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       The  Choice  of  Proper  Filling

                       Material

          BY J. FOSTER FL-\GG. D.D.S., SWARTHMORE, PA.
                          June, 1899.

 "Failure in operations is mainly due to incompatibility  of
 filling material with toothbone."

   Fellow members of the California State Dental Association.
     Greeting -

   The text  which I have chosen as the theme upon which  to
 talk to you  at this time is the germ of that egg  which, when
 hatched, developed  into what came to be  known as  " The New
 Departure.''
   Without touching at all upon  the  other points at issue be-
 tween the " creed " of that movement and what was known  as
 the  " accepted creed "  of twenty years ago, and which in yet
 largely—though  not so largely—"accepted" as basal rules
 for dental practice,  I wish to ask your special consideration  of
 this,  the third article of  the " New Departure Creed."
   It cannot  be denied that for a very long time—at least forty
 or fifty years—a tendency to " recurrence of decay " around
 fillings has been noticed, thought upon, written about and dis-
 cussed ; and that this tendency, as especially illustrated by the
 disintegration of  tooth substance around  gold fillings, and yet
 again as, probably,  most noticed from frequent " recurrence
 of decay " at the cervical margins of cavities, gave to  dentis-
 try, at a  time beyond the recollection of almost  everyone now
 practicing, the term " cervical decay " with its universally re-
 ceived explanation of  " defective manipulation."
  That this  idea is yet strongly retained  is seen by reference
 to page 217  of  " The American Text Book of Operative Den-
tistry," where is found " defects which arise from subsequent
caries are perhaps more frequent in approximal  surfaces at  or
near the cervical margin.  These borders are vulnerable points
for the recurrence of caries, and imperfect adaptation is not in- 
                              WU


                                leee

 2       THE CHOICE OF PROPER  FILLING MATERIAL.

frequently the determining cause of the beginning of such decay.
 (the italics are mine)
   "Not infrequently " is synonymous  with sometimes,  or it
 may even be regarded as almost frequently ! but what are some
 other causes  for this undesirable result ?  and how is it that
 '' not infrequently '' this imperfect adaptation is  permitted to
 exist ?
   But the three paragraphs following are those to which my
 text directs  special  attention.
   First, '' repair '' of such imperfect fillings is taught  to  be
 made with gold, and such teaching is concluded in the  begin-
 ning of the  third paragraph in these words '' Such repairs are
 often required in the bicuspids  and molars,  and large fillings
 othenoise good are saved by a successful repair at the  cervix.''
 (italics are mine, for the purpose of accentuating the points I
 desire particularly to impress by this paper.)
   Now I would ask if "imperfect adaptation" not infrequently
 results from a first effort under former conditions, what induce-
 ment is offered for another trial of  the same kind under  con-
ditions  of  increased inaccessibility  and consequent greater
 difficulty? and, more than this, if  this  "subsequent caries"
 has developed in, say,  from three to five years  (and such cases
 are very frequent) what incentive exists for such further ef-
 fort ?
   But as we read on we find that "The plastics are sometimes"
 (note this word) "indicated in this class of cases,  provided
 they be not  so near  the  anterior part  of the mouth as to  be
 unsightly ''  and then Gutta Percha is said to  often serve a
good purpose but "  is less reliable than  gold."   And continu-
ing with the  '' oxyphosphates '' these  are '' contraindicated
because of their liability to wash away after a few months."
   At last we  come to amalgam, in connection with which I
 naturally feel a close interest, as I first suggested, its use  not
only  for  these cervical repairs   but  for '' guards "  (as I
termed them)  to prevent, for the greatest  possible length of
time this '' recurrence  of caries ''  at the cervical margins of
gold fillings-This " guarding " (which I wish you to note is
practice distinctly in advance of  " repairing'')  I have been 
 3       THE CHOICE OF PROPER FILLING  MATERIAL.

 doing  for over  30 years (since  1865) and  this " repairing "
 for more than 40 years (since 1857) and  it is  this constant
 utilization of this material for all  this time, and  its use in re-
 current caries of the  soft and  softest teeth,  exclusively, for
 more than twenty years, during which time I operated upon
 no  teeth  above  medinm  in structure,  that  makes the word
 " sometimes,"  quoted above, sound to me peculiarly inappro-
 priate.
  The teaching of this '' Text Book'' given in the next ten
 lines is a fair illustration of the Plastic question from the view
 of one of the best gold workers that ever handled a plugger.
  These ten lines begin '' amalgams are more frequently used,
 and nearly always serve well when thus employed ; but un-
 fortunately the contact with gold insures discoloration, and an
 unsightly filling is the result."
  Again the  word  '' unfortunately'' sounds  strangely  to
 Plastic  workers, for this fortunate  discoloration is the result
 upon which we base  our hope for the long  continued exemp-
 tion from recurring  caries.   No  true utilizer of amalgam for
 this purpose would think  of using an amalgam which  would
 best maintain a  good color   but, on the contrary,  " in propor-
 tion as  the  tooth  needed  saving'' would select that alloy
 from which he  would most surely  make a discoloring amal-
 gam—and if the cavity of repair was not  entirely  above the
 free edge  of the gum,  he would drill out  the  discolored
 amalgam  in such wise as that  a  continuation of the  gold
 could be made in the portion exposed to view.
  The  next   statement also,  from the "Choice of Filling
 Material " standpoint, does not appeal to the Plastic filler, for
 it is stated  that ''  The discoloration of the surface  of the
 alloy"  (meaning amalgam)  "does  not lessen its value as  a
 preserver of the tooth, but its unsightliness is often  too  great
 to be tolerated ; nevertheless, utility enters  so largely into the
equation that the operator feels justified in  using the alloy"
 (amalgam) " because with it he feels sure of making a  better
repair."
  Our glorious old '' Patriarch  ''  Atkinson used to tell us '' not
infrequentlv " that " half a truth was worse than a whole lie " 
4       THE CHOICE OF PROPER FILLING  MATERIAL.

and  it seems  to  me that  a  half  century  of experience has
taught us, beyond a peradventure,  that to say no more for the
sulphiding of amalgam than that it  '' does not lessen its value "
puts the statement in the category of a "half truth," for  no
other reason has ever  been given for the  marvelous tooth
saving ability  of coin amalgam other than that  it  turns '' as
black as one's  hat."
  But it is the last few words of our quotation '' because with
it he feels sure of making a better repair "  which is my war-
rant for sending you this paper, for  the two fold purpose of
assuring you of my  continued loyalty and affection for our
beloved California, and to prepare  the way  for a future com-
munication to  our  " Pacific Coast  Dental Gazette" upon the
"Consonance of Potential'-' and the  Specified using of  given
filling materials  for  the  " compatible "  filling of teeth  of
varied given structure. 
THE  GH01GE OF  PROPER FILLING MATERIAL.

     BY J. FOSTER FLAGG, 1). D. S.,  SWARTHMORE, PA.

    THIRD ARTICLK  OF  THE NEW DEPARTURE  CREED.
  " Failure iu .operations is mainly due to incompatibility of filling material with
                 toothbone."— 5. B. Palmer, M. D. S.
         " Because with it he feels sure of making a better repair."
                —American Text-Book of Operative Dentistry, p. 217, line 3$.

                       [PART FIRST.]
  IT is now forty-two years since I began my systematic work as
   to the results of the utilization of different filling  materials in
the filling of cavities of dental decay, together with the tabula-
tion of such results in order that statistics might give value to
the record.
  To the fact that I was a  competent  gold-worker I think no
one conversant with my work will offer denial, while hundreds
of fillings which have now done from twrenty-five to more than
forty years of service, and are yet in perfect condition, will
render any needed corroborative testimony.
  Had I not felt my own ability iu  this regard, I  could never
have successfully maintained the  position  I have taken in the
teaching of this "Third Article of  the New Departure Creed."
  In the early  days  of  the  New Departure struggle, when
occasional question was  made as to  my gold work, I always
met the  insinuation  by promptly offering to fill with gold,
against the gentlemen, all kinds of teeth,  and with cavities in
every position—and I may now say that such offer was never
accepted.
  I felt sure of equal success,  and, in the majority of instances,
of decided triumph, as I was a soft gold worker even in the
large "contouring" of cuspids, bicuspids and molars, or in the
"edge  building" of incisors, and  my soft gold and hand pres-
sure operations were largely to be made against cohesive gold
and malleting, therefore,  I felt confident.
  Upon my return from California in 1855, I found both gutta-
percha  (Hill's stopping) and amalgam (Townsend's), added
to the accepted list of filling materials, which at the time of my
leaving for California in  1849 consisted,  practically, of gold 
2
 and tin foils, there having been an equally practical abandon-
 ment of lead, fusible metals and amalgam.
   The  results  of my father's experience with the two newly
 accepted filling materials, together with the enthusiasm of the
 friend of both my young and more mature years, Prof.  Elisha
 Townseiid (see Plastics, p. 34), soon  engendered the desire to
 experiment with them for  myself, and now, after  more than
 forty years of that successful  utilization of them,  for which I
 am  supremely  grateful, I look back  upon  my life work as
 associated with dentistry  as  something  eminently  satisfactory
 to my patients, my students and myself.
   It has  been  my privilege to discuss so extendedly, before
 classes, the matters of which I propose now to write, that to
 my Pacific Coast students  these  articles  may seem like old-
 time talks, but the vital importance of the  subject  and the
 advantage of its  concise, systematic and minute presentation
 will, I  hope, be  recognized and  prove both  acceptable  and
 profitable.
   Again,  much of which I must write will seem to  me merely
 reiteration, for  it  has  been so many  years  since discussions,
 magazine articles, society papers  and  deliberate publications
 have pointed both generally and specifically in the  direction of
 "choice of filling  material," that I repeat because even now
 the need for this is positively denied,  while twenty  years ago,
 and  as the result of a carefully  tabulated experience of twenty
 years before that, I wrote  that  even then we  had  the "tests"
 for this choosing, saying:' 'By means of these tests we are enabled to
 make A CHOICE OF MATERIAL to meet the varied indications that
 constantly present  in practice, which,  to our apprehension, ap-
proaches to SOMETHING LIKE SCIENCE."
   And more than this, it is also twenty years since I was able
 to say to  the American Dental Association  this utilization of
 specially chosen materials enabled those who  had adopted it to
 then  "take any denture so forlorn as to be hopelessly abandoned
 by the BEST gold operator  in the world, and make of it a com-
 fortable, SATISFACTORY and  BEAUTIFUL SUCCCSS."
  And has the  twenty years  of added  experience  since then
 given any cause for the least change  in these enunciations ?—
 Most emphatically I answer,  No.
  And so it is that now, as then, a combination of "two, three 
3
four or more different materials  is made in the filling of one
cavity, each of which  best subserves its  purpose in its appro-
priate  position, and insures  an operation which  for comfort,
beauty and  permanency can in no other way be equaled."
  That this may be done requires  the most  complete knowl-
edge  possible  of  all the attributes  of  the varied "filling
materials" now used by dentistry, together with a like knowl-
edge of all the  "adjunctives"  which are ever assigned a place
within a cavity of decay as a component of the filling.
  Those of  these  which can  be  classed as "filling materials"
are Gold, in its various forms;  Tin,  usually as foil; Amalgam,
of the three varieties, Sub-marine  or  Discoloring; Contour or
Usual, for ordinary work; and Facing or  White, where main-
tenance of color is specially  desirable; Gutta-percha Stopping
—White or Shaded, Yellow, or Grey, and of High,  Medium,
or  Low  Heat; Pink Gtdta-percha Base-plate, for occasionally
desirable use;  and Porcelain in its properly styled "art work."
  The reason why these alone can be ranked as "filling mate-
rials"  is because  we know sufficiently  their capabilities for
resisting outside influences to  be able to prognose, with much
certainty, their probable rendering of  service, while with  the
"adjunctives"  we either do not utilize them for  external posi-
tion, or, if for any  reason this  is sometimes done, it is absolutely
impossible to prognose anything regarding  the  future  of the
work.
  Of these we  have Oxy-chloride of Zinc, with its usual rapid
disintegration  and its occasional marvelous endurance as an
outside material;  Zinc-phosphate, the  powder of which is an
accurately nitrated oxide of zinc; Oxy-phosphate, the  powder of
which is calcined or, so-called, vitrified,  oxide  of zinc; Zinc-
sulphate, specially useful as  a pulp-capper;  Temporary Stop-
ping, of great value as an "intermediate" from its non-leakage,
its  impermeability and its adhesive plasticity at comparatively
low temperature;  and Rubber Varnish, unique in its value both
as a "liner,"  an "intermediate" and protector of soluble  fill-
ings from the immediate action of the  fluids of the mouth.
  It is with these, then, that we  will have to do, directly and
incidentally, in the discussion of "the choice of proper filling
material." 
4
                      [PART SECOND.]
   IN  the  treatment of any subject it is often of as much im-
    portance  to  decide the points  proper  to disregard as to
 establish those which, in different degree, claim more or less
 attention until we reach that imperative which  demands the
 most positive recognition and the greatest  amount of knowl-
 edge, experience and skill for the  accomplishment of the best
 result.
   It  is therefore with the size of a cavity that we have first
 to do as regards the principles which underlie the choice of
 filling material.
   Size of cavity  has NOTHING to do with it.
   That this should be made clearly manifest is needed because
 it is such ancient and is, even yet, such almost  universal  be-
 lief, that  small cavities should, as a matter of course, be filled
 with gold, and that it is an  equally frequent deduction that
 some cavities are too large for that filling material and, because
 of their size, some other material is  indicated, and further,
 that  the limit of size for the one filling material or the other is
 too undecided for the practice of scientific dentistry.
   And yet, the fallacy of the idea that  size had  anything  to
 do with the choice of filling material suggested  itself  to the
 dental mind fully fifty years ago and in no indefinite manner.
   When, after what he thought sufficient experimentation
 with his gutta-percha stopping Dr. Hill concluded to offer it
■ as a  filling material,  he said that while  he had no idea that it
 would  supercede gold  he nevertheless believed it  could  be
 advantageously used, instead of gold, in many cavities.
   Together with this hinting that gold had  not, at that com-
 paratively early date, proven to be all  that could be desired,
 it was suggested that the color of Hill's Stopping was a desir-
 able  attribute in certain cavities in  front  teeth  in connection
 with which a considerable  degree  of freedom  from attrition
 would add much to the duration and consequent value of  the
 filling.
   There  was no mention made as to the size of such  cavities,
 but in the later 50's it had been noticed that the smaller  the
 cavities the lesser the loss of the  Hill's Stopping from attri-
 tion, which result was recognized then, as now,  to be its vul-
 nerable attribute. 
5
   In contradistinction to these small cavities it was soon found
of exceeding value on what were then regarded as  enormous
cavities in the buccal faces of lower molars,  and especially in
cases where by repeated failure  of gold fillings  the  cavities
had increased in  size until, as it  was said, "they  were rather
too large  to be filled with gold on the score of expense."
   So  it was that, as  Dr. Hill had said, "in many cavities,"
small and large alike, a choice of filling material seemed  desir-
able, and  thus the idea grew that the  size of the cavity was
not only not a controlling factor in the making of this choice,
but that it had little to do with it ; and then as both  small fill-
ings and large fillings of both gold and  gutta-percha had been
proven to be eminently serviceable under certain circumstances
it finally began to dawn upon dentistry that this  "little"
amounted practically to nothing.
   It was at  this time  that  amalgam again came  to the  front,
and under such respectable auspices as to warrant  its imme-
diate and  enthusiastic reception.
   This  material,  easy  to prepare, easy to introduce, easy  to
smooth  and finish, and absolutely resistant to attrition and the
fluids of the mouth,  being recommended by one whose official
position  was  that  of President  of the  American Society  of
Dental Surgeons, and who was known as a " most earnest and
indefatigable worker,"  it is not  strange that its  use was not
then regarded  as confined to " lazy men "  and " quacks."
   But  again  it  was demonstrated  most markedly  that the
association of size of cavity and choice of filling material was
dominant  in the dental mind, for, while amalgam was freely
accepted as  the " Succedaneum " for gutta-percha stopping it
was, by no means, accepted as such for gold  in any other than
large cavities,  except by very few.
  These were those  who  had  already  noted the decided in-
crease in length of service given by "Hill's Stopping" as con-
trasted with gold in certain kinds of teeth which in those days
were said  to be "prone  to decay. "
  In these,  then, certain men who, as experience has proven,
were  in  advance of their fellow  practitioners,  substituted
amalgam for gutta-percha in the small cavities in which the
latter had been found to do service until by  attrition and the
action of the fluids of the mouth it had been  worn out. 
6
   That this is so is definitely proven by an extract from the
 speech I made before the  New York Odontological Society,
 November  20th,  1877, (note,  if  you please,  that  this was
 twenty-two years ago!) relating to small cavity work  and to
 the sarcastic remark regarding "the pin-head cavities in cen-
 trals filled  with amalgam by Dr. Clowes" following this refer-
 ence by an assertion, based upon an experience then, of more
 than fifteen years of carefully tabulated results, that I "would
 rather have one  of  Dr. Clowes' 'pin-head' amalgam fillings
 in one of my centrals" than  to have  such fillings as  it had
 been demonstrated  would permit repeated recurrence of decay.
   But leaving the matter of  size of cavity  out of the  question
 it was soon found that amalgam, though quite sufficiently
 proven to be  a  valuable "succedaneum"  in such  cases, was
 undesirable in view of its practically universal discoloration of
 the surrounding structure of such "prone to  decay" teeth,
 and it  was  this result which  soon led me to the experimental
 "lining" of cavities  in  the  early  6o's  with  the  then new
 "Sorel's Cement," the first of all the  "Oxy-chlorides."
  Although large cavities in  molars and, even more, in bicus-
 pids were thus filled and, as was promptly shown, most ad-
 vantageously, this new device was immediately utilized  in the
small cavities as well as the larger ones in incisors and cuspids,
thus continuing the elimination of size as a factor in the choice
of material  for the filling of cavities from dental decay.
  Size of cavity has nothing to do with it.
                      [part third.]
    THE second proposition in the study of the choice of proper
      filling material is, that The accessibility or relative
inaccessibility of the cavity has something to do -with it.
  So many considerations are important to the full apprecia-
tion of  this proposition  that  a complete discussion of our
subject  is essential to it, nevertheless so much  may now be
said upon it that can be utilized, and  so comparatively unim-
portant to the final accurate selection of filling material is this
"accessibility or relative inaccessibility of the cavity" that its
discussion in this, its proper place, is desirable.
  It will be recognized first, that the manipulative attributes 
                              7
 of the various filling materials proper, as well as of the adjunct-
 ives when these, for any reason, are to be tested as  fillings in
 special cases, are as widely different as is the manipulative
 ability of those who propose  using them, and, as the proper
 recognition of our  second proposition depends upon both an
 exhaustive knowledge of these attributes  under all circum-
 stances, and that just appreciation of  one's own manipulative
 ability, which is to be gained only by long-continued observant
 experience, it will be seen that the something which the access-
 ibility or relative inaccessibility of the cavity has to do with
 the choice of filling material is not the simple factor to deter-
 mine which it might at first seem to be, but that it is, perhaps
 more  than  any other,  that  one  which  depends upon the
 individuality of the operator.
   Thus it is that in a case in which gold would be "the proper
 filling material," an operator  might decide that "under the
 circumstances" amalgam would be the material to use; while,
 on the other hand, in  a case in  which amalgam would be
 decidedly "the proper filling material," the  knowledge  that he
 could introduce  a good gold  filling  into that cavity might
 decide him to use that material.
   In neither case would the proper material  be  used, but in
 neither case would it be recognized by the  operator that  this
 was so, while again "all round excellence" would feel compe-
 tent to use gold properly, and  thus  to  the best interest of his
 patient, even "under the circumstances" in the first instance,
 and as well, it would use amalgam iu the second instance not
 because of the difficulty of the introduction of the  gold, but
 because of its knowledge of  other considerations which made
 amalgam the "choice for a proper filling material."
   And thus it is, again, that while  the discussion of this sec-
 ond proposition  brings its accurate appreciation under that
 delicate control which is known as "self-estimation," it is for
 that very reason a factor of varying influence, one which may
 be so unfortunately admitted as to make the decision for the
proper material erroneous, and yet one which just in proportion
 to  the  ability  of the  operator in  all directions, makes  it a
 "something" which  has its  place iu determining his  final
 choice.
  The third proposition  is that " The  location of the cavity 
8
 has a GREAT deal to do zvith it."   Under  this heading  the
 subject opens  up more extendedly, and seems rather to call
 for a monograph instead of curtailing its discussion to a maga-
 zine article, for it will be found that this  "great  deal"  is
 certainly so.
   The time  is not in the far-distant past when the  idea that
 the location of the cavity had, practically, everything to do with
 the choice of the proper filling material,  and "location" was
 divided, as Solomon  proposed dividing the  contested infant,
 into two.
   Tbis division consisted (and I think I may say consists)  in
 assigning gold to all cavities in front teeth,  and anything one
 thinks best to cavities in back teeth.
   Is not this a scientific  treatment of the proper choice  for a
 filling  material?  and yet it is well known that this is so.
   And upon what grounds has this division been made? first,
 upon  the   ground of  appearance, it being accepted that gold
 fillings, both small and large, present  the  best appearance of
 any that can ordinarily be made in the anterior teeth; second,
 upon  the   fact that gold  exceeds all  other filling  materials
 except porcelain in its maintenance  of  integrity  both  as  to
 color and  perfection of finish; and  third, that per se fillings of
 this material would not discolor the teeth.
   it was recognized as unfortunate  that much skill was  abso-
 lutely  necessary for  the attainment of  perfect results; that
 much time was  needed for  the introduction  of  the fillings;
 that much infliction,  or at least  inconvenience,  to  patients
 was attendant upon such work, and that much expense was
 necessarily entailed—but—"if the best was desired  that was
 the best."
   Regarding the back  teeth, great latitude  was permissible
 in all  these directions; appearance was a matter  of  not vital
 importance; the non-maintenance of integrity as regards either
 color or polish  could  be permitted, and even tooth discolora-
 tion was not intolerable.
  The  bicuspids, especially those of the upper jaw, occupied a
sort of "debatable ground" which,  under the control of  these
 same considerations secured for them gold, if it  was desired
 and could be  paid for, or amalgam,  gutta-percha or "white
 filling," as "the next best." 
9
  My own experience during  the  past  forty years has led me
to view all this practice with nothing less than amazement,
and it has been  one of the chief joys  of my  professional life
that I have had such opportunities to teach of all this from
such  totally different standpoints.
  That I have done this in no half-hearted  way is, I am glad
to know,  gratefully appreciated and acted  upon  by hundreds
of  practitioners,  but  these  are   even yet only the  leaven,
which I trust will, in time, leaven the whole loaf.
  That "the location'''' of the cavity has a great deal to do with
the choice of proper filling material  is patent to even small
knowledge of the requirements, but that any tooth,  or parts
of the entire denture, are entitled to special consideration I fail
to see.
   That every attribute of every filling  material, and, if needed,
every attribute of every adjunctive material should be recognized,
and, if required,  utilized, is what I should teach as the basis for
the choice of proper filling material for every cavity of decay  in
every tooth.
                      [PART FOURTH.]
    HAVING thus given the basis for the choice  of proper fill-
       ing material for every cavity of decay  in  every tooth it
will readily be seen that any such  dual division as has  been
referred to  would not only  be  unwarrantable but  would  be
unworthy of the least consideration; and it is from this fact
that I desire to so present it as that it shall be promptly recog-
nized  as  having no place  in the  theories of dentistry  and,
surely, no place in dental practice.
  Take, for instance, a cavity on the buccal surface of a lower
molar  of excellent  quality; a cavity which  has,  for various
reasons, been permitted to become very large, and which is now
attended to only because of the trifling uneasiness which is
annoying.
  Why would not gold be the  material par excellence  for  the
filling  of that cavity ?   And would the  fact that  the  time
required for the introduction of a filling of that material, and
the expense necessarily entailed by its employment, either sep-
arately or combinedly, prevent  the patient from having what 
IO
would truly be the best, make the utilization of  any other
material the " proper " material for the filling of that cavity ?
Surely not.
  It is true  that  "circumstances" would make the employ-
ment of some other material advisable and perfectly justifiable,
but whatever material is then used it is the second best, or third
best, ox fourth best, as the case might be; and then  does it not
become even more apparent that, as the proper material is not
to be used, an exhaustive knowledge as to the attributes of all
the other materials can alone  suffice to make this substitute
choice, of the greatest possible service to the patient ?
  If amalgam is chosen is it essential that it should be a " good
color keeper?"   Is it essential that it should be exceedingly
resistant under pressure, when it is to be placed in  such posi-
tion as that  hardly any pressure will ever be  brought to bear
upon it ?  Is it sufficient for the operator  to  know that it is
made from a "Gold  and Platina"  alloy, or from a  "Gold
Alloy ! " or  from a " Crystal Diamond Edge " ! ! alloy ? is this
the kind of knowledge that ensures  to  the patient that  the
second best  is second best?—I should  say not.
  If gutta-percha stopping is the material decided upon, from
the belief of either operator or patient that mercurial fillings
are  injurious to health, is it not essential that a durable article
should be chosen and that this  should  be manipulated by  the
best known methods,  and how can these ends be attained
unless the operator is capable of " testing " his material and
is conversant with,  and is possessed  of, both  methods and
appliances ?   Not infrequently gutta-percha stoppings in such
cavities are worthless in a year or two, while again such fillings,
in such location, will maintain  their  integrity and perfectly
preserve the teeth for ten, fifteen or even more  years.
  Is it to be supposed that  these  results are purely  accidental,
and if such  is the supposition, is it creditable to dentistry ?
  Is it not vastly more reasonable to conclude that  in  the  one
case the requisite knowledge is not utilized, and in the other
it is decidedly in evidence?
  And when, as is sometimes the case,  a greater deviation
from the proper material is illustrated in the using of one of
the zinc plastic " adjunctives " is it not all-important that the
operator should know that this  filling is purely  experimental 
II
and that while it may last for years, it may be practically worth-
less in a few months, and that he should so inform the patient?
  And again is it not essential that the operator  should know
what it is he is  using ?  Whether  it  be an oxychloride  (so-
called) or a zinc-phosphate (so-called) and, if  the latter, as to
whether it is an oxy-phosphate,  as all of these  materials are
usually designated, or,  whether it is a properly  nitrated pow-
der,  and as such likely to give a better result ?
  Thus it is that location even in posterior cavities, has  a great
deal to do  with  choice of filling material.
  But now let us have a small cavity  in the  distal  face of a
right upper lateral incisor; the tooth is  a  frail  one; the  left
upper lateral  has already, even  in young  life, given decided
evidence  of predisposition to decay;  it has been twice filled
with gold, and the present filling, though somewhat defective,
is evidently the work of a fine operator.
  This is no overdrawn picture; on the contrary there are few
dentists of reasonably  long experience  that  have  not seen
such, and many have seen many!
  Is this cavity to be filled with gold ?
  Would  it not be better to try the experiment of a  gutta-
percha filling ?
  And would the gutta-percha filling be any more an  experi-
ment than  had been  the gold fillings, one of which  "experi-
ments " had failed, and the other of which was failing?
  This is  a small cavity; is quite accessible; is in a front tooth;
and  is gold—simply gold,  without  any  "adjunctive"—the
best material  with which to fill it?
  Would any one of us prefer to have this cavity so filled if
the tooth, and the experience, were ours ?
  And if  I have shown that gold would be the proper material
for the buccal cavity in a lower molar and that it would be an
improper material for a distal cavity in an upper lateral incisor,
it cannot   but be  admitted that location, whether anterior or
posterior,  is entitled to great consideration in the making of
the decision as to the choice of proper filling material.
  But more than this, when location is taken from mesial,  dis-
tal, buccal and lingual surfaces and is transferred to the morsal
surfaces, to cusps and  to edges,  then  the large  dominance of
resistance to attrition has to be admitted with all its narrowing 
12
complications;  appearance has to be regarded or  put aside;
maintenance of integrity as regards both color  and  finish is
of great importance or of little or no moment, all dependent
entirely upon location and all equally subservient, wholly or in
part, to the ability of the result to withstand the wear  incident
to mastication.
  This is a problem to be solved  only by the "ideal " filling
material, but until such  is obtained  it remains one of the most
important and most difficult endeavors of operative dentistry,
and as such it calls most loudly for that k?wwledge of every
attribute of every filling material which  I have stated to be
essential to the peifeet choice of the proper  filling  material in
each and every case.
  '' The location of the cavity has a GREAT deal to do with it."
                       [PART FIFTH.]
    THE fourth proposition is that " The depth of the cavity
      has much to do with it."
  If ever the word  much  meant much !  it does so in its con-
nection with this fourth proposition, for we have now arrived
at that parting of the ways  when the  whole future of any
tooth rests with the  decision of  the dentist as to what  is the
proper material,  or  materials, with which  to  fill  any given
cavity of decay as dependent upon its depth.
  Recognizing as "  superficial caries" only that form of decay
which admits of advantageous removal by files, burs, disks or
chisels, we  begin our consideration of depth of cavity as per-
taining to " simple caries," and it is here that the " parting of
the  ways"  begins,  and here that in a largeness  of degree,
seemingly but little appreciated, the future of the  tooth  is
under the control of the dentist who fills this cavity.
  It is just at this  condition of things  that cavities of very
small size in front teeth of structure decidedly below medium
have been filled with gold by the hundreds of thousands, and
this notwithstanding the  periodic recurrence of decay and the
palpable worthlessness of these fillings in from  three  to five
years from the  date of their introduction.
  These cavities are returned both larger and deeper.
  Again larger, and yet " simple  caries" cavities in just such 
teeth  are  filled, by some,  with amalgam with the idea that
as gold has proven  inadequate to the making of satisfactory
results, it would be well to try something else;  the amalgam
is  chosen  without any  knowledge as to the components or
proportions of these in the  alloy ; without any knowledge as
to its maintenance of color, a knowledge so very easy to obtain,
one of the most important,  perhaps the most important!—of
its attributes,  and without any other  knowledge, in fact than
that the alloy is the cheapest, or else, is the highest priced—for
a high price  is warrant  for great respect from  some among
those who do not know.
   In longer or shorter length of time these fillings return more
or  less discolored—sometimes  darkened  to  blackness—and,
again, sometimes, with so much contiguous darkening of the
tooth  structure  as  to utterly  ruin the  appearance  of  any
denture.
   Are not these illustratious sufficient to show  conclusively
that in even the smallest cavities, with the most shallow depth,
a proper choice of filling material is  that which enables the
dentist to literally hold,  largely,  the  future of the tooth "in
the hollow of his hand?"
   But it is as  the cavities increase in  depth that  the  responsi-
bility  of  the dentist increases apace  until at last the proper
preparation and filling of  the  deepest of these,  affords, as I
VIEW IT, the highest possible test of supreme dental knowledge and
skill.
   All along this "way"  the  need for accurate  knowledge is
exemplified so markedly  that the wonder ceases, that  so much
trouble,  dissatisfaction, pain  and  loss of teeth  attend the
effort  to   "save"  them,   and  that  general "experience"
points  to the artificial denture as the  sign  of  the  goal for
comfort.
   It  will readily be recognized how  largely dental pathology
and therapeutics enters into this work  as factors, seemingly,
all important, but, with that knowledge which alone  can give
that  acceptable,  non-inflictive and most truly  "thorough"
preparation of the cavities of varied  depth, in teeth of  varied
structure, all  is, practically, for naught—absolutely for naught
—without that further  knowledge  which  gives the  proper 
14
material or combination of materials,  with which to fill com-
fortably, most permanently and altogether most satisfactorily,
such excellently prepared cavities.
  I have said it is as cavities increase in depth that the respon-
sibility of the  dentist increases in degree, but how extended
is the discussion which shall show  this clearly and in all its
positive importance.
  All  the gradations from  "simple  caries" through "deep
decay,"  "very deep  decay,"  "almost  exposed pulp"  and
even  to " exposed pulp"  itself must  be thoroughly appre-
ciated,  thoroughly understood  and  thoroughly acted upon
before it can possibly be recognized  how completely everything
of the future of  all this work depends not  only upon what
these cavities are filled with, but upon how the proper materials
are manipulated and utilized.
  And is it to be supposed, for a moment, that such work is a
simple thing; that  knowledge for this is easily  and  quickly
acquired; that ability to do this is an attribute usually pertain-
ing to any large proportion of those who  profess to practice
dentistry ?
  From my standpoint I am compelled to say that I think not;
and it is because of this thinking that I  feel moved to urge
attention to,  and recognition of this need for closer and more
decided thought of this, and that I use  the pages of  our jour-
nal to further impress that which I  have  tried to teach from
my lecture-stand and  to  illustrate and  demonstrate to  the
smaller classes in my "little Clinic  Room "—I know of no
other line of dental work that begins to compare with this in
need for accuracy and extent of information regarding so much
that is essential to the daily requirements of dental practice,
and when I speak of dental practice I  do  not mean  that usu-
ally given and received as such, but I mean that practice which
dentistry is  capable of giving, and  which is in  very truth a
" boon to suffering humanity "—a welcome refuge in time of
dire distress.
  All this seems to me to rest upon  that complete recognition
of everything which pertains to any tooth that is less or more
decayed and yet is wholly vital; and  all this, again seems to me
to rest, at last, upon the final work  of the filling of the cavity.
  This is the battlefield upon which war is waged between 
15
those of one side and those of the other in every minute par-
ticular; it is here that every so-called "principle of practice"
is extolled  or  condemned; it is here that every method, and
indeed every minutiae  of practice has  its champions and  its
antagonists; it is here that it seems " doctors must disagree; "
then who shall decide?
  The " treatment of the dental pulp " upon which papers are
so constantly written, is child's-play compared to that which
is intended to forestall all need  for any such treatment, and it
is  just because this is so that the " treatment of the pulp"
becomes a  necessity.
  And yet, with all this unquestionably so, does it not become
patent that it  is all the more to be  desired that  some order
should be brought out from this seeming chaos and that every
effort should be earnestly directed to the end that  such points
as can be positively decided should be settled.
  To this  end all should contribute, but, to contribute  with
contribution that has value, one must educate for the wotk,
and it is this which I feel to urge, and for  this I  say that, in
my experience, no one thing is of so much importance as knowl-
edge of filling materials and of the adjunctives to this 7cork.
  But with this I wish  it to be distinctly  appreciated that I do
not  in the lease undervalue that knowledge which  I  have
referred to as dento-pathologic and  therapeutic,  for I regard
this as the foundation for all accurate work in  this connection,
but I also  desire to make it positive that with all this the final
result is largely,  if not  almost entirely  dependent  upon the
proper choice, in each  instance, of the  filling material,  and
that this choice becomes, more  and more, difficult to make in
proportion to  the depth of the cavity until, with close approach
to pulp, associated with  adverse  temperamental  attributes, it
becomes that  complex  utilization  of "materials" and "ad-
junctives " which is, par excellence,  the  problem of operative
dentistry—for upon success or failure depends the entire future
of the tooth. 
i6
                       [part sixth.]
    THE fifth proposition is that " The structure of the tooth
      has MOST to do with it."
  We have now reached  that part  of our  subject which may
be truly regarded  as the all important, for whether a cavity be
small or large; whether it be accessible or relatively inaccessible;
whatever its location and  whatever  its depth the consideration
of the  structure  of the  tooth is  paramount.   This,  at once,
places discussion under four heads :
  rst.  Teeth that are very dense and sensitive.
  2d.  Very dense without sensitivity.
  3d.  Very soft and sensitive.
  4th. Very soft without sensitivity.
  It is now that the Third Article of the New Departure Creed
becomes  our text,  for compatibility or incompatibility between
filling  material  and tooth-bone has to  do entirely  with  the
structure of  tooth  tissue.  In my paper  to our California State
Dental Association, 1899, I concluded  by  saying that it  was
sent partly " to prepare the way for a future communication to
our  Pacific Dental Gazette upon the  "Consonance of
Potential" and  the specified using of given filling  materials
for the "compatible filling of teeth  of  varied structure," and
it is to  this  point that, by systematic gradation,  we  have
come.
   "Consonance  of Potential,"  what do  we mean  by this?
What is  " Potential?"   Probably the  most concise  definition
that can  be  given is that from Webster's High School Diction-
ary,  which, though old, yet seems  to cover  the ground, with
all its modern  complications,  "Potential, existing iu possi-
bility, not in act."  It  is then a state  of existence which is
capable of development into actuality under certain influence;
it is  possession of attributes; it is its power  to be itself.*
  It seems to me  that  this series  of definitions gives to the
term " Potential " a tangible something, which, as it is every-
thing to each thing it is necessary we should accept  clearly as
   *Note— In my lectures I used to say, " It is that which makes anything itself,"
but in recent discussions, having asked suggestions as to possible modifications of
thisfinalily, my friend, Dr. L. Ashley Faught, proposed the change to "its power to
be itself," which I have accepted as more positively definite. 
                             r7
such in order that we shall have a  solid basis upon which to
build.
  As potential, then, is  " the power of each thing to be itself,''
it must be through this that any and every  change to this self
must be effected, whether it be a building up, a breaking down
or an apparently simple maintenance of integrity.
  Now, what influence and what alone can exert such power
as to cause to act these dormant possibilities?  Can any other
than  the potential  of   some other thing ?  And what  can
eventuate in producing these results other than the difference
in potential between the two f
  Thus, then, it must be that the nearer  alike any two poten-
tials are  the greater would be the "consonance"  of these
potentials and possibility  of harmony; while, on  the other
hand,  it equally  must  be  that  the greater the difference in
potential the greater  would be the  " disonance"  of these
potentials and consequent producing of "clash."
  Dependent, then, upon what is desired is the question as to
whether consonance or disonance of potential is  desirable.
  If, for example, a current  of electricity  is desired  for  any
purpose, it  would ensue  that  the greater the difference in
potential between  the anode and cathode the more satisfactory
would be the result.
  If, on the contrary,  stability is the  object  desired  in  the
bringing together of potentials for any purpose, it  again must
be that so far as  is compatible  these  potentials should be in
consonance.
   In the former "clash"  would be the  desideratum ; in the
latter  " harmony " would be the condition to be obtained.
  The former would be illustrated by the juxtaposition of zinc
and copper,  zinc  and platinum, zinc and  carbon, or  by the
transformation,  by  proper appliances,  of the energy of the
steam  engine or the waterfall.
  The latter would be  illustrated by our choice of red cedar
rather than  hemlock for our fence posts.
  And now it becomes  needful that, as in the early considera-
tion of our subject, we  should proceed carefully, step by step,
until  we have reached the teeth  and  the  various  filling
materials and adjunctives we would  utilize for the saving of
the variously structured dentures given into our care. 
i8
  I wish to emphasize  here  the  word saving, as it is so often
deemed synonomous with filling.
  The first article  of the New  Departure Creed  leads thus :
"In proportion as  teeth need saving, gold is the worst material
to use, "and this has been  travestied  by would-be critics into
" In proportion as  teeth need filling gold is the worst material
to fill them with."  With the most  appropriate  query, "Do
not all decayed teeth need filling ? "
  Comment seems needless even here, but I  am desirous that
thought should be given such points as we pass along.
  Filling is filling, but saving has been proven to  be a very
different thing,  as masterpieces of manipulative skill have
declared  themselves impotent while  other  efforts  evidently
inferior from the " filling " standpoint, and even doubted when
done, have declared themselves equalto the emergencies.
  It is next for us to recognize that no potential can  be known
other than as a mere existence  until it  is tested;  and, again,
that facts of observation are the  foundation upon  which to
build theory, and  that whether the  theory  prevail or fall the
facts remain the same, for ii  they do not they are not facts.
  And, further than this,  it  must be remembered that no
potential is fully known, no  matter how much is known of it,
as any tomorrow may give evidence of far more wonderful
potential pertaining to  anything than has heretofore  been
deemed possible to the most  remarkable.
  That all  these considerations  pertain  to dental  thought and
work is admitted by all thoughtful and working dentists, but it
is known to them alone, and only so because they have given so
much thought and work to them.
   A  familiar  illustration of this  is  the immense amount of
experimental work which has  been given to the production
of an "ideal" filling material, and the  ignoble failures which
have, thus far,  resulted from these efforts.   And this, again,
is accentuated  by the knowledge that it has proven  vastly
more difficult than some of the very abstruse and singularly
varied  demands of photography, and  that, as its incentive,
there are "millions in it."
   To  what alone can this  be  due?  Manifestly to the com-
bined potential of the teeth  and of the fluids of the  mouth.
   It will be seen that every  paragraph of our discussion brings 
                             19
us nearer to our point of destination, viz., the consideration of
the varied potentials of teeth; of the fluids of the mouth; of
their concomitants; of filling materials, and of the adjunctives
used in the endeavors to arrest  the progress  of dental caries
and supply an acceptable substitute for such  tooth  tissue as
has been lost.
  It is one point upon which all  dentists are agreed, that no
filling material,  nor any known combination of filling materials
and adjunctives can, in anywise,  be regarded  as " the ideal
filling," and it must be admitted that, under these'circum-
stances, the results  which clinical  experience  has proven
attainable in efforts to save teeth of every variety of structure
is most creditable  to dentistry.
   And it is just here, in this connection, that it seems proper
to ask if this general advance in saving effort does not pertain
markedly to the last twenty-five years?
   I would ask if operative practice has not, during that period,
so changed as to be unrecognizable from old-time standpoints ?
   I would ask if the results, in  lines  of work that twenty-five
years ago would have been deemed  by the  vast majority of
dentists as  unworthy  of attempt, are  not eminently  satis-
factory ?
   I  would  ask if this increase   of success,  where success
seemed almost impossible, can  be  attributed to an equally
decided increase in manipulative skill?
   Is it to be supposed that  " the noble army " of ancient days
would  admit this, or that  the  representatives  of " wonderful
progress" would  think of claiming it?
   And, if the  first  three  of my queries  are  answered as I
should answer them—yes !—and  the last  two are answered as
I should answer them—no !—then I  would ask, to what is all
this changed utilizing of means and methods and this increase
of saving of the dreadfully soft, poor structured teeth due ?
   To which / should reply that  it is because of the rapidly
growing increase  in the utilization of materials more  facile of
manipulation,  and which are proven, experimentally, to  be
more in " Consonance of Potential" with tooth-bone. 
20
                    [part  seventh.]
  IT will be noted that in the classification of teeth from "very
    dense and  sensitive" to "very  soft without sensitivity"
we have every variety of tooth  structure  that  can possibly
exist, as all degrees  of density pertain  to  teeth above medium
in structure,  while all  degrees  of softness  are found in teeth
below medium in structure.
  Beginning, then, ist, with Teeth that are very dense and sen-
sitive, we have a condition in which recurrence of decay is
practically ignored as an event  not to be considered;  but,
while maintenance of integrity of filling material  has always
an  important place in  connection with the filling of all teeth
above medium in structure, we are,  in this extreme of our first
class, confronted with  the paramount consideration of Comfort.
  In such teeth caries  is found almost exclusively confined to
sulci, while other sensitivity is  associated with fractures of
teeth or with abrasions from occlusion.
  These lesions induce, in  varied  degree of severity,  such
discomfort or pain as is incident to irritation of sensitive den-
tine from the usual salt, sweet or sour irritants;  from direct
touch or impact; and  possibly,  in  some degree, from undue
heat or cold.
  The location of trouble having been  diagnosed, an unbear-
able infliction is found to result from the slightest  attempt to
excavate, but  with  the varied  methods and medicaments a
preparation  is finally  effected, and  the  extreme sensitivity is
sufficiently obtunded to permit of the introduction of a filling.
  It is now that clinical experience, that greatest and best of
teachers, soon tells  us that "Justin pro ortion" to extreme of
sensitivity any filling material which, as the result ,of its intro-
duction, produces  impact,  is contra-indicated,  as  sometimes
almost immediately, and always more or less promptly, uneasi-
ness of the tooth, followed with  pain, is the sequence.
   This uneasiness or even pain is almost always promptly re-
lieved by the mere removal of the filling.   It is therefore from
this want  of consonance that gold—or, in some  exquisitely
sensitive  cases, tin—is not the  proper  filling material, so
rendered by the structural sensitivity.
   But as gold is, almost absolutely, the best filling material 
21
 for teeth of dense structure it  may be now utilized by  follow-
 ing the method of fifty years ago for  overcoming that conduc-
 tivity which in very  deep cavities has  proven prejudicial to
 pulps.
   This—applicable only to soft foil—is the introduction of the
 first pellels with very ge?itle pressure and making gradually
 increased condensation until the face of  the  filling has that
 coin-like  surface  so  desirable.
   These fillings—soft as velvet at the bottom, and hard as coin
von the face—did  excellent service  in both  pulp and tooth
 preservation, and are more  a?id more  worthy of trial  in  very
 dense and sensitive  teeth  as the sensitivity diminishes  in
 degree.
   But, inasmuch  as  in extreme  instances, even  this  will  be
 found unendurable,  a greater consonance is found, in zinc-
 phosphate  cement, the  potential of which seems  especially
 adapted for this work.
   As I have, necessarily, to give  fully the attributes of each
 filling material and adjunctive as they are utilized—from the
 fact, as I have shown, that  it is the attributes of anything,
 which is its potential, I shall thus speak of zinc-phosphate.
   It is not to be denied that the  nomenclature of dentistry is
 to  be credited with descriptive, concise practicality, rather
 than  with "scientific accuracy," but there is  no  warrant for
 the almost universal name of "oxyphosphate"  as given to
 those  cements which are the nitrated oxide of zinc products,
 such   as Poulson's,  Fletcher's,  Justi's, Harvard, Dawson's,
 Hammond's, and others of that class.
   It  is true there  are  a  few of these cements which use a
 phosphoric acid menstruum with a calcined oxide of zinc pow-
 der, but none  of these will make a cement worthy the name
 of  "zinc-phosphate."
   If it could be understood that by the name "oxyphosphate"
 was meant some one of these inferior  products, it would  be
 well,  but this name is used  for the  good  and the poor alike,
 which is not just to either.
   There is no oxide of zincin the powder of any properly pre-
 pared  "zinc-phosphate"—not that it might not be possible to
 again  make oxide of  zinc from nitrated oxide but that no such 
22
transformation  is  made  by the  processes  used  in  making
"zinc-phosphate" powder.
   The oxide of zinc is accurately nitrated; this can be done by
adding to  an aqueous  suspension of the zinc just sufficient
nitric acid to clear the milky fluid—this is then filtered and
evaporated until a hard cake of nitrated oxide  remains, this
is broken up, placed in crucibles  and subjected  to  glowing
heat for from thirty minutes to an hour;  it is  then ground to
an "air floated" fineness, as nothing less than this grade  is
sufficient.
   We  are told by chemists that this result is again oxide of zinc,
but this powder has nothing in common with that from which
it was made; its "feel" between the fingers is entirely  differ-
ent;  its color is light yellow instead of white; its  weight, in
equal bulk, is more than twice that of  oxide  of zinc, while its
product, with phosphoric acid solutions, is utterly distinct from
that df the oxide.
   For  these reasons I  hold it not coirect to call "zinc-phos-
phate" oxyphosphate.
   As I have said, the potential of zinc-phosphate  seems spe-
cially  adapted to  the  work of filling,  at least temporarily,
cavities of decay in teeth which combine exceeding sensitivity
with exceeding density.
   This is because, ist, it is  introduced without inflictive pres-
sure; 2d, it adheres strongly to the walls of the  cavity; 3d, it
is not only non-irritating, but its phosphoric acid is accredited
as an  obtunder  of sensitive dentine;.4th, it  neither shrinks
nor  expands, therefore neither impacts nor leaks;   5th, in
places  exposed to attrition its clinical  record for durability  is
remarkable, many such fillings being now good, after from six
to twelve years' service; 6th, in places exposed to the known
solving power of fluids  of the  mouth, the surface  of the fill-
ing can be protected by "combining"  a covering of amalgam.
   From such considerations, then, as  I have given, it will be
noted that gold, tin, lined amalgam or zinc-phosphate are the
materials to be utilized  for  the making  of fillings in the ex-
treme cases of our first division structurally.
   It will further be recognized that in proportion as sensitivity
diminishes, so the  utilization of the more surely permanent
filling  materials  increases  until,  as confidence  is  the  more 
                             23
decided as to the permanent removal of dentinal complications
we  gradually  reach  that condition which "all  dentists are
pleased to see'' and which we find as
  2d.   Teeth that are very dense without sensitivity.
  This is the realm of the "king of all filling materials."
  These are the teeth, most positively,  of the sanguo-bilious
temperament; the dark  yellow teeth, large and  strong, with
splendid enamel, strong  dentine, firmly planted  in the jaws,
which are of the flat-arched type with prominent cuspids.
  It is seemingly natural that such teeth should not be liable
to decay, and that imperfect or fissured sulci should  remain
unfilled, sometimes for a lifetime without detriment, but it is
found, in even these dentures, that certain of the teeth almost
always develop tendency to decay, and  it is therefore, some-
times, that comparatively large cavities are presented  associ-
ated  with which, however, is rarely—very rarely—pain, but
which give inconvenience from collecting food;   from  attrac-
tion toward cavity edges, of tongue; or from mere knowledge
of their existence.
   It is for cavities in such teeth as these, and in  those of the
closely allied teeth of the bilio-sanguine temperament, whether
they be small or large;  whether they be in  front  teeth or back
teeth; whether they be simple cavities or even very deep, that
gold is par excellence, the material with which to fill them.
   It is in these cavities  that gold, even reasonably well intro-
duced, does remarkably acceptable service,  and  that gold fill-
ings, made as they should be, are  likely to  "last a life time."
   It is in these teeth  also that, occasionally "circumstances"
compel  a second choice of filling material, when, with the
alloys of the present day, it would seem as though  amalgam
was the only alternate.
   In years gone by, tinfoil was the alternate, and again, "cir-
cumstances" maybe such  as  even yet to  induce its employ-
ment, for, next to gold,  tin is a most excellent filling material.
   In such teeth, in such  jaws as we are discussing,  tin is un-
equal to the attrition sometimes likely  to be given  it,  but in
cavities where fillings are not subject to direct wear from mas-
tication it makes a durable and entirely unobjectionable filling.
   But the introduction of a tin filling  is, practically, not less
than one of gold, and it is therefore, with the present methods, 
24
almost as much a question of time, while, except in fillings of
more than average size, the actual cost of material is a consid-
eration of comparatively minor importance.
  For  this  reason, then, as  I  have said,  it would  seem  as
though amalgam was the alternate.
  It is  here that these alloys  which are of the "usual"  or
"contour" class, seem  only to be considered,  for these have
now done so ma?iy years of acceptable service in teeth of good
structure that it seems unwise, in this connection, to experi-
ment, and it is therefore at this point that knowledge of amal-
gam alloys begins to have importance.
                      [part  eighth.]
 TT AVING referred to tin as a possible second choice in the
 -*--*-   filling of cavities of decay in  teeth which are "very
 dense without sensitivity," I have  yet said that inasmuch as
 both  time and expense  were the usual factors urging to this
 second choice, amalgam seemed to  be the alternate, and that
 this conclusion brought us to that point in  the  practice of
 operative dentistry when knowledge of amalgam alloys began
 to have importance.
   That this is the beginning is proven from the fact that  it is
 in  such cases  that almost no knowledge  is necessary for the
 accomplishment of what may be called useful results.  Almost
 any alloy, made into amalgam in almost any  way, introduced
 in almost any fashion, will almost  always give  satisfactory
 service, but it cannot be  denied that an appropriate alloy,
 made properly into its amalgam,  and introduced and finished
 as it should be, would make a much better filling and be, in
 every  way,, vastly  more satisfactory and more creditable to
 dentistry.
  It is therefore proper that an alloy should be  chosen  which
 will make a non-discoloring amalgam; one which will make a
 strong amalgam, as, in such teeth it will  be liable  to be  sub-
jected to hard usage, and this again, in proportion  as  the fill-
 ing will  be  exposed  to attrition;   one  which  will make  an
 amalgam that will "set" with celerity, that it may be promptly 
25
finished, and this especially when time is largely a considera-
tion for second choice.
  And is it to be supposed that the advertisements which state
alloy and amalgam attributes should  be  the foundation  upon
which  dentistry should rely for its knowledge in this regard ?
Would it not be better that every dentist should "test" these
things and thus know of his own knowing ?  And wrould it
not be a step forward that society  work  should trend toward
such experimentation as would give  reliable information con-
cerning these materials which are so much to both patient and
operator ?
  It may well  be  admitted that I have not used the word
"importance" as the concluding one  of my last article without
weighing its significance, for, as I view it, knowledge of amal-
gam alloys and amalgam working has grown to be  one of the
most important items of a dental education;  the item upon
which, probably more than any other  one, will depend the
failure or success of any future dental practice.
  I base this opinion  upon five reasons:  ist, because with an
intelligent use of amalgams one can accomplish  far more in
the work of saving teeth than with any one or all of the other
filling  materials together.
  2nd.   Because in despite of all opposition,' misrepresenta-
tion,  inferior  and  objectionable,  manipulation and pseudo-
scientific handicapping, amalgams have so demonstrated their
value as that in the short period of twenty-five years they have
risen from obloquy and comparative  disuse to the position of
the most used of any filling material.
  3rd.   Because amalgam so  nearly approaches the "ideal"
filling  material in so many points,  that,  unless the absolute
ideal is given  to dentistry it will  retain its present position,
and, as it is better known  and better  worked, will  gain in
position as a reliance, even more than it has already.
  In support of this reason one has  but  to compare the  attri-
butes desired for the  "ideal" with those possessed by amal-
gam as made from its various alloys: 
26
    ATTRIBUTES  OF "iDEAI,."
  I. Easy to mix.
  2. Easy to introduce.
  3. Adhesive to cavity walls.

  4. Sufficient  plasticity for con-
tinuous manipulation.
  5. Sufficiently  rapid hardening
after completion of filling.
  6. Possessing good edge strength.

  7. Maintenance of form integrity.

  8. Resistant to  attrition.
  9. Non-irritant to pulp.
  10. Compatible with tooth struc-
ture.

  n. Non-conductive.
  12. Capable of being colored to
match the tooth.
  13. Capable  of being  finished
with enamel lustre.
  14. Insoluble in the fluids of the
mouth.
   ATTRIBUTES OF AMALGAMS.
  1.  Easy to mix.
  2.  Easy to introduce.
  3.  In  combination  with  zinc-
phosphate  this  is  accomplished.
  4.  Sufficient plasticity for con-
tinuous manipulation.
  5.  Sufficiently  rapid  hardening
after completion of filling.
  6.  Not so good edge  strength as
gold, but very fair edge  strength.
  7. Not detrimentally insufficient
in this regard.
  8.  Resistant to attrition.
  9. Non-irritant to pulp.
  10. The most compatible,  in its
variety, of any filling material ex-
cept gutta-percha.
  11. Of low conductivity.
  12.
13-
  14. Insoluble in the fluids of the
mouth.
   It will  thus be seen  that of 14 attributes amalgam quite
 completely meets  12 of them, while the remaining 2, though
 all important to the complete "ideal" are  just those which, as
 yet, have been found absolutely unattainable except in porce-
 lain.
   4th.   Because, notwithstanding the  almost universal use of
 amalgam by dentists, its proper use and proper using is so far
 from general,  as that I may truly say it is very exceptional.
   In support of this it is only necessary for an expert, or even
 one tolerably  proficient,  to witness  its  usual, or  ordinary,
 using.
   From the selection of  alloy, without any knowledge of its
 appropriateness, to the making of its amalgam  in the crudest
palm fashion,  without the slightest idea of proportions of alloy
and mercury, as positively governed by requirements,  to  the
final introduction of the material, sometimes by smooth instru-
ments, sometimes  by those with  serrations, sometimes  cold, 
27
and even sometimes warm !   Sometimes by rubbing,  some-
times  by pressure, sometimes  by tapping and sometimes  by
malleting ! all is indicative of anything, and indeed of every-
thing except either system or knowledge.
   In proof of the  probable  continuance of  this it is only
needed to read the teachings given in the American Text-Book
of Operative Dentistry, pp. 231 to 239  inclusive.
   I regard it as  fortunate that a few are able to  demonstrate
how alloy should be made into amalgam; how  it should  be
worked in the palm make; how it should be introduced  into a
cavity; how it should be "wafered" if watering  is indicated;
how the wafer should be utilized; how the filling should be
trimmed, smoothed and  polished, in the  comfortable, non-
inflictive, prompt and  satisfactory way in which  it  should
always be done.
   I hope the folly of the rubber  dam  accompaniment  to this
work will, poco  a poco, become so evident as that  it will  be
utterly discarded,  for, with  proper   manipulation,  it  is  an
adjunct which is entirely unnecessary.
   5th.  Because the stereotyped  enunciations antagonistic to
amalgam are gradually becoming less in frequency, and, when
given, only evoke a smile, while the  triumphs of amalgam,
properly used, from the wisdom teeth to the median line  of  the
dentures,  are proving it to be "the saving grace"  of  the teeth,
all of which seems to me sufficient warrant  for the continued
belief  that "truth is mighty and will prevail."
   That the proper using of amalgams is a work requiring both
much knowledge and great skill is admitted in exact propor-
tion as one becomes conversant with its demands, just  as the
utilization of a violin or  a  set of chess-men becomes both a
science and an art in relative degree with the users' proficiency,
while the comparatively short, space of time consumed in the
introduction and finishing of  the fillings will be found to give
greater opportunity  for the cultivation of the more scientific
study and practice of dental  pathology and dental therapeu-
tics which, in my experience, I have been led to regard  as the
true "saving  grace of dentistry." 
28
                      [part ninth.]
     HAVING written as I have regarding the choice  of  alloys
       and the making and using of amalgams it would seem
 that such assertions would sufficiently entail the necessity  for
 at least a  few salient directions as  to  methods in this work,
 even though  our papers are strictly discussing merely the
 "choice of proper material"—but comparatively recently given
 "methods" are so entirely at  variance with all that I should
 esteem desirable, that it seems no less than a duty.
  Take, for instance, the method given by Dr. G. V. Black in
 the Cosmos of December, 1896, p. 973: In "part eighth" of my
 Review of  the work of Dr. Black I have given  at length my
 reasons for ranking his method as simply absurd from begin-
 ning to end, but I refer to it  as  accentuating  what I now say
 regarding amalgam using, for, if one who  poses  as a teacher
 adds such teaching, to  that of the  generally  accepted "Text
 Book," it would be strange indeed if amalgams should not be
 dreadfully  misused.
  But these are not alone  in their peculiar educating, for dur-
 ing the Spring just passed directions were given that seemed
 truly the echoes of a long-gone time when lamp-lrghters, with
 their little ladders, made  their rounds and cities were lighted
 by  oil  lamps !
  The conclusion of this method was the removal of excess of
 mercury  by "one or more pellets of tin"; the bringing to  "a
 smooth surface with a soft pine stick,"  or  "with  a pellet of
 bibulous paper  and pumice  held  with pliers,"  and  finally
 "wait several hours /"  for a finish.
  When  we  remember that  "quick-setting"  amalgams have
 been in use experimentally for a dozen  years, and that teach-
 ings and clinical demonstrations  of  them have been given for
seven years; and that these have been  increased in number
 until now there are many accepted alloys that make amalgams
 which  will "set" in from  thirty to  forty minutes sufficiently
to take a burnish finish, it seems odd, to "wait  several hours."
  In the using of amalgam for the  filling of cavities in teeth
which are "very  dense, without sensitivity," I have said that
a quick-setting,  strong, non-discoloring amalgam  should  be
chosen.   This, of course, practically excludes all copper, coin 
29
or other sub-marine amalgams, even though these would un-
doubtedly do good service in cavities in molars where discol-
oration of filling, or even of tooth, would  not be  a  matter  of
serious moment.
  It  would  also exclude  absolutely all so-called "White"  or
"Facing'' amalgams whose chief attribute is maintenance  of
color; I emphasize  the word "chief" here because  although
maintenance of color (with elimination  of injurious compon-
ents  such  as cadi mum)  should be the chief attribute of an
amalgam truly "White" or "Facing" there are yet a number
of alloys which are called  "White"  and which will "test"
well as color-keepers, and yet which possess fair  edge-strength
and which set with reasonable celerity, such as "Dawson's"
and others of that class, but my choice would be  any strictly
legitimate  alloys of the "contour" class, such  as have been
furnished by many makers, and  used for the past twenty
years.
  With such an alloy I should first experiment by weighing
proportions of alloy and mercury  that  I  might  know how,
accurately,  to  make an  average or soft mass of amalgam  as
indicated desirable.
  Even with my forty  years of amalgam using, I am all the
time more and more impressed  with the value of this prelim-
inary; primarily it is of importance just in proportion to the
goodness of the alloy, for  it will  be  found, by experiment,
that  so  tiny  a globule of mercury as would weigh only one
grain will make a decided difference in the mixing and using
of a mass of amalgam of sufficient size for an ordinary filling,
say from 10 to 20 grains.
  For the weighing of mercury and alloy  I prefer a two-plate
scale—with removable  plates—for  with such the globule  of
mercury needed for any given filling is  soon  closely  approxi-
mated as to size, (about two-thirds  the size of the cavity) and
the mercury being  placed  in  one scale the alloy is weighed
light or heavy or equally as evidenced by  the position of the
scale  beam,  and as desired for  any given  purpose for any
given alloy.
  This soon becomes a "habit  of  make"  by means of which
any  amalgam  mass is made as it should be done  for each
special purpose. 
3°
  For example, if certain portions of any cavity should be  so
shaped as to render it important that the greatest edge-strength
possible to the amalgam should  be attained, it is proven, by
testing, that if just sufficient  mercury  to make  a  workably
plastic  mass  is  used and  the mass is allowed  to  make its
natural set the edge-strength will be at its strongest.
  Again, should it be desired that the mass be made more
plastic,  in order  that  greater  facility  and  perfection of its
insertion be  assured to completely fill the cavity,  that  then
a surplus of amalgam, thoroughly made into a "wafer," might
be utilized  to hasten the setting, this should be done in  such
cavities as will be filled with strong square-edged  fillings,  such
as need strength of edge in smaller degree.
   NOTE.—I have been in  the habit of explaining in lectures that the
"increase of edge-strength" referred to as resulting from "wafering"  on
p. 204, "Plastics," was that gained over such as resulted from the natural
setting of soft made amalgam, and not as  a means for making the best
edge possible to amalgam.
  Having then placed upon one scale plate the approximately
sized globule of mercury I should balance it  (light, even, or
heavy) with the alloy and make a mortar mix.
  For this my preference would be  a glass  mortar, delicately
ground, and at once we here begin with the proper, or more or
less  improper manipulation of amalgam,  for, while it  is true
that alloy can be amalgamated in  any kind of a mortar  from
porcelain to India rubber, and indeed in the palm of the hand
(as has been done for almost a century), it is yet easy to dem-
onstrate the advantages of a mortar mix,  and as well, the
advantages of the  ground  glass  mortar over all other appli-
ances.  If for no other reasons than  neatness and cleanliness
the glass mortar would be preferable, but  with an  acceptable
glass mortar every  attribute  is superior to those of any other
kind.
  But here we must admit  the difficulty of obtaining acceptable
glass mortars, a difficulty  which  is so great as,  up  to the
present time,  to practically preclude the possibility  of getting
them.
  An amount of care in moulding them, even  with a perfectly
accurate mould; of exceeding care  in taking  cff a proper pro- 
                             3i
portion of the smooth inner surface, and leaving the "ground"
portion rough enough and yet not too rough; this  is most  im-
portant;  of care in the shaping the ball of the pestle, that it
may properly mull the amalgam and be readily and perfectly
cleaned,  all tend to make a glass mortar and pestle  expensive
or to make a cheap one undesirable.
  Again, the danger of air-cracking is one which seems to be
impossible to avoid, even with the most careful and prolonged
annealing—and yet—with  all these objections, I very much
prefer  the glass  mortar,  and, so  far as  I  know,  those  who
use them agree with this preference.
  Next to the  glass mortar is the "Wedgewood"—and with
these, there is decided choice as  to glaze or roughness, which
also pertains alike to mortar and pestle.
  Besides having  a  mortar for the making of amalgam  it is
essential to use it—and here again   directions  are so varied as
to  be  surprising, while it  only  requires a trial to show  that
thorough and moderately long continued mulling is necessary
for the best making of any  amalgam.  I think it will be dem-
onstrated to nearly every amalgam  worker  that almost, if not
quite, as much again mulling of amalgam mass as  is usually
given will yield a  material of such decidedly increased velvety
plasticity as to be  fully compensating, and I should there-
fore advise the trial.
  Having  made the mortar mix the mass should  be gathered
by the finger from the pestle and mortar into the  palm of the
hand  and is  kneaded  until it becomes a "button."
  As  I  have  written  upon  this  very precisely, and  as this
manipulation, even now, so tests the plastic-filler,  I cannot  do
better than refer to "Plastics" pp.  91 and 92.
  I think  I   have left  it clear that in teeth which are very
dense,  without sensitivity, amalgam, made from proper alloys,
is a very acceptable "alternate,'' or "second  choice" for  the
filling  of their cavities of decay;  and yet I  have left it defin-
ite that,  almost without exception, gold is their proper filling
material.
  The exceptions would  be in enormous  cavities in such
"peculiar^ predisposed to decay" teeth, as  have been referred
to as occasionally  pertaining to such dentures. 
                             32
  I  have also  admitted  that "sub-marine"  or  discoloring
amalgams might be admissible when such discoloration would
not be seriously objectionable; but it now is in place to make
again mention of "lining" which was spoken of  in connection
with' hyper-sensitivity  of dense tooth  structure when  zinc-
phosphate was  to be protected by amalgam.
  Then many reasons were given for that peculiar use of what
was practically a "lining," but I refer to it now  as of but one
use, viz.: preventive of possible discoloration of  tooth.
  As I have permitted  discoloration in  non-conspicuous  posi-
tions so I must insist on its positive prevention in all conspicu-
ous and even semi-conspicuous positions, as it is this possibility
which has permitted the use of amalgam in teeth from centrals
to bicuspids inclusive.
  Lining.—"Consists in covering  the  inner surface of cavity
walls,  either partially  or entirely, with  a thin  stratum of
material which shall subserve the purpose either  of preventing
recurrence   of decay; or  of affording support to  unyielding
filling material  which  would otherwise rest upon  an unsub-
stantial foundation; or  of preventing discoloration from filling
materials liable to tarnish; or of precluding the  possibility of
clouding from leakage;  or of strengthening frail cavity walls."
(See "Plastics," p. 190.)
  It is of the utilization of this method in all such cavities of
deca)'  in dense,  non-sensitive,  anterior teeth,  as from  their
size; or their labial or  buccal proximity;  or the  thinness of
their walls,  might permit of even the slightest discoloration of
tooth-tissue from possible amalgam tarnish.
  For this purpose I should  teach  the  "combination" filling
which I have used now for twenty  years, and can, therefore,
speak  most solidly regarding it.
  "Combination  filling" is the  name which I gave to the
using  of  zinc-phosphate and  amalgam, while both  were in a
plastic condition, and thus were combined, in  contra-distinction
to the "composite"  work  of lining  the  cavity with  oxy-
chloride and allowing it to "set","  and afterward introducing
either gold or amalgam, thus making a filling composed of two
materials, but not combined.
  The advantage of the "combination " over the  " composite " 
33
filling, as associated with very dense teeth is four-fold; first,
the amalgam  follows  the  introduction  of the zinc-phosphate
immediately;  second, there is,  practically, no  danger to pulp
from  the action  of the  phosphate  (if  such exists) as  the
dentine is too dense;  third, tho the tooth-saving  attribute of
zinc-phosphate is not yet positively  known  to  be equal with
that of zinc-chloride, it is yet sufficient for dense tooth-bone,
as such structure rarely permits recurrence of decay, and this
"lining" is  only  to prevent discoloration; fourth, altho zinc-
phosphate is not so hard nor so strong as  a properly mixed
zinc-chloride it is  yet hard enough, and dense structured cavity
walls are usually strong enough even tho thin.
   The fluid and powder having been placed upon the mixing
slab, the amalgam mass (soft), is  made  and  held in the palm
of the hand (see "Plastics," p. 92), while  the zinc-phosphate
mix is made; this is  then placed on the side, or sides, of the
cavity from the point of the spatula.
    Note—The taper point of the spatula is an essential; the round and
square ends of spatulae, so frequently diagramed, are not  only purpose-
less, but with such the use of the point is lost.
   Having thus placed the lining in position approximately, it
is  accurately  brought to the  desired  feather-edge, at cavity
opening, by  the  introduction  and manipulation of the  amal-
gam, which is done deliberately and carefully  to the ends that
the walls are completely lined, and  that the lining is com-
pletely covered, all which is accomplished without any special
regard to the immediate completion of the filling as a necessity,
for it is much more important that the lining  and  the covering
work should be perfect at this juncture, as the remaining con-
cavity of amalgam can easily  be filled  and the  filling finished
by cold soldering (" Plastics,"  p. 177), as soon  as it is  found
that the important part of the  work is satisfactory.
   This possibility is  an immense relief  in all "lining" work
fust in proportion to  the size  and irregularity  of cavity  and
edges; the  relative  inaccessibility of  cavity;  the  incidental
fatigue to the patient and the anxiety of the operator, and is
well worthy  of occasional trial, even in simple cases, that  one
may thus he prepared and confident in times of need. 
/
                             34

                      [part tenth.]
    AI/THO, as  I  have said, all degrees of density pertain to
       teeth above medium in structure, it will nevertheless be
 accepted  that this density  becomes less in proportion  as we
 approach those which are recognized as  " medium."
   But in  this approach we pass the finely structured and well-
 planted  teeth of both lymphatico-sanguine and lymphatico-
 bilious temperaments, in connection with which the teachings
 and methods given, as pertaining to  the bilio-sanguine and
 sanguo-bilious teeth  are practically the same; and yet such
 slight increase of complications as certainly demand increased
 care  from the  pathologic  and therapeutic  standpoints will
 necessarily be in evidence.
   It  will be found  that  teeth of these  dentures  having
 that individual  pre-disposition to decay which has been men-
 tioned as possible to all dentures, will be better saved by
 increased utilization  of plastics as "linings"  associated with
 gold principally and amalgam incidentally.
   I wish it to be noted  that in the  work of filling teeth from
 the saving,  instead of the  manipulative plane, esthetics have
 had as large a share of  consideration  from  plastics  as ever it
 has had from those who esteem  gold as  the esthetic of dentistry;
 indeed it has, from the earliest work of  the '' New Departure
 Corps,"  (which I  claim  to be the beginning of systematic
 plastic  work) been regarded as one  of the  most important
 features of its practice, and it  was in this interest almost as
 much as in that of the  saving of the  teeth that I devised the
 work of "lining, "and it is the consequently great importance
 that I attach to this, which will make me advocate it strongly,
 and teach it minutely in these papers.
  To  impress this  I will say that without its varied "lining"
 work plastic dentistry could do but little more than save  the
 poor  teeth of the  frail dentures, and  of these, mostly  those
 situated posteriorly, while with this work, artistically utilized,
 plastic dentistry can do almost everything required of operative
dentistry, and do  it  with  a combined  beauty and  durability
 which cannot be equaled in any other  way.
  Were it not that, as I have said, I am  writing of that which
 I have for many years taught and demonstrated  in  the  clinic 
35
room and in my practice, it would seem strange that I should
now say this, for  it is no new or untried thing, and  by no
means a new enunciation,  as it is  exactly what I said  more
than twenty years ago (Cosmos, September, 1878),  and what
has been done for many hundreds of patients ever since  that
time.
  And  yet  the denunciation  of this  work continues; the
extolling of that which gave rise  to this is yet indulged in,
and, more than this,  the  status of dentistry, even now,  is
stated to depend upon  proficiency in such manipulation as has
proven itself utterly incapable  of satisfactorily responding to
the requirements demanded.
  It is this which I feel it my duty  to antagonize; this which I
desire to urge thought upon, that it may be stamped out as a
disgracefully mean and narrow  base upon which to place so
broad and  capable a calling  as is the "Profession" which  we
practice.
  Having passed the teeth of the lymphatico-bilious tempera-
ment we have now reached that  most interesting grade  of
tooth tissue associated with our nervo-bilious patients.
  With  these long, narrow-necked,  yellow and blue  teeth,
well-planted, with  hard and polished enamel but  with  that
softly organized dentine so  prone  to  decay and so generally
very sensitive, we find  that tendency to rapid, horny caries,
which gives us large  cavities  with  small orifices, together
with such increased specialization of decay as pertains notably
to upper lateral incisors and upper bicuspids.
  With  this nervo-bilious  temperament,  besides  the  usual
general decay we find, almost as a rule, in comparatively early
life, discolored upper  laterals resultant from primary decay,
repeated recurrent decay and final death of the pulp, either as
a natural sequence or due to  intentional devitalization.
  But more than this the absence of one or more of  the upper
bicuspids is so almost universal, in equally early  life, as  to
have  caused Professor Elisha  Townsend, so eminent  as an
operator, to have given these nervo-bilious bicuspids the name
of the " American teeth."
  And  this condition of things, so conspicuous in his day,
forty or fifty years ago, is but little less so today.
  This then was one of the problems for plastic dentistry, and 
36
it has been solved with highly gratifying results; the dentures
of those patients who have always been under such treatment
as I advocate in  these papers, have practically  no discolored
laterals, and usually have all four upper bicuspids; while even
those with such teeth as have experienced primary decay, land
even  one or  two recurrents,  yet have their teeth  and with
scarcely any indications of all this previous trouble.
  It is with these teeth, then, that with  their primary decay
we can commence  the utilizing of their excellent enamel for
the maintenance of both form and appearance;  and especially
with  them that we can continue this conserving practice as
the enlarging of recurrent decay gives us even  greater dis-
proportion between the cavities  left  by  decomposed dentine
and the orifices of these, circumscribed by overhanging enamel.
  It will readily be admitted  that for a gold preparation it is
well made just in proportion as all this enamel is removed and
strongly  finished edges given to the cavities.
  This necessarily makes large and larger fillings, while with
the lining process  the  enamel walls are sustained instead of
having to  sustain, and  are strengthened by support,  instead
of being weakened  by pressure from impact.
  And, besides all  this, the  color of the tooth  is accurately
retained  by the  choice of an  accurately shaded lining, thus
adding greatly  to the  beauty  of the work.
  It is with  these  teeth that the  complications of vital pro-
cesses with pathologic, therapeutic and  operative dentistry,
not only begin  to be  simply immense, but that possibly they
cover an extent wrhich is, at most, rivaled rather than exceeded
by the demands  of conditions pertaining to "treated" teeth.
  We have here, as a first consideration, the conservation of
the pulp, and this, which in all previous work has been a com-
paratively  easy  matter  to  even  ordinary  proficiency, now
becomes  a difficult matter, greatly increasing in difficulty with
every degree of approach to pulp, and with every diminution
of systemic ability, for, we have now a temperament {and con-
sequently a pulp) which  is not only  markedly  and  promptly
recuperative, but which also may be markedly  and promptly
the reverse.
  It i?, therefore, in these teeth that the conservation of  de- 
                             37
calcified dentine is as important, in its way, as  is the conser-
vation of enamel for the reasons already given; and thus it
will be seen that we are now controlled largely  in our choice of
proper filling material by  our decision  as to what we will do
with the decalcified dentine.
   It is now more than forty years since, as the result of  much
argument, Prof. Robert Arthur convinced me that, theoretically,
the leaving of decalcified  dentine in the cavity when its re-
moval would endanger the integrity of the pulp (even in less
degree than exposure) was the only proper  practice.
   Believing what  he told me  of his results during  ten  years
of experience, I commenced  that clinical  testing  which, for
me,  could alone confirm or disprove the solidity of his teach-
ing, and, as I refer to what I wrote  twenty-five years  ago
{Cosmos, November, 1875, p. 564) I  clearly recognize  how
much more cordially the experience of the added twenty  years
enables me to urge the leaving of the decalcified dentine even
in greater quantity than was ever  advocated by my esteemed
teacher—Prof. Arthur—and especially  in just  the teeth  and
kind of structure we are now discussing.
   At this time (as then) I shall sufficiently  define my own po-
sition by the statement that, as the result of all these (forty)
years of experience,  I  find quite frequent necessity for the
adoption  of  the practice,  and have  many  hundreds  (now
thousands) of teeth which today are rejoicing their possessors
by their natural translucency, instead  of increasing the  num-
ber of the host of discolored  teeth which are  the  results of
what is known as  " thorough '' excavation.
   That I may  be  clearly placed on record in  this regard, I
wish to teach—as  I have  done for quite a number of  years in
lectures—that all pulp  considerations  in connection with the
leaving of decalcified dentine in cavities  of decay  pertaining
to soft-structured teeth, have long since been ignored, unless
in exceptional  instances  of  " very deep " decay,  while all
thought^has been given to filling integrity.
   This principle of practice has therefore given the  formula
" conserve all decalcified dentine consistent  with integrity  of the
filling."  Upon which principle I have practiced and  cliniced
for so long a time  as to have sufficiently  demonstrated its im-
mense value. 
38
   In this connection, I have found the oils of cloves and cin-
 namon my best reliance for both disinfection and  antisepsis;
 while periods of time varying from fifteen to thirty-five years
 amply testify as to their durability, and to the important part
 which they exercise in their permission  of re-calcification of
 decalcified  tooth tissue.
   This point, as associated with the work of recalcif cation of
 decalcified  dentine is so important that I wish not only to im-
 press it but to make it perfectly clear.
   It is therefore to be recognized that only corrective applica-
 tions are to be made with reference to existing conditions and
 by no means are any medicaments to be used which can possi-
 bly interfere with such desired  future action  as is entirely
 under the control of vitality.
   With these thoughts in view the first indication  is to cau-
 tiously remove the contents of the cavity  of decay,  recogniz-
 ing  that the basal boundary  of the cavity is  that  portion of
 remaining dentine which is merely more  or  less decalcified
 and equally more or less responsive  to either litmus or  tur-
 meric paper as it is ?ww hyper-acid or hyper-alkaline.
   If hyper-acid the treatment for neutralizing this  condition
 is, of course, governed by its degree, and calls for applications
 of prepared chalk or bi-carbonate of  soda, slightly moistened,
 or of aqua ammonia fortior  applied with  precision,  and with
 due  regard  to its pungently irritating evaporation.
   If hyper-alkaline the application for a minute or two of di-
 lute vinegar (one to two or three of water) is usually  suffici-
 ent to induce a neutral response and there  then  remains only
 the consideration of the concomitant micro-organisms which
 are the attendants upon decay and which are so strangely and
 so erroneously taught as its cause!
   "Disinfection "is simply the prompt and energetic antagon-
 izing of these organisms in infectious matter or  tissue;  " An-
 tisepsis " is intended to prolong,  as  indefinitely  as  possible,
 exemption from further  infection;  the  first may  be accom-
 plished by remedies which are so potent as to produce almost
instantaneous disinfection, but which from their potential are
practically incapable of any long-continued antiseptic action;
the second result is produced by remedies which though they 
39
may be not nearly so promptly disinfective, are nevertheless,
vastly more durable in their maintenance of the integrity of
decomposable tissue.
  With all this, there is  yet more, for us  to think  of in  con-
nection with the decalcified dentine which it  is proposed to
leave, for the  two-fold reason  that it is  such tissue as  can,
possibly,  be made the most acceptable of any covering to the
tooth pulp, and, as well, that in the event of recurrent decay
there may be a basal boundary, for the future, of solid instead
of softened dentine.
  It is for these reasons, then, that I have recommended the
oils  of cloves  and cinnamon  as  medicaments possessing in
marked degree, not only the reasonably disinfectant and won-
derfully  antiseptic qualities that  have been  so thoroughly
tested, but that all-important one of non-interference with the
recalcification  of,  at least,  by far  the  larger  portion  of the
decalcified dentine.
                    [part eleventh.]
  IT will thus be seen that with but partial  consideration for
    pulp conservation and with large  view  to better  cavity
walls for the future, we are brought into direct thought and
work for the maintenance of integrity of the filling.
  Just in proportion, therefore, to the  depth of the  cavity,
and, to the  thinness of the stratum of  decalcified dentine, I
should regard it of importance that an intermediate should be
placed first, and that the choice from cur three intermediates
should be restricted to temporary stopping and rubber varnish,
and, that the latter should be used in conjunction with muslin,
or, preferably, with disk of rubber dam—as suggested by Dr.
How.
  On the contrary, in proportion as the cavity is of moderate
depth and the stratum of combined normal and  decayed den-
tine  which it is proposed to leave is of decided thickness, so I
should regard  it as indicated that the  zinc-phosphate  lining
should be placed in immediate apposition with  the cloves or
cinnamon saturated dentine, that thus  greater strength  of lin-
ing and more assurance of future integrity of filling might be
given. 
4o
  The enunciation which placed  Prof. Robert  Arthur in the
" Gallery of Heretics" was "I do affirm that in a vast majority
of cases caries of the teeth remains stationary if the opening of
the cavity of  decay is  well prepared and the cavity so filled as
to exclude everything from it although decayed, dead and
decomposed  bone be LEFT in it,"  and during the first ten
years of my own experiments I examined  a sufficient number
of cases to warrant me in teaching this assertion as true.  At
first  Prof.  Arthur's enunciation was criticised as a loose and
consequently  unworthy  assertion,  and it  was stated that the
gradation  of  "decayed,  dead and decomposed"  proved this,
as bone must be dead before it could decay  and that it was more
than useless  to associate decomposed bone  in  this connection.
But  Prof. Arthur maintained his position and gradation by
showing that the  word decayed was used as it was universally
applied to dentine, and that the decided pain incident to its
removal positively proved that it was  not  dead]—also, that in
making radically  antagonistic affirmations it was not useless to
make them the strongest possible,  and it was  to this end that
he had gone  so far as  to leave decomposed  bone  to show that
even that  was rendered  impotent provided " the  cavity was
so filled as to exclude everything from it."
  At this  point, it seems to me, that we have another instance
of the logical deductions which governed the  progress of this
work during  the '70's and which  placed  it upon that  basis
where, since then, it has remained for  those who have, during
the past twenty years practiced it; thus it is shown why the
gradual change from pulp consideration to filling integrity as-
surance, was  a natural evolution,  as,  in no other way  could
this  "exclusion of everything" be  accomplished.
  Is  it needed that more should be said to  show how vital to
all this became  " The  Choice of Proper Filling Material " and
thus to prove the continuity of our chain  to this most import-
ant factor  in the work of so filling teeth as best to save  them.
  There is, probably, no class of teeth, and no conditions of
combined  normality and abnormality that  will better illustrate
how  very  much more than is yet usually taught, or generally
appreciated, is needed for the  acceptable preparation and the
permanent and altogether satisfactory filling  of cavities of decay,
than is this of the nervo-bilious temperament. 
4i
  With the pearly, polished and resistant enamel, which, for
these attributes, should be sedulously conserved, we have the
highly organized and exquisitely sensitive dentine, that calls
for care requiring the highest order of dental skill and knowl-
edge for its treatment; and, with these apparently antagonistic
tissue complications, we have to consider a systemic control,
than which no other weighs, more accurately,  everything in
its delicate balance.
  With all this, is it any wonder that its laterals are discolored,
or that its bicuspids are " among the missing? "
     And what a plume it is in the cap of dentistry that such
treatment, and such choice of filling material  as I have indi-
cated can make  for itself such a record as has been proven pos-
sible.
  Next in gradation, and the last of the dentures which den-
tistry can rank  as  "good," we have  the handsome, rich,
cream-colored teeth of the nervo-sanguine, with their shapely
edges and well developed cusps; their excellent  enamel and
dentine, and well planted in the jaw.
  But in the usually circumscribed cavities of decay, we meet
the equally  usually exquisitely sensitive dentine, so in accord
with all the  other tissues, and  equally with them, intolerant
of infliction.
  If there are any teeth whose successful care may be said to
depend largely upon judgment,  these are they.
  But, most  emphatically, it must be a judgment  based upon
much knowledge, for, while it  is  the nervo-bilious results of
so-called "judgment "  dentistry that has  made it a by-word
as to its inability to save teeth, it is the  same kind of "judg-
ment "  dentistry that has, by its work on nervo-sanguine teeth,
given it its horrid reputation for torture.
  It is at this point,  therefore, that I would urge  a  thorough
knowledge of all that is known in connection  with  the treat-
ment of sensitive dentine as the prelude to  the  preparation of
the cavities in these teeth; and in addition to this I would  add
my voice to those I am glad to  read  of,  in society reports, as
urging  the  employment  of soft gold in these cavities when
gold, either alone or in " composite " work, is to be utilized.
  It is with these teeth that  all infliction should be specially 
                             42
avoided, and it should be recognized that the term '' inflictive'
is applied as appropriate to dental manipulation " early in the
fray !"
   It is with these dentures, then, that napkins should largely
take the place of rubber-dam; that the use of clamps is almost
positively contra-indicated, for, it  is  with these teeth  vastly
more than with any others that " a knowledge of the presence
of the tooth " is occasionally never lost after  its having been
clamped.
   It is in these teeth that the difference between " hand-pres-
sure " with soft toil, and " malleting," with either hand mallet,
electric,  pneumatic or automatic, with any  form  of  cohesive
gold, is most  decided,  and great preference for the former
method expressed by patients; afcd it  is especially with these
that operations with plastic filling materials appeal most power-
fully, and even regardless of every other consideration than
that of exemption from pain during their introduction.
   Thus it is that, from numerous considerations, the " choice
of proper filling material "  becomes  here a  most important
matter, and one  which is complicated almost,  if not indeed
positively, beyond that of any  other  class of teeth; it is here
that "gold is an excellent filling material, if the necessary pres-
sure is tolerated; if not tolerated,plastics are indicated," but it is
here also, most absolutely, that the extreme aesthetics of plas-
tic work should be utilized, in order that the equally extreme
beauty of the denture should be maintained.
   It is in this work that the beauty and gentleness of '' com-
posite '' soft-foil  work can be most notably utilized, for, with
properly  made oxy-chloride of  zinc linings, and an  equally
properly  introduced  soft-foil  gold  filling, a beautiful, durable
and delightfully  acceptable  result can  be attained in any of
the anterior teeth; while large or small cavities in the molars
—lined or unlined, as indicated—can be as serviceably, and as
acceptably, filled with an appropriate  amalgam.
   With  considerations pertaining to the  sanguo-lymphatic
teeth we have  reached that dividing line in the "  choice of
proper filling material" which seems  to be a sort of boundary
between gold work and plastic  work, for. up to this  point we
have found gold  to be the more or less proper material in the 
43
 varying degrees from " king of all  filling  materials," undis-
 puted in its position of excellence,  to  its  almost universal
 acceptance as the most useful, and the most beautiful, of all
 our materials, in its associate capacity.
   But,  from now, we shall find the utilization of gold becom-
 ing less in frequency until it finally disappears entirely; and yet,
 as it has remained, prominently,  with us through  six grades
 of tooth tissue, so it will be found,  in diminishing  degree,
 through three or four other grades before plastic filling  ma-
 terials will, in turn,  become the  "Rulers" of their special
 realms.
   This  difference between  Kingly and Princely governance, is
 one of the special points which has  always been  taught by,
 and very seldom accredited to,  the "New Departure."
   In  the very beginning, in the talk given for the  "New-De-
 parture Creed " in New York,  November, 1877, it  was stated
 by me,  as its mouth-piece,  " I do not wish to say anything to
 you of  the teeth which you are in the habit of filling success-
 fully, and, as we express it, satisfactorily, with  gold; teeth of
 dense structure, whose cavities have walls so strong that  you
 can impact a filling which  lasts a lifetime."
   Could anj' words be more definite than these ?  Could gold
 be accredited with anything more than  ability  to  last a life-
 time ?  And now,  after all  these  more  than twenty years,
 have  I not placed it in exactly the same position ?
   But while we recognize the regal ability of the King we are
 also forced to acknowledge that his power does not extend be-
 yond  the confines of his kingdom; that he  has  accomplished
 practically nothing in his attempts to control beyond  his do-
 main; at the same time we  are compelled to admit that there is
 no other King !—no other material which, in its  realm, admits
of no discoimt.  While we are also  thankful, very thankful,
that  we have amalgam, gutta-percha stopping and  porcelain,
 with adjunctives  which render  eminently satisfactory work,
with them, possible.
  For the sanguo-lymphatic teeth, therefore, with their creamy
gray color; their  rather excessive size; their broad,  shapely
edges and cusps; and their fairly firm planting in the  jaw;  we
find a fair, though not a strong, enamel; a  fair  dentine, and 
44
thus a tooth structure in apposition with which, although gold
fillings may often last fairly well, it will be found, clinically,
that amalgams, in lined and unlined  cavities, do seem espec-
ially indicated.
                      [part twelfth.]
    NEXT in order for our consideration are the teeth of those
      whom we class as bilio-nervous; those individuals with
less than average size; (always remember  that height is not
regarded) decidedly less than average osseous, muscular and
contour development; with high and usually prominent cheek
bones; with forehead broad in proportion to the  rest of the
face, and with small chin and jaws,
  I speak rather especially of these temperamental  diagnostics
because we have now, probably, the most peculiar and trying
teeth, of all the dental range, to  deal  with, and  this not as
regards any special dental tissue, but alike with all.
  These teeth  are  variable in size and form, being sometimes
broad,  sometimes  narrow,  but with either, the necks are
usually narrow and the  cusps and cutting edges usually long
and thin.
  Though almost always  fairly firmly set  in the jaws—an
attribute that may  usually be regarded  as an indication of
enamel and dentine, above medium in structure—yet here we
find  this not to be  relied upon, for  both these tissues of the
bilio-nervous teeth are generally so far from  this as to permit,
not infrequently, decided and extensive decay.
  Again in the matter of sensitivity we will  find this  both
excessive and not  unduly acute;  but, with  either condition,
that perceptivity of pain, which almost entirely precludes the
possibility of anything like comfortable operating, and which
demands  the utilization  of obtundents  with most systematic
gradation as to possible infliction.
  It surely will be readily admitted that every concomitant
associated with gold work, from  the need  of such a cavity
preparation as  all  know to  be proper  for gold ;  on  through
the application of the rubber dam; the placing of clamps or
ligatures; the length of time required for the introduction of the 
45
filling; the impacts as piece after piece is welded and consoli-
dated; the filing or disking, the  pumiceing and burnishing or
other incidentals to finishing, all this is, in  lesser or greater
degree, not to be easily tolerated by the bilio-nervous patients
and to some of them it is simply intolerable.
  And yet—it is the temperament, par excellence, that admires
the gold filling, while  experience tells it that these fillings, as
a rule, entail a too  frequent renewal.
  At this time,  and in the face of the strong assertions on the
part of even some of the Professors of Operative Dentistry,
that gold fillings  are  more than equally capable with any for
the saving of teeth, I shall not make other effort  at opposing
this  teaching except to say that it does not at all agree with
my extended observation and my 30 years of carefully tabu-
lated statistics in this regard.
  Here then we find a "debatable area" of intense interest
alike to patient and operator; one which I think will be found
well  worthy of most careful study  and of the  most decided
consideration—for  with all this no sweeping  success  must be
thought possible, but on the contrary, failure must be accepted
as an occasional, if not more than occasional, result.
  Just in  proportion as these views are accepted as true, and
their meaning realized, so will it be  found necessary to inform
oneself regarding the minutice of filling teeth to a degree that
has, until now,  been unnecessary; for it is in this very " debat-
able  area" that, for the very finest, most acceptable,  most
durable and altogether most satisfactory  results,  a combined
amount of knowledge, judgment and  skill  will  be  required
that can only be appreciated by those who are most proficient.
  It is iu this line of work that the progressive worker realizes
and  enjoys his constant progress, and, as  well, his perception
of evidently increasing capability; and it  is here that he first
desires to know7 of  the varied attributes of the different mate-
rials he utilizes, in a way  that until now he has never believed
possible.
  It is with these teeth, the peculiarities of which have given
to their possessors an apparently   unconquerable  dread of
dentistry, that the greatest triumphs of " uon-inflictive" work
are enjoyed alike by patient and operator, and that results are 
46
accomplished  which,  with  all the experience  of  the past
twenty years,  are yet viewed as incredible, and  seem nothing
less than marvelous.
  Nor is it strange that this should be so, for upon this plane
dentistry is, even today to the vast majority of its practitioners,
an  almost unknown art.  It may well be admitted that I
would not make such an assertion without the fullest warrant
for doing  so; and I think it cannot be  denied  that my oppor-
tunities for knowing this  could not well  have'been greater;
and it has been from this that I have striven to concentrate
energy upon work that I  regarded as purely dental, to the
exclusion  of wanderings in  the paths of  so-called  '' Stoma-
tology."   It is therefore in connection  with the treatment and
filling of  cavities of decay in the bilio-nervous teeth that I
shall  insist upon the need for the most absolute knowledge
possible, regarding every attribute of every dental medicament,
method and appliance for the obtunding of local and general
sensitivity; upon an  equal knowledge of  every attribute of
every filling material  and  every adjunctive; and finally upon
a reasonable degree of experience, and vastly more than a
reasonable degree  of manipulative skill in the  utilization of
all this knowledge as a preliminary to the expectation of any
respectable realization of that which can be done with these
troublesome dentures.
  With all this knowledge  and  ability the meeting of indica-
tions  begins to  " take shape" and  it is because  of this being
but a beginning that I have been careful to say that in this
work  '' the progressive worker realizes and enioys his constant
progress"  and I can now say that with thirty years of experi-
ence—from the  early experimental utilizing of the oxy-chlo-
ride of zinc and the varying grades of gutta-percha stopping—
together with the creasote,  the deplorable arsenical paste and
the  inflictive deliquesced chloride  of zinc as  obtundents,  all
through the long line of improved filling materials and adjunc-
tives,  together with the numerous and acceptable medicaments
and appliances for  systemic sedation and local relief from pain
which have been, from time to time, added to  our list, it has
been an uninterrupted advance toward an ideal which is most
delightfully creditable—and yet the '' perception of increasing
capability" is the ever present incentive to  better things. 
47
   That I may place this in some tangible form for a beginning
 I  would say that  for work upon  anterior teeth it must be
 accepted that unlined cavities are practically never to be thought
 of; while even in the posterior teeth these are, as a rule, indi-
 cated—indeed I would say, that in  proportion as I have lined
 the  cavities of  the hilio-nervous patients so have my results
 been generally satisfactory.
   This brings the  work of lining  so far to the  front as to
 leave only the preparation of the patient and the cavities as a
 prior consideration.
   For this, from the systemic standpoint,  the various allo-
 pathic, homeopathic  and other remedies are so  universally
 known and employed that such patients will frequently sug-
 gest that which is most acceptable, when the desired end to be
 attained is made known.
   This, from a dental aspect,  is not  only admissible, but may
 be decidedly  preferable, as it is almost universally better to
 encroach in minimum degree upon  the domain of the general
 practitioner.
   For the local obtundents I would suggest that the method
 known as " consecutive application" beginning with the mild-
 est and  positively non-inflictive remedies, and grading on in
 strength and  efficiency  until  a satisfactory result  has been
 accomplished and the cavity prepared as desired.
   Does it need be mentioned that the very words " as desired"
 at once  opens that discussion  which will eventuate in every
 variety of procedure  from that which might  be eminently
 acceptable to that which might be quite the reverse; and with
 the  diversity of opinion, and especially of teaching,  regard-
 ing almost every phase of every dental operation, will it not be
 recognized  that  pitfalls  beset the  path of  him who, as  a
 beginner (in this difficult work) would essay to gain experience.
   It is for this reason  that I have found, as a basal proposition,
 that the endeavor should be directed to the abrogation of pain—
 or even of less than pain—that the aim should be to avoid even
 discomfort;  and that this is to be done in no other ways than
 such as  cannot  by any possibility do more harm than good—
as, for instance, an  arsenical  application  for the removal of
sensitivity  of dentine, except  wh6n  it is not intended  to pre-
serve the vitality of the pulp. 
                            48
  It is for such reasons that I insist upon exhaustive knowl-
edge of everything in connection with each step  taken, for it
is not alone that evil may result  from any given procedure,
but with  patients and with teeth, like these, it often becomes
needful to decide between two goods as to which is the better,
and again, as between  two evils which is the lesser.
  As I view it no slight degree of knowledge will suffice for
this; and experience teaches us that great proficiency is some-
times insufficient to accomplish all one would desire.
  I desire, extremely,  that it may present itself to my readers
as it does to me, that if there be any special portion of the  long
battle ground upon which  is fought the variance of opinions
and procedures of " Operative Dentistry" we are on it now.
  There is no one step, from the incipiency to the  final com-
pletion  of any  work  upon bilio-nervous  teeth, for  which
teachings and practice are more dimetrically antagonistic  than
any other; and,  while  it is true that  this condition  of  things
pertains in extraordinary  degree  throughout, it is  yet, as it
seems to me, no  where else so positively decided as here.
  Thus it is, that it is not sufficient for me  now to say that
for  the cavities of decay in such teeth certain specified mate-
rials are indicated as  "proper" for  filling them, but that it
should  be made clear that the preliminaries to  their using
should be shown to have that immense importance in deciding
the final results which it is impossible to over-estimate.
  And so it is, again, that in the very beginning of work the
question as to  the using of rubber-dam or napkins presents
itself.
  This would be answered by  most, I believe, at present,  in
deciding for the rubber-dam; while others, now the few, would
equally promptly decide for napkins.
  For myself I should say that with the decision for rubber-
dam would probably be associated successive discomforts (not
to say  inflictions), which would be pronounced " unavoidable"
or "necessary"  as would be said of the placing, ligating or
clamping of the rubber, while the truth would be that most, if
not all of these,  would be neither unavoidable,  necessary, or
other than needless, and even objectionable.
  As regards the use of napkins it is only to say that it is their 
49
abuse far more  than their use which is now indulged in, and
that to this should be directed an earnest effort toward reform.
  It is sufficient to  read instructions in this art as given in
"The American Text-Book of Operative Dentistry," pp. 164-
165, where directions regarding size, shape and applying are
glibly tossed off in four paragraphs !
  And this is "  The Text-Book !"
  Napkins should not be of either the size or shape as there
given; the manner of folding is utterly wrong; the method of
handling and placing is just the reverse from what it ought to
be—and yet there is one  sentence strictly true—viz.: "Here
the reliance is upon  napkins and with them much skill may be
displayed by deft operators."
  This assertion is surely beyond dispute, and this is the reason
why, in connection with work upon the bilio-nervous teeth,
the "deft" napkiner would decidedly prefer napkins to rubber.
  It was the discussion of successive points in this connection
that from the attendance, the manifest interest, the almost end-
less interrogating, the clinical testing and  the testimony after
graduation, has impressed  me as the culmination of value in
my  combined course of lectures on Dental  Pathology and
Therapeutics and Plastics and Plastic Work, and I now realize,
as  I have never  done before, the need for long and careful
preparation of the soil, before such sowing of seed as shall yield
a  compensating return of  ability to practice a non-inflictive,
tooth-saving dentistry.
                   [part thirteenth.]
  I  have said that at this point in  my  contributions I am
impressed, as I have never  been in lecture courses,  of the
need for long educative preparation of the  student, to the end
that the  practice of a  non-inflictive,  tooth saving dentistry
may be a  possibility.
  This, I  now recognize, has been due to the combined  patho-
logic and  therapeutic teaching as associated with that portion
of operative  dentistry included under "Plastics  and Plastic
Filling."
  In this  work, I left to the  Chairs of Physiology and  Bac-
teriology  the minute  discussion and demonstration of these 
                             5°
subjects, and  confined  myself to  a  concise teaching of those
salient  points which are regarded as conditions admitted in
connection with any  and all theories and  which, as I view it,
sufficiently  educate to  diagnose  relative phases  of  special
dental perversions from normality, and to  intelligently "meet
the indications."
  If it  be granted that,  with the  physiological  teachings
regarding digestion and renewal and  aeration of blood, there
is given a sufficiently tangible basis for normal nutrition, and
that microscopic observation will show such characteristics as
may reasonably be regarded as nearly normal capillary circu-
lation, while slight irritation, by any  form of irritant, can be
seen to produce that  change in the circulation which would
indicate that  slight  deviation from  normality which is so
well  defined  by  the phrase '' a determination of blood to  a
part," I have come to regard this as the best presentation for a
practical conception  of those  consecutive   deviations from
normal  that eventuate in conditions known as truly inflamma-
tory,  and which,  if not overcome, pass on to those serious
complications which, for our present purpose,  may be grouped
as pus formation, gangrene, caries and necrosis.
  I have felt that  as physiology, even with its ever changing
theories, gives us an  ever present basis for health,  so  the
microscope, in its  simplest utilizing gives us  an ever present
basis for the practical recognition of disease;  and that, for its
general acceptance, and greatest  usefulness,  the  less  this is
clouded by complicated theories,  as  these are discarded and
promulgated, the better for both practitioner and patient.
  Upon such  foundation I  have  constructed  and  taught for
many years what I have termed " visual pathology," dividing
it, from normal to death,  into four  parts,  according to  old
nomenclature, viz., "determination," "congestion,"  "inflam-
mation" and  "resolution,"  or  "suppuration"   with their
concomitants.
  I have continued, from year to  year, on this line because I
could really see no reason  for  change, and I think I have,  by
this  consecutive  treatment  of these varied perversions from
normal  nutrition,   given to the  minds  of students a better
mental vision of the conditions they would be called to treat
han  I could have  done in any other way. 
5i
  It may possibly be recognized  that in connection with all
the  discussion  of the  signs, symptoms and  results of each
phase of altered circulation, constant reference would be made
to the varying  special requirements, appliances,  medication
and  instrumentation demanded by  dentistry, and it  is this
voluminous "preparation" that I feel the want of now, for,
just  in proportion  as we leave the  strong teeth,  with their
resisting and  enduring temperamental attributes, the utiliza-
tion  of gold, in large degree as a "proper" filling material,
with its adjunctives of rubber-dam, mallets,  disks, finishing
burs and long sittings,  all of which are  needed for the  accom-
plishing of beautiful and durable work,  so we are brought
into  contact with all those  conditions which make '' plastic
work" as entirely different from "gold work"  as any two
departments of any special calling can possibly be.
  It is for this reason that the consideration of moisture is the
very first indication of this decided difference:
  Dryness,  long continued, perfect dryness, is  a condition the
value of which in connection with gold work cannot be over-
estimated.   It can truly be regarded  as an essential.
  I do not  know of  that  demand in connection  with  plastic
work  that  calls for any special dryness  (absence of breath
moisture) or for any long  continuation of even moderate dry-
ness, except in the  filling  of a  discolored  tooth which has by
any  of the various methods been more or less perfectly restored
in color.
  In a practice  of almost  twenty years  devoted exclusively to
the  treating and filling  of teeth below  medium in structure,
and  for which work no other than plastic filling materials
were employed, I never  used  the rubber dam except in the
very infrequent cases I have noted.
  But  when, in the use of napkins  or  properly secured cot-
tonoid rolls, I claim  an all  sufficiency,  and a  more acceptable
means for maintaining the required dryness for plastic filling,
I do not accept any other than the regular systematic "6 nap-  ,
kinings" with  the double folded, long, narrow napkins (2^ /
inches by  14 inches) such  as  have been  used, with gradual /
modifications, ever since the time of that very "deft" nap-/
kiner,  Elisha Townsend.                                    / 
52
   The second series of indications are grouped under that long
 line of  considerations pertaining to  such modifications as are
 presented  by temperamental  governance  in the increase of
 sensitivity; increase of weakness of tissues; increase of doubts
 as to eventual success, and increase of constant thoughtfulness
 for,  and appreciation of, this combination of complications.
   On the other hand, we have, as we pass on  in the downward
 gradation of the various dentures, that decrease  of sensitivity
 which is so  treacherously conducive  to  irreparable injury of
 pulps; that decrease of energy which almost entirely precludes
 response to therapeutic efforts, and that  remarkable decrease
 of everything upon which to build, except the equally remark-
 able possibilities of  dentistry, provided that all this combination
 of complications is, if it may be, even more fully appreciated,
 and most capably provided against.
   We have then first to regard non-infliction as of prime impor-
 tance, and to recognize, to the full, that the term " thorough-
 ness" as applied to dental  manipulation, is  thoroughly indefi-
 nite, and that it does not mean, truly, anything less than work
 done exactly as one would desire it to be done for oneself.
   This covers the ground  accurately for each  practitioner,  for,
 just what each dentist would desire should be done for himself
 to a tooth in like condition with the one which he is operating
 upon, is just what should be done by him; and if he cannot do
 it, he should not say, or  even think, that it is impossible, or,
 that  it  is  necessary, or that it is best to do otherwise, but at
 least should acknowledge to himself, and better yet, to the
 patient, that he does not know how—and then  try to learn.
   As I have experienced it,  and as I have  taught it, this has
 seemed to me the basis for solid dental education, and the only
 basis upon which,  from  the  bilio nervous on through to  the
 soft and almost hopelessly worthless teeth of the nervo-lym-
 phatic temperament, any eventual average of " proper choice
 of filling material'' can be taught.
   And  so it is that here we largely leave much thought of
 gold, and enter the special range of the different amalgams and
 the adjunctives of oxy-chloride  of zinc  and zinc-phosphate
^cements.
   And yet again  it  is here  that we find that front-tooth work 
53
of oxy-chloride "lining" and soft foil gold filling which has
made most notable and most acceptable results during the past
fifteen (and,  in limited degree, twenty) years.
   In this work the thin lining of the oxy-chloride should be
pelleted  into position—see "Plastics," p,  193—and covered
with temporary stopping, which should be allowed to remain
for at least  twenty-four  hours, and preferably, three or four
days.
   If then the filling of gold be introduced in the usual "piece
to piece" manner, it should be done with extra gentleness and
care, not to  fracture  the lining, and with  thought for the
gentlest  utilization of  all  objectionable appliances.  But  it is
here, probably more markedly than at any other place in the
whole range  of gold work, that the advantage of soft foil work
is made  apparent to fhe patient, and, from its comfortable pos-
sibilities, as well to the practitioner.
   The steady, gentle pressure in  the introduction  of  the first
"cylinders," the gradual filling  of  the cavity with appropri-
ately placed and semi-condensed  " pellets" and " tacks," and
the final single-point subsequent condensation of the filling as
an entirety, is a manipulation which, to those of us to whom
it is familiar, is the source of never-ending amazement—and I
may venture  to say amusement!—as  we  view the ordinary
cavity filling, and even the contouring work, as taught at the
present time.
   In connection  with the gold  work  in  filling the "lined"
cavities of the nervo-bilious front teeth, as well as in  the nap-
kining pertaining to the same, I must  maintain  that  a return
to the  methods of forty years ago would be a decided  advance,
and  I write in  the hope that  all  the seed sowed may not fall
upon " stony ground!"
  Next iu order are the composite fillings of oxy-chloride and
amalgams, and  for these we  have the first modification, in
practice, of immediate filling, for a good oxy-chloride, properly
worked,  should "set"  sufficiently in fifteen minutes, to permit
the introduction of an amalgam filling.
  For  these fillings we have, first, those amalgams made from
so-called  "white alloys," which,  however, for this work,
should be " tested" by immersion in a solution of  sulphide 0/ 
54
potassium (ten or fifteen  grains to the ounce of water) to  be
reasonably sure that their  amalgam will keep its color, which
it should do for ten days or two weeks.
  Second—We  have those combination  amalgams made  by
mixing "facing" and " contour" alloys in varying proportions,
usually equal parts; or, for greater strength, if needed, one
part "facing" two parts "contour;" these amalgams  should
be,  preferably, made by accurate  weighing  of mercury and
alloy, with alloy  down for all the mercury will make into the
least plastic (and  yet plastic) mass.
  It appears,  from testing, that the more accurately  this is
done  the  better the result so far  as maintenance of color is
concerned, while, with just the right degree of plasticity  for
working without  expressing any mercury, all other attributes
are at their best.
  Third—We have any good  " contour"  amalgam, which, in
cavities that are not directly exposed to view, has been my
reliance for this work for twenty years,  and for which no other
amalgam has made, for me, an equal record.  In these  cases I
always finish the fillings with a  burnish, for, while I leave
other  fillings of  this kind in  front teeth,  with pumiced faces,
for  the greater whiteness, until some discoloration may demand
their brightening and burnishing, I deem it better to burnish
when not contra-indicated and thus secure the most positively
permanent finish.
  Fourth—We are now having the trial work upon the third
line of amalgams made  from either four or five  metal alloys
into which both copper and zinc enter, either as distinct com-
ponents, or as  some one of the various compounds known as
" brass."
  The  first work of this kind that I know of, I inaugurated
about fourteen  years ago—see "Plastics," p.  104 b—as a
result of four years of experiments upon two lines of "front
tooth" amalgams, neither of which proved satisfactory,  though
both promised  well for several years and finally gave the idea
of making an  alloy, in which the then strange incorporation
of both copper and zinc should occur.
  I do not know  of any other line of work in amalgams that
promised so much, and eventually so disappointed the expecta- 
55
tions, except the dreadful cadmium amalgam, which was more
than  disappointing, as in its  dentine  staining  and its pulp
devitalizing record it was fearful.
  But, as in the  cases of their  predecessors, the five metal
alloys, beside being very expensive (costing nearly $3.00 per
ounce to make), gave evidences of unreliability in the several
directions of edge-crevicing,  discoloring,  pitting  and  the
peculiar corroding which had been first noticed in  the earlier,
heavily copper, front-tooth amalgams.
  Having indulged in "bronzes"  (copper and  tin alloys) in
connection with sub-marine alloys it was an outgrowth of that
work that the apparently disintegrating work  of the antag-
onistic (so  regarded) copper and zinc might be modified by
their union  in the form of brass, while the constant incentive
to this work was the attribute of "quick-setting" in  a degree
far greater than pertained to any other class of amalgams.
  This  gave, for  me, the division  of these alloys  into two
classes which I named " bastard'' as made by the utilizing of
the two metals as  such, and  " brass" as  made by having this
for a distinguishing component.
                     [part fourteen.]
   SINCE 1886 work has been going on in connection with these
     peculiar alloys, as  it was, and is yet, of much interest in
just this filling of cavities of decay in such positions, and with
such "composite" work, in teeth of the bilio-nervous, sanguo-
nervous, lymphatico-nervous, bilio-lymphatic  and nervo-lym-
phatic temperaments; but  it has been with much disappoint-
ment as to results and with never ceasing suspicion as to the
"eventual" of these  curious combinations.
  It is for these  reasons that I have always taught that they
should  be  used only in "lined"  cavities, and it is because of
their unique attribute of quick setting, that this lining is bet-
ter made of oxy-chloride, and, as  one  becomes  the more
familiar with both oxy-chloride   and  zinc-phosphate lining
work, this teaching will  be  the more  appreciated.  And in this
connection I would again  urge the  advantage of  the oxy- 
56
chloride lining in these front teeth, from the fact that its gen-
eral reputation  as associated with pulp devitalizing irritation
is better than that of zinc-phosphate, which, though not posi-
tively proven detrimental, is nevertheless largely discredited,
and in connection with which I have always  advised giving any
approach to pulp the benefit of every doubt, and the invariable
use of either temporary stopping or rubber  varnish (see Plas-
tics, p. 171), as  an "intermediate."
  In  connection with the  use  of any of   these  "brass"  or
"bastard"  alloy  amalgams  I would have it understood that
this attribute of "quick-setting" is the only one  about which
much  is known.
  This is a positively placed matter  for a   properly   mixed
"brass" amalgam will "set" nicely in from five to ten minu-
tes, and should be hard enough to receive a fine burnish in
from  twenty to thirty minutes at most.
  The next attribute about which something is  known is its
maintenance of color.  This  is  quite "undetermined," for it
is sometimes very good, but  again  sometimes not good, but
with this,  as with all amalgams, a fairly good result may be
usually attained by carefully smoothing and burnishing.
  Beyond  this, so far as I  know with all my years of experi-
ence in this work, nothing  is known as to the eventualities of
these amalgams. That there has been a  gradual  gain  in
"maintenance of integrity" I do know, but that this is yet, in
much degree, to be compared with that of the three metal al-
loy amalgams I have no reason to believe, for the same cor-
rosive disintegration that came comparatively early  in the
"buttons"  and  in the fillings made  from   the  "front-tooth"
amalgams  of from 1888 to 1890 yet continues in the experi-
mental buttons even of the four metal alloy amalgams of the
past six or eight years, and indeed in the most recent samples
of my own, and  other, amalgams of this class.
  This "corrosive disintegration" is, with the exception of the
"heating," the  "swelling up"  and the "crumbling into dark
powder" of the trial  aluminum amalgams, the most curious of
all  my amalgam experiences, and  although, as I have said,
its  occurrence  is .greatly delayed in the most recent  "brass"
testings, it is yet sufficiently in evidence to warrant continued 
57
use of every precaution against unsatisfactory results, as the
brown, crumbly debris which has dropped from  the  various
"test buttons" of the last two or three years is  a most note-
worthy object lesson as contrasted  with  the   satisfactory
maintenance of integrity of the "test buttons" made from any
of the  three metal alloy amalgams.  And now as we proceed,
meeting the peculiarly varied decay of  the sanguo-nervous
teeth "either limited and circumscribed or almost unlimited
and extended" we advance even more decidedly into the do-
main  of "Plastic" filling materials, and  yet because of these
duplex attributes I have practically divided  the "choice  of
proper filling material" into two great divisions  and assigned
gold to the accessible, circumscribed, oxy-chloride  of  zinc
lined cavities, more especially  in the anterior teeth,  and amal-
gam to the less accessible cavities of extended decay in bicus-
pids and molars using "composite," or "combination" work,
or appropriate sub-marine  amalgams in unlined cavities as
indicated.
   In these ways  the beautiful, shapely,  bluish-cream colored
teeth of this temperament are most acceptably,  most durably
and most satisfactorily filled in such wise as to secure, during
the passing  of the years, an  increasing appreciation  of this
comparatively permanent dental service  given to perceptions
which are  always acute,  repeatedly hopeful,  and yet (as  we
know) based upon a foundation that is, naturally, without en-
durance or  strength.
   With a step both sudden and decided we now pass to the
teeth of the lymphatic-nervous patients;those persons of quite
average size, but with less than average osseous  and muscular
development, and yet with more than average contour tissue.
   These grayish-blue teeth, of average size  and  shapely,
though fairly planted in the jaw, will be found soft in both
enamel and dentine, prone to rapid and recurrent  decay and
with pulps liable to irritation and indisposed toward any  re-
cuperative or self-protective effort.
   It is with these  that discussion as  to pulp  conservation
seems a mere waste of words, while pulp-capping is  a  work
absolutely contra-indicated; with exposed pulps  in connection
with such teeth I have, long  since, been directed  by  experi- 
58
 ence to devitalize at once, while in deep decay I should treat
 with all the care given to exposed, or nearly exposed, pulps
 in warrantable cases, using not only porous cappers Coxy-sul-
 phate or plaster of paris)  together with appropriate antiseptic
 medicaments, such as acetate of morphia and oil of cinnamon
 or oil of cloves paste, or a pad of inspissated canal paste, and
 in conjunction with these  either rubber varnish  on rubber
 disk, or a  thin disk of slightly warmed temporary stopping;
 and all this with the full recognition  that pulp conservation
 was doubtful and with the filling work in compprt with such
 recognition.
  It would therefore ensue that as a first  consideration re-
 garding filling material it  should be decided what relation the
 existing cavity of decay,  and the manner and   materials  in
 which, and with which, it  was filled, would bear to  any future
 demands arising from possible pulp complications.
  Thus it  would be that  if in  such event the  present filling
 would  not  be disturbed, as its removal  would neither facilitate
 devitalizing applications to pulp nor favor direct   access  to
 canals and consequent complete  extirpation,   such  filling
 should be  made  with methods and materials  such  as have
 already been  directed for  permanent work   in  the teeth
 "below medium in structure."
  If, however, in view of  future trouble it is decided that ap-
 plications and Ingress to pulp cavity and canals would be best
 made by removal of filling we are at once brought into con-
 tact with all those  varied devices that the experience of the
 past twenty-five years has proven advantageously possible in
 the utilization of plastic materials,  for these only  have been
 found equal to this emergency.
  It is at this point in our  discussion  that Ave  find ourselves
 not only in the domain of "plastics"  but with the practical
 recognition that in order to accomplish the best known re-
 sults it is needful that these be used under the direction of the
 most thorough knowledge  as to their   attributes   and  the
 methods of their using.
  In the "Flagg-Inglis,  Questions and  Answers," p. 45, under
the lymphatico-nervous "Considerations pertaining to filling"
will be found "Use plastics  with great care," but  these five 
59
words represent a needed volume of instruction both didactic
and technical, and it is this fact which is clogging the prog-
ress  of operative dentistry in this regard to an  incredible de-
gree.
  From  the Chairs of Operative Dentistry but little instruc-
tion  is given regarding amalgams (the most important of all
the plastics) while for gutta-percha stopping and the adjunc-
tive  plastics, oxy-chloride  of zinc,  zinc-phosphate, zinc-sul-
phate and temporary stopping, vitally important, as each is in
its proper  place,  and with proper manipulation from  first to
last, and with  the need  for daily,  and sometimes  frequent
daily utilization, all these, and this work, receives not so much
attention as is given from the Prosthetic Chair  to the soften-
ing of beeswax and the mixing of plaster of paris.
  And the result of this is the very careful and  most accurate
manipulation of the latter, failures with which can be remedied
by other attempts, while with the former, a supposed capability
as to efforts with methods and means of easy acquirement,
will eventuate in disappointments, failures and results impos-
sible to remedy, all of which are ascribed to everything except
the real cause.
  It is a comfort to  me to know  there   are  hundreds  who
realize thoroughly the truth of every word of this that I have
written, but it is a great trial to know that there are thousands
who have not the least idea  that this is so.  My intimate and
long association  with the  using, making, teaching and clini-
cally  demonstrating  all this, gives  me  the  desire and  the
power to write of it, foreknowing it thus, the telling of it be-
comes both a pleasure and a duty.
  And so it is that while the filling  of the cavity which is in-
tended as a permanent work would usually require  only one
or two materials, and never more than three, the filling of a
cavity  from which the removal of the filling, either entirely
or partially, would be more or less  indicated, could never be
done with  less than three materials,  and for the nicest  and
most thorough work four, five and even six of these would be
required.
  It  was by this kind  of work and this kind of  teaching that
I have made the record which I hold; and by  this that I have 
6o
been able to save, comfortably, economically and almost uni-
versally, the teeth of these very trying dentures.
Contour.   Facing. Zinc-phos:  Temp'y Stop'g.
  Case: Large cavity on buccal face of lower molar—pulp ir-
ritated—soothe pulp, with campho-phenique,  gently  remove
debris and cleanse with tepid  water, excavate carefully,  ob-
tunding if necessary cervically  and morsally, leaving decayed
(decalcified) dentine toward pulp, proven vital by sensitivity;
disinfect and antisept this by oil of cloves or oil of cinnamon;
dry gently with bibulous paper; mix pad of oxy-sulphate of
zinc  and place  near pulp by pushing from end  of  oointed
spatula with a  fine probe—see "Plastics,"  p.  160—let "set,"
ten or fifteen minutes; cover with disk of  slightly  warmed
temporary stopping, making this  adhere to  cavity walls  by
gentle pressure; place on slab the fluid and powder for a zinc-
phosphate  mix, and then make button  of Facing  amalgam;
hold this in palm of hand and make zinc-phosphate mix; place
on cavity walls and combine Facing amalgam with it, working
them to feather edge at mouth of cavity  and leaving exposed
face  of temporary  stopping at bottom  of  cavity; when suf-
ficiently set (four or five minutes) make solid cylinder of tem-
porary stopping, of the diameter of exposed face of stopping;
warm this  to flexibility and place it so it will adhere to  the 
6i
disk of stopping and rest against the cervical part of the facing
amalgam with its  combination feather edge; the end of this
cylinder should protrude a little beyond the edge of the cavity
and the space above it  is then filled with Contour  amalgam
cold-soldered to the combined Facing amalgam; if  properly
mulled and, possibly, slightly wafered, the Contour should set
in twenty minutes sufficiently to permit of the cutting off of
the protruding stopping with a warmed instrument  (number
3 of the amalgam  set) flush with the face of the filling.  It is
unnecessary to do anything more to this filling immediately,
and I prefer that  it should be given time, according to  the
exigencies, for the pulp  to determine something for itself.
  If needful, however, the work can be finished as soon as  the
Contour amalgam is  thoroughly set—in a half day or  even
less— by removing some of the outer portion of the cylinder
with a warm instrument (number 5 of the amalgam set) and
replacing it with a covering of "high heat" gutta-percha  stop-
ping.
  This makes of the work a permanent filling, giving ample
opportunity for any future  pulp demonstrations which,  in
these teeth, according to my experience, requires from  three
to five years at least.
  With a moderately careful study, it will be seen that every
indication of every step  in this work is accurately met in such
wise as  could not be done in any other way; and as well that
from the best to  the  worst of the future possibilities, every-
thing is provided  for so that should  trouble come  it can be
relieved or  removed with the least possible infliction to  the
patient and with the greatest possible ease to the operator.
  To those who would  be inclined to view such work as this
askance I would say that I am merely telling how I have  done
it and how I have taught it,  and that, as in our California ver-
nacular we would put it, it has made "the claim pay."
                      [part fifteen]
I HAVE said that with a moderately  careful study it would
    be seen that every indication of every step in  the  com-
pound filling diagramed is accurately met in such wise as could 
62
not be done in any other way, and it is for us now to give that
study.
  The tooth is  one of a patient  of lymphatico-nervous tem-
perament; the cavity a large one on the buccal face of a lower
molar; a very deep cavity and with an irritated pulp.
  In the Flagg-Inglis resume  p.  44,  under Vital Force, it is
said "But little vitality is  possessed  by  this temperament to
give support to treatment," therefore,  in recognition of this,
every supporting consideration should be carefully included in
the treatment.
  It is stated,  "If exposed  pulp,  devitalize; in  deep decay
treat  as for exposed pulp of lymphatico-sanguine;  success
doubtful."   Then under lymphatico-sanguine, p.  40,  we find
under Conservation of  Pulp  "Apply soothing,  constringing
and  porous  cappers (oxy-stdphate or  plaster of  Paris)  if
nearly or quite exposed; in deep decay apply intermediates."
  Therefore, it is that having prepared the  cavity for filling,
the first recognition is that gentle effusion is  the early result
of irritation in such a soft tissued pulp as this one; that with
the removal of cause  for irritation by  exclusion of external
irritants this effusion will gradually cease—but that this cessa-
tion will be gradual—and that  if an impervious barrier  is
placed in its way the slight effusion will  soon become, in turn,
an irritant which the " little  vitality"   would  be unable  to
vanquish.
  In oxy-sulphate of zinc we  have not only a porous or per-
vious barrier but the happy combination of a gently constring-
ing medicament by means of  which the indications seem most
fully met.
  But now this very porosity must be regarded as permissive
of being occupied by any other fluid as well as that of effusion,
and it is therefore imperative  that an " intermediate "  shall  be
so placed as that this porosity will subserve  its purpose.
  For this, of our  three intermediates the temporary stopping
best subserves the present purpose from  its  various attributes
of  ease of placing with  very  moderate  warmth;  absolute
absence of  any moisture (as with varnish) and ease of  perfora-
tion or removal in case of subsequent need for either.
  Having done thus much  for the protection and  preservation 
63
 of the pulp, the next consideration is toward the making of a
 substantial, tooth-conserving filling,  and yet one which shall
 combine with this the peculiarities of  maintenance of integ-
 rity, should that prove to be the object desired,  and yet the
 possibly even more important attributes of facility for giving
 relief by medication  in  the event—"success doubtful"—of
 future suffering, or, even the more remote trouble, from event-
 ual death and putrescence of pulp, necessitating  free opening
 into pulp cavity and easy access to pulp canals.
   With all this in view the  stratum  of  temporary stopping is
 extended cervically and having thus practically precluded any
 undue effect from the  phosphoric acid  of the zinc-phosphate
 cement, arrangements are made for the  introduction of a thi?i
 "combination lining " of this cement and " facing" amalgam,
 which is now made.
   When this has partially set that portion  of  it  which covers
 the approach to the pulp cavity  is carefully removed to the
 temporary stopping arid  a cylinder of  temporary stopping is
 made, slightly warmed and placed in position at the cervical
 edge of the cavity in such wise as to protrude  a  little beyond
 the edge.
   A permanent contour amalgam filling is then  made around
 the temporary  stopping cylinder,  trimming  the filling into
 shape and leaving it unfinished until it is sufficiently set  to
 premit of the trimming off of the protruding end of cylinder
 with No. 3 heated, when, unless otherwise indicated, the work
 may be left for a week or two or more until a reasonable length
 of time shall give evidence of a present success.
   If in the near future the desired promise is given, the amal-
 gam should he finished and the external  portion of the cylinder
is removed with No. 5 heated, and its  place filled with high
 heat G. P. thus making a permanent filling.
   And now, if in the  course of time symptoms  of recurrent
 pulp irritation are given, and are of sufficient  magnitude to
require relief, this can  readily be given without the least inflic-
tion by gently burring out the high heat G. P.,  removing the
temporary stopping by slightly warmed  instrument, and mak-
ing the soothing applications of campho-phenique, acetate of 
64
morphia paste or'other preferred medicament, which soothing
is to be followed by devitalization of the pulp.
  And again, if years pass by, two, three or five, and eventu-
ally signs of peridental irritation which are diagnosed as due
to  probable pulp'Jputrescence, the same  removal  of readily
removed filling material opens the  way to  easy drill entrance
into pulp cavity and almost immediate subsequent  comfort,
but, with the'recognition that at least the treatment for  third-
grade periodontitis  should be indulged in prior  to further
mechanical irritation from largely "opening up."
  And when it is found that the free opening into pulp cavity
is tolerated, there is nothing to remove except the thin stratum
of zinc phosphate  and  facing amalgam  lining, when  easy
access to cavity and canals is afforded.
  I have been thus  minute in describing such work  as I  have
done many]hundreds of times because it is just here  that the
line of demarcation is drawn between the elegant  results of
such work as I have given in the earliest of these papers, and
the almost incredibly acceptable  results of the best  of plastic
work.
  And this dividing line is one which cannot be  overstepped
in  either way; the work is  different;, the materials are different;
the instruments and appliances are different; the knowledge
needed is different and the results are different; but  each is, in
its way, the best, the very  best that can be done.
  It is for such work as this that I have so earnestly cham-
pioned " Plastics,"  and  it  has been to secure  recognition of
this that I have taught and demonstrated as I have, and that
I now>rite in the hope, and with  the belief, that much good
may come of it.
  We now come to  that portion  of the dento-temperamental
classes which is included in the 4th division; those teeth whose
every attribute is graded as "Positively bad" and,  beginning
with the bilio-lymphatic as the better of the  two we find the
individuals of decidedly more than average size with largeness
of development but with neither beauty of form nor strength
of structure.
  We find teeth  yellowish in color; of good  polish, but of 
65
suspicious opacity; large and bulky; almost worthless; loosely
planted in the jaw and subject to extended, asthenic decay.
  Individually and dentally we have  a vital  force  far below
average, and under the feeble  dominance  of  which  compara-
tively slight irritation may produce serious lesions.
  Experience has, for many  years, taught me that plastics only
can subserve any good purpose in the filling of such teeth;
that these must be used with the most possible  knowledge
regarding their quality and their attributes, and the methods
of,  and appliances for, their proper manipulation; and,  with
all  this, that the frequent repairing and renewing of fillings
must be anticipated and that, again, even with this, these  teeth
will be found very hard to save.
  And it is the apparent efforts to  do,  that are  frequently
most misleading, giving hopes that are  never  realized, and
indeed  the semblance of assurances that are utterly unreliable,
for the great sub-stratum of  all effort as  associated  with the
bilio-lymphatic temperament is " weakness trying to be strong;
vacillation trying to  be decided; softness  trying to  be  solid,
and inertia trying to be momentum."
   It is  then in the filling of  a  large proportion of the cavaties
in such teeth that our reliance is found  in gutta percha  stop-
ping, and not infrequently in the ordinary red gutta percha
base plate, that material  which in the earlier  days  so well sub-
served its tooth-saving purpose (as the previous reliance—Hill's
stopping—gradually deteriorated until it became almost worth-
less) as to have caused me to  say of it  in the  first edition of
" Plastics " p. 143 that it was " very useful and eminently ser-
viceable."
   I desire that it shall here be noted that in our serial we have
passed gradually and systematically from all gold to that point,
which  we have now reached, of all gutta  percha, and that  as
gold is decidedly  the best material  with which to fill the teeth
of  the first class, so gutta percha is equally decidedly the best
material with which  to fill such cavities in teeth of this fourth
class as are so situated as that the filling will not be subjected
to undue attrition, and that  just in proportion as these fillings
are exempt from attrition so they will prove  the most perman-
ently tooth-saving of any that can be introduced. 
66
   With all the added experience of another twenty years I
 cannot more strongly accentuate the value of this  filling ma-
 terial than I did in 1877.   I had just then  finished  the most
 arduous and  most careful line of experimental work that I
 ever undertook for dentistry.
   I had striven to follow, for  eight years, two thousand tabu-
 lated fillings of gutta perchas in soft teeth,  and I had accom-
 plished this almost positively; during these eight years I had
 found but eight per  cent, of  failures, while in  hundreds  of
 these cavities, well introduced gold fillings, had failed almost
 universally  in from two to five years.
   It was because of this work  and of  these  positive results
 that I then  felt able to take  the stand I did  and from  that
 time to this the " provings " of  gutta percha work have only
 corroborated the truth of the teaching.
   Of all the enunciations of the " New Departure Creed " no
 others have been  viewed as so  utterly  absurd as the Articles
 VI, VII and VIII, while the truth is that none of the ten arti-
 cles were more carefully considered  or  more thoroughly  dis-
 cussed than were these three;  and it  is  just  here,  in our dis-
 cussion of the "Choice of  Proper Filling  Material,"  that an
 experience of  thirty years of  my long practice devoted almost
 exclusively  to the soft and softest teeth, teaches me that I must
 build my structure entirely upon these three articles.
   " Article  VI.   A filling may be the best known for the tooth
 and yet leak badly."
   It was not known  until the  work of the " N. D. Corps"
 proved it, that gutta percha fillings were  leaky—and, at that
 time, when  I asked from the members of the " Odontographic
 Society of Pennsylvania" an opinion as to "With what filling
 material the least leaky filling could be made with the greatest
 ease " it was agreed, without one dissenting voice, that gutta
 percha was that material, while  the fact is that even  with the
greatest care a gutta percha filling leaks badly.
   This  attribute  of  gutta percha stopping is attributed  to
 "inconsiderate manipulation "on p.  246 of "The Text Book
 of Operative Dentistry " but the entire  chapter from p. 219  to
 p. 257 is such a collection of palpable error that I regaid it  as
 unworthy any consideration, while the  fact  of wonderfully 
67
long duration of  fillings so  introduced  seems  to  indicate a
manipulation not so very inconsiderate.
  It was, therefore,  because of the experimental showing of
the extraordinary  tooth-saving ability of  these fillings and, as
well, their equally demonstrated decided  leakage, that Article
VI  was incorporated in the  " N. D. Creed."
  " Article  VII.   Gutta Percha properly  used is the most per-
manent filling material we possess."
  From the same  careful consideration and thorough discus-
sion this was made one "Article" of  the Creed, and it  is in
this connection that it becomes important it should  be clearly
understood, for if it  is, under any circumstances,  the  most
permanent filling material we possess,  it  surely  should  be dis-
tinctly decided what those conditions are, and  this  is decided
by  the two italicized words  "properly used."
  It is  readily admitted  that gutta percha  stopping is a rea-
sonably permanent filling material in numerous instances, but
in many of these it is used under such limitations as to render
it far less permanent than  would be other materials,  which
again have attributes  more  objectionable than  is the  one of
lesser permanence.
  In such cases gutta percha cannot be said to be used in an
italicized properly manner, for it has serious discount, but for
some cavities  of such teeth as pertain to  the bilio-lymphatic
temperament there is no other material so well  adapted as  is
gutta percha.
  These are such cavities as will permit little or no attrition to
wear upon the filling, and these are proper cavities  in propor-
tion as they will permit no  attrition;  but while in  these the
employment of gutta  percha is strictly proper, it may be, and
to an enormous extent  it is, that   it is  not at all " properly
used."
  I know of no other filling material which so suffers misuse
at the hands of recognized  "good operators"  as does  gutta
percha stopping; from the selection of the material; the heat-
ing of it for introduction;  the instruments and condition  of
instruments for the purpose of its  insertion, and finally for the
finishing of the fillings; all is usually  as unlike what it should
be  as it well can be; and it  is from this that  the permanence  of 
68
gutta percha  fillings is doubted,  and  that  its  position as
" most permanent," under any conditions, is scoffed at.
  The  first  consideration,   then,  in  connection with the
"proper use" of gutta percha  as  a filling material is the
selection of a good " stopping," and unless  this  is done it is
useless to proceed further in the directiori of  permanence.
  The two " tests " for  quality  of G.  P. S. are  so  easy to
make and so  almost positively conclusive that I  regard  it as
absolutely necessary they should be familiar to any who desire
to do the best that can be done in G. P. work.
  These tests are the "Heat  Test " and the " Fire Test " and
both are so important and so  decisive that I  will say at once it
is better to have the combined G. P.  and  instrument  warmer
for the first, as it is an essential in the doing of G. P. filling,
and is sufficiently accurate for all practical purposes,  as  when
" low-heat G. P."  or red G. P. base plate are put on the uppei
plate; "high-heat"  or shaded  G.  P. on middle plate; and
instruments,  on lower plate,  the  heat  for instruments, the
handles being comfortable to  work with (and this regulated by
raising  or lowering the lamp  wick) all heats are right.
   If when this heat of instruments is acceptable  the "high-
heat G. P." is more than sufficiently soft, it is not up to grade,
either from poor quality of G. P. or insufficiency of  inorganic
admixture; while if it is then not perfectly plastic it is possible
that this may be due to being "  saturated with zinc oxide," a
condition which renders the  G.  P. S. practically  good for
nothing.
                    [part  sixteenth]
    HAVING thus by the "Heat Test" settled the question
      as to  the  proper grades  of  G. P.  S.  it then becomes
needful that the relativity  of proportion of gutta-percha and
inorganic admixture shall  be .decided,  because  upon  this
equally rests the ability of the  G. P.  S.  to do " permanent"
work.
  For this we have the " Fire Test;"  this is  easily and  con-
veniently made by weighing  a small  quantity—say  ten or
twelve grains—preferably in one piece.  This is then subjected 
69
 to high heat by being placed upon a long-handled iron spoon
and this held in the flame of a Bunsen burner or put on a hot
fire; in a few minutes it takes fire; burns with .a  bright blaze;
ceases to burn; becomes red hot and thoroughly calcined, while
it perfectly retains its original shape.  If ten grains of G. P.
S.  has been  thus treated, the residuum should  weigh about
seven grains if the G. P.  S. has been graded, by the heat test,
as of  " low-heat."   If the ten grains  is of "high-heat" the
residuum  should weigh eight  and one-half grains,  or a trifle
less; (one  G. P.  to six inorganics).
  If the residuum weighs nine grains that  stamps  the G. P.
as unreliable ('one G.  P.  to nine inorganics)  as  it  indicates
"saturation with zinc oxide."   It may seem strange  that so
little difference in weight  of residuum should make  the great
difference between "excellent" and "almost worthless" but
this it is which  has taken  many years to work up and to demon-
strate, and this certainly has been done.
  And it is well worth knowing.
  Having thus  settled the quality of  the G.  P.  S.  it  is next
essential that it  be " properly used."   I have already referred
to  the G.  P. and instrument warmer as a means for  testing,
the grade and quality of gutta-percha  stopping, though there
are other ways of doing this even more accurately—see "Plas-
tics" p. 147—but for the proper using of this material there is
no other appliance equally good.  A device  called the "Ther-
moscopic Heater "—a  steatite plaque—is one which answers
the purpose for some, and perhaps would for many, operators,
but for those who desire  to do the best that can be done in
gutta-percha work, the dry heat combined  gutta-percha and
instrument warmer is an essential.
  Having thus  prepared  for  the  "proper using "  of  G. P.
stopping it  is only needed  now that  I should say that  the
" piece to piece " work of the gold filling of the present day
is  precisely that of  the introduction of a' good  gutta-percha
filling.
  The instruments best adapted for the introduction of these
fillings are—with the occasional exception of a ball burnisher
—certain forms of those used for the manipulation of cohesive
foil. 
70
  It must, however,  be noted that those instruments which
consolidate  foil  by "direct impact"  are  the least useful in
packing  G. P. stopping, for  the principles  that govern the
value of  a* gold foil filling are precisely opposite to those which
govern the value of gutta-percha fillings.
  For the perfect  introduction of foil it is essential that fair
ingress to cavity shall be obtained; for the  acceptable introduc-
tion of gutta-percha this is not essential.  For the former it
is  frequently  necessary to  remove  large  portions of both
enamel and dentine; for the latter it is as frequently even more
desirable that these tissues be conserved that they  may guard
against attrition during mastication.
  For the integrity of foil fillings, it is better that cavity walls
should possess both thickness and  strength;  for the integrity
of gutta-percha fillings it is not important that  walls of cavi- 
7i
ties  should,  in  much  degree,  possess  either thickness or
strength,  for some of the greatest triumphs of gutta-percha
stoppings have been made in teeth in which  excellently made
gold fillings had repeatedly failed, until  the  walls of the now
enormous cavities were almost as thin as letter paper.
  For full directions as to instruments for introducing and fin-
ishing G. P. fillings see  "Plastics"  p.  146,  but it seems in
place here to say a few words  as to the definite manner of
making such fillings as given in paragraph 3, p. 146.
  "The filling material and instruments (both plugging and
finishing) being properly warmed, the gutta-percha should be
taken in small pieces—piece by piece—from its plate by means
of a moderately fine probe, and thus carried  to the cavity and
placed in  position.  If practicable, each  piece should be made
to adhere to the  wall  of  the cavity,  and then be  accurately
packed into position by the appropriate plugger, until the cav-
ity is either entirely lined, or is partly  filled, when the com-
pletion of the operation  is only  a question  of a short time;
but when this  adhesion  of the  first  pieces  is difficult, they
should be held in position by the probe until they are made
to adhere to the walls by the use of a  plugger, when that
adhesion should, in turn, be maintained  by the plugger, while
the probe is carefully withdrawn."
  It is also a  much more important matter than is  usually
recognized  that  the utmost accuracy possible in  amount of
filling material should be regarded, as thus the minimum of
surplus—and better none—will  remain  for removal  prior to
finishing.
  In proportion as a  gentle smoothing  out of the  serrated
marks  from  the pluggers is the only  needed finishing,  so I
have found my gutta-percha fillings most acceptable and most
serviceable.
  It is, therefore, as pertaining  to the  properly tested gutta-
percha stopping; properly warmed; properly introduced, and
placed in properly selected cavities, that I claim  it to be the
most permanent  filling  material dentistry possesses for such
work.
  With the  additional experience of almost  twenty years I
claim that such fillings will do service  at least three times as 
72
 ong as well-introduced gold fillings;  and yet, in the criticism
 in the March " Items of Interest " upon the " Second Edition
Revised" of "The  American Text  Book of Operative  Den-
tistry " it is stated by the Reviewer that it  is " the gene;ally
accepted belief of the profession that a gold filling properly
inserted in a properly prepared  cavity  is the best  known
method of ultimately preserving any tooth.   (Italics mine.)
  For myself, in  this matter,  I think I  can justly claim  a
vastly greater experience  than can  any other observer, and
that though in this regard I may be only one as against, pos-
sibly, more than  twenty thousand! I yet desire to place myself
upon record,  at  this date, as having belief in  what  I  have
written, and, furthermore,  that my view is not an opinion, but
a conviction based upon  more than thirty  years  of carefully
tabulated and observant clinical experience.
  For teachings  regarding other  than purely gutta-percha
fillings in the teeth of  this 4th Dento-Temperamental division
—" Positively Bad "—it is  unnecessary that  they should  be
other than grouped, for with both the bilio-lymphatic and bilio-
nervous teeth the peculiar attributes  pertaining to the latter
are decidedly more pathologic rather  than structural.
  It is not rapid and recurrent decay that  we  have to guard
against so much as it is dentinal, pulp and peri-dental  compli-
cations as regards sensitivity; liability to irritation;  inability to
resist,  and even less to recuperate.
  Thus it is that while therapeutic requirements have, in the
nervo-lymphatic  temperament,  reached  the  culmination of
possibility, the "proper choice of filling material " is, practic-
ally, one with that  as  regards the bilio-lymphatic cavities of
decay.
  It is in these two grades of teeth, therefore, that aside from
all gutta-percha fillings, we  most utilize  the "Submarines"
and even the coin amalgam, and, as well, the " Adjunctives"
to filling materials.  It is here that plaster of paris; oxy-sul-
phate  of zinc; temporary  stopping; oxy-chloride of zinc and
the various oxy and  nitro-phosphates  of zinc are variously and
extensively, and, I must say,  satisfactorily  used, just in pro-
portion to the knowledge of attributes pertaining to each, and
to the special manipulative skill of each operator. 
73
   That both knowledge of attributes, and manipulative ability
are as widely diverse  among individual dentists as are any
other  of the requirements for the  best possible practice  of
dentistry I have also had ample opportunity for learning, for
my office  was, for many years, an open clinic room, and  it
was from the teachings of these experiences that I wrote as I
did in " Plastics " p. 192, that it was from want of knowledge
that some of the most miserable plastics had secured " testi-
monials" as to their excellence; and this because " they mixed
easily; required no knowledge of attributes;  no dexterity; no
promptness,  neither proper patience; no manipulative ability
for their using," requiring nothing but "judgement !"
   Now the utilization of any and all  "plastics"  requires
everything  except that  which complacently poses under the
name of "judgment." It requires knowledge of all their attri-
butes.  It requires, at times, a dexterity  that is truly seldom
attained because it is not known to be a  requisite. It requires
a manipulative ability in the  way of quickness and decision
combined, that is  to  some impossible to attain, just as it  is
impossible for some to ever attain the ability  to introduce that
which by a first-class gold operator would  be pronounced '' a
first-class gold filling."
   All this is not " generally " conceded, and, strange as pos-
sibly it may be, it seems to be least  conceded among some of
those who bear the title of " eminent" ;  but this I cannot but
regard as an illustration  of  " When ignorance is  bliss, 'tis
folly to be wise "—and there  must be some  accepted reason
for the " bliss," through in my extended practice of dentistry
I have never yet learned what it is.
   I must say that  the most awkward manipulations of plastics
I have ever witnessed have been at the  hands  of some whom
I have known as beautiful manipulators of gold; though again,
I must say that some fine gold workers have  given me the best
demonstrations of  the working of  plastics; but, I do not know
one of these who believes that " a gold filling properly inserted
in a properly  prepared cavity is  the  best known method of
ultimately preserving any tooth."
  If any of these did so believe, they  would so fill the  teeth
they fill with plastics; but because they  do not so believe  is 
74
their reason for filling some teeth with these materials; and it
is because they have learned how to use them that their results
are such as to warrant them in a continuance of that practice.
  But more than this, in the by-gone days, when I was in the
arena to prove my words by deeds, either in gold  or plastic
work, I never found 07ie who was willing to put his "piece to
piece " work against my "soft-foil "  work; and still  less, his
gold work, in the softest teeth, as against my plastic work.
  The nearest I ever came to this was when  Dr.  Marshall
Webb agreed to fill '' gold against  plastics ''  and the  Cosmos
went so far as to have " set up " an editorial comment on the
encounter, of which I have  the "proof" and which, until
quite recently, I thought was published, though it.was not,
for some reason, thought  sufficient, by my  friend Dr. J. W.
White.
  Among the most interesting  of  the  many  very  interesting
relics of a long, and certainly unique,  practice of, and literary
and collegiate association with,  "dentistry,"  I have no other
more  so,  to  me,  than  the letters which passed,  and this
" proof" of  unpublished intentions, as to this " Challenge "
and " Acceptance."
  The proposed corrected  editorial "proof"  commenced thus
            "plastic fillings versus  gold."
  '' When Greek meets Greek then comes the tug '' will now
receive a new exemplification, as the  challenge of Dr. Flagg,
the earnest advocate of plastic fillings,  is accepted  by the no
less earnest advocate of contour fillings, Dr. "Webb.  We trust
that the preliminaries  may  be speedily and satisfactorily
arranged, and that the  contest  may take place under  such
conditions that others, beside the  contestants,  shall reap the
benefit of a competitive test of what may, without impropriety,
be termed the opposing theories of these two representative
operators."
  It would seem as  though something should have  come of
this, but nothing did, for reasons that are fully explained in the
valued  package of  correspondence.   But what makes  this
reminiscence  justly a-pro-pos in this  connection,  is  the fact
that having selected a patient, as desired to do by Dr. Webb, I
showed him a gutta-percha filling which  had already  done 
75
eighteen months' service  in that mouth,  and  told him " I
would give him that much excess from the time of trial."
  Such  was, and is, my faith in gutta-percha "properly used,"
as is distinctly stated in connection with  the statement as to
its permanency.
  It now only remains for me to thank the pages of our Paci-
fic Dental Gazette for having afforded me the opportunity
and incentive for the writing  of that  without  which I never
could have felt that I had done all which  evidently had been
given me to do, and it is with the hope that  this effort may
enable some to reap from  it the giving of such comfort, and
such joy,  and the receiving  of such outpouring of gratitude
as has been so heartily given to me during the many years of
practice based upon "The Proper Choice of Filling Material"
as the true means for the almost universal satisfactory saving
of teeth  that I am glad  to send it forth  as a contribution from
a " '49er California Pioneer." 
& 
 
 
 
NLM052297962