I Columbia WlnMv&itp in ti)t €it$ of jfreto gorit g>cjjool of Cental anb <2£ral gmrgerp Reference Htftrarp ■ $ ^^1 *=■ H DENTAL SURGERY. DENTAL SURGERY FOE PRACTITIONERS AND STUDENTS BY ASHLEY W. BAKKETT, M.B.(Lond.),M.K.C.S., L.D.S. DENTAL SUEGEON TO THE LONDON HOSPITAL. PHILADELPHIA PEESLEY BLAKISTON, SON AND CO. 1012 WALNUT STREET 1885 PBEFACE. Having stated as concisely as possible the substance of what for several years I have been teaching to students of medi- cine in the Dental Department of the London Hospital, I venture to hope that this small book may prove useful to the busy medical practitioner, too much occupied to study larger and more exhaustive works on Dental Surgery. To such matters as the filling of teeth with gold, the pivoting of mineral crowns, and to others which fall only within the scope of the specialist, reference is intentionally omitted. My aim throughout has been to give upon dental matters as much practical information, and no more, as may suffice the student of medicine in the after work of his profession. VI PREFACE. To the practice and teaching of my uncle, H. J. Barrett, I am mostly indebted for what may be found to possess value in these pages; and to my brother, S. E. Barrett, my thanks are due for his assistance in revising the proof sheets. For the illustrations of Dental Forceps, I am obliged to the courtesy of Messrs. Ash and Co. A. W. BAREETT. 42 Finsbuky Squake, London, E.C. TABLE OF CONTENTS. CHAPTER I. The First Dentition. PAGE Eruption of Temporary Teeth. Lancing the Gums. Ab- sorption of Temporary Fangs. When to Extract Tem- porary Teeth for relief of Irregularity. Undesirability of Extracting Temporary Teeth. Ulceration through the Gums of Temporary Fangs ..... 1 CHAPTER II. The Second Dentition. Order of Eruption of Permanent Teeth. Eruption of Wis- dom Teeth. Diagrams of Teeth at Three Periods of Childhood. How to distinguish between Temporary and Permanent Teeth ....... 6 CHAPTER III. Abnormalities in Development of Permanent Teeth. Retarded Eruption. Supernumerary Teeth. Abortive Teeth. Dilacerated and Geminated Teeth. Honey-combed and Syphilitic Teeth 10 Vlll TABLE OF CONTENTS. CHAPTER IV. Irregularity in the Positions of the Permanent Teeth. PAGE Cause of Irregularity among Teeth of the Present Time. Treatment of Irregularity by Extraction and the Regu- lating Plate. Symmetrical Extraction. Six Common Forms of Irregularity: — 1. Underhung Incisors; 2. Rotated Incisors; 3. Projecting and Diverging In- cisors ; 4. Projecting Canines ; 5. The V-shaped Dental Arch; 6. Irregular Articulation of Upper with Lower Teeth. The Excavator and the Mouth Mirror . . 14 CHAPTER V. Dental Caries. Tendency of Teeth to become rudimentary. Local and General Causes of Decay. Two Varieties of Caries. Liability of Various Teeth to Decay. General Direc- tions as to Treatment of Caries. Symptoms and Treat- ment of Caries in its First Stage. Caries in its Second Stage, with Antiseptic Treatment of the Pulp Cavity, and Symptoms and Treatment of Periodontitis and Alveolar Abscess. Caries in its Third Stage, with Contraction of Temporo- Maxillary Articulation and Fis- tulous opening through Cheek 27 TABLE OF CONTENTS. IX CHAPTER VI. Toothache. PAGE Odontalgia. Periodontitis. Gas Pressure on the Nerve. Neuralgia . . ' CHAPTER VII. Mechanical Injuries to the Teeth. Wearing down of the Teeth from Friction of Mastication. Hunter's Denuding Process. Fracture and Dislocation of a Tooth from Violence . . • • • • 54 CHAPTER VIII. Extraction of Teeth and Stumps. Conditions necessitating Extraction. General Directions as to the position of Operator and Patient. Concerning the application of Forceps. As to the Extraction of the Tooth. Accidents during Extraction. A list of Instru- ments needed for Extraction. Forceps, their General Characters and Various Forms. The Elevator, its De- scription and Mode of Using. The Screw Extractor . 57 CHAPTER IX. Anesthetics. Preparation of the Mouth for Frames. Salivary Calculus 75 LIST OF ILLUSTRATIONS. Fig. 1. — Diagram from a cast of the upper jaw of a neglected mouth in a child aged eight .... 3 „ 2. — At the age of three years showing the ten upper temporary teeth ....... 7 ,, 3. — At the age of seven years, showing the ten tempo- rary teeth and also the two six-year-old molars . 8 ,, 4. — At the age of thirteen years, showing the fourteen upper permanent teeth ..... 9 ,, 5. — Diagram of lower jaw, showing retention of tempo- rary molar . . . . . . . .11 ,, 6. — Diagram of a mouth showing supernumerary teeth displacing incisors . . . . . .11 „ 7. — Malformed Incisor ...... 12 ,, 8. — Two lower temporary incisors united by cementum 12 ,, 9. — Syphilitic Incisors . . . . . . .13 „ 10. — Honey-combed Incisors . . . . .13 „ 11. — Regulating Plate for treatment of irregularity among the upper front teeth . . . .17 „ 12. — Model of upper jaw with rotated incisors . . 19 ,, 13. — Model of upper jaw with widely spaced and diver- gent incisors ....... 20 „ 14. — Model of jaw with projecting canines . . .21 „ 15. — Model of a V-shaped upper jaw . . . .22 „ 16. — Excavator ........ 24 ., 17. — Mouth Mirror 25 Xll LIST OF ILLUSTRATIONS. PAGE F IG . 18. — Nerve Extractor for removing devitalized dental nerve ........ 38 19. — Upper incisor and canine forceps . . . .66 20. — Upper bicuspid forceps for either side . . .67 21. — Forceps for lower incisors, canines and bicuspids . 68 22. — Forceps for upper right molars . . . ,69 23. — Forceps for upper left molars . . . .70 24. — Lower molar forceps for either side of the mouth . 70 25. — Upper stump forceps ...... 71 26. — Lower stump forceps . . . . . .71 27. — Elevator — front view ...... 73 28. — Elevator — side view 73 29. — Screw extractor for removal of stumps of upper incisors and canines 74 30. — Telescopic gag or mouth prop, for use during in- halation of nitrous oxide 76 31. — Mouth opener, to be used with the administration of chloroform . 77 ERRATUM. Page 45, line 3 from bottom, and page 56, last line, for Rhizodon trophy read Rhizodontropy. DENTAL SURGERY. Chaptek I. THE FIBST DENTITION. Eruption of Temporary Teeth. Lancing the Gums. Absorption of Temporary Fangs. When to Extract Temporary Teeth for relief of Irregularity. Undesirability of Extracting Temporary Teeth. Ulceration through the Gums of Temporary Fangs. The temporary teeth are twenty in number, and their eruption usually begins and ends between the ages of six months and two and a half years. The following table gives the order and times of cutting of the various mem- bers of this series. The 2 Lower Central Incisors, about 6th Month. „ 2 Upper ,, ,, „ 8th „ ,, 2 Lower Lateral ,, „ 10th „ „ 2 Upper „ 12th „ ,, 4 1st Molars ... „ 16th „ ,, 4 Canines ... „ 20th ,, ,, 4 2nd Molars ... „ 30th ,, The protrusion of the tough unyielding gum by a grow- ing tooth is apt at times to be attended with much suffer- 2 DENTAL SURGERY FOR ing, evinced by a greatly increased flow of saliva, with febrile symptoms and convulsive movements. Belief may be then afforded by passing a well protected lancet through the whitened nodule of gum down to the erupting crown. Such an operation should, however, be performed only when the mucous membrane of the mouth is in a healthy condition, and when also it is quite evident to the sense of touch, that the cutting edge of the new tooth is bound down by the tense and fibrous gum. At the age of four years absorption of the fangs of the temporary teeth commences and those of the incisors are first attacked. This process, in its nature purely vital and in no way mechanical, is brought about by the action of the Absorptive Papilla, a mass of many nucleated cells that lies closely behind and eating into each temporary fang, and intervening between the latter and the crown of its permanent successor. A growing permanent tooth is placed immediately behind and beloiv the fang of each temporary incisor and canine, while underneath each temporary molar, and embraced within its widely diverging fangs, is the crown of the bicuspid that is to take its place. A knowledge of the latter fact is of value when it becomes necessary to extract a temporary molar, and the forceps should then be applied with caution and not thrust deeply into the alveolus, lest the permanent be taken out with the temporary tooth. It is not often necessary to extract a temporary tooth to make room for its permanent successor, since the rapid development of the jaw and consequent expansion of the alveolar arch that occurs during childhood tends to per- GENERAL PRACTITIONERS. 3 mit permanent teeth to fall into their normal situations, al- though at the time of, and shortly after their eruption, they may have been crowded out of line. Under these circum- stances, however, the extraction of a temporary tooth for the relief of irregularity may become necessary. If such a tooth or its decayed fang be retained considerably after the time at which it should normally be shed, while an un- usual degree of fixity in its socket shows that the action of the Absorptive Papilla upon its fang has been but slight ; if also the eruption of the crown of its permanent successor has well advanced, while the line in which the latter is growing diverges considerably from its normal direction ; if these conditions be present the obstructing temporary tooth may with advantage be removed. It becomes quite necessary that this should be done when the irregularity Fig. 1. Diagram from a cast of the upper jaw of a neglected mouth iu a child aged eight. The four permanent incisors have erupted, so that they bite within and behind the lower teeth when the mouth is closed. The four temporary are unduly retained with their fangs but slightly absorbed. b2 4 DENTAL SURGERY FOR occurs among the upper front teeth, for if a permanent Upper Incisor or Canine be allowed to grow so irregularly that when fully erupted it bites behind the lower teeth, it becomes necessary to adopt a course of tedious dental treatment that might have been avoided by a timely re- moval of a temporary tooth. The temporary molars are prone to early and rapid de- cay ; their dental pulps are large, highly sensitive, and ready, as the result of such quickly advancing caries, to take on a j)rocess of destructive inflammation, thus becom- ing rapidly devitalized and decomposed. The treatment, however, of decay with its sequelae among temporary and permanent teeth must be referred to later on. Suffice it now to say that a badly developed and carious set of per- manent teeth does in no way necessarily occur in a mouth which may have been conspicuous by the faulty character of its milk teeth. Also it should be noted that temporary molars should never be extracted save as a last resource and when every attempt to relieve pain by other means has failed. Small cavities occurring in them, should if possible be filled before decay has encroached greatly upon their walls, and in so doing it is well always to avoid caus- ing pain to the child. Carious dentine and enamel should be very lightly removed, and for the stopping of the cavity such a material as gutta-percha gently warmed over a candle flame, or cotton wool that has been dipped into a solution of gum mastic in alcohol, answers admir- ably. Decay when more advanced, with death of the pulp resulting, may necessitate other treatment; but always this should be remembered, that a broken down temporary GENERAL PRACTITIONERS. 5 molar, if only it be not causing pain, is better than none at all and may be invaluable to the child for the mastica- tion of its food and the due nutrition of its body. It has been said that it is occasionally necessary to ex- tract temporary teeth to prevent irregularity. Under these conditions also they may require to be removed ; when as the result of the absorption of the posterior surfaces of their fangs, the sharp ragged ends so resulting have ulcerated through the gum and have wounded the lip or cheek. The laceration and inflammation of the soft parts is apt to be more severe when it results from a lower than when caused by an upper fang, owing to the greater mobility of the tissues around the former. The trouble of course ceases as soon as the cause is recognised and removed, but the condition should be carefully noted, lest it be wrongly attributed to necrosis and exfoliation of a portion of the maxilla. DENTAL SURGERY FOR Chaptek II. THE SECOND DENTITION. Order of Ekuption of Permanent Teeth. Eruption of Wisdom Teeth. Diagrams of Teeth at Three Periods of Childhood. How to distinguish between Temporary and Permanent Teeth. The order and times of eruption of the permanent teeth are as follows : — The 4 1st Molars at about the 6th year. ,, 2 Lower Central Incisors ,, 2 Upper ,, 4 Lateral Incisors ,, 4 1st Bicuspids „ 4 2nd „ 4 Canines ,, 4 2nd Molars „ 4 3rd Molars As a rule but little local or general disturbance attends the eruption of the permanent teeth. They grow up be- hind their temporary predecessors which in due course become loosened and are shed. And thus the process is quietly effected without attracting much notice. The cutting of the lower wisdom tooth is often, however, 71 5) ?? 7 8th , ?» ? 9th , 73 3 10th , 33 7 11th , 77 3 , 12th , 73 7 , 13th , 73 3 , 20th , GENERAL PRACTITIONERS. 7 attended with a good deal of suffering. A flap of gum is lifted up by its growing crown and between this last and the upper second molar the gum structure is liable to be bruised during mastication. Belief may at times be given by incising the constricting tissue and by touching the in- cised surface lightly with nitrate of silver. Usually the pain and inflammation subside in the course of a few days, and the treatment of such cases may generally be limited to the use of hot fomentations inside the mouth. If, how- ever, the erupting third molar be impacted between the base of the coronoid process and the back of the second molar its Fig. 2. At the age of three years showing the ten upper temporary teeth. Two Temporary Central Incisors. ,, ,, Lateral „ ,, ,, Canines. ,, „ 1st Molars. ,, ,, 2nd Molars. extraction may become necessary, and if this be found to be quite impracticable it may be needful to remove the second molar to give relief. It should of course be borne 8 DENTAL SURGERY FOR in mind that a second molar is perhaps more useful and durable than any other tooth in the mouth, so that its ex- traction should be regarded as quite a last resource. The accompanying diagrams represent the upper teeth at three characteristic periods of childhood. Fig. 3. At the age of seven years, showing the ten above mentioned temporary teeth, and also the recently erupted 1st permanent or six year old molars. Two Temporary Central Incisors. ,, „ Lateral „ ,, „ Canines. „ „ 1st Molars. ,, „ 2nd Molars. ,, Permanent 1st Molars. The need for being able to decide on examining a mouth, whether any given tooth be temporary or permanent is evident. As a rule there is no difficulty in so doing. The permanent incisors are larger and more yellow in tint than those of the milk dentition, while their cutting edges are serrated for a year or two after eruption. Later on the GENERAL PRACTITIONERS. 9 serrations become obliterated, as occurs among young milk teeth which are soon worn smooth by the friction of eating. The bicuspids can not easily be mistaken for the temporary Fig. 4. At the age of thirteen years, showing the fourteen upper permanent teeth. All the temporary teeth have been replaced by their ten corres- ponding permanent ones, and also the 1st aud 2nd permanent molars have been cut. The six temporary incisors and canines have been replaced by the six permanent incisors and canines ; and the four temporary molars have been replaced by the four bicuspids. Two Permanent Central Incisors. ,, Lateral ,, ,, Canines. ,, 1st Bicuspids. ,, 2nd Bicuspids. ,, 1st Molars. ,, 2nd Molars. molars which they replace, but it is well to guard against extracting a permanent canine tooth under the impression that it is the corresponding temporary one, and also the first permanent molar should not be mistaken for the second temporary one. 10 DENTAL SURGERY FOR Chapter III. ABNORMALITIES IN DEVELOPMENT OF PERMANENT TEETH. Retarded Eruption. Supernumerary Teeth. Abortive Teeth. Dilacerated and Geminated Teeth. Honey- combed and Syphilitic Teeth. Retarded eruption. — The cutting of a permanent tooth may be delayed long after the normal time, or its absence may continue through life. To teeth thus buried and but partly developed have been attributed myeloid and other growths which have been found within the maxillae in their neigh- bourhood. Whether it be true or not that such tumours have arisen from such causes, the author is unable to say, but he is inclined to believe the dental irregularity to have been merely a coincidence with, or even a result of, the pro- gress of the diseased growth. At times an incisor or canine tooth may remain throughout life embedded in the the palatine process of the upper maxilla or but partially erupted from its lower surface. A lower wisdom tooth has been removed from the cheek, near the angle of the jaw, where its late eruption caused much distress and deformity. Irregularity in excess of the normal number. — Such addi- tional teeth are Supernumeraries. They are usually found in the front of the mouth, in the neighbourhood of the upper GENERAL PRACTITIONERS. II permanent incisors, among which by their presence they may cause a good deal of irregularity. Supernumerary teeth are more or less conical, with stunted fangs. As a Fig. 5. Diagram of a model of the right side of a lower jaw aged 36. All the lower permanent teeth are erupted with the exception of the 2nd bicus- pid. The 2nd temporary molar is retained and serves to illustrate the difference in level between the temporary and permanent series. Fig 6. Diagram of a mouth aged 13. In the front of the mouth are two super- numerary teeth which are displacing permanent incisors from their rightful positions. 12 DENTAL SURGERY FOR rule it is well to extract them, if by their presence they are causing the normally developed teeth to take up improper positions in the dental arch. Abortive Teeth. — A tooth though normally placed in the series may be irregular in form. Annexed is a drawing of a permanent central incisor, or of what corresponded there with, which was removed on account of its deformity from a patient in the dental department of the London Hospital. Fig. 7. Further as the result of developmental irregularity, the long axis of a tooth may be bent at an angle near its neck, when it is said to be dilacerated. Also two adjacent teeth may be geminated, or united by their adjacent surfaces, the union being sometimes so complete that they have but one common pulp cavity. Fig. 8. Two lower temporary incisors united by cementum on their adjacent sides. Certain structural defects may be evident among all the teeth of the permanent series. GENERAL PRACTITIONERS. 13 Honeycombed or Strumous Teeth. — The incisors and first molars most often present the appearance of such. These are dark-yellow in colour and deeply pitted or ridged transversely upon their surfaces, as though the deposition of enamel had been injuriously affected during the develop- ment of the organs. The inheritance of a strumous dia- thesis, or overdosing with mercury in early childhood, have both been said to have induced this condition, but its cause is still obscure. A careful distinction must be drawn between this and the following abnormality. Syiihilitic or Specifie Teeth. — These, the result of inherit- ance of the syphilitic taint, show the following well marked characteristics : — One crescentic notch in the middle of the cutting edges of the upper and lower permanent incisors. These teeth are also separated from each other ; are of dark colour, and of peg-top shape. The development of the bicuspids and molars is also modified, but the central notch of the incisors is most typical of the diathesis. The temporary teeth of children with syphilitic parentage pre- sent no peculiar traits. The annexed two diagrams are Fig. 9. Fig. 10. ''iii u ,i;.ii'lwiiiuii'»- Syphilitic Incisors. Honeycombed Incisors. from drawings by Mr. Hutchinson, and show the features of typically marked honeycombed and syphilitic permanent upper central incisor teeth. 14 DENTAL SURGERY FOR Chapter IV. IEKEGULABITY IN THE POSITIONS OF THE PEKMANENT TEETH. Cause of Irregularity Among Teeth of the Present Time. Treatment of Irregularity by Extraction and the eegulating plate. symmetrical extraction. Six Common Forms of Irregularity : — 1. Underhung Incisors ; 2. Kotated Incisors ; 3. Projecting and Diverging Incisors ; 4. Projecting Canines ; 5. The V-shaped Dental Arch ; 6. Irregular Articulation of Upper with Lower Teeth. The Excavator and the Mouth Mirror. Irregularity in the arrangement of the permanent teeth is among civilized races greatly on the increase, and its cause may be found in the lessened work thrown up6n the organs of mastication by the appliances and requirements of modern life, whence results decreased development of both teeth and jaws. But while the shape size and number of the teeth has not undergone much change, with the exception of the wisdom-tooth which is now more variable and less developed than in skulls of earlier date, we find that the development of the maxillary bones is frequently far less complete than in the older periods of man's history. So, with a stunted alveolus and GENERAL PRACTITIONERS. 15 teeth of normal size, overlapping and crowding of the latter too often ensues. Such irregularities are so varied that an altogether satis- factory method of classifying them is not very practicable. The common and typical deformities are therefore only described and it must be noted that any one may co- exist with other forms. Irregular and overlapping teeth when occurring in the front of the upper jaw are more unsightly than when they are found in the lower, but under all cir- cumstances it is desirable that the teeth should be evenly arranged in the maxillae. Behind projections and between overlapping teeth the food that always collects and is apt to escape the cleansing action of the tooth brush will cer- tainly decompose and thus favour the attack of caries. For the curing of irregularity, we have two methods of treatment which may be applied singly or combined ; we may extract teeth to give additional room, or we may em- ploy a regulating plate to produce a like effect by forcing the teeth outwards and so expanding the dental arch. If extraction alone be practised these points should be noted. The front teeth, and especially the canines, should if possible be spared, since the loss of the two upper eye teeth is apt to alter the appearance of the face by the considerable absorp- tion of alveolar process that follows their extraction and the consequent sinking in of the angle of the mouth. The canines moreover have more value for purposes of mastica- tion than other front teeth, since they are less liable to decay and are more firmly implanted in the alveolar sockets. Before deciding which teeth may best be spared careful ex- amination of the mouth with the assistance of a fine exca- vator and a mouth mirror should be made. l6 DENTAL SURGERY FOR If all bicuspids and molars be well developed and free from decay then the best and speediest mode of curing the irregularity may be by the removal of the two upper and possibly also of the two lower first bicuspids. But if as is more likely to be the case, decay be present among the first permanent molars, two or four of these should be ex- tracted. It is upon these teeth that the choice will pro- bably fall since, from a cause that has not yet been ascertained, dental decay is more prevalent and commences earlier among the first molars than among other teeth. Such extraction should be practised symmetrically. If an upper molar or bicuspid on one side be removed, then also the corresponding tooth on the other side of the mouth should be taken out ; or if of the four six-year-old molars, or of the four 1st bicuspids, two only, an upper on the right and a lower on the left, be decayed, or if three of the series be carious and the other sound, then the extraction should be completed as regards all four corresponding teeth. Thus from a timely and judicious symmetrical extraction will often follow a natural and symmetrical regulation of the crowded front teeth, and the forces tending to bring this about are the continuous pressure exerted upon the dental arches by the lips and muscles of the face and the tongue. If then it be advised to part with four 1st molars, the time most suited for such extraction is that at which the four 2nd, or 12-year-old, molars are just erupting. The latter then advance and in two years time the spaces resulting from extraction are nearly obliterated. Although the re- moval of four decayed first molars may hardly serve of it- self to materially alter the positions of much overlapping GENERAL PRACTITIONERS. 17 front teeth, yet the additional room thus gained in the mouth can not but be salutary, since the increase of the irregularity from the pressing forward of erupting and ad- vancing back teeth is certainly arrested. Also the more perfect cleansing and polishing of the sides of bicuspids and molars which is rendered practicable by the slight separa- tion that ensues among them conduces very greatly to their ultimate preservation from caries. The regulating plate, usually of vulcanite or gold, is con- structed by the dentist to a plaster model of the jaw with its contained irregular teeth. Such a plate carries elastic gold wires which looping over the outstanding teeth serve to draw them back into line, and also if needed it may con- tain small wooden pegs to press upon the posterior surfaces Fig. 11. Vulcanite regulating plate for treatment of irregularity among the upper front teeth, showing the gold wires and wooden pegs referred to. of back-standing teeth. Thus by the forcing of these out- wards the dental arch is expanded and increased room ob- tained for the reduction of any irregularity. c l8 DENTAL SURGERY FOR During the wearing of all regulating plates great cleanli- ness should be observed ; the teeth being brushed with soap and water each morning and evening, and the plate being taken from the mouth after every meal to be brushed in like manner on both surfaces. If this be done a regu- lating plate may be safely worn for several months, but if it be omitted the acid produced by decomposition of food and saliva will shortly soften and erode the crowns of the teeth. The irregularities most often met with are as follows : — 1. One or more permanent incisors may be erupted con- siderably behind the line of their neighbours, as the result of undue retention of temporary teeth (vide fig. 1, Chap. I). This may be prevented by the judicious removal of the latter when required, but if the abnormality happen to upper front teeth these may be found to be underhung, or to bite be- hind the lower incisors when the jaws are closed. In this last case a regulating plate (vide fig. 11) mus be worn for three or four weeks, which shall force out with the aid of steel screws, or a series of wooden pegs each longer than its predecessor, the back- standing tooth or teeth. That this may be effected the jaws must be kept a little apart by carrying the vulcanite plate over the masticating surface of the molars and bicuspids, and but a short course of such treatment will be needed to push forward, the back- standing upper incisor, so that its lower antagonist shall close be- hind rather than, as was the case before treatment com- menced, in front of it. As soon as this changed condition is brought about the regulating frame may be left off, since the misplaced tooth cannot relapse into its old posi- GENERAL PRACTITIONERS. 19 tion, and the closure of the lower jaw upon the upper will shortly induce a symmetrical arrangement of the upper front teeth. 2. An incisor tooth may be partly rotated on its long axis (videftg. 12). This should be treated with a regulating plate constructed to draw back, by the aid of a gold wire, the projecting margin, and with a wooden peg to push out the side of the tooth that is so rotated inwards. A few years back it was not unusual to forcibly turn such teeth into proper position with the aid of forceps. This course is not to be recommended, as the disruption that it causes to the nerves and vessels entering the tooth at the end of its fang is very liable to induce death and early loss of the organ. Fig. 12. Model of upper jaw with rotated incisors. 3. The upper incisor teeth may be widely spaced and divergent (vide fig. 13). Such cases are best treated by the dental surgeon, who, if there be no obstacle to regu- lation, such as a pressure upon then back surfaces of the lower incisors, may draw in two divergent centrals by j)lacing around their necks a thin elastic band. It must be noted that such treatment needs close watching, and c2 20 DENTAL SURGERY FOR the band must be prevented from forcing itself up the necks of the teeth beneath the gum by attaching to it one or more gold wire loops, which may be hooked over the cutting edges of the teeth that are being operated upon. If this be neglected the latter will certainly be loosened and will probably be lost. Model of upper teeth with widely spaced and divergent incisors. 4. The canines may greatly project while the incisors are overlapping (vide fig. 14). This is a very common form of irregularity, and is doubtless favoured by the later eruption of the eye-teeth, as compared with that of the incisors and bicuspids, whereby the former find the spaces into which they should normally fall in the dental arch closed to their admission by the approximation of the lateral incisors with the first bicuspids. In such an irregularity much improve- ment may be hoped for with time and during that growth and expansion of the maxillse which continues for a few years after the canines are erupted. Should this, however, seem insufficient to provide such space as may be required by the projecting eye-teeth it will be necessary to extract GENERAL PRACTITIONERS. 21 first bicuspids, and into the gaps caused by their removal the former will in all probability be conducted by the gentle but continuous pressure upon then outer surfaces of the muscles of the lips and cheeks. More complete symmetry may with certainty be given to the dental arch if, in addition to extraction of bicuspids, a vulca- nite regulating plate be employed for a few weeks to draw back the canines, and at the same time to push out into a symmetrical curve the irregular and crowded incisor teeth. Fig. 14. Model of upper jaw, aged 14 years. The canines are projecting but these were subsequently drawn backwards and inwards by a dental plate into the spaces caused by the removal of the first bicuspids. At the same time the four incisors were pushed slightly outwards by wooden pegs connected with the frame. The model was taken a month after re- moval of the two 1st bicuspids. 5. A V-shaped dental arch may be combined with a deeply vaulted palate {vide fig. 15), and this form of irregu- larity is often associated with congenital idiocy. The upper 22 DENTAL SURGERY FOR teeth are here found to be arranged along two more or less straight lines converging towards and meeting at the front of the mouth. Treatment should go in the direction of expanding the arch by regulating plates, and of gaining additional room by a judicious thinning out of bicuspids or first molars. Fig. 15. Model of a V-shaped upper jaw. This was co-existing with a vaulted palate and idiocy of a congenital nature. The V-shaped arch, and the form of irregularity to be next described, are frequently transmitted by inheritance, and it is not unusual to find a like defect among all the children of parents presenting either of these deformities. It cannot be disputed that such errors in maxillary develop- ment are infinitely more frequent among civilized than among savage races, and though the V-shaped arch and a deeply vaulted palate may co-exist with well developed cerebral organs, yet, as Dr. Langdon Down has pointed out, (Transactions of Odontological Society, 1871), it is extremely GENERAL PRACTITIONERS. 2$ common to find such well marked defects in the mouths of congenital idiots, and this, as the same authority ha- si : i, possesses practical value. Given a V-shaped arch and vaulted palate in the mouth of an idiot, we may assume that the defective development in mouth and brain results from a cause which acted prior to the birth of the patient ; that the idiocy was congenital. If, on the other hand, a nor- mally developed mouth co-exist with idiocy it is probable that the latter was acquired after birth. Concerning the treatment of the former a more favourable prognosis may be given, since a brain imperfectly developed is more amenable to treatment than one whose functions have been impaired by some grave lesion induced after birth. 6. In a less common fomi of irregularity, which like the Y-shaped arch is frequently hereditary, we find the cutting edges of the lower incisors set at a level higher than that of the grinding surfaces of the lower bicuspids and molars. Ab a result of this the upper incisors are gradually bitten out and loosened by the pressure upon their backs of the lower teeth whenever the jaws are closed. In a case such as this. lately under treatment, the only plan that promised ultimately to be successful in prevent- ing the loss of the two upper central incisors was to adapt a thin gold plate to the grinding surfaces of the lower masti- cating teeth, and thus the lower front teeth were kept out of reach of the upper ones which they were rapidly destroy- ing. Before the wearing of this plate, which served only to prevent increase in the irregularity and in no way tended to reduce it. a prolonged but quite unsuccessful attempt to improve the positions of the upper and lower teeth had 24 DENTAL SURGERY FOR been made. The four first bicuspids had been removed ; the lower incisors had been slightly shortened by filing away a little from their cutting edges ; the lower incisors with the lower canines had been drawn back by a vulcanite regulating plate ; this being effected, the projecting upper incisors and canines were then drawn in by the continuous and gentle contraction of an elastic band passed round the back of the head and attached to each end of a narrow gold band that impinged upon the front surfaces of the six projecting upper front teeth. By this prolonged treatment the irregularity was almost entirely cured, but on discontinuing the apparatus the case unfortu- nately relapsed into something much like its first con- dition, through the renewed pressure upon the backs of the upper front teeth of the cutting edges of the lower ones. From this it may be inferred that malformations of this nature are less amenable to treatment than those spoken of before. Fig. 16. An excavator for use in examination of teeth and preparation of cavities. The Excavator (videfLg. 16) should be strong and well tem- pered, so that it may neither readily bend nor break. While the operator is conveying it towards the patient's face and into his mouth, its cutting edge should be pressed firmly against the end of the second finger, that there may be no chance of wounding either face or eyes by any incautious GENERAL PRACTITIONERS. 25 movement on the part of the patient. The excavator may be used as a probe to search for half concealed stumps, or to explore a cavity in a carious tooth. In doing the last Fig. 17. A mouth mirror for use in examination of the teeth. guard against wounding a sensitive dental pulp and so in- flicting much unnecessary pain. Also the excavator may be employed to prepare a cavity for the reception of a 26 DENTAL SURGERY FOR gutta-percha or other stopping by cutting away softened and decayed tooth structure. It may be used to carry into the mouth a dressing of absorbent wool, which may be used as a mop to remove blood or saliva from the part to be operated upon. Also the excavator is of great value in enabling us to learn if the tooth to be extracted is rigidly implanted in the maxilla or is at all moveable. When used thus, the instrument, which should be a specially strong one, should rest upon a solid part of the crown of the tooth, and thus, with a very small amount of force, most teeth may be slightly moved laterally to and fro. Such mobility may teach the operator that no special difficulty is to be expected in the removal of the tooth ; but if the latter be glued down into its socket by inflammatory exudation, or if its fangs be solidly implanted in a massive and unyielding maxilla, we shall not succeed in producing any movement of its crown by manipulation with the excavator. The Mouth Mirror (vide fig. 17) is of value when it is desired to reflect a ray of light upon some obscure situa- tion in the mouth, and also for showing cavities in the backs of molar teeth. It is well before its use to slightly warm it in hot water, or over the lamp, in order that its face may not be clouded by moisture condensed from the breath. GENERAL PRACTITIONERS. 27 Chapter Y. DENTAL CAEIES. Tendency of Teeth to Become Kudimentary. Local and General Causes of Decay. Two Varieties of Caries. Liability of Various Teeth to Decay. General Directions as to Treatment of Caries. Symptoms and Treatment of Caries in its First Stage. Caries in its Second Stage, with Antiseptic Treatment of the Pulp Cavity and Symptoms and Treatment of Periodontitis and Alveolar Abscess. Caries in its Third Stage, with Contraction of Temporo- Maxillary Articulation and Fistulous Opening Through Cheek. Dental decay is far more prevalent among the civilized races of the present day than among the aboriginal tribes of Africa, America, and Australia ; also an examination of ancient skulls proves it to be one of the incidents of advanc- ing civilization. This is the outcome of several causes : such as the preservation of the weakly and their greater re- production that now obtains ; the general lessening of bodily vigour and development that is apt to go with increased men- tal cultivation ; and the smaller need for dental organs that comes from improvement in the quality and preparation of modern food. It is perhaps not easy to say what degree of value should be set upon this last, but certain it is that the teeth and jaws of to-day have far less work thrown upon them than in times when man lived upon roots and imper- 28 DENTAL SURGERY FOR fectly prepared coarse flesh, and we may assume that the development of the teeth, as of other organs, varies with the amount of labour they are called upon to perform. The frequent absence of one or more third molars, their often late eruption, and their commonly dwarfed size ; the in- crease of dental caries ; and the tendency to early shedding of the teeth from absorption of their alveolar sockets, all suggest that the dental organs of civilized man are tending to become rudimentary. The local conditions predisposing to decay are twofold ; defective development of dentine and enamel, and abrasion and crushing of the latter from overcrowding of the teeth. If either condition be present the tooth, like a badly built house, admits moisture into its interior. The evidence of defective development may be found in those linear cracks between the cusps of molars and bicuspids, or uj>on the back surfaces of upper lateral incisors, which a careful scrutiny will often reveal shortly after their eruption. The abrasion of enamel which favours decay occurs in crowded mouths upon the lateral surfaces of bicuspids, which by their slight mobility during mastication are ren- dered liable to such injury. With such defects present in the structure of a tooth it is certain that saliva and debris of food will find their way into its interior, there to decom- pose and generate those acids which serve to dissolve out its lime salts. Dental decay consists essentially in the solution and separation of the earthy or inorganic salts of a tooth, from its animal matrix, and chiefly of this last does carious dentine consist. The reaction of the latter is markedly acid to litmus paper, and microscopic examina- GENERAL PRACTITIONERS. 20, tion reveals upon its surface, and within its tissue, a copi- ous development of the cryptogam, Leptothryx Buccalis, the sporules of which penetrate into and between the den- tinal tubules. Although the existence of this is perhaps not essential to decay, since a healthy tooth may be decal- cified by immersion in acetic acid, yet we may believe that the growth of the cryptogam favours the decomposition of the dentine by exercising upon it such a catalytic action as is induced by the introduction of the yeast plant into a saccharine solution. The dentine of a tooth is always more prone to decay than its enamel, and while the latter is solid and free from defects a tooth will always withstand such injurious influence as may be brought to bear upon it. As a rule decay radiates throughout the dentine from the bottom of enamel flaws, and the presence of mischief is often not revealed by pain or other symptoms until the force of mastication crushes in the roof of enamel that arches over a mass of yielding and disintegrated dentine. Caries will at times take another form and appear as a general softening of enamel and dentine around the necks of various teeth. Such a condition is apt to occur about the middle period of life when the recession of the gums and commencing absorption of the edges of the alveolar plates expose to the action of the saliva the softer and less durable cementum that coats the fangs. The tendency to caries shown by various teeth differs greatly. Those most liable to it are the four six-year-old molars, and of all decayed teeth extracted by the operator about one third will belong to this series. Those least liable to this disease are the four lower incisors and two 30 DENTAL SURGERY FOR lower canines, but why the development of the six last should be more complete than that of the four former is at present unknown. The fact, however, remains and to it we may attribute their far greater longevity. With the condition of the health generally the tendency to decay naturally varies, and so our efforts to combat the latter should be both general and local in their nature. The local treatment of a carious tooth should have a double aim; firstly, to relieve the toothache which is usually the exciting cause of our patient's visit ; secondly, to preserve the tooth usefully and to retard or prevent the extension of caries. It is evident that the insertion of gold fillings, which is usually the most successful way of effect- ing the last, is as much outside the work of a medical practitioner as is the making of plates for artificial teeth. Indeed, the filling of a tooth with any material, be it oxy chloride of zinc, amalgam, or gold, in such a way as to make a perfectly water-tight durable plug that shall with certainty prevent any extension of disease for a number of years, must come within the scope only of such practi- tioners as devote their whole time to such work. Still much remains that a doctor may do for a patient who is unable to visit a specialist. He may by treatment of the tooth, or its extraction, relieve pain, and he may usefully prolong its existence, though he can hardly hope to per- manently save it, by carefully filling the carious cavity with a plug of gutta-percha or wool and mastic. The course of dental caries varies greatly in duration with the habits, health, and age of the patient, being most rapid for a few years after the attainment of puberty. GENERAL PRACTITIONERS. 31 We may divide it into three stages. Each of these condi- tions presents well-marked and unvarying characters, and familiarity with them is the more necessary since treatment that serves to relieve pain from caries in its first stage would, if adopted in the second, make matters very much worse. Caries in its First Stage. Symptoms. — The first stage of caries endures until the dental pulp or any portion of it has become gangrenous. The patient complains of severe intermittent pain, in- creased and induced by cold water, hot fluids, the sucking of air from the carious cavity by the tongue, and the pre- sure of food within it during mastication. Frequently the carious and aching tooth cannot be exactly indicated by the sufferer. Pain, as he says, flies round the teeth so that he hardly knows which is in fault. Careful examina- tion with the aid of a mouth- mirror, and an excavator carrying a small dressing of absorbent wool, will usually reveal a cavity of moderate size in some tooth around which pain seems to centre. Our examination shows : — 1. The tooth is not discoloured. 2. Pain is not complained of when a moderate pressure is made upon a sound por- tion of its crown with a strong blunt pointed excavator, and the absence of such pain shows that the tissues out- side and embracing its fangs are in a normal condition. Guard, however, against being deceived by the starting and flinching in which nervous patients will indulge at the moment of contact of the excavator with the tooth. A 32 DENTAL SURGERY FOR good plan is to test other teeth near the suspected and carious one before coming to the latter. 3. Most acute and darting pain is felt when the edge of the excavator is inserted into the decayed dentine in the floor of the cavity, or when the dressing of wool is wiped across its surface. Be it remembered that this should be very cautiously and gently conducted, the walls and floor of the cavity being stroked rather than cut with the instrument, since intense pain may readily be caused and the dental pulp, if not ex- posed by the progress of decay, may be thus accidentally laid bare. 4. The crucial test, to ascertain if the nerve be still alive and sensitive, i.e., if the caries be still in its first stage, may now be applied. Inject from the nozzle of a small syringe three or four drops of cold water into the cavity in the tooth. This will cause severe though momentary pain, but before inflicting it the patient should be cautioned that what is about to be done will probably produce this re- sult. These four conditions then ; the absence of dis- colouration, the absence of tenderness on pressure upon the crown of the tooth, the sensitiveness of the decayed dentine, and the pain caused by injecting cold water, go to show that the nerve is alive and in a normal, though per- haps irritated condition, and that the first stage of caries still continues. * Tkeatment. — The cavity small and nerve not exposed, or ex- posed by only a small opening through the wall of thejjuljj cavity. Carefully examine the bottom of the cavity to learn if the nerve be exposed, which, if such be the case, may be seen as a bleeding highly sensitive spot. If this be not evident, or if the point of exposure be very minute and the cavity GENERAL PRACTITIONERS. 33 of small or moderate size and so situated in the tooth that a plug of wool if inserted will be retained, a temporary filling may be applied. Before doing this all irritating particles of food should be washed from the cavity by syringing with warm water, and its walls and floor should be dried by gentle wiping with a dressing of absorbent cotton-wool upon the end of an excavator. The filling may consist of Wool with Carbolic acid, Wool with Tinc- ture of Mastic, or Gutta-percha. The first may be used if the walls of the cavity are very sensitive, if the nerve be exposed by a minute puncture, or if the tooth be aching at Ihe time of treatment. It may remain in for a day or two and then be replaced by a similar dressing ; after which, if tenderness be lessened, a wool and mastic, or gutta- percha filling, may be inserted. In applying the carbolic dressing the end of an excavator should be rotated within a small piece of cotton-wool held between the thumb and fingers. The wool is thus rolled into a compact plug, the end of which may be dipped into a phial containing wool already saturated with carbolic acid. Thus only a small quantity of the latter is absorbed by the dressing, and indeed a larger application is undesirable as it is apt to excoriate the gums and cheek. Care should be taken that the plug is not inserted with so much force as to cause pain by pressure upon a nerve possibly exposed ; and sometimes when the application of carbolic acid fails to soothe an aching dental pulp relief may be readily obtained by the substitution for it of thymol or eucalyptin. The wool and mastic plug may be inserted when the cavity has only slight tenderness. In applying it, the end D 34 DENTAL SURGERY FOR of an excavator should be armed as before with a little cotton-wool, which may be dipped into a strong solution of gum mastic in alcohol, after which a little dry wool should be wrapped around the plug. This may be intro- duced into the cavity, which has previously been washed out and dried, and maybe allowed to remain for a few days, after which it is apt to acquire an offensive odour and should be changed. The gutta-percha filling may be used under such conditions of the tooth and cavity as make a wool and mastic plug possible, and it is more durable and less absorbent of the fluids of the mouth than the last. Its durability will be greatly increased if, after washing and drying the cavity as before, a sharp excavator be carried round the walls of the cavity, removing the softened dentine until the underlying hard tooth structure is reached. In so doing- care must be taken to cause but little pain, and not to expose the dental pulp. To avoid this last, operate only on the edges of the cavity, leaving untouched on its floor the carious tissue. The gutta-percha, having been warmed over a candle flame, should be inserted while soft, and while only so hot that it may be applied to the back of the operator's hand without causing any pain. If the cavity be dry while it is being filled, and if such a stopping be in con- tact all round with hard walls, it may endure for some years ; but be it remembered that the durability of any stopping is proportionate to its faculty for excluding moisture. In this connection reference to gold, amalgam, and oxychloride fillings is purposely omitted, such materials having no value save in the hands of those trained to their use. The employment of temporary plugs has, however, been GENERAL PRACTITIONERS. 35 treated of at some length, as such will often do good service in allaying toothache, and preventing for a considerable time its return, by their exclusion of food, cold air, and hot and cold fluids from the sensitive surface. The cavity large and nerve exposed. — Under these circum- stances it may be impracticable to retain a temporary filling in the tooth, either on account of its extreme sen- sitiveness and constant aching, or from the absence of such adjacent teeth, or overhanging walls to the cavity, as would prevent the plug from coming out during mastica- tion. Usually under these conditions extraction is the best course to adopt, but the health of the patient or other causes may prohibit this. The employment of arsenic is then indicated and should be thus applied. Equal parts of yellow soap and arsenious acid are to be well worked into a bolus, of which a pellet, as large as the head of a good sized pin, should be carried on an excavator into the bottom of the washed and dried cavity, as near as jjo-ssible to the point of exposure of the pulp. The pellet may be held in situ by a plug of wool, which should be removed after 24 hours and replaced with a wool and mastic filling. One application of arsenic generally suffices to devitalize a dental pulp, but sometimes a second and smaller piece may be introduced into the tooth after two or three days, if it be found still sensitive to cold water from the syringe. The pain caused by the action of arsenic on a pulp is generally severe for three hours and commences within half an hour of its application. After six hours the pain has generally quite departed, and the condition of the tooth so changed that the patient no longer dreads to inhale a d2 36 DENTAL SURGERY FOR deep breath of cold air or to brush the teeth with cold water. Thus, at the expense of a temporary increase in such toothache as he may have already long suffered, may be gained complete relief, and the tooth, though its exist- ence may not be prolonged, will no longer remain a con- stant source of pain. In applying arsenic guard against allowing the soft pellet to be squeezed out of the cavity, while the wool plug is being introduced, so that it is brought into contact with the surrounding gum. Thus much painful ulceration may be caused, and no beneficial action upon the aching dental pulp result. Guard also against using a pellet larger than the head of a good sized pin ; and also avoid its use altogether if decay has so far advanced that both walls, or the floor of the pulp cavity, are perforated so that the caustic should exert its destruc- tive influence upon the socket on the opposite side of the tooth. Caries in its Second Stage. The second stage of dental caries has been reached when the dental pulp, or any portion of it, has become gan- grenous, i.e., dead and decomposing. Such a condition always results from, decay when it is allowed to go on un- checked by natural or artificial means. A natural limita- tion of caries sometimes occurs when the disease in its progress reaches a substratum of solid, well- developed, non- absorbent dentine. Then we find the floor of the cavity composed of hard dark ivory, which shows no tendency to softening. The artificial means employed GENERAL PRACTITIONERS. 37 to permanently arrest decay consist in excavating and filling the tooth with some imperishable material, or in cutting out the decayed tissue and carefully polishing the resulting surface. As a consequence then of the advancing caries the pulp becomes irritated, aches, and at last takes on a process of destructive inflammation, by which after several hours of severe pahi its vitality is destroyed. Or this last condition may be reached more gradually and without any attack of severe pain. Here it may be noted that the vitality of a dental pulp may depart without any pre- existent decay and as a result of a generally depressed condition of the health ; or again it may be destroyed by a violent blow upon the tooth ; also by the action of arsenious acid em- ployed as before mentioned. The pulp having lost vitality will in a few weeks become putrescent, evolving the usual gaseous products of decomposition. The pulp cavity and the canals down each fang are now charged with a dark, viscid, fetid substance, from which gas is constantly es- caping by any opening that may exist through the wall of the pulp cavity. This opening may be found at the bottom of the original cavity of decay, the result of the softening and destructive action of disease upon the dentine, or it may have been made artificially by the excavator of the operator. Such is the usual course of events : — the putre- faction of a dental pulp follows its death, unless, when arsenic has been used to induce this, a careful antiseptic treatment has been employed. To achieve this, to destroy a pulp and to protect it subse- quently from septic change, a minute attention to these 38 DENTAL SURGERY FOR Fig. 18. details is needed. The central cavity and the fang canals should be cleared three days after the application of arsenic of all devitalized organic filaments by inserting and with- drawing minutely barbed and antiseptic ally treated steel instruments. The fang canals and central cavity should then be dried with absorbent wool, and should be filled with filaments of wool saturated with carbolic acid. These should be tightly coin- pressed within the tooth and allowed to re- main, while over them the permanent metal stopping is inserted. Thus the tooth may be made to last for many years, protected by the stopping from the advance of caries, and by the carbolised wool within it from the genera- tion of products' of decomposition ; its vitality being sustained through the membrane cover- ing the cementum of its fangs. In the absence of such antiseptic measures, the death of the pulp, whether it come from the advance of caries, from depressed state of general health, from traumatic cause, or from arsenical action, induces putre- factive change within the pulp cavity. So long as the evolved gas can escape freely into the mouth no special symptoms, beyond a disagreeable odour of the breath, result. If, however, there be no such opening through the wall of the pulp cavity, or if one that has tor for removing existed, or has been made, be plugged up by tal nerve. a particle of food, or by a filling of any kind GENERAL PRACTITIONERS. 39 inserted by the operator, we find at once, or within a few hours, a special and characteristic set of symptoms induced. The septic gas now collects within the pulp cavity, where it is pent up unable readily to escape, and it may cause very severe toothache within half an hour of the plugging up of the hole if there be a small portion of the pulp still alive in one of the fangs. To the pressure of such elastic vapor thus suddenly ap- plied to a dental nerve of which the upper part was gan- grenous while the lower half was alive and sensitive, and to no other cause, can I attribute the severe pain which I had an opportunity of observing within twenty minutes of the closure of an opening at the bottom of a carious cavity and leading into the pulp chamber from which a discharge was escaping from a semi-devitalized pulp. My opinion as to the mode in which pain was induced, and which always .occurred within a short time of the aperture being blocked by particles of food, was confirmed when the tooth was subsequently removed, when on splitting it open the deeper lying parts of its nerve tissue were found to be perfectly healthy, those nearer the surface being gangrenous. If, however, the pulp be entirely gangrenous throughout, the pressure of the pent up gas serves to force out some of the softened and decomposed nerve tissue through the openings at the fang extremities into the socket of the tooth. The extrusion of such septic particles into proxi- mity with the healthy membrane lining the socket serves in most cases to induce more or less severe periodontitis, the cause of which, when it is localized around one tooth, is al- most invariably such as has been indicated, and it is a 40 DENTAL SURGERY FOR tooth producing this condition which is popularly said to have " caught a cold." Periodontitis, then is in almost all cases preceded by the death and putrefaction of the whole of the pulp and the extrusion of putrescent particles through the openings at the ends of the fangs. My own experience induces me quite to dissent from the views of those who hold that periodontitis may result from extension of inflammation from an inflamed pulp within a tooth to the healthy tissue outside its fangs, and, in support of my view, I may say that I have never yet met with periodon- titis, attended with suppuration, around the fangs of teeth containing vital nerves. On opening into the pulp cavi- ties of such teeth as were causing periodontitis, their pulps have always been found to be in a decomposed state, and it is not evident how inflammatory action can extend, as has been asserted, from a tissue which is itself already dead. We find further evidence in support of the cause here assigned for the production of periodontitis, localised around one tooth, in the fact that the condition may be almost invariably relieved in a few hours by drilling through the walls of the pulp chamber, and so allowing the gas to escape into the mouth rather than through the fang ends. If the opening so made be accidentally or inten- tionally closed in the course of a day or two, the gas which collects within the pulp cavity will again force its way into the socket through the openings of the fangs, and thus acute periodontitis may be once more set up. It may be noted that the rheumatic diathesis, mercurial treatment, or a traumatic cause, may produce sub- acute inflammatory GENERAL PRACTITIONERS. 41 change within the maxillary socket ; but this may he dis- tinguished from periodontitis arising from putrefactive change within a pulp cavity. The latter is at first localized beneath one tooth, which is tender to pressure, often much decayed, and with pus escaping around its neck if the in- flammation in the neighbourhood of its fangs have pro- ceeded to the production of an alveolar abscess. Periodontitis thus caused by a process of putrescent inoculation may be acute or chronic. Symptoms of Acute Periodontitis. — 1. Dull, aching, contin- uous pain around a tooth which is usually much decayed. It must be noted, as has already been observed, that the pulp may die and decompose within a tooth that is in no way affected by caries ; so the presence of a cavity is not in- variable, and acute periodontitis may occur around the teeth of old persons, or of those in feeble health, or as a sequence to some injury that has devitalized a dental pulp. 2. The tooth is slightly raised from its socket and so stands above the level of its neighbours and to the patient feels " longer " than others. This comes from the swelling of the tissues inside the socket, whereby the conical fangs are slightly lifted out. From the same cause the tooth is rather loosened and may be rocked readily from side to side. 3. It is very tender on pressure and tapping, and this results from the communication of the force through the tooth to the highly sensitive and inflamed tissues around its fangs. In applying this test it is well to tap other teeth before the suspected one so that the element of nervousness may be excluded. 4. Our crucial test is to inject cold water with a syringe into the carious cavity, 42 DENTAL SURGERY -FOR which of course, as the nerve is quite dead, causes no pain. On cutting the decayed dentine very lightly with a sharp excavator there is also no pain produced, since there is no longer sensation in the tooth. If the instrument be used at all forcibly the patient will complain, but this comes irom pressure of the tooth into its inflamed socket, and cannot be mistaken for the acute pain caused by cutting the dentine of a tooth affected by caries in its first stage. 5. Around the fangs and within the socket a collection of pus soon forms, which discharges around the neck of the tooth, and with the formation of this Alveolar Abscess, as it is termed, relief from pain is generally experienced. The pain and inflammation may now subside, and the tooth may become fairly firm again, but while it remains in the mouth it is likely to cause again similar trouble, or to act as a source of chronic periodontitis. Treatment of Acute Periodontitis. — As a rule it is best to extract the tooth causing the mischief ; but relief may usually be given in an hour or two by opening into the pulp chamber through its walls at any part with an ex- cavator or sharp drill. By so doing the imprisoned gas, generated of the putrefaction that is going on within the tooth, is permitted to escape freely into the mouth, and so is no longer compelled to leak from the fang ends. The opening should be free, and kept patent by a filling' of dry cotton- wool, loosely inserted and changed daily. This treat- ment may be applied to such teeth as it may not be desir- able to extract, and relief from pain may be almost certainly promised. The decayed temporary molars of children may be so treated (vide ante Chapter I.), also among adults we GENERAL PRACTITIONERS. 43 may thus relieve inflammation around a tooth which may be valuable for appearance or mastication. Extraction, or opening into the pulp cavity, afford the only means of re- lieving acute periodontitis, and a slight consideration of the cause leading up to this condition will serve to con- vince of the absolute inutility of applying escharotics or counter-irritants to the gum overlying the affected part. A popular impression is apt to prevail as to the undesira- bility of extracting a tooth around the fang of which acute inflammatory action, or an alveolar abscess, is existing. This it may be said is quite erroneous. With the removal of the tooth that is the cause of the periodontitis, whether the latter be attended with the formation of matter or not, the pain and swelling in and around the alveolar structures will soon subside, and, if extraction be deemed desirable, the operation should be effected without any delay. Not infrequently a good deal of dull aching pain with a sense of tension and throbbing within the socket will follow the removal of the tooth. This may endure for two or three days unless relief be given by occasionally raising from the site of extraction with the point of an excavator the firm blood-clot beneath which sanguineo-purulent fluid is apt to collect and be pent up within the inflamed socket. This is a point of some importance and the patient, if un- able to obtain medical assistance daily, should be instructed to perform the operation for himself, using for the purpose the point of a pair of scissors or the end of a sharpened quill. Symptoms of Chronic Periodontitis. — The inflammatory action set up around the fangs may take a chronic form, 44 DENTAL SURGERY FOR though the cause is the same whether the periodontitis be acute or chronic, and relief may be given by similar treatment in both cases. The gaseous products of decom- position from the interior of the tooth leaking through the fang ends, with the purulent secretion that forms around it within its socket, escape through a sinus which usually opens through the outer alveolar plate and the gum covering it. The orifice of such sinus is marked by a small papilla, or gum-boil as it is termed, from which pus may be often found escaping in small quantities. The gum-boil may at times be found on the palatine mucous membrane over the inner fang of an upper molar, but as a rule it is placed on the outer surface of the gum. This condition may endure for several years, the gum- boil alternately coming and going, and the tooth slightly loosened in its socket and occasionally tender on pressure. An alteration in the colour of a tooth containing a decom- posed pulp is generally evident in the course of a few weeks from the time at which the latter became devitalized. The coffee- coloured fluid within the pulp chamber fills the dentinal tubules, stains the dentine, and its dark tint is apparent through the semi-translucent enamel. If then any tooth in the neighbourhood of which there is a gum- boil, and which is a little loose, and occasionally rather ten- der, shows on examination by daylight a darker tint than its neighbours we may safely conclude that its contained pulp is decomposed, and that a condition of chronic periodontitis is established around its fangs. In such a condition we often find a tooth containing a large stopping under which the pulp has died and decomposed, or in which the pulp GENERAL PRACTITIONERS. 45 at the time of stopping was devitalized by the operator with the aid of arsenic. It should be noted, however, that if such antiseptic precautions as have already been men- tioned be taken after the use of the latter there is but little fear that putrefactive changes within the tooth, and chronic periodontitis around its fangs, will be the sequel to its stopping. Such a mishap may generally be attributed to the neglect of such precautions, or to the imperfect manner in which they have been carried out. It is not unusual to find a tooth, which has for some years caused in the manner described a slight irritation within its socket and a gum- boil over its fang-ends, becoming eventually quiet and ceas- ing to trouble by the generation and extrusion of putrefac- tive products from its interior. Frequently, however, such teeth become gradually loosened and are shed, or by their becoming a source of pain their extraction is necessitated. Then their fangs are found to be rough and partly eroded towards then- extremities, around which also are adherent shreds of fibrous exudation. Treatment of Chronic Periodontitis. — Chronic periodontitis, whether it be caused by a carious tooth ; by a tooth sound as regards decay ; or by a tooth in which a stopping has been inserted, may be relieved by drilling or excavating an opening through the walls of the pulp chamber, or through the stopping as the case .may be. Such a hole may be minute, and may be drilled through the outer side of its fang on a level with the edge of the gum, an operation to which the name of rhizodontrcphy has been given. Thus a vent is afforded to the imprisoned gas, the irritation within the socket is usually allayed, and the gum -boil disappears 46 DENTAL SURGERY FOR and is absent so long as the opening into the pulp cham- ber remains patent. By a careful introduction of car- bolic acid or Condy's fluid into the fangs, if access can be obtained thereto, the putrefactive change may be partially arrested ; but such an operation can at the best be only im- perfectly performed, and the dentinal tubules, charged as they are with fetid organic matter, remain inaccessible to the agents and instruments of the operator. If the pulp has but recently died and decomposed these measures should be adopted and have great value, but if the stain- ing of the tooth shows that the septic change is of long standing they cannot be expected to prevent further putre- factive change within the tooth. Care should be taken when introducing Condy's fluid on the dressing of wool into a fetid fang lest any decomposed organic matter be driven be- fore the piston through the opening at the fang end. Such a mishap has frequently resulted in the treatment, which was designed to relieve chronic periodontitis, becoming in it- self a cause of acute inflammatory action within the socket. Caries in its Third Stage. If decay advance unchecked the crown of the tooth disappears, leaving sharp spicule of enamel that are apt, un- less filed down, to excoriate the cheek or tongue. With the disappearance of the crown decay may be said to have reached its third stage, and nought now remains of the tooth save the fangs, the dentine of which has become ca- rious and softened, and which contain the debris of dead and decomposed nerve tissue. Such stumps may remain GENERAL PRACTITIONERS. 47 for years without causing any trouble, but frequently they set up a condition of chronic inflammation, as the result of which they may become rough and eroded and more or less enlarged or exostosed, as it is termed. Moreover, by an exudation around them of inflammatory lymph, they may be glued into then sockets so tightly that their extraction becomes at times no easy task. The difficulties met with in the removal of such stumps arise from three causes : 1. the glueing of the fang into its socket which prevents the ready introduction of the blades of the forceps ; 2. the hollowed condition of the interior of the fang which induces its walls to collapse as soon as the instrument is forcibly closed upon it ; 3. the exostosed condition of its surface, which is often caused by chronic periodontitis, and by which it is firmly rivetted, as it were, into the maxilla. Pain, when it is caused by decaying stumps, is of a neuralgic nature, not located around its exciting cause, but intermit- tent and flying over the side of the face and head, and it is increased by hunger, fatigue, or other depressing cause. As to the propriety of removing such fangs there can be no question. With their removal the neuralgic trouble will vanish, and it may be confidently stated that facial neural- gia has almost invariably a dental cause. Stumps, if quiet, may be disregarded, since they may be of a certain use in masticating food ; but, if it be thought desirable that artificial teeth should be worn, it is generally well to ex- tract all such stumps as are causing any local or nervous irritation before taking the models to which the frames are to be constructed. It should be noted that chronic inflammatory action or 48 DENTAL SURGERY FOR irritation, when produced by any of the six lower molars or their fangs, is apt to prove the cause of the two following well marked conditions, which, though they may be caused by other teeth, are not often associated with disease of any but the lower molars. 1. Closure of the jaws. — This rarely results from irritation save that which is caused by a second or third lower molar, and more often comes from the latter than the former tooth. Inflammatory exudation, slowly organized into fibrous bands, may have slowly formed around the temporo-maxil- lary articulation on the affected side, and by its gradual contraction may have so reduced the opening into the mouth between the incisor teeth that the introduction of solid food may have become almost impossible. Under these circumstances the patient should be well anaesthetised and the mouth forcibly opened with the aid of a powerful screw gag (vide fig. 30) placed between the bicuspid teeth. Pres- sure should bear upon these rather than upon the incisors, since the latter may be broken or dislocated by the required force. The ligamentous adhesions around the articulation being thus stretched, the dental cause of the mischief may be searched for, and should be entirely removed. For the after treatment of such cases a daily separation of the teeth should be gently and gradually effected with the aid of the screw gag, and will serve to restore in a week or two the original mobility of the jaw. 2. Fistulous opening through the cheek. — This rarely pro- ceeds from any but the lower molars, and of these the first molar is more apt than the second or third to prove the cause. It may be apprehended when the cheek over- GENERAL PRACTITIONERS. 4g lying the seat of periodontitis, whether this be acute or chronic, is found to become glazed, reddened, and adherent to subjacent structures. No time should then be lost in extracting the tooth or stumps that appear to be causing mischief, and thus by timely action the disfigurement may be averted. The fistulous opening when once established may remain for years a channel through which puru- lent fluid, secreted around the diseased fangs, occasionally escapes. After a time the discharge may cease by natural causes ; but the extraction of the stump, which being usually glued into its socket is sometimes difficult of re- moval, will at once cure the condition, if it be not so far advanced that necrosis of a portion of maxilla has been induced. If this last exist the healing must of course be delayed until the dead structure has been thrown off or removed, but always an unsightly pucker in the face will mark the site of the old fistulous opening. E 50 DENTAL SURGERY FOR Chapter VI. TOOTHACHE. Odontalgia, Periodontitis, Gas Pressure on the Nerve, Neuralgia. Pain in or around a tooth is, as a rule, one of the at- tendants upon its decay at some stage of the disease, and usually takes one of the following forms. I. Odontalgia, or the pain that accompanies the first stage of decay (see Chap. V). This varies in severity, is inter- mittent, and at times comes on in sharp paroxysms. It is located usually in the aching tooth, but, if a lower wisdom tooth be affected, it may fly up into the neigh- bourhood of the ear. It is increased and induced by hot and cold fluids, cold air, pungent or sweet food, and pres- sure of particles into the carious cavity during mastica- tion ; while, as its cause, is always to be found some tooth of which the crown is more or less damaged by decay or mechanical violence, and of which the dental pulp is in a vital, highly sensitive, and irritated condition. The treatment of odontalgia must vary with the local condition producing it. If decay be not far advanced, and the nerve not exposed, or exposed by only a small aper- ture, the cavity should be syringed out with warm water, and should be x^lugged with a dressing of wool and carbolic acid (see Chap. Y). Thus the irritated pulp is soothed, GENERAL PRACTITIONERS. 51 and protected by a non-conductor of heat from thermic and other influences. The wool may be changed daily, or may be replaced in a few days by a filling of gutta-percha. Should the cavity be large and the pulp freely exposed it will probably be necessary to destroy the latter with the aid of arsenic (see Chap. V), or to extract the tooth. II. That which attends Acute Periodontitis. — Such pain is constant, as distinguished from the intermittent pain of odontalgia. It is at first dull, but becomes more severe as the inflammation increases, and endures often until a discharge of pus takes place, which wells up around the neck of the tooth from the alveolar abscess that may have formed within the socket around its fangs. With the formation of matter a sensation of throbbing is experienced within the maxilla, and considerable swelling of the soft parts around the seat of mischief is then noticeable. The tooth becomes very tender to pressure or gentle tapping, is raised from its socket, and so loosened that its crown may at times be readily moved laterally to and fro, but it is not sensitive to hot or cold fluids. Its pulp cavity and fang canals contain always dead and decomposed nerve tissue, from which septic particles have been extruded into the alveolar sockets through the orifices at the ends of the fangs by expansion of gaseous products of putrefaction pent up within the pulp cavity (see Chap. V). A tooth thus cir- cumstanced is usually found to be much decayed, but, as before mentioned, periodontitis may be induced by the action of one in which the pulp has lost its vitality from causes other than caries, as from a blow, or from general ill-health. To relieve the pain of periodontitis e2 52 DENTAL SURGERY FOR the pulp cavity should be opened with a drill or an exca- vator, so that the pent up gas may escape, or, if the mischief be far advanced, the tooth should be extracted. The latter operation, as before said, may be performed at any stage of the disease ; indeed, the more severe the in- flammatory action may be, the more needful it becomes to extract the tooth. III. That caused by gas pressure upon a sensitive portion of a dental pulp. — Such pain is most intense, constant, of several hours in duration, and located strictly within the affected tooth. This will be found to contain semi-gan- grenous nerve tissue ; that portion of the latter situated within the fang canals being still vital and sensitive, while that occupying the pulp chamber has lost vitality, is gan- grenous and evolving gaseous products of putrefaction. These, pent up within the sealed pulp chamber, unable t'j discharge themselves into the mouth, produce by their in- creasing pressure on the nerve filaments still retaining sensibility the intense pain that accompanies this condition, which may endure until the vitality of the whole of the nerve has been destroyed. The tooth thus affected is sensitive to neither heat nor cold, since its nerve is par- tially dead ; nor is it tender on tapping, since as yet no periodontitis exists within its socket. Belief may be in- stantaneously afforded by opening with drill or excavator into the pulp chamber, through the floor of the carious cavity which generally exists, and by so doing the gaseous tension within the tooth is at once relieved. The opening should be kept patent by a plug of cotton wool, loosely inserted and changed daily. From what has been already said it may GENERAL PRACTITIONERS. 53 readily be understood that the death, and subsequent pu- trefaction of the u'hole of the dental pulp thus brought about may, in the course of a few weeks, produce a condition of periodontitis within the alveolar socket. IV. Alveolar and Facial Neuralgia. — This is variable in degree, becoming more severe when the general health is disturbed, and after bodily fatigue and want of food. It flies up the side of the face, into the neighbourhood of the ear, or downwards towards the shoulder and arm. There may in almost all cases be found the stumps of decayed teeth, which should be completely removed if the neuralgic symp- toms are persistent, and it may be noted that most cases of what is termed face-ague and tic douloureux have, as their exciting cause, a dental condition such as that described. The four preceding conditions " are those usually accom- panying pain in and around the dental structures, and such admits of ready relief if its cause be recognised and the appropriate remedy adopted. 54 DENTAL SURGERY FOR Chapter VII. MECHANICAL INJUEIES TO THE TEETH. Wearing down of the Teeth from Friction of Mastica- tion. Hunter's Denuding Process. Fracture and Dislocation of a Tooth from Violence. Towards middle life the cutting edges of incisors, and the grinding surfaces of the masticating teeth, show signs of wearing down, and the rapidity of such action is dependent upon the density of the tooth structure, and upon the nature of the food. Among savage races, who live mostly on coarse badly prepared materials, we see such extensive attrition that the pulp cavities would be speedily opened into, did not a development of secondary dentine within the pulp cavity and adherent to its walls prevent such a result. It, is also not unusual to find among middle aged per- sons a deep horizontal well polished groove, reaching almost into the pulp chamber, across the outer surfaces of the necks of incisor, canine, and bicuspid teeth. This condition, to which the name of Hunter's denuding jwocess- has been applied, results from the friction of the tooth- brush acting upon the softer cementum of the neck of the tooth which has become exposed by the commencing re- cession of the gums. From this last cause the necks ot GENERAL PRACTITIONERS. 55 the teeth are towards middle life frequently laid bare, and their less durable structures are liable to be thus damaged by a mechanical cause, aided by the solvent action of the fluid of the mouth. The surface tenderness which is often associated with this action may be relieved by a frequent application of eau de Cologne upon wool ; but if there be a deep cup-shaped cavity in the grinding surface of a molar, or a groove upon the neck of an incisor opening almost into its pulp-cham- ber, it may become necessary to insert a metal filling in order to prevent further and more serious damage to the tooth. Moreover, all rapidly cutting tooth-powders, such as charcoal or pumice powder, should be at once discon- tinued, and a soft brush be used with soap and chalk. These last only should indeed be employed in all cases, and if used twice daily will be quite effective in keeping the teeth well polished. One or more teeth may be fractured by a blow acting directly upon the damaged organs, or indirectly through the sudden closure of the lower teeth upon the upper, as when a heavy fall is sustained upon the chin in the hunt- ing field. The rough fractured surface may be smoothed down with a fine file if the damage be but slight, and sur- face tenderness may be relieved by an application of eau de ' Cologne or nitrate of silver. If the pulp cavity be broken into it may be necessary to destroy the nerve with arsenic, and subsequently to fill the tooth or to file it down to a level with the gum ; or to extract its fang pre- paratory to the insertion of a plate carrying an artificial tooth. 56 DENTAL SURGERY FOR An incisor tooth may be partly or entirely dislocated by violence. It is well in such cases to replace it and by a careful moulding of gutta-percha, softened in warm water, around it and its neighbours, to retain it in situ, in the hope that it may again become firm in its socket. This it will very frequently do, but the violence to which it has been subjected generally destroys its dental-pulp, which by subsequent decomposition is liable to induce periodon- titis in the course of a few months. For this last the remedy, as before pointed out, is to drill a small opening through the neck of the tooth into its pulp chamber (see Chap. V., rhizodontrophy) . GENERAL PRACTITIONERS. 57 Chapter VIII. EXTBACTION OF TEETH AND STUMPS. Conditions Necessitating Extraction. General direc- tions as to the Position of Operator and Patient. Concerning the Application of Forceps. As to the Extraction of the Tooth. Accidents during Extraction. A List of Instruments needed for Extraction. Forceps, their General Characters and Various Forms. The Elevator, its Description and Mode of Using. The Screw Extractor. Attention to some practical points in connection with this subject is necessary to the medical practitioner, who, though his dental practice should have a wider range, is likely to be more often called upon to use the forceps than to perform other dental operations. He may be required to relieve irregularity and overcrowding among the per- manent teeth of his young patients by the judicious re- moval of one or more dental organs. He may find extraction to be the only means by which he can cure the toothache for which his patient has consulted him, and he will be called upon to adopt this treatment when, from the necessities of the case, immediate relief from severe pain is urgently demanded. This last may be required 58 DENTAL SURGERY FOR when extensive caries, or fracture from direct or indirect violence, lias laid bare an aching dental pulp ; or when acute periodontitis is producing alveolar abscess. He will find it absolutely necessary to extract a diseased lower wisdom tooth which is causing closure of the jaws through the contraction and rigidity it may have induced around a temporo-maxillary articulation. Moreover, to cure a fistu- lous opening through the cheek, or to prevent its occur- rence when threatened, nothing will suffice but the complete removal of the lower molar which he will pro- bably discover to be the cause of mischief. He may be required to take out a loose temporary tooth the fangs of which, sharpened by partial absorption, are ulcerating through the gum and excoriating the cheek or lip ; extrac- tion may be needed by a decayed lower molar whose ragged edges are threatening to produce malignant disease of the tongue; or for the cure of epulis some decayed stump, underlying the tumour, may need removal. As the teeth become loosened by the absorption of alveolar process and recession of gums that accompany other senile changes, extraction will from time to time be required to XDre-vent them from proving a hindrance to mastication. The foregoing are the most frequent conditions under which the use of forceps is indicated, though doubtless from time to time their employment will be required from other causes. To apply them effectively it is necessary to place the patient in a solidly made chair with the back sufficiently low and so cushioned that, if the removal of an upper tooth be required, the head may be readily thown back and supported. The head and hand of the operator should GENERAL PRACTITIONERS. 59 never be allowed to intercept the light which should fall directly upon the tooth. When an upper tooth on either side is to be extracted, he should stand with feet well separated by the right hand of his patient; he should stand immediately behind the latter and leaning over his head when about to take out a lower tooth on the right side ; and when extracting any lower tooth on the left side the opera- tor should place himself by the left side of his patient. The attitude of the operator should be easy and uncon- strained, so that his power may be exerted to the best advantage. With this in view the operating arm should be held fairly close to the side that its movements may be well regulated and under control ; the head of the patient raised or lowered ; the chin thrown upwards or depressed ; and the head always so turned towards the operator that his forceps may have easy access to the tooth. If it be an upper tooth that is to be extracted his left hand must be used to steady the upper maxilla during application of the forceps, and to aid the extraction by providing an oppos- ing force to the traction of the instrument. To effect this he should firmly grasp with fingers and thumb the alveolar process on either side of the tooth he is about to remove. If the tooth be in the lower jaw the left hand should be used to prevent all rocking and depression of the inferior maxilla by rigidly securing it between the fingers and thumb. In applying forceps to a tooth with a view to its extrac- tion the operator should determine to insert their blades as deeply into the socket and as far up the fang as is practic- able. An exception to this holds good when the removal of 60 DENTAL SURGERY FOR a temporary molar is demanded, since the crown of the underlying permanent bicuspid may be grasped by the in- strument if this be used too vigorously. In the application of forceps these points should be regarded. 1. The tooth should be grasped very lightly between the blades of the in- strument in order that the latter may travel freely up its fang. 2. The forceps should be pushed freely and vigor- ously home. 3. During this process the instrument should receive the slightest possible rotation on its long axis. This should hardly amount to more than a tremulous movement, but it suffices to convince the operator that the blades are not gripping the neck of the tooth so tightly as to prevent them from travelling up it. 4. The long axis of the blades of the forceps should be continuous with or in the same direction as the long axis of the tooth. If this be disregarded the margin of the blades may impinge upon a neighbouring tooth, which by its resistance may greatly hamper the opera- tor while performing extraction. This precaution is very necessary when an upper bicuspid has to be removed. 5. The eye of the operator should be fixed upon the tooth and it should never be lost sight of throughout the operation. ,Ihe neck of the tooth being thus securely and firmly grasped, extraction should be effected by steady and contin- uous traction. Combined with this should be partial rotation on its long axis, if it be a single fanged tooth, as an upper or lower incisor, canine, or bicuspid, with also a slight amount of rocking or lateral movement applied judiciously and with great caution. Be it born in mind that the risk of break- ing a single fanged tooth is greatly increased when this rocking movement is applied, but in some cases it is quite GENERAL PRACTITIONERS. 6l necessary to adopt a certain amount of it. If it be an upper or lower molar, the tooth should be freely rocked in- wards and outwards while forcible traction is being em- ployed, and with such teeth any rotation upon the long axis is of course prohibited by the arrangement of their fangs. There are certain untoward occurrences, by no means uncommon in tooth extraction, which must be noted as follows. A. The tooth to which forceps are applied may break. This accident usually results from one of the following causes. 1. The long continued progress of decay may have almost entirely softened the dentine of which its fangs are com- posed. Added to this may be the glueing of their exteriors into their sockets by inflammatory exudation before re- ferred to {see Chap. V.) These conditions prevent the blades of forceps from travelling down, and favour the collapsing of the walls of the stumps as soon as pressure is brought to bear upon them. In such cases it is well to commence by using the elevator to partially dislodge them, and the forceps may then complete their removal. In this state do we often find a carious lower molar with which a fistulous opening through the face is connected. 2. The fangs may be con- siderably curved and clinging tenaceously to septa of bone or to fangs of neighbouring teeth. 3. The fangs may have, as the result of chronic inflammatory action, become enlarged or exostosed, and so rivetted into the alveolar process. 4. The dentine may have as the result of senile changes become almost as brittle as glass, and on this account it is well to be on one's guard when dealing with the teeth of 62 DENTAL SURGERY FOR elderly persons. From any of these causes a tooth or stump may break, and blame in many cases is not to be attributed to the operator if it do so. He should al- ways, before applying his forceps, ascertain the mobility of the tooth in its socket by rocking it carefully and slightly to and fro with a strong excavator resting against the inner or outer wall of its crown. If fracture occur during extraction, he should wipe away with a plug of absorbent wool on the end of an excavator any blood which may conceal the surface of the stump, and then attempt its removal with a finer or narrower instrument. If he now fail after a reasonable attempt, let him desist, since a prolonged operation serves but to exhaust his patient, and prevents his own success in any subsequent operation he may enter upon. If, as the result of the fracture, there be apparent a vital and intensely sensitive exposed dental pulp, this may be removed as completely as possible by passing down the fang a finely barbed nerve extractor (vide fig. 18, Chap. Y). The stump, if it cannot be removed, may be allowed to remain with the probability that it will now give no more trouble, since the nerve which was pre- viously aching has been removed, and being healthy and free from septic change it is not likely to set up perio- dontitis. If the motive for the attempted extraction be the relief of periodontitis, this condition will be relieved by the complete opening of the fang canals and the free escape thus given to imprisoned gas by the breaking off of the crown of the tooth. The patient may be further consoled by an assurance that after a year or two the pro- gress of absorption both of fang and alveolar process will GENERAL PRACTITIONERS. 63 probably render the removal of the broken stump compara- tively easy. B. While extracting a lower molar an upper incisor may be broken by the back of the forceps. This results from the sudden parting of the tooth from its socket after a pro- longed effort has somewhat exhausted the muscular power of the operator. Guard against this by keeping the opera- ting arm well under control, and by intently watching for the moment when the tooth is about to sever connection with its socket. C. A tooth may be taken out other than that which it was designed to extract. This can result only from w r ant of care, and should be guarded against by closely watching the forceps and the tooth they are enclosing throughout the whole operation. During hurried extractions under nitrous oxide this misfortune is liable to occur, when the instrument is applied within a moment of the removal of the face-piece by an operator whose haste and nervousness may prevent him from duly observing the parts with which he is dealing. D. The alveolar process may be fractured, and indeed it is very common to find a small fragment of the outer al- veolar plate adherent to the fangs of a molar after it has been removed. More than this has not happened within my experience, but a separation of the intermaxillary bone from the superior maxilla during removal of an upper in- cisor, and of transverse fracture of the ramus of the lower jaw while a lower tooth was being extracted, have been re- corded by Mr. Salter. The accidents occurred in both cases to operators who possessed such skill and knowledge as to 64 DENTAL SURGERY FOR make it certain the like may in some conditions be inevit- able. Apart from this, however, must be regarded the breaking off of the tuberosity of the upper maxilla during the the use of an elevator for removal of an upper wisdom tooth, For extraction of this last, forceps should be used, and the powerful leverage afforded by the former in- strument served in a case that came under my notice a few years since to break away, with the upper third molar which was extracted, a mass of spongy bone in size as large as a walnut. E. The gum may be lacerated during removal of a lower second, or third molar, through its occasionally strong ad- hesion to the neck of the tooth. If this be the case a scalpel should be used to divide it before the molar is entirely withdrawn from its socket. F. The tongue or cheek may be punctured, and a large blood vessel thus opened, by the slipping of an elevator. The firm pressure of the end of the first finger of the operating hand upon the blade within one quarter of an inch of its extremity, at the moment of introduction, and then, as it is being thrust into the alveolus, upon the tooth to be taken out, or upon its fulcrum, will suffice to prevent this mishap. G. The extracted tooth or stump may slip from the grasp of the instrument and passing into the trachea may cause much trouble. This is an accident which those operating upon an anaesthetised patient should guard against by carefully folding a mouth-napkin within the mouth behind the teeth or stumps that are about to be removed. GENERAL PRACTITIONERS. 65 H. Persistent haemorrhage after extraction, or coming on within a few hours of the operation, may need prompt at- tention. The firm blood clot which may often be found concealing the bleeding socket and its neighbouring teeth should be vigorously wiped away with a plug of wool on an excavator; a strip of dry lint, J of an inch wide and about 6 inches long, should then be plugged into the socket, being condensed tightly and carried down completely to its bottom, with the aid of the excavator. Over the plug should be ap- plied a'compress of lint, and on this the jaws should be kept tightly closed for a few hours. In this way the bleeding may with certainty be controlled, and though the compress may be changed daily, the plug within the socket should remain undisturbed for three or four days. In arresting haemorrhage under these circumstances dry lint will be found more effective than that moistened with any fluid styptic, such as Tinct. Ferri Perchlor. A complete equipment of instruments for extraction should include eight forceps, one elevator, and one screw extractor and drill for the latter, and with less than these a practitioner will hardly be enabled to deal with all cases presenting for treatment. The eight forceiDS should have these characters. Their handles should be strong, unyielding, and quite without spring, which tends to prevent an operator from judging ac- curately of the amount of pressure he is applying to a tooth. Their joints should be strong, and without any play, which, if it occur after considerable use, should be remedied by careful tightening up of the central rivetted screw. A loose joint causes much inconvenience during extraction, and F 66 DENTAL SURGERY FOR while wrenching the fangs from their sockets, since it allows the blades to slide to and fro over the sides of the tooth. Care should be taken that water, when cleansing the for- ceps, does not enter its joint, and the latter should be occasionally oiled that it may work freely and without any rigidity. The blades should be well tempered, being neither so soft as to bend or splay out at their edges, nor so hard as to chip or fly. Also the space between them, towards the joint, should be wide enough to enable them to close firmly upon the neck of a tooth without coming in contact with its crown. The stock of forceps should consist of the following. Fig. 19. Upper incisor and canine forceps. One pair of 'upper incisor and, canine forceps. It will be seen that the long axis of the handles of these is not quite continuous in the same line, but is set at a slight angle with the long axis of their blades. In applying them to an upper front tooth they should be so placed that their handles incline towards the patient's chin rather than from it. To summarize the directions before given, remem- ber in their application to force them well up the neck of the tooth. Ensure this by grasping the latter lightly, regulating the pressure by firmly pressing the ball of the thumb of the operating hand into the space between GENERAL PRACTITIONERS. 67 the handles. Also while forcing them up within the socket give them a slight tremulous movement, or one of partial rotation upon their long axis, amounting to about -£% of a circle, so that the sharp cutting edges of their blades shall sever the membranous- connections between the fang and its socket. Extraction will be performed by steady continuous traction, increasing gradually in amount, during which the fang, being firmly and cautiously grasped, may be slightly rotated on its long axis. Any rocking movement, to and fro, or in an antero-posterior direction, is, as before men- tioned, here injudicious. Efforts in this direction should at any rate be applied with much circumspection and only when traction with rotation does not promise to produce the desired result. The operation should not be hurried, and if the fang show signs of giving way the grasp of the in- strument should be relaxed and it should be thrust more deeply into the socket. What is applicable to these forceps may be held to apply equally to those intended for the re- moval of lower front teeth and of upper and lower bicus- pids. Fig. 20. Upper bicuspid forceps for either side. One pair of upper bicuspid forceps for either side. The use of these should be confined to the extraction of upper f2 68 DENTAL SURGERY FOR bicuspid teetli, of entirely detached molar fangs, and occa- sionally of upper wisdom teeth. They should never be employed for the removal of badly decayed upper first or second molars, whose fangs are still united. Fig. 21. Forceps for lower incisors, canines and bicuspids. One pair of forceps for lower incisors, canines and bicuspids. These are of much service also in the extraction of greatly decayed lower molars, which threaten to be fractured if grasped by the ordinary lower molar forceps. With the former, one fang, usually the anterior, may be grasped deeply in the alveolus and removed separately ; or, as often happens, with the posterior fang attached to it. It should be noted that the second permanent or twelve year old molars are more rigidly fixed in the maxillae than are the first or six year old molars. It follows therefore that the former, when greatly decayed, are more liable than the latter to fracture when the ordinary molar or double for- ceps (to be spoken of later on) are applied to them. For extraction therefore of second permanent molars, the lower bicuspid, or, as they are sometimes termed, stump forceps, are of considerable value. When one fang has been de- GENERAL PRACTITIONERS. 69 taclied and removed, but little difficulty will usually be encountered in taking out also the remaining fang. One pair of forceps for upper right molars. The tang pro- jecting from one blade is inserted between the two outer fangs, and the neck of the tooth being rigidly grasped, Fig. 22. Forceps for upper right molars. well within the socket, should be steadily rocked inwards and outwards while forcible traction is being exercised. No movement of rotation is admissible during extrac- tion of upper and lower molars, owing to the arrangement of their fangs. An upper wisdom tooth, if not too firmly rooted, may be readily removed by upper molar, or stout bicuspid forceps. If it be very rigid and unyielding, it is well to commence by moving it slightly in its socket with the aid of an elevator, which should be thrust in between it and the second molar. The use of the elevator in this situation requires considerable care, owing to the liability thus encountered of breaking away the tuberosity of the superior maxilla, and the extraction of the tooth is to be completed with the forceps. 7o DENTAL SURGERY FOR One pair of forceps for upper left molars. The tang pro- jecting from one blade is inserted between the two outer fangs. Fig. 23. Forceps for upper left molars. One pair of lower molar forceps for either side of the mouth. Each blade presents a projecting tang which should be inserted between the two fangs of the tooth. If the latter Fig. 24. Lower molar forceps for either side of the mouth. be fairly solid and resisting these should be used in prefer- ence to the lower stump, or single fang forceps, since they afford a more secure and complete grasp of the tooth. As the long axis of lower molar teeth is frequently directed upwards and somewhat inwards, the operator should guard against depressing the handle of the forceps too GENERAL PRACTITIONERS. 7 1 freely, by doing which he may at any time readily break off the crown of the tooth. If the lower molar be at all tilted inwards, he should aim at lifting it upwards and in- wards at the time he is engaged in rocking it freely inwards and but slightly outwards. Fig. 25. Upper stump forceps. One pair of upper stump forceps. These are of use when searching for deeply buried single fangs, and being of somewhat delicate construction should not be too severely taxed. Fig. 26. Lower stump forceps. One pair of lower stump forceps. These resemble those in fig. 21. Their blades, however, are somewhat longer, are more delicate, and close more completely at their cut- ting edges. . The Elevator should be strong and unyielding. Its length, inclusive of handle and blade, should be from five to six inches. The handle should possess a smooth broad 72 DENTAL SURGERY FOR end, that the palm of the hand may not be injured when using it forcibly. The blade should be two inches long ; and, for its lower inch, it should be flat on one side, convex on the other, and one quarter of an inch wide. Its extremity should possess a sharp cutting edge, and be neither pointed nor flat, but gently rounded. All spear and spoon shaped elevators are to be avoided ; also, the in- strument should be straight throughout, without curve or bend of any nature. The elevator is of great value for extraction of lower wisdom teeth and of firmly implanted stumps. It can be employed only when there is a vacant space, or portion of maxilla free from any stump or tooth, immediately adjacent to the tooth for removal of which it is to be used ; and for extraction of upper wisdom teeth it is rarely to be used, owing to the liability of fracturing the tuberosity of the upper maxilla. It should be inserted forcibly into the alveolus, alongside and in front of the tooth on which it is to operate, with its flat face adjacent to the latter, and its convex side in contact with the fulcrum. Its point should be directed during insertion downwards and in- wards, so that the long axis of the instrument is about half way between the horizontal and the perpendicular. The elevator can be used effectively only if there be some strong, firmly implanted tooth, against which it can rest, as on a fulcrum ; and if it be remembered that the ele- vator is used only as a lever of. the first order, the need for this rigidity in its fulcrum must be apparent, since the pres- sure bearing upon the latter will be the sum of the force ap- plied by the operator's hand, and of the resistance offered by GENERAL PRACTITIONERS. 73 the tooth which is being extracted. Usually it will be found needful that the fulcrum should be in front of the tooth that is to be taken out, but this can hardly be laid down as a rule. Fig. 27. Fig. 28. Diagrams of Elevator — front and side views. The blade being the exact size, the handle should be four inches long. During the insertion of the blade into the alveolus, the end of the first finger of the operating hand must be pressed firm- ly upon it, within half an inch of its end, and also upon the side of the fulcrum, or of the tooth to be extracted. Thus any puncturing of the tongue or cheek may be quite pre- vented in the event of a slip, a by-no-means unusual event, 74 DENTAL SURGERY FOR since the force needed to insert the instrument is fre- quently very great. After the insertion of the blade its handle should be carried forward towards the median line. At the same time the instrument should be slightly rotated on its long axis, so that the lower edge of its blade may tend to lift up and loosen the stump from its socket. Dur- ing these operations the eye should be fixed intently upon the fulcrum, which may, if care be not taken, readily start from its position. Thus used, the elevator serves to raise and slightly detach a tooth, but for the completion of its extraction, which is thus rendered an easy task, the for- ceps may be required. For the removal of lower wisdom Fia. 29. teeth the elevator is very serviceable, and it should then be thrust freely into the alveolar process between the second and third molars. The Screw Extractor is of use for removal of decayed stumps of upper incisors or canines. The fangs gene- rally need to be opened up with a conical four- sided drill, passed up the fang canal, and rotated between the anger and thumb ; after which the instrument may be carefully screwed into the fang, which should be re- moved by gentle traction and rock- Diagram of a screw ex- tractor for removal of stumps of upper incisors and canines. ing. GENERAL PRACTITIONERS. 75 Chapter IX. ANESTHETICS. PKEPARATION OF THE MOUTH FOR FRAMES. SALIVARY CALCULUS. Nitrous Oxide, Chloroform, and Ether are employed to prevent pain during extractions. Inasmuch also as they lessen the shock of an operation they are beneficial when dealing with children and those whose health is enfeebled. Nitrous oxide is now supplied in a liquid form, condensed by pressure and cold into strong wrought iron bottles, whence it is liberated into the bag from which it is to be inhaled. It is an anaesthetic well suited for minor extrac- tions, and may safely be re -inspired when a second or third tooth has to be removed. It may be applied to patients of all ages, but is very suitable for young healthy persons fairly free from nervousness. It has great value when anaesthesia is needed by one whose heart is enfeebled from age or ill-health, and then should be greatly preferred to chloroform, since it acts as a stimulant to the weak organ, while the latter tends to depress its action. Ner- vous, hysterical girls, will frequently not take " gas " well, and for such chloroform should be used, and will usually be found quite safe and efficient. A sine qua non in the employment of nitrous oxide is a free and full expansion of the chest during inspiration, and this the highly strung nervous patient is frequently quite unable to effect. It j6 DENTAL SURGERY FOR may be breathed until blueness of the face and commenc- ing stertor indicate that the right degree of insensibility has been attained. This, if the mask fit so accurately that no air be introduced with the inhaled gas, is usually arrived at within 50 to 80 seconds from the commencement of inhalation. The extraction should of course be per- formed as rapidly as possible after withdrawing the mask, and great care needs then to be taken lest the tooth slip from the grasp of the forceps down the trachea of the patient, and lest a like accident occur with the gag or prop that has been used to keep the jaws apart. To pre- vent the latter a short piece of thin twine should always be attached to the gag, which should be of a telescopic or sliding pattern. Fig. 30. A telescopic gag or mouth prop for use during inhalation of nitrous oxide. It should be placed between the front teeth before the gas is inhaled. Chloroform is useful when many teeth have to be ex- tracted, or when from nervousness and absence of deep GENERAL PRACTITIONERS. 77 breathing the gas is contra-indicated. In a word, with a weak heart use gas rather than chloroform, and for a nervous hysterical female employ chloroform rather than Fig. 31. A mouth opener to be used with the administration of chloroform. jas. The administration of chloroform for dental pur 78 DENTAL SURGERY FOR poses should never be pushed to any extent, and before stertor and relaxation of the muscles show that the third stage of anesthesia has been reached, the mouth should be forcibly opened by a powerful screw gag placed between the upper and lower bicuspid teeth. The gag should be held by an assistant between the bicuspids while the oper- ation is completed, and thus, while the sense of pain is dulled or entirely removed, we avoid • causing that nausea and prostration which generally follow upon a large use of chloroform. Ether is used at times for patients of middle age, but for dental purposes is not very convenient. It causes great excitement, salivation, and bronchial irritation, also its pungent vapor is apt to inconvenience the operator. The undesirability of employing any anaesthetic, be it gas, ether, or chloroform, without the presence and assistance of a companion, who should be a qualified medical practi- tioner, needs hardly to be indicated. The 'preparation of the Mouth for the Insertion of Frames. — Artificial teeth are now made of mineral materials only, and are carried on a base of either gold or vulcanite. They are worn for the sake of appearance, and to prevent lisping during speech, as when an artificial incisor is adopted ; to restore or increase power of mastication, as when, molars and bicuspids are inserted; or to serve as props when all the back teeth of one or both jaws have been lost. Thus they prevent the lower jaw from approxi- mating too closely to the upper, and so directly tend to preserve the upper front teeth, which would otherwise be bitten out and loosened by the increased pressure upon GENERAL PRACTITIONERS. 79 their back surfaces of the lower incisors and canines. This last is certainly not one of their least useful duties. Further, by keeping the jaws apart, they prevent that pro- trusion of the inferior maxilla, and raising of the chin towards the nose, that characterises the aged. After deciding from any of the foregoing reasons that frames should be worn, it is usually desirable that any greatly decayed, or very loose teeth, or tender stumps should be removed ; and after such extractions an interval of from a day or two to six months should elapse before the models of the mouth are obtained to which frames are to be made. The wax impression should indeed not be taken until absorption of the alveolar process is well ad- vanced or completed. Only a short delay, however, need occur if before their removal the extracted teeth have been very loose, since already much of their sockets has disap- peared ; and if there be necessity for immediate wearing of artificial teeth, the impressions may be taken within a week or so of the operation. From these a temporary frame may at once be made, to be replaced by one of a more permanent character at the end of a year or so, when the alveolar ridge has settled down somewhat to its ulti- mate level. Tartar or Salivary Calculus. — This earthy deposit, which consists of lime salts with animal matter, is found to collect around the teeth under these circumstances. I. At the back of the lower incisors and canines, which is a part of the mouth always escaping that friction from the tooth brush and from the passage of food during mastica- tion, which tends to polish the surface of the teeth and to prevent lodgment thereon of calcareous particles. 80 DENTAL SURGERY FOR II. Upon and around any masticating tootli which from decay has become tender to pressure and change of tem- perature, and so has got thrown out of work. Thus, if from a tender molar the side of the mouth on which it is placed is unused, the buccal and lingual surfaces of molars and bicuspids of both upper and lower jaws on that side will shortly become much coated with deposit, and its occur- rence may be accounted for, as in the previous case, by the absence of the cleansing influence of friction. III. Towards middle life upon the necks of teeth which. from absorption of the alveolar process and gum are becoming exposed, and probably in such cases the growth of the deposit is but a sequence to the absorption and in no manner its cause. The removal of tartar may be readily effected by detach- ing it from below upwards with a strong excavator, and thus it may be scaled off the surface of the teeth, which should if loose be steadied with the fingers of the left hand. Its formation is undesirable since it is apt to induce an irri- tated state of the gums and to form a lodgment for par- ticles of food. GENERAL PRACTITIONERS. 8l INDEX. A BSORPTION of temporary **■ ■*■ fangs, 2 Absorptive papilla, 2 Abortive teeth, 12 Antiseptic treatment of fang canal, 38 Anaesthetics for dental operations, 75 Arsenic, application of, 35 Artificial teeth, preparation of the mouth for, 78 reasons for employment of, 78 Attrition, 54 /^ ARIES of crown of tooth, 28 ^- / Caries of neck of tooth, 29 Caries, its first stage, 31 — its second stage, 36 — its third stage, 46 Chloroform, 76 Closure of jaws, 48 Cryptogam, Leptothryx Buccalis, 29 T^vECAY of teeth, causes of, 28 ^-^ Decay of first molars, 29 Decay of temporary teeth, 4 Dilacerated teeth, 12 Dislocation of teeth, 56 T7 LEVATOR, description and -■— ' use of, 72 Enamel, defective, 28 Eruption, retarded, 10 — of temporary teeth, 1 — of permanent teeth, 6 Ether, 78 Excavators, their form and use, 24 Extraction of teeth, reasons for, 57 — of a wrong tooth, 63 — of temporary teeth, 4 — for the cure of irregularity, 15 — symmetrical, 16 1/TLLING of teeth temporarily, 34 Fistulous opening through cheek, 82 DENTAL SURGERY FOR Forceps, their mode of using, 59 — their general characters, 65 Fracture of a tooth by forceps, 61 — of alveolar process during ex- traction, 63 /"""* AS pressure on the nerve, 52 KJ Geminated teeth, 12 Gum, lancing of, 2 Gum-boil, 44 Gum, laceration of, during extrac- tion, 64 Gutta-percha as a filling, 34 T T^MORRHAGE after ex- -*- -*■ traction, 65 Honeycombed teeth, 13 Hunter's denuding process, 54 Hutchinson's teeth, 13 1 J RREGULARITY in positions of teeth, causes of, 14 AWS, closure of, 48 L EPTOTHRYX Buccalis, 29 IV /TECHANICAL injuries of **-■* teeth, 54 Mirror for mouth examination, 26 Myeloid tumours of jaw, 10 TVT ERVE devitalizing by arsenic ^ 35 Nerve, death of, 37 — exposure of, 35 — extraction of, 38 Neuralgia, 53 Nitrous oxide gas, 75 o DONTALGIA, 50 "PERIODONTITIS, acute, 41 -*- Periodontitis, cause of, 40 Periodontitis, chronic, 43 Permanent teeth, to distinguish, from temporary, 8 T) EGULATING plates, 17 ■*-^- Rhizodontropy, 45 SALIVARY calculus, 79 Screw extractor, use of, 74 Stopping temporary teeth, 4 Strumous teeth, 13 GENERAL PRACTITIONERS. 83 Supernumerary teeth, 10 Symmetrical extraction, 16 Syphilitic teeth, 13 npARTAR, 79 ■*■ Teeth, eruption of tem- porary, 1 Teeth, decay of temporary, 4 — ulceration through gum of fangs of, 5 Tic doloureux, 53 Tooth-ache, 50 Torsion of teeth, 19 Tooth powder, 55 T T LCERATION through gums ^-^ of fangs of temporary teeth, 5 V ■shaped jaw, 22 WEARING down of crowns of teeth, 54 Wisdom teeth, eruption of, 7 extraction of, 7 62 CATALOGUE No. 7. A CATALOGUE OF BOOKS FOR STUDENTS; INCLUDING A FULL LIST OF The ? Quiz- Com ft ends? AND MANY OF THE MOST PROMINENT Students' Manuals and Text-Books PUBLISHED BY P. BLAKISTON, SON & CO., Medical Booksellers, Importers and Publishers, No. 1012 WALNUT STREET, PHILADELPHIA. ***For sale by all Booksellers, or any book will be sent by mail, postpaid, upon receipt of price. Catalogues of books on all branches of Medicine, Dentistry, Pharmacy, etc., supplied upon application. THE PQUIZ-COMPENDS? A NEW SERIES OF COMPENDS FOR STUDENTS For Use in the Quiz Class and when Preparing for Examinations. Price of Each, Bound in Cloth, $1.00 Interleaved, $1.25. Based on the most popular text- books, and on the lec- tures of prominent professors, they form a most complete set of manuals, containing information nowhere else collected in such a condensed, practical shape. The authors have had large experience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent advances and methods. The arrangement of the subjects, illustrations, types, etc., are all of the most improved form, and the size of the books is such that they may be easily carried in the pocket. No. 1. ANATOMY. (Illustrated.) THIRD REVISED EDITION. A Compend of Human Anatomy. By Samuel O. L. Potter, m.a., m.d., U. S. Army. With 63 Illustrations. " The work is reliable and complete, and just what the student needs in reviewing the subject for his examinations." — The Physi- cian and Surgeon 's Investigator , Buffalo, N. Y. " To those desiring to post themselves hurriedly for examination, this little book will be useful in refreshing the memory." — New Orleans Medical and Surgical Journal. " The arrangement is well calculated to facilitate accurate memo- rizing, and the illustrations are clear and good." — North Carolina Medical Journal. Nos. 2 and 3. PRACTICE. A Compend of the Practice of Medicine, especially adapted to the use of Students. By Dan'l E. Hughes, m.d., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part II. — Diseases of the Respiratory System, Circu- latory System, and Nervous System ; Diseases of the Blood, etc. *£* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Price of each Book, Cloth, $1.00. Interleaved for Notes, $1.25. THE ? QUIZ-COMPENDS ?. Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and includ- ing a number of new prescriptions. They have been compiled from the lectures of prominent Professors, and reference has been made to the latest writings of Pro- fessors Flint, Da Costa, Reynolds, Bartholow, Roberts and others. " It is brief and concise, and at the same time possesses an accu- racy not generally found in compends." — jfas. M. French, M.D., Ass't to the Prof, of Practice, Medical College of Ohio, Cincinnati. " The book seems very concise, yet very comprehensive. . An unusually superior book." — Dr. E. T. Bruen, Demonstrator of Clinical Medicine, University of Pennsylvania. " I have used it considerably in connection with my branches in the Quiz-class of the University of La." — y. H. Bemiss, New Orleans. " Dr. Hughes has prepared a very useful little book, and I shall take pleasure in advising my class to use it." — Dr. George W. Hall, Professor of Practice, St. Louis College of Physicians and Surgeons. No. 4. PHYSIOLOGY. Second Ed. A Compend of Human Physiology, adapted to the use of Students. By Albert P. Brubaker, m.d., De- monstrator of Physiology in Jefferson Medical College, Philadelphia. Second Ed. Enlarged and Revised. " Dr. Brubaker deserves the hearty thanks of medical students for his Cornpend of Physiology. He has arranged the fundamental and practical principles of the science in a peculiarly inviting and accessible manner. I have already introduced the work to my class." — Maurice N. Miller, M.D., Instructor in Practical His- tology , formerly Demonstrator of Physiology, University City of New York. " ' Quiz-Compend ' No. 4 is fully up to the high standard estab- lished by its predecessors of the same series." — Medical Bulletin, Philadelphia. " I can recommend it as a valuable aid to the student." — C. N. Ellinwood, M.D., Professor of Physiology, Cooper Medical Col- lege, San Francisco. " This is a well written little book." — London Lancet. No. 5. OBSTETRICS. Second Ed. A Compend of Obstetrics. For Physicians and Students. By Henry G. Landis, m.d., Professor of Obstetrics and Diseases of Women, in Starling Medical College, Columbus. With Index and 22 Illustrations. "We have no doubt that many students will find in it a most valuable aid in preparing for examination." — The American your- nal of Obstetrics . "It is complete, accurate and scientific. The very best book of its kind I have seen." — y. S. Knox, M.D., Lecturer on Obstetrics , Rush Medical College, Chicago. Price of each Book, Cloth, $1.00. Interleaved for Notes, $1.25. THE ? QUIZ-COMPENDS ?. " I have been teaching in this department for many years, and am free to say that this will be the best assistant I ever had. It is ac- curate and comprehensive, but brief and pointed." — Prof. P. D. Yost, St. Louis. No. 6. MATERIA MEDIOA. Revised Ed. A Compend on Materia Medica and Therapeutics, with especial reference to the Physiological Actions of Drugs. For the use of Medical, Dental, and Pharma- ceutical Students and Practitioners. Based on the New Revision (Sixth) of the U. S. Pharmacopoeia, and in- cluding many unofficinal remedies. By Samuel O. L. Potter, M.A.,M.D., U. S. Army. " I have examined the little volume carefully, and find it just such a book as I require in my private Quiz, and shall certainly re- commend it to my classes. Your Compends are all popular here in Washington." — "John E. Brackett, M.D., Professor of Materia Medica and Therapeutics , Howard Medical College, Washington. " Part of a series of small but valuable text-books. . . . While the work is, owing to its therapeutic contents, more useful to the medical student, the pharmaceutical student may derive much use- ful information from it." — N. Y. Pharmaceutical Record. No. 7. CHEMISTRY. Revised Ed. A Compend of Chemistry. By G. Mason Ward, m.d., Demonstrator of Chemistry in Jefferson Medical Col- lege, Philadelphia. Including Table of Elements and various Analytical Tables. " Brief, but excellent. ... It will doubtless prove an admirable aid to the student, by fixing these facts in his memory. It is worthy the study of both medical and pharmaceutical students in this branch." — Pharmaceutical Record, New York. No. 8. VISCERAL ANATOMY. A Compend of Visceral Anatomy. By Samuel O. L. Potter, m.a., m.d., U. S. Army. With 40 Illustrations. *#* This is the only Compend that contains full descriptions of the viscera, and will, together with No. i of this series, form the only complete Compend of Anatomy published. No. 9. SURGERY. Second Edition. A Compend of Surgery; including Fractures, Wounds, Dislocations, Sprains, Amputations and other opera- tions, Inflammation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Eye, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., with 62 Illustra- tions. Second Edition. Enlarged and Revised. Price of Each Book, Cloth, $1.00. Interleaved for Notes, $1.25. THE TQUIZ-COMPENDS?. No. 10. ORGANIC CHEMISTRY. JUST PUBLISHED. A Compend of Organic Chemistry, including Medical Chemistry, Urine Analysis, and the Analysis of Water and Food, etc. By Henry Leffmann, m.d., Pro- fessor of Clinical Chemistry and Hygiene in the Phila- delphia Polyclinic ; Professor of Chemistry, Penn- sylvania College of Dental Surgery ; Member of the N. Y. Medico-Legal Society. Cloth. $1.00 Interleaved, for the addition of Notes, $1.25 Nature of Organic Bodies. Transformations under various con ditions. Organic Synthesis. Homologous and Isomeric Bodies Empirical and Rational formulae. Classification of Organic Bodies Hydrocarbon. Derivatives of Hydrocarbons, Alcohols and Ethers Benzenes and Turpenes. Fat Acids, Oils and Fats, Sugars, Gluco sides. Cyanogen Compounds, Amines and Amides. Alkaloids Ptomaines. Animal Chemistry. Nutrition and Assimilation Food, Water and Air. Urinary Analysis. Index. The Essentials of Pathology. BY D. TOD GILLIAM, M.D., Professor of Physiology in Starling Medical College, Columbus, O. With 47 Illustrations. 12mo. Cloth. Price $2.00. *** The object of this book is to unfold to the beginner the funda- mentals of pathology in a plain, practical way, and by bringing them within easy comprehension to increase his interest in the study of the subject. Though it will not altogether supplant larger works, it will be found to impart clear-cut conceptions of the generally accepted doctrines of the day, and to prevent confusion in the mind of the student. A POCKET-BOOK OF PHYSICAL DIAGNOSIS OF THE Diseases of the Heart and Lungs. A MANUAL FOR STUDENTS AND PHYSICIANS. BY DR. EDWARD T. BRUEN, Demonstrator of Clinical Medicine in the University of Pennsyl- vania, Assistant Physician to the University Hospital, etc. Second Edition, Revised. With new Illustrations. 12mo. $1.50 ***The subject is treated in a plain, practical manner, avoiding questions of historical or theoretical interest, and without laying special claim to originality of matter, the author has made a book that presents the somewhat difficult points of Physical Diagnosis clearly and distinctly. STUDENTS' MANUALS. GOODHART AND STARR ON DISEASES OF CHILDREN. A Practical Guide for Students. Demi-Octavo. Cloth, $3.00; Leather, $4.00. LANDOIS' MANUAL OF PHYSIOLOGY. With Special Reference to Practical Medicine. Vol. 1, with 176 Illustrations. 8vo. Cloth, $4.50. Vol. II. Nearly Ready. TYSON, ON THE URINE. A Practical Guide to the Examination of Urine. For Physicians and Stu- dents. By James Tyson, m.d., Professor of Path- ology and Morbid Anatomy, University of Pennsylva- nia. With Colored Plates and Wood Engravings. Fourth Edition. i2mo, cloth, $1.50 HEATH'S MINOR SURGERY. A Manual of Minor Surgery and Bandaging. By Christopher Heath, m.d., Surgeon to University College Hospital, London. 6th Edition. 115 111. i2mo, cloth, $2.00 MACNAMARA, ON THE EYE. A Manual for Students and Physicians. 4 Colored Plates and 65 Wood Engravings. Demi 8vo. Cloth, $4.00. DULLES' ACCIDENTS AND EMERGEN- CIES. What To Do First in Accidents and Emer- gencies. A Manual Explaining the Treatment of Surgical and other Accidents, Poisoning, etc. By Charles W. Dulles, m.d., Surgeon Out-door De- partment, Presbyterian Hospital, Philadelphia. Col- ored Plate and other Illustrations. 32mo, cloth, .75 BEALE, ON SLIGHT AILMENTS. Their Na- ture and Treatment. By Lionel S. Beale, m.d., f.r.s. Second Edition. Revised, Enlarged and Illus- trated. 283 pages. 8vo. Paper covers, 75 cents; cloth, $1.25 ALLINGHAM, ON THE RECTUM. Fistulse, Hemorrhoids, Painful Ulcer, Stricture, Prolapsus, and other Diseases of the Rectum ; Their Diagnosis and Treatment. By Wm. Allingham, m.d. Fourth Re- vised and Enlarged Edition. Illustrated. 8vo. Paper covers, 75 cents; cloth, $1.25 . STUDENTS' MANUALS AND LEXICONS. MARSHALL AND SMITH, ON THE URINE. The Chemical Analysis of the Urine. By John Mar- shall, M.D., Chemical Laboratory, University of Penn- sylvania, and Prof. E. F. Smith. Illus. Cloth, #1.00 MEARS' PRACTICAL SURGERY. Surgical Dressings, Bandaging, Ligation, Amputation, etc. By J. EwiNG Mears, M.D., Demonstrator of Surgery in Jefferson Med. College. 227 Illus. 2d Ed. In Press. KIRKE'S PHYSIOLOGY. A Handbook for Stu- dents. Eleventh Edition, 1884. 466 Illustrations. Demi 8vo. Cloth, $5.00 TYSON, ON THE CELL DOCTRINE; its His- tory and Present State. By Prof. James Tyson, m.d. Second Edition. Illustrated. i2mo, cloth, $2.00 MEADOWS' MIDWIFERY. A Manual for Stu- dents. By Alfred Meadows, m.d. From Fourth London Edition. 145 Illustrations. 8vo, cloth, $2.00 WYTHE'S DOSE AND SYMPTOM BOOK. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Eleventh Edi- tion. 32mo, cloth, $1.00; pocket-book style, #1.25 PHYSICIAN'S PRESCRIPTION BOOK. Con- taining Lists of Terms, Phrases, Contractions and Abbreviations used in Prescriptions, Explanatory Notes, Grammatical Construction of Prescriptions, etc., etc. By Prof. Jonathan Pereira, m.d. Sixteenth Edi- tion. 32mo, cloth, $1.00; pocket-book style, $1.25 POCKET LEXICONS. CLEAVELAND'S POCKET MEDICAL LEXI- CON. A Medical Lexicon, containing correct Pro- nunciation and Definition of Terms used in Medi- cine and the Collateral Sciences. Thirtieth Edition. Very small pocket size. Red Edges. Cloth, 75 cents; pocket-book style, $1.00 LONGLEY'S POCKET DICTIONARY. The Student's Medical Lexicon, giving Definition and Pro- nunciation of all Terms used in Medicine, with an Appendix giving Poisons and Their Antidotes, Abbre- viations used in Prescriptions, Metric Scale of Doses, etc. 24mo, cloth, #1.00; pocket-book style, #1.25 ROBERTS' PRACTICE. Fifth Edition. Recommended as a Text-book at University of Pennsylvania , Long Island College Hospital, Yale and Harvard Colleges, Bishop's College, Montreal, University of Michigan, and over twenty other Medical Schools. A HANDBOOK OF THE THEORY AND PRACTICE OF MEDICINE. By Frederick T. Roberts, m.d., m.r.c.p., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Fifth Edition. Octavo. CLOTH, $5.00 ; LEATHER, $6.00. *#* This new edition has been subjected to a careful revision. Many chapters have been rewritten. Important additions have been made throughout, and new illustrations introduced. "A clear, yet concise, scientific and practical work. It is a capi- tal compendium of the classified knowledge of the subject." — Prof. J. Adams Allen, Rush Medical College, Chicago. " I have become thoroughly convinced of its great value, and have cordially recommended it to my class in Yale College." — Prof David P. Smith. " I have examined it with some care, and think it a good book, and shall take pleasure in mentioning it among the works which may properly be put in the hands of students." — A. B. Palmer, Prof, of the Practice of Medicine, University of Michigan. " It is unsurpassed by any work that has fallen into our hands, as a compendium for students preparing for examination. It is thoroughly practical, and fully up to the times." — The Clinic. By Same Author. A NEW COMPEND FOR STUDENTS. ROBERTS' NOTES ONMATERIAMEDICA AND PHARMACY. Just Ready. i2mo. Cloth, Price $2.00. BIDDLE'S MATERIA MEDIGA. Ninth Revised Edition. Recommended as a Text-book at Yale College, University of Michigan, College of Physicians and Surgeons, Baltimore , Baltimore Medical College, Louisville Medical College, and a number of other Colleges throughout the U. S. BIDDLE'S MATERIA MEDICA. For the Use of Students and Physicians. By the late Prof. John B. Biddle, m.d., Profes- sor of Materia Medica in Jefferson Medical College, Philadelphia. The Ninth Edition, thoroughly revised, and in many parts re- written, by his son, Clement Biddle, m.d., Past Assistant Surgeon, U. S. Navy, assisted by Henry Morris, m.d. CLOTH, $4.00 ; LEATHER, $4.75. "I shall unhesitatingly recommend it (the 9th Edition) to my students at the Bellevue Hospital Medical College. — Prof. A. A. Smith, New York, June, 1883. "The larger works usually recommended as text-books in our medical schools are too voluminous for convenient use. This work will be found to contain in a condensed form all that is most valuable, and will supply students with a reliable guide." — Chicago Med. yi. *#* This Ninth Edition contains all the additions and changes in the U. S. Pharmacopoeia, Sixth Revision. STAND ARD TEXT -BOOKS. BLOXAM'S CHEMISTRY. Inorganic and Organic, with Ex- neriments Fifth Edition. Revised and Illustrated, penments. r 8vo, cloth, $3.75; leather, $4.75 CARPENTER ON THE MICROSCOPE and Its Revelations Sixth Edition, Enlarged. With 500 Illustrations and Colored Plates handsomely printed. Demi 8vo, cloth, $ ao o FLOWER, DIAGRAMS OF THE NERVES of the Human Bodv Oriein, Divisions, Connections, etc. 410, cloth, £3.50 GLISAN'S MODERN MIDWIFERY. A lext-book 129 Illustrations 8 vo, cloth, $ 4 -°° \ leather, $5 ; oo HOLDEN'SOSTEOLOGY. A Description of the Bones with Colored Delineations of the Attachments of the Muscles. Sixth Edition. 6x Lithographic Plates and n-yjood^f^ HEADLAND, THE ACTION OF MEDICINE in the System. mSn^PSYCH^OGICAL MEDICINE 8 and ffedfe vous Diseases ; including the Medico-Legal Aspects of Insanity. With Illustrations. 8vo, cloth, $5.00 ^leather $6.00. MEIGS AND PEPPER ON CHILDREN. A Practical Trea- tise on Diseases of Children. Seventh Edition, Revised. use on i^c gvo ^ doth ^ ^ 6qo . leather> j 7-00 PARKES' PRACTICAL HYGIENE. Sixth Revised and En- larged Edition. Illustrated. 8vo, cloth, $ 3 -°o RIGBY'S OBSTETRIC MEMORANDA. 32m , cloth > -5° SANDERSON & FOSTER'S PHYSIOLOGICAL LABOR- ATORY. A Handbook for the Laboratory. Over 350 Illustra- Hons 8vo - cloth ' ^ 5 -°° ; leather ' ^ 6, °P WILSON'S HUMAN ANATOMY. General and Special. Tenth Edition. 26 Colored Plates and 424 Illustrations. $6.00 WYTHE'S MICROSCOPIST. A Manual of Microscopy and Compend of the Microscopic Sciences Fourth Edition. 252 Illustrations. 8vo, cloth, $ 3 -°° 5 leather, $ 4 -°° ACTON ON THE REPRODUCTIVE ORGANS. Their Functions Disorders and Treatment. 6th Edition. Cloth, $2.00 FOTHERGILL, ON THE HEART. Its Diseases and their Treatment Second Edition. 8vo, cloth, fc-So HARLEY ON THE LIVER. Diagnosis and Treatment. Col- ored Plates and other Illustrations. 8vo, cloth, $5-00 ; sheep, £6.co HOLDEN'S ANATOMY. Fifth Edition. Just Ready. A MANUAL OF THE DISSECTION OF THE HUMAN BODY. By Luther Holden, m.d., Late President of the Royal College of Surgeons of England, Consulting Surgeon to St. Bartholomews Hospital. Fifth Edition; edited by John Langton, m.d., f.e.c.1. Surgeon to, and Lecturer on Anatomy at, St. Bartholomew s Hos- pital • Member of the Board of Examiners Royal College of Sur- geons of England; with 208 fine Wood Engravings. Octavo. 886 pages. Cloth, #5.00 ; Leather, $6.00. REESE'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. A Text-book of Medical Jurisprudence and Toxicology. By John J. Reese, m. d., Professor of Medical Jurisprudence and Toxicology in the Medical and Law Departments of the University of Pennsylvania ; Vice-President of the Medical Jurisprudence So- ciety of Philadelphia ; Physician to St. Joseph's Hospital ; Corres- ponding Member of the New York Medico-legal Society. One Volume. Demi Octavo. 606 pages. Cloth, $4.00 ; Leather, $5.00. " Professor Reese is so well known as a skilled medical jurist that his authorship of any work virtually guarantees the thorough- ness and practical character of the latter. And such is the case in the book before us. * * * * We might call these the essentials for the study of medical jurisprudence. The subject is skeletonized, condensed, and made thoroughly up to the wants of the general medical practitioner, and the requirements of prose- cuting and defending attorneys. If any section deserves more dis- tinction than any other, as to intrinsic excellence, it is that on toxi- cology. This part of the book comprises the best outline of the subject in a given space that can be found anywhere. As a whole, the work is everything it promises and more, and considering its size, condensation, and practical character, it is by far the most useful one for ready reference that we have met with. It is well printed and neatly bound. — N. Y. Medical Record, Sept. 13th, 1884. RICHTER'S CHEMISTRY, A TEXT-BOOK of INORGANIC CHEMISTRY for STUDENTS. By PROF. VICTOR von RICHTER, University of Breslau, Authorized Translation from the Third German Edition, By EDGAR F. SMITH, M.A., Ph.D., Professor of Chemistry in Wittenberg College, Springfield, Ohio ; formerly in the Laboratories of the University of Pennsyl- vania; Member of the Chemical Society of Berlin. 12mo. 89 Wood-cuts and Col. Lithographic Plate of Spectra. $2.00 In the chemical text-books of the present day, one of the striking features and difficulties we have to contend with is the separate presentation of the theories and facts of the science. These are usually taught apart, as if entirely independent of each other, and those experienced in teaching the subject know only too well the trouble encountered in attempting to get the student properly in- terested in the science and in bringing him to a clear comprehension of the same. In this work of Prof, von Richter, which has been received abroad with such hearty welcome, two editions having been rapidly disposed of, theory and fact are brought close together, and their intimate relation clearly shown. From careful observa- tion of experiments and their results, the student is led to a correct understanding of the interesting principles of chemistry. In preparation, "ORGANIC CHEMISTRY," By the same author and translator. YEO'S PHYSIOLOGY. A MANUAL FOR STUDENTS. JUST READY. 300 CAREFULLY PRINTED ILLUSTRATIONS. FULL GLOSSARY AND INDEX. By Gerald F. Yeo, m.d., f.r.c.s., Professor of Physi- ology in King's College, London. Small Octavo. 750 pages. Over 300 carefully printed Illustrations. PRICE, CLOTH, $4.00; LEATHER, $5.00. " By his excellent manual, Prof. Yeo has supplied a want which must have been felt by every teacher of physiology. * * * * In conclusion, we heartily congratulate Prof. Yeo on his work, which we can recommend to all those who wish to find within a moderate compass a reliable and pleasantly written exposition ot all the essential facts of physiology as the science now stands." — The Dublin yournal of Med. Science. " The work will take a high rank among the smaller text-books of Physiology." — Prof. H. P. Bowditch, Harvard Med. School, Boston. " The brief examination I have given it was so favorable that I placed it in the list of text-books recommended in the circular of the University Medical College." — Prof. Lewis A. Stimpson, M. D.,37 East 33d Street, New York. " For students' use it is one of the very best text-books in Physi- ology."— Prof L. B. How, Dartmouth Med. College, Hanover, N.H. RINDFLEISCH. THE ELEMENTS OF PATHOLOGY. TRANSLATED BY WM. H. MERCUR, M.D. REVISED AND EDITED BY PROF. JAS. TYSON, Of the University of Pennsylvania. 263 PAGES. CLOTH. PRICE $2.00. *V*It is the object of Prof. Rindfleisch to present in this volume of moderate size the fundamental principles of Pathology A large number of the general processes which underlie disease, a knowledge of which is essen- tial to the practical physician, are plainly presented. They include, among others, inflammation, tumor forma- tion, fever, derangements of nutrition, including atrophy, derangements of the movement of the blood, of blood formation and blood purification, hyperesthesia, anaesthe- sia, convulsions, paralysis, etc. The well-known reputa- tion of the author, his thorough familiarity with and his method of treating the subject, make this most recent work peculiarly useful to the student, as well as to the prac- ticing physician who wishes to brush up his pathology. Tttst Publish £cL VAN HARLINGEN ON SKIN DISEASES. A Handbook of the Diseases of the Skin, their Di- agnosis and Treatment. By Arthur Van Harlingen, M.D., Professor of Diseases of the Skin in the Philadelphia Polyclinic, Consulting Physician to the Dispensary for Skin Diseases, etc. Illustrated by two colored litho- graphic plates. 12mo. 284 PAGES. CLOTH. PRICE $1.75. ***This is a complete epitome of skin diseases, arranged in al- phabetical order, giving the diagnosis and treatment in a concise, practical way. Many prescriptions are given that have never been published in any text-book, and an article incorporated on Diet. The plates do not represent one or two cases, but are composed of a number of figures, accurately colored, showing the appearance of various lesions, and will be found to give great aid in diagnosing. BYPORD, DISEASES OF WOMEN. NEW REVISED EDITION. The Practice of Medicine and Surgery, as applied to the Diseases of Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology in Rush Medical College; of Obstetrics in the Woman's Medical College ; Sur- geon to the Woman's Hospital; President of the American Gynaecological Society, etc. Third Edition. Revised and Enlarged; much of it Rewritten; with over 1 60 Illustrations. Octavo. PRICE, CLOTH, $5.00; LEATHER, $6.00. " The treatise is as complete a one as the present state of our science will admit of being written. We commend it to the diligent study of every practitioner and student, as a work calculated to in- culcate sound principles and lead to enlightened practice " — New York Medical Record. " The author is an experienced writer, an able teacher in his de- partment, and has embodied in the present work the results of a wide field of practical observation. We have not had time to read its pages critically, but freely commend it to all our readers, as one of the most valuable practical works issued from the American press." — Chicago Medical Examiner. MACKENZIE, THE THROAT AND NOSE. By Morell Mackenzie, m.d., Senior Physician to the Hospital for Diseases of the Chest and Throat ; Lecturer on Diseases of the Throat at the London Hospital, etc. Vol. I. Including the Pharynx, Larynx, Trachea, etc. 112 Illustrations. Cloth, $4.00 ; Leather, $5.00 Vol. II. Diseases of the CEsophagus, Nose and Naso-pharynx, with Formula and 93 Illustrations. Cloth, $3.00; Leather, $4.00 The two volumes at one time, Cloth, $6.00 ; Leather, $7.50. RK522 Barrett B27 Dental surgery for medical prac- titioners. COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) HK 522 B27 C.1 Dental surgery for general practitioners 2002398990 ^4 m Ml* ■ ■