Columbia ®nibergitp in tfie Citp of ^eto §orfe ^^ ZZ ^cijool of liental anti 0vai burger? Eefereitte l^ibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/moderndentalmate1917buck MODERN DENTAL MATERIA MEDICA, PHARMACOLOGY AND THERAPEUTICS BUCKLEY Copyright, 1909, by P. Blakiston's Son & Co. Copyright, 19 10, by P. Blakiston's Son & Co. Copyright, 191 i, by P. Blakiston's Son & Co. Reprinted, October, 1911; June, 1912; April, 1913; October, 1913; November, 1914; June, 1915; November, 1915; January, September and October, 1916. Copyright, 1917, by P. Blakiston's Son & Co. Printed, April, 19 17. Reprinted, May, 1920. Reprinted, July, 1922. "The use in this volume of certain portions of the text of the United States Pharmacopceia is by virtue of permission received from the Board of Trus- tees of the United States Pharmacopoeial Convention. The said Board of Trustees is not responsible for any inaccuracy nor for any errors in the statement of quantities or percentage strengths." "Permission to use for comment parts of the text of the National Formu- lary, Fourth Edition, in this volume, has been granted by the Committee on Publication by authority of the Council of the American Pharmaceutical Association." K7 \S7.^ THE M.4.PI,E PRESS X O K K PA TO THE MEMORY OF MY MOTHER. WHOSE ENCOURAGEMENT IN MY BOYHOOD DAYS SERVED ME SO WELL, AND TO MY WIFE, FOR MANY WILLING SACRIFICES DURING THE PAST EIGHTEEN YEARS, THIS VOLUME IS FONDLY DEDICATED. PREFACE TO THE FOURTH EDITION This book has been rewritten and thoroughly revised; Part I in accordance with the United States Pharmacopeia IX, which be- came ofi&cial on September i, 1916; and Part II in accordance with the knowledge of to-day relating to the treatment of diseases of the teeth and associated structures. The U.S.P. IX has discarded the term cubic centimeter (abbrev. c.c.) on the ground that the United States Bureau of Standards declared the term a misnomer, there being a shght difference be- tween the thousandth part of a liter and a cubic centimeter. The word mil, the first three letters of the whole word milUliter, has been adopted; therefore, in this work the word mil is used instead of c.c. The National Formulary is referred to in this edition more than was done heretofore, for the reason that many valuable pharmaceu- tical preparations have been omitted from the U.S.P. IX, and are found in the N.F. The laws passed by various States of the Union, in con- formity with the National Food and Drugs Act which was passed by Congress on June 30, 1906, make both the United States Phar- macopeia and the National Formulary the standards for drugs. An effort is being made in the profession of dentistry to-day to treat teeth under as nearly aseptic conditions as possible. With this end in view an article on Dental Sterilization has been written; as has also an article on Biologic Products. The advanced therapy of many infectious diseases includes the intelligent use of products from the Biologic Laboratories. Many of the systemic diseases of this character are now known to have a direct relation to diseased mouth and throat conditions; therefore, it is important that the student and the practitioner of dentistry understand the principles upon which this therapy is based. It will be found that Part II, which deals with Dental Thera- peutics, is more profusely illustrated than in former editions. There is no problem in dentistry at the present time of greater importance than the treatment of pulpless teeth and their sequelae. On this particular subject many illustrations have been added which show results of the treatment after the methods described in the text. The colored illustrations, especially those relating to the diseases of the soft tissues of the mouth, will aid greatly in the recognition of these diseases as they present in practice. viii PREFACE The author is indebted to Prof. John F. Biddle, of the Dental Department of the University of Pittsburg, for illustrated cases in his practice; and also desires again to record his appreciation of the cordial reception which this book has received from dental teachers of the subject, and from the profession at large. Chicago. J- ?• BuCKLEY. PREFACE TO THE THIRD EDITION The printing of the third edition in twenty months after the first appearance of this book has enabled the author to again make such alterations and corrections as would enhance the value of the work. The text has been changed slightly throughout and several new and original illustrations have been added. The greatest change has been made in the treatment of chronic alveolar abscess. Dentists in the past have placed too much dependence in drugs as the means of cor- recting root and bone comphcations; and, as a result, many teeth, thus diseased, have been needlessly extracted. Therefore the sur- gical treatment of these complicated conditions has been considered more fully and new illustrations added to aid in both the diagnosis and treatment. It has been my desire to improve the book without enlarging it, and to make the text still more clear, direct and practical. Chicago. J- P- BuCKLEY. PREFACE TO THE FIRST EDITION The general plan of tliis book is the outgrowth of many years of experience as a dental practitioner and teacher of Materia Medica, Pharmacology and Therapeutics in dental colleges. During these years, the author has realized the need of a text-book which would meet the wants of teacher, student and practitioner. The book is intended to include all that a dentist should know about drugs and remedies and their practical appHcation in the treat- ment of disease. The work is divided into two parts. The first is devoted to Materia Medica and Pharmacology, with enough Therapeutics to indicate clearly the uses of the various drugs and remedies; and an effort has been made to include herein every drug or remedy which is employed in Dental Therapeutics, except those which are obsolete, untried or savor of the "secret formula" variety. To accomplish this end, it was, of course, necessary to consult freely the United States Pharmacopeia, and other standard works on these subjects. Drugs marked with an asterisk (*) mean that the drug is a member of the group under consideration, but because of other prop- erties which the agent possesses, it has been elsewhere considered. In most instances, the drug is discussed under the group in which it is first mentioned, and if it is referred to subsequently in another group, it is there marked with an asterisk. For example, phenol is mentioned first as a disinfectant under which group of drugs it is discussed. Later it is mentioned in the group of escharotics, and is there marked with an asterisk. In this part of the book, also, is included Prescription Writing and its associated subjects — Metrology, Medical Latin and Incom- patibility, all of which have been given the dignity and importance they deserve in a dental course. It will be observed that no prescrip- tions have been written until after Prescription Writing has been discussed; after which, however, no formula has been mentioned with- out a correctly written prescription for the same. This plan was followed for the benefit of teachers and students in dental colleges. Prescriptions, as a rule, are confusing, though enticing to beginners, and questions naturally suggest themselves in regard to the various signs and terms used. For the teacher to attempt to explain these before the subject proper had been studied would be a loss of time, as no one can write a prescription intelligently without first being XU PREFACE familiar with drugs. Therefore, it is better, in the author's opinion* to avoid even the suggestion of questions pertaining to prescriptions at this time. By thus deferring the study of Prescription Writing to about the close of the Junior year, an excellent opportunity is afforded for practice work throughout the entire Senior year when Practical Therapeutics is taught. By this means only can students become good prescription writers — a faculty not developed by the average dentist. The second part of the book is devoted to Practical Dental Thera- peutics. In writing it the author was actuated by the belief that Dental Therapeutics is of sufficient importance to occupy a place in dentistry by itself. It is to be hoped that this subject may ulti- mately be divorced from Operative Dentistry, to which it has long been subordinated. No attempt has been made to describe all of the many methods of treatment, nor to give the endless formulas suggested in the vari- ous text-books and journals, for the pathologic conditions mentioned herein. To do so would lead to confusion, as well as make the book unnecessarily voluminous, in which case the word "practical" in connection \\"ith "therapeutics," as used here, would be a misnomer. Therefore, in most instances, only the methods by which the condi- tions are treated in the author's own practice are detailed. These methods, of course, are not wholly original. They have been gleaned from clinical experience, from extensive reading, and from observa- tion and association with other practitioners; and in both private and infirmary practice they have given good results. The prescriptions for remedies, for the most part, are original with the author, and have been worked out along the lines of practi- cal pharmacy and therapeutics. Where the formulas are not original, due credit, so far as is known, has been given. It is unnecessary to profusely illustrate a book of this kind. Only such illustrations as will tend to better explain the subject matter of the text are given. These, with few exceptions, were taken from actual cases in the author's practice, or from private patients referred to him for treatment. The author desires to express his grateful appreciation to Dr. E. W. Elliot for valuable suggestions, to Dr. Lee K. Stewart for furnish- ing models to illustrate a practical retaining appliance, and to other professional friends for the encouragement given in undertaking the work. He further records his appreciation of the publisher's unfail- ing courtesy. J. P. Buckley. Chicago. CONTENTS PART I DENTAL MATERIA MEDICA AND PHARMACOLOGY Modern Dental Materia Medica, Pharmacology and Therapeutics, i General Considerations, i Sources of Drugs and Constituents of Those of Vegetable Origin, 4 Parts of Plants Used for Drugs, 7 Pharmaceutic Preparations, 8 The Solutions, 8 The Mixtures, 11 Products by Extraction, 12 Mixtures of Solids, 16 Preparations for External Use, 18 Miscellaneous List of Nonofificial Bandages, Splints, Medicated and Antiseptic Dressings, and Medicated Gauzes, 20 Methods of Administering or Applying Drugs, 21 By the Mouth, 21 Hypodermic, 22 Epidermic or Inunction, 25 Intravenous, 26 Cataphoresis, 26 By the Rectum, 26 Inhalation, 26 Conditions Modifying the Action and Effect of Drugs, 27 Habit, 27 Idiosyncrasy, 27 Tolerance, 27 Cumulative Effect, 28 Dosage or Posology, 28 Age and Sex, 28 Pathologic Conditions, 29 Method and Time of Administration, 29 Classification of Medicines, 29 Definitions of Remedies, 30 =^s^__^___^_Foods, Hematics, and Tonics, 34 DnigsTs^ST""^" Local Remedies, 36 Antacids, 36 Antiseptics, Disinfectants, and Deodorants, 41 Astringents, Styptics, and Hemostatics, 72 Other Silver Salts and Soluble Compounds, 87 Bleachers, 88 Oxidizing Agents, 88 XIV CONTENTS Escharotics or Caustics, 93 Irritants and Counterirritants, 106 Emollients, Demulcents, and Protectives, 115 Local Anesthetics, 126 Refrigerant and Paralyzant, 126 G eneral Anesthetics, 140 Antipyretics, 145 Hypnotics, 150 Narcotics, 156 Stimulants, 163 Cardiac, 163 Respiratory, 175 Gastric, 177 Miscellaneous Group, 179 Alteratives and Restoratives, 181 Digestants, 205 Cathartics, 208 Diuretics, 222 Diaphoretics, 228 Emetics, 230 Expectorants, 234 Sialogogues, 236 Carminatives, 237 , Flavoring Agents, 240 Biologic Products, 245 Antitoxins, 246 Serums, 247 Vaccines, 248 Remedies Other Than Drugs, 249 Heat, 249 Cold, 250 Compressed Air, 251 Light, 251 Rontgen or X-ray, 252 Radium, 253 Electricity, 253 Massage, 254 Suction, 254 Suggestion, 255 Metrology, 257 The Metric System, 259 Equivalents to the English Weights and Measures, 261 -Percentage in Solutions, 263 Prescription-writing, 264 Medical Latin, 268 Examples of Practical Prescriptions, 270 Incompatibility in Prescriptions, 274 Antagonism of Drugs, 276 Dental Sterilization, 277 General Considerations, 277 Methods of Dental Sterilization, 277 Direct Flame, 277 Moist and Dry Heat, 278 Chemic Agents, 278 CONTENTS XV PART II PRACTICAL DENTAL THERAPEUTICS General Considerations, 281 Diseases of the Hard Tissues of the Mouth and Associated Structures, 283 Hypersensitive Dentin, 283 General Considerations, 283 Previous Attempts at Controlling Pain, 284 Therapeutics, 285 I. Physical Agents, 285 Heat, 285 Cold, 286 Light; Electricity, 287 II. Escharotics or Caustics, 287 Phenol and Zinc Chlorid, 287 Trichloracetic Acid, Silver Nitrate, and Trioxymethylen, 288 III. Local Anodynes or Local Anesthetics, 289 Cocain, 289 Novocain, 290 Neothesin, Menthol, Oil of Cloves, Eugenol, Phenol, Ethyl • Chlorid, Ether, and Chloroform, 291 IV. General Anodynes or Analgesics, 291 Opium, the Bromids, Nitrous Oxid, and Chloroform, 992 Desensitizing Paste, 293 Physiologic Action, 293 Indications, 294 Making the Apphcation, 294 Precautions, 295 Caution in Relation to Diseased Pulps, 296 Diagnosis and Treatment of Diseases of the Dental Pulp; including the Destruction and Removal of the Organ, 298 General Considerations, 298 The Normal Dental Pulp, 298 Character of Blood-vessels, 299 Common Soiirces of Irritation, 299 Constructive Diseases, 302 Secondary Dentin, 302 Pulp Nodules, 303 Destructive Diseases, 306 Diagnosis of Active and Passive Hyperemia and True Pulpitis, 307 Differential Diagnosis, 308 Treatment of Active Hyperemia, 308 Factors to be Considered in Pulp Capping, 308 Exceptional Cases of Exposvire, 309 Therapeutics of Pulp Capping, 310 Precautions, 310 Technic, 311 Treatment of Passive Hyperemia and True Inflammation, 313 The Removal of Vital Pulps and Subsequent Treatment, 314 General Considerations, 314 General Factors to be Observed in Removal of Pulp, 315 I. Anesthetization, 315 I. Pressure Anesthesia, 315 Sterilization, 315 XVI CONTENTS The Solution, 317 Pressiire, 318 Confining the Solution under Pressure, 319 Opening the Pulp Chamber to Expose Canals, 319 Selecting and Testing Broaches, 320 Control of Ordinary Hemorrhage and Removal of Blood, 320 Small Canals, 321 After-treatment, 322 When to Fill Canals, 322 Excessive Hemorrhage, 323 Objections to the Use of Adrenalin Chlorid, 323 2. Cataphoresis, 324 II. Devitalization, 325 The Preparation, 326 Technic of Application, 327 Length of Time Application Should Remain, 328 Opening Pulp Chamber and Exposing Canals, 328 Objections to the Use of Dialysed Iron and Tannic Acid, 329 Complications, 330 Hypertrophied Gum Tissue, 330 Diagnosis as to the Kind of Tissue in Cavity, 331 Hypertrophied Pulp Tissue, 332 Secondary Dentin, Pulp Nodules, and Pulp Calcification, 332 Removal of Pulps from Deciduous Teeth, 333 Arsenical Poisoning, 334 Diagnosis and Treatment of Pulpless Teeth and their Sequelae; including the Preparation of the Canals for Filling, 336 General Considerations, 336 Coagulating Drugs, 336 Important Products of Pulp Decomposition, 337 Drugs Indicated, 337 Factors to be Considered, 338 Diagnosis of Dead Pvilps, 338 Treatment of Pulpless Teeth, 339 Potassium and Sodium, 340 Technic of Using Schreier's Alloy, 341 Rationale of Rhein's Method, 341 Advantages of Phenolsulphonic Acid, 343 Caution in Using Callahan's Method, 344 Technic of Using Acid Method, 344 Nonpurulent Variety, 345 Removing old Root Filling, 346 Removing Blockade in Canal, 347 Purulent Variety, 347 Ionization, 347 Ionic Theory, 348 Complications, 349 Badly Decayed Root, 349 Pulp Partially Alive, Pulpal Abscess, Dry Gangrene, 350 ■ History and Treatment of Practical Cases, 351 Diagnosis and Treatment of Nonseptic Pericementitis, 358 General Considerations, 358 Drug Irritants, 358 Mechanical Irritants, 360 Treatment of Nonseptic Pericementitis, 361 CONTENTS XVU Diagnosis and Treatment of Septic Pericementitis and Acute Alveolar Abscess, 364 General Considerations, 364 Local Treatment, 364 General Treatment, 365 The Question of Extraction, 368 Chronic Alveolar Abscess, 370 General Considerations, 270 1. Abscess without Sinus, 370 Disposing of the Pus, 370 Therapeutics, 370 Weeping of Serum, 371 Complications, 372 2. Abscess with Sinus, 373 Therapeutics, 373 Establishing Sinus and Disposing of Pus, 374 Cauterizing Sinus, 374 Complications, 376 1. Denuded End of Root, 377 2. Resorbed or Roughened End of Root, 378 3. Encystment of Root, 378 4. Involving Bone, 378 5. Extensive Caries or Necrosis, 379 6. Involving Vault, 380 7. Secondary Abscess Pocket, 381 8. Involving Two or More Teeth, 381 9. Involving Antrum, 382 Periapical Cysts, 382 Surgical Treatment of Chronic Alveolar Abscesses and Their Sequelae, 382 Indications for Surgery, 382 The Anesthetic; Incision and Control of Hemorrhage, 383 Exposing the Area Involved, 385 Curetting the Area, 386 Filling End of Root, 386 Washing and Packing the Wound, 386 Subsequent Treatment, 387 Treatment of Gangrenous Pulps and Abscesses in Deciduous Teeth, 390 Pericemental Abscess, 391 Therapeutics, 391 Filling Root-canals, 394 Precautions, 396 Callahan's Rosin Solution, 400 Technic, 400 Discolored Teeth, 402 Principle of Bleaching, 403 Methods of Bleaching, 404 Oxidation, 404 Reduction, 405 Using Sodium Dioxid, 405 Preparation of the Tooth, 406 Ethereal Solution of Hydrogen Dioxid, 407 Antrum of Highmore, 410 Causes of Diseases of the Antrum, 410 Diagnosis, 412 XVlll CONTENTS Therapeutics, 413 Surgical Treatment, 413 ■ Medicinal Treatment, 414 Pyorrhea Alveolaris, 416 Probable Causes, 416 Systemic Effects, 417 Description of Classes, 419 Therapeutics, 422 Surgical Treatment, 423 Medicinal Treatment, 42S Astringent Mouth-washes Contraindicated, 429 Mechanical Treatment, 440 Neuralgia, 444 Facial Neuralgia, 445 Therapeutics, 445 Medicinal Treatment, 447 Local, 447 General, 448 Surgical Treatment, 451 Tic Douloureux, 451 Diagnosis and Treatment of Diseases of the Soft Tissues of the Mouth not Directly Associated with the Teeth, 453 General Considerations, 453 Canker Sores, 454 Herpes Labialis, 455 Syphilis, 455 Primary, 456 Secondary, 458 Tertiary, 460 Mercurial Stomatitis, 461 Tuberculosis, 462 Leucoplakia Buccalis, 463 Actinomycosis, 464 Acute Ulcerous Gingivitis, 464 Ludwig's Angina, 466 Gonorrhea, 466 Examination of Urine, 468 Total Solids in Normal Urine, 469 Urine Analysis, 471 Fehling's Solution, 471 General Index, 473 PART I MODERN DENTAL MATERIA MEDICA, PHARMACOLOGY AND THERAPEUTICS Materia medica is the science that treats of drugs, the study of which includes the source, constituents, physical and chemic properties of the inorganic and organic materials used for drugs. Pharmacology is the science that treats of the action of drugs upon the tissues, organs and functions of the body. It is, therefore, the study of the changes induced in Hving organisms by the adminis- tration of such substances as do not act as foods. Formerly this science was called Pharmacodynamics. That part of Pharmacology devoted to the study of Poisons is called Toxicology. Therapeutics is the science that deals with the application of drugs or remedies to the treatment of disease. The treatment of disease based solely on cHnical experience, whereby remedies are administered or applied without reference to their physiologic action, is known as empirical therapeutics. The application of the essential oils to ike canals of teeth contaming gangrenous (putrescent) pulps, or the giving of salicyHc acid, sodium salicylate or the lithium salts in cases of pyorrhea alveolaris, sup- posed to be associated with rheumatism or gout, are examples of empirical therapeutics. The treatment of disease by the employment of drugs which, from a knowledge of their physiologic actions, are expected to counteract certam known pathologic conditions, is recognized as rational therapeutics. The application of remedies containing for- maldehyd to a gangrenous root-canal, wherein it is expected that the formaldehyd gas will neutralize the gaseous end-products of pulp decomposition, may be given as an illustration of rational therapeutics. While it is essential that the student should understand at the very outset the definition of the terms materia medica, pharmacology and therapeutics, it is also essential that other general terms used throughout the text should be thoroughly mastered at this time. A medicine is any substance used in the treatment of disease. A drug is any substance which may be used as a medicine, or 2 DEFINITIOX OF TERMS it may be used purely in chemic processes and not directly in the treatment of disease. A remedy is a broader term and includes, besides material sub- stances, such agents or means employed in therapeutics as heat, cold, light, electricity, massage and suggestion. Remedies, therefore, may be di\'ided as follows: Prophylactic Remedies. — Those used to prevent disease, as polishing tooth-surfaces to prevent caries, or vaccination to prevent smallpox. Hygienic Remedies. — Those that assist in the maintenance of health, such as pure air, water, food and bathing. Imponderable Remedies. — These include heat, cold, Hght, electricity, massage and suggestion. Mechanical Remedies. — These involve the use of bandages, spHnts, instruments, etc. Pharmacologic Remedies. — These are called also medicinal remedies and are the material substances or medicines used in the treatment of disease. Biologic Remedies. — These are bacteriologic and chemic products obtained from the biologic laboratories, and are known as serums, vaccines and antitoxins. There are several closely related terms employed in the study of the practical uses of remedies, which often lead to confusion. It is well that the student understand these terms at the very outset. The term specific has a double meaning. When used in connection with a remedy it means that the remedy, if used in the proper manner, can generally be depended upon to produce definite results in certain diseases. For example, formocresol is a specific for gangrenous pulp conditions; antitoxin is a specific for diph- theria. There are but few specific remedies. AppHed to a disease, the term specific means syphilis, and it is so used by physicians and dentists to indicate that disease which has associated with it the stigma of vice. Therefore, s}^hins is generally spoken of as a specific disease. The terms physiologic action, physiologic effect and therapeutic effect are too frequently used interchangeably, without reference to their true meaning. There is a distinction between the action and the effect of a drug. Many times the action of a drug is obscure, but the effect, if produced, must necessarily be apparent. This is nicely illustrated by the inhalation of ammonia in cases of syncope (fainting). The action of the ammonia gas is that of an irritant on THE UNITED STATES PHARMACOPEIA 3 the respiratory mucous membrane, while the physiologic effect desired in this instance is cardiac and respiratory stimulation. This is brought about reflexly by the local irritation ; for ammonia, thus ad- ministered, produces a marked increase in both the strength and rapidity of the pulse and the depth and rapidity of the respirations. In the case mentioned above, the therapeutic effect would be the return of consciousness, which might not follow without further treatment. It is, therefore, possible to have the physiologic action and effect of a drug without the therapeutic effect. Resolution is a term which indicates the return of an abnormal to a normal condition, and means structural recovery. Dissolution is a term which means death. The author desires here to emphasize the importance of learning the distinction between these several terms, for they are too often used sjmonymously, without reference to their true meaning. A poison is any substance which, when administered or applied, by its inherent physical or chemic properties causes disease or death. That branch of medical science which treats of the action and effects of poisons, their detection, and the treatment of the conditions resulting therefrom, is called Toxicology. Pharmacy is the art of preparing, compounding and dispensing medicines. The Pharmacopeia is an authoritative work which: (i) Estab- lishes standards and tests for the identification, quahty, purity and strength, and (2) gives directions for the preparation, purification and preservation of drugs and medicines. How to prepare, purify and preserve medicines is the work of the pharmacist, but every practicing dentist should be famihar with certain standards and tests for the identity, quahty, purity and strength of the medicines employed in daily practice. The pharmacopeias may be considered the medico-legal authori- ties for drugs and medicines in their respective countries. The United States Pharmacopeia (abbreviation, U.S.P.) is prepared by a committee consisting of delegates appointed by authority from regularly incorporated medical and pharmaceutic societies and colleges. This pharmacopeial committee meets at the beginning of each decade, and the code of remedial agents thus estabhshed is intended to serve as a standard until superseded by a new revision. The last (ninth, ix) edition of the U.S.P. became the ofi&cial standard September i, 19 16. This book has been thoroughly revised in accordance therewith. By admitting certain articles to the pages of the U.S.P., it declares them to be of sufl&- 4 SOURCES OF DRUGS dent importance as to merit confidence in their use in the practice of medicine. Articles thus recognized are known as "official," which is S3nionymous with "pharmacopeial." This should not be taken to mean that articles not admitted are valueless, for there are many formulas in common use to-day which are exceedingly valuable, though not ofl&cial. National Formulary (abbreviation, N.F.) is a collection of formulas issued by the American Pharmaceutical Association as a supplement to the United States Pharmacopeia. Food and Drugs Act is a National law, which was passed by Congress on June 30, 1906. This was soon followed by similar legislation in the various States of the Union. These laws make the United States Pharmacopeia and the National Formulary the standards for drugs. The National Act states: "The term 'drug,' as used in this Act, shall include all medicines and preparations recognized in the United States Pharmacopeia or National Formulary for internal or external use, and any sub- stance or mixture of substances intended to be used for the cure, mitigation, or prevention of disease of either man or other animals." This legislation has been the means from which a great improve- ment in the quality of medicines has resulted. On account of the recognition given the National Formulary by the Food and Drugs Act, many formulas heretofore included in the previous Pharmacopeias have been omitted in the ninth edition. These formulas are now found in the National Formulary; and whenever occasion requires, throughout this work, reference will be made to this standard authority, though the official prepara- tions, or a combination of two or more, will largely furnish the basis for the formulas given by the author in that part of the book de- voted to practical therapeutics. A dispensatory is a commentary on the pharmacopeia, including, as do the American Dispensatories, all information pertaining to the pharmacy as well as the action and uses of medicines. Dis- pensatories are private pubHcations, and should be used only as references, for they are not intended to take the place of the standard and legal authorities — the Pharmacopeia and National Formulary. SOURCES OF DRUGS AND CONSTITUENTS OF THOSE OF VEGETABLE ORIGIN Drugs are derived from the three kingdoms of nature — mineral, animal and vegetable. Those which belong to the mineral kingdom CONSTITUENTS OF VEGETABLE DRUGS 5 are called inorganic drugs, and are obtained by chemic processes di- rectly from nature. Many valuable drugs are made by synthesis — the artificial formation of the product by chemically combining its con- stituents. Those so made are known as synthetic drugs. Organic drugs are those which are taken from the animal and vegetable king- doms. The element, carbon, plays the leading role in all organic drugs, and is combined in the compounds of carbon with such ele- ments as hydrogen, oxygen, nitrogen, and others. A great many medicinal products are being produced by biologic processes. They include the various serums, vaccines and antitoxins. A serum for therapeutic use is a product obtained from the blood of an immunized animal. A vaccine is any substance used for preventive inoculation, and is obtained in various ways — as lymph from a cowpox vesicle; from the patient himself. A vaccine made from a bacterial culture obtained from the patient is known as an autogenous vaccine. An antitoxin is a counterpoison or antidote elaborated by the body to counteract the toxins of bacteria. Antitoxins are frequently used in the treatment of certain infectious diseases, and also to confer immunity against these diseases. The constituents of vegetable drugs of value in medicine and dentistry are called the active principles, and they include carbohy- drates, alkaloids, glucosids, neutral principles, organic acids, volatile oils, resins, gums, fixed oils and fats, camphors and other miscellane- ous compounds. Carbohydrates are largely used as foods, yet many of them, owing to their bland and soothing action, are employed as medicines. These include starch and the sugars. 'Alkaloids are nitrogenous compounds, having the reaction and basic properties of alkahes. They are odorless, have a bitter taste, and generally possess powerful physiologic actions. Alkaloids are almost insoluble in water, but they readily combine with acids to form crystalHzable salts which are freely soluble. For example, cocain is an alkaloid, and, as such, is not largely used in dental prac- tice; but, when acted upon by hydrochloric acid, cocain hydrochlorid is formed, and this alkaloidal salt is one of our most useful drugs. Other examples of alkaloids are, strychnin, morphin, atropin, etc. The term artificial alkaloid is used to designate secondary alkaloids derived from natural ones, as apomorphin, which is obtained by abstracting from morphin a molecule of water. Glucosids comprise those vegetable principles which may be resolved by boiling with dilute acid or alkahes, or by the action of ferments, into glucose and one or more other products peculiar to the 6 SOURCES OF DRUGS substance tested. Glycyrrhizin, obtained from liquorice-root, and salicin, from willow-bark, are examples. Neutral principles are neutral constituents, differing from alka- loids in not being basic in character and from glucosids in not being resolvable into glucose. Aloin, from aloes, and piperin, from black pepper, are examples. Organic acids are found in many plants, either free or combined with alkaloids or inorganic bases. Those of most value in dentistry- are acetic, benzoic, lactic, salicylic, oxalic, and tannic acids. Volatile oils, also called essential oils, form a large group of organic bodies, from which they are chiefly obtained by distillation. They are highly odorous, oily, sparingly soluble in water, more or less soluble in alcohol and ether, and prone to become resinous on expo- sure to air. In the past the volatile oils have occupied a prominent place in dental practice. Those to be remembered are the oils of cassia {cinnamon), cloves, peppermint, winter green, turpentine, eucalyp- tus, and cajuput. Resins are exudations associated with, and probably derived from, volatile oils. They are insoluble in water, but freely soluble in alcohol. Examples of resins are those of jalap, podophyllum and common rosin. When a resin and volatile oil are both constituents of the same drug, the former is held in solution by the latter, making a natural oleoresin. Gums are dried exudations obtained by incising the Hmbs and branches of certain plants. Gums, contrary to resins, are insoluble in alcohol, but freely soluble in water. The most important gums are those of acacia and tragacanth. Ordinary mucilage is a solution of certain gums in water. Fixed oils and fats are obtained by simple pressure, and are not readily volatiHzed. Those used chiefly in dentistry are lard, lard oil, olive oil, castor oil, and oil of theohroma {cacao butter). Camphors are soHd and crystalHzable bodies, closely associated in plants with ter penes, i.e., compounds of carbon and hydrogen in the proportion CioHie, and probably derived from them by oxida- tion. The principal member of the group is offlcial camphor, CioHieO. Stearoptenes, obtained from various essential oils, as menthol and eucalyptol, are sometimes called camphors, but should not be so considered. Miscellaneous compoimds are such proximate principles as are not referable to the groups mentioned. They include several com- pounds of value to dentistry, as eucalyptol, eugenol, thymol and guaiacol. PARTS OF PLANTS USED FOR DRUGS 7 PARTS OF PLANTS USED FOR DRUGS The crude organic drugs which form a large part of the materia medica are chiefly derived from the vegetable kingdom. All the different parts of plants are used. The active principle is often dis- tributed throughout the entire plant, but is generally found more abundantly in one particular part, which is then used. For con- venience in study, the parts oj plants used for drugs can be divided into portions which grow under and above the ground. Portions Under Ground. — The root {radix) proper is that part of the plant-axis which does not bear leaves. Roots are ordinarily subterranean (grow underground) in their habits, and serve the double use of attaching the plant securely to the soil and of enabling it to absorb from the latter the necessary- food. The roots of some plants not only perform these functions, but become greatly thick- ened and serve also for the accumulation of reserve food material and are then called tubers (potato, beet and turnip). Roots possess a bark which is sometimes used separately (sassafras). If the under- ground portion of a root does bear leaves, it is termed rhizome [rhiz- oma). This is sometimes called a subterranean stem. When the root-leaves become enlarged and serve as storehouses for food, a bulb (bulbus) is formed. The onion is an example. The lowest part of the stem of a plant is often thickened, and is then called corm (cormus) . Portions Above Ground. — When the entire plant, except the root is employed, it is called herb {herba). This consists of stems, leaves, and often flowers or fruit. The stem proper is that part of the plant-axis which bears leaves or some modification of them. Its functions are, to form such a support for the leaves as will duly expose them to the influence of light and air, to bear the floral organs and convey to them the neces- sary nutriment, and to form a means of communication and inter- change between the roots, or organs which absorb the crude nutritive material from the soil, and the leaves, or organs which assimilate this food. With small, herby plants the stem is called stipes; with larger plants it is transformed into wood (lignum) and is covered with bark (cortex). The outer layers of the older bark are always corky, and a secondary bark develops inside of this which is called liber. The leaves (folia) are stem-appendages, regularly arranged upon the stem, and consist of expansions of its tissues. Buds may be con- sidered as rudimentary stems, with rudimentary leaves compactly arranged upon them. 8 PHARMACEUTIC PREPARATIONS The flower (flos) is a special modification of the leaves. It con- sists of the calyx (usually green parts called sepals) and a corolla. The latter is made up of showy leaflets (petals) and the inconspicuous, but important, male and female elements called stamens and pistil, respectively. The stamens bear the fertilizing element in the form of granules, termed pollen. The pistil consists of the ovary, which develops the seed {semen), and the style and stigma, which ser\e to receive the pollen. After fertilization takes place, the ovary develops into the fruit (fructus) ; this may also involve neighboring parts, es- pecially the top of the stem, as in the apple and strawberry. The fruit consists of the outer portion, pericarp, and the seeds. The latter contain the embryo and nutriment material, and are protected by a more or less hard shell. Certain organic drugs consist of the coagu- lated juices of the plants and show no structure (opium, etc.) , PHARMACEUTIC PREPARATIONS Pharmaceutic preparations are those preparations made by pharmacists, the formula and directions being given for their prepara- tion in the United States Pharmacopeia and National Formulary; and nearly one-half of the articles of the U.S.P. and all in the N.F. are pharmaceutic. The pharmaceutic preparations of the U.S.P. may be classified as follows: I. The solutions. 11. The mixtures. III. Products by extraction. IV. Mixtures of solids. V. Preparations for external use. These groups are subdivided into a number of classes, each class having a distinct Latin title which officially designates its members, or individual preparations, and by which they are alphabetically arranged in the U.S.P. Besides the Latin and EngKsh titles, each class is also known by an English name and various synonyms. In the U.S.P. IX the synonyms and official abbreviations are given. The student will gradually become acquainted with the vari- ous classes and names of each by carefully studying the following classification : I. THE SOLUTIONS The general class of pharmaceutic preparations called "The Solutions" includes nine subclasses, each classified according to the solvent used: PHARMACEUTIC PREPARATIONS 9 1. Aromatic Waters. — ^Aquae Aromaticae. — Aromatic waters are solutions of volatile substances in water. • They embrace the popular aqueous solutions of the volatile oils, and in these cases are made by first triturating the oil with some insoluble substance, as talc, pre- cipitated calcium phosphate, or magnesium carbonate, thus dividing t]ie globules of the oil and distributing it over much surface, after which distilled water, recently boiled, is added, when, by filtering, the water abstracts from the mixture all of the oil that it is capable of holding in solution. These aromatic waters were formerly known as "medicated waters" and are popular in dental practice. Unless otherwise directed, they should be made by the following general process: GENERAL PROCESS, U.S.P. IX Volatile Oil, two milliliters (2 rails — 30 m.). Purified Talc, fifteen grammes (iS-o Gm. — 3.9 dr.). Distilled Water, recently boiled, one thousand milliliters (1,000 mils-i qt.). Triturate the volatile oil with the purified talc, add the recently boiled distilled water gradually with continued trituration, filter, and pass the filtrate through the filter repeatedly until the Aromatic Water is perfectly clear. The waters most commonly used are: Ammonia Water (Aqua Ammoniae). Camphor Water (Aqua Comphorae). Cinnamon Water (Aqua Cinnamomi). Distilled Water (Aqua DestUlata). DistUled Water Sterilized (Aqua Destillata Sterilisata). Hamamelis (witch-hazel) Water (Aqua Hamamelidis) . Peppermint Water (Aqua Menthse Piperitse). Rose Water (Aqua Rosae). 2. Solutions. — ^Liquores. — These preparations are solutions of non-volatile substances in water. The official solutions contain only inorganic salts. The most important solutions are: Antiseptic Solution, Mouth-wash (Liquor Antiseptici, N.F.). Alkaline Antiseptic Solution, Mouth- wash (Liquor Antisep- tici Alkalini, N.F.). Solution of Calcium Hydroxid, Lime-water (Liquor Calcis). Compound Solution of Cresol (Liquor Cresolis Compositus). Compound Solution of Chlorin (Liquor Chlori Compositus). Solution of Ferric Subsulphate, Monsel's Solution (Liquor Ferri Subsulphatis). Solution of Formaldehyd, Formalin (Liquor Formaldehydi). Solution of Hydrogen Dioxid (Liquor Hydrogenii Dioxidi). 10 PHARMACEUTIC PREPARATIONS Solution of Hypophysis, Solution of the Pituitary Body (Liquor Hypophysis). Compound Solution of lodin, Lugol's Solution (Liquor lodi Compositus). Solution of Magnesium Citrate (Liquor Magnesii Citratis). Solution of Potassium Hydroxid (Liquor Potassii Hydroxidi). Solution of Chlorinated Soda, Labarraque's Solution (Liquor Sodae Chlorinatae). Physiologic Solution of Sodium Chlorid, Physiologic Salt Solution (Liquor Sodii Chloridi Physiologicus). Solution of Sodium Hydroxid (Liquor Sodii Hydroxidi). Solution of Zinc Chlorid (Liquor Zinci Chloridi). 3. Spirits. — Spiritus. — The spirits are solutions of volatile sub- stances in AlcohoL Several of the oflicial spirits are solutions of essential oils, and. are frequently called "Aromatic Spirits" or "Essences." The most important spirits are: Spirit of Ammonia (Spiritus Ammonise) (Nonofficial). Aromatic Spirit of Ammonia (Spiritus Ammoniae Aromaticus). Brandy (Spiritus Vini Gallici) (Nonofficial). Spirit of Camphor (Spiritus Camphorae). Spirit of Cinnamon (Spiritus Cinnamomi). Compound Spirits of Ether, Hoffmann's Anodyne (Spiritus ^theris Compositus). Compound Spirit of Juniper (Spiritus Juniperi Compositus). Spirit of Myrcia, Bay-rum (Spiritus Myrciae) (Nonofficial). Spirit of Nitroglycerin, Spirit of Glonoin (Spiritus Glycerylis Nitratis). Spirit of Peppermint (Spiritus Menthae Piperitae). Whisky (Spiritus Frumenti) (Nonofficial). 4. S3niips. — Syrupi. — Syrups are nearly saturated solutions of sugar in water, in which medicinal or flavoring agents are dissolved. The most important syrups are: Simple Syrup (Syrupus) (85 per cent. Sugar). Syrup of Acacia (Syrupus Acaciae). Syrup of Calcium Lactophosphate (Syrupus Calcii Lacto- phosphatis). Syrup of Wild Cherry (Syrupus Pruni Virginianae). Syrup of Ginger (Syrupus Zingiberis). Syrup of Hypophosphites (Syrupus Hypophosphitum) . Syrup of Ipecac (Syrupus Ipecacuanhas). Syrup of Iron, Quinin and Strychnin Phosphates (Syrupus Ferri, Quininae et Strychninae Phosphatum (Nonofficial). Syrup of Orange (Syrupus Aurantii). Compound Syrup of Sarsaparilla (Syrupus Sarsaparillae Com- positus). PHARMACEUTIC PREPARATIONS II Compound Syrup of Squill, Hive Syrup (Syrupus Scillse Compositus). Syrup of Senna (Syrupus Sennse). Syrup of Tolu (Syrupus Tolutanus). 5. Honeys. — ^Mellita. — Honeys are solutions of certain substances in clarified honey. Honey of rose (mel rosae) is an example. 6. Elixirs. — Elixiria. — EHxirs are solutions containing aromatic substances, sugar, alcohol, and water. They are used largely to mask the taste of nauseating drugs. There are only two ofi&cial elixirs : Aromatic Elixir, Simple Elixir (Elixir Aroma ticum). Elixir of Glycyrrhiza, Elixir of Licorice (Elixir Glycyrrhizae). Elixir of Iron, Quinin and Strychnin Phosphates (Elixir Ferri, Quininas et Strychninae Phosphatum) (Nonofi&cial). 7. Glycerites. — Glycerita. — Glycerites are solutions of medicinal substances in glycerin. The most important glycerites are: Glycerite of Boroglycerin (Glyceritum Boroglycerini). Glycerite of Iron, Quinin and Strychnin Phosphates (Glyceri- tum Ferri, Quininae et Strychninae Phosphatum) (Nonofi&cial). Glycerite of Phenol, Glycerite of Carbolic Acid (Glyceritum Phenolis). Glycerite of Starch (Glyceritum Amyli). Glycerite of Tannic Acid (Glyceritum Acidi Tannici). 8. Oleates. — Oleata. — Oleates are solutions of metallic oxids or alkaloids in oleic acid. The useful oleates are : Oleate of Cocain (Oleatum Cocainae) (Nonofificial). Oleate of Mercury (Oleatum Hydrargyri). 9. Collodions. — Collodia. — Collodions are solutions of medicinal substances in collodion, i.e., gun-cotton (pyroxyhn) dissolved in ether and alcohol. These preparations are used externally, and chiefly as protectants. The important collodions are: Collodion (Collodium). ^ Cantharidal Collodion, Blistering Collodion (Collodium Can- tharidatum). Flexile Collodion (Collodium Flexile). Styptic Collodion (20 per cent. Tannic Acid) (Collodium Stypticum) (Nonofficial). n. THE MIXTURES This general class of pharmaceutic preparations includes such liquid preparations as are not clear solutions, or solutions that can- not be classified according to the solvent used. There are three subclasses: 12 PHARMACEUTIC PREPARATIONS 1. Mixtures. — ^Misturae. — Mixtures are liquid preparations usu- ally holding in suspension in water some insoluble substance. Mix- tures should be well shaken before being administered. Examples of official mixtures are: Chalk Mixture (Mistura Cretae). Compound Mixture of Glycyrrhiza, Brown Mixture (Mistura Glycyrrhizae Composita). 2. Emulsions.— Emulsa. — Emulsions are liquid preparations consisting of oily, fatty, resinous, or otherwise insoluble substances, suspended in water by the aid of some gum or mucilage called the emulsifying agent, as acacia or tragacanth. Milk and the yolk of egg are natural emulsions. The important official emulsions are: Emulsion of Cod-liver Oil (Emulsum Olei Morrhuae). Emvdsion of Oil of Turpentine (Emulsum Olei Terebinthinag), 3. Liniments. — Linimenta. — These are liquid preparations for external use, consisting of solutions of oily or resinous constituents in alcohol or oils, or mixtures of liquid soaps. With the exception of belladonna liniment and lime liniment, which are used as seda- tive applications, all the official liniments are of a stimulating character, and should be applied with friction or massage. The useful official liniments are: Belladonna Liniment (Linimentum Belladonnae). Lime Liniment, Carron Oil (Linimentum Calcis). Camphor Liniment (Linimentum Camphorae). Liniment of Soft Soap, Tincture of Green Soap (Linimentum Saponis MoUis). m. PRODUCTS BY EXTRACTION^ The medicinal constituents, called active principles, of crude drugs are obtained by extraction. The Hquid used is termed the menstruum, and may be water or alcohol or both in varying propor- tions, with sometimes the addition of glycerin. This general class is represented by nine subclasses. 1. Mucilages.— Mucilagines. — These are solutions of gums or other mucilaginous constituents of vegetable drugs extracted with an aqueous menstruum. They are used as emollients, as emulsify- ^The U.S. P. formerly recognized a class of preparations known as "Wines" under "Products by Extraction." This class has been dropped in the U.S.P. IX. It is there stated that wine as a menstruum or solvent can with advantage be replaced by alcohol of various strengths, and the uncertainties due to the variability in quality and alcoholic content of the wines of commerce are avoided. Wines, therefore, will not be discussed here. PHARMACEUTIC PREPARATIONS 1 3 ing agents for suspending insoluble substances in liquids, and as excipients for pills. • The important mucilages are: Mucilage of Acacia (Mucilago Acaciae). Mucilage of Sassafras Pith (Mucilago Sassafras Medullae) (Nonofi&cial). Mucilage of Tragacanth (Mucilago Tragacanthae). Mucilage of Elm (Mucilago Ulmi) (Nonofl6cial). 2. Infusions. — ^Infusa. — ^Infusions are liquid preparations made by pouring boiling water on vegetable drugs in a suitable vessel provided with a cover, allowing it to stand for half an hour, and then straining. Tea, if properly made, is an infusion. There are two official infusions: Infusion of Digitalis (Infusum Digitalis). Compound Infusion of Senna, Black Draught (Infusum Senn« Com- positum) . 3. Decoctions. — Decocta. — Decoctions are liquid preparations made by pouring boiHng water on vegetable drugs in a suitable vessel provided with a cover, allowing it to boil for fifteen minutes, and then, when sufficiently cooled, strain. Coffee, as usually made, is a decoction. There are no official decoctions. 4. Vinegars. — Aceta. — Vinegars are liquid preparations made by treating vegetable drugs with dilute acetic, acid. They are not much used in dentistry. Only one is official: Vinegar of SquiUs (Acetum Scillae). 5. Tinctures. — Tinctura. — These are alcoholic or hydroalcohoKc solutions of the soluble constituents of crude drugs or of non-volatile substances (except iodin). Tinctures are the simplest form of alco- hoHc products by extraction, and as a class have no uniform strength. Tinctures of potent drugs are made of the strength of ten grammes of drug in one hundred mils of tincture. The other tinctures vary in the proportion of drug in the finished product. Where it has been found possible and desirable to standardize the tinctures, an assay is required by the U.S. P. This is true of tincture of opium, tincture of deodorized opium, and tincture of nux vomica. From a tincture all the other preparations may be progressively pro- duced through concentration by evaporating the menstruum, as follows: Fluid extract representing a uniform drug-strength, viz.: i troy ounce in i fluidounce (i gram in i mil). Extract, or "solid extract," a semi-solid mass of pilular consistence 14 PHARMACEUTIC PEEPARATIONS of no uniform drug strength, or assayed and powdered with diluent, to represent a certain alkaloidal strength (opium and nux vomica). Abstract, or "powdered extract," by incorporating sugar of milk with the extract to represent one-half the weight, or twice the strength of the drug. Resins, separation of the resinous constituents, by precipitation in water of a concentrated alcoholic tincture. Tinctures are applied locally or administered internally by den- tists more than any other subclass of pharmaceutic preparations. The following tinctures are among the most important: Tincture of Aconite (Tinctura Aconiti). Tincture of Belladonna Leaves (Tinctura Belladonnas Folicrum). Tinctura Benzoin (Tinctura Benzoini). Compound Tincture of Benzoin (Tinctura Benzoini Com- posita). Tincture of Cannabis (Tinctura Cannabis). Tincture of Cantharides (Tinctura Cantharidis). Tincture of Capsicum (Tinctura Capsici). Tincture of Calendula (Tinctura Calendulae) (Nonofficial). Tincture of Cinchona (Tinctura Cinchonae). Compound Tincture of Cinchona, Huxham's Tincture (Tinctura Cinchonae Composita). , Tincture of Cinnamon (Tinctura Cinnamomi). Tincture of Digitalis (Tinctura Digitalis). ' Tincture of Ferric Chlorid (Tinctura Ferri Chloridi). Tincture of Gelsemium (Tinctura Gelsemii). Compound Tincture of Gentian (Tinctura Gentianae Com- posita). Tincture of Hyoscyamus (Tinctura Hyoscyami). Tincture of Hydrastis, Tincture of Golden Seal (Tinctura Hydrastis) . Tincture of lodin (Tinctura lodi). Tincture of Kino (Tinctura Kino), Tincture of Myrrh (Tinctura Myrrhae). Tincture of Nux Vomica (Tinctura Nucis Vomicae). Tincture of Opium, Laudanum (Tinctura Opii). Camphorated Tincture of Opium, Paregoric (Tinctura Opii Camphorata). Tincture of Deodorized Opium (Tinctura Opii Deodorati). Tincture of Rhubarb (Tinctura Rhei). Ammoniated Tincture of Valerian (Tinctura Valerianae Am- moniata). 6. Fluid Extracts. — Fluidextracta.-^These are concentrated tinc- tures of such strength as to closely represent the drug volume for PHARMACEUTIC PREPARATIONS 1 5 weight, i.e., one fluidounce must represent the active principles of one troy ounce of the air-dried and powdered drug of standard quality ( I mil = I gram) . The preparations in this class are prescribed largely by physi- cians, for they possess the advantage of having a uniform strength. They are not employed by dentists, however, as much as are the tinctures. The most important fluid extracts are: Fluid Extract of Aconite (Fluidextractum Aconiti). Aromatic Fluid Extract (Fluidextractum Aromaticum). Fluid Extract of Belladonna Root (Fluidextractum BeUa- donnae Radicis). Fluid Extract of Cannabis (Fluidextractum Cannabis). Aromatic Fluid Extract of Cascara Sagrada (Fluidextractum CascarcC Sagradse Aromaticum). Fluid Extract of Cinchona (Fluidextractum Cinchonse). Fluid Extract of Digitalis (Fluidextractum Digitalis). Fluid Extract of Ergot (Fluidextractum Ergotae). Fluid Extract of Eucalyptus (Fluidextractum Eucalypti). Fluid Extract of Gelsemium (Fluidextractum Gelsemii). Fluid Extract of Gentian (Fluidextractum Gentianae). Fluid Extract of Hydrastis (Fluidextractum Hydrastis). Fluid Extract of Hyoscyamus (Fluidextractum Hyoscyami). . Fluid Extract of Ipecac (Fluidextractum Ipecacuanhas). Fluid Extract of Nux Vomica (Fluidextractum Nucis Vomicae). Fluid Extract of Senna (Fluidextractum Sennae). 7. Extracts. — Extracta. — These are soluble active principles of vegetable drugs concentrated by evaporation to a soft solid. They are called "solid" or "pilular" extracts to distinguish them from fluid extracts. They preserve the useful constituents of the drug in a concentrated, relatively uniform and permanent condition, and in a form suitable for medication. When employed, they are usually dispensed in pills or capsules. The extract of opium and extract oj nux vomica are required to be assayed, as are other extracts of potent drugs where it has been found possible and desirable to standardize them . The important extracts are : Extract of Aloes (Extractum Aloes). Extract of Cinchona (Extractum Cinchonae). Extract of Ergot (Extractum Ergotae). Extract of Hyoscyamus (Extractum Hyoscyami). Extract of Nux Vomica (Extractum Nucis Vomicae). Extract of Opium (Extractum Opii). Abstracts. — Abstracta. — These are a class of powdered extracts, formerly recognized by the U.S. P. (1880), prepared from the ex- 1 6 PHARMACEUTIC PREPARATIONS tracts by the addition of sufficient sugar of milk to make the product represent one-half its weight of the crude drug. The abstracts have a uniform relation to the drug in that one grain represents two grains of the drug, just as the fluid extracts have the uniform relation of representing the drug volume for weight. There are no official abstracts. An ideal abstract can be made from tincture of valerian, as the volatile oil in valerian does not permit of the evaporation necessary for an extract. Abstract of valerian is one of the most practical preparations of the drug. 8. Oleoresins. — Oleoresinae. — There are natural and pharma- ceutic oleoresins. The natural oleoresins have been elsewhere considered. The pharmaceutic oleoresins are semi-liquid extracts, obtained by exhausting oleoresinous drugs with ether. The ether extracts ^::cg(/ and volatile oils from drugs, as well as resins. Oleo- resins are not used in dentistry to any extent, but have been briefly considered here in order to make our classification complete. An ex- ample of an official oleoresin is : Oleoresin of Capsicum (Oleoresina Capsici). 9. Resins. — Resinae. — Resins have previously been considered under the constituents of drugs. The official resins may be divided into the (i) natural resins, (2) resins obtained from oleoresins by separating the volatile oil by distillation, and (3) pharmaceutic resins, prepared by precipitation. An example of an official resin is: Resin of Podophyllum, May Apple (Resina Podophylli). IV. MIXTURES OF SOLIDS The general class called mixtures of solids includes several sub- classes of pharmaceutic preparations for internal use: 1. Powders. — ^Pulveres. — These are impalpable mixtures of one or more active drugs, usually with some nearly inert substance, as sugar and aromatics. The nearly inert substance used to give bulk to official powders is called the diluent. The important powders are: Compound Acetanilid Powder (Pulvis Acetanilidi Com- positus) (Nonofficial). Compound Chalk Powder (Pulvis Cretse Compositus). Compound Effervescing Powder, Seidlitz Powder (Pulvis Effervescens Compositus). Powder of Ipecac and Opium, Dover's Powder (Pulvis Ipecacuanhae et Opii). Compound Powder of Morphin, TuUy's Powder (Pulvis Morphinae Compositus). PHARMACEUTIC PREPARATIONS 1 7 2. Effervescent Salts. — Sales Effervescentes. — These are granu- lated mixtures of salts with sugar, sodium bicarbonate and organic acids (tartaric and citric) , which effervesce when the mixture is added to water and furnish agreeable aerated draughts. They were new additions to the U.S. P. VIII, but as a class are dropped in the U.S. P. IX. They are highly useful in dentistry, and the following examples are here given: Effervescent Cafifein Citrate (Caffeina Citrata Effervescens). Effervescent Lithium Citrate (Lithii Citrata Effervescens). Effervescent Magnesium Sulphate (Magnesii Sulphas Effer- vescens). Effervescent Potassium Citrate (Potassii Citrata Effer- vescens). Effervescent Sodium Phosphate (Sodii Phosphas Effer- vescens). 3. Confections. — Confectiones. — These are flavored masses wherein the adhesive substance is sugar and water, or honey, serving as a vehicle to mask the taste of the drug. None are official in the U.S.P. IX. Examples are: Confection of Rose (Confectio Rosae). Confection of Senna (Confectio Sennae). 4. Troches or Lozenges. — ^Trochisci. — These are confections made in various forms and dried. Most of the troches are intended to influence the mucous membrane of the mouth and throat, and are useful preparations. The most important are: Troches of Tannic Acid (Trochisci Acidi Tannici). Troches of Ammonium Chlorid (Trochisci Ammonii Chloridi). Troches of Potassium Chlorate (Trochisci Potassii Chloratis). Troches of Sodium Bicarbonate (Trochisci Sodii Bicarbonatis). 5. Masses. — ^Massae. — These are plastic mixtures preserved in bulk and intended for forming into pills. There are two offlcial: Mass of Ferrous Carbonate, Vallet's Mass (Massa Ferri Carbonatis). Mass of Mercury, Blue Mass (Massa Hydrargyri). 6. Pills. — ^Pilulae. — These are spherical, more or less soluble masses of medicinal substances rendered cohesive, plastic, and firm in consistence by the addition of some substance (usually inert), called excipient. The kind of excipient used varies with the nature of the medicinal substance. The various excipients employed are water, alcohol, glycerin, syrups, glucose, glycerite of starch, mucilage of tragacanth, etc. 1 8 PHARMACEUTIC PREPARATIONS The following pills are important : Pills of Aloes (Pilulse Aloes). Compound Cathartic PiUs (Pilulag Catharticae Compositae). PiUs of Ferrous Carbonate, Blaud's PiUs (Pilulse Ferri Carbonatis). Pills of Phosphorus (Pilulae Phosphori). 7. Tablets. — ^Tabellse. — These are small disks containing med- icinal substances mixed with sugar and mucilage. They are a con- venient form in which to administer potent remedies, such as the alkaloids, calomel, etc. Blank tablets, i.e., those containing no medicinal substance, can be obtained and serve as a pleasant means of administering concentrated liquid preparations, such as the fluid extracts, by dropping from two to five minims of the preparation on the tablet. The U.S. P. IX recognized only one tablet; and this is not for internal use. It is here given : Poison Tablets of Corrosive Mercuric Chlorid, Corrosive Sublimate Tablets, Bichlorid Tablets (Toxitabellae Hydrargyri Chloridi Corrosivi). These tablets are of an angular shape (not discoid), each having the word "POISON" and the skull and cross bones design dis- tinctly stamped upon it. The tablets are to be colored blue, and each must contain a specified amount of corrosive mercuric chlorid. V. PREPARATIONS FOR EXTERNAL USE This class of pharmaceutic preparations includes such products as are used for external medication. Liniments, oleates, and collo- dions are employed externally, but being true solutions are classified as such. The classification of the groups here considered is based upon the fusibility, or melting-point, of the preparations, which is governed by the respective vehicles employed. 1. Ointments. — ^Unguenta. — These are mixtures wherein med- icinal substances are incorporated in a fatty vehicle. The vehicles used are: Benzolated lard, lard and wax or spermaceti in varying' proportions, lard oil, olive oil and suet. Petrolatum and lanolin (wool-fat) are largely used in nonofiicial ointments. The following are important official ointments: Ointment of Boric Acid (Unguentum Acidi Borici). Ointment of Tannic Acid (Unguentum Acidi Tannici). Ointment of Rose Water, Cold Cream (Unguentum Aquae . Rosae). PHARMACEUTIC PREPARATIONS 1 9 Mercurial Ointment (Unguentum Hydrargyri). Diluted Mercurial Ointment, Blue Ointment (Unguentum Hydrargyri Dilutum). lodin Ointment (Unguentum lodi). Iodoform Ointment (Unguentum lodoformi). Ointment of Phenol, Ointment of Carbolic Acid (Unguentum Phenolis) . Ointment of Zinc Oxid (Unguentum Zinci Oxidi). Nonofficial ointments in use are: Ointment of Arsenic Trioxid, Devitalizing Paste (Unguentum Arseni Trioxidi). Ointment of Camphor (Unguentum Camphorse, N.F.). Ointment of Europhen and Orthoform, Euroform Paste (Unguentum Europheni et Orthoformi). Ointment of Paraformaldehyd and Neothesin, Desensitizing Paste (Unguentum Paraformaldehydi et Neothesini). 2. Cerates. — Cereata. — These are mixtures of medicated fats similar to ointments, but of firmer consistence because they contain wax, resin, or paraffin, which raises the melting-point. The im- portant official cereates are: Simple Cereate (Cereatum). Cantharides Cereate, Blistering Cereate (Cereatum Can- tharidis). Important nonofficial cereates are : Compound Cereate of Camphor, Camphor Ice (Cereatum Camphorae Compositum, N.F.). Cereate of Bismuth Subnitrate, Beck's Cereate (Cereatum Bismuthi Subnitras). 3. Suppositories. — Suppositoria. — These are variously shaped masses of medicated fats, intended to be inserted into the orifices of the body, as the rectum, vagina, urethra, or nostril. The usual vehicle is oil of theobroma (cacao butter). Suppositories are expected to melt at body temperature. The only ofiicial one is: Suppositories of Glycerin (Suppositoria Glycerini). 4. Plasters. — ^Emplastra. — Mixtures of soHds having a fatty or resinous vehicle, and of such high melting-point as to be friable when cold, but rendered adhesive by the warmth of the body. The vehicles of plasters are: Lead plaster; resinous substances, made adhesive by admixture with the medicinal ingredients, and simple plasters, such as isinglass. Important official plasters are: Belladonna Plaster (Emplastrum Belladonnae). Capsicum Plaster (Emplastrum Capsici). 20 PHARMACEUTIC PREPARATIONS Rubber Plaster, Rubber Adhesive Plaster (Emplastrum Elasticum). Mustard Piaster, Mustard Paper (Emplastrum Sinapis). A nonofficial plaster is : Isinglass Plaster, Court Plaster (Emplastrum Ichthyocollse). 5. Papers. — Chartas. — These are strips of unsized, white paper saturated or coated with some medicinal substance. They are intended to be moistened and apphed as a plaster, or else to be burned and the fumes inhaled. The only one official in the U.S. P. Vin was Mustard Paper (Charta Sinapis) . This is now recognized as a plaster proper, as mentioned above. 6. Poultices. — Cataplasmata. — These are semi-Hquid prepara- tions made by mixing such coarsely ground substances as flaxseed, elm-bark, or bread, with hot water or milk. They are spread upon cloth or poured into porous bags, and used for appl3dng heat and moisture to the tissues, or for securing a local stimulant effect. Charcoal is sometimes added as an absorbent and mustard as a stimulant. There are none official. The U.S.P. VIII recognized the following: Cataplasm of Kaolin (Cataplasma Kaolini). 7. Fomentations. — ^Fomenti. — These are porous woolen cloths saturated with hot infusion or decoction of herbs, or other hot Hquids or lotions (saturated solution of boric acid) , and appUed hot. They are useful preparations, but none official. 8. Absorbent Cotton. — Gossypium Purificatum. — The hairs of the seed of cotton, freed from oil and resinous substances by treat- ment with alkalies and bleaching agents. These hairs represent microscopic ducts through which Uquids are absorbed by capiUary attraction. The absorbabihty of cotton, then, depends upon its purity, or the freedom from oily and resinous substances. This is equally true of all other material used for bandages. MISCELLANEOUS LIST OF NONOFFICIAL BANDAGES, SPLINTS, MEDICATED AND ANTISEPTIC DRESSINGS, AND MEDICATED GAUZES Bandages. — These are mechanical supports, serving also to keep wounds clean by absorbing and withdrawing such secretions as would otherwise prove irritating, and by protecting the wound from extraneous matter, thus promoting the process of healing. METHODS OF ADMINISTERING OR APPLYING DRUGS 21 Plaster-of-Paris Bandages. — These are made by thoroughly incorporating a good quality of plaster-of-Paris (calcium sulphate) into linen bandages. After the bandage is adjusted, water is applied, when it sets in a few minutes. Splints. — These are mechanical supports made from wood, metals (gold, platinum, lead, German silver, etc.), and vulcanite rubber. They serve the purpose of holding in proper position or aHgnment fractured bones and loosened teeth. The metallic splints are especially useful in orthodontia, pyorrheal treatment and the reduction of fractures of the mandible. Medicated and Antiseptic Dressings. — These are made by satu- rating such materials as cotton, silk, wool, or asbestos fiber in a certain strength solution of the medicinal agent, or by incorporating the latter in powdered form. The fabric, which conveys the agent, simply serves as a vehicle for the medicinal or antiseptic drug. This means is largely employed in the application of medicines to the canals of teeth. Medicated Gauzes. — The material used in making medicated gauzes is pure muslin gauze, which is thoroughly saturated with a certain strength solution of the medicinal substance desired, then forcibly expressed, after which it is ready for use. Medicated gauzes should be kept in tightly covered boxes or jars in a cool, dry place. They are largely used for packing and medicating wounds. The following gauzes are in common use: B orated Gauze. Iodoform Gauze. Phenolized Gauze. Euroform Gauze. METHODS OF ADMINISTERING OR APPLYING DRUGS The physiologic and therapeutic effect of remedies is often largely determined by the methods in which they are administered or ap- plied ; and it is a well-estabHshed principle that the nearer the remedy is appUed to the site of the disease the more effectual and safer is its use. Recognizing this principle, remedies should be appHed locally as far as possible. There are many pathologic conditions, however, confronting the dentist which cannot be reached and acted upon favorably by the local appHcation of medicines. It is, there- fore, the plain duty of every practitioner of dentistry to so familiar- ize himself with drugs and their internal administration that he will be able to treat successfully any case which arises in his practice. By the Mouth. — This is the original and most common method employed for the administration of the great majority of medicines. 22 METHODS OF ADMINISTERING OR APPLYING DRUGS Drugs are given by the mouth for their local action on the mucous membrane and deeper seated tissues of the mouth, throat, stomach, or intestines, or for the purpose of being absorbed. The absorp- tion of drugs may take place from any part of the alimentary canal. Some powerful remedies are readily absorbed from the tongue. A dose of spirit of nitroglycerin, placed under the tongue, will pro- duce its physiologic effect in from three to five minutes. Remedies intended to influence the mouth or throat are often given in the form of a troche or lozenge. When absorption of the remedy from the stomach is desired, it should be administered in solution or in such condition as to be acted upon by the gastric secretions and made soluble. The reaction of the gastric juice is acid, while the intestinal juices are alkaline. Any substance, therefore, soluble in either an acid or alkaline medium, is acted upon favorably by the secretions of the stomach or intestines. Such remedies as calomel, salol, and salophen, requiring an alkaline liquid for their solution, pass through the stomach practically unchanged, and are digested and absorbed almost entirely in the intestines. The general rule for administering remedies intended to be absorbed in the stomach is to give them on an empty stomach, that is, half an hour or an hour before meals. This rule should not be followed, however, in the case of remedies having a local irritant action, as potassium bromid or potassium iodid, etc. It is far better to give these remedies well diluted in water, and immediately after meals, so that their local effect is more or less avoided by their admixture with the food. Hj^odermic. — This method consists in injecting solutions of medicinal substances into the submucous and subcutaneous tissues by means of the hypodermic needle and syringe, and is largely employed in dental practice. The method has many advantages, such as the great rapidity with which absorption is effected, for local medication, and the certainty of securing the action of the entire dose. The alkaloidal salts, as cocain hydrochlorid, on account of their small bulk, are especially adapted for hypodermic use. The dose of a drug given hypodermically is generally about one-half that given by the mouth or stomach. There are several conditions wherein the hypodermic method of administering drugs is strongly indicated, viz. : 1 . In conditions where the patient is unable to swallow, or where the stomach is unable to receive or retain medicines. 2. In conditions necessitating the immediate action of a drug or remedy, or where absolute certainty of the dose is desired. METHODS OF ADMINISTERING OR APPLYING DRUGS 23 3. In conditions where local medication is desired for the pro- duction of local anesthesia, for the relief of pain, as in neuralgia, or for stimulation of a deep-seated part. The first two indications mentioned for this method of administer- ing drugs are of interest to dentists in that the method is employed here in cases of emergency, as in collapse. The third indication is of prime importance, as it is employed every day in a busy practice for the purpose of injecting local anesthetics and other drugs for the mitigation of pain. The factors to be remembered in using this method are: 1. Guard against septic infection. 2. Prevent the injection of air into a vein. 3. Prevent the injection of the medicine into a vein, unless in cases of emergency. To guard against septic infection, it is necessary to have the hands and the field of operation as nearly sterile as they can be made and to have the h3^odermic syringe, needle, and the solution absolutely sterile. To prevent injecting air into a vein, it is essential that all of the air should be exhausted from the syringe before the injection is made. When the syringe is filled by drawing the solution into it, hold the point upward, tapping the side of the syringe gently to dislodge any air bubbles, then by pushing the piston until the solu- tion escapes, the air is expelled. There is little danger of injecting air into a vein when the solution is injected into the submucous tissue of the mouth; nevertheless, it is well to avoid injecting air into the tissues, and when this method of drug administration is used other than in the mouth, the danger is correspondingly in- creased. If air enters a vein it is carried directly to the right side of the heart, where by the action of the tricuspid valve it forms a foam with the blood, resulting in air-thrombosis, which might cause death. Occasionally in an emergency it is desired to inject the medicine into a vein that it may be at once carried to the heart; but ordinarily this should be avoided. To unintentionally inject the entire quantity into a vein might result in an overdose. By injecting slowly and holding the finger over the needle-point, one can readily guard against this danger. If the fluid accumulates, which should be easily de- tected by the finger, nothing need be feared; but if the fluid escapes readily and the accumulation cannot be detected, one may suspect that a vein has been punctured. In this case the needle should be slightly withdrawn and the injection continued. 24 METHODS OF ADMINISTERING OR APPLYING DRUGS The Hypodermic Syringe. — There are many varieties of hypo- dermic syringes on the market. It was difficult to thoroughly steril- ize the old-style glass barrel and leather-covered piston syringe. During the past few years a great improvement has been made in both the glass barrel and all-metal syringes. The former has the advantage of permitting a view of the fluid or air within the barrel; the latter the advantage, if, indeed, it is an advantage, of being sterilized by boiling. It is no doubt true that the repeated boiling of a hypodermic syringe will soon cause it to leak and unfit it for use. It has also been found the safest and best practice to keep the syringes, needles, etc., when not in use, immersed in about a 70 per cent, solution of alcohol, to which i per cent, of thymol and about 5 per cent, of glycerin has been added. This may be done by having a suitable glass jar for the purpose. There are a variety of syringes and needles on the market. The operator should select and keep on hand the kinds which best meet his daily need. Technic of the Injection. — The method of injecting medicines hypodermically differs somewhat with the site of application; there- fore, it will be discussed under different headings: 1. Through the skin into the cellular tissue of the body. 2. Through the mucous membrane into the various submucous tissues, such as the gums, gingivae and alveolar process. 3. Through the tooth structure into the pulp tissue. • In injecting drugs hypodermically through the skin it is essential to guard against the dangers incident to this method of administering medicine. The solution should be sterile to begin with, the syringe and needle may be sterilized as the operator deems best, the hands by washing with green soap and followed with an application of alco- hol (60 to 70 per cent.), 1-1,000 solution of mercuric chlorid, or 1-500 solution of sublamin; the site of application may be sterilized in the same manner as the hands. Various solutions containing iodin are also popular for this purpose. The selection of the site for making the injection depends upon the circumstances of the case. It may be made upon any accessible part of the body, usually, however, the arm or lumbar region of the back. After exhausting the air from the syringe, hold it firmly in the right hand, and with the left grasp the skin at the selected site. The needle should now be pushed quickly through the skin at nearly right angles to the surface, and should penetrate quite deeply. The injection should be made slowly, and with the forefinger of the left hand determine whether it is causing distention of tissue or escaping rapidly. The dentist, as has been intimated, is particularly interested METHODS OF ADMINISTERING OR APPLYING DRUGS 25 in the technic of injecting drugs li3^odemiically through the mucous membrane and into the various submucous tissues (both soft and hard) for the purpose of producing local anesthesia. In the past there seems to have been an inherent prejudice by many practi- tioners against the use of local anesthetics in dentistry. The author and many others have advocated their use for years. Cocain was the drug largely used. With the introduction and use of novocain, a synthetic substitute for cocain, and a drug claimed to be far less toxic, this prejudice has gradually disappeared. The insistent demand for "painless dentistry" has made the use of local anesthetics and the h3rpodermic method of administering the same very popular in dental practice. It is sufficient at this time for the student to learn that local anesthesia in the mouth is produced in three ways: Infiltration, interosseous and conductive (nerve blocking) anesthesia. In the infiltration method the local anesthetic solution is injected in the submucous tissues immediately around the part to be anesthetized, simply permitting the solution to infiltrate the tissues. The interos- seous method consists of first making a small submucous injection to anesthetize a small area of gum tissue when the latter and cortex of the bone are pierced with a suitable drill; through which opening a few minims of the solution are deposited slowly, permitting it to difuse through the spongiosa of the hone, thus producing complete anesthesia of one or two teeth almost instantly. By conductive anesthesia or nerve blocking is meant the process of injecting local anesthetic solutions submucously into the tissues surrounding the foramen through which the nerve makes its entrance or exit; thus anesthetizing the nerve at this point, when the effect of which is conducted to the periphery, blocking the nerve as it were, and causing temporary loss of sensation in the part supplied by this nerve. Before anesthetizing any part or undertaking any surgical operation, the mouth should be rinsed, or, better, sprayed with an antiseptic solution. The solution, syringe, needle, hands of the operator, and field of operation should be sterilized as previously mentioned. We have considered here the principles of local anesthesia only; the detailed technic of making the various injections will be considered later as occasion requires. The forcing of local anesthetic agents through the tooth structure and into the pulp is known as pressure anesthesia and is elsewhere considered. Epidermic or Inunction. — This method consists in applying medicinal substances, dissolved in fatty vehicles, to the unbroken 26 METHODS OF ADMINISTERING OR APPLYING DRUGS skin when absorption of the remedy is fairly well brought about, espe- cially if friction be used in their application. Ointments are largely employed in this manner. Intravenous. — This method is used in great emergency where it is desired to inject a stimulating or restorative agent directly into a vein. Physiologic salt solution (6 parts of sodium chlorid in i,ooo parts of sterile water — 6 grams in i,ooo mils) is the remedy mostly employed in this manner. The solution is intended to correspond to blood serum in salinity, and is given intravenously in cases of copious hemorrhage, or in collapse. Cataphoresis. — This method consists in the introduction of drugs in molecular form into tooth structure or living tissue by means of the electric current. The positive-pole applicator is saturated with a concentrated solution of the drug and placed within a cavity in the tooth being treated, or directly over the part to be medicated, the negative pole being placed somewhere on the patient's body, — usually held in the hand by means of a moist sponge. This method, with cocain hydrochlorid as the drug, has been used to obtund sensitive dentin and to anesthetize the dental pulp for the purpose of its pain- less removal. The method will, therefore, again be considered more in detail. By the Rectum. — This method is employed for the administra- tion of both medicines and food, whenever, on account of inability to swallow or persistent vomiting, the mouth or stomach route cannot be used. The process of making the rectal injection is known as Enema. Absorption through the rectum is not nearly so rapid as through the stomach, hence to accomplish the same result it generally requires twice the dose by the rectum that would be neces- sary by the mouth, and solution of the drug should be assured before it is administered, unless a local effect is intended. For local medica- tion suppositories are largely employed. Inhalation. — This method can only be employed for volatile drugs or finely atomized liquids. Volatile drugs are rapidly absorbed from the respiratory tract, and this method is largely used in dental practice for the administration of such drugs as nitrous oxid, chloro- form, and ether, when the general analgesic or general anesthetic effect is desired. The stimulating effect of such drugs as ammonia and amyl nitrite is also produced by inhalation. When it is desired to influence directly the mucous membrane of the mouth and respira- tory tract, medicated vapors and sprays are often employed. CONDITIONS MODIFYING THE ACTION AND EFFECT OF DRUGS 27 CONDITIONS MODIFYING THE ACTION AND EFFECT OF DRUGS There are many conditions or circumstances which influence and modify the action and effect of drugs, chief of which are the age of the patient, the sex, race, size, temperament, disease, temperature, habit and idiosyncrasy, the method, time of administration, prepa- ration, and dose of the drug. Habit. — The tissues of the body can be induced to tolerate many drugs by their continuous administration. This is particularly true of opium and cocain. It is not definitely known just how this condition is brought about, but it is beheved to be largely due to a change in the tissues themselves whereby they are rendered less susceptible to the influence of the drug. There is a crying demand to-day for "pain- less dentistry," and most dental operations can be made practically painless by the judicious use of narcotic drugs, especially the local anesthetics. Therefore, a word of caution here regarding the danger of forming the drug-habit will not be out of place. This habit is far more common than is generally known. It is the duty of every dentist to employ such reasonable measures as will mitigate pain, but he should constantly guard his patient, as well as himself, against the formation of the drug-habit. In order to prevent the miscella- neous and injudicious prescribing of such habit-forming drugs as opium and cocain. Congress in 191 5 passed a law, known as the "Harri- son Narcotic Act," which requires physicians, dentists, and veterinar- ians to keep a record of all drugs used which are included in the Act. Idiosyncrasy. — This is a pecuHar susceptibihty or insusceptibility of one or more of the tissues of the body to the influence of certain drugs for which no explanation can be found. Less than 3^ of a grain of calomel has been known to induce salivation, causing an inflam- mation in the pericemental membrane and teeth sore to pressure. With some individuals the smallest dose of quinin will produce a diffuse erythematous rash. Many patients have an idiosyncrasy for cocain, the smallest amount causing all of the toxic symptoms characteristic of the drug. Other patients have what may be called a presupposed idiosyncrasy, for cases are on record where the patient had all the S3niiptoms of cocain-poisoning when only distilled water had been hypodermically injected, the patient, however, thinking cocain had been used. One form of idiosyncrasy consists in the failure of the individual to react to the ordinary dose of the drug, and this particular form is called Tolerance. 28 CONDITIONS MODIFYING THE ACTION AND EFFECT OF DRUGS Cumulative Effect. — This is another phenomenon of drugs caused by their prolonged administration when sudden and often- times a severe effect is produced, o^dng to the "accumulation of the drug in the tissues of the body. Cumulative action may occur along with tolerance. Dosage or Posology. — Under this heading can be discussed most of the conditions which modify the effect of drugs not previously considered, for whatever modifies the effect of drugs must also neces- sarily influence dosage. In regard to dosage Butler^ says : " Common sense ought long since to have told us that the doses prescribed in text-books are only based upon experience in certain cases, or upon experimentation made upon animals. From such data, however, the first author who wrote upon the posology of different substances started, and others have simply copied after the first. If any fact went beyond the well-defined limits, it was wont to be explained by the defective quality or method of preparation of the drug, or by an idiosyncrasy so rare that one would not even take the pains to investigate the matter, and see if it were reaUy less rare than had been beheved." While there is perhaps a maximum and a minimum dose for the various drugs, the dose of a remedy should be governed largely by the conditions found at the time the diagnosis is made and the medicine prescribed, taking into consideration the various circumstances which influence the action and effect of drugs. The U.S.P. IX, recognizing this fact, gives only the "average dose" for an adult. Commenting upon this the U.S.P. states: "It is to be distinctly understood that neither this Convention nor the Committee of Revision created by it intends to have these doses regarded as obligatory on the physician or as forbidding him to exceed them whenever in his judgment this seems advisable." Only the average dose of drugs and their preparations will be given in this book. The age of a patient must be taken into account in the internal administration of drugs. Children ought to receive much smaller doses than adults. Young calculates the dose for a child according to the following formula: Divide the age by the age + 12, the frac- tion obtained is taken as the proportion of the adult dose required. Thus, for a child four years old, the dose would be (4 + 12 = ) ^i of the adult dose; for a child twelve years old (77-+ — ^ =) /4 oi the adult dose. In regard to the sex, women require somewhat smaller doses than men. During pregnancy, purgative drugs, or preparations of ergot ^ Text-book of Materia Medica, Therapeutics, and Pharmacology, p. 46. CLASSIFICATION OF MEDICINES 29 used frequently in dental practice in cases of hemorrhage after ex- traction, have to be used with the greatest care, because purgatives induce congestion of the pelvis, and ergot acts directly upon the muscular walls of the uterus, causing contraction, either of which conditions may lead to abortion. Many drugs also pass from the mother to the child, and this should be remembered, as quantities which are insujQ&cient to poison the former may have serious effects upon the latter. During lactation, it should be borne in mind that many active drugs may be excreted in the milk, and may either act on the child or render the milk distasteful to it. Pathologic conditions very often modify the effects of drugs to a considerable extent, and in a way which pharmacologists at present cannot explain. As an example of this, the antipyretics reduce the temperature in fever, but have no effect on it in health; bromids lessen the convulsions in epilepsy, or during the teeth-erupting period in children, but have much less effect in depressing the brain in normal persons. Strange as it may seem to the student or inexperienced practitioner, the climate or temperature has a con- trolling influence on the action and effects of drugs, as well as on pathologic conditions, which fact has been demonstrated by clinical experience. The method and time of administration also have some influence on the effects of drugs. It has been mentioned elsewhere that the nearer the site of the disease the remedy is applied the more effectual and safer is its use. It is also true that the body is generally more resistant in the morning than in the evening, especially in the case of hypnotic drugs; thus a dose of chloral hydrate, for example, which may have httle or no effect in the morning when the brain is clear and active, induces sound sleep when given in the evening, because the brain now is already fatigued and depressed. CLASSIFICATION OF MEDICINES In their attempt to keep pace with the advancement of knowl- edge, writers upon, and teachers of. Materia Medica, Pharmacology, and Therapeutics have devised, from time to time, various systems of classification of drugs and remedial agents. The unsettled state of knowledge regarding normal physiologic processes and of the physiologic action of remedies upon pathologic conditions which they are expected to correct, is sufficient reason, in the author's opinion, for stating that therapeutics is far from being an exact science. At this time, therefore, no really scientific classification of these substances is possible. It is imperative, however, as an 30 DEFESriTIOXS OF REMEDIES aid to the student, that some system of classification be followed, and, inasmuch as the tendency in modern therapeutics is along rational lines, i.e., administering or applying the remedy because of its known pharmacologic action, a system of classification will be followed by which drugs will be divided into local and general remedies, and grouped, so far as possible, according to their physio- logic action and therapeutic application. It is important, however, that the student familiarize himself at the beginning of the study of drugs and their uses with the definitions of remedies with reference to their action upon the tissues, organs, and functions of the body. Therefore, as an appropriate introduction to that part of this work devoted to drugs proper, brief definitions of remedies, alphabetically arranged, are here inserted, together with practical examples of each. DEFINITIONS OF REMEDIES Antacids. — These are agents which neutralize acids by reason of their alkaHne or basic properties. Examples are : Sodium Bicarbonate. Solution of Calcium Hydroxid (Lime-water). Magnesium Hydroxid (Milk of IMagnesia). Alteratives. — Agents that alter or counteract morbid condi- tions by promoting metabolism or the processes of nutrition. Exam- ples are: Potassium lodid. Arsenic. Mercury. Cod-liver Oil. Analgesics or Anod3aies. — These are agents which relieve pain either by direct depression of the centers of perception and sensation in the cerebrum or by impairing the conductivity of the sensory nerve fibers. Examples are: Opium. The Bromids. Butyl-chloral Hydrate. Aspirin. Anesthetics. — These are agents which temporarily destroy sensation. They are divided into two classes, local and general. A local anesthetic aboHshes sensation in a part, while a general anes- thetic abolishes all sensation and induces unconsciousness. Exam- ples are: Local anesthetics. General anesthetics. Cocain Hydrochlorid. Nitrous Oxid. Eucain Hydrochlorid. Chloroform. Novocain Hydrochlorid. Ether. Ethyl Chlorid spray. DEFINITIONS OF REMEDIES 3 1 Antagonists. — These are agents which directly oppose each other in some or all of their pharmacologic actions. Advantage is taken of drugs which antagonize each other in cases of poisoning. Important examples are: Strychnin and Cocain. Atropin and Morphin. Caffein and Cocain. Anthelmintics. — These are agents which destroy (vermicides) or expel (vermifuges) intestinal worms. Examples are: Pepo (Pumpkin-seed). Oil of Turpentine. Thymol. Antipyretics. — These are drugs or remedies which reduce the body temperature when abnormally high. Examples are: Aconite. The Coal-tar Products: Quinin. Antipyrin. Acetanilid. Phenacetin. Antiseptics. — These are agents which inhibit the growth of microorganisms. Examples are: Oil of Cloves. Benzoic Acid. Phenol (5 per cent, solution). Sodium Borate (Borax). Boric Acid. Glycerin. Alcohol (20 per cent, solution). Betanaphthol. Antispasmodics.' — These are agents which control spasms and lessen states of general nervousness. Examples are: Camphor. Compound Spirit of Ethef (Hoffmann's Anodyne). Valerian. Astringents. — These are agents which contract or condense tissue. Examples are: Alum. Zinc Phenolsulphonate. Tannic Acid. Zinc lodid. Bismuth Subnitrate. Silver Nitrate. Zinc Chlorid. Copper Sulphate. Bleachers. — These are agents used to restore the color of tooth- structure. Examples are: Sodium Dioxid. Alphozone. Hydrogen Dioxid. Chlorin. Sulphurous Acid. Carminatives. — These are agents which promote the expulsion of gas from the stomach. Examples are: 32 DEFINITIONS OF REMEDIES Capsicum. Pepper. Mustard. Cinnamon. Ginger. Cardamom. Cathartics. — These are agents used to produce evacuation of the bowels. Cathartic drugs are classified according to the intensity of their action. Thus, those that are mild in action and produce a nearly normal stool are called laxatives. Those more powerful, usu- ally producing more copious stools, are termed purgatives. Those which produce a watery evacuation of the bowels are called hydragogues. Those which gripe, having a violent action, are called drastics. Examples of each class follow: Laxatives. Purgatives. Tamarind. Aloes. Cascara Sagrada. Senna. Manna. Castor Oil. Honey. Calomel. Figs. Rhubarb. Prunes. Blue Mass. Hydragogues. Drastics. Magnesium Sulphate. Croton Oil. Sodium Sulphate. Colocynth. Potassium and Gamboge. Sodium Tartrate (Rochelle Salt). Jalap. Sodium Phosphate. Podophyllum. Magnesium Citrate. Demulcents. — These are substances largely of a mucilaginous nature, which soothe and protect the parts to which they are applied. Examples are: Acacia. MarshmaUow. Licorice. Starch. Sassafras Pith. Flaxseed. Slippery Elm. White of Egg. Dentifrices. — These are medicated powders or pastes applied with a suitable brush to cleanse the teeth and gums. Precipitated chalk (calcium carbonate) is the base of all dentifrices. For ex- amples, see Practical Therapeutics, p. 270. Deodorants. — These are agents which destroy offensive odors. Examples are: Formaldehyd. Potassium Permanganate. Chlorin Gas. Charcoal. Hydrogen Dioxid. Sulphurous Acid. Diaphoretics or Sudorifics. — These are agents which promote the secretion of sweat. When the action of the remedy is such that DEFINITIONS OF REMEDIES ^^ the perspiration stands in beads upon the surface, it is called sudorific. Examples are: Pilocarpus (Pilocarpin). Ammonium Acetate. Dover's Powder. Spirit of Nitrous Ether. Disinfectants or Germicides. — These are agents which destroy microorganisms and their spores. Examples are: Mercuric Chlorid. Urotropin. Formaldehyd. Hydrogen Dioxid. Cresol. Potassium Permanganate. Phenol. Silver Compounds. Thymol. Betanaphthol. Heat. Chlorin Gas. Diuretics. — These are agents which increase the flow of urine. Examples are: Potassium Salts. Spirit of Nitrous Ether (Sweet Lithium Salts. Spirit of Niter). Effervescent Salts. Emetics. — These are agents which produce vomiting. Exam- ples are: Ipecac. Alum. Tartar Emetic. Mustard. Zinc Sulphate. Apomorphin. Copper Sulphate. Tepid Water, in quantity. Emollients. — These are substances which protect, soften, and relax the tissues to which they are applied. Examples are: Hot Fomentations. Linseed Oil. Poviltices. Petroleum. Lard. Cacao Butter. LanoHn. • Glycerin. Olive Oil. Almond Oil. Escharotics or Caustics. — These are agents which destroy the tissues upon which they act. Examples are: Mineral Acids. Osmic x\cid. Caustic Alkalies. Zinc Chlorid, Phenol. Sodium Ethylate. Arsenic Trioxid. Mercuric Chlorid. Trichloracetic Acid. Silver Nitrate. Actual Cautery. Expectorants. — These are agents which modify the secretion of mucus from the mucous membrane of the air-passages and facilitate its expulsion. Examples are: 34 DEFINITIONS OF REMEDIES Ammonium ChJorid. Squill. Eucalyptus. Ipecac. Potassium Citrate. Hypnotics or Somnifacients. — These are agents which produce sleep. Examples are: Chloral Hydrate. Pyramidon. Butyl-chloral Hydrate. Trional. Sulphonal. Paraldehyd. Opium (and Alkaloids)-. The Bromids. Irritants. — These are agents which, when applied to the skin or mucous membrane of the mouth, cause active hyperemia or inflam- mation. When they are applied not simply for their local action, but to influence favorably a deep-seated part which is diseased, they are called counterirritants. Irritants are largely used for the latter purpose in dental practice. Examples are: lodin. Aconite. Mustard. Chloroform. Capsicum. Volatile Oils. Camphor. Menthol. Mydriatics. — These are agents which produce dilatation of the pupil of the eye. Examples are: Atropin. Homatropin. Hyoscyamin. Cocain. Anesthetics (late in their action). Myotics. — These are agents which produce contraction of the pupil of the eye. Examples are: Physostigma, Eserin. Anesthetics (early in their ac- Opium, Morphin. tion.) Narcotics. — These are agents which produce stupor. Examples are: Opium (and Alkaloids). Chloroform. Alcohol. Ether. Restoratives. — These are agents, somewhat similar to altera- tives, which promote constructive metamorphosis. Restoratives include : FOODS, HEMATICS, AND TONICS Foods are substances which, when introduced into the body, supply material to renew some structure or to maintain some vital process. They differ from medicines in that the latter modify vital processes, but furnish no material to sustain such. DEPINITIONS OF REMEDIES 35 Hematics are medicines which increase the hematin in the blood, and enrich the red blood-corpuscles. The compounds of iron are the principal hematics. Tonics are agents which improve the tone and give strength and energy to the tissues. Among the tonics are: Iron and Compounds. Cod-liver Oil. Phosphorus. Nux Vomica. Calcium Phosphate. Cinchona. Hypophosphites. Arsenic. Sedatives. — These are agents which exert a soothing influence on the system by lessening functional activity and diminishing pain. They have been largely considered in other classes of remedies, as: General sedatives include anesthetics and narcotics. Nervous sedatives include the bromids, tobacco, etc. Sialogogues. — These are agents which stimulate the salivary and buccal mucous glands, increasing the secretion and flow of saliva and buccal mucus. Holding the mouth open, as in dental operations, changes the character and flow of the mouth secretions. Examples of drugs producing this effect are: Pilocarpus (Jaborandi). lodin Compounds. Mercurials. Tobacco. * Echinacea, Echafolta. Potassium Chlorate. Stimulants. — These are agents which increase the activity of an organic function or process. When applied to medicinal agents the term is used in various senses, for different agents stimulate the functional activity of the various organs of the body. As examples we have: Cardiac. Respiratory. Gastric. Restorative. Strychnin. Atropin. Gentian. Physiologic Salt Solution. Digitahs. Bitter Tonics. Caffein. Alcohol. St3^tics and Hemostatics. — These are agents which arrest hemor- rhage. When the agent is applied locally it is called a Styptic; when administered internally it is called a Hemostatic. Examples are: Styptics. Hemostatics. Acids. . Ergot. Alum. GaUic Acid. Ferric Subsulphate. '' Hamamelis. Adrenalin Chlorid. Cauterization. 36 DRUGS DRUGS As stated elsewhere, an effort will be made to divide drugs into local and general remedies, and group them, so far as possible, accord- ing to their physiologic action and therapeutic application. Those drugs which are largely applied locally in dental practice will first be considered. LOCAL REMEDIES ANTACIDS Antacids are agents which neutralize acids by virtue of their alkaline or basic property. All acids, whether mineral or organic, have a destructive action on the tooth-structure. Acids are found in the mouth as a result of the fermentation of carbohydrate food- stuffs, from eructations of the stomach, and from perverted buccal mucous glands. Agents which are capable of neutralizing acids, therefore, have an important role to play in the broad field of oral prophylaxis. They form the base of nearly all dentifrices and enter as an essential constituent into most of the mouth-washes on the market. The most important antacids are : Precipitated Calcium Carbonate. Sodium Borate (Borax). Lime-water. Magnesium Oxid. Sodium Bicarbonate. Soap. CALCn CARBONAS PRS:CIPITATUS— U.S.P. (Precipitated Calcium Carbonate; Precipitated Chalk; CaCOs.) Formerly there were two official forms of chalk : Precipitated cal- cium carbonate and prepared chalk. The former is the only form rec- ognized in the U.S.P. IX and is made by mixing aqueous solutions of calcium chlorid and sodium carbonate, the resulting precipitate of calcium carbonate being purified. The latter is native calcium carbonate, freed from most impurities by elutriation (washing). Precipitated calcium carbonate occurs as a fine, white, micro-crys- talline powder, odorless and tasteless, and permanent in the air, nearly insoluble in water; the solubility is increased by the presence of ammonium salts and especially by carbon dioxid. It is insoluble in alcohol. The average dose is 15 gr. (i.o Gm.). Therapeutics. — Chalk is an antacid and mild astringent. It is an excellent antacid when the acidity of the fluids of the mouth is due to eructations from the stomach. It may be prescribed as an LIQUOR CALCIS — SODII BICARBONAS 37 antidote in general poisoning by any of the mineral acids or by oxalic acid, care being taken to avoid the rapid evolution of large quantities of gas (CO2). Because of its antacid properties and its almost absolute insolubility, it enters into the composition of nearly all dentifrices, forming the base of most tooth-powders and pastes. LIQUOR CALCIS— U.S.P. (Solution of Calcium Hydroxid; Lime-water; Ca(0H)2.) Lime-water is a saturated solution of pure calcium hydroxid in water. The liquid should be clear and colorless, without odor, and having a saline and feebly caustic taste. It should contain not less than 0.14 per cent, of calcium hydroxid. When administered in- ternally the average dose is 4 fl. dr. (15.0 mils). A useful official preparation is Linimentum Calcis (equal volumes of lime-water and linseed oil). Therapeutics. — In all cases where cows' milk is the chief article of diet, as in the artificial feeding of children, lime-water should be added to the milk to prevent the formation of hard curds in the stomach. In cases of obstinate vomiting, as in pregnancy, when the vomiting or eructations are due to a high degree of acidity, it is a useful remedy. In chronic catarrh with an excessive secretion of mucus, lime-water diluted with two-thirds cinnamon water, to which a smaU amount of alcohol is added, can be used as a spray and for rinsing the mouth and brushing the teeth, gums, and tongue with gratifying results. The official Hniment, called also Carron Oil, is employed as a soothing application for hums and scalds. SODH BICARBONAS— U.S.P. (Sodium Bicarbonate; NaHCOa.) Sodium bicarbonate is a white, opaque powder, without odor, and having a cooHng and slightly alkaline taste. It is freely soluble in water, i part dissolving in 10 parts of water at 25°C.; insoluble in alcohol. The average dose is 15 gr. (i.o Gm.). An important official preparation is : TrocMsci Sodii Bicarbonatis (containing about 2)4, gr. (0.18 Gm.) each). Therapeutics. — Sodium bicarbonate is extensively used to neutralize the excess of hydrochloric acid or abnormal acids in the stomach. Given in the form of a troche an hour or two before 38 ANTACIDS meals, it allays the burning pain, eructations, and palpitations caused by the acids of fermentation. Sodium bicarbonate is often applied externally as a sedative dressing for superficial burns. A 5 to 10 per cent, solution has been used in cases of thrush with excellent results. It is an ingredient of the popular Dobell's solution (see p. 271) and used as an antacid or detergent in many mouth-washes. Sodium bicarbonate is added to the water in which instruments are boiled for sterilization to prevent the latter from rusting. Sodium carbonate and borax are also used for this purpose. When acids are employed in root- canals, they should subsequently be neutralized with some ant- acid, and nothing is better than a solution of sodium bicarbonate. The agent not only neutralizes the excess acid, but the effervescence produced removes from the canal all of the "mushy" and disinte- grated material; thus leaving it clean and sterile. The powder is used by direct application to lessen the hypersensitiveness of dentin when due to acidity. In the treatment of pyorrhea and oral prophy- laxis, the teeth, oftentimes after the scaling and polishing, are ex- tremely responsive to thermal changes, especially where the gums have receded, exposing the cementum. This can be controlled by warm solutions of the drug. It is stated in many clinical, pharmacologic and physiologic text-books that the alkaline salts of sodium promote a flow of gastric juice. Pawlow, Sippy, Stone, and other internists claim that clinical experience does not confirm this theory. In fact, it has been shown that alkalies exert a distinct inhibitory influence on the gastric glands, separate and distinct from their neutralizing effects on acids already present in the stomach. Sodium bicarbonate 20 parts, heavy magnesium oxid 5 parts, and bismuth subcarbonate 5 parts make an excellent "alkaline powder" to be taken after meals in from one-half to one teaspoonful doses in cases of hyper- acidity oj the stomach, gastric and duodenal ulcers. The powder should be taken in a small quantity of water, thoroughly agitated, as the magnesia oxid and bismuth salt do not dissolve in the water. Incompatibilities. — Sodium bicarbonate is incompatible with acids, metallic salts, and alkaloids. SODII BORAS— U.S.P. (Sodium Borate; Sodium Pyroborate; Borax; Na2B407-ioH2O.) Borax occurs in colorless, transparent, monoclinic prisms, or white powder; inodorous, and of a sweetish, alkaline taste. It is MAGNESII OXIDUM 39 soluble in about i6 parts of water and i part of glycerin, and is insoluble in alcohol. The average dose is 12 gr. (0.75 Gm.). An ofl&cial preparation for external use containing a small amount of borax is: Unguentum Aquae Rosse (Cold Cream). Theapeutics. — The alkaline and antiseptic properties of borax make it a useful drug. It is a valuable ingredient in mouth-washes possessing the above qualities, and can be used freely in saturated solution {6}4 per cent.) in cases of stomatitis and in thrush. In the latter disease, which generally occurs in the mouths of infants where it is impracticable to use a mouth-wash to advantage, a saturated solution in glycerin, made by dissolving the drug in hot glycerin, can be employed. This thick, sweet solution should be appHed by means of a swab to the mucous membranes of the infant's mouth. A saturated solution in a 10 per cent, formaldehyd solution makes an excellent sterilizing fluid for small instruments. The borax prevents the formaldehyd from attacking the metal. A good coUyrium (eye-water) can be made by adding 2 per cent, of borax to a saturated solution of boric acid. IncompatibiUties. — Borax is incompatible with acids, metallic salts, and alkaloids, and glycerin slowly converts it into boric acid. MAGNESn OXIDUM— U.S.P. (Magnesium Oxid; Light Magnesia; Calcined Magnesia; MgO.) Light Magnesia is a white, very bulky, and very fine powder, without odor, and having an earthy-Hke taste. It is practically insoluble in water, and insoluble in alcohol, but chemically soluble in dilute acids. The average dose is 30 gr. (2.0 Gm.). An important official preparation is: Ferri Hydroxidum cum Magnesii Oxido (Arsenic Antidote). Therapeutics. — The preparation of ferric hydrate with magnesia has long been recognized as an efficient antidote in arsenical poison- ing. Other compounds of magnesia, recognized by the U.S. P., are Heavy Magnesia (Magnesia Oxid — $^2 times as heavy as Ught magnesia) and Magnesium Carbonate. Both have practically the same properties and uses as light magnesia. Magnesium carbonate, however, should be used cautiously when there is much acid in the stomach on account of the unpleasant eructations of gas (CO2). Magnesium carbonate, being cheap and insoluble, is often substi- tuted for talc or precipitated calcium phosphate in the preparation 40 ANTACIDS of the aromatic waters/ The suspended precipitate of magnesium hydrate, commercially called milk of magnesia, is a useful antacid. In cases of erosion of the teeth, in pregnancy, and other conditions wherein the mouth secretions are acid in reaction, it can be used to advantage by coating the exposed tooth-surfaces with it. Its gelatinous consistence causes it to adhere and remain for a consider- able length of time, especially if applied on retiring at night when the jaws and buccal tissues are at rest. In cases of hyperacidity of the stomach, due either to an excess of ■ hydrochloric acid or the acids of fermentation, Sippy recommends an average dose (30 gr.-2.o Gm.) each of heavy magnesia and sodium bicarbonate; this to be taken in a small amount of water soon after each meal. Besides these antacids, the proper diet must be observed and I fl. oz. (30.0 mils) each of milk and cream should also be taken after the meal. Magnesia is partly converted by the acids of the stomach into soluble salts that act as laxatives; hence, when inter- nally administered, the antacid properties of magnesia are combined with those of a mild aperient or laxative. SAPO— U.S.P. (Soap; White Castile Soap.) The only official soap is white castile soap, made by boiling olive oil with sodium hydroxid. Any fat boiled with sodium or potassium hydroxid will form soap. Hard soap is a sodium soap, soft soap is a potassium soap. White castile soap should be hard, but easily cut when fresh, easily pulverized when dry, and free from rancid odor. It has a rather unpleasant taste and an alkaline reaction, hence it is an antacid, soluble in. water and in alcohol. A useful preparation is: Linimentum Saponis Mollis — U.S.P. (Liniment of Soft Soap, Tincture of Green Soap). Therapeutics. — White castile soap is alkaline in reaction and somewhat antiseptic, possessing detergent properties to a marked degree. The greatest value of soap lies in its power to dissolve fats. Advantage is taken of this fact in bleaching teeth, as will be explained in Practical Therapeutics (p. 407). White castile soap is chiefly used in dental practice as a constituent of dentifrices, both tooth- powders and tooth-pastes. The preparation should not contain more than about 15 per cent.; for, in greater quantities, too much suds is formed in the mouth by its employment. The preparation known as tincture of green soap is a valuable toilet article for dentists' hands. ANTISEPTICS, DISENFECTANTS, AND DEODOEANTS 4 1 Incompatibilities. — Soap is incompatible with all acids and with earthy and metallic salts. It is precipitated in hard water (con- taining earthy salts) as an insoluble soap. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS The term antiseptic has been defined elsewhere as applying to that class of remedies which inhibit or have a restraining influence on the life and activity of microorganisms. The terms disinfectant and germicide have been previously referred to as applying to that class of remedies which destroy microorganisms and their spores. Some authors have endeavored to distinguish between the two latter terms, using the term germicide in the sense that the agent simply kills the germ, and disinfectant in the sense that the agent not only kills the germ, but also acts upon the noxious products of putrefac- tion and fermentation. As a matter of fact, this distinction is largely theoretical, for there are few agents which, if used in sufficient strength to kill the germ, will not also act upon and thus destroy or remove the by-products of germ-growth. In this work, therefore, the term disinfectant will be used in preference to the term germicide, and for the reason given. A deodorant is an agent which destroys offensive odors, and inasmuch as the odor generally comes from the noxious products of putrefaction, the deodorization results from true disinfection. Therefore, deodorants will be discussed conjointly with antiseptics and disinfectants. Many agents belong to both the antiseptic and disinfectant classes of remedies, depending upon the strength in which they are employed. In weak solutions they act as antiseptics; in strong solu- tions, as disinfectants. These two classes of remedies are among the most important classes employed in dental practice, and it is well that the student should understand at the outset the significance of these remedies. In all surgical work the ideal condition sought is the absence of disease-producing germs (asepsis), rather than to depend upon the chemic destruction of them at the time of operating. With this end in view, the instruments are sterilized by boiling, and the site of operation as well as the operator's hands are disinfected by washing in certain solutions. Strictly speaking, infected animal tissue cannot be sterilized by employing disinfectants. An ideal disinfectant would be an agent which, employed in certain strength solution in a septic process or disease, would kill the disease-producing germ and destroy or remove the poisonous by-products without acting deleteri- 42 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS ously upon the animal cell. But bacteriologists inform us that the cell-wall of a vegetable cell (.bacteria) is less permeable to disinfecting agents than is the cell-wall of the animal cell. -Therefore, in our present state of knowledge we should not employ disinfectants in our effort to kill the germ when its habitat is among living animal cells. It becomes necessary, then, to attack these germs in another manner. This can be done by the use of certain antiseptic agents which check the growth and activity of the germs, cripple them, as it were, and which agents also are just sufficiently irritating to the animal cells to produce stimulation. This stimulating or awakening process on the part of the animal cells will cause the latter to attack and des- troy the already crippled vegetable cells, thus bringing about nature's method of steriHzation. When the germs which we are endeavoring to destroy are among the contents of a gangrenous root-canal, for example, surrounded by hard tooth-structure and removed from live animal tissue, the prob- lem presents an entirely different aspect. Here true disinfectants can be employed. The fact that a remedy will destroy microorganic life in a certain length of time in a test-tube, or in a gangrenous root- canal, is no criterion that the remedy, as such, can be used for disin- fecting the soft tissues of the mouth. The chief antiseptics are: Boric Acid. Many VolatUe Oils: ^ Borax. OU of Cajuput. ^ Benzoic Acid. OU of Cinnamon. "^ Salicylic Acid. - ^ OH of Cloves. • Salol. " s ^^' OU of Eucalyptus. Salophen. v Oil of Peppermint. "* Sodium Salicylate. OU of Thyme. lodin and Compounds. Charcoal. Betanaphthol. \ Calendula. Resorcin. Arnica. SUver Compounds. Myrrh. Ozone and Oxygen. The chief disinfectants are: Mercuric Chlorid (Discussed Urotropin. . under Mercury in Alteratives). Hydrogen Dioxid. '' Phenol. Potassium Permanganate. N» Cresols. Chinosol. Creosote. Heat. Formaldehyd. ACmUM BORICUM 43 ACmUM BORICUM— U.S.P. (Boric Acid; Boracic Acid; H3BO3.) Boric acid occurs in transparent, colorless, pearly scales or crystals, nearly colorless and of a somewhat bitterish taste, and slightly unctuous to the touch. It is soluble in about 18 parts of water and alcohol, and 4 parts of glycerin at 25°C. When given internally the average dose is 8 gr. (0.5 Gm.). It enters into two official preparations which are valuable in dental practice. They are: Glyceritum Boroglycerini, Glycerite of Boroglycerin (contains 31 per cent, of boric acid in glycerin). Unguentum Acidi Borici, Ointment of Boric Acid (10 per cent.) . Liquor Antisepticus, Antiseptic Solution (contains 2 per cent, of boric acid, o.i per cent, each of benzoic acid and thymol, 25 per cent, of alcohol, and minute quantities of eucalyptol, oil of peppermint, oil of gaultheria, and oil of thyme, in an aqueous vehicle). N.F. Physiologic Action. — Boric acid is a nonirritating antiseptic and deodorant. In quantities generally employed by dentists, boric acid produces no appreciable symptoms. It is rapidly absorbed and rapidly eliminated by the saliva, perspiration, feces, and urine — the bulk of it escaping in the urine within twenty-four hours after its administration. It is not a drug to be used indiscrimi- nately, for repeated external applications have led to the same train of symptoms as those observed following the continued internal administration of the drug. The term borism has been appHed to this condition, and the most important phenomena are digestive disturbances, dryness of the skin and mucous membranes, and a tendency toward certain rashes. The drug has been used as a pre- servative of milk and foods, and there is a difference of opinion among investigators as to whether or not boric acid has a deleterious action when so used. Therapeutics. — Boric acid is a constituent of many mouth- washes. It is largely employed in a saturated aqueous solution (5 per cent.) as an antiseptic and stimulating wash. Because of its nonirritating properties it can be applied to the most sensitive tissue. A good collyrium (eye-wash) can be made by adding 10 gr. (0.6 Gm.) of borax to i fl. oz. (30.0 mils) of the saturated solution of boric acid. Lotions, ointments, and dusting-powders containing boric acid are used to advantage in many acute inflammatory conditions of the mucous membranes and skin. As a stimulating and antiseptic mouth- wash there are few better than the formerly official liquor antisepticus. 44 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS Probably the only objection to boric acid as a constituent of mouth-washes is its slightly acid reaction and rather sparing solu- bility in water. Whenever a stronger solution than the saturated is desired, the official glyceritum boroglycerini (glycerite of boro- glycerin) can be used. This is neutral in reaction and can be em- ployed in full strength or diluted. However, strong solutions should not be used continuously on account of the tendency to produce borism. Incompatibilities. — In aqueous solution it will decompose car- bonates and bicarbonates. SODH BORA.S— U.S.P. Borax. — This salt has been fully discussed under Antacids (see p. 38). Its antiseptic and alkaline properties give it a prominent place among dental remedies. The physiologic action of borax closely resembles that of boric acid, for which it is often substituted to good advantage, especially in mouth-washes where it is desired to have an alkaline solution, and in tooth-powders and pastes. Boric acid, as well as all other acids, is incompatible with carbonates, and as calcium carbonate (chalk) is the base of nearly all dentifrices, boric acid should not be a constituent. Here the sodium salt, borax, can be employed with the same result without any reaction (incompatibility) between the ingredients of the mixture. ACIDUM BENZOICUM— U.S.P. (Benzoic Acid; HC7H5O2) Benzoic acid is an organic acid obtained from benzoin and balsam of Peru, or prepared synthetically. It occurs in white or slightly yellow scales or needle-shaped crystals of an aromatic odor and taste. It is sparingly soluble in water, but with an equal quantity of borax it can be dissolved to the extent of i per cent., freely soluble in alcohol and glycerin. The average dose is 8 gr. (0.5 Gm.). Physiologic Action. — Benzoic acid has proven to be an antiseptic of considerable power. Long states that a solution of i 1400 has been found to destroy developed bacteria. It also acts as a stimu- lant to mucous membranes. Internally administered it increases, to a variable degree, the nitrogenous output and lessens the quantity of ethereal sulphates and indican in the urine. In large doses benzoic ACIDUM SALICYLICUM 45 acid and benzoates have an irritant action on the stomach, and in consequence excite nausea and vomiting (Stevens), Therapeutics. — It is found that a saturated solution of borax (634 pei^ cent.) will dissolve i per cent, of benzoic acid and still be alkaline. This is doubtless due to a reaction between the substances whereby sodium benzoate is formed, which is freely soluble. In this way it may be employed as a constituent of mouth-washes. It possesses no advantage over the sodium salt, which had better be employed direct. Sodium benzoate is an excellent constituent of dentifrices. In the form of the benzoates it has been recommended in rheumatism or the gouty diathesis, but is not so efficacious as the salicylates. Balsam of Peru, which contains benzoic acid, is used externally as a parasiticide in scabies (itch) . The acid is frequently added to ointments to prevent rancidity. Incompatibility. — Benzoic acid in the presence of moisture will react upon carbonates and bicarbonates. It should not be employed, therefore, as a constituent of dentifrices with calcium carbonate as the base. ACIDUM SALICYLICUM— U.S.P. (Salicylic Acid; HC7H5O3.) Salicylic acid is an organic acid obtained from various plants, especially from gaultheria (wintergreen) , but it is chiefly prepared synthetically. It occurs as a white crystalline powder, or in fine needle-shaped crystals, or as a bulky crystalline powder, odorless, but possessing a sweetish, afterward acrid taste. It is soluble in about 460 parts of water, 13 parts of alcohol, and 60 parts of glycerin at 25°C. The average dose is 12 gr. (0.75 Gm.). Physiologic Action. — Salicylic acid, like many other drugs, acts differently upon different individuals and upon the same individual at different times. In susceptible subjects even small doses give rise to a peculiar feeling of fullness in the head, ringing in the ears, and, at times, interference with the senses of hearing and sight, causing deafness and dimness of vision. It enters the circulatory fluids as an alkaline salicylate, and is eliminated from the body in most of the secretions, but principally in the urine. It is claimed on good authority that it increases the output of urea and uric acid. Therapeutics. — This drug must be classed with our best anti- septics. MiUer has shown that a i per cent, solution of saHcylic acid will disinfect the mouth, as ordinarily considered, in one-quarter of a minute. It must not be forgotten, however, that the mouth cannot 4 6 AXTISEPTICS, DISIXFECTAXTS, AND DEODOEAXTS be disinfected in the true sense of the term. Its sparing solubility in water and its acid character render it practically useless as a constitu- ent of mouth-washes, unless a salt, like borax, or alcohol be added to the solution. The chief use of salicylic acid and its compounds is in acute rheumatism, in which condition they are considered specific remedies. In some diseases, as certain kinds of pyorrhea alveolaris, which seem to be related to the rheumatic diathesis, salicylic com- pounds have proven to be efficacious. Dissolved in collodion, a dram (4.0 Gm.) to the ounce (30.0 mils), it has been long used with success in removing corns and warts. Incompatibilities. — Salicylic acid will react with carbonates, potassium chlorate, and potassium permanganate. PHENYLIS SALICYLAS— U.S.P. (Phenyl Salicylate; Salol; C6H5C7H5O3.) Salol is prepared by heating salicylic acid with phenol in the presence of phosphorus pentachlorid. It occurs as a white crystalline powder, of a faintly aromatic odor, and slightly sweetish taste; prac- tically insoluble in water, but soluble in alcohol, and freely so in ether, chloroform, and in fixed and volatile oils. The average dose is 5 gr. (0.3 Gm.). Physiologic Action. — Salol acts as an antiseptic Hke either of its constituents, salicylic acid and phenol. It is not a disinfectant, as it wiU not destroy bacteria, although it prevents their proliferation. It differs from sahcylic acid in its action in that it is not irritating to the mucous membrane. Salol resists to a great extent the action of the gastric juice, passing through the stomach practically unchanged, but is gradually broken up in the intestine by the alkaHne fluids into salicyHc acid (60 parts) and phenol (40 parts). Therapeutics. — On account of its insolubility in water, salol is not employed, to any extent, as a local antiseptic, except at times in alcohoHc solution, as in mouth-washes. We find its chief use as an intestinal antiseptic. Like other saHcyHc compounds, it is used in the various forms of rheumatism. It may be prescribed in powders or capsules in diarrheas and other intestinal fermentations. Large doses must be avoided on account of the possible poisoning by phenol, which is Uberated. In cases of neuralgia associated with rheumatism, the salicylates combined with some hypnotic drug are especially indicated. A powder composed of 5 gr. (0.3 Gm.) of salol and 4 Gr. (0.27 Gm.) of phenacetin to the dose is a useful combination. ASPmiN — SALOPHEN , 47 ASPIRIN (Nonofficial) (Acetyl-saKcylic Acid; C9H8O4.) Aspirin is the acetyl derivative of salicylic acid. It is prepared by the prolonged heating of 50 parts of salicylic acid and 75 parts of acetic anhydrid at about i5o°C. under a reflux condenser, and sub- sequently purified by recrystallization from chloroform. It occurs in the form of smaU, colorless, crystalline needles, odorless, and ha\'ing an acidulous taste; soluble in 100 parts of water, freely soluble in alcohol and ether. Boiling water decomposes the drug into acetic acid and salicylic acid or a salicylate. The average dose is 5 gr. (0.3 Gm.) in capsules or wafers. It should be dispensed in wax paper, free from moisture. Physiologic Action and Therapeutics. — Aspirin passes through the stomach unchanged, the decomposition being in the intestine. Its action is similar to that of saHcylic acid, over which it possesses the advantage of producing less of the undesired local and systemic side effects, due to the slow Uberation and assimilation of the salicylic acid. The promiscuous use of aspirin by the laity, especially for the relief of headache, has frequently led, even in small doses, to cases of rather severe poisoning; the chief symptoms being edema (swelling) of the lips, tongue, eyelids, nose, or entire face, and occa- sionally an erythematous rash. Some individuals are especially susceptible to the drug and these s}Tnptoms are usually ascribed to an idiosyncrasy. Aspirin is especially useful in cases of rheumatism of a neuralgic character. Incompatibles. — Heat, moisture, alkalies, their carbonates and bicarbonates. It keeps well when properly protected. SALOPHEN (Nonofficial) (Acetyl-paramino-phenyl Salicylate; C7H5O2.) Salophen is an unofficial compound of saHcylic acid, and is pre- pared by a chemic process similar to that of preparing salol. It occurs in white scales, tasteless and odorless; insoluble in water, but soluble in alcohol and ether. The average dose is 5 gr. (0.3 Gm.) . On account of the liability to poisoning from the phenol which is liberated in the intestine from salol, this compound was introduced. It con- tains about 50 per cent, of saHcylic acid, and is decomposed by the alkaHne fluids of the intestine into saHcyHc acid and a comparatively nonpoisonous compound, acetyl-paramino-phenyl. The action of 48 ANTISEPTICS, DISINPECTANTS, AND DEODORANTS salophen is similar to that of other salicylic compounds. While it is not as efl&cacious in rheumatism as sodium salicylate, being tasteless and unirritating to the stomach it can be given before meals in the milder manifestations of the disease. In cases of neuralgia of rheu- matic origin associated with acute pain, salophen may be combined with such drugs as phenacetin and codein sulphate. A powder com- posed of 5 gr. (0.3 Gm.) each of salophen and phenacetin and J-^ gr. (0.016 Gm.) codein sulphate is a valuable combination. SODH ' SALICYLAS— U.S.P. (Sodium Salicylate; NaCyHsOs.) Sodium salicylate occurs as a white amorphous powder, without odor, but of a sweetish, saline taste. It is freely soluble (0.9 part) in water, in 9 parts in alcohol, and in glycerin at 25°C. The aver- age dose is 15 gr. (i.o Gm.). Physiologic Action and Therapeutics. — The action of this salt is the same as that of salicyhc acid. It has the advantage, however, of being more soluble and less irritating to the stomach. It is prob- ably the most generally used of all the salicylic compounds, and is especially indicated in the acute stage of rheumatism. In cases of pyorrhea associated with rheumatism it may be given in 5 gr. (0.3 Gm.) doses after meals, well diluted with water. Sodium sahcylate is discussed here more because of its relation to the previously considered drugs than because of its antiseptic properties. It is not considered a very efficient antiseptic. ^_^,_ VOLATILE OIL GROUP ^ A true classificauon of this general group is not practicable. The volatile oils vary so markedly in their physical and chemic make-up that only those which possess antiseptic properties, and are employed in dental practice as such, will be considered here. As a class the volatile oils have enjoyed a wide range of usefulness as antiseptic remedies in the past. They are sparingly soluble in water, but freely soluble in alcohol. Some are useful remedies to be applied to carious cavities in vital teeth, where the pulp is involved, because of their penetrating and slightly analgesic properties. Those which are just sufficiently irritating to stimulate the pulp to healthy activity are the ones especially indicated for this purpose. These will be men- tioned later. For years the volatile oils were employed in an effort to disinfect gangrenous root-canals. In this they have proved to be a OLEUM CAJUPUTI — CINNALDEHYDUM . 49 dismal failure. Here the noxious products of pulp decomposition are surrounded by hard tooth-structure and removed from live ani- mal tissue; therefore, we are justified in using true disinfectants- agents which will kill the germs and destroy their by-products. To use any of the essential oils for this purpose to-day, is but to adhere to the old empirical method of treatment. OLEUM CAJUPUTI— U.S.P. (Oil of Cajuput.) Oil of cajuput is a thin, bluish-green, volatile oil distilled from the fresh leaves and-^^w^gj of Melaleuca Leucadendron, a small tree growing in the East Indies. It has a camphoraceous odor and an aromatic, bitter taste. Its chief constituent is cineol, of which it should contain not less than 55 per cent, by volume. The average dose is 8 min. (0.5 mil). Physiologic action and therapeutics resemble those of oil of cloves and oil of eucalyptus. OLEUM CASSLS:— U.S.P. (Oil of Cinnamon, Oil of Cassia.) Oil of cinnamon is a yellowish or brownish volatile oil distilled from the bark of the shoots of Cinnamomum Cassia, a tree which grows in China. The oil is sometimes commercially called oil of cassia, and the U.S.P. IX recognizes it by this name. A species of cinnamon which grows in the Ceylon Islands produces a volatile oil having a finer flavor, though less employed. It has the character- istic odor of cinnamon and a spicy, burning taste. The chief con- stituent of oil of cinnamon is cinnamic aldehyd, formerly ofiicial and of which it should contain not less than 80 per cent, by volume. The average dose is 3 min. (0.2 mil). There are two official prepara- tions of oil of cinnamon; both are valuable in dental practice. Aqua Cinnamomi (Cinnamon Water), used as a spray and as a vehicle for mouth- washes. Spiritus Cinnamomi (Spir't of Cinnamon) used largely as a flavoring agent. CINNALDEHYDUM (Nonofficial) (Cinnamic Aldehyd; CgHsO.) Cinnamic aldehyd. is a colorless liquid obtained from the oil of cinnamon or prepared synthetically. It has a cinnamon-like odor, 50 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS and a burning, aromatic taste. Sparingly soluble in water, freely in alcohol, fixed and volatile oils. Pure synthetic cinnamic aldehyd has largely displaced the natural oil of cinnamon* and may be used for nearly all purposes for which the latter is employed. The average dose is the same as oil of cinnamon. Physiologic Action. — Oil of cinnamon and cinnamic aldehyd are active antiseptics. Both are rather irritant to the pulp and peri- cemental membrane. Cinnamon is an agreeable aromatic stimu- lant, carminative, and stomachic. It is also claimed to possess feebly astringent properties. It enters into aromatic fluid extracts and also into many of the compound tinctures. Therapeutics. — Oil of cinnamon has been employed in root- canal treatment, but because of its irritant properties and of its liability to stain the tooth-structure, it should be used cautiously, if at all. It is a constituent of Black's 1-2-3 mixture which con- tains oil of cassia i part, oil of wintergreen 2 parts, and phenol (carbolic acid) 3 parts. The most practical use that can be made of oil of cinnamon in dental practice, however, is as a flavoring agent. The official water may be employed as a vehicle for mouth-washes and sprays. Every dentist should know how to prepare the solu- tion (see p. 9) , as it should be freshly made and used freely in prophy- lactic and phyorrheal treatment. OLEUM CARYOPHYLLI— U.S.P. (Oil of Cloves.) Oil of cloves is a thin, pale yellow, volatile oil distilled from cloves, the dried flower buds of Eugenia Aromatica, a shrubby ever- green, introduced and cultivated in the East Indies. It has a strong aromatic odor of cloves and a pungent, spicy taste. The oil gradually becomes darker and thicker by age and exposure to the air. Its chief constituent is eugenol, which is also official, and of which it should contain not less than 82 per cent, by volume. The average dose is 3 min. (0.2 mil). EUGENOL— U.S.P. (Eugenol; C10H12O2.) Eugenol is an aromatic phenol obtained from oil of cloves and other sources. It occurs as a thin, colorless or pale yellow liquid, highly refractive, and possessing a strongly aromatic odor of cloves 4 nd a pungent, spicy taste. It is practically insoluble in water, but OLEUM EUCALYPTI — ^EUCALYPTOL 5 1 freely soluble in alcohol. It may be used instead of oil of cloves, of which it is the chief constituent; it is also the chief constituent of oil of pimenta (allspice). The average dose is the same as of oil of cloves. Physiologic Action. — Oil of cloves is jiist sufficiently irritant to the animal cell to be classed as an ideal antiseptic. It also possesses marked local analgesic properties. Internally administered, it is a powerful carminative and stimulant. Therapeutics. — Because of its antiseptic and local analgesic properties, oil of cloves is one of the most valuable volatile oils. It has long been a popular remedy for odontalgia (toothache). Oil of cloves, and its chief constituent, eugenol, are excellent agents to be employed as the liquid for making pastes when pulp-capping is indicated. A paste made of precipitated calcium phosphate or pure zinc oxid, in either of which 2 per cent, of thymol has been incor- porated as the powder, and oil of cloves or eugenol as the liquid, is a valuable remedy for capping the pulp, or protecting this organ when it is involved from a deep-seated carious cavity. (See Practical Therapeutics, p. 312.) AppHed to a canker sore or in cases of ulcerative stomatitis, oil of cloves will prove to be one of the best healing agents. It is a counter-irritant, and as such will stimulate morbid processes. OLEUM EUCALYPTI— U.S.P. (Oil of Eucalyptus.) Oil of eucalyptus is a colorless, or faintly yellowish volatile oil distilled from the fresh leaves of Eucalyptus Globulus, a tree which grows in the swampy regions of Australia and California. It has a characteristic, aromatic, somewhat camphoraceous odor and a pungent, spicy, and cooHng taste. The chief constituent is eucalyptol, also official, and of which it should contain not less than 70 per cent, by volume. The average dose is 8 min. (0.5 mil). EUCALYPTOL— U.S.P. (Eucalyptol; CioHisO.) Eucalyptol is a colorless liquid, obtained from oil of eucalyptus and several other volatile oils, especially oil of cajuput. It is an organic oxid, probably identical with cineol, the chief constituent of oil of cajuput. It has a characteristic and distinctly camphoraceous odor and a pungent, spicy, and cooling taste. Almost insoluble in water, freely soluble in alcohol. The average dose is 5 min. (0.3 mil). 52 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS Physiologic Action. — ^Locally applied, both oil of eucalyptus and eucal}ptol are antiseptics, but have an irritant action. Commercial oil of eucal}^tus is so irritating that it should not be employed in root-canal treatment. Many cases of pericementitis have been produced by commercial oil of eucal}^tus having been sealed in the canals of teeth. Eucalj^Dtol is also irritant, but not nearly so irri- tant as commercial oil of eucalj^tus. When desired to be used in root-canal treatment, eucal^'ptol should be employed, or a refined specimen of the oil which is practically all eucal}^tol. Therapeutics. — Both oil of eucalyptus and eucalyptol have been employed in root-canal treatment. Like all of the volatile oils, they are practically worthless as remedies for correcting gangrenous pulp conditions, where they have been largely employed in the past. While eucalyptol is not nearly as irritant as the oil of eucalj^Dtus, it is still too irritant, unless modified, to be sealed in a canal as an antiseptic remedy after the removal of a Hve pulp. Agents, such as oil of cloves or eugenol, having local analgesic as well as antiseptic properties, are far preferable. Oil of cajuput, containing cineol, a compound identical with eucalyptol, has a solvent action on gutta- percha, as has also eucal}ptol, hence these agents find their greatest use in dental practice as remedies for moistening cavities to be temporarily sealed with gutta-percha, or root-canals previous to fining with gutta-percha. The author's formula for a remedy to be used for this purpose, as well as for sealing in the canals of all teeth where a mildly antiseptic dressing is indicated, is: Menthol 2 gr. (0.14 Gm.), thjonol 3 gr. (0.2 Gm.), eucalyptol i dr. (4.0 mils). This remedy is called eucalyptol compomid (modified eucalyptol) . Oil of eucal}^tus is an excellent remedy in chronic inflammation of mucous membranes, where it can be used as a spray combined with liquid petroleum in the proportion of 30-60 min. to the ounce (2-4 mils to 30.0 mils) . An infusion of eucalyptus leaves (5 per cent.) can be used as a mouth-wash or gargle in stomatitis. As a stimulant expectorant eucalyptus is of great value in colds and chronic bronchial catarrh. A few drops of the oil of eucalyptus, or eucalyptol, can be dropped into hot water and the steam inhaled.. OLEUM MENTHA PIPERIT-S;— U.S.P. (Oil of Peppermint.) Oil of peppermint is a colorless, or pale green volatile oil, distilled from the fresh or partly dried leaves and Uowering tops of Mentha MENTHOL 53 piperita, having the characteristic strong odor of the latter plant and a strong, aromatic, pungent taste, followed by a cool sensation upon inhalation. Its chief constituent is menthol, also official, and of which it should yield not less than 50 per cent. The average dose is 3 min. (0.2 mil). There are two official preparations of oil of peppermint, both of which are useful in dental practice. Aqua Menthae Piperitae, Peppermint Water, used as a spray, as a vehicle for mouth-washes and local anesthetic solutions. Spiritus Menthae Piperitae, Spirit of Peppermint, is used also as a flavoring agent. 3VIENTH0L— U.S.P. (Menthol; C10H20O.) Menthol is a stearoptene, or secondary alcohol, obtained from the oil of peppermint and other mint oils. It occurs in colorless, acicular, or prismatic crystals, having a strong and characteristic odor of peppermint, and a warm, aromatic taste, followed by a sensation of cold when air is inhaled. Sparingly soluble in water, freely in alcohol, ether, and chloroform. When triturated with about equal amounts of phenol, thymol, camphor, or chloral hydrate, it forms a liquid. The dose is i gr. (0.06 Gm.). Physiologic Action. — Oil of peppermint and menthol are anti- septics, as well as possessing local analgesic properties to a marked degree. Like many other volatile oils of an aromatic character, oil of peppermint is a valuable carminative, stimuj^ht, antifer- mentative, and antispasmodic. Therapeutics. — Oil of peppermint, or menthol, is an ingredient of many remedies for obtunding sensitive dentin. A useful formula consists of menthol 20 gr. (1.33 Gm.), chloroform 2 fl. dr. (8.0 mils), and ether 6 fl. dr. (24.0 mils). The official water is an excellent vehicle for local anesthetic solutions, as well as for mouth-washes and sprays. Menthol is a constituent of many dental Hniments for neuralgia and pericementitis. A good liniment for this purpose contains menthol 20 gr. (1.33 Gm.), chloroform i3^ fl. dr. (6.0 mils), and tincture of aconite 6 fl. dr. (24.0 mils). Oil of peppermint, or menthol, is a constituent of many lotions and sprays for the local treatment of diseases of the mouth, ear, nose, and throat. Menthol is used extensively in headache, being rubbed on the forehead or inhaled from a metal container. In cases of itching of the skin or mucous membrane, menthol is a valuable remedy because of its analgesic properties. For this purpose it 54 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS should be dissolved in a bland oil, like liquid petroleum, in the proportion of 30 gr. to the ounce (2.0 Gm.-3o.o mils). It is also a constituent of phenol compound (see below). OLEUM THYMI— U.S.P. (Oil of Thyme.) Oil of thyme is a thin, colorless or pale yellow, sometimes red, volatile oil, distilled from Thymus vulgaris, a common shrub (garden thyme) which is indigenous to France, but cultivated in the gardens of the United States. It has a strong odor of thyme, and a warm, pungent and, afterward, cooling taste. Its chief constituent is thymol, which is official, and of wliich the oil should contain not less than 20 per cent, by volume, of phenols. The average dose is 3 min. (0.2 mil). THYMOL— U.S.P. (Thymol; C10H14O.) Thymol is a phenol obtained from the oil of thyme. It occurs in large, colorless, translucent crystals, having a^a^^-like odor and a pungent, aromatic taste, with a slight cajj^iWnect upon the lips and mucous membranes. It is sparip^'^soluble (about 1,100 parts) in water and in less than its o^jja-'^^ght in alcohol, ether, and chloro- form, also readily solub^HliMed and volatile oils. When triturated with about equa^fTl'an titles of phenol, menthol, camphor, or chloral hydrate, it liquefies. Physiologic Action. — Thymol is a powerful antiseptic. It might almost be classed as a true disinfectant. It resembles phenol in its action, but being slowly absorbed is far less poisonous, yet vastly superior to it as an antiseptic. It possesses a peculiar, but favorable action on animal tissue. It undoubtedly has a preservative action on dead animal tissue. It is a stimulant though not an irritant or corrosive, and also has local analgesic properties. Therapeutics. — Oil of thyme is not much used in dental practice except as a source from which thymol is obtained. Thymol has not been used to the extent which its importance merits, although it is rapidly gaining favor with modern therapeutists. It is a constituent of many remedies for root-canal treatment after live pulps have been removed. The author's phenol compound for this purpose contains menthol, 20 gr. (1.3 Gm.), thymol, 40 gr. (2.6 Gm.), and phenol (U.S.P.) 3 dr. (12.0 mils). In order to make the remedy less irritating, camphor has been substituted for the thymol in the latter lODUM — lODOFORMUM 55 formula. Dr. E. C. Kirk suggests using equal parts of thymol and phenol, called thymophen. Dr. H. Prinz uses th3miol, camphor and phenol, called thymocamphen. A solution of a grain (0.06 Gm.) to the ounce of water (30.0 mils), with a Httle alcohol used as a solvent, makes a good mouth-wash in the infectious forms of stomatitis and pharyngitis (Stevens). It is a constituent of the formerly official mouth-wash, Hquor antisepticus (see p. 43); also the author's Desensitizing Paste (see p. 293). lODUM— U.S.P. (lodin; I.) lodin is a nonmetallic element obtained chiefly from the ashes of sea- weeds (kelp) . Fine specimens of such sea- weeds may be seen in the "submarine gardens" around Catalina Island, off the shore of Southern Cahfornia. It occurs in heavy, bluish-black, friable crystals, having a metaUic luster, a distinctive odor, and a sharp, acrid taste. On heating, it emits a violet-colored vapor. lodin is sparingly soluble in water (5,000 parts), quite soluble in a solution of potassium iodid, and freely so in alcohol, ether, and chloroform. The average dose is 3^2 gr. (0.005 Gm.). The three official preparations are of value in dental practice. They are: Liquor lodi Compositus, U.S.P. Compound Solution of lodin (Lugol's Solution; 5 per cent, of lodin in a 10 per cent, solution of Potassium Iodid). Tinctura lodi, U.S.P., Tincture of lodin (7 per cent.). Unguentum lodi, U.S.P., lodin Ointment (4 per cent.). lODOFORMUM— U.S.P. (Iodoform; CHI3.) Iodoform is methyl tri-iodid, made by heating in a closed vessel iodin, alcohol, sodium hydrate, and water, wherein 3 atoms of hydro- gen of the methane radicle (CH4) are displaced by 3 of iodin. It occurs in small, lemon-yellow, hexagonal crystals, having a pecuHar, very penetrating, and persistent odor, and an unpleasant, slightly sweetish, and iodin-Kke taste. It is very feebly soluble in water, soluble in about 60 parts of alcohol at 25°C. and freely soluble in ether, chloroform, and oils. It contains about 96 per cent, of iodin. The average dose is 4 gr. (0.25 Gm.). The official ointment of iodo- form contains 10 per cent. 56 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS lODOLUM (Nonofficial) (lodol; Tetra-iodo-pyrrol; C4I4NH.) lodol, or tetra-iodo-pyrrol, is a derivative of the base pyrrol (C4H6N), obtained by the direct action of iodin upon the base in the presence of alcohol. It occurs as a yellowish, crystalline pow- der, without odor or taste, and contains about 90 per cent, of iodin. lodol is practically insoluble in water, but freely soluble in alcohol, ether, and oils. It is used as a substitute for iodoform, and, though more expensive, has the decided advantage of being odorless. THYMOLIS lODIDUM— U.S.P. (Thymol lodid; Di-thymol-di-iodid ; Aristol; C2oH2402l2.) Thymol iodid or aristol, is obtained by acting upon thymol in aqueous solution of sodium hydrate with iodin dissolved in a solution of potassium iodid. It occurs as a brownish-red powder, tasteless and almost odorless, and contains about 43 per cent, of iodin. It is nearly insoluble in water, but freely soluble in ether, chloroform, and oils. It is used as a substitute for iodoform, but is rather un- stable, being decomposed by heat, light, acids, alkahes, alcohol, and corrosive sublimate. It is more expensive than iodoform and less effective. EUROPHEN (Nonofficial) (Di-isobutyl-cresol-iodid; C22H29O2I:) Etirophen is obtained in exactly the same manner as that of pre- paring aristol, except that isobutyl-cresol is substituted for thymol. It occurs as a very bulky, yellow, amorphous powder, of an aro- matic odor, and contains 28 per cent, of iodin. It is insoluble in water and glycerin, but freely soluble in alcohol, ether, and oils. In dental practice it is an excellent substitute for iodoform, and is far more stable than aristol. NOSOPHEN (Nonofficial) (Tetra-iodo-phenol-phthalein ; (C6H2I2OH) 2C8H4O2.) Nosophen is obtained by the action of iodin on a solution of phenol-phthalein. It is a pale yellow powder, without odor and taste, and contains 60 per cent, of iodin. It differs from iodoform in being an active antiseptic and in not 3aelding its iodin to the tissues. NOSOPHEN 57 Physiologic Actions. — lodin can be classed as an ideal anti- septic in that it is just sufficiently irritant to the animal cell to cause stimulation, giving to the latter new life and energy whereby the ani- mal cells attack and kill the invading germ, thus producing nature's method of disinfection. When applied to the skin or mucous membrane it produces a yellowish-brown or black evanescent stain, and acts as an irritant or caustic, according to the strength of the solution used, and the fre- quency of the application. This discoloration can be readily re- moved by solutions of potassium cyanid, sodium hj^osulphite or ammonia. When tincture of iodin is frequently applied, vesication is produced, or perhaps sloughing. The blood-vessels subjacent to the area to which it is applied are reflexly dilated, hence this drug is an efficient counterirritant. When internally administered, it is rapidly absorbed in the form of iodids and soon reappears in all the secretions of the body; the bulk being eliminated, however, in the urine, also in the form of iodids. The continuous use is followed by a group of symptoms known as iodism. The more common manifestations of this condi- tion are associated with the mucous membrane of the respiratory tract and with the skin, consisting of froatal headache, lacrimation, coryza, soreness of the throat, an increased flow of saHva, and some- times an eruption on the skin. The amount of the drug required to produce iodism varies with different individuals. Iodoform differs somewhat in its action from iodin. Instead of being an irritant, it acts as a mild analgesic when applied to the mucous membrane and abraded surfaces, especially the latter. Iodoform and allied com- pounds have a favorable action on infected wounds, but how the result is produced is not well understood. It is known that as dry powders they possess little or no bactericidal action, yet when applied to raw surfaces they retard germ-growth, probably through the free iodin liberated, as they nearly all Hberate their contained iodin when in contact with the fluids of the tissues. Therapeutics. — Applied to infected wounds, iodin is an efficient antiseptic. The tincture of iodin or the compound solution may be employed in full strength, or diluted, to sluggish ulcers and abscess cavities, or in cases of local arsenical poisoning. For the latter condi- tion, a creamy paste made of europhen and liquid petroleum can be appKed to the affected part on sterile gauze or cotton. Where pain is a prominent symptom, as in cases of lacerated gum tissue and exposed process after extraction, othoform (40 parts) can be mixed with euro- phen (60 parts) and made into a paste with Hquid petroleum. Ap- 58 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS plied in the same manner it will stop the pain Hke magic. This remedy is called euroform paste. As a counterirritant iodin is a valuable drug, as the blood-vessels subjacent to the area to -which it is applied are reflexly dilated. The tincture of iodin in full strength should not be used as a dental counterirritant because of its local destructive action on the mucous membrane. For this purpose the compound solution should be employed or the tincture of iodin modified. A favorite combination is tincture of aconite 2 parts, tincture of iodin and chloroform, of each, i part. The chloroform volatilizes rapidly when applied and the irritant action of the iodin is modified by the aconite, a local sedative. This remedy is especially valuable in cases of pericementitis, where a mild but persistent counterirritant effect is desired. It is also used to steriHze the mucous membrane before injecting local anesthetic solutions. Iodin will stain the tooth-structure and there is no necessity for using the drug within the tooth, as other remedies are at hand which will .accomplish all that can be expected of iodin without discoloration. Iodin is useful as an antiseptic and stimulant in the treatment of pyorrhea alveolaris and will be referred to again in Practical Therapeu- tics (p. 435). Iodoform has little use in dental therapeutics except iodoform gauze, which is used in packing surgical wounds, abscess cavities, etc. BETANAPHTHOL— U.S.P. (B etanaphthol ; C10H7OH.) Betanaphthol is a monatomic phenol occurring in coal-tar, but usually prepared artificially from naphthalene. It occurs in white, shining crystalline scales, or as a yellowish-white crystaUine powder, having a faint, phenol-like odor and a sharp, pungent, but not per- sistent taste. It is sparingly soluble in water, freely in alcohol, ether, and chloroform. It should be kept in dark, amber-colored, well- stoppered bottles. The average dose is 4 gr. (0.25 Gm.). Physiologic Action. — Betanaphthol is antiseptic, antifermenta- tive, deodorant, and may also be considered a disinfectant. Its action closely resembles that of phenol, but is less poisonous. When appHed locally to the skin or mucous membrane, betanaph- thol is readily absorbed, and, in concentrated solutions, it is irritating to the tissues to which it is appHed. Toxic symptoms may result from its absorption by the skin; these also resemble those of phenol. Therapeutics. — Betanaphthol has been recommended as a con- stituent of root-canal filHng materials. It will not corrode metal EESORCmOL 59 instruments, therefore solutions can be used for immersing instru- ments during the surgical treatment of pyorrhea and other opera- tions. The solubiUty of the drug is increased in boiling water. A suitable solution can be prepared in hot water and used when suffi- ciently cooled. Some of the drug will be precipitated as the solu- tion cools, but as it is not irritating in this strength solution it does not matter materially. The saturated aqueous solution may also be employed to irrigate wounds and as a constituent of mouth-washes. In medicine it is used as a parasiticide in certain diseases of the skin, as scabies (itch) and ring-worm. It is best to employ it in the form of an ointment in the strength of a dram (4.0 Gm.) to the ounce (30.0 Gm.), for in this way it is not irritating. RESORCmOL— U.S.P. (Resorcin; C6H4(OH)2.) Resorcin is a diatomic phenol occurring in the form of colorless or faintly reddish, needle-shaped crystals, or rhombic plates, having a faint peculiar odor and a sweetish, and afterward pungent taste. It is freely soluble in water, alcohol, ether, and glycerin. It darkens when exposed to light and air, and should be kept in dark amber- colored, well-stoppered bottles. The average dose is 2 gr. (o.i 25 Gm.) . Physiologic Action. — Resorcin acts very much Uke phenol, but is less poisonous and less irritant. It has marked antiseptic properties, and being practically nonirritating is a useful drug in the treatment of many pathologic conditions about the mouth and throat. Therapeutics. — Resorcin has been used for keeping instruments sterile during surgical operations, but its continued use will affect the metal. In a 2 to 5 per cent, solution it is efficacious as a mouth- wash or gargle in the treatment of certain subacute and chronic con- ditions of the mucous membrane, as in ulcerative stomatitis, pharyn- gitis, laryngitis, whooping-cough, and diphtheria. An ointment of resorcin (5 per cent.) is an excellent remedy to apply to sloughing wounds, foul ulcers, and syphilitic ulcers. A dusting powder, con- sisting of I part resorcin and 10 parts boric acid, can be used with much benefit in cases of suppurating wounds. As a remedy for dandruff of the scalp, Stevens recommends the following: Resorcin i}4 dr. (6.0 Gm.), castor oil TH, xx-xxx (1.2-2.0 mils), bay-rum 33^^ fl. oz. (105.0 mils). 6o ANTISEPTICS, DISINFECTANTS, AND DEODORANTS CARBO LIGNI— U.S.P. Carbon was formerly official in the following forms: Animal charcoal, purified animal charcoal, and wood charcoal. The latter is the only form recognized in the U.S. P. IX. Animal charcoal, or bone-black, is prepared by burning bones in closed iron cylinders. It is composed of carbon and certain earthy salts (calcium carbonate and phosphate) . Purified animal charcoal is bone-black from which the above-mentioned salts have been removed by hydrochloric acid. Wood charcoal is prepared by burning soft wood without access to air; it is very finely powdered. It occurs as a black, odorless and tasteless powder, free from gritty matter. Charcoal is mentioned here because of its deodorizing power. It has the peculiar property of absorbing many times its own volume of gases and vapors. It is not used much in dental practice, except in the laboratory for refining metals. When well ignited it will deoxidize the most obdurate metals. Animal charcoal is largely used by chemists for decolorizing many solutions and for removing color- ing matter from alkaloids. It is also employed as a filtering medium for purifying drinking-water. White wood ash was formerly used for cleaning teeth by the laity. Because of the grittiness of the particles, it should not be so employed. It is sometimes in- ternally given as an absorbent in flatulent dyspepsia. Here it is best administered in the form of lozenges. CALENDULA (Nonofficial) (Marigold.) . Calendula is the dried ligulate florets of Calendula officinalis, an annual plant, indigenous to Southern Europe and the Levant, fre- quently cultivated as a garden ornament. It contains a bitter principle, calendulin, and a trace of volatile oil. The average dose is 5 gr. (0.3 Gm.). The tincture is the only preparation employed: Tinctura Calendulas, U.S. P. VIII (20 per cent.). Dose, 15 min. (i.o mil). Physiologic Action and Therapeutics. — Calendula has a stimu- lating action upon mucous membranes, and has been used chiefly for its local influence. It acts similar to arnica, and is employed for practically the same conditions. The tincture may be applied to recent wounds, lacerated gums, open sores, etc. It hastens the heaHng of wounds, and materially aids union of coapted surfaces by first intention. It causes a scar, or cicatrix, to form without contraction of tissue, and is especially useful in severe hums. AENICA — OXYGENIUM 6 1 ARNICA— U.S.P. Arnica is the dried flower-heads of Arnica montana, a perennial plant/ growing in temperate regions of Europe, Asia, and America. It contains a glucosid, arnicin, and a volatile oil. The dose is about 15 gr. (i.o Gm.). The tincture is the only ofl&cial preparation: Tinctura Arnicae, U.S.P. Average dose, 15 min. (i.o mil). Physiologic Action and Therapeutics. — The action of arnica closely resembles that of calendula. The tincture has been exten- sively used as a stimulating application in sprains and bruises. Its antiseptic power is doubtless due to its irritant effect upon animal cells, and to the alcohol which the tincture contains. MYRRHA— U.S.P. (Myrrh.) Myrrh is a gum-resin obtained from commiphora myrrha, a small tree growing in Eastern Africa and Arabia. It occurs in the form of brownish-red, irregularly-shaped tears, having an agreeable aromatic odor and a bitter, acrid taste. The dose is about 5 gr. (0.3 Gm.). Its official preparations and those into which it enters are : Tinctura Myrrhae, U.S.P. Average dose, 15 min. (1.0 mil). Pilulae Rhei Compositse, U.S.P. (Aloes, ^ gr. o.i Gm.; Rhubarb 2 gr .-0.13 Gm.; Myrrh, I gr.-o.o6 Gm.). Average dose, 2 pills. Physiologic Action and Therapeutics. — Myrrh is a stimulant to mucous membranes and acts as an antiseptic and astringent. The tincture,' diluted with water or with a weak solution of borax or potassium chlorate, has been extensively used as a local application in ptyalism, ulcerative stomatitis, and spongy gums. Water added to the tincture causes a milky solution on account of the resinous constituent of myrrh. OXYGENIUM— U.S.P. (Oxygen; O.) Oxygen, for the first time, is recognized by the U.S.P. It is a colorless, odorless and tasteless gas; practically insoluble in water, more readily soluble in alcohol. It contains not less than 95 per cent, by volume of O (16) ; and, for convenience, it is usually com- pressed in metal cyHnders. The U.S.P. IX has adopted oxygen (16) as the standard for atomic weights, in accordance with the report of the International Committee on Atomic Weights for 1915. Formerly hydrogen (i.oi) was taken as the standard. Oxygen is 62 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS correct as it weighs exactly i6, while hydrogen was only approxi- mately correct since it weighs i.oi. The gas is used extensively in nitrous oxid, ether and chloroform narcosis, as well" as in bronchitis, anemia, phthisis, and the later stages of acute pneumonia. It is given by inhalation by means of a specially devised apparatus. It is also used in dentistry as a bleaching agent (see Practical Therapeutics p. 404). For bleaching purposes the oxygen is obtained from com- pounds containing it, such as sodium dioxid and hydrogen dioxid. For experimental purposes, it may be obtained by carefully heating potassium chlorate in a suitable retort. If the potassium chlorate be previously mixed with about one-fourth of its weight of man- ganese dioxid, it gives up the whole of its oxygen at a temperature considerably below the melting-point of the salt, and at a greatly accelerated rate. Ozone is an allotropic form of oxygen, and may be prepared from the latter electrically. It occurs in the air, especially after an elec- trical storm. It is no doubt an important factor in the antiseptic processes of nature, and has been used to some extent as a thera- peutic agent in the treatment of pyorrhea alveolaris, and other patho- logic conditions; but its practical application, as yet, has not been fully demonstrated. PHENOL— U.S.P. (Phenol; Carbolic Acid; CeHgOH.) Phenol is obtained from coal-tar by fractional distillation. It is also prepared synthetically. When pure, it occurs in the form of colorless, needle-shaped crystals, of a characteristic odor and of an acrid, burning taste. On exposure to damp air it deliquesces, and the solution exposed to light gradually acquires a reddish tint. It is soluble in about 15 parts of water, at 2 5°C., and freely in alcohol, glycerin, ether, chloroform, and oils. It should be kept in dark amber-colored bottles, well-stoppered. Although it was official up to 1900 under the name Acidum Carbolicum, chemically con- sidered, it is not an acid, but an alcohol of the benzene group. The average dose is i gr. (0.06 Gm.). All of the official preparations are valuable in dental practice. They are: y Phenol Liquef actum, U.S. P. (contains 86.4 per cent, of absolute Phenol and 13.6 per cent, of Water). Unguentum Phenolis, U.S. P. Ointment of Phenol (2^ per cent.). Glyceritum Phenolis, U.S. P. Glycerite of Phenol (20 per cent.). PHENOL 63 Physiologic Action. — Phenol is a disinfectant, as it destroys microorganisms. Some spore-bearing forms, however, are very resistant to its action. In weak solutions (2 per cent.) it acts as an antiseptic. Phenol is also a caustic and local analgesic. When apphed to the skin or mucous membrane it blanches the surface and causes a burning sensation, which is soon followed by numbness. Later the part becomes red, then brown, and ultimately desquamation takes place. Its action is much more severe on mucous membranes, and it should be used about the mouth with caution. Phenol coagu- lates albumin, therefore its caustic action is limited, and does not extend deeply into the tissues. Absorption of the drug occurs readily from the skin, mucous membranes, and wounds. Its prolonged use, even in dilute solutions (2-5 per cent.) may cause gangrene of the parts. Poisoning by Phenol. — Poisoning by phenol may occur either from the drug being taken internally or from its external appli- cation. It is a poison used more widely for suicidal purposes, per- haps, than any other. Because of this fact, a law is in force in many States of the Union preventing its sale to the laity in stronger solutions than 333^ per cent, the dilution being made with alcohol or glycerin. Toxic doses render the patient rapidly unconscious, or the patient may drop dead in from twelve to fifteen minutes after taking it from respiratory paralysis. Butler states that 8.5 Gm. have caused the death of an adult in fifteen minutes. One and one-half grams have caused the death of a child in a short time. If the dose has not been sufficient to cause respiratory paralysis in so short a time, the symp- toms are those of gastroenteritis — intense pain, violent vomiting of white slimy mucus, and purging. The pupils are contracted, sterto- rous breathing appears, with cold, clammy skin, pinched face, anxious expression, and a rapid, feeble pulse, finally followed by unconscious- ness and death from failure of respiration. The characteristic phe- nomena are the odor on the breath, the destruction of the buccal mucous membrane, and the smoky urine. In poisoning from the external use of phenol the initial symptoms generally are headache, vertigo, pallor, muscular weakness, and discoloration of the urine. Treatment of Poisoning. — When the poison has been taken by the mouth there are two drugs especially indicated in the treatment — alcohol and magnesium sulphate (Epsom salt). The alcohol neu- trahzes the caustic action, and the soluble sulphate forms with the phenol the innocuous phenol sulphonate. Two or three ounces (60.0 -90.0 mils) of diluted alcohol should be poured into the stomach 64 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS through a tube, followed by frequent washing out of the stomach with warm water containing magnesium sulphate. Warm demulcent drinks are useful in allaying the irritation. To increase the efficiency of the function of the heart and respiration, strychnin sulphate and atropin sulphate are indicated. For the relief of pain, opium or its alkaloids may be administered. When phenol is accidentally or otherwise appUed to the skin or mucous membrane, its caustic action can be prevented by immediately appl5dng alcohol to the part. Therapeutics. — Phenol, possessing as it does the properties of an antiseptic, disinfectant, cauterant, and local analgesic, is one of the most useful drugs in dental practice. As a disinfectant, the true value of the drug has been overestimated. Its great affinity for al- bumin, which it quickly and firmly coagulates, prevents any penetra- tion beyond the superficial layer of tissue to which it is applied. At best, then, it is but a surface disinfectant. A i per cent, solution can be employed for immersing the points of instruments while scaling the teeth in pyorrheal treatment. Probably the only objection to this solution is the odor, and yet patients have been taught that any solu- tion possessing the odor of phenol is cleansing, so even this objection loses its weight. The drug can be added to local anesthetic solutions for the purpose of keeping the latter sterile. Two to 3 gr. (0.13-0.19 Gm.) to the ounce (30.0 mils) is sufficient to prevent the growth of bacteria, and in this strength it can be injected into the tissue without any appreci- able coagulation of the albumin. Its local analgesic property makes it a valuable remedy for desen- sitizing dentin, to apply to an aching pulp in the early stages of pulpitis, and also as a root-canal dressing after the removal of the pulp tissue by either the anesthetization or devitalization method. It has been used for devitalizing the pulp tissue in deciduous teeth. Its action here is slow and unsatisfactory. As a stimulating agent for cauterizing sinuses associated with dento-alveolar abscesses, it has long been used with success where there is no root or bone compUcation. In cases of painful canker sores it is a most useful remedy. Applied full strength to the ulcerated or denuded spot, it arrests the septic process, and the coagulum formed serves as a protection to the exposed nerve-endings. CRESOL— U.S.P. .CH3\ (Cresol; Tricresol; C6H4(' . I OH/ CRESOL 65 Cresol, formerly commercially called tricresol, is a refined mixture of three isomeric cresols obtained from coal-tar, freed from phenol, hydrocarbons, and water. It occurs as a colorless or straw-colored refractive liquid, having a phenol-Hke odor and a burning, caustic taste. It is soluble in 50 parts of water at 2 5°C., and miscible with alcohol and glycerin in all propotions. Cresol is sometimes errone- ously called crecyHc acid. It is not an acid, but is methyl phenol, the three isomeric forms being known chemically as ortho-, meta-, and paracresol. On exposure to hght, cresol turns to a yellowish-brown color. It should be kept in dark amber-colored bottles, well-stop- pered. The dose is i minim (0.06 mil.). The official Liquor Cresolis Compositus (Compound Solution of Cresol) is practically identical with the commercial preparation known as lysol. It is a linseed-oil-soap solution of cresol, 50 per cent, in strength. Lysol (nonofficial) is a cresol preparation made by dissolving in fat, and subsequently saponifying with alcohol that portion of tar-oil which boils between 347° and 392°F. (190° and 2oo°C.). It con- tains 50 per cent, of comparatively pure cresols. It is a brown, oily liquid, and mixes with water to form a clear, saponaceous, frothy liquid. Physiologic Action. — Cresol is one of the newer preparations, and its action is almost identical with that of phenol. Some authorities claim, however, that cresol is more toxic to bacteria than is phenol, but that it is less toxic to the animal cell than is the latter. In this respect it approaches what might be termed an ideal disinfectant — an agent which will kill the bacteria without acting deleteriously upon the animal cell; but cresol is too toxic to the animal cell to be so consid- ered. Cresol is a caustic, though somewhat milder in action than phenol, and it possesses marked local analgesic properties. Therapeutics. — Cresol is a disinfectant. It may be used in dental practice with equal results in almost every condition where phenol is indicated. In some instances it is greatly superior to the latter drug. Its odor maybe considered an objection, but its valuable properties far outweigh this slight objection. As a local analgesic or anodyne for root-canal dressings it is valuable, and can be used with success as a cauterizing and stimulating agent in uncomplicated sinuses associated with dento-alveolar abscesses. It can be dissolved in glycerin or alcohol, with both of which it is miscible in all propor- tions, and the solution added to mouth-washes, sprays, and other antiseptic remedies. A i : 500 solution may be used as a vehicle in which to dissolve local anesthetic agents, as cocain hydrochlorid. Such solutions remain free from bacteria, and are not irritant to the 66 ANTISEPTICS, DISIXFECTAXTS, AXD DEODORANTS tissues in which they are injected. It is a constituent of the author's formocresol remedy which is an absolute specific for gangrenous pulp conditions. The compound solution of cresol and lysol is used in from i to 2 per cent, solutions in surgical work, as in the treatment of pyorrhea. CREOSOTUM— U.S.P. (Creosote.) Creosote is a mixture of phenols and phenol derivatives, chiefly guaiacol and creosol, obtained during the distillation of wood-tar, preferably of that derived from the beech. It is an almost colorless, or a faintly yellow, oily liquid, having a penetrating, smoky odor, and a burning, caustic taste. It is sHghtly soluble in water, soluble in all proportions in alcohol, ether, chloroform, and oils. It seems rather dif&cult to obtain pure beech-wood creosote. Much of the creosote on the market is impure phenol (carbolic acid). Tests for the purity of the drug can be made as follows: i. Mix equal quan- tities of the suspected specimen and collodion in a clean, dry test- tube; the formation of a coagulum wiU indicate the presence of phenol. 2. Mix intimately equal volumes of the suspected liquid and glycerin, then add one or more volumes of water; the absence of tur- bidity indicates an impure specimen of creosote. The average dose is 4 min. (0.25 mil). The one oflEicial preparation. Aqua Creosoti, is not much used in dentistry. As stated above, the chief con- stituents of creosote are guaiacol and creosol; the former is official. GUAIACOL— U.S.P. Guaiacol is a phenol derivative obtained by fractional distilla- tion from creosote. It is a colorless, oily liquid, having a rather unpleasant aromatic odor and taste. It is sparingly soluble in water, freely so in alcohol and ether. The average dose is 8 min. (0.5 mil). Physiologic Action. — Like all members of the phenol groups, creosote is an antiseptic, disinfectant, caustic and local analgesic. Its action closely resembles that of phenol, but it is less irritant and toxic. Therapeutics. — Creosote is employed in dental practice chiefly as a disinfectant and local analgesic. It is probably used more because of its analgesic property than any other. Three or four minim's (0.18-0.24 mil) placed on a blank tablet, a piece of loaf sugar, or candy form a valuable remedy for preventing nausea in taking impressions. This should be held in the mouth until the vehicle is dissolved. Creosote mixed with an equal volume of Hquor for- FORMALDEHYDUM 67 maldehyd, to which a small quantity of alcohol (20 min. to the ounce — 1.3-30.0 mils) is added, makes an excellent remedy for the treat- ment of gangrenous pulp conditions. Equal volumes of creosote and tincture of iodin have long been employed as a local analgesic and stimulant in apical pericementitis. Care must be taken to pre- vent the remedy from staining the dentin of the crown of the tooth, causing discoloration. Creosote is largely used as a toothache remedy by the laity. Guaiacol is not much used in dentistry, but is used in medicine in pulmonary tuberculosis as a substitute for creosote. FORMALDEHYDUM (Nonofficial) (Formaldehyd ; Formic Aldehyd;, CH2O.) Formaldehyd is a colorless gas, having a very pungent odor, obtained by the partial oxidation of methyl alcohol (wood-alcohol). The Pharmacopeia recognizes a 37 per cent, aqueous solution of the gas under the name Liquor Formaldehydi — Solution of Formaldehyd. Various solutions of the gas are on the market, commercially called formalin, formol, etc. The gas in solution readily undergoes poly- merization, whereby a solid form is obtained, now also recognized by the U.S. P. as Paraformaldehyd and called synonymously trioxymethylen or parajorm (CH2O3). This is a white crystalline powder, which yields formaldehyd on heating, or at body tempera- ture. The average dose is 8 gr. (0.5 Gm.). Physiologic Action. — Formaldehyd is one of the best disin- fectants. Stevens states that a i per cent, solution of liquor for- maldehyd kills pure cultures of pathogenic bacteria in an hour. It is a powerful deodorizer, readily uniting with hydrogen sulphid, mercaptan, ptomains, ammonia, and fetid ammonia bases to form inodorous compounds. The gas is intensely irritating; when inhaled it causes severe hyperemia and even inflammation of the mucous membrane of the entire respiratory tract. Concentrated solutions will produce a slough almost as readily as arsenic trioxid. The antidote for formaldehyd poisoning is ammonia, with which it forms the harmless hexamethylenamin (urotropin) . Therapeutics. — Because of the power formaldehyd has of uniting with the intermediate and end-products of pulp decomposition, form- ing with them nonpoisonous substances and converting the gases into liquids and solids, it is a most essential constituent of gangrenous pulp remedies. Its irritating action can be controlled by mixing the official liquor formaldehyd with cresol, phenol, or creosote. The 68 ANTISEPTICS, DISINFECTANTS, AND DEODORANTS author's formocresol remedy is equal volumes of cresol and liquor formaldehyd. When used, this remedy should always be hermeti- cally sealed within the tooth with a nonyielding sealing material, such as the dental cements. A lo per cent, solution of liquor formaldehyd, to which 2 per cent, of borax or sodium carbonate is added, makes an excellent sterilizing fluid for small instruments. The alkaHne salt (borax or sodium carbonate) prevents the formaldehyd from attacking the metal. In weak solutions (i : 1,000 to i : 500) it may be added to mouth- washes and sprays. Apparatus are on the market for using paraform for sterilizing instruments. Probably the only objection to this method is the liability of the gas escaping in the office. Some individuals are peculiarly susceptible to formaldehyd, having an idiosyncrasy for the drug. The author has known of a few such cases among dentists, where even a slight exposure to the gas would cause red blotches on the face and hands, resulting in desquamation (^scaling). The con- dition has been erroneously diagnosed as psoriasis, a chronic inflam- matory disease of the skin characterized by the development of red- dish patches covered with whitish scales. Individuals thus affected should avoid exposure in any manner to formaldehyd. Fortunately these cases are rare, for the drug is a valuable one in dental practice, if properly used. In medicine formaldehyd is extensively employed as a surface disinfectant for rooms containing the germs of contagious diseases. Both the aqueous solutions and the solid paraform are used for this purpose. iQCompatibilities. — Formaldehyd is incompatible with ammonia, alkalies, tannic acid, and mineral salts. HEXAMETHYLENAMINA— U.S.P. (Hexamethylenamin; Uro tropin.) Hexamethylenamin, or urotropin, is the product formed by the action of formaldehyd on ammonia. It is not used in dental practice, but mentioned here because of its formation within the tubular struc- ture of the dentin when formaldehyd gas is sealed within a gangren- ous root canal. The average dose is 4 gr. (0.25 Gm.). The drug is especially indicated in suppurative diseases of the genito-urinary tract; and is also frequently given in severe sore throat, especially in cases of infection by the streptococcus germ. LIQUOR HYDROGENII DIOXIDI 69 LIQUOR HYDROGENH DIOXIDI— U.S.P. (Solution of Hydrogen Dioxid; H2O2.) Hydrogen dioxid is a very unstable compound, prepared by the action of mineral acids (usually sulphuric acid) on barium dioxid. The offi cial aqueous solution should contain, when freshly prepared, about 3 per cent, by weight of absolute hydrogen dioxid, which cor- responds to about 10 volumes of available oxygen. In previous pharmacopeias the solution was classified as a "water." It is now properly classified as a "liquor." The solution is a colorless liquid, without odor, sHghtly acidulous to the taste, and producing a pecu- liar sensation and a soapy froth in the mouth. It is Uable to deterio- rate with age or by exposure to heat or protracted agitation. The dose is I fi. dr. (4.0 mils), well diluted with water. There is an unofl&cial ethereal solution of hydrogen dioxid on the market which contains 25 per cent, of the drug. Physiologic Action. — When hydrogen dioxid is applied to mucous membranes it decomposes into water and oxygen, the latter being given off in large quantities. The oxygen thus Hberated is in the nascent state and readily oxidizes surrounding substances. Applied to suppurating wounds or abraded surfaces, effervescence follows from the free oxygen. This effervescence is not necessarily an indi- cation of the presence of infection or pus, as hydrogen dioxid will pro- duce effervescence when in contact with blood. Hydrogen dioxid, because of the Hberation of nascent oxygen, destroys healthy granu- lations in healing wounds and should, therefore, be employed with caution, if used at all. It may cause sudden death when injected hypodermically or intravenously by the formation of gaseous emboli in a blood-vessel. Therapeutics. — As a cleansing agent and disinfectant, hydrogen dioxid has been extensively applied to diseased surfaces, such as canker sores and other ulcers, pyorrheal pockets, sinuses, etc. It is used extensively by the laity for cuts and bruises. It has little value here as a therapeutic agent, except that the effervescence caused by its action on the blood may mechanically remove dirt or other foreign bodies. In diluted solution it has been much used as an antiseptic remedy in many diseases of the mouth, throat, and nose. The drug may be used as a gargle or spray, or applied with a syringe or a swab. The value of hydrogen dioxid as a therapeutic agent depends upon the readiness with which it liberates oxygen when it is brought in con- tact with abraded tissues and with the fluids of the body. It should, therefore, be used with great caution in all practically closed sinuses 70 ANTISEPTICS, DISINFECTANTS, AND DEODOEANTS and on granulating surfaces. While the drug has its use in dental practice, its real value has been overestimated, and much harm has resulted from its injudicious employment. It is used for moistening pumice in prophylactic work; the only objection to its employment here is that the agent causes effervescence and hides the field of opera- tion. As a cleansing and whitening agent for the teeth, it is also used by the laity, but its continued use as a mouth-wash is likely to affect deleteriously the tooth-structure, on account of the uncombined sulphuric acid it contains. This latter agent seems necessary to preserve the solution, and is added by manufacturers. As a bleach- ing agent it is of great value. The preparation mostly used for bleaching tooth-structure is the 25 per cent, ethereal solution. POTASSn PERMANGANAS— U.S.P. (Potassium Permanganate; KMn04.) Potassium pennanganate occurs in the form of slender, dark- purple prisms, odorless, and of a sweetish, astringent taste. It is soluble in 13.5 parts of water at 25°C., and is decomposed by alcohol and hydrogen dioxid. It should be kept in glass-stoppered bottles, protected from light, and care should be taken not to bring it in contact with organic or readily oxidizable substances. The average dose is I gr. (0.06 Gm.). Physiologic Action. — In the presence of organic matter potassium permanganate quickly yields its oxygen; hence it is a good disinfect- ant and deodorant. Its usefulness, however, is limited, for when its oxygen is given up it is rendered inert. Therapeutics. — Its readiness to part with oxygen renders it of great value as a deodorant, and in dilute solutions, 1-5 gr. (0.06-0.32 Gm.) to I ounce (30.0 mils) of water, it is a useful remedy in thrush^ foul ulcers, putrid sore throat, syphilitic chancre, and cancer of the tongue. It is employed in surgical practice for disinfecting the hands, and should be followed with a saturated solution of oxalic acid to remove the stain. Its disadvantage for use in the mouth is its tendency to discolor the enamel of the teeth. This is only a surface and, therefore, temporary discoloration. Incompatibilities. — Potassium permanganate is incompatible with organic substances, alcohol, and hydrogen dioxid. CHINOSOL (Nonofficial) Chinosol occurs as a yellowish, crystalline powder, having a saffron-like odor and a burning taste; soluble in water, but insoluble HYDRARGYRI CHLORIDUM CORROSIVUM 7 1 in alcohol and ether. The aqueous solution has an acid reaction. The average dose is 5 gr. (0.3 Gm.). Physiologic Action and Therapeutics. — Chinosol is a powerful antiseptic. Cook and Mawhinney have spoken highly of the drug as a pus-destroyer, recommending its free use in from i to 10 per cent, solutions in foul, chronic abscesses and all other violent suppura- tions. Experimental evidence thus far has proven chinosol to be non- toxic. As a disinfectant it is weaker than phenol, and much weaker than mercuric chlorid ; though as an antiseptic it is considered stronger than and preferable to either of these drugs. It has been found to exert a restraining (antiseptic) influence on germs in solutions con- taining I part to 10,000. The drug does not coagulate albumin nor injure the mucous membranes or tissues. Therefore, its solution in various strengths is used to advantage in treating many conditions in both medicine and dentistry. As an antiseptic wash the average strength of solution is i: 1,000. In gargles the strength may be in- creased to 1 : 250. The drug is claimed to possess marked analgesic power and to be an efficient deodorant. HYDRARGYRI CHLORIDUM CORROSIVUM— U.S.P. While mercuric chK)rid will be discussed with the class of altera- tives under Mercury and its Compounds (see p. 198), the class of disinfectants would indeed be incomplete without the mention of this important and valuable drug. Mercuric chlorid is the most popular of aU the disinfectants for surgical work. The drug is cheap, soluble, and attacks bacteria and their by-products with energy. However, there are three principal objections to its employment: It is extremely poisonous; it attacks metallic instruments detrimentally; and it readily acts upon albumin- ous matter, rendering the drug inert. Stevens claims this last ob- jection may be eliminated by adding to its solution a weak acid (tartaric or citric acid) , Heat is a valuable disinfectant, and without doubt is the most reliable for sterilizing instruments. All known pathogenic bacteria and their spores are destroyed by heat. The best method of steril- izing operative and surgical instruments is to immerse them in boiling water for from 2 to 15 minutes, according to the demands of the case. Many practical ''sterilizers" are on the market for this purpose (see p. 278). 72 ASTRINGENTS, STYPTICS, AND HEMOSTATICS ASTRINGENTS, STYPTICS, AND HEMOSTATICS Astringents are agents which produce contraction and condensa- tion of tissue. Styptics and hemostatics apply to agents that arrest hemorrhage. When the agent is applied locally it is called a styptic; when administered internally it is called a hemostatic. Many of the styptic and hemostatic agents control hemorrhage by virtue of their astringent property, for which reason these classes of remedies are discussed here conjointly. Astringent agents exert their influence most markedly when applied upon raw surfaces and mucous mem- branes. Many of them also have the property of diminishing or ar- resting glandular secretion. This result is produced more by the direct action of the agent upon the secreting cell than it is by the con- striction of the blood-vessels of the part. Cook, in his experiments upon dogs, has shown that mouth-washes which contain astringent agents, notably zinc chlorid, arrest the secretion of ptyaHn for a con- siderable number of hours after the solution is employed. Most of the astringents are also irritants ; especially is this true of some of the metallic salts, the action of which is more irritant and caustic than astringent. This is largely due to the liberation of an acid by the union of the metal with the albumin of the cells. Astringents may be conveniently divided into two classes, vege- table and mineral. The efficacy of those of vegetable origin depends upon the tannic acid which they contain. It should be remembered that among the mineral astringents, bismuth subnitrate, zinc oxid, and lead acetate have more of a sedative than an irritant action. The vegetable astringents of importance are: Tannic acid. Ergot. Gallic Acid. Krameria. Hematoxylon. HamameKs. Hydrastis. The important mineral astringents are: Alum. Zinc Oxid. Lead Acetate. Zinc lodid. Copper Sulphate. Zinc Chlorid. Zinc Sulphate. Calcium Chlorid. Zinc Phenolsulphonate. Bismuth Subnitrate. Silver Compounds. ACmUM TANNICUM— U.S.P. (Tannic Acid; Tannin; HC14H9O9.) Tannic acid is the active constituent of all vegetable astringents. Its chief source is from nutgall. It occurs in the form of a light- ACIDUM TANNICUM 73 yellowish, amorphous powder, odorless, and of a strongly astringent "taste. Soluble in about 0.34 part of water and in 0.23 part of alcohol; also soluble in about i part of glycerin with the aid of moderate heat. The average dose is 8 gr. (0.5 Gm.). All of the official preparations are valuable astringent remedies. They are: Glyceritum Acidi Tannici, Glycerite of Tannic Acid (20 per cent.). Unguentum Acidi Tannici, Ointment of Tannic Acid (20 per cent.). Trochisci Acidi Tannici, Troches of Tannic Acid (i gr.-o.o6 Gm. in each). CoUodium Stypticum, Styptic Collodion (20 per cent.), u.s.p. vni. Physiologic Action. — Tannic acid, especially when applied to raw surfaces, coagulates the albumin of the superficial celis, causing con- densation of the tissue, which is evidenced by the sensation of puck- ering. On mucous membranes it acts in a similar manner, combin- ing with the proteids of the glandular cells, thus drying up the secre- tion. It also paralyzes the sensory nerve-endings and blunts the sense of taste. It may be considered a styptic, as it coagulates the albumin of the blood and checks hemorrhage. When administered internally, tannic acid is changed in the intestine into gallic acid, and in this form a certain amount is absorbed and eliminated in the urine ; it also acts as a hemostatic. Therapeutics. — Tannic acid is a valuable astringent drug. It may be appUed locally in the form of the glycerite in cases of spongy gums, or the glycerite may be added to mouth-washes to the extent of from 2 to 5 per cent., thus giving to the solution an astringent property. For years the glycerite was appHed to the pulp tissue after devitalization for the purpose of toughening the tissue and aid- ing in its subsequent removal from the canals of teeth, but its liability to discolor the tooth-structure when so used constitutes a serious objection to its employment (see p. 329). A solution of from 3^ to i per cent, is a useful remedy to be used as a spray or gargle in cases of stomatitis, laryngitis, and pharyngitis. Many dentists are troubled with hy paridrosis of the hands. Lotions containing tannic acid are often beneficial in this condition. Dust- ing-powders, as well as lotions, are also used in hyperidrosis of the feet. Styptic collodion serves as a protection to lacerated or incised 74 ASTRINGENTS, STYPTICS, AND HEMOSTATICS wounds. Troches of tannic acid may be dissolved in the mouth with benefit in cases of sore throat. Incompatibility. — Tannic acid is incompatible with alkaloids, gelatin, lime-water, the salts of iron, silver, lead, and copper. When potassium chlorate is triturated with tannic acid or organic drugs containing the latter, the mixture is liable to explode. ACmUM GALLICUM (Gallic Acid; HC7H5O5 + H2O.) Gallic acid is prepared generally from tannic acid. It occurs as white or pale fawn-colored, silky needles, odorless, having an as- tringent or slightly acidulous taste. It is soluble in 87 parts of water, in 4,6 parts of alcohol, and in 10 parts of glycerin at 25°C. The average dose is 15 gr. (i.o Gm.), given in powders or capsules. Physiologic Action. — Gallic acid resembles tannic acid when ad- ministered internally; but, applied locally, it is a very feeble astrin- gent, as it does not coagulate albumin and hence does not influence the tissue Hke tannic acid. Therapeutics. — ^About the only indication for gallic acid in dental practice is in cases of hemorrhage following extraction. Here it would be employed purely as a hemostatic, and its action as such is ques- tionable, except in intestinal hemorrhage. KRAMERIA (Nonofficial) (Krameria ; Rhatany.) Krameria is the dried root of Krameria triandra, a low shrub grow- ing in sandy locaHties in the mountains of Bolivia and Peru. Tannic acid is the chief constituent. The following preparations, which with the drug itself were official in the U.S. P. VIII, are of value in dentistry: Extractum Krameriae. Average dose, 5 gr. (0.3 Gm.). Fluidextractum Krameriae. Average dose, 10 min. (0.6 mils). Syrupus Krameriae. Average dose, i fl. dr. (4.0 mils). Tinctura Krameriae. Average dose, }-2 fl. dr. (2.0 mUs). Trochisci Krameriae. Average dose, 2 troches (each contains I gr.-o.o6 Gm. of the extract). Phyiologic Action. — The action of krameria is identical with that of its chief constituent, tannic acid. Therapeutics. — The astringency of the drug is due entirely to the tannic acid which it contains in large amount. It has no special ad- vantage over tannic acid. The various preparations of krameria, ELAMAMELIS — ^HiEMATOXYLO N 75 especially the tincture, may be added to mouth-washes and gargles to be used in cases of rubber sore mouth, spongy gums, ptyalism, and pharyngitis. The troches are also useful in sore throat. HAMAMELIS (Nonofficial) (Witch-hazel.) Hamamelis was formerly official as the bark and dried leaves of Hamamelis Virginiana, a shrub growing in the damp woods of North America. It contains a volatile oil, a small amount of tannic acid, and a bitter principle. The official preparations are: AquaHamamelidis, U.S.P.; distilled extract of Witch-hazel. Average dose, 2 fl. dr. (8.0 mils). Physiologic Action. — The action of hamamelis is that of an astrin- gent, due largely to the tannic acid it contains. Besides its astringent property, the drug is credited with having a marked sedative effect when topically applied. Therapeutics.- — Preparations of hamameUs are useful household remedies. As a topical application after shaving, and for sprains and bruises hamamelis water has long enjoyed a popular reputation. Diluted with water, alcohol, or glycerin (i part to 3), the distilled ex- tract may be used as a spray in inflamed and spongy gums, in pharyn- gitis, and applied to the nasal mucous membrane after the removal of polypi. Hamamelis water has been recommended, diluted one-haH with distilled water, as a vehicle for local anesthetic solutions. It should not be so employed, as the tannic acid will act upon the alkaloidal salt (usually cocain hydrochlorid) and precipitate the alkaloid. HLffiMATOXYLON (Nonofficial) (Logwood.) Hematoxylon is the heart-wood of Hcematoxylon campechianum, a rather small tree growing along the shores of the Gulf of Campeachy and in certain parts of South America. Besides tannic acid it con- tains a crystalline coloring principle, hematoxylin. The extract as well as the drug itself was official in the U.S. P. VIII. The drug has no dental use except as a staining agent for tissues in microscopic study, for which purpose it is extensively employed, and may be found among the "reagents" of Part II, U.S. P. IX. 76 ASTRINGENTS, STYPTICS, AND HEMOSTATICS ERGOTA— U.S.P. (Ergot; Ergot of Rye.) Ergot is the sclerotium of Clavicefs purpurea, a parasitic fungus, which replaces the grain of rye, Secale cereale. Ergot is obtained chiefly from the rye growing in Russia, Spain, and Germany. The following preparations are official : Fluidextractum Ergotse, U.S. P. Average dose, 30 min. (2.0 mils). Extractum Ergotse, U.S. P. Average dose, 4 gr. (0.25 Gm.). Physiologic Action. — Ergot has no local action. The drug must be taken internally to produce its effects. When it enters the circu- lation it acts directly upon the muscular coats of the vessels, causing constriction of the arterioles, with an increase in arterial pressure. The involuntary muscles throughout the body appear to be influenced by ergot; the voluntary muscles are unaffected. Therapeutics. — Ergot is used in dentistry for its hemostatic prop- erty. In cases of known hemorrhagic diathesis {hemophilia) , it is well to administer the drug a few hours previous to the extraction of teeth or other operations involving hemorrhage. The fluid extract is the most reliable preparation and may be given in doses of 3^^-! fl. dr. (2.0-4.0 mils). Ergot should not be given when the hemorrhage proceeds from a large vessel, because here the muscular contraction could not close the vessel, and the increased arterial pressure, occasioned by the drug, would naturally increase the flow of blood. The drug should not be given to pregnant women, because of the contraction it produces on the unstriped muscle of the uterus. Ergot is the one drug relied upon to prevent postpartum hemorrhage during and following labor in confinement cases. HYDRASTIS— U.S.P. (Golden Seal.) Hydrastis is the dried rhizome and roots of Hydrastis canadensis, a perennial herb growing in the woods of North America. One of the chief constituents is hydrastin, which is official under the title Hydrastina. Hydrastin hydrochlorid, Hydrastinse Hydrochloridum, is also official; as is also the hydrochlorid of an alkaloid obtained by the oxidation of hydrastin, called Hydra stinin Hydrochlorid, Hy- dras tininae Hydrochloridum. Other constituents are herherin and canadin. SUPRAEENALUM SIC CUM 77 The official preparations of Hydrastis are : Fluidextractum Hydrastis, U.S.P. Average dose, 30 min. (2.0 mils). Tinctura Hydrastis, U.S.P. Average dose, i dr. (4.0 mils). Glyceritum Hydrastis, U.S.P. Externally. Physiologic Action and Therapeutics. — The action of Hydrastis is due almost entirely to the presence of the alkaloid, hydrastin, which it contains. Applied locally, it appears to have a stimulating influ- ence upon the oral mucous membrane. The glycerite may be added to mouth-washes (5 per cent.) and used in sluggish conditions of the mucous membranes, as in chronic catarrh, etc. The drug also has astringent and antiseptic properties. The fluid extract appHed to indolent ulcers stimulates the condition to a healthy activity. In- ternally administered it acts as a stomachic and is a constituent of many bitter tonics. Incompatibles. — These are the same as those of other alkaloids. SUPRARENALUM SICCUM— U.S.P. (Desiccated Suprarenal Glands; Suprarenal Extract.) This product is neither a vegetable nor mineral astringent, but is considered here because it belongs to this group. It is the suprarenal gland of the animals which are used for food by man (sheep, ox, etc.), freed from fat, cleaned, dried, and powdered; and containing not less than 0.4 per cent, nor more than 0.6 per cent, of epinephrin, the active principle of the suprarenal gland. It occurs as a light, yellowish-brown powder, having a slight, characteristic odor; partially soluble in water. The average dose is 4 gr. (0.25 Gm.). The active principle has been separated by different men and variously named epinephrin (Abel), suprarenin (Von Furth), adrena- lin (Takamine and Aldrich). According to the best authoritiesfihe last-named, adrenalin, represents more fully the active properties of the gland. It occurs as a white, crystalline substance. It dissolves with difficulty in cold water; but dissolves readily in acids, forming salts. A solution of adrenalin chlorid is on the market, as are other liquids and solids for styptic and hemostatic purposes. Epinephrin is produced synthetically and is on the market in various forms under the name "L. -Suprarenin Synthetic. " Physiologic Action and Therapeutics.- — Suprarenal gland, or solutions of its active principle, act locally on a variety of structures, probably by stimulating the sympathetic nerve terminals. Its most important action is the constriction of blood-vessels, with the usual 78 ASTRINGENTS, STYPTICS, AND HEMOSTATICS high rise of blood pressure. The drug is used in dentistry largely for its hemostatic properties. It should be remembered that the solution of epinephrin (adrenalin, suprarenin) will better prevent hemorrhage if used before operating than it will check hemorrhage after it has begun. Braun, Fischer and others recommend its use for the vasoconstrictor action to intensify and prolong the anesthetic effect of local anesthetics by retarding the circulation in the affected part and thus hindering the dilution of the anesthetic agent by too rapid absorption into the general blood stream. Solutions of adrenalin chlorid have been recommended as the vehicle for dissolving cocain hydrochlorid in the removal of the dental pulp by pressure anesthe- sia. Its use here, however, is unwarranted and objectionable (see Practical Therapeutics, p. 323). The dilute aqueous solutions are rather unstable, the deterioration being accompanied by a reddish or brownish discoloration. The drug can be obtained alone or combined with other drugs, in tablet form. The powder is stable. THYROrOEUM SICCUM— U.S.P. (Desiccated Thyroid Glands; Thyroid Extract.) This product is the thyroid gland of animals which are used for food by man, freed from fat, cleaned, dried, and powdered. It must contain not less than 0.17 per cent, nor more than 0.23 per cent, of iodin in thyroid combination. One part represents approximately 5 parts of the fresh gland. It is a yellowish, amorphous powder, partially soluble in water. Average dose, i3^ gr. (o.i Gm.). The product is not much used in dentistry, its general properties being alterative, hemostatic, and antifat. ALUMEN— U.S.P. (Alum.) The United States Pharmacopeia now recognizes two kinds of alum — ammonium alum and potassium alum. The ammonium or potassium is combined chemically with aluminum in the form of a sulphate, and is what is known in chemistry as a double sulphate. Both occur in large, colorless, octahedral crystals, odorless, but hav- ing a sweetish and strongly astringent taste. Soluble in water and in warm glycerin, insoluble in alcohol. The ammonium alum is somewhat less soluble in water than is the potassium alum. The average dose is 8 gr. (0.5 Gm.) . As an emetic it may be given in much larger doses — 1-2 dr. (4.0-8.0 Gm.). The dried or burnt alum is also ofl&cial under the title Alumen Exsiccatum, U.S.P. PLUMBI ACETAS 79 Physiologic Action. — Alum is a powerful astringent when appHed to the broken skin or mucous membranes. It acts by coagulating the albumin of the superficial cells, thus causing condensation of the tissues. With the blood it forms a firm coagulum, and tends to arrest hemorrhage. When applied to the unbroken skin, it has a tendency to thicken and harden it. Therapeutics. — In edentulous mouths alum may be used to toughen the mucous membrane. A solution of from 5 to lo gr. (0.3-0.6 Gm.) to the ounce (30.0 mils) is a useful remedy in cases of rubber sore mouth, subacute and chronic pharyngitis and laryngitis, especially where there is a viscid mucous secretion. It has a de- structive action on the tooth-structure, hence its prolonged use in the mouth is contraindicated, except in edentulous mouths. It may be used as a styptic to arrest hemorrhage from small wounds. A large smooth crystal may be moistened and applied to the face after shav- ing, as the alum thickens and toughens the unbroken skin and also tends to arrest any small hemorrhages which may follow the operation. Dried alum may be employed as a mild caustic for indolent ulcers and for destroying exuberant granulations, as are often seen covering the fragment of a broken tooth-root a few days after an unsuccessful attempt at extraction. Lotions of alum and dilute alcohol are sometimes employed in hyperidrosis of the hands and feet. Incompatibles. — Alum is incompatible with alkalies, alkaline carbonates, lead acetate, mercury, iron salts, and tannic acid. PLUMBI ACETAS— U.S.P. (Lead Acetate; Sugar of Lead; Pb(C2ll302)2 + 3H2O.) Lead acetate occurs in colorless, shining, transparent, heavy prismatic crystals or crystalline masses, having a faintly acetous odor and a sweetish, astringent, afterward metallic taste. It is soluble in 1.4 parts of water and in 38 parts of alcohol at 25°C. The average dose is I gr. (0.065 Gm.). Physiologic Action. — MetaUic lead is practically inert, and the tissues take kindly to it. A clean lead bullet may become encysted in the tissues. Lead acetate has valuable therapeutic properties. Applied in solution to denuded or highly inflamed surfaces, its action is both astringent and sedative. In the mouth it acts immediately, coagulating the mucus and producing a sweet, styptic taste. When taken internally and absorbed, the lead enters as a constituent part into the protoplasm of the cells, and is exceedingly slow in being 8o ASTRINGENTS, STYPTICS, AND HEMOSTATICS eliminated. Lead poisoning may result from the internal adminis- tration, but the cases fortunately are rare, for the acetate is an emetic and the emesis produced prevents toxic effects of the drug. Therapeutics. — Lead acetate is not much employed in dental practice. Its sedative as well as its astringent properties make it a useful drug to be applied to acute inflammatory conditions of all mucous membranes. In cases of inflammation following the removal of foreign substances from the eye, a solution of lead acetate, 1-2 gr. (0.065-0.13 Gm.), to the ounce (30.0 mils) of distilled water makes an excellent collyrium. Should the solution be turbid or milky, it indicates a trace of lead oxid. The smallest amount (i min.-0.05 mil) of dilute acetic acid will clear the solution. CUPRI SULPHAS— U.S.P. (Copper Sulphate; Blue Vitriol; CUSO4 + 5H2O.) Copper sulphate occurs in large, transparent, deep-blue crystals, odorless, and of a nauseous metallic taste. It is soluble in about 2.5 parts of water at 25°C., and almost insoluble in alcohol. The average dose as an astringent is }4 gr- (0.032 Gm.) ; as an emetic, 4 gr. (0.25 Gm.). Physiologic Action. — The mode of action of copper sulphate de- pends largely upon the strength of the solution employed. Dilute solutions act upon mucous membranes and raw surfaces as an astrin- gent. In concentrated solutions or appHed in the crystal or pow- dered form, it acts as a mild caustic. Internally administered in large doses, it produces emesis by its direct irritant action on the stomach. Therapeutics. — Copper sulphate is a useful drug in cases of canker sores, ulcerative stomatitis, and other indolent ulcers. Light applications of the solid crystal produce a stimulant effect upon the sluggish cells. It is a prompt and powerful emetic, but considered too irritant to the stomach for ordinary use. Bevan and Brophy report good results with copper sulphate in the treatment of actinomycosis occurring in man. They begin with about yi gr. (0.016 Gm.) given three times a day, gradually increas- ing the dose to i gr. (0.065 Gm.). In addition to the internal admin- istration of the drug, irrigations of a i per cent, solution are also employed. CUPRI OXIDUM — ZmCI SULPHAS 8 1 CUPRI OXIDUM (Nonofficial) (Black Copper Oxid; CuO.) Copper oxid occurs as a heavy dark-brown powder; insoluble in water. This product has been modified by Ames, and is used as the powder for the copper phosphate cement, a material extensively employed in filling cavities in children's teeth. This cement is claimed to possess marked antiseptic properties as well as serving the function of a temporary filling material. It has one distinct advan- tage in that it may be applied directly against the gums or other tissues, which take kindly to it. ZINCI SULPHAS— U.S.P. (Zinc Sulphate; White Vitriol; ZnSO* + 7H2O.) Zinc sulphate occurs in colorless, transparent crystals, or granu- lar crystalline powder, odorless, and of an astringent metallic taste. It is efflorescent in dry air. Soluble in less than its own weight (0.53 part) in water, in about 2.5 parts glycerin at 25'^C.; insoluble in alcohol. It is rarely given internally except as an emetic, when the average dose is 15 gr. (i.o Gm.). Physiologic Action.- — Zinc sulphate acts as an astringent, styptic, emetic, and antiseptic. In weak solutions it is astringent and anti- septic; in strong solutions it acts as an irritant or caustic, tending to arrest slight hemorrhage when applied externally, and, when admin- istered internally, producing emesis. Therapeutics.- — Weak solutions of zinc sulphate may be applied to raw surfaces and to mucous membranes whenever a sHght astrin- gent effect is desired. A solution of from 3^-2 gr. (0.06-0.1 Gm.) to the ounce (30.0 mils) is a valuable collyrium in simple conjunc- tivitis. A I per. cent solution is also useful in ulcerative stomatitis, cancrum oris, and as a gargle in enlarged tonsils and sore throat. As an emetic it is employed in narcotic poisoning, 10-30 gr. (0.6-2.0 Gm.) dissolved in water, being given and repeated in fifteen to twenty minutes, if necessary. Incompatibles. — Zinc sulphate is incompatible with alkalies, alkaline carbonates, vegetable astringents, lead acetate, silver nitrate, and lime-water. 82 ASTRINGENTS, STYPTICS, AND HEMOSTATICS ZmCI PHENOLSULPHONAS— U.S.P. (Zinc Phenolsulphonate ; Zinc Sulphocarbolate ; Zn(C6H4(OH)S03)2.) Zinc phenolsulphonate, also commonly, though erroneously, called zinc sulphocarbolate, occurs in colorless, transparent prisms, or tabular crystals, odorless, and having an astringent, metallic taste; on exposure to air and Hght it effloresces and may acquire a pink tint. It is freely soluble in water and alcohol. The aqueous solution is acid to litmus. It is rarely given internally; the average dose is 2 gr. (0.125 Gm.). Physiologic Action. — Zinc phenolsulphonate is an astringent and antiseptic, and produces a stimulant effect upon mucous membranes. It acts similarly to other zinc salts, but the contained phenol radical adds to its antiseptic power. Therapeutics. — This salt has but recently been employed in dental practice. Whitslar suggests the use of a 10 per cent, solution in cinnamon water as a stimulating antiseptic following the surgery of pyorrhea alveolaris. 14 dr. (2.0 Gm.) added to 8 oz. (240.0 mils) of hquor antisepticus makes a valuable astringent mouth-wash to be used in stomatitis and sore throat. ZINCI OXroUM— U.S.P. (Zinc Oxid; ZnO.) Zinc oxid is a fine, white, amorphous powder, without odor or taste. Insoluble in water or alcohol. It is rarely used internally, an average dose being 4 gr. (0.25 Gm.) . There is one official prepara- tion : Unguentum Zinci Oxidi, U.S. P. (20 per cent.). Physiologic Action. — Zinc oxid is a mild astringent and antiseptic. Therapeutics.- — This drug has been used extensively as a vehicle for making pastes of liquids for treating gangrenous pulps and dento- aheolar abscess, also for root-canal fillings. In the light of our pres- ent knowledge of ''focal infection" and its relation to systemic disease, all "pastes" of whatever nature should be discarded for filling root-canals. Zinc oxid is the base of the powder for all zinc phosphate cements. The ointment may be employed to soften and protect the mucous membrane of dry and cracked lips previous to operating or adjusting the rubber dam. The ointment is also extensively used as a sHghtly ZINCI lODIDUM — ZINCI CHLORIDUM St, astringent and protective dressing for cold-sores, burns, acute ulcers, and acute inflammatory skin diseases. ZINCI lODEDUM (Nonofficial) (Zinc lodid; Znl2.) Zinc iodid is a white, granular powder, without odor, and having a sharp, sahne, and metallic taste. It is a very deliquescent salt and liable to absorb oxygen from the air, becoming brown from liberated iodin. Readily soluble in water, alcohol, or ether. It should be kept in glass-stoppered bottles. When used internally the average dose is }/2 gr- (0-03 Gm.). Physiologic Action. — Zinc iodid is astringent, antiseptic, and alterative. Therapeutics. — This salt may be used as a mild astringent, anti- septic and alterative in cases of ulcerative stomatitis and pyorrhea aheolaris. Talbot suggests using the following remedy in cases of flabby and inflamed gums; Zinc iodid 15 parts, water 10 parts, iodin 25 parts, and glycerin 40 parts. The salt can also be added to mouth- washes to give astringency to the solution. ZINCI CHLORIDUM— U.S.P. (Zinc Chlorid; ZnCla.) Zinc chlorid occurs as a white, granular powder, or fused mass, very deliquescent, odorless, and of a caustic, metallic taste. // is so intensely caustic as to make tasting dangerous, unless the salt is dissolved in a large quantity of water, in which it is freely soluble; it is also freely soluble in alcohol. It is not used internally. The official preparation is : Liquor Zinci Chloridi, U.S. P. (50 per cent.). Physiologic Action.' — Zinc chlorid is feebly astringent and anti- septic. It is the most caustic of all the zinc salts, and possesses marked styptic properties. Its prolonged use in the mouth interferes with the secretory action of the salivary glands (Cook) . Therapeutics. — Solutions of zinc chlorid of various strengths have enjoyed an unmerited reputation as disinfectants in dental practice. For years the saturated solution has been mixed with zinc oxid to make the so-called zinc oxychlorid cement, and used for filling root- canals. This cement is not used to-day to any great extent for filling root-canals; but its use is strongly recommended for the purpose of covering the gutta-percha canal filling. Webster proved the material 84 ' ASTRINGENTS, STYPTICS, AND HEMOSTATICS to be impervious to bacteria, which is a distinct advantage. Black, Poundstone, and others claim this is not true of the ordinary zinc phosphate cements. A lo per cent, solution may be employed for arresting profuse hemorrhage in pressure anesthesia. Applied to sensitive dentin it acts as an obtundent. Care must be taken not to use it in deep-seated cavities nearly involving the pulp, as the hy- drochloric acid liberated will irritate the pulpal organ. This irritant property may be controlled by dissolving the salt in alcohol and then adding chloroform. A formula for sensitive dentin follows: Zinc chlorid 2q gr. (1.3 Gm.), alcohol and chloroform, of each, }^ fl. oz. (15.0 mils). The drug has been recommended to be added to mouth- washes to impart astringency to the solution. Its value here has been overestimated, for it is the least astringent of all zinc salts, and its continued use in the mouth changes temporarily the character of the saliva. CALCn CHLORroUM— U.S.P. (Calcium Chlorid; CaCla.) Calcitim chlorid occurs in white, rather translucent, hard frag- ments, is very deliquescent, odorless, and of an acrid saline taste. It is freely soluble in water, somewhat less so in alcohol. The av- erage dose is 8 gr. (0.5 gm.). Physiologic Action and Therapeutics. — Internally administered calcium chlorid increases the coagulability of the blood. This prop- erty was first mentioned by Wright, of England, in 1893. It has been used with success in hemophilia, and in small persistent hemor- rhages, like those which sometimes follow the extraction of teeth. Wright found that the prolonged administration of the drug rather decreases than increases the coagulability of the blood, and that it acts best as a hemostatic by giving it in doses of from 3-10 gr. (0.2-0.6 Gm.) three times a day, for a period of two or three days, and discontinuing its use for a like period. The drug is very irritating to the stomach and should be given after meals, well diluted. BISMUTHI SUBNITRA.S— U.S.P. (Bismuth Subnitrate; BiONOs + H20(?).) Bismuth subnitrate is a heavy white powder, of a somewhat varying chemic composition, odorless, almost tasteless, and slightly hygroscopic. It is insoluble in water and alcohol, but soluble in glycerin in about 12 parts (Hereth). The average dose is 8 gr. (0.5 Gm.). ARGENTTIM — ^AUGENTI NITEAS 85 Physiologic Action. — Upon the unbroken skin bismuth subnitrate simply acts as a protective agent; but upon raw surfaces and mucous membranes it also acts as an astringent and antiseptic. From denuded surfaces absorption of the drug takes place rather speedily, and poisoning has been known to occur from its too frequent appli- cation. The s3anptoms of bismuth poisoning are stomatitis, saHva- tion, black discoloration of th* mucous membrane of the mouth, and finally ulceration of the throat, diarrhea and albumin in the urine. Because of the protection the insoluble compound affords to the part, and also because it is just sufficiently astringent to act as a stimulant to the sluggish cells, this drug may be called an ideal antiseptic when applied to abraded surfaces. Therapeutics.^Until recently bismuth subnitrate had not been employed in dentistry. In medicine it has long been a standard remedy in both acute and chronic gastric catarrh and gastric ulcer. Beck has recently proved its value in chronic tubercular sinuses. The drug is now extensively employed in dento-alveolar sinuses, pyorrhea pockets, and as a packing for wounds after surgical opera- tions about the roots of teeth and the alveolar process. The formula for Beck's paste is: Bismuth subnitrate 30 parts, white wax and paraffin, of each 5 parts, and vaselin 60 parts. Mix with heat. ARGENTUM (Nonofficial) (Silver; Ag.) Metallic silver is used extensively in dental practice in the form of a wire for suturing fractured jaws, ligating loose teeth, etc. The most important salt of silver used in dentistry is silver nitrate, which is official. ARGENTI NITEAS— U.S.P. (Silver Nitrate; AgNOs.) Silver nitrate occurs in colorless, transparent, tabular crystals, odorless, and of a caustic and rather metalHc taste. It is soluble in about 0.4 part of water and in 30 parts of alcohol at 25°C. The salt darkens on exposure to light, and should be kept in amber- colored bottles. The average dose is }/q gr. (o.oi Gm.). The only official preparation is: Argenti Nitras Fusus, U.S.P., Lunar Caustic (Silver Nitrate fused and molded into hard white cones or pencils). Physiologic Action. — While silver nitrate, in dilute solution, acts as an astringent upon mucous membranes and raw surfaces 86 ASTEINGENTS, STYPTICS, AND HEMOSTATICS in that it contracts the tissues to which it is applied by precipitating the albumin of the cells, in concentrated solutions or crystal form it acts as an unirritating caustic, coating and pro'tecting the parts with white silver albuminate. Much investigation has been done by dentists in regard to the depth of penetration of silver nitrate, especially when applied to the tooth-structure. The prevailing opinion is that its penetration is#Umited on account of the im- penetrable nature of the coagulum formed. In weak solutions (1:2500), silver nitrate is active as a disin- fectant. Internally administered in medicinal doses, its only action is that of an astringent and antiseptic. The long-continued use of silver nitrate, even when locally ap- plied, may result in a condition known as argyria. The manifesta- tion of this condition is a characteristic, bluish-gray discoloration of the skin and mucous membranes. As a rule, it does not interfere with the general health, but the discoloration is permanent. Therapeutics. — Silver nitrate is a valuable therapeutic agent in dentistry, being used largely for its caustic action. It is chiefly employed for its beneficent effect on unnatura lly exposed tooth- structure, and on inflamed mucous membrane s and ul cerjitive surfaces. To exposed sensitive cementum it may be applied in from 10 to 20 per cent, solution, the part first being dried; or the surface to be cauterized may be left moist and the soHd stick used. Black calls attention to the fact that exposure to sunlight aids the action of the salt. In the absence of sunlight, the electric mouth lamp will be found serviceable. This drug is one of the best caustics for destroying exuberant and superfluous granulations, for which purpose a solution may be used up to 50 per cent, in strength. In chronic stomatitis a 2 to 5 per cent, solution may be used with advantage; the pencils may be used in lightly touching mucous patches. Elliot recommends a 10 per cent, solution as a local application in the cracks which frequently occur about the hands and feet. It is stated on good authority that there are 60,000 blind people in the United States, and that fuUy one-third of these unfortunates are blind because of a disease which is easily preventable. This is known scientifically as ophthalmia neonatorum; but mothers and midwives simply call it "baby sore eyes." It can be prevented by dropping a few minims of a one per cent, solution of silver nitrate in the baby's eyes when born. Some States have a law making it obligatory for the physician in attendance at birth to use a solution of the silver compounds. P*recautions. — There is Httle danger of producing argyria from SILVER SALTS AND SOLUBLE COMPOtOSTDS 87 silver nitrate in dental practice, yet dentists should be familiar with this condition. In using the drug, care should be taken to prevent the cauterization of parts not intended, as the patient's lips, gums, tongue, buccal mucous membranes, etc. Sodium chlorid (common salt) is a positive antidote, as it forms with the drug the insoluble and inert silver chlorid. A solution of the antidote should always be in a convenient place when silver nitrate is used about the mouth . Incompatibles. — With creosote it causes an explosion. It is also incompatible with organic matter and many salts, as chlorid s, bromids, iodids, sulphids, cyanids, carbonates, and phosphates. OTHER SILVER SALTS AND SOLUBLE COMPOUNDS An effort has been made by manufacturing chemists to produce compounds of silver which possess the stimulant and disinfectant power of silver nitrate and which will not precipitate albumin or chlorids. Some of these preparations have proved exceedingly valuable. Arg3n:ol (Silver Vitellin). — This is a compound of a derived vege- table proteid and silver oxid, containing from 20 to 25 per cent, of silver. It occurs in black, glistening, hygroscopic scales, freely soluble in water and glycerin, insoluble in alcohol and oils. Physiologic Action and Therapeutics. — In strong solutions (20- 50 per cent.) argyrol is claimed to be nonirritating to mucous mem- branes. It, without doubt, possesses marked antiseptic properties. It is recommended in nearly all diseased conditions of the mucous membranes; as in stomatitis, acute ulcerous gingivitis, aphthous sore mouth, maxillary sinusitis, -pharyngitis, and conjunctivitis. Brophy recommends the drug in the after-treatment of antral operations. It is used in from 10 to 50 per cent, solutions. It will stain the skin and mucous membrane as well as the clothing. Care should be taken, therefore, in using the drug not to stain the latter. Hot water immediately appUed will remove the stain from fabrics. Protargol. — This is a proteid compound containing about 8 per cent, of silver. It occurs as a f§,wn-colored powder, freely soluble in water. It is claimed to be a good disinfectant, and comparatively free from irritant properties. Its action is similar to that of argyrol, and it is used for practically the same pathologic conditions. The extreme solubility of argyrol and the high percentage of silver which it contains have caused this drug to largely supersede protargol in dental practice. 8b BLEACHERS Silver Preparations, Colloidal. — Under certain conditions involv- ing a very fine state of subdivision, metallic silver and some of its compounds ordinarily insoluble become capable of colloidal suspen- sion, forming with water mixtures closely resembling solutions. These preparations are not precipitated by the ordinary precipitants of silver salts. As a result they can be mixed with organic liquids or injected into tissues or even into the blood-stream without precipita- tion and without causing marked symptoms of irritation. They possess to a greater or less degree the antiseptic properties of solu- tions of silver compounds. Several similar preparations of this kind are on the market and are variously known as cargentos, collargol, eleclrargol. BLEACHERS Bleachers, or bleaching agents, have been defined as agents used to restore the color of tooth-structure. The methods employed in bleaching teeth will be described in detail later in this work. It is intended here to discuss only the drugs used for this purpose. However, it is important that the student should know that the methods of bleaching teeth involve more or less of chemistry. The general principle of bleaching teeth is to chemically change the insolu- ble colored pigment into a soluble compound so that it may be washed out of the tooth-structure, or else chemically attack the pigment in such a way as to break up its molecular arrangement and thus destroy its color. This may be accompHshed by one of two general chemic processes — oxidation or reduction. The agents used for bleaching teeth, therefore, can be divided into two classes: Those which oxidize and those which reduce the pigment. OXIDIZING AGENTS This class of drugs may also be conveniently subdivided into two classes — direct and indirect oxidizing agents. The former is any agent from which oxygen may be obtained directly, and the latter is any agent from which oxygen may be obtained indirectly. The direct oxidizing agents used for bleaching teeth are : Sodium Dioxjd. Acetozone. Hydrogen Dioxid.* Alphozone. Oxalic Acid. There is only one indirect oxidizing agent used and that is: Chlorin. SODII DioxmuM 89 SODH DIOXmUM (Nonofficial) (Sodium Peroxid; Na202.) Sodimn dioxid occurs as a light yellow, more or less granular powder. It is the sodium salt of hydrogen dioxid containing at least 90 per cent. Na202, equivalent to 18.4 per cent, available oxygen. It is chemically soluble in water, and insoluble in absolute alcohol and chloroform. It readily absorbs moisture from the air, thus deteriorating, and is best kept in tightly covered tin cans. The drug is never given internally. Action.— To speak of the physiologic action of sodium dioxid would be incorrect, for it is such a violent caustic when applied to live tissue that its action cannot be confined within physiologic Kmits. It is, therefore, rarely used in medicine. As a direct oxidizing agent for bleaching teeth, where its action can be confined to the tooth- structure, it has no equal; especially is this true when the sodium dioxid is decomposed by water, which Hberating nascent oxygen forms sodium hydroxid as a by-product. The nascent oxygen attacks the pigment which has stained the tooth, and the sodium hydroxid at- tacks any fatty substances which may be present, forming therewith a soluble soap. This double action of sodium dioxid, when decom- posed by water, gives to the agent its great advantage as a bleaching agent. The drug may be decomposed by acids with the Hberation of nascent oxygen, but by this means the valuable by-product (sodium hydroxid) is destroyed. Used in this way, then, sodium dioxid has no advantage over any other agent which liberates an equal volume of oxygen. It is a fact long recognized by those engaged in the bleach- ing of hair, feathers, wool, broom-corn, ivory, bone, etc., that the bleaching process is favored when carried on in an alkaline medium. This is likewise true in bleaching teeth. Therapeutics. — In dental practice, where the violent caustic properties of sodium dioxid can be confined to the tooth-structure, this agent has a rather wide range of usefulness. Both the powder and a solution made by carefully adding the powder to cold water are used. There are two important reactions which take place when sodium dioxid is added to water, and it is well to explain these here. If the powder is added to water in small quantities, care being taken to keep down the temperature with ice or cold water, a reaction takes place which results in a solution containing hydrogen dioxid and sodium hydroxid. This solution freshly prepared may be used for bleaching teeth. The hydrogen dioxid will liberate oxygen which does the 90 BLEACHERS bleaching and the sodium hydroxid creates an alkaline medium which favors the bleaching process ; it also acts to advantage upon any fats which may be present. The great difficulty here is in obtaining the solution fresh, as the sodium hydroxid gradually decomposes the hy- drogen dioxid into water and oxygen, the latter gas being lost. If sodium dioxid is added to water without any precaution as to lower- ing the temperature, a somewhat different reaction takes place. Here the drug is at once decomposed into oxygen and sodium hydroxid. For all dental purposes this is the best way to use the drug, viz. : Place the powder in the cavity or canal of the tooth and decompose it into oxygen and sodium hydroxid by adding distilled water. In this way it may be used for bleaching teeth, disorganizing remnants of pulp tissue, and enlarging tortuous root-canals. For the latter purposes the use of the drug should alternate with a 30 per cent, solution of sul- phuric acid. Though not employed to any extent in medicine, the drug has been used in acne, applied in the form of a paste prepared with liquid paraffin, or as a soap to remove comedones. It has been suggested as an air purifier; this suggestion being based on the theory that the moisture of the air would decompose the chemical gradually,' thus Hberating oxygen and forming the alkali, sodium hydroxid, which absorbs carbon dioxid. The theory is correct, but it is doubt- ful if the drug could be used to any practical advantage, except, per- haps, on a Hmited scale. Incompatibles. — Sodium dioxid will produce a pyrotechnic display with many of the volatile oils, ether and phenol. It is decom- posed by water and acids. HYDROGEN DIOXID The direct oxidizing agent has been fully discussed under the heading of Disinfectants. 'The official 3 per cent, solution is some- times concentrated or used with other drugs for bleaching purposes. As a bleacher this solution has largely been superseded by the com- mercial preparation called "caustic pyrozone," which is a 25 per cent, ethereal solution of pure hydrogen dioxid. Like all direct oxidizers, its value depends upon the nascent oxygen which it Hberates. For bleaching teeth better results are produced when the tooth-structure has been previously moistened with a weak alkaline solution, such as lime-water. ACETOZONE (Nonofficial) (Benzoylacetyl Dioxid; CeHgCOO.O.COCHs. = CgHsO*.) Acetozone, or benzoylacetyl dioxid, is made by the oxidation of a mixture of benzaldehyd and acetic anhydrid. It occurs as a ALPHOZONE 91 white, shining crystalline powder. Slightly soluble in water, alcohol, and fairly so in ether and chloroform. In oils it is soluble to the ex- tent of about 3 per cent. All solvents slowly decompose the drug with the exception of neutral petroleum oils. Not used internally in dentistry. Action and Uses. — Acetozone belongs to a class of compounds known as the organic dioxids or peroxids in which an excess of oxygen has been combined in such a way that it is slowly given off in the nascent state. In the presence of water it hydrolyzes, forming ben- zoperacid and aceto-peracid which exert marked oxidizing and disin- fectant action. Acetozone is used in dentistry as a bleaching agent. Hoff recommends placing the powder in the cavity of the tooth to he bleached, moisten with water to bring about the hydrolysis, and her- metically seal. It is claimed to be useful as an antiseptic in ophthal- mic, aural and nasal practice, and to give good results by acting as an intestinal antiseptic when given internally, especially in typhoid fever. ALPHOZONE (Nonofficial) (Succinic Dioxid (COOH.CH2.CH2.CO)202 = CgHioOg.) Alphozone, or succinic dioxid, is an organic dioxid, or peroxid, resulting from the condensation of hydrogen dioxid with succinic anhydrid. It occurs as a fluffy, white, crystalline powder. Soluble in 30 parts of water at ordinary temperature; moderately soluble in alcohol, sparingly so in ether, and insoluble in chloroform. It should be kept in a dark place and in tightly stoppered bottles. Not used internally in dentistry. Action and Uses. — Alphozone is a powerful oxidizer, and thus becomes an antiseptic, disinfectant, and deodorant. It possesses marked bleaching properties. It is claimed to possess an advantage over hydrogen dioxid as a therapeutic agent in that it does not effervesce with pus nor in contact with Hving tissues. Alphozone may be used for bleaching teeth in the same manner as acetozone. Water does not decompose the drug. It may also be employed for disinfecting the hands and such instruments as are not attacked by oxidizing agents. The drug can be obtained in the powder form or in tablets containing i gr. (0.065 Gm.) each, which is used for making solutions for external use. One tablet to 2 fl. oz. (60.0 mils) makes a suitable disinfectant solution for general use. 92 BLEACHERS ACIDUM OXALICUM (Nonofficial) (OxaUc Acid; H2C2O4 + H2O.) Oxalic acid occurs in the form of transparent, prismatic crystals, is odorless, and of a very acid taste. It is readily soluble in water and alcohol. Not used internally in dentistry. Action and Uses. — OxaHc acid is a direct oxidizer. As a bleach- ing agent for teeth its power is limited. Kelley and others have recommended it as a disinfectant for the hands. CHLORUM (Nonofficial) (Chlorin; CI.) Chlorin is a heavy, yellowish-green gas, of a very suffocating odor and a caustic taste. It may be prepared by acting upon chlorinated lime with an acid. The gas is soluble in water. Action and Uses. — Chlorin is a powerful irritant. When inhaled it causes inflammation, and, at times, edema of the lungs. It has such a great afi&nity for hydrogen that it will abstract this element from a molecule of water, liberating the oxygen in the nascent state.' Because of this fact it is an indirect oxidizing agent, and its bleach- ing ability as well as its disinfectant power depends upon this property. About the only use made of chlorin in dental practice is as a bleaching agent. It bleaches indirectly. For bleaching teeth^ compounds and preparations of chlorin, from which the gas is liberated, are used. CALX CHLORINATA— U.S.P. (Chlorinated Lime; CaOCl + CaCl2.) Chlorinated lime is a mixture of calcium hypochlorite and calcium chlorid. It is prepared by acting upon slaked Ume with chlorin gas, and should contain not less than 30 per cent, of available chlorin. It occurs as a grayish-white powder, having a strong odor of chlorin and a disagreeable saHne taste. It is partially soluble in water and alcohol. Action and Uses. — As the mixture constantly Uberates chlorin gas, it is a disinfectant and bleacher. It is used in dentistry as a means of obtaining chlorin for bleaching teeth. LIQUOR ^ODM CHLORINATE— U.S.P. (Solution of Chlorinated Soda; Labarraque's Solution.) This is a solution of several chlorin compounds of sodium con- taining not less than 2.5 per cent, by weight of available chlorin. ACIDUM SULPHUROSUM 93 Action and Uses. — Solution of chlorinated soda is a disinfectant, deodorant and bleacher. Like chlorinated lime, it is used in dentistry as a means of obtaining chlorin for bleaching teeth. The solution should be freshly prepared. REDUCING AGENTS These are agents which have the power of abstracting oxygen from a compound containing it. The process is called reduction or deoxidation. There is only one reducing agent used for bleaching teeth. That is sulphurous acid. ACmUM SULPHUROSUM (Nonofficial) (Sulphurous Acid; H2SO3.) Sulphurous acid is generally used in the form of a 6 per cent. aqueous solution of sulphur dioxid. This was the official solution of the U.S.P. VIII. Action and Uses. — Sulphur dioxid is a gas which chemically dissolves in water and forms sulphurous acid. This acid has a great affinity for oxygen, and absorbs the latter gas from the air or abstracts it from compounds containing it, thus reducing the compound and forming sulphuric acid. For bleaching teeth it is best to use a mixture of such compounds as, when dissolved, will react upon each other and produce sulphur dioxid within the tooth to be bleached. The gas unites with the water present, forming sulphurous acid, which has a tendency to abstract oxygen from the colored pigment which has stained the tooth, and thus the rearrangement of the elements of the colored molecule destroys its color. Kirk suggests using a mixture of 10 parts of sodium sulphite and 7 parts of boric acid. This mixture may be packed into the cavity of the tooth, moistened with water, and hermetically sealed. The tooth should subsequently be washed . with an alkahne solution to neutralize the acid formed. ESCHAROTICS OR CAUSTICS Escharotics or caustics are agents which destroy the tissue upon which they act. While the action of this class of drugs varies with the drug employed, it may be stated in general that their action is purely chemic or physico-chemic. Many of them have an immediate chemic action upon the tissues, and are sometimes called corrosives. Nearly all escharotics produce an eschar, the character 94 ESCHAROTICS OR CAUSTICS of which depends largely upon the tissue involved. This eschar is ultimately separated from the living tissues by the inflammatory process thus inaugurated. Some of the agents belonging to this class are quite readily absorbed, and may cause systemic poisoning. The compounds of arsenic — especially arsenic trioxid, long used in dentistry for devitalizing the pulps of teeth — are of this character, as they have a specific poisonous action upon the cells. The salts of chromium and osmium may also be mentioned in this connec- tion. The strong mineral acids abstract water from the tissues and precipitate the proteids; the alkaline hydrates, on the other hand, not only abstract water but dissolve the proteids and form with them soluble compounds. The chief escharotics are: Mineral Acids: Arsenic Trioxid. Sulphuric Acid. Chromium Trioxid. Nitric Acid. Osmic Acid. Hydrochloric Acid. Potassium Hydroxid. Phenol.* Sodium Hydroxid. Acetic Acid. Zinc Chlorid.* Trichloracetic Acid. Mercuric Chlorid.* Monochloracetic Acid. Silver Nitrate.* Lactic Acid. Actual Cautery. Several of the above escharotics have been considered elsewhere. Those which have not will here be discussed in detail. ACmUM SULPHURICUM— U.S.P. (Sulphuric Acid; Oil of Vitriol; H2SO4.) Sulphuric acid is a colorless, heavy, oily liquid, without odor, and of an extremely sour taste and acid reaction. It is miscible with water and alcohol in all proportions with the evolution of heat. A precaution to be remembered is that, in diluting, the acid should be added to the water or other diluent, and not the reverse. The acid is not used internally in dentistry. The official preparations are: Acidum Sulphuricum Dilutum, U.S. P. (Contains 10 per cent, of absolute Sulphuric Acid.) Acidum Sulphuricum Aromaticum, U.S. P. (Contains about 10 per cent, of Sulphuric Acid in Alcohol with the addi- tion of such aromatics as Ginger and Cinnamon.) Phenolsulphonic acid (HC6H3(HS03)20) is prepared from phenol and chemically pure sulphuric acid. It occurs as a faint reddish- colored, heavy, syrupy liquid, of a rather phenol-like odor and a char- acteristic acid taste and reaction. It unites with some metals to form ACIDUM SULPHURICUM 95 salts, notably zinc. It is rather difficult to combine phenol and sul- phuric acid so that the resultant mixture may be diluted with water without separation of the original constituents. Inasmuch as the concentrated phenolsulphonic acid is rarely used in dentistry, direc- tions here follow for preparing it so that any dilution may be made: Ninety- seven parts by weight of pure concentrated sulphuric add are gradually added to 93 parts by weight of pure phenol and the mixture kept at a temperature of about ioo°C. for about twenty hours, until only a small percentage of sulphuric acid remains uncom- bined. When the reaction is thus complete, sufficient distilled water is added to make the finished product assay about 80 per cent, phenol- sulphonic acid. This Hquid is miscible with water in all proportions; and whenever phenolsulphonic acid is mentioned in these pages this product is meant. It should not be confused with the preparation suggested by Cook, of Chicago, which is a heavy, oily, dark brown liquid made by mixing crude sulphuric acid and crude phenol, and which can only be used in full strength, as water causes a separation of the constituents. Physiologic Action. — When applied to the skin, accidentally or otherwise, sulphuric acid in concentrated form causes an intense, burning pain, and results in a rapid destruction of tissue. The eschar is at first white, gradually becoming brown. The corrosive effect upon mucous membranes is stiU more marked than upon the skin. The acid rapidly extracts water from the tissue, the alkalies are neu- trahzed, and the proteids precipitated; this results in the complete destruction of the tissue (dissolution) . When taken internally large doses cause burning in the throat and esophagus, violent pain in the abdomen, constant vomiting of dark matter, mixed with blood and mucus, difficult breathing, and ultimate collapse. Therapeutics. — Sulphuric acid is used in dentistry more than any of the other mineral acids. Because of its violent action upon soft tissue, it is seldom used as an escharotic except at times on pulp tissue where its action can be controlled. By many it is used in 30 per cent, solution to neutralize the contents of gangrenous root-canals, and for enlarging fine and tortuous canals. This is known as the Callahan method. It may also be employed to destroy a remnant oj a ptdp in the apical end of a root, and for dislodging pulp nodules in the pulp-chambers and root-canals of teeth. A 10 per cent, solution may be cautiously used for steriHzing the dentin and opening the tubules previous to removing a pulp by pressure anesthesia or bleaching the tooth-structure. Care must always be exercised in the use of sulphuric acid, even in weak solutions, not to get the agent on 96 ESCHAROTICS OR CAUSTICS the enamel of the crown of the tooth or soft tissues of the mouth. ' It should be remembered here that a weak solution of an alkaline salt, such as sodium bicarbonate, will at once neutraHze the action of all mineral acids, and such a solution should be ready to use when these agents are employed. Perhaps the most useful combination of sul- phuric acid in dental practice is phenolsul phonic acid. This agent may be used in nearly every instance where sulphuric acid is indi- cated and often to advantage. The author especially recommends its use following the initial dressing of formocresol in cases of gangren- ous pulps and dental granulomas. In caries or necrosis of bone, in chronic • alveolar abscess, and pyorrhea alveolaris, where the "acid treatment" is indicated, phenolsulphonic acid, properly employed, will give beneficial results. Incompatibles. — Sulphuric acid is incompatible with alkalies, alkahne carbonates, iodids, and certain salts of lead. It is explosive with oil of turpentine and sugar, and carbonizes syrups because of the sugar therein contained. ACEDUM NITRICUM— U.S.P. (Nitric Acid; Aqua Fortis; HNO3.) Nitric acid is a strongly corrosive, fuming, caustic liquid, com- posed of 68 per cent, absolute nitric acid and 32 per cent, of water with which Hquid it is miscible in all proportions. It reacts explo- sively with alcohol and glycerin, and is not used internally in den- tistry. The official preparations are: Acidum Nitrohydrochloricum, U.S. P. (Aqua Regia; Nitric Acid 18 vols.; Hydrochloric Acid 82 vols.). Acidum Nitrohydrochloricum Dilutum, U.S. P. (Nitric Acid, lo.o mils; Hydrochloric Acid, 45.5 mils; Distilled Water, 194.5 mils). Physiologic Action and Therapeutics.— Nitric acid, though a powerful escharotic, is not as penetrating or painful as sulphuric acid. It produces a characteristic yellow stain on the skin and mucous membrane. In large doses it causes practically the same train of symptoms as sulphuric acid, except that the discoloration is yellow instead of white and then brown. The acid is not used to any extent in dental practice. It may be applied to warts and other fungous growths, and has proved to be a reliable agent in phagedenic ulcers, chancroids and chancres. Incompatibles. — This acid is incompatible with alkalies, alkaline carbonates, oxids, lead acetate, and iron sulphate. It explodes with such agents as alcohol, glycerin, phenol, and volatile oils. ACmUM HYDROCHLOE.ICUM — ^ACIDXJM ACETICUM 97 ACmUM HYDROCHLORICUM— U.S.P. (Hydrochloric Acid; Muriatic Acid; HCl.) Hydrochloric acid is a fuming, corrosive liquid, consisting of about 32 per cent, of absolute hydrochloric acid. It is miscible with water and alcohol in all proportions. It is not used internally in dentistry. The ofi&cial preparation is: Acidum Hydrochloricum Dilutum, U.S. P. (10 per cent, by weight.) Physiologic Action and Therapeutics. — The action of hydro- chloric acid closely resembles that of the other mineral acids. As a therapeutic agent the strong acid is not used to any extent in dentis- try. It is chiefly used to prepare the diluted and other acids. Di- lute hydrochloric acid has been used by Andrew and Morris for the removal of sequestra, and necrosed bone in osteitis and caries. It is inferior to phenolsulphonic acid for these purposes. Incompatibles.' — The acid is incompatible with alkalies, car- bonates, and silver nitrate. Treatment of Poisoning by Mineral Acids. — The treatment of poisoning by the mineral acids to be effective should be prompt. The cautious administration of alkalies is indicated to chemically neutralize the acid. Lime-water, magnesia, and soap are best. Carbonates must be used with care, if at all, on account of the lia- bihty to rupture the stomach from the evolution of carbon dioxid (a gas). Stevens cautions against the use of the stomach-pump on account of the risk of piercing the softened esophagus. After the acid is neutralized with the alkaline solutions, demulcent drinks, such as albumin- water, milk and raw eggs, should be given to soothe the parts. To control the pain, opium, or its alkaloids, are indi- cated, and whisky or brandy should be injected subcutaneously in case of collapse. ACIDUM ACETICUM— U.S.P. (Acetic Acid; HC2H3O2.) Acetic acid is a liquid composed of 36 per cent, by weight of absolute acetic acid and 64 per cent, of water. It occurs as a clear, colorless Hquid, having a strong, vinegar-like odor, and a purely acid taste. Miscible with water and alcohol in all propor- tions. The average dose of the diluted acid is 30 min. (2.0 mils). 98 ESCHAROTICS OH CAUSTICS The ofificial preparations are : Acidum Aceticum Dilutum, U.S. P. (6 per cent, by weight of absolute Acetic Acid). Acidum Aceticum Glaciale, U.S. P. (Glacial Acetic Acid; 99 per cent, absolute Acid). Physiologic Action. — The concentrated acetic acid when appKed locally produces redness, vesication, and ultimately slight sloughing. Internally it causes severe gastritis. Therapeutics. — Acetic acid is applied externally to indolent ulcers of the mouth and canker sores. A weak solution may be used as a gargle in cases of pharyngitis or sore throat. Glacial acetic acid may be applied to fungous growths in the mouth. It is also used to remove warts and corns. The dilute acid or vinegar is especially indicated as an antidote in cases of poisoning by alkalies. The quantity to be given must be governed largely by the probable amount of alkali to be neutralized. In bleaching teeth with sodium dioxid, or in using the caustic alkalies about the teeth, a weak solu- tion of acetic acid should be at hand to neutralize any alkali which may get on the soft tissues of the mouth. ACmUM TRICHLORACETICUM— U.S.P. (Trichloracetic Acid; HC2CI3O2.) Trichloracetic acid occurs as white, deliquescent crystals, freely soluble in water, alcohol, and ether. It is made by acting on glacial acetic acid with chlorin or on hydrated chloral with fuming nitric acid. Physiologic Action and Therapeutics. — Trichloracetic acid acts as an escharotic, astringent, and hemostatic. A solution of 5 to 10 per cent, may be applied to indolent ulcers, mucous patches, etc. A 10 to 20 per cent, solution is an excellent stimulating agent to be forced through a sinus in chronic alveolar abscess and into a stubborn pyorrheal pocket. It may also be employed in this strength solution as a hemostatic in case of profuse hemorrhage after the removal of a pulp by pressure anesthesia. The pure drug or a concentrated solution has been employed to some extent for the removal of small growths about the mouth, such as hy pertro phied gum or pulp tissue. The agent is also used for the removal of warts and corns. Monochloracetic Acid. — (HC2H2CIO2). — This agent occurs as a white crystalline substance, soluble in water and alcohol. As shown by the formula, only one of the hydrogen atoms in glacial ACiDi:::^! lacticum — ^arseni xRioxrouM 99 acetic acid is displaced by chlorin. Harlan recommended the use of this agent in the treatment of gangrenous canals of teeth. The remedy never gained any favor, as its action is uncertain. ACmUM LACTICUM— U.S.P. (Lactic Acid; HC3H5O3.) Lactic acid is an organic acid usually obtained by the fermenta- tion of grape-sugar or milk-sugar. The ofi&cial preparation is com- posed of not less than 85 per cent, nor more than 90 per cent, abso- lute lactic acid. It occurs as a colorless, or slightly yellow, syrupy liquid, nearly odorless, having an acid taste, and absorbing moisture on exposure to air. Besides being miscible with water, it will mix with alcohol and ether in all proportions. The average dose is 30 min. (2.0 mils). Physiologic Action and Therapeutics. — ^Lactic acid acts as a mild caustic on mucous surfaces. It is also a stimulant and re- frigerant. Younger advocates the use of the official acid as a stimu- lating agent in pyorrhea alveolaris. After the roots are scaled, the acid is warmed and injected into the pockets. Stevens recom- mends a 20 to 50 per cent, solution to be applied to tuberculous and lupous ulcerations oj mucous membranes. ARSENI TRIOXIDUM— U.S.P. (Arsenic Trioxid; Airsenous Acid; White Arsenic; AS2O3.) Arsenic trioxid occurs either as an opaque, white powder, or in irregular, heavy masses of two varieties: one, amorphous, trans- parent, and colorless, like glass; the other, crystalline, opaque, and white, resembling porcelain. Contact with moist air gradually changes the glassy into the white, opaque variety; and frequently the same piece has an opaque, white outer crust enclosing the glassy variety. Both are odorless and tasteless. The drug is soluble in water, the amorphous or glassy variety being somewhat more soluble than the crystalHne variety. It is sparingly soluble in alcohol and ether, but freely soluble in glycerin, hydrochloric acid and alkahne solutions. In the presence of water it reacts and forms arsenous acid (HaAsOs). The average dose is y^o gr. (0.002 Gm.). Physiologic Action. — Internally administered in the proper form and dose arsenic acts as an alterative and tonic, improving the appetite and increasing the secretions. It modifies the blood, and in this manner removes morbid conditions. For this reason it is frequently used in the treatment of syphilis, phthisis, and certain nervous diseases. Salvarsan and neosalvarsan, newer remedies for lOO ESCHAROTICS OR CAUSTICS syphilis, and which will be discussed later, are compounds of arsenic. The drug has been used by some people as a beautifier of the com- plexion to whiten the skin. Care must be exercised in gi\ang arsenic internally OT\'ing to its cumulative effect which may develop poisonous symptoms. It is the local action in which dentists are most interested. AppHed to denuded surfaces, such as an exposed pulp, unless its action is controlled, arsenic trioxid is a powerful and painful escharotic. It is readily absorbed by the tissue, and exerts a specific poisonous action upon the cells. It is a peculiar escharotic, and stands in a class by itself. Long^ states that "the dry powder may be placed on the tongue and allowed to remain for one minute ■R-ithout causing the slightest irritation and, if then thoroughly- removed, without producing any efl'ect upon the tissues. On the contrary, if it is allowed to remain until it becomes dissolved and penetrates the tissues, extensive sloughing will result. It acts only after being absorbed by the tissue elements, altering or destroying their lital processes in an obscure manner. Because of this action it is difficult, if not impossible, to limit or antagonize its influence upon the tissue which it has penetrated; and its penetration is not limited by any action of its own, as it does not coagulate albumin. The fact of its being tasteless and nonirritating at first renders its use about the mouth the more dangerous, for by careless handling it may become lodged about the teeth or beneath the edge of the gum, and its presence be not appreciated for hours, until devitalization of the tissue has begun." Under certain conditions, which are not well understood, the pulp tissue, though exposed, will absolutely resist the action of arsenic trioxid. When this occurs the tissue will generally be found to be equally resistant to other drugs. It is claimed that many of the peasants of Austria have acquired a toleration for the drug, and can take large doses wdthout any untoward effects. Poisoning and Tretament. — Arsenical poisoning may well be considered in two forms — local and systemic. Local arsenical poison- ing occurs most frequently by the escape of arsenical preparations from the cavity during the de\dtalization of pulp tissue. There is seldom any pain connected with the devitalization of the gum tissue, and herein lies the great danger of extensive necrosis of the soft and frequently the bony structures. The prominent S5niiptom is a white gum, absolutely lifeless; there may be pain, most frequently this symptom is absent; the tooth becomes sore to percussion. In the ^ Dental Materia Medica, Therapeutics and Prescription Writing. ARSENI TRIOXrOUM lOI more severe cases the destruction of soft tissue, if unnoticed, goes on until the alveolar process between the affected teeth becomes involved and is destroyed. Sometimes the affected tooth is lost, together with one or two teeth on either side. In the treatment of local arsenical poisoning where the drug has remained only long enough to cause devitalization of the gum tissue, all that is necessary is to first wash the part with an antiseptic solution and then mechanically pick off the dead or sloughed tissue with ster- ile pliers until hemorrhage ensues, if this is possible; after which stimulating disinfectants should be employed. Here is a good place to use the official solution of hydrogen dioxid. The cavity is open and there is no danger of spreading a possible infection. After re- moving the dead tissue and disinfecting, the author suggests drying the part and covering it with the oleaginous euroform paste. The patient should be instructed to keep the mouth clean by the use of an antiseptic wash, and the local treatment repeated every day until granulations begin to form ; usually one or two treatments will suffice. In those severe cases where the agent has penetrated to and devi- talized the alveolar process, as well as the overlying soft tissue, the first treatment is surgical. After washing with an antiseptic solution, the affected part should be thoroughly curetted with a bone curet or a suitable bur in the engine. It may be necessary in extensive cases to extract the affected tooth, after which the treatment is practically the same as has been outlined above, except where there has been much removal of tissue in operating it is best to pack the part at first with plain gauze thoroughly saturated with the euro- form paste. The case should be watched closely, and the stimulat- ing treatment kept up until the part has healed. The tissue in the interproximal space will never be fully reproduced, and will always be the source of more or less annoyance. Acute systemic arsenical poisoning is manifested by severe ab- dominal pains, vomiting and purging of "rice-water," persistent thirst, muscular cramps, .cyanosis, and collapse. Death usually occurs in from one to three days, and is often preceded by delirium, convulsions, and coma. If recovery follows, the acute symptoms may be gradually replaced by those of chronic arsenical poisoning. This condition may also follow the prolonged use of the drug as a medicine, may result from the use of foods or Hquors contaminated with arsenic (beer, etc.), may occur from constant inhalation of dust arising from wall-paper or other fabrics colored with arsenical pig- ments, or may be acquired by workmen in arsenic mines, or in fac- tories in which fumes of the metal are formed. This form of poison- I02 ESCHAROTICS OR CAUSTICS ing may be manifested by gastroenteritis, conjunctivitis, and catarrh of the upper air-passages, anemia, peripheral neuritis, and various cutaneous lesions. In the treatment of acute systemic arsenical poisoning, emetics should be promptly given or the stomach emptied by means of the stomach-pump. The best chemic antidote is freshly prepared ferric hydroxid or ferric hydroxid with magnesia, administered while moist in doses of a tablespoonful or more every ten or fifteen minutes. These compounds themselves are harmless and act by forming insol- uble arsenites. Dialysed iron liberates in the stomach a certain amount of free ferric hydroxid and may also be given. This agent has also been recommended in local arsenical poisoning, but its use here is of no benefit, and is wrong (see p. 329). Demulcents and opiates are usually indicated. Therapeutics. — Arsenic trioxid is used only in dental practice for the purpose of devitalizing the pulp tissue. The agent was introduced to the dental profession by Spooner, of Montreal, in about 1836. He first advocated its use for the treatment of sensitive dentin, for he discovered that by sealing the drug in a cavity for a few days, the most sensitive dentin yielded to its influence. The fact, however, that nearly all teeth thus treated subsequently gave trouble because of the death of the pulp and the usual sequelae, led the profession to abandon this agent for the purpose for which it was introduced ; but it has ever since been used as a means of destroying the vitality of the pulp. In fact, until the last few years, it was the only agent employed with any satisfaction. The detail method of using arsenic trioxid as a devitalizing agent will be discussed later. It is well to remember here, however, that when the drug is applied to the pulp of a fully developed tooth, its action and effect are confined to the pulp tissue only, as the organ dies by strangulation at its apex due to the inflammatory reaction from the drug when thus used. Here thrombosis and death of the pulp take place and absorption of the drug by continuity is not hkely to occur. This is not true in teeth the roots of which are not fully developed, as in young patients; therefore, arsenic trioxid should be used very cautiously in such cases, if at all. This does not mean that the drug may be used indis- criminately in any case. There is no excuse for careless technic in the local use of the agent. CHROMn TRIOXIDUM— U.S.P. (Chromium Trioxid; Chromic Acid; CrOs.) Chromium trioxid, called also chromic acid, occurs in small, crimson crystals or rhombic prisms of metallic luster. The drug is OSMII TETROXIDUM IO3 without odor, very deliquescent, and thus freely soluble in water. It should be "kept in glass-stoppered bottles, and great caution should be observed to avoid an explosion when brought in contact with organic substances, such as cork, tannic acid, sugar, alcohol, glycerin, ether, and collodion. It is very destructive to animal and vegetable tissues. Physiologic Action and Therapeutics. — Chromic acid is an active escharotic, due to its powerful oxidizing influence. Internally ad- ministered, it causes intense pain in the abdomen, vomiting and purging; often there is blood in the vomit and stools, ultimately col- lapse, which frequently ends in death. Alkahes neutralize the com- pound, but the salts thus formed are poisonous and the stomach should be emptied after the administration of the antidote. Chro- mium trioxid has been employed for the purpose of devitalizing the pulp tissue in children's teeth. Though the agent may be considered safer than arsenic trioxid, because it is less penetrating, its action is uncertain and unreHable. Stevens recommends a solution of from 20-30 gr. (1.3-2.0 Gm.) to the ounce (30.0 mils) as a stimulating ap- plication in mucous patches. The fused crystals on a suitable probe may be used with excellent results in the removal of hypertrophied gum or pulp tissue, and in closing small salivary fistulcB. Incompatibles. — With organic substances, such as cork, tannic acid, alcohol, glycerin, etc., chromic trioxid easily explodes. Potassium Dichromate (K2Cr207). — This salt, sometimes called potassium bichromate, may be employed in weak solutions (5 per cent.) in indolent ulcers, mucous patches and sloughing wounds. OSMH TETROXIDUM (Nonofficial) (Osmium Tetroxid; Osmic Acid; OsOi.) Osmium tetroxid, called also osmic acid, occurs in yeUow, crys- talline needles, possessing a pungent odor and burning taste. It is slowly soluble in water (i : 50) ; also soluble in alcohol and ether, but the solutions decompose. Physiologic Action and Therapeutics. — This is a very irritant and caustic agent. When injected into the tissues, even in weak solutions, the blood and tissues turn black, but healing of the wound generally proceeds without interruption. Intraneural injections are used to produce degeneration of nerves for the relief of persistent neuralgias. Murphy, Bennett, and others claim excellent results. The affected nerve is exposed by a small incision, and a 1.5 per cent, solution, freshly prepared, is injected into its substance at different I04 ESCHAROTICS OR CAUSTICS points, to the amount of from 5-10 min. (0.3-0.6 mil). If successful, the effects may persist for several months, when it may become neces- sary to repeat the injection as the cure is rarely, if ever, permanent. Murphy especially mentions the inherent tendency of nerve tissue to regenerate. POTASSn ET SODH (Nonofficial) (Kalium and Natrium; Potassium and Sodium; K and Na.) Potassiixm and sodium are known in chemistry as alkali-metals; they vigorously decompose water at ordinary temperatures, forming the hydroxid (hydrate) of the metal, with Hberation of hydrogen. The metals occur in soft cyHnders, having a silver- white color; and on account of their tendency to combine with oxygen they must be kept under a hydrocarbon liquid, such as coal-oil, benzene, etc. Action and Therapeutics. — Because of their violent action on soft tissue they are not used as such in medicine. Schreier, of Vienna, introduced a mixture of these metals as a remedy for treat- ing gangrenous root-canals. When the mixture is placed in a canal containing dead pulp tissue a violent reaction takes place, water is decomposed, with the evolution of considerable heat, and the hy- droxids of the metals are formed. The potassium and sodium hydroxids unite with the fatty products present to form soluble soap, which may be removed by washing. Thus it will be seen that the contents of the canal are chemically destroyed and physically removed, leaving the canal white and clean. Rhein recommends a further sterilization of the canal with a i : 500 solution of mercury bichlorid in a 3 per cent, solution of hydrogen dioxid. The use of metallic potassium and sodium will be discussed in detail in that part of this book devoted to Practical Therapeutics. POTASSn HYDROXmUM— U.S.P. (Potassium Hydroxid; Caustic Potash; KOH.) Potassiiun hydroxid, more commonly called caustic potash, occurs in hard, white, translucent pencils or fused masses, odorless, and having an acrid and caustic taste. It is freely soluble in water and in alcohol. The ofi&cial preparation is: Liquor Potassii Hydroxidi, U.S. P. (5 per cent.). SODn HYDROXIDUM— U.S.P. (Sodium Hydroxid; Caustic Soda; NaOH.) Sodium hydroxid, or caustic soda, occurs in hard, white, trans- lucent pencils or fused masses, odorless, and having an acrid and soDii HYDROxromi 105 caustic taste. It is freely soluble in water and in alcohol. The official preparation is : Liquor Sodii Hydroxidi, U.S. P. (5 per cent.). Physiologic Action and Therapeutics. — The action of caustic potash and caustic soda is similar. They may be classed among the strongest and most penetrating escharotics known. They should he handled about the mouth and other soft tissues with the greatest caution. Their action is both rapid and painful. When applied to soft tissue they produce a slough which separates in a few days leaving a granulating ulcer. The escharotic effect is caused by the abstraction of water from the tissues; this softens the latter, and the hydroxyl radical forms with the proteids a soluble alkaline albuminate. When either are taken internally in large doses they produce all the symptoms of corrosive poisoning — burn- ing in the throat and esophagus, intense pain in the abdomen, vom- iting and purging of mucus and bloody matter, dysphagia, and ultimate collapse. Small doses freely diluted have the same action as the alkaline carbonates — that of an antacid. Caustic potash and caustic soda are sometimes employed in dental practice to destroy exuberant granulations. They are also used in about 10 per cent, solutions to cauterize and destroy a remnant of a pulp and to disorganize and aid in the removal of all organic material from the canals of pulpless teeth. This is recog- nized to-day as absolutely essential in the treatment of these teeth. Whenever these alkahes are employed in the canals of teeth, care must be taken not to force them through the root-end, and their caustic action should be neutralized with weak acids. Treatment of Poisoning. — The treatment of poisoning with the caustic alkalies to be effective must be prompt. Dilute acetic acid or vinegar will neutralize the alkali and should be given at once. Demulcent drinks are indicated to soothe the corroded parts, and opium to control the pain. Hydrofluoric Acid (HF). — This is a colorless gas, freely soluble in water. It may be obtained commercially in solution, and because of its power to etch glass, it must be kept in rubber or gutta-percha bottles. On account of its extremely irritating and penetra ng property, it is not employed as a therapeutic agent, but is u ed extensively in dentistry for etching porcelain inlays. It must be handled with the greatest care, for if it is accidentally applied to the soft tissue and not instantly neutralized it will penetrate deeply I06 IRRITANTS AND COUNTERIRRITANTS and produce an ugly ulcer. Many cases of sevef^ local poisoning by the agent have been reported, and it is largely for this reason that it has been included in this work on therapeutics. The treatment of local poisoning consists in neutraHzing the drug chemically by the use of alkalies. A weak solution (5 per cent.) of ammonia water serves the purpose nicely, and the sooner the application is made after the discovery of the burn, the less destruction of tissue there will be. To apply the antidote, the part can be wrapped in plain sterile gauze and this saturated with the remedy. The ammonia will irritate the part and probably cause pain, but the acid must be neutralized, even at the expense of caus- ing pain. After we are reasonably certain that the acid is neutral- ized, the burn should be antiseptically treated in the usual way. The euroform paste is an excellent remedy to employ. Ionization. — This is the process of dissociating the ions or radicals of a salt or compound by setting them free by means of the electric current (electrolysis). When the process is used in the treatment of disease, it is called ionic medication. Ionization with solutions of zinc chlorid and iodin is frequently used in the -treatment of dental granulomas and infections about the root-ends of pulpless teeth. Whether the benefit comes from the supposed fact that the tissues thus treated are sterilized by virtue of the ions being set free, or from the cauterization by the current used, is a debatable ques- tion. Price is of the latter opinion. Actual Cautery. — The cauterization of tissue by means of heat should be considered briefly under the heading of Escharotics. This is accomplished by means of the hot iron or platinum wire, or the galvano-cautery, and affords a prompt and powerful means of destroying tissue. The process is not as painful as one would natur- ally suppose, and may be used for the purpose of destroying hyper- trophied gum tissue and other growths. The dental switch boards have an attachment by which this means of cauterization . may be easily and practically applied. IRRITANTS AND COUNTERIRRITANTS Irritants have been elsewhere defined as agents which, when appHed to the skin or mucous membrane of the mouth, produce active hyperemia or inflammation. When irritants are applied to a normal part for the purpose of influencing favorably a diseased part, usually deep-seated, they are called counterirritants, and the IRRITANTS AXD COUNTERIREITANTS I07 process counterirritation. It is for this latter purpose that irritants are largely employed in dentistry. The extent to which counter- irritation may be carried depends upon how severely diseased is that part which the irritation of the normal part is intended to influence. The agents used are subdivided into different classes according to the degree of irritation folloT\-ing their appUcation. Those which simply produce active h\'peremia (redness) of the surface are called rubefacients; those which act more severely and cause the formation of a bhster are known as vesicants or epispastics. In many instances the same agent may produce a rubefacient or a vesicant effect, depending upon the strength of the drug and the duration of its apphcation. Counterirritation may be carried to a greater degree of intensity ■when a true escharotic effect (destruction of tissue) is produced. This, however, is seldom necessary in dental practice. In fact, as a rule, it should be guarded against, for the formation of an ulcer in the mouth is Kable to so cripple the cells that a mixed infection may readily follow. Care should be exercised in the application of counterirritants when the inflammation is superficial. To apply an irritant directly to an inflamed part would only tend to aggravate the condition. Here the site of apphcation should be a short distance from the diseased part. In all deep-seated inflammations, or in cases of neuralgia, it is best to make the apphcation directly over the affected part. Long^ states that "the remedial effect of a counterirritant is probably brought about by a threefold action. They influence, first, the circulation by causing a hA^peremia at the point of irrita- tion, the tendency of the blood supply will be in that direction and away from the original disease; second, they turn the attention of the system toward the new point of irritation and away from the disease, partly a mental effect; and, third, they influence the inner- vation of the diseased part by the reflex influence of the irritation. In the sum of their effects they stimulate the movement of fluids within the tissues; hence they are regarded as honphatic stimulants, and are often employed to stimulate the absorption of a serous or inflammatory exudate." Counterirritation may be said to be truly indicated in dental practice in the treatment of pericementitis and trigeminal neuralgia. ^ Dental Materia Medica, Therapeutics and Prescription Writing. Io8 IRRITANTS AND COUNTERIRRITANTS The most important irritants used in dentistry for counter- irritation are: Heat. Cantharides. lodin.* Chloroform. Capsicum. Aconite. Mustard. Camphor. • Oil of Turpentine. , Volatile Oils.* Menthol.* Heat. — This physical agent occupies a prominent place in dentistry as a counterirritant, because of the convenience of the variety of forms and the different degrees in which it can be utilized. Moderate heat applied over a deep-seated inflammation will at once produce active h3q3eremia. The heat may be gradually carried to a higher degree with comfort to the patient until the serum escapes from the engorged blood-vessels, thus promoting resolution. Hot water, the hot-water bag, hot foot-bath, and dry and moist poultices, are all employed in various manners in the treatment of pericemen- titis, acute alveolar abscess, neuralgias, and for the absorption of serous or inflammatory exudates. . CAPSICUM— U.S.P. (Cayenne Pepper.) Capsicum is the dried ripe fruit of Capsicum frutescens, a plant growing in tropical America, in Asia, in Africa, and cultivated in gardens. The active principle is capsicin, which appears in the form of colorless crystals and has an exceedingly pungent odor; other constituents are a volatile alkaloid, fixed and volatile oil, and fatty acids. The average dose is i gr. (0.06 gm.). All of the official preparations may be used in dentistry. They are: Tinctura Capsici, U.S. P. Dose, 8 min. (0.5 mil). Oleoresina Capsici, U.S. P. Dose, }i gr. (0.03 Gm.). Emplastrum Capsici, U.S. P. (externally). Physiologic Action. — Applied to the skin or mucous membrane, capsicum produces a burning sensation and results in a rubefacient or vesicant effect, depending upon the concentration of the drug. Taken internally, in medicinal doses, it creates a sense of warmth in the stomach, stimulates the circulation, and aids the digestive process. In large doses it acts as an irritant poison. Therapeutics. — Capsicum is used chiefly as a rubefacient, stomachic, and carminative. In dentistry advantage is taken of its irritant properties, and it is largely employed as a counterirri- SINAPIS ALBA — SINAPIS NIGRA IO9 tant in pericementitis. The oleoresin is the most irritating prepara- tion. The official plaster may be prepared by spreading the oleo- resin upon resin plaster; this may be cut in convenient form and applied to the dried gum over the affected tooth, resulting in a small blister, but having a beneficial effect upon the deep-seated inflam- mation. When a rubefacient effect only is desired, the powdered drug may be confined in small concave rubber disks and pressed on the gum, suction holding the remedy in place. SINAPIS ALBA— U.S.P. (White Mustard.) SINAPIS NIGRA— U.S.P. (Black Mustard.) White mustard is the seed of Sinapis alba. Black mustard is the seed of Brassica nigra. Both of these herbs are cultivated exten- sively in Europe aiid America. The powdered mustard of com- merce is a ground mixture of white and black seed, often more or less adulterated. Mustard in the dry state is not irritating, but in the presence of water it is extremely irritating, and for this reason : White mustard contains a ferment, myrosin, and a glucosid, sinalhin. In the presence of water the myrosin acts upon the sinalbin and separates from it an irritant volatile oil. Black mustard contains the same ferment, myrosin, and a glucosid, sinigrin, which by the action upon it of the ferment in the presence of water also converts it into an intensely irritant volatile oil. This oil of mustard is official, and to it is due both the pungent' taste and odor of the moistened powder. Average emetic dose, 2}4 dr. (10. o Gm.). The following preparation is official: Oleum Sinapis Volatile, U.S.P. (Volatile Oil of Mustard). Dose, 14. iiiin. (0.008 mil). Physiologic Action. — Mustard made into a paste with water and applied to the skin, or the powder applied to the moist mucous membrane, causes redness, heat, and a burning pain. Any degree of irritation, from a slight rubefacient effect to severe vesication, may be produced. It should be remembered that the presence of moisture is necessary for the irritant action of mustard, the dry powder is not irritating. Hot water should not be used, as the high heat tends to destroy the ferment necessary to evolve the irritating oil from the glucosid. Taken internally in small doses, mustard acts as a carminative. no IRRITANTS AND COUNTERIRRITANTS In large doses it acts as an emetic, producing prompt emesis without depression, owing to the reflex stimulation of the cardiac and respiratory centers. Therapeutics. — Mustard is useful in dentistry as a rubefacient. The paper, which was formerly ofl&cial, cut in proper form, may be applied to the moist gum in nonseptic pericementitis. Concave rubber cups may also be used to hold the powder, and applied by suction. Powdered mustard may be mixed with warm water to bring about the reaction necessary to produce the irritant volatile oil, and this added to the hot water in taking a hot foot-bath for counter- irritant purposes. To add the mustard direct to the hot water would defeat the object for which the drug is used, as the heat checks the action of the ferment. On account of the prompt emetic properties of mustard the drug may be employed in cases of narcotic poisoning, the dose being a tablespoonful stirred up in warm water, and repeated in fifteen minutes, if necessary. The drug is sometimes used in neuralgia and muscular rheumatism. The blisters produced by mustard heal with difficulty; therefore, extensive vesication should be guarded against. TEREBINTHINA (Nonofficial) (Turpentine.) Turpentine is a solid oleoresin, or pitch, obtained from Pinus palustris and other species of Pinus, growing in the Southern United States, especially in North Carolina. The oleoresin exudes from the pine tree when the bark is cut, and when subjected to distilla- tion it yields a volatile oil, which is official, and a solid residue called resin or rosin, also official. OLEUM TEREBINTHINA— U.S.P. (Oil of Turpentine.) Oil of turpentine is a thin, colorless liquid, highly inflammable, and of a characteristic odor and taste. It should be kept in well- stoppered bottles, protected from light. The rectified oil is made by distilling the ordinary oil with lime-water. This is the preparation which is largely used in dentistry and the one always used for internal medication. Average dose is lo min. (0.6 mil) in emulsion. The official preparations are: Oleum Terebinthinae Rectificatum, U.S. P. Emulsum Olei Terebinthinae, U.S. P. (15 per cent.). Liniment Terebinthinae, U.S. P. ('35 per cent, with Resin Cerate). EESINA III Physiologic Action. — When applied to the skin, the drug dilates the cutaneous blood-vessels, producing a sensation of heat and red- ness, and, if continued long, vesication follo'ws. The drug has de- cided antiseptic properties, and even in dilute solutions prevents fermentation and putrefaction. Taken internally in medicinal doses, it produces warmth in the stomach, quickened respiration, and in- creases the rate and tension of the pulse. It also acts as a circula- tory stimulant and diuretic. In large doses it produces all the s}Triptoms of an irritant poison. Some individuals are pecuHarly susceptible to the drug, and an erythematous or papular eruption may result from either its internal or external use. Therapeutics.' — Externally, oil of turpentine may be used as a rubefacient in various inflammatory affections. In an aciite alveolar abscess a turpentine stupe may be employed to advantage. The latter is made by soaking a large piece of flannel in boihng water, wringing it dry, and folding it several times until it is about 6 in. square; from lo to 30 min, (0.6-2.0 mils) of the oil are then distrib- uted over it, and it is quickly apphed to the cheek of the affected side and covered with several layers of fabric. The official liniment makes an excellent remedy to be applied in cases of neuralgia and muscular rheufnatism. RESINA— U.S.P. (Rosin; Colophony.) Rosin is the residue left after distilling the volatile oil from the concrete oleoresin obtained from Pinus palustris, and from other species of Pinus. It generaUy occurs in sharp, angular, transparent, amber-colored fragments, frequently covered T\dth a yellow dust; brittle at the ordinary temperature; odor and taste slightly terebin- thinate. It is freely soluble in alcohol, ether, chloroform, benzene, fixed or volatile oils. There is one official preparation: Emplastrum__Resinae; U.S. P. (Rosin Plaster). Therapeutics. — Rosin is recommended by Callahan to be dis- solved in chloroform, making a thin solution to be used in filling the canals of pulpless teeth with gutta-percha. Callahan's "rosin solu- tion" contains rosin 12 gr. (0.8 Gm.) and chloroform 3 fl. dr. (12.0 mils). 112 IRRITANTS AND COUNTERIRRITANTS TEREBENUM— U.S.P. (Terebene.) This is a liquid hydrocarbon made by oxidizing oil of turpentine with strong sulphuric acid. The average dose is 4 min. (0.25 mil). Terebene has proved to be a very satisfactory remedy in bronchitis with free expectoration. It has also been used in phthisis, and may be inhaled from a spray or from the sponge of a respirator. Harlan recommended its use for gangrenous root-canals; but, like the essen- tial oils, its use here is unreliable. CANTHARIS— U.S.P. (Cantharides; Spanish Flies.) Cantharides, commonly called Spanish fly, is the dried and pow- dered beetle or insect, Cantharis vesicatoria, indigenous to Southern and Central Europe. The active principle is cantharidin, which is also found in a number of beetles. The drug is used only externally in dentistry. The official preparations are: Tinctura Cantharidis, U.S. P. Ceratum Cantharidis, U.S. P. CoUodium Cantharidatum, U.S. P. (60 per cent.). Physiologic Action. — Cantharides is a powerful irritant, though rather slow in its action. When applied to the skin or mucous mem- brane, the drug excites a tingling and burning sensation, producing redness and, later, vesication. Its long-continued application often results in pustulation, ulceration, and sloughing. Butler states that the drug not only causes vascular dilatation of the part to which it is applied, but reflexly dilates the blood-vessels of the deep-seated organs underneath, thus acting as a counter- irritant. The active principle, cantharidin, may be absorbed through the unbroken skin, and is quite readily absorbed through the mucous membrane, thus its constitutional effects may result from the exter- nal use of the drug. The toxic symptoms are great pain in the throat, stomach, and bowels, excessive thirst, irritation of the geni- tourinary tract with a desire to urinate constantly, albuminous and bloody urine, painful erections of the penis in males, and in women abortion may follow the irritant effect of the drug upon the pelvic viscera. While these symptoms are not liable to follow the use of ACONITUM 113 the drug in dental practice where a limited area is selected as the site of application for counterirritant purposes, it is, nevertheless, well to be familiar with them. Treatment of Poisoning. — The stomach should be emptied, and demulcents given freely to relieve the irritation. Opium may be required to relieve the pain, and stimulants administered, if necessary. Oils and fatty substances dissolve the cantharidin, and thus hasten its absorption; they should therefore be avoided as demulcents. Therapeutics. — Cantharides may be used as a counterirritant in cases of severe pericementitis, and as it dilates the arterioles sub- jacently the effect of the drug will ultimately afford relief. Its action is slow but certain. The cerate may be applied as a plaster or the collodion as a varnish. To insure greater activity of the drug, the site of application should be oiled. In facial neuralgia canthar- ides is valuable, the preparation being applied behind the ear. ACONITUM— U.S.P. (Aconite; Wolfsbane; Monkshood.) Aconite is official in the form of the dried tuberous root of Aconi- tum Napellus, a plant growing in Europe, Asia, and in America, mostly in mountainous regions. The root closely resembles horse- radish; the latter, however, has a pungent odor when scraped, while aconite is odorless. The root at first has a sweetish taste, but soon produces a sense of warmth and tinghng, followed by numbness. The active principle is aconitin, also official under the title Aconitina, U.S.P. This is an alkaloid, occurring in colorless or white rhombic prisms or prismatic powder, is without odor, permanent in the air, and when brought in contact with the mucous membrane, even in dilute solutions, produces a characteristic tingUng and more or less anesthesia. The average dose of aconitin is 3-^00 gr- (0.00015 Gm.). The official preparations of aconite are: Tinctura Aconiti, U.S.P. (10 per cent.). Dose, 5 rain. (0.3 mil). Fluidextractum Aconiti, U.S.P. Dose, ^i min. (0.03 mil). Extractum Aconiti, U.S.P. Dose, % gr. (o.oi Gm.). Linimentum Aconiti (nonofl&cial; externally). Physiologic Action. — Aconite is a true circulatory depressant. It may also be considered a nervous sedative. AppHed to the mucous membrane or to the skin for any length of time, it first irritates, caus- 114 IRRITANTS AND COUXTERIRRIT.IXTS ing stimulation, and then depresses the sensory nerve-endings, pro- ducing, respectively, tingling, numbness, and local analgesia. The drug lowers the blood-pressure by directly depressing the heart. In the febrile state, moderate doses of aconite cause a decided fall of temperature. Butler claims this is due to various causes: (i) The slowing of the circulation, diminishing the metabolism; (2) the peripheral action of the drug, causing dilatation of the cutaneous blood-vessels; (3) the depressant action upon all muscle-tissue. Toxicology. — Poisoning by aconite is first manifested by a pecu- liar tinghng sensation of the tongue and lips, which soon extends to the fingers, and may afi'ect the entire surface of the skin. The pulse be- comes slow and weak; later it may become rapid and irregular; the respiration is slow and feeble. There is an extreme muscular weak- ness, especially noticeable in the lower extremities. Treatment of Poisoning. — The patient should be kept in a recumbent position, the feet slightly raised. The stomach should be thoroughly emptied, keeping the patient in this position. Ex- ternal apphcations of heat should be made to raise the tempera- ture, and diffusible stimulants, such as alcohol and aromatic spirit of ammonia, should be given; strychnin, atropin, and digitalis may be h}'podermically administered for their eft'ect upon the cardiac and respiratory centers; and, if necessary, artificial respiration should be employed. Therapeutics. — Though the first eff'ect of aconite, locally applied, is that of an irritant, it has not been discussed here because of this property; but rather for the reason that certain preparations of the drug, notabh' the tincture, have long been used in dental practice as a constituent of counterirritant remedies for the treatment of apical pericementitis and facial neuralgia. Tincture of aconite has been extensively used to dilute the tincture of iodin for dental pur- poses. A favorite Hniment of the author's for nonseptic pericemen- titis is: Menthol, 20 gr. (1.3 Gm.) ; chloroform, i}i A- dr. (6.0 mils) ; tincture of aconite, 6yi A- dr. (26.0 mils). The therapeutics of aconite \d\\ be discussed more fully later. CAMPHORA— U.S.P. (Camphor; CioHieO.) Camphor is a stearoptene obtained from Cinnamomum Camphora, a tree indigenous to Eastern and Southeastern Asia, and cultivated in Italy as an ornamental tree. The drug occurs in white, trans- CAMPHOR 115 lucent masses, of a tough consistence and crystalline structure, readily pulverizable in the presence of a little alcohol, ether, or chloroform. It is sparingly soluble in water, but freely soluble in alcohol, ether, chloroform, fixed and volatile oils. When camphor is triturated in about equal proportions with menthol, thymol, phenol, or chloral hydrate, a syrupy liquid results. The average dose is 2 gr. (0.125 Gm.). The following preparations are official: Aqua Camphorse, U.S. P. Linimentum Belladonnae, U.S. P. (5 per cent.). Linimentum Camphorae, U.S. P. (20 per cent, in Cottonseed Oil). Linimentum .Chloroformi, U.S. P. (30 per cent. Chloroform in Soap Liniment.). Linimentum Saponis, U.S. P. (4.5 per cent.). Spiritus Camphorae, U.S. P. (10 per cent.). Tincturas Opii Camphorata, U.S. P. (Camphorated Tincture of Opium; Paregoric; 0.4 per cent.). Dose, 2 fl. dr. (8.0 mUs). Physiologic Action. — Upon the unbroken skin, camphor acts as an anesthetic; but on the mucous membrane it is irritating, and in concentrated form may produce inflammation and even sloughing. In medicinal doses it acts as a carminative and antispasmodic. In large doses, it causes confusion of thought, headache, gastric irritation, a rapid feeble pulse, convulsions, and collapse. Therapeutics. — Camphor is used as a rubefacient, circulatory stimulant, and antispasmodic. The spirit of camphor has long been a household remedy for headache, syncope, and faintness. It is ad- ministered by inhalation; camphorated oil (5 per cent, of camphor in oHve oil) is a useful remedy in colds and croup. The Hniments containing camphor, as well as the spirit, are extensively used in sprains, bruises, muscular rheumatism, and neuralgia. Prinz advo- cates a combination of thymol (2 parts), phenol crystals (2 parts), and camphor (i part), called thymocamphen, as an anodyne in root- canal treatment. In acute coryza, Stevens recommends adding a teaspoonful of powdered camphor to a tumbler of hot water, and inhahng the fumes. EMOLLIENTS, DEMULCENTS, AND PROTECTIVES Emollients are substances of a fatty nature which soften and relax the tissue to which they are appKed, and at the same time shield the part from external irritation. Il6 EMOLLIENTS, DEMULCENTS, AND PROTECTIVES The most important emollients are : Glycerin. Fats and Oils: Soap Liniment. Lard. Starch. . Olive OU. Hot Fomentations. Almond Oil. Poultices: Linseed OU. Linseed Meal. Cottonseed Oil. Oatmeal. Lanolin. Bran. Petrolatum. Bread. Parafi&n. Flour. Cacao Butter. Figs, etc. Wax. Demulcents are substances largely of a mucilaginous character which soothe and protect the tissues to which they are applied. The important demulcents are: Acacia. MarshmaUow. Tragacanth. White of Egg. Licorice Root. Sassafras Pith, Flax Seed. Slippery Elm. P^otectives are agents used to mechanically cover and protect injured or diseased surfaces from extraneous influences, as air, water, bacteria, etc. Some protectives, besides affording mechanical pro- tection to the part, also absorb moisture or fluids by capillary attrac- tion. The so-called dusting powders 2ind fixed dressings are included in this group. The chief protectives are: Collodion. Talc. Solution of Gutta-percha. Kaolin. Court Plaster. Lycopodium. Charcoal.* Zinc Oxid.* Animal Charcoal.* Chalk.* Purified Cotton. Magnesium Carbonate.* "EmolHent" and "demulcent" are largely interchangeable terms, and no distinct division between the substances used as such can be made. The emollient, demulcent, and protective agents will, there- fore, be discussed here without reference to the three subdivisions into which they have been grouped. GLYCERINUM— U.S.P. (Glycerin; C3H5(OH)3.) Glycerin is a syrupy Hquid obtained by the decomposition of fats and fixed oils. It is clear, colorless, without odor, of a sweetish, warm taste, and when exposed to the air slowly absorbs moisture. GLYCERINUM II7 Freely soluble in water and alcohol, but insoluble in ether, chloro- form, and oils. Chemically considered, it is an alcohol. Average dose is I fl. dr. (4.0 mils). The following preparations are official: Glyceritum Phenolis, U.S. P. (20 per cent, of Phenol). Glyceritum Acidi Tannici, U.S. P. (20 per cent. Tannic Acid). Glyceritum Amyli, U.S. P. (Starch, 10; Water, 10; Glycerin, 80). Glyceritum Boroglycerini, U.S. P. (50 per cent, of Borogly- cerin). Glyceritum Hydrastis, U.S. P. (i.o mils of preparation contains i.o gm. of Hydrastis). Glyceritum Ferri, Quininae, et Strychninag Phosphatum, U.S. P. VIII. Dose, 10-30 min. (0.6-2.0 mils). Gelatinum Glycerinatum, U.S. P. (equal parts of Gelatin and Glycerin). Suppositoria Glycerini, U.S. P. (each Suppository contains 45 gr.-3.o gm. of Glycerin gelatinized by means of a Sodium Soap). Cataplasma Koalini, U.S. P. VIII. (Kaolin, 57.7 parts; Glycerin, 37.5 parts; Boric Acid, 4.5 parts; Methyl Salicylate, 2 parts; Thymol and Oil of Peppermint, each J'i part). Glycerin is also a constitiient of many extracts and fluid extracts, added largely to preserve the preparations. Physiologic Action. — When glycerin is applied to sensitive skin or mucous membrane, it has a tendency to irritate, due to the abstraction of water from the tissues. Taken internally, in large doses, glycerin acts as a cathartic, its action here probably being due also to its hygroscopic property. It is antiseptic in that it inhibits, to an extent, microorganic growth. Authorities differ as to whether or not glycerin in moderate doses acts as a food. Therapeutics. — Externally applied, glycerin is an efficient and popular emollient. For chapped hands and after shaving the follow- ing lotion is valuable: Witch-hazel and bay-rum, each i fl. oz. (30.0 mils); glycerin, i fl. oz. (30.0 mils); borax, }^ dr. (2.0 Gm.). The formerly official cataplasm of kaolin, applied hot, is an excellent substitute for ordinary poultices where the latter are indicated. In inflammatory disease of the mouth, throat, and nose, glycerin is used to advantage as a vehicle for other drugs. Glycerite of boroglycerin is a constituent of many antiseptic mouth-washes; and glycerite of tannic acid may be added, 3^ fl. dr. to the fl. oz. (2.0 mils-30.0 mils), to mouth-washes to add astrin- gency. Glycerite of tannic acid may also be appHed to flabby and inflamed gums. Glycerin is a constituent of the author's "pyorrhea Il8 EMOLLIENTS, DEMULCENTS, AND PROTECTIVES astringent" (see p. 429). It not only depletes the engorged capil- laries, but also serves -to spread the drugs contained therein over the entire surface. Internally it is largely employed in habitual constipation. Here the official suppository may be employed. Incompatibles. — Powerful oxidizing agents, like sodium dioxid, chromic acid, and potassium permanganate, explode with glycerin. AMYLUM— U.S.P. (Starch; CeHioOs-) Starch is a white powder, or masses, obtained from the fecula of the seed of Zea Mays, or Indian corn . Wheat starch (flour) and rice starch are also used in therapeutics. It is insoluble in water; soluble in boiling water. There is only one official preparation: Glyceritum Amyli, U.S. P. (10 per cent.). Therapeutics. — Starch is used externally in the form of dusting powders or "pastes" as protective applications. It is an antidote for iodin poisoning, the insoluble starch iodid being formed. In pharmacy the glycerite of amyl is used as an excipient for making pill-masses of certain drugs. OLEUM OLIViE— U.S.P. (OHve Oil; Sweet Oil.) Olive oil is a fixed oil expressed from the ripe fruit of Olea euro pea, a shrubby tree indigenous to Western Asia, but cultivated in several countries, including the southern part of the United States, especially California. The oil is a pale yellow or light greenish-yellow Hquid, of a characteristic odor, and an oleaginous taste. It should be kept in well-stoppered bottles, in a cool place. The average dose is i fl. oz. (30.0 mils). Physiologic Action and Therapeutics. — Olive oil is a bland and agreeable oil, and is used extensively as an emollient and demulcent. It is readily absorbed from the skin and mucous membrane, and with phenol (5 per cent.) it makes a soothing, protective application for superficial wounds, bruises, burns, insect bites, stings, etc. Camphor- ated olive oil (camphor 5 per cent.) is a useful remedy to rub on the throat and chest in cases of colds and croup in children. In cases of poisoning from corrosive irritating drugs, olive oil is a valuable demulcent, unless the poison be soluble in an oil, in which LIlSrUM — OLEUM GOSSYPII SEMESTIS II9 case any fat or oil is contraindicated, as it would tend to hasten the absorption of the poison. Internally administered, olive oil is not only demulcent, but possesses marked nutritive and laxative prop- erties. It is often taken in wines and liquors for its nutritive value. LINUM— U.S.P. (Linseed; Flaxseed.) Linseed is the ground seed of Linum usitatissimum, or common flax, which is cultivated in all temperate countries. Its chief ingre- dients are a fixed oil and a mucilaginous principle. The oil (Oleum Lini, U.S.P.) is official, and enters as an essential constituent into the following preparations: Linimentum Calcis, U.S.P. Liquor Cresolis Compositus, U.S.P. Physiologic Action and Therapeutics. — An infusion or tea of flaxseed makes an excellent demulcent drink. The ground flaxseed is probably used for the ordinary poultice in deep-seated inflammations more than any other substance. The oil is similar to olive oil in its action and uses. Mixed with an equal quantity of Hme-water, it makes the official linimentum calcis, commonly called carron oil, an excellent remedy for the treatment of hums. The Hniment of soft soap, called tincture of green soap, should be in every dental ojQ&ce, and used frequently on the hands for detergent purposes, OLEUM GOSSYPH SEMINIS— U.S.P. (Cottonseed Oil.) Cottonseed oil is a fixed oil obtained from the seed of cultivated varieties of Gossypium herbaceum. It occurs as a pale yellow, oily Hquid, odorless or nearly odorless, and having a bland taste. It is sHghtly soluble in alcohol; miscible with ether, chloroform, and petrolatum. It enters as an essential constituent into soft soap. which is official (Sapo MolHs, U.S.P.); as is also the liniment of soft soap (Linimentum Saponis MolHs, U.S.P.). Physiologic Action and Therapeutics. — Cottonseed oil is used for its emolHent and soothing properties. It has taken the place of Unseed oil in the U.S.P. IX in the manufacture of soft soap. It is also used as a substitute for almond and olive oil, and enters into the composition of many liniments. I20 EMOLLIENTS, DEMULCENTS, AND PROTECTIVES ADEPS LAN^— U.S.P. (Lanolin; Wool Fat.) Lanolin, or wool fat, is the purified fat of the wool of sheep, freed from water. It is a yellowish-white, unctuous substance, having a faint pecuHar odor. The Pharmacopeia also recognized a wool fat which contains about 30 per cent, of water (Adeps Lanae Hydrosus, U.S.P.). Therapeutics. — Lanolin is extensively used as a vehicle for oint- ments. It is bland and unirritating, does not become rancid, and has the distinct advantage of being miscible with twice its weight of water without losing its ointment-like character. With this vehicle, therefore, aqueous substances may be made into ointments. It is used as the vehicle for devitalizing pastes for the dental pulp. The hydrous wool fat, in pharmacy, is used as a constituent in many of the ofl&cial ointments. It possesses the advantage over many vehicles used for ointments in that it is rapidly absorbed by the skin, thus carrying with it the medicaments contained therein. PETROLATUM— U.S.P. (Petroleum Jelly; VaseHn.) Petrolatum is a mixture of hydrocarbons, chiefly of the methane series, obtained by distilHng off the more volatile portions of petrole\mi and purifying the residue. The melting-point should- be between 45° and 48°C. Three forms are official: Petrolatum, U.S. P. (ordinary petrolatum), a yellowish, ointment-like mass; Petrolatum Album, U.S.P. (white petrolatum), a white ointment- like mass, and Petrolatum Liquidum, U.S.P. (liquid petroleum), a clear, colorless, oily Hquid. The latter is also called Liquid vaselin and is known by such trade names as petronol and alholin. Therapeutics. — Petrolatum is bland and unirritating, and is extensively used as an emolHent and protective dressing. It is largely substituted for benzolated lard in ointments. Phenolized vaseHn (3 per cent, phenol) is a household remedy for hums, bruises, and other excoriations. An ointment made from orthoform (40 parts) and europhen (60 parts), with hquid vaselin as the vehicle, is a specific for pain following the extraction of teeth where the alveolar process has been exposed; it acts here also as an emollient and pro- tective. Liquid vaseHn containing 2 per cent, of menthol is an excellent emollient to be used as a spray in aciite coryza. paeaffhstum — tragacantea 121 PARAFFmUM— U.S.P. (Paraffin.) Paraffin should be discussed in connection with petrolatum. It is a mixture of soUd hydrocarbons obtained from the same source. It is a white solid, and should melt between 51.6° and 57.2° C. Therapeutics. — Gersung, in 1900, recommended the subcutane- ous and submucous injection of paraffin for the correction of various defects and for cosmetic purposes. Beck, of Chicago, has employed the method quite extensively for the correction of nasal deformities; and paraffin has also been injected about the jaws with excellent results in cases of necrosis and other diseases where hone tissue has been lost or removed. The paraffin should be sterilized by boihng and must be injected with a specially prepared syringe while warm and semisolid. This substance when so injected is not absorbed, but finally becomes encapsulated. Paraffin has also been used for ffiHng root-canals. It affords the protection from moisture necessary when filling teeth with "plastic porcelain, " or the various silicate cements on the market; and may also be used to protect the enamel of the crown of the tooth when employing acids in the canal. ACACIA— U.S.P. (Gum Arabic.) Acacia is a gummy exudation obtained from Acacia Senegal, and other species of Acacia, a small tree, deeply and firmly rooted, grow- ing in India, Africa, and other countries. It is soluble in water. The following preparations are official: Mucilago Acaciae, U.S. P. Dose, freely. Sjrrupus Acaciae, U.S. P. Dose, freely. Therapeutics. — Acacia is used in therapeutics chiefly for its demulcent property. The mucilage may be further diluted with water and administered freely in cases of ■poisoning from corrosive drugs. In pharmacy it is the emulsifying agent generally employed in making emulsions of oleaginous drugs; it is also used in pills and lozenges for holding together the active ingredients. Incompatibles. — It is incompatible with alcohol, ferric salts, and borax. TRAGACANTHA— U.S.P. (Tragacanth.) Tragacanth is a gummy exudation obtained from Astragalus gummifer, a small shrub growing in Western Asia. This gum differs 122 EMOLLIENTS, DEMULCENTS, AND PROTECTIV^ES from acacia in that it does not dissolve in water, but swells up in it and forms a gelatinous mass. The of&cial preparation is: Mucilago Tragacanthae, U.S. P. Therapeutics. — Though possessing demulcent properties, it is impracticable to use it as such on account of its insolubility. The mucilage of tragacanth may be used as an emollient in chapped hands and other skin lesions. In pharmacy it is used for suspending resin- ous and oleaginous drugs in water; it also enters into most of the official troches. GLYCYRRHIZA— U.S.P. (Licorice Root.) Glycjnrhiza is the dried rhizome and root of Glycyrrhiza glabra, or Glycyrrhiza glandulifera, a perennial herb growing in the countries lying on the northern and southern shores of the Mediterranean Sea ; also cultivated in England and the United States. It contains a glucosid, glycyrrhizin, to which is due its sweetish taste; it also con- tains an acrid resin, starch and gum. The following preparations of licorice are official: Fluidextractum Glycyrrhizje, U.S. P. Dose, 15-60 min. (1.0-4.0 mils). Extractum Glycyrrhizas, U.S. P. Dose, freely. Extractum Glycyrrhizae Purum, U.S. P. Dose, freely. Mistura Glycyrrhizae Composita, U.S.P. Dose, 1-4 fl. dr. (4.0-16.0 mils). Piilvis Glycyrrhizas Compositus, U.S.P. Dose, 3^-2 dr. (2.0-8.0 Gm.). Elixir Glycyrrhizae (from Fluidextract), U.S.P. Dose, freely. Glycyrrhizinum Ammoniatum, U.S.P. Dose, 4 gr. (0.25 Gm.). Physiologic Action and Therapeutics. — ^Licorice root is demul- cent and slightly laxative, and when chewed increases the flow of saHva. It sHghtly stimulates and favors the secretion of mucus in the respiratory passages. It is a popular remedy for cough, sore throat, and hoarseness. It is found in many of the pharmaceutic preparations, and may be used to advantage in masking the taste of nauseating drugs. The official fluid extract, the extract, and the syrup (N. F.) are largely used for this latter purpose. ALTILEA— U.S.P. (Marshmallow Root.) Marshmallow is the dried root of Althcea officinalis, a perennial herb growing in most countries with a temperate cHmate. Its chief constituents are mucilage, sugar, and starch. SASSAFRAS MEDULLA— CO LLODIUM 1 23 Physiologic Action and Therapeutics. — Marshmallow is emol- lient, demulcent, and protective, and may be employed as such in all irritable and inflamed conditions of the mucous membrane and skin. SASSAFRAS MEDULLA (Nonofficial) (Sassafras Pith.) Sassafras is the dried pith obtained from the branches of Sassafras variifolium, a tree indigenous to North America. Both the drug and mucilage of sassafras were official in the U.S. P. VIII. Physiologic Action and Therapeutics. — Mucilage of sassafras pith is a pleasant demulcent, and may be used wherever such is indi- cated. An infusion or tea made from the bark of the root of the sassafras tree has long been a domestic remedy as a "spring tonic." ULMUS— U.S.P. r (SHppery Elm.) Slippery elm is the dried inner bark of Ulmus fulva, a large tree growing in the United States and Canada. It contains much muci- laginous matter. Physiologic Action and Therapeutics. — The mucilage of elm, for- merly official, is a decided demulcent, and is supposed to possess nutritive properties. It is pleasant to the taste, and generally does not disturb the stomach. It is especially useful after washing out the stomach for any purpose. In the form of troches (elm lozenges), it is useful as a soothing agent in irritated or sore throat. COLLODIUM— U.S.P. (CoUodion.) Collodion is a solution of pyroxyhn, or gun cotton, 4, in ether 75, and alcohol 25 parts. It is a colorless, syrupy hquid, highly inflam- mable, and having a strong ethereal odor. The following prepara- tions are official: CoUodium Flexile, U.S.P. CoUodium Cantharidatum, U.S.P. (Blistering CoUodion; Cantharides, 60 per cent.). Therapeutics. — When applied to the skin, collodion quickly dries and forms a thin film, which not only protects an exposed part, but produces shght compression. It therefore makes an excellent pro- tective for aseptic wounds, fissures, and punctures. This agent affords 124 EMOLLIENTS, DEMULCENTS, AND PROTECTIVES an efficient means of securing neat antiseptic dressings on dentists' hands which may be abraded or punctured by instruments. The wound, if necessary, can be cauterized with phenol or silver nitrate, and then covered with an antiseptic powder like europhen or boric acid; this should be covered with absorbent cotton and the dressing retained with collodion. Thus treated, the wound is well protected and should heal by first intention. The flexible collodion cracks less readily than the plain collodion, and may be used if desired. Styptic collodion was formerly official and contained 20 per cent, of tannic acid. When applied to small wounds, hke cold-sores on the lip, it will check capillary oozing. Cantharidal or blistering collodion may be used as a counterirritant in pericemental inflammations and neuralgias. Gutta-perchse (nonofficial). — Gutta-percha is a milky, concrete exudation, occurring in several species of the gutta tree, which is indig- enous to the Malay Archipelago, Sulu Islands, and Java ; recently it was learned that the gutta tree grows abundantly in the Philippine Islands. When pure, gutta-percha has a specific coloring between pink and grayish-white. Single pieces are not adhesive at ordinary temperatures, but heated slightly and pressed together the piece^ adhere and cannot be separated. Gutta-percha is insoluble in water and alcohol, but soluble in chloroform, eucal3^tol, and cineol. Therapeutics. — Gutta-percha dissolved in chloroform may be used as a protective for small wounds. It has also been employed as a means of retaining antiseptic and other dressings in the canals of teeth. For this purpose it does not exclude the bacteria-laden saliva, and should be discarded. The solution, known as chloropercha, has long been successfully used in moistening the dried canal previous to filling with a gutta-percha cone. The author suggests heating the .white base-plate gutta-percha in eucalyptol (see p. 360), when a thick, creamy solution results, which becomes a soft soHd when cold. This preparation is used in filling root-canals, as will be explained in Practical Therapeutics. Cochran suggests making a saturated solu- tion of thymol in eucalyptol, and after cutting the gutta-percha with chloroform mixing the two solutions, permitting the chloroform to evaporate, when a soft solid results which is used in filling root-canals. TALCUM PURIFICATUM— U.S.P. (Purified Talc; Magnesium Silicate; Soapstone.) Purified talc is a native, hydrous magnesium silicate, and occurs as a very fine, white, or grayish-white powder, which adheres to the KAOLESrUM — LYCOPODIUM 1 25 skin. It feels greasy to the touch, hence it is commonly called soapstone. The Pharmacopeia suggests using purified talc in the preparation of essential oil waters. Therapeutics. — Finely powdered talc is employed as a dusting powder in inflammatory diseases of the skin, such as acute erythema- tous eczema. A useful formula is: Pulverized talc, 4 dr. (16.0 Gm.); zinc oxid, 3 dr. (12.0 Gm.); boric acid, i dr. (4.0 Gm.). This powder is also useful in chafing. Many of the commercial talcum powders contain talc and boric acid in varying proportions. Talc, or soap- stone, is used in dentistry also to coat the model so that it will draw nicely from the moulding sand in making a metal die. KAOLmUM (Nonofficial) (Fuller's Earth; Hydra ted Aluminum SiUcate.) Kaolin is a native aluminum silicate, occurring as a soft, white, or yellowish-white powder, odorless, and having an earthy or clay- like taste. It is insoluble in water, but becomes unctuous when moist. It is a very pure clay, having the chemic formula, H2Al2Si208.- H2O. Therapeutics. — The cataplasm, formerly official, is used as a poultice, applied hot, in mild local infections about the face and jaws. Kaolin is also used in dusting powders, and is a constituent of porce- lain body. In pharmacy it is used in pills containing easily reduced drugs, like silver nitrate and potassium permanganate, which cannot be mixed with the ordinary pill excipients. LYCOPODIUM— U.S.P. Lycopodium is the spores of Lycopodium clavatum and other species of Lycopodium, mosses growing in nearly all temperate coun- tries. It is a fine powder, pale yellow in color, very mobile, nearly inodorous, tasteless, floats upon water and is not wetted by it, and burns quickly when thrown into a flame. Therapeutics. — ^Lycopodium is employed in therapeutics as a protective. It possesses great absorbent power for oils, which, to- gether with its dryness and lightness, renders it an excellent dusting- powder for superficial ulcers, eczema, etc. In dentistry it is also used, like soapstone, for coating models in making dies; and in pharmacy it is employed to prevent the adhesion of newly-made pills and suppositories. 126 LOCAL ANESTHETICS In the discussion of drugs thus far, the author has endeavored to group them, as far as was possible, into local and general remedies. Those which have been considered are employed largely in thera- peutics for their local effects upon the skin and mucous membranes of the respiratory and alimentary passages. The consideration of the next group, local anesthetics, will naturally lead us into the discussion of general anesthetics, and from then on general remedies will be considered. ANESTHETICS Anesthetics have been elsewhere defined as agents which tempo- rarily destroy sensation. They are subdivided into two classes: (i) Those which produce local anesthesia; and (2) those which produce general anesthesia. By local anesthesia is meant the abolition of sen- sibility to pain in a part; general anesthesia means the abolition of all sensibility, including unconsciousness. In the administration of general anesthetics, the patients experience a stage where they are insensible to pain, though not unconscious. This condition is known as analgesia, which means the absence of sensibility to pain. Agents which produce the condition, whether general anesthetics, like nitrous oxid, chloroform or ether, or other drugs, such as opium, the coal-tar derivatives — antipyrin, acetanilid, and phenacetin — the bromids, chloral, etc., are called analgesics. Closely associated with these drugs is the term anodyne, which means an agent that relieves pain. An anodyne effect presupposes the presence of pain, an analgesic effect does not; it simply means that pain cannot be experienced. Many drugs possess local anodyne properties, such as many volatile oils, phenol, cresol, etc. LOCAL ANESTHETICS Local anesthetic agents may be conveniently subdivided into two classes, according to the mode of action by which the anesthetic effect of the drug is produced. 1. Refrigerant.' — Those agents which produce a degree of cold by the abstraction of heat from the part to which they are applied, even to the point of freezing the tissue. 2. Paralyzant. — Those agents which, when appHed locally, have a direct paralyzant action upon the sensory nerve terminals. Refrigerant. Paralyzant. Ethyl Chlorid Spray. Cocain. Ether Spray. Tropacocain. ^THYLIS CHLOREDUM 1 27 Rhigolene Spray. Eucain. Ice. Novocain. Neothesin. Chloretone, Orthoform. ^THYLIS CHLORIDUM— U.S.P. (Ethyl Chlorid; Kelene; C2H5CI.) Ethyl chlorid is prepared by the action of hydrochloric acid gas upon absolute ethyl alcohol, the hydroxyl radical in the latter being replaced by chlorin. It occurs as a colorless, extremely volatile liquid, having an odor resembling that of chloroform and a burning taste. The vapor is highly inflammable, and it should not he used near a gas- flame or burning alcohol-lamp. Physiologic Action.- — Applied locally by means of a spray, ethyl chlorid acts as a refrigerant local anesthetic, the tissues soon becoming white and superficially frozen from the abstraction of heat. The drug may be inhaled from gauze or a specially devised in- haler which is adjusted to the face, when it acts as a general anes- thetic. The anesthesia is usually accompanied by a fall of arterial . pressure and a gradual decrease in the pulse-rate, due in all proba- bility to a direct action upon the heart. The patient becomes anesthetized, as a rule, in from i to 3 minutes, and from 1-2 fl. dr. (4 0-8.0 mils) of the drug being required, depending upon the patient. Its action is rapid and unirritating to the mucous membrane of the respiratory passages; there is an absence of choking sensation or cyanosis; and but rarely does nausea or vomiting follow. The recovery is generally complete in from 2 to 5 minutes. Therapeutics. — Ethyl chlorid is usually sold in small metallic or glass tubes, provided with a lever-spring or screw top. When the lever is depressed or the screw released, the liquid is expelled as a spray by the heat of the hand. This drug is a safe and convenient local anesthetic for minor operations requiring but a single incision, as in the lancing of abscesses, boils, etc., or for the extraction of loose teeth. Its local anesthetic action is not sufficiently profound to permit the painless extraction of firmly attached teeth. There is very little danger attending the local use of the drug from inhalation. The drug may be used as a general anesthetic for minor surgical operations necessitating the administration of a general anesthetic. Ethyl chlorid is a constituent of many commercial products sold for general anesthetic purposes, among which may be mentioned somnoform, narcotile, etc. 128 LOCAL ANESTHETICS As a general anesthetic, ethyl chlorid has the one advantage over nitrous oxid, or nitrous oxid and oxygen, of not requiring a cumber- some apparatus for its administration, but its safety cannot be com- pared with that of nitrous oxid. Though the drug has only been used a few years as a general anesthetic, quite a number of deaths from its use have been reported. Ether Spray. — Ether, or ether and alcohol, in the form of a spray, has been suggested as a means of desensitizing dentin. It acts, as a refrigerant local anesthetic. Rhigolene Spray. — Rhigolene is an unof&cial distillate of petroleum. It may be used as a spray for the same purpose as ether, but has no advantages over the latter. Ice. — Ice, or the ice and salt mixture, was probably the first of all local anesthetics. Though its use is largely superseded, espe- cially in the mouth, by the volatile liquids, like ether and ethyl chlorid, it still has a place of usefulness upon accessible surfaces. An ice-poultice may be made by sewing up tightly in rubber cloth crushed ice mixed with salt and sawdust, bran, or ground flax- seed. Local appHcations of cold in this manner abstract heat from the part, lessen the sensibiHty of the peripheral nerve-filaments, cause constriction of the blood-vessels traversing the tissues exposed to the cold, and by reflex action affect the vascularity of the parts subjacent to the site of application. COCA (Nonofficial) Coca is the dried leaves of Erythroxylon coca, a plant growing in the mountainous regions of Peru, Bolivia, and other South American states. It contains a number of alkaloids, the most important being cocain, which is official both as the alkaloid and alkaloidal salt under the titles, respectively, Cocaina and Cocaince Eydrochloridum. The general rule adopted by the United States Pharmacopeia in the nomenclature of articles of botanical origin is for the Latin title to be the genus name of the plant and not the species. Coca, which was official in the U.S. P. VIII, is a notable exception to this rule; for instead of calling this article Erythroxylon it was officially designated Coca. While the early generic names of plants were selected rather arbitrarily, the differentiation of their species is almost invariable indicated in their specific names; yet some of the native plant names lead to great confusion. Students frequently confuse the names cocoa (cacao), coco (nut), and coca, three separate and distinct plants. When Von Humboldt discovered the chocolate nut he COCAINA — COCAINE HYDROCHLORIDUM 1 29 named it Theobroma (meaning God's drink) and cacao, after the native Indian name; but it has always been confused, because of the similarity of names, with the Cocos nucifera, the milk-bearing cocoa- nut; and by many to-day the oil of theobroma is called cocoa-butter instead of cacao. It should be remembered that coca is the name for the plant, from the leaves of which that valuable alkaloid, cocain is obtained. There are now no official preparations of this drug. COCAINA— U.S.P. (Cocain; C17H21NO4.) Cocain occurs in the form of colorless, prismatic crystals, having the bitter taste characteristic of all alkaloids, and producing on the tongue a temporary numbness. It is sparingly soluble in water (1-600 parts), much more so in alcohol (1-6.5 parts), more readily in both when warm, in ether (1-3.5), ^^^ i^ the oils (about 1-12). The average dose is about 3^^ gr. (0.016 Gm.). COCAINE HYDROCHLORIDUM— U.S.P. (Cocain Hydrochlorid; C17H21NO4.HCI.) Cocain hydrochlorid, called previous to the U.S.P. of 1900 cocain hydrochlorate, occurs in the form of colorless prisms, lustrous leaflets or flakes, or crystalline powder. This alkaloidal salt, like the alkaloid itself, has a bitter taste, and leaves a temporary numb- ness on the tongue. It is freely soluble in water (1-C.4 part), somewhat less so in alcohol (1-3.2 parts); soluble in glycerin and insoluble in ether and oils. The amount to be injected h)^odermically at one time should not exceed M to 3^ gr. (0.016-0.03 Gm.). Brief History. — It may be stated as a matter of history that the introduction of cocain to the medical and dental world was due to Koller, of Vienna, who, in 1884, reported his experiments with the drug to the Congress of German Oculists, In a few weeks cocain or the alkaloidal salt, cocain hydrochlorid, was being used as a local anesthetic all over the world. Among the men whose names should be mentioned as early investigators are the following: Hepburn, Biggs, Hall, Halsted, Rudolph Matas, J. L. Corning, and C. P. Pruyn. Hall, in 1884, demonstrated by an experiment upon himself that he could inject solutions of cocain hydrochlorid into the infraorbital nerve and anesthetize the teeth. Halsted, in the following year, 1885, and some gentlemen in South America about I30 LOCAL ANESTHETICS the same time, not knowing that Halsted was working along the same line, demonstrated that they could inject 9 min. of a 4 per cent, solution into the inferior dental nerve as it jentered the inferior dental canal, and produce complete anesthesia of the gums and teeth on that side of the jaw. This method is known to-day as ' ' nerve blocking" or conductive anesthesia. It was about this time that Pruyn, of Chicago, conducted a long series of experiments on dogs, and to him much credit is due for the high place which cocain occu- pies in dental practice to-day. In speaking of these experiments, Pruyn^ says: "The first dog that I experimented on, and sub- sequently killed, made me shudder to see the poor animal in the throes of d^d^th. fighting for his breath. It made an impression on me that has lasted ever since, and taught me that cocain should be handled very carefully, particularly when we are using it upon the human subject." Therefore, the alarming symptoms and the fre- quent fatalities which followed the early use of cocain caused it for a time to be barred from general use in general and dental surgery. The fact, however, that many patients objected to general anesthetics on account of the unconsciousness induced, and the further fact that every conscientious surgeon recognized that a certain amount of danger always attends the administration of general anesthetics were sufi&cient to cause a few men to experiment further with the drug. They diminished the strength of the solution, and gradually mastered the technic of its administration until alarming symptoms and fatalities became very infrequent. Physiologic Action.' — Whatever effects result from the admin- istration of preparations of coca are due entirely to the alkaloids contained therein. Cocain is a t3^ical local anesthetic of the paralyzant group. When the drug enters the circulation its first action is that of a stimulant, followed shortly by a depressant effect. It is a general protoplasmic poison, and acts deleteriously upon all kinds of tissue. It has been supposed that the drug acts more prominently upon nerve tissue, but such is not the case. It is true that its action is more discernible upon nerve tissue for the reason that this tissue is the medium of sensation and expression. When appUed locally or injected beneath the mucous membrane or skin, its depressant action on the sensory nerve filaments is sufficiently profound to induce complete local anesthesia or analgesia. It is also a powerful vaso-constrictor; the ischemia produced, however, is ultimately followed by congestion. Long before the drug was used as a medicine, the natives of 1 Dental Review, Vol. 16, p. 312. COCAINiE HYDEOCHLORIDUM 131 South America learned that by eating the leaves of the coca plant they could travel for days through the deserts without experiencing the sensation of hunger. We now know that the cocain paralyzed the nerve filaments which control the appetite. Poisoning and Treatment. — The symptoms of acute cocain poison' ing are rather variable. The usual manifestations are nervous Fig. I. — Artificial Respiration. First Movement. excitement, followed by delirium, and later by drowsiness and stupor; nausea, vomiting, a rapid pulse, hurried and difficult respira- tion, dilatation of the pupils, cold sweat, blanched expression, blue lips, convulsive seizures, and finally death through asphyxia. Fig. 2. — Artificial Respiration. Second Movement. Individuals differ widely in their susceptibility to cocain. The local application of even moderate solutions of the drug to the nose or throat in some subjects is followed by toxic symptoms. Some have a peculiar idiosyncrasy for cocain. Cases have been authenti- cally reported where the drug was not used, but where the patient 132 LOCAL ANESTHETICS supposed it had been, and exhibited the usual toxic symptoms in mild form. There is no known antidote for cocain; therefore, the treatment of poisoning is purely symptomatic. When the symptoms are rather mild the patient should be kept in a recumbent position, the head lower than the feet, if possible (the modern dental chair makes this possible), and such stimulants given as whisky, brandy, and aromatic spirit of ammonia, 15-20 min. (i. 0-1.3 mils) of the latter in a small quantity of water. The irritation of the ammonia is what is desired, and it is best here not to dilute the drug too much. Spirit of ammonia or spirit of camphor may be given by inhalation. Ammonia irritates the mucous membrane, and thus directly stimu- lates the heart. When the s3miptoms are more pronounced, espe- cially when the patient is unable to swallow and a direct cardiac stimulant is required, strychnin is the drug to administer. This may be given hypodermically in the form of strychnin sulphate, the injection being made in the arm or cellular tissue of the lumbar region. One-thirtieth grain (0.0025 gm.) may be administered at a time and repeated every 15 minutes, if occasion requires, until 3 injections are made. When there is danger of respiratory failure atropin sulphate in from M.20~}'60 gr. (0.0005-0.001 Gm.) should be given. As a last resort to prevent asphyxia, artificial respiration should be performed. Sylvester's method is the one most commonly employed. Figs, i and 2 show the position of patient and attendant. With the patient placed on his back, on a flat surface, supporting the head and shoulders with a cushion or articles of dress, all tight clothing should be loosened or removed from the neck and chest. The movements of inspiration and expiration should regularly succeed each other at the rate of from 20 to 25 respirations per minute, or slightly in excess of the normal rate (about 18 per minute). The inspiratory period should be sHghtly longer than the expiratory. In all cases artificial respiration should be continued until natural respiration is established. This may require hours, and necessi- tate a relay of assistants. In the treatment of poisoning of any kind the operator should avoid the appearance of excitement, and remember that as long as there is life there is a chance of recovery. Habit. — Cocain is one of the most seductive of the drugs that are taken habitually, and its effects are most disastrous. A potent cause of the cocain habit has been the frequent use of the drug in diseases of the nose and throat. As the drug is used in dentistry there is Httle chance of producing the habit; yet it is very unwise to prescribe the drug to be used by the patient at home in the form of toothache reme- COCAINE HYDROCHLORIDUM 1 33 dies, mouth-washes, gargles, or nasal sprays. Cocain is one of the drugs that come under the "Federal Narcotic Law;" and whenever ordered or prescribed, it must be done on a "record blank" furnished by the United States Government. The chief symptoms of the cocain habit are emotional excitement, physical unrest, mental im- pairment, a disregard for morals, hallucinations, gastric disturbances, a gradual wasting away, and anemia. Therapeutics. — There is a demand by the laity for painless dentistry, and no one drug aids the dentist more in meeting this de- mand than cocain or its alkaloidal salt, cocain hydrochlorid. The drug is extensively used in the painless extraction of teeth, lancing of abscesses, removal of vital dental pulps, and many other conditions. Cocain hydrochlorid is recommended in cases of nausea in taking im- pressions. Goslee suggests using a 2 per cent, solution in an atom- izer, spraying the entire palate and the uvula. A glass of tepid water should be at hand and the patient may rinse the mouth after a few seconds, to avoid swallowing the solution. The spraying process may be repeated about every five minutes until two or three applica- tions have been made. Cocain is also added to many arsenical preparations to control the irritating action of the arsenic trioxid. If the vehicle for such prepa- rations is an oil, the alkaloid should always be used, as the alkaloidal salt is insoluble in oils. The formerly official oleate (5 per cent, of the alkaloid) may be used to lessen the pain in setting crowns and bridges. This is done by applying the remedy under the margin of the gum a few minutes before setting the crown. Cocain hydrochlorid is used more exten- sively by the hypodermic method of administration for the painless extraction of teeth than for any other purpose in dentistry. A brief discussion, therefore, of the hypodermic use of the drug will here be considered. Sodium chlorid has been recommended by Schleich and others as an excellent agent to be added to local anesthetic solutions for two reasons: One is that it aids in the elimination of the drug, and the other, and more important, is that with it isotonic solutions can be prepared with local anesthetics as the base. The action of the so- called "salt solutions" will be discussed under Cathartics (which see, p. 215). Transitory anesthesia can be produced ultimately by pres- sure, or by simply injecting with force distilled water into the gum tissue; but distilled water being hypoiso tonic to the normal fluids in the tissues, its injection causes a temporary swelling of the cells, due to osmotic action, and primary pain is produced. On the other 134 LOCAL ANESTHETICS hand, the injection of a hj^perisotonic solution causes a temporary condensation of the cells, due also to osmosis, and primary pain is produced. If, therefore, isotonic solutions are employed for the pur- pose of inducing local anesthesia, osmotic action is avoided, and the relation of the cells to each other is not materially affected. Prinz suggests adding sodium chlorid in the following proportion in making an isotonic solution of cocain hydrochlorid : Cocain Hydrochlorid, 5 gr. (0.3 Gm.) Sodium Chlorid, 4 gr. (0.25 Gm.) Distilled Water, i fl. oz. (30.0 mils) To each syringeful (30 min.-2.o mils) add one minim (0.065 i^iO of a I- 1 000 solution of adrenahn chlorid when used. The adrenahn solution should be fresh. The technic of making the injection has been fully discussed under the Hypodermic Method (p. 24). The principal objections to the use of cocain hydrochlorid as a local anesthetic for hypodermic use are the sloughing of tissue so often induced, and the liability to poisoning. These are important consid- erations and wiU be discussed separately. 1. Sloughing. — It has been demonstrated quite conclusively that the aseptic injection of sterile isotonic solutions of cocain hydro- chlorid will not result in sloughing. Therefore, sloughing is caused either by septic infection due to the injection or to the irritation pro- duced by the disturbed relations of the cells from the injection of solutions which are not isotonic to the fluids in the tissues. It must be understood here that the latter cause mentioned would not result in sloughing of itself, but the irritation thus produced, together with the poisoning of the protoplasm of the cells by the cocain, so lowers the vital resistance of the affected tissues that infection is more liable to follow hematogenously (through the blood stream) , or from external influences, especially where there has been laceration of tissue, as in extraction. Sloughing, therefore, is due entirely to septic infection, either directly or indirectly from the injection or from external influ- ences. How to guard against septic infection has been previously considered. 2. Poisoning.- — Poisoning by cocain hydrochlorid is due either to the injection of an overdose or to idiosyncrasy. As has been else- where stated, individuals differ widely in their susceptibiHty to co- cain. In the manner of its action, which has alse been mentioned cocain is a pecuUar drug. Its action differs with different individuals, and with the same individual at different times. There is no way of foretelling how the drug is going to affect the patient in a given case. COCAINE hydrochloridiim: 135 For this reason many physicians and dentists are afraid to use co- cain. However, if we master the technic of its administration and always know the quantity injected, there is no necessity for fright, even though toxic symptoms develop, providing, of course, that an over- dose has not been injected. It is practically agreed by the best au- thorities that the maximum quantity of cocain hydrochlorid to be permitted to enter the circulation at one time should not exceed one- quarter of a grain (0.016 Gm.). A great many of the ill-results attributed to cocain are due to the carelessness with which the drug is used or to shock or fright on the part of the patient for which the drug is not at all responsible. This is equally true of the hypodermic use of all local anesthetics. Many times patients collapse from shock or faint from fear or dread of the operation; and, when cocain was used these results have frequently been attributed to the drug, when, as a matter of fact, the same result might have been and often is produced when no anesthetic has been used. Whenever cocain is used about the mouth for any purpose we should always have the patient rinse the mouth to prevent swallow- ing any of the remedy, for the smallest quantity of cocain in the stomach will often produce nausea; Solutions of cocain hydrochlorid should be made at the time from soluble hypodermic tablets, or should contain antiseptics to keep the solution sterile. Phenol is an excellent agent to add for this purpose, and in from 3^ to i per cent, it has no perceptible coagulant action on the albumin of the cells. Two per cent, of boric acid may also be added. The author's formula for hjrpodermic injection, which is practically isotonic, follows: Cocain Hydrochlorid, 5 gr. (0.3 Gm.) Sodium'Chlorid, i gr. (0.06 Gm.) Phenol (95 per cent.), 2 min. (0.13 mil) Peppermint Water, i fl. oz. (30.0 mils) It is well to add i min. (0.06 mil) of a fresh 1-1,000 solution of adrenahn chlorid to 30 min. (2.0 mils) of the solution at the time of injection. It should be remembered that about 23 min. (1.5 mils) of this solution contain 3^ gr. (0.016 Gm.) of the alkaloidal salt, the maximum quantity which may safely enter the circulation at one time. This does not mean that only 23 min. can be used at one injection; for a certain amount is lost in exhausting the air from the syringe, and a certain amount actually injected is re- moved before it enters the circulation, due to the subsequent hemor- rhage. If the technic of injection has been mastered, one barrelful 136 LOCAL ANESTHETICS of the syringe should be amply sufficient to painlessly extract all of the teeth that should be extracted at one tirne, when any local anesthetic has been employed. Cocain should never be used with- out having at hand in a convenient and practical form the several antidotes for the drug. There are many proprietary local anesthetic solutions on the market, and it is safe to say that cocain enters into most of them as the base of the formula. In this day of advanced dental therapeutics there is no necessity or excuse for using any proprietary remedy, the composition of which is unknown, especially when we are dealing with so powerful a drug as cocain. The National Food and Drugs Act makes it obligatory for manufacturers to place on the label the amount of cocain in their preparations; and, as previously men- tioned, the Anti-Narcotic Law requires practitioners to keep a record of the amount of cocain ordered and used. Neurocain. — Neurocain is a name given to billets of cocain hydrochlorid, each containing 3-f 2 gr. (0.005 Gm.), without excipient. The billets are 3^^ in. long, J-^o in. in diameter, and very soluble in water. Cocain hydrochlorid is put up in this form expressly for dentists' use in the removal of the pulp by pressure anesthesia. They are convenient for this purpose, especially where it is desired to dis- solve the local anesthetic in the serum of the blood in cases of pulp exposure. Similar preparations on the market are called cocain points. Incompatibles. — Cocain hydrochlorid is incompatible with alka- lies and alkaline carbonates and all alkaloidal reagents. The drug is decomposed by boiling water. Tropacocain Hydrochlorid. — Tropacocain is an alkaloid obtained from the leaves of the Java coca plant. The hydrochlorid occurs as white needles, readily soluble in water. In its action it resembles cocain, but is less toxic and does not produce contraction of the blood-vessels. Its local anesthetic property is not sufficiently profound to merit emplo3mient as such in dental practice. Ever since cocain has been used as a local anesthetic in dental and general surgery numerous attempts have been made by manu- facturing chemists to prepare, synthetically, substitutes for the drug; among which may be mentioned the following: The eucains, acoin, nirvanin, stovain, chloretone, novocain, and neothesin. Many of these products were short-lived and failed to fill the place for which they were introduced, viz., to displace cocain as a local anesthetic. Those which proved to possess merit will here be discussed. EUCAINA — ^NOVOCAINiE HYDROCHLOREDUM I37 EUCAINA (Nonofficial) (Eucain; C:2Hi2N02(CH3)3.) Eucain is a synthetic product and was placed upon the market at first as "Alpha-eucain" and "Beta-eucain," two closely allied bases, differentiated as eucain "A" and eucain "B." The former has been withdrawn from the American market, while the latter is used quite extensively in dentistry as a local anesthetic in the form of beta-eucain hydrochlorid. BETA-EUCAINiE HYDRO CHLORIDUM (Nonofficial) (Beta-eucain Hydrochlorid; Eucain Hydrochlorid B; Ci2Hi2N02(CH3)3.HCl.) Beta-eucain hydrochlorid occurs as a white crystalhne powder, soluble in 20 to 30 parts of water at the ordinary temperature, more soluble in warm water, soluble in 25 to 30 parts of alcohol. The solutions are neutral and can be sterilized by boihng without change. Physiologic Action and Therapeutics. — Eucain is a local anes- thetic, Hke cocain, but weaker and devoid of the stimulating action of the latter. It does not dilate the pupil, and it differs from cocain in that it does not produce ischemia by the contraction of the blood-vessels. By some this is claimed to be an advantage, as it permits more profuse hemorrhage after operating, and thus it is supposed some of the drug is carried out of the part and does not enter the circulation. The solutions of beta-eucain hydrochlorid have the one distinct advantage of being stable even on prolonged boiling. The drug may be used in almost all cases where cocain is indicated, a 2 per cent, solution being about the strength used for the painless extraction of teeth. Incompatibles. — AlkaHes and their carbonates and alkaloidal reagents. NOVOCAINS HYDROCHLORIDUM (Nonofficial) (Novocain Hydrochlorid; C13H20O2N2.HCI.) Novocain hydrochlorid is a synthetic product, and occurs in colorless needle-shaped crystals, readily soluble in water (i part) and less soluble in alcohol (30 parts). The aqueous solutions of the salt are neutral and may be boiled without decomposition. The dose depends upon the purpose for which the drug is employed. 138 LOCAL ANESTHETICS Owing to its feeble toxicity it may safely be used hypodermically up to 4 gr. (0.25 Gm.) in adults. Physiologic Action and Therapeutics. — Novocain is claimed to be far less toxic than any of the synthetic substitutes for cocain. It is unirritating, but when injected beneath the skin or mucous membrane it exerts a prompt and powerful local anesthetic action. This effect, however, is not long sustained, but may be overcome by the simultaneous injection of the suprarenal alkaloid (adrenalin or suprarenin). The drug may be employed as a local anesthetic wherever cocain is indicated, and often to advantage. It is exten- sively employed for producing anesthesia by the conductive or "nerve- blocking" method. This method requires special study and technic. Excellent books on the subject, to which the reader is referred, are those of Braun-Shields, Fischer-Rietmiiller, Lederer, and Throma. In recent years many valuable articles have appeared in dental literature by Prinz, Blum, Rietmiiller, Smith, and others. Incompatibles. — Novocain hydrochlorid is incompatible with alkalies and their carbonates and all alkaloidal reagents. NEOTHESm^ HYDROCHLORIDUM (Nonofficial) (Neothesin Hydrochlorid; (CH3)2;N(C2Hii)(C2H5)OCO (C6H5).HC1.) Neothesin is a new S3nithetic product. It occurs as a white, freely soluble powder. Not administered internally. Physiologic Action and Therapeutics. — This drug possesses marked local anesthetic properties. Experiments have shown it to be equal in anesthetizing power to cocain, one-half as toxic and more rapid in its action. It has the disadvantage of being irritating to the tissues when administered hypodermically; and is used only thus far in dentistry as a constituent of the author's "Desensitizing Paste." Here its rapid anesthetic action is of great value and its irritant effect is of no consequence. AppHed directly to the exposed sensitive dentinal fibrillae it acts quickly thereon and temporarily paralyzes the terminal ends thus exposed. It should be remembered that the drug, Hke cocain or other local anesthetics, thus applied will not penetrate the softened dentin. To desensitize the dentin sufficiently deep to permit of its painless removal, agents like para- formaldehyd, from which formaldehyd gas is generated by the heat of the body, must be used. Neothesin will prevent the tooth from aching while the dentin is being desensitized. CHLOKBUTANOL — ORTHOFORMUM I39 (CHLORBUTANOL (Nonofficial) (Chloretone; C2Cl3(CH3)20H.) Chlorelone is a synthetic product, and occurs as a white crystal- line powder, with a camphoraceous odor and taste. It is sparingly soluble in water, but freely so in alcohol and ether. The average dose is 10 gr. (0.6 Gm.). Physiologic Action and Therapeutics. — Chloretone, when first introduced, was claimed to have marked, local, anesthetic properties and was recommended as a substitute for cocain. The local anes- thetic property, however, proved to be rather feeble. The drug may be classed as a local anodyne and antiseptic, and also acts when taken internally as a somnifacient. Its use in dentistry is largely that of an antiseptic, and it is added as a preservative to solutions of organic compounds, such as cocain and adrenalin. ORTHOFORMUM (Nonofficial) (Orthoform; Methyl Meta-Amino-Para-Oxybenzoate; CsHgOsN.) Orthoform, called also orthoform-new, is a synthetic compound, and is the methyl ester of meta-amino-para-oxybenzoic acid. It occurs in a fine, white, or yellowish-white, crystalline powder, neutral in reaction, odorless and tasteless. It is practically insoluble in water, but soluble in 5 or 6 parts of alcohol and in 50 parts of ether. The average dose is 10 gr. (0.6 Gm.). Physiologic Action and Therapeutics. — Orthoform is a local anesthetic, and in its local action closely resembles cocain, but differs from the latter in that it does not penetrate the tissue on account of its insolubility. It has practically no action on the unbroken skin or mucous membrane and produces no irritation except slight corro- sion about the site to which it is applied. The drug is mildly anti- septic and practically nontoxic in the usual doses. As an anodyne remedy for painful wounds or abraded surfaces it is an absolute specific. Mawhinney suggests using equal parts of orthoform and euro- phen as a dusting powder for burns, exposed alveolar process after ex- traction, etc. It can be handled more conveniently in the mouth if a paste be made of the mixture of orthoform and europhen, using liquid petroleum as the vehicle. Plain aseptic gauze may be satu- rated with this paste and carefully packed into painful sockets after extraction, covering the exposed process and lacerated tissue with the oleaginous paste. The same packing is excellent after root amputation and other minor operations about the jaws. I40 GENERAL ANESTHETICS Incompatibles. — Orthoform is decomposed by boiling water, and incompatible with alkalies and their carbonates. GENERAL ANESTHETICS . The detail technic of the administration of general anesthetics is a topic of sufficiently great importance as to merit discussion in a separate volume by specialists in this line of work. Several excellent books covering this phase of general anesthetics are on the market. In our discussion of the drugs grouped under this heading, the author will confine himself largely to materia medica proper. The description of the drugs, their general action, and the indication or contraindication for their use are subjects which should naturally be considered in a work of this kind. The most important general anesthetics are: Nitroui 3 Oxid. Chloroform. Ether. Ethyl Chlorid.* Ethyl Bromid. NITROGENH MONOXIDUM— U.S.P. (Nitrogen Monoxid ; Nitrous Oxid ; Laughing Gas ; N2O.) Nitrous oxid is a gas prepared by carefully heating, in a proper apparatus, ammonium nitrate. The gas is collected over water and purified by running it through a series of wash-bottles. It is colorless, odorless, and possesses a somewhat sweetish taste. By cold and pressure it is converted into a liquid, when it is usually placed in iron cylinders and kept for subsequent use. When the gas is administered many times daily, as with extraction specialists, it is best to manu- facture the gas fresh each morning and store it in an ordinary gas tank for this purpose. Physiologic Action. — Nitrous oxid is the safest known general anesthetic. The death-rate from this gas, used as an anesthetic, is less than i : 500,000. It is nonirritating when inhaled, but pro- duces an increase of blood-pressure, a sense of exhilaration, ringing in the ears, and lividity of the face; in about one minute, if the gas is undiluted with oxygen, these symptoms are followed by complete unconsciousness. The muscles are not fully relaxed, and the conduct of the patient while under the influence of the gas depends largely upon the confidence the patient reposes in the anesthetist. Excite- ment, laughing, cr)dng, and a pugilistic tendency, though all un- consciously, are often indulged in. It is claimed that the anesthesia ^THER 141 is induced by a twofold action: the temporary displacement of oxy- gen from the blood, and the direct influence of the gas on the central nervous system. The recovery is almost instantaneous upon the removal of the anesthetic agent. When the gas is mixed with air or pure oxygen the excitement is apt to be greater and the anesthetic effect more slowly produced. Therapeutics. — Nitrous oxid is the ideal general anesthetic for all minor surgical operations. Indeed, the gas mixed in proper propor- tions with pure oxygen has gained a reputation for operations in major surgery. By this means the patient may be kept under the influence of the anesthetic for hours. Much credit is due Teter, of Cleveland, Bevan, of Chicago, and others, for developing the technic and encouraging the use of prolonged anesthesia by nitrous oxid and oxygen. Many dental operations, like the preparation of cavities in sensi- tive teeth, opening abscesses, removing partially decalcified pulp tissue, etc., may be performed absolutely without pain under the influence of nitrous oxid and oxygen, carried to the analgesic stage. This method was quite popular for a few years past; but it has been practically superseded by the author's Desensitizing Paste for painless cavity preparation, and by conductive anesthesia for this and other dental operations. iETHER— U.S.P. (Ether; Ethyl Oxid; (C2H5)20.) Ether is made by the action of sulphuric acid on ethyl alcohol. It is a transparent, colorless, mobile, and very volatile liquid, having a characteristic odor and a burning, sweetish taste. Freely soluble in alcohol, chloroform, oils, and in about ten times its volume of water. Ether is highly inflammable; its vapor, when mixed with air and ig- nited, explodes violently. It should be kept in well-stoppered con- tainers, preferably in tin cans, in a cool place, away from Hghts or fire. The official product contains about 4 per cent, of alcohol. The average dose is 15 min. (i.o mil); for anesthesia about i fl. oz. (30.0 mils) . When ether is to be used for anesthesia it is to be dispensed only in small, well-closed containers and is not to be used for this purpose if the container has been opened longer than twenty-four hours. The following preparation is of&cial: Spiritus i^theris, U.S.P. Dose, about i fl. dr. (4.0 mils). Physiologic Action. — When applied to the skin, mucous mem- brane, or tooth-structure, ether produces intense cold by its rapid 142 GENERAL ANESTHETICS evaporation, and acts as a refrigerant local anesthetic. If it is con- fined on soft tissue, great irritation results. When inhaled as a gen- eral anesthetic, it irritates the mucous membrane of the respiratory tract, and at first coughing, choking, and a sense of strangulation follow. These symptoms are soon overcome, and complete loss of consciousness marks the subsequent stage of anesthesia, when total relaxation supervenes, accompanied by gentle, regular breathing. The drug is eHminated chiefly by the lungs and kidneys; on the latter organs it has an irritant effect, therefore, it should be employed cau- tiously as a general anesthetic in cases of nephritis. Therapeutics. — Ether is used largely as a general anesthetic, and, when thus administered for dental purposes, it had better be given by an experienced anesthetist. The ether spray is used for ohtnnding sensitive dentin. This requires a specially designed apparatus. Good results can also be immediately obtained by adjusting the rubber dam and evaporating the following remedy, applied to the cavity on a small pledget of cotton: Cocain, 20 gr. (1.3 Gm.) ; chloro- form, 2 fl. dr. (8.0 mils); ether, 6 fl. dr. (24.0 mils). Ether is a valuable solvent for many substances insoluble in water, such as resins and oils. The spray may also be used as a local anesthetic, preliminary to opening abscesses, but it is inferior to ethyl chlorid for this purpose. The compound spirit of ether (formerly official and commonly called "Hoffmann's Anodyne") may be mixed with an equal volume of camphorated tincture of opium (paregoric) and given in doses of i fl. dr. (4.0 mils) to check diarrhea in hot weather. The compound spirit of ether also is a useful remedy as an antispasmodic in children with complications of first dentition. Contraindications. — Ether is contraindicated as a general anes- thetic in cases of advanced arteriosclerosis; tuberculosis with a tend- ency to hemorrhage; acute and chronic diseases of the kidneys; anemia, when the hemoglobin is less than 30 per cent.; diabetes, especially when well established. Death from ether usually results from asphyxia. CHLOROFORMUM— U.S.P. (Chloroform; Methyl Trichlorid; CHCI3.) Chloroform is made for commercial purposes by the action of chlorin on alcohol. It is a heavy, clear, colorless, mobile, and dif- fusible liquid, having a characteristic odor and a burning, sweet taste. Soluble in about 200 times its volume of cold water, and in CHLOROPOEMUM 143 all proportions in alcohol, ether, and oils. It is not inflammable, but its heated vapor burns, emitting a green flame and noxious gases are produced. For this reason care should be taken not to vaporize chloroform in the presence of a naked flame. It should be kept in amber-colored, glass-stoppered bottles, in a dark, cool place. The average dose is 5 min. (0.3 mil) ; for anesthesia, about }^ fl. dr. (15.0 mils). The following preparations are official: Aqua Chloroformi, U.S. P. Dose, J-^-2 fl. oz. (15.0-60.0 mils). Spiritus Chloroformi, U.S. P. Dose, 20-60 min. (1.3-4.0 mils). Lim'mentum Chloroformi, U.S. P. (externally). Physiologic Action.' — When applied to the skin or mucous mem- brane locally, chloroform produces a sense of coldness by its rapid evaporation. If confined, it causes redness and even vesication. When inhaled it produces general anesthesia; the phenomena ob- served may be grouped under three stages, and are described by Stevens^ as follows: The first stage is characterized by excitement, muscular rigidity, and lessened sensibility (analgesia); the second by anesthesia and muscular relaxation; and the third by stertorous breathing, aboHtion of reflexes, profound narcosis, and absolute muscular relaxation. The drug is eliminated practically unchanged through the lungs and kidneys, and while it irritates the latter organs its deleterious effects are less pronounced, owing to the smaller quantity necessary to induce profound anesthesia. Therapeutics. — Chloroform is a rapid and agreeable general anesthetic. It is far more dangerous than ether, the mortality being five times greater, and should never be administered as a general anesthetic except by, or in the presence of, an experienced anesthetist. With the patient in the upright position, chloroform may be carried to the analgesic stage, and sensitive cavities prepared, deciduous teeth extracted, or abscesses lanced. Most authorities agree, however, that the drug should not be inhaled by the patient unless in the re- cumbent position, and that the analgesic stage is the most dangerous. It is the safest practice to refrain from using the drug in this manner, except, perhaps, in special cases. Chloroform is a constituent of many hniments used for counter- irritation in cases of pericementitis and neuralgia. The drug itself may be confined, and redness and even vesication follow. It has long been used as a solvent for gutta-percha, forming a solution known as chloropercha, used in filling root-canals. Like ether, the ^ Modern Materia Medica and Therapeutics. 144 GENERAL ANESTHETICS agent is used also as a solvent for many otherwise insoluble substances. The liniment of chloroform has been extensively used as a stimu- lating remedy in muscular rheumatism, sprains,.Sind bruises. Indications and Contraindications. — Chloroform, though more dangerous than ether, is to be preferred to the latter as a general anesthetic in all acute inflammatory diseases of the bronchi or lungs, advanced diseases of the blood-vessels, acute and chronic diseases of the kidneys. In the extraction of teeth ether is considered the safer anesthetic ; chloroform being more apt to cause cardiac paralysis reflexly by way of the superior or inferior dental nerve. Chloroform is contraindicated in all cardiac diseases, and if administered here must be given cautiously. Death from chloroform usually results from circulatory failure. As has been stated, the drug is pleasant to inhale, and many individuals have the chloroform habit. ^THYLIS BROMmUM (Nonofficial) (Ethyl Bromid; Hydrobromic Ether; C2H5Br.) Ethyl bromid is made by heating a mixture of ethyl alcohol, sulphuric acid, and potassium bromid. When pure, it occurs as a colorless, highly volatile Hquid, having an odor resembling chloro- form and a sweetish taste. It is inflammable, and on exposure to air it liberates bromin and hydrobromic acid and becomes unfit for use. It should be kept in dark amber-colored bottles, tightly stop- pered. The dose as a general anesthetic is from i-6 drams (4.0- 24.0 mils), depending upon the age and condition of the patient. Physiologic Action and Therapeutics. — ^As a general anesthetic, ethyl bromid somewhat resembles the action of chloroform. It may be used for short operations, but has nothing to recommend its employment over nitrous oxid except that it does not require cumber- some apparatus for its administration. The anesthesia is quickly and pleasantly induced and the recovery is rapid, but subsequently the patient may have general mild depression. Pain is abolished before consciousness. The respiration is paralyzed at about the same time as the reflexes, so that the zone of safety is very narrow. Tetanic spasms have occurred. Deaths caused by this drug were formerly attributed to impurities, but several have occurred when a pure article was given. It must be regarded as a very dangerous agent, especially in inexperienced hands. Those drugs not included in this group, which possess general ANTIPYRESTA 145 analgesic or anodyne properties, will -be considered under other headings in the following pages. ANTIPYRETICS Antipjrretics, called also febrifuges, are drugs which reduce the body temperature when abnormally high. This group includes: Coal-tar Derivatives: Cinchona, especially its alkaloid, Antipyrin. Quinin. Acetanilid. Phenacetin. Pyramidon. ANTIPYRINA— U.S.P. (Antipyrin; C6H5(CH3)2C3HN20.) Antipyrin is a coal-tar derivative, basic in character, obtained by the condensation of phenyl hydrazin with diacetic ether and methyl- ization of the product. It occurs as a white, crystalhne powder or scales, odorless, of a slightly bitter taste, freely soluble in water, alcohol, and chloroform. The average dose is 5 gr. (0.3 Gm.). Physiologic Action. — Antipyrin has no action on the unbroken skin. It first irritates and then blanches mucous membranes, result- ing in an analgesic effect. It may be considered a mild antiseptic, and applied locally to abraded surfaces it contracts the blood-vessels and acts as a mild styptic. Internally administered, it reduces abnormally high temperatures, as in fevers, but has practically no action in health. The drug here dilates the blood-vessels and in- creases perspiration, and thus heat reduction is brought about. Anti- pyrin differs from other aniUn derivatives (acetanilid) in that it has no appreciable action upon the blood itself, and in this respect it is a much safer analgesic. Therapeutics. — Antipyrin is a comparatively safe and useful drug in all conditions, the treatment of which calls for the relief of pain. Some authorities place it next to opium as a general analgesic. The drug may be given in powdered form or in solution for the relief of pain of a neuralgic character, and whenever it is desirable to lower temperature in fever. As an antispasmodic, it is useful in the child- hood period of tooth-eruption, in whooping-cough, etc. Here it may be taken in combination with a bromid. The following may be given in teaspoonful doses, further diluted with water, to a child three years old, varying the dose according to the age: Antipyrin, 45 gr- (3-° Gm.); sodium bromid, i3-^ dr. (6.0 Gm.); glycerin, 3^ fl. 146 ANTIPYRETICS oz. (15.0 mils); peppermint water, 23^ fl. oz. (75.0 mils). In capil- lary oozing after operations, the drug may be applied locally in powdered form, or a 20 to 30 per cent, solution, which is less irritating. Incompatibles. — Antipyrin is incompatible with tincture of iodin, mercuric and mercurous chlorid, the ferric salts in solution, phenol, chloral, beta-naphthol, sodium bicarbonate, sodium salicy- late, orthoform, spirit of nitrous ether, and the salts of quinin and caffein. The wide range of incompatibles is due to the basic prop- erties of the drug. ACETANILIDUM— U.S.P. (Acetanilid; Antifebrin; C6H5NH.C2H3O.) Acetanilid is a coal-tar product, derived from anilin, an atom of hydrogen in the latter being replaced by the acetic acid radical. It occurs as a white, shining, crystalline powder, without odor, of a faintly burning taste ; sparingly soluble in water, freely in alcohol and chloroform, and somewhat less so in ether. The average dose is 3 gr. (0.2 Gm.). There was formerly one official preparation: Pulvis Acetanilidi Compositus, U.S. P. VIII (Compound Acetanilid Powder; Acetanilid, 70 parts; Caffein, 10 parts; Sodium Bicarbonate, 20 parts). Dose, 7^^ gr. (0.5 Gm.). Physiologic Action. — ^Like antipyrin, in moderate doses in health acetaniUd has no perceptible effect. Internally administered in fever, the drug produces marked fall of temperature, due, in all proba- biHty, to its direct influence on the centers which regulate heat- production. Free perspiration frequently accompanies the fall of temperature. In large doses acetanilid acts as a cardiac depressant and induces blood-changes. The blood assumes a chocolate color, due to the production of methemoglobin. It is, therefore, not as safe an analgesic as antipyrin, though exerting a greater influence over the nerve centers which control pain. Applied locally to mucous membranes or abraded surfaces, the drug is nonirritating and exerts an analgesic effect by depressing the sensory nerve-endings. Poisoning and Treatment. — The symptoms of poisoning by acetanilid are marked cyanosis, feeble breathing, pulse soft, slow, later rapid and weak, free perspiration, pupils dilated and ultimate collapse. In the treatment of poisoning the body temperature should be maintained by external heat and such cardiac and respiratory stimulants given as strychnin sulphate, ammonia, and atropin sul- ACETPHENExmrisruM 147 phate. In combating the cyanosed condition inhalations of pure oxygen and artificial respiration are important. Therapeutics. — Acetanilid, judiciously employed, is a valuable drug for the relief of pain in many diseased dental conditions, such as acute abscess, neuralgia, headache, etc. It is always best to combine the drug with a stimulant to overcome the depressant effect of ace- tanilid upon the heart. In the formerly official powder, caffein is added for this purpose. Harlan suggested a formula wherein whisky was added as the cardiac stimulant. It is: Acetanilid, 10 gr. (0.65 Gm.) ; simple syrup, }4 A- oz. (15.0 mils) ; whisky, 2 3^ fl. oz. (75.0 mils). The compound powder, which can be obtained in tablets, is an ex- cellent form in which to administer the drug. The drug may be cautiously applied locally in powdered form in the treatment of wounds, burns, ulcers, or other abraded surfaces, but is far inferior, as a local analgesic, to orthoform. ACETPHENETIDINTJM— U.S.P. ' (Acetphenetidin; Phenacetin; C6H4OC2H5.NHC2H3O.) Acetphenetidin, commonly called phenacetin, is a coal-tar prod- uct obtained by the action of glacial acetic acid on paraphenetidin (an anilin derivative), one atom of hydrogen in the latter being re- placed by the acetic acid radical. It occurs as white, glistening, crystalline scales or fine powder, without odor or taste, sparingly soluble in water, but freely so in alcohol and glycerin. The average dose is 5 gr. (0.3 Gm.) . Physiologic Action and Therapeutics. — Internally administered, phenacetin exerts a similar action to that produced by antipyrin and acetanihd, though all authorities claim that it is far less toxic than either of these drugs. Everything considered, it is the most satis- factory of all of the coal-tar antipyretics. Probably the only objec- tion that may be offered to its use is that it is more expensive than antipyrin or acetanilid, but when its safety is considered even this possible objection is outweighed. It may be advantageously em- ployed in all cases where the other coal-tar analgesics have been men- tioned. A useful formula is the combination of phenacetin and codein sulphate in the proportion of 5 gr. (0.3 Gm.) of the former to ^i gr. (0.03 Gm.) of the latter for an adult dose. Though the actions of antipyrin, acetanilid, and phenacetin are similar, frequently results are obtained by the use of one of the drugs where the others have failed. 148 ANTIPYRETICS PYRAMIDON (Nonoflacial) /CO-CN(CH3)2 C6H5N< ^N(CH3).C(CH3). Pyramidon is dimethylaminoantipyrina and differs from anti- pyrin in that a dimethylamino group, N(CH3)2, has replaced a hydro- gen atom of the pyrazolon nucleus. It occurs in small, colorless, slightly alkaline crystals, almost tasteless; soluble in 11 parts of cold water and readily soluble in alcohol, ether and benzene. The average dose is 5 gr. (0.3 Gm.), most conveniently given in the form of tablets, a single dose usually sufficing for twenty-four hours. Physiologic Action and Therapeutics. — Pyramidon acts as an antipyretic and general anodyne, like antipyrin, but is effective in smaller doses and the effect persists longer, though somewhat slower at the beginning. It is claimed to be comparatively free from harm- ful influences on the blood, heart, or kidneys. In all cases in den- tistry calling for the relief of pain it may be given. Like other antipyretics, it should be cautiously employed in the treatment of infectious fevers. Incompatibles. — In general the drug is incompatible with the same agents as is antipyrin. Oxidizing agents (also acacia) often produce colored solutions. CINCHONA— U.S.P. (YeUow Peruvian Bark; Yellow Cinchona.) Cinchona is the dried hark of Cinchona calisaya, Cinchona ledger- iana, Cinchona officinalis, and several other species of Cinchona, tall evergreen trees indigenous to South America, and now cultivated in Ceylon, Java, and Jamaica. Red cinchona is also official. Cinchona Rubra, U.S. P., and is the dried bark of Cinchona succirubra. Both specimens should yield not less than 5 per cent, of total anhydrous cinchona alkaloids, of which there are several; the most important are quinin, quinidin, cinchonin and cinchonidin. The following prepa- rations are official : Fluidextractum Cinchonae, U.S. P. Dose, }i-i fl. dr. (2.0- 4.0 mils). Tinctura Cinchonae, U.S. P. Dose, 1-2 fl. dr. (4.0-8.0 mils). Tinctura Cinchonae Composita, U.S. P. (Huxham's Tincture; Red Cinchona, 10; Bitter Orange Peel, 8; Serpentaria, 2). Dose, 1-4 fl. dr. (4.0-15.0 mils). QumiNA ■ 149 Several of the alkaloids and their salts are also official. They are: Qiiinina, U.S. P. Dose, i-io gr. (0.06-0.65 Gm.). Quininse Sulphas, U.S. P. Dose, 1-20 gr. (0.06-1.3 Gm.). Quininae Bisulphas, U.S. P. Quininse Dihydrochloridum, U.S. P. Quininae Hydrochloridum, U.S. P. Quininae Hydrobromidum, U.S. P. Quininae Salicylas, U. S. P. Dose, i-io gr. (0.06-0.65 Gm.). Cinchoninae Sulphas, U.S. P. Dose, 1-15 gr. (0.06-1.0 Gm.). Cinchonidin^ Sulphas, U.S.P. / ^'"'^ ^"^-^ ^'- ^^'^^'^'^ ^^•)- Quininae Dihydrochloridum, U.S.P. Dose, 1-15 gr. (0.06-1.0 Gm.). Quininae et Ureae Hydrochloridum. Dose, hypodermic (one dose daily) 15 gr. (i.o Gm.). It will be observed that there is rather a wide range of dosage given for these alkaloidal salts of quinin. The reason for this is that they, Uke quinin itself, are given both as a tonic and antimalarial. The dose as a tonic is much smaller than for antimalarial purposes. Inasmuch as quinin is the most important alkaloid of cinchona and represents largely its active properties, it will be the only con- stituent here described. QummA— U.S.P. (Quinin.) Quinin occurs as a white, flaky, amorphous or crystalline powder, odorless, and of an extremely bitter taste. It is practically insoluble in water, but is readily soluble in acidulated water, alcohol, and ether. Physiologic Action. — Quinin acts differently upon different in- dividuals. In large doses, and with some subjects in comparatively small doses, it causes a sense of fullness in the head, ringing in the ears, deafness, headache, and sometimes dimness of vision. This group of S3nnptoms is included in the term cinchonism. The drug is ab- sorbed chiefly from the stomach, and its action augments the secre- tions from the salivary and gastrointestinal glands ; it, therefore, may be considered a stomachic and tonic. Through the kidneys is the principal mode of elimination. Butler^ states that quinin has a remarkable effect upon the constituents of the blood. The ameboid movements of the white bfood-corpuscles are arrested, preventing them from migrating through the capillary walls in inflammation. Full doses of the drug also diminish the white blood-corpuscles, while the red corpuscles are proportionately increased. Quinin diminishes the metabolism of the body by lessening the oxygen-carrying power ^ Text-Book of Materia Medica, Therapeutics and Pharmacology. 150 HYPNOTICS of the red blood-corpuscles. Though it is doubtful that quinin ever directly caused the death of a human being, idiosyncrasies are fre- quently encountered. Two or 3 gr. (0.13-0.2 Gm:) have been known to produce intense cinchonism in some individuals, and quinin rashes are not uncommon. The drug also acts as an antiseptic and it is claimed to possess local anesthetic properties. Quinin and urea hydrochlorid is now being used as a local anesthetic. This is a com- pound of quinin hydrochlorid and urea hydrochlorid, containing approximately 60 per cent, of anhydrous quinin. When injected hypodermically or when applied locally to mucous membranes it exerts an anesthetic action similar to that of cocain, which, however, may be prolonged for several days. Therapeutics. — Quinin has been used extensively as a domestic remedy for many ills, and most individuals know how the drug affects them. This will govern the dentist in regard to the dose to be administered in a given case. The drug is a specific iox malarial fever, and may be given in cases of neuralgias associated with the teeth; especially is it indicated here in malarial regions and in the spring of the year when the cHmate is more or less damp. The author prefers quinin bisulphate, as it is more soluble. It should be given in gelatin capsules rather than in the dry, hard, pilular form, as the latter may pass through the stomach undissolved. The newly official quinin dihydrochlorid is also very soluble, and its use has been proposed where concentrated solutions of quinin are wanted, as for subcutaneous injections and similar purposes. Quinin is a constituent of many bitter tonics. Quinin sulphate has been recommended for its tonic and antiseptic properties as a local appH- cation in pyorrheal pockets. The bitter taste of the drug makes its use here almost prohibitive. HYPNOTICS H3^notics, also called somnifacients, are agents which induce sleep. The chief hypnotics are: Chloral Hydrate. Trional. Butyl-chloral Hydrate. Paraldehyd. Sulphonal. The Bromids. CHLORALUM HYDRATUM— U.S.P. (Hydrated Chloral; Chloral; C2HCI3O -|- H2O.) Hydrated chloral is obtained by the union of a molecule of water with trichloraldehyd, commonly called chloral, the latter being pre- CHLOEALUM HYDRATUM 151 pared by the action of chlorin upon alcohol, whence the name chlor-al. Chloral hydrate is the official preparation and the only one used in dentistry or medicine. It occurs as colorless, transparent crystals, having an aromatic, penetrating odor, and a bitterish, caustic taste; freely soluble in water, alcohol, ether, and chloroform. It Hquefies when triturated with an equal quantity of menthol, thymol, phenol, or camphor. The average dose is 8 gr. (0.5 Gm.). Physiologic Action. — AppHed locally, chloral hydrate acts as an antiseptic, mild anesthetic and vesicant. Even when applied to the unbroken skin, it produces redness and sometimes vesication. Inter- nally administered in therapeutic doses, the drug induces quiet sleep of a natural character. It is irritating to the stomach and had better be given after meals. The chief action of chloral hydrate is upon the nervous system, the sleep being the result of the direct influence of the drug over the cerebral cells which lessens reflex activity by depress- ing the motor neurons of the spinal cord. The drug has a depressant effect upon the cardiac and respiratory centers, which is an objection to its use. Attempts to modify the drug so as to make it safer have resulted in weakening its h3^notic action. It is the standard h.y^- notic of its class. It is eUminated principally by the kidneys. Poisoning and Treatment. — The symptoms of acute chloral poison- ing are sleep, deepening into coma. The pulse is feeble, thready, and irregular; temperature subnormal; respiration slow, followed by rapid shallow breathing, and ultimate collapse. Death may result from either cardiac or respiratory paralysis. In the treatment of poisoning the temperature should be maintained or restored by artificial heat — warm blankets, hot bottles, etc. Cardiac and respiratory stimulants, Hke strychnin, ammonia, atropin, and digitalis should be employed. To prevent asphyxia, inhalations of pure oxygen and artificial respira- tion should be resorted to early. Therapeutics. — The principal use of chloral hydrate is to induce sleep in cases of insomnia. It is especially indicated when the sleep- lessness results from overwork, excitement, fear, or dread. It should not be given continuously on account of the Hability to form habit. As a hjrpnotic for insomnia resulting from pain, the drug is far inferior to opium. On account of the powerful depressant effect chloral hydrate exerts upon the motor neurons of the spinal cord, it is a valuable drug in the treatment of the various convulsions and spas- modic disorders of childhood, such as the complications of temporary dentition, whooping-cough, etc. Combined with potassium bromid it is considered one of the best sedatives in the treatment of the con- vulsions of tetanus and strychnin poisoning. 152 HYPNOTICS Chloral camphor, a clear, syrupy liquid, can be made by triturat- ing equal parts of chloral hydrate and camphor. This remedy may be used as an anodyne in cases of pulpitis, and in neuralgia. Contraindications. — The drug is contraindicated in cases of marked cardiac and respiratory weakness. Incompatibles. — Chloral hydrate is incompatible with alkalies and strong solutions of antipyrin. Butyl-chloral Hydrate.' — This product is produced by the action of chlorin on acetic aldehyd, hydrated by the addition of water. It occurs in white, pearly scales, having a pungent odor, and an acid, disagreeable taste. It is practically insoluble in water, but freely soluble in alcohol and glycerin. The average dose is 8 gr. (0.5 gm.). Physiologic Action and Therapeutics. — In its action, butyl-chloral hydrate resembles chloral hydrate, except that it is less powerful as a hypnotic and more analgesic. Authorities claim that the fifth or trigeminal nerve is especially susceptible to the influence of butyl- chloral hydrate, and the drug has been extensively used in the treat- ment of trifacial neuralgia and migraine. The drug is best given in the form of capsules on account of its disagreeable taste. Incompatibles. — Butyl-chloral hydrate is incompatible with alkahes. SULPHONMETHANUM— U.S.P. (Sulphonmethane ; Sulphonal; (CH3)2C(S02C2H5)2.) Sulphonal is a synthetic product obtained by the oxidation of a mixture of ethyl hydrosulphid and acetone (a Uquid resembHng ethyl alcohol in its action). It occurs as a colorless, odorless, and nearly tasteless, crystalline powder; soluble in 360 parts of cold water, in 15 parts of boihng water, and in 65 parts of cold or 2 parts boihng alco- hol. The drug is stable and is not affected by strong acids or alka- lies. The average dose is 12 gr. (0.75 Gm.). Physiologic Action. — Sulphonal is a pure h3rpnotic, its action as such being intensified by combining it with morphin or codein. It has no depressant effect upon the heart, but, like chloral hydrate, it acts chiefly on the nervous system by depressing the cerebral cortex; its influence, however, is less than the latter drug and its action much slower, due to its insolubiHty in the gastric fluids. The hypnotic effect of sulphonal may not be evidenced for several hours after the administration of the drug. Poisoning and Treatment. — The symptoms of acute sulphonal poisoning are headache, vertigo, marked cyanosis, vomiting, dia,rrhea, SULPHONETHYLMETHANTJM — PARALDEHYDUM 1 53 respiration shallow, pulse feeble, unconsciousness and final collapse. Some individuals who become habitual takers of this class of drugs present irregular toxic symptoms, consisting of sleepiness and stu- pidity, loss of appetite and muscular weakness. With some papu- lar eruptions are not uncommon. The treatment of acute poisoning con- sists in the discontinuance of the drug; the administration of saHne cathartics, and cardiac and respiratory stimulants as indicated by the symptoms present. Therapeutics. — Sulphonal is used internally as a hypnotic. It has no other effect, and is never used externally. In insomnia, caused by nervous excitement, grief, or overwork, it is a useful hypnotic. In insomnia due to pain, it is practically worthless, unless combined with the alkaloids of opium. Sulphonal should always be given in powder or capsules or hot whisky. The compressed tablets, unless crushed, should be avoided on account of the sparing solubility of the drug. SULPHONETHYLMETHANUM— U.S.P. (Sulphonethylmethan ; Trional; C2H5.CH3.C(S02C2H5)2.) Trional is a synthetic product containing three ethyl radicals, where sulphonal contains but two. It occurs in colorless, lustrous, odorless, and almost tasteless, crystalline scales; soluble in 195 parts of cold water, and freely soluble in hot water, alcohol and ether. The average dose is 12 gr. (0.75 Gm.). Physiologic Action and Therapeutics. — Trional closely resembles sulphonal in its action. Being more readily soluble, however, the drug acts more quickly and has a tendency to accumulate in the body. It is, therefore, more poisonous than sulphonal. It is best adminis- tered in a warm vehicle, such as milk, tea, of brandy. The treatment of poisoning does not differ from that of sulphonal. PARALDEHYDUM— U.S.P. (Paraldehyd; C6H12O3.) Paraldehyd is a synthetic product obtained by treating aldehyd with dilute sulphuric or nitric acid. It occurs as a colorless Uquid, having a strong ethereal odor, and a burning, pungent taste. It is soluble in 8 parts of cold water, somewhat less so in hot water, and is miscible in all proportions with alcohol, ether, chloroform, and the oils. The average dose is 30 min. (2.0 mils). Physiologic Action and Therapeutics. — Paraldehyd resembles chloral hydrate in its action in that it depresses the brain and spinal 154 HYPNOTICS cord. It differs from the latter, however, in that its depressant action upon the heart is not nearly so marked, though it causes a noticeable fall in arterial pressure. The drug is used only internally as a hyp- notic, and as such it is safe and reliable. It has the great disadvan- tage of a nauseating taste which is difficult to mask, and its disagree- able odor is imparted to the breath for some time after its administra- tion. The s}Tnptoms of poisoning and the treatment of the same are similar to chloral hydrate. As a hypnotic in dental practice, chloral hydrate is far preferable to sulphonal, trional, or paraldehyd. THE BROMIDS The bromids of certain metals, notably potassium, sodium, and ammonium, might well be discussed under different headings; but they are true spinal cord depressants, and when administered produce hypnotic influence; therefore, they will be considered here. POTASSn BROMIDUM— U.SJ>. (Potassium Bromid; KBr.) Potassium bromid is a salt which occurs in colorless, or white cubical crystals or granules, odorless, with a pungent, saline taste; soluble in about 1.5 parts of water and in 180 parts of alcohol.- The average dose is 15 gr. (i.o Gm.). Physiologic Action. — The chief action of potassium bromid is on the nervous system. It depresses both the cerebrum and spinal cord. The drug is rapidly absorbed from the stomach, having been found in the urine fifteen minutes after its ingestion. Its elimination is somewhat slower than its absorption, and there is a tendency for the drug to accumulate in the body. The continued use of potassium bromid is followed by a group of symptoms, called hromism, chief among which are anemia, fetor of the breath, gastric disturbance, mental depression, failure of memory, aboHtion of sexual appetite, and muscular weakness. In the treatment of acute poisoning, ehminatives should be given (diuretics and cathartics), the adminis- tration of the drug should be withdrawn, and other symptoms treated as presented. No fatal case of poisoning by potassium bromid is on record. Therapeutics. — Perhaps there is no drug which will control the nervousness due solely to the dread of the dental chair better than potassium bromid. The drug is especially indicated in nervousness caused hy fear or dread. In cases of highly nervous individuals the SODII BROMmUM — ^AMMONII BROMIDUM 1 55 drug may be given in lo gr. (0.6 gm.) dose, after meals and well diluted, one day previous to. the time of the dental operation. On account of the nauseating taste the drug should be dissolved in one of the official syrups. The compound syrup of sarsaparilla is an excellent vehicle. Potassium bromid is one of the best drugs to control the con- vulsions of epilepsy, and is often used to advantage in the complica- tions of temporary dentition. The drug is irritating to the stomach, and should always be given after meals, well diluted. It may be combined with the antipyretic drugs with excellent results. Incompatibles. — Potassium bromid is incompatible with acids and acid salts. Certain alkaloids are precipitated from neutral solutions by the drug. SODH BROMIDUM— U.S.P. (Sodium Bromid; NaBr.) Sodium bromid is a salt which occurs in colorless, or white, cubical crystals or granules, odorless, and of a saline, bitter taste; soluble in 1.7 parts of water and in 12.5 parts of alcohol. The average dose is 15 gr. (i.o Gm.). Physiologic Action and Therapeutics. — Sodium bromid closely resembles potassium bromid in its action. It is less irritant to the stomach and less depressant, due to the sodium ion. Because of this fact, it may be substituted to advantage for the potassium salt in certain cases in which a bromid is indicated. It should be given after meals, well diluted. Incompatibles. — The same as protassium bromid. AMMONH BROMIDUM— U.S.P. (Ammonium Bromid; NH4Br.) Ammonium bromid is a salt which occurs in white crystals or as a yellowish-white powder, odorless, and having a disagreeable salty taste; soluble in 1.2 parts of water and in 12.5 parts of alcohol. The average dose is 15 gr. (i.o Gm.). Physiologic Action and Therapeutics. — Ammonium bromid resembles potassium bromid in its action. Like the sodium salt, it is less irritant to the stomach and less depressant to the nervous system. It may be substituted for potassium bromid in all cases calHng for the administration of a bromid. It should be given after meals, well diluted. 156 NARCOTICS Incompatibles. — The same as potassium bromid, also spirit of nitrous ether. NARCOTICS Narcotics are agents which induce stupor, and are closely related to stimulants in that the first effect of their action is generally that of an excitant and stimulant to the higher brain, to the mind, and to all of the bodily functions ; this stage of their action is followed by pro- found sleep characterized by increasing stupor, and, if the dose has been sufficient, the second stage is followed by a third, that of coma and insensibihty (narcotism) and ultimate death due to paralysis of the centers which govern respiration and other functions of Hfe. The chief narcotics are: Opium (and Alkaloids). Alcohol. Hyoscyamus. Ether.* Scopola. Chloroform.* Cannabis Indica. Chloral Hydrate.* Tobacco. OPIUM— U.S.P. Opium is the concrete milky exudation (Juice) obtained by incising the unripe capsules of Papaver somniferum, a poppy plant indigenous to Western Asia and cultivated in Egypt, Persia, Asia Minor, and other countries. It appears in irregular cakes or lumps, having a dark brown color, a gummy consistence, a pecuUar narcotic odor, and a bitter taste. With the possible exception of cinchona, opium con- tains more alkaloids than any other drug. The chief alkaloids, in the order of their therapeutic significance, are morphin, codein, narcein, thebain, narcotin, and papaverin. To be up to the official standard, opium, in its normal, moist condition, should yield not less than 9.5 per cent, of anhydrous morphin. The average dose is i gr. (0.6 gm.). The official preparations are : Opii Pulvis, U.S. P. (should contain not less than 10 nor more than 10.5 per cent, of anhydrous Morphin). Dose, 34~2 gr. (0.016-0. 13 Gm.). Opium Deodoratum, U.S. P. (Denarcotized Opium, 10 to 10.5 per cent, of Morphin). Dose, 3^-2 gr. (0.03-0.13 Gm.). Opium Granulatum, U.S. P. (10 to 10.5 per cent, of Morphin). Dose, J^-2 gr. (0.03-0.13 Gm.). Extractum Opii, U.S. P. (20 per cent, of Morphin). Dose, J^-i gr. (0.016-0.65 Gm.). Tinctura Opii, U.S. P. (Laudanum; 10 per cent.). Dose, 5-20 min. (0.3-1.3 mils). OPIUM 157 Tinctura Opii Deodorati, U.S. P. (10 per cent.). Dose, 5-20 min. (0.3-1.3 mils). Tinctura Opii Camphorata, U.S. P. (Paregoric; contains Camphor, Benzoic Acid, Oil of Anise, and Powdered Opium; 4 fl. dr. (15.0 mUs) represent about i gr. (0.065 g^a-) of Opium). Dose, }i-4 fl. dr. (2.0-15.0 mUs). Pulvis Ipecacuanhae et Opii, U.S. P. (Dover's Powder; contains 10 per cent, of Powdered Opium; 10 per cent, of Powdered Ipecac; and 80 per cent, of Sugar of Milk). Dose, 5-10 gr. (0.3-0.65 Gm.). Mistura Glycyrrhizae Composita (from Camphorated Tincture ' of Opium). Dose, 2-3 fl. dr. (8.0-12.0 mils). Morphin and codein are the chief alkaloids of opium, and they represent the physiologic activity of the drug. Both are official. Morphin occurs in white, prismatic, shining crystals or fine needles, odorless, of a bitter taste, and sparingly soluble in water, freely so in alcohol. The average dose is }/§ gr, (0.008 Gm.). Codein occurs in white or nearly translucent prisms, or a crystal- line powder, odorless, and having a faintly bitter taste; soluble in 120 parts of water and in 2 parts of alcohol. The average dose is 3^gr. (0.03 Gm.). The salts of morphin and codein are much more soluble than the alkaloids themselves, and these are generally prescribed. The follow- ing are official: Morphinae Hydrochloridum, U.S. P. Dose, H-}^ gr. - (0.008-0.032 Gm.). Morphinae Sulphas, U.S. P. Dose, }i-}i gr. (0.008-0.032 Gm.). Codeinae Sulphas, U.S. P. Dose, }i-2 gr. (0.03-0.13 Gm.). Codeinae Phosphas, U.S. P. Dose, 3^-2 gr. (0.03-C.13 Gm.). Physiologic Action. — Opium is a narcotic inducing stupor, and** as a result true analgesic and hypnotic effects are produced, the dominant action being due to the morphin which it contains. The drug acts principally upon the brain, which it soon depresses, causing sleep. When the dose has been moderate, a stage of excitement or exhilaration generally precedes the narcosis. In large doses opium is a powerful respiratory depressant, and in fatal cases of poisoning death usually results from paralysis of the respiratory centers. All of the secretions, except the perspiration, are diminished by opium ; the saHvary glands are especially affected, causing great dry- ness in the mouth and consequent thirst; digestion is also impaired and constipation results. There is a difference of opinion in regard to the local action of 158 NARCOTICS morphin. Stevens^ states that morphin, applied locally, acts as a direct depressant to the sensory nerve filaments. Many pharma- cologists claim that the alkaloid has little or no local action, and that to produce its effect it must enter the circulation and be carried to the brain where it depresses the central nervous system. Opium is rapidly absorbed and is eUminated chiefly from the viscera of the stomach and intestines (gastrointestinal mucous mem- brane) and very Httle by the kidneys. Conditions and Drugs Modifying the Action of Opium. — There are certain symptoms, diseases, and drugs which greatly modify the action of opium. Patients suffering from severe pain, as in acute alveolar abscess, neuralgia, etc., or patients having diabetes can frequently take with advantage doses which, under ordinary circum- stances, would produce profound narcosis. The age and sex also modify the action of opium. Children are pecuUarly susceptible to the drug on account of their sensitive nervous mechanism, and, there- fore, smaller doses must be given than the age would naturally indi- cate. The action of opium is more pronounced on women than on men. Patients rapidly acquire a tolerance of the drug through frequent repetition of the dose, so that habitues can often take large quantities without experiencing the usual effects. The hypnotic action of opium is enhanced by combining it with hypnotic drugs ; its anodyne influence is increased by belladonna and cocain, and its diaphoretic effects by ipecac. Poisoning and Treatment. — It is the acute rather than the chronic poisoning by opium with which the dentist should be familiar. Unless the dose is very large, the narcotic symptoms are manifested by three distinct stages. The first is excitement or exhilaration, in which the imagination is stimulated and the feelings are exalted. This is soon followed by the second stage in which listlessness and drowsiness are the prominent symptoms, the patient finally falling into a deep sleep ; the pulse is slow and full, the pupils are contracted to a pin-point size, the respirations are slow and difi&cult, the muscles are relaxed, and the face is pale. In this stage it is still possible to arouse the patient by loud noises, shaking, etc. From this stage, unless proper treatment is given, the patient gradually passes into the third, that of absolute coma and insensibility — a sleep from which he never awakens, death finally resulting from paralysis of the respira- tory and other Hfe-centers. The author well remembers his first experience in poisoning a cat ^ Modern Materia Medica and Therapeutics. OPIUM 159 with opium in the pharmacy course of instruction. A moderate dose of morphin sulphate was h3rpodermically administered. In a few minutes the animal imagined it had caught a mouse and was happy playing with it; after a short time, it became drowsy and fell asleep — here the pupils were contracted, respiration was slow and labored, and the muscles completely relaxed ; finally, perhaps a half -hour from the time the first symptoms were manifested, the cat passed into that comatose state from which it never awoke. In the treatment of acute opium poisoning, at least three objects are of prime importance: to eHminate the poison, maintain respiration, and prevent failure of the circulation. The first thing to do is to empty the stomach either by means of the stomach-pump or stimu- lating emetics, as zinc sulphate or mustard flour, and evacuate the bowels. Strong black coffee may be given by the mouth or bowel; it promotes wakefulness and stimulates respiration. Atropin and strychnin may also be given. The best chemic antidote is potassium permanganate; 3-5 gr. (0.2-0.3 gm.) of this drug should be dissolved in a glassful of water and given at once, repeated in thirty minutes, if necessary. Tannic acid has also been recommended as a chemic antidote, but neither the morphin sulphate nor hydrochlorid is pre- cipitated by it. Counterirritants, slapping, shouting in the ear, may arouse the patient from his lethargy. Continually walking the patient or anything to keep him awake is indicated. When the third stage (narcotism) is approaching, artificial respiration by Sylvester's method or by a pump is imperative. Therapeutics. — Opium, or its alkaloids, have practically but one use in dental practice and that is to control or relieve pain. It is the greatest analgesic known and may well be remembered as the great "pain killer." In allaying the severe pain of fractures, malignant growths, and acute inflammations of serous membranes this drug has no rival. Pain of moderate intensity may often be allayed by the ordinary antipyretic and hypnotic drugs; when it is severe and ex- cruciating and the cause cannot be at once removed, it is a waste of time to experiment with other drugs when so potent an agent as opium is obtainable. In neuralgias and other forms of recurrent pain opium or morphin should be used only after all other measures have failed, and then with extreme caution, on account of the danger of forming the opium habit. No drug except, perhaps, alcohol is more entic- ing, nor its continued use more liable to form the drug-habit than opium. It is safest for a dentist never to write a prescription for the drug. With a prescription the patient may be reheved from the pain for which the remedy was prescribed, but subsequently he l6o ' NARCOTICS might get the prescription refilled on the least provocation, and thus the habit be innocently formed. Dover's powder is a common and valuable remedy in acute coryza. It is also a most-efficient diaphoretic, and may be used in dentistry to abort an acute alveolar abscess. In conditions where the pain is not so severe, codein sulphate may be advantageously combined with other hypnotic drugs, such as phe- nacetin, etc. Morphin has been added to various formulas for devitalizing the pulps of teeth. But as the drug has been shown to possess Httle or no local action, its use here is practically valueless, cocain being far preferable to control the irritating action of the devitahzing agent (arsenic trioxid) . It should be remembered that opium and its alka- loids come under the Federal Anti-Narcotic Law; and when purchased or administered a record must be kept. Contraindications. — On account of the pecuHar susceptibility of children to the drug, if avoidable, opium should not be given under five years of age. One minim (0.06 mil) of tincture of opium (lauda- num) has caused the death of a child one day old, and a few minims of camphorated tincture of opium (paregoric) have proved fatal to an infant nine months old. The death of a nursing babe is even reported where the mother had taken a medicinal dose of laudanum. The drug is, therefore, contraindicated in pregnancy and nursing mothers. HYOSCYAMUS— U.S.P. (Henbane.) Hyoscyamus is the dried leaves and flowering tops of Hyoscyamus niger, a plant growing in Europe, Asia, and North America. The specimen should be collected from plants of the second year's growth, and should >deld, when assayed, not less than 0.065 P^^ cent, of alka- loids, of which there are two — hyoscyamin and hyoscin. Both are official in the form of the hydrobromid, the former Hyoscyaminae Hydrobromidum, U.S.P.; the latter Scopolamine Hydrobromidum ; also known as hyoscin hydrobromid, obtained from various plants of the Solanacece. The average dose of the leaves of hyoscyamus is 4 gi". (0.25 Gm.). The average dose of hyoscyamin hydrobromid is 1^00 gr. (0.0003 Gm.). The average dose of scopolamin hydrobromid is 3^00 gr. (0.0003 Gm.). The following preparations of hyoscyamus are official: Tinctura Hyoscyami, U.S. P. Dose, 10-60 min. (0.6-4.0 mils). Fluidextractum Hyoscyami, U.S. P. Dose, 5-15 min. (0.3- i.o mil). Extractum Hyoscyami, U.S. P. Dose, H~3 g^. (0.03-0.2 Gm.). CANNABIS l6l Physiologic Action. — In therapeutic doses hyoscyamus resembles belladonna in its action; it causes dilatation of the pupils, checks the salivary secretions, produces dryness of the throat, and quickens the pulse and respiration. Its narcotic action upon the brain is some- what more profound than that of belladonna. The consensus of clinical experience seems to be, also, that hyoscyamin and atropin closely resemble each other in their action; with scopolamin (hyoscin) the action is quite different, this drug being a distinct hypnotic in that it depresses rather than stimulates the respiratory center. Therapeutics. — Neither hyoscyamus nor its alkaloids are exten- sively used in dentistry; belladonna and atropin answering all of the purposes for which the former drugs could be employed. Scopola- min hydrobromid and morphin sulphate in combination have been injected hypodermically previous to the administration of general anesthetics as a means of inducing a more tranquil anesthesia. By this means there is said to be an absence of mental excitement, bronchial irritation, and vomiting. In neuralgia in individuals where a tonic is indicated or in malarial regions, the following remedy made into 12 pills or capsules, one given before meals, will prove beneficial: Quinin Valerianate, 24 gr. (1.5 Gm.). Extract of Hyoscyamus, 4 gr. (0.25 Gm.), Extract of Cinchona, 8 gr. (0.5 Gm.). CANNABIS— U.S.P. (Cannabis Indica, U.S.P. VIII; Indian Hemp.) Cannabis is the dried flowering tops of Cannabis sativa, or of the variety indica, a pistillate plant growing in the East Indies. It contains a natural resin called cannabin, and the specimen of the drug should be collected while the fruits are as yet undeveloped, for they then carry the whole of their resin. The average dose is 2 gr. (0.13 gm.). The official preparations are: Tinctura Cannabis, U.S.P. Dose, 5-20 min. (c.3-1.3 mils). Fluidextractum Cannabis, U.S.P. Dose, 2-5 min. (0.13- 0.3 mils). Extractum Cannabis, U.S.P. Dose, 3^-i gr. (0.008-0.065 Gm.). Physiologic Action. — Internally administered in therapeutic doses, cannabis acts as a mild analgesic, hypnotic, and sedative. At first there is a marked stimulation of cerebral activities, the imagina- tion is quickened and the flow of ideas heightened. There is generally 1 62 NARCOTICS a dreamy state accompanying these symptoms, and the sensation of pain and touch are blunted, as the centers governing these are affected. The excitement is finally followed by sleep which may last for several hours. Although alarming symptoms often follow large doses of the drug, death directly attributable to it has not been reported. Therapeutics. — Cannabis is employed for its mild analgesic action in certain forms of neuralgia, especially migraine and headache. It is extensively employed as a hypnotic in melancholia. The extract should be given in pill or capsule, the tincture and fluid extract in alcoholic menstruum on account of the resinous con- stituent (cannabin) being precipitated by aqueous solutions. The drug is not employed for many of the disorders for which it was for- merly used. TABACUM (Nonofficial) (Tobacco.) Tobacco is the commercial dried leaves of Nicotiana tabacum, an annual plant indigenous to tropical America, but cultivated in several parts of the world, especially in Virginia and Cuba. It contains a very poisonous, volatile, oily Uquid alkaloid, called nicotin. The quantity of the alkaloid varies greatly in the different specimens, de- pending largely upon the climate and soil of the various countries in which it is raised. Cuba is supposed to produce about the best specimens of tobacco. Physiologic Action and Therapeutics. — Tobacco is a marked depressant nauseant, and produces emesis by irritation as well as by systemic action. Its continued use by smoking or chewing it to ex- cess produces granular inflammation of the mucous membrane of the mouth and pharynx, atrophy of the retina, dyspepsia, lowered sexual vitahty, sudden faints, nervous depression, and cardiac irrita- bility. Used by the young, it hinders the development of the brain, and interferes with metaboHsm in general (Osier) . It is claimed to produce cancer of the lips and tongue, blunting of the moral sense, mental aberration, and even insanity. The so-called " tobacco heart," induces many forms of nervous, painful, and oppressed cardiac action, depending upon the age, quantity used, and other conditions. Nicotin is one of the most deadly poisons known. The author remembers poisoning a cat with this agent in the pharmacy school. The animal at once became greatly excited, then there was a wild stare, a deep sigh, and sudden death within three minutes after the STIMULANTS 1 63 ingestion of the drug. The claim that nicotin enters the body from smoking tobacco is without foundation, as the liquid alkaloid is vola- tile and the heat breaks it up into other compounds far less poison- ous. Chewing tobacco is supposed by many laymen to allay tooth- ache. The claim is not justified from the physiologic action of the drug. Tobacco is not used therapeutically in dentistry. STIMULANTS Stimulants are agents which increase the activity of life processes or functions. When the term "stimulant" is applied to medicinal agents it is used in various senses and is generally accompanied by such adjectives as cardiac, respiratory, gastric, restorative, etc., to indicate the various organs and processes of the body stimulated by the administration or application of the drug. CARDIAC STIMULANTS These are agents which increase the junctional activity or the effi- ciency of the heart's action. The chief cardiac stimulants are : Nux Vomica (Strychnin). Digitalis. Alcohol. The Nitrites. Ammonia. Camphor. Caffein. NUX VOMICA— U.S.P. Niix vomica is the dried ripe seeds of Strychnos nux vomica, a small tree growing in the East Indies. The drug contains two important alkaloids — strychnin and hrucin, the former being in excess and fully representing the action of the crude drug, which should contain, when assayed, not less than 2.5 per cent, of the alkaloids. Brucin resem- bles strychnin in its action, but is much less powerful. The average dose of powdered nux vomica is i gr. (0.06 Gm.). The following preparations are official: Tinctura Nucis Vomicae, U.S. P. Dose, 5-20 min. (0.3-1.3 mils). Fluidextractum Nucis Vomicae, U.S. P. Dose, 1-5 min. (0.06-0.3 niil). Extractum Nucis Vomicae, U.S. P. Dose, 3^-K gr. (0.008- 0.03 Gm.). As has been stated, strychnin fully represents the action of nux vomica. This alkaloid is official. 164 STIMULANTS STRYCHNINA— IJ.S.P. It occurs as colorless crystals or a white crystalline powder, odor- less and having an intensely bitter taste; sparingly soluble in water, Two salts of strychnin are official, the sulphate (Strychnine Sulphas, U.S. P.) and the nitrate (Strychninee Nitras, U.S. P.). Both in appearance resemble the alkaloid itself, but are much more soluble in water. The average dose of strychnin or of either of its salts is ^'io gr. (0.0015 Gm.). Strychnin is a constituent of the following preparations: Glycerite of the Phosphates of Iron, Quinin, and Strychnin, N.F. Syrup of the Phosphates of Iron, Quinin, and Strychnin, N.F. Compound Syrup of Hypophosphites, N.F, Compound Laxative Pills, N.F. EUxir Iron, Quinin, and Strychnin, N.F. Physiologic Action. — Strychnin is a true cardiac stimulant, the pulse becoming stronger and more rapid under its influence as a result of its action upon the heart and vasomotor center. The drug also acts as a powerful respiratory stimulant, the movements of respira- tion becoming deepened and quickened. The chief action ol strychnin is upon the nervous system. Here it acts as a powerful stimulant to the spinal cord, especially the centers governing the move- ments of the body. The most marked effect of the drug, in toxic doses, is increased reflex irritabiHty of the spinal cord, which is shown most conspicuously by the production of muscular rigidity. Nux vomica or strychnin, in small doses, strengthens the muscular move- ments of the stomach and increases the flow of gastric secretions. It therefore acts as a stomachic. The drug is eliminated principally through the kidneys. Poisoning and Treatment. — If the dose of strychnin is within therapeutic limits, yet sufficient to produce shght toxic effects, the first symptom is hkely to be a feeHng of uneasiness with heightened reflex irritability, and this may be followed by muscular twitching in some part of the body. With larger doses, spinal convulsions result from the slightest external irritation, causing the patient to rest on his head and feet (opisthotonos) ; the flexor muscles are overcome by the extensors, and the feet are curved inward. The convulsions for the most part are intermittent; during the intermission there is complete muscular relaxation. During the attack the contraction of STRYCHNINA 165 the facial muscles causes the patient to grin in a ghastly manner, but the muscles of the jaws are unaffected until toward the last. This latter diagnostic sign should be remembered, as strychnin poisoning may become confused with tetanus on account of the rigidity of the muscles during the convulsive attacks. In tetanus the muscles of the jaw are very early implicated. Other diagnostic marks of tetanus, as contrasted with it, are slower development of the symptoms and the continuous muscular rigidity. There is never complete muscu- lar relaxation even in the intermission of the spasms as there is in strychnin poisoning. The number of convulsive seizures varies in different instances, but generally three or four are fatal; the patient succumbing to asphyxia and exhaustion. In the treatment of strychnin poisoning, if the patient is seen early enough, emetics, particularly apomorphin hydrochlorid (Ko gr.-o.oo6 Gm.) hypodermically, should be given, followed by washing out the stomach. If violent convulsions already are present, evacuation of the stomach, as a rule, is contraindicated, as either emetics or the stomach-pump would provoke further attacks. Inhalations of chloroform or amyl nitrite will control the spasms. As a chemic antidote tannic acid in solution may be administered. Probably the best physiologic antidotes are potassium bromid (1-2 dr. — 4.0-8.0 Gm.) and chloral hydrate (20 gr.-i.3 Gm.); when the patient is unable to swallow, the latter drug (i dr.-4.o Gm.) may be given in an enema (per rectum) . These agents depress the nerve centers stimulated by the strychnin. Since the sHghtest external stimulus will provoke convulsions, the patient should be disturbed as little as possible. Therapeutics. — Nux vomica or strychnin is used chiefly as a cardiac stimulant, a respiratory stimulant, a motorexcitant, and a stomachic. Strychnin sulphate, in soluble tablet form of proper therapeutic dose {yio gr.-0.0015 Gm.), should be in every dental office. Being both a cardiac and respiratory stimulant it makes a valuable remedy in cases of poisoning by drugs which depress the cardiac and respiratory center. In poisoning by cocain, opium, chloral hydrate, aconite, ether, chloroform, or ethyl chlorid, it should be given hypodermically in full doses and repeated, if necessary, in fifteen minutes. In neuralgia due to an atonic condition, strychnin is indicated. Here it may be given in either the eHxir, syrup, or glycerite of the phosphates of iron, quinin, and strychnin. Xncompatibles.' — Strychnin is incompatible with tannic acid, alkalies, and the salts of the halogen elements (CI, I, and Br.). 1 66 STIMULANTS ALCOHOL— U.S.P. (Ethyl Alcohol; C2H5OH.). Etiiyl alcohol is obtained by the distillation of fermented sac- characeous substances. To be up to the official standard it must con- tain 92.3 per cent, by weight or 94.9 per cent, by volume at i5.56°C. of absolute ethyl alcohol. It vnR be observed that the tempera- ture at which alcohol is measured is not the standard temperature (25°C.) of the U.S.P. IX. Exception was made in the temperature for alcohol in order to correspond with the Government regulation. It occurs as a colorless, transparent, mobile, and volatile liquid, hav- ing a pungent odor, and a burning taste; miscible with water, ether, and chloroform in all proportions. It is inflammable and burns with a bluish, nonluminous flame. The following preparations are official: Alcohol Dehydratum, U.S.P., Alcohol Absolutum, U.S.P. VIII (99 per cent. Alcohol). Alcohol Dilutum, U.S.P. (41 to 42 per cent, by weight or 48.4 to 49.5 per cent, by volume, at i5.56°C. of Absolute Alcohol). The following nonofficial preparations contain alcohol: Spiritus Frumenti, U.S.P. VIII (Whisky; 37 to 47.5 per cent. Alcohol, distilled from fermented grain). Spiritus Vini Gallici, U.S.P. VIII (Brandy; 39 to 47 per cent. Alcohol, distilled from fermented grapes). Spiritus luniperi Compositus, U.S.P. VLll (equivalent to Gin; about 60 per cent. Alcohol). Vinum Album, U.S.P. VIII (White Wine; 7 to 12 per cent. Alcohol). Vinum Rubrum, U.S.P. \TII (Red Wine; 7 to 12 per cent. Alcohol). Rectified Spirit (85 per cent, by weight of Absolute Alcohol). Proof Spirit (49 per cent, by weight of Absolute Alcohol, Volatile Oil, and other foreign material). Gin (42 per cent, by weight of Absolute Alcohol, distilled in Holland from rye or barley, and flavored with juniper berries or hops). IMalted Liquors (Beer, Ale, and Porter) are prepared by fer- menting malted grain with hops and adding other bitters. Beer contains 2 to 3 per cent, of Alcohol; ale and porter, from 4 to 6 per cent., besides carbonic and lactic acids, malt extract, various aromatics, and certain salts of sodium and potassium. The formerly official wines are made by fermentation of pure grape juice. ALCOHOL 167 Physiologic Action. — There is much diversity of opinion regarding the physiologic action and uses of alcohol. Applied to the skin, it extracts water from the tissues and acts as a detergent and antiseptic. On the mucous membrane it extracts water with greater rapidity, coagulates albumin, and causes a whitened and corrugated surface. The gastric functions, as well as the flow of saHva, are reflexly stimu- lated by its local action in the mouth. Internally administered, alcohol reflexly and rapidly stimulates the heart before absorption can take place, the effect upon the circu- lation persisting after the absorption of the drug. It depresses the vasoconstrictors; thus arterial tension is raised, though the arterioles are dilated. Toxic doses depress the heart's action, and still further dilate the peripheral blood-vessels. This action of alcohol, in causing the heart to beat stronger and faster, at the same time dilating the blood-vessels — especially those of the peripheries — renders the drug one of the most valuable diffusible stimulants (Butler). The domi- nant action of alcohol is on the nervous system. It first stimulates and then paralyzes all parts of the nervous system. Poisoning and Treatment. — The poisonous action of alcohol may be discussed as acute and chronic alcoholism. Acute Intoxication.^ — The ingestion of large quantities of alcohol produces certain characteristic symptoms: Flushing of the face, men- tal excitement, a quickened pulse and respiration ; in a short time the speech becomes incoherent, the pupils are dilated, then follows dehrium, loss of coordination, subnormal temperature, vomiting, loss of abiHty to control the acts of toilet, and, finally, stupor and coma. If the dose has not been too large, recovery follows in a day or two. Stevens^ emphasizes the care to be taken in order to distinguish acute alcohoHsm from uremia, opium poisoning, and apoplexy. The urinous odor of the breath, the small pupils, and the presence of albumin in the urine will serve to distinguish uremia. The small pupils, slow and labored respiration,, and slow and fuU pulse will point to opium poisoning. The unequal pupils, hemiplegia, and high tem- perature will indicate apoplexy. In the treatment of acute alcoholism the stomach should be emptied of all unabsorbed alcohol by the stomach-pump, and a stimulating emetic (mustard flour), or the hy- podermic injection of apomorphin (ifo gr.-o.oo6 Gm.) is indicated. Cautious inhalations of ammonia should be given, together with the internal administration of black coffee. The patient should be made to perspire freely by the appHcation of external heat (warm blankets, ' Modern Materia Medica and Therapeutics. 1 68 STIMULANTS etc.), and if there is danger of collapse, strychnin sulphate (>^o gr- 0.002 Gm.) should be hypodermically administered and artificial respiration practised. Chronic alcoholism is generally the result of the continuous and excessive use of alcohol, and is characterized by disturbed sleep, fine tremor, mental impairment, gastric irritation, injection of the eyes, ' and redness of the nose and cheeks from permanent dilatation of the capillaries. A frequent compUcation of chronic alcoholism is delirium tremens. This condition is manifested by great mental excitement, insomnia, incoherent speech, tremors, and terrifying hallucinations of sight and hearing. In favorable cases recovery follows in a few days, but frequently symptoms of typhoid and pneumonia develop, and the attack ends in death. In the treatment oj delirium tremens the main indications, according to Butler,^ are: 1. Elimination by diaphoresis, catharsis, diuresis, warm baths, etc. 2. Support. — Some alcohol may be necessary. Easily digested food. Enema ta, if necessary. 3. Quiet. — Hypnotics: opium, chloral hydrate, the bromids. In the treatment of chronic alcoholism it is necessary to consider the character of the individual affected. Butler states that a thought- ful and extended experience with dipsomaniacs will convince most observers that the vast majority of them suffer from a disease possess- ing usually a distinct and traceable etiology, and resulting from either an inherited or acquired neurosis. It is a condition akin to epilepsy; the treatment, therefore, turns on the discovery of the conditions preHminary to the drinking period and the determination whether this can be prevented by dietetic and therapeutic measures, as is done in cases of epilepsy. The medicinal agents employed are strychnin, atropin, small doses of such alteratives as arsenic, potassium iodid, and mercury, while phosphorus and other restoratives and tonics will prove efl&cacious. Therapeutics. — Alcohol is extensively used locally in dentistry as a dehydrater, detergent, and antiseptic. Its action upon bacteria is no doubt due to its power of abstracting water and of coagulating albumin. According to the experiments of pharmacologists, the most effective dilutions of alcohol against the strongly resisting (nonsporing) bacteria, such as the pus organisms, are those containing from 60 to 70 per cent, by volume. The author suggests 70 per cent, alcohol to which i gr. (0.064 gm.) of thymol to the fl. oz. (.30.0 mils) is added. This is called modified alcohol, and is useful for sterilizing ' Text-Book of Materia Medica, Therapeutics and Pharmacology. AMMONIA 169 the teeth included in the rubber dam for aseptic root-canal work, and other aseptic operations involving the mucous membrane. For spraying the mouth previous to performing any dental oper- ation, the author is very partial to cinnamon water to which from 2-5 per cent, of alcohol has been added. It should be remembered that alcohol is less valuable as a disinfectant than as an antiseptic and as a vehicle for stronger agents of this class; therefore, from 10 to 25 per cent, alcohol makes an excellent addition to aqueous antiseptic solutions. Absolute alcohol is frequently added to tooth-pastes for its antiseptic and solvent power. The drug is used as a styptic to check capillary oozing, and a very efficient means of reducing tempera- ture in fever is to bathe the skin with alcohol; the method is also em- ployed to check excessive sweating. Alcohol is a positive antidote for phenol, and whenever the latter agent is being used about the mouth, it should be in a convenient place to neutralize the caustic action of phenol, should the latter accidentally get on the soft tissues of the mouth. Alcohol is employed internally as a diffusible circulatory stimulant, a stomachic, a food, and a chemic antidote for phenol. In all forms of sudden heart-failure, as in syncope, shock, snake-bite, etc., it is an invaluable stimulant. Whisky or brandy should be in every dental office to be used as a cardiac stimulant in cases of cocain poison- ing or other conditions which depress the heart. AMMONIA (NH3.) Ammonia is obtained as a by-product in the manufacture of coal- gas. It occurs as a colorless gas, having a very penetrating odor and an acrid taste. It is chemically soluble in water, and in chemistry it is considered a h)^othetical metal, as it acts like a base in uniting with acids to form salts. 'The following preparations are official: Aqua Ammonise Fortior, U.S. P. (Stronger Ammonia Water; 28 per cent, by weight of the Gas). Aqua Ammoniae, U.S. P. (Ammonia Water; 10 per cent, by weight of the Gas). Spiritus Ammoniae Aromaticus, U.S. P. (Aromatic Spirit of Ammonia; contains Ammonium Carbonate, 34; Ammonia Water, go; Oil of Myristica, i; Oil of Lemon, 10; Oil of Lavender Flowers, i; Alcohol, 700; Water to make 1,000). Dose, 3^ to I fl. dr. (1.0-4.0 mils). Linimentum Ammoniae, U.S. P. Externally. Physiologic Action. — Ammonia has a decidedly irritant local action, and in concentrated solution it speedily produces vesication. lyo STDTCLAXTS The drug has the decided advantage of being a gas which permits of inhalation, and its irritant action upon the mucous membrane of the respiratory passages reflexly stimulates the cardiac and respiratory centers; both the strength and rapidity of the pulse and the depth and rapidity of the respirations are markedly increased. Given in weak solutions, the drug stimulates the flow of gastric juice, its action here resembhng that of other alkahe s. The gas acts upon the nen/ous system by stimulating the motor centers of the spinal cord, and thus reflex acti^-ity is increased. Poisoning and Treatment. — In toxic doses preparations of am- monia 'are powerful corrosive poisons. The characteristic symptoms are severe burning pain in the fauces, esophagus, and stomach, with intense gastroenteritis. The \'iolent irritation of the throat some- times causes edema of the larynx, resulting in almost immediate death from asphyxia. In the treatment of ammonia poisoning the drug should be neutraHzed by some weak acid, hke vinegar. This should be followed by demulcent drinks, opium being indicated for the relief of pain. Therapeutics. — The chief use of ammonia in dental therapeutics is as a cardiac and respiratory stimulant. The drug acts quickly, and is an invaluable remedy in syncope, collapse, and other forms of sudden heart failure. When it is desired to give the drug by inhalation, as can easily be done on account of the volatiHty of the gas from its solutions, it is best to select ammonia water as the preparation to use. For internal administration the aromatic spirit of ammonia should be selected and given well diluted Ammonia water in a specially pre- pared ampule, called ''aspirol," and aromatic spirit of ammonia in 30 min. (2.0 mils) ampules are now on the market. These are con- venient forms in which to keep the drug and should be in every dental office. The liniment of ammonia is a popular counterirritant remedy in chronic rheumatism, joint afections, and chilblains. Incompatibles. — Ammonia is incompatible mth all acids, chlo- ral hydrate, and alkaloids. With ferric salts it forms ferric hy- droxid, which is an antidote for arsenic. With formaldehyd it forms urotropin. AMMONH CARBONAS— U.S.P. (Ammonium Carbonate; XH4HC03.NH4XH2C02.) The official ammonium carbonate is really a mixture of ammo- nium acid carbonate and ammonium carbamate. It occurs in white, CAFFEINA 171 internally translucent, crystalline masses, having an extremely pun- gent odor, and an acrid taste; soluble in 4 parts of water. The aver- age dose is 5 gr. (0.3 Gm.). Physiologic Action and Therapeutics.- — This drug is a cardiac and respiratory stimulant, due to the ammonia gas which is constantly liberated. It is also a stimulating expectorant. It enters into the composition of aromatic spirit of ammonia, which preparation is ex- tensively used in dental therapeutics. CAFFEINA— U.S.P. (Caffein; C8H10N4O2.H2O.) Caffein is an alkaloid obtained from the leaves of Thea sinensis (tea), or from the seeds of Cofea arahica (coffee). It occurs in fine, colorless, silky crystals, without odor, and having a bitter taste; soluble in about 46 parts of cold water. The average dose is 2}^ gr. (0.15 gm.). The following preparations are official: Caflfeina Citrata, U.S.P. (Caffein Citrate). Dose, 2-5 gr. (0.13-0.3 Gm.). Caffeina Citrata Effervescens, U.S.P. Dose, 1-2 dr. (4.0-8.0 Gm.). Caffeinae Sodio-Benzoas, U.S.P. Dose, by mouth, 5 gr. (0.3 Gm.), hypodermic, 3 gr. (0.2 Gm.). Physiologic Action. — Caffein is a powerful cardiac and respiratory stimulant. Its action upon the circulatory system results in high blood-pressure and increased frequency of the pulse, due in part to its direct influence upon the heart and its stimulating action upon the vasomotor centers. The brain seems to be especially susceptible to the influence of caffein, small doses sharpen the intellect and produce profundity of thought, and wakefulness. The drug also acts as a diuretic, stimulating the secreting structure of the kidneys, and is quickly eliminated through these organs. Therapeutics. — Caffein is an entirely safe drug to be used in large dose, hence it is one of the best stimulants to employ in poisoning by narcotic drugs, Uke cocain, opium, etc. Caffein citrate is the prepara- tion generally used because it is more soluble than caffein. Strong black coffee is also used. The drug is a constituent of compound acetanilid powder, N.F. Its action overcomes the depressant effect of acetanilid upon the heart. It may also be combined with phenacetin or a bromid and used with excellent results in migraine and nervous headache. 172 STIMULANTS / DIGITALIS— U.S.P. (Foxglove.) Digitalis is the dried leaves of Digitalis purpurea, a biennial plant growing in Central and Southern Europe. It contains several princi- ples, all of which are glucosidal in character, the most important being digitalin, digitoxin, digitalein, digitonin, and digitin. The first two represent more or less imperfectly the action of digitalis upon the heartj and since both are freely soluble in alcohol and practically insoluble in water, it will at once be observed that the most active principles of the drug are contained in the tincture and fluid extract, and the least active in the infusion; all of which preparations of digitaHs are oflScial: Tinctvira Digitalis, U.S. P. Dose, 5-20 min. (0.3-1.3 mils). Fluidextractum Digitalis, U.S. P. Dose, 1-2 min. (0.06- 0.12 mils). Infusum DigitaHs, U.S. P. Dose, 1-4 fl. dr. (4.0-15.0 mils). Physiologic Action. — DigitaHs is a powerful cardiac stimulant. It does not increase the rapidity of the heart's action; it rather slows the pulsations and raises the blood-pressure, but in spite of this the efficienc}' of the contraction is increased and the pulse improved in character. In therapeutic doses the drug has practically no effect except on the circulation. The slowing of the pulse results from a prolongation of the diastole, and this in turn is due to stimulation of the vagi. The increased blood-pressure is due to the twofold action of the drug, that of securing efficiency by the direct action upon the heart, and to the contraction of the arterioles, which results indi- rectly from the stimulation of the vasomotor center, and directly from the action on the vessel-walls. In cases of low arterial pressure, when the urine is scanty, digitalis acts as a diuretic. A disadvantage of digitalis medication is the varying strength of the crude drug. Pharmaceutic chemists have attempted to remove this disadvantage by standardizing their preparations. The follow- ing methods of standardization are most extensively used: 1. The frog-lethal dose method. 2. The frog-systohc standstill method, of which there are several modifications. 3. The guinea-pig lethal dose method. 4. The intravenous cat method. Poisoning and Treatment. — DigitaHs is more rapidly absorbed than eHminated; because of this, cumulative action may follow the prolonged use of the drug even in therapeutic doses. Toxic s}Tnp- AMYLIS NITRIS 1 73 toms may result from this source or from the ingestion of a single poisonous dose. Poisoning is characterized by gastrointestinal dis- turbances, abdominal pains, vomiting, and purging, with slow pulse, feeble respiration, dilated pupils, headache, delirium, and stupor. If a fatality results, it is generally from ten to forty-eight hours after the ingestion of the drug, as digitaUs is a slow poison. In the treatment of poisoning, the stomach-pump should be employed. Tannic acid is a chemic antidote and may be given. Body tempera- ture should be maintained by external heat, especially applied to the abdomen. AlcohoHc stimulants are often indicat-ed. The patient should be kept in the recumbent position, not being allowed even to raise his hand or head from the bed. Therapeutics. — The chief use of the drug in dental therapeutics is as a cardiac stimulant. Hypodermic injections of the tincture of digitalis or of digitahn may be employed to increase the efficiency of the heart's action in syncope, collapse, and poisoning by cardiac de- pressants. It is best here to use the drug in conjunction with stimu- lants which act more quickly (alcohoUc stimulants). The drug is contraindicated in cases of aneurysm. AMYLIS NITRIS— U.S.P. (Amyl Nitrite; C5H11NO2.) Amyl nitrite is prepared by the action of nitric acid upon amylic alcohol; the product, being a highly volatile Hquid, is obtained by distillation. It has a strong ethereal odor. Physiologic Action. — Following the inhalation of amyl nitrite there is a marked flushing of the face, due chiefly to the dilatation of the capillaries. The heart's action is increased, and the pulse is soft and compressible. There is a marked fall in blood-pressure because of the dilatation of the arterioles, which results from the paralyzant action of the drug upon the muscle fibers found in these structures. The nitrites cannot be regarded as powerful cardiac stimulants, but their action is equivalent to such, for by dilating the arterioles they largely remove the resistance against which the heart has to force the blood, thus making the work of this organ much easier to per- form. These drugs, therefore, should be regarded as vasodilators, and not as true cardiac stimulants; but, on account of their action as vasodilators, they may be considered circulatory stimulants. The drug is largely eHminated through the kidneys. Poisoning and Treatment. — In toxic doses amyl nitrite produces an exceedingly rapid and weak heart, cyanosis, slow and shallow 174 STIMULANTS respiration, vertigo, headache, and disordered vision, death result- ing from cardiac and respiratory failure. In the treatment of poison- ing the heart's action must be sustained. Strychnin and digitahs will be foimd useful. Atropin may be administered, together with cold applications to the head, alcohoHc stimulants, and, if necessary, artificial respiration. Adrenahn is claimed to be useful as it contracts the dilated arterioles. Therapeutics. — Long^ states that it is to be regretted that the nitrites have been considered direct heart stimulants; because of this they are extensively used in cases where the blood-pressure is already too low to permit efficiency of circulation, as in chloroform and other drug poisonings. Amyl nitrite is useful to relax spasms and to lower arterial tension. On account of the rapidity with which the drug is absorbed it is never necessary to give nitrites hypodermically. The effect of amyl nitrite may be obtained almost instantly by inhalation, and a dose of spirit of nitroglycerin (1-3 min.— 0.06-0.2 mil) placed under the tongue will produce its full effect in less than five minutes. Amyl nitrite may be obtained in^glass capsules or pearls, containing the requisite dose (2-5 min. — 0.13-0.3 mil), which are easily crushed in a handkerchief, and should always be given by inhalation. In this manner it may be employed with benefit to reHeve the convulsions of epilepsy, tetanus, uremia, and strychnin poisoning. The drug is used in syncope and collapse from other causes, but the diffusible stimulants are far preferable. GLYCERYLIS NITRAS (Nitroglycerin; Glonoin; Glyceryl Trinitrate; C3H5(N03)3-) Nitroglycerin is obtained by nitric acid or a mixture of nitric and sulphuric acid on dehydrated glycerin. It occurs as a clear, colorless Hquid, with an odor and taste resembling that of alcohol. It explodes with great force, and should be kept in a cool place, away from Hghts and fire. It is official in the following form: Spiritus Glycerylis Nitratis, U.S. P. (Spirit of Nitroglycerin; an alcoholic solution containing i per cent, by weight of Glyceryl Trinitrate). Dose, 1-3 min. (0.06-0.2 mil.) Physiologic Action and Therapeutics. — Nitroglycerin is prefer- able to amyl nitrite, whose action it resembles, for internal adminis- tration. It is used in dentistry as a cardiac stimulant, and for this purpose it may be found as a constituent of local anesthetic solutions. It, however, is far inferior to strychnin or atropin as an agent to over- come the depressant effect of cocain upon the heart. ^ Dental Materia Medica, Therapeutics and Prescription Writing. RESPIRATORY STIMULANTS 1 75 Nitroglycerin is a valuable drug in those cases where it is desirable to relieve blood-pressure. For example, when it is deemed neces- sary to apply arsenic trioxid to a pulp which is in an inflammatory state, the engorged capillaries may be relieved and the pain mitigated by the administration of this drug (see page 327). RESPIRATORY STIMULANTS These are agents which increase the functional activity of the res- piratory centers or the efficiency of the respiratory apparatus. The chief respiratory stimulants are: Belladonna (Atropin). Strychnin.* Ammonia.* Caffein.* All of these drugs have been elsewhere discussed except the first- mentioned. BELLADONNA (Deadly Nightshade.) Beiladonna is a herbaceous perennial plant growing in the woods, chiefly in the mountainous districts of Central and Southern Europe. Both the dried leaves {Belladonna Folia, U.S. P.) and the dried root {Belladonna Radix, U.S. P.) of Atropa Belladonna are official. The drug contains an important alkaloid, atropin, to which its physiologic activity is due. The average dose of the powdered leaves and root is I gr. (0.06 Gm.). The following preparations are official: Tinctura Belladonnse Foliorium, U.S. P. Dose, 5-20 min. (0.3-T.3 mils). Extractum Belladonnae Foliorium, U.S. P. Dose, y^-Vi gr. (0.008-0.016 Gm.). Emplastrum Belladonnae, U.S. P. Unguentum Belladonnas, U.S. P. (10 per cent, from Extract). Fluidextractum Belladonnae Radicis, U.S. P. Dose, 1-3 min. (0.06-0.2 mil). Linimentum Belladonnae, U.S. P. (contains Camphor, 5 parts; fluid extract of Belladonna Root, 95 parts). The action of belladonna is due entirely to atropin which it con- tains. This alkaloid is official. ATROPINA— U.S.P. Atropin occurs in the form of white, acicular crystals, or a crys- talline powder, odorless, having a bitter, acrid taste; soluble in 455 176 STIMULANTS parts of water, 2 parts of alcohol, 25 parts of ether, i part of chloro- form, and about 27 parts of glycerin, at 25°C. One salt of atropin is ofl5.cial (Atropinas Sulphas, U.S. P.), and in appearance resembles the alkaloid itself, except that it is more freely soluble in water. The average dose of atropin or of its salt is 3^120 gr- (0.0005 Gm.). Physiologic Action. — The action of belladonna is dependent upon the amount of contained atropin. AppHed locally in combination with absorbable substances — alcohol, camphor, animal fat, glycerin, etc. — atropin acts as a depressant to all highly organized tissues, exerting an analgesic and antisecretory influence. ^Medicinal doses of atropin, taken internally, produce dryness of the throat, dilatation of the pupils, quickening of the pulse, deepening of the respirations, and occasionally talkative delirium and erythematous rash. It is well to remember here that medicinal doses stimvdate the respiratory center, while toxic doses paralyze it. The saUvary secretion is lessened through paralysis of the periph- eral endings of the secretory fibers only of the chorda tympani nerve in the submaxillary gland (Butler). The drug also diminishes all of the secretions of the body, and its elimination is effected chiefly through the kidneys^ Poisoning and Treatment. — The characteristic symptoms of atropin poisoning are dryness of the throat, dilated pupils, rapid pulse, quick respiration, uneasiness, talkative delirium, erythematous rash, with, ultimately, stupor, collapse, and death from paralysis of the respiratory center. In the treatment of poisoning the stomach should be evacuated and then washed out with solutions of tannic acid — the chemic antidote. Cardiac and other respiratory stimulants (caffein) should be cautiously administered as the symptoms indicate. Therapeutics. — Atropin is one of the best remedies at our com- mand for controlKng the secretions of the body. In cases where it is necessary to keep the field of operation dry, as in treating and filling teeth where the rubber dam cannot be successfully adjusted, atropin may be administered a few hours previous to operating with excellent results. In salivation from mercury the drug is hkewise useful. In hyperidrosis of the hands and feet preparations of belladonna are used both externally and internally. Combined with camphor and other drugs, extract of belladonna is a useful remedy in acute coryza. Probably the greatest use atropin has in dental therapeutics is in the treatment of shock and collapse from local and general anesthetics, and also in the treatment of poisoning from narcotic drugs. In these cases atropin sulphate, hypodermically administered, stands next to strychnin and its salts. GASTRIC STIMULANTS 177 Liniment of belladonna is a valuable remedy in the treatment of neuralgia. GASTRIC STIMTJLANTS Gastric stimulants, called also stomachics, are agents which sharpen the appetite and promote the functional activity of the stomach. The gastric stimulants are called "bitter tonics/' and they include the following: Gentian. Cinchona.* Wild Cherry. Hydrastis.* Nnx Vomica.* GENTIANA— U.S.P. (Gentian.) Gentian is the dried rhizome and roots of Gentiana lutea, a small perennial plant indigenous to the mountainous districts of Central Europe. It contains a bitter glucosid, gentiopicrin, to which its stomachic property is due. The average dose is 15 gr. (i.o Gm.). The official preparations are : Tinctura Gentianse Composita, U.S.P. (10 per cent, with Orange Peel and Cardamon Seed). Dose, 1-2 fl. dr. (4.0-8.0 mUs) . Fluidextractum Gentianae, U.S.P. Dose, i5-3omin. (1.0-2.0 mUs). Extractum Gentianae, U.S.P. Dose, 2-10 gr. (0.13-0.6 Gm.). Infusum Gentianae Compositum (Nonofficial). Dose, K to i fl. oz. (15.0-30.0 mUs). Physiologic Action and Therapeutics. — The action of gentian is due to the bitter glucosid which it contains, and Hke all bitter tonics its effect is immediate, due to the local action of the drug. It aug- ments the secretions from the salivary and gastric glands, and thus aids digestion and improves nutrition. There is an intimate relation- ship between the stomach and the senses of taste and smell, and any- thing bitter in the mouth reflexly stimulates the gastric secretion. Gentian is not much employed in dental practice. It may be con- sidered one of the most reUable bitter tonics. In pyorrhea akeolaris associated with neuralgia due to a general atonic condition, the compound tincture of gentian may be advantageously combined with tincture of valerian (equal parts of the two) and given before meals in teaspoonful doses. Where the pyorrhea has caused indigestion an antacid, hke sodium bicarbonate, may be combined with some prepa- ration of gentian; because of the insolubility of sodium bicarbonate in alcohol, the compound infusion of gentian should be selected. A lyS STIMULANTS useful combination is: Sodium bicarbonate, 3=-^ dr. (2.0 Gm.); com- pound infusion of gentian, 3 fl. oz. (90.0 mils). This may be given in tablespoonful doses, before meals. PRUNUS VIRGINIANA— U.S.P. (Wild Cherry.) Prunus virginiana is the hark of Prunus serotina, a large tree in- digenous to North America. It contains tannic acid, a bitter princi- ple, a ferment, emulsin, and a glucosid, amygdalin. In the presence of the ferment and water the glucosid is broken up into hydrocyanic acid and a volatile oil. The average dose of wild cherry bark is 30 gr. (2.0 Gm.). The following preparation is official: Syrupus Pruni Virginianae, U.S.P. Dose, 1-4 fl. dr. (4.0-15.0 mils). Physiologic Action and Therapeutics. — Wild cherry is a bitter tonic. It might also be considered a sedative tonic. While it is pecuUarly bitter, it is not unpleasant, and is well tolerated by the stomach. The syrup of wild cherry is a common ingredient in "cough-mixtures," and is supposed to quiet the cough and allay the irritabiUty of the nervous system in bronchial affections. This effect is doubtless due to the hydrocyanic acid which it contains. The syrup has an agreeable taste and serves as an excellent vehicle for unpal- atable drugs. The other stomachics have been discussed under other headings. RESTORATIVE STIMULANTS These are agents which maintain or restore the bodily functions. The principal restorative stimulant is: LIQUOR SODII CHLORIDI PHYSIOLOGICUS, U.S.P. (Physiologic Salt Solution; Normal Salt Solution.) This is a solution of 8.5 parts of sodium chlorid in 1,000 parts of sterile water, and closely corresponds in salinity to blood-serum. It is regarded as a valuable stimulant in cases of shock or collapse, espe- cially from loss of blood by hemorrhage. It is injected intravenously by permitting the solution, quite hot, to run slowly through a large- sized, long hypodermic needle from a fountain syringe into the lumbar region or underneath the breast. From 2 fl. oz. (60.0 mils) to 10 fl. oz. or even i qt. (300.0-1,000 mils) may be used at frequent intervals. Sollmann^ states that the action is only short, and the injection must 1 A Text-Book of Pharmacology, MISCELLANEOUS STIMULANTS 1 79 therefore be repeated. The restoration is brought about by the sub- stitution of this fluid for the blood-serum. The solution is an excel- lent bland remedy to be used in establishing sinuses associated with alveolar abscesses, and also as a vehicle for local anesthetics and other agents (adrenalin, etc.). For making local anesthetic solutions, Ringer tablets are frequently added to sterile distilled water to make an isotonic solution. The Ringer tablet "B", which is generally employed, contains sodium chlorid % gr. (0.05 Gm,), calcium chlorid 3^5 gr. (0.004 Gm.), and potassium chlorid 3^o gr- (0.002 Gm.). One Ringer tablet "B" dissolved in 23^ fl. dr. (10. o mils) of water makes a 0.56 per cent, solution of the salts, which with the addition of the anesthetic agent approximates closely the specific gravity of the blood-serum, making the solution isotonic. According to Dr. Alexis Carrel of the Rockefeller Institute for Medical Research, and Dr. W. Crile, of Cleveland, Ohio, and others, the latest method of treating infected wounds consists in thoroughly irrigating the part with Dakin's hyperchlorous acid solution, and then exposing the wound to light from electric lamps placed in paste- board cones on metal hoods suspended from an adjustable frame. The amount of light and the proximity of the lamps to the wound are governed by the comfort of the patient. When coagulated serum develops, Crile suggests a hot pack for half an hour with Wright's hypertonic solution. A hypertonic solution is one whose osmotic tension exceeds that of the blood-serum. The formulae for Danny's and Wright's solutions are here given: Dakin's Solution. — Dry sodium carbonate 200 Gm. Chlorinated lime 140 Gm, Tap water 10 L. Mix and filter through cotton. Add 40 gm. boric acid. Wright's Solution.— Sodium chlorid 3 parts. Sodium citrate I parts. Water 96 parts. MISCELLANEOUS GROUP There are several drugs which have a peculiar action upon "the nervous system other than those thus far discussed under the various headings of general remedies. Some of these drugs stimulate, while others depress the nervous system. They will be considered here under this heading. Those of importance to dentists are: Gelsemium. Valerian. l8o - STIMULANTS GELSEMIUM— U.S.P. (Yellow Jasmine.) Gelsemimn is the dried rhizome and roots of Gelsemium semper- virens, a climbing plant growing in the moist woods of southern United States. It contains two alkaloids — gelsemin and gelseminin — the former stimulates, while the latter depresses the nervous system. The general effect of the drug is the result of a blending of the actions of the two alkaloids, although in man gelseminin appears to be more potent. The average dose of powdered gelsemium is 3^^ gr. (0.03 Gm.). The official preparations are : Tinctura Gelsemii, U.S.P. Dose, 10 to 30 min. (0.6-2.0 mils). Fluidextractum Gelsemii, U.S.P. Dose, 2-10 min. (0.13-0.6 mU). , Extractum Gelsemii, U.S.P. Dose, }^ gr. (o.oi Gm.). Physiologic Action and. Therapeutics. — Gelsemium has a distinct action upon sensory nerves and is useful, therefore, in painful affec- tions. In large doses it depresses the spinal cord, especially its motor neurons. The drug is used in trifacial neuralgia, and appears to be most serviceable when the neuralgia arises from diseased conditions of the teeth. The fluid extract is the preparation generally employed, although Marshall^ prefers gelseminin sulphate, giving >^o gr- (0.002 gm.) every two hours until the constitutional eff'ects are produced. This salt naturally would be more effective in neuralgic conditions than gelsemium preparations, as it is the alkaloid that depresses the nervous system ; the other alkaloid (gelsemin) stimulates. Poisoning and Treatment. — The toxic symptoms of gelsemium are drooping eyeUds, disordered \-ision, frontal headache, falhng of the jaw, muscular weakness, slow respiration, and, finally, collapse. In the treatment of poisoning the stomach should be evacuated, tannic acid administered as the chemic antidote, and collapse combatted with such stimulants as strychnin, whisky, and ammonia. VALERIANA— U.S.P. (Valerian.) Valerian is the dried rhizome and roots of Valeriana officinalis, a herbaceous, perennial plant, native of Europe. It contains valerianic acid and a volatile oil. The average dose is 30 gr. (2.0 Gm.). The following preparations are official: Tinctura Valerianae, U.S.P. Dose, 1-2 fl. dr. (4.0-8.0 mils). Tinctura Valerianae Ammoniata, U.S.P. Dose, 1-2 fl. dr. (4.0-8.0 mils). ' Injuries and Surgical Diseases of the Face, ]Mouth and Jaws. ALTERAXrVES AXD RESTORATR'ES l8l Physiologic Action and Therapeutics. — The principal action of valerian is upon the nervous system, and it may be classed as a nervine in that it produces, in moderate dose, a sedative effect upon the brain and spinal cord. In pyorrhea akeolaris associated with more or less neuralgia due to a general atonic condition it may be com- bined with gentian with excellent results. ALTERATIVES AND RESTORATIVES Altei*atives are agents which promote metabolic processes and thus counteract morbid conditions. They are closely related to restoratives in that both classes promote the processes of nutrition and aid metabolism. The latter class includes foods, hematics, and tonics. Foods are substances which, when introduced into the body, supply material with which some structure is rebuilt or some vital process is maintained. They differ from medicines in that the latter modify vital processes, but furnish no material to renew the structures of the body. Hematics or hematinics are agents which increase the hematin in the blood and restore or maintain bodily functions by enriching the red blood-corpuscles. The compounds of iron are the chief hematics* Tonics are agents which improve the tone and impart strength and energy to the tissues. The main tonics are: Iron and Compounds. Hypophosphites. Phosphorus. Cod-liver Oil. Calcium Phosphate. Nux Vomica.* Cinchona.* The principal alteratives are : Potassium lodid. Sarsaparilla. Mercury. Echafolta. Arsenic* Calx Sulphurata. Gold and Sodium Chlorid. FERRUM— U.S.P. (Iron; Fe.) Metallic iron is of&cial in the form of line, bright wire. Physiologic Action and Therapeutics. — Iron is an essential ele- ment of the body and may be regarded as a food as well as a medicine. It enters as an essential constituent (0.4 per cent.) into a pecuHar proteid body — the hemoglobin of the blood. It is through the iron compounds of the body that the greater portion of the oxidizing func- tions of the various cells are carried on. In a healthy state of the 102 ALTER-\Tr\'ES AXD RESTORATR^ES body, when the processes of mastication, digestion, assimilation, and nutrition are normal, there is a sufficient amount of iron furnished by the mixed diet to answer all physiologic requirements; but in many pathologic conditions there is a deficiency of iron, and the element must be furnished in the form of selected food or medicine. There is a difference of opinion as to whether metalHc iron can be assimilated by the body; some authorities claiming that it is necessary first to have the iron organized by plant Kfe into compounds containing it, while others claim that this is not necessarily essential to the assimilation of the metal. Bunge supposed that only "organic iron" could be absorbed and assimilated by the body, the reputed action of inor- ganic iron being altogether indirect and due to its local efi'ect on the aHmentary canal. This theory was modified by Abderhalden to the effect that inorganic iron, while it could not be converted into hemoglobin, nevertheless stimulated the conversion of "organic iron." Later work, however (Tartakowski), seems to prove con- clusively that inorganic iron is assimilated and converted into hemo- globin and in so far is therapeutically fully equal to natural complex iron compounds. IMany authors and practitioners, nevertheless, still adhere to the theories of Bunge and Abderhalden. There can be no question regarding the local and astringent action of most in- organic preparations, which is absent in most of the complex iron compounds. These local actions may be desirable in some cases and undesirable in others. This aids in determining the selection of the particular iron preparation most suitable for each individual patient. ^NletalUc iron is not used as a therapeutic agent in dentistry. In medicine it is extensively employed in diseases which afl'ect the cir- culation, as anemia and chlorosis. ]Many iron compounds are used in dentistry and will here be considered. Iron Compounds. — Iron forms two series of compounds —/err<9W5 and ferric. The former are white when freshly precipitated in the absence of oxygen, but when moist and exposed to air they readily absorb oxygen and gradually change into ferric compounds, which are usually reddish-brown in color. In this change there is an array of four distinct colors — white, green, black, and brown, respectively — and in the blending of these colors there may be produced every variety of shades seen in discolored teeth. As it is quite generally conceded that iron is the most important element to be considered in the many factors entering into the complicated problem of tooth discoloration from pulp decomposition, the above fact should be remembered. With the exception of the carbonate, the hydroxid, and the hypo- FERRI SULPHAS 1 83 phosphite, all of the compounds of iron are freely soluble in water, but insoluble in alcohol. The so-called scaled salts are all ferric com- pounds of phosphoric acid, or the organic acids, citric and tartaric; they are rendered more soluble in combination with citrates, tar- trates, and phosphates of the respective alkahes — ammonium, potassium, and sodium — and some are known as "soluble" salts. The scale salts are comparatively free from astringency, usually well borne by the stomach, and are used in medicine as mild and agreeable hematinics. The dose, with one exception (that containing strych- nin), is 4 gr. (0.25 Gm.). The official Latin titles do not distinguish between the ferrous and ferric compounds, but they are so distin- guished in the English titles. Iron is used in medicine: (i) in the form of metalHc or elementary iron (Reduced Iron, U.S. P.); (2) in the ferrous or unoxidized form of combination — responding to tests for ferrous ions (ferrous carbonate in mass of ferrous carbonate and pill of ferrous carbonate, ferrous iodid in syrup of ferrous iodid, U.S. P.); (3) in trivalent or oxidized form, the ferric compounds — re- sponding to tests for ferric ions (ferric chlorid in tincture of ferric chlorid, U.S. P.); and (4) complex compounds of iron. Complex (masked or nonionic) iron compounds are those compounds of iron wherein iron is part of a radical, and whose solutions do not respond to the ordinary tests for ferrous or ferric ions. Such compounds of iron do not have the astringent taste of simple iron solutions. As they are not decomposed by gastric digestion, they are also devoid of gastric effects; but, on the other hand, it has been claimed that cer- tain hemoglobin-like compounds escape absorption altogether. It should be remembered that "masked" iron can often be administered in sufficient amounts and most economically by selecting a dietary rich in iron, such as red meat, egg-yolk, green vegetables, whole wheat, etc. The iron compounds used in dental therapeutics here follow. FERRI SULPHAS— U.S.P. (Ferrous Sulphate; Green Vitriol; FeS04.7H20.) Ferrous sulphate occurs in the form of bluish-green, effiorescent prisms, odorless, having a sahne, stj'ptic taste. It is freely soluble in water, insoluble in alcohol. The average dose is i}4 gr. (o.i gm.). The official preparations are : Ferri Sulphas Exsiccatus, U.S. P. Dose, 1-3 gr. (0.06-0.2 Gm.). Ferri Sulphas Granulatus, U.S. P. Dose, 1-3 gr. (0.06-0.2 Gm.). 184 ALTERATIVES AND RESTORATIVES Physiologic Action and Therapeutics. — Iron sulphate is an active astringent. It may be applied to canker sores, but is inferior to cop- per sulphate. It is frequently used as a deodorant for privies and cesspools. FERRI SUBSULPHAS (Nonofficial) (Ferric Subsulphate; Basic Ferric Sulphate; Monsel's Salt; Fe40(S04)5.) Ferric subsulphate occurs as a yellow, hygroscopic, astringent powder, freely soluble in water. There is one official preparation: Liquor Ferri Subsulphatis, U.S.P. (Monsel's Solution). Dose, 3—5 min. (0.2-0.3 mil). Physiologic Action and Therapeutics. — Monsel's salt or the official solution (Monsel's solution) is a prompt and powerful styptic, and as such it has long been used in dentistry to control hemorrhage following the extraction of teeth. When the hemorrhage proceeds from a tooth-socket it is better to use the salt than the solution, for the reason that the hard black clots formed by the latter may conceal the deep-seated hemorrhage. The salt can be incorporated in moist cotton and, after washing the socket, the medicated cotton should be packed tightly into it. Sometimes it is necessary to hold the packing firmly for some time in order to control the hemorrhage. FERRI CHLORIDUM— U.S.P. (Ferric Chlorid; Iron Perchlorid; Fe2Cl6.i2H20.) Ferric chlorid occurs in orange-yellow, crystalUne pieces, having an astringent taste. It is a highly deHquescent salt, and therefore freely soluble in water, also in alcohol. The official preparations are: Liquor Ferri Chloridi, U.S.P. Dose, 3-10 min. (0.2-0.6 mil). Tinctura Ferri Chloridi, U.S.P. Dose, 5-30 min. (0.3-2.0 mils). Liquor Ferri at Ammonii Acetatis, U.S.P. Dose, 1-4 fl. dr. (4.0-15.0 mils). Physiologic Action and Therapeutics. — Ferric chlorid is an active astringent and styptic. It is employed in the control of hemorrhage, after the extraction of teeth, removal of small growths, etc. As a styptic in dental therapeutics, it is inferior to Monsel's solution or salt. The tincture has a deleterious action upon the teeth, and should be used about the mouth with caution. FEE.RI CARBONAS FERRI HYDROXIDUM CUM MAGNESII OXIDO 185 Ferrmn Dialysatum (Dialysed Iron). — This is a nonof&cial prepa- ration of iron oxychlorid from which acidulous matter has been separated by dialysis, hence the name, dialysed iron. It is a dark red, neutral liquid, without odor or taste. It has been employed freely as a local antidote in arsenical poisoning. Dentists have been prone to rely upon this agent when other remedies would serve better (see p. 329). FERRI CARBONAS (Nonofficial) (Ferrous Carbonate; FeCOs.) Ferrous or iron carbonate is an unstable compound which is readily converted into ferric hydroxid (^hydrate) when moist and ex- posed to air — a characteristic of most ferrous compounds. The salt may be protected from oxidation and enters into the following official preparations : Ferri Carbonas Saccharatus, U.S. P. Dose, 5-15 gr. (0.3-1.0 Gm.). Massa Ferri Carbonatis, U.S. P. (Vallet's Mass). Dose, 3-5 gr. (0.2-0.3 Gm.). PHulae Ferri Carbonatis, U.S.P. (Blaud's Pills, each contain- ing not less than i gr. (0.069 Gm.) of pure Ferrous Carbonate). Dose, 1-3 pills. Physiologic Action and Therapeutics. — Ferrous carbonate acts as a tonic, and the preparations containing it, being free from agtrin- gency, may be used whenever iron is demanded by the tissues. The preparations are especially useful in anemia. FERRUM REDUCTUM— U.S.P. (Reduced Iron; Iron by Hydrogen.) Reduced iron occurs as a fine, grayish-black, insoluble powder, without odor or taste. It should contain not less than 90 per cent. of metallic iron. It is a valuable hematinic, as it is free from astrin- gency and has little tendency to cause constipation. The average dose is I gr. (0.06 Gm.) given in the form of pills, capsules, or lozenges. FERRI HYDROXIDUM CUM MAGNESH OXIDO— U.S.P. (Ferric Hydroxid with Magnesium Oxid.) Ferric hydroxid with magnesium oxid is made by adding ammonia water to a solution of ferrous sulphate, collecting and washing the 1 86 ALTERATIVES AND RESTORATIVES precipitate, when magnesium oxid is added in excess. The prepara- tion is used exclusively as an internal antidote in arsenical poisoning. It should be freshly made and given freely, while still moist, in table- spoonful doses or more every few minutes. The average dose is 4 fl. oz. (120.0 mils). FERRI lODroUM (Nonofficial) (Iron lodid; Fel2.) Ferrous iodid occurs in grayish- white, crystalline masses; soluble in water with partial decomposition. It enters as an essential con- stituent into the following official preparations: Syrupus Ferri lodidi, U.S. P. (5 per cent.). Dose, 5-60 min. (0.3-4.0 mils.). Pilulas Ferri lodidi, U. S. P. (i gr. o.g6 gm., each). Dose, 1-3 pills. Physiologic Action and Therapeutics. —Iron iodid acts as an alterative, and as such is used in certain syphilitic conditions. The syrup is injurious to the tooth structure, and it should be taken through a tube, or given well diluted with instructions to thoroughly rinse the mouth after its administration. FERRI HYPOPHOSPHIS (Nonofficial) (Ferric Hypophosphite.) This salt occurs as a white powder, odorless, and practically taste- less. It is but sparingly soluble in water. The average dose is 8 gr. (0.5 Gm). It is contained in the following preparation: Syrupus Hypophosphitum Compositus, N. F. Dose, 1-4 fl. dr. (4.0-15.0 mils). This preparation is adopted from the National Formulary, and is similar to a number of proprietary syrups of hypophosphites. The preparation is used as an alterative and hematinic. PHOSPHORUS— U.S.P. (P.) Phosphorus occurs as a translucent, nearly colorless soHd, of a waxy luster, and at ordinary temperatures having about the con- sistence of beeswax. When kept for some time the surface becomes red and occasionally black. When exposed to air it emits white fumes, visible in the dark, which have an odor somewhat like garlic. PHOSPHORUS 187 Upon prolonged exposure to air it takes fire spontaneously. The drug should be carefully kept under water, in which it is practically insoluble, in strong, well-closed vessels. The average dose is 3^20 gr. (0.0005 Gm.). The following preparation is offi.cial: Pilulae Phosphor], U.S. P. (each pill contains Koo gr.- 0.0006 Gm.). Dose, 1-3 pills. Physiologic Action. — Phosphorus stimulates the bone-forming tissues, when given in small doses, rendering the bones more dense, and diminishing the cancellous structure; if the administration of the drug is continued, the marrow-cavity becomes more or less obliter- ated. There has been a difference of opinion among investigators as to how this result was brought about. Some believed that an excess of phosphates was deposited, while others felt that it was due to a specific irritation of the bone-forming cells, causing stimula- tion. The latter theory is more nearly correct, for Wegner has shown by a series of experiments on growing animals fed with phosphorus, but deprived of phosphates, that the same hyperplasia in the bones resulted, but that the new tissue was soft and gelatinous instead of hard. The dominant action of phosphorus is upon the osseous system. Stevens claims, however, that there is considerable clinical testimony to show that the drug improves the nutrition of other tissues, especially of the nervous system. Phosphorus is extensively used in the manufacture of matches, and the fumes so common in these factories often produce the most serious results. Where dental caries is present extensive maxillary necrosis has been re- ported by Brophy and others, as well as great irritation of the con- junctivae and the respiratory mucous membrane. In most match factories a strict rule is adopted requiring the employees to have their teeth examined at stated intervals and, if found necessary, put in order. Poisoning and Treatment. — The effects of a toxic dose of phos- phorus are not generally manifested for several hours after its inges- tion. The earliest symptoms are intense abdominal pain, persistent vomiting, thirst, a garlicky taste in the mouth, restlessness, and prostration. At the end of twenty-four to thirty-six hours, these acute symptoms gradually subside, and the hope is raised that the patient will surely recover, but frequently after a lapse of a few hours, or even two or three days, the symptoms of the acute stage may recur. In these cases there is great weakness, the symptoms becom- ing more acute, mucus, bile, and occasionally disintegrated blood being contained in the ejected materials, which for a time retain the l88 ALTERATR"Z5 AND RE5T0RATI\'ES odor and luminosity of phosphorus: jaundice develops; the liver becomes enlarged and painful, and the pulse grows very feeble. In fatal cases death generally occurs in from a few days to two weeks, and is often preceded by delirium, conAOilsions, stupor, and coma. In the treatment of pJios phones poisonings if the drug has recently been taken, emetics and purgatives are from the first necessary. Copper sulphate is considered the most efficient emetic as well as the best chemic antidote, since any excess forms with the phos- phorus the insoluble copper phosphid. Since oily and fatt}- sub- stances are active solvents for phosphorus, all such material should be withheld. Castor oil, then, as a cathartic, should not be used. As prophylactic measures for the protection of workmen against phosphor-necrosis, masks covering the mouth and nose have been found serA-iceable. as well as the inhalation of the vapor of turpen- tine obtained by suspending a small A-ial of the fluid at the neck. As has been mentioned, the teeth should be exa m ined, especially for caries, at stated intervals, since the presence of carious teeth favors the tendency to maxillar}- necrosis. Therapeutics. — Phosphorus is employed as a tonic to the osseous tissues and in certain diseases of the nervous system that are de- pendent upon exhaustion rather than upon organic changes. In neurasthenia and chronic nen-ous exhaustion it is a useful therapeutic agent. Some cases of neuralgia, particularly of the fifth nerve and accompanied by great debility, may be relieved by full doses admin- istered every four hours (Butler). The drug has proved efficacious in caries, delayed union of fractures, osteomalacia, and rachitis (rickets). In functional impotence from sexual excess, phosphorus is also a valuable remedy. The pill is considered the most stable, and therefore the best preparation in which to administer the drug. ACmUM PHOSPHORICUM— U.S.P. (Phosphoric Acid; Orthophosphoric Acid; H3PO4.) Under Phosphorus it was stated that when exposed to air the drug burns, emitting white fumes. Chemically considered, this means that phosphorus combines directly with oxj'gen to form phos- phorus pentoxid (P2O5). This oxid is capable of combining chemi- cally with one, two, or three molecules of water, forming thereby three different acids, as: P2O5 + H2O = H2P2O6 = 2HPO3, Metaphosphoric Acid. P2O5 + 2H2O = H4P2O7, P>Topho5phoric Acid. P2O5 + 3H2O = H6P2O8 = 2H3PO4, Orthophosphoric Acid. CALCII PHOSPHAS PR^CIPITATUS 1 89 These three acids show different reactions, act differently upon the animal system, and form different salts. The acid of phos- phorus recognized by the United States Pharmacopeia is a colorless liquid, composed of 85 per cent, by weight of absolute orthophos- phoric acid and 15 per cent, of water. It has a strong acid taste. There is an official diluted phosphoric acid (Acidum Phosphoricum Dilutum, U.S.P., 10 per cent.) which is usually employed when phos- phoric acid is indicated, the average dose of which is 30 min. (2.0 mils) in water. Physiologic Action and Therapeutics. — The action of phosphoric acid is somewhat like that of the dilute mineral acids, and has no relation to the action of phosphorus itself. In medicine the drug is used to allay thirst in diabetes and febrile diseases, and to promote gastric digestion. The acid has practically no use in dental thera- peutics, but is discussed here because phosphoric acid (modified somewhat) is the Hquid combined with zinc oxid (cement powder) to make the zinc phosphate cement, so extensively used in dental practice. Nearly all of the phoshates found in nature are ortho- phosphates. CALCn PHOSPHAS PRiECIPITATUS (Nonofficial) (Precipitated Calcium Orthophosphate; Bone Phosphate; Ca3(P04)2.) Precipitated calcium phosphate occurs as a white, odorless, taste- less, amorphous powder; insoluble in cold water and alcohol. The average dose is 10 gr. (0.6 gm.). There is one official preparation: Syrupus Calcii Lactophosphatis, U.S. P. (contains about 3 per cent, of the double soluble salt). Dose, 1-4 fl. dr. (4.0-15.0 mils). Physiologic Action and Therapeutics.^ — Calcium phosphate may be taken as the type of the insoluble salts of calcium, which are so frequently referred to in dental literature as "lime-salts." Lime is calcium oxid, and as there is no such thing in chemistry as a salt of an oxid, this term, lime-salts, should be discarded. When taken internally, calcium phosphate, for the most part, resists absorption and reappears in the stools; a small amount, however, is assimilated, and in case of a deficiency of phosphates in the food is appropriated by the tissues. Where the phosphates in the natural food-supply meet all physiologic requirements, any excess of the insoluble calcium salts is slowly excreted by the intestinal epithelium and kidneys. Food ordinarily contains more calcium phosphate than the body I go ALTERATIVES AND RESTORATIVES requires; it is, therefore, difificult to explain how the insoluble salts of calcium (phosphate and hypophosphite), administered as a remedy, can be of any physiologic importance. Stevens^ states that the difficulty, however, is no greater than that which is encountered in attempting to explain the undoubted efficacy of iron in chlorosis, a disease that is certainly not dependent upon a want of iron salts in the food. There is no convincing evidence to show that the in- soluble calcium salts are of much value in themselves as therapeu- tic agents. On theoretical grounds they have been prescribed to prevent the rapid decay of teeth during pregnancy and the nursing period, in osteomalacia, and in rachitis. They seem to exert a favorable influence on general nutrition in such diseases as chlorosis, anemia, scrofula, tuberculosis, tertiary syphilis, and neurasthenia. Calcium phosphate may be given in powders or capsules; the lacto- phosphate, being soluble, may be administered in the form of the official syrup or in an emulsion of cod-liver oil. As a vehicle for making pastes used in capping pulps, bleaching teeth, etc., the author recommends combining precipitated calcium phosphate with thymol (2 per cent.). This will be explained in Practical Therapeutics (see page 312). CALCn HYPOPHOSPHIS— U.S.P. (Calcium H3rpophosphite ; Ca(PH202)2-) Calcium hjrpophosphite occurs in colorless, transparent crystals, or small lustrous scales, having a bitter, nauseating taste. It is soluble in about 7 parts of water, insoluble in alcohol. The average dose is 8 gr. (0.5 Gm.). It enters as an important constituent into the following official preparation: Syrupus Hypophosphitum, U.S. P. Dose, 1-2 fl. dr. (4.0-8.0 mils). Physiologic Action and Therapeutics. — The action of hypo- phosphites, of which the calcium salt is a fair representative, is simi- lar to that of calcium phosphate, and they may be employed as therapeutic agents in the same class of cases in which the latter has been recommended. Calcium hypophosphite, being more soluble in water, may be assimilated more readily, but the same remarks hold true of this agent as were made of calcium phosphate in regard to the power of the system to utilize the agent in the constructive processes of the body. ^ Modern Materia Medica and Therapeutics. OLEtIM MOREHU^ 19I OLEUM MORRHU^— U.S.P. (Cod-liver Oil.) Cod-liver oil is a fixed oil obtained from the fresh livers of Gladus morrhua and other species of Gladus. It occurs as a thin, pale yellow liquid, having a characteristic fishy odor and taste. It contains the glycerids of olein, palmitin, and stearin, traces of iodin, bromin, chlorin, phosphorus, sulphur, biliary salts, and several alkaloids (leucomains) . The average dose is 2}4 A- dr. (lo.o mils). The ofl&cial preparation is: Emulsum Olei Morrhuae, U.S. P. (50 per cent.). Dose, 1-8 fl. dr. (4.0-30.0 mils). Physiologic Action and Therapeutics. — From the constituents of cod-liver oil it may readily be seen that it is a food rather than a medicine, and is a true restorative. In moderate doses it improves the general nutrition, increases the number of red blood-corpuscles, and favors the accumulation of fat — a normal and necessary constitu- ent of the body. Fat is the fuel used to supply energy, and the most active tissues and organs require the most fuel. Consequently, nerves, muscles, and glands are more abundantly supplied with fat than cartilage; and, in cases of starvation, those structures demand- ing the greater supply must have it, at the expense of the less highly organized and active tissues. This is illustrated in certain diseases — tuberculosis, for example. Butler^ states that the blood contains about one-half of i per cent, of fat; the muscles, 3 per cent. ; the brain, 8 per cent.; and the nerves, 22 per cent. This equilibrium must be maintained in order that the various cells of the body may possess sufi&cient vitaHty to physiologically resist the encroachments of disease and the invasion of pathogenic bacteria. It is rather diffi- cult to digest and assimilate ordinary fat; and this must be done before it can enter the various cells of the body and act as a food, and, consequently, be a source of energy. Cod-liver oil is more readily absorbed and oxidized than any other fat, due to the fact that it has already been prepared by the liver, and therefore partially elaborated ; and also to the bihary salts which it contains, causing it to pass more readily through animal membranes. Therapeutics.— Cod-liver oil is a valuable restorative in all emaciating diseases resulting in anemia. It is especially indicated as a nutritive tonic in tuberculosis. As a food it may be given in any case where fat is deficient, and therefore needed to supply energy to the tissues. ^ Text-Book of Materia Medica, Therapeutics and Pharmacology. 192 ALTERATIVES AND RESTORATIVES POTASSII lODIDUM— U.S.P. (Potassium lodid; KI.) Potassium iodid occurs as colorless, transparent or translucent crystals or as a white granular powder, having a pungent, saline taste; soluble in 0.75 part of water, 2.5 parts of glycerin, and 22 parts of alcohol. The average dose is 3-5 gr, (0.3 Gm.), given well diluted after meals; but in tertiary syphilis often i dr. (4.0 Gm.) may be given with advantage. The drug is a constituent of Lugol's solu- tion (Liquor lodi Compositus, U.S. P.) Physiologic Action. — Potassium iodid is a true alterative and has a favorable action in a variety of morbid conditions. As is true with many drugs, potassium iodid, given in a single, moderate dose in health, produces no noticeable effects beyond a slight increase in the secretion of urine and some disturbance of the stomach, due solely to its local irritant property. The drug is rapidly absorbed from all parts of the digestive tract, and reappears in the secretions in less than fifteen minutes after its ingestion. By far the greater portion is eHminated through the kidneys, but small quantities es- cape in almost every secretion of the body, as in the saliva, milk, perspiration, and even the tears. There is little doubt that a small quantity of the drug is retained, for a time at least, by the cells of the body and that a cumulative action may result, for its continuous use is generally followed, sooner or later, by a group- of symptoms known as iodism. This condition has previously been mentioned, and in this instance results from the local irritant effects of free iodin, into which a portion of the iodid appears to be converted. There is a remarkable variance in the susceptibility of individuals to the iodids, and idiosyncrasies are frequently encountered. The amount of the drug, therefore, required to induce iodism depends upon the subject. Daily doses of from 3^^-^^ oz. (7.5-15.0 Gm.) are sometimes well borne, and, on the other hand, doses of from 2-3 gr. (0.13-0.2 Gm.) a day may soon produce intense discomfort. Therapeutics. — Potassium iodid is the one drug relied upon in nearly all cases where an alterative drug is indicated. Its best effects are observed in tertiary syphilis, in which stage of the disease its efficacy is equal to that of mercury in the secondary stage. The initial dose should be small, and the amount gradually increased until improvement follows or symptoms of iodism appear. It is neces- sary in syphiHs to continue the treatment for six months or a year, and even longer, if permanent results are to be expected. In acute alveolar abscess the author has secured excellent results OTHER lODIDS 1 93 in many cases by the repeated internal administration of small doses of potassium iodid. The nauseating taste can be masked by dissolv- ing I dr. (4.0 Gm.) of the drug in 3 fi. oz. (90.0 mils) of the com- pound syrup of sarsaparilla or syrup of wild cherry. One teaspoon- ful in water can be given every two hours until three or four doses have been taken. Potassium iodid has been combined with expectorants, and used with advantage in chronic bronchitis, when the sputum is composed of thick, viscid mucus. In morbid conditions of the mucous membrane in chronic catarrh the drug is also useful. In actinomycosis^ occurring in man, the drug has been used internally with complete success as a curative remedy in a number of cases (Stevens). Potassium iodid is highly efficacious in chronic metallic poisoning, especially from lead and mercury, as it aids in the elimination of the metal by forming with it in the tissues a double soluble salt. OTHER lODIDS The iodids of several metals are used in medicine. Sodium, aiimionitmi, and strcntiiiiii iodid resemble potassium iodid in their action, and may be used for the same purposes; but they do not possess in the same degree the virtues ascribed to the potassium salt. Zinc iodid has different properties, due to the zinc ion, and has been elsewhere discussed. HYDRARGYRUM— U.S.P. (Mercury; Quicksilver; Hg.) Mercury is a shining, silver-white, heavy metal, without odor or taste. It is a liquid at the ordinary temperature, and easily divided into spherical globules; but when cooled to — 40°C. it forms a ductile, malleable mass. The metal is insoluble in ordinary solvents, but miscible with sacchareous substances and fats, through which, by tritutration, the globules may be so finely divided as not to be dis- cernible by the naked eye, in which condition the drug is very active medicinally. Mercury is largely used in therapeutics in the form of its com- pounds, but there are several ofl&cial preparations in which metalHc mercury is incorporated, after being reduced to the finely divided condition. They are: Hydrargyrum cum Creta, U.S. P. (contains 38 per cent, of Mercury). Dose, '^i-io gr. (0.03-0.6 Gm.). Unguentum Hydrargyri, U.S. P. (contains 50 per cent, of Mercury). 1 94 ALTEE_\TI\'ES AXD RE5T0R.\TI\'ES Unguentum Hydrargyri Dilutum, U.S. P. (Blue Ointment; contains 2>d per cent, of Mercury; made by mixing Ointment of Mercur>-, 2; Petrolatum, i part). Massa Hydrarg}-ri, U.S. P. (piU mass of Mercun,-; contains 33 per cent, of Mercury). Oleatum HydrargjTi, U.S. P. (contains 25 per cent, of Mercur^O • Physiologic Action. — Zvlercury is an alterative and tonic. Every dentist should be thorouglily familiar with the action and effects of this metal. When small doses of an imirritating preparation of the drug are given continuously for a certain length of time, the first effects are observed in the mouth, for it has a selective influence upon the gums, jaws, and adjacent structures. There is produced an in- creased flow of saHva, fetor of the breath, redness of the gum margins, and pericementitis, causing soreness of the teeth when the jaws are forcibly brought together. If the drug is not withdrawn upon the appearance of these s^inptoms, the condition gradually grows worse; sahvation becomes excessive (continual drooling), the gums become swollen and spongy, the teeth are loosened in their sockets and may be easily extracted with the fingers, the tongue and parotid glands enlarge — the former sometimes to the extent that it protrudes from the mouth, and, finally, the soft tissues slough away, necrosis of the bones sets in, and large sequestrum form. This group of sjTnp- toms is known as ptyalism or salivation. In these cases the general health is naturally affected, the patient becoming pale and losing flesh. Chronic mercurial poisoning occurs most frequently in work- men who handle the metal or who are exposed to its fumes, such as makers of thermometers, mirrors, scientific instruments, etc. It is too frequently induced, however, by the prolonged use of mercury as a medicine. The drug is supposed to enter into the composition of the cell by combining with the nucleinic acid, forming mercury nucleinate. It is absorbed gradually, and although every secretion of the body con- tributes to its general expulsion from the system, traces of the drug have been detected in the urine months after its use had been discon- tinued. It is, therefore, one of the slowest drugs known to be ehmi- nated, and its cumulative action is a well-estabhshed fact. Treatment of Poisoning. — If the s}-mptoms of ptyaUsm are not too pronounced, discontinuance of the mercury and mouth hygiene usually clear up the symptoms. In more severe cases, besides dis- continuing the use of mercury and emplo}"ing prophylactic measures, certain medicinal remedies are indicated. The teetJi should not he HYDRARGYRUM 1 95 extracted, unless so loose that they virtually fall out. Potassium chlorate can be dissolved in cinnamon water (lo gr.-o.6 Gm. to the fl. oz. — 30.0 mils) and used as a mouth-wash. Atropin, in medicina doses, may be used twice daily to control the flow of saliva. The internal administration of potassium iodid is recommended, as it aids in the elimination of mercury by forming with it in the tissues the double soluble salt. Where necrosis of the bones is evident, Cook and Mawhinney recommend the local application of a 50 per cent, solution of phenolsulphonic acid. This agent acts as a stimu- lant and hastens the formation of the sequestra. When the pain is very severe, morphin may be given ; and tonics are indicated to com- bat the exhaustion and anemia. Therapeutics. — Mercury and its compounds are used in general therapeutics for a variety of purposes. They act as antisyphihtics, antiparasitics, disinfectants, cathartics, and diuretics, as well as alteratives and tonics. The early methods of administering mercury were by mouth and inunction. The oral method continues to be popular, but often causes troublesome gastrointestinal symptoms. The inunction method obviates the digestive disturbances, but the amount of the drug absorbed cannot be well controlled and it is practically impossible to introduce an amount sufficient for syphilis. In recent years the attempt to improve mercurial therapy has been mainly along two Unes: The perfection of the hypodermic usage, and the introduction of the organic compounds. The organic com- pounds of mercury, such as mercurol (mercury with nucleinic acid from yeast, containing 20 per cent, of metallic mercury), are said to be less irritating to the gastrointestinal tract than the inorganic salts. The use of such agents, however, is rather experimental, and further investigation is needed to determine their real value. In syphilis, mercurials and the iodids act as specifics. Sollmann^ states that the use of the former, as yet, rests entirely upon an em- pirical basis. It is not even known whether the action of mercury here is due to specific toxicity for the germ of syphilis (Spirocheta pallida), or whether it is due simply to the general effects upon metabolism. The former seems to be the case. There is no reason to doubt that mercury is not only palliative, but curative, in the secondary stage of syphilis, congenital as well as acquired ; while it is useless in the first and third stages. The first stage is best treated expectantly, or now with salvarsan, "go6;" the third, with iodids. Syphilograhers have learned from sad experience that mercury can be pushed much further in the treatment of secondary syphilis with- ^ A Text-Book of Pharmacology. 196 ALTERATR'ES AND RESTOEATR'ES out producing ptyalism if the mouth has first been placed in a hy- gienic condition, i.e., if all irritants (deposits, overhanging fillings, etc.) have been removed by thorough prophylactic treatment. The preparations most frequently prescribed in s}'philis are mercury vdth chalk and compounds, Hke the bichlorid, biniodid, and protiodid. As mentioned (page 195), the organic compounds of mercury are also used, and under observation. The ointments are used by inunction. In pediculosis pubis (crab-Hce) the parasites are quickly destroyed by rubbing into the affected parts a small amount of blue ointment. It is the compounds of mercury that are most valuable in dental therapeutics. ^Mercury, however, is used extensively in the amalga- mation of dental alloys in the preparation of dental amalgams, which occupy a prominent place in dental practice as fiilLing material for teeth. Many homeopathic practitioners object strenuously to the use of amalgams for filling the ca\'ities in the teeth of their patients; some go so far as to order all amalgam filHngs removed and fillings of other material substituted, in the behef that the amalgam lilhng is gradually worn away and enough mercury is thus carried into the stomach and absorbed to cause systemic disturbances. The idea is certainly far-fetched, for while metaUic mercury can be sepa- rated from an amalgam by high compression or heat, it, nevertheless, is combined in the amalgam by a more or less definite chemic union. The author has no positive proof to show that mercury cannot be thus absorbed; but by close observation in a long chnical experience no constitutional disturbances from this source have been dis- covered. The same objections are offered to the wearing of a red- rubber denture, because mercury compounds are used as pigments for coloring the rubber. Surely, -^dth the high heat necessary for \ailcanization, the mercury would combine -^ith the other elements to form such insoluble (nonabsorbable) compounds that there would be no danger of systemic disturbances from this source. COMPOUNDS OF MERCURY Mercury, like iron, forms two series of compounds which are not distinguished in their Latin titles as they are in their EngUsh titles: mercurous and mercuric. The former are sparingly soluble and less active, while the latter are more readily soluble in water and alcohol and so irritant as to be classed with the poisons. The two classes also diff'er somewhat in regard to their physiologic HYDRARGYRI CHLORIDUM MITE I97 activity. The mercurous compounds, of which the chlorid (calomel) is a type, powerfully stimulate the glandular system and are anti- septics, alteratives, and cathartics. The mercuric compounds, of which the chlorid (corrosive sublimate) is a type, are potent altera- tives, and powerful antiseptics and disinfectants. It is easy to distinguish between the two classes by the different coloration pro- duced with Hme- water (Hquor calcis). The former (ous) forms a black precipitate, the latter (ic), a yellow. HYDRARGYRI CHLORIDUM MITE— U.S.P. (Mild Mercurous Chlorid; Calomel; HgCl.) Calomel occurs as a white, amorphous powder, without odor or taste. It is insoluble in all ordinary solvents. The average dose as a laxative is 23^ gr. (0.15 gm.) ; as an alterative, 3=-^ gr. (0.015 gm.). It is an important constituent of the following official pill: Pilulae Catharticae Compositae, U.S.P. (each contains Calo- mel, I gr. — 0.06 Gm., with Gamboge, Compound Extract of Colycinth, and Resin of Jalap). Dose, 1-3 pills. Physiologic Action and Therapeutics. — Externally appHed, calomel acts as a stimulant, antiseptic, and desiccant. Internally administered, it acts as a cathartic, diuretic, and antisyphihtic. Zinc ointment to which calomel, 10 gr. (0.6 Gm.) to the ounce (32.0 Gm.), has been added makes an excellent application in subacute and chronic eczema, and indolent venereal ulcers are desiccated and much improved by dusting them with calomel. Calomel acts as a laxative or purgative, according to the way in which it is administered and the susceptibility of the patient. It is a rather peculiar cathartic in that its effect does not increase in direct ratio with the dose, as is true with most cathartic drugs. Small doses repeated every half -hour until i or 2 gr. (0.065-0.13 Gm.) have been taken generally operate more freely than a dose of 10 gr. (0.6 Gm.) taken at once. Calomel produces a thorough evacuation, the stools being large and loose, and usually charged with undecom- posed bile. Whether the drug increases the quantity of bile formed in the liver or simply hastens the flow through the intestines and prevents its reabsorption is an unsettled question. Experimental and clinical evidence point more strongly to the latter assumption. In cases of a sluggish liver, the drug has been used in small, oft- repeated doses (Ko gr.-o.oo6 Gm.) to advantage. No remedy is so useful as calomel in the condition known as '' biliousness y^ which is 1 98 ALTERATIVES AND RESTORATIVES characterized by a thickly coated tongue, fetid breath, heavy urine, headache, and depression of spirits. In these cases 3^ gr. (o.oi Gm.) may be given every fifteen or twenty minutes until i gr. (0.06 Gm.) has been taken. If the bowels do not move freely, it is well to follow the mercurial with a saline cathartic (Epsom salts or a Seidlitz powder) . Incompatibles. — Calomel is incompatible with hydrochloric add, chlorids, chlorates, iodids, bromids, and lime-water, as well as with alkaHes, alkaline carbonates, iron, lead, and copper. HYDRARGYRI CHLORIDUM CORROSIVUM— U.S.P. (Mercuric Chlorid; Mercury Bichlorid; Corrosive Sublimate; HgCl2.) )i. Mercuric chlorid might well have been discussed under the heading of Disinfectants, as it is for this purpose only that it is used in dental therapeutics; but it was left that it might be considered and discussed here with the other compounds of mercury. It occurs in the form of colorless, odorless crystals or a fine white powder, having an acrid, metallic taste. It is soluble in 13 parts of water and in 3 parts of alcohol. The average dose is }4o gr- (0.003 Gm.). The U.S.P. IX for the first time recognizes an official tablet: Toxitabellae Hydrargyri Chloridi Corrosivi, U.S.P. Exter- nally (see p. 18). Physiologic Action and Therapeutics. — Mercuric chlorid, called usually bichlorid or corrosive sublimate,'^ acts as an antisyphilitic and tonic, as well as an energetic disinfectant. It is for the latter action that it is extensively employed in dental as well as in general therapeutics. The drug is capable of destroying most bacteria in solutions as dilute as i : 20,000, and their spores in solutions of i : 10,000. Certain germs, however, hke the anthrax bacillus, are more resistant to its action, and stronger solutions are necessary for their complete de- struction. On the whole, it has been the most popular of the disinfec- tants, and took first rank with surgeons for use upon the skin of the pa- tient and the hands of the operator and /or irrigating infected wounds and cavities. For the patient's skin and the surgeon's hands, solutions of from I : 1,000 to i 1500 have been employed; for large wounds and cavities, i : 10,000 to i : 5,000; and for small wounds, i : 2,000. The drug is an irritant, and should not be used, even in dilute solutions, on serous membranes. It should be observed that solutions of mercury bichlorid are not used to-day for irrigating wounds to the extent that they were in times past. HYDEARGYRI lODIDUir RUBROI 1 99 Mercuric chlorid has three disadvantages as a disinfectant: it is extremely poisonous; it is readily converted into an inert compound (mercury albuminate) in the presence of albuminous matter, and it is destructive to metal instruments. This last drawback is a serious objection in dental therapeutics; for, were it not for this fact, the drug would be an ideal disinfectant for instruments. It is energetic, soluble, and cheap. Tartaric or citric acid may be advantageously combined with bichlorid solutions to prevent the mercuric salt from forming an insoluble albuminate with the albumin in the tissues. Compressed tablets of mercuric chlorid, each con- taining 73^^ gr. (0.5 Gm.) with tartaric or citric acid are in common use. One of these tablets dissolved in a pint (480.0 mils) of water makes a i : 1,000 solution. For sterilizing infected dentin a i : 500 solution is an excellent remedy. The author suggests keeping the pure drug in papers (chartulee) each containing i gr. (0.06 Gm.) . By so doing, an approxi- mate I : 500 solution may be conveniently made at any time by dis- solving the contents of one paper in one ounce (30.0 mils) of distilled water. Ordinary water, containing traces of calcium salts, par- tially precipitates the bichlorid in the form of mercuric oxid. In applying this solution to the tooth-structure with a pledget of cotton and pliers, the latter should be dried immediately after the appHca- tion on a clean, aseptic doily, to prevent the action of the mercury upon the instrument. As a parasiticide, mercury bichlorid is a valuable remedy in pediculosis pubis and ring-worm. In these affections, 2-4 gr. (0.13- 0.26 Gm.) to the ounce (30.0 mils) of tincture of benzoin make an excellent appHcation. In syphilis the drug may be given in pill or in solution. One- twentieth of a grain (0.003 gm.), gradually increased to ^-{2 gr. (0.005 Gm.), may be given after meals. HYDRARGYRI lODIDUM RUBRUM— U.S.P. (Red Mercuric lodid; Mercury Biniodid; Hgl2.) Mercury biniodid occurs as a bright red, amorphous powder, without odor or taste. It is practically insoluble in water, soluble in 116 parts of alcohol, and freely soluble in solutions of potassium iodid. The average dose is }4q gr. (0.003 Gm.). There is one oflScial preparation: Liquor Arseni et Hydrargyri lodidi, U.S.P. (Donovan's Solution; i per cent, of each Iodid). Dose, 1-5 min. (0.06-0.3 mil). 200 ALTERATIVES AND RESTORATIV^ES Physiologic Action and Therapeutics. — Mercury biniodid re- sembles the bichlorid in its action and effects. In the late secondary stage oj syphilis it may be combined to advantage with potassium iodid. Stevens^ recommends the following formula: Mercury bin- iodid, I gr. (0.06 Gm.); potassium iodid, 3 dr. (12.0 gm.); water,. 2 fl. oz. (60.0 mils); compound syrup of sarsaparilla, sufi&cient to make 4 fl. oz. (120.0 mils). The dose is a dessertspoonful in water after meals. Donovan's solution is given with benefit in medicinal doses as an alterative in chronic rheumatism, tuberculosis, adenitis, tertiary syphilis, and during convalescence in many exhaustive diseases. HYDRARGYRI lODIDUM FLAVUM— U.S.P. (Yellow Mercurous Iodid; Mercury Protiodid; Green Mercury Iodid; Hgl.) Mercury protiodid occurs as a yellow, amorphous powder. It is insoluble and without odor or taste. The average dose is % gr. (o.oi Gm.). Physiologic Action and Therapeutics. — Mercury protiodid, being an ous compound is far less irritant than the bichlorid or biniodid. It is considered the best compound of mercury for use in syphilis, and should be given in pills or capsules to which a little opium may be added in case colic or diarrhea is induced by its ingestion. Mercurol (Mercury Nucleinate) is an organic compound of mercury with nucleinic acid from yeast. It contains 20 per cent, of metallic mercury, and occurs as a brownish-white powder ; soluble in water (warm water), insoluble in alcohol. The average dose is I gr. (0.06 Gm.). The drug does not coagulate albumin; it has marked bactericidal power, and possesses the pharmacologic action of the soluble com- pounds of mercury. It is recommended as a local antiseptic and as an antisyphilitic remedy. Sublamin (Mercuric Sulphate-ethylenediamin ; HgS04.2C2H4 (NH2)2.2H20). — This compound is composed of one molecule of mercuric sulphate and two molecules of ethylenediamin (a com- pound of ethylene and ammonia). It contains about 44 p6r cent, of metallic mercury, and occurs in white needles, odorless, but pos- sessing a very disagreeable taste; readily soluble in water and in 10 parts of glycerin, sparingly soluble in alcohol. It is only used externally as a disinfectant, similar to mercuric chlorid, over which ^ Modern Materia Medica and Therapeutics. ARSENUM 20I it has the advantage of being nonirritating, more penetrating, and readily soluble. A 1:200 solution is an excellent remedy for the immediate sterilization of infected dentin. The drug will attack steel instruments, and the same precautions must be observed here as with mercuric chlorid. It is used in i : 1,000 solution for hand dis- infection, etc. By a carefully conducted series of experiments, Mawhinney has shown that the time required for a 1-200 solution to sterilize a broach was two minutes, and he recommends this strength solution for sterilizing steel instruments. The experience of the author with sublamin has proved it to be a good disinfectant, but that it attacks steel instruments immersed in its solution for any length of time. Incompatibles. — Sublamin is incompatible with sodium chlorid and should not be exposed to air. ARSENUM (Nonofficial) (Arsenic; As.) MetalKc arsenic is not official, for as such it is not employed as a medicine. The chief compound used in therapeutics, especially dental therapeutics, is arsenic trioxid, which has been fully discussed as a devitalizing agent under Caustics. Certain salts of arsenous acid (arsenites) and arsenic acid (arsenates) are also used. The following compounds and preparations containing arsenic in combination are official : Arseni Trioxidum, U.S.P. Dose, Hq-Mo gr. (0.001-0.003 Gm.). Liquor Acidi Arsenosi, U.S.P. (contains i per cent, of Arsenic Trioxid and 5 per cent, of dilute Hydrochloric Acid). Dose, 1-5 min. (0.06-0.3 mil). LiquorPotassiiArsenitis, U.S.P. (Fowler's Solution; contains the equivalent of i per cent, of Arsenic Trioxid and 3 per cent, of compound tincture of Lavender). Dose, 1-5 min. (0.06-0.3 mil). Sodii Arsenas, U.S.P. Dose, }i6~H g^- (0.004-0.008 Gm.). Sodii Arsenas Exsiccatus, U.S.P. Dose, >|o-H2 gr- (0.002 -0.005 Gm.). Liquor Sodii Arsenatis, U.S.P. (Pearson's Solution; contains I per cent, of Exsiccated Sodium Arsenate). Dose, 1-5 min. (0.06-0.3 mil). Arseni lodidum, U.S.P. Dose, Ho-Ko gr. (0.002-0.006 bm.). Liquor Arseni et Hydrargyri lodidi, U.S.P. (Donovan's Solu- tion). Dose, 1-5 min. (0.06-0.3 mil).. 202 ALTEIL\TWES AND RESTOEATIVES Physiologic Action and Therapeutics. — The action and uses of arsenic trioxid have been elsewhere considered. Arsenic in thera- peutic doses acts as an alterative by favoring nutrition. Just how the action is brought about is not well understood. The drug is used internally in a number of quite diverse patho- logic conditions. Its use, however, is purely empirical. It stands next to iron in the treatment of anemia. Fowler's solution, although not curative, is the most efficient remedy in pernicious anemia. In neuralgia dependent upon anemia, arsenic is valuable. The dose should be gradually increased until symptoms of saturation appear. No general tonic, except cod-Hver oil, is so efficacious as arsenic in pulmonary tuberculosis. The drug has long been used with reported good results in diabetes mellitus. It is an excellent alterative in pyorrhea alveolaris associated with chronic rheumatism or the gouty diathesis. The prolonged use of arsenic (Koo-z-oO g^- — 0.0006- 0.0012 Gm.) has been spoken of in the highest terms in myocardial degeneration and angina pectoris. In these cases it may be combined advantageously with strychnin, and sometimes also with digitaUs (Stevens). Individuals vary considerably in their susceptibiUty to the action of arsenic, therefore it is best to begin with small doses of the drug and gradually increase them as occasion demands. The indications of saturation are puffiness under the eyes, especially noticeable in the morning, and looseness of the bowels with cohcky pains. For pills arsenic trioxid is generally selected, and for solutions the solution of potassium arsenite (Fowler's solution). Incompatibles. — Arsenic is incompatible with salts of iron, silver, copper, and ammonium, magnesium, calcium, and tannic acid. Salvarsan, "606." — This is a complex arsenic compound, the hy- drochlorid of 3-diamino-4-dihydroxy-l-arsenobenzene, corresponding to 31.57 per cent, of arsenic. The average dose is 5 gr. (0.3 Gm.). Salvarsan is useful as a specific remedy for syphilis in all stages. It is claimed that the drug is especially beneficial in those cases which respond slowly to mercury and iodids ; and that it is useful in all spirillum afections, such as malaria. Neosalvarsan is a similar and later compound in which the arsenic content of three parts is approximately equal to 2 parts of salvarsan. It is merely a soluble compound of salvarsan and its action and uses are the same. Contraindications. — Salvarsan preparations are contraindicated in severe disturbances of the circulatory organs, advanced degenera- tions of the central nervous system, fetid bronchitis, and cachexias, S.AJISAPARILLA ECHINACEA 203 unless these are a direct result of s}^liili3 ; also in patients who have a pronounced idiosyncrasy against arsenic. SARSAPARILLA— U.S.P. Sarsaparilla is the root of Smilax officinalis and other species of Smilax, chmbing evergreens growing in swampy forests of Mexico and as far south as the northern portion of Brazil. It contains sev- eral glycosids — parilUn, saponiyi, and sarsa-saponin. The average dose is 30 gr. (2.0 Gm.). The follo\\dng preparations are ofl&cial: Fluidextractum Sarsaparillse, U.S. P. Dose, 3^-2 fl. dr. (2.0- 8.0 mils). Fluidextractum Sarsaparillae Compositum, U.S. P. Dose, 3^-2 fl. dr. (2.0-8.0 mils). Syrupus Sarsaparillae Compositus, U.S. P. (contains fluid ex- tract Sarsaparilla, 20; fluid extract Glycyrrhiza, 1.5; fluid extract Senna, 1.5; Oil of Sassafras, Oil of Anise, Methyl Salicylate, of each, 0.02; Alcohol, 1.9; Syrup, to make 100). Dose, 1-4 fl. dr. (4.0-15.0 mils). Physiologic Action and Therapeutics. — Sarsaparilla owes its phar- macologic activity entirely to the saponins which it contains. The drug has been empirically used as an alterative in syphilis and tuber- culosis for centuries, but this view of its action is not accepted at the present time, and if it possesses any action at all it is simply that of a very mild nauseant (Sollmann) . It is chiefly used in the form of the compound syrup as a pleasant vehicle for potassium iodid, potas- sium bromid, and certain salts of mercury. ECHINACEA (Nonofficial) (Cone Flower.) Echinacea is the dried root of Echinacea angustifolia, a perennial herb gromng in the central and western portions of the United States. A fluid extract may be obtained, the dose of which is from 15-30 min. (1.0-2.0 mils) . The dose of specific echinacea (tincture) is from 5-30 min. (0.3-2 .0 mils) . Echafolta is a purified, assayed form of echinacea. The dose is the same. Externally or for surgical purposes, it is con- sidered greatly superior to any other preparation of echinacea, and is prescribed for the same conditions. Echinacea was kno\vTi to the Indians as a cure for snake poison. The experiments with the drug have been confined almost entirely to the eclectic school of medicine, and remarkable properties almost, bordering on the miraculous, are ascribed to it. 204 ALTERATIVES AND RESTORATIVES Physiologic Action. — Applied to the mucous membrane, a warm and tingling sensation is at once experienced. It is similar to that of aconite, without the sedative effect. The sensation persists for some time, even though the throat is gargled, and the agent entirely removed. The drug actively promotes the flow of saliva, and if swallowed, the warmth and tingling extend down the esophagus to the stomach, but no further unpleasant influence is observed. In a short time diaphoresis is observed, and the continuation of the remedy stimulates the kidneys to increased action. All of the glandu- lar organs seem to respond to its stimulating influence, and their functional activity is increased. The stomach is improved in its function, the appetite increases, the food is more perfectly digested, the bowels operate better, and absorption, assimilation, and general nutrition are materially improved. It encourages secretion and excretion, preventing further autointoxication, and quickly correct- ing the influence in the system of any that has occurred. It stimu- lates retrograde metaboHsm, or tissue waste, more markedly than any other single remedy known. There are but few subjective symptoms from large doses of the drug. It is apparently nontoxic, and, to any unpleasant extent, non- irritant. It has a marked effect upon the nervous system, but its action here has not yet been determined (ElUngwood) . Therapeutics. — Hewitt, CahiU, and others have recommended the drug in dental therapeutics. Some enthusiasts go so far as to recommend the use of the drug in almost every disease to which the body is heir. The drug has been used in acute alveolar abscess to prevent the formation of pus, or after pus-formation to hasten its evacuation. In septicemia (blood-poisoning), it is claimed to be almost a specific. In ulcerative stomatitis^ sore throat or mouth of any character, the local application of echafolta is prompt and effectual. CALCn SULPHmUM CRUDUM— U.S.P. (Sulphurated Calcium ; Crude Calcium Sulphid.) Sulphurated calcium is a mixture containing at least 60 per cent, of calcium sulphid, together with calcium sulphate and varying pro- portions of carbon. It occurs as a pale gray powder, having a nause- ating, alkaline taste and a faint odor of hydrogen sulphid. It is but sHghtly soluble in water and insoluble in alcohol. Exposure to air causes gradual decomposition. The average dose is i gr. (0.06 Gm.), in pills, tablets, or capsules. AURI ET SODII CHLORIDUM 20$ Physiologic Action and Therapeutics. — The action of calcium sulphid is not well understood. Its power of preventing and arrest- ing suppuration was first mentioned by Ringer. It has been found especially useful in boils and carbuncles Excellent results are ob- tained in follicular tonsillitis and quinsy by giA^ng small doses {}4o gr.-0.003 Gm.) at short intervals. Harlan recommended giving the drug in doses of Ko gr- (0.006 Gm.), at short intervals, in acute alveolar abscess and other suppurative conditions, claiming that it pre- vented the formation of pus, if given early enough, or, if too late for this, that the agent hastened the evacuation of the pus. Only fresh preparations should be employed on account of the UabiUty of the drug to deteriorate. AURI ET SODII CHLORIDUM— U.S.P. (Gold and Sodium Chlorid; AuCla -fNaCl) This preparation is a mixture of equal parts, by weight, of dry gold chlorid and sodium chlorid. It is an orange-yellow powder, deliquescent, and of a sahne and metalHc taste; freely soluble in water. The average dose is J^2 gr. (0.005 Gm.), in pill. Physiologic Action and Therapeutics. — Gold and sodium chlorid is supposed to act as an alterative, tonic, and stimulant to the digestive system. It has been recommended in a number of diseases where an alterative and tonic effect is desired, but it is of doubtful value. Solutions of gold chlorid have been recommended by Ames for cauterizing exposed sensitive cementum, and he claims that its effect is nearly equal to that of silver nitrate without the discolo- ration. DIGESTANTS The mouth and the stomach are intimately connected and closely related; so much so that pathologic conditions in one often predis- pose to disease in the other. It is therefore important that the dentist be familiar with the action and uses of certain agents which materially assist in the digestion of food. Those not discussed under other headings will here be considered. They are: Pepsin. Malt. Pancreatin. Papain. PEPSINUM— U.S.P. (Pepsin.) Pepsin is a proteolytic ferment or enzyme obtained from the glandular layer of fresh stomachs from healthy pigs. It occurs as a 2o6 DIGE5TANTS yellowish.- white, amorphous powder, or in thin, pale yellow scales, ha%dng a faint odor and a sHghtly acidulous or saline taste. It is soluble in 50 parts of water, more so in water acidulated with hydro- chloric acid, and insoluble in alcohol. The Pharmacopeia of the United States requires the drug to be capable of digesting not less than 3,000 times its weight of freshly coagulated and disintegrated egg albumin. The average dose is 8 gr. (0.5 Gm.) Physiologic Action and Therapeutics. — Pepsin is an excellent digestive, being a normal constituent of the gastric juice, and in the presence of hydrochloric acid (a natural acid of the stomach) it digests the proteid elements of the food, converting these insoluble substances into albumoses, and finally into soluble peptones. The drug is given in cases where there is a lessened secretion of gastric juice, as in atonic dyspepsia, cancer of the stomach, and gastric ulcer. Many organic acids, alcohol, and alkalies impair the proteolytic action of pepsin. PAKCREATINTJM— U.S.P. (Pancreatin.) Pancreatin is a mixture of enzymes naturally existing in the pancreas of warm-blooded animals, and is obtained from the fresh pancreas of the hog or the ox. It consists principally of amylopsin, trypsin, and steapsin. To be up to the ofticial standard it should be capable of converting not less than 25 times its weight of starch into water-soluble substance (dextrose). It occurs as a cream- colored powder, slowly but not completely soluble in water, insoluble in alcohol. The average dose is 8 gr. (0.5 Gm.). Physiologic Action and Therapeutics. — The action of pancreatin is due to the active erLZ}Tnes which it contains, of which tr}^sin digests proteids, amylopsin acts upon starches, and steapsin emulsi- fies fats and oils, resolving them into fatty acids and glycerin. The drug, like pepsin, is used as an artificial digestant in certain disorders of the stomach wherein digestion is impaired. MALTUM— U.S.P. (Malt.) Malt is the grain of one or more varieties of Eordeum sativum (barley), partially germinated artificially, and then dried. The extract is official : DIASTASUM — PAPAYOTIN 207 Extractum Malti, U.S. P. Dose, 4 fl. dr. (15.0 mils). Fluidextractum Malti, N.F. (contains 25 per cent. vol. alcohol). Dose, 2 fl. dr. (8.0 nuls). If the extract of malt is prepared according to the process of the United States Pharmacopeia, the fresh preparation will contain diastase, an efficient ferment and capable of converting starch into dextrose. The diastatic power rapidly deteriorates on keeping. The extracts of malt are extensively used as digestants and as general tonics, but their value is more or less questionable, probably on account of the difficulty of obtaining the preparation fresh and properly prepared . Heat above 57°C. (i35°F.) destroys the diastase. DIASTASUM— U.S. P. (Diastase.) Diastase is a mixture containing amylolytic enzymes obtained from an infusion of malt. It occurs as a yellowish-white, amorphous powder, or in translucent scales; odorless and tasteless. It has the power of converting not less than 50 times its weight of potato starch into soluble carbohydrates (dextrin and maltose). It should be kept in weU-closed containers, protected from light, heat and moisture. Diastase is soluble in water, the solutions being more or less turbid; almost insoluble ia alcohol. The drug is used as a digestant and general tonic. The average dose is 8 gr. (0.5 Gm.). PAPAYOTIN (Nonofficial) (Papain; Papoid; Caroid.) Papain is a natural albuminous ferment obtained from Carica papaya, the papaw tree, growing in the tropics. It occurs as a grayish- white, amorphous powder, without odor or taste. It is soluble in water and glycerin, but insoluble in alcohol and ether. The average dose is 8 gr. (0.5 Gm.). Physiologic Action and Therapeutics. — It is claimed that papain will convert proteids into peptones, starch into maltose, and emulsify fats; and that although it will act in neutral or acid solutions, it is most active in solutions of an alkahne reaction (Stevens). Harlan introduced the drug in dental therapeutics for digesting pulp tissue after devitahzation. He suggested making a paste wdth glycerin, acidulating with i or 2 min. of a i : 500 solution of hydrochloric acid. The pulp was devitaHzed in the usual V\'ay, and this paste sealed in contact with the dead tissue for one or two weeks, when 2o8 CATHARTICS the tissue was supposed to be liquefied. Clinical experience with the drug in dental, as well as in general therapeutics, proves it of doubtful value. CATHARTICS Cathartics have been elsewhere defined as agents which produce evacuation of the bowels. The drugs having this property are classi- fied according to the intensity of their action and the character of the stool thus produced. Those that are mild in action and pro- duce a nearly normal stool are called laxatives. Those more power- ful, usually producing more copious stools, are termed purgatives. Those which produce a watery evacuation of the bowels are called hydragogues. Those which gripe, having a violent action, and in overdoses produce symptoms of acute enteritis, are termed drastics. The chief laxatives are: Cascara Sagrada. Figs. Tamarind. Prunes. Manna. Honey. ef purgatives are: Aloes. Calomel.* Senna. Blue Mass.* Castor Oil. Sulphur. Rhubarb. Phenolphthalein, The principal hydragogues are: Magnesium Sulphate. Sodium Phosphate. Sodium Sulphate. Magnesium Citrate. Potassium and Sodium Tartrate. The main drastics are: Croton Oil. Gamboge. Colocynth. Jalap. Podophyllum. CASCARA SAGRADA— U.S.P. (Rhamnus Purshiana, U.S.P. VIII; Chittem Bark.) Cascara sagrada is the dried bark of Rhamnus Purshiana, a small tree growing along the Pacific coast of North America. It contains a crystalline glucosid, purshianin, that is several times as active as the crude drug. The average dose of cascara sagrada bark is 15 gr (i.o Gm.). The following preparations are ofl&cial: TAMARINDUS FICUS 209 Fluidextractum Cascara Sagrada, U.S. P. Dose, 10-30 min. (0.6-2.0 mils). Fluidextractum Cascara Sagrada Aromaticum, U.S. P. Dose, 10-30 min. (0.6-2.0 mils). Extractum Cascara Sagrada, U.S. P. Dose, 2-8 gr. (0.13- 0.5 Gm.). Physiologic Action and Therapeutics. — Cascara sagrada is a peculiarly efficient laxative. Its action is somewhat slow and is seldom accompanied with irritation or unpleasant symptoms. It is used exclusively as a tonic laxative, and in habitual constipation it is a reliable remedy. The drug possesses a distinct advantage over many cathartics in not readily losing its effect when frequently taken ; in fact, in most cases the dose can be diminished gradually, and this is usually the most satisfactory way of administering the remedy. On account of the unpleasant bitter taste the aromatic fluid extract is the best preparation to use. TAMARINDUS (Nonofficial) (Tamarind.) Tamarind is the preserved pulp of the fruit of Tamarindus indica, a large tree indigenous to Africa and cultivated in the West Indies. It is a gentle laxative about equal in power to the fig and prune. Its action is due chiefly to the potassium salts of tartaric, citric, malic, and acetic acids, of which it contains from 8-12 per cent. The average dose is 4 dr. (16.0 Gm.). It is a constituent of the formerly official confection of senna. MANNA— U.S.P. Manna is a concrete saccharine exudation from Fraxinus Ornus, a small native tree of Sicily and other Mediterranean islands. Its chief constituent is mannite (50-80 per cent.) a sweet crystalline principle, soluble in water. It acts as a mild laxative in doses of 1-2 oz. (32.0-64.0 Gm.). It is usually given in combination with other cathartics, and is a constituent of the official compound infusion of senna. FICUS (Nonofficial) (Fig.) Fig is the dried fruit of Ficus Carica, a native tree of the shores of the Levant, but cultivated in tropical countries. It contains about 62 per cent, of grape-sugar, also gum, fat, etc. It acts as a demulcent 2IO CATHARTICS and laxative, and is a constituent of the formerly official confection of senna. Figs are chiefly used as an article of diet in habitual constipation. PRUNUM (Nonofficial) (Prune.) Prune is the dried fruit of Prunus Domestica, the plum tree, indigenous to Western Asia, but cultivated in most temperate countries. It contains sugar, pectin, albumin, malic acid, and salts. Prunes are laxative and nutritious, and are freely used as food and sweetmeat. Stewed prunes are an excellent remedy for constipation in children. They are a constituent of the formerly official confection of senna. MEL— U.S.P. (Honey.) Honey is a saccharine secretion deposited in the honey-comb by Apis Mellifica, the honey-bee. It is a strong aqueous solution of several sugars (cane- and grape-sugar, levulose) with wax pollen, coloring and odorous matters, etc. Honey is often adulterated with starch and glucose. The dose is indefinite. Clarified honey is official (mel depuratum, U.S. P.), and is an ingredient of con- fection of senna, U.S. P. VIII, and of the official honey of rose (mel rosas, U.S. P.). Honey is a laxative, nutritive, and emollient. It is used chiefly as an emollient in diseases of the throat to reheve dryness, pain, cough, and dysphagia, and also as a pleasant vehicle for certain nauseous drugs. Honey of rose is slightly astringent, and is used in gargles, sprays, or washes for inflammatory and ulcer- ating conditions of the mucous membrane of the mouth, throat, and nasal passages. The wax obtained from the honey-comb is a useful material in dental practice. ALOE— U.S.P. (Aloes.) Aloes is the inspissated juice obtained from the leaves of several species of genus Aloe, a familiar example of which is the American century plant. It grows abundantly in nearly all hot, dry countries. Two varieties were formerly recognized by the United States Phar- macopeia (1890): Barbadoes aloes {Aloe barbadensis) , obtained from Aloe vera, and Socotrine aloes (Aloe socotrina), obtained from Aloe SENNA 211 perryi. The chief constituent is aloin, also official, a neutral crys- talline principle, and from which is obtained emodin, a glucosid to which the purgative property of the drug is doubtless due. Emodin is also found in senna and rhubarb. The average dose of aloes is 4 gr. (0.25 Gm.). The following preparations are official: Aloninnm, U.S. P. Dose, 3-1-2 gr. (0.016-0. 13 Gnu). Tinctura Aloes, U.S. P. Dose, 3^-2 fl. dr. (2.0-8.0 mils). Pilulas Aloes, U.S.P. (contains about 2 gr.-0.13 Gm.). Dose, 1-5 pills. Pilulae Rhei Compositse, U.S.P. (contains Aloes, i3^ gr.-o.i Gm.; Rhubarb, 2 gr.-0.13 Gm.; Myrrh and Oil of Pepper m int). Dose, 1-5 pills. The drug enters into other official preparations, as compound extract of colocjTith, compound tincture of benzoin, compound cathartic pills, and other vegetable cathartic pills. Physiologic Action and Therapeutics. — .Aloes is a rather slowly acting but effective purgative. It will be noticed from the list of preparations that aloes is rarely used singly as a cathartic. In simple, persistent constipation, it may be combined advantageously with other drugs, nux vomica, ipecac, rhubarb, or podophyUum. Pills of aloes and iron, formerly official, are often given with benefit in chlorosis with constipation. The liquid preparations have a dis- agreeable taste which is difficult to mask and are rarely given. The pill is the popular form of administering the drug. SENTTA— U.S.P. Senna is the leaflets of Cassia acutifolia and Cassia angustiiolia, smaU shrubs growing, respectively, in Africa and India. It contains chiefly an active acid glucosid, cathartin or cathartinic acid, also emodin. The average dose is i dr. r4.oGm/'. The following prepa- rations are official: Fluidextractum Sennie, U.S.P. Dose. 1—2 fl. dr. (4.0-S.o mils). Syrupus Senme, U.S.P. (25 per cent.}. Dose. 1-4 fl. dr. (4.0- 15.0 mils.). Infusum Sennae Compositinn, U.S.P. (Black Draft: Senna, 6; Fennel, 2; Manna, 12; Epsom Salts, 12). Dose, 1-4 fl. oz. (30.0-120.0 mils). Confectio Sennae, U.S.P., \lli (10 per cent., with Cassia Fistula, Tamarind, Prune, Fig, Sugar, and Coriander Oil). Dose, 1-2 dr. (4.0-8.0 Gm.). Pulvis Glyc^Trhizs ComposiDJS, U.S.P. (i3 per cent, of 212 CATHARTICS Senna, with Licorice, Sulphur, Sugar, and Fennel Oil). Dose, H~2 dr. (2.0-8.0 Gm.). Syrupus Sennae, U.S.P, (from Fluidextract) . Dose, 1 fl. dr. (4.0 mUs). Extract of senna (1.5 per cent.) is a constituent of compound syrup of sarsaparilla. Physiologic Action and Therapeutics. — Senna acts energetic- ally as a purgative. Its action is more irritating than that of rhu- barb and more prompt and powerful than that of aloes. It is one of the best vegetable purgatives, and its effect is certain and reliable in simple, acute constipation. In habitual costiveness, compound licorice powder is a popular household remedy. It is given at bed- time in about a teaspoonful dose, governed by the age of the patient. OLEUM RICmi— U.S.P. (Castor Oil.) Castor oil is a fixed oil expressed from the seed of Ricinus com- munis, a plant indigenous to India, but cultivated in many other temperate countries. It occurs as a pale yellow, viscid oil, having a faint odor and a slightly acrid, offensive taste. It is freely soluble in alcohol. It contains the glycerid of ricinoleic acid, called ricin- olein, and to which the purgative property of the drug is due. The dose of castor oil is from i fl. dr.-i fl. oz. (4.0-30.0 mils), governed by the age of the patient. Physiologic Action and Therapeutics.^ — Castor oil is a mild, but thorough purgative. Stevens^ states that while its fate in the body has not been definitely determined, it is probable that it escapes from the stomach unchanged, and that in the presence of the alka- hne juices of the intestines saponification occurs with the liberation of ricinoleic acid, which is subsequently converted into ricinoleates. The latter induce catharsis by stimulating the muscular coat of the bowel, and are probably absorbed, since the oil is known to impart its purgative properties to the milk when given to nursing women. Castor oil has long been a household remedy to remove irritant material from the bowel in the beginning of acute inflammatory diarrhea, especially in children. It is not a suitable remedy for habitual constipation, as is generally supposed by the laity. The drug is a desirable constituent of many lotions, used on the scalp for dandruff, etc., owing to its solubility in alcohol. Patrick, Moyer, and other neurologists highly recommend large ^ Modern Materia Medica and Therapeutics. RHEUM 213 doses of castor oil in tic douloureux. Smaller doses are first admin- istered, and gradually increased until large quantities may be taken daily without inducing catharsis. The main objection to castor oil as a therapeutic agent is its disagreeable taste. Many substances have been suggested to over- come this objection, among which may be mentioned the oils of peppermint, gaultheria, and cinnamon, A pleasant combination follows : Castor Oil, 8 oz. (240.0 mils); Oil of Peppermint, 5 min. (0.3 mil); Saccharin, 2 gr. (0.13 Gm.); and Alcohol, i dr. (4.0 mils). The Oil of Peppermint and Saccharin should first be dissolved in Alcohol and then added to the Castor Oil. The usual dose may be given. Castor Oil may also be given in flexible capsules. RHEUM— U.S.P. (Rhubarb.) Rhubarb is the root of Rheum officinale, a perennial herb resem- bHng garden rhubarb, but of larger growth, and a native of China, Thibet, and other Asiatic countries. It contains chrysophanic acid, emodin, tannic acid, and several resinous principles. It is to emodin and possibly some of the resinous principles that rhubarb owes its purgative properties, for chrysophanic acid has no purgative action and tannic acid is an astringent. The average dose of rhubarb is 15 gr. (i.o Gm.). The following preparations are official: Tinctura Rhei, U.S. P. (10 per cent., with Cardamom). Dose, 1-2 fl. dr. (4.0-8.0 mils). Tinctura Rhei Aromatica, U.S. P. (20 per cent., with Aromat- ics). Dose, }'i-i fl. dr. (2.0-4.0 mils). Fluidextractum Rhei, U.S. P. Dose, 10-30 min. (0.6-2.0 mils). Extractum Rhei, U.S. P. Dose, 5-10 gr. (0.3-0.6 Gm.). Syrupus Rhei, U.S.P. (10 per cent, of the fluid extract). Dose, 1-6 fl. dr. (4.0-22.5 mils). Syrupus Rhei Aromaticus, U.S.P. (15 per cent, of aromatic tincture and spiced syrup of Rhubarb). Dose, 1-6 fl. dr. (4.0-22.5 mils). Pulvis Rhei Compositus, U.S.P. (Gregory's Powder; Rhu- barb, 25; Magnesia, 65; Ginger, 10). Dose, 20-60 gr. (1.3-4.0 Gm.). Pilulae Rhei Compositae, U.S.P. Dose, 1-5 pills. Physiologic Action and Therapeutics.^Rhubarb acts, in appro- priate doses, as a purgative and stomachic. As a secondary effect, however, it frequently causes constipation, due to the tannic acid it 214 CATHARTICS contains. Doses of from 1-3 gr. (0.06-0.2 Gm.) often produce no cathartic action, but its effect upon the stomach is that of a mild astringent and tonic. As an agent for removing irritant material from the bowel in the beginning of acute inflammatory diarrhea, especially in children, rhubarb is highly efficient. To check diarrhea in cholera morbus the following has been a popular remedy: tincture of rhubarb, tinc- ture of capsicum, tincture of opium, spirit of camphor, and spirit of peppermint — an equal quantity of each. The dose is from 15-30 min. (1.0-2.0 mils), in water. SULPHUR (S.) The element sulphur is recognized by the United States Pharma- copeia in three forms: Sulphur Sublimatum. — ^U.S.P. (Subhmed Sulphur; Flowers of Sulphur). — This occurs as a fine yellow powder, having a sHghtly characteristic odor and a faintly acid taste. It is insoluble in water, partially soluble in absolute alcohol, ether, and chloroform. The average dose is i dr. (4.0 Gm.). Sulphur Lotum — ^U.S.P. (Washed Sulphur) . — This form of sul- phur is prepared by digesting sublimed sulphur for three days in weak ammonia water, and then washing. It enters into two official preparations: Unguentum Siilphuris, U.S. P. (15 per cent.). Pulvis Glycyrrhizae Compositus, U.S. P. (8 per cent.) Also, Unguentum Sulphuris Compositum, N.F. Sulphur Praecipitatum — ^U.S.P. (Precipitated Sulphur; Milk of Sulphur) . — This is a fine, almost white powder, without odor or taste. It is prepared by precipitation from calcium sulphid solutions with diluted hydrochloric acid. The average dose is i dr. (4.0 Gm.). Physiologic Action and Therapeutics. — Sulphur acts locally as a stimulant and parasiticide. Internally, it acts as a mild purgative. As a stimulating remedy it has been recommended in pyorrhea alveolaris, but its use is of doubtful value. It is a reliable remedy, however, in parasitic diseases, like scabies (itch) and ring-worm. The ointment may be employed. The drug may be given internally, mixed with honey or molasses, as a laxative. When sulphur is burned in the air, sulphur dioxid (SO2) is formed. This acid-forming oxid (anhydrid) unites with water to form sulphurous acid (H2SO3), which latter product is a potent disinfectant and bleaching agent. PHENOLPHTHALEINITM MAGNESH SULPHAS 21 5 Kirk recommends a mixture of boric acid- and sodium sulphite as a bleaching agent for tooth-structure. The mixture should be placed in the cavity dry, then moistened and hermetically sealed. A re- action is brought about whereby sulphurous acid is formed. PHENOLPHTHALEmUM— U.S.P. (Phenolphthalein ; C20H14O4.) Phenolphthalein is a dibasic phenol derivative. It occurs as a white or faintly yellowish- white, crystalline powder; without odor or taste; permanent in the air. Almost insoluble in water; soluble in 13 parts of alcohol, and in 70 parts of ether at 25°C. It is dis- solved by solutions of the alkali hydroxids and carbonates with a red color. The solutions are decolorized by the addition of acids in excess. Owing to this peculiar property the agent is used as an indicator in volumetric assaying and in quantitative analysis. The drug has been recommended as a purgative. The average dose is 2}i gr. (0.15 Gm.). MAGNESn SULPHAS— U.S.P. (Magnesium Sulphate; Epsom Salt; MgS04.7H20.) Magnesium sulphate occurs in small, colorless, rhombic prisms or acicular crystals, without odor, and having a cooling, saline, un- pleasant, and bitter taste; soluble in 1.5 parts of water, and insoluble in alcohol. The average dose is 4 dr. (16.0 Gm.). The drug enters into one official preparation : Infusum Sennae Compositum, U.S. P. Dose, 4-6 fl. oz. 120. 0-180.0 mils). Magnesii Siilphas Effervescens, U.S. P. \T;II (contains Magne- sium Sulphate, 500; Sodium Bicarbonate, 403; Tartaric Acid, 211; Citric Acid, 136). Dose, 1-8 dr. (4.0-32.0 Gm.). Physiologic Action. — Magnesium sulphate is a typical represen- tative of the class of saKne cathartics, all of which produce evacuation of the bowels chiefly by increasing the amount of fluid in the intestine. They differ in their action from vegetable cathartics in that they stimulate peristalsis but feebly. They not only hinder the absorp- tion of fluid taken with the food, but they abstract more fluid directly from the tissues and blood. To understand thoroughly this so- called salt action — i.e., the behavior of saline solutions of varying degrees of concentration in relation to the saHnity of the blood serum, by which a flow of fluid to or from the blood is determined — it is necessary that we be familiar with certain physical processes, chief 2l6 CATHARTICS among whicli is that of osmosis — the passage of salts through animal membranes, or the force by which fluids are impelled through organic membranes. If, for example, a lo per cent, solution of common salt is placed in the bottom of a container and water placed in the top, the two liquids being separated by a more or less permeable animal membrane, in a few moments it will be observed that the specific gra\'ity of the two fluids is the same. By the process of osmosis, then, the salt from the solution in the bottom has passed through the membrane, and a 5 per cent, solution of common salt on both sides of the separating medium is the result. A semipermeable membrane is one which allows the passage of one sort of molecules (usually the solvent), while imper\-iou3 to another (usually the dissolved substance). The interposition of such a membrane between salt solutions of varpnCT degrees of concentration introduces very impor- tant modincations in the osmotic process, and results in the develop- ment of what is termed osmotic pressure. The walls of the intestines are only partly semipermeable; -i.e., they are partly permeable to salts, though much less readily than to water. If two solutions hav- ing the same molecular concentration in dissolved substance (i.e., equimoleadar) are separated by a semipermeable membrane imper- meable to the dissolved substance, it is e^'ident that no change of Liquid will occur. Such solutions, ha\ing the same specific gra\^ty and, therefore, the same osmotic tension or pressure, are called isotonic to each other. In physiologic hterature "isotonic" usually means solutions ha\'ing the same concentration (specific gra\ity) as blood- serum, and it is in this sense that the term is used in these pages. If one solution has a greater concentration than the other and the separating medium be a partly semipermeable membrane, like the waUs of the intestines, water principally -^-ill pass from the weaker into the stronger solution until both are of the same concentra- tion. The stronger solution is then called hyperisotonic; the weaker, hypoisotonic. Neither being isotonic, they are called anisotonic. With this knowledge of salt action we can readily understand how saline cathartics, in normal subjects, act as hydragogues, i.e., pro- duce a watery evacuation of the bowels, and why they are absorbed from the intestine very slowly and in but small quantities, the greater portion escaping from the body in the stools. The action of sahne cathartics, therefore, is purely local, which fact is sustained by the further fact that they do not produce catharsis when intra- venously injected. Wlien saline cathartics are administered to an anhydremic patient (having a deficient amount of water in the blood) the process of their action is reversed; instead of the blood in the SODII SULPHAS 217 adjacent tissues yielding its water to the intestine, the blood ab- stracts water from the bowel, the greater portion of the salt is ab- sorbed, and purgation does not ensue. This means that a hypoiso- tonic solution of the salt must necessarily be administered, otherwise this result would not follow. An isotonic or perhaps a hyperiso- tonic solution with a normal subject might be hypoisotonic in cases of anhydremia. Magnesium sulphate in concentrated solution (hyperisotonic) , is an active hydragogue cathartic, producing in a few hours a copious watery evacuation of the bowel without much pain or systemic dis- turbance. Dilute solutions (hypoisotonic) do not produce purga- tion, but, the salt being absorbed in greater quantity, they act as diuretics, increasing the flow of urine. Therapeutics. — Magnesium sulphate, being practically free from irritant properties, is an excellent cathartic for removing undigested material from the bowel in acute enteritis and colitis (colic). Stevens speaks favorably of saline cathartics in chronic constipation, giving a small dose before breakfast, claiming that they are sometimes more efficacious than vegetable cathartics. While vegetable cathartics are usually given at night on account of their rather slow action, generally causing no inconvenience until morning, saline cathartics act more promptly and powerfully when given before breakfast. Saline cathartics are especially indicated in acute alveolar abscess as they deplete the engorged tissues, preventing stagnation of the blood in the affected part, thus aiding nature materially in prevent- ing the infected tissues from being broken down into pus. A heap- ing teaspoonful of Epsom salt may be dissolved in a wineglass half full of warm water, having at hand, in another glass, some fr^sh water. By drinking the fresh water as soon as the concentrated solution is taken, the bitter taste of the drug will scarcely be noticed. Epsom salt is also used in phenol poisoning, and in acute lead poisoning. With phenol, the innocuous phenol sulphonate is formed, and with the soluble salts of lead (acetate) an insoluble sulphate. Incompatibles. — Magnesium sulphate is incompatible with lead acetate (sugar of lead), silver nitrate, alkaline carbonates, and lime-water. SODII SULPHAS— U.S.P. (Sodium Sulphate; Glauber's Salt; Na2S04.ioH20.) Sodimn sulphate occurs in large, colorless, transparent prisms or granular crystals, odorless, and having a bitter, saline taste. It 2l8 CATHARTICS is soluble in 1.2 parts of water, and . insoluble in alcohol. The average dose is 4 dr. (16.0 Gm.). Physiologic Action and Therapeutics. — Sodium sulphate acts as a powerful hydragogue cathartic, producing large watery stools. Its action is accompanied, by considerable griping, because of which Epsom salt has largely superseded the drug. Sodium sulphate enters into the mixture known as artificial Carlsbad salt, which, given in doses of a teaspoonful in a glassful of hot water half an hour before breakfast, makes an efi&cient mild aperient. The formula follows: sodium sulphate, 5 oz. (160.0 Gm.); sodium bicarbonate, 2 oz. (64.0 Gm.); sodium chlorid, i oz. (32.0 Gm.). Both sodium and magnesium sulphates are active ingredients in certain natural mineral waters, like Hunyadi Janos, Carlsbad, etc. These waters may be given in cases of pyorrhea alveolaris associated with rheu- matism or gout. SODII PHOSPHAS— U.S.P. (Sodium Phosphate; Na2HP04.i2H20.) Sodium phosphate occurs in large, colorless, prismatic crystals, without odor, but having a cooHng, saUne taste. It is soluble in 2.7 parts of water, and insoluble in alcohol. The dose is from i gr.- 4 dr. (0.06-16.0 Gm.), depending on the age of the patient. For a young child a small amount only is necessary. The following preparations are ofiicial: Sodii Phosphas Effervescens, U.S.P. Dose, 1-8 dr. (4.0- 32.0 Gm.). Sodii Phosphas Exsiccatus, U.S.P. Dose, 10-60 gr. (0.6- 4.0 Gm.). Liquor Sodii Phosphatis Compositus, U.S.P., VIII (each fl. dr. (4.0 mils) contains i dr. (4.0 Gm.) of Sodium Phosphate, with Sodium Nitrate and Citric Acid). Dose, 1-3 fl. dr. (4.0- 12.0 mils.). Physiologic Action and Therapeutics. — The manner of action of sodium phosphate depends upon the quantity administered. In small doses it acts as a laxative; in large doses, as a purgative. Its mild action and agreeable taste especially commend it for children, to whom the proper doses may be given in milk or other Hquid food. Stevens speaks favorably of the drug, given in small doses in hot water before breakfast, in chronic gastric catarrh with constipation, also in simple catarrhal jaundice. MAGNESII CITRAS POTASSII ET SODII TARTRAS 219 MAGNESII CITRAS (Nonofficial) (Magnesium Citrate; Mg3(C6H507)2.i4H20.) Magnesium citrate is obtained by dissolving magnesium car- bonate in citric acid. It is a colorless substance, easily soluble in water. It is only ofi&cial in the form of solution of magnesium citrate, which is compounded in a specially prepared 12 fl. oz. (^360.0 mils) bottle. Liquor Magnesii Citratis, U.S. P. Dose, 6-12 fl. oz. (180.0-360.0 mils). In cases of acute alveolar abscess where it is desired to administer a saKne cathartic, this solution is highly efi&cacious. It is well tolerated by the stomach, and its action is effective. It is somewhat irritating, and should not be administered when there is any inflam- mation of the gastrointestinal tract. An effervescent salt of mag- nesium citrate may be obtained from the pharmacies. POTASSn ET SODn TARTRA.S— U.S.P. (Potassium and Sodium Tartrate; Rochelle Salt; KNaC4H406.4H20.) Rochelle salt occurs in colorless, transparent, prismatic crystals or as a white powder, without odor, but having a cooHng, saHne taste; soluble in about i part of water. The average dose is 2}-^ dr. (lo.o gm.). It is an essential constituent of the official compound effervescent powder. Pxilvis Effervescens Compositus, U.S. P. (Seidlitz Powder). Dose, I powder. A dose of Seidlitz powder is contained in two different colored papers — one blue, the other white. The blue paper contains Potassium and Sodium Tartrate, 120 gr. (8.0 gm.); and Sodium Bicarbonate, 40 gr. (2.6 gm.). The white paper contains Tartaric Acid, 35 gr. (2.3 gm.). The contents of each paper should be dissolved separately, the two solutions mixed, and the whole taken while effervescence is taking place. Physiologic Action and Therapeutics. — Rochelle salt may be given as a hydragogue cathartic in the same conditions for which magnesium sulphate was recommended. Its administration is more agreeable than the latter, but its action is less active. The carbonic acid evolved during the effervescence of a Seidlitz powder exerts a more or less sedative influence on the stomach, as well as making the solution more palatable. As a mild saHne cathartic, especially dur- ing the summer season, a dose of Seidlitz powder is highly efl5.cacious. 2 20 CATHARTICS OLEUM TIGLU— U.S.P. (Croton Oil.) Croton oil is a fixed oil expressed from the seeds of Croton Tiglium, a small native tree of China, but extensively cultivated in India and the Philippine Islands. It occurs as a yellowish, viscid oil, having a faint odor and an acrid, burning taste. It contains croton-oleic acid, both free and as a glycerid, together with several other inactive fatty acids. The average dose of croton oil is i min. (0.05 mil). Physiologic Action and Therapeutics. — Croton oil is a violent irritant. When appHed, undiluted, to the skin it causes redness and burning, followed by a copious eruption of pustules. When inter- nally administered it acts as a powerful drastic cathartic, causing in one or two hours several copious movements of the bowels, attended with considerable pain, and sometimes with nausea. Large doses produce all the symptoms of a severe gastroenteritis — burning sensa- tion in the stomach, pain, etc. On account of the ease with which it may be administered (small quantities being so effectual) the drug is a convenient cathartic to give in cases where the patient can swallow only with difficulty. It may be taken in a small amount of oHve oil or in a pill with bread-crumbs as an excipient. The prompt irritant action of croton oil on the bowel makes it a useful revulsant in cases of cerebral congestion; therefore, its effect is advantageous in uremia, apoplexy, and acute mania. In cases like lead poisoning, where olsti- nate constipation is a concomitant, the drug is especially useful. Croton oil may be mixed with some indifferent oil (croton oil, I part; oHve oil, 7 parts) and used as a dental counterirritant. It has no advantage here, however, over the more generally used coun- terirritants (iodin, mustard, capsicum, etc.). Stevens speaks favor- ably of a mixture of croton oil (i part) and tincture of iodin (2 parts) to be used as a pigment in neuritis. COLYCYNTHIS— U.S.P. (Colycynth.) Colyc3mth is the fruit of Citrullus Colocynthis deprived of its rind . The plant grows in arid places in Asia, Africa, and Southern Europe. It contains colocynthin, a bitter glucosid, to which its cathartic prop- ^ erty is largely due. The average dose of colocynth is i gr. (0.06 Gm.). The following preparations are official: Extractum Colocynthidis, U.S. P. Dose, 2-5 gr. (0.13-0.3 Gm.). Extractum Colocynthidis Compositum, U.S. P. Dose, 5-20 gr. (0.3-1.3 Gm.). GAMBOGIA JALAPA 221 Pilulse Catharticae Compositae, U.S. P. Dose, 1-3 pills. Pilulae Catharticae Vegetabiles, U.S. P., VIII. Dose, 1-3 pills. Physiologic Action and Therapeutics. — Coloc}Tith is an ener- getic drastic cathartic, producing in full doses copious, watery stools, accompanied frequently by griping. In large doses the irritation excites inflammation of the whole ahmentary tract, which may prove fatal. The drug is too irritant to be used alone, and is only given in combination mth other drugs in cases of obstinate chronic constipation, which frequently accompanies old age. CAMBOGIA— U.S.P. (Gamboge.) Gamboge is a gtim-resin obtained from Garcinia Hanburii, a laurel-like tree growing in the East Indies. Its active principle is cambogic acid. The average dose of the drug is from 2 gr. (0.13 Gm.). It enters into the following official preparation: Pilulae Catharticae Compositae, U.S. P. Dose, 1-3 pills. Physiologic Action and Therapeutics. — Gamboge is an active drastic cathartic. In large doses its irritant effect is capable of caus- ing fatal gastroenteritis. It is never used alone, but may be com- bined with less powerful cathartics and used in obstinate chronic constipation. JALAPA— U.S.P. (Jalap.) Jalap is the tuberous root of Exogonium Purga, a perennial herb growing in jMexico. It contains two resins, jalapin and convol- vulin, both of which are active. The average dose of jalap is 15 gr. (i.o Gm.). Its official preparations follow: Resina Jalapae, U.S. P. Dose, 1-5 gr. (0.06-0.3 Gm.). Pulvis Jalapae Compositus, U.S. P. (contains Jalap, 35; Potassium Bitartrate, 65). Dose, 15-60 gr. (1.0-4.0 Gm.). Pilulae Cathartae Compositae, U.S. P. Dose, 1-3 pills. Pilulae Catharticae Vegetabiles, U.S. P. \T;II (each pill con- tains extract of Jalap, }i gr.-0.03 Gm.; compound extract of Colocynth, about i gr.-o.o6 Gm.; extract of Hyoscyamus, H gr.-0.03 Gm.; extract of Leptandra, 3^gr.-o.oi5 Gm.; extract of Podophyllum, J^ gr.-0.015 Gm.; and Oil of Peppermint). Dose, 1-3 pills. Physiologic Action and Therapeutics. — The action of jalap is more like that of the hydragogue cathartics than it is of the drastic. 222 DIURETICS It acts gently, producing, within three or four hours, copious, watery stools. Pharmacologists (Stadelmann, and others) claim that the drug has no action in the absence of bile, the latter serving in all probability as a solvent. For removing the water from the tissues in dropsy the drug is frequently combined with a sahne, as in the official compound powder of jalap. It is not employed alone as a carhartic, but it is an ingredient of both the official compound cathartic pills and formerly official compound vegetable pills, which preparations are frequently given in habitual constipation. PODOPHYLLUM— U.S.P. (May Apple; Mandrake.) Podophylluin is the rhizome and rootlets of Podophyllum peltatum, a perennial herb, growing in the moist woods of Canada and northern United States. It contains two isomeric glucosids, podophyllotoxin and picropodophyllin, and also a resin, podophyllin, which is official. The average dose of podophyllum is 5 gr. (0.3 Gm.). The official preparations are: Resina PodophyEi, U.S. P. Dose,y i-y^gr. (0.008-0.03 Gm.). Fluidextractum Podophylli, U.S. P. Dose, 5-20 min. (0.3- 1.3 mils). Pilulae Podophylli, Belladonnae et Capsici, U.S. P. VIII (each pill contains Podophyllin, J^ gr.-o.oi6 Gm. ; extract of Belladonna, J^ gr.-o.oo8 Gm.; pulv. Capsicum, 3^^ gr.-0.03 Gm. ; with Acacia and Sugar of Milk). Dose, 1-2 pills. The resin is also a constituent of compound cathartic pills. Physiologic Action and Therapeutics. — Podophyllum is an active drastic cathartic. Its action is rather slow, however, com- pared with most other drastics; it generally requires from ten to twelve hours to produce an evacuation of the bowel. The stools are copious and watery, and usually attended with more or less griping pain. The drug is used in habitual constipation, associated with so-called biliousness. When combined with other cathartic drugs, those should be selected which are also slow in action, Uke aloes, calomel, etc. The resin is the most reliable preparation and is generally given in the form of pills. DIURETICS Diuretics are agents that increase the flow of urine. They may act indirectly by forcing a greater volume of blood through the kidneys, or directly by stimulating the renal epithelium. A number POTASSII BICARBONAS POTASSII CARBONAS 223 of them act in both ways. Certain circulatory stimulants also act as diuretics, among which may be mentioned digitalis and caffein; digitalis appears to have no special action on the secreting cells of the kidneys ; its effect as a diuretic is almost entirely dependent upon the influence the drug has over the cardiovascular system. Caffein, on the other hand, is a powerful diuretic, acting directly on the renal epithelium, and, in a lesser degree, on the circulation. The inorganic salts, urea, and other soluble proteids, normally present in the blood, may be regarded as the physiologic stimuli of the secreting cells of the kidneys. Many other substances, not natural components of the blood, increase the secretion of urine by exerting a direct and specific influence on the cells of the glomeruli and convoluted tubes (Stevens). Diuretics are employed in dental practice principally for the purpose of removing from the blood certain excrementitious matters, which are supposed to be forerunners of pyorrhea alveolaris. The agents used are chiefly the vegetable salts of potassium and lithium, which not only increase the amount of urine excreted, but, being eliminated through the kidney in large part as carbonates, they tend to make the urine alkaline in reaction. Examples follow: Potassium Bicarbonate. Potassium Chlorate. Potassium Carbonate. Potassium Nitrate. Potassium Citrate. Lithium Carbonate. Potassium Acetate. Lithium Citrate. Potassium Bitartrate. Lithium Benzoate. POTASSn BICARBONAS— U.S.P. (Potassium Bicarbonate; KHCO3.) Potassium bicarbonate occurs in colorless prismatic crystals, without odor, but having an unpleasant, saline, alkaline taste; soluble in 3 parts of water, and practically insoluble in alcohol. The average dose is 15 gr. (i.o gm.). Potassium bicarbonate, though not contained therein as such, is used in making the following official solutions: Liquor Potassii Arsenitis, U.S. P. (Fowler's Solution). Liquor Potassii Citratis, U.S.P. Liquor Magnesii Citratis, U.S.P. POTASSII CARBONAS— U.S.P. (Potassium Carbonate; K2CO3.) Potassiiim carbonate occurs in a white, granular, deliquescent powder; freely soluble in water, but insoluble in alcohol. The 2 24 DIURETICS average dose is 15 gr. (i.o Gm.). The drug is very irritant and rarely used as such internally; from potassium carbonate, however, the following official preparations are made : Mistura Ferri Composita, U.S.P. VIII. PUulae Ferri Carbonatis, U.S.P. (Blaud's Pills). POTASSII CITRAS— U.S.P. (Potassium Citrate; K3C6H5O7.H2O.) Potassium citrate occurs in transparent, prismatic crystals or white, granular, deliquescent powder, without odor, but having a pleasant saline taste; soluble in 0.5 part of water, but sparingly soluble in alcohol. The average dose is i dr. (4.0 Gm.). There are two official preparations. They are: Liquor Potassii Citratis, U.S.P. Dose, J^-i fl. oz. (15.0- 30.0 mils). Potassii Citras Effervescens, U.S.P. Dose, 30-90 gr, (2.0- 6.0 Gm). POTASSn BITARTRAS— U.S.P. (Potassium Bitartrate; Cream of Tartar; KHC4H4O6.) Cream of tartar occurs in colorless, or slightly opaque, rhombic crystals, or as a white powder, without odor, but having an acidulous taste; soluble in about 155 parts of water, and very sparingly soluble in alcohol. The average dose is 15 gr, (1,0 Gm,). It is a component of the following official preparation: Pulvis Jalapae Compositus, U.S.P. Dose, 15-60 gr. (1.0-4.0 Gm.). POTASSII ACETAS— U.S.P. (Potassium Acetate; KC2H3O2.) Potassium acetate occurs in the form of a white powder or crystalline masses, very deliquescent, odorless, and having a pleasant, saline taste; soluble in 0.4 part of water and in 2 parts of alcohol. The average dose is 15 gr. (i.o Gm.). Physiologic Action. — The vegetable salts of potassium act similarly and will, therefore, be discussed here conjointly. The potassium ion is much more physiologically active than is the sodium ion, and as a result the potassium salts, as a rule, are more irritant and depressant than are the corresponding sodium salts. With the vegetable salts of potassium, however, the action of the base is POTASSII CHLORAS 225 entirely subordinate to that of the acid radical, and a depressant effect is never observed except when administered continuously or in enormous doses. The dominant action of any one of the vegetable salts of potassium is upon the secreting cells of the kidneys, increas- ing the amount of urine. The mineral salts of the urine, both of potassium and sodium, are increased, but the evidence is not con- vincing that the vegetable salts of potassium materially assist oxidation in the tissues, and in consequence augment nitrogenous elimination. In large doses they do, however, impart an alkaline reaction to the urine, and in h}7)erisotonic solution they act as saline cathartics, producing free watery discharges. Potassium bitartrate differs somewhat from the other vegetable salts of this metal in that it resists oxidation in the body, and, therefore, much of it is eliminated unchanged. It is also a more active cathartic. Therapeutics. — Clinical experience has fuUy demonstrated that acute rheumatism is influenced favorably by the administration of the vegetable salts of potassium; and it is also true that pyorrhea alveolaris in rheumatic or gouty subjects is favorably influenced by these salts, but until we have a clearer understanding of the nature of these diseases, it is useless to speculate upon the mode of action of the remedies employed in their treatment. In these cases 10-30 gr. (0.6-2.0 Gm.) of the salt maybe dissolved in water and admin- istered. The dose should be repeated every three or four hours until the urine becomes neutral or sHghtly alkaline. Both the official solution of potassium citrate and the effervescent salt are agreeable preparations to take. Stevens^ speaks favorably of combining an alkaline salt with a saHcyHc compound. Salophen may be selected for this purpose, for while it is practically insoluble in water, it is freely soluble in watery solutions of the alkaline salts. The vegetable salts of potassium are efficient sedative expecto- rants in the beginning of acute bronchitis, especially when the secre- tion is viscid and scanty. Incompatibles. — The vegetable salts of potassium are incom- patible with acids, mineral salts, and alkaloidal salts. POTASSn CHLORAS— TJ.S.P. (Potassium Chlorate; KCIO3.) Potassium chlorate occurs in colorless, crystalline plates, with- out odor, but having a cooling saHne taste; soluble in 11.5 parts of ^ Modern Materia Medica and Therapeutics. 15 2 26 DIURETICS water, sparingly soluble in alcohol. The average dose is 4 gr. (0.25 Gm.)- There is one official preparation: Trochisci Potassii Chloratis, U.S. P. (each contains about 2^-^ gr.-0.15 Gm.). Dose, 1-5 troches. Physiologic Action. — Potassium chlorate, when applied in dilute form to the mucous membrane, acts as a stimulating alterative; in concentrated form it is a decided irritant. The exact manner of its action is not fully understood. It was supposed formerly that the drug, when internally administered, yielded its oxygen to the blood, but recent investigation tends to prove that this theory is erroneous and that fully 90 per cent, passes out of the body unchanged in the urine, though small quantities have been detected in the saliva, tears, and milk of nursing women. In moderate doses, well diluted, its only noticeable effect is to increase the flow of urine. Poisoning and Treatment. — In excessively large doses potassium chlorate produces toxic symptoms. Its basic radical or potassium ion depresses the circulation and nervous system, while its acid radi- cal or chlorate ion irritates the stomach, intestines, and kidneys. In the treatment of poisoning the stomach should be evacuated by emetics or the stomach-pump, followed, as usual, with demulcents. In case of exhaustion, physiologic salt solution may be subcutane- ously injected. Therapeutics. — In all inflammatory conditions of the mouth and throat, potassium chlorate makes an excellent local application. Ten grains (0.6 Gm.) to the ounce (30.0 mils) may be used as a wash, gargle, or spray. In mercurial stomatitis, the salt is almost a specific, and may be employed internally as well as locally. It is quite gen- erally believed by medical men that salivation is less likely to follow the continuous use of mercury in secondary syphilis when a solution of potassium chlorate is simultaneously used as a mouth- wash. Cushney^ states that the drug may be given internally as a prophy- lactic to prevent stomatitis when mercury is being prescribed, but that it does not prevent the saHvation. Oral prophylaxis and mouth hygiene are considered important factors in the treatment of syphilis to-day. The drug is used as a constituent of dental pastes which have gained some prominence as a cure for many mouth diseases. The amount of potassium chlorate in these pastes ranges from 10 to 50 per cent., and in this strength they should not be appHed to the mucous membrane of the mouth, as harm is Hkely to follow. Where ^ Pharmacology and Therapeutics, or the Action of Drugs. POTASSII NITEAS LITHII CARBONAS 227 the drug is indicated, it is far better to confine its use to weak solutions. Incompatibles. — Potassium chlorate, being rich in oxygen which it readily gives up, makes the drug incompatible with many easily oxidizable substances, Hke sulphur, phosphorus, pulverized charcoal, tannic acid, sugar, sulphids, hyposulphites, hj-pophosphites, and ammonium chlorid. POTASSn NITRAS— U.S.P. (Potassium Nitrate; Saltpeter; KXO3.) Potassium nitrate occurs in colorless, transparent, rhombic prisms or as a crystalline powder, odorless, and having a cooling saline taste; soluble in 3.6 parts of water, sparingly soluble in alcohol. The average dose is 8 gr. (0.5 Gm.) in solution, well diluted. Physiologic Action and Therapeutics, — Except that it is more irritating to the stomach, the action of potassium nitrate in moderate doses does not differ materially from the vegetable salts of potas- sium ; it increases the secretion of urine through direct action on the renal epithelium. In large doses potassium nitrate is not only more irritating than the vegetable salts, but is markedly more depressant to the heart and nervous system; for here the action of the base (potassium) is not subordinate to that of the acid radical. Toxic doses produce the symptoms of gastroenteritis, muscular weakness, and collapse. Potassium nitrate is not used in dental therapeutics. It has been employed in general dropsy, but it has no greater efficacy than the less irritating vegetable salts. Inhalations of the smoke of burning niter paper, formerly official, sometimes afford relief in asthma. Solutions of the drug, caUed "brine," are useful for pre- serving meats. A mixture of equal parts of potassium nitrate and borax makes a most excellent reducing agent for refining gold scrap. The latter should be placed on charcoal and fused, when the "oxidiz- ing mixture" is added. The potassium nitrate will oxidize the base metals which oxids are dissolved by the borax and absorbed by the charcoal, leaving the gold practically pure. LITHH CARBONAS— U.S.P. (Lithium Carbonate; Li2C03.) Lithium carbonate occurs as a white powder, without odor, but having an alkahne taste; soluble in 75 parts of water and insoluble in alcohol. The average dose is 8 gr. (0.5 Gm.).^ 2 28 DIAPHORETICS LITHH CITRAS— U.S.P. (Lithium Citrate; Li3C6H507.4H20.) Lithiiim citrate occurs as a white, deliquescent powder, without odor, but having a cooling saline taste; soluble in 2 parts of water, insoluble in alcohol. The average dose is 8 gr. (0.5 Gm.). Physiologic Action and Therapeutics. — The action of the vege- table salts of lithium is very similar to that of the corresponding salts of potassium, because the action of the base in both groups is en- tirely subordinate to that of the acid radical. They increase the quantity of urine and lessen its acidity. The salts of lithium have been recommended in the treatment of gout and the uric acid diathesis because it was found that outside of the body lithium united with uric acid to form a more soluble salt than did either potassium or sodium, but since it has been clearly demonstrated that alkaline medication is without influence on the uratic salts present in the blood or tissues, it is doubtful whether the salts of lithium are any more potent in these diseases than are the vegetable salts of potassium (Stevens). On the hypothesis that the concretions in pyorrhea alveolaris were precipitated and deposited on the roots of teeth as the blood, supercharged with suboxidized or excrementitious material, slowly passed through the pericemental membrane, lithium salts and the natural mineral waters have been extensively employed in the treatment of this condition. But, as above mentioned, since it is clearly proven that lithium salts are without influence on the urates in the blood or tissues, and since, too, it has never been clearly demonstrated that the deposits are formed from the source mentioned, it is indeed doubtful whether these salts play any role in the eradication of the disease, except to increase the amount of urine. In the case of the natural waters, the eflacacy which they may possess in this disease is probably de- pendent upon the depurant (purifying) action of the water itself, and not upon the small amount of salt they contain. On this basis, the drinking of large quantities of pure, wholesome water in the treatment of this disease is recommended. DIAPHORETICS Diaphoretics are agents which promote the secretion of perspira- tion. When the action of the remedy is such that the sweat stands in beads upon the surface, it is called a sudorific. The agents employed may act directly by stimulating the special PILOCARPUS 229 nerve fibers supplying the sweat glands, indirectly by stimulating the sweat centers of the central nervous system from which those fibers originate, or reflexly by irritating peripheral sensory nerves. The activity of the sweat glands is increased by dilatation of the peripheral vessels, external heat, muscular exercise, dyspnea, strong emotion, nausea, and various drugs (Stevens). Diaphoretics are chiefly used for their evacuant, revulsive, and alterative effects, and also to promote absorption. The drugs usually employed for promoting perspiration are : Pilocarpus. Liquor Ammonium Acetate. Spirit of Nitrous Ether. Opium.* PILOCARPUS— U.S.P. (Jaborandi.) Pilocarpus is the leaflets of Pilocarpus Jaborandi and Pilocarpus microphyllus, shrubs growing in South America. It contains three alkaloids — pilocarpin, pilocarpidin, and isopilocarpin — all of which are physiologically * active, but pilocarpin is the most active, is present in greater quantity, and yields with acids soluble crystalline salts, of which two are official: Pilocarpines Nitras, U.S. P., and Pilocarpines Hydrochloridum, U.S.P. These salts are most com- monly used; the average dose of either is by mouth, 3^ gr. (o.oi Gm.); hypodermic, 3d^2 gr- (o-oo5 Gm.). The average dose of pilo- carpus is 30 gr. (2.0 Gm.). There is one ofi&cial preparation of the drug. Fluidextractum Pilocarpi, U.S.P. Dose, 10-60 min. (0.6- 4.0 mils). Physiologic Action and Therapeutics. — Probably no other single drug exerts the same influence on the secretory glands of the body as pilocarpin. When internally administered, even in small doses, the sweat and saliva are markedly increased. It also increases, but to a lesser degree, the lacrimal, nasal, bronchial, gastric, intes- tinal, and renal secretions. The fact that atropin completely sus- pends the efl'ect of pilocarpin on the secretions has led pharmacolo- gists to believe that the drug acts by stimulating the peripheral fibers of the nerves supplying the various glands. Pilocarpin is not much used in dental therapeutics. In acute uremia large doses 3^-3^ gr. (0.01-0.02 Gm.) may be used in con- junction with external heat (hot air or hot vapor baths). The drug is sometimes used for its diaphoretic effect in acute rheumatism and acute coryza. 230 EMETICS SPIRITUS ^THERIS NITROSI— U.S.P. (Spirit of Nitrous Ether; Sweet Spirit of Niter.) Spirit of nitrous ether, commonly called sweet spirit of niter, is an alcoholic solution of ethyl nitrite, containing not less than 4 per cent, of pure ethyl nitrite. It occurs as a clear, volatile, inflam- mable liquid, having a yellowish or greenish tint, a pleasant ethereal odor, and a sharp, burning taste. It should be kept in well-stop- pered bottles away from light. The dose is from 10-120 min. (0.6- 8.0 mils), depending upon the age of the patient. Physiologic Action and Therapeutics. — Spirit of nitrous ether acts as a mild diaphoretic, diuretic, and antispasmodic. Its diapho- retic effect is more pronounced than its diuretic effect when the patient is kept well under cover after its administration; the action is reversed when the patient is lightly covered. It appears, therefore, that external heat augments its diaphoretic action. Sweet spirit of niter is used extensively as an antispasmodic remedy in convulsions which frequently occur in children during the eruptive period of the deciduous teeth. It is best given in small doses, at frequent intervals, weU diluted with water. LIQUOR AMMONH ACETATIS— U.S.P. (Solution of Ammonium Acetate; Spirit of Mindererus.) This is a solution of diluted acetic acid nearly saturated with ammonium carbonate. It should be slightly acid in reaction, con- tain about 7 per cent, of ammonium acetate, and prepared as wanted. Somewhat like sweet spirit of niter, it acts as a feeble diaphoretic or diuretic according as the patient is kept warm or cool. It is largely used in mild febrile affections of children as a vehicle for spirit of nitrous ether or preparations of aconite. The average dose is 4 fl. dr. (15.0 mils). EMETICS Emetics are agents which produce vomiting (emesis) . It is sup- posed that drugs act to produce emesis either by directly affecting the center in the medulla or by indirectly affecting it through irrita- tion of the sensory nerve endings in the stomach. There is little doubt that the action of apomorphin is a direct one; ipecac and antimony undoubtedly act both directly and indirectly; and all evidence goes to show that zinc sulphate, copper sulphate, alum, mustard, and tepid water act, in the main at least, indirectly. APOMORPHIN^ HYDROCHLORIDUM 23 1 Emetics may be used for one of four purposes : 1. To expel poisons, or undigested food which is causing pain, headaches, etc., from the stomach. For this purpose the indirect or local emetics are the most reliable, especially in cases of poisoning. 2. To expel foreign bodies, false membranes, or excessive secre- tion from the respiratory tract; the effort of vomiting often being sufficient to dislodge and remove the membrane or foreign body. For this purpose the direct or systemic emetics should be used. 3. To expel foreign bodies from the esophagus. Diret ore systemic emetics are here also indicated. 4. To expel mucus and bile from the gall-ducts in catarrhal jaundice. For this purpose the direct or systemic emetics are, perhaps, the most useful. Emetics are principally used in dental therapeutics for the im- mediate expulsion of poisons that may have been swallowed acci- dentally or otherwise. It should be remembered that for this purpose the local emetics are employed. The chief emetics are: Apomorphin. Copper Sulphate.* Ipecac (emetin). Alum.* Tartar Emetic. Mustard.* Zinc Sulphate.* Tepid Water, in quantity. APOMORPHINiE HYDROCHLORIDUM— U.S.P. (Apomorphin Hydrochlorid.) Apomorphin is an artificial alkaloid obtained from morphin by abstracting a molecule of water. It is official as the hydrochlorid, which occurs in minute, grayish-white, acicular crystals, odorless, and having a slightly bitter taste; soluble in about 50 parts of water or alcohol. The average dose as an emetic by mouth is 3^^ gr. (o.oi Gm.) ; hypodermic, ^■{2 gr- (0-005 Gm.) ; as an expectorant, ^^0 gr. (0.003 Gm.). Physiologic Action and Therapeutics. — From five to twenty minutes after ingestion, according to the dose and method of admin- istration of apomorphin, vomiting ensues, being repeated three or four times at intervals of about fifteen minutes. The emesis is preceded and attended by slight nausea, but with moderate depres- sion. The entire action of apomorphin is upon the medulla; it is, therefore, a direct or systemic emetic, being the most powerful and certain we possess; and is used whenever such an emetic is indicated. 232 EMETICS IPECACUANHA— U.S.P. (Ipecac.) Ipecac is the root of Cephaelis Ipecacuanha, or Cephaelis acumi- nata, a perennial shrub gro'^'ing in Brazil and other South American states. It contains two alkaloids, emetin and cephaelin; and, accord- ing to some authorities, also psychrotin. The average dose of the powdered drug as an emetic is 15 gr. (i.o Gm.); as an expectorant, 3^ gr. (0.03 Gm.). The following are its official preparations : Fluidextractum Ipecacuanhse, U.S. P. Dose, as an emetic, 15-30 min. (i.a-2.0 mils); as an expectorant, 2-5 min. (o.i- 0.3 nul). Syrupus Ipecacuanhas, U.S. P. Dose, as an emetic, 2-4 fl. dr. (8.0-15.0 mils); as an expectorant, 10-60 min. (0.6-4.0 mils). Pulvis Ipecacuanhse et Opii, U.S. P. (Dover's Powder; Ipecac, I part; Opium, i part; Sugar of Milk, 8 parts). Dose, 5-10 gr. (0.3-0.6 Gm.). The action of ipecac is dependent almost entirely on its emetin content. This alkaloid is now official as the hydrochlorid. EMETINiE HYDROCHLORIDUM— U.S.P. This product is the hydrochlorid of the alkaloid emetin, obtained from ipecac. It contains various amounts of water of crystallization, and should be preserved in dark amber-colored vials, protected from light. The average hypodermic dose is ^^ gr. (0.02 Gm.). Most pharmaceutical houses prepare the drug in solution in ampules, con- taining the average dose. Alcresta Ipecac Tablets. — These are tablets containing an ab- sorption product of ipecac alkaloids with hydrated aluminum silicate, each tablet representing 10 gr. (0.64 Gm.) of ipecac. The dose is 2 or 3 tablets three times a day for a period of four to six days, then discontinued for two or three days if the laxative effect is too pronounced. In the stomach where the content is acid, the tablets disintegrate but do not liberate the ipecac alkaloids. The latter are released in the intestines where the secretions are alkaline, and thus enter the circulation. Alcresta ipecac tablets afford a means of administering ipecac by way of the mouth without the nausea which is certain to follow the mouth administration of the drug in other forms. Physiologic Action and Therapeutics. — Ipecac is a powerful irri- tant to the mucous membranes of the respiratory tract when the ANTIMONII ET POTASSII TARTRAS 233 powdered drug is inhaled. Its prolonged application to the skin produces much irritation, and even vesication, pustulation, and ulceration often result. The drug is claimed to possess some anti- septic properties. Internally administered in small doses, ipecac acts as a stimulant to the salivary and gastric glands; its action here is not unHke that of the vegetable bitters. In large doses the drug is a powerful irritant and emetic, the emesis in all probability being due to both a local irritation of the peripheral sensory nerve endings in the stomach and some slight action on the medulla itself. The drug also exerts a favorable influence on the bronchial mucous membrane, acting as a sedative expectorant, and is fre- quently employed as a component of cough mixtures. Ipecac, though not very prompt in its action, is a safe and reliable emetic. It is especially useful in children, with whom it is extensively used to expel irritant material from the stomach. The drug has been empirically used for a variety of purposes other than that of an emetic and expectorant. It is used as an antiemetic, antidysenteric, diaphoretic, etc. Recently ipecac, or its alkaloid emetin, has gained a wide reputation in amebic dysentery and all other diseases due to pathogenic amehas. It has been claimed that pyorrhea alveolaris is caused by pathogenic amebas; and, on this basis, emetin is recommended in the treatment of this disease (which see, p. 436). The drug may be administered in the form of alcresta ipecac tablets. ANTIMOim ET POTASSn TARTRAS— U.S.P. (Antimony and Potassium Tartrate; Tartar Emetic; 2K(SbO)C4H406.H20.) Tartar emetic occurs in the form of colorless, transparent crystals or as a white granular powder, odorless, and having a sweetish, metallic taste ; soluble in 1 2 parts of water, and practically insoluble in alcohol. The average dose as an emetic is i gr. (0.06 Gm.) ; as an expectorant, ^2 gr. (0.005 Gm.). The official preparations are: Mistura Glycyrrhizae Composa, U.S.P. (contains Extract of Glycyrrhiza, 3; Antimony and Potassium Tartrate, 0.024; Syrup, 5; Acacia, 3; Camphorated Tincture of Opium, 12; Spirit of Nitrous Ether, 3; Water to make 100). Dose, 2H fl. dr. (10. o mils). Syrupus Scillae Compositus, U.S.P. (contains Tartar Emetic, 2; Squill, Senega, Sugar, and Water to make 1,000). Dose, 5-60 min. (0.3-4.0 mils). 234 EXPECTORANTS Physiologic Action and Therapeutics. — Tartar emetic is an irri- tant and acts as an emetic and expectorant. The drug is fast falling into disuse in medical practice, having been displaced largely by other drugs which are more prompt in their action and less de- pressing. There is Httle need of the drug in dental therapeutics, but it has been considered here because of its past record as an emetic, sedative expectorant, diaphoretic, and counterirritant. Tepid water in large quantities generally acts as an emetic. EXPECTORANTS Expectorants are drugs which modify the secretion of mucus from the mucous membrane of the air-passages, affect its quantity, and faciHtate its expulsion. The exact mode of their action is not well understood. Those that promote secretion and render it less vis- cid in character, and, therefore, more easily removed, are generally called sedative expectorants. Examples of this class are: Ipecac* Tartar Emetic* Apomorphin.* Potassium Citrate.* Those drugs which stimulate the mucous membrane of the respira- tory tract and lessen the quantity of sputum are termed stimulant expectorants. The most important are : Ammonium Chlorid. Squill. Eucalyptus (Eucalyptol) . * Benzoic Acid.* Oil of Myrtle. AMMONH CHLORIDUM— U.S.P. (Ammonium Chlorid; Sal Ammoniac; NH4CI.) Ammonium chlorid occurs as a white crystalline powder, odor- less, and having a coohng, saline taste; soluble in 2.6 parts of water and in 100 parts of alcohol. The drug has the pecuUar physical property of passing, when heated, directly from the sohd to the gaseous state, and on cooHng, from the gaseous directly to the soHd state. In other words, it differs from most salts in that it cannot be Hquefied by heat. The average dose is 5 gr. (0.3 Gm.). The following preparation is ofl5.cial: Trochisci Ammonii Chloridi, U.S. P. (each contains Ammon- ium Chlorid, i}4 gr. o.i Gm.; Extract of Licorice, 3 gr. 0.2 Gm.; with Tragacanth, Sugar, and Syrup of Tolu). Dose, 1-2 troches. SCILLA OLEUM MYRTI 235 Physiologic Action and Therapeutics. — Administered in moderate doses by the mouth, ammonium chlorid acts chiefly as a stimulant to the mucous membrane of the respiratory tract and perhaps, also, of the stomach and bowel. It increases the quantity and renders less viscid the mucous secretion. The drug for the most part is eliminated in the urine unchanged. Ammonium chlorid is extensively employed as a stimulant expectorant in acute bronchial catarrh, subacute and chronic pharyngitis, etc. Incompatibles. — The drug is incompatible with alkalies, mineral acids, tartaric acid, and the soluble salts of silver and lead. SCILLA— U.S.P. (Squill.) Squill is the bulb of Urginea maritima, a perennial herb, growing on the shores of the Mediterranean Sea. It is supposed to contain several active principles, no one of which, when isolated, fully repre- sents the activity of the crude drug. The average dose is i3'^ gr. (o.i Gm.). The official preparations are: Acetum Scillae, U.S.P. Dose, 10-30 min, (0.6-2.0 mils). Tinctura Scillae, U.S.P. Dose, 5-20 min. (0.3-1.3 mils). Fluidextractum Scillae, U.S.P. Dose, 1-3 min. (0.06-0.2 mil). Syrupus Scillae, U.S.P. Dose, ^-i fl. dr. (2.0-4.0 mils). Syrupus Scillae Compositus, U.S.P. (contains fluid extract of Squill, 8 per cent.; fluid extract of Senega, 8 per cent.; Tartar Emetic, 2 per cent.). Dose, 10-60 min. (0.6-4.0 mils). Physiologic Action and Therapeutics. — The action of squill somewhat resembles that of digitalis, though it is much less powerful. It also acts as a stimulant expectorant and a diuretic. The syrup of squill is a common component of cough mixtures. OLEUM MYRTI (Nonofficial) (Oil of Myrtle; Myrtol.) Oil of myrtle is a greenish-yellow, volatile oil, distilled from the leaves a,nd flowers of Myrtus communis, the common European myrtle. Its properties are almost identical with those of eucalyptol. The average dose is 5 min. (0.3 mil). It may be employed as a stimu- lant expectorant in cases of cold in the head. A few minims may be added to a basin of hot water and the fumes inhaled. It may also be 236 SIALOGOGUES taken internally by placing 2-3 min. (0.13-0.2 mil) of the oil on a blank sugar tablet or a piece of loaf-sugar. Harlan recommends the drug for the treatment of gangrenous pulps, but it is of doubtful value, other remedies for this purpose having completely displaced the essential oils. SIALOGOGUES Sialogogues are drugs or remedies which stimulate the salivary and buccal mucous glands, increasing the secretion and flow of sahva and buccal mucus. There are many diseases and conditions which change the character and flow of the mouth secretions. Among the men who have experimented with mouth secretions in relation to health and disease may be mentioned Black, Miller, Williams, Michaels, Kirk, Acre, Hinkins, Cook, Bunting, and Howe. Michaels claims that the saliva is pathognomonic of certain diseases, the diagnosis being made by physical and chemic examinations of the saliva. Cook has shown that astringent mouth-washes inter- fere for hours with the action of ptyalin upon starchy food. The mixed saliva is normally alkaline in reaction. The author, collab- orating with Hinkins and Cook, spent considerable time investigat- ing the cause of erosion. One point established beyond doubt, which has also been mentioned by other investigators, was that the saliva in typical cases of erosion is always acid. Hinkins has repeat- edly called attention to the fact that simply holding the mouth open for any length of time, as in dental operations where the rubber dam is used, materially affects the character and flow of saliva. Chewing a piece of clean wood, rubber, and even gum or tobacco, augments the flow of sahva, as does also the smell of victuals. Many drugs also produce a sialogogue effect, the most important of which have been discussed under other headings. They are: Pilocarpus (Jaborandi).* Potassium Chlorate.* Mercurials.* Echafolta.* lodin Compounds.* Tobacco.* Acetic Acid.* To collect saliva for experimental purposes almost any clean substance may be chewed; the mere movements of the jaws stimu- late the glands. Another means is to place the tongue on the roof of the mouth and inhale dilute acetic acid through the mouth. This stimulates the secretion especially from the sublingual gland. The role played by the saliva in mouth diseases is by no means settled, and this field offers an excellent opportunity for further inves- tigation to those scientifically incHned. C ARMEST AT R'E S 237 CARMINATIVES Carminatives are drugs that aid in the expulsion of gas from the stomach or intestines. The gas found in the alimentary canal comes from various sources: it may have been swallowed with the food, formed by the action of acid upon the carbonates contained in the food and saliva, or it may be generated through fermentation or putrefaction of the stomach contents; fermentation being the most common cause of abnormal accumulation of gas. Although drugs of this class are chiefly valuable in the expulsion of gas already formed, they also prevent, in greater or less degree, the formation of flatus, for, by quickening the gastric circulation, they doubtless stimulate glandular activity, thus acting as stomachics by aiding digestion and lessening fermentation. Carminatives are frequently combined with purgative drugs ; here they act as correctives by modify- ing or correcting the griping pain which purgatives are hkely to induce when given alone. Most of the drugs belonging to this class are aromatics containing essential oils as their chief active constituent. Alcohol, ether, and chloroform are the exceptions. The principal carminatives are: Capsicum.* Cardamom. Caraway. Pepper. Cloves.* Fennel. Nutmeg. Cinnamon.* Coriander. Ginger, Anise. Mustard. * Peppermint.* Allspice. Alcohol.* Spearmint. Sassafras. Chloroform.* Ether.* PIPER— U.S.P. (Black Pepper.) Black pepper is the unripe fruit of Piper nigrum, a climbing vine cultivated in the East Indies. It contains a crystalline neutral principle, piperin, a volatile oil, and a pungent resin. The average dose of ground pepper is 8 gr. (0.5 Gm.). The only oflacial preparation foUows: Oleoresina Piperis, U.S.P. Dose, J-^-2 min. (0.03-0.1 mil). Pepper is a carminative and is largely used as a condiment. MYRISTICA— U.S.P. (Nutmeg.) Nutmeg is the seed of Myristica fragrans, an evergreen tree grow- ing in the Molucca Islands and other East India islands. It con- 238 CARMINATWES tains a volatile oil, to which its aromatic properties are due, also a fixed oil. The average dose is 8 gr. (0.5 Gm.)- The volatile oil is official. Oleum Myristicse, U.S.P. Dase, 1-5 rain. (0.06-0.3 mil). Nutmeg is used as a condiment. It also enters as an aromatic into many of the official aromatic and compound preparations. Mace is the ground fleshy covering (arillode) of nutmeg. It is used as a condiment. ZINGIBER— U.S.P. (Ginger.) Ginger is the ground rhizome of Zingiber officinale, a perennial herb which grows in tropical countries. It contains a volatile oil, having the odor of ginger, p,nd a viscid resinous principle, having a hot, pungent taste. The average dose is 15 gr. (i.o Gm.). The following preparations are official: Tinctura Zingiberis, U.S.P. Dose, 20-60 min. (1.3-4.0 mils). Fluidextractum Zingiberis, U.S.P. Dose, 10-30 min. (0.6-2.0 mils). Syrupus Zingiberis, U.S.P. Dose, ^-4 fl. dr. (2.0-15.0 mils). Oleoresina Zingiberis, U.S.P. Dose, }i-2 min. (0.03-0.13 mil). Ginger is used as a carminative and as a flavoring agent. It is also a constituent of the official compound powder of rhubarb, aromatic powder, and aromatic fluid extract. MENTHA VmrDIS— U.S.P. (Spearmint.) Spearmint is the leaves and tops of Mentha spicata, a perennial herb growing wild in the woods and along the roadsides of Europe and North America. Its official preparations are: Oleum MenthaeViridis, U.S.P. Dose, 1-5 min. (0.06-0.3 mil). Spiritus Menthae Viridis, U.S.P. Dose, 10-30 min. (0.6-2.0 mUs). Aqua Menthae Viridis, U.S.P. Dose, 1-4 fl. dr. (4.0-15.0 mils). Therapeutically, spearmint is almost equivalent to peppermint, and is used for practically the same purpose. CARDAMOMI SEMEN— U.S.P. (Cardamom Seed.) Cardamom seed is the dried seed of Elettaria Cardamomum, a perennial herb, cultivated in the mountainous portions of India. ANISUM SASSAFRAS 239 Its active principle is a volatile oil, of which it contains about 5 per cent. The official preparations are: Tinctura Cardamomi, U.S. P. Dose, 1-2 fl. dr. (4.0-8.0 mils). Tinctura Cardamomi Composita, U.S. P. (contains also Cin- namon, Caraway, Cochineal, and Glycerin). Dose, 1-2 fl. dr. (4.0-8.0 mils). Pulvis Aromaticus, U.S. P. Aromatic Powder (contains Car- damom Seed, Ginger, Cinnamon, and Nutmeg). Dose, 10-30 gr. (0.6-2.0 Gm.). Cardamom seed also enters into several of the official aromatic and compound preparations. It is used as a flavoring agent and carminative. ANISUM— U.S.P. (Anise.) Anise is the small fruit of Pimpinella Anisum, a small plant cultivated in Southern Europe and North America. It contains a volatile oil, having the characteristic odor of the drug, and a sweetish, aromatic taste. Its preparations follow: Oleum Anici, U.S. P. Dose, 2-5 min. (0.13-0.3 mU). Spiritus Anici, U.S. P. Dose, 1-2 fl. dr. (4.0-8.0 mils). Aqua Anici, U.S. P. Dose, 2-8 fl. dr. (8.0-30.0 mUs). The drug also enters into many of the official aromatic and com- pound preparations. It is used chiefly as a flavoring agent. PIMENTA (Nonofficial) (Allspice.) Allspice is the nearly ripe fruit of Pimenta officinalis, an evergreen tree growing in the West Indies and South America. It contains a volatile oil, the active constituent of which is eugenol. The oil only is official, and is a constituent of spirit myrica, or bay-rum. Oleum Pimentse, U.S. P. Dose, 1-5 min. (0.06-0.3 mil). SASSAFRAS— U.S.P. Sassafras is the bark of the root of Sassafras variijolium, a shrubby tree growing in the eastern and central parts of North America. The pith was formerly official {Sassafras medulla, U.S. P. VIII). It contains an aromatic, fragrant, volatile oil and taijnic acid. The official preparation is : 240 FLAVORING AGENTS Oleum Sassafras, U.S. P. Dose, 1-5 min. (0.06-0.3 mil). Mucilago Sassafras Medallae, U.S. P. VIII (2 per cent.). Dose, 1-8 fl. dr. (4.0-30.0 mils). Sassafras oil also enters into the official compound fluid extract of sarsaparilla and compound syrup of sarsaparilla. The mucilage is an excellent demulcent in cases of drug poisoning, and a tea made by steeping the bark of the root is extensively used by the lay American as a "spring tonic." CARUM— U.S.P. (Caraway.) Caraway is the fruit of Carum Card, a native herb of Asia, but cultivated in Europe and North America. Its active constituent is a volatile oil. Caraway is used as a flavoring agent, and as such it enters into the official compound tincture of cardamom and compound spirit of juniper. The oil is official: Oleum Cari, U.S. P. Dose, 1-5 min. (0.06-0.3 mil). FCENICULUM— U.S.P. (Fennel.) Fennel is the fruit of Fceniciilum vulgare, a plant growing chiefly in Southern Europe. It contains an aromatic oil. The official preparations are: Oleum Foeniculi, U.S. P. Dose, 1-5 min. (0.06-0.3 mil). Aqua Fceniculi, U.S. P. Dose, 1-8 fl. dr. (4.0-30.0 mils). As a flavoring agent fennel enters into compound licorice powder, compound spirit of juniper, and compound infusion of senna. CORIANDRUM— U.S.P. (Coriander.) Coriander is the fruit of Coriandrum sativum, an herb grown in all parts of Europe and the United States. It contains a volatile oil, which is official. Oleum Coriandri, U.S.P. Dose, 1-5 min. (0.06-0.3 niH)- The oil is used as a flavoring agent, and as such it enters into the syrup of senna and compound spirit of orange. FLAVORING AGENTS Flavoring agents are used to mask the taste of nauseous drugs, to flavor foods, drinks, etc. The chief flavoring agents are: L IMON — AURANTIUM Lemon. Rose. ' Orange. Sugar and. Sugar of Milk. Vanilla. Honey. * Lavender. Saccharin. Sarsaparilla. * Glucose. Persio (Cudbear). LIMON (Nonofficial) (Lemon.) 241 Lemon is the ripe fruit of Citrus medica Limonum, a tree culti- vated in most semitropical countries. The rind contains a volatile oil, and the juice, citric acid. The following preparations are ofi&cial: Limonis Cortex, U.S. P. (Fresh Rind). Limonis Succus, U.S. P. VIII (Juice). Dose, 1-4 fl. oz. (30.0-120.0 mils). Tinctura Limonis Corticis, U.S. P. Dose, >^-i fl. dr. (2.0- 4.0 mils). Oleum Limonis, U.S. P. Dose, 1-5 min. (0.06-0.3 nail). Acidum Citricum, U.S. P. Dose, 5-20 gr. (0.3-1.3 Gm.). Syrupus Acidi Citrici, U.S. P. (i per cent.). Dose, 1-4 fl. dr. (4.0-15.0 mils). The oil also enters into other official preparations as a flavoring agent. Lemon juice has been used in scurvy, both as a preventive and curative agent. In the form of cold lemonade it makes a pleas- ant refrigerant drink. Hot lemonade is a useful remedy for colds. Both the fresh rind and juice are used extensively as flavoring agents. AURANTIUM (Nonofficial) (Orange.) There are two varieties of orange : Sweet orange, Citrus auran- tium, and bitter orange. Citrus vulgaris. The following preparations are official: Aurantii Amari Cortex, U.S. P. Dose, 15-30 gr. (1.0-2.0 Gm.). Fluidextractum Aurantii Amari, U.S. P. Dose, }i-i fl. dr. (2.0-4.0 mils). Tinctura Aurantii Amari, U.S. P. Dose, 1-2 fl. dr. (4.0-8.0 mils). Aqua Aurantii Florum, U.S. P. Dose, indefinite. Aqua Aurantii Florum Fortior, U.S. P. Syrupus Aurantii Florum, U.S. P. Dose, indefinite. Auranti Dulcis Cortex, U.S. P. Dose, 15-30 gr. (1.0-2.0 Gm.). Tinctura Aurantii Dulcis, U.S. P. Dose, 1-2 fl. dr. (4.0-8.0 mils). 16 242 FLAVORING AGENTS Syrupus Aurantii, U.S.P. Dose, indefinite. Oleum Aurantii Cortex, U.S.P. Dose, 1-5 min. (0.06-0.3 mils). Syrupus Aurantii Compositus, U.S.P. Dos6, 1-4 fl. dr. (4.0-15.0 mils). Elixir Aromaticum, U.S.P. Dose, 1-4 fl. dr. (4.0-15.0 mils). Both varieties of orange are used almost exclusively as flavoring agents. VANILLA (Nonofficial) ^■ Vanilla is the fruit of Vanilla planifolia, a perennial climbing plant, native of the West Indies and tropical America. Its charac- teristic odorous principle is vanillin. The tincture was official: Tinctura Vanillas, U.S.P. VIII (10 per cent.). Dose, a few minims, according to the strength of flavor desired. Vanilla is employed chiefly as a perfume and as a flavoring agent. LAVANDULA (Nonofficial) (Lavender.) Lavender is the flowers of Lavandula officinalis, a native shrub of Southern Europe. It contains a fragrant volatile oil, tannic acid, and resin. The official preparations are: Oleum Lavandulae Florum, U.S.P. Dose, 1-5 min. (0.06-0.3 mil). Spiritus Lavandulae, U.S.P. Dose, }4-i fl. dr. (2.0-4.0 mils). Tinctura Lavandulae Composita, U.S.P. Dose, H-i fl. dr. (2.0-4.0 mUs). The compound tincture is also an ingredient of Fowler's solution. The preparations of the drug are used only for their agreeable flavor. ROSA GALLICA— U.S.P. (Red Rose.) Red rose is the dried petals of Rosa gallica, a species of red rose cultivated extensively in Western Asia and Southern Europe. It contains a volatile oil, tannic acid, sugar, and mucilage. The for- merly official oil of rose is distilled from the fresh flowers of the Damascus rose {Rosa damascena.) The following are its official preparations : SACCHARUM — BENZOSULPHINIDUM 243 Fluidextractum Rosae, U.S. P. Mel Rosae, U.S. P. (12.5 per cent, of the fluid extract in clari- fied Honey). Aqua Rosae Fortior, U.S. P. (Water saturated with Oil of Rose). Aqua Rosae, U.S. P. (equal parts of Stronger Rose Water and Distilled Water). Preparations of rose also enter into several official preparations as flavoring agents. The ointment of rose water (cold cream) makes an excellent application for the hands and face. A splendid lotion for the hands is: Phenol (95 per cent.) 6 min. (0.36 mil); borax, 14. dr (2.0 gm.); rose water and glycerin, of each i3^ fi. oz. (45.0 mils). SACCHARUM— U.S.P. AND SACCHARUM LACTIS— U.S.P. (Cane-sugar; Sugar and Sugar of Milk; Lactose.) Cane-sugar is refined from sugar-cane, Saccharum officinarum, from various species of broom-corn, Sorghum, and from one or more varieties of sugar-beet, Beta vulgaris. A saturated solution is official as: Syrupus, U.S.P. (Simple Syrup). Sugar enters as a flavoring agent, preservative, vehicle, or excipi- ent into many official compound preparations. Sugar of milk is the sugar obtained from the whey of cow's milk. It is harder, less solu- ble, and less sweet than ordinary sugar, and is largely used as a diluent for powders, as in Dover's powder. BENZOSULPHINIDUM— U.S.P. (Benzosulphinid; Saccharin) Saccharin is obtained from the coal-tar derivative, toluene. It occurs in a light, white, crystalline powder, is odorless, and possesses 500 times the sweetening power of cane-sugar. It is soluble in 290 parts of water, more so in alcohol or glycerin, and readily soluble in alkaline solutions. Saccharin is used as a flavoring agent for mouth-washes, tooth- pastes, tooth-powders, etc. Internally, in large doses, it retards digestion and, therefore, metabolism. The average dose is 3 gr. (0.2 Gm.). 244 FLAVORING AGENTS GLLXOSUM— U.S.P. (Glucose; Syrupy Glucose.) Glucose is a product obtained by the incomplete hydrolysis of starch, and consists chiefly of dextrose and dextrins. It is a colorless or slightly colored, thick, syrupy liquid; odorless and has a sweet taste; freely soluble in water, and sparingly soluble in alcohol. Glucose is used as a flavoring agent; but should not enter as such into dentifrices, as it is a fermentable sugar and its fermentation in the mouth produces the acid (lactic) which causes caries of the teeth. PERSIO (Nonofficial) (Cudbear.) Cudbear occurs as a purplish-red powder prepared from species of Rocella De Candolle, or other lichens. The drug is not used as a flavoring agent, but solutions of it are employed extensively for coloring purposes. An aqueous or alcoholic preparation of cudbear is of a deep red color which is rendered lighter in tint by the addition of acids and changed to purplish red on the addition of alkalies. There are no oflacial preparations, but the National Formulary gives directions for the preparation of a tincture and compound tincture of cudbear. These are the preparations used for coloring solutions of various kinds (mouth- washes, etc.), as well as the powdered cudbear itself. BIOLOGIC PRODUCTS The advanced therapy of many infectious diseases includes the intelligent use of biologic products. Many of the systemic diseases of this character are known to have a direct relation to diseased mouth and throat conditions (teeth and tonsils). It is, therefore, important that the student and practitioner of dentistry understand the principles upon which this therapy is based; and be familiar with the nature and character, as well as the indications and uses of the products obtained from Biologic Laboratories. An infectious disease is one caused by the invasion of micro- organisms into the tissues of an animal (or plant). The invading germ gains admission into the body and tissues in various ways; through the air into the respiratory passages (mouth, nose, throat and lungs) ; through food and water into the digestive tract (stomach and intestines) ; through cuts and abrasions of the skin and mucous membranes (inflamed and bleeding gums) ; through the canals of pulpless teeth; and through direct injection into the blood stream. When these bacteria have thus gained entrance into the tissues, where they find the proper food, moisture and temperature neces- sary to their growth, they multiply and proliferate rapidly; and dur- ing this growth they produce substances known as Toxins, which are poisons to the tissues of the body. Sometimes these poisons remain largely within the cell body of the bacteria and are given o2 at the death of the germ. Such poisons are called intracellular toxins. An example is the staphylococcus pyogenes aureus, the germ which causes boils. In other instances the poisons are excreted by the bacteria into the tissues or blood stream and may be thus carried to various parts of the body, attacking those parts which are subnormal and have the least resistance. Poisons of this kind are called extracellular toxins. Examples of such germs are the bacillus diph- theria and bacillus tetani, which cause, respectively, diphtheria and tetanus (lock-jaw). The streptococcus viridans also belongs to this class of germs, and is of special interest to dentists for the reason that the poisons are elaborated in pyorrheal pockets about the teeth and in dental granulomas and den to-alveolar abscesses in the periapical region. The poisons being of the extracellular variety are continually formed and constantly charging the blood stream as long as the infec- 245 246 BIOLOGIC PRODUCTS tion in these areas is present. Thus may follow diseases of the joints (arthritis), heart (endocarditis), kidneys (nephritis), etc. It will be observed then how absolutely essential- it is for the dentist to eradicate all infections about the teeth. Nature is constantly on the alert to protect the body against the invasion of these germs and their poisons. Stimulated by the bacterial toxins, the body tissues react and produce substances known as Antitoxins and Antibodies. The antitoxins are chemic substances which destroy the poisonous nature of the toxins. The antibodies are substances which antagonize the bacteria themselves, actually kilUng and destro3dng them, or preventing their growth and proHferation. The manufacture and use of biologic products are based upon these principles; and, before considering the subject further, it is well that the student should understand what is meant by the term Immtinity. This is recognized as the ability or power which enables certain individuals to resist disease. There are two kinds of im- munity — natural and acquired. Natural immunity is that which exists in a normal, healthy animal or human body. In this case the tissues of such bodies contain or produce substances which are antagonistic to the pathologic bacteria. Hence these germs cannot grow in the body and no disease results. Acquired immunity is the resistance to a disease which exists either after an attack of that disease, or after inoculation with some specific culture, vaccine, antitoxin or serum. An example of the first is a person who Jias had smallpox ; an example of the second is a person who has been vacci- nated with smallpox virus — both are immune to smallpox, and the immunity has been acquired. This brings us to a discussion of biologic products, which may be divided into at least three general classes — Antitoxins, Serums and Vaccines. ANTITOXINS Antitoxins are among the simplest and most useful of the anti- bodies. As the name implies, they antagonize toxins. Though toxins may be excreted by plants other than the bacteria and some animals, e.g., in snake venoms, the typical toxins are the soluble poisons thrown ofif by diphtheria and tetanus bacilli. Diphtheria and tetanus are dangerous diseases almost entirely because of the action of these toxins and, conversely, their pre- vention and cure, when the organisms have once gained entrance to the body, depends on the work of the particular antitoxin. SERUMS ■ 247 Though the presence of the toxin stimulates the body to produce antitoxin, this active immunity may not be enough to save Hfe; and, at any rate, assistance by the injection of antitoxin, ready made in the blood-serum of another animal, hastens the cure or may prevent the disease. The antitoxins for both diphtheria and tetanus are official: Serum Antidiphthericum, U.S. P. and Serum Antitetanicum, U.S. P. These antitoxins are obtained from the coagulated blood of the horse, or other large domestic animal which has been properly immunized against the toxin produced by the germ ca,using the disease. Diphtheria and tetanus are not dental diseases, nor have they any direct relation to diseased mouth conditions ; therefore, the dentist will not be called upon to administer the commercial anti- toxins prepared for these diseases. SERUMS Serums are more complex in action and much less satisfactory for therapeutic purposes than are the antitoxins. With these products the contained antibodies are expected to resist the bacteria themselves — not simply neutraHze their toxins, as is the case with antitoxins. In the manufacture of serums proper, horses are im- munized by inoculation first, with dead cultures, and, secondarily, with increasing doses of living culture of the specific bacteria, until their blood contains substances that directly or indirectly destroy either Ihe life or the activity of these specific bacteria. The sub- stances in the immune serum that destroy the hfe or the activity of the specific germ are collectively spoken of as antibodies. They have never been isolated as specific chemic substances, but their presence in the serum is assumed from their definite efl'ects on bac- teria. The names given to the more important of these antibodies are baderiolysins, bacteriotropins, opsonins and agglutinins. Of these antibacterial substances, the bacteriolysins are those which both kill and dissolve the bacteria, and are considered to be the anti- bacterial bodies proper. For example, take a serum from an animal immunized against the streptococcus germ, and put into it some Uving streptococci; after a brief period of incubation, an examination will show that the streptococci are not only killed but have been dissolved as well. This phenomenon is called bacteriolysis. Aside from the direct killing 01 cne Dactena oy the blood serum, the invaders may be taken up by the leukocytes — though not, as a rule, until they have been acted upon by other substances in the 248 BIOLOGIC PRODUCTS serum, mentioned above as bacteriotropins and opsonins, according to whether they resist moderate heat or not. The agglutinins are antibodies which act directly, causing the bacteria to gather in clumps. They are valuable in diagnosis on account of their specificity, but probably have no important action in protecting the human organism from an infection. Among the more important antibacterial serums may be men- tioned antistreptococcus serum, antistaphylococcus serum, and Guti- pneumococcus serum. VACCINES Vaccines or bacterins are suspensions of killed bacteria in physiologic salt solution, usually with the addition of some preserva- tive such as 0.4 per cent, of cresol (tricresol) or 0.5 per cent, of phenol. An autogenous vaccine is one made from the bacteria infecting the person immunized. A stock vaccine is one made from standard cultures of the germ. A mixed vaccine is one prepared from more than one species of bacteria. The use of bacterial vaccines is associated with the development of the opsonic theory; but it is claimed by those in authority that the opsonic index as a measure of immunity is open to question. It may be said that bacterial vaccines are of particular value in locaHzed affections, especially those due to infection by the staphy- lococcus and streptococcus germs. Dental literature to-day is replete with articles on the relation of focal infection to systemic disease. It has been definitely shown by Murphy, Billings, Rose- now, Rhein, Grieves, Hartzell, Price, and others that infections about the teeth, especially from dental granulomas and dento- alveolar abscesses, may result in systemic diseases involving the joints, heart, kidneys, stomach, and other tissues and organs. By a series of experiments, Gilmer, Moody, and others, have found that the predominating organism in conditions resulting from a gangrenous pulp, therefore the group active in bringing about the decomposition, is a streptococcus. The use of antistreptococcus vaccines in the treatment of chronic arthritis and other ajffections resulting from a streptococcus infection about the teeth or tonsils has been reported by various authorities as affording much relief and in many cases effecting a permanent cure. It is understood that eradication of the foci of infection is of the first and prime importance. Among the more important bacterial vaccines may be mentioned streptococcus vaccine, typhoid vaccine, and smallpox vaccine. REMEDIES OTHER THAN DRUGS 249 In the discussion of biologic products and their uses, the author has made no attempt here to go into the subject in detail. He has endeavored to give only the principles underlying the therapy, which as yet is more or less speculative. REMEDIES OTHER THAN DRUGS The object sought in all therapeutics is simply to assist Nature in her efforts to ward off disease and to restore an abnormal to a normal condition. In dental therapeutics this gives to the resource- ful dentist a wide range of activity. There are several means of combating disease other than by the use of drugs. Those deserving mention will briefly be discussed here. They are: Heat. Electricity. Cold. Massage. Compressed Air. Suction. Light. Suggestion. HEAT Heat is a useful therapeutic agent. It is largely employed locally in dentistry, and is utilized in both the dry and moist forms. Dry heat is applied by means of hot cloths, bran-bags, water-bags or water- bottles, or superheated dry air. Moist heat may be appKed by means of fomentations, poultices, or the hot-water s}Tinge. Hot-water baths are also applicable to certain limited portions of the body, as the feet, and are used for counterirritant purposes. Locally applied, heat allays irritation of the peripheral sensory nerves, dilates the cutaneous vessels, increases perspiration, and, like cold and counterirritation, doubtless exerts a favorable influence on the subjacent structures. The general application of heat may be obtained by means of the hot-water bath, hot pack, hot-vapor bath, or hot blankets. In the Russian bath steam replaces the hot-dry air of the Turkish bath. The first effect of the general application of heat is free perspiration from dilatation of the cutaneous vessels. Moist external heat is used for a variety of diseases, especially subacute and chronic rheumatism. Dry external heat may be em- ployed in many cases of drug poisoning, one symptom of which is the characteristic cold, clammy sweat. Moist heat is used locally in pericementitis, in acute alveolar abscesses accompanied by pain and swelling, and many other dental conditions. Dry heat is chiefly used in dentistry for drying tooth- structure and obtunding sensitive dentin. For this purpose many 250 REMEDIES OTHER THAN DRUGS apparatuses have been devised for heating dry air. For root-canal work properly-shaped wire may be heated and used. Heat is also employed to the extent of actual destruction of tissue in vesication and cauterization. The thermocautery and galvano- cautery are exceedingly valuable as counterirritant, revulsive, and hemostatic measures. Thennometric Scale.— For determining the temperature, the Fahrenheit scale is in ordinary use in America and England; the Centigrade is used on the European Continent; the latter scale is also largely used in the sciences. The freezing-point of water with the Fahrenheit scale is 32° above zero; with the Centigrade scale it is at zero. The boiling point of water with the Fahrenheit scale is 212°. This minus the 32° equals 180° above zero. The boiling- point of water with the Centigrade scale is 100°. Therefore, stated in terms of proportion: ioo°C. :i8o°F. :;5 19, hence the following simple rules for converting the degrees of one scale into the other. To Convert Degrees of the Fahrenheit Scale into those of Centi- grade: If the temperature be above the freezing-point (32°), sub- tract 32; if it be below the freezing-point, subtract the number from 32, algebraically; then multiply the remainder by 5 and divide by 9. To Convert Degrees of the Centigrade Scale into those of Fahren- heit: Multiply the number of the former by 9 and divide by 5; if the temperature be above the freezing-point (0°), add 32; if it be below the freezing-point, subtract the result from 32, algebraically. COLD Cold, like heat, may be used either locally or generally as a thera- peutic agent. It is the local appHcation of the remedy with which dentists are mostly concerned. It may be locally applied by means of cloths wrung out of iced water, an ice-bag, an ice-poultice, etc. As cold is but a lesser degree of heat, the latter may be abstracted and cold produced by spraj^ng the part with a highly volatile liquid, like ethyl chlorid, ether, etc. Local applications of cold abstract heat from the part, lessen the sensibility of the peripheral nerve-endings, cause constriction of the blood-vessels traversing the tissues exposed to the cold, and affect, reflexly, the vascularity of the structures subjacent to the site of application. The general application of cold to the body may be accomplished in several ways: By a cold-water bath, cold sponge-bath, cold pack, or the cold douche. When followed by vigorous rubbing with a Turkish towel, cold bathing exerts a powerful tonic effect. It sharpens the COMPRESSED AIR — LIGHT 25 1 appetite, aids digestion, promotes metabolism, and greatly favors the elimination of waste products. Cold is employed for a variety of purposes in the treatment of disease. In dentistry it is used as a counterirritant in acute alveolar abscess, in pericementitis, neuralgia, and other conditions. As a re- frigerant local anesthetic, the effect of cold may be obtained by using ether, combinations containing it, or ethyl chlorid, as a spray. In this manner cold is used in lancing abscesses, obtunding sensitive dentin, extracting loose teeth, etc. COMPRESSED AIR Compressed air is one of the most convenient agents in the mod- ern dental office. While in itself it may not be considered a thera- peutic agent, except as a vehicle for applying heat or cold, it is, never- theless, a valuable adjunct to the use of many such agents. For drying a sensitive cavity, clearing away the " chips, ^^ and lessening the pain of drilling, it has no equal (see p. 286). In treating pyorrhea alveolaris it serves a useful purpose. By its employment the pocket may be kept dry sufficiently long for the operator to see in many cases whether or not the deposits have been thoroughly removed. It may be used as the force for spraying solutions all through the operation ; and when the teeth are scaled and polished the field may be kept dry by the use of compressed air while the astringent remedy is applied. The resourceful dentist will find many uses for this agent. LIGHT Light is a form of energy which has recently been brought forth as having a peculiarly favorable effect upon diseased tissues of the body, and is employed to-day for a variety of purposes in therapeu- tics, both general and dental. The blue light, lucodescent light, and other forms are used. The mode of action is not well understood. Extravagant claims are being made for the lucodescent light, but it is thought by many that its real virtue lies in the soft penetrating heat produced. It may prove to be a practical means of applying heat, which has long been recognized as a therapeutic agent. Reliable evidence has thus far been lacking to prove that Hght has an ac- tion upon the tissues other than through the heat generated. The blue hght has been suggested for obtunding sensitive dentin, and is ob- tained in one way by passing the ray through blue glass. A blue bulb (16 or 32 c. p.) is used on an ordinary electric socket. The room is dark- ened and the patient requested to look at the light which is held from 252 REMEDIES OTHER THAN DRUGS 6 in. to I ft. from the eyes. Whether the Ught acts locally or affects the vision and thus the general nervous system has yet to be determined. The author's experience with light thus far has not been encouraging. It is true, however, that light differs in effect from heat, though both come from the same heated body. This phenomenon is observed in the action of Hght on certain chemicals; for example, the silver salts undergo a chemic change when exposed to sunHght or luminously hot bodies. For this reason Black and others have suggested that the tooth-surface treated with silver nitrate be exposed to the sunlight, if possible. The author finds a more practical way of accomplishing the change in the decomposition of the salt by using the small electric mouth-lamp. Light from a small electric mouth-lamp serves almost as a positive means of diag- nosing a dead pulp in a tooth where the color is practically normal; it also aids materially in confirming the diagnosis of obscure antrum involvement. Carrel, Crile, and others, advocated the use of light or heat from an electric lamp in the treatment of injected wounds. It is to be hoped that further investigation may be made with Hght as a thera- peutic agent that its action may be better understood, for it seems to possess sufl&cient merit to justify such investigation. Rontgen or X-ray. — The Rontgen or X-ray has been employed extensively in both general and dental therapeutics; in dentistry it is largely used for diagnostic purposes. By means of the radiograph (an X-ray picture) the diagnosis of the following conditions may be confirmed: 1. Fracture of the jaw and the relation of the fragments. 2. Fracture and dislocation of the teeth in the jaw. 3. Alveolar abscess: involving more roots than one; in relation to the nasal cavity ; in relation to the maxillary antrum (antrum of High- more). 4. Impacted and nonerupted teeth; the cause of neuralgic conditions, and in point of treatment, extraction, etc. 5. Pulp-nodules, pulp-calcification, and secondary dentin. 6. Cementosis. 7. Foreign bodies in the maxillary antrum. 8. Broken broach in tooth-root. There are other conditions in dental practice wherein the X-ray aids materially in arriving at a correct diagnosis. Much credit is due to Kells, Price, Shamburg, Lewis, Raper, and others for develop- ing radiography in dentistry. The X-ray treatment has been found extremely valuable in super' ELECTRICITY 253 jicial cancer, lupus vulgaris, and acne. It has also been employed in the treatment of pyorrhea alveolaris with varying results. The powerful actinic properties of this modified form of light are illus- trated by the fact that several deaths and many injuries, such as burns, necessitating amputation in some cases, have be^n traced to long-continued exposure to the X-ray. The method devised by Finsen of concentrating rays of either sunHght or electric arc-light has met with more or less success in the treatment of lupus vulgaris and other skin diseases, but it has not been utilized in dentistry to any extent. Radium. — The salts of radium (bromid and chlorid) give out three kinds of rays, known as alpha, beta, and gamma rays. The therapeutic uses of radium rays have been shown to follow practically the same lines as those of the X-ray, but they are generally considered less useful. At the present time the use of radium rays is only in the experimental stage and no positive evidence is at hand to prove their superior value. They require the same careful handhng as the X-ray, as they are capable of producing severe burns and even deep-seated ulcers. ELECTRICITY Electricity is used as a therapeutic agent in itself, as well as a carry- ing medium for drugs (cataphoresis) , and for purposes of diagnosis and prognosis. Two currents are employed, the primary, or galvanic, and the induced, or faradic, the battery furnishing the current being supplied with a positive pole, or anode, and a negative pole, or cathode. When the electric current is passed through a muscle it causes con- traction of the latter. As a muscle degenerates it gradually loses its electrocontractility, the response to the faradic current disappearing first, while the galvanic current produces contraction for some time longer, until finally no current will produce any effect. Electricity is used as a muscle and nerve stimulant for a variety of conditions, such as the so-called idiopathic forms of neuralgia, in neurasthenia, hysteria, etc. In poisoning by opium and other nar- cotics a strong faradic current often affords a means of arousing the patient without increasing the exhaustion or causing any ill effects. Electricity affords almost a positive means of diagnosing a dead pulp in a tooth. The suspected tooth is tested by using a dry-cell vibrat- ing coil, which will be explained in Practical Therapeutics (see p. 338). In dental therapeutics, perhaps, the greatest use of electricity has been in connection with a method of treatment called cataphoresis. 254 REMEDIES OTHER THAN DRUGS Cataphoresis. — This is a term applied to the process of carrying medicinal agents in solution into the various tissues and organs of the body by means of the electric current. It is used chiefly for obtund- ing sensitive dentin and for the purpose of anesthetizing the pulp to facilitate its painless removal (see p. 324). MASSAGE Massage is a term used to designate methodical kneading, rub- bing, and percussion of the body. The person practising massage is known as a masseur (male) or masseuse (female) . The efficacy of proper massage in many pathologic conditions can no longer be doubted. It acts as a stimulant to both nerve and muscle and to many of the bodily functions, assisting circulation and favoring the elimination of waste-products. Massage is employed in dentistry for both its local and systemic effects in neuralgia, pyorrhea aheolaris, and edema resulting from alveolar abscess and other conditions; in medicine it is used in rheumatism, paralysis, synovitis, sprains, and fractures. In the "rest cure" of Mitchell it is combined with isolation, rest, forced feeding, and faradism. It is also used for its general effect in neurasthenia, nervous prostration, and hysteria. SUCTION The method of producing h}T:eremia in a part by means of suction for the purpose of combating disease is fast gaining recogni- tion in medicine, and it has been employed also, to some extent, in dentistry. When some noxious influence acts on a more or less limited area of the body, local resistance is manifested by the production of granu- lation tissue and of hyperemia. Under favorable circumstances the granulation tissue repairs defects resulting from the noxa, or more or less completely encapsulates the irritating agent. Under less favorable circumstances, the irritation being continuous, e.g., in tuberculous infection, granulomata are formed, these granulomata being evidence of defense. If the resisting power is sufficient, the embryonic tissue overcomes the irritant and incloses it in fuUy de- veloped scar tissue. Stimulation of the production of granulation in and around a tuberculous focus seems to be the therapeutic action of injections of emulsions containing iodoform, bismuth, finely divided carbon, etc., and of sclerogenic injections. The second method by which Nature resists a noxa (or infection) is by h}'peremia. When an irritant, e.g., the staphylococcus, gains SUGGESTION 255 access to the tissues, the flow of blood to the part becomes increased, there is exudation of fluids and leucocytes from the vessels into the tissues. The blood serum contains antibodies or antitoxins which neutralize the chemic products of bacterial activity; bacterial agents which attack the bacteria themselves; opsonins which prepare the bacteria for absorption and destruction by phagocytes, or perhaps act as a sort of appetizer to the phagocytes, and lastly there are the leucocytes which act as phagocytes, directly killing bacteria or, as scavengers, removing the debris of the fight. Thus, while the granu- lation tissue acts as a sort of passive role besieging the invading irritant, the h3rperemia directly and actively combats it (Binnie).^ The suction method of producing hyperemia cannot but prove eflScacious in the treatment of certain forms of alveolar abscess and pyorrhea alveolaris. It now remains for some ingenious dentist to devise a practical appliance by which dental appHcations can be made, and much good will surely result from this method of assist- ing nature in her efforts to restore an abnormal to a normal condi- tion. Keefe has applied suction in the treatment of pyorrhea alveo- laris with good results by taking an impression in wax, removing and cutting the wax from around the imprints of the teeth, thus creating a space from which, after reinserting the impression, the air can be withdrawn by means of a large bulb or syringe attached to a tube leading through the impression tray and into the space. Other apparatuses for the purpose have also been suggested. The former application of the leech, called leeching, was some- what on this same principle, but the practice, especially in dental therapeutics, is gradually becoming obsolete. SUGGESTION Suggestion, as used in therapeutics, is the method of employing faith or confidence in the treatment of disease. There is no doubt that faith is one of the oldest therapeutic agents known. Guerini^ refers to the confidence placed in ancient times in the power of the priests to cure the sick, and relates how, to maintain this confidence, the latter gradually resorted to the administration of infusions and decoctions made from fresh herbs, etc. With all peoples, from the earliest centuries to the present day, suggestion has ever been active. Where the disease is purely functional, and not organic, the influence which the mind can be made to exert over the body is a potent factor 'Journal of the American Medical Association. ^ History of Dentistry. 256 REMEDIES OTHER THAN DRUGS in the treatment of the condition, whether this influence be called psychotherapy, mental-healing, Christian Science, or by some other name. Hypnotism is practised by many dentists as a means of prevent- ing pain and controlling patients. Confidence is an important factor in dental practice. The dentist should ever strive to win the con- fidence of his patients, be they young or old, and when obtained he should constantly guard against abusing it by careless and indifferent methods of operating. METROLOGY Metrology is the science that treats of the gravitating force of a body, called weight; its extension, bulk, or volume, called measure, and the relation of these to each other, called specific gravity. In pharmacy, liquids, as a rule, are measured, while soHds are weighed; however, certain liquids are required to be weighed. The difference between measuring and weighing some liquids is not great, while with others it is considerable, and if this difference is not considered, varying results frequently follow. This, of course, is due to the different specific gravity of the liquids {e.g., chloroform is heavy while alcohol is light) . The systems of weight in the United States are Avoirdupois and Apothecaries', or Troy. The United States Pharmacopeia, in all of its editions previous to 1880, adopted the apothecaries' weight as the ofiQcial standard. In 1880 the parts-by-weight system was adopted. During the ten years of its official life this system never became popular, owing to the difficulty of having to weigh all liquids, regardless of their specific gravity. However, its adoption at this time paved the way for the adoption of the Metric System in 1890, and again in the eighth and ninth decennial revisions of the U.S. P., in 1900 and 1910. The metric system, therefore, is now the official standard. Never- theless, although not officially sanctioned, the apothecaries' weight still remains in common use in prescribing medicines, owiiig to the ease with which it can be subdivided into simple fractions. Through- out this work the apothecaries' weight has been given the preference, the metric equivalent being enclosed in parentheses. One troy ounce, equal to 480 grains, is easily divided by any even number — 2, 4, 8, etc. This quality is of great practical value to the dispenser and prescriber alike. For the latter it simplifies prescription-writing because of its easy division; the quantity of a remedy required for administration may be computed with the measure of the solvent very quickly in simple fractions. The fluid measure used in pharmacy can always be reduced to drams — the equivalent of a teaspoonful. This being the measure ordinarily used in administering medicines, the quantity of a dose is 257 258 METROLOGY readily ascertained. When, for example, 30 grains of potassium iodid in one fluidounce of compound syrup of sarsaparilla is pre- scribed, with directions "one teaspoonful at a dose," it is readily computed that the quantity of potassium iodid in each dose must be 3M gr-7 since one fluidounce contains eight fluidrams, or teaspoonfuls. The tables for the various systems of weights and measures are here given : Troy, or Apothecaries' "Weight 20 grains (gr.) = i scruple O) = 20 grains. 3 scruples = i dram (5) = 60 grains. 8 drams = i ounce ( § ) = 480 grains. 12 ounces = i pound (lb.) =5,760 grains. Wine, or Apothecaries' Measure 60 minims (TTl) = i fluidram (f 5)- 8 fluidrams = i fluidounce (f o)- 16 fluidounces = i pint (0). 2 pints = I quart (qt.). 4 quarts = i gallon (Cong., C.) = 231 cubic inches A fluidounce of water at its maximum density (4°C.) weighs 456.37 grains. Avoirdupois Weight I ounce (av. oz.) = 437.5 grains. 16 ounces = i av. lb. I pound = 7,000 grains. The odd number of grains in the avoirdupois ounce, as compared with the round, easily di\-ided number of grains of the apothecaries' ounce, is due to the fact that in the latter system the unit is the ounce, and from this the pound was formed. In the former the pound is the unit, which di\dded by 16 gives an ounce containing only 437.5 grains, as against 480 grains in the apothecaries' ounce. The troy or apothecaries' weight is used in the compounding of prescriptions; the wine or apothecaries' measure is used for meas- uring liquids in pharmaceutic work, and the avoirdupois weight is in common use generally. The troy and avoirdupois pounds are abbreviated in the same manner, lb., but differ in the number of grains contained (5,760, 7,000). The troy pound is rarely used, and the use of the scruple O) is practically obsolete; it is just as convenient to write for 20 grains, and there is less Hkehhood of a mis- take, for the abbreviation for scruple may be taken for a carelessly written dram mark. THE METRIC SYSTEM Approximate Fluid Measures Teaspoonful = fSJ Dessertspoonful = fSiJ Tablespoonful = fSiv Wineglassful = fBiJ Teacupful = f§iv 259 One cubic inch of distilled water, at its maximum density, a tem- perature of 4°C. in vacuo, weighs 252.892 gr., and 231 cubic inches is a measure equivalent to the U. S. gallon. The gallon is divided into 8 pints; i pint into 16 fluidounces; i fluidounce into 8 fluidrams, and I fluidram into 60 minims. The measure of volume may, there- fore, always be compared with the weight of water as above, the standard for comparison, thus: One cubic inch = 252.892; 252.892 X 231 = 58,418 gr. = i gallon. 58,418 -T- 8 = 7,302 grains = i pint. 7,302 -T- 16 = 456.37 grains = i fluidounce. 456.37 -J- 480 = 0.95 grains = i minim. For all practical purposes a minim may be considered the equiva- lent of a grain (i min. = 0.95 gr.). A drop is not a minim, although generally considered its equivalent, and the measurement of liquids by drops does not give uniform and accurate results. The size of drops varies greatly with different liquids ; also with the same Hquids, according to the conditions governing the process of dropping. Among these conditions may be mentioned: 1. The quantity of the liquid contained in the vessel. 2. The size and shape of the lip of the vessel. 3. The rapidity of the dropping. 4. The temperature and character of the Hquid. THE METRIC SYSTEM The metric system of weights and measures was first introduced in France at the close of the eighteenth century; hence it is often called the French system. Owing to its decimal parts, it is frequently termed also the decimal system. This system has gradually dis- placed all the various systems of weights and measures throughout the European continent, and is the only recognized system in all countries except Russia, Great Britain and her colonies, and the United States of America. For this reason the metric equivalent has been given for quantities throughout this work. 26o METROLOGY Hallberg states that because of its simplicity in construction, regularity and convenience in exact calculations, it has become the only system for scientific work, and is no doubt destined to soon displace the older systems in art and commerce throughout the civilized world. Through dur system of decimal numbering — ones, tens, hundreds, thousands, etc. — the monetary systems of all civilized nations, except Great Britain, have also become decimal and brought with them the metric system. The functions of money and weights and measures are so intimately related and interdependent that a decimal system in one practically demands a decimal system in the other. The decimal system of money was one of the privileges accorded the people of the United States by early adoption, but while adopting this great improvement over the old English pound, shilling, and pence, the old English weights and measures, based on the penny-system, were unfortunately retained. Although the U. S. Government, in 1867, made the metric system obligatory in the three branches of its medical service — the Army, Navy, and Marine Hospital — and also legally permissible through- out the Union, all efforts to make it obligatory in the various States have so far failed. It is difl&cult to change a long-established custom, but it does seem that there is little excuse for not adopting the metric system generally in the United States with our decimal proportions of the dollar, the dime, and the cent, based upon exactly the same principle. The metric system is based upon the meter, which is the standard unit of linear measure, being the ten-millionth part of one-fourth of the circumference of the earth (the quadrant). It is, therefore, the one forty-millionth part of the entire circumference of the earth taken around the poles, measured by a ■ meridian and not by the equator. One meter is equal to 39.37 inches. The liter is the unit of liquid measure, and is the cube of one-tenth of the meter, or cubic decimeter, and one-thousandth part of it, or the cube of one-hundredth of the meter, is one cubic centimeter. The term "cubic centimeter" has been replaced in the U.S.P. IX by the word "mil." The United States Bureau of Standards declared that the term cubic centimeter was a misnomer, there being a slight dif- ference between the thousandth part of a liter and the cubic centi- meter, as I liter was determined to be equivalent to 1.000027 cubic decimeters. The Committee of Revision decided that the time had come to adopt the word mil, the first three letters of the whole word "milliliter." In this work, therefore, the abbreviation "mil" is used instead of the abbreviation "c.c." The unit of weight is the gramme or gram, the weight of i milli- EQUWALENTS TO THE ENGLISH WEIGHTS AND MEASURES 261 liter of pure water in vacuo at its maximum density, and is equivalent to 15.432 grains. The unit gram (written mth a period immediately following, thus, I.) is divided or multiplied to express smaller or larger denomi- national quantities, respectively, by simply mo\dng the decimal point to the left or to the right. This illustrates the simplicity of the entire system. To designate the quantities thus obtained, Latin prefixes are used to describe those less than one gram, and Greek those larger than one gram — the former being written with a small letter, the latter with a capital letter. Metric Weights I myriagram (Mg.) = 10,000 grams. I kilogram (Kg.) = 1,000 grams. I hectogram (Hg.) = 100 grams. I decagram (Dg.) = 10 grams. I gram (Gm.) = ■v\-eight of I mil of water at 4°C. (unit) I decigram (dg.) = 0.1 gram. I centigram (eg.) = o.oi gram. I milligram. (mg.) = o.ooi gram. Metric Meastires of Capacity. I myrialiter (Ml.) = 10,000,000 milliliters. I kiloliter (Kl.) = 1,000,000 milliliters. I hectoliter (HI.) = 100,000 milliliters. I- decaliter (Dl.) = 10,000 milliliters. I liter (L.) = 1,000 milliliters (unit). I deciliter (dl.) = 100 milliliters. I centiliter (cl.) = 10 milliliters. I milliliter (ml.) = I milliliter. Equivalents to the English Weights and Measures. ^ — Various methods have been proposed for adapting the metric weights to our apothecaries' weights used in prescription-writing without entaihng calculations in fractions, as the exact equivalent would necessarily do. The method of accepting 32 grams as equivalent to one troy ounce and 30 mils as equal to one fluidounce seems to be the least objectionable. To convert avoirdupois or troy into metric weights, the equivalent of the gram in grains — 15.432 — should be remembered, as it serves the purpose of a basis for obtaining the equivalent of all the higher denominations. It will be observed that this number is composed of the first five numerals in reversed order, except the figure i. For 262 METROLOGY all practical purposes the fraction may be dropped, and i Gm. may be said to equal 15 gr. The Liter is equivalent to 34fluidounces (approximately i quart) ; half a Liter, therefore, approximates i pt., and is sometimes called a metric pint (17 fl. oz.). The Meter is equivalent to nearly 40 inches, from which the divisions may easily be rendered as follows : i decimeter, 4 in. ; i centimeter, cm., 0.4 in.; i millimeter, mm., 0.04 (3^5) inch. Hallberg sums up the advantages of the metric system as follows : 1. Simplicity of construction, abolishing complex tables. 2. Uniformity, through its adoption in all scientific work. 3. Permanency and stabiHty of its standard unit derived from the earth itself. 4. Facility of its multiplication and division by decimal points. 5. Commensurabihty of all its units and denominations in weight, volume, linear measures, and our system of money. Eqiiivalents of Apothecaries' in Metric Weights Grain. Gram. Grain. Gram. Moo = .000324 H = .0324 H50 = .00043 I = .0648 Hoo = . 00064 2 = .1296 ^5 = . 00086 5 = .3240 Mo = .00129 8 = .5184 Mo = .00162 10 = .6480 Ho = .00324 15 = .9720 (approx. 1.0 Gm.) Ho = . 00648 20 = 1 . 2960 H = .0108 30 = 1 . 9440 (approx. 2.0 Gm.) K = .0162 40 = 2.5920 H = .0216 60 = 3.888 (approx. 4.0 Gm.) Equivalents of Apothecaries' in Metric Measures of Capacity - Minims. Milliliters. Fluidounces. Milliliters. I = 0.061 I = 29.57 (approx. 30.0 mils) 2 = 0.123 2 = 59-14 3 = 0.185 3 = 89.00 5 = 0.308 4 = 118.29 7 = 0.431 6 = 177.42 10 = 0.616 10 = 295-73 IS = .9: >4 (approx. i.o mil) 12 = 355-00 20 = I. 23 16 = 473.17 (approx. H L.) 30 = I .84 (approx. 2.0 mils) 20 = 591-50 40 = 2.46 24 = 710.00 60 = 3 ■7 (approx. 4.0 mils) 32 = 946.35 (approx. I L.) PERCENTAGE IN SOLUTIONS 263 PERCENTAGE IN SOLUTIONS To estimate the quantity of a drug required to make a certain volume of a solution of a given percentage, divide the weight of the volume of the Hquid to be used as the solvent by loo, and multiply by the percentage. Thus, in an ounce of a lo per cent, aqueous solution of silver nitrate there are 45.6 grains of the salt. 100 per cent. = 456.37 gr. (weight of a fl. oz. of water). I per cent. = Koo of 456-37, or 4.56 gr. 10 per cent. = 10 X 4.56, or 45.6 gr. Therefore, it is well to remember that 4.56 gr. or, approximately, 4.5 gr. of any drug added to a fluidounce of water makes a i per cent, solution of the drug. The amount of a drug necessary for any quan- tity of any per cent, solution may be ascertained by rnuUiplying the quantity by the percentage, and the product by 4.5. Thus, to ascer- tain the amount of cocain hydrochlorid required to make two ounces of a 1.5 per cent, solution, we would multiply 2 X 1.5 X4.5 = 13.5 gr. Where there is a fraction of a grain in the ultimate result it is best to drop it if less than one-half, or raise it to one if over one-half. To determine the weight of a fluidounce of a hquid other than water, multiply 456.37 by the specific gravity of the liquid, and the product will be the weight desired. PRESCRIPTION-WRITING The literal interpretation of the word prescription is a written order for something — from prcs, for, and scribo, 1 write. The popular use of the term, however, relates to medicines, usually meaning a written order for medicines, although it is frequently employed to designate the remedy or mixture itself. The art of prescription-writing is one that requires practice for its perfection, as well as a broad knowledge of drugs, their actions and their doses, and their indications for certain diseases. It is also essential to know the physical and chemic properties of drugs as related to the form of administration and possible combination with other substances. Through the development of the sciences of pathology and pharmacology we have learned that it is unnecessary to exhaust our materia medica in prescribing for any one disease, and with this more definite knowledge of the action and effects of drugs upon the diseased tissues, organs, and functions of the body, we find that only a few agents can be employed with actual benefit in our endeavor to assist Nature in her efforts to restore an abnormal to a normal condition. To-day simplicity in prescriptions is evi- dence of a broad knowledge of the conditions to be met by the application of drugs or remedies to the treatment of disease. In former days many drugs were combined in one prescription, and the remedy was given with the hope and expectancy that at least one ingredient might, perchance, hit the spot. To such formulas the term "shot-gun " prescriptions is now applied. The most important considerations in writing prescriptions as well as in reading them are: 1. The language and abbreviations. • 2. The signs and terms. The language of prescription-writing is primarily Latin, because pharmacopeial titles are chiefly used in designating remedies. Medical Latin will be referred to later. Abbreviations in prescrip- tion-writing are perfectly proper, provided they are not carried so far as to cause confusion in compounding the prescription. The signs and terms used will be considered conjointly with the analysis of a prescription. 264 PRESCRIPTION-WRITING 265 A prescription may be divided into five parts, as follows: 1. The superscription, or heading. 2. The inscription, or names and quantities of ingredients. 3. The subscription, or directions to the compounder. 4. The signa, or directions to the patient. 5. The name of the prescriber, his degree, and the date. The superscription, or heading, consists of the abbreviation.!^, for the imperative of the verb recipio — recipe, with a terminal stroke on the R, forming the sign of Jupiter, x> which survives as a relic of ancient times when all medical formulae were preceded by this sign as an invocation to Jupiter, the chief God. Literally translated "take thou" or "take," it tells the pharmacist to compound the ingredients which follow. The name of the patient is generally, though not necessarily, included in this part. A perfect prescrip- tion should always bear the name .of the person for whom the medicine is intended, and if for a child it should be so designated. The inscription, containing as it does the names and quantities of the ingredients, is the most important part of the prescription, and the ingredients are invariably written in Latin with the genitive ending, the quantities following on each line, indicated by the customary abbreviation. Thus: gr. for granum, plural grana — grain or grains; 5 for dram (drachma); § for ounce (unica); and O for pint (octarius). The abbreviations lb. for pound (libra) and Cong, or C. for gallon (congius) are rarely employed. TTl stands for minim (minmum); and the fluidrams and ounces are indicated by the prefex fi, thus f5j, f5j- Semissis, abbreviated ss, is used to indicate a half. A prescription written with the troy system of weights always contains Roman numerals: gr. iv, gr. xx, etc.; when written with the metric weights and measures they are expressed in decimals in Arabic numerals, followed by Gm. or mil, signifying weight or measure: 5.65 Gm., 30.0 mils. Signs for designating the measure or weight of the mixture are sometimes affixed to the last ingredient. The most commonly used are: Ad, the preposition "to;" ad f§iij = to (measure) three fluid- ounces. Quantum sufficiat, abbreviated q. s. — as much as is suffi- cient. Of these signs q. s. is preferable, since ad may be confused with the abbreviation of the verb adde, meaning to add. Ana, abbreviated da, meaning *'of each," is appended when the same quan- tities are required of two or more ingredients; it follows the last of these, just preceding the quantity. 266 PRESCRIPTION- WRITING While it is the rule that every word in the inscription must terminate in the genitive or accusative (the names of the ingredients in the genitive, the quantities in the accusative), they are rarely written out in full, but nearly always abbreviated. Where the first, or the first and second, syllables of words are the same, e.g., hydrar- gyrum and hydrastis, the abbreviation must not be carried so far as to involve doubt as to which drug is really meant. To further illustrate, the drugs just mentioned are often abbreviated hydr., which may mean either of them, or when followed with chlor., would doubtless mean hydrated chloral, but might also be mistaken for hydrargyrum chloridum; both calomel and mercuric chlorid being sometimes erroneously, though not infrequently, so written. The author's experience behind the prescription-counter leads him to emphasize the importance of correctly writing the inscription. The complete inscription is made up of the basis, or active con- stituent; the adjuvant, or aid to the basis; the corrective, or agent to counteract, modify, or correct some unpleasant property of the basis ; and the forming substance. The forming substance is variously termed according to the form or consistence of the mixture. For liquids and ointments it is called vehicle; for powders, diluent; and when in a mass, as in pills or troches, excipient. This is according to the maxim of Asklepiades, which reads curare (basis), cito (adju- vant), tuto (corrective) et jucunde (vehicle, diluent, or excipient), to cure quickly, safely, and pleasantly. Most prescriptions do not contain all of these ingredients; many call for but one. The subscription consists of certain signs and terms conveying directions as to the compounding and dispensing. Generally it is better to leave the detail of compounding to the pharmacist who is trained in the art of pharmacy; therefore, the abbreviation, M., which stands for the Latin imperative of the verb misce, meaning mix, is usually all that is necessary. This sign may follow a dash, thus — M., just to the right of the last ingredient in the inscription, or it may be placed to the left under the sign of the superscription. When special directions are necessary, as in directing the number of powder, capsules, or pills, into which the mixture is to be divided, they may be written in either Latin or EngHsh — the former is preferable, provided they are correctly written. Special directions abbreviated are: M. ft. pulv. chart, div. No. — , mix and make a powder, divide in papers No. — . M. ft. cap. No. — , mix and make capsules No. — . M. ft. mass. pil. div. No. — , mix and make a mass, divide in pills No. — . PRESCRIPTION- WRITING 267 The Signa, abbreviated Sig. or S., includes the directions to be written on the label and affixed to the package or container. These should be written in English in a plain, bold hand-writing. Some- times it is better for the patient not to know what drug is taken; for this reason the inscription and subscription are written in Latin, but no secrecy is necessary here; in fact, to write the directions in plain EngKsh and to read them to the patient or attendant may serve as a check on any possible error in copying the directions on the label. The stereotyped expression, "Use as directed," should be avoided as far as possible, especially where the prescription is intended for internal administration. Many serious consequences might have been averted if specific directions had been given. The name of the subscriber, his degree, and the date are added be- . low the signa. Generally it is not in good taste to flourish the degree after one's signature every time it is written; but in the case of a prescription it is essential for authenticity. The pharmacist desires to know whether the prescriber has the right to prescribe, and this can only be known by the degree. When prescription blanks are used, having the prescriber's name, degree, and address printed above or below the space reserved for the prescription proper, all that is necessary is to write the initials and the date. The date is valuable for reference. It may be questioned by some whether dentists have the right to prescribe internal remedies. A large part of the work of the dentist is to treat the diseases of the mouth and adjacent tissues, thus allevi- ating human suffering, and surely he has the right to use any drug which he knows from his experience will aid Nature in overcoming the pathologic condition. The author entered upon the practice of dentistry through the gateway of pharmacy, and it has been his experience, both as a pharmacist and as a dentist, that the right to prescribe will never be questioned if inteUigence is shown in the writing of the prescription. The order usually adopted in prescription- writing is as follows: First, after the I^, the names of the ingredients are written, in the order of their importance ; then the number of doses is decided upon ; the individual dose of each drug multiplied by the number of doses ■gives the quantities to be afi&xed to the names of the ingredients. In selecting the proper quantity for Hquid mixtures, the regular sizes of vials alone are considered. These are 1,2, and 4 dram, and i, 2,3, 4, 6, 8, and 16 ounce capacity, and it should be remembered that in all cases a bottle should be filled. A partially filled bottle immedi- ately arouses suspicion on the part of the patient as to the possi- bility of mistake in compounding the prescription. MEDICAL LATIN The language used in prescription-writing is primarily Latin, because pharmacopeial titles are chiefly employed in designating remedies. It is never necessary to tell the patient what drug is being used, and frequently it is far better that they should not know, because of certain idiosyncrasies, prejudices, and other reasons. Therefore, it is wise always to WTite the inscription and sometimes the sub- scription of a prescription in Latin. The rule is to have the name of every ingredient end in the genitive and the quantities in the accusa- tive. It is true that much ignorance of the Latin language can be covered up in prescription- writing by using abbreviations, and while it is also true that to abbreviate is perfectly proper, provided it is not carried so far as to involve doubt as to what drug is wanted, nevertheless, a working knowledge at least of this dead language will be of inestimable value. Therefore, a few rules of Latin grammar applicable to prescription-writing are here given: The quantities of the ingredients appear in the accusative case, governed by the impera- tive of the verb "Recipe;" the quantities, however, are seldom writ- ten out in full. The names of the ingredients appear in the genitive case, the construction reading "Recipe drachmam unam phenolis," take one dram of phenol, I^ phenolis, 5j- The directions to the pharmacist are very simple, unless special instructions are' necessary: M. for "misce,V is generally all that is required. The directions to the patient should always be written in EngHsh. All nouns ending in a in the nominative, end in ce in the genitive, and are of the first de- clension; the accusative ends in am and the nominative plural in ce; there are a few exceptions of Greek derivation, such as enema, gram- ma, theobroma — the genitive ending for these is atis. Xouns termi- nating in us in the nominative, end in i in the genitive, and are of the second declension, um for the accusative singular, and i for the nominative plural; there are a few exceptions to this rule with nouns of the fourth declension, as fructus and spiritus (these do not change in the genitive). The nouns ending in um in the nominative singular are neuter in gender and of the second declension; they change to i in the genitive, um in the accusative, and a in the nominative plural. 268 MEDICAL LATIN 269 All other pharmacopeial nouns belong to the third declension and change variously in the different cases, and for the most part must be studied individually. For example: as becomes atis; is may remain is or change to idis, itis, or eris in the genitive; the accusative of as becomes am, the nominative plural atea. Some nouns do not change at all, e.g., sassafras. Adjectives agree with their nouns in number, gender, and case; those ending in tis, terminate with a for the femi- nine and um in the neuter gender, and are declined according to the first and second declensions. Adjectives ending in is and ens are decHned according to the third declension; the first ends in e in the neuter gender. A few nouns of Greek origin end in e, and form a genitive of 'is, and an accusative of en; aloe, aloes, is an example. When special directions are necessary for the dispensing of powders, capsules, and pills, they may be given as follows: Fiat puhis et divide in chartulas No. x. — make a powder and divide into lo papers. Dispensa in capsulis No. xij — dispense in 12 capsules. Fiant pilulce No. xx — make 20 pills. An official formula may be specified in a prescription as follows : I^ Pulveris opii et ipecacuanhse, gr. xx. Fiat chartulas Xo. iv. Sig. — Take one or two powders on retiring and keep well covered. In this prescription the nominative pulvi5 changes to pulver/5 in the genitive; opiww changes to opw; and ipecacuanha changes to ipeca- cuanha. Thus the value of the above rules of Latin grammar is seen. To abbreviate the names of the ingredients in the above, we could use pulv. for pulveris, ipecac, for ipecacuanhas, but we could not intelligently abbreviate opii — it would be necessary to write it in full in the Latin nominative or the English (which is the same in this instance — opium). To write it in the Latin nominative in the in- scription is wrong, and to write it in EngHsh with the other words abbreviated in Latin is also wrong. So, while much ignorance of the Latin language may be covered up by abbre\-iation in prescription- writing, occasionally this lack of knowledge will manifest itself; therefore, it is the wiser plan to become familar \\ith these simple rules. As has been elsewhere stated, the art of prescription-writing is one that requires a great deal of practice for its perfection. In conclusion the author desires to state that if any part of the inscription or subscription cannot be properly written in Latin, by all means write the entire prescription in Enghsh. This is by no means meant to discourage the use of Latin in prescription-writing.^ Those desiring to study this subject further will find St. Clair's "Medical Latin" and Robinson's "Latin Grammar of Pharmacy and Medicine" excellent books for the purpose. 270 PRACTICAL PRESCRIPTIONS EXAMPLES OF PRACTICAL PRESCRIPTIONS Powders. For Mrs.- I^ — Pulveris Acetanilidi Compositse, gr. xv (i.o Gm.) Fiat chartulae No. ij. Sig. — Take one (i) powder at once and the other in two (2) hours, if not relieved. (Date) , D. D. S. For Baby . I^ — Hydrargyri chloridi mitis, gr. j (0.06 Gm.) Sodii bicarbonatis, gr, xx (1.3 Gm.) — M. Fiat chartulae No. x. Sig. — Take one (i) powder every hour untU three (3) or four (4) are taken. (Date) , D. D. S. For Mr. . R — Acetphenetidini, SaJophen, aa gr. x (0.6 Gm.) Codeinse Sulphatis, gr. j (0.06 Gm.) — M. Fiat chartulae No. iv. Sig. — Take one (i) powder every three (3) hours. (Date) — , D. D. S. Tooth Powders. No. I. For General Use. 3 — Calcii carbonatis ppt., 5xiv (448.0 Gm.) Saponis pulveris (U.S. P.) , Sacchari pulveris, aa gij (64.0 Gm.) Sodii benzoatis, Bss (16.0 Gm.) Eucalyptolis, lUx (0.6 mil) Thymolis, gr. x (0.6 Gm.) Cinnaldehydi, lUxv (i.o mil)— M. Fiat pulvis. Sig. — Use as a general tooth powder. (Date) , D. D. S. No. 2. For General Use. '^, — Calcii carbonatis ppt., Bxx (640.0 Gm.) Orris radices pul v., giv (128.0 Gm.) Saponis pulv. (U.S.P.), gij (64.0 Gm.) Sacchari, Sodii boratis, aa 5j (32.0 Gm.) Thymolis, gr. xv (1.0 Gm.) PRACTICAL PRESCRIPTIONS 271 Eucalyp tolis, TTlx (0.6 mil) Olei gaultherias, Olei menthae piperitae, aa lUxx (1.3 mils) — M. Fiat Pulvis. Sig. — Use as a general tooth powder. (Date) , D. D. S. Capsules. For Mr. . I^ — Quininae bisulphatis, gr. xxiv (1.5 Gm.) Dispensa in capsulis No. viij. Sig. — Take one (i) capsule before meals and on retiring (Date) — , D. D. S. PiUs, For Mrs. I^ — Quininae valerianatis, gr. xviij (1.2 Gm.) Extracti hyoscyami, gr. iv (0.26 Gm.) Extracti cinchonae, gr. viij (0.5 Gm.) — M. Fiat massa et divide in pilulae No. xij. Sig. — Take one (i) pill before meals and on retiring (Date) , D. D. S. {Cosmos.) Solutions (Dobell's Solution). For Mr. . I^ — Sodii bicarbonatis, Sodii boratis, aa 3j (4-o Gm.) Phenolis (crys.), 3ss (2.0 Gm.) Glycerini, f§j (30.0 mils) Aquae, Oij (i.o L.)— M Sig. — Use as a spray, mouth-wash, or gargle. (Date)^ , D. D. S. (Antiseptic Solution N.F.) For Mrs. . I^ — ^Liquoris Antiseptici, f§viij (240.0 mils) Sig. — Dilute with one-half warm water and use as a mouth-wash. (Date) , D. D. S. For Miss . I^ — Antipyrini, 5ss (2.0 Gm.) Sodii bromidi, 5j (4-o Gm.) Glycerini, f3ij (8.0 mils) Aquae cinnamomi, q. s. ad. fgj (30.0 mils) — M. Sig. — Take a teaspoonful three times a day, after meals. (Date) , D. D. S 272 PRACTICAL PRESCRIPTIONS For Mrs, • I^ — Potassii iodidi, 5J5S (6.0 Gm.). S>Tupi sarsaparillae comp., f^iij (90.0 mils) — M. Sig.^Take a teaspoonful in water three times' a day, after meals. (Date) , D. D. S. For Mr. . I^ — Acetailnidi, gr. viij (0.5 Gm.) Syrupi simplex, fSss (15.0 mils) Spiritus frumenti, q. s. ad. f oiij (90.0 mils) — M. Sig. — Take one-half at once and the remainder in two (2) hours, if not relieved. (Date) '■ , D. D. S. Collyrium (Eye-water). For Mr. . I^ — Sodii boratis, gr. x (0.6 Gm.) Acidi borici, sat. sol., f5j (30-° mils) — ^SI. SigT — Warm to body temperature and drop into the eye with a drop applicator. (Date) , D. D. S. Gargle (Mercurial Stomatitis or Sore Throat). For Miss . I^ — Potassii chloratis, 5jss (6.0 Gm.) Tincturae mj-rrhae, f5'j (8.0 mils) Alcoholis, fgss (15.0 mils) Aquae cinnamomi, fSvi (180.0 mils) — M. Sig. — Thoroughly gargle the throat three times daily. If too strong, dilute with warm water. (Date) . D. D. S. Liniments. For Dentists^ Use. I^ — Mentholis, lodi (crys.) aa gr. x (0.6 Gm.) Chloroformi, f Sj^s (6.0 mils) Tincturae Aconiti, q. s. ad. fsj (30.0 mils) — M. Sig. — Use as a refrigerant counterirritant. (Date) , D. D. S. For Dentists' Use. I^ — Mentholis, gr. xx (1.3 Gm.) Chloroformi, fSJss (6.0 rrdls) Tincturae aconiti, q. s. ad. foj (30.0 mils) — M. Sig. — Apply freely to gums in cases of nonseptic pericementitis. (Date) . D. D. S. PRACTICAL PRESCRIPTIONS 273 For Mr. I^— Camphorae (gum), 3ij (8.0 Gm.) Tincturae aconiti, fgj (30.0 mils) Linimenti saponis, q. s. ad. fgiij (90.0 mils)— M. Sig. — Apply locally with massage in case of neuralgia. (Date) , D. D. S. INCOMPATIBILITY IN PRESCRIPTIONS When two or more different substances are brought together in a mixture, be it liquid or soHd, with the result of undergoing a more or less complete change, not intended, they are said to he incompatible. Incompatibility, so far as it applies to the combination (not the action) of drugs, may be of two kinds — physical and chemic. The only truly scientific method of determining the incompatibility, or the contrary, of the ingredients of a mixture is a correct knowledge of physical and chemic laws and their practical application iii pharmacy and therapeutics. Physical incompatibility is largely a question of the solubility of drugs. It results when precipitates are formed without the precipi- tated substance losing its former identity; i.e., without chemic change. It also occurs when an effort is made to mix nonmiscible substances, as oil and water. Gums and other mucilaginous substances are soluble in water, but insoluble in alcohol. Therefore, the addition of alcohol to an aqueous solution of a gum results in the precipitation of the gum without chemic change. Example: Mucilage of tragacanth with any alcohoHc tincture (tincture of aconite) will precipitate the tragacanth. Resinous substances are soluble in alcohol, but insoluble in water. The addition of water, therefore, to an alcoholic solution of a resin results in the physical precipitation of the resin. Example: Water added to tincture of podophyllum will precipitate the resinous active constituent, podophyllin. Any mouth-wash or solution containing a considerable amount of the essential oils, held in solution by alcohol, will become turbid upon the addition of water, owing to the physical incompatibiHty of the oil and water. ' Chemic incompatibility involves a chemic change when sub- stances are mixed, whereby their former identity is lost. To be able to predict chemic incompatibiHty requires a knowledge of chemic laws and their practical appUcation. It is well to remember a few of the more common of these laws. For example: I. It is a principle in chemistry that when solutions of soluble salts are brought together there is generally an exchange of radicals 274 INCOMPATIBILITY IN PRESCRIPTIONS 275 with the formation of a precipitate, if either of the newly formed salts is insoluble. To illustrate: When solutions of silver nitrate and sodium chlorid are brought together a white precipitate of silver chlorid is formed. Here there is an exchange of radicals, and the silver chlorid, being insoluble in the water, is precipitated, while the sodium nitrate, being soluble, dissolves as soon as it is formed. Advantage is taken of chemic incompatibility when silver nitrate is used about the mouth; any excess can be neutralized at once by having the patient rinse the mouth with a solution of common salt. 2. Strong mineral acids decompose salts of the weaker mineral or vegetable acids, and also form ethers with alcoholic preparations. To illustrate: Sodium bicarbonate is chemically incompatible with hydrochloric acid. Here the chlorin of the hydrochloric acid has a greater affinity for sodium than has the weaker carbonic radical, hence it displaces the latter, forming sodium chlorid and liberating carbonic acid, which immediately breaks up into water and carbon dioxid. The carbon dioxid, being a gas, causes the effervescence. An illustration of the formation of ethers by adding a strong mineral acid to alcohoUc solutions is found in making ether, where sulphuric acid is added to alcohol. In this case, of course, sulphuric acid and alcohol are not considered incompatible because ether is the product desired ; but if it were not, then they would be chemically incompatible. As a matter of fact, all drugs are incompatible with their chemic tests or antidotes, a knowledge of which means a knowledge of the science of chemistry, and to mention all would be inappropriate in a work of this kind. A few common examples are here given: Alkalies and alkaline carbonates are incompatible with acid solu- tions, acid salts, and alkaloidal salts. Arsenic trioxid with tannic acid and salts of iron. Alkaloids and alkaloidal salts with tannic acid. Phenol with collodion. Powerful oxidizing agents with easily cxidizaUe substances, causing combustion, and even explosion. Oxid- izing agents are: potassium chlorate, potassium permanganate, chromic, nitric, and nitrohydrochloric acids. Easily oxidizable agents are: sugar, glycerin, alcohol, fats, sulphur, carbon, and phosphorus. The following drugs, so far as possible, had better be prescribed alone : Strong mineral acids. Potassium Chlorate. Alkalies. Potassium Permanganate. Arsenic Trioxid. Silver Nitrate. Iron salts. Tannic Acid. Mercuric Chlorid (incompatible with almost everything). 276 ANTAGONISM OF DRUGS ANTAGONISM OF DRUGS As has been observed in the study of physiologic action, certain drugs produce opposite effects. This is known as antagonism of drugs, called also physiologic or therapeutic incompatibility. The antagonistic effects of drugs are recognized in therapeutics as a means of guarding against drug poisoning and as an aid in the treatment oj poisoning when toxic symptoms are manifested. In this connection the term physiologic antidote is used. The antagonistic action of drugs, however, is never as positive as is the case with chemic incompatibility, for there are few drugs, indeed, whose action is directly opposite, and whose effects will neutralize completely the effects of other drugs. The antagonism of drugs or physiologic antidotes is well illustrated in the treatment of cocain poisoning {see p. 1^2). DENTAL STERILIZATION GENERAL CONSIDERATIONS Throughout Part II of this work on Practical Dental Therapeu- tics the author will endeavor to emphasize the importance of dental sterilization. The term Sterilization as used in medical and dental practice, means a process by which the destruction or removal of aU micro- scopic living organisms and their spores is accomplished. Some bacteria, under certain conditions, undergo a transformation into a resting stage when they are called spores. In the spore state they are able to resist influences which would kiU the bacteria. Most disease-producing germs do not form spores and, therefore, are easily killed. The anthrax and tetanus bacilli are exceptions to this, as their spores are quite resistant. An object which is free from living microorganisms is spoken of as being "sterile," but it should be remembered that this condition can be maintained only so long as the necessary precautions are taken to prevent contact with the atmosphere or other media or instrument which may carry micro- organisms. The methods and means of sterilizing tooth-structure and the field of operation will be fully discussed in the description of the various operations which are performed in and about the mouth; and while the importance of having the instruments and material used, as well as the operator's hands, in a sterile condition will be repeat- edly mentioned, in all operations which involve in any way the soft tissues of the mouth where an infection may follow, the means of sterilizing the same should now be discussed. The importance of personal cleanliness on the part of the dentist and of his armamen- tarium is, of course, understood and need not be considered here. A principle in modern surgery is to prevent the presence of germs. This means that the instruments and materials used must be sterile, as well as the field of operation and the operator's hands. The same principle holds true in dental as well as general surgery. METHODS OF DENTAL STERILIZATION Direct Flame. — In dental practice it is often possible to sterilize small objects by the direct application of heat from the flame of 277 278 DENTAL STERILIZATION the Bunsen burner or lamp, provided the object will not be injured. Such instruments as burnishers, root-canal pluggers, platinum needles, the points of pliers used for handling steriUzed cotton, gutta-percha points, etc., may be rapidly steriHzed in this manner by holding them in the flame, or playing the latter over them a few times. Moist Heat. — The use of live steam for sterilization, usually in a covered kettle or boiler, electrically or otherwise heated, is gererally applicable for sterilizing dental instruments, such as broaches, burs, pyorrhea scalers, etc. There are many practical devices on the market for this purpose. By practical here we take into considera- tion the convenience and expense. Such an apparatus must be convenient to use, and no reasonable amount of expense should deter dentists from accompUshing this end. Live steam has great penetrating power, and a temperature of ioo°C. (the boiling point of water) for from three to five minutes generally is sufficient for the sterilization of such dental instruments as may be thus sterilized, and which are used and so sterilized several times daily. The instru- ments should be brushed with a stiff brush to remove whatever de- bris may be present before they are placed in the steriUzer, and the latter should be rinsed and fresh water added every morning. In cases of questionable specific infection, the instruments should be boiled for at least fifteen minutes. Sodium carbonate or borax should be added to the water to prevent tarnishing and probable rusting of the instruments. Dry Heat. — This method requires the object to be heated in an oven or suitable apparatus at a temperature of from 160° to lyo^C, continued for at least two hours. Up to the present, apparatus for the practical sterilization of the material used in dental surgery, such as cotton, gauze, etc., have not been obtainable; and, therefore, dentists have reHed largely upon obtaining this material in sterile condition from the manufacturers. Even if this be possible, which is open to question, the material, with the best of ordinary care, be- comes contaminated in the office. It is important, therefore, that all such material as may be sterilized by dry heat should be so sterilized just previous to use; and the better way to be assured of sterilization is to prepare this material in advance and keep it in a dry heat sterilizer ready for use. Such sterihzers are now on the market, and improved ones are being constructed. They should be a part of the equipment of every practising dentist. Where the material is kept constantly ready for use in such sterilizers, a much lower heat than 160° to i7o°C. is sufficient. Chemic Agents. — For the purpose of assisting in sterilization or DENTAL STERILIZATION 279 of protecting substances from subsequent contamination, chemic agents are frequently employed. It is to be regretted that many of our most potent disinfectants, such as formaldehyd, mercuric chlorid, etc., while excellent for the sterilization of the hands and the site of operation, cannot be used for the sterilization of metal instruments, on account of the agents acting deleteriously upon the metal. These agents, therefore, should be used only as adjuncts, and generally in quantities insufficient to insure sterility in themselves. This method is used in dentistry for the following purposes: 1. For the disinfection of the hands and the site of operation. 2. For the disinfection of tooth-structure, such as carious dentin, gangrenous canals, etc. Here stronger solutions of the drug may be safely employed — thus approaching more nearly complete steriHza- tion than should be expected from the general use of chemic agents for this purpose. 3. For the disinfection of glass containers, etc., alcohol being chiefly used for the purpose; but sterilization by heat is better. 4. To maintain in a sterile condition various remedies, such as local anesthetic solutions, antitoxins, serums, vaccines, etc. If done with aseptic precautions, it is best for the dentist to prepare local anesthetic solutions at the time they are intended to be used. However, stock solutions may be safely employed and can be kept sterile indefinitely by the addition of 0.5 per cent, of phenol or 0.4 per cent, of cresol. The latter is from two and a half to three times as strong a disinfectant as phenol and scarcely more poisonous. It is impossible to set definite Umits which will fit all cases for the amounts of the chemicals which may be employed, because the composition of the substance and its degree of contamination are important factors in steriHzation. Gutta-percha points may be positively sterilized by immersion in a 10 per cent, solution of formaldehyd or in a 70 per cent, solu- tion of alcohol, to which latter solution should be added one grain of thymol to the fluid ounce. This solution will be known through- out the text here as modified alcohol. It is an excellent solution for the chemic steriUzation of the teeth included in the rubber dam, and for the immediate sterilization of carious dentin. It may not com- pletely steriHze in the latter instance, but it aids greatly in estab- lishing asepsis. Of the organic bodies, alcohol stands first in dental practice as a disinfectant. It is an efficient antiseptic when present by volume in from 20 to 40 per cent. Solutions containing from 40 to 70 per cent, are actively disinfectant, the latter strength being most effectual. Above 70 per cent, its efficiency tends to diminish. 28o DENTAL STEEILIZATION lodin is one of the most effective disinfectants, and preparations containing free iodin in material proportions become sterile of them- selves. For this reason solutions of iodin are valuable and largely used for sterilizing the mucous membrane previous to making sub- mucous injections of local anesthetics, and before operating upon the part. The responsibility of having all instruments and material used in dental surgery sterile, where it is possible to cause an infecHon through an open wound or otherwise, is rightfully thrown upon the dentist; and in assuming this responsibility he should study carefully the various methods of sterilization, and exercise judgment in his application of the principles involved. PART II PRACTICAL DENTAL THERAPEUTICS GENERAL CONSIDERATIONS Therapeutics is the application of drugs or remedies to the treat- ment of disease. Dental therapeutics differs in no way from general therapeutics, except that it includes only the treatment of diseases of the mouth and adjacent structures or such general diseases as are manifested in the mouth. In the latter instance it is the duty of the dentist to collaborate with the family physician in the treatment of the case. In this day when so many systemic diseases are known to be directly traceable to foci of infection in the mouth, it is more essential than ever that the physician and dentist work together in harmony for the relief of suffering humanity. In considering the practical therapeutics of the more common diseases which the dentist is called upon to treat, the author will draw largely upon his own experience gained from actual practice and irom extenisive reading of current dental and medical literature. It should be understood at the outset that there are three essen- tial factors upon which all successful therapeutics rests. First, to be able to recognize a pathologic condition and make a correct diag- nosis. This means that the successful therapeutist must possess a broad knowledge of general pathology and a special knowledge of dental or oral pathology; secondly, to know what drug, or remedy, if properly applied or administered, will reach the recognized patho- logic condition and act the most favorably. This means that suc- cessful therapy depends upon a broad knowledge of pharmacology — a science which treats of the action of drugs and remedies upon the tissues, organs, and functions of the body; and thirdly, to have at hand, in a convenient and practical form, that drug or remedy which experience has taught will assist Nature in her efforts to restore an abnormal to a normal condition. The tendency in dental as well as in general therapeutics to-day is to place the treatment of disease upon a rational basis. The pro- gressive dentist, therefore, is no longer satisfied to know that results may be obtained by the use of certain remedies in the treatment of certain diseases, but he has a strong desire to know also why those 252 PRACTICAL DENTAL THEEAPEUTICS results are brought about. In the following pages only such patho- logic data will be given as are deemed essential to the therapeutics of the condition under consideration, but every effort will be made to tell, as far as is known, why the reinedies suggested are indicated and what may be expected from their judicious employ- ment. This means that it will be necessary to practically discard all obsolete or untried remedies. In other words, only such remedies will be considered in detail here as have been found to be of real practical value. DISEASES OF THE HARD TISSUES OF THE MOUTH AND ASSOCIATED STRUCTURES HYPERSENSITIVE DENTIN GENERAL CONSIDERATIONS In the early history of civilization, we find that the possession of the cardinal virtue of fortitude was considered a mark of courage, strength and character, because it enabled the individual to willingly undergo the necessary pain, peril or danger incident to Hfe. But the discovery of anesthesia by humanity's greatest benefactor, Horace Wells, the dentist, together with the humanitarian tendencies of the years, have so changed human nature that we find few people to-day who possess in any marked degree the spirit of fortitude as manifested in ancient times. Among other things in life, this condition of affairs demands more painless methods of 'practising dentistry. The one -dental operation which has caused more pain in the past than all others combined is that of the preparation of cavities in vital teeth. Ever since the art of filling teeth was first begun both the dentist and patient have cherished the ardent hope that some day it would be possible to perform this operation without pain. Especially is this true in these modern times when, to carry out the basic principles of cavity preparation, as understood to-day, it is necessary that the cavity have a flat seat with practically parallel walls; that it should possess powers of resistance and retention, and be of convenient form, and that the outHne be carried to areas of immunity — all of which requires drilling into sound and usually extremely sensitive dentin. Authorities differ in regard to the sensitivity of dentin. Accord- ing to Barrett, dentin in the normal condition should be without sensation ; the source of sensitive dentin, or of impressionable pulps, lies in their continued subjection to irritation by which responsive- ness is developed. Burchard-IngHs states that all vital dentin is sensitive; that the degree of sensitivity differs markedly in indi- viduals; and it is only when hypersensitiveness is observed that the condition becomes pathologic. It might also be mentioned that the sensitivity differs in the same individual at different times. Black differentiates between hypersensitiveness and thermal sensi- tiveness of dentin, claiming that the sharp pain caused by sudden 283 284 PRACTICAL DENTAL THERAPEUTICS changes of temperature is normal, though no other tissue or organ of the body shows a like resistance to thermal changes. Under certain conditions hypersensitiveness to thermal changes may de- velop, when the condition becomes pathologic. Thermal sensi- tiveness as well as hypersensitiveness of dentin is often developed during the progress of decay; therefore, in the preparation of cavi- ties for fillings we find few teeth the dentin of which is without sensation. This fact is not surprising, nor can it be construed as being contrary to the statement that normal dentin is not sensitive when we remember that there are few teeth in the mouths of patients demanding the services of the dentist, the dentinal fibrillae and pulps of which have not been subjected to continued irritation. Previous Attempts at Controlling Pain. — For years men of all classes, from the conscientious practitioner to the charlatan and quack, have endeavored to invent means or discover remedies for the elimination of pain caused by operations upon vital teeth. In 1836 Dr. Spooner, of Montreal, thought he had made the discovery when he introduced arsenic trioxid as a remedy for desensitizing dentin. In more recent years cataphoresis, high pressure injec- tion of cocain, interosseous and conductive anesthesia have had their advocates. All kinds of local remedies have been suggested. General analgesia by chloroform and nitrous oxid has long been used by a limited number. Later, analgesia by somnoform or nitrous oxid and oxygen has been revived. Many are using these various agents to-day with more or less success — not because they are in full sympathy with the methods or means, but because they seem to be forced to use something; and their patients are willing to submit to almost any process if pain can be avoided. Any method or remedy for the elimination of pain in filling teeth, which necessitates placing the tooth or patient in such condi- tion that the dentin can be painlessly drilled to any depth, is a dangerous one to place in the hands of the profession in general. Pain is Nature's indicator, and pain should be our guide. The author has been of the opinion for years that the ideal method of desensitizing dentin would be the application of a remedy within the cavity which would affect the dentin only to a given depth, and thereby not reach nor affect the pulp. In the discussion of means and methods by which the sensitive- ness of the dentin can be allayed, I shall not attempt to enter into the details of the many histologic and pathologic phenomena which are certain to arise in the consideration of the therapeutics of this subject, but shall confine myself largely to the drug aspect. HYPERSENSITIVE DENTIN - 285 The sensitiveness of the dentin can be obtunded in no small degree by the use of various therapeutic agents; and I might state that there are few operations which we are called upon to perform wherein the patient will appreciate our efforts more than in this of applying drugs and remedies for the mitigation of pain. But in order to apply intelHgently and successfully any remedy, whether it be a drug or an agent, to the dentin and thereby obtund the sensi- tivity of the dentinal fibrillae without endangering the vitaUty of the pulp itself, we must be familiar with several factors or conditions, which I cannot with propriety here discuss, in detail at least. For instance, a thorough knowledge of the anatomic and histologic struc- ture of the tooth is of the. highest importance, as is also a knowl- edge of the pathology, not only of the fibrillae, but of the pulp tissue as well — the changes which these structures are capable of undergoing if unduly irritated by the appUcation of the remedy employed. Still another factor, of equal importance and one which more directly relates to the phase of the subject under consideration, is a knowl- edge of the pharmacologic action and the therapeutic application^ of the drugs and remedies used for this purpose. Before using a drug or an agent for allaying the sensitiveness of dentin, or for any other purpose, we should know what action to anticipate from its employment. This is not too much to expect from the trained dental practitioner of to-day. THERAPEUTICS The remedies suggested in the past for obtunding sensitive dentin have been many and varied. ] shall discuss only those which, from clinical experience, have proved of sufficient value to merit considera- tion; and, for convenience of study, will divide them into four general classes. I. PHYSICAL AGENTS There are some physical agents by the proper use of which the sensitiveness of dentin can, in a measure, be obtunded. The most common are: Heat. Light. Gold. Electricity. Heat. — The appUcation of dry heat to a sensitive cavity, espe- cially in conjunction with a dehydrating agent, such as absolute alcohol, is always an aid ; and this is accomplished by means of heat- ing dry air, and gently directing a current of air thus heated into the cavity which has been isolated by the rubber dam and mois- 286 PRACTICAL DENTAL THERAPEUTICS tened with the dehydrating agent used. Care must be taken not to primarily cause pain, otherwise the object of using the agent would be defeated. Several apparatuses have been devised for heating the air. Dr. Rudolph Beck perfected a convenient electrical device by means of which compressed air can be heated as it passes through. Other such devices are on the market. In the absence of these, however, the chip-blower can be employed, but with less satisfaction. Inasmuch as heat is used in conjunction with another and more important class of remedies, I shall refer to this agent later. Cold. — This is another physical agent sometimes employed for the purpose of desensitizing the dentin. Heat may be abstracted from the tooth-structure by spraying the cavity with a highly vola- tile liquid, like ether, rhigolene, or ethyl chlorid. In the use of these agents, advantage is taken of the physical law that a solid in changing .its form to a liquid, or a liquid in changing its form to a vapor or gas, must abstract from the thing to which it is applied a certain amount of heat in order to effect the change. Ether, or combinations containing ether, and ethyl chlorid, both used as sprays, have proved valuable in some instances, especially in shallow cavities near the gum the dentin of which is difficult to obtund by the usual methods employed heretofore, and to which reference will be made later. A precaution to be taken to prevent primary pain in applying this remedy is to fill the cavity temporarily with stopping and direct the spray first on this and surrounding parts, after which the stop- ping can be removed and the spray directed into the cavity without any appreciable pain. The degree of refrigeration must not be car- ried to the point of having subsequently a possible deleterious effect upon the pulp or gum tissue. A practical method of combining dryness and cold as a means of obtunding sensitive dentin has been suggested by Dr. W. T. Reeves. It consists in directing a small jet of compressed air directly into the cavity a few moments before operating, and keeping it up during the drilling process. To prevent primary pain, cotton saturated with an analgesic and antiseptic remedy may be placed in the cavity first. The air serves a threefold purpose ; it keeps the cavity dry ; clears the field from chips; and, what is important here, it lessens the heat of drilHng which is responsible for most of the pain in cavity preparar tion. Those inexperienced with the method must be careful at first, as the absence of pain and the clear field may lead one to think that the bur is not cutting; as a result one is liable to drill deeper thanjs absolutely necessary. HYPERSENSITIVE DENTIN 287 Light. — This agent has been brought forth at different times as having a peculiarly favorable effect upon hypersensitive patients. In one method the rays of light are colored by passing through a blue glass. This is accompKshed by darkening the room and em- ploying a blue bulb (i6 or 32 c. p.) on an ordinary electric socket. Whether the light acts locally or affects the vision and thus the general nervous system has yet to be demonstrated. In the author's experience with this agent the result thus far has not been encouraging. Electricity. — The electric current has been employed as a means of carr3dng certain drugs into the dentin and pulp tissue for obtun- dent purposes. The method is called cataphoresis; but because of the expensive and compHcated apparatus, the length of time required to obtund, as well as the often unsatisfactory, and, in not a few in- stances, disastrous results, the method has generally been discarded. n. ESCHAROTICS OR CAUSTICS Any drug or agent which will cauterize the dentinal fibrillae, will obtund sensitive dentin. There are many drugs, however, belonging to this class that cannot be used for this purpose because of their deleterious effect upon both the tooth structure and the pulp tissue. For instance, the strong mineral acids will disorganize the proto- plasmic dentinal fibrillae ; but they will also disintegrate the inorganic structure of the tooth. Arsenic trioxid has a specific poisonous action upon the fibrillae, but there is no known means of preventing the same deleterious effect upon the cells of the pulp tissue. The most valuable escharotics for desensitizing the dentin are: Phenol. Trichloracetic Acid. Zinc Chlorid. Silver Nitrate. Trioxymethylen. It must be noted that, while these agents will obtund, the ultimate result is too often produced, with the possible exception of phenol, at the expense of quite as much suffering as they save. Phenol. — This drug has local analgesic properties besides those of a cauterant, and will, therefore, be discussed under another and more important class of agents. Zinc Chlorid. — Solutions of this drug of various strengths can be used to advantage in a class of cavities where the decay or softened dentin does not extend too close to the pulp. Zinc chlorid coagulates albumin, and in the process hydrochloric acid is Uberated. For this reason the application of strong solutions is painful and should not 255 PRACTICAL DENTAL THERAPEUTIC5 be resorted to in deep ca\'itie5 unless the irritating action of the agent is modified. This can be done to a marked degree by selecting alco- hol and chloroform as the vehicle in which to rnake the solution. A useful formula is here given: R — Zinci Chloridi, gr. xx (1.3 Gm.) Alcoholis, foiv (i5-o mils) Chloroformi, q. 5. ad. foj (30-0 mils) — M. Sig. — Apply to the cavity on a small pledget of cotton and gently evaporate to dnmess. Xote. — If the zinc salt in alcohol does not niake a clear solu- tion, it indicates that some of the salt has been oxidized; the solution can be cleared by adding one drop of dilute hydrochloric acid. This is an excellent remedy to apply to the ca^'ity immediately before using compressed air. Trichloracetic Acid. — In concentrated solution trichloracetic acid causes considerable pain when first applied to a sensitive ca\aty, therefore defeating the object of its use; but in a 10 or 15 per cent. solution it produces but little pain or inflammatory reaction. In this strength it may be employed, but not always with satisfactory results. Silver Nitrate. — This agent is perhaps the only known prophy- lactic drug for decay of tooth-structure. In the posterior part of the mouth where the cementum is exposed to external influences and thus is sensitive, or in shallow ca\dties, especially in children's teeth, the use of this drug, in the soHd pencil form or in solutions of varying strength, T^dll be found valuable, both as a means of reducing the sensitiveness and preventing further ingress of caries. As an agent for obtunding the sensiti\dty of the dentin in an ordinary cavity it should not be considered, for various reasons. When the agent is employed for the purposes above mientioned, the ca^dty, after the application, should be kept free from saliva for a few minutes, and. if possible, exposed to sunHght, thus decomposing the silver salt as referred to under the subject of Light (see p. 252). A solution of sodium chlorid should always be at hand when using silver nitrate, and in case any of the latter agent should accidentally get on the mucous membrane of the patient's mouth its action can be checked at once by rinsing the mouth -vNdth this antidotal solution. TrioxjTuethylen. — The use of this drug for desensitizing pur- poses will be mentioned later under Desensitizing Paste. HYPERSENSITIVE DENTIN 289 m. LOCAL ANODYNES OR LOCAL ANESTHETICS In the judicious use of agents belonging to this class the author firmly believes will ultimately be found the surest and safest road to success. This statement stands as it first appeared in this book (1909). Subsequent investigation by the author, which will be re- ferred to later under Desensitizing Paste, has proven the correctness of the statement. The following agents, or a combination of two or more, will be found to be of the utmost value : Cocain. Eugenol. Novocain. Phenol. Neothesift: Ethyl Chlorid. Menthol. Ether. Oil of Cloves. Chloroform. Cocain. — Both the alkaloid, cocain, and the alkaloidal salt, cocain hydrochlorid, are used in various ways for obtunding sensitive dentin. An important physiologic property of cocain to be remembered here is its power, when applied directly to the mucous membrane or when injected or forced into the pulp tissue, of inducing a condition of analgesia in the part by paralyzing the sensory nerve filaments. In addition to this, it causes a blanching of the part which is subse- quently followed by congestion. It should also be remembered that pharmacologists have proved beyond a doubt that cocain is a general protoplasmic poison; that muscles as well as nerves and nerve- ends cease to contract or to conduct stimuli when they are exposed to even dilute solutions of the drug. The only reason why the dele- terious effect is more noticeable upon nerve than upon other kinds of tissue is that here we are deaHng with the medium of sensation and expression. The author deems it wise to call attention to these well-estab- lished physiologic, pharmacologic and pathologic facts, for many instruments have been devised for forcing solutions of cocain hy- drochlorid of various strengths, not only into the dentinal tubuli, thereby paralyzing the fibrillae, but into the pulp proper, anesthetizing this organ as well. In view of these facts, it would appear that we are seldom justified in completely anesthetizing the pulp of a tooth for the purpose oj painlessly preparing a cavity therein. Therefore, under the subject of Cataphoresis previously referred to, little was written; and, for the same reasons, the method of anesthetizing the pulp by high- pressure, interosseous, or conductive anesthesia for obtundent purposes only will not be considered. These methods will be discussed subsequently under Pulp Removal. 290 PRACTICAL DENTAL THERAPEUTICS Cocain and the alkaloidal salt, cocain hydrochlorid, are safe and reliable agents for obtunding sensitive dentin, if confined to the dentinal structure of the tooth. Frequently, in deep-seated cavi- ties, especially in children's teeth, the sensitiveness can be com- pletely overcome by sealing in the cavity for a day or two a creamy paste made by mixing the alkaloid with liquid petroleum. The oleate of cocain (N.F.) can also be used for this purpose. The paste or^oleate should cover the entire surface of dentin which we subse- quently expect to excavate. Good results can also be immediately obtained by the use of the following remedy: I^ — Cocainae, gr. xx (1.3 Gm.) Chloroformi, f5ij (8.0 mils) Etheris, q. s. ad. foj (30.0 mils). — M. Sig. — After the rubber dam has been adjusted, apply to the cavity on a small pledget of cotton and evaporate to dryness. In the use of this remedy, advantage is taken of the physical law previously referred to in connection with Cold. As the volatile liquids, ether and chloroform, evaporate, a certain amount of heat is abstracted from the tooth-structure, and a coating of the alkaloid, driven to an extent into the dentin, is left in the cavity. This remedy will not completely obtund all sensitive dentin, but its use will be a material aid. There can be no objection in favorable cases, provided the dentin has been previously sterilized, to using aqueous solutions of cocain hydrochlorid with uniform pressure over the entire area of the cavity, thus forcing the anesthetizing solution an equal distance into the dentin. This is an extremely difficult thing to do without forcing the solution at some more favorable point in the cavity through the tubuH and into the pulp. However, there are cavities where good results can be accomplished by the careful use of this method. In some cases of gingival cavities good results can be obtained by hypodermically injecting a i to 1.5 per cent, solution of cocain hydrochlorid into the pericemental membrane somewhere near the apex of the root. This practice should not be generally recommended. Novocain. — This drug may be substituted for cocain and used as above described. Its action is much slower; and, for the pur- poses mentioned, it possesses no advantages. Sterile, isotonic solutions are recommended to be used hypodermically for hyper- sensitive dentin. The drug is injected by the infiltration, inter- HYPERSENSITIVE DENTIN 29I osseous, and conductive anesthesia methods (see pp. 130 and 138, and works on Local Anesthesia.) Neothesin. — The use of this agent in combination with other drugs for desensitizing dentin will be considered later. Menthol. — This drug can be substituted for the cocain in the above prescription with ether and chloroform, and used in exactly the same manner. An oily liquid (mentho-chloral) can be formed by heating together over a water-bath, or rubbing in a mortar, an equal amount of menthol and chloral. This remedy will be found ef&cacious by seaHng in the cavity for a few days. Oil of Cloves. — ^A profound analgesic effect can be produced upon sensitive dentin, especially in deep-seated cavities, by using oil of cloves and heat in the following manner, as suggested by Dr. C. N. Johnson: After carefully desiccating the dentin by means of warm alcohol and gentle heat, a pledget of cotton saturated with oil of cloves should be placed in the cavity and a current of heated dry air directed thereon until the cotton is nearly dry. This should be repeated as often as the case demands. Eugenol. — Eugenol is the chief constituent of oil of cloves and can be used in the same manner as the latter drug, as above de- scribed. Phenol. — This drug can be substituted, with equally good results, for the oil of cloves or eugenol, as described in the foregoing method. Care should be taken here, however, in directing the heated air, that the fumes of phenol do not escape in the patient's face. Oil of cloves, eugenol, and phenol are three true local anodynes^ any one of which, if hermetically sealed in a cavity for a few weeks, will check the continued irritation of the fibrillae and pulp, and thus aid Nature to restore these structures to their normal condition when they should not be responsive. The author's phenol compound (see p. 3 1 1) is an excellent remedy for this latter purpose. By this means, then, the sensitiveness of the dentin can also be allayed. Ethyl Chlorid, Ether, and Chloroform. — These agents, by their extreme volatility, produce a condition of analgesia, thereby obtund- ing sensitive dentin, as previously explained under Cold. IV. GENERAL ANODYNES OR ANALGESICS Before the introduction of Desensitizing Paste and the modern and improved methods of using local anesthetics, it was sometimes necessary in order to do permanent work for certain highly nervous 292 PRACTICAL DENTAL THERAPEUTICS patients to resort to the administration of this class of drugs. The agents largely used for this purpose are: Opium. Nitrous oxid. The bromids. Chloroform. Opium. — This drug is a most powerful analgesic, and while there are some dental conditions where it or its chief alkaloid, morphin, is truly indicated, the drug ought not, in the author's judgment, to be given for the treatment of sensitive dentin. The Bromids. — The bromids of potassium, sodium, and ammo- nium are valuable drugs in certain cases. Perhaps there is no drug which will quiet a nervous patient more readily, when the nervous- ness comes purely from fear or dread, than potassium bromid, which is the representative of this class. In such cases, where it is deemed necessary, the following prescription will prove helpful: I^ — Potassii bromidi, 3jss (6.0 Gm.) Syrupi sarsaparillae comp., fgiij (90.0 mils.) — M. Sig. — Take a tablespoonful in water after meals the day before coming to the office. Nitrous Oxid. — There are varying apparatus on the market by which nitrous oxid gas can be administered through the nose. It is possible with such an apparatus to carry the patient just to the analgesic stage, and hold him under its influence until a sensi- tive cavity has been painlessly prepared. Oxygen, in proper pro- portions, is generally mixed with the anesthetic agent for this pur- pose, as it overcomes the cyanosis which frequently follows the prolonged use of nitrous oxid alone. In cases where the operator feels that it is necessary to resort to this method, good results can be accomplished. Chloroform. — With the patient in the upright position, chloro- form can be carried to the analgesic stage and sensitive cavities prepared. Most authorities agree, however, that chloroform should not be administered unless the patient is in the recumbent position, and that the analgesic stage is the most dangerous. Death has been known to occur suddenly after a few inhalations in cases of marked idiosyncrasy against the drug. Hewitt, De Ford, and others report excellent results from the use of chloroform in the manner described above. In selected cases the author has used the method with uniformly good results; but the general use of the drug in this manner is not advised. HYPERSENSITIVE DENTIN 293 DESENSITIZING PASTE Desensitizing Paste is a preparation introduced by the author to the profession as an absolute specific for hypersensitive dentin. The formula contains neothesin, th}Tnol and trioxymethylen, in the proportion of ii, 12 and 77 parts, respectively; all combined with a petroleum base, and incorporated in a fibrous vehicle and colored with an insoluble pigment. One grain of the preparation is sufficient for about fifteen applications. On this basis the amount necessary for one application contains neothesin J-^oo gr-, thymol 3^70 gr., and trioxymethylen 3^3 gr. The use of the remedy in the hands of careful operators is safe and absolutely reliable. In the hands of careless operators no effective remedy or method of desensitizing dentin is safe. The dental pulp is a delicate and highly susceptible organ, and it must, therefore, be handled with intelligence and care. Most patients who repose confidence in the operator are sensible, and are willing to endure some pain in the preparation of cavities in their teeth. With confidence, a true running engine, a sharp bur, a dry cavity, a steady hand, and a knowledge of what ought to be done in a given case, it is not necessary to use Desensitizing Paste or any other absolute and positive means of desensitizing the dentin in every case which pre- sents. Yet, it must not be forgotten that the preparation of cavities in vital teeth without some means of obtunding the dentin more positively than has been done in the past, is generally a pain- ful operation which is dreaded by most patients. In his work on "Operative Dentistry," published in 1908, on page 149, Dr. G. V. Black says: "The treatment of sensitive dentin for the purpose of relieving or limiting the pain-in the excavation of cavities has been prominently before the dental profession since the first discovery of anesthesia, and, perhaps, for many years before that time. Personally, I have watched the progress of this effort through many years of what has been fairly close, careful observation in clinical practice, and always with an earnest desire to reHeve patients of suff'ering in the necessary cutting in the preparation of ca\dties. In all of this time, and up to the present, the results have been so poor, or so uncertain, that, as compared w^th skillful use of well- selected cutting instruments, well-tempered and always sharp, they have not been a success." The author concludes by saying: "But the relief of suffering is an ever-present duty, and the search for this very desirable thing should continue." Physiologic Action. — It is highly essential that we understand how desensitization is brought about when Desensitizing Paste 294 PRACTICAL DENTAL THERAPEUTICS is applied to the dentin. The neothesin applied directly to the exposed sensitive dentinal fibrillae acts quickly thereon and tempo- rarily paralyzes the ends thus exposed. The thymol volatilizes and permeates the softened dentin. The heat of the body gradually Uberates formaldehyd from the trioxymethylen, which gas diffuses through the decayed dentin, combining chemically with the amine group of the protein constituent of the dentinal fibrillae. The formaldehyd also acts upon certain intermediate and end-products that may be present in the carious tooth-structure as a result of albuminous decomposition, and this agent, together with the thymol, brings about complete sterilization. Thus the dentin affected by the remedy is not only desensitized, but sterilized as well, which is an all-important factor. The vitality of the fibrillae is destroyed in the area affected, but the remedy will not affect sound dentin to any dangerous depth. In the preparation of the cavity, in the average case, the dentin affected by the remedy is practically all removed. If it is not, I know from my experience with the prepara- tion that the vitality of the fibers is subsequently restored, for after a few weeks sensation returns. While this regeneration is being brought about, the tooth may develop slight thermal sensitiveness which lasts for about a week. This occurs only in a small per- centage of cases. It is mentioned here simply that the operator may know the cause, and that should such sensitiveness develop, it will be of short duration. Indications. — Desensitizing Paste may be used with perfect safety in all cases of hypersensitive dentin where the pulp of the tooth is not diseased to the extent of necessitating the removal of the organ because of its pathology. As has previously been men- tioned, it is not necessary to employ the remedy in every case of cavity preparation. Where the pain is not great, and where the patient is willing to endure the small amount, no therapeutic remedy is needed; but every dentist has cases in which it is impossible to do satisfactory work because of the hypersensitiveness of the dentin. In all such cases the use of Desensitizing Paste will prove a blessing to humanity and a godsend to those earnest practitioners who have grown gray and nervous standing at their chairs trying to properly prepare cavities in the teeth of hypersensitive patients. Making the Application. — In employing Desensitizing Paste, it is not necessary to remove any of the carious dentin that is at all sensitive. To attempt this often causes pain, and the remedy, if used at all, is intended to, and will, absolutely eliminate all pain in cavity preparation. The cavity and immediate tooth-surface should HYPERSENSITIVE DENTIN 295 be dried with alcohol and a small amount of the paste sealed therein with a good cement. Better results will be obtained if the remedy is spread over the cavity surface. This can be accomplished with a ball of cotton held in the phers. In gingival cavities, such as is illustrated in Fig. 3, it is often necessary to flow the cement over the enamel surface, depending entirely on its adhesiveness to hold the paste on the softened tooth-structure. Twenty-four to forty-eight hours is sufficiently long to bring about complete desensitization, and this is the proper length of time to leave the remedy sealed in a tooth. However, no harm will follow if the paste should remain in the tooth for a longer period. The small amount employed will soon exert its full influence, after Fig. 3. — Prepared cavity. which no further action follows. An effort should be made to hermetically seal all the margins of the cavity — thus confining the action of the remedy to the dentin. This is sometimes difficult to do with gingival cavities. If it is not accomplished, a certain amount of the formaldehyd gas may escape as it is liberated, in which case the dentin would not be profoundly affected. When it becomes necessary to prepare a cavity in practically sound dentin, as is frequently the case for bridgework and in super- ficial cavities, it may be necessary to make a second application of the paste in order to prevent any pain. In all cases where there is considerable decay, one appHcation will be sufficient to desensitize the entire cavity. The depth to which the dentin is affected by the remedy will depend upon the condition of the dentin. In using Desensitizing Paste it will be found that in about 5 to 10 per cent, of all cases the teeth to which it has been applied with grumble or have a tendency to ache. If the remedy has been used where indi- cated, no alarm need be felt because of this, for it will subside in a few hours. Precautions. — There are no special precautions to be observed in using Desensitizing Paste, so far as the remedy itself is concerned. 296 PRACTICAL DENTAL THERAPEUTICS It will not even destroy normal gum tissue to any appreciable extent, at least, if sealed in contact with it. It will be necessary, however, for the dentist who desires to use this remedy intelligently to so school himself in pulp pathology that the remedy may not be used in those cases where the reading of the clinical symptoms would clearly indicate the removal of the pulp. In deep-seated cavities which approximate the pulp, yet where the organ is not diseased to the extent of necessitating its removal, the paste need not be applied to the entire cavity. In these cases very small doses may be placed over such areas only as will need to be drilled subsequently in the cavity preparation, and some anodyne remedy like phenol compound placed immediately over the pulp. The danger in using this preparation does not He in the possibility of affecting deleteriously a healthy pulp, provided there is sound dentin between the bottom of the cavity and the pulp proper, but rather in the probabiHty of diseased pulps being left in teeth to die and putrefy, because of the absence of sensation in the dentin after the remedy has been used. The decision, therefore, as to whether or not the pulp is diseased and removal necessary should be made before employing Desensitizing Paste. In my clinical experiments I have, at times, purposely used the paste in cavities of extensive decay, where I suspected the pulp was affected. At the subsequent sitting I was able to painlessly remove all of the carious dentin which extended very nearly, and in some cases quite to the pulp. In cases where the pulp was exposed it was found to be sensitive and would bleed freely, indicating, to my mind, that it had not been affected by the remedy. However, it is our plain duty in such cases as these to remove the pulp, for I do not believe that decay can extend to or nearly to the pulpal organ without the latter being affected by the carious process, if not infected by the germs present in the cavity. Caution in Relation to Diseased Pulps. — In detailing the use of this valuable remedy I wish specifically to call attention to the fact that every dentist has had cases in his practice where vital teeth have ached after permanent fillings have been inserted, and that pulps occasionally die following these operations. Unless the dentist is well posted on pulp pathology and is cautious in his diag- nosis similar experiences will follow the use of Desensitizing Paste. If such should be the case, however, it will be through no fault of the remedy — it will be the fault of mistaken diagnosis. I can under- stand how much harm may follow the use of any remedy or method by which cavities can be painlessly prepared. In the hands of the HYPERSENSITIVE DENTIN 297 careless operator pulps may be left in which should have been removed. In the hands of that great army of conscientious practitioners, who constitute the vast majority, Desensitizing Paste will lighten their burdens and prove its worth (Fig. 4). Fig. 4. Fig. 4. — This radiograph was taken of one of the first cases in which the author used Desensitizing Paste in his practice. The patient was a girl about fourteen years of age whose teeth were extremely hj^^er sensitive and decayed rapidly. On account of the nervousness of the little patient and the hypersensitiveness of the dentin, only tem- porary work could be done. This first lower bicuspid erupted when the child was seven years old, and began to decay at once. As will be noticed it is a malformed tooth. A small mesial cavity had been filled with amalgam. The larger distal cavity was filled several times with cement. Desensitizing Paste was applied on April 3, 19 14. The following day the cavity was prepared absolutely without pain in the presence of several dentists during the "Office Clinics" held in connection with the Fiftieth Anniversary of the Illinois State Dental Society. The cavity was subsequently filled with porcelain. On account of lack of proper anchorage: (over one-half of crown was gone) this filling came out the following January. I decided to fill the cavity with synthetic porcelain. Upon drilling for anchorage, the dentin was as sensitive as though it had never been completely desensitized. The radiograph was taken April 3, 1916, two years after desensitization; and the tooth has been tested for vitality every few months with the electric current. The case is one of hundreds in the author's practice which prove that, properly used, Desensitizing Paste will not kill the dental pulp. In closing, I want to say that the dread of the dental chair, the severe nervous strain upon dentists, the failure of operative pro- cedures upon vital teeth and the ruthless destruction of the dental pulp, with its frequent evil sequelae, have been more largely due to hypersensitive dentin than to all other causes combined. It is a great pleasure and satisfaction, therefore, for the author to here discuss the uses of Desensitizing Paste in connection with the therapeutics of this condition. DIAGNOSIS AND TREATMENT OF DISEASES OF THE DENTAL PULP; INCLUDING THE DESTRUCTION AND REMOVAL OF THE ORGAN GENERAL CONSIDERATIONS In the treatment of the dental pulp, as in all other therapy, it is highly essential that we differentiate between the various kinds of diseases of this organ, and by means of reasoning, using com- mon sense and judgment, and the process of exclusion, arrive at a correct diagnosis before applying our therapeutics. Any other method of procedure is Httle short of guesswork; and we must admit that there has been too much guessing at results, on the part of many, in the dental therapeutics of the past. In order to correct this evil we should delve more deeply into the science of pathology, and then, learning to properly interpret the clinical manifestations of these various diseases, we can select and apply our remedies along more rational lines. The Normal Dental Pulp. — To know a tissue or organ in disease one must first know it in health. Therefore, let us briefly review the anatomy and physiology of the dental pulp (Fig. 5). Our his- tologists inform us that this organ is the remains of the original dental papilla, changed somewhat to meet its present environment, and is composed of soft embryonal connective tissue, with an outer layer of odontoblastic cells, the whole being well supplied with blood-vessel and nerves. The blood-vessels of the pulp are sup- posed to communicate with the general circulation through the apical foramen or foramina of the tooth. One or more small arterial trunks enter the pulp cavity at the apex, and, coursing occlusally through the center of the tissue, give off many branches. Near the occlusal end of the pulp they further divide into capillaries, and form a fine plexus around the peripheral portion of the pulp. The blood-vessels are generously distributed through the tissue. The veins form a similar plexus, and a central vein, analogous to the artery, receives the blood from these many venules and conducts it through the apical foramen. The nerves of the pulp are transmitted through the apical foramina together with the blood-vessels. Several bundles of medullated nerve fibers enter the foramen and break up into a plexus of nerves, which are widely distributed through the pulp tissue (Turner). Lines of Schreger. Lines of Retzius. Enamel rods. Enamel. Dentin. Dentinal tubuli. Dental pulp. — ' Odontoblasts. " Epithelium. Principal fibers. Interglobular spaces. Cementum. Pericementum. Cement corpuscles. Tomes's granular layer. Bone trabecule. Bone. Pulp cells. Arteries, veins, nerves. Periosteum. Multiple foramina. Fig. 5.— Showing histology of the normal tooth and supporting structures. TREATMENT OF DISEASES OF THE DENTAL PULP 299 . Character of Blood-vessels. — The walls of the pulpal blood-vessel are unusually thin. The arteries are found to be almost devoid of the external fibrous coat; and, according to Noyes, the muscular layer is represented by a single involuntary fiber, while the walls of the veins are formed by a single layer of endothelial cells. It has long been known that the pulp tissue, like the brain, contains no lymphatics, and when we recall the thinness of the walls of the blood-vessels and that the organ is confined within a cavity having unyielding walls, the absence of lymphatics becomes of the greatest pathologic significance. Common Sources of Irritation.- — Before taking up the pathology of the pulp, let us consider for a moment some of the more common sources of irritation of this organ and pericemental membrane, due to ignorance or carelessness, or both, on the part of dentists. So far as drugs are concerned, I am of the opinion that alcohol causes more irritation to these structures than any other one remedy. Ethyl alcohol, 95 per cent., is a most excellent agent, but a much abused one in dental practice. For removing the gelatinous coating and steriHzing the crowns of teeth included in the rubber dam, it is invaluable, but it is never necessary to use alcohol in this strength to desiccate or sterilize the dentin of a cavity in a vital tooth which we desire to fill, or for desiccating a canal previous to the insertion of a root-filling. That these results can be accomplished by using this agent, no one will deny; but, if we will only stop to consider, we must also know that the results are too frequently obtained at the expense of irritation of the pulp and tissue in the periapical region. I know that the use of 95 per cent, alcohol for such purposes has long been an estabHshed practice, and how startHng and, to some perhaps, unfounded these statements may appear; but, never- theless, I know too that these indictments against the indiscrimi- nate use of alcohol in the treatment of teeth are justifiable, when we are considering the etiology of these diseases. What then shall we use as a substitute? My answer is to use either alcohol modified, which is 70 per cent, alcohol and 30 per cent, water, to which solu- tion I gr. of thymol is added to each fluidounce; or a 10 per cent. alcohoHc solution of phenol compound, or some other remedy ha\'ing similar properties — those of desiccant, anodyne and disinfectant. The popular behef is that phenol is hke an oil and that it is neces- sary to follow its use in a cavity, for example, mth ethyl alcohol in order to have the cement adhere. This is an erroneous idea. Phenol, though oleaginous in its physical appearance, is not an oil, any more than is sulphuric acid which is also oleaginous in character. 300 PRACTICAL DENTAL THERAPEUTICS Phenol is an alcohol and can be evaporated with warm air almost as readily as ethyl alcohol, and absolutely without irritation (pain) of the tissues involved. Still another common and fruitful source of pulp irritation is the lack of protection to the organ in our extreme methods of cavity preparation in filling vital teeth, frequently resulting in the metallic inlay or filling being placed in too close proximity to the pulp. It is not my intention to decry the principles involved in Operative Dentistry; but my experience has taught me that in filling proximo- occlusial cavities in molar and bicuspid teeth, -especially with inlays, with the opportunity afforded for occlusal anchorage, it is not neces- sary to approximate the pulp as closely as is advocated by some teachers on the ground of principle. This word "principle" is a broad term, and we should remember that there are principles involved in the treatment and protection of the dental pulp as well as in the retaining of a filling or inlay in the tooth. I have long since stopped trying to make myself and my patients believe that teeth, the pulps of which are thus continuously irritated by thermal changes, will soon be cared for by Nature, when no further trouble will be experienced. On the contrary, I know that while Nature is a kind mother, sometimes I think so kind that we are inclined to take undue advantage of her, yet in the majority of cases, both constructive and destructive diseases result which subsequently necessitate the removal of the pulp. Many pulps have been irritated and frequently passive hyperemia or inflammation has been produced by the injudicious use of gutta- percha for sealing-in dressings or for separating purposes when proximal cavities existed. Unless due care is taken in the use of this material, even when the cavities are not deep and when no active hyperemia is present, infectious material or the medicine is liable to be forced through the dentin and into the pulp, causing the diseases above mentioned and jeopardizing the life of the organ. Cement had better be used for temporary sealing purposes, and before- separating carious teeth with gutta-percha the cavities should be cleansed of debris, and the dentin sterilized. The cause of pulp trouble following the filling of a vital tooth can often be traced to the lack of sterilization of the dentin before the filling was inserted. Let it be remembered that preventive therapeutics is the watch-word of the hour. It should be understood', then, that the dental pulp is a delicate and susceptible organ, responding to the slightest irritation, it matters not whether the irritant be of a thermal, mechanical, TREATMENT OF DISEASES OF THE DENTAL PULP 3OI chemical, or electrical nature. Inasmuch as any one of these various classes of irritants may cause hyperemia of the pulp, and this disease, if continuous and progressive, may result in more serious pathologic conditions, I will now direct your attention to the pathology of this organ, considering the etiology, diagnosis and treatment of (i) such Constructive and (2) Destructive Diseases as are commonly found in the general practice of dentistry. CONSTRUCTIVE DISEASES SECONDARY DENTIN The deposition of what is known as secondary dentin frequently occurs in the pulp-chambers of teeth as the result of sHght but con- tinued irritation of the pulpal organ, after ithias enjoyed a physiologic period of rest from dentin formation. This particular calcific deposit is always attached to the dentin, immediately under the site of irritation; and, if produced in a limited amount only, affords a natural protection to the pulp. The causes of secondary dentin are many and varied. The stimulus may result from such external irritation as follows: 1. Exposed Cementum. 2. Abraded or Eroded Surfaces. 3. Cavities of Decay. 4. Metallic Fillings. 5. Gold or Porcelain Jacket Crowns upon ground-down vital teeth, etc. It is possible and oftentimes advantageous to so treat, stimulate and yet protect the pulp in cases of deep-seated cavities that a layer of secondary dentin will be deposited. I shall refer to this again in connection with the treatment of active hyperemia of the pulp. In those cases where the stimulus continues over a period of years, we are quite likely to find the pulp-chamber and root-canals filled with secondary dentin. The diagnosis and treatment of this condition is unimportant unless untoward symptoms arise indicat- ing an acute apical pericemental involvement or neuralgia, in which case the pulp should be removed. The radiograph here is an in- valuable aid in arriving at a correct diagnosis. The removal of the pulp in these cases is often a difficult problem, for neither cocain hydrochlorid nor arsenic trioxid will affect pulps thus diseased in the usual way. It is frequently necessary to resort to conductive or interosseous anesthesia or to the administration of nitrous oxid and oxygen in order to remove these pulps without pain. Many an obscure case of neuralgia has this condition as its greatest etio- logical factor. This will be referred to again in detail under the 302 CONSTRUCTIVE DISEASES 303 Diagnosis and Treatment of Neuralgia. The author has had many cases in his practice where the canals were nearly and in some instances completely obliterated without any untoward symptoms being manifested. Such a case is illustrated in Fig. 6. In this case I desired to insert a bridge. On opening into the third molar and second bicuspid, which teeth were to be used for the abut- ments, we were unable to find any canals in the bicuspid and only a small lingual canal in the molar. The radiograph confirmed Fig. 6. the clinical findings. The patient gave a history of having had an operation for abscess of the frontal sinus and both antrums about ten years previous. The bridge was inserted in January, 1909, and has given no trouble since. PULP NODULES ■ Pulp nodules are calcific bodies of varying shapes and sizes, supposedly the result of secretion, and occurring within the pulp, rarely, if ever, being attached to the dentin. They are found more generally in middle-aged or elderly patients whose teeth have been subjected to that continued irritation the source of which was mentioned, as an etiologic factor in the formation of secondary dentin. Black, however, observes that pulp nodules may, and fre- quently do, form in other teeth of the same denture which are not directly involved in the irritation; and that irritation of the pulp of one tooth very frequently causes a general hyperesthesia of the pulps of all the teeth in that mouth ; especially is this true of that type of individual classed as neuralgic. The diagnosis of pulp nodules is not always a simple matter. The symptoms are of the subjective variety, and the radiograph does not always confirm the suspicion. Moorehead, Raper, and others have reported cases where pulp nodules are distinctly shown 304 PRACTICAL DENTAL THERAPEUTICS in the picture. The author has recently observed several such cases. On opening into the tooth the nodule was found to be present. In Fig. 7 is shown the best specimen of a pulp nodule that I have ever seen. The tooth is a lower third molar and was extracted because it was causing more or less trouble. There is but slight mechanical abrasion and no other known cause for the pathologic Fig. 7. condition. Fig. 8 shows a pulp nodule nearly one-quarter of an inch long which fits the canal as perfectly as a pea fits the pod. The tooth for years had carried an ill-adjusted gold shell crown, which had been placed without devitahzation and the proper trimming of the root. In the illustration also are shown several nodules of vary- ing shapes and sizes, such as are commonly found in practice. The 'ft.' tei* Fig. 8. following five illustrations are from Dr. Howard R. Raper, of Indianapolis, a dental radiographer, whose opinion I value highly. His description follows: "Fig. 9. The upper arrow points to a pulp nodule in a lower first molar. The radiograph is by Pfahler, of Philadelphia, and I have no rehable history of the case. The radiograph would lead me to believe that the pulp-chamber has been opened up and much of the dentin cut away from about the nodule; hence the latter can Fig. 9. Fig. 10. Fig. II. Fig. 12. Fig. 13 CONSTRUCTIVE DISEASES $0$ be seen much more clearly than any other I have ever seen in a radiograph. "Fig. lo. In this case the upper third molar is missing. A pulp nodule is seen in the pulp-chamber of the upper second molar. This molar has not been opened as yet, nor will I advise the operator to open the tooth until I have made another radiograph to verify the findings in the 'first one. The case is one of neuralgia with an obscure etiology and a history of pulp nodules having been found in other teeth. I am, therefore, strongly of the opinion that the shadow seen in the radiograph is a pulp nodule. The radiograph shows also a faulty canal filling in the lower molar — a condition capable of causing pain. The treatment of the lower molar, however, has failed to give rehef , which leads me to believe that the neuralgia is due to the pulp nodule. "Fig. II. This is a case from the practice of Dr. M. L. Rhein, of New York) and shows a pulp nodule in an upper lateral incisor with an abscess at the end of the incompletely formed root. The diagnosis was verified by removing the nodule. "Fig. 12 shows a shadow in the lower first molar which might be mistaken for a pulp nodule. The shadow is a small amalgam filHng on the buccal near the gingival line. "Fig. 13. These negatives show nodules in all four lower in- cisors. The nodules in the central incisors extend practically from chamber to apex. The teeth have been extracted and dissected and the diagnosis verified. Though these nodules can be seen in the negatives it is improbable that lantern slide cuts made from the negatives would show them. "There is no longer any doubt as to whether or not pulp nodules can be radiographed. They can be, but it is difficult, I would never make a diagnosis from one radiograph. I would make at least two." The treatment of teeth containing pulp nodules which are causing neuralgia or other disturbances is practically the same as that of secondary dentin, which involves the removal of the pulp, and will be considered later. DESTRUCTIVE DISEASES It is often a difficult problem for the conscientious operator to decide upon a method of procedure that will best conserve the interest of the patient. Especially is this true when we are trying to deter- mine whether a diseased pulp should be saved or whether it would be best for all concerned to destroy and remove it. It is so easy in most cases to anesthetize or devitalize the pulp that many dentists resort to this method of treatment in nearly all diseases of the organ. When we consider the fine and tortuous canals which we so frequently encounter and the difficulty, both of removing the dead tissue from such canals and of thoroughly filling them subsequently, it is a ques- tion whether or not the best interest of the patient is conserved by adopting this method as the general practice. While it is true, generally speaking, that pulps which are diseased beyond the condition of active hyperemia should be removed, it is also true that this organ has been destroyed far too ruthlessly in the past. The work of Rosenow, the observations of Hunter, Murphy, Billings, the Mayos, Crile, and others of the medical profession, and the investigations of Grieves, Rhein, Gilmer, Price, Logan, Moorehead, HartzeU, and others of our own profession, along the line of periapical infections and the systemic results, should teach us to conserve the dental pulp in every case where it is practicable and consistent with good dentistry. Thousands upon thousands of nor- mal pulps have been sacrificed for no other reason than that the dentin of the tooth was h3rpersensitive. When we think of the diffi- culty — not to mention the carelessness — under which these pulps are often removed, and of the frequent periapical infections resulting therefrom, we behold a sad spectacle, indeed! I have never heretofore, nor do I intend now, to plead for the life of the pulp when the reading of the clinical symptoms clearly indicates its removal; but I do mean to say that in all cases an effort should be made to determine as nearly as possible the exact patho- logic condition, and our decision should be based upon these findings. From the viewpoint of the diagnostician there are few subjects of greater importance than those of hyperemia and inflammation of the dental pulp. 306 DESTRUCTIVE DISEASES 307 Diagnosis of Active and Passive Hyperemia, and True Pulpitis. — In the pulp tissue, as in all living tissues of the body, we may have two kinds of hyperemia — active, or arterial, and passive, or venous. The former is defined as an excessive amount of blood in the arteries and the latter as an excessive amount of blood in the veins. Active hyperemia is due to a determination of blood to a given part as the result of reaction to an irritant, and as long as it remains without an excessive immigration of the white blood corpuscles, it is active, or arterial hyperemia. The cause of passive hyperemia is different. Here the blood may be held back by some obstruction in the veins which prevents the return of blood to the heart. Inglis says: "The backing up of the blood following venous obstruction produces ten- sion upon the vessels, followed by diapedesis of red corpuscles and exudation of watery fluid — the condition of edema. In inflamma- tion arterial h3^eremia appears as the first stage, followed by a collec- tion of leucocytes along the walls of the small veins, and the immigra- tion of some into the perivascular tissue. As this eventually leads to stoppage of the blood current, and even to stasis, the condition is essentially a venous hyperemia. Accompanying the immigration of leucocytes is an exudation of lymph, highly coagulable in character, which distends the lymph spaces in the tissue and produces the characteristic swelling." The thing of special interest here is that in inflammation or even in venous hyperemia certain blood elements escape through the temporarily dilated vessels into the perivascular tissue, which becomes coagulated, and when the tissue involved is the dental pulp, which, as we have learned, is without lymphatics, this coagulation of the fluid elements of the blood means death. The procedure of many practitioners when an aching tooth presents involving the pulp is simply to find out whether the latter is dead or alive. If alive, cocain hydrochlorid or arsenic trioxid is generally applied, or else the tooth is treated tentatively by placing cotton dipped in oil of cloves or some other soothing remedy in the cavity, and the patient is dismissed without making any effort to ascertain the condition of the pulp — whether it is in the stage of active hyperemia or passive hyperemia or true inflammation. If, on the other hand, the pulp is found to be dead, the tooth is too frequently treated by opening up the pulp chamber and placing therein a pledget of cotton dipped into the most convenient remedy at hand, leaving the cavity un- sealed for fear of causing septic pericementitis or an acute alveolar abscess, and making no further effort to ascertain whether the pulp has been infected by pyogenic microorganisms, producing pus on 3o8 PRACTICAL DENTAL THEEAPEUTICS the exposed surface or, as sometimes occurs, within the substance of the tissue, or whether the germs inaugurating the changes are of the saprophitic variety causing pulp decomposition with gaseous end-products. It is highly essential, therefore, when a patient presents with an aching tooth, that we take the time and trouble to determine not only whether we have a Hve or a dead pulp with which to contend, but, if the pulp is aHve, whether the condition is one of active hyperemia only or passive hyperemia or inflammation; or, if the pulp is dead, whether the condition is a so-called septic pulp with pus formation (pulpal abscess) or one of true gangrene with gase- ous end-products. To confirm our diagnosis the tooth should be iso- lated and kept dry, preferably with the rubber dam, and a careful examination made. On no other basis can rational therapeutics be practised. Differential Diagnosis. — It is generally a simple matter, by asking a few questions and observing conditions, to differentiate between the pathologic conditions of a vital pulp sufficiently to determine whether the pulp had better be saved or destroyed. In acute active hyperemia the pain occurs only when the irritant is applied, and subsides almost momentarily without treatment. Logan states that ''active hyperemia exists in a pulp when the pain begins with a known irritation, lasting only a few moments, or min- utes at the most, and subsiding without treatment and not starting again until the application of another known irritant is made." Treatment of Active Hyperemia. — The treatment of this con- dition consists in pr£)tecting the tooth from the irritant which caused the disease. If a cavity exists which is causing the trouble an ano- dyne remedy is indicated. One treatment with phenol compound, or other remedies possessing similar properties, should cure a case of active hyperemia due to caries of the tooth. At the second sitting, if the case has a favorable history, the rubber dam should be ad- justed and the dressing and carious dentin removed, after which a base of cement may be inserted, the cavity prepared, and the tooth filled. In those cases where the cavity is deep and encroaches upon the pulp, and where the removal of the softened dentin practically or actually exposes the organ, it is necessary, in order to save the pulp, to cap and protect it. This brings us to a consideration of pulp capping. Factors to be Considered in Pulp Capping. — There are several important factors to be considered, and upon these will largely de- pend the success or failure following an attempt to save the pulp after it has actually been exposed. In an accidental exposure in the DESTRUCTIVE DISEASES 309 preparation of a cavity, the chances of saving the pulp, provided the injury has not been too great, are far more favorable than if the pulp had been exposed by the necessary removal of the carious dentin. Our success will also depend in no small degree upon the condition of the pulp as well as upon the general condition of the mouth of the patient in which the exposure occurs. In cases of hyperemia of the pulp an effort should be made to determine whether it is active or passive hyperemia, and where pulpitis is present our prognosis will be governed largely by ascertaining whether the pulpitis is partial or complete, or of the nonseptic or septic variety. If there is con- gestion or any evidence of degeneration of the structural compo- nents of the pulpal organ itself, it would be futile to attempt to cap it. Logan is of the opinion that most pulps, the exposure of which has been brought about by caries, have undergone sufficient inflammatory changes to cause their ultimate death, even when carefully capped. Any attempt to permanently save an exposed pulp in the mouth of a patient who is suffering from some systemic derangements inter- fering with the general circulation, thus lessening vital resistance, would doubtless result in failure also, for in such cases the pulp would fail to receive from the blood supply the necessary elements for the restoration of its functional activity. The general condition of the mouth itself and the care it receives daily from the patient, are essential factors to be taken into consideration before proceeding to cap a pulp; for Hopkins, of Boston, in a carefully conducted series of experiments to ascertain the difference in virulency of certain pathogenic bacteria in different mouths, and in the same mouth under differing conditions, proved that not only did the germs proliferate more rapidly in neglected and uncared-for mouths, but their patho- genic properties were greatly increased. Exceptional Cases of Exposure. — There is one class of cases of pulp exposure which frequently present in a busy practice and in which it is our plain duty to make the attempt to restore the organ to its normal function, even though the conditions for doing so are not altogether favorable. I mean here those cases in the mouths of young patients where the pulp is exposed from decay and the roots of the tooth have not been fully developed. Every effort should be made to cap such a pulp, provided the cUnical symptoms are at all favorable, and thereby save it, if for only a year or two; for experi- ence has demonstrated that to remove the pulp and properly close the large openings in the ends of the roots is, at best, a difficult pro- cedure; that a tooth in this condition, thus treated, is usually a source of infection and its usefulness generally of short duration. 3IO PRACTICAL DENTAL THERAPEUTICS In another class of cases the author also believes that we are justi- fied in capping the pulp. For instance, in those cases of exposure where for certain reasons it is desirable to save^ the tooth, and on which it would be difficult to adjust the rubber dam, aseptically remove the pulp, and thoroughly fill the canals. I wish to state here, however, that I do not mean to infer that a pulp should be capped in an anterior tooth, because of the liability of the tooth- structure discoloring after the pulp has been removed. This phase of the subject will be referred to in detail subsequently under the Preservation of the Color of the Tooth in Pulp Removal. From the foregoing, then, it should readily be understood that no set of rules can be given, the application of which will surely lead to success. Every case must be studied and treated according to the pathologic conditions found and the operator's best judgment, after having taken into consideration all these various factors. Therapeutics of Pulp Capping. — There are several methods of capping the pulp, each differing in minor details, such as the use of various cements, gutta-percha, concave metallic disks, etc., etc. The reader's attention will first be directed to the general precautions to be taken in following the different methods of capping; after which one method will be described in detail which has proved successful in the author's practice. By this I do not mean to convey the idea that all pulps which I have attempted to save have been rehabiHtated to their functional activity — many have not; however, a sufficient number of those thus treated have remained quiet, and proved years later to be vital, to justify making the attempt where the case demands it. Precautions. — The precautions to be observed in following any method are: 1. By the use of an anodyne, the hyperemic pulp, if in this con- dition, must he restored to normal before the final capping. 2. The dentin overlying the pulp must he thoroughly sterilized. It should be noted here that the usual perfunctory method of steriliz- ing the dentin by simply applying a germicidal solution to the cavity for a few moments does not sterilize to the degree necessary for suc- cessful results. The lack of thorough sterilization has, without doubt, been the chief cause of failure in many instances. The accuracy of this statement will be seen when we remember that our greatest success has followed the capping of pulps which have been accidentally exposed with a bur or instrument in preparing a cavity, although, in most cases, greater mechanical injury had been caused than when the exposure was due to caries or the removal of carious, dentin. DESTRUCTIVE DISEASES 31I 3. Pressure in applying the material for capping, or the cement which covers the capping, must he avoided. Technic. — ^After breaking down all overhanging edges of enamel and removing as much of the debris and softened dentin as can be done without pain or injury to the pulp, the cavity should be flooded with a mild, nonirritating, antiseptic solution, previously heated to the temperature of the body. For this purpose the author suggests the use of one of the following remedies: I^ — Phenolis, fSss (2.0 mils) \ Aquae menthae piperitse, fSvj (180.0 mils) — M. Sig. — Use wherever a mild, nonirritating antiseptic solution is indicated. I^ — Alcoholis, 3j (4-0 mils) Aquae cinnamomi, f§vj (180.0 mil) — M. Sig. — Use as a spray. These solutions can be used as a spray or with a water syringe before appl3dng the rubber dam, thus adding comfort and cleanliness to the operation. The excess can now be absorbed from the cavity with cotton and the dam adjusted. By using some obtunding rem- edy and a sharp spoon excavator, or oftentimes a large round bur in the engine, the carious dentin can be removed. If, however, the thorough removal of all the discolored dentin would make a large exposure, it is best to leave the layer overling the pulp and depend upon the sterilizing agent, rather than to jeopardize the life of this organ by the injury thus produced. The delicate pulp tissue will not tolerate much abuse and remain quiet, therefore, if it is injured to any great extent it had better be removed at once. The dentin can now be steriUzed by sealing in the cavity, for a few days, the following remedy which is not only germicidal in action, but possesses marked anodyne properties as well: I^ — Mentholis, gr. xx (1.3 Gm.) Camphorae gr. xl (2.69 Gm.) Phenolis, (U.S.P.) f 3iij (12.0 mils)— M. Sig. — Use as directed. For convenience this remedy has been called phenol compound. It is best to seal with a veneer of quick-setting cement, previously filUng most of the cavity with cotton, thereby avoiding pressure and facilitating the subsequent removal of the dressing. By this means the dentin can be thoroughly sterilized, and the pulp, if at all hyper- emic, as it is likely to be, will return to its normal condition. Thymol has a peculiar but favorable action on animal tissue and for this reason it was formerly incorporated in the above pre- 312 PRACTICAL DENTAL THERAPEUTICS scription. The later formula for phenol compound contains cam- phor instead of thymol, which enhances the anod3aie property of the remedy. At the next sitting, the case giving a favorable history for the interim, the dam should always be applied,- the teeth included sterilized, and the previous dressing carefully removed, when the exposure and dentin immediately over the pulp can be gently covered with a thin paste made by mixing thymolized calcium phosphate with oil of cloves or eugenol. A prescription for the thymolized calci'am phosphate follows: I^ — Thymolis, gr. x (0.6 Gm.) Calcii Phosp. ppt. (purificata), oj (32.0 Gm.) — M. Sig. — Use as the powder for making paste. The paste should be placed on one side of the cavity and gently coaxed over the exposure in such a manner as to exclude the air. I desire to emphasize the importance of covering the entire dentin im- mediately over the pulp, as well as the exposure, with this antiseptic and non-irritating paste. By this means we prevent the phosphoric acid of the cement, used to cover the paste and to temporarily fill the cavity, from irritating the pulp. It should be understood that this paste is only intended as a nonirritating, antiseptic covering for the pulp. 1 1 does not set. To bring about "setting," it would be neces- sary to use a substance for the powder and an acid for the liquid which react upon each other. This would cause irritation, thus defeating our object. It is best, as intimated here, to fill the entire cavity with cement and wait for a few months or perhaps a year before inserting the permanent filling or inlay; and even then we should be certain that the vitality of the pulp has been retained, for frequently exposed pulps, under the most careful treatment, gradually die without any objective symptoms. The fact that the tooth has given no trouble should not be taken as evidence that the pulp is alive, for the reverse is too often true — the drugs in the capping material keeping the tis- sue, though dead, from undergoing decomposition for months and sometimes for years. Every advantage should be taken to prevent all possible means of subsequent irritation to the pulp. For this reason the author uses precipitated calcium phosphate instead of calcined zinc oxid, which latter substance is recommended by many writers. The powder (largely zinc oxid) which comes with a package of cement is supposed to be chemically pure. Those who are familiar with the science of chemistry, however, know that arsenic is found associated in Nature with many of the metals, among which is zinc; and, while it can be DESTRUCTIVE DISEASES 313 done, it is difl&cult to obtain these metals or their oxids free from arsenic. It is well in those cases where the pulp is not quite exposed, to add a small amount of either aristol or europhen to the paste. These are iodin compounds and are used as substitutes for iodoform. They act as a mild stimulant to the pulp, thus causing secondary dentin to be deposited, when we have Nature's protection. Both are tasteless, practically without odor, and insoluble in water, but soluble in the oil used as the vehicle for the paste; therefore, only a small amount should be added, for it is possible to overstimulate the pulp, with the result of bringing about a pathologic rather than a physiologic condition. I desire to emphasize the importance of studying carefully the conditions as found in each case; and to say that the opportunity here for exercising good judgment is very great, and that there is a satisfaction in realizing, whether we succeed or fail in our effort to save the pulp, that we did our duty as we saw it. Treatment of Passive Hyperemia and True Liflammation.— As far as therapeutics is concerned, it is of little importance to know whether the pathologic condition of the pulp is passive hyperemia or true inflammation. In either case we have transudation of the fluid elements of the blood and diapedesis of the red corpuscles occurring, and this means death ultimately. In passive hyperemia the pain is more constant than in active hyperemia, and may start without the application of a known irritant. In inflammation the pain is continuous and of a boring character, or it may be lancinat- ing, and is frequently described by the patient as a ''jumping tooth- ache." When the reading of the symptoms indicates either of these conditions, our therapeutics differs from that prescribed for active hyperemia, for here, as has been previously stated, the pulp must be destroyed. THE REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT GENERAL CONSIDERATIONS Embryologists claim that when the roots of a tooth are fully developed, the pulp has no further function to perform. If this theory can be accepted as correct, and I think that it is quite well established, it would appear from the large percentage of failures following the most careful methods of pulp capping that the safest and, therefore, the best practice would be to destroy the vitality and remove the pulp in all cases where this deHcate and susceptible tissue has been previously irritated for any great length of time, un- less, as explained under Exceptional Cases of Exposure (p. 309), there is some special reason for attempting to restore the organ to its functional activity. From sad past experience the author has been led to adopt this general practice. By this I do not wish to convey the idea that it is advisable or necessary to injudiciously or ruthlessly destroy pulps, for this is not the case. As has been previously emphasized, it is the plain duty of every dental practi- tioner to save the pulps of teeth, if it can be done with any reasonable degree of success. There are many conditions, some of which are pathologic and others are not, which necessitate the removal of the pulp, such as: 1. Dental Caries. — In those cases where dental caries has en- croached upon the pulp to the extent of producing passive hyperemia or true inflammation, especially the latter disease. The pulp here oftentimes has been invaded by pathologic bacteria, and frequently the tissue has absorbed poisonous ptomains or toxins. This is, per- haps, the most prolific source of pulp irritation, 2. Mechanical Irritation. — This is due to such cases as abrasion, thermal changes, close proximity of metallic fillings, injudicious regulating, excessive grinding, etc. 3. Calcific Deposits. — This includes pulp nodules, partially cal- cified pulps, and secondary dentin. These calcific deposits result from slight but continued irritation of the pulpal organ. 4. Crowning Teeth and Filling Large Cavities. — It is usually diffi- cult to grind a vital tooth sufficiently to adjust properly the band for a crown without irritating the pulp and thus endangering its life. Sometimes in filling teeth it is advisable to remove the pulp in order to properly anchor a large ffiling or inlay. 314 REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 315 5. Pyorrhea Alveolaris. — Frequently in treating this disease, where the teeth are acutely sensitive or where the pockets are deep and the infection in the apical area has left the pulp in a low state of vitality, the best results can be accompHshed by removing the organ, and surgically eradicating the pocket. General Factors to be Observed in Removal of Pulp. — Having considered all of the conditions and decided that the removal of the pulp is indicated, the method by which this can be accomplished with the least inconvenience to the patient and to the operator is the most important consideration. Whatever method is employed in the re- moval of pulps from teeth and the subsequent treatment, there are at least three factors to be observed, viz. : 1. Establish and maintain asepsis in performing the operation. 2. Preserve the color of the tooth. 3. Thoroughly fill the root. There are two general methods employed in the removal of pulps — anesthetization and devitalization. I. ANESTHETIZATION In the author's opinion a method of removing pulps from teeth, which is satisfactory to both patient and operator, all things con- sidered and conditions being favorable, is to anesthetize the tissue by the use of local anesthetics in solutions of various strengths. The solutions are forced or carried through the dentin and into the pulp by means of pressure or the electric current. In exceptional cases conductive or interosseous anesthesia may be employed. 1. PRESSURE ANESTHESIA.— By pressure anesthesia is meant the process of anesthetizing the pulp by forcing solutions of local anesthetics, usually cocain hydrochlorid, into the tissue by means of pressure. The pressure is applied either by using un- vulcanized rubber or gutta-percha and a blunt instrument, or by specially devised instruments for this purpose. There are many such instruments on the market; and while they are often an aid in accomplishing the ultimate result, they are not an absolute neces- sity. Sterilization. — The rubber dam should be employed in every case where it is possible to adjust it, and the teeth included sterilized. In cases where the dam cannot be adjusted, it would doubtless be best to remove the pulp by the devitalization method, to which reference will be made later, for in using the method under consid- eration care must be taken to prevent pericementitis following the 3l6 PRACTICAL DENTAL THERAPEUTICS operation; and one of the precautions to be observed in preventing this result is to thoroughly sterilize the cavity before applying the pressure. It should be remembered that the majority of canals which contain live pulps are sterile, generally speaking, and if they become septic at any time before the root is filled, it is the fault of the operator ; hence the importance of always adjusting the rubber dam, using sterile instruments, and having in a convenient and conspicuous place an antiseptic doily on which to wipe the blood and dry the instruments used. Attention is again directed to the fact that the usual custom of applying coagulating agents, such as phenol, cresol, etc., to the cavity for a few seconds does not sterilize the dentin to the degree desired. The best results are accompUshed by employing germicidal agents which are soluble in water. In cavities where the decay is not too deep, the dentin can be sterilized by the use of a lo per cent, solution of formaldehyd to which 5 per cent, of sodium borate (borax) or sodium carbonate has been added. Where the decay is near the pulp this solution is liable to cause pain, in which case the same result can be accomplished by the use of a i : 500 solution of mercury bichlorid or a 1 : 200 solution of sublamin. In using the latter solutions the pliers on which the remedy is applied should be wiped immediately on an antiseptic doily to prevent the mercury from acting upon the instrument. One of the best solutions with which to chemically sterilize the dentin, especially in those cases where the cavity has previously been filled, the tubuli are closed, and, perhaps, there is secondary dentin, is a 25 per cent, solution of sulphuric acid. Cook recommends using pure sulphuric acid for this purpose. The solu- tion can be applied to the floor of the cavity, being careful not to get the agent on the crown of the tooth. After a few minutes the excess can be neutralized with a solution of sodium bicarbonate. After the dentin is sterilized the cavity should be desiccated with warm alcohol and gentle heat, when we are ready to use the anesthetizing solution. Before taking up the technic of this method, however, I desire to again emphasize the importance and necessity of cavity sterilization. In our discussion later of the devitalization method, it will be pointed out that the carious and infected dentin can be completely and painlessly removed after the devitalizing agent has been appHed, thus mechanically sterilizing the cavity; but in the anesthetization method the infected dentin is sensitive and cannot be removed without unnecessarily producing pain. The dentin in this case must, then, be sterilized by chetnic means, for to force the anesthetizing solution through the dentin without previously REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 317 sterilizing it, means the forcing of microorganisms and, perhaps, poi- sonous ptomains or toxins, into the pulp tissue and many times into the tissue surrounding the apical end of the root, for it is difficult to force the solution to, and only to, the apex; thus too much pressure and the lack of thorough sterilization constitute a proUfic source of pericementitis following the removal of pulps by this method. For the same reason, a pulp which is exposed by caries, and, therefore, undoubtedly infected, had better not be removed by pressure anesthesia. The Solution. — With the cavity thoroughly steriHzed we are now ready to use the anesthetizing solution, which should be made at the time. For this purpose the crystals, previously powdered, or flaked cocain hydrochlorid should be used as the base, and freshly distilled or boiled water as the vehicle. In my own practice I use "cocain points," which are compressed points or cyHnders of pure cocain hydrochlorid containing ^2 grain (.005 Gm.) each, as the base and my regular local anesthetic solution as the vehicle for making the stronger solution. A prescription for the regular local anesthetic solution here follows: I^ — Cocainae hydrochloridi, gr. v (0.3 Gm.) Sodii chloridi, gr. j (0.06 Gm.) Phenolis, m. ij (0.13 mil) Aquae menthse piperitae, fgj (30 mils) — M. Sig. — Use as a local anesthetic for hypodermic injections. There are many advantages in using the anesthetic agent in cylin- der form. The exact amount of the drug used is known, the points are readily soluble and, in many cases, they can be conveniently placed in the sterile cavity and dissolved therein, either in the serum of the blood, if an exposure exists, or in the vehicle used for this purpose. There is no advantage in using the above solution rather than dis- tilled or boiled water or freshly prepared peppermint water, except that the solution is always at hand in a convenient container and is sterile. Sterile physiologic salt solution is an excellent vehicle for making the anesthetic solution. The thumb and forefinger with which cotton is to be wrapped around the broach should be sterilized by dipping a large pledget of cotton in 10 per cent, formaldehyd, or i : 500 mercury bichlorid, or 1:200 sublamin solution, and rolling this between the thumb and finger. A cocain point or a small amount of the flaked cocain hy- drochlorid is now placed on a clean glass slab and a pledget of cotton, dipped in the vehicle selected, a few drops of which have previously been placed on one end of the glass slab or in a clean glass watch- 3l8 PRACTICAL DENTAL THERAPEUTICS crystal or other container, is gently placed in contact with the alka- loidal salt, when the latter readily dissolves, making a strong solution. It is never necessary to make a saturated solution, for oftentimes better results will be obtained, especially if the solution is to be forced through the dentin, if the strength of the solution approximates only 4 or 5 per cent. If an exposure exists, as stated above, the point can be placed directly in contact with the pulp and be dissolved in the blood-serum. Pressure. — The cotton thus saturated is placed in the cavity as nearly over the pulp as possible. A piece of unvulcanized rubber which will approximately fill the cavity is selected and passed through the flame. There are two objects in doing this: It sterilizes the rubber and also makes it more pliable, in which form it conforms readily to the cavity of the tooth. The rubber is now placed in the cavity, and by means of gentle but firm pressure with a suitable blunt instrument the solution is forced through the dentin and into the pulp. If there is any evidence of pain as the pressure is applied, it should be stopped for a moment, but never released. The slight pain is only momentary and is an indication that the solution is being confined under the pressure, which is essential for the success of this method. It may be necessary in those cases where there is considerable den- tin between the cavity and the pulp to make two or three applications before the pulp is reached without pain, after which one application should complete the thorough anesthetization of the organ. After the first application a small depression can be drilled into the dentin toward the pulp, in which the solution can subsequently be placed, thereby aiding materially in confining the solution under the pressure. When an exposure exists, it requires but little pressure to anesthetize the pulp. In these cases the cocain point can be placed in the cavity near or over the exposure and the pulp gently pricked with a sharp explorer, causing it to bleed; this, if done carefully, will produce very little pain. The blood-serum will dissolve the cocain hydro- chlorid, when pressure can be applied and the pulp anesthetized. In doing this, however, there is greater danger of forcing the blood into the tubuli of the dentin of the crown of the tooth, thereby making it more difficult to remove the blood. Care should also be taken not to force the solution any further than is necessary for the painless removal of the pulp, and it should here be again noted that cocain is a general protoplasmic poison, and if even weak and sterile solutions are forced past the apices of the roots pericementitis is almost sure to follow. REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 319 Confining the Solution Under Pressure. — In removing pulps by pressure anesthesia without employing instruments devised for this purpose, the best results are obtained in cases where there are four walls to the cavity, for in this condition the solution is easily con- fined under the pressure. In proximo-occlusal cavities, the missing wall can be built temporarily with gutta-percha or cement. This is seldom necessary, however, if, in packing the rubber in the cavity, care be taken to cover the gingival wall first and thus seal at this point, then working the rubber over the occlusal and gradually creating the pressure. Whatever means are adopted for the purpose of confining the solution, we must avoid having the solution escape at the gingival margin of the cavity and thereby be forced into the gum tissue and pericemental membrane. The cause of much pericementitis following this method of removing pulps can be traced to carelessness or ignorance in this regard. As stated elsewhere, there are many ingeniously devised instru- ments on the market, the use of which is often a material aid in con- fining the solution under pressure and forcing it through the dentin. The same precautions should be observed in using any of these in- struments as have been emphasized in the application of pressure by other means. Opening the Pulp Chamber to Expose Canals. — When the pulp is anesthetized, the pulp chamber should be opened into in such a manner as to expose the canals. This is best accomphshed with a Fig. 14. — This radiograph shows that the dentist, in opening into the lower first molar, drilled through the floor of the pulp chamber and exposed the tissue between the bifurcated roots; and, as a result, an abscess subsequently developed. The case was treated by sterilizing and stimulating the necrotic area between the roots with phenol- sulphonic acid, subsequently flowing eucapercha compound over the puncture and packing firmly with warm base-plate gutta-percha. large round or inlay bur by means of which the entire roof of the chamber can be obHterated. A bur suggested by the author for this purpose is simply a large inlay bur with the end rounded. In opening into the pulp chamber of the molar teeth care should be taken not to disturb the floor or walls of the chamber; for by so doing we are hable 320 PEACTICAL DENTAL THERAPEUTICS to drill through the bifurcation or the mesial or distal surface of the roots. Even if such disastrous results do not follow the destruction of the floor or walls of the chamber, it at least adds to the difi&culty of entering the canals with a broach. (See Fig. 14.) While we are never justified in drilling unnecessarily for the purpose of freely expos- ing the canals, it is, if necessary, far better to weaken the crown of the tooth somewhat by this means rather than leave a portion of the pulp in an inaccessible canal which may decompose and subsequently cause an infection in the periapical area. Selecting and Testing Broaches. — The selection of a proper broach is an important matter. Every broach should be tested be- fore entering the canal. This can be done by bending it in various directions. If the broach is weak in any particular place it can be detected by this means; thus we avoid breaking the broach in the canal, the removal of which is often a difficult procedure. Many good operators claim to be able to remove all pulps by using a smooth, three-cornered broach on which a few threads of cotton are wound. Others use twist or spiral broaches. In all large canals the author has had the most satisfaction from the use of a barbed broach. The broach should be gently worked along the side of the canal as far as it will go without using too much force, twisted once or twice to en- tangle the pulp, and then withdrawn. By this means the pulp can be removed from large canals in its entirety. In inserting the broach into the canal, care should be exercised to avoid pushing the tissue before the broach and thus pack it into the apical area, where it is difficult of removal. Many root-canals have been imperfectly filled and abscesses subsequently developed, because of the fail- ure to remove all of the pulp tissue at the time it was anesthetized or devitaHzed. Control of Ordinary Hemorrhage and Removal of Blood. — In the removal of Hve pulps by the anesthetization method, there nec- essarily wiU be more hemorrhage than in those cases where the pulp is devitaHzed before attempting to remove it. However, the control of hemorrhage is not as difficult a procedure as many writers have led us to believe. In most cases the hemorrhage, if undisturbed, will be checked by Nature's method in a few minutes, after which the blood in the cavity and canal should be thoroughly removed. I desire here to emphasize the importance of removing the blood. One of the factors to be observed in extirpating pulps from teeth and the sub- sequent treatment, is to preserve the color of the teeth. The cause of many teeth darkening after the pulp has been removed can be traced directly to the failure to remove the blood from the dentin of the REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 32 1 crown of the tooth. The far too prevalent practice of wiping out the bloody canal with a solution of hydrogen dioxid, bhndly thinking the blood can be removed by this means, cannot be too strongly con- demned. The hydrogen dioxid simply decomposes the blood within the tooth-structure, oxidizing the iron of the hemoglobin ; and the gases evolved in the decomposition force this pigment into the tubuh, which, if left (and it is dij6&cult to remove it), will cause the tooth to darken in almost every instance. Therefore, we should avoid forming within the tooth-structure a pigment which we know will discolor teeth. The color of a tooth does not depend upon the life and vitality of the pulp, hut upon the array of colors in the dentin which are reflected through the nearly colorless and transparent enamel. If, then, these colors are not changed by our failure to remove the blood or by the use of stain- ing remedial agents in the treatment subsequent pulp removal, the tooth will not discolor. To remove the blood from the canal, alcohol can be used, or even better than this agent is Nature's greatest solvent, water. The water should, of course, be sterile, and the same specimen can be em- ployed here as was used in making the anesthetizing solution, i.e., freshly distilled or boiled water, or peppermint water to which two minims (0.12 mil) of phenol have been added to the fluidounce (30.0 mils). Sterile physiologic salt solution is perhaps the best solution to use for this purpose. By this means the blood can be completely removed, not decomposed in the canal and forced into the structure of the tooth. Small Canals. — There are many canals so small and tortuous that even a fine broach will not readily enter, to any depth at least. In these cases, after the hemorrhage from the larger canals has been checked and the blood removed it is well to stop the mouth of each with cotton or temporary stopping, when the pulp tissue in the small canals can be disorganized by the use of strong solutions of mineral acids or alkalies. The author formerly used a paste of sodium dioxid and dehydrated (absolute) alcohol, placing the paste in the pulp chamber over the small canals, and working it down as far as possible with a smooth broach. The alcohol gradually evaporates, when the sodium dioxid can be decomposed into oxygen and caustic soda by placing a pledget of cotton in the cavity moistened with dis- tilled water. After the reaction has taken place, the alkali can be neutralized with a weak solution of sulphuric acid (2 per cent.). This process can be repeated until the desired end is attained. A more convenient preparation to use here is a saturated solution of potassium or sodium hydroxid. There are other means by which the 32 2 PRACTICAL DENTAL THERAPEUTICS same results can be accomplished, such as the use of phenolsulphonic acid, a 30 per cent, solution of chemically pure sulphuric acid, strong solutions of potassium or sodium hydroxid, or a mixture of metallic potassium and sodium (Schreier's paste). For reasons mentioned later under the Treatment of Pulpless Teeth, the author now uses phenolsulphonic acid. These same agents can be used to advantage for the purpose of disposing of a remnant of a pulp in larger canals. It is not safe to anesthetize this remnant by means of pressure. The only cases on record, to my knowledge, where toxic symptoms have resulted from the removal of a pulp by pressure anesthesia, followed an attempt to anesthetize a remnant of a pulp or to make a second application of the anesthetizing solution. After-treatment. — After the pulp has been removed and the canals dehydrated with modified alcohol and heat, an anodyne treat- ment is indicated. For this purpose such drugs as phenol, oil of cloves, or eugenol can be employed. The author suggests here euca- lyptol compound. In using any of these remedies, especially the last- named, it is best to insert dry cotton in the canal and then place a pledget dipped in the remedy in the pulp chamber and seal with temporary stopping and cement. The dry cotton in the canal will absorb the moisture from the apical end of the root and the anodyne remedy from the pulp chamber. There is an advantage in using the dry cotton, for it is almost impossible to completely dehydrate the canal at this sitting. If asepsis has been maintained in removing the pulp, all that is necessary is to keep the canal in this condition until the root can be filled; therefore, only a very small amount of the remedy should be used. The tendency here is to use too much with the frequent result of a mild active hyperemia in the pericementum. This condition, of course, soon subsides, but it is always best to pre- vent it when possible. The purpose of sealing the cavity with both temporary stopping and cement is to insure hermetic seaHng of the canal. Eucalyptol compound has no advantage here over other remedies suggested for the purpose except that, besides being an anti- septic, it also aids in the hermetic sealing. The heated stopping (good grade) is placed immediately over the eucalyptol compound dressing and it adheres firmly to the walls of the cavity; the excess is removed and the remaining portion of the cavity is filled with cement. When to Fill Canals. — The canals should not be filled at the sitting at which the pulp has been removed by pressure anesthesia, unless there be some exceptional reason for doing so. There are many good reasons why the canal should not be filled at this sitting: I. While it is our object to force the solution just sufficiently to REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 323 anesthetize the pulp, our main object is to remove the pulp absolutely without pain; and it is very difi&cult to force the solution to the end ©f the root without forcing it through the apex to some extent and anesthetizing the tissue in the periapical area. With the tissue anesthetized, we would have no guide as to when the root was thoroughly filled. 2. The tearing away of the pulp from its connection at the apex causes more or less irritation, and a few days should elapse to give Nature a chance to readjust the condition. The root-filHng would only serve at this time to further irritate the tissues. 3. Sometimes with the utmost care in removing the pulp, second- ary hemorrhage ensues with the formation of a clot in the periapical area, causing soreness, in which case greater comfort can be given the patient by the proper treatment through the root-canal than simply by counterirritation or ext-ernal treatment only. At the second sitting, the case giving a favorable, history, the canal should be filled, after having used phenolsulphonic acid as explained on p. 344 under Technic of Using Acid-Method. Excessive Hemorrhage.- — There are cases occasionally where Nature does not stop the hemorrhage as readily as we desire. In these exceptional cases the hemorrhage must be stopped by artificial means, even at the possible expense of producing pericementitis. Cauterizing agents are useful here. For this purpose 95 per cent, phenol or, what is still better, phenolsulphonic acid can be worked down into the canal against the injured and bleeding tissue, after which the acid should be neutralized with a solution of sodium bicarbonate (10 per cent.) and an anodyne treatment employed as usual. Where the above treatment does not produce the desired result, cotton satu- rated with a fresh i : 1,000 solution of adrenalin chlorid can be placed in the canal and with unvulcanized rubber forced into the tissue beyond the end of the root. This agent should only be used in extreme cases because of the soreness and injurious effect it is Hable to produce upon the tissues involved. Objections to the Use of Adrenalin Chlorid. — In this connection I desire to discuss the use of solutions of adrenaUn chlorid as the vehicle for making the anesthetizing solution, or the use of adrenahn chlorid and cocain hydrochlorid tablets for anesthetizing the pulp. The adrenalin chlorid has been suggested as a means of preventing hemorrhage. Now, it ought to be evident to anyone who has studied this subject that, to prevent hemorrhage by the use of any st5^tic or hemostatic agent, it is necessary to force the agent into the tissue from which the hemorrhage comes. Therefore, to get the effect of 324 PRACTICAL DENTAL THERAPEUTICS the adrenalin chlorid in removing pulps by pressure anesthesia, it is absolutely essential that the anesthetizing solution, which also con- tains the hemostatic agent, be forced through the apex and into the periapical area — the very thing we have been taught, from sad experi- ence, not to do. When we remember that the majority of pulps we are called upon to remove are those in which there is, or has been, more or less pulpitis, and when we remember also that pathology teaches that this condition is frequently associated with pericementitis, it is questionable whether or not we ought to prevent hemorrhage in re- moving pulps from teeth. For to permit the escape of blood from the hyperemic tissue at the end of the root is one of the best means of aiding Nature to readjust the abnormal to the normal condition. In case the primary hemorrhage has been prevented by the use of hemostatic agents, such as adrenalin chlorid, secondary hemorrhage is almost certain to follow with the formation of a clot, the absorption of which in the periapical area is an extremely slow and tedious- process. 2. CATAPHORESIS. — Cataphoresis, as has been elsewhere ex- plained, is a term appUed to the process of carr3dng medicinal agents in solution into the various tissues and organs of the body by means of the electric current. Formerly there was a variety of cataphoric outfits on the market. To anesthetize a pulp by this means the tooth should be insulated by the rubber dam, care being taken that no moisture escapes from the gum. A small pledget of cotton saturated with the anesthetizing solution is now placed in the cavity, the posi- tive pole, or anode, apphed to the solution, and the negative pole, or cathode, moistened with water, applied to some part of the patient's body, usually the hand, thus completing the circuit, A steady and continuous current is desired, and the perfected instruments are so devised that the amount of current can be measured. The time re- quired to anesthetize the pulp by this means depends largely upon the density of the dentin and the perfection of the instruments used. With the pulp anesthetized, the same method of removal and of subsequent treatment is followed as in pressure anesthesia. Cata- phoresis, while successful in the hands of those who mastered the technic, never became popular, largely because of the time required to accomplish the result and because of the complicated and expensive apparatus necessary. If the method of anesthetizing the pulp be followed and the pre- cautions observed, as detailed here, it will be found that there are few pulps which will not yield to the influence of cocain hydrochlorid applied directly by means of pressure. It takes time, however, to REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 325 adjust the rubber dam, sterilize the cavity, remove the pulp and blood from the canal and seal in the anodyne remedy. Many times the operator is not able at this sitting to give the necessary time to complete this operation. There are cases also where the condition or the location of the tooth in the mouth is such as to favor the re- moval of the pulp by another method, which will now be considered. n. DEVITALIZATION In discussing Sensitive Dentin under the subject of escharotics or caustics, reference was made to the fact that there are many drugs belonging to this class of agents that cannot be employed in the treat- ment of sensitive dentin, for the reason that they are penetrating and have the same deleterious effect upon the cells of the pulp tissue as upon the dentinal fibrillae. Some of the agents which cannot be * used for allaying the sensitiveness of dentin are exceedingly valuable and are employed for the purpose of destroying the vitality of the pulp, thus aiding in its painless removal. The most prominent of these agents is arsenic trioxid (AS2O3), formerly called arsenious acid. The use of this agent in the treatment of sensitive dentin was first ad- vocated by Dr. Spooner, of Montreal, who discovered that by seaHng the drug in a cavity for a few days the most sensitive dentin yielded to its influence. The fact, however, that nearly all teeth thus treated subsequently gave trouble because of the death of the pulp and the usual sequelae, led the profession to abandon this agent for the pur- pose for which it was introduced; but it has ever since been used as a means of destroying the vitality of the pulp. In fact, for years it was the only agent employed with any satisfaction. At the present time there is considerable discussion in dental litera- ture as to whether or not the effects of arsenic trioxid when applied to a dental pulp are self-limiting. Some men of high standing in the profession are of the opinion that the drug is too destructive an agent to be used for the purpose of pulp devitahzation. It seems to the author that these opinions are not well founded when we consider the long clinical record of the drug as a devitalizing agent. It has been used since 1836. There can be no question regarding the harmful effects of the drug when injudiciously employed. Its action is not self-limiting. Its effects are produced only after the drug is absorbed by the tissue elements, altering or destroying their vital processes in an obscure manner. The reason why the drug may be safely em- ployed in devitalizing the pulp of a fully erupted tooth lies in the fact that here the effects are confined to the pulp tissue, since the organ 326 PRACTICAL DENTAL THERAPEUTICS dies by strangulation at the apex due to the congestion caused by the drug when so used. Thrombosis and death of the pulp take place; and, owing to the small foramina of the tooth-root, absorption of the drug by continuity of tissue is prevented. In those cases where the apices of the roots are not fully formed the drug, if used at all, should be left sealed in the tooth only a short time. Fig. 15 shows the Fig. 15. — Tooth and alveolar process exfoliated as a result of arsenical poisoning. results of arsenic trioxid having been left in such a tooth for too long a period of time. Fig. 16 proves that the drug may be safely used if the proper precautions are observed. Fig. 16. — The pulp in the second bicuspid was devitalized, canal treated, and filled by the author in September, 1902. The molar had been treated by an unknown den- tist previous to this time. The radiograph was taken March 28, 1916, fourteen and one- half years after root-canal operation on bicuspid. Tooth has always been comfortable. The Preparation. — Much difficulty has been experienced in the use of arsenic trioxid, largely because of the uncertainty of the preparations employed. Many arsenical preparations are on the market. The white powder can be used by moistening a small pledget of cotton with some liquid, such as phenol, cresol, creosote, or oil of cloves; then by touching the cotton to the powdered arsenic trioxid, a sufficient amount will adhere which should be transferred to the cavity and sealed, preferably with cement. It is well for each operator to select an arsenical preparation with which he can obtain REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 327 good results, and then this should be used to the exclusion of all others. By this means only can we become thoroughly familiar with the action of the preparation employed. The following formula is here given for those who prefer a paste : I^ — Arseni trioxidi, 5j (4-o Gm.) Cocainae, gr, x (0.6 Gm.) Thymolis, gr. v (0.3 Gm.) Petrolati, gr. x (0.6 Gm.)— M. Fiat Unguenta. Sig. — Apply a small amount to the dentin immediately over the pulp. I wish to state here something about the pharmacy of this pre- scription, for, if the preparation does not work satisfactorily, it has not been properly compounded. Arsenic trioxid is the base; cocain is a local anesthetic, and when applied to the pulp produces a condition of analgesia by which the irritating action of the arsenic trioxid is without effect, and thus prevents the tooth from aching while the pulp is being devitalized. With the alkaloidal cocain and thymol, together with this amount of petroleum, a nice paste can be made with the arsenic trioxid. The author prefers a fiber which is made from the same formula as above by thoroughly incorporating it in some fibrous vehicle. The fiber may be stained so that it will be of a dif- ferent color from the ordinary cement, which is used to seal the preparation in the cavity. Technic of Application. — In those cases of pulpitis where the tooth has ached before the patient presents for treatment, it is always the best practice to allay the pain for at least twenty-four hours before attempting to devitalize the pulp. If for any reason this cannot be done conveniently and it is deemed best to make the arsenical appli- cation at this sitting, the engorged capillaries may be reheved by ad- ministering two or three doses of nitroglycerin, letting about one hour intervene between the doses. This will also tend to mitigate the pain which sometimes accompanies the devitalization of the pulp. The pain in these cases of pulp congestion can be absolutely controlled by carefully excavating until the pulp is exposed ; then apply one-half of a "cocain point" to the exposure, permitting the serum to dissolve the drug, after which the arsenical application may be made in the usual manner. In any case, whether the tooth has ached or not, before applying the arsenical preparation or before adjusting the rubber dam, it is best to break down all overhanging edges of enamel and carefully remove or wash out with a nonirritating antiseptic solu- tion any food-stuffs or debris which may be in the cavity. Food- 328 PRACTICAL DENTAL THERAPEUTICS stuffs contain albumin, and if this is in the cavity of the tooth when the arsenical preparation is applied, the arsenic trioxid will act upon the albumin, forming arsenic albuminate, and > thereby a certain amount of the agent is neutralized or becomes inert. As much of the carious dentin should also be removed as can be done without pro- ducing pain, for the application should be made to a sensitive spot in the cavity. It is never necessary to have an exposure of the pulp; and in case an exposure exists, it is just as well to apply the preparation to the dentin immediately over the pulp, rather than to the organ it- self, though in using the fiber suggested here there is no logical reason why it should not be applied directly to the exposed pulp. In any event the preparation should be covered with cotton or a small metallic or paper disk to prevent pressure and also to prevent the phosphoric acid of the cement from coming in contact with the in- gredients of the preparation. Length of Time Application Should Remain. — There are at least four factors which govern the length of time an arsenical application should remain sealed within a tooth, viz.: 1. The age and general condition of the patient. 2. The general condition of the pulp itself. 3. The amount and condition of the dentin intervening between the pulp proper and the application of the preparation. 4. The climate or season of the year, strange as it may seem, in- fluences the action of arsenic trioxid. Taking into consideration these various factors, the arsenical preparation should remain in the cavity from one to four days. At the second sitting the rubber dam should be adjusted, the teeth in- cluded sterilized, and the cement and preparation removed, after which every surface of the cavity should be freshened with a large round bur. This not only insures the thorough removal of the arsen- ical preparation, which, should a portion remain, is liable to produce pericemental inflammation, but it also mechanically sterilizes the cavity by removing the carious and infected dentin. This is impor- tant and is an aid in maintaining asepsis in the removal of the pulp. In the author's judgment, this is much better practice than to depend upon a solution of dialysed iron to neutralize the arsenic trioxid. Opening Pulp Chamber and Exposing Canals. — The pulp chamber can now be opened, observing practically the same details as were explained under the anesthetization method. Oftentimes, in the initial opening into the pulp chamber, and sometimes on entering the canal, after the application of arsenic trioxid, the patient will expe- REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 329 rience some pain. This condition should be anticipated ; for the safest method of devitalizing pulps with arsenic trioxid is to leave the drug sealed in the tooth only srffficiently long to poison the tissue — not completely devitalize it; and depend upon the subsequent application of some remedy containing formaldehyd to complete the devitaliza- tion. For this purpose the author uses formocresol. This remedy should be left in contact with the tissue for about three days. The formaldehyd generated from formocresol not only completes the devitalization of the tissue; but it also desiccates and toughens it, which faciHtates its subsequent removal. Strange as it may seem, in those cases of arsenical soreness where the arsenic trioxid had been left in the tooth for too long a period, formocresol will absolutely correct the soreness. The clinical experience of the author leads him to believe that formaldehyd acts here as a chemic antidote for arsenic trioxid. At the subsequent sitting the tissue may be removed, and phenolsulphonic acid employed to enlarge the canals and remove therefrom every vestige of organic matter, when the canals should be filled. Objections to the Use of Dialysed Iron and Tannic Acid. — In connection with the preservation of the color of the tooth, under the anesthetization method the author stated his objection to the use of hydrogen dioxid for removing the blood from the cavity and canal. It is necessary here, also, to refer briefly to a well-established practice of treating teeth after the pulps have been devitalized. It is the practice of many dentists, after removing the arsenical dressing, to flood the cavity with a solution of dialysed iron, after which the pulp chamber is opened, which usually produces some hemorrhage; then, without any especial effort being made to remove the dialysed iron or blood, tannic acid in some form is sealed in contact with the pulp for a week or ten days, it being deemed advantageous to constringe and toughen the tissue by this means before attempting its removal. Let us consider the rationalism of such treatment. The pulp tissue in all large canals is sufficiently tough to be removed in its entirety, and it must be disorganized or removed piecemeal in small canals, whether it has been previously constringed or not. Hence, there is no advantage in using tannic acid, and there is a serious objection. If those who follow this practice are observing, they will notice that after removing the tannic acid dressing the pulp tissue is dark in appearance. They will also observe that many teeth thus treated subsequently discolor. The cause for this is found in the fact that tannic acid and iron, in any form, are chemically incompatible, the resulting compound being iron tannate, one of the most insoluble sub- 330 PRACTICAL DENTAL THERAPEUTICS stances known to chemistry. In the presence of moisture a form of ink is produced which is a great staining agent for dentin, and one that it is almost impossible to remove by any known process of bleaching. As has been stated elsewhere, there are cases where, for want of time or other reasons, the pulp can be removed to advantage by de- vitalization; however, when this method is followed tannic ?cid should not be used, and every trace of dialysed iron (if used at all, and it is unnecessary to use it) and blood should be removed with alcohol or water. COMPLICATIONS.— In our discussion thus far of the methods of removing pulps from teeth, we have considered only favorable cases, selecting the method best adapted to the case at hand. There are many instances, however, where it is difficult to remove the pulp by either the anesthetization or devitalization method, at least until the tooth is placed in a more favorable condition. Hypertrophied Gtim Tissue. — Oftentimes in approximating cavi- ties the decay in one or both teeth has extended far beneath the gum, the rough gingival margin of the cavity acting as a slight irritant by which the gum tissue is stimulated, causing it to proliferate until it fills a portion of, and in some instances the entire, cavity. In such cases the first consideration is to dispose of the hypertrophied tissue. Where the gum fills only a portion of the cavity and the pulp of the tooth is not causing trouble, the cavity should first be enlarged and washed with a warm antiseptic solution, after which it should be dried as well as possible and packed with warm gutta-percha. But in those cases where the gum tissue occupies the entire cavity, and especially where the tooth is aching, it should be removed at once. The electric cautery is doubtless the best means to use for disposing of this tissue. It is practically painless and no hemorrhage follows its use, which is an advantage. In the absence of this, other means may be employed. Hypertrophied gum tissue is quite tough and fibrous, and if it is elevated or pushed back by means of a flat instru- ment, it will usually be found that the attachment at the gingival margin is small and can easily be severed by employing gum scissors or a lancet, previously dipped in phenol. It is best not to tell the patient what you are going to do, for scarcely any pain will be experi- enced. The hemorrhage in these cases is usually profuse, but caii readily be stopped by cauterization with 95 per cent, phenol or a 50 per cent, solution of phenolsulphonic acid. The blood should now be thoroughly removed, the cavity dried, moistened with eucalyptol, and packed with gutta-percha, letting it extend buccally and Hngually REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 33 1 to fill the interproximal space. The gutta-percha can be removed from the interior of the cavity with a heated flat instrument. Quite often the most practical way of adjusting the rubber dam in these cases is to place the clamp on the tooth posterior to the one thus packed, letting a single hole in the dam include both teeth. The pack- ing, if properly placed, will prevent leakage. The pulp can now be removed by the method which the operator deems the most feasible. It might be mentioned in this connection that hypertrophied gum tissue may and frequently does occur from irritants other than rough- ened cavity margins near the gingivae. The condition results from chronic inflammation of the gums and from such mechanical irri- tants as salivary and serumal deposits, ill-fitting crowns, bridges and partial dentures. Certain constitutional conditions may also pro- duce h37pertrophy of the gums. Among these may be mentioned scurvy, mercurial poisoning and malnutrition, especially in children and particularly among the poor in large cities. Marshall^ classifies hypertrophy of the gums as a precancerous lesion and says, "Me- chanical irritation is dangerous and should, therefore, be removed at once." Importance of a Correct Diagnosis as to the Kind of Tissue in a Cavity. — There is one instance in the removal of pulps from teeth where students, particularly, are liable to make a serious mistake if they are not extremely careful. This is in cases where, in large occlusal cavities, especially in lower first molars of children, the pulp has died and the decay has extended through the bifurcation of the roots, leaving rough edges which continually irritate the tissue, caus- ing it to proliferate and ultimately fill the cavity. To carelessly force the anesthetizing solution into such a cavity, where the pulp in the canals is gangrenous, would be the means of causing an acute alveolar abscess. The apphcation of arsenic trioxid would mean the loss of at least one tooth, perhaps one or two on either side of the one to which the application is made, with a portion of the alveo- lar process. Before applying either the anesthetizing or devitalizing agent, a correct diagnosis should be made; we should ascertain definitely the kind of tissue in the cavity. With a little experience this is usually a simple matter. The history of the case as related by the patient will often serve as a guide. Pulp tissue is generally more sensitive than gum tissue, and when slightly pricked with a sharp instrument bleeds more profusely. If the tissue proves to be hypertrophied gum tissue it can be disposed of in the usual manner, the puncture ^Pacific Dental Gazette, November, 1916. 332 PRACTICAL DENTAL THERAPEUTICS closed temporarily with cement or gutta-percha and the tooth treated as the condition necessitates (see Fig. 14). When this cannot be accompHshed, and the tooth kept free from infection, it should be extracted. Hypertrophied Pulp Tissue. — In cases where the tissue is hyper- trophied pulp tissue, it will generally be found unusually resistant to both cocain hydrochlorid and arsenic trioxid, and it is sometimes necessary to resort to interosseous or conductive anesthesia, or to the administration of such general anesthetics as nitrous oxid and oxygen, in order to painlessly remove the tissue. Secondary Dentin, Pulp Nodules, and Pulp Calcification. — Quite frequently we find cases where it seems almost impossible to force the anesthetizing solution through the dentin and into the pulp, and when arsenic trioxid is applied it has little or no effect. In these cases we can suspect that the pulp has receded because of some sHght but continued external irritation, the space being filled in with secondary dentin, the tubuli of which are irregular and do not run at right angles to the base upon which they rest, as in the normal dentin. Occasion- ally cases will present where the entire canal has been obHterated (see Fig. 6 and p. 303). This condition is more often found in elderly patients. As a result also of external irritation, pulp nodules and pulp calcification are sometimes encountered. In removing the pulp in these cases, often the most painless and best results are obtained only by a combination of both the anesthetization and devitahzation' methods; for the removal of these pulp nodules and calcified pulps is often a difficult procedure. After we have used cocain hydrochlorid and pressure or previously applied arsenic trioxid and anesthetized or devitalized a portion of the pulp, we may be able to reach the pulp nodule or nodules without producing pain. But frequently these calcific bodies are agglutinated, and close the mouth of the canal; especially is this condition found in the molar teeth. The pulp tissue immediately under the nodule is extremely sensitive. In such a case the anesthetizing solution could not be forced into the canal without first removing the obstruction, and arsenic trioxid, if applied, would have no effect. These are cases which require much perseverance and patience on the part of both patient and operator. The nodule can sometimes be loosened by gently working around it with an exploring or other suitable instrument. The author has met with success by taking a small round bur and drilling past the nodule, care being taken not to puncture the root, then with the engine run- ning rapidly the nodule is tapped and dislodged. When the obstruc- tion in the pulp chamber and canals is removed the remaining tissue REMOVAL OF VITAL PULPS AND SUBSEQUENT TREATMENT 333 can be anesthetized or devitalized in the usual manner. If the de- vitalization method is employed, the arsenical preparation can be placed over the mouth of the canal with safety; but it is never advis- able to place the preparation down in the canal. In extreme cases it may be necessary to inject local anesthetics by the conductive or interosseous methods, and thus anesthetize the pulps, or nitrous oxid and oxygen may be administered. REMOVAL OF PULPS FROM DECIDUOUS TEETH There is, perhaps, no dentist who has been in practice for any length of time but has been called upon to remove an exposed pulp from a deciduous tooth. With the so-called ''horrors of the dental chair" magnified in the child's mind, as is too generally the case, this is not often the most pleasant thing the dentist is called upon to do. The question resolves itself largely into the proper hand- ling of the child. Any expedient may be employed to gain the con- fidence of the little patient, after which either anesthetization or devitaHzation may be used as is deemed best under the conditions. Generally the latter method is preferable; and it will be found that the pulps are peculiarly susceptible to the action of arsenic trioxid. The preparation should not be left in the tooth longer than from ten Fig. 17. — This skiagraph, taken by Ream, shows the resorption of the deciduous molar roots, due to the eruption of the permanent bicuspids. In this case the pulps of the deciduous molars were vital. to sixteen hours and then only a small amount should be employed. When the pulp is thus poisoned, formocresol should be used to com- plete the devitalization. After the pulp is removed, all that is nec- essary to fill the root is to flood with chloroform and eucapercha com- pound, and fill the entire cavity with gutta-percha. It is supposed by some dentists that resorption of the roots does not take place when the pulp is destroyed. This supposition is wrong. The root may not be destroyed as readily as though the pulps were alive, but that resorption does take place has been clinically demonstrated in the author's practice. Hunt, of Indianapolis, was of the opinion that 334 PEACTICAL DEXTAL THERAPEUTICS the process here involved is one of absorption rather than resorption, and that the loss of tooth-root is usually due to the advances of the permanent teeth (see Fig. 17). ARSENICAL POISONING It may be well to re-consider here the treatment of local poisoning by arsenic trioxid. However, when such treatment is necessary, it is due to carelessness on the part of the dentist or the patient, or both. It is never necessary to tell the patient what drug or remedy has been used in the treatment of teeth, many times it is advisable not to do so; but whenever an agent as destructive as arsenic trioxid is sealed within a tooth, the patient should be thoroughly impressed with the importance of keeping an appointment, and of returning before the appointed time should any untoward symptoms develop. The patient should also be informed that the teeth thus treated might ache for a few hours, as they sometimes do, even when cocain is a constituent of the arsenical preparation; but that the aching will be of short duration. In case, however, the tooth or gum becomes sore, they should be instructed to return at once. In those cases where the arsenical preparation is not hermetically sealed within the tooth and some of it gets on the gum tissue, remain- ing only long enough to cause devitalization, all that is necessary is to first wash the part with an antiseptic solution, and then mechanically pick off the dead or sloughed tissue with sterile pliers until bleeding is produced, if this is possible, after which the part should be disinfected and the tissue stimulated. To disinfect the part, any good disinfect- ant can be used. Nothing is better here than the official 3 per cent, solution of hydrogen dioxid. As a means of stimulating the cells, iodin compounds are useful. The official compound solution of iodin (5 per cent.) can be applied by first drying the part. After removing the dead tissue and disinfecting, the author prefers applying the euroform paste on cotton or gauze. A prescription should also be written for an antiseptic mouth-wash with which the patient should keep the mouth as clean as possible. The treatment can be repeated as often as the case necessitates; usually one or two treatments will suffice. In those severe cases where the arsenic trioxid has penetrated to, and devitalized the process as well as the gum, the first treatment is surgical. After washing with an antiseptic solution, the affected proc- ess should be removed with a suitable bur in the engine. It may be necessary in extensive cases to extract the tooth, after which the treatment is practically the same as has been outlined above (see REMOVAL or VITAL PULPS AND SUBSEQUENT TREATMENT 335 Fig. 15, p. 326). Sometimes there is pain following the surgical removal of the affected process. In this case the euroform paste is especially indicated; the orthoform controls the pain, the europhen disinfects and stimulates, and the liquid petroleum keeps the saliva, laden with bacteria, out of the wound. The case should be watched closely and the stimulating treatment kept up until the part has healed. The tissue in the interproximal space will never be fully reproduced, and will always be a source of more or less iannoyance. It will be noted that in discussing the treatment of local arsenical poisoning, no mention has been made of dialysed iron. The practice of applying this agent to the affected part is both useless and wrong. In conclusion, the author desires to emphasize, what was stated in the beginning, that it is the plain duty of every practitioner to save the pulps of teeth in all cases where it can be done with any reasonable degree of success; yet experience and observation will soon show the folly of attempting to save a pulp that is in a state of passive hyper- emia or true inflammation, and will prove also that in these cases the safest practice is to remove the pulp and subsequently fill the canals, notwithstanding the difficulty often attending the performace of this operation. It behooves us, therefore, to study carefully the pathology of the dental pulp, that we may be able to diagnose the condition correctly and apply our therapeutics accordingly. DIAGNOSIS AND TREATMENT OF PIItPLESS TEETH AND THEIR SEQUELS; INCLUDING THE PREPARA- TION OF THE CANALS FOR FILLING GENERAL CONSIDERATIONS The treatment of pulpless teeth with gangrenous pulps and their sequelae has in the past, to a great extent, been purely empirical. The reason for this can be found in the apparent lack of interest which generally has been shown in the chemistry of pulp decomposition. A knowledge of the changes wrought in the splitting up of the com- plex bodies of the dental pulp by microorganisms is of vital interest to every practising dentist; and every student should, therefore, familiarize himself with this important subject. The only method by which drugs and remedies can be scientifically applied to the treat- ment of the condition under consideration is to have a definite knowl- edge of the intermediate and end-products resulting from the putre- factive process. Every practitioner of dentistry knows from sad past experience that in the process of pulp decomposition some kinds of mephitic gases are evolved which, if confined, would produce severe pathologic disturbances; but just what the gases were and how the unfavorable conditions were brought about we were left to conjecture. From our study of the chemistry of pulp decomposition we have every reason for believing that the main gases produced Sive ammonia and hydrogen sulphid. When these gases are generated and cannot readily escape through a cavity, pressure is produced, thereby forcing the infectious material through the apices of the roots into the surrounding tissues from which infection, septic pericementitis and, in many instances, an alveolar abscess result. Coagulating Drugs. — There has been much discussion in the dental literature of the past in regard to the penetrating or non- penetrating power of coagulating agents in gangrenous root-canals. It is true, as claimed by some authorities, that such drugs as phenol, creosote, solutions of zinc chlorid, etc., are contraindicated in the treatment of gangrenous pulps, but not because they possess the coagulating property; for when the dental pulp is undergoing or has undergone the process of decomposition, the proteid constituents, or coagulable substances, have lost their former identity, and new com- 336 DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 337 pounds, with entirely different properties, have been formed. In selecting drugs to be used in the treatment of this condition, the author will therefore eliminate the question of coagulation, and will select drugs which, if properly used, will unite chemically with the intermediate and end-products of decomposition, converting them into odorless and non -infectious compounds, as well as destroy germ life. Important Products of Pulp Decomposition. — In this connection it should be remembered that the gangrenous condition has been brought about through the agency of microorganisms by a gradual analytic process, and among the products formed which must be con- sidered in the treatment are hydrogen sulphid, poisonous ptomains or toxins, and ammonia or derivatives, the latter gas being evolved from the further putrefaction of the intermediate compounds (ptomains and amido acids). It is well to remember also that/a/^ or fatty acids are a class of end-products resulting from the putrefaction of proteid substances. The main gases formed, then, are ammonia and hydrogen sulphid. Now it will be necessary to dispose of these gases by our initial treat- ment in order to hermetically seal the cavity, an object the accom- plishment of which is much desired in the treatment of these cases; for by so doing we prevent the oral fluids from contaminating the medicine within the tooth, the medicine from escaping into the patient's mouth, and the tooth from changing color during the time of treatment. Drugs Indicated. — It has been shown by Cassidy and others that formaldehyd (CH2O) is a valuable therapeutic agent if properly used. This gas occurs in commerce in a 37 per cent, aqueous solution, which solution is recognized by the United States Pharmacopeia under the name of liquor formaldehyd, or formalin. The gas will unite with ammonia, producing uro tropin, a solid, as 6CH2O -f 4NH3 = (CH2)6- N4 + 6H2O. Formaldehyd unites also with hydrogen sulphid, forming, in the author's opinion, methyl alcohol, a liquid, and sulphur, a solid, as 2CH2O + 2H2S = 2CH3OH + S2. It is stated on good authority that this same gas, formaldehyd, unites with basic ptomains, forming inodorous compounds. By the use of formaldehyd, then, in our initial treatment for a gangrenous pulp, the irritating gases and poisonous liquids (largely ptomains) can be changed chemically into nonirritating and nonpoisonous liquids and solids. The official solution of formaldehyd, however, is too irritating for general use; therefore, inasmuch as fats result from pulp 338 PRACTICAL DENTAL THERAPEUTICS decomposition and are present as such in a gangrenous root-canal, the author, several years ago, selected cresol as an agent with which to dilute the ofiicial solution and thereby modify the irritating action of formaldehyd. Cresol is also recognized by the United States Pharmacopeia under this name. Formerly the product was commer- cially called tricresol. This agent has a tendency to darken when exposed to light. It is recommended that a clear solution be obtained and then kept in an amber-colored bottle. Liquor formaldehyd can be diluted with such other agents as phenol, or creosote, if, in the latter instance, a small amount of alcohol is added to clear the solution. Cresol, however, is recom- mended for four principal reasons: 1. It is miscible with the liquor formaldehyd in all proportions, thus making, without the addition of alcohol, a good pharmacal product from which formaldehyd gas is constantly generated. 2. It is a good disinfectant — much more powerful than phenol. 3. It possesses an anodyne property which modifies the irritating action of formaldehyd. 4. It acts chemically upon fatty compounds, thereby disposing to advantage of these substances. Factors to be Considered. — In the successful treatment of the conditions under consideration, there are three important purposes to be accomplished: 1. Establish asepsis. 2. Prevent recurring sepsis. 3. Preserve or restore the color of the tooth. In calUng the attention of the reader to a method of treating this condition, which has proved very successful in the author's practice, I desire to emphasize the necessity of observing the details of the method. The successful management of pulpless teeth is largely a matter of chemistry, and the treatment involves the use of certain chemical agents. In view of our present knowledge of focal infection and its relation to systemic disease, the author considers the treat- ment of pulpless teeth one of the most important subjects before our profession to-day. Diagnosis of Dead Pulps. — It is not a difficult matter, as a rule, to differentiate between teeth containing Hving or dead pulps. The cUnical history, the color of the tooth, its response or nonresponse to thermal or electrical stimuli, will lead us to suspect that the pulp is dead or aUve. Now we are ready to confirm our diagnosis. One of the best means of confirming the diagnosis of a dead pulp is the use of electricity by an instrument known as the "vibrating coil." This Dental caries. Saprophytic bacteria. Mephitic gases. (NH3-H2S.) Water. Fatty products. Fig. 18. DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 339 consists of a single dry cell and a vibrating coil with a switch to control the current. The cord leading from the positive pole is arranged with a holder so that a broach may be attached ; cotton is wrapped around the broach and moistened when it is applied to the suspected tooth. The cord from the negative pole is attached to a metal holder, which is held by the hand of the patient; thus the circuit is completed. A stronger current may be had by moving the positive pole to the right on the instrument or by gradually withdrawing the cylinder which runs through the coil. One should always start with a weak current, gradually increasing the strength if no response is obtained. It is best to apply the current first to a tooth known to be vital, and use this as a control or guide. When two approximating teeth contain metal fillings, the current should be applied to the tooth so as not to come in con- tact with the filling; otherwise the current may be conducted to the filHng of the adjoining tooth, which, if vital, would respond, leading one to believe that the tooth to which the current is ap- plied is vital, when, as a matter of fact, it may be pulpless. After the diagnosis of a dead pulp has been confirmed, the pulp chamber is freely opened with a suitable round bur. It is not enough here to simply determine whether the pulp is dead or alive ; but, if dead, an effort should be made to determine whether the con- dition is one of true gangrene with its characteristic odoriferous and gaseous end-products or whether, as sometimes occurs, the active pyogenic microorganisms have Hquefied a part or all of the bulbous portion of the pulp, forming drops of pus in the pulp chamber with practically no odor, and with the tissue in the canals still vital. Treatment of Pulpless Teeth. — When a patient presents with a pulpless tooth, the original pulp tissue is generally either in a moist gangrenous condition, as a result of the action of bacteria (Fig. i8) or a previous attempt has been made to remove the pulp and fill the canals. (See History of Cases, p. 351.) In either case, the first treatment here, in my opinion, should be a dressing of formocresol. I^ — Cresolis, Liquoris formaldehydi, aa f 3j (4.0 mUs). — M. Sig. — Use as directed. Other preparations may be just as effective; but this is the one I have used for years and about which I can speak with assurance. Under aseptic precautions, this remedy should be placed in the pulp chamber only, and the dressing retained with cement. This dressing 340 PRACTICAL DENTAL THERAPEUTICS should remain at least twenty-four hours, and in the interim a radio- graph of the tooth and periapical area should be obtained. The chemical action of formocresol on a gangrenous pulp has been published so often and is now so well known that I need not repeat it here.^ I know that many good men to-day advocate the immedi- ate cleansing of a gangrenous canal; but I am firmly of the belief that the safest and best practice is to first supply at -least one dressing of formocresol. Gilmer, Moody, and others, have found that the pre- dominating organism in the conditions resulting from a gangrenous pulp, therefore the group active in bringing about the decomposition, is a streptococcus, "with graded variations from a hemolytic strep- tococcus with a wide zone of hemolysis in the acute abscess to a streptococcus viridans in the chronic." One initial treatment of for- mocresol in these cases, while it may not kill all of the organisms present, will certainly lessen the number and lower the virulency of those remaining. Surely no one will deny the favorable and valuable effect of formaldehyd gas on the intermediate and end-products of pulp decomposition. With these poisonous and irritating products chemically neutralized; with the bacteria, inaugurating the process, killed or their virulency lowered, we may the more safely, I believe, work to the root-end, and clean and enlarge the canal by a chemico- mechanical process. By this I mean the use of chemicals in connec- tion with broaches, reamers, files, and other necessary instruments. At the present time, so far as I know, there are three chemical agents in general use for this purpose — metallic potassium and sodium, as advocated by Rhein; sulphuric acid by Callahan; and phenolsul- phonic acid by the author. We will now consider the chemistry and pharmacology of these agents. Potassium and Sodium (K and Na) . — This is an alloy composed of a mixture of the two metals. It occurs as a semi-solid, silvery- white preparation. Like the metals of which it is composed, it must be kept under a hydrocarbon oil or paraffin to protect it from the air and moisture. It was first introduced in the United States by Schreier, of Vienna, in 1893, ^t the World's Columbian Dental Con- gress in Chicago. So far as I am able to learn, Schreier has never pubHshed the proportion of the metals in his product. The metals will produce an alloy in varying proportions ; and, in my opinion, the more sodium in the mixture the better the preparation will be as long as there is enough potassium to make an alloy when the two metals are properly mixed. No attempt should ever be made to mix the ^ The chemistry of pulp decomposition has been discussed by the author in Johnson's Text-book of Operative Dentistry," p. 341, and in various dental journals. DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 341 metals unless they are constantly kept under a hydrocarbon oil, such as kerosene, gasoline or benzene; and, even then, it is best to leave the compounding to an experienced chemist or pharmacist. Technic of Using Schreier's Alloy. — Schreier's preparation comes in a small glass tube, one end of which is open so that the alloy may be covered with paraffin, which prevents undue exposure to air or moisture. It is to the advocacy of Rhein that the preparation owes its popularity in this country. He has developed a technic which, if followed carefully, insures success. With the rubber dam adjusted and everything in readiness, a barbed broach may be pushed through the paraffin cover and into the metallic mass ; on gently withdrawing it small particles adhere to the broach. It is best to have these particles as near the end of the broach as possible, in which manner the alloy is transferred to the canal. It is presumed that the canal is moist, which is generally the case. A violent reaction at once takes place, the metals attack the water molecule and hydroxids are formed, liberating hydrogen gas. If potassium predominates in the alloy, or even if it is present in equal proportion with the sodium, a sufficient amount of heat is generated by the reaction to cause the liberated hydrogen to burn. To set the hydrogen off actively and start it burning requires a temperature of from 500° to 6oo°C. This burning of the hydrogen is an objection, in my opinion, and it was for this reason that I suggested (above) the employment of an alloy with sodium predominating. After the initial reaction and the hydroxids are formed, they in turn act upon the fatty end-products, in case of a gangrenous pulp, forming a soluble soap. Where the organic tissue has not been decomposed by bacteria the action of the hydroxids differs somewhat in that the hydroxyl ion unites with the protein constituent of the tissue, forming a soluble alkaline albuminate. In either case, it will be observed, the product formed is soluble, and may be washed out of the canal, leaving it clean and sterile. The action of potassium and sodium hydroxid on the contents of a canal of a tooth, whether or not the tissue is decomposed, is the same. When the salts and compounds of these metals are internally administered their action differs only in that the potassium ion is more depressant than the sodium ion in its influence upon the cardiac, muscular and nervous systems. But in the canal of a tooth we do not have this pharmacologic effect of the metal ion ; here we get only that which is desired — the chemical action of the hydroxyl ion. Rationale of Rhein's Method. — With this information before us, let us examine the rationale of Rhein's method of using metallic potassium and sodium in the treatment and preparation of canals 342 PRACTICAL DENTAL THERAPEUTICS for filling. The chemistry is correct; a description of the method reads well. The question is whether the preparation is safe and practical. My reply is that it is safe in the hands of those who will master the technic and use it with intelligence and care; but that it is not as practical as other chemicals which may be used with equally good results. It must be remembered that each particle of alloy that is introduced into a canal is decomposed just as soon as it comes in contact with moisture. This practically means that the initial reaction between the metals and water takes place at the mouth of the canal; for it is difficult to keep the canal free from mois- ture down to the place at which we stop each succeeding time we enter it with the broach or other instrument. The mere withdrawal of the latter would necessarily moisten the canal, more or less, which had been affected by the remedy. Then, too, if we are using an alloy, like Schreier's, in which there is enough potassium to cause the Uberated hydrogen to burn, as a result of the intense heat from the violent reaction between the metals and water, we are constantly moistening the canal; for when hydrogen burns it does so by virtue of the oxygen in the air supporting the combustion, and water (H2O) is chemically formed. Therefore, it is impossible to keep the canal free from moisture when we use an alloy which reacts on water with such violence that the heat generated causes the hydrogen to burn. Even Rhein himself, with all his experience, technic and care, wisely cautions against the possibiHty of destroying, or affecting deleteri- ously, 'the tooth structure at the mouth of the canal by this "burn- ing" process. Does this not mean, then, that unless extreme care is taken to prevent the initial reaction until the alloy is down in the canal to the point desired, the chemicals which actually do the work down in the canal proper are the hydroxids of the metals? If this be true, why should we not introduce into the canal and use one of these hydroxids (there is absolutely no advantage in using both) from the beginning? When I want the action of these alkalies in a canal, I generally use, after the method of Pruyn, of Chicago, a saturated solution of sodium hydroxid (NaOH). This is a rather thick, syrupy solution, which may be applied like any solution of its kind. There is another objection to the use of metallic potassium and sodium, especially a mixture of the metals in which potassium pre- dominates or is present in equal proportion. Granting that with proper care one could keep moisture from the canal as he gradually approached the end in the use of the alloy, I am one of those who firmly believe that we should not burn our way through the live, DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 343 healthy cementum at the end of the root from which a live pulp has been removed. One of the first things a student learns in study- ing chemistry is "that hydrogen burns with the hottest known flame." With a dental granuloma or alveolar abscess in the peri- apical region, it is a different proposition; but, even here, we may accomplish our purpose with far less destructive chemicals. This brings us to a discussion of the use of "acids" instead of "alkalies" for the purpose under consideration. The acids which I shall discuss are sulphuric acid (30 per cent.) and phenolsulphonic acid (80 per cent.). Advantages of Phenolsulphonic Acid. — The chemical action of sulphuric and phenolsulphonic acids for the use under consideration is practically the same; and they will be discussed here conjointly. Personally, I prefer phenolsulphonic acid. Its consistency is thick and syrupy in the 80 per cent, strength which is recommended ; thus a drop will adhere to the end of a broach or other applicator, per- mitting it to be carried even into the canals of upper teeth without difficulty. The acid does not materially affect a broach, and if any of it accidentally gets on the enamel of the crown of the tooth and is not noticed for a time, it does not decalcify and whiten the spot to the extent that sulphuric acid would do. When the acid is worked through the end of the root, as is desirable for cauterization in cases of a dental granuloma or alveolar abscess, it is sufficiently cauterant for the purposes desired, yet not as destructive as sulphuric acid would be; and, owing to its analgesic tendencies, causes less pericementitis. In this connection, however, I want to say that we should not expect to do this work as it must be done, without more or less soreness following the treatment. There is a wide variance in patients regarding the reaction of the periapical tissues to these agents: and in these chronic conditions it is generally best to invite and create inflammatory reaction that the sluggish cells in the area may take on new Hfe and activity. This should not be done, however, at the expense of unnecessary destruction of tissue. It might be supposed by those who have not used phenol- sulphonic acid that, possessing the above-mentioned advantages over plain sulphuric acid, it would be less effective in the canal. I have not found this to be the case. The agent has one possible disad- vantage. In using either of these acids, after they have been intro- duced into the canal for a time and the walls thereof filled with a suitable broach, they should be neutraHzed with a solution of sodium bicarbonate (NaHCOs). In the case of sulphuric acid the 344 PRACTICAL DENTAL THERAPEUTICS salt formed as a result of the reaction is sodium sulphate (Na2S04), a freely soluble salt. With phenolsulphonic acid the salt formed is sodium phenolsulphonate (NaSO3.C6H4.OH + 2H2O), which is not as soluble as sodium sulphate. I can conceive how it might be pos- sible in a very fine canal to temporarily block it with the salt formed. An excess of water would readily dissolve the salt or by using a solution of sodium bicarbonate of not more than 10 per cent, strength the salt would be dissolved as soon as formed by the reaction. This is a thing which probably would never occur in practice; but I mention it as a possible disadvantage. Caution in Using Callahan's Method. — In using sulphuric acid Callahan advises that it be a 30 per cent, solution. In this strength there is not the danger of charring or carbonizing the pulp tissue which may be in the canal undecomposed, that there would be if a more concentrated solution were used. Sulphuric acid is one of the most corrosive acids. When applied to the skin, accidently or other- wise, in concentrated form, it causes an intense, burning pain, and results in a rapid destruction of tissue. The eschar is at first white, gradually becoming brown, and causes a coal-black slough. The corrosive effect upon mucous membranes or the tissue in the peri- apical area of teeth is still more marked than upon the skin. The acid rapidly abstracts water from the tissue, the alkahes are neu- tralized and the proteins precipitated, which results in complete destruction of the tissue. This carbonizing of the undecomposed tissue in the canal should be avoided, as it forms a mechanical ob- struction difficult to remove; and it is for this reason that the 30 per cent, solution is recommended by Callahan. Technic of Using Acid 'Method. — We will now consider the technic of treating pulpless teeth and preparing the canals for fill- ing by the "acid method." I take it to be thoroughly understood that good root-canal work means the use of the rubber dam in all cases, and the strict observance of asepsis. With me at this time, as heretofore, it means asepsis fortified by antiseptic precautions. I make this statement because it is so difficult to observe strict asepsis in our dental offices. In a large percentage of cases of gangrenous pulps or imper- fectly filled canals, the radiograph will disclose a dark and suspicious area at the end of the root. With this evidence, and under the con- ditions, we may properly diagnose the case as a dental granuloma or alveolar abscess. This growth may be nonpurulent or of the pus- discharging variety. It is only recently that these nonpurulent growths — true dental granulomas — have been recognized as such; DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 345 and the treatment of such conditions in the past has not been as specifically emphasized as their significance merits. Nonpiirulent Variety. — It makes no difference with me whether this growth is associated with a tooth, the canal of which contains a gangrenous pulp, per se, or an imperfect root-canal filling — the treat- ment is practically the same. At the first sitting, when the diagnosis is made by the aid of a radiograph, or even before the latter is ob- tained, under aseptic precautions, the pulp chamber is opened into freely and a dressing of formocresol is hermetically sealed in for two or three days. Cement should always be used here to retain the dressing. This treatment is for the purpose of neutralizing the gan- grenous contents of the canal, or, in a measure, sterilizing the old root filling, as the case may be. In making an attempt to work one's way by chemico-mechanical means to and through the root-end with- out the previous apphcation of some strong disinfectant, like formo- cresol, I have found that acute symptoms too frequently develop. This initial formocresol treatment prevents many of the acute symptoms which follow the immediate attempt to reach the root-end, however careful one may be. At the second sitting, I want the radio- graph; then with the rubber dam always in place and all necessary instruments steriHzed, I carefully work to the apex with phenol- sulphonic acid, using in connection therewith fine, smooth, twist and file broaches. This is what I call the chemico-mechanical proc- ess. The acid is frequently neutralized with a solution of sodium bicarbonate; and since phenolsulphonic acid is the chemical I am using, for reasons previously mentioned I prefer not to have the alkaline solution more than lo per cent, in strength. If sulphuric acid is the agent used, this point is not so essential. The sodium bicarbonate solution not only chemically neutralizes the acid, but the effervescence caused by the reaction aids materially in removing the "mushy" and disintegrated material from the canal. After I am satisfied that I am at the end of the root, that the acid is neutral- ized and the canal perfectly clean and sufficiently enlarged, then, if the radiograph has indicated a periapical involvement, with the acid and a smaU stiff broach, I work my way through into the affected area. Some of the acid is purposely worked through the end for the express purpose of destroying the growth by cauterization. In the first edition of this book (1909), I spoke of phenolsulphonic acid as a stimulating cauterant and called it a "bone cell stimulant;" and after seven years of further use of the agent in these conditions, I am stiU of this opinion. Personally, I have obtained better results by using phenolsulphonic acid than any other cauterant at my com- 346 PRACTICAL DENTAL THERAPEUTICS mand. When I am through the root-end, the acid in the canal — not that which has passed through — is neutraHzed with the sodium bicar- bonate solution, the canal desiccated with modified alcohol (70 per cent, alcohol to which i gr. of thymol is added to the fluid ounce), and a dressing of eucalyptol compound (very Uttle of the remedy on the cotton) is sealed in the canal. This remedy is used here because it is a stimulating antiseptic, thus fortifying asepsis with antiseptics; but, as elsewhere mentioned, it also aids in hermetically sealing the canal which is done at this time by using a combination of a good grade of temporary stopping and cement. The heated stopping is placed immediately over the eucalyptol compound dressing and it adheres firmly to the walls of the cavity; the excess is removed and the remaining portion of the cavity filled with cement. This dress- ing is left for a period of from four days to a week, when, if the case has progressed nicely and pericementitis is absent, the canals are filled. What becomes of the growth and tissues that were cauterized in the periapical region, I frankly admit I do not know; neither does anyone else. Nature here, as in many other instances, has not re- vealed her secret; but I do know that it is disposed of in some way, for under the above treatment bone and soft tissue regeneration is effected (see History of Cases with Illustrations, p. 356). When, in all therapeutics, we learn to work with and not against Nature, we will have taken a long step forward. If, in these cases, the root- end can be put and kept in such condition that the surrounding tis- sues can lie in physiologic contact with it, regeneration is effected; if this biologic condition cannot be brought about, all medication fails and surgery is the only road to success. Removing Old Root-filling. — In those cases where a previous attempt had been made to fill the canal with gutta-percha, it is nec- essary, after the initial formocresol treatment, to first remove the old root-filling. Generally in these cases there is only one cone in each canal, in which event the acid will soon work its way around the cone when it may be loosened with a suitable instrument and re- moved in one piece. However, occasionally it becomes necessary to remove a filHng where the gutta-percha has been fijmly packed in the canal. Here the use of xylol, or xylene, as it is also called, will aid materially in disintegrating the gutta-percha. This is dimethyl- benzene (C6H4(CH3)2), and while the agent does not dissolve the gutta-percha in the sense that chloroform would, it readily attacks and disintegrates the material, making its removal, after a few min- utes, comparatively easy. My attention was called to this agent DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 347 by Best, of Minneapolis; but I think he credits another with its introduction. It may be procured from any pharmacy. Removing Blockade in Canal. — We should never use any drug or chemical bhndly. Therefore, if in working up or down a canal, we find it blocked and are unable to reach the end, instead of going on blindly using only one chemical, whatever it may be, and running the risk of making a false pocket, we should stop and ascertain, if possible, and it is generally possible, the nature and character of the material causing the blockade. It may be a remnant of an old gutta- percha cone; it may be pulp tissue undecomposed which has been inadvertently packed in the canal; it may be some inorganic material, such as a pulp nodule, secondary dentin, or other loosened inorganic material which has been pushed into the canal. If we have reasons for concluding that an old gutta-percha filhng is caus- ing the blockade, xylol is the chemical to use; if we think it is organic tissue, the alkalies, Hke potassium and sodium or a strong solution of one of the hydroxids of these metals, is indicated; if an inorganic material, sulphuric acid or phenolsulphonic acid will best answer our purpose. My plea is not to become wedded to any one chemical or method. Be eclectic and take the necessary time to do this work carefully and well. It is the most important work you have to do. Purulent Variety. — The treatment of an alveolar abscess of the pur- ulent or discharging variety is practically the same as previously out- lined, except that in these cases there is not the danger of acute symp- toms arising; therefore, one may safely, under aseptic precautions, work to and through the root-ends without the initial formocresol treatment. However, even here I beheve it is the best practice to use formocresol first; but it is not so essential as in the case of non- purulent growths. After we are through the end of the root, it is best to first force a physiologic salt solution through the sinus, and if no sinus is present it is generally best to establish an opening through the overlying soft tissue and process, then cauterize the track with some stimulating cauterant. Here, I also use phenolsul- phonic acid, fuU strength, as was used above for reasons mentioned. After this my treatment is the same as previously given for a dental granuloma. Ionization. — Some of my readers may be surprised that I could discuss at this time the treatment of dental granulomas or alveolar abscesses without the mention of the so-called ionization method. The intimation has gone out from dift'erent sources that unless ioni- zation is employed in the treatment of these conditions, a cure will not be effected. I want to brand any such intimation as being 348 PILICTICAL DENTAL THERAPEUTICS absolutely erroneous. There are many chemic agents which act as cauterants and which may be relied upon to eradicate "this patho- logic growth at the end of the root." ]\Iuch, of course, will depend upon the extent of the destruction of the pericemental membrane and the consequent amount of denuded root-end as a result of the granulomatous growth. As stated above, for years I have advocated and used phenolsulphonic acid for both the nonpurulent and pus- discharging varieties; and I desire to state that I have been curing these conditions. I do not msh to imply that phenolsulphonic acid is the only agent that will accompHsh favorable results; but it is the one I have successfully used. What a dismal old world this would be if there were only one royal road to success in any line of human endeavor! I do not object to anyone using so-called ionization. I know results may be obtained by the proper use of the method; but I do object strenuously to the opinion which is prevalent in some quarters that those who are not using this method are failing to cure their cases. Ionic Theory. — Now let us discuss the ionic theory from the chemic and pharmacologic viewpoint. Ionization in chemistry means the act of dissociating the ions of a salt or compound by passing it in solution or by means of the electric current. The men who have been attempting to cure, and I want to say that in many instances they do cure, dental granulomas or alveolar abscesses by dissociating the ions of certain salts — notably zinc chlorid, with the electric current — have been taught by Rhein, the most ardent advocate of the method in the United States, that results are obtained by virtue of the infected tissues in the area being sterilized by the so- called ionization. Price, of Cleveland, takes issue with Rhein on this point; and states that he had aspirated in many cases after using the current by Rhein's method and that he was able in nearly every instance to make a culture from the germs thus obtained from the area supposed to have been sterihzed. The aspiration was done immediately after the current and salt solution were employed. This does not prove that we cannot cure these conditions by this method of treatment. Rhein and others have proved conclusively that such conditions can be so cured; but it does prove that the results are not obtained by complete steriHzation as claimed. Price further makes the statement that ionization as such cannot be accomplished in the manner explained by Rhein; and Price is of the opinion that what is really done by the current in these cases is cauterization oj the affected area. The point I wish to make is this: If cauterization of the tissues involved will effect a cure in dental granulomas or alveolar DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 349 abscesses, as I and many others know it will, the proposition resolves itself into the question: What is the most practical and effectual means of bringing about this result? It is simply a question which each one must decide for himself; and each should use those agents and methods which in his hands offer the greatest opportunity for ' success. It is wrong for any man, especially one who is looked upon as an authority, to claim that there is only one method or means of accomplishing definite results, and that that method is the one which he champions, and perhaps has originated. It is wrong be- cause it is not true; and, not being true, it is discouraging to the thousands of men in the profession who are anxious to do honest, conscientious root-canal work, but who are absolutely at a loss at this time as to just how good work may be done. We need here, as in all lines of dental practice, a standard on which we may all agree. In recent years much has been written about the health-value of removing focal infection. This is all important, but I wish to state, with all the emphasis at my command, that the majority by far of teeth thus involved may be therapeutically or surgically treated so that they will not be a menace to the health of the indi- vidual. Physicians and dentists should work together and in harmony on this proposition. The former should not advise the extraction of teeth without first consulting the latter. When focal infection is found or suspected in the mouth by the medical practi- tioner, his plain duty lies in referring the patient back to the family dentist with such suggestions as he may deem advisable in the case ; and the dentist's duty lies in removing the focus of infection by treat- ment or extraction. The members of the two professions should work together harmoniously for the benefit of the patient's health, which is being done to-day. COMPLICATIONS.— Occasionally we encounter complications in the treatment of pulpless teeth. These will now be considered. Badly Decayed Root. — Formocresol is very destructive to the soft tissues of the mouth, therefore the importance of always adjust- ing the rubber dam. If this cannot be done on account of a badly decayed root, it is suggested that care be taken in seahng the remedy in the cavity at the first sitting, and, in placing the cement, the original outHne of the root can be approximated. After the cement has set, a band or matrix of gold or German silver can be fitted to, and cemented to the root. In doing this it is best to use a cement of different color from that employed for treatment purposes; and in treating the case where there is a tooth posterior, it is best to place a clamp on this tooth, gently stretch the rubber over the band and 35© PRACTICAL DENTAL THERAPEUTICS thereby avoid loosening it. With the complication thus removed, the treatment is the same as previously given. Pulp Partially Alive. — In those cases where the pulp tissue is gangrenous in one or more canals of a multirooted tooth and alive in the other one or two canals, as the case may be, we will find much satisfaction in using the formocresol remedy (Fig. 19). These are exceptional cases and it is difficult to know whether this condition exists until the second sitting. If there be much vitality in the live pulp tissue, the formaldehyd in the remedy will doubtless make the tooth ache, but after we know the conditions our method of procedure is simple, and the results will be certain. A small pledget of cotton dipped in the remedy can gently be placed over the mouths of the canals which contain putrescent material, and a thin quick- setting cement flowed over the cotton. After the cement has set, the live pulp tissue in the remaining canals can be anesthetized or devitalized, as the operator deems best at the time. These remnants of pulps may generally be desensitized and removed with very little pain by gently working phenolsulphonic acid up or down the canal with a fine broach. Formerly these were difficult cases to treat, but with a remedy which can be hermetically sealed in a gangrenous root-canal, the procedure is materially simpHfied. Pulpal Abscess. — It was previously mentioned that one may occasionally open into a suspected tooth, having all the symptoms of a dead pulp, and find a drop of pus in the bulbous portion of the pulp with the remaining portion still aHve. Some writers call this condition a septic pulp or pulpal abscess in contradistinction to gan- grene or true putrescence (presence of gases). In such a case, any remedy containing formaldehyd may cause the tooth to ache; there- fore, this must be taken into consideration, and in the treatment of so-called septic pulps, the pus should be washed out of the cavity with a warm antiseptic solution, the cavity dried, and asepsis estab- lished by hermetically sealing in a much smaller amount of formo- cresol than that generally used in cases of true gangrene. If this precaution is taken the tooth will not ache long, even in cases where no odor is present and the vital tissue is still quite sensitive. This remedy will sterilize the tissue, after which, at the second sitting, the pulp can be anesthetized or devitalized as usual. Dry Gangrene. — Sometimes on opening into a pulpless tooth we find the canal dry and odorless. This condition is called dry gangrene of the pulp. It is not really a complication if we recognize that microorganisms may be present and seal a disinfectant in the canal for at least twenty-four hours. One treatment of formocresol DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 35 1 or phenol compound will correct any possible trouble, when we are ready to use phenolsulphonic acid, after which the canal can be filled. The author realizes that the method of treating pulpless teeth, here given, is a radical departure from those generally used in the past. With the knowledge we have to-day of the dire results of focal infection; and with the X-ray showing that the root-ends of pulpless teeth in so many instances are foci of infection, it becomes necessary to either improve our treatment or extract these teeth. The following cases from the author's practice, treated after the methods here advocated, speak for themselves. HISTORY AND TREATMENT OF PRACTICAL CASES Series No. i. Patient. — Female. Age, about 33 years; of a nervous tempera- ment, and not in good physical condition. Had suffered more or less from neuralgia. All teeth extremely h3^ersensitive. Picture for Fig. 20 was taken February 2, 1916. Treatment. — The excementosed second bicuspid was extracted February 21. (Fig. 21.) The porcelain crown was removed from the first bicuspid on February 28th, and formocresol sealed in canals. On March ist the canals were cleansed and opened with xylol and phenolsulphonic acid, when diagnostic wires were placed in canals and picture for Fig. 22 taken. The canals were filled on March 6th, when pictures for Fig. 23 and Fig. 24, showing two views of root-filling, were taken. Series No. 2 {a and h). Paitent. — Female. Age, about 32 years. Presented in March, 1916, suffering with intermittent, radiatmg pains in the back of her head and both sides of her neck. The general condition of the patient was good, except that she was rather depressed from over- work. She had had several radiographs taken the preceding Sep- tember. A nonpurulent dental granuloma was disclosed on the lower second bicuspid on either side. Fig. 25 of this series shows the granuloma on the lower right bicuspid. Treatment. — {a) Removed porcelain crown on March ist and sealed formocresol in the canal. On March 3, the canal was cleaned and opened with xylol and phenolsulphonic acid and eucalyptol compound sealed in. The canal was filled on March 8, when picture for Fig. 26 was taken. The tooth was giving no local 352 PRACTICAL DENTAL THERAPEUTICS trouble, apparently, when treatment was begun; nor was any sore- ness manifested throughout the treatment. Picture for Fig. 27 was taken July 11, about 4 months after the canal was filled. Picture for Fig. 28 was taken September 25, about 6^ months after root- filling operation, (b) Picture for Fig. 29 of this series shows the granuloma on the lower left bicuspid. As was mentioned of the tooth on the opposite side of the mouth, this tooth also was giving no apparent local trouble when treatment was begun. The gold crown was removed on March 4 and I immediately worked to the end of the root with xylol and phenolsulphonic acid. Sealed eucalyptol compound in the canal. Patient returned March 8, giving history of acute apical pericementitis, which was still in evidence. Placed diagnostic wire in the canal with formocresol dressing, when picture for Fig. 30 was taken. On March 14 the soreness had entirely subsided, when canal was filled. This case illustrates the value of the initial formocresol dressing, which you will notice was not used here. Picture for Fig. 31 was taken July 11, about 4 months after root-filling operation. In the meantime the lower left first molar, carrying a gold inlay which restored nearly the occlusal third of the crown, became uncomfortable, though the radiating pains in the back of head and neck had completely disappeared. Fig. 31 shows the diagnostic wires after devitalizing and removing, by the aid of phenolsulphonic acid, an almost completely calcified pulp. Picture for Fig. 32 was taken September 25, about 63^^ months after root- filling operation on bicuspid, and 2 months after that on the molar. Series No. 3. Patient. — Male. Age, about 40 years. Nervous, not in good physical condition. An upper right first molar had been treated and filled about 3 months previous to the time patient was re- ferred. Complained that his tooth " had never felt right since it had been treated." Picture for Fig. 33 was taken May 26, 1916, before I saw the patient. Treatment. — On June 10, the amalgam filHng was removed, as was also the old root-filling, using xylol and phenolsulphonic acid. The lingual canal seemed blocked and a false pocket* had been made. The canal proper appeared to be blocked with undecomposed pulp tissue. I used a saturated solution of sodium hydroxid and . in 5 minutes' time, with a small twist broach, the end of the root was reached. The alkali was then neutralized with phenolsulphonic acid. Time consumed for entire operation at this sitting — one hour. I mention this here simply to show that if we go at these Series No. i. Fig. 20. Fig. 21. Fig. 22. Fig. 23. Fig. 24. Series No. 2. (a) Fig. 2;. Fig. 26. Fig. 27. Fig. 2i Series No. 2. (b) Fig. 29. Fig. 30. Fig. 31. Fig. 32. Series No. 3. Fig. 33. Fig. 34. Fig. 35. Series No. 4, Fig. 36. Fig. 37. Fig. 38. Series No. 5. Fig. 39. Fig. 40. Fig. 41. Series No. 6. Fig. 42. Fig. 43. Fig. 44. Series No. 7. Fig. 45. Fig. 46. DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 353 cases in an intelligent manner, it does not require as much time as some operators have led us to believe. The diagnostic wires were also put in at this sitting with a dressing of eucalyptol compound, when picture for Fig. 34 was taken. This picture shows that the wire in the mesio-lingual canal was not in as far as the canal had been explored, or else, as proved to be the case, the canal was not properly opened. Patient returned June 16. Thinking undecomposed pulp tissue also blocked the mesio-lingual canal, the saturated solu- tion of sodium hydroxid was used. In 3 minutes' time the end of the root was reached. The alkali was neutrahzed with phenolsul- phonic acid, canals desiccated and filled. Ordered radiograph for Fig. 35. The patient called when he was in the city, late in September, and reported tooth entirely comfortable. Series No. 4. Patient. — Female. Age, about 45 years. Physical condition very good. Presented May 5, 191 6. No pain or discomfort of any kind; but she had noticed a discharging sinus in the region of the apex of the upper left second bicuspid. So far as patient knew, the abscess had been standing for about 2 years. Ordered radiograph for Fig. 36. Treatment. — Opened into the pulp chamber on the above date (May 5) and cleaned canal with phenolsulphonic acid, working the same through end of root and sinus, after using physiologic salt solution. As there was a bad odor, formocresol was sealed in the canal. On May 8 the canals were filled and picture for Fig. 37 was taken. Picture for Fig. 38 was taken January 4, 1917. Series No. 5. Patient. — Male. Age, about 55 years. Blood-pressure abnorm- ally high, and occasionally had spells of dizziness. Two involved teeth were extracted and upper lateral treatment was given as follows for gangrenous pulp. Treatment. — On May 31, 1916, the canal was exposed and a dressing of formocresol sealed in. The patient could not return until June 29, when the canal was cleaned and enlarged with phenolsulphonic acid, and unexpectedly an abscess sa,c was ruptured and pus, thick and yellow, with streaks of blood, flowed freely from the canal. The discharge was checked, the acid worked through the end and formocresol sealed in the canal. On this date (June 29) picture for Fig. 39 was taken. Patient did not return, owing to absence from city, until July 20, when the root-filUng was inserted. 23 354 . PRACTICAL DENTAL THERAPEUTICS Picture for Fig. 40 was taken September 9, about 7 weeks after root-filling operation and about 9 weeks after the pus was noticed. Picture for Fig. 41 was taken December 30, 1916. This case illus- trates the advantage of the radiograph in the treatment of all cases of pulpless teeth. Notice how the fluid gutta-percha escapes through the multiple foramina. Series No. 6 Patient. — Male. Age, about 38 years. The vital teeth in picture for Fig. 42 had carried an inlay bridge for several years. Decay had progressed under the molar inlay, and when patient presented the pulp of this tooth was highly congested and aching severely. Treatment. — On Sept. 5, 1916, when I first saw the patient, the pulp was caused to bleed and phenol compound sealed in the cavity. On Sept. 7 the patient returned giving history of the tooth being comfortable. At this time the bridge was removed and devitalizing fiber appHed. On account of my leaving the city and the patient being a dentist, the arsenical dressing was left for one week, with instructions to remove the same in case the tooth manifested sore- ness. This was not necessary and the patient returned on Sept. 14. Contrary to my usual custom of using formocresol after a pulp has been poisoned with arsenic trioxid, I removed the pulp at this sitting and cleaned the canals with phenolsulphonic acid. Eucalyp- tol compound was then sealed in, and on Sept. 18 the canals were filled. Picture for Fig. 43 was taken Oct. 5. In Fig. 44 we find a good illustration of the care that should be taken in the interpretation of dental radiographs. There is shown a dental granuloma on the mesial root of the lower molar, as was subsequently verified by treatment; but the point to which I desire to call especial attention is the dark line parallel with the distal root. This might be mistaken for a gutta-percha point passing through a punctured root. Closer examination will show that some- thing on the film, having no relation to the tooth, produced the shadow, for the line curves upward and may be noticed distal to the gold crown. Radiographs are a great aid in dental diagnosis, but they are by no means positive. Series No. 7 Patient. — Female. Age, 11 years. While playing at school, ah accident occurred on Oct. 20, 1916, in which both upper central incisors were broken off — one exposing the pulp, the other being nearly exposed. DIAGNOSIS AND TREATMENT OE PULPLESS TEETH 355 Treatment. — The pulp in the left central, which, was exposed, was carefully anesthetized by pressure anesthesia and removed by the family dentist. The pulp in the right central (not quite exposed) was removed under nitrous oxid-oxygen anesthesia. As the roots were not fully formed and the apices were large, the patient was referred for the root-filling operation. Picture for Fig. 45 was taken Oct. 21, after both pulps had been removed. On Oct. 24, both canals were cleaned with phenolsulphonic acid and eucalyptol compound was sealed in with double sealing. The root-filling operation in the left central was done on Oct. 26; in the right central on Oct. 30, when picture for Fig. 46 was taken. The root-filling was covered with zinc oxychlorid cement, as is my practice where it may be done, and the patient referred back to the family dentist with the sug- gestion that porcelain jacket crowns be made which would not disturb the root-fillings. The following two cases are from the practice of Dr. J. F. Biddle, Pittsburgh, Pa. Series No. 8 Patient. — Female. Age, 22. Presented with a badly swollen upper lip, nose and surrounding tissues. The tissues were so dis- torted that it was dif&cult to tell where the lip ended and the nose began. In the preceding 48 hours she had had chills and fever intermittently and her temperature at this sitting was 1023^°. Treatment. — On account of her extreme nervousness, it was im- possible to make an oral examination at this time; hence, nitrous oxid and oxygen were administered and the soft tissues at the jimc- tion of the Up and gum were lanced, about 45 minims of a thick yellow- ish-green pus being removed, after which the cavity was irrigated with physiologic salt solution and injected with 10 minims of tinc- ture of iodin. The patient was instructed to take a dose of Epsom salts and to keep an ice bag over the affected part. The following day her condition was much improved, temperature 99^°, and upon reopening the wound about 30 minims of pus and blood were removed. Radiograph for Fig. 47 was taken which shows that, of the four teeth crowned, none of their roots had been filled and all were ab- scessed. The crowns were removed and a treatment of formocresol was sealed in the canals. On the third day, the canals were opened to the apex with reamers, aided by 50 per cent, sulphuric acid. Upon going through canals at apex of roots there was no sensation, hence wires were inserted, and a second radiograph (Fig. 48) taken, to 356 PRACTICAL DENTAL THERAPEUTICS determine whether all canals had been properly opened. The worst condition was over the right lateral and central incisors, and as it was necessary to restore a healthy condition as quickly as possible on account of the patient's leaving the city, 50 per cent, sulphuric acid was forced through the canals of these two teeth and out through a sinus over the lateral incisor. This was followed by 4 ounces of physiologic salt solution using a 2-ounce syringe vnth a fine platinum point which was forced into the canal, while the sides were packed with unvulcanized rubber to prevent the return of the fluid. A second treatment of formocresol was sealed in the four teeth, and allowed to remain for 48 hours. The canals were then enlarged and a third treatment of formocresol (modified) was sealed in for 24 hours, followed by a treatment of oil of cloves which remained for four days. The canals were then filled and a temporary plate which had been made when the crowns were removed did duty for six months, after which the third radiograph (Fig. 49) was taken. Fearing lest the shadow over the right lateral might be an abscess still exist- ing over this tooth, the soft tissues were injected with novocain and a small bur used to enter the bone at the apex of the root, but it was found to be in normal condition and a specimen taken from this location was found to be negative. The fact that this area was not as dense as the remainder of the tract is evidently due to the amount of bone that was removed in enlarging the sinus and the area at the apex. Four years ago new crowns were adjusted to these teeth, from which time they have given the patient no further discomfort. Series No. 9. Patient. — Male. Age, 50. Very active — at his desk greater part of the day — conferences, also outside interests — works from 14 to 16 hours daily, hearty eater, moderate drinker. Had great powers of concentration which appeared to be much impaired within the last year. Examination revealed a sKght leaking of one of the valves of his heart, gastrointestinal disturbances, also trace of albumin in the urine. X-ray examination showed a number of unfilled roots, misfit crowns and pyorrhea alveolaris. Treatment. — The crowns and three teeth were removed. All other partially filled or gangrenous canals were treated and filled and the gums restored to a healthy condition. One tooth, a radio- graph of which I shall use to illustrate the regeneration of bone Series No. 8. Fig. 47. Fig. 48. Fig. 49, Series No. 9. Fig. so. Fig. si. DIAGNOSIS AND TREATMENT OF PULPLESS TEETH 357 around the apex, was considered hopeless. This tooth was exceed- ingly loose and when the debris was removed a flow of pus filled the cavity. The pus was evacuated as thoroughly as possible and a specimen was sent to the laboratory. It was found to contain strep- tococcus fecalis, streptococcus salivarius and streptococcus viri- dans. A treatment of formocresol was sealed in the pulp chamber. After 48 hours the treatment was removed and the canal was en- larged. Next the canal was cleaned with 50 per cent, sulphuric acid, and a second treatment of formocresol was sealed in for another 48 hours, after which a treatment of oil of cloves was allowed to remain in the canal for a week. The canal was flooded with eucalyptol which displaced the air, this in turn being displaced by chloro- percha, followed by a number of fine gutta-percha points, packed until the mass became solid. A crown with very Kttle contour was inserted, which was used as an attachment for a clasp on a plate. At the time of beginning of treatment of this case, radiograph for Fig. 50 was taken, and four months later for Fig. 51, which shows the rarefied area at the apex of the root to be filling in with bone in a very gratifjdng manner. I could cite many other cases with larger denuded areas, but this one I consider one of the most hopeless I ever attempted to treat. Since the patient's teeth have received attention and his mouth has been placed in hygienic condition his health has greatly improved. Whether or not this improvement be due to the correction of diseased oral conditions, I think we will all agree that abscessed teeth should receive early attention, no matter how or where we may find them. DIAGNOSIS AXD TREAT^IEXT OF NONSEPTIC PERICEMENTITIS GENERAL CONSIDERATIONS It is not the intention to introduce in these pages needless patho- logic facts, yet in the treatment of pericementitis it is important to remember that the pericemental membrane is very vascular and well supplied with nen,-es; that it is enclosed within bony walls, and, therefore, when inflammation exists in the tissue the membrane becomes thickened, forcing the tooth from its socket. This elonga- tion of the affected tooth is one of the chief symptoms of true pericementitis. Before discussing the therapeutics of this condition, I desire to indeHbly impress upon the mind of the reader the fact that this con- dition is too frequently produced by carelessness on the part of den- tists. It is not always possible to successfully perform dental opera- tions without irritating the susceptible pericemental membrane; however, much of the trouble can be avoided if judgment is exercised and proper precautions are taken in treating teeth. It is essential that we differentiate between nonseptic and septic pericementitis. Both are inflammatory conditions of the perice- mental membrane, the difference being due largely to the exciting agents causing the pathologic condition. Nonseptic pericementitis results largely from drug or mechanical irritants, while septic perice- mentitis is caused by pathogenic bacteria and other poisonous and irritating substances which have escaped from septic root-canals. Both conditions may result in suppuration; the former through cryp- togenic or hematogenous infection from the circulation, the latter as the natural consequence of the progress of the disease. I shall discuss here the treatment of nonseptic pericementitis only. Those cases resulting in pus formation or alveolar abscess -^dll be con- sidered subsequently. There are at least two classes of irritants by which nonseptic pericementitis is produced, \'iz. : 1. Drug irritants. 2. Mechanical irritants. Drug Irritants. — There are many circumstances and conditions which influence the action of drugs upon dift'erent individuals and TREATMENT OF NONSEPTIC PERICEMENTITIS 359 upon the same individual under different conditions. We find cases occasionally where pulps have been removed by pressure anesthesia, and where, seemingly at least, every precaution was taken in steriUz- ing the dentin, selecting a sterile anesthetizing solution, and in applying the pressure, yet severe apical pericementitis follows. This may or may not be due to the drugs used in performing the operation. There are cases, too, where the pericemental membrane becomes highly inflamed and extremely responsive from the action of arsenic trioxid, even when the drug was properly sealed within the tooth only a short time. These are conditions over which the operator seems to have no control. I know that this is a dangerous doctrine to promulgate; for it is so easy to blame the patient for some idiosyn- crasy, when the fault is ours. Drugs are often responsible for these conditions by having been injudiciously employed; yet it is only fair to state what every pharmacologist knows to be a fact that the action and effect of drugs are modified or influenced by such conditions as disease, temperament, sex, race, size, age, habit, idio- syncrasy and temperature, and the method, time of administration, preparation and dose of the drug. It has been stated elsewhere that anodyne treatment is indicated after the mechanical or surgical re- moval of the pulp. Therefore, care should be taken to select drugs for this purpose which produce a soothing and not an irritating effect. There are some instances in dental practice where we desire to irritate and thereby stimulate the pericemental membrane; but this should be avoided here. Judgment should also be exercised in sealing in anodyne remedies, such as phenol, oil of cloves, etc., in the canals, especially in bicuspid and molar teeth, for should the temporary filling be left too full and the remedy forced through the apex by the closing of the jaws, even these agents cease to be anodynes and be- come irritants. Whether phenol, oil of cloves, and similar drugs or remedies are anodynes or irritants, depends largely, then, on where and how they are used. In filling root-canals it is the practice of many dentists to moisten the canals with eucalyptol before introducing chloropercha and the gutta-percha cone. Care must be taken here to use eucalyptol and not oil of eucalyptus, unless it be the refined product. Commercial oil of eucalyptus has been the cause of many cases of apical perice- mentitis following the most careful filling of root-canals. The eucalyptus tree produces a volatile oil which contains three constitu- ents, each distilHng over at different temperatures ; the first product thus obtained is eucalyptol, hence the most volatile constituent of oil of eucalyptus and the one which is the solvent for gutta-percha. 36o PRACTICAL DENTAL THERAPEUTICS While eucalyptol is a slight irritant, it is not nearly so irritating as oil of eucalyptus. The irritating property of eucalyptol can be modified and its antiseptic value increased by adding menthol and thymol in the following proportions. I^ — Mentholis, Thymolis, Eucalyptolis, Sig. — Use as directed. gr. ij (0.13 Gm.) gr. iij (0.18 Gm.) f5j (4.0 mils) — M. This remedy is equally as good a solvent for gutta-percha as is euca- Ij^tol alone, and will be called eucalyptol compound in the following pages. Some drugs when internally administered, notably mercury and its compounds, are capable of producing nonseptic pericementitis. This has been previously mentioned under Mercurial Stomatitis. Mechanical Irritants. — The pericemental membrane is fre- quently, I might add too frequently, irritated by mechanical irritants, such as root-canal fillings. There is, perhaps, more pericementitis produced by root-canal fillings than by any other mechanical irritant. In filling root-canals we should be absolutely certain that the canal is aseptic. If there be any doubt as to this, the operation should be deferred. The technic of filling root-canals will be discussed later. Fig. 52. There are many other mechanical irritants which can be men- tioned as causative factors in producing pericementitis; suchjas ill-fitting partial plates, crowns and bridges, malleting, regulating, faulty occlusion, calcific deposits on the roots of teeth, impaction of f od betv/een teeth with faulty or no contacts, etc. (Fig. 52.) This patient presented with a case of severe pericementitis. Not having treated the tooth myself, the picture was taken to ascertain the condition of the canals of the second molar. It shows that the mesial canals were small and tortuous and not filled to the end. This might have caused the pericemental trouble; but, at the time, I TREATMENT OF NONSEPTIC PERICEMENTITIS 36 1 questioned it very much. You will also notice that a pulp nodule shows distinctly in the third molar. This was verified by a second radiograph. As yet the nodule is causing no trouble. The occlu- sion on the inlay was a little too full and there was a slight tendency toward a pyorrheal pocket on the distal, due to the tooth tipping forward owing to the loss of the first molar and the occlusion — thus opening the contact slightly. Here we had four possible causes for the pericementitis: The nodule in the third molar, the faulty contact and the resultant impaction of food between the molars, the occlusion, and the imperfectly filled root-canals of the second molar. The adjustment of the occlusion and the scaling and polish- ing of the exposed tooth-surface cured the case. This was done three years ago and there has been no recurrence of the trouble. Treatment of Nonseptic Pericementitis.— ^The first step in the treatment of nonseptic pericementitis is to adopt the surgical prin- ciple of ascertaining the cause and removing or correcting it, if at all possible. In the earUer stages of pericemental inflammation, it is not always an easy matter to ascertain the true cause of the dis- turbance. For instance, in those cases following the removal of the pulp tissue, it is difficult to know whether the cause is the root- filUng, the medicine used in the treatment, or whether we failed to estabHsh and maintain asepsis in performing the operation. The • author is inclined to believe that it is more frequently the latter than most operators are willing to admit; for certain it is that the more nearly we approach absolute asepsis in these operations, the less pericemental trouble we will have. The teeth thus affected are extremely sore, and any remedy can be used in the treatment that will give immediate relief. This is what the patient most desires, and, too often it appears, it is that which the dentist fails to give. Both local and general remedies can be employed. General remedies are more valuable in the treatment of septic pericementitis. If they are used at all in treating nonseptic pericementitis, they should be used only in cases where the patient is nervous and has lost con- siderable sleep, unless some drug, like nitroglycerin, is given to relieve the engorged capillaries. For immediate relief we must depend largely upon the local application of drugs and remedies. In those cases following the removal of the pulp by either the anesthetization or devitahzation method, and where the canals have not been filled, the pain can be relieved almost instantly by the following method: Adjust the rubber dam. If it is necessary to use a clamp, it should be placed on the tooth posterior to the one affected. Sterilize the teeth included in the dam and remove the dressing from the canals. 362 PRACTICAL DENTAL THEEAPEUTICS Dehydrate the tooth-structure with modified alcohol. Then wrap cotton loosely around a smooth, sterile broach, dip in oil of cloves or eugenol, and carefully work in each canal. Remove the broach, leaving the cotton. Heat should now be apphed to the remedy by means of a hot-air instrument or a chip-blower until the cotton be- comes dry. Repeat this process several times, after which the same remedy should be carefully sealed within the canal. Under no condition should the cavity be left unsealed. In the above treatment, we not only get the benefit of the heat, which is valuable, but the eugenol, the constituent of cloves, is driven into the tooth-struc- ture, producing a profound anodyne effect upon the sensitive mem- brane. The author has succeeded in giving immediate rehef by this method of treatment when many others have failed. Grinding the cusps of the tooth where it can be done without injury is advisable; a counterirritant can be appHed to the gum and the patient dismissed for several days. It is weU also to prescribe two or three doses of nitroglycerin to faciUtate the circulation of blood in the membrane. It is scarcely necessary to instruct the patient to favor the tooth. In the treatment of pericementitis following the filHng of the root, having every reason for beUeving the canals to be aseptic, one of the last things the author would suggest doing would be to attempt to remove the root- filHng. Usually this only serves to further aggra- vate the condition. These cases can best be treated by counterir- ritation and general remedies. By counterirritation is meant the appHcation of an irritant to some normal part of the body for the purpose of influencing favorably some other part, usually deep-seated, which is diseased. This irritant is generally applied to the gum over the affected tooth. Capiscum plasters, black mustard papers and cantharidal collodion are valuable; or the following liniments, which are more generally used, give much relief : I^ — Mentholis, gr. xx (1.3 Gm.) Chloroformi, fSJss (6.0 mils) Tincturae aconiti, q. s. ad. f5j (30.0 mils) — M. Sig. — Dry the gum and apply freely over the affected tooth, keeping the field dry for a few seconds This preparation is known as dental linifnent. I^ — Mentholis, lodi (crys.), aa gr. x (0.6 Gm.) Chloroformi, fSjss (6.0 mils) Tincturae aconiti, q. s. ad. f5j (30.0 mils) — M. Sig. — Make one application to the dry gum as above. This liniment is called refrigerant counterirritant. TREATMENT OF XOXSEPTIC PERICEMENTITIS 363 I^ — ^Liquoris iodi compositas, f5j (30.0 mils). Sig. — Use as above. This is the official compound solution of iodin, known also as Lugol's solution. Inasmuch as tincture of aconite is an important ingredient in many liniments used in the local treatment of pericementitis and facial neuralgia, it is well to remember that the United States Pharmacopeia of 1900 reduced the strength of this preparation from 35 per cent, to 10 per cent. This is also the strength of the prepara- tion in the U. S. P. IX. Therefore the new tincture can be employed more freely in these cases without danger of poisoning. However, care should be taken to see that, in applying remedies containing tincture of aconite to posterior teeth, the patient does not swal- low the remedy; especially should this precaution be observed in using dental liniment. As a remedy to be apphed by the patient at home, a split raisin, soaked in hot water, and on which is dusted red pepper, can be held on the gum over the affected tooth. A very efficacious remedy is to direct hot water -^-ith some force on the part, beginning -vN^ith warm water and increasing the heat gradually until it is nearly boiling. This must be kept up until we get the full benefit of the heat and resolution is promoted. Another good remedy that the patient may employ is the hot foot-bath. The value of this remedy, Hke the appHcation of hot water to the gums, depends largely upon the man- ner in which it is applied. A deep foot-bath tub should be used and the temperature of the water gradually increased until it is as hot as can be borne. This should be continued from twenty to thirty minutes. There are many other drugs and remedies which can be employed in the local treatment of this condition. Those which have been mentioned here the author has found valuable in his practice. It is far better to have a practical knowledge of a few remedies than a superficial knowledge of many. The general remedies to be admin- istered in the treatment of nonseptic pericementitis, if found neces- sary, will be discussed subsequently under the treatment of septic pericementitis and incipient abscess, which conditions are closely related. DIAGNOSIS AND TREATMENT OF SEPTIC PERI- CEMENTITIS AND ACUTE ALVEOLAR ABSCESS GENERAL CONSIDERATIONS The treatment of septic pericementitis and acute alveolar ab- scess, as was intimated under Nonseptic Pericementitis, is so nearly identical that the therapeutics will be discussed here conjointly. Suppurative pericementitis which occurs in the periapical area means an alveolar abscess, for suppuration implies the presence of pus. In those cases of gangrenous pulps where the patient did not present for treatment until the confined gases had escaped into the periapical tissue, carrying therein the bacteria and toxins, we will find that a practical knowledge of pathology and therapeutics will serve us well. It is in these cases that good judgment must be exer- cised and extreme care taken. Frequently patients delay coming to the dentist until the infection has progressed to the point where all remedies will fail in preventing suppuration; but in many in- stances this result may be attained by the proper use of drugs. In this connection it is well to remember that Hopkins, of Boston, a few years ago conducted a series of experiments in which he proved that not only did bacteria proliferate more rapidly in uncared-for and neglected mouths, but that their virulency was greatly enhanced. Blair states that "certain pus-producing organisms, such as the Staphylococcus and Streptococcus pyogenes, will always tend to pro- duce pus. Often, however, owing to the lack of virulence or lack of sufficient numbers in proportion to the tissue resistance, the inflam- matory process may be cut short before it reaches the stage of sup- puration. Thus there may be swelling of the gum and face around an infected tooth, but this may subside without the formation of pus." To this I may add that this is especially true if the tooth receives the proper treatment. Local Treatment.' — The local treatment here differs in no par- ticular essential from that outlined for a case of gangrene of the pulp. The tooth should be located and the pulp-chamber opened into freely, under aseptic precautions, holding the tooth in some manner so that the chisel, bur or excavator will not further aggravate the condition . Then the cavity should be sprayed or washed with an antiseptic solution, dried, in this case with alcohol, and formocresol sealed in 364 TREATMENT OF SEPTIC PERICEMENTITIS 365 the pulp-chamber with cement. I know, to my regret, that this is not the general method of procedure in the handling of these cases; but I am certain that the best results will be obtained when we follow the general rule that all remedies should be sealed with cement. This will force us to correctly diagnose the condition and employ the means and remedies indicated in the rational treatment of the case. Until we are wilHng to spend the necessary time to accomplish this end, we are not living up to the highest ideals of our calling. Let it be remembered that as yet there is no suppuration in these cases, and any dentist who deliberately leaves the canal and cavity open to external influences, or who uses temporary stopping because it is easily removed, and instructs his patient how to remove it should the tooth continue to ache, either does not understand the condi- tion he is treating or else he lacks confidence in his remedy. Make a correct diagnosis, use the proper remedy in the proper way and the tooth will not ache long — it matters not what the pathologic condition may be. General Treatment.' — After applying the local remedies, our attention should be given to the treatment of the infection and inflammation in the periapical area, which consists in promoting or regulating the inflammatory process. Again quoting from Blair, he says: "After an infection has once gained a foot-hold in the living tissue, we must in our treatment regard not only the infection but the inflammatory process that it has excited. We are not certain that the inflammatory process itself ever needs treatment, and we know that there are very few, if any, infections that could ever be overcome without inflammation. Inflammation is Nature's way of fighting infections, and we must work with it, not against it; for otherwiseour efforts will be in vain. * * * One of the first requisites is the regulation of the body functions, especially the excretory organs. In the presence of an infection, the parenchymatous cells of various organs may become sluggish in their action and may require stimulation." In such cases the skin may be stimulated by bathing, and saline cathartics are indicated. Owing to the faciHty with which it can be taken and its acceptability to the stomach, the official solution of magnesium citrate is an excellent remedy to prescribe. I^ — ^Liquoris magnesii citratis, f§xij (360.0 mils). Sig. — Take one-half at once and the other half in two (2) hours, if necessary. Magnesium sulphate can also be given for the same purpose. With this drug the patient should be directed to take a teaspoonful 366 PRACTICAL DENTAL THERAPEUTICS dissolved in a wineglassful of warm water, having a glass of cold drinking water at hand to drink at once after taking the strong hyperisotonic salt solution. The cold water .instantly removes the bitter and unpleasant taste of the salt. Most of .the large pharma- ceutical houses to-day prepare "effervescent salt mixtures," of which the more important saHne carthartics are constituents. These are kept by the pharmacies and come as a granulated powder which when dissolved in water makes an effervescent solution. Several that can be mentioned are: Effervescent Magnesium Citrate, Effervescent Magnesium Sulphate, Effervescent Laxative, Effer- vescent Seidlitz Mixture, Effervescent Sodium Phosphate — any one of which can be prescribed. Potassium iodid in medicinal doses can frequently be admin- istered, with beneficial results. The taste can be masked to a large degree by dissolving it in one of the official syrups. The official compound syrup of sarsaparilla and aromatic syrup of eriodictyon (yerba santa), N.F., are both good. A prescription is here given: I^ — Potassii iodidi, 5ss (6.0 Gm.) Syrupi sarsaparillas comp., fSiij (90.0 mils) — M. Sig. — Take a teaspoonful in water after meals. Ordinarily, the directions would be as given, to have the patient take a teaspoonful three times a day after meals; but in these cases of septic pericementitis or incipient alveolar abscess it is best to direct the patient to take a teaspoonful every two hours until three or four doses are taken, and then follow the directions written on the label. A very good remedy to have the patient employ at home is the hot foot-bath; unless some condition exists which is a contrain- dication, it is always good practice to administer nitroglycerin to de- plete the capillaries in the affected, and in these cases infected tissues. As stated on p. 203, echafolta is a purified, assayed form of echinacea — a drug which is used extensively by eclectic medical practitioners. The author is able at this time to report favorably on the use of echafolta in all cases of infection. The dose here is from 5-30 min. (0.3-2.0 mils) given in water every two hours, until the acute symptoms subside. Heretofore I have prescribed and recommended, purely on an empirical basis, the salts of quinin in the treatment of infections in certain cases. I have since learned, however, that this drug inter- feres with the ameboid movement of the white blood corpuscles, preventing them from migrating through the capillary walls in Fig. 53. — An acute alveolar abscess with extensive swelling, involving^ the entire side of the face, and completely closing the eye. If extraction of the offending tooth is necessary to effect a cure, the operation should be postponed until the inflammation and swelling have been reduced by proper treatment. In this case it was necessary to make an external incision. Generally this may be avoided by making a deep intra-oral incision, as recommended by Brophy. TREATMENT OF SEPTIC PERICEMENTITIS 367 inflammation. The arrest of this movement lessens the phago- cytic power of these scavengers; therefore, quinin is contraindicated in the treatment of periapical infections, unless we desire to lessen tissue resistance and hasten the formation of pus, when it might be given. The salt which the author prefers giving, if indicated in the conditions under consideration, is quinin bisulphate. Nearly all pharmacies have the salt of quinin bisulphate put up in the form of pills. While these pills may be given, it is much better to write a prescription for capsules. The gelatin capsule is soon dissolved in the stomach; thus we obtain the action of the drug more rapidly than when given in the dry, hard, pilular form. The following prescription can be written for the drug in two-grain doses: I^ — Quininse bisulphatis, gr. xxiv (1.5 Gm.)- Ft. capsulce No. xij. Sig. — Take one capsule every hour until the effect becomes noticeable. Quinin acts differently upon different individuals. Most adult patients know the effect of this drug upon their systems, and therefore will be able to aid the dentist in determining the amount to be taken in a given case. One of the most prominent symptoms with which we have to contend here is pain. In most cases the pain will subside soon after the local treatment; however, it is necessary, occasionally, where the patient is nervous and has lost considerable sleep, to administer drugs which act upon the central nervous system, thereby controlHng the pain. There are several drugs which, if properly given, will produce the desired effect. The official compound powder of ace- tanilid is here recommended and can be prescribed as follows : I^ — Pulveris acetanilidi comp., gr. xij (0.8 Gm.) Ft. chartulae No. ij. Sig. — Take one powder at once and the other in two (2) hours, if not relieved. Another very useful prescription for acetanilid is one suggested by Harlan. It follows: I^ — Acetanilidi, gr. viij (0.5 Gm.) Syrupi simplex, fgss (15.0 mils). Spiritus frumenti, q. s. ad. f§iij (90.0 mils) — M. Sig. — Take one-half at once and the remainder in two (2) hours, if not relieved. 368 PRACTICAL DENTAL THERAPZUTICS Keefe. of Chicago., suggests using dilute alcohol by which in- stantaneous and often permanent relief can be obtained in those cases where the tooth involved is one of the six upper anterior teeth. A prescription for the remedy is here given: E — Alcoholis, Aquae, a a foj .30.0 mils'.' — 'M. Sig. — Use as directed. This remedy is best administered in the form of a spray, using a watch-case atomizer for liquids, forcing the spray well back into the nostril on whichever side the afiected tooth is located. The apphca- tion can be repeated as often as is necessary, without any ill effects. In case an atomizer of any kind is not at hand, about fifteen minims (i.o mil) of the remedy can be placed far back in the nostril with a suitable syringe. The author does not wish to be understood as suggesting these various internal remedies in all cases of acute abscess. Xo therapeu- tist can tell exactly what internal drugs he would suggest v.-ithout seeing th€ case and knowing the history; for there are many circum- stances and conditions which modify the efiect of drugs. Every remedy here mentioned, however, v,-ill be foimd useful in certain cases. The Question of Extraction. — The question of extraction in acute alveolar abscess is a disputed one. Many writers recommend extraction as a speedy means of affording rehef (see Fig. S5^- Fig. 54. — This shovrs a sequestrum which, was exfoliated from the lovrer javr. This result followed extensive infection, endangering the life of the patient, and uldmate necrosis from the extraction of a lower second bicuspid root during the acute stage of an alveolar abscess. A mLxed infection doubdess resulted from the laceration of tissues. It wdl be noticed that the sequestrum contains the mental foramen, which means, of course, that the inferior dental nerve, arter\-, and vein were severed. The Up on the afiected side was partially paralyzed for a period of two or three years; and, in opening into the first bicuspid for the purpose of pulp removal for bridge-work, six months later, the pulp was dead and just beginning to "undergo the process of decomposition. I rather suspected a specific his ton.-, but was unable to confirm the suspicion. Unfortunately, however, this is not always the solution of the problem; for if there be much osteomyehtis and the roots of the offending tooth be firmly embedded, it is a rather dangerous pro- cedure to extract during the developmental stage, on account of the liabilitv of a mLxed infection, resulting oftentimes in necrosis and TREATilEXT OF SEPTIC PERICEMENTITIS 369 frequently even th.reatening the life of the patient (see Fig. 54). If the root be a worthless one and easily extracted, its removal would doubtless afford free drainage for the abscess. There is no set rule governing extraction in these cases. The operator must be guided largely by the conditions as found. When extraction is resorted to, antiseptic mouth-washes should be prescribed and the case watched closely for a few days until we are certain that no com- plication will follow. CHRONIC ALVEOLAR ABSCESS GENERAL CONSIDERATIONS There are two varieties of chronic alveolar abscesses — those without an external opening except, perhaps, through a cavity in the offending tooth, and those which are discharging through a sinus. In these cases the decomposition of the pulp tissue is complete; the inter- mediate products (ptomains and amido-acids) have largely been broken up, and pus has been formed from the tissue and fluids sur- rounding the ends of the roots. Wherever it is possible, a radiograph of the affected tooth and periapical area should be obtained; for upon the radiographic findings to a large degree will our decision depend as to whether the case should be treated medicinally, surgically, or both. In the past many teeth with chronic alveolar abscess as- sociated therewith have been retained in the mouth, in utter disregard of the possible deleterious effects they might have on the general health of the patient. This will not be the practice of dentists in the future; though it may safely be said that, at the present time, many teeth are being sacrificed which, under proper treatment, might be saved without menacing or jeopardizing the patient's health. I. ABSCESS WITHOUT SINUS In treating that variety of alveolar abscess which is without an external opening, our method of procedure is somewhat different from that of an acute abscess. The tooth should be located; the rubber dam adjusted, and the teeth sterilized as before; then the pulp chamber is opened with a suitable round bur. Disposing of the Pus. — Usually the pus flows freely, in which case it is permitted to do so, pressure being made on the tissue im- mediately over the end of the root. It should be our effort to me- chanically evacuate as much pus at each sitting as is possible; for it is far better to remove pus in this manner, when it can be done, than to depend upon some chemic agent to destroy it, or upon Nature to dispose of it. THERAPEUTICS The formocresol remedy will be useful here. The canals should be dried with alcohol as thoroughly as possible and the remedy on 370 CHRONIC ALVEOLAR ABSCESS 371 cotton hermetically sealed in each canal. It is, however, at this sitting, impossible to get the canals dry, and it is unnecessary to have them so, for the remedy will penetrate where moisture is present. This is an advantage over most remedies suggested for this purpose. In those cases where there is pain and swelling, together with a copious flow of pus which seemingly cannot be checked at this time, it may be necessary to evacuate the pus as completely as possible, loosely place in the canal a few shreds of cotton saturated with an antiseptic remedy (phenol compound), and then place in the cavity a pledget of cotton dipped in liquid petroleum. In no case should the cavity be left entirely open; and the author desires to emphasize that it is seldom necessary to resort to this temporary expedient, if the proper time is spent in opening into the tooth and evacuating the pus. The dressing, in any event, should be changed every day until it can be removed without the pus flowing from the canals. When pus is forming rapidly at the ends of the roots, the dressing soon be- comes dissipated, the remedy loses its effect, and it is a loss of time to leave it in the canals more than twenty-four hours. Unless there be some complication, the pus formation should be checked in one or two treatments, at which time phenolsulphonic acid can be used in the same manner as in the treatment of gangrenous pulps, and eucalyptol compound sealed in the canal with the double sealing material as elsewhere explained. It is now possible to change the dressings too often, however. The formation of pus has been checked, and the tooth should not be disturbed for at least one week or ten days, in order to give Nature a chance to effect a cure. If, at the end of this time, there is no evidence of pus and the case gives a favorable history, the canals can be filled. Should there, however, be a slight odor, although the tooth has not caused any trouble, we are not justified in filling the root. In these cases we may suspect a root-end involvement, or some other complication, when the radio- graph is invaluable. Formocresol may be used again as in the initial treatment; but it should be remembered that the value of formal- dehyd in any remedy to be used in the treatment of these conditions depends upon the power this agent has of uniting chemically with hydrogen sulphid, ammonia and poisonous ptomains. When these substances are not present, formaldehyd should be used with care and judgment. This precaution is mentioned here because formaldehyd is an irritating gas, and the amount of any remedy con- taining it should be in accordance with the conditions as found. Weeping of Serum. — Quite frequently in these alveolar abscess cases, after the formation of pus has been checked, we have a weep- 372 PRACTICAL DENTAL THERAPEUTICS ing of serum from the canals. An excellent remedy to use in this case is eucal3T)tol to which thymol has been added in the following proportion: I^ — Thymolis, gr. x (0.6 Gm.) Eucalyptolis, f5j (4-o mils) — M. Sig. — Dry the canal as thoroughly as possible and hermetically seal in the remedy. If this remedy fails to check the secretion and the fluid is serum, not pus, no hesitancy need be felt as to filling the root, although the canals cannot be dried. The condition should not be confused with a cyst, which quite frequently occurs in the apical area of teeth. Brophy defines a cyst as a sac containing fluid, or a semi-fluid sub- stance, which may be gelatinous or inspissated. A cyst may con- tain mucus, saliva, bile, urine, etc., depending upon the organ with which it is associated. It should not be diflicult to differentiate cystic fluid from normal serum which also frequently fiJls a cavity formed by an abscess. In fact the serum contains the elements with which Nature rebuilds the lost tissue. If a cyst is suspected the diagnosis should be confirmed. The treatment of a cyst is surgical, for which the reader is referred to works on Oral Surgery. Complications. — Occasionally we find a chronic alveolar abscess of this variety where it is almost impossible to check the formation of pus by applying drugs to the canals of the teeth. In those cases where the pus continues to flow freely when the dressing is removed at the third or fourth sitting, some complication can be expected. It is necessary then to force some stimulating agent through the apices of the roots, after the pus has been mechanically evacuated. The stimulating agent which the author uses almost invariably is phenolsulphonic acid. In resorting to this means of bringing about a more acute condition, I desire to emphasize the necessity of first evacuating the pus as completely as possible before using the remedy, after which the agent should be placed in the canal on cotton and gently forced through the apices, then neutralizing that which remains with a solution of sodium bicarbonate, desiccating the canal with alcohol and hermetically sealing therein an antiseptic like phenol com- pound or eucalyptol compound. It will be found that one or two treatments will usually check the formation of pus, after which the case can be treated as an ordinary abscess of this kind. In case this method fails to effect a cure, however, it will be necessary to estab- lish surgically an opening through the overlying process and soft tissue and treat as for an ordinary discharging abscess — which treatment will be considered later. Fig. 55. — A chronic alveolar abscess from an upi _: !_-: niolar, where the pus in making its exit worked its way upward and outward, over the outer wall of the antrum and opened externally on the face. The tooth was badly decayed and was extracted May 12, 191 2. The picture was taken two days later. The case >"ielded nicely to treatment, which consisted in washing the part with an antiseptic solution, lea\"ing only a sHght indentation on the cheek. This case is unusual. Generally these abscesses open within the mouth or occasionally into the antrum, rarely externally. Abscesses from lower teeth frequently discharge externally (see Fig. 83). CHRONIC ALVEOLAR ABSCESS 373 Hypertrophied Alveolar Process. — This condition is quite fre- quently associated with abscesses without a sinus, or a low chronic inflammation of the alveolar process due to septic foci at the root- ends of pulpless teeth. It is the safest practice to extract teeth which have caused hypertrophy of the alveolar process. Even the aseptic treatment and filling of the canals of the affected teeth will not reduce, in many cases, the hypertrophied process, and to permit it to remain might lead to an osteoma or an osteosarcoma (Marshall). 2. ABSCESS WITH SINUS In those cases where the pus is discharging into the mouth through a sinus, our first duty is to locate the offending tooth. This is gener- ally a simple matter fpr the reason that the sinus usually opens imme- diately over the tooth from which it comes. The pus in making its exit, however, follows the line of least resistance, and in some cases the condition of the process is such that the pus burrows forward or backward, and opens through the gum at a point several teeth removed from the one which is causing the trouble. (Fig. 55.) These are the cases that are difficult to diagnose, especially when the abscess has been discharging for some time, when there is not much tenderness in any special tooth, and when there are several pulpless teeth on this side of the mouth. Sometimes two or more teeth containing gangrenous pulps have a common sinus (see Fig. 65 and Figs. 83 and 84). In this case it would be impossible to heal the tract by treating only one of the teeth. The use of a silver probe will be valuable in all such cases. By gently working the probe forward or backward the sinus can be explored and the offending tooth or teeth located without drilling into innocent teeth — a discour- aging procedure to both patient and dentist. In all such cases the radiograph is an invaluable aid in diagnosis. THERAPEUTICS The tooth being located, all that is necessary to effect a cure — there being no complication — is to clean the canal with acids or alkalies, preferably the former, and then force some bland solution through the root-canal and sinus, thus being certain it is well estab- lished; cauterize the tract with phenolsulphonic acid, or other stimu- lating cauterant, hermetically seal in the canal or canals an anti- septic, like phenol compound or eucalyptol compound, and, at the subsequent sitting, the case giving a favorable history, fill the root 374 PRACTICAL DENTAL THEEAPEUTICS Establishing Sinus and Disposing of Pus. — If the abscess is not discharging, and in those cases where it is discharging, it is well before adjusting the rubber dam to enlarge the mouth of the sinus with a lancet or bistoury. By dipping the lancet in phenol, this may be accomplished with very Uttle pain to the patient. After this is done, the rubber dam should be adjusted and the canals freely exposed. Now that the infection is past the end of the root, we need not hesitate to clean the canal at this sitting by chemico- mechanical means. The canals being clean, we are ready to establish the sinus. To do this we need a bland solution and a good hypo- dermic syringe with a long straight needle for anterior and a long curved needle for posterior teeth. There is an advantage in having a long needle, for the nearer the point is to the apex of the root, the less packing and force are required to send the solution through the sinus. Any bland solution can be used for this purpose. The author suggests physiologic saline solution or peppermint water to which 2 min. (0.12 mil) of phenol have been added to the fluidounce (30.0 mils). A piece of unvulcanized rubber of the proper size should be selected, softened in the flame, and a hole made in the center through which the needle is placed and inserted into the canal. The rubber should now be tightly packed around the needle and held on either side with flat-nose pHers, when pressure can be made on the piston of the syringe and the solution forced through the sinus. This should be repeated several times, care being taken not to break the needle in the canal. If convenient, one corner of the dam can be raised, exposing the mouth of the sinus to view. There are two objects in forcing a bland solution through the sinus: one is to be certain that it is open, and the other is to mechanically wash out the pus. Whenever pus can be mechanically removed, it is always better to dispose of it by this means rather than to do so by the use of some chemic agent. It has been a common practice, after establishing the sinus, to use a solution of hydrogen dioxid. This is often a dangerous procedure and always unnecessary if the first solution has been used in sufficient quantity. Cauterizing Sinus. — For cauterizing the sinus in simple cases 95 per cent, phenol has been largely employed. An excellent prepa- ration to use for this purpose is the phenolsulphonic acid. With the sinus well established, it is never necessary to place either of these solutions in a hypodermic syringe. The author knows of several instances where this has been tried with disastrous results. The remedy can be appHed to the canals on cotton, when, with unvul- canized rubber and a suitable instrument, it can be forced through CHRONIC ALVEOLAR ABSCESS 375 the sinus. Alcohol is a positive antidote for phenol; if this agent is used, the alcohol bottle should, therefore, be in a convenient place so that the remedy used in the canal can be neutralized at once when it appears at the mouth of the sinus, Phenolsulphonic acid may be neutralized in this case with alcohol followed with a solution of sodium bicarbonate. If this has been well done, it matters little what drug or remedy is sealed in the canal. The phenol compound or eucalyp- tol compound remedy will give excellent results if hermetically sealed in the canals for about one week, always using the double sealing process. In cases of long standing when we can reasonably suspect a rough- ening of the end of the root or process through which the pus has been Fig. 56. — This radiograph illustrates an interesting case, which was not treated by the author and the history is, therefore, negative. The radiograph shows that the canal is not properly filled, while the root carries a well-adjusted porcelain crown. It is futile to attempt to cure an abscess under such conditions by simply injecting such an agent as bismuth paste through the sinus into the affected area. The crown must be destroyed, the canal reopened, when one or two treatments of phenolsulphonic acid should effect a cure. Had the radiograph shown that the canal was properly filled, external curettement would have been the proper treatment. In fact, had the canal been properly filled, the abscess, in all probability, would not have developed. discharging, it is best to depend upon phenolsulphonic acid as the cauterizing agent (see Fig. 56). This agent, as heretofore made, con- tained an excess (15 per cent.) of uncombined sulphuric acid, which rapidly disintegrated cotton; therefore, it was necessary to place it in the canal on threads of asbestos, wool fiber, or silk, and force it through the sinus in the usual manner, cauterizing the tract, and also stimulating the sluggish cells in the area to healthy activity. It is now possible to procure phenolsulphonic acid with less than i per cent, of free sulphuric acid (see p. 95). This product can be used 'with cotton. It is sometimes difficult to establish the sinus, especially on molar teeth. In all such cases, if there is no compHcation, the 376 PRACTICAL DENTAL THERAPEUTICS treatment can be that outlined under Treatment of Abscess Without Sinus. The author does not believe in delaying the root-filling long after the sinus has been cauterized in uncompHcated cases; for by filling the root as soon as we are certain that the sinus is heahng, we avoid a weeping condition, which usually exists and which is annoying when this part of the treatment is delayed for one month or six weeks as advocated by some writers. In these case's where the first treatment has been thorough, and the case gives a favorable history, the root should be filled at the second or, at latest, the third sitting. If the case does not yield to the above treatment, some complication may be suspected. COMPLICATIONS There are several complications of chronic alveolar abscess of both varieties, with and without a sinus, where it is necessary to Fig. 57- Fig. 57. — This radiograph shows an abscess with extensive resorption of alveolar process between the central and lateral roots, both of which had been previously filled and carried jacket crowns. The radiograph shows the lateral root perfectly filled and the abscess caused by the imperfectly filled central. These cases are often diflacult to diagnose. Fig. s8. — This radiograph shows a simUar case to that illustrated in Fig. 57. It was difficult to determine whether the abscess came from the central or lateral root. The radiograph shows the lateral root over-filled, but the abscess coming from the central. modify or change the general method of treatment to meet the condi- tions as they exist. For instance, in the case of an abscess without a sinus where we can reasonably suspect, and where the indications point to, a roughening of the end of the root, we ought not to expect to cure the case by simply seaHng remedies within the canals of the tooth. If we do, we are expecting too much of drugs. Again, in a case of abscess with a sinus where the pus has been discharging for Labial glands. Muscle Muscles. Sinus. Fig. 59. — Chronic abscess discharging under the chin. CHRONIC ALVEOLAR ABSCESS 377 several months, with the not unusual result that the end of the root or process through which the pus has discharged has become roughened, we should not expect to effect a cure by forcing phenol or the phenol compound through the sinus, because such agents as these have no action whatever on the bony structures. The author desires to emphasize again the value of the radiograph in determining the extent of involvement and the nature of the complication. It is not always a positive means of diagnosis, but it is a material aid (see Figs. 57 and 58, also Fig. 59). 1. Denuded End of Root. — One complication we may expect to find in abscesses of long standing, especially in the variety without a sinus, is where a large area of tissue in the periapical area has been re- sorbed or broken down, denuding the end of the root and the denuded Fig. 60. — This radiograph shows a typical abscess without a sinus which developed from an imperfectly filled root of a lateral incisor. portion projecting into the absorbed area (see Fig. 60) . It is possible, in these cases, to make pressure over the end of the root and mechani- cally evacuate all of the pus above the apices ; but we cannot expect by this means to evacuate the pus below and surrounding the end of the root projecting into the space. In this case we must do one of two things: Force some stimulating agent through the end of the root into the infected area, to create a more acute condition ; or surgically estabhsh a sinus through the overlying process and soft tissue, and treat as an ordinary discharging abscess. While the author does not hesitate to adopt the latter method if necessary to effect a cure, it will be found that the use of a stimulating agent will generally suflace in these cases. The agents recommended are phenolsulphonic acid or a 15 per cent, solution of trichloracetic acid. In using either of these solutions, the pus should first be evacuated as much as is possible; then the solution selected can be placed in the canal and gently 378 PE_\CTICAL DENTAL THERAPEUTICS forced through the apices, and an antiseptic sealed in the canal. One or two treatments \vill usually be sufficient to check the pus formation, when the case can be treated in the ordinary manner. If, however, this does not effect a cure, it is a waste of time to prolong such treatment, and recourse should be made to surgical methods, which will be discussed later. 2. Resorbed or Roughened End of Root. — Another compHca- tion of both varieties of chronic alveolar abscess is where the pus has been in contact with the end of the root sufficiently long to cause resorption, leaving a roughened end which irritates the tissue Fig. 61. — This shows an upper second bicu-pid exfoliated by Xature with the entire surrounding alveolar process attached This re-ult followed a slight traumatic injury to the part, shortly after the pulp had been removed by pressure anesthesia. The first bicuspid ultimateh- became so loose that its removal was necessary. The author was able to elicit a preWous historj- of s^-philis, the disease having been cured a number of years before. and prevents heahng. Sometimes, also, the process through which the pus has burrowed is left with sharp edges. In all such compli- cations, surgical treatment is especially indicated. These cases generally yield nicely to the removal of the denuded and roughened root-end, and the thorough curettement of the aff"ected area. 3. Encystment of Root. — A difficult compHcation to treat is an abscess which forms on a root, the end of which has become encysted from deposits, excementosis or other causes. In order to effect a cure in these cases, it is necessary to establish a sinus and remove the deposits, excise the root-end, or extract the tooth. The method of excising the root-end wiU be discussed later. 4. Involving Bone. — Every acute and chronic alveolar abscess invites bone complication. During the progress of the abscess the bone-marrow (spongiosum) becomes infected by the pathogenic bacteria and is broken down into pus. If extraction is resorted to and laceration of the soft tissue and alveolar margins results^ a mixed infection is liable to follow, as has been previously stated. The germs are highly virulent, and among them are frequently found the diplococcus pneumoniae and the tubercular bacillus, as well as the streptococcus viridans. CHRONIC ALVEOLAR ABSCESS 379 In these cases it is necessary to see the patient frequently, wash- ing the part with warm antiseptic solutions and covering the entire exposed process with the euroform paste or other stimulating remedies. The orthoform will control the pain and the iodin Hber- ated from the europhen will stimulate and disinfect the part. If gauze is used in applying the paste, it should be changed frequently; for, if left long, it invites further infection, even when saturated at first with the oleaginous paste. After the pain subsides bismuth paste may be freely injected every few days. In employing the latter remedy, however, care should be taken to prevent the wound from healing over the paste. The author has observed several cases where the part had to be reopened after several months and the bismuth paste removed, since it is not absorbed, as was supposed at first. Fig. 62. — This radiograph shows bismuth paste which was injected into an abscess pocket. Extensive caries of bone resulted from a dead pulp in the cuspid tooth. An opening was made both labially and lingually, the part curetted and packed with euroform gauze. The second day after operation the bismuth paste was injected, and the radiograph taken. 5. Extensive Caries or Necrosis. — Bone infection from alveolar abscesses often results in either caries or necrosis of bone. Pus is formed from the breaking down of the tissues and fluids, and, in case of caries, escapes through several sinuses (see Fig. 62). The porous dead bone may be detected by a pointed steel probe. In necrosis the parts involved die en masse, and the sequestra are finally loosened and gradually work out as one large or several small pieces. In cases with a syphilitic history, even if the case has long been considered cured, there is a great tendency toward necrosis (see Fig. 61). The treatment here is largely surgical. The dead bone must be removed, after which the parts should be kept clean and stimulated until healed. It is generally best in cases of necrosis to wait for Nature to separate the dead from the hving bone. A 50 per cent, solution 38o PRACTICAL DENTAL THERAPEUTICS of phenolsulphonic acid hastens the formation of the sequestrum; after the dead bone is removed bismuth paste should be injected until the part heals. 6. Involving Vault. — Still another complication often difficult to cure ig where the pus has worked its way through the lingual plate of bone and involves the vault of the mouth (see Figs. 63 and 64). The dense fibrous tissue covering the vault is very tough, and the pus often separates the periosteum from a considerable area of bone before ultimately discharging into the mouth. Generally a lancet Fig. 03. , Fig. 64. Fig. 63. — This radiograph shows a large abscess cavity under the floor of the nasal and antral cavities, the result of the death and decomposition of the pulp in the lateral incisor. The dark spot shows the outUne of the cavitj^ which had been injected with bismuth paste from a hngual opening. To cure the case it was necessary to open from the labial, excise the lateral root and thoroughly curette the affected bone. .Ai ter the operation the case was first packed for 24 hours with euroform gauze to control the pain, followed with the injection of bismuth paste until granulation filled the cavity. Fig. 64. — This radiograph shows the case, illustrated in Fig. 63, immediately after the surgical operation. In excising the root, the end dropped into the deep Hngual pocket where it was difficult to find and remove (see a) . The radiograph aided materially, as it verified the presence of the root-end and its location. is required to evacuate the pus. In treating these conditions it is essential to explore the affected area, using a sharp steel instrument in order to determine whether there is caries or necrosis. Unless too much bone is involved, the case can be successfully treated by first making a liberal opening with a sharp bistoury and, if necessary, breaking down the sharp edges of bone, through which the pus has burrowed, with a round bur having a long shank, after which the sinus should be estabhshed in the usual manner, using a considerable quantity of the bland solution. Now dry the canal and force through the sinus full strength phenolsulphonic acid. Sometimes it is advisable to place a piece of blotting-paper soaked in liquid petroleum over the lingual opening when forcing the acid through. CHRONIC ALVEOLAR AESCESS 381 This causes the agent to spread and come in contact with the entire area involved. Alcohol and the oils will neutralize any excess of the phenolsulphonic acid that may get on the other tissues of the mouth. This treatment should be repeated as often as the case demands. When there is no evidence of pus and the case has healed sufi&ciently so that there is only a watery discharge, the root can be filled. 7. Secondary Abscess Pocket. — Occasionally we find an abscess of the discharging variety which does not yield to our general treat- ment, yet we are reasonably certain that none of the complications so far mentioned are present. In these cases we can suspect a sec- ondary abscess pocket. This is especially true where the sinus opened into the mouth several -teeth removed from the affected tooth. This pocket can usually be discovered by the aid of a small silver probe. The treatment is simple — all that is necessary is to open the Fig. 65. — This radiograph shows the involvement of the upper left central and lateral incisors, with a common sinus. Both teeth carried perfectly-adjusted porcelain crowns. The radiograph not only shows the involvement of both teeth, but also shows that the roots are properly filled. The treatment here is purely surgical and means the curettement of the affected area. pocket, wash it out first with a bland solution, then inject phenol- sulphonic acid. In using phenolsulphonic acid in such cases it can- not be injected through the tooth, therefore it is necessary to use a syringe — a glass syringe with an asbestos-packed plunger and a gold or a platinum needle. 8. Involving Two or More Teeth. — It is not an uncommon thing to find two or more teeth involved with a common sinus. Such a case is illustrated in Fig. 65. This figure also shows the importance of radiography in the diagnosis of these complicated ab- sent conditions. Here it would be impossible to cure the disease by simply treating either one of the aft'ected teeth. In this particular 382 PRACTICAL DENTAL THERAPEUTICS case, the root-canal of both teeth having been properly filled, external curettement is the treatment indicated. 9. Involving Antrum. — The pus in making -its exit follows the line of least resistance, and sometimes it is easier to work its way through the floor of the antrum than through the labial or Hngual plate of bone. The treatment of this compHcation is of sufficient importance to merit discussion by itself, and will be considered later; but in this connection it is well to remember that so good an authority as Kyle, viewing the question from the nasal side, finds that fully 50 per cent, of antral diseases are of dental origin. Periapical Cysts. — Cysts are quite frequently associated with pulpless teeth in which are abscesses which have passed through the acute stage. Logan was, perhaps, one of the first to direct attention to the presence of cysts in connection with pulpless teeth. Surgery is the treatment indicated. The area involved must be thoroughly curetted and the part packed until granulation fills the space. SURGICAL TREATMENT OF CHRONIC ALVEOLAR ABSCESSES AND THEIR SEQUELS In all complicated abscesses which do not yield to medicinal treatment as outHned in the preceding pages, we can often save the affected tooth and make it healthy and useful by adopting surgical methods. Thorough curettement of the area involved and, if neces- sary, excision of the root-end will save many teeth, such as have been too frequently lost in the past by extraction. Many dentists have preferred to extract the tooth in these complicated cases rather than undertake to effect a cure by means of surgery. It is because of this fact, and with the hope of stimulating a greater interest in this phase of the subject, that the author includes herein a description of his method of treating these cases. Indications for Surgery. — Surgical treatment is indicated in those cases where medicinal treatment has failed to effect a cure, or where the root-canal has been thoroughly filled and the abscess develops subsequently. Especially is surgery indicated in this latter class of cases, if the affected tooth-root is firm in the jaw and has a good natural crown or carries a well-adjusted artificial crown. It is always best, where practicable, to have a radiograph taken to aid in determining the area involved and whether or not the root-canal has been properly fiJled. In those cases of failure to cure by treatment through the canal, and where surgery is to be undertaken, the author advises filling the CHRONIC ALVEOLAR ABSCESS 383 canal, using gutta-percha for the purpose, before operating, especially if the root-end is to be excised; for, while it can be done, it is rather difficult to close the generally large apical opening of the root after excision. This operation should be done under the most aseptic conditions; the hands of the operator and assistant, the site of operation, as well as all instruments used should be sterilized; and, in the absence of a radiograph, a thorough exploration should be made before operating so that the amount of process and root involved may be noted. The instruments used here were selected for the purpose from the surgical supply houses, and some of them have been modified by the author to better meet our demands. They are all-metal instruments and can be sterilized by boihng. The Anesthetic. — The success of the operation will depend entirely upon the thoroughness with which it is done. It is, therefore, highly essential that the patient be assured that the operation not only can but will be performed with very little pain. This will be interesting to the patient and will increase his confidence in the operator. It is unnecessary to administer a general anesthetic, as the area can be completely anesthetized by the proper use of local anesthetics. Either infiltration or conductive anesthesia may be employed, as the operator deems best. The author generally uses the infiltration method. With a strong all-metal syringe, the healthy tissue on either side of the abscess area is infiltrated with the solu- tion, two injections being made on the labial or buccal and one on the lingual, if the abscess is discharging labially, and the reverse if dis- charging hngually. If pressure is made over the point of the needle with the forefinger of the left hand as the solution is being injected, only a small amount of the solution will be necessary to thoroughly anesthe- tize the part. It is essential that the area be completely anesthe- tized; for we have assured our patient that there would be practically no pain, and if this assurance is carried out, we are more likely to do our work so thoroughly that there will be no question as to the ultimate success of the operation. It is but natural that most opera- tors should do their work more thoroughly when the factor of pain is eliminated. The author desires to speak plainly on this point; for it will be far better for all concerned not to undertake the operation than to fail to do it with that degree of thoroughness which means success. The Incision and Control of Hemorrhage.^When the part is anesthetized and only one tooth is involved, a vertical incision is made about one-half or three-quarters of an inch in length, directly over the affected root. In case two teeth are involved, it is necessary to 384 PRACTICAL DENTAL THEEAPEUTICS make a circular incision. A bistoury, such as is illustrated in Fig. 66, is used, and care should be taken to make the incision as high as possible (if the case is an upper tooth) , stopping it about on a line with the floor of the necrotic area. If the incision is made any lower than this, the healthy process is likely to be left exposed, when it is more difl&cult for the tissues to close over this part. After the Fig. 66. incision is made, and sponged to check the primary hemorrhage, a flat bone chisel (Fig. 67), used as a periosteotome, is employed to separate the periosteum from the bone for about one-fourth inch on either side of the incision. The part is again sponged and a tissue retractor (Fig. 68) is firmly adjusted (see also Figs. 69 and 70). The arms of the retractor can be spread so that the soft tissues over- FlG. 67. lying the bone can be held back, and at the same time the pressure produced controls the hemorrhage from this source. There is a great difference in the resihency of the soft tissues, and with some patients the resihency is soon overcome by the pressure of the retractor, in which case the retractor vdW. loosen. To overcome the difficulty in such cases, the author has had made a spring retractor which may Fig. 68. Fig. 68a. be used. The operation from now on should be practically blood- less; especially is this true if adrenalin chlorid is added to the local anesthetic, as should always be done. One minim (0.06 mil) of a 1—1,000 adrenaUn chlorid solution added to 30 min. (2.0 mils) of the local anesthetic solution is about the right proportion. Fig. 69. — This picture shows a case where the abscess had not been treated. Therapeutics alone will not cure such a case, surgery being indicated. Fig, 70. — The same case as illustrated in Fig. 69 after the canal had been properly treated and filled. The retractor is adjusted ready for the root-end resection. CHRONIC ALVEOLAR ABSCESS 385 Exposing the Area Involved. — We now have the alveolar process over the root-end exposed to view, unless this has been destroyed by the necrotic process, which is frequently the case. Where it has not been destroyed, it is removed by means of bone chisels and mallet. The latter is shown in Fig. 71. The use of chisels and mallet was suggested to the author by Shamberg, of New York. The flat chisel is used across the lower part of the opening and along either side, by the claws of the retractor. To chisel across the upper part of the opening, a half-round chisel is used (Fig. 72). Many patients do not like the malleting process of removing bone. While it is not Fig. 71. necessarily painful, if the part has been thoroughly anesthetized, nevertheless it is not pleasant. To overcome this feature, the author has had heavier chisels and curettes made by means of which the bone may be removed by hand pressure. The loosened bone is then removed when the root-end and area involved should be ex- posed to view. We are now able to make an ocular examination and determine whether the case simply needs curettement or whether the root-end should also be excised. If the necrotic area extends below the apex of the root, it is always best to excise as much of the MiiiJiiiigiiiJiMiiiiiiM Fig. 72. latter as is involved, to make sure that healthy bone is reached on either side. It makes no difference whether the end of the root is left flat, round, or slanting, as long as healthy bone is reached. Before excising the end, it is best to drill on either side with a fissure bur. If this is done, the root-end, after excision, can be easily removed with an ordinary pair of pliers. The exposed end can now be excised with sharp fissure or cross-cut burs. Several such burs should be in readiness as they soon clog in a wet field. The opera- tion of excising the root-ends of teeth is known as apicoectomy or apexotomy. 25 386 PRACTICAL DENTAL THERAPEUTICS Curetting the Area.- — After removing the excised root-end, which as stated above is an easy matter, the remaining end of root should be made smooth, using a large round bur for the purpose. The affected area is now thoroughly curetted, removing any carious or necrosed bone. Here bone curettes of varying sizes (Figs. 73, 74 and 75) are employed. This is the only part of the entire operation which may be at all painful, and the patient should now be so in- formed. Even here the curetting can be done with very Uttle pain, if the anesthetic has been injected lingually as mentioned. Filling End of Root. — The process of filling the end of the root with amalgam has been suggested by Lucas, Henshaw, and others. Copper cement has also been suggested for the purpose. The author Fig. 74. has followed these suggestions in a few instances with seemingly good results; but he is of the opinion that a good sterile gutta-percha root- filling, recently inserted, will prove more compatible with the tis- sues. It is the safest practice, therefore, always to retreat and refill the canals of such teeth previous to performing the surgical opera- tion. Even though the radiograph indicates that the canal has been Fig. 75- filled to the end, in these long-standing cases we have no assurance that the root-filHng was inserted under aseptic conditions or that the canal is sterile. Washing and Packing the "Wound. — With the end of the root smooth and cut down to healthy process on either side, the area thoroughly curetted, the wound should now be washed with a warm antiseptic solution. This may be done without removing^the re- tractor. Following the washing process, the moisture should be CHRONIC ALVEOLAR ABSCESS 387 absorbed and the wound packed with sterile gauze, saturated with euroform paste. The orthoform in this paste will absolutely control the pain which nearly always follows the use of local anesthetics* and the cutting of bone, while the europhen, giving off iodin, will stimulate Fig. 76. Fig. 77. Fig. 76.— This radiograph shows a long-standing abscess on an upper left lateral. The root had been filled with lead. The dark line is a silver probe which was placed in the sinus while radiograph was being taken. FiG._ 77. — This shows the same case the day after the root-end was excised. The pocket is now ready to be filled with bismuth paste. Fig. 78. Fig. 79. FiG. 78. — This radiograph shows a chronic alveolar abscess on an upper right central. The canal was filled and the root carried a good porcelain crown. Fig. 79. — This shows the same case four days after excision of the denuded root- end and the curettement of the afi'ected area. the cells and hasten granulation; the oleoaginous vehicle (liquid petroleum) keeps the saliva, laden with bacteria, out of the wound. Subsequent Treatment. — The patient should be instructed to keep the mouth as clean as possible by using an antiseptic mouth- wash; and after the initial packing, which should be left only twenty- 388 PRACTICAL DENTAL THERAPEUTICS four hours, bismuth paste is injected every few days until granulation fills the cavity with healthy tissue. Radiographs showing cases in the author's practice, before and after treatment, are illustrated in Figs. 76, 77, 78 and 79. See also Fig. 80 and Figs. 85 and 86. In those cases where the lingual plate Fig. 80. — This radiograph shows an abscess which developed on the distal root of a lower molar, after the mesial root had been pre\'iously excised and a bridge adjusted. Thorough curettement and keeping the pocket filled with bismuth paste cured the condition. The abscess was of the pericemental variety, and was doubtless caused by injury to the alveolar process and pericemental membrane, produced in the removal of the excised mesial root. of bone has been destroyed and a deep pocket is present, or where the abscess involves the antrum, care should be taken that the root- end, when excised, does not drop into the deep pocket or antral cavity, as it is often difficult to locate and remove. Such a case is Fig. 81. Fig. 82. Fig. 81. — This shows a tumor which developed in the apical area of a central incisor which carried a Richmond crown. The tooth had been improperly treated. Fig. 82. — This shows a central incisor carrjdng a Richmond crown. Pink gutta- percha can be seen in the apex of the original (A,) showing that the root was perfectly filled at first; but in driUing for the dowel subsequently the dentist punctured the root, afterward forcing gutta-percha through the puncture (5). An abscess developed, doubtless from lack of asepsis. illustrated on p. 380 in Fig. 64. It is a good plan in such cases to drill a small hole through the end of the root through which a small wire may be inserted and bent to form a hook. Then, when the root-end is excised, it can be easily removed \nth. the wire without danger of being lost. CHRONIC ALVEOLAR ABSCESS 389 Other complications are illustrated in Figs. 81 to 84. Whenever the operator is in doubt as to the best means of treating complicated alveolar abscesses, he should not hesitate to consult with a practitioner who has had more experience in treating these cases. Such a course cannot be construed as evidence of lack of knowl- FiG. 83. Fig. 84. Fig. 83. — This radiograph illustrates a case where three of the lower incisors con- tained dead pulps, causing an abscess with a common sinus which opened externally under the chin, just to the right of the median line. The dentist had been treating the abscess by washing through the left central only and sinus, finallj^ filling the root. The case failing to heal after several months' treatment, the patient was referred. The radiograph shows, as stated, that the right central and lateral were also involved. By sterilizing the contents of the canals of these teeth and forcing phenolsulphonic acid through the sinus, the case seemed to heal. It was necessary, howeverj to operate and curette the area. Pig. 84 shows the external sinus before treatment. Fig. 85. Fig. 86. Fig. 85. — This abscessed tooth was treated and the canal filled in Nov., 1911, when radiograph was taken. As might have been expected the sinus did not heal. Apicoectomy was performed Dec. 11, 191 1. Pig. 86. — This picture shows the same case and was taken Mar. 21, 1914. The tooth is solid in the jaw and perfectly comfortable. edge, but of conservatism and progress. The foci of infection about the teeth, as in all other parts of the body, must he removed. We should not let the extraction of a tooth, or any number of teeth, stand in our way in accomplishing this end ; but the author's cHnical experience leads him to the belief that many good men to-day are 390 PRACTICAL DENTAL THERAPEUTICS unnecessarily advising the extraction of teeth as the only means of eliminating focal infection in the mouth. Both dentists and physi- cians have sadly neglected this phase of practice in the past, for lack of knowledge of the results of such practice. Much good work is being done along this line at the present time in the research insti- tutions of both the dental and medical professions; and the future will bring a solution of the many problems involved. In the mean- time dentists must continue to do their best, which, it must be admit- ted, is very good. TREATMENT OF GANGRENOUS PULPS AND ABSCESSES n^ DECroUOUS TEETH In treating the conditions under consideration in the mouths of children, it is necessary in most cases to modify our usual method of treatment. Our first duty here is to gain the confidence of the child. If the abscess is associated with a deciduous molar which we would desire to save for at least a year or two, it can be treated nicely in the following manner: After gaining the confidence of the little patient the mouth can be rinsed with an antiseptic solution — one which has a pleasant taste. Then open into the pulp chamber and place a pledget of cotton in the opening. Now mix on one end of the cement slab thymoHzed calcium phosphate and the formocresol remedy, making a stiff paste. On the other end of the slab have a quick-setting ce- ment ready to mix. Again rinse the patient's mouth and, keeping the cavity as dry as possible, gently pack the paste into the pulp chamber and flow the cement over it, filhng the cavity. It is re- markable how rapidly these abscesses will heal and remain quiet when treated in this manner, provided, of course, there be no caries or necrosis of bone, which condition is rarely found in the mouths of chil- dren as the result of abscess from deciduous teeth. If it is desirable to keep the tooth in the patient's mouth for more than a year, it is better to neutralize the putrescence with formocresol as usual, .when the root-canals can be flooded with chloroform and eucapercha com- pound, and the entire cavity filled with gutta-percha. The gutta- percha filling, if properly inserted, will last as long as is necessary to save the tooth, even in occlusal cavities where it is exposed to the stress of mastication. PERICEMEXT.\L ABSCESS GENERAL CONSmERATIONS All of the alveolar abscesses which we have discussed thus far have been the result of an infection in the periapical area, the infection being due to pathogenic bacteria, poisonous ptomains and irritating gases, which have escaped from a gangrenous root-canal. There is, however, an abscess that occurs in the alveolar region about the roots of teeth, and is not due to the causes mentioned. This particular kind of abscess occurs in connection with Hve teeth; not necessarily so, however. There is a progressive breaking down of the perice- mental membrane, which in dental Hterature is called a pericemental abscess. The origin of this particular kind of abscess is rather vague ; but it is generally supposed to be due to some traumatic injury, the infection being blood-born or hematogenous. It frequently occurs on the mesial, labial or distal surface of the roots of the anterior teeth involving most of the surface. The Hngual surface of these teeth is seldom involved. It has also been known to occur be- tween the roots of molar teeth, especially upper molars. It may discharge through a sinus near the apical end of the roots or at the gum margin ; in the latter case it resembles a pyorrheal pocket. THERAPEUTICS For convenience in outHning our treatment for a pericemental abscess, the condition may be classified as acute and chronic. As a rule, there is very little pain associated with either variety of perice- mental abscess. In the acute form, which, as such, is extremely difl&cult to diagnose, the patient will complain of "something being wrong with a particular tooth." About all that can be done thera- peutically with the acute form is to pacify the patient, as best we can, until the acute abscess develops into the chronic variety, when pus is formed and discharges and a sinus is estabhshed ; thus the diag- nosis is more easily made. In those cases where the sinus opens on the labial or buccal surface of the gum and not at the gum margin, care should be exercised in the diagnosis so as not to confuse the con- dition with an abscess of the ordinary variety, and open into \ital teeth. A case where an incorrect diagnosis was made is illustrated in Fig. 87. 391 392 PRACTICAL DENTAL THERAPEUTICS If the abscess occurs on the anterior teeth where the area in- volved can be curetted and cauterized, it will generally yield to the treatment; but the treatment of a chronic pericemental abscess on molar teeth is at best a discouraging procedure. If it is possible to thoroughly curette the area the tooth can be saved, provided the surrounding surfaces are kept clean. In those cases where the area can be reached, an opening, if necessary, can be made through the gum, the root thoroughly scraped and poHshed; then, after wash- ing out the abscessed area, it should be cauterized with some cauter- izing agent. Nothing gives better results than phenolsulphonic acid Fig. 87. — This radiograph partially shows the result of an incorrect diagnosis, where a pericemental abscess was mistaken for an alveolar abscess. The abscess occurred between the roots of the upper right central and lateral incisors with a sinus opening on the labial midway between the gum margin and the apex of the central incisor. The case gave a history of having received a blow on these two teeth about two months previous. The dentist, thinking the pulp in the central' was dead, de- liberately opened into the vital tooth. The patient then went to another dentist who attempted to remove the pulp by pressure anesthesia. It was difficult to anesthetize and a remnant was left in the apical area. Acute pericementitis followed and nitrous oxid and oxygen were administered and the remnant removed. This only aggravated the pericemental trouble; the cavity was left unsealed and the crown of the tooth became dark blue in color. The patient was now referred. Two treatments of phenol com- pound cured the pericementitis, when the root was filled. Subsequently the tissue about the abscess was anesthetized, the area curetted, and the wound packed for twenty-four hours with sterile gauze saturated with euroform paste. Two subsequent injections of bismuth paste cured the case; after which the color of the tooth was re- stored by sealing caustic pyrozone in the cavity, when a gold inlay was inserted. The patient in this instance was a lady, and when we recall that the tooth involved was an anterior one, the seriousness of the mistaken diagnosis becomes all the more apparent. With a proper glass syringe and a gold or platinum needle, the remedy can be injected into the abscess pocket. One thorough treatment should effect a cure. In curetting these cases it is far better to go a little beyond the affected territory rather than fail to remove all of the affected tissue and have the abscess recur. Where the abscess can be reached, thorough curettement and cauterization will effect a cure. That portion of the pericemental membrane which has been destroyed will, perhaps, never be regenerated, but if we succeed in PERICEMENTAL ABSCESS 393 having granulations fill in the area involved, even though the mem- brane is not regenerated over that particular surface of the root, the tooth can be saved for a considerable length of time. (See Figs. 88 and 89.) Fig. 89. Fig. 88. — This radiograph shows a pericemental abscess on the distal root of a lower first molar. The patient, a lady, has a perfect set of teeth and gums healthy, except this area. The part was anesthetized vnth a local anesthetic, the gum lanced freely on the buccal, the root scaled and area curetted. The exposed root being hyper- sensitive was subsequently cauterized with silver nitrate. The abscess 3aelded to the treatment. The cause of this particular abscess was a wooden toothpick having been broken off between the teeth. Fig. 89. — The case illustrated in Fig. 88 was treated in April, 1916. This radio- graph was taken Jan. i6, 191 7. Notice the bone regeneration between the roots and the absence of deposits which show plainly in the negative for Fig. 88. The tissues around the tooth are as healthy as though no infection had ever been present, and there is very little depression of the soft tissues between the first and second molars. Fig. 90. — A case sirhilar to that illustrated in Fig. 88, in the mouth of a male patient. Treated in the same manner, with a good^ result. FILLIXG ROOT-CAN.\LS GENERAL CONSIDERATIONS The operation of filling root-canals stands as a sort of dividing line between the subjects of Therapeutics and Operative Dentistry proper. There has been a great variance of opinion in the past regarding the methods and materials used for this purpose. The method employed in this operation depends largely upon the mate- rials which the individual operator uses, and a great variety of materials have been suggested and used, among which the following may be mentioned: 1. Cotton. — Saturating it with such antiseptics as creosote, iodoform, etc. 2 . Zinc Oxychlorid Cement. — Chemically pure zinc oxid (powder) and a saturated solution of zinc chlorid (liquid). Some operators advise fiUing the apex with soft gold and the canal proper with the cement. 3. Paraffin. — Using the material alone or in combination \^^th such agents as bismuth oxid, etc. 4. Medicated Pastes. — A variety of such pastes have been used, the powder for which consists of zinc oxid as the base with thymol, alum, chinosol, etc., in varying proportions; the Hquid containing formaldehyd in solutions of different strength in such Hquid drugs as phenol, cresol, creosote, etc. 5. Gutta-Percha. — Using the material in solution in such solvents as chloroform, eucal>^tol, and oil of cajuput. In connection with the gutta-percha solution, gutta-percha points, gold, copper and lead wire, etc., have been employed. In the Hght of our knowledge to-day of focal infection, it would be fortunate indeed if it could be correctly stated that all of the materials above mentioned, except gutta-percha, had been discarded; for all, with the one exception, have been tried and found wanting. The radiograph has proved the correctness of this statement. In the opinion of the author, which is shared by men Hke Rhein, Black, Callahan, and others, gutta-percha, modified and used in such a manner as to best meet the needs of the individual operator, is the only material at our command to-day upon which reliance may be placed. From experiments made. Price is even skeptical regarding 3Q4 FILLING ROOT-CAXALS 395 gutta-percha on account of its inherent tendency to shrink; but against his laboratory experiments stands the record of thousands of clinical cases which proves conclusively that this material, properly used, answers our every purpose for jiUing the canals of pulpless teeth. This being true, the proposition resolves itself into the problem of determining the best method of modifying and using the material. We may modify the properties of gutta-percha by incorporating -s^-ithin its substance certain drugs; and drugs are added to root- filling materials for two purposes: One a pharmaco-mechanical reason; the other on a therapeutic basis. In the case of gutta-percha, Fig. 91. — These teeth were treated and the canals filled in November and December, 1902. The radiograph was taken Apr. 3, 1916, over fourteen years after the three teeth had been treated. While there is no infection at the end of the roots, though noneof the canals is well tilled, this is an exception to the rule and will not excuse any dentist for not filling the canals of teeth to-day better than they have been filled in the past. _ Xotice the mental foramen between the bicuspids. ]\Iany times this appears in a radiograph near the end of a bicuspid root, and may be mistaken for a "rarefied area." The in- ferior dental canal may also show near the end of a lower molar (see the distal root of Fig. 42) . it is admissible to add to and use in connection ^-ith the material such drugs as chloroform and eucal}^tol, for pharmacal and mechanical purposes. In the opinion of Callahan, even rosin may be added on this basis. The solvents, chloroform and eucah-ptol, soften the material which permits its adaptation, by proper manipulation vdth heat and instruments, to every irregularity in the canal which has been cleaned and opened by the previous treatment — thus the latter is completely filled with a nonabsorbable, and, if properly manipu- lated, I believe, nonshrinkable material. Whether or not we are justified in adding drugs to root-filling materials to-day for therapeutic purposes is a debatable question. Speaking of the use of the many so-called "permanently antiseptic" root-filling pastes of various kinds that have been advocated and used, Best says:^ "The only possible excuse I can see for the use of ^ Dental Items of Interest, July, 1015, page 50S. 396 PRACTICAL DENTAL THERAPEUTICS these preparations in the roots of teeth is that the operator knows he has left something in the root which he should not have left; and in- stead of remo\dng it, he places his 'life-saver' in Qn top of it and then rests assured he 'will have no trouble' from it in the future." When we remember that to which I have repeatedly directed attention, viz., there is no such thing as a permanently antiseptic root-filling material, we cannot rightfully have this satisfying assurance. That gutta-percha aseptically introduced in an aseptic canal will remain aseptic for years is the firm belief of the author and others, based upon years of clinical experience and observation. We have no right to fill a canal of a tooth which requires an antiseptic, as such, in our filling material. Referring again to Best, he makes the statement " that the only solution lies in an almost entire nondependence upon antiseptics in canal fillings and in the maintaining of asepsis in the operation." I fully agree with the first part of the statement that we should not depend upon antiseptics, as such, in our root-filling material; but I firmly believe in the liberal and generous use of antiseptics, and in the careful and intelligent use of disinfectants, in establishing and main- taining asepsis in treating pulpless teeth and preparing the canals for filling. Precautions. — It will be remembered that three factors were emphasized under the Removal of Pulps and the Subsequent Treat- ment, viz.: 1. Establish and maintain asepsis. 2. Preserve the color of the tooth. 3. Thoroughly fill the canal. The author suggests filling all canals, for reasons previously mentioned, with gutta-percha in the manner which will be subsequently.described. In connection with the preservation of the color of the tooth, it should be mentioned that white base plate gutta-percha should be used, especially for the purpose of dissolving in eucalyptol, making eucapercha. If this white substance is forced into the tubuli of the crown of the tooth, as it is liable to be, it will not change the color of the tooth-structure as woiild the pink gutta-percha. A great many dentists have been moistening the canal, previous to filling with gutta- percha, with oil of eucalpytus; and, as a result, much unnecessary pericementitis has followed this operation. If oil of eucalyptus is used at all, the refined oil only should be selected; and far more satis- factory results will follow the use of eucalyptol, the most volatile con- stituent of oil of eucalyptus. While eucalyptol is irritating, it is not nearly so much so as is oil of eucalyptus. The author suggests modi- FILLING ROOT-CANALS 397 fying the irritating property of eucalyptol and enhancing its anti- septic power by combining menthol and thymol, as suggested in the prescription of eucalyptol compound in the discussion of Nonseptic Pericementitis (p. 360). In this proportion, the agents added do not interfere with the solvent power of eucalyptol for gutta-percha; but if the amounts are increased to any appreciable extent, this does not hold true. Oil of cajuput has also been used for moistening the canal; but it has no advantage since its constituent, cineol, is chemically identical with eucalyptol. In filling root-canals it is always the safest practice to adjust the rubber dam, /or asepsis must be established and maintained. The same agents may be used for sterilizing the teeth after the dam is adjusted as were described in removing pulps by the Anesthetization Method. The canals should be aseptic before the operation is attempted. If there is any doubt in this regard, the operation should be deferred until they are in such a condition. Not o*nly should the canals be sterile; but all instruments and material should be germ free. Meth- ods of accomplishing this end were considered under Dental Sterili- zation (p. 277). The instruments may be sterilized by moist heat, the cotton wrapped on broaches, and other such material may be steril- ized by dry heat; but it is necessary to rely upon chemic agents for sterilizing the gutta-percha points. The latter should always be sterilized when first purchased by immersion for a few hours in modi- fied alcohol or other suitable disinfecting solutions, when they may be removed and placed on sterile gauze to absorb the liquid, thus dried and put in gelatin capsules, Petri dishes, or other sterile containers. Even with this method of keeping the points, it is well to place them in modified alcohol a few minutes before they are used. Though it may be done, it is impracticable to sterilize the hands and keep them germ free throughout the operation; and it is not necessary to have them absolutely sterile, if the cotton on the broaches was sterilized by dry heat after being wrapped, as first suggested by Best. This is the safest practice. If the author's suggestion has been followed in regard to using eucalyptol compound for the final dressing in treating pulpless teeth, the canal will generally be in condition to fill, so far as moisture is con- cerned, when the dressing is removed. Black states^ that "moisture is effectively removed by flooding the canals previous to filling with eucalyptol or oil of cajuput. The oils have a greater ajQS.nity, or attraction, for the dentin than has the moisture, therefore, displace it. " If testing with sterile cotton or an absorbent point indicates ^ Special Dental Pathology, p. 328. 398 PRACTICAL DENTAL THERAPEUTICS moisture in the apical end, it should be absorbed before attempting to fill the canal. Overdrying with heated air or instruments should be avoided. Filling Large Canals. — In filling large canals, especially those in connection with which dental granulomas or alveolar abscesses have been treated, where the apex is large and where we ought not to ex- pect to get a response from the patient when the gutta-percha cone reaches the apex, on account of the loss of tissue in the periapical area, it is best to measure the canal and then use one cone which approximately fits it rather than use two or three smaller cones with the possibility of unnecessarily forcing one through the apex and into the periapical area. To measure the canals, cotton may be tightly wrapped around a smooth, sterile broach and inserted. When after repeated trials the cotton fits the canal, a cone should be selected which is slightly smaller than the tightly wrapped cotton. The canal should now be moistened with chloroform, then a small amount of eucapercha introduced, the latter being worked up or down into the canal with a fine smooth broach, exhausting the air. If cotton is wrapped around the broach used for this latter purpose, only a few shreds should be used; for we should avoid making a piston out of the broach and thus defeat our object of exhausting the air. This accompHshed, the selected cone, flattened on the large end, should be dipped in chloroform and placed in the canal; when it should be worked up and down a few times with a slight pumping motion. In this manner the chloroform and eucapercha soften the outer sur- face of the cone, leaving the central portion with sufficient resistance to cause the mass of gutta-percha to spread laterally as the cone is finally pressed to place with the phers. Root-canal pluggers may now be used and the mass of gutta-percha firmly packed in the canal. If chloroform is used, very Httle heat is required to soften the cones. The final packing may be done with a tampon of cotton or Japanese bibulous paper saturated with chloroform, as suggested by Rhein. In filling large canals from which five pulps have recently been re- moved, the patient will generally flinch before the cone reaches the apex. When this occurs, we should wait a few minutes, when the cone can be gently pressed much farther without causing the patient to flinch a second time. If these precautions are observed, they will be the means of preventing much of the pericementitis following the filHng of root-canals. We should make every endeavor to have our sterile root-filling reach at least to the end of the root; and Rhein has repeatedly emphasized the necessity of encapsulating the apical end of the root FILLING ROOT-CANALS 399 with the fluid gutta-percha, in all cases where gangrenous canals had been treated which in any way involved the periapical tissues. The author believes the future will prove this to be necessary in cases where dead and infected pulps have been treated. In clean cases it is not necessary for the filling material to protrude beyond the apex, though it is difficult to fill canals as they must be filled for success without ha\dng the material pass through the apex to a greater or less extent. Fortunately the tissues take kindly to sterile gutta-percha. Filling Small Canals. — In filHng all canals where we can enter nicely with a small canal plugger, it is best to follow the technic out- lined above, using a cone which mil enter the canal. However much we may regret it, there are canals, especially in molar teeth, so small and tortuous that only a fine, smooth broach will enter, at least to any depth. It is useless to try to fill such canals with a gutta-percha cone. The methods of enlarging the canal by the use of acids and caustics, as referred to in connection with the destruction of pulp tissue in such canals, can be employed; but it is not always advisable to enlarge them sufficiently to admit a cone of any appreciable size, and there is no resistance to a very small cone, especially after it has been softened with solvents or heat. After the larger canal or canals in a multi-rooted tooth are filled in the ordinary manner, the smaller ones can be moistened with chloroform and eucapercha and the solu- tion worked up or down into the canal. This process should be kept up for some time until the chloroform evaporates, leaving the gutta- percha rather thick and quite plastic. The sides of the pulp chamber can now be moistened with eucalyptol compound and a piece of base plate gutta-percha, selected and softened in the flame, can be packed into the pulp chamber, when pressure can be made toward the small canals and the plastic gutta-percha forced into them. This is much better practice than simply ffiling the mouth of the canal with a gutta-percha cone, leaving the rest of the canal empty. If the canal is so small and tortuous that even a small broach will not enter, and if it cannot be enlarged by the use of acids or caustics, as referred to previously, it will be necessary either to extract the tooth, or record the fact and occasionally check up on the case with a radiograph to ascer- tain if any infection is present at the end of the root. In every case where it can be done, the gutta-percha in the canals should be pro- tected by zinc oxychlorid cement (see Fig. 92). This may be done in all cases except those where it is necessary to subsequently insert a post in the canal for some purpose. The technic of filling root-canals with gutta-percha, as described by difi'erent operators, varies slightly, as, for instance, in the drugs 400 PRACTICAL DENTAL THERAPEUTICS used as solvents and in the manner of introducing and packing the material in the canal. Some operators believe they can get a more compact mass of gutta-percha in the canal by cutting the points and introducing them in small pieces. Whatever method is employed, the gutta-percha must be left firmly packed in the canal; and it is the duty of every dentist to use this material in filling root-canals accord- ing to the method which in his hands offers the greatest opportunity for success. The operation is one that requires attention to detail, and, while the author does not believe it necessary to radiograph every root-filling, a sufficient number should be radiographed until the operator is satisfied he has mastered the technic of the method em- ployed. All difficult cases and questionable root-fillings should be radiographed. If in treating pulpless teeth, preparing the canals for filling, and in root-filling operations, the dentist always tries to do his best, he will be rewarded by finding that the radiograph will prove his best is very good. Callahan's Rosin Solution. — A discussion of filling root-canals would not be complete without mention of Callahan's rosin solution. The formula follows: I^ — Resinae, gr. xii (0.75 Gm.) Chloroformi, fl. 5iii (12.0 mils) — M. Sig. — Use as directed. In directing attention to the method of using this solution Calla- han says:^ "Most of us at some time or other have shared in the opinion that it mattered but little what material was used in filling root-canals. It does matter as to the material; it does matter as to the manner of placing the material in the canal. The matter of prime importance is the sealing of the more or less numerous foramina, and, as we have no assurance that all of the foramina in a given root- canal are located near the apex, it becomes our duty to seal the whole of each canal with a material that will search out and seal minute canals or openings which, owing to physical conditions, we are unable to see." Technic. — After desiccating the canal, observing strict asepsis, the latter is flooded with the thin rosin solution, purnping it up or down into the canal. When the latter is full of the solution, the air is exhausted by passing a fine wire or broach to the end. A gutta-per- cha cone which reaches to or near the end is selected and gently placed about halfway within the canal ; the cone is pumped up and down, from forty to sixty times, and, as it dissolves in the chloroform, it is ^ Dental Items of Interest, 1915, p. 585. FILLING ROOT-CANALS 4OI advanced farther toward the apex. This pumping motion forces the rosin solution, according to Callahan, into every opening, seaHng all tubuli and foramina that have been opened in the preparation of the canal for filling. If this does not leave the large end of the gutta- percha cone at or near the mouth of the canal, a smaller cone may be placed and packed into the mass v*Tith cold root-canal pluggers, using warm air to soften the protruding gutta-percha, if necessary. This packing forces the semifluid chloropercha and rosin into the unknown canals and pockets, and, at the same time, brings the surplus chloro- percha to the mouth of the canal, where it may be removed with cotton. The author can see no advantage in the addition of rosin, for the chloroform solution will only enter the tubuli as far as moisture has been removed. It is difficult in the mouth to deplete the tooth- structure of its moisture, and, were it possible, it is questionable whether it ought to be done. Then, too, if we are justified in follow- ing Rhein, as I beheve we are where the periapical tissues have been involved in the infection, it surely is best to attempt to encapsulate the end with bland gutta-percha, rather than have a substance Like rosin incorporated with the material. 26 DISCOLORED TEETH GENERAL CONSIDERATIONS In the discussion of the methods of removing pulps from teeth and the subsequent treatment, the treating of gangrenous pulps and the various kinds of alveolar abscesses, the author endeavored to emphasize the necessity of preserving or restoring the color oj the tooth. There is, perhaps, nothing more annoying to a conscientious dentist and to an appreciative patient than a discolored tooth in the patient's mouth. If the precautions, which have been mentioned throughout this work with reference to this factor, are observed in the treatment of teeth, the necessity for bleaching may often be avoided ; for, after all that has been written on this subject is studied, it must be admitted that the most successful method of bleaching teeth is to so treat them that they will not need to be bleached. Sources of Discoloration. — There are three principal sources of the discoloration of tooth-structure, viz., 1. Pulp decomposition. 2. Remedial agents. 3. Metallic fillings. The most common source is that of pulp decomposition. Many teeth containing gangrenous pulps are discolored before the patient presents for treatment. In those cases where the color is not lost the gangrenous conditions can be corrected and the color preserved by the method of treatment outlined under Gangrenous Pulps. Occasionally, however, teeth have been observed to assume a pinkish hue shortly after some traumatic injury, rapid regulation, or after some irritating drug had been appHed to a small exposure of the pulp, as, for instance, arsenic trioxid. Kirk has offered us a very plausible explanation of this immediate discoloration. He says: "It is now known that the pink staining of the tooth is brought about by a rupture of the stroma of the red blood disks Hberating their contained hemoglobin, which dissolves in the plasma, forniing a solution of hemoglobin which readily penetrates the dentinal tubuli, the lumen of which is of insufficient diameter to admit the unbroken red corpuscle. This pink discoloration resulting from the infiltra- tion of hemoglobin solution represents the first stage of tooth dis- 402 DISCOLORED TEETH 403 coloration. The pink stain readily undergoes alterations, later on assuming a brownish tint, due to the breaking down of the highly complex molecule of hemoglobin into a reduced product known as hematin." Maimer of Discoloration. — There are two ways by which the discoloration is produced, i.e., by solutions which stain the cement- Hke substance uniting the tubuli and by the ingress into the tubuli of insoluble coloring substances. For instance, many remedial agents in solution, such as oil of cassia, silver nitrate, etc., have the property of staining the cementing substance and producing discolorations; while the sulphids formed from certain metals, as, for example, in amalgam filHngs, produce discoloration by virtue of being forced into the tubular structure of the dentin. If, in the treatment of teeth, more care were taken to select remedial agents which would not stain the tooth-structure, and if high-grade alloys were selected in making amalgam fillings, the cavity properly prepared, amalgam inserted and polished when set, there would be few teeth discolored from these causes. But, as has been stated, many teeth containing gangrenous pulps are discolored before the patient pre- sents for treatment; and, inasmuch as this is by far the most common source, it is well to try to ascertain definitely the true cause of these discolorations; for it is difficult and unsatisfactory to try to bleach a tooth when we have no knowledge of the nature of the pigment we are trying to bleach.^ Principle of Bleaching. — The principle which governs the suc- cessful bleaching of teeth is to chemically change the molecule of the pigment in such a manner as to destroy its color, or chemically change the insoluble coloring substance to a soluble form, when it can be washed out of the tooth-structure. Important Factors. — When a case presents for bleaching there are three important factors to be determined: 1. Ascertain, if possible, the cause of the discoloration. 2. Decide whether or not the color can be successfully restored. 3. The selection of the proper bleaching agent with which to re- store the color. The general cause of the discoloration can usually be ascertained from the history of the case as related by the patient. Whether or not the tooth can be successfully bleached depends largely upon the 1 The author has explained the chemistry of tooth-discoloration from pulp decom- position in Johnson's "Text-book of Operative Dentistry" and in various dental journals. 404 PRACTICAL DENTAL THERAPEUTICS cause of the discoloration, the condition of the tooth-structure, and the length of time the tooth has been discolored. Experience will prove that the teeth which will permanently retain their color, after it is restored, are those that have a good bulk of dentin, which dentin can be protected by the remaining enamel and some filling material, preferably porcelain if this material is at all indicated. I desire to emphasize the fact that it is folly to expect a tooth to retain its color any length of time after once being bleached, unless the dentin is properly protected. Ha\'ing ascertained the cause of the discoloration and believing that the condition of the tooth-structure justifies us in attempting to bleach the tooth, we come to the most important consideration, viz., the selection of the bleaching agent with which the color can be re- stored with the least inconvenience to the patient and operator. METHODS OF BLEACHING All of the methods employed in bleaching teeth involve more or less chemistry and from a chemic vieA\'point there are two general methods of bleaching teeth — oxidation and reduction. I. Oxidation.- — This general method is of two kinds also, direct and indirect. 1. Direct. — By direct oxidation is meant the use of any agent or agents from which oxygen can be directly obtained. The agents used for the purpose are : Sodium dioxid, XaoOa- Twenty-five per cent, ethereal solution of hydrogen dioxid, H2O2. Alphozone. (COOH.CH2.CH2CO)20o. Acetozone, CeHsCO.O.O.COCHs. Aluminum chlorid. AkCle. and a 3 per cent, aqueous solution of hydrogen dioxid. Oxalic acid, H2C2O4. 2. Indirect. — By indirect oxidation is meant the use of any agent or agents by which oxygen can be obtained indirectly. The agents employed are such as will liberate nascent chlorin, CI, a chemically active gas, which, in the presence of moistures, seizes upon a molecule of water, H2O, abstracts the atoms of hydrogen, H, forming hydro- chloric acid, HCl, and liberates the oxygen, 0, in the nascent state, as H2O -|- 2CI = 2HCI + (nascent; . Some of the agents used for this purpose are: Aluminum chlorid and a freshly prepared Labarraque's solution (Harlan). DISCOLORED TEETH 405 Chlorinated lime and dilute acetic acid (Truman). Powdered alum, Al2K2(S04)4, and Labarraque's solution. Solution of sodium chlorid electrically decomposed. II. Reduction. — By reduction is meant the use of any agent or agents which will abstract oxygen from a compound containing it. The agents which have been- Recommended are sodium sulphite, Na2S03, 10 parts, and boric acid, H3BO3, 7 parts. These are mixed and placed within the tooth, moistened with water and hermetically sealed (Kirk). A reaction occurs between the two substances, with the ultimate formation of sulphurous acid which has a great afiSnity for oxygen and is, therefore, a good reducing agent. In some cases where the tooth has been discolored by remedial agents, and where it is desired to break up the color molecule, good results are obtained by this method. Whenever the method is used, the tooth should subse- quently be thoroughly washed with an alkaline solution, such as a 10 per cent, solution of sodium bicarbonate or borax, to neutralize the acid. In most cases of discoloration, the direct oxidation method is pref- erable; and, in view of the fact that all of the agents used in the indi- rect method of bleaching depend upon the generation of oxygen for their efficacy, it can readily be understood that the direct method is far more satisfactory. The fact, also, that hydrochloric acid is a constant by-product in the indirect method, thereby creating an acid medium, adds to the objectionable features of this method; for manu- facturers have recognized for years that better results can be ob- tained in bleaching ivory, wool, hair, feathers, etc., when the bleach- ing process is carried on in an alkaline medium. This is likewise true in bleaching teeth. Believing, then, that the direct oxidation method is far superior to the indirect, I shall not burden my readers by describing the latter method, but will direct attention to the de- tailed use of sodium dioxid and 25 per cent, ethereal solution of hydrogen dioxid — both direct oxidizing agents, which, if their chemic properties are known and their dental application understood, the author believes to be the best agents for bleaching teeth thus far suggested to the profession. Using Sodium Dioxid.- — Sodium dioxid occurs in commerce as a yellow powder and is readily decomposed by water into caustic soda and oxygen. Because of this latter fact, much of the product obtained from wholesale druggists labeled "sodium dioxid," is nothing but caustic soda. This accounts for the fact that many dentists have tried this method of bleaching and failed to get results. The fault is not with the method, but with the powder used. In order that we 4o6 PRACTICAL DENTAL THERAPEUTICS might be able to ascertain the efficacy of the chemical, some years ago I devised a simple chemic test for this purpose. In a clean, dry test-tube place about 15 gr. (i.o Gm.) of the powder and to it add 30 min. (2.0 mils) of water. If the specimen is good sodium dioxid, enough oxygen should be generated to kindle a glowing spHnter held at the mouth of the tube. Having tested the chemical and proved it to be sodium dioxid, and not caustic soda, the next thing is to prop- erly prepare the tooth, which, of course, should have been previously treated and the root filled with white gutta-percha. Preparation of the Tooth.' — The rubber dam should be adjusted, if possible, without the use of the steel clamp. The ligature should be wrapped twice around each tooth included in the dam, which should be at least two teeth on either side of the one to be bleached. This will prevent the by-product, caustic soda, from getting on the soft tissue and destroying it. The lower third of the root-filUng should now be removed with a good-sized round bur — it being necessary, for permanent results, to bleach the tooth rootwise as far as possible. We are now ready to apply our bleaching agent. Making the Application. — Both the dry sodium dioxid and a solution made by carefully dusting the powder into ice-water are rec- ommended to be used. The best results are obtained by using the dry powder, placing it in the cavity and, with a platinum broach or pointed glass instrument, working the powder well up into the canal from which the root- filling has been removed. Care should be taken not to use steel instruments, as oxygen will attack the steel, forming ferric oxid, and, therefore, we may get into the tooth the pigment we are trying to remove. In some cases it is rather difficult to place the powder in the cavity without getting it on the patient's face or cloth- ing. To overcome this a strip of unannealed i : 1,000 platinum foil can be placed between the discolored and adjacent tooth, letting it extend above or below the cutting-edge, as the case may be, when white base plate gutta-percha can be warmed and pressed against the lingual surfaces of the teeth included in the dam. This forms a pocket on the labial side within which the powder can be easily placed, . using a little gold or platinum spoon or spatula. In more difficult cases a paste can be made of the powder and chloroform, in which it is insoluble, quickly packing the paste into the cavity, evaporating the chloroform, and leaving the dry powder where it is desired. Distilled water is now dropped upon the powder, causing a Hvely effervescence and the following reaction takes place : Na202 + H2O = 2NaOH + {nascent). DISCOLORED TEETH 407 This nascent oxygen is a powerful oxidizing agent. It attacks and rapidly destroys any organic matter which may be present in the tubular structure of the dentin. It also thoroughly bleaches vege- table colors and acts upon any iron compounds which may have pro- duced the discoloration. It converts ferric hydroxid, if present, into ferric oxid — still an insoluble compound. If ferrous sulphid is pres- ent in the moist state, it may be converted into ferrous sulphate, a soluble salt; but in the presence of caustic soda it would be reprecip- itated as ferrous hydroxid, which, in turn, in the presence of oxygen, is at once reconverted into ferric oxid. Therefore, the pigment to be removed, if our chemic reasoning is correct as to the cause of the dis- coloration from pulp decomposition, is ferric oxid, an insoluble com- pound, and it must be removed mechanically by washing the tooth. Its removal is faciHtated by the by-product, caustic soda, acting upon any fatty substances — fat being an end-product of the putre- faction of the proteid material — which may be present in the tubuli. The result of this action is a soluble soap, the removal of which by washing aids, as stated, the mechanical removal of the insoluble pigment. It is the opinion of the author that the ultimate success depends quite as much upon the mechanical removal of the coloring matter as upon its chemic destruction, therefore the necessity of thor- oughly washing the tooth after each appHcation of the bleaching agent. Warm distilled water should be used in a strong syringe, letting a moist sponge absorb the water. The cavity is now dried, the color of the tooth observed and the process repeated, if necessary. Usually two or three appHcations are sufficient. If the color is not readily restored, the dentin can be saturated with a 2 per cent, solu- tion of sulphuric acid which now enters the tubuh and chemically converts the oxids, that may not have been mechanically or otherwise removed by the saponifying and washing process, into sulphates. The salts produced are freely soluble, and can readily be washed out by again using the warm water. Final Treatment. — When the tooth is satisfactorily bleached, a paste of precipitated calcium phosphate and distilled water can be placed in the cavity, packed into the lower third of the root and burnished, with a warm burnisher, against all exposed dentin. This is thoroughly dried by burnishing, the excess removed, and a light- colored, quick-setting cement used to form a base for the final filling. Using 25 per cent. Ethereal Solution of Hydrogen Dioxid. — A 2 5 per cent, ethereal solution of hydrogen dioxid, called also caustic pyrozone, can be obtained in specially prepared and hermetically 4o8 PRACTICAL DENTAL THERAPEUTICS sealed glass tubes. The date of its preparation is stamped upon the tube to guarantee its activity, for its value as a bleaching agent de- pends upon the volume of nascent oxygen which is liberated. It is, therefore, important that a good specimen of the agent be obtained. Care must be exercised in opening the tube, which should be wrapped in a cold, wet towel and held firmly in the left hand. With a sharp file make a groove around the pointed end of the tube, after which this end may be easily broken with a pair of pliers, the tube being pointed away from the face. A sharp file should be used, as a dull one might produce a spark and cause an explosion. When the tube is opened the contents should be transferred at once to a clean glass-stoppered bottle. The stopper should be sealed with parafiin when the remedy is not being used. In making the transfer, care should be taken to keep the agent from coming in contact with the fingers, as it readily cauterizes soft tissue. Preparation of the Tooth. — The tooth should be prepared exactly as in using sodium dioxid, except that the cavity of the tooth should be moistened with an alkaline solution (lo per cent, solution of borax or sodium bicarbonate) before making the application. This is done in recognition of the fact that the bleaching process is more successful if carried on in an alkaline medium. Making the Application. — There are some cavities within which it is difficult to place sodium dioxid, even if a paste has been made with chloroform, on account of the rapid evaporation of the latter. This is especially true where the cavity is small and in the lingual surface of one of the six upper anterior teeth. Teeth containing such cavities can usually be bleached more conveniently by using caustic pyrozone. The remedy can be applied in the canal loosely on cotton. To hasten the liberation of oxygen, a heated platinum wire can be gently placed on the cotton. The wire should not be too hot, as the heat may cause a flame from the ether in the solution. Heated dry air may also be used for the same purpose. After each application the tooth struc- ture should be thoroughly washed with a warm alkaline solution, and the process repeated until the color is satisfactorily restored. If, after repeating the application two or three times, the tooth is not satisfactorily bleached, the solution may be hermetically sealed in the cavity (see Fig. 93). If the cavity is small and on the lingual surface, the sealing can best be done by the use of gutta-percha (not temporary stopping) . The excess of solution can be dried from the cavity and the hot gutta-percha applied, the heat of which hastens the liberation of oxygen which, together with the expansion of the confined ether, is carried into the entire tubular structure of the den- DISCOLORED TEETH 409 tin. It is well to have the gutta-percha just flush with the margins of the cavity and then cover it with cement. By this means we are doubly certain that the remedy cannot escape. The final treatment is exactly the same as in using sodium dioxid. Caustic pyrozone is a very escharotic agent, and equally as much care should be taken to prevent the remedy from coming in contact with the soft tissues of the mouth or the fingers of the operator as in using sodium dioxid. The remedy being in liquid form is more easily handled than the sodium dioxid powder. Fig. 93. — This is the case of a young lady, about 17 years of age, who met with an accident in which the maxilla was fractured, loosening the central and lateral incisors. The fracture was reduced by Dr. W. H. G. Logan. About one year later the central began to discolor slightly, when patient was referred. The tooth was opened on Dec. 29, 1914, and the pulp was found to be dying, though not completely dead. For- mocresol was sealed in contact with the tissue. On Jan. 4, 1915, the pulp was removed and phenolsulphonic acid was employed. Phenol compound was sealed in the canal. The root-filling operation was performed on Jan. 7, and the color restored by sealing caustic pyrozone in the canal; after which a lingual filling was inserted. The radio- graph was taken April i, 1916, about fifteen months after the root-filling operation. The color of the tooth at this time was perfectly normal. Notice that there is no periapical involvement. The other direct oxidizing agents are used in practically the same way. The alphozone and acetozone powder can be~ placed in the cavity, moistened with an alkaline solution and hermetically seaead. The volume of oxygen liberated from these agents is not great, and the process of bleaching, therefore, is much slower than when sodium dioxid or caustic pyrozone is used. In conclusion, I desire to say that in the bleaching of teeth we find a practical application of the science of chemistry to the practice of dentistry, and that in the discoloration of tooth-structure from the various sources can be found a fruitful field for further investigation AXTRUIM OF HIGHMORE GENERAL CONSIDERATIONS The antrum of Highmore, or maxillary sinus, is a chamber or cavity in the body of the superior maxillary bone on either side of the jaw. It should be remembered in connection with the therapeutics of the diseases of the antrum that the cavity is normally lined with mucous membrane, which is continuous from the nasal cavity through a small opening, called the ostium maxillare; that the cavity varies in location and size, and is capable of containing from two drams (8.0 mils) to, sometimes, one ounce (30.0 mils) of fluid. Fortunately, the dentist, in general practice, is not often called upon to treat dis- eases of the maxillary sinus, but when a case presents of purely dental origin, he should be prepared to make a correct diagnosis and to properly treat the case. (See Figs. 94 and 95.) Causes of Diseases of the Antrum. — There are many contributing causes of diseases of the maxillary antrum, among the more import- ant of which are: I. Dental Conditions. — It is quite generally conceded by both rhinologists and dentists that the teeth, or conditions associated with the teeth, are the greatest source from which the membrane lining the chamber may become irritated to the extent of bringing about a de- generation of the cells, when infection is liable to occur and pus result. It has been previously mentioned that one of the serious com- plications of alveolar abscesses is where the pus is evacuated into the antral cavity, instead of working its way through the labial or buccal, and sometimes through the lingual plate of bone emptying into the mouth, as is the case usually. (See Fig. 55.) The author reports here two cases in the College Infirmary where a stu- dent had removed a vital pulp and entered the antrum through the canal, showing that all that separated the end of the root from the floor of the antrum was the mucoperiosteum, which the student penetrated. One case was the lingual canal of a first molar, and the other the canal of a second bicuspid. Other cases of this character have since been observed in the College clinic. If abscesses occur in connection with teeth thus situated in the jaw, the antrum will at once become involved. 410 ANTRUM OF HIGHMORE 411 Hiatus semilunaris Ostium maxillare ;.v ~^y^^^ Fig. 94. — Antero-posterior division through the maxillary sinus. (Cryer.) Sound passing through in- fra-orbital canal and foramen Infra-orbital sinus Infra-orbital foramen Maxillary sinus (antrum) Opening caused by apical abscess Fig. 95.— Vertical transverse section showing the close relation of the roots of the molar teeth to the maxillary sinus (antrum). (Cryer, Dental Cosmos.) 412 PRACTICAL DENTAL THERAPEUTICS 2. Catarrhal Inflammation. — Since the Schneiderian membrane which lines the nasal cavity passes through the ostium maxillare and the continuation of it lines the antral cavity, any inflammation of the nasal mucous membrane, if continuous and progressive, may involve the antrum. Especially is this true of patients who have catarrh, influenza, or grip. Even an acute coryza may seriously involve the antrum. 3. Foreign Material. — Foreign material constitutes another pro- lific source of disease of the antrum. Teeth, especially third molars, have been known to erupt into the antrum; dentigerous cysts and polypi are frequently found; and, occasionally, in the careless ex- traction of a pointed root, and even at times when due care and judg- ment are exercised, if the root is badly decayed, it may be forced by the forceps into the antral cavity. Fig. 96. — This radiograph shows a case of suspected antral involvement. There was no external discharge of pus, but severe neuralgia and some of the other subjective symptoms of antral disease. The cuspid and first bicuspid, on the affected side, carried artificial crowns. The radiograph indicates that the antrum is not involved, but shows that the canal of the cuspid root is not filled, this was found to be gangren- ous, also a necrotic area about the apical end of the imperfectly filled first bicuspid root. 4. Traumatism. — The antrum frequently becomes involved as a result of some traumatic injury, such as a blow, etc. It is frequently difficult to make a correct and positive diagnosis of antral disease. The symptoms generally are of the subjective variety, unless the cause is some traumatic injury, in which case the diagnosis is readily made. Diagnosis. — The symptoms which aid in arriving at a diagnosis are : A sense of fullness on the affected side ; at times the pressure may be so great as to cause the eye to distend from its orbit; frequently an odor and discharge of bloody pus or mucus through the nose, especi- ally when the patient coughs or sneezes, or when he lies in a certain position. The use of the X-ray and the little electric mouth-lamp. ANTRUM OF HIGHMORE 413 while by no means positive, are invaluable aids in making the diag- nosis (see Fig. 96). By pulling down the shades, making the room as dark as possible, and placing the electric mouth-lamp on the lingual side of the teeth a dead pulp may be detected which is causing the trouble. Placing the lamp higher in the vault, the antrum, if diseased, will .generally present a more cloudy or foggy appearance than will the healthy antrum. After making the diagnosis, the next important step is to decide on the method of treatment. If no dental condition seems to be causing the disease, the patient should be referred to a rhinologist for further examination; but if the dis- eased condition of the antrum is of dental origin, it is the prerogative of the dentist to treat the case, if he so desires. THERAPEUTICS The treatment is of two kinds — surgical and medicinal. 1. Surgical Treatment. — The surgical treatment of diseases of the antrum will be discussed here but briefly. To intelligently treat the condition it is, of course, essential to find the cause and remove it. Let it be understood that this does not necessarily mean that if the cause of the antral trouble is an abscessed tooth, it is necessary to extract the tooth. Frequently, by treating the affected tooth and opening into the antrum and washing out the cavity, the case will yield nicely. Whether it is necessary to extract the offending tooth is often a difficult problem to solve. Many teeth have been need- lessly sacrificed in the surgical treatment of diseases of the maxillary antrum, especially by the general surgeon; while, on the other hand, many antrums have become chronically diseased, which condition might have been avoided and the case cured during its incipiency, had it not been for the presumable conservativeness of dentists, espe- cially, in their efforts to cure the antral disease and at the same time save the tooth. It should be remembered that important as every tooth is — a healthy antrum is of greater importance. In making this statement the author does not mean to encourage the needless ex- traction of teeth in connection with the surgical treatment. The site of making the opening depends upon the conditions as found. Probably no two cases will need exactly the same kind of opening. It may be made through a tooth-socket, just posterior to the canine fossa, between the roots of teeth, or through the nose. The latter opening should be made by a rhinologist, if necessary. The tendency at first is to make the opening too small rather than large enough. In many cases it is necessary to have the opening 414 PRACTICAL DENTAL THERAPEUTICS sufficiently large to permit an ocular or digital examination. A thorough examination at this stage of the operation will determine whether the cavity needs curettement or simply the establishment of drainage and evacuation of the pus or mucoserous fluid. It is seldom necessary to administer a general anesthetic other than nitrous oxid and oxygen for the purpose of opening into the antrum painlessly. It may be accomplished in most cases practically without pain by the use of local anesthetics. With the soft tissues anesthetized little pain is produced in drilling through the bone. Where curettement is indicated, a general anesthetic had better be given. Nitrous oxid and oxygen serves the purpose admirably. We now come to the phase of the subject of most interest from our point of view — the therapeutics. Before discussing the drugs used in treating diseases of the antrum of Highmore, I desire to emphasize the fact that it matters little what drugs are used as long as they are practically nonirritating and antiseptic, if the surgical treatment has been all that is required. If the cause has not been surgically re- moved or corrected, drugs will be of little avail; for this reason the surgical treatment has been discussed here briefly. 2. Medicinal Treatment. — The therapeutics of the condition under consideration consists in washing the antral cavity with bland remedies for the purpose of disposing of the pus and mucoserous fluid; this to be followed by antiseptic and stimulating remedies. Any bland solution may be used which is nonirritating and antiseptic, provided the odor and taste of the agent employed are not objection- able. A warm saturated solution of boric acid serves the purpose admirably. The author, however, prefers using a warm sterile physiologic salt solution. These solutions may be used in a fountain syringe, the latter being placed on the wall as high as convenient so that considerable force may be exerted in the washing process. A glass or hard rubber point should be attached to the rubber tubing, and should be of such shape and size as to pass easily into the open- ing. The escape of fluid from the syringe should be controlled by a stop-cock. By this means the cavity can be well flushed out, using a considerable quantity of fluid. In the absence of a fountain syringe, a strong water syringe may be used. The physiologic saHne solution also acts as a stimulant to the mucous membrane. After thoroughly washing the cavity, most of the solution which naturally remains can be absorbed with cotton and the cavity injected full of some antiseptic and stimulating remedy. Brophy recommends argyrol, using all the way from a lo to a 50 per cent, solution. Beck suggests using bismuth paste. This has the distinct ad- ANTRUM OF HIGHMORE 41S vantage of completely filling the space with a semi-solid, oleaginous paste, which guards against septic invasion from the mouth, and at the same time holds the stimulating drug in contact with the entire membrane of the cavity. Some care must be exercised in making the injection so as not to force the paste into communicating sinuses. The injection may be repeated as often as the necessity of the case de- mands. If there be no complication, two or three injections, at inter- vals of two or three days, will generally suffice. The author prefers using antiseptic and stimulating solutions, like 25 per cent, argyrol, or I or 2 per cent, iodin, rather than bismuth paste. There is little necessity for using strong disinfectant or cauteriz- ing agents in the medicinal treatment of diseases of the maxillary sinus. If the case does not yield to the treatment here given, some complication may be suspected, for which see works on Oral Surgery. PYORRHEA ALVEOLARIS GENERAL CONSmERATIONS Because of the customary use of the term, and for want of a better one, this much-named disease has been called throughout this work pyorrhea aheolaris. Generally speaking, it may be con- sidered a chronic suppurative disease of the supporting or investing tissues of the teeth (gums, pericemental membrane and alveolar process), progressing insidiously with occasional acute exacerba- tions. The disease begins as an interstitial gingivitis; the gum septum first becomes reddened, then swollen and tender and bleeds easily. The swollen gum frequently assumes a deep red or purple color and forms spongy festoons between the affected teeth (see Fig. 98, p. 4). The true pathology and etiology of this disease is yet an unsolved problem, notwithstanding the fact that its solution, for years, has been attempted by the most scientific men of the profession. In recent years, the disease has engaged the attention of the medical as well as the dental profession; for it is now well recognized that, whether or not the disease is of purely local origin or is a local mani- festation of some constitutional disorder, its presence in the mouth is the forerunner of many grave systemic diseases. Probable Causes. — The causes of pyorrhea alveolaris may be grouped into two classes: predisposing and active. The conditions which predispose to the disease are many and varied, and include the following: Faulty occlusion, irregular teeth, faulty or no contacts between teeth, ill-fitting crowns, bridges and partial dentures, calcific deposits, bacterial plaques, certain drug poisons (mercury), certain constitutional diseases, etc. The active or exciting cause of the disease is a pathogenic micro- organism of some kind. In the past many organisms have been credited with being the specific cause of pyorrhea alveolaris. A bacteriologic examination of the pus from a pyorrheal pocket will disclose a vast number of bacteria. The difficulty is to ascertain, with any degree of certainty, which organism is pathogenic in a case. The work of Barrett and Smith, ^ of Philadelphia, corroborated ^Dental Cosmos, 1914. 416 PYORRHEA ALVEOLARIS 417 by that of Bass and Johns, ^ of New Orleans, would seem to prove quite conclusively that the causative agent is not a bacterial organ- ism, but a protozoon — the Endameba huccalis, and perhaps other species of endamebae. After making hundreds of smears, Hartzell,^ of Minneapolis, found the streptococcus viridans and the fusiform bacillus and its accompanying spirocheta universally present in all pyorrheal pockets and on tooth surfaces. This author concludes by saying, "The finding by culture of viridans below the level of attachment in the membrane also impresses us with the thought that streptococci are the principal organisms of pyorrhea alveolaris and that amebae and all other germs are contributing factors only." Brook,^ of London, England, and others, have also found the streptococcus family to be the predominating organism in infections about the teeth. Whether the endamebae or the streptococci viridans or other bacteria are the specific cause will not be discussed further here. Enough has been introduced to show that the true pathology and etiology of pyorrhea alveolaris are still unsolved problems. The efifects of the disease upon the system will now engage our attention. Systemic Effects. — The systemic effects of pyorrhea alveolaris may result in two ways, as pointed out by Brook: (i) By the absorption of toxins and germs locally, through the infected gums and alveolar process, or, (2) by the absorption of toxins after the bacteria have entered the gastrointestinal tract, either from the stomach or intestines. This author points out the fallacy of the too common beUef that the gastric secretion is sufficiently antiseptic to kill all of the bacteria reaching the stomach from the mouth; for he states that the same type of streptococcus found in the pyorrheal pus can be also isolated in many cases from the feces in persons suffering from the disease. It is also mentioned that a very limited amount of infection in the mouth may give rise to a great deal of systemic toxemia, owing to the fact that the bacteria multiply at such a great rate, one producing many millions in twenty-four hours, so that even a trivial amount of o^al infection may mean an enormous number of pathogenic bacteria by the time the intestinal contents are evacuated from the bowel. While it is possible, as stated, that absorption of toxins and germs may iake place locally through the infected gums and alveolar * Journal American Medical Association, Feb. 13, 1915. ^Dental Review, Sept., 191 5. ^Dental Review, June, 191 5. 27 41 8 PRACTICAL DENTAL THEEAPEUTICS process, there can be little doubt that the absorption of toxins from the gastrointestinal tract is of far greater significance. Logan^ has repeatedly shovvTi that the blood count in cases of pyorrhea alveolaris gives very little e\ddence of infection unless the pocket is deep, extending to or nearly to the root apex and involving the alveolar process. CarmichaeP expresses the opinion that for the bacteria and toxins to be absorbed locally, it is essential that the pressure within the infected area shall exceed the pressure within the blood-vessels themselves; and this author concludes that inas- much as the pyorrheal pocket in the vast majority of cases is in open and direct communication with the oral cavity by means of an external sinus, the toxic bacterial products Hberated in the pocket are far more frequently emptied into the mouth, finding their way into the gastro-intestinal tract, rather than gaining direct entrance into the circulation. This theory would seem to prove the correct- ness of Logan's observations; though the latter author does not base his findings on such a theory, nor does it harmonize with the statement of bacteriologists to the effect that certain poisons known as extracellular toxins are excreted by the bacteria directly into the tissues or blood-stream. The toxins excreted by the streptococcus viridans are extracellular. (See Biologic Products, p. 245.) With this knowledge before us, it will be interesting to trace the pus, containing the bacteria and toxins, in its course after it leaves the pyorrheal pocket, and to learn the diseases which may, and frequently do, result therefrom. This has been well done by Brook, from which author I here quote : ''The pus passes first into the mouth, where it may give rise to ulcerative stomatitis, mixing here with the saliva, it flows first over the tonsils, which it may infect mth the result of acute tonsillitis and quinsy. It then passes into the pharynx and then the esophagus, where it may cause pharyngitis and esoph- agitis. Should any be drawn into the trachea and bronchi it may produce bronchitis, acute and chronic, and gravest of them all — pneumonia or bronchopneumonia; passing down the esophagus it next enters the stomach. Chronic indigestion is by far the common- est sequela here, but another very grave trouble may result — gastric ulcer. ^ In the small intestine, it causes chronic intestinal indiges- tion, and flatulence, and may infect the bile duct, giving jaundice and gall-stones, etc. It then enters the cecum and the appendix. 1 Various Journal articles. 2 Dental Review, August, 1915. 2 This complication has been pointed out by Sir Bertrand Dawson, of England, and conclusively proven by Rosenow, of Chicago. PYORRHEA ALVEOLARIS 419 Passing on into the colon, we come to the subject of colitis. This disease is much more prevalent than is commonly thought. It is marked by diarrhea, more or less spasmodic, and the passage of mucus in the stools. In acute cases, blood in more or less large quantities may be passed. In the chronic cases, chronic abdominal pain often amounting to colic, diarrhea, vmformed stools, or occasional con- stipation, local abdominal tenderness, flatulence, and distention result." In connection with appendicitis, this author emphatically states his view that a large majority of cases are due to pyorrhea alveolaris and nothing else. Most of the cases, if examined, show symptoms of the disease, often of old standing, and then the same bacterium, streptococcus pyogenes longus, can be isolated from the pyorrheal pocket and from the appendicular abscess. This means, according to Brook, that had the patient been cured of this pyorrhea before his appendix became infected he would never have had the attack of appendicitis which brought him into the hands of the physician and, perhaps, surgeon. So far as the treatment of pyorrhea alveolaris is concerned, the author is of the opinion that a mistake has been made by the profes- sion generally in grouping all of the disorders commonly called pyorrhea alveolaris under one heading and endeavoring to effect a cure of the entire group by a common treatment. It is true that the treatment of the various diseases affecting the gum, pericemen- tal, and alveolar tissues have many things in common, yet the correct treatment must necessarily involve special measures to meet the demands of a given case. Therefore, for convenience in outlining our treatment the various disorders so commonly grouped under the heading of pyorrhea alveolaris will be arbitrarily divided into three classes. It must be understood, however, that in reahty no dis- tinct line of demarcation can be drawn. The division is made purely for convenience in studying the disease from the therapeutic point of view. DESCRIPTION OF CLASSES Class I. — This class includes such cases as often present where upon examination it will be noticed that around several teeth in the mouth, just under the free margin of the gum, there is a hard, dark, flint-like, annular deposit, which in some instances nearly and often- times completely encircles the tooth. This deposit comes from the blood, and is known as serumal calculus. It is caused by some local irritant at the gum margin, generally oral fllth and bacteria, which results in gingivitis — always a characteristic symptom of this class. 420 PRACTICAL DENTAL THERAPEUTICS There may or may not be pus, generally there is not; the pockets, if any, are shallow. It will usually be noticed that there is more or less salivary deposit on the lingual surfaces of the lower anterior teeth and on the buccal surfaces of the upper first and second molars. The general condition of the mouth gives every evidence of neglect, which may be considered the cause of this class of pyorrhea alveolaris. Fig. 97 shows the extent to which saUvary deposits may accumulate in a neglected mouth. Fig. 99 shows the results which frequently follow faulty occlusion. Fig. 97. — This shows the extent to which salivan' calculus will form on the roots of the lower anterior teeth in some mouths, if neglected. The crown is nearly covered as is also most of the root — only a small portion near the apex being free from deposit. Class n. — This class is what might properly be called true pyor- rhea alveolaris. In it will be considered those aggravated cases wherein there is Httle e\T[dence of gingivitis; the gum, in fact, appears anemic rather than h\"peremic, and is gradually receding from the neck of the tooth. The pericemental membrane is being rapidly destroyed; the alveolar process is resorbed — \drtually melting away; the pockets are deep and variously located around the single root of a tooth, and oftentimes between the roots of multi-rooted teeth. Pus is generally present, and there may or may not be hard deposits. Unless the disease is checked, there is a progressive loosening of the teeth, to the extent that they ultimately drop out. The cause of this class is unknown. It may be a bacterium, but as yet no specific germ has been satisfactorily demonstrated to be the exciting agent, though the presence of various pathogenic germs has been scientifi- cally proven, as is evidenced also clinically by the pus formation. Surely the cause cannot be neglect on the part of the patient, for the disease occurs and often persists in the mouths of patients who are scrupulously clean so far as the toilet of the niouth is concerned. The cause in far too many instances can rather be traced to neglect on the part of the family dentist, who either failed to recognize and cure the disease in its incipiency, or, recognizing it, informed the Fig. 98. — The picture of the model on the left shows a typical case of Class I, involving both central and one lateral incisors. The picture of the model on the right shows a pyorrheal case which has been treated and cured. The central was treated by the author in 1904, the cuspid in 1915. The case being a referred one, I did not see the patient from the time the pocket along the labial of the central was cured until the cuspid became involved. The results here emphasize the advisability of surgically eliminating the pocket whenever indicated. Fig. 99. — This picture is from a model taken of a case where the upper third molar prevented the lower third molar from fully erupting. Food pocket between the upper second and third molars, causing the third to decay. Frequently pyorrheal pockets form from just such conditions. Where the third molars are the teeth involved, it is generally best to extract the tooth, as was done in this case. The upper third molar shown in the picture is the actual tooth extracted. It was placed in the impression, and the model made. PYORRHEA ALVEOLARIS 42 1 patient that nothing at all could be done and advised letting it go, ultimately extracting the teeth. It is sadly to be regretted that so many teeth have been needlessly lost in the past because of the seem- ing indifference of dentists; but the wave of prophylaxis that is floating over the profession to-day, due to the efforts of D. D. Smith and others, is an encouraging sign that individual dentists are either equipping themselves to combat the disease or are referring the patients thus afflicted to dentists who are so equipped. Fig. loo illustrates a tj^ical case of this class. Fig. 100. — This shows the recession of gum tissue due' to the resorption of the alveolar process between the central incisors — the result of pyorrhea alveolaris. Class m. — In this class will be considered those cases in which we are reasonably certain that the local condition in the mouth is at least aggravated by, if not entirely due to, some systemic derange- ment. It has been quite clearly demonstrated by Pierce, Rhein, Talbot, Kirk, Fletcher and others, that at least certain kinds of pyorrhea alveolaris are closely associated with, if not caused by, such general diseases and conditions as syphilis, tuberculosis, actinomy- cosis, diabetes, osteomyelitis, salivation, phosphor poisoning, mal- nutrition, and faulty metabolism in general. The symptoms here are variable, and depend largely upon the general complication. In such diseases as syphilis, tuberculosis, actinomycosis, and osteo- myelitis, the alveolar process is extensively involved and usually rapidly resorbed, the teeth are loosened, there is generally an absence of hard deposits, the pus is persistent, and recovery is much slower than usual. In diabetes the gums are often turgid and raw, the pericemental membrane is inflamed and highly sensitive, there is a tendency toward the formation of serumal deposits, and pus may or may not be present. The mouth symptoms of salivation or mercurial stomatitis and phosphor poisoning have been elsewhere described. In faulty metaboHsm the symptoms are variable, and none has been demonstrated to be truly characteristic of the general condition. Pyorrhea alveolaris was formerly thought by certain investigators to be caused by gout or what was known as the "rheumatic diathesis." To-day it has been definitely proven 422 PRACTICAL DENTAL THERAPEUTICS that rheumatism (arthritis) is due to an infection, and the foci of infection has frequently been traced to pyorrheal pockets about the teeth. With this understanding of the conditions which present in the various classes of the disease under consideration, we will now discuss the treatment. THERAPEUTICS When cases of pyorrhea alveolaris present for treatment, the first important consideration is to impress upon the minds of the patients the fact that you must have their hearty cooperation, and that in order to obtain permanent results it will be necessary for them to follow your instructions closely. There is, perhaps, no condition which dentists are called upon to treat wherein the con- fidence, and especially the cooperation of the patient is of such vital importance, so far as permanent results are concerned, as in the treat- ment of true pyorrhea alveolaris; and it is truly surprising what good results can be accomplished by the conscientious and persistent efforts of both dentist and patient. Before undertaking the treatment of a case, then, there should be a distinct understanding as to what may reasonably be expected. The discerning patients will, naturally, want to know at the outset if their cases can be cured. The word "cure" here is but a relative term, and an explanation should be made in regard to what a so- called cure includes. It does not mean that the lost tissues — gum, pericemental, and alveolar — can be restored. It should mean, how- ever, that the teeth treated can ultimately be made healthy, com- fortable, and useful, so far as mastication is concerned. Any tooth which we cannot reasonably expect to restore to this condition had better be considered a hopeless tooth and extracted at once, and there are many such in the mouths of pyorrheal patients. As has been elsewhere explained, while the presence of pus which is constantly being mixed and swallowed with the saliva and food is of greater importance, so far as health is concerned, than is the looseness of the teeth in the jaw, patients, until recently, were more interested in the latter phase of the question; and they are always anxious to know whether the now loosened teeth will become firmly fixed in the jaw after the treatment. This all depends upon the case at hand and the mechanical treatment involved. In the past too much dependence has been placed in drugs, and too much also has been left to Nature to tighten the teeth, when this should not have been expected on account of the extensive loss of the supporting Fig. ioi. — This picture is of a model taken of a case after being cured of pyorrhea alveolaris. Notice the second bicuspid which was badly affected and loose, but is now firm and comfortable. PYORRHEA ALVEOLARIS 423 or investing tissues ; and the conscientious dentist who makes extrava- gant statements in this respect will cause much disappointment to both himself and to the patient. It is surprising, at times, how loosened pyorrheal teeth will tighten in the jaw under proper treat- ment without mechanical assistance, but too much should not be promised in this respect (Fig. loi). The author desires to speak plainly on this point, for herein often lies the greatest source of dis- appointment. Unless the end of the root is resorbed, leaving it roughened, the pus formation can be checked, the gum can be made to resume a healthy appearance, but many times the teeth, without mechanical aid, will not materially tighten, though otherwise they are perfectly healthy and comfortable. Their usefulness, of course, is impaired on account of their being loose. A thorough understanding at the beginning of the treatment, then, serves as a means of stimulating confidence on the part of the patient in the operator's ability to meet the conditions as found and the conscientiousness with which he works. No dentist should undertake the treatment of a case of true pyorrhea alveolaris unless he is equipped to render the best possible service, considering always the personal equation, and then only with the understanding that both he and the patient are to work in harmony — each exerting their best efforts to eradicate the disease. It is far better not to undertake the treatment of a case than to have it end in disappointment. The detailed treatment of the three classes into which the dis- orders commonly called pyorrhea alveolaris have been divided will be considered separately, for herein lies the value of making the subdivisions. The treatment is of three kinds — surgical, medicinal, and mechanical. CLASS I 1. Surgical Treatment. — In this class, it will be remembered, deposits are always in evidence. The first step in the treatment is to remove the deposits. This is accompHshed by instrumentation, care being taken to remove the irritant material without undue injury to gum, pericementum, and tooth-structures. The instru- ments which the author uses for this purpose are the Logan-Buckley set, illustrations and brief descriptions of which are found in Fig. 102. Another very excellent set of instruments is known as the Carr set. By the use of either of these sets of instruments the deposits can be removed with a minimum amount of injury to the structures involved. Mawhinney has especially emphasized the injury done to the so-called dental ligament and the other soft tissues by careless 424 PRACTICAL DENTAL THERAPEUTICS ^ rj " "" ■" '■'■ " " "■"" ' ' """f ;: '■ -til Fig. io 2.— Logan-Buckley set of pyorrhea and prophylactic instruments. t or description of their uses, see next page. PYORRHEA ALVEOLARIS 425 instrumentation, and Patterson, James, Hartzell, and others have demonstrated the fact that better results are obtained when the deposits are removed in such a manner as to leave the tooth-surface smooth and easily polished. Extreme care should always be taken in removing hard deposits from the necks of teeth to avoid having the deposit when loosened fly in the eye of the operator or patient. Several cases are on record where the dentist's eye became seriously infected, and in a few cases the sight was lost by such an accident. Before beginning the scaling process the mouth should be thor- oughly sprayed or rinsed with an antiseptic solution. For this purpose the author uses cinnamon water to which about 2 per cent, of alcohol is added. The cinnamon water is an agreeable solution, and the alcohol aids in removing the mucoid material with which the teeth in this class of cases are generally coated. A glassful of the cinnamon water should also be in a convenient place. This solution .can be colored pink or a reddish tinge by adding a small amount of tincture of cudbear. The object in having the solution colored is to prevent the patient from seeing the blood which is always more or less in evidence in scaling these teeth on account of the gingivitis — a characteristic symptom of this class. The solution is used with a strong water syringe as often as is necessary to clear the field of opera- tion. The scaling should be begun on some certain tooth in the mouth and this should not be left until it is thoroughly scaled. This can only be done with any degree of certainty by following some defi- BRIEF DESCRIPTION OF HOW TO USE THE LOGAN-BUCKLEY SET OF INSTRUMENTS These instruments are so designed that the teeth may be scaled systematically. Beginning on the mesiobuccal surface of an upper molar or bicuspid tooth, the in- struments are used as follows: No. i for the mesiobuccal, No. 2 for the buccal, No. 3 for the distobuccal, No. 4 for the distolingual, No. 5 for the lingual, and No. 6 for the mesiolingual surface. These six instruments, therefore, scale systematically around the tooth. If at any point a pocket is found too deep to be reached with these instru- ments, their counterparts, except with a narrower point and exaggerated in form, are found in Nos. 16 to 21 inclusive. For example, No. 16 is the exaggerated form of No. I, and so on with the entire six instruments. For the lower teeth the positions of the instruments are exactly reversed, i.e., Nos. i and 16 are here used on the mesiolingual surface, etc. With one or the other of these groups of six instruments the molar and bicuspid teeth can be scaled, except, occasionally, where deep pockets are found between the roots of molar teeth and on the lingual surface of the divergent lingual root of upper molars. For these exceptional cases, Nos. 9 and 10 are right and left and are employed for scaling between the roots of molars, and Nos. 24 and 25 are right and left for the lingual surface of a divergent lingual root of upper molars. No. 23 is for the distal surfaces of posterior teeth (third molars). For the anterior teeth, upper and lower. No. 7 is designed for the lingual surfaces, and No. 8 for the labial. In cases where there is a deep lingual pocket which cannot be reached with No. 7, No. 22, the exaggerated form, can be used. No. 11 is a push instru- ment used in removing deposit from between crowded and irregular teeth. No. 15 is a general hook for removing the bulky deposit before the more delicate instruments are used. Nos. 12, 13, and 14 are prophylactic instruments which can be used with either a push or pull movement and will be found useful in removing superficial decay and in smoothing and polishing rough surfaces. 426 PRACTICAL DENTAL THEBAPEUTICS nite system. By using either of the sets of instruments mentioned, the scaling can be done systematically. With the L.-B. set, the author begins on the mesiobuccal surface of the upper third molar, and with the six instruments designed for the purpose one can work completely around the tooth in an intelligent manner. From here we can proceed from one tooth to another around the arch, using the instruments designed for the various surfaces. If there be a bulky deposit, such, for instance, as salivary deposits, this should be re- moved first with the hook instrument designed especially for this purpose. Fig. 103. — This shows the instruments in their proper places in the tray ready for use. After an instrument has been used the point, at least, should be kept immersed in an antiseptic solution during the entire time the scaling is being done. This can best be done by having a tray which is designed to hold the instruments in their proper places. Such a tray with the entire L.-B. set of instruments in their proper places is illustrated in Figs. 103 and 104. The instruments are presumed to be sterile before they are used; it is, therefore, unnecessary to have a strong disinfecting solution in the tray. Such a solution would either act upon the instruments or taste badly when the instrument is placed in the patient's mouth, for the necessary instrument should be taken directly from the rack of the tray and used in the mouth. A pleasant antiseptic solution, therefore, should be in the tray. It is a principle in surgery to avoid the presence of germs by having the instruments sterile before using rather than to endeavor to kill the germs by the use of strong disinfec- tants during the operation. The author uses a 20 per cent, solution PYORRHEA ALVEOLARIS 427 of phenol compound in glycerin, and of this about 10 min. (0.6 mil) is added to about }/2 pint (240.0 mils) of sterile water, which is in the tray. This solution can also be colored with tincture of cudbear to conceal the blood. The pockets here, if any, are not deep; the deposits are readily removed, and a number of teeth may be scaled at one sitting. Un- less there be some good reason for extending the length of time of the operation, it should be limited to one hour, and the scaling process should be stopped in sufi&cient time to permit a thorough prophylactic treatment with Arkansas and carborundum stones, orange wood, ^^^W^pr^^ \ l^fl * ^?:*i«^ •■ - ^-*— -rV-"^ r 1 H ^ , . '''^'^ 2* 25 26 27 28 29 30 d ^..'*'^H ti^. . ^ FxG. 104. — This shows how the inner rack can be removed for the purpose of sterilization. pumice, and tape, according to the method of D. D. Smith, before applying the medicinal treatment. The teeth here are not loose and, therefore, they need no mechanical support. A record should be kept of the teeth treated at each sitting, so that we may know exactly where to begin when the patient returns. HartzelP advises the prophylactic treatment before undertaking the root surgery. On this point he says: "Experience has taught us that the logical place to begin the treatment of pyorrhea is the tooth's surface and that the first step in the treatment of any pyorrhea is to demonstrate to the patient and to the operator the relative amount of bacterial growth on the tooth's surface. This is important to both — impor- tant to the patient because it directs his attention to those areas of the tooth's surface which need the greatest daily care, and important to the operator because it explains to him the reason for gingival ^ Dental Review, September, 1915. 428 PRACTICAL DENTAL THERAPEUTICS inflammation where oftentimes no other rational cause can be found. These areas may be shown by using 'disclosing solutions.'^ Follow- ing such demonstration, the next step should be. the elimination of all rough areas on the tooth's surface which may retain bacteria on or in the tooth-surface, and this is accompHshed by applying to them Arkansas and carborundum stones, swinging them across the enamel surfaces, thus bringing out all pits that have been induced by the acid formed by the bacteria on these surfaces, getting rid of the bacteria themselves and poHshing out the inequalities, which serve to retain and foster bacterial growth. After the use of the coarse stones on the tooth-surfaces, disclosing solution should again be used to make sure that all pits have been beveled out. After all pits that contain bacteria and inequalities have been thus beveled out, and the application of the disclosing solution reveals nothing, then the tooth-surface should be thoroughly poHshed with fine Arkansas stones, and the brilliance increased by the use of moose- hide wheels loaded with jeweler's rouge or any other abrasive which will give a high degree of brilliance to the enamel. When the tooth's surface has been properly cared for in this manner we are then ready to attack the root-surface." Whether the prophylactic treatment is given the crown surface of the tooth before or after the root sur- gery, it should be done thoroughly before applying the medicinal treatment. 2. Medicinal Treatment. — After the teeth have been thoroughly scaled and poUshed, the mouth should again be carefully sprayed with the antiseptic solution, forcing it well between the teeth and around the gum margins to mechanically remove any loose deposit and pumice which may be left from the polishing. By the use of cottonoid rolls the parts treated can be kept dry and an application made of some astringent remedy. This can be worked with a glass instrument under the free margin of the gum and over the gum sep- tum, keeping the parts dry for a few moments, when the mouth can again be thoroughly sprayed and rinsed with the antiseptic solution. If the teeth are at all responsive to heat and cold, the solutions used should always be warmed to the temperature of the body. Spray- ing outfits are now on the market which keep the solutions warm; and, if the dentist devotes much time to pyorrheal or prophylactic treatment, these outfits should constitute a part of the ofl&ce equip- ment. As a local astringent in these cases, the author suggests the following : ^ Strong aqueous solutions of iodin and potassium iodid. PYORRHEA ALVEOLARIS 429 I^ — ^Zinci phenolsulphonatis, Potassii iodidi, aa gr. xx (1.3 Gm.) lodi (crys.), 5ss (2.0 Gm.) Mentholis, gr. iij (0.19 Gm.) Thymolis, gr, ij (0.13 Gm.) Glycerini, q. s. ad. f§j — M. Sig. — Use as directed above. This remedy is called pyorrhea astringent. The patients should now be instructed how to properly brush, massage, and care for their teeth generally, prescriptions should be written for a tooth-powder or paste and an antiseptic mouth-wash, and the patient dismissed until a second sitting. In giving the instruction relative to brushing the teeth and massaging the gums, it should be emphasized that the gums should be vigorously brushed as well as the teeth — thus we get the benefit of massage. Many hand and electrical appliances are also on the market for massaging the gums. The above treatment, in practically every detail, should be re- peated at each sitting until the mouth is in good condition, after which there will probably be little need for further medication. The patient should be requested to return at frequent intervals that the case may be watched, and each time the patient returns an examina- tion should be made with respect to the care given the teeth. If all is well, the patients should be complimented; if not, they should be cautioned accordingly. Astringent Mouth-washes Contraindicated. — The general pre- scribing of mouth-washes containing highly astringent drugs, as the zinc salts, in the treatment of pyorrhea alveolaris, is, in the opinion of the author, wrong. It is true that certain tissues of the mouth need to be constringed and stimulated to healthy activity, but surely the entire mucous membrane of the mouth does not need to be so treated. Cook has shown that the continuous use of astringent mouth- washes interferes for hours with the action of the ptyalin upon starchy foods. The astringent remedy should be applied by the dentist to the parts only which need such treatment, and an anti- septic mouth-wash, together with the proper brush, tooth-powder or paste, and other utensils for the mouth toilet is all the patient should use. If the patient is to use an astringent remedy at all, the con- stringing agents should rather be a constituent of a tooth-paste than of a mouth- wash. A prescription for a tooth-paste follows : 430 PIL^CTICAL DENTAL THEEAPEUTICS I^ — Calcii carbonatis ppt., oiijss (112. o Gm.) Saponis, 5ss (16.0 Gm.) Sodii benzoatis, 5j (4-° Gm.) Eucalj-ptolis, Olei menthce piperitae, aa m. x (0.6 mil) Th>Tnolis, gr. iv (0.25 Gm.) Saccharini, gr. iij (0.2 Gm.) Giycerim", q. s. ad. pasta. — M, Sig. — Use as a tooth-paste. As a mouth- wash any known antiseptic solution can be prescribed. It is as unnecessary as it is un\s'ise for the dentist to prescribe "cure-all" mouth-washes or those the constituents of which are to him unknown. The formerly official mouth-wash, Liquor Antisep- ticus, (X.F.) or Dobell's solution (X.F.) may be prescribed and diluted to suit the case. The formula for the Liquor Antisepticus follows: Boric Acid, 5 dr. (20.0 Gm.) Benzoic Acid, 15 gr. (i.o Gm.) Thymol, 15 gr. (i.o Gm.) Eucal>-ptol, 4 min. (0.25 mil) Oil of Gaultheria, 4 min. (0.25 mil) Oil of Peppermint, 8 min. (0.5 mil) Oil of Thyme, 2 min. (o.i mil) Alcohol, 8 fl. oz. (240.0 mils) "Water, to make i qt. (1,000.0 mils) In prescribing this solution it is never necessary to remember all of the various drugs and their quantities. We can take advantage of the fact that the solution was formerly recognized by the United States Pharmacopeia and vvTite its official title, as: I^ — ^Liquoris antiseptic!, f§\^j (240.0 mils) Sig. — DHute with one-half of warm water and use as an antiseptic mouth-vrash. It is well to remember, however, that the solution contains about 2 per cent, of boric acid, o.i per cent, of benzoic acid and thymol, 25 per cent, of alcohol, and other aromatics and antiseptics added to water as the vehicle. Herein is illustrated a practical application of a knowledge of the Pharmacopeia and National Formulary. In those cases compUcated by indigestion and where the patient complains of a sour taste in the mouth, especially on rising in the morning, due either to local fermentation or to the regurgitation -lof acid from the stomach, the condition may be corrected by the follow- ing prescription: I^ — Sodii bicarbonatis, 5j (4-o Gm.) Infusi gentianae comp., fohj (90.0 mils) — M. Sig. — Take a tablespoonful before meals and on retiring. PYORRHEA ALVEOLARIS 43 1 Where the sour taste comes purely from fermentation in the mouth, all that is necessary is to have the patients use frequently a warm solution of sodium bicarbonate, or the following alkahne and antiseptic mouth- wash may be prescribed : I^ — Sodii bicarbonatis, Sodii boratis, aa 3ss (2.0 Gm.) Thymolis, Mentholis, aa gr. ss (0.03 Gm.) Alcoholis, fSijss (lo.o mils) Glycerini, fSij (8.0 mils) Aquae cinnamomi, q. s. ad. fSviij (240.0 mils) — M. Sig. — Use wherever an alkaline and antiseptic mouth-wash is indicated. CLASS II 1. Surgical Treatment. — In this class of cases we are dealing with what may very properly be called true pyorrhea alveolaris, and in the surgical treatment it is especially necessary to use such instruments as will accomplish our end in a definite and certain manner. Here the exaggerated forms of the L.-B. set and those designed for scaling between the roots of molar teeth will be found extremely useful. If deposits are present, they must he removed, observing the same precautions as have been elsewhere mentioned. In the absence of deposits, the pockets, including both the affected tooth-surface and alveolar process, must be thoroughly curetted. We have here a more aggravated condition with which to deal, and from one to four teeth will doubtless be all that should be treated at one time, for the teeth thus operated upon are usually sore and more or less sensitive to thermal changes; therefore, the lesser number of teeth treated, the greater will be the comfort of the patient. The pockets are generally deep in this class of cases, and compressed air is an excellent agent to use for clearing the field and locating pockets. In the light of our present knowledge of focal infection and the grave systemic diseases resulting therefrom, it must ever be kept in mind that all teeth which cannot he treated so as to be kept free from infection should be extracted. Indications for the Removal of Pulps. — The question of remov- ing the pulps from the affected teeth in this class of cases is an important one. It may be safely stated that there are at least three indications for pulp removal, viz.: (i) where the pockets are deep and the infection in the apical area has left the pulp, if still ahve, in a low state of vitality; (2) where it is necessary to adjust some 432 PRACTICAL DENTAL THERAPEUTICS mechanical appliance (see Figs. 105 and 106); and (3) where the tooth is so acutely sensitive as to cause constant annoyance to the patient. The latter condition may be overcome by sealing desensi- tizing paste on the exposed cementum for a period of twenty-four Fig. 105. Fig. 106. Figs. 105 and 106. — This is a case where there was an abnormal space between the lower central incisors, about the width of one tooth. All of the four incisors were loose; the left central hopelessly so. The pulps were removed from the two lateral and right central incisors, and the canals filled. The radiograph for Fig. 105 was taken Mar. 9, 1916. The combination bridge and retainer was adjusted a few days later. The radio- graph for Fig. 106 was taken Nov. 30, 1916. The teeth are solid and comfortable, and the gums pink and healthy. Fig. 107. — This radiograph shows the result of an incorrect diagnosis. Pus was flowing from between the two central incisors and from between the left central and lateral incisors. The condition was mistaken by the dentist for an alveolar abscess; he drilled into the left central only to find a live pulp, which was removed and root filled. In the operation the perfect natural crown was so mutilated that a Logan crown was subsequently adjusted. The pus still continuing to flow, an attempt was made to open into the lateral, as the skiagraph shows On finding another live pulp, the dentist became discouraged, to say nothing about the patient, and referred the case. The curettement of two rather stubborn pyorrheal pockets effected a cure. hours, or, if a posterior tooth, by cauterizing the exposed cementum with silver nitrate (see p. 86). The transitory sensitiveness fol- lowing the scaling and poUshing of the teeth may generally be re- duced by poHshing the surfaces with moist sodium bicarbonate, PYORRHEA ALVEOLARIS 433 and having the patient rinse the mouth, especially before retiring, with a warm sodium bicarbonate solution. It has been chnically observed by White, of Nashville, and others that the removal of the pulp of a badly affected pyorrheal tooth is followed by a more rapid response to the local treatment of the disease. The theory has been advanced that in the removal of the pulp the entire circulation of the tooth is thrown to the sluggish pericemental membrane and thus stimulation is brought about. This is an erroneous idea, for Noyes and Broomell have clearly demonstrated histologically that the pericemental membrane is normally well suppHed with blood-vessels, and that to extirpate the pulp would not materially affect the circulation in this membrane. However, there are many cases wherein the removal of the pulp is clearly indicated — not, however, because of the supposed stimula- tion which results, but because of its low state of vitaHty and ulti- mate death, in which case the pyorrheal condition is liable to be compHcated by the presence of an alveolar abscess. Fig. 107 illus- trates the result of a mistaken diagnosis, where a pyorrheal condition was mistaken for an alveolar abscess. Fig. 108. Fig. 109. Fig. 108. — This shows an exposed molar root, such as is frequently encountered in the treatment of pyorrhea alveolaris. Fig. 109. — This shows the case after the excision of the root. A, excised root; B, cavity after removal. Denuded Roots. — Whenever a single root of a multi-rooted tooth is practically denuded of its pericemental attachment, ^\-ith the remaining roots in fairly good condition, the badly affected root should be completely excised. Such a condition is illustrated in Figs. 108 and 109. (See also Figs, no and in.) This necessitates, of course, the removal of the pulp and the filling of the root. If two roots are thus affected, the tooth had better be extracted. The use of local anesthetics in connection with the surgical treat- 28 434 PRACTICAL DENTAL THEEAPEUTICS ment of pyorrhea alveolaris, is not advised, as a rule. To further poison the tissues by actual injection when they are already in a low state of vitality is contraindicated, and the slight anesthesia otherwise induced is too often obtained only at the expense of quite as much pain as J the careful scaHng and curetting with the proper instru- ments would produce. The parts not being anesthetized will serve as a guide to the careful operator in locating the pockets, when the surgical treatment can be accomplished with a minimum amount of injury to the soft parts involved. If care and judgment are exer- cised, neither the pain nor the discomfort is as great as might naturally be supposed. After the surgical treatment is completed, the prophylactic treatment with the usual instructions should be given. Patterson^ states, "Experience has taught that the time spent in smoothing the roots is well worth the endeavor, for the rapidity and permanency of the recovery is greatly enhanced, and the operation cannot be considered completed until as much time is given to the polishing as to the removal of the deposits." Elimination of Deep Pockets. — It is always best in deep pockets, where there is considerable detachment of the pericemental mem- brane, to surgically eliminate the pocket, as shown in Figs. 112, 113, and 114. This is done by using a local anesthetic solution or spraying the part with ethyl chlorid, when a V-shaped piece of the gum is removed. Often the mere slitting of the gum with a sharp lancet will suffice, if the pocket is packed to prevent the edges of the wound from uniting. It is far better to have an exposed root sur- face free from infection, than to retain a pocket which cannot be kept from reinfection. On this point, Noyes^ says, "It is important to remember that whenever the fibers (of the pericemental mem- brane) have been stripped from the surface of the cementum, they can be reattached to it only by the formation of a new layer of cementum, building the fibers into it. This is certainly possible if the conditions are properly controlled, but the cells of the tissue must be in a normal and vitally active condition, and the surface of the root must be such that they can lie in physiologic contact with it. The cure of a pyorrhea case, therefore, becomes a biologic problem. In this connection it is important to remember that a surface of cementum which has long been bathed in pus may be so filled with poison that no cell can lie in contact with it and perform its function." Hartzell believes that these surfaces may be smoothed ' Johnson's Operative Dentistry, p. 467. ^ Dental Histology and Embryology, page 248. Fig. iio. — The picture here is of a model taken from a case after the mesiobuccal root of an upper first molar had been excised. The excised root is shown on the wire. With a little care, patients may keep such an area clean and the tooth may be saved for a number of years, free from infection. Fig. III. — The picture of the model on the right shows a case where the lingual root of an upper first molar was practically denuded of its pericemental attachment. The picture of the model on the left shows the case after the entire root had been excised and the tissues had healed. The excised root is shown on the wire. Fig. 112. — The picture of this model shows the result of eliminating the pyorrhea) pocket by surgically removing the overlying soft tissues. Fig. 113. — This picture shows where a deep pocket on the distal of a lateral incisor has remained permanently cured for a number of years after surgically eliminating the pocket. Fig. 114. — These are pictures of models of cases cured by surgically eliminating the pockets about the affected teeth. PYORRHEA ALVEOLARIS 435 by proper instrumentation and thus left free from bacteria and toxins, when the tissue surrounding the pocket is caused to bleed, filhng the latter with a sterile blood-clot and, under favorable conditions, new bone is formed. This may be .possible, but hardly probable, considering the conditions in the mouth. 2. Medicinal Treatment. — The medicinal treatment for this class of cases is practically the same as for the preceding class. The pockets should be washed out thoroughly after the surgical treat- ment. This may be accomplished with either the spraying apparatus or water syringe, having a small point on the nozzle. lodin, because of its penetrating and stimulating property, is especially efficacious in these bone affections. The case generally yields nicely when the appHcation of the local astringent remedy is made at intervals of two or three days. The time of making the subsequent apphca- tions should gradually be lengthened, and in about two or three weeks the case should be ready for the patient to care for him- self. It should be remembered that in this class of cases the patient, as well as the dentist, is confronted with a more serious proposition. The instruction, therefore, should be explicit and the progress of the case closely watched. In stubborn pus pockets it is sometimes necessary to thoroughly cauterize the area involved in order to check the pus formation. For this purpose excellent results may often be had from the use of a 25 or 50 per cent, solution of phenolsulphonic acid. This is a valuable stimulating agent, and may be appHed deep down in the pocket with a Dunn drop applicator; on general principles, however, the use of acids in the treatment of this disease is contraindicated, not because they will not assist Nature in effecting a cure, but because of the extreme sensitiveness which they produce. Phenolsulphonic acid is an exception to the rule, as this agent does not leave the teeth sensitive. It is generally best to surgically eHminate such pockets. Occasionally the pus formation will persist in a pocket where we are reasonably certain that the ordinary surgical treatment has been thorough, and where also the pocket has been cauterized. Here we can suspect resorption of the root in the apical area, leaving sharp, needle-like points, which keep up the irritation. In these cases it is necessary to amputate the root-end or extract the tooth. The author's experience with replantation as a last resort in the cure of badly affected teeth in pyorrheal or abscessed conditions has not been encouraging. For permanent results it is absolutely essential that the replanted tooth be held firmly in position by some permanent appliance, and generally its extraction and the insertion of an arti- 436 PRACTICAL DENTAL THERAPEUTICS ficial tooth is far more sanitary and satisfactory. It is not a question here of what a dentist can do by his ingenuity and skill, but rather a question of what is best for the patient. Head, of Philadelphia, a few years ago, brought forth the use of ammonium hydrogen fluorid as a tartar solvent in the treatment of pyorrhea alveolaris. The solution which he recommends is made as follows : Commercial hydrofluoric acid is completely neutralized with ammonium carbonate and ammonium fluorid formed which dissolves in the water present. This solution is filtered, and as such has little chemic action on the so-called "tartar" on the teeth. To make the more active acid salt solution the ammonium fluorid solu- tion is now evaporated in a leaden dish to one-half of its original bulk, an equal amount of hydrofluoric acid is added, and the whole again evaporated to one-half of its bulk. The resulting solution is ammonium hydrogen fluorid. Great care must be exercised in making this solution, for if any of the hydrofluoric acid is left free, its action would produce serious results. Head recommends making the application to a pyorrheal pocket with a rubber syringe having a platinum point or with a drop appli- cator. The claim is made that it will dissolve the deposit without any deleterious effect on the soft tissues. The author again desires to emphasize the precautions to be observed in obtaining a solu- tion of ammonium hydrogen fluorid free from uncombined hydro- fluoric acid, for a burn from this acid is at best a stubborn condition to treat, especially in the mouth where there is always danger of a mixed infection. For various reasons, the remedy has not met the earlier expectations. Use of Emetin. — The discussion of the medicinal treatment of pyorrhea alveolaris would not be complete without at least brief reference to the use of ipecac and its chief alkaloid, emetin. For years certain preparations of ipecac root have been used empirically in the treatment of amebic or tropical dysentery, an ulcera- tive disease of the intestines due to the presence of the Endameha histo- lytica. When Barrett and Smith discovered the universal presence of the Endameha buccalis in pyorrheal pockets, the use of emetin at once suggested itself. Barrett recommends the local use of a 3^ per cent, solution of emetin hydrochlorid, as stronger solutions cause irritation of the soft tissues. The solution is warmed and introduced into the pyorrheal pocket, using an ordinary hypodermic syringe with a flexible blunt needle. In addition to filling the definite pockets, a small amount of the solution may be permitted to run into the interdental spaces, care being taken to avoid any chance that PYORRHEA ALVEOLARIS 437 the patient will swallow the remedy. Emetin is a prompt emetic. Such treatment should be repeated daily for five or six days, to be followed by similar treatments every other day for as many times. According to Barrett the amebae disappear rapidly and are rarely found in the lesions after the second or third apphcation. Another method of using emetin in the treatment of pyorrhea alveolaris was introduced by Bass and Johns, after their discovery, almost simultaneously with Barrett and Smith, of the presence of amebse in pyorrheal lesions. Their original method consisted of the hypodermic injection, in any part of the body, usually the arm, of 3^ gr. of emetin hydrochlorid in solution. Ampules con- taining the proper dosage are readily obtainable. These injections were made daily for three or four days, repeating the treatment on one or more days after an interval of three to ten days. Accord- ing to these authorities amebas disappear from all lesions in practi- cally all cases after six days' treatment. Still another method of using emetin in the treatment of this disease is the oral administration of alcresta ipecac. This prepara- tion is an absorption compound of the ipecac alkaloids, emetin and cephaeHn, with a form of hydrated aluminum siHcate, an alkaloidal reagent discovered by Professor John Uri Lloyd, of Cincinnati, Ohio. This combination prevents the alkaloids from being dis- solved in acid or neutral solutions and permits their solution in alka- line media only. In this manner these alkaloids pass unchanged through the stomach, which prevents entirely the nausea and vomit- ing caused by the oral administration of preparations of ipecac in any other form. This means that the alkaloids are physiologically inert as long as they remain in the stomach and become active when set free in the alkahne intestinal secretions, where they not only act on the amebse and bacteria locally in the intestine, but whence they are absorbed and carried by the blood-stream to the alveolar lesions, acting there also upon the infecting organisms. The tablets of alcresta ipecac should be given while the surgical treatment of the case is in progress or even preceding it. Two tab- lets in one-half glass of water one-half to one hour before meals and on going to bed is the proper dosage to be continued for a period of five days, when the drug should be discontinued for about a week, at the end of which time a second course may be prescribed. In some cases there will be a slight looseness of the bowels after the fifth or sixth day. It is seldom necessary to discontinue the admin- istration of the drug on this account. The author has used emetin in every manner in whichjt has been 438 PRACTICAL DEXTAL THERAPEUTICS suggested, both in college and in private practice; and I can say- that there is no longer any doubt in my mind about the efficacy of the drug. Used locally, as suggested by Barrett and Smith, in my hands the remedy has been disappointing; but the results are surely noticeable when the drug is internally administered, as suggested by Bass and Johns. As stated above, there are two ways in which this may be accompUshed : By the hypodermic injection of emetin hydro- chlorid, and by the mouth administration of alcresta ipecac. So far as I have been able to observe, there is little, if any, difference in the results obtained by these two means of getting the drug into the circulation whence the blood-stream carries it to the alveolar lesions. Because of the ease of accompHshment, and also because of the local effects of the drug on the organisms in the intestines, the mouth administration is far preferable, and the results equally as good, if not better. The present opinion of the author regarding the "emetin treat- ment" for pyorrhea alveolaris is that the remedy is not a specific for the disease. In itself, used as many physicians have used it, without the all-important local treatment, in my hands it will not cure the disease; but used internally, as the surgical treatment is undertaken and accomplished, the inflammation subsides more readily, the gums resume their normal color and tone more quickly, and the teeth and general mouth conditions are more comfortable than when the drug is not administered. I beheve the future will demonstrate that emetin when internally administered has some therapeutic effect, other than its amebicidal action, which makes its use valuable in the treatment of certain mouth conditions. It may be its hemostatic action upon the blood. The remedy is equally efiSicacious for flabby and bleeding gums and aU other inflammatory conditions resulting from local irritants, and tending toward pyorrhea. It must be remembered, however, that no remedy should be administered for such conditions wdthout a thorough prophylactic treatment of the mouth. When Bass^ made the statement that 95 per cent, of all adults examined by him had pyorrhea alveolaris, he must have used the term in a broad sense and included gingivitis and all other inflammatory mouth conditions. Strictly speaking these conditions should not be classed as pyorrhea. Use of Mercury Succinimid. — The effects of mercury succinimid, when internally administered, upon pyorrheal lesions was noticed wholly by chance by Dr. Paul G. White,^ assistant dental surgeon, ^ Journal of the American Medical Association, Feb. 13, 1915. * Dental Cosmos, April, 1915. PYORRHEA ALVEOLARIS 439 U.S.N., at the Portsmouth Navy Yard. In relating his experience White says: "Two patients, who had been under local treatment for pyorrhea alveolaris, presented themselves upon different days with gums swollen and exquisitely tender, and often with free saHvation. Being unable to account for such conditions, which occurred at regular intervals, the patients were questioned, and the fact that they were also being treated for other troubles at the same time by Dr. Barton L. Wright, U.S.N., senior surgeon at the Yard, was brought to light. Investigations showed that both patients were being given deep muscular injections of mercury at regular intervals, and that the changes in the gum tissues and their hypersensitiveness were usually most prominent on the second day after treatment. The surprisingly quick cessation of the pus flow from the pockets and the corresponding return to normal of the gum tissues led to the introduction of mercury succinimid in other cases." These authors report startling results in a number of cases. The use of the remedy, as yet, has not been demonstrated to be practical, nor is it of sufiS.- cient value to be employed generally in the treatment of the disease. What the future holds forth, remains to be seen. There is no longer any doubt in the minds of those who have given serious study to the relation of pyorrhea alveolaris to systemic disease, regarding the effects of syphilis on the supporting or investing structures of the teeth. It may be that mercury will prove most beneficial in the treatment of mouth conditions when known to be associated with a specific history. Use of Vaccines. — The raising of the opsonic index has been sug- gested as a means of combating pyorrhea alveolaris, as has also the use of specific vaccines (Hecker and others). The efficacy of these methods has not been sufficiently demonstrated to merit their discus- sion in a work on "practical therapeutics" at this time. In this con- nection, however, it should be remembered that we should never be in too great haste to remove foci of infection when the patient is systemically involved. In these cases, several pyorrheal pockets should not be curetted at one sitting, nor should several involved teeth be extracted at one time, on account of the reaction which frequently follows the disturbance of areas of infection. It is best in all such cases to confine the operation to one or two teeth. It is to be hoped the true cause of pyorrhea alveolaris will soon be discovered, when the medicinal treatment can be instituted along more rational fines or, what would be better, such prophylactic measures inaugurated that the disease might be prevented. In our present state of knowledge it must be said that too much 440 PRACTICAL DENTAL THERAPEUTICS dependence should not be placed upon drugs, for at this time there is no known specific for the cure of the disease. Where the loss of tissues has been extensive and the teeth are so loose as to interfere with their usefulness in mastication, the correct treatment necessarily includes the making of mechanical appliances for their support. 3. Mechanical Treatment. — The importance of what the author has chosen to call the mechanical treatment of the disease under consideration has previously been emphasized. A detailed de- scription of the method of making the various mechanical appli- FiG. 115. — This shows loosened lower anterior teeth, temporarily wired with a 26 gauge platinoiridium wire, to hold the teeth during the scaHng process, after which a permanent retainer, as illustrated in Figs. 116 and 117, was adjusted. Fig. 116. Fig. 117. Fig. 116 — This shows the retainer in wax with the sprue inserted ready to be in- vested for casting. Fig. 117. — This shows the completed appliance set on the model. directions for making A modehng compound impression is taken of the cutting edge and upper lingual third of the teeth to be included in the appliance. From this impression a model is made with a good investment material. It is best to let it set over night, when the modeling compound can be removed by using dry heat. Care should be exercised notjto chip |the margins of the investment teeth. On this model the retainer can be made in wax just as it is desired when completed. The model is trimmed so it can be put into a casting flask, the sprue inserted and it is ready for investing (Fig. 116). After casting, it is finished and set in the usual manner (Fig. 117). ances is not properly included in a work of this character. The proper apphance for holding loose teeth in the jaw will naturally suggest itself to the ingenious dentist. They consist of a combina- tion of inlays, crowns and bridges, the so-called splints, and various retainers. For the benefit of the beginner a splint suggested by Dr. C. L. Hine, of Tuscola, 111., for loose teeth, the pulps of which need not be devitalized, is illustrated and briefly described in Figs. 115, 116 and 117. On the following pages the reader will find Figs. 118 PYORRHEA ALVEOLARIS 441 to 130, inclusive, with descriptions which were furnished the author by Dr. Lee K. Stewart, of Chicago, and explain fully his method of treating the conditions under consideration from the mechanical viewpoint. It should be borne in mind that no tooth should be retained in the mouth that cannot be kept free from infection. Fig. 118 a. Fig. 1x8 B. Fig. 119 A. Fig. 119 B. Fig. 120 A. Fig. 120 B. Fig. 121 a. Fig. 121 B. Fig. 121 C. Fig. 122. Fig. 118. — "A"and"B". Loose teeth from which the pulps have been removed, the canals filled, prepared for insertion of soft platinum wire and ready for the wax pattern or modeling compound impression. Fig. 119. — "A" and "B". One or more teeth with soft platinum wire in position. The exposed end is barbed to hold either in the wax pattern or the impression material. The operator may prepare the wax model for casting directly upon the tooth, or upon the models. Fig. 120. — "A" and "B". Modeling compound impressions of one or more teeth. Fig. 121. — "A", "B" and "C". Models of one or more teeth made from impres- sions, waxed and ready for investing for casting. Notice the pin has been placed to direct the flow of gold by rather than at the model. Models made of equal parts of plaster and silica. Fig. 122. — Double wax model made directly upon the teeth and ready for invest- ment. 442 PRACTICAL DENTAL THERAPEUTICS Fig. 123. Fig. 124. Fig. 123. — Method of investing. Fig. 1 24. — Two castings in position and ready for the impression. Notice that the exposed end of soft platinum wire has not been cut off. Do not attempt to assemble more than two at one time, and take the impression of the parts ready to be united either with a small piece of modeling compound or just a little plaster. Fill the impression with ordinary soldering investment, separate and solder. Fig. 125. — Two castings soldered. Continue in this manner, making single, double or larger castings, either from models or by carving the wax upon the natural tooth. Fig. 127. Fig. 126.— Finished case with pins well barbed. Do not cut barbs opposite each other; and remember not to cut off the exposed ends of soft platinum wire until the case is ready for the final pohshmg. No gold should be noticeable in the patient's mouth. The larger barbs will prevent a tooth that has been shortened from dropping below the others. Fig. 127. — A case with loss of the lateral incisor. Fig. 128. — Retaining appliances replacing lost incisor. Many cases present where one or more teeth have been lost and the others are very loose. This appliance will support the loose ones and replace the lost ones. PYORRHEA ALVEOLARIS 443 Fig. 129. Fig. 130. Fig. 129. — ^Labial view. Fig. 130. — ^Lingual view. This method can be used in any place in the mouth to support loose teeth and to carry bridged ones. Where it is desirable to retain the pulps, use one or two short soft platinum pins in each tooth and prepare nearly parallel pits as far away from the pulp as possible. Before placing the appliance, barb the pins well and undercut the cavities. (L. K. Stewart.) CLASS m In considering the therapeutics of this class of cases from the dental viewpoint it can be stated that the treatment is both local and general. 1. Local Treatment. — The local treatment involves practically the same surgery, drugs and remedies, and mechanical appliances as in the preceding classes, modified only to meet the conditions as found. To be effective and permanent the treatment by the dentist must be given conjointly with the general treatment by the physician in charge. 2. General Treatment. — Whenever the local condition in the mouth seems to be aggravated, if not caused, by some of the systemic diseases elsewhere mentioned, it is the plain duty of the dentist to refer the patient to his family physician for the general treatment. In fact, it is almost useless to undertake the local treatment unless measures are simultaneously instituted for the correction of the systemic disease; but when the physician and dentist work together in harmony, it is surprising what great relief can be given the patient by the proper local treatment, for the mouth in many instances is in a hideous condition. In all cases wherein some systemic complica- tion is suspected, the dentist should not fail to have the urine examined for at least such abnormal constituents as albumin and sugar. With a little practice the dentist may readily make these tests himself. A brief, but practical outline for the examination of the urine will be found on p. 468. In conclusion, I desire to state that it is a pleasure to work for pyorrheal patients. In many instances they have been informed that nothing could be done, and that they must soon lose their teeth; therefore, in most cases, they appreciate fully your every effort. NEURALGIA GENERAL CONSIDERATIONS Neuralgia may be defined as a severe paroxysmal pain in the area of distribution of a nerve, or along its course; and, according to Barrett, true neuralgic pain is principally confined to the afferent or sensory nerves, but it may be of a reflex character and hence have its origin in the efferent or motor nerves. It is not a disease in itself, but is rather a manifestation of a disease or perverted function; therefore, the conditions which may cause neuralgia are many and varied; and, for convenience in study, they may be classified as follows : I. General Diseases. 1. Those Which Lower Vital Resistance. — This class includes anemia, or other diseases which interfere with such vital functions of the body as the circulation, respiration, secretion, digestion, assimilation and ehmination, 2. Those Which Produce Foreign or Abnormal Substances in the Blood. — This includes syphilis, gout, rheumatism, diabetes, nephritis, malaria, chronic pyemias or any foci of infection, metallic poisoning, etc. II. Local Diseases. 1. Those Which Cause Reflex Peripheral Irritation. — In this class are included diseases of the teeth, eyes, ears, stomach, uterus, and ovaries. 2. Those Which Produce Pressure. — This includes various tumors, and especially such abnormal growths as occur within bony canals through which nerve-trunks pass. 3. Chronic Inflammation of the Nerve-sheath or of the Nerve Itself. — This includes neuritis, or actual diseased conditions of the nerve. III. Certain Intractable Cases. This class includes a large number of cases of neuralgia for which no cause can be found. The neuralgias which generally come under the observation of the dental practitioner are chiefly those manifested in the area of distribution or along the course of the fifth cranial nerve, and are accordingly called facial, trifacial or trigeminal neuralgia. 444 NEUEALGIA 445 FACIAL NEURALGIA There are many local conditions in and about the teeth which may cause facial neuralgia. Chief among them are: 1. Pulpitis. 2. Pulp nodules, partially calcified pulps, and secondary dentin. 3. Pericementitis. 4. Cementosis. 5. Deposits on the roots of teeth. 6. Infections about the roots of teeth. 7. Exposed dentin and cementum. 8. Impacted teeth. 9. Faulty occlusion. THERAPEUTICS The first essential in the treatment of neuralgia due to diseases of the teeth is to ascertain the cause and remove or correct it, if possible. As Harlan says: "The dentist should consider no time lost in an endeavor to find the cause of facial neuralgia." It is essential here, as in all treatment cases, to make a correct diagnosis. In most cases the symptoms are of the subjective variety and a correct diagnosis is often difficult to make. It is necessary often- times to take into consideration the diseases outlined in the classi- fication on the preceding page; and it is also well to remember that women are especially prone to neuralgia during the period of the so-called "change of life." Fortunately, however, by means of radiography many of the conditions mentioned as being productive of facial neuralgia may be positively diagnosed. Illustrations of several of these conditions are found on the following page in Figs. 131, 132, 133, 134, 135 and 136. The late Dr. J. N. Grouse, of Chicago, reported an interesting case in his practice which occurred before radiography was known (see Figs. 137, 138, 139 and 140). The author desires to emphasize the importance of ascertaining, if at all possible, the cause of the neuralgia, for upon this depends largely the method of applying our therapeutics. In radiographing the teeth for possible causes of neuralgia, it is well always to radiograph the areas where teeth have been extracted. In this way many an obscure cause may be located in a root-end which had been left and which has a low grade of infection associated with it. With the cause known, the treatment is of two kinds — medicinal and surgical. 446 PRACTICAL DENTAL THERAPEUTICS Fig. 131. — This radiograph shows an impacted lower third molar, frequently the cause of facial neuralgia. Fig. 132. Fig. 133. Fig. 134. Fig. 135. Figs. 132, 133, 134 and 135. — These all show cementosed roots, the cause of facial neuralgia. Fig. 136. — This shows a lower third molar coalesced to and between the roots of the lower second molar. NEURALGIA 447 I. Medicinal Treatment. — The medicinal treatment of facial neuralgia may be subdivided into local and general. 1. Local Treatment. — There are many drugs and remedies which act favorably upon the sensory nerve-endings, and are, therefore, efficacious in the local medicinal treatment of this disorder. Fig. 137. Fig. 138. Fig. 139. Fig. 140. The above figures are illustrations of perfectly sound teeth which were extracted from one mouth. The symptoms were different from those of any other case with which I have had to deal. When the patient first presented, in the middle of the night, he was suffering such severe paroxysms of pain that during one of the attacks he dropped to the floor almost senseless. The attacks were of short duration, but several occurred before I could learn what the trouble was. Directly after one of these spells, by tap- ping the teeth on the side where the pain was most severe, I found slight sensitiveness; particularly was this so of the first upper bicuspid, although the pain radiated all over the head. I attempted to drill into this tooth and found the canal obliterated, so I extracted it (Fig. 137). Notice also the cementosed root. The history of the other teeth (Figs. 138, 139 and 140) is similar, except that I could locate the trouble with less diflS- culty after the first experience; then, too, the disease had not progressed quite so far before the teeth were extracted. I lost track of the patient and do not know whether he had further trouble or not. (/. N. Crouse.) The author's dental Uniment mentioned in connection with non- septic pericementitis (p. 362) will often give excellent results, or any of the follpwing remedies may be prescribed: gr. XXX (2.0 Gm.) I^ — Mentholis, Alcoholis, Etheris, aa f5vi (24.0 mils) Chloroformi, q. s. ad. f5iij (90.0 mils) — M. Sig. — Apply by vigorous rubbing or massage over the area of distribution of the affected nerve, or along its course. I^ — Camphorse (gum), Tincturae aconiti, Linimenti saponis, Sig. — Use as above. 3ij (8.0 Gm.) foj (30.0 mils) s. ad. fSiij (90.0 mils) — M. 448 PRACTICAL DENTAL THERAPEUTICS W. H. Truman suggests the following: I^ — Camphorae (gum), 5j (4-o Gm.) Etheris, f5ij (8.0 mils) Alcoholis, f§j (30.0 mils) Chloroformi, q s. ad. fgiij (90.0 mils) — M. Sig. — Use as above. The various liniments here given have practically the same thera- peutic effect — that of a sedative upon the peripheral sensory nerves. In cases where the pain comes from pericementitis or from a developing abscess associated with the upper anterior teeth, it may be stopped in many instances like magic by spraying the posterior nares with alcohol and water, as suggested by Keefe (see p. 368). Electricity is often of great value. Marshall suggests applying the positive pole of a galvanic battery to the painful spot, when a current of from one to three milliamperes is applied for from two to five minutes. Freezing the area with ethyl chlorid will frequently afford much relief, especially in cases of acute pericementitis. 2. General Treatment. — The general medicinal treatment in- volves the administration of drugs systemically. If certain drugs are indicated for the correction of some systemic derangement which is causing reiiexly the facial neuralgia, as, for instance, iron compounds in anemia, quinin in malaria, mercury and iodids in syphiHs, etc. they had better be prescribed by the family physician. Here again is a condition wherein the best results from the treatment are ob- tained only when both the family dentist and the physician work in harmony. Cases have been authentically reported where physicians had treated patients systemically for neuralgia for months without effect, when ultimately the case was cured instantly by the dentist in relieving some local condition about the teeth; while, on the other hand, dentists have been known to keep patients suffering for months in an endeavor to locate the cause about the mouth, when ultimately the correction of some systemic trouble cured the local neuralgia. While patients should be referred to the family physician for the general treatment of constitutional diseases, it is not only the privi- lege but the plain duty of dentists to prescribe internal drugs for the reUef of pain while the cause of the neuralgia is being searched for and removed. It is true that this involves a knowledge of drugs and their uses, but surely this is not too much to expect of the trained dental practitioner of to-day. The classes of drugs indicated for the control of pain are the hypnotics or general anodynes or analgesics. Several prescriptions are here given. The practitioner can select the one which best seems to suit the case at hand. NEURALGIA 449 I^ — Pulveris acetanilidi comp., gr. xx (1.3 Gm.) Fiat chartnlse No. iv. Sig. — Take one powder every hour until two or three are taken; if not relieved after two or'three hours, take the remaining one or two. In cases of neuralgia of rheumatic origin phenacetin may be com- bined with salophen and codein sulphate to control the pain. A prescription follows: I^ — Phenacetini, Salophen, aa gr. xx (1.3 Gm.) Codeinae sulphatis, gr. j (0.06 Gm.) — M. Fiat chartulae No. iv. Sig. — Take one powder every two hours. Note. — This prescription will require a Federal blank, with the prescriber's registered number. When the neuralgia is associated with nervous headache the following prescription may be given: I^ — Caflfeinae citratis, gr. xij (0.8 Gm.) Phenacetini, 3ss (2.0 Gm.) — M. Fiat chartulae No. vj. Sig. — Take one powder every two hours untU relieved. Occasionally patients do not like to take a powder, preferring a liquid preparation. In these cases we can prescribe antipyrin in solution with an aqueous vehicle, for, unhke acetanilid and phen- acetin, this drug is soluble in water. Sometimes it is advisable to combine the coal-tar analgesics with a bromid; a prescription for such a combination is here given: I^ — Antipyrinae, 5ss (2.0 Gm.) Sodii bromidi, 3j (4-o Gm.) Glycerini, f5ss (15.0 mils) Aquae cinnamomi, q. s. ad. f5ij (60.0 mils) — M. Sig. — Take a dessertspoonful three times a day, and oftener if conditions necessitate. Sometimes the coal-tar analgesics fail to produce the desired effect, in which case there is always one drug that can be relied upon to control the pain, and that is morphin. This drug is truly indi- cated for the control of pain from whatever source and may be given here in ^ gr. (0.008 Gm.) dose, but under no conditions should a prescription be written for the drug. Many patients are in the habit of keeping a copy of the prescription, and when the remedy 450 PRACTICAL DENTAL THERAPEUTICS works well in a certain case they often get the prescription refilled for themselves or friends on the least provocation. In the case of- morphin this might innocently lead to the "habit." Tablets con- taining the usual dose (3^ gr.-o.oo8 Gm.) may be kept on hand, and, if necessary, two such tablets may be given by the stomach within one-half hour, and then the patient can take one tablet home — never more than one, if two have been given at the office — which can be taken in the course of an hour, if not relieved. It is necessary to keep a record when using drugs which come under the "Federal Antinarcotic Law." Fortunately, it is seldom necessary for the dentist to prescribe opium or its alkaloids; but when indicated, in their judgment, they have the legal right to prescribe any drug to relieve suffering humanity. Of the newer synthetic products, pyramidon is one of the best. This may be prescribed in five-grain (0.3 Gm.) tablets every two hours until relief is obtained, or until four or five tablets have been taken. It should be remembered that no drug should be taken continuously for the relief of pain. These remedies are only intended to control the pain until the cause is corrected or removed. When the patient is unable to sleep, chloral hydrate or butyl- chloral hydrate may be prescribed. The fifth nerve is supposed to be especially sensitive to the influence of butyl-chloral hydrate. A prescription follows: I^ — Butyl-chloralis hydratis, 5j (4-o Gm.) . Fiat capsulis No. xij. Sig. — Take one capsule every three hours until four are taken. In cases where a tonic is indicated, as in anemia, the syrup or glycerite of iron, quinin, and strychnin phosphate (N.F.) may be given. A prescription for the syrup follows: I^ — Syrupus ferri, quininje et strych- ninae phosphatis, fSiij (90.0 mils) Sig. — Take a teaspoonful in water before meals. Where the neuralgia is of malarial origin, quinin is indicated. An excellent prescription follows : ^I^ — Quininae valerianatis, gr. xviij (1.2 Gm.) Extracti hyoscyami, gr. iv (0.25 Gm.) Extracti cinchonae, gr. viij (0.5 Gm.) — M. Fiat capsulae No. xij. Sig. — Take one capsule before meals and on retiring. ' Taken from the Dental Cosmos. NEURALGIA 45 I It will be noticed that only a few doses have been prescribed in any of the above prescriptions. This precaution has been taken because some of these patients suffer untold agony; in fact, they may be considered temporarily demented, and no matter how specific your verbal and written directions have been, they may ignore your directions entirely and take one dose after another on the general principle that "if a little is good, more is better," until they have taken such a quantity as may result in an overdose. Therefore, it is well for dentists, especially, to be careful in this respect. n. Surgical Treatment. — The surgical treatment often involves major surgery, for a discussion of which see works on Oral Surgery.^ TIC DOULOUREUX The discussion of facial neuralgia would indeed be incomplete without at least brief mention of tic douloureux, so named by Trous- seau, a Frenchman. The condition frequently results from chronic irritation of the filth cranial nerve. The pain is very acute, and occurs in distinct paroxysms, gradually increasing in severity, until it reaches a climax, when it quickly subsides. The attack may occur at any time and may be provoked by laughing, talking, the movement of a muscle, etc.; even a slight noise or Hght touch, as placing the hat on the head, may cause a paroxysm. The patient lives in constant dread of an attack. There is no condition which elicits greater sympathy than this, for the experienced physician or surgeon realizes that little can be done either medicinally or surgically. Materia medica has been exhausted in search of a cure, and surgery affords only temporary relief. Patrick, Moyer, and others report favorably upon the use here of castor oil. The drug is first pushed almost to catharsis, then the dose is decreased, but the administration of the drug is still kept up. Ultimately the patient can take large quantities of castor oil without the cathartic effect. Stekoulis, Schapiro, Bennett, Murphy, and others have injected osmic acid into the substance of the affected nerve and report encouraging results. The late Dr. J. B. Murphy, however, has directed attention to the great tendency of nerve tissue to regenerate; and states that many cases of tic douloureux will recur, even when the affected nerve has been severed by destroying an area with osmic acid or when blocked with such material as gutta-percha. Deep injections of alcohol in the region of the orbit of the affected ^"Oral Surgery," by Dr. Truman W. Brophy, is highly recommended. 452 PRACTICAL DENTAL THERAPEUTICS nerve have been recently suggested for the rehef of facial neuralgia. Patrick, Moorehead, Potts, and others report favorably on the method. The needle generally employed is one adopted by Levy and Bandonin, which is graduated in centimeters up to five. The alcohol should be about 75 per cent., and should contain a very small amount of cocain hydrochlorid. The success of the operation will be indicated by a slight anesthesia over the parts supplied by the nerve. Upon the slightest return of the pain the operation should be repeated, after which relief for some months, and even two years or more, may be expected. The formula used by Patrick is here given: I^ — Cocainse hydrochloridi, gr. j (0.064 Gm.) Chloroformi, m. x (0.61 mil) Alcoholis, fSiij (12.0 mils) Aquae distillatae, q. s. ad. f5ss (15.0 mils) — M. Sig. — Use as directed above. On the whole, it may be stated that the therapeutics of tic doulou- reux is discouraging to all concerned. Hirt sums up the conditions very properly when he says: "Numerous are the means at our com- mand for combating tic douloureux, and quite as numerous are the patients who, after hundreds of unsuccessful trials, have given up in despair all medicines and all physicians." The condition has not been thus briefly discussed here because of the likelihood of dentists being called upon to treat it, but rather because they are often called in consultation on the case to aid in making a correct diagnosis. DIAGNOSIS AND TREATMENT OF DISEASES OF THE SOFT TISSUES OF THE MOUTH NOT DIRECTLY ASSOCIATED WITH THE TEETH GENERAL CONSIDERATIONS In this general group will be considered certain diseases of the soft tissues of the mouth other than those directly associated with the teeth, The etiology and pathology of these diseases will be consid- ered somewhat more fully than has been done with the diseases of the hard tissues of the mouth and associated structures, for the reason that dentists, as a rule, are not so familiar with the etiology and pathology of the diseases under consideration here, and, therefore, find it more difficult to differentiate between some of these condi- tions and to make a correct diagnosis — upon which the successful therapeutics is based. Our profession has been criticised in the past, and, perhaps, in a measure justly so, because it is claimed that in our examinations of the mouth we have been looking only for cavities in the teeth and have not noted, at the same time, the condi- tion of the oral mucous membrane and soft tissues. The tendency is to broaden our perspective, and the live dentist of to-day realizes the importance of a knowledge of the pathology of the soft tissues of the mouth as well as of the teeth themselves. The mouth is a hot-bed for many kinds of bacteria, and is there- fore a fruitful field for diseases of almost every description. Some of these diseases are purely local, having certain definite causes, while others are local manifestations of some general disorder. Even those diseases that are caused by local infections are influenced in most instances by the condition of the stomach or general metabolism of the individual. The mouth and the stomach are intimately con- nected and closely related ; so much so in fact that pathologic condi- tions in the one often predispose to disease in the other. We can more readily understand the close relation that exists between dis- eases of these two organs when we remember that much of the septic material of the mouth ultimately finds its way to the stomach and intestines, and the toxins absorbed from the digestive tract are fre- quently excreted in the saliva. Michaels claimed the saliva to be pathognomonic of certain systemic diseases, the diagnosis being made by him solely by physical and chemic examinations of the saliva. 453 454 PRACTICAL DENTAL THERAPEUTICS Some of the diseases of the mouth are characteristic and easily differentiated and diagnosed; while the correct inteipretation of the clinical manifestations of others is exceedingly difficult and often- times baffles the most skillful diagnostician. In our larger cities we are fortunate in having the pathologic laboratories which must fre- quently be used in order to confirm our clinical diagnosis. CANKER SORES Canker sores are true ulcers and are among the more common pathologic conditions of the soft tissues of the mouth. They are sup- posed to have their origin primarily in the mouth, yet Pusey and others believe them to arise from trophic disturbances. The author has observed that women are peculiarly susceptible to this condition during the menstrual period. Some women have canker sores nearly every time they menstruate. They seem to be associated also with gastrointestinal distrubances. They always appear sud- denly and are very persistent unless given suitable treatment. Diagnosis. — Gilmer^ states that "they most commonly occur at the duplicature of the mucosa of the cheek and the gums, though they are occasionally seen on the floor of the mouth and on the edges and under the surfaces of the tongue. They vary in size from that of a grain of wheat to that of a small-sized bean. Their depth varies, but they can never be considered superficial. Their margins are rather well-defined, but not so markedly as are chancrous ulcers of similar tissues, neither are they so irregular as lupous ulcers of the mouth. The mucosa for a quarter- to a half-inch from the ulcer is a deep red color. The base of the ulcer is overlaid with a grayish- white necrotic covering, not unlike that found in syphiHtic ulcers in the mouth. When this coating is removed, a granulating surface is exposed, which, while extremely sensitive to the touch, bleeds but slightly, if at all. These ulcers are so distinctive in their appearance that they can hardly be mistaken for any other lesion." Therapeutics. — The treatment of canker sores is purely local, and the sooner it is instituted the less persistent the ulcer will be. The necrotic tissue may be carefully removed by scraping, or cleansed with hydrogen dioxid, after which the raw surface should be dried and cauterized. They generally yield nicely to one application of silver nitrate. For this purpose a lo per cent, solution may be used; a 20 per cent, solution of argyrol may also be employed. The ulcer being acutely sensitive, it is sometimes better to use 95 per cent. 1 Dental Review, Vol. XXIII, p. 496. DISEASES OF THE SOFT TISSUES OF THE MOUTH 455 phenol as the cauterizing agent. The analgesic effect thus produced is often of value. The mouth should be kept clean, when the ulcers usually heal without further treatment. HERPES LABIALIS Herpes labiaKs, also called cold sores or fever sores, have a similar origin to canker sores. They are of a herpetic nature, and differ in appearance from the latter principally on account of the location and tissues involved. Of these Gilmer says: "Herpes of the lips (herpes labialis) and occasionally of the gums (herpes gingivalis) sometimes follow dental operations and cause uneasiness on the part of patient, who often attributes this condition to infection from unclean arma- mentarium used by the dentist, when, in truth, the patient is of a herpetic diathesis, and under such circumstances a slight irritation only, in such locations, being sufficient to excite the condition." Diagnosis. — The diagnosis of cold sores is a simple matter. They occur frequently when the patient is suffering from colds or during convalescence from fevers, hence the name. The tissues immediately around the area involved are swollen and tender; the membrane is dry and has a tendency to crack and bleeds readily. Therapeutics. — The treatment of cold sores consists in cleaning the part with such agents as hydrogen dioxid or alcohol, then drying and making an application of oil of cloves or spirit of camphor. Either of these latter agents is just sufficiently irritating to produce stimulation of the cells and promote healing. If the cold sore is large and liable to crack and bleed on moving the lips, it can be kept soft and pliable by frequently applying euroform paste, or may be immobilized by applying collodion. In the latter instance the part should be dusted with boric acid before coating with collodion. SYPHILIS S3rphilis is a chronic infectious disease now known to be produced by a specific microorganism, the spirocheta pallida — a germ discovered March 3, 1905, by Schaudinn and Hoffmann. This disease is much more common than is generally supposed, and it is essential that every practising dentist be famihar with its characteristic symptoms. Skill in the diagnosis of syphiHtic manifestations is of the utmost importance, not only for the protection of the dentist himself, but for the protection of his patients as well. Whenever the skin on the hand or finger of the dentist is broken, or the mucous membrane of the patient's lip, gum, or cheek is punctured by an instrument, the 456 PRACTICAL DENTAL THERAPEUTICS part should be immediately cauterized. It matters not whether the dentist ever expects to treat a case of syphilis, or not, the menace of the presence of this disease can only be avoided by the careful and intelligent reading of the clinical symptoms. Acquired extragenital syphihs is primarily manifested in and about the soft tissues of the mouth in what is known as the initial lesion or hard chancre, which, as a rule, develops in from three to six weeks after infection. The chancre may occur in various locations — on the lips, tips of the tongue, and the pharynx — and is character- istic of what is known as primary symptoms. Primary Syphilis. — The infection here is produced by direct con- tact of the spirocheta pallida with an abraded surface. According to Logan, ^ the principal means of conveying the infection extragenitally is through the act of kissing, drinking from a broken utensil, the use of a pipe or handkerchief that has been contaminated with the germ, or from physicians' or dentists' instruments or fingers that have had the infected secretions from the mouth of a previous patient dried upon them. Diagnosis. — In the locations found in the mouth, chancre is usually single, though it may be multiple (Fig. 141). It may appear first as a papule, the superficial cells of which finally ulcerate, with necrosis of the central area quickly following, when a copious and highly infectious discharge comes from the crater-like opening that is forming on the tissues involved. The ulceration occurs in from four to ten days after full development of the chancre, until which time the patient, as a rule, experiences very little pain or discomfort. Therapeutics. — The treatment of the primary symptoms, until recent years, was considered unimportant. In fact, unless a positive diagnosis could be made, and it is still often difficult to be certain of the cHnical diagnosis at this stage of the disease, it was suggested that the treatment be deferred until the diagnosis was established by the manifestations of the secondary symptoms. This has been changed. Ehrlich, the discoverer of salvarsan — or "606," as it is commonly called — the new specific for syphilis, says, "too much weight can- not be laid upon the importance of diagnosing a syphilitic sore as soon as possible. We should certainly not wait for secondaries to develop or until the Wassermann reaction has become positive. In no period of syphilis is salvarsan more strongly indicated than when the chancre is the sole symptom." S3^hilis is now known to be a germ disease, and the only positive means of confirming the diagnosis of the clinical symptoms in this stage is the microscope by ^Denial Review, Vol. XXII, p. 800. Fig. 141. — Chancres of the lower lip, and mucous patches of the tongue. The disease was contracted by kissing, a, Chancres; b, mucous patches. {Brophy, after Zinsser-Stein.) DISEASES OF THE SOFT TISSUES OF THE MOUTH 457 which the spirocheia pallida may be discovered. These appear as fine, closely coiled spirals, 6 to 15 microns long, and feebly motile. They are most abundant in the margins of the lesions, and are practically constant in chancre and mucous patches. Old chancres and those treated by local antiseptics may easily fail to show the organisms (White and Martin). The technic of injecting salvarsan or neosalvarsan will not be described here, for the author believes it to be the duty of the dentist, as soon as he observes the suspicious sore in the mouth, to consult with the family physician, who should inaugurate and follow up the specific treatment. Oral hygiene, of course, should not be neglected. For a great many years mercury has been the only specific for syphilis, except in the tertiary stage when potassium iodid is indi- cated. But, unfortunately, mercury in its curative dose is extremely poisonous, so that small doses must be used for a long period of time. Because of this disadvantage many attempts have been made to discover a mercurial compound which would fulfil the ideal thera- peutic requirement; viz., to kill the spirochetae by means of a single injection. The nearest approach to this was the discovery of atoxy- late of mercury by Uhlenhuth and Manteufel. By using this drug they were able with four injections to kill all of the spirochetae which were produced by local inoculation of the testicles in rabbits. Not only were four injections insufficient to have a like effect in man, but the doses required were much larger comparatively, and, as a result, toxic symptoms developed and recurrences were frequent; so atoxylate of mercury was never extensively employed. The dis- covery of this product, however, acted as a stimulus and spurred chemists on to further investigation. It may seem strange to those who are more or less familiar with the drugs that have been employed in the treatment of syphilis that the latest specific for the disease is a compound of arsenic and not of mercury. The formula for '606' is C12H12N2O2AS2. Ehrlich claims that his discovery was due largely to the well-known fact that the compounds of arsenic exerted a far greater influence in sleeping sickness than did the compound of mercury, and it was for this disease that atoxyl was discovered. When it was shown, in 1905, that s3q)hiHs was caused by the spirocheta palHda, a protozoon which doubtless belonged to the same group as the germ which produces sleeping sickness (trypanosomes) ; and since arsenic had often played an important role in the treatment of syphihs, the later synthetic compounds discovered, of which atoxyl was the stimulus, came to be used for syphihs as well as for sleeping sickness. 458 PRACTICAL DENTAL THERAPEUTICS Secondary Syphilis. — The manifestations of what is known as the secondary symptoms do not appear until from four to six weeks after the development of the hard chancre. Diagnosis. — If no treatment has been instituted, eruptions on the skin usually mark the beginning of this stage, and, according to L. Blake Baldwin, eruptions are frequently found on the oral mucous membrane quite similar to those upon the skin. These eruptions are accompanied by fever, sometimes preceded by it. Simultaneously with the eruptions and fever characteristic mucous patches occur, and may be located on any part of the mucosa of the mouth, regard- less of whether the disease originated primarily or secondarily in the mouth. (Fig. 141, h, and Fig. 142, a, b, and c.) The presence of mucous patches is a positive sign of syphiHs. They differ from canker sores in that they have more clearly defined margins and are not so painful to the touch, and the immediate area is not of such a deep red color (Gilmer). The mucous patches are exceedingly infectious, and due caution should be observed not to carry the infection from one patient to another. Therapeutics. — Inasmuch as secondary syphilis is manifested in the mouth and leaves its indelible effects upon the gums, jaws, and adjacent structures, mercury is the one drug indicated in its treat- ment, for this drug has a selective influence upon these structures. In fact, mercury is a specific for the secondary symptoms, though its action, as yet, rests purely upon an empirical basis. It is not even known whether the action of the drug here is due to specific toxicity for the spirocheta pallida or whether it is simply due to its general effects upon metabolism. The former, according to Sollmann, seems to be the case. Mercury is not only palHative, but curative in this stage — congenital as well as acquired — whilst its administra- tion is worse than useless in the first and third stages. The systemic treatment, of course, should be relegated to the family physician. Long^ very properly emphasizes a word of cau- tion here. He says: "It may fall to the dentist to discover a case of syphilis, by mouth symptoms, where it had not been suspected, but he must be exceedingly cautious about discussing this finding with the patient. He is dealing with a matter for which he has not been consulted, and in any suspicious acts or words of his lie the possibilities of much unpleasantness. If the patient be an innocent wife, a statement of his discovery might produce domestic discord. While she would have a most serious grievance, entitling her to our pity, a revelation could only add to her unhappiness. A suggestion ^ Dental Materia Medica and Therapeutics, p. 206. a Fig. 142. — Syphilitic mucous patches of the lips. The lips are swollen, a, Ulcerated mucous patch. On the base of the ulcer is a yellow coating with dried secretions about its borders, h. Ulcerations which are not as far advanced as a. c, Mucous patch. {Brophy, after Zinnser-Stein.) DISEASES OF THE SOFT TISSUES OE THE MOUTH 459 to her to see her family physician for certain general conditions that you find evidence of, would be the proper course; and even this advice must be given tactfully, without arousing suspicion as to the probabilities in the case, for, after all, a mistaken diagnosis is possible." The preparations of mercury most frequently prescribed in syphilis are mercury with chalk, and compounds like bichlorid, biniodid, and protiodid. The ointments are used by inunction. None of these preparations should be pushed to the extent of producing ptyalism or salivation. An accurate and positive diagnosis of syphilis should always be made before instituting the mercurial treatment, otherwise disastrous results are almost certain to follow. In a recent case of a little girl, seven years old, of doubtful syphiHtic history, coming under the observation of the author, a sequestrum was removed which con- tained the erupted first permanent molar and the crowns of the non- erupted first and second bicuspids. The case terminated fatally. Syphilographers have learned from sad experience that mercury can be pushed much farther without producing ptyalism, if the mouth has first received a thorough prophylactic treatment. This includes the removal of all local irritants, such as hard and soft deposits, overhanging fillings, ill-fitting crowns, and bridges. In fact, it is only when the mouth and teeth are clean that the symp- toms of ptyalism are valuable as an index that the system is taking all the mercury it can absorb without producing marked toxic effects. If the teeth are not clean and the mucous membrane healthy, it is best to wait until the mouth receives proper attention before attempt- ing to find the minimum toxic dose of the drug. On this point, White and Martin^ state that "the teeth should be put in perfect order by a competent dentist, and should be kept scrupulously clean throughout the entire course of treatment by cleansing washes, astringent and mildly antiseptic powders (or pastes), and careful removal of particles of food by means of tooth-picks and dental floss immediately after eating. Upon the health of the mucous mem- brane of the mouth depends, to a great extent, the abihty of the patient to take an efficient quantity of mercury without causing salivation." Dentists in the past have hesitated to work for patients who were known to have the specific disease on account of the danger of self-infection, and the subsequent necessity of discarding all ^ Genito-Urinary and Venereal Diseases, Ninth Edition, p. 1008. 460 PRACTICAL DENTAL THERAPEUTICS instruments used. Logan^ says: "These syphilitic individuals can be cared for with impunity if the operator protects his hands with rubber gloves and then scrubs all the instruments employed and boils them for fifteen minutes. If this plan is pursued, there is no need of such absurd action as is often recommended — that all such instruments should never be used again, but thrown away." Tertiary Sjrphilis. — This condition may be prevented if proper treatment has been previously inaugurated. In cases not so treated the tertiary symptoms usually occur in from one-half to two years after infection. Diagnosis. — Gummata mark the third stage of syphilis and first appear as hard bodies or nodes occurring mostly under the skin, although they may form under the mucosa of the mouth. They gradually increase in size, and become more superficial, with a tend- ency to break down and ulcerate. (Fig. 143, a.) When they occur in the region of the hard palate, the underlying bone frequently becomes involved and extensive necrosis of the palate and nasal bones follows. (Fig. 144.) Gilmer^ states that subperiosteal gummata are especially destructive to bone, and reports having seen cases in which the soft palate also was completely destroyed from ulceration of gummata in that locality. Authorities differ in regard to whether the lesions of tertiary syphiHs are infectious. They are probably but slightly so, if at all; however, it is well here also to guard against spreading possible infection. Therapeutics. — The one drug indicated in the treatment of tertiary sj^hilis is the great alterative, potassium iodid. In this stage of the disease the efficacy of potassium iodid is equal to that of mercury in the secondary stage, and it may be considered a specific. The systemic treatment should be relegated again to the family physician. The initial dose of the drug should be small, and the amount gradually increased until improvement follows or symptoms of iodism appear. For permanent results it is necessary to continue the antisyphilitic treatment for from six months to a year or more. The question of whether syphilis can be cured or not has been a debatable one in the past, but its cure is no longer questioned by experienced syphilographers. Yet it may be safely stated that few cases are ever permanently cured, for only a small percentage of patients will continue the treatment sufficiently long, after they feel perfectly weU, to effect a permanent cure. It should be remembered that syphilis stamps its indelible effects 1 Dental Review, Vol. XXII, p. 813. * Dental Review, Vol. XXIII, p. 4g8. h Fig. 143. — Ulcerated gummata of the hard palate mucous membrane, a, Grayish- yellow deposits upon the ulcerated surface; h. highly congested mucous membrane. {Brophy, after Zinsser-Stein.) h Fig. 144. — Perforated hard palate. Perforation of the hard palate due to gummata with general periosteitis of the alveolar processes, a, Hole left in the palate by the de- struction of the bone and soft parts; h, destruction of the alveolar processes and perfor- ation into the nose; c, change of position of the teeth. {Brophy, after Zinsser-Stein^ DISEASES OF THE SOFT TISSUES OF THE MOUTH 46 1 upon the individual thus afflicted in almost every case, and that any subsequent infection, like that in alveolar abscess or pyorrhea alveo- laris, is likely to extensively involve the osseous structures, and yield to the ordinary treatment with difficulty. The author has previously referred to a case of extensive necrosis following sUght trauma after the removal of a pulp by pressure anesthesia, where every due pre- caution was taken to maintain asepsis in performing the operation (see Fig. 6i, p. 378). In conclusion I desire here again to emphasize the fact that every dentist should so school himself in this dreadful disease that he may be able to at once recognize its various manifestations. When in doubt about a lesion in the mouth, it is always better for dentists to assume that it is specific in character, and take every due precaution against infecting themselves or their patients. MERCURIAL STOMATITIS Mercurial stomatitis is a condition of the mouth frequently fol- lowing the administration of mercury and its compounds for the treatment of syphilis and other conditions. The drug is used for its alterative and tonic effects. As has been mentioned, it is a specific for secondary syphiHs, and every dentist should be thoroughly familiar with the effects of this metal when taken internally. Diagnosis. — When small doses of an unirritating preparation of the drug are given continuously for a certain length of time, the first effects are observed in the mouth, for it has a selective influence upon the gums, jaws, and adjacent structures. There is produced an increased flow of saHva, fetor of the breath, redness of the gum margins, and pericementitis, causing soreness of the teeth when the jaws are forcibly brought together. If the drug is not withdrawn upon the appearance of these symptoms, the condition gradually grows worse; salivation becomes excessive (continual droohng), the gums become swollen and spongy, the teeth loosen from their sockets and may be easily extracted with the fingers, the tongue and parotid glands enlarge — the former sometimes to the extent that it protrudes from the mouth; often there are deep sloughing ulcers made by indentations of the teeth upon its edges, also upon the mucous membrane of the cheeks; and, finally, the soft tissues around the teeth slough away, necrosis of the bones sets in, and large sequestra form. This group of symptoms is known "as ptyalism or salivation. In these cases the general health is naturally affected, the patient becomes pale and loses flesh. Chronic mercurial poisoning occurs 462 PRACTICAL DENTAL THERAPEUTICS frequently in workmen who handle the metal or who are exposed to its fumes, such as makers of thermometers, mirrors, scientific instru- ments, etc. The condition, however, is too frequently produced by the prolonged use of mercury as a medicine. Therapeutics. — The treatment of mercurial stomatitis has been fully considered under Mercury (see p. 194). TUBERCULOSIS Tuberculosis is known as the "great white plague." The disease is caused by the tubercle bacillus. Brophy^ says: "The tubercle bacillus may enter the body by several avenues. The inhalation method is the one most commonly met with. The sputum of con- sumptives contains vast numbers of the bacilli and the atmosphere immediately surrounding these patients, as well as the dust, is very infective. Those who contract tuberculosis by this method usually develop the pulmonary form of the disease or the bronchial glands become the seat of infection and other organs are involved from these. The tonsils also may be the seat of the primary lesion, as the crypts offer an excellent place for the growth of the tubercle bacillus. The glands of the neck may become secondarily involved, following infection of the tonsil." In this connection it may be remembered that Cook, Moorehead, and others have reported cases where the bacilli have entered the system through the canals of pulpless teeth and pyorrheal pockets, involving the glands in the neighboring region. The disease is occasionally seen on the mucosa of the mouth. Gilmer^ reports having seen three cases, one of the tongue, one of the sublingual salivary gland, and one an extensive involvement, includ- ing a part of the lips, the mucosa of the cheek, the soft palate, the tongue, and a portion of the pharynx. Diagnosis. — The microscope will aid in definitely determining tubercular lesions in the mouth, as well as in other parts of the body (Fig. 145). The tubercle is the characteristic lesion produced by the bacillus. It will be noticed that the ulcers arise from the confluence of numerous miliary tubercles. The ulcers are usually covered with yellowish- white pus. Therapeutics. — The dentist may first discover the lesion and aid in making the diagnosis; but treatment had better be given by the general medical practitioner or specialist, for the cases are rare * Oral Surgery, p. 67. 2 Dental Review, Vol. XXIII, p. 499. Fig. 145. — Tuberculosis of the upper lip and gum, shomng the tubercles. {Brophy, after Royal College of Surgeons.) Fig. 146. — Leucoplakia of the tongue of many years' duration, in a male of 50 years, with one slightly raised firm spot, where a small innocent wart had been cut out a 3^ear before. This spot was not excoriated or raw and could only be distinguished from the surrounding white patches by its slight induration, which was quite superficial. Examined by the Imperial Cancer Research, and found to be a small but typical squamous-celled carcinoma. {Brophy, after Builin.) DISEASES OF THE SOFT TISSUES OF THE MOUTH 463 and no definite local treatment has thus far been permanently established. It may be stated, however, that various forms of light have been used in many cases with favorable results in tubercular and similar affections. Where there is bone involvement Beck reports surprising results from the injection of bismuth paste. LEUCOPLAKIA BUCCALIS Leucoplakia is a disease of the mouth and tongue, the etiology of which is as yet unknown. A large percentage of the cases of leuco- plakia buccalis give a previous history of syphilis. It is, therefore, suspected that the latter disease has a causative relation to leuco- plakia, though no definite evidence in this respect has been produced. Gilmer,^ who has seen a large number of cases, is of this opinion. He says: "Many cases of leucoplakia buccalis have come under my observation, and, with few exceptions, I was able to ehcit a history of syphilis." Diagnosis. — The disease manifests itself upon the buccal mucosa, portions of the gums and the dorsum and edges of the tongue, and other places. There appear, sharply outlined, whitish or silver- colored points, streaks, bands, or patches of irregular shape, either flattened or slightly elevated above the level of the general mucosa. Ordinarily they simply present a roughened surface without much discomfort. They occur almost exclusively in the mouths of men who are excessive smokers. The condition, however, should not be mistaken for that which is frequently seen in the mouth of excessive smokers, especially pipe smokers, where there is a whitening of exten- sive areas of the tongue or hard palate or both. Gilmer^ says: " The epithehum of the smoker's tongue is of a brownish-white, while in leucoplakia the patches are of a clear white color." Leucoplakia patches are very characteristic, no other condition of the mouth presents the same cHnical picture. The alTection is painless, and may be overlooked by the patient unless it becomes complicated with cancer (See Fig. 146). Therapeutics.- — It has been observed that carcinoma frequently has its beginning in the site of an old leucoplakia patch. Since this is true, an early diagnosis should be made, and the proper treatment instituted by the family physician. In cases of known syphilis the antisyphilitic treatment would be indicated. The general tendency of dentists in conditions of this kind is to use cauterants, such as ^ Dental Review, Vol XXIII, p. 500. ^Ibid. 464 PRACTICAL DENTAL THERAPEUTICS silver nitrate. In the treatment of leucoplakia this should be avoided, as it only tends to aggravate the disease. ACTINOMYCOSIS Actinomycosis is a common disease among the lower animals, especially cattle, and is known as lumpy -jaw, the disease affecting the lower jaw and cervical glands. Cases in the human being have been reported by Brophy, Bevan, Zederbaum, and others. It is produced by the ray-fungus, which is normally found in grain, and is supposed to find its way into the mouth from the habit of chewing straws. The germs gain admittance into the tissues from the mouth through decayed teeth. Diagnosis. — The microscope affords a positive means of diag- nosis. Blair states^ that "the disease first manifests itself in the form of a small nodule, which for a time may give no trouble, but later softens and forms sinuses from which is discharged a thin fluid which usually contains the fungus." Therapeutics.- — The treatment of the disease had better be car- ried on by the medical speciaHst, as it is so rare in the human being that dentists but seldom see the condition. Based on observations made at the Wisconsin Experimental Agricultural Station, Bevan introduced the copper sulphate treatment in man, and both he and Brophy report good results by using the drug to the limit of tolera- tion. They begin with about 3^^ gr. given three times a day, gradually increasing the dose to i gr. In addition to the inter- nal administration of copper sulphate, irrigations of a i per cent, solution are also employed. ACUTE ULCEROUS GINGIVITIS Acute ulcerous gingivitis is a comparatively rare disease. The author, however, has seen a number of cases in the mouths of children coming to the College Infirmary for treatment from the so-called "slum districts " of Chicago. This may have been a coincidence, but I have never observed the typical disease in well-kept mouths. It may be regarded as a filth disease. Diagnosis. — Gilmer^ well describes the disease as follows: "It attacks simultaneously the gum margins on their buccal or labial aspect about two, three, or possibly four teeth, at the same time. ^ Surgery and Diseases of the Mouth and Jaws, p 304 • ^Dental Review, Vol. XXIII, p. 501. DISEASES OF THE SOFT TISSUES OF THE MOUTH 465 The ulcers come suddenly, quickly destroying the gingivae down to the alveolar process, but seemingly not invading it, exposing the roots of the teeth to this extent. The margins of the ulcers are everted, crater-Hke, somewhat Hke chancrous ulcers. The base of the ulcers is overlaid with a grayish-white covering. When this covering is removed, the granulating surface bleeds freely. The lymphatics related to the area become enlarged, and, unlike chancrous lymphatic enlargements, are tender. It is also unlike chancre in that the ulcers are nearly always multiple and, exceedingly painful to touch. Saliva- tion is much increased, with frequent drooling, the breath is fetid, and, owing to the absorption of toxic elements, there is a slight rise in tem- perature. The contiguous lingual gingivae become reddened, but do not participate in the ulceration. The condition has been mistaken for syphilis." Therapeutics. — The ordinary local remedies used for somewhat similar conditions are of Httle value here unless systemic treatment is simultaneously instituted. Calomel is the drug to give internally, a prescription for which follows : I^ — Hydrargyri chloridi mitis, gr. ij (0.13 Gm.) Sodii bicarbonatis, 5 3 (4-o Gm.) — M. Fiat chartulee No. xx. Sig. — Take one powder every two or three hours. The local treatment consists in cleansing the ulcer with such agents as hydrogen dioxid, drying the part and applying a lo per cent, solution of silver nitrate or a 20 per cent, solution of argyrol. If the ulceration is checked, complete restoration of the gum tissue by granulation follows. Mouth hygiene should, of course, be instituted and strenuously carried out. A form of ulcerous gingivitis, somewhat resembling the above condition, frequently occurs in the mouths of young people, espe- cially young men who are addicted to the habit of smoking. The gum in the interproximal space first is reddened, this being quickly followed by necrosis which extends around the teeth. The gingiva of all the teeth in the mouth may be simultaneously involved. The disease is exceedingly painful, is sometimes accompanied by fever and loss of flesh, and, by the dentist who called almost every disease of the mouth pyorrhea, patients, thus afflicted, have frequently been informed that they were suffering from the latter disease. Generally in these cases the teeth have been neglected, so far as prophylaxis is concerned, and an irritant of some character will be 30 466 PRACTICAL DENTAL THERAPEUTICS found about the necks of the teeth or under the free margin of the gums. This is about the only symptom that the disease has in common with pyorrhea. In these and all such similar cases the highly astringent pyorrheal remedies should not be employed. What is needed here is a thorough prophylactic treatment, the local applica- tion of mildly stimulating remedies, such as a 25 per cent, solution of argyrol, and the daily use of an antiseptic mouth wash. If neces- sary, a cathartic should be prescribed. With the above treatment these disagreeable cases yield nicely. LUDWIG'S ANGINA Ludwig's angina is an acute infection of the floor of the mouth. Starting from a surface focus, usually within the mouth and in- significant, a severe infection passes to the submaxillary lymph nodes, where it takes on virulent activity, leading to an extensive cellulitis and producing a very hard, tumor-like mass betw^een the borders of the mandible. The edema frequently extends to the larynx, alarming the patient because of the difficulty in breathing. Diagnosis. — The manifestation of the above described symptoms would lead to but one conclusion — ^Ludwig's angina. According to Hofheinz, the symptoms as outhned by Ludwig have never been questioned, though their cause has been much disputed. As a rule, there is very Httle constitutional disturbance. Ptyalism may be produced. The tongue is not sensitive, but its movement causes pain. Therapeutics. — The treatment of this disease had better be undertaken by an oral specialist. Drainage must be established. The mouth should be irrigated every two hours while the patient is awake with a warm antiseptic solution, and Brophy advises paint- ing the throat with a 10 per cent, solution of iodin in glycerin. This author also warns us against the extraction of a tooth which may have started the infection until, at least, the acute stage has passed. GONORRHEA According to Burchard-IngHs, undoubted cases of oral infection by the specific germ of gonorrhea {gonococcus) have occurred. The author has seen at least one such case. The mucosa of the cheekSj gums, tongue, and even of the hard and soft palates may undergo intense suppuration. Mouth hygiene and the systemic treatment of the constitutional trouble cure the case. ' DISEASES OF THE SOFT TISSUES OF THE MOUTH 467 There are a variety of tumors and other diseases which manifest themselves in the mouth, involving both the soft and osseous struc- tures, for the diagnosis and treatment of which see works on Oral Pathology and Surgery. The more common of the diseases of the soft tissues of the mouth and their treatment have been thus briefly considered here with the hope of stimulating a greater interest in this phase of mouth diseases. EXAMINATION OF URINE^ 1. The Sample. — That passed on arising in the morning. 2. Quantity. — In 24 hours = 1,000 to 1,500 mils. 3. Condition. — Clear or sedimentary. ^ Filter, if sedimentary, and examine color. 4. Color. — Pale yellow, yellow (normal). Reddish yellow (bile coloring). Blood red (excess of urates). Reddish brown (breaking up of blood-corpuscles). 5. Consistency. — Thin (normal). Thick, syrupy or stringy (indication of sugar, albumen, pus or fibrin). 6. Reaction. — By litmus paper. Mild red (slightly acid, nor- mal). Neutral or alkaline (inflammatory condition of urinary tract) . 7. Specific Gravity. — With urinometer. 1,015 to 1,025 (nor- mal), 1,015 or below (excess of water) 1,030 or above (excess of solids — urea or sugar). 8. Albumen. — (i) Heat Test. — Pour urine in a test-tube to 2 in. in depth. Boil gently, heating from top downward. If a precipi- tate is formed it is either (a) earthy phosphates (soluble in acetic acid), (b) albumen (insoluble in acetic acid). (2) Nitric Acid Test.- — To 2 in. of urine in a test-tube, held slantingly, add five to ten drops of concentrated nitric acid c. p., permitting it to run carefully down the side of the slanting test-tube. A white coagu- lum at the zone of contact of the two liquids indicates albumen. To eliminate error, both the heat and nitric acid tests should be made. 9. Total Solids. — Multiply the last two figures of the sp. gr,, if it is below, 1,018, by 2, the coejficient of Trapp. If above 1,018 by 2.33, the coefiicient of Haser. This gives the total solids in 1,000 mils. As the quantity of urine passed in twenty-four hours is about 1,500 mils, the above result should be multipHed by i}'^, which will give the total soHds for twenty-four hours. ^This outline was condensed by Professor J. N. Roe, whom the author assisted for several years in the Chemic Laboratories of the Chicago College of Dental Surgery, ^Set sample of urine aside in a conical glass and examine the sediment with a microscope. 468 EXAMINATION OF URINE TOTAL SOLIDS IN NORMAL URINE Excreted in T"wenty-four Hours 469 Total Solids. Constituents Grains 60.0 to 70.0 Urea Uric Acid Creatinin Hippuric Acid Chlorids Earthy Phosphates. . Alkaline Phosphates. Sulphates SO.O to40.0 o . 4 to 0.8 0.5 to i.o 0.3 to 1.0 10.0 to IS. . 9 to 1.3 2 • 3 to 3.5 1 . =; to 2 . T 10. Urea. — If the urine is above sp. gr. 1,025, test as follows: Pour exactly 2 in. in depth of urine into a test-tube, and con- centrate just one-half by boiling gently in the test-tube, or by pour- ing into a porcelain dish and concentrating over water bath, sand bath or wire gauze. Pour the concentrated urine back into the same test-tube and ascertain if it is concentrated to exactly one-half the original volume. Introduce one- third volume of concentrated nitric acid c. p. (free from red or yellow fumes). Place the test-tube and contents in a vessel of cold water. A precipitate of Urea Nitrate is formed. a. Immediately (very copious, filling the entire volume of hquid) . Excess. b. After twenty minutes (not heavy). Normal. ^ c. Not after several hours. Decrease. 11. Urates, — Pour 2 in. of urine into a test tube, add fifteen to twenty drops of concentrated hydrochloric acid. Allow the mixture to stand twelve to twenty-four hours. The urates will be decom- posed, and red crystals of uric acid (corresponding to brick-dust deposit) will collect in the bottom and on the sides of the tube. The crystals on the sides of the tube may be loosened with a little stick or glass rod, when they will rapidly settle at the bottom. a. Copious (covering bottom of tube). Excess. h. Moderate (total bulk size one-half grain of wheat). Normal ^ c. Very sHght. Decrease. 12. Chlorids. — To 2 in. of urine in a test-tube, add five to ten drops of nitric acid and solution silver nitrate by drops as long as The Uric Acid pre- cipitate is, h. Moderate {% in. in depth). Normal. 470 PRACTICAL DENTAL THERAPEUTICS any precipitate forms; shake slightly and set aside for a few moments to settle. The Silver a. Co/'^'ow^ (over 3^ in. in depth) . Excess. Chlorid pre- s b. Moderate {}4 in. in depth). Normal. cipitate is, [ c. Slight (less than above). Decrease. 13. Sulphates. — To 2 in. of urine in a test-tube, add five to ten drops of hydrochloric acid c. p. and solution of barium chlorid by drops as long as any precipitate forms; set aside and allow to settle. The Barium a. Copious (over }4 in. in depth). Excess. Sulphate pre- 1 b. Moderate {}4 ^^- in depth). Normal. cipitate is, [ c. Slight (less than above). Decrease. 14. Earthy Phosphates. — To 2 in. urine in a test-tube, add ammonium hydroxid until it smeUs strongly of ammonia; heat gently and set aside. The Ammonio- fa. Copious (over % in. in depth). Excess. Magnesium and Calcium < Phosphates are, I c. Slight (less than above). Decrease. 15. Alkaline Phosphates. — Filter the Hquid from No. 14 into a clean test-tube (or prepare another specimen as above and filter), add ten drops of ammonium chlorid and magnesium sulphate by drops as long as any precipitate is formed. Heat gently and set aside to settle. The Ammonio- [ a. Copious (over i^-^ in. in depth). Excess. _,, , ^ i Moderate (i}4 in. in depth). Normal. Phosphate pre- cipitate is, [ c. Slight (less than above) . Decrease. 16. Sugar. — Remove any trace of albumen or earthy phosphates by^boiling and filtering. Use the clear filtrate. Pour into a test- tube I in. of Fehling's solution and add same quantity of water. Boil gently. If precipitate is formed, filter; when, after repeated boiling and filtering, no precipitate is formed, add urine and heat as before. No change in color = No sugar. Slight change to dirty green = Trace of sugar. Bright yellow = Sugar over i per cent. Red = Excess of sugar. In case it is desired to have a microscopic and bacteriologic ex- amination of the urine, the specimen may be sent to a Pathologic EXAMINATION OF URINE 471 Laboratory, these are now in every large city. But every dentist should be prepared to make physical and chemical examinations, according to the outHne here given. The results of the analysis should be recorded and preserved. This may be done in the following form : URINE ANALYSIS Name, Date, Physical Characters. Amoiunt in 24 hours,- Specfic gravity, Condition, . Color, Consistency, - Chemic Characters. Reaction with litmus,- Reaction with heat, Reaction with nitric acid, Total solids, Urea, Urates, Chlorids, Sulphates, Earthy phosphates, _ Alkaline phosphates, Abnormal constituents. Albumin, Sugar, Clinical Memoranda. FEHLING'S SOLUTION FehUng's Solution is made by mixing exactly equal volumes of the below- mentioned copper solution and alkaline solution at the time required. Copper Solution: Crystallized copper sulphate, 34-64 gm. Sterihzed distilled water, sufficient quantity to make 500 mils. Alkaline Solution: Potassium sodium tartrate (Rochelle salt), 173 gm. Potassium hydro xid, 125 gm. Sterilized distilled water, sufficient quantity to make 500 mils. These solutions should be kept in well-stoppered bottles, in a cool, dark place, and mixed only at the time needed. If a precipitate forms when the cold solutions are first mixed, it should be dissolved by agitating the test-tube; and no precipitate should form when the mixed solutions are heated. By keeping the copper solution and alkaline solution in separate bottles in a cool, dark place, they shovdd keep without change almost indefinitely; however, it is best to have fresh solutions prepared at least once a year. GENERAL INDEX ABDERHALDEN on inorganic iron, 182 Abrasions, 139, 147, 302, 304 Abscess alveolar, acute, 108, iii, 160, 192, 219 chronic, 96, 370 between roots, 391 caries in, 379 caused by toothpick, 393 cavity, 57 dental, early treatment of, 357 dento-alveolar, 64, 65, 82 drainage of, 369 due to blow, 392 in deciduous teeth, 390 involving several teeth, 381 lancing of, 127, 141, 143 of both antrums, 303 of frontal sinus, 303 pericemental, 391, 393 pocket, secondary, 381 pulpal, 308, 350 rupture of, 353 treatment of, 192, 219, 370 by ionization, 347 with sinus, 373 Absorbent cotton, 20 Absorption of drugs, 22 Abstracts, 14, 15 Acacia, 121 Acetanilid, 146, 147 powder, effect of, on heart, 171 prescriptions for, 367 Acetic acid, 97 Acetozone, 90, 409 Acetphenetidin, 147 Acetyl-paramino-phenyl salicylate, 47 Acetyl-salicylic, 47 Acid, acetic, 97 benzoic, 31 boric, 31 cambogic, 221 gallic, 35 hydrochloric, 97 hydrocyanic, 178 hydrofluoric, 105 lactic, 99 "method," 344 mineral, 33 monochloracetic, 98 nitric, 96 oleic, II osmic, 33 oxalic, 92 phenolsulphonic, 94, 95 phosphoric, dilute, 189 salicylic, 45 sulphuric, 94, 340 Acid, sulphurous, 31, 32, 93, 214 tannic, 31, 72, 74, 329 treatment, 96 trichloracetic, 33, 98, 288 Acids, organic, 6 Acne, 90 Aconite, 113 poisoning, 114,363 Aconitina, 113 Actinomycosis, 464 _ treatment of, 80, 193, 464 Active principles of drugs, 5, 15 Adenitis, 200 Adrenal chlorid combined with cocain, 134 Adrenalin, 77 chlorid for hemorrhage, 323 objections to, 323 combined with cocain, 138 Age a factor in dosage, 28 Agglutinins, 247 Air, compressed, in dentistry, 251, 286, 288 purifier, 90 Air-thrombosis, 23 Albolin, 120 Albumin, coagulation of, 63, 64 in urine, 468 Alcohol, abuse of, in dentistry, 299 as antiseptic, 169 as disinfectant, 279 dehydrated, 166 diluted, 166 for relief of pain, 368 modified, 168, 279, 299, 346 official standard for, 166 physiological action of, 167 therapeutics of, 168 Alcoholism, acute, differentiation of, 167 chronic, 168 Alcresta ipecac in pyorrhea alveolaris, 437 tablets, 232 Alkali-metals, 104 Alkalies, poisoning by, 98 Alkaline powder, 38 solution, 471 Alkaloids as medicines, 5 Allspice, 239 Aloes, Barbadoes and Socotrme, 210 Aloin, 211 Alpha-eucain, 137 Alphozone, 91, 409 Alteratives, 30, 181 Alum, ammonium, 78 potassium, 78 Aluminum chlorid as a bleacher, 404 siHcate, hydrated, 125, 437 473 474 INDEX Alveolar abscess, acute, extraction of tooth in, 368 treatment of, by magnesium citrate, 219 by potassium iodid, 192 chronic, 96, 370 bone involvement in, 378 complications of, 372, 376, 389 evacuation of pus from, 377 involving vault, 380 necrosis in, 379 sequelce of, 382 sinus in, 98, 373 treatment of, 370, 373, 389 surgical, 382 diagnosed by radiograph, 344 external opening of, 373 from broken toothpick, 393 process, exfoliation of, 326 exposed after extraction, 139 hypertrophy of, 373 removal of, 385 resorption of, 376, 421 purulent, 347, 370, 374, 410 without sinus, 370 Amalgam fillings, 196, 305, 386, 403 Ameba, pathogenic, diseases due to, 233 Amebae in pyorrheal pockets, 436 Ammonia, 2, 169 as heart stimulant, 132 gas in pulp decomposition, 336 physiologic action of, 1 70 poisoning, 170 Ammonio-magnesium and calcium phosphates, 470 phosphate precipitate, 470 Ammonium acetate, solution of, 230 bromid, 155 carbonate, 170 chlorid, 234 hydrogen fluorid, 436 iodid, 193 Amputation of root-end, 435 Amygdalin, 178 Amylopsin, 206 Amyl nitrite, poisoning by, 173 therapeutics of, 1 74 Analgesics, 30, 126, 291 Anchorage for filling, 314 occlusal, 300 Anemia, iron in, 182, 185 pernicious, 202 Anesthesia, advocates of, 284 cocain, 130 conductive, 25, 130, 138, 289 discovery of , 283 high-pressure, 289 interosseous, 289 local, 23, 25, 130 oxid-oxygen, 355 pressure, 25, 136, 315, 318, 319 prolonged, 141 tranquil, 161 Anesthetics, 30, 126 for curetting abscess, 383 general, 126, 140 local, 126, 137, 289 safest, 140 Anesthetization by cataphoresis, 324 in removal of pulp, 315 solution, 317 under pressure, 319 Aneurysm, contraindications in, 173 Angina, Ludwig's, 466 pectoris, 202 Animal tissue, action of thymol on, 54 Anise, 239 Anisotonic solution, 216 Anodynes, 30, 291 general, 291 in pulp removal, 322 local, 126, 289 Antacids, 30 in oral prophylaxis, 36 Antagonism of drugs, 31, 276 Anthelmintics, 31 Antibodies, 246, 247, 255 Antidote for arsenic, 39, 102, 185, 186, 329 for digitalis, 173 for gelsemium, 180 for hydrofluoric acid, 106 for iodin poisoning, 118 for mineral poisons, 37, 97 for opium poisoning, 159 for phenol, 169, 375 for phosphorus, 188 for silver nitrate, 87 for strychnin poisoning, 165 in corrosive poisoning, 105 physiologic, 276 Antimony and potassium tartrate, 233 Anti-Narcotic 'Law, 133, 136, 160 Antipyretics, 31, 145, 147 Antipyrin, action of, 145, 146 Antisepsis in canal filling, 396 of mouth, throat, nose, 69 Antiseptics, 31, 41, 271 Antispasmodics, 31 Antitoxins, 5, 246, 255 Antral cavity, washing of, 414 Antrum, abscess of, 380, 382, 388 diseases of, 410, 412 diagnosis, 412 due to trauma, 412 from catarrhal inflammation, 412 from dental conditions, 410 treatment of, by rhinologist, 413 medicinal, 414 surgical, 413 foreign bodies in, 252, 412 healthy, importance of, 413 of Highmore, 410, 414 opening of, painless, 414 Apexotomy, 385 Apicoectomy, 385, 389 Apomorphin, 5 hydro chlorid, 231 Apoplexy distinguished from alcohol- ism, 167 Apothecaries' weight, 257, 258 Appendicitis due to pyorrhea, 419 Appliances for loose teeth, 440, 441 for replanted teeth, 435 Argyria, 86 Argyrol, 87 INDEX 475 Aristol, 56, 313 Arnica, 61 Aromatic spirit of ammonia, 170 waters, 9 Arsenic albuminate, 328 as escharotic, 100 compound, as specific for syphilis, 457 compounds of, 201 poisonous action of, 94 metallic, 201 poisoning by, 57, 94, 186, 326 acute and chronic, loi local, 57, 100 systemic, 1 01 preparations of, 201, 326 toleration for, in Austria, 100 trioxid, 99, 201 a cause of pericementitis, 359 application of, 327 as an escharotic, 94 as devitalizing agent, 325 in desensitizing, 284 poisoning, local, 334 white, 99 Arsenical pigments, inhalation of, loi Arsenous acid, 99 Arterial hyperemia, 307 pressure reduced by paraldehyd, 154 Arthritis, chronic, treatment of, by vaccines, 248 Asepsis, 41 absolute, in operation, 361 during pulp decomposition, 338 in pulp removal, 322, 328 in root-canal work, 169, 396 Asphyxia from ether, 142 prevention of, 151 Aspirin, promiscuous use of, 47 Aspirol, 170 Assay of drugs, 13, 15 Assaying, indicator in, 215 Asthma, inhalations of niter in, 227 Astringents, 31, 72 mineral, 72 pyorrhea, 428, 429 vegetable, 72 Atropin, 161, 175, 176, 229 poisoning by, 176 Aurantium, 241 Avoirdupois weight, 257, 258 BACILLUS diphtherias, 245 fusiform, 417 tetani, 245 tubercle, 462 Bacteria a cause of pericementitis, 358 action of alcohol upon, 168 ctiltures of, 247 destruction of, 42, 277 entrance of, into body, 245 in mouth, 309, 453 in pyorrheal pocket, 416 multiplication of, 417 toxicity to, 65 Bacterins, 248 Bacteriolysins, 247 Bacteriotropins, 247 Balsam of Peru, 45 Band, fitting of, 349 Bandages, 20 Barium sulphate precipitate, 470 Baths, Russian and Turkish, 249 Bay-rum, 239 Beck's paste, 85 compressed air apparatus, 286 Belladonna, 161, 175 action of, physiologic, 176 liniment, 12, 177 Benzoic acid, 44 Benzosulphinid, 243 Benzoylacetyl dioxid, 90 Berberin, 76 Beta-eucain, hydrochlorid, 137 Betanaphthol, 58 Bichlorid of mercury, 198 tablets, 18 Bicuspid, second, excementosed, 351 "Biliousness," 197, 222 Biologic processes, 5 products, 245 Bismuth paste, 388 in antral disease, 414 healing of wound over, 379 poisoning, 85 subnitrate, 84 Bitter tonics, 177 Black copper oxid, 81 Black's 1-2-3 mixture, 50 Blaud's pills, 185 Bleachers, 31, 88, 214 Bleaching agents, 404 of teeth, 70, 88. 90, 93, 98, 190, 403 applications for, 93, 405, 406, 408 by oxidation, 88, 404 by reduction, 88, 405 principles of, 403 Blindness in United States, 86 Blood, abnormal substances in, 444 coagiilability of, 84 count in pyorrhea, 418 corpuscles, white, action of quinin on, 366 deficiency of water in, 216 hemoglobin of, 181 -pressure, action of digitalis on, 172 relief of, 175 removal of, 320 -serum, salinity of, 215 substitute for, 179 stream, bacteria in, 245, 418 Blue light, treatment by, 251, 287 Boils, 127, 205 Bone cell stimulant, 345 phosphate, 189 pus formation in, 380 regeneration of, 356, 393 removal of, by maUet, 385 tissue, loss of, 121 Bones, action of phosphorus on, 187 Boracic acid, 43 Borax, 38, 39, 44 Boric acid, 43 Borism, 43 476 INDEX Boroglycerin, gl3^cerite of, 117 Breath, fighting for, 130 Bridge and retainer, combination, 432 inlay, decay under, 354 Bridgework, 295, 303, 443 Broach, broken, 252 selection of, 320 Bromids, the, 154 as analgesics, 292 Bromism, 154 Bronchial catarrh, 52, 235 Bronchitis, acute, 225 chronic, 193 terebine in, 112 Brown mixture, 12 Brucin, action of, 163 Bruises, treatment of, 61, 75, 120, 144 Brushing of teeth, 429 Bunge on organic iron, 182 "Burning" process, 342 Burns from hydrofluoric acid, 436 treatment of, 37, 38, 60, 83-, 118, 120, 147 Butyl-chloral hydrate, 152, 450 CACAO-BUTTER, 129 Caflfein, action of, 171 as diuretic, 223 Calcific deposits, 314, 332 Calcification of pulp, 332 Calcium carbonate, precipitated, 36 chlorid, 84 hydroxid, 37 hypophosphite, 190 phosphate, effect of, on nutrition, 190 paste, 51, 407 precipitated, 189, 312 thymolized, 312, 390 sulphurated, 204 Calculus, serumal, 419 Calendula and calendulin, 60 Callahan's method, 95, 344 rosin solution, iii, 400 Calomel, action of, physiologic, 197 idiosyncrasy, 27 incompatability of, 198 Camphor, 114, 115 Camphors, derivation of, 6 Canadin, 76 Canals, blocking of, 347, 352 exposure of, 319, 328 filling of, III, 322, 383, 398 gangrenous, 99, 340 moistening of, 342, 396 obliteration of, 303, 332, 447 preparation of, for filling, 336 removal of blood from, 32 1 small and tortuous, 321, 399 Cancer of stomach, 206 of tongue, 70 superficial, 253 Cancrum oris, 81 Cane-sugar, 243 Canker sores, 51, 64, 69, 80, 98, 184, 454 differentiated from mucous patches, 458 Cannabis indica, 161 Cantharides and cantharidin, 112 Capillaries, depletion of, 366 Capillary attraction, absorption by, 116 oozing, 146, 169 Capping of pulp, 190, 308 Capsicin and capsicum, 108 Capsicum, oleoresin of, 16 Capsules, 213, 271, 367 Caraway, 240 Carbohydrates as medicines, 5 Carbon, 60 dioxid, evolution of, 97 in drugs, 5 Carborundum stones, 427, 428 Carbuncles, 205 Carcinoma on leucoplakia patch, 463 Cardamom seed, 238 Cargentos, 88 Caries, dental, 96, 244, 314, 379 exploration for, 380 removal of, 97, 311 Carlsbad salt, artificial, 218 Carminatives, 31, 237 Carr instruments, 423 Carron oil, 37, 119 Cascara sagrada, 208 Cases, history and treatment of, 351 Castings, 442 Castor oil, 212, 213, 451 Cataphoresis, 26, 254, 287 in pulp removal, 324 Catarrh, chronic, 37, 77 Cathartics, 32, 208 saline, 215, 217 Caustic, lunar, 85 potash, 104 pyrozone, 90, 392 as a bleacher, 407 • as an escharotic, 409 soda, 104 Caustics, 33, 93 desensitizing, 287 for bleaching teeth, 98 Cauterization, 205, 250, 348, 374 after hemorrhage, 323 in abscess cases, 392 Cautery, actual, 106 electric, 330 Cavity, excavation of, 293, 294 gingival, 290, 295 packing of, for bleaching, 406 preparation of, 141, 143, 283, 300 painless, 289, 294 sealing of, 295 sensitive, 251, 328 sterilization of, mechanical, 316 Cement, copper phosphate, 81 for sealing, 300, 365 zinc oxychlorid, 83, 394, 399 phosphate, 189 Cementum exposed, cauterizing of, 205 irritation from, 302 sensitive, 86 Centigrade scale, 250 Cephaelin, 232, 437 Cerates, 19 Chafing, powder for, 125 Chair, dental, dread of, 154 INDEX 477 Chalk, precipitated, 36 prepared, 36 Chancre, syphilitic, 70, 76, 456 Chancroids, 96 Change of life, 445 Charcoal, animal purified, 60 as deodorant, 60 poultice, 20 Chartas, 20 Chemico-mechanical cleansing of canal, 340 process, 345 Chemistry, principles in, 274 Chewing, effect of, on saliva, 236 Chilblains, 170 Childhood, spasmodic disorders of, 151 Children, dosage for, 28 febrile affections of, 230 hypersensitive dentin in, 290 pulp removal in, 333 Children's teeth, cement for, 81 treatment of, 390 Chinosol, 70 Chip-blower, 362 Chips, clearing away of, 251 Chloral camphor, 152 hydrate, 29, 150 as hypnotic, 151 poisoning by, 151 Chlorbutanol, 139 Chloretone, 139 Chlorin, 92 nascent, 404 Chlorinated lime, 92 soda, 92 Chloroform, 142 as analgesic, 143, 291, 292 contraindications for, 144 dangers of, 143, 292 habit, 144 in canal-filling, 398, 401 narcosis, 62 physiologic action of, 143 therapeutics of, 143 use of, cautions, 143 Chloropercha, 124, 143 Chlorosis, 182, 211 Cholera morbus, 214 Christian Science, 256 Chromic acid, 102 Chromium trioxid, 102 Cinchona, 148 Cinchonidin and cinchonin, 148 Cinchonism, 149, 150 Cineol, 49, 5i- 397 Cinnamic aldehyd, 49 Cinnamon, oil of, 49 water spray, 169 Circulation, pericemental, 433 Citrus aurantium and vulgaris, 241 Cleanliness of mouth, 459 CHmate, influence of, on drug action, 29 Cloves, oil of, 50 Coal-tar antipyretics, 147 Coca, 128 Cocain, action of, paralyzant, 130 anesthesia, fatahties from, 130 local, 129 Cocain, as protoplasmic poison, 289, 318 by hypodermic, author's formula for, 135 combined with adrenalin, 138 with arsenic, 133 experiments in, 129, 130 habit, 132 hydrochlorid, 5, 128, 129, 136 billets of, 136 dosage of, maximum, 135 hypodermic use of, 133 solutions of, 135 idiosyncrasy, 27, 132, 134 points, 136, 317 -poisoning, 131, 134 treatment of, 132, 169, 276. sloughing from, 134 substitutes for, 136 susceptibility to, 131 therapeutics of, 133, 136 Cocaina, 128 Codein, 156, 157 Cod-liver oil, action of, restorative, 191 in emaciating diseases, 191 Coffee in narcotic poisoning, 171 Coil, dry-cell vibrating, 253, 338 Cold, application of, to sensitive den- tin, 286 as therapeutic agent, 250 cream, 39, 243 . in the head, 235 physical law concerning, 290 sores, 83, 124, 455 Colds, treatment of, 52, 241 Colitis due to pyorrhea, 419 Collapse, 23, 26, 173, 178 from anesthetics, 176 CoUargol, 88 Collodion, 11, 123 cantharidal, 124 flexible, 124 styptic, 73, 124 CoUyrium, 81, 272 Color molecule, breaking up of, 405 of tooth, 320, 321 preservation of, 320, 329, 402 restoration of, 338, 402 by caustic pyrozone, 392, 409 Coloring agent, 244 Colycynth, 220 fatal irritation from, 221 Compound licorice powder, 212 Compounds, ferrous, 185 miscellaneous, 6 Compressed air, 251, 286, 288 Conductive anesthesia, 25, 130, 138, 289 Cone flower, 203 Cones, fitting of, 398, 399 Confections, 17 senna, 209, 210, 21 1 Confidence of patient, 255, 423 Congestion, cerebral, croton oil in, 220 Conjunctivitis, 81, 87 Conservativeness of dentists, 413 Constipation, chronic, 118, 209, 210, 211, 212, 221, 222 due to rhubarb, 213 in children, 210 478 INDEX Constructive diseases, 302 Convalescence in exhaustive diseases, 200 Convolvulin, 221 Convulsions in childhood, 151, 230 in strychnin poisoning, 164 in tetanus, 174 Convulsions, relief of, 174 Copper cement for filling, 386 oxid, 81 solution, 471 sulphate, 80 as emetic, 188 in actinomycosis, 464 Coriander oil, 211, 240 Corns, removal of, 46, 98 Correctives, 237 Corrosive sublimate, 198 as an alterative, 197 Corrosives, 93 Corj'za involving antrum, 412 treatment of, 115, 120, 160, 176, 229 Cotton for filling root-canals, 394 Cottonseed oil, 119 Cough, 122 Counterirritants, 34, 58, 106, 108 refrigerant, 362 Counterirritation, remedial effect of, 107 Cracks in feet and hands, 86 Cream of tartar, 224 Creosote, 66 Cresol as diluent, 338 as disinfectant, 65 Croton oil, 220 Croup, 115 Crown, gold, 302, 304 perfect, mutilation of, 432 porcelain, 302, 355, 375 setting of, painful, 133 Crowned teeth, abscesses of, 355 Crowning, dangers of, 314 Cudbear, tincture of, 244, 425, 427 Curettement of abscess, 375, 382, 389 hemorrhage in, 383 incision for, 383 Currents, electric, 253 Cusps, grinding of, 362 Cyanosis from nitrous oxid, 292 Cystic fluid differentiated from serum, 372 Cysts, periapical, 372, 382 r^AKIN'S hyperchlorous acid solu- ^-^ tion, 179 Dandruff, 212 Dead pulp, diagnosis of, 338 Death from use of cocain, 130 chloroform, 143, 144, 292 ethyl chlorid, 128 hydrogen dioxid, 69 opium, 160 Decay of teeth, rapid, 190 Deciduous molar roots, resorption of, 333 teeth, abscess in, 390 pulps of, gangrenous, 390 removed, 333 Decoctions, 13 Deformities, nasal, 121 Delirium tremens, 168 Demulcents, 32, 116 Dental liniment, 362, 363 author's, 447 Dental pastes, potassium chlorate in, 226 pulp, diseases of, 298 sterilization, 277 therapeutics, 281 Dentifrices, 32 Dentin, blood in, 320 desensitizing of, 128, 138, 288,293, 295 hypersensitive, 283, 284 infected, sterilizing of, 199, 201 obtunding of, 53, 142, 251, 254 by cold, 286 by heat, 285 by physical agents, 285 protection of, 404 secondary, 302, 332 sensitive, 53, 142, 251, 254, 285 treatment of, 84, 293 sensitiveness of, thermal, 283 sterilization of, 201, 294, 310, 316 Dentist and physician, relations of, 349, 443 right of, to prescribe, 267, 450 Dentistr}^, painless, 25, 27, 133, 283 Dentition, temporary, 151, 155 Denture, red-rubber, 196 Denuded roots, 433 Deodorants, 32, 41, 70 Deoxidation, 93 Deposit encircling tooth, 419 removal of, 423, 425, 431, 436 salivary, 420 Desensitization of dentin, 128, 138, 288, 293, 295 Desensitizing paste, 55, 138, 141, 293, 297 on exposed cementum, 432 precautions in using, 295 Desquamation due to formaldehyd, 68 Destructive diseases, 306 Devitalization of pulp, 315, 325, 326 by formocresol, 329 technic of, 327 Dextrins and dextrose, 244 Diabetes mellitus, 202 teeth in, 421 Diagnosis by radiograph, 252, 345 mistake in, 391, 432, 433 Diaphoretics, 32, 228 Diarrhea, 46, 142 inflammatory, 212, 214 treatment of, by salol, 46 Diastase, 207 Diathesis, hemorrhagic, 76 rheumatic, 421 uric acid, 228 Digestants, 205, 206 Digestive tract, toxins in, 453 Digitalein and digitalin, 172 Digitalis, 172 action of, cumulative, 172 physiologic, 172 INDEX 479 Digitalis, as diuretic, 223 poisoning by, 173 preparations of, standardization of 172 therapeutics of, 173 Digitin, digitonin and digitoxin, 172 Di-isobutyl-cresol-iodid, 56 Diluent of powders, 16 Diphtheria bacillus, 245 Diphtheria, resorcin in, 59 toxins of, 245, 246 Dipsomaniacs, 168 Direct oxidation, 404 Discharge, syphilitic, 456 Disclosing solutions, 428 Discoloration of teeth, 73, 182, 392, 402 by fracture, 409 by iron tannate, 329 by potassium permanganate, 70 causes of, 402, 403 pink, 402 Disease, treatment of, rational^ 281 Diseases, constructive, 302 destructive, 306 Disinfectants, 33, 41 surgical, 71 Disinfection by alcohol, 279 by cresol, 65 by formaldehyd, 67 by mercury, 71, 198 in dentistry, 279 of hands, 91, 92 of rooms, 68 of site of operation, 279 Dispensatory, 4 Dissolution, 3 Di-thymol-di-iodid, 56 Diuretics, 33, 222 Dobell's solution, 271, 430 Donovan's solution, 199, 200, 201 Dosage, 28, 267 Dover's powder, 157, 232, 243 Drastics, 32, 208 Dressings, antiseptic, 21 fixed, 116 Drilling, dangers of, 284, 320 into innocent teeth, 373 of teeth, painless, 284, 286 Dropsy, general, 222, 227 Drug, definition of, i, 4 Drug-habit, 27 irritants, 358I poisoning, 121, 240, 249, 276 Drugs, action of, 2, 27, 285, 359 added to root-fillings, 395 administration of, 21 by hypodermic, 22 by inhalation, 26 by inunction, 25 by mouth, 21 by rectum, 26 intravenous, 26 time of, 29 antagonism of, 276 antidotes to, 275 chemic tests of, 275 coagulating, 336 effects of, 2, 27, 359 Drugs, effects of, cumulative, 28, 172 in pathologic conditions, 29 local, 126 for local use, 36 general, 36 incompatibility of, 274, 275, 276 inorganic and organic, 5 masking taste of, 122 miscellaneous group of, 1 79 neutral principles of, 6 sources of, 4 standardizing of, 172 to be prescribed alone, 275 vegetable, 4 Dry gangrene of pulp, 350 Dysentery, amebic, 233, 436 tropical, 436 Dyspepsia, atonic, 206 flatulent, 60 Dysphagia, 210 pCHAFOLTA, 203 ■*-' in cases of infection, 366 Echinacea, 203, 204 therapeutics of, 204 Eczema, acute erythematous, 125 ointment for, 197 treatment of, by talc, 125 Edema of larynx, 466 Effervescent salts, 17, 366 Ehrlich's discovery of "606," 456, 45; Electrargol, 88 Electricity as a nerve stimulant, 253 as therapeutic agent, 253, 287 in neuralgia, 448 Electric mouth lamp, 86, 252 Elixirs, 11 Elongation of tooth, 358 Emboli, gaseous, a cause of death, 69 Emetics, 33, 230, ammonium alum, 78 in str>"chnin poisoning, 165 mustard, no tepid water, 234 Emetin, hemostatic action of, 438 hydrochlorid, 232 treatment in pyorrhea alveolaris, 436, 438 Emodin,2ii Emollients, 33, 115 Empirical therapeutics, i Emulsifying agents, 12, 121 Emulsin, 178 Emulsions, 12 Enamel, brilliancy of, 428 Encystment of root,' 378 Endameba buccalis, 417, 436 histolytica, 436 Enema, administration of, 26 Epidermic medication, 25 Epilepsy akin to alcoholism, 168 convulsions of, 155 Epinephrin, 77 Epispastics, 107 Epsom salt, 215, 217 Equimolecular concentration, 216 Ergot, 76 in pregnancy, 28 48o INDEX Eriodictyon, aromatic syrup of, 366 Erosions, 302 saliva in, 236 Eruptions, syphilitic, 458. Erythroxylon coca, 128 Eschar of sulphuric acid, 344 production of, 94 Escharotics, 33, 93 cautious use of, 105 desensitizing, 287 Esophagus, piercing of, 97 Essences, 10 Ether, 141 as analgesic, 291 contraindications of, 142 inflammability of, 141 inhalation of, 142 making of, 275 narcosis, 62 spray, 142 Ethyl alcohol, 166 bromid, dangers of, 144 chlorid, 127, 250 as analgesic, 291 inflammable vapor of, 127 use of, fatal, 128 Eucain, 137 Eucalyptol, 51 and gutta-percha solution, 124 compound, 52, 346 formula for, 360 use of, for abscess, 371 for moistening canals, 359 solvent power of, 396, 397 with thymol, 372 Eucapercha, 396 Eugenol, 50, 239 for sensitive dentin, 291 Euroform paste, 58, 387 in abscess, 379 in arsenical poisoning, 335 Europhen, 56, 313 Examination of urine, 468 Excipient for pills, 17 Excitement, nervous, 153 Excoriations, 120 Excretions, stimulation of, 365 Exfoliation from arsenical poisoning, 326 Expectorants, 33 sedative, 233, 234 Experiments with phosphorus, 187 Explosion, caustic pyrozone, 408 ether, 141 nitric acid, 96 silver nitrate, 87 sulphuric acid, 96 External use, preparations for, 18 Extract, powdered, 14 Extraction of teeth by specialists, 140 deciduous, 143 hemorrhage following, 74 in antral diseases, 413 in cases of abscess, 368 in mercurial poisoning, 194 painful sockets after, 139 painless, 137 unnecessary, 390 Extraction, products by, 12, 13 Extracts, assay of, 15 pilular, 15 solid, 13, 15 Exudates, absorption of, 108 Eyes of baby, sore, 86 Eye-wash, boric acid, 43 UACIAL neuralgia, 444, 445, 451 ■*■ Fahrenheit scale, 250 Family physician, case of syphilis re- ferred to, 457, 458 collaboration with, 281, 448 Paradic current, 253 Fat a product of putrefaction, 407 as source of energy, 191 digestion of, 191 supply of, in body, 191 Fats in dentistry, 6 Federal Anti-Narcotic Law, 27, 136, 160, 450 Narcotic Law, 27, 133 record blank, 449 Feet, hyperidrosis of, 73, 79 Fehling's solution, 471 Fennel, 240 Ferment, albuminous, 207 Fermentation, acids of, 38 in the mouth, 244, 431 Ferric chlorid, 184 compound, 182, 183 hydroxid with magnesium oxid, 185 hypophosphite, 186 oxid a cause of discoloration, 407 subsulphate, 184 Ferrous carbonate, 185 compound, 182, 183 iodid, 186 ions, 183 sulphate, 183 Ferrum dialysatum, 185 Fever sores, 455 Fiber, devitalizing, 354 Field of operation, dry, 1 76 Fig as a laxative, 209 Filling materials, drugs added to, 395 metallic, 302 of teeth, painless, 284 root-canals, 336, 394, 399 Filter, charcoal as, 60 Filth disease, 464 Fissures, protective for, 123 Fistulae, salivary, 103 Flatus, prevention of, 237 Flavored masses, 17 Flavoring agents, 10, 239, 240 Flaxseed poultice and tea, 119 Flowers of sulphur, 214 Fluid extracts, 14 Fomentations, 20 Food and Drugs Act, National, 4, 136 Foods, definition of, 34, 181 preservative of, 43 Foot-bath in pericementitis, 366 Foramina, sealing of, 400 Foreign bodies, expulsion of, 231 INDEX 481 Formaldehyd, 67 as antidote for arsenic, 329 chemic changes produced by, 337 gas, generation of, 338 treatment of gangrenous pulp, 337 use of, cautious, 371 Formalin, 67 Formocresol, 345 dressing, 339, 352 for devitalization, 329 in treatment of abscess, 370 pulpal, 350 purulent, 347 remedy, 66, 68 Formol, 67 Fowler's solution, 201, 202, 223, 242 Fracture of jaw, 252, 409 Fractures, pain of, 159 Fuller's earth, 125 Fumes of phosphorus, 186 Fungous growths, 96, 98 Fusibility of preparations, 1 8 GALLIC acid, 73, 74 Galvanic current, 253 Gamboge, 221 Gangrene of pulp, 308, 350, 364, 390 in deciduous teeth, 390 treatment of, 390 Gangrenous root-canals, 99, 336 Gargle, chinosol, 71 for sore throat, 81, 272 Gas in alimentary canal, 237 Gases, conversion of, into liquids and solids, 67 noxious, from chloroform, 143 of decomposition, 337, 339 Gastric catarrh, 85, 218 digestion, 189 juice, 38 stimulants, 177 ulcer, 85, 206 due to pyorrhea, 418 Gauze, euroform, 380 medicated, 21 Gelseminin sulphate, 180 Gelsemium, 180 poisoning, 180 Genito-urinary diseases, suppurative, 68 Gentian, 177 Gentio picria, 177 Germicides, 33, 41 Germs of disease, 245 Gin, Holland, 166 Ginger, preparations of, 238 Gingivitis, 419 acute, ulcerous, 87, 464 distinguished from pyorrhea, 466 in pyorrhea, 425 interstitial, 416 Glands, mucous, stimulation of, 236 suprarenal, 77 thyroid, 78 Glass containers, disinfection of, 279 Glonoin, 174 Gloves, rubber, 460 Glucose, 244 Glucosides, 5 Glycerin, 116 Glycerite of tannic acid, 73 Glycerites, 11 Glyceryl trinitrate, 174 Glycyrrhiza and Glycyrrhizin, 122 Gold and sodium chloride, 205 crowns, 302 inlay, 392 scrap, refining of, 227 Gonorrhea of mouth, 466 Gout, use of lithium for, 228 Gouty diathesis, 202 Granulation tissue, 254 Granulations, exuberant, 79, 86, 105 treatment of, 70 Granulomas, dental, 96, 106, 344 non-purulent, 344, 345, 351 treated by ionization, 347 Grape juice, pure, fermented, 166 Green soap, tincture of, 40, 119 Gregory's powder, 213 Growths, smaU, removal of, 184 Guaiacol, 66 Gummata, 460 Gums, brushing of, 429 derivation of, 6 hypertrophy of, 98, 103, 106, 330 inflamed, 75, 83, 117 lacerated, 57, 60 recession of, 38, 420, 421 slitting of, 434 sloughing of, 334 solubility of, 6, 274 spongy, 61, 73, 75, 416 Gun cotton, 123 Gutta-percha, 124 addition of drugs to, 395 and eu'-alyptol solution, 124 cones, 399 filling, 52, 333 for deciduous teeth, 390 for root-canals, 386, 394, 399 hermetic sealing with, 408 points, 279, 357, 397 solvents, 359, 395 use of, injudicious, 300 white base-plate, 396 HABIT, drug, 27 Haematoxylon campechianum, 75 Hallberg on metric system, 261,- 262 Hamamelis Virginiana, 75 Hands, chapped, 117, 122 disinfection of, 91, 92, 397 lotion for, 243 of dentist, abraded, 124 puncttu-ed, 124 Harrison Narcotic Act, 27 Headache, 53, 115, 162, 171 nervous, 449 Healing by first intention, 60 Heart failure, sudden, 170 stimulants, 163 tobacco, 162 Heat, application of, 249, 285 as a counterirritant, 108 482 INDEX Heat, as a disinfectant, 71 in the treatment of pericemen- titis, 363 Hematics, 35, 181 Hematinics, 181, 183, 185 Hematoxylon, 75 Hemoglobin in tubuli, 402 Hemophilia, 76, 84 Hemorrhage after extraction of teeth, 184 removal of hypertrophied gum, 330 capillary, 169 intestinal, 74 persistent, 84 post-partum, 76 prevention of, 78, 323, 324 profuse, after pulp removal, 98, 320, 323 arrest of, 84 secondary, 323 small, 79, 84 treatment of, with salt solution, 178 Hemostatics, 35, 72 Henbane, 160 Herbs used for drugs, 7 Herpes gingivalis, 455 labialis, 455 Hexamethylenamin, 68 Highmore, antrum of, 410 Hoarseness, 122 Hine, Dr. C. L., splint suggested by, 440 Hoffmann's anodyne, 142 Honeys, 11, 210 Horse, antitoxin from, 247 Hydrastin and hydrastina, 76 hydrochlorid, 76 Hydrastis canadensis, 76 preparations of, 77 Hydragogues, 32, 208 Hydrargyrum, 193 Hydrated chloral, 150 Hydrobromic ether, 144 Hydrochloric acid, 97 Hydrocyanic acid, 178 Hydrofluoric acid, 105 Hydrogen dioxid, 69, 90 as a bleaching agent, 407 as a mouth-wash, 70 ethereal solution of, 407 explosion of, 408 in pulp removal, 321 sulphid in pulp decomposition, 336, 337 Hyoscin hydrobromid, 160 Hyoscyamin hydrobromid, 160 ' HyoScyamus, 160, 161 Hyperacidity of stomach, 38 Hyperemia of pulp, 307, 308 treatment of, 308, 313 production of, 254 Hyperidrosis of feet and hands, 73, 79, Hyperisotonic solutions, 216 Hypertrophy of gums, 98, 103, 106, 330 of piilp tissue, 332 Hypnotics, 34, 150 Hypnotism, 256 Hypodermic injection, fright due to. 135 into vein, 23 technic of, 24 irrigation of sinus, 374 medication, indications for, 22 syringe, varieties of, 24 Hypoisotonic solution, 216 Hypophosphites, syrup of, 186, 190 ICE, application of, 250 as local anesthetic, 128 -bag, 355 Idiosyncrasy to cocain, 131, 134 to drugs, 27 to potassium iodid, 192 to quinin, 150 Immunity, acquired and natural, 246 Impacted teeth, 252 Impotence, functional, 188 Impression, compound, 440 Incompatibility, chemic and [physical, 274 in prescriptions, 274 of antipyrin, 146 _ of potassium bromid, 155 of sodium bicarbonate, 38, 275 of tannic acid, 74 physiologic, 276 therapeutic, 276 Incompatible drugs, list of, 275 Indian hemp, 161 Indirect oxidation, 404 Infection, alveolar, germs found in, 378 . focus of, 82 removal of, 349, 351, 389 mixed, due to extraction, 368 from ulcer formation, 107 of face and jaws, 125 of mucous patches, 458 open wound, 280 root-end, 106 septic, a cause of sloughing, 134 from hypodermic injections, 23 streptococcus, 248 syphQitic, 455, 459, 461 Infectious diseases, therapy of, 245 Infiltration anesthesia, 25, 383 Inflammation as natural process, 365 of pulp, 307 pericemental, 124 Infusions, 13 Inhalation of arsenic, in dust, loi of chloroform, 143, 292 of drugs or liquids, 26 of ether, 142 of ethyl chlorid, 127 of nitrite of amyl, 174 Injections, hypodermic, 24 intraneural, 103 intravenous, 178 Injury from careless instrumentation, 423 Insect bites, 118 Insomnia, 151 from grief, relieved by sulphonal, 153 Instrument tray, 426 INDEX 483 Instruments, boiling of, 38, 41 for curettement, 384, 385 for piilp removal, 319 for scaling, 425 in syphilitic cases, 460 Logan-Buckley, 423-426, 431 metal, effect of mercury on, 199, 201 oxygen on, 406 rusting of, 278 sterilization of, 38, 71, 201, 278, ^ 383, 397, 426 by paraform, 68 by resorcinol, 59 Interosseous anesthesia, 25 Intestines, absorption of drugs in, 22 Intoxication, acute, 167 Inunction, 25 lodin, 55 as antiseptic, 57 as counterirritant, 58 as disinfectant, 280 compound solution of, 334, 363 discoloration, 57, 58 poisoning, 118 stimulation by, 334, 387, 435 use of, In bone affections, 435 lodism, 57, 192 Iodoform, 55 action of, 57 lodol, 56 Ionic medication, 106 _ theory, 348 Ionization, 106, 347 Ipecac, 232 root, preparations of, 436 Iron carbonate, 185 compounds, 182, 183 deficiency of, 182 dialysed, 185 objections to, 329, 335 injurious to teeth, 186 iodid, 186 masked, 183 metallic, 181, 182 organic, 182 perchlorid, 184 quinin, and strychnin phosphate, 450 reduced, 185 tannate, 329 Irritants, 34, 106, 358 mechanical, 360 Irritation, reflex peripheral, 444 Isopilocarpin, 229 Isotonic solutions, 133, 179, 216 Itching, 53 TABORANDI, 229 *J Jalap, preparations of, 221 Japanese bibulous paper, 398 Jaundice, catarrhal, 218, 231 Jaws, operations about, 139 Joint affections, 170 Juices of plants as drugs, 8 KALIUM, 104 Kaolin, 117, 125 Keefe's suction apparatus, 255 Kirk's bleaching mixture, 93 reduction process, 405 Koller, introduction of cocain by, 129 Krameria, preparations of, 74 triandra, 74 T ABARRAQUE'S solution, 92, 404 ^ 405 Laboratory, biologic, 245 pathologic, 454 Lactation, medication during, 29 Lactic acid, 99 Lactose, 243 Lanolin, 120 Laryngitis, 59, 79 Larynx, edema of, 170 Latin, medical, 268 Laudanum, 156 Laughing gas, 140 Lavender, preparations of, 242 Laxatives, 32, 208 Lead acetate, 79 filling, 387 poisoning, 80, 217 croton oil in, 220 Leeching, 255 Lemon juice in scurvy, 241 Leucocytes, action of, 255 Leucoplakia buccalis, 463 "Life-saver," 396 Light as remedial agent, 251, 287, 463 Lime, chlorinated, 92 liniment, 12 Lime-salts, 189 Lime-water, 37 Liniments, 12, 272 ammonia, 170 belladonna, 175 camphor, 115 chloroform, 143 dental, formula for, 362 for pericementitis, 114 soft soap, 119 Linimentum calcis, 37, 119 Linseed, 119 Lips, dry and cracked, 82 Liquids, poisonous, of decomposition, 337 . Liquor antisepticus, 43, 55 formtda for, 430 cresolis compositus, 65 Lithium carbonate, 227 citrate, 228 Liver, sluggish, 197 Logan-Buckley instruments, 423-426, 431 Logan crown, 432 Loose teeth, prognosis for, 422 Lozenges, 17 "L.-Suprarenin Synthetic," 77 Lucodescent light, 251 Ludwig's angina, 466 Lugol's solution, 55, 192, 363 Lumpy-jaw, 464 Lunar caustic, 85 Lupus vulgaris, 253 Lycopodium, 125 Lysol, 65 484 INDEX MACE, 238 ^"1 Magnesia, calcined, 39 heavy and light, 39 Magnesium carbonate, 39 citrate, 219 solution of, formula for, 365 oxid, 39 silicate, 124 sulphate, 215, 217 Malaria, salvarsan in, 202 • quinin a specific in, 150, 450 Malignant growths, pain of, 159 Malt, 206, 207 Malted liquors, 166 Manna and mannite, 209 Marshmallow, 122 Massage in dentistry, 254, 429 Masses, 17 Materia medica, definition of, i Maxilla, fracture of, 409 Maxillary sinus, relation of molar roots to, 411 sinusitis, 87 Measures, approximate, 259 Mechanical irritants, 358, 360 Medication, epidermic, 25 hypodermic, 22 ionic, 106 Medicines, classification of, 29 Melancholia, hypnotic in, 162 Membrane, pericemental, 358 semipermeable, 216 Menstruation and canker sores, 454 Menstruum, 12 Mental healing, 256 Menthol for headache, 53 for sensitive dentin, 291 Mercurial stomatitis, 194, 226, 272, 461 Mercuric chlorid, 71, 198, 199 iodid, red, 199 poisons, 196 sulphate-ethylenediamin, 200 Mercurol, 200 Mercurous chlorid, mild, 197 iodid, yeUow, 200 Mercury, 193 absorption of, 194 action of, cumulative, 194 physiologic, 194 as specific for syphilis, 195, 457, 458, 459 atoxylate of, 457 bichlorid, 198 biniodid, 199 compounds of, 195, 196 organic, 195 in dental amalgams, 196 inunctions of, 195, 196 iodid, green, 200 nucleinate, 200 poisoning by, 194, 196, 461 protiodid, 200 succinimid, 438 systemic disturbance from, 196 therapeutics of, 195 Metal die, 125 Metallic potassium and sodium, 340 Metaphosphoric acid, 188 Meter as unit of linear measure, 260 Methemoglobin, 146 Methyl meta-amino-para-oxybenzoate, 139 Methyl trichlorid, 142 Metric system,'257, 259 advantages of, 262 measures of capacity, 261 weights, 261 Metrology, 257 Microorganisms, 245 Migraine, 152, 162, 171 Milk of sulphur, 214 Mineral acid, neutralizing of, 96 poisoning, 97 waters, natural, 218 Mitchell's "rest cure," 254 Mixtures, 11 of soUds, 16 Model, coating of, 125 wax, 441 Moisture, removal of, 397 in canals, 342, 359 Molars, pericemental abscess of, 392 Money, decimal system of, 260 Monochloracetic acid, 98 Monsel's salt and solution, 184 Morphin, action of, local, 158 anhydrous, 156 for neuralgia, 449 habit, 159 prescription for, 449 salts of, 157 Mouth and stomach, relations of, 453 aphthous sore, 87 bacteria in, 309, 364 diseases of, 283, 453 disinfection of, 45 hygiene of, 309, 459 after operation, 387 infection of, gonorrheal, 466 -lamp, electric, 412 rubber sore, 75 secretions of, 236 syphilitic symptoms in, 458 tissues of, hard, 283 soft, 453 -washes, antiseptic, 117 astringent, 72, 236, 429 cinnamon, 50 dangers of, 70 for pyorrhea, 430, 431 Mucilages, 12 Mucoperiosteum, penetration of, _4io_ Mucous membrane, hypodermic in- jection through, 25 inflammation of, 80, 86, 123 morbid conditions of, 193 oral, 77, 453, 459 tuberculosis of, 462 ulceration of, 99 patches, syphilitic, 98, 103, 458 Mucus, secretion of, 234 Mustard, black and white, 109 blisters from, no paper, 20 Mydriatics, 34 Myocardialdegeneration, 220 INDEX 485 Myotics, 34 Myrosin, 109 Myrrh, 61 Myrtol, 235 NARCEIN, 156 Narcotic poisoning, 81, 171, 176 electricity in, 253 Narcotics, 34, 156 federal law concerning, 27, 133, 136, 160, 449, 450 Narcotile, 127 Narcotin, 156 Nasal cavity, abscess under, 380 deformities, correction of, 121 Nausea due to cocain, 135 from ipecac, 437 in taking impressions, 66, 133 National Formulary, 4 Natrium, 104 Narcosis, 62, 156, 159 Necrosis in gingivitis, 465 maxillary, 188 of bone, 96, 121, 379 Neosalvarsan, 99, 202 Neothesin, 138, 291, 294 Nerve blocking, 130, 138, 451 _ Nerve, inflammation of, chronic, 444 sheath, inflammation of, 444 tissue, regeneration of, 451 Neuralgia, 444 agonizing, 451 causes of, 444 ' due to anemia, 202 general diseases, 444 pulp nodule, 305 facial, 113, 114, 445 intractable, 444 malarial, 450 obscure cause of, 302 of fifth nerve, 188 persistent ^ 103 rheumatic, 449 treatment of, 108, no, 145, 161, 177, 181, 273,445 anodyne, 448, 449 by alcohol and cocain anesthesia, 452 by counterirritation, 124, 143 by injections of alcohol, 451 by liniments, 447, 448 by menthol, 53 by morphin, 159, 449 by quinin, 150 by salicylates, 46, 48 general, 448 local, 447 medicinal, 447 surgical, 451 systemic, 448 trifacial, 152, 180 trigeminal, 107 with pyorrhea alveolaris, 177 Neurasthenia, phosphorus in, 188 Neuritis, 220 Neurocain, 136 Nervine, 181 Nervous diseases, treated by arsenic, 99 prostration, massage in, 254 system, action of alcohol on, 167 Nicotin poisoning, 162 Niter paper inhalations, 227 sweet spirit of, 230 Nitric acid, 96 Nitrites as heart stimulants, 174 Nitrogen monoxid, 140 Nitroglycerin, 174, 366 Nitrous oxid, 62, 128, 140 as analgesic, 292 combined with oxygen, 414 Nodules, ptdp, 95, 332 Nosophen, 56 Novocain hydrochlorid, 137 as local anesthetic, 25, 137 for hypersensitive dentin, 290 Nutgall, 72 Nutmeg, 237 Nutrition, effect of calcium phosphate on, 190 Nux vomica, 163, 165 OCCLUSION, faulty, 361, 420, 445 Odontalgia, 51 Odor, significance of, 371 "Official" remedies, 4 Oil, camphorated, 115 cod-liver, 191 cottonseed, 119 croton, 220, 222 of cajuput, 49, 397 of cassia, 49 of cinnamon, 49 of cloves, 50, 357 for sensitive dentin, 291 of eucalyptus, 51 commercial, 359 of myristica, 238 of myrtle, 235 of peppermint, 52 of theobroma, 129 of thyme, 54 of turpentine, 110 Oils, essential, 6, 10 fixed, 6 volatile, 6, 48, 238 Ointment, tannic acid, 73 Ointments, 18, 19 Oleate of cocain, 290 Oleates, 11 Oleoresins, natural, 6, 16 pharmaceutic, 16 Olive oil, 118 Operations about jaws, 139 bloodless, 384 minor, anesthesia in, 127, 141, 144 Ophthalmia neonatorum, 86 Opisthotonos, 164 Opium, 156 action of, physiological, 157 as analgesic, 292 contraindications, for, 160 denarcotized, 156 elimination of, 158 habit, 158, 159 486 INDEX Opium, poisoning, 158, 159, 160 distinguished from alcoholism, 167 treatment of, 159 Opsonic index, 439 Opsonins, 247, 255 Orange, preparations of, 241 Organic dioxids, 91 peroxids, 91 Orthoform, 139 Orthophosphoric acid, 188 Osmic acid, 103, 451 Osmium tetroxid, 103 Osmosis, process of, 216 Osseous system, action of phosphorus on, 187 tissues, tonic for, 188 Osteitis, 97 Osteoma, cause of, 373 Osteomalacia, 188, 190 Overwork a cause of insomnia, 153 Oxalic acid, 92 Oxidation as bleaching agent, 404 Oxidizing agents, direct, 88, indirect, 88, 92 mixtiire, 227 Oxids, metallic, solutions of, il Oxygen, 61 as a bleacher, 62 combined with nitrous oxid, 141 nascent, liberation of, 89, 408 power of, 407 Ozone, 62 PAIN after pulp removal, 361 control of, methods for, 284 from cutting of bone, 387 in septic pericementitis, 367 "killer," 159 of drilling, 251 relief of, by anodynes, 126 by opium, 159 by pyramidon, 148 immediate, 361 severe paroxysms of, 447 Painless dentistry, 25, 27, 133, 283 Palate, soft, destroyed by gummata, 460 Pancreatin, 206 Papain, 207 Papaverin, 156 Paraffin filHng for root-canals, 394 injections of, 121 Paraform, 67 Paraformaldehyd, 67 Paraldehyd, 153 Paralysis of fibrillae, 289, 294 Paralyzant agents, 126 ■ Parasiticide, 199 Paregoric, 157 Parillin, 203 Parts-by-weight system, 257 Paste, antiseptic, 395, 396 arsenic trioxid, 327 desensitizing, 55, 138, 141, 293, 297 devitalizing, 120 for filling root-canals, 394 for pulp -capping, 51 orthoform and europhen, 139 Paste, sodium and alcohol, 321 thymolized calcium phosphate, 312 Patches, leucoplakia, 463 mucous, 86, 98, 103, 458 Pearson's solution, 201 Pediculosis pubis, 196, 199 Pepper, black, 237 Peppermint, oil of, 52 Pepsin, 205, 206 Percentage in solutions, 263 Pericemental abscess, 391 therapeutics of, 391 membrane, circulation in, 433 regeneration of, 392 Pericementitis, apical, 67, 114, 359 causes of, 52, 317, 318, 358, 360 counterirritation in, 107, 109, 113, 143, 362 home remedies for, 363 nonseptic, due to irritants, 358 liniment for, 114 treatment of, no, 358, 361 by aconite, 363 by heat, 363 septic, 358, 364 causes of, 364 diagnosis of, 364, 365 treatment of, by drugs, 365 by heat, 108 by menthol, 53 general, 365 local, 364 Persio, 244 Peruvian bark, yellow, 148 Petrolatum and petronol, 120 Pharmaceutic preparations, 8 Pharmacodynamics, i Pharmacology, definition of, i Pharmacopeia, United States, 3, 4 Pharmacy, 3 Pharyngitis, 59, 75, 87, 98 chronic and subacute, 79, 235 Phenacetin, 147 Phenol, action of, 62, 63 as analgesic, 287 as local anodyne, 291 compound, 54, 311, 427 for hermetic sealing, 375 in pulp treatment, 299 poisoning, 46, 63, 217 Phenolphthalein, 215 Phenolsulphonic acid, 94, 95 advantages of, 343, 345 as cleansing agent, 340 as stimulant, 372 in pulp removal, 322 in pus pockets, 435 in treatment of abscess, 375, 392 indications for, 96 neutralizing of, 381 syringe for, 381 Phenyl salicylate, 46 Phosphoric acid, 188 Phosphor-necrosis, protection against, 188 Phosphorus, 186 action of, physiologic, 187 inflammability of, 187 INDEX 487 Phosphorus, poisoning, 187 therapeutics of, 188 Physicians and dentists, harmonious work of, 349, 443 Phthisis, treatment of, by arsenic, 99 by terebene, 112 Picropodophyllin, 222 Pigment a cause of discoloration, 403 Pills, 17, 271 aloes and iron, 211 cathartic compound, 197 rhubarb compound, 211 vegetable cathartic, 221 Pilocarpin, effect of atropin on, 229 Pilocarpus, 229 Pimenta, 239 Pinus palustris, no, in Piperin, 237 Plants, parts of, used for drugs, 7 Plaster-of- Paris bandages, 21 Plasters, 19 capsicum, 109 mustard, 20 Plastic porcelain filling, 121 Pockets, deep, elimination of, 434 lingual, 380, 388 pyorrheal, 85, 98, 417 curettement of, 431, 432, 439 location of, 434 Podophyllin and podophyllotoxin, 222 Podophyllum, 222 Poison, definition of, 3 tablets, 18 Poisoning, acetanilid, 146 aconite, 114 alcohol, 167 ammonia, 170 amyl nitrite, 173 arsenical, 39, 100, loi, 185, 186, 326 local, 334 .,, aspirin, 47 atropin, 176 bismuth, 85 by alkalies, 98 by corrosives, 105, 118, 121 by depressant drugs, 165, 173 by mineral acids, 37, 97 cantharides, 112, 113 caustic potash, 105 chloral, 151 cocain, 131 digitalis, 173 gelsemium, 180 hydrofluoric acid, 106 iodin, 118 lead, 80 mercurial, 194, 196, 461 metallic, chronic, 193 narcotic, 81, no, 176 nicotin, 162 opium, 158 oxalic acid, 37 paraldehyd, 154 phenol, 63 phosphorus, fatal, 188 potassium bromid, 154 chlorate, 226 strychnin, 164 Poisons, anatagonists to, 31 expulsion of, 231 Polishing of teeth, 428 Polypi, nasal, removal of, 75 Porcelain body, 125 filling, 121, 297 jacket crowns, 302, 355 Posolog^', 28 Posture when inhaling chloroform, 292 Potash, caustic, 104 Potassium acetate, 224 and sodium, 104 metallic, 340 tartrate, 219 bicarbonate, 223 bitartrate, 224 bromid, 154, 155 carbonate, 223 chlorate, 225, 226 citrate, 224 dichromate, 103 hydroxid, 104 iodid, 192 action of, cumulative, 192 physiologic, 192 in tertiary syphilis, 460 ion, 224 nitrate, 227 permanganate, 70 in opium poisoning, 159 incompatibility of, 70 Poultices, 20 ice, 128 kaolin, 125 Powders, 16, 270 dusting, 116, 125 Practical cases, history of, 351 treatment of, 351 Precipitates, formation of, 274 Pregnancy, a factor in dosage, 28 and ergot, 76 mouth secretions in, 40 purgation in, 28 Prescription, basis of, 266 official formula in, 269 refilling of, 160 -writing, 264, 269 abbreviations in, 264 by the dentist, 267 in Latin, 268 Prescriptions, incompatibility in, 274 practical, 270 Pressure anesthesia, 25, 136, 315, 318, 319 for pulp removal, 392 ' instruments for, 319 from abnormal growths, 444 in pulp removal, 318 osmotic, 216 Prinz's isotonic solution, 134 Privies, deodorant for, 184 Probing for caries, 379 sinus, 373 _ Process, de\'italization of, 334 exposed, after extraction, 57 removal of, surgical, 335 Prophylaxis, dental, 421 _ in pyorrhea alveolaris, 427 48S INDEX Proprietary- local anesthetics, 136 Protargol, 87 Protectives, 116 Protozoon a cause of pyorrhea, 417 Prune as a laxative, 210 Prunus virginiana, 178 Pruyn's method, 342 Psoriasis, simulation of, 68 Psychotherapy, 256 Psychrotin, 232 Ptomains in pulp decomposition, 337 Ptyalin, secretion of, arrest of, 72 Ptyalism, 61, 75, 194, 461 Pulmonarj- tuberculosis, 67 Pulp, anesthesia of, 25, 26, 254, 289 blood-vessels of, 298, 299 calcification, 332, 352 capping, factors in, 308 pastes for, 51 technic of, 310, 311 chamber, opening of, 319, 328, 339 pus in, 339, 357 dead, diagnosis of, 252, 253, 307, 338 decomposition a cause of discolora- tion, 402 end-products of, 67, 337, 340 dehcacy of, 300, 311 devitalization of, 102, 160, 207, 298, . 314 diseases of, destructive, 306 diagnosis of, 296, 298 exposure, 308, 309, 310 by accident, 354 in the young, 309 function of, 314 gangrene of, 350, 364, 390 diagnosis of, 308 in a child, 390 specific for, 66 treatment of, 353, 390 ■with oil of myrtle, 236 with phenolsulphonic acid, 96 with sinus, 373 hyperemia of, 307 irritation of, 299, 312 mechanical, 314 nodules, 95, 303, 305, 332, 361 in neuralgic case, 305 radiographs of, 304 normal, anatomj- of, 298 sacrifice of, 306 partially aUve, 350 pathology, 296 poisoning of, 329 remnant, destruction of, 90, 95, 105 removal, 98, 136, 296, 298, 315, 320, 431 after-treatment, 322 complications of, 330 from deciduous tooth, 333 indications for, 314, 431 painless, 323 septic, 308, 350 slow death of, 312 stimulation of, 48 tissue, decalcified, 141 digestion of, 207 Pulp, tissue, hypertrophy of, 103, 332 treatment of, 298 vital, removal of, 314 Pulpal abscess, 308, 350 Pulpitis, anodyne for, 152 associated \^ith pericementitis, 324 diagnosis of, 309 treatment of, by phenol, 64 true, 307, 313 Pulpless teeth, compHcations of, 349 diagnosis of, 336 sequelse of, 336 treatment of, 336, 339 by acid method, 344 by formocresol, 345 Punctures, protective for, 123 Purgatives, 32, 208 Purshianin, 208 Pus, burrowing of, 373 disposing of, 370 evacuation of, 204, 372, 377 from abscess, 370 mechanical, 374 formation, causes of, 364 checking of, 371, 372, 378 pockets, cauterization of, 435 pyorrheal, diseases due to, 418 examination of, 416 Putrescence, true, 350 Putrid sore throat, 70 Pyorrhea alveolaris, 416 a cause of pulp removal, 315 antiseptic in, 82 causes of, active and predisposing, 416 classes of, 419 systemic, 421, 443 cure of, 422, 434 deposits in, 419 extraction of teeth in, 422 gouty, I, 225 mistaken for alveolar abscess, 433 percentage of cases of, 438 pus in, diseases traced to, 418 rheumatic, 48, 202, 225, 421 stimulation in, 99 systemic eflfects of, 417 treatment of, 42 i acid, 96 by betanaphthol, 59 by cresol and lysol, 66 by emetin, 233 by iodin, 58 by hthium, 228 by mercury succinimid, 438 by ozone, 62 by suction, 255 by zinc oxid, 83 general, 443 local, 443 mechanical, 440 medicinal, 46, 428, 435 surgical, 423. 43 1 true, 420, 431 with indigestion, 430 with neuralgia, 177, 181 Pyorrhea astringent, author's, 117, 429 Pyorrheal pockets, 69 INDEX 489 Pyramidon, 148, 450 Pyrophosphoric acid, 188 Pyrotechnics from sodium dioxid, 90 QUINIDIN, 148 Quinin, action of, on blood, 149 on white blood corpuscles, 366 as a tonic, 150 as specific for malaria, 150, 450 bisulphate, 367 elimination of, 149 idiosyncrasy to, 150 valerianate, 161 Quinsy, 205 RACHITIS, 188, 190 Radiograph, value of, in dentistry, 252, 394 in diagnosis, 345, 371, 373, 377 Radiographs in operative cases, 388 interpretation of, 354 of nodules, 304 of pulpless tooth, 340 Radium salts, rays of, 253 Rarefied area, 395 Rash, boric acid, 43 quinin, 150 Rational therapeutics, i Ray-fungus, 464 Rays, alpha, beta, and gamma, 253 Reaction of boric acid, 44 of saliva, 236 of sodium dioxid, 89 . Recession of gum, 38, 420, 421 "Record blank" for narcotics, 133, 136 Rectum, medication by, 26 Reducing agents, 93, 405 Reduction, process of, 93 Reflex peripheral irritation, 444 Refrigerant agents, 126 Remedies-, classes of, 2 definitions of, 30 desensitizing, 284 local, 36 other than drugs, 249 specific, 46 Research, institutions for, 390 Resins, derivation of, 6 precipitated, 16 preparations of, 14 solubility of, 274 Resistance, vital, lowered, 444 Resolution, 3 promotion of, 108 Resorcinol, 59 Resorption in cases of abscess, 376, 378 Respiration, artificial, 131, 132, 159 Respiratory apparatus, efficiency of, 175 centers, functional activity of, 175 failure, 132 stimulants, 175 Restoratives, 34, 178, 181 Retainer for teeth, 440 wax, directions for making, 440 Retractor, use of, 384 Rhein's ionic theory, 348 method of filling canals, 341 Rheumatism, 45 acute, 48, 225, 229 salicylic acid in, 46 chronic, 170, 200 due to pyorrheal infection, 422 muscular, no, iii, 144 treatment of, by aspirin, 47 by salol, 46 Rhigolene spray, 128 Rhizome of plants, 7 Rhubarb, preparations of, 213 Ricinolein, 212 Ringer tablet "B," 179 Ring-worm, 59, 199, 214 Rochelle salt, 219 Roe, Prof. J. N., 468 Rontgen ray, 252 Root amputation, 139 -canals, asepiss of, 360 enlargement of, 90 filUng of, 82, 394 with chloropercha, 143 with various materials, 394 gangrenous, 42, 95, 104 sterilization of, 104 tortuous, 90, 95 treatment of, 52 aseptic, 169 standar for, 349 with thydmocamphen, 115 cementosed, 446, 447 decayed, 349 denuded, 433 encystment of, 378 -end, denuded, 377, 433 encapsulated, 398, 401 filling of, 386 infection of, 445 roughening of, 376, 377 resorption of, 378 excision of, 382, 385, 433 -filling, asepsis in, 396 old, removal of, 346 pastes, 395 pus formation in, 371 surface, exposure of, 434 Roots of plants, 7 Rose, red, preparations of, 242 Rosin, III Rubber dam, adjustment of, 176, 315, 344, 349. 397. 4o6 sore mouth, 75, 79 Rubefacients, 107 C ACCHARIN, 243 >-5 Sacrifice of teeth, 370, 421 Sal ammoniac, 234 SalicyUc acid, 45 Saline cathartics, 216, 366 Saliva, change in, 84 examination of, 236, 453 pus-laden, swallowing of, 422 Salivation, 194, 459, 461 atropin for, 176 effect of, on teeth, 421 free, in pyorrhea, 439 prevention of, 226 490 INDEX Salol, 46 Salophen, 47 Salt action, 133, 215 solution, 133, 215 physiologic, 26, 178, 356 Saltpeter, 227 Salts, effervescent, 17 soluble, 183 Salvarsan, 99, 195, 202, 456 contraindications of, 202 or "606," 202, 456 Saponin, 203 Sarsaparilla, 203 as alterative in syphilis, 203 compound syrup of, 212, 366 Sarsa-saponin, 203 Sassafras, 123 medulla, 239 Scabies, 45, 59, 214 Scalds, 37 Scale salts, 183 Scaling, process of, 425 D. D. Smith's, 427 Scar tissue, 254 Schreier's alloy, use of, technic of, 341 Scopolamin hydrobromid, 160 Sealing, hermetic, 322, 375, 408 in root-canal work, 400 in of remedies, 300, 359 of cavity, 362 with cement, 365 Secretion, excessive, expulsion of, 231 gastric, antiseptic action of, 417 glandular, arrest of, 72 of serum, 372 Secretions, control of, 176 effects of opium on, 157 pilocarpin on, 229 Sedatives, 35 Seidlitz powder, 219 Senna, 209, 210, 211 Septicemia, treatment of, by echafolta, 204 Sequestra, exfoliation of, 368 removal of, 97 Serous membranes, inflammation of, 159 Serum antidiphthericum, 247 antipneumococcus, 248 antistaphylococcus, 248 antistreptococcus, 248 antitetanicum, 247 production of, 5 weeping of, 371 Serums, action of, 247 "Setting" of paste, 312 Sex, a factor in dosage, 28 Shaving emollient, 75, 79, 117 Shock, alcohol in, 169 from anesthetics, 176 from hemorrhage, 178 "Shot-gun" prescription, 264 Sialogogues, 35, 236 Sight, accidental loss of, 425 Silver chlorid precipitate, 470 metallic, 85 nitrate, 85 as prophylactic, 288 Silver, nitrate, for babies' sore eyes, 86 neutralizing of, 275 preparations of, colloidal, 88 salts, action of sunlight on, 86, 252, 288 • vitellin, 87 Sinalbin, 109 Sinigrin, 109 Sinus, apical, of bicuspid, 353 cauterizing of, 64, 65, 374 closed, 69 dento-alveolar, 85 discharging for several months, 376 establishment of, 374, 377 in alveolar abscess, 98, 373 irrigation of, 374 opening into mouth, 373 treatment of, by hydrogen dioxid, 69, 374 by trichloracetic acid, 98 tubercular, chronic, 85 weeping of, 376 Skin, hypodermic injection through, 24 inflammation of, 83, 123 lesions, 122 Sleep, narcotic, 156 Sleeping sickness, 457 Slippery elm, 123 Sloughing of tissue, causes of, 134 from arsenic trioxid, 1 00 Smallpox vaccine, 248 Smokers, gingivitis in, 465 mouths of, 463 Snake-bite, 169, 203 Soap, incompatabihty of, 41 soluble, 407 white castile, 40 Soapstone, 125 Sockets, painful, 139 Soda, caustic, poisoning by, 105 chlorinated, 92 Sodium benzoate, 45 bicarbonate, 37 incompatibility of, 38, 275 ■ borate, 38 bromid, 155 dioxid, 89 as bleaching agent, 405, 406, 408 ice-water solution of, 406 hydroxid, 104 as a by-product, 89 . iodid, 193 ion, 155 peroxid, 89 phenolsulphonate, 344 phosphate, 218 pyroborate, 38 salicylate, 48 sulphate, 217, 344 Solids, mixtures of, 16 Solutions, 9 anesthetizing, 279, 317 antiseptic, 271, 311, 316 bichlorid of mercury, 198 concentration of, 216 cudbear, 425, 427 Dakin's, 179 disclosing, 428 INDEX 491 Solutions, emetin hydrochlorid, 436 Fehling's, 471 hyperchlorous acid, 179 hyperisotonic, 216 hypertonic, 179 isotonic, 133, 179, 216 magnesium sulphate, 217 of non-volatile substances, 9 percentage in, 263 pharmaceutic, 8 prescriptions for, practical, 271 rosin, iii salt, 26, 133, 178, 215, 356 sodium bicarbonate, 433 sodium dioxid, 89 true, 18 Solvent, chloroform as, 143 eucalyptol as, 396, 397 Somnifacients, 34, 150 Somnoform, 127 Sores, open, 60 Spanish fly, 112 Spasms, relaxation of, 174 Spearmint, 238 Specific disease, 2, 455 gravity, 257, 468 remedy, 2, 150, 202 Spinal cord depressants, 154 Spirillum, affections due to, 202 Spirits, 10, 166 aromatic, 10 of ether, compound, 142 of mindererus, 230 of nitrous ether, 230 Spirocheta in pyorrhea! pus, 417 _ pallida, 195, 455, 457 Splints for teeth, 21, 440 Spooner, use of arsenic by, 102, 325 Spore formation, 277 Sprains, 61, 75, 144 Spray, alcohol, 368, 448 cinnamon, 50 cocain, 133 ether, 142, 286 ethyl chlorid, 250 rhigolene, 128 Spraying outfits, 428 Sputum of consumptives, 462 Squill, preparations of, 235 Stain from silver nitrate, 87 ineradicable, 330 nitric acid, 96 removal of, 321 Staining agent, 75 Staphylococcus pyogenes, 364 aureus, 245 Starch, 118 Starvation, deficiency of fat in, 191 Steapsin, 206 Stearoptenes, 6, 53 Sterilization by sublamin, 201 dental, 277, 397 by chemic agents, 278 by direct flame, 277 by dry and moist heat, 71, 278 by f ormaldehyd, 294, '295 by ionization, 348 in pulp removal, 315 Sterilization, mechanical, 328 of dentin, 199, 310 of fingers, 317 of hypodermic syringe, 24 of instruments, 38, 71, 201, 278,383 397. 426 responsibility for, 280 surgical, 41 Sterilizers, 71, 278 Stewart, Dr. Lee K., appliances of, 441 Stimulants, 35, 163 cardiac, 163 gastric, 177 respiratory, 175 , restorative, ,178 Stings, 118 Stock solutions, 279 Stomach, absorption of drugs in, 22 disorders of, 206 hyperacidity of, 38, 40 irritant material in, 233 -pump, dangers of, 97 rupture of, 97 washing of, 123 Stomachics, 177 Stomatitis, argyrol in, 87 chronic, 86 mercurial, 194, 226, 272, 461 treatment of, 39, 52, 55, 82, 194 ulcerative, 51, 59, 61, 80, 81, 83, 204 Stopping, temporary, use of, 365 Streptococcus decomposition, 340 fecalis, 357 infection, 68 pyogenes, 364 longus, 419 pyorrhea!, in feces, 417 salivarius, 357 vaccine, 248 viridans, 245, 340, 357 in pyorrhea, 417, 418 Strontium iodid, 193 Strychnin, 164 as alkaloid of nux vomica, 163 physiological action of, 164 poisoning, 164, 174 diagnostic sign in, 165 sedatives in, 151 treatment of, 165 therapeutics of, 165 value of, in poisoning by depres- sants, 165 Stupe, turpentine, iii Styptics, 35, 72 Sublamin, 200 "Submarine gardens," 55 Succinic dioxid, 91 Suction, hyperemia produced by, 254 Sudorifi.cs, 32, 228 Sugar of milk, 243 Suggestion in treatment of disease, 255 Sulphonal, hypnotic action of, 152 poisoning by, 152 Sulphonmethane, 152 Sulphur, action of, physiologic, 214 in parasitic diseases, 214 lotum, 214 492 INDEX Sulphur,poisoning in match factories, 187 precipitated, 214 sublimatum, 214 Sulphurated calcium, 204 Sulphuric acid, 94, 340 action of, corrosive, 344 free, in phenolsulphonic acid, 375 in pulp removal, 316 in treatment of pulpless teeth, 343 therapeutics of, 95 Sulphurous acid, 31, 32, 93, 214 Sunlight, eflFect of, on silver salts, 86, 252,288 Suppositories, 19 glycerin, 117 Suppuration, arrest of, 205 in wounds, 59 Suppurative pericementitis, 364 Suprarenal gland, I'j Suprarenin, 77 Surgery in alveolar abscess, 382 in antral diseases, 413 major, nitrous oxid in, 141 Sweat, clammy, 249 glands, activity of, 229 Sweating, excessive, 169 Sweet oil, 118 Swelling due to abscesses, 355 Sylvester's artificial respiration, 132, Syncope, 115, 169, 173 Synthetic drugs, 5 substitutes for cocain, 136 Syphilis 2, 455 cure of, 460 diagnosis of, certain, 459 differentiated from gingivitis, 465 germ of, 455 infection of, 459 prmiary, 456 diagnosis and treatment of, 456 secondary, 192, 195, 226, 458 diagnosis and treatment of, 458 specific for, 202, 460 symptoms of, 455 tertiary, 200, 460 potassium iodid in, 192 treatment of, by arsenic, 99 by merciuy, 195, 199, 200 by "606," 195 Syphilitic conditions, iron iodid in, 186 mucous patches, 458 Syringe for phenolsulphonic acid, 381 Syrups, 10 Systemic diseases, origin of, 248 y ABLETS, 18 •^ alcresta ipecac, 232 corrosive sublimate, 18, 198 Ringer, 179 Talc, purified, 124 Tamarind, 209 Tannic acid, 31, 72, 74, 329 in krameria, 74 use of, objections to, 329 Tartar emetic, 233 solvent, 436 Teeth, anesthetization of, 129 artificial, 436 bleaching of, 70, 88, 90, 93, 98, 190, 403 bridged, 295, 303, 443 care of, 358, 429 cleanliness of, 459 coalescing of, 446 discoloration of, 320, 402, 407 dropping out of, 420 erosion of, 40 eruption of, 145 examination of, in match factories, 187 exfoliation of, 326 extraction of, 74, 120, 127 needless, 370, 421 painless, 133, 136 fracture of, 252 impacted, 445, 446 loose, in pyorrhea, 421, 422 support for, 442 lost, replacing of, 442 pink staining of, 402 replantation of, 435 scahng of, 64, 425 shortening of, 442 sound, extraction of, 447 whitening of, 70 Temperature, fever, reduction of, 145, 169 influence of, 29 Terebene, 112 Terpenes, 6 Test, chemic, for sodium dioxid, 406 heat, 468 nitric acid, 468 Tetanus, convulsions of, 151, 174 distinguished from strychnin poi- soning, 165 toxins of, 245, 246 Tetra-iodo-phenol-phthalein, 56 Tetra-iodo-pyrrol, 56 Thebain, 156 Theobroma, 129 Therapeutics, definition of, i practical, 281 preventive, 300 Therapy, successful, 281 Thermal sensitiveness, 283, 284, 294 Thermometric scale, 250 Thirst, allaying of, 189 Throat, diseases of, 210 Throat, sore, 74, 75, 81, 82, 98, 122, 123 putrid, 70 Thrush, 38 treatment of, 39, 70 Thyme, oil of, 54 Thymocamphen, 55, 115 Thymol, action of, 54, 311 in eucalyptol, 124 iodid, 56 Thymophen, 55 Thyroid glands, desiccated, 78 Tic douloureux, therapeutics of, '45 1, 452 Tincture of opium, camphorated,' 157 Tinctures, assay of, 13 use of, by dentists, 14 INDEX 493 Tissue in cavity, nature of, 331 laceration of, 134 waste, 204 Tissues after cauterization, 346 constringing of, 429 . of mouth, hard, 283 not associated with the teeth, 453 soft, 453 sloughing of, 134 Tobacco, 162 Tolerance of drugs, 27 Toluene, 243 Tongue, cancer of, 70 Tonics, 35, 181 quinin, 150 spring, 123, 240 TonsilUtis, follicular, 205 Tonsils, enlarged, 81 Tooth, anatomic structure of, 285 bacterial growth on, 427 -pastes, base of, 37 for pyorrhea, 429 powders, base of, 37 for general use, 270 ♦structure, disinfection of, 279 exposed, 86 sterilization of, 277 vital, opening of, 392 Toothache during devitalization, 327 jumping, 313 relief of, by chewing tobacco, 163 treatment of, 67, 307 Toxicology, definition of, 1,2 Toxins, absorption of, 417 extracellular, 245, 418 in digestive tract, 453 in pulp decomposition, 337 intracellular, 245 Tragacanth, 121 Trauma a cause of antral disease, 412 Trichloracetic acid, 33, 98, 288 Tricresol, 65, 338 Trifacial neuralgia, 444 Trigeminal neuralgia, 444 Trional, 153 Trioxymethylen, 67, 288 Troches, 17, 75 ammonium chlorid, 234 tannic, acid, 73 Tropacocain hydrochlorid, 136 Troy weight, 257, 258 Trypsin, 206 Tubercle bacillus, entrance of, into body, 462 Tuberculosis, 462 cod-liver oil in, 191 - pulmonary, 67, 202 treatment of, 200, 203, 462 Tumor, apical, 388 Turpentine, no, in Typhoid fever, intestinal antiseptic in, 91 vaccine, 248 T TLCERATION, lupous, 99, 454 ^ tuberculous, 99, 462 Ulcers, 59, 83, 86, 147 Ulcers, chancrous, 454 duodenal, 38 dusting powder for, 125 gastric, 38 gingival, 465 in the mouth, 454 indolent, 77, 79, 80, 98, 103 phagedenic, 96 sluggish, 57 syphiUtic, 59, 197, 454, 456 tubercular, 462 United States Pharmacopeia, IX, 3 previous to 1880, 257 Urea hydrochlorid and quinin, 150 nitrate precipitate, 469 Uremia, acute, 229 convulsions in, 174 distingmshed from alcoholism, 167 Uric acid precipitate, 469 Urine, albumin in, 443 alkaUnity of, 223, 225 analysis of, 471 chlorids in, 469 effects of potassium on, 225 examination of, 468 mercury in, 194 phosphates in, 470 reaction of, 468 secretion of, 223, 225 solids of, 468, 469 specific gravity of, 468 sugar in, 443, 470 sulphates in, 470 urates in, 469 urea in, 469 Urotropin, 68 VACCINES, autogenous, 5, 248 mixed and stock, 248 use of, in pyorrhea, 439 Valerianic acid, 180 Vallet's mass, 185 Vanilla, 242 Vasehn, liquid, 120 Vault of mouth in abscess cases, 380 Vegetable drugs, 5, 7 Vehicles for drugs, 17, 18, 19 Vein, air injected into, 23 Venous hyperemia, 307 Vesicants, 107 Vesication, 250 Vibrating coil, 338 Vinegars, 13 Vital pulp, removal of, 314 resistance, lowered, 444 Vitality of tooth after desensitizing, 297 Vitriol, white, 81 green, 183 Volatile oils, 48 _ prunus virginanai, 178 valerian, 180 substances, solutions of, 9, 10 Volume of drugs, 14, 16 Vomiting induced by apomorphin, 231 lime-water for, 37 Vital resistance, lowering of, 444 494 INDEX WARTS, removal of, 46, 96, 98 Washed sulphur, 214 Wassermann reaction, 456 Waters, aromatic and medicated, 9 Wax models, 441 Weight of drugs, 15, 16 Weights and measures, English, equiva- lents to, 261 Whooping-cough, 59, 145, 151 Wild cherry, syrup of, 178 Wine measure, 258 Wines, 12, 166 Wires, diagnostic, 351, 353 Witch-hazel, 75 Wood charcoal, 60 Wool fat, purified, 1 20 Wounds, aseptic, 123 healing of, 60 incised, 73 infected, 179, 252 lacerated, 73 packing of, 85, 386 painful, 139 protected by gutta-percha, 124 sloughing, 59, 103 Wright's hypertonic solution, 179 V-RAYS in diagnosis of abscess, 370, ^^ 382 of neuralgia, 445 of pulpless teeth, 351, 354 in disease of antrum, 412 in root-canal work, 400 in therapeutics, 252 Xylene, 346 Xylol, 346, 351, 352 VELLOW cinchona, 148 *■ Yerba santa, 366 ZINC chlorid as a dangerous caustic, 83 in treatment of cavity, 287 iodid, 83 ointment with calomel, 197 oxid, 82, 312 phenolsulphonate, 82 sulphate, 81 sulphocarbolate, 82 COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- | rangenaent with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE '■, "IS^ 2 2 M,n CZ8(a39)M100 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RK701 B85 1922 C.I Modern dental materia medica. 2002403870 RK701 T3^..„T-T ^ ., B85 1922