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 RK301 M44 Oral pathology and^ 
 
 BAJHOLOGY 
 
 AND 
 
 APEUTIGS 
 
Columbia Winibtxaitv 
 in tf)t Citj) of j^eto Hork 
 
 ^cfjool of Bental anb 0val ^urgerp 
 
(•Dial patl)olomj 
 
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 ^J)eiapeiittC0 
 
 A systematic presentation of the suljject from the standpoint of modern therapeutics. 
 
 WITH 11(1 ILLUSTRATIONS 
 
 By 
 
 ELGIN ^IaWHINNEY, D.D.S. 
 
 Chicago. 
 
 Professor of Special Pathology, Materia Medica and Therapeutics, Northwestern University Dental 
 
 School; Member International Dental Federation, National Dental Association, 
 
 Chicago Dental Society, Odontographic Society of Chicago; Secretary 
 
 Illinois State Dental Society, etc., etc. 
 
 THE CONSOLIDATED DENTAL MFG. CO. 
 New York, N. Y., U. S. A. 
 
 CLAUDIUS ASH & SONS (Limited), 
 London, Eng. 
 
 1905. 
 

 Copyright, 1905, by Elgin MaWhinney, D.D.S. 
 Entered at Stationers' Hall, London. Eng. 
 
CHARLES P. PRUYN, M.D., D.D.S, 
 
 who for over fifteen years has been my friend and councillor 
 in all the affairs of life 
 
 THIS BOOK IS RESPECTFULLY DEDICATED BY 
 THE AUTHOR. 
 
Digitized by tine Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/oralpathologytheOOmawh 
 
Preface, 
 
 In nearly all branches of dental science progress has been rapid, and 
 especially in the departments of surgery, operative procedures and pros- 
 thodontia, but in the field of therapeutics empirical methods of treatment 
 still abide. 
 
 This volume is presented with the hope that it may furnish at least 
 a rational scientific basis for the management of many oral diseases the 
 treatment of which constitutes a large part of our professional service. 
 The recognition and prevention of disease and its consequent misery 
 should be the highest aim of all who follow the healing art as a profession. 
 
 It has been the aim of the author not to burden the volume with need- 
 less pathological or histological detail, but rather to present such phases 
 of these subjects as will furnish a scientific basis for practical therapeu- 
 tics. Treatment of disease without knowledge of its pathology has and 
 always will be a decided failure. 
 
 Although the preparation of this work has been an arduous task 
 coming into a busy professional life, still it has been a pleasure, for the 
 hope of being helpful to the toilers of the profession, as well as to those 
 who are preparing for their life's work, has been the dominating spirit in 
 which the work has been done. 
 
 The author wishes to disclaim originality for much of the subject 
 matter here presented ; for the most part it has been gained from recog- 
 nized authorities, as well as from clinical observations in the college 
 infirmary and private practice extending over a period of nearly twenty 
 years, supplemented by such scientific investigation as a teacher in one 
 of our large schools and a full private practice would permit. 
 
 The author wishes to render grateful acknowledgment to Dr. E. S. 
 Willard for personal encouragcrhent and assistance in the work, and to 
 Dr. G. V. Black, Dr. F. B. Noyes, Dr. Martin H. Fisher, Dr. G. W. 
 Cook, Dr. W. D. :Miller, Prof. Goadby, Prof. Hopewell Smith, Dr. Osier, 
 Dr. Jas. Nevins Hyde, Dr. E. S. Talbot, Dr. John S. Marshall, Dr. J. 
 Leon Williams, Dr. Hugh Blake Baldwin, Dr. E. C. Kirk, Dr. Sudduth 
 and Dr. Burchard, whose published writings have been drawm on for 
 much subject matter as well as illustrations. 
 
Oral Patbology and Cberapeutics. 
 
 CHAPTER I. 
 
 Dental paries* 
 
 Introductory. History. Recent Theories. Etiology. Bacteriology of Dental 
 Caries. Therapeutics. Curative Methods. 
 
 Tntroductory. 
 
 There is no subject in the entire range of dental science that is so 
 important to the dentist as that of caries. The treatment of its ravages 
 constitutes the greater part of his professional labors. The subject will be 
 presented in this chapter from a therapeutic rather than an operative 
 standpoint, although the cure of its ravages most frequently requires 
 operative procedures. 
 
 Tooth decay has been prevalent in all ages and among all races of 
 people, but it is only in recent years that its nature has been understood. 
 
 Caries of the teeth is a pathological process differing from that found 
 
 in the tissues in that it is not associated with, or a result of preceding 
 
 inflammation ; dental caries consists in a chemical dissolution of the tooth 
 
 substance. 
 
 history. 
 
 In the literature, the names of Boudett and Jourdain seem to be. 
 associated with the first scientific movement about 1776, which afterwards- 
 led to the theory of decay as a result of inflammation. A little later John 
 Hunter disputed this theory, but advanced no new one. 
 
 About the year 1806 Fox offered a further explanation ; he held. 
 decay was due to inflammation of the lining membrane of the pulp cham- 
 ber. In 1829 Bell and Fitch held that decay was due to inflammation of 
 the dentine immediately underneath the enamel. Koecker held that not 
 only was the process inflammation of the dentine, but that a second ele- 
 ment entered and dissolved the dead portion by means of chemical decom- 
 position. 
 
 In 1835 Robertson held that decay was due to chemical decomposi- 
 tion and that inflammation had nothing to do with the process. 
 
 Tomes held to this idea and added that there was some disturbance 
 of the dentine, and that the natural resistance of dentine to decay differed 
 according to its vitality. 
 
 Here the matter rested for many years. Dr. Watt adding that this- 
 chemical decomposition was due to mineral acids developed in the 
 mucous of the mouth. A little later Magitot held that decay was due tO' 
 chemical alteration in the enamel and dentine brought about through acids 
 developed in the saliva or through agents introduced into the mouth, and 
 
• 7 
 
 later that putrid decomposition of animal and vegetable substances is 
 responsible for acids found in the saliva. 
 
 A little later, about 1867, he brought forward the theory of micro- 
 organic fermentation as a cause for the appearance of acids in the saliva, 
 and that these acids so formed were the direct cause of tooth decay. 
 
 Recent Cbecrlcs. 
 
 Here the matter rested until Miller began his remarkable series of 
 experim.ents, the results of which were published in 1884 and 1885. Pro- 
 fessor Miller clearly demonstrated that caries of the teeth is brought 
 about by an acid, probably lactic acid, produced by the growth of micro- 
 organism in the mouth. While Dr. Miller was experimenting and study- 
 ing in Germany Dr. Black was at work along the same lines in America, 
 and brought out the additional fact that decay is not only the results of 
 acids produced by micro-organic fermentation, but in order to cause decay^ 
 those acids must be produced at the exact point where decay is to begin. 
 
 The profession rather reluctantly accepted this theory, and much 
 controversy has taken place in relation to the manner in which these 
 organisms work. Many have thought that some teeth were more prone to 
 caries than others because of the inherent nature of the tooth ; that some 
 were harder than others, richer in lime salts, and that some teeth after 
 calcification undergo a degenerative change, especially in particular spots^ 
 which render them more liable to caries. 
 
 All of these notions were dashed to pieces when, as a result of experi- 
 ments accurately made. Dr. Black in 1893 announced to the profession 
 that teeth do not materially differ in this regard, and that our term hard 
 and soft teeth is a misnomer as far as liability to caries is concerned, and 
 that "imperfections of teeth, such as pits, fissures, rough or uneven sur- 
 faces, bad forms of interproximate contact points, are causes of caries only 
 in the sense of giving opportunity for the action of the causes that induce 
 caries." — Black. 
 
 The carious process is slightly different in dentine and cementum 
 from that of enamel. On enamel the organism has to do its work under 
 the influences of a changing saliva, and in the presence of different kinds 
 of food, and is subject to dislodgment by the excursion of foods in masti- 
 cating, while in the dentine the organisms have a cavity which protects, 
 them from most of these influences. 
 
 Enamel is harder, has less animal matter, and therefore is more resist- 
 ant in a certain sense than dentine. The way in which decay of enamel 
 occurs is by the attachment of micro-organisms to its surface, and by their 
 action a dissolution of the cementing substance which holds the enamel 
 rods in place is the first step. 
 
Fig. 1. 
 
 Bacilli and micrococci in dental tubules. C, micrococci; T, bacilli. (Hopewell Smith.) 
 
 With dentine a somewhat different process occurs. As soon as 
 enamel is destroyed the lime salts around the tubules is dissolved and 
 soon the organisms penetrate the dentine tubules, Fig. i, and then spread 
 laterally, hence it is that decay passes into the tooth in a somewhat conical 
 shape. 
 
 Beyond the field occupied by organisms the lime salts are in a state 
 of decomposition for a considerable distance, which is preparing the way 
 for further ingress of the organisms. As the lime salts are dissolved there 
 is left the animal matrix which furnished food for these organisms. 
 
 The profession has been slow to take up these theories of Miller and 
 Black; many objections have been offered, chief of which centered in the 
 thovight expressed in the question, how is it possible for micro-organisms 
 to temain in contact with luibroken enamel long enough to accomplish 
 its dissolution? This question was finally answered by Dr. J. Leon Wil- 
 liams, of London, England, in 1897. ^^ demonstrated that the micro- 
 organisms that cause tooth decay are gelatine producing organisms. 
 These organisms collect in protected spots about the teeth and form a 
 gelatinous film which is very adherent to the enamel, and under this pro- 
 tection they do their work. Dr. Williams succeeded in grinding speci- 
 mens thin enough without disturbing the gelatinous plaque over the 
 decaying enamel to show the carious process, Fig. 2. These gelatinous 
 plaques seem to be rio bar to the passage of food material for the 
 organism. 
 
y 
 
 Fig. 2. 
 From a section of human enamel in early stages of decay. A, micro-organisms deeply stained; 
 b evidences of recent vigorous action of acids; c, temporary arrest of the organisms. (Williams.) 
 
 etiology. 
 
 Trom a Cberapcutic Standpoint 
 
 The present understanding of the causes that have to do with tooth 
 decay are divided into two classes, predisposing and exciting. 
 
 By predisposing causes is meant that condition of the general system 
 whereby the secretions of the mouth favor a certain kind of micro-organic 
 growth and development. Just what these conditions of saliva are has not 
 been made out. It was formerly believed that acid conditions favor the 
 carious process, but this has been proven erroneous. Certain it is that 
 the presence of carbohydrates in the saliva favor the process, for they 
 act as food material for the organisms. 
 
lO 
 
 The second predisposing cause lies in tooth imperfections which 
 make favorable places for these organisms to take hold and develop. 
 
 The exciting cause is acid produced at the immediate point of decay 
 by the action of micro-organisms. 
 
 Bsctcriology of Dental Caries. 
 
 Tooth decay is essentially a bacteriological problem. Without bac- 
 teria there would be no tooth decay. They are found everywhere, and 
 especially in the human mouth ; here certain forms are constantly found. 
 
 It seems that both coccus and bacillus forms have to do with caries, 
 although Miller was formerly of the opinion that only the bacillus form 
 were directly concerned. He isolated four varieties of bacillus, and 
 Goadly classifies three forms of cocci in addition. Black is of the opinion 
 that both varieties have to do with caries, and certainly they are both 
 frequently found in the dentinal tubules, as Fig. i illustrates. 
 
 Cberapeutics. 
 
 What has been said up to this point is a brief resume of the carious 
 process given as a basis for the practical therapeutics of the subject. 
 
 The practical therapeutics of this subject can most easily be presented 
 under two heads. 
 
 First, Prophylaxis, which relates to the means of preventing or 
 limiting tooth decay. Second, Curative methods, which relate to the 
 arresting of its ravages in a given tooth or several teeth when the carious 
 process has once begun. 
 
 The subject of prophylaxis is one of great interest, and although 
 caries has been known for many centuries, still very little has been accom- 
 plished in the way of prevention. It is in this direction that scientific 
 work is needed. 
 
 Since bacteria everywhere abound, it is not possible for us to prevent 
 them gaining access to the oral cavity, but we are able to hold in check 
 their ravages by three methods. 
 
 First and most important relates to the limiting of their food material, 
 which can only be done by limiting the amount of carbohydrates allowed 
 to remain in the oral cavity. Second relates to the cultivation of 
 habits of cleanliness about the oral cavity. Third relates to the use of 
 antiseptics in the oral cavity that will in a measure at least control bac- 
 terial activity. 
 
 It should be stated that while carbohydrates are essential to proper 
 nutrition, the tendency to consume far in excess of the needs of the system 
 is very great, especially among children. After all, the important point of 
 the matter is not to allow these things to remain in the mouth long enough 
 to undergo fermentation. 
 
II 
 
 The second method. 
 
 Many a person is unclean about his mouth because he does not 
 know how to properly care for it and others fall into careless habits. If 
 individuals could be taught to habitually cleanse every surface of every 
 tooth twice daily there would be very little decay. As stated before, these 
 gelatinous plaques cling in out-of-the-way places, and unless an efifort 
 is made to cleanse these spots decay will result. 
 
 The eating of coarse foods has a tendency to cleanse the teeth by its 
 excursion over their surfaces in mastication, and from this standpoint is 
 valuable. Some think too much brushing injures the teeth, but I have 
 never seen such a case. For prevention of decay, on retiring is the 
 important time to brush. 
 
 This subject will be treated further in the chapter on Cleaning Teeth. 
 
 The third method, regarding the use of antiseptic mouthwashes, it 
 should be stated that no known remedy can be used strong enough to 
 insure thorough antisepsis. Such a thing as asepsis of the oral cavity 
 cannot be hoped for. There are remedies that would render conditions 
 decidedly antiseptic, but they are so irritating to soft tissue that they can 
 only be employed in attenuated solutions. 
 
 Most mouthwashes in the market are antiseptic in their tendency, 
 although the most of them are more adapted to furnishing a pleasant taste 
 than to rendering conditions antiseptic. Conditions of the mouths differ, 
 requiring a little different wash for each case. 
 
 The agents that will furnish a basis from which to combine a mouth- 
 wash adapted to individual mouth conditions are benzoic acid, borax,, 
 carbolic acid, boric acid, oil cassia, trikresol, Black- 1-2-3, bichlorid of 
 mercury, hydrogen dioxid, permanganate, wintergreen and other essen- 
 tial oils as flavors. 
 
 In the use of an antiseptic mouthwash the patient should not only 
 rinse the mouth but should hold a mouth full of the solution for several 
 minutes. 
 
 €uratiDe methods. 
 
 The curative methods are three. First, The removal of all disinte- 
 grated tooth substance and polishing the surface. Second, The removal 
 of decay and filling the cavity. Third, The use of medicinal agents that 
 arrest the progress of decay. 
 
 The first method is only adapted to those cases where only a slight 
 amount of enamel is disintegrated, and which can be removed without 
 exposing the dentine or impairing the service form of the tooth or its 
 approximate contact. In these cases not only should the softened enamel 
 be removed, but that surface should be made smooth and highly polished. 
 
12 
 
 Second, The curative effects of fillings depend on three things, that 
 the area of liability of that cavity has been included in the prepared 
 cavity, and that a properly shaped tight filling is made and that no dentine 
 has been left exposed. 
 
 The third method relates to the use of such agents as nitrate of silver 
 in shallow, slow forming cavities in deciduous teeth, which will often 
 arrest decay until time for them to be shed. This method is also recom- 
 mended in those cases where slight decay occurs along the gingival line 
 of molars and bicuspids. Not only will it relieve the sensitiveness which is 
 usually found at those points but will often arrest further decay. Other 
 agents have been suggested, for example, formalin, chloride of zinc, 
 trichloracetic acid. 
 
 Recently McKesson & Robbins have suggested a tooth powder of 
 calcium carbonate which will generate hydrogen dioxide when in contact 
 with the lactic acid of decay, which they claim will effectually arrest 
 decay. 
 
CHAPTER II. 
 
 Cbe Dentdl Pulp. 
 
 The Functions of the Pulp. Sensitive Dantine. Other Cells. Blood Vessels. Nerve 
 
 Supply. 
 
 Before entering into a study of pulp diseases it seems wise that we 
 hastily reveiw the histology of the tissues involved. 
 
 Dental pulp is the name given to the soft tissue occupying the central 
 cavity of the dentine. It is made up of embryonal connective tissue, and 
 many blood vessels and nerves, but no lymphatics. There are four dis- 
 tinct kinds of cells, easily recognized the odontoblasts. Fig. 3, round, 
 spindle shaped, and stellate cells. The odontoblasts form a continuous. 
 
 Fig. 3. 
 Odontoblasts clinging to a fragment of dentine, showing their form. (Black.) 
 
 layer over the surface of the pulp, sometimes referred to as the membrane 
 eboris. (See Fig. 4). This so-called membrane is composed of columnar 
 cells lying close to each other, and sometimes present the appearance of 
 being crowded out of shape. Each cell has four projections or processes. 
 
 1. The dentinal fibrils or fibers of Tomes. 
 
 2. Tw'o lateral fibrils extending from the sides of each cell and 
 uniting with adjoining cell to make a complete layer. 
 
 3. A process passing into the pulp tissue. 
 
 The fibers of Tomes are small projections which extend from the 
 cell proper out through the dentinal tubules to the enamel and cementum^ 
 (See Figs. 5 and 5a and 6). 
 
'4 
 
 Fig. 4. 
 Longitudinal section pulp. O, odontoblasts; D, dentine; P, pulp. (Noyes.) 
 
r 
 
 
 .l-!g. 5a. 
 Section of dentine from the root, cut in length of tubyles. (Noyes.) 
 
 i'ig. .1 
 Section of dentine in crown cut in length of tubules. (Xoyes.) 
 
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 Fig. 6. 
 
 Section of dentine at right angles to tubules. (Noyes.) . 
 
 Cbe functions of tbe Pulp, 
 
 The dental pulp performs two functions, viz., a vital and a sensorv 
 function. The vital function is the building of dentine, which is done 
 through the odontoblastic layer. This function is most active while the 
 papilla Is large and dentine is forming, but after the tooth is once thor- 
 oughly formed this function seems to lie dormant unless some irritation 
 excites the trophic centers, which may result in the formation of secondary 
 dentine. The sensory function resembles that of the internal organs of 
 the body — sensation of pains when irritated in any manner, but has not 
 the sense of touch. This explains the difficulty Ave experience in locating 
 the source of pain when it comes from a vital pulp. There is one other 
 important point regarding the normal pulp which has a very direct bear- 
 ing upon the pathology, and that is this — the pulp tissue completely fills 
 the chamber and root canals. 
 
 Sensitive Dentine. 
 
 Normal dentine is not very sensitive, and the same is true of the 
 pulp. The most generally accepted explanation regarding sensitiveness 
 of the dentine is about as follows : The fibrils of Tomes, as we have 
 before stated, are prolongations of the substance of the odontoblasts ; 
 they are a portion of the odontoblasts extending through the dentine to 
 the dento-enamel junctions. These cells lie in direct physiological rela- 
 tion with the nerves of the pulp. (See Figs. 3 and 4.) 
 
17 
 
 Oih«r eells. 
 
 There does not seem to be any regular arrangement for the other cehs 
 of the pulp. For the most part they may be said to be sparsely scattered 
 throughout the tissue, assuming some regularity along the blood vessels. 
 These cells are held in a gelatinous-like matrix with few fibers. 
 
 Blood Uessels. 
 
 The blood supply of the pulp is abundant ; a number of arteries enter 
 through the apical foramen, and extend occlusally through the central 
 portion of the tissue, giving off many small capillaries (Fig. 7). The 
 
 Fig. 7. 
 
 Blood supply in point of pulp. 
 
 (Black.) 
 
 blood is collected into the veins and returns apically through the central 
 portion of the pulp tissue, passing out through the apical openings. The 
 blood supply does not always all come from the inferior and superior 
 dental arteries, but sometimes a portion of it comes from the alveolar cir- 
 culation, and occasionally there are lateral openings through the sides 
 of the roots. An interesting specimen is now in the school museum. The 
 thinness of the arterial walls is a peculiarity which we need to remember. 
 
 nerve Supply. 
 
 Several large bundles of nerve fibers enter the pulp along with the 
 blood supply and occlusally through the central portion, giving off many 
 branches, which penetrate the entire tissue, even passing between the cells 
 
of the odontoblastic layer. As yet no fibers have been seen to follow into 
 ihe dentinal tubules. 
 
 Whenever these fibrils are irritated the sensation is carried directly 
 to the sensorium through the central ganglia. The area of dentine that is 
 most sensitive is at the termination of these fibrils — and in this particular 
 they resemble other nerve endings. It is the finger tips that are most 
 sensitive, not the deeper parts. This leads up to the consideration of 
 hypersensitive dentine. 
 
CHAPTER III. 
 
 1)ypcr$en$itive Dentine. 
 
 The Management of Sensitive Cases. Systemic Medication. Management of Sen- 
 sitive Dentine. Obtundants. Thermal Sensitiveness. 
 
 Che IDanagtmcnt of Sensitive €4$e$. 
 
 Hypersensitive dentine is a term used to designate dentine which is 
 unusually sensitive to filling operations; it is a subject that has attracted 
 the best thought of the profession ever since filling operations began. 
 
 The proper preparation of cavities is often a very painful process; 
 patients differ widely in this regard. A cavity that is unusually painful 
 for one may scarcely be at all sensitive for another, although the cavity 
 may be very similar and the process of preparation be identical. Why is 
 this ? Why do patients suffer so differently from similar operations ? The 
 reason may be one or all of three. First, the condition of the fibrils may 
 be large and active to slight irritation, i. e., they may respond to the 
 ■slightest irritation. Second, the nervous sensibilities may be more acute. 
 A slight irritation may be magnified in its transmission to the brain. It 
 may be true that this nerve of transmission is perverted in itself, magni- 
 fying the actual irritation before it gets to the center, and so the patient 
 •suffers increased pain from that cause. And the third, the fear or dread 
 of the operation, may have induced an oversensibility in the pain centers 
 of the brain, responding to the slightest irritation, etc. In preparing 
 ■cavities in teeth containing living pulps we are usually causing pain, be- 
 -cause we are actually working on live tissue capable of responding to the 
 slightest irritation. The manner in which these dentinal fibrils respond to 
 irritation has already been explained. Another element that enters into 
 the cause of pain in these cases is the peculiar noise made by the instru- 
 ments used in the work ; particularly is this true of burs and stones in the 
 engine. Patients frequently present themselves in a highly nervous, ex- 
 cited condition, due to meditating upon the fact that they have som-cthing 
 to be done which they think will cause the ma degree of suffering beyond 
 their power to endure. I might say that this is quite the usual attitude 
 of mind that the patients present if they are coming to you for the 
 first time. Not infrequently they faint upon sitting in the dental chair 
 before you have done anything at all for them. This is an experience 
 which I have had a number of times, and others, too, have had the same 
 •experience. 
 
20 
 
 Our success in practice building will depend on our ability to decide 
 what to do for these patients. If for a few minutes I seem to digress and 
 preach a sort of sermon I hope you will excuse it. There are some 
 things that I want to impress upon your minds now ; they have been so 
 profitable to me and so profitable to hundreds of others, and I think this 
 is a good way to do it. The first thing, then, that we must do for these 
 patients, presenting themselves in the condition that I have indicated, is 
 that we must get their confidence. How is this done? I can't tell you. 
 Each case perhaps itself inspires the operator with the knowledge of what 
 to do; but I want to indicate to you along what line it comes. I am sure 
 all of you have had cases that to work for was irksome, not because of the 
 work itself, but because of the condition of the patient, or the attitude 
 of the mind of the patient towards you. They have a sort of a notion that 
 you are not going to do the work well, perhaps, or that you will hurt them 
 needlessly, and you can never get them to have confidence in what you 
 are going to do. When you get into practice here are some of the things 
 you must consider. First, the personnel of the dentist. You must have 
 a professional air about you. You want to recognize the fact that our 
 calling is something more than trade ; that it is a profession ; there is a 
 dignity about it, a professional air. Kind in manner and speech, and, as 
 someone has said : "Keep your voice low." There is a whole lot in that. 
 The dentist, of course, must be clean, quiet, cool-headed and in perfect 
 poise. ■ If you are nervous yourself about what you are going to do; if 
 your mind is all uneasy and your hand is shaky and you are in dread of 
 what you are going to undertake yourself, you can be sure that the 
 patient will catch every bit of that and magnify it in himself or herself. 
 I would like to cite you a little incident which came to my notice some 
 years ago. One of my confreres in practice here in the city, a most thor- 
 ough dentist and an excellent gentleman, came to me one day and said: 
 "Doctor, I don't know what I am going to do; every patient that has 
 come to me this week has fainted." I said: "How many hours a day are 
 you working?" "About twelve." I said: "You look as though you were. 
 How long since you had a vacation ?" "I didn't get my vacation this year ; 
 I was so busy and had so much to do that I couldn't get away." "You 
 had better take your vacation now ; now is the time. Your patients are 
 fainting because you impart this dread and fear to them yourself. You 
 are all nerves ; you are all unstrung ; you can't do anything the way you 
 want it done ; you can't find your instruments, and when you do you drop 
 them on the floor. You had better take a vacation." He took my advice, 
 and when he came hgme from his vacation he didn't have any more people 
 fainting in his chair. Then, you must give the patient your undivided 
 attention. Don't hurry, take your time, and give the patient all your 
 
21 
 
 attention. Then, of course, the dentist himself must be clean as to his 
 morals. What we are shows in our faces and our demeanor in every way ; 
 we can't hide it ; we can't debauch and conceal it. Then the next thing 
 is the office itself. The office must be clean and tidy ; there must be 
 evidences that the patient's comfort is considered, and above all it must 
 have a business-like air, i. e., it must appear to the patients when they 
 come in that this is a place where people come to have dental work 
 done. It is not a place to play in. It is a business office where everything 
 is arranged for the comfort of your patients and to execute business. You 
 don't know what an impression it makes upon patients for the first time 
 if they find an air of business about your office in general. I once went 
 into an office and saw in the reception room the gentleman's hunting boots 
 tliat had been there from the season before, and a lot of traps pertaining 
 to his hunting outfit laying there, covered with dirt and papers and cir- 
 culars and things wdiich will accumulate were thrown over this, and on 
 every chair you could write your name in the dust. I went into his pri- 
 vate office, and what did I see? On the bracket of his chair lay a forcep 
 with an old tooth in it. That tooth, I am sure, had been extracted the 
 day before, at least. The cuspidor was all covered with dried blood and 
 sputum. I said to him: "How is business?" He said: "Business is 
 bum." That gentleman tried to practice in Chicago for upward of fif- 
 teen years, and he has gone to a little town of one thousand inhabitants 
 now. Not that he was not a good dentist, for he was, but the inattention 
 to all these details disgusted everybody. Then, have an absence of dis- 
 agreeable odors about the office. How often you have patients tell you 
 that the odor about a dentist's office is the hardest thing for them to 
 bear. You do not need anything of the kind ; have the cuspidor clean. 
 And do not have any instruments in sight ; that is a hobby of mine. 
 When I first began practice I thought a pretty good stock in trade would 
 be to have a nice array of nickel plated instruments in sight. So I 
 started out with that idea, and patients would look in the direction of 
 these instruments, especially the extracting forceps, and wish they 
 hadn't come. I never have any instruments in sight now ; I mean by 
 that, when the patients comes into my operating room to have their teeth 
 examined they sit in the chair, and there is not an instrument in sight. 
 I have my case convenient and my instruments so arranged that I can 
 put my hand on any instrument I want immediately. Then after they are 
 used the young lady takes them and sterilizes and sharpens them, and 
 puts them back where they were before. This is a thing that I have no 
 special patent on; others do it the same as I do. Then you want your 
 instruments clean. • Nothing will disgust a patient so quickly as for you 
 to dismiss one patient and invite another one in with the dirty instru- 
 
22 
 
 ments you have been using lying on your bracket. Perhaps people who* 
 do not think of these things do not care, but the class of patients that 
 you want do care. The world over the laity understand about infection ; 
 they understand about the danger of carrying disease from one to an- 
 other on instruments, and you will fool yourself if you think they don't. 
 I have had any number of patients come to me for the reason that their 
 dentist seemed to use instruments on one after another without sterilizing. 
 In the first place it isn't correct practice ; if you should infect a patient 
 in that way you would be liable for malpractice ; and in the second place, 
 it is absolutely false business principles. Then attend to the details for 
 the patient's comfort. One of those little details is this, and will serve to 
 make clear my meaning : patients often come with their lips chapped, and 
 you should have a little cold cream or something of the kind, that you 
 can smear on the lip to protect it. Let the patients have an idea that you 
 are thinking a little about their comfort. Then assure your patient that 
 your aim is to work with as little pain as possible, and do operations well, 
 that you will not hurt needlessly. I say to patients : 'T will tell you when 
 I am going to hurt, and so you need not be expecting it until I tell you.'^ 
 That helps a whole lot. And then they don't worry about it. And get 
 your patients calm and relaxed before you attempt to do anything. Make 
 Lhem let go of their nervous tension. You will find patients when they 
 come for the first time will usually grip hold of the arm of the chair, put 
 their feet down against the footrest and stififen themselves right up — just 
 the opposite to what you want them to do. The first thing to do is to 
 explain to them the philosophy of the action of their nervous system 
 regarding pain, which can be done in half a dozen sentences, and get 
 patients to release their hold on the chair, drop their hands at their 
 side or into their lap and relax themselves entirely ; tell them to take 
 in a few full breaths, quiet and restful ; lower your voice and talk to them 
 in that way, and tell them to Just forget themselves and let their mind 
 be relaxed. I do not know anything about hypnotism, but if this is 
 hypnotism that is the thing you want to practice ; it will bring you success, 
 I think I used to suffer more than anybody else having my teeth attended 
 to; dentists always do. When you get into practice and have 25 or 30 
 dentists on your regular list you will find that they always think they are 
 the ones who suffer the most. I was sure I did. I used to have a terrible 
 time. I got to thinking about this thing, and I concluded I would prac- 
 tice on myself some of the things I was preaching. I go to my dentist 
 and sit down in the chair, and in a few minutes I get myself so relaxed 
 that scarcely any operation in the mouth causes me any pain whatever. 
 Not that I am not just as sensitive, but because I am able to relax my 
 entire system in such a way that I suffer less than others do. That is the 
 
23 
 
 kind of thing I want you to get in the habit of doing. You will be aston- 
 ished to find how it will aid you. Then after you have done this under- 
 take something easy the first sitting and gradually work towards the 
 more difficult and severe. When your patient trusts you implicitly you 
 have won a lasting friend and a most profitable patient. The fact of the 
 matter is, if you will just take time to do this thing the first time the 
 patient comes, you will have no trouble in keeping that patient as long as 
 you are in practice. They will come to you under all circumstances. It 
 is the first visit that bothers all of us. I have patients, and so has every 
 practitioner, the first time they came to me was almost killing on myself 
 to do anything for them. Every move you make their hands will go up 
 and catch your hand. "Oh, dear, I really don't think I can stand this; 
 you will have to let me rest awhile," and all that sort of thing, and you 
 put in an hour or two in doing something that you could do in five 
 minutes. 
 
 But when they get confidence in what you are going to do, you will 
 not have any trouble. I have people with whom I have had just such 
 experience, who come to me now v/ithout the least dread, and it is a 
 positive pleasure to work for them. I remember one case in particular 
 about eight years ago. I was associated in my office at that time with a 
 very estimable gentleman. This patient made so much fuss that it dis- 
 turbed his patient and himself and everyone in the office, over work that 
 was not painful in itself, and I pretty near killed myself trying to 
 do decent work for her the first few visits. 
 
 Finally my associate came to me and said : "There is no use talking, 
 you will have to let that patient go or she will drive everybody out of the 
 office." I was quite inclined to adopt his notion of it; but I finally got 
 through with that series of operations, and I have had no trouble with 
 that patient since. She comes to me regularly and has sent me dozens of 
 others. She came to me from another dentist because his operations 
 were not successful ; she was losing fillings all the time. Why ? Not be- 
 cause he wasn't a good dentist, but because he couldn't get that woman 
 into condition where he could work for her. If you cannot get a patient's 
 confidence let him go. You can't afford to do otherwise. Working for 
 people who are set against everything you are going to do is absolute 
 folly, because you are killing yourself, you are killing the patient, you 
 are doing poor work ; you can't help yourself, and it will add nothing to 
 your credit, and in building up a practice you do not care so much for 
 cases that just happen in to have something done. What you want are 
 families that are going to come to you year after year, that are going to 
 say a good word for you among their neighbors and friends, and because 
 you are just starting in practice and need every dollar you can get will 
 
24 
 
 lead you to undertake things, just for the sake of that income which you 
 cannot properly do. Such a procedure is absolutely foolish business 
 policy. If you dismiss that patient with a distinct understanding, say 
 to him : "You have no confidence in what I am trying to do for you ; you 
 have set yourself against what I am trying to do, and under those condi- 
 tions I cannot do you good work ; I am unwilling to do what I know to 
 be poor work, and you will have to go to someone else." That will often 
 bring them to their senses and they will appreciate what you are trying 
 to do. Make a practice of studying each patient ; no two are exactly 
 alike, and what I have said will not appl}' to each case, but will serve to 
 indicate the method of procedure. In managing children in order to 
 have them bear things that are painful requires a good deal of tact. And 
 your success in m.anaging these little folks has much to do with building 
 up a practice, for it is astonishing how rapidly little folks grow up to 
 be big folks. 
 
 Systemic medication. 
 
 For the purpose of allaying this nervous irritability we frequently 
 need to call to our aid some systemic remedies. Hypnotic anodynes, 
 agents that have the power of allaying sensibilities of the nerve centers, 
 or the peripheral terminations, are those of most value to us. In this 
 class belongs opium and its various preparations and most important alka- 
 loids, chloral, trional, sulphonal, bromide of potassium. Morphine is one 
 of the alkaloids of opium, and the one mo^t used. For purposes of alle- 
 viating pain it is without a rival. It is given in doses of j4 grain an hour 
 before the operation, and another fifteen minutes before. I never tell my 
 patients what they are taking when they take morphine, because so many 
 have a prejudice against it. When they come in for exam.ination and 
 you recognize that you are going to have trouble, you can give them 
 one of these little tablets, and tell them to take it an hour before they 
 come the next tirne, and when they come to the office you give them 
 another one. 
 
 Dover powder is the form of opium frequently given for allaying 
 painful conditions, especially about the peridental membrane, in 5 gr. 
 doses. . " 
 
 Codeine, another alkaloid, is frequently used ; it is much less powerful 
 than morphine. 
 
 Chloral is often of value, especially for the purpose of allaying ner- 
 vousness where there is little pain to be endured. In large doses chloral 
 produces sleep quite like natural sleep, from which the patient can readily 
 be aroused. If operations are painful it is not so valuable as the opium 
 preparations, but I have had very excellent results in doses of from 5 to 
 20 grains simply .for the purpose of quieting the patient. 
 
25 
 
 Trional I have tried with success in many cases in doses of from 15 
 to 30 grains, also sulphonal, tetronal and hydronal. Fhiid extract of 
 Jamaica dogwood is said to be of value, but personally I have never seen 
 its value. I have frequently received surprising results from the use of 
 bromide of potassjum in 10 grain doses. Next to opium I rely on this. I 
 have never received any assistance f rOm the coal tar antipyretics. You will 
 find in the literature men recommending these for the purpose of allay- 
 ing nervous irritation, but personally I have received no benefit from them. 
 
 ntanasemcnt of Sensitive Dentine. 
 
 Locally, i. e., to the cavity itself. Have the cavity perfectly dry. 
 Never attempt to excavate a sensitive cavity without the rubber dam on. 
 Use warm air and alcohol to assist you. Use only sharp burs, and if you 
 have teeth to be filled just try the experiment of having the operator use 
 a dull bur and a sharp one, and note the difference in the amount of pain 
 they induce. Have your excavators sharp, avoid overheating and make 
 no false moves, but make each stroke count. When you are not going 
 to hurt say so, and when you are tell the patient : "This will hurt a little 
 bit ; I will be careful, and it will be only for a moment." 
 
 Obtundents. 
 
 For purposes of obtunding the sensitiveness in the cavity many sub- 
 stances have been used. Once upon a time men used arsenous acid, seal- 
 ing it for twelve hours, but all those pulps died. Then came the use of 
 chloride of zinc, which is still used by applying the crystals directly to the 
 cavity and allowing to liquefy in the cavity, i. e., allowing the crystals 
 to absorb sufficient moisture to become liquid, leaving it tor fifteen minutes 
 or so. This frequently assists greatly. You must not use chloride of 
 zinc when your pulpal wall is very thin, or too near the pulp. The next 
 agent which was used is nitrate of silver. This, perhaps, is as efficient 
 as any agent we have, but because it discolors the teeth it cannot be used 
 inany anterior teeth, and I never like to use it in a cavity at all, except 
 in children's teeth, of which I will speak later. But around sensitive mar- 
 gins in the posterior teeth, where no actual decay occurs, it is of value. 
 The method that I employ of using it is this : I make my solution fresh 
 each time, making a saturate solution of nitrate of silver in sterilized 
 water. Then I take an orangewood or rosewood stick, whittle it flat like 
 a spatula, then dry the surface to which it is to be applied, dip the point 
 of this stick in the solution and rub it back and forth over the sensitive 
 part, doing this four or five times, and avoid getting it on the soft tissue. 
 I find that to be a very efficacious method. Others crystallize this nitrate 
 of silver on the point of a platinum wire, and then allow the moisture to 
 remain on the surface, rubbing this point over the moist surface. Others 
 
26 
 
 use it by making thpir saturate solution and then cutting little squares of 
 asbestos or blotting paper. This blotting paper I had prepared tor the 
 infirmary as far back as 1892, and I am surprised to have someone bring 
 it forward as an original notion of his. When you wish to use it, allow 
 the surface to be moist, and take up this little piece of paper and rub it 
 back and forth over the surface. That is a very nice way to have it for 
 purposes of applying it to the soft tissue where you want to burn out a 
 mucous patch, little ulcers that occur on the tongue and around inside the 
 lip that are painful. But I have got in the habit of using it in the method 
 spoken of first. Others use a silver wire and dip it into nitric acid, 
 forming their nitrate of silver direct. 
 
 Now, care must be taken in using these preparations not to get 
 ihem over the soft tissue as it will burn the tissue wherever it touches. 
 If accidents do occur with this, what is the thing to do? Use salt and 
 water, forming a comparatively insoluble chloride of silver, and you 
 have corrected the harm the quickest way you can. When the sur- 
 faces are badly discolored from its use, and for any reason you wish to 
 bleach it, use a solution of cyanide of potash, or another way is to paint 
 the discolored surface several times with the tincture of iodine, rubbing 
 it back and forth until the iodine has actually cut the stain ; then bleach 
 your iodine with ammonia. 
 
 Absolute alcohol is a valuable obtundaht. It should be applied di- 
 rectly to the cavity with a fine spray and continued for a few minutes. 
 The benefits derived are due to the extreme dryness caused. A mixture 
 of ether, chloroform and alcohol is valuable used in a similar manner. 
 Ether, chloroform, alcohol, menthol in equal parts has been suggested 
 as a valuable obtundant. This mixture should be used in an especially 
 made compressed air atomizer. A very fine spray is what is needed and 
 should be directed into the cavity while excavating or burring. Rhigo- 
 line, a light petroleum ether, has been recommended. Ethel chloride. 
 
27 
 
 which is sold under many names by different firms, is a valuable remedy. 
 It comes to us in a special container made of thin glass or metal, with 
 a stop screw so arranged that it can readily be opened when the heat 
 of the hand will cause a fine spray to spurt out ; this spray should be 
 directed into the cavity a few moments before beginning work and re- 
 peated frequently while excavating. Fig. 8. All of these ether mix- 
 tures obtund the sensitive dentine by their excessive drying action and 
 also by the extreme cold the}^ cause, and therefore some care must be 
 exercised in order to avoid pain while using and death of pulp as a 
 final result. 
 
 Carbolic acid applied warm to the cavity will often prove helpful. 
 
 Cocain, used in connection with ether, is of value, and also used 
 under pressure in a similar manner is applied for immediate extirpation 
 of pulps. That cocain used under pressure will obtund sensitive dentine 
 there can be no doubt, but the after effect upon the pulp is a matter 
 still to be determined. 
 
 Cocain citrate sealed in the cavity for 24 hours sometimes proves 
 helpful. Many operators inject one per cent, cocain hydrochiorate solu- 
 tion into the gum tissue the same as for tooth extraction, which will 
 often prove helpful. Recently it has been suggested that nitrous oxide 
 be administered. The Hurd, Clark and Tetter inhalers have been made 
 for the purpose. The plan is to have the gas given by way of the nose 
 and not to completely anesthetize the patient; but just enough is given 
 to produce sem.i-consciousness, which condition can be maintained for 
 several minutes, during which time the excavation is completed. The 
 author has never had much success with this method. The difficulty of 
 preventing the patient taking air through the mouth and maintaining 
 dryness while working, added to the dislike patients have for taking the 
 gas seems to indicate that the plan will never be generally adopted. 
 
 Hemicranin dissolved in nitrous ether sealed in the cavity for a 
 few minutes will often prove helpful. 
 
 In concluding this subject I wish to emphasize the importance of 
 working with precision and decision, using sharp instruments, and 
 when possible cutting the fibrils a little way from their terminations par- 
 ticularly in labial and buccal cavities, absolute dryness is essential ta 
 success. 
 
 When all has been said the fact remains that some cases present 
 that will not yield to any measures suggested, and it is my teaching- 
 not to attempt the impossible. If permanent operations cannot be made 
 without too much suffering then by all means do temporary work and 
 have it so understood. When cavities are filled with oxyphosphate 
 
28 
 
 cement for a year or so the fibrils lose their sensitiveness, when perma- 
 nent fillings can more easily be made. 
 
 tbermal Sensitiveness. 
 
 The tooth pulp is peculiarly sensitive to thermal changes. Everyone 
 has had the unpleasant experience of allowing ice water to come sud- 
 denly in contact with the teeth. The sensation is always one of pain 
 more or less severe according to the condition of the pulp. Normally 
 the pulp responds in this way to excessive changes of temperature and 
 cannot differentiate between heat and cold. Within reasonable bounds 
 this is normal, but under certain conditions it becomes hypersensitive to 
 these changes — the slightest elevation or reduction of temperature pro- 
 duces pain, and, while this is unpleasant to the patient, it is sometimes 
 of diagnostic aid to us, to Which I shall refer in another chapter. When 
 such conditions present you may feel very certain that changes are 
 going on in the pulp itself. There is present a pathological condition 
 and at least the beginning of hyperemia of the pulp, which is the subject 
 of another chapter. All I wish to say here in this connection is that 
 there is an injury to the blood vessels of the pulp accomplished by trau- 
 matic or chemical irritation through the fibrils and odontoblastic cells 
 as a rule, but may be brought on by a variety of things — the clearest 
 statement I find on this point is in Dr. Black's lectures, page 216, which 
 is as follows : "Thermal sensitiveness is liable to be aroused in many 
 different ways. I have suffered from it myself occasionally in my incisor 
 teeth from its being aroused from heat of a cigar in smoking, so much so 
 that I had to either cease smoking or protect the teeth. It may be caused 
 suddenly by an extraordinary exposure to cold, as ice water. It may be 
 caused suddenly by exposure to hot drinks, and the dentist may develop it 
 suddenly by the heat of the disc in finishing a filling or the heat of a 
 bur in excavating, in any tooth that has a living pulp. Often the ther- 
 mal sensitiveness is aroused during the progress of decay, especially when 
 the decay has reached the neighborhood of the pulp of the tooth, and the 
 patient will have paroxysms of pain continuing longer. This continua- 
 tion of the paroxysms of pain marks the severity of the case, and finally, 
 if it continues to grow worse, the patient will have pain when lying down, 
 will have pain at night; the difference in blood pressure between the 
 horizontal position and the upright position wlill be sufficient to deter- 
 mine a condition of pain. They will become sensitive as that. I have 
 seen cases in which throwing of a stream of water on the tooth three 
 degrees off either way from the normal temperature of the body would 
 induce excruciating pain. In the management of cases it is the utmost 
 importance that we recognize what may occur, and due caution in regard 
 
29 
 
 to running disks dry, or even in running them wet we may sometimes 
 produce too much heat, or running burs too long in excavating, or any 
 of these things that are calculated to produce heat which may suddenly 
 precipitate a condition of hyperemia of the pulp or thermal sensitive- 
 ness. 
 
 What will we do for it? There is only one thing to do, and that is 
 to protect the case as absolutely as possible from thermal changes until 
 it recovers. That may be done in various wavs. In some of the worst 
 cases I have put caps of gutta-percha over the teeth involved, covering 
 them in completely, particularly with persons who must be out in the 
 cold air, and where I could not otherwise induce persons to protect 
 them from thermal changes. The patient himself, or herself, may pro- 
 tect the teeth from thermal changes ; they may avoid cold or hot drinks ; 
 they may avoid cold or hot foods ; they may avoid breathing from the 
 mouth, and in this way protect the teeth, and it is very much the best 
 way to protect them from thermal changes. If we put gutta-percha 
 caps over the teeth they will be very annoying, and it is often difficult to 
 induce patients to wear them. 
 
 Cases of very severe thermal sensitiveness will get well if properly 
 protected, generally promptly, within a week or ten days. Sometimes, 
 however, it may require more time, and wherever we find them devel- 
 oped to any extraordinary degree, so as to be very annoying, we should 
 desist from all operations upon that tooth except those calculated to 
 mitigate this condition. If it has occurred from a cavity of decay it is 
 best to remove all decayed dentin completely, so as to remove the irrita- 
 tion caused by the irritants in the decaying mass. When the cavity is 
 prepared do not make a filling, but make a temporary filling of gutta- 
 percha, and be sure you make a tight filling. Have the walls dry first, 
 and moisten them with eucalyptol, so as to have your gutta-percha 
 adhere and make your filling tight. This is the best treatment, for 
 gutta-percha is the best non-conductor we have with which to make these 
 temporary fillings. A gold filling at that time would be the worst thing 
 that could be done. Then await the cure of this condition before making 
 any other operations upon that tooth, and if it is severe avoid any opera- 
 tions whatever in the mouth until that tooth shall have recovered, or at 
 least any operations that are not absolutely necessary at the time. 
 
 Now, this condition often ends in death of the pulp from strangula- 
 tion or infarction. Today the tooth may be extremely sensitive to ther- 
 mal changes ; tomorrow the pulp may be dead, and this sensitiveness 
 may have disappeared completely. The sudden disappearance of this 
 thermal sensitiveness marks very certainly the death of the pulp, and 
 when the pulp of a tooth has died under these conditions it is of extra 
 
30 
 
 importance that we get the pulp out as quickly as possible. When recov- 
 ery is complete in these cases it is usually by the pulp receding from the 
 point of irritation and depositing through the odontoblasts a layer or 
 layers of secondary dentine. 
 
CHAPTER IV. 
 
 Constructive Diseases of tbe Pulp. 
 
 Secondary Dentine and Pulp Nodules. Causation. Pulp Nodules. Symptoms. 
 Calcific Degeneration of the Pulp. 
 
 Seconaary Dentine ana Pulp nodules. 
 
 By the term secondary dentine is meant dentine formed about the 
 walls of the pulp chamber abnormally. Pulp nodules is a term used to 
 define irregular masses of calcic material occurring within the pulp tis- 
 sue. These appear to be slightly different phases of the same process. 
 The pulp seems to throw out a layer or layers of dentine or bony 
 substance resembling it, as a means of protecting itself from the irrita- 
 tion of encroaching caries, erosions, abrasions, and from the thermal 
 irritation as a result of large metallic, especially gold fillings. In the 
 majority of cases where gold fillings are placed teeth are more or less 
 sensitive for some weeks, and only passes away as new tooth material is 
 deposited in the tubuli over the point of pulp exposed to such irritation. 
 With advancing years pulp chambers become smaller, made so by the 
 continuous deposit of dentine ; the lumen of the tubules lessens. This 
 process goes on until the pulp is almost obliterated in extreme old age. 
 
 Fig. 9. 
 Deposits of secondary dentine. A, section of an incisor showing caries at a and secondary 
 dentine at b; B, section of secondary dentine; a, pulp chamber; b, b, secondary dentine; c, 
 primary dentine— notice directions of tubules in each. (Black.) 
 
32 
 
 Within certain limits the formation of secondary dentine is purely a 
 physiological process, and seems to be a part of nature's scheme to pro- 
 tect the pulp, and is deposited by the odontoblasts. 
 
 Fig. 10. 
 
 Secondary dentine filling the pulp cliamber of an abraded cuspid. A, part abraded; c, the 
 abraded surface; rf, secondary dentine; <?, a slender point of pulp; f, deposits on wall of canal;. 
 g, deposits in pulp tissue. (Black.) 
 
 FiR. 11. 
 The same as Fig. 10 — magnified to show difference in primary and secondary dentine. D, 
 normal dentine; b, secondary; e, remains of pulp; /, small oval deposits in pulp. 
 
33 
 
 Secondary dentine differs anatomically from normal dentine, from 
 Avhich it can usually be distinguished by its lessened translucency and 
 changed direction of the tubules ; indeed, the microscope will show fewer 
 tubules in the secondary than in the normal dentine, and the line of 
 demarcation can easily be seen. (See Fig. 9.) 
 
 The extent of these deposits is important to note. Some observers 
 think it never progresses so far as to completeh' fill the chamber and 
 root canals ; others have cited cases where the entire canal seemed to be 
 filled. I have had several cases where the upper two-thirds were com- 
 pletely filled as a result of wearing down the teeth. They were abraded a 
 considerable distance below the covering of the normal chambers. (See 
 Figs. 10 and 11.) 
 
 In the molar teeth these deposits occur most peculiarly. In some 
 instances sim.ph' a small amount immediately under the carious cavity 
 only ; and in other cases the deposits wall not only be at that point but 
 on the floor of the pulp chamber as w^ell when the normal grooves in the 
 floor will be obliterated. In other cases the deposits will occur on oppo- 
 site walls and progress until the chamber proper is completely obliterated 
 CFig. 12). In still other cases it will deposit in well rounded tumor-like 
 masses held to the wall by a narrow pedicle. 
 
 Fig. 12. 
 A, outline of lower molar with cavity at h: at a is seen a large mass of secondary deposit's: 
 B — a, the granular mass of secondary deposits; h, a little different form of deposits, and e, 
 cylindrical form of deposits; c, growth from floor quite regular in form; d, outline of cavity. 
 (Black.) 
 
34 
 
 I have seen some cases of one rooted teeth where the deposit occurred 
 on the walls of the root canal, producing- a stricture, as it were, of the pulp. 
 
 Causation. 
 
 Very little can be said regarding- the cause of secondary dentine ; 
 much has been written, most of which is conjecture. Reasoning from the 
 cases we know about it would seem to be due to some mild form of irri- 
 tation from without, to which I have previously alluded, or to some 
 trophic nerve disturbances. In all" instances it seems clear that there 
 must be a constantly recurring hyperemia of a very mild type, for in 
 all of these cases of purely secondary dentine we get no history of pain 
 of any marked degree, and in most instances no pain whatever. The 
 clinical importance of these cases relates to the fact that sooner or later 
 the pulp is lost, and in case the pulp has to be removed for any cause it 
 makes the accomplishment of that end more difficult. This point will be 
 referred to again in the chapter on capping pulps, and also in the chapter 
 on the management of root canals. 
 
 Pulp nodules. 
 
 As before stated, they are irregular masses of bone-like substances 
 occurring within the pulp itself. They resemble secondary dentine in 
 chemical and physical construction, but differs from it in anatomical char- 
 acteristics. They seem to more nearly resemble bone. They are not 
 built by the odontoblasts, but the exact method of their formation seems 
 to be in doubt. Dr. Black, who seems to have done most work in study- 
 ing out these formations, describes three distinct forms. 
 
 I. Deposits of calcoglobulin, in form resembling the other two, but 
 soft and always found in the inflamed portion, usually just beneath the 
 odontoblasts. (See Fig. 13.) Some think these are masses from which 
 nodules are formed. 
 
 - ^'"v^m. : 
 
 Fig. 13. 
 Deposits of calcoglobulin within the pulp tissue. 
 
35 
 
 2. Calcospherites — hard round bodies differing in size, but formed 
 in layers like the onion. (See Fig. 14.) These seem to be formed in any 
 portion of the pulp, and are usually mixed in among the nodules and 
 sometimes are contained within the nodule itself. 
 
 Pulp nodules, tooth of a whale. 
 
 (Barrett.) 
 
 3. Pulp nodules, the hard irregular masses above referred to and 
 illustrated in Fig. 15, occur throughout the pulp tissue, but more abun- 
 dantly in the crown portion, and we are sometimes astonished to find 
 such large numbers of them within a single pulp. One case in my prac- 
 tice I succeeded in removing 66 distinct nodules, and yet the tooth had 
 given very little trouble to the patient. Dr. Black is of the opinion that 
 they originated within the veins of the pulp and are more abundant in 
 middle age. They seem to occur in perfectly sound and otherwise healthy 
 teeth. 
 
 -^.^ V^^-^V-^SJi^ Vv X 
 
 Fig. 15. 
 Pulp nodules in the central portion of pulp. (Black.) 
 
 Symptoms. 
 
 Pulp nodules may exist in great numbers and give rise to no dis- 
 comfort, as I have often seen in extracted teeth, which have given no 
 
36 
 
 history of pain, and also in cases where pulps were destroyed for bridge 
 abutments. 
 
 Then again the pulp of a tooth may be the seat of the most excru- 
 ciating pain without the least external evidence as to cause, and when 
 the pulp is destroyed it is found to be filled with very small nodules. 
 Reflex pain is very commonly associated with these deposits, and pulps 
 containing them become exceedingly painful to the mildest irritation. 
 Persistent neuralgia with the pain deflected into some distant organ or 
 part of the head is very commonly found to be associated with these 
 deposits. Indeed, after 15 years' experience in handling these cases I 
 have come to the conclusion that when these neuralgic pains persist 
 about the face and jaws and also the ears, and I cannot find any external 
 signs about the teeth as the probable cause, the cause is the formation 
 of these nodules or other deposits within the pulp chamber of some 
 tooth which can only be located by using all tests known, and sometimes 
 by cutting into the tooth and devitalizing can the fact be found ; although 
 hypersensitiveness to thermal changes or little or no response will often 
 aid in locating the offending tooth. Treatment must always be devital- 
 ization and removal of pulp involved, which is by no means an easy 
 matter in many cases, requiring patience, perseverance and weeks of 
 time. This will again be alluded to in the chapter on devitalization. 
 
 Calcific Degeneration of tbe Pulp. 
 
 Calcification of the tissues of the pulp is another problem presented. 
 This is a condition which the pulp itself, especially the fibrous tissue, 
 becomes calcified, resembling calcifications occurring elsewhere in the 
 body. It seems to follow certain degenerative changes in the pulp tissue 
 itself, usually low chronic inflammation. The morbid anatomy presents 
 some marked differences from that seen in the nodular and dentine cal- 
 cifications. In this variety the pulp tissue itself seems to be converted 
 into hard bony substance, and in the root portion assumes a cylindrical 
 form apparently about the fibers. (See Figs. 16 and 17.) In some cases 
 this calcification may go on until the whole central portion of the pulp 
 is involved, extending from the crown chamber to nearly the apical for- 
 amen. I have such a specimen now where I succeeded in removing a 
 bony cone from an upper cuspid which is nearly as long as the root canal 
 and chamber, and is surrounded by a thin layer of pulp tissue. In this 
 case there was no symptomatology. Indeed, in any cases there does not 
 seem to be any differentiating symptoms. In concluding this chapter I 
 wish to cite a case that came under my observation, as follows : 
 
 A gentleman about 48 years of age came to the office complaining 
 of severe pain in the right side of his face, a sort of paroxysmal pain. 
 
Fig. 16. 
 
 A, entire pulp; b, pulp nodules; c. pulp without nodules. (Schlenker.) 
 
 Fig. 17. 
 Acute inflammation of the pulp. D, dentine; P, pulp; B, enlarged capillary; C, calcoglobular 
 mass. (Hopewell Smith.) 
 
 Examining his teeth, I could not find any cause for trouble excepting that 
 the occlusal surfaces of the molar teeth were abraded mechanically, the 
 cusps were worn down. The application of the usual means of detecting 
 hyperemia failed to detect any. I used in his case electricity, together 
 
38 . 
 
 with a liniment and massage to his face, and it seemed to relieve him 
 somewhat for a time. By and by these pains would come with increasing 
 intensity, so that the muscles of the face would undergo spasmodic con- 
 traction beyond his control entirely. Well, he was an individual who 
 wouldn't bear much work with his teeth. He was one of those indi- 
 viduals who didn't believe much in having much done with his teeth any- 
 way, and consequently had neglected them until he had lost a num.ber of 
 his molars. He decided on his own hook when we couldn't find the cause 
 of the trouble, that he would have a certain one out, and he went and had 
 a lower second molar extracted. He brought the tooth back to me and 
 I cracked it open. The contents of the pulp-chamber and the three canals 
 were completely calcified, so that I removed it all in one piece, a thing 
 which occurred in successive teeth of his until five teeth went in the same 
 way. I don't know what the cause was. It didn't scarcely seem prob- 
 able that the mechanical attrition was the cause. I rather think it was 
 something of a systemic nature that had to do with it, but I don't know. 
 Hypertrophy of pulp will be treated under inflammation of pulp. 
 
CHAPTER V. 
 
 Destructible Cbanges in tbe Pulp. 
 
 HviJeremia. ' Causes of Active Hyperemia. Causes of Passive Hyperemia. Causes 
 
 of Hyperemia of the Dental Pulp. Painful Process. Discoloration. 
 
 Symptomology. Treatment. 
 
 It does not seem to me desirable that I should here go into a 
 lengthy explanation of the hyperemic process other than as seen in the 
 tooth pulp. Your studies in general pathology have made you familiar with 
 this general subject, and yet I think it wise to present concisely the main 
 facts. For further consideration you are referred to general text books 
 on the subject of pathology and surgery. Hyperemia is a condition in 
 which there is an increased amount of blood in the part. When due to 
 increased arterial flow of blood it is called active hyperemia, and when 
 ^\\^ to an obstruction in the flow of blood away from the part, we call it 
 passive hyperemia. 
 
 Causes of Jlctit^c Byvcremia. 
 
 Active hyperemia may be purely a physiological process ; unusual 
 exercise of any organ calling for increased nutrition through the circu- 
 lation will cause a physiological hyperemia. That is the method by 
 which nutrition is supplied. The blood supply of the tissues and organs 
 of the body is under the direct control of the vaso-motor system of 
 nerves ; when any part is in need of increased nutrition this fact is, as 
 it were, telegraphed to the centers, and at once the arteries and capillaries 
 relax, and an increased amount of blood passes through, and so long as 
 the normal physiological function is maintained in the part we have purely 
 a physiological hyperemia ; but if carried beyond this, and we have a 
 considerable amount of blood with widely distended vessels, injured walls, 
 etc.j we have a pathological hyperemia, and the beginning of inflamma- 
 tion. Active h^'peremia may be caused also by disease of the heart, e. g., 
 over activity of the heart or disease of the arterial walls, they being too 
 relax, etc. 
 
 €<iu$c$ of Passive l^yperemia. 
 
 Active hyperemia is liable to become passive. After a time, from 
 overwork or injury the veins fail to carry away the blood as fast as it is 
 supplied ; there is then a slowing of blood movement in the part. The 
 vessels' walls lose their tone and the blood collects and become stagnant. 
 I mean by stagnant that there is not sufficient oxygen in it ; then we have 
 
40 
 
 passive hyperemia. We have passive hyperemia from still another cause, 
 namely infarction, when from any reason some semi-solid substance, a 
 blood clot, calcarious matter, an embolus, or what not, breaks away from 
 its original moorings and floats into the blood stream until it lodges in a 
 small artery, which in turn collects other blood cells to itself, resulting 
 in complete or partial stoppage of the vessel. Blood continues to flow In 
 increasing quantities to the part ; little or none passes away ; then we 
 have truly a pathological condition, which soon results in serious inflam- 
 mation. The amount of blood stagnant in the part will depend somewhat 
 on the number of anastomosing branches in the exact locality. Infarc- 
 tion can be artificially produced. Let me say that the method used for 
 demonstrating that is to take some of the lower animals, more particu- 
 larly the frog. Conheim, for example, took little balls of wax, opened the 
 aorta and dropped these balls of wax into it. Then as they passed along 
 the circulation he lifted up the tongue, and could see the balls of wax 
 stopping in the arterioles under the tongue. 
 
 Illustrating the fact that when these things that I have spoken of as 
 an embolus, a little blood clot, or a little calcarious matter, or anything 
 of the kind that has formed and becomes attached somewhere, breaks 
 loose and floats down the stream, and when it o'cts to where it can't go 
 any farther it plugs it up, and as a result we have blood flowing to the 
 part in an increased quantity, none going away, and we have as a result, 
 infarction and passive hyperemia. If we watch the tissues under the 
 microscope during the process and progress of hyperemia what do we 
 see? The most common experiment is to take the web of a frog's foot, 
 stretch it tightly across the field of the microscope and notice the blood 
 flowing; you can see it readily; then irritate the part so as to injure the 
 tissue. First, you will notice a slight contraction, followed immediately 
 by distention of the vessels. The white corpuscles begin to hover around 
 the injured tissue; the vessels continue to distend; by and by the serum 
 of the blood begins to escape through the vessel wall. Next, the red 
 corpuscles work their way out into the tissue in increasing numbers. 
 The part becomes swollen and red, due to the increased number of rd'd 
 blood cells in the tissue, and finally we have complete infarction and 
 stasis. This is the thing that often occurs in the dental pulp, and it Is 
 exactly at this point that we have the beginning of inflammation. 
 
 Causes of 1)yperetiiia of tAe Dental Pulp. 
 
 First, and most common, perhaps, is a simple irritation of the dental 
 fibrils. You are all familiar with the progress of decay into the cavity. 
 A small break occurs through the enamel, and then underneath the 
 •enamel a great hole is burrowed out, always keeping conical in shape. In 
 
41 
 
 the progress of this decay these micro-organisms actually work into the 
 dentinal tubules and there perform their function, i. e., the function of 
 growth and reproduction — the function of nutrition. They take their 
 nutrition first by producing something to act as a solvent of the things to 
 be taken into the system, in the process of which they evolve their irritant 
 waste product, which continues to irritate these fibers, and in turn the 
 odontoblasts are irritated, and they in turn affect the pulp itself, which 
 calls for increased nutrition in the part; the poisons formed from solu- 
 tion of their dead bodies act in a similar manner. It is a very important 
 thing for us to remember that these micro-organisms produce irritation 
 by all of these ways. This irritation may occur through abraded or 
 eroded surfaces by the influence of the irritant action of substances such 
 as acids, heat, cold or attrition. 
 
 We have another class of cases where there is no decay. Teeth 
 apparently sound suddenly become sensitive to thermal changes. It may 
 be caused by continued contact with heat, such as the cigar or pipe, or 
 something of that sort, or it may be from some systemic disturbance 
 which dilates the arteries — hyperactivity of the vaso-dilator or vaso- 
 constrictor in the vessel wall, a thrombus in the circulation, a shock of 
 some kind— all of which may give rise to hyperemia of the pulp, and not 
 infrequently, death. Sometimes this occurs from overheating with burs 
 and stones, polishing strips and disks, as I have stated. I think I ought 
 to emphasize that. It is so easy to cause hyperemia of the pulp by exces- 
 sive heating from our instruments. More particularly do I think that 
 students are likely to cause this by the use of their strips, taking strips 
 and drawing them from one end to the other between the teeth, filing 
 down their fillings, in that way causing excessive heating of the part, a 
 thing to be avoided. When the pulp is irritated from such a cause what 
 occurs ? First, if the irritant be of mild nature we have a physiological 
 hyperemia, increased nutrition carried on and a protection thrown out 
 and a drawing back of the pulp and new dentin formed, usually over the 
 spot of irritation, i. e., irritation to the odontoblastic layer and then irri- 
 tation to the pulp itself; and the pulp will gradually recede from this 
 irritant, and throw out through the medium of the odontoblasts a second 
 deposit of dentin, thereby protecting the pulp tissue itself from the irritant. 
 That is nature's method of protecting the pulp from the irritant without. 
 Sometimes this physiological process becomes diverted in some manner, 
 and we have deposits occurring within the pulp tissue itself which we 
 have fully explained in Chapter IV. If this irritation be very sudden or 
 violent, then we have active hyperemia rapidly becoming passive, and 
 stagnation, destroying the whole pulp, either by infarction or through 
 the inflammatory process. It is passive hyperemia we have to fear in the 
 
42 
 
 dental pulp. In a previous chapter I called attention to the fact that the 
 pulp-chamber was normally filled with pulp tissue. 
 
 Painful Process. 
 
 In extensive hyperemia we have a painful condition, due to the 
 swelling of the soft tissue. We have the normal process going on that 
 we have in other tissue, i. e., the enlargement of the vessels, swelling out 
 of the tissue ; the tissue being unable to expand beyond the confines of 
 the pulp chamber, of course make a very painful condition, due to the 
 pressure on all the tissue confined in this canal, nerve fibers and all. A 
 swollen or enlarged vessel must of necessity press upon those lying next 
 to it, and thus we have pain, from increasing pressure. We find the blood 
 vessels become much enlarged under more severe irritation (Fig. i8). 
 
 Fig. 18. 
 Dilated blood vessels from a hyperemic pulp. 
 
 (Black.) 
 
 and by and by their contents begin to escape into the tissue through the 
 vessel wall; not at first through a break in the wall, but between the 
 cellular structure of it. First we have the liquor sanguinis and then the 
 red corpuscles, by their amoeboid movement, as seen In Fig. 20. Blood 
 may pour out in considerable quantity and form a clot in the tissue and 
 yet recover. In these cases the clot is carried away partly by the process 
 of absorption and partly by the leucocytes, which are the scavengers of the 
 body, for remember we stated that the pulp tissue has no lymphatics. 
 If, however, this escape of blood be too great or for any reason recov- 
 ery does not ensue, the case is liable to go through complete stagnation 
 and a whole mass of pulp die by strangulation or infarction at the apical 
 foramen. You will remember as we approach the foramen the root canals 
 become constricted until it is very small at the apical opening, and it is 
 in this part of the tooth that w^e have infarction occurring, shutting ofif 
 completely the circulation in the pulp itself. 
 
43 
 
 Discolorations. 
 
 When the plup dies from such a cause and the mass of pulp remains 
 in the chamber a solution of the coloring matter of the blood sometimes 
 occurs and penetrates the dentin, spreads to the enamel and redness can 
 sometimes be seen at the neck of the tooth just above the enamel, and the 
 whole color of the tooth is changed darker, not that the red corpuscles 
 penetrate the dental tubuli, but rather, as I have said, a solution of the 
 coloring m.atter wbich readily enters them. We shall refer to this fact 
 again when we come to talk about the causes of discolored teeth. I wish 
 to say here that when pulps in this condition die they should be removed 
 immediately to prevent such discoloration. Thus we have seen that irri- 
 tation of the dental fibrils produces hypersensitiveness of the pulp. Heat 
 and cold cause increasing pain and add further injury, until finally the 
 elastic walls of the vessel lose their tone, become greatly enlarged and 
 more and more blood escapes through the walls ; stagnation occurs and 
 we have the beginning of inflammation. It must be borne in mind that 
 these eases often get well under favorable treatment. 
 
 Symptomology. 
 
 What are the symptoms of hyperemia of the pulp, and how may we 
 learn to recognize it? 
 
 First, get a complete history of the case ; find out what caused the 
 pain, something about the nature of the pain. In hyperemic conditions 
 the pain is paroxysmal, usually induced by hot or cold ; pain lasting a 
 few moments, and then all is quiet until again irritated. Patient notices 
 pain on taking hot or cold drinks, or even cold air. Unless the condition 
 be relieved the pain soon begins to last longer each time ; now an hour, 
 perhaps next time two hours, and by and by the slightest thermal change 
 produces the most violent paroxysms. The condition grows until death 
 or violent inflammation takes place. Then, I say, the first thing to do 
 is to get the history of the case ; find out the things that caused pain ; 
 how long the pain lasts when it comes, and all that. Second, pain may 
 be slight during the day when all faculties are active, using the blood 
 supply for nutrition of the body everywhere ; but at night, when active 
 faculties are resting and the patient is in a recumbent position, pain en- 
 sues, due to increased circulation in the injured vessel, so that it not infre- 
 quently occurs that you will have patients complaining that as soon as 
 they go to bed their tooth begins to ache ; it may not ache at all in the 
 day time. Third, in going from a cold room, where the patient has been 
 for some time, into a warm room, pain increases ; or In going from a 
 warm room into a cold room sometimes pain increases. These are the 
 symptoms. 
 
44 
 treatment. 
 
 What shall we do to relieve them? First, when we can locate the 
 cause, remove it and put the part at rest. That is the fundamental prin- 
 ciple in treating hyperemia. The most common cause, as I have said, is 
 caries. If dental caries is the cause of hyperemia of the pulp, then we 
 must remove the cause, all of it. We must remove all the decay ; get it 
 all out. I need to emphasize that fact because so many neglect that 
 thing. They will excavate a cavity until they think it is approaching the 
 pulp, and they leave a lot of dead, rotten material over the pulp itself 
 and expect that pulp to get well. If the micro-organisms die and decom- 
 pose there they will poison the pulp effectually, because if you have decay 
 extending into the pulp you have an exposure in the sense of being ex- 
 posed to the influences of the saliva and other substances present. Do not 
 leave decalcified dentin that is filled with micro-organic life over the 
 pulp for the purpose of avoiding exposing the pulp, because if the removal 
 of it would expose the pulp then you have a pulp exposed already. 
 When we have an actual exposure of the pulp in this way we not only 
 have hyperemia, but we nearly always have inflammation. Provided no 
 actual exposure occurs, you may treat the cavity with a bland, soothing 
 agent, such as oil of cloves and iodoform. 
 
 Bear in mind that no agent should be used that will in any way 
 irritate or poison the tissue. 
 
 After you have this done, make a tight filling of gutta-percha or 
 some good non-conducting material, avoiding pressure upon the pulp, 
 which requires some care when the pulpal wall is thin. Then let your 
 case rest until recovery is complete, when you can make a permanent 
 filling. In some cases it may require the complete covering of the af- 
 fected tooth with gutta-percha for a time, as previously referred to. 
 Most cases of this kind get well. Bear in mind that I am speaking of 
 hyperemia of the pulp, not inflammation. 
 
 In those cases where painful hyperemia is the result of traumatic 
 injuries, overheating by instruments, stones, burs, disks, strips, etc., re- 
 sulting in thermal sensitiveness, the important thing to do is to put the 
 part to rest. Avoid the use of hot or cold or other irritating things in 
 the mouth ; covering the tooth with a non-conductor will often be helpful ; 
 in every way protect the tooth against anything that causes pain in a 
 given case — and recovery can be looked forward to in a majority of cases 
 — and yet some will die, and there seems to be no way of avoiding it. 
 
CHAPTER VI. 
 
 Destructive gbanges eontiiiued. 
 
 Inflammation. Causes of Inflammation. Symptoms of Local Inflammation. In- 
 flammation as a Reparative Process. Conheim's Theory. 
 
 Tnflatnitiatiom 
 
 Inflammation may be defined to be a morbid process going on in 
 some tissue of the body which is characterized, when on the external sur- 
 face, by its heat, redness, swelHng and pain. You readily see that this 
 definition will also accurately describe hyperemia. The first step in the 
 inflammation process is hyperemia. Let us return to the web of a frog's 
 foot, which we used to illustrate hyperemia. When an irritant is applied 
 we see first a slight contraction in the vessels. Second, an expansion of 
 the vessels ; increased amount of blood in the part ; vessel walls become 
 inactive ; the blood is not forced on and so continues to accumulate. The 
 third thing we see is that the serum of the blood begins to escape ; this is 
 not coagulable ; coagulable elements do not yet escape. This escape is 
 made through the vessel walls between the cells of the endothelial lining. 
 Fourth, the peripheral stream containing the white corpuscles begins to 
 slow until complete stasis occurs, and here is where inflammation begins. 
 Inflammation begins with an exudation of coagulable lymph. Remember, 
 w,e stated in our study of hyperemia that the liquid sanguinis which 
 escapes out into the tissue is not coagulable; but soon these coagulable 
 elements begin to escape out into the tissue, and there we have the begin- 
 ning of inflammation. The next step in the inflammatory process is the 
 escape of the white blood cells. They pass through for four reasons. 
 First, the injured vessel wall is less resistant. Second, the amoeboid 
 movement. Third, the pressure from within, the force from within, accu- 
 mulation of blood and so on within the vessel wall forces it out. Fourth, 
 by its chemotactic property. The study of the chemotactic property of 
 cells is indeed one of the most interesting. By chemotactic property I 
 mean the attraction which one cell, under certain conditions, has for 
 another cell. If you watch these little white blood cells as they go out 
 into the tissue you really feel as though they had a separate intelligence 
 capable of directing their movement. They will wander about into the 
 injured tissue, carrying nutrition and carrying away broken down tissue. 
 We have two kinds of chemotactic properties — what is known as the 
 positive chemotactic, i. e., the attraction that one cell has for another, 
 and the negative, or the repellant action which one cell has for another. 
 
46 
 
 And this is all important in the process of inflammation. Bear in mind 
 that the escape of the leucocytes is a distinctive feature of inflammation, 
 not occurring in hyperemia. Then the sixth thing we will see is the 
 escape of the leucocytes, going on and on until the whole region is filled 
 with these cells. (See Fig. 19.) Then the next thing that occurs is a 
 
 Fig. 19. 
 Section of tooth pulp showing the inflammatory process along the veins with diapedesis ot 
 white blood cells. (Black.) 
 
 change in the normal cell elements of the part into round cells. Nowhere 
 can this be seen more clearly than in the tooth pulp, because nearly all of 
 the normal cells are spindle or star shaped cells, so that the change from 
 star shaped to round cells can be easily seen (Fig. 20). 
 
 Fig. SO. 
 Inflammation of dental pulp. A, a, normal cells; b, h, b, b, inflammatory elements; c, cell? 
 dividing. (Black.) 
 
 The inflammation I have described up to this point is called simple 
 inflammation, from which recovery may be rapid, much on the same plan 
 as recovery is made from hyperemia. When these cells begin to change. 
 
47 
 
 we have a central focus of inflammation containing coagulable lymph which 
 creates a hard swelling. Around that we have oedema, or a soft swelling, 
 and around that a hyperemic condition. Up to this time w^e have no 
 suppuration. Then if we watch this still farther, the next element, or 
 the eighth thing which I have indicated, is the appearance of bacteria in 
 the region of injury, and we have a contest ensuing between the new 
 reparative animal cells and bacteria. Sometimes the bacteria are com- 
 pletely digested and carried away and we have little or no suppuration, 
 but perhaps more often these bacteria get the upper hand, the animal 
 cells are rapidly broken down and rapid suppuration occurs. I have 
 used this description because it more nearly represents what actually 
 occurs in the tooth pulp undergoing the inflammatory process. For many 
 years there was much discussion as to whether we ever had infJamniation. 
 untJwiit micro-organisms, or whether w^e ever had suppuration wdthout 
 micro-organisms. We certainly do have inflammation without micro- 
 organisms, as you have seen, but never suppuration without them. In 
 the dental pulp they are most frequently the cause of inflammation. 
 
 Cau$($ of Tnflammation. 
 
 I want to say just a word about the causes of inflammation in general. 
 We divide it into two general classes — predisposing and exciting. By 
 a predisposing cause we mean that condition of the whole system which 
 so acts as to reduce the resistance of the body ; impoverished blood, 
 Bright's disease, syphilis, and other forms of blood poisoning are wdiat we 
 mean by predisposing causes. 
 
 The second element, a perverted nerve supply. For som.e reason 
 the nerve supply becomes perverted and does not perform its functions 
 correctly. 
 
 Third, the climate. 
 
 Fourth, the age. 
 
 Fifth, lowered vitality of the cells of the part. 
 
 The exciting causes may be simple irritation, i. e., mechanical, as it 
 were, and chemical. Cold, producing sudden changes in the blood whereby 
 it fails to carry away its waste product, and local poisoning occurs. The 
 whole process of taking cold is simply a process whereby the waste prod- 
 uct of the tissue is not carried away properly, and consequently the whole 
 system is being poisoned from reabsorption. Chemical irritations, 
 poisons, etc., enter into this process of irritation. Then heat, as burning 
 or scalding, as you all know. 
 
 Symptoms of Cocal Inflammation. 
 
 Redness. — "This symptom is persistent, and is due to hyperemia. By 
 digital pressure the capillaries can be emptied, but on removing the pres- 
 
48 
 
 sure the redness immediately returns. The shade of color depends upon 
 the freedom from obstruction in the vessels, and the rapidity of the cir- 
 culation. When the color is dark or purplish it denotes stasis ; rose-red 
 streaks along the tract of the lymph-vessels indicate lymphangitis ; a dark 
 red tract along the course of the veins would point to phlebitis ; while a 
 copper red color would denote syphilitic inflammation. 
 
 Sisuelling. — This symptom is due to the engorgement of the blood 
 vessels of the part, to exudation from the blood-vessels and to prolifera- 
 tion of cells. In acute inflammation the swelling is soft ; in the chronic 
 forms it is hard. Swelling is especially marked in loose connective 
 tissue. 
 
 Heat. — This symptom is most marked at the center or focus of the 
 inflamed area. It is thought to be produced by the increased rapidity of 
 the circulation, and the volume of blood in the part. Hunter taught that 
 the heat of the part was never above the heat of the internal organs. 
 Hunter's Law reads as follows : "In inflammation the heat of the part is 
 increased above the normal temperature of the part, but not beyond the 
 temperature of the internal organs." 
 
 Pain. — This symptom is persistent, and is increased by pressure, by 
 motion of the part or by general exercise. Exercise increases arterial 
 tension, and thus augments the pain. The pain is most intense in dense 
 structures, and is mainly due to mechanical pressure upon the nerve- 
 filaments, and is sometimes reflected to regions remote from the seat of 
 the inflammation. Examples are, knee pain in hip-joint disease, shoulder 
 pain in hepatitis, otalgia in pulpitis. 
 
 Disturbances of Function. — This symptom is marked in its action 
 upon the secretions, which often become perverted or suppressed. The 
 reflexes are generally exaggerated. Examples are the tenesmus of dys- 
 entery, the strangury of cystitis, the convulsions of teething. Non-sensi- 
 tive parts become hypersensitive, examples being the pain of pleurisy, 
 peritonitis, teething, or decayed dentine in vital teeth." — Marshall. 
 
 Tnflammation as a Keparatioc Prtcess. 
 
 I stated that following the escape of the coagulable lymph and leuco- 
 cytes out into the injured tissue we see certain changes in the normal cell 
 elements of the tissue ; the normal, or star shaped cells are converted into 
 round cells and rapidly increase in number until the whole region is 
 filled. This increase is brought about in an interesting manner. The 
 first plausible theory advanced, which, by the way, was the theory adopted 
 by Virchow and Bilroth, explained the increase in the number of cells to 
 a proliferation of the cells in the tissue. The inflammatory irritant causes 
 the cells to take on an increased activity, attracting to themselves nutri- 
 
49 
 
 ment in unsual quantity, and consequently growth and rapid multiplica- 
 tion (see Fig. 20 at C). 
 
 Cenl)elm'$ theory. 
 
 Conheim set aside this theory and advanced the idea that leucocytes 
 furnished all material in the reparative process. This theory was gener- 
 ally accepted for at least two decades. He attempted to prove that the 
 cells of the part did not undergo any active change during the inflam- 
 matory process except degeneration or breaking down. Conheim claimed 
 that the normal cells of the tissue took no part whatever in the repara- 
 tive process ; the only change that took place during the inflammatory 
 process in these cells was that of degeneration. The manner in which 
 he attempted to prove this was indeed very interesting. For this pur- 
 pose he took the cornea, because of its transparency. When he treated 
 the cornea with chloride of gold a most perfect network of stellate cells 
 appeared lying in the inter-cellular substance, which suggested to him 
 that these spaces, i. e., these inter-cellular honey-combed spaces, fur- 
 nished opportunity for the migration of these wandering leucocytes, i. e., 
 they were able to migrate out through this inter-cellular substance. See- 
 ing these apparent wandering cells lodged therein he determined that it 
 was a process of passing through the tissue which he saw, and conse- 
 quently he believed that they were the agents which had most to do with 
 the reparative process. The following was his experiment : He drew; a 
 ligature through the bulb of the eye of a rabbit. In 24 hours the trans- 
 parent cornea became opaque, due to the increased, number of leucocytes 
 which were present, as shown by taking the cornea before it became 
 opaque and examining it under a high power. He claimed that all the 
 new cells were identical with leucocytes, i. e., the new cells that he saw 
 in this cornea. To further -prove his point, he injected small granules of 
 carmine, held in suspension, into the lymph sacs and the blood vessels of 
 a frog; he then produced his inflammation of the cornea and many of 
 the new cells which he found contained these granules, which, by the 
 way, he was unable to find anywhere else in the system. These experi- 
 ments were performed in 1867, and they created the most widespread dis- 
 cussion everywhere. Scientists everywhere were discussing this theory 
 of Conheim's, and as a result it created a great amount of opposition. 
 Many men attempted to prove the old theory of cell proliferation, and 
 Strycher, of Vienna, took up this theory and advanced it still further, 
 and evolved his theory of tissue metamorphosis in which he claimed that 
 not only did the cells, but the entire tissue, inter-cellular substance, etc., 
 all return to their embryonic condition. He took up this theory of cell 
 proliferation and did an immense amount of work. Few of us can com- 
 
50 
 
 prehend the amount of work these scientists did along these lines, trying 
 to prove that not only the cell elements, but the inter-cellular substance 
 and all returned to its embryonic condition, from which it rapidly grew, 
 and separated into amoeboid masses from which new tissue was grad- 
 ually developed. From that time on men everywhere have been studying 
 this process. 
 
 Grazvit::'s theory was based on the fact that throughout all tissue in 
 the inter-cellular spaces are seen slumbering cells, i. e., the cells which 
 Conheim claimed to be leucocytes, but which Grawitz claimed were 
 really slumbering cells, which under certain conditions are capable of 
 waking up, as it were, and undergoing certain changes. By their amoe- 
 boid movem.ent they wander out through the tissue, taking on active life. 
 At first the slumbering cells have but a small nucleus and little or no 
 protoplasm. Their nuclei gradually enlarge and acquire a cell body and 
 assume all the functions of tissue cells, with protoplasm and all. This, 
 then, was the cell, according to Grawitz, which produced the process of 
 repair. At the present time, scientists account for the presence of such 
 a large number of cells in reparative inflammations to all three of these 
 sources. The normal tissue cells multiply, in three ways. 
 
 Fig. 21. 
 Karyokinesis. A, resting stage; B, convolution stage; C, wreath stage; D, monoster stage; 
 E, lengthening of cells toward the poles; F and G, the rosette dividing into two groups; H, the 
 two groups pass to opposite poles; I, diaster stage; J, diaster stage, with complete neuclei; K, 
 convolution stage, daughter cells; L, daughter cells at rest. 
 
51 
 
 First, By budding. 
 
 Second, by direct cell division (see Fig. 20, c). 
 
 Third, which, of course, is by far the most interesting and the one 
 that is the most common, most usually known as karyokinesis, which I 
 have attempted to illustrate in Fig. 21. That is the process by which the 
 cell elements of tissue reproduce themselves mostly. 
 
 The second element in this inflammatory process of repair, the slum- 
 bering cells awaken into new activity. These cells resemble the leuco- 
 cytes in appearance, and it is doubtful if one is not taken for the other. 
 These cells lie caught, as it were, in the network composing the normal 
 tissue. Many consider them purely embryonic cells left from the em- 
 bryonic condition of the tissue. In the growth and development tissue 
 maintains largely an embryonic condition until maturity. During all of 
 this developmental stage a greater amount of these cellular elements are 
 required than after maturity is reached, consequently, the theory is that 
 this excess of cells that have not been used atrophy and are caught and 
 lie there in the inter-cellular spaces — one of the wonderful provisions 
 of Nature ; they are a reserve fjimd, kept there to be used in time of need. 
 They are used in time of over-exertion of muscular tissue and during 
 inflammatory processes always. That is the second element as seen in 
 tissue repair. 
 
 I stated that when they are first seen they scarcely seem to have 
 even a nucleus — simply a small speck, with no protoplasm. When they 
 are brought into action they gradually enlarge their nucleus and take on 
 forms of protoplasm. Protoplasm furnishes the means of carrying, shall 
 I say food, to build up the waste tissue. 
 
 Then the third element that we account for in this process of repair 
 from inflammation — the leucocytes normally floating in the blood stream 
 are attracted there for reparative purposes. They bring fresh nutriment 
 and more especially carry away useless, broken down material, waste tis- 
 sue, etc. ; that is the greatest function of these leucocytes which normally 
 float in the blood stream. What other function they perform we at 
 present haven't a clear idea. We thought we had a few years ago, but 
 that whole notion has been changed now. There is an actual increase of 
 white blood cells during inflammation, not only out in the injured tissue, 
 but also in the whole blood stream. The whole system thus appears in 
 sympathy with the injured tissue and those organs in which the white 
 blood cells normally abound and perhaps have most to do with their 
 formation — especially the spleen and lymphatic glands — are much en- 
 larged during the process of severe inflammation, due to reflex action 
 from the injured arterioles. The greater the injury, the larger the num- 
 ber of cells. Slight inflammations require but a few in the process o£ 
 
52 
 
 repair and Nature provides but few. Severe inflammation and suppura- 
 tions requirmg more, Nature provides more. Those white blood cells 
 which have to do with the carrymg of food material, so to speak, and the 
 carrying away of waste material, we call phagocytes. The most interest- 
 ing process taking place in the animal body is that of metabolism. All 
 higher forms of life are but many simple cells so arranged as to form a 
 structural unit. These cells are only capable of growing under favorable 
 -conditions. The whole mechanism of the body is a unit of cell collec- 
 tions ; in order for these cells to grow and perform their function, they 
 must have food; they must grow and reproduce themselves. You can 
 readily see that if these cells did not constantly reproduce themselves the 
 whole body would soon die out. 
 
 Third, they form waste products which must be secreted. When food 
 is taken into the stomach, having previously been acted upon by the 
 saliva, it is further acted upon by the gastric juices, and part of it, which 
 is now ready for absorption, passes directly into the blood through the 
 walls of the stomach. The remainder passes on to the intestines, and is 
 there again acted upon and absorbed directly into the iacteals ; from there 
 into the blood. This blood is then taken to the lungs and to the liver, 
 respectively, and then passes directly to the tissue. Each time it enters 
 the blood it unites into chemical combination with the protoplasm of the 
 cells. 
 
 The process by which all of this is carried on is a chemical process 
 pure and simple, and when the blood passes through the lungs it adds 
 oxygen, as you know, and we have a highly complex substance of many 
 chemical elements united in such a way as to be readily exchanged into 
 cell tissue. At the present time the chemistry of the proteid molecule is 
 poorly understood. There is room for some of you gentlemen to do some 
 splendid work along that line, and it is the only thing we need now -to 
 perfect us in m.any lines of medication. Just as soon as we are able to 
 know definitely the chemical combination of this proteid molecule, just 
 so soon will we be able to know what substance we can administer 
 that will chemically unite with it to change it in the direction we wish it 
 changed. The process, then, by which this nutrition is taken up in the 
 cell — the phagocytes bring this material in its most absorptive form, the 
 form in which it can be most readily used by the cells of the tissue. Then 
 by the process which I spoke of as the chemotactic property, cells in cer- 
 tain conditions are attracted to cells in certain condition, chemically. The 
 phagocytes containing certain chemical elements are attracted to the tis- 
 sue cells containing certain chemical elements. These chemical elements 
 are constantly changing in the tissue cell, as well as in the phagocytes. 
 The process of wear on tissue cells is a chemical process. Fatigue is a 
 
53 
 
 chemical process in the cehs themselves. We are just beginning to real- 
 ize this, it is the all important phase of physiological chemistry. 
 
 The waste products that these cells form — speaking now of the tis- 
 sue cells — has to be carried away. The waste product is largely urea and 
 uric acid, and one of the functions of this phagocyte is to exchange its 
 nutriment for the waste product of the tissue cells. It is carried away by 
 way of the kidneys and excreted in the form of urea, and excreted 
 partly by way of the lungs in the form of carbonic acid. That is the 
 whole chemical philosophy of the system, and nutrition is purely a chem- 
 ical process. I hope I can firmly impress that upon your minds. 
 
 I think I have said sufficient to enable you to follow my further 
 illustrations. Take a simple incised wound. The* edges are covered 
 over with this coagulable exudate and clot, rich in album.en. I might say. 
 that in olden times the surgeon was governed in his treatment of these 
 wounds by the presence of this coagulable exudate upon the surface of 
 his incised wound. He waited until that appeared, as he thought, good 
 and healthy, then he brought his wound together, believing thereby that 
 he would cement the wound by bringing these two coagulable exudates 
 together. Of course, the method which we now follow is to bring our 
 incised wound in direct opposition. If we can do that we have our slight 
 exudate forming, filling in the mechanical defect. Then these cells 
 abounding in this exudate, being transformed into embryonic tissue grad- 
 ually change into permanent tissue form, into which we have the little 
 vessels sprouting out, as it were following out into the tissue itself, until 
 finally the blood vessels unite on opposite sides and we have the circula- 
 tion re-established, and lastly we have the epithelium growing out and 
 covering over the wound. Take a wound Avhere a large surface is in- 
 volved, where it is not possible to bring all the surfaces of the wound 
 together ; the healing process is brought about by the building up of this 
 embryonic tissue from the bottom until the whole tissue is filled up ; then 
 we have the epithelium reproducing itself, quite in the same manner 
 that ice freezes over a pond, first beginning at the circumference, then a 
 little farther in and so on until finally it covers over the whole mass. All 
 of these cells, of course, as the change is made from embryonic to per- 
 manent tissue, assume the spindle shaped form and become fully organized 
 into fibrous tissue. The first process that I outlined to you is what is 
 known as healing by first intention. 
 
 Chronic inflammation is a condition in which we have the symptoms 
 of acute inflammation, but to a less degree. It usually follows an acute 
 attack, and may continue for years without much apparent change. 
 Usually the tissue hypertrophies— we have fungous growths, elephant- 
 iasis, tumors, etc., but more frequently is the end of acute inflammation 
 and passes directly into suppuration. 
 
54 
 treatment of Tnflammatioiu 
 
 General Considerations. 
 
 The first principles in the treatment of any inflammation is to remove 
 the cause and to put the part to rest. If the cause be systemic, then we 
 must have that corrected first ; if due to irritation of any kind that must 
 be removed. This irritation may be of such a nature as to require sys- 
 temic medication ; indeed, in all severe inflammations the eliminative 
 organs should all be stimulated. The bowels and kidneys should receive 
 special attention as well as the skin. In addition to administering ca- 
 thartics, diuretics and diaphoretics, the frequent sponging the surface of 
 the body with tepid water and drinking large quantities of water will 
 prove most valuable. The application of ice, cold water, either sprays in 
 the early stages of inflammation before stasis has occurred, especially 
 where heat and redness is pronounced, is considered most potent for 
 good. 
 
 Heat in the form of compresses wrung out of hot antiseptic solu- 
 tions, changing as often as they become cool, is a very excellent method 
 of stimulating the collateral circulation and relieving the pain. When 
 the pain is severe it may be necessary to resort to the use of some of the 
 coal tar derivative anodynes, narcotics or opiates. What is meant by put- 
 ting the part to rest is best illustrated in the prevention of occlusion of a 
 tooth that has becom.e sore from pericementitis or excluding the light 
 from an inflamed eye. Among the other local measures that are of value 
 blood letting, scarifying, cupping, the use pf leeches and the application 
 of counter irritants, are suggested, especially over deep seated inflam- 
 mations. When the blood pressure is high and the pulse very rapid the 
 use of circulatory depressents are indicated. 
 
 Symptoms of Inflammation of the tooti) Pulp. 
 
 There are no special symptoms of inflammation of the tooth pulp ; 
 they are those of hyperemia in a more aggravated form, the paroxysms 
 of pain last longer and are more intense. We have some difficulty in 
 making a differential diagnosis of inflammation because we cannot see 
 the swelling, the redness, etc., that we can see on external surfaces in 
 the soft tissue. Pulps often become inflamed, suppurate and die without 
 any pain whatever. In hyperemia there is no tissue change. All the 
 cells in the tissue are unchanged, except the walls of the vessel ; while 
 in inflammation all the changes are taking place as I have described, 
 namely, the presence of coagulable lymph, the white cells out in the tis- 
 sue, etc. Up to this point recoverv is nossible, and, indeed, this stage is 
 about the healing process of all simole inflammations, such as the healing 
 of surgical wounds. Remember, simple inflammation is aWays a repara- 
 
55. 
 
 tive process. All tissue injury is healed by this process, which is purely 
 physiological. Inflammation of the tooth pulp occurs, after that organ 
 is exposed, either from decay or other cause. More frequently it is caused 
 by caries that has penetrated to the pulp, or at least the poisons of micro- 
 organisms in the carious cavity penetrating to the pulp. We doubtless 
 do have inflammation of the pulp without micro-organisms being pres- 
 ent in the tissue, as we have simple inflammation anywhere. It is not 
 always possible to tell just where we have hyperemia conditions and 
 where we have inflammation. We can only decide as we work at the 
 cavity, removing the carious dentin. We may have only a slight por- 
 tion undergoing the inflammation process immediately around the point 
 of exposure, and the rest of the pulp remain practically healthy, perhaps 
 a little hyperemic immediately around the point of inflammation. But 
 as time goes on and exposure to saliva and micro-organisms continues, 
 we will see the inflammation spreading in the direction in which the 
 poison is carried by the circulation. 
 
 By and by suppuration occurs ; not in all cases. Some exposed 
 equally long do not suppurate ; due, doubtless, to the condition of the cells 
 of that organ, and perhaps som.ewhat to the nature of the irritant. This 
 will be referred to under the head of suppuration. After securing the 
 history of the case we must depend upon what we find when opening the 
 cavity, to determine our condition. Does decay penetrate the pulp cham- 
 ber? If so, we have a real exposure. What is the condition of the 
 decay ? Is it black, hard, dead decay in which the former life has died 
 and passed away largely ; has it progressed slowly ; does slight pressure on 
 the pulpal wall cause pain ; has the pulpal wall been broken through ; is 
 there growth of the pulp tissue out into the cavity? These are the 
 things that aid us in determining upon the correct diagnosis. 
 
 Rypertropby of the Pulp. 
 
 In inflammatory cases where suppuration does not ensue the pulp 
 oftentimes seems to grow rather than break down. There is a continual 
 growth of new cells, just as in reparative inflammation in healthy tissue. 
 These cells of repair continue to divide, after forming new nuclei within 
 themselves, until we actually have a growth of new tissue out into the 
 cavity of decay (see Fig. 22). 
 
 In a cavity of this kind the pulp is actually pushed into it. Often- 
 times the odontoblasts and fibrils are pushed out also. In other cases the 
 growth is within the tissue itself, and not simoly the exposed point. 
 These cases are not usually painful, for the reason that there is a way of 
 escape for the swollen enlarged tissue. 
 
56 
 
 Fig. 23. 
 A, diagram of lower molar with cavity at a completely filled with hypertrophied pulp tissue 
 grown out through opening into pulp chamber at b; B, showing granulation tissue of hyper- 
 trophied portion; a, epithelial cells with papilla; h, epithelial cells without papilla. (Black.) 
 
 1>ow to study 1>yperemia ana Tnflammation Tn tooth Pulp. 
 
 A word as to how we study the conditions of hyperemia and inflam- 
 mation in the dental pulp. I will give you a method which has been 
 quite universally adopted of late, a method suggested by Dr. Black. That 
 is first to get the patients wliile they are sufifering from the paroxysms 
 of pain. If the paroxysm has passed over, wait for another attack, or 
 excite it by thermal changes ; then while the pain is at its height extract 
 the tooth and immediately drop it into Miller's fixing fluid. 
 
 The object is to capture the condition, as Dr, Black states, and harden 
 the tissues so it can be handled without in any way disturbing the con- 
 tents of the vessels. Then it is broken open in a vise and the whole thing 
 dropped into Miller's fluid again, and while under this fluid the pulp is 
 separated out and lifted out of its bed. Oftentimes you will lift the pulp 
 with the odontoblasts' and the fibrils attached to it, some of them. Now 
 leave in Miller's fluid for farther hardening, after which it is dropped 
 into a solution of gum arable which has been thickened by slow evapora- 
 tion. Of course the object of this is to fix it so it will be hard enough to 
 handle. After 24 hours it is put in wax, and after 12 hours it is cut in 
 
57 
 
 the ordinary manner of cutting specimens, mounted and examined under 
 ihe -microscope, with the results that I have given here. 
 
 Causes. 
 
 There is very httle that can be said as to the causes of inflammation 
 in the tooth pulp other than what has been said regarding hyperemia, to 
 which the reader is referred. Indeed, as has been said, inflammation 
 usually begins in hyperemia, and the reader must bear in mind the fact 
 that all severe hyperemias are liable to run into inflammation, and unless 
 steps are taken early to prevent this, the vitality of the pulp will have to 
 be sacrificed. Bear in mind that inflammation rapidl}^ follows pulp expo- 
 sure from caries or accidents in excavation ; but inflammation of the pulp 
 does not depend on these, but the same variety of causes that have to do 
 with hyperemia obtained as well. 
 
 The use of corrosive agents, shock, lowered vitality of the general 
 system have an important bearing on inflammation in the tooth pulp, the 
 same as in other parts of the system. 
 
 treatment of Inflammation of tbe tootb Pulp. 
 
 Regarding the treatment of pulp inflammation the same principles 
 that are carried out regarding other inflammations elsewhere about the 
 body must be followed here, which relates to removing the cause and in 
 putting the proper part to rest. We must remember that intense pain 
 is usually present, and it is our business to relieve this as quickly as 
 possible. 
 
 If irritation through a carious cavity is the cause, then that should 
 receive our first attention. The method I follow in this regard is to care- 
 fully break down the overhanging enamel and wash the cavity thoroughly 
 with warm antiseptic solution, after which I apply the rubber dam and 
 dry the cavity, using dehydrating agents and warm or cool air, which- 
 ever feels more comfortable to the patient. I next excavate the carious 
 dentine, proceeding in such a manner as to produce the least possible 
 pain ; this usually can be accomplished best by removing the decay from 
 all walls around the pulp first, leaving the pulpal wall to be removed 
 with one stroke of the excavator. In the use of our excavators if we cut 
 from the pulp rather than towards it, we are less liable to injure it and 
 to produce pain. 
 
 In making the excavation if the pulp is exposed so as to bleed the 
 pain will be relieved thereby in most cases. If exposure does not occur 
 in this manner it is regarded as good practice to open the pulp, provided 
 this can be accomplished without causing too much suffering. Often- 
 times this can be accomplished with the aid of warm carbolic acid, cocain 
 or other local anesthetics, and some operators administer nitrous oxide. 
 
58 
 
 and remove the pulp immediately. I wish to emphasize the value of blood 
 letting whenever severe pain is present. The next step is to apply some 
 mild antiseptic soothing- agent and seal the cavity in such a way as not 
 to produce pressure on the pulp and at the same time preclude any possi- 
 bility of the patient forcing the stopping down against the pulp in the act 
 of masticating. The hot foot bath will serve to attract the force of the 
 circulation from the head and thus relieve the pain. A little mustard 
 added to the hot water will increase its efficacy. The administration of 
 saline cathartic is commended in severe cases, especially where there is 
 some tendency to pus formation. For the purpose of relieving pain it 
 is occasionally necessary to resort to the use of some of the narcotics and 
 heart depressants. It is not considered good practice to attempt pulp de- 
 vitalization in these painful cases until the pain has been relieved and the 
 patient m.ade comfortable for at least forty-eight hours. This fact will 
 be alluded to under pulp devitalization. 
 
CHAPTER VII. 
 
 PuliJ Capping. 
 
 History. Favorable and Unfavorable Cases. ^Methods of Pulp Capping. 
 
 history. 
 
 In looking over the literature I find that men have long been cap- 
 ping pulps. I find records of pulp capping as far back as 1850. In that 
 early day men knew nothing scarcely of how to treat diseased pulps and 
 fill root-canals, so palliative measures were used until the aching tooth 
 was quiet : then fillings were made, sometimes without even linmg the 
 cavitv. ]\Iost of their cases died and suppurated. Then they either bored 
 a hole underneath the gum margin or extracted the tooth. A little later 
 than this, in about 1858. men began to cap pulps with oxychloride of zinc, 
 and from that early time until this the subject has engaged the attention 
 of many experimenters. Almost all sorts of materials have been used — 
 lead, tin. asbestos, varnishes, gutta-percha, oxyphosphate. all of these 
 have had their adherents. In 1888 I remember hearing this subject dis- 
 cussed before the American and Southern Dental Societies, which met 
 in joint session in Louisville. There seemed to be a very unanimous opin- 
 ion then that failures were had more frequently than success. I remem- 
 ber well the remarks of Dr. Storey, of Dallas, Tex. He stated that he 
 had taken up the then prevalent fad of capping pulps and had used all 
 the accepted materials, and in the next few years had more business 
 than he could possibly attend to. and most of it was caring for putrescent 
 pulps and abscesses in teeth whose pulps he had previously successfully 
 capped. AMiile this has not been my experience, yet I have capped many 
 pulps, a majoritv of Avhich have been failures. I have tried to study out 
 the causes of these failures, with the result that I now cap comparatively 
 few exposed pulps, and those under the most favorable circumstances, 
 which circumstances I have already stated to you. Many men report suc- 
 cessful cases of capping who have not the opportunity of following them 
 up. Cases leave us when we are unsuccessful and we never learn of our 
 failures. I know I am called upon frequently to treat cases where pulps 
 were previously capped by others. These cases sometim.es go on for 
 vears and give no trouble. I have had cases under direct observation 
 for three and four years ; I was able to know that the pulp was alive dur- 
 ing that time, and then all at once, without warning, trouble begins. 
 
 There are men who claim, to be able to remove a portion of the pulp 
 
6o^ 
 
 surgically, as it were, and cap the remaining portion. They sometimes 
 remove the bulbous portion in the pulp-chamber and the contents of one 
 of the root canals in a molar and cap the remainder. You will find as 
 you read the literature on the subject that men have actually practiced 
 this sort of thing, not only practiced it, but advocated it for years. I 
 must say that it will require much stronger evidence than I have seen to 
 convince me that the remaining portion lives in a healthy state any 
 length of tijne. 
 
 Taporable and Unfavorable €a$<$. 
 
 When to cap a pulp and when to destroy it are questions which can 
 only be decided after considering a great many things, among which are 
 the following : 
 
 First — The exposure. Is there an actual exposure ? Has the carious 
 process exposed the pulp? Is there only a slight exposure in the horn 
 of the pulp? Was it exposed in removing the decalcified dentine? Was 
 it exposed by an accidental slip of the instrument? These conditions 
 can all readily be observed after the tooth has been cleaned, washed and 
 dried. If there is any doubt, slight pressure on the pulpal wall with a 
 small ball of cotton or round burnisher, when, if exposed, pain will be 
 felt by the patient. 
 
 Second — Has the pulp been infected? This is usually the case if 
 caries has penetrated directly to it, or if exposed by accident, which 
 sometimes unavoidably occurs. Infection is very likely to result if ex- 
 posed to the air for any length of time. 
 
 Third — What is the history of the case? Has the pulp caused pain 
 to any extent ? Has it been hyperemic or congested at any time ? These 
 are all unfavorable indications, and failure will surely result from at- 
 tempting to cap such pulp, no matter what method is followed. 
 
 Fourth — Has the pulp been actually injured? How? 
 
 Fifth — What is the history of previous cappings in the same mouth ? 
 Had the patient the unpleasant experience of having pulps capped under 
 similar conditions and then die with all the pain of an acute alveolar 
 abscess resulting therefrom ? 
 
 Sixth — Has the tooth fully developed? It is so important to pre- 
 serve the vitality of the pulp until the tooth is thoroughly formed that I 
 sometimes take a chance even when certain conditions are inclined to be 
 unfavorable, for to destroy a pulp in a partially formed root means the 
 loss of that tooth sooner or later. 
 
 Seventh — What is the general health of the patient? I have poor 
 success in capping pulps for anemic individuals, those suffering from 
 poor elimination, or those of nervous, hysterical makeup. 
 
6i 
 
 Eighth — Is the tooth situated in the anterior part of the mouth, 
 where the natural translucency of the tooth is very desirable ? 
 
 Ninth — Is is not desirable to cap pulps that require much medication 
 to restore them to comfort ? 
 
 These are some of the questions which must pass through your mind 
 before you should decide either for or against capping. There is still 
 another important point to consider in this matter, and that is with ref- 
 erence to the personality of the patient. Is she one of those who will un- 
 reasonably blame you if failure results ? There are a few people who feel 
 that when they have a cavity filled that should for all time end their 
 trouble with that tooth, and if the pulp should die in such a tooth they 
 would condemn the dentist both loud and long as an impostor. 
 
 methods of Pulp Capping. 
 
 In preparing pulps for capping it is desirable to free the cavity from 
 all poisonous material and cut to sound dentine upon which to rest the 
 periphery of the capping. If this does not actually uncover the pulp so 
 much the better, but in any event it is important that there should be no 
 space between the cap and the pulp. It should lie down on the pulpal 
 wall, or in case of an actual exposure down on the pulp itself with no 
 space for air, secretions or excretions from the pulp, and yet this must be 
 done without the slightest pressure upon that organ. 
 
 Materials. — A great variety of substances have been suggested as 
 pulp cappings, many of which have been tried and discarded. Oxychlo- 
 ride of zinc mixed into a thin paste, dropped on one of the walls of the 
 cavity and coaxed over the pulp in such a manner as to exclude the air 
 has been used by some for many years. Others cut a piece of white 
 linen paper just large enough to cover the pulpal wall and put the zinc 
 cement on this and carry one end to place, then gently press from this 
 towards the opposite end, forcing some cement ahead of your pressure 
 and out around the periphery. Many advocate zinc oxyphosphate cement 
 used instead of the oxychloride, and others the oxysulphate of zinc. 
 Zinc oxide cement powder mixed with oil of cloves or other similar 
 oil has many advocates. Some practitioners use iodoform lo per cent 
 with the cement powder, then mix either with oil of cloves or the cement 
 liquid ; in all of these the method of capping is the same. Instead of the 
 white linen matrix many use gutta-percha disks cut small enough and 
 depressed slightly in the center of the surface to be placed next to the 
 pulp ; on this depressed surface is placed some one of the above mixtures 
 and carried to place, as before described. Small metallic concave disks 
 have been made for this purpose, and have the advantage of being more 
 convenient of application. Solution of gutta-percha in chloroform and 
 
62 
 
 some of the balsam varnishes in alcohol, to which may be added oil of 
 cloves, iodoform or some other agent, have been suggested. These solu- 
 tions are used on the little disks in the same manner as the cement mix- 
 tures. A word of caution needs to be given regarding the use of zinc 
 oxide ; many specimens have arsenic present in them which should be 
 avoided. 
 
 Insist on having a pure oxide. Dr. A. E. Royce has recently sug- 
 gested incorporating 5 per cent hydronaphthol in the cement powder, 
 and from this make a mix, using the same means of applying that I have 
 already suggested. I have had very satisfactory results from this mix- 
 ture, that is, if an opinion formed after two years of frequent using is of 
 value. 
 
 It is the usual practice to complete the filling in all these cases either 
 with gutta-percha or oxyphosphate cement — especially a layer of cement 
 over the capping. If the tooth remains normal for a period of six 
 months it is usually considered proper to place the permanent filling. 
 
 I think it wise to add this further word — all modern pathologists 
 regard vital pulps that are normal to be of great advantage to teeth as 
 regards their resitance to decay, their color and general comfort to the 
 patient. 
 
 In concluding this subject I wish to say that when you have used 
 your best judgment both as to the case, the materials, and the method of 
 doing the operation, sometimes failures will result. Some cases will go 
 for years without the least discomfort to the patient, and all at once 
 take on violent inflammation ; others die and give no trouble, and still 
 others start up trouble immediately after the capping is placed, which in- 
 creases until death of the organ results either of itself or at the hands of 
 the operator — so that we must not be too sure of success, and yet this 
 operation is done successfully often, and under favorable conditions in a 
 great majority of cases. 
 
CHAPTER VIII. 
 
 Pulp Devitalization. 
 
 Methods. Preparation of Cavity to Receive Arsenic. 
 
 Devitalization of pulps is a subject of increasing'interest. Many teeth 
 come under our care that have passed beyond our ability to save with pulp 
 alive, and have them remain so for any length of time. We devitalize 
 pulps for the following reasons : 
 
 First. Inflamed, aching pulps that have gone beyond conditions 
 favorable for capping. 
 
 Second. Cavity may be so shaped or caries progressed so far as to 
 make permanent filling impossible without anchoring in the pulp-chamber. 
 
 Third. A crown may be necessary, either to restore a broken down 
 tooth or as an abtitment for a bridge. In these cases it is seldom possible 
 to properly prepare for a crown without removing the pulp, on account of 
 its sensitiveness and the danger of approaching too near the horn of the 
 pulp ; also danger of exposing the entire dentin and fibrils to severe irri- 
 tation of large amount of zinc cement, thermal changes, etc., etc. I am 
 not one of those who claim that it is impossible to occasionally fit a crown 
 for an abutment of a bridge without devitalizing the tooth ; I believe 
 there are many teeth where it is possible to do that, but in the great 
 majority of cases it is not possible. It is claimed by some that when teeth 
 are ground in this manner for the adjustment of crowns and bridges, and 
 the pulps left alive, that the action of the arsenic contained in the cement 
 will eventually destroy the pulp. I have never been able to get interested 
 in the theory of pulps dying under the arsenic contained in the cement. 
 I never felt that that was sufficiently proven to be taken as a fact. 
 
 Fourth. We devitalize pulps in teeth in advanced stages of pyorrhea 
 alveolaris. 
 
 Fifth. We devitalize pulps where the patient is suffering from 
 calcific deposits within the pulp itself. Oftentimes, as I stated before, 
 this occurs in teeth that are perfectly sound, so far as we can tell, and our 
 only method of getting permanent relief for the patient is to devitalize 
 and remove the pulp. 
 
 Before attempting to devitalize we should first restore the tissue to a 
 normal condition, so far as possible. Inflamed, aching pulps need some 
 palliative treatment first, either by actually exposing the pulp and letting 
 out some of the blood, or in case the pulp is very hypertrophied, with 
 
64 
 
 the use of a little carbolic acid and cocain we cut off the hypertrophied 
 portion before attempting- to apply the devitalizing paste. For the pallia- 
 tive treatment we usually use oil of cloves, carbolic acid, creosote, chloro- 
 form and some of the oils, cocain and warm oil of cloves, morphia, lauda- 
 num, alcohol and the essential oils ; any of these sealed in widiout pressure, 
 and left for a day or two until the pain has subsided. The reasons for 
 doing this are two. First, an inflamed pulp is very resistant to the ab- 
 sorption of devitalizing agents. That is an experience that I am sure 
 all have had who have attempted to devitalize aching pulps. Second, our 
 devitalizing agent acts as a further irritant and sometimes causes intense 
 suffering needlessly. In cases where there is only slight sensitiveness and 
 the pulp has begun to suppurate in its horn, I have had best results by 
 letting out the pus, washing out freely with warm antiseptic solutions, 
 using then a good antiseptic or germicide to do away with the suppura- 
 tion, and then proceed to devitalize and remove the living portion. 
 
 Care must be taken not to mistake pressure on the pulp-chamber 
 content for irritation to the fibrils. That is a mistake that is made very 
 frequently. When we come to excavating close to the pulp we will find 
 that we give pain oftentimes when really the pulp itself is practically 
 jdead. The reason for this pain is that the chamber is filled, literally filled 
 -full of material, and the slightest pressure upon it produces irritation 
 beyond the apex. You will often open up teeth, even after you have 
 applied your devitalizing paste, that seem sensitive upon excavation, when 
 with a little care you can succeed in exposing a little corner of the pulp, 
 and after you have done that you can proceed to open it completely and 
 remove it without any pain whatever. 
 
 The object in devitalizing pulps is, of course, that they may be 
 removed painlessly. I might say that dentists oftentimes really forget 
 the object of devitalizing pulps, and proceed to half devitalize and remove 
 them with as much pain as if they hadn't attempted to devitalize at all, 
 
 methods. 
 
 Orangewood stick. The oldest method so far as I can learn that 
 is practiced to any extent at the present time is called knocking the pulp 
 out. For this method the pulp-chamber must be thoroughly opened, 
 the entire pulpal wall removed, a piece of orange or rose wood is whittled 
 quite like a sharpened lead pencil approximating the size and shape of the 
 root canal, this is dipped in carbolic acid, and held in direct line with the 
 pulp the point touching it, the stick is then struck a quick blow with the 
 mallet. If everything works weli, the pulp can be removed c[uickly and in 
 some instances painlessly, but many unlocked for things may happen 
 such as breaking the stick, driving it through the apex, or failure because 
 
65 
 
 of the irregular shape of the canal Then the pain caused in so thoroughly 
 opening the chamber is frequently severe. Altogether I regard this as a 
 relic of barbarism, which should be forgotten, and yet some good prac- 
 titioners use this method occasionally. My only excuse for presenting the 
 subject is its antiquity. 
 
 Carbolic acid method. Carbolic acid has been used for many years 
 as a corrosive agent to destroy pulps little by little, requiring frequent 
 applications, and many days' time ; but more recently it has been used by 
 hyperdermic injection directly into the pulp tissue using a very fine needle 
 carried up along the wall of the chamber for nearly half the length of the 
 canal, then forcing a drop or so of the melted crystals into the pulp. In 
 a few moments it can be removed quite painlessly, the pain of opening 
 the chamber and introducing the needle are often as great as to remove the 
 pulp forcibly without it. 
 
 Cocain. Many methods of using cocain for the purpose of anesthetiz- 
 ing the pulp have been tried, only two of which seem to be used at the 
 present time — viz., the cataphoric electric apparatus, and pressure method 
 used in exactly the same manner as has alread\' been suggested in Chapter 
 II. for obtunding sensitive dentine, with addition' of forcing the cocain 
 so thoroughly into the pulp tissue that all sensation is lost. The objec- 
 tions to cocain extirpation are these : 
 
 First. The danger of forcing poison of some nature through the apex 
 and injuring the tissue beyond. 
 
 Second. The injury to the tissues in the apical space caused by tear- 
 ing the pulp away. 
 
 Third. The hemorrhage that usually follows. 
 
 Fourth. The soreness attending the absorption of the blood clot left 
 in the apical space. 
 
 Fifth. The danger of leaving a small fragment of pulp tissue. 
 
 The advantages are these : 
 
 First. The time saved ; operation can be completed in one sitting. 
 
 Second. Less liability of tooth discoloration. 
 
 Third. In many cases less painful than the arsenic method. 
 
 Cocain method. The pressure method seems to have entirely dis- 
 placed the cataphoric electrolysis. The first essential in the use of the 
 pressure method is a clean cavity, so shaped that cocain solution can be 
 confined under pressure — this will often necessitate the building of a 
 third wall, to m.ake the cavity nearly cup shaped. After the pulpal wal! 
 is obtunded it should be thoroughly removed before continuing pressure to 
 fully anesthetize the pulp in order to avoid forcing micro-organic poisons 
 into the tissues beyond ; then the pumping can be done with some such 
 instrument as is represented in Fig. 23A, or a piece of soft rubber a little 
 
66 
 
 III 
 
 larger than the cavity, and forcing the cocain solutions into the tubuh 
 by pressing this against the cotton carrying the solution, with a sort of 
 
 pumping motion, gently at first and then in- 
 creasing gradually. This pumping should 
 continue until all signs of sensitiveness are 
 quite gone. This pumping should begin 
 gently then with increasing force until consid- 
 erable force is exerted. A smooth, fine broach 
 should be passed along the chamber wall, and 
 if slight sensitiveness is found the cocain 
 should again be pumped — until the smooth 
 broach will pass to the apex without causing 
 pain which should require not more than five 
 minutes. A barbed piano wire broach which 
 has been selected for the case, tested and 
 sterilized should be carried well into the canal, 
 turned half a revolution and withdrawn, when 
 in most cases the pulp will come away entirely. 
 Care should be exercised not to cut or tear the 
 pulp tissue, roughly forcing in the broach, or 
 turning it too much and cutting the tissue into 
 little pieces. When the pulp is torn in this 
 manner it is almost impossible to remove all 
 the shreds before sensitiveness returns, and to 
 remove these shreds is a task that sometimes 
 puzzles the most skilful ; in my hands the most 
 successful method of doing so is by entangling 
 I'i^H them in cotton loosely wound on a broach and 
 
 dipped in 95 per cent carbolic acid. 
 
 For the purpose of controlling and prevent- 
 ing hemorrhage a number of hemostatic agents 
 have been suggested but the use of i-iooo 
 solution of adrenalin chloride as a vehicle for 
 dissolving the cocain crystals seems to be most 
 often used, and in cases where there is no 
 hyperemia of the tissue in the apical space, 
 seems to meet every requirement. We should 
 bear in mind that most cases calling for pulp 
 removal are those that have recently been in 
 a state of inflammation, and it is almost cer- 
 tain that a hyperemic condition exists beyond 
 Tuiier's cataphoretic instrument the apcx, in which case a reasonable amount of 
 
67 
 
 bleeding will be helpful and should be encouraged. So far as using 
 blood coagulating or clotting agents is concerned for the purpose 
 ■oi stopping the hemorrhage after pulp is removed, I wish to ask 
 what is to become of this clot which to be of any value must be beyond 
 the root canal foramen ? Clearly it must be absorbed or organized and is 
 this not a source of danger? I think it best to wait a few minutes on 
 nature, and let her stop the bleeding by closing the lumen in the broken 
 vessels. The next step is to remove the blood mechanically, with aseptic 
 ■cotton and proper broaches, and finally with alcohol. Dr. J. P. Buckley 
 calls attention to the error of using hydrogen dioxide for this purpose ; 
 it tends to discolor the tooth substance. After thorough dehydrating some 
 mild soothing agent should be sealed in for a few days, to allow nature 
 to heal and restore to normal the tissues about the root apex. 
 
 For this purpose I use a mixture of eucalj'ptol, oil of cloves and 
 trikresol, placing the smallest quantity possible on antiseptic cotton 
 carried well into the canal. The reasons for not filling the canal imme- 
 diately upon the pulp removal, are two ; the tissues beyond are more or 
 less anesthetized and consequently will not respond in such a way as to tell 
 you when apex is just closed, and no filling material forced beyond and 
 second, there is some liability of leaving a tiny shred of pulp tissue at the 
 apex, which will not only prevent thorough filling, but will afterwards 
 cause considerable pain when the anesthesia has passed. 
 
 If we will keep all these suggestions in mind, I have no doubt we will 
 find the removal of pulps by this method very satisfactory in most cases, 
 and perhaps the most satisfactory of all methods, all things considered, 
 for all single rooted teeth in the mouths of the average patient, but in 
 three rooted teeth, especially where some of the canals are very small, and 
 in the mouths of very nervous people, the arsenic is preferable. 
 
 Arsenic method. The standard method, the one most frequently 
 used, and of most general application is the arsenic method. Arsenic acts 
 by first exciting the sensory nerves and then paralyzing them. It always 
 arouses a degree of inflammation somewhat dependent upon the amount 
 used so that it is advisable to use the least possible quantity to accom- 
 plish the desired result. While sensation is somewhat paralyzed a few 
 hours after the application of arsenic, yet the tissue is not dead, or even 
 senseless for several hours after application. Arsenic causes death by 
 its irritant corrosive action ; death by infarction in the apical portion is a 
 result of the inflammation caused. Inflammation may be so severe as to 
 prevent the ready absorption of the arsenic and hence death will be very 
 slow in such cases, and usually attended with considerable pain. This 
 -emphasizes the folly of attempting this method where pulp is in an 
 inflamed condition. If the pulp is quiet and small quantity used in con- 
 
68 
 
 junction with soothing agents the desired resuh can be attained without 
 pain, indeed, in my own hands it is rare indeed tliat I iiave trouble of this 
 kind. The preparation I use is made as follows : Arsenious acid and 
 finely powdered cocain hydrochlorate are taken in equal quantity and 
 thoroughly rubbed together, after which sufficient oil of cloves is added 
 to make a thin cream ; to this mixture I add one-half millimeter squares 
 of white hard blotting paper until the cream is absorbed. In a few hours 
 these will dry sufificiently to put in a jar and not stick together. 
 
 The tiny squares can be carried with the pliers and does away with 
 all danger of getting arsenic anywhere but at the point desired. The 
 brown color which they soon assume is an added advantage. It is 
 advisable to place arsenic preparation directly over an exposure of the 
 pulp, but this is not absolutely necessary for it will cause death of the 
 pulp when applied just beneath the enamel if long enough time is 
 given — but the danger lies in tooth discoloration from solution of liemo- 
 globin in the blood — and yet this danger is not so great as miake exposure 
 an absolute necessity, when that can only be accomplished at the cost of 
 a great deal of pain. As stated before the object of devitalization is that 
 the pulp may be removed painlessly and if we cause much pain in 
 applying the remedy we have not accomplished the thing desired. In 
 most cases calling for this treatment the pulp is already exposed by caries, 
 and is only covered by decayed dentine which can easily be removed by 
 following the method in excavating already suggested. After the prep- 
 aration is placed it should be covered with some material that will make 
 a perfect seal and yet not press on the tissue. 
 
 Preparation of €auity to Receive Jlrsenic, 
 
 A very important point to consider is the proper preparation of the 
 cavity — it must have sound walls and margins, particularly at the 
 gingival — and so shaped that the sealing wall not be driven out or down in 
 the act of mastication. 
 
 In very many proximal cavities the gingival wall is under the gum 
 gingivus and indeed that tissue is very often grown into the cavity, which 
 requires special care in removing 'or by wedging back. In all cases the 
 rubber dam should be applied and the field of operation made clean 
 surgically. Then a properly fitting matrix can be placed, and a fourth 
 wall built of cement or in favorable cases gutta-percha, never temporary 
 stopping, may be used ; this should be done before the arsenic is applied 
 and allowed to harden, when the application can be made and sealed with- 
 out danger of either pressing on the pulp or forcing the arsenic out upon 
 the gum. The tendency in the use of arsenic is not to leave it in contact 
 with the pulp long enough. I think 36 or 48 hours is short enough even itt 
 
69 
 
 the most favorable cases, and yet if a very large quantity is used there is 
 some danger of it being carried beyond the apex, especially in young teeth 
 with large foramen, which means the ultimate loss of that tooth. After 
 arsenic is removed it is best practice not to attempt removal of pulp, but 
 to seal in tannic acid to harden the tissue or sodium hydroxid to partially 
 saponify it. The practice of applying dialyzed iron to the pulp after ar- 
 senic is removed is both useless and dangerous, liable to cause serious 
 discoloration of the tooth. 
 
 Either of the above preparations should be left sealed in for at least 
 four days and ten is better. Before applying these, however, the pulp 
 should be completely exposed, all decay removed and tested with a smooth 
 broach. Alany practitioners believe it best to remove the pulp immediately 
 on the removal of the arsenic, and in many cases for lack of time and 
 other special reasons this may be necessary. If, on the other hand, these 
 other agents are used and allowed to remain until the pulp has been 
 thrown off from the tissues beyond the apex, root canal cleaning is greatly 
 simplified ; especially do I like the use of solution of sodium hydroxid. I 
 have used this preparation for several years, and in all cases where the 
 pulp was completely destroyed by arsenic before applying it I am able 
 to remove the pulp in one piece leaving the canals clean and white, a con- 
 dition that is most desirable. 
 
 The cleaning of pulp chambers will be the subject of the next chapter, 
 but before dismissing this subject I wish to refer to the treatment of 
 arsenical poisoning of the gum tissue. When arsenic remains in contact 
 with the gum tissue for any length of time wide destruction of that tis- 
 sue results which often involves the periosteum, pericementum and bone. 
 
 By way of emphasis I will cite a case in point which came to me not 
 long ago. 
 
 A lady who had formerly been a patient of mine went to a neigh- 
 boring dentist, a young gentleman that she was somewhat interested in, 
 and anxious to aid in building up a practice, and he devitalized the 
 pulp of a superior second bicuspid tooth. She came to me and said: 
 "Doctor, I want you to give me a few minutes time." She didn't tell me 
 the dentist's name, and I didn't ask her, but she said that he had been six 
 weeks attempting to devitalize that pulp, and that the tooth had gotten 
 A^ery sore and she was alarmed. Well, I put her in the chair and I 
 examined her case, and I saw immediately the thing that had occurred. I 
 applied the rubber dam that she might not know just what I was doing. 
 T didn't want to tell her because she was very bitter against the young 
 man by this time, and I didn't want her to know what had occurred there. 
 I applied the rubber dam over the two teeth mesial and distal to the space 
 where the trouble was, and then with a little manipulation I brought away, 
 
70 
 
 I should say, a piece of bone fully a half by an eighth of an inch, or in 
 other words, I brought away completely the entire alveolus between those 
 two roots clear to the apex. I slipped it out over the gum, and threw 
 it away, and she didn't see it at all and never knew what had occurred. I 
 washed it out, and packed it with antiseptics and it is filling in nicely, but 
 in all these cases where the gum septum peridental membrane and alveolar 
 border are lost it is never fully restored and always will prove a source 
 of annoyance and require constant watching. 
 
 If you get some arsenic on the gum accidentally, what is the thing 
 to do ? Swab it off with dialyzed iron, or what is better, freshly prepared 
 solution sulphate of iron with magnesia. If at the second operation you 
 find the gum is destroyed quite largely, what are you going to do ? You 
 may apply your dialyzed iron, but it won't do any good. You simply have 
 to treat as you would a surgical wound. Remove the dead material,, 
 either by actual operation, or by cauterizing it with carbolic acid, nitrate 
 of silver or something of that sort, and then keep the wound antiseptic, 
 encouraging it to heal in every way you can. I shall speak of the man- 
 agement of these gums later in connection with another subject. 
 
CHAPTER IX. 
 
 eieansittg and filling Pulp (Kbambers. 
 
 The Pulp Chamber. Variations of the Form of Pulp Chambers. Removing Pulps. 
 
 Filling Pulp Canals. 
 
 the Pulp Chamber. 
 
 The term pulp chamber is used to designate the central cavity in the 
 dentine of the tooth, and is usually divided into a crown part known as 
 the pulp chamber proper, and a root portion, known as the root canal or 
 root canals. An accurate knowledge of the anatomy of pulp chambers is 
 of the utmost importance, and without it many mistakes are made in 
 operating, both in the preparation of cavities for fillings as well as in 
 opening chambers for the purpose of removing pulp, treatment and filling 
 canals. While pulp chambers often vary somewhat from the normal, 
 yet an accurate knowledge of the normal will be most helpful in dealing 
 with such abnormalities as may be met with in daily practice. 
 
 Teeth of different denominations have different canals, and it mav 
 be said that teeth of the same denomination often differ in this regard. 
 In teeth with only one canal the pulp is usually conical, being large in the 
 pulp chamber proper and gradually tapering to the apical foramen, which 
 in fully developed teeth is very small. The following description and 
 illustration is adapted from Black's "Dental Anatomy." 
 
72 
 
 L4 
 
 A ^3 ^C WD ^^E TF 
 
 Xi H I 
 
 J ^K 
 
 
 Fig. 23. 
 Longitudinal section through the center of the teeth, showing outline form of pulp chamber 
 and root canals. (Adapted from Black.) 
 
73 
 
 In the upper central and lateral incisors (Fig. 23, A, B, C, D) there 
 is no distinct division of the pulp cavity into the pulp chamber and root 
 canal ; but there is one straight canal, from the interior of the body of 
 the crown to the apex of the root, of which the crown portion is the 
 larger. In young teeth, this has very distinctly the form of the surface of 
 the tooth and root, except that it is much more slender. The largest 
 diameter of the cavity is about level with the gingival line on the labial 
 surface. From this point, the pulp chamber, or canal, extends toward 
 the cutting edge of the tooth, about two-thirds the length of the crown, 
 sometimes a little more, often less, and ends in a thin edge broad from 
 mesial to distal. From the level of the gingival line towards the apex of 
 the root it tapers very gradually and regularly to a narrow canal. Just 
 within the apex of the root, almost at the end, there is usually a sudden 
 contraction of the diameter of the canal, lessening it from one-third to 
 one-half. 
 
 The pulp chamber and root canal of the upper cuspid (Fig. 23, e, f) 
 is about the same in form as that of the central and lateral incisors, ex- 
 cept that the coronal extremity has the central horn much extended 
 toward the apex of the cusp of the tooth, and the mesial and lateral 
 horns are practically absent. The coronal portion of the pulp chamber 
 of the lower incisors is much flattened (Fig. 23, g, h). 
 
 At the level of the gingival line, the long diameter is from labial to 
 lingual. The chamber extends towards the cutting edge of the tooth, 
 about two-thirds the length of the crown, and in this extension its diam- 
 eter is progressively diminished from labial to lingual, and extended 
 from mesial to distal, following the contour of the surface of the tooth, 
 and ends in a thin edge. In young teeth this has three short projections 
 towards the mammelons on the cutting edges of the young, unworn 
 teeth. The root has usually a narrow slit-like opening for the greater 
 portion of its length, corresponding with the form of the flattened roots. 
 
 The pulp chamber and root canal of the lower cuspid (Fig. 23, i, j, k) 
 are variable in size and form. At the neck of the tooth the cham.ber is 
 usually irregularly flattened, with the longer diameter from labial to 
 lingual, and the labial portion wider than the lingual. The coronal por- 
 tion extends about two-thirds of the length of the crown towards the 
 point of the cusp, ending in a point, or horn, which is often very slender. 
 The form of the root portion of the canal depends on the form of the 
 root. It is sometimes nearly round but more frequently it is sharply 
 flattened for the greater portion of its length, becoming more rounded 
 towards the apex. 
 
 Occasionally, this canal is divided for a part of the length of the 
 root. In upper first bicuspids the pulp chamber and root canals differ 
 
74 
 
 from those of the incisors and cuspids by a coronal chamber distinguished 
 sharply from the root canals (Fig. 2^,, 1, m). 
 
 The chamber is centrally located in the long axis of the crown of 
 the tooth, the axial walls being about equal in thickness. The center of 
 the pulp chamber is about level with the gingival line, or a little towards 
 the occlusal surface. The occlusal walls are thicker than the axial, and 
 vary in thickness from one-third to two-thirds of the length of the crown 
 of the tooth. The form of the pulp corresponds closely with the form 
 of the tooth. A horn extends from the coronal portions towards the 
 apex of each cusp. 
 
 The root canals in upper first bicuspids that have two roots pass 
 from the pulp chamber through the 'tenter of each root to the apex, and 
 are known as the buccal and lingual root canals (Fig. 23, m). The buc- 
 cal canal arises from the extreme buccal side of the pulp chamber, and 
 the lingual canal from the extreme lingual side, and their course is 
 almost parallel with the walls of these two portions of the pulp chamber.. 
 
 The pulp chamber of the upper second bicuspid (Fig. 23 n, o)is similar 
 to that of the first, but. the horns of the pulp are usually shorter. In this 
 tooth there is generally but a single root canal, and sometimes there are 
 two canals which end in a common apical foramen, and sometimes these 
 canals continue separately to the apex. The pulp chambers of the 
 lower bicuspids (Fig. 23, p, q) seldom show a marked distinction from 
 the root canals. There is, however, usually a coronal bulbous portion 
 which connects with the pulp canal proper by an extended funnel-shaped 
 construction. In the lower first bicuspid, the coronal extremity ends in a 
 horn, which -^xtends towards the point of the buccal cusp. The root 
 canals of ^he lower bicuspids are usually large in the first half, tapering 
 to a fine '"anal in the apical third of their length. The canal of the lower 
 first bicuspid is usually nearly round, and that of the second is consid- 
 erably flattened — and in both they are usually straight. Bifurcations of 
 these canals are rare, but occur occasionally. 
 
 The pulp chamber of the upper molars (Fig. 23, R, S) is very dis- 
 tinct from the pulp canals, the latter often leaving the former by very 
 small openings. The form of the pulp chamber is generally similar to 
 that of the crown of the tooth ; but the horns in the young tooth are often 
 quite slender as compared with the cusps, and penetrate far towards the 
 enamel. The length of these diminishes as age advances. In teeth much 
 flattened mesio-distally, as often occurs in the upper first molars, and espe- 
 cially with the second, the equal thickness of the axial walls is usually 
 maintained pretty closely, so that the flattening of the pulp chamber 
 seems out of proportion to the form of the tooth. The floor of the pulp 
 chamber is rounded or arched in the center (Fig. 24, A, f) and falls away 
 
75 
 
 towards the mouths of the canals. The latter is situated in the portions 
 of the angles of a triangle. 
 
 The opening into the lingual root is the simplest and most direct. 
 Generally, it begins in a funnel-shaped opening inclining to the lingual,. 
 
 Fig. 24. 
 A, the upper teeth cross section showing the entrance to all the canals from a to h and a 
 to /;; D. the lower teeth cross section showing the entrance to all the canals with same letters. 
 
 which quickly narrows to the dimensions of a moderately small canal,, 
 and continues to taper to the apical foramen. It is usually straight, or 
 but slightly curved. 
 
 The opening into the mesial canal is under the mesio-buccal cusp, 
 close against the mesio-buccal angle of the pulp chamber. To find this 
 canal the point of the broach should be directed into the mesio-buccal 
 angle of the pulp chamber; and, while held against the wall within this 
 angle, it is slid towards the root, and will rarely fail to glide into the 
 
76 
 
 canal. The distal canal usually begins abruptly as a fine opening situated 
 at the disto-buccal angle of the floor of the pulp chamber, so that a 
 broach pressed into that angle will easily glide into it. But in some 
 instances, especially in the upper second molars, the opening is in the 
 floor of the pulp chamber at a little distance from the immediate angle 
 towards the center of the floor, and then, in positions which limit the use 
 of the eye, it is often difficult to find. In teeth much flattened at the 
 neck, the opening of this canal may begin very close to the mouth of the 
 mesial canal or close against the distal wall of the chamber, half-way from 
 the buccal to the lingual wall or anywhere between this point and the 
 disto-buccal angle. This description will do fairly well for all upper 
 molars. 
 
 The pulp chamber of the lower molars (Fig. 23, T, W) has the 
 same general form as the surface of the crown, but is generally rather 
 more angular. The wall of the chamber towards the occlusal surface is 
 convex toward the pulp ; the horns extend from the extreme angles 
 towards the apex of each cusp. The floor through the central portion is 
 arched or convexed mesio-distally, and concave bucco-lingually (Fig. 
 24-Bf). The mesial wall of the cavity is flat and longer than the distal. 
 The mesio-buccal and mesio-lingual angles are sharp and projecting, 
 while the distal angles are rounded. The size of the chamber varies 
 much. The root canals of the lower molars proceed from the mesial 
 and distal portions of the pulp chamber. The mesial canal, at its mouth, 
 is usually about as broad from buccal to lingual as the whole breadth of 
 the chamber, including its angular projections. Either at or a little root- 
 wise from the floor of the pulp chamber, it is usually divided into two 
 very small canals which diverge at first, and approach each other after- 
 wards, but usually remain distinct, each ending in its own apical foramen. 
 Occasionally, how^ever, they are united in the apical third of the root, 
 and end in a common apical foramen. By placing the point of the broach 
 through the mesio-buccal angle of the chamber and pushing it gently on, 
 it will generally glide into the canal. The broach easily glides into the 
 mesio-lingual canal by placing the point in the mesio-lingual angle of 
 the pulp chamber and sliding it towards the root. The first inclination 
 is to the mesial, but occasionally to the lingual, after which it curves to the 
 distal and buccal. The distal canal is approached by a funnel-shaped 
 opening, of which the central part of the distal wall of the pulp cham- 
 ber becomes a portion. Its direction is a little to the distal, and generally 
 very nearly straight to the apex. It is generally much larger than the 
 canals of the mesial root, and is easily cleaned with the broach. If the 
 mouth is wide open and the handle of the broach brought against the 
 upper central incisors with the point directed against the posterior wall 
 
of the pulp chamber, it will easily glide into the canal, and pass to the 
 apical foramen. Fig. 24 should be carefuly studied ; it represents the 
 locations of all the pulp chambers. 
 
 Uariations of tbc Torm cf Pulp ebasnbm. 
 
 Many variations of form occur in the pulp chambers and root canals. 
 The roots of the teeth may be abnormally crooked, and then the canals 
 will be abnormall}- crooked. In many instances the pulp chamber will 
 have in it secondary formations, called nodules, which may be adherent 
 to the walls or block the mouths of the canals and prevent a broach 
 gliding into them. These also occur, occasionally, within the canals, par- 
 tially blocking the way of the broach. Sometimes the pulp chamber 
 will be filled with nodular deposits so completely that there seems to be 
 no room for the tissue of the pulp. These deposits will have to be 
 removed before the root canals can be reached and entered, after which 
 the canals will generally be found open. These deposits occur within the 
 pulp chambers of any of the teeth ; but they cause annoyance more fre- 
 quently in the molars. Occasionally lateral openings occur from the root 
 canals to the surface of the root. I have seen more of these from the 
 canals of the lower molars than from those of any other teeth. Gener- 
 ally they follow the course of the dental tubules, and open on the side of 
 the root. They may diverge to one side and curve towards the apex of 
 the root. These cannot often be detected, except in dissections of the 
 root, and occur so rarely they may be ignored in practice. Sometimes 
 the horn of the pulp approaches abnormally near the points of the cusps 
 of some of the teeth, as in the upper first molar. Then the pulp is 
 more liable to exposure in excavating carious cavities." 
 
 Remooina Pulps. 
 
 Removing pulps is an operation that is sometimes difficult on ac- 
 count of the smallness, irregularity and inaccessibility of the pulp canals ; 
 particularly is this true in the buccal canals of upper molar and the 
 mesial canals of lower molars — but in all single rooted teeth and the large 
 straight canals the operation is very easy. The first requisite for such 
 operations is proper instruments. A smooth fine piano wire broach, the 
 Donaldson or Realization barbed broach of various sizes, and the Downey 
 spiral broach of various sizes are the instruments most needed (see Fig. 
 25A). Each of these broaches should be carefully tested for weak places; 
 particularly is this a necessity with all barbed broaches, for weak places 
 are very liable to exist. The easiest w^ay of making such a test is to take 
 the handle and hold the point obliquely against the glass slab with 
 enough force to spring it, at the same time rotating it ; if a weak place 
 
78 
 
 exists it will fracture at that point, and save you the annoyance of having 
 it break in the canal. The next important thing is to secure the best pos- 
 sible access to the canals. I am amazed sometimes to see operators try- 
 ing to remove a pulp from a three canaled molar through an opening in 
 the central fissure the size of a No. 5 round bur. The complete removal 
 of the roof of the pulp chamber is the best plan, which in most cases is 
 easily done with an inverted cone bur. In opening up pulp chambers the 
 operator should avoid disturbing the floor of the pulp chamber, particu- 
 larly in molar teeth, for, as has already been alluded to, the floor is a 
 guide to the entrance of the root canals and makes the finding of each a 
 simple matter. I wish to deprecate the use of round burs for the purpose 
 of opening pulp chambers, for with them the chamber floor is so liable 
 to be cut and the entrance to the canals filled with fine chips, making it 
 almost impossible to locate and enter a broach in them. 
 
 Fig. 25A. 
 
 All of this work must be done under the most thorough antiseptic 
 precautions. The dam must always be in place, the field of operation 
 cleansed and dried, the immediate tooth cavity sterilized and dried with 
 alcohol, the broaches and other instruments used must be sterilized, and 
 from the time you open the chamber nothing should ever enter except 
 such instruments and agents as are placed there by the operator. After 
 the chamber has been opened the cavity should again be flooded with 
 alcohol to wash out all loose fragments and then dried with warm air ; 
 the drying has a tendency to shrink the pulp tissue, making its removal 
 all the easier. The next step is to remove the large bulbous portion of 
 the pulp with the pliers or a spoon excavator. In many cases where 
 sodium hydroxid has previously been sealed, the entire pulp will come 
 away with the pliers or excavator ; indeed, I have several such speci- 
 mens preserved that were taken from molar teeth in this manner. 
 
79 
 
 A fine broach is then passed along the walls of the various canals to 
 explore and locate any irregularities, after which a barbed broach is car- 
 ried along the wall well into the canal and turned just sufficient to 
 entangle the pulp, when it will easily come away in one piece; this will 
 nearly always be true in large canals, but oftentimes canals are too small 
 to admit of even the finest barbed broach with safety, for the danger of 
 ■catching the barbs in the dentine is very great in small canals, with the 
 result that a portion of the broach is left in the canal, which is a very 
 difficult thing to remove. In these small canals I have been using for 
 several years the Downey or Ivory twist of spiral broach. With a little 
 experience they can be turned into almost the smallest canal, not only 
 removing the pulp but enlarging the canal slightly. After the pulp is 
 removed the walls of the canals should be scraped to remove the odonto- 
 blasts that may be clinging thereto. This can be done in all but the 
 smallest canals with the barbed broach by introducing and withdrawing 
 without turning or rotating it. It is considered best not to disturb these 
 walls further than this in all except the very smallest canals ; but in these 
 small canals it is often necessary to enlarge them in order that they may 
 be filled. The Downey broach is admirably adapted for this purpose, but 
 the point needs to be dulled a little in order to prevent it boring through 
 the side of the root in tortuous canals. This broach should not be turned 
 into the apex before withdrawing and cleaning it, but it should be turned 
 in and back, little by little, withdrawing and cleansing every few moments. 
 
 There still remains some very small inaccessible canals that cannot 
 be cleansed in this manner, and for this several methods have been 
 suggested. 
 
 First- — The use of 50 per cent sulphuric acid to cut the soft tissue 
 and dissolve a little of the dentine, thereby enlarging and cleaning the 
 canal. It should be introduced on zephyr wool fiber with a platina 
 iridium broach ; except in rare instances it should not be allowed to 
 remain in the canal but a few minutes, after which it is neutralized with a 
 solution of sodium bicarbonate. This preparation is specially valuable 
 in loosening pulp nodules and tumor-like deposits occurring sometimes 
 in the canals. 
 
 Second — The use of pulp digestors such as carica papaya, dissolved 
 in slightly acidulated water and allowed to remain sealed in the chamber 
 for 10 to 20 days. 
 
 Third — Mummifying paste, for which I have no respect. 
 
 When the canals have been thus mechanically, and, when need be, 
 chemically cleansed, they should be flooded with alcohol worked well 
 down to the apex ; this will wash up all loose particles ; clean and dry 
 the canals, in which condition thev are ready for the filling. At this 
 
8o 
 
 point I want to emphasize the value of mechanically cleaning the canals 
 rather than relying on medicines to do this work. This point was well 
 emphasized by Dr. Logan in an article read before one of our societies 
 recently. 
 
 Many operators advise the filling of root canals immediately after 
 removing the pulp, and if the work of cleansing has been thoroughly 
 done, with all precautions against infection, it would seem advisable after 
 bathing in some mild antiseptic like my eucalyptol, oil cloves, trikresol 
 mixture, and again drying with alcohol. This procedure is permissible in 
 those cases where sodium hydrate has been applied following the arsenic, 
 but in all other cases it is wisest to allow the dressing before alluded to 
 to remain for a few days in order to be certain of our conditions before 
 root filling. 
 
 Tilling Pulp Canals. 
 
 There is no subject in operative dentistry that has received so much 
 attention in the last 15 years as has the proper filling of pulp canals, and 
 yet the ideal filling material has not been found. First came cotton, then 
 wood, followed by gold, charcoal, tin, wool, chloride of zinc, paraffine, 
 gutta-percha, and lastly balsam varnish — but none are ideal. 
 
 The ideal root filling should be non-porous, non-irritating, non- 
 shrinking, and of such a nature that it can easily be placed. Such a ma^ 
 terial we have not, but the most nearly ideal material we have at the 
 present time is gutta-percha, and is the one that is most universally used. 
 
 The technique of using this material for the filling of large canals 
 is to first select a small piece of conical shape that by exploration you 
 have decided will close the apical foramen. The dry and sterile canal is 
 slightly moistened with eucalyptol, all excess removed and with the aid 
 of a properly shaped root canal plugger the selected piece of gutta-percha 
 is slightly heated and packed in the apical end, completing the operation 
 by packing piece upon piece until the whole canal is tightly filled, using 
 hot air to soften when needed. 
 
 In smaller canals it is customary to select a gutta-percha cone small 
 and stiff enough to admit of being forced to the apex ; the canal is, as 
 before, slightly moistened with eucalyptol and chlora-percha — that is, 
 gutta-percha dissolved in chloroform — is pumped into the canals with a 
 fine smooth broach. In the very small canals much care must be exer- 
 cised and the pumping continue for a considerable time to force the chlora- 
 percha clear to the apex, then the selected cone is carried to place gently, 
 allowing the excess chlora-percha to escape back into the cavity and not 
 forced beyond the foramen. Where the canals are very small fine 14k. 
 gold and also copper points are made to take the place of the gutta-percha. 
 They are much stififer and so can be forced where so small a gutta- 
 
8i 
 
 percha cone would not go. In the larger canals the walls only should be 
 coated with chlora-percha and the gutta-percha cone placed. As the 
 chloroform evaporates the gutta-percha should be warmed and again 
 packed in order to fill in the shrinkage. Many use eucalypto-percha, 
 others sandarac varnish instead of the chlora-percha. The object to be 
 attained is to completely fill the canal and not force any material beyond 
 the foramen. While this is a very delicate matter, a little practice will 
 develop that intuitive perception that will enable one to do it well ; the 
 slight flinching of the patient is only valuable when we know by our 
 sense of touch that it is the filling at the apex that is the cause and not 
 air. It is impossible to accurately describe the filling of root canals. Tt 
 is an operation which only the trained finger touch, as elsewhere in the 
 field of operative dentistry, will make the successful operator. 
 
CHAPTER X. 
 
 Suppuration of tbe Cootb Pulp. 
 
 Immunity and Susceptibility. Kinds of Pus. Fever. Symptoms of Fever. Sup- 
 puration of the Pulp. Cases of Open Cavities. Cases of Putrefaction 
 Under Fillings. Treatment. 
 
 Suppuration. — The formation of pus ; the act of becoming converted 
 into pus, is the definition given, I think, by most authorities. Thus far 
 we have for the most part been studying inflammation, which I have en- 
 deavored to show, when confined within certain Hmits, is purely a process 
 of repair. When the heahng process becomes infected with bacteria, 
 then we have what is termed an infected inflammation, a condition unlike 
 simple inflammation, which shows a tendency to confine itself to a local 
 area and to heal ; when it once becomes infected it shows a tendency to 
 spread and take in the neighboring parts and no tendency to heal. In our 
 study of inflammation of living tissue we stopped with the exudate of 
 coagulable lymph into which tissue building cells congregate, and grad- 
 ually transformation into granulation tissue, and then fibrous tissue and 
 healing is completed by the growth of epithelium. 
 
 Let us return to our case at the point where tissue building cells 
 are gathering in this coagulable exudate, and here introduce an element 
 which often unexpectedly appears always uninvitedly, namely, certain 
 micro-organisms. We see, then, a most interesting process, usually re- 
 sulting in suppuration, but not always. Sometimes we will have the 
 presence of pus forming bacteria in these inflammations in considerable 
 numbers and no perceptible suppuration occurring. Why? This is a 
 point I wish to clear up first. 
 
 First — The condition of the germ with which we infect. 
 
 Second — The condition of the whole cells in the part infected. 
 
 Third — The condition of the whole organism, constituting what is 
 known as immunity. 
 
 Tmmunity and Susceptibility. 
 
 Immunity is the condition in which the body as a whole animal 
 organism resists the entrance of disease producing germs, or, when they 
 have entered, resists their growth and pathogenesis. The opposite of 
 which is the term susceptibility, in which, instead of resistance, favorable 
 conditions are present for the growth of these germs and their patho- 
 genesis. 
 
 The study of immunity and susceptibility is perhaps the most inter- 
 esting of all physiology and pathology. 
 
83 
 
 Man suffers from many diseases which are never observed in the 
 animal. The laity have always explained this fact by saying that animals 
 .are different from man ; but the more the scientist contemplates this sub- 
 ject the more complex it becomes, and today the whole investigation is 
 only in its infancy. It was early thought that the chemistry of the body 
 constituents would explain all, and indeed this has a very important part 
 in it ; but it does not explain why, for example, the white mouse is espe- 
 cially susceptible to anthrax, while the house mouse is almost immune 
 to its ravages. Nor is this the most remarkable thing about the subject. 
 Why does one attack of yellow fever, smallpox or typhoid fever render 
 the subject practically immune to the second attack? 
 
 And furthermore, a few drops of blood taken from the mouse recov- 
 ered from tetanus injected into another renders it immune to that dis- 
 ease. These are some of the interesting things that we observe. I want 
 you to get the various explanations for this thing, because. if there is one 
 subject a dentist should be familiar with, it is the subject of pus forma- 
 tion, how it occurs, what it does when it does occur, etc. 
 
 The first theory, perhaps, is known as the Exhaustion Theory. 
 Pasteur explained this im.munity by saying that the micro-organisms had 
 used up all of som.e certain material in the body which is essential to the 
 growth of these germs; hence they die from exhaustion, i. e., from lack 
 of food. Hence the removal of this material by any means will perma- 
 nently remove all liability to disease produced by these germs. Stern- 
 berg pointed out the weakness of this theory. He said if it were true we 
 must have in our body a' variety of this material, of smallpox, of measles, 
 of scarlet fever, and a hundred others to be exhausted by its appropriate 
 organism, and shows how exceedingly complex and stable the chemistry 
 of the body must be in order to make this theory hold good. 
 
 The second theory is known as the Retention Theory. In the same 
 year that Pasteur and Sternberg were working, Chauvan pointed out 
 the fact that probably the progress of any disease may develop in the 
 system a substance which hinders its further growth. There seems to be 
 a large amount of truth in this ; but if entirely true, what amount of ma- 
 terial and how many different kinds would be added to our blood in case 
 we had smallpox, measles, scarlet fever, typhoid fever and all the rest. 
 Following this, in 1881, Carl Rosser showed the relation of phagocytosis 
 to immunity. Similar observations were made by Sternberg in the United 
 States and Koch in Germany. This theory was more thoroughly and 
 fully developed by Metschinoff in 1884 advancing his theory regarding 
 the process in a long series of experim.ents, he showed the relation of the 
 leucocytes to bacteria. The phagocytes, which we have alluded to in 
 a previous chapter, are cells without maich resisting cell wall and are 
 
84 
 
 capable of amoeboid movement. Outside of the body, if we place the 
 amoeba in a suitable liquid containing bacteria although the amoeba pos- 
 sesses neither nervous system, eyes, nose, or volition of any kind, it will 
 nevertheless seek out these bacteria. They surround the bacteria and 
 really digest it completely. The property which enables it thus to find 
 the bacteria I have explained under the head of chemotaxis. This is 
 exactly what takes place in the body, and is what I have alluded to. 
 Metscliinofif, a man who has done perhaps more of real scientific work than 
 any living man along this line, succeeded in catching some of these leuco- 
 cytes, each containing an anthrax spore. After inoculating his subject 
 with anthrax he succeeded in getting any number of these wandering 
 leucocytes containing anthrax spores within themselves. He placed them 
 in culture media, which, of course, was ill suited to the life of the leuco- 
 cytes but better so to the bacteria, and watched the result. The leuco- 
 cytes died and the germs lived and grew. Taking this, then, and the 
 amoeboid movement, we have the process of suppuration and immunity 
 as explained by Metschinoff, which is known as the Metschinoif Theory 
 of Phagocytosis. 
 
 A word further in explanation of the action of leucocytes upon bacteria.. 
 Hankin and Hardy found three varieties of leucocytes had a part to play 
 in the process, the outline of which is given in ]\IcFarland's work on 
 bacteriology. Hankin and Hardy, taking up Metschinoff's suggestion, 
 went to work to study just the kind of leucocytes that have to do in this 
 thing. They found that certain eosenophilic cells approach and swallow 
 up the bacteria ; then certain other cells, known as the hyalin cells, take 
 up the remains left by the former cells and destroy it. Another cell, 
 which is known as the basophilic cell, supposed to be antidotal to the 
 poisons surrounding the combatants, neutralizing the bacteria poisons and 
 setting free the contestants. 
 
 We have another theory which I want to call your attention to,, 
 known as the humoral theory, a theory worked out by Buchner. In short,, 
 it is this, that the serum of the blood possesses certain germicidal powers 
 which may be destroyed by heat, fever, etc. Jetter claimed this was due 
 to certain salts contained in solution in this serum. Hankin thought this 
 action was due to some substance contained in the eosenophilic cells. 
 In no field has so much experimental work been done as in this. At the 
 present time the relation of the blood serum is not exactly understood. 
 The experimentation has given rise to the present theory of antitoxin., 
 which, as I have previously stated, is at present in its infancy. In short, 
 it is a process of cultivating germs in the living body, and taking the 
 serum of this subject at a certain point when it contains poisonous prod- 
 ucts of these germs, and the tissue change, and injecting in man to im- 
 
85 
 
 munize him. And this same process is now being developed to include 
 immunity from infection. To what extent this theory will carry us the 
 future alone can decide. Space will not permit me to go further into the 
 subject. I simply wanted to bring enough of these theories to your 
 attention to furnish a rational basis for what I have to say about sup- 
 puration. 
 
 Let us return to our consideration of suppuration, and perhaps this 
 little apparent digression may aid us in comprehending what does occur. 
 The cells, indeed the whole tissue involved in the process of repair, 
 may possess sufficient vital force to withstand the onslaught of these 
 micro-organisms, and they are literally destroyed and carried away, and 
 we have no infection, which, of course, is Metschinoff's theory regarding 
 non-infection. Every operator I know has had abundant experience to 
 demonstrate the fact that simply introducing through the skin some in- 
 fectious material does not always bring infection. I know that many of 
 3^ou have already pricked your fingers with broaches and exploring in- 
 struments that you knew were infected and had no result. Another time, 
 you do not know how, you have pricked your finger, and the first thing 
 you know you have a swollen finger, it begins to get sore and you have 
 the whole process of inflammation and suppuration going on m it. Sup- 
 puration is a subject which has challenged the attention of the brightest 
 minds among scientists for many hundred years, and the opinions of men 
 have undergone most radical changes within the last thirty years, and, 
 indeed, I may say that it is only within the last fifteen years that the 
 cause of pus formation is at all understood. Up to that time the theory 
 advanced by Bilroth, and afterwards elaborated upon by Conheim, 
 seemed to satisfy most minds. This theory is briefly stated thus: Sup- 
 puration consists in an enormous multiplication of the cells of the part 
 due to diapedesis of leucocytes, and that the fluid portion of the exudate 
 fails to coagulate, and this with the softening of intercellular substance 
 produces liquefaction of the forming tissue and pus. So far as it goes, 
 it is correct, so far as we know. The only addition made since is to show 
 exactly why the exudate fails to coagulate. 
 
 Bilroth's theory was that we have this great multiplication of cells 
 out into the forming tissue. The serous exudate fails to coagulate, lique- 
 faction of tissue forming cells and pus. All we have done to that in the 
 last thirty years has been to try to clear up and explain why this exudate 
 fails to coagulate. 
 
 Suppuration is a bacteriological process. The process by which this 
 has been brought out, although exceedingly interesting, I can only hint 
 at. Scientists generally agree with Bilroth and other experimenters as to 
 what is seen in the suppurating tissue. Everyone agrees that what 
 
86 
 
 Bilroth and Conheim and others saw at that time in the tissue was. 
 . correct. 
 
 Lister, in 1869, threw some light as to how this liquefaction occurs. 
 He called attention to the many micro-organisms found in the invaded 
 1 issue, as had also Pasteur, and suggested that perhaps they had some- 
 thing to do with the process. Lister probably was the first to clear up 
 this subject at all. In proof of his claim that perhaps these micro-organ- 
 isms had something to do with it, he set about to exclude bacteria from 
 wounds and see what the result would be. This he started out to do in 
 wounds made by the surgeon. It was just a little before this that the 
 value of carbolic acid becamie understood as an aid in treating suppura- 
 tion. Lister then operated under a carbolic and water spray. He first 
 sprayed the whole room in which he was operating ; the patient was 
 cleansed ; the part to be operated upon was thoroughly cleansed and 
 sprayed, and after he had finished his operation the wound was covered 
 with gauze and over this gauze cotton to keep the air away, and thus 
 prevent the ingress of micro-organic life from the air. The world was 
 surprised at his results. He had no suppuration. Up to this time the 
 surgeon always looked forward to the time when this appearance of sup- 
 puration, or this sort of liquid or exudate would appear on the surface 
 of the wound, or establishing of the secretions, and as the pus appeared 
 he would look at it and examine the nature of it ; under certain circum- 
 stances this is healthy pus, we will get healing right away here, believing 
 that the suppuration was a necessary part of the process of healing. But 
 Lister excluded all of these bacteria, .operated under antiseptic conditions 
 and he had no suppuration, but exactly what part the micro-organisms 
 played in the process he did not know. He was read}^ to believe that 
 micro-organisms had something to do with inflammation. He thought 
 the degree of inflammation was somewhat dependent upon the number 
 of these germs. This was away back in 1869. In 1881 he was still of 
 the opinion that they were not a necessary part of pus formation in all 
 cases. 
 
 So far as I can learn, Volkman was the first to declare that without 
 micro-organisms we could have no pus. This was in 1881. A school 
 was soon developed with Henter at its head, which had for its motto : 
 "No pus without bacteria." This brought out most violent opposition. 
 
 Bilroth maintained that the bacteria were an accompaniment, not an 
 essential part of suppuration. Pasteur was able to produce suppuration,, 
 with pus, in which he had destroyed all germs by heat of no C, leaving 
 only the chemical products of those organisms. For the purpose of 
 testing this idea severely men tried to produce suppuration with chemical 
 irritants only — croton oil, turpentine, mercury, etc. Their results were 
 
87 
 
 unsatisfactory, although many succeeded to their own satisfaction. A 
 number were convinced that such a thing could be done, but the truth, 
 doubtless, is that they infected their tests either from without or within 
 the circulation, because they would succeed on one animal in producing 
 pus and fail on two or three. The method was to make a fresh wound 
 under aseptic precautions. A small glass phial charged with some con- 
 centrated irritant, as oil of mustard, was placed in the wound and the 
 wound sewed over and allowed to heal. After the healing had occurred 
 the flask was broken and the contents forced into the tissue. A hard 
 swelling and severe inflammation was the result, but usually no pus. When 
 pus did occur it doubtless was due to the presence of germs somewhere 
 in the tissue or circulation, and carried there, a thing which occurs very 
 frequently ; hence surgeons will not perform a severe operation when there 
 is a pus forming process going on somewhere else in the body. A thing 
 that was noticed of course, in the cases where they succeeded in producing 
 pus by chemical irritants, was that in this pus there were great colonies 
 of bacteria, always. They were never able to get the pus without finding 
 bacteria in it. Today it is fairly conceded among pathologists that we 
 have no pus with micro-organism.s. A word as to how micro-organisms 
 do their work. Dr. Black says: "Pus formation consists in the fermen- 
 tation and liquefaction of plastic exudate thrown out in the process of 
 inflammation. It seems, therefore, necessary that we have inflammation' 
 and inflammatory exudate before we can have any pus formation." This 
 inflammatory exudate is completely studded with leucocytes, as we have 
 already explained, into this substance wander these micro-organisms. If 
 the germs possess sufflcient vital force and the condition of the exudate 
 is so lowered as not to be able to resist them, they find lodgment and 
 perform all the functions of life, and in this process a peptonizing ferment 
 is formed, which in turn liquefies the exudate, little by little, and being 
 filled with these reparative cells all is carried away in the form of pus. 
 
 Then suppuration takes place in the tissue by virtue of the peculiar 
 peptonizing or digestive action which the bacteria exert upon the tissue. 
 In the beginning the same changes occur as in inflammation. Some 
 oedema of the part is first observed. At the same time leucocytes are 
 accumulating, the intercellular substance is gradually undergoing trans- 
 formation, and as you approach the point of pus formation there is an 
 mcreasing number of leucocytes and some red blood cells with increasing 
 liquefaction of this intercellular substance, and pyogenic germs abound. 
 
 As the virus acts more and more intensely on the part, the entire 
 structure breaks down, being digested, as it were, by the chemical pepton- 
 izing substance, and the tissue liquefies and floats away a fluid pus instead 
 of solid material. 
 
This, then, is the process. Remember first we must have inflamma- 
 tion and the inflammatory exudate. 
 
 Second, we must have bacteria before Ave can have pus. 
 
 Kind$ of Pu$. 
 
 We have several varieties of pus, and it is subject to constant change 
 liepending somewhat upon the location and form of the disease as well 
 xas the condition of the patient. When pus is of a yellowish white color, 
 ;and about the consistency of cream it is usually composed of a large 
 number of pus globules, and is known as healthy or laudable pus. You 
 have observed when you have abscesses filled with this kind of pus, that 
 when you once evacuate the abscess and disinfect the part you have 
 recovery immediately. 
 
 It is the sort of pus from which recovery is readily made. 
 
 When pus is thin and reddish and streaked with blood it is called 
 fcanious pus, and very frequently is mixed with particles of fibrin and dead 
 tissue. This sort of pus is mostly seen in certain bone diseases. When- 
 ever you have caries of the maxillary bones you will always have this 
 kind of pus and in phagedenic ulcers abscesses that have been standing 
 sort of dormant for years, and tumors, etc. On opening into a tooth 
 whose pulp is dead, the kind of pus that comes away will determine some- 
 what the condition beyond the apex. If you have the yellowish white 
 pus you have a condition not to be dreaded very much, but when thin red- 
 dish pus comes sweeping down through the cavity you have a condition 
 affecting the bone, almost always, and a condition that is going to be 
 slow to heal. 
 
 Then watery, acrid pus is termed ichorous pus, and Is common to 
 chronic ulcers and certain bone diseases. When coming from the mucous 
 membrane pus is called muco-pus. From the serous membrane, sero-pus. 
 
 Thick, ropy pus of syphilitic abscesses is termed gummy pus. When 
 the sanious pus contains flakes of coagulated fibrin it is called cheesy pus. 
 It is a sort of pus that very frequently is seen in the bone abscesses in 
 abscesses of the superior maxillary bon?, for instance, wherever pus is 
 sort of confined under pressure, you will get pieces of white coagulated 
 fibrin in the pus. 
 
 In the suppurative process we usually have as an accompaniment, 
 fever. It is usually an accompaniment of inflammation and suppuration. 
 Indeed, it always occurs in acute suppuration. Whenever you have an 
 acute alveolar abscess forming, if it be any way violent in nature, if it 
 lias developed very rapidly, you will always have the patient presenting 
 fever, as indicated by your thermometer. 
 
89 
 
 fewer. 
 
 What is fever? An abnormal elevation of the body temperature. 
 In hyperemia or simple inflammator}^ conditions we have a rising 
 temperature in the part due to increased oxydization on account of the 
 increased blood cells, but this is not fever, strictly speaking. Only when 
 we have a rise in the whole body temperature do we regard it as fever. 
 In ordinary acute alveolar abscess we sometimes have a rise in tempera- 
 ture to loi, up to 105 in severe cases. I want, if I can, to impress upon 
 you the value of using this, as a diagnostic aid. 
 
 Often patients will present suffering severe pain. Often they will 
 present with a tooth very sore and you wonder whether or not the process 
 of suppuration has started in or whether you simply have a case of apical 
 pericementitis. If you will take your thermometer and put it under the 
 tongue and find a rising temperature to 10 1, you can make up your mind 
 that the patient is being poisoned w4th the pus. This fever is the result 
 of the poisonous products of micro-organic life. To understand it thor- 
 oughly a knowledge of the laws governing the mechanism of heat pro- 
 duction and heat dissipation is essential. The normal temperature in a 
 state of health is 98 4-10,° or 37 C, which is practically stable, varying 
 slightly in torrid and frigid zones. The body is constantly producing heat 
 by the process of combustion, oxygen being taken up by the tissue and 
 carbonic acid eliminated. Enough heat is produced daily to raise the body 
 temperature forty-eight degrees Centigrade, an amount far beyond possible 
 life. Then there must be an arrangement by which this heat is liberated 
 and the whole process is carefully balanced in order that the temperature 
 remain stable. If we take a large amount of food, or unusual exercise, 
 an increased amount of heat is produced ; during sleep or repose the 
 amount is decreased. The red face, moist skin, increased respiration, 
 and all are evidences of this regulating process at work. The increased 
 amount of heat production is offset by the increased amount of blood in 
 the surface being cooled. You must remember that the temperature 
 lowers slightly as we get away from the center of the organism. The 
 surfaces of extremities are normall}' cooler than the thorax contents. The 
 extra heat produced by food is rapidly carried to the surface to supply the 
 tissue and be cooled. The point I want to bring out is that there is an 
 automatic arrangement which seems to protect the body from ordinary 
 changes to which it is subjected. The mechanism or arrangement only 
 works within certain limits. All heat produced in the tissue is produced 
 by assimilation of nitrogenous material brought about through the nervous 
 and partly by the muscular tissue, and is a chemical process in which 
 oxygen is absorbed and carbonic acid given oft". Anything that will 
 increase the amount of heat produced and at the same time interfere with 
 
90 
 
 its dissipation, will produce fever. When a patient gets a temperature 
 of 105 the nurse immediately understands that she must bathe the body in 
 cold water, the philosophy of which is simply the cooling of the blood 
 through the surface. So long as fever does not endanger the burning up 
 of tissue it is not a dangerous thing, consequently it is not the habit of 
 controlling fever by systematic medication in typhoid fever, and such, but 
 by the constant cooling of the surface. Indeed, in typhoid fever many 
 cases are bathed ten and a dozen times in twenty-four hours with cold 
 water. 
 
 Symptoms of Tcver. 
 
 The early symptoms of fever is a sense of lassitude or malaise, and 
 if you examine the patient you will find there is a slight rise in tempera- 
 ture and rapidity of the pulse. The skin of the head and body feels warm 
 to the touch, although the extremities may be cold. If the attack is severe 
 and the temperature rises rapidly this condition is followed immediately 
 b)^ what is known as a chill. The skin is cold, particularly in the extremi- 
 ties ; usually looks pale or slightly purple, accompanied with involuntary 
 chattering. This will last for an hour or two, and is quickly followed 
 by a sense of heat, flushed face. During the chill the patient crouches 
 over the fire and wants to be covered with blankets, etc., when the chill 
 passes they want the clothing removed again. If the fever be due to pus 
 production, or rather if pus poisoning is gradual, there will usually be an 
 absence of chill with but little fever. In all acute suppuration we have 
 a decided rise in temperature, as I have stated, loi, 102, 103, 104, 105 
 or even 106 occasionally from acute alveolar abscess. 
 
 The thermometer is a diagnostic aid in these cases. If there is a 
 chronic case where a large amount of pus is present we v/ill also have 
 some fever. What is it that causes the fever? 
 
 Just how are these symptoms brought about? We stated that sup- 
 puration was purely a bacteriological process. 
 
 Can the same be said of fever? Not all kinds of fever are due to 
 micro-organism action directly, but all pyogenic fever is. It is probably 
 an effort of Nature to rid herself of some irritant which may be the 
 product of bacterial action or of the bacteria themselves. This irritant 
 may be in the nature of a ferment-like substance, or in some cases may be 
 the result of cell disintegration. Bacteria do not grow well except in 
 nearly normal temperature, and it may be that this rise of temperature 
 has a beneficial result in inhibiting the growth of these low forms of life 
 within the body. Indeed, this is the late idea regarding fever, that it is 
 simply an effort on the part of Nature largely, to throw off these bacteria, 
 Warren says — "In general, it may be said that fever is due to the presence 
 
91 
 
 in the blood of a pyogenic substance of an organic nature that may have 
 been produced by bacteria. That is the most common way. Second, to 
 the presence of bacteria, or finally, to some ferment-like substance which 
 has resulted from cell disintegration." 
 
 The poisonous products of bacteria, known as leucomaines and tox- 
 albumens, act directly upon the nerve centers in such a way as to interfere 
 with the mechanism of heat production and heat dissipation. Sufficient 
 has been said regarding suppuration in general to enable the reader to 
 follow the process as seen in the tooth pulp. 
 
 Suppuration of the Pulp. 
 
 Putrescent Pulps. 
 
 In the chapter on inflammation of the pulp we endeavored to show 
 that inflammation sometimes only affects small areas around the point of 
 exposure. When aft'ected in this area, by some of the active pus germs, 
 rapid liquefaction of the exudate and pus is the result. If there be a ready 
 way of escape through the horn of the pulp out into the cavity, this 
 process may be slow and the main body of the pulp may remain alive for 
 some time, and death and suppuration come gradually, little by little, 
 painlessly. But if that exit is closed, or nearly so, a rapid increase of 
 inflammation will soon involve the whole pulp tissue, perhaps within 
 eighteen hours, and on to rapid infection and suppuration of the whole 
 organ. This is usually painful process, lasting from twelve to twenty- 
 four hours, and sometimes, unless relieved runs directly into alveolar 
 abscess. Such a process as this is usually what occurs when we cap an 
 infected pulp or cover in some infective material. These cases, after once 
 started usually work rapidly, and pain ensues and continues say about 
 twenty-four hours, and with a sudden stop the pulp is all dead, and may be 
 it will pass on to the peridental membrane and the tooth becomes sore to 
 the touch, and alveolar abscess almost certainly will follow, although 
 occasionally in robust individuals, persons whose circulation and elimina- 
 tion are good, it may stop for a time and all soreness pass away. The 
 first or chronic form of suppuration, where progress is slow, little by little, 
 is the most common. When the pulp once starts to suppurate it rarely 
 recovers. The tissue cannot heal by cicatrization, i. e., it does not cover 
 over its injury with epithelium as other wounds do, therefore it is always 
 liable to reinfection in case the tissue does throw off one attack. When 
 you open into these cases, say when simply the horn of the pulp is sup- 
 purated, you at first decide that you have a dead pulp to deal with, but 
 when you attempt to pass your fine smooth broach through the opening up 
 into the canal, you suddenly produce pain ; you are then surprised to learn 
 that a little way down the pulp is alive and normally sensitive. Oftentimes 
 
92 
 
 it is fairly healthy; the living vital portion has separated itself from the 
 suppurating portion by this wall of plastic exudate, similar to all inflam- 
 matory processes. 
 
 That is the usual way in which pulps die from infection. It some- 
 times happens that the pulp tissue in one canal in a three-rooted tooth will 
 remain alive while the other two are undergoing suppuration. I think 
 all have probably seen cases where a typical acute alveolar abscess form- 
 ing, upon opening the tooth two canals probably filled with suppurating 
 material, and the other canal sensitive, unable to enter it at all. Then, 
 again, the suppuration may pass along down the center of the tissue, as 
 shown in Fig. 25. 
 
 Fig. 25. 
 Chronic inflammation of the pulp. B, blood vessels crowded with corpuscles; C, nuclei of 
 inflammatory cells. CHopewell-Smith.) 
 
 Pus will work its way down, following the direction of the blood 
 vessels until the center is largely destroyed and suppurated, and yet 
 alongf the wall next to the odontoblasts the tissue is alive. In other of 
 these cases there may have been symptoms of hyperemia, toothache a little 
 while at a time, then passing away completely. Patients will say that 
 perhaps six months or a year ago they had a severe toothache in a tooth ; 
 it was very sensitive to thermal changes. By and by it all passed away, 
 and the tooth is comfortable. No matter what the symptoms are in these 
 cases, you must rely on what you see while making your excavation and 
 exposing the pulp, rather than outward symptoms ; the latter are often 
 
93 
 
 misleading. I repeat here for emphasis pulps inflame, suppurate and die 
 in this slow chronic way without causing the patient the slightest annoy- 
 ance. 
 
 Cases of Open Cavities, 
 
 "When the pulp of a tooth is exposed and becomes the seat of that 
 series of vascular and nutritive disturbances — hyperaemia, inflammation 
 and suppuration — eventuating in its gradual death_, the necrotic portions 
 undergo putrefactive decomposition. Several processes are in operation 
 at the same time, so that diJTerent portions of the pulp exhibit differences 
 in chemical composition, differences in the nature of the infection and 
 also in the pathological conditions existing. 
 
 For example, while the apical portion of the pulp is the seat of 
 inflammation and suppuration, the portion of the pulp previously 
 destroyed through these processes, is the seat of later stages of chemical 
 destruction, until that portion which was first acted upon is being revolved 
 into the end-products of albuminous decomposition, of putrefaction. 
 
 In this serial decomposition albuminous substances are first trans- 
 formed into peptones and allied substances, some of them being very 
 toxic. Compound ammonias, known as ptomaines, or animal alkaloids, 
 are probably next formed. Next the nitrogenous bases-leucin, tyrosin 
 and the amins (methyl, ethyl, and propyl) make their appearance together 
 with organic fatty acids. Next aromatic products, indol, phenol, creasol, 
 etc., and finally hydrogen sulfid, ammonia, carbon dioxid, and water. 
 
 By alternating processes of hydration, reduction, and oxidation,^ 
 bodies of increasing simplicity of chemical composition are formed. 
 Miller found in the deepest portions of the degeneration, putrefying, 
 pulps, where inflammation and suppuration were in progress, a pre- 
 ponderance of small cocci and diplocci, and proceeding toward the open 
 pulp chamber an increasing number of large cocci, several forms of 
 bacilli, vibrios, and other spirillae, spirochaetae, and long thread forms. 
 
 Until infection of the pericementum occurs these cases give rise to 
 no symptoms, except odor. 
 
 Cases of Putrefaction Under Tillings. 
 
 When a filling is placed over an infected pulp, or when the pulp 
 dies subsequent to the insertion of the filling, the organ undergoes 
 decomposition, the decomposition being carried on in this mstance witn 
 the access of air, i. e., is accomplished by anaerobic organisms. 
 
 Miller found that bacteria of pulp-putrefaction cultivated in gela- 
 tin, with and without the access of air, exhibited a difference in the 
 poisonous properties of their products. Those developed with free access 
 of air produced reaction and more extensive suppuration than those 
 developed without the access of air."' — Kirk. 
 
94 
 
 treatment. 
 
 What shall be done for these cases? 
 
 Should they ever be capped ? No, for they will all die. 
 
 Shall we proceed to devitalize at once? No, not until the suppura- 
 tion has been stopped — the reason therefor relates to the fact that the 
 presence of dried suppuration material in the chapter will prevent the 
 arsenic from coming in contact with the living portion — and also there 
 is some danger of setting up severe pain from sealing an active suppura- 
 tive condition without proper drainage. It is not considered good prac- 
 tice to attempt pressure anesthesia in these cases. There is great 
 danger of forcing the infective material beyond the apex and causing 
 a most violent acute abscess. It is in this class of cases where the pulp 
 is partially dead that one is tempted to use cocain, but in my hands these 
 cases are unfavorable. 
 
 The treatment should be as follows, of course varying somewhat 
 to meet the various conditions presented where the pulp is completely 
 dead and undergoing suppuration, the first steps are the same as where 
 a portion of that organ remains alive. 
 
 The rubber dam should be applied and the field sterilized, cavity 
 washed, disinfected, and the pulpal wall removed as thoroughly as 
 possible avoiding pressure on the contents of the chamber. 
 
 I find the inverted cone bur very helpful for this purpose. 
 
 The next step is to absorb away with cotton any exuding pus and 
 wash with alcohol and dry thoroughly then seal in a good antiseptic 
 such as beechwood creosote, 1-2-3, or camphophenique, trikresol, oil 
 cloves, etc., which should be allowed to remain from 24 to 48 hours. 
 At the next sitting if all has been quiet and no pus present arsenic method 
 of destroying vital portion may be followed. In case the entire pulp is 
 dead, and suppurating it can usually be thoroughly mechanically cleaned 
 at the second sitting, and one of the agents suggested sealed in for 
 another 48 hours, when the canals should be ready for filling. In man- 
 aging these cases it is well not to poke around in the canals with a broach 
 very much until the contents have been disinfected. 
 
 If this outline is carefully foriov\^ed and no infection material forced 
 beyond the apex the treatment of putrescent pulp is a very simple matter. 
 
CHAPTER XI. 
 
 Cbe Bacteria of Fu$. 
 
 €. $. millard, D.D.S. 
 
 Constantly present in the atmosphere, in water and in the dust ; in the 
 mouth, on the skin and inhabiting the air-tracts of the human body, are 
 to be found micro-organisms, which, for the most part, are perfectly 
 harmless. Some, however, will prove to be pathogenic when a lesion or 
 break in the mucous membrane or skin (which act as outer defenses) 
 affords them entrance into the tissues, or when some other abnormal 
 condition favors their multiplication. 
 
 Of these micro-organisms I wish to speak more particularly of a cer- 
 tain few which seem to exhibit pathogenic characteristics only by their 
 ability to form pus, and for this reason are known as Pyogenic Bacteria. 
 There are other forms, which, under certain circumstances produce pus, 
 but are not classified as pus producing micro-organisms, because they 
 are more strictly identified with the diseases that they are known to 
 cause. 
 
 The character of the pus produced by one organism does not dififer 
 from that produced by another organism. In fact the character of non- 
 specific pus, or pus that may be produced by some powerful irritant as 
 croton oil or carbolic acid, does not differ from specific pus or that pro- 
 duced by living germs, for in each case the cause is chemical, micro- 
 organisms producing pus by the chemical operation of their enzymes or 
 digestive exudates. The color, odor, or quantity of pus, however, are 
 ■controlled by the particular species growing in the abscess. 
 
 It is a fact known to bacteriologists, that where disease is present 
 as the cause of micro-organisms, the natural flora of that particular 
 locality is in some cases, entirely absent, while the specific germ of the 
 disease dominates. 
 
 In suppurative lesions, while there are many cases of contamination 
 of species, yet quite frequent are the instances where pure cultures are 
 obtainable from the inoculation of culture media with pus, even from 
 localities that normally are teeming with varied forms. 
 
 Some of the organisms known to produce suppurative conditions 
 are as follows : 
 
 Staphylococcus Pyogenes Aureus. 
 
 Staphylococcus Pyogenes Citreus. 
 
96 
 
 Staphylococcus Pyogenes Albus. 
 
 Streptococcus Pyogenes. 
 
 These are known as the pus cocci. 
 
 Microccus Tetragenus. 
 
 Pneumococcus or Diplococcus Lanceolatus, 
 
 Gonococcus. 
 
 Bacillus Pyocyaneus. 
 
 Bacillus Typhosus. 
 
 Bacillus Coli Communis. 
 
 Streptothrix Actinomyces. 
 
 Many other forms, among them some of the yeasts and moulds, 
 might be mentioned, but this will suffice, and from these I will select 
 three for description which are, strictly speaking, pus producers. 
 
 Name. Staphylococcus Pyogenes Aureus. Meaning the golden 
 pus producing staphylococcus. Fig. 26. 
 
 Fig. 26. 
 
 Staphylococcus pyogenes aureus from agar culture. (McFarland.) 
 
 Morphology. Spherical. It multiples on two or more poles 
 irregularly taking a growth form, as its name signifies, after the manner 
 of a bunch of grapes ; groups of irregular dimensions, or it may be found 
 as single cells or as diplococci. It measures ordinarily about .8 microns 
 or about i/io the diameter of a red blood corpuscle i. e., 1/31000 of 
 an inch ; and it has been estimated that one grain of these individuals 
 will number something like 125,000,000,000. A little figuring will show 
 that a space measuring about i cu. millimeter could contain 1,952,625,000 
 or nearly 2,000,000,000 cells. 
 
 Discovered by Rosenbach in 1884. 
 
 Origin. It is the most common of the pus producing organisms 
 and variously estimated as present in from 50 to 80 per cent of the 
 
07 
 
 abscesses examined. It might be said, however, that in abscesses of the 
 mouth the white variety of the plant is more frequently met with; the 
 staphylococcus pyogenes albus. It is found in saliva, on the skin, in 
 water, on particles of dust floating in the air or wherever dust may 
 settle. 
 
 Mobility. It has no motion, having no flagella. 
 
 Spores. None. It multiplies by fission. 
 
 Staining. It is easily stained by all the common table stains, also by 
 gram. 
 
 Growth. It grows very readily on all the ordinary culture media. 
 
 Bullion shows a cloudy appearance with yellowish sediment and 
 a decided acid reaction. 
 
 Gelatin stab culture shows decided liquefaction along the entire 
 tract of the needle. The growth shows a yellow precipitate at the 
 bottom of the liquefaction. 
 
 Agar slant culture shows a moist golden yellow streak on the surface 
 of the media. 
 
 From all of these cultures a peculiar sour or acid odor is noticeable. 
 
 Aerobiosis. It grows best in the presence of oxygen, where it pro- 
 duces its color, but will grow as a facultative anaerobe, and as such, 
 produces no pigment. The optimum temperature is about 'T^y Centigrade, 
 or that of the incubator, though it will grow at ordinary or room 
 temperature. 
 
 Pathogenesis. The staphylococcus aureus is ordinarily a parasite 
 though it will grow as a saphrophyte as is seen from its growth on 
 ordinary culture media. Its enzyme separated from the media will 
 produce characteristic pathogenic results in the formation of pus in living 
 tissue. This organism is particularly pathogenic to man, and external 
 applications of pure cultures have been known to produce suppuration and 
 carbuncles (Garre), while inoculations may result in pyemia, infection of 
 the kidneys, or metastatic abscesses. The infection, however, is more 
 inclined to be local and less violent than that produced by the strep- 
 tococcus pyogenes, and is, therefore, not very serious. Sterilization may 
 be easily effected by subjection to streaming steam or the application 
 of various germicides. Sterilized cultures contain the poisonous pro- 
 ductions of the germs, and will produce suppuration. 
 
 Diagnosis. Microscopic observations will oftentimes lead to a sus- 
 picion of the presence of the staphylococcus aureus in suppurative areas, 
 and microscopic examination of the pus with artificial cultivation will 
 reveal the characteristics as above described. 
 
 The staphylococcus pyogenes citreus and the staphylococcus pyo- 
 genes albus are considered by some to be the same as the staphylococcus 
 
98 
 
 pyogenes aureus, except that they grow under different conditions. That 
 they are of the same species there seems to be no doubt, for all that may 
 be said of the aureus may be said of the others, unless it be in so far as 
 color and virulence are concerned ; the albus being white and the citreus 
 producing a definite lemon yellow pigment : Again it is the common opin- 
 ion that the staphylococcus aureus is more virulent than the citreus and the 
 citreus more virulent than the albus. 
 
 Name. Streptococcus pyogenes, this of all the pus producing organ- 
 isms is the most dreaded by the surgeon. Fig 27. 
 
 Fig. 27. 
 Streptococcus longus from a fatal case of pyemia. Magnified 1,000 times. (Hopewell Smith.) 
 
 Morphology. It is in many respects similar and in other respects 
 quite unlike the staphylococci just described. It is spherical in form. 
 As the name implies, it grows in chains, multiplying upon one pole. These 
 chains may be of greater or less length. Names have been given to 
 supposed varied species of Streptococci according as they are known to 
 assume greater or less length of chain, as Continuousum, longus, brevis, 
 media, etc. Whether these are varieties of the same or of different species 
 is yet a question ; it is, however, certain that they seem to exhibit different 
 physiological phenomena and show greater differences than may be 
 noted between the staphylococcus aureus, citreus, and albus. Some are 
 not known to produce pus. The particular form under discussion dis- 
 tinguished as pyogenes usually extends to from 6 to 8 cells in length, 
 though oftentimes in bouillon the extension will be to upwards of a 
 hundred in number. In size the cells are a trifle smaller than the 
 staphylococcus. 
 
99 
 
 Discovered by Rosenbach in 1884. 
 
 Origin. In abscesses, pyemia, erysipelas. Found in the mouth, 
 Tiose and throat. It seems to find its natural habitat about or in the 
 vicinity of human beings. 
 
 Spores. None have been discovered. It multiplies by fission. 
 
 Stains by all the common table stains and by gram. 
 
 Growth is readily obtained on a slightly alkaline medium, though 
 its vegetative function does not seem to be so well marked as in the 
 staphylococcus. 
 
 Bouillon growth in the incubator shows at times a clouded medium 
 with white precipitate, again the medium will be clear with the white 
 precipitate at the bottom of the tube, and also attached along the sides. 
 
 Gelatin. We note that it does not liquefy, but small white colonies 
 are formed along the entire track of the needle in stab cultures. 
 
 Agar slant culture. The growth is very slight, looks like small white 
 drops and does not tend to run over the surface. 
 
 Aerohiosis. Grows best in the presence of oxygen. It is a faculta- 
 tive anaerobe. Grows at 37 Centigrade and gives a feeble growth at 
 lower temperatures. 
 
 Pathogenesis. This organism seems to be more particularly a human 
 parasite. It is pathogenic to man, rabbits and mice, and its virulence 
 is particularly marked, producing spreading inflammatory infection, 
 septicemia, pyemia and erysipelas, in which the organisms seem to infest 
 the lymph channels. Pure cultures of streptococcus pyogenes may at 
 any time be made from the pustules of erysipelas sores. Most of the 
 more serious suppurative conditions of man are due to the presence of 
 this organism. 
 
 Diagnosis. Microscopic observation of suspected pus, as in empye- 
 .mia of the antrum. Artificial cultivation on glycerine agar in the incu- 
 bator and intravenous inoculation of rabbits. 
 
 Name. Bacillus pyocyaneus. The micro-organism of green pas. 
 Pig. 28. 
 
 Morphology. A rod form, small in size, scarcely exceeding I 
 micron in length by from .3 to .5 microns in width. The ends are 
 rounded. It is sometimes found in short chains but nearly always 
 detached or as single cells. 
 
 Discovered by Gessard in 1882. 
 
 Origin. It is very commonly met with in nature. It is found in the 
 air on particles of dust. It is found all over the body, and in the internal 
 organs of man and animals. Pus, when infected with this organism or 
 -caused by this organism, becomes green in the presence of oxygen. 
 
too 
 
 ^V '^•-\=\>.v7 iJ .•>'•"' ..•"'^ ■•',^ (!/ 
 
 r'-^^yS; 
 
 \ 
 
 Fig. 28. 
 Bacillus pyocyaneus from an agar culture. (McFarland.) 
 
 Motility. Active. It has one flagellum. 
 
 Spores have not been discovered. Reproduction is by fission. 
 
 Stains b}- all the common anilin dyes and by gram. 
 
 Grozvtli is readily obtained on artificial media. 
 
 BouiUon soon becomes cloudy and a white growth soon forms on the 
 surface. Very early in the growth the upper part of the medium becomes 
 green, and gradually extending deeper, it finally becomes brown. 
 
 Gelatin stab cultures. Liquefaction occurs along the track of the 
 inoculating needle. A white growth shows upon the surface. And as 
 in the case' of bouillon, the green pigment shows at the top of the gelatin, 
 gradually extending downward and finally becoming brown. 
 
 Agar slant shows yelloAvish or whitish slimy growth along the line 
 of the inoculation and the pigment production gives the same indications 
 as in gelatin. 
 
 Potato shows a brownish slimy growth : oftentimes no green appears., 
 
 Aerohiosis. Facultative anaerobe. The organism se^ms to grow as 
 well out of the incubator as in it. 
 
 Gas production. It gives off different gases, and has a character- 
 istic aromatic odor. 
 
 Cliromo genesis. Two pigments are developed, a dark brown, or 
 pyocyanin, and a beautiful deep green, or fluorescin. 
 
 Pathogenesis. This organism shows peculiar phenomena; at times 
 it is harmless, and again decidedly toxic. Subcutaneous injections in 
 guinea pigs produce violent inflammation and death. Post-mortem 
 examination shows bacteria. Animals infected with anthrax, after being- 
 inoculated with the bacillus pyocyaneus, have been known to recover. 
 
lOI 
 
 Bacillus tetanus, known to be an obligate anaerobe, will when contami- 
 nated with the bacillus pyocyaneus, grow as an aerobe. This may account 
 for many deaths by lockjaw. 
 
 Diagnosis. It is most often discovered by the green pigment which 
 it elaborates, but must be distinguished from the bacillus fluorescens by 
 its liquefaction of gelatin in stab cultures. 
 
CHAPTER XII. 
 
 Diseases Hffecfiitd tbe FeriaeRtal membrane mm tbe J\p\m 
 of m Roots of CeetD. 
 
 Histological Structures of the Peridental Membrane. Functions. Structures. Cells.. 
 Blood Supply Nerves. Apical Pericementitis. Causes. Symptom. Treatment. 
 Chronic Apical Pericementitis. Cases. Treatment. Alveolar Abscess. 
 Causes. Symptoms and Pathology. Treatment. Chronic Alveo- 
 lar Abscess. Aneurysm. Blind Abscess. Treatment of 
 Pulpless Teeth. Special Cases. 
 
 I)i$to1o0ical Structures of tbe Peridental membrane. 
 
 Before considering the pathological conditions affecting this mem- 
 brane it seems wise to briefly review its histological structures. 
 
 The peridental membrane is the soft tissue occupying the space 
 between the tooth root and the alveolar wall. In the literature it is often 
 referred to as dental periosteum, pericementum, alveo-dental periosteum. 
 
 It completely surrounds the tooth root from the enamel line, and 
 serves as a connection between the tooth and its bony socket as well as 
 gum tissue. It is thickest in childhood and thinnest in old age. 
 
 Tuttctions. 
 
 This membrane differs from true periosteum in that both its surfaces 
 are functioning. It can be said to have three functions, first, a physical 
 function, that is it serves to maintain the tooth in its socket and to hold 
 the gum around the tooth neck. Second — A vital function. The build- 
 ing of bone on the alveolar wall and of cementum on the tooth and it 
 always maintains the tooth vitality after the pulp has been destroyed. 
 Third — A sensory function. It not only transmits pain sensations, but 
 the entire sense of touch is supplied by this membrane. 
 
 Structures. 
 
 The peridental membrane is made up of dense fibrous tissue, and in. 
 addition has certain cells^ blood vessels and nerves. The arrangement 
 of the fibres is intended to hold the tooth and support it against force from 
 every direction. 
 
 For convenience of description, histologists divide the membrane into 
 three portions, first, the gingival portion which includes all the membrane 
 just under the free margin of the gum and over the border of the 
 alveolus ; second, the alveolar portion, which includes all the membrane 
 from the alveolar border to the root apex ; third, the apical portion which 
 surrounds the immediate root apex and occupies what is known as the 
 apical space. 
 
 If we examine the gingival portion under the microscope beginning 
 at the center of the mesial or distal we will observe the fibres at the 
 enamel junction of the cementum passing out from the cementum at right 
 
103 
 
 angles to the long axis of the tooth, gradually dipping down to unite with 
 the periosteum of the alveolus and some of the fibres pass directly into the 
 gum septum and others pass over the border of the alveolus to mingle 
 Avith the fibres of the adjoining tooth, and some of them passing directly 
 into the cementum of that tooth, sometimes called dental ligament. 
 Fig. 29. 
 
 Fig. 29. 
 Cross section of central and lateral incisois below the -im of the alveolus through the neck 
 of the teeth. A, central; b. lateral; c, pulp chamber of lateral; d, d, cementum; e, e, cementum; 
 g, g, fibres of peridental membrane; h, h, j, j, epithelium. (Black.) 
 
 This you see is intended to hold the gum septum in position between 
 the teeth and hold the tooth to the alveolar border as well as to the neigh- 
 boring tooth. Passing around to the mesio-lingual or mesio-labial you will 
 see the fibres pass out and turn to the right and left on a tangent entering 
 the periosteum and gum (see Fig. 30). These are intended to prevent the 
 tooth from rotating. 
 
 On the labial and lingual the fibres pass out at right angles directly 
 into gum and periosteum and bone. In the alveolar portions the fibres 
 coming out of the cementum in its occlusal portion pass at right angles 
 into the alveolus, while a little nearer the apex they incline occlusally, and 
 still a little nearer they incline still more. 
 
 In the ipical portion the fibres are arranged somewhat fan-shaped 
 over the apex. These fibres often pass out of the cementum in little 
 bundles and split up before entering the alveolus. In examining the 
 cementum it is seen that these fibres do not all penetrate to the first layer — 
 that is, the layer immediately over the dentine — some pass in, only the 
 last layer. 
 
104 
 
 M ^ » .,1^- p 
 
 Fig. 30. 
 Transverse section of peridental membrane in alveolar portion. M, muscle fibres, periosteum; 
 Al, bone of alveolar process; Pd, peridental membrane; Cm, cementum; P, pulp; D, dentine. 
 (Noyes.) 
 
 Cells. 
 
 The cells of the peridental membrane are — I, Fibroblasts, spindle 
 shaped cells whose functions seem to be the building of membrane fibres. 
 II. The cementoblasts which lie in around the fibres on the cementum side ; 
 their function is the building- of cementum (Fig. 30). Ill, Osteoblasts, 
 which lie in around the fibres on the bone side ; their function is bone build- 
 ing. IV, Osteoclasts, oftener called myaloplaques or giant cells. They are 
 not always present, but seem to appear at times around among the fibres 
 from some cause. They are the bone, cementum and dentine destroyers ; 
 when active they lie down close to the bone or tooth. They sometimes 
 seem to be active when no cause can be assigned. Often cementum and 
 even considerable dentine is cut away and again filled with cementum 
 (Fig. 31). V, Epithelial cells. There is a set of cells that resemble 
 epithelial cells which group themselves together so as to appear as 
 epithelial glands (Fig. 32). 
 
 Many dispute their presence and think what is seen is something else, 
 but the strongest evidence of their nature is the fact that the peridental 
 
105 
 
 Fig. 31. 
 Transverse section of peridental membrane in gingival portion. Ep, epithelium; Cm, cemen- 
 tum; C)u-, cementum refilling absorption; Ec, epithelial cords or glands. (Noyes.) 
 
 membrane has a secretive function. Many substances taken into the 
 system are excreted around the gum margins. 
 
 Fig. 32. 
 Peridental membrane ne-xt to cementum highly magnified. Fb, fibroblasts; Cb, cementoblasts; 
 7ot, cementum; D, dentine; Ec, epithelial cords or glands. (Xoyes.) 
 
io6 
 
 Blood Supply nerves. 
 
 The blood supply of the peridental membrane is very abundant- 
 Blood vessels not only enter at the apex, but from the bone and also over 
 the alveolar border, and are distributed everywhere throughout the tissue 
 twining in and out among the fibres. The capillaries are believed to be 
 few. The nerves enter in large bundles at the apex, a few from the wall 
 of the alveolus and a few over the alveolar border. 
 
 It will be seen then that this richly nourished membrane is very 
 dense in structure, and arranged to literally suspend the tooth in its socket 
 and hold it and the gum in position against all direction of the force of 
 mastication. 
 
 Jfpical Pericementitis. 
 
 The term of apical pericementitis is applied to the inflammation of 
 tha-t portion of the peridental membrane situated about the root apex. 
 There are two varieties of this affection, acute and chronic. An acute 
 apical pericementitis is an inflammation just forming and characterized 
 by all the pathological changes which occur in other acute inflammations. 
 
 There is a decided thickening of the membrane, and because of its 
 bony surrounding it is a painful process. 
 
 When we remember that the sense of touch in the tooth lies in this 
 membrane it can readily be seen why this is such a painful process. 
 
 Causes. 
 
 The causes of apical pericementitis most frequently lie within the 
 pulp chamber, but not always. It is usually dependent upon the death and 
 putrefaction of the pulp, but may be caused by a great variety of things 
 such as a shock, severe use, unusual stress, irritating substances passing- 
 through the canal, following pulp extirpation, root fillings, too severe 
 wedging and the use of the mallet in large gold fillings, taking cold, etc, 
 I have occasionally observed that very rheumatic individuals sometimes 
 suffer from disturbances of this nature, which is only temporary, rapidly 
 passing away when the constitutional conditions are relieved. In its 
 simplest form it is caused by the hyperemia or inflammation existing in 
 the pulp tissue extending through the apex to that tissue. 
 
 In its severest form it is caused by infection from pulp putrefaction 
 by pyogenic organisms. 
 
 Symptom. 
 
 The most prominent symptom and the one always present in acute 
 cases is tenderness to percussion. 
 
 Patients complain of the tooth feeling long, occluding before the 
 others, and for this reason they can locate it. There is usually some slight 
 redness of the gum tissue opposite the apex and often slight tenderness 
 
I07 
 
 to digital pressure in the same region. There is an actual elongation of 
 the tooth due to the thickening of this membrane forcing the tooth down 
 from i'ts socket. To percussion the tooth has a dull sound and if 
 the pulp is dead there will be the absence of sensitiveness to thermal, 
 changes. 
 
 treatment 
 
 In acute cases the treatment is very simple. 
 
 Remove the cause and put the part to rest. If the cause lies within 
 the pulp canal then that must receive first attention, and be thoroughly 
 cleansed and, so far as the membrane itself is concerned, it will take care 
 of itself. 
 
 Many teeth in this condition are lost or turned into chronic form by 
 loo frequent medication, especially with irritating agents ; however, when 
 the canal is filled with putrescent material it must receive careful attention 
 in order to avoid running into acute alveolar abscess. This treatment has. 
 been fully described in the previous chapter and all I wish to say here is. 
 that careful instrumentation is the essential requirement in treating these 
 cases together with mild non-irritating antiseptics, and rest. Do not be 
 poking medicines in there every day for months ; apply your remedy the 
 first sitting, change it in 24 or 48 hours, and mechanically clean the canal, 
 then reapply your dressing and allow to remain a week or ten days when, 
 in the great majority of cases, the canal filling may be proceeded with. 
 
 Occasionally we meet with cases that do not yield so readily. Pain 
 continues, and must be met by other means, such as counter-irritants with 
 the pepper pads, tr. iodine, chloroform confined, or blood letting; some- 
 times opening into the apical space through the outer wall of the alveolus 
 and lacerating the tissue will be helpful. This opening can be made by 
 dipping a coarsely saturated plugger in 95 per cent carbolic acid and al- 
 lowing this to touch the mucous membrane over the root apex ; then rub- 
 bing off the white eschar, repeat until the bone is reached when, with a 
 proper drill in the engine, you can penetrate the space painlessly. 
 
 This should be supplemented by the hot foot bath, 5 to 10 grains of 
 quinine followed by small does of tr. aconite and tr. gelsemium, alternately, 
 half hour for 6 or 8 hours, and at bedtime 10 to 15 grains of Dovers 
 powder, followed in the early morning by a copious saline cathartic. 
 
 This same line of treatment is sometimes indicated in acute forming 
 alveolar abscess. 
 
 In acute cases where there is no perceptible putrescence in the canal 
 don't imagine you have an abscess at the apex because of the tenderness, 
 and don't try to enlarge the foramen so you can force medicines through,, 
 but lay in a mild antiseptic and let it rest a week or two. 
 
io8 
 
 Where acute pericementitis develops while devitalization and pulp re- 
 moval are in progress, it is probable that the operator is to blame. He may 
 have been careless with his instruments as regarding their proper 
 sterilization, or pushed one through the apex, or used irritating agents in 
 too great a quantity in the canal. A case I had a few years ago illustrates 
 the point I wish to make. A well known dentist devitalized a pulp in a 
 central incisor in a gentleman of good health about the age of thirty-five. 
 He removed the pulp and sealed in some oil of cloves and dismissed the 
 case for a week. Patient returned in three days, tooth sore to the touch ; 
 dentist removed dressing, washed out and sealed in fresh dressing of the 
 same. Conditions grew rapidly worse and he concluded he had some 
 infection, so after changing again he sealed in oil of cassia because of 
 its reputed great antiseptic power. This made matters worse and when 
 patient returned he could hardly bear to have the tooth touched, but when 
 the dentist did succeed in removing the dressing down came thin, watery 
 fluid, and he at once concluded he had violent infection and left the root 
 open. Up to this time eight weeks had been consumed, all of which time 
 patient was in agony, but as he left the tooth open with no irritating oil 
 in the canal it rapidly quieted down. Patient returned again and dentist 
 sealed in his powerful antiseptic with like results, and patient removed 
 the dressing himself, which the dentist had recommended him to do in 
 case he had trouble. By and by there was real infection, as you can 
 readily see from leaving this canal open. They battled along this way for 
 a year and a half until the dentist became alarmed and feared serious 
 necrosis and advised extraction, but it was a case where it would be the 
 only tooth the gentleman had lost in his upper jaw and he disliked very 
 much indeed to lose it. So he brought the patient to me for counsel, and 
 after examination he turned him over to me to make a trial. I cleansed out 
 the tooth thoroughly, dried it, sealed in a powerful non-irritating germi- 
 cide, forcing a little beyond the apex into the cavity absorbed in the bone. 
 And let me say that when I saw the case there was absorption beyond the 
 end of the root almost as deep as the length of the root itself ; a great 
 pocket there ; of course, it was filled with pus. The agent that I used in 
 that particular case was a ten per cent solution of chinosol, which I will 
 have occasion to refer to later. After carrying this medicine a little into 
 the absorbed pocket beyond, I sealed the cavity and instructed the patient 
 to return in five days, but if the soreness increased markedly, not to open 
 it himself, but to return at once to me. At the end of five days the tooth 
 was completely comfortable. I redressed it as before and dismissed him 
 for two weeks. On examining the case this time I noticed the tissue 
 rapidly filHng in the absorption. I redressed it and dismissed him for two 
 weeks more, at the end of which time I filled the root with no unpleasant 
 
after effects. I have had occasion to watch the case and have seen it 
 within the last two months and know that it has never given any trouble. 
 This is typical of many, many cases. 
 
 There is often a little soreness following pulp extirpation and the 
 same following pulp canal filling. Give it absolute rest, don't try to put 
 a filling in or otherwise further irritate it. The point is, do not get any 
 irritating oil or its vapor through the apex in cases where pulps have been 
 devitalized and removed. If you should accidentally do so, just let it rest, 
 do not disturb it, nature soon recovers. 
 
 gbronic Jlpical Pericemcntltl$« 
 
 Acute apical pericementitis will usually naturally terminate in one or 
 two conditions, namely, either in acute alveolar abscess or in chronic apical 
 pericementitis, depending quite largely on the nature and severity of the 
 irritant. 
 
 If it be mild nature, somewhat constant, not suppurative in its nature, 
 it is very liable to terminate in the chronic form, to treat which often 
 bafiles the skill of the best practitioners. 
 
 Chronic apical pericementitis presents all the symptoms of the acute 
 in modified form. Patients usually complain of much or little soreness, 
 which may have extended over months of time continuously, or the 
 tenderness may come and go every few days. Usually the gum is a little 
 red over the apex and slightiv tender to digital pressure. I have met 
 several cases where there was a decided thickening of the bone over the 
 apex, and many times there is a thickening of the cementum. 
 
 0a$c$. 
 
 The chronic form usually follows an acute attack where the irritant is 
 mild and continuous, sometimes following pulp canal treatment, root fill- 
 ings, broken broaches, and such, but most frequently is the result of very 
 mild putrescence in the pulp canals where pulps die under fillings or from 
 irritation of some kind, and very slowly disintegrates, just enough poison 
 being formed to keep up a constant irritation. 
 
 Occasionally we run across a patient whose peridental membranes are 
 very prone to inflammation. I usually find such an individual suffers from 
 chronic inflammation of all the mucous membranes. 
 
 treatment. 
 
 The management of these cases often try the patience of the operator.* 
 The technical procedure must be along the lines already mentioned. 
 Relieve the tooth by grinding its occlusal surface or that of its opposite 
 in such a way that the stress of closing the jaws will be borne by the 
 other teeth. I sometimes get good results by sealing in the canal well up 
 to the foramen a saturated solution of iodine in creosote, for its irritant. 
 
no 
 
 alterative effect. Its liability to cause discoloration is its chief objection, 
 and so must be cautiously used. 
 
 Sometimes stirring up by passing a smooth broach through the fora- 
 men will be helpful. A 3 per cent solution of formaldehyde is sometimes 
 helpful ; anything that will cause a mild increase of the soreness will 
 usually aid. These are the kind of cases that usually get sore soon after 
 treatment is sealed and patients either open the approach or ask the den- 
 tist to. They should be encouraged to bear the added pain for a little 
 time in the interest of permanent cure. What I said regarding treatment 
 of acute cases applies here ; do not keep changing the dressings every day, 
 but leave one good dressing applied on cotton in the canal tightly sealed 
 for two weeks at a time. Many times for a second treatment I have used 
 a paste made of hydronaphthol with trikresol, and left it in the canals for 
 six weeks, with gradual disappearance of symptoms and permanent cure 
 as a result. No hard and fast rules can be laid down for treating these 
 ■cases ; the good judgment of the operator must determine how to manage 
 each individual case that is presented. 
 
 Jllveoliir Hbscess. 
 
 An abscess is a collection of pus within the tissues which is always 
 preceded by a circumscribed destructive inflammation which results in the 
 breaking down of the tissues in a given area. The term alveolar abscess 
 has been arbitrarily restricted to those occurring at the apical portion of 
 teeth or the apical portion of the peridental membrane, although strictly 
 speaking any abscess occurring in the alveolus would be an alveolar 
 abscess (Fig. 33). These abscesses are divided into two general classes, 
 namely, acute and chronic. 
 
 Fig. 33. 
 
 Showing abscess on the side of buccal roots of an upper molar. (Barrett.) 
 
Ill 
 
 €au$e$. 
 
 Acute alveolar abscess occurs when apical pericementitis becomes 
 ■infected with pus forming germs. It is always dependent upon the death 
 of the pulp. As all forms of apical pericementitis of any marked degree 
 can onfy occur after the pulp is dead, so also we can only have alveolar 
 abscess after the pulp is dead and infected. For here, as elsewhere, we 
 ■can have no pus Avithout pus producing micro-organisms. When the in- 
 flammatory condition around the apex becomes infected, usually inflam- 
 mation rapidly increases, sometimes slowly, being governed here as else- 
 where by the condition of the germs, of the local tissue and the general 
 .system. 
 
 This inflammation causes rapid swelling of the peridental membrane, 
 causing the tooth to be lifted out of the socket, unless the condition of 
 the bone beyond offers less resistance. As in severe cases of apical perice- 
 mentitis the tooth is actually elongated; patients always complain of the 
 tooth being long, being in the way, they strike it before they do the other 
 teeth in occluding. And, as a matter of fact, the tooth is elongated, i. e., 
 it is actually pushed down out of the socket by the swelling of the mem- 
 brane at the apex. You can readily see why this must be such a painful 
 process. Indeed, acute alveolar abscess is usually the most painful con- 
 dition with which we have to deal. 
 
 We divide acute alveolar abscess into four classes according to the 
 manner of the escape of pus. First, where the pus passes through the 
 alveolus into the soft tissue, producing a rounded fluctuated tumor 
 directly over the root of the affected tooth. This is the form most fre- 
 quently met with and is most easily handled (Fig. 34). Second, where 
 
 Fig. 34. 
 Acute alveolar abscess of upper 
 central incisor, pointing on the gum. 
 A J abscess cavity; b, floor of nos- 
 tril; c, lip; d, tooth. (Black.) 
 
 "the pus passing through the alveolus tears up the periosteum, a thing 
 ■which often occurs (see Fig. 35, also Fig. 36). 
 
112 
 
 I'lg. 35. 
 Acute alveolar abscess with pocket 
 of pus between periosteum and bone 
 A, abscess cavity; b, floor of nos- 
 tril; c, lip; d, tooth; e, pus cavity 
 beneath the periosteum. (Black.) 
 
 Fig. 36. 
 Acute alveolar abscess with pus 
 pocket between periosteum and bone 
 of palate. A, abscess cavity; b, pus 
 cavity beneath periosteum; c. lip; d, 
 tooth; c. floor of nostril. (Black.) 
 
 The pus here has passed through the bony process and has taken up 
 the periosteum of the bone, which can usually be determined by finding 
 a broad, long, flat tumor, sometimes extending two or three teeth mesially 
 and as far distally as the last tooth. When you cut in with a lancet you 
 discover an area of some size denuded of the periosteum. 
 
 I have seen many cases hold pus in such a sac for days and show a 
 tendency to pass along towards the gingiva and discharge. These cases 
 are not so frequent as the others, but every practitioner meets a consider- 
 able number every year. Usually when pus is discharged they get well 
 readily; the periosteum reattaches itself to the bone. After the pus has 
 discharged it will usually lie back upon the bone and reattach itself. 
 
113 
 
 Usually, I say, but sometimes these cases terminate seriously by the de- 
 struction of large areas of bone as a result of tearing away the periosteum. 
 The third form is where the discharge occurs along the side of the 
 root between the peridental membrane and the tooth. This is by far the 
 least frequent of all forms of alveolar abscess, I am glad to say ; but it is 
 
 Fig. 37. 
 Chronic alveolar abscess at root of 
 lower incisor, discharging under 
 chin. ,-Jj abscess cavity; b, b, b, 
 fistula; c, lip; d, tooth. (Black.) 
 
 Fig. 38. 
 Abscess of buccal roots of upper molar discharging on the face. A, abscess cavity; h, pomi 
 of discharge on face; c, antrum; /, lip; e, tooth. (Black.) 
 
114 
 
 also much the most difficuU to handle and when chronic is liable to be mis- 
 taken for pyorrhea alveolaris. Fourth class is where the pus, instead of 
 making an exit in any of the ways indicated, follows along the sheath of 
 some muscle, or its fibres, until it finds an easy exit. In some cases it may 
 follow until it reaches the muscle attachment to the bone and then its exit 
 at that point. You may set down a rule that pus will always go in the 
 directir"" of least resistance. Very often it comes to the skin in all sorts 
 of places, particularly around the lower jaw (Fig. 37), upon the cheek 
 (Fig. 38), under the eye, in front of the ear; when they open on the face 
 they make ugly scars. 
 
 Symptoms and Pathology. 
 
 Tooth feels longer and strikes occluding teeth before others do. At 
 first the striking may give relief, i. e., when the inflammation is first 
 started up, to bite on the tooth may feel good. But it soon becomes ex- 
 tremely painful; the slightest jar causes pain. In these acute cases the 
 patient can scarcely lie down ; temperature and pulse go up ; agony in- 
 creases every minute until it becomes almost intolerable. Let me say that 
 in the great majority of cases of acute alveolar abscess you can tell what 
 the patients are suffering from by seeing them come into the office. You find 
 the patients coming in walking on their toes ; they don"t want to set their 
 heels down because the slightest jar causes pain. And, of course, they 
 usually have the expression of agony written upon their faces. As the 
 inflammation increases the bone around the apex begins to absorb to 
 accommodate the swelling membrane and the forming pus. On and on 
 it goes, pus forming a little faster than space to accommodate it, and the 
 temperature continues to rise. By and by one or more Haversian canal? 
 running into this space begin to enlarge or absorb, the pus follows in 
 these canals until by and by it reaches through the bone to the soft tissue. 
 It usually goes towards the labial, rarely towards the lingual, although oc- 
 casionally. When the soft tissue is reached the swelling begins. Pus goes 
 in the way of least resistance. The swelling continues sometimes to enor- 
 mous size and shape. Pus continues to burrow in the way of least resist- 
 ance until it finally approaches the surface of the gum, which usually puffs 
 out in the form of a rounded tumor which points more and more until 
 finally it breaks through and pus is discharged and pain subsides. Indeed, 
 pain begins to quiet down as soon as the pus passes through the bone and 
 the swelling begins. 
 
 treatment. 
 
 In all acute cases the first thing to attend to is the forming tumor. 
 Where there is a well rounded tumor forming on the gum over the root 
 apex the only thing needed so far as the tumor itself is concerned is to 
 
1^5 
 
 let the pus out by cutting with a lancet at the most dependent part. I 
 wish to emphasize the idea of cutting by drawing the edge of the blade 
 along the bottom of the tumor rather than attempting to puncture it with 
 the point of the lancet. The latter is usually painful because of the pres- 
 sure exerted on already distended and tightly drawn tissue. 
 
 After this has been done the case should be allowed to rest for a 
 few days until tenderness has subsided, when the offending pulp cham- 
 ber can be opened and proper treatment proceeded with. In the second 
 class it is necessary to make a free long incision at the most dependent 
 part of the tumor, press out the pus and thoroughly irrigate, examining 
 to see if an}- necrosed bone be present. The offending tooth then is al- 
 lowed to rest until soreness has subsided. I have had a number of cases 
 where these alveolar abscesses had literally torn away the periosteum from 
 the alveolus around two or three or maybe four teeth, and the whole mass 
 of bone dead, so that the teeth and bone and all would come out with the 
 slightest eft'ort. This is a thing that is likely to occur in cases of serious 
 accident, people meeting with traumatic injuries, etc. These cases where 
 surgical interference is sometimes necessary, but frequently, and, indeed, 
 usually, the bone will be thrown off in a large mass, and if the periosteum 
 remains alive it will gradually rebuild the bone. This is a most remark- 
 able thing, and I have seen some of the most remarkable recoveries where 
 the bone became necrosed and sloughed off a large area. That is the proc- 
 ess by which all fractures are healed, so that you do not need to worrv in 
 those cases where the periosteum is alive ; but if the periosteum is gone, 
 then your case is hopeless. In these cases the parts must be made clean, 
 surgically clean, all dead bone removed, and kept clean until recovery is 
 complete. In the cases that I have just illustrated in Fig. 35, when you 
 make your opening with the lancet and have all the pus out, always take 
 pains to wash out such a case as this, cleanse it out with carbolized water, 
 differing in that respect from the rounded tumors. The irregular places 
 in which pus may have caught, as it were, make it necessary that you 
 wash it out with carbolized water. Always do that after opening this 
 kind of a case. In the third variety there is usually no tumor, although 
 sometimes the pus makes its way out into the gum tissue near the gingi- 
 vus, in which case the tumor should be opened and drained. AVhere the 
 discharge is along the peridental membrane, making its exit between the 
 gum and the neck of the tooth, the pulp canals must receive immediate 
 attention. 
 
 In the fourth class, where pus is attempting to make an exit on the 
 skin surface, especially about the face, very careful attention, too, is re- 
 quired. When a case comes to you with the tissue much swollen and 
 hard in certain areas, never poultice — please bear that in mind — but dis- 
 
ii6 
 
 courage its coming to the surface by free incision in the mouth. Let us 
 illustrate : Take a case where the swelling is on the lower jaw, perhaps in- 
 volving the submaxillary gland. The tissues are very much distended and 
 a certain area, perhaps the size of a twenty-five cent piece, is very hard 
 and has already begun to get red or purple in that particular region. If 
 you poultice that a few days it will break on the outside. Instead of that, 
 as soon as you see the case you take a lancet and make a free incision 
 into that abscess from within the mouth, drawing out the cheek and mak- 
 ing an incision clear along the periosteum of the bone until you reach the 
 abscess and get the discharge within the mouth. Oftentimes cases will 
 come to you too late for that sort of thing, that have perhaps already 
 broken and are discharging on the face. Then, in that case, the first thing 
 to do is to cut off that discharge as soon as possible, either by the extrac- 
 tion of the tooth, in case the tooth can be spared, or making this incision 
 in the soft tissue from within the oral cavity, thereby cutting off the 
 discharge from the external surface. 
 
 The case may come to you before the pus has appeared beneath the 
 surface of the gum ; in this acute condition when the tooth is so. 
 sore you can scarcely touch it, and a collection of pus in the apical 
 space ; it hasn't even penetrated the bone yet ; or it may have 
 gone far enough for the pus to have penetrated the bone and no farther ; 
 indeed, that is quite a usual condition that we meet with. In this case, 
 when you feel certain that the pus has already passed the bone, inject a 
 little cocaine and make a deep incision over the root clear to the bone 
 until you find the pus. You usually will be able to detect whether the 
 pus has escaped through the alveolus by the finger gently pressing upon 
 the soft tissue ; you will get the slight fluctuation that always presents after 
 the pus has passed beyond the bone. In case the pus has not reached the 
 periosteum, is still confined within the' bone, what shall we do to relieve 
 that case? That case is more difficult to handle. Many dentists send pa- 
 tients away to poultice and await swelling and breaking on the surface, 
 which seems a cruel thing to do. In this class of cases it has been my cus- 
 tom to open into the apical space, either by the use of a strong knife passed 
 through the soft tissue and bone, after having anesthetized the parts with 
 cocaine, or, in case that seems impracticable, the bone is very heavy and 
 I do not succeed in that method, or for any other reason I decide that 
 this is not practicable, then the method that I use is the same as described 
 for opening the apical space in apical pericementitis. 
 
 The advantages of using this carbolic acid and plugger method are 
 two. It prevents hemorrhage and can be done painlessly. Care must be 
 taken not to drill into the tooth root. 
 
 When it is possible to open into these cases directly through the tooth 
 
117 
 
 or cavity at the first sitting, it is always advisable to do so. In case there 
 is no cavity, we open upon the lingual or occlusal surface. But often the 
 teeth are so sore as to make the operation impossible, especially if we 
 liave to open in through sound tooth structure or a filling. Of course, 
 you readily understand that if there was a large cavity and the pulpal 
 wall was thin, there would be very little difficulty, even though the tooth 
 was sore, in making that slight opening ; but in case it is necessary to 
 drill through sound tooth structure like this, or a filling, they are often 
 50 sore as to make it quite impossible. 
 
 I want to suggest a few methods that will often make this possible. 
 After you have everything in readiness for opening, place the finger or 
 thumb of the left hand on the crown of the tooth and begin by pressing 
 gently, increasing gradually until you have accustomed the tooth to it ; 
 then hold it rigid and open directly with a rapidly revolving drill. If it 
 were a molar tooth on the lower jaw I probably would hold it v^dth my 
 thumb. I sometimes take the sore tooth and its neighbor between the 
 thumb and forefinger in a tight grasp, thereby holding firm and prevent- 
 ing much of the jar of the drill. Another method is to surround the 
 sore tooth and its neighbors with plaster of paris. That is a metliod I 
 use especially where teeth are very loose, and it is very serviceable. 
 
 Let us take, for example, a lower first molar, all neighboring teeth in 
 position. We decide that it must be opened and we are going to try to open 
 it rather than take the chances of opening through the soft and hard 
 tissues. First dry surfaces ; pack toward the tongue and toward the 
 cheek with cotton to keep the secretions away; then, mix plaster with a 
 little salt in it so it will set quickly, and cover the second molar and 
 wisdom tooth, if they be present, clear down to the gum on either side as 
 far down as you can ; also cover the sore tooth and the two teeth anterior to 
 it ; then before it gets real hard remove the plaster from the occlusal sur- 
 face of the tooth upon which you are going to drill ; then let the whole 
 thing set very firmly. This will often help when the tooth is quite sore. 
 Try it and see. Your success will depend upon the perfection with which 
 you get your plaster around the tooth, so it is in contact with all the 
 tooth and the gum, thereby distributing the pressure from one tooth to five 
 teeth. That I suppose you would call making a temporary splint. Where 
 teeth are affected with pyorrhea and are very loose and it is necessary 
 to open into the canal (many of these come to us with pulps dead), that is 
 the method that I use almost universally. Then another method is to 
 ligate the teeth, beginning with the second molar, tying your ligature on 
 the mesial surface of it, then around the sore tooth and ligating again on 
 the mesial surface of that, and then around the second bicuspid in the 
 same manner ; passing your ligature back and forth in that way bind and 
 
ii8 
 
 lock rhe teeth solidly together. The objection to that method is that it 
 is sometimes painful in tying the ligature. Otherwise, it is very useful. 
 Another method that I use very frequently is to tie the ligature strongly 
 around the neck of the tooth to be drilled into, and then with the thumb 
 or the forefinger I catch a loop of the ligature and gently Hft up on the 
 tooth, increasing until I get a good strong pressure, literally lifting the 
 tooth away from the swollen and irritated peridental membrane ; and drill 
 as before. Another method that I use frequently is to take the ligature 
 and tie it around the "sick" tooth, making the knot distally ; take another 
 one and bringing it around the tooth and making the knot mesially ; that 
 gives two ligatures, one to the mesial and one to the distal. Then take 
 ligature and pass it from the mesial around to the distal of the second 
 molar, and tie it. Then I do the same thing with the second bicuspid, 
 having the ligature tied between the two bicuspids, bring ligature that is 
 on the distal surface of the second molar up over the occlusal surface and 
 the one on the distal surface of the first molar and tie over the occlusal of 
 the second molar and likewise, the one on the mesial of the second bicus- 
 pid and on the mesial of first molar tied on the occlusal of second bicuspid. 
 You see, this actually lifts the sore tooth out of the socket, a thing that is 
 very simple to do, is not painful, and is very successful. 
 
 There are many cases presented in which we fail to give relief either 
 because of the nervousness of the patient or the severely painful condition 
 present, and all we can do is to administer such general remedies as will 
 aid the sufferer in accordance with the plan suggested in the treatment 
 of painful pericementitis. One thing in addition can be done^ and that is 
 to make hot water applications to the face, which will tend to relieve the 
 pain and at the same time hasten the pointing of the abscess. We should 
 keep in mind the danger of hard swollen areas breaking on the face, and 
 discontinue such applications where this tendency is shown, although my 
 experience has been that where moist heat is used that danger is not so 
 great as where dry heat is used. In all cases we should seek the first oppor- 
 tunity to make an opening either through the gum or into the pulp cham- 
 ber, and thus afford relief, and avoid those serious conditions which are 
 liable to happen. 
 
 Cbronic Hiveolar Hb$cc$$« 
 
 The tendency of all acute abscesses is to become chronic; when they 
 discharge their pus upon the surface, either of the skin or the gum, they 
 frequently Tieal over ; then in a few days they break and discharge again, 
 and repeat this process every few days for weeks and years. Usually 
 patients with such cases think nothing of it at all ; usually painless. After 
 they have discharged the first time the patient will come to you, perhaps 
 
119 
 
 telling- you that a little swelling occurs in a certain region of the mouth ; 
 it puffs up, they pass their fingers over it, it breaks and that is the end 
 of it, until it recurs. 
 
 It is in this class of chronic cases that we have the worst burrowing 
 of pus. Little by little the pus will burrow along the periosteum of the 
 bone. Take a case where it has discharged upon the gum and heals over 
 (Fig. 39). The next time that Nature makes an effort to force the pus 
 
 Fig. 39. 
 Chronic alveolar abscess at root of 
 lower incisor. A^ abscess cavity; 
 bj Estula discharging on gum; c, 
 lip; d, tooth. (Black.) 
 
 out through that tract it will drop down a little lower each time, until by 
 and by you will have pus burrowing in all sorts of directions (See Figs. 
 27 and 38). I have had some very remarkable cases. I remember one 
 case which was the most interesting of all. It w'as during the early years 
 of my practice. I was called upon to extract a lower wisdom tooth on the 
 right side. The tooth was badly broken down, was not paining at all, but 
 the odor from it was offensive, and I found that the wisest thing to do 
 was to extract it. The patient told me that she suffered at times with 
 what appeared to be a sort of paralysis of the right arm, i. e., it would 
 be all numb, and the same on that side of the neck. I did not associate 
 it with the tooth, but after extracting the tooth and washing out the 
 socket I found that I readily forced water out just at the clavicle, and 
 upon inquiry I found that she had a place that was discharging there. 
 
120 
 
 She thought it was a tubercular gland and had it opened twice by a 
 surgeon and the bone scraped, .1 flooded it through with carbolized 
 water and then washed it through with a twenty-five per cent emulsion 
 of carbolic acid, when it healed up without trouble. 
 
 I remember another case that I had where the discharge was just 
 under the lower jaw about the region of the submaxillary gland. I was 
 doing some dental work for this case also; patient did not come to me 
 for treatment of this, believing that it was a cancer there. She had it 
 opened and scraped any number of times ; it would heal up and be all 
 right for two or three weeks and then it would puff out again and 
 break and discharge. On making a filling in a lower first molar I dis- 
 covered that the pulp was dead. I opened into that tooth, cleaned out 
 the root canal and had no difficulty in washing through the root of that 
 tooth right through this opening. In that case the pus had gone directly 
 through the bone ; the channel was directly through the bone, appearing 
 on the under side. In that particular case we were able to save the tooth 
 and heal up the difficulty in the jaw. 
 
 But oftentimes in these cases where pus has burrowed either through 
 the bone or along the periosteum for some way before it discharges we 
 
 b 
 
 Fig. 40. 
 Chronic alveolar abscess, lower 
 incisor with abscess cavity extending 
 through the body of bone, discliarg- 
 ing on chin. A, abscess cavity; b, 
 inouth of fistula; d, tooth; c, lip. 
 (Black.) 
 
121 
 
 have serious necrosis of the bone, and it does require something of a 
 surgical nature. I think perhaps you have all read of the interesting 
 case of Dr. Black where the pus had burrowed from a lower central in- 
 cisor directly through the jaw (see Fig. 40). He was consulted in the 
 matter by the surgeon who was handling the case and asked if he thought 
 the tooth might have anything to do with it, and he said he would be 
 decidedly of the opinion that it might have. Then they wanted to know 
 what they would look for to tell ; he told them that perhaps the tooth was 
 loose; perhaps discolored or something of that kind; perhaps it had a 
 history of being sore once upon a time, or something of that kind. They 
 made an examination and decided that the tooth was responsible and ex- 
 tracted it and washed down through the socket underneath the chin. Then 
 they made an arrangement whereby they tied- a string on a sponge, and 
 saturated this sponge with medicine and pulled it through, and then 
 pulled it back again. They told the patient it was a very serious case 
 and had her coming every day to run this sponge through to keep it clean 
 and open. It happened that she lived quite a little ways from the office, 
 and there came up a very severe storm, making it impossible for her to 
 come out, and I believe she didn't come for three days, and when she did 
 come it was all healed up, which is the usual thing. These cases get 
 well readily usually where the pus has burrowed without much difficulty, 
 especially where it has not met with much resistance. 
 
 It is probable that these cases discharge more frequently in the 
 antrum than we imagine (Fig. 41). If you will examine all the skulls 
 
 Fig. 41. 
 
 Alveolar abscess at the roots of upper molar discharging into the antrum. 
 ■ b, mouth of fistula; c, pus in antrum; d, nostril; e, tooth; f, lip. (Black.) 
 
 Aj abscess cavity; 
 
 you get an opportunity to, you will be surprised at how thin the floor of 
 the antrum is in many cases, and I am sure often we have these cases 
 penetrating the antrum when we do not realize it ; because of the absence 
 
122 
 
 of pain patients frequently do not know of the trouble until severe 
 empyemia results. In chronic cases where pus is discharging on the gum 
 or other surface careful exploration should be made through the sinus 
 with the silver probe to locate its direction and discover if anything un- 
 usual is present. I wish to emphasize the value of the silver probe as a 
 diagnostic aid in these cases where the point of discharge is upon the 
 face or neck ; in addition to cutting off the sinus and emptying it in the 
 mouth, some attention must be given to the scar. It should be dissected 
 away from the periosteum, to which it is usually attached, packed, and 
 if need be held out in proper position with a long silver pin passing 
 through the scar tissue, resting on the surrounding parts in such a way 
 as to hold the depressed part out level with the adjacent tissues. The 
 packing must be kept up until healing results from that side. In all cases 
 of alveolar abscesses, the offending teeth — the teeth whose pulp have died 
 — must receive proper treatment and the canals thoroughly filled if a per- 
 manent cure results. 
 
 A word should be said here regarding molar teeth. It is sometimes 
 seen that only one root canal is discharging on the gum, or perhaps the 
 two buccal roots in an upper molar, while the lingual root may be dis- 
 charging in the palate or only presenting a tumor-like swelling (Fig. 42), 
 which swelling often resembles aneurysms. There is danger of mistaking 
 the latter for a forming abscess (Fig. 43). 
 
 Fig. 42. 
 Acute abscess at buccal roots and chronic abscess at lingual root. A, acute abscess cavity; 
 b, pus cavity between bone and periosteum; c, lip; d, tooth; e, antrum; f, nostril; g, molar 
 process; h, chronic abscess discharging at i. (Black.) 
 
 JIncurysm. 
 
 "Aneurvsm does not often come under the observation of the dentist, 
 but it does occur occasionally in the tract of the posterior palatine artery, 
 and in this locality I have known it to be mistaken for an alveolar abscess 
 with seriou.s results ; therefore never incise tumors on the hard palate 
 
123 
 
 Fig. 43. 
 Aneurysm of posterior palatine artery. 
 
 (Marshall.) 
 
 without first having given them a careful examination to determine cer- 
 tainly their nature. 
 
 In order to differentiate between an alveolar abscess pointing on the 
 hard palate and an aneurysm of the palatine artery, make pressure on the 
 proximal side of the artery from the tumor, and if the tumor decreases 
 in size the indications point to an aneurysm. 
 
 Again, place the thumb on one side of the tumor and the index 
 finger on the other ; if there is decided pulsation, which not only raises 
 the thumb and finger, but at the same time perceptibly separates the two, 
 this also is an indication of an aneurysm. Simple pulsations do not cer- 
 tainly indicate an aneurysm. As a tumor overlying an artery may give 
 sufficient impulse to the tumor, so that the result of the heart's action 
 may be felt through its substance, if the tumor be not toO' massive and 
 the artery sufficiently large. 
 
 To come to a positive diagnosis, it may be necessary to aspirate a 
 part of the contents of the tumor. This may be done by inserting the 
 needle of a hypodermic syringe into the tumor and then withdrawing the 
 piston. If it is an aneurysm the barrel of the syringe will contain arterial 
 blood ; if an abscess it will contain pus. This precaution may prevent a 
 serious result, and is advised in all cases where there is doubt." (Gilmer). 
 
 Blind JIb$ce$$. 
 
 The term blind abscess is applied to those cases where there is a pus 
 cavity about the root apex with no fistulous or other opening to the ex- 
 ternal surfaces. They are for the most part chronic cases that lay dor- 
 
124 
 
 tnant, although they may occasionally have periods of tenderness. They 
 seem to be very slowly progressing, absorbing the bone little by little, 
 and show no tendency to heal. 
 
 The pus is usually of the laudable variety, although very liable to take 
 on the septic thin serous or watery form, in which case acute conditions 
 are set up, with more rapid destruction of both bone and soft tissue. This 
 is the thing that is so liable to happen when the pulp chamber of a tooth 
 in this condition is opened for the first treatment, and requires the same 
 •care as is necessary in putrescent cases, which has already been alluded to. 
 
 treatment of Pulpless Ceetb. 
 
 For convenience of treatment description it seems advisable to divide 
 all these varieties of alveolar abscess into four classes. 
 
 First — Those cases where the pulp canals are open and have been 
 ■exposed to the fluids of the mouth. 
 
 Second — Cases where pus is discharging through a fistulous opening 
 •on the gum. 
 
 Third — Those cases where the discharge of pus is at some point dis- 
 tant from the root of the ofl:ending tooth. 
 
 Fourth — Blind abscesses and other dormant cases. 
 
 Each class requires some important modification in detail of treat- 
 ment. In the first class are those cases where the pulp has died as a result 
 of exposure by caries and gone through the stages of putrescence into 
 acute alveolar abscess and perhaps on to the chronic form. 
 
 The management of these cases is among the most difficult, for like 
 many dormant cases they are very prone to take on active condition 
 when treatment begins. 
 
 The first step is to remove all the decay from the carious cavity and 
 pulp chamber, opening up thoroughly to get free access. This can usually 
 be accomplished best with spoon excavators and inverted cone bur after 
 the enamel has been chiseled to outline. This part can usually be done 
 without the application of the rubber dam, which will allow free flushing 
 with warm antiseptic solution, washing out all the debris as fast as it is 
 loosened in excavating, keeping in mind always that it is important that 
 nothing whatever shall be forced through the apical foramen. The next 
 step is to apply the rubber dam. Then flood the cavity and chamber with 
 alcohol, absorbing with cotton and reapplying until all is clean and dry ; 
 flood again with alcohol, this time carefully working it down into the 
 canal with a smooth broach and then wash out all debris ; the next step is 
 to dry first with alcohol on cotton, then dry cotton and finally with 
 warm air. 
 
125 
 
 In this dry warm condition a non-irritating antiseptic should be 
 introduced loosely on cotton, for which purpose oil of cloves, 1-2-3, trik- 
 resol, oil cloves and eucalyptol. Creosote has also proven a good agent,. 
 and sealed with gutta-percha in such a way as not to allow anything forced 
 through the foramen. If all keeps well this agent should be allowed to 
 remain for four days. 
 
 At the second sitting the dam is applied, the field of operation 
 cleansed, the canals reopened, and this time thoroughly cleansed with 
 proper broaches, so that all walls of the canals are free from any clinging 
 debris; alcohol is again used to float out all loose material and dry the 
 canals under the same precaution as before. A second sealing of the 
 same kind of agent allowed to remain 10 days will usually effect a cure 
 and prepare the tooth for root canal filling. In the management of these 
 cases if acute conditions should set in during the progress of treatment 
 the patient should return immediately, the case be reopened and treated as 
 an acute apical pericementitis. 
 
 The second class of cases includes both the acute and chronic forms.. 
 I have previously stated in this chapter that the first thing to do in 
 acute cases is to get an outlet for the forming pus and dismiss the case 
 until tenderness has subsided. When the patient returns for the second, 
 sitting and the opening, if made on the gum, has healed, you proceed ex- 
 actly as described in Class i ; if said opening still remains the procedure 
 is the same as for the ordinary chronic case with discharge on the gum. 
 The first step is to clean the carious cavity if one is present, and adjacent 
 teeth, then apply the dam and thoroughly cleanse and disinfect the field 
 of operation, particularly the tooth to be opened. The second step is to 
 secure convenient access to the chamber and canals, floating out all debris 
 with a solution of bicarbonate of soda in distilled water ; the canals should 
 then be mechanically cleaned and again washed with the above solution, 
 taking plenty of time to wash out all debris possible from the tubuli. The 
 next step is to thoroughly dry the canals and disinfect and deodorize the 
 dentine with free application of oil of cloves, using gentle heat to force 
 it throughout the dentine as far as possible ; the object is to cleanse and 
 deodorize the dentine before any agent is used that will seal the tubuli 
 filled with filth. The excess of oil is removed by alcohol and the tooth 
 made ready for washing through the fistula, A smooth broach is used 
 to make free the opening through the apex. If the approach to the canals 
 is not so shaped as to prevent the escape of solutions under pressure it 
 should be so arranged either by the use of gutta-percha or cement, as 
 seems best. 
 
 The next step is to force a saturated solution of bicarbonate of soda 
 through the canals and out the fistulous tract freely ; for this the Dunn,, 
 
126 
 
 or Farrar syringe or hypodermic syringe with platinum point are well 
 adapted ; over the needle is placed a tapering rubber cone, the needle car- 
 ried into the canal and the cone held with a strong pair of cotton pliers 
 against the prepared orifice. Force enough is exerted on the plunger to 
 thoroughly wash the abscess contents out through the fistula. It is impor- 
 tant to empty the abscess of its pus before using coagulating agents. 
 
 The next step is to dry the canal and fill it with cotton soaked in 
 1-2-3 or 95 per cent carbolic acid, or phenol-sulphonic acid, depending on 
 the conditions about the apex. Some cotton smeared with vaseline should 
 be placed around the opening on the gum to prevent severe burning in 
 case an excess of the escharotic escapes. The medicine in the canal is then 
 forced through, using a piece of soft rubber and an amalgam plugger 
 as a plunger. When the agent appears at the opening on the gum it can 
 readily be detected by the white appearance of the orifice of the fistula. 
 
 At this point it has been my practice, in bad cases, to hold a soft piece 
 of rubber over this opening and again pump, thereby forcing the agent into 
 every corner of the abscess cavity. A mild dressing is sealed in the canal 
 for a week, when if all goes well the root may be filled. In some cases 
 one repetition of this treatment through the fistula may be wise. This 
 procedure will bring the desired result in the great majority of cases, but 
 for reasons which I shall presently point out some cases do not get well. 
 
 Occasionally one of these cases is met with where it is not possible 
 to force anything through the apical foramen. When possible this should 
 be opened, but this is an operation that requires skill. A Downey or a 
 triangular piano wire broach are the best instruments to use for this pur- 
 pose, and even with these there is some danger of breaking in the 
 foramen. The operator should work with the idea of such a possibility 
 in mind and proceed very slowly, frequently withdrawing the broach to 
 make sure that it should not bind and break. As I have said, it is desir- 
 able to make such an opening when possible, but there are some cases 
 where for various reasons this cannot be done. This treatment, then, 
 must be the same as in Class i, and in addition carbolic acid, 1-2-3, 
 or phenol-sulphonic acid are carried into the abscess through the fistulous 
 opening with the syringe. In many cases this will be sufficient (see 
 apical cases). In the third class of cases, where the discharge is at some 
 distant point, the treatment procedure is exactly the same as for Class 2, 
 with this exception, namely, escharotics must not be forced through long 
 distance of fistulous channels. It is safer practice to cut into the channel 
 as near the tooth as possible and treat the tooth as though the discharge 
 was at this point. The treatment of the rest of the channel and the 
 external opening when on the skin has already been outlined in this chapter. 
 
 The fourth class — blind abscesses and dormant cases — often try 
 
12/ 
 
 men's souls, because of the great liability of stirring up a hornet's nest. For 
 the most part they are teeth whose pulp have died under filling or from 
 traumatic injuries. I read a paper before the Chicago Dental Society in 
 1889 on this subject which was published in the Dental Reviezv for May, 
 1900, from which I quote. 
 
 Every practitioner constantly meets with teeth whose vitality has been 
 lost from causes that we do not understand. 
 
 That teeth sometimes lose their vitality and give no disturbance for 
 years is a fact well known to all. Why this is so cannot always be ac- 
 counted for. Sometimes the reasons can easily be understood. When a 
 pulp dies it remains comparatively harmless until it becomes infected by 
 micro-organisms — for without them we will have no putrefaction. If a 
 tooth has no external opening into the pulp canal, then micro-organisms 
 must enter — if they enter at all — through the apical end, and their only 
 way of getting there is through the medium of the circulation. The blood 
 does not normally contain micro-organisms, therefore it is only by acci- 
 dents such as functional disturbances of nutritive processes, that they 
 are enabled to live therein. When they gain entrance into the system in 
 sufficient quantities and conditions are favorable they seem to immediately 
 seek out dead or dying matter in which to grow and multiply. This ex- 
 plains why many teeth containing dead pulps, though remaining quiescent 
 for years, suddenly develop acute conditions ending in acute and finally in 
 chronic alveolar abscess. 
 
 When micro-organisms enter a pulp canal which is filled with dead 
 matter we do not always have appreciable physical disturbances. In 
 many cases we find foul smelling root canals when there has been no dis- 
 turbance, even though the canals were closed. The understood reasons for 
 this are three : 
 
 First- — The animal cells surrounding the part affected may be suffi- 
 ciently active to literally digest the micro-organisms and hold in check 
 their putrefactive process. 
 
 Second — The system may be able to readily carry off the products of 
 putrefaction. 
 
 Third — There may be present in the blood certain antitoxines which 
 reduce the activity of the putrefactive process or neutralize its effects. 
 
 These reasons explain why teeth containing imperfect root filling 
 remain quiet for years and other cases give occasional slight disturbances, 
 which pass off and remain quiet for another period ; then again the 
 trouble is repeated and again ceases, and so on for years and years. 
 
 Why is it, when we open into the pulp chamber of teeth containing 
 dead putrefactive matter, that we so often start up violent acute condi- 
 tions? Why is it that we sometimes stir up a veritable ''hornets' nest"? 
 
128 
 
 1 can only answer in part : We disturb the balance of power existing be- 
 tween the putrefactive process on one side, and the animal cell, anti- 
 toxines, or systemic conditions, on the other. We do this in four ways : 
 By introducing fresh infectious material, or by forcing septic material 
 through into the apical space, or by introducing some agent that will 
 interfere with the local animal cell activity or admitting air. 
 
 There still remains unexplained many disturbances that follow the 
 opening of certain cases. There is room for further study on these cases. 
 
 In certain cases after the death of the pulp, the apical foramen be- 
 comes closed either by deposit of cementum or by the peridental membrane 
 growing tightly over it. All that is needed in treatment of these cases 
 is to remove all dry material, moisten walls with a mild disinfectant, dry 
 and fill immediately. 
 
 In a large number of cases examined every case containing moisture 
 contained also pyogenic germs. 
 
 In those cases where there is no tenderness of tooth or tissue adja- 
 cent to the apex of the root, and no opening into the pulp chamber, after 
 adjusting the dam, and disinfecting the tooth externally and surrounding 
 tissues, I drill into the tooth almost, but not quite to the pulp chamber, 
 and seal therein a mild penetrating antiseptic and let remain forty-eight 
 hours. I now use my trikresol, oil of cloves and eucalyptol mixture — equal 
 parts. 
 
 At the next sitting I enter the pulp chamber at its horn, using a 
 small sterilized bur, cutting in such a way as not to produce the slightest 
 pressure upon the contents of the canal ; then I lay a piece of cotton con- 
 taining some of the above solution over the opening partly to disinfect 
 and partly to absorb the liquid present ; then I carefully enlarge the open - 
 ing and draw ofif the contents of the canal, which can be done nicely b}^ 
 the careful use of the hypodermic syringe, and dry thoroughly ; next I 
 lay a potent diffusible germicide and seal ; care should be taken not to 
 produce the slightest pressure. I allow this to remain thirty-six hours, 
 when the case is again opened, now thoroughly — canal mechanically 
 cleaned, reamed out and dried thoroughly. A non-irritating disinfectant is; 
 then introduced clear to the apex of the root, and volatilized by heat, then 
 more introduced, sealed and allowed to remain a week or two longer. 
 At the next sitting if canals are sweet and dry, and there has been no. 
 conscious disturbance, the roots are dried and filled. 
 
 In cases where there is tenderness to pressure, I open immediately,, 
 as before described, remove as much moisture as possible, and lay into the 
 pulp chamber a potent germicide, seal with cement and drill a small 
 "vent hole" through the cement and dismiss the case for twenty-four 
 hours, after which I cleanse and dry the canal, as before described. If. 
 
129 
 
 tenderness continues I:use creosote and iodine for second treatment, car- 
 ried well up to the apex, seal, and allow to remain a week. In anterior 
 teeth care must be taken not to introduce. so much of this agent as to dis- 
 color the teeth. I wish to recommend this agent for cases of abscess in 
 syphilitic patients. If tenderness now has disappeared I dry and fill 
 immediately. If tenderness continues, however, as sometimes occurs, I 
 treat with 12 per cent sulphuric acid, forcing carefully, a little through 
 the apex, allow to remain twenty-four hours, and follow with mild anti- 
 septic and dismiss for two weeks, when, unless a large absorption exists 
 around the apex, the root may be filled. The sulphuric acid is recom- 
 mended for the double purpose of dissolving any slight uneven, sharp 
 points of foreign deposits on the root and destroying the so-called 
 pyogenic membrane existing about the apex. 
 
 Since following the above plan I have had very little trouble, but 
 when acute disturbances do arise the case must be treated the same as 
 indicated for Class i. 
 
 Special €a$e$. 
 
 After all I have said there yet remains many cases belonging to none 
 of these classes and some in each of the four classes that do not yield to 
 such comparatively simple measures, and sometimes cause a great deal 
 of anxiety. For convenience of treatment description I place them in 
 three classes. 
 
 First — Those cases where there • is considerable absorption of bone 
 around the root apex. . - 
 
 Second — Those cases where there is some absorption of the root end. 
 
 Third — Those cases where there is serumal calculus deposits on the 
 apical end of the root (Fig. 44). 
 
 Fig. 4i. 
 Serumal calculus covering 
 the apical third of rout of 
 bicuspid. 
 
130 
 
 In all of these cases there is more or less absorption of bone around 
 the root apex, which can readily be detected by exploring- through the 
 sinus or by the amount of discharge coming through the root canal upon 
 opening it up. 
 
 The nature of the absorption can, to some extent, be determined by 
 the nature of the discharge. If it is thin, watery, yellowish, with little 
 granules of bone mixed in, you can be pretty certain that caries of bone 
 exists. If thick, rich pus, simple absorption. If this yellow is streaked 
 with blood, no granules, you can count on a roughened root end, which 
 should a little later be confirmed by exploring through the external 
 opening. 
 
 I always proceed in the management of these cases exactly as I 
 would for any chronic abscess, namely, open up canals, drain, dry, steril- 
 ize, deodorize the dentine ; then if there be a fistulous opening I wash 
 through with the bicarbonate of soda water, followed by 95 per cent of car- 
 bolic or 50 per cent phenol-sulphonic acid, using the latter if I am certain 
 of considerable bone absorption. If it has been a bad pus case I next seal 
 in 10 per cent chinosol for a week ; if it is not such a case, but instead 
 thin ichorous fluid present, I use paraform, or creosote and iodine well 
 up to the apex. If there is no fistulous opening then I use the same treat- 
 ment, except, of course, I do not wash through, but instead I force a 
 little 50 per cent phenol-sulphonic through the apex into the space be- 
 yond. When the patient returns I always closely observe the conditions. 
 Is there any further discharge through the fistula or down into the canal ? 
 What is its nature? Is the pus controlled? Does hemorrhage occur down 
 into the canal ? What does the blood look like ? Is it rich red, showing 
 that new granulations are present and the healing process nicely begun ? 
 
 If I am favorably impressed with the progress of the case then I seal 
 in a mixture of trikresol, oil of cloves and hydronaphthol and leave from 
 two to four weeks, when I expect to fill the root canal. If there be a 
 little thin yellow serous fluid weeping down into the canal on the second 
 visit, and especially if there is a little soreness of tooth, I seal in creosote 
 and iodine carried well up toward apex, absorbing excess to prevent dis- 
 coloration. I will leave this from two to four weeks, when I will expect 
 to fill the root canal. Occasionally I treat one of these cases a third time, 
 but rarely. At this point I want to say that as a rule we over treat teeth, 
 treat them to destruction. I know men who have these cases running to 
 them every other day for weeks and months. Do you know such treatment 
 does more harm than good ? Be thorough in the detail of your work and 
 use proper remedies and give nature time in which to make the recovery. 
 If the cases do not progress favorably I fill the root canal and proceed to 
 treat from the outside, for the reason that I probably have one of the 
 
J3I 
 
 three conditions already described. For the last three or four years I 
 have been studying these cases carefully and examining teeth removed by 
 our extracting specialists, and in 85 per cent of the teeth removed, because 
 chronic abscesses could not be cured, I found the trouble v^as either root 
 roughened by absorption or deposits of calculus. 
 
 It has been my observation that most regular practitioners are either 
 afraid or do not know how to make these explorations. The method I 
 follow is this : First, I carry my index finger along the gum over the root 
 apices both lingually and labially, using sufficient pressure to detect any 
 tender, soft, or springy spots. If the case be long standing and considerable 
 amount of absorption, I will usually find a spot over the apex where 
 the bone has disappeared or has been so absorbed that only a thin plate 
 remains, which will readily spring in, showing the absorption underneath. 
 Next I inject a little cocain solution into the gum over the apex, and with 
 a good strong lancet cut into it, making a good, generous opening, which 
 with a little experience can be done painlessly; then with proper shaped 
 instruments I explore every nook of that pocket, as well as the end of the 
 root. If I am in doubt as to the conditions present, I will pack with 
 antiseptic gauze and leave twenty-four hours, when if a little care is 
 observed in removing the gauze I can readily see into the pocket and 
 know for certain what has taken place and proceed accordingly. In cases 
 like Class i, the treatment is very simple. If it fails to heal 
 readily from treatment as described through the root canal, which 
 frequently occurs, I fill root canal and then make the generous opening 
 as before mentioned ; next pack the pocket with cotton saturated in cocain 
 solution, being careful to so place loose cotton around the opening. as to 
 absorb any cocain that may exude. 
 
 I leave the cotton pack in the pocket for about five minutes, when I 
 proceed to thoroughly curette the pocket, scraping all rough or dead bone 
 (rather take a little more than necessary than not enough). While 
 scraping I flood with cassia water, keeping it clean, so I can see exactly 
 what I am doing. If the case should belong to the second or third class 
 I proceed in exactly the same manner, and in addition I scrape off the 
 serumal calculus and smooth up the root apex. In the second class of 
 cases I resect the root end, cutting away all that portion that is roughened 
 by absorption and at the same time make the end of the root round and 
 smooth (see Fig. 69). This completes the surgical part of the work. 
 There only remains the after treatment, which is very simple, and consists 
 packing with plain gauze saturated with 25 per cent phenol-sulphonic 
 acid, leave for 48 hours, remove pack, wash with cassia water and pack 
 with antiseptic gauze, preferably aristol; repeat every third day for a 
 couple of weeks, when the case should be well. The important point in 
 
132 
 
 the treatment is to keep antiseptic and compel healing from bottom, 
 keeping sinus open until pocket is quite nearly filled in. Of course each 
 treatment will require less and less gauze, and at no time after the opera- 
 tion should there be pus present ; if there is then you have not thoroughly 
 used your curette. I know that many of you will think that this method of 
 treatment is severe and difhcult, but I want to assure you that such is 
 not the case, and the pain that I cause by such an operation is not at all 
 severe. In treating several hundred of these cases I have only used a gen- 
 eral anesthetic twice. To those that have not tried this method I ask them 
 to try it and see if it does not prove helpful and a tooth saver. I recom- 
 mend it most cordially over the old method of treating through root canal 
 for months and then losing the tooth in the end. 
 
CHAPTER XIII. 
 
 Infection, Instrument Sterilisation, ana Germicides. 
 
 Infection. Carrying Infection. A Germicidal Solution. Broach Sterilization. In- 
 strumental Sterilization. Germicides ; Some Dental Uses. 
 
 The subject of infection and instrument sterilization bears such an 
 important relation to the treatment of pulpless teeth that I decide to in- 
 clude in this volume parts of two articles written by myself, the first on 
 infection, published in The Dental Summary for June, 1903, and the latter 
 published in The Dental Review for May, 1903. 
 
 Tttfectioiu 
 
 To infect means to introduce into the tissues a poison or virus which 
 has the power of invading and multiplying, thereby setting up serious 
 disturbances of physical well-being. This disturbance may be local only, 
 or it may affect the whole organism as well ; indeed, it is certain if the 
 local infection is violent, that the system as a whole will suffer. 
 
 This is a subject upon which much has been written of late years, 
 and yet I am of the opinion that the profession does not appreciate its im- 
 portance. I have formed this opinion as a result of many years' experi- 
 ence in directing the treatment of cases in a large public infirmary, as 
 well as in private practice, to both of which many serious cases are sent 
 by regular practitioners. I think it is true that most dentists have learned 
 to recognize syphilitic cases, and are fully aware of the danger of in- 
 fecting themselves and others from them ; also I believe that a large ma- 
 jority understand the precautions that are necessary in order to avoid 
 doing so, and is it not a fact that a majority of dentists regard this disease 
 as the only source of danger? I am certain they practice as if they do. 
 This article is written to point out some of the most common ways in 
 which we may infect pulps, gums or other tissues of the mouth, and to 
 suggest a method to avoid doing so. Infection depends upon certain 
 things, among which are : 
 
 First — The nature and condition of germs infecting, with reference 
 to virulency. 
 
 Second — The condition of the part through which infection occurs, 
 with reference to location, cellular elements of the tissues as well as its 
 chemistry. 
 
 Third — The condition of the system as a whole, with reference to 
 ■nutrition, including where the physiological functions are disturbed, in- 
 fection takes place more readily. - 
 
134 
 
 All agree that the mouth is usually a "hot-bed" of micro-organic 
 life; almost every known variety there abound. Were is not for the fact 
 that the saliva is normally antiseptic to a slight degree, and is constantly 
 moving, we would have more difficulty in getting open wounds in the 
 mouth to heal. In this sense nature favors healing. When tissue be- 
 comes injured, abraded or loses its vital force, and infectious material is 
 confined within or retained upon it for a period of time, of course the 
 liability of infection increases ; for these reasons I want to call attention 
 to the advisability of thoroughly cleansing surfaces through which hypo- 
 dermic needles, lancets or exploring needles are to be introduced. Sur- 
 geons quite universally take these precautions, but how many dentists do? 
 How many are in the habit of forcing needles or lancets through surfaces 
 that are covered with all sorts of infectious material? When pain, sore- 
 ness and sloughing follow, we wonder why. Before scaling teeth, how 
 many take the precaution to first rid the mouth of all putrefactive material 
 lying upon the gum margins around the necks of the teeth ? 
 
 When you think of it, how important it is. How many take the same 
 precautions before placing the rubber dam clamp around the necks of 
 teeth? In the majority of cases that instrument injures the gum, and 
 with rubber dam, retains the infectious material in contact with it for the 
 length of time required for the operation. The same is true of rubber 
 dam when applied alone or with ligatures, but to a less degree. The dan- 
 ger is even greater when wedges or separators are used. A rule, then, I 
 would like to advance is : Always cleanse the teeth and gums, especially 
 around the gum margin, of all particles of food and putrefactive debris 
 before beginning any operation. The most particular attention should 
 be given the teeth in the immediate field of operation. For this purpose 
 I first use a ball of cotton in the pliers, saturated with dioxygen and carry- 
 ing a little fine powder. With this I scrub the teeth and gums ; then I 
 use the compression air atomizer and wash out the interproximate spaces 
 with an antiseptic solution. I thoroughly flood the mouth, depending as 
 much on the mechanical cleansing as on the antiseptic wash. 
 
 With this method you can feel reasonably certain that you have re- 
 duced the liability of infection to a minimum, and it only required a 
 minute. In operating on teeth, especially where the pulp is involved, I 
 take the additional precaution of washing off the teeth with alcohol after 
 the rubber dam is in position. 
 
 earrying Infection. 
 
 In scaling teeth it is important to keep the instrument in a good 
 germicidal solution, and do not carry scalers from a pus pocket on one 
 tooth to another tooth without first wiping off and dropping it into the 
 
135 
 
 solution. I am thoroughly satisfied that many carry infection from such 
 pockets to the healthy peridental membrane or other teeth by carelessness 
 in this regard. 
 
 H eermicidal Solution. 
 
 As a germicidal solution I use sublamine, one in two hundred, and 
 for the purpose of wiping off the scales I use small squares of chinosol 
 gauze. I attribute much of my success in treating "pyorrhea alveolaris"" 
 to these precautions. 
 
 My brother, I want to interrogate you again ; you see I am after you. 
 How often do you take a nerve broach from a putrescent canal and carry 
 it up into a pulp you have devitalized, or a clean canal, without sterilizing 
 it? Take a case, we will say an upper first molar with three root canals, 
 one putrescent or filled with pus, the others clean, perhaps made so by 
 you; now, honestly, don't you frequently take your broach from the 
 putrescent canal and carry it into others without first sterilizing it ? Don't 
 you sometimes take a broach from a pus-filled canal and carry it into the 
 canal in a neighboring tooth where you are removing a non-infected pulp ? 
 How often do you wind cotton on a broach with unclean fingers, and 
 carry this into the canals? Perhaps you don't, but the majority of prac- 
 titioners do. Then they wonder why teeth become sore after the pulp is 
 removed. Many think they sterilize their broach when they dip it into 
 oil of cloves, cassia, or such agents, and leave it there a few seconds, but 
 I assure you they don't. 
 
 Broad) Sterilization. 
 
 For the purpose of getting some fairly accurate information regard- 
 ing broach sterilization, I undertook a series of experiments. The method 
 was this : I took small pieces of broaches, both steel iridio-platinum, and 
 sterilized them by heat to redness. When cool, which only took a few 
 seconds, they were carried into foul root canals, pus pockets, abscesses 
 and ulcers, then dipped into various agents and left various lengths of 
 time, after which they were removed, washed, and dropped into tubes 
 containing beef bouillon culture media, and readings made from time to 
 time for 96 hours. Test tubes were made from each case used, and 
 microscopic comparisons frequently made. The length of time broaches 
 were kept in the medicament was gradually increased until no cultures 
 were obtained. The table of results follows, and is self-explanatory: 
 Time required to sterilise broach. Time required to sterilize broach. 
 
 Medicament. Min. Medicament. Min. 
 
 Oil of Cloves 37 Trikresol 5 
 
 " Cassia 35 Creolin ^ 5 
 
 " Sassafras 40 Sublamine, i in 200 2 
 
136 
 
 Time Required to Sterilise Broach. Time Required to Sterilise Broach. 
 Medicament, Min. Medicament. Min. 
 
 Oil of Peppermint 40 Chinosol, 10 per cent solution. . i 
 
 Cade 25 Dioxygen 25 
 
 " Birch tar .... .. ?. .... . 25 Bichloride of Mercury, i in 500. 10 
 
 " Wintergreen 60 Campho-phenique .......... . . 20 
 
 " Cajeput 30 Hydronaphthol, 20 per cent in 
 
 " Cinnamon 40 alcohol 20 
 
 " Eucalyptus 45 Beta-naphthol, 20 per cent in 
 
 Carbolic acid 20 alcohol 32 
 
 Creosote, Beechwood 25 
 
 These tables only prove so far as small broaches are concerned, but 
 not for larger instruments, although they will readily show what agents 
 would be likely to be most effective for such. They show the absurdity 
 of attempting to sterilize an unclean broach by simply dipping it in any 
 of the essential oils, or in fact any but a very few agents. Chinosol, ten 
 per cent, proved most efficacious, but cannot be used for steel, as it cor- 
 rodes it, but for other metals it is very valuable. Corrosive sublimate 
 has the same objections. Carbolic acid, trikresol, and the like, are too 
 irritant to be carried into soft tissue by instruments, and unless you 
 wanted their special escharotic effects in a root canal, you would scarcely 
 like to dip broaches in them. From my experience I recommend the use 
 of sublamine, i to 200, for steel instruments ; chinosol, 10 per cent, for 
 those of other metals. 
 
 Instrument Sterilization. 
 
 The most practical method of sterilizing instruments after each case 
 is by boiling water containing a slight amount of sodii bicarbonatis, for 
 which purpose I have had made a small sterilizer consisting of a zinc 
 box with a tight closing lid four inches wide, eight inches long and 
 seven inches high, into which a removable tray is fitted and arranged so 
 the instruments will stand upright. This box rests upon a standard 
 and has a gas jet underneath. I had it made by a tinsmith at an expense 
 of $7, and I think it fills the requirements better than any other. It does 
 not heat the room to any extent, is sightly and very convenient, and 
 inexpensive to run. If instruments are boiled in it for 15 minutes you 
 can be reasonably sure they are well sterilized. The instruments we need 
 to be most careful about sterilizing are clamps, separators, files, reamers, 
 trimmers, scalers, lancets, needles, broaches. The simplest, easiest and 
 surest way of doing so is by boiling. Before boiling they should be well 
 scrubbed with soap and water. Try the precaution herein suggested and 
 you will be delighted — at least they are very helpful to me. 
 
137 
 Germicides: Some Dental Uses. 
 
 A germicide is an agent that destroys germ life and their spores. 
 It is a term of recent origin, and is derived from the Latin, german =^ 
 germ + csedere = to kill ; literally, to kill germs. In dental literature 
 the term is quite generally used to mean pus-germ destroyers. It is 
 only since the germ theory of putrefaction became understood that this 
 word, germicide, has taken on its present significance. The recent 
 studies into the phenomena of life, physiological chemistry and phar- 
 macology, bid fair to completely change our present system of thera- 
 peutics. We are beginning to see that our present accepted so-called 
 rational system of treating pathological conditions is indeed most irra- 
 tional and empirical. Not much longer will it do to treat certain condi- 
 tions with certain remedies simply because our fathers did, or even be- 
 cause we have observed in a previous case good results followed like 
 treatment we must now know the reason why. 
 
 There is no department of medicine (using the term medicine to 
 include our and all other specialties) that is so unscientific as that of 
 therapeutics. Enough work has been done to show conclusively that all 
 remedial agents, of whatever nature, that have any action upon the 
 physical organism do so by means of the chemical relation which they 
 bear to the organ, tissue, or pathological condition treated. They act 
 by means of a certain selective chemical affinity. Certain organs and 
 tissues under certain conditions attract and appropriate certain medicinal 
 agents, when so placed as to be accessible. Scientists have for several 
 years recognized what is known as the chemotactic property of cell life — 
 the attracting and repelling force which one cell or set of cells exert 
 toward another. They look upon all organized life as a multiplication 
 of cells, each having a specific function or functions, and each related 
 to the other in a chemical way. The whole physical life process is a 
 chemical one. The laws which govern the selection and preparation of 
 food digestion, assimilation and throwing off waste material are chemi- 
 cal. This is not only true of the whole organism we call man, but is 
 equally true in the micro-organic world. Furthermore, it also holds true 
 in the relation of the former to the latter. The baneful influences of 
 micro-organic life upon higher organisms is exerted through chemical 
 processes. The solution of animal cell tissue, plastic exudate in wounds, 
 and formation of pus are all chemical processes in which micro-organic 
 life plays the important role. 
 
 Tonight I want to present the thought of destroying the micro- 
 organic life and their baneful influences in animal tissue, by chemical 
 
 *Read before the Chicago Dental Society, Jan. 6, 1903. 
 
138 
 
 The disassociation theory of Arrhenius, which had many able ex- 
 ponents, and which has been developed to a marvelous point in recent 
 years, throws much light on this problem. The theory explained in a 
 few words is this : When certain organic and inorganic acids or salts 
 are carried into solution, either in the body or outside, they split up into 
 ions — the negatively charged ones called anions, and the positive ones 
 called kations. The action of such agents, therefore, depends upon the 
 nature of its ions. This fact was brought out through a marvelously 
 interesting series of experiments of Professor Jacques Loeb, formerly of 
 the University of Chicago, but now of the University of California. No 
 longer do we deal in the main with the molecules of which a substance 
 is composed, but with the ions into which it breaks up. "We know, for 
 example, that we can substitute at will sodium iodide for potassium 
 iodide, in order to produce certain therapeutic effects. These salts are 
 alike in that they both yield I-ions ; they differ in that the former yield 
 sodium ions and the latter potassium ions. Any similarity manifested in 
 the therapeutic effects of these two salts is determined by the similarity 
 of their iodine ions. But we know that the potassium iodide is much 
 more depressant than the sodium salts. This is due to the direct poison- 
 ous effects of the potassium ions upon muscle and nerves, an effect not 
 exhibited by sodium ions."* 
 
 This same principle holds true regarding the germicidal action of 
 drugs. They are efficient in proportion to the number of ions they con- 
 tain. In mercury compounds, for example, it is not the amount of mer- 
 cury in the salt, but the number of mercury ions that determines the 
 efficiency. Example : A given per cent solution of HgClg in alcohol ; 
 a solvent in which slight disassociation occurs is less potent than 
 aqueous solutions. 
 
 What is needed now is an extended study of the exact action of 
 various ions. We must learn what kind of ions produce a certain result. 
 Then the chemist will have little difficulty in furnishing us with sub- 
 stances capable of disassociating into such ions as we need for a 
 given purpose. This disassociation may often be brought about by first 
 undergoing some change or changes within the tissue, and then going 
 into solution and disassociation by means of the solvent in the tissues. 
 With these ideas in mind, the chem_ists have been at work with no end of 
 new remedies as a result, many of which are useless because they have 
 not been sufficiently tested, but rushed into the market to precede some 
 other fellow. A few are excellent, and to some of which I want to call 
 your attention. While these studies have been going on the physiologist 
 has been at work, and shown us that germicides act upon the protoplasm 
 
 *Dr. Martin H. Fisher, American Journal of Physiology, 1901. 
 
139 
 
 of the proteid molecule in this chemical way. Proteids are the most im- 
 portant substances occurring in animal and vegetable organisms. None of 
 the phenomena characteristic of life occur without their presence ; they 
 are invariably and constantly constituents of protoplasm. They are 
 highly complex and uncrystallizable (for the most part) compounds of 
 carbon hydrogen, oxygen, nitrogen and sulphur. The difference between 
 the proteid molecule of higher forms of multi-cellular life and that of the 
 purely vegetative forms has not yet been well made out. 
 
 An enormous amount of work is necessary to bring out the exact 
 relation and the exact composition of each. The inorganic salts, espe- 
 cially those of the heavy metals, such as mercury, iron, copper, lead, 
 zinc, etc., act by forming insoluble compounds with protoplasm of bac- 
 teria. They do not penetrate deeply into the cell, and their action is, 
 therefore, uncertain and usually very slight, HgCl^ being the most po- 
 tent of the group, because of its special toxic property, but its efficacy 
 is greatly lessened if there are other proteids present, especially in the 
 solutions which can be safely used on account of their toxicity. 
 
 The fatty acid series, the coal tar derivatives, phenol, naphthol, re- 
 sorcin, salol, thymol, guaiacol, cresol, etc., and to this group we may add 
 beechwood creosote, salicylic acid, etc., also act by coagulating the proto- 
 plasm to a greater or less degree ; but with these agents the coagulum 
 is quite soluble, and so the agents, if kept in contact, penetrate deeper, 
 and to that extent are fairly germicidal, especially to germs that have an 
 easily permeable cell wall, and this is especially true of carbolic acid, 
 which is more or less volatile. 
 
 It must be understood that none of these agents acts in a chemical 
 way, but simply by coagulation, which is a molecular process. None 
 of these agents enters into chemic combinations with the proteid. While 
 the salts of the metals produce insoluble precipitates, and thus prevent 
 greater penetration, so that their germicidal power depends upon the 
 degree of precipitability of the different proteids, the aromatic series, 
 to which belong the essential oils, can scarcely be called germicides. They 
 act by simple irritation ; in no sense chemic. 
 
 The oxidizers and reducers all tend to produce chemic changes in 
 micro-organisms. They all act rapidly, and are rapidly decomposed by 
 all organic matter. Hydrogen dioxide is perhaps the best known of this 
 class of agents. The rapid effervescence is evidence of its rapid action. 
 The failure to get good germicidal results from this class lies in the dif- 
 ficulty to bring each germ into contact with the agents long enough to be 
 destroyed. This difficulty is increased a hundred-fold when used within 
 the tissues of the body, for the reason that they are equally active towards 
 the organic matter of the tissues. 
 
140 
 
 There is a fact which is often lost sight of in considering this sub- 
 ject which is of vast importance, and that is this : In the appHcation of 
 germicides to suppurations we must consider the tissue in which the 
 suppurative process is going on. Nearly all these old agents act more 
 forcefully against the cells of the tissue than against the micro-organisms 
 therein. 
 
 Many, and indeed, most germicides are so coagulant, or otherwise 
 destructive of the cell tissue, as to make their use in concentrated form 
 dangerous, and, indeed, most of them possess general toxic or other dele- 
 terious properties after absorption which often endanger life. There- 
 fore, in the practical applications of germicides, we must always consider : 
 
 1. Action on the system. 
 
 2. Action on the tissues of the part. 
 
 3. Action on the germs in the part. 
 
 And this brings us to two important points for consideration, namely, 
 ( I ) the stimulating influence that certain agents exert toward the normal 
 cell elements of the part; (2) the antiseptic influence that certain agents 
 exert upon the whole organism, through the medium of the blood stream. 
 
 When suppurative micro-organisms get into the injured tissue of a 
 part, by any means, there occur some interesting things. The injured 
 tissue will soon be seen to be literally filled with reparative cells, cells 
 which are carrying the necessary elements of repair to the injury, and 
 carrying away the useless, discarded elements to be excreted and thrown 
 ofif from the body. Mixed into this veritable beehive will be seen these 
 micro-organisms, and if conditions are favorable they will grow and 
 multiply rapidly. A "battle royal" occurs between these invading ene- 
 mies and the reparative cells ; sometimes one is victorious and sometimes 
 the other, depending upon (i) the condition and nature of the micro- 
 organisms; (2) the condition of the cells of the part; (3) the condition 
 of the general system. There is some interesting detail in this connection, 
 but time forbids further elucidation. It must, however, be clear to 
 everyone, and this is the point I am trying to bring out, that favorable 
 resolution may sometimes be brought about by directing our attention 
 to any or all of these three things ; ( i ) We may destroy or inhibit the 
 growth of the micro-organism direct. (2) We may stimulate the cells 
 of the part to increased activity and they in turn destroy, break down, 
 these enemies. (3) We may act upon the whole organism with refer- 
 ence to stimulated circulation, assimilation and excretion, or increase 
 the blood antisepsis, or any one or all of which, within certain limitation, 
 would be equally potent so far as results are concerned. This explains 
 why we have long been using certain agents which are not, strictly 
 speaking, germicides, with good results. Iodoform, for example. I want 
 
141 
 
 to emphasize, if I may, the need of attention to all three of these things-, 
 if we would be very successful in treating serious suppurations. In every 
 serious infection we should always look to the nature of the micro-organ- 
 ism infecting ; the condition of tissues of the part ; and the condition of the 
 whole system, with reference to nutrition, including excretion and circu- 
 lation, and also the condition of the nervous system, before we determine 
 what agent or agents we shall use. 
 
 The methods employed for determining the germicidal power of 
 agents are many, all of which are imperfect, and whenever you read a 
 statement of the germicidal power of any agent you must know the na- 
 ture of the germs used in the test ; how they were previously grown ; 
 how they were tested ; in what media they were grown before and after, 
 and what was the method of subjecting them to the agent, before you 
 can have any idea of its value. All tests only prove so far as these things 
 are known, and do not prove anything beyond that; because an agent 
 proves germicidal toward a particular germ or mixture of germs, under 
 certain conditions, using any method, only proves so far as that series, 
 but does not prove anything so far as other germs or methods of using 
 are concerned ; therefore all experimental tests are only relatively valu- 
 able, and only useful for comparison, and beyond that prove nothing. 
 
 The literature of the medical and dental professions is full of con- 
 flicting statements regarding the potency of various agents, classed as 
 germicides, the reasons for which are explained by the foregoing state- 
 ment. In most cases I have succeeded in duplicating their experiments 
 when the above conditions have all been stated. In not a few instances I 
 have clearly demonstrated their faulty technique. I have tried almost 
 every published method at some time or other in the last five years, and 
 have concluded that the method suggested by myself in 1899 is open to 
 the least objection, and yields results most nearly uniform, and yet I do 
 not wish to convey the idea that this method will any way accurately tell 
 what will occur when applied to actual practice in treating suppurations 
 in the living tissue ; but when these results are applied to such treatment, 
 and there studied, and modified to meet condition, good results will fol- 
 low. Until the chemistry of the proteid molecule under its various patho- 
 logical changes is more clearly made out this is the best we can do. 
 Pharmacology, the study of the action of remedies when practically ap- 
 plied, must at present be our main reliance. Science and experience must 
 go hand in hand. 
 
 In making experimental tests, it is essential that the agent used be 
 pure and reliable ; that the germs be exposed to it in equal numbers under 
 the same conditions ; that they be at their maximum height of virulency, 
 should be pure cultures, and that they be cultivated in media and tern- 
 
142 
 
 perature most favorable to their growth. In the experiments from 
 which the following tables were made up the following method was used ; 
 Organisms were grown in bouillon made from lean beef (not beef extract) 
 in the usual manner, and neutralized with sodium hydrate (not sodium 
 bicarbonate). In series D and E it was made slightly alkaline. The 
 germs were grown and distributed throughout the media in equal num- 
 bers, as shown by microscopic examination. The germs were transferred 
 in loopfuls to small squares (a centimeter) of filter paper, which was 
 previously sterilized and kept in a petri dish ; there they were allowed to 
 dry; then on to this was carried by means of the loop sufficient of the 
 medicament to completely cover the filter paper, and left for various 
 lengths of time, when each square was washed, so as to remove the 
 medicament, and planted in fresh tubes of culture media, and placed in 
 an incubator, at 37° Centigrade. Readings were taken from time to time 
 for a week. The germicidal power of the medicaments is here determined 
 by the time necessary to expose germs to it, and, as you will see, a great 
 difference appears. You will notice that some agents were used in full 
 strength and others in per cent solutions, according as they could be used 
 in practice. 
 
 In all of these series of experiments I began by exposing the germ 
 to the medicament five minutes, and worked each way from that point, 
 according as growth appeared or not. When doubt existed, inoculations 
 were made in fresh media and in animals — guinea pigs and young rabbits 
 mostly. 
 
 In these tables only fiinal results are given. They are made up after 
 many repetitions. 
 
 $erlc$ D. 
 
 Germ used, staphylococcus pyogenes aureus. Grown and plated out 
 from abscess pus. 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Oil cassia Full strength 55 
 
 Oil cinnamon Full strength 55 
 
 Oil cloves Full strength 55 
 
 Oil cajeput Full strength 50 
 
 Oil eucalyptus Full strength 60 
 
 Oil wintergreen Full strength 60 
 
 Oil peppermint Full strength 55 
 
 Oil cade . ..Full strength 50 
 
 Oil birch tar Full strength 30 
 
 Oil pennyroyal Full strength 42 
 
143 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Carbolic acid 95 per cent 30 
 
 Creosote, B. W Full strength 40 
 
 Campho-phenique Full strength 40 
 
 Guaiacol Full strength 40 
 
 Thymol Alkaline, Saturate solution 30 
 
 Thiocol Alcoholic, Saturate solution 30 
 
 Aspirin Alcoholic, 9 per cent solution 22 
 
 Bichloride mercury 1-1,000 20 
 
 Phecene Sat. solution 12 
 
 Creolin Full strength 3 • 
 
 Trikresol Full strength 5 
 
 Sublamine i in 250 c 
 
 Xresamin Full strength 5 
 
 Phenol sulphonic Full strength 5 
 
 Pormalin Full strength 3 
 
 Chinosol 10 per cent solution i 
 
 Series €. 
 
 Germ, streptococcus pyogenes in virulent form from periosteal 
 abscess. 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Oil cassia Full strength 60 
 
 •Oil cinnamon Full strength 60 
 
 Oil cloves Full strength 60 
 
 Oil cajeput Full strength 55 
 
 Oil eucalyptus Full strength 60 
 
 Oil wintergreen Full strength 60 
 
 Oil peppermint Full strength 55 
 
 Oil cade Full strength 40 
 
 Oil birch tar Full strength 30 
 
 Oil pennyroyal Full strength 35 
 
 Carbolic acid 95 per cent 30 
 
 Creosote, B. W Full strength 40 
 
 Campho-phenique Full strength 60 
 
 Thymol Alkaline, Saturate solution 40 
 
 Thiocol Alcoholic, Saturate solution. 32 
 
 Aspirin "'. Alcohol, 9 per cent solution 22 
 
 Mercury bichloride i in 1,000 15 
 
 Phecene Sat. solution 10 
 
144 
 
 Per Cent Time Required, 
 
 Agent. Solution. ^Alinutes. 
 
 Creolin Full strength 5 
 
 Trikresol Full strength 5 
 
 Sublamine i in 250 . 5 
 
 Kresamin Full strength 5 
 
 Formalin Full strength 3 
 
 Chinosol 10 per cent i 
 
 Scries T. 
 
 Germ, Proteus bacillus. 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Oil cassia Full strength. 55 
 
 Oil cinnamon Full strength 40 
 
 Oil cloves Full strength 45 
 
 Oil cajeput .Full strength 50 
 
 Oil eucalyptus .Full strength 50 
 
 Oil wintergreen Full strength 55 
 
 Oil peppermint Full strength 50 
 
 Oil cade Full strength 40 
 
 Oil birch tar Full strength 30 
 
 CarboHc acid 95 per cent 20 
 
 Creosote Full strength „ 15 ■ 
 
 Thymol Liquor, potass., Sat. solution 20 
 
 Thiocol Alcoholic, Sat. solution 10 
 
 Aspirin Alcoholic, 9 per cent solution 18 
 
 Naphtha eucalyptus Alcoholic, Sat. solution 10 
 
 Chinosol 10 per cent solution i 
 
 Mercury bichloride 1-1,000 22 
 
 Phecene Sat. solution 10 
 
 Creolin Full strength 8 
 
 Trikresol Full strength 5 
 
 Formalin Full strength i 
 
 Tribromo phenol Alcoholic, Sat. solution 8 
 
 Trichlorphenol Alcoholic, Sat. solution 8 
 
 Sit'm 6. 
 
 Germ used, mixed pus culture. 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Oil cassia Full strength 40 
 
 Oil cinnamon Full strength 40 
 
 Oil cloves Full strength 40 
 
145 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Oil cajeput Full strength 45 
 
 Oil eucalyptus Full strength 40 
 
 Oil wintergreen Full strength 60 
 
 Oil peppermint Full strength 50 
 
 Oil cade Full strength 25 
 
 Oil birch tar Full strength 20 
 
 Oil pennyroyal Full strength 45 
 
 Carbolic acid Full strength 30 
 
 Creosote, B. W Full strength 30 
 
 Campho-phenique Full strength 40 
 
 Mercury bichloride 1-1,000 25 
 
 Creolin Full strength 5 
 
 Trikresol Full strength 5 
 
 Sublamine i in 250 3 
 
 Kresamin Full strength 5 
 
 Formalin Full strength ,2 
 
 Chinosol 10 per cent i 
 
 Phenol sulphonic Full strength 5 
 
 Tribromo phenol Alcoholic, Sat. solution 10 
 
 Trichlorphenol Alcoholic, Sat. solution 8 
 
 Series 1). 
 
 Bacillus pyoscyaneus. Isolated from pus. 
 
 Per Cent Time Required, 
 
 Agent. . Solution. Minutes. 
 
 Oil cassia Full strength 38 
 
 Oil wintergreen Full strength 45 
 
 Oil cinnamon Full strength 40 
 
 Oil cloves Full strength 40 
 
 Oil cajeput Full strength 45 
 
 Oil eucalyptus Full strength 40 
 
 Oil wintergreen Full strength 40 
 
 Oil peppermint Full strength 40 
 
 Oil pennyroyal Full strength 40 
 
 Carbolic acid 95 per cent full strength 10 
 
 Creosote, B. W Full strength 20 
 
 Oil sassafras Full strength 40 
 
 Creolin Full strength 5 
 
 Trikresol Full strength 2 
 
 Formalin Full strength i 
 
146 
 
 Per Cent Time Required, 
 
 Agent. Solution. Minutes. 
 
 Sublamine i in 250 2 
 
 Bicliloride of mercury i in 1,000 5 
 
 Kresamin . . . ". Full strength 3 
 
 Phenol sulphonic Full strength 2 
 
 Chinosol 10 per cent strength i 
 
 Campho-phenique Full strength 10 
 
 Eugenol P\ill strength 30 
 
 Permanganate of potash . 10 per cent strength 30 
 
 
 
 
 Scries T. 
 
 Germ, 
 
 bacillus 
 
 prodi 
 
 igiosus. 
 
 Per Cent. 
 
 Agent. 
 
 
 
 Solution. ' 
 
 Time Required, 
 Minutes. 
 
 Oil cassia Full strength 35 
 
 Oil cinnamon Full strength 35 
 
 Oil cloves Full strength 35 
 
 Eugenol Full strength 32 
 
 Oil cajeput Full strength 40 
 
 Oil eucalyptus Full strength 40 
 
 Oil wintergreen Full strength 40 
 
 Oil peppermint Full strength 30 
 
 Oil pennyroyal Full strength 35 
 
 Carbolic acid Full strength 15 
 
 Creosote Full strength 18 
 
 Trikresol Full strength •. . 2 
 
 Kresamin Full strength 2 
 
 Bichloride of mercury 1-1,000 5 
 
 Sublamine 1-500 2 
 
 Permanganate of potash. . . 10 per cent 25 
 
 Phenol sulphonic Full strength 5 
 
 Chinosol 10 per cent i 
 
 These tables only show the time required to completely destroy all 
 life. Nearly all agents showed marked restraint in less time. ]\Iany of 
 the germs exposed to the essential oils fifteen, and, indeed, thirty minutes, 
 grew as quickly and as luxuriantly as the controller. 
 
 You will note the excellent showing made by the following agents : 
 Formalin, sublamine, phenol sulphonic acid, trikresol, creolin, kresamin, 
 phecene, chinosol. 
 
 The application of germicides as such to treatment of oral diseases 
 is quite limited. It is only in violent, acute, chronic, necrotic suppurations ; 
 
147 
 
 in syphilitic ulcers, eczema, etc., and in each case the selection of the 
 particular agent will be determined by the conditions present. They are 
 also of value as hand and instrument disinfectors. 
 
 Formalin is a colorless liquid, resembling water in appearance, and 
 is a 40 per cent solution of formaldehyde gas. It is probably the most 
 potent germicide that can be used. Its dental uses are limited!, because 
 of its extreme irritating property. I have used it in old chronic abscesses, 
 but in nearly every instance severe pain and swelling resulted, which has 
 caused me to abandon it except in weak dilutions in such agents as 
 creosote. 
 
 Paraform, a new solid polymer, has recently been recommended. 
 There is a class of cases where it is of value, if used with care. I refer 
 to old blind abscesses on the roots of teeth, containing small tortuous 
 canals. This agent readily gives up formaldehyde gas, which is very 
 penetrating. It should only be placed in the large entrance to the pulp 
 chamber, and not down in the root canals, and even then it stirs up some 
 irritation. In coming to this conclusion, I have lost some teeth from its 
 use, but if you are careful and use it as stated you will find it of excel- 
 lent value. Recentl}^ some practitioners have recommended it as a com- 
 ponent part of root fillings. I am somewhat skeptical of the result. In 
 old chronic cases, where there is little or no discharge of pus, but instead 
 a thin ichorous fluid comes weeping down into the canal, cases that are 
 not causing any great amount of pain, but sore and constantly annoying, 
 in all such cases I get good results from this drug. It always increases 
 the soreness and inflammation, which soon terminates in resolution. 
 Perhaps the most valuable use we can make of this agent is as a disin- 
 fectant for foul rooms, for operating rooms, where serious surgical cases 
 are attended to ; for instruments, especially those used on syphilitic 
 cases. 
 
 Paraform has recently been put upon the market in tablet form, 
 especially designed for use in Schering's sterilizer. It is both efifective 
 and convenient. 
 
 Bichloride of mercury as a germicide was first brought to the atten- 
 tion of the medical profession by Koch, since which time its use has 
 become almost universal. It is a potent germicide toward all germs that 
 have a very permeable cell wall. It is very corrosive, producing insoluble 
 coagulum, and therefore limiting its power. Its most serious objections 
 are its irritant and toxic properties. In dental practice its use has been 
 quite generally abandoned, except as a hand disinfectant, and on gauze 
 for packing suppurating antrum ; also in syphilitic cases. 
 
 Sublamine. Ethylenediamine sulphate of mercury. A new agent, 
 recommended as a substitute for bichloride of mercury. 
 
148 
 
 Ethylenediamine is an organic base, with a chemical formula of 
 C H, — N Ho 
 
 I 
 C H2 — N Ho 
 
 It is a clear, colorless liquid of alkaline reaction, and gives off the 
 odor of ammonia. This substance is used in connection with several 
 coagulant germicides, for the purpose of reducing their irritant property 
 and increasing their penetrative power. Sublamine comes to us in solid 
 form, and is freely soluble in water. I have been using it in the strength 
 of I in 500, and find it but very slightly irritating. It is a non-coagulant, 
 and will penetrate much more deeply than bichloride. In all the tests 
 it has proven much more efficacious than bichloride, and certainly is 
 much more agreeable to use. I can most heartily recommend it for ster- 
 ilizing hands, washing indolent ulcers, flushing the antrum, for washing 
 through chronic abscesses, sterilizing the skin before operations. For all 
 these purposes I have been using it in my private practice, as well as in 
 the public infirmary. It is a chemical germicide, carrying pus into 
 solution. 
 
 Phenol sulphonic acid is a light reddish-colored liquid, made by conv 
 bining equal parts of sulphuric and carbolic acid. It is not so coagulant 
 or irritating as either of the substances from which it is made. It can be 
 used in full strength for burning through old chronic abscesses, and is 
 especially recommended where cases are of long-standing, with more or 
 less of bone absorption around the apex of the root. It is valuable to 
 enlarge root canals, and to burn out the socket after a badly abscessed 
 tooth is removed. Of course, it must always be used with caution. A 50 
 per cent solution is especially recommended to aid in the exfoliation of 
 necrosed bone ; it will also disintegrate and dissolve small pieces of tooth 
 and necrosed bone that may be left after burring or curetting about the 
 jaws. I use it on gauze for the first packing after such operations, espe- 
 cially in the antrum. Weaker solutions may be used to wash out after 
 surgical operations on the jaws. I have come to look upon it as one of 
 my most valuable agents. 
 
 Trikresol ; another product from Schering's chemical laboratory. Its 
 composition is as follows : Ortho-cresol, 35 per cent; metacresol, 40 per 
 cent, and para-cresol, 40 per cent. It is a clear liquid pungent odor, 
 resembling phenol ; turns slightly red on exposure to strong sunlight. Is 
 soluble in 2 per cent water, but freely in alcohol and oils. It is a splen- 
 did germicide, as shown by these experiments, and an agreeable prepara- 
 tion to use. I have been using it about four yeais, and now find I am 
 using it in almost every condition where I formerly used carbolic acid or 
 creosote. It is not so escharotic as carbolic acid ; will penetrate much 
 
149 
 
 deeper into vegetable cells, and will destroy spores. Two per cent solu- 
 tion is antiseptic. I recommend it to burn out old abscesses; as a dress- 
 ing in root canals in acute apical pericementitis ; in putrescent pulp ; to 
 relieve odontalgia, applied warm or almost hot. It penetrates the den- 
 tine as readily as the essential oils, but does not discolor it. A little (not 
 an excess) is useful as a dressing after pulps are extirpated, before filling 
 root canals. To keep scalers and such instruments sterile while using, I 
 keep them in a ten per cent solution in alcohol and water. It is an excel- 
 lent agent, used full strength, as a first treatment in pus pockets about the 
 roots of teeth. 
 
 Kresamin is the <name given to a combination of ethylenediamine and 
 trikresol, containing equal parts of each. It is a reddish-colored, phenol- 
 like liquid; has an agreeable odor, and is very slightly irritant. It is 
 practically non-caustic, and but feebly coagulant. It is powerfully germi- 
 cidal, equal to i in 500 bichloride of mercury. I have been using it 
 lately in the clinic, with most flattering results. I am satisfied if used in 
 acute or recent chronic abscesses it will be of value. I wash through 
 such abscesses freely with it. I have passed some around among a few 
 of my dental friends, and they are all delighted with the results they are 
 getting with it. It is freely soluble, and may be used as an antiseptic in 
 dilute solutions. It is a chemical disinfectant. When brought in contact 
 with thick pus, kresamin seems to immediately dissolve it, and turn it a 
 dark brown color. In apical pericementitis from any cause, it seems to be 
 of great value ; also applied to inflamed pulps it has an immediate quieting 
 influence. In all inflammations accompanied with pus form.ation I am 
 sure of its efBcacy. 
 
 Chinosol has a chemical formula of CgHgNo KSO^, and is prepared 
 by the action of sulphate of potassium on chinoline, a basic coal tar de- 
 rivative. It occurs in the form of a crystalline yellow powder, possessing a 
 very slight odor, and pungent coal tar taste. It is freely soluble in water, 
 but insoluble in ether or alcohol. It is a chemical germicide. When 
 brought in contact with pus in the slightly alkaline fluid of the tissues, 
 it is readily broken up into oxychlorine, and it is this that is so power- 
 fully germicidal. So far as my knowledge goes, it is the most potent 
 germicide, so far as pus germs are concerned, of any agent at our com- 
 mand. I began using and recommending it for the eradication of pus in 
 1893, since which time it is my main standby. It has two slight objec- 
 tions, namely, it corrodes steel instruments (not others), and has a slight 
 tendency to darken teeth ; such discoloration is very readily removed with 
 any oxygen bleacher. Being almost devoid of odor, it is not a very good 
 deodorant for foul-smelling dentine, but as a pus-destroyer it certainly 
 has no equal. 
 
150 
 
 It is practically non-irritating; is wholly non-coagulant and non- 
 caustic. I use it in 2 per cent solution for washing out bad pus pockets, 
 abscesses in antrum, and alveolus. I use a ten per cent solution in 
 chronic, foul, violent abscesses, and all other violent suppurations. It is 
 used only for the purpose of getting rid of pus. When you need to 
 burn out necrotic tissue, it is not recommended. It is wholly non-toxic, 
 and can be used ad Uhitiun in these solutions. Injected into a forming 
 abscess, boil or carbuncle, it will immediately get rid of the pus. In any 
 case of violent pus infection, where there is danger of serious results, this 
 is the most efficient agent ; especially in streptococcus infection, which is 
 active, you can use no better drug. Chinosol gauze, absorbent cotton, and 
 soap may be had in the market. If you have an abscessed antrum, where 
 pus is rapidly being formed, try chinosol irrigation, and chinosol gauze, 
 pack to control it, and you will be delighted. 
 
 I have shown you these cultures and tests, and called your special 
 attention to these agents, not because they are the only good ones, but 
 rather because I have had the most practical experience with them. I have 
 used all of them on many hundred cases in th'e infirmary, and have the 
 written history of treatments to corroborate all I have said. Some of 
 you I know have tried some or all of these agents ; others have not tried 
 any. I simply want to make a plea for their value over the remedies you 
 are using. Won't you try them? 
 
CHAPTER XIV. 
 
 matiddement of Discolcrea teetb* 
 
 General Considerations. Causes of Tooth Discoloration. Methods of Tooth 
 
 Bleaching. Agents. The Direct Oxygen Alethod. Method of Using. 
 
 Ethereal Solution. Sodium Dioxide. Chlorin Method. 
 
 General Considerations. 
 
 There is no subject in the whole range of dental science that needs 
 to be more thoroughly understood than the management of discolored 
 teeth. The operator must always keep in mind the possibility of pulpless 
 teeth becoming discolored and particularly is it important to avoid such 
 results in the anterior part of the mouth. We should not use rusty 
 instruments or medicines that tend to discolor the dentine and in a 
 general way keep our cases clean and free from outside contamination. 
 
 The tendency of all pulpless teeth is to change their normal color. 
 Not all pulpless teeth discolor perceptibly, but they all lose their normal 
 translucency. In many teeth this change is not sufficient to attract atten- 
 tion, but upon very close examination it will be seen. It must not be taken 
 as a positive proof that a tooth has lost its pulp when it is a slightly dif- 
 ferent shade in color from its neighbor ; indeed, teeth of different denomi- 
 nations in the same mouth differ in this respect. 
 
 The cuspid teeth are ahvays darker than the incisors or bicuspids, and 
 in not a few instances one central Avill differ from the other a shade or 
 more. I have had a few cases where discoloration was marked, and yet 
 upon opening the chambers the pulps were found vital and healthy. I 
 think it is an established fact that under certain inflammatory influences 
 pigmentation of the dentine may result, and yet the pulp return to health, 
 although the instances are rare. 
 
 Causes of tootb Discoloratiom 
 
 For convenience of study I like to group the causes of tooth discolora- 
 tion under three heads. 
 
 First. Discoloration following the death of the pulp where there is no 
 pulp exposure. 
 
 Second. Discolorations following death of pulp and subsequent 
 exposure of the chamber to the secretions of the mouth. 
 
 Third. Special discolorations from the staining influences of 
 medicines, amalgam fillings, etc. 
 
 In the first class the source of pigmentation is in the decomposition of 
 the pulp tissue, and such other secretions as may enter the canals from 
 
1=^2 
 
 the blood stream and surrounding tissues entering through the foramen. 
 In the simplest form it is the direct result of severe inflammations of the 
 pulp, which result in the destruction of that organ. These inflammations 
 may be the result of irritation of fillings, arsenic, traumatic injuries of all 
 sorts, in which the vascular supply is the prominent factor. 
 
 The various changes produced in the pulp by such forms of irritation 
 have been fully explained in Chapter X, and all I wish to do here is to offer 
 such explanations as are at hand as to the process by which such resulting 
 discolorations are produced. 
 
 In such cases the discoloration is directly due to the breaking down of 
 the corpuscular elements of the blood in which the hemoglobin is set free 
 from the red corpuscles, and passes into solutions which readily infiltrate 
 the tubuli of the dentin, giving the tooth a decidedly pinkish hue. Every 
 operator can call to mind many such cases, following arsenical application, 
 where the pink cast can readily be seen, especially when the eye is aided by 
 transillumination. Teeth so discolored readily change unless the operator 
 interferes, from pink to yellow, which gradually grows darker until brown 
 and finally become a grayish black. 
 
 The violence of the pulpitis seems to have something to do with the 
 degree and rapidity of the discoloration and hence, from this sta>"idpoint, 
 it is inadvisable to apply arsenic to an already inflamed pulp. Kirk 
 says : "In passing through its cycle of color changes hemoglobin under- 
 goes several alterations in composition, during which a number of definite 
 compounds are formed, each having marked chromogenic features. Of 
 these composition products methemoglobin (brownish red), hemin 
 (bluish black), hematin (dark brown or bluish black), and hematodin 
 (orange), are best known." 
 
 It is doubtless true that this accounts for those discolorations resulting 
 from inflammation and death of the pulp before putrefactive decompo- 
 sition sets in, but, when that process has begun, there are other elements 
 to consider and, before we can understand them, it is necessary to take into 
 consideration the chemistry involved. The chemistry of the proteid mole- 
 cules of all albuminous material, including pulp tissue, is not very well 
 understood, but enough is known to furnish a rational explanation for 
 tooth discoloration resulting from the decomposition of the pulp tissue. 
 The important elements in the composition of the proteid substance of the 
 pulp tissue are carbon, oxygen, hydrogen, nitrogen, phosphorus and sul- 
 phur; in the putrefactive decomposition of this tissue certain chemical 
 compounds are formed, among which are carbon dioxid, ammonia, hydro- 
 gen sulphid, and water, none of which in themselves cause the discolora- 
 tion, but when hydrogen sulphide is brought in contact with hemoglobin 
 in solution in the presence of oxygen sulfo-methemoglobin is formed, 
 
153 
 
 resulting in a certain amount of ferrous sulphide and other iron salts 
 being formed, and it is these that furnish the green, brown, and black 
 colors when forced into the tubuli — at least they play a very important 
 part in tooth discoloration. In the second group of cases there are added 
 factors both in the causation and modifying influences upon the resulting 
 discoloration which must be considered. 
 
 When a pulp dies from exposure and putrefactive decomposition occurs 
 in the presence of such oral secretions as may enter through such exposure, 
 the process is modified greatly, and the character of the discoloration like- 
 wise changed. 
 
 The breaking down of the tissue, the changes in the vascular elements 
 and subsequent putrefaction, are more rapid in these cases, and a ready 
 way of escape for forming gases and salts makes deep discoloration less 
 liable, and then the oral secretions may bring some substances that will 
 enter the tubuli and thus modify the character of the color and make suc- 
 cessful bleaching difficult. In the third group of cases are included those 
 discolorations resulting from metallic and medicine stains, and are among 
 the most difficult to handle. 
 
 Metallic salts are very apt to stain the tooth substance by their chemi- 
 cal reaction with the hydrogen sulphid with which dentine is saturated in 
 putrefactive cases. Iron from rusty instruments, particularly when 
 brought in contact with iodine and copper, producing those greenish stains, 
 which after a tim.e become black, that we often see from the use of copper 
 alloy fillings, posts, dowels, screws, etc. These stains are difficult to 
 remove. 
 
 Silver and mercury stains are usually black and are the direct result 
 of certain combinations of metals in dental alloys, in which the silver and 
 mercury are so acted upon by the secretions of the mouth, that slight 
 amount of salts are formed which, in time, stain the dentine. The nitrate 
 of silver, sometimes used as an obtundant, always stains the dentin black. 
 These are easily removed. 
 
 methods of tc^otb Bkacbind. 
 
 The process of tooth bleaching is a chemical problem in which there 
 must be a reaction between the agents used and the staining or discoloring 
 substance. 
 
 The chemical reaction must result in the formation of such new com- 
 pounds with the coloring substance as are either freely soluble and can 
 be washed out, or colorless compounds which are stable and not liable to 
 change back to their original state or into some other coloring substance. 
 
 If the chemistry of the coloring substance could always be understood 
 it would be a comparatively easy matter to find a substance that would 
 combine with it in such a way as to bring about the desired result, but at 
 
154 
 
 the present time we find many teeth discolored by some agent the nature 
 of which we do not know, and, therefore, some cases do not yield to any 
 bleaching method at our command. 
 
 Agents, 
 
 There are two general groups of agents used at the present time for 
 tooth bleaching. 
 
 First. Oxydizing agents, substances which give ofif oxygen in a 
 nascent condition. 
 
 Second. Reducing agents, substances which have a strong affinity 
 for oxygen. 
 
 In the first group, there are two distinct classes, namely: Direct 
 oxydizers, such as hydrogen, dioxid and sodium dioxide, and indirect 
 oxydizers, such as chlorin^ bromin. 
 
 In the group of reducing agents only one substance has been used 
 to any extent, and that is sulphurous oxid. 
 
 In the use olall bleaching agents there are certain things which are 
 fundamental, and success with any of them will depend on how thoroughly 
 the detail is carried out. 
 
 First. All metallic fillings in the tooth to be bleached must be removed. 
 
 Second. The rubber dam must be securely applied to the discolored 
 tooth only. 
 
 Third. The apical third of the root must be filled with gutta-percha. 
 
 Fourth. The pulp chamber must be completely opened, and as much 
 dentin as can easily be removed without endangering the integrity of the 
 tooth should be cut away. The chamber should be enlarged to include the 
 thin points where the horns of the pulp were. 
 
 Fifth. The shape of the cavity in the teeth must be such as to permit 
 of rapid closing so as to prevent the escape of the gases as much as possible. 
 If it is not so naturally, then it must be made so by using gutta-percha. 
 
 Sixth. No metal instruments should be used in the work with agents 
 that will readily corrode them, and thus produce a new staining substance. 
 
 Seventh. The bleaching process should be continued until the dis- 
 colored tooth is a shade or two lighter than its neighbors, for the tendency 
 of all cases is to go back a little. 
 
 Eighth. When the bleaching process is finished the chambers must be 
 lined by some white substance upon which permanent filling can be built. 
 
 Ninth. Teeth that are checked badly or whose dentine is exposed to 
 the fluids of the mouth are very liable to discolor again. 
 
 Tenth. Teeth that 'have been bleached should be temporarily filled for 
 three months in order to a;scertam rf the result is permanent before the 
 trouble and expense of permanent operations are undertaken. 
 
155 
 tbe Direct Oxygen method. 
 
 In bleaching discolored teeth with hydrogen dioxid, two solutions are 
 used, namely, a 25 per cent aqueous, and a 25 per cent ethereal solution. 
 
 The methods are slightly different; the ordinary hydrogen dioxid 
 obtainable in the market is a 3 per cent aqueous solution, which is not 
 strong enough for our purpose as a bleacher. 
 
 Its strength can be increased by slowly and carefully evaporating 
 
 some of the water ; this is best accomplished as follows : Select a small 
 
 porcelain evaporating dish which must be smooth and free from flaws ; 
 
 into this pour two ounces of hydrogen dioxid, then float it on a water bath, 
 
 cover with loose paper to protect from dust, and slowly heat until the two 
 
 ounces are reduced to one-quarter of an ounce, which usually takes about 
 
 45 minutes ; this will give about a 25 per cent solution, which is the most 
 
 desirable strength, and will keep in' a colored bottle loosely corked for 
 
 several davs. 
 
 method of Using. 
 
 When the chamber and cavity are ready to receive this bleaching agent 
 it is applied on a loose roll of cotton into the chamber, and also the outside 
 of the crown is moistened, then a draught of warm air is directed on the' 
 tooth, w^hich will assist in the free liberation of oxygen. The agent is 
 renewed every five minutes or so for about four applications, between each 
 of which I dry the tooth with warm air. In the majority of cases half an 
 hour will be all the time that is required for the bleaching of recently dis- 
 colored cases, particularly teeth of a pinkish hue. 
 
 When the bleaching is completed the dentin should be thoroughly 
 washed with warm distilled water. A convenient little rubber bag for 
 catching the water used in flushing can be made of rubber dam with the 
 aid of rubber cement. This bag or pocket can be so shaped as to admit 
 of passing up on the lingual of the teeth, and held by the dam holder and 
 the overflow carried away with the saliva ejector. It is sometimes neces- 
 sary to repeat the bleaching operation once or twice a few days apart. 
 
 In my hands this has proven a very successful method. 
 
 etbmal Solution. 
 
 In bleaching with the 25 per cent ethereal solution of hydrogen dioxid 
 the procedure is exactly the same, with this additian, that in very stubborn 
 cases it may-be sealed in the chamber for 24 hours. 
 
 The best results seem to be attained from this solution when it is 
 rendered slightly al4<aline by the addition of a little sodium dioxid. 
 
 ^/ - Sodium Dioxid naa O2* 
 
 Sodium di&xid is another compound that readily parts with. its extra 
 atom of oxygen, and only differs in its bleaching effect from hydrogen 
 dioxid by the action of its by-product. • • ', 
 
156 
 
 When sodium gives up its atom of oxygen it becomes sodium hydroxid 
 NagO, which has decided saponifying action upon all vegetable and animal 
 oils and fats, and a solvent action on animal tissue. 
 
 I have called attention to its value as a pulp canal cleanser after 
 devitalization. 
 
 The tendency of this agent then, is not only to chemically change the 
 coloring matter in the dentin of discolored teeth, but also to saponify and 
 dissolve the contents of the tubuli. 
 
 Theoretically at least this is the ideal bleaching agent, because it 
 removes more thoroughly than either agent the contents of the tubuli and 
 consequently the normal tooth translucency is restored instead of the 
 opaque whiteness which often follows other methods. For bleaching pur- 
 poses it is used in two different ways, and each has its advocates. 
 
 It is mostly used in the form of a saturate solution in distilled water. 
 This solution must be carefully made, as the tendency is on combining 
 with water to lose its extra oxygen by the heat generated in the 
 combination. 
 
 The solution is easily made by placing a small graduate glass con- 
 taining half an ounce of distilled water in a large pan of broken ice ; into 
 this a tiny bit of fine powder is taken on a wooden spatula and gently 
 sliaken into the glass ; this should be repeated every fifteen minutes until 
 the solution assumes a milky appearance throughout, indicating that a 
 saturate solution has been obtained. In a few minutes the cloudiness will 
 disappear, when the solution is ready for use. The method of using this 
 solution is exactly the same as already described for hydrogen dioxid 
 except that instead of cotton, asbestos wool should be used as a means of 
 applying. The solution should be allowed to remain for about five 
 minutes, when the dentin should again be washed and thoroughly dried, 
 then another application and so on for three or four times, and while the 
 dentin is thus saturated. 
 
 A 10 per cent solution of sulphuric acid is applied to neutralize the 
 alkali and liberate hydrogen dioxid, which aids in still further bleaching 
 When the desired point has been reached the dentin should be thoroughly 
 washed with warm distilled water the same as when the former method 
 has been used. 
 
 Another method of using sodium dioxid has recently been suggested. 
 It consists of placing the sodium dioxid powder into the chamber, and to 
 this adding distilled water, then wash, dry and repeat, finally flooding the 
 chamber with 10 per cent sulphuric acid and washing the dentin as above 
 described. 
 
157 
 
 Cblorin method. 
 
 The chlorin method has been used longer than any other. 
 
 It consists in hberating chlorin gas in the pulp chamber which in turn 
 unites with the hydrogen of the coloring substance and thus destroying its 
 color. The agent is obtained by decomposing calcium hypochlorite (chlor- 
 inated lime), in the pulp chamber by the action of dilute acetic acid. 
 Another method of using chlorin is to pack the chamber with chlorin of 
 aluminum and decomposing the same with hydrogen dioxid, in which case 
 both chlorin and oxygen are given off — and it is probable that the oxygen 
 is the bleacher. In the chlorin method no metallic instruments of any 
 kind should be used, even gold is readily acted upon by chlorin and a 
 yellow insoluble stain results. 
 
 When the bleaching powder is placed in the chamber, and the other 
 agent applied, the opening should be instantly closed with gutta-percha 
 in order to prevent the ready escape of the chlorin, and in very bad cases 
 the seal may be left 24 hours and then repeated if necessary. Many other 
 agents and methods have been tried. At one time some operators were 
 very enthusiastic over the cataphoric method, but none of these at all 
 approached the direct oxygen method, and especially do I regard the 
 sodium dioxid as the nearly ideal. 
 
 When the discoloration is due to metallic stains it is best to use direct 
 chlorin method and follow with an ammoniacal solution of hydrogen 
 dioxid. In a general way, it should be said that where one method fails, 
 others should be tried, and even by so doing a few teeth will present where 
 little can be accomplished in the way of bleaching. 
 
 The best lining for pulp chamber is paraffin where that can be used; 
 it gives the natural translucent effect, which nothing else does. I make 
 a solution in petroleum ether, and coat the wall toward the labial, when 
 conditions will permit, and then fill the canal and chamber with white oxy- 
 chloride of zinc, which has the tendency to continue the bleaching process. 
 Before concluding this chapter let us repeat a few important points. 
 
 Gutta-percha must be the root filling for bleaching cases. The gum 
 must be carefully protected else wide destruction will be the result ; cover 
 exposed tubuli if you expect permanent results. It is possible to carry the 
 bleaching process so far as to destroy the integrity of tooth substance. 
 
CHAPTER XV. 
 
 Diseases #f the Periaental membrane f)w\m tbeir Beginniitg 
 
 at the 6ittdivus. 
 
 Calcic Inflammation. Salivary Calculus. Treatment. Removal of ^Salivary Cal- 
 culus. Scalers. Removal of Stains from the Teeth. Serumal Calculus. 
 Phagedenic Pericementitis. Etiology of Phagedenic Pericementitis. 
 Treatment of Serumal Calcic Inflammation and Phagedenic 
 Pericementitis Diagnosis. Treatment. Instruments. 
 Prognosis. Management of Loose Teeth. 
 
 In Chapter XII, we studied those diseases of the peridental mem- 
 brane affecting its apical portion, and also reviewed its histology, to 
 which the reader is asked to refer before beginning a study of this chapter, 
 for the reason that the subject matter presented liere can best be under- 
 stood with the histology fresh in mind. The reader is asked especially to 
 note the arrangement of the fibers at the gingivus. 
 
 The peridental membrane is subject to a great variety of diseases, 
 many of which are little understood. Some of these diseases have their 
 origin in the membrane, and others in the immediate surrounding parts. 
 These diseases seem to become more and more prevalent with advancing 
 civilization ; and yet we have convincing evidence that the prehistoric 
 races suffered from some of these diseases to a degree. 
 
 The prevalence of these diseases is partly accounted for by the fact 
 that human teeth were designed to chew coarse foods, and as our habits 
 have changed in this regard, so the teeth, gums and jaws have deterior- 
 ated. Organs that are not used atrophy. Then again, the excursion of 
 coarse, tough foods over the teeth and gums tends to clear them of ac- 
 cumulating mucous and debris, and thus help in the preservation of the 
 health of these organs. Perhaps the outdoor life of our ancestors, with 
 its consequent robust health, had something to do with the health of the 
 organs of mastication. Be that as it may, the facts are that more teeth 
 are lost from these diseases than all other causes combined. 
 
 For many years these diseases, in a general way, were known to exist, 
 and spoken of as one disease. Dr. J. M. Riggs, of Hartford, Conn., was 
 one of the first to call the attention of the profession to this trouble, and 
 outlined a kind of treatment in 1875, hence the term Riggs disease was 
 given to it ; other names that were applied to it were spongy gums, scurvy 
 of the gums, diseased gums, inflammation of the gums, gingivitis, and 
 latterly, pyorrhea alveolaris. 
 
159 
 
 This latter term has been quite generally accepted by the profession 
 as the most expressive of the conditions ; it signifies a copious discharge 
 of pus from the alveolus, which is very often present in these cases, but not 
 always. If the term could be restricted to those cases which it describes 
 I can see no objection to it. 
 
 About the year 1887 Dr. G. V. Black presented a classification of 
 these diseases that seemed to more nearly describe conditions found, and 
 yet there are cases that do not come within this classification. Dr. Black 
 divides these diseases into three classes : Simple Gingivitis, Calcic Inflam- 
 mation and Phagedenic Pericementitis. 
 
 Simple Gingivitis : By the term simple gingivitis is meant those in- 
 flammations of the gum which are not the result of calculus irritation. 
 The simplest form of gingivitis we meet with is seen in young people, and 
 occasionally where the teeth are clean. The gums become red and swol- 
 len, and bleed upon the slightest touch ; the margin may be slightly thick- 
 ened and everted, although the inflammation is not usually of a destruc- 
 tive nature. It is usually transcient, caused by some. slight constitutional 
 disturbance, and readily subsides when the teeth are kept clean. 
 
 A solution of resorcin used around the free margin of the gum, a fresh 
 fruit diet recommended, supplemented by a slightly astringent and anti- 
 septic mouth-wash, is usually all that is needed. 
 
 In others this inflammation may extend so as to include the entire 
 gum septum and alveolar border. In these cases the gum is usually of a 
 purple hue, and swollen sometimes so as to completely cover one or more 
 crown surfaces of a tooth, or several teeth. Gums in this condition are 
 more or less painful, and always bleed on the slightest touch. Fig. 45. 
 
 Fig. 45. 
 
 Showing hypertrophy of gum gingivus. (Burchard.) 
 
 Treatment consists of cleaning the toothneck and scraping the alve- 
 olar border where exposed, free blood letting and using powerful astrin- 
 gent applications such as iodide of zinc crystals, sulphate of copper, alum, 
 glycerite of tannin. 
 
 Treatment should be daily at first, and then every third day supple- 
 mented with massage and vigorous brushing, and the use of astringent 
 mouth-wash several times daily. There is another form of simple gingiv- 
 
i6o 
 
 itis which seems to affect the gum tissue at the hngual or labial surface of 
 upper incisors, labial surface cuspids and lingual of first molars. 
 
 The gum at first swells, and then drops away, leaving the root ex- 
 posed for a considerable distance above the enamel line. There is no pus 
 or tendency to bleeding, and all that can be done is to cleanse the surface 
 by frequent massage^, and instruction should be given the patient in the 
 proper use of the brush, so as to keep the parts clean, and not force 
 the gum farther away. 
 
 The most severe forms of gingivitis occurring where there are no de- 
 posits are constitutional in origin, and are usually, but not always, the 
 result of the presence in the system of such drugs as phosphorus, mer- 
 cury, lead and iodine, which are excreted by the fluids of the mouth, par- 
 ticularly the mucous and peridental membrane fluids. This will be con- 
 sidered in the next chapter. 
 
 There is another variety which I regard as the result of poor elimi- 
 nations, auto-intoxication, in which all the secretions of the mouth arc 
 foul, and the gums hypertrophied and very tender ; teeth are sore and the 
 tongue badly coated. This can only be cured by proper physical treat- 
 ment under the physician's direction, and all that is needed of the dentist 
 is to cleanse the teeth and mucous surfaces, provide the patient with a 
 suitable mouth-wash and otherwise meet the local conditions by such treat- 
 ment as each case may require. 
 
 It is impossible to enumerate all the kinds of cases that come under 
 this class, but I think sufficient has been said to point to the kind of treat- 
 ment needed for all. I am quite sure that simple gingivitis often leads 
 to more serious diseases of the peridental membrane itself. When the 
 gingivae becomes swollen, from any cause, and there is an accumulation 
 of foul mucous and debris, it affords a good lodgment for bacteria. The 
 gums soon become sore, teeth tender and consequently are not kept clean, 
 because of the pain and the bleeding upon brushing. In most inflamma- 
 tions of this kind the patients will not use the teeth for masticating, and 
 therefore the gums do not have the benefit of that natural method of 
 cleaning, and this is another reason why they become more tender and 
 inflamed. Such conditions also favor deposit of calculus. When calculus 
 is present this rapidly passes into calcic inflammation. 
 
 0iikic Tnflamntation. 
 
 By the term calcic inflammation I mean inflammation of the gums 
 and the peridental membrane, caused and maintained by the presence of 
 calcuhis on the necks of the teeth. This is one of the most serious of all 
 diseases of the peridental membrane. The degree of inflammation is 
 dependent upon the amount and nature of the deposits. The greater 
 
i6i 
 
 number of these cases I see leads me to conclude that some of these de- 
 posits are much more irritant than others. Cases occasionally present 
 with large quantities of calculus on the crowns and around the necks, 
 Avith little or no accompanying inflammation ; and then again others will 
 show the most violent inflammation resulting from, a very small amount 
 of calculus. 
 
 The calculus is of two varieties, named with reference to the source 
 from which they come. These two forms occur separately or together; 
 one above the other or mixed throughout. 
 
 Salivary Calculus. 
 
 The form most commonly found is known as salivary calculus, and 
 is deposited by the saliva. These deposits are composed of earthy matter, 
 consisting of saliva mucous, animal matter and phosphate of calcium, and 
 perhaps other salts. It is usually most thickly deposited on those teeth 
 situated nearest the openings of the ducts of the salivary glands, namely, 
 the upper first molar and lower incisors and cuspids. It is deposited just 
 above the gum or occasionally extending slightly under the gum margin. 
 The amount of this sort of deposit on the teeth seems to depend largely 
 upon two things : First, personal uncleanliness and carelessness about 
 thoroughly brushing the teeth ; second, upon certain constitutional dis- 
 turbances. This form of calculus is most readily deposited at night, when 
 the tongue and saliva are quiet, and hence the need of a most thorough 
 brushing of the teeth upon arising. If taken thus early most of it can 
 be brushed off before it has thoroughly hardened. Especially is this true 
 if a stiff, properly shaped brush is used in connection with some good 
 tooth powder. From this standpoint, the most important time to brush 
 the teeth is upon arising in the morning. 
 
 As to the constitutional cause, I can say but little. We have not yet 
 found out all there is to be known in this direction, but certain it is that 
 there are some systemic conditions that favor these deposits. One in- 
 dividual who may be quite careless about brushing his teeth may have 
 little or no deposits, and someone else who may be very particular in 
 this regard, may be troubled very annoyingly. All that we know to do 
 that will aid the system is to prescribe large quantities of fresh fruit 
 juices, to be taken especially before retiring, also the drinking of large 
 quantities of water. 
 
 In these cases of salivary calcic inflammation as fast as the peridental 
 membrane is destroyed, the gum recedes, and the space is soon covered 
 with fresh deposits ; this process goes on gradually until after a time the 
 alveolar border is absorbed, and the tooth appears to have grown up out 
 of the socket until it becomes very unsightly. Oftentimes the gum sep- 
 
l62 
 
 turn is destroyed, and the entire alveolus disappears, and the tooth drops 
 out. Whenever these deposits occur they destroy the tissue, and then 
 deposit fresh calculus on the ground gained. The membrane is not de- 
 stroyed to any great extent in advance of the deposits. 
 
 Occasionally, I see cases where the salivary calculus seems to deposit 
 over the edge of the gums in great, thick masses, covering nearly the 
 whole tooth crown. Particularly does this often occur with lower in- 
 cisors. See Fig. 46. 
 
 Fig. 46. 
 Deposits of salivary calcu- 
 lus. (Barrett.) 
 
 treatment 
 
 The treatment necessary for the relief of calcic inflammation, when 
 due to the salivary variety, is very simple. It is always well to scrub the 
 teeth and gums with hydrogen dioxide on a large ball of cotton carried 
 in the pliers, the first thing; next, syringe around the teeth with 1-2-3 
 water, to remove as much infectious material as possible, and render 
 everything as nearly antiseptic as possible. These precautiojjs will often 
 prevent severe inflammation following the cleansing of the teeth. 
 
 The essential thing in the management of all calcic inflammations is 
 the thorough removal of the deposits, which is a simple matter when only 
 the salivary variety is present. 
 
 Remcval of Salivary Calculus. 
 
 There are two general plans of procedure followed in the removal of 
 salivary deposits, one known as the push method, and the other known as 
 the pull method. In the push method the general shape of the scaler is 
 that of a chisel, the edge of which is brought to bear on the deposit at a 
 point nearest the occlusal surface, forcing the deposit away with a 
 chiseling motion. In the pull method the scaler is hooked at the lowest 
 point of the deposit, just under the free margin of the gum, forcing the 
 deposit off by pulling toward the occlusal. Each of these methods has 
 its advocates, and the method easiest for one operator may not be for 
 another, and perhaps the great majority of operators use both methods, as 
 seems most convenient for the different locations. 
 
i63 
 
 In the use of either method it is essential that the scaler be grasped 
 firmly, and the guide finger be firmly braced on the occlusal surface, or 
 the occluso-labial or buccal angle, of the neighboring teeth particularly, 
 is the essential when the push motion is used, in order to prevent acci- 
 dents and serious injury to the gums or peridental membrane. Where 
 the deposit requires considerable force for its dislodgment, patients are 
 fearful lest the instrument slip and injure them seriously, especially when 
 the push motion is used. The operator should always take pains to allay 
 such apprehension ; first, by verbal assurances, and second, by firmly brac- 
 ing the guide finger. 
 
 The operator should always arrange the patient in such positions 
 in the chair as will enable him to get at the various locations in the mouth 
 in the most accessible manner. The mirror should be used to reflect light, 
 and at the same time hold back the cheek, lips and tongue, as may be re- 
 quired from time to time. The operator should stand firmly on both feet, 
 and have nothing around that will interfere with his free movement 
 about the chair, and he should learn to assume as comfortable a position 
 as possible, for there is nothing so fatiguing and eventually so ill-health- 
 producing as standing for hours in strained, unnatural positions, which, if 
 we allow ourselves to assume, soon become a habit, from which it is dif- 
 ficult to break away. 
 
 In scaling the lower teeth, the operating chair should be at the low 
 position, patient in upright position, and the operator free to move about 
 from side to side, sometimes assuming a position in front or right of 
 patient, then to right back of patient, and left front, according as each 
 position will bring in direct view the tooth surface upon which he is 
 working. 
 
 Scalers. 
 
 The scalers which I find admirably adapted for the purpose intended 
 are illustrated in Fig. 47. For several reasons, it seems best to begin the 
 removal of salivary calculus on the lingual surfaces of the lower incisors 
 first. At that point the deposit is thickest, and consequently a good im- 
 pression is made at the outset on the mind of the patient as to the desir- 
 ability and necessity of having the scaling done, and also because most 
 easily removed at this point the patient gets over the fear or dread of the 
 operation, before the more difficult places are undertaken. 
 
 Scaler Number 10 is intended to remove the heavy mass of the deposit 
 in this position, and Number 9, in addition, to go in between the teeth 
 better, and Numbers 5 and 6, being right and left push, are used to com- 
 plement the other two, and especially to finish up after the larger part has 
 been removed with 9 and 10; 7 and 8 are used to scrape around under the 
 
1 64 
 
 ■:: 
 G 
 
 Fig. 47. 
 MaWhinney scalers. 
 
 gum margin, to remove any particles left by the other instruments. In the 
 use of these instruments the rest finger is braced on the adjacent teeth, 
 and with firm, positive strokes the deposit is dislodged, always holding the 
 mirror in the left hand, with which the tongue is held back and light re- 
 flected on the field of operation. In removing deposits on the lingual sur- 
 faces of all the lower teeth, the author finds the right front position most 
 convenient, occasionally changing to left front, if teeth incline out of nor- 
 mal position. 
 
 After the lingual surface and mesio-lingual and disto-lingual angles, 
 are thus cleaned, using i and 2, I proceed to the labial and buccal surfaces 
 and angles in exactly the same manner, passing from the incisors to the 
 third molar on the right, then left, cleaning one tooth at a time as I go. 
 As I get to the posterior part of the mouth I use 3 and 4 instead of i and 
 2, although Number 2 is well adapted to remove the calculus from the 
 mesial surface of bicuspids and molars. I should also repeat here that 
 warm antiseptic solutions in the syringe with which to wash away all 
 loosened calculus must be at hand, and frequently used. I like this plan 
 better than that of allowing the patient to take the solution from a glass, 
 which consumes much time unnecessarily, although a glass of antiseptic 
 solution should be at hand for the patient to use in case conditions arise 
 requiring it. 
 
 The operator should always be careful that chips of tartar do not fly 
 into his eyes. I have known two very serious accidents which occurred in 
 that way. 
 
 In scaling the upper teeth the chair should be raised, and the patient's 
 head thrown well back, and the front position taken, turning the head so 
 as to bring each surface of each tooth into direct view. I begin at the 
 
i65 
 
 upper right third molar distal surface, passing- around to the buccal, using 
 Number 4; then from distal to lingual, using Number 3, and on the mesial, 
 using Number 2. I proceed in exactly the same manner with the second 
 and first molar, but with the bicuspids and incisors I use Number i for 
 the distal. When I get to the median line I take the left third molar, 
 using Number 3 for the distal and buccal surfaces, and Number 4 for 
 the lingual, and pass along, completely cleaning one tooth at a time, until 
 the median line is again reached, using 7 and 8 for finishing up, the same 
 as directed for the lower teeth. 
 
 After all the teeth have been thoroughly scaled they should be pol- 
 ished, to remove all stains. 
 
 Removal of Stains from the tcetb. 
 
 For the purpose of polishing the crown surfaces of the teeth, many 
 iiseful appliances have been devised, the best of which are in the form 
 of rubber cups, wheels, cones, moose-hide points, brushes and wood 
 points, all of which are to be used in the engine, and carry pulverized 
 pumice, moistened with hydrogen dioxid. 
 
 Care must be observed not to lacerate the gum or burn the tissues, 
 which is a thing likely to occur unless appliances of proper shape are 
 selected. The rubber cup is usually most convenient for polishing around 
 the gum margin, and the brush for other surfaces. As a final touch, the 
 approximal surfaces should be polished with the flattened point of a rose- 
 wood stick, carrying the pumice. 
 
 When the polishing is complete, silk floss should be passed between 
 all the teeth to remove any tartar or pumice that may have lodged there, 
 and the whole gum margins flushed with warm antiseptic solutions in the 
 syringe, to wash out every particle of pumice, and finally the patient 
 should rinse the mouth thoroughly with a palatable antiseptic solution. 
 The patient is now ready to receive such instruction as to the proper care 
 of his teeth as his case may require, and further appointments made, if 
 other attention is necessary, 
 
 Serumal 0alculu$. 
 
 Many different names have been given to these deposits, most com- 
 mon of which are sanguinary deposits, gouty deposits, black tartar and 
 serumal calculus. The last term seems to be most generally accepted. 
 
 Serumal calculus has its source in the blood stream, and probably di- 
 rectly from the serum of the blood that exudes through the tissues about 
 the teeth. It seems quite certain that diseased conditions about the gum 
 margins favor the deposition of serumal calculus. Probably all of the 
 various forms of gingivitis already alluded to act as exciting causes. 
 These deposits often occur on teeth in mouths kept scrupulously clean. 
 
1 66 
 
 From a clinical standpoint, there does not appear to be much differ- 
 ence in different specimens of this variety of calcuius. 
 
 Dr. Pierce held to the idea that serumal calculus contained large 
 quantities of urates and uric acid, and that its presence in calculus was 
 largely a result of the presence in the system of unusual quantities of 
 urates and uric acid, and that gout}^, rheumatic and albuminuric individ- 
 uals suffered mostly. This idea was and is also held by Magitot, Tru- 
 man, Darby, Kirk, Marshall, Reese. On the other hand, Talbot states 
 that only 6 per cent of a thousand specimens of different cases examined 
 were found to contain uric acid or urates in any form, and claims the 
 serumal calculus is deposited as a result of disease conditions present in 
 the alveolus surrounding the tooth. 
 
 The great objection I see to the uric acid theory is that many indi- 
 viduals suffer from this kind of calcic inflammation when there cannot 
 be found any trace of gout or rheumatic tendencies, and no excess of 
 urates can be found in the system; and again, many who suffer from 
 gout and rheumatism in most severe acute and chronic forms do not have 
 the least signs of calcic inflammation. Then, again, many severe cases get 
 well permanently, when only local treatment is given. 
 
 Perhaps no investigator along this line has done so much work as 
 Dr. Talbot. He claims that both serumal calcic inflammation and phage- 
 denic pericementitis are slightly different manifestations of the same 
 disease, and that its immediate seat is in the alveolar process, and not a 
 disease of the peridental membrane. He has given the name interstitial 
 gingivitis to this trouble. 
 
 Dr. Talbot's theory regarding the diseases which the profession in- 
 cludes in the term pyorrhea alveolaris is about as follows : "This disorder 
 is a local inflammatory condition of the gums tending to accelerate their 
 normal tendency to disappearance at certain period of stress, or involu- 
 tion, of which the changes produced by old age are a type. There are 
 two great causes — exciting and predisposing. The exciting may be purely 
 local, or a local expression of a constitutional state. The local causes 
 assigned are acute inflammation of mucous membranes, catarrhal states, 
 germs, fungi, irregular teeth, lactic acid, pocket disease, serumal calculi, 
 uncleanliness and local degeneracy. 
 
 "The constitutional causes — heredity, constitutional disorders, exces- 
 sive lime salt secretion, meat eating, nervous exhaustion, scorbutus, uric 
 acid and auto-intoxication states." 
 
 In the light of much clinical experience, I can scarcely agree wath all 
 of Dr. Talbot's conclusions, particularly regarding those cases which are 
 here classified as phagedenic pericementitis — of which I shall hereafter 
 speak ; but, in the main, his conclusions seem rational, and have only been 
 
1 67 
 
 arrived at after years of careful research, and are therefore entitled to 
 honest consideration. His book on this subject should be read. 
 
 This variety of calculus is usually very hard, of a dark brown or 
 black color, and is most frequently deposited in a ring just underneath 
 the free margin of the gums. There are no specially favorable teeth 
 where this variety is found. It occurs on any and all teeth. If allowed to 
 remain any length of time it produces severe inflammation of gum margin, 
 and often destruction of the gum septum and alveolar border. See 
 Fig. 48. 
 
 Fig. 48. 
 Showing absorption of gum gingivus and alveolus. (Burchard.) 
 
 Sometimes these deposits occur more on one side of a tooth than 
 another, and pass rapidly toward the apex, covering one side of the root 
 completely, in which case the gum septum will have disappeared, and 
 the alveolus as well, to a considerable extent on that side, and the rest 
 of the gum and peridental membrane remain normal. 
 
 There are other cases where the deposit occurs high up on the root, 
 or perhaps between the roots of molars, and none to be seen around the 
 gingivus, and, indeed, the membrane may seem to be attached all around 
 the gingivus, and yet considerable serumal deposit be found high up on 
 the root (see Figs. 49 and 50). Often there will appear a narrow, tor- 
 
 a 
 
 Fig. 49. 
 necrotic tissue; h, serumal calculus. (Barrett.) 
 
1 68 
 
 tuous channel leading down to the gingivus, making the exact location of 
 the deposit difficult to find ; still other cases are seen where the deposit is 
 high up on the root, and the alveolar wall immediately over it absorbed 
 away, and perhaps a discharge of pus coming through the gum immedi- 
 ately over the deposit. 
 
 Fig. 50. 
 Serumal calcic inflammation. A, serum calculus; b, inflammatory corpuscles; c, d, peridental 
 membrane intact; e, pulp. (Burchard.) 
 
 In some of these cases, where there is a large deposit of serumal cal- 
 culus on one side of the tooth only, it is not unusual to find that the tooth 
 is drawing away from its position ; particularly is this true if the deposit 
 extends high up toward the apex. Frequently this condition occurs be- 
 tween the central incisors. Indeed, I have seen such cases where the 
 ■centrals have separated the width of a tooth. It is simply the effort of 
 nature to get away from the irritant, and is partly due to the fact that 
 the peridental membrane which holds the tooth in that direction is de- 
 stroyed, allowing the remaining portion of the membrane to draw the 
 tooth away toward the opposite side. In this case the gum septum may 
 :still be intact, although in most instances the septum of the alveolus is 
 fcompletely destroyed, and pus will be found flowing from the socket. 
 
 The gum and peridental membrane continue to recede, and in some 
 cases salivary calculus is deposited above the original ring of serumal 
 calculus, and this process goes on until the tooth becomes very loose in 
 its socket. Sometimes these mixed deposits will encroach upon the apex, 
 but more usually the deposit is of serumal variety. I have often seen 
 
169 
 
 large deposits pass up on one side of the root until the apex was reached, 
 resulting in the death of the pulp. Figs. 51, 52, 53. 
 
 In all of these cases the remaining peridental membrane becomes very 
 much thickened and tougher, and in attempting to extract these teeth, 
 .after treatment has failed, you will be surprised at the force required to 
 remove them. Oftentimes the membrane is so firmly attached to the gum 
 
 Fig. 51. 
 
 Serumal calculus covering 
 root of lower bicuspid. 
 
 the 
 
 Fig. 52. 
 Serumal calculus covering root of 
 an upper cuspid, gum tissue was in 
 normal position. 
 
 at some point as to result in badly tearing the tissues unless care be 
 taken to cut it loose. I have frequently had cases where the teeth were 
 so very loose that with the finger you could turn the apex out of the socket, 
 but it was firmly attached on one surface by the peridental membrane, 
 which made it necessary to clip off the gum on that side; otherwise I 
 should have torn a great amount of gum tissue and periosteum in the 
 operation. As a precautionary measure, it is well to pass a thin, sharp 
 lancet around the neck of the tooth, and cut loose all attachment before 
 removing these very loose teeth. 
 
 The important thing for the operator to remember regarding the 
 etiology of this disease is that the immediate cause of calcic inflamma- 
 tion is the deposits present on the tooth root, and the first step in the 
 treatment thereof is to thoroughly remove every particle of calculus, 
 which, with this variety, is not always an easy task, but when success- 
 fully done, recovery in ordinary cases is very rapid. 
 
 Inasmuch as the scaling of teeth where serumal calculus is present 
 does not dififer from that necessary in phagedenic pericementitis, I shall 
 
i^o 
 
 Fig. 53. 
 
 Serumal calculus covering root of molar. 
 
 reserve the description of that technique and subsequent treatment until 
 after that subject is presented. 
 
 Phagedenic Pericementitis. 
 
 The term phagedenic pericementitis was first suggested by Dr. G. 
 V. Black, in 1883, and while I cannot say it has been very generally 
 accepted by the profession, yet it seems most expressive of the conditions 
 present in this disease. 
 
 Phagedenic pericementitis is a destructive inflammation of the peri- 
 dental membrane, which may or may not be accompanied by calcific de- 
 posits, and is nearly always accompanied with pus. 
 
 It usually has its beginning in some form of gingivitis, and most fre- 
 quently starts at the gingivus and passes up along the root, destroying 
 the peridental membrane as it progresses. Sometimes it passes along one 
 side of the root in a narrow channel, which, toward the apical third, will 
 widen out, forming a very distinct pocket. Other times it may affect 
 all of one side of a root, either mesial, distal, labial or lingual, and I do 
 not think it can be said that one side is more liable to be aft'ected than 
 another. The channel often takes a very tortuous course, and oftentimes 
 the pocket will be found on one side of a root and the point of discharge 
 or starting point at the gingivus on another side. In other cases there 
 may be no pockets, but a progressive destruction of the entire membrane 
 all around the tooth, but this form is not very common. 
 
 There are still other cases where the pockets seem to have no con- 
 nection with the gingivus, but form high up on the root, with a discharge 
 
171 
 
 of sero-pus through an opening in the gum directly over the pocket. 
 Careful examination must be made in this class of cases, in order to 
 avoid mistaking it for a chronic alveolar abscess dependent upon the 
 death of the pulp. See Fig. 50. 
 
 In this class of cases the point of discharge differs somewhat from 
 the fistulous opening or "gum boil" of an alveolar abscess, in which the 
 discharge is through a small, conical, tit-like projection, with the bone 
 underneath in fairly hard normal condition, while in this variety of 
 phagedenic trouble the point of discharge is wide open, with gum tissue 
 around it slightly elevated, thickened, very red, and will bleed on the 
 slightest touch, and the bone underneath absorbed to considerable extent, 
 so that an explorer will readily pass through the outer opening directly 
 to the root, revealing a root denuded of pericementum over a large area, 
 for in all these cases the pockets tend to spread laterally along the mem- 
 brane, never forming pockets which lead away from the tooth to any ex- 
 tent, but are largest next to the tooth. 
 
 Many of these cases come to us while still in the acute form, and will 
 present considerable soreness and show these raised areas on the gum 
 over the root, which has never broken and discharged pus, and yet if you 
 take a fine, sharp explorer, you will be able to pass it through this area 
 directly to the root, and discover that much of the root has lost its mem- 
 brane. 
 
 I have seen many cases of this kind, particularly on the labial sur- 
 face of cuspids and buccal surfaces of upper molars and bicuspids, where, 
 try as hard as I could, I was not able to find an opening at the gingivus 
 leading to the pocket, and yet when I opened the pocket with a lancet I 
 found roots bare to a considerable extent, in many cases extending from 
 the gingival third to the apex, bringing about the death of the pulp, and 
 oftentimes find such roots covered with serumal deposits, and many cases 
 have no such deposits. Recently I had a case of a lady of about forty 
 years of age, where two upper bicuspids had such pockets, involving the 
 entire middle third of the roots, with small openings at the lingual 
 gingival margin of each. The gum was in normal position, but the teeth 
 were very loose, and digital pressure on the gum brought away great 
 quantities of pus. The general health of the patient was such as to pre- 
 clude any attempt at treatment, so the teeth were removed, bringing away 
 the gingival third of the buccal alveolar plate, and revealing the fact that 
 the middle third, and extending almost to the apex, had lost its mem- 
 brane, and yet there were no deposits of any kind. This was a true 
 phagedenic case in acute form, which had, as nearly as could be ascer- 
 tained, been developed within three months' time. In my private prac- 
 tice, as well as in the infirmary of the school, I have seen many such cases, 
 
1/2 
 
 but the percentage is small compared to those which are complicated with 
 serumal deposits. 
 
 In many cases where tbe disease has progressed slowly, you may see 
 a decidedly thickening of the bone, particularly at the gingivus, which is 
 brought about by the mild stimulation of the osteoblast, resulting from 
 continuous irritation. Usually the membrane has lost its attachment to 
 the cementum, and the bone next to the tooth absorbed some- 
 what, and the thickening occurs by building on the outer surface 
 of the bone. 
 
 Where these pockets exist, we occasionally see large absorption of 
 tooth substance. I have collected several specimens. The absorbed areas 
 present a variety of shapes, from broad, rough, shallow places, to small, 
 round holes, that look almost as though they had been made with a drill. 
 I am very glad to say, however, that these cases are rare. 
 
 With regard to the development and progress of phagedenic perice- 
 mentitis, it should be said that cases present a wide difference. 
 
 Some cases begin and go on violently, until the tooth becomes so 
 loose that it is lost within a few weeks ; others progress very slowly, and 
 take years to produce any serious trouble. In some cases the teeth early 
 become very sore, sensitive to thermal changes, and the seat of neuralgic 
 pains that become very severe. In other cases the development and pro- 
 gress of the trouble is painless, and the first indication of trouble is the 
 looseness of the tooth ; more particularly is this true of simple phagedenic 
 cases, that is, those cases not complicated with serumal deposits. In such 
 cases there sometimes is no apparent inflammation of the gums ; on the 
 contrary, they often appear anemic. 
 
 etiology of Phagedenic Pericementitis. 
 
 All observers seem to agree as to the clinical aspect of these cases, 
 but there is a wide difference of opinion regarding its etiology. 
 
 Dr. G. V. Black states that the disease is fundamentally one of the 
 peridental membrane affecting its attachment to the tooth ; fiber by fiber 
 that membrane is torn away from the cementum, and is the result of 
 specific infection, probably due to a special micro-organism vv^hich has 
 not been isolated as yet, although he has done much work in an endeavor 
 to find it. 
 
 Dr. George W. Cook is of the same opinion, and has done a great 
 amount of work, resulting in finding a germ that he thinks is responsible 
 for the trouble. Certain it is that he has produced similar pockets by 
 introducing this germ under the gum, particularly where some irritation 
 of the gingivus already existed. 
 
/6 
 
 Dr. M, L. Rhein presents some interesting theories. He calls this 
 disease pyorrhea alveolaris, and divides it into two general classes, which 
 he terms pyorrhea simplex and pyorrhea complex. 
 
 Under the head pyorrhea simplex he includes all those cases of what 
 he calls purely local origin, and which are amenable to simple local 
 treatment. 
 
 Pyorrhea complex he regards to be of constitutional origin, present- 
 ing slightly different forms, according to the physical disorder of the 
 patient, which forms are readily recognizable. 
 
 This class he subdivides into four groups, according to their 
 causation. 
 
 (a) Those due to disorders of nutrition, gout, diabetes, nephritis, 
 scurvy, chlorosis, chronic rheumatism, anemia, leukemia, pregnancy. 
 
 (b) Those resulting from acute attacks of infectious diseases, among 
 which he specified typhoid fever, tuberculosis, malaria, acute rheumatism, 
 pleurisy, pericarditis, syphilis. 
 
 (c) Those due to nervous disorders, cerebral disease, spinal disease, 
 neurasthenia, hysteria. 
 
 (d) Those conditions which are the result of drug poisoning, par- 
 ticularly mercury, lead and iodides. 
 
 It is doubtless true that many of these diseases do make a distinct 
 impression in the mouth, but as a cause for pyorrhea alveolaris they can 
 only be considered as predisposing and never as the exciting cause, be- 
 cause all forms of this disease are seen in the mouths of individuals who 
 have never had any of the diseases enumerated, and, again, individuals 
 who have suffered from many of these diseases have never had the slight- 
 est indication of peridental trouble ; and, again, most forms of this trouble 
 yield to local treatment. 
 
 Dr. Talbot's theories, which have already been explained, are to the 
 effect that this disease has its seat in the alveolar process, to which I sug- 
 gest the following criticism: If the process is the seat of trouble, why 
 does the membrane lose its attachm.ent to the tooth first? Many cases 
 that I have examined show the membrane attached to the bone and torn 
 away from the cementum. Again, why, on the removal of the aft'ected 
 teeth, does the disease terminate without further treatment? Why does 
 the disease never occur in edentulous jaws? 
 
 Dr. J. W. Younger believes the disease to be purely local, and 
 caused by a special germ. He states that from years of experience in 
 managing these cases he very rarely finds one that will not yield com- 
 pletely to local treatment. 
 
 I have had several patients who continually suffered from simple 
 phagedenic trouble requiring constant watching. No sooner would one 
 
174 
 
 pocket be healed than the patient would return with one or more new 
 pockets filled with pus, perhaps on teeth that had never been affected 
 before. And after years of this constant watching-, the trouble would 
 entirely disappear following some severe illness, and in four cases has not 
 reappeared in five years, and one case in ten years. Clearly, then, the 
 changed physical condition had something to do with the disappearance of 
 the disease. 
 
 I think I have collected enough opinions to show the reader that 
 the mind of the profession is not made up regarding the etiology of this 
 disease, but that there is a great difference of opinion regarding this 
 point. I have faith to believe that soon new light will be thrown on this 
 subject, for many able men are bending their best energy to the solution 
 of this problem. 
 
 Crcatttieitt of Sertitntil Calcic TnfUtnmation ana PDddeaeHic Pericementitis. 
 
 Diasnosis. 
 
 The first step in the management of these cases is a correct diagnosis. 
 We need to know exactly what the conditions are. 
 
 In making a diagnosis, first get a complete history of the case ; find 
 out about the character of the pain; how long has the trouble existed? 
 Have any teeth been lost from this cause? Are the teeth sore to pres- 
 sure ; tender to hot and cold drinks ; sweet and sour things ? Are any 
 teeth loose? Has there been any swelling? Is there an offensive odor 
 and a bad taste in the mouth ? Do the gums bleed readily ? 
 
 A knowledge of these things gained from the patient not only is 
 helpful to the operator, but has a good mental influence on the patient. 
 
 The instruments needed to make a thorough examination are two 
 explorers, a mouth mirror, a mouth lamp, supplemented by a well- 
 trained index finger. After learning the history of the case, a good 
 way to make the mouth examination is to begin with a general survey of 
 the entire mouth ; then with a surgically clean index finger pass it along 
 the gum high up, and then along the gingivus, and on labial, buccal and 
 lingual surfaces of gum, using enough pressure to detect any soft, tender 
 places, and to force any pus present out at the gingivus. Next press on 
 the teeth to determine looseness and tenderness, and observe if any of the 
 teeth have moved out of normal position ; and, finally, with mouth lamp 
 and mirror to light up every pocket, proceed with proper explorers to 
 examine every surface of every tooth, passing the explorer around the 
 free margin of the gum, dropping it into each pocket, noting its shape, 
 and the character of the deposits. All the points observed should be 
 
175 
 
 written down for future reference, and particularly should this be done 
 if the case is sent to you for consultation. 
 
 treatment. 
 
 The first essential in the treatment of these diseases is thorough 
 cleaning of the teeth. Even in simple phagedenic cases, thorough scraping 
 of the root at every point where the membrane has separated from, the 
 cementum is necessary, because there are always present either concretions 
 of calculus or pus globules, or other foreign matter which must be re- 
 moved. 
 
 Instruments. 
 
 The instruments necessary to do this work must be small, of good 
 texture, and so shaped as to readily reach every surface of all the teeth 
 roots in the mouth. Many sets of scalers have been devised for this 
 purpose, each possessing certain merits. The Younger set of thirty- 
 seven answers admirably for those who are skilled in their use, but I am 
 satisfied they are too complicated for use of general practitioners, re- 
 quiring years of constant using to become proficient. The Harlan and 
 Gushing sets are used by many operators. The Tompkins set has ex- 
 cellent points. 
 
 The author's set (Fig. 47) was devised especially for students' use, 
 and presents the following points : 
 
 1. The cutting edge is in line with the shaft, so the instrument does 
 not roll in the fingers under stress. 
 
 2. The shapes are admirably adapted to reach every surface. 
 
 3. They are small, with rounded backs, and therefore injure the gum 
 less than other sets. 
 
 4. They are stiff, and will not spring over hard deposits under stress. 
 
 5. They are easily sharpened. 
 
 In the main, the points that have been insisted upon for the removal 
 of salivary calculus hold good in the removal of serumal deposits, to 
 which the reader is referred for the instrumental technique. The im- 
 portant thing is to get it all off, which I can assure you is never an easy 
 task. Always instruct your patient as to the conditions and necessary 
 treatment. 
 
 The following outline of procedure should prove helpful : 
 
 First. — Clean the gums with hydrogen dioxid on a swab of cotton, 
 and with an antiseptic solution in the syringe flush out all debris from 
 around the necks of the teeth. 
 
 Second. — Keep the working end of the scalers immersed in an anti- 
 septic solution. 
 
176 
 
 Third. — Select some point in the mouth to begin on, and proceed 
 from that, thoroughly cleansing one tooth at a time. 
 
 In this class of cases I begin with the lower right third molar, and 
 pass around the lower jaw first, and then take the upper in the same way. 
 The important thing is to take one tooth at a time and confine all your 
 thought and energy to that one, until the scaling of it is completed. 
 
 Fourth. — When the pockets are deep and the tissues tender, 1 always 
 pack the pockets with a rope of cotton saturated with one per cent solu- 
 tion of cocain in peppermint water, previously packing bibulous paper, 
 gauze or absorbent cotton around the tooth, to prevent any of the cocain 
 solution escaping into the throat. The cotton rope should be left in the 
 pocket for two or three minutes. 
 
 Fifth. — If the tooth neck is very sensitive, I dry it and lay 30 per 
 cent chloride of zinc around it for a few minutes. 
 
 Sixth. — If the pockets are tortuous and the gingivus tight around 
 the tooth, I pack the gum away with a rope of zephyr wool, saturated in 
 25 per cent phenosulphonic acid, for twenty-four hours, which will not 
 only gain ready access, but will tend to soften the deposits. 
 
 Seventh. — If the pocket is high up, the gum tight around the tooth 
 neck, and the outer plate of the alveolus over the middle or apical third 
 destroyed, I invariably make an opening through the gum at that point, 
 through which to do the scaling. 
 
 Eighth. — Where the pocket is very large and membrane entirely de- 
 stroyed at that point, it is well to curette the bone as well as the tooth, and 
 treat as a surgical wound. 
 
 Ninth. — Use the explorer frequently to determine the progress made 
 in scaling on each surface. Special care is needed in the grooves and 
 depressions in root surfaces. 
 
 Tenth. — Flush the pockets frequently with antiseptic solutions, to 
 keep a clean field upon which to work. 
 
 Eleventh. — Where the teeth are very loose some method of fixation 
 must be adopted, for loose teeth never can recover unless held immovably. 
 
 Twelfth. — In very bad cases the pulp should be destroyed and canals 
 filled. If pulp is dead, root canals must receive first attention. 
 
 The operator should be cautioned against attempting too much at one 
 sitting, for not only does the patient become fatigued, but the operator 
 loses that delicacy of touch which is so essential to successful work. 
 
 Sometimes a whole sitting will be consum.ed in scaling a single tooth, 
 but one tooth well done is far better than more half done. 
 
 In very bad cases radical measures are necessary to bring about 
 changed conditions. Dr. A. W. Harlan has said, in efifect, that in some 
 of these cases you need to tear up and literally burn the tissues involved 
 
177 
 
 before recovery will result. Growth through stimulation by irritation 
 seems to be the thought. 
 
 Most operators find the pull motion produces less pain, and is more 
 positive in its results than the push motion. In the pull method the scaler, 
 of proper shape, is carried to the bottom of the pocket first, and gradually 
 worked toward the crown, removing and reinserting the scaler as few 
 times as possible. I always use Numbers 7 and 8, which can be used with 
 either a push or pull motion to finish up with. They are admirably 
 adapted for reaching into grooves, crevices and all irregular surfaces. 
 
 In very bad cases, where the membrane is largely destroyed, many 
 operators recommend extraction, cleansing, filling root canals, deepening 
 the socket, and replanting. Oftentimes one root of a molar may be 
 removed and the remaining one or two, as the case may be, carry the 
 tooth successfully. These operations will be described in another chapter. 
 
 After the instrumentation has been completed, the pockets should be 
 thoroughly washed to remove all debris and blood clot, which, if not 
 removed, make a favorable field for the growth of micro-organisms. 
 
 I do not recommend hydrogen dioxid for this purpose, except in 
 those cases where the pockets are wide open, for there is danger of the 
 rapid efi^ervescence tearing away the attached membrane. 
 
 As a first treatment, many operators use concentrated lactic acid for 
 its irritant stimulating effect; others use 30 per cent chloride of zinc, 10 
 per cent trichloracetic acid, sulphate of copper powder, campho-phenique, 
 Black's I, 2, 3, resorcin, hydronaphthol, iodide of zinc, tincture of iodine, 
 some of the silver salts, and a lot of other remedies have been suggested. In 
 my hands a combination of iodine and iodide of zinc have proven very 
 efficient for the ordinary case. This remedy was suggested by Dr. Talbot, 
 and is made of five parts of iodine crystals; seven parts of iodide of zinc; 
 glycerine to make thin cream. Sometimes, if the pockets are large and 
 flow of pus profuse, I will burn it out with 50 per cent phenosulphonic 
 acid, and pack it with chinosol gauze, wdiich I leave for forty-eight hours. 
 In the average case I dry the gum and pocket as well as I can, and flow on 
 the gum., and into the pockets Talbot's glycerol iodine and zinc freely, 
 keeping them dry with a piece of aseptic dental napkin for a couple of 
 minutes, when the excess may be washed ofif with antiseptic solution in 
 the syringe, and the mouth rinsed. The patient must return in twenty- 
 four hours, when, if there is pus present, I feel certain that at that point 
 the tooth has not been thoroughly cleansed, and I proceed to do so. 
 
 It is very rare, indeed, that pus presents at the third sitting. 
 
 If the case is progressing, I do not again open the pockets, but allow 
 the same medicine to flow down by gravity, or capillary attraction. Of 
 course, at each sitting the gum and necks of the teeth must be cleansed, for 
 
• 178 
 
 which purpose I usually use a warm antiseptic solution in a compressed air 
 atomizer. 
 
 I repeat this treatment every third day for a week or so ; then every 
 fourth day; then once a week, and so on, never dismissing- a case under 
 three months, except in rare instances. 
 
 I frequently change to plain tincture of iodine, especially if the gums 
 get very sore from the iodine and zinc, and if the necks of the teeth are 
 very sensitive I use chloride of zinc, nitrate of silver, or trichloracetic acid, 
 as conditions indicate. The patient should always be provided with an 
 antiseptic astringent mouth wash, and good tooth powder. 
 
 ^ 
 
 
 Sodii bcras^ 
 
 3 iv 
 
 Acidi Carbol^ 
 
 3 i 
 
 Glycerite Tannin, 
 
 3ii 
 
 Tinct. Myrrh, 
 
 3i 
 
 Ol. Cassia, 
 
 3 ss, 
 
 Ol. Pepperminti, 
 
 m.x. 
 
 Alcoholis, 
 
 o ii 
 
 Aquae dist., q. s. ad. 
 
 § vi 
 
 M. Sig. Use a teaspoonful in one-quarter glass of warm water 
 as a mouth wash several times daily. 
 
 This should be supplemented by thorough brushing, using a good 
 powder and a hard brush. Daily massaging the gums with the fingei 
 moistened with the above solution, directing the force toward the tooth 
 crown, will also prove helpful in most cases. The patient's general health 
 must be looked after ; all the functions of the body must be normally per- 
 formed. The eliminative organs should be stimulated. The daily drinking 
 of eight glasses of pure water should be insisted upon, and a minimum 
 amount of sweets and meats taken, and the patient should be encouraged 
 to eat plenty of fresh, ripe fruit, and to take wholesome exercise in the 
 open air. 
 
 In a work of this kind it is impossible to do m.ore than indicate the 
 line of treatment that should be followed, but the operator's knowledge 
 of the conditions and the remedies at hand will be able to modify the 
 treatment for each individual case. 
 
 A few things must be kept in mind. Perfect cleanliness, thorough- 
 ness as to detail. Insist on the patient doing his part, and do not tear 
 open the pockets or poke instruments into them when healing has once 
 favorably begun, and if there is any physical cause of irritation, such as 
 improper contact points, rough filling margins, improper use o-f the brush 
 or toothpicks, these must first be attended to. 
 
179 
 
 Prognosis. 
 
 Regarding the prognosis of these cases I can only say that the cause 
 which produced it in the first place will bring it back, and that no positive 
 assurance can be given the patient as to freedom from future attacks, and 
 the fact that such attacks recur is no proof that the disease was not cured 
 in the previous attem.pt, for this disease is not like smallpox, in which one 
 attack insures the patient against a future one. 
 
 Teeth in all varieties of this disease have been cured and remained so 
 for many, many years. The fallacious notion given the public by many 
 dentists that this disease is incurable is not only untrue, but it is unjust 
 to the many scientific and skilled men who are making a success of the 
 treatment of the great majority of cases presented, and equally unjust to 
 those who suffer and lose their teeth because of this false idea. 
 
 Before dismissing this subject, a word should be said regarding the 
 reattachment of the peridental membrane. 
 
 Does the peridental membrane reattach itself when once torn from 
 the cementum? The answer must be in the affirmative, when the con- 
 ditions are favorable. If the membrane is attached to the bone side, and 
 only separated from the tooth in comparatively small areas, and the tooth 
 in those areas has been thoroughly cleaned, the membrane will lie down 
 on the cementum and reattach its fibres by a new deposit of cementum, but 
 if tlie membrane is totally destroyed over any considerable area, reattach- 
 ment is impossible, and only a mechanical union will exist between the 
 bone and cementum at those points. For further consideration, see chapter 
 on implantations, etc. 
 
 management of Eoose teeth. 
 
 Many of these cases present with one or more teeth loose, and before 
 permanent results can be expected the teeth must be held firmly in the 
 socket. Oftentimes teeth are so loose as to make scaling impossible until 
 they are held firmly in the socket. ]\Iany methods and appliances have 
 been suggested for this purpose, most of v/hich have for their object the 
 binding of several teeth together in a solid compact. Splints of either 
 rubber or gold are frequently made to fit along the lingual surfaces of 
 teeth down to the free margin of the gum, and ligated in position by 
 passing either gold wire or silk twist through small holes in the splint to 
 the mesial and distal of each tooth, and tying on the labial or buccal. 
 
 Another method is to swage shallow caps to fit over the occlusal where 
 the occlusion will permit. This mav often be made in one piece to cover 
 several teeth, and extending over the labial and lingual surfaces about 
 two millimeters, and is cemented into place. (See Fig. 54). 
 
 Another method is to surround each tooth with narrow bands of 
 o-auge 26, 22 karat gold, allowing but one thickness of gold between the 
 
i8o 
 
 Fig. 54. 
 
 Swedged gold caps to retain lower incisors. 
 
 teeth. The bands should be on the occlusal third of the tooth, and held 
 in position with cement. (See Fig. 55.) Many operators bind the teeth 
 together with pure gold wire. (See Fig. 56). 
 
 Fig. 55. 
 Gold bands for retaining loose lower incisors. 
 
 Showing 
 
 Fig. 56. 
 wire ligature for retaining 
 
 loose teeth. (Rhein.) 
 
 When it is only necessary to hold the teeth temporarily, I find nO' 
 better way when teeth on either side of the loose ones are present than to 
 ligate one to the other, using silk thread. Take a case where two lower 
 centrals are loose. I begin by wrapping number A, waxed silk thread 
 twice around the right lateral, tying on the mesial just below the contact 
 point ; pass it around the right central in exactly the same way, and tie on 
 the mesial, and so on, around the left central and lateral. A little 
 experience will enable the operator to adapt this same plan to various 
 locations about the mouth. 
 
 Take this same case, where the teeth are very loose and the alveolus 
 largely gone, a permanent appliance is necessary, and for this purpose 
 I find nothing so good as to devitalize the pulps in the four incisors ; 
 grind the lingual surface slightly immediately over the opening made for 
 
pulp removal and canal filling, over which burnish pure gold, each tooth 
 separately, and pass a short post into each canal ; take an impression with 
 all in position, make a cast and flow solder over the whole, uniting all 
 together, polish, and set wath cement. I have several of these splints that 
 have been worn from five to twelve years, with the utmost satisfaction. 
 
 The same method can be adapted to the upper incisors and cuspids, 
 and oftentimes without devitalizing the pulps by making the hole to receive 
 the pin to the mesio-lingual or disto-lingual of the pulp. (See Fig, 57.) 
 
 
 a c 
 
 Fig. 57. 
 Splint for retaining loose teeth. (Ames.) 
 
 The same principle can be adapted to molar and bicuspids, using the oc- 
 clusal instead of the lingual surface. Oftentimes by cutting a groove 
 extending along the center of the occlusal from one tooth to the other, 
 into which a heavy platino-iridium wire is laid, around which amalgam 
 or gold foil is packed, a permanent result is obtained. 
 
 The Carmichael attachment is admirably adapted for this purpose. 
 
 AVhen these badly diseased teeth are situated on either side of short 
 edentulous spaces, good results are often obtained by cutting off and 
 crowning the teeth, and bridging in the missing teeth. I have several such 
 cases that have remained comfortable for ten years. It goes without say- 
 ing that in all these cases the usual measure to effect a cure must be 
 adopted, and carried out. 
 
 Before dismissing this subject, I wish to speak of a method suggested 
 by Dr. W. V.-B. Ames, for the cure of the disease, and the retention of 
 loose teeth, particularly lower incisors and cuspids that are very loose, and 
 that have lost much of the alveolus surrounding them. It consists in de- 
 stroying the pulps, filling pulp canals, and thoroughly cleaning the teeth, 
 after which he saws the crowns off at the gum line and bands each root 
 the same as for a Richmond crown, and in case the natural crowns are 
 good, he utilizes them instead of porcelain for the crown, a detailed de- 
 scription of which does not come within the scope of this book, but which 
 
1 82 
 
 can be found in the Dental Cosmos, May, 1903. Dr. Ames claims that 
 by this method he not only fixes the teeth firmly in position, but the 
 gold collar acts as a stimulant aiding- recovery. 
 
CHAPTER XVI. 
 
 gVPcrcemento$i$ and Root Resorptions. 
 
 Morbid Anatomy. Causes of Hypercementosis. Pathology. Symptoms. 
 
 The terms Hypercementosis and Excementosis have been used 
 synonymously to designate a secondary deposit of cemenlum on the tooth 
 root ; this deposit may occur upon any part or surface of the root, but is 
 most frequent about the apical end. 
 
 In the normal process of tooth formation, cementum is deposited 
 layer upon layer, which not only continues until the root has assumed 
 complete form but slowly continues throughout life. Unless disturbed in 
 the process of formation these layers pass in one continuous line from the 
 enamel line to apex, differing very little as to thickness at dififerent points 
 until apex is reached, where it becomes slightly thicker and at the enamel 
 junction it tapers off quite thin. 
 
 morbid Jfnatomy. 
 
 It is difficult to say exactly where hypertrophy begins and the normal 
 physiological formation ends. In ground specimens it is clearly seen that 
 a certain layer often becomes greatly hypertrophied at a certain point and 
 all the rest of it formed in normal thickness (See Fig. 58). 
 
 Fig. 58. 
 Hypercementosis. A, dentine; b, layers of cementum; c, peridental membrane; d, thickened 
 layer; e, same layer normal. (Black.) 
 
 Hypercementosis may occur in one or more of these regular layers 
 or lamellae, and it may occur in the first layer or any or all subsequent 
 layers, and in many ground specimens it is clearl}' seen that absorption of 
 small areas of previously deposited cementum occurs, which is afterwards 
 filled in as the next lavers are formed. 
 
i84 
 
 Fig. 60. 
 Hypercementosis of entire root. (Barrett.) 
 
 Fig. 61. 
 Hypercementosis, round, 
 smootli form, involving ap- 
 ical third of root. 
 
 Fig. 63. 
 Hypercementosis, with de- 
 posit of cementum uniting 
 root apices. 
 
 Fig. 63. 
 Hypercementosis, showing the union of 
 roots of two molars. 
 
 Fig. 64. 
 Hypercementosis. Union of distal root 
 of lower second molar with mesial root of 
 lower third molar. 
 
i85 
 
 Teeth affected with hypercementosis present a variety of forms. In 
 some cases the entire root is enlarged (see Fig. 60) ; in others the enlarge- 
 ment is confined to the apical third, (Fig. 61,) and in still other cases the 
 cementum may have united two roots of the same or adjoining teeth. 
 (Figs. 62, 63, 64.) 
 
 The accompanying illustrations will furnish interesting study. They 
 are made from specimens among the writer's collection. (Fio-s 6^ 66 
 6y, 68.) ' ' 
 
 Fig. 65. 
 Hypercementosis, irregular 
 form. 
 
 Fig. 66. 
 Hypercementosis, round, 
 smooth form, involving the 
 apical third. 
 
 Fig. 67. 
 Hypercementosis, irregular form. 
 
 Fig. 68. 
 Calcific structureless mass 
 involving roots of molar. 
 (Barrett.) 
 
0au$($ of 1)ypercemento$i$. 
 
 As to the causes of hypercementosis very little can be definitely stated. 
 It is doubtless due to some undue irritation, which disturbs the normal 
 physiological process. It seems probable that many times the irritant 
 is chemical in its nature, and has its source in the blood of the surround- 
 ing parts^ and in a great majority of cases is due to a mild form of irri- 
 tation to the peridental membranes. 
 
 This irritation may be the result of continued extra stress on the 
 tooth, difficulty in erupting and passing into normal position, and certain 
 forms of chronic pericementitis. 
 
 In short anything that will cause hyperemic condition of the peri- 
 dental membrane, and through that and over activity of the cementoblasts 
 is liable to cause hypercementosis, but the facts are that a very small per- 
 centage of teeth subjected to unusual stress or irritation of every kind are 
 ever affected with this disorder. 
 
 Pathology. 
 
 The pathology of hypercementosis is vague and uncertain, and many 
 writers are of the opinion that it has no defined or distinct pathology. 
 
 The facts are that most of the cases that have come under my obser- 
 vation presented no untoward symptoms of any kind, and were only dis- 
 covered when teeth were removed for other reasons. 
 
 A few writers report cases where hypercementosis seemed to be the 
 cause of trigiminal neuralgias ; shifting pains about the face, eyes and 
 ears have been attributed to this cause, but evidence is wanting to prove 
 such claims, and even when the extraction of such a tooth is followed by 
 cessation of pain does not prove it to be the cause. See chapter on neu- 
 ralgia. 
 
 Diagnosis. — A diagnosis can only be made by exclusion. 
 
 When every other possible cause of these disturbances has been 
 examined into wnth negative results, hypercementosis may be suspected, 
 but the only means of positively determining the existence or non-existence 
 of hypercementosis is the X-ray. 
 
 Resorption of the roots of permanent teeth. — By this term is meant 
 the absorption of portion of roots of permanent teeth. 
 
 As has been previously stated, cementum, and even dentin, is often 
 absorbed in certain areas and refilled with new cementum, and this appears 
 to be a purely physiological process. 
 
 The w^ork of cutting out is doubtless done by osteoclasts, a multi-nu- 
 cleated cell, M^hich is situated here and there among the pericementum 
 fibers. The work of building up is due to the cementoblasts which have 
 been referred to in the beginning of Chapter XII. 
 
i87 
 
 Many writers are of the opinion that when absorption is going on at 
 one point, an extra amount of cementum is being deposited at another 
 point. At what point the absorption process can be called pathological I 
 do not know, but it is my opinion that the entire process is physiological 
 and is Nature's method of getting rid of foreign inharmonious bodies. 
 
 That sometimes this normal process becomes perverted is doubtless 
 true, but as to why such is the case we do not know. 
 
 Cause. — That any mild irritant is likely to act as a cause, anything 
 that would act as a special stimulus to the osteoclasts would doubtless 
 cause resorption. 
 
 In these hollowed out places osteoclasts are found in great numbers 
 but as to the how or why they are there we do not seem to know. 
 
 The process is exactly the same as that occurring in implanted teeth, 
 but differs markedly from absorption of roots of temporary teeth. 
 
 Resorption occurring in permanent teeth seems to attack the 
 cementum much more rapidly than the dentin. In all the specimens that 
 I have seen even when the apex of the root was involved, the cementum 
 was removed from large areas of dentin, showing that dentin is more 
 resistant to its action, while if you examine a temporary undergoing this 
 process you will find the dentin is hollowed out, undermining the 
 cementum to considerable extent. 
 
 As to the pathology of resorption very little can be said as previously 
 stated. This is Nature's method of getting rid of any aseptic foreign sub- 
 stance, which doubtless explains why planted teeth lose their roots by this 
 process, because it must be quite clear to every one that a planted tooth, 
 which has no peridental membrane for its support and nourishment can 
 not be considered as anything but a foreign substance, although, of course, 
 more in harmony with its surroundings than most anything else that could 
 be put there. 
 
 This is Nature's method of getting rid of teeth, where their function is 
 accomplished, but once in a while a temporary tooth fails to absorb, and 
 insists on remaining even when the permanent one is ready to occupy its 
 place. 
 
 Why this is so, we do not know ; a good deal of guesswork has been 
 indulged in regarding this whole subject, and very little fact adduced. 
 
 Symptoms. 
 
 What are the symptoms of root resorption? 
 
 I do not know of any except in cases of plantation when the tooth 
 often has short periods of soreness, an itching feeling in the gums and 
 bone, and a feeling of uncertainty which is cleared up when the tooth 
 loosens and droDS out. 
 
Diagnosis. — In this case also a positive diagnosis can only be made by 
 the X-ray. 
 
 Treatment. — Relieve the conditions that present, look to the root 
 canal, and the peridental membrane and relieve any irritation that can be 
 found and failing to relieve and make the tooth comfortable, extraction 
 must be resorted to. 
 
CHAPTER XVII. 
 
 Resection of Roots ana Plantation of Ceetb. 
 
 Replantation as a Cure for Alveolar Abscess. 
 
 The operation of resection consists in the excision and removal of a 
 portion of any organ ; and is especially applied to the end of bones and 
 teeth. The resection of a root is an operation for the removal of its apical 
 end, although the term is often applied to operation for the renewal of an 
 entire root of a two or three rooted tooth to which the term amputation is 
 commonly given. 
 
 Elsewhere I have alluded to the fact that frequently in persistent 
 alveolar abscess the root apex is partially absorbed, resulting in very rough 
 sharp surfaces, which interfere with the healing process. In such cases 
 the operation of resection is advised especially when one of the ten 
 anterior teeth on either upper or lower jaw is involved. 
 
 On the molar teeth I do not consider this operation practical except 
 where the entire root is to be removed. The first step in resection after 
 the root canal filling is completed is to make all the surrounding tissues 
 surgically clean. 
 
 Next a circular incision is made in the gum over the root apex and 
 the flap thus formed is desected up and held with a suitable instrument ; 
 the root is exposed by cutting away the bone with a suitable bur in the 
 engine, oftentimes the bone has been absorbed to considerable extent 
 making this part of the operation very simple. The parts should now 
 be cleansed and bleeding stopped. With a bibevel drill a hole is made in 
 the center of the root a little above the point at which it is desired to cut 
 it off, Fig. 69 ; into this hole is introduced a fissure bur, the engine run 
 rapidly cutting to right and left from the hole, thus cutting off the desired 
 portion which can easily be removed with a small excavator. 
 
 The root end should be carefully rounded. (Fig. 69B.) 
 
 The entire pocket should be thoroughly curetted and washed out with 
 antiseptic gauze. The irrigation and packing should be repeated every 
 two or three days, using less gauze each time and watching that healing 
 from the bottom occurs. This operation is not difficult, and with the aid 
 of a local anesthetic can be done quite painlessly, and the results are quite 
 satisfactory. I know of several teeth doing good service that were thus 
 treated over six years ago. 
 
 Amputation. — The removal of the entire root of a molar tooth is to 
 be recomm.ended when that root has lost its membrane, and much of the 
 
190 
 
 Fig. 69. 
 A diagram of tooth with 
 apex absorption. a, the 
 drill hole; B, the finished 
 rounded tooth apex. 
 
 alveolus and the other root or roots are sufficiently healthy to insure the 
 useful retention of the tooth. 
 
 In some severe phagedenic cases, especially when complicated with 
 serumal calculus, we often find the lingual root of upper molars so badly 
 diseased that recovery is impossible and yet the two buccal roots may be 
 in a good state of attachment ; in all such cases amputation of the lingual 
 root is to be recommended. 
 
 This operation is very simple and is most easily done with a fissure 
 bur in the engine, cutting off the root on a level with the bifurcation ; the 
 root can easily be removed with a small elevator or root forcep. A stone 
 should then be used with which the tooth at this point should be beveled 
 toward the occlusal and lingual surface so that no shoulder remains on 
 which food will lodge (see Fig. 70). 
 
 Fig. 70. 
 Showing upper molar with 
 lingual root removed. (Black.) 
 
 The socket from which the root is removed should be curetted and 
 kept clean until it fills in with bone, which will be an added protection 
 to the remaining roots. 
 
 This operation is adapted to lower molars as well and in rare cases 
 to two rooted bicuspids (see Fig. 71). The prognosis for such cases is 
 
191 
 
 -very good, a great majority of such teeth when the operation has been 
 well done will do good service for many years. Indeed, I regard this 
 operation most satisfactory of all the operations suggested in this chapter. 
 
 Plantation. — The plantation of teeth has been practiced for many 
 years with varying success. The subject matter is best presented under 
 three heads : Replantation, which is the replacing of a tooth in the socket 
 from which it is removed ; transplantation, which is the insertion of a 
 natural tooth in a natural socket from which another was recently 
 extracted and implantation, which is the insertion of a tooth root in a 
 socket in the alveolus which has been artificially made. 
 
 The operation of replantation has been practiced for many years. As 
 far back as I have access to the literature, I find dentists have recommended 
 the immediate replacement of teeth that have been accidentally lost. 
 Indeed mothers and fathers have frequently replaced teeth of their chil- 
 dren that have been lost by accidental means such as blows, kicks of horses, 
 falls, etc., especially, when a thread of attachment remained, and in many 
 cases good results were obtained. These facts induced dentists to remove 
 teeth that were hopelessly diseased either from alveolar abscess or pyorrhea 
 trouble and replant them. 
 
 Replantation as a Cure for Jllweolar Abscess. 
 
 In some chronic forms of alveolar abscess where there is considerable 
 absorption of bone, replantation has been suggested as a cure and many 
 successful cases are reported, but this practice has been quite generally 
 abandoned in favor of the more successful method of curetting the bone 
 around the root apex, and the root as well when foreign deposits are 
 present or resection when the apex is absorbed or roughened. 
 
 Replantation as a cure for so-called pyorrhea alveolaris was practiced 
 to a considerable extent a few years ago, but at the present time has fallen 
 into disrepute, partly because of improved methods of treating the disease. 
 The operation consisted in the extraction of the affected tooth, immersing 
 it immediately in antiseptic solutions, under whch it is thoroughly cleansed 
 of all foreign matter and if roughened it is made smooth. 
 
 The, root canal is cleansed through the apical end unless a cavity exists, 
 then the canal is cjuickly dried and filled with gutta-percha, and the tooth 
 again immersed in the antiseptic solution, where it should remain until the 
 socket is made ready. The socket is thoroughly curetted and slightly 
 deepened, and the tooth inserted while fresh hemorrhage ensues. 
 
 The tooth must be immobilized by the use of bands, caps or wire 
 ligatures as seems best adapted to the case. This practice has been gen- 
 erallv abandoned for this class of cases because at best the alveolar process 
 
192 
 
 around the tooth in bad pyorrhea cases has already been destroyed to a very 
 considerable extent, and it is therefore quite impossible to establish a socket 
 that will retain the tooth for any great length of time ; I have had a few 
 cases remain two years. 
 
 Replantation is best adapted to those cases where healthy teeth have 
 been accidentally dislodged and which can be replaced within a short period 
 of time after the accident. 
 
 When such cases can be attended to within a few hours of the accident, 
 best results are obtained. In every case the root canal must be filled, and 
 the whole tooth rendered antiseptic, and the socket cleansed of blood clot, 
 and if possible a normal hemorrhage restored. The tooth is then forced to 
 place and retained by some of the appliances previously suggested. 
 
 I have a case of this kind where two centrals have remained for eight 
 years, and are still doing good service. 
 
 Transplantation. — When from any cause a tooth is lost from a com- 
 paratively good socket it may be replaced by another tooth. 
 
 There are several things in the way of this operation which relate to 
 the difficulty of getting a freshly extracted tooth adapted as to size, shape 
 and denomination, to fit the already existing socket and m.any a patient is 
 reluctant about having some other person's tooth in his mouth, and there 
 in some danger of transmitting disease. 
 
 Some operators recommend old, dry teeth, but I have not been suc- 
 cessful in their use, and among my professional acquaintances I find the 
 practice has been quite generally abandoned, although there might be 
 exceptional circumstances where it could be recommended, but a freshly 
 extracted root even if an artificial crown is necessary, will often give 
 sufficient service to repay for the trouble. 
 
 Implantation. — Dr. Younger was the first dentist to give any 
 prominence to this operation and I think he is justly entitled to the author- 
 ship of this operation as it is practised at the present time. 
 
 His first great recorded operation was in 1885, since which time he 
 has probably performed it more than any other operator, and his success 
 is probably due to his splendid skill. 
 
 In this operation a tooth is taken from another mouth and planted in 
 a socket which is artificially made in the alveolus. The operation is 
 intended to supply a missing tooth where one has failed to erupt or where 
 it had been extracted some years before. Here as in other cases a freshly 
 extracted tooih or root is to be desired. 
 
 The special instruments necessary with which to perform this opera- 
 tion are the Younger trephines illustrated (Fig. 72) ; Ottofy spiral knives 
 (Fig. 74), and the Ottolengui reamers (Fig. 73), and a few long-shanked 
 burs of dififerent shapes (Fig. 75). 
 
Fig. 71. 
 
 Showing lower molar with 
 distal root removed. (Black.) 
 
 Fig. 73. 
 Younger trephines. 
 
 Fig. 73. 
 Ottolengui's reamers. 
 
 Fig. 74. 
 Ottofy's spiral knives. 
 
 ,12 3 4 
 
 Fig. 75. 
 Long-shanked burs of necessary shapes. 
 
194 
 
 The first step in this operation is to select a tooth that will fill the 
 space accurately, and if a root an artificial crown must be properly 
 adjusted both as to shape, form and contour. 
 
 The tooth should be kept in an antiseptic solution, and all the work 
 done under antiseptic precautions. 
 
 Local anesthetics are all that are usually needed, although in many 
 cases general anesthesia will have to be resorted to. 
 
 The writer follows the method outlined by Dr. Ottofy in 1887, which 
 is as follows : A deep incision is made in the gum and periosteum at a 
 point that will form the lingual gingivus (Fig. 76), and turned up and 
 out toward the labial. (See Fig. yj^. 
 
 Fig. 76. 
 Showing Dr. Ottofy's in- 
 cisions. 
 
 Fig. 77. 
 Showing the flap as sug- 
 gested by Dr. Ottofy. 
 
 With proper trephines, knives and burs a socket is drilled to receive 
 the new root. The tooth should be tried in the socket at frequent 
 intervals to insure a proper fit, bearing in mind that the root must fit 
 the socket very tightly. After the socket is drilled it must be cleared of 
 blood clot and bone chips and a fresh hemorrhage started into which the 
 root is forced and retained by a suitable appliance. Every efl^ort should 
 be made to keep the parts antiseptic until healing is complete. 
 
 General considerations. — Planted teeth are only held in the socket by 
 the deposit of bone around the root and the union is only a mechanical one. 
 
 The peridental membrane is never again formed or reattached except 
 in very rare instances where teeth have been immediately returned to other 
 sockets when only partially knocked out. 
 
 Dr. Younger and many others have held that there is a rejuvenation 
 and reattachment of the membrane, but careful investigation does not 
 substantiate their claims. 
 
 However, it must be said that such teeth often become more firm 
 in the jaw, and require greater force to dislodge them than their neigh- 
 bors, which is accounted for by the fact that the newly formed bone 
 is more dense, and has not the natural channels through it that are present 
 in the normal alveolus. 
 
 When planted teeth are lost it is usually by process of absorption. 
 This absorption sometimes begins at the apex and gradually proceeds 
 crownward, but more often it begins on the sides of the root ; this process 
 
195 
 
 sometimes ceases for a time and bone is deposited in these places, but 
 sooner or later all these teeth will be lost, quite after the plan of absorption 
 of temporary teeth. 
 
 The operations of transplantation and implantation should be con- 
 fined to the incisors, cuspids, and bicuspids, and should only be attempted 
 where it seems very undesirable to replace the missing teeth with artificial 
 ones either in the form of plates removable or fixed bridges. 
 
 At this time when the means of reproducing the natural tooth is so 
 good, both as regards appearance and usefulness these operations are not 
 frequently indicated especially when we remember that planted teeth only 
 last from two to six years, and at best not more than fifteen years. 
 
 And at best the operation is quite severe on the patient even when 
 an anesthetic is employed. 
 
CHAPTER XVIII. 
 
 Diseases of tbe Soft tissues of tbe IDouth. 
 
 Stomatitis. Aphthous Stomatitis. Treatment. Ulcerative Stomatitis. Mercurial 
 
 Stomatitis (Ptyalism). Symptoms. Treatment. Eczema of the 
 
 Tongue. Leukoplakia. Causes. Treatment. 
 
 Stomatitis. 
 
 The word stomatitis is of Greek origin and signifies inflammation of 
 the mouth. 
 
 Acute stomatitis is the most common form of mouth inflammation, 
 and is usually the result of som.e local or constitutional irritant. It is 
 frequent in all ages and is often associated with acute attacks of indiges- 
 tion following acute specific fevers. 
 
 In poorly nourished children it is often associated with dentition or 
 may appear as a result of some gastro-intestinal disturbance. Tobacco 
 users often suffer from this affliction, but more particularly have I seen 
 it in the mouths of excessive smokers of cigarettes. 
 
 The chief characteristic of this disease is a general redness and dry- 
 ness of the gums, sometimes extending to all the membranes of the mouth 
 and lips, and the tongue may be slightly swollen, furred and indented 
 along its margins by the teeth. All the mucous membrane may become 
 tender to the touch and severely painful in mastication and particularly 
 if hot drinks be taken. - 
 
 Sometimes in children the temperature will rise one or two degrees. 
 Treatment consists in removing the cause as far as possible and applying 
 weak solution of nitrate of silver or chloride of zinc, three grains to the 
 ounce, to the afflicted parts, and the frequent use of a borax mouthwash. 
 
 Jlpbthous Stomatitis. 
 
 This form is often spoken of as follicular or vesicular stomatitis. 
 It usually appears in the form of small, slightly elevated spots about two 
 ram. in diameter surrounded by a somewhat reddened zone ; these vesicles 
 soon rupture, forming ulcers with grayish bases and bright red margins. 
 
 The ulcer seems to sink into the tissue and the margins stand up 
 above the surrounding parts. They most frequently occur on the margins 
 of the tongue, inner surface of the lip and cheek. 
 
 They are usually associated with an attack of nervous indigestion, 
 but many observers seem to be of the opinion that they may exist, as an 
 independent affection. They occur in young children's mouths very fre- 
 
197 
 
 quently, and I have served patients past the age of forty that suffer 
 almost continually from them. The rapidity with which they form is a 
 peculiarity of them. 
 
 The ulcers are usually very painful to the touch, making the taking of 
 food difficult, and greatly interfering with dental operations, when present 
 on the lips or cheeks. Young children complain of the pain and refuse 
 to take food. 
 
 treatment 
 
 The local condition can usually be benefitted and the painful ulcer 
 entirely relieved by touching it with a saturate solution of nitrate of silver. 
 This remedy is so violently escharotic that care must be taken not to get it 
 anywhere but on the ulcer, which will soon present a white coagulated 
 appearance. ■«' 
 
 The ulcer should be kept dry for a few minutes after the application. 
 One painting is usually all that is needed. An alkaline antiseptic wash 
 should be prescribed, and patient referred to a physician for constitutional 
 treatment if the local conditions are at all persistent. 
 
 Parasitic stomatitis or thrush, as it is commonly called, is a peculiar ' 
 inflammation of the mucous membranes of the mouth. It is most com- 
 monly seen in very young children, and is dependent upon a peculiar 
 fungus called the saccharomyces Albicans. The fungus belongs to the 
 yeast family and has branching filaments. (Fig. 78.) 
 
 Fungus 
 
 Fungus 
 
 Fig. 78. 
 Ordium Albicans (thrush fungus). (Marshall.) 
 
198 
 
 Osier says this disease does not arise in a normal mucosa, but may 
 rapidly develop in unclean mouths, especially when catarrhal conditions 
 of the mucous membranes are present, and acid fermentations of food 
 remnants is permitted to occur. 
 
 This disease is not confined to children, but is often met with in adults 
 during final stages of fever, chronic tuberculosis and kidney diseases. 
 The disease usually attacks the tongue first, and then rapidly spreads to 
 all mucous surfaces, and appears as slightly raised, pearly white spots 
 which gradually enlarge and coalesce. 
 
 The parasite develops in the upper layers of the mucous membrane, 
 and its filaments rapidly penetrate the epithelial cells, forming a dense net- 
 work which can readily be scraped off, or if left alone in a short time 'will 
 slough off, leaving a raw, bleeding, ulcerating surface, differing entirely 
 from mucous patches which are confined to a small depressed area, while 
 in thrush, the whole surface soon becomes involved. 
 
 Thave seen a few cases where the entire mucous membrane on the 
 lips, tongue, palate and cheeks were covered with what appeared to be 
 a fuzzy grayish white membrane. A few cases are reported where this 
 disease has extended to the soft palate, the throat and the stomach. 
 
 It is not often that the dentist is called upon to treat these cases, but 
 he should be familiar with its clinical appearance. 
 
 It is epidemic in the spring and fall and in babies it is often the direct' 
 result of improper care of nursing bottles and nipples. 
 
 Treatment. — The child's mouth must be kept scrupulously clean and 
 an alkaline wash used to relieve the burning sensation. A little lime 
 water administered will often correct the acid mucous secretions and do 
 away with the pain. 
 
 Osier suggests the use of a borax spray ; the phenate of soda is also 
 recommended. 
 
 Sudduth suggests the following prescription : 
 
 Acidi Carbolici 3 h i 
 
 Olei Gaultherise 3 h ii 
 
 Olei Menthse Peperitae I h iii 
 
 M. Sig. Use as a spray. 
 
 In every case the patient's general health miust be looked after by the 
 physician, for in these cases it will usually be found that the child's nutri- 
 tion is poor, presenting some marked disturbance of digestion. 
 
 Gangrenous stomatitis (concrum oris noma) is an affection char- 
 acterized by a rapidly progressing grarigrene usually beginning in the 
 gums, and soon extending to the cheek, rapidly leading to sloughing and 
 destruction. 
 
199 
 
 It is the most formidable disease of childhood and fortunately it is 
 "very rare, and is seen only in children living under most unsanitary con- 
 ditions or many times during convalescence from severe acute fevers. It 
 is most frequently seen between the ages of one to five years, and is 
 more common in girls than boys. 
 
 Some authors think it due to some specific organism, but it seems 
 more like a coagulative necrosis. It usually attacks the gum high up on 
 the buccal side of upper molar, and when first seen the mucous membrane 
 only is affected but soon leads to induration of all the adjacent tissues ; 
 the sloughing extends and the blood vessels supplying the part are soon 
 affected and the whole tissue of the cheek becomes hard and indurated and 
 filled with pus and fibrin, and soon the cheek is perforated and intense 
 inflammation spreads rapidly, and the tissues rapidly ulcerate away. 
 
 Severe constitutional disturbances ensue, the pulse rapid, tempera- 
 ture high, prostration very extreme and death within a week usually from 
 perforation of a large vessel and hemorrhage; the child passing into a 
 comatose state passing away without pain. 
 
 The treatment of this disease is usually unsuccessful. The constitu- 
 tional conditions must be met. nourishments and tonics given. 
 
 The diseased parts should be burned with the cautery and nitric acid 
 applied to the edges of the ulcers, and deodorant antiseptic lotions applied 
 to destroy the very fetid odor which is always present. 
 
 ,When the disease is recognized and treatment begun early recovery 
 may be hoped for. • 
 
 Ulcerative Stomatitis. 
 
 This form of stomatitis usually begins at the free margins of the gums, 
 which become red and swollen and bleed on the slightest touch. At the 
 outset the mouth is hot and painful, and saliva flows freely, and the breath 
 is offensive. The glands are usually swollen, and also the lips; a rash 
 often appears resembling measles. 
 
 As the disease progresses ulcers appear along the gum margins of 
 both upper and lower jaws. At the base of these ulcers is a firmly 
 adherent grayish white membrane ; and in very severe cases the edge of 
 the alveolus may become necrosed and the teeth loosened. 
 
 It is a disease that rarely proves fatal, although death occasionally 
 results in very debilitated children. The local treatment is to clean the 
 teeth and treat the ulcers with dilute chloride of zinc, or what is better, 
 the powdered chlorate of potassium applied directly. 
 
 Osier recommends the administration of chlorate of potassium in lo 
 grain doses, three times daily. Fresh air, wholesome food, proper elimina- 
 tion, are the essential requirements as general treatment for this, and all 
 other forms of ulcerations about the mouth. 
 
200 
 
 mercurial Stomatitis (Ptyali$m). 
 
 This is an inflammation of the mouth and sahvary glands caused by 
 mercury. It occurs in individuals whose business is associated with the 
 constant handling of mercury and only rarely now as the result of mercury 
 administration. 
 
 Twenty years ago this disease was very common when large mercury 
 dosing was frequent and even now in an especially susceptible case mild 
 attacks are seen, especially in individuals undergoing mercury treatment 
 for specific disorders. 
 
 It should be said here that individuals differ greatly in this regard, 
 and the susceptible cases cannot be distinguished beforehand, so that the 
 physician needs to be on his guard and watch for the first signs of stoma- 
 titis, when the drug should be suspended for a time. 
 
 As soon as the gums are touched, the drug should be discontinued. 
 To produce mercurial ptyalism it is not necessary that large doses be given, 
 indeed many cases are recorded where a dozen doses of calomel i-io grain 
 four hours apart produced serious results. 
 
 Symptoms. 
 
 The first mdication of this affliction is a metallic taste which is soon 
 followed by swelling and redness of the gum margins, teeth become sore 
 and mastication difi:icult. The saliva begins to flow freely, and by and by 
 runs out of the mouth. The breath becomes foul, tongue swollen, and 
 after a few days ulceration of the gum margins appear and necrosis of 
 particles of the alveolar border. 
 
 The teeth become loose and in many instances are lost or so affected 
 that marked recession of the gum and absorption of alveolus results, which 
 so weakens the structures that eventually the teeth, are lost, and in a few 
 instances necrosis of the lower jaw results. Marshall reports only two 
 cases, both of which proved fatal. 
 
 treatment. 
 
 The treatment must be largely symptomatic. The drug should be 
 discontinued immediately or if the affection has resulted from the fumes 
 while handling mercury the patient should get away from those surround- 
 ings. In either case the mercury should be driven from the system by 
 the administration of alkaline waters in large quantities and frequent hot 
 baths given. 
 
 If there is much salivation and accompanying prostration, the patient 
 should be given atropine and other supporting treatment, liquid nourish- 
 ment should be freely given, and if the pain is severe, Dovers powders 
 should be given. 
 
201 
 
 The local treatment consists in cleaning the teeth and gums as well 
 
 as possible, and an application of chlorate of potassium mouth wash. If 
 
 ulceration appears astringent mildly escharotic agents should be applied. 
 
 The case should be watched for several days, and if looseness of the 
 
 teeth appears the application of iodide of zinc will be helpful. 
 
 A word should be said here regarding the general catarrhal inflam- 
 mation of the membranes of the mouth, throat, and nose, which is so 
 common in this climate. 
 
 In these cases all the membranes are more or less afifected and present 
 a decidedly reddened appearance more severe in some spots than others, 
 and arc usually accompanied by slight digestive disturbances. Unless 
 some attention is paid to it more severe forms may result. 
 
 The treatment consists in correcting the digestive disturbances ; and 
 spraying the mouth, throat and nose with a carbolic acid and m^enthol 
 solution several times a day until relieved. 
 
 Phosphorous necrosis.— This subject does not properly come under 
 the scope of this book, and is only presented because of its similarity to 
 mercurial stomatitis. 
 
 Phosphorous necrosis is the result of poisoning from fumes of phos- 
 phorous and is only seen in the individuals who work in match factories, 
 fertilizer factories and the like. 
 
 Etiology. — There is some difference of opinion as to the exact mode 
 of attack, but the preponderance of evidence seems to prove that the 
 phosphorous necrosis is the result of local poisoning produced by the 
 fumes entering the tissues through some break in the continuity of the 
 mouth structures whereby they get access to the periosteum (Marshall), 
 and carious teeth seem to be the most frequent route through which the 
 fumes pass to the periosteum. 
 
 Symptoms.— This affection usually begins to manifest its presence by 
 mild toothache and pain about the jaws ; soon the pain becomes severe and 
 . swelling starts and spreads rapidly until the entire face and head are 
 involved ; it may affect one or both sides. 
 
 Abscesses rapidly form and may discharge on the face. The pus is 
 very offensive and may exude around the necks of the teeth, which soon 
 become loose, and small pieces of bone will often work out around the 
 gum margin. ' Sometimes several teeth will be retained in a sequestrum of 
 bone, which can readily be removed. 
 
 Treatment consists of supporting the general system, meeting any 
 special conditions that may arise and surgically treating the necrosis. 
 
 Glossitis and eczema of the tongue— The tongue is liable to the same 
 forms of catarrhal inflammation as the other soft tissue of the mouth and 
 
202 
 
 throat, and the ■ treatment must be suited to each condition beside these 
 local affections.^ 
 
 The tongue is the index to many disorders of the general system. 
 In health it presents a moist, smooth, pink surface, and any change from 
 this indicates some pathological conditions not usually of itself, but more 
 frequently of the general system of which Sudduth gives the following 
 interpretations. 
 
 "A white coated tongue denotes febrile disturbance ; a brown moist 
 tongue indigestion; a brown dry tongue, depression, blood-poisoning, 
 typhoid fever ; a red, moist tongue, feebleness, exhaustion ; a red, dry 
 tongue, inflammatory fever ; a red glazed tongue, general fever ; a tremu- 
 lous, moist and flabby tongue, with blue appearance, tertiary syphilis. 
 
 "A moist, flabby tongue, with the imprint of the teeth in its sides, indi- 
 cates general anemia ; a pointed tongue shows intestinal derangement ; a 
 yellow furred tongue indicates bilious disorder; a moist tongue is a good 
 indication of sickness ; while a dry tongue represents the converse 
 condition.^' ■ 
 
 Glossitis signifies inflammation of the tongue. It may be either 
 acute or chronic. 
 
 The acute form may often be the result of careless use of dental 
 instruments. Recently I attended an alarming case where the tongue 
 was badly lacerated as a result of tooth extraction. The patient had been 
 put under gas anesthesia and accidentally the mouth prop slipped out of 
 place and the jaws closed, and the tongue was caught between the teeth, 
 resulting in cutting and tearing the tongue badly ; infection resulted, fol- 
 lowed byvery alarming symptoms, several abscesses formed in the tissues, 
 a rise of temperature to 104 degrees, and almost total collapse from the 
 pain. The tongue was so badly swollen that deep punctures with a 
 bistoury were necessary. 
 
 I have also seen a few cases where the tongue was infected from 
 injuries made with broaches, scalers, forceps, etc. 
 
 Treatment. — In ever}^ case the conditions present must govern the 
 treatment. The general elimination must be looked after, abscesses 
 opened and drained, ulcers cauterized and general antisepsis maintained. 
 The tongue usually makes quick recovery where proper treatment is 
 instituted. . : 
 
 eczema Of tbe tongue. 
 
 This is a disease of the tongue which is characterized by remarkable 
 sloughing off of the outer epithelium. It usually begins in small patches 
 which gradually spread, uniting with one another, presenting an irregular 
 shaped raw surface which has been likened to a geographical map. 
 
203 
 
 It is usually accompanied with a good deal of itching and burning 
 pain. The etiology of the disease is not known and treatment consists in 
 frequent applications of solution of nitrate of silver. 
 
 Ceukoplakia. 
 
 Leukoplakia buccalis is a subject that has received considerable atten- 
 tion of late from many writers. The term leukoplakia is derived from 
 the Greek and signifies white plates or plaques. 
 
 The affection is often referred to as buccal psoriasis, leucoma, ichthy- 
 osis linguate, smokers' patches and superficial glossitis. 
 
 Leukoplakia is a chronic inflammation of the mucous surface which 
 manifests itself in irregular thin, smooth patches, white or pearly white 
 color, which show no tendency to ulcerate. The spots are hard and 
 resemble corns, indeed they are sometimes termed lingual corns. 
 
 The ichthyos variety, however, resembles warts more than corns and 
 are slightly raised. 
 
 Location. — The plaques most frequently appear on the dorsum of the 
 tongue, but many may be seen on its margins and all the mucous surfaces 
 of the m.outh. 
 
 Marshall reports several cases where the beginning was on the 
 gingivus, others on edentulous spaces in the upper jaw, and a few on the 
 buccal gum of the lower jaw. 
 
 Etiology. — The etiology of leukoplakia is not well understood and 
 marked difference of opinion is expressed by different writers. Some 
 writers regard it as a mouth manifestation of psoriasis and others think 
 it a form of skin disease resembling herpes zoster or hives. 
 
 Many seem to regard it as due to syphilis, and still others think it is 
 a purely local affection induced by smoking tobacco. The bulk of evi- 
 dence seems to point out that this is a distinct affection, and while it 
 resembles some mouth manifestations of other diseases still it does not 
 often appear in connection with any of them. 
 
 Women seem to be almost entirely free from it so far as I can learn, 
 and it rarely manifests itself in men under twenty-five and most frequently 
 about the age of fifty. A little experience in observation of these cases 
 will enable the dentist to distinguish these plaques from syphilitic mucous 
 patches. 
 
 The latter always present a curdy grayish white appearance and are 
 slightly raised above the surrounding tissue. Syphilitic patches show a 
 tendency to ulcerate and discharge a thin watery fluid and on the surface 
 look like a corroded spot and always yield readily to treatment. 
 
 If any doubt exists a short course of mercury treatment will clear 
 the matter up. The dentist should be familiar with all these mouth 
 affections. 
 
204 
 
 Leukoplakia plaques may extend in size and become papillomatous and 
 many instances are recorded where genuine epithelioma was developed 
 from them. 
 
 Marshall calls special attention to this affection for following reasons. 
 
 I. It is an exceedingly dangerous affection, often being a forerunner 
 of carcinoma. 2. It is a disease which from its innocent appearance and 
 the painless character of its early stage is seldom recognized until the dis- 
 ease has progressed to a stage which renders a favorable prognosis exceed- 
 ingly doubtful. 3. The disease seems from personal observation to be 
 on the increase. 4. The dental surgeon, from the very nature of his spe- 
 cialty, is in a position to see and recognize the disease in its earliest stages, 
 and to warn the patient of his condition before it has progressed so far 
 as to prove a menace to life. 
 
 The disease in its earliest stages is much more likely to come under 
 the notice of the observing dentist, or stomatologist, than of the surgeon 
 or the laryngologist. As a rule the patient does not consult a surgeon 
 until the disease becomes troublesome ; it may then have progressed so 
 far as to give unmistakable evidences of degenerative changes of a 
 malignant character. 
 
 The dentist therefore should be so familiar with the characteristic 
 features of the disease that he could recognize it at a glance ; while it 
 would be his duty to impress upon the patient the urgent necessity of con- 
 sulting an oral specialist with the view of instituting measures calculated 
 to arrest its further development, or for its complete extirpation. 
 
 The causes of leukoplakia seem not to be well understood. Many 
 writers seem to think there is always a peculiar thinness of the mucous 
 membranes prone to eruption of every sort and regarded as especially deli- 
 cate. Many claim that chronic dyspepsia and gout predispose the indi- 
 vidual to this affliction. 
 
 The exciting cause is charged to the use of tobacco, particularly the 
 pipe and cigarettes, and the use of undiluted spirituous liquors ; but any 
 constant irritant such as ill-fitting plates, rough teeth, large amount o£ 
 salivary calculus may be exciting causes also. 
 
 treatment. 
 
 This affliction does not readily yield to treatment, and most authors 
 recommend that it be let alone, but a few suggest the use of a i per cent 
 solution of chromic acid applied directly to the patch. 
 
 All sources of irritation should be removed. When the spots take on 
 a papillomatous form they should be surgically removed. Many authors 
 recommend this procedure for all forms of the disease as the only means 
 of cure. 
 
CHAPTER XIX. 
 
 Oral in<inife$tmion$ of $ypl)ili$. eencral Considerations. 
 
 Location. Source of Infection. Diagnosis. Tlie Dry Scaling Papule. Pathology. 
 Positive Diagnosis. The Secondary Stages of Syphilis. Secondary 
 Eruption. Treatment. Tertiary Syphilis. Congenital 
 Syphilis. An After Word. 
 
 At the outset I wish to say that no description that I can give will 
 convey such accurate knowledge of the appearance of primary syphilis as 
 can be obtained by seeing a few cases. 
 
 "Syphilis is a general infectious disorder, both acc^uired and transmis- 
 sible by inheritance, chronic in course, and displaying in a determinate 
 order specific symptoms." — Hyde. It is produced by a specific micro- 
 organism whose identity has not been definitely established. 
 
 The history of the disease extends as far back as we have any records, 
 and its ravages at the present time are simply appalling. "The infection is 
 always conveyed from one to another either by direct contact or through 
 the medium of some instrument, utensil or other article upon which it has 
 been deposited." — Baldwin. 
 
 Before infection can occur it is not only necessary that the virus be 
 present, but it must gain entrance to the system through some abraded 
 surface. It cannot enter through the healthy skin or mucous membrane, 
 but so virulent is this disease that if the virus does find such an entrance 
 to the circulation syphilis will certainly develop. 
 
 Cocation. 
 
 Next to the genitals the mouth is the most frequent location for the 
 primary lesion, and it is because of this fact that dentists should be very 
 familiar with its many manifestations. It has been stated by several 
 syphilologists that over 70 per cent of all extra genital chancres are found 
 in the mouth, tongue, gums, tonsils, avula and buccal mucous membrane, 
 and of all these, the lips and tongue are most frequently affected. 
 
 The most frequent modes by which transmission of virus occurs are 
 kissing, passing around smoking pipes, using common towels and hand- 
 kerchiefs, drinking vessels, knives and forks, blow pipes, whistles, wind- 
 instruments, tooth brushes, and, in the case of infants, the nursing bottle 
 is a frequent source. 
 
 Source of Infection. 
 
 The infectious material may come from both primary and secondary 
 lesions and from the blood of the victim. These secretions when deposited 
 
206 
 
 on towels, etc., and allowed to dry are still infectious during these 
 periods, but all the other secretions of the body are regarded as non- 
 infectious, as is also true of all secretions in the tertiary stage. _ 
 
 Diagnosis. 
 
 When infection occurs there is within twenty-one days a primary 
 sore developed which is termed a chancre. The period of incubation 
 varies from six to thirty days. These chancres are always single and 
 are not auto-inoculable. They differ in appearance, each presenting 
 certain marked characteristics. 
 
 These variations may depend on accidents attending inoculation, 
 peculiarities of the individual, or on the particular tissue affected. The 
 typical and most usual form of chancres as seen on the lip is what is 
 known as the Hunterion or ulcerating chancre (Fig. 79). 
 
 Fig. 79. 
 
 Chancre of the upper lip. 
 
 (Barrett.) 
 
 In common with most forms of chancre, this variety begins in a 
 small papilla, which very soon sloughs off its apex and presents a deep 
 red round or oval ulcer. The margins are usually elevated and very red. 
 
207 
 
 while the center is concave and presents an ulcerating appearance and 
 secretes a thin serous fluid, and not infrequently this sore may become 
 infected with pus or other germs, when a mixed infection occurs, result- 
 ing in deceiving complications. This form is always on the mucous 
 surface. 
 
 Superficial chancrous erosion is a form frequently met with in the 
 mouth. It begins with a little round or oval red spot, from which the 
 epithelium soon sloughs off, giving the appearance of a raw sore, which 
 is never deep and presents a smooth surface, which occasionally may be 
 covered with a gray film, which makes it easily mistaken for leukoplakia 
 or aphthous stomatitis. 
 
 The duration of this form of chancre is usually short and often goes 
 •unnoticed until constitutional symptoms appear. 
 
 Cbc Dry Scaling Papule. 
 
 This variety begins in a small dull red slightly elevated papule, 
 which gradually elevates and turns purple ; it is hard to the touch. The 
 outer epithelium is soon lost, presenting a dry crust. When found in 
 the mouth is usually seen at the junction of two mucous surfaces, and 
 those I have seen were high up on the buccal gum over the upper third 
 molar. 
 
 The incrusted chancre is the variety usually seen on the skin, and is 
 the form usually seen when the finger or other part of the hand has been 
 accidentally infected. 
 
 The indurated nodule is the form usually seen at the junction- of the 
 skin and mucous membrane, particularly of the lip. It-has a sharply 
 defined plaque, or nodule, elevated with sloping edges and is dry. 
 
 When the primary sore appears on the lip, it is most apt to occur 
 in the fissure in the mnddle of the lower lip or on the upper a little to 
 one side of the median line (see Fig. 79). Of course it may occur at 
 any other abraded point. 
 
 As previously stated, it is the ulcerating chancre that usually appears 
 on the lip and presents a vermilion border with red or grayish base. 
 When it occurs on the outside of the lip it usually presents considerable 
 induration, but when within the lip little or no induration. The sub- 
 maxillary glands are always enlarged. 
 
 When the chancre occurs on the tongue it is usually flat or very 
 slightly elevated, usually reddish, and when just at the tip the appear- 
 ance is often as though a piece had been cut ofif. It is usually sharply 
 defined, and can readily be distinguished from ordinary aphthous 
 patches by its elevated border and less concave center (Fig. 80)-,- but 
 when doubt exists watch for the enlargement of the suprahyoid glands.- 
 
208 
 
 Fig. 80. 
 
 Syphilitic ulcer on the tongue. (Black.) 
 
 Patbology. 
 
 The pathology of the initial chancre is one of unusual interest. 
 When the virus is planted an interesting cycle of phenomena at once 
 begins. "Here if it finds favorable soil it grows and slowly increases till 
 its intrusive presence becomes a source of offence to the tissues harboring 
 it, and gradually inflammatory reaction sets in." — Bronson. 
 
 At first it does not appear that the virus passes directly into the 
 circulation, or if it does it is in such small quantity that it does not 
 make an impression, for not until after the chancre appears do we see 
 any manifestations of general infection. 
 
 The pathological changes in the tissues at the point of infection, are 
 described by Baldwin as follows : 
 
 "When the poison of syphilis is deposited on an abrasion in otherwise 
 healthy skin, a cycle of phenomena at once begins. The first manifesta- 
 tion of this cycle is the infiltration of the tissue at the site of infection 
 with small round cells, exactly as in any inflammation. With these 
 small round cells are also to be seen large round or oval and polyhedral 
 cells, filling up the interstices between the meshes of the network of 
 blood capillaries. 
 
 "At first the blood vessels are involved, but by extension they are 
 included in the inflammatory process. No connective tissue of a perish- 
 able or embryonic type is formed. This tendency to connective tissue 
 formation is also observed in the tertiary stage in lesions of the nervous 
 system due to syphilis. 
 
 "The lymphatic channels are soon involved in the inflammatory process, 
 and the virus, which is either a microbe, or, as Otis suggests, a microbe- 
 bearing cell, is borne along these vessels to the nearest lymphatic glands. 
 
209 
 
 it is deposited, and the same process of inflammation is repeated and the 
 glands become swollen and indurated. 'First intuition virus' of infection 
 has traveled. This is the period of first incubation.'^ 
 
 The microscopical changes are at first those that occur in all forms 
 ■of local inflammation. The white blood cells flock to the seat of infec- 
 tion and are soon modified by the action of the virus, and it is the 
 cells that carry the infection to other parts of the body, particularly to 
 the lymphatic glands. 
 
 Chancroid is a soft chancre which does not incur any constitutional 
 ■symptoms. It is of a pustular form and its secretions are infectious and 
 also inoculable, and hence they are usually multiple. It is never seen in 
 the mouth and causes no mouth lesions, and therefore has no special 
 interest to dentists. 
 
 Positive Diagnosis. 
 
 I scarcely need remind the reader that it is not always possible to 
 distinguish the beginning of chancre in the mouth from many other 
 mouth lesions, and while I have tried to point out the distinguishing 
 •characteristics they are not always an infallible guide, and even in the 
 more advanced stages it is rarely wise to trust the history obtained from 
 the patient, for they will usually deny any knowledge of it, some be- 
 cause they do not know it and others because they wish to conceal it 
 from the dentist; and yet every sore on the lips and in the mouth should 
 not be suspected to be of specific origin, and we should be careful about 
 alarming patients by stating positive conditions until they are positively 
 proven. 
 
 Many of these cases are first seen by the dentist, for when the 
 primary sore appears in the mouth the patient usually consults the dentist, 
 thinking it to be associated with some affection of the teeth. 
 
 The first duty of the dentist is to obtain the history of the case, even 
 though in some instances he may have to listen to a carefully concocted 
 -Story as to how the infection occurred, that will more than tax the cre- 
 dulity of the novice. 
 
 To one who has a little experience these stories serve as convincing 
 proof of the conditions present. If there can be no definite history ob- 
 tained then we must wait the development of positive proof, which if 
 not immediately seen in the characteristic appearance of the sore will be 
 ■cleared up in a few days by the appearance of glandular enlargements 
 and indurations, which ushers in the period of second incubation. 
 
 From quite an extensive experience in handling syphilitic cases in all 
 stages of the disease, I find that nearly every sufferer is glad and anxious 
 to furnish you all the information at his command. 
 
210 
 
 The treatment of the primary lesion is to apply some form of cau- 
 tery, usually nitric acid, nitrate of silver or chromic acid, but the most 
 important thing is to clean the mouth and put the patient in the hands of 
 a competent specialist, who will put him through a thorough course of 
 treatment which will eventually drive the virus from the system. 
 
 This treatment consists in the use of mercury and potassium salts, 
 which are pushed to the limit of tolerance, each alternating with the 
 other. This disease is considered very amenable to treatment, but it 
 requires from two to five years to accomplish a cure, which cannot even 
 then be considered permanent or positive. 
 
 Cbe Secondary Stages of Syphilis. 
 
 While the primary manifestations of syphilitic infection is in a local 
 lesion or chancre, sooner or later distinct signs appear which show that 
 the whole system is being infected. These signs, which are at first 
 scarcely noticeable, become pronounced toward the end of what is known 
 as the second incubation period. 
 
 "In distinction from all other known infectious diseases, syphilis 
 has a second period of incubation, by which is meant the time elapsing 
 between the advent of the so-called secondaries — a generalized eruption 
 and its concomitants." — Ziesler. 
 
 The secondary manifestations of syphilis begin to appear about the 
 fourth week, although it should be stated that sometimes they appear 
 in twelve days, and occasionally they never appear, the patient skipping 
 periods of several years, when the tertiary or third stage may appear. 
 
 The secondary manifestations are usually ushered in by a short 
 period of fever and fatigue and headache, particularly over the frontal 
 region. As soon as the initial sore has taken root there is some general 
 morphological changes in the blood and the glands in the neighborhood 
 become indurated, especially the small glands about the neck and behind 
 the ears ; they attain the size of small peas. 
 
 It is probable that the virus is carried throughout the system through 
 both the lymph and blood vessels. The hair begins to fall. 
 
 Secondary eniption, 
 
 , The recognition of the secondary eruption is very important because 
 it not only confirms the diagnosis, but its secretions are also infectious, 
 and the mucous patches which usually develop are most frequently the 
 source from which infection is disseminated. 
 
 These eruptions begin in the form of a rash known as syphilides, and 
 which assume every variety of form that the nature of the skin and 
 mucous membrane will permit. 
 
311 
 
 Syphilides are always situated in the papillary layer of the skin, and 
 appear at different parts of the body; they have their beginning in a 
 kind of roseola or skin redness over the abdomen, front of the leo-s, 
 back of the neck and scalp. 
 
 Fig. 81. ' ' 
 
 .Syphilides on 'the face. (Fox.) 
 
 The face is not so often affected except in the more severe forms 
 (Fig. 8i). The mucous membranes of the mouth are often affected. 
 These syphilides may present in any or all of the following forms : erythe- 
 matous (red blotches), copper colored spots, scaly spots, vesicular pimples, 
 tubercular nodules, rupial or crusty form ; all of these forms may exist on 
 the same subject and many intermediate forms as well. The first mani- 
 festation in the mouth of this secondary stage is the presence of erythe- 
 matous spots all over the palate and fauces. 
 
 In the mouth the mascular copper colored spots are frequently seen ; 
 they occur on the tongue, hard and soft palate, mucous membrane of the 
 cheek, and especially underneath the tongue in the mucous membrane 
 folds. 
 
 The papular form begins as a reddish pimple on the skin, but in the 
 mouth as an erosion and not as a pure 'type. They are situated in the 
 submucous structures and present the appearance of a raw sore with 
 sharply defined edges which are slightly raised, sinking in the center. The 
 bottom may be red or slightly yellowish, the discharge is not great, but 
 it is regarded by syphilologists as the most infectious of all the secondary 
 mouth lesions. 
 
212 
 
 The other variety of syphilides with which the dentist has most to 
 do is known as mucous plaques or mucous patches. They are most fre- 
 quently seen on the border of the tongue, the inside of the cheek or inner 
 surface of either lip. 
 
 In general appearance they resemble the ordinary aphthous patches 
 "which are so frequently seen, and which have been spoken of in the pre- 
 ceding chapter. Syphilitic mucous patches assume two forms, one 
 ■erosive, with a moist, brownish red surface, with decided hypertrophy 
 around its margins ; under the finger they are hard and are warty in 
 appearance. 
 
 The other form present is milky white secreting center, which is 
 somewhat depressed, surrounded by a red elevated margin ; the secretions 
 are foul smelling and infectious. The number of these patches present 
 in the mouth of a given case depends somewhat on personal uncleanli- 
 ness, decayed, rough teeth, using hot foods, alcoholic beverages and 
 tobacco smoking. 
 
 treatment 
 
 The treatment of these mucous patches is very important, for, as 
 stated, the secretion from them is very infectious. In addition to the proper 
 mercury course each ulcer should be cauterized with nitrate of silver, or 
 chromic acid lo drch. to the ounce, and suitable germicidal mouth wash 
 prescribed and all sources of irritation removed. 
 
 tertiary $yt>bili$. 
 
 While the tertiary form of syphilis usually follows the secondary 
 stages it does not always develop. Many cases are terminated by proper 
 treatment and no tertiary symptoms appear. 
 
 The second and third stages may be merged into one and many 
 authorities consider the third stage only the sequelae of the other forms 
 and not true syphilis ; but be that as it may, the fact is that this form 
 usually follows the other, and is, strictly speaking, the destructive stage. 
 
 This stage is usually manifested by more or less rapid destruction 
 of both hard and soft tissue, and is, strictly speaking, an ulcerative proc- 
 ess, in which the tendency is to eat deeply into the tissue and spread in 
 all directions. Fig. 82 represents a case in which a hole was eaten 
 through the hard palate. 
 
 This stage usually begins with the appearance of tubercles or super- 
 ficial gumma, which appears in skin and mucous surfaces, and as time 
 goes on the deeper structures are involved and the surface begins to eat 
 away. 
 
 Gummata are often seen in the mouth, particularly on the tongue 
 (Fig. 83). They usually begin as a collection of small round spots, which 
 
^K\ 
 
 Fig. S3. 
 
 Syphilitic ulceration of hard and soft palate. (Marshall.) 
 
 Fig. 83. 
 Gumma— toad's back appearance of tongue in syphilis. (Wende.) 
 
214 
 
 seem to pain and soften, and finally break down and begin their peculiar 
 process of ulceration, which gradually spreads to all the adjacent tissues. 
 
 The margins of these ulcers are usually irregular, overhanging, and 
 often small pieces of soft tissue will be cut off and float away. The 
 secretions from these ulcerating surfaces, while exceedingly foul smelling, 
 is not infectious. 
 
 The dentist is not called upon to treat the latter stages of this affec- 
 tion, and yet a knowledge that will enable him to recognize it at sighr 
 is important, for during this stage no serious operation should be under- 
 taken, especially if it contemplates the cutting or lacerating of tissue to 
 any extent ; even the extraction of a tooth often leaves a wound that is 
 very slow to heal. 
 
 The temptation to cut the gummata is very great unless one recog- 
 nizes their character. 
 
 eongenital $ypl)i1i$. 
 
 It is a lamentable fact that this disease is hereditary and that so 
 many infants are born into the world with a syphilitic taint. 
 
 The disease may be transmitted to the offspring by either father or 
 mother, and the father may transmit it without infecting the mother. 
 Many times the disease proves fatal to the fetus, and more often the 
 child dies soon after birth ; but there are many cases where the taint is 
 not shown until considerably later in life. 
 
 It always begins in the tertiary form, and is therefore not infectious, 
 and in this connection it should also be said that it is very much more 
 resistant to treatment than when acquired. 
 
 It usually manifests its presence by a peculiar erythematous rash, 
 although often at birth there may be other unmistakable signs such as 
 cracks in the lips and fissures in the tongue, rough nails, cleft palates and 
 other indications of faulty development, 
 
 Hutchinson's teeth are no longer considered signs of syphilis, but 
 rather signs of some disturbance of nutrition during the period of tooth 
 formation. If none of these signs appear during the first year the anxious 
 parents may feel quite certain that their child has escaped the taint. 
 
 m Hftcr Ulord. 
 
 Syphilologists have discovered that they can push the mercury treat- 
 ment safely and to a much farther extent without danger of salivation 
 and necrosis; when the mouth is in a healthy condition, so that it has 
 become a custom among them to first send these syphilitic cases to the 
 dentist that his mouth may be put in order, particularly relating to thor- 
 ough cleansing of teeth and gums. 
 
 Many of these cases apply to the dentist before they do to the 
 physician because, as stated before, they often think the initial mouth 
 
215 
 
 lesion due to some disorder associated with the teeth ; the dentist, there- 
 fore, should be able to recognize the condition, and after putting the 
 mouth in order as to cleanliness, the patient should be directed to a 
 competent specialist. 
 
 In this regard it should be stated that only temporary work in the 
 way of fillings is attempted until the proper course of treatment has been 
 carried through by the physician. 
 
 Crowns and bridges and all work of that nature is not attempted. 
 Dentists must use every precaution in handling these cases, both in regard 
 to avoiding infecting themselves through sores, scratches, hangnails or 
 any kind of abrasion on the hands ; and when cleaning teeth avoid specks 
 of tartar or debris flying into the eye. 
 
 The care of instruments is spoken of in Chapter XIII, to which the 
 reader is referred. I ask the reader to familiarize himself with this dis- 
 ease ; learn to recognize it at a glance by observing well understood cases, 
 many of which can be found in almost every hamlet. 
 
 That the dental profession is sadly ignorant of the manifestations of 
 this disease cannot be denied. 
 
 That many operators work day in and day out, utterly careless of 
 the dangers of carrying this virus from one mouth to other mouths, or 
 of infecting themselves, is equally true. 
 
 From the facts I have tried to present regarding this disease it must 
 appear to be of very serious importance to the dental profession, for how 
 culpable is the operator who unwittingly or even through ignorance of 
 its nature infects an innocent human being with this most awful malady, 
 a disease which, though now considered amenable to treatment, always 
 leaves in its wake not only death, but living destruction, shame, loath- 
 someness, rottenness, paralysis, and horrible markings to untold thousands 
 of the best families of our country. 
 
CHAPTER XX. 
 
 Diseases of tbe IDdxillary Sinus. 
 
 Empyema. Etiology. Symptoms and Diagnosis. Treatment. Ulcers. Necrosis, 
 Causes. Treatment. Tumors. 
 
 The maxillary sinus, or antrum of Highmore, is a triangular shaped 
 cavity contained within the body of the superior maxillary bone. It has 
 a natural opening into the nose through which the normal secretions 
 pass, and is lined with a mucous lining which is analogous to the schnei- 
 derian membrane of the nose. 
 
 This membrane is covered with ciliated cells so arranged that in, 
 normal action they carry the secretions out through the opening into the 
 nose. This opening is not at the most dependent part of the antrum, and 
 hence this provision of nature. 
 
 The floor of the antrum is immediately over the apices of the roots 
 of the posterior teeth, and in many specimens examined the floor is con- 
 voluted, each little eminence being over a root apex. 
 
 Antrums dififer both as to size and shape ; in some cases its anterior 
 wall is as far forward as the cuspid root apex ; in others it does not come 
 forward to the second bicuspid. 
 
 Most antrums are divided into two or more chambers by thin bony 
 partitions arising from the floor to about one-quarter the height of the 
 sinus, and many cases have no divisions. The antrum serves as a 
 sounding board for the voice. 
 
 Diseases of the antrum are very common, more so than formerly, 
 especially among the lower classes ; and climatic conditions have much to 
 do with its prevalence in certain localities, and certain constitutional 
 conditions have much to do with these diseases. 
 
 The diseases of the antrum can be divided into four general classes. 
 
 First — Empyema, a suppurative inflammation. 
 
 Second — Ulcerations of its mucous lining. 
 
 Third — Necrosis of some portion of its walls. 
 
 Fourth — Tumors. The last two requiring essentially surgical 
 treatment. 
 
 Empyema. 
 
 Empyema of the antrum is a purulent inflammation affecting the 
 antrum. 
 
217 
 
 etiology. 
 
 Empyema often has its source in acute or chronic catarrhal inflamma- 
 tion, which may come from the nasal cavity on account of its close prox- 
 imity. Inflammation of the membranes of the nose may result in partial 
 or complete closure of the natural antral opening, and as a consequence 
 stagnation of its fluid contents, which in time may become infected witli 
 pyogenic germs, resulting in suppurating inflammation, with breaking 
 down of the lining membrane. This is probably the most common cause. 
 
 Another point that should be mentioned here which may act as a 
 causative factor, and that relates to the fact that sometimes the secretions 
 of the frontal sinus and the ethmoid cells, instead of discharging through 
 the infundibulum into the middle meatus of the nose, discharge directly 
 into the antrum. This fact was pointed out by Cryer. 
 
 Abscessed teeth are a frequent cause by discharging pus into the 
 antrum. The presence of foreign substances such as roots of teeth that 
 have accidentally been forced there in extracting. Malposed teeth have 
 been found erupting into the antrum. 
 
 Symptoms and Diagnosis. 
 
 The symptoms of this form of antrum disease are sometimes mis- 
 leading, particularly if the case is one of chronic slow suppuration, when 
 the discharge will often not be noticed. In the great majority of cases 
 there will be an offensive odor, a feeling of fullness, a discharge into the 
 nose when lying on the opposite side of the face, or in very acute cases^ 
 where suppuration is rapid and opening partially closed, there will be 
 severe pain and swelling, pain often in the eye, and occasionally pus dis- 
 charging into the mouth through a sinus in alveolus where tooth had 
 recently been removed. 
 
 Examination through the nose by use of nasal speculum and probing 
 needle pus or other purulent fluids can be extracted. Trans-illumination 
 will sometimes assist. 
 
 treatment. 
 
 The treatment of the usual engorgements of the antrum where there 
 is no pus or local lesion is very simple. It consists in reopening the 
 natural opening into the nose and expanding it with a trocar or inserting 
 a piece of tubing to allow free drainage and douching with warm normal 
 salt solutions. A few treatments will usually suffice if the nasal condi- 
 tions are attended to. 
 
 In severe suppurating cases it is always best to secure an artificial 
 opening; it is best to make this opening into the mouth because it can be 
 made in the most dependent part of the sinus, and is more easy of access 
 
2l8 
 
 and consequently better drainage. I have never had any success in treat- 
 ing these cases through the nasal cavity, although some recommend that 
 method. 
 
 If the first molar is missing it is easiest to make the opening through 
 its socket. If all the teeth are present then I like Dr. Gilmer's plan of 
 opening above the mesio-buccal root of the first molar, where the cheek 
 will close it and keep food out. 
 
 A small opening is all that is needed at first, although it must l)e 
 large enough to furnish ready drainage. The antrum should then be 
 irrigated with copious quantities of normal salt solution, repeating every 
 day for a week, when recovery will result in the simple cases; but if 
 considerable foul smelling pus be present then more radical measures 
 are necessary. 
 
 In these bad cases I usually proceed as above for a treatment or two, 
 then if pus continues, I make a large enough opening to place the small 
 electric bulb inside the antrum to light it up, and not only explore with an 
 instrument but with the finger. 
 
 Sometimes the bony partitions may have to be broken down, and of 
 course if there is any dead necrotic tissue it should be removed and the 
 lining carefully curetted, and all flushed with normal salt solutions and 
 borax water with cinnamon and carbolic acid. After irrigating freely the 
 sinus should be packed with iodoform gauze. 
 
 Irrigation and repacking should be repeated every few days accord- 
 ing to conditions until all pus ceases. In cases of violent pus formation, 
 I use I per cent chinosol solution as a final douche and pack chinosol 
 gauze a time or two. 
 
 In addition to this the patient should use solution of Siler's antisep- 
 tic nasal tablets with which to douche the nose twice daily. It is some- 
 times advisable to use a gutta-percha plug to keep the opening from 
 closing. This can usually be kept in place by clasping it to an adjoining 
 tooth. 
 
 Ulcm. 
 
 Ulcerations are usually the result of some constitutional disturbance 
 and usually affect the mucous lining of the nose and mouth. The only 
 ulcerations of serious moment are associated with syphilis, which some- 
 times destroys not only the linings but periosteum and bone. 
 
 The treatment must be constitutional, using those remedies Indicated 
 for tertiary syphilis. The local treatment consists in keeping the parts 
 clean. 
 
 It is sometimes difficult to make these artificial openings close per- 
 fectly. In several cases I have scarified the edges and sutured together. 
 
219 
 
 necrosis. 
 
 Necrosis of any of the walls of the antrum is a possibility, but I 
 have never seen any except those involving the floor and outer wall. 
 
 Causes. 
 
 Necrosis may result from the same variety of causes as that occurring- 
 in the other portion of the body, but most commonly from inflammation 
 of the periosteum as a result of some disease associated with the teeth 
 or traumatic injuries. 
 
 Alveolar abscess may result in alveolar necrosis involving the floor 
 of the antrum, and the outer wall may be destroyed as a result of pus 
 poisons in the antral cavity. 
 
 treatment. 
 
 In either case if a sequestrum has formed the necrotic bone should 
 he surgically removed and treatment instituted the same as for empyema. 
 There Is one additional point which relates to holding the contour of the 
 face after outer wall is destroyed. This is usually done with antiseptic 
 wax or gauze packing until such time as nature can supply the needed 
 
 bone. 
 
 tumors. 
 
 Tumors of the antrum may occur in every variety, but most com- 
 monly as polypi and other mucous cysts. They are usually very vascular, 
 usually arising from the floor, and rarely attain such size as to cause 
 serious trouble, although some authorities claim they are malignant in 
 their tendencies. The treatment is a radical surgical one, in which a 
 generous opening into the antrum must be made either through the 
 nasal or outer wall, through which the tumor can be thoroughly removed, 
 and after treatment similar to that already described. 
 
CHAPTER XXI. 
 
 matiiigement of tbe Diseases of ehMtzWs Ceetb. 
 
 Dentition. Pathology. Treatment. The Diseases of Deciduous Teeth, and Soft 
 
 Tissues of the Mouth. Diseases of the Pulp. Putrescent Cases. Root 
 
 Filling. Sensitive Dentine. Cleaning Teeth. Management of 
 
 Permanent Teeth During Childhood. Management 
 
 of Sensitive Cases. 
 
 The pathology and therapeutics of the diseases common to children's 
 teeth can most easily be presented under three heads. 
 
 1. Those diseases incident to the process of teething. 
 
 2. The diseases of the deciduous teeth and soft tissue before the 
 permanent set are erupted. 
 
 3. The care of permanent teeth during childhood. 
 
 Dentition. 
 
 Dentition may be defined as the process of teething; it is the physio- 
 logical process of supplying the infant with teeth. The process may be 
 said to begin when the crown of the tooth has formed and begins to 
 pass through the bony covering in which it is held. 
 
 It must be remembered that the early calcifying tooth is contained 
 in a bony crypt which is separated from the bone of the jaw by vascular 
 tissue on all sides. In the lower jaw the floor of the crypt rests imme- 
 diately over the inferior dental canal, and in the upper jaw it rests over 
 the infraorbital canal. 
 
 The covering of the crypt is a thin layer of bone which forms the 
 outline of the alveolus. It can readily be seen then that the roots cannot 
 form until the crown passes toward the surface away from the canals 
 in the jaw. 
 
 The bone over the crypt is slightly fissured to facilitate absorption 
 and make the passing through of the tooth crown easier. As the crown 
 passes through this bone the roots begin to develop and continue until 
 some little time after the tooth crown has assumed its position in the 
 mouth. 
 
 While this is going on there is gradually forming an alveolar wall 
 which is to make the tooth socket. This is the method by which all the 
 teeth develop and take their places in the arch, both upper and lower. 
 
 It does not seem to come within the province of this article to pre- 
 sent data regarding the time of eruption and calcification of the various 
 
221 
 
 teeth, which can be learned by referring to books on dental anatomy. 
 What we are interested in now is the diseases associated with the 
 process of dentition. 
 
 While the process of tooth erupting is physiological it is nearly 
 always associated with disturbances which are pathological. The process 
 by which the tissues over the erupting tooth are forced out of the way 
 is one of resorption under pressure. 
 
 The teeth cusps act as the irritant which produces the stimulus to 
 the resorption process, and consequently the tissues must in themselves 
 be tender and a source of considerable pain. 
 
 A glance at the tissues will reveal the hyperemic condition present, 
 which as the tooth presses through the gum tissues often becomes in- 
 flammatory. The pressure on the nerve filaments must be a source of 
 considerable pain. The parts become hot, which is shown by the infant's 
 desire to bite on something cold. 
 
 It is doubtless true that the desire to bite things is an effort of the 
 child to relieve the pressure irritation, and yet it seems to be a pro- 
 vision of Nature by which the gum is forced out of the way of the 
 erupting teeth, and hence the value of the ivory or silver ring, which 
 can be kcDt clean, and affords a means by which the infant may aid 
 nature. 
 
 So long as the process does not exceed the bounds of a reasonable 
 physiological process very little disturbance results ; but when either 
 from the density of the tissues or other complicating circumstances such 
 as faulty nutrition the normal process is interfered with, then we often 
 have a train of consequences which may even seriously endanger the 
 life of the infant. 
 
 When we remember that the nerve which supplies these tissues is 
 the fifth cranial nerve, and that this is the largest and most sensitive of 
 all the nerves, and that these tissues are so intimately associated with 
 the great sympathetic system, we can readily see why such grave dis- 
 turbances occur. 
 
 Coupled with this, also, is the fact that at this period of life the 
 spinal system predominates the system. Then, again, the mucous lining 
 of the mouth and tongue are in such close proximity to the throat, oeso- 
 phagus and stomach, that the affection of the mouth can readily spread 
 to these organs, which are necessarily sensitive to environment. 
 
 When we take all of these things into consideration we can see a 
 rational explanation why sometimes such serious disturbance may be 
 rightly attributed to faulty dentition. However, I am quite convinced 
 that much mischief is laid at the door of erupting teeth which does not 
 rightly belong there, but which for lack of better understanding of the 
 
222 
 
 real cause can easily be explained to the satisfaction of mothers by say- 
 ing, "your baby is teething." 
 
 Patbolegy. 
 
 The first indication of teething is seen in the increased flow of saliva. 
 This "drooling" is due to irritation of the fifth nerve, which in turn 
 afifects the salivary glands through another of its branches. This is evi- 
 dently a plan of nature to cool and keep moist and clean the parts. 
 
 The next indication is the cheek eruptions, which are doubtless re- 
 flex in origin, Sometimes this takes the form of mucous ulcers, which 
 are sore and must cause a degree of pain and restlessness. The child 
 usually becomes wakeful and peevish, and if the gums become severely 
 inflamed cries and displays "fits of temper." If several delayed teeth 
 are erupting at the same time and the consequent local condition unusu-, 
 ally severe, diarrhoea, colic and even convulsions may develop. 
 
 Miller points out that the germs which cause infant diarrhoea are 
 usually found in the mouth, by which route they probably enter. I should 
 add here that frequently carelessness about sterilizing nursing bottles and 
 nipples is responsible for many serious mouth affections. 
 
 In examining the mouth of an infant in such distress the thing to 
 look for is evidence of severe active inflammation over the region where, 
 according to the age, the tooth should erupt, and then such other sore 
 places as can be found. 
 
 treatment 
 
 If severe localized inflammation presents then the thing needed is the 
 lancet used under antiseptic precautions. It is not so much to remove the 
 o-um over the tooth (although it is as well to cut deep) as to let the con- 
 o-ested blood out that the lancet is used. The accompanying illustration 
 will indicate the best method of lancing (Fig. 84). 
 
 Fig. 84. 
 
 Showing method of lancing gums over erupting teeth. (Burchard.) 
 
 Care must be taken to hold the infant securely and guide the lancet 
 so as to avoid all danger of slipping and doing serious damage to adjacent 
 parts. 
 
223 
 
 The parts should be carefully sponged with a boric acid solution and 
 the constitutional disturbance attended to by the physician. 
 
 ZM Diseases of Deciduous teetb, and Soft tissues of the mouth. 
 
 The care that the temporary teeth receive has much to do with the 
 value of the permanent set, both in relation to their formation and posi- 
 tion in the arches. The child should be brought to the dentist early in 
 order that its teeth may be examined and whatever treatment necessary 
 given, and wholesome instruction given both parent or governess 
 and the child. 
 
 The objects of caring for the deciduous teeth are three: First, that 
 they may be preserved to do necessary mastication until permanent teeth 
 erupt; second, that the normal process of development may prepare the 
 way for normal occlusion of the permanent set, and third, that the child 
 may avoid a series of painful conditions which will result in severe opera- 
 tions and consequent everlasting dread of the dental chair. 
 
 The dentist should do all he can to correct the false notion in the 
 minds of parents that these teeth are unimportant because temporary. 
 
 There is another point in this connection and that relates to the cul- 
 tivation of good hygienic mouth habits, which once established will con- 
 tinue through life, and also the development of that friendship between 
 dentist and child which will entirely do away with that awful dread of 
 the dentist and dental operations which so many experience. 
 
 Diseases of tbe Pulp. 
 
 Temporary teeth are subject to all the diseases common to the per- 
 manent, but in a modified form. 
 
 Hyperemia of the pulp results from the same causes, but It rarely 
 produces such severe pain. This is accounted for by the fact that the 
 canal has usually begun to enlarge by resorption before such conditions 
 arise and also the lymphatic connections are better. 
 
 The treatment must always be palliative. The carious cavity should 
 be cleansed as well as possible of all loose material and anything pressing 
 on the pulpal wall removed, after which the cavity should be dried and an 
 application of iodoform and hydronaphthol made into a paste with pure 
 oil of cloves should be made, when the cavity can safely be filled with 
 cement, gutta-percha or amalgam, as seems best suited. 
 
 Unless positive Infective Inflammation has begun such cases will 
 usually get well and remain so. If, however. Infective Inflammation has 
 begun, which can usually be determined by the history of the case and 
 the presence of an exposure, then the procedure must be different. 
 
 The destruction of the pulp In temporary teeth should not be at- 
 tempted with the use of arsenic; the chances of it passing through the 
 
224 
 
 wide open root and affecting the underlying tissues is very great, as well 
 as the danger to the surrounding parts. 
 
 Many operators suggest the use of corrosive agents such as zinc, 
 chloride, silver nitrate or carbolic acid, which will often work well; but 
 I find the ordinary anodyne treatment, with the use of clove oil and the 
 like, to serve fully as well, which will keep the tooth quiet until death of 
 the pulp results, when it can be cared for. It should be said, however, 
 that exposed pulps of deciduous teeth take more kindly to capping than 
 •do the pulps of permanent ones. 
 
 Putre$ccnt 0a$c$. 
 
 In the management of putrescent and abscessed cases the same gen- 
 eral principles obtain as in permanent teeth with this exception, that cor- 
 rosive agents are never needed. 
 
 The important points are to mechanically clean the canals, and force 
 ^ome oil of cloves through the fistulous opening if there be one, and if 
 not then the clove oil should be sealed in the canal, and in each case the 
 clove dressing is allowed to remain a week, when in the great majority 
 •of cases the root filling may be proceeded with. 
 
 Koot Tilling. 
 
 As a root filling in these cases I have had excellent results from the 
 use of gutta-percha, in which I have incorporated a little iodoform and 
 hydronaphthol dissolved in eucalyptol. I use it quite thick and fill the 
 chamber proper with gutta-percha. The tooth cavity may be filled with 
 any material suitable to the case. 
 
 $en$itife Dentine. 
 
 As a means of doing away with the sensitiveness and at the same 
 
 time stopping the progress of caries in shallow cavities, silver nitrate 
 
 is very efficacious. 
 
 eieaning teetl). 
 
 It is important to keep children's teeth clean, and as often as tartar 
 •or green stains appear they should be removed. The removal of calculus 
 and polishing the teeth is a very simple matter for children. 
 
 A little hydrogen dioxid added to pumice stone will aid in removing 
 green stains. As a general rule it is never advisable to keep children in 
 the dental chair longer than a half hour, nor is it advisable to adopt 
 heroic painful measures when it can possibly be avoided even by a long 
 way around. 
 
 By diverting the attention of a child we can often do quite painful 
 things and have them bear it nicely ; by this I do not mean that it is ever 
 permissible to deceive a child. Once deceive a child he will always 
 remember it and will never trust you or any other dentist again. By put- 
 
225 
 
 ting into child phrases the condition present, and what you are trying to 
 do for his rehef and future comfort, and telhng him some good stories of 
 bravery and heroic deeds, and incidentally getting him interested in your 
 imaginary rabbits, chickens, etc., you will accomplish what you desire and 
 he will bless you always. 
 
 management of Permanent Ceetb Durins Cbildbood. 
 
 Very little needs to be said on this subject, because the various patho- 
 logical conditions have already been presented either in this chapter or in 
 the preceding ones. Happily the diseases of the gums and peridental 
 membrane are rare at this period. I only wish to state that the most 
 critical time for the permanent teeth is between the ages of six and four- 
 teen, during the early period of which many first molars are lost. Parents 
 as a rule regard this as a temporary tooth, and before the dentist has an 
 opportunity to correct their mistake many teeth are hopelessly ruined. 
 
 In the chapter on capping pulps reference was made to the desir- 
 ability of keeping pulps alive until the roots are fully developed. When 
 the pulp is gone all further development of dentine ceases, and teeth 
 whose roots are only partially formed cannot be expected to do a lifetime 
 service, therefore every effort should be made to preserve the pulp, and 
 when pulps are lost before the roots are nearly completed it is better to 
 extract early, especially in six year molars, with the hope that the space 
 will be occupied by the second molar by and by. 
 
 manasement of Sensitive €a$($. 
 
 While the usual obtundant remedies act well with children, it must 
 be borne in mind that teeth are more sensitive during this period than 
 later in life. Sensitive to malleting in fillings and also to excavating 
 dentine, and that growing, maturing children cannot bear pain as well 
 as older people, and yet if you have their confidence it is surprising what 
 they will endure. 
 
 This is a period when it is difficult to get children to take that interest 
 in the care of their teeth that they should, and consequently good mouth 
 hygiene is often lacking, and as a result decay is more prevalent. 
 
 It is often wisest for all these reasons not to attempt permanent 
 gold fillings, but rather to carry the teeth along in comfort with 
 the use of the plastics until the time comes when all these conditions 
 change and permanent results can be hoped for. 
 
. CHAPTER XXII. 
 
 facial neuraldia. 
 
 Etiology, Neuralgic Pains of Dental Origin. Causes. Symptoms. Diagnosis. 
 
 Treatment. Resection. 
 
 The term neuralgia is derived from the Greek, and signifies nerve 
 pain, and may be defined as "a painful afifection of the nerves, due either 
 to functional disturbance of their central or peripheral extremities or to 
 neuritis in their course." — Osier. 
 
 Facial neuralgia is a term used to designate neuralgic pains in the 
 region supplied by the fifth cranial nerve, sometimes called trifacial and 
 trigeminal neuralgia. 
 
 etioiosy. 
 
 Individuals who suffer from any chronic nervous disorder are most 
 liable to this affection. \\^omen more liable than men, and syphilitic, 
 gouty, diabetic or anemic persons are most liable. In malarial districts 
 the disease is very prevalent. Any irritation, especially if long continued, 
 to any sensory nerve filament may be reflected in other sensory nerves, 
 and if long enough continued may result in permanent neuritis. 
 
 The trifacial nerve arises by two roots, a small motor root and a large 
 sensory root, upon which is situated the gasserion ganglion. Passing 
 out from the ganglion are three main branches. First, the ophthalmic, 
 which with its branches supplies the eye muscles, lachrymal gland, frontal 
 muscles, eyelids, the nose ; second, the superior maxillary, which with its 
 branches supplies the upper jaw, the teeth, the orbit, the cheek; third, in- 
 ferior maxillary, which through its terminal branches supplies the lower 
 jaw, the teeth and some of its branching filaments pass to the ear and 
 temporal region. 
 
 It readily can be seen, therefore, that any irritation to one of these 
 branching filaments may be reflected in any branch of all three main divi- 
 sions, and there is possibility of certain pains being transferred to another 
 center in the brain through the anastomosing branches of other trunk 
 nerves. 
 
 neuralgic Pains of Dentai Origin. 
 
 The dentist is mostly interested in pains arising from the dental 
 organs or reflected to them. Sometimes these reflexes may be either or 
 both motor and sensory, manifesting itself in pain and motor twitching 
 and spasms. 
 
227 
 
 Causes. 
 
 Facial neuralgia may develop from a variety of causes, both local 
 and constitutional, as previously stated. When local the cause frequently 
 lies within the tooth pulp or peridental membrane. Hyperemia of the pulp 
 IS sometimes the exciting cause. Pulp nodules impinging on the nerve 
 filaments, all of which is contained with the walls of the pulp canals, 
 may be an exciting cause; a case in point has been cited in Chapter IV. 
 Uncovered sensitive dentine may transmit neuralgic pains. 
 
 Hypercementosis is sometimes considered a cause; septic diseases 
 of the pulp have also been considered a cause. 
 
 Impacted teeth, particularly lower third molars, spicula of bone left 
 after extraction, may impinge on the nerve. Ill-fitting lower dentures 
 may press on the mental foramen, tumors in the bone, aneurysms, tumors 
 of the nerves are frequent local causes. 
 
 Other causes which lie outside of the strictly dental organs are 
 catarrhal conditions of the frontal or of the maxillary sinuses, inflam- 
 matory conditions about the eye and ear, and most important of all, in- 
 flammation of the nerves of the region affected, impingement of nerves 
 in cicatrics about the jaws, following surgical operations. 
 
 All of these act more or less severe, according to this idiosyncrasy of 
 the patient and the peculiar constitutional conditions present. After all has 
 been said regarding these causes it must be stated that the more severe 
 forms of facial neuralgia do not come from these sources, but in all 
 probability arise from the nerve trunk itself or in the brain cells. 
 
 That most horrible of all forms, known as tic-douloureux, cannot be 
 said to be caused by any condition associated with the teeth, unless it 
 be as a mere starting point, from which it rapidly passes into serious trunk 
 nerve disturbances, if, indeed, the brain cells are not the source. (Manv 
 think anemia of the nerve trunk is the cause.) 
 
 About this particular neuralgia we know very little except its mani- 
 festations. It produces the most excruciating pain; its attacks are 
 paroxysmal, occurring with ever-increasing frequency until life becomes 
 absolutely unendurable. The sight of the suffering of even one 
 of these unfortunate victims will make a lasting impression on 
 the observer. 
 
 When due to other dental causes than these there is never any con- 
 stancy regarding the location of the pain; sometimes it will appear in 
 one spot and sometimes in another; tenderness of the eyeball, the tem- 
 poral and anterior auricular region, will usually indicate the trouble to 
 be in the same part of the inferior maxillary branch. 
 
 Sometimes pains deflected to the ear, to the mastoid cells, in the 
 infra-orbital or mental foramen region (Dr. Brophy has recited some inter- 
 
228 
 
 esting cases of this character) have their origin in the lower teeth or 
 jaw. 
 
 It is very rare to find neuralgia of dental origin affecting more than 
 one of the trifacial branches at a time ; the one most commonly affected 
 when of dental origin is the inferior maxillary ; when the upper teeth are 
 responsible the pain may be deflected to the lip, nose or the cheek. 
 
 Symptoms. 
 
 There are very few dependable symptoms, although certain symptoms 
 may serve as guide posts to direct the practitioner to the source. Before 
 the onset of the pain there may be a peculiar tingling sensation in the 
 part. The pain is not constant like from a forming abscess, but parox- 
 ysmal darting pains, twitching of the muscles of the part is usual. 
 
 The spasms come and go sometimes at regular intervals, and if it 
 be a true neuralgia of trophic affection the pain will become severe, and 
 even the skin may become so sensitive that the slightest touch will cause 
 the sufferer to cry out with the pain. 
 
 If the pain be reflex and due to dental origin usually there is some 
 discomfort about the mouth, or a careful examination as to caries, in- 
 flamed pulps, pericementitic erosions and the like will reveal the cause. 
 As stated before, when the teeth themselves are responsible, it usually 
 can be easily found either hot or cold sudden changes, recumbent posi- 
 tion, tenderness to percussion or some recognizable disturbance can be 
 seen. 
 
 When due to other than these peripheral causes the nerves will be 
 tender to pressure at the points where they emerge from the bone. 
 
 Diagnosis. 
 
 The first essential in making a diagnosis of this trouble is to get a 
 complete history of the case, even to the minutest detail ; the patient may 
 be able to give you a clue to the real trouble. The actual diagnosis 
 must be made by exclusion ; examine each tooth on the affected side for 
 every known lesion, and, if none is found, the X-ray may be helpful in 
 locating hypercementosis, pulp, nodules or impacted teeth, as well as 
 tumors. 
 
 Next the region of the affected nerves should be examined for tender 
 spots, which in tic-douloureux are located at the supra-orbital foramen, 
 the upper eyelid, the cartilage of the nose, the parital eminence, when the 
 ophthalmic branch is affected. The infra-orbital foramen, malor bone, 
 upper lip, palate or other places in the upper jaw will be tender, when 
 the superior maxillary is affected, or the tender spots may be in front of 
 the ear, over the inferior dental foramen or over the mental foramen when 
 the inferior maxillarv branch is affected. 
 
229 
 
 treatment. 
 
 If any dental lesion exist it should be put in order, and thrice happy 
 A-ou should be if in doing so the source of the trouble has been found. It 
 must be remembered that these pains sometimes continue for a few days 
 after the exciting cause has been removed, but will gradually grow less 
 and less. 
 
 ^lany therapeutic agents have been suggested as available in the 
 treatment of facial neuralgia, among which are the following : 
 
 Phenacetine acetanilid in doses from five to ten grains in neuralgic 
 pains about the face due to exposure to cold and dental irritation. Aco- 
 nite tincture in five drop doses every twenty minutes will usually help the 
 acute forms; it is administered until numbness of the lips appear; it is 
 also u.^ed as a lotion painted liberally over the affected parts. 
 
 Arsenic in the form of Fowler's solution is especially recommended 
 for neuralgias of malarial origin. It is best to begin with about ten 
 minims and gradually decrease until one minim is given, then gradually 
 increase again. 
 
 Butyl-chloral hydrate is strongly recommended in doses of about five 
 grains. I\Iany seem to rely on this drug. A mixture of butyl-chloral 
 hydrate and tincture of camphor may be locally applied. 
 
 Belladonna is very useful if violent spasms are present. 
 
 Gelsemium in the form of the tincture and also the sulphate gelsemi- 
 nine has been found by the author to be very efficacious when the neuralgia 
 is of dental origin. 
 
 Colcliicum is a valuable remedy when the neuralgia is of gouty origin, 
 best given in form of the wine of colchicum root, dose 5-20 minims. 
 
 Cannabis Indica has been praised as a remedy by manv writers, but 
 the author has had very negative results. 
 
 The opiates can never be considered as curative, but thev are often 
 our only means of controlling the severe pain. ^lany recommend inject- 
 ing morphine directly into the afifected region. 
 
 Cod liver oil and phosphorus has proven very efficacious in four cases 
 treated by the author. 
 
 Iroji and qiii)ii}ic are given often with helpful results when neural- 
 gia is due to anaemia and malaria. 
 
 Local application of freezing mixtures such as methyl-chloride sprayed 
 over the affected region has been helpful in some cases. 
 
 Electricity is considered by many very helpful. It must be carefully 
 applied, using the positive electrode over the seat of the trouble. The 
 current should be increased gradually and continued for twenty minutes 
 at a time and repeated daily. 
 
230 
 
 Castor oil treatment has been highly praised by many neurologists. 
 The plan seems to be to give as much castor oil as possible without 
 purgative effect. Dr. Patrick suggests that it is best given at bedtime. 
 The first night a large dose is given which will purge considerably ; the 
 next night the same dose will purge less. This plan is followed for three 
 or four days, when an additional dose may be given in the morning with- 
 out purgative effect, and thus gradually the patient can take from two to 
 four ounces in twenty-four hours without active purgation and at this 
 point the real benefit begins. 
 
 The same author says that he has found this treatment beneficial in 
 40 per cent of the cases and curative in a somewhat smaller percentage. 
 
 In the treatment of these cases it is wise to try all of these means of 
 relief before attempting the surgical methods, for the reason that even 
 surgery fails to permanently cure many of these severe cases. 
 
 I have known of several cases where extraction of one tooth after 
 another until all on the affected side were removed with only temporary 
 benefit, and others where removal of the nerves in both jaws brought 
 relief only for a few weeks. A great variety of surgical operations have 
 been tried in times past for the relief of this trouble, all but four of which 
 have been discarded. 
 
 The removal of the Gasserion ganglion promises the most perma- 
 nent results, but even this has failed, and lately a suggestion has come 
 from Abbe to sever the maxillary branches from the ganglion and place 
 a piece of gutta-percha between the severed ends, thus preventing any 
 future reunion. This operation is fraught with grave dangers to life and 
 does not promise a permanent cure in all cases. 
 
 A German scientist has recently suggested injecting into the ganglion 
 a one-half per cent solution of osmic acid. It seems to have proved 
 successful in a few cases. 
 
 Resection. 
 
 llesection, an operation by which a portion of the affected nerve is 
 removed. If the affected portion is removed before the entire trunk is 
 involved success will follow, and in any event the patient will be free 
 from pain for a period from two to six years. 
 
 This operation is simple compared with that of removing the gan- 
 glion, and if skillfully done is not dangerous. ]\Iost surgeons recommend 
 that this operation be tried first, and if necessary the ganglion removed 
 later. 
 
 Subcutaneous division, an operation by which the nerve trunk is di- 
 vided, is successful for a short time; but my experience is that the pain 
 returns with greater force and persistency. 
 
22,1 
 
 Evulsion, an operation by which a portion of the nerve is torn out, 
 is highly recommended by some surgeons, and by this method it is pos- 
 sible to tear out the nerve for a considerable distance, and thus bring 
 freedom from pain for a considerable time. 
 
 A description of the technique of these operations does not come 
 within the province of a work on therapeutics. The reader is referred to 
 modern text books on surgical procedure. 
 
CHAPTER XXIII. 
 
 SDock* 
 
 Etiology. Symptoms. Causes. Treatment. 
 
 Shock is a depression of the vital powers caused by injuries or from 
 some great mental disturbance. It is manifest by a sudden check in the 
 circulation brought about through the cerebro-spinal centers. 
 
 etiology. 
 
 The condition follows accidents often in railway trains, or it may 
 follow a profound mental impression or severe prolonged mental strain. 
 It is not necessary that there be some physical lesion in order to produce 
 shock from accidents, indeed, some of the severe forms appear when no 
 physical signs can be found. 
 
 Shock from dental and surgical operations sometimes result when 
 there is little or no loss of blood and most frequently from prolonged 
 sittings in the dental chair ; not always on account of the pain, but most 
 frequently as a result of long mental strain from dread or fear. 
 
 Shock is not to be confounded with simple fainting, in which there 
 is also a cessation of vital functioning. Shock may or may not appear 
 for some time after accidents or operations. The usual history when 
 caused by dental operations is, first, a feeling of over-excitement, which 
 gradually passes into prostration, which may last for several days ; and a 
 few cases are reported where patients failed to rally and death resulted. 
 
 Symptoms. 
 
 The symptoms of shock usually begin by a tired feeling and appear- 
 ance of prostration, and if profound the patient passes into a state of 
 coma, where consciousness can scarcely be aroused, pallor of the face and 
 the whole body surface, which is especially seen in the lips. The body 
 is cold and covered with sweat, the eyelids droop, the features look 
 pinched or the eyes in severe cases remain wide open and staring and have 
 a weird and uncanny sunken look. The pulse is almost imperceptible, very 
 weak and thready. The thermometer will show a temperature of 96° or 
 97°, respiration is short and feeble, or may be panting. 
 
 In these cases there is usually no great loss of sensibilities. Some- 
 times there will appear marked hysteria. 
 
 pauses. 
 
 Whatever the source of shock may be, it produces heart disturbance 
 through the vaso motor system ; there is a partial paralysis of this system, 
 with some real cell injury which at present is not thoroughly understood. 
 
233 
 
 Many regard shock as a temporary paresis of the muscles of the heart, 
 but there evidently must be something more, and is probably explained by 
 the theory of molecular nerve cell disturbance. Prognosis of shock is 
 always uncertain. Of course the severity of the form will have much to 
 do with the outcome. 
 
 treatment. 
 
 The treatment must always be based on the severity of the various 
 symptoms. The recumbent position is essential. As soon as possible 
 warm stimulating drinks should be given ; whiskey or brandy are com- 
 mon remedies which are valuable. Volatile heart and respiratory stimu- 
 lants, such as amyl nitrate and ammonia, should be held before the face 
 to tide over the temporary vital depression. 
 
 The slapping of the face with a cold wet towel and the chafing of the 
 extremities are helpful especially in the cases of syncope or fainting. 
 Then artificial respiration should be undertaken and kept up as long as it 
 is helpful. 
 
 Hypodermic injections of atropine to maintain the respiration and 
 nitro-glycerine, one two-hundredth of a grain. Digitalis and strychnine, 
 one-twentieth of a grain, are the remedies to support the circulation. 
 
 When hysterical excitement prevails, morphine one-eighth to one- 
 fourth of a grain should be given. When the patient can readily swallow, 
 the aromatic spirits of ammonia is a valuable remedy, as well as valerian. 
 
 In concluding this article I wish to call attention to the danger of 
 shock from severe prolonged dental operations. The symptoms may not 
 appear at the time, but may develop several hours or days after the sit- 
 ting. Long sittings should be avoided, especially if patients are nervous 
 or excitable. 
 
 It is better to make two or more short sittings, or if necessary make 
 only temporary operations rather than run the risk of inducing disturb- 
 ances which are fraught with such grave dangers. 
 
 The medicine case should always be supplied with the usual remedies 
 indicated in these cases, for oftentimes they will be called for on a 
 moment's notice. 
 
INDEX 
 
 Active Hyperemia, Causes of, 39. 
 
 Agents, 154. 
 
 An After Word, 214. 
 
 Alveolar Abscess, 110. 
 
 Chronic, 118. 
 
 Replantation, as a Cure for, 191. 
 Aneurysm, 122, 
 Aphthous Stomatitis, 196. 
 Apical Pericementitis, 106. 
 
 Chronic. 109. 
 
 Bacteria of Pus, the, 95. 
 
 Bacteriology of Dental Caries, 10. 
 
 Blind Abscess, 123. 
 
 Blood Supply Nerves, 106. 
 
 Blood Vessels, 17. 
 
 Broach Sterilization, 135. 
 
 Calcic Inflammation, 160. 
 
 Calcific Degeneration of the Pulp, 36. 
 
 Caries, Dental, 6. 
 
 Carrying Infection, 134. 
 
 Cases, 109. 
 
 Cases of Open Cavities, 93. 
 
 Case's of Putrefaction Under Fillings, 
 
 93. 
 Causation, 34. 
 
 Causes, 57, 106, 111, 204, 219, 227, 232. 
 
 of Active Hyperemia, 39. 
 
 Hyperecementosis, 186. 
 
 Hyperemia of the Dental Pulp, 40. 
 
 of Inflammation, 47. 
 
 Passive Hyperemia, 39. 
 
 Tooth Discoloration, 151. 
 Cells, 104. 
 
 Other, 17. 
 Changes Continued, Destructive, 45. 
 
 in the Pulp ; Destructive, 39. 
 Children's Teeth, Management of the 
 
 Diseases of, 220. 
 Chlorin Method, 157. 
 Chronic Alveolar Abscess, 118. 
 
 Apical Pericementitis, 109. 
 Cleaning Teeth, 224. 
 Cleansing and Filling Pulp Chambers, 
 
 71. 
 Congenital Syphilis, 214. 
 Conheim's Theory, 49. 
 Constructive Diseases of the Pulp, 31. 
 Curative Method, 11. 
 
 Degeneration of the Pulp, Calcific, 36. 
 Dental Caries, 6. 
 
 Bacteriology of, 10. 
 
 Pulp, the, 13. 
 
Dentine, Hypersensitive, 19. 
 
 Sensitive, 16, 224. 
 Dentition, 220. 
 Destructive Changes Continued, 45. 
 
 in the Pulp, 39. 
 Diagnosis, 174, 206, 228. 
 
 Positive, 209. 
 Direct Oxygen Method, the, 155. 
 Discolorations, 43. 
 
 Discolored Teeth, Management of, 151. 
 Diseases Affecting the Peridental Mem- 
 brane About the Apices of the 
 Roots of Teeth, 102. 
 of Children's Teeth, Management of 
 
 the, 220. 
 of Deciduous Teeth and Soft Tis- 
 sues of the Mouth, the, 223. 
 of the Maxillary Sinus, 216. 
 of the Peridental Membrane Hav- 
 ing Their Beginning at the Gin- 
 givus, 158. 
 of the Pulp, 223. 
 Constructive, 31. 
 
 of the Soft Tissues of the Mouth, 
 196. 
 Dry Scaling Papule, the, 207. 
 
 Eczema of the Tongue, 202. 
 Empyema, 216. 
 Ethereal Solution, 155. 
 Etiology, 217, 226, 232. 
 
 from a Therapeutic Standpoint, 19. 
 
 of Phagedenic Pericementitis, 172. 
 
 Germicides, 133. 
 
 Some Dental Uses, 137. 
 General Considerations, 151. 
 
 Histological Structure of the Peridental 
 Membrane, 102. 
 
 Pli story, 6, 59. 
 
 How to Cure Hyperemia and Inflam- 
 mation in Tooth Pulp, 56. 
 
 Hypercementosis and Root Resorp- 
 tions, 183. 
 Causes of, 186. 
 
 Hyperemia, 39. 
 
 of the Dental Pulp, Causes of, 40. 
 
 Hypersensitive Dentine, 19. 
 
 Plypertrophy of the Pulp, 55. 
 
 Immunity and Susceptibility, 82. 
 Infection, 133. 
 
 Carrying, 134. 
 
 Instruments Sterilization and Germ- 
 icides, 133. 
 Inflammation, 45. 
 
 as a Reparative Process, 48. 
 
 Calcic, 160. 
 
 Causes of, 47. 
 
 of the Tooth Pulp, Symptoms of, 
 54. 
 
 Treatment of, 57. 
 
 Symptoms of Local, 47". 
 
 Treatment of, 54. 
 Instruments, 175. 
 
 Instruments Sterilization, 133, 136. 
 Introductory, 6. 
 
 Facial Neuralgia, 226. 
 
 Favorable and Unfavorable Cases, 60. 
 
 Fever, 89. 
 
 Symptoms of, 90. 
 Filling Pulp Canals, 80. 
 
 Chambers, Cleansing and, 71. 
 Functions, 102. 
 
 of the Pulp, the, 16. 
 
 Germicidal Solution, a, 135. 
 
 Kinds of Pus, 88. 
 
 Leukoplakia, 203. 
 
 Local Inflammation, Symptoms of, 47. 
 
 Location, 205. 
 
 Loose Teeth, Management of, 179. 
 
 Management of Discolored Teeth, 151. 
 Loose Teeth, 179. 
 Permanent Teeth During Child- 
 hood, 225. 
 
ni 
 
 Management of Sensitive Cases, 19, 225. 
 
 Sensitive Dentine. 25. 
 
 the Diseases of Children's Teeth, 
 220. 
 Maxillary Sinus, Diseases of the, 216. 
 Medication, Systemic, 24. 
 Mercurial Stomatitis (Ptyalism), 200. 
 Method of Using, 155. 
 Methods, 64. 
 
 Curative, 11. 
 
 of Pulp Capping, 61. 
 
 of Tooth Bleaching, 153. 
 Morbid Anatomy, 183. 
 
 Necrosis, 219. 
 
 Nerve Supply, 17. 
 
 Neuralgia, Facial, 226. 
 
 Neuralgic Pains of Dental Origin, 226. 
 
 Obtundants, 25. 
 Open Cavities, Cases of, 93. 
 Oral Manifestations of Syphilis, Gen- 
 eral Considerations, 205. 
 Other Cells, 17. 
 
 Painful Process, 42. 
 Passive Hyperemia, Causes of, 39. 
 Pathology, 186, 208, 222. 
 Peridental Membrane About the Apices 
 of the Roots of Teeth, Diseases 
 Afifecting the. 102. 
 Having Their Beginning at the 
 
 gingivus. Diseases of the, 158. 
 Histological Structures of the, 102. 
 Permanent Teeth During Childhood, 
 
 Management of, 225. 
 Phagedenic Pericementitis. 170. 
 Etiology of, 172. 
 Treatment of, 174. 
 Plantation of Teeth, Resection of Roots 
 
 and, 189. 
 Positive Diagnosis, 209. 
 Preparation of Cavity to Receive Ar- 
 senic, 68. 
 
 Prognosis, 179. 
 Pulp Canals, Filling, 80. 
 Capping, 59. 
 Methods of, 61. 
 
 Chamber, the, 71. 
 
 Devitalization, 63. 
 
 Diseases of the, 223. 
 
 Functions of the, 16. 
 Pulpless Teeth, Treatment of, 124. 
 Pulp Nodules, 34. 
 
 Secondary Dentine and, 31. 
 
 the Dental, 13. 
 Pus, Kinds of, 88. 
 
 the Bacteria ot, 95. 
 Putrefaction Under Fillings, Cases of, 
 
 93. 
 Putrescent Cases, 224. 
 
 Pulps, 91. 
 
 Recent Theories, 7. 
 
 Removal of Salivary Calculus, 162. 
 
 Stains from the Teeth, 165. 
 Removing Pulps, 77. 
 Reparative Process, Inflammation as a, 
 
 48. 
 Replantation as a Cure for Alveolar 
 
 Abscess, 191. 
 Resection, 230. 
 
 of Roots and Plantation of Teeth, 
 
 189. 
 Root Filling, 224. 
 
 Salivary Calculus, 161. 
 
 Removal of, 162. 
 Scalers, 163. 
 
 Secondary Dentine and Pulp Nodules, 
 81. 
 
 Eruption, 210. 
 
 Stages of Syphilis, the, 210. 
 Sensitive Cases, Management of, 19, 225. 
 
 Dentine, 16, 224. 
 
 Management of, 25. 
 Sensitiveness, Thermal, 28. 
 Serumal Calcic Inflammation and Pha- 
 gedenic Pericementitis, Treat- 
 ment of, 174. 
 
 Calculus, 165. 
 
IV 
 
 Shock, 232. 
 
 Sodium Dioxid, Na. O2, 155. 
 Soft Tissues of the Mouth, Diseases of, 
 196. 
 
 Source of Infection, 205. 
 
 Special Cases, 129. 
 
 Stains from the Teeth, Removal of, 165. 
 
 Sterilization, Broach, 135. 
 
 Instrument, 136. 
 Stomatitis, 196. 
 
 Aphthous, 196. 
 
 (Ptyalism), Mercurial, 200. 
 
 Ulcerative, 199. 
 Structures, 102. 
 
 Suppuration of the Pulp, 91. 
 Tooth Pulp, 82. 
 
 Susceptibility, Immunity and. 82. 
 
 Symptomology, 43. 
 
 Symptoms, 35, 106, 187, 200, 228, 232. 
 and Diagnosis, 217. 
 Pathology, 114. 
 of Fever, 90. 
 Inflammation of the Tooth Pulps, 
 
 54. 
 Local Inflammation, 47. 
 
 Syphilis, Congenital, 214. 
 
 General Considerations; Oral Mani- 
 festations of, 205. ■ - 
 
 Tertiary, 212. 
 Systemic Medication, 24. 
 
 Teeth, Cleaning, 224. 
 
 Tertiary Syphilis, 212. 
 
 Therapeutics, 10. 
 
 Thermal Sensitiveness, 28. 
 
 Tooth Bleaching, Methods of, 153. 
 
 Discoloration, Causes of, 151. 
 
 Pulp, Suppuration of the, 82. 
 Treatment, 44, 94, 107, 109, 114, 162, 175, 
 197, 200, 204, 212, 217, 219, 222, 
 229, 233. 
 
 of Inflammation, 54. 
 
 of the Tooth Pulp, 57. 
 
 Pulpless Teeth, 124. 
 
 Serumal Calcic Inflammation and 
 Phagedenic Pericementitis, 174. 
 Tumors, 219. 
 
 Ulcerative Stomatitis, 199. 
 Ulcers, 218. 
 
 Variations of the Form of Pulp Cham- 
 bers, 77. 
 
 Willard, E.S., D.D.S., 95. 
 
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