 
operation for radical treatment of epithe- 
lial cancer, 919. 
for resecting nerves at base of skull, 
1124. 
for salivary fistule, 992. 
Automatic pluggers, 416. 
Buckingham's, 48. 
electro-magnetic, 417. 
hand instrument, 417. 
B. 
Baby's sore mouth, 680. 
Bacilli, 229, 1318. 
theory of cancer, 919. 
Backing continuous-gum work, 597. 
teeth, 588. 
Bacteria, 229. 
Bad breath, 223, 723 
ether, 1265. 
taste in mouth and amalgam, 385. 
Baker's velum, 633. 
Baking Brown's bridges, 510. 
continuous gum, 600. 
enamels, 602. 
Bald tongue, 746. 
Bamberger's views on the nature of the 
aphthae, 680. INDEX. 
1327 
Bandages, 1041. 
Barton's, 1042. 
Garretson's, 1042. 
Gibson's, 1042. 
Bands and loops in orthodontia, 532. 
used in support of artificial teeth, 
594. 
Barber's itch, 903. 
Barks, bitter, in angina, 172. 
Barnum's rubber dam, 366. 
Bars for removing teeth, 531. 
Bartholin's duct, 133 
Barton in exsection of the jaw, 1069. 
Barton's jaw-bandage, 1042. 
Basal nutritive agent, 209. 
Base of skull, 59. 
of tongue, 127. 
Basis operation in harelip, 927. 
Batley's solution in cancer, 917. 
Bayberry powder in hemorrhage, 165. 
Beaked forceps, 448. 
Bean's splint, 1044. 
Bearing of impression material, 547. 
Beer or wine in rickets, 242. 
Beer's rubber disk, 552. 
Beeswax as an impression material, 546. 
Bell's case of hygroma, 798. 
Belladonna in angina, 168. 
in dentition, 163. 
in epithelial cancer, 917. 
in infantile spasms, 178^ 
in tetanus, 178, 1083. 
in tonsillitis, 718. 
Belloc's canula, 838. 
Benign tumors, 1136. 
Bicarbonate of soda in burns, 713. 
Bicuspid approximal cavities, 412. 
forceps, 434. 
Bicuspidati teeth, 141. 
filling of, 412. 
Bilateral luxation of jaw, 1031. x 
Billings's tonsillotome, 726. 
Billroth on phosphor-necrosis, 1028. 
on tetanus, 1082. 
Billroth's operation on tongue, 1028. 
Bing's gold crown, 463. 
Bite in denture-making, 553. 
of rabid animals, 697. 
Biting the cheek, 590. 
Bitter barks in angina, 169. 
Black tartar, 651. 
teeth, 295, 316, 319. 
tongue, 743. 
vulcanite, 570. 
Blank celluloid rim, 579. 
Blasius's lip operation, 948. 
Bleaching teeth, 316. 
Bleeding at bend of arm, 1300. 
Blindness in antral disease, 37, 972. 
Blisters in periodontitis, 290. 
Blood and tooth health, 209. 
and typhoid condition, 224. 
composition of, 210. 
in typhoid fever, 224. 
supply of muscles of face, 70. 
Blood-vessels, diseases of, 892. 
angeioma, 892. 
arterial tumors, 892. 
capillary naevi maculae, 894. 
erectile growths, 898. 
Blood-vessels, diseases of: macula, 892. 
mother-mark, 892. 
naevus vasculosus, 892. 
port-wine stain, 895. 
venous tumors, 893. 
of the pharynx, 84, 802. 
Blotting-paper in mask-making, 636. 
Blow-pipe, Fletcher's, 567. 
proper use of, 566. 
Blue line in saturnine alfections, 669. 
teeth, 246. 
Blunt burs, 266. 
Boiler of vulcanite apparatus, 573. 
Boiling-point of ether, 1260. 
Boils, 1297. 
Bond's oesophagus forceps, 808. 
Bone scissors, 1066. 
Bones of head, 26. 
frontal, 59. 
ethmoid, 50. 
hyoid, 58. 
inferior maxillary, 42. 
lachrymal, 57. 
malar, 57. 
nasal, 33, 56. 
occipital, 61. 
palate, 46. 
parietal, 68. 
sphenoid, 52. 
superior maxillary, 36. 
temporal, 63. 
turbinated, 48. 
vomer, 48. 
Bonwill's dental engine, 342. 
diamond reamer, 251. 
mallet, 417. 
method of rapid breathing, 1285. 
on relation of dental arches, 586. 
pivot tooth, 473, 479, 480. 
surgical engine, 1072. 
Bony septi in cystoma, 1170. 
Booth's claw-forceps, 440. 
velum, 632. 
Bottle-corks in anchylosis, 1097. 
Bougies in imperforate nostrils, 864. 
Brain-like character of encephaloma, 1207. 
Branches of external carotid artery, 82. 
of internal maxillary artery, 85. 
Breaking jaw purposely, 1047. 
suction in impressions, 547. 
up sac of alveolar abscess, 293. 
Breaks in hard palate, 815, 1005. 
in soft palate, 814. 
Bridges of bone in anchylosis, 1100. 
Bridgman's experiments, 230. 
on electro-chemical cause of dental caries, 
230. 
on filling materials, 233. 
Bridge-work, 461, 501. 
Bristle probangs, 809. 
Brittleness in gutta-percha, 387. 
Broach, pricking with, for destruction of 
dental pulp, 311. 
use of, in dentistry, 307. 
Broaching dental pulp, 311. 
Brodie on diseases of tongue, 758. 
Broken jaw-bones, 1036. 
teeth, cap-crowning, 461. 
Bromide of potassium in angina, 168. 
in dentition, 163. 1328 
INDEX. 
Bromide of potassium in febrile conditions, 
173. 
in infantile spasms, 179. 
in neuralgia, 1113. 
in periodontitis, 289. 
in retching, 547. 
Bronchial sounds, 1239. 
tubes, view of, 731. . 
Bronchocele, 1211. 
cystic, 1212. 
symmetrical, 1212. 
Bronchophony, 1242. 
Bronchotomy, 730. 
intubation, 738. 
laryngotomy, 733. 
thyrotomy, 738. 
tracheotomy, 734. 
Broom-splint in duct of Steno, 993. 
Brown, Parmley, crown, 482. 
porcelain facing, 508. 
Brown-Sequard's neuralgic pill, 1119. 
Brown tongue, 743. 
Brown's three-edged chisel, 344. 
Brutes' teeth in human sockets, 324. 
Buccal nerve, 115. 
Buccinator muscle, 75. 
Buchu as a diuretic, 168. 
Buckingham's mallet, 418. 
obturators, 614. 
Buckland's cicatrix cutter, 1099. 
Buckman's rubber-dam clamps, 368. 
Buffy coat, 1311. 
Building gold tooth-crowns, 413. 
gum, 599. 
Bulb support for obturator, 616. 
Bulging or spheroiding of amalgam, 378. 
Bullae, 183. 
Bunsen burner, 566. 
Bur and wheel files, 421. 
thimble, 340. 
Burne's mask, 637. 
Burnishers, 421. 
Burnishing in sensitive dentine, 268. 
Burns, 712. 
treatment of scars from, 714. 
Burrowing of pus in necrosis, 1014, 1024. 
Burs, diagram of, 266. 
dull and sharp, 265. 
Bursae of front of neck, 796. 
Butler's pluggers, 406. 
Buttner and pivot teeth, 475. 
Button-hole in velum, 848. 
Butyric acid and teeth, 257. 
C. 
Cachectic mucous membrane, 544. 
state and rickets, 199. 
Cachexia in dental caries, 198. 
in dentition, 166. 
Cacoplastic lymph, 201. 
Cadmium in amalgam, 377. 
Calabar in treatment of tetanus, 1084. 
Calcareous tumor upon floor of mouth, 648. 
Calcification of dental pulp, 278. 
of dentinal tubules a cause of chronic 
ulitis, 674. 
of permanent teeth, 158. 
as a cause of chronic ulitis, 281. 
Calculi in salivary ducts, 646. 
Calculus, salivary, 645. 
acids used in, 652. 
instruments used in removing, 652. 
Calendula as a mouth-wash, 673. 
Callositas, 877. 
treatment of, 877. 
Campbell's new mode heater, 570. 
Camphor and morphine in sensitive dentine, 
265. 
Canal, Fallopian (see Temporal Bone), 65. 
infra-orbital, 31. 
interpalatine, 28. 
lachrymal, 40. 
naso-palatine, 28. 
pluggers, 310. 
pterygo-palatine, 54. 
vidian, 55. 
Canals out of correspondence, 471. 
Cancer, 1193. 
encephaloid, 1207. 
illustration of, 1207. 
epithelial, 910. 
juice, 1206. 
of cheek, 910. 
of eyelid, 919. 
of gums, 914. 
of lip, 914. 
of maxillary bones, 1193. 
of nose, 843. 
of throat, 807. 
scirrhoma, 1145. 
treatment of, 1193. 
Cancerous epithelioma, 910. 
ulceration of lip, 911. 
Blasius's operation, 948. 
Celsian operation, 947. 
Chopart's operation, 947. 
Dieffenbach's operation, 942, 953. 
Dupuytren's operation, 947. 
Horn's or Roonhuysen's operation, 
947. 
Leidillot's operation, 953. 
Liston's operation, 948. 
Morgan's operation, 948. 
Miitter's operation, 948. 
operative treatment, 942. 
Roux's operation, 947. 
Serres's operation, 949. 
Tagliacotius's operation, 946. 
ulcers of nose, 840. 
Cancrum oris, 678. 
and salivary fistule, 678. 
Candle-wick and pumice-stone, 425. 
Canine forceps, 435. 
fossa, 31. 
teeth, 141. 
Canker sore, 678. 
Canula in tracheotomy, 736. 
Cap for front teeth, 533. 
Cap-crowning, the pivoting process, and 
bridge-work, 461. 
Cap-crowns, 461. 
Bing's, 463. 
Cryer's, 464. 
Raynor's, 464. 
Talbot's, 463. 
Capillary congestion, 1307. 
erectile tumors, 894, 1149. 
hemorrhage, 693. INDEX. 
1329 
Capillary na?vi maculae, 894. 
Capping dental pulps, 312. 
with clarified quill, 314. 
with lead, tin, and asbestos, 315. 
with metal caps. 314. 
with oiled silk or vellum, 315. 
with oxychloride of zinc, 313. 
with oxysulphate, 315. 
Caps in dental inflammation, 312. 
Capsicum and myrrh, formula for, 658. 
in affections of the gums, 658. 
in angina. 171. 
in hemorrhage, 456. 
Capsular ligament of lower jaw, 133. 
Capsule of encephaloid cancer, 1207. 
Carbolic acid and teeth, 241. 
as a parasiticide, 241. 
Carbonate of magnesia as a decolorizer, 316. 
in phosphor-poisoning, 1022. 
of potassium in sensitive dentine, 265. 
Carbonic acid and temperature, 262. 
in dental caries, 262. 
Carbuncle, treatment of, 692. 
Carcinoma of jaw, 1193. 
Carded cotton in burns, 713. 
Cardiac syncope, 1270. 
Caries and necrosis of walls of nares, 851, 860. 
Caries of antral walls, 850. 
of maxillary bone, 995. 
of teeth, 286. 
cachexia in, 198. 
causes of, 198. 
complicated cavities, 353. 
constitutional relations, 197. 
differs from caries in bone, 242. 
general manner of treating, 242. 
inflammatory process of, 198. 
on approximal faces of teeth in general, 
353. 
on buccal face of molars, 352. 
on grinding face of molars, 351. 
on labial face of incisors, 352. 
on neck surface of incisors, 352. 
on posterior face of incisors. 352. 
principles of treatment, 351. 
Caries of the maxillae, 995. 
common treatment of, 999. 
diagnosis of, 995. 
osteitis the cause of, 995. 
treatment by sulphuric acid, 1001. 
by surgical engine, 1000. 
Carious denture, 353. 
Carnoehan's operation for exposure of second 
branch, 1127. 
of fifth nerve, 1127. 
Carotid arteries, 81,958. 
external, 44, 965. 
primitive, 45, 966. 
ligation of, 958. 
in inferior triangle, 967. 
in superior triangle, 967. 
Carron oil and burns, 713. 
Cartilaginous jaw planes, 145. 
tumors, 891. 
of tongue, 771. 
Casserio's ganglion, 117. 
Cast of mouth, 547. 
Castile and other soaps as a cause of disease 
of the gums, 661. 
Catalan's inclined plane, 535. 
Catalogues, dental, 478. 
Catarrh, nasal, 836. 
Schneiderian membrane, 836. 
Catechu and kino in dental hemorrhage, 456. 
Cathartics in neuralgia, 1116. 
Caudate cells, 1196. 
Cauliflower epithelioma, 911. 
Causes of consumption, 201. 
of dental abscess, 201. 
of erysipelas, 1316. 
of gum diseases, 654. 
of irregularities of the teeth, 524. 
of neuralgia, 1102. 
of odontalgia, 263. 
of palatine deficiencies, 814. 
of salivary calculus, 645. 
of sensitive dentine, 263. 
of tooth discoloration, 316. 
Caustic potash in osseous caries, 1001. 
remedies in treatment of naevi, 897. 
of epithelial cancer, 913. 
Fell's, 913. 
Landolfi's, 913. 
Mackey's, 913. 
Vienna paste, 913. 
Cauterization in dental hemorrhage, 456. 
in salivary fistulas, 991. 
in sensitive dentine, 265. 
Cavernous rale, 1241. 
Cavities among imperfect enamel, 352. 
at neck of incisors, 352. 
for filling, 351. 
approximal, 360. 
crown, 351. 
in teeth, exposure of, 350. 
Cavities of decay opening into pulp-cham- 
ber, 312. 
on buccal fa^e of molars, 353. 
on posterior face of incisors, 352. 
Cazenave's neuralgic pomade, 1117. 
Celluloid and vulcanite, 570. 
gum on metal base, 580. 
Celsian lip operation, 947. 
Cement plombe, 392. 
Cementation of seamless gold crown, 521. 
Cementum, 137-157. 
analysis of, 144. 
Centre of gravity in dentures, 160. 
Cereals, analysis of, 216. 
Cerebral diseases and chloroform, 1278. 
Cervical anastomosis, 960. 
Cervico-facial nerve, 105. 
Chain-saw, use of, 1072. 
Chalk and dental caries, 235. 
Chalky teeth, 246. 
Chambers's mixture for epilepsy, 179. 
Chancre of nose, 865. 
Changes in rami of lower jaw, 43, 534. 
in the blood, 1310. 
in the tongue, 774. 
Character of agents in contact with teeth, 
198. 
of correcting dental apparatus, 526. 
of epithelioma, 910. 
Charging a coke furnace, 601. 
Chase's case of secondary cvst of antrum, 
1190. 
new amalgam, 376. 
Chassaignac's gcraseur, 777. 
Cheeks and lips, 123. 1330 
INDEX. 
Cheesy deposits and ptyaline, 259. 
Cheever's ablation of tonsil gland, 728. 
osteoplastic exsection of upper jaw, 1066. 
Cheiloplastic operations, 945. 
by Blasius, 948. 
by Celsus, 947. 
by Chopart, 947. 
by Dieffenbach, 948. 
by Dupuytren, 947. 
by Horn, 947. 
by Liston, 948. 
by Morgan, 948. 
by Mutter, 945. 
by Roonhuysen, 947. 
by Roux, P., 947. 
by Roux, T. W., 947. 
by Serres, 947. 
Chemical decomposition of bone, 1002. 
treatment of dental hemorrhage, 456. 
Chemico-vital relation of dental caries, 197. 
Chemistry of amalgam, 386. 
Children and chloroform, 1288. 
Chimney-sweep's cancer, 910. 
Chip-blower, 349. 
Chisels in treatment of osseous caries, 1000. 
used in dentistry, 342. 
Chloasma, 879. 
Chloral hydrate in tetanus, 1084. 
Chlorate of potassium as a tooth-bleacher, 
317. 
in stomatitis, 167. 
Chloride of iron in dental hemorrhage, 456. 
of sodium and the teeth, 259. 
of zinc as a calcific agent, 253. 
as a cause of pulpitis, 264. 
as a cleanser of amalgam, 380. 
as a pain-obtunder, 264. 
in cancer, 917. 
in dental caries, 264. 
Chlorine gas as a decolorizer, 317. 
water in cancerous affections, 917. 
in decolorizing, 317. 
Chloroform, 1268. 
action on heart, 1269. 
age in relation with, 1274. 
and laudanum as a local anaesthetic, 457. 
apparent death from, 1280. 
appearance of, 1269. 
as a specific in ether-sickness, 1266. 
cerebral disease in relation with, 1278. 
composition of, 1268. 
dangerous character of, 1268. 
degradation of, 1269. 
dilution of, by air, 1272. 
disease of the heart in relation with, 
1269. 
disease of the lungs in relation with, 
1276. 
hysteria in relation with, 1275. 
in neuralgia, 1115. 
induction of insensibility by, 1271. 
insanity in relation with, 1279. 
minims required for anaesthesia, 1270. 
position for administering, 1271. 
preparatory stimulation, 1271. 
relation of atmosphere with, 1270. 
of fear with, 1271. 
smell of, 1269. 
strength or debility in relation with, 
1275. 
Chloroform subcutaneously used. 1286. 
surgical operations in relation with, 
1274. 
taste of, 1269. 
treatment of accidents with, 1289. 
use of, in conjunction with brandy or 
ether, 1274. 
use of, in spasms, 181. 
weight of, 1269. 
Cholera infantum in dentition, 174. 
Cholesterine in saliva, 362. 
Chromidrosis, 888. 
Chronic angina, 170. 
inflammation, 1306. 
periodontitis, 286. 
phagedaena of the tongue, 753. 
pharyngitis, 806. 
Cicatrices, rules for treatment of, 956. 
Cicatricial tissue, 931. 
Cicatrix cutter, automatic, 1099. 
from burns, 956. 
in harelip, 931. 
Cider and the teeth, 235. 
Ciliary ganglion, 117. 
Ciliated epithelium, 131. 
Circle of Willis, 82. 
Circular saw, use of in exsections, 1063. 
Circumvallata papillae. 129. 
Circumvallation in inflammation, 1296. 
Cirrhosis of lungs, 1246. 
Clamps used with rubber dam, 367. * 
Buckman's pattern, 368. 
Elliot's pattern, 368. 
Hickman's pattern, 368. 
Clasp-teeth, 594. 
Classes of teeth, 245. 
in relation with the operation of extrac- 
tion, 248. 
Classification of pulp-nodules, 281. 
of teeth, 140, 245. 
of tumors, 1136. 
Clean cutting in nerve-sections, 1-129. 
Cleaning an alloy, 378. 
tracheal tubes, 736. 
Cleanliness and the teeth, 237. 
Cleansing of mouth before taking impres- 
sions, 544. 
Cleft lip, 925. 
palate, 814. 
complete, 814. 
Fergusson's operation for, 824. 
incomplete, 814. 
of hard parts, 815. 
operation for, 818. 
preparation of patient for operation, 
819. 
Roux's operation for, 822. 
surgical anatomy of parts, 819. 
the author's operation for, 824. 
uranoplasty, 830. 
Warren's operation for, 823. 
velum, 818. 
Clifford's disk, 552. 
Clinical consideration of dentition, 157. 
histories of naevi, 892. 
illustrations in necrosis, 1005. 
in tumor diagnosis, 1136. 
remarks on treatment of epithelial can- 
cer, 910. 
Clinoid processes of os sphenoiditun, 53. INDEX. 
1331 
Clogging of tracheal tube, 738. 
Cloquet's ganglion, 119. 
Closing break in hard palate, 818. 
Closure of tear-canal, 40. 
Clot-forming agents, 456. 
Club shape prolongation of epithelium, 156. 
Cobweb in hemorrhage, 455. 
Cocaine, 1253. 
dangers of, 1257. 
in extraction, 460. 
in tonsillitis, 718. 
Cod-liver oil in angina, 172. 
in burns, 7 13. 
in rickets, 172. 
Codman and Shurtleff's atomizer, 459. 
Coffee in neuralgia, 1104. 
as a specific in ether sickness, 1266. 
Coffer-dam, 366. 
viewed mechanically and surgically, 372. 
Coffin's system in orthodontia, 530. 
Cohesive gold, 395. 
Cohnheim and white blood corpuscles, 1312. 
Coin plates, 562. 
Colchicum in neuralgia, 1114. 
in rheumatic odontalgia, 272. 
Cold a cause of dental caries, 262. 
in anaesthesia, 457. 
in the head, 1310. 
the cause of diarrhoea, 174. 
water in burns, 713. 
in hemorrhage, 694. 
Colic in tetanus, 1081. 
Collars, seamless^ 513. 
Collecting nitrous oxide, 1282. 
College operating-case, 407, 409. 
Color in calculi, 651. 
Columnar epithelium, 131. 
Coma and polypi, 849. 
Combination, anaesthetic, 1291. 
pivoting, 471. 
Combustibility of ether, 1260. 
Comedo, 885. 
Comminuted fractures, 1037. 
Common carotid artery, 44, 45, 966. 
Compatibility with tooth-substance of gutta- 
percha, 387. 
Complete luxation of jaw, 1031. 
Complex apparatus in relation with ortho- 
dontia, 543. 
osteo-dertal tumors, 1176. 
Complexion in phosphor-necrosis, 1022. 
Complicated arthritis, 1077. 
fractures, 1043. 
harelip, 933. ' 
teeth-cavities. 353, 411. 
wounds of face, 693. 
Complications in nasal fractures, 868. 
Composition of amalgam, 374. 
of black vulcanite, 574. 
of blood, 210. 
of celluloid, 574. 
of teeth, 210. 
of vulcanite, 570. 
Compound jack-screw, 537. 
Compression in dental hemorrhage, 405. 
in facial hemorrhage, 693. 
in lingual hypertrophy, 770. 
of naevi, 896. 
Compressors of ducts, 365. 
used in dentistry for control of saliva, 365. 
Concave surface of scirrhus, 1206. 
Concentric fibroma, 1194. 
Conclusion concerning vela obturators, 631. 
Condensing instruments, 423. 
plugs, 423. 
Conditions of parts in jaw luxation, 1031. 
to be appreciated in orthodontia, 523. 
Conduction in celluloid, 574. 
Condyloid process, 43. 
condition of, in luxation, 1031. 
Condylomata of tongue, 746. 
of uvula, 787. • 
Confluent form of aphthae, 678. 
Congenital adhesion of mouth and nares, 668. 
of nares, 668. 
fissure of hard palate, 814. 
luxation of lower jaw, 1033. 
relations with the teeth, 237. 
tougue-tie, 783. 
union of gums, 667. 
Congestion in spasms, 1 79. 
of spleen and tongue, 744. 
of the lungs, 1234. 
Conical teeth and the rubber dam, 372. 
Conjoined loss of nose and lip, 952. 
remedies, 227. 
Connective tissue, diseases of, 888. 
keloid, 888. 
molluscum fibrosum, 890. 
rhino-scleroma, 890. 
tumor, 890. 
xanthoma, 890. 
Consistence in calculi, 651. 
Constipation in tetanus, 1081. 
Constituents of mucus. 124, 131. 
Constitution of teeth, 135. 
Constitutional cause of nasal hemorrhage, 
840. 
diseases associated with antral disorders, 
984. 
import of tumors, 1193. 
relation of dental caries, 222. 
treatment of dental caries, 197. 
vices in angina, 170. 
Construction of obturators, 606. 
Continuous gum made of celluloid, 580. 
body material, 603. 
enamel material, 603. 
Moffitt's body formula, 603. 
objections to, 604. 
recommendation of, 604. 
teeth used for, 598. 
work, 597. 
Contour amalgam, 376. 
filling, 413. 
of lip in denture-making, 544, 591. 
plugs, 416. 
Contouring in mechanical dentistry, 544, 591. 
Contracted maxilla, 187. 
oral orifice, 942. 
treatment of, by Dieffenbach, 942. 
by Mutter, 942. 
modifications of, by author, 943. 
Contracting exposed pulp, 269. 
Controlling dental hemorrhage, 453. 
progress of cancer, 923. 
Conveniences in dentistry, 426. 
Convex file in separating teeth, 354. 
Convulsion from irritation in teething, 177. 
Convulsions and polypi, 849. 1332 
INDEX. 
Cooper Rose's gum tube, 838. 
Copland on treatment of tetanus, 1083. 
Copper and dental caries, 377. 
and pulp tonicity, 254. 
and therapeusis, 253. 
as an excitant of calcification, 254. 
in amalgam, 377. 
Coppery taste in mouth, 1018. 
Coral and pumice as a cause of ulitis, 661. 
Corium, 124. 
diseases of, 880. 
dermatolysis, 881. 
elephantiasis, 882. 
framboesia, 883. 
morphoea, 883. 
naevus pilosus, 880. 
scleroderma, 880. 
unilateral atrophy, 882. 
Cork, use of, in false anchylosis, 1098. 
Corn, analysis of, 216. 
Cornu cutaneum, 877. 
treatment of, 878. 
of dental pulp, 136. 
of hyoid bone, 58. 
Coronary arteries, 80, 85. 
Corpuscles, Purkinjean, 137. 
salivary, 244. 
Corpuscular lymph, 100, 1142. 
Correcting apparatus, 528. 
Angle's, 1051. 
Coffin's, 530. 
Farrar's, 538. 
Flagg's, 531. 
Kingsley's, 535. 
McQuillen's, 530. 
Westcott's, 529. 
White's, 528. 
double harelip, 934. 
Corrosive sublimate as a parasiticide, 240. 
in stomatitis, 163. 
in syphilitic stomatitis, 163. 
Corrugated powder-disk, 422. 
Corrugator supercilii muscle, 72. 
Cortex strata, 1183. 
Corundum disks, 348, 422. 
points, 423. 
tape, 422. 
Coryza and bromide of potassium, 837. 
in infants, 861. 
Cosmoline in burns, 713. 
Costiveness in epistaxis, 840. 
Cotton as an obturator, 607. 
in root filling, 310. 
seton in salivary fistule, 992. 
twine in harelip operation, 940. 
Counter-casts, 609. 
openings in alveolar abscess, 293. 
Cow-horn forceps, 440. 
Crackling rale, 1241. 
Cracks and fissures of tongue, 751. 
in enamel a cause of pulpitis, 272. 
Crapulous diarrhoea, 174. 
Cream in angina, 172. 
in scrofulosis, 172. 
Creasote as a cause of ulitis, 661. 
as a disinfectant, 240. 
as a parasiticide, 240-254. 
in dental caries, 240. 
in ether-sickness, 1266. 
in neuralgia, 1117. 
Crepitant rale, 1241. 
Cribriform plate of ethmoid bone, 50. 
Crimson-tinged tumors of jaw, 1198. 
Crista galli of ethmoid bone, 50. 
Criticism on operations for neuralgia, 1126. 
Crown cavities, 410. 
extension work, 501. 
surface of cape, how made, 462. 
Crowning broken teeth, 461. 
Crowns for pivoting, 468. 
Crucial incisions in cystoma, 1171. 
Crusta dentium adamantina, 1183. 
petrosa, 135. 
Cryer, Dr., on development of enamel, 157. 
Cryer's cap-crowns, 464. 
plan of repairing celluloid dentures, 
577. 
Cupping, 720, 1299. 
glasses, 720. 
Cups for impression purposes, 545. 
for relief of visceral congestion, 1298. 
Cure of dental caries by filing, 252. 
Curette in lupus erythematosus, 909. 
Curtis's bridge-work, 506. 
Cuspidati teeth, 141. 
Cutaneous horns, 878. 
hypermmia, 182. 
Cuts of tongue, 745. 
Cutting an alloy, 378. 
forceps, 446. 
frajnum of tongue, 783. 
teeth, irritation from, 161. 
Cutting-bone scissors, 1066. 
Cylinders for liquid nitrous oxide, 1283. 
in tooth-filling, 395. 
Cyst, general diagnosis of, 1170. 
Cystic disease of tonsil glands, 728. 
tumors, 1170. 
non-explainable, 1193. 
of tongue, 758. 
self-explainable, 1170. 
Cystiform antra, 1189. 
Cystoma of maxillary ramus, 1177. 
of tongue, 758. 
parasitic, of cheek, 903. 
Cystomata, 1175. 
Cysto-sarcoma, 1201. 
phyllodes, 1202. 
succulent tumors, 1202. 
Cysts of salivary ducts and glands, 789. 
D. 
Da Costa's neuralgic ointment, 1119. 
Dam, rubber, 363. 
Danger of chloroform, 1268. 
Darby crown, 481. 
Data concerning dental tumors, 1187. 
Dead or loose teeth as a cause of disease of 
gums, 428. 
Dead teeth, 294. 
Deadrick in jaw operations, 1070. 
Deafness in angina, 168. 
Debility and infantile diarrhoea, 174. 
in aphthee, 676. 
of organization, 161. 
or strength in relation with use of chlo- 
roform, 1275. 
Deciduous teeth, 139. INDEX. 
1333 
Deciduous teeth, absorption of roots of, 159. 
decrease of, 158. 
exposed pulp of, 188. 
foramina of, 158. 
in orthodontia, 524. 
Decomposition of dental pulp, 274. 
Deep arteries of the face, 85. 
jugular vein, 94. 
seated ranula, 792. 
temporal artery, 87. 
Defects in suction, 591. 
in the hard palate, 606. 
in the soft palate, 627. 
Definition of dental tumors, 1160. 
of skin diseases, 877. 
of term tumor, 1136. 
Deformed or anomalous teeth, 450. 
Deformities of head in rickets, 199. 
in dentition, 523. 
Deformity after exsection of the jaw, 1074. 
correction of, 1074. 
from burns, 712. 
Delayed dentition in rickets, 199. 
Delicate infants and dentition, 161. 
Dennet's pivot tooth, 472. 
Dens sapientiae, 143. 
Dental abscess, 292. 
arches in articular relation, 556. 
art, 337. 
canal and implantation, 332. 
carbolic acid soap as an oral parasiticide, 
228. 
caries, 197. 
chisels, 342. 
conveniences, 426, 562. 
cysts, 1170. 
drain tubes, 323. 
engine, 340. 
Bonwill's, 341. 
in pivoting, 468. 
White's, 341. 
evolution a cause of febrile manifesta- 
tions, 161. 
exostosis, 1160. 
files, 344. 
fungoid tumors, 1147. 
hemorrhage, 453. 
irregularities, 523. 
irritation and skin eruptions, 184. 
in association with dental evolution, 
176. 
mirror, 350. 
napkin, 362. 
necrosis, 1008. 
nerves, 111, 114. 
inferior maxillary, 114. 
superior maxillary, 111. 
operating-chair, 426. 
operations and the teeth, 236. 
periostitis, 286. 
pits, 140. 
plates, 581. 
in oesophagus, 808. 
practice out of the mouth, 361. 
pulp, 135. 
decomposition, 274. 
exposure of, 267. 
reformative efforts of, 280. 
treatment of, 269. 
screw, 447. 
Dental splint, 1042. 
supplies, 562. 
therapeusis, 252. 
trays, 545. 
Dentata articulation, 36. 
Dentes sapientiae, 143. 
forceps, 443. 
Dentifrices, 226. 
improper use of, 285, 661. 
non-soluble, 661. 
Dentigerous tumors and successional teeth, 
. 1189. 
Dentinal tubules, 135. 
Dentine, 135, 157. 
analysis of, 144. 
formation of, 135, 149. 
moist, 246. 
sensitive, 268. 
soft, 246. 
Dentinification, 149. 
Dentinoma, 1161. 
Dentition, 145, 148. 
associate lesions of, 161. 
dental germ, 147. 
enamel formation of, 149. 
origin of the teeth, 145. 
tunica propria, 148. 
reflexa, 148. 
views of microscopists concerning, 146. 
Denture, 544. 
imperfect, 211. 
perfect, 211. 
Denudation, 355. 
treatment of, 336. 
Depletion, 1300. 
in periodontitis, 289. 
Deposits of pigment, 879. 
Depressed rubber dam, 366. 
Depressing action of heart as an anti-hem- 
orrhagie, 290. 
Depression of tongue, 362, 717. 
Depressor angulari oris, 75. 
Derangement of bowels in phosphor-necrosis, 
1022. 
Dermatitis, 183. 
Dermatolysis, 881. 
Descendens noni nerve, 967. 
Descending palatine artery, 88. 
Desirabode's palatine obturators, 619. 
Destiny of milk-teeth, 159. 
Destruction of alveolar process, 1011. 
of dental pulp, 274. 
Detaching teeth from celluloid plates, 578. 
Details and principles in diagnosis, 1215. 
Deteriorated antral secretions, 978. 
molecules, 238. 
Development of teeth, 145. 
forward, 527. 
Deviation of nasal septum, 834, 864. 
Dewar's dressing, 930. 
Dewees's membrane, 728. 
Dewey crown, 482. 
Diabetes mellitus and tongue, 743. 
Diagnosing dead teeth, 294. 
Diagnosis as applying to anaesthesia and 
anesthetics, 1219. 
general, 1215. 
medical, 1215. 
of dental irritative fever, 172. 
of polypi, 844. 1334 
INDEX. 
Diagnosis of the aphthae, 675. 
of tumors, 1136. 
surgical, 1218. 
Diagram of burs, 266. 
of contour-work, 416. 
of gum-lancing, 164. 
of imprisoned teeth, 302. 
of inflammation, 1296. 
of nerve-canal pluggers, 310. 
of nodular dentine, 281. 
of squamous epithelioma, 924. 
of tooth nutrition, 157. 
showing secondary dentine, 281. 
teeth. 140. 
development, 151, 154. 
Diameter of dental tubules, 136. 
Diamond reamers, 251. 
Diamonds in teeth as ornaments, 477. 
Diaphoresis in angina, 169. 
Diarrhoea from atmospheric changes, 175. 
from dentition, 174. 
from enteritis, 175. 
from excess of food, 175. 
from food not easily digested, 175. 
from hepatic derangement, 174. 
from infusoria, 174. 
from malarial influence, 174. 
from scrofulous diathesis, 175. 
from unhealthy milk, 176. 
from worms, 175. 
mixture, 177. 
Dibble's saliva-pump, 363. 
Dickens's illuminator, 812. 
Dieffenbach's operation for atresia oris, 943. 
for staphyloplasty, 829. 
on lip, 948. 
Diet and aphthae, 691. 
and bad teeth, 209. 
in angina, 170. 
in inflammation, 1303. 
Difference in vice tumors, 1193. 
of dental and osseous caries, 242. 
Differentiation of tumors of constitutional 
import, 1193. 
Digastric muscle, 78. 
Digitalis in neuralgia, 1114. 
Dilatation of the heart, 1224. 
Dilator naris muscle, 73. 
Diminution of appetite in prosphor-necrosis, 
1022. 
of pulp-cavity, 279. 
Diphtheria and nose-bleeding, 840. 
Diphtheritic inflammation, 803. 
Diplococci, 1320. 
Direct drying of dental cavities, 372. 
occlusion, 533. 
Directions for making obturators, 600. 
Dis, 1215. 
Disappearance of eruptions associated with 
convulsions, 178. 
Discoloration of teeth caused by amalgam, 384. 
Discolored teeth, 316. 
Disease a generic term, 1215. 
Diseases of external nose, 866. 
fractures, 867. 
loss of substance, 852, 952. 
of first dentition, 163. 
of the face, 877. 
immediate, 877. 
mediate, 877. 
Diseases of the floor of mouth, 789. 
enlargement of sublingual folds, 794. 
epithelioma, 795. 
Fleischman's synovial sac, 794. 
lipoma, 791. 
muciparous cysts, 794. 
ranula, 789. 
• venous aneurism, 795. 
of the gums, 654. 
of the periodonteum, 275. 
of the pharynx, 801. 
accidental lesions, 806. 
angina simplex, 802. 
effusions, 804. 
follicular inflammation, 803. 
herpes, 804. 
pharyngitis sicca, 804. 
polypi, 808. 
post-pharyngeal abscess, 805. 
of the teeth, 197, 286. 
Disinfecting dental pulp-canal, 307. 
Disking incipient caries, 349. 
Disks, corundum, 348. 
Dislocation of the inferior maxilla, 1031. 
cause of luxation, 1031. 
condition of parts in luxation, 1032. 
congenital luxation, 1033. 
diagnosis of luxation, 1031. 
forms of displacement, 1031. 
fracture associations, 1033. 
in men and women, 1032. 
subluxations, 1033. 
treatment of luxation, 1034. 
use of anaesthesia in, 1035. 
Disparting apparatus, 530. 
Dispensing nitrous oxide, 1282. 
Displaced heart, 1232. 
Displacement of nasal septum, 866. 
Dissection of lips and cheeks, 69. 
of pharynx, 802. 
of soft palate. 123. 
of tongue, 126. 
Distention of antral walls, 977, 986. 
Distinction of blood in hemorrhage, 1245. 
Distribution of nerves of face, 103, 106. 
Disturbances in tissue metamorphosis, 1310. 
Diuretics in inflammation, 1303. 
Diversion in angina, 168. 
Division and distribution of fifth nerve, 107. 
of frrenum in tongue-tie, 781. 
Donovan's solution in neuralgia, 1115. 
in syphilis of the tongue, 750. 
Dorr's treatment of green stain on teeth, 655. 
Double harelip, 934. 
complications of, 938. 
door-knob deformities in, 939. 
forms of, 934. 
screw in orthodontia, 537. 
Douche in ozaena, 876. 
Dover's powder, 1302. 
in odontalgia, 270. 
Dovetail tooth-crown, 4S8. 
Drain in necrosis, 1026. 
Drainage in treatment of ranula, 791. 
Drain-tubes in replantation of teeth, 323 
Dressing contour fillings, 425. 
gutta-percha plugs, 388.. 
jaw fractures, 1040. 
Dribbling, treatment of, 994. 
Dried fruits and the teeth, 236. IADEX. 
1335 
Drill, Merry's, 340. 
Drill-holes in orthodontia, 529. 
Drilling engines, 340. 
roots and necrosis, 1008. 
Drills, rose and spear, 340. 
Drip-tube, Herrick's, 349. 
Drooling, 994. 
of antrum. 977. 
of chest, 1244. 
Drop-tubes, 349. 
Dry cupping. 719, 1299. 
rale, 1240. 
Dryness and sensitive dentine, 267. 
and tooth-filling, 372. 
of nares, 985. 
in harelip operation, 929. 
Dubs's screw-forceps, 447. 
Duct compressors, 365. 
Hawes's, 363. 
Morrison's, 363. 
Osborn's, 363. 
Rich's 365. 
Smith's, 363. 
of Bartholin, 133. 
of Rivini, 133. 
of Steno, 131. 
of Wharton, 132. 
and alveolar abscess, 298. 
thoracic, 94. 
Ductus ad nasum, 27. 
Duplay's speculum, 862. 
Dupuytren's lip operation, 947. 
Duration of acute tetanus, 1080. 
of scirrhomata, 1206. 
Dyscrasia in relation with orthodontia, 523. 
Dyspepsia and anaemia as causes of dental 
caries, 223. 
E. 
Earth as a dressing, 713. 
Earthy concretions in duct of Steno, 646. 
Ease, 1215. 
Ease or difficulty in extracting teeth, 428. 
Eau de luce in seborrhoea, 885. 
Eburnification, 248. ' 
Eccentric fibroma, 1194, 
Ecraseur, 777. 
Edentulous arches, taking impressions of, 
549. 
Edge-strength in an alloy, 377. 
Effects of salivary calculus, 645. 
Effusions, character of, 1309. 
in burns, 713. 
in the tissue of pharynx, 804. 
in tongue, 767. 
in uvula, 786. 
Egg-shaped nodules in dental pulp, 281. 
Electric illuminator, 812. 
Electrical disturbances in dentistry, 230. 
Electro-chemical dental experiments, 230. 
relations with caries, 230. 
galvanism in tooth-extraction, 457. 
magnetic mallet, 418. 
Electrolysis in treatment of vascular naevi, 
898. 
of tumors, 898. 
Elephantiasis, 882. 
Elevators used in extracting teeth, 442. 
Elliot's rubber-dam clamps, 368. 
Elongated tongue, 770. 
Elongation of uvula, 785. 
Emery in plug-finishing, 423, 
Emetics in angina, 169. 
in sore throat, 169. 
Emotional disease of sweat-glands, 888. 
Emphysema, 1243. 
and chloroform, 1289. 
and ether, 1288. 
in tracheotomy, 737. 
Emprosthotonos in tetanus, 1080. 
Enamel, 136, 156. 
abrasion of, 336. 
analysis of, 144. 
denudation of, 355. 
formation of, 149. 
membrane, 148. 
stopping, Oehlecker's, 392. 
Enamelling continuous-gum work, 602. 
Enamels, 603. 
Encephaloma, 1207. 
early ulceration of, 1207. 
illustrations of, 1208. 
malignancy of, 1207. 
microscopic views of, 1211. 
protrusion of fungus from, 1207. 
Enchondrpma, 891. 
Enchondromatous tumors, 891, 1202. 
Encysted tooth-germs, 195. 
Encystment of teeth by salivary calculus, 646. 
Endermic application of morphia in neural- 
gia, 1116. 
Engine, dental, 340. 
Bon will's 341. 
White's, 341. 
drill in extraction of roots, 451. 
English chalk as a decolorizer, 317. 
method of rhinoplasty, 869. 
operation in harelip, 933. 
Engorgement of antrum, 983. 
Enostosis, 1159. 
Enteric fever and tongue, 744. 
Enteritis in dentition, 172. 
Epiderm, diseases of, 877. 
callositas, 877. 
chloasma, 879. 
cornu cutaneum, 877. 
ichthyosis, 884. 
lentigo, 879. 
lichen pilaris, 878. 
naevus pigmentosus, 879. 
verruca, 883. 
vitiligo, 879. 
Epiderm et corium, diseases of, 883. 
Epiglottis, 13(4. 
Epilepsy from dental irritation, 179. 
Epistaxis, 837. 
associated with hemorrhagic diathesis, 
840. 
passive, 837. 
plethoric, 837. 
traumatic, 837. 
Epithelial involution, 155. 
Epithelioma, 910. 
author's treatment of, 919. 
definition of term, 910. 
general consideration of, 910. 
illustrations of, 914. 
microscopic character of, 912. 
of face, 921. 1336 
INDEX. 
Epithelioma of larynx, 742. 
of lingual fraenum, 756. 
of nasal septum, 917. 
of tongue, 756. 
significance of, 910. 
three forms of, 911. 
treatment of, 91 2. 
Epithelium of mouth, 124. 
Epitome of myeloid growths, 1197. 
Epsom salts in angina, 169. 
Epulic tumors, 1146. 
Epulides not self-explaining, 1146. 
Epulo-erectile tumors, 1149. 
definition of, 1149. 
treatment by cauterants, 1150. 
by electrolysis, 1150. 
by injection, 1149. 
by pressure, 1151. 
by the serres-fines, 1150. 
by the seton, 1150. 
varieties of, 1146. 
Epulo-fungoid tumors, 1146. 
Erectile epulides, 1149. 
growths, 1149. 
tumors of tongue, 768. 
Erigeron Canadense in hemorrhage, 454. 
Errors of nutrition and tongue, 771. 
Eruption of temporary teeth, 158. 
upon skin, 182. 
in dentition, 182. 
Erysipelas, 182, 1313. 
and burns, 715. 
as a complication in epithelioma, 918. 
forms of, 1313. 
of nose, 837. 
of tongue, 767. 
specific for, 1313. 
treatment of, 1313. 
Erythema, 182., 
Escape of gas in pivoting, 479. 
Eschar and scar, 712. 
Ether, sulphuric, 1260. 
absorption of, 1263. 
action of, on nervous system, 1264. 
boiling-point of, 1260. 
carbonic acid as an antidote for sick 
stomach, 1266. 
chloroform as an antidote for sick stom- 
ach, 1266. 
coffee as an antidote for sick stomach, 
1266. 
combustibility of, 1260. 
continuance of patient in anaesthetic 
condition, 1266. 
creasote as an antidote for sick stomach, 
1266. 
criterion for judging effects of, 1266. 
effects of a bad article, 1265. 
essentials of exhibition, 1261. 
evanescence of effect, 1263. 
freezing-point of, 1260. 
idiosyncrasies, 1267. 
immediate and obvious effect of, 1264. 
indicated in obscure neuralgia, 1115. 
instruments used for administering, 1261. 
Jackson's formula for preparing, 1260. 
physical characteristics of, 1260. 
quantity employed, 1266. 
relation of action with that of common 
alcoholic beverages, 1263. 
Ether, relation of atmosphere with, 1267. 
safety of, 1267. 
sick stomach from use of, 1266. 
specific gravity of, 1260. 
spice-plaster in sick stomach from, 1266. 
volatilization of, 1260. 
Ethmoid bone, 50. 
articular relations of, 52. 
boxes of, 50. 
cells of, 51. 
cornea of, 50. 
cribriform plate of, 50. 
crista galli of, 50. 
foramina of, 50. 
general construction of, 50. 
nasal slit of, 50. 
olfactory depressions of, 50. 
perpendicular plate of, 50. 
turbinated scrolls of, 51. 
unciform process of, 51. 
Ethyl bromide, 1285. 
accidents associated with use of, 1285. 
color of, 1285. 
mixture with ether and water, 1285. 
mode of preparing, 1285. 
odor and taste of, 1285. 
quantity required for ana?sthesia, 1285., 
rapidity of action of, 1285. 
Ethylate of sodium in treatment of naevi, 
897. 
Etiology of aphthae, 685. 
Evans's studies in dental prosthetics, 559. 
system of seamless gold contour crowns, 
515. 
Evulsion in treatment of polypi, 845. 
Examples in alveolar abscess, 295. 
in tumor diagnosis, 1137. 
Exanthemas in alveolar necrosis, 1020. 
Exanthemata, 184. 
and dentition, 184. 
in antral disease, 987. 
necrosis associated with, 1020. 
Excavating dental cavities, rules for, 360. 
for contour fillings, 360. 
, in dental caries, 351. 
instruments nsed for, 358. 
Excavators, 338. 
Excising forceps, 466. 
saw, 467. 
Excision of naevi, 895. 
of tongue, 772. 
Exciting causes of dentigerous cysts, 1170. 
of jaw luxation, 1031. 
Excito-motor capacity of fifth nerve, 121. 
Exclusion, the process of, 1218. 
Exfoliation of dead tooth, 1010. 
of lamina of bone, 1005, 1014. 
Exophthalmic goitre, 1233. 
Exostosis, 1159. 
and subacute inflammatory tumors, 
1159. 
antral, 849. 
dentium, 1160. 
nasal, 849. 
non-specific, 959. 
of the fangs of teeth, 450, 1160. 
specific, 1162. 
sphenoidal, 849. 
spongy,1163. 
varieties of, 1159. INDEX. 
1337 
Exploring needle in diagnosis of bone dis 
eases, 1163. 
of odontocele, 1175. 
Exposed pulp in milk-teeth, 188. 
in permanent teeth, 267. 
treatment of, 269. 
Exposing dental cavities, 249. 
Exposure of nerves, 1121, 1131. 
auricularis magnus, 1133. 
great occipital, 1134. 
inferior maxillary, 1122, 1124. 
infra-orbital, 1132. 
lingual, 766, 1122. 
superior maxillary, 1125. 
Expression, as influenced by the teeth, 525. 
muscles of, 69. 
of primary shock, 695. 
of tongue in disease, 743. 
Exsection of inferior maxilla, 1070. 
of nerves, 1121, 1131. 
Carnochan's operation, 1127. 
Garretson's operation, 1122. 
Langenbeck's operation, 1127. 
Pancoast's operation, 1127. 
of the maxillary bones, 1059. 
author's operation for, 1071. 
history of, 1059. 
Horner's operation for, 1061. 
instruments used for, 1062. 
Extension finger, McQuillen's, 364. 
Taft's, 364. 
External auditory outlet, 34. 
carotid artery, 83. 
branches of, 83. 
jugular veins, 94. 
lateral ligament of lower jaw, 133. 
Extirpation of tonsil gland, 728. 
by use of London paste, 724. 
Cheever's operation, 728. 
tonsillotomy, 725. 
Billings's tonsillotome, 726. 
Kolbe's tonsillotome, 726. 
Physick's tonsillotome, 726. 
use of bistoury for, 727. 
Extra-articular anchylosis, 1076. 
Extraction, general remarks on, 452. 
mistakes in, 320. 
of teeth, 428. 
forceps used for, 430. 
in orthodontia, 531. 
indication for operation, 428. 
of tooth-roots for operation, 428. 
Extractum elateri in inflammation, 1303. 
Exudation into trachea and bronchi, 742. 
Eye-teeth, 141. 
F. 
Face, anatomy of, 26. 
diseases of, 877. 
angeioma of, 892. 
anidrosis, 888. 
arterial tumors, 892. 
callositas, 877. 
capillary naevi maculae, 894. 
chloasma, 879. 
chromidrosis, 888. 
comedo, 885. 
cornu cutaneum, 877. 
dermatolysis, 881. 
Face, diseases of: elephantiasis, 882. 
enchondromata, 891. 
facial tubercles, 901. 
framboesia, 883. 
gumma, 901. 
hyperidrosis, 887. 
hypertrophy of mucous su-face of 
lip, 882. 
ichthyosis, 884. 
keloid, 888. 
lentigo, 879. 
lichen pilaris, 878. 
lupus erythematosus, 906. 
vulgaris, 907. 
maculae, 894. 
milium, 885. 
molluscum fibrosum, 890. 
molluscum sebaceum, 885. 
morphoea, 883. 
mother-mark, 892. 
naevus pigmentosus, 879. 
pilosus, 880. 
vasculosus, 892. 
parasites, 902. 
port-wine stain, 895. 
rhino-scleroma, 890. 
scleroderma, 880; 
scrofuloderma, 900. 
sebaceous tumors, 886. 
seborrhoea, 884. 
sudamina, 888. 
syphiloderma, 901. 
tinea circinata, 903. 
sycosis, 903. 
unilateral atrophy, 882. 
venous tumor, 893. 
verruca, 883. 
vitiligo, 879. 
wounds of, 693, 877. 
xanthoma, 890. 
muscles of, 69. 
nerves of, 103. 
Faces of molar teeth, 142. 
Facial anastomosis, 962. 
artery, 85. 
notch for, 34. 
expression, 527. 
hemorrhage, 693. 
hypertrophy, 881, 909. 
marks, 892. 
nerves, 103. 
surface of superior maxilla, 41. 
syphilitic tuberculosis, 901. 
vein and branches, 97. 
Facing amalgam, 376. 
Facings of plastics, 477. 
of porcelain, 474. 
Fahnestock's tonsillotome, 725. 
False anchylosis, 1098. 
bites, 555. 
bottomed trays, 545. 
joint in anchylosis, 1101. 
occlusion a cause of periodontitis, 301. 
Farrar's correcting apparatus, 538. 
Fascia of parotid gland, 132. 
Fat and flour, 220. 
Fatty heart, 1225. 
tumors of tongue, 768. 
Febrifuges in angina, 170. 
Fell's caustic, 913. 1338 
INDEX. 
Fergusson's incisions in jaw exsections, 1064. 
operation for cleft palate, 824. 
Ferruling tooth-crowns and roots, 478. 
Fetid discharges depending on tooth abscess, 
975. 
Fetor in mercurial disease, 1019. 
Fever in phosphor-necrosis, 1021. 
irritative, 172. 
Fibro-plastic tumors of Lebert, 1195. 
recurring tumors, 1196. 
serum, 1141. 
Fibroid phthisis, 1246. 
Fibromata, 1194. 
diagnosis of, 1195. 
microscopic appearance of, 1195. 
Fibrous polypus, 846. 
Fifth pair of nerves, 106. 
divisions of, 107. 
function of, 120. 
ganglia of, 117. 
inferior maxillary branch of, 114. 
ophthalmic branch of, 109. 
superior maxillary branch of, 111. 
Figure-of-eight tie, 941. 
manner of making, 941. 
Files, 344. 
as a prophylactic and curative agent, 
249. 
carriers, 346. 
finishing, 344. 
Forbes's carrier, 346. 
Line's carrier, 347. 
Miller's carrier, 346. 
objections to use of, 250. 
Filiform papilla? of tongue, 130. 
Filing in dental caries, 249. 
in pivoting operations, 467. 
Filling in tooth extraction, 322. 
lower teeth, 413. 
over exposed tooth-pulp, 312. 
pulp-canals, 308, 322. 
teeth, 396. 
with amalgam. 374. 
with cohesive gold, 403. 
with gold, 395. 
with gutta-percha, 387. 
with non-cohesive gold, 396. 
with oxychloride of zinc, 389. 
with plastic, 394. 
with tin, 393. 
with zinc phosphate, 391. 
Filth in tetanus, 1085. 
Finishing a denture, 590. 
approximal fillings, 424. 
files, 420. 
plugs, 420. 
stones, 424. 
vulcanite plates, 574. 
First teeth, 139. 
Fish-bones in pharynx, 809. 
Fish-hook in throat, 809. 
Fish-skin disease, 884. 
Fish-tail screw, 542. 
Fissures and cracks of tongue, 751. 
papayotin in treatment of, 751. 
of hard palate, 814. 
of soft palate, 814. 
pterygo-maxillary, 34. 
spheno-maxillary, 34. 
Fistulas, salivary, 990. 
Fistule, salivary, Agnew's operation for, 991. 
author's operation for, 992. 
common treatment of, 991. 
Horner's cure for, 992. 
illustrative case of, 992. 
Fitting a plate to the mouth, 590. 
the Evans crown, 518. 
up a dental workshop, 564. 
Fixation of artificial denture, 551, 594. 
of masks to face, 637. 
of plates to mouth, 551, 594. 
Flagg's method of pivoting teeth, 471, 472. 
tongue-holder, 362. 
zinc phosphate, 392. 
Flaps in plastic operations, 919, 956. 
in treatment of cancer, 919. 
Flasking celluloid-work, 574. 
vulcanite-work, 576. 
Flasks for vulcanizing, 571. 
Flat files, 345. 
pigmentary naevi, 879. 
warts, 883. 
Fleischman's bursa, 794, 796. 
Fletcher's blow-pipe, 567. 
radial burner, 567. 
Floor of mouth, diseases of, 789. 
calculi in salivary ducts, 791. 
epithelioma, 795. 
lipoma, 791. 
naevi, 795. 
ranula, 789. 
Flour, superfine, 216. 
unbolted, 216. 
Fluids, oral, 243. 
analysis of, 245. 
Fluosilicate of soda as an antiseptic, 1320. 
Flux, to make, 603. 
Fly-blisters, 1299. 
in periodontitis, 289. 
Fly-larvae in sinuses, 989. 
Foil-carrier, 397. 
Foils, cohesive, 403. 
gold, 395. 
soft, 396. 
tin, 393. 
Follicles of mucous membrane, 124. 
Follicular inflammation, 677. 
of pharynx, 803. 
Fontanel and rickets, 202. 
anterior, 36. 
posterior, 36. 
Food and dental caries, 209. 
Foot-lathe, 564. 
sprayer, 459. 
Foramen, infraorbital, 31. 
mental, 32. 
Forbes's chisels, 344. 
Forceps for cutting bone, 1066. 
for excising operculum, 1093. 
for extracting teeth, 430. 
Foreign bodies in nasal associate sinuses, 866. 
in nose a cause of ozasna, 851. 
in pharynx, 808. 
in Steno's duct, 993. 
particles in face wounds, 712. 
Forget's unique case of odontoma, 1178. 
Fork screw-driver, 474. 
Formation of enamel, 149. 
Formative branches of jugular veins, 95. 
of temporo-maxillary, 95. INDEX. 
1339 
Forms of gutta-percha, 388. 
of harelip, 934. 
of tongue-tie, 781. 
Formula for amalgam, 374. 
for aperient mineral-water, 168, 673. 
for antacid mouth-wash, 226. 
for continuous-gum work, 603. 
Fossa, canine, 31. 
incisive, 31. 
myrtiform, 31. 
pterygoid, 46. 
spheno-maxillary, 34. 
sublingual, 44. 
submaxillary, 44. 
temporal, 33. 
zygomatic, 33. 
Foster crown, 484. 
Foul breath, 223, 723. 
Foundation cement, 391. 
Fountain drip-point, 349. 
Four stages of staphylorraphy, 822. 
Fracture in alveolar process, 1037. 
in tooth extraction, 452. 
of maxillary bones, 1036. 
bandages used, 1041. 
Barton's bandage, 1041. 
Bean's splint, 1042. 
character of, as influenced by cause, 
1037. 
comminuted, 1038. 
complicated, 1043. 
Garretson's bandage, 1043. 
Gibson's bandage, 1043. 
simple, 1036. 
Nasmith's splint, 1049. 
splints used, 1040. 
Sudduth's splint, 1045. 
treatment of, 1040. 
Fractured tooth-roots, 445. 
extraction of, 445. 
cutting forceps used for, 446. 
Dubs's forceps used for, 447. 
Ilullihen's forceps used for, 447. 
screw used for, 447. 
Fractures of nasal bones, 867. 
displacement of, 867. 
gutta-percha splint, 867. 
pasteboard splint, 867. 
Fraena, 124. 
of epiglottis, 124. 
of lips, 124. 
of tongue, 124. 
Frail teeth and oxychloride, 390. 
Framboesia, 883. 
Framework of pharynx, 801. 
Frankel's nasal speculum, 862. 
Freckles, 879. 
Freezing the gums, 457. 
Fremitus, vocal, 1242. 
Fright as cause of shock, 696. 
Frog-face, 847. 
Frog-spawn gum, 672. 
Frontal bone, 59. 
angular processes of, 60. 
articulation of, 59. 
horizontal portion of, 61. 
lachrymal fossae of, 61. 
longitudinal groove of, 61. 
muscles of, 61. 
nasal spine of, 60. 
Frontal bone, supraorbital notch of, 60. 
temporal ridge of, 60^ 
vertical portion of, 59. 
Frontal sinus, 60. 
abscesses of, 989. 
illustrations of, 989. 
Front-tooth amalgam, 376. 
Fruits and soft teeth, 236. 
Fulcrum forceps, 443. 
Functional disorder in inflammation, 1297, 
1308. 
tumors, 1136. 
Functions of dyscrasic children, 161. 
of nose, 835. 
Fungi and salivary calculus, 645. 
Fungiform papillae of tongue, 129. 
warts, 883. 
Fungoid scirrhoma, 1145. 
tumors, 1147. 
Fungus haematodes in odontocele, 1175. 
in tongue, 754. 
Furnace for baking continuous-gum work, 
600. 
Parker's, 600. 
Teese's. 600. 
Verrier's, 600. 
White's, 600. 
of vulcanite apparatus, 573. 
Furred tongue, 743. 
Furuncular epidemics and antrum, 986. 
Fused teeth, 193. 
Fusing-point of metals used in dental alloys, 
377. 
G. 
Gagging and retching, 591. 
Gags in mouth operations, 830, 1099. 
Elsberg's, 830. 
Goodwillie's, 831. 
Kolbe's, 1098. 
Whitehead's, 830. 
Wood's, 831. 
Galvanic cauterization in disease of tongue, 
755. 
Galvanization in scleroderma, 880. 
Galvano-cauterant in treatment of naevi, 
898. 
Ganglia of fifth pair of nerves, 117. 
Gasser's, 117. 
lenticular, 117. 
Meckel's, 117. 
naso-palatine, 119. 
ophthalmic, 117. 
otic, 120. 
submaxillary, 120. 
Gangraena oris, 678. 
Gangrene of gums, 673. 
of pharynx, 803. 
Garengeot's key, 444. 
obturator, 626. 
Gargarysma guaiaci composita, 719. 
Gargle in angina, 169. 
in chronic angina, 171. 
in tonsillitis, 717. 
Garretson's exsection of inferior maxilla, 
1071. 
jaw bandage, 1043. 
operation for cleft palate, 824. 1340 
INDEX. 
Garretson's operation for exposure of maxil- 
lary nerve, 1121, 1122. 
for salivary fistule, 992. 
Gas and pus in dental pulp-cavities, 275. 
escape of, in pivoting, 479. 
nitrous oxide, 1280. 
Gates's tooth-crowns and method, 494. 
Gauze and collodion in harelip, 938. 
Gelatinoid polypus, 844. 
Gemischte narkosc, 1286. 
General indications in treatment of alveolar 
abscess, 293. 
remarks on extraction of teeth, 452. 
rules for excavating dental cavities, 360. 
treatment of inflammation, 1297. 
view of head circulation, 81. 
Genial tubercles, 44. 
Genio-hyoid muscle, 79. 
Genioplastic operations, 945., 
Germ of tooth, 147. 
theory, 1318. 
German experience in necrosis, 1028. 
method of rhinoplasty, 868. 
Germicide table, 240. 
Germs of heterogeneous development, 193. 
Gibson's jaw bandage, 1042. 
Gingivitis of pregnant women, 673. 
Giraldes on multiple cysts of antrum, 1191. 
Glairy mucus, 259. 
Glanders, 843. 
Glands, salivary, 131. 
Glandulm buccales, 124. 
labiales, 124. 
Glass fillings, 394. 
Glenoid cavity of temporal bone, 133. 
Globus hystericus, 807. 
Glossitis, danger of, 762. 
Glue paste in mask-making, 637. 
Goitre, 1211. 
cystic, 1212. 
symmetrical, 1212. 
Gold, 394. 
apices to teeth, 323. 
as a conductor, 311. 
as a filling material, 394. 
as a non-therapeutic agent, 252. 
blocks, 395. 
cohesive, 395. 
cylinders, 395. 
forced beyond foramen, 311. 
in amalgam, 377, 379. 
in dental thcrapeusis, 252. 
in root-filling, 310. 
mats, 395. 
pellets, 395. 
ribbons, 395. 
soft, 395. 
twists, 395. 
Gomphosis, articulation, 35. 
Gonorrhoea of nares, 865. 
treatment of, 865. 
Gooch's canula, 845. 
Good on aphthae, 682. 
Goodwillie's mouth-stretcher, 831. 
Goulard's extract as an antiphlogistic, 1301. 
Gout and neuralgia, 1102. 
in alveolar dental abscess, 300. 
in pulpitis, 272. 
in tonsillitis, 723. 
Grafting tooth-crown, 481. 
Graham's respirator, 1022. 
Granular character of dental germ, 277. 
hypertrophy of tongue, 771. 
Granulated body, 603. 
Granulations in chronic angina, 170. 
Granules of dentine in pulp, 277. 
Grapes and dental caries, 235. 
Grasp of sequestrum by overlying soft parts, 
1027. 
Graves's disease, 1233. 
neuralgia plaster, 1117. 
Grinding face cavities, 351. 
of pivot tooth, 469. 
Groove for passage of facial artery, 85. 
infra-orbital artery, 87. 
primitive dental, 145. 
Grooving bur engine-bit, 463. 
Groups of facial muscles, 70. 
blood-supply of, 70. 
lymphatics of, 71. 
nerve-supply of, 70. 
veins of, 71. 
Growth of bone around tooth-germs, 147. 
of teeth roots, 150. 
Guilford on use of cutting burs, 265. 
Guilford's matrices, 401. 
Guillois's cement, 392. 
Gum arabic in chronic angina, 170. 
boil, 286. 
camphor in sensitive dentine, 265. 
frit, to make, 604. 
Gumma of forehead, 901. 
of nose, 858. 
Gummatous tumors of tongue, 746. 
Gums, 654. 
abscess of, 286. 
anatomical character of, 654. 
congenital union of, 667. 
diseases of, 654. 
effect upon, of chloride of zinc, 662. 
of creasote, 661. 
of dead or loose teeth, 660. 
of improperly-inserted artificial den- 
tures, 663. 
of overcrowded dental arch, 661. 
of periodontitis, 656. 
of scorbutus, 658. 
of syphilis, 660. 
of tartar, 654. 
of the mercurial impression, 656. 
of the use of improper dentifrices 
and brushes, 661. 
freezing in tooth-extraction, 458. 
gangrene of, 673. 
healthy state of, 654. 
inflammation of, 654. 
lancing, 164. 
lead-line upon, 670. 
nerves of, 1112. 
oidium albicans upon, 673. 
showing unduly, 591. 
Gunshot wounds in jaw fractures, 1040. 
of pharynx, 807. 
Gustatory nerve, 115. 
Gutta-percha, 386. 
as a tooth-filling material, 387. 
as an impression material, 546. 
brittleness of, 387. 
combinations with, 387. 
forms for setting pivot teeth, 466. INDEX. 
1341 
Gutta-percha, forms of, in market, 388. 
Hill's stopping, 387. 
in dental therapeusis, 252. 
in fracture of nasal bones, 867. 
in jaw fractures, 1042. 
instruments used for working, 389. 
porosity of, 387. 
red, 388. 
splint, 1049. 
stickiness in, 389. 
test of quality, 387. 
white, 388. 
Guy's hospital neuralgic liniment, 1119. 
Gymnastics of the teeth, 236. 
H. 
Haematin a colorizer of dentine, 318. 
Haemoptysis, 1245. 
Hainsby's compressor, 930. 
Hair moles, 880. 
Half-dentures, 594. 
Half-erupted wisdom-teeth, 1092. 
Halitus of tooth-sac, 149. 
Hamilton on jaw fractures, 1047. 
Hamilton's dressing for fracture of lower 
jaw, 1041. 
Hamular process of sphenoid bone, 55. 
and tenotomy of tensor palati muscle, 
55, 827. 
Hand-lathes, 470. 
mallet, 410. 
pieces used with dental engine, 342. 
sprayer, 459. 
Hard palate, 28. 
necrosis of, 1005. 
stone, 422. 
Harelip, 925. 
condition of patient, 925. 
double, 934. 
Hainsby's compressor for, 930. 
illustrative operation, 927. 
mode of operating, 927. 
single, 927. 
time suited for operation, 925. 
Harmbnial articulation, 38, 40. 
Harris's tooth-forceps, 439. 
Harrower's method of gauging root, 491. 
of porcelain facing, 477. 
Hatchet excavators, 338. 
Haversian canals in cementum, 137,1010. 
Hawes's duct compressor, 363. 
Hawk-bill tooth-forceps, 431. 
Head, antero-lateral view of, 27. 
cranial portion of, 26. 
facial portion of, 26. 
form of, 26. 
human, 26. 
Healing wounds, 698. 
approximating, 698. 
by first intention, 698. 
by granulation, 698. 
by ligature materials, 698. 
by use of plasters, 699. 
Health and dental organism, 197. 
of child in relation with operation for 
harelip, 925. 
relation of vulcanite to, 574. 
Healthy saliva, 243. 
Heart, the, 80. 
and chloroform, 1276. 
beginning of study of, 1220. 
diseases, 1219. 
and chloroform, 1276. 
locating lesions of, 1221. 
Heart-colored tumors of jaw, 1198. 
Heat in inflammation, 1293, 1308. 
Heated needles in treatment of naevi, 899. 
Heavy foils, 403. 
Hemorrhage after lancing gums, 165. 
bayberry powder in, 165. 
dependent on anaemia, 455. 
on purpura, 455. 
on typhoid condition, 453. 
ergot in, 695. 
erigeron Canadense in, 165, 454. 
in exsection of jaw, 1053. 
in facial wounds, 693. 
in phosphor-necrosis, 1026. 
in tonsillotomy, 727. 
in tooth extraction, 453. 
alum-water in, 456. 
bayberry powder in, 455. 
medicinal agents used for, 165, 695. 
Monsel's solution in, 165. 
nasal, 837. 
nitrate of silver in, 456. 
of lungs, 1245. 
of uvula, 788. 
opium and lead in, 455. 
packing alveolus, 455. 
arterial, 693. 
capillary, 693. 
venous, 693. % 
treatment by acupressure, 694. 
cold water, 694. 
knotted bandage, 694. 
ligation, 694, 958. 
medicaments, 694. 
pad and bandage, 694. 
tannic acid in, 165. 
Herbst's dentine obtunder, 361. 
glass filling, 394. 
or rotation method, 419. 
plan for retaining replanted teeth, 
321. 
Hereditary dental caries, 238. 
Hereopath's method of resuscitation in anaes- 
thesia, 1289. 
Herpes of pharynx, 804. 
Herpetic tonsillitis, 722. 
Herrick's fountain drip-point, 349. 
Heteroclitic cells, 1121. 
Heterogeneous tooth-germs, 193. 
Hexagonal fibres of enamel, 136. 
Heyfelder's operation for removal of both 
superior maxillae, 1065. 
Hey's saw, 1071. 
Hickman's rubber-dam clamps, 368. 
Hidden suture in harelip, 929. 
High melting-point as an influence on the 
setting of amalgam, 378. 
Hill's stopping, 387. 
Hindostan stone, 422. 
Histogenesis of epithelioma, 910. 
Histoid mixed tumors, 1204. 
Histological appearance of myeloid growths, 
1198. 1342 
INDEX. 
Histological distinctions in tumors, 1136. 
view of dentition, 154. 
History in tumor diagnosis, 1138. 
of phosphor-necrosis, 1023. 
of rachitis, 202. 
Hoe excavators, 338. 
Holding jaw-splints in position, 1042. 
Holes in the palate, 814. 
Holmes on tetanus, 1082. 
Homologous tumors, 1137. 
Horn's or Roonhuysen's lip operation, 947. 
Horne & Thornwaite, refrigerating apparatus 
of, 457. 
Horner on fistule operations, 992. 
on jaw operations, 1061. 
Horny excrescences of skin, 878. 
Hospitals and aphtha, 680. 
Hot and moist applications in neuralgia, 
1116. 
foot-baths in periodontitis, 289. 
in shock, 697. 
Hot-air syringe, 373. 
How's system of pivoting, 485, 498. 
Howard's method of resuscitation, 1291. 
Hullihen's screw forceps, 448. 
Hulme on calcification of dental tissue, 
280. 
Humoral origin of tetanus, 1080. 
Humphrey on tumor softening, 1204. 
Hunter's transference of teeth, 326. 
Hurd's tooth-forceps, 445. 
Hutchinson's syphilitic teeth, 207. 
tooth-forceps, 440. 
Hydatid cysts, 1192. 
Hydrastis Canadensis in cancer, 916. 
Hydrate of chloral in periodontitis, 290. 
in tetanus, 1084. 
Hydrobromic ether, 1285. 
Hydrochloric acid in aphthae, 690. 
in saliva, 261. 
in typhoid condition, 224. 
Hydro-naphthol, 328, 1320. 
Hydrops antra, 1190. 
Hydrothorax, 1244. 
Hygromata of bursae, 796. 
of deep-seated ranula, 800. 
of neck, 796. 
treatment of, 797. 
Hygrometric character of gelatinoid polypus, 
844. 
Hyoid bone, 58. 
and tongue, 703. 
cornuse of, 58. 
fracture of, 1054. 
muscles of, 59. 
Hyoscyamus in dental irritation, 181. 
Hyperdrosis, 887. 
Hyperostosis, 1159. 
Hypertrophic tumors, 1142. 
Hypertrophy of gum-structure, 665. 
1 of heart, 1222. 
of maxillary tuberosity, 914. 
of mucous surface of lip, 882. 
of nasal mucous membrane, 864. 
of tongue, 769. 
of tonsil glands, 722. 
of uvula, 785. 
Hypodermatic, or hypodermic, medication, 
1255. 
Hysteria and chloroform, 1275. 
I. 
Ice-bags in hemorrhage from extraction, 457. 
Ice-cream in angina, 168. 
Ice-water in epistaxis, 837. 
Ichthyosis, 884. 
Idiopathic glossitis, 760. 
trismus, 1080. 
Idiosyncrasies in ether, 1267. 
Idiosyncrasy in accident, 696. 
Ill odor in necrosis, 1025. 
Illumination in rhinoscopy, 810, 862. 
Illustration in amalgam, use of, 383. 
in cheiloplasty, 942. 
in contouring, 413. 
after Dorr, 416. 
after Webb, 414. 
after Weld, 415. 
in cystoma, 1171. 
in diagnosis of tumors, 1137. 
in encephaloid disease, 1207. 
in epulic operations, 1146. 
in exsection of lower jaw, 1069. 
of upper jaw, 1062. 
in filing, 250. 
in gum-lancing. 164. 
in hygroma, 796. 
in inflammation, 1294. 
in jaw fractures, 1050. 
in orthodontia, 538. 
in phosphor-necrosis, 1025. 
in ranula, 789. 
in rhinoscopy, 810, 862. 
of alveolar abscess, 295. 
of cancerous tumors, 1206. 
of cement and dentine, 135. 
of deciduous teeth, 139. 
of dental anomalies, 193. 
nerves, 136. 
pulp, 136. 
of dentinal tubules, 136. 
of diminishing pulp-cavities, 279. 
of enamel columns, 137. 
of enlarged tonsil glands, 719, 723. 
of epulides, 1147, 1153. 
of face wounds, 700. 
of Farrar system, 538. 
of horns of face, 878. 
of interglobular spaces, 138. 
of lip operations, 933. 
of neuralgic lesions, 1105. 
of obturators, 612, 635. 
of osseous caries, 10<>2, 1004. 
of permanent teeth, 140. 
of polypi operations, 845, 848. 
of sarcomata, 1197. 
of scirrhoma, 1205. 
of tooth development, 145, 159. 
pivoting, 462, 521. 
of tumors, 1142, 1212. 
of use of surgical engine, 1070, 1073. 
of vascular tumors, 893, 897. 
of vela, 627, 635. 
Illustrative cases of tumors at large, 1213. 
of a dental bridge, 502, 505. 
Imitation coral, 392. 
Immediate bleaching of teeth, 317. 
diseases of facial skin, 877. 
anidrosis, 888. 
atrophy, 882. INDEX. 
1343 
Immediate diseases of facial skin : 
callositas, 877. 
chloasma, 879. 
chromidrosis, 888. 
comedo, 885. 
cornu cutaneum, 877- 
dermatolysis, 881. 
elephantiasis, 882. 
enchondromata, 891. 
framboesia, 883. 
hyperidrosis, 887. 
ichthyosis, 884. 
keloid, 888. 
lentigo, 879. 
lichen pilaris, 878. 
milium, 885. 
molluscum fibrosum, 890. 
sebaceum, 885. 
morphcea, 883. 
naevus pigmentosus, 879. 
pilosus, 88. 
vasculosis, 892. 
rhino-scleroma, 890. 
scleroderma, 880. 
sebaceous tumors, 886. 
seborrhoea, 884. 
sudamina, 888. 
telangiectasis, 892. 
verruca, 883. 
vitiligo, 879. 
xanthoma, 890. 
Immobile tongue, 771. 
Impaction of wisdom-tooth, 1013. 
Impaired nutrition and purulency, 978. 
Imperfect denture, 338. 
Imperfectly-treated jaw fractures, 1047. 
Imperforate nostril, 668, 886. 
use of bougies in, 864. 
pharynx, 807. 
Implantation of teeth-, 326. 
an unsurgical procedure. 326. 
method of procedure, 327. 
preliminary treatment of tooth, 327. 
preparing the cavity, 327. 
Implanted teeth as posts for bridge-work, 
332. 
Impression materials, 546. 
gutta-percha, 549. 
modelling compound, 549. 
plaster of Paris, 548. 
wax, 546. 
trays, 545. 
Impressions for artificial teeth, 544. 
Imprisoned teeth and abcess, 302. 
Improper diet and the teeth, 239. 
union of metals as a cause of pulpitis, 
272. 
Incasing continuous-gum work, 598. 
Incipient disease on approximal faces of 
teeth, 249. 
Incising tooth forceps, 467. 
Incisions in jaw exsections, 1060. 
in treatment of ulcers, 1016. 
of tongue diseases, 743. 
Incisive fossa, 31. 
Incisor forceps, 430. 
teeth, 140. 
Inclined planes in dentistry, 249. 
Incomplete luxation of jaw, 1031. 
Increase of cemental tissue, 1160. 
Incubative state of rickets, 202. 
Indian corn, analysis of, 216. 
method of rhinoplasty, 869. 
India-rubber in tooth separation, 356. 
ring as an anti-hemorrhagic, 166. 
Indications for the extraction of teeth, 428. 
in treatment of dental caries, 197. 
to be met by an artificial denture, 544. 
Induration of tongue, 753. 
Infant and adult teeth, 137, 139, 140. 
Infantile disease and first dentition, 161. 
eruptions, 183. 
trismus, 1085. 
Infants' sore mouth, 680. 
Inferior dental artery, 87. 
nerve, 116. 
labial artery, 85. 
maxillary bone, 42. 
nerve, 114. 
Garretson's operation for ex- 
section of, 1122. 
triangle of neck, 969. 
turbinated bone, 48. 
Infiltrated epithelioma, 911. 
Infiltrating lupus, 908. 
Inflammation, 1292. 
active congestion, 1296. 
and jaw fractures, 1047. 
and sensitive dentine, 263. 
definition of, 1292. 
diagrams of expression of, 1294, 1295, 
1296. 
functional disorder, 1293. 
heat, 1293, 1308. 
of local import, 1296. 
of pulp, 267. 
of systemic import, 1297. 
of throat, 802. 
pain, 1308. 
phenomena associated with, 1296. 
redness, 1308. 
relation of irritant with, 1293. 
repair, 1311. 
simple vascular excitement, 1296. 
stagnation, 1296. 
suppuration, 1296. 
treatment of, 1297. 
Inflammatory tumors, 1159. 
Infraorbital canal, 31. 
foramen, 31. 
groove, 31. 
nerve, exposure of, 1133. 
Infusoria and diarrhoea, 175. 
and tartar, 645. 
Inhaler for ether, 1261, 1262. 
for nitrous oxide, 1282. 
Injections in salivary fistule, 991. 
in treatment of naevi, 897. 
Inner tracheal tube. 736. 
Innominate veins, 94. 
Innutritio ossium, 202. 
Insanity and chloroform, 1279. 
Insect bites of tongue, 767. 
Inside of nose, 29, 30, 833. 
Inspection, 1239. 
Instruments lor extracting teeth, 430. 
for raising soft tissue from hard palate, 
830. 
for removing tartar, 652. 
for tooth-plugging, 337, 425. 1344 
INDEX. 
Instruments for working amalgam, 382. 
cohesive gold, 404. 
gutta-percha, 389. 
used in exsection of upper jaw, 1062. 
in preparation of dental cavities, 
337. 
Interarticular fibro-cartilage of lower jaw, 
133. 
Interdental splint, 1042, 1048, 1049. 
Interdigitation in gold filling, 404. 
Interference of hearing in hypertrophy of 
tonsil, 722. 
Interglobular spaces, 137. 
Interlocking of cusps, 590. 
Internal carotid artery, 90. 
branches of, 92. 
cavernous portion of, 91. 
cervical portion of, 90. 
surgical relation of, 71. 
jugular veins, 94. 
lateral ligament of lower jaw, 133. 
maxillary artery and its branches, 85. 
surgical anatomy of, 88. 
vein, 96. 
Intestinal worms, 175. 
Intestines of infants, 174. 
Intra-antral cysts, 1190. 
Intra-cranial disease and polypi, 849. 
Introduction of gutta-percha into teeth, 388. 
Intrusion of plate on soft palate, 591. 
Intubation, 738. 
Investing batter, 598. 
metal-work, 587. 
Involution of epithelium, 155. 
Iodide of potassium and syphilis, 1305. 
as a sorbefacient, 1301. 
in stomatitis, 167. 
of zinc in hypertrophy of tonsil, 723. 
Iodine as a local anaesthetic, 457. 
as a parasiticide, 240. 
as a pulp-devitalizer, 188, 274. 
in antral disease, 981. 
in lupus, 909. 
in replantation, 321. 
use of, for green stain on teeth, 655. 
lodoform-poisoning, 715. 
Ipecacuanha in spasms, 181. 
Iron and quinia in angina, 171. 
in rickets, 206. 
use of, in epithelioma, 916. 
Irregularities of the teeth, 523. 
Irregularity corrected by pivoting, 474. 
Irritable systems and dead teeth, 1009. 
tooth-root, 286, 309. 
Irritation and dentition, 172. 
the cause of inflammation, 1293. 
Irritative fever in dentition, 163, 172. 
diagnosis of, 173. 
treatment of, 173. 
Italian method of rhinoplasty, 868. 
Ivory exostosis, 1159. 
J. 
Jack's enamel cutters, 344. 
matrice, 400. 
Jack-screw, 537. 
Jagged bodies in oesophagus, 808. 
Jameson and exsection of jaw, 1059. 
Japanese bibulous paper, 372. 
Jarvis's separators, 356. 
Jaw articulation, 133. 
dilators, 1098. 
Goodwillie's, 831. 
Kolbe's instrument, 1098. 
Mears's, 831. 
Scultetus's wedge, 1099. 
exsection, 1059. 
Jones's fulcrum forceps, 444. 
Jourdan and exsection of jaw, 1059. 
Jugular veins, 94. 
and pneumogastric nerve, 967. 
anterior, 94. 
external, 94. 
internal, 94. 
posterior, 94. 
Jujubes in chronic angina, 170. 
K. 
Kane on cold as a cause of tetanus, 1080. 
Keloid, 888. 
Kentish ointment in burns, 714. 
Key instruments in tooth extraction, 442. 
Kinds of dental plates, 544. 
of tongue-tie, 781. 
of tumors, 1143. 
Kingsley's artificial vela, 628. 
correction of dental irregularities, 535. 
Kirby's neuralgic liniment, 1117. 
Kirk's method of pivoting, 484. 
Knife in the treatment of ranula, 790. 
Knife-edge circular-saw, 1060. 
Knotted bandage in facial hemorrhage, 694. 
Koch's bacillus, 1318. 
Kolbe's artificial leech, 720. 
jaw dilator, 1098. 
powder insufflator, 845. 
screw lever, 831. 
tonsillotome, 726. 
L. 
Labarraque's solution, 317. 
Labi inferioris, 75. 
Laboratory, furnishing of, 562. 
Lacerated foramen, 54. 
Laceration of gum in tooth extraction, 453. 
Lachrymal bone, 57. 
canal, 58. 
groove, 58. 
nerve, 72. 
tubercle, 40. 
Lactic acid and teeth, 227, 260. 
Lactucarium in irritation, 181. 
Laminae exostosis, 1159. 
of bone, exfoliation of, 1005. 
of sarcomatous tumors, 1196. 
La Monier and staphylorraphy, 822. 
Lamps for burning alcohol and kerosene, 
565. 
Lanceolate cells, 1198. 
Lancets, 1300. 
bistoury, 1300. 
spring, 1300. 
thumb, 1300. 
[ Lancing, astringents used in, 165. INDEX. 
1345 
Lancing gums in periodontitis, 287. 
hemorrhage in, 165. 
infants' gums, 164. 
preliminary to tooth extraction, 451. 
Landolfi's caustic, 913 
Langenbeck's operation for polypus, 848. 
osteoplastic resection, 1066. 
section of maxillary nerve, 1127. 
Laryngoscopy by sunlight, 811. 
Laryngotomy, 733. 
Larynx, fractures of, 1055. 
treatment of fracture of, 1055. 
view of, 731, 732. 
Late dentitions, 160. 
Lateral region of skull, 27. 
view of nares, 30. 
Lathes, foot, 469. 
hand, 470. 
Latitude in treatment of epulides, 1146. 
Laying open wounds in tetanus, 1083. 
Laxity of articular connections of jaw, 1031. 
Lead and opium in hemorrhage, 455. 
as a canal-filling, 312. 
for modelling oral plates, 551. 
water and laudanum in periodontitis, 
290. 
wire sutures, 698. 
Leather-sucker cavities, 552. 
Leech, artificial, 720. » 
Leeches in angina, 169. 
in periodontitis, 290. 
in phosphor-necrosis, 1025. 
Leeching, 1299. 
Leidillot's lip operation, 953. 
Lemonade in irritative fever, 173. 
Lemon-juice and the teeth, 235. 
Lenticular ganglion, 117. 
Lentigo, 879. 
Leptothrix filaments, 229. 
Lesions of first dentition, 161. 
Levator labii superiorus almque nasi, 74. 
palati muscle, 821. 
section of, 821. 
Levis's double V in harelip, 933. 
Liabilities of teeth to caries, 197. 
Lichen pilaris, 878. 
treatment of, 878. 
Ligation of arteries, 958. 
carotid, 966. 
in exsection of jaw, 1059. 
facial, 963. 
lingual, 965. 
occipital, 964. 
temporal, 963. 
thyroid, 964. 
Ligatures in orthodontia, 532. 
in wounds of face, 693. 
Limbosa articulation, 35. 
Lime and discolored teeth, 316. 
in rickets, 202. 
Linear cicatrix in harelip, 931. 
Lines for locating arteries, 962. 
Lingua vitula, 775. 
Lingual artery, 84. 
branches of, 84. 
surgical anatomy of, 84. 
hypertrophy, 770, 775. 
nerve, 115. 
neuralgia, 765. 
Lion forceps, 1065. 
Lipoma simulating ranula, 791. 
Lips and cheeks, 123, 925. 
operations upon, 925. 
retractors, 1068. 
Liquefied nitrous oxide, 1283. 
Liquid soap in seborrhoe:i, 885. 
Liquorice powder as a laxative, 168. 
Listerism, 1318. 
Liston's lip operation, 948. 
Litmus paper, 245. 
Littlejohn's flexible-shafted bur, 308. 
Lobelia in spasms, 178. 
Lobules of salivary glands, 131. 
Local anresthesia in tooth extraction, 456. 
contamination a cause of necrosis, 1005. 
disease of tongue, 744. 
expression of alveolar abscess, 292. 
features of dental abscess, 292. 
irritation the chief cause of exostosis, 
1160. 
lesions of tongue, 744. 
remedies in neuralgia, 1116, 1120. 
treatment of dental hemorrhage, 453. 
of inflammation, 1297. 
of lupus, 909. 
use of ether in neuralgia, 1116. 
Localized stomatitis, 163. 
Location of ganglia of fifth nerve, 117. 
of Casserio's or Gasser's, 117. 
of Meckel's, 117. 
of naso-palatine, 119. 
of ophthalmic, 117. 
of otic, 120. 
of spheno-palatine, 117. 
Lockjaw in adults, 1080. 
in infants, 1085. 
Logan's crown and system, 490. 
London hospital anodyne liniment, 1119. 
paste, 275, 724. 
use of, in sensitive dentine, 265. 
in tonsillar hypertrophy, 724. 
Loop matrices, 400. 
Loops and bands in orthodontia, 538. 
Loose teeth in relation with gums, 660. 
tooth-structure and discoloration, 316. 
Lorinser's statistics in phosphor - necrosis, 
1023. 
Loss of substance from nose, 868. 
of tip of nose, 875. 
of translucency in teeth, 316. 
Lower bicuspid and canine tooth-forceps, 435. 
cow-horn forceps, 439. 
incisor and bicuspid tooth-forceps, 435. 
jaw, anatomy of, 42. 
luxation of, 1031. 
lip, ablation of, 949. 
molar tooth-forceps, 439. 
teeth partly worn away, 591. 
Lung disease and chloroform, 1276. 
Lungs, diseases of, 1234. 
Lupus, 906. 
erythematosus, 906. 
vulgaris, 907. 
Luxation of inferior maxilla, 456, 1031. 
forms, 1031. 
from tooth-extraction, 456. 
treatment of, 1034. 
Lymph, 100, 1141, 1312. 
and pus, 1296. 
the vis vitse, 1141. 1346 
INDEX. 
Lymph tumors, 1141. 
Lymphangitis, 199. 
Lymphatic vessels and glands of the head, 
99. 
corpuscles of, 101. 
deep, of face and neck, 102. 
office of, 99. 
superficial, of face and neck, 102. 
system consists of, 99. 
M. 
Machine-cut burs, 266. 
Mack's screws in pivoting, 472. 
in plugging, 472. 
Mackenzie's dilator, 733. 
Mackey's cauterant, 913. 
Macula, 892. 
Maggots in sinuses, 866. 
salt water in treatment of, 866. 
Magitot's experiments, 257. 
Magnet, use of, in dentistry, 379. 
Magnified dental pulp, 135. 
Magnifying mouth-mirror, 350. 
Maisonneuve's zinc arrows, 755. 
Making an alloy, 377. 
and applying cap-crown, 461. 
model of mouth, 545. 
partial plates, 595. 
suction cavities, 547. 
zinc cast of mouth, 581. 
Malaise in tetanus, 1081. 
Malar bone, 57. 
borders of, 57. 
likened to pads, 57. 
process of, 39, 57. 
shape of, 57. 
surface of, 57. 
Malarial poisoning and tongue, 744. 
Malarticulation, 556. 
a cause of alveolar abscess, 301. 
Mal-eruption of the wisdom-tooth, 1014. 
Malgaigne's ellipse in harelip, 933. 
Malic acid and the teeth, 235. 
Malignancy of encephaloma, 1207. 
Malignant epulides, 1146. 
Mallets, plugging, 410. 
automatic, 416. 
Bonwill's, 418. 
Buckingham's 418. 
electro-magnetic, 418. 
Holmes's 418. 
lead, 410. 
lignum-vitae, 410. 
Mandrels for shaping collars, 513. 
Mania a potu and chloroform, 1279. 
Manipulation of impression trays, 547. 
with rhinoscope, 812. 
Manner of extracting teeth, 428. 
of holding partial dentures, 594. 
of operating in harelip, 927. 
of pivoting teeth, 461. 
of using an alloy, 380. 
Manufacture of amalgam, 375. 
of artificial denture, 548. 
of obturators, 606. 
Margetson's illuminator, 813. 
Marion Sims on tetanus, 1086. 
Marrow-like tumors, 1197. 
Marshall Hall's method of resuscitation, 
1291. 
Marshall Webb's pivot-tooth, 473. 
Masks, facial, 636. 
Massage, 1308. 
in neuralgia, 1120. 
Masseter muscle, 77. 
Masseteric nerve, 115. 
Mastication, muscles of, 76. 
Match-stick for testing fit of pivot-tooth and 
root, 470. 
Materials for dental impressions, 546. 
for filling canals, 308. 
for filling teeth, 374. 
amalgam, 374. 
cement plombe, 392. 
enamel stopping, 392. 
gold, 394. 
gutta-percha, 386. 
Herbst's glass, 394. 
Hill's stopping, 387. 
oxychlorides, 389. 
plastic tin, 394. 
test plugs, 308. 
tin, 393. 
zinc phosphates, 391. 
used for continuous-gum work, 602. 
body material, 603. 
enamel material, 603. 
Matrices in tooth-filling, 400. 
Mats in tooth-filling, 395. 
Maxillary bone-, inferior, 42. 
alveolar process of, 42. 
angle at varying ages, 43. 
caries of, 995. 
treatment of, 999. 
condyloid process of, 44. 
coronoid process of. 44. 
external face of, 43. 
oblique line of, 43. 
fractures of, 1036. 
internal face of, 45. 
luxation of, 44, 1031. 
mental foramen of, 43. 
mylo-hyoid ridge of, 44. 
necrosis of, 1005. 
rami of, 42. 
relation with muscles of, 42. 
semilunar notch of, 43. 
shape of, 42. 
sublingual fossa of, 44. 
submaxillary fossa of, 44. 
symphysis of, 43. 
Maxillary bone, superior, 36. 
anterior palatal canal, 40. 
articulations of, 42. 
crest for turbinated bones, 42. 
lachrymal tubercle, 38. 
muscles associated with, 42. 
orbital surfaces of, 41. 
orifice of antrum, 37, 38. 
palatal process of, 40. 
posterior dental groove, 41. 
processes of, 38. 
alveolar, 38. 
malar, 39. 
nasal, 39. 
palatal, 40. 
shape of, 36. INDEX. 
1347 
Maxillary bone, superior, sinus of, 37. 
surfaces of, 41. 
facial, 42. 
nasal, 42. 
orbital, 41. 
tuberosity of, 39. 
zygomatic surface of, 41. 
Maxillary sinus, diseases of, 970. 
tooth-hills in, 37. 
tuberosity, 31. 
Maynard's forceps, 437. 
McGrath's obturator, 612. 
McLean's button, 927. 
McQuillen's correcting apparatus, 530. 
extension finger, 363. 
Meanings expressed by changes in the 
tongue, 743. 
Means for holding plates in place, 592. 
for separating teeth, 349. 
of dryness in dental operations, 364. 
Fisk's saliva ejector, 364. 
Flagg's tongue-holder, 362. 
hot-air syringe, 373. 
McQuillen's extension-finger, 364. 
Morrison's duct-compressor, 363. 
Rich's duct-compressor, 365. 
rubber dam, 366. 
clamps used for, 367. 
saliva pump, 363. 
Taft's thimble, 364. 
use of napkins, 362. 
Mears's gag, 831. 
Measles, necrosis from, 1020. 
Measure of mouth, 545. 
Measuring cervix of root to be crowned, 518. 
root for pivot, 491. 
Meatuses of nose, 49. 
Mechanical dentistry, 544. 
destructives and the teeth, 236. 
diseases of the antrum, 988. 
treatment of breaks in hard palate, 832. 
of dental caries, 351. 
of hemorrhage, 694. 
wants in oral surgery, 562. 
Mechanico-dental lesions in trismus, 1088. 
Mechanism of speech, 631. 
Meckel's ganglion, 107. 
Mediate diseases of facial skin, 900. 
acne rosacea, 904. 
cancer, 910. 
exanthemata, 184. 
facial tubercles. 901. 
gumma of forehead, 901. 
parasites, 902. 
scrofuloderma, 900. 
syphilis, 901. 
tinea circinata, 903. 
sycosis, 903. 
Medical diagnosis, 1215. 
relations of vulcanite, 574. 
Medication in typhoid fever, 224. 
of sensitive dentine, 263. 
Medicinal agents in hemorrhage, after ex- 
traction of teeth, 455. 
Medicines and articles of food, 235. 
and dental caries, 235. 
used in hypodermatic injections, 1255. 
Medulla oblongata in tetanus, 1082. 
Meigs's ether cure in neuralgia, 1117. 
Melanoid tumors, 1143. 
Mellotte's blow-pipe pad, 568. 
gas blow-pipe, 568. 
soldering appliances, 567. 
Meningocele, 1191. 
Mental foramen, 32. 
Mento-dental splint, 1045. 
occipital sling, 535. 
Mercurial diathesis and antrum, 987. 
enlargement of tongue, 752. 
necrosis, 1018. 
ulcer of tongue, 752. 
ulitis, 656. 
Mercurio-syphilis, 199. 
syphilitic cachexia and dentition, 199. 
Mercury and dental caries, 199. 
and syphilis, 856. 
and the antrum period, 988. 
and the dentitional period, 167. 
and the teeth, 235. 
in alloys, 380. 
in inflammation, 1304. 
in syphilis of tongue, 747. 
solvent of alloys, the, 380. 
Meriam's method of pivoting, 484. 
Merry's drill, 340. 
Metal basis in celluloid gum, 580. 
cap-crowns, 461. 
forced through tooth foramen a cause of 
abscess, 288. 
pivots, 470. 
Metallic admixture in gum body, 604. 
taste in mouth, 1018. 
Metals subject to quicksilver, 376. 
Metastatic disease of tongue, 768. 
neuralgia, 1103. 
Metz's nasal reflector, 862. 
Micrococci, 1325. 
Micro-organisms, 1320. 
Microscopic analysis of the odontomata, 1182. 
anatomy of tooth, 135. 
appearance of encephaloid, 1211. 
of myeloid, 1199. 
cells of hard cancer, 1206. 
character of epithelial cancer, 912. 
Migrating white corpuscles, 244. 
Milium, 885. 
Milk, analysis of, 213. 
and infantile diarrhoea, 174. 
in chronic inflammation, 176, 1308. 
in saliva, 262. 
Milk-teeth, 139. 
absorption of roots of, 159. 
destiny of, 158. 
foramina of, 158. 
Miller on caries of bone, 999. 
on prevention and treatment of osseous 
caries, 999. 
Mindererus in angina, 177. 
Mineral acids in syphilitic ulceration, 806. 
water, artificial, 168, 673. 
for costiveness, 168. 
Mirror of Anagnostakis, 350. 
used with rubber dam, 366. 
Misplaced teeth, 195, 1173. 
Mistakes in tooth extraction, 320. 
Mixed narcosis, 1286. 
Mixing amalgams, 380. 
Mode of operating in harelip, 925. 
Modelling compound, 549. 
Models for teeth, 549. 1348 
INDEX. 
Modification on impression trays, 545. 
Modified excavators, 338. 
Moffitt's aluminium dentures, 605. 
body formula, 603. 
Moist dentine, 246. 
rale, 1241. 
Moisture and tooth-filling, 362. 
in tracheotomy, 737. 
Molar forceps, 436. 
teeth, 142. 
Molluscum fibrosum, 890. 
sebaceum, 885. 
Monsel's salt in hemorrhage, 165. 
solution of iron as a pulp-devitalizer, 
188. 
Morgan's lip operation, 948. 
Morning sickness in phosphor-necrosis, 1021. 
Morphia and sensitive dentine, 265. 
hypodermatic use of, in cancer, 918. 
Morphoea, 883. 
Morrison's compressor, 363. 
Mother-mark, 892. 
Motor cord of fifth nerve, 120. 
nerve of face, 103. 
Motores uvulas muscle, 123, 802. 
Mouth, the, 122. 
anatomy of, 28, 122. 
as an archway, 122. 
central pendulum of, 123. 
commencement of alimentary canal, 122. 
fluids of, 131. 
lips as boundaries of, 123. 
models, 549. 
offices of, 122. 
osseous boundaries of, 28. 
roof of, 28, 122. 
sectional expression of, 125. 
skeleton of, 28. 
stretchers, 830. 
in atresia oris, 944. 
veil of, 122. 
vestibule of, 123. 
washes, 225. 
Muciparous cysts in floor of mouth, 794. 
Mucoid engorgement of antrum, 977. 
Muco-musculo-aponeurotic nature of phar- 
ynx, 801. 
Mucous deposits, 223. 
glands, 124. 
of tongue, 130. 
lesions of tongue, 751. 
membrane of mouth, 123. 
Mucus, 124. 
constituents of, 124, 255. 
Muguet, 688. 
Multiple antral cysts, 1191. 
scarification in lupus, 909. 
screw in orthodontia, 529. 
Multi-rooted teeth and test fillings, 309. 
Muriate of ammonia in neuralgia, 1115. 
Muscles attached to ethmoid bone, 50. 
to hyoid bone, 58. 
to lachrymal bone, 58. 
to maxillary bone, 42. 
to palate bone, 47. 
to sphenoid bone, 52. 
blood-supply of, 70. 
buccinator, 75. 
compressor naris, 73. 
corrugator supercilii, 72. 
Muscles, depressor ate nasi, 73. 
anguli oris, 75. 
labii inferioris, 75. 
digastric, 78. 
dilator naris, 73. 
genio-glossal, 127. 
hyoid, 79, 127. 
groups of, 70. 
hyoglossal, 127. 
levator anguli oris, 75. 
labii superiorus ateque nasi, 74. 
lingual, 127. 
lymphatics of, 71. 
masseter, 77. 
nerve-supply of, 70. 
of expression and mastication, 69. 
of tongue, 127. 
orbicularis oris, 73. 
palpebrarum, 72. 
pterygoidei, 77. 
pyramidalis nasi, 72. 
risorius, 76. 
stylo-glossal, 127. 
pharyngeal, 127. 
temporal, 76. 
veins of, 71. 
zygomatici, 74. 
Muscle-strain in staphylorraphy, 820. 
Muscular structure of tongue, 127. 
Mutter's lip operation, 945. 
Myeloid tumors, 1197. 
microscopic appearance of, 1198. 
Mylo-hyoid groove, 44. 
muscle, 79. 
Myomata of Virchow, 1195. 
Myrrh and capsicum in gum affections, 658. 
Myrtiform fossa, 31. 
N. 
Naevus, arterial, 892. 
maculae, 894. 
pigmentosus, 879. 
pilosus, 880. 
port-wine stain, 895. 
vasculosus, 892. 
Names of teeth, 143. 
Napheys's sedative, 1119. 
Napkin, dental, 362. 
Narcotics in inflammation, 1304. 
Nares, 833. 
dryness of, 985. 
Narrow-beak forceps, 433. 
Nasal abscess, 849. 
bone, 33, 56. 
fractures of, 867. 
surfaces of, 56. 
catarrh, 836. 
as cause of antral disease, 985. 
chancre, 865. 
douche applied, 861, 876. 
dryness, significance of, 985. 
fossae, 29. 
gonorrhoea, 865. 
treatment of, 865. 
hemorrhage, 837. 
mucous membrane, hypertrophy of, 864. 
treatment of, 834. 
nerve, 113. INDEX. 
1349 
Nasal process, 39. 
reflector of Metz, 862. 
septum, 29. 
and double harelip, 937. 
deviation of, 864, 867. 
speculum, Frankel's, 862. 
surface of submaxilla, 42. 
Nasmith's jaw splint, 1049. 
Naso-palatine ganglion, 119. 
pharyngeal polypi, 808. 
extirpation of, 808. 
syringe, 876. 
pharyngoscopy, 810. 
Natural cure of dental caries, 249, 253, 280. 
Nature of ulceration, 854. 
Nature's removal of dead tooth, 1010. 
Nebulizer, 806. 
Necrosis, 1005. 
alveolar, 1011. 
definition of, 1005. 
from alveolar diseases, 1011. 
from dental diseases, 1008. 
from injuries, 1020. 
from lack of room for eruption of wisdom- 
tooth, 1013. 
from mercury, 1018. 
from osteal inflammation, 1007. 
from periosteal inflammation, 1008. 
from phosphorus, 1021. 
treatment of, 1025. 
from syphilis, 1014. 
from the exanthems, 1020. 
Needle-point pluggers, 404. 
Negrier's treatment of epistaxis, 838. 
Nelaton's method of inversion, 1289. 
plan in jaw-luxation, 1031. 
Neoplasms, 1193. 
of nose, 864. 
of pharynx, 807. 
of uvula, 785. 
Nerves of face, 103, 106. 
anterior dental, 113. 
auriculo-temporal, 115. 
author's operation for section of inferior 
maxillary, 1122. 
author's operation for section of nasal, 
1124, 1129. 
buccal, 115. 
canal pluggers, 310. 
Carnochan's exposure of superior max- 
illary, 1127. 
character of, 103, 106. 
ciliary, 111. 
deep temporal, 115. 
extractors, 240. 
facial, 103. 
fifth pair, 106. 
frontal, 110. 
function of, 104, 120. 
ganglia, 117. 
of Gasser or Casserio, 117. 
gustatory, 115. 
inferior dental, 116. 
inferior maxillary, 114. , 
labia], nasal, palpebral, 113. 
lachrymal, 110. 
lesions proper and their treatment by 
operation, 1121. 
lingual, 115. 
masseteric, 115. 
Nerves of face: Meckel's ganglion, 117. 
motor, 103. 
nasal, 113. 
naso-palatine, 119. 
ophthalmic division, 109. 
orbital, 112. 
origin of, 108. 
otic ganglion, 120. 
Pancoast's operation for exposure of 
second branch of fifth, 1127. 
paste, 188, 274.* 
pterygoid, 115. 
sections, 1121. 
submaxillary, 114. 
superior maxillary divisions, 111. 
supply of muscles of face, 70. 
trifacial, 106. 
Nervous mania, 1279. 
temperament and neuralgia, 1104. 
in relation with orthodontia, 523. 
Neuralgia, 1102.. 
after amputation, 1105. 
Anstie's view of, 1103. 
arising out of pulp-calcification, 277. 
atmospheric relations to, 1104. 
character of pain, 1102. 
definition of term, 1102. 
derangements in respiration, 1104. 
from gas in pulp-cavity, 275. 
functional disturbances in, 1103. 
illustrations of condition, 1105. 
improper aeration of blood, 1104. 
malaria as a cause of, 1104. 
neuromata in, 1105. 
not a disease, 1103. 
odontalgic relations, 1104. 
of tongue, 765. 
predisposing causes of, 1103. 
syphilis as a cause of, 1104. 
treatment of, 1113. 
ulcerating nerve-cords, 1129. 
various medicaments used in, 1114. 
vascular perversion, 1103. 
Neuroma of nasal nerve, 1125. 
Neuro-paralytic ulcers, 843. 
Neutral mixture, 169. 
New bone in necrosis, 1028. 
Nicking fraenum in tongue-tie, 781. 
Niemeyer's neuralgic pill, 1120. 
Nitrate of silver in angina, 171. 
in synovitis, 1077. 
Nitrous oxide gas, 1280. 
action of, 1284. 
collecting, 1282. 
condition demanding caution, 1284. 
discovery of, 1280. 
dispensing, 1282. 
illustration of apparatus, 1281. 
liquefied, 1283. 
manner of preparation, 1280. 
use as a pain-obtunding agent, 1252. 
washing, 1282. 
Nitrous oxide spray as an obtunder, 361. 
Nodular dentine, 281. 
Nodules in scirrhoma, 1205. 
Non-closure of antral openings, 981. 
cohesive gold, 395. 
manner of using, 396. 
conducting substances in root-filling, 
311. 1350 
INDEX. 
Non-explainable tumors, 1193. 
treatment of, 1193. 
explaining epulides, 1146. 
soluble dentifrices a cause of gum reces- 
sion, 661. 
specific exostosis, 1159. 
Noni nerve descendens, 967. 
Normal condition of gum covering simple 
osseous cysts, 1170. 
Northrop's corundum points, 422. 
Nose, 833. 
anatomy of, 833. 
artificial, 620, 625. 
surgical, 868. 
bleeding of, 837. 
deviation of septum, 834. 
diseases of, 833. 
epithelial sores, 843. 
foreign bodies in, 851. 
in associated sinuses, 866. 
fractures of, 867. 
glanders, 843. 
hemorrhage from, 837. 
hypertrophy of mucous membrane of, 
864. 
imperforate nostril, 866. 
loss of substance of, 852, 952. 
nasal abscess, 849. 
ozaena, 851. 
polypi, 844. 
fibrous, 846. 
gelatiniform, 844. 
intruding on antrum, 38. 
sarcomatous, 847. 
rhinoscopy, anterior, 862. 
scrofulous ulcers of, 840. 
sectional expression of, 125. 
simple nasal catarrh, 836. 
skeleton of, 28. 
specific disease of, 857, 865. 
studies in rhinoplasty, 868. 
syphilitic coryza, 858. 
ulcers of, 840. 
cancerous, 843. 
neuro-paralytic, 843. 
scorbutic, 842. 
scrofulous, 842. 
syphilitic, 843. 
traumatic, 840. 
Notch in harelip, 932. 
semilunar, 43. 
Notched teeth, 207. 
Nourishment of pulp, 135. 
Number and shape of roots of teeth, 139, 
140. 
in gold, 395. 
in tin, 393. 
of hpman teeth, 139. 
Nunneley on excision of tongue, 779. 
Nutrition and jaw fractures, 1045. 
of enamel, 136. 
of teeth, 209, 1008. 
Nutritional pabulum exuding from blood- 
vessels, 1309. 
O. 
Objection to continuous-gum work, 604. 
to file, 249. 
to use of amalgam in pivoting, 479. 
Obscure case of salivary calculus, 648. 
Obstruction of Wharton's duct, 793. 
Obtunding agents, 1249. 
dental agents, 264, 361. 
Obturators, 606. 
Baker's, 633. 
Booth's, 632. 
Buckingham's, 614. 
casts for, 608. 
cotton packing, 607. 
definition of term, 606. 
Desirabode's, 619. 
Dieffenbach's rubber stud, 607. 
Garangeot's, 626. 
impression for, 608. 
Kingsley's, 628. 
McGrath's, 612. 
models for, 609. 
Park's, 626. 
Steam's, 628. 
Suersen's, 631. 
vela, 606. 
Wildman's, 620. 
Occipital artery, 89, 1134. 
exposure of, 1134. 
bone, 61. 
articular relations of, 63. 
basilar process of, 63. 
condyles of, 62. 
crest of, 62. 
foramen magnum of, 62. 
jugular notch of, 63. 
muscles of, 61. 
nerves transmitted by, 63. 
tubercles of, 62. 
nerve, exposure of, 1134. 
Occipito-frontal bandage, 1044. 
frontalis muscle, 71. 
mental sling, 534. 
Odontalgia, 263. 
from confinement of pus and gas in pulp- 
cavity, 275. 
from exposure of pulp, 267. 
from recession and absorption, 284. 
from sensitive dentine, 268. 
hysterical, 283. 
nodular, 281. 
reflex, 282. 
rheumatic, 272. 
sympathetic, 282. 
Odontalgic associations with viscera,282. 
Odonto-cardialgia, 276. 
cephalalgia, 276. 
gastralgia, 276. 
neuralgia, 276. 
otalgia, 278, 1108. 
periosteal tumors, 1148. 
sciatica, 276. 
common treatment of, 276. 
illustrative cases of, 276. 
Odontocele, 1173. 
examples of, 1173. 
Odontoma, 1161. 
Forget's case, 1178. 
Odor in inspissated mucus, 257. 
(Edema of lungs, 1245. 
Oehlecker's enamel stopping, 392. 
(Esophageal bougie, 810. 
(Esophagitis, 809. 
Offensive breath, 223, 723. INDEX. 
1351 
Office of uvula, 123, 785. 
Offices of fifth nerve, 121. 
Oidium albicans, 675. 
Oil of turpentine in neuralgia, 1115. 
Oils in tuberculosis, 206. 
Olfactory channel, 835. 
Ollier's osteogenetic experiments, 1060. 
U-incision, 1067. 
On exciting cause of dental tumors, 1161. 
Opaque teeth, 295, 316. 
Operating-case of Philadelphia Dental Col- 
lege, 409. 
Operating-chair for dentists, 426. 
Operation for removal of inferior maxilla, 
1067. 
for removal of superior maxilla, 1059. 
Operations practised upon the tongue, 772. 
upon the lips and cheek, 925. 
Blasius's, 948. 
Chopart's, 947. 
cleft palate, 822. 
complicated harelip, 934. 
Dieffen bach's, 942. 
double harelip, 934. 
Dupuytren's 947. 
Horn's, 947. 
Liston's, 948. 
Morgan's, 948. • 
Mutter's, 945. 
Roux's, 947. 
section of lip, 948. 
Serres's, 947. 
simple harelip, 925. 
Operative dentistry, 337, 351, 362, 374, 396, 
428, 461, 523. 
Operculum-excising forceps, 1093. 
of gum a cause of dental caries, 1092. 
Ophthalmic ganglion, 117. 
nerve, 109. 
Ophthalmoscopic mirror for dental purposes, 
350. 
Opiates in carcinoma, 917. 
Opisthotonos in tetanus, 1080. 
Opium and ether in neuralgia, 1115. 
and lead as an anti-hemorrhagic, 695. 
and mania, 1279. 
Optic foramina, 53. 
Oral aesthetics, 578, 597. 
cavity, 27,125. 
fluids, 255. 
healthy, 256. 
unhealthy, 257. 
gangrene, 678. 
mucous membrane, 123. 
parasites, 227. 
secretions, 131. 
surgery, 25. 
definition of, 25. 
typh fever, 224. 
Orbicularis palpebrarum muscle, 72. 
Orbit, composition of, 30. 
Orbital cavity, 30. 
surface of submaxilla, 41. 
Order of eruption of temporary teeth, 158. 
Organic and inorganic matter of teeth, 135. 
diseases and chloroform, 1288. 
Origin of carcinoma, 1193. 
of fifth nerve, 106. 
of growth of polypi, 844. 
of names of teeth, 139. 
Origin of obturators, 626. 
of periodonteum, 148. 
Oro-nasal innervation, 106. 
pharynx, 802. 
secretions, 131. 
Oro-pharyngeal space, 126. 
Orthodontia, 523. 
Osborn's porcelain compressor, 363. 
Osseo-spongy character of alveolar process, 
39. 
Osseous anatomy of skull, 26. 
caries, 995. 
repair in disease of upper jaw, 1029. 
Osteoblasts, 1006. 
Osteo-dental tumors, 1178. 
dentine in tooth-pulp, 281. 
enchondroma, illustration of, 1192. 
gingivitis, 639, 645, 654. 
gangraenosa neonatorum, 671. 
Osteomatous tumors, 1159. 
Osteophytes in phosphor-necrosis, 1024. 
Ostosis, 997. 
Otic ganglion, 120. 
Ottolengui's bur, 329. 
Outlet of antrum, 37, 38. 
Oval files, 344. 
Overcrowded condition of dental arch as 
cause of ulitis, 661. 
Overfed infants, 174. 
Overhanging jaw, 538. 
Overriding teeth, 528. 
Over-stimulation in dental caries, 249, 253. 
Oxide of tin in dental caries, 253. 
Oxychlorides, 389. 
as a filling material, 390. 
as a foundation material, 391. 
as a hardener of teeth, 391. 
as a pulp-capper, 391. 
as a whitener of teeth, 390. 
composition of, 390. 
formula for, 390. 
introduction of, 390. 
manner of using, 390. 
use of, in poor teeth, 390. 
Ozaena, 850. 
as a dyscrasic disease, 850. 
as a parasitic disease, 850. 
from accumulation and degeneration of 
common antral secretion, 851. 
from caries and necrosis of osseous boun- 
daries of nares, 851. 
from caries of walls of antrum, 851. 
from constitutional causes, 851. 
from lodgement and retention of foreign 
bodies, 851. 
from tooth abscess discharging into an- 
trum, 852. 
from ulceration of mucous membrane of 
antrum, 853. 
of caries, 851. 
origin of term, 851. 
treatment of, 856. 
P. 
Packing amalgam, 381. 
in jaw exsection, 1025. 
Paget on the myeloid growths, 1197. 
Paget's operation on tongue, 780. 1352 
INDEX. 
Pain in angina, 168. 
in inflammation, 1308. 
in removing dead pulp, 306. 
in scirrhoma, 1205. 
in use of oxychloride of zinc, 389. 
resulting from over-suction, 591. 
Paint as a whitener, 318. 
Palatal defects, 814. 
cleft palate, 814. 
treatment by obturators, 606. 
by surgical operation, 814. 
process, 40. 
Palate, hard, 28. 
soft, 122. 
Palate bone, 45. 
articular process of, 47. 
articulation of, 47. 
attachment of muscles, 47. 
nasal surface, 46. 
orbital process of, 47. 
palatine surface of, 46. 
pterygo-palatine canal, 46. 
relation of, with inferior meatus, 47. 
resemblance to letter L, 46. 
sphenoid process of, 46. 
Palatine deficiencies, 814. 
Palato-glossus muscle, 821. 
pharyngeus muscle, 821. 
Palpation, 1239. 
Pancoast's antiphlogistic touch, 1307. 
operation for exposure of maxillary 
nerve, 1127. 
Pandora's box, 187. 
Paper in mask-making, 636. 
litmus, 261. 
tumeric, 261. 
Papillae, dental, 145. 
of tongue, 128. 
Papillary epithelioma, 756. 
Papilloma of tongue, 771. 
Paraboloid chisels, 342. 
Paradox of congestion, 1311. 
Paralysis of cheek, treatment of, by opera- 
tion, 954. 
of oral roof, 591. 
Parasites and dental caries, 227. 
of skin, 902. 
oral, 227. 
Parasitic fungi, 902. 
theory of dental caries, 227, 240. 
Parasiticides, 228, 254. 
Park's obturator, 626. 
Parietal bone, 68. 
Parker's improved gas furnace, 600. 
convexity and concavity of, 68. 
external view of, 68. 
internal view of, 68. 
Parmley Brown's bridge-work, 508. 
Parotid gland, 131, 255. 
secretion, 255. 
Parr's flux, 589. 
united with wax, 589. 
Partial dentures, 553, 594. 
Partly-developed teeth and the rubber dam, 
372. 
Parulis, 286. 
Passive epistaxis, 837. 
motion in false anchylosis, 1076. 
pharyngitis, 804. 
Pasteboard splint in jaw fractures, 1040. 
Pathology of burns, 716. 
of tetanus, 1082. 
Paul, James, M.D., on nutrients, 210. 
Pearls in epithelioma, 912. 
Pearly teeth, 246. 
Peck's cylinders, 395. 
Peculiarities in articular relations of jaw, 538. 
in teeth, 555. 
of bile, 586. 
Pediluvia in angina, 169. 
Pedunculated polypi, 846. 
Peen hammer, 513. 
Pelvic anastomosis, 962. 
Pemphigus in infants, 184. 
Percussion, 1238. 
Perfect denture, 211. 
Pericardial effusions, 1226. 
Pericementitis, 286. 
Periodonteal abscess, 976. 
hypertrophy, 1178. 
Periodonteum, 137. 
diseases of, 286. 
formation of, 148. 
Periodontitis, 286. 
acute form of, 286. 
caused by false occlusion, 288. 
chronic form of, 286. 
from rubber ring, 289. 
from wedging, 289. 
relation with pulp-cavity, 287. 
tartar as a cause of, 288. 
the cause of ulitis, 286. 
treatment of, 289. 
Periosteum in exsections, 1060. 
in phosphor-necrosis, 1021. 
Periostitis, dental, 286. 
Permanent germs, position of, 158. 
teeth, 140. 
of lower jaw, 140, 429. 
of upper jaw, 140, 429. 
Permanganate of potash as a disinfectant, 240. 
Peroxide of hydrogen as an antiseptic, 1319. 
use of, in dentistry, 1319. 
Perrine's fulcrum forceps, 444. 
Perspiration in spasm, 179. 
Persulphate of iron in hemorrhage, 695. 
Peruvian bark and snake-root in gangrene 
of gums, 673. 
in malarial disturbances, 1305. 
Perversion of circulation, 1292. 
synonymous with inflammation, 1292. 
Petroleum in burns, 713. 
Phagedenic ulcers of mouth, 1016. 
Phantom aneurism, 1232. 
Pharyngitis, 806. 
sicca, 804. 
Pharynx, 801. 
blood-vessels of, 89. 
communication with, 801. 
description of, 801. 
effusion into, 804. 
foreign bodies in, 808. 
imperforate, 807. 
inflammation of, 802. 
neoplasms, 807. 
nerves of, 802. 
post-pharyngeal abscess, 805. 
sectional expressions of, 125. 
stricture of, 807. 
syphilitic ulcers of, 805. INDEX. 
1353 
Pharynx, tubercles of, 805. 
wounds of, 807. 
Phenate of soda as a disinfectant, 1026. 
PhSnol-sodique, 1301. 
in hemorrhage, 695. 
in phosphor-necrosis, 1026. 
Phenomenon in neuralgia, 1103. 
Phlegmonous erysipelas, 1314. 
Phosphor-necrosis, 1021. 
periodontitis, 286. 
Phosphorostitis secondary to periostitis, 1030. 
Physical condition of infant in dentition, 168. 
diagnosis, 1218. 
expression of teeth, 559. 
Physick's tonsillotome, 725. 
tooth-forceps, 442. 
Physiognomical adaptation of teeth, 559. 
Physiology of fifth nerve, 120. 
Pigmental deposits, 879. 
Pillars of fauces, 126. 
Pimples, 183, 825. 
Pins or stitches in face wounds, 699, 928. 
swallowing, 809. 
use of, in harelip, 940. 
Pits a cause of dental caries, 197. 
of alveolar process, 45, 147. 
Pitted teeth, 207. 
Pittings of tooth-enamels, 207. 
Pivot crowns, 473. 
Bonwill's, 473. 
Darby's, 481. 
Dewey's, 482. 
Gates's, 494. 
How's, 485, 498. 
Kirk's, 482. 
Logan's, 490. 
Meriam's, 484. 
Parmley Brown's, 482. 
Richmond's, 483. 
Stowell's, 482. 
files, 467. 
teeth, 465. 
and trismus, 1096. 
Bonwill's method, 473. 
grinding, 469. 
Pivoting to correct irregularity, 471. 
teeth for bridge-work, 498. 
in absence of root, 480. 
Pivots, wood and metal, 470. 
Plans of pivoting teeth, 461. 
of tooth-filling, 396. 
Plaster cups, 550. 
of Paris as a tooth whitener, 318. 
as an impression material, 548. 
Plasters in wounds of face, 699. 
Plastic enamel, Flagg's, 393. 
facing, 477. 
surgery in cicatricial wounds, 956. 
in treatment of epithelial cancer, 
919. 
tin, 394. 
tumors of Lebert, 1200. 
Plastic-caught nerves, 1105. 
Plasticity in enamel, 377. 
of gutta-percha, 387. 
Plate for study of tracheotomy, 721, 742. 
Plates and necks of teeth, 526. 
for dental purposes, 551. 
for teeth, 551. 
waxed and ready for bite, 554. 
Platina pivots, 472. 
Plethora and dental hemorrhage, 453. 
Plethoric epistaxis, 837. 
Pleural friction, 1242. 
sac, 1235. 
Pleurosthotonos in tetanus, 1080. 
Plug mass, amalgam, 380. 
Pluggers for dental canal, 310. 
for gold, 404. 
Abbott's pattern, 408. 
Atkinson's pattern, 405. 
Butler's pattern, 406. 
Smith's pattern, 407. 
Plugging alloy combinations, 379. 
mallets, 410. 
nares in epistaxis, 838. 
teeth, 351. 
Plumpers, 559. 
Pneumatosis, 1237. 
Pneumogastric nerve and jugular vein, 967. 
Pneumonia, 1243. 
Pointed files, 346. 
tongue, 743. 
Poison of typhoid fever, 224. 
Pollock's treatment of caries by sulphuric 
acid, 1001, 1002. 
Polypi, 844. 
fibrous, 846. 
gelatinoid, 844. 
Langenbeck's operation for, 848. 
Maune's operation for, 848. 
Nelaton's operation for, 848. 
origin of, 844. 
sarcomatous, 847. 
treatment of, by desiccation, 844. 
by galvanic Scraseur, 844. 
by Gooch's canula, 845. 
by injection, 847. 
by polyptrites, 845. 
by torsion forceps, 846. 
Polyptrite, 845. 
Polypus intruding on antrum, 38. 
nasal, 844. 
Poor diet and neuralgia, 1104. 
Porcelain facings, 474. 
Brown's, 508. 
Harrower's, 477. 
Rambo's, 475. 
on living teeth, 507. 
Porosity of bone in phosphor-necrosis, 1023. 
Porte polishers, 422. 
Portio dura nerve, 104. 
mollis, 104. 
Port-wine stain, 895. 
Position of operator when taking impressions, 
547. 
Positive method in orthodontia, 538. 
Post or pin in pivoting, 480. 
Posterior auricular artery, 89. 
dental foramen, 38. 
Post-pharyngeal abscess, 805. 
Potassio-mercuric iodide as an antiseptic, 
1320. 
Potatoes, analysis of, 216. 
Potential cauterants in sensitive dentine, 265. 
used in cancer, 913. 
Powder blowers, 844. 
insufflators, 844, 845. 
Powders for the teeth, 226. 
Predisposing causes of neuralgia, 1102. 1354 
INDEX. 
Predisposition to dental caries, 197. 
to rickets, 199. 
Prejudice and the file, 250. 
Preparation of gutta-percha, 386. 
of mouth for artificial dentures, 544. 
of patient for cleft-palate operation, 819. 
of roots for pivoting, 465. 
of tooth-cavities for filling, 351, 361. 
Preparatory to fixing Brown's bridge, 512. 
Preparing plaster model for the mould, 593. 
Prescriptions for neuralgia, 1114, 1120. 
Preserving vitality of exposed pulp, 313. 
Pressure in hemorrhage, 694. 
in treatment of cleft of hard palate, 81 7. 
Prevailing theories of repair in implantation, 
333. 
Preventing separated teeth from falling to- 
gether, 357. 
Prevention of osseous caries, 906. 
Priestley, Dr., and nitrous oxide, 1280. 
Primary expressions of osseous necrosis, 
1005. 
shock, 697. 
Primitive carotid artery, 81. 
ligation of, 966. 
of inferior triangle, 967. 
of superior triangle, 967. 
dental groove, 145. 
Principles and details in diagnosis, 1215. 
related with extracting teeth, 428. 
Probangs, 809. 
Process, alveolar, 32. 
Prodroma of phosphor-necrosis, 1022. 
of rickets, 202. 
of tetanus, 1081. 
Progress of contour-work, 416. 
Projection of intermaxillary bone in harelip, 
938. 
of lower teeth, 583. 
Prolapsus of tongue, 774. 
Proliferative gingivitis, 672. 
Prolonged shock, 696. 
Pronunciation after amputation of tongue, 
772. 
Proper bite in articulation, 555. 
odontocele, 1173. 
Prophylaxis and predisposition to disease, 
210. 
soft teeth, 210. 
in alveolar abscess, 293. 
in rickets, 203. 
Prosthetic dentistry, 544, 562. 
Protecting a burned part from the air, 713. 
Protococcus dentales, 228. 
Protoplasm, 201. 
Protoplasmic cells and dentine, 153. 
Protruding jaw, 533. 
Pseudo-salivary fistule, 994. 
Psoriasis of tongue, 747. 
Pterygoid branches of fifth pair of nerves, 115. 
process of os sphenoideum, 55. 
Pterygoidii muscles, 77. 
Pterygo-maxillary fissure, 34. 
Ptyaline and cheesy deposits, 259. 
Puffiness of the gums, 659. 
Pulp, dental, 135. 
caps for, when exposed, 314. 
cavity, diminution of, 279. 
decomposition of, 274. 
destruction of, 274. 
Pulp, exposure of. 267. 
filling over, when exposed, 312. 
granules of osteo-dentine in, 277. 
in connection with pivot teeth, 465. 
inflammation of, 267. 
of milk-teeth, 136. 
nodules in, 281. 
palliative treatment of, 263, 269. 
paste for destroying, 274. 
radical treatment of, 274. 
removal of, in deciduous teeth, 188. 
tumors of, 1146. 
Pulp-chambers and canals, 306. 
containing dead pulp, 306. 
cotton plug of, 308. 
disinfection of, 311. 
gold plug of, 310. 
permanent plug of, 310. 
removal of pulp from, 307. 
sealing after removal of pulp, 307. 
temporary plug of, 308. 
Pulpitis, 269. 
Pulse in fever, 173. 
study of, 1221. 
Pumice in plug-finishing, 423. 
Puncture in alveolar abscess, 293. 
Punctured fractures of skull, 1056. 
Purkinjean cells of cement, 137. 
Purple of Cassius, 604. 
Purpura as a predisposing cause of hemor- 
rhage, 453. 
Puruloid secretion of antrum, 979. 
Pus and gas in dental pulp-cavities, 275. 
and lymph, 978,1312. 
formation of, in tonsillitis, 721. 
in cavity of alveolus, 294. 
in phosphor-necrosis, 1024. 
meaning of, 1296. 
Pustular inflammation, 183. 
Pustules, 183. 
Putrescence and mercurial necrosis, 1018. 
Putrescency of pulp, and amalgam, 384. 
Putrescent caries, 228. 
Pyogenic membrane, 293. 
Pyorrhoea alveolaris, 639. 
Allan's typical case of, 640. 
features and causes of, 639. 
illustrations of, 641, 644. 
treatment of, 640. 
typical case of, 641. 
Pyramidalis nasi muscle, 72. 
Q- 
Qualitative testing of amalgam alloys, 379. 
cadmium, 379. 
copper, 379. 
gold, 379. 
silver, 379. 
tin, 379. 
zinc, 379. 
Quality test of gutta-percha, 387. 
Question of tooth extraction in alveolar ab- 
scess, 428, 432. 
Quick narcotism from ether, 1262. 
Quicksilver as a solvent of metals, 374. 
Quinine and snuff in neuralgia, 1116. 
iron, and cinchona in treatment of ery- 
sipelas, 1313. INDEX. 
1355 
R. 
Rabid animals, wounds received from, 697. 
Rachitis, 202. 
Radial burner, Fletcher's, 567. 
Raisins and the teeth, 236. 
Rales, 1240. 
Rambo's porcelain facing, 475. 
Rami of lower jaw, 43. 
Ranula, 789. 
illustrations of, 789. 
in front of neck, 796. 
treatment of, 790. 
Rapid breathing as an anmsthetic, 1284,1285. 
Rare case of salivary calculus, 648. 
Rashes, 183. 
Rauque's liniment in neuralgia, 1116. 
Raw tongue, 767. 
Rawness after amputation of uvula, 788. 
of throat in chronic angina, 170. 
Reamer blades, 329. 
Reaming dental canal, 308. 
Recalcification of teeth, 253. 
Recession and absorption of gum and alveo- 
lus, 284. 
treatment of, 284. 
Recipe for zinc chloride, 389. 
Recipes for angina, 177. 
Recognition of causes of irregularities, 524. 
Recommendation of continuous-gum work. 
604. 
Recurrence of syphilitic ulcers, 843. 
Recurring epulo-fibrous tumors, 1194. 
Red gutta-percha, 388. 
hot needles in treatment of naevi, 899. 
tongue, 746. 
vulcanite, 674. 
Redman's correcting plate, 536. 
pluggers, 398. 
Redness in inflammation, 1308. 
Reducing plates, 514. 
Reduction in jaw luxation, 1031. 
Refinements in tooth nutrition, 1009. 
Reflex odontalgia, 282. 
Reformative effort of dental pulp, 253. 
Regnoli's operation on tongue, 778. 
Regurgitation, 1229. 
Reinforced plate, 597. 
Relation of bands and plate, 595. 
of fractured roots to alveolar line, 446. 
of moisture with tooth-filling, 362. 
of rickets with scrofulosis, 198. 
of teeth with jaw, 139. 
of tooth-form with caries, 197. 
Relational anatomy of carotid artery, 958. 
Relationship of tumors, 1140. 
Remarks on extraction of teeth, 452. 
Remedies used in tetanus, 1083. 
Removable bridge denture, 503. 
Removal and restoration of lower lip, 949. 
of upper lip, 951. 
of foreign bodies from nose, 861. 
of mouth, impressions, 547. 
of plaster impressions, 548. 
of plasters, 928. 
of polypus, 844. 
Removing broach from teeth, 311. 
dead tooth-pulp, 307. 
Repair and inflammatory act, 1311. 
of broken teeth, 465. 
Repairing celluloid dentures, 577. 
Replantation and transplantation of teeth, 
320. 
by transposition, 326. 
danger from tetanus, 326. 
for cure of dental abscess, 321. 
for mistakes in extraction, 320. 
in restitution, 326. 
Reproduction of bone in necrosis, 1030. 
Requirements of dental trays, 545. 
for pronunciation, 631. 
Resecting lower jaw, 1067. 
upper jaw,1059. 
Resections in necrosis, 1029. 
of nerves, 1121. 
Resistance in dental caries, 242. 
Resistiveness in gutta-percha, 387. 
Resorcin in cancer, 913. 
Respiration in angina, 168. 
in ether exhibition, 1266. 
Respirator, Graham's, 1022. 
Respiratory channel, 835. 
murmur, 1237. 
Rest in hemorrhage, 455. 
in inflammation, 1239. 
Restitution of tooth, 326. 
Restoration of lost lower lip, 949. 
of upper lip, 951. 
Resum6 of the subject of anchylosis, 1101. 
Retained secretion in antrum, 979. 
Retaining screws, Mack's, 472. 
points, 415. 
Retention of arsenic in a tooth, 274. 
Retractors in jaw operations, 1068. 
Retro-pharyngeal abscess, 805. 
Reunion of implanted teeth, 333. 
Rheumatic diathesis in alveolar dental ab- 
scess, 300. 
neuralgia, 1102. 
odontalgia, 272. 
pulpitis, 272. 
Rheumatism a cause of pulpitis, 272. 
Rheumatoid arthritis, 1077. 
Rhigolene, 458. 
Rhinoplastyj 868. 
Dieffenbach's operation, 873. 
English method, 869. 
German method, 869. 
Indian method, 869. 
Italian method, 868. 
Pancoast's operation, 873. 
Syme's operation, 869. 
Tagliacozzis operation, 868. 
Von Graefe's operation, 869. 
Watson's operation, 874. 
Rhinorrhoea, 842. 
Rhino-scleroma, 890. 
Rhinoscopic view of posterior nares, 863. 
Rhinoscopy, anterior, 862. 
by artificial light, 863. 
by sunlight, 862. 
posterior, 810, 863. 
Rhonchi, 1240. 
Rhubarb as a laxative, 168. 
Ribbon-filling, 395. 
Rich's duct-compressor, 365. 
Richardson on oral parasites, 227. 
on salivary corpuscles, 244. 
Richardson's atomizer, 458. 
Richmond crown, 483. 1356 
INDEX. 
Richmond's bridge, 505. 
Rickets, 199, 202. 
and hereditary syphilis, 199. 
Riggs's calculi instruments, 652. 
Rimming plates, 592. 
Rim-support for obturator, 612. 
Ringworm, 903. 
Risorius muscle, 76. 
Rivet punch, 565. 
Roasted fig in gumboil, 291. 
Robin, microscopically, on odontoma, 1184. 
Rogers and exsection of maxilla, 1059. 
Roller in jaw fractures, 1040. 
Roof of mouth, 122. 
Roonhuysen's or Horn's lip operation, 947. 
Root-filling, 306. 
forceps, 449. 
growth, 150. 
Roots of milk-teeth, 158. 
of teeth and artificial dentures, 544. 
requiring to be extracted, 445. 
Ropes of gold in tooth-filling, 395. 
Rose and spear drills, 339. 
Rotating teeth, 539. 
Rotten sponge-like sequestra, 1024. 
Rotten-stone in plug-finishing, 423. 
Rouge in plug-finishing, 423. 
Round-celled sarcoma, 1196. 
Roux's operation for cleft palate, 822. 
for lip, 822. 
Rubber dam, 363. 
applied, 366. 
applier, 367. 
Barnes's adjustable, 370. 
clamps, 367. 
Buckman's pattern, 368. 
Elliot's pattern, 368. 
Hickman's pattern, 368. 
How's cervix, 369. 
Johnson's lever, 369. 
Ottolengui's pattern, 368. 
mirror, 366. 
rings, Palmer's, 369. 
tubing in orthodontia, 531. 
wedges, 350. 
weights, 371. 
Rugae and dental models, 594. 
Rules for excavating teeth, 360. 
for insertion of dental plates, 544. 
for lancing children's gums, 164. 
for rubber damming, 372. 
Rumbold's treatment of hypertrophy of ton- 
sil, 725. 
Ruppaner's treatment of hypertrophy of ton- 
sil, 724. 
S. 
Saliva, 255. 
abnormal, 255. 
analysis of, 255. 
from parotid gland, 255. 
from sublingual gland, 255. 
from submaxillary gland, 255. 
healthy, 256. 
pump, Dibble's, 363. 
relation of, with dental operations, 362. 
tests for accidental substances found in, 
261. 
for acid condition of, 261. 
for alkaline condition of, 261. 
Saliva, tests for hydrochloric acid in, 261. 
for lactic acid in, 261. 
for nitric acid in, 261. 
for sulphuric acid in, 262. 
unduly acid, 260. 
alkaline, 260. 
unhealthy, 257. 
Salivary calculus, 645. 
acids, 652. 
analysis of, 645. 
anomalous cases of, 648. 
instruments used in removing, 652. 
simulating cancer, 649. 
Salivary corpuscles, 244. 
Salivary fistule, 990. 
Agnew's operation for, 991. 
author's operation for, 992. 
causes of, 990. 
common treatment of, 991. 
Horner's operation for, 992. 
irregular track in, 991. 
Salivary glands, 131. 
parotid, 131. 
sublingual, 131. 
submaxillary, 132. 
secretions, 255. 
sluggish, 645. 
Salivation in mercurial-poisoning, 1019. 
in phosphor-necrosis, 1024. 
temporary, 1018. 
Salt sheet-bath, 1307. 
water destructive of leeches, 290. 
Salter on advent of wisdom-tooth, 1013. 
Sanguineous reaction in burns, 716. 
Saponis viridis in seborrhoea, 885. 
Sarcoma, 1196. 
globo-cellulare simplex, 1196. 
round-celled, 1196. 
spindle-celled, 1196. 
Sarcomatous polypi, 847. 
Saws, dental, 348. 
surgical, 1071, 1073. 
Scalds, 712. 
Scaly diseases, 183. 
Scar in burns, 715. 
Scarification of gums, 164. 
Schindylesis articulation, 36. 
Scirrhoma, 1145, 1205. 
Scirrhous cancer, 1145. 
of tongue, 754. 
Scissors for amputation of uvula, 786. 
for cutting bone, 1062, 1066. 
Scleroderma, 880. 
Scorbutic ulcers of nose, 843. 
Scorbutus and antrum, 987. 
Scotch stone, 423. 
Scrapings of apple in burns, 713. 
of carrot in burns, 713. 
of potato in burns, 713. 
Screw-driver in pivoting, 474. 
Screw-receiver, 471. 
Screws for extracting teeth, 447. 
Scrofuloderma, 900. 
Scrofulosis, 198. 
a cause of dental caries, 198. 
Scrofulous and scorbutic tumors, 1162. 
angina, 171. 
children and dentition, 198. 
tonsil, 729. 
ulcers of nose, 842. INDEX. 
1357 
Scrolls, turbinated, 48. 
Scurvy, 658. 
Turner's antidote for, 660. 
use of vegetables in, 658. 
Seamless collars, 513. 
Sebaceous glands, diseases of, 884. 
comedo, 885. 
milium, 885. 
molluscum sebaceum, 885. 
seborrhoea, 886. 
tumors of, 887. 
Seborrhoea, 886. 
Secondary breaking of jaw, 1047. 
cyst in antrum, 1190. 
dentine, example of, 281. 
indications in dental caries, 247. 
shock, 696. 
syphilis of tongue, 745. 
Secretion of dental pulp, 145. 
Section of cranial bones, 58. 
of cutaneous horn, 878. 
of dental nerve and maxillary canal, 
1122. 
of enamel, 137. 
of inferior maxillary nerve, 1121. 
of maxillary nerve at oval foramen, 1123. 
of nasal nerve, 1125. 
of superior maxillary nerve at foramen 
rotundum, 1125. 
of teeth, 138. 
temporo-maxillary articulation, 133. 
Sectional dissection of mouth, 125. 
view of new mode heater, 575. 
Seed-like bodies in ranula, 795. 
Selection of pivot teeth, 468. 
Self-explaining cystic tumors, 1170. 
tumors, 1136. 
Semilunar ganglion, 117. 
Sensitive dentine, 268. 
aconite as an obtunder of, 269. 
action of cold or hot drinks upon, 264. 
of sweets upon, 264. 
actual cautery as an obtunder of, 265. 
as a cause of odontalgia, 263. 
campho-phenique as an obtunder of, 270. 
camphor and morphia as an obtunder 
of, 264. 
carbonate of potassium as an obtunder 
of, 265. 
chloride of calcium as an obtunder of, 265. 
of zinc as an obtunder of, 264. 
chloroform as an obtunder of, 269. 
cocaine as an obtunder of, 270. 
creasote as an obtunder of, 269. 
definition of term, 264. 
etherization as an obtunder of, 265. 
ethylate of sodium as an obtunder of, 265. 
glycerole of thymol as an obtunder of, 265. 
hypothesis of cause of, 246. 
in filed teeth, 250. 
instrumentation in, 265. 
iodine as an obtunder of, 265. 
London paste as an obtunder of, 265. 
morphia as an obtunder of, 265. 
nitrate of silver as an obtunder of, 265. 
oil of cloves as an obtunder of, 269. 
pain in excavating, 265. 
state of oral fluids in, 266. 
subcutaneous use of morphia in, 270. 
temporary oxychloride of zinc plugs, 271. 
Sensor portion of fifth nerve, 106. 
Separating files, 346. 
teeth, 357. 
Separation as a prophylactic and curative 
agent, 247. 
Septic discharges of nose, 843. 
Septicaemia in tongue operation, 781. 
Septum of nose, 29. 
Sequestra in necrosis, 1024. 
removal of, 1027. 
Sequestrum after measles, 1020. 
Serous effusions in uvula, 786. 
Serrated instruments, 404. 
Serumic deposits, 642. 
Seton, use of, with naevi, 898. 
Sex in orthodontia, 523. 
Shade teeth, 553. 
Shading oxychlorides, 390. 
Shakespeare, Dr. E. 0., on dentition, 154. 
Sharp bodies in oesophagus, 808. 
excavators and sensitive dentine, 265. 
Sheath of carotid artery, contents of, 967. 
Sheet-bath, salt, 1307. 
Sheet-tin, 393. 
Shock, 695. 
characteristics of, 695. 
definition of, 695. 
idiosyncrasies in connection with, 696. 
interference with function, 695. 
intermediate, 695. 
primary, 697. 
prolonged, 696. 
relation with lymphatic temperament, 
695. 
secondary, 696. 
simple, 695. 
treatment of, 696. 
Shreddy sac in dental abscess, 292. 
Shrunken tongue, 743. 
Sick stomach in use of ether, 1266. 
Significance of nasal dryness, 985. 
of tumors, 1136. 
Signs in phosphor-necrosis, 1022. 
Silver wire in face wounds, 698. 
Silvester's method of resuscitation, 1289. 
Simple angina, 168. 
bone cysts, 1170. 
cystomata, 1170. 
inflammatory tumors, 1159. 
nasal catarrh, 836. 
shock, 695. 
splints in jaw fractures, 1040. 
tooth-cavities, 351. 
Single harelip, 925. 
Sinus, maxillary, diseases of, 970. 
Sinuses in necrosis, 1026. 
Skeleton of the mouth, 28. 
of the nose, 28. 
Skin disease of face, 183, 877. 
grafting, 715. 
parasites, 902, 1320. 
state of, in dentition, 168. 
Skull, 26. 
and hyperostosis, 1164. 
bones of, 26. 
fractures of, 1056. 
trephining, 1056. 
sutures of, 35. 
Slavering in dentition, 163. 
Sleep in fever, 173. 1358 
INDEX. 
Sling for protruding lower jaw, 535. 
Slop-fed cows, 215. 
Sloughing in burns, 714. 
Slow-setting plaster, 548. 
Sluggish salivary secretions, 645. 
system, 198. 
Smell and taste, 121. 
Smith's pluggers, 407. 
tongue-compressor, 363. 
Smoker's tongue, 751. 
Snaring of polypi, 846. 
Sneezing, 836. 
Snell's obturator, 626. 
Snuff and quinine in neuralgia, 1116. 
Soda, bicarbonate of, in burns, 712. 
Soft bodies in oesophagus, 810. 
dentine, 246. 
gold, 395. 
palate, anatomy of, 126. 
injuries of, 712. 
part of mouth, 122. 
teeth and clasps, 544. 
filing, 249. 
Softening of tumors, 1203. 
Soldering a denture, 589. 
and appliances, 566. 
continuous-gum work, 598. 
Solders, gold, 589. 
silver, 589. 
Sordes, 245. 
Sore throat, 802. 
Sounds in health and disease of lungs, 1239. 
Spaces, interglobular, 137. 
Spasmodic trismus, 1088. 
Spasms, 177. 
atropia in, 178. 
belladonna in, 178. 
bromide of potassium in, 179. 
cantharides and camphor in, 179. 
defined, 177. 
from congestion of nerve centres, 179. 
hepatic derangement in, 179. 
in dentition, 163, 177. 
lancing gums for, 181. 
of glottis from use of nitrous oxide, 1284. 
of pharynx, 809. 
passive congestion a cause of, 180. 
pure irritation, 180. 
steam-bath in, 179. 
treatment of, 177. 
valerian and gentian in, 178. 
Spear and rose drills, 339. 
Special instruments used in Farrar system, 
539. 
Specific conditions of pharynx, 805. 
inflammation, 1304. 
treatment of tonsillitis, 718. 
Specula, 863. 
Dicken's, 863. 
Duplay's, 862. 
Frankel's, 862. 
Margetson's, 813. 
Metz's, 862. 
Starr's, 863. 
Tobold's, 862. 
Speech after operation upon tongue, 772. 
mechanism of, 631. 
Sphenoid bone, 52. 
articulation, 55. 
body of, 52. 
Sphenoid bone, clinoid process of, 53. 
concave plane of, 53. 
ethmoidal spine of, 53. 
greater and lesser wings of, 53. 
hamular process of, 55. 
muscles related with, 55. 
nutritional foramina of, 53. 
olfactory foramina of, 53. 
grooves of, 53. 
olivary process of, 53. 
pterygoid process of, 55. 
resemblance of, to bat, 52. 
rostrum of, 54. 
sella turcica of, 53. 
surfaces of, 53. 
turbinated lamella; of, 53. 
Spheno-maxillary fissure, 34. 
fossa, 34. 
palatine ganglion, 117. 
artery, 88. 
Spice-plaster, 176. 
Spider-web in hemorrhage, 455. 
Spina ventosa, 1170. 
Spindle-celled sarcoma, 1196. 
jack-screw, 540. 
Spiral knives, 329. 
springs in dentistry, 552. 
Spirit of Mindererus in inflammation, 1303. 
Spiritus nitri dulcis and the teeth, 236. 
Splitting of teeth from gas in pulp-cavity, 
277. 
Sponging hot skin with alcohol, 173. 
Spongy exostosis, 1163. 
Spray apparatus, 459. 
nozzles, 1253. 
of ether or rhigolene as a local anaesthetic, 
458. 
Spring lancet, 1300. 
Squire's cross-cuts in treatment of port-wine 
stain, 900. 
Standard alloy, 375. 
Stannous gold, 394. 
Staphylococci 1320. 
Staphylorraphy, 814. 
and syphilis, 608, 814. 
Starr on relation of dental arches, 586. 
Starr's root reducer, 464. 
Starvation of naevi, 897. 
Steam's velum, 628. 
Steel wire, use of, in orthodontia, 530. 
Stellwagen's cutting forceps, 446. 
Steno's duct, 131. 
complication of, with dental abscess, 298. 
Stenosis of heart, 1229. 
Stern's illuminator, 812. 
Stethoscope, 1238. 
Sthenic fever, 172. 
Stickiness in gutta-percha, 389. 
Stimulants in dental hemorrhage, 456. 
in stomatitis, 163. 
Stippled celluloid gum, 580. 
Stitches and pins in face wounds, 698. 
Stomach of infants, 174. 
teeth, 141. 
Stomatitis, 163. 
Stones, Arkansas, 424. 
hard, 422. 
Hindustan, 422. 
Scotch, 422. 
Stop-hinge in artificial vela, 633. INDEX. 
1359 
Stowell crown, 482. 
Strain in cleft-palate operations, 940. 
Strangulation of naevi, 896. 
of tongue, 776. 
Strength or debility in relation with chloro- 
form, 1275. 
Streptococci, 1320. 
Stretching nerves, 1131. 
auricularis magnus, 1134. 
inferior maxillary, 1122. 
infraorbital, 1133. 
lingual, 1134. 
occipital, 1134. 
supraorbital, 1133. 
Stricture of pharynx, 807. 
Strophulus, 183. 
Strumous rhinorrhoea, 842. 
Studies in aesthetic dentistry, 559. 
in bite, 587. 
in bridge-work, 503. 
in condition of patient for operation for 
harelip, 925. 
in gold filling, 396. 
in harelip, 938. 
in mode of operating for harelip, 925. 
in obturators, 606. 
in plastic surgery, 945. 
in rhinoplasty, 869. 
in teeth articulation, 556. 
in time of life best suited to operation 
for harelip, 945. 
Study of tumors, 1136. 
Stylo-maxillary ligament, 133. 
Styrone, 1320. 
Subacute inflammatory tumors, 1159. 
synovitis, 1077. 
Subcutaneous strangulation of naevi, 896. 
Sublingual gland, 133. 
and ranula, 793. 
secretion, 256. 
Subluxations of lower jaw, 1031. 
Submarine amalgam, 375. 
Submaxillary ganglion, 120. 
gland, 132. 
secretion, 256. 
triangle, 78, 968. 
Substances used for making artificial nose, 
622. 
Substitution in broken teeth, 463. 
Suction cavities, 593. 
cup, 1299. 
over-strong, 591. 
Sudamina, 888. 
Sudduth, Dr. on involution of epithelium, 155. 
Sudduth's splint, 1045. 
Suersen's velum, 632. 
Suffocation, treatment of, 733. 
Sugar and the teeth, 235. 
Sulphate of iron in epithelioma, 917. 
of lime as an impression material, 548. 
of potassium in hypertrophy of tonsil, 
723. 
Sulphuric acid in dental abscess. 299. 
in maxillary caries, 1001. 
in treatment of salivary calculus, 652. 
ether, 1260. 
Superficial burns, 713. 
and deep vessels of face, 80. 
caries, 249. 
Superfine flour, 216. 
Superior dental arch, 337. 
maxilla, removal of, 1061. 
maxillary bone, 36. 
nerve, 111. 
author's operation for exposure 
of, 1122, 1123. 
Carnochan's operation for ex- 
posure of, 1127. 
Langenbeck's operation for ex- 
posure of, 1127. 
Pancoast's operation for expos- 
ure of, 1127. 
thyroid artery, 84. 
branches of, 84. 
Supernumerary teeth, 190. 
as cause of tumors, 1175. 
Support of changed teeth, 526. 
in harelip, 928. 
Supporting artificial teeth, 551. 
Suppositories, 1258. 
formula for, 1258. 
Suppuration, 1296. 
Supra-hyoid bursa, 796. 
Supraorbital nerve, exposure of, 1133. 
Surfaces of sphenoid bone, 53. 
of teeth, 139. 
Surgical anatomy of facial region, 25, 958. 
of neck, 958. 
of nerves of head, 1121. 
of nose, 833. 
of soft palate, 819. 
of the maxilla?, 330, 331. 
of the teeth, 135. 
cementum, 135. 
dental pulp, 135. 
dentine. 135. 
enamel, 135. 
consideration of dental caries, 242. 
diagnosis of maxillary sinus, 971. 
engine in exsection, 1073. 
in general oral practice, 1074. 
in maxillary caries, 1000. 
lesions of tongue, 744. 
relations of anomalous dentition, 186. 
of veins of face, 963. 
treatment of defects of hard palate, 829. 
triangles of neck, 967. 
Sutures and skull, 35. , 
Swaging dental plates, 582. 
Swallowing pins, 809. 
the tongue, 783. 
Sweat-glands, diseases of, 887. 
anidrosis, 888. 
chromidrosis, 888. 
hyperidrosis, 887. 
sudamina, 888. 
Sweating in inflammation, 1303. 
Swedish leeches, 1299. 
in angina, 168. 
Sweet spirits of nitre and the teeth, 236. 
Swelling in inflammation, 1309. 
of uvula, 786. 
Sycosis, 903. 
Syme's operation on tongue, 779. 
view of trismus nascentium, 1086. 
Sympathetic odontalgia, 282. 
Symptoms of jaw fractures, 1037. 
of tetanus, 1080. 
Synarthrodial joints, 36. 
Synonymes of tumors, 1144. 1360 
INDEX. 
Synovial fluid, 133. 
membrane of lower jaw, 133. 
Synovitis, 1077. 
acute, 1077. 
suppurative, 1078. 
treatment of, 1079. 
Syphilis, 199, 206. 
a retarder of development, 209. 
and antrum, 987. 
as a cause of dental disease, 206. 
of tongue, 745. 
of uvula, 787. 
Syphilitic affections of the tonsils, 728. 
necrosis, 1014. 
teeth, 209. 
ulcers of nose, 843. 
Syphiloderma, 901. 
Syringe, hot-air, 349. 
water, 349. 
Systemic complications and amalgam, 385. 
inflammation, 1297. 
T. 
Tabes mesenterica and dentition, 175. 
Tact in preparing cavities, 361. 
Taft's thimble, 364. 
Taking away sequestra, 1027. 
cold, 1310. 
impressions of mouth, 544. 
Talbot's tooth-crown, 463. 
Tampon in epistaxis, 839. 
Tannic acid in hemorrhage, 165. 
Tartar, 645. 
and parasiticides, 653. 
on teeth, 645. 
analysis of, 645. 
Tartaric acid and the teeth, 235. 
Taste and smell, 121. 
Tearing sac of alveolar abscess, 293. 
vascular nsevi, 899. 
Teese's furnace, 600. 
Teeth, 135. 
abrasion of, 336. 
and their diseases, 197, 263. 
bicuspidati, 141. 
bleaching, 316. 
cementum of, 137. 
chalky, 246. 
classification of, 139. 
cuspidati, 141. 
dark, 316. 
deciduous, 139. 
dentine of, 135. 
denudation of, 335. 
discolored, 316. 
enamel of, 136, 149. 
exostosis, 450, 1160. 
extraction of, 428. 
filling, 396. 
found in the antrum, 986. 
gymnastics of, 236. 
held in false position, 526. 
incisors, 140\ 
molar, 142. 
most frequently found encysted, 1189. 
not to be clasped, 544. 
of sanguine and allied temperaments, 245. 
of the blue shade, 246. 
Teeth, pearly, 246. 
periodonteum of, 137. 
surfaces of, 139. 
transplantation of, 320. 
tunica propria, 148. 
reflexa, 148. 
whitening, 319. 
with tuberculous disposition, 246. 
Teeth to be extracted, 428. 
affording no prospect of usefulness, 428. 
associated with incurable abscess, 428. 
congesting and debasing neighboring 
parts, 428. 
containing nodules of dentine, 428. 
lacking antagonists, 428. 
overcrowded in arch, 428. 
roots badly putrescent, 428. 
the source of unendurable pain, 428. 
with fungoid excrescences, 428. 
Temperament and dyscrasia, 523. 
Temperature in celluloid-work, 576. 
in gutta-percha, 573. 
in relation with ether, 1267. 
in tonsillitis, 717. 
in vulcanite work, 573. 
Temporal fossa, 33. 
bone, 63. 
auditory meatus of, 67. 
basilar view of, 66. 
encranial portion of, 68. 
external view of, 64. 
Glaserian fissure of, 66. 
glenoid fossa of, 66. 
internal view of, 65. 
mastoid process of, 65. 
muscles of, 67. 
petrous portion of, 64. 
squamous portion of, 65. 
styloid process of, 67. 
muscle, 76. 
vein, 95. 
Temporary matrice, 400. 
salivation, 385. 
teeth, 158. 
order of eruption, 158. 
Temporo-maxillary articulation, 133. 
capsular ligament of, 134. 
character of, 133. 
interarticular fibro-cartilage of, 134. 
synovial membrane of, 134. 
Tensor palati muscle, 821. 
Tertiary syphilis of tongue, 745. 
Test bite in articulation, 551. 
filling in pulp-canals, 308. 
for acid secretions, 261. 
for quality of gutta-percha, 387. 
Testing for warping, 599.. 
gutta-percha, 387. 
Tetanus, 1080. 
acute, 1080. 
causes of, 1080. 
chronic, 1081. 
from replantation of tooth, 326. 
idiopathic, 1080. 
pathology of, 1082. 
symptoms of, 1080. 
traumatic, 1080. 
treatment of, 1083. 
Therapeusis, dental, 252. 
Therapeutical filling, 388. INDEX. 
1361 
Third dentition, 191. 
Thoracic anastomosis, 962. 
ducts, 94. 
Throat and erysipelas, 1316. 
tickling and rawness of, 170. 
treatment of, 171. 
Thrush, 676. 
Thudichum's douche, 861. 
Thymus gland in tracheotomy, 736. 
Thyroid artery in tracheotomy, 735. 
axis anastomosis, 961. 
Thyrotomy, 738. 
Time for operation in harelip, 925. 
of retention of pins and stitches, 699. 
Tin in amalgam, 376. 
plugs in children's teeth, 393. 
Tinea circinata, 903. 
sycosis, 903. 
Tin-foil, 393. 
for filling children's teeth, 393. 
Toad-marks, 880. 
Tobacco as a parasiticide, 241. 
chewing and abrasion, 336. 
heart, 1233. 
tongue, 758. 
Tobold's illuminating apparatus, 862. 
Tongue, the, 126, 743. 
abscess of, 764. 
acute inflammation of, 760. 
amputation of, 778. 
arteries of, 130. 
as a sentinel of medical diseases, 743. 
atrophy of, 771. 
cartilaginous tumors of, 771. 
coating of, 743. 
color of, 743. 
cystic tumors of, 758. 
diseases of, 743. 
dissection of, 125, 127. 
effusions of, 767. 
epithelioma of, 757. 
erectile tumors of, 768. 
erysipelas of, 767. 
fatty tumors of, 768. 
holder, Flagg's, 362. 
Morrison's, 363. 
Osborn's, 363. 
Smith's, 363. 
hypertrophy of, 745, 769. 
immobility of, 771. 
insect bites of, 767. 
local injuries of, 744. 
meaning of, in form, 743. 
metastatic disease of, 768. 
moisture of, 743. 
motion of, 743. 
muscular structure of, 127. 
neuralgia of, 765. 
operations practised upon, 772. 
papillae of, 129. 
papilloma of, 771. 
scirrhus of, 754. 
syphilitic ulcers of, 747. 
temperature of, 743. 
tie of, 781. 
tubercle of, 758. 
venous tumors of, 771. 
views of, 125. 
Tonic compound, 1305. 
Tonsil glands, 126, 717. 
Tonsil glands, abscess of, 729. 
extirpation of, 728. 
hypertrophy of, 722. 
inflammation of, 717. 
syphilitic affections of, 729. 
tonsillotomy for, 725. 
use of London paste in, 724. 
Tonsillitis, 717. 
common treatment of, 717. 
specific treatment of, 718. 
Tonsillotomes, V26. 
Tonsillotomy, 726. 
Tools used for celluloid-work, 563. 
for metal-work, 564. 
for vulcanite-work, 564. 
Tooth abscess discharging into antrum, 973. 
ache, 263. 
bleaching, 316. 
brushes, improper use of, 654. 
capping in periodontitis, 313. 
crowns, Bonwill's, 473. 
Gates's, 494. 
cysts, 1170. 
extracting instruments, 430. 
extraction, 428. 
accidents associated with, 452. 
hemorrhage associated with, 453. 
germs, 145. 
of heterogeneous development, 186. 
hills in maxillary sinus, 37, 973. 
nutrition, 1009. 
picks, 237. 
powders, 226. 
sac, 153. 
tunics, 148. 
Torsion in hemorrhage, 994. 
Townsend formula for amalgam, 374. 
Trachea, fractures of, 1055. 
view of, 737. 
Tracheal sound, 1239. 
tubes, 735. 
Tracheotomy, 734. 
atomization of fluids in, 737. 
complications in, 736. 
wire brush in, 736. 
Translucency in teeth, loss of, 316. 
Transplantation and replantation of teeth, 
320. 
of brutes' teeth, 324. 
of human teeth, 324. 
of skin, 875. 
Traumatic epistaxis, 837. 
study of, 875. 
trismus, 1080. 
ulcers of nose, 840. 
Trays for taking impressions, 545. 
Treating and filling teeth in relation with 
laws of surgery, 252. 
Treatment for gum absorption, 639. 
of dental caries, 337 to 427. 
irregularities, 523< 
of exposed pulp,' 269. 
of nose ulcers, 840. 
of phosphor necrosis, 1021. 
of pulp-cavity in replantation, 321. 
of salivary calculi, 651. 
Trephines, dental, 329. 
surgical, 1056. 
Trephining, 1056. 
use of surgical engine in, 1057. 1362 
INDEX. 
Trial plate, 551. 
Triangles of neck, 967. 
submaxillary, 78. 
Trifacial nerve, 106. 
Trigeminus nerve, 106. 
Trismus, 1080. 
dentium, 1088. 
from pivot teeth, 1096. 
nascentium, 1085. 
traumaticus, 1080. 
Trouvti's polyscope, 813. ' 
Tubercle, lachrymal, 40. 
of tongue, 758. 
Tubercles, genial, 44. 
of pharynx, 805. 
Tubercula, 183, 185. 
Tuberosity of maxilla, 31. 
Tubular consolidation, dental, 280. 
lupus, 906. 
Tumefaction of gum, 643. 
Tumors, 1136. 
arterial, 893, 1149. 
classes of, 1143. 
classification of, 1143. 
definition of term, 1136. 
dental fungoid, 1146. 
epulo-erectile, 1149. 
exostosis and subacute inflammatory, 
1159. 
histological distinctions, 1143. 
homologous, 1137. 
hyperostosis, 1159. 
hypertrophic, 1142. 
illustration of, 1136. 
in diagnosis, 1137. 
local and dyscrasic, 1136. 
microscopic appearance of encephaloma, 
1210, 1211. 
non-self-explaining epulides, 1151. 
odontoma, 1170. 
odonto-periosteal, 1174. 
of the antrum, 989. 
recurring fibrous, 1196. 
relationship of, 1140. 
resultant from interference with func- 
tion, 1142. 
rules for understanding, 1136. 
simple inflammatory, 1159. 
stand-point of study of, 1136. 
the epulic. 1146. 
ulitic, 1147. 
venous, 893. 
Tunica propria, 148, 1010. 
reflexa, 148. 
Turbinated bones, 48. 
articulation of, 50. 
inferior, 48. 
lachrymal and ethmoid processes of, 49. 
maxillary process of, 49. 
muscles of, none, 50. 
relation of, with meatuses, 48. 
scroll-like character of, 48. 
susceptibility to inflammation, 49. 
Turk's Island salt bath in scrofula, 1307. 
Turmeric paper as a test for alkalinity, 245. 
Turnbull's experiments with ethyl bromide, 
1285. 
Tuson on use of chlorine in cancer, 917. 
Twin teeth, 406. 
Twisted or harelip suture, 941. 
Two kinds of tumors only, 1136. 
Typh fever, 225. 
poison, 224. 
Typhoid condition as a predisposing cause 
of dental hemorrhage, 455. 
state and plastic operations, 926. 
U. 
Ulcer of antrum of Highmore, 853. 
of necrosis, 1016. 
acid nitrate of mercury in treatment 
of, 1015. 
corrosive sublimate in treatment of, 
1015. 
incision in treatment of, 1016. 
iodide of potassium in treatment of, 
1016. 
iodine and creasote in treatment of, 
1016. 
syrup of pyrophosphate of iron in 
treatment of, 1015. 
of nose, 840, 848. 
cancerous, 843. 
exanthematous, 843. 
neuro-paralytic, 843. 
scorbutic, 843. 
scrofulous, 842. 
syphilitic, 843. 
traumatic, 840. 
Ulceration of mucous membrane of antrum, 
853. 
of nares, 849. 
Ulcers, 840. 
found in the mouth, 675. 
Ulitic tumors, 1147. 
Ulitis, 664. 
causes of, 664. 
from chloride of zinc, 662. 
from creasote, 661. 
from dead or loose teeth, 660. 
from improperly-inserted artificial teeth, 
663. 
from overcrowded dental arch, 661. 
from periodontitis, 656. 
from scurvy, 658. 
from syphilis, 660. 
from the mercurial impression. 656. 
from use of improper dentifrices and 
brushes, 661. 
from vulcanite, 663. 
Unbolted flour, 216. 
Uncovered pulp-chambers, 312. 
Uncovering upper jaw, 1059. 
Underhung jaw, 533. 
Undeveloped teeth as cause of tumors, 1175. 
Unilateral facial atrophy, 822. 
jaw luxation, 1031. 
Union of wounds by first intention, 932. 
Unique case of odontoma, 1178. 
Universal root forceps, 445. 
Unloading capillaries, 1307. 
Unsuccessful tracheal operations, 742. 
Ununited jaw fractures, 1045. 
Upper cow-horn forceps, 438. 
jaw in necrosis, 1028. 
lip, making, 942. 
Uranoplasty, 830. 
Urticaria of tongue, 769. INDEX. 
1363 
Use of gutta-percha in dentistry, 386. 
of rhinoscope, 863. 
Uvula, 123, 785. 
amputation of, 786. 
diseases of, 785. 
engorgement of, 785. 
hypertrophy of, 785. 
in angina, 168. 
neoplasm of, 785. 
scissors, 786. 
swelling of, 720. 
tumors of, 785. 
V. 
Vacuum chamber, 593. 
Vallet's mass in epithelioma, 916. 
Value of histological distinctions, 1145. 
Valvular affections of the heart, 1227. 
Varieties of gutta-percha, 386. 
of ostosis, 1159. 
Varying angles of jaw rami, 534. 
Vascular system of external and deep facial 
region, 82, 958. 
ligation of external carotid artery, 966. 
of facial artery, 963. 
of lingual artery, 962. 
of occipital artery, 964. 
of primitive carotid artery, 966. 
of temporal artery, 963. 
line of arteries, 960. 
warts, 883. 
Vaseline in burns, 713. 
Vault of nose, 834. 
Vegetable parasites, 902. 
Veins of facial region, 93. 
auricular, 95. 
frontal, 96. 
internal jugular, 97. 
labial, 96. 
lingual, 97. 
maxillary, 95. 
pharyngeal, 97. 
nasal, 96. 
temporal, 95. 
thyroid, 97. 
Vela, 606. 
Baker's, 633. 
Booth's, 632. 
Kingsley's, 628. 
Stearn's, 628. 
Suersen's, 631. 
Velum palati, 122. 
Vena cava superior, 93. 
Venereal and tubercular tumors, 1162. 
Venesection, 1300. 
in infantile spasms, 179. 
Venous circulation of head and neck, 93. 
hemorrhage, 693. 
after tooth extraction, 453. 
tumors, 893. 
of tongue, 771. 
Veratrum viride as a depressant, 455, 1302. 
in periodontitis, 290. 
Vermifuge medicines in neuralgia, 1116. 
Verrier's furnace, 600. 
Verruca, 883. 
acuminata, 884. 
digitata, 883. 
Verruca filiformis, 883. 
plana, 883. 
vulgaris, 883. 
Vertical section of face and neck, 125. 
Vesiculae, 185. 
Vesicular murmur, 1237. 
Vessels of dental papillae, 157. 
Vestibule of mouth, 122. 
Vicarious dental hemorrhage, 455. 
diseases of sweat-glands, 887. 
epistaxis, 840. 
Vice tumors, 1136. 
Vidian artery, 88. 
Vienna paste, 913. 
View of air-tubes, 731. 
of fifth pair of nerves, 106. 
of inferior maxillary and gustatory 
nerves, 114, 1121. 
of posterior nares, 813. 
of right half of base of skull, 59. 
of teeth, 138 to 140. 
Views illustrative of bronchotomy, 731, 732. 
Vinegar and dental caries, 235. 
Virchow and cell segmentation, 1312. 
on caries, 998. 
Virginia snake-root as a tonic, 1305. 
Virus, 697. 
Viscosity in saliva, 260. 
Vitality in ulceration, 1018. 
Vitiated nutrition and purulency, 978. 
Vitiligo, 878. 
Vitrifaction, 248. 
Vocal resonance, 1242. 
Volta's pile, 804. 
Vomer bone, 47. 
articulation of, 48. 
with maxillary and palate bone, 
48. 
association with triangular cartilage, 48. 
naso-palatine groove, 48. 
relation of septum of nose, 48. 
shape of, 48. 
view of, in position, 48. 
separated, 48. 
V-shaped cuts, 927. 
dental arch, 525. 
Vulcanite and celluloid, 570. 
apparatus for working, 570. 
as a cause of ulitis, 663. 
black, 574. 
blank rim, 579. 
composition of, 570. 
continuous gum, 579. 
dental plates made of, 570. 
flasks for moulding, 571. 
obdurators made of, 619. 
packing for dental plates, 572. 
repairing, 577. 
Vulcanized splints, 1049. 
tooth pivots, 471. 
Vulcanizing a rubber splint, 1050. 
W. 
Warm climates, relation of, with health of 
teeth, 262. 
Warren's operation for cleft palate, 823. 
Warts, 883. 
Warty teeth, 1161. 1364 
INDEX. 
Washes for the teeth, 226. 
Washing nitrous oxide, 1282. 
Water-syringes, 349. 
tight tooth-dam, 363. 
Watery effusions, 1311. 
Watson's chlorine-water, 804. 
in nasal ulcerations, 840. 
in pharyngitis, 804. 
Wax for impressions, 546. 
Weakly children and aphthae, 684. 
Wearing down of teeth a cause of pulpitis, 
336. 
Webb, Marshall, on contour-work, 414. 
on pivoting, 473. 
Wedge in tooth-filling, 356. 
Wedges, rubber, 350. 
wood, 350. 
Wedging in orthodontia, 530, 537. 
in tooth extraction, Physick's forceps, 
442. 
teeth, 356. 
Weld on contour-work. 415. 
Wells, Dr. Horace, and nitrous oxide gas, 1280. 
Westcott's correcting apparatus, 529. 
Weston's insoluble cement, 375. 
pulp-caps, 314. 
soft cement, 374. 
Wet cupping, 1299. 
Wharton's duct, 132. 
obstruction of, 793. 
What to do in burns, 713. 
Whiskey in rattlesnake-bite, 698. 
White corpuscles, excess of, 1310. 
enamel stopping, 392. 
fur on tongue, 743. 
gutta-percha, 388. 
oak bark in stomatitis, 167. 
paint in burns, 713. 
sores of the aphthae, 675. 
tongue, 758. 
wax, 546. 
White's correcting apparatus, 528. 
dental engine, 342. 
furnace, 600. 
head-rest, 427. 
Whitehead's operation on tongue, 781. 
Whitening teeth, 318. 
Wildman's artificial nose, 620. 
obturator, 620. 
Willis's circle, 82. 
Wings of sphenoid bone, 54. 
Wire brush in tracheotomy, 736. 
seton in salivary fistule, 992. 
Wisdom-teeth, 143. 
forceps, 441. 
in alveolar abscess, 296. 
Withdrawal of pin or ligature in face wounds, 
699. 
Wolverton's tooth-forceps, 440. 
Wood pivots, 470. 
polishing points, 422. 
Wooden spatula in harelip, 927. 
Woorara in treatment of tetanus, 1084. 
Worms in comedo, 885. 
in dentition, 161. 
Wounds left by transfer of a flap( 957. 
of mouth and associate parts, 693. 
burns and scalds, 712. 
complications, 693. 
deformities, 714. 
healing, 698. 
illustrations, 700. 
indications in, 693. 
relation of foreign particles to, 693. 
shock, 695. 
virus, 697. 
of pharynx, 806. 
Wrench and screw in orthodontia, 537. 
Wrist-bathing in fever, 1303. 
X. 
Xanthoma, 890. 
Y. 
Yaws, 883. 
Yellow fur on tongue, 743. 
tartar, 651. 
Young teeth, separation of, 357. 
Younger's reamers, 329. 
Z. 
Zinc and dental caries, 240. 
as a cause of pulpitis, 264. 
as a cleanser of amalgam, 380. 
as a decolorizer, 316. 
as a filling material, 390. 
as a pain obtunder, 264. 
as a parasiticide, 240, 254. 
as a pulp-capping material, 313. 
as a recalcifier, 253. 
as an ingredient in amalgam, 376. 
cast of mouth, making, 581. 
chloride and necrosis, 1011. 
in sensitive dentine, 264. 
in stomatitis, 167. 
phosphates, 391. 
composition of, 392. 
forms of, 392. 
plaster in epithelial cancer, 917. 
sulphate in antral disease, 981. 
treatment of tonsillar affections, 723. 
Zygomatic fossa, 33. 
muscles, 74. 
surface of submaxilla, 41. 
THE END. 
Printed by J. B. Lippincott Company, Philadelphia, U.S.A.