if)ENTAL SUEGEEY^ 
 
 JOH 
 
 COKIIESPOXDIXG MEMBER OF THE PHILADELPHIA ACADEMY OF NATURAL SCJE^JCE.^ 
 LATE DEXTAL SURGlIoX TO THE MIDDLESEX AXD DEXTAL HOSPITALS 
 
 CHAELES S. TOMES, M.A. 
 
 LECTURER OX DEXTAL AXATOMT AXD PHYSIOLOGY 
 AND ASSISTANT DENTAL SURGEON TO THE DEXTAL HOSPITAL OF LOXDOX 
 
 SECOND EDITION 
 
 REVISED AND ENLARGED 
 
 Wiih 263 IllttstraliotTS 
 
 LONDON 
 
 J. & A. CHURCHILL, NEW BURLINGTON STREET 
 1873
 
 LONDON . 
 
 <TKl> CT W. CLOWES AND SOX?, -STAMfoKD STilliET 
 AND CHAUrNG CKOSS
 
 100 
 
 CONTENTS. 
 
 TEE THING. 
 
 DEVELOPMENT OF JAWS AXD TEETH . 
 ERUPTION OP TEMPORARY TEETH . 
 IRREGULARITIES OF TEMPORARY TEETH 
 IRREGULARITIES OF POSITION OP TEETH 
 ERUPTION OF PERMANENT TEETH 
 IRREGULARITY OF PERMANENT TEETH 
 
 o 
 17 
 
 37 
 
 G3 
 
 84 
 
 117 
 
 THE DENTAL TISSUES. 
 
 ENAMEL 'Ji-i 
 
 DENTINE 259 
 
 DISEASES OF THE TEE PI 1. 
 
 CARIES 29o 
 
 TREATMENT OF CARIES 308 
 
 DENTAL EXOSTOSIS 422 
 
 NECROSIS OF THE TEETH 44U 
 
 ABSORPTION OF PERMANENT TEF.TII 440 
 
 EROSION OP THE TEETH . 450 
 
 IRRITATION OF THE PULP 456 
 
 ACUTE INFLAMMATION OF THE PULP 4G2 
 
 CHRONIC INFLAMMATION OF THE PULP 40G
 
 17 CONTESTS. 
 
 PAGE 
 
 INFLAMMATION OF ALVEOLAR PERIOSTEUM 476 
 
 NECROSIS OF THE JAWS 495 
 
 ABSORPTION OF THE ALVEOLI 509 
 
 HYPERTROPHY OF ALVEOLAR BORDER 515 
 
 HYPEROSTOSIS 523 
 
 STOMATITIS 526 
 
 ULCERATION OF THE TONGUE 542 
 
 TUMOURS OF THE GU3IS 545 
 
 SALIVA AND SALIVARY CALCULUS 554 
 
 ODONTALGIA 561 
 
 NEURALGIA 567 
 
 SECONDARY AFFECTIONS DUE TO DISEASED TEETH . . . 587 
 
 ODONTOMES 598 
 
 DENTIGEROUS CYSTS 616 
 
 DISEASES OF ANTRUM 634 
 
 CLOSURE OF THE JAWS 644 
 
 FRACTURE OF THE TEETH 649 
 
 DISLOCATION OF THE TEETH 655 
 
 INJURIES OF THE JAWS 659 
 
 PIVOTING TEETH 663 
 
 EXTRACTION OF TEETH 670 
 
 HiOIORRHAGE AFTER EXTRACTION 706 
 
 ANAESTHESIA 711 
 
 APPENDIX ON DENTAL CARIES 716
 
 I 
 
 PREFACE 
 
 TO THE FIRST EDITION. 
 
 In the following pages an attempt lias been made to produce 
 within the limits of a manual a strictly practical work on 
 Dental Surgery. In order to fulfil this object, it became neces- 
 sary to enter upon the structure and development of the teeth 
 and jaws in a limited degree only, and to leave untouched 
 any historical account of the writings of those who have 
 from time to time contributed to our knowledge in this 
 branch of surgery. The diseases of the teeth, and of the 
 parts subservient to them, together with the coincident 
 maladies, have been treated of, so far as may be, in the 
 natural order of their occurrence, and the structure and 
 development of the tissues involved have been to some 
 extent described before entering upon the diseases to which 
 they are respectively liable. 
 
 In a work devoted to the description of practical details, 
 the modes of proceeding in the treatment of diseases, whether 
 by operations or otherwise, must necessarily be those prac- 
 tised by the author. The methods adopted by others are 
 known only through published descriptions, the mere reprint 
 of which would be but a work of supererogation. On this 
 account, together with the want of space, the quotations
 
 VI PREFACE. 
 
 from other writers have been but limited. I must, however, 
 express my obligatiou to many of those who have written 
 upon dental surgery, and I cannot leave immentioned the 
 names of Mr. Bell, Mr. Spence Bate, Mr. Samuel Cartwright, 
 Mr. Chapin Harris, and Mr. Arthur. Reference is not 
 unfrequently made to a series of lectures published in 1848. 
 Many subjects but imperfectly touched upon in these pages 
 are more fully treated in that work, and many specimens 
 are there figured which illustrate subjects discussed in this 
 volume. 
 
 The demands of an active practice leave but little leisure 
 for writing, and that little has been seriously interrupted by 
 engagements consequent upon the gradual organization which 
 the dental profession has recently undergone. From these, 
 and from causes less controllable, the present work has 
 passed very slowly through the press, mau\' of the earlier 
 sheets having been in print upwards of eighteen months. 
 
 To Mr. Bajg I am greatly indebted for the highly artistic 
 illustrations which he has produced from sjjecimens in my 
 own collection, and from others which have been liberally 
 contributed by my professional friends. 
 
 JOHN TOMES. 
 
 37. Cavexdish Square, 
 Febrmry 28, 1859.
 
 PREFACE 
 
 TO THE SECOND EDITION. 
 
 The material progress which has been made by the science 
 of Dental Surgery since the publication of the first edition of 
 this work, has necessitated large additions to the text; the 
 bulk of the volume has, however, been kept within con- 
 venient limits by a slight reduction in the size of the print. 
 Those portions of the book w-hich are devoted to the 
 description of neuralgia, dentigerous cysts, odontomes, 
 secondary affections resulting from the irritation set up by 
 dental disease, as well as many other shorter sections, are 
 entirely new ; and nearly sixty fresh illustrations have been 
 added, of which a few have been, by permission of Messrs. 
 Longman, borrowed from my father's earlier work, the 
 lectures on dental physiology and surgery; others have 
 been, with the consent of the Council, reprinted from the 
 Transactions of the Odontological Society ; to the kindness 
 of Mr. Christopher Heath also I am much indebted for the 
 use of several figures, which have been reproduced from his 
 valuable work on the " Diseases and Injuries of the Jaws," 
 to which frequent reference will be found in these pages ; 
 whilst a considerable number of woodcuts have been specially 
 executed for this edition bv Mr. W. H. Weslev.
 
 Vlll PEEFACE. 
 
 The description of deatal caries, with the exception of 
 some slight additions and alterations, remains much the 
 same as in the first edition ; but a fuller discussion of the 
 whole subject has been added in the form of an appendix, in 
 which a summary of the conclusions to be drawn from receipt 'i 
 investigations will be found. V- 
 
 In the section relating to the dental tissues due prominence 
 has been given to the opinions of continental observers, and 
 references to the more important works consulted have been 
 inserted, though it would be impracticable, even were it de- 
 sirable, to encumber a text-book by tracing every statement 
 to its source. But I cannot refrain from acknowledging the 
 assistance which I have derived from Prof. Wedl's recent 
 work, " Die Pathologic der Zahne," as well as from the atlas 
 published jointly by Professors Heider and Wedl. 
 
 CHARLES S. TOMES. 
 
 37, Cavendish Square, 
 January, 1873.
 
 A SYSTEM 
 
 OP 
 
 DENTAL SUEGEEY, 
 
 TEETHING. 
 
 The term teething miglit be employed to express the develop- 
 ment of tlie teeth from the commencement to the completion 
 of the formative action ; but custom has limited its use to 
 the expression of a single phase of the process —that is, to 
 the eruption or cutting of the temporary teeth. Although 
 this, nearly the last in a series of developmental actions, may 
 be regarded in many respects as the most interesting, and the 
 one which the medical practitioner is usually required to watch, 
 yet if observation were restricted to the eruption of the teeth 
 ^vithout instituting an inquiry into the preceding conditions, 
 our knowledge of the subject would be very imperfect. It is 
 proposed, therefore, in the present instance, to describe the 
 conditions of the teeth and jaws at the time of birth, and to 
 trace the changes onwards until the temporary teeth have 
 arrived at maturity. 
 
 At the time I undertook to write the present volume, the 
 museums in which an extended series of young skulls would 
 be likely to be found were visited, but without success. So 
 far as I could learn, no such series existed. It therefore 
 became necessary to make a collection, taking care that the 
 age of each specimen should, if possible, be ascertained. This 
 has been done, and the preparations comprised in the collection 
 are sufficiently numerous to allow of deductions being made 
 
 B
 
 2 A SYSTEM OF DENTAL SUBGERT. 
 
 from the characters they present. But should the conclusions 
 drawn from the study of these ultimately prove in some 
 respects incorrect, the want of accm'acy can only be substan- 
 tiated by the study of a still more extended series. But until 
 such a collection is made, it will be safer to adopt the con- 
 ditions of the preparations at present at my disposal, as fair 
 examples of the states of the dental apparatus at the several 
 ages, than to assume that the opinions generally extant, when 
 at variance with them, are in all cases correct. Feeling that 
 this course is the more likely one to lead to a coiTect 
 knowledge of the subject, I shall, in the following pages, 
 tlescribe the conditions presented by individual specimens, 
 selecting such as appear most typical of the ages chosen for 
 description. 
 
 If two i^erfectly healthy children, whose ages are similar, 
 be selected for examination, we shall rarely find that they 
 present precisely similar conditions as. regards the rate of 
 teething ; yet there will probably be no great disparity in the 
 conditions of the two. Each will pass through the same 
 phases, although, until the process of dentition is completed, 
 one may be a few weeks, or even months, in advance of the 
 other. 
 
 There is, however, another source of fallacy to be guarded 
 against. The specimens obtained are necessarily taken from 
 individuals who have been the subjects of disease ; and sup- 
 posing the fatal illness to h^ve been of long standing the jaws 
 may have been modified. That such has occurred to some 
 members of the series is sufficiently obvious, but the diseased 
 action appears to have influenced the growth of the jaws them- 
 selves, rather than the rate of development of the teeth. 
 Hence, even these specimens may serve to confirm the results 
 obtained from an examination of healthy jaws so far as the 
 teeth are concerned. 
 
 Those minor difi"erences in size and form which constitute 
 in4ividuality, by which we are enabled to distinguish one 
 person from another, though in all essential characters they
 
 TEETHING. O 
 
 are precisely similar, must be borne in mind when investiga- 
 tions of this character are undertaken. 
 
 It would perhaps be difficult to find a more interesting 
 subject for investigation, than the progressive changes in form 
 and of relative proportion between the various parts of the 
 jaws during infancy which occur as necessary consequences 
 of their mode of growth, and are connected with the develop- 
 ment and arrangement of the teeth. 
 
 The fact that the development of the hard tissues of a 
 tooth is preceded by the formation of soft tissue, or tooth- 
 pulp, of equal size and form to the future tooth, must at all 
 times be kept in view. Xot that the pulp assumes the 
 dimensions of a perfected tooth before the development of the 
 hard tissues commences, but that each part of the gradually 
 developing tooth is first formed in soft tissue of its full size, 
 and then calcifies. For example, the cusps of the molars and 
 the edges of the front teeth first assume their full dimensions 
 • in the form of pulp, and then calcify ; the process of gradual 
 development and subsequent calcification proceeding until 
 the teeth are perfected. In dentine, which forms the great 
 bulk of each tooth, we have no such thing as outward growth ; 
 no addition to the external surface of the formed tissue ever 
 takes place, excepting by the superposition of the enamel, and 
 cementum, which respectively coat the crown and the root of 
 the tooth ; but these add comparatively little to the size of the 
 organ. Hence it follows that boAh the forms and dimensions 
 of the crowns of the teeth are unalterably fixed long before 
 the jaws are sufficiently enlarged to admit of their ultimate 
 and normal arrangement. 
 
 If the maxillee ol" a full-grown foetus be examined, it will 
 be found that the union of the two halves both of the upper 
 and lower jaws is effected by the interposition of fibro-car- 
 tilage, which allows a certain amount of motion between 
 the parts thus connected. The alveolar margins are deeply 
 indented with large open crypts, more or less perfectly formed. 
 The depth of these bony cells is only sufficient to contain tlie
 
 4 A SYSTEM OF DENTAL SUEGEET. 
 
 developing teeth and teeth-pulps, the former rising to the 
 level of the alveolar margins of the jaws. At this period 
 the crypts or alveoli are not arranged in a perfectly uniform 
 line, neither are they all equally complete. The septa, which 
 divide into a series of cells that which at an earlier age was 
 but a continuous groove, are less perfect at the back than at 
 the front part of the mouth. The alveoli of the central in- 
 cisors both of the upper and lower jaws are a little larger within 
 than at the orifice, and this diflerence is made still greater 
 by a depression upon the lingual wall of each for the reception 
 of the pulp of the corresponding permanent tooth. They are 
 divided from the crypts of the lateral incisors by a septum, 
 which nms obliquely backwards, and a little inwards towards 
 the median line. The sockets of the lateral incisors occupy 
 a position slightly posterior to those for the central teeth, and 
 are divided from the canine alveoli by a septum which pro- 
 ceeds obliquely backwards, and in the lower jaw (as regards 
 the median line of the mouth) outwards (Fig. 2). By the 
 arrangement of these divisions, the alveoli of the central in- 
 cisors are rendered broader in front than behind, and the 
 relative dimensions of the sockets of the lateral teeth are re- 
 versed, as shown in Figures 1 and 2. The crypts of the 
 canine teeth are placed a little anterior to those of the 
 laterals, and nearly in a line with the central incisor sockets, 
 giving to the jaws a somewhat flattened anterior surface. 
 The septum dividing the canine from the first temporary 
 molar crypt is not subject to the obliquity observed in the 
 two preceding examples, but proceeds directly across from 
 the outer to the inner alveolar margin, giving to the socket 
 for the canine a greater breadth in front than behind, which 
 peculiarity is still further increased by the anterior wall being 
 bulged outwards. In these alveoli we have at present no 
 depression provided for the pulps of the permanent teeth. 
 
 The sockets for the first temporary molars are placed in the 
 median line of the alveolar ridge ; have a somewhat square 
 form, with the outer margins inverted; and in the lower
 
 TEETHING. 5 
 
 maxilla are marked on their floors by a slight groove, in 
 which the inferior dental nerve and artery lie. The very 
 close approximation of the nerve to the developing teeth may 
 serye^in some measure to explain the liability of children to 
 reflex nervous disturbances dependent on the teeth. The 
 nerve and artery enter the alveolus on either side through an 
 aperture in the base of the septum, which divides imperfectly 
 the first from the second temporary molar, and pass out to 
 the external surface of the jaw through an orifice in the 
 septum dividing the canine from the former tooth. 
 
 Posterior to the alveoli for the first temporary molars we 
 have a large open socket, which, in the upper maxilla, has 
 but a very imperfect posterior wall. Projecting inwards from 
 the free edge of the outer and inner alveolar walls, we may 
 observe small spicula, the rudiments of septa which are 
 destined to divide the cavity into two distinct sockets, and 
 thus separate the pulps of the second temporary and first 
 permanent molar teeth, both of which at present occupy one 
 large alveolus. The division usually takes place a little earlier 
 in the lower than the upper jaw. The groove which marks 
 the passage of the nerve and artery in the floor of the socket 
 of the first temporary molar, is continued through the alveoli 
 of the two posterior teeth, having entered the jaw by the 
 inferior dental foramen, which is situated midway between 
 the angle of the jaw and the edge of the inner wall of the 
 alveolus of the first permanent molar, a little below the floor 
 of the posterior part of the last alveolus. 
 
 At this period the articular process of the lower jaw is 
 scarcely raised above the level of the alveolar edge, while the 
 angle is projected downwards a little below the general level 
 of the inferior margin of the jaw. The coronoid process rises 
 at an angle of forty-five degrees from the alveolar edge, its 
 ascent commencing at the anterior boundary of the socket 
 of the first permanent molar. In the upper jaw the zygo- 
 matic process proceeds, outwards from the anterior margin of 
 the large open socket of the second temporary molar.
 
 A SYSTEM OF DENTAL SURGERY. 
 
 Fig. 1. (1) 
 
 Fig. 2. (2) 
 
 (i; The upper jaw of a nine-months' foetus deprived of the soft parts, 
 showing the rekitive positions and dimensions of the alveoli, the partly deve- 
 loped teeth having b-en removed from the sockets on the right side of the 
 jaw. a, the socket of the lateral incisor ; h, that of the canine ; c, the alveolus 
 of the second temporary molar, the po>terior wall at this age being absent. 
 This and the subsequent figures are two-thirds life-size. 
 
 (2) The lower jaw of a nine-months' foetus, showing the condition of the 
 alveoli, a, the sockets of the lateral incisors; b, those of the canine teeth; 
 c, the alveoli of the second temporary and first permanent molars. A bristle 
 is placed in the inferior dental canal.
 
 TEETHING. 7 
 
 It is necessary to notice, with some degree of accuracy, the 
 relative position of these points, as in tracing the growth of 
 the jaws, changes occur which can be recognised only by a 
 knowledge of the preceding conditions. 
 
 The inferior edge of the lower jaw in the nine-months' 
 foetus is undulated ; the angle and the point where the sockets 
 of the first and second temporary molars join being the lowest 
 points, while the intermediate parts of the margin are curved 
 upwards. Viewed in profile, it will be seen that the alveolar 
 margin projects over, and therefore forms a bolder curve than 
 the inferior borders of the jaw. At the junction of the two 
 halves each jDortion is expanded, forming on the anterior 
 surface a vertical process, which extends from the alveolar tc) 
 the inferior margin of the maxilla, the greatest prominence 
 being attained in the middle part of its course. (Fig. 4.) 
 
 The position of the zygomatic process has been already 
 noticed, but the general peculiarities of the alveoli remain to be 
 described. In the upper jaw the inner alveolar ridge descends 
 but little below the level of the hard palate, although the 
 sockets have attained a considerable depth. At this age the 
 antrum is represented by a depression on the outer wall of the 
 nasal cavity, while the alveolar cavities extend to the base of 
 the orbit, from which they are separated by a thin plate of 
 bone ; similar relations being maintained with regard to the 
 anterior part of the nasal cavity. 
 
 The temporary teeth at this period are partly foiTaed. The 
 central incisors are calcified through the greater length of the 
 crown ; but the lateral teeth are less advanced. The terminal 
 points only of the canines are calcified, while the masticating 
 surfaces of the first temporary molars are completed, excepting 
 the enamel, which at this stage has uot attained more than 
 half its thickness, a condition common also to the more 
 anterior teeth. The second temporary molar is represented 
 by calcified cusps, which are united in a circle, the central 
 part of the crown being as yet uncalcified. These conditions 
 are shown in Figs. 1 and 2. If examined in the recent
 
 8 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 condition, it will be seen that in the front teeth calcification 
 has advanced nearly to the base of the tooth pulp, which ends 
 
 Fig. 3. (1) 
 
 Pig. 4. (2) 
 
 in a broad flat surface; while in the canines and molars the 
 pulp extends a short distance below the terminal line of 
 calcification. 
 
 By dividing the mucous membrane and subjacent periosteum 
 a little below^ the upper margin of the alveoli, both on the 
 labial and lingual surfaces of the jaw, in a specimen which 
 has been kept a short time in sjarit, and then carefully raising 
 the membrane from the surface of the bone, we shall be 
 
 (1) The upper jaw of a nine-months' foetus, the soft parts having been 
 removed, showing the outer surface of the alveolar processes, a, the depressed 
 portion corresponding to the position of the lateral incisor. 
 
 (2) The lower jaw of a nine-months' foetus, showing the relative size and 
 position of the several parts of the bone at this age.
 
 TEETHING. » 
 
 enabled to withdraw from their sockets the developing teeth 
 enclosed in their sacs, which will remain firmly attached to 
 the gum. The relative position of the dental sacs will be 
 seen to correspond with the arrangement of the alveoli 
 already described. The union of the external coat of the 
 sac with the tissues of the gum, and of the lower portion of 
 the pulp with the base of the sac, may be demonstrated. 
 
 At the age_of^ two mordhsjont little change from the foetal 
 characters has taken place in the upper jaw. The maxilla is, 
 however, generally a little larger, and the sockets slightly 
 deeper and more prominent at the anterior free margins, than 
 at the time of birth ; the relative position of the teeth being 
 unchanged. In the lower jaw the differences are much more 
 strongly marked. In addition to a general increase of size, 
 growth has advanced rapidly in the ramus, and the angle 
 become less obtuse. The articular process rises above the 
 general level of the alveolar ridge, an indication that during 
 the early weeks of infancy growth is more active in the 
 ascending ramus than in any other part of the lower jaw. At 
 the point of junction of the two halves, increase in the depth 
 of the jaw may be observed. This has been in great part 
 effected by additions to the free edge of the alveoli, which 
 have been extended anteriorly into a somewhat larger curve. 
 But in addition to growth in the positions mentioned, develop- 
 ment has gone on from the opposed surfaces of the two halves 
 encroaching upon the fibro-cellular tissue which connects 
 them. The structural character of this development will be 
 subsequently considered. Similar changes occur in the 
 suture connecting the two halves of the upper jaw. Growth 
 proceeds in the line of junction of the two halves, and indeed 
 at each of those points where the bone is at present connected 
 only by soft tissue to the adjoining bones. Increase of bone 
 in the median line would necessarily lead to separation of the 
 central incisors ; this is, however, prevented by the teeth on 
 either side inclining towards the centre, and the sockets 
 partake in a similar change of direction, the free edges of
 
 10 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 which are closely approximated, while the deeper parts becom 
 separated from each other. 
 
 Fig. 6. (-) 
 
 At the age of tico months, the teeth are more advancai in 
 development than at the time of birth, but the change is not 
 so strongl)^ marked in them as in the maxillae. The crypt 
 of the pulp of the first pennanent molar is yet without a 
 posterior wall in the upper jaw ; and in the lower jaw, the 
 
 (1) The upper Jaw of a male two months old, showing the general increase 
 of size as compared with the foetal jaw, and the increased depth of the alveolar 
 processes. 
 
 (2) The lower jaw of a male t« o months old, showing the increased size as 
 compared wi;h the fcctil jaw given in Fig. 4, and the changes in the relative 
 position of the body and ascending ramus during the two months succeeding 
 birth.
 
 TEETHING. 
 
 11 
 
 septum dividing this from the socket of the second temporary 
 molar is incomplete. 
 
 When the third month has been attained, the maxillae show 
 
 Fig 7. (1) 
 
 Fig. 8. (2) 
 
 (1) The upper jaw of a male two months old, showing the condition of the 
 alveoli and forming teeth at that age. 
 
 (2) The lower jaw of a male two months old, showing the condition of the 
 alveoli and teeth at that period.
 
 12 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 a further development in the directions already indicated. 
 The angle of the lower jaw is more pronounced, and the bone 
 much more solid. The alveoli, however, exhibit a considerable 
 change in character ; their depth has increased ; and the free 
 edges, which were before open, so that in a macerated pre- 
 paration the teeth readily fall out, are now turned inwards 
 towards the median line of the alveolar ridge, thereby (;on- 
 tracting the orifices, and affording protection to the enclosed 
 teeth, which are no longer hable to fall out when the bone is 
 examined. The direction of the rami is but little changed. 
 
 Fig. 9. (I) 
 
 rig. 10. (2) 
 
 (>) The upper jaw of a male three months old, two-thirds life-size. 
 (2) The lower jaw of a male three months old. In the ^pecimen from which 
 this figure is taken the lat-ral incisors are wanting.
 
 TEETHING. 
 
 13 
 
 but considerable addition of bone at the lower border of the 
 angle will be observed, the sigmoid notch at the same time 
 being widened. The symphysis is still strongly marked in 
 
 Pig. 11. (n 
 
 Fig. 12. (2) 
 
 (1) Theuppsrjaw of a male three months old, showing the advanced con- 
 dition of the alveoli, and the inversion of the edges of each socket, together 
 with completion of the posterior wall of the sockets which contain the second 
 temporary molar and the pulp of the first permanent molar. 
 
 (2) The lower Jaw of a male three months old, showing the inversion of 
 alve(jlar edges, and consequent contraction of the apertures. The lateral 
 incisors are wanting.
 
 14 A SYSTEM OF DENTAL SURGERY. 
 
 each half of the bone, and viewed in profile the curved out- 
 line is still preserved. The figures illustrating the condition 
 pecuHar to this age are singular from the absence of lateral 
 incisors in the lower jaw, and in the want of a crypt for the 
 first permanent molar on one side of the up]X}r jaw. In other 
 respects they present the characters common to jaws of similar 
 age. 
 
 Passing from a subject of three to one of six months old, 
 the differences are not at first sight very "sffi"kmg. The 
 angle formed by the borders of the body and ramus of the 
 lower jaw does not appear to be less obtuse than' in younger 
 skulls. This is, however, due to a considerable increase 
 of bone on the lower border, especially near. and about 
 the symphysis, at the same time that the mental promi- 
 nence_is beginning to appear and occupy a more forward 
 position than the margin of the alveolar ridge. The sockets 
 are generally increased in depth, but in a greater degree in 
 the anterior than at the posterior part of the line. The 
 posterior w'all of the crypt of the first pennanent molar in 
 the upper maxilla is still imperfect ; and the septum between 
 the second temporary and first permanent molars in the lower 
 jaw is incomplete. The teeth a't the age of six months are 
 more advanced than at the ages previously described ; but the 
 difference is much more marked in the incisors than in the 
 other teeth. The canines and second molars are more forward, 
 but the rate of progress has been slower than in the other 
 teeth. 
 
 The inversion of the edges of the alveoli, and consequent 
 narrowing of the apertures described as pertaining to the 
 jaws of three months old, is less pronounced at six months, 
 although as yet the teeth lie below the free edges of the 
 sockets. The increased size of the alveolar orifices must be 
 Ts^vded as the first of those changes which precede the 
 eruption of the teeth. 
 
 The relative position of the teeth is but little changed ; the 
 canines of the upper jaw are even more out of the regular
 
 TEETHING. • 15 
 
 line than formerly, being placed at this period almost external 
 to the lateral teeth, thereby producing great prominence in 
 the jaw at these points. 
 
 The bony cells for the permanent central incisors are now- 
 well marked, producing a prominence on the palatine surface 
 of the alveolar process, but they usually communicate with 
 crypts of the temporary teeth by a large orifice. The cells for 
 the permanent lateral incisors are at present indicated only by 
 a depression on the lingual surface of the crypts occupied by 
 the temporary teeth. 
 
 At the age of eight months^ we may see indications of 
 further progress^ In the specimen figured, that of a male 
 nine months old, the conditions of the alveolar ridge are 
 becoming rapidly changed. At the front part of the mouth, 
 the alveoli, which have hitherto developed more rapidly 
 than those situated further~ba'clj, now' become the seat of 
 absorption ; while the more posterior ones assume a greater 
 activity of growth. The central incisors of the upper jaw, 
 although they do not descend below the general level of the 
 alveolar ridge, are exposed on their anterior surfaces by the 
 absorption of great part of the outer wall of the sockets, at 
 the same time that the teeth have moved bodily a little forward. 
 The outer edges of the central teeth are in front of the lateral 
 teeth, the latter being still placed in a line internal to the 
 canines, so that if the teeth were cut in their present posi- 
 tions, the arrangement would be extremely irregular. Indica- 
 tions of the removal of the anterior walls of the sockets of the 
 lateral incisors are shown in their emarginated edges, while the 
 alveoli of the other teeth still preserve their inverted margins. 
 
 The crypts of the permanent central incisors are becoming 
 separated from those of the temporary teeth by the growth 
 of septa, which rise towards the surface from the deeper part 
 of the sockets ; and growth is continued in this direction until 
 the opening becomes level, or nearly so, with the free margin 
 of the sockets of the temporary tooth. 
 
 The sockets of the molar teeth, which in the fcetus ex-
 
 16 
 
 A SYSTEM OF DENTAL SUBGEEY. 
 
 tended to the floor of the orbit, are now separated from it by 
 the antrum, which at this time is represented by a deep 
 
 Fig. 13. 0) 
 
 Fig. 14. (2) 
 
 depression, extending under the orbit in its inner two-thirds. 
 The septum between the socket of the second temporary 
 
 (1) The upper jaw of a male nine months old, showing absorption of the 
 anterior walls of the sockets of the central incisors preparatory to the escape 
 of the crowns of the teeth from their alveoli. 
 
 (2) The lower jaw of a male nine months old, showing absorption of the 
 outer walls of the socket of the incisors preparatory to the eruption of those 
 teeth. Two-thirds life-size.
 
 TEETHING. 17 
 
 and first permanent molar is still imperfect, and the pos- 
 terior wall of the crypt of the latter tooth, although incom- 
 plete, is in progress of development. 
 
 In the lower jaw the changes from the earlier conditions 
 are more striking. The two halves, which in the upper are 
 still separable, are in the inferior maxilla becoming united, 
 and no longer part under maceration. The symphysis and 
 mental prominence are strongly marked, the bone behind 
 the front teeth is thickened, and at the alveolar margin 
 turned outwards, giving a curved surface, the convexity 
 being directed towards the tongue, — a form altogether dit- 
 ferent from that of the corresponding part in the mature 
 foetus, when the line of the symphysis at the posterior sur- 
 face of the jaw is straight. It was shown that in the foetal 
 jaw the point of the interior border corresponding to the 
 position of the first and second temporary molars, descends 
 to a lower level than the parts anterior or posterior to 
 it. In the nine-months' jaw, the relative heights of the 
 three parts indicated are changed, the middle portion now 
 being the highest. The removal of the anterior wall of the 
 alveoli of the central incisors, and partly also of that of the 
 lateral teeth, has been efiected in the lower as in the upper jaw. 
 
 Taking the jaw figured as a fair standard of the con- 
 ditions peculiar to this age, it will be seen, on comparison 
 with the preceding figures, that the bone has undergone 
 great change, not only in size, but also in form, and that 
 the changes in form are more remarkable in some parts of 
 the jaw than in others. 
 
 In order to institute a comparison of the relative changes 
 which mark the growth of a bone, it is necessary to find 
 some fixed points from which to take measurements ; this, 
 however, is no easy matter, seeing that processes for the 
 attachment of muscles, or foramina, change their position 
 from time to time. To illustrate what is meant by this 
 change of position, suppose that a process for the attach- 
 ment of a muscle is situated at a point one-third of the way 
 
 c
 
 18 A SYSTEM OF DENTAL 8UEGERY. 
 
 down a long bone of a fcetus. Now if this bone grow equally 
 at its two ends by dei[3osition in its epiphyses, eventually 
 the process (if it remained still) would come to be very 
 nearly in the middle of the bone, for that approximation 
 towards one end which made a great difference in a small 
 foetal bone would make only an inappreciable difference in 
 an adult bone six or seven times the length of the former. 
 But as a matter of fact such is not the case: a process 
 situated at a point distant from one end of a long bone by 
 one-third of its length preserves that proportionate distance, no 
 iriatter how much the bone may grow ; obviously this can 
 only come about by the process shifting its position,^ and 
 as it were gliding along the surface of the bone. Now if 
 the jaw-bone were in all respects comparable to a long bone, 
 this fact would offer an insuperable objection to the choice 
 of any muscular process or foramen as a point of measure- 
 ment. Fortunately, however, for our present purpose, the 
 lower jaw-bone stands in quite a different position to that 
 of a long bone: if we draw a horizontal line through the 
 level of the upper pair of spinte mentales in an adult jaw 
 we shall about equally divide it ; but the life history of that 
 part which lies above the line and that which lies below 
 it is widely different. The lower jjortion is the jaw that 
 supports muscles of deglutition, of mastication, and the 
 like structures essential to the well-being of the animal, and 
 is progressively developed from the earliest time of ossifica- 
 tion until it has attained its full size without intermission ; 
 not so however the }X)rtion of bone above our imaginary 
 line. This is subservient to one purpose only : that of sup- 
 porting the teeth when perfected, that of protecting them 
 whilst developing. And so far from being itself gradually 
 elaborated and developed without a check, it was built up 
 around the calcifying temporary teeth, and then in part 
 removed to allow of their eruption : built up again around 
 their fangs, and yet once more absorbed to give exit to the 
 (1) G. M Humphrey, in Trans. Med. Chirurgical Society, vol. xiv.
 
 TEETHING. 19 
 
 permanent teeth : then developed afresh around the roots of 
 the permanent set of the teeth, so that in the sockets of the 
 permanent teeth probably not one fragment of the original 
 alveolar portion of the jaw remains. And when the teeth 
 are shed for the last time the alveolar portion of the jaw 
 is again removed, Kelatively, then, to the changeable al- 
 veolar portion we may regard the body of the ramus as fixed 
 and immutable, and we shall not be led into any error of 
 consequence by taking muscular processes or foramina on 
 the latter as points of measurement from which to estimate 
 the relative proportions of these two parts of the horizontal 
 ramus at various ages. 
 
 The foramen mentale is particularly suitable as a point 
 from which to take relative dimensions, as its position may 
 be practically assumed as fixed, undergoing little or no 
 change after birth. In the full-grown foetus it is situated 
 at the point corresponding to the septum which divides the 
 sockets of the temporary canine and first temporary molar, 
 and on a plane with the bottom of the alveoli. In the adult 
 jaw, the foramen is in close proximity with the extremity 
 of the root of the first bicuspid — that is, on a level with 
 the bottom of the socket of the tooth which succeeds the 
 first temporary molar. Now, assuming that the position 
 of the latter tooth and its successor remains unchanged 
 during growth, while other parts undergo alterations, we 
 have a point from which the relative amount of increase 
 of different parts, and of the same part at different ages, can 
 be estimated. If the terminal portion of the inferior dental 
 canal be examined in the foetus its orifice will be found to 
 be in the direct line of its course, opening forwards, but in 
 an adult jaw it will be found to look outwards, upwards, 
 and backwards, so that its position is slightly posterior to 
 that which it would have assumed had it remained in 
 the line of the canal. This change in position is due to a 
 great increase in the thickness of the bone from deposition 
 on its outer surface, and to that tendency to a preservation 
 
 c 2
 
 20 . A SYSTEM OF DENTAL SURGERY. 
 
 of its original position relatively to the length of the jaw 
 already alluded to (page 18). But inasmuch as the grovrth 
 of the jaw differs in many important particulars from that 
 of the long bones, the foramen does not fully preserve its 
 original position relatively to the two ends of the bone, 
 but in the adult is proportionally farther from the ascending 
 ramus than in the fcetal jaw. 
 
 An examination of a series of jaws serves to show that 
 almost the whole change which is effected in the position 
 of the foramen is completed within the first few months 
 after birth ; after this time no marked change takes place, 
 it having then become opposite to the middle of the socket 
 of the first temporary molar, and remaining in the adult 
 opposite to the root of the first bicuspid. 
 
 On the inner surface of the jaw the tubercles for the 
 attachment of the genio-hyo-glossus and genio-hyoideus 
 undergo but little change during the growth of the jaw. 
 In the fcetus they are placed opposite to and a little below 
 the base of the sockets of the central incisors; the two 
 upper tubercles being even at this early age well marked. 
 In the adult subject the position, as regards the central 
 incisors, is the same, excepting in those cases in which the 
 alveolar process is developed in an unusual degree, in which 
 case the extremities of the roots of the teeth occupy a 
 higher level than the spina3 mentales. The upper of the 
 two pairs of processes are at all ages nearly at the same level 
 as the mental foramina, though where the latter have a dis- 
 tinctly upward direction, as is sometimes the case in the 
 adult, they rise to a somewhat higher level. 
 
 If, on the inner surface of the jaw, the distance between 
 the junction of the septa between the sockets of the first and 
 second temporary molars and the inner plate of the alveoli 
 of either side be measured in the full-grown fcetus, and in 
 jaws up to the age of nine months, when osseous union 
 between the two halves usually commences, this measure- 
 ment being: made on a level with the attachment of the
 
 TEETHING. 21 
 
 genio-liyo-glossus muscle, it will be found, that although 
 the jaws have with age greatly increased in size, yet the 
 distance between these points has not materially increased. 
 Again, if a line be stretched across from the above points, 
 and measurements be made from the centre of the line to 
 the upper of the two pairs of spinae mentales, it will also 
 be found that the distance has not increased with the ageing 
 of the subject. But if the measurement be made from the 
 centre of the line to the anterior alveolar plate, it will be 
 seen that the distance between these two points gradually 
 increases with the age of the subject, and that the front teeth 
 contemporaneously assume a more forward position. The 
 stationary condition of the inner, while the outer alveolar 
 plate and teeth are moved forward, allows the former to 
 increase in thickness, and afford receptacles for the pulps 
 of the anterior permanent teeth. 
 
 Three years after the publication of the preceding state- 
 ments in the first edition of this work. Dr. Humphrey read a 
 paper before the Cambridge Philosophical Society,(^) in which 
 an identical conclusion was arrived as to the growth of the 
 jaw by inferences from a series of experiments performed by 
 inserting wires into the jaws of growing animals. 
 
 The following diagram may serve to render this point 
 , clearer ; in it a jaw from a nine-months' foetus is placed over 
 ' an adult jaw, the limits of which are marked by unshaded 
 lines. 
 
 It will be seen that the arch of the jaw in the foetus is 
 as wide and as large as in the adult ; the difference between 
 them in this part being simply due to additions to its thick- 
 ness, to a slight extent on the inside, but very much more 
 on the outside of the jaw. It will also be seen that the 
 increase in size in the adult jaw is gained exclusively by 
 its prolongation backwards, and not by anything like inter- 
 stitial growth. As expressed by Dr. Humphrey, " Although 
 the bones of the alveolar arch are lengthened, and the arch 
 0) " British Journal of Dental Science," vol. vi., p. 548.
 
 22 
 
 A SYSTEM OF DENTAL SUEGERY. 
 
 is rendered more elliptical, it is not widened. The widening 
 of the jaw, in correspondence with the increasing width of 
 the base of the skull, takes place behind the alveolar arch 
 in the ascending portion, and is effected by the progression 
 of absorption on the inner and addition to the outer surface 
 of this part." But without the aid of this modelling pro- 
 
 Fig. 15. 
 
 t) 
 
 cess, the mere prolongation backwards of the horns would 
 give a considerable increase in width. 
 
 The growth of the anterior part of the jaw by addition of 
 bone previous to union at the symphysis, may be computed 
 by relative measurements of the foetal and nine-months' jaws. 
 An increase of distance between the symphysis and mental 
 foramen, amounting to the eighth of an inch in favour of the
 
 TEETHING. 23 
 
 older jaw, is shown. This increase will be found to corre- 
 spond in amount with the greater thickness in the antero- 
 posterior direction near the symphysis of the nine-months' jaw 
 compared with the foetal bone. If a line be drawn the 
 eighth of an inch in front of the symphysis of the foetal jaw, 
 and the distance from the mental foramen to that point of 
 the line corresponding to the symphysis be taken, it w^ill be 
 fotmd to agree with the measurement of the nine-months' 
 jaw between the points already described. The foregoing 
 facts show sufficiently clearly that the growth of the anterior 
 parts of the lower jaw is produced by addition of bone to the 
 anterior surface, rather than by any material increase by 
 the, development of bone in the fibro-cellular tissue which, 
 up to this period, unites the two halves. Development in 
 the latter position appears to have its period of activity 
 limited to intra-uterine life. After birth, the process of 
 growth in this direction is all but suspended until the 
 period arrives for the osseous union of the two halves of jaw, 
 when the action is resumed, the fibro-cellular tissue is re- 
 placed by bone, and all further increase at this point is then 
 at an end. Still keeping the mental foramen as the point 
 from which to make the computations of relative growth in 
 different directions, it will be found, by examining the series 
 of jaws, that additions have been made to the lower border 
 of the jaws, but that there has been relatively a much greater 
 activity shown in the alveoli, which at the age of nine 
 months have acquired their maximum height in the front 
 part of the jaw. The length of the jaw posterior to the 
 mental foramen has steadily increased with the increasing 
 age of the subject, the direction of the growth being indi- 
 cated by a series of minute vascular grooves which mark 
 the bone at and near the angle of the jaw. Between these 
 groQves the bone rises into minute ridges, many of which 
 are continued to the posterior border of the ramus, and there 
 terminate in short slender spicula, giving to the border a 
 rough surface, which, although well marked in many dry
 
 24 A SYSTEM OF DENTAL SUEGERT. 
 
 specimens, is much more strongly pronounced before the 
 bone is allowed to dry, and the partly-calcified spicula to 
 become contracted by the loss of moisture. If these grooves 
 are traced through a series of specimens of progressive ages, 
 commencing with the foetal jaw, it will be seen that those 
 about the coronoid process indicate the course in which that 
 part has advanced; a line which, I shall subsequently be 
 able to show, is peitnanently marked in the adult jaw by tte 
 external oblique line. Then, again, a similar line of grooves 
 indicates the course which has been taken by the articular 
 process in its progressive growth upwards and backwards. 
 Indeed, this line is also indicated by the surface being 
 slightly raised, there being a distinct rounded eminence along 
 the outer surface of the jaw, ending in the condyle, which 
 becomes less marked in the adult. Below, and a little pos- 
 terior to this line, we have the angle of the jaw, the increase 
 in which has been already noted. 
 
 M. KoUiker has shown that the articular cartilage is of 
 unusual thickness for cartilage so placed ; and that, in addition 
 to the usual functions of articular cartilage, it is here subser- 
 vient to the purposes of development, its office in one respect 
 being similar to the cartilage which in childhood is placed be- 
 tween the epiphysis and shaft of a long bone. It is not proposed 
 to enter upon the subject of osseous development, until the 
 changes of form and increase of size of the maxilla have been 
 traced from birth to manhood. But the discovery first re- 
 corded by j\I. Kolliker has been mentioned, in order to show 
 that in whatever direction the jaw has increased, the in- 
 crease has been produced by additions to the external sur- 
 face. There are no indications of interstitial growth within 
 and throughout the whole substance of the bone. It is not 
 unusual to find increased size of a bone described as expan- 
 sion, but the teim is not applicable. We may have great 
 increase in the size of the medullary cavity and of the cir- 
 cumference of a long bone, as seen in diseased limbs ; but in 
 such cases the enlargement of the cavity is produced by pro-
 
 TEETHING. 
 
 25 
 
 gressive absorption of its parietes, and the enlargement of 
 the outer dimensions by development of bone upon the 
 surface. 
 
 The description of the jaws of the nine-months' child has 
 been given at greater length, in consequence of the specimen 
 having attained that stage of development which immediately 
 precedes the eruption of the teeth. 
 
 The conditions of the alveoli coincident with the progres- 
 sive development of the teeth, do not appear to have attracted 
 that amount of attention which the subject deserves ; and the 
 stage in which the wall or walls of the sockets are partially 
 absorbed preparatory to the passage of the teeth thrbugh the 
 gums, although an important and necessary action for the 
 liberation of the crown of the tooth from the socket, seems, 
 so far as I know, to have escaped observation altogether. 
 
 If the teeth of the specimen which has been under con- 
 sideration be removed from their sockets and examined sepa- 
 rately, it will be seen that the crowns of the central incisors 
 are perfected so far as their exteriors are concerned, and that 
 the production of the necks of the teeth has commenced. 
 The enamel of these teeth presents the character which marks 
 the completion of its development — namely, the smooth and 
 polished surface which succeeds to the dull, opaque, and almost 
 chalk-like character maintained so long as the tissue is incom- 
 plete. The lateral incisors present similar appearances, except- 
 ing that the neck is less pronounced than in the central teeth. 
 The canines at present are placed deep in the sockets, the 
 crowns being incomplete, contrasting strongly with the teeth 
 immediately behind them. These, the first temporary molars, 
 have the crowns nearly completed, the masticatory sur- 
 faces of which are on a level with the alveolar margin. The 
 latter parts have already been slightly reduced by absorption, 
 and the outer apertures of the sockets have been thereby en- 
 larged. The second temporary and the first permanent molars, 
 although considerably advanced as compared with those of 
 the six-months' subject, are still considerably below the level
 
 26 A SYSTEM OF DENTAL SURGERY. 
 
 of the alveolar margins, the outer of which is turned very- 
 much inwards, and hence the openings of the sockets are 
 contracted, an arrangement calculated to afiford protection to 
 the developing teeth. 
 
 Passing from the nine to the twelve-months* suhiecty further 
 changes in the dental apparatus will be observed, indicating 
 that during the intervening three months the process of teeth- 
 ing, as the term is commonly understood, has fairly set in, and 
 at the latter age is in full activity. In the ujDper jaw the 
 two halves of the bone are becoming united ; and although 
 they may be separated after maceration, yet it requires some 
 force to part them, a condition veiy difierent to that which 
 obtains at an earlier period, when they readily fall apart. It 
 was stated that the anterior wall of the alveoli of the central 
 incisors in the nine-months' jaw had been diminished by ab- 
 sorption, exposing to view the crowns of the teeth, although 
 these organs did not rise above the general level of the alveolar 
 ridge. At the age of twelve months the crowns of these teeth 
 have escaped from the sockets to the extent of half their 
 length, the whole of the enamel on the anterior surface being 
 visible. They are placed against the anterior wall, and are 
 separated by a considerable interval from the posterior wall 
 of the alveoli. The latter process at this age descends below 
 the level of the anterior wall of the sockets, at the same time 
 that an increase of thickness of the bone at this part is allowed 
 by the forward movement of the incisor teeth. The crypts of 
 the jiermanent teeth become enlarged, occupying the space 
 which has been gained. The apertures leading to the per- 
 manent incisors are now situated near the alveolar margin, 
 but at present open upon the inclined surface which forms 
 the ix)Sterior wall of the enlarged sockets of the temporary 
 teeth. 
 
 The alveoli of the canines preserve their depth, but the 
 opening is somewhat larger than heretofore, indicating the 
 commencement of the change which precedes the eruption of 
 those teeth. The lateral incisors have escaped from their
 
 TEETHING. 
 
 27 
 
 alveoli to the extent of two-thirds of their crowns. The canine 
 prominences on the anterior surface of the jaw, which during 
 the earlier months of life form so strong a feature, are now 
 becoming lost ; not, however, by their own subsidence, but 
 by the advancing forwards of the alveoli of the neighbouring 
 
 Fig. 17. (2) 
 
 (1) Upper jaw of a male thirteen months old, showing the incisors, with 
 the crowns escaped from the alveoli, and the emargination of the soclcet of 
 the first temporary molar. 
 
 (2) The palatal surface and the alveolar margins of the same specimen.
 
 28 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 teeth. The first temjDorary molars at this age have passed 
 through the apertures of the sockets, and the emargination 
 of the external plate is gradually hecoming lost, the process 
 of development having succeeded to that of absorption. 
 
 . Fig- 18- (0 
 
 Fig. 19. (1) 
 
 (}\ The condition ol the lower jaw and teeth of a thirteen months' male 
 eubject. In this example, the first temporary molars of the upper do not 
 appear more advanced than the corresponding teeth of the lower jaw— a 
 condition which is rather unusual.
 
 TEETHING. 29 
 
 The alveolus of the first "permanent molar, which at an 
 earlier age was destitute of any posterior wall, and had a large 
 open orifice, has now become more perfect, and communicates 
 with the surface by a comparatively small opening situated on 
 the alveolar ridge, and in a line with the openings of the an- 
 terior sockets. The lingual margin of the socket is much more 
 strongly developed than that of the outer alveolar plate, and 
 indeed rises into a process continuous with the corresponding 
 part of the sockets of the more anterior teeth. The .base is 
 continued outwards so as to arch over the inner part of the 
 developing tooth, a condition calculated to protect the latter 
 from mechanical injury, now that the mouth is becoming 
 furnished with organs of mastication. 
 
 Excepting in a general increase of size, the lower jaw does 
 not present any considerable change in character from that 
 of the nine-months' subject. The central incisors have risen 
 out of the sockets, and the emargination of the outer plate 
 of the alveoli of the lateral incisors and of the first temporary 
 molars has commenced ; those teeth are, however, scarcely 
 raised above the level of the alveolar ridge. 
 
 The next specimen in the series is that of a female subject, 
 eighteen months of age. This, as compared with the twelve- 
 months' maxillge, shows an advance in the process of dentition, 
 but not to the extent usually assigned to the age. The crowns 
 of the central incisors both of the upper and lower jaws, are 
 fully exposed ; but the fangs, although approaching the normal 
 length, are as yet incomplete, the extremity of each present- 
 ing a sharp thin edge, with a large aperture, instead of the 
 conical termination, perforated by a minute foramen, peculiar 
 to perfected teeth. The lateral incisors have emerged from 
 their sockets, but the crowns have not reached to the level 
 of the central teeth, those of the upper being more forward 
 than the corresponding teeth of the lower jaw. The conical 
 points of the canines have become visible above the emar- 
 ginated edges of their alveoli; while the first temporary 
 molars have been protruded in the upper to the extent of two-
 
 30 A SYSTEM OF DENTAL SURGERY. 
 
 thirds of their crowiis, and to one-third in the lower jaw. 
 The roots exhibit corresponding stages of development, those 
 of the upper jaws being nearly half their ultimate length, 
 and the lower ones about one-third. The second temporary 
 molar is at present wholly within the socket, the margins of 
 which are arched over so as to diminish the alveolar a|3er- 
 ture, and protect the developing tooth, an effect which is 
 partly produced by the edge of the external alveolar plate 
 being more produced in height, and at the same time more 
 arched over the tooth than the inner edge of the socket. The 
 roots of these teeth are scarcely indicated, excepting by the 
 septum of dentine which in each may be seen extending 
 across the base of the crown, and marking the position for 
 the future roots. The first permanent molars lie deep within 
 their respective sockets, the orifices of which in the lower jaw 
 are contracted by the inversion of the outer alveolar plate and 
 the base of the coronoid process, the teeth at this time being 
 placed with their posterior two-thirds internal to and beneath 
 that portion of the jaw. The posterior edge of the socket is 
 brought forward over the back part of the crown to the extent 
 of one-fourth of its antero-posterior dimensions. On the upper 
 surface of this, within a line of its edge, a depression in the bone 
 may be seen. This is the commencement of a crypt for the 
 second permanent molar. (Fig.l9.) The corresponding teeth of 
 the superior maxilU'e occupy the tuberosity, the posterior part 
 of which is extremely thin, and in the median line imperfect. 
 This gives a long and curved opening to the socket, and a 
 posterior direction to its further half. In the upper jaw we 
 have as yet no indication of preparations for the fodgment of 
 the second permanent molar. 
 
 If the eighteen months' maxillaj are compared with those 
 of twelve or thirteen months, the relations of growth between 
 the teeth and sockets may be seen. The emargination of the 
 sockets of the central incisors, and consequent enlargement of 
 the alveolar apertures necessary for the evolution of the 
 crowns of these teeth, having been accomplished, and the
 
 TEETHING. 31 
 
 crowns having passed through, absorption is suspended, and 
 the several alveoli becoming contracted, apply themselves to 
 the teeth, development at the margins keeping pace with the 
 growth of the roots of the teeth. The socket of an incisor, ; 
 so long as the crown is below the alveolar margin, is larger at 
 its base than at its more external boundary ; but no sooner 
 does the crown leave the socket, than the relative dimensions 
 reverse themselves. The base contracts, by the development 
 of new bone, to the dimensions of the fang. The level of the 
 socket is not, however, at present changed. If the com- 
 parison of the two subjects be continued, it will be seen that 
 although the length of the ascending rami has considerably 
 increased in the older jaw, yet that the angle formed by the 
 two portions remains pretty much the same. 
 
 Twenty-one Months. — The differences observable between 
 the preparation last described and the maxilla of a female 
 subject twenty-one months old, with the exception of a slight 
 general increase in size, are confined to the more advanced 
 condition of the teeth. The four incisors of either jaw have 
 assumed the normal position ; the crowns being fully exposed, 
 although the fangs are not quite completed. The sockets 
 have, however, contracted, and closely embrace the implanted 
 portions of the teeth, at the same time that they have grown 
 up with the teeth as the latter have increased in length. 
 The canines show only their tips above the alveolar marsin ; 
 but the first temporary molars in the upper jaw have fully 
 emerged, and are closely embraced at their necks by the 
 margins of the sockets. In the lower jaw, these teeth have 
 escaped from their sockets, but as the thicker part of the 
 crown is scarcely through the aperture, the emargination of 
 the edge of the alveoli has not been obliterated by develop- 
 ment of bone at these points. 
 
 Twenty-eight Months. — In a twenty-eight-months' subject, 
 in addition to the teeth which have been described as havino- 
 taken their permanent position in the younger jaws, the crowns 
 of the canines have partly passed out of their sockets, those
 
 32 A SYSTEM OF DEXTAL SURGERY. 
 
 of the upper being in advance of the corresponding teeth of 
 the lower jaw. 
 
 Forty Moiiths.—li we now pass to maxilla from a subject 
 forty months old, it will be seen that the whole of the tem- 
 porary teeth have taken their normal position in the jaws, 
 and ajjpear complete ; but if the roots are examined, the 
 i inaccuracy of this conclusion will be discovered. The incisors 
 i are the only teeth in which the fangs are completely formed. 
 The canines are destitute of about one-third, the first tempo- 
 rary molars of a fifth, and the second temporary molars of at 
 least one-half, of their normal length. 
 
 At this period a change takes place in the form of the jaw, 
 and it may be regarded as the second epoch, at which this bone 
 shows a more rapid rate of development towards the adult 
 form. It was stated that within two months subsequent to 
 birth, the angle of the lower maxilla became less obtuse ; and 
 in tracing the same jx)int in jaws of progressive ages, it may 
 be seen that but little further change takes place in respect 
 to the angle until the subject arrives at the third year. But 
 at this age a manifest alteration may be observed. If a hue 
 be drawn along the alveolar margin, and across the ascending 
 ramus, it will be seen that the angle formed by this line and 
 the latter part is between fifty and sixty degrees ; and that 
 the articular and coronoid processes rise high above the 
 alveolar line. It is important to observe how the angle has 
 been diminished, as the recognition of this process of change 
 will to a considerable extent elucidate the manner in which 
 the adult is reduced to the j-ieculiar form assumed by the jaw 
 in advanced age. At tlie time of birth, the sockets are not 
 decider than the partially formed crowns of the teeth. The 
 development of the sockets and of the teeth proceeds together, 
 but the rate of growth is somewhat greater in the bone than 
 in the teeth ; so that the walls of the crypts rise above the 
 contained teeth, and eventually arch over and protect them. 
 When the crowns of the teeth are completed, the inverted 
 edges of the sockets are absorbed, and reduced in height
 
 TEETHING. 33 
 
 until they are lower than the teeth. The crowns of the 
 latter gradually pass through the widened apertures of their 
 respective sockets. When the portions of the teeth which 
 are invested with enamel have passed the edges of the 
 bone, development of the latter is resumed, and keeps pace 
 with the increasing length of the teeth. Now, if attention 
 be directed to the mental foramen at the several ages which 
 have been noticed, it will be seen that from first to last this 
 aperture is in close connection with the terminal portion of 
 the first temporary molar ; indicating that the gradually in- 
 creased depth of the jaw has been obtained by additions to the 
 alveolar edge of the bone. If equal additions had been made 
 to the lower border, the relations between the body and the 
 rami would have been maintained. But growth at that part is 
 relatively slight, hence the angle formed by the two divisions 
 of the jaws has become changed contemporaneously with 
 rapid growth of the alveolar margin. (^) The rami have been 
 gradually elongated. The rate of growth is not, however, 
 subject to sudden acceleration, as in the case of the alveolar 
 border ; a condition which is compensated by the increased 
 depth.of the alveoli, still further by the protrusion of the several 
 teeth taking place at different periods in different parts of the 
 jaws. If, for instance, the whole of the temporary teeth were 
 cut at the same time, and the growth of the alveoli were 
 equal throughout the whole line, the elongation of the rami 
 must assume a sudden activity, otherwise the front part of 
 the mouth could not be closed. With deficient length of 
 the rami, the molar teeth alone would come in contact, — an 
 abnormal condition not very rare in the adult, and to which 
 I shall subsequently advert. In the child, however, the 
 eruption of the front teeth, and the subsequent rapid develop- 
 ment of their alveoli, produce depression of the chin when 
 the mouth is closed ; at the same time the upper and lower 
 gums, situated behind the front teeth, no longer come in 
 close contact. The rami steadily increase in length, and after 
 (0 Compare diagrams on page 104. 
 
 D
 
 34 A SYSTEM OF DENTAL SURGERY. 
 
 a time the back teeth appear through the gums, and occupy 
 the space which has been gained, first by the separation 
 occasioned by the prior development at the front part of the 
 . mouth, and afterwards increased by the lengthening of the 
 rami. 
 
 By the uninterrupted but comparatively slow elongation of 
 the rami, and the rapid but successive growth of the frtnt 
 and back parfs of the jaws, a relation of parts is brought 
 about by which the whole series of teeth are allowed to be 
 brought in contact simultaneously. If it were necessary to 
 find a reason why the rami should not be subject to irregular 
 rates of growth, similar to, and in accordance with, such as 
 are seen to occur in the alveolar portions of the jaws, a 
 sufficient reason might be found in the fact that bone which is 
 developed in temporary cartilage under ordinary circumstances 
 increases steadily, and that the articular processes of the lower 
 maxilla are increased in length by development in cartilage 
 situated beneath the surface of the articular cartilage ; the 
 development in this situation offering no exception to what 
 appears to be a general law in relation to the development of 
 bone in temporary cartilage. On the other hand, bone may 
 be formed with comparative rapidity upon a free surface of 
 pre-existing bone. 
 
 The more acute angle formed by the alveolar margin and 
 the ascending rami in the jaw of the forty-months' subject, 
 as compared with younger subjects, has been already men- 
 tioned. But if the line formed by the lower border of the 
 body of the jaw be examined in relation to that bounding the 
 posterior portions of the rami, it will be found that the angles 
 formed are more obtuse, hence preserving at these points a 
 greater similarity to the younger jaws ; and the condition is 
 maintained so long as the jaw continues to increase in length. 
 The deep portion of the articular cartilage is to the articular 
 portion of the jaw, as regards growth, what the cartilage inter- 
 posed between the epiphysis and apophysis is to a long bone. 
 If, therefore, the lines last referred to were rectangular, as is
 
 TEETHING. 35 
 
 the case in some finely-developed adult jaws, we might have 
 a further increase in the length of the rami, and in the depth 
 of the jaws ; but it would be difficult to see how the length 
 could be increased in the horizontal direction. 
 
 At the age under consideration, the first permanent molar 
 in the lower maxilla lies internal to the anterior portion of the 
 base of the coronoid process ; that is, supposing the jaw to be 
 viewed from the outer side. The opening of the socket is con- 
 tracted, of oval form, and directed upwards and inwards. Pos- 
 terior to this opening we have the depression for the reception 
 of the pulp of the second permanent molar, which at present lies 
 upon the upper surface of the hinder part of the process of bone 
 covering the first molar, a slight groove passing from the new 
 to the older socket. In the upper maxilla we find a similar 
 condition as regards the first permanent molar. The walls of 
 the socket are strong ; the aperture is small, and in a line with 
 the alveolar margin, being directed downwards instead of 
 downwards and backwards, as in the younger examples. On 
 the posterior surface of the tuberosity a slight depression may 
 be observed, connected, as in the lower jaw, by a shallow 
 groove with the socket of the first molar. In this depression 
 we have the earliest indication of a crypt for the reception of 
 the pulp of the second permanent molar of the upper jaw. 
 
 Four Years and One Month. — The next specimen in my 
 series was taken from a subject who died at the age of four 
 years and one month. In these jaws, the incisor teeth are 
 the only ones which are really perfected. The fangs of the 
 'others are slightly deficient in length, and are hollow at their 
 extremities. Four or five additional months would probably 
 have served for their completion. At the commencement of 
 the six th jyear the temporary teeth are all fully formed, a 
 condition which is most likely attained six months prior to 
 this period ; but I have not specimens of determined ages 
 ranging between the fourth and fifth year suitable for the 
 elucidation of the point. Seeing, however, that at the 
 termination of the fourth year the development of the first
 
 36 A SYSTEM OF DENTAL SURGEET. 
 
 set of teeth is not completed, and that at the commencement 
 of the sixth year these teeth are perfectly formed, it may be 
 assumed that at four and a half years of age the primary 
 dentition is completed. 
 
 If the maxillee of the forty-nine months' subject be com- 
 pared with the one previously described, it will be seen that 
 the slight depressions which marked the spots destined for the 
 pulps of the second permanent molars, have now become large 
 crypts with well-defined margins, the superficial extent being 
 proportionately much greater than the depth. In the upper 
 jaw these depressions look backward towards the pterygoid 
 plates of the sphenoid bone : in the lower, upwards and a 
 little inwards, their floors lying immediately over the inferior 
 dental canal, near its commencement. Situated on the floor, 
 near the posterior wall of the crypt, is a small foramen, which 
 passes through into the dental canal, and gives passage to 
 vessels which supply the developing tooth. Passing over the 
 septum, dividing the sockets of the permanent molars, is the 
 groove which in the younger specimen was but slightly 
 marked. In this subject it is broad and strongly pronounced, 
 the margins being raised into tM^o thin processes of bone. 
 
 Having traced the progress of the temporary teeth from 
 the time of birth up to the period of their completion, and the 
 contemporaneous conditions of the jaws, the further changes 
 in form of the jaws will be resumed in connexion with the 
 development and eruption of the permanent teeth. 
 
 In describing the different parts of individual teeth which 
 may or may not hold the normal position, there is some little 
 difficulty in writing intelligibly without first defining the 
 precise meaning of the terms used. The teeth being placed in 
 an ellii^se, the terms anterior and posterior, if applied indif- 
 ferently in describing the surface of an incisor and a molar 
 tooth, would indicate different parts in the two teeth, and the 
 confusion would be still greater when the teeth are altogether 
 out of the usual position. In order to avoid this difficulty,
 
 TEETHING. 37 
 
 arbitrary terms must be adopted and used without reference 
 to the actual situation of any individual tooth, even supposing 
 it be misplaced. Thus, the surface which normally is directed 
 towards the lips or cheeks will be described as the labial, and 
 that directed towards the tongue as the lingual, surface. The 
 surface which lies against a neighbouring tooth, and is directed 
 towards the point of junction of the two halves of the alveolar 
 ridges, will be termed the mesial surface ; while that which 
 is directed outwards in the front, and backwards in the molar 
 teeth, will be called the distal surface. 
 
 Irregularity in the position of the temporary teeth is seen in 
 children whose jaws have not acquired the size necessary for 
 the normal arrangement. The defect is, so far as I know, 
 confined to the incisors, and may be limited to slight crowding 
 and a consequent want of uniformity of position in several 
 contiguous teeth. In three children, members of a large 
 family, one of the central incisors of the lower jaw is in each 
 turned, so that the median side of the tooth stands in the 
 position which should be occupied by the anterior or labial 
 surface. The dentition in other respects is regular, both in 
 these and in the brothers and sisters, although the jaws in 
 each child are unusually small. A transverse section of a 
 permanent central incisor of the lower jaw, when taken imme- 
 diately below the enamel, gives an elongated oval, the long 
 axis of which corresponds in direction with the median line 
 of the mouth. Hence the turning of such a tooth in the jaw 
 would only crowd to a greater degree the contiguous teeth. 
 But the fangs of the temporary lower incisors are cylindrical, 
 so that these teeth, when turned in the manner described, 
 give greater room for those near them than would have been 
 obtained had the normal position been preserved. Hence this 
 deviation from the usual arrangement must be regarded as a 
 means taken by nature to accommodate the want of concord- 
 ance between the size of the teeth and the size of the jaws. 
 
 Irregularity in the number of the temporary teeth. — The
 
 38 A SYSTEM OF DENTAL SURGERY. 
 
 number, order, and position of the deciduous teeth, as they 
 arise in the jaws when the development is normal, have been 
 described. The deviations from these conditions remain for 
 consideration prior to entering upon the eruption, or cutting 
 of the teeth, as the process is commonly called. 
 
 As regards the number, a child may have either more or 
 less than the twenty. Instances are cited in which the jaws 
 have been entirely edentulous. I have not had an opiX)rtunity 
 of examining a case, either in the living subject or in a pre- 
 jiaration. Eecently I met with a gentleman who informed 
 me that a member of his family, a female, about fifteen years 
 old, was then, and had been from the time of her birth, entirely 
 edentulous, and that the lower part of the face preserved the 
 appearance usually presented by a child prior to the eruption 
 of the teeth. Such cases, hoAvever, must be extremely rare. 
 A diminution in the ordinary number of temporary teeth is, 
 however, not so uncommon. I have in my own collection two 
 instances in which the lateral incisors are absent — one in which 
 they are wanting in the lower (Fig. 12), the other in which 
 they are absent in the upper, jaw (a view of which will be 
 found in a subsequent figure). These cases of deficiency in 
 the number of the first teeth possess but little practical inte- 
 rest, and, in a physiological point of view, we can do nothing 
 more than recognise the bare fact. We are as little able to 
 account for the absence of a temporary tooth usually present, 
 as to determine why twenty, rather than a smaller or greater 
 number, constitute the normal series. 
 
 The presence of teeth in excess of the usual number de- 
 mands more attention, as we may in certain cases be called 
 upon to determine whether or not they should be allowed to 
 remain. I am indebted to Mr. Ibbetson for a cast taken 
 from a case under his charge, in which there were five incisors 
 in the lower jaw. They were uniformly arranged, and there was 
 nothing peculiar in the form of either : so similar indeed were 
 they, that it was difficult to determine which should be re- 
 garded as the supernumerary tooth. In my own collection,
 
 TEETHING. 39 
 
 there is an upper jaw, the age of which is probably five years, 
 having two sujDernumerary teeth. They are placed behind the 
 central incisors, near the median line of the jaw; have conical 
 crowns and roots, the latter being a little short of completion. 
 Indications are present of their having passed through the 
 gum, or rather the palate, for they are situated posterior to 
 that part which is usually designated gum. The circumstance 
 that the other temporary teeth are fully formed, while these 
 are not quite completed, might lead to the question, whether 
 they should not be reckoned as supernumeraries of the perma- 
 nent teeth ; but examination of the latter shows that the 
 enamel of the most forward of them is at present incomplete, 
 and that the formation of the roots has not commenced. 
 Hence it is fair to conclude, that the palatal teeth are super- 
 numeraries of the first set of teeth. In this case it is quite 
 possible that articulation was to some extent interfered with, 
 and if so, their immediate removal would have been desirable. 
 
 Several years since, a child, aged five years, was brought to 
 me, having a supernumerary tooth similar in character and 
 in position to those last described. The tooth was removed 
 in consequence of a difficulty in articulation, which arose con- 
 temporaneously with its appearance in the palate. 
 
 Another case came under my treatment, p^g 20. ri\ 
 in which the central and lateral incisors were 
 united, and to these a third tooth was at- 
 tached ; this, the supernumerary, was united 
 through the greater part of its length to the 
 lateral. When the time arrived for the 
 eruption of the permanent central incisor, 
 the removal of the three became necessary. It was then 
 seen that the root of the central incisor had been absorbed, 
 
 (1) Temporary teeth. The central and lateral incisors, left side of the upper 
 jaw, together with a supernumerary tooth, united. The root of the central 
 had been absorbed, and the permanent tooth was ready to pass out of its 
 socket; hence the removal of the united teeth was necessitated. The 
 patient, a female, was eight years of age. The other teeth were free from 
 peculiarities.
 
 40 A SYSTEM OF DENTAL SURGERY. 
 
 but that the corresponding parts of the other two teeth 
 retained their full dimensions. I have seen other instances 
 of an unusual number of temporary teeth, but the excess has 
 always been in the incisors themselves, or in their neighbour- 
 hood. Similar examples are recorded by many writers on the 
 subject of dental surgery. 
 
 The temporary appear much more exempt from individual 
 deformity than the permanent teeth. I have but one example. 
 In this a strongly-pronounced conical cusp arises from the 
 posterior surface of a central incisor. 
 
 Another deviation from the ordinary course of development 
 remains for consideration, and which, like the preceding 
 instances of departures from the usual laws, cannot be con- 
 sidered in connection with those conditions which are attri- 
 butable to disease. The pulps for the development of the 
 individual teeth are not only distinct from each other, but are 
 contained each one in its own crypt. Occasionally, however, 
 the alveolar septum is absent, and two become laterally 
 united, and the teeth produced from the adherent pulps form 
 one mass, distinguishable from one another only by the pre- 
 sence of a more or less distinctly pronounced groove which 
 marks the line of confluence. Sometimes the crowns of the 
 teeth are more or less distinct, the roots only being united ; 
 while in others the crowns are united, and the fangs are to 
 some extent separated. At the points of union the dentine 
 is common to the two teeth, the cementum or the enamel, as 
 the case may be, forming a common investment. This con- 
 dition was kno\vn to M. Desirabode, who says, "The union 
 of the crown is a real fusion of the two teeth in which the 
 ivory substances are common to each other." (^) 
 
 Mr. Salter has a paper in the " Transactions of the Medico- 
 Chirurgical Society " upon this subject, and gives an illus- 
 tration confirmatory of the fact advanced by Desirabode, but 
 taken from two similarly united permanent teeth. (^) Mr. 
 
 (1) American Joamal of Dental Science, 1847. 
 
 (2) iledicu-Chirurgical Transactions, vol. xxxv.
 
 TEETHING. 
 
 41 
 
 Brookhouse, of Manchester, sent me two examples of gemi- 
 nated teeth. The laterals and centrals are joined laterally 
 throughout their length, and have a pulp cavity common to 
 the two teeth. This was the more apparent in consequence 
 of their removal (necessitated by caries) prior to the comple- 
 tion of their roots, thus affording an opportunity for a com- 
 plete examination. A transveise section through one of the 
 specimens, made immediately below the termination of the 
 enamel, exhibits the commpn pulp cavity constricted at the 
 point corresponding to the line of junction, and dilated at 
 either extremity. 
 
 The central and lateral incisors, or the lateral incisors and 
 canines, appear to be the only teeth of the temporary set 
 subject to gemination. The accompanying figures illustrate 
 the appearances presented by united teeth. (Figs. 21 and 22.) 
 
 Fig. 21. (1) Fig. 22. (2) 
 
 The eruption or cutting of temporary teeth. — Having traced 
 the growth of the temporary set of teeth in connection 
 with the jaws, from the time of birth up to the period of 
 their completion, upon a series of preparations from which the 
 soft parts had been removed, it is now necessary to consider 
 
 (1) Shows the front view of the lateral incisor 'and canine from the left 
 side of the under jaw, united throughout their entire length, but with the 
 line of junction well marked. The age at which they were removed was 
 seven years. The corresponding teeth on the opposite side of the jaw were 
 similarly united. 
 
 (2) Shows the representation of the lateral incisor and canine from the 
 left side of tiie lower jaw of a patient Rged nine years. In this example the 
 line of junction is less distinctly marked than in the preceding illustration, 
 and is altoijether wanting near the base of the enamel.
 
 42 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 the conditions of the latter so far as they are connected with 
 the eruption of the teeth. 
 
 If we decalcify the lower jaw of a nine months' foetus, and 
 
 Fig. 23. (1) 
 
 
 make a section through 
 the gum and jaw, pass- 
 ing through one of the 
 developing teeth, the tis- 
 sues will be exposed in 
 the following order : — 
 First, we have a thick 
 layer of epithelium, the 
 cells of which are flat- 
 tened, but gradually in- 
 crease in thickness the 
 further they are removed 
 from the surface, and 
 eventually terminate in a 
 series of slightly elongated 
 cells, the long axes of 
 which are placed at a right 
 angle with the surface of 
 the gum. Below the epi- 
 thelium comes a thick 
 layer of stellate areolar 
 
 Q) Showine the relative posi- 
 tion of the tissues exposed in a 
 vertical section throneh the lower 
 jaw of a nine months' foetus, 
 a, series of elongated cells, form- 
 ing the bnse of the epithelial 
 layer; h, stellate areolar tissue; 
 c, condensed tissue, forming 
 dental sac, on the inner surface 
 of which is the enamel pulp; d, 
 the enamel organ ; e, the enamel ; 
 /, the dentine, with the dentinal 
 pulp; g, the bone forming the 
 lower border of the jaw ; h, the 
 periosteum.
 
 TEETHING. 43 
 
 tissue, the meshes of which are comparatively large and 
 open. Nuclei are present in the centres of the stellations, 
 while others may be found in fibres wliich have not con- 
 formed to the axial arrangement, or which, in progressive 
 growth, have not yet arrived at the stellate form. In the 
 meshes of the areolar tissue a few free cells may be found, 
 but they are not abundant. Blood-vessels traverse this 
 texture in considerable numbers. Near the lower boundary 
 they become more abundant, are of larger size, and the 
 tissue itself becomes more condensed. The fibres are 
 placed nearer each other, and assume collectively the form of 
 an ill-defined fibrous membrane, which dips down within the 
 socket in the form of a sac — the sac or outer investment of 
 the developing tooth. Still proceeding from above downwards, 
 after passing through the upper part of the sac we come to 
 the " enamel ofgan," then to the dentine and the dentinal 
 pulp, which at its base merges into the lower portion of the 
 sac, without any definite line of separation or structural 
 distinction between the two. Below this, again, we have a 
 little loose areolar tissue which connects, although but feebly, 
 the sac with the bony socket. Then comes the bone, which 
 forms the base of the socket on the one surface, and the 
 lower border of the jaw on the other ; succeeded by the 
 periosteum, which on its osteal surface is in great part formed 
 of nucleated cells, the bulk of the membrane being made up 
 of fibrous tissue, tending in character rather towards the 
 stellate areolar tissue, than to the fibrous tissue of older 
 subjects. 
 
 After the crown of a tooth has been formed, before it 
 can be cut, the aperture of the socket must be enlarged, the 
 coat of the sac immediately above the crown of the tooth 
 removed, together with the superimposed fibro-areolar tissue 
 and epithelial layer. These parts — wliich stand in the way 
 of the eruption of a tooth — may, however, be removed in 
 such strict accordance with the rate of growth and outward 
 progress of the tooth — growth and waste may be so nicely
 
 44 A SYSTEM OP DENTAL SURGERY. 
 
 balanced — that the subject of these changes suffers no in- 
 convenience. In a child who was constantly under my own, 
 notice, tooth after tooth appeared without any premonitory 
 symptoms. The period of teething came and went, attracting 
 attention only when a new tooth was discovered. Instances of 
 teething such as the foregoing are, I believe, comparatively 
 rare, and can only occur in children who are and have been 
 in all respects perfectly healthy, the fulfilment of which 
 involves a series of conditions which our artificial state ot 
 living does not tend to bring about, or, it may be said, 
 can scarcely allow. 
 
 Eesidence in crowded cities, even in members of the middle 
 classes, seldom fails to j^roduce some amount of injurious in- 
 fluence upon childhood; and among the working classes, 
 insufficient or improper food greatly tends to increase the 
 evil which the want of a good atmosphere has been suflicient 
 to create. Among the agricultural population we often find 
 great crowding in the individual dwellings, a scarcity of 
 animal food, and, by way of making the matter worse, a 
 perfect indifi"erence to the condition of the precincts of the 
 cottages. A stagnant pond or a filthy ditch, into which is 
 thrown the refuse from the house — one or other, or both, are 
 found in most of our rural villages, within a few yards of the 
 labourer's house. The a,lmost universal presence, in one form 
 or another, of these disturbing causes, is attended with a loss 
 of that balance of the various functions of the body which 
 constitutes perfect health. Hence we find that but few 
 children pass through the period of teething without sufi"ering. 
 In some cases the attendant ailment is slight and unimpor- 
 tant ; in others, maladies arise which endanger life. To these 
 deviations from normal dentition, attention must now be 
 directed ; but in treating upon this part of the subject, I 
 must borrow largely from the experience of others. The 
 management of children during the eruption of the temporary 
 teeth is seldom entrusted to those who confine their practice 
 to dental surgery, and therefore their knowledge of the coin-
 
 TEETHING. 45 
 
 cident disorders necessarily becomes limited and excused, a 
 condition which has arisen within the last fifty or sixty years. 
 Many of the earlier writers upon dental surgery were evidently 
 consulted in cases where disease was supposed, correctly or 
 otherwise, to arise from obstruction to the eruption of the 
 temporary teeth. 
 
 Dentition as a cause of local and constitutional disturbance. — 
 In estimating the amount of influence dentition may have in 
 the production of disease, those changes in the teeth, and in 
 the parts connected with them, which I have endeavoured to 
 describe in the foregone pages, must be kept in the mind ; 
 but not those only. "There are other parts in the alimentary 
 tract which in the healthy subject undergo concordant changes. 
 Dr. West, in his valuable work " On Diseases of Infancy and 
 Childhood," has brought together many of the facts which bear 
 upon this subject, and I cannot do better than avail myself 
 of his words ; 
 
 " The shape of the human stomach in the first month of 
 existence approaches that which it retains through life in the 
 carnivora, in whom the process of digestion is more simple 
 than in any other mammalia. It is long, but little curved, 
 growing narrower toward either end, where it passes into the 
 oesophagus on the one hand, and into the intestine on the 
 other. Its small curvature is but little arched, and approaches 
 nearly to a straight line ; the large curvature is but slightly 
 developed, and runs almost parallel with the other, — charac- 
 teristics which are all found in the stomach of carnivorous 
 animals. Compare with this the form of the stomach in the 
 adult. It is altogether more rounded : the oesophagus no 
 longer enters at its left extremity, but nearly midway between 
 that point and the pylorus. The pylorus itself is drawn back 
 towards the cardia, and the two orifices are thus brought near 
 to each other : hence the small curvature is very short ; the 
 great curvature of considerable extent, forming not merely 
 the whole under part of the circumference of the stomach, 
 but likewise bounding the whole of that pouch which is
 
 46 A SYSTEM OF DENTAL SURGERY. 
 
 situated beyond its cardiac orifice. Besides this, too, the 
 transition from the pylorus to the intestine is gradual in the 
 child, while in the adult the demarcation between stomach 
 and intestine is well marked. The result of all this is, that 
 in the adult, who is an omnivorous animal, the stomach 
 presents a form not unlike that which it has in some of the 
 rodents — as the rat and the rabbit ; and that the food, in the 
 course of digestion, undergoes somewhat of a rotatory motion, 
 not the simple onward movement w^hich is communicated to 
 it in the stomach of the carnivora. The stomach of the 
 adult, then, is framed to act upon substances which may 
 require some time for their digestion, while that of the infant 
 is ill suited to retain matters long within it, and its small 
 size unfits it for receiving much at once. If, therefore, the 
 food given to an infant be such as can be digested with 
 facility, it soon passes out of the stomach, and the infant 
 speedily seeks for more. Nor are these arrangements, cal- 
 culated for the rapid digestion of easily-assimilated food, 
 confined to the stomach of the infant, but the form and 
 proportions of the intestines correspond thereto : the small 
 intestine is relatively shorter than in the adult ; the large 
 intestine of smaller calibre ; the ceecum less developed ; whilst 
 the peristaltic action of the bowels is more rapid than in later 
 life ; excrementitious matters are quickly expelled, and the 
 healthy infant passes three or four evacuations in the twenty- 
 four hours." 
 
 • Thus it is shown that while the organs of mastication are 
 coming forward for use, the alimentary canal is at the same 
 time assuming a form suitable for tbo digestion of substances 
 that require to be masticated before they are passed into the 
 stomach. And it may be assumed if the normal relations 
 existing between the dental and digestive apparatus, as regards 
 their respective rates of development, be disiturbed, that the 
 child will become predisposed to disease. 
 
 The tables of mortality, under the head of death from 
 teething, give over four per cent, of the whole number of
 
 TEETHING. 47 
 
 deaths under the age of twelve months, and over seven per 
 • cent, between the latter age and three years. In these cases 
 death is not, I presume, supposed to arise directly from dis- 
 ordered dentition, but from disease produced by teething. But 
 before full credence is given to facts advanced in these returns, 
 it should be shown that the disordered dentition is not itself 
 a secondary affection, or that its cause was incapable of pro- 
 ducing the fatal disease. I have not been able to find any 
 account of careful post-mortem examinations of the teeth and 
 jaws, in cases of death attributed to abnormal dentition. It 
 should be shown, in individual cases the symptoms of which 
 had been watched, in what particular the process of teething 
 differed from the normal course — whether the crowns of the 
 teeth being ready for eruption, the margins of the alveoli had 
 not been sufliciently dilated by absorption of the bone to allow 
 of their passage towards the surface of the gums, or whether 
 the gums only impeded the eruption of the teeth ; and more- 
 over, that in the presence of other unnatural conditions, the 
 dental was the primary aftection — that it was, in truth, the 
 first link in the chain of disordered actions. There can be 
 but little doubt that difficult dentition has been overrated, as 
 a cause of fatal disease occurring during the period of its 
 presence. This has been strongly felt by Dr. West, who 
 says: 
 
 "The error which has been committed with reference to 
 this matter, not merely by the vulgar but by members of our 
 own profession also, consists, not in overrating the hazards of 
 the time when changes so important are being accomplished, 
 but in regarding only one of the manifestations — though that, 
 indeed, is the most striking one — of the many important ends 
 which nature is then labouring to bring about. A child in 
 periect health usually cuts its teeth at a certain time and in a 
 certain order, just as a girl at a certain age presents the various 
 signs of approaching puberty, and at length begins to men- 
 struate. In her case we do not fix our attention solely on 
 the menstrual flux ; nor, if it fail to appear, do we have re-
 
 48 A SYSTEM OF DENTAL SURGERY. 
 
 course to the empirical employment of emmcnagogue me(U- 
 cines. We examine into the cause of its absence ; try to 
 ascertain whether it depends on the state of the health in 
 general, or of the uterine system in particular, and regulate 
 accordingly our attempts at cure. The epoch of dentition is 
 to be looked at just in the same way as that in which we 
 regard the epoch of puberty. Constitutional disturbance is 
 more common, and serious disease more frequent, at those 
 times than at others ; but their causes lie deeper than the 
 tooth which irritates the gum that it has not yet pierced in 
 the one case, or than the womb which has not yielded the due 
 discharge of blood in the other. You might produce haemor- 
 rhage from the uterine vessels in the latter instance, or might 
 cut through the gum which enclosed the teeth in the former, 
 with no other effect than that of aggravating the condition of 
 your patient." 
 
 Yet the phrase, " Bel enfant jusf^u'aux dents " gives ex- 
 pression to a belief very widely spread, and unfortunately 
 too well grounded, that this is the period at which many a 
 child becomes sickly, and perhaps never again recovers 
 strength. 
 
 Dr. Copland gives the following definition of Difficult 
 Dentition : — " Slow or retarded evolution of the teeth, with 
 signs of local irritation and constitutional disturbance, often 
 with disorder manifested especially in the digestive organs 
 and nervous system, occurring chiefly in weak or over- fed 
 children." In desciibing the local symptoms I must again 
 borrow from Dr. West : 
 
 " Though a perfectly natural process, dentition is yet almost 
 always attended with some degree of sufifering. Many of us, 
 no doubt, can remember feeling much pain when we cut our 
 wisdom teeth, and children probably exf)erience the same kind 
 of annoyance. This, however, is not always the case ; for 
 sometimes we discover that an infant has cut a tooth, who 
 had yet shown no sign of discomfort, nor any indication that
 
 TEETHING. 49 
 
 creased flow of saliva. More frequently, indeed, the mouth 
 becomes hot, and the gums look tumid, tense, and shining, 
 while the exact position of each tooth is marked, for some 
 time before its aiDpearance, by the prominence of the gum ; or 
 the eruption of the teeth is preceded or accompanied by a 
 somewhat different condition of the mouth, in which there are 
 much heat, and intense redness of the mucous membrane, an 
 extremely copious flow of thin saliva, and a disposition to the 
 formation of small aphthous ulcerations on the tongue, at the 
 outer surface of the alveolae, or at the duplicature of the lip, 
 though the gums themselves may not be particularly swollen 
 or painful. Either of these states is usually attended with 
 some degree of febrile disturbance, and apparently with con- 
 siderable suffering to the infant, who is constantly fretful and 
 peevish, or cries out occasionally as if in pain. A third morbid 
 condition of the mouth is sometimes seen, which is usually 
 ushered in or attended by very considerable fever and dis- 
 order of the chylopoietic viscera. The gums then become 
 extremely hot and swollen, and unusually tender, especially 
 over some tooth or other in particular, and in that situation 
 we find the gum swollen up into a kind of little tumour. 
 Small unhealthy ulcerations, with a sloughy appearance, often 
 form upon the summit of the gum, and especially around any 
 tooth which has partly pierced through it. To this affection, 
 which is often very painful, and often difficult of cure, the 
 name of Odontitis Infantum has been applied by some Con- 
 tinental writers." 
 
 One of the most common diseases incident to this period is 
 diarrhoea, attacks of which will come on as each group of 
 teeth comes to the surface, and pass away in the intervals : 
 sometimes, however, from the long continuance of the diar- 
 rhea, the child will pass into the condition of marasmus. 
 
 Many of these symptoms, according to Dr. Copland, fre- 
 quently precede the appearance of the teeth by several weeks, 
 but do not always maintain a uniform severity. Indeed, they 
 may altogether subside and reappear before the teeth are cut. 
 
 £
 
 50 A SYSTEM OF DENTAL SURGERY. 
 
 In such cases, the old nurses tell you that the teeth were 
 breeding in the first attack, and in the second cutting the 
 gums. A more probable explanation is, that in the one case 
 they were passing through the alveolar opening — in the other, 
 making their way through the gums. It has been pointed 
 out by Trousseau (^) that teething is not a continuous process 
 which, once begun, is carried on without interruption till its 
 completion, but that it takes place in well marked stages. 
 The teeth are cut in groups, and when one group of teeth is 
 fairly erupted there is a period of rest till it is time for the 
 next group to appear. It will of course be understood by 
 every one who is familiarised with the numerous irregula- 
 rities arising in dentition, that this definite serial order will 
 in some instances be departed from, though the statement is 
 none the less very generally true. 
 
 At an age varying from six to nine months the lower 
 central incisors appear, their eruption being rapid, and being 
 completed in from three to ten days ; then comes a period of 
 rest of two or three months, at the end of which the four 
 upper incisors come down into place. Then again after the 
 lapse of some months the lower lateral incisors and the four 
 first molars are cut, their eruption being followed by a con- 
 siderable lapse of time, amounting often to four or five, 
 months, when the four canines commence to come through. 
 The eruption of the canine teeth covers a very long period, 
 taking perhaps two or three months for its completion, and 
 it is during the eruption of these teeth (according to 
 Trousseau) that a child suffers most severely, though a dif- 
 ferent opinion has been lately expressed by Dr. West,(-) who 
 considers that the four first molars cause the greatest amount 
 of constitutional disturbance during their progress from the 
 alveoli. The greater time taken by the canine teeth, and the 
 severer symptoms occasioned by them, are accounted for by 
 Trousseau, by the fact that they are the only members of the 
 
 (1) Clinical Lectures, Trousseau, vol. iv. fSydenham Society Edition). 
 
 (2) On some Nervous Disorders of Childhood, by Charles West, M.D.
 
 TEETHING. 
 
 51 
 
 temporary series which come into place between two other 
 previously erupted teeth, so that they are likely to meet 
 with greater resistance in their transit. But he appears to 
 have in some degree misapprehended the conditions under 
 which the eruption of teeth takes places when he mentions 
 their length of fang as being another difficulty in the way of 
 their easy transit ; for the fang is not fully formed until the 
 crown is well advanced in its movement towards its final 
 position. 
 
 Tubercle does not appear to interfere with the progress of 
 dentition, but rickets does so in a very great degree ; in fact 
 gi'eat delay in the appearance of the teeth would always lead 
 to a suspicion of the existence of rickets. Q) 
 
 Among the collection of infantile maxillse which has been 
 made, there are several specimens of local disorder which may 
 be noticed at this point of the inquiry. In one example, taken 
 from a subject nearly nine months old, the teeth present no 
 obvious peculiarity either as regards structure or forwardness. 
 The jaws are, however, small, and the bone is unusually porous, 
 the alveoli being at many points imperfect, leaving the forming 
 teeth partly exposed on their anterior surfaces. In a second 
 specimen, twenty-one months old, a similar condition of the 
 maxillse exists. The incisors and first temporary molars have 
 been erupted, and appear tolerably well developed. Nothing 
 is known of the history of these cases, but surely the unusual 
 condition of the bone of the alveolar processes must have 
 been attended with local indications of disorder. In a third 
 specimen we have the enlarged cranium peculiar to chronic 
 hydrocephalus, accompanied with an absence of the outer 
 alveolar plate, so that the teeth are exposed over the whole 
 of their anterior surfaces. The bone does not exhibit any 
 
 (1) It will be noticed on looking over the maxillae figured in this work, that 
 the teeth are, in many instances, hardly as far advanced as would be expected 
 from the age of the child ; this may be due to the fatal illness having been 
 of considerable duration, but that within certain limits there is some little 
 variability, even in healthy children, is indicated by the fact that almost every 
 author assigns a different period to the eruption of the tettli. 
 
 /
 
 62 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 unusual porosity, the defect being in quantity only, — a pecu- 
 liarity which is extended to the whole of the bones of the 
 face. (Fig. 24.) I saw a patient some months since, who 
 presented similar conditions. The anteiior surfaces of the 
 teeth could be felt through the gums. The child was under 
 the treatment of Dr. West, who tells me that he has observed 
 in cases of this kind dentition is seldom attended with local 
 irritation or any increase of the pre-existing constitutional 
 disturbance. If this be a constant condition, it goes some 
 way towards showing that the local irritation so commonly 
 observed is consequent upon the obstruction offered to the 
 eruption of the teeth by the margins of the sockets, rather 
 than to that afforded by the gums. Further observation is 
 
 Fig. 2i.{i) .4 
 
 required before the question can be set at rest. Indeed, 
 this remark may be applied to the whole subject. Some 
 practitioners attribute almost every ailment of infancy to 
 dentition, without, however, attempting to explain how so 
 much mischief is produced, contenting themselves with the 
 
 (») View of the facial portion of skull of child who had suffered from 
 hydrocephalus, showing the developing temporary teeth, and the defective 
 anterior walls of the sockets.
 
 TEETHING. 53 
 
 general statement, without telling us in what particulars the 
 series of changes which accompany the eruption of the teeth 
 were defective. Other medical men entertain the opinions so 
 clearly set forth by Dr. West. 
 
 In addition to the various characters presented by the 
 gums which have been already noticed, there is a condition 
 which I have seen in a few cases only. The gum over the 
 coming tooth is enlarged, but the enlargement is circum- 
 scribed, has a blue or purple colour, and yields to pressure. 
 If an incision be made into it, a small quantity of transparent 
 fluid will escape, and we shall find the tooth at the bottom of 
 the emptied cyst. In these cases, the enlargement apparent 
 on the surface of the gum was obviously produced by the 
 secretion of fluid between the surface of the enamel and the 
 superjacent soft tissue. I was unable to determine whether 
 the lining of the cyst was composed of the fibrous tissue which 
 forms the base of the enamel-pulp, or of the stellate areolar 
 tissue which lies external to the latter. There appears to be 
 no connection kept up between the enamel and the tooth sac 
 when once the former is completed, and it is not improbable 
 that a slight amount of fluid may be present as a normal 
 condition. The inconvenience experienced by the patients 
 appeared to be very slight, and the occurrence of efi'usion in 
 the sac would merit little attention but that it offers a 
 probable explanation as to the source of another disease 
 which sometimes arises in connection with the evolution of 
 teeth — a subject which will be considered in a future page. 
 
 Hunter, after stating that the teeth, in their advance 
 towards the surface of the gum, exert pressure upon the 
 superimposed parts, thereby causing inflammation and ulcer- 
 ation, goes on to say, " that ulceration which takes place in ' 
 dentition is one of the species which seldom or never produces 
 suppuration ; however, in some few cases I have found the 
 gums ulcerated, and the body of the tooth surrounded with 
 matter ; but I believe this seldom happens till the tooth is 
 near cutting the skin of the gums." The condition here
 
 64 A SYSTEM OF DENTAL 8UEGERY. 
 
 described is probably subsequent to the infiltration of serous 
 fluid within the capsule investing the enamel. 
 
 The most common result of difficult dentition is a general 
 febrile condition. Hunter says : 
 
 " The fever is sometimes slight, and sometimes violent. It 
 is very remarkable both for its sudden rise and declension : so 
 that in the first hour of this illness, the child shall be per- 
 fectly cool ; in the second, flushed and burning hot ; and in a 
 third, temperate again." 
 
 Disorders of the nervous system frequently arise at this 
 epoch, varying in intensity from slight muscular twitching to 
 violent convulsions. The following case occurred in the 
 family of a medical man : — A child, playing round the dining- 
 room table, suddenly fell down in a state of insensibility. 
 The father at the time was absent, and a neighbouring practi- 
 tioner was called in, who, on examining the mouth, found that 
 the gum was raised, and in a state of tension over a temporary 
 molar. An incision was made down to the tooth, the child 
 immediately recovered its sensibility, and in a few hours 
 was perfectly well. Now, as no medicine was given, and as 
 the insensibility was continued until the gum was divided, it 
 would be too much to assume that the operation and the re- 
 covery had no further relation than mere coincidence, espe- 
 cially when it is remembered that the majority of those 
 engaged in extensive general practice could furnish cases 
 similar to the one cited above. On the other hand, we may 
 have convulsions when teeth are about to be cut, and the 
 gums may be lanced with no apparent advantage, the disease 
 running its course towards recovery or death, uninfluenced 
 by the dental operation. Q) 
 
 Instances of epileptiform convulsions dependent on the 
 eruption of the temporary teeth are far from uncommon 
 and in some few cases where partially erupted temporary 
 
 (1) Two equally striking cases of convulsions with considerable pyrexia at once 
 relieved by lancing tumid reddened gums were communicated by Mr. Stevenson 
 Smith to the Edinburgh Obstetrical Society, and are quoted in the Dental Cosmos 
 vol. xii., p. 209.
 
 TEETHING. 55 
 
 teeth have appeared to be sources of irritation, medical 
 men,(^) all other- remedies having failed, have extracted 
 them with the effect of at once relieving the convulsions. 
 Hunter, whose work on the teeth cannot be too often referred 
 to by those engaged in the practice of dental surgery, or in 
 the treatment of disorders coincident with an abnormal state 
 of the dental apparatus — states : " The partial or local con- 
 sequential symptom's are the most varied and complicated ; 
 for the appearance they put on is in some degree determined 
 by the nature of the parts they affect ; wherefore they imitate 
 various diseases of the human body. These symptoms we 
 shall describe in the order of their most frequent occurrence : 
 diarrhoea, costiveness, loss of appetite ; eruptions on the skin, 
 especially on the face and scalp ; cough, shortness of breath, 
 with a kind of convulsed respiration, similar to that observed 
 in hooping-cough ; spasms of particular parts, either by inter- 
 vals or continued ; an increased secretion of urine, and some- 
 times a diminution of that secretion ; a discharge of matter 
 from the penis, with a diflSculty and pain in making water, 
 imitating exactly a violent gonorrhoea." 
 
 A case is given in which this disturbance of the urinary 
 organs was invariably coincident with cutting of teeth, the 
 one as it were keeping time with the other. Hunter's own 
 words are : " It was observed at last, that they (the urinary 
 symptoms) returned only upon his cutting a new tooth; this 
 happened so often, regularly, and constantly, that there was 
 no reason to doubt but that it was owing to that cause." 
 
 Here, then, we have, on the highest authority, a long list 
 of the n;iany ailments that may be consequent upon disordered 
 dentition ; and it is for the practitioner to distinguish in in- 
 dividual cases, whether the disease present during the time 
 of teething is consequent upon some derangement of this pro- 
 cess, or upon an abnormal condition of some other organ or 
 organs, of which the dental diflSculty is but itself a symptom. 
 
 (1) Portal, Observations snr I'Epilepsie, p. 333, and Dental Cosmos, vol. xii., 
 p. 211, in which latter case the patient was in a state of collapse.
 
 56 A SYSTEM OF DENTAL SURGERY. 
 
 In forming this distinction, the state of the jaws must 
 1)6 the principal guide. If, in the presence of symptoms 
 which might arise from teeth, we find that teeth are not 
 pressing forward towards the surface of the ^ms, and that 
 the latter maintain their normal appearance, it will be useless 
 to have recourse to the gum lancet ; yet, even in this case, 
 the disorder may be flue to, or much influenced by, the teeth. 
 They may be confined by the sockets, a difiiculty beyond 
 the reach of mere division of the gum. It is not easy to 
 see how wounding the superjacent soft tissues should promote 
 absorption of the osseous margins of the sockets ; yet there 
 are those who, on all occasions, have recourse to this practice. 
 
 There are, however, cases in which this simple operation 
 will at once either mitigate or entirely remove most alarming 
 symptoms; but in such we shall find the gum prominent, 
 and in a state of tension over the advancing tooth. Under 
 these conditions the gum should be divided down to the sur- 
 face of the tooth, and not at a point only, but across the 
 whole breadth or length of the crown ; in fact, the imprisoned 
 organ should be entirely set free. 
 
 Then, again, there are cases in which the gums may l>e 
 lanced with advantage, for the sake of local depletion, with- 
 out reference to the liberation of the teeth. When we find 
 the part inflamed and painful, this measure may be adopted : 
 the incisions should not, however, be deep, as in the former 
 case, but superficial only, and performed with a sharp instru- 
 ment, shaped like an ordinary lancet, and with an equally 
 sharp edge. The indiscriminate adoption of this treatment in 
 all cases when the gums are turgid and inflamed will occa- 
 sionally lead to mischievous results. In children who are 
 enfeebled, either from disease or residence in a bad atmo- 
 ssphere, ulceration of the wounded parts may follow as a 
 consequence of the operation, or in some instances severe 
 haemorrhage, which has been known to prove fatal. 
 
 Trousseau expresses a strong opinion adverse to scarifi- 
 cation of the gum, which is, nevertheless, undoubtedly of
 
 TEETHING. 57 
 
 great service in some cases, and it will be long before the 
 practice is abandoned, if indeed it ever will be. 
 
 For a detailed account of the symptoms and treatment of 
 those diseases which may be occasioned or aggravated by 
 abnormal dentition, I must refer the reader to works treating 
 upon the diseases of infancy and childhood. These are 
 subjects which seldom come under the notice of the dental 
 surgeon ; he, having his attention constantly directed to the 
 organs of mastication in all their varied conditions, should 
 be able to point out any deviation from the normal state of 
 the teeth and jaws with greater precision than those whose 
 practice ranges over a wider field. The conditions necessary 
 to the acquisition of this special knowledge preclude the 
 possibility of his gaining an amount of practical information 
 upon the general subject of disease sufficient to place him 
 upon an equality with those who devote themselves to the 
 study of the diseases of infancy and childhood. 
 
 Belations of the temporary to the developing permanent teeth 
 at the period when the former are fully formed. — In following 
 the plan which has been adopted in arranging the matter of 
 the present volume, it will be necessary to point out the 
 normal relations of the two sets of teeth before entering 
 upon the irregularity in the arrangement of the permanent 
 organs while still within the alveoli. If we select for exami- 
 nation perfectly well-formed jaws from a subject in which the 
 first permanent molars have not appeared through the gums, 
 but in which the temporary teeth are all perfect, we shall 
 find that eachjnember of the latter set has become slightly 
 separated from its fellow; a condition' indicating that the 
 growth of the jaws has been in all respects normal^ and con- 
 sequently that a good and well-arranged set of permanent 
 teeth may reasonably be expected. 
 
 The crowns of the permanent incisors, both of the upper 
 and lower jaws, are perfected, excepting perhaps at that part 
 where the enamel terminates. There the dull and chalk-like 
 appearance which that tissue presents when the develop-
 
 58 A SYSTEM OE DENTAL SURGERY. 
 
 ment is progressing, may be observed. The cani nes a re still 
 less advanced, while the crowns of the first bicuspids have 
 not attained to more than two-thirds, and those of the second 
 bicuspid not more than a third, of their ultimate lengths. 
 The crowns of the first permanent molars are, as respects 
 their external surface, fully developed; and the septa_of 
 dentine which extend across the base of the pulps marking 
 out the several roots yet to be developed are fully pro- 
 nounced. The second permanent molars are at present repre- 
 sented by about two-thirds of their crowns, and invested 
 with a thin layer of partially-developed enamel. The posi- 
 tions of the pulps of the wisdom teeth are but faintly indi- 
 cated by slight depressions in the bone posterior to the 
 sockets, which contain the forming second molars. These 
 "marks may, however, at this period, be altogether wanting. 
 
 The position of the temporary teeth in the jaws difters 
 from that of the permanent set in being^ perfectly vertical. 
 The crowns do not occupy a more forward position in the 
 dental circle than their respective roots ; the cro%vn of each 
 tooth is directly over or under (as the case may be) its own 
 root, the latter standing immediately in front of oile or other 
 of the succeeding teeth. 
 
 The permanent teeth are at this age contained within bony 
 cells, which have been aptly enough compared to the dense 
 layer of shell which surrounds an almond, and which, like 
 the dental cells, is connected with the contiguous tissue by 
 a comparatively i)orous structure. The alveolar cells may be 
 readily isolated by breaking away the porous bone by which 
 they are surrounded, except at those points where they come 
 in contact, and blend with the dense lx)ne which contributed 
 to form either the outer surface of the jaw, or the dense wall 
 of a neighbouring cell. 
 
 On removal of the bone from the anterior surface of the 
 maxilla, it will be seen that the permanent central incisors 
 are placed nearly parallel with each other, the cutting edges 
 in the upper teeth being inclined a little forwards, while the
 
 TEETHING. 
 
 59 
 
 I 
 
 parts corresponding to the base of the crowns of the two 
 teeth respectively arc placed immediately below the floor of 
 the Bose, from which cavity they are separated by a thin 
 layor of bone only. The teeth at this stage of growth com- 
 pletely fill the cells or crypts. The corresponding lower 
 teeth hold a similar position in the lower jaw, but have a 
 strictly vertical position, and show a slight advance in de- 
 velopment as compared with the upper centrals. 
 
 The lateral incisors of the upper jaw have a slightly oblique 
 direction, the cutting edges being more forward than the base 
 of the crowns, which are nearly on a level with the corre- 
 sponding parts of the central teeth. The labial surface of each 
 
 Fig. 25. (1) 
 
 is often slightly turned, so that the mesial surface which lies 
 against the central incisor is directed outwards, while the 
 mesial angle of the tooth stands in front, and a little over the 
 contiguous portion of the central incisor. The point at which 
 
 (1) Shows the relations of the temporary and permanent teeth at the 
 period when the former are perfectly formed, in an example of well-formed 
 maxillae.
 
 60 A SYSTEM OP DENTAL SURGERY. 
 
 the one tooth overlaps the other, corresponds to the position 
 of the root of the temporary lateral incisor. That side of the 
 lateral which in the perfected teeth lies against the canine, 
 here rests against the cell which contains the first bicuspid ; 
 while the developing canine is at this period above the latter 
 tooth. In the lower jaw the lateral incisors are placed less 
 regularly, holding a position slightly more backward than 
 the centrals. The tooth of either side is turned from the 
 mesian line, and lies obliquely over the canine, to the extent 
 of alx)ut half of that tooth. They do not, however, as in 
 the upper jaw, come in contact with the cells that contain 
 the first bicuspids. 
 
 The permanent canine teeth at this stage of dentition are 
 situated above the line of the other teeth in the upper, and 
 below it in the inferior maxilla. Those of the upper jaw are 
 directed slightly forwards and outwards, while in the lower 
 jaw these teeth have a direction upwards and a little in- 
 wards. T he bicuspids are placed in cells situated be tween 
 t he roots of the temporary molars . 
 
 In the specimen which I have chosen for description, and 
 from which the illustration is taken, we have perfectly well- 
 grown jaws, showing very completely the relations in position 
 of the first to the second set of teeth, and the relative posi- 
 tion of the several members of the latter to each other. It is 
 very desirable that the practitioner should be well acquainted 
 with the conditions which this, in common with many other 
 similar specimens, presents. We see in it all the early con- 
 ditions necessary to the development of a perfectly regular 
 set of teeth fulfilled. 
 
 In another specimen (Fig. 26), the arrangement is equally 
 normal, but difi"ers in one respect from that which has been 
 described. In this case the mesial sides of the upper lateral 
 incisors are placed behind the distal sides of the central 
 teeth. The degree of overlapping is perhaps rather in excess 
 of what may be regarded as a perfect arrangement, and the 
 lateral have descended nearer to the alveolar margin than
 
 TEETHING. 
 
 61 
 
 the central incisors; but still the specimen will serve for 
 illustrating the relative position of the several teeth alluded 
 to, at the same time that it exhibits an irregularity in the 
 position of the right lateral incisor in the lower jaw. This 
 tooth has its median edge turned outwards towards the lips 
 and is accompanied with a diminished size of the anterior part 
 of the jaw, as compared with many other jaws of similar age. 
 Attention may again be directed to the fact that the tem-l 
 porary teeth are placed vertically in the jaws, and that if their \ 
 
 Fig. 26. (1) 
 
 I 
 
 successors were similarly implanted, there would not be room 
 
 in the upper jaw for the canine teeth. But the upper incisors 
 
 in the place of a vertical have an oblique direction forwards 
 
 and outwards towards the lips, while the vertical line is at 
 
 this age followed by the bicuspids. Now, if we produce an 
 
 imaginary line through the axes of the upper incisors in 
 
 their present state, to the extent of perfected teeth, it will be 
 
 (1) Showing the relative position of the two sets of teeth, with the upper 
 lateral incisors descending lower than the central teeth, and the right lower 
 lateral with its distal edi^e turned outwards.
 
 62 A SYSTEM OF DENTAL SURGERY. 
 
 seen that the difference in the direction of the line of growth 
 between the incisors and the bicuspids will lead to a separa- 
 tion between these teeth sufficient to admit the canine into 
 the dental line. In order that this result shall be attained, 
 it is necessary that the relative rate of growth between the 
 several teeth shall remain undisturbed. If, for instance, the 
 canine advances too rapidly upon the lateral incisor, and 
 makes its appearance through the gum before the lateral tooth 
 has advanced sufficiently forwards and outwards, both teeth 
 will be displaced : the lateral will be forced within the proper 
 line, and the canine will occupy a place external to it. 
 
 Many children, however, either from hereditary tendency 
 or from ill-health and consequent defective growth in the 
 jaws, have the permanent teeth during their development 
 placed irregularly. Attention has already been directed to 
 the fact that the size of the crowns of the teeth is determined 
 at an early age, and is not capable of subsequent alteration. 
 It would appear, however, that a want of proper relation in 
 respect of size between the teeth and the jaws may become 
 a permanent hereditary character, quite apart from the influ- 
 ences of health and disease. In certain families we may see 
 large teeth associated with small jaws, the want of the requi- 
 site size in the latter parts necessitating the removal of two 
 or more of the permanent teeth before the regular arrange- 
 ment of the remaining ones can be assumed — and this 
 without any indication either of want of constitutional vigour, 
 or of predisposition to disease. It is, in fact, a peculiarity 
 transmitted from parent to child, and must be regarded rather 
 as an hereditary characteristic, than as an abnormal condition 
 resulting from an arrest in the development of the maxillas, 
 capable of amendment if the patient be subjected to treat- 
 ment during the period of childhood. It is very necessary 
 that this part of dental surgery should receive far more con- 
 sideration in an anatomical and physiological point of view 
 than it has hitherto done. In the absence of precise know- 
 ledge upon the subject, there is room for great disparity
 
 TEETHING. 63 
 
 of opinion as regards treatment, leaving a wide and very pro- 
 ductive field for the cultivation of the charlatan, who sees 
 in every case of irregular disposition of the teeth an oppor- 
 tunity for mechanical interference, in some cases securing to 
 himself a large fee for doing by means of mechanism that 
 which Nature would have efi'ected, had the opportunity been 
 allowed ; and in other cases submitting the patient to a long 
 course of treatment, which entails no useful result. 
 
 In the subsequent pages, an attempt is made to bring 
 together a seiies of conditions connected with the subject of 
 irregularity of the permanent teeth, taking up the inquiry at 
 an earlier period than is usually done, and tracing the devia- 
 tions onward until the teeth are matured. 
 
 Irregularity in the position of the permanent, during the 
 existence of the tempo7^ary, teeth. — The first example selected 
 for description in illustration of irregularity in the position of 
 the permanent teeth, will be that of a child who died when a 
 little over the age of four years. The temporary teeth in the 
 front part of the mouth are crowded, the mesial edges of the 
 lateral incisors of the upper jaw being directed forward, 
 from insufficient space for a more regular position of these 
 teeth. The permanent central incisors, although uniform as 
 regards each other, hold an unusual position. The mesial 
 edges are turned forward, and the cutting edges of the teeth, 
 from the obliquity of the crowns, are directed towards the 
 mesial line. The upper lateral incisors lie in front of the 
 distal edges of the central teeth, and the canines are placed 
 immediately over the roots of the first temporary molars, and 
 consequently immediately over the developing cusps of the 
 first bicuspids. We have in this case a deranged position 
 which, until the teeth have passed through the gums, cannot 
 be materially changed. The development of the teeth has 
 been continued while the jaws have been comparatively 
 stationary. The oblique and twisted position of the central 
 incisors will be maintained until they are acted upon by the 
 antagonistic teeth of the lower jaw ; and the first bicuspids.
 
 64 
 
 A SYSTEM OP DENTAL SXJBGEBT. 
 
 which have been encroached upon and retarded in gi'owth by 
 the canines, will be crooked and misshaped, at the same time 
 that they will be forced into an irregular position in common 
 \vith the impinging canines, leading probably to one or other 
 of the permanent forms of displacement of the later teeth 
 
 considered in a future page. In this case, the teeth in the 
 lower jaws are subject to but slight irregularity. 
 
 Fig. 23. (2) 
 
 #i*%) / 
 
 (1) Showing the permanent central incisors, with their median side 
 directed forwards and outwards, while the dUtal edges lie behind the median 
 sjides of thp laterals. 
 
 (2) Side view of the same specimen, showing the relative positions of the 
 central and lateral incisors, the canine and the first bicuspids, the latter tooth 
 being interrupted in its development by th? canine.
 
 TEETHING. 
 
 65 
 
 In another specimen, from a subject who died at the age 
 of four years and thirty-six days, the lateral incisors of the 
 upper jaw are placed behind the centrals, the latter teeth 
 and canines being separated only by the common wall of 
 their respective crypts. 
 
 In a third specimen, the mesial surface of the left upper 
 central is turned outwards, while the corresponding part of 
 
 Fig. 29. (1) 
 
 the fellow tooth is turned inwards. The mesial side of the 
 left lateral incisor lies in front of the distal side of the cen- 
 tral, and on the opposite side of the jaw the mesial side of 
 the lateral is placed behind the distal side of its contiguous 
 central tooth. The canine and bicuspid teeth hold the 
 normal position. 
 
 In a fourth specimen we have an arrangement of teeth 
 which may not unfrequently be seen in the adult. The 
 deviation from the natural form is but slight, yet gives a very 
 characteristic appearance to the mouth, and one which indi- 
 cates a want of activity in the growth of the jaw during 
 
 (1) Shows mal-position of the incisors. The left central has its median 
 edge turned outwards, with the lateral lying in front of the distal edge. The 
 right central incisor has its distal side everted, with the lateral placed 
 behind.
 
 66 
 
 A SYSTEM OP DENTAL SURGERY. 
 
 childhood. In this the distal sides of the upper centrals are 
 slightly everted, while the crown of each tooth, regarded in 
 its length, slants outwards from the mesian line. Usually, 
 the upper and smaller parts are separated by a wider interval 
 than the lower portions of the crown ; in this case the mesial 
 surfaces are parallel throughout the whole length of the 
 crowns. Hence the aversion. 
 
 Fig. 30. (1) 
 
 Hitherto, the relations of the teeth to each other and to the 
 laws, have been considered in cases where themaxillas present 
 the normal structural appearance, as distinguished from cases 
 in which there are obvious marks of a diseased condition of 
 the bone. In the specimen from which the two succeeding 
 figures are taken, the bone is defective both in the quantity 
 and in the quality of the tissue. The temporary t^eth are 
 ahnost devoid of sockets, while the developing permanent 
 teeth — in the absence of sufficient bone to admit of the 
 existence of normally-formed crypts — are covered at certain 
 points by soft parts only. The subject— a male — from which 
 the maxilla? were taken, died exhausted by strumous abcesses 
 
 (1) Shows the centrals srmmetrically axranged, but with the distal side of 
 each tooth turned slightly outwards.
 
 TEETHING. 67 
 
 when he was said to be six years old. Both in the upper and 
 lower jaws, the incisors and canines are almost without 
 sockets, and the molars have but imperfect ones. The 
 general dimensions of the jaws, even supposing the age to be 
 overstated to the extent of eighteen months, are a third below 
 the normal size. This has led to the mal-position of the 
 permanent teeth. The central incisors of the upper jaws are 
 of the usual size and shape, although the enamel is at 
 certain points defective. 
 
 Fig. 31. (0 
 
 The canines lie with their median surfaces in contact with 
 the distal sides of the central teeth, leaving no space what- 
 ever for the lateral incisors. These are placed within the 
 dental line, behind the temporary canines (Fig. 32), lodged 
 in very imperfect crypts, and placed at right angles to their 
 proper position, the cutting edge of each tooth being directed 
 outwards instead of downwards. The first permanent molars 
 have their crowns nearly perfected, and are placed with the 
 
 (I) Front view of the upper jaw of a male subject who died at the age of 
 six years, showing a defective condition of the outer alveolar ph\te and an 
 imperfect implantation of the temporary teeth.
 
 68 A SYSTEM OF DENTAL SUBGERY. 
 
 masticating surfaces directed obliquely backwards, the base 
 of the crown running over the fangs of the second temporary 
 molar, and encroaching upon the space which should be 
 occupied by the second bicuspids. 
 
 The second permanent molar, the cusps of which are calci- 
 fied and united the one to the other, is altogether without an 
 osseous receptacle. 
 
 In this specimen we have a remarkably good example of 
 
 Fig. 32. (1) 
 
 the effects produced from the development of the maxillai 
 having been suspended, while that of the permanent teeth 
 was continued. We here see the great amount of displace- 
 ment that may arise from the presence of long-standing 
 constitutional disease. 
 
 Local disease in the temporary may also affect the perma- 
 nent teeth; but the effect will be limited to those in the 
 immediate neighbourhood of the disease. Caries, and con- 
 sequent alveolar abscess, arising in a temporary tooth, some- 
 times produces injurious effects upon, and even displacement 
 of the succeeding tooth ; and this is, I think, a more fre- 
 quent consequence when the disease is situated in the first 
 
 (') Palatal view of the specimen Illustrated In the last figure, showing 
 an abnonnal condition of the bone and the exposure of the permanent 
 canines.
 
 TEETHING. 69 
 
 or second temporary molars, than when the front teeth are 
 affected. In a preparation figured to illustrate the effects of; 
 dead teeth, it may be seen that the developing first bicuspid, 
 of the upper jaw has been driven outwards by the mischief 
 arising from the presence of a dead temporary molar. 
 
 Fig. 33. (1) 
 
 In addition to the causes already enumerated, mechanical i 
 injury of the maxillae or of the temporary teeth, may be cited | 
 as producing displacement of the permanent teeth while I 
 lodged within the dental crypts. 
 
 Among mechanical causes, the extraction of temporary ] 
 teeth may be placed. We have most of us seen examples ' 
 where removal of the second temporary molar has been 
 
 (1) The upper and lower jaws at the age when the permanent incisors are 
 about to appear through the gums, showing the relative position of the two 
 sets of teeth. The left lateral incisor of the upper jaw is Imperfectly developed, 
 and placed external to the central tooth ; and the first biciispid of the same side 
 has been forced outwards by disease, and subsequent death, of the preceding 
 temporary molar.
 
 70 A SYSTEM OF DENTAL SURGERY. 
 
 accompanied by that of the partly-formed second bicuspid, an 
 accident which has arisen either from the unusual convergence 
 of the roots of the temporary, or from the absorption of the 
 walls of the crypt of the permanent tooth. The latter 
 condition is .not, I think, extremely rare in those cases where 
 alveolar abscess is consequent upon disease in the temporary 
 molar. A certain degree of inflammatory action of the soft 
 parts in the immediate vicinity of bone leads to more or less 
 absorption of the latter, and at the same time the former be- 
 come glued together by effused lymph. Supposing these con- 
 ditions to prevail, it will not be difficult to conceive how, in 
 attempting the extraction of one, both teeth may be removed. 
 
 Taking the phases of dentition in the order of their occur- 
 rence, the next point which presents itself for consideration 
 is the absorption of the roots of the temporary teeth. 
 
 Shedding of the temporary teeth. — No sooner is the tempo- 
 rary set of teeth fully formed, than a process is set up for the 
 removal of some of its members. Within twelve or eighteen 
 months of the completion of the roots of the second molars 
 and canines, the fangs of the incisors are attacked by 
 absorption. 
 
 The destruction may commence on any part of the root, or 
 at several spots simultaneously. Particle after particle is by 
 degrees carried away, until nothing but the crown of the tooth 
 is left, and even this is often so much hollowed out, that 
 little save the enamel remains, and sometimes not all of that. 
 
 Although among a number of temporary teeth we may find 
 that absorption has commenced at several and distant points, 
 and not uncommonly on the labial surface of the root ; yet, 
 in the majority of cases, that part which lies nearest to the 
 growing tooth will be the first to show indications of wasting, 
 and upon which the process will be the most active. The 
 opposed surfaces of the roots of the lower temporary molars, 
 embracing bicuspids, are acted upon, while the outer surfaces 
 usually escape. The lingual surface of the fang of a front 
 tooth is commonly attacked, the process commencing at
 
 TEETHING. 
 
 71 
 
 or near the extremity ; but the proximity of the permanent 
 tooth is not by any means a necessary point. I have 
 examined many specimens, in which a portion of the labial 
 surface midway between the neck and the point of the root 
 has been carried away. 
 
 Having latterly had occasion to devote considerable atten- 
 tion to the phenomena attending the absorption of bone and 
 
 Fig. 34. (1) 
 
 the wasting of the roots of the deciduous teeth, several con- 
 ditions relative to absorption have come under my notice, 
 which, as applied to teeth, had, I think, hitherto escaped 
 observation. The cementum is first attacked, then the dentine 
 disappears, and the enamel at those points where the dentine 
 has been entirely removed suifers from the same action. But 
 
 [}) A section from a temporary tooth, in which the dentine (o) and the 
 enamel (6) have been removed by absorption, leaving the festooned out- 
 line (c).
 
 72 A SYSTEM OF DENTAL SURGERY. 
 
 whichever of the three tissues is attacked, we see the same 
 characteristic surface as that shown by bone when undergoing 
 a similar action — namely a surface full of deep indentations, as 
 though they had been made by a sharp piercing instrument, 
 having a semicircular extremity. These minute holes or 
 depressions proceed in various directions, several advancing 
 from contrary points towards the same spot, not unfrequently 
 isolated pieces of dentine. If a section be taken through 
 the substance of a tooth, so as to cut the wasting part 
 at a right angle, we shall find the surface acted upon 
 
 to have an irregular festooned outline, so characteristic 
 in appearance, that when once seen it cannot fail to be again 
 recognised. 
 
 Closely applied to this surface a cellular mass will be found, 
 which is but slightly adherent, the wasting and growing 
 surfaces readily parting, unless the two are held together by 
 the irregularities on the surface of the former. It will some- 
 times happen that the cellular mass penetrates into the 
 dentine through a small opening, and there dilates, in which 
 case its withdrawal becomes impeded. This condition is now 
 and then found in sections prepared for examination, and 
 
 (1") Shows the compound cells which form the sorfiace of the absorbent 
 papilla.
 
 TEETHING. 73 
 
 affords a favourable opportunity for examining the two tissues 
 in situ. Indeed, we may find a few cells adherent to the sur- 
 face of the dentine where less deep burrowing has occurred. 
 By the aid of the microscope, the structure of this peculiar 
 organ can be determined. The surface is made up of peculiar 
 multiform cells, each one being composed of several smaller 
 cells, the number varying from two or three to as many as 
 fourteen or fifteen. The form is variable, but egg-shaped or 
 spherical figures are found to prevail, although some few 
 deviate from these forms, and offer a very strong resemblance 
 to those cells described by M. KoUiker as myeloid cells. 
 
 The relation the more superficial of these cells bear to the 
 wasting surface of the dental tissues is peculiarly interesting. 
 It has been already stated that the surface of the papilla is 
 closely applied to the wasting surface of the tooth ; and in 
 favourable specimens it may be shown that the individual 
 indentations correspond to, and are occupied by, these large 
 cells. On several occasions I have obtained specimens in 
 which the two retained their natural positions. Each semi- 
 circular indentation in the dentine was occupied by a com- 
 pound cell. Very possible in other cases several cells may 
 take the place of a single cell. Below the surface the 
 papilla is made up of ordinary nucleated cells and free nuclei, 
 similar to those contained in the superficial compound cells ; 
 while at and near the base, the tissue assumes the charac- 
 teristics of developing fibrous tissue. 
 
 1 f a tooth which has lost its fang be carefully removed, we 
 shall find remaining in its place the growing papilla, corre- 
 sponding exactly in size and form to the surface from which 
 it has been separated; and this separation may often be 
 effected with so little injury, that no blood appears upon its 
 surface after the operation, although the organ is highly vas- 
 cular and readily torn.(^) The superficial extent of the papilla 
 
 (1) Laforgue and Bourdet recognised the presence of the absorbent organ, 
 but supposed it exhaled a fluid capable of dissolving the roots of the temporary 
 tooth.
 
 74 A SYSTEM OP DENTAL SURGEBT. 
 
 will be equal to that part of the tooth undergoing waste, but 
 the extent, as regards depth, is slight ; for, as the root of the 
 tooth disappears, the socket is contracted by the deposition 
 of bone, which forms at the base of the absorbent organ as 
 rapidly as the cellular surface encroaches upon the tooth. 
 The cases in which we find an exception to this condition are 
 those in which the permanent has advanced close to the fangs 
 of the temporary tooth, when the crypt containing the one 
 communicates with the socket of the other, indicating that 
 the rate of growth of the permanent, has been equal to if not 
 greater than the absorption of the deciduous, organ. But 
 even in these cases we may occasionally observe some part 
 in which the contraction of the socket has been coincident 
 with the absorption of the occupant fang. From the follow- 
 ing quotation, it does not appear that Mr. Bell observed these 
 conditions : 
 
 "It has been already stated, that the permanent teeth 
 during their formation are crowded together in the jaw, by 
 being placed in a smaller arch than they would occupy if 
 regularly placed side by side. As the latter, however, is 
 their destined situation, we find that as soon as they are 
 advanced to a certain point of their formation, and can no 
 longer be contained within the alveoli, absorption takes place 
 in the anterior parietes of the cavities, by which means the 
 teeth are allowed to come in some measure forward. In 
 consequence of this absorption it often happens, that not 
 only the socket of the corresponding temporary tooth, but 
 that of the tooth on each side, is also opened to the perma- 
 nent one. Absorption now commences in the root of the 
 temporary tooth, generally on that part nearest its successor, 
 and thus goes on by degrees as the latter advances, until the 
 root is completely removed, the crown at length falls ofl, 
 leaving room for the permanent tooth to supply its place." 
 
 Mr. Bell, however, rejects the idea that mere pressure of 
 the one tooth against the other has anything to do with the 
 absorption of the first set ; an opinion that he would probably
 
 TEETHING. 
 
 75 
 
 have expressed even more strongly, had he observed the 
 shallow but perfect sockets which are formed when the 
 temporary teeth are shed before their successors are ready 
 to appear. This, however, must be a very common condition ^ 
 
 Fig. 36. (1) 
 
 (1) The upper and lower jaw of a female subject, six years and five months 
 old, showing the layer of bone which forms the bottom of the socket of the 
 temporary incisors after the roots have been absorbed.
 
 76 A SYSTEM OF DENTAL SURGERY. 
 
 as I have in my own collection several specimens illustrating 
 the point. 
 
 The fact was not overlooked, I think, by Hunter, although 
 his description is not very clear. He states, at page 99 in 
 his " Natural History of the Teeth :" — " The new alveoli rise 
 with the new teeth, and the old alveoli decay in proportion 
 as the old teeth decay ; and when the first set falls out, the 
 succeeding teeth are so far from having destroyed by their 
 pressure the parts against which they might be supposed to 
 push, that they are still enclosed and covered by a complete 
 bony socket. From this we see that the change is not 
 produced by a mechanical pressure, but by a particular 
 process in the animal economy." 
 
 But there is still a disposition on the part of many who are 
 entrusted with the treatment of teeth, to attribute the absorpr 
 tion of the roots of the one tooth to pressure occasioned by 
 the growth of its successor ; and the development of the 
 permanent may have something to do with the shedding of 
 the other. But this does not offer a satisfactory explanation 
 of all the circumstances attending the absorption of the fangs 
 of teeth. In the first place, we sometimes meet with cases in 
 which the fangs of permanent teeth are as completely ab- 
 sorbed as those of the temporary organs. Then, again, the 
 fangs of temporary teeth, which have no successors, are also 
 absorbed : and it not uncommonly happens that absorption 
 takes place at several points on the fang, some of which are 
 far removed from the successor, being oftentimes on the 
 opposite side of the root. These circumstances, taken with 
 the hitherto overlooked fact, that with the waste of the tem- 
 porary tooth we have in many cases a corresponding develop- 
 ment of bone within the socket, to be removed before the 
 permanent tooth appears through the gum, render the pres- 
 sure theory altogether untenable. Another condition may 
 be adduced, tending also against that opinion, — namely, that 
 temporary teeth occasionally maintain their place to the 
 exclusion of the permanent ones, which are then kept
 
 TEETHING, 77 
 
 within the substance of the jaw, or appear in some unusual 
 position. 
 
 The relations as regards time between the absorption and 
 shedding of temporary teeth and the appearance of the suc- 
 ceeding permanent teeth, are by no means constant. In some 
 cases the temporary teeth are thrown off two years before 
 the corresponding permanent ones come through the gums. 
 In others, again, the new will replace the old ones in as many 
 weeks or even days. 
 
 Before the laws which regulate the absorption of the fangs 
 of teeth can be fully recognised, a more perfect knowledge of 
 the condition attending the process must be acquired. Recent 
 examinations have enabled me to add the following additional 
 facts bearing upon this subject to those already known. 
 When the process of absorption has once commenced, it 
 appears to have been assumed that the action would be con- 
 tinued, with more or less rapidity, until the tooth falls out. 
 Such, however, is not constantly the case. Xot only is the 
 action of absorption suspended, but one of development takes 
 its place. We find the excavated surface of the dentine, 
 cementum, and enamel covered with cementum, the latter fol- 
 lowing all the irregularities of the former tissues, and closely 
 united to them. (Fig. 37.) In cases where this development is 
 going on, or in which the new tissue is retained, the teeth 
 offer considerable resistance when their removal is attempted. 
 In those instances where the first teeth have remained, and 
 tend to the displacement of the second set, this deposit of 
 cementum will be found to exist in considerable quantity. 
 
 The development of bone upon the surface which had 
 formerly been the seat of absorption, by no means indicates 
 that the tooth will not again be subject to destructive action. 
 On the contrary, specimens in my , collection show that the 
 bone deposited under the above circumstances may itself 
 become the subject of absorption, that this process may be 
 again suspended and development be renewed, that the 
 absorption may again take the place of development ; in fact, 
 that wasting and reparation may alternate until, by the
 
 78 
 
 A SYSTEM OP DENTAL SURGERY. 
 
 preponderance of the former, the tooth is shed. In sections 
 of teeth showing this peculiar condition of development, we 
 may find upon the growing bone numerous osteal cells, with 
 here and there a lacunal cell. A bone lacuna, situated with- 
 in a semi-circular indentation in the dentine, gives the ap- 
 pearance of a lacunal cell, and a lacuna similarly situated in 
 
 Fig. 37. (1) 
 
 the cementum (a circumstance of common occurrence), has 
 possibly been supposed by Mr. J. Salter to be what has been 
 described in the paper before referred to as a lacunal cell.(2) 
 
 The part of a tooth which has the greatest powder of resisting 
 absorption is that which is in immediate contact with the pulp. 
 
 (») A section from the fang of a tooth in which the dentine (a) has been 
 removed, together with the cementum (c), and again made good by the depo- 
 sition of cementum. The appearance presented at the junction of the den- 
 tine and cementum, where absorption has not encroached upon the tissues 
 at that point, is shown at (V). The curved irregular line in the cementum 
 indicate the extent of absorption at various periods, and the boundaries of the 
 tissue which lias replaced the lost parts. 
 
 (2^ Transactions of the Pathological Society, vol. vi., p. 169.
 
 TEETHING. 
 
 79 
 
 We find examples in which, a thin shell of dentine encircles 
 that organ, while all around it has been in great part taken 
 away. This is, however, eventually removed, and the pulp 
 itself changes its character, and becomes an absorbent organ^ 
 or makes way for that which is. In a fortunate selection we 
 may find sections showing in one part dentine which has been 
 
 Fig. 38. 0) 
 
 h 
 
 (0 A section from a temporary tooth, the fangs of which have been 
 absorbed, and the crown hollowed out; the enamel having been partly removed, 
 and both tissues coated over with new ceiuentum. a, the dentine ; h, the 
 enamel; c, the cementum; d, the junction of the absorbed surface of the 
 enamel and new cementum.
 
 80 A SYSTEM OF DENTAL 8URGEET. 
 
 but recently formed, with its nodular outline and contiguous 
 cells capable of developing dentine ; in another part, absorp- 
 tion in active progress ; and in a third, the deposition of 
 bone on the surface of the wasted dentine. In no instance, 
 however, have I seen dentine deix)sited upon the surface of 
 that which has been diminished by absorption. 
 
 It would appear that the dentinal pulp, although its func- 
 tion may be changed into that of absorption, or its place be 
 taken by an absorbent organ, and this, again, changed to one 
 for the development of bone, is incapable of resuming under 
 any recognised circumstances its primary function of dentinal 
 development. In other words, that a portion of dentine when 
 removed by absorption, cannot be replaced ; while in bone, 
 or cementum, the renewal of a lost portion is of frequent 
 occurrence. 
 
 It will be seen that the foregoing facts bear upon the 
 opinions advanced by Mr. De Morgan and myself, in the 
 paper on the structure and development of bone before cited ; 
 that we have indications in teeth, as in bone, of alternations 
 of removal and of deposition of tissue. In the young subject, 
 the development of bone tissue is in excess of absorption, 
 allowing the bones to increase in size : in middle life the two 
 powers, under ordinary circumstances, balance each other, 
 and the bones preserve their adult dimensions ; while in old 
 age the absorbent action apjiears to preponderate. Con- 
 ditions pretty nearlj- parallel occur in the dental tissues after 
 the temporary tooth has been fully formed ; portions of ce- 
 mentum are removed, and with them, in some cases, a little 
 dentine ; the lost parts are replaced by cementum, and the 
 tooth is again jierfect. When the time approaches for shed- 
 ding the teeth, the two actions alternate ; but the absorption 
 being in excess of the development, the tissues disappear, 
 and the tooth is shed. After the fonnation of the permanent 
 teeth we have occasional alternations of the two actions ; but 
 they are balanced, and neither increase nor diminution in 
 size is observed. But as age comes on, it often happens that
 
 TEETHING. 81 
 
 absorption is in excess, the fangs diminish in size, the teeth 
 become loose, and eventually fall out. 
 
 The normal shedding of one or more of the temporary- 
 teeth is, however, sometimes subject to interruption. The 
 absorption of the roots is suspended, and the tooth holds its 
 place, while its successor is matured within the jaw in some 
 unusual position ; or the permanent tooth may be altogether 
 wanting. It is not uncommon to find the temporary incisors 
 firmly implanted, with the permanent teeth appearing through 
 the gum behind them. In instances of this kind it is diffi- 
 cult to determine whether or not the permanent teeth were 
 developed in a perfectly normal position, and their position 
 subsequently changed by the persistence of the milk teeth 
 consequent on the arrest of absorption, or whether the relative 
 position of the two sets has been from the first irregular. 
 Judging from the conditions presented in my own specimens, 
 I should incline to the opinion that the presence of the 
 temporary teeth is in such cases due to some extent to 
 original malposition of the developing permanent organs. 
 Many instances in which the second temporary molars have 
 been retained until the middle period of life has passed, have 
 come under my notice. The second bicuspid has been want- 
 ing, and the temporary tooth has retained its original position. 
 
 The influence of the first and second sets of teeth upon 
 each other at the time of replacement is so constant, and so 
 varied in character, that it becomes impossible to treat fully 
 of all that relates ta the disappearance of the one, prior to 
 entering upon the relations of the other. It will therefore 
 be convenient to revert to several points connected with the 
 shedding of the temporary (and especially those relating to 
 treatment), in connection with the eruption and arrangement 
 of the permanent teeth. 
 
 Before we dismiss the subject of absorption, a few lines 
 may be devoted to the consideration of the manner in which 
 the absorbent organ is developed, and of the tissues from which 
 it arises ; both are points of great physiological interest. 
 
 G
 
 82 A SYSTEM OF DENTAL SURGERY. 
 
 In a paper read before the Odontological Society, Mr. 
 Sj^ence Bate advanced the opinion that the outer surface of 
 the enamel organ assumed an increased degree of vascularity, 
 and took upon itself the office of absorption. If our observa- 
 tions were restricted to the phenomenon as it is usually pre- 
 sented in the temporary molars, this opinion might, perhaps, 
 be maintained ; but when we find absorption commenced and 
 continued upon the labial surfaces of the front teeth, where 
 no enamel organ exists ; and when we find a number of 
 specimens in which a layer of bone separated the developing 
 tooth from the one undergoing absorption, considerable doubt 
 is thrown u^xin the accuracy of Mr. Bate's views. He, how- 
 ever, considers the foregoing as exceptional cases, and regards 
 them as abnormal. Any vascular tissue, on assuming an 
 increased degree of vascularity, may, he considers, exercise 
 the function of absorption. But the wasting of the fangs of 
 permanent teeth, together with the class of cases cited above, 
 he regards as instances of abnormal action, the absorption 
 being performed by the peridental membrane, the vascularity 
 of which has been increased by irritation at the same time 
 that it has become detached from the surface of the tooth. 
 The admission of this distinction into normal and abnormal 
 absorption, in respect to the removal of the tissues of tem- 
 porary teeth, will not, I think, help us to a better compre- 
 hension of the subject ; for in the one case we cannot know 
 when the action has commenced on a part distant from the 
 enamel organ until the tooth has been removed, and in the 
 other the septum of bone cannot be recognised but by 
 dissection. But the most fatal objection of all to such a far- 
 fetched supposition is, that at the period when absorption of 
 the fang of the temporary tooth is going on with the utmost 
 activity, the enamel organ of its successor has not only long 
 ceased to be vascular, but has in most instances actually ceased 
 to exist, the external cpithelm of the enamel organ having 
 become inseparably attached to the surface of the enamel. 
 
 All recent observers will, I think, admit that the dental
 
 TEETHING. 83 
 
 tissues are removed through the agency of a growing 
 papilla, and I do not think a difference of structure or func- 
 tion, referable to the particular tissue from which it may 
 have arisen, can be established. Whether the development 
 takes place from the enamel capsule or from the peridental 
 membrane, the structure and the function of the papilla will 
 be the same. The precise nature of the action by which 
 the cells eat away the hard tooth structures still remains 
 a matter of great uncertainty. Kehrer, having observed 
 chalk granules in the protoplasm of young cells, believes 
 that the amaeboid cells of the granulations destroy the 
 dental tissue by a kind of mining process, effected by their 
 pseudopodia; (Waldeyer, in Strieker's Human and Com- 
 parative Histology.) 
 
 In a paper published in the " Philosophical Transactions," 
 some of the foregoing facts are described in connection with 
 the absorption of bone, and an opinion was advanced, to the 
 effect that the absorbent organ grew at the expense of the 
 wasting bone or dental tissue, as the case may be. At that 
 time the peculiar character of the superficial compound cells, 
 and their correspondence to and lodgment in the minute 
 concavities of the wasting tissue, had not been observed. 
 But when it is considered that the dental tissue is decreasing, 
 while the compound or mother cells (as they have been 
 called) are increasing, and that the convexities of the latter 
 are fitted into the concavities of the former, we are iiTesistibly 
 led, not only to the conclusion that the growing papilla is 
 the absorbent organ, but also to the belief that the superficial 
 compound cells are the immediate agents by which the 
 tissues are removed, and that the peculiar surface presented 
 by either bone or dental tissues, is secondary to, and produced 
 by the cells which form the surface of the papilla. 
 
 Perhaps Mr. Spence Bate might be right were he to assert 
 that the outer surface of the capsule of the developing per- 
 manent tooth, may become the seat of the vascular structure 
 which fulfils the office of absorption. But I am unwilling to
 
 8i A SYSTEM OF DENTAL SURGERY. 
 
 admit that a similar structure arising in other parts and 
 under other circumstances, is to be regarded as abnormal. 
 Supposing the distinction to hold good, we must regard the 
 action by which bone is at all periods of life removed, prior 
 to the development of new tissue, as an abnormal process, 
 and also the corresponding changes which go on in the 
 cementum clothing the roots of permanent teeth. It would 
 appear rather, that wherever the necessity for the removal of 
 osseous tissue arises, the structure capable of fulfilling the 
 oflnce is developed, and in a vast number of cases quite in- 
 dependently of abnormal action, and that the seat of the 
 development may be in any vascular structure. 
 
 The observations at present at our disposal are not suflB- 
 ciently numerous and varied to admit of the deduction of 
 any general law, as regards the power by which absorption of 
 one tissue by another is effected. But I think they point 
 strongly to the idea, that a cell structure in an active state 
 of development, is capable of appropriating or removing out 
 of its way a matured tissue. 
 
 The eruption of the 'permanent teeth. — Attention has already 
 been directed to the changes in the condition of the alveolar 
 processes antecedent to the eruption of the temporary teeth. 
 Very similar conditions prevail when the permanent organs 
 are about to make their appearance through the gums. It 
 has been shown that absorption of the alveolar margin of the 
 sockets of the first teeth is not necessarily coincident with 
 the removal of their roots, but that the opposite condition 
 very commonly obtains ; that absorption of the dental tissues 
 may be accompanied by development of osseous structure. 
 When, however, the permanent tooth is ready to emerge 
 from its bony cell, absorption is again set up, and in this 
 case the bone which lies over the crown of the growing tooth 
 is attacked. The coronal portion of the crypt is enlarged, 
 and the outer alveolar plate emarginated in the manner 
 which we have seen precedes the evolution of the temporary 
 tooth. The aperture becomes enlarged until the crown of
 
 TEETHING, 85 
 
 the tooth can readily pass through. The comparatively large 
 size of the crown as compared with the neck or the root of a 
 tooth, necessitates a breadth of socket, during the period both 
 of development and of evolution, far greater than is required 
 for the implantation of the fully-emerged organ. Hence a 
 tooth at this stage of its progress can be readily moved from 
 side to side by moderate pressure, and very slight mechanical 
 obstruction will turn it either into or out of its normal 
 positiou. The presence even of a small portion of the root of 
 a temporary tooth will be sufficient to change its direction ; 
 and on the other hand, the action of the tongue on the lips 
 will suffice to bring the out-growing organ into its natural 
 position, if the impediment be removed during the period of 
 active eruption. The condition to which I have alluded is 
 shown in the enlarged alveolar apertures of the first per- 
 manent molar teeth in Fig. 36, and will be seen in connec- 
 tion with other permanent teeth forming the subject of 
 subsequent illustrations. 
 
 The provision for a tooth to take its proper place, displayed ■ 
 in the greatly widened socket at the period of eruption, 
 would however be insufficient if the whole of the front teeth 
 advanced towards their ultimate position simultaneously. It 
 has been shown that the crowns, while within the jaws, are 
 necessarily placed in an uneven line, and this irregularity 
 would become permanent if all were to make their appearance 
 through the gums at the same time. But, although the jaws 
 at the age of five or six years do not afford sufficient space 
 for the uniform arrangement of the crowns of the developing 
 teeth, yet there would be ample room for the roots of these 
 teeth to be placed in an even line. It has been stated that 
 the crowns of the forming teeth are inclined slightly out- 
 wards, and that the growth of the alveolar arch is principally 
 confined to the free edges and the outer surface. Bone is 
 added externally, while it is being removed from the inner 
 surface of each crypt to allow space for the increasing tooth, 
 at the same time that the tooth is moved bodily forward.
 
 86 A SYSTEM OF DENTAL SURGERY. 
 
 If adult specimens in which the teeth and jaws are well 
 formed, be examined, it will be found that growth in the 
 direction indicated has been continued until the parts have 
 arrived at maturity. In the adult the crowns of the front 
 teeth are placed in advance of the base of the nose ; in the 
 child they are in a line vertical to it : and if we measiure the 
 ellipse formed by the anterior surface of the upper jaw in a 
 horizontal line with the last-named point, extending on 
 either side to the second bicuspids, and then apply the 
 measure to the corresponding part in an adult, or in an 
 edentulous old person, we shall find the result in each case 
 very nearly similar. In tracing the permanent teeth as they 
 are respectively protruded and take their position in the 
 dental arch, it is desirable to bear the foregoing points in 
 mind. In certain cases we shall find mischief arises from 
 want of growth in the facial bones at the earlier periods of 
 life, but in many instances the deviations from the normal 
 position of the teeth and alveoli are independent of insufficient 
 size of the bodies of the maxillae ; or in other words, cases in 
 which the basal line has attained its usual extent, while the 
 teeth are irregularly placed in an irregularly-formed arch. 
 
 It is necessary to draw a distinction between the bodies of 
 the maxillae and the alveolar processes, as it will subsequently 
 be shown that in cases of irregular dentition, the irregularity 
 may depend upon a want of accordance between the general 
 dimensions of the jaws and the determined size of the teeth ; 
 or the mal-arrangement may depend solely upon imperfect 
 development, in respect to position, of the teeth and the 
 alveoli. 
 
 In describing the evolution of the teeth individually, and 
 the coincident conditions, the chronological order in which 
 they usually appear will be followed. 
 
 The first permanent molar of the upper not uncommonly 
 precedes by a few weeks the corresponding tooth of the lower 
 jaw ; but I do not know that, in respect to priority, any great 
 uniformity prevails. The conditions presented by these teeth
 
 TEETHING. 87 
 
 at the age of six years and Jive months, are shown in Fig. 36. 
 In the upper jaw, the bone which lay over and protected the 
 tooth at an earlier age, is entirely removed, not only from the 
 coronal surface, but also to a great extent from the labial side 
 of the crypt ; and this has taken place prior to the tooth being 
 raised above the general level of the alveolar margin. It is 
 now, however, in a condition for rapid development of the 
 fangs, and two or three months would have served to bring 
 it to the surface of the gums. On removing one of the teeth 
 from the upper jaw, the roots, although very short and 
 imperfect, are seen to have their respective positions defined, 
 the neck of the tooth being perfected. The enamel has at- 
 tained its maximum thickness, and is deficient only in density. 
 At the age under consideration, the first molars occupy 
 the posterior part of the alveolar arch, the second molar in 
 the upper being confined to the back part of the tuberosity, 
 and in the lower jaw to an excavation beneath the base of 
 the coronoid process. 
 
 In a specimen obtained from a female subject aged seven 
 years, the first molars have gained the level of the temporary 
 teeth, although the fangs are at present very short and 
 truncated at their as yet incomplete ends ; each fang has its 
 own well-defined socket, the depth of which is equal to the 
 length of the developing root. If a tooth be extracted before 
 decomposition has commenced, it will be found that the for- 
 mative pulp is contained within the large and open cavity 
 of the fang, projecting only in a very slight degree fVom the 
 extremity. It looks as though it had been cut off on a level 
 with the end of the root, so abrupt and flat is the termina- 
 tion of the soft tissue. Were it otherwise, pressure upon the 
 masticating surface of the tooth would produce compression 
 of the pulp, as the socket has not yet contracted to the 
 dimensions of the tooth, and the septa of bone which even- 
 tually rise between the roots, are not sufficiently developed 
 to take the pressure, and thus relieve the roots from being 
 driven against the bottom of the socket.
 
 S8 
 
 A SYSTEM OF DENTAL SUEGERT. 
 
 In the accompanying figure (Fig. 39), the molar of the 
 right is in advance of the corresponding tooth of the opposite 
 side of the jaw. On the one side the tooth had appeared 
 through the gum, while on the other the surface of the mucous 
 membrane had not been pierced. The position of the second 
 molar is indicated by the asterisk. In the specimen previously 
 described, the first molars occupied the terminal portion of 
 
 Fig. 39. (1) 
 
 the alveolar arch; in the present case a small amount of 
 space posterior to them is gained, and the second molars, 
 which were placed at the back part of the tuberosity and 
 directed backwards, are now descending into the dental line, 
 and are directed obliquely downwards and backwards. 
 
 In the specimens which have been described, the new teeth 
 in their implanted portions are quite equal to the depth of 
 the sockets, the bottoms of which reach in the upper jaw to 
 'the floor of the antrum, and in the lower maxilla to the 
 inferior dental canal. This leaves no room for growth in the 
 
 (1) Sho\ring the condition of the alveoles of the first permanent molar at 
 the time the tooih is advancing to the surface of the gum. The tooth on the 
 Tight side is a little in advance of that on the left side of the mouth. 'The 
 crypt of the second permanent molar.
 
 TEETHING. 
 
 89 
 
 direction of the deeper parts. The increasing length of each 
 tooth must therefore be accompanied by an increased depth 
 of socket produced by addition of bone to the free margin 
 of the alveohis. 
 
 The develophient proceeds rapidly until the opposing 
 teeth come in contact, when the antagonism becomes ad- 
 justed, a process which is rendered easy by the comparatively 
 loose implantation of the teeth. 
 
 The teeth which usually succeed the first permanent 
 
 Fig. 40. (1) 
 
 molars in the order of emergence, are the central incisors of 
 the lower jaw. After the temporary central incisors have 
 been shed, absorption of the corresponding edges of the 
 alveoli commences, and commonly carries away the outer 
 
 (1) Shows the relative position of the two sets of teeth, and the absorption 
 of the anterior plate df the alveoli of the lower central incisors antecedent 
 to their emergence. In the upper jaw the roots of the temporary incisor 
 have been removed, and absorption of the edge of the alveolus of the left 
 central incisor has commenced. It will be seen that the depth of the alveoli 
 at this point is equal to the length of the developing teeth.
 
 90 A SYSTEM OF DENTAL SURGERY. 
 
 plate to a considerable depth. The condition is shown in 
 Fig. 40 ; in this case the whole of the bone which lay in 
 front of the crowns of the new teeth has been absorbed. In 
 other instances the waste may be rather more limited, but in 
 all cases the depth of the jaw becomes diminished at the 
 points corresponding to the teeth, which are about to advance 
 from their osseous crypts to the surface of the gums. The 
 posterior alveolar plate, although diminished in height, 
 usually suffers in a much less degree than the outer surface 
 of the jaw, and consequently offers a less broken outline than 
 that shown in the last figure. If the specimen under con- 
 sideration be compared with an adult jaw from which the 
 outer alveolar plate has been removed, it will be seen that 
 the terminations of the two advancing incisors hold the 
 position which the ends of the roots of the fully fonned 
 corresponding teeth occupy. 
 
 The conditions which have been described as pertaining to 
 the eruption of the lower central incisors, will be found to 
 accompany the evolution of the upper central teeth ; the 
 amount of bone removed by absorption varying with the 
 position and size of the teeth. It is, however, by no means 
 easy to obtain specimens of the age required to illustrate the 
 changes attendant upon the eruption of the permanent teeth. 
 The dealers do not appear to regard them as saleable, and 
 they can be acquired from other sources only at uncertain 
 intervals. 
 
 The subject (a female) from \vhich the following figure has 
 been taken, died at the age of seven years and eight months. 
 The central incisors have emerged from the alveoli to the 
 extent of about two-tliirds of the length of their crowns, the 
 right being a little in advance of its fellow tooth. The 
 respective alveolar apertures are greatly enlarged, allowing 
 the teeth to be moved either outwards or inwards. 
 
 In this instance, the jaw is rather contracted in size, and 
 the new teeth, in the absence of the temporary laterals, have 
 their distal sides situated but a short distance from the
 
 I 
 
 TEETHING. 
 
 91 
 
 canines, leaving insufficient space for the permanent lateral 
 teeth, supposing the present position of the centrals to be' 
 maintained. But the provision afforded for adjustment by 
 the enlarged sockets, will allow the crowns of the teeth to 
 
 Fig. 41. (1) 
 
 take a more forward position, which, as they descend obliquely 
 outwards, will be still further increased when the teeth have 
 attained their full length. And thus the space, at present 
 too limited for the normal arrangement of the neighbouring 
 teeth, will eventually become sufficiently extended. 
 
 The phenomena which have been described as attending 
 the eruption of the central incisor, are repeated when the 
 lateral teeth are protruded. These are, however, subject to 
 an influence as regards their position, from which the central 
 incisors are exempt. The canines are at this period far 
 advanced in development, and their large, rounded, mesial 
 
 (1) Upper jaw of a female subject seven years and eight months old, showing 
 the central incisors taking their place in the alveolar arch. The right tooth 
 is well placed, but the left is a little turned on its axis. The alveolus of each 
 is larger than the contained tooth, affording space for the teeth to assume a 
 normal position.
 
 92 A SYSTEM OF DENTAL SURGERY. 
 
 sides not unfrequentlv interfere with the direction of the 
 roots of the lateral teeth, and thus tend to turn the crowns of 
 the teeth out of their natural position — an evil which is 
 usually- remedied by the further descent of the canines 
 towards the alveolar margin. The normal position of the 
 incisors after falling into line, is shown in Fig. 42. 
 
 Fig. 42.0) 
 
 Taking what may be regarded as the normal order of 
 eruption, the first bicuspids will succeed the lateral incisors. 
 If Fig. 40 be examined, it may be seen tbat the convex distal 
 side of the crown of the upper canine lies upon the mesial 
 side of the neck of the first bicuspid, and necessitates the 
 flattened or grooved surface which characterises that part 
 of the tooth, while the distal side of the tooth is similarly 
 influenced (although in a less degree) by the second bi- 
 cuspid. 
 
 After the first bicuspid has taken its position, the canines 
 are the next to appear in the line of the erupted teeth. The 
 
 (1) Showing the permanent central and lateral incisors in their nonnal 
 position in the dental arch, with the canine and bicuspids within the jaw.
 
 TEETHING. 
 
 93 
 
 appearances presented by the teeth in a favourable specimen 
 are shown in Fig. 43. 
 
 Fig. 43. (1) 
 
 /\ "111 
 
 I hi 
 
 After the canines, the second bicuspids appear through the 
 gums, and make up the full complement of those which have 
 been preceded by temporary teeth. The preceding may be 
 looked upon as the natural order in which the first permanent 
 molars, and the teeth anterior to them, appear; but this 
 order is frequently subverted, and in very many cases with- 
 out entailing any evil consequences. It will, however, be 
 convenient to consider all the deviations from that which is 
 regarded as the normal order, under one general heading, 
 after the evolution of the second permanent molar has been 
 considered, and after the changes in the form and size of 
 
 (1) Showing the conditions of the peiiDanent teeth after the eruption of 
 tlw .canines ; in the upper jaw, the second, bicuspid.
 
 94 A SYSTEM OF DENTAL SUBGERT. 
 
 the jaws coincident with the eruption of the permanent teeth 
 have been traced. 
 
 Between the age of twelve and thirteen years, the second 
 permanent molars advance towards the surface of the gmns, 
 their advance being accompanied by alveolar changes similar 
 to those which have been described in connection with the 
 emergence of other teeth. At this time the crypts for the 
 third molars hold the positions which those for the second 
 molars held when the first molars emerged from their bony 
 cells, and occupied the terminal portion of the alveolar tract. 
 
 If the mouth be examined immediately after the eruption 
 of the second molars, the dental arches will appear fully 
 occupied. In the lower jaw, a tooth on either side will be 
 placed close to the base of the coronoid processes, and in the 
 uj)per maxilla at the extremities of the alveolar portion of 
 the bone. But by the time the patient has reached the 
 sixteenth or twentieth year, the jaws will have lengthened 
 posteriorly to an extent sufficient for four new teeth to 
 take their respective positions in the dental arches. Under 
 favourable circumstances, the development and eruption of 
 the wisdom teeth is but a repetition of those progressive 
 changes which have already been described in respect to the 
 first and second molars, and therefore need not be dwelt upon. 
 No doubt these teeth are seldom cut without greater incon- 
 venience to the patient than the anterior molars, and the 
 period of emergence is less defined; but we have hitherto 
 considered the eruption of the permanent teeth when the 
 process has been perfectly normal, the deviations from which 
 have yet to be considered. 
 
 The periods of eruption of the permanent teeth have in 
 the foregoing pages been traced from preparations. But the 
 subject has been examined statistically. 
 
 In 1837, Mr. Saunders published a monograph, entitled, 
 " The Teeth a Test of Age." About this time, the miseries 
 entailed by employing young children in factories were, not 
 for the first time, forced upon the attention of the Legislature.
 
 TEETHING. 
 
 95 
 
 The necessity of restricting the hours of labour and of esta- 
 blishing laws for defining the period at which children should 
 be allowed to enter upon factory labour, was admitted. But 
 a difficulty arose as to the principles upon which this period 
 should be fixed. It was contended by some that a certain 
 state of physical development should be taken as the 
 standard, while others thought that the age would form a 
 better criterion of the capabilities of enduring labour without 
 injury. The statements of parents as respects the ages of 
 their children could not be depended upon ; hence it became 
 necessary that some means should be found whereby the age 
 of a child could be determined independently of the repre- 
 sentations of interested parties. With this view, Mr. Saunders 
 entered upon an inquiry respecting the relations of the 
 eruption of the permanent teeth to the age of the individual. 
 He visited many of the large metropolitan schools, and 
 selected for examination those children who had reached the 
 ninth and the thirteenth year, and published the results in 
 a series of tables, of Avhich the following are characteristic 
 examples : 
 
 Of 457 boys of nine 
 
 Incisors. 
 
 Cus- 
 pid. 
 
 Bicuspid. 
 
 Molars. 
 
 Cent. 
 
 Lat. 
 
 Ant. 
 
 Post. 
 
 Ant. 
 
 Post. 
 
 years of age — 
 20 had 
 
 4 
 
 4 
 
 
 
 
 4 
 
 
 • 77 had 
 
 4 
 
 3 
 
 
 
 
 4 
 
 
 91 had 
 
 4 
 
 2 
 
 
 
 
 4 
 
 
 5 had 
 
 4 
 
 1 
 
 
 
 
 4 
 
 
 34 had 
 
 4 
 
 
 
 
 
 4 
 
 
 20 had 
 
 3 
 
 3 
 
 
 
 
 4 
 
 
 10 had 
 
 3 
 
 
 •• 
 
 
 
 4 
 
 
 Of 227 boys of thirteen 
 
 
 
 
 
 
 
 
 years of age — 
 104 had 
 
 4 
 
 4 
 
 4 
 
 4 
 
 4 
 
 4 
 
 4 
 
 . 57 had 
 
 4 
 
 4 
 
 3 
 
 4 
 
 4 
 
 4 
 
 3 
 
 29 had 
 
 4 
 
 4 
 
 3 
 
 4 
 
 3 
 
 4 
 
 2 
 
 33 had 
 
 4 
 
 4t 
 
 3 
 
 4 
 
 2 
 
 4 
 
 1 
 
 4 had 
 
 4 
 
 4 
 
 2 
 
 4 
 
 1 
 
 4...,
 
 96 A SYSTEM OF DENTAL SURGERY. 
 
 Mr. Saunders sums up the results of his investigations in 
 the following words : 
 
 " Thus, then, it api^ears that of 70S children of nine years 
 of age, 389 would have been pronounced, on an application 
 of this test, to be near the completion of the ninth year; 
 that is, they presented the full development for that age. 
 But on the principle already stated, that of reckoning the 
 fourth tooth as present when the three are fully developed, a 
 still larger majority would be obtained, and instead of 389, 
 the proportion would be as follows : of 708 children, no less 
 a number than 530 will be fully nine years of age. What, 
 then, are the deviations in the remaining 178 ? They are the 
 following : 126 would be pronounced eight years and six 
 months, and the remaining 52 eight years of age, so that the 
 extreme deviations are only twelve months, and these only 
 in the inconsiderable proportion (when comjjared with the 
 results obtained by other criteria) of 52 in 708. 
 
 " Again, of 338 children under thirteen years of age, no 
 less than 294 might have been pronounced with confidence 
 to be of that age. The remaining 44 would have been 
 considered as follows : 36 in their thirteenth and eight near 
 the completion of their twelfth year." 
 
 More recently Mr. S. Cartwright, jun., has published a 
 Table which embraces a much more extended period, and gives 
 results obtained from 3074 cases. After describing the order 
 and the j^eriods of eruption of the permanent teeth, he makes 
 the following remark : 
 
 " These periods I find form a moderately fair average. I 
 have particularised them for the sake of afibrding you some 
 idea of the times of replacement of the various classes of 
 teeth ; but exceptions are so frequent, that it is not possible 
 to give with accuracy the exact time for their change. These 
 tables will show you the times of appearance of the teeth in 
 the given number of cases — upwards of 3000 — which I have 
 collected and which have^ come under my notice." 
 
 The following is a reprint from his fourth lecture, published 
 in the " British Journal of Dental Science," May, 1857 :
 
 TEETHING. 
 
 97 
 
 •sjBioni loua^sod jaAioi 
 
 • 
 
 
 : : ^ 
 
 S 
 
 OS 00 CO 
 
 f^ s 
 
 •sa^ora Jou8!jsod jaddj^ 
 
 
 : 
 
 , . «, 
 
 • 00 
 
 3 S 1 
 
 00 o 
 *- CO 
 
 •sa\?ioOT JOTJO^UB jaM07 
 
 00 
 
 s 
 
 ft ^ ^ 
 
 ■^ m -rn 
 
 s 
 
 CO M O 
 
 ^ ^, 3 
 
 «o s 
 
 •sjuioui joua!)tre jaddfj 
 
 n 
 
 1 
 
 § 1 s 
 
 1 
 
 CO CO o 
 
 CO & i-< 
 
 «o o 
 
 00 CO 
 
 •spidsnojq jou3?sod jbulo-i 
 
 : 
 
 ■* 
 
 in N N 
 
 rS CO 
 
 
 CO W CO 
 
 <N O 0-. 
 
 1 
 
 •spidsnoiq joua^sod aaddji 
 
 fH 
 
 « 
 
 M O f-l 
 
 o 
 
 «o M< e» 
 
 to Tjl 0« 
 
 s g 
 
 •spidsnoiq joua^uB j9avot 
 
 
 - 
 
 t- 00 o 
 CO o 
 
 s 
 
 S g 2 
 
 s s 
 
 •spidsnoiq aoiaaimj jaddfi 
 
 • 
 
 n 
 
 2 S 5 
 
 2 
 
 u S S 
 
 ^ ^ 
 
 •spidsna j9mot 
 
 : 
 
 '■■ 
 
 : - 5 
 
 00 
 
 to OS <= 
 
 50 in N 
 
 s ^ 
 
 •sptdsno J8dd£i 
 
 • 
 
 : 
 
 : « S 
 
 00 
 
 ?» to in 
 
 ^ CO — 
 
 - ^ i 
 
 •sjosput ja.woT; 
 
 t- 
 
 i 
 
 o iM in 
 
 Tjt lO -* 
 
 ^ 
 
 i i 1 
 
 ^ s 
 
 •siospm jaddn 
 
 in 
 
 in 
 
 o 05 m 
 
 CO in CO 
 
 00 
 
 CO 
 
 CO CO o 
 
 ^ ^ ^ 
 
 !0 O i 
 
 00 CO 1 
 
 3074 cases. 
 
 1 Between the 5th and 6th birthdays: ) 
 
 Out of 170 children i 
 
 fthand7th: ) 
 
 1 Out of 340 children )■ 
 
 7thandSth: ) 
 
 1 Out of 496 children )' 
 
 1 „ 8th and 9th : ) 
 
 Out of 530 children j 
 
 9th and IGth : ) 
 
 i Out of 454 children T 
 
 10th and llth: ) 
 
 Out of 322 children T 
 
 llth and 12tii: ) 
 
 tut of 303 children T 
 
 12th and 13th : ) 
 
 Out of 203 children i" 
 
 13th and 14lh: [ 
 
 Out of 140 children J 
 
 14th and 15th: > 
 
 Out of 8G children f 
 
 „ 15th and 16th : > 
 
 Out of 30 children )"
 
 98 A SYSTEM OF DENTAL SURGERY. 
 
 Before we enter upon the subject of irregularities in the 
 development of the permanent teeth, and the various dis- 
 turbing causes, it will be advantageous to give some further 
 attention to the conditions under which the alveolar pro- 
 cesses are formed, and to the laws which regulate the growth 
 of the jaws. 
 
 Development of the alveolar processes in connection with 
 second dentition. — In the earlier pages, it was stated that the 
 alveolar processes are formed after the dental papillaj are 
 developed, and that at the time of birth they have risen up 
 to the level of the developing teeth. Within two or three 
 months they arch over and nearly enclose the teeth, thereby 
 evincing a more rapid rate of growth than the teeth them- 
 selves. TVhen the teeth are ready for eruption, the anterior 
 wall of each alveolus is absorbed to the extent of about half 
 its whole depth. The teeth emerge, and the alveolar pro- 
 cesses again commence to grow; but not as in the former 
 cases, more rapidly than the teeth. They now keep jjace 
 with the teeth. At the time the development of the several 
 teeth is commenced, the papillae are placed at the ultimate 
 depth in the jaws. They do not grow into, but up from the 
 maxillae, and the alveoli grow with them. At the period of 
 eruption the lower end of the truncated and unfinished root 
 reaches to the bottom of the socket, the position of which, as 
 regards depth, is not changed with the gradual lengthening 
 of the root of the tooth. After emergence, the depth of the 
 alveolus is equal to the length of the root of the inclosed 
 tooth, the subsequent growth of the root at its base being 
 equalled by the development of the alveolus at its fre€ edge. 
 When the permanent teeth are ready to emerge, the pro- 
 cess of absorption is again called into requisition, and the 
 labial wall of each alveolus is, in the anterior part of the jaws, 
 removed, the loss of bone being extended to a point corre- 
 sponding to the neck of the emerging tooth. This condition 
 is shown in Figs. 33 and 40 ; but the accompanying illustra- 
 tions exhibit in a remarkable manner the dependency of
 
 TEETHING. 
 
 99 
 
 alveolar on dental development. The dentition is in many- 
 respects irregular ; but tlie point to which I would draw 
 attention is the extremely broken line described by the 
 alveolar margin, both in the upper and lower jaws. It may 
 be seen that the terminal edge of each socket corresponds 
 
 Fig. 44. ( 
 
 with the neck of the contained tooth, however irregularly the 
 latter may be placed with respect to its fellows, exception of 
 course being made to those teeth which have not yet passed 
 through the gum. On the right side of the lower jaw, the 
 first temporary molar is retained ; and on the left, the second 
 
 (1) The upper and lower jaws of a subject about fourteen years of age ; 
 showing the relations of the alveolar processes to the teeth. In the upper 
 jaw the temporary canine and tlie first and second molars are retained. * A 
 supernumerary tooth has taken the place of the permanent lateral incisor, ihe 
 lateral being forced backward towards the palate. The central incisor has 
 lieen obstructed in its descent, and the root consequently curved. The 
 permanent canine is far advanced in its development, but its descent is 
 obstructed by the supernumerary tooth and the lateral Incisor. In the lower 
 jaw the first temporary molar has been retained, and raisi-d to a higher level 
 than usual, and with it the alveolus.
 
 100 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 temporary molar is present. In eacli case the tooth and its 
 alveolus is raised to a higher level than is usually attained by 
 the temporary teeth, and higher than the adjoining first 
 permanent molars and their sockets. This elevating process 
 
 Fig. 45. (1) 
 
 has no doubt been effected after the tooth itself had been 
 matured, and shows in a remarkable manner the relation of 
 alveolar development to the changes of position in the teeth. 
 It is not uncommon to find temporary molars present, even 
 in patients of advanced age. I occasionally see a gentleman, 
 over fifty years of age, in whose lower jaw the second 
 tcmix)rary molars have been retained. They range with 
 the adjoining teeth, and perform their part in mastication. 
 
 (1) View of tbc left side of the specimen figured Xo. 44. In the upper 
 jaw, the irregular line described by the alvtolar margin is shown in connection 
 with the permanent teeth. In the lower jaw, the first and second temporary 
 molars are retained, and both the teeth and their alveoli are raised above 
 the level of the permanent teeth and their sockets. Boih this and the pre- 
 ceding figure Illustrate irregularities in the position of the permanent teeth, 
 and will be referred to in connection with the subject of irregularity.
 
 TEETHING. 101 
 
 The teeth generally are of the usual size, and the jaw and 
 alveolar processes maintain the usual depth. In this case 
 the temporary teeth and their alveoli must, at the period of 
 second dentition, have been raised to the level of the adjoin- 
 ing parts of the dental arch. Other instances present them- 
 selves in which the persistent temporary teeth do not gain 
 the general level. The cause is, however, usually very appa- 
 rent : the contiguous teeth hang over, and as it were hold 
 down the depressed tooth ; and here again the socket corre- 
 sponds to the level of the neck of the tooth. There is no 
 disposition on the part of the bone at this point to grow up 
 to the general line of the alveolar processes, independently of 
 the tooth to which it gives implantation. In the one case 
 we have a tooth raised above, and in the other held down to, 
 the normal height of a temporary tooth ; and in each the 
 alveolar development has strictly conformed to the position 
 of the tooth. 
 
 The appreciation of the foregoing conditions will be found 
 of great practical value in respect to the treatment of irregu- 
 larities in the position of the permanent teeth. Diseased 
 action in the structures may, however, modify the relations of 
 the one part to the other. I have seen a case in which the 
 alveolar processes were enormously thickened, and so raised 
 that the teeth lay in grooves ; and instances are not very un- 
 common in which development of the osseous tissue is arrested. 
 But the results of normal action only have as yet been con- 
 sidered. The consequences entailed by disease upon the 
 permanent teeth and their sockets, will be treated in a future 
 page. 
 
 Growth of the maxiUce during second derdition. — In pursu- 
 ing this inquiry, the natural variation in absolute size and in 
 the minor details of form, which the jaws, in common with 
 other parts of the body, present in diiferent individuals, must 
 be kept in view. It will be desirable, therefore, in repeating 
 these observations, to select for examination specimens which 
 present the average condition of the parts.
 
 102 A SYSTEM or DENTAL SURGERY. 
 
 On comparing the jaws of a child in whom the first per- 
 manent molars are advancing towards the surface with the 
 maxillje in which the wisdom teeth have taken their ultimate 
 I)osition, we are at once struck with the great diiference in 
 size, not only of the teeth, but of the jaws themselves ; and 
 it seems at first sight very difiicult to explain how the smaller 
 can assume the characters of the older specimen, without 
 having recourse to the undefined idea of general expansion 
 by interstitial growth throughout the whole substance of the 
 bones. 
 
 It has been shown how the alveolar portions grow up, are 
 partly removed, and again grow up ; how they are from time 
 to time moulded to the required forms ; and it will not be 
 difficult to point out how the other parts of the jaw are, by 
 the progress of developmental changes, gradually advanced 
 towards the adult form. 
 
 At a preceding page (page 19) mention was made of certain 
 points as convenient for the purposes of measurement, as being 
 liable to little alteration during the growth of the maxillfe, the 
 tubercles for the attachment of the genio-hyo-glossus and 
 the mental foramen being selected as the most suitable for 
 the purpose. When rightly interpreted, measurements taken 
 from these two points give identical results ; but before pro- 
 ceeding further it will be well to explain that at first sight 
 measurements taken from the mental foramen will give mis- 
 leading results, owing to an abrupt change in the direction of 
 the canal at its anterior extremity. If the outer surface of 
 the bone be removed so as to expose the whole length of the 
 inferior dental canal in a series of specimens of difi"erent ages, 
 the manner in which the mental foramen has become raised 
 will be apparent. In the nine months' subject the orifice is 
 on a level with the course of the canal and looks forwards : 
 now the portion of the canal already formed does not undergo 
 any further change, but, as the thickness of the bone is aug- 
 mented by dejx)sition on its outer surface, the canal comes to 
 lie at a greater depth within the bone.
 
 TEETHING. 103 
 
 The necessary addition to the length of the canal before it 
 can reach the surface does not, as might perhaps have been 
 expected, take place in direct continuation of its previous 
 course ; but, in obedience to a law already alluded to (page 18), 
 gives to the added portion of canal an upward and backward 
 direction. 
 
 This fresh addition to the canal therefore forms within the 
 thickness of the jaw an angle with that previously existing, 
 and this angle corresponds in position with the opening or men- 
 tal foramen in the fcetal jaw. If then we rasp off the siu-face 
 till we reach this angle, and take our measurements from it 
 instead of from the external opening, we shall have an un- 
 changing point, and the results of our inquiry will be con- 
 sistent with those attained when the tubercles were chosen 
 as the fixed points. In old age nature perfomis this operation 
 for us and removes the bone till this angle is nearly, or quite, 
 reached — hence the foramen is brought down nearer to the 
 lower border of the jaw. But with the exception of additions 
 to either end during the period of growth and | consequent 
 alterations of the aperture, there is not the smallest reason to 
 suppose that the position of the canal is in any way changed 
 at any period of development. 
 
 In the former edition of this work certain actual measure- 
 ments of a particular series of jaws were given ; but as I havd" 
 found that students have experienced some little difficulty in 
 grasping the meaning of the passage when placed before them 
 in this form, it has seemed prefei'able to embody the results 
 of these investigations in the accompanying diagrams. 
 
 As some variations, due to individual peculiarities such as 
 greater or less development of the chin, exist between dif- 
 ferent specimens, these diagrams are drawn up according to 
 average dimensions taken from a considerable number of jaws, 
 and are drawn to scale. 
 
 The horizontal line represents the level of* the anterior 
 portion of the inferior dental canal in the fcetus, and the cor- 
 responding portion in the adult jaw, which may be taken as
 
 104 
 
 A SYSTEM OF DENTAL SUEGERY. 
 
 separating the alveolar portion, strictly subservient to the 
 lodgment of the teeth, from the basal portion which subserves 
 other pui-poses. 
 
 Figs. 46 ari'l 47. (i) 
 
 earj 
 
 Fig. 48. 0); 
 
 On comparing the jaw of the nine months' foetus with that 
 of a seven years' child it is seen that that portion which lies 
 
 (1) Figs. 46, 47, 4S.— In these figures the horizontal line marks the corre- 
 ppondinfc parts of the several jaws, so that the relative increase above and 
 below it, that is to say, in the alveolar and basal portions of the jaw, may be 
 readily seen.
 
 TEETHING. 
 
 105 
 
 below the line lias more than doubled in its depth ; but on 
 looking at the adult and the aged jaw it is apparent that this 
 portion of the bone has attained its full development in 
 depth, or very nearly so, at the age of seven years, and that 
 it remains comparatively unchanged after that time until the 
 death of the individual. 
 
 Looking, however, at the alveolar portion above the hori- 
 zontal line, it is apparent that it does not attain to its full 
 
 Fig. 49. (1) 
 
 development till after the permanent teeth are in place, and 
 that so soon as the teeth are lost, it disappears, so that in the 
 aged jaw here figured it is almost absent. 
 
 Such measurements prove very conclusively the difference 
 between the basal and alveolar portions of the jaw, and bring 
 prominently forward the entire dependence of the latter on 
 the teeth, a point which cannot be too strongly insisted on, 
 as it has practical bearings to be alluded to in a future page. 
 
 In the nine months' subject, when the anterior teeth are 
 
 (*) The dotted line in this figure represents the outline w hich would have 
 been presented by the same jaw during the middle period of life, the parts 
 intervening between this lit)e and the drawing having been removed by 
 absorption, after the loss of the teeth.
 
 106 A SYSTEM OF DENTAL SURGERY. 
 
 about to be cut, the canal is nearly straiirht from end to end, 
 its whole length corresponding to that portion which in the 
 adult lies under the bicuspids and first j^rmanent molar, and 
 forming scarcely more than one-third of its entire length in the 
 adult. The straightness of this jx)rtion is permanently pre- 
 served in all the specimens I have examined. The middle 
 third is slightly curved upwards, and the posterior portion is 
 still more curved, and if prolonged, would pass through or im- 
 mediately in front of the articular process. The course of this 
 jwsterior third traverses the ascending ramus of the adult 
 jaw rather obliquely, and in the great majority of cases corre- 
 sjx)nds with the direction of the condyle rather than that of 
 the ramus. These points have been entered upon with some 
 degree of minuteness, in consequence of their aflbrding evi- 
 dence as to the manner in which the jaw becomes lengthened 
 to so great an extent by additions at its posterior portions. 
 
 In tracing the growth of the jaw backwards, we may take 
 the inferior dental canal as marking pretty accurately the line 
 of gro^vth followed by the condyle, and the external oblique 
 line as that which has been followed by the base of the coro- 
 noid process. For the sake of facilitating description, it may 
 be assumed that the backward gi'owth takes place at three 
 I)oints — in the sub-articular cartilage of the condyle, in the 
 periosteum investing the coronoid process, and in that in- 
 vesting the angle. 
 
 The condyle stands with its long axis directed nearly trans- 
 versely across the ramus, the one extremity lying nearly on 
 a plane with the outer surface of the bone, while the other 
 overhangs to a considerable extent the inner surface of the 
 ramus. Now, if we take a thin vertical section, suitable for 
 microscopic examination, from a perfectly fresh young jaw, it 
 will be seen that new bone is developing in the temporary 
 sub-articular cartilage — not, however, in the linear manner 
 usual in the temporary cartilage of long bones, but by the 
 extension of ossification among small groups of cells. As the 
 action extends throughout the articular extremity, the bone so
 
 TEETHING. 107 
 
 produced would, if permanently retained, assume the form of 
 a broad process, marking the course through which growth 
 proceeded. On the outer surface we frequently can discern 
 a slight ridge, extending a short distance from the head of 
 the bone ; but if the prominence were preserved on the inner 
 surface, the inferior dental artery and nerve would be turned 
 from its course towards the canal. Hence the hard tissue, 
 although produced, is at this point speedily removed, and in 
 the place of a ridge extending from the articular process 
 downwards, we have a concavity immediately below the arti- 
 culation, and along it the vessels and nerves pass before 
 entering the bone. A section taken from this part will show 
 that the newly-formed bone has been removed by absorption. 
 
 The progressive growth of the coronoid process is effected 
 in the usual manner of sub-periosteal development — that is, 
 by the ossification of cells and connective blastema ; and here, 
 again, the modelling process effected by the supervention of 
 absorption is called into requisition. If all the bone which is 
 developed were retained, we should have a breadth of ramus 
 extending forward over half the alveolar margin. If a trans- 
 verse section be taken from the base of the ramus of a growing 
 jaw, it will be found that indications of absorption are pre- 
 sented at the anterior edge ; and at the point corresponding 
 to the posterior border of the jaw, evidences of osseous deve- 
 lopment are present. The fact, that the enlargement of the 
 jaw takes place by backward growth almost exclusively, has 
 been already alluded to (page 22) ; in this respect also Dr. 
 Humphrey's experiments are confirmatory of the inference 
 here drawn. 
 
 The correctness of the above views, as to the development 
 of the jaw, has received a somewhat unexpected confirmation 
 from two examples of arrested development of the one ramus 
 of the jaw whilst the other has attained its normal size. The 
 first of these two specimens Q) was brought before the Patlio- 
 
 (1) Figured and described in Pathological Society's Transactions, vol. xii., 1861 , 
 p. 238.
 
 108 A SYSTEM OF DENTAL SURGERY. 
 
 logical Society by Mr. Edward Canton ; it occurred in a girl 
 of generally stunted growth, in whom the whole left side of the 
 face was flattened, and the external ear was almost absent. 
 At the post-mortem examination the zygomatic and auditory 
 processes were found to be altogether absent, while the glenoid 
 cavity was represented by a perfectly smooth surface. 
 
 As is seen in the figure, on the left side of the jaw the 
 ascending ramus is a very short, narrow process terminating 
 in two points, which may perhaps represent the coronoid and 
 condyloid processes. But there is nothing to be seen at all 
 like a condyle at the summit of this process, and therefore, 
 there being no articular surface, there can be no articular 
 cartilage. 
 
 Fig. 50. 
 
 But it has just been pointed out that the backward and 
 upward elongation of the jaw takes place in great part by 
 ossification in this articular cartilage, just as a long bone 
 grows by ossification progressing in its epiphyses. Hence the 
 absence of the condyle accounts perfectly for the arrest in 
 the development of this portion of the jaw ; it will however 
 be noticed that the vertical development of the horizontal 
 ramus, which is entirely correlative with that of the teeth, 
 has not suffered in a like degree : the teeth have been deve- 
 loped, and consequently the alveolar portion of the jaw has 
 attained to something approaching its normal depth and 
 width. The length of this aborted side of the jaw does not 
 exceed that attained by that of a child aged two years and a 
 half. 
 
 The great elevation of the incisor teeth is simply the con-
 
 TEETHING. 109 
 
 sequence of imperfect antagonism, an explanation rendered 
 the more certain by their serrated edges, which have obviously 
 not come into contact with the upper teeth. 
 
 On the inner surface of the stunted process, at a level cor- 
 responding to that of the crown of the second molar tooth, is 
 the Inferior Dental Foramen, which is much smaller than 
 that of the right side. The mental foramen is entirely absent, 
 the nerves and vessels having been apparently wholly used 
 up in the substance of the bone. 
 
 The second specimen, which is in the museum of the 
 Odontological Society (^), presents somewhat similar cha- 
 racters ; of its history nothing whatever is known, but it 
 appears to be the jaw of quite an aged jDerson, and the alveolar 
 portions of the jaw having been for the most part absorbed 
 after the loss of the teeth, the fact of the entire dependence 
 of the growth of this region of the jaw on the presence of the 
 teeth is not so strongly exemplified as was the case in the 
 last-mentioned specimen. But that the aborted ramus has 
 at one time been of a depth apparently disproportionate to 
 its backward elongation, is probable from the presence along 
 its upper surface of the sharp ridge which is usually left after 
 absorption of alveoli, consequent on the loss of the teeth. In 
 the spinous process which terminates this stunted ramus, no 
 separate representatives of coronoid and condyloid processes 
 can be traced ; it is a simple spine, which from its relation 
 with the external oblique ridge would correspond more nearly 
 with the coronoid than with the condyloid process, and 
 presents on its inner surface a prominence apparently giving 
 attachment to ligaments or muscles. There is not a trace of 
 an inferior dental canal, and consequently no mental foramen ; 
 but whether this absence of its proper vascular supply is to 
 be regarded as a cause or an effect of the stunted growth is 
 an almost insoluble problem. 1'he tubercles for the attach- 
 ment of the genio-hyoid and genio-hyo-glossus, which probably 
 marked the median line of the body, do not correspond with 
 (1) Transactions, Odontological Society, March, 1872.
 
 110 A SYSTEM OF DEXTAL SURGERY. 
 
 the position of tlie mental prominence on the outside of the 
 jaw, which latter has partaken in the asymmetrical develop- 
 ment of face which must have existed, and is considerably 
 displaced tOAvards the right side. 
 
 In examining a series of suitable preparations, it may be 
 seen that the crypts for the permanent molar teeth are in 
 the first instance formed internal to the ridge of bone which 
 forms externally the base of the coronoid process, and that this 
 ridge is continuous with the external oblique line of the jaw. 
 Absorption in this neighbourhood appears to stop short before 
 reaching the absolute base, and leaves a trace of the ridge 
 alluded to: the trace constituting the oblique hne within 
 which the alveoli of the molar teeth gro"\\»up. 
 
 The development of the jaw may, in some respects, be 
 compared to modelhng. Tortious of new tissue are laid 
 upon that already formed, and reduced to the fitting size and 
 shape, and again renewed at such points as the attainment 
 of the ultimate form of the part may require. 
 
 Still, even during manhood, the maintenance of the form 
 of the jaw is dependent to a great extent upon the teeth. 
 When the organs of mastication are lost, the whole of the 
 alveolar processes are by degrees removed, the process of ab- 
 sorption being arrested only at those points where muscles are 
 inserted (see Fig. 49) ; neither is the waste limited to the 
 alveolar margin. Both the outer and inner surfaces of the 
 bone are reduced, and even the interior becomes more porous 
 than during the period when the teeth were present. The 
 spinse men tales, however, retain nearly their full size, although 
 the angle of the jaw about which the masseter muscle is in- 
 serted, suffers considerable loss — not however until that muscle 
 is thrown partly out of use by the loss of the teeth, and con- 
 sequently of the capability of mastication. If two jaws be 
 taken, the one full of teeth, the other from an old edentulous 
 subject, and in each the dental canal be exposed throughout 
 its length, we may then, by the use of a file, taking the canal 
 as our guide in removing the bone, reduce the younger to
 
 TEETHING. Ill 
 
 the form of the older jaw. In the one c.ise we have a jaw 
 for the implantation of teeth, and for the insertion of power- 
 ful muscles for bringing the teeth into effective use, in 
 addition to affording attachment for muscles connected with 
 the organs of speech and deglutition ; and in the other, the 
 jaw is subservient only to the latter purposes. 
 
 We have hitherto spoken of the lower jaw, which, from 
 ts slight connection with the other bones of the face, can be 
 studied in its progressive changes of form and size more 
 readily than the superior maxilla. Mr. Hilton, in his mono- 
 graph on the development of certain portions of the cranium, 
 makes the following statement : 
 
 " The sphenoid bone forms the centre around which all 
 the other bones, both of the cranium and face, are developed. 
 It is truly and literally indeed a wedge, as its name implies ; 
 and thus impacted or wedged in amongst all the other cranial 
 and facial bones, its progressive development spreading its dif- 
 ferent processes out in all directions, plays a most important 
 part ; not only in determining the adult configuration of the 
 skull, but in adopting the final conformation of the organs 
 of the face to the increasing perfection of their associated 
 functions. The mouth, nose, orbits, and pharynx, are all 
 more or less directly influenced, and contemporaneously ren- 
 dered more perfect in form by the complete development of 
 this bone. 
 
 " The primary idea, or primary intention of the develop- 
 ment of the sphenoid, seems chiefly with reference to the 
 masticatory function ; but in the changes that it produces in 
 the direction of the cranial and facial bones, it may not 
 inaptly be compared to the scaphoid bones of the carpus and 
 tarsus; for in its gi'owth and final development it effects 
 for the cranium and face precisely the same object that these 
 bones effect for the hand and foot. 
 
 " Like these bones, then, the growth and completion of the 
 sphenoid, in spreading out the cranium, and in enlarging the 
 cavities of the organs belonging to the face, supplies the defi-
 
 112 A SYSTEM or DENTAL SURGERY. 
 
 ciency of the muscular tension wliicli in other parts of the 
 body has so large a share in determining the final or perfect 
 forms of the bones." (^) 
 
 Of the different parts of the sphenoid bone, those which 
 undergo the greatest change during the period under con- 
 sideration, as regards size, and which are also the most directly 
 connected with the present inquiry, are the pterygoid plates. 
 These parts increase to the extent of one-third of their ulti- 
 mate length between the age of seven and twenty-one years. 
 In a specimen of seven years, the anterior surface of the 
 pterygoid process is separated from the first permanent molar 
 by a distance scarcely exceeding a quarter of an inch, and 
 the nascent second molar lies in the tuberosity, in great part 
 external to the sphenoidal processes. The space, at present 
 so inconsiderable, has, before the adult form is acquired, to 
 be increased fully two-thirds, accompanied by an increased 
 length of the pterygoid plates, the general direction of which 
 remains unchanged. The general principles which have been 
 pointed out as pertaining to the development of the lower 
 jaw, may be applied to those facial bones which are connected 
 with the masticatory apparatus. The tuberosity is to the 
 upper -what the base of the coronoid process is to the lower 
 jaw. From this point the alveolar line is lengthened. In 
 the specimen last mentioned, the second molar is biu-ied high 
 up in the tuberosity. Soon after the expiration of the twelfth 
 year, the distance between the pterygoid process and the 
 first molar will have increased sufficiently to allow the second 
 molar to take its place in the dental line, and by the expira- 
 tion of the twentieth year the third molar is usually found 
 in its normal position. Up to this period, the facial bones 
 are connected to each other and to the bones of the cranium 
 by sutures only; and in the soft tissue within these, develop- 
 ment of bone takes place. 
 
 (») Notes on some of the Developmental and Functional Relations of certain 
 Bones of the Cranium. Selected by F. W. Pavy, M.D., from Lectures on 
 Anatomy by John Hilton, F.R.S. 1S55.
 
 TEETHING. 113 
 
 The maxillary bones, while their processes are increased in 
 length, are moved bodily forward, the rate of growth keeping 
 pace with tlie increase at the tuberosity. Coincident with 
 development, the modelling of certain parts by superficial 
 absorption is carried on. By this process, the anterior sur- 
 face of the lower border of the malar process is removed, and 
 thus thrown backward. In the seven-years' specimen, it lies 
 immediately above the anterior third of the first molar; at 
 twenty-one it holds a similar position with respect to the 
 second molar, thus showing a recedence equal to the width 
 of one tooth. 
 
 As respects the changes of form and position which the 
 glenoid cavity undergoes during growth, but little need be 
 said. Here we have articular cartilage, beneath which the 
 required amount of bone is slowly developed in the same 
 manner as in the sub-articular cartilage of the lower jaw. 
 
 The growth of the alveolar process need not be again 
 referred to. 
 
 After the teeth are lost, the upper jaw undergoes great 
 change both in size and in form, not, however, from what is 
 called interstitial absorption, but simply from progressive 
 superficial absorption. The alveolar processes are gradually 
 lost, and the whole bone is reduced in thickness. The ptery- 
 goid plates of the sphenoid bone become greatly diminished 
 in size and strength, while the glenoid cavity loses its strongly- 
 pronounced margin, and hence becomes flattened. 
 
 Certain forms of irregularity in the conformation of the 
 Jaws being closely connected with deviation from the normal 
 arrangement of the teeth, will be considered in connection 
 with the latter subject. 
 
 Irregularity of the Permanent Teeth, — Hitherto the, de- 
 scription of the permanent teeth has been confined to their 
 evolution when those general laws which regulate the time 
 of appearance, the position, the form of the individual mem- 
 bers, and the implantation of the whole set, have operated 
 without interruption. 
 
 I
 
 114 A SYSTEM OF DENTAL SURGERY. 
 
 The deviations from the normal conditions as respects 
 arrangement, nimiber, form, and the period of eruption, have 
 yet to be considered before we come to the conchision of that 
 division of the subject which has been placed under the 
 general head of teething. The divisions of this subject will 
 be treated in the order in which they have been enimie- 
 rated. 
 
 But before passing to the consideration in detail of these 
 several irregularities, it will be interesting to inquire into 
 the conditions under which deviations from a normal tyjje 
 occur. In a very considerable number of cases the whole 
 abnormality is caused by purely mechanical agencies, such 
 as the undue retention of temporary teeth, and may be 
 almost regarded as accidental in their origin. The crowns 
 of the teeth in such cases deviate from their normal posi- 
 tion far more considerably than their roots, the apices of 
 which will very generally be found to occupy their proper 
 places. 
 
 But it is far from uncommon for the alveolar border, or 
 even the whole jaw, to be malformed, so that the whole 
 length of the implanted portions of the teeth will particijxite 
 in the irregularity. 
 
 The origin of such malformations must be sought at a 
 period long antecedent to the eruption of the permanent 
 teeth; they are, in fact, often congenital, and traceable to 
 hereditary tendencies. 
 
 It must not however be supposed that because an abnor- 
 mality is slight, and is apparently due to some mechanical 
 cause, it may not have been inherited- 
 There is no lack of evidence to prove that variations in the 
 position or number of teeth which might at first sight seem 
 accidental are transmitted from parents to children ; of this 
 Dr. M'Quillen gives some striking examples. (^) Thus, he 
 found the upper lateral incisors biting inside the corre- 
 sponding lower teeth in a gentleman, and in three out of 
 
 (') Dental Cosmos, voL xii., p. 75, et seq.
 
 TEETHING. 115 
 
 four of his children ; the fourth child had not cut these 
 teeth at the time when the observation was made. In 
 another family a gentleman, his son, and his grandson alike 
 never had any lateral incisors in the upper jaw ; a second 
 son of the same gentleman had them exceedingly dwarfed, 
 and in some of his children these dwarfed lateral incisors 
 had been so unsightly as to lead to the teeth being extracted 
 and artificial substitutes put in their place. In a later num- 
 ber (^) of the same journal a family is mentioned as well 
 known to American dentists, in whom n(^ permanent teeth 
 at all are found. 
 
 An instance of the congenital absence of bicuspid teeth is 
 given by Mr. Heath (^), and in my own practice I have lately 
 met with an example of the absence of the left upper lateral 
 incisor in three sisters ; on the right side these teeth are 
 present. 
 
 Irregularities apparently most trivial may be, in fact, con- 
 genital: thus I have lately seen an instance in which, 
 although there is no crowding in the jaw sufficient to 
 account for it, the right upper central incisor is to a slight 
 extent twisted on its axis, and lies a little behind its fellow 
 tooth : precisely the same irregularity exists in the father 
 of the child, and will apparently be repeated in another 
 child, in whom the tooth is as yet only partially erupted, 
 A case is quoted by Mr. Sedgwick in which, during h.tli 
 dentitions, Si, ^ov^Ac. tooth took the place of the left lateral 
 incisor, this peculiarity being inherited from a paternal 
 grandfather. (^) 
 
 Numerous other examples might be collected, but the 
 foregoing will sufficiently serve to illustrate that strong 
 tendency to hereditary transmission of peculiarities which is 
 found to exist, and to suffice to cause dental irregularities. 
 
 Correlations of growth are found to exist between parts 
 
 (1) Dental Cosmos, vol. xiii., p. 123. 
 
 (2) Injuries ami Diseases of the Jaws, p. 185. 
 
 (3) British and Foreign Medico-Chirurg. Review, April, 1863.
 
 116 A SYSTEM OF DENTAL SURGERY. 
 
 of the organism, which, so far as we know at present, have 
 little or nothing to do with one another; but in other 
 examples of this concomitant variation some homological 
 relation can be traced between the varying organs. Such 
 is the case with hair and teeth, which in their origin are 
 closely similar, and which only become strongly differenti- 
 ated in their after development. 
 
 For example, the hairless, naked Turkish dog is extremely 
 deficient in its teeth, often having none except one molar 
 on each side, and^perhaps one or two imperfect incisors Q) ; 
 and the same fact has been observed in a hairless terrier. 
 Inherited baldness has been found associated with inherited 
 deficiency of the teeth, and it is stated by ^Ir. Sedgwick (-) 
 that in rare cases where the hair has been renewed in old 
 age this has usually been accompanied by a renewal of the 
 teeth. 
 
 Mr. Craufurd, as quoted by Mr, Darwin, states that at 
 the Burmese Court there was a man covered with straight 
 silky hair, which on the spine and shoulders was as much 
 as five inches in length. He had no molar teeth, and the 
 incisors were very small ; his daughter inherited the pecu- 
 liarity of a hairy skin, her face, even including the nose, 
 being covered with silky hair, and, like her father, she had 
 neither molar nor bicuspid teeth. 
 
 These hairy persons did not present any marked pecu- 
 liarity at birth, save that there was a little hair about the 
 ears, whence it spread all over the body ; and it is a signifi- 
 cant fact that there was nothing abnormal in their milk 
 dentition. In the case of Julia Pastrana, rendered famous 
 by the exhibition of her stufied skin after her death, the 
 forehead and the chin were densely covered with hair, and 
 there were so many supernumerary teeth in the mouth that 
 the appearance of a double row of teeth in each jaw was 
 presented. 
 
 (') Darwin, Animals and Plants under Domestication, vol. i., p. 31. 
 (0 British and Foreign Medico-Chirurg. Review, April, 1863.
 
 TEETHING. 117 
 
 It is remarked by Mr. Darwin (^) that those orders of the 
 Mammalia which are most aberrant in their dermal cover- 
 ings, namely, the Cetacea and Edentata, are also remark- 
 able for deficiency or redundancy in the number of their 
 teeth. 
 
 The association of certain forms of maxillary deformity 
 with other defects, such as congenital idiocy, may perhaps 
 be explained on the principle of correlation of growth, but it 
 will be more convenient to defer the discussion of this 
 branch of the subject until the special irre'gularities alluded 
 to are described. 
 
 Dental irregularities in some few instances only are refer- 
 able to the action of the law of " correlation of growth ;" in 
 all the instances with which I am acquainted this law has 
 operated in producing either deficiency or redundancy in the 
 number of the teeth, rather than in causing the assumption 
 of abnormal forms or position. 
 
 Irregularity in the position of the permanent teeth, irre- 
 spective of the number involved, admits of division into two 
 distinct groups. 1st. Irregularity in the position of the 
 crowns, while the roots at their terminal points hold the 
 usual place. 2nd. Irregularity both in the position of the 
 cro^vns and roots. The former usually admit of treatment 
 which does not necessarily involve the loss of either the 
 misplaced or a neighbouring tooth ; while the latter cases do 
 not admit remedy, excepting by removal of the malplaced 
 organs. 
 
 Those examples which fall within the first division will be 
 first considered. 
 
 The front teeth of the upper jaw, including the canines, 
 may deviate from the usual position either by projecting 
 forward or retreating backward. In the former deformity, 
 the prominence is sometimes sufficient to prevent the lips 
 from closing ; hence the teeth are constantly exposed, even 
 
 (1) Animals and Plants under Domestication, p. 328.
 
 118 A SYSTEM OF DENTAL SURGERY. 
 
 when the mouth is shut. The lower lip, instead of lying 
 over the edges of the teeth, passes behind them, while the 
 lower teeth meet the gum posterior to the necks of the upper 
 teeth. In searching for the cause of this unsightlj' form of 
 irregularity, we must examine the condition of both the 
 upper and lower jaws, and also the state of antagonism of the 
 upi^er and lower teeth. 
 
 The deformity may result from excessive development of 
 the alveolar processes of the anterior part of the upper jaw, 
 but more commonly we shall find that the molar teeth arc 
 unusually short, thereby allowing the incisor teeth of the 
 lower to press unduly upon the incUned lingual surfaces 
 of the teeth of the upper jaw. The upper teeth, yielding to 
 the pressure, are forced outward, and are retained in the 
 malposition by the teeth which have led to the displacement. 
 If, in cases resulting from the latter cause, the inquiry be 
 extended to the condition of the lower jaw, it will be found 
 that with the short molar teeth we have a short alveolar 
 range and short rectangular ramus. This conformation is 
 probably the primary cause of the mischief. Supposing the 
 line of growth in the ramus to have become nearly rectan- 
 gular, as regards the body of the jaw, prior to the develop- 
 ment of the wisdom teeth, and the amount of growth in the 
 vertical direction to have been deficient, the molar teeth 
 would be limited in height by the antagonism of the corre- 
 sponding teeth of the upper jaw. That the length of the 
 molar teeth is influenced by the growth and position of the 
 ramus, a case at present under my treatment satisfactorily 
 demonstrates. In this instance the ramus has preserved the 
 obliquity characteristic of childhood, and occasions the per- 
 manent separation of the upper and lower front teeth when 
 the mouth is closed. The patient is upwards of fifteen, and 
 the usual number of teeth are present, but the second per- 
 manent molars are the only teeth that come in contact, and 
 these scarcely project above the level of the gums. Here 
 the ramus is sufficient in actual length, but the obliquity
 
 TEETHING. 119 
 
 renders its length unavailable for the vertical development 
 of the molar teeth. If, then, we have a rectangular ramus 
 of diminished length, with short grinding teeth coincident 
 with well-developed incisors, it is not difficult to see that the 
 upper will be driven outwards by the lower front teeth. 
 
 The condition under consideration may also arise from the 
 tardy eruption of the molar teeth leaving the incisors to act 
 for a time upon each other, as they do when from any cause 
 the back teeth are lost. Then, again, the incisors of the 
 lower jaw may attain an unusual height, or they may project 
 in an unusual degree, and produce the mischief. Or the 
 result may be consequent upon a regular linear arrangement 
 of large teeth in a jaw having a small alveolar base, in which 
 case the teeth prior to their eruption will assume an unusual 
 anterior obliquity. In some instances the teeth have been 
 slowly forced outwards by mechanical pressure consequent 
 on a child practising the habit of sucking its thumb. 
 
 But whatever the cause, the treatment of this form of irre- 
 gularity is apt to be very troublesome. It is not difficult to 
 reduce the teeth to a proper position, but it is very difficult 
 to keep them there. In a case which came under my treat- 
 ment four years since, the upper teeth projected outwards, so 
 that it required a great effort to get the upper lip over them, 
 and when the mouth was closed the finger could be laid 
 between the lingual surface of the upper and labial surface 
 of the lower teeth. The habitual position of the under lip 
 was behind the upper front teeth — a habit which in itself 
 no doubt tended to increase the amount of deformity. The 
 arrangement of the teeth, as respects each other, was per- 
 fectly uniform and without intervening spaces, while the base 
 of the jaw was normal in size. It was therefore quite obvious 
 that before the teeth could be pressed backward, space must 
 be provided to allow of their movement in that direction. 
 In order to effect this, the two posterior bicuspids were re- 
 moved ; a metal plate was then fitted to the labial surface 
 of the projecting teeth as far on either side as the canine,
 
 120 A SYSTEM OF DENTAL SURGERY. 
 
 and was extended inwards below the edges of the teeth in snch 
 a manner as to prevent the under Hp from passing behind 
 the upper teeth. A strong band of vulcanized caoutchouc 
 was connected with the plate, and passed round the back of 
 the head. By means of this apparatus the teeth were in the 
 course of six weeks pressed into a very good position. The 
 lips could be closed in the usual manner, and the mouth 
 when seen in profile had lost its objectionable prominence. 
 The patient on leaving for the country was directed to wear 
 the apparatus during the night for six months. After the 
 lapse of eighteen months she returned to town with the 
 mouth just as prominent as it had been before treatment. 
 On inquiry I found that she wore the plate for one month 
 only, the elastic bands had then given way, and the precau- 
 tionary measures had from that time been neglected. In the 
 interval the wisdom teeth of the upper jaw had been cut, 
 and they seemed to have exercised some influence in forcing 
 the teeth into the forward position. But some other cause 
 than this was also in operation, as the teeth, although pro- 
 minent, were not now, as formerly, in close lateral contact. 
 The wisdom teeth, from their position, being perfectly use- 
 less, were removed, and the treatment already described was 
 renewed, and with the former success. The teeth have now 
 settled down into a position intennediate between that which 
 they held before they were subjected to treatment, and that 
 to which they were reduced by the use of the plate. 
 
 The foregoing case may, I think, be regarded as pre- 
 senting typical characters, and may therefore be dwelt upon 
 for the purpose of elucidating some of the general features 
 connected with irregularities before we advance fiuther. 
 Possibly the front teeth, while within the alveolar crypts, 
 assumed an unusual obliquity of position, and thus grew 
 outwards independently of any influence exerted by the 
 antagonistic teeth. But whatever may have been the cause 
 of malposition, the growth of the teeth was accompanied by 
 the development of strongly-pronounced alveoli, correspond-
 
 TEETHING. 121 
 
 ing in direction with that of the teeth. In cases such as that 
 desciibed, it is suiSiciently obvious that before the direction 
 of the teeth can be permanently changed, the direction of 
 the sockets must also be altered ; a considerable portion of 
 the existing alveolar processes must be removed, and new 
 bone for the repair or rebuilding of the sockets be produced. 
 It may not, however, be necessary that the position of the 
 bottom of the sockets should be changed, although the mar- 
 gins require to be reduced to a semicircle of much smaller 
 radius. Now we know that moderate pressure, constantly 
 maintained upon bone, will lead to its absorption; if therefore 
 the crowns of the teeth be steadily and constantly pressed 
 upon, that portion of the socket which receives the pressure 
 will gradually disappear. The immediate result will be an 
 enlargement of the socket in which the tooth will for the 
 time move freely ; in other words, it will become loose. This 
 condition, if long continued, would lead to the early loss of 
 the tooth; hence, to ensure success in our operations for 
 readjustment, new bone must be produced in those parts 
 of the socket from which and towards which the root of the 
 tooth has moved. The fact of a tooth becoming loose under 
 undue pressure, shows that the absorption may proceed 
 more rapidly than development of bone. 
 
 The recognition of this fact, which may be assumed as a 
 constant condition, suggests a very important question — viz., 
 at what rate in respect to time can new alveolar bone be 
 developed, when the removal of the pre-existing tissue has 
 been induced by pressure ? The determination of this point 
 will also assist in determining the degree of pressure which 
 can be used most advantageously, and the length of time it 
 will be necessary to employ mechanical means for retaining 
 the tooth in the position into which it has been forced. If 
 an extreme case be taken for treatment, the extent of change 
 produced, supposing the treatment to be permanently suc- 
 cessful, will amount to the destruction of a considerable 
 portion of the existing, and the production of new alveoli.
 
 122 
 
 A SYSTEM OF DEXTAL SURGERY. 
 
 In the absence of well-established facts gained from dis- 
 sections, in respect to the period required either for the re- 
 development of alveoli, or the degree to which restoration is 
 carried, we are thrown upon the general results obtained in 
 the treatment of cases, and upon the conditions which are 
 found to obtain in the development of alveoli during the erup- 
 tive period of dentition. It has been shown that the socket 
 grows up cotemporaneously with the gradual development of 
 the tooth, but in this case the process of growth is extended 
 over many months, and the results obtained in the reduc- 
 tion of irregularities do not tend to show that the alveolar 
 reparation is more rapid than the original alveolar develop- 
 ment. 
 
 If, for example, slightly projecting teeth are by means of 
 pressure brought rapidly into the proper line, and are then 
 left without mechanical restraint, they will speedily return to 
 their former place, and become firmly fixed in their sockets in 
 a much shorter time than they would have done if retained 
 in the newly-acquired position. This circumstance would 
 seem to indicate that in moving the teeth the sockets had 
 been stretched or bent rather than absorbed; but there are 
 many cases in which the assumption that the bone yields by 
 its elasticity in the direction of the pressure applied to the 
 teeth, does not offer a satisfactory explanation; and I am 
 disposed to think that even in the cases where this expla- 
 nation would at first sight appear tenable, the phenomena 
 may be attributed to other causes. 
 
 The immediate consequence of continued pressure ujxju 
 the crown of a tooth, is irritation and thickening of the peri- 
 dental membrane ; and this results in the tooth being raised 
 in its socket to an amount equal to the increased thickness 
 of the membrane. 
 
 The root of the tooth, from its more or less conical form, 
 acquires, when raised in the socket, an increased capability of 
 motion, without the alveolus itself becoming enlarged. In- 
 stances in which these conditions are produced by disease are
 
 TEETHING. 123 
 
 of daily occurrence. A tooth is attacked with pain, and in a 
 few hours the patient discovers that the tooth has become too 
 long, and feels slightly loose. The increased capability of 
 motion is recognised if the tooth be grasped between the 
 thumb and fingers ; but it will at the same time be found, 
 that although it readily yields within certain limits to pres- 
 sure, yet that the movement is abruptly stopped when the 
 side of the root comes in contact with either wall of the 
 socket. A piece of india-rubber compressed between two teeth 
 will, in the course of a few hours, force them apart, each 
 tooth becoming tender to the touch and slightly loose ; but 
 although the teeth, on the removal of the caoutchouc, for a 
 time stand apart, they will speedily resume their former 
 positions, become firm, and free from tenderness. In this 
 case, it can scarcely be assumed that the socket became en- 
 larged by absorption, and again contracted by deposition, 
 although the separation was greater in amount than could be 
 accounted for on the supposition that the peridental mem- 
 brane only yielded to the jDressure ; but the difficulty of 
 explanation disappears on finding that the teeth are slightly 
 raised in the sockets. In these instances we have examples 
 of the manner in which the position of a tooth may, under 
 pressure, become changed, without the socket undergoing any 
 enlargement. In the treatment of cases, we find that within 
 the first two days the out-standing teeth show most satis- 
 factory results, and we are apt to conclude that the difficulty 
 will be readily overcome ; but in subsequent examinations 
 we fail to recognise a corresponding amount of progress. The 
 involved soft tissues readily yield, but until removed or 
 weakened by absorption, the bone of the sockets resists the 
 further movement of the teeth. The rate at which its 
 removal can be safely induced is not, I think, satisfactorily 
 ascertained. That we can induce its absorption, numerous 
 examples prove ; but in order to bring about the result, it is 
 necessary that the pressure should be uniform in degree, and 
 uninterrupted. Destructive inflammation will be set up if the
 
 124 A SYSTEM OF DENTAL SURGERY. 
 
 pressure be too great, and if it be too slight the teeth will not 
 move, or the movement Le so slow that both the patient and 
 practitioner will become wearied before a successful result has 
 been gained. A certain amount of irritation in the socket is 
 a necessary attendant upon the treatment, otherwise absorp- 
 tion of the socket would not be induced. Other conditions 
 being the same, the age of the patient will influence the 
 results. The younger the patient, the more readily can the 
 teeth be moved ; the older, the more difiScult will the operation 
 become. 
 
 Supposing the irregular teeth to have been reduced to a 
 proper position, and that the movement of them has been 
 attended with a certain amount of destruction of the existing 
 socket, we have then to inquire whether the lost parts will be 
 fully replaced, and if so, the length of time required for the 
 formation of the new bone. It is not probable that a series 
 of preparations, illustrating the condition of the parts at 
 different stages of treatment, will be obtained; we must 
 therefore be content with less positive information than such 
 a series would furnish, and avail ourselves of such facts as 
 can be gathered from those cases in which teeth have been 
 forced from their former position by a loss of proper antago- 
 nism. The dissecting-room will furnish examples of this 
 character, and in them we shall find that the shifted teeth 
 have a less perfect implantation than those which have been 
 undisturbed. The sockets will not rise to the level of those 
 of the other teeth ; from which it may be inferred that the 
 loss of the displaced teeth will be hastened. Whether the 
 same conditions obtain in teeth which have in early life been 
 intentionally moved, observations directed to individual cases 
 over very many years can alone determine. But supposing 
 they do, we must put against the disadvantage the fact that 
 the labial walls of the sockets of outstanding teeth are very 
 commonly deficient in strength, or imperfect, and that teeth 
 so placed are liable to become loose prematurely. 
 
 Admitting, then, that sockets partly removed under treat-
 
 TEETHING. 125 
 
 ment will be restored, the question arises as to the time which 
 will be occupied in the restoration, — in other words, how 
 long it will be necessary to hold the teeth in the newly- 
 acquired situation. If unrestrained by mechanical means, 
 and uninfluenced by antagonistic teeth, the old position will 
 soon be regained, and the teeth will become firmly fixed in a 
 much shorter time than they would do in the acquired posi- 
 tion. It would apjDcar as if there were a natural law tending 
 towards the maintenance of a conformation when once as- 
 sumed, although an irregular one, and which calls into action 
 the reproduction of a lost part more rapidly in the place in 
 which a tooth has been moved from, than in that into which 
 it has been moved. 
 
 We constantly hear of and see cases in which outstanding 
 front teeth have been reduced to regularity, and have subse- 
 quently regained the objectionable position, notwithstanding 
 the assurances which have been held out that such untoward 
 results are consequent upon want of proper management on 
 the part of the practitioner. There is, perhaps, no point in 
 the whole field of dental surgery that yields a finer harvest to 
 the charlatan than that afforded by the treatment of irregular 
 teeth. The patients are necessarily young people who have 
 not passed from the care of their parents. There is a great 
 desire on the part of the latter that the teeth should be good- 
 looking, or at least not ill-looking ; at the same time, there is 
 great unwillingness, both with the patient and the parent, 
 that the treatment should be extended over a long i)eriod of 
 time. The presence in the mouth of a mechanical apparatus 
 pressing upon the teeth interferes with the comfort of the 
 young patient, and the frequent attendance at the house of 
 the dentist encroaches upon the hours allotted for study. 
 Both circumstances render prolonged treatment irksome, 
 impatience is shown, the instructions are neglected, and, as 
 a natural consequence, the results fall short of those which 
 might have been obtained had the treatment been consistent. 
 I believe it is in accordance with the experience of those
 
 126 A SYSTEM OF DENTAL SURGEBY. 
 
 who have devoted their attention to the treatment of irregu- 
 larities, that where the front teeth have been brought in 
 by mechanical means, and where mechanical means are 
 required to hold them in place until they become perma- 
 nently fixed, the treatment must be continued for twelve 
 months. It may not be necessary that the apparatus should 
 be constantly worn for the whole i^criod, but it cannot be 
 wholly thrown aside. Towards the latter part of the time, 
 it may be worn occasionally only ; but even after the lapse 
 of twelve months, should the teeth show any indication of 
 movement from the desired position, mechanical restraint 
 must be resumed. 
 
 The foregoing remarks apply generally, but each case will 
 present its own peculiar characteristics, and the treatment 
 must be varied to meet them. The age of the patient, the 
 state of health, the degree of susceptibility to irritation and 
 pain, the number and condition of teeth present, the size 
 of the teeth themselves, the size and form of the base of the 
 alveolar portion of the jaw, and the configuration of the 
 same part in the parents — all these points must be taken 
 into consideration before a course of treatment is deter- 
 mined on. 
 
 Reverting to the case related for the purpose of introducing 
 a statement of those conditions which prevail more or less 
 in all cases of malix)sition of the teeth, it may be observed 
 that other methods than that adopted might have been pur- 
 sued for bringing inwards the projecting teeth. Thus, a 
 plate either of vulcanite or of metal might have been fitted 
 to the hard palate and to the necks of the molar teeth, and 
 to this the front teeth might have been tied, either with silk 
 or caoutchouc ligatures ; or a metal plate might have been 
 fitted to the palate, and extended to the labial surfaces of 
 the molar teeth, and on either side attachments for a band of 
 india-rubber stretched over the labial surfaces of the front 
 teeth might have been made. The apparatus adopted, how- 
 ever, possessed an advantage over these ; it prevented the
 
 TEETHING. 
 
 127 
 
 Tinder lip from exercising an antagonistic influence, while it 
 was simple in construction, and readily applied. 
 
 An opposite form of displacement to that which has been 
 described is far from uncommon, — The anterior teeth, instead 
 of standing out far in front of those of the lower jaw when 
 the mouth is closed, are directed inwards, and pass behind 
 them. The patient is said to be under-hung. The upper lip 
 is generally short and retreating, while the lower lip and 
 chin hold an unusually forward position. 
 
 If the coincident conditions of the jaws be examined, it 
 will be found either that the alveolar ridge of the upper 
 
 Fig. 51. (1) 
 
 maxilla is unusually small, as shown in the accompanying 
 figure, or that the lower jaw has departed from the normal 
 form. In the specimen from which the illustration is taken, 
 the inferior maxilla does not differ, either in general dimen- 
 sions or in configuration, from the normal specimens ; but 
 the upper jaw in its alveolar portion is below the usual di- 
 
 ■ (I) Showing the condition of the teeth and jaws in a specimen in which the 
 anterior upper teeth were inverted coincidently with defective size in the 
 tuperior maxilla.
 
 128 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 mensions. The teeth are placed regularly, but the alveolar 
 line is fully occupied, to the exclusion of the wisdom teeth ; 
 and the second molar closes upon the third molar of the 
 lower jaw in the position usually assigned to the wisdom 
 tooth, which, from its backward direction, is thrown alto- 
 gether out of use. 
 
 The figure which illustrates the inversion of the upper 
 teeth coincident with a well-gro^vn upper jaw, is taken from 
 
 Fig. 52. (1) 
 
 a specimen in which the temporary teeth are present. In 
 this case we have an excess of growth in the lower jaw, the 
 body of which is unusually long, and is associated with a 
 ramus which has preserved the obliquity characteristic of an 
 earlier age. The line of growth, as indicated by the jwsition 
 of the articular process, is calculated to give great length of 
 
 (>) Shows inversion of the upper front teeth coincident with un>isual 
 development of the lower jaw, the upper maxilla having attained the normal 
 dimensions.
 
 TEETHING. 129 
 
 jaw at the expense of depth in the iDOsterior portions of the 
 alveolar line. 
 
 The cause of this want of proper relationship between the 
 upper and lower jaws and their respective teeth, is in many- 
 cases very obscure. In certain families it occurs as an 
 hereditary character. In other cases, the deformity may 
 have been consequent upon the relatively tardy eruption or 
 the inverted position of the upper teeth in infancy. 
 
 But whatever may have been the cause, the malposition 
 will be persistent, unless remedied by mechanical interfe- 
 rence. The under teeth will present a barrier to the out- 
 ward movement of the inturned teeth. 
 
 If subjected to treatment at a sufficiently early period, 
 these cases may be brought to a successful issue with much 
 less difficulty than those in which the teeth are everted. The 
 difficulty of keeping the teeth in the position into which they 
 have been moved is remedied by the antagonistic teeth of the 
 lower jaw. When, therefore, the upper are brought suffi- 
 ciently forward to close in front of the lower teeth, our treat- 
 ment may be discontinued. 
 
 Kow there can be no difference of opinion as to the 
 propriety of adopting measures for reducing to a normal 
 position teeth which are permanently turned inwards. We 
 have therefore to consider the age at which the operation 
 can be most advantageously undertaken, and the manner of 
 performing it. 
 
 The anatomical conditions of the teeth, and the parts about 
 them, at the period of eruption, have been already described. 
 If these conditions are understood, but little doubt wall be 
 entertained upon the propriety of adopting mechanical treat- 
 ment at a comparatively early period. There would be no 
 advantage gained by waiting till the sockets are fully formed, 
 as the treatment must then involve their partial destruction, 
 and the reproduction of new ones. On the other hand, if the 
 treatment be commenced sufficiently early, the large open 
 sockets will allow the growing teeth to be moved forward, 
 
 K
 
 130 A SYSTEM OF DENTAL SURGERY. 
 
 and those parts of the sockets as yet unformed will be deve- 
 loped in accordance with the direction given to the teeth. 
 So soon, therefore, as it is discovered that the upper fall 
 within the lower front teeth, the treatment may be com- 
 menced. If measures were adopted prior to the establish- 
 ment of irregular antagonism, we should perhaps be efifecting 
 by mechanical interference that which nature would have 
 accomplished with much less inconvenience to the patient. 
 Few can have failed to remark the much greater prevalence 
 of irregularity in the permanent teeth about the time of their 
 eruption, than at a later period, in that class of society the 
 members of which do not avail themselves of the services of 
 the dentist, excepting when the presence of an aching tooth 
 can no longer be borne. That in many instances teeth which 
 on their first appearance through the gums hold an objec- 
 tionable position, will, if left to themselves, ultimately fall 
 into the proj)er line, is a fact sufficiently well established to 
 warn us against interference until it is clearly shown that 
 our assistance is required. 
 
 From the frequency with which irregularities are remedied 
 by nature, it has been supix)sed that there is a strong in- 
 herent tendency towards the assumption of a normal position, 
 and that teeth will in consequence of this tendency, all 
 mechanical obstacles being removed, take up a regular 
 arrangement. 
 
 This explanation is not, however, wholly satisfactory, in- 
 asmuch as it ignores the existence of certain mechanical 
 agencies which are in constant operation, namely the 
 pressure exerted by the tongue and by the lips. If any 
 tooth project outwards or inwards beyond the line of the 
 surrounding teeth, it will obviously sustain more than its 
 share of the pressure exerted by the muscles of the lips or of 
 the tongue. And as the lips and tongue act evenly and 
 symmetrically on every part of the alveolar arch, their action 
 will obviously tend to the correction of any irregularitj" 
 that may have occurred, if a regular disposition of the teeth
 
 TEETHING, 131 
 
 be not rendered impossible by want of space, or other me- 
 chanical obstacle. 
 
 The muscles of the tongue in its varied movements exert a 
 more powerful influence than those of the lips ; and thus it 
 happens that a tooth placed inside the arch is far more 
 quickly pushed into its normal position by the operation of 
 natural forces than one which lies outside the line. A very 
 slight amount of force, if only it be constantly applied, is 
 sufficient to alter the position of a newly-erupted tooth ; and 
 this even pressure of the lips and tongue is probably the chief 
 agency, not only in correcting any irregularity that may have 
 arisen, but also in determining the regular arrangement of 
 the teeth dm-ing their eruption where no mechanical obstacle 
 interferes with their even disposition. 
 
 Some difference of opinion exists as to the best mode of 
 pressing the teeth outwards. The older method of procedure 
 consisted, in fitting a metal plate to the lower teeth, from the 
 upper surface of which a plate of metal projected, which, on 
 closing the mouth, passed behind the teeth whose position 
 required change. In fact, the lower 'teeth were by this pro- 
 cess artificially lengthened and turned inwards, and conse- 
 quently the amount of force exerted upon the misplaced 
 teeth depended entirely upon the volufitary action of the 
 lower jaw in closing the mouth. In many cases this method 
 of treatment will be successful, but it is slow, and conse- 
 quently produces a prolonged impediment to articulation and 
 mastication ; and it is open to a further objection. It is not 
 uniformly successful, and at best depends in great part upon 
 the voluntary efforts of the patient. 
 
 More recently, vulcanite plates fitted to the palate, and 
 extended over the molar teeth, have been adopted. The vul- 
 canite over the masticating surfaces of the molar teeth is left 
 sufficiently thick to prevent the upper and lower front teeth 
 from influencing each other when the mouth is closed. The 
 plate is fitted to the necks of the teeth to be operated upon, 
 between which and the plate portions of dry compressed
 
 132 A SYSTEM OF DEXTAL SUKGERT. 
 
 wood are placed, in cavities cut in the vulcanite for their re- 
 ception. Each instanding tooth will have its coiTesponding 
 cavity in the plate, the formation of which requires some 
 little attention. The form should be similar to that of a 
 shallow drawer, the front of which has been removed, and so 
 proportioned as regards the upper and lower surfaces of the 
 plate in which it is cut, that the section of wood will not 
 fall out into the mouth. The wood should be fitted to the 
 cavity, and left a little thicker at that end which lies.towards 
 the gimi. The plate having been adjusted to the mouth, 
 holes must be drilled through it for the admission of liga- 
 tures, which may be passed round and tied to one or other of 
 the molar teeth on each side of the mouth. 
 
 In arranging the ligatures, care must be taken that they do 
 not press upon and irritate the gums. It will be remembered 
 that the gums approach nearer to the masticating surfaces of 
 the teeth on the lingual than on the labial side. Hence, the 
 holes in the plate should be made at the point corresponding 
 to the free edge of the gum against which it rests, and con- 
 tinued obliquely in a direction continuous with the line fol- 
 lowed by the gum in its passage between the teeth. If this 
 precaution be observed, the ligature when tied will pass in a 
 straight line from the labial surface of the tooth to the lingual 
 surface of the plate, without interfering with the gums. In 
 selecting the teeth around which the ligatures are to be 
 passed, we must be guided by the forms and the position of 
 the teeth available for the pur^wse ; but should the temporary 
 molars be present it will be well to make use of them in 
 preference to the permanent teeth. The abnipt termination 
 of the enamel renders them particularly suitable for the 
 purpose, and the short period during which they will be 
 retained renders their injury a matter of little consequence. 
 
 By the foregoing means the f)late may be firmly fixed in 
 order to afi'ord a point d^appui for the action of the com- 
 pressed wood, the cells for the reception of which will be 
 formed on the one side by the teeth to be moved, and on
 
 TEETHING. 133 
 
 the other three sides by the plate. After compressing for 
 some hours a piece of dry willow, plane, or some other soft 
 wood, small strips may be cut off, and from these fragments 
 must be prepared which will fit with moderate accuracy to 
 
 Fig 53. (1) 
 
 the spaces formed by the plate and teeth, taking care that 
 the grain of the wood runs parallel with the long axes of the 
 teeth. So soon as the wood commences to absorb moisture 
 it will expand, and in a direction transverse to that of its 
 grain. In expanding, either the tooth in front of it must move 
 outwards, or the plate must be driven backwards, and with 
 it the molar teeth to which it is fitted. But as the front teeth 
 
 (1) Showing a vulcanite plate fitted to the upper jaw, for the purpose of 
 forcing outwards the central incisors. The vulcanite is left suflaciently thick 
 over the masticating surface of the back teeth to prevent the lower teeth from 
 influencing those to be operated upon. The plate is retained by ligatures 
 passed through the vulcanite and round the temporary molars ; posterior to 
 the central incisors, the apertures of the cells for the reception of the com- 
 pressed wood are shown. 
 
 Below the figure, a section of the parts in situ is given, showing the cell m 
 its length, with the piece of wood removed and placed underneath. I am in- 
 debted to my friend, Mr, Harrison, for the specimen from which this figure has 
 been taken.
 
 134 A SYSTEM OF DENTAL SURGERY. 
 
 are capable of the least resistance, they are the first to yield, 
 and therefore gradually advance before the expanding wood. 
 From time to time the wedges must be renewed, each new 
 piece being slightly larger than its predecessor ; and as the 
 t^eth move upon an axis situated near the apices of their re- 
 siDective roots, the receptacles become changed in form, and it 
 will be necessary to modify the form of the grooves in the 
 vulcanite plate. If this precaution be neglected, there will 
 be a difficulty in retaining the wood after the teeth have been 
 moved from their original position. The receptacle will have 
 changed in form as respects the relative size of the upper and 
 lower portions. Hence it becomes necessary to deepen that 
 end of the groove which lies near the gum, and the exca- 
 vation must be made sufficiently deep to restore the paral- 
 lelism which has been lost by the outward movement of the 
 tooth. When the required amount of change in position is 
 considerable, and the half of this has been gained, it may be 
 necessary to discard the original plate, and substitute a new 
 one fitted close to the teeth operated upon, so as to admit a 
 thinner and more manageable wedge than that which would 
 have been required had the treatment been continued with 
 the first-made apparatus. 
 
 It is doubtful whether, as a general rule, more than two 
 teeth can be advantageously operated upon at the same time. 
 If, for instance, the four incisors are involved in the irregu- 
 larity, it may be desirable to push forward the central teeth 
 first, and then move the lateral teeth, or vice versa. But in 
 adopting this plan we must not neglect to take means to 
 prevent the teeth first operated u^wn from retreating to their 
 old place while the others are being forced forward. This 
 may be accomplished by inserting into the vulcanite frame 
 pegs of wood, the free ends of which rest upon the backs of 
 the moved teeth. In this application of the wood the end of 
 the grain will rest upon the tooth, and as there is but very 
 slight expansion lengthwise of the grain, the teeth will be 
 simply held in position.
 
 TEETHING. 
 
 135 
 
 "When the whole of the instanding teeth have been moved 
 outwards to an extent sufficient to ensure their passing in 
 front of the lower teeth on the mouth being closed, the use 
 of the apparatus may be discontinued. Sometimes, however, 
 it will be found that the back teeth of the upper and lower 
 jaws, from having been kept apart during the treatment, 
 lose their proper antagonism. They become raised in their 
 sockets, and prevent the front teeth from meeting each other ; 
 under these circumstances, those portions of the vulcanite 
 plate which extended over the masticating surfaces of the 
 back teeth must be removed so as to allow the teeth to come 
 in contact, while the plate prevents the front teeth from 
 falling back into the former position. In a few days the 
 proper antagonism will be restored, and the plate may be 
 discarded. 
 
 Instead of using vulcanite, metal may be used for the plate. 
 The molar teeth on either side are capped with gold, the caps 
 
 Fig. 54. (1) 
 
 being made so that they fit tightly upon the teeth. From 
 these a band of metal is extended in front of the teeth. 
 
 (1) Shows metal caps fitted to the molar teeth, with a band extending from 
 them in front of the incisors. To the metal band so fixed, ligatures, after 
 being passed round the front teeth, were attached, and drew the inverted teeth 
 forward until they came in contact with the band. The case was treated by- 
 Mr. Harrison, to whom I am indebted for the specimen given in the figure.
 
 136 A SYSTEM OF DKNTAL SURGERY. 
 
 Holes are drilled in the baud opi^osite to the teeth, and 
 strong silk thread is passed round the neck of each tooth and 
 through the corresponding holes, and tied tightly on the outer 
 surface of the band. The teeth will by degrees be drawn 
 towards the band, but the process is a slow one, and requires 
 frequent renewal of the ligatures. 
 
 I have commonly used vulcanized caoutchouc in the place 
 of silk ; with this material, the tension is more uniform, and 
 the renewals need not be made so frequently. The fixing of 
 the india-rubber to the band was at first a diflBculty ; tying 
 was impracticable, and hooks could not well be usi^. I 
 found, however, that by cutting fine slits with a hair saw 
 obliquely through the metal band, and then passing the two 
 ends of the caoutchouc in a state of tension into them, the 
 ligatures were firmly retained. Silk ligatures require renewal 
 every second day, but the caoutchouc will last double the 
 time, and will produce a much more rapid eflect. I have in 
 favourable cases succeeded in bringing teeth out in the course 
 of a fortnight, and the case has been dismissed. 
 
 In the place of using metal in the foregoing manner, a plate 
 may be fitted to the palate, and retained by bands passing 
 round the back teeth, or by portions of wire extended over 
 the crowns and bent down so as to clasp the necks of the 
 teeth. To the palatal jx)rtion of the plate, bands of metal 
 rendered elastic by hammering, may be attached,, adjusting 
 the free ends so that they shall press upon the backs of the 
 malplaced teeth. This manner of proceeding is inferior to 
 the two preceding methods where a number of teeth are in- 
 volved, although in cases where two or three teeth only are 
 required to be shifted, not only outwards or inwards, but also 
 uix)n their axes, it ofifcrs some advantages. 
 
 The treatment upon the principle of elongating the lower 
 teeth need not be reciu-red to, as it has nothing whatever to 
 recommend it. The plates used may be made of vulcanite 
 or of gold, each ha^^ng its special advantages. Excepting in 
 those cases where the antagonistic teeth serve for maintaining
 
 TEETHING. 137 
 
 the position acquired by mechanical interference, regulation 
 plates must be worn for many months, and whatever may be 
 the material used in their construction, the teeth to which 
 they are attached gain nothing by being so used. Metallic 
 bands encircling natural for the support of artificial teeth, 
 not uncommonly produce injury to the former ; and it is fair 
 to infer that when, in protracted cases, regulation plates are 
 retained by similar means, some amount of mischief may 
 result. Hence there are those who condemn the use of metal. 
 The question arises as to whether vulcanite is really less 
 injurious to the invested teeth than gold ; and, judging from 
 the experience gained by watching the effects of artificial 
 teeth constructed with each, I think we shall be constrained 
 to answer in favour of the former. Still, before any appre- 
 ciable hurt can be produced, the metallic frame must be 
 worn for a long time, and supposing it can be attached to 
 temporary teeth, this consideration need not influence our 
 selection. 
 
 The advantage in respect to time and the relative amount 
 of inconvenience entailed upon the patient by the one or other 
 method of procedure must not be disregarded. The ever- 
 varying character of the cases renders it difficult to lay down 
 any general rule as to the advantages of the one method over 
 the other, as regards the time required to produce the desired 
 effect. On the whole, perhaps, although cases treated by the 
 use of metal plates are more speedily completed, nevertheless 
 vulcanite is more generally to be preferred as more com- 
 fortable, and less injurious to the teeth. 
 
 Although in the majority of cases it will be necessary to 
 rectify such malposition of the teeth as nature alone will not 
 remedy, by the use of plates, there are other methods by 
 which their position may be changed. A patient possessed 
 of sufficient determination may often succeed in bringing 
 forward a misplaced upper incisor by the use of a piece of 
 wood, employed like a lever to force it forward, the lower 
 teeth being taken as a fulcrum.
 
 138 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 Ligatures or elastic bands may be adapted to the tooth 
 which it is required to move in such ways as the ingenuity 
 of the operator may devise, always bearing in mind, however, 
 that unless a considerable number of teeth are embraced by 
 it, those taken as the supports will probably be as much acted 
 on as the tooth which is to be moved. 
 
 But whatever course of procedure is decided upon, there is 
 one point which must carefully be kept in mind : the direc- 
 tion of the long axis of the tooth may be changed, but that 
 is all. The apex of the fang will remain fixed, or nearly so ; 
 while the crown of the tooth will move in an arc of a circle 
 the centre of which lies at or very near to the apex of the 
 fang. It is therefore of the utmost importance in estimating 
 the probability of success to ascertain as far as possible the 
 
 Fig. 55. (1) 
 
 position of the apex of the fang ; and it is obvious that those 
 cases in which the irregularity is due to some such mecha- 
 nical cause as the retention of temporary teeth will yield to 
 
 Q) Showing the front teeth meeting edge to edge.
 
 TEETHING. 
 
 139 
 
 treatment far more readily than those in which the whole 
 alveolar portion of the jaw is involved, and which are often 
 of congenital origin (Cf. p. 114), 
 
 Intermediate betiveen the two forms of irregularity already 
 described, is that in which the front teeth meet edge to edge, 
 as shown in the preceding figure (Fig. 55). It may be re- 
 garded as differing only in degree from those cases in which 
 the upper front teeth are inverted, and as dependent upon 
 similar causes which have operated with less force. 
 
 A form of irregularity involving more or less the whole of 
 
 Fig. 56. (1) 
 
 the teeth is found associated with an abnormal development 
 of the maxillae. In the description of case alluded to, the 
 molar teeth, on closing the mouth, alone come in contact ; 
 while the upper and lower incisors, without being either 
 unduly turned outwards or inwards, stand apart. 
 
 In the specimen from which the illustration is taken 
 
 (1) Showing that conformation in which the molar teeth only come in contact 
 when the mouth is closed, and the peculiar form of the lower jaw coincident 
 with the imperfect antagonism of the teeth.
 
 140 A SYSTEM OF DENTAL STJEGEBY. 
 
 (Fig. 56), the degree of separation is moderate in amount, as 
 compared with many cases presented to the practitioner ; but 
 it affords an opportunity of showing a peculiarity in the con- 
 formation of the lower jaw usually coincident with this form 
 of irregularity. It consists in a great development of the 
 anterior part of the jaw in the vertical direction, with a dimi- 
 nished depth in the parts which sustain the molar teeth, asso- 
 ciated with an unusual obliquity of the ascending ramus. 
 The line of growth in the latter part has not taken the rect- 
 angular direction which characterizes the well-formed adult 
 jaw. The anterior part of the alveolar ridge of the upper 
 maxilla has not attained the normal depth — a peculiarity 
 which the accompanying illustration does not exhibit in the 
 degree commonly seen in cases of this nature. I have seen 
 several instances in which in the closed mouth the finger 
 could be passed between the front teeth. 
 
 The teeth themselves, and especially the first permanent 
 molars, usually present indications of imperfect development 
 of their tissues. The surface of the enamel is irregular, and 
 marked with pits and transverse grooves, is yellow in colour, 
 and readily broken down. 
 
 The anatomical conditions which are coincident with this 
 form of irregularity are readily distinguished, but the causes 
 which have destroyed the relations of the several parts of 
 the jaws during development are very obscure. In most 
 instances the patients have been unable without effort to 
 breathe through the nose, and the mouth has consequently 
 been habitually kept open, even during sleep. Possibly the 
 constant traction exercised ujxjn the anterior part of the jaw 
 in keeping the mouth open may have had some influence in 
 determining the j^eculiarity of form, and the freedom from 
 the pressure exercised mutually by the antagonistic molar 
 teeth upon each other, may have led to their rising higher 
 with their sockets than they do when their conformation is 
 normal. 
 
 I have attempted to diminish the amount of deformity
 
 TEETHING. 141 
 
 in one case only. The patient was a female, twelve years old. 
 The front teeth were separated by a wide interval when 
 the first molars were in contact, and the lips closed with 
 difficulty. The chin, although retreating, was of unusual 
 depth, and, associated with the unclosed lips, gave a vacant 
 expression to the face. The method of treatment which 
 offered the greatest prospect of success consisted in main- 
 taining a steady upward pressure upon the anterior part of 
 the lower jaw, leaving the antagonizing molar teeth to act 
 as a fulcrum. A sheet of gutta-percha was moulded to fit 
 the point of the chin, and a cap fitted to the head, and the 
 two were connected by strong bands of caoutchouc — one on 
 each side. The amount of pressure exerted by this con- 
 trivance was sufficient to produce tenderness in those teeth 
 which closed upon each other. This source of discomfort 
 passed away of itself in the course of a fortnight, without 
 any modification of the plan of treatment. 
 
 At the end of three months the front teeth, which at the 
 time the treatment was adopted were separated by three- 
 eighths of an inch, now came in contact, and the general 
 appearance of the face was greatly improved. The patient 
 was directed to use the apparatus during the night-time for 
 at least six months, and to show herself at the expiration 
 of that period. These instructions were disregarded, and it 
 was only after a lapse of two years that she was again brought 
 to me. The deformity had returned with the eruption of the 
 second permanent molars, the masticating surfaces of which 
 teeth alone came in contact when the mouth was closed. The 
 treatment which two years before had been attended with 
 a fair amount of success was again adopted, but either from 
 want of perseverance or from the increased age of the patient, 
 a slight advantage only was gained. Had the patient perse- 
 vered from the first in the course she was directed to follow, 
 the deformity would to a great extent have been overcome. 
 In examples of the form of irregularity under consideration, 
 the most striking and the most important feature is the obli-
 
 142 A SYSTEM OF DENTAL SURGERY. 
 
 quity at which the ramus is placed with respect to the body 
 of the lower jaw. The line of growth has been almost directly 
 backwards, and the inferior dental canal, instead of being 
 carried upwards in its pDsterior third, is almost straight from 
 end to end. That form in which the rectangular position has 
 been prematurely assumed, and the ascending ramus below 
 the usual height, has already been adverted to. Here we 
 have a class of cases in which the obliquity peculiar to infancy 
 has been maintained throughout the whole period of growth, 
 and, as a consequence, an alveolar line of unusual length is 
 produced. In the prematurely rectangular jaw we seldom 
 find sufficient space for the normal implantation of the wis- 
 dom tooth ; in the oblique maxilla, on the contrary, there is 
 room even for a fourth molar. 
 
 The specimen from which the preceding figure (Fig. 56) 
 has been taken, aflbrds a better opportunity of examining the 
 anatomical relations of the several parts of the jaw than is 
 afforded in the living subject. In this we shall see that, had 
 the alveolar portion been developed in accordance with the 
 usual form, while the obliquity of the line of development 
 was preserved, the separation of the front teeth would have 
 been far greater than it is ; but nature, having departed from 
 the normal form in one particular, to a certain extent counter- 
 balances the deformity by a deviation in another direction. 
 Here, the alveolar processes at the back part are unusually 
 shallow, and in the front part of the jaw are unusually deep ; 
 the back teeth are kept down to a low, and the front teeth 
 are raised to a high, level. The treatment adopted in the case 
 already cited was in accordance with the indications aflbrded 
 by the specimen ; the back formed the fulcrum by the aid 
 of which the elastic bands pressed the front part of the jaw 
 upwards, and drew the ramus downwards. 
 
 The following interesting case shows to what extent the 
 form of the jaw may be modified by the maintenance of con- 
 stant pressure during early life. The patient was a strong 
 healthy young woman, twenty-two years of age. Her chin
 
 TEETHIXG. 
 
 143 
 
 was drawn down toward the sternum by a broad cicatrix, con- 
 sequent upon a burn received when five years old. The teeth 
 of the lower jaw stood out almost at right angles, and were 
 far in front of those of the upper jaw. The accompanying 
 illustration is taken from a cast made when the patient was 
 in the Middlesex Hospital, and shows accurately the position 
 of the teeth and the form of the alveolar ridge. The position 
 
 Fig. 57. (1) 
 
 and the proportions of the lower border of the jaw and the 
 ramus, being enclosed by a tense hard cicatrix, could only 
 be guessed. The accuracy, therefore, of the illustration as 
 respects the hidden parts cannot be depended on. The injury 
 occurred after the temporary teeth were matured, but prior 
 to the emption of the permanent organs. Hence the traction 
 exerted by the cicatrix in opposition to the natural action of 
 the jaw, and of the endeavour to keep the face in the natural 
 
 (•) Drawing taken from a cast of the upper and lower teeth and gums of a 
 patient, aged twenty-two, who at the age of five years was badly burnt about 
 the neck and chest. The chin was, by the contraction of the cicatrix, gradually 
 drawn down towards the chest, and the alveolar portion of the lower jaw became 
 everted in the manner shown in the figure. The teeth are perfect as regards 
 number, and are tolerably well formed. The outline of the bones has been 
 abided by the artist, and hence must not be depended on as a faithful repre- 
 sentation of the condition of those parts.
 
 144 A SYSTEM OF DE^fTAL SUBGEBY. 
 
 position, came into operation when the permanent teeth were 
 passing through the gums, and when their alveolar processes 
 were growing up with them. As the permanent alveoU were 
 for the most part developed under the influence of the ever- 
 contracting cicatrix, we shall be justified in assuming that 
 they were originally formed in the everted position shown 
 in the figure, rather than that they were developed in 
 the normal jwsition, and bent outwards and downwards 
 subsequently. But whatever explanation may be adopted 
 as regards the process by which the deformity has been pro- 
 duced, the case offers a very instructive illustration of the 
 amount of change in form that a force incessant in its 
 operation may bring about in the jaw during the period of 
 growth. 
 
 There is yet another form of irregularity in which the 
 whole of the teeth of one or of both jaws are more or less in- 
 volved. It is that which is commonly called the "V or wedge- 
 shaped mouth ; the teeth, in place of holding the elliptical 
 arrangement, occupy two converging lines which meet at 
 an angle in the anterior part of the jaw, producing, as an 
 almost invariable result, an extremely high and vaulted 
 palate. The position of the teeth on the two sides of the 
 jaws may be perfectly symmetrical, and the conformation 
 may, in rare instances, correspond in the upper and lower 
 maxillae. More commonly, however, the deformity is con- 
 fined to, or exists in a much greater degree in, the upper 
 jaw, the central incisors of which frequently slant forward 
 and stand in advance of those of the lower maxilla. There 
 is an appearance of contraction across the line of the bicuspid 
 t€eth, looking as if the jaw had been pinched inwards at this 
 point (see Fig. 57); behind this the molar teeth rapidly 
 diverge. Each case will present its special peculiarities. In 
 one, the median sides of the central incisors will project 
 forwards and meet at angle ; in another, angles will be formed 
 at the junction of the lateral and central incisors ; in a third, 
 the central incisors will form at the junction of their median
 
 TEETHING. 145 
 
 sides an angle directed inwards, and with their distal sides 
 and the median sides of the lateral incisors, two angles 
 directed outwards not unlike an inverted W. The deep 
 vaulted form, of the hard palate is sometimes carried to such 
 an extent as to suggest the idea of the two sides of the jaw 
 having been forced towards each other, and the roof of the 
 mouth driven upwards. In other cases the height is not 
 greater than would necessarily result from the substitution 
 of the vertical for the oblique positions of the alveolar por- 
 tions of the jaw, and it is not uncommon to find that the 
 height, although apparently in excess of the normal eleva- 
 tion, does not in measurement exceed that of a finely 
 developed maxilla. 
 
 It will not, however, be necessary to enter into all the 
 minor modifications of form presented in cases where this 
 character of deformity prevails. Although numerous ex- 
 amples present themselves in which parentage cannot be 
 adduced as a cause for V-shaped dental arches, yet in many 
 families this peculiar conformation of the mouth will be found 
 as an hereditary characteristic. But through whatever influ- 
 ence the defect may have jDrimarily arisen, the result is a 
 departure from the normal anatomical relations between the 
 teeth and the jaws, and as the • size of the former is deter- 
 mined some years before the latter have arrived at their ulti- 
 mate dimensions, we can but regard the fault as originating 
 in the jaws. 
 
 Mr. Coleman (^) has examined a large number of children 
 with a view to tracing the connection between the general 
 development and that of the jaws, and the conclusions at 
 which he has arrived are so instructive as to call for mention 
 in this place. The antecedents and parentage of the children 
 brought to a hospital must always be a difiicult if not? an 
 impossible subject of inquiry ; but not so their appearance, 
 which will afi"ord a fair guide in determining whether they 
 are coarse, brutal and low bred, or whether they bear the 
 (1) Transactions of the Odontological Society, 1864, p. 233. 
 
 L
 
 146 A SYSTEM OF DENTAL SURGERY. 
 
 Stamp of a higher civilisation — in other words, may be 
 six)ken of as " well bred." 
 
 Taking children of " well-bred aspect," no less than sixty- 
 nine per cent, were found to have more or less contracted, 
 badly developed jaws ; whereas taking children of decidedly 
 low aspect, only from seven to eight per cent, manifested this 
 condition of the jaws. Amongst children of doubtful aspect, 
 who could not certainly be referred to either of the above 
 classes, twenty-four per cent, had contracted jaws, thus 
 coming in an intermediate jwsition betwixt the iirst two 
 classes. 
 
 It was remarked by Mr. Mummery Q), in the course of a 
 very extended series of observations on the teeth of savage 
 races, that irregularities of the teeth and contracted jaws 
 were as rare as destructive attrition was common amongst 
 them, whilst precisely the contrary is true of civilised races. 
 
 And Messrs. Cartwright and Coleman report that they did 
 not find any example of contracted jaws in the large collec- 
 tion of skulls contained in the crypt of Hythe Church ; 
 skulls which are certainly of very great antiquity, though 
 their precise history is, I believe, a matter of dispute. 
 
 That the comparative disuse of the organs of mastication 
 among civilised races, who cook and thoroughly soften their 
 food before masticating it, should have led to a less powerful 
 development of the jaws, is a thing that might fairly be 
 expected, and were the occurrence of contracted jaws a thing 
 2)er se, it would have comiiaratively little significance. But 
 it hapi^ens that the V-shai">ed conformation of the jaws is 
 very often associated with other deviations from the standard 
 of healthy organisation ; thus it is extremely common for 
 the subjects of this malformation to suffer from enlarged 
 tonsils, and to present many indications of weak health, 
 whilst it is rare to meet with it in strong robust persons. 
 
 And Dr. Langdon Down (^), after making observations on 
 
 (1) Transactions of the Odontol<^cal Society, new series, vol. ii., 1869. 
 
 (2) Ibid., vol. iv., p. 16, 1671.
 
 TEETHING. 147 
 
 a very large number of congenital idiots, has found, with 
 hardly an exception, that there was always a diminution of 
 width betweea the posterior bicuspids, and an inordinate 
 vaulting of the palate ; in fact a typical V-shaped maxilla. 
 Although the typical characters of the V-shaped maxilL-e 
 are dependent in some degree on the presence of the perma- 
 nent teeth, Dr. Langdon Down is of opinion that this mal- 
 formation may be detected at a much earlier period, and he 
 is so convinced of its constancy that he relies upon its 
 presence as a diagnostic test whether the idiocy of the 
 individual be truly congenital, or be the result of pathological 
 processes occurring at some subsequent period. 
 
 The fact that this deformity of the i^ermanent dentition 
 is held to be the mark of congenital defects of organisation 
 lends a special interest to the enquiry, at what period does 
 it really originate ? It has been usually explained as in great 
 part a consequence of a disproportion between the size of 
 the teeth and the base of the jaw, but this explanation 
 obviously will not account for all the observed facts. 
 
 If reference be made to that ^wrtion of the work in which 
 the growth of the jaw is described (page 102), it will be seen 
 that the front portion of the jaw, that which contained the 
 temporary teeth and afterwards the permanent incisors, 
 canines and bicuspids, undergoes no material alteration in 
 form after birth, but the gain in size is effected by addition 
 to its outer surface and to its posterior cornua. 
 
 But an increase in width is a necessity, in order that the 
 jaw may maintain its relations with the increasing cranial 
 base ; and if the cornua of the foetal jaw are not in the first 
 instance divergent, the newly added portion at the back of 
 the alveolar border will form an angle with that previously 
 existing. 
 
 Hence, if the foetal jaw have not attained to the form 
 appropriate to its further growth at an early period, the fault 
 is not obliterated by the further process of development, but 
 the newly added portions form an angle in the bicuspid
 
 148 A SYSTEM OF DENTAL SUBGEBY. 
 
 « 
 
 region, which remains through life as a mark of malforma- 
 tion, scarcely noticeable at the time, which occurred during 
 intra-uterine life. This serves to explain how it is that a 
 character of permanent dentition may come to be diagnostic 
 of congenital disease, and also how it is that the lower jaw 
 is so seldom affected by this malformation. For, as has 
 been more fully described elsewhere (^), the comua of the 
 alveolar border of the lower jaw have attained to their poste- 
 rior divergence at a period when the corresponding parts in 
 the upper jaw are as yet parallel. 
 
 Fig. 58. (2) 
 
 In some instances the deformity is confined to the al- 
 veolar ridges, whilst in others the whole base of the jaw is 
 involved. 
 
 (1) Cliarles S. Tomes, " On the Developmental Origin of the V-shaped 
 Maxilla." .Monthly Review of Dental Science, June, 18T2. 
 
 (2) Shows a case in which the V-shaped conformation was attended with 
 unusual contraction in the neighbourhood of the bicuspid and first permanent 
 molar teeth. On the left side both of the bicuspids were removed, and in the 
 right the second bicuspid was extracted without any advantage being gained as 
 regards the contracted condition of the palate. I am indebted to Mr. Harrison 
 for the nse of this interesting specimen.
 
 TEETHING; 149 
 
 If the process of outward growth during the presence of 
 the temporary teeth has been defective, and the permanent 
 teeth while within the alveolar crypts have been forced to 
 take such a position as the space allotted to them would 
 allow, on successively appearing through the gums they will 
 necessarily present the irregularity of arrangement into 
 which they had fallen during development. But if the base 
 of the alveolar portion of the jaws has reached the normal 
 dimensions, the teeth, although mal-placed at the time of 
 eruption, may ultimately become regular, as at this period 
 the alveoli have yet to undergo modification and further 
 development. 
 
 If some of the preceding figures be examined and com- 
 pared with those in which the arrangement of the two sets 
 is normal, the manner in which irregularities arise may be 
 seen. In studying the causes which produce the mal- 
 positions in which the whole of the anterior teeth are 
 involved, the investigation must be commenced prior to the 
 eruption of the permanent teeth. 
 
 It has been usual to assume that the premature extraction 
 of the temporary teeth occasions contraction of the jaw, but 
 I do not think that any anatomical facts can be brought for- 
 ward in support of the supposition. If a temporary tooth be 
 removed, the crowns of the contiguous teeth may lean 
 towards each other, and give an appearance of contraction, 
 but it does not really involve a diminished size of that part 
 of the jaw from which the tooth has been lost. In the case 
 from which the accompanying illustration is taken, the two 
 central incisors were lost long before their successors were 
 ready for eruption; hence the sockets became obliterated, 
 and the alveolar ridge made good ; but we do not see the 
 slightest trace of contraction in the jaw. It has been stated 
 by Mr. Cartwright Q), that if the central incisors happen to be 
 cut at birth, and at once removed, on account of the injury 
 
 (») Transactions of the Odontological Society, 1863, p. 132.
 
 150 A SYSTEM OF DENTAL StlRGEET. 
 
 inflicted on the mother's nipple, the laterals when erupted do 
 not obliterate the space. 
 
 Then again, if specimens be examined in which the two 
 sets of teeth are present, it will be seen that the implantation 
 of the temporary teeth occupies but a very small space in 
 the alveolar ridge, as compared with that occupied by the 
 crowns of the permanent teeth. Now, it is extremely diflB- 
 cult to conceive how the removal of the temporary teeth can 
 induce the jaw to contract upon the crowned and growing 
 permanent teeth. Organs in an active state of development 
 induce the expansion of parts about them, and there is no 
 good reason for supposing that the jaw forms an exception 
 to this rule. The persistence of the first, which are placed 
 immediately in front of the second set, may, and frequently 
 does, interfere with the outward progress of the latter ; but 
 I cannot see how the removal of the temporary can produce 
 
 (0 The upper jaw of a subject between six and seren years oW. The central 
 incisors had been lost, and the alveolar ridge had become rounded bj the 
 obliteration of the sockets of the temporary teeth and the development of new 
 bone. If the premature loss of the temporary teeth were followed by contrac- 
 tion of the jaw, the condition should be shown in this case.
 
 TEETHING. 151 
 
 a prejudicial influence upon the arrangement of the per- 
 manent teeth. In the case shown in Fig. 59, the temporary 
 incisors have been shed some time prior to the eruption of 
 their successors ; yet there is no indication of contraction of 
 jaw. A case came under my notice recently, in which the 
 child had been destitute of temporary teeth, excepting 
 only the second temporary molar on the right side of the 
 lower jaw ; the maxillae were, notwithstanding, well formed, 
 and the permanent teeth appeared with an unusual regu- 
 larity of arrangement. Had the development of the jaws 
 depended upon the presence of temporary teeth, we should 
 surely have seen in this case some amount of contraction. 
 
 Subsequently, however, there may be some amount of 
 practical inconvenience resulting from the premature re- 
 moval of the temporary teeth, but it is altogether indepen- 
 dent of contraction of the jaw. The newly-cut incisors, in 
 the absence of adjoining teeth, will sometimes lean away 
 from the median line, leaving a central opening between 
 them. This is, however, an evil that generally cures itself. 
 The canines and bicuspids, when they appear, force the 
 slanting teeth into the vertical position, and the space be- 
 comes obliterated. 
 
 It may in some respects be disadvantageous to remove the 
 temporary teeth prematurely, but the disadvantages will not 
 be shown in the mal-position of the succeeding teeth at the 
 period of their eruption. But should the first teeth be re- 
 tained beyond the normal period, the mischief resulting from 
 their presence will be sufficiently obvious. When the sub- 
 ject of partial irregularity is considered, this point will be 
 rendered evident by the accompanying illustrations. 
 
 Before the course of treatment is decided upon, the con- 
 ditions presented by the jaws must be accurately ascertained, 
 and it should be known whether the deformity is hereditary 
 or accidental ; and it must also be ascertained whether the 
 jaws are contracted at their bases — at that point where the 
 alveolar portion merges in the body of the bones. And it is
 
 152 A SYSTEM OF DENTAL SURGERY. 
 
 equally important that we should learn whether the mal- 
 jX)sition of the second, has arisen from the tardy shedding of 
 the temporary, set. If the case presented for treatment 
 exhibits a form common to the family of which the child is 
 a member, we shall probably have to encounter greater diffi- 
 culty than if it be a solitary example. After the teeth have 
 been removed, there will be a greater tendency in the one 
 case than in the other to return to the original position. 
 Supposing the Y-shaped arch be forced into the elliptic form 
 in a case where the base of the jaws is below the normal 
 size, the position of the teeth individually will be so oblique, 
 as respects the jaw, that they will become unsightly ; and 
 moreover, it is questionable whether the subsequent alveolar 
 development will be sufiBcient to secure a firm implantation. 
 Hence, in cases which present this character, it may be 
 desirable to remove permanent teeth, one on either side of 
 the jaw, more especially when the front teeth are unduly 
 prominent, and consequently require to be brought inwards. 
 If the mal-position has resulted from the persistence of 
 temporary teeth, the permanent teeth will tend to fall into 
 the elliptical arrangement so soon as the obstruction is 
 removed, from causes which have been explained on a 
 preceding page (p. 130). 
 
 When there is every reason to suppose that the base of 
 the jaw is free from contraction, the teeth may then be 
 forced outwards till the desired conformation is attained ; 
 and in cases where the deformity has been equal both in the 
 upper and lower jaws, and the antagonism perfect, it will be 
 necessary, after the upper teeth have been re-arranged, to 
 repeat the operation in the lower teeth, and thereby restore 
 the antagonism which would otherwise be disturbed, and in 
 the efforts of re-adjustment, influence unfavourably the 
 results of the operation. 
 
 The form of apparatus suitable for expanding the V-shaped 
 dental arch need not be minutely described, as either the 
 ivory or the metal plate — a description of each of which
 
 TEETHING. 153 
 
 is given in connection with the treatment of inverted teeth — 
 will be found effective. 
 
 In the succeeding figure, furnished me by Mr. Harrison, 
 the deformity is so great, and the base so contracted, that 
 successful treatment would be attended with great difiSculty. 
 The bicuspids were removed with the hope that the front 
 teeth would fall back ; but, with the eruption of the wisdom 
 teeth, the first permanent molars moved forwards into the 
 vacant spaces, and the more anterior teeth preserved their 
 original position. It would appear in this, as in many other 
 cases, that nature, having recognised a special, though an 
 irregular form, off'ered resistance to any subsequent change 
 (Fig. 60). 
 
 Hitherto attention has been directed to those cases only 
 in which the front teeth, though uniform as regards their 
 individual arrangement, have been as a whole out of the 
 natural position. Instances in which some of the teeth are 
 mal-placed as respects the crowns, while the remainder hold 
 the normal position, have now to be considered. 
 
 Separation of the central incisors, leaving an unoccupied 
 space in the mesian line, is perhaps the most simple, and at 
 the same time the most manageable, form of irregularity 
 which comes under our notice. If the teeth are otherwise 
 correctly placed, a ring of india-rubber stretched over the 
 two teeth will in the course of a few days bring them to- 
 gether, after which the occasional use of the ring or of a silk 
 ligature will be sufiicient to retain the teeth until they 
 become fixed in the new position. 
 
 Although the true V-shaped jaw is a congenital mal- 
 formation, yet the deformity so produced may be in some 
 cases partially remedied, or at least improved by treatment ; 
 and this opportunity may be taken of discussing some points 
 which bear on the whole question of dental irregularities. 
 It must first be determined how far the whole jaw is mal- 
 formed, for it sometimes happens that while the V-shaped 
 conformation is presented by the upper jaw, the back teeth
 
 154 A SYSTEM OF DENTAL SURGERY. 
 
 of the lower bite outside those of the upper jaw. But little 
 can be done to remedy such extended malformation by- 
 treatment ; it is, however, interesting to note that this, like 
 the occurrence of the Y-shaped upper maxilla, is in a measure 
 the retention in the adult of a condition of things which in 
 the foetus is normal. For at the period of development 
 already alluded to (p. 148), the posterior divergence of the 
 lower jaw would, if there were teeth in it, lead to their 
 biting outside those of the upper maxilla at the back part 
 of the mouth. 
 
 Inversion or eversion of the central incisors is not uncom- 
 monly seen in cases where the ejection of the temporary 
 teeth has been delayed, and the successors have come down 
 either behind or in front of them, or when the eruption has 
 been postponed until the lower teeth have attained their full 
 height, and in the absence of any counteracting influence 
 from antagonistic teeth, have either taken a higher or a 
 more forward position than they should have done ; conse- 
 quently the upper teeth have been driven, when in a state of 
 active growth, either outwards or backwards, just as they 
 m-ay strike on the labial or lingual surfaces immediately 
 after emergence. 
 
 On the other hand, the lateral incisors may, as in the case 
 figured at page 64, lie in front of the central teeth during 
 development, and the four teeth, advancing in growth with 
 equal rapidity, oblige the latter, at the time of eruption, to 
 take a backward place. 
 
 But by far the most common cause of displacement is the 
 persistence of the temporary teeth. The following figure 
 may be taken as a fair example of irregularity arising from 
 this cause. The temporary teeth being retained, their 
 successors have consequently taken a posterior position, 
 which allows the lower teeth, when the mouth is closed, to 
 pass in front of them ; and thus, in the absence of mechani- 
 cal interference, render permanent the mal-position. 
 
 Whatever may be the cause of the irregularity, the diffi-
 
 TEETHING. 155 
 
 culty involved in its reduction will not be great. In case 
 they are directed inwards, the use of either a metal or a 
 vulcanite plate, provided with chambers for compressed 
 wood, will speedily force them into a sufficiently forward 
 position. Or they may be dragged outwards by caoutchouc 
 bands passed through a slit bar of metal, passing in front in 
 the manner already described. If the fault be undue pro- 
 minence, this may be overcome either by an elastic band of 
 
 Fig. 60. (I) 
 
 metal attached to the labial surface of caps fitted to the 
 molar teeth, or fixed to metal studs placed immediately 
 behind the incisors to be acted on ; or by silk ligatures 
 passed through a plate adapted to the hard palate, and over 
 portions of compressed wood, which have been fitted in 
 square chambers produced on the lingual surface for their 
 reception. When applied in this manner, the wood will 
 expand in the inward direction, and consequently carry the 
 ligatures backward, and with them the outstanding teeth. 
 Should the mesial edges of the lateral teeth be so placed that 
 the inward movement of the central incisors is obstructed, 
 
 (1) Shows the permanent central incisors coming through the gum poste- 
 riorly to the persisting temporary teeth, leaving an interval into which the 
 lower incis'-rs pass when the mouth is closed.
 
 156 A SYSTEM OF DENTAL SFBGERY. 
 
 our treatment must commence by forcing the former out- 
 wards from the median line, until they cease to embarrass 
 the oj^eration. This may in most cases be done by placing 
 pieces of india-rubber l^etween the lateral and central teeth. 
 It is scarcely necessary to repeat, that when the lower teeth 
 close in front or upon the edges of the upper, the plate must 
 be made sufficiently thick at those parts which pass over the 
 back teeth to prevent the antagonistic influence. 
 
 Torsion, or twisting of the central incisors upon their axis, 
 is far from rare. The defect in }X)sition may be common to, 
 and equal in each tooth, or it may be greater in the one than 
 in the other, or it may be confined to one tooth only. Either 
 the mesial sides may be directed towards the palate, or they 
 may be turned, towards the lips ; or the one tooth may be 
 twisted in the one, and the fellow tooth in the other direc- 
 tion (Fig. 29). 
 
 In a case recently under treatment, the right incisor made 
 its appearance at the age of thirteen, with the lingual sur- 
 face parallel with the median line of the mouth. In this case 
 the tooth is a quarter of a turn out of place, but instances 
 are recorded in which the twisting has extended to as 
 much as half a turn, so that the lingual surface presents to 
 lips. I have one example showing this amount of torsion 
 in a bicuspid tooth. In many cases of this kind the mal- 
 position has been assumed during the period of development, 
 and is then consequent upon arrested development of the 
 anterior part of the jaw. Sometimes, however, it results 
 from the retention of the temjxjrary incisors. And it is not 
 improbable that the root of a temix)rary tooth, if displaced 
 by a blow or by a rude oj^eration, may disturb and turn the 
 successor upon its axis while within its crypt. The retarded 
 development or eruption of a tooth may also be cited as a 
 cause of its torsion ; and it is not difficult to see how the 
 mal-iX)sition is then produced. The adjoining teeth being 
 already through the gums, lean toward the unoccupied space, 
 and ofier an imj)ediment to the progressing tooth, which,
 
 TEETHING. 157 
 
 from its comparatively loose implantation at the eruptive 
 epoch, turns on its axis, and descends or ascends, as the case 
 may be, in that positioji in which the least resistance to its 
 progress is offered. 
 
 In no case is it desirable to lose a central incisor ; hence, 
 if we have reason to suppose that the twisted tooth is in 
 itself perfect, it must be brought to the proper position ; and 
 should it appear impossible to obtain sufficient space with- 
 out sacrificing a tooth, we must remove one or other of the 
 more posterior teeth. 
 
 It is quite possible cases may, occur in which such a pro- 
 ceeding becomes necessary, although I have rarely met with 
 them in my own practice. But before deciding upon sacri- 
 ficing a sound tooth, we must be well assured that the 
 incisor is not subject to deformity, like that shown in 
 Fig. 43, where the descent being arrested by the presence of 
 a supernumerary tooth, the fang has been developed in an 
 irregularly curved form. Instances will sometimes present 
 themselves in which the exposed portion of the crown is 
 twisted and directed towards the palate, while the root of 
 the tooth is in the usual position, the crown and the fang 
 being joined at an angle, presenting that peculiarity of con- 
 formation which has been denominated dilaceration. (^) If 
 in such a case a healthy tooth were removed, we should be 
 committing a serious error. It therefore becomes necessary 
 that a very careful examination of the mouth should be 
 made before the treatment is determined on. The position 
 of the root of the erring tooth should be ascertained, and 
 this may generally be done by a careful examination of the 
 gum, beneath which the outline of the root, if in the usual 
 position, may be felt. 
 
 It is scarcely necessary to remark, that when the necessity 
 for the removal of a tooth arises, our choice will fall upon an 
 unsound one, should such be present, even though it be at 
 some distance from the point where the space is required. 
 (1) Lectures on Dental Physiology and Snrgery.
 
 158 A SYSTEM OP DENTAL 8UBGERY. 
 
 As respects the treatment to be adopted, I cannot do 
 better than describe the course pursued in the following case, 
 inasmuch as the illustratious necessary for the elucidation of 
 details will sei-ve the further purpose of showing the method 
 applicable to cases of irregularities affecting other teeth. The 
 patient was a female, aged fourteen years. The left central 
 incisor up to the age of thirteen did not make its appearance, 
 consequently the crown of the right lateral and left central 
 teeth leaned towards each other, leaving an interval insuffi- 
 cient for the missing tooth to take its natural position. At 
 thirteen, however, the tooth ap]3eared, with its median side 
 directed towards the lip, but it was not till a year had 
 elapsed that the case came under treatment. The succeed- 
 ing figure will show the general j^sition of the teeth, and it 
 may be remarked that the canines were slightly more pro- 
 minent than the anterior teeth. A careful examination led 
 to the conclusion that, supix)sing the laterals and the left 
 central incisor were pressed out, so as to range evenly with 
 the canines, sufficient space would thereby be gained to 
 allow the twisted tooth to hold the normal position. Acting 
 under this impression, a plate was made to fit the palate, 
 and attached to the bicuspids by wire continued over the 
 crowns of those teeth on either side of the mouth, and 
 terminated by a small T-like extremity, which, by way of 
 protecting the teeth, was covered with a thin investment of 
 floss silk. In this manner the plate was firmly retained in 
 its place. 
 
 The next proceeding consisted in soldering to the back 
 part of the plate two bands, composed of gold, rendered 
 elastic by the addition of three grains of platinum to one 
 pennyweight of the ordinary eighteen-carat gold. The free 
 ends of the bands were adjusted to press outwards and from 
 the irregular tooth, the two contiguous t-eeth, in the manner 
 shown in the accom];:)anying figure. 
 
 In the course of nine days, sufficient effect had been pro- 
 duced to render it desirable that the incisor itself should be
 
 TEETHING. 
 
 159 
 
 acted upon in order that the increased interval should be 
 occupied by the tooth for which it had been obtained. A 
 second plate was constructed. In this a bar of gold was 
 continued in front of the teeth, and attached to the anterior 
 T-piece on either side. Metal cells for the reception of com- 
 pressed wood were then soldered to the plate and to the 
 band. One was placed so that the wood would press upon 
 
 ^^V- 61.(1) 
 
 the distal angle of the tooth, the other ujx)n the labial 
 surface near the median angle. The forces thus brought 
 into play acting in opiX)site directions, turned the tooth 
 upon its axis, and were sufficient to influence the impinging 
 lateral and central teeth, and force them out of the way of 
 
 (1) Shows the right central incisor twisted on its axis to the fall extent of 
 a quarter of a revolution, with the adjoining incisors in close contact with 
 its labial and lingual surfaces. I'he metal plate used in the first stage of the 
 operation is shown in situ, with the two elastic bands of gold soldered to the 
 back part of the plate, and the free ends in a position for separating the right 
 lateral and left central incisor in order to gain space for turning the displaced 
 tooth. In the sketch below, the manner of adjusting the wire bands for the 
 retention of the plate is shown.
 
 160 A SYSTEM OF DENTAL SURGERY. 
 
 the slowly turning tooth. In a few days it became neces- 
 sary to alter the position of the receptacles for the wood, and 
 subsequently to move them from time to time towards the 
 retreating angles of the tooth. 
 
 After the second plate had been in use three weeks, the 
 tooth had so far changed its position that the mesial side 
 Stood slightly in front of the left incisor, and the distal side 
 
 Fig. 62. (1) 
 
 a little posterior to the lateral incisor, presenting a degree of 
 irregularity which would attract but little notice. 
 
 As the left incisor was still a little internal to the arch 
 which would be described if the canines were taken as the 
 guide for its formation, a cell was adjusted upon the plate 
 behind that tooth, and the wood brought into operation. 
 At the same time, the operation upon the lingual surface 
 near the distal angle was continued, and the degree of 
 pressure upon the labial surface was considerably reduced. 
 
 (1) Shows the condition of the case illustrated in the pre^^edlng figure after 
 the adjoining teeth have been separated by the elastic bands, and the displaced 
 tooth turned slightly from its original position. The plate used in this, the 
 second stage of the operation, is shown in situ, with the metallic boxes for the 
 reception of the compressed wood in the positions suitable for effecting the 
 further progress of the treatment. It will be apparent that the boxes will 
 require a change of position when the tooth has moved away from them.
 
 TEETHING. 161 
 
 In the course of a second term of three weeks, the tooth was 
 brought into position, ranging evenly with the contiguous 
 teeth. 
 
 The foregoing illustration will show the principles upon 
 which the operation was conducted, although the wood- 
 retaining cells are given in one position only. It must be 
 understood that they were moved from time to time, so as 
 to follow up the moving tooth, and so adjusted as to bring 
 the pressure to bear in such directions as at the time ap- 
 peared to be required. 
 
 This case will be regarded as one presenting a considerable 
 amount of difficulty. A successful operation involved not 
 only twisting a tooth upon its axis to the extent of a 
 quarter of a revolution, but also the shifting outwards of the 
 left central and both of the lateral incisors, in order to make 
 room for the crossing tooth to turn. The base of the 
 alveolar arch was, however, sufficiently developed to render 
 the readjustment of the teeth practicable without having 
 recourse to extraction. 
 
 The front teeth having been carried into the desired posi- 
 tion, it became necessary to take measures to keep them 
 there until they became firmly fixed in their sockets. To 
 effect this retention, an ivory plate was fitted to the palate 
 and to the lingual surfaces of the teeth, extending as far 
 back as the first permanent molars. The bicuspids being a 
 little internal to the proper outline of the arch, pegs of wood 
 were inserted into the ivory at the points corresponding to 
 the necks of these teeth. After adjustment, the pegs pro- 
 jected from the plate sufficiently to press firmly upon the 
 four instanding teeth, and thus perform the double purpose 
 of retaining the plate in its place, and of forcing the teeth, 
 upon which its retention depended, slightly outwards. This, 
 then, is the condition of the case at the time I am writing 
 (1859), and I feel no doubt that before the expiration of 
 twelve months the teeth will have settled down in their 
 present position. 
 
 M
 
 162 A SYSTEM OF DENTAL SUEGERY. 
 
 But the process of twisting a tooth on its own axis by- 
 means of gradual pressure is one that necessitates the use of 
 a plate for a very considerable length of time, and inflicts no 
 small discomfort on the patient ; and it has been found that 
 the same end may be attained by seizing the tooth in a pair 
 of forceps and forcibly twisting it round. 
 
 It might have been anticipated that such a procedure 
 would be followed by the death of the pulp and consequent 
 alveolar abscess, but this untoward result happens very 
 rarely, and may almost always be avoided by performing 
 the operation only on favourable cases. 
 
 Before deciding on forcibly twisting the tooth, the operator 
 should satisfy himself that there is sufficient space for the 
 crown in its new position, and also that the direction of the 
 root is such that it will allow of the crown ranging regularly 
 with the surrounding teeth. 
 
 The most favourable period for its performance appears to 
 be the age of eight or nine years, when the teeth are fully 
 erupted, but their sockets have not yet attained their full 
 strength. I have however successfully twisted the central 
 incisors in a patient aged fifteen, and in several instances in 
 patients aged thirteen ; but, as a rule, it should be done at a 
 much earlier age, for the sockets become very dense and un- 
 yielding, so much so that in several cases I have failed to 
 move the t^eth with any degree of force which it has seemed 
 safe to apply, and have been therefore compelled to abandon 
 the attempt. 
 
 The tooth may be seized by its labial and lingual, or by 
 its mesial and distal surfaces ; and it will often be con- 
 venient to change the hold of the forceps after the tooth is 
 partially twisted. Thus, if the tooth stands nearly at right 
 angles to its proper position (as, for example, the right 
 central incisor in Fig. 61), it would be easiest to apply one 
 blade of the forceps to the mesial and the other to the distal 
 surface, but it would not be possible to complete the torsion 
 with the blades in this position, as they would come in
 
 TEETHING 163 
 
 contact with the lateral and the other central incisor. Hence, 
 when the tooth is partially turned, the forceps must be 
 applied to the lingual and labial surfaces, by which means 
 the operation may be completed, and the tooth left in a 
 perfectly normal position. 
 
 The instrument used should be a pair of straight incisor 
 forceps, the blades of which should be prevented from chip- 
 ping the enamel, by the interposition of some soft substance. 
 Some operators use a slip of sand-paper for the purpose; 
 others use paper, but this is apt to slip. A piece of lead- 
 foil answers the purpose very well, and is free from the 
 objections which apply to the other two. The tooth should 
 be firmly grasped at the edge of the gum, and steadily 
 twisted in the desired direction until it is felt to yield ; no 
 attempt should be made to loosen it by twisting it alter- 
 nately in opposite directions, as has been done by some 
 operators, as this loosening is precisely what it is desirable 
 to avoid as far as is possible. As the tooth on being released 
 springs back somewhat, it is generally necessary to twist it 
 somewhat farther than into its normal position. Where the 
 tooth has to be twisted through a quarter of a circle in a 
 somewhat old subject, the resistance will sometimes be very 
 considerable, and I have in several instances obtained a 
 thoroughly satisfactory result by turning -it through only 
 half the required distance, and allowing it to get firm again ; 
 then, after the lapse of a fortnight or three weeks, com- 
 pleting the operation by twisting it through the remaining 
 distance. Although on the first occasion the resistance may 
 have been very great, the tooth generally yields very readily 
 to the second attempt, and I think such a course preferable 
 to the use of very great force in order to complete the 
 operation at the first attempt. 
 
 There is generally very little bleeding, and not much pain 
 resulting from the operation, though, of course, the tooth is 
 somewhat loose and tender at first. In order to ensure it 
 being left at perfect rest, and retained in its new position,
 
 164 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 it is advisable to soften a piece of gutta-percha and press it 
 over the incisors and canines of the upper jaw immediately 
 after the operation, directing the patient to bite the lower 
 teeth into it while it is still soft. 
 
 This will keep in its place, and should be worn for twenty- 
 four hours at least, or longer if the tooth remains very loose ; 
 of course it must be removed during meals, but it is safer to 
 confine the patient's diet to soft things for a day. The 
 extreme tenderness and looseness will pass off in a day or 
 two, when the use of the gutta-percha splint may be discon- 
 tinued. If there is swelling and tenderness over the socket, 
 this may be painted strongly with tincture of iodine, or a 
 leech applied; but the necessity for any such treatment 
 seldom arises. 
 
 I am acquainted with one case only in which necrosis 
 of the tooth ensued ; the patient was a child of suitable age, 
 but was a hospital patient, apparently not much tended by 
 its parents, and probably no care was taken after the 
 operation to preserve the tooth from movement. In this case, 
 I believe, the pulp cavity was di-illed into, through the 
 lingual surface of the crown, and the fang filled with cotton 
 wool steeped in carbolic acid. This treatment was per- 
 fectly successful, and the tooth after a short time became 
 firmly fixed in its socket. I do not know through what 
 distance the tooth was turned, nor whether it ofi"ered more 
 than usual resistance, but the untoward result was attri- 
 buted to the want of proper care exercised after the opera- 
 tion. 
 
 Irregularity in the position of the lateral incisors. — In the 
 upper jaw these teeth may be misplaced in any of the 
 directions enumerated and described in the preceding pages 
 in connection with malpositions of the central incisors, hence 
 the description which has served for the one may be applied 
 to the other series of del'ormities. Perhaps the most common 
 form of irregularity of the lateral incisors is that in which 
 they take a posterior position, the median edge of each lying
 
 TEETHING. 165 
 
 behind the contiguous side of the central incisor, and the 
 distal edge behind the median side of the canine. 
 
 Fig. 63. (1) 
 
 In the example figured the teeth have retained the position 
 assumed during their development, when, from the insuf- 
 ficient size of the anterior part of the arch, this or some 
 other form of displacement was a necessity. The canines 
 here hold the place which should have been occupied by the 
 lateral teeth, but had the latter taken their normal position, 
 the former would have been thrown out of the dental line. 
 
 We must not, however, in endeavouring to trace the cause 
 of mere misplacement in cases like the one figured, forget 
 that had a proper direction been given to the teeth as they 
 successively appeared through the gums, the alveoli would 
 have grown up with them, and if the base of the jaw had 
 attained a sufficient size, no irregularity would have occurred, 
 even had the teeth, when within the jaw, been somewhat 
 irregularly disposed. 
 
 In the case from which the succeeding illustration is 
 
 (1) Showing the lateral incisors placed internal to the dental arch, the 
 alveolar arch being contracted. This illustration is taken from a cast of the 
 mouth.
 
 166 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 taken, there is no indication of contraction of the jaw. On 
 the one side of the mouth, the teeth are perfectly regular ; 
 on the other, the lateral incisor and the canine are directed 
 inwards, and pass, when the mouth is shut, behind the 
 corresponding teeth of the lower jaw. The arch being at 
 this point bent inwards, and the alveolar space thereby 
 contracted, the teeth, in order to find a place for themselves, 
 have forced the central incisor forward, and driven its median 
 edge over the labial surface of the adjoining tooth. In this 
 
 Fig. 64. (1) 
 
 specimen we have an example of irregularity consequent on 
 the t€eth, from some cause (probably the retarded ejection of 
 the temporary teeth), taking an improi^er direction at the 
 time of eruption, the jaw being normal in size ; in the pre- 
 ceding case, an illustration of irregularity consequent upon 
 a contracted maxilla. 
 
 A slight degree of eversion and separation of the lateral 
 
 (1) Showing the lateral incisor and canitie inverted, and the central incisor 
 driven outwards and across the fellow tooth, the alveolar arch at its base being 
 free from contraction.
 
 TEETHING. 
 
 167 
 
 from the central tooth at the time when the canine is ad- 
 vancing towards the surface of the gum, is far from un- 
 common, and when the latter tooth is impeded in its progress 
 by the presence of its temporary i^redecessor, the disturbance 
 of the lateral incisor becomes still more marked. The 
 following figure shows the effect produced by the foregoing 
 combination of circumstances. 
 
 When the conical form of the canine, its crown being so 
 greatly wider than its somewhat flattened fang, and the 
 strongly prominent convexity of its median side are taken 
 into account, we shall not be at a loss to see how during its 
 descent the root of the lateral incisor is pressed upon, and the 
 crown consequently forced out of position. Instances are 
 not wanting in which the root of this tooth has been more 
 or less absorbed, to make way for the canine ; and I have an 
 example in which the fang has been bent during its develop- 
 ment, so as to form a hollow, within wliich the convexity of 
 the canine lay. 
 
 In connection with malposition of the canine, a figure will 
 
 (1) Showing the lateral incisor pressed out of the normal position by the 
 canine in its descent to the surface of the gum. The presence of the temporary 
 canine has in this specimen occasioned the pennanent tooth taking the oblique 
 direction.
 
 168 A SYSTEM OF DENTAL SUKGERT. 
 
 be given, taken from a case in which the lateral incisor has 
 been driven outwards towards the lip, by the canine coming 
 through the gum immediately behind the former tooth 
 (Fig. 67). 
 
 The principles which have been laid down for the treat- 
 ment of the various forms of irregularity in the central, apply 
 equally to the lateral tooth, when similarly situated, except- 
 ing that the one is, as respects appearance, a less valuable 
 tooth than the other, and may therefore, under certain 
 circumstances, be sacrificed with less hesitation. When, 
 for instance, the lateral teeth are situated as in Fig. 63, we 
 need not hesitate to remove them, supposing the antagonism 
 is normal, and a more forward position of the central teeth 
 would leave a wide interval between the lingual surface of 
 the upper and labial sm-face of the lower teeth on the mouth 
 being closed. But if the central incisors in such a case 
 passed behind the corresponding teeth of the lower jaw, it 
 would then be our duty to bring them forward, and after- 
 wards force the laterals into the space which the previous 
 operation had gained. In cases presenting the peculiarities 
 shown in the Fig. 64, the operation is very simple. We 
 have only to bring the inverted tooth, or teeth, outwards, 
 and the antagonising teeth will keep them there. 
 
 SupiX)sing the displacement to be caused by the canine 
 when about to take its place in the series, we must wait 
 until the evolution is completed, removing, of course, any 
 temporary tooth which may operate in disturbing its course. 
 If after the eruption of the canine the lateral does not regain 
 the proper position, the usual means must then be adopted 
 for its restoration. But it may happen that the teeth are 
 driven inwards or outwards, or are twisted by the canines, 
 which, in the absence of sufficient space for their proper 
 evolution, take a position either external or internal to the 
 dental line. 
 
 Irregularity in the position of the canine teeth. — Of all the 
 teeth, none are so frequently out of the normal position at
 
 TEETHING. 169 
 
 the time of eruption as the canines, and it may be stated, 
 without fear of contradiction, that no other members of the 
 set so frequently fall from an objectionable into the proper 
 position without mechanical assistance. We constantly see 
 cases in which, at the age of ten or twelve years, these teeth 
 hold a situation somewhat external to the arch formed by 
 the incisors ; but if they are watched it will be found that 
 before the eighteenth year has been attained all irregularity 
 has disappeared. It becomes a matter of some moment to 
 ascertain by what process the uniformity of arrangeinent is 
 attained. .The agencies which tend to bring about a normal 
 arrangement of the teeth have already been mentioned 
 (page 130), and these will operate not only by bringing in 
 the outstanding canine, but also, probably, by in some degree 
 pressing outwards the incisors. There are, however, many 
 cases in which the interval between the lateral incisors and 
 the anterior bicuspids is so small that the canines necessarily 
 appear external to the dental arch, and stand so much in 
 front of the lateral teeth that the outward movement of the 
 latter or the inward progress of the former by a natural 
 process is rendered impossible. On referring to the preced- 
 ing figures, it will be seen that if the outward development 
 of the alveolar ridge is suspended, this position of the canine 
 follows as a necessary result, the degree of displacement 
 according with the amount of suspension. Then, again, if the 
 normal obliquity is not assumed by the front teeth, a similar 
 condition as respects the canines results. The prolonged 
 retention of the temporary predecessor may also be cited as 
 tending to a like effect. 
 
 Although the anterior is by far the more common form of 
 displacement, we not unfrequently see the canine piercing 
 the gum posterior to the dental line, the terminal portion of 
 the root being in this, as in all the forms of irregularity 
 hitherto considered, in the normal position as respects the 
 base of the alveolar ridge. 
 
 In determining upon the method of treatment, we must be
 
 170 A SYSTEM OF DENTAL SURGEBY. 
 
 guided by the principles laid down in respect to the treat- 
 ment of similar forms of irregularity occurring in other teeth. 
 Whether the involved tooth is external or internal to the 
 dental line, either the arch must be expanded or a tooth 
 must be removed, before sufficient space can be gained for its 
 admission to uniformity. TVe have the alternative of press- 
 ing outwards the neighbouring teeth or sacrificing a tooth. 
 
 The canine is the most durable member of the whole series, 
 hence it must, if possible, be brought into place ; moreover, 
 the pointed form of the canine gives it a character not 
 shared by the other teeth, so that its absence is noticeable. 
 But circumstances arise under which its extraction becomes 
 exjDedient. If, for instance, the tooth pierces the gum con- 
 siderably above the alveolar margin, and is directed outwards, 
 and the interval between the lateral and first bicuspid but 
 slight, we shall then do well to remove it. Teeth so situated, 
 being very frequently short, and having im^^erfectly-formed 
 curved roots, are often incapable of taking their proper place 
 in the series. A case presented itself, only a few days since, 
 in which the right canine was so placed. On removal, the 
 root was foimd to be short and curved. Had an attempt 
 been made to bring it into line, the aj^ex of the root would 
 have been forced through the labial siu^face of the gum, and 
 the crown would have stood at a higher level than the 
 corresponding parts of the neighbouring teeth. To have 
 sacrificed the lateral or bicuspid for this defectively-developed 
 tooth, would have been an obvious error ; and to have forced 
 the anterior teeth outwards would have been equivalent to 
 producing a deformity in the whole in order to meet that 
 which had arisen in one of the front teeth. Hence, although 
 the rule that the canine should be preserved is a sotmd one, 
 it must not be blindly followed in every case, but the ul- 
 timate prosj)ect of getting it into place must be carefully 
 considered. 
 
 When we have reason to supix)se that an out or instanding 
 canine is not in any way defective, yet the space accorded to
 
 TEETHING. 171 
 
 it is insufficient, and the anterior teeth, as respects the teeth 
 of the opposite jaw, are well placed, it becomes a question 
 which of the neighbouring teeth should be removed. The 
 selection must be made in reference to the condition of the 
 adjoining teeth. Should either the first permanent molar, 
 or either of the bicuspids, or even the lateral incisor, l)e 
 carious, we shall have no difficulty in making our choice ; 
 and should more than one of these teeth be diseased, we 
 should then select for removal that one which is nearest to 
 the canine. But if all the teeth are sound, we may then 
 sacrifice that whitjli is the most liable to become diseased. It 
 has been shown that the first permanent molar exhibits the 
 greatest tendency to disease ; thus, under the age of fifteen, 
 the respective liability to loss from caries runs in the fol- 
 lowing order : — Lateral incisors, 83 per cent. ; first bicuspids, 
 7 per cent. ; second bicuspids, 85 per cent. ; first permanent 
 molars, 68j per cent. Q) 'J"he statistical facts advanced in 
 the lectures from which the foregoing details have been 
 extracted have met with confirmation at the hands of Mr. 
 Underwood, in a paper containing similar statistical results 
 published in the " American Journal of Dental Science." 
 
 Supposing, then, a sound tooth must be sacrificed, there 
 can be butf little doubt that we shall do wisely in selecting 
 the first permanent molar. 
 
 After the condemned tooth has been removed, the next 
 step in our proceeding may be considered. We must deter- 
 mine whether the bicuspids will fall back and allow the 
 canine to take a proper position without mechanical assist- 
 ance, or whether our assistance will be required. In deter- 
 mining this point, the age of the patient and the degree of 
 irregularity as regards the canine, will form our principal 
 guides. It is also necessary to notice how far the articulation 
 of the upper and lower teeth may prevent the bicuspids 
 falling back ; for instance, when the upper jaw is small the 
 lower bicuspid may bite behind the upper, in which case it 
 (1) Lectures on Dental Physiology and Surgery.
 
 172 A SYSTEM OP DENTAL SUEGEET. 
 
 would present a serious obstacle to its movement back- 
 wards. 
 
 Should it be determined to bring an outstanding canine 
 into the dental line, either by acting on the tooth itself, or 
 by operating on the neighbouring teeth, as well as upon the 
 canine, the method described as having been successful in 
 turning into place a twisted central incisor will be found 
 effective ; or a vulcanite plate may be used, if the operator 
 regards metallic regulation plates with distrust. 
 
 Irregularity in the position of the bicuspids. — It rarely 
 happens that the front teeth are crowded, without the 
 bicuspids to some extent participating in the general irregu- 
 larity. They are usually situated internally to the normal 
 position, and are instrimiental in throwing the canines 
 out of the proper line, or in giving the aj^pearance of 
 undue prominence to those teeth. The bicuspids may be 
 regarded as forming the base of the semicircular dental 
 curve, which, if contracted, necessarily involves either a 
 deviation from the normal figure, as seen in the Y-shaped 
 mouth, or it obliges some of the teeth to take either an 
 external or an internal position. 
 
 If the curve described by a perfectly well-arranged set of 
 teeth be examined, it will be found that it approaches a 
 semicircle as far as the bicuspids, and that the molars occupy 
 curvilinear lines, diverging slightly as they proceed back- 
 wards. The arch admits of division into two parts ; the 
 anterior semicircular portion being occupied by the successors 
 of the deciduous teeth, the posterior division by the true 
 molars — teeth which have no predecessors. Should, there- 
 fore, the breadth of the jaw at the junction of the two 
 divisions fall below the proper extent, and the bicuspids of 
 either side consequently approach too near the median line, 
 not only will the front teeth be thrown out of the semi- 
 circular curve, but the molar teeth' will occupy lines which, 
 although diverging from the Starting-points, will nevertheless 
 fail to attain an amount of separation as respects the two
 
 TEETHING. 173 
 
 sides of the moutb, consistent with a well-developed denture. 
 The case figured at page 148 illustrates the condition, and 
 indeed shows an indentation in the arch at the points of 
 junction of the molar and bicuspid teeth, the origin of 
 which has been already explained (page 148). 
 
 Although not a common cause, cases may be found in 
 which disease in the temporary molars, and subsequent 
 alveolar abscess, have occasioned the displacement of the 
 bicuspids. In the case figured at page 69, the first bicuspids 
 have been driven outwards by disease about the first tem- 
 porary molars. Like the teeth in the front of the mouth, the 
 bicuspids may be diverted from their proper position by the 
 persistence of temporary teeth. 
 
 When one only of the two bicuspids is involved, we shall 
 generally find the second bicuspid to be the misjDlaced tooth. 
 In that case, the mischief may have been produced either by 
 want of sufficient space for a regular arrangement, or from 
 the presence of the whole or a part of its predecessor. 
 
 When the former cause has led to the deformity, the 
 degree of displacement will vary in accordance with the 
 amount of contraction of the allotted space. Thus, when 
 the first bicuspid and first molar are closely approximated, 
 the second bicuspid or premolar commonly comes through 
 the gum internally to the arch. 
 
 It is far from uncommon to find the latter tooth, twisted 
 upon its axis by the presence of the lingual root of the 
 second temporary molar, wedged between the first perma- 
 nent molar and the former tooth. In a succeeding figure 
 (Fig. 69), the second bicuspid is completely turned round, 
 so that the lingual has become the labial surface, and in 
 this case the labial root of the temporary tooth has been 
 retained. 
 
 In determining upon the course of treatment, we must be 
 guided, in the first place, by the condition of the jaw. If 
 the base is contracted, it will be" necessary to remove a tooth ; 
 but should the teeth be turned inwards, and their outward
 
 174 A SYSTEM OF DENTAL SURGEBT. 
 
 movement possible without derangement of the anterior part 
 of the dental arch, we must then adopt a plate, and have 
 recourse to the compressed-wood wedges. Either metal or 
 vulcanite may be used in constructing the apparatus, and 
 the wedges, if properly proportioned, will serve for its 
 retention without the aid of ligatures or clasps. The move- 
 ment is very readily effected, being sometimes uninten- 
 tionally brought about by the very moderate pressure of 
 artificial teeth, but we must not neglect to take into account 
 the antagonism of the opposing teeth ; usually the lingual 
 cusps of the upper close between the outer and inner cusps 
 of the lower teeth, and unless the lower bicuspids are moved 
 outwards contemporaneously with the upper teeth, the 
 normal antagonism will be destroyed.. Moreover, there will 
 be a strong counteracting force exercised by the stationary 
 teeth upon those under operation. If the upper teeth, for 
 example, are moved outwards so that the lingual cusps close 
 on the apices of the labial tubercles of the lower teeth, the 
 other teeth will be kept apart until the lingual cusps of the 
 moved teeth slide down either upon the inner or outer sur- 
 face of the labial cusps of the lower teeth. In those cases in 
 which we find a faulty antagonism, our treatment becomes 
 more simple. If, for example, an upper tooth closes exter- 
 nally or internally to its antagonist, our operation will be 
 confined to the malplaced tooth, which, so soon as it ap- 
 proaches its proper position, will be carried onwards in the 
 proper direction by the influence exerted by the antagonising 
 tooth of the lower jaw, in the manner described in connection 
 with misplaced central and lateral incisors. 
 
 Irregularity in the position of the crowns of the permanent 
 molars, without the roots participating in the displacement, 
 is of less frequent occurence than derangement of the more 
 anterior teeth ; still, cases sometimes present themselves in 
 which the normal positions are not maintained. Perhaps 
 the most common form of deviation is that in which the 
 second permanent molar on either side is turned inwards
 
 TEETHING. 175 
 
 towards the median line of the mouth. In a cast given to 
 me by my friend Mr. Alfred Canton, the three molars are 
 arranged in a triangle, the second being placed internally to 
 the other two molars. In this case, the obvious remedy 
 would be the removal of the malplaced tooth. In cases 
 where the first molar leans in towards the palate, the posi- 
 tion might, I presume, be changed by the persistent use of 
 compressed wood applied in the manner already described ; 
 but we rarely find these teeth out of place without the 
 anterior teeth participating in the derangement, in which 
 case the treatment would become very tedious, were we to 
 attempt to reduce to order the whole of the teeth 
 situated anterior to the second permanent molar. In an 
 early number of the " American Journal of Dental Science," 
 an apparatus for expanding the whole arch is described and 
 figured. It consisted of a metal plate fitted to the palate, 
 and jointed in the median line. The plate was fitted to the 
 necks of the teeth, against which it was made to press bj'- a 
 spiral spring, the extremities of which were connected to 
 either side of the plate. I have no experience of the value 
 of this method of proceeding, neither have I attempted to 
 change the position of molar teeth by mechanical means. 
 In the vast majority of the cases which have come under my 
 notice, this treatment has been rendered inadmissible by the 
 coincident contraction of the base of the jaw ; and in those 
 in which pressure might have been used, not only must the 
 upper teeth have been operated upon, but the corresponding 
 teeth of the lower jaw also, in order to maintain the proper 
 antagonism. 
 
 As malposition of the wisdom teeth almost invariably in- 
 volves their removal, whatever may be the position of the 
 roots, the consideration of the whole subject in respect to 
 these teeth will be given in connection with complete irregu- 
 larity. 
 
 In treating of those cases of irregularity which admit of 
 mechanical correction, I have confined the description for the
 
 176 A SYSTEM OF DENTAL SURGEEY. 
 
 most part to the teeth of the up}>er jaw, under the impres- 
 sion that it would be unnecessary to give a detailed account 
 of the defects of arrangement in the corresponding organs 
 in the lower maxilla. It may, however, be stated generally, 
 that the forms of irregularity which occur in the upper may 
 also arise in the lower teeth, and that the treatment suitable 
 for the one will be equally fitted for the other. The con- 
 struction of the plate, whether metal or vulcanite be used, will 
 of course be modified. We have here to adapt the apparatus 
 to the teeth and the lingual surface of the gums only ; ex- 
 cepting in the foregoiDg particulars, the methods of operation 
 will be precisely similar to those already described. The 
 vertical position of the lower teeth renders the retention of 
 the compressed wedges of wood particularly easy, and this 
 advantage is still further increased when the teeth so operated 
 upon are inclined either outwards or inwards. The opera- 
 tions for the adjustment of irregularities of position are, 
 however, less frequently attempted on the lower than the 
 upper jaw, owing to the former being hidden to a great 
 extent by the lip, so that they fail to attract that amount of 
 attention which is given to upper teeth. 
 
 Irregularities of the permanent teeth in which both the crowns 
 and the roots are out of the normal position — total or com- 
 plete displacement of the permanent teeth. — Transposed teeth 
 come under this head, but as they do not admit of restorative 
 treatment, examples illustrative of this form of departure 
 from the normal arrangement may be given at the conclusion 
 of the present division of the subject. 
 
 The following illustration (Fig. 66) shows the amount to 
 which a central incisor may be thrown out of the proper 
 ]^X)sition. Here the cause is sufliciently obvious in the 
 presence of a supernumerary tooth. Cases in which the 
 centrals are completely displaced are, however, comparatively 
 rare. All attempts at treatment would in any such case as 
 that which is figured necessarily be useless, supposing the 
 development of the root to have been advanced. Had the
 
 TEETHING. 177 
 
 supernumerary tooth Leen removed as soon as it appeared, 
 the incisor would probably have taken its normal position, 
 although even then the displacement during development 
 might have been too great for the operation to have resulted 
 successfully. 
 
 Fig. 66. (1) ' 
 
 I do not remember to have seen any cases in which a 
 lateral incisor had been totally displaced, excepting when 
 teeth have been transposed ; there is, however, no reason to 
 suppose that they are more exempt than the central teeth 
 from this form of irregularity. 
 
 The foregoing observation cannot be applied to the canine 
 teeth. They are more frequently than any other description 
 of teeth the subjects of total displacement. Even in my own 
 collection there are many examples illustrative of the ab- 
 normal positions into which these teeth may be thrown. 
 
 Perhaps one of the most common forms of displacement is 
 that in which the canine is situated posterior to the dental 
 line, at a point corresponding to the space which divides the 
 central and lateral incisors. It may happen that the crown 
 only occupies this position, in which case the deformity 
 would admit of remedy; but where the root participates 
 equally with the crown, as in the example which forms the 
 
 (1) Shows the right central incisor with both the crown and root displaceti 
 its normal position being occupied by a sup.^mumerary tooth.
 
 178 
 
 A SYSTEM OF DENTAL 8UBGERY. 
 
 subject of Fig. 67, restoration to the normal arrangement, 
 though perhaps not impossible, would be attended with 
 difficulty. The question then arises as to which of the teeth 
 should be removed. The tem}X)rary canine, if left, may 
 endure for some years, but if it be extracted we may be 
 unable to force the permanent tooth into its place, and should 
 we succeed, the crown only would be moved, hence the tooth 
 would hold a slanting and probably imsightly position. My 
 
 own choice would fall upon the canine. It would, I think, 
 be more easy to press the lateral tooth inwards, the terminal 
 portion of the root of which is not displaced, than to draw 
 outwards into line the canine. In deciding on our treatment, 
 we must in no case lose sight of the fact, that although it 
 may be quite possible to force a tooth from an irregular intc» 
 a regular position, yet that the operation may, under some 
 
 (1) Shows the left canine placed behind the dental line, its crown holding a 
 vertical position, and the root, unless ^eatly curved, equally with the crown, 
 displaced. The lateral incisor has been evertod by the canine, while the 
 temporary canine holds the position which should have been occupied by the 
 displaced tooth. The right temporary canine is retained, and the permanent 
 tooth placed horizpntally, a portion of the crown only being seen.
 
 TEETHING. 
 
 179 
 
 circumstances, be so prolonged and painful, that the proposed 
 advantage will not compensate for the suffering which its 
 accomplishment would entail. 
 
 Fig. 63. (1) 
 
 ^^ 
 
 In the preceding figure a case is shown in which the right 
 canine is placed across the dental arch, the root being 
 directed towards the median line of the palate, and the 
 crown towards the cheek. The point of the crown was the 
 only part which was not completely buried in bone. The 
 latter tissue has been cut away for the purpose of showing 
 the course taken by the tooth. 
 
 A horizontal position in the base of the alveolar ridge is 
 sometimes taken by the canine, the apex of the crown being 
 exposed to view, or covered only by gum or imbedded in 
 bone. 
 
 Teeth so placed may remain without producing incon- 
 venience through a long life, and be discovered only towards 
 
 (1) Shows the right canine placed transversely in the base of the alveolar 
 tract, the crown being directed towards the cheek, and the root towards the 
 median line of the mouth. The bone has been removed to show the course 
 taken by the root of the displaced tooth.
 
 180 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 its close. When with advancing age the teeth fall out, ami 
 the alveolar j)rocesses disappear, the long-hidden teeth are 
 brought to light, and the patient fancies he is cutting a third 
 
 Fig. 69. (1) 
 
 set of teeth. The two following illustrations are taken from 
 a remarkable specimen given to me by Dr. Brinton, in which 
 the canines were symmetrically arranged in the horizontal 
 position described in a preceding case. 
 
 A patient admitted into the Middlesex Hospital under the 
 care of Mr. De Morgan, lost a ]X)rtion of the upper maxilla 
 from syphilis. The dead bone on its coming away was found 
 to contain a canine tooth, which ran under the floor of the 
 nose in a direction parallel with the median line of the palate 
 (Fig. 72). Excepting the absence of the canine, the dental 
 
 (1) Shows the right canine of the npper jaw buried in the base of the 
 alveolar prominence, its course corresponding with that of the latter part. 
 The bone has been cut away to show the direction taken by the tooth. The 
 first bicuspid has become slightly twists on its axis by the malplaced canine. 
 On the left side of the maxilla the second bicuspid has been twisted round until 
 its lingual surface is directed towards the cheek. The presence of the root 
 of the second temporary molar has probably been instrumental in producing 
 this change from the normal position. This case is referred to in a previous 
 page.
 
 TEETHING. 
 
 181 
 
 series was normal. Several examples of the canine being 
 found in the antrum have been recorded, in one instance its 
 attachment appearing to be to the floor of the orbit. 
 
 Fig. 70. (1) 
 
 Fig. 71. (2) 
 
 (1) Front view of a specimen in which the canines are placed horizontally 
 in a line corresponding with the base of the alveolar processes. They have 
 been exposed to view by the loss of the teeth and subsequent absorption of 
 the entire part. 
 
 (2) Palatal view of the same specimen shown in the preceding figure.
 
 182 
 
 A SYSTEM OP DENTAL SUKGEBT. 
 
 Although total displacement of the canine teeth is less 
 common in the lower than in the upper series, examples of 
 this form of irregularity in the lower jaw are sometimes met 
 
 Fig. 72. (1) 
 
 Fig. 73. (2) 
 
 (1) Shows a sequestrum from the upper jaw which became detached during 
 an attack of syphilis. It contains a canine tooth situated horizontally in the 
 floor of the nose, its direction being parallel with the median line of the palate. 
 
 (2) From a specimen in which the temporary canines were persistent, and 
 the permanent canines placed horizontally. On the left side, a sufficient 
 amount of bone has been removed to show the position of the buried tooth. 
 On the right side the point of the canine may be seen between the lateral and 
 the central incisor. The right temporary lateral incisor has been retained, 
 wedged between the permanent central and lateral teeth.
 
 TEETHING. 
 
 183 
 
 with. Of the two specimens selected for illustration, the one 
 in which the tooth is placed horizontally is the more pecnliar. 
 
 Fig. 74. (1) 
 
 In the second, the temporary canines were retained, and the 
 permanent canines became matured within the substance of 
 
 (1) Shows an inferior maxilla in which the left canine is placed horizontally 
 in the alveolar border anterior to the dental series. The tooth was exposed 
 to the extent shown in the figure. 
 
 (2) Shows a lower maxilla in which the temporary (the sockets of which 
 are shown by the dotted lines) were retained, and the permanent canines 
 developed within the substance of the jaw. The bone has been removed on 
 the one side to show the direction taken by the tooth, which has been twisred 
 on its axis to the extent of a quarter of a turn.
 
 184 A SYSTEM OF DENTAL SURGERT. 
 
 the jaw. The retention of the temporary may be adduced 
 as the prevailing cause of total displacement of the permanent 
 canine. In several of the preceding illustrations, these 
 members of the temporary set are present. In other cases, 
 however, the arch is fully occupied by the permanent teeth, 
 to the exclusion of the canines, and as these are commonly 
 the last to take their respective places in the series, they are, 
 when so excluded, liable to be turned completely out of their 
 normal position. 
 
 The presence of disease, or the occurrence of mechanical 
 injury in that part of the jaw in which the canines are situ- 
 ated when undergoing development, may drive them from 
 their proper position. I cannot, however, call to mind a 
 case which would serve for illustration on this point. 
 
 The results entailed by total malposition of the canines 
 are usually unimportant. Tumours arising in the osseous 
 structure of the jaw have however, in a few cases, been 
 found to contain a hidden tcoth in their centre, and the teeth 
 so placed have been regarded as the cause of the disease ; 
 and in more than one instance, a missing tooth has been 
 removed from the interior of a tumour, and the operation 
 lx?en followed by subsidence of the disease. That teeth 
 embedded in the substance of the jaw may become a source 
 of irritation, and predispose to disease in the part in which 
 the}'' are situated, can scarcely be doubted. In the case shown 
 in Fig. 72, it is probable that the presence of the canine not 
 only determined the site of the necrosis, but also the occur- 
 rence of the disease, seeing that the loss of the bone was, as 
 regards the alveolar portion of the jaw, limited to the parts 
 immediately around the tooth. In the year 1859 a speci- 
 men was exhibited to the members of the Odontological 
 Society, in which a canine tooth lay horizontally on the 
 floor of a large cavity formed in the substance of the lower 
 jaw near its lower border. The history of the case, with the 
 characters presented by the enlargement of the bone, induced 
 the surgeon to excise that portion of the maxilla in which
 
 TEETHING. 
 
 185 
 
 the disease was situated, and it was the excised portion 
 which was shown at the Society. This case will be found 
 more fully described in the chapter treating on diseases of 
 the jaws induced by misplaced teeth. 
 
 Complete irregularity in the position of the bicuspids to 
 the extent shown in some of the preceding figures of mis- 
 placed teeth, is of very rare occurrence. In the most strongly 
 pronounced case which has come under my own observation, 
 the root of the second bicuspid of the upper jaw passed 
 backwards between the lingual and labial roots of the first 
 molar. In the case illustrated, the direction of the tooth 
 
 Fig. 76. (1) 
 
 is much the same as in the foregoing case, although situated 
 in the lower jaw. The first molar had been lost, hence the 
 relations between the roots of that and the displaced bicuspid 
 can only be surmised. 
 
 Examples in which a bicuspid stands obliquely across the 
 dental line are not uncommon, but in these the displacement 
 is rarely complete; the extremity of the root is usually in the 
 
 (1) Shows a lower maxilla in which the right second bicuspid is placed 
 obliquely, the root being directed backwards. The crown, though exposed, 
 does not rise above the level of the alveolar margin.
 
 186 A SYSTEM OF DENTAL SURGERY. 
 
 normal ix)sition, and the crown, if there were sufiScient space 
 in the dental line, could be brought into the normal position. 
 Xow and then, however, a bicuspid may be found with the 
 crown directed towards the tongue, and situated below the 
 alveolar margin. Such a case is figured by Goddard. Q) 
 
 The first j)ermanent molar apj^earing, as it does, posteriorly 
 to the temporary teeth, at a time when the jaw is in a state 
 of active growth, seldom, if ever, becomes the subject of com- 
 plete displacement ; and I know only of one case in which a 
 fully-developed second permanent molar has been found below 
 the alveolar margin. It is figured by Goddard from a pre- 
 paration in the cabinet of the University of Pennsylvania. 
 
 The third molars, or wisdom teeth, being the last to take 
 their place in the series, are, from the obstacles opposed to 
 their eruption, a frequent cause of suffering, more especially 
 those of the lower jaw. The second molar immediately in 
 front, and the terminal point of the alveolar line behind, 
 bound the space accorded to the wisdom tooth ; each tooth 
 which has no deciduous predecessor is developed beneath the 
 base of the coronoid process in the first instance, and as the 
 coronoid process recedes by absorption on its anterior and 
 deposition on its posterior surfaces, the tooth is enabled to 
 come into its proper position ; but if the backward develop- 
 ment of the maxillae has been arrested, the inter\-al will be 
 insuflicient for the normal arrangement of the presenting 
 tooth. It would appear to be the exception rather than the 
 rule for the wisdom teeth, especially of the lower jaw, to take 
 their place among the organs of mastication, without pro- 
 ducing some amount of sufiering at the time of their eruption, 
 and the degree of inconvenience experienced is often suffi- 
 ciently great to induce the sufterer to apply for professional 
 assistance. In many of the cases which arise in the lower 
 maxilla the teeth can scarcely be said to be displaced. The 
 deviation from the normal conditions is confined to the jaw 
 
 (1) The Anatomy and Physiology of tlie Human Teeth. By Paul B. Goddard. 
 Philadelphia, 1344.
 
 TEETHING. 187 
 
 itself. The tooth takes its natural direction, but the space 
 into which it has to force itself is insufficient, consequently 
 the distal side lies close against the anterior surface of the 
 coronoid process, leaving no room for the gum. The latter 
 part, under these circumstances, is pressed upwards, and lies 
 more or less over the masticating surface of the tooth, and 
 is consequently subject to be bruised from time to time by 
 the tooth or teeth of the upper jaw. In this manner inflam- 
 mation in the gum is set up and maintained. The disease 
 seldom limits itself to the part injured. It more commonly 
 extends to the adjoining parts, involving the soft textures 
 about the ascending ramus, and extending from thence to 
 the fauces. The act of deglutition becomes painful, and the 
 motions of the jaw are restricted. The patient tells you 
 that it is quite impossible for him to open the mouth suffi- 
 ciently wide for you to make an examination of the tooth 
 which has occasioned his misery. After a time, the over- 
 lying gum suppurates, and the movement of the jaw becomes 
 less constrained. 
 
 The patient, however, is extremely cautious in using the 
 teeth, until the inflammatory action has subsided, leaving 
 in some cases the gum in a position to be again wounded 
 by the upper teeth ; in other cases leaving the whole of the 
 masticating surface of the tooth perfectly uncovered. If the 
 patient be seen before any great difficulty in opening the 
 mouth has arisen, the tooth may be removed ; indeed, in all 
 cases where the tooth is wedged tightly between the parts 
 already described, this treatment will be the most judicious 
 we can adopt ; for should the gum, after the inflammatory 
 symptoms subside, retreat behind the tooth, still the back- 
 .ward position renders the latter useless as an organ of mas- 
 tication. And should the gum retain its unnatural position, 
 the patient will be liable to repeated attacks of inflammation 
 until either the gum-covered tooth or its antagonist has been 
 removed. 
 
 There may not, however, be sufficient space between the
 
 188 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 second molar and the ramus for the wisdom tooth to protrude 
 itself; it then either becomes developed below the alveolar 
 margin, or it comes up partl}^ within the base of the ramus — 
 one half of the crown of the tooth being covered by bone, the 
 other by gum. In either of these cases the patient may or may 
 not be subjected to suffering, consequent upon the abnormal 
 lx)sition of the tooth ; and the absence or presence of mis- 
 
 /'I'sr. 77.(1) 
 
 .-<a^/'^. 
 
 chief will be determined partly by the height to which the 
 tooth rises in the jaw, as respects the antagonistic tooth, 
 and partly by the constitutional state of the patient. The 
 same condition of parts which in one person would lead to 
 little or no inconvenience, would in a less healthy subject 
 produce great irritation, and even necrosis ; the extent of the 
 disease varying, again, with the susceptibility of the indi- 
 vidual. In any case the involved tooth should be extracted 
 so soon as it is found to be a source of irritation. 
 
 (1) From a specimen in which the third molar has been developed below 
 the alveolar margin, with the distal tide under the base of the ascending 
 ramus of the lower jaw.
 
 TEETHING. 
 
 189 
 
 In the two preceding forms of deviation from the normal 
 position, the teeth presented themselves in the alveolar line. 
 But cases now and then occur in which, while the vertical 
 position is maintained, the tooth is removed from the alveolar 
 portion of the jaw. In the upper maxilla, it may be situated 
 in the posterior portion of the tuberosity, above the level of 
 the alveoli, and in the lower jaw within the ramus. I am 
 indebted to Mr. Saunders for the use of the specimen which 
 forms the subject of the following illustration. In this ex- 
 ample the wisdom tooth on either side is situated high up in 
 
 Pig. -iS. (1) 
 
 the ramus, the crown reaching nearly to the level of the sig- 
 moid notch. Although situated in such an unusual position, 
 judging from the state of the bone, it does not appear that 
 they were a source of irritation. There is a total absence 
 of that porous condition indicative of increased vascularity in 
 the parts immediately surrounding the teeth. It is probable 
 that during life the presence of the third molar could not have 
 been detected, and in the absence of disease about the jaw 
 their detection was a matter of no great importance. Still, 
 
 (1) Showing the wisdom teeth imbedded in the rami of the lower jaw Pie- 
 sented by .Mr. Saunders to the museum of the Odontological Societj-.
 
 190 A SYSTEM OF DENTAL SUEGERT. 
 
 it is desirable that it should be borne in mind, when disease 
 about the posterior part of the jaws is coincident with the 
 absence of the wisdom teeth from the usual situation, that 
 the lost teeth may lie buried in the substance of the bone, 
 and be the exciting cause of mischief. 
 
 In the majority of cases, however, the third molars, wh^n 
 misplaced, lose the vertical position. They commonly take 
 an oblique direction, either forwards, outwards, inwards, or 
 backwards. In the lower jaw, the forward direction is by 
 far the most common form of irregularity, the degree varying 
 from a slightly oblique to a perfectly horizontal direction. 
 The succeeding series of figures show various degrees of this 
 form of misplacement. 
 
 Fig. 79. (1) 
 
 In endeavouring to trace the causes which have produced 
 this class of irregularities, we must recognise two distinct 
 conditions. In the one, the tooth, in pressing forwards, has 
 taken the direction in which the least resistance was offered 
 to its progress; in the other the malposition has been 
 assumed at a comparatively early period of development, 
 
 (I) View of the inner stirface of left side of the lower jaw. the bone being 
 removed to show the oblique direction of the third molar.
 
 TEETHING. 
 
 191 
 
 irrespective of resistance at the time of eruption. In 
 Figs. 79 and 80, the teeth appear to have advanced until 
 
 Fig. so. (1) 
 
 Pig. 81. (2) 
 
 (1) View of the right side of the lower jaw, the inner al%-eolar plate having 
 been partiaUy removed to show the oblique direction of the third molar. 
 
 (2) Showing the outer surface of the lower jaw, with the third molar placed 
 horizontally, the side of the crown of which rises slightly above the level of 
 the alveolar margin.
 
 192 A SYSTEM OF DENTAL SURGERT. 
 
 the median edge or angle of the crowns impinged upon the 
 necks of the anterior molars. The forward movements of the 
 teeth then became completely arrested. In Figs. 81 and 
 82, the teeth must have been from the first formed pretty- 
 much in the position which they are shown to occupy. 
 
 Fig. 82. (I) 
 
 In the upper wisdom teeth the oblique direction forwards is 
 less frequently assumed. The following figure will, however, 
 illustrate the form of irregularity in the upper maxilla 
 (Fig. 83). 
 
 In the lower jaw it is not common to find the third molar 
 directed obliquely outward, although cases have occurred in 
 which it has assumed that position. In one or two instances 
 I have seen the crown of the tooth buried in the substance 
 of the cheek, and so much obscured by tVie swelling and 
 inflammation of the soft parts around, that its presence was 
 detected with some difficulty. 
 
 In the upper jaw, however, the outward direction is more 
 frequently taken. In the accompanying figure (Fig. 84), 
 taken from a specimen in my own collection, this form of 
 
 (1) Shows a lower jaw in which the wisdom tooth has taken a horizontal 
 position below the level of the alveolar margin.
 
 TEETHING. 
 
 19J 
 
 malposition is shown. A few years since, many practitioners 
 had an opportunity of seeing a case in which the wisdom tooth 
 
 Fig. 83. (1) 
 
 .^^. 
 
 Fig. a4. (2) 
 
 u.VA^ '^ 
 
 (1) Showing an upper Jaw, with the third molar directed forward, and 
 impinging upon the second molar. The small tooth situated high up in tbt- 
 anterior part of the jaw, was forced there by the spade of the grave-digger. 
 The artist s accuracy in delineating all parts of the specimen has rendere«J this 
 explanation necessary. 
 
 (2) Shows the wisdom tooth of the loft side of the upper jaw directed 
 outwards. 
 
 O
 
 194 
 
 A SYSTEM OF DEXTAL SURGERY, 
 
 pierced the cheek. The crown of the tooth was, however, 
 hidden "by the whiskers, and apjjeared to produce no incon- 
 venience. Casts of the cheek, with the projecting tooth, were 
 taken, and I believe one of them may be seen in the musemn 
 of the College of Sm-geons. 
 
 A case occurred in the practice of the late Mr. Craigie, in 
 which a lower wisdom tooth had made its way to the sur- 
 face and pierced the skin close to the angle of the lower jaw. 
 The crown of the tooth, as is seen in the accompanying 
 figure, was fii'mly embraced by the puckered skin, which 
 presented the appearance of cicatricial tissue. 
 
 Fig. So. (1) 
 
 In this case the tooth was removed, and the opening in 
 the skin closed spontaneously, without necessitating any 
 further surgical interference. 
 
 Cases in which the third molar is directed with more or 
 less obliquity inwards are met with in the lower jaw, but 
 in the upper maxilla they are very imcommon. Examples 
 of teeth which lean inwards in a slight degree may be seen 
 from time to time, but such hardly call for description in 
 this place. 
 
 I do not remember to have seen a case in which a lower 
 
 (1) The figure is taken from a wax model belonging to Mr. Cartwright. 
 which is deposited in the museum of the Odontological Society.
 
 TEETHING. 195 
 
 wisdom tooth assumed the horizontal position, with the 
 crown directed backwards towards the posterior border of the 
 ascending ramus of the inferior maxilla ; but of this form 
 of irregularity in the upper jaw I have several examples. In 
 one specimen the crown of the tooth rests against the ptery- 
 goid plate of the sphenoid bone; in another, it takes the 
 
 Fig. 86. (1) 
 
 horizontal position, with the crown directed backwards and 
 a little outwards, and in the museum of the Odontological 
 Society is a model showing a wisdom tooth erupted in the 
 middle line of the palate. 
 
 There is no reason for supposing that the irregular tooth 
 in these instances produced any inconvenience. 
 
 Two cases have come under my notice, in which the direc- 
 tion of the third molars has been completely reversed. The 
 teeth have been upside down. The first example of this 
 
 (1) Showing the wisdom tooth of the left side of the upper jaw, with the 
 crown lying against the pterj'goid plate of the sphenoid bone.
 
 196 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 rare form, of displacement came into my possession with the 
 following history. The patient suffered pain from a carious 
 
 Fig. 87. (1) 
 
 second molar of the upper jaw. The aching tooth was re- 
 moved, and with it came the third mokr, the fangs of which 
 
 Fig. 88. (2) 
 
 (1) Shows the wisdom tooth of the right side of the upper jaw placed hori- 
 zontally, and the crown directed backwards and a little outwards. The bone 
 has been removed to show the position of the tooth. 
 
 (2) A second molar of the upper jaw, with the wisdom tooth inverted and 
 embraced within the roots.
 
 TEETHING. 
 
 197 
 
 were interlocked with those of the diseased tooth. The 
 crown and roots of the second held the usual position, but 
 the corresponding parts of the third molar were completely 
 inverted, the well-developed roots of the one embracing those 
 of the other tooth (Fig. 88). 
 
 Irregularity from transposition of permanent teeth. — In a 
 practical point of view, no great interest is attached to this 
 form of irregularity, as it does not admit of remedy. The 
 succeeding illustration is taken from a case in which the 
 canine is placed between the central and lateral incisor. Some- 
 
 Fig. 89. (1) 
 
 times the canine will be found between the bicuspid teeth. 
 The manner in which transposition may arise will be seen 
 if some of the earlier figures are examined. The position 
 of the canine of the upper jaw is, during the period of 
 development, so much above the adjoining teeth, that any 
 irregularity in the growth of the neighbouring parts of the 
 alveolar ridge, or of its contents, may throw it either in 
 front of the lateral or behind the first bicuspid tooth. Even 
 the position of the developing cusp of the canine itself may 
 lead to a similar result. If, for instance, the point be 
 
 (1) Taken from the cast of a mouth in which the canine (a) occupies the 
 place of the lateral incisor (6). The temporary canine (c) is retained, and 
 placed between the lateral incisor and first bicuspid. In all other respects 
 the series is normal.
 
 198 A SYSTEM OF DENTAL SURGERY. 
 
 directed either forwards or backwards, the tooth in its 
 descent may lose the proper position, and come either between 
 the incisors or the first and second bicuspids. 
 
 Irregularity in the number of the ptrmanent tteth presents 
 itself as the next subject for consideration. Thirty-two 
 being the number in a normal series of permanent teeth, any 
 deviation, whether it be in an excess or in a diminution of 
 that number, will constitute an irregularity. In other words, 
 there may be irregularity from too many or too few^ teeth. 
 Each of these forms of departure from the normal series is 
 far from rare; but of the two forms it is perhaps more 
 common to find that in which the teeth are in excess, one or 
 two supernumerary teeth, as they are termed, being present. 
 The connection which seems to exist between the hair and 
 teeth, in respect of abnormal development has already been 
 noticed (page 116), as was also the fact that such abnor- 
 malities are often inherited. At all events we will first 
 consider that condition in which the teeth exceed the proper 
 number. 
 
 Supernumerary teeth may spring up during the second 
 dentition in any part of the alveolar arch, and the forms 
 of such teeth may either resemble those of special members 
 of the normal series, or they may deviate from each of the 
 recognised forms, and assume a somewhat irregular conical 
 shape, sufiiciently characteristic in itself to be at once recog- 
 nised as that of a supernumerary tooth. (^) 
 
 Several cases, occurring either in the first or the second 
 dentition, have come under my own observation in which 
 five equally well-formed incisors occupied the lower jaw. 
 In neither case was it possible to determine from an examina- 
 tion of the crowns of the teeth which was the supple- 
 mental tooth. A third lateral incisor in the upper jaw, 
 
 (1) Seeing that supernumerary teeth assume two distinct forms, the one 
 being regular, the other irregular, it might, perhaps, be advantageous 
 when speaking of those which in no respect differ from members of the 
 normal series, to use the term supplemental, reserving supernumerary for 
 the irregular-shaped teeth.
 
 TEETHING. 199 
 
 undistinguishable from the normal tooth, I have seen in 
 one case only. Instances of a third canine or of a fifth 
 bicuspid, and also of supplemental molar teeth (the form 
 of the additional tooth being perfectly normal), have been 
 seen, though I believe they are extremely rare. But 
 examples in which an ill-shaped tooth without determined 
 form is found placed between the front teetb, or behind 
 them, or even holding the place to the exclusion of the 
 normal member of the set, are met with by all who are 
 engaged in practice. The number is commonly limited to 
 one, or at most two, supernumerary teeth symmetricall}^ 
 arranged ; but I have seen a case in which there were four 
 supernumerary teeth, forming a group with the upper in- 
 cisors and canines. The front part of the mouth looked to 
 be studded over with teeth, without any attempt at a definite 
 arrangement. Indeed, there was some little difficulty in 
 recognising the normal members of the series : for while the 
 supernumerary teeth to some extent resembled normal front 
 teeth, the latter were ill-formed, ajad approached the former 
 in character. As cases like the foregoing occur from time to 
 time, in which the recognition of the supernumerary tooth 
 or teeth is attended with difficulty, it becomes necessary that 
 we should, if possible, establish the special characters which 
 are peculiar to supernumerary teeth, as distinguished from 
 faulty-shaped normal members of the series. In the absence 
 of such knowledge, we may allow a supernumerary tooth to 
 remain and exclude the normal tooth from its place, as 
 shown in Fig. 65 ; or we may be induced to remove a badly- 
 shaped tooth under the impression that it is not a member 
 of the series. 
 
 Yet, where the discrimination depends upon very nice 
 shades of difference, the necessary knowledge, even if it is jios- 
 sessed by the author, can scarcely be conveyed in a written 
 description. Mr. J. Parkinson has placed his collection of 
 supernumerary teeth at my disposal. These, with a consider- 
 able number collected by myself, form a series sufficiently
 
 200 A SYSTEM OF DENTAL SURGERY. 
 
 large to justify the observer in regarding any peculiarity of 
 torm which prevails throughout the collection as a special 
 characteristic of supernumerary teeth. After removing from 
 the series those which are not distinguishable from normal 
 forms, we have remaining, teeth the crowns of which exhibit 
 the following characters : — The lingual and labial surfaces 
 are not distinguished by any difference of form. The enamel 
 terminates on the neck of the tooth in an even line, differing 
 in this res}>ect from the terminal line in ordinary teeth. The 
 crown of the tooth will, in the majority of cases, present a 
 simple cone with a sharp apex ; in other instances, the point 
 will be replaced by an irregularly depressed surface, cor- 
 
 Fig. 90. (J) 
 
 responding in character to the masticating surface of a bi- 
 cuspid or molar. More rarely the conical or cylindrical form 
 is lost, and in its place we have a more or less flattened 
 crown, the grinding surface being marked longitudinally vdih. 
 a deep fissure. Several examples have come under my 
 observation, in which the crown has been divided into three 
 or four plates, meeting at a common centre in such a manner 
 as to produce a cross. It would, however, be hopeless to 
 attempt to describe more than the general characters of super- 
 nimierary teeth, inasmuch as the minor differences of form 
 are infinitely varied ; no two are precisely similar. 
 The roots of supernumerary teeth are, I think, almost 
 
 (1) Shows the front view of a specimen in which a supemnmerary tooth 
 external to the front teeth occupies the space between the lateral incisor and 
 canine teeth.
 
 TEETHING. 201 
 
 invariably single. The crown not uncommonly presents a 
 certain amount of complexity, and approaches to the form of 
 a molar tooth, but I do not remember to have seen a single 
 specimen of a strictly so-called supernumerary tooth, in 
 which the root was divided. 
 
 The history of supernumerary teeth has not attracted that 
 degree of attention at the hands of practitioners which the 
 subject deserves. There are several points the investigation 
 of which would be attended with advantage. . Thus we find 
 that supernumerary teeth, for the most part, are matiured and 
 make their appearance before the permanent teeth situated 
 in the same part of the mouth. 
 
 Fig.n. (1) 
 
 In the case figured at page 177, the position of the central 
 incisor is preoccupied. In the succeeding illustration, a 
 supernumerary tooth holds the place of the lateral incisor, 
 which, with the central, is held back from taking the normal 
 position. In the specimen from Mr. Saunders' collection, 
 
 (1) A palatal view of the specimens shown in Figs. 44 and 45. The super- 
 numerary tooth is situated between the canine and the central incisor of the 
 
 right side.
 
 202 A SYSTEM OF DENTAL SURGERY. 
 
 two supernumerary teeth (Fig. 93) occup}^ the place of the 
 central incisors. One of the excluded teeth has come through 
 above the alveolar line. 
 
 Again, in Fig. 92 there are two supernumerary teeth, and 
 one of these has to a certain extent interfered with the posi- 
 
 Fig- 92. (1) 
 
 tion of the central incisor. Now, in each of these instances 
 the abnormal have preceded the normal teeth, and occasioned 
 the malposition of the latter. But it may happen that a 
 supernumerary tooth appears in the place and at the time of 
 a normal tooth, the latter having been retarded in its 
 development by the presence of the former. In one case a 
 central incisor of the upper jaw was cut at the usual time, 
 and by the side of it a supernumerary. The latter was at 
 once removed, under the strong belief that the absent central 
 tooth would after a time make its appearance. The expecta- 
 tion was realised, but three years elapsed first. The neigh- 
 bourhood of the incisors must be regarded as the most 
 common position for supernumerary teeth to take, and the 
 upper is more frequently favoured than the lower jaw. 
 Instances, however, are not wanting in w^hich the additional 
 teeth appear among the molar division of the series. In a 
 
 (1) Shows the appearances presented by a cast taken from a month in 
 which two supernumerary teeth appeared behind the incisors*, one resembling 
 to some extent an incisor, the other altogether irregular in shape.
 
 TEETHING. 
 
 203 
 
 patient of my own, a diminutive tooth, resembling a small 
 and badly-formed wisdom tooth, appeared on each side of 
 the mouth external to the first and second permanent molars 
 of the upper jaw (Fig. 94). The age of tlie x)atient and the 
 appearance of the teeth themselves led to the supposition 
 
 that they were the representatives of the wisdom teeth. 
 Within two or three years the eruption of the true wisdom 
 teeth in the usual position showed that the supposition was 
 incorrect. 
 
 Instances have, however, occurred in which an additional 
 
 Fig. 94. (2) 
 
 '•'' ''iWl/f'IWIn::,. 
 
 molar tooth has appeared undistinguishable as regards form 
 from a normal member of the series, and a similar occurrence 
 has been remarked in respect to the bicuspids. 
 
 (1) Shows the front view of a specimen in which two supernumerary teeth 
 (a) hold the place of the central incisors, while the left central (6) has appeared 
 above the alveolar line. I am indebted to Mr. Saunders for the use of this 
 specimen. " 
 
 (2) Shows a supernumerary tooth placed externally to the first and second 
 permanent molars of the upper jaw.
 
 204 A SYSTEM OF DENTAL SURGERY. 
 
 The following illustration is taken from a specimen in 
 which a wisdom tooth and a supernumerary occupy the 
 same socket. Although in this case the hard palate is 
 thickened in a peculiar manner, and terminates in four 
 processes, yet the jaw is well formed as respects the dental 
 
 F!g. 95. (1) 
 
 arch, and the teeth are both well developed and well ar- 
 ranged. In this instance, the form of the jaw can have 
 nothing to do with the development of the additional tooth. 
 
 Fig. 96. (2) 
 
 Indeed, I do not know that any connection between good or 
 bad development of the jaw, and the occurrence of super- 
 
 (1) A palatal view of an upper jaw in which a supernumerary tooth occupies 
 the external portion of the socket of the right wisdom toottf!, 
 
 (2) Supernumerary tooth from between the second and third molars of the 
 lower jaw.
 
 TEETHING. 205 
 
 numerary teeth, can be traced. Still, my own personal 
 observations would, perhaps, justify me in stating that super- 
 numerary teeth are more frequently found in perfect than in 
 imperfectly-developed jaws. 
 
 The relations of supernumerary to the temporary teeth 
 during the development of the former are not, in the absence 
 of actual observations, readily understood. The growth of 
 the formative pulps of the permanent within the sockets of 
 the temporary teeth has been described, together with the 
 progressive formation of crypts in the inner walls of the 
 sockets for the reception of the pulps. Now, where we have 
 supernumerary teeth in the front part of the mouth taking 
 precedence slightly, in respect to time, of the permanent 
 teeth, a question is suggested as to the relations at an early 
 period of the formation of the latter to the temporary teeth, 
 and to the supernumerary. It remains for future anatomists 
 to determine whether supernumerary teeth arise in connection 
 with the temporary or with the permanent teeth, or whether 
 a normal permanent tooth may arise in connection with a 
 supernumerary, the one holding the same relations to the 
 other as, under ordinary circumstances, the first and second 
 teeth do to each other. 
 
 A single phrase will suffice to describe the treatment of 
 cases in which supernumerary teeth make their appearance. 
 They should be extracted so soon as their character is clearly 
 established. 
 
 Instances may, however, occasionally present themselves 
 to the practitioner, in which a supernumerary tooth may be 
 retained with advantage ; but these will, for the most part, be 
 confined to those cases in which, from neglect, the whole of 
 the teeth have been allowed to remain imtil all chance of the 
 normal tooth coming into its proper position on the removal 
 of the intruder is lost. 
 
 In the case shown in Fig. 66, the central incisor would 
 have probably occupied the usual place, had the supernume- 
 rary tooth been removed on its first appearance through the
 
 206 A SYSTEM OF DENTAL SURGERY. 
 
 gum, but had its extraction been performed after the com- 
 pletion both of itself and of the displaced central tooth, no 
 advantage would have been gained by the operation. The 
 position of the central incisor having been unalterably 
 determined, the space left by the extraction of the intruder 
 would have remained unoccupied. 
 
 Under the head of irregularity in the number of the per- 
 manent teeth, those cases in which the dental series is more 
 or less defective, yet remain to be considered. 
 
 Instances have been cited of a total absence of the perma- 
 nent teeth. (^) One or two such cases have been described 
 to me by gentlemen who have examined the subjects for 
 themselves. In my own practice, however, I have failed to 
 meet with an individual w^ho from the first was perfectly 
 destitute of permanent teeth. The nearest approach to the 
 edentate condition which has in any way come under my 
 own observation, is exhibited in two casts taken by Mr. 
 Harrison from a patient under his treatment. One molar 
 occupied each side of the upper and lower jaws. These four 
 molar teeth, with four incisors (two in each jaw), were all 
 the permanent teeth. 
 
 According to the statements of the patient and of her 
 friends, the temporary teeth presented no peculiarities either 
 as regards their number or the manner or the time of their 
 shedding. A temporary canine tooth was retained in the 
 upper and lower jaw ; the other members of the deciduous 
 set dropped out at the usual time, but, with the exception of 
 the four central incisors, their successors were wanting. A 
 case has been already described, in w^hich there was an 
 almost total absence of the temporary series, yet permanent 
 teeth not only made their appearance at the usual time, but 
 took their place with great regularity as respects arrange- 
 
 (1) In the mnseum of the Odontological Society are several models of cases 
 in which the teeth were deficient (see Catalogue, page 23), and allusion has 
 already been raade to the subject, in discussing the origin of various abnor- 
 malities (page 116).
 
 TEETHING. 207 
 
 ment. Now, although these two instances may be looked 
 upon as very rare and exceptional ones, yet they prove that 
 temporary do not necessarily precede permanent teeth, and 
 that temporary are not necessarily followed by permanent 
 teeth. With these facts before us, we are not able to turn 
 to the condition of the temporary teeth for explanation of 
 any diminution in the permanent series, with much hope of 
 success. 
 
 Although any great diminution in the number of the 
 permanent series is rarely seen, the absence of one or two 
 
 Fig. 97. (1) 
 
 members of the set is far from uncommon. I know several 
 families the members in each of which are destitute of 
 lateral incisors in the upper jaw. Although it is usual for 
 abnormalities, whether consisting in an excess or a deficiency 
 of number, to affect both sides of the mouth, yet this 
 symmetry is not always meet with. I have two patients 
 (sisters) in whom the right upper lateral incisors are absent 
 the left laterals are small, but otherwise well formed. 
 
 (I) Front view of an upper jaw of a young subject. The temporary alveoli 
 show that the temporary Literal incisors w,ere wanting, and the absence of 
 permanent lateral teeth is also shown.
 
 208 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 I am indebted to Mr. James Parkinson for a specimen of a 
 yomig jaw in which both the temporary and permanent 
 lateral incisors are wanting. 
 
 The son and daughter of a gentleman who had no lateral 
 incisors in the upper jaw, each bore the marks of their 
 parentage in respect to the teeth. The son had but one 
 lateral incisor, and that was a very small and imperfectly- 
 developed tooth. The daughter had, however, two lateral 
 incisors. They made their appearance at a very late period, 
 and presented the characters common to supernumerary 
 teeth, each tooth being nothing more than a small sharp- 
 pointed cone ; and other instances of inherited peculiarities 
 have already been given at page 114. 
 
 Fig. 98. (1) 
 
 I believe when one description of tooth only is wanting, it 
 will generally be found that the lateral incisor is the missing 
 member. Perhaps we should except from this rule the 
 wisdom teeth. They, however, are so extremely irregular in 
 all respects, as compared with the other teeth, that we are 
 seldom in a position to declare them absent, although they 
 may not have appeared above the surface of the gums. But 
 if the third molars are less frequently absent than the lateral 
 
 (1) Shows a well-developed adult jaw, in which the second temporary 
 molar is persistent, no second bicuspid having been developed.
 
 TEETHING. 209 
 
 incisors, they stand next in the order of absentees. The 
 second bicuspid is sometimes absent, and its place supplied, 
 as in the preceding illustration, by the second temporary 
 molar. 
 
 From a strictly practical point of view, these cases of. 
 deficiency in the number of the second set of teeth have 
 but little interest. By those, however, who pursue dental 
 surgery as a liberal profession, they will not be passed over 
 with indifference, although our present knowledge of the 
 subject will not enable us to recognise the cause which has 
 produced the defect. 
 
 It is, however, of great practical importance that we 
 should be fully aware that Nature sometimes fails to produce 
 those permanent teeth which are preceded by temporary 
 teeth, and that in such cases the latter will, if allowed to 
 remain, serve the purposes of mastication and articulation 
 up to the middle period of life, and in some instances even 
 later. 
 
 Irregularity in the forms of .the permanent teeth — It is 
 not proposed at this place to enter into a minute description 
 of those slight deviations from what may be regarded as the 
 typical form of any member of the dental series, but the 
 allotted space will be occupied in considering the more 
 strongly-marked cases of departure from the usual cha- 
 racters. 
 
 Teeth, though individually well shaped, may be so much 
 above or below the ordinary size, that they become dis- 
 figuring to the possessor. The two accompanying illustra- 
 tions (Figs. 99 and 100) are taken life-size from two sets of 
 teeth, the one composed of teeth individually the largest, 
 the other of the smallest, I have ever seen. 
 
 In these examples, the peculiarity has been common to all 
 the members of the respective sets of teeth ; but we shall 
 sometimes find in the same mouth teeth excessively large 
 associated with teeth excessively small. For example, the 
 central incisors may greatly exceed the average size, while 
 * p
 
 210 
 
 A SYSTEM OF DENTAL SURGERY. 
 -Fi^. 99-0) 
 
 i^i^r. 100.(2) 
 
 (1) A front view, life size, of an unusually large set of front teeth, of the 
 upper and lower jaws. 
 
 (2) A front view, life-size, of an extremely small set of permanent front 
 teeth from the upper and lower jaws.
 
 TEETHING. 211 
 
 the lateral teeth are represented by small cones only. Then, 
 again, the corres}X)nding teeth of the same jaw may differ in 
 size and form. The one may be large and well formed, the 
 other small and imperfectly developed. 
 
 I am indebted to Mr. Alfred Canton for the very large 
 wisdom tooth which forms the subject of the next figure, 
 and illustrates the point just mentioned. The tooth is 
 double the usual size, and is the only member of the set 
 which exhibits any peculiarity either as to dimensions or 
 form. 
 
 Fig. 101. (1) 
 
 Irregularity of form is, however, sometimes connected 
 with diminution of size ; one tooth may be unusually small 
 and ill shaped, while the other members of the set are well 
 developed. A case came under my treatment about four 
 years since, in which one of the upper central teeth was 
 irregular in shape, and about one-fourth the size of the 
 
 Fig. 102. (2) Fig. 103. (3) 
 
 corresponding tooth (Fig. 102). From some cause, the 
 diminutive incisor occasioned a good deal of irritation in the 
 
 (1) Shows, life-size, an unusually large wisdom tooth from the lower jaw. 
 
 (2) Deformed and stunted central incisor of the upper jaw. 
 
 (3) Bicuspid of the upper jaw, with the fang imperfectly developed.
 
 212 A SYSTEM OP DENTAL SURGERY. 
 
 gum ; this, with the unsightly character of the tooth itself, 
 led to its being extracted. The teeth adjoining the vacated 
 space were, by means of ligatures, gradually brought towards 
 each other, and eventually so far reduced the interval, that 
 the absence of the faulty central was not missed. 
 
 The irregularity as regards size will sometimes be limited 
 to the root of a tooth. In the example from which the 
 preceding illustration was taken, the crown has attained "the 
 usual size ; the enamel, however, exhibits indications of 
 defective organisation, and the root is most imperfectly 
 developed. The tooth was removed within two years of its 
 appearance, in consequence of the irritation it excited in the 
 surrounding gum (Fig. 103). It can scarcely be supposed 
 that any constitutional condition would cause the production 
 of one defective tooth, and leave uninfluenced other teeth 
 developing at the same time. A strictly local cause may be 
 looked for with much greater chance of success. The 
 prolonged existence of gum-boil in connection with a tem- 
 porary tooth may produce the result, or the encroachment of 
 a neighbouring tooth upon the formative pulp may lead to 
 the formation of a dwarfed and misshapen tooth (Fig. 27). 
 
 Perhaps we shall not find a more fitting place for con- 
 sidering those deviations from the normal forms of the teeth 
 which are consequent upon interrupted development of the 
 dental tissues. The crowns of the afi"ected teeth, instead of 
 presenting the beautiful smooth and glossy surface charac* 
 teristic of finely-developed enamel, are disfigured by the pre- 
 sence of an irregularly grooved or pitted surface, accompanied 
 by a considerable diminution in size. The incisors are 
 commonly very thin and compressed, while the canines and 
 the cusps of the molars are terminated by sharp points. By 
 the aid of the microscope we may learn that the tissues are 
 not only deficient in quantity, but that they are defective 
 also in equality. Neither the enamel nor dentine is perfectly 
 developed ; the elements of the former are imperfectly com- 
 l)ined, hence the tissue is porous, yellow, opaque, and very
 
 TEETHING. 213 
 
 fragile, and in the latter, the dentinal tubes are wanting in 
 that uniformity of size and arrangement which they exhibit 
 in well-developed teeth. 
 
 Fig. 104. (1) 
 
 The condition of system which operates so unfavourably 
 upon the developing teeth frequently passes off before they 
 are perfected ; consequently those parts of the teeth which 
 are formed after the health has improved assume the normal 
 appearances. It is very common to find teeth which show 
 most distinctly that they have been produced under two con- 
 ditions of system ; the one half of a tooth will be imperfectly, 
 the other perfectly developed. The observation may with 
 equal justice be applied to whole sets of teeth. The whole 
 
 (I) Showing the front teeth, grooved from the alternation of perfectly and 
 mperfectly developed portions of enamel.
 
 214 A SYSTEM OF DENTAL SURGERY. 
 
 of the crowns of the central incisors may be altogether im- 
 perfect, while a small portion of the lateral teeth will be well 
 formed. In the canine, the good portion of the crown will 
 be larger than the bad, and the second molar will be 
 altogether without any visible defect. Tracing the teeth 
 from front to back, we may see that the defect crops out 
 at a definite point, and that there will be in this respect a 
 strict correspondence in the two sides of the mouth. 
 
 The defect of structure will be limited to such portions of 
 the several teeth as w^ere undergoing development at the 
 same time, and consequently under the same constitutional 
 state. If, for instance, we find the one-half of the crowns 
 of the central incisors and first permanent molars imperfect, 
 one-third of the lateral teeth will be in a corresponding con- 
 dition, while the defect will not extend over more than a 
 fourth of the crowns of the canines. Again, if the extent 
 of the defect be limited to the cutting edges of the central 
 incisors, the lateral incisors may be free from imperfections. 
 
 As yet, those cases only have been described in which the 
 dental tissue exhibits over a certain portion of a tooth ob- 
 vious signs of a defective organisation. But we sometimes 
 find teeth which are marked by grooves and ridges, very 
 regularly disposed. The grooves are the result of impei-fect, 
 and the ridges of perfect development of the enamel and 
 subjacent dentine. These transverse markings, resulting 
 from alternations in the developmental process, find an exact 
 parallel in the stria3 produced by similar causes on the nails. 
 Owing to the more rapid and persistent growth of the latter, 
 it is often possible to see the mark left by a severe illness in 
 the form of a transverse groove across the nail, this being the 
 result of a temporary cessation of its development. Althougli 
 in many, it is not in all cases easy to trace this ridged, or 
 pitted, or honeycombed condition of the teeth to the presence 
 of serious indisposition of the patient during the period when 
 the defective portions of the teeth were being developed ; it 
 can, however, be scarcely doubted that an imperfect organisa-
 
 TEETHING. 215 
 
 tion of the teeth, if not the result of some special disease, 
 such as measles, influencing the system generally, is yet 
 consequent upon a constitutional condition. The fact that 
 if one tooth is affected, those parts of other teeth which 
 correspond in respect to the period of formation will present 
 a similar condition, precludes the supposition that the effect 
 has been produced by a merely local cause. The evidence 
 points to a general cause, but it will not uncommonly be very 
 difficult to discover the precise nature of that cause. The 
 parents may tell you that your young patient has been par- 
 ticularly healthy from the time of birth, having at no time 
 suffered from more than a very trifling and short-lived in- 
 disposition. On inquiry, you find that the temporary teeth 
 were well develoj^ed, lasted their time, and then dropped out. 
 I have a preparation in which the jaws are particularly well 
 grown, and the temporar}^ teeth unusually fine ; yet, on re- 
 moving the bone to show the permanent teeth, it was found 
 that the latter were honeycombed to a great extent. The 
 converse of this is often seen. The temporary teeth may be 
 lost from caries at an early period, and the maxilla be con- 
 tracted, and still the permanent teeth may to all appearance 
 be well shaped and free from structural defects. There is 
 ample evidence to show that the condition of the temporary 
 set cannot be taken as a positive indication of the nature of 
 the succeeding permanent teeth ; neither will the evidence 
 furnished by the parent in all cases enable us to account for 
 the presence of the peculiar form of defect in the teeth to 
 which attention has been directed. 
 
 It is believed that the effects of hereditary syphilis may 
 often be traced as the cause of a peculiar dwarfed condition 
 of certain teeth. Attention has been drawn to this point by 
 Mr. Jonathan Hutchinson (^), who has pointed out that, inas- 
 much as specific inflammations do not occur during the period 
 of intra-uterine life, the teeth belonging to the deciduous 
 
 (I) Transactions of the Pathological Society, vol. ix., p. 449, and vol. x.. 
 p. 287, and Transactions of the Odoiitological Society, vol. ii., p. 95, 1857.
 
 216 A SYSTEM OF DENTAL SURGERY. 
 
 series are not liable to be affected, though they may be lost 
 by exfoliation consequent on stomatitis and periostitis. On 
 the other hand, the occurrence of specific affections of the 
 mouth soon after birth may be readily supposed to aifect 
 the permanent teeth which are at this time developing, and 
 certain characters are enumerated as indicative of such in- 
 terference with the growing teeth. 
 
 The incisors and canines are of small size, and peg-shaped ; 
 the crown is notched, the notch being in the main a concavity 
 from the one corner to the other, though there may be 
 secondary notches in this general concavity. 
 
 Fig. 105. (•) 
 
 A. 
 
 "- ^M^/^W^- ~ • -■ -'"^ 
 
 The existence of a " circumferential notch " encircling 
 the canines near their points, is also noted by Mr. 
 Hutchinson, but is by him attributed to a " circumferential 
 wearing " of the one tooth on its opponent. This explanation 
 is inadmissible ; the groove running round the crown of the 
 canine near its apex is simply the mark of a temporary arrest 
 of development (see page 214), and is precisely analogous to 
 the similar groove across a nail which sometimes is seen 
 after a serious illness. It is very possible that the arrest of 
 development may have been brought about by an attack of 
 stomatitis, and a similar circumferential groove would 
 probably be found encircling the incisors at a point lower 
 
 (1) " Syphilitic " incisors ; copied from Mr. Hutchinson's Paper Qoc. cit.').
 
 TEETHING. 
 
 217 
 
 down on their crowns, seeing that calcification of these teeth 
 is in advance of that of the canines. As however the true 
 origin of the groove on the canine was not recognised, the 
 presence or absence of similar marks on the incisors is not 
 mentioned. 
 
 Teeth described as "syphilitic" have a dusky, opaque 
 appearance, and are small relatively to the size of the jaws, 
 so that distinct intervals are left between them ; moreover, 
 they are of a very soft character, so that they speedily be- 
 come worn down, and the characteristic transverse notch 
 obliterated. 
 
 It must, however, be borne in mind that even though the 
 association of teeth of this form with inherited syphilis were 
 fully established, it by no means necessarily follows that 
 they are the direct result of attacks of stomatitis. The 
 influence of inherited syphilis is capable of profoundly 
 modifying the nutrition of many parts of the body, and it is 
 quite as likely that its effects would be brought about directly 
 as that they should be manifested secondarily through the 
 intervention of an attack of stomatitis. 
 
 Moreover, constitutional syphilis attacks the hair, the 
 nails, and the skin generally with great frequency, and the 
 homological relation which exists between the teeth and 
 various dermal appendages may serve, if not to explain, at 
 least to render less surprising the fact that the developing 
 teeth should be a chosen site for its manifestation. 
 
 It has been poiiited out by Trousseau (^) that the various 
 syphilitic affections of the mouth in a child are rarely seen 
 before the second week, and seldom manifested after the 
 eighth month (unless they have previously made their 
 appearance). 
 
 It becomes, then, a matter of importance, in deciding upon 
 the correctness of Mr. Hutchinson's views, which have been 
 unreservedly accepted in a recent paper by Mr. Berkeley 
 
 (') Troiissean. Clinical Lectures (New Sydenham Society's translation). 
 " On Infantile Syphilis."
 
 218 A SYSTEM OF DENTAL SURGERY. 
 
 Hill (^), to ascertain with precision the extent to which cal- 
 cificatiou has proceeded in the affected teeth at this period of 
 the child's development. Unfortunately, the jaws to be 
 found in museums have almost invariably been macerated, 
 and the minute calcifying tips of the permanent teeth lost, 
 so that it is not easy to acquire definite knowledge on the 
 subject ; moreover, the statements of various authors differ 
 in the times assigned to the commencement of calcification 
 in the permanent teeth. 
 
 In Grray's Anatomy (the authority for the periods not being 
 given) it is stated that calcification in the central incisors 
 takes place about the sixth or seventh month ; in the laterals 
 and the canines about the eighth or ninth month of foetal 
 life. Should these dates be correct, the theory that the 
 deformity is produced by stomatitis is placed in jeopardy, 
 seeing that the part most profoundly malformed is the ex- 
 treme tip of the incisor — that is, the part first formed — the 
 calcification of which is said to begin at the seventh month ; 
 in other words, at least two months before the probable 
 occurrence of a specific stomatitis. 
 
 On the other hand, KoUikerQ, without giving definite 
 dates for the commencement of calcification, implies that it 
 is some^^hat later ; and Robin and Magitot (^) state that the 
 follicles of the permanent incisors and canines first appear 
 within a range of about fifteen days before or after birth, but 
 they do not say at what time calcification first commences 
 on the papillfe. 
 
 One point, however, appears to have been overlooked by 
 Mr. Hutchinson, namely that the calcification of the tempo- 
 rary teeth is not so far advanced at the time of birth but 
 that we may expect them to be influenced by the occurrence 
 of disturbing causes during the first month or two after birth. 
 On reference to Fig. 1 (page 6), it will be seen that only the 
 
 (1) Monthly Review of Dental Science. June, 1872. 
 
 (2) Ki)lliker. Manual of Human Microscopic Anatomy. 1S60. 
 
 (3) Robin et Magitot. Memoire sur le genese et developpement des FoUicules 
 Dentaires. 1860.
 
 TEETHING. 219 
 
 tip of the temporary canine is as yet calcified, so that any 
 check occurring in its development will be marked by a 
 circumferential groove not quite at its tip, but a little way 
 down the crown. 
 
 But little can be done to improve teeth with faulty organi- 
 sation. We may direct the patient to keep the teeth scrupu- 
 lously clean, and we may from time to time remove or 
 reduce with a fine file the irregularities of surface. When 
 the defective part is confined to the immediate vicinity of 
 the cutting edge of a tooth, it may in many cases be wholly 
 removed. The teeth will look short, perhaps, after the 
 operation, which should, however, be delayed until the 
 development of the tooth is completed. In many instances 
 I have been able to file off all the faulty tissue from the 
 canine teeth, a considerable portion of it from the lateral 
 incisors, and a little from the central teeth. 
 
 Some degree of caution will be needed in using the file. 
 If too mucli at a time be removed, or if the operation be per- 
 formed at too early a period, the teeth operated upon will be- 
 come extremely tender. As a general rule, it is well to delay 
 any attempt to improve the appearance of the defective teeth 
 by filing until the patient is from twelve to eighteen years of 
 age. 
 
 The depressions or faults in the enamel must, however, 
 from time to time be carefully examined, and should any 
 indication of caries be discovered, the cavity in which the 
 disease is situated must be filled without delay. 
 
 Slight deviations from the usual forms of the crowns of the 
 permanent teeth need not be described, but it is necessary 
 that attention should be drawn to the fact that supplemental 
 cusps are sometimes found arising from the necks of teeth, 
 and presenting all the appearances of distinct supernumerary 
 teeth. 1 have known a practitioner seize upon such a cusp, 
 believing it, I presume, to be a suijernumcrary tooth, and 
 drag out, not only the cusp, but the incisor from which it 
 arose.
 
 220 A SYSTEM OF DENTAL SURGERY. 
 
 The case from which the following illustration (Fig. 106) 
 is taken occurred in my own practice. A large nodule or 
 cusp projected from the neck of the tooth. It was perfectly 
 covered by the gum, so that its presence could not be sus- 
 })ected, until, in passing the forceps up towards the neck of 
 the tooth, some unusual obstruction was felt. 
 
 Fig. 106. (1) Fig. 107. (2) 
 
 Supplemental cusps only have been spoken of, but we 
 sometimes see a tolerably perfect little tooth growing out, as 
 it were, from the side of another tooth. In Fig. 107 a small 
 tooth is shown connected with the distal side of the second 
 or third lower molar below the termination of the enamel. 
 
 Mr. Harrison placed at my disjDosal a molar, from the 
 lateral surface of the crown of which a minute but well- 
 formed supplemental tooth projects at a right angle. 
 
 Under the head of irregularities in the forms of teeth, 
 several physical peculiarities have jet to be considered, for 
 describing which it is difficult to find a more fitting place. 
 
 Those deviations from the normal number and arrange- 
 ment of the roots of teeth which influence dental operations, 
 will be treated of in connection with the operations them- 
 selves. But as the discussion of the subject of irregularities 
 of form generally would include such as are manifested in 
 the roots, as well as those which occur in the crowns of the 
 
 (1) A permanent tooth, with a large nodule of enamel attached to the neck 
 below the point covered by the edge of the gum. 
 
 (2) A lower molar, with a small tooth projecting from its side.
 
 TEETHING. 221 
 
 teeth, the matter cannot be altogether passed over at this 
 place. 
 
 The incisors may have their roots crooked or bent, or even 
 twisted in a spiral form, but 1 have seen only one example 
 in which they were bifid. In that case, a lateral incisor of 
 the upper jaw had a cusp rising up from the base of the crown 
 on its lingual surface, and a small supplemental root held a 
 corresponding position as respects the root of the tooth. 
 
 In the upper canine teeth, two or three specimens only 
 have fallen under my notice which have exhibited a tendency 
 to a division of the one large and strong root into two, an 
 actual division being confined to the immediate vicinity of 
 the apex. In the lower teeth bifid roots are more common. 
 
 The bicuspid teeth, unlike the front teeth, are very liable 
 to irregularity in the arrangement of the roots. Normally 
 they have but one root, which is laterally compressed in 
 upper teeth, and in the lower teeth also it is to some extent 
 compressed laterally, yet in a much less degree than in the 
 corresponding teeth of the upper jaw. Very commonly, 
 however, we shall find that the flattened single root of the 
 first bicuspid of the upper is replaced by two, and sometimes 
 even by three, well-formed fangs, holding the same relative 
 position as the roots of the upper molar teeth. 
 
 Indications of a division into three fangs in the upper, and 
 into two in the lower bicuspids, may often be seen, even 
 where they are not actually separated ; and the teeth on the 
 opposite sides of the mouth usually preserve an exact sym- 
 metry in this respect. 
 
 The differentiation between molar and premolar (bicuspid) 
 teeth, which in some animals, as, for instance, in the horse, 
 can hardly be said to exist, is not carried to any very great 
 extent in man ; and it is interest! ng^to note that in the an- 
 thropomorphous apes the bicuspids have three fangs in the 
 upper, and two in the lower jaw as a normal condition. 
 
 Whether or not we are disposed to accept such facts as the 
 occurrence of threc-fanged bicuspids as indications of reversion
 
 222 A SYSTEM OF DENTAL SURGERY. 
 
 to an ancestral type, there can be no doubt that the explana- 
 tion of the occurrence of this abnormality in the fangs of the 
 bicuspids is to be found by a reference to the teachings of 
 comi^arative anatomy. 
 
 The bicuspids of the lower jaw, although their fangs may 
 be bent, but seldom terminate by two roots. 
 
 Among the molar teeth, the first permanent molars will be 
 found to be the most constant, and the third the least con- 
 stant, in the number, shape, and position of their roots. Three 
 may be regarded as the typical number of the roots of the 
 upi>er molar, and two as that of the lower molar t^eth. 
 Now, although we find occasional exceptions to these rules in 
 the first permanent molars, they are very unusual. In the 
 
 Fig. 108. (1) 
 
 two teeth from the upper jaw which are figured, the three 
 roots are, by the confluence of two, reduced to two in num- 
 ber; and I have seen one or two cases in which the two roots 
 of a first permanent lower molar were united so as to form 
 '>ne conical mass. 
 
 On the other hand, in the place of a diminished, we may 
 have irregularity from an increased number of roots. The 
 lower molar may have three, or even four, roots, and the cor- 
 resjx)nding upper teeth four in the place of three roots. But, 
 
 (1) Shows two first permanent molars of the upper jaw. In the tooth to 
 the ricrht the two labial roots are united and reduced to one, and in the left- 
 hand figure the posterior labial and the palatal roots are united so as to form 
 one broad and flattened root.
 
 TEETHING. 223 
 
 as was before stated, these departures from the normal number 
 and arrangement of the roots are very uncommon in the first 
 permanent molars. 
 
 In the second permanent molar, however, they are by no 
 means rare, and in the wisdom teeth the typical form is very 
 seldom produced. 
 
 No rule can be laid down for the form and number of the 
 roots of the dentes sapientia3, so variable and inconstant are 
 the forms assumed by these teeth. In one case the tooth is 
 terminated by a single conical root ; in another, the one is 
 replaced by five, or even six, small roots. The accompany- 
 ing figure is taken from a wisdom tooth of the upper jaw, the 
 single sharjily-pointed fang of which occasioned pain when- 
 
 /■t^. 109.(0 
 
 ever the crown was pressed upon. This, which is life-size, 
 may be compared with the figure of a wisdom tooth given in 
 a previous page (211), in illustration of the sizes between 
 which the third molar may range. 
 
 The accompanying figure (Fig. 110), which is borrowed by 
 the permission of the Council of the Odontological Society, 
 represents a tooth the fang of which is expanded out at its 
 apex into a cup-shaped disk, on the margins of which 
 are several foramina by which the nerves and vessels gained 
 access to the pulp. The tooth is more fully described in 
 the Transactions of the Society. (^) 
 
 There appears to be good foundation for the statement 
 that the upper wisdom teeth in the lowest savage races have 
 
 Q) Shows, life-size, a wisdom tooth from the upper jaw. 
 
 (2) Transactions of the Odontological Society, new series, vol. iii., p. 200, 1871.
 
 224 A SYSTEM OF DENTAL SURGERY. 
 
 their three fangs distinct (^), although, on looking over a large 
 number of skulls in various museums, I have found excep- 
 tions to this rule. 
 
 The great variability in the size and shape of the wisdom 
 tooth in civilized races, its occasional absence, and the irre- 
 gularity of the period at which it is erupted, may, when 
 contrasted with its large size and regular form in the lowest 
 savage races, be taken as an indication that the wisdom 
 tooth is slowly disappearing, and that there is a strong 
 probability that in future generations it will be normally 
 absent. Moreover, comparative anatomy lends a certain sup- 
 
 Fig. 110. 
 
 port to this conjecture, inasmuch as in the anthropomorphous 
 apes, where it is a proportionately larger tooth, it is erupted 
 at an earlier period, coming into place before the canine 
 tooth. On this matter Professor Huxley (2) says : " In the 
 Gibbons, the permanent canine emerges contemporaneously 
 with, or before, the last molar ; but in the other anthropo- 
 morpha the last permanent canine is cut, ordinarily, only 
 after the appearance of the last molar." 
 
 In connection with irregularities in the number and form 
 of the roots of the teeth, the unusual deviations in the 
 size may be mentioned. The corresponding teeth will vary 
 slightly in almost every instance where a comparison can be 
 made; but in a few cases the departure from the normal 
 length will be greatly in excess of what may be regarded as 
 
 (1) Owen. Anatomy of Vertebrates, vol. iii., p. 320. 
 
 (2) Huxley. Anatomy of Vertebrate Animals, p. 186.
 
 TEETHING. 225 
 
 the average standard. Mr. J. Parkinson gave me a pair of 
 canine teeth which had attained the length of one inch and 
 three-eighths, the roots alone measuring one inch. Excessive 
 length in the root of a tooth cannot be productive of injury 
 to the tooth itself; but the opposite condition, excessive 
 shortness in the root, is often connected with the early loss 
 of the tooth. Instances are sometimes found in which, 
 although the crown of a tooth has acquired the usual size, the 
 root is extremely short and weak; consequently the im- 
 plantation is deficient in that strength and even firmness 
 which is necessary to insure the durability of the organ. 
 
 J'^ig. 111. (1) 
 
 In another place, under the head of Dilaceration(^), I have 
 described a condition of tooth resulting from displacement of 
 the calcified portion of a tooth from the tissues which were 
 instrumental in its production, the development being con- 
 tinued after the normal position of the calcified part had been 
 lost. Supposing, for example, the crown of an incisor when 
 partly formed be moved from its position upon the pulp, and 
 turned outwards or inwards, or to either side, and there to 
 remain in a state of rest, the development of the tooth may 
 then be continued with the displacement of one-half of the 
 crown permanently preserved. 
 
 In some cases the amount of distortion will be slight, in 
 others so great and so disfiguring that the tooth is neces- 
 
 (•) Showing a central incisor of the upper jaw, the root of which Is deficient 
 in size. 
 ^ (2) Lectures on Dental Pliysiology and Surgery.
 
 226 A SYSTEM OF DENTAL SUKGEET. 
 
 saril}" sacrificed. I have seen specimens in which the crown 
 of an incisor has been placed at a right angle ^vith the root. 
 
 The instances of dilaceration which have fallen within my 
 own notice have been limited to incisors and bicuspid teeth. 
 There is no reason why the molar teeth should not be subject 
 to the deformity equally with the front teeth, excepting that 
 the situation in the mouth of the former renders them less 
 liable to accidental disturbance than the front teeth. 
 
 To the naked eye the displacement of the crown is sufl&- 
 ciently apparent, but the coincident derangement of the tissues 
 can be seen only by the aid of the microscope. If, however, 
 
 Fig. 112. (1) 
 
 we take a thin section from a tooth the crown of which has 
 been moved on its pulp during the period of calcification, we 
 shall find the dentinal tubes greatly bent or disturbed in 
 their course at the point of injury. The relations of the 
 enamel, the dentine, and of the cementum, are also interfered 
 with at a corresponding point. 
 
 There is one other deviation from the normal condition 
 which, as it affects the forms of individual teeth, must be 
 included under the present heading — viz., the union or gemi- 
 nation of contiguous teeth. This subject was entered upon 
 
 (1) Shows three instances of dilaceration. The figure to the left is taken 
 from an upper bicuspid, the crown of which had been moved on the pulp. 
 The centre figure is that of a central incisor removed from a boy in conse- 
 quence of the cutting edge of the tooth being directed towards the tongue. 
 The boy had received a blow upon the mouth. The right-hand figure shows 
 the appearance presented by a section of an incisor similarly deformed to 
 the preceding example, although the development has yet to be completed.
 
 TEETHING. 227 
 
 in connection with the temporary teeth (page 157), but in 
 respect to the permanent teeth it has yet to be considered. 
 
 When two teeth are permanently united, the union must 
 have been effected through the medium of their respective 
 pulps prior to the development of the teeth themselves ; or 
 the connection must have resulted from diseased action in- 
 volving teeth placed in close apposition. Cases of this latter 
 class, being the result of exostosis, will be considered in con- 
 nection with that disease. In the specimen which forms thc- 
 subject of the following figure, the pulps of the central 
 incisors must not only have come in contact, but have been 
 
 Fig. 113. (1) 
 
 pressed upon each other with sufficient force to cause the 
 left to have become to a slight extent imbedded in the right 
 tooth-pulp. The development of the united crowns having 
 been perfected, each tooth had its root separately produced. 
 
 In a very interesting specimen, for the use of which I am 
 indebted to Mr. Styers, of Nottingham, the central and 
 lateral incisors were united throughout their whole length. 
 The line of confluence, though sufficiently marked for recog- 
 nition, was not deeply cut, consequently the four teeth at 
 a short distance looked like two extremely large but sjin- 
 metrical central incisors. 
 
 Union of the lateral incisor and canine is now and then 
 
 (1) Shows a view of the lingual and of the labial surfaces of two permonect 
 central incisors of the upper Jaw, the crowns of which are united.
 
 228 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 met with. The accompanying figure (Fig. 115) is taken 
 from a specimen in which both the crowns and roots of 
 the lateral incisor and canine are united. The appearance 
 produced by this large tooth was objected to on the part 
 of the parents, who induced a dentist to make an artificial 
 division by means of a file. The operation resulted in open- 
 ing the pulp-cavity, and consequently in the death of the 
 united teeth. Extensive alveolar abscess followed, for the 
 relief of which I removed the teeth nine days after the opera- 
 tion of filing. In this example, although the union was 
 perfect, and efi'ected by the dentine of each tooth being, at the 
 point of junction, commou to the two, yet the position and 
 
 Fig. 114. (1) 
 
 Fig. 115. (2) 
 
 size of each tooth were defined by a dej^ression running the 
 whole length of the teeth, and corresponding to the depressed 
 line on the surface is a contraction in the pulp-cavity which 
 is common to the two teeth. In examining connate teeth, 
 it will sometimes be found that a supernumerary has become 
 united to a normal member of the dental series. Two cases 
 have fallen within my own observation, in each of which 
 a lateral incisor was united to an equally well-developed sup- 
 
 (1) Shows the ponnanent central and lateral incisors of the upper jaw, 
 united throushout the whole length of the teeth. From a specimen lent to the 
 author by Mr. Styers. 
 
 (2) The permanent lateral incisor and canine from the right side of the 
 upper jaw, united.
 
 TEETHING. 229 
 
 plemental lateral. In one example, the teeth had been 
 removed from the upper, in the other the teeth remained in 
 the lower jaw of a patient. In a third case, each central 
 incisor of the upper jaw had joined to its median side a super- 
 numerary tooth, equal to about one-half of its own breadth, 
 thus producing by the union two front teeth individually 
 one-third larger than the normal size. 
 
 Union between a canine and a bicuspid, or between the 
 two bicuspids, or between a bicuspid and first molar, except- 
 ing as the result of diseased action set up long after the 
 development of the teeth has been completed, is of very rare 
 occurrence. 
 
 The molar teeth are not, however, equally exempt from 
 gemination. Many specimens have been preserved showing 
 permanent union between the second and third molars. In 
 the example figured, the third molar passes obliquely between 
 the palatine and posterior labial roots of the second molar, 
 and is united to each of them. 
 
 In another specimen, placed at my disposal by Mr. Har- 
 rison, the second and third upper molars are united at several 
 points, without the ordinary position in the jaw of either 
 tooth being materially altered. The masticating surface 
 
 (1) Shows the second and third molars united. The right figure represents 
 the two teeth from the labial aspect; the left, from the lingual or palatal 
 aspect.
 
 230 A SYSTEM OF DENTAL SUEGERT. 
 
 of the -svisdom tooth is upon a higher level than that of the 
 second molar ; but the difference is not greater than is often 
 seen to exist between the corresix>nding teeth in the mouths 
 of patients. 
 
 In examining a series of connate permanent teeth, it will 
 1)6 found that where the crowns are involved, the union is 
 effected by a continuity both of the dentine and of the 
 enamel, the connecting ]X)rtions of the tissues being common 
 to the two teeth, and by dentine and cementum, or by 
 cementum only, where the union is limited to the roots. 
 
 In the one case, both the dentinal and enamel pulps were 
 united, and thus produced a geminated tooth ; in the other 
 case, the union must have been effected long after the crowns 
 of the teeth were developed, and at the time the roots 
 were forming. In cases of union occumng under the latter 
 circumstances, the medium of connection may be limited to 
 the cementum, much in the same manner as we see the con- 
 tiguous roots of a tooth bound together by the interposition 
 of cementum. Those examples in which, by the large deve- 
 lopment of cementum consequent upon disease, two con- 
 tiguous teeth become united, must not be classed with such 
 as may be regarded as cases of congenital union. The 
 cementum may be the uniting medium in either case ; but 
 in the one the cementimi will not exceed the normal amount, 
 in the other it will exist in excess, and constitute a disease. 
 
 Under the head of irregularity of the permanent teeth, one 
 subject only remains for consideration — namely. Irregularity 
 in the period of their eruption; the premature or the retarded 
 appearance of members of the permanent set of teeth, and the 
 deviations from the natural order of eruption. 
 
 The molar teeth will vary in different individuals as to the 
 time of theu' eruption, but the amount of variation is seldom 
 sufficient in extent fairly to come under the head of pre- 
 mature eruption. But in those teeth which succeed to mem- 
 bers of the deciduous set, a considerable amount of devia- 
 tion in antecedence of the normal period may sometimes
 
 TEETHING. 231 
 
 be observed. Before this, however, can occur, the pre- 
 ceding occupant of the space must have been prematurely 
 lost. But in the shedding of the temporary teeth there will 
 be a certain range of variation in respect of time within 
 which the loss of teeth cannot be regarded as jDremature. 
 The condition of health may hasten or retard the process, 
 and it is probable that hereditary predisposition may also 
 exert an influence in determining the time at which the 
 deciduous teeth fall out, and make room for their successors. 
 In the vast majority of cases, however, the premature loss 
 of temporary teeth depends upon the occurrence of caries, 
 and the consequent extraction of the diseased organs. Many 
 children sufi"er so much pain from decayed temporary molars, 
 that the general health becomes disturbed, and their removal 
 is consequently necessitated. Now, it is in these cases that 
 the succeeding teeth sometimes appear prematurely, and 
 consequently out of the usual order. A certain number of 
 examples have fallen under my notice, in which one or more 
 of the bicuspid teeth have appeared as early as the lateral 
 incisors ; and although in one or two instances the teeth have 
 been imperfectly developed, in other cases all indications 
 of faulty organization have been absent. In a little patient 
 of my own, the whole of the deciduous teeth decayed nearly 
 down to the level of the gum, and produced such serious 
 suffering that the child fell into bad health. At the age of 
 three years and a half the decayed teeth were all removed 
 (excepting the second temporary molars), under the influence 
 of chloroform. The operation was succeeded by a restoration 
 of health, and the permanent teeth are now appearing in the 
 usual order, both as respects the time and the place of their 
 eruption. Now, in this case the premature loss of the first 
 has not been followed by the premature eruption of tlie 
 second set of teeth. In a less healthy subject the result 
 might have been difi'erent ; or had the teeth been allowed to 
 remain in this case, and, as stumps, had kept up irritation 
 in the gums, it is more than possible that some of the per-
 
 232 A SYSTEM OF DENTAL SURGERY. 
 
 manent teeth would have been injured, and have appeared 
 prematurely through an inflamed gum. 
 
 In a practical point of view, the accelerated is less inte- 
 resting than the retarded eruption of teeth. The premature 
 ai)pearance of a tooth cannot be prevented, and when in 
 sight, the mischief it may occasion can be ascertained ; but 
 when the eruption of a tooth is delayed, there is great diffi- 
 culty in learning its relations in respect to the other teeth, 
 its ovm conditions as regards size, shaf»e, and stage of 
 development, and the amount of influence it may exert 
 either in the production or in the maintenance of neuralgic 
 pains. 
 
 The irregularities of position, and the results to which 
 they lead, have been already described ; hence, in the present 
 section the inquiry may be limited to the question of retarded 
 eruption of teeth which are not irregularly placed during 
 the period of growth ; in other words, to teeth irregular only 
 in respect to the period of their eraption. It is by no means 
 uncommon to find that certain members of the permanent do 
 not appear at the usual time, and even after the lapse of 
 some few years are still absent from the usual position ; and 
 it is not, perhaps, until long after their presence has been 
 called in question that they penetrate the gum. In a case 
 which has been described at page 158, the right central 
 incisor of the upper jaw appeared at the age of thirteen, that 
 is, six years after the fellow tooth. In a second case, an 
 upper canine pierced the gum at the age of two-and-thirty ; 
 and in a third, a similar tooth cut the gum after the patient 
 had passed the age of forty. Again, many cases have occur- 
 red in which teeth have been cut at a very advanced age. 
 The recognition of this wide range in respect to the time 
 of the occurrence of a process which is coincident with a 
 kno\NTi epoch of general growth of the body, suggests an 
 inquiry into the condition of the teeth themselves at the 
 period of eruption, and also into the nature of the process of 
 eruption in these exceptional cases. In reference to the first
 
 TEETHING. 
 
 233 
 
 point, we have to learn whether, when the eruption of a 
 tooth is retarded, the development is equally delayed, and 
 whether the former is consequent upon the latter condi- 
 tion, or whether the one process may be quite independent 
 of the other. To meet the second question, two processes 
 by which a tooth may be cut must be recognised. In one, 
 the tooth itself presses forward, and makes its way to the 
 surface ; in the other, the gums recede and expose the tooth, 
 
 Fig. m. (1) 
 
 which, having been stationary, would have remained in 
 concealment but for the recedence of the gums. 
 
 In the cases of reiarded eruption of special teeth in which 
 I have had an opportunity of examining the teeth them- 
 selves, there has been no evidence to show that the deve- 
 lopment of the dental tissues had been interrupted. The 
 roots may be shorter than usual, and the crown faulty in 
 respect of form and organization, but the presence of these 
 
 (1) Shows the persistence of the second temporary molar retarding the 
 reception of the second bicuspid, which is shown, by the small size of the 
 crypt in which it was contained, to have been stunted and deformed. The 
 temporarj' tooth is marked by the asterisk. The author is indebted to 
 Mr. Saunders for the use of this specimen.
 
 234 A STSTEiil OF DENTAL SURGEBT. 
 
 defects does not prove that the production of the tooth was 
 delayed. Indeed, there is a want of decisive evidence in 
 support of the opinion that the actual development of the 
 teeth is delayed much beyond the usual period, although the 
 numerous cases of late eruption would at first sight favour 
 the supposition. The period of eruption does not, however, 
 in these exceptional cases, bear any necessary relation with the 
 time at which the development of the teeth was completed. 
 In some examples, the obstructing cause is sufiiciently ob- 
 
 Fig. 118. (1) 
 
 vious, but in others, we fail to see why the tooth did not 
 take its place in the series at the usual time. In the case of 
 a female, the upper canine was absent, a space bemg left 
 between the first bicuspid and lateral incisor. At the age of 
 forty-five, the missing tooth slowly protruded itself. Kow, 
 in this instance the way was not prepared by the loss of a 
 tooth, neither were the gums receding ; hence we are at a 
 loss to see why the eruption of the tooth was delayed, or 
 why it appeared at that age rather than at any other. The 
 
 (I) Showing the first biscuspid retarded in its eruption by the presence of 
 a temporary tooth. The bicuspid is a perfectly will-developed tooth, but 
 the outer wall of the alveolus is absent. The temporary tooth is marked by 
 the asterisk.
 
 TEETHING. 
 
 235 
 
 case is, however, instructive, as respects the process of 
 eruption in retarded teeth. There is no reason for assuming 
 that the development of the tooth was later than of the 
 corresponding tooth which appeared at the usual time ; 
 supposing, then, it to be admitted that the tooth was com- 
 pletely developed before the process of cutting commenced, 
 the process itself must be in some respects different from 
 that which occurs when teeth are cut under ordinary cir- 
 
 Fig. 119. (1) 
 
 cumstances. When the process is normal, as respects the 
 time and the stage of development of the tooth, the crown 
 appears through the gum long before the root has attained 
 its full length. The crown is in great part brought towards 
 the surface of the gum by the progressive lengthening of the 
 root, and is afterwards still further raised by the same 
 process. Now, when the eruption is accomplished subsequent 
 to the development of the root, the movement of the tooth 
 must be effected by some other means than by the progres- 
 
 (1) An adult lower jaw, with the canine retarded in its eruption. The 
 outer plate of the jaw has been cut away to show the position of the tooth.
 
 236 A SYSTEM OF DENTAL SUEGERT. 
 
 sive lengthening of root. The completed tooth has to change 
 its place without itself undergoing any change. The bone 
 which stands in its way must be absorbed, and the lower 
 portion of the socket from which the root of the tooth moves, 
 must be contracted by the deposition of bone. Indeed, in 
 the absence of a better hyix)thesis, it may be assumed that 
 the gradual contraction of the socket is the means used by 
 nature for bringing teeth to the surface when the process of 
 eruption has been delayed beyond the normal period. In 
 the one case, the movement is effected by the development 
 of bone within the alveolus ; in the other, by the progressive 
 development and consequent lengthening of the tooth. 
 
 In many cases, however, the retarded teeth become ex- 
 posed to view by the absorption of the superjacent gum, the 
 teeth themselves being perfectly stationary. The pressure 
 on the gum caused by artificial teeth will not uncommonly 
 cause its absorption and the exposure of a hidden tooth, 
 and this tooth, once having been bared, will often descend 
 to a lower level than that which it had previously occupied. 
 The manner in which this takes place, and the effect produced, 
 may be seen on referring to the figures illustrating irre- 
 gularities in the position of the permanent teeth. 
 
 The cause which most commonly retards the cutting of a 
 permanent tooth is strictly a mechanical one. The space 
 which should afford a place for the missing tooth is ahead}' 
 occupied either by a persistent deciduous tooth, or by the 
 crowding together of the contiguous permanent t€eth. Under 
 these circumstances, the normal occupant of the spot is 
 either held back, as in Fig. 117, &c., or takes some ex- 
 tremely irregular position. In the accompanying figiu-e, the 
 second bicus[!ids of the upper jaw were retarded by the 
 presence of the temporary molars. The deciduous tooth on 
 the one side of the mouth had lost all its roots, and there 
 appears no reason why the bicuspid did not take its place at 
 the usual time ; but on the other side the temporary molar 
 has retained the greater portion of its palatal root, and was
 
 TEETHING. 
 
 237 
 
 consequently held firmly in place- to the exclusion of the 
 bicuspid. Although in this example the usual period for 
 the replacement of the temporary molars has not been 
 exceeded by more than two years, it is not on that account 
 less instructive. 
 
 When a temporary tooth does not fall out at the usual 
 time, it becomes a serious question whether we should allow 
 it to remain ; whether we should wait until it becomes loose 
 before its removal is attempted, or remove it irresi)ective of 
 
 Fig. 120. (1) 
 
 this consideration. It is also desirable that the question 
 should in each case be settled before the period of rei^lace- 
 raent has been long passed by. Now, in the example which 
 forms the subject of the last figure, the bicuspid on the right 
 side has been slightly, perhaps not injuriously, retarded by 
 the temporary molar, but the latter tooth would have 
 speedily given place to its successor. * Not so, however, on 
 the right side of the mouth. The retention of the palatal 
 
 (•) Showin?? tbe second bicuspids, at the age of lifteen years, retardetl by 
 the presence of the preceding temporary teeth.
 
 238 A SYSTEM OF DENTAi SUBGERY. 
 
 root on the part of the deciduous tooth, would have enabled 
 it to hold possession of the position, to the exclusion of the 
 second bicuspid, producing, perhaps, a similar result to that 
 shown in Fig. 117. But if we resolve upon removing deci- 
 duous teeth in all cases when the normal period arrives for 
 their replacement, the practice will now and then lead to 
 disappointment ; we may remove a temporary tooth which J 
 is destitute of a successor, as sho^vn in Fig. 98, or we may ^ 
 make way for an imperfect tooth, inferior in every respect to 
 its predecessor. These exceptional cases are, however, of such 
 rare occurrence, that although they should not be entirely 
 disregarded, their influence upon our practice should be but 
 comparatively slight. Then, again, the temporary tooth may 
 not only retard the permanent tooth, but it may also lie at a 
 lower level than the adjoining teeth, and consequently if 
 allowed to remain, render little or no service in mastication, 
 as in Fig. 117. ^ 
 
 Regarding, then, the persistence of temporary t^eth as a 
 cause which commonly operates unfavourably, not only by 
 retarding the eruption of j^ermanent teeth, but also by pro- 
 ducing irregularities in the dental series, their removal must, 
 as a general rule, be attended with advantage. 
 
 The wisdom tooth is sometimes prevented from assuming 
 its proper position by being situated immediately beneath 
 the second molar. Very recently a second upper molar was 
 extracted at the Dental "Hospital, between the fangs of which 
 was a hemispherical cup of bone with a perfectly smooth 
 surface, which was at first sight imagined to be a portion of 
 the floor of the antrum. On examining the mouth, however, 
 the crown of the wisdom tooth was found to occupy the 
 space whence the tooth had been extracted, so that the cup 
 of bone proved to be a portion of the bony cell in which it 
 had lain buried. 
 
 Whether the wisdom tooth will now descend into the 
 alveolar line (the patient being over thirty years of age) 
 remains to be seen.
 
 TEETHING. 
 
 239 
 
 The consecutive changes in the teeth and jaws, which in 
 the healthy subject keep pace with the general gro\yth of 
 the body, have to some extent been traced ; and the results 
 which are entailed when the development of those parts is 
 interfered with have been pointed out ; and this brings us 
 to the end of one division of our subject. The section may 
 
 Fig. 121. 
 
 be concluded by the introduction of the preceding figure 
 (Fig. 121), The specimen delineated is, I think, unique ; a 
 hippopotamus's tusk, the cutting edge of which, from want 
 of antagonism, and the consequent absence of wearing away, 
 gradually advanced until it entered the pulp cavity, and thus 
 ])ut an end to the further development of the tooth.
 
 [ 240 ] 
 
 THE DEXTAL TISSUES; 
 
 List of works referred to in the sectioa relating to the 
 Dental Tissues :— Q) 
 
 1. KoLLiKEK. — " Handbiich der Gewebelehre." ote Auflage. 
 
 1867. 
 
 2. Waldeyer. — " Strieker's Handbook of Human and Com- 
 
 parative Histology." Sydenham Society Translation. 
 1870. 
 
 3. Boll, F. — " Untersuchungen liber die Zahnpulpa." 
 
 Archiv fiir Mikros. Anat. Vol. iv. 1868. 
 
 4. Hertz. — " Untersuchungen liber den feineren Bau der 
 
 Zahne." Virchow Archiv. 1866. 
 
 5. Beale, Dr. L. S. — "On the Structure of the Simple 
 
 Tissues," 1861 ; and, " Lectures on the Structure and 
 Formation of the Teeth." (Reprint in " Archives of 
 Dentistry," vol. i.) 
 
 6. Hoppe-Seyler. — "Tirchow's Archiv." Bd. v. and Ixl. 
 
 xxiv. 
 
 7. Tomes, J. — " Transactions of the Eoyal Society." 1850. 
 
 8. Salter, S. J.— "Archives of Dentistry." 1865. 
 
 9. Neumann. — " Beitrage zur Kentniss des normalen Zahn- 
 
 und Knochengewebes." 1863. 
 10. RoBTN et Magitot. — " Sur la genese et developpement des 
 Follicules dentaires." "Journal de la Physiologic." 
 1860 and 1861. 
 
 (1) As repeated reference will have to be made to the views held by various 
 authorities, it has s^med advisable, in order to avoid needless repetition of the 
 titles of books, to give a list of works referred to in a coUecied form.
 
 THE DENTAL TISSUES. 241 
 
 11. Huxley. — "On the Development of the Teeth," &c. 
 
 " Quarterly Journal of Microscopical Science." October, 
 1853. 
 
 12. Harting. — " Quarterly Journal of Microscopical Science." 
 
 April, 1872. 
 
 13. Rainie. — " British and Foreign Medico-Chirurgical Ee- 
 
 view." No. xl. October, 1857. 
 
 14. CzERMAK. — " Beitrage zur Mikr. Anat. d. Menschl. 
 
 Zahne." Zeitschrift. f. Wiss. Zool. 1850. 
 
 15. Wenzel, Bruck, Sakti Sirena, as quoted in Henle's 
 
 " Bericht iiber die Fortschritte der Anatomic im Jahre. 
 1871." 
 
 16. E. Lent. — "Ueber die Entwicklung des Zahnbein und 
 
 des Schmelzes.'' Zeitscrift. f. Wiss. Zool. 1854. vi. 
 
 17. Tomes, J. — "On the Structure of the Dental Tissues in 
 
 the order Rodentia." " Philos. Transact." 1850. 
 
 18. Tomes, J. — " On the Structure of the Dental Tissues of 
 
 Marsupial Animals." " Philos. Transact." 1849. 
 
 19. Tomes, C.S. — "On the Nature of Nasmyth's Membrane." 
 
 " Quart. Journal of Microsc. Science." 1872. 
 
 Those abnormal conditions of the teeth and of the dental 
 arch which are the direct consequence of interruption, either 
 in the progressive development of the alveolar portions of the 
 maxilla3, or in the en^ption of the teeth, have been described 
 under the general head of Teething. We have now to con- 
 sider the dental tissues in relation to the diseases to which 
 they are subject, before passing to the study of the diseases 
 themselves. 
 
 Imperfect structural development, although a predisposing, 
 cannot be regarded as the exciting cause of diseased action. 
 Irregularity, either in the form or the position of teeth, is 
 altogether attributable to a disturbance in the laws presiding 
 over the development of the dental organs ; but the destruc- 
 tion of a tooth by caries commences after the tooth takes its 
 place in the alveolar line, and becomes exposed to influences 
 
 R
 
 242 A SYSTEM OF DENTAL SURGERY. 
 
 from which it was altogether protected prior to its eruption. 
 The teeth may, and very commonly do, present all the general 
 characters of well-developed organs, and yet when examined 
 by the aid of the microscope, exhibit unmistakeable signs of 
 defective organization, rendering them highly susceptible to 
 disease when placed within the influence of the necessary 
 conditions. 
 
 On the other hand, those defects of structure which render 
 the tooth liable to early and rapid destruction, may be appa- 
 rent to the naked eye so soon as the crown of the tooth 
 becomes visible. 
 
 Before, however, the characteristics of the diseases, and of 
 their predisposing and exciting causes, are entered upon, it 
 will be desirable to give a short sketch of the histological 
 characters of the tissues in which they are situated. It will 
 not be necessar}^ to enter at any great length, either into the 
 development or the structure of the tissues of the teeth, in a 
 work on dental surgery, though, inasmuch as an under- 
 standing of pathological conditions requires an accurate 
 knowledge of the characters which appertain to the normal 
 structure, it is desirable to give a brief account of the various 
 dental tissues in this place. 
 
 A tooth is composed of enamel, cementum, dentine, and 
 dental pulp. 
 
 The relative position of the several structures which col- 
 lectively form a tooth may be best seen by dividing one of 
 the front teeth longitudinally. Commencing the examination 
 from the surface, we shall find the crown is encrusted by a 
 layer of enamel, which is comparatively thick over the pro- 
 minent parts of the masticating surface, but becomes thinner 
 on the sides, and is eventually lost on the neck of the tooth. 
 At its terminal edge, the enamel is slightly overlapped by the 
 cementum, which holds to the fang and neck of the tooth 
 similar relations, in respect of position, to that which the 
 enamel does to the crown. 
 
 The cementum attains its maximum amount of thickness
 
 THE DENTAL TISSUES. 243 
 
 abont the terminal portion of the root, and suffers a gradual 
 diminution until it is lost on the neck of the tooth. In a few 
 instances it may be traced, not only over the terminal edge 
 of the enamel, but for some little distance upon the coronal 
 portion of the tooth, and specimens are now and then found 
 in which it appears to partially fill up deep fissures situ- 
 ated between the tubercles of the molar teeth. Such, at 
 least, seems the most probable explanation of the occurrence 
 of bodies occupying deep fissures in the enamel, which pre- 
 sent all the characters of so-called lacunal cells. 
 
 They are, unless distorted by mutual pressure, rounded 
 bodies in the centre of which are hollow spaces of varying 
 size ; in some instances the central space is small, in others 
 large and produced out into numberless canaliculi. The re- 
 semblance of these bodies to those lacuna3 contained in cap- 
 sule-like investments, which are to be seen wherever cementum 
 is thick (they are commonly abundant in exostosed cementum, 
 or the thick cementum which fills up the interstices of the 
 crown in pachyderms), is most complete, both in size and 
 appearance ; and it is diflicult to suppose that their origin is 
 difterent. It would, however, be out of place to enter into 
 any long discussion whether coronal cement exists in man, in 
 the present work ; the more so as the facts bearing on the 
 question are to be found in a collected form elsewhere (19). 
 It may, however, be mentioned here that the dark masses 
 found in the fissures of enamel may, by using acid until the 
 enamel is destroyed, be easily shown to be nothing else than 
 portions of Nasmyth's membrane, which has in these places 
 attained a greatly increased thickness. 
 
 The enamel and the cementum enclose the dentine, the 
 outer surface of which, if the investing tissues were removed, 
 would still present the characteristic form of the tooth with 
 but little alteration, excepting a slight diminution of size, 
 while the cusps would be somewhat sharper than before the 
 removal of the enamel. 
 
 The great bulk of the tooth is made up of dentine, in the
 
 244 A SYSTEM OF DENTAL SURGERY. 
 
 centre of which is found a cavity, bearing a general resem- 
 blance in form to that presented by the tooth itself. In the 
 central cavity the pulp of the tooth is contained. In the 
 roots of the teeth the cavity is small, and the pulp is at this 
 point principally composed of nerves and bloodvessels ; but 
 as the neck of the tooth is approached, the cavity attains its 
 maximum size, and afterwards diminishes as it assumes the 
 form presented by the outer surface of the tooth. The pulp 
 cavity communicates with the surface of the tooth by a small 
 opening situated at the end of the root, and through this 
 opening the nerves and vessels enter. In a few cases, canals 
 for the passage of vessels may be found entering the pulp 
 cavity through the side of the tooth, midway between the 
 neck and the apex of the root, while in a few others they 
 enter by several minute canals ; but these must be regarded 
 as exceptional cases. 
 
 The Enamel. — In a fully formed tooth the enamel contains 
 only from one to three per cent, of organic matter, though in 
 the opaque chalky-looking enamel of a tooth not yet com- 
 pleted the organic constituents amount to as much as fifteen 
 l>er cent. This organic matter, said not to belong to the class 
 of gelatinous tissues, but to be closely similar to epithelium 
 in its chemical relations, is stated not to exist between, but 
 in the substance of the prisms (Hoppe-Seyler). The enamel 
 is made up of parallel fibres which lie in close contact with 
 one another, no intervening substance being demonstrable. 
 From their close mutual apposition they assume forms more 
 or less nearly approaching that of hexagonal prisms ; so that 
 on transverse section a mosaic-like pattern of hexagonal areas 
 is seen ; but some fibres will be found to be nearly square, 
 others nearly circular. 
 
 The inner ends of the fibres rest upon and are united to 
 the surface of the dentine, while the outer extremities form 
 the surface of the crown of the tooth. 
 
 In tracing the course of the fibres, it will be found that 
 those situated on the prominent parts of* the crown take a
 
 THE DENTAL TISSUES. 245 
 
 vertical course, while on the sides of the tooth they pursue a 
 horizontal direction. Every intermediate position between 
 the vertical and the horizontal will be seen on examining the 
 enamel as it passes from the cutting edge of an incisor, or the 
 cusp of a molar, down the side of the tooth. The surface of 
 the dentine presenting a more or less conical figure, the 
 enamel fibres in their passage outwards would become sepa- 
 rated from each other, unless the fibres gradually enlarged, or 
 unless supplemental fibres filled up the intervals. Most fibres 
 appear to extend from the surface of the dentine to the sur- 
 face of the enamel ; and as there is no reason to think that 
 the fibres are subject to gradual enlargement, the presence of 
 supplemental fibres need not be doubted, though their ex- 
 istence is not easy to demonstrate. 
 
 The fibres, in their passage from the dentine to the free 
 surface, pursue a waved, or, according to Hannover, a spiral 
 course ; in man the varying direction of contiguous bands of 
 fibres is not sufficiently regular to be readily traced out ; but 
 in certain of the rodentia (7) alternate layers of straight 
 fibres pass in directions at right angles to one another, so as 
 to produce a very regular pattern. By tracing the gradations 
 presented in the enamel of such rodents through those in 
 other members of the order in whom the pattern becomes less 
 regular, owing to the assumption of a waved course by the 
 fibres, many of the peculiar appearances presented by human 
 enamel may be more readily understood. 
 
 These appearances, known as the "decussation of the 
 ■fibres," are due to the fact that in the thickness of the section 
 several layers of enamel fibres are included, and the fibres of 
 the several layers passing in more or less different directions 
 give rise to various patterns. 
 
 If a thin section, in which the fibres are exposed in their 
 length, be examined, it will be found that they are indi- 
 vidually marked by transverse lines, or stria?, situated at 
 tolerably regular intervals. These strife do not necessarily 
 coincide in the contiguous fibres throughout the specimen,
 
 246 A SYSTEM OF DEXTAL SURGERY. 
 
 although they may be continuous over a considerable number 
 of fibres in certain parts of the preparation. 
 
 If sections taken from a number of teeth be examined, it 
 will be found that the strias are much more strongly marked 
 in some than in others, and that they are most strongly 
 pronounced in those parts of the specimens which, when seen 
 by transmitted light, have a brown colour. This, which is an 
 exceptional condition, and limited in extent in well-formed 
 teeth, will be found to pervade the whole of the enamel in 
 the teeth of certain unhealthy subjects. The teeth, in place 
 of the brilliant white and almost translucent appearance, have 
 a dull opaque yellow colour. Enamel having this defect 
 presents structural characters which are much more strongly 
 marked than obtain in that which is more perfectly deve- 
 loped. The cause of this appearance of striation is still a 
 doubtful question, none of the very various explanations 
 which have been offered proving wholly satisfactory. 
 
 It is explained by Waldeyer by a reference to the decussa- 
 tion of the prisms ; seeing that the prisms are united without 
 intermediate substance, and that contiguous layers do not 
 pass always in parallel directions, it follows as a necessary 
 consequence that the outlines of each enamel prism cannot 
 be perfectly straight and regular, and it is to this cause that 
 he ascribes the varicosities; while Hertz (4) accounts for 
 their presence by the assumption of intermittent calcification 
 of the prism. 
 
 The distinctness of the transverse striation can be greatly 
 increased by the use of dilute hydrochloric acid. The manner 
 of procedure is as follows : after reducing a section of enamel 
 sufficiently thin, place it for two or three seconds in the acid 
 (one part of hydrochloric acid to twelve parts of water). 
 Wash the section and examine it in water under a I objec- 
 tive. It will now be seen that the acid has acted upon the 
 difi"erent portions of the enamel fibres with varying efiect, 
 attacking the central portions of the fibres with the greatest 
 vigour.
 
 THE DENTAL TISSUES. 247 
 
 The appearances just described are somewhat difficult of 
 explanation ; but exceedingly similar sections may be ob- 
 tained from developing enamel without the use of an acid. 
 The deposition of the hardening salts takes place in the first 
 place at the periphery of the enamel cells, and goes on to- 
 wards its centre until it is filled up entirely. Hence enamel 
 as at first formed is fenestrated, and the older the forming 
 enamel the smaller are the perforations ; this condition has 
 been well figured by Hertz (4). 
 
 It seems, therefore, that the action of dilute acid is to 
 reverse the course of calcification, removing first that which 
 was last deposited, and the varying appearance of the dif- 
 ferent sections is, in all probability, referable merely to their 
 obliquity. 
 
 When enamel is fractured, the line of fracture appears to 
 run through the centre of the fibres, and not, as might have 
 been expected, through their interspace. 
 
 In the parts of the section where the fibres have been 
 divided transversely the appearance of a perforated membrane 
 will be left, the openings corresponding to the centre of the 
 fibres. 
 
 Fig. 122. (1) 
 
 If the section chance to divide the fibres obliquely, the 
 openings left after the action of acid will approach an oval or 
 even a squarish form, according to the forms assumed by the 
 prisms themselves as a result of mutual pressure. Now and 
 
 (1) A tranverse section of the enamel, showing the fenestrated structure left 
 after the removal of the central portions of the fibres by acid.
 
 248 A SYSTEM OF DENTAL SUEGERY. 
 
 then, however, an appearance is seen which is depicted in the 
 accompanying illustration (Fig. 124). In this case the acid 
 has stopped short of wholly removing the axial portion of the 
 fibres, which remain as a granular opaque mass. From the 
 general appearance of the section from which this drawing 
 
 was taken, it would be taken for a longitudinal section of 
 enamel ; it is, however, exceedingly difficult to get a truly 
 longitudinal section, as the very varied course of the fibres 
 precludes the possibility of getting a section in which their 
 direction remains the same for any distance ; and it is more 
 
 Fig. 124. (2) 
 
 (1) A section similarly treated, in which the plane of the section crosses the 
 direction of the fibres obliquely. 
 
 (2) Section in which the acid has stopped short of oansini? actual perforations, 
 leaving instead the centres of the fibres (cut ends of.') looking dark and 
 granular. Ti.e figure is in one respect faulty ; it is never possible to see the 
 outlines of the dark ma?.ses very sharply defined, and they generally have a 
 more square or oviU furm than is here depicted.
 
 THE DENTAL TISSUES. 249 
 
 probable that the appearance here depicted is due to the 
 obliquity of the section. 
 
 But the conditions which are manifested in perfectly ma- 
 tured normal enamel do not obtain until the development of 
 the tissue is fully accomplished ; and it will be recollected 
 that young enamel contains as much as fifteen per cent, of 
 organic matter, whilst this is diminished in adult enamel to 
 three per cent. During the process of formation, the fibrous 
 arrangement is exceedingly distinct, and may readily be 
 demonstrated by the aid of hydrochloric acid. If, for 
 example, a thin section be made from a tooth the crown only 
 of which is undergoing development, and submitted to the 
 action of acid, it will be found that the earthy ingredient dis- 
 appears, leaving a series of decalcified fibres attached like a 
 fringe to the surface of the dentine. The manner in which 
 these differences arise may, however, be seen if the enamel 
 be carefully examined during the progressive stages of its 
 development. It is desirable to enter to some extent into 
 the subject of enamel development in order that structural 
 defects may be the more readily understood ; the more so as 
 the information on this matter contained in the text books 
 ordinarily accessible to the dental student is but scanty. 
 
 The investigation may be pursued with advantage in the 
 teeth of a seven or nine months' foetus. If an incisor be re- 
 moved from its crypt in the jaw, enclosed within its in- 
 vesting sac, we should, were it possible to make a section 
 through it without disturbing its several parts from their 
 normal relations, find the following succession of structures 
 over the crown of the tooth. On the immediate inner surface 
 of the sac would lie the rounded epithelium-like layer of cells 
 which constitute the external epithelium of the enamel 
 organ ; in contact with this, subsequently to the disappear- 
 ance of the stellate reticular tissue, would lie the cells con- 
 stituting the stratum intermedium, and next to these the 
 hexagonal, prismatic, cells which are called the internal 
 epithelium of the enamel organ or enamel cells. These last
 
 250 A SYSTEM OF DENTAL SURGERY. 
 
 are connected b}' one extremity with the cells of the stratum 
 intermedium, by the other with the surface of the deve- 
 loping enamel. 
 
 Such a section cannot well be made, on account of the 
 great hardness of the enamel ; but these relations may be 
 well seen on sections of the tooth sacs of young animals, 
 which have been hardened in chromic acid, and subsequently 
 decalcified and cut. But most instructive preparations may 
 be made, by which the process of enamel development may be 
 traced, in fresh tooth sacs. 
 
 If, for example, a dental sac which has been removed from 
 the foetal jaw be carefully opened, it will be found that a 
 gelatinous semifluid substance is interposed between the inner 
 walls of the sac and the coronal surface of the young tooth. 
 Cylindrical columns, having near the extremity which lies 
 farthest from the formed enamel a large oval nucleus, together 
 with a large number of spherical or ovoid nucleated cells, will 
 be seen to make up this gelatinous matter. 
 
 The long cells are the formative cells or internal epithelium 
 of the enamel organ ; and if the enamel itself be examined, 
 similar columns will be found adherent to its surface. Their 
 presence may also be demonstrated in the following manner. 
 After dividing the dental sac, and turning it back so as to 
 expose the forming tooth, place the preparation in a watch- 
 glass containing dilute hydrochloric acid. In a short time we 
 shall see a membrane-like substance detach itself from the 
 surface of the enamel, which, with a littte careful manipu- 
 lation, may be removed to the microscope for examination, 
 and it will then be seen that one side of the membrane is 
 composed of columns of the enamel pulp, and the other of 
 decalcified enamel fibres, and that the columns and fibres are 
 joined end to end. 
 
 The columns are, however, very readily detached from the 
 peripheral ends of the enamel fibres, which are at this point 
 laterally united, presenting the appearance of a membrane 
 which not uncommonly assumes a deep brown colour, contrast-
 
 THE DENTAL TISSUES. 251 
 
 ing with the more internal and colourless portion of the fibres, 
 which, like the columns of the pulp, may become detached. 
 When the columns are detached from the one surface, and the 
 transparent portions of the enamel fibres are removed from the 
 other, we have remaining that which Mr. Huxley has regarded 
 as the membrana preformativa situated between the enamel 
 pulp and the enamel. Mr. Huxley was the first to discover 
 
 that this membrane could be raised from the enamel at any 
 period of its growth. Up to the time of this discovery it was 
 generally believed that the enamel was formed by the calcifi- 
 cation of the columns of the enamel pulp ; but if the membrane 
 raised by the acid should prove to be, in the strict sense of 
 the term, a well-defined membrane, separable both from the 
 enamel pulp and the enamel, and not to be a transitional 
 condition of the one in its gradual progress towards becoming 
 the other, then the conversion hypothesis must be relin- 
 quished, and we shall fall back upon the opinions held by 
 the older authors ; and we must, with Mr. Huxley, regard 
 the enamel organ as exerting no direct infiuence in the deve- 
 lopment of the enamel. 
 
 (1) Showing the columns of the enamel pulp b, connected at c with the 
 decalcified enamel fibres at a. The nuclei of the enamel cells have been omitted 
 from the figure.-
 
 252 A SYSTEM OF DENTAL SUKGEEY. 
 
 But in a series of investigations made in reference to the 
 elucidation of this point, the results did not coincide with 
 those recorded by Mr. Huxley (11), and subsequently by M. 
 Lent (16). The manner of proceeding was similar to that 
 pursued by the authors cited, which is described in the pre- 
 ceding page. Xo difl&culty attended the production of the 
 membrane, but the columns of the enamel pulp were found 
 at many points adherent, and their continuity with the fibres 
 could in some cases be distinctly traced, as sho\\Ti in the pre- 
 ceding figure (Fig. 125). Again, the detached columns ad- 
 hered in bimdles to each other by the ends which approached 
 the enamel, and many of the columns were terminated by 
 
 Fig. 126. 
 
 delicate processes, which must at the time of separation have 
 been withdra\vn from the interior of the partially calcified 
 fibres, and consequently must have passed through the mem- 
 brane which is supposed to separate the two tissues. 
 
 Immediately above the point from which the process starts, 
 each column has, when separated from its fellows, a slight 
 circumferential dilatation, as though the cylinder had been 
 everted at the edge when the separation was efiected. On 
 closer examination, the columns appear to be made up of 
 tubular membranous sheaths, within which, at the end most 
 distant from the enamel, are large oval nuclei, the remainder 
 of the cell being filled with contents more or less granular. 
 At the end dkected towards the enamel the investing mem- 
 brane appears to be absent, and it is often possible to see with
 
 THE DENTAL TISSUES. 253 
 
 the utmost distinctness that the enamel cell terminates by a 
 tubular opening. The processes shown in the last figure are 
 not by any means constantly present ; the cells often termi- 
 nate by a somewhat everted, trumpet-shaped mouth, this 
 appearance of eversion being probably due to the fact that 
 the rest of the cell has shrunk in consequence of immersion 
 in alcohol or glycerine, whilst the end lying in contact with 
 the calcified enamel has been so far altered that it is rigid 
 and incapable of shrinking under the action of reagents. It 
 is often possible to see the orifice of this everted mouth in 
 the same cells which present the processes above figured ; 
 concerning which it may be added that Hertz (4), and 
 Waldeyer (2), confirm the fact of their occurrence, and accept 
 the explanation here offered of their nature. 
 
 Now, supposing the decalcified enamel fibres are detached 
 from the columns and are viewed singly, it will be seen that 
 tlie ends which approached the dentine are clear and trans- 
 
 Fig. 127. (1) 
 
 parent, while those which meet the columns are coarse and 
 granular, appearing by transmitted light of a deep brown 
 colour ; indeed, but for the colour, it would be difficult to 
 distinguish the distal extremities of the decalcified enamel 
 fibres from the proximal ends of the columns of the enamel 
 organs. (Fig. 127.) 
 
 The conclusions respecting the development of the enamel 
 which are most in accordance with the appearances observed 
 
 fi) Showing the decalcified enamel fibres connected with the granular 
 columns of the enamel organs.
 
 254 A SYSTEM OF DENTAL SURGERY. 
 
 are these. The columns of the enamel organ {enamel cells, 
 internal epithelium of the enamel organ) are subservient to 
 the development of the enamel prisms, into which they by- 
 calcification become actually converted. This conversion 
 goes on in the following method : the proximal end of the 
 cell undergoes some chemical change preparatory to calcifi- 
 cation, 'and is subsequently calcified ; but this calcification 
 does not go on uniformly throughout its whole thickness, but 
 proceeds from its periphery towards its interior, the central 
 portion of the cell thus being calcified later than the external 
 portion which lies at the same level. At the same time that 
 calcification is proceeding inwards in each individual cell it has 
 united the contiguous cells to each other. At this point, 
 namely, at the extreme margin of calcification, the columns 
 {cells) very readily separate from the calcified fibres, leaving 
 the surface of the latter having the appearance of a perforated 
 membrane ; the perforations being due to the withdrawal of 
 the central uncalcified portions of the cells, which coastitute 
 the processes of the enamel cells figured on a preceding page. 
 
 The calcification of the central portions of the enamel 
 fibres does not, as has been already stated, keep pace with 
 that of their exteriors ; nor even in fully completed enamel 
 does it attain to precisely the same characters. For, as was 
 mentioned on page 246, the action of acids is more rapid on 
 the axial portion of the adult fibres than on their exteriors, 
 so that by irs use that appearance of fenestration which is 
 seen to normally exist in young developing enamel may be 
 restored. In the progress of calcification the nuclei of the 
 enamel cells disappear, and it is probable, as is believed by 
 Waldeyer (2), that the internal epithelium of the enamel is 
 recruited by the cells of the stratum intermedium as it 
 becomes itself used up by advancing calcification converting 
 it into enamel fibres. 
 
 But, although the balance of evidence seems to be in 
 favour of this view, it is not assented to by all observers. 
 Thus Kolliker (1) imagines that the enamel cells do not
 
 THE DENTAL TISSUES. 255 
 
 undergo direct conversion into enamel fibres, but that the 
 enamel is, as it were, shed out from their ends ; that it is 
 a secretion from them, not a deposition in their own sub- 
 stance. 'The processes which are so often to be seen on the 
 ends of enamel cells he regards as artificial products, and 
 explains as being fragments of partially-developed enamel 
 accidentally torn away with the cells. ^ 
 
 More recently, Wenzel has written (15) in support of this 
 excretion theory of enamel development, but the grounds 
 advanced by him do not appear at all conclusive. 
 
 Again, Professor Huxley (11), whose opinion on histolo- 
 gical matters must always carry great weight, expressed the 
 opinion that, " Neither the capsule nor the ' enamel organ,' 
 which consists of the epithelium of both the papilla and the 
 capsule, contribute directly in any way to the development 
 of the dental tissues, though they may indirectly." 
 
 This opinion is based upon the fact that, by means of an 
 acid capable of dissolving calcium carbonate and phosphate, 
 a membrane can be raised from the surface of developing 
 enamel at any stage in its growth, the membrane so obtained 
 being identical with the membrana preformativa of Raschkow. 
 The structural characters of this membrane have been 
 already in some measure described (page 250), and it now 
 remains to inquire somewhat more closely into its true 
 nature. Whatever be the explanation, it must not be for- 
 gotten that the presence of this so-called membrane can be 
 demonstrated only after the use of reagents, and that a tissue 
 the existence of which can only be discovered after the 
 application of potent chemical reagents, is open to the sus- 
 picion of being merely an artificial product. 
 
 It will be remembered that this membrane, which is found 
 to be foraminated, is what remains after the enamel cells have 
 been torn away from one of its surfaces, and the calcified 
 enamel fibres from the other. But it may be asked. Why is 
 it that we have cohesion at this part, while tlie cells above, 
 and the fibres below, so readily separate from each other and
 
 256 A SYSTEM OF DENTAL SURGERY. 
 
 from the coherent part? The solution of this question is 
 probably to be found in the chemical nature of the parts con- 
 cerned. It is probable that this, which intervenes between 
 the fully calcified and the uncalcified parts, has undergone 
 some chemical change preparatory to, or coincident with, the 
 first deposition of lime salts, by which it is rendered more 
 resistant to the action of reagents than that which lies on 
 either side of it. What the nature of this change may be, is 
 to some extent conjectural, though the researches of Professor 
 Harting, to be mentioned on a succeeding page (page 282), 
 throw much light on the question. 
 
 In fine, then, this membrane is to be regarded as the 
 youngest layer of enamel, as yet but slightly impregnated 
 with mineral constituents ; and this view has lately received 
 full confirmation at the hands of Waldeyer (2). 
 
 Although the fibres of the enamel have attained their full 
 length some time before the tooth is cut, the development of 
 the tissue can scarcely be regarded as matured until after that 
 period ; for at the time a tooth passes through the gum, the 
 enamel is comparatively soft and fragile, and it is only after 
 the lapse of some months, or even years, that it attains its 
 full degree of hardness. 
 
 Prior to the surface suffering any wear, a membrane can be 
 separated from the surface of the enamel by the employment 
 of an acid. Mr. Nasmyth was the first to draw attention to 
 this fact, and he described the membrane so separated as the 
 persistent dental capsule. 
 
 Mr. Huxley considers it to be identical with the membrana 
 preformativa, that is to say, the membrane intervening be- 
 tween the enamel cells and the enamel fibres; which must be 
 regarded as a mere artificial product, and as having no real 
 existence. 
 
 Waldeyer (2), who recognises the artificial nature of the 
 so-called " membrana preformativa," regards this Nasmyth's 
 membrane, or cuticula dentis, as formed from the external 
 epithelium of the enamel organ, which, after the disappearance
 
 THE DENTAL TISSUES. 
 
 257 
 
 of the stellate tissue, comes into contact with the internal 
 epithelium, or enamel cells. According to this observer, the 
 cells of the external epithelium of the enamel organ have 
 undergone a metamorphosis into a cornified tissue, and he 
 states that the outline of the cells can be mapped out by 
 staining with nitrate of silver. 
 
 KoUiker (1), however, strongly dissents from this view of 
 its origin, and, whilst admitting that accurate researches on 
 the matter are wanting, thinks it more likely that it is a 
 connected layer furnished by the enamel cells as a covering 
 to the whole enamel, a maimer of finish for which, he says, 
 many analogies may be found. But none of these views are 
 capable of accounting for all the appearances observed in it. 
 
 The cuticula dentis (enamel cuticle, Nasmyth's membrane) 
 is a membrane which may be raised as a continuous layer 
 from the surface of an unworn tooth by the action of acids. 
 It is unchanged by maceration in water, by boiling in strong 
 acetic, hydrochloric, sulphuric, or nitric acids, by the last of 
 which it is stained yellow. Boiled in caustic potash it swells 
 slightly. When burnt it gives off an ammoniacal odour, and 
 leaves a spongy ash. 
 
 In the first edition of this book it was stated that in 
 several specimens which had been decalcified after being 
 reduced sufiiciently thin for microscopic examination, this 
 membrane was obviously continuous with the cementum of 
 the fang ; and in other specimens w^hich had not been treated 
 with acid, the membrane was thickened in the deep de- 
 pressions of the crowns of molar teeth, and there tenanted by 
 distinct lacunae. The occurrence of these two circumstances 
 would indicate that Nasmyth's membrane is cementum, 
 rather than membrana preformativa. The general absence 
 of lacunse in this membrane is due to its want of sufficient 
 thickness to contain them, just as we find these bodies want- 
 ing in the cementum of the fang when the layer of that tissue 
 is very thin. 
 
 But inasmuch as these facts appear to have been overlooked
 
 258 A SYSTEM OF DENTAL SURGERY. 
 
 by most recent writers, and this view as to its nature ignored, 
 a series of observations on a large number of specimens have 
 recently been made, which are in the fullest degree con- 
 firmatory of the conclusions stated in the first edition of this 
 book. It would here be out of place to enter at any length 
 into the facts on which this statement is based, the more so 
 as they are to be found elsewhere (^) ; but it may be mentioned 
 that it often seems to be continuous, not with the fully 
 formed cementum which forms a thin structureless layer round 
 the neck of the tooth, but with something external to this. 
 And it is a very significant fact, that this membrane presents 
 all the characters of tissue prepared for calcification, which 
 we already know undergoes some chemical change preparatory" 
 to the actual deposition of salts, conferring upon it a remark- 
 able power of resisting reagents (see pages 256 and 28li). 
 
 According to these researches, then, Nasmyth's membrane 
 is to be regarded as cementum either imperfectly calcified, or 
 not yet calcified at all. 
 
 Apart, however, from this apparently structureless layer 
 described by Mr. Nasmyth, we may sometimes observe a 
 diminution in the fibrous character of the enamel at the ter- 
 minations of the fibres on the surface of the tooth, and also 
 at the terminal edge of the enamel on the neck of the tooth. 
 In each of these situations appearances may be found which 
 suggest the idea that a fluid blastema became calcified, and 
 that the fibres had in the process become fused and more or 
 less lost in the mass so formed. Indeed, in the situation last 
 mentioned, lamination of an indistinct character may take 
 the place of fibres ; or both the laminated and fibrous ar- 
 rangement may be replaced by a structure exhibiting little 
 arrangement of parts. In well-developed teeth, however, this 
 deviation from the usual character of enamel is limited to the 
 terminal edge of the tissue. 
 
 The preceding observations for the most part relate to the 
 
 (1) C. S. Tomes. On the Xature of Nasmyth's Membrane. Quarterly Journal 
 <rf Microscopical Science, 1872.
 
 THE DENTAL TISSUES. 259 
 
 enamel when perfectly formed. We have now to direct our 
 attention to defects in the structural character of the tissue. 
 Faulty organization very frequently leads indirectly to the 
 development of disease; it is therefore desirable that the 
 conditions which characterise the imperfections should be 
 recognised. We may divide them into defects in the quantity 
 and in the quality of the tissue. 
 
 The Dtntlne. — If a median longitudinal section of a tooth 
 be made, it will be seen that the surface of tlie central cavity 
 is everywhere pierced by an infinite number of extremely 
 minute openings. Tliey are the orifices of the dentinal tubes, 
 the parietes of which, together with the matrix in which they 
 lie, make up the walls of the pulp-cavity. The tubes take a 
 radiate course from the central axis formed by the pulp- 
 cavity towards the surface of the tooth. In the crown, and 
 also to some extent, though in a less degree, in the root, in 
 addition to numerous secondary minute undulations, the 
 tubes describe several bold curves, which are commonly de- 
 scribed as resembling the italic letter/. Those situate in the 
 crown differ in some respects from those which occup}^ the 
 I'oot of the tooth. In each situation the branches which are 
 given off are very numerous, but in the crown there are com- 
 paratively few, until the tubes approach the surface encrusted 
 by the enamel ; while in the root blanches are given off from 
 the tubes throughout the Avhole of their course, more abun- 
 dantly, however, as they near the surface of the dentine. 
 The dentinal tubes, by the anastomosis of their branches, 
 become connected with each other, and also establish rela- 
 tions with the external dental tissues ; in the crown of the 
 tooth they terminate by forming loops, or become too minute 
 to be traced, or pass into the enamel and become lost. In 
 teeth the dentine of which is imperfectly developed, the 
 terminal branches are lost among, or end in, the minute 
 cavities which abound in the layers at or near the peripheral 
 surface of the dentine. In the neck and root of the tooth, 
 the branches of the tubes anastomose freely, and are lost
 
 260 A SYSTEM OF DENTAL SURGERY. 
 
 near the surface of the tissue ; near the neck they stop short 
 of the cementum, but towards the end of the root they not 
 uncommonly pass into the cementum, and connect them- 
 selves with the lacunae. By the extension of the dentinal 
 tubes into the enamel Q) and into the cementum, a connection 
 is formed more intimate than mere superposition and ad- 
 hesion of the one to the other would have established, and 
 the more so as the three tissues are developed from distinct 
 formative elements. 
 
 In a section which has been dried the tubes become very 
 distinct, and it is often possible, by adding a coloured fluid 
 to the preparation whilst it is under the microscope, to ob- 
 serve its gradual passage into the tubes. 
 
 With respect to the contents of the tubes in the fresh state, 
 it was formerly supposed that they contained a clear fluid, and 
 were hence not easy to observe in a fresh wet preparation. 
 
 But the view that the canals are hollow tubes conveying a 
 nutrient fluid has, for many years, been almost universally 
 abandoned ; M. Kolliker (1) and others, who were at first dis- 
 posed to call in question the existence of solid contents 
 in the tubes, having for some time past given expression 
 to their conviction that they do exist, and may readily be 
 demonstrated. (^) 
 
 If a portion of enamel be accidentally broken from the 
 crown of a tooth, so that the dentine becomes exposed, the 
 
 (1) In the marsupial animals the uniform extension of the dentinal tubes, 
 not only into but through the greater portion of the whole thickness of that 
 tissue, forms a character sufficiently marked to distinguish the teeih of that 
 from any other order of mammals.— On the Structure of the Dental Tissues of 
 the Marsupiata, Philosophical Transactions, Part II., 1849. It may be ind- 
 deutally mentioned here that this penetration of the enamel by the dentinal 
 tubes has been doubted by Waldeyer and Hertz ; nothing can possibly be more 
 clear than their passage across the boundary in any well-prepared section, and 
 Kolliker remarks (1) that he cannot conceive how Waldeyer and Hertz can deny 
 its existence. 
 
 (2) Mr. Salter (8) stands almost or quite alone in denying the existence of 
 soft fibrils in the dentinal tubes, but the grounds on which he does so bein-; 
 fully met by the statements of various writers, notably of M, Kolliker, do not 
 call for more than passing notice here.
 
 THE DENTAL TISSUES. 261 
 
 surface of the latter will be highly sensitive to any variation 
 of temperature, or to the contact of foreign bodies ; even 
 slight pressure from the tongue will give pain. It is, however, 
 noteworthy that the degree of pain is not increased by in- 
 creasing the pressure. Then again, it is a fact of every day 
 observation that the dentine immediately below the enamel 
 is much more sensitive than that which lies deeper in the 
 substance of a tooth. 
 
 If the pulp of a tooth be destroyed, either by an instrument 
 or by the use of an escharotic, the sensitiveness of the Avhole 
 of the dentine is immediately lost, no pain being experienced 
 when it is subsequently cut, either near to the enamel or to 
 the pulp-cavity. 
 
 If the pulp be destroyed the dentine loses for ever its 
 power of feeling pain, though it may in favourable situations 
 remain hard and free from discoloration, even if exposed to 
 the fluids of the mouth ; its sensitiveness is then wholly 
 dependent on its connection with the pulp of the tooth, and 
 it has no inherent sensibility in its own substance. 
 
 Nevertheless, the sensitiveness of dentine may be got over 
 without the death of the pulp taking place as a necessary 
 condition. The teeth of young subjects are much more sen- 
 sitive than those of older people, and this is more especially 
 the case when they are attacked by caries. 
 
 The dentine of teeth which are rapidly decaying is much 
 more sensitive than that of teeth in which the destruction 
 progresses more slowly. The former condition is indicated by 
 the light colour of the decomposing j^art, together with the 
 extent of tissue involved ; the latter by the deep brown 
 colour, and the comparative hardness of the affected dentine. 
 In certain cases of caries, the softened tissue appears to be 
 extremely sensitive, so that the patient can scarcely bear its 
 removal; but when the instrument reaches the comparatively 
 healthy dentine, the pain, although present, is much less 
 severe. 
 
 After a portion of dentine has been for some time exposed.
 
 262 A SYSTEM OF DENTAL SURGERY. 
 
 or if the exposure be brought about gi'adually by the slow 
 wearing away of the enamel, that acute sensitiveness which 
 has been described is not found to exist. In parts which 
 have been subject to the foregoing conditions, it will, 
 on examination, be found that the dentinal tubes, the peri- 
 pheral extremities of which have been exposed, are more or 
 less obliterated in some part of their course between the 
 surface and the pulp-cavity. 
 
 And it is possible to destroy the sensitiveness of dentine 
 by local applications, such as nitrate of silver, chloride of 
 zinc, or arsenious acid, any one of which will have the effect 
 of rendering perfectly insensible the surface to which it may 
 be applied, though, unless its action be very prolonged, it will 
 not penetrate to any great depth. On removing the imme- 
 diate surface which has been acted on by these escharotics 
 the dentine beneath will be found to be as sensitive as ever ; 
 thus unequivocally showing that their action has not been 
 upon the pulp, but upon the spot to which they have been 
 applied. 
 
 On reviewing the various circumstances under which den- 
 tine evinces sensibility, and those under which that sensibility 
 is lost, it is difficult to avoid the conclusion that the dentinal 
 tubes are in some way the medium through which sensation 
 is distributed through the substance of the tissue. But if the 
 sole office of the tubes were conveyance of nutrient fluid 
 derived from the pulp, the difficulty of accounting for the 
 sensitiveness of the dentine remains, inasmuch as we have no 
 instance of sensation being manifested in a fluid. We might 
 endeavour to get out of the difficulty by assuming that the 
 dentinal tubes are constantly filled by fluid, and that pres- 
 sure made upon the fluid at the exposed ends of the tubes is 
 felt by the pulp at their inner extremities. This assumption 
 does not, however, account for nearly all the circumstances 
 of the case, failing altogether to ex[)lain the greater sensi- 
 bility of the dentine at one part of the tooth than at another, 
 or the local effect of escharotics.
 
 THE DENTAL TISSUES, 263 
 
 The want of accordance between the views formerly enter- 
 tained upon the structure of dentine and the physiological 
 conditions manifested by that tissue when in connection with 
 the body, has wholly arisen from the assumption that the 
 dentinal tubes are solely for the conveyance of fluid, and that 
 they were destitute of solid or semi-solid contents. With the 
 hope of gaining some further knowledge upon this point, I 
 commenced a series of observations, having, however, but 
 little expectation of finding that one of the most important 
 parts in dental structure had been overlooked, namely, that 
 each dentinal tube is permanently tenanted by a soft fibril, 
 which, after passing from the pulp into the tubes, follows 
 their ramifications. Q) 
 
 If a tooth or a section be subjected to the action of dilute 
 acid (hydrochloric acid answering the purpose well), a firm 
 elastic mass is obtained which preserves the external form of 
 the tooth, and, on microscopic examination, is found also to 
 preserve its structure. It is in fact the organic basis of 
 dentine, the framework in which the calcareous salts were 
 deposited, which is left behind after their removal by the 
 acid. 
 
 But if in the place of dilute acid, concentrated hydrochlo- 
 ric acid had been employed, after a time nothing but a 
 sticky, slimy mass would have remained, in no way retaining 
 the form of the tooth. And, on microscopic examination, this 
 would be found to consist wholly of long tubes tangled toge- 
 ther, and obviously very flexible and very tough. 
 
 These tubes, which constitute the special walls of the 
 dentinal canals, are the most indestructible part of the whole 
 tooth ; prolonged boiling in strong hydrochloric acid or in 
 caustic alkalies has no effect upon them ; and they may be 
 obtained even from fossil teeth (Hoppe-Seyler). They consti- 
 tute the " dentinal sheaths '* of Neumann, and previously to 
 
 (1) On the Presence of Fibrils of Soft Tit-sue in the Dentinal Tubes, by 
 John Tomes, F.R.S., Surgeon-Dentist to the Middlesex Hospital.— Philosophical 
 Transactions, Vol. 14t). Ib5l).
 
 264 A SYSTEM OF DENTAL SURGERY. 
 
 the decalcification were intimately connected with the matrix 
 which they traverse. 
 
 They may be obtained after the tooth has been long mace- 
 rated so as to putrefy, or has been long boiled in caustic 
 alkalies so that any soft tissue would have been destroyed 
 (Kolliker, 1). Their precise chemical nature remains some- 
 what doubtful. Waldeyer (2) considers them allied to elastic 
 tissue ; but Neumann (9) holds them to be calcified ; whilst 
 Kolliker (1) compares them to the internal sheaths limiting 
 old Haversian canals, and to the capsules around osteoblasts 
 which may sometimes be isolated in cementum. 
 
 Deferring for the present the further consideration of the 
 dentinal sheaths, we pass to their contents. In the interior 
 of each (in the fresh tooth) lies a soft homogeneous fibril Q), 
 by no means so indestructible as the sheath. Thus, if the 
 tooth be allowed to putrefy, or be boiled, or even treated in 
 the cold with caustic alkalies, it absolutely disappears ; and 
 it is by no means diflBcult to destroy it by the use of acids. 
 
 If a section be made of a recently extracted tooth in a 
 direction parallel with the tubes, placed in dilute hydrochlo- 
 ric acid till it is decalcified, and then torn in a direction 
 transverse to that of the tubes, the torn edges will be seen to 
 be fringed with transparent processes of varying length. 
 
 In repeating the experiment, it is desirable to place the 
 decalcified section upon the slide before tearing it, as if it be 
 lifted from the surface on which it has been torn, some of the 
 longer fibrils may get folded back upon the body of the 
 section, and thus become hidden from view. 
 
 Where the separation between the torn surfaces has been 
 but slight, we may often see an unbroken cord stretching 
 across the interval between the two halves of the dentine. 
 
 If a section be taken in which the tubes are extended into 
 the enamel, and submitted to the action of acid, it will be 
 found that after the latter tissue has been dissolved, fibrils 
 
 (1) Kolliker, Waldeyer, Beale, Neumann, Lent, Boll, Santi Sirena (who has 
 demonstrated their existence in amphibia and in lizards), Wenzel, and others.
 
 THE DENTAL TISSUES. 
 
 265 
 
 will remain connected with the dentine at those points where 
 the tubes penetrated the superjacent structure. 
 
 Nqw, it is perfectly possible to get both the sheaths and 
 their contained fibrils standing out from the edge of the den- 
 tine in one and the same specimen. Neumann (9) has suc- 
 ceeded in demonstrating both the sheaths and the fibrils in the 
 same specimen by the use of acids ; and Boll (3) has described 
 and figured the sheaths projecting from the edge of the den- 
 
 Fig. 128. (1) 
 
 tine, and the fibrils from the end of the sheaths, using for 
 the purpose teeth which had been placed in chromic acid in 
 order to harden the soft parts, and subsequently decalcified. 
 
 It is quite possible that in some of the decalcified speci- 
 mens originally figured as showing the fibrils, what were 
 really seen were the dentinal sheaths, the separate existence 
 of which was not at that time fully recognised ; but this does 
 not apply to sections which have not been decalcified ; in 
 these the fibrils, and they alone, are found to project from the 
 cut edges. 
 
 But if the soft parts have been destroyed by caustic 
 
 (1) A section from the crown of the tooth of an adult, made in a plane with 
 the direction of the dentinal tubes, and afterwards decalcified and then torn in 
 a line transverse to the direction of the tubes. The fibrils are shown extending 
 from the torn edge of the dentine.
 
 266 
 
 A SYSTEil OF DENTAL SURGEBY. 
 
 alkalies, or by putrefaction, the soft fibril can no longer be 
 brought into view, although there is no difficulty whatever 
 in demonstrating the walls of the tubes (Koliiker, 1). 
 
 . It is not necessary, however, to decalcify dentine in order 
 to show the fibrils. If a similar section to that already de- 
 scribed be divided with the edge of a knife, many of these 
 
 Fig. 129. Cn 
 
 
 mm 
 
 delicate organs will be seen, but they are usually broken off 
 much shorter, many of them scarcely projecting beyond the 
 orifices of the tubes. Again, if a minute portion of dentine 
 be cut with a sharp knife from the surfoce produced by frac- 
 turing a perfectly fresh tooth, the same appearances will be 
 seen, but not with the same certainty and distinctness, as in 
 the previous examples. 
 
 In order to demonstrate the connection of the fibrils with 
 the pulp, fine sections should be made with a sharp knife from 
 the edge of the pulp-cavity. In this manner I obtained the 
 specimen from which Mr. De Morgan has been kind enough 
 
 (1) After Boll. In this section the dentinal sheaths project for a short 
 distance beyond th? investing matrix, whilst the fibrils are seen issuing from 
 the termination of the sheath.
 
 THE DENTAL TISSUES. 
 
 267 
 
 to draw the accompanying illustration, showing the fibrils 
 stretching from the pulp to the displaced dentine, and some 
 of them passing out on the other side of the fragment 
 (Fig. 130). That the fibrils proceed from the pulp ma}' be 
 seen by carefully fracturing a fresh tooth with as little dis- 
 placement of the fractured parts as possible ; and then, by 
 
 Fi'j. 130. (1) 
 
 
 slowly removing the pulp from its place in the tooth, we 
 shall be enabled to examine the fibrils which have been 
 drawn out from the tubes. By this procedure some of the 
 fibrils will be withdrawn from their normal position in the 
 dentine in the greater part of their length, a few of them re- 
 taining short lengths of their branches, but sufficient to show- 
 that they have come from the branches of the dentinal tubes ; 
 
 (1) A section made with a knife from the edge of the pulp-cavity of an adult 
 tooth, including a portion of the pulp ; (o) the dentine ; (b) the pulp, with the 
 peripheral cells arranged in lines ; (c) the dentinal fibrils drawn out of the 
 displaced dentine ; (d) fibrils which pass through the fragment of dentine, and 
 ai p?ar on the surface farthest removed from the pulp.
 
 268 A SYSTEM OF DENTAL SURGERY. 
 
 and Dr. Beale has figured (5) a fibril proceeding from an 
 odontoblast through a minute fragment of dentine, in which 
 it appears as though the cell nucleus were produced out into 
 the fibril. According to Neumann (9) and Waldeyer (2), 
 the fibrils become atrophied in their peripheral portions in 
 advanced age, and ultimately the canals become obliterated. 
 This coincides with the observations of Dr. Beale, that the 
 canals are largest near to the pulp, and become progressively 
 smaller towards the periphery ; and with the remarks of Kobin 
 and Magitot (10), who point out that the great discrepancies 
 found in the results of analyses of human teeth arise out of 
 the fact that the teeth become more rich in calcareous salts 
 as age advances ; so that, unless teeth from individuals of the 
 same age, or rather teeth which are just in the same stage of 
 their slow calcification, are selected, the results must be of 
 necessity very various. 
 
 This, probably, also accounts for the statements of Hertz, 
 who believes that the soft fibril exists only in the dentine 
 near to the pulp, but that at a distance it is absent ; the proba- 
 bility is that the teeth submitted to examination were from 
 individuals of advanced age. 
 
 In preparations in which we are fortunate enough to retain 
 a portion of the pulp with the dentine, it may readily be seen 
 that the soft fibrils are processes of the cells known as 
 "odontoblasts," which constitute the peculiar layer called 
 the " membrana eboris." If a tooth be taken in which the 
 formation of dentine is no longer active, the cells are elon- 
 gated and oval in form, tapering down towards the dentine 
 till they attain the size of the fibril ; but if the same cells be 
 examined in a young and rapidly-growing tooth they are found 
 to be much wider and to be truncated towards the dentine, 
 so that they present flat ends, from which spring, rather 
 abruptly, one or more processes which enter the tubes and 
 constitute the dentinal fibrils. Boll (3) has counted as many 
 as six processes from a single cell, but this is an exceptionally 
 large number.
 
 THE DENTAL TISSUES. 269 
 
 The process which enters the canals in the dentine is not 
 the only one proceeding from the cell; there is always a 
 process at its opposite pole, proceeding down into the pulp 
 and connecting it with cells of a deeper layer, and there are 
 also lateral processes which connect it with the odontoblast 
 which lie around it. 
 
 The fibrils are solid and homogeneous, and may be stained 
 with carmine, though they do not take the pigment with the 
 same readiness as the nuclei of the cells do. 
 
 On examining a pulp with a low magnifying power a large 
 number of fasciculi of nerve fibres are seen passing upwards, 
 parallel with the long axis of the pulp ; these are mainly 
 derived from a single largish nerve trunk which passes into 
 the fang, often accompanied by several smaller branches. In 
 the expanded portion of the pulp in the crown of the tooth 
 these nerve fibres form a rich plexus with elongated meshes, 
 and, according to Professor Kblliker, break up into primitive 
 fibres which form evident loops. By treating perfectly fresh 
 pulps with a very dilute solution of chromic acid Q^ per 
 cent.) Boll (3) was able to discover an enormous number of 
 very minute fibrils, which he traced into continuity with the 
 dark-bordered nerve fibres. 
 
 What becomes of these fine fibres, which are especially 
 abundant immediately beneath the membrana eboris, is 
 not certainly known ; but from this plexus Boll observed 
 numerous fibrils passing up between the odontoblasts, 
 and projecting out beyond them amongst the dentinal 
 fibrils. 
 
 From the direction so frequently assumed by these very 
 fine fibrils. Boll supposes that they must, like the dentinal 
 fibrils, have been drawn out from the tubes, but he has not 
 been successful in actually seeing one passing into a dentinal 
 c^nal. 
 
 The nature and functions of the dentinal fibrils still remain 
 for consideration ; but, as Boll also found, the study of this, 
 matter is so inextricably mixed up with that of the develop-
 
 270 A SYSTEM OF DENTAL SURGERY. 
 
 ment of dentine, that the one cannot be dealt with without 
 entering at some length into the other. 
 
 Various and irreconcilable opinions are held on this matter 
 of development, but on the one point, namely, that the 
 odontoblasts play some very important part in the process, 
 most authorities are agreed ; though Professor Huxley main- 
 tained that the dentinal pulp had no very direct influence in 
 the formation of the dentine. 
 
 The tooth germ, or papilla dentis, corresponds in form to 
 the future tooth, or at least to that part of it which is at the 
 particular time about to be calcified. In its central portion 
 it is very rich in nerves and also in vessels, the latter forming 
 a dense plexus immediately l)eneath the outer layer pf^s^e- 
 cjaljsed cells. This layer, the niembrana eboris, is notjDene- 
 trated by vessels, but consists of a number of celIsj^odonto-_^ 
 blasts) arranged perpendicularly on the surface, like an 
 epithelium, and pressed closely together so as to be in intimate 
 contact with one another. 
 
 'J'he internal portions of the pulp consist of a fine fibrous 
 connective tissue containing great numbers of cells, at first 
 round but later becoming spindle-shaped (Kolliker). With 
 respect to the outer layers of the papilla, some little difi"erence 
 of opinion exists ; thus KoUiker holds that it is bounded exter- 
 nally by a structureless membrane (membrana preformativa), 
 which, however, plays no part in the development of the den- 
 tine, while the existence of any membrane in this situation is 
 denied by many other observers. The explanation given by 
 Robin and Magitot (10) of this appearance of a membrane in 
 a place where none exists seems reasonable : they point out 
 that the gelatinous-looking intercellular substance which 
 abounds in an early embryonic pulp ]3rajects outwards beyond 
 the odontoblast layer, so that it appears to form a sort of film 
 or varnish over these cells. Moreover it is stated by them 
 that this intercellular nature is more dense at the periphery 
 of the pulp than in its interior, so that the resemblance to a 
 definite limiting membrane is vet further increased. This
 
 THE DENTAL TISSUES. 271 
 
 view, namely, that the membrana preformativa of Raschkow 
 is the most external layer of matrix, projecting beyond the 
 odontoblasts, is also advocated by Hertz and Wenzel (15). It 
 does not, however, appear that this structureless matiix plays 
 any part in dentine formation ; in fact. Boll states that it dis- 
 appears. 
 
 With regard to the share taken by the odontoblast cells, 
 the prevalent opinions admit of division into two classes ; 
 according to the one, the whole of the dentine structures, 
 namely the fibrils, the sheaths of Neumann, and the matrix, 
 are wholly and directly derived from the odontoblasts, whilst 
 according to the other, the matrix is a separate secretion, 
 an " intercellular " substance, and the canals and fibrils alone 
 are derived directly from a conversion of the odontoblasts. 
 
 To take the latter view first, it is supposed by Kolliker and 
 Hertz that the odontoblast layer of cells furnish a secretion 
 which is of a gelatinous nature, and is shed out from the layer 
 of cells in common, but does not stand in any definite struc- 
 tural relation to the individual cells; by the calcification of 
 this secretion the intertubular matrix is formed, whilst the 
 cells and their processes go to form the tubes and their con- 
 tents. (See also Wenzel, 15.) 
 
 M. Lent figured and described long filamentous processes 
 of the dentine cells M^hich he regarded as forming the canals, 
 the existence of the soft fibrils not having been recognised at 
 that time. Professor Kolliker considers that a single cell may 
 generate the whole length of a tube and its contents, but 
 qualifies the statement by saying that, though constricted 
 cells occur, it is possible that the connection with the mother 
 cell may never be lost, so that it may or may not be true 
 that one cell forms the whole length of the fibril. 
 
 In opposition to the views above briefly indicated, is the 
 opinion held by Waldeyer, Boll, Dr. Beale, and many others, 
 that every part of the dentine is a direct product of the con- 
 version of the odontoblasts. This latter view is probably the 
 true one ; but, as will presently be seen, it does not, after
 
 272 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 all, differ so very widely from that held by KoUiker and 
 Hertz. 
 
 On reference to the accompanying figure, or to the excellent 
 figures given by Boll (3), it will be seen that the odontoblasts 
 close up to the dentine are in actual contact with one another, 
 and that there is no room for an intercellular substance. 
 
 Fig. 131. (1) 
 
 The preparation was made by breaking the tooth through 
 the centre immediately after its removal from the mouth, and 
 cutting with a sharp scalpel a very thin fragment from the 
 edge of the pulp-cavity, the pulp itself being present at the 
 time. We have in this example the dentinal cells adherent 
 to the developing dentine, and the continuity of the cal- 
 cified and uncalcified tissues clearly shown ; and further, 
 that it is only necessary for the cells to become hardened, 
 and, as it were, fused together, by the reception of the salts 
 
 (») Showing the appearance presented by a section cut with a sharp knife 
 from the edge of the pulp cavity of a tooth recently extracted. The peri- 
 pheral dentinal cells are retained in their natural position as respects tlie 
 developing dentine.
 
 THE DENTAL TISSUES. 
 
 273 
 
 of lime, in order to convert them into a mass similar to the 
 dentine to which they are attached. 
 
 The most external portions of the odontoblasts undergo a 
 metamorphosis into a gelatigenous matrix, which is the seat 
 of calcification, while their most central portions remain soft 
 and unaltered as the fibrils. Intermediate between the cen- 
 tral permanently soft fibril and the general calcified matrix, 
 is that portion which immediately surrounds the fibril, 
 
 Fig. 132. (1) 
 
 namely, the dentinal sheath. According to this view the 
 fibril, the sheath, and the matrix are but three stages in the 
 development of the same tissue ; as it is expressed by Dr. 
 Beale, they are bioplasm, or germinal matter, formed material, 
 and calcified formed material. There is much to be said in 
 favour of this theory of dentine formation ; there is the fact, 
 insisted on by Dr. Beale, that the hollows of the canals are 
 largest nearest to the pulp, and smallest at the periphery of 
 the tooth, in other words, at the oldest part ; and that cal- 
 cification is still slowly going on, even in advanced life, 
 leading to the peripheral obliteration of the tubes. A further 
 corroboration of this may be found in a paper published 
 
 (1) Isolated dentinal cells, which have become detached, and were fomul 
 floating about in the fluid in which the preparation formin;; the subject of the 
 last illustration was placed. In these the pulp process and the lateral processes 
 are not seen, as is apt to be the case unless special precautions are tiiken in 
 preparing the specimen. 
 
 T
 
 274 A SYSTEM OF DENTAL SURGERY. 
 
 some 3'ears ago, on the Dental Tissues of the order Eodentia 
 (Tomes, 17). 
 
 It was there stated, speaking of the incisor teeth of rodents, 
 that " the tubes which proceed from the pulp-cavit}' near the 
 biise of the tooth, are, in most cases, perceptibly larger than 
 those that are situated higher up ; hence it follows that, as 
 the latter were once near the base of the tooth, the dentinal 
 tubes undergo a diminution of calibre after their formation. 
 In the teeth of the Sciuridte I have found a difference of size 
 amounting to a third or half between the tubes near the base 
 and those near the surface ifi wear." 
 
 Then, again, there is the strongly-expressed opinion of Boll, 
 who states that the odontoblasts have certainly no limiting 
 membrane, but shade off insensibly from tlieir innermost to 
 their outermost portion, and it is noticed by Wenzel (15) 
 that fresh odontoblasts have no membranous investments, 
 sharply-defined contours being seen only after the use of 
 re-agents. The recent valuable researches of Professor Hart- 
 ing (12) serve to throw considerable light on the question. 
 He appears to have followed in the line of inquiry first 
 pursued by Mr. Eainie (page 281), and was successful in 
 making a variety of structural forms by inducing the very 
 gradual precipitation of lime salts in solutions containing 
 albumen, or other organic constituents ; and not only did the 
 lime salts assume a definite structural arrangement, but the 
 albumen itself became profoundly modified. 
 
 It was found that on treating one of the " calcosj^herites," 
 or other forms thus artificially produced, with an acid, though 
 the lime was entirely removed, the mass retained its form and 
 structure; it had, in fiict, an organic matrix. 
 
 This matrix was composed, not of ordinary albumen, but 
 of a substance closely resembling chitine in its chemical 
 relations ; that is to say, a body exceedingly insoluble and 
 exceedingly resistant to the action of re-agents. 
 
 Kow, it is a very remarkable fact, that parts which are just 
 on the borders of calcification do present this very character,
 
 THE DENTAL TISSUES. 275 
 
 namely, a remarkable power of resisting re-agents ; thus it 
 will be remembered that the most indestructible part of the 
 whole tooth substance is the dentinal sheath of Neumann, or 
 that part which intervenes between the soft fibril and the 
 completed matrix of the dentine. 
 
 Similarly, it is found that the linings of Haversian canals, 
 or the immediate surroundings of a bone lacuna, may be 
 isolated by the use of acids ; that is to say, they have a 
 greater power of resistance than either the fully calcified 
 tissue or the soft tissue which Dr. Beale terms bioplasm. 
 
 If a tooth which has been affected by caries be taken, 
 appearances may be seen which are wholly confirmatory of 
 the views just expounded. When the pi'ogress of the disease 
 has been rapid, the effect is precisely that of an acid ; that is 
 to say, the very resistant dental sheaths of Neumann may be 
 isolated in short lengths, and appear as distinct tubes. 
 
 But if W' e take a carious tooth in which the progress of the 
 disease has been slow% and the diseased part consequently 
 firm, and of a deep brown colour, and make thin sections 
 with a knife transverse to the direction of the dentinal tubes, 
 it will be found, by the use of the microscope, that the pre- 
 paration is made up of comparatively large discs, each having 
 a central aperture or mark; and that the discs are united to 
 each other by an interposed tissue, small in amount, but 
 capable of distinct recognition. Now, these discs have a 
 much greater diameter than the dentinal, tubes, as seen in a 
 transverse section of healthy dentine, and they have, more- 
 over, a very varying diameter. If the caries is in an early 
 stage the discs are not very large, and the inteiTening sub- 
 stance is present in considerable amount, but as the disease 
 progresses, the discs enlarge till they meet one another. 
 
 If it be granted that the soft fibril, the sheath, and the 
 matrix are but three stages of the same formative elements, 
 the phenomena observed are readily explicable. The fibre or 
 germinal matter disappears, and leaves the central aperture ; 
 the chitinous (?) intermediate layer which forms the sheath
 
 276 A SYSTEM OF DENTAL SURGERY. 
 
 resists the disintegrating action, while the progress of the 
 disease gradually undoes the work of calcification. 
 
 In a certain stage of the disease the tubes appear to have 
 extremely thick walls, so that but little space is left for an 
 intertubular connecting tissue, whereas in healthy dentine 
 the diameter of the tubes is relatively small, and the amount 
 of intertubular tissue is comparatively large. The different 
 characters seen in the two cases may perhaps admit of 
 explanation on the following hypothesis, namely, that the 
 optical difference between the sheaths and the calcified 
 matrix is removed by the disease as it effects the work of 
 decalcifying the tissue ; but in the later stages the greater 
 power of resistance due to the peculiar chemical characters 
 of the sheaths lead to their remaining behind, isolated by the 
 total disintegration of the intervening tissue. It is quite 
 possible to conceive that an equal degree of calcification would 
 efface the differences which were apparent in the soft tissue 
 prior to its induration, and that a higher or lower degree of 
 calcification in the part in immediate contact with dentinal 
 fibrils, would produce such a distinction of parts as that 
 w^hich characterises the dentinal tubes ; and that decalcifi- 
 cation might, under favourable circumstances, restore an 
 appearance which had been lost, and obliterate one which 
 had been produced by calcification. 
 
 It has already been ix)inted out that every odontoblast 
 communicates by means of its pulp process with the cells 
 which lie deeper in the pulp. Hence when one odontoblast 
 is fully used up in the process of calcification, another is ready 
 to take its place without any breach of continuity, and every 
 dental fibril may be regarded as tlie remnant of several con- 
 tinuous odontoblasts. 
 
 In respect to the parenchyma of the dentinal pulp, M. 
 Kolliker speaks of its relation to connective tissue. Now, I 
 have seen instances, and not uncommonly, in which connec- 
 tive tissue very similar to the stellate areolar tissue, could 
 be traced in the substance of the pulp of a forming tooth.
 
 THE DENTAL TISSUES. 277 
 
 Again, the relations of the peripheral dentinal cells to each 
 other, and to the cells placed internally to the outer layer, 
 are not fully made out by the authors cited. If one cell, or 
 even two or three only, is concerned in the formation of a 
 dentinal tube throughout its whole length, it would be 
 difficult to account for the presence of obliterated tracts of 
 vessels found in the teeth of many animals, and occasionally 
 in the teeth even of the human subject. I have several 
 sections of molar teeth, in which large looped tubes, cor- 
 responding in size to the capillaries of the dentinal pulp, are 
 present in the dentine. Their position and size will justify 
 the conclusions that they were once occupied by vessels — 
 that they are the remnants of the vessels of the formative 
 dentinal pulp. Now, supposing the parenchyma of the pulp 
 had been bodily removed to make way for the centripetal or 
 inward growth of the dentinal cells, it is not easy to see how 
 these canals could have been left. But if the cells are pro- 
 duced in linear series, the more internal ones becoming 
 gradually developed as the external undergo calcification, the 
 persistence of obliterated vascular canals can be readily under- 
 stood. It is true the existence of these canals in the dentine 
 is quite exceptional in human teeth, but in the teeth of many 
 mammals they form a constant character. The dentine of 
 mammalian teeth, however, in other respects corresponds too 
 closely to admit of the supposition that the process of develop- 
 ment varies in any essential particular. If, for example, we 
 take the developing incisor of a cnlf, and examine the pulp 
 alter withdrawing it from the investing cap of dentine, we 
 shall find here and there long tubular processes projecting 
 from the surface, the continuations of which may be traced 
 into the substance of the pnlp. Their size, position, and 
 connection with the pulp leave no doubt that they are obli- 
 terated capillaries, the coats of which have been retained 
 while the cells around them have undergone calcification. 
 Had the parenchyma of the pulp gradually made way for tlie 
 inward growth of the external cells — the memhrana eboris of
 
 278 
 
 A SYSTEM OF DENTAL SUHGERT. 
 
 Kolliker— these canals would surely have gone with it. I 
 have made preparations in which several cells, more or less 
 elongated in form, have been united end to end, not with 
 that uniformity, as regards size and position, which charac- 
 terises the members of a linear series of cells in ossifying 
 temporary cartilage, but still their position and connection 
 with each other has been suflQciently distinct for positive 
 recognition. Again, if we examine the peripheral cells in a 
 pulp in which calcification is about to commence, and com- 
 pare them with similar cells in a pulp taken from a tooth the 
 development of which is approaching completion, it will be 
 seen that in the former they are much smaller in size and 
 more numerous than in the latter example. 
 
 It may be asked, whether one element of the pulp more than 
 another suffers absorption, in order to give space for the 
 dentinal cells to grow, seeing that after the cap of dentine 
 has been formed, it limits, by enclosing within its unyielding 
 case, the general bulk of the pulp. Such a question can be 
 answered ouly hypothetically. The pulp contains an infinite 
 number of nuclei, any or a certain number of which are pro- 
 bably capable of becoming developed into cells. I believe it 
 will ultimately be found that a growing cell, when placed in 
 organized matter which is not itself in a state of develop- 
 ment, is capable of growth at the expense of such matter, 
 whatever may be the degree of its organization. It is quite 
 clear that many of the nuclei, the vessels, and connective 
 inuterial, which constitute the dentinal pulp, disappear in 
 lavour of the dentinal cells prior to the calcification of the 
 latter, though the manner of their disappearance is not fully 
 made out. 
 
 We have now reached a point when the functions of the 
 dentinal fibrils may be more profitably discussed. The con- 
 ditions under which sensation is manifested in the dentine 
 have already been stated, together with those under which 
 it is lost, and the difficulty felt in accounting for these 
 phenomena has been pointed out. The recognition of the
 
 THE DENTAL TISSUES. 279 
 
 dentinal fibrils may, however, I think, help to remove that 
 difficulty, and enable the physiologist to explain why, under 
 certain circumstances, dentine is susceptible of pain, while 
 under other conditions the sensitiveness is lost. 
 
 That the dentine, owes its sensation to the presence of 
 soft tissue in the tubes cannot, I think, be readilj'- doubted, 
 seeing that if their connection with the pulp be cut off by 
 the destruction of the latter, all sensation is at once lost. 
 
 As has already been stated (page 269), no one has ever 
 seen a nerve fibre enter a dentinal tube, though Boll considers 
 it probable that they do so. The present knowledge of the 
 peripheral distribution of the nervous system is by no means 
 so complete that generalisations may be safely drawn from 
 it, and as the use of the higher powers of the microscoi>e 
 becomes more understood, nerves of extreme minuteness are 
 being almost daily traced into tissues whence they had pre- 
 viously been supposed to be absent ; at least, in so far as they 
 had never been demonstrated. 
 
 It is not absolutely certain that no structures other than 
 nerves have the power of conducting sentient impressions, 
 and hence it is not quite necessary to assume that the den- 
 tinal fibrils are actual nerves before allowing them the power 
 of communicating sensation. Many animals are endowed 
 with sensation, which yet possess no demonstrable nervous 
 system ; and we may find many points in the human body 
 highly sensitive, without our being able to demonstrate the 
 presence of nerves in such numbers as would account for the 
 pain uniformly experienced from the puncture of a needle, 
 upon the supposition that the needle had in each case wounded 
 a nerve. Additional evidence in favour of the view that the 
 fibrils, or other soft contents of the tubes, possess sensation 
 may be obtained by examining their condition in diseased 
 teeth, in connection with the phenomena manifested by the 
 disease. In those cases in which the fibrils are obliterated 
 in the manner which will be hereafter described, there is 
 perfect absence of pain when the affected part is cut into, but
 
 280 A SYSTEM OF DENTAL SURGERY. 
 
 SO soon as the instrument reaches the healthy dentine, more 
 or less inconvenience is felt. If, on the other hand, there is 
 no consolidation of the fibrils, but the pulp is yet living, the 
 operation of removing the carious part is productive of pain, 
 even from the commencement ; indeed, pressure upon the 
 surface of the softened tissue gives rise to discomfort. If in 
 such cases the softened dentine be examined, fibrils may here 
 and there be found but little altered from their natural 
 appearance. 
 
 The greater degree of sensitiveness observable in the den- 
 tine immediately below the enamel — that is, at the point of 
 ultimate distribution of the dentinal tubes, and consequently 
 of their contents — may be fully accounted for on the sup- 
 position that the latter are organs of sensation, and subject 
 to the same laws as nerves of sensation, the highest sensi- 
 bility of which is confined to their terminal branches. 
 
 The recognition of the dentinal fibrils must lead to a 
 modification of the opinions once entertained as regards the 
 office of the tubes, namely, that they are for the circulation 
 of fluids only. The presence of soft tissue would not, how- 
 ever, hinder the slow passage of fluids ; there are abundant 
 instances of nutritional changes taking places at a distance 
 from vessels, and the fact that calcification of the fibrils goes 
 on in old age shows clearly that fluids can and do pass along 
 them. For when the fibrils become calcified near the surface 
 of the dentine, the hardening material must have been 
 derived from the pulp; at least, when the consolidation has 
 taken place in the crown of the tooth. 
 
 From what has been said, it will be obvious that some 
 uncertainty must at present rest on the functions of the 
 dentinal fibrils. That they, or some other soft contents of 
 tbe tul)es, are the agents by which sensation is carried to the 
 pulp may be regarded as perfectly established ; and, inasmuch 
 as no other soft structures have been traced into the tubes, 
 the inference is that the fibrils themselves possess this 
 function. At the same time, in other parts of the body there
 
 THE DENTAL TISSUES. 281 
 
 exist nerves of such minute size that their existence, though 
 it may be inferred elsewhere, has only been as yet demon- 
 strated in tissues which naturally present great facilities for 
 examination, such as the bat's wing stripped of its outer 
 layers ; and were such fibres to exist in the teeth, which 
 l>resent such great obstacles to the use of high powers, they 
 would almost surely escape our notice. 
 
 With reference to this matter, Professor Kolliker remarks, 
 that, inasmuch as cellular elements have been, according to 
 modern observations, often found in connection with nerve 
 endings, it is not at all impossible that the odontoblasts may 
 stand in some relation to the endings of nerves in the pulp. 
 
 In the present state of our knowledge, the question cannot 
 be regarded as capable of being definitely settled ; this 
 much only is certain, that sensation is conveyed by some 
 soft contents of the tubes, whether by the fibrils or by some- 
 thing else cannot be positively stated. 
 
 According to the researches of Mr. Rainie, already alluded 
 to (13), if carbonate of lime is formed in a thick solution 
 of mucilage or albumen by the decomposition of carbonate 
 of soda or of potash, the newly-formed salt takes a globular 
 instead of a crystalline form. The globules produced are 
 composed, however, not only of carbonate of lime, but also of 
 a certain portion of the mucilage or albumen in which the 
 combination has taken place. In proof of this assertion, he 
 states that the lime may be removed by an acid, without 
 occasioning the destruction of the form of the globule from 
 which it has been so abstracted ; just as the form of a bone 
 is maintained after the earthy matter has been removed. It 
 is further stated, that phosphate of lime, if produced under 
 similar circumstances, supposing a minute quantity of car- 
 bonate of lime be present, will, like the carbonate, assume 
 the globular form. These globules are laminated in structure, 
 and appear to be capable of increase by the addition of new- 
 layers upon the surface. If two or more lie in contact, they 
 become perfectly united into one laminated mass, by the
 
 282 A SYSTEM OF DENTAL SURGERY. 
 
 blending or fusion of the laminfe which come in contact. 
 The globules themselves are stated to be produced by the 
 coalescence of smaller masses, which again are made up of 
 still smaller spherules of similar material ; the individuality 
 of the constituent bodies being ultimately lost in the uniform 
 fusion of the whole into one compact mass. Globular masses 
 which at one time have a rough and mulberry-like appearance, 
 gradually, by the coalescence and, as it were, fusing down of 
 the constituent spherules, become perfectly smooth. The 
 lamination is supposed to result from the arrangement of the 
 masses in concentric layers, and their subsequent coalescence. 
 In the discovery of the substitution of the globular for the 
 crystalline form of these two salts of lime, Mr. Eainie con- 
 siders he has found an explanation of the process of calcifica- 
 tion, not only of bone and teeth, but also of the formation of 
 shells, and his results have been confirmed and extended by 
 the more recent researches of Professor Harting (12), who 
 has added to what was already known the important and 
 significant fact that the albumen itself becomes changed into 
 a remarkably insoluble and resistant substance, resembling 
 chitine in its behaviour with re-agents, to which he gives the 
 name of calcoglobulin. 
 
 If the thin edge of the forming cap of dentine be examined, 
 it will be found to have the appearance of being made up of 
 globules of varying size, this appearance being in great part 
 destroyed by treatment with a dilute acid. 
 
 This condition has been well figured by Messrs. Robin and 
 Magitot, and is familiar to all who have watched the develop- 
 ment of dentine. The calcareous matter is in the first 
 instance deposited in the matrix in the form of isolated 
 globules, these increase in size and ultimately coalesce, their 
 outlines becoming obliterated by the deposition of calcareous 
 salts in their interstices. 
 
 Dentine in the globular form may be found in semi- 
 detached masses adherent to the surface of the pulp-cavity, 
 and in perfectly detached spherules in the substance of the
 
 THE DENTAL TISSUES. 283 
 
 pulp itself, in the teeth of adults. In the latter situation 
 these bodies are very abundant in teeth which have been 
 attacked by a caries ; and Mr. Salter appears to consider the 
 presence of the detached masses of dentine in the pulp as the 
 consequence of disease. I do not think this view is quite 
 correct, for in three out of five specimens of perfectly sound 
 molar teeth removed from subjects in the post-inortem room 
 of the hospital, I found globular masses of dentine within the 
 substance of the pulp. Again, in the developing teeth of 
 ruminants, these globular masses are scattered freely through 
 the dentuial pulp, and as ossification advances, become sur- 
 rounded by, and lost in, the general mass of the dentine. If 
 the surface of the pulp-cavity of a partly-formed tooth of a 
 ruminant be examined, the globules will be found embedded 
 to various depths in the substance of the dentine. Messrs. 
 Robin and Magitot call attention to the existence of small 
 isolated calcareous granules of spheroidal form, which are to 
 be found in considerable numbers scattered through the 
 substance of the pulp at an early period of dentine develop- 
 ment ; they have also been described by Henle and others in 
 the teeth of man, as well as in those of ruminants and rodents, 
 and they may be found at all periods of development, as well 
 as in adult teeth. 
 
 Sometimes, however, the coalescence of the globules formed 
 in developing dentine only takes place imperfectly ; that is 
 to say, contiguous globules may coalesce in such a way as to 
 cut ott' and isolate a portion of the formed matrix which has 
 not as yet been impregnated with salts. When the tooth is 
 dried the soft matrix which had occupied this situation dries 
 up and shrinks so that a more or less irregular cavity, look- 
 ing black, from its containing air, is left. 
 
 These cavities are known as " interglobular " spaces, and 
 were so described by Czermak (14) ; they may be excellently 
 seen in teeth which have been rendered translucent by boil- 
 ing in wax. In the specimen here figured (which has been 
 so prepared) it may be seen that the walls of the cavity are
 
 284 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 made up of globules, and that its irregular form with pro- 
 cesses rumiing out from it is referable merely to the fact that 
 interspaces are left between a number of unyielding spherical 
 masses. 
 
 ^As has already been mentioned, in the fresh state these 
 cavities are not empty, but are occupied by Jbrmed structural 
 matrix which has not been as yet calcified. As might be 
 expected, therefore, the tubes and their contents pass across 
 the spaces without any inteiTuption in their continuity. 
 The soft matrix which fills the interglobular space may be 
 
 Fig. 133. 
 
 slightly stained by prolonged soaking of a fresh tooth in Dr. 
 Beale's carmine fluid, and it diflers from the surrounding 
 matrix which has been impregnated with lime in salts, in 
 that it is more resistant to the action of acids. Like the 
 dentinal sheaths, the lining of Haversian canals, or the 
 encapsukd lacunfe of cementum, the soft contents of the 
 space may be isolated by maceration of the tooth in acids ; 
 and they present us with another example of that remarkable 
 chemical transformation which tissue undergoes immediately 
 before the deposition of lime salts, conferring on the structures
 
 THE DENTAL TISSUES. 285 
 
 immediately on the verge of calcification such a remarkable 
 power of resisting re-agents. 
 
 Occasionally, however, the contents of the space appear to 
 undergo calcification at a period subsequent to its formation, 
 and this does not have the effect of entirely obliterating all 
 traces of its original contour. 
 
 In this way an appearance may be produced exceedingly 
 suggestive of portions of areolar tissue having become in- 
 volved in the calcifying process ; but the more probable 
 explanation of the appearance is, that an interglobular space 
 has been formed, and subsequently obliterated by the further 
 progress of calcification. 
 
 ]n the neighbourhood of well-marked interglobular spaces, 
 more or less distinctly defined, globular forms may almost 
 always be traced. 
 
 Teeth in which globules and interglobular spaces abound 
 suffer very rapid destruction when attacked by caries — a 
 result which is consequent upon the porous state of the 
 tissue; but they present considerable variations in this 
 respect, those teeth which present the appearance which 
 has been described as areolar dentine, often possessing great 
 ix)wers of resistance, so that the progress of caries in such 
 teeth is slow, rather than otherwise. 
 
 Although the presence of defects in the structure of the 
 dentine no doubt contributes to hasten the destruction of 
 teeth when attacked by caries, yet, as a predisposing cause, 
 they are secondary in importance to similar foults in the 
 organization of the enamel. Sufiicient importance, however, 
 attaches to the departures from the normal condition of the 
 dentine, to render it desirable that some account should be 
 given of the characters by which such departures are dis- 
 tinguished. 
 
 When the organization is perfect, the subdivisions of the 
 dentinal tubes pass up to the line of junction formed between 
 the inner surface of the enamel and the outer surface of the 
 dentine, the intertubular tissue being at this point clear and
 
 286 A SYSTEM OF DENTAL SUEGERT. 
 
 transparent. In less perfect teeth the clearness and trans- 
 parency are replaced by a granular condition of the tissue ; 
 granules, or spherules, or minute globules, although united, 
 yet retain some traces of their individuality, and among these 
 the coronal dentinal tubes are lost. This condition, in a 
 greater or less degree, is almost uniformly present in the 
 peripheral portion of the dentine of the root ; but its existence 
 in the crown of the tooth must be reganied as an indication 
 of faulty development. In seeking to explain the cause of 
 this granular condition, Mr. Eainie (if I have read his paper 
 coiTectly) would regard the phenomenon as resulting from an 
 arrest in the coalescence of the dentinal globules ; and this is 
 probably the true explanation of the fact, the so-called 
 granular layer, which underlies the cementum in tlie fangs, 
 being made up of a great number of minute interglobular 
 spaces. 
 
 Any change in the direction of greater porosity of the 
 dental tissues, may be regarded as favourable to the de- 
 struction of teeth, supposing them to be attacked by caries ; 
 and it is only to such forms of departure from the normal 
 state of the tissue that attention need be directed. Under 
 ordinary circumstances, the dental tubes diminish slightly 
 in diameter as they approach the peripheral portion of the 
 crown of the tooth, but it will in some specimens be seen 
 that in passing an interglobular space they are considerably 
 dilated. Again, the terminal coronal branches, instead of 
 terminating by anastomosis, or by becoming imj-erceptibl)' 
 minute, may pass into small irregular cavities situated near 
 the surface of the dentine. 
 
 In a well-developed tooth a certain number of the dentinal 
 tubes will be seen to pass across the line which marks the 
 junction of the enamel and the dentine, without suffering 
 any increase in size, and after proceeding a short distance in 
 the former tissue, become extremely minute and are lost. 
 But in teeth of less perfect organization the dentinal tubes, 
 after passing into the enamel, become suddenly dilated into
 
 THE DENTAL TISSUES. 287 
 
 conii)aratively lar^e elongated cavities, somewhat irregular in 
 outline, but tolerably uniform in their direction (^). Without 
 following closely the course of the enamel fibres, they have 
 a general direction towards the surface of the tooth, and 
 terminate abruptly after advancing but a bhort distance into 
 the substance of that tissue. 
 
 Many other deviations from that which must be regarded 
 as the normal fc^rm of the dentinal tubes, have been already 
 described (^), and might now be enumerated, but that they 
 for the most part are strictly local, being often confined to a 
 few tubes, and are consequently incapable of exerting any 
 influence upon the teeth in which they occur, hence the 
 enumeration does not full within the scope of the present 
 work. 
 
 The structure of the ccmentum will be described before 
 treating upon its diseases. 
 
 The structure of the enamel and the dentine has been 
 entered into at some length, piior to treating upon the 
 diseases to which they are subject, on the supposition that 
 the organization of a part should be kept clearly in view 
 when an attempt is made to appreciate the nature of its 
 diseases. 
 
 The most apparent defect in the enamel is that in which 
 the surface is irregular, either from the presence of numerous 
 pits, or indentations, or of deep transverse grooves, the inter- 
 vening parts being normal in appearance. In either case the 
 defect may be rather in quantity than in the quality of the 
 tissue, although in the lattter respect the organization may 
 also be imperfect. Teeth presenting such characters are 
 commonly spoken of as honeycombed. They frequently 
 want the clear colour and the semi-transparency of healthy 
 organs, for which is substituted a dull yellow appearance, 
 the decider shades of colour being confined to the depressed 
 
 (1) Professor KiJlliker gives an excellent figure of such cavities in his work 
 on hlstolopj', 80 frequcntlj^ cited. 
 
 (2) Lectures on Dental Physiology and Surgery.
 
 288 A SYSTEM OF DENTAL SURGERY. 
 
 portions of the enamel. If a section be made from a tooth 
 which presents these external characters, it -will be seen that 
 the surface of the dentine does not necessarily deviate from 
 the usual form, but that itTegularity in thickness is confined 
 to the enamel which lies upon it ; at one point the dentine 
 will support only a thin and perhaps imperfectly developed 
 layer ; at another, a considerable depth of well-formeti 
 enamel. 
 
 In teeth which are grooved only while the natural colour 
 is maintained, it may be found that the deviation from the 
 normal condition is confined to alternations in the quantity 
 of the tissue, the natural characters, as respects the structure 
 of the enamel, being preserved throughout. But it is 
 frequently seen, that in the deeper portions of the grooves 
 the colour differs from that which obtains in the contiguous 
 healthy structure. In this, as in the case of the honey- 
 combed teeth, the abnormal colour indicates a defect in the 
 structure. 
 
 It has been stated, that irregularity in the surface of the 
 enamel does not imply a corresponding irregularity in the 
 surface of the dentine ; under ordinary circumstances, the 
 elevations and the depressions on the surface of the crown, 
 have counterparts on the surface of the subjacent dentine, 
 differing only in the extent of the elevation. The enamel 
 attaining its maximum thickness over those parts of the 
 tooth which are most prominent, consequently breaks the 
 parallelism of the lines fonned by the surfaces of the two 
 tissues. Although this is the general rule, many cases will 
 be seen in which the surface of the dentine pi-esents the 
 usual form, while the enamel, from defect of quantity, fails 
 to contribute its share in buihling up the crown of the tooth ; 
 and the cusps of the molars are consequently stunted. 
 
 On the other hand, the surface of the dentine may deviate 
 from the natural conformation ; the masticating surfaces of 
 the molar teeth may be flattened, or the cusps may be thin 
 and spear-shaped, as though pinched flat, and the incisors
 
 THE DENTAL TISSUES. 289 
 
 may have the same compressed form. In all such cases the 
 enamel will be defective in amount and irregular in its 
 distribution. The same cause which influenced the develoi> 
 ment of the dentine on the surface of the tooth, will have 
 equally influenced that portion of the enamel which lies in 
 contact with the dentine. Had the formation of the super- 
 ficial portion of the dentine been normal, the enamel, which 
 is developed upon its surface so soon as that surface is formed 
 to receive it, would have been free from defect, although more 
 external portions, formed at a later period, might have been 
 defective. 
 
 There is another form of defect in quantity. A molar 
 tooth may present to the naked eye all the appearances of a 
 well-developed organ, and yet the enamel may be imperfect, 
 and the imperfection may be in such a form as to insure the 
 early loss of the tooth. From the natural depressions which 
 separated the cusps of molar teeth, minute but deep fissures 
 may be extended through the enamel to within a short dis- 
 tance of the dentine, and they may become larger as they 
 recede from the surface of the tooth. In most cases which I 
 have examined, they have been filled with cementum, ur 
 rather with that modification of cementum which constitutes 
 Nasmyth's membrane, and very commonly they become the 
 seat of caries (Fig. 134). 
 
 These minute crevices, the existence of which in many 
 teeth an ordinary examination would not lead one to suspect, 
 are constantly met with in connection with those forms of 
 defective enamel which have been already described. 
 
 Independent of the quantity, the quality of the tissue may 
 be defective, and consequently unable to resist the influence 
 of agents calculated to injure the tooth. The account which 
 has been given of the structure and development of the 
 enamel will, though in a histological point of view very 
 imperfect, be sufficient to render intelligible that which has 
 to be said on the subject of imperfection in the organization 
 tissue. 
 
 u
 
 290 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 The fibrous character of the enamel, which in the perfect 
 tissue is lost by the blending or fusion of the sheaths of the 
 columns of the enamel-pulp in the process of calcification, 
 may be permanently maintained. Each fibre may to a 
 considerable extent preserve its individuality, a condition 
 which gives an opaque appearance t^ the tissue, and at the 
 
 Fig. 134. (1) 
 
 same time greatly imi)airs its strength. The fibrous cha- 
 racter may prevail in certain parts of a tooth, or it may 
 extend through the whole of the enamel. More commonly, 
 however, it will be seen in lines parallel, not with the 
 surface of the enamel or of the dentine, but with the line of 
 growth. 
 
 The fusion of the sheaths of the original fibres may, 
 ]ic»wever, be perfect, while the central portions or contents, 
 
 (1) Shows a deep fissure in the enamel invisible to the naked eye. The 
 section was taken from a first permanent molar of the lower jaw, removed soon 
 after its eruption.
 
 THE DENTAL TISSUES. 291 
 
 may have fallen short of perfect development. In the place 
 of faintly-marked striation, we may find either parallel series 
 of well-defined rounded masses, as shown in Fig. 124, or a 
 line of fine granules. Again, minute cavities arranged in 
 single lines may occupy the centres of the fibres, and in some 
 few cases I have seen \w the confluence of a series, a tube 
 produced. 
 
 The foregoing conditions may be sometimes found in 
 patches amongst the normal tissue of teeth which have the 
 general appearance of being perfectly developed ; but when 
 the enamel is obviously imperfect, and presents the honey- 
 combed character, the structural defects will be much more 
 generally diffused. 
 
 Not only may the fusion of the sheaths be imperfect, and 
 the central portions of the fibre fall short of the normal 
 conditions, but even the arrangement of the elements of the 
 tissue be lost. Both the longitudinal and transverse markings 
 may be replaced by a general granular condition, as though 
 the tissue had been formed by the calcification of unarranged 
 spherical masses, about the size of bluod-globules, with 
 perhaps here and there a cavity of irregular form inter- 
 
 In the most perfectly developed enamel, the longitudinal 
 and the transverse markings are comparatively faint, and 
 under a high magnifying power with a good light, they 
 appear, not as dark, but as light lines, enclosing spaces which 
 are occupied by a material which is a little more dense or 
 opaque than that which forms the lines. Any departure 
 from this condition may be justly regarded as a predisposing 
 cause of caries, the degree of predisposition being proportioned 
 to the relative amount of porosity in the tissue. In the 
 foremost rank, as a predisposing cause, must be placed the 
 deep but minute fissures found on the masticating surface of 
 molar teeth ; and next in order, the imperfect fusion of the 
 sheaths, and the consequent retention of the fibrous state of 
 the enamel so frequently seen on the sides of teeth .
 
 292 A SYSTEM OF DENTAL gUBGEBY. 
 
 Many other structural defects in the enamel might be 
 noticed here, but, inasmuch as they have no very practical 
 bearing, want of space forbids their introduction. 
 
 The close relation which exists between constitutional 
 conditions and imperfect development of the teeth is often 
 exceedingly clearly indicated by the four first permanent 
 molars, which, being simultaneously developed, all present in 
 an extreme degree the character of honeycombed teeth, 
 whilst the other teeth in the same mouth are well formed.
 
 ( 293 ) 
 
 CAKIES. 
 
 The enamel and the dentine are the tissues which are 
 more especially liable to be affected by caries. In them the 
 process of destruction commences. The disease may extend 
 to, or may even commence in, the cementum in teeth from the 
 necks of which the protecting gum has been removed. But 
 these are exceptional cases ; we may therefore, for the pre- 
 sent, treat of the disease as an affection of the enamel and 
 dentine only, leaving for future consideration the results 
 which follow when the disease becomes complicated by ex- 
 tending so far into the tooth as to lay open the pulp-cavity, 
 and involve the pulp itself in rapid destruction or in chronic 
 disease. 
 
 Although dental caries has been investigated and described 
 by all who have written upon the subject of dental surgery, 
 from the earliest period when disorders of the teeth first 
 attracted attention down to the present time, yet it can 
 scarcely be said that the nature of the disease is perfectly 
 understood ; for even now two hypotheses prevail. In one, 
 the disease is assumed to be no disease whatever, but merely 
 the result of chemical solution of the dental tissues, and there- 
 fore dependent, both in its origin and its progress, on the 
 uncontrolled action of physical and chemical laws. 
 
 According to the other hypothesis, the fact that teeth are 
 part of a living organism, if not essential to the origin of the 
 mischief, at all events profoundly modifies its progress. 
 Much has been written in favour of each of these views, and
 
 294 A SYSTEM OF DENTAL SURGERY. 
 
 yet the subject cannot by any means be held to be settled. 
 As it would be impossible to summarise and criticise the 
 views advanced by the numerous English and foreign autho- 
 rities who have contributed to the literature of the subject, 
 without unduly encumbering the text, and as, at the same 
 time, the present volume would be incomplete without such 
 a chapter, it is thought desirable to embody these theore- 
 tical considerations in the form of an Appendix, merely 
 giving here in the text a brief account of the appearances 
 actually observed. 
 
 The physical signs which mark the presence of caries are 
 first visible in or through the enamel. But they will vaiy 
 somewhat in accordance with the character of the surface 
 affected. If the disease arises in a fissure on the masticating 
 surface, or in a depression on the crown of a tooth, a dark- 
 coloured spot will be the first indication of its presence ; but 
 if the disease has attacked a surface free from any indentation 
 or fissure, the aftected j^art will lose its translucency, and 
 become opaque and white : subsequently the white will be 
 succeeded by an ash or slate, and finally by a brown colour, 
 more or less deep. If the enamel be examined when in the 
 earlier stages of disease, it will be found that the presence of 
 opacity is accompanied, and no doubt occasioned, by an in- 
 creased porosity of the tissue, a condition which has succeeded 
 to one of the forms of imperfect development already de- 
 scribed. Either the union between the sheaths of the forma- 
 tive fibres has been imperfect, and the strictly fibrous 
 condition has been maintained until, under the influence of 
 disease, the union, at best but imperfect, becomes sufliciently 
 interrupted to give opacity to the parts; or the granular 
 condition previously alluded to has been continued, and thus 
 rendered the tissue susceptible to influences which would 
 have failed to produce any injurious effects had the organi- 
 zation been more j^erfect. The predisposing causes to disease 
 have, however, been described in connection with the struc- 
 ture and the development of the enamel, and the description
 
 CARIES. 295 
 
 need not be repeated. After recognising a distinction between 
 the central and the external portions of the so-called fibres, 
 and the more rapid action of a mineral acid upon the 
 contained than upon the containing part, it may reasonably 
 be expected that some such difference would be observed 
 in enamel when undergoing changes from the action of 
 disease. It would be most difficult to obtain a transverse 
 section of enamel which has been subject to the changes 
 produced by caries, but we may, by breaking down upon a 
 glass slide fragments of the brittle and chalk-like enamel 
 taken from a carious tooth, produce a sufficiently satisfactory 
 preparation for demonstrating the fact that the central 
 portion of the fibre is the first to suffer decomposition, much 
 in the same manner as when the destructive agent is inten- 
 tionally applied to a section prepared for experimental 
 treatment. 
 
 The foregoing description applies to those cases where the 
 disease has conniienced upon a surface free from depressions, 
 and extended through the porous enamel into the dentine. 
 Not that the process of decay materially differs in con- 
 formity with the character of the surface attacked, but the 
 progress is somewhat varied, both in respect to the direction 
 in which the disease extends, and in the rate of destruction. 
 When the disease is established in a fissure, the indications 
 of its presence are not strongly pronounced, until a very con- 
 siderable amount of destruction has been produced. A con- 
 sequence which results from the disease having extended into 
 the dentine, penetrating to a considerable depth in the direc- 
 tion of the tubes, and spreading laterally under the enamel, 
 without affecting its outer surface : with the softening of the 
 dentine, the inner surface of the enamel becomes softened 
 from within, until the tooth at that point is so much reduced 
 in strength that the enamel breaks in, and suddenly reveals a 
 large and scarcely suspected cavity. 
 
 For the convenience of description, the disease, when it 
 assumes this form, may be termed penetrating caries, re-
 
 296 A SYSTEM OF DENTAL SURGERY. 
 
 serviug the terms, spreading caries, for the form previously 
 described. 
 
 As respects the dentine, the progress of decay does not 
 follow the same course as that which has been described in 
 reference to the enamel. It will be remembered that the 
 dentine is formed from cylindrical cells, or rods, of the 
 dentinal pulp, the individuality of which is lost in the 
 process of calcification. If we take a thin section from a 
 carious tooth, it may be seen, in those parts of the preparation 
 where the tubes are divided transversely, that each tube is 
 surrounded by a very thick sheath — the diseased condition 
 
 Fig. 135. (1) 
 
 has in a measure undone the work of development and 
 thrown light on the question how this was effected ; it may 
 almost be said to have restored the outline of the formative- 
 cells — the tissue is to a certain extent broken up into its 
 histological elements. Under the microscope the section 
 looks as though it might have been built up of multitudes of 
 tobacco-pipe stems, united by an intervening substance. 
 Such is the condition when disorganization has advanced up 
 to a certain point ; at a later period short lengths of the walls 
 of the tubes (dentinal sheath, zahnscheiden of Neumann) are 
 
 (1) A section from dentine softened by caries, showing the consolidated 
 dentinal tubes and fibrils cut transversely.
 
 CARIES. 297 
 
 found isolated; and finally the whole tissue breaks down 
 into minute granular particles, which are by degrees washed 
 away in the saliva. 
 
 The first chemical change consists in the removal of the 
 lime-salts from the gelatine, leaving the dentine of a con- 
 sistence capable of being readily cut with a sharp knife, when 
 it will be found to exhibit the structural characters just de- 
 scribed. It might be supposed that similar results would be 
 produced from decalcifying a tooth by the aid of a dilute 
 mineral acid ; such, however, has not been the case in expe- 
 riments instituted with the view of determining the point. 
 Indeed, I know of no artificial means whereby the appear- 
 ances which have been described can be as fully brought out 
 as by the progress of disease. The question naturally 
 suggests itself, may not the appearance of dentinal rods be 
 nothing more than a certain stage in progressive decompo- 
 sition, due to a solvent fluid obtaining access to the tissue 
 through the tubes, and the outline of each rod be indicative 
 only of the depth to which the fluid has permeated ? 
 
 As a matter of fact the connecting material is the first, and 
 the walls of the tubes the last, to become disintegrated ; and 
 this, previous to the discovery by Neumann of the very in- 
 destructible nature of the dentinal sheaths, seemed to answer 
 the question m the negative. Knowing, however, as we now 
 do, what great powers of resistance the walls of the canals 
 possess, this explanation of the tobacco-pipe appearance is 
 rendered far more probable. Occasional exceptions to this 
 sequence of disorganization, will, however, be found in teeth 
 which are destroyed with great rapidity. In them the tubes 
 will appear to have become enlarged in the manner figured in 
 my previous work ; and the distinction of the tubular and 
 intertubular parts of the tissues will be but faintly pro- 
 nounced, and indeed may be altogether wanting. But suppos- 
 ing a section from a carious tooth in which the destruction 
 has been gradual, be taken, the following conditions may be 
 observed : commencing at the part where the dentine pre-
 
 298 A SYSTEM OF DENTAi SURGERY. 
 
 sents pretty nearly its natural appearance, we then pass to a 
 point where the api>earances depicted on the preceding page 
 are seen ; still further on, this condition becomes yet more 
 strongly marked ; and at the extreme edge, supposing the 
 section to have extended to the surface of the cavity, the 
 process of disintegration may be seen. 
 
 If the dental tubes be isolated by the application of acids, 
 they will often be found to present varicosities and globular 
 swellings. Q) 
 
 If a tooth in which the disease is limited in extent be 
 divided, the relations of the diseased to the healthy parts may 
 be examined. The affected dentine will be either opaque in 
 appearance, or it will have assumed a brown colour ; and 
 these changes from the condition of health will be seen to 
 extend underneath the enamel beyond the limits which bound 
 the external indications of disease in that tissue. But it will 
 be in the direction of the dentinal tubes that the disease will 
 be found to have made the greatest progress. Supposing the 
 disease to have commenced upon the masticating surface of 
 a molar tooth, it will commonly be found that the mass of 
 diseased tissue, when limited in amount, presents the shape 
 of a cone, the apex of which is directed towards the pulp- 
 cavity, and the base towards the enamel. 
 
 The section will show that the destructive agent, having 
 gained access to the dentine thi'ough an opening in the 
 enamel, has spread, to a certain extent, upon the peripheral 
 surface of the tissue, through the terminal branches of the 
 tubes, and thus formed the base of the cone ; but that it has 
 spread to a greater length in the course of the trunks of the 
 involved tubes following their convergent course towards the 
 
 (1) Excellent figures are given of these beaded, elongated bodies in Heider 
 and Wedl's Atlas zur Pathologie der Zahne, part iii., pp. 792, 93 ; and they are 
 further described in \Vedrs Pathologie der 2^hne. In both places, however, 
 they are described as " Dentinzellenfortsiitze," a word the exact meaning 
 attached to which I do not know, seeing that its significance greatly depends 
 on the view held by the writer of the share taken by the odontoblasts in the 
 formation of dentine, and of the ultimate structure of dentine. Thus it might 
 mean the dentinal fibril, the dentinal sheath, or both.
 
 CARIES. 299 
 
 pulp-cavity, and thus produced the apex of the cone. But if 
 an example be taken in which the disease has assumed the 
 spreadinfi; character, the conical form of the disorganized part 
 will be less strongly, if at all, pronounced. In certain cases, 
 indeed, the whole of the masticating surface of a molar tooth 
 is lost before the disease has advanced to a sufficient depth 
 in the direction of the pulp-cavity to expose its vascular 
 contents. In the defective teeth described as " honeycombed 
 teeth," the disease, after the enamel has been destroyed and 
 the dentine reduced in thickness, becomes in certain cases 
 arrested. The exposed tissue assumes a polished siu-face, deep 
 brown colour, and acquires a density which enables the crown, 
 though deprived of enamel, to serve the purpose of masti- 
 cation with scarcely less efficiency than an uninjured 
 tooth. 
 
 Coincident with structural changes in the dentine a certain 
 amount of uneasiness exists and marks the i^resence of the 
 disease ; and of this we have yet to speak. 
 
 I believe it rarely happens that the presence of caries in 
 its earlier stages is altogether unattended by some uneasiness 
 in the affected tooth. The amount is often very slight, so 
 slight, that the attention will be directed to the part in those 
 only who are in the habit of devoting considerable care to 
 the preservation of the teeth : on the other hand, there are 
 many who immediately recognise the presence of disease by 
 the discomfort it occasions ; and in exceptional cases the 
 patients describe the affected teeth as giving them a con- 
 siderable amount of pain long before the disease has pro- 
 gressed to an extent capable of directly involving the pulp. 
 Toothache of this description must be distinguished from 
 that which is consequent upon inflammation of the pulp, 
 whether resulting from exposure produced by caries, or 
 arising from any other cause ; and the distinctions may be 
 made by observing the characters of the pain. There is an 
 absence of throbbing, and a less degree of intensity as com- 
 pared with that occasioned by inflammation of the i)ulp.
 
 300 A SYSTEM OF DENTAL SUEGERY. 
 
 Contact with hot or cold fluids does not usually produce 
 any unpleasant effect. 
 
 I believe the seat of pain to be mainly in the j^eripheral 
 portion of the dentine, and that after the destruction of 
 vitality in this part of the tooth has been completed, the 
 sensation of discomfort in great part passes away. 
 
 Xo doubt there are cases in which the presence of caries is 
 unattended with any feeling even of discomfort, for we find 
 those in whom the pulp becomes exposed and disappears 
 without a moment's toothache. If a part endowed with. 
 vessels and nerves, and a very high degree of sensibility, 
 can be destroyed without pain, as it were unconsciously, it 
 would be unreasonable to suppose that the dentine cannot 
 undergo disintegration without manifesting sensation. Why 
 in one person the destruction of a tooth should be attended 
 with so much, and in another with so little suffering, is a 
 question which we are as little able to answer, as we are to 
 account for the great ditference in susceptibility to the action 
 of remedies, so frequently manifested in patients in whom 
 such constitutional peculiarities can be discovered by experi- 
 ment only. 
 
 The dentinal fibrils are subject to a change more or less 
 complete, the existence of which may be recognised even by 
 the naked eye. If we divide a sound tooth through its long 
 axis, the dentine exposed by the section will present a tole- 
 rably uniform degree of opacity ; but if the tooth has been 
 attacked by caries, in addition to the discoloration of the part 
 which has undergone chemical change, we shall find a com- 
 paratively transi^arent zone removed a short distance from, 
 and surrounding the disorganizing mass. If a thin section 
 be taken from the tooth, it may then be seen that the trans- 
 parency is produced by the air being thoroughly excluded 
 from the dentinal tubes in this part of the section. This 
 seems to be due to the consolidation of the dentinal fibrils 
 within the tubes, thereby obliterating the latter, and ren- 
 dering their outline obscure. The consolidated condition of
 
 CARIES. 301 
 
 the fibrils may, however, be shown in a more satisfactory 
 manner by taking a tooth in which the progress of decay has 
 been slow, leaving the disorganizing dentine of a deep brown 
 colour, and comparatively firm in texture. If we cut with a 
 sharp knife a thin section in the direction taken by the den- 
 tinal tubes from the discoloured portion (if the tooth be well 
 selected), the consolidated fibrils will be seen within the 
 tubes broken abruptly into short lengths. Sometimes they 
 are present in great numbers, scattered over the specimens, 
 many lying within the tubes, others upon the surface, and 
 
 Fig. 136. (1) 
 
 occasionally they may be seen with one end projecting from 
 the edge of the section, and the other within the tube. 
 
 This consolidation of the fibrils necessarily exercises a con- 
 siderable influence in arresting the progress of disease, by 
 
 (1) A section in a plane with the tubes, from carious dentine, showing 
 consolidation of the fibrils, some of which are seen projecting from the edge 
 of the specimen, while others have been broken within the tubes and are 
 displaced.
 
 302 A SYSTEM OF DENTAL SURGERY. 
 
 rendering the dentine mucli more dense and impervious than 
 when in the normal state. The zone of consolidation cuts off 
 and isolates the disease from the healthy portion of the 
 tooth, and its production must be regarded as an attempt on 
 the part of nature to circumscribe and limit the mischief. 
 That this interpretation of the phenomenon is correct, will 
 be seen on examining teeth in which *the rate of progressive 
 destruction has varied, and also by considering the conditions 
 presented in other tissues when they are attacked by local 
 disease. 
 
 In respect to teeth, it Avill be found that when the dentine 
 has been rapidly destroyed — when, in fact, the amount of 
 softening is great, and the external indication but compara- 
 tively slight — when that which at first sight would appear to 
 an unaccustomed eye a small cavity, is, on the removal of the 
 disorganized tissue found to be a very large one ; that the 
 consolidation of the fibrils has been im[.erfect, or perhaps 
 altogether -wanting, and that there is coincidently a high 
 degree of sensitiveness under operation. Again, compare the 
 foregoing case ^vith one in which the destruction has been 
 comparatively slow, and the extent of the disease more 
 limited, and it will then be seen that the evidences of conso- 
 lidation are in the former very slight, in the latter very 
 abundant. It will, in fact, be found that the rate at which 
 the disease advances will accord with the amount of consoli- 
 dation. It must be borne in mind that the disease is, for the 
 present, regarded as strictly limited to the dentine and enamel, 
 and that the teeth are assumed to be in an otherwise healthy 
 condition. When the pulp becomes exposed, or when the 
 gums have receded and exposed the necks of the teeth, other 
 conditions come into operation, and modify the symptoms. 
 
 To what extent this obliteration of the tubes is to be re- 
 garded as a vital action is a question the discussion of which 
 must be deferred to the Appendix on the nature and causes 
 of dental caries. 
 
 Litmus paper applied within the cavity of a carious tooth
 
 CARIES. 803 
 
 almost invariably gives strongly-marked acid reaction, and 
 thus furnishes evidence of the existence of an agent capable, 
 if unresisted by the vitality of the dentine, of depriving that 
 tissue of its earthy constituents, leaving the gelatine to 
 undergo gradual decomposition, favoured by the heat and 
 moisture of the mouth. 
 
 In examining the circumstances under which the decom- 
 position of the dentine takes place, and under which it is 
 resisted, apart from the influence of vitality, any one must 
 be struck with the power that is exerted by the mere form , 
 of the surface involved. Supposing the disease to be situated 
 in a deep fissure, or upon the side of a tooth, against which 
 another tooth is placed, the decomposition will go on with 
 more or less rapidity, the rate being varied in accordance 
 with the condition of the oral fluids. But if the cavity be 
 superficial, and so placed that it is subject to friction during 
 mastication, the progress is usually relatively slow ; and if 
 the low walls of such a cavity be removed, the part will 
 become polls lied by the act of mastication and by the 
 motions of the tongue, and decomposition will be com- 
 pletely arrested quite independently of any power of resist- 
 ance exercised by vital action. Again, let a tooth be placed 
 under circumstances the opposite of the preceding. For 
 example : take a bicuspid of the ujDper jaw, the distal surface 
 of which is decayed, and remove the softened dentine ; then 
 let dry cotton wool be forced between the defective tooth 
 and its neighbour, and renewed only once in three or four 
 days ; at the end of a fortnight or three weeks it will be 
 found that the surface of the cavity which was left hard and 
 dense after the first operation, has become soft, and that the 
 softening extends to a considerable depth. Had the cotton, 
 prior to its introduction between the teeth, been dipped into 
 a solution of any resinous gum, such as mastic, the surface 
 of the cavity would have remained unaltered, owing to the 
 exclusion of moisture. But where wool only is used, the 
 secretions of the mouth are not only not excluded, but are
 
 304 A SYSTEM OF DENTAL SURGERY. 
 
 held in constant apposition with the exposed dentine by the 
 saturated wood. 
 
 Experiments of this character lead to the conclusion that 
 ■v\ithin the mouth agents are present which, under favouring 
 circumstances, are capable of decomposing the dental tissues, 
 and the source of these agents becames the next question 
 which naturally suggests itself. 
 
 The secretion from the mucous membrane is ordinarily 
 slightly acid, while the salivary fluid, when normal, is alkaline. 
 .The result of the admixture of these, if equally proportioned, 
 would be a neutral fluid. In certain conditions of health even 
 the saliva Q) may be acid, and the mucus would then retain • 
 its original character after the mixture of the two fluids. 
 Again, the degree of acidity of the mucus may be increased 
 beyond the nonnal amount, and its tenacity may enable it to 
 remain in certain situations unmixed, and consequently un- 
 influenced by the alkaline character of the salivary fluid. 
 The quantity of the mucus may be excessive either from a 
 local or a general cause. We not uncommonly find in mouths 
 tenanted by numerous carious teeth, the gums thickened and 
 vascular, and covered Avith a coating of thick adhesive mucus 
 capable of being drawn from the gums in long strings. A 
 case is fresh in my memory in which the teeth were rapidly 
 destroyed by caries, and coincident with the destructive 
 process the salivary fluid was scanty in amount. The mouth 
 owed its moisture to the secretion of the mucous membrane. 
 The patient complained of great discomfort from the dry 
 and clammy condition of the mouth and throat. The teeth 
 that were first lost decayed in those situations in which we 
 usually expect caries to show itself; but at a later period the 
 whole of the remaining teeth were almost simultaneously 
 attacked near the edge of the gum, producing round each 
 tooth an annular belt of softened tissue. The patient suffered 
 from long-standing dyspeptic symptoms ; and among these 
 a vitiated condition of mucus secreted from the surface of 
 
 J See the chapter on the Saliva.
 
 CARIES. 305 
 
 the mouth, and a diminished amount of saliva formed pro- 
 minent features. 
 
 In the foregoing case there could be no doubt that the state 
 of the oral fluids was dependent upon the general condition 
 of the body ; but in many cases it is by no means easy to 
 determine how far the disorder of the teeth is dependent uix)n 
 a general derangement of the system having a coincident ex- 
 istence, or how far the general disturbance of health may be 
 dependent upon the diseased condition of the teeth. Young 
 people are often brought to us in whom, coincident with the 
 extensive development of caries, we find an abundant flow of 
 saliva, and a free secretion of mucus ; but I think the latter 
 is usually in excess, and is found clinging to the teeth, 
 instead of becoming dissolved in the saliva. In cases like 
 those just cited, I believe we must regard the mucus as fur- 
 nishing the agent by which' the dental tissues are decomposed ; 
 and this opinion has been strengthened by the results which 
 followed upon treating several teeth in a manner calculated 
 to test the capability of the mucous membrane to furnish an 
 agent destructive to the teeth. The softened tissue was re- 
 moved from a cavity on the distal side of a first bicuspid of 
 the upper jaw, and some dry cotton was forced between the 
 bicuspids in such a manner as to press strongly upon the 
 gum. The cotton was renewed once in three days. After 
 the first application the gum became slightly inflamed, and 
 bled on the removal of the cotton, and in the course of a 
 fortnight the softening of the dentine was found to have 
 extended to a considerable depth, showing forcibly that the 
 rate of decay had been increased by the treatment. Having 
 frequently observed with more or less distinctness similar 
 results follow a similar mode of treatment, and the absence 
 of such results where the gum has not been irritated by the 
 pressure of the cotton, the conclusion, that the mucous 
 membrane when irritated throws out a secretion capable of 
 injuring susceptible teeth, follows as a necessary deduction. 
 This conclusion will also be justified by the results which 
 
 X
 
 306 A SYSTEM OF DENTAL SUKGERT. 
 
 often follow when the filling introduced into a cavity is 
 allowed to project so as to keep up a state of irritation in the 
 gum. The patient after a time returns with toothache, and 
 on examination we find that the tooth has decayed above the 
 stopping in the immediate vicinity of the irritated gum. 
 The irritation, if continued, may lead to the secretion of pus. 
 But pus, when secreted by the mucous membrane, presents 
 the ordinary alkaline character of that fluid, and does not 
 appear to exercise an influence upon the dentine. 
 
 The ca?e as respects the liuing membrane of the mouth is, 
 however, not without a parallel. The mucous membrane of 
 the bladder, when in a state of irritation, pours out a strongly 
 acid secretion. 
 
 A disordered state, local or general, of the mucous mem- 
 brane, must not, however, be regarded as the only source from 
 whence may be produced agents capable of decomposing 
 faulty enamel or dentine. For instance, examples j^resent 
 themselves in which the teeth rapidly decay in mouths 
 free from any increased vascularity, local or general — free 
 from adherent mucus about the teeth, and also from any 
 sign of that fluid being either excessive in quantity or 
 vitiated in quality. If in such cases the oral fluid be care- 
 fully examined, I believe it will be found that the saliva 
 itself has at intervals lost its alkaline character and become 
 acid. Several patients (females) returning after a prolonged 
 residence in India, have presented the foregoing conditions of 
 the mouth. They have been pale, bloodless, and greatly de- 
 bilitated, though not necessarily greatly attenuated, subjects. 
 
 In speaking of the oral fluids as having constituents pos- 
 sessing suflBcient activity to rob dentine of its phosphate of 
 lime, we must not lose sight of the fact, that where teeth 
 decay very slowly, and the disease arises in situations in 
 which defective organization is very often found, an abundant 
 supply of acid may be produced by fermentation of the food, 
 or may find its way from the stomach. 
 
 Without going into the consequences produced by caries.
 
 CAEIES. 307 
 
 when the pulp-cavity is laid open, the influence exerted upon 
 the pulp when the disease is advancing towards it, may 
 be noticed before the question of treatment is entered upon. 
 With the advance of age, the area of the pulp-cavit}'' becomes 
 gradually diminished by the slow addition of dentine to that 
 which was formed when the tooth was in a state of active 
 growth; and this condition is still more strongly marked 
 in those teeth which have been worn by mastication ; indeed, 
 in some cases the cavitj^ is almost, in others perfectly, oblite- 
 rated. In either case the effect is, as respects the contraction 
 of the cavity, general, but the local development of dentine 
 continuous with the pre-existing tissue, is very often coinci- 
 dent with caries. When the crown of the tooth is attacked, 
 the pulp very commonly resumes its formative functions at 
 a point corresponding to that towards which the disease is 
 advancing, and adds as it were a patch, or plate, of new den- 
 tine (or secondary dentine, as it is commonly called), the 
 tubular and intertubular substance of which is continuous 
 with that of the older tissue, and thus the tubes of the two 
 parts are continuous, although at the point of junction they 
 are often marked by a slight dilatation. When the tooth is 
 strengthened by additions made upon the walls of the pul])- 
 cavity, in consequence of the tooth becoming weakened by 
 disease operating upon the outer surface, we have a remarkable 
 example of the manner in which Nature attempts to remedy 
 a defect. But the reparative efforts are not always pro- 
 ductive of favourable results. In the place of additions being 
 made to the pre-existing dentine by the calcification of the 
 superficial part of the pulp, several, or even many, indepen- 
 dent centres of calcification may be established within" its 
 substance. In some cases, we find numerous irregularly 
 globular masses of dentine ; in others, one or two nodules 
 suQaciently large to occupy nearly the whole of the cavity. 
 It seldom happens that the larger masses are developed from 
 a single centre. They appear to have been produced by the 
 aggregation and coalesce nc(4 of a number of lesser globules.
 
 308 A SYSTEM OF DENTAL SURGERY. 
 
 This secondary nodular dentine may or may not be adherent 
 to the walls of the pulp-cavity ; it is, however, more fre- 
 quently free than attached, and in that case fails to answer 
 the useful purpose of protecting the pulp from exposure. 
 
 Mr. Salter speaks of the calcification of the pulp when it 
 occurs upon the surface, producing new dentine continuous 
 with the older tissue, as extrinsic calcification, and the new 
 tissue as dentine of repair. Q) 
 
 Caries. — Treatment. — The disease at present has been re- 
 garded as confined to the dentine and enamel only, and in 
 entering upon the treatment, the same limitation will be ob- 
 served. The exposure of the pulp and other complications 
 will be subsequently considered. 
 
 In the treatment of simple caries two methods are em- 
 ployed. The removal of the diseased, together with the 
 surrounding healthy tissue, to such an extent as to leave 
 a perfectly smooth surface, constitutes one method; the 
 removal of the diseased tissue, and the substitution of some 
 indestructible material for the lost part, constitute the 
 second method of treatment. In either case the diseased 
 part must be removed, or, at all events, such portions of it as 
 have been softened by the abstraction of the lime salts. 
 
 In selecting between these two operations, we must be 
 guided in the first place by the depth to which the disease 
 has penetrated, and by the situation in which it is esta- 
 blished. If the disorganization has not extended into the 
 dentine to a depth which greatly exceeds the thickness of the 
 enamel, and either the median or distal surface of a tooth (es- 
 l)ecially of a front tooth) be the part attacked, the operation 
 of excision may be performed with advantage. But if the 
 teeth are irregularly placed, the advantages of this method 
 of treatment may be either increased or diminished by the 
 peculiarity of the case. Teeth, when crowded together, will 
 l>e improved by the operation if they have been attacked 
 
 (1) For further information relative to the occurrence of dentine nodules, 
 se; l)iseases of the Pulp.
 
 TREATMENT OF CARIES. 309 
 
 with disease on the lateral surfaces, but when a separation 
 exists already, the widening of the aperture by the file will 
 produce an unsightly appearance, without offering any ad- 
 vantage over filling the cavity. 
 
 The operation of filing is not confined to the simple re- 
 moval of the affected portion of a tooth by the file. Not 
 only must the diseased "part be cut away, but it must be re- 
 moved with such other portions of the surrounding parts of 
 the tooth as will enable the operator to leave a perfectly 
 smooth surface, and one which can readily be reached when 
 the teeth are cleaned. Files of several degrees of coarseness, 
 or cut, as it is called, are required, and of various shapes. 
 Both these conditions have been carefully considered, and we 
 can now find at the dental instrument makers almost an 
 endless variety of the required forms. But should we fail in 
 finding such a file as would best answer our purpose, a pat- 
 tern may be made in any soft metal, and forwarded to the 
 file-maker. It would be an endless task to describe every 
 form of file which has been used in operating on the teeth, 
 more especially as each operator will seek for himself such 
 shapes as suit his own views, and are adapted to his own 
 method of operating. The use of the file having been carried 
 to a sufficient extent, the rough surface left by that instru- 
 ment has next to be removed, and a smooth and polished 
 one, free from angles or depressions, substituted. In the 
 production of this surface pumice powder is used after the 
 file is abandoned, and subsequently chalk, applied by means 
 of a strip of linen or a piece of wood cut into a suitable 
 shape. 
 
 The median or distal side of a front tooth is the situation 
 in which the file is most commonly applied, and the operation 
 will leave the dentine exposed to a greater or less extent. 
 Now, if the rough or grained surface left by the file be 
 allowed to remain, and be so situated that the food in 
 mastication, or the tongue in its constant motion over the 
 part, fails to remedy by friction the defective operation, we
 
 810 A SYSTEM OF DENTAL SUEGERY. 
 
 shall soon find the exposed dentine extremely sensitive, dis- 
 coloured, and softened. Examples are sufficiently numerous 
 in which a dividing file has been passed between two sound 
 front teeth for the purpose of relieving lateral pressure. 
 The division so produced has closed up, and the part placed 
 beyond the influence of friction. In the course of a com- 
 paratively short time, each tooth tKe enamel of which has 
 been cut through is attacked by decay ; a cavity results, less 
 favourable for plugging than would have arisen had the 
 operation of filing been omitted. 
 
 Nature sometimes performs for herself an operation which 
 is analogous to filing when" properly performed, both as re- 
 gards its physical peculiarity and its results. The walls 
 of a broad but shallow cavity produced by caries break 
 down, the softened tissues are exposed to friction and 
 rubbed away, till at last the hard dentine is reached ; this 
 becomes brightly polished, and endures for an indefinite 
 time unaltered. 
 
 The frequent occurrence of unfavourable results has led 
 many to regard with considerable distrust the operation of 
 filing, and the distrust is justified when that instrument is 
 used upon sound teeth for the purpose of relieving the 
 lateral pressure of one tooth upon another. But we may see 
 cases in which great advantages have resulted from the 
 operation, and it will not be difficult to discover the con- 
 ditions the observance of which has led to those advantages. 
 In the majority of cases it will be found that, with the whole 
 of the disorganized, a considerable portion of sound tissue 
 has been cut or filed away, and the surface resulting from 
 the operation placed Avithin the influence of the food in 
 mastication, and of the tongue. In order to secure these 
 two conditions, it may be necessary to remove so much of a 
 tooth as will interfere with its appearance. It is better, 
 however, that the form should sufier slightly than that the 
 whole tooth should be lost. 
 
 The file only has been spoken of, but instruments known
 
 TREATMENT OF CARIES. 311 
 
 as enamel-cutters, or chisels, are freqently used in conjunction 
 with the file. With these instruments the diseased part 
 may, in many cases, be removed much more rapidly, and 
 with less inconvenience to the patient, than with the file, 
 and the surface will be quite equal to that produced by the 
 latter instrument. 
 
 And the comfort of the patient is not the only advantage 
 possessed by the enamel-cutter over the file, for with the 
 latter it is often difficult or impossible to avoid removing 
 much of the labial surface of the tooth, which, so far as the 
 ultimate -results of the operation go, might have been allow^ed 
 to remain, and the absence of which must prove very dis- 
 figuring. Thus, it need hardly be said that, in operating 
 upon an upper incisor, the anterior surface of the tooth 
 should be as little encroached upon as possible, the removal 
 of the enamel and dentine being confined to the median and 
 lingual surfaces. Supposing the contiguous surfaces of two 
 teeth to be affected, the interval between them produced by 
 the operation should be wedge-shaped, the edge of the wedge 
 being directed towards the lip, and the base towards the tongue. 
 
 If the bicuspids or molar teeth were subjected to a similar 
 operation, the edge of the wedge-shaped interval would be 
 directed towards the gums, and the base on a line with the 
 masticating surface of the teeth ; the separation would also 
 be wider towards the tongue than towards the lips. 
 
 A very useful form of enamel-cutter has been recom- 
 mended by Dr. Arthur for the cutting down of teeth with 
 the object of leaving a smooth and well-shaped surface. It 
 consists of a thin flat blade, of hardened steel, the edge of 
 which has been ground off square. Thus the cutting edge 
 is a right angle, and it will be found very efficient in re- 
 moving dense enamel ; it may be made of very various 
 shapes, its peculiarity being that as the edge is a right angle, 
 it can only be conveniently sharpened when the blade is 
 thin ; it may be left almost or quite hard without danger of 
 chipping, if the quality of steel be good.
 
 312 A SYSTEM OF DENTAL SURGERY. 
 
 The results of cuttiDg away superficial decay in such a 
 manner as to leave a polished and thoroughly exposed surface 
 are often exceedingly satisfactory ; the difficulty, however, 
 lies in the selection of cases, for it is at times attended with 
 the most disastrous results. It is often possible to recognise 
 cases of caries in which, although the diseased part might be 
 removed by the file, its use would be injudicious. At, all 
 times the sensation produced by filing the teeth, to say the 
 least, is very disagreeable ; but in certain states of the teeth 
 the procedure is attended with great pain, so much so that 
 the operation cannot be properly performed. Again, when 
 we find associated with caries a thickened and vascular 
 condition of the gums generally, and more especially of those 
 parts which pass between the teeth, together with an 
 exudation of the thick ropy mucus to which I have already 
 referred, the operation of filing will be attended with very 
 doubtful success. If we filed out a small cavity, it is pro- 
 bable that in a short time another, equal to the extent of 
 dentine exposed, would take its place. 
 
 On the other hand, cases apparently most favourable for 
 this mode of treatment will now and then show results 
 equally unsatisfactory. It has recently been proposed by 
 Dr. Arthur Q) to very greatly extend the applicability of this 
 operation, and to use it not merely as a remedy, but as a 
 preventive against the attacks of caries. Starting with the 
 assumption that in certain individuals decay of the teeth is 
 perfectly certain to occur, and that these individuals may be, 
 with but little chance of error, recognised by the dentist, he 
 proposes to cut away sound teeth soon after their eruption, 
 in such a manner that they may be isolated from one another. 
 Where doubt exists as to the necessity of such a procedure, 
 he advocates separating the incisors from one another as soon 
 as they take their places, and carefully examining their 
 proximal surfaces ; he states his conviction that if the 
 
 (1) Treatment and Prevention of Decay of the Teeth. R. Arthur, M.D. 
 Philadelphia, 1871.
 
 TREATMENT OF CARIES. 313 
 
 smallest indication of caries is detected on their proximal 
 surfaces before the twelfth year, the molar and bicuspid 
 teeth are perfectly certain to be attacked. To quote his own 
 words, " What I propose is the separation of teeth closely in 
 contact, which are of such frail character, and are exposed to 
 such destructive influences, that their decay is inevitable, or 
 has already occurred." 
 
 Although it is probably true that the treatment of caries 
 by excision and subsequent polishing of the surface might be 
 practised with advantage more frequently than it is, yet it 
 may be doubted whether there is much evidence in favour of 
 so bold a plan of treatment as this. In the first place, it is 
 undoubtedly true that there are some mouths of which the 
 dentist may confidently predict that almost all the teeth will 
 successively decay ; but are not these exactly the cases in 
 which every point of exposure of the dentine made by the 
 file, or enamel-cutter, becomes a starting-point for caries ? 
 And, on the other hand, are not those favourable instances 
 in which caries has never recurred after its first excision, 
 almost always to be found in mouths where there is no 
 strong tendency to caries? 
 
 Again, it is admitted by Dr. Arthur that the operation 
 may have to be repeated over and over again, and that 
 constant care and attention is required on the part of 
 patients. But, as has very truly been remarked by a critic, 
 had all this polishing with tape, &c., been carried out by the 
 patient without any operation having been performed, inter- 
 stitial caries would probably have never occurred. 
 
 Moreover, teeth thus artificially separated are very prone 
 to shift their position and close up again, necessitating 
 repetitions of the operation, and involving great loss of tooth 
 substance ; even if they do not, the inevitable exposure of 
 the gum at the bottom of the wedge-shaped spaces will lead 
 to its being kept in a state of irritation by food forced down 
 upon it. 
 
 The file and the enamel-cutter have been spoken of in con-
 
 314 A SYSTEM OF DENTAL SURGERY. 
 
 nection with those cases which may be treated by operations 
 in the performance of which these instruments only are used. 
 But we shall have again to recur to them in connection with 
 the operation of filling, and as the manner of using such 
 instruments will then be described, it will be unnecessary to 
 enter upon the consideration here. 
 
 In the treatment of caries, filling must ever be regarded as 
 the great remedy by which the disease may be arrested, and 
 the defective tooth restored to a state of efiiciency. The 
 operation consists in the removal of the disorganized tissues, 
 and replacing them by a material fitting perfectly the cavity 
 produced by their removal, and capable of resisting the 
 chemical influence of the oral fluids, and the mechanical 
 effects of the food during mastication. 
 
 The disorganized portion of the tooth is cut out, and the 
 lost part is made good by an inorganic material. 
 
 There is, perhaps, no other operation performed upon the 
 human body which is attended with the same unqualified 
 success as that of filling teeth, for we not only succeed, in 
 the great majority of cases, in arresting the further progress 
 of disease, but we also replace the part which has been lost 
 by an imperishable material, and render the organ as useful 
 as it was prior to its becoming the subject of caries. It is, 
 however, a great error to suppose that filling will, under all 
 circumstances, permanently save the tooth, even in cases 
 which at the time the operation is performed promise 
 favourably. 
 
 There are those who are disposed to' regard the decay of 
 a tooth which has been filled as the result of want of skill 
 or of care in the operator ; such an opinion is perfectly 
 untenable, when the character of the operation is considered 
 in connection with the tissues which are involved, and the 
 various conditions under which disorganization may be 
 effected. The very fact that caries has appeared in a tooth 
 demonstrates its predisposition to disease. We can, for the 
 time being, arrest the disorder, but it may reappear in some
 
 TREATMENT OF CARIES. 315 
 
 other part of the tooth, and may in fact commence a second 
 time in the enamel and dentine in the immediate vicinity of 
 the plug, which will then form part of the circumference of a 
 new cavity. Such results will occasionally arise in the prac- 
 tice of those who use the utmost skill in their operations, 
 and they will be seen still more frequently among the patients 
 of those whose cry is infallibility. The ultimate success of 
 an operation will in great part depend upon the skill with 
 which it is performed, but it will not depend wholly upon 
 the operator. There are other sources of failure than the 
 assumed want of skill in operating, and such as are not under 
 the control of the dental surgeon or of the patient. 
 
 In some mouths the majority of the teeth will contain 
 plugs of various ages, ranging perhaps over a period of twenty 
 or even forty years, all of them looking bright, and the 
 contiguous dental tissue free from discoloration, the mucous 
 membrane of the gum healthy in appearance, and free from 
 adhesive mucus. In another mouth, again, in which there 
 are many plugged teeth, treated by the same operator, we 
 may find each plug surrounded by discoloured dentine, 
 associated with a thickened and vascular state of the mucous 
 membrane. With the lajDse of time the decay indicated by 
 the discoloration extends, and the plug falls out. Again, 
 instances will be seen in which a number of plugged teeth, 
 after standing without appreciable change for years, show 
 signs of giving way — not, however, in consequence of the 
 defective character of the operation, but in consequence of 
 failure in the general health, and a concomitant vitiation of 
 the oral fluids. 
 
 Attention has been called to the fact, that instances will 
 occur in which the operation of filling fails to secure a 
 permanent advantage, not for the purpose of depreciation, 
 but in order that its value as a mode of treatment may be 
 fully recognised and rendered independent of the injurious 
 effects which the exaggerated expectation encouraged by 
 some, and the want of proper confidence entertained by others,
 
 316 A SYSTEM OF DENTAL SURGERY. 
 
 have a tendency to produce in the minds of those whose field 
 of observation has been but limited. 
 
 The operation of ]ilugging is divided into two distinct 
 stages — the first of which is confined to the removal of the 
 disorganized tissues and the production of a cavity of suit- 
 able shape ; the second consisting in the introduction of the 
 material used for making the plug. For the present the 
 preparation of the cavity for the reception of the plug must 
 receive attention, upon the proper jDerformance of which 
 the ultimate success of the operation will in great part 
 depend. 
 
 In the treatment of a case, the first point for decision will 
 be the extent to which the diseased dentine can be removed. 
 The general rule is to cut out the disorganized tissue, until 
 the walls of the cavity present the colour of healthy dentine ; 
 but there are exceptions to this rule. In the first place, the 
 dentine may have become to a certain extent discoloured, and 
 yet have retained its normal hardness. Again, the dis- 
 coloration, and even softening, may have advanced so far 
 into the tooth that the removal of the whole would endanger 
 the exposure of the pulp. If the pulp be exposed during the 
 operation, the loss of the tooth is to some extent endangered ; 
 consequently it is better that a layer of discoloured dentine 
 should be allowed to remain for the protection of the pulp, 
 rather than run the risk of sacrificing the tooth. Supposing 
 that the walls near the orifice are strong and sound, it does 
 not appear that the retention of a little slightly-softened 
 dentine at the bottom of the cavity interferes seriously with 
 the durability of the plug. The presence of any softened 
 tissue at or near the orifice of the cavity must, however, be 
 carefully guarded against, for the neglect of this precaution 
 would be followed by the extension of the disease. 
 
 An exposed edge of disorganized dentine will allow solvent 
 fluids to pass through it to the sonnd tissue, rapidly or other- 
 wise, as the surface exposed is relatively great or small, and 
 spreading from a single point at the circumference of a plug,
 
 TREATMENT OF CARIES. 317 
 
 the decay will by degrees encircle it with a softened and 
 porous layer. This, though a sufficient, is not the only 
 reason for attending carefully to the removal of all the dis- 
 organized tissues near the orifice of the cavity. It is next to 
 impossible to produce a sound and solid plug the circum- 
 ferential boundary of which is soft and yielding, and the 
 difficulty would be still farther increased if the substance 
 against which the gold is pressed be saturated with moisture. 
 The retention of softened dentine, even in the bottom of a 
 cavity, should, if possible, be avoided ; but if it be allowed 
 to remain both in the bottom and on the side of a cavity, 
 the operation of plugging will be attended with but temporary 
 advantage. The gold in such cases cannot be fully condensed 
 either by direct pressure against the bottom or against the 
 sides of the cavity by the process of wedging. 
 
 The first step of the operation is not, however, completed 
 on the removal of the softened tissue, for the resulting cavity 
 would seldom present a form favourable for the retention of 
 the plug. When the disease has penetrated to a short dis- 
 tance only, the removal of the decayed part would leave a 
 mere concavity, the sloping sides of which would favour the 
 escape of the plug when pressed upon one side only. It 
 consequently becomes necessary, after the disorganized matter 
 has been taken away, to proceed with the excision of more or 
 less of the healthy tissue, until a cavity of suitable form 
 has been produced. A cylindrical hole may be regarded as 
 presenting the most advantageous form for the reception of a 
 plug, but it is in a comparatively limited number of cases 
 only that this regular figure can be" obtained. A certain 
 degree of approximation can, however, be generally reached, 
 and the nearer the approximation the greater will be the 
 facility with which the operation of plugging is performed, 
 and the greater also will be the chance of producing a durable 
 plug. 
 
 When the disease has advanced to a greater extent than 
 it is assumed to have done in the preceding example, the
 
 318 A SYSTEM OF DENTAL SURGERY. 
 
 removal of the softened tissue will often leave a large cavity, 
 the orifice of which is considerably contracted, owing to the 
 enamel, and perhaps a thin layer of the subjacent dentine, 
 having resisted the influence of the destructive agents more 
 successfully than the more deeply-seated tissue. It might be 
 thought that the overhanging of the sides of the orifice would 
 favour the retention of a plug, and the assumption would 
 l)erhaps be justified if it were practicable to introduce a 
 i:>erfectly solid plug in a cavity so shaped. Unfortunately it 
 is extremely difficult to force a filling under a projecting 
 ledge so as to produce even a moderate degree of solidity in 
 the part which occupied the angle ; and the consequent im- 
 perfection is still further increased when, in condensing the 
 surface, considerable pressure is directed in a line from the 
 top to the bottom of the plug, the efi'ect of which is to 
 depress the gold and carry it away from the under surface of 
 the projecting margin of the cavity. The plug may have a 
 very satisfactory appearance when finished, but in a com- 
 paratively short time evidence of failure will be discovered-. 
 That portion of the tooth which overhangs the plug being 
 but imperfectly supported from within, will break down, 
 moisture will find its way around the plug, decay will be 
 re-established, and if the operation is not repeated, the tooth 
 will be lost. 
 
 In order to avoid unfavourable results arising from the 
 foregoing cause, the overhanging edges must be cut away, if 
 not sufficiently to produce rectilinear walls, yet to reduce 
 the angles to moderately curved surfaces. The walls of a 
 cavity may bulge outwards or inwards, but anything iqy- 
 proaching to receding angles or sharp corners must be 
 avoided. It may be necessary to repeat, that the pressure 
 applied by the filling instruments condenses the gold only in 
 the line in which the force is directed. The metal is con- 
 densed beneath the instrument, but it does not spread to any 
 appreciable extent in the lateral direction, unless a perforation 
 be made by the instrument, and the direction of the force
 
 TREATMENT OF CARIES. 319 
 
 changed; and in no case will the condensation extend to 
 any considerable distance. For instance, if gold be pressed 
 into an acute angle, it will become hard upon the surface 
 pressed upon by- the instrument, and also upon the surfaces 
 which have rested upon the sides of the cavity which at their 
 point of junction form the angle, but the gold which lies in 
 the angle will remain porous. If the instrument used were in 
 each case sufficiently sharp or pointed to fit into the terminal 
 point of the cavity, of course the gold could be forced into 
 it, but in practice it would be extremely inconvenient to 
 employ such an instrument, and under the circumstances 
 of ian angular depression extending around the cavity, 
 impossible. 
 
 When the cavity is very shall6w, the general rule with 
 respect to the sides being parallel may be deviated from with 
 advantage. It will be w^ell to make the bottom compara- 
 tively flat and the sides rectilinear, or divergent from without 
 inwards. It may happen, however, that this form cannot, 
 owing to the condition of the tooth, be produced ; that the 
 convergence will be from without inwards, giving the outline 
 of an inverted cone. To render a cavity so shaped capable 
 of retaining a plug, one or two shallow grooves should be cut 
 around the circumference of sufficient depth to hold the gold 
 firmly in its place when forced into them in the operation 
 of filling. 
 
 It will be unnecessary to enter farther into the form of 
 cavities until we consider the operation of filling in special 
 cases ; but there are other points in respect to the pro- 
 cedure which may be considered in connection with cavities 
 generally. 
 
 The strength of the walls of a cavity is a very important 
 subject. It is useless to leave a portion of a tooth standing 
 which a trifling degree of force will at any time break down, 
 and thus expose the plug ; and it is worse than useless to 
 leave that which will give way during the operation of filling, 
 and thus perhaps endanger the whole tooth. An unwilling-
 
 320 A SYSTEM OF DENTAL SURGERY. 
 
 ness to interfere with the appearance of a tooth not un- 
 commonly induces the operator to attempt the preservation 
 of a part which eventually gives way, and necessitates the 
 perfoi'mance of a second operation under circumstances less 
 favourable than obtained on the first occasion, and the tooth 
 is left in as more unsightly condition than it would have been 
 had the fragile portion been freely cut away in the first 
 instance. The absolute strength required will vary with the 
 position which the tooth occupies in. the mouth. In a molar 
 tooth, which has to sustain the full force of mastication, the 
 walls of the cavity must be composed of enamel and dentine, 
 with a considerable thickness of the latter ; whereas, in front 
 teeth a much thinner layer will be found sufficient. Indeed, 
 in incisor teeth the enamel alone, if the extent be limited, is 
 sometimes sufficiently strong, when supported by a plug, to 
 endure for many years. The colour of the gold may show 
 through at the point where the dentine is entirely absent, 
 and yet there may be sufficient strength in the enamel for 
 the maintenance of the plug and of its own structure. . 
 
 There is yet another point in the formation of a cavity to 
 which attention may be advantageously directed. 
 
 The character of the margin of the orifice is scarcely less 
 important than the shape of the cavity itself. As a general 
 rule, the plugs which ^e surrounded by enamel are more 
 durable than those inserted in cavities the margins of which 
 are partly formed by dentine or cementum. It is conse- 
 quently desirable to preserve, if possible, the former tissue, 
 and to remove the dentine at the margin of the orifice in 
 such a manner as to allow the gold to come in contact 
 with the enamel, so that the dentine may be wholly covered 
 over and protected. Where the circumference of a plug is 
 bounded by strong enamel, as on the masticating surface of 
 a molar tooth, the undulating character of what we may call 
 the top of the wall, is unimportant; but should dentine 
 form a part of the whole of the boundary, as it will do when 
 the disease is situated on the mesial or distal side of a tooth,
 
 TREATMENT OF CARIES. 
 
 321 
 
 then it will be necessary to reduce the margin of the orifice 
 to a flat and smooth surface. 
 
 Several forms of instruments are used in preparing cavities 
 for the reception of plugs, but they come under one or other 
 of two heads, viz., cutters and drills. The one class will 
 include what are commonly called " excavators " and enamel 
 cutters, while in the other will be ranged drills of various 
 forms, and burr-heads, as they are called. 
 
 Fig. 137. (1) 
 
 I 
 
 It will not be necessary to do more than make a few 
 general observations upon the manner of using the instru- 
 ments employed in removing the diseased tissues. The 
 forms which have been figured may be taken as those most 
 commonly used, but the minute variation in size and shape 
 
 (1) Figs. 137, 138, show some of the most useful forms of excavators. 
 
 Y
 
 322 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 required from time to time generally leads to a great accu- 
 mulation of this description of instruments. The operator 
 should be able to make for himself excavators to suit any- 
 peculiar case which may arise. There is, however, one 
 property which should be possessed by all, whatever the 
 shape or size of the instrument. It should be made of good 
 steel, and kept perfectly sharp. A blunt instrument tends 
 to prolong an operation which is always disagreeable and 
 
 Fig. 138. 
 
 ^ ^ 
 
 G H 
 
 J K L 
 
 sometimes very painful. With a perfectly sharp excavator 
 the diseased tissue is quickly removed, and with a com- 
 paratively slight amount of discomfort. A few rapid and 
 well-directed strokes of the blade, and the softened tissue is 
 cut away, and although a proper form has yet to be given to 
 the cavity, the subsequent steps of the operation are seldrao
 
 TREATMENT OF CARIES. 
 
 323 
 
 productive of as mucli discom- 
 fort as attended the reraoval of 
 the softened tissue. In the re- 
 moval of softened dentine from 
 a tender tooth, the excavator 
 should be used in such a manner 
 as always to cut, and not scrape ; 
 this is a point which can hardly 
 be too strongly insisted on, 
 though it is very often neglected. 
 
 Under the head of drills are 
 included those instruments used 
 in the preparation of cavities 
 for the reception of plugs, which 
 cut by a rotatory motion. 
 
 The rose-head is very service- 
 able in reducing to a cylindrical 
 form the ragged opening of a 
 small cavity. The file-like char- 
 acter of the surface enables the 
 operator to cut away with readi- 
 ness the enamel which has be- 
 come weakened by the softening 
 of the subjacent dentine. Six or 
 eight sizes of heads should be at 
 hand, and each may form a 
 separate instrument made in 
 pinion wire, or from a seven-inch 
 length of square or round steel. 
 But it is perhaps better to have 
 a set of blades fitted to a com- 
 mon holder, and the crutch- 
 handled rose-head and drill- 
 
 Fig. 139. (1) 
 
 140.(2) 
 
 (1) Showing three sizes of rose-heads, the centre one placed in the crutch 
 handled stock or holder. 
 
 (2) Modified form of rose-head.
 
 n 
 
 324 A SYSTEM OF DENTAL SURGERY. 
 
 holder will be found to present many advantages. The 
 crutch rests between the thumb and forefinger, or between 
 the latter and the second finger, leaving the tips of the 
 Tr/. 141. (1) thumb and finger free to rotate the shaft of the in- 
 strument, while pressure is made upon the crutch. 
 (Fig. 139.) 
 
 For some years I have used this instrument with 
 the form of the cutter modified. Instead of pro- 
 ducing a spherical head, the steel has been allowed 
 to retain an uniform cylindrical figure, and teeth 
 have been cut, not only at the extremity, but for 
 some distance up the shaft. (Fig. 140.) 
 
 With this construction of cutter we secure all 
 the advantages of the rose-head, accompanied with 
 an additional amount of strength in the part cor- 
 responding to the neck of the latter ; also the ca- 
 pability of enlarging an orifice through which the 
 point has entered by the cutting surface of the 
 shaft. 
 
 The rotating file or rose-head is very serviceable 
 when the enamel requires removal, but for cutting 
 the dentine an ordinary drill presents many points 
 of superiority. It cuts more rapidly, can be more 
 easily made sharp, and its course can be more 
 readily directed than the rose-head, owing to the 
 greater amount of pressure required to bring the 
 latter into efi"ective operation. Drills of various 
 size and shapes may be mounted in the crutch- 
 handled stock shown in a preceding figure, or the 
 drill and shaft may constitute one continuous 
 length of steel (Fig. 141). The latter arrange- 
 ment ix)ssesses some advantages. The shaft is held, when 
 rotated, between the thumb and finger ; and as but little 
 pressure is required to make the blade cut, the direction and 
 
 (1) J>riU made from a cylindrical piece of steel, with the point chaptered 
 from each side.
 
 TREATMENT OF CARIES. 325 
 
 the rate of progress which the instrument makes can be very 
 readily felt. The operator will find advantage in having 
 various sizes of this instrument, the form of the points being 
 also varied. 
 
 Several forms of metallic sockets which receive the head 
 of the drfll, or rose-headed instrument, are sold for the 
 purpose of protecting the hand, which is otherwise apt to be 
 chafed by the pressure necessary to make the instruments 
 cut ; one which answers the purpose exceedingly well, 
 consists of a metallic cup, in which the upper end of the 
 instrument rests, and a ring which retains it in its place by 
 passing over one of the fingers. But, as drilling is at all 
 times tedious and fatiguing, many attempts have been made 
 to devise drills driven by mechanical means. Such an in- 
 strument is Harrington s erado, in which the motive power 
 is a strong spring. The drill is driven at a great speed by 
 an arrangement of cog-wheels contained in the box, but, as a 
 matter of course, with a corresponding loss of power. This 
 is the objection that has proved fatal to each of the numerous 
 pieces of mechanism devised ; there is a lack of power, so 
 that the drill stops so soon as it is pressed hard against its 
 work. But for finishing the surface of a plug, or any similar 
 purpose, where much power is not required, both Harring- 
 ton's erado, and the American pneumatic drill, which is 
 driven by a pair of bellows, are useful instruments. 
 
 Lately, however, an arrangement in which the motive 
 power is derived from a treadle has been, introduced under 
 the name of Morrison's dental engine, and this appears to 
 possess that power the lack of which is so fatal to the use- 
 fulness of the other forms of mechanism contrived for this 
 purpose. To minutely describe the apparatus would take 
 up too much space, but by an ingenious adaptation of spiral 
 springs as a means of conveying the rotatory motion, very 
 great flexibility is given to that end of the long arm on 
 which the drill or rose-head is carried. In this instrument, 
 the difficulty of securing adequate power appears to have
 
 326 A SYSTEM OF DENTAL SURGERY. 
 
 been siu-mounted, but it has not been sufficiently long in use 
 in this country to speak very positively as to its value. 
 
 Bemoval of Sensitive Dentine. — Cases are not infrequently 
 met with in which the carious dentine possesses such an 
 exalted degree of sensibility that its removal cannot be borne, 
 and the patient flinches from the slightest touch of any 
 instrument. A minute quantity of arsenic placed in the 
 cavity, and retained for a few hours, will render the part 
 absolutely insensible to pain. The objection, however, to 
 such a course is the difficulty of limiting the action of the 
 arsenic to the surface on which it is applied. It may find 
 its way to the pulp, and occasion the death of that organ — a 
 condition speedily followed by discoloration of the whole 
 crown of the tooth, and very probably by the supervention 
 of alveolar abscess. Thus Dr. Kingsbury, in a recent number 
 of the " Denial Cosmos," relates an instance in which arsenic 
 had been used for the purpose of obtunding the sensibility of 
 dentine, and had caused the ultimate death of the pulp in no 
 less than seven teeth in the mouth of one individual. 
 
 Hence the use of arsenic is perfectly inadmissible when 
 the cavity is deep, and can only be used with any degree of 
 safety for allaying tenderness of the layer of dentine im- 
 mediately beneath the enamel. If it is to be used at all, it 
 should be applied dry, or very nearly so, to avoid the risk of 
 its reaching the deeper portions of the cavity, and the cavity 
 carefully sealed, preferably by a temporary filling of gutta 
 percha. But as there are other agents which are capable of 
 reducing the sensitiveness of dentine, its use is to be de- 
 precated ; though it must be admitted that it is the most 
 efficient and most certain in its action of all the remedies 
 proposed for the purpose. 
 
 Next to arsenic, in point of efficacy, comes zinc chloride ; a 
 small fragment of the partially deliquesced salt, or a piece of 
 wool dipped in the solution produced by allowing the salt to 
 deliquesce, will, if held in the cavity for a few minutes, 
 greatly reduce the sensitiveness of the dentine. The appli-
 
 TREATMENT OF CARIES. 327 
 
 cation of tlie zinc chloride often causes severe burning or 
 aching pain for a few minutes, but after this has passed 
 away, little tenderness remains. Although the application 
 is painful and less efficacious than that of arsenious acid, 
 it is to be preferred, inasmuch as there is little danger 
 of causing the death of the pulp. I have lately adopted 
 a manner of using the zinc chloride which is convenient, 
 and yields satisfactory results. A small fragment of 
 cotton wool is teased out till it is very thin, and mixed 
 up in some very fluid zinc oxychloride ; then put into 
 the tooth and left to harden there, just as though a dressing 
 of gum sandarac were being applied. Zinc oxychloride, even 
 when mixed up thick, contains some little free zinc chloride, 
 and when used very fluid (which we are enabled to do by 
 incorporating a little wool with it), there is an amj)le amount 
 of the free salt to allay the sensitiveness of dentine Q). 
 After the lapse of a few days, this dressing, which does not 
 cause so much pain at the time of its application as that of 
 the pure salt, is removed, and the tooth is then usually 
 absolutely insensitive to the touch of an instrument. 
 
 A variety of substances, such as chromic acid, caustic 
 potash, and other escharotics, have been used for this purpose, 
 but the results are by no means such as to recommend their 
 employment. Camphorated spirits of wine, tannin, carbolic 
 acid, or thymol, repeatedly applied on cotton wool, will 
 generally reduce the sensibility sufficientlj'- to allow the 
 operation to be performed ; and, in fact, any form of tem- 
 porary filling introduced, with sufficient care to exclude the 
 saliva, will soon be followed by a subsidence of the extreme 
 sensibility of the tissue. 
 
 (1) On Oxychloride of Zinc. C. S. Tomes, in British Journal of Dental 
 Science, vol. xiii., p. 552.
 
 ( 328 ) 
 
 MATEEIALS USED IN FILLING TEETIJ. 
 
 Temporary fillings. — There is a variety of conditions, such 
 as a doubtful exposure of the nerve, extreme sensitive- 
 ness of the dentine, or the pouring out of a certain amount 
 of discharge through or from the pulp cavity, which renders 
 it undesirable to insert a permanent filling. We may have 
 resort to some of the various temporary fillings, either for 
 the specific object of curing one of the conditions which 
 preclude the immediate use of a permanent filling, as, for 
 example, the use of gum mastic and creosote when the nerve 
 is nearly exposed, or the insertion of a gutta percha filling in 
 a tooth very sensitive to changes of temperature ; or we may 
 employ them simply then as experimental fillings, to be 
 replaced by permanent plugs so soon as we are satisfied that 
 no mischief is going to be set up by the tooth being filled. 
 
 When from any cause it is inadvisable to place a perma- 
 nent filling in a tooth, we have recourse to various substances 
 suitable for temporary purposes. Solutions of various gum 
 resins in ether or alcohol are exceedingly useful ; gum 
 sandarac, animi, mastic, copal, or dammar, reduced by the 
 solvent to the fluidity of thin treacle, may be introduced 
 into the cavity on a suitable piece of cotton- wool. By evapo- 
 ration of the solvent, and partly by its dilution by the saliva, 
 the gum is precipitated, and forms with the wool a tolerably 
 hard mass, capable of lasting for some days, or even a 
 few weeks, though, as a general rule, it should be renewed 
 every two or three days. The cavity should be dried out 
 with cotton-wool, or what is better, amadou, before the in- 
 troduction of the mass.
 
 MATERIALS USED IN FILLING TEETH. 329 
 
 There is but little choice between the gum resins enu- 
 merated ; either of' them, in a state of solution, will answer 
 sufficiently well. I give the preference to gum sandarac, 
 as being more free from taste than the others, if copal be 
 excepted. But ether, being the solvent of copal, renders 
 the solution rather less manageable than those made with 
 alcohol. The rapidity with which the ether escapes, how- 
 ever well the bottle in \vhich it is kept may be corked, very 
 soon reduces the solution to a condition unavailable for dental 
 purposes. 
 
 Gutta percha, with which some mineral substance, such as 
 powdered silex or glass, has been incorporated, makes a re- 
 markably good temporary filling, capable of lasting for some 
 months. In using this compound, a piece of suitable size 
 must be taken, and warmed over a spirit lamp until the 
 whole mass is softened. The cavity having been dried, the 
 heated gutta percha is introduced, and the superfluous por- 
 tion removed with a warm instrument. Care must, of course, 
 be taken that the filling is not too hot, otherwise its intro- 
 duction will be attended with pain. But, on the other hand, 
 it must be sufficiently warm for the surface to be a little 
 sticky, or it will not adhere to the surface of the cavity. 
 Care must also be taken that the gutta percha is not burnt 
 when it is heated over the flame. An excellent method of 
 securing its adhesion to the walls of the cavity is, after 
 thoroughly drying the cavity, to mop it out with a pledget 
 of wool dipped in chloroform ; this, being a ready solvent for 
 gutta percha, secures its perfect adhesion to the walls. A 
 little chloroform applied in this way is also often very useful 
 for smoothing the edges of gutta percha fillings. 
 
 Of all the temporary fillings in use, the preparations of 
 gutta percha are far the most reliable; and, where it is 
 protected from the wear of mastication, it is exceedingly 
 durable. This form of filling is particularly useful in those 
 cases in which the teeth, although generally free from pain, 
 will not bear the pressure required for the introduction of a
 
 330 A SYSTEM OF DENTAL SUEGERY. 
 
 metallic plug — a condition which will commonly pass away 
 in the course of three or four months, if the cavity be sealed 
 up with the gutta percha. Instances are not uncommon 
 where, after the introduction of a gold filling, the tooth is so 
 painfully sensitiye to changes of temperature, that the patient 
 is in dread of either hot or cold beverages, or even of drawing 
 cold air through the mouth. If the gutta percha be substi- 
 tuted, the inconvenience passes ofi', and the tooth will, at the 
 end of a few months, bear the re-introduction of the gold 
 without any of the preceding discomfort. 
 
 Gutta percha is also very useful as an exjjerimental filling, 
 where there is some doubt whether the nerve can be preserved 
 alive, as in the case of the tooth aching, it can readily be 
 removed, even by the patients themselves, should the neces- 
 sity for their so doing arise. 
 
 For temporary fillings, the various preparations of zinc oxy- 
 chloride are exceedingly useful. Zinc oxide is mixed with a 
 strong solution of zinc chloride into a thick paste, which, after 
 the lapse of a short time, becomes perfectly hard. Difibrent 
 makers introduce difierent substances which in some degree 
 modify the rapidity with which it sets, and possibly alter 
 the resultant compound to some slight extent. Thus borax 
 is often introduced into the fluid ; and powdered glass, or 
 actual silica, into the powder, for the purpose of mechanically 
 conferring greater hardness on the mass when it has set. 
 But the various osteoplastic fillings which I have examined 
 difier only in slight and immaterial jx>ints, and the objec- 
 tions which can be urged against one, apply, I believe, 
 almost equally to all. 
 
 The zinc oxychlorides are a class of bodies for the most 
 part readily decom}X)sed by the action of acids and alkalies ; 
 moreover, the manner in which the mixture is made pre- 
 cludes the possibility of a definite chemical compound, with- 
 out excess of either constituent, being formed. As a matter 
 of fact, there is always free zinc chloride to be found in the 
 finished filling, and the filling is consequently hygroscopic.
 
 MATERIALS USED IN FILLING TEETH. 331 
 
 The objections to its use, which embody the results of many 
 experiments, have been elsewhere described (^), and it is only 
 necessary here to say, that experience of its nse in the mouth 
 goes to confirm the conclusions which had been arrived at on 
 chemical grounds, namely, that it is unreliable. 
 
 I have never seen an instance in which a zinc oxychloride 
 stopping, which was at any point in contact with the gum, 
 remained intact for any considerable length of time. No 
 matter how carefully it has been applied, if it reaches down 
 to the gum, sooner or later it will assuredly fail ; and this 
 practical result is nothing more than what might have been 
 expected from purely chemical considerations. 
 
 Where, however, it is away from the edge of the gum — 
 as, for instance, on a grinding surface — it lasts much longer, 
 though it wears down with the friction of mastication. But 
 where it is wholly protected by being covered in under a gold 
 filling, it lasts an indefinitely long time. 
 
 As a ^empor«?'2/ filling, then, it is very valuable; but it 
 has no claim to the name of a permanent filling. In apply- 
 ing it, the paste should be used very dry, and the filling 
 carefully protected from moisture till it has fully set ; this 
 may be done either by keeping the rubber dam applied to 
 the tooth, or by varnishing its surface with a solution of 
 gutta percha in chloroform. But all our precautions are to 
 some extent futile, for the paste has hygroscopic properties 
 which cause it to imbibe water, even from the atmosphere, 
 after it has hardened; nevertheless, it is very essential to 
 prevent a flood of saliva from washing away the zinc chloride 
 before it has had time to combine with the zinc oxide. 
 
 Permanent fillings. — Passing to the class of metallic sub- 
 stances, which do not undergo very material change in 
 the mouth, we have three diflerent kinds : fusible metals, 
 amalgams, and pure metals. 
 
 It is a curious property of certain alloys to have a melting 
 
 0) C. S. Tomes, in British Journal of Dental Science, vol. xiii., p. 552. Ou 
 Zinc Oxychloride.
 
 332 A SYSTEM OF DENTAL SUEGERT. 
 
 point below that of the constituent metals ; thus, the addi- 
 tion of cadmium to certain other alloys confers this property 
 in a marked degree. 
 
 Several formulae have been proposed (of which the best 
 known is Dr. ^Yood's) for forming alloys which melt at a 
 sufficiently low temperature to be applied to a tooth by the 
 aid of hot instniments ; but such preparations have found 
 little favour in this country, and I have but little experience 
 in their use. 
 
 It may, I think, be assumed as a settled point, that for 
 dental purposes a pure metal, such as gold, or even tin, is in 
 all respects preferable to any mixtures of metals at present 
 known. But there are cases in which the one can be used 
 while the other cannot. The American writers on dental 
 surgery have urged every possible argument against the use 
 of amalgams, and have gone so far as to pass rules for the 
 expulsion from dental societies of members who would not 
 pledge themselves to discontinue the use of mercurial fillings. 
 Yet there are teeth the condition of which is such that gold 
 fillings cannot be inserted with any chance of success, but 
 which, if plugged with a good amalgam, wiU last for years, 
 and be perfectly effective for a long period. 
 
 Common sense will, I think, decide the question whether 
 it is better to have a tooth filled with amalgam, or to lose 
 it at once. It has been urged that the mercury used in 
 making the alloy will salivate the patient. I have never 
 seen a case in which this result was produced, nor do I know 
 of a well authenticated instance, and I think we may fairly 
 conclude that the instances are so extremely rare that they 
 need not influence our practice. 
 
 It must, however, be borne in mind that I am not 
 advocating the use of amalgams where pure metals can be 
 used, but I do contend that the former are extremely useful 
 where the employment of the latter is prohibited. Take, as 
 an example, a tooth the crown of which has been hollowed 
 out to such an extent that the introduction of a foil filling
 
 MATERIALS USED IN FILLING TEETH. 333 
 
 would break down all that remains above the surface of the 
 gum, yet in which the pulp has been calcified and the tooth 
 is free from tenderness. Such a tooth if left to itself will 
 soon crumble away, but if carefully filled with amalgam it 
 may last for years. 
 
 Many examples may be found in which these kinds' of 
 filling have preserved the teeth in a state of usefulness for 
 long periods, the use of gold at the time the operation was 
 performed, from some cause having been interdicted. It is 
 true the teeth may be stained by the filling, but the presence 
 of a stained tooth is preferable to vacant gums, more espe- 
 cially when situated at the back part of the mouth, and sub- 
 servient only to the purpose of mastication. This objection, 
 however, can at the present time be scarcely said to hold 
 good. The amalgams now in use do not stain the substance 
 of the tooth as the older preparations did — a property due, I 
 think, to the presence of more or less copper in the com- 
 ix)unds formerly employed. 
 
 It is not uncommon to meet with cases which support 
 these view's in respect to the occasional use of amalgams. 
 Patients sometimes request that such fillings may be re- 
 moved and gold substituted, but more frequently an officious 
 operator urges the necessity of refilling teeth which have 
 been judiciously and efi"ectively treated. One of two results 
 follows ; either the teeth remain as useful as they were 
 before the substitution of gold for amalgam, or, what is very 
 common, the teeth are rendered tender by the operation, and 
 the patient, after more or less suffering from inflammation 
 about the roots of the refilled teeth, is obliged to submit to 
 the extraction of organs which, had they been allowed to 
 remain undisturbed, would in all probability have continued 
 serviceable for years. 
 
 I have in my own mouth two wisdom teeth which, three 
 years since, were so much decayed that it seemed hopeless 
 to attempt their preservation. They were extremely tender 
 when brought in contact with hard food, such as biscuit or
 
 33J: A SYSTEM OF DENTAL SUKGERT. 
 
 crust of bread, and felt as though they would ache before 
 many weeks had passed. I removed as well as I could the 
 carious portions, of course very imiDcrfectly, and filled them 
 with amalgam. These teeth have since that time given me 
 no discomfort : hence I have a right to consider that the use 
 of amalgam has enabled me to retain two teeth which 
 would otherwise have been removed or have fallen into 
 disuse three years ago. 
 
 Till within a comi)aratively recent period it was customary 
 to reduce into filings the ordinary silver coin, mercury was 
 added, and the compound worked up in a mortar or in the 
 palm of the hand until the whole became reduced to a stiff 
 paste. The superfluous mercury was then squeezed out, 
 either by pressing the mass between the thumb and finger or 
 in a fold of chamois leather. After this manipulation the 
 compound is placed in the tooth, and in the course of a few 
 hours becomes quite hard. Although this form of amalgam 
 is bright when introduced, yet in a short time the surface 
 becomes black and the whole body of the tooth by degrees 
 assumes a dark grey colour. 
 
 A series of amalgams have been long known as Sullivan's 
 cements, which are in the main composed of copper, but the 
 composition of the several qualities offered for sale has not 
 been described. They are sold in large pill-shaped masses, 
 and the operator is directed to crush in a mortar a suflScient 
 quantity for the case under treatment ; and to place the 
 mass in an iron spoon, which is to be held over the flame of 
 a spirit-lamp until globules of mercury appear upon the 
 surface of the fragments. In the heated condition the 
 compound is returned to the mortar, and rubbed until 
 reduced to a paste. It is afterwards squeezed in chamois 
 leather, to separate the excess of mercury, and is then ready 
 for use. These amalgams possess the same objectionable 
 qualities as the one already noticed, but in a less degree, and 
 are therefore preferable. 
 
 Precipitated palladium, when rubbed up with mercury.
 
 MATERIALS USED IN FILLING TEETH. 335 
 
 fonns an amalgam which does not stain the tooth although 
 it becomes in the mouth of a dark grey colour. The process 
 of uniting the two metals is a little tiresome. The mercury- 
 rolls about in a finely-divided palladium, and at first shows 
 no disposition to unite ; but when the combination com- 
 mences it proceeds rapidly, and is accompanied by the 
 evolution of considerable heat. After the metals are incor- 
 porated, no time must be lost before the mass is introduced 
 into the faulty tooth, as the process of hardening proceeds 
 very rapidly. This alloy in the soft state is very plastic, 
 and will take an extremely delicate counterpart of any 
 surface upon which it is pressed, much more so, indeed, than 
 any other form of amalgam with which I am acquainted. 
 The preceding compounds when pressed in the soft state 
 between the thumb and finger, impart a very peculiar grating 
 sensation, a property which the palladium amalgam does not 
 possess. 
 
 Dr. Evans introduced, several years since, a compound of 
 cadmium, tin, and mercury, which at first appeared to possess 
 many advantages over all other similarly-constituted alloys. 
 When perfectly set, the colour resembled that of tin, and the 
 degree of hardness was about equal to that metal. These 
 conditions presented great advantages over the hard, brittle, 
 and dark amalgams formerly used, and the new compound 
 was consequently very generally adopted. It was, however, 
 soon found that the cadmium, when used as a filling for 
 teeth, became subject to rapid oxidization. The mass lost 
 its tin-like softness, and became friable, while those portions 
 in contact with the tooth were converted into the yellow 
 oxide, giving to the surface against which it rested a brilliant 
 yellow or orange colour. Hence it happened that the use of 
 cadmium as a basis of dental amalgams was no sooner 
 adopted than abandoned. Attention had, however, been 
 drawn to the subject, and attempts were made to find a 
 compound which would neither oxidize nor assume an ob- 
 jectionable colour.
 
 336 A SYSTEM OF DENTAL SURGERY. 
 
 Mr. Arnold Eogers published, in 1850, an account of au 
 amalgam which he had used for several years with success Q). 
 It was composed of one part of gold, one part of silver, and 
 seven parts of mercury, and required heating before use, 
 much in the same manner as Sullivan's cements. This pre- 
 paration was not subject to discoloration, but I am told by 
 Mr. Rogers there was some difficulty in obtaining unifonn 
 results as regards the degree of hardness of the plugs, and 
 the time required for the hardening when used in the mouth. 
 These difficulties led him to discontinue its use in favour of 
 other formulas which have since been introduced. 
 
 Messrs. Ash, of Broad-street, vend an alloy, supposed to 
 be composed of silver, and tin, and a small percentage of gold, 
 to which mercury is added when required for use. And 
 Mr. Robertson, of Birmingham, at about the same date, 
 published a formula, containing similar ingredients. It is 
 composed of "gold, one part; silver, three parts; and tin, 
 two parts." The metals, which must be perfectly free from 
 impurities, are melted together, and run into an ingot, and 
 afterwards reduced into filings Q). To these mercury is 
 added at the time of using, and the quantity required is 
 equal in weight to the filings. 
 
 But, although the tissues of the teeth are not discoloiu-ed, 
 yet even these preparations become a little dark in hue after 
 they have been some weeks in the mouth. Moreover, they 
 are hard and brittle ; hence a preparation capable of retaining 
 the physical properties which Dr. Evans's amalgam possessed 
 at the onset, would be au improvement upon those sold by 
 Messrs. Ash and othei-s. 
 
 When required for immediate use, the requisite amount of 
 filings is placed in a mortar, or in the palm of the hand ; 
 mercury is added, and the two are rubbed together until a 
 stiff paste is formed. This should be washed, either with 
 alcohol, or (according to Mr. Rogers) with compound spirits 
 
 (1) Phannaceutical Journal, vol. is., p. 402. 1950. 
 
 (2) Ibid., vol. xi., No. 12. 1852.
 
 MATERIALS USED IN FILLING TEETH. 337 
 
 of ammonia. The first portion of fluid will be deeply 
 coloured, but after one or two repetitions the amalgam will 
 cease to impart any stain to the liquid. The mass may then 
 be dried in a napkin, and after squeezing out all the super- 
 fluous mercury, is ready for insertion into the faulty tooth. 
 
 In conducting the operation, the cavity should be freed 
 from moisture, and the amalgam may then be pressed firmly 
 in, care being taken that the cavity is thoroughly filled, 
 while none is allowed to project — a precaution that must 
 be especially observed where the gum lies over the margin, 
 and thereby conceals the edge of the orifice. The plug will 
 become perfectly hard in the course of a day, and should, if 
 opportunity is offered, be filed smooth and polished, together 
 with the margin of dentine or enamel by which it is sur- 
 rounded. 
 
 The kind of surface assumed by amalgams in the process 
 of hardening will be considered in connection with the 
 surfaces presented by those parts of gold fillings which lie in 
 contact with the walls of cavities. 
 
 A peculiar effect upon the dentine, produced more fully by 
 the copper amalgams than by those at present in use, may 
 be noticed. The blackened tissue against which the amal- 
 gam has rested for a lengthened period, is commonly found 
 to be extremely hard, much more so than healthy dentine, 
 and much more so than that which is subjacent. It is often 
 difficult to cut away the discoloured and indurated tissue, 
 but when this is effected the instrument readily operates 
 upon that which is next presented. 
 
 It would be out of place to enter at any great length into 
 the chemical and physical properties of amalgams in this 
 work; they have been more fully discussed elsewhere (^) ; 
 but there are some few characters shared by all of them 
 which require mention here. Dissatisfied with the amalgam 
 at present in use, 1 undertook an extended series of experi- 
 
 (}) C. S. Tomes, on "Physical and Chemical Properties of Amalgams." 
 Transactions of Odontological Society, March, 1&72. 
 
 Z
 
 338 A SYSTEM OF DENTAL SURGERY. 
 
 ments with the view of determining the real sources of 
 failure, and was led to the conclusion that chemical action 
 on the alloy had little or nothing to do with it, but that 
 amalgams at no time form perfect plugs. Every one of those 
 which were submitted to experiment contracted as it became 
 hard ; some very greatly, others less, but still all contracted 
 to an extent that must imperil the preservation of contact all 
 round the circumference of the plug. But this contraction 
 takes place with the greatest rapidity in the first few hours 
 after the amalgam has been mixed up, and subsequently 
 is slight in amount, though it is often not completed for 
 twelve hours. Hence we may partly get over the difficulty 
 by employing an amalgam which sets with great rapidity, 
 such as palladium. In using this metal as an amalgam 
 the greater part of the shrinkage is over before the plug 
 is completed. 
 
 General experience had already shown that of all amalgams 
 in use, i^alladium was decidedly the best, and that next to 
 this came cof)per ; and it was exceedingly satisfactory to find, 
 in my experiments on this matter, that these two displayed 
 less shrinkage than any of the others. But of the numerous 
 amalgams submitted to experiment there was not one which 
 did not contract markedly as it hardened ; so that they must, 
 one and all, a priori be pronounced unreliable. It was found 
 that the addition of platinum to silver and tin amalgams 
 greatly hastened their setting, whilst the addition of gold 
 lessened their contraction ; there is, however, a limit to the 
 quantity of gold which can be advantageously added, inas- 
 much as it eventually interferes with the complete setting 
 of the compound. 
 
 So far as I am aware, no serviceable amalgam which does 
 not contract as it hardens has as yet been produced; 
 Mr. Fletcher has, however, by the addition of both gold and 
 platinum to a silver and tin alloy, succeeded in producing an 
 amalgam in which the total shrinkage is not great, whilst the 
 rapidity with which it sets allows some part of the contrac-
 
 MATERIALS USED IN FILLING TEETH. 339 
 
 tion to take place before the operation is complete. These 
 amalgams have not been in use for a length of time sufficient 
 to test their actual value in the mouth. 
 
 There is, however, another fault possessed by amalgams, 
 which has been lately pointed out by Mr. Kirby : not only do 
 they contract, but they often undergo considerable changes 
 in form as they harden. Thus, he found that on moulding 
 specimens of amalgams into the form of long bars, with a 
 view of measuring their longitudinal contraction by a micro- 
 meter screw, that in some instances it was impossible to 
 replace the sample in the little trough used for the purpose. 
 
 From various grounds, it would seem advisable to use as 
 little mercury as possible in mixing up an amalgam, and it 
 is probable that the most durable plugs would be made in 
 this way ; but it should be mentioned that in Mr. Kirby's 
 hands the bars which showed the greatest alteration in form 
 were those which had been mixed very dry. 
 
 Inasmuch as the solvent powers of mercury are greatly 
 increased by warmth, if it be desired to introduce the 
 amalgam in a very dry and almost friable condition, warm 
 instruments should be employed. 
 
 As has been lately pointed out by Mr. Makins, in the 
 employment of a semi-fluid amalgam we get an effect 
 analogous to that produced by squeezing a sponge ; that is 
 to say, the fluid, in this case mercury, gets forced to the 
 surface, so that the composition of the mass in difierent parts 
 varies. It is easy to see that this may lead to a vacancy 
 round the edges in two ways : by the absorption of the free 
 mercury back into the contiguous portions of the plug, or by 
 its gradual evaporation. 
 
 Gold. — This metal is pre-eminently suitable for the pur- 
 pose of filling teeth on account of its softness, which renders 
 it possible to get very accurate adaptation to the walls of the 
 cavity, and also on account of its power of resisting oxidation. 
 It has also another valuable property, closely dependent on 
 its softness, namely, the readiness with which it may be
 
 340 A SYSTEM OF DENTAL SUEGERT. 
 
 welded at ordinary temperatures. For dental purposes, the 
 gold is presented to us in two forms ; the one being gold leaf 
 or foil, the other sponge, or, as it is preferably called, crystal 
 gold. Great purity is an essential, and this can only be 
 secured by refining the gold by the wet method ; that is to 
 say, dissolving it in aqua regia, and subsequently preci- 
 pitating it ; the form assumed by the precipitated gold 
 varying greatly with the re-agent used to effect this purpose, 
 and with many other conditions, not well understood. 
 
 When the aqua regia solution is precipitated by means of 
 oxalic or sulphurous acids, the gold comes do^vn in a coherent 
 spongy mass of crystalline structure. 
 
 Mr. Makins was, I think, the first who procured sponge 
 or crystal gold, as it is now called, with a view to its being 
 used for dental purposes. His preparation consisted of 
 minute octahedral crystals, connected loosely together by 
 fibres, which at parts exhibited a crystalline character, the 
 whole forming a spongy mass of dead gold colour. The 
 sponge under pressure became consolidated, in whicji state 
 it could not be distinguished from solid metal. Additional 
 pieces of the sponge, if added to that which had already been 
 condensed, on the employment of moderate pressure became 
 adherent. This adhesive or welding property rendered the 
 gradual formation of a plug, solid in all its parts, a matter of 
 but little difficulty ; and in the absence of a distinct recog- 
 nition of the adhesive properties of certain samples of foil, the 
 new gold appeared to ofler great advantages, and seemed likely 
 to supersede the use of foil in certain characters of plugs. I 
 have seen, from time to time, fillings which were made with 
 Mr. Makins's first batch of sponge, and up to the present 
 period they have remained unaltered. A description of 
 the gold, with the manner of using it, was published by 
 myself. 
 
 Mr. ;Makins did not enter upon the manufacture as a 
 commercial matter. The subject having attracted notice, 
 others attempted to produce a similar preparation, but the
 
 MATERIALS USED IN FILLING TEETH. 341 
 
 results were so unfavourable, that for a time the use of the 
 sponge gold was abandoned. 
 
 Subsequently Mr. Barling, of Maidstone, gave his attention 
 to the subject, and introduced a sponge gold not altogether 
 dissimilar to that which Mr. Makins produced. It is formed 
 mainly of octahedral crystals and indistinct fibres. 
 
 Soon after the production of sponge gold in this country, 
 the attention of transatlantic practitioners became directed 
 to the subject. Many experiments there, as here, were made, 
 with very questionable success. Ultimately, however, a very 
 beautiful preparation was made by Mr. Watts, and this is, I 
 believe, a favourite form of sponge gold in America. We 
 know it as Watts's American crystal gold, the valuable pro- 
 perties of which have been very strongly put forward by 
 Dwinelle and others in the American dental journals. The 
 gold comes to the hand of the operator in the form of light 
 spongy cakes, readily compressible between the thumb and 
 finger. Several degrees of density are produced, but the 
 character of the gold is otherwise the same. By the aid of 
 the microscope, we are enabled to see that the American 
 differs in its structure from the English sponge gold. Each 
 is crystalline, but while the latter consists of crystals of 
 the form normal to the metal, the former is made up of 
 beautiful foliaceous crystals closely resembling in general 
 appearance the leaf or frond of a common fern. They have 
 considerable superficial extent with very slight thickness, 
 and lie together greatly entangled and interlocked. 
 
 In the earlier samples a considerable amount of amorphous 
 gold was entangled amongst the crystals, and in some cases 
 oxide of gold was present in a small amount. These imper- 
 fections have been remedied, and the reguline condition is 
 obtained by all the manufacturers. More recently samples 
 of sponge gold prepared in Paris reached this country. 
 
 In order to command the best results in the use of the 
 crystal gold, four points require attention. 
 
 The gold must have been recently manufactured, or re-
 
 34*2 A SYSTEM OF DENTAL SURGERY. 
 
 cently annealed, in order that the adhesive property shall be 
 fully pronounced. The plugs must be built up of small frag- 
 ments, each one being perfectly consolidated before another 
 is added. The metal must be presei-ved from the contact 
 of moisture until the plug is formed. And appropriate 
 instruments nmst be used in performing the operation. The 
 neglect of either of these conditions will be followed by an 
 unfavourable result. 
 
 Sponge gold on exposure to the atmosphere soon loses its 
 peculiar adhesive quality, and becomes quite unmanageable ; 
 instead of welding together under the stopping instrument, 
 it falls to pieces, and all attempts to make additions to that 
 which is already consolidated are unsuccessful ; on this 
 account it is desirable to anneal the metal where any doubt 
 exists as to its condition. By the process of heating, the 
 adhesive property is restored, even though the temperature 
 to which the gold is exposed falls short of a red heat. But 
 to whatever extent the welding property is produced, the 
 presence of moisture will at once render it unavailable. The 
 metal, from its porous condition, absorbs like a sponge, and 
 instead of consolidating under the pressure of the instrument, 
 works up into powder. We must therefore guard against 
 the admission of the saliva, and also protect the tooth under 
 operation from the expired breath, which being charged with 
 moisture will, if the metal be of a lower temperature than 
 itself, deposit upon it a sufficient amount of fluid to interfere 
 with the adhesive proj^rty of the gold. 
 
 The instruments fitted for operating with crystal gold 
 difler from such as are required for the introduction of non- 
 adhesive foil, but in most respects resemble those best 
 adapted for adhesive foil. 
 
 The working end, instead of terminating like a wedge, is 
 more or less flattened, and cut up into a series of small 
 jxiints or ridges, in the formation of which it is necessary to 
 exercise some little care. The more perfectly formed are 
 the ridges or quadrilateral cones, the more easy will be the
 
 MATERIALS USED IN FILLING TEETH. 
 
 343 
 
 management of the gold. After a little use the edges or 
 points become blunted, and require restoration. 
 
 An instrument which presents a working surface of some 
 little size, will be found convenient for introducing the gold 
 into the cavity; but so soon as we have compressed the gold 
 firmly against the wall of the cavity, or upon that which has 
 
 Fig. 142. (1) 
 
 Fig. 143. 
 
 been consolidated, a smaller instrument must be worked over 
 the surface, and ultimately a still smaller one; indeed, a point 
 may be exchanged for the chequered working surface. By 
 the repeated use of a pointed instrument, after a new piece 
 of gold has been added to that which had been previously 
 
 (1) P'igs. 142 and 143 show forms of instruments for Introducing and com- 
 pressing sponge gold.
 
 344 A SYSTEM OF DENTAL SUEGEBT. 
 
 introduced, the solidity of the plug is ensured, and a surface 
 favourable for the addition of still more gold is produced. 
 
 The character of the surface to which further additions of 
 gold are required is of considerable importance. In the first 
 place, it must be perfectly clean, and free from moisture of 
 any kind ; and in the second, it must be rough, either 
 from the impressions of the one or the many-pointed instru- 
 ment. 
 
 Let the surface be made wet by the tongue, or smooth by 
 the burnisher, and no more gold will adhere until it is again 
 rendered perfectly clean and reduced to the rough condition 
 previously mentioned. - 
 
 Much has been said in praise Of crystal gold, owing to the 
 readiness with which the lost half, or even two-thirds of a 
 tooth can be restored by building up in metal a copy of the 
 absent part. When out of the mouth the half or the whole 
 of the crown of a tooth may be reproduced in sponge gold ; 
 but in the mouth the operation of restoration is by no means 
 so easy : it is not impossible, but it is generally impracticable. 
 There are few patients who could keep the mouth open for a 
 sufficient length of time, and when they can, the tooth 
 gradually cools down to a lower temperature than the expired 
 breath, and precipitation of moisture upon the metal is the 
 result. The operation may be suspended for a short time, 
 if on recommencing it the gold be wiped dry, and the 
 surface scraped or filed, so as to ensure a clean surface. It 
 is seldom, however, that the result is perfectly satisfactory 
 when the procedure is intermpted ; indeed, the restoration 
 of any considerable amount of the crown of a tooth is rarely 
 attended with lasting success. A few show-cases may be 
 produced, but the operation is too tedious, and the ultimate 
 result is too uncertain, to admit of general application. 
 
 In instituting a comparison between gold foil and crystal 
 gold, the microscope may be called into requisition with 
 advantage. If plugs be made in perforated pieces of ivory 
 (in the manner already alluded to) with the various forms of
 
 MATERIALS USED IN FILLING TEETH. 345 
 
 crystal gold, we shall find that the surface which has been 
 pressed upon, and has rested against the ivory, is made up 
 of crystals, the forms of which have been unaltered by the 
 pressure. Their presence in this situation indicates a certain 
 amount of porosity, and it is due to the dentine not offering 
 sufiicient resistance to interfere with the crystalline character 
 of the metal. Had the hole been in metal, instead of ivory, 
 the inserted plug would have presented a much greater 
 density upon the lower surface ; or had the cavity been lined 
 with enamel, a similar advantage would have been gained. 
 In practice it is very frequently necessary to plug a tooth 
 from which the whole of the diseased tissue cannot be 
 removed ; hence a substance softer than healthy dentine 
 forms the surface, the resistance offered by which will be 
 quite incapable of producing condensation of the gold to the 
 extent obtained where the disorganized part is wholly re- 
 moved : consequently, if crystal gold be used, the enclosed 
 surfaces of the plug will be imperfect, they will be capable 
 of absorbing moisture, and may after a time be broken down 
 with very slight force. On the other hand, when the cavity 
 is shallow, with the bottom hard, and the orifice surrounded 
 by enamel, perfectly satisfactory results may be obtained. 
 In those cases where decay has commenced upon the labial 
 surface of the front teeth, the crystal gold may be used 'with 
 great advantage. The plug should be made to project, and 
 then be filed down to the level of the surrounding surface 
 of the tooth. 
 
 The attainment of absolute solidity in a gold plug made 
 in the mouth, is not possible. If crystal gold be used, the 
 microscope will show a certain amount of porosity ; if foil be 
 employed, it will show the presence of fissures in the peri- 
 pheral surface of the plug. Now, if moisture finds its way 
 to the surface of the former, it will spread over the whole 
 circumference of the plug ; but in the latter it will be con- 
 fined to the minute fissures situated at distant intervals over 
 its surface. After using crystal gold for some years, and
 
 346 A SYSTEM OF DENTAL SUEGERT. 
 
 examining very closely into the results, I have come to the 
 conclusion that it is inferior to foil for the construction of 
 that }X)rtion of the plug which rests against the dentine. 
 But if the operation be commenced by lining the cavity with 
 foil, the central portion of the plug may be advantageously 
 made with crystal gold. By thus combining the two forms 
 of gold, plugs may be produced, the density and imperme- 
 ability of which connot be surpassed. 
 
 Sjwnge gold when long kept, appears to undergo some 
 molecular change, greatly interfering with its welding pro- 
 perties, which are only in a measure restored by annealing. 
 
 Gold foil is prepared by beating, or sometimes, in the case 
 of very heavy foils, rolling, into thin sheets a perfectly pure 
 metal. The sheet when prepared for dental purposes is 
 usually four inches square, and is numbered in accordance 
 with its weight. Thus the Xos. 4, 5, 6, 7, 8 indicate the 
 number of grains contained in each four-inch sheet, and 
 recently very much heavier foils have been employed, 
 reaching as high as two hundred and forty grains per 
 sheet. 
 
 The gold leaf of commerce is an altogether different article. 
 In order to. produce a leaf sufficiently thin for gilding pur- 
 poses, it is necessary to introduce a certain amount of copper, 
 as otherwise the metal when greatly reduced in thickness 
 will not leave the vellum, between sheets of which it is 
 beaten. 
 
 Considerable care is necessary in the preparation of the 
 gold leaf, as it is absolutely essential that it shall possess 
 certain physical characteristics as well as chemical purity. 
 Thus it must be tough and soft, and must possess either a 
 high degree of adhesiveness, or else must be completely non- 
 adhesive. In the one case, if several strips be placed in a 
 pill-box and well shaken, they should become inseparably 
 united, whilst in the other they should not adhere when 
 firmly pressed together. 
 
 Much lio;ht has been thrown on this matter of adhesive-
 
 MATERIALS USED IN FILLING TEETH. 347 
 
 ness in a valuable paper read by Mr. Makins Q), in which it 
 was laid down that the requisite conditions for complete 
 welding were a perfect absence of impurities from the surface, 
 adherent air even operating disadvantageously ; freedom 
 from moisture ; and a soft, yielding condition of the metallic 
 particles, which must not have suffered great previous com- 
 jDresssion. Thus, although silver, copper, or platinum, when 
 in the pulverulent condition, may be welded by pressure, 
 careless manipulation of the powder by which the particles 
 have become in a measure burnished effectually prevents 
 their union. Mr. Makins, in speaking of adhesive foil, says, 
 " The surface obtained is not a smoothed one, and is far 
 from polished : when examined by the microscope it will be 
 seen to be covered with corrugations with corresponding 
 depressions. The upper edges of these appear burnished, 
 but the depressions with which the greater part of the 
 surface is covered are perfectly matted ; and this is par- 
 ticularly the case in what is sold as adhesive, foil, which is 
 far more matted, and of that brown colour which, in pre- 
 cipitated gold, denotes but slight condensation of the metal." 
 Again, he says, " In adhesive foil we have a rough surfai:e, 
 and also many of the conditions present in sponge gold." 
 Thus, in adhesive gold it seems that the metal is only par- 
 tially welded, so that it is in a very favourable condition for 
 further welding under an instrument ; whilst in non-adhesive 
 foil the surface is already burnished, so that it has no great 
 tendency to cohere. A very slight amount of molecular 
 change, such as may be brought about by annealing, suffices 
 to convert the non-adhesive into the adhesive form ; this 
 process of annealing is, however, advantageous from other 
 causes, besides that of altering molecular condition, as it 
 secures the absence of moisture, and also gets rid of adherent 
 air. 
 
 Like crystal gold, gold leaf appears to undergo some 
 
 (•) G. H. Makins, " On the Union of Metals by Welding." Transactions of 
 Odoutological Society, June, 1872.
 
 348 A SYSTEM OF DENTAL SUKGEKT. 
 
 molecular change when kept for a length of time, leading to 
 its assuming a hard, harsh texture. 
 
 Before describing the manner of introducing the gold, it 
 will be well to devote a little space to the consideration' of 
 the instruments employed, and the methods of keeping the 
 cavity free from moisture. 
 
 Methods of Titeping the cavity dry. — The most universally 
 applicable appliance for this purpose is a small napkin 
 twisted into the form of a rope ; the roll being passed 
 over the crowns of the teeth behind the tooth to be operated 
 on, and held down on either side of it by the operator's 
 fingers. Though it is easy to demonstrate the various 
 ways in which the napkin may be applied, it would be an 
 endless task to attempt to describe them. In employing the 
 napkin in the lower jaw it is generally possible to make 
 pressure over the mouth of the salivary duct, so as to 
 prevent or retard the exit of saliva ; when operating on 
 the left side of the jaw, the first and second fingers of the 
 operator's lefc hand may be most conveniently used to hold 
 the napkin down, whilst in operating on the right side of 
 the lower jaw, it will generally be more convenient to stand 
 behind the patient, and employ the thumb of the left hand 
 on the inside and the first finger on the outside of the teeth. 
 It is often, however, excessively fatiguing to hold the napkin 
 in its place, and this may be done by a Hawes's tongue com- 
 pressor applied over the inner portion of napkin, whilst a 
 single finger of the operator's hand holds down the outer 
 fold. Dr. P. Smith has modified and greatly improved 
 Hawes's duct compressor, and the instrument so altered is 
 extremely useful. The figure which is here given will 
 explain itself ; in applying it the napkin is first adjusted, 
 and then held down by the introduction of the horizontal 
 arm with its horse-shoe end, which has been previously 
 detached from the rest of the instrument. Whilst this is 
 held in its place, its free end is slipped through the hole at 
 the top of the upright (which has been previously raised to
 
 MATERIALS USED IN FILLING TEETH. 
 
 349 
 
 its full extent), and the padded plate adapted below the 
 patient's chin. The upright, which is furnished with a 
 ratchet at its back so that it will slip down, but not upwards, 
 is then pressed down until the napkin is securely fixed. As 
 a rule, patients much prefer the use of this instrument to the 
 introduction of the operator's fingers. 
 
 Fig. UA. 
 
 §.3ize 
 
 In prolonged operations the napkins are apt to become 
 saturated, and the difficulty of keeping a lower tooth dry 
 is often very great. To meet this difficulty various forms of 
 saliva pumps have been devised. 
 
 But the appliance which gives the greatest security against 
 the inroads of saliva is the rubber dam. This consists of a 
 sheet of thin india-rubber, which must be sufficiently tough 
 to stretch readily without tearing. A sheet of such size is 
 taken that all four corners may be brought outside the 
 mouth when it is applied ; holes are then made in it in a 
 suitable position, through which the crowns of the teeth are 
 passed. These holes may be made with a punch, or by 
 suddenly forcing the handle end of an excavator through the 
 tightly- stretched sheet. 
 
 It is seldom sufficient to pass the rubber over one tooth 
 only ; unless the tooth to be operated on stands alone, the 
 rubber would rise so high around it that the li^ht and the
 
 350 A SYSTEM OF DENTAL SURGERY. 
 
 view of the cavity would be obscured. Hence it is usually- 
 passed over the tooth in front and that behind the one to be 
 operated on ; but, of course, no general rule can be laid down 
 on this ])oint. If tlie teeth stand close to one another, only 
 about the eighth of an inch should intervene between the 
 holes in the rubber, but if there is an interval between the 
 teeth a larger space must be left, so that the intervening 
 gum may be covered. 
 
 In applying the rubber the sheet is put on the stretch 
 between the forefingers of the right and left hands, placed on 
 either side of the first hole : it is thus forced over the front 
 tooth, then over the next, and so on from before backwards, 
 till all the teeth which are intended to be included are 
 through their respective openings in the sheet. 
 
 The rubber is then slightly pulled away from each, tooth, 
 and the free edge lying against the neck of the tooth, which, 
 from the manner in which the rubber has been applied, \^ill 
 look upwards, is tucked in by the side of the neck of the 
 tooth so that it is directed downwards ; this may easily be 
 effected by the use of a burnisher, or other blunt instrument. 
 When the shape of the teeth is favourable to its retention, 
 no further measures are required to keep it in its place ; but 
 should it tend to slip upwards, pieces of waxed silk may be 
 passed down between each tooth, and their ends tied together. 
 In other cases wooden wedges may be employed to retain it 
 in its place, or ligatures of waxed silk tied around the neck 
 of the tooth previously to the application of the rubber, so 
 as to form artificial ledges. 
 
 It is seldom necessary to apply the rubber dam in order to 
 fill cavities in the grinding surfaces of upper teeth ; a fold of 
 napkin placed between the cheek and the alveolar ridge will 
 generally answer the purpose in such cases. 
 
 There are, however, many cases in which the application 
 is exceedingly difiicult, and in which the labour and possible 
 failure, after every precaution has been taken, render its use 
 hardly worth the trouble of its adjustment. Minor dififi-
 
 MATERIALS USED IN FILLING TEETH. 351 
 
 culties may, however, be got over : in the first place, it may 
 be stated as generally true that, wherever the floss silk will 
 pass down between teeth, it will carry down the rubber with 
 it. When, owing to the conical shape of the tooth, the 
 rubber, after being fairly applied, slips off, and cannot be 
 retained by a ligature of waxed silk, it may be held down by 
 a piece of soft iron wire, bent so as to roughly fit the tooth, 
 and having its free ends carried out on the buccal side, 
 where they are held down by a single finger. Q) 
 
 In certain positions the rubber may be held out of the way 
 by an instrument grasped in the left hand ; thus, in an inter- 
 stitial cavity, the cervical edge of which is below the gum, a 
 view of the upper part of the cavity may be obtained by the 
 use of a blunt-ended instrument bent at a right angle, which 
 is employed to force the edge of the rubber above the margin 
 of the cavity ; when the upper part of the cavity is filled, 
 the Necessity for holding back the rubber is over, and the 
 instrument may be laid aside. 
 
 For cases in which the above-mentioned measures prove 
 insufficient to retain the rubber, it has been proposed (loc. 
 cit.) to use metallic clasps fitted to the teeth, but I have no 
 experience in their use. 
 
 Separating TtetH. — As the teeth, and more particularly the 
 incisors, are in close apposition, it often becomes necessary 
 to effect some separation in order to allow of the introduction 
 of instruments. In some instances we do not hesitate to cut 
 away sound portions of the tooth to effect this purpose, but 
 such a course is not always advisable. In the case of front 
 teeth, if the decay has a considerable superficial extent, it 
 will be well to cut away the lingual surface of the tooth with 
 an enamel-cutter, in such a manner as to leave a V-shaped 
 division, which does not encroach on the buccal surface. If 
 this be not done, a cavity with brittle, ragged walls will 
 result ; but where the superficial extent of the disease is 
 limited, it will be better to avoid cutting into the tooth. 
 
 (1) Dr. Hodson, in Dental Cosmos, vol. xii., p. 507.
 
 352 A SYSTEM OF DENTAL SURGERY. 
 
 The required space may be gained by the introduction of 
 strips of wood, of india-rubber, or of cotton-wool between the 
 teeth. 
 
 The separation may be effected at once, or the force may 
 be more gradually exerted, which latter is the safest course 
 if any considerable amount of space has to be gained. 
 
 The method of " quick wedging," as it is termed, has, how- 
 ever, a good many advocates, and may be first described. 
 For this j.urpose two wedges of orange wood are required ; 
 one is forced between the necks of the teeth, and the second, 
 whicli is more tapering, is forced between the points of the 
 teeth. Gentle taps of a mallet are given to the latter, and 
 the space thus gained is secured by a tap on the first wedge. 
 Thus, by alternate taps on the wedges, the teeth are forced 
 apart, and when an adequate interval has been gained the 
 second wedge is withdrawn. The force which may be 
 exerted in this way is very great, and many untoward 
 accidents have been reported from an incautious use of the 
 mallet. 
 
 This method can only be recommended in the case of 
 incisor teeth, which require to be moved through a very 
 short distance ; and it must not be resorted to where there 
 is any unhealthy condition of the gums or alveoli. On the 
 whole, the method of slow wedoring is safer, and is the one 
 generally adopted in this country. If wood be employed, only 
 a moderate degree of force should be used in inserting the 
 wedge, which may require to be replaced by a larger one 
 after the lapse of a few days. But the most convenient 
 material is india-rubber; this should be employed only in 
 veiy thin pieces, which may be cut from the solid lump. It 
 should not be left many days without renewal, and in no case 
 should a thick piece be introduced at once, as this would 
 exert a degree of force which might prove injurious. 
 
 In many cases the separation may be veiy conveniently 
 effected by the use of cotton-wool, fiiTuly pressed between the 
 teeth : this should be frequently renewed. The time required
 
 METHODS OP INTRODUCING THE GOLD. 353 
 
 for separating teeth will vary from two to seven days, much 
 depending on the age of the patient. 
 
 When teeth have been moved by the process of wedgin;!, 
 it will generally conduce to the comfort of the patient to 
 place a wedge moderately tightly between the teeth while 
 they are being filled, as this will keep them firmly fixed, 
 and to a considerable extent obviate the tenderness which 
 always exists in teeth forced from their proper position. 
 
 Methods of introducing the Gold. — Crystal Gold. — The 
 sponge must be torn up into small fragments, the size of 
 which will be in some degree regulated by that of the cavity. 
 Each fragment, on its introduction, must be thoroughly con- 
 densed before we proceed to add another ; and this conden- 
 sation must be done gradually, and at first gently, so as to 
 avoid pulverising the gold. Any attempt to introduce a 
 large amount of sponge, and then consolidate it as a whole, 
 will eventuate in the production of a plug hard on its surface 
 and very soft in its interior. Such results were common 
 before the use of sponge gold was properly imderstood. The 
 plugs looked very bright and solid on the surface ; but their 
 disintegration speedily commenced, and the cavity operated 
 upon, instead of containing a plug of solid metal, was found 
 to be occupied by a more or less coherent mass, so soft that 
 it could be broken up by the' finger-nail. 
 
 The fragments of crystal gold may be very conveniently 
 picked up and carried to the cavity with plugging forceps, 
 and the condensation may be, to a considerable extent, 
 effected wnth the same instrument. On page 343, figures 
 of instruments which may be used for the introduction of 
 sponge gold are given, but the most generally suitable forms 
 are the foot-shaj)ed pluggers. As it is absolutely necessary t<> 
 develop the adhesive properties of the gold to the utmost 
 extent, it is generally advisable to anneal the gold imme- 
 diately before use. The fragments ])rcpared for use may be 
 annealed by heating tliem on a sheet of mica over a spirit- 
 lamp, or by passing each piece tlirough the flame as it is 
 
 2 A
 
 354 A SYSTEM OF DENTAL SURGERY. 
 
 about to "be used. Sometimes the one plan, and sometimes 
 the other will be found to succeed best. 
 
 Gold Foil, non-adhtsiue. — The methods in which the 
 gold may be used are various. The leaf may be folded into 
 ribands of suitable length and breadth, and these may be 
 cut up into more or less square pieces ; or the whole may be 
 loosely twisted into ropes (Fig. 145). 
 
 Fig. 145. 
 
 Or, again, the leaf may be cut into four or more pieces, 
 each of which is crushed up into the form of the rope by 
 means of the instrument sold for the purpose, which consists 
 of two sheets of metal, one edge of each of which is turned 
 up so as to form a ledge about one-fourth of an inch deep. 
 1 he riband or rope is cut into lengths somewhat more than 
 twice the depth of the cavity, and the pieces introduced by 
 means of an instrument with a tolerably large extremity ; 
 the middle of each is carried down to the bottom of the 
 cavity, so that the two ends project from its orifice. "SVhen 
 the cavity is nearly full, an instrument with a smaller point 
 is used, and one end of each strip" carried down to the bottom. 
 AVhen we are unable to introduce any more foil, a sharp 
 wedge-shaped or trocar point is forced into the centre of the 
 plug, so that in the act of perforation the gold is very forcibly 
 pressed from the centre towards the circumference of the 
 cavity. The hole thus made is filled by folding in strips 
 until no more can be introduced. The operation of perforating, 
 and filling the perforations, is repeated until it is no longer 
 ix)ssible to make the instrument enter. The success of the 
 proceeding will depend upon the character of the foil em- 
 ployed, that which is destitute of adhesive properties being 
 alone suitable when the foregoing manner of ojierating is 
 adopted. Had the operation been conducted with adhesive
 
 METHODS OF INTRODUCING THE GOLD. 300 
 
 foil, great difficulty would have been encountered in carryinii; 
 the folds to the bottom of the cavity when the operation 
 approached completion. Each fold would adhere when it 
 came in contact with the gold already impacted, and if force 
 were employed the instrument would cut through the riband, 
 leaving the orifice narrowed, while the lower portion of the 
 cavity remained undirninished ; and unless great care were 
 taken the operation would terminate in the production of a 
 plug very hard on the surface, and soft or porous in the 
 interior — a character of filling presenting a good appearance, 
 but capable of saving the tooth but for a short time. The 
 hardened surface will give way, and the plug either become 
 depressed, or it will fall out. It might be supposed that in 
 filling a small cavity, which in the general sense of the term, 
 though it equals the size of the whole tooth, cannot be very 
 large, the gold foil would be compressed throughout the whole 
 mass of the plug by pressure made upon the external surface. 
 Experience, however, shows that this effect cannot be pro- 
 duced. The foil, whatever its character, becomes condensed 
 immediately imder the instrument into a thin, hard scale, 
 which arches over and protects from pressure that which is 
 below. This condition obtains in all the forms of gold avail- 
 able for dental purposes. In no case can a moderate-yized 
 plug be introduced and compressed as a mass — to be efifective, 
 the pressure must be applied consecutively to each of the 
 many portions (and these must be small portions) of which 
 the plug is gradually built up. But although we cannot de- 
 pend upon producing a sound plug, unless it is formed by the 
 gradual addition and compression of small pieces of gold, yet 
 there is a great difi"erence in the qualities of foil in respect to 
 the manner in which they are influenced by pressure. Thus 
 a sheet of the non-adhesive, when made into a ball by rolling 
 between the fingers, may be compressed and adapted to the 
 sides of the cavity with some degree of unifoi-mity throughout 
 the mass ; but if adhesive foils be similarly treated, we shall 
 find that the surface against which the plugging instrument
 
 356 A SYSTEM OF DENTAL SUKGERY. 
 
 has been pressed is condensed into a hard layer, while that 
 which lies next to the cavity has been relatively but sUghtly 
 acted upon, and probably, instead of adapting itself, has 
 turned away from the tooth at several points towards the 
 instrument, and become loose in the cavity. 
 
 With the non-adhesive foil, a mass after introduction is 
 readily applied to the walls of the cavity, which becomes 
 contracted to an amount corresponding to that of the metal 
 added, until at last the whole space is occupied by gold. 
 But each mass so added, although closely adapted to that 
 already introduced, will preserve its own identity, and on 
 the tooth being broken up, may be separated from those with 
 which it has lain in contact. On breaking up the plug, it 
 will become apparent that the component masses have been 
 held together by a system of packing within a circumscribed 
 space, not by the adhesion to each other of the several por- 
 tions of which the plug has been built. It is very necessary 
 that this point should be fully understood. 
 
 If the operator proix)ses using the non-adhesive foil, he 
 must proceed upon the principle of packing, and the layers 
 of foil must pass in a direction from the bottom to the orifice 
 of the cavity. The foil may, however, be introduced in other 
 forms than that of a loosely-twisted rope : it may be rolled 
 into a ball of suiiicient size to loosely fill the cavity before it 
 is compressed, and when in position perforated with a sharp- 
 pointed conical instrument, of sufficient size to force the foil 
 against the circumference of the cavity. In filling up the 
 central aperture thus produced, the sides of the filling should 
 be forced down. At this stage of the operation we shall have 
 a dense plug immovably fixed upon the floor of the cavity, 
 and rising up the sides to within a limited distance of its 
 orifice. To complete the filling, the careful su})erix)sition of 
 layers of adhesive foil is alone necessary. In this manner a 
 plug may be built up in a cavity, two sides of which have 
 been lost, supposing the two remaining walls are strong. 
 For example, a large fissure running across the masticating
 
 METHODS OF INTRODUCING THE GOLD. 357 
 
 surface of a bicuspid, and cropping out upon the mesial and 
 distal sides of the crown of the tooth, may be thus effectively 
 filled. 
 
 Another method of manipulation, by which a perfectly 
 satisfactory plug may often be made with non-adhesive foil, 
 consists in folding the sheet into a long, flat riband of suitable 
 width, and cutting it into narrow strips. These strips, which 
 should be rather more than twice as long as the cavity is 
 deep, are successively picked up by a blunt-pointed plugger, 
 so that they are arranged on its point like a star ; or the 
 strips may be so arranged on a thick piece of vulcanised 
 
 Fig. 146. 
 
 
 caoutchouc, and picked up by pressing the point of the in- 
 strument on the centre of the star. 
 
 In this form the strips are carried to the cavity and pressed 
 in, leaving the radii of the star projecting ; a second and a 
 third star are taken up in a similar manner, and forced into 
 the cavity. When the centre has become full, the projecting 
 ends or radii may be forced in near, but not at, the circum- 
 ference, by the use of a fine-pointed instrument. If the 
 instrument has been well chosen with respect to a gradual 
 diminution of size, an extremely dense plug will be the 
 result. 
 
 The Americans were the first to propose the formation of 
 the foil into cylinders ; these cylinders may be made in two 
 ways, the one by loosely folding the sheet three or four times 
 and then twisting it into a rope, from which short lengths
 
 358 
 
 A SYSTEM OP DENTAL SUEGERT. 
 
 are cut off; the other, by closely folding it into a flat riband, 
 and rolling the riband round a fine broach, or, what is better, 
 an instrument made for the purpose. The cylinders pro- 
 Fig. 147. Fig. i48.(i) duccd by the first method are soft and very 
 ^ SB compressible ; those by the last much less 
 ^ \\ so, the respective advantages of the two 
 forms being dependent on the nature of the 
 cavity. 
 
 The cylinders are made a little longer 
 than the depth of the cavity which they are 
 intended to fill, and are introduced by plug- 
 ging forceps. (See Fig. 154.) 
 
 Every cylinder is placed in such a po- 
 sition that one end rests on the bottom 
 whilst the other projects from the orifice of 
 the cavity; thus, if the cavity be on the 
 grinding surface, each cylinder will stand 
 vertically, but if it be interstitial, every 
 cylinder will lie horizontally. As it has 
 been happily expressed, the cylinders are 
 placed in the cavity like cigars in a 
 tumbler. 
 
 Two methods may be pursued in their 
 introduction into the cavity : a number of the tightly-rolled 
 cylinders may be set upright in the cavity till it is loosely 
 filled by them ; a wedge or trocar- shaped instrument is then 
 forced in between them at any point where it can be made 
 to enter, and the holes thus produced filled by fresh cylin- 
 ders. At the last, when only small perforations can be 
 made, it will be found easier to fill these up by the use of 
 
 (1) Instrument for rolling the foil into cylinders. The sheet is cut into two, 
 and foliied on itself till the resulting riband is >omewhat wider than the cavity- 
 is deep; it is seized close to one end between the thin points of the instrument, 
 which are closed by pushing up the sliding ring. Wlien a suflBcient length has 
 been rolled up, the riband is cut off, and the cylinder released by very slightly 
 drawing back the sliding ring. It is convenient to make a stock of cylinders 
 of convenient sizes, keeping them in a bottle until required for use.
 
 METHODS OF INTRODUCING THE GOLD. 359 
 
 stars of gold foil, or of adhesive gold, the heavy numbers 
 of foil answering this purpose admirably. 
 
 Or, to begin with, a cylinder of such a size that it will only 
 just enter the orifice of the cavity is placed in it, care being 
 taken to avoid pressing it, lest it become condensed before it 
 has reached its place : this cylinder is then forced against 
 one wall of the cavity by the use of a foot-shaped plugger, 
 and malleted, if the mallet be used ; other cylinders are then 
 placed in the space so made, and similarly condensed against 
 the walls of the cavity and the gold already introduced, the 
 filling being, as in the first method, finished by making 
 perforations in the centre and filling these up. 
 
 As the foil, rolled up into cylinders, is already closely 
 pressed together, great care must be taken not to render the 
 cylinders hard, unmanageable lumps, by compressing them 
 against the edges of the cavity during their introduction, or 
 by incautious touches of an instrument. The cylinder should 
 be carried to its place perfectly soft, and there condensed by 
 pressure applied to its sides, and not to its ends. 
 
 The great point to attend to is to apply all the force to 
 the sides of the cylinders ; we are then compressing together 
 parallel layers of foil, and can succeed in making an extremely 
 solid plug, whereas if we attempt to condense them by com- 
 pressing their ends, they at once become knotty and hard. 
 Of course, when the utmost solidity attainable has been pro- 
 duced by force applied to the sides of the cylinders, whether 
 by wedging or by the use of foot-shaped pluggers, then the 
 surface of the plug must be condensed ; but if the preceding 
 directions have been followed, very little impression can be 
 made upon it. 
 
 When, from the shape of the cavity, it is likely that the 
 first portion of gold introduced would roll about, the softer 
 cylinders loosely rolled are the most convenient to commence 
 with, changing to the firmer ones when the first pieces are 
 well fixed. By introducing the foil rolled up into cylinders, 
 the layers all run from the orifice to the bottom of the cavity,
 
 360 A SYSTEM OF DE.XTAL SUEGEEY. 
 
 instead of lying in any chance direction, so that it is quite 
 impossible l\)r fragments to peel off the surface of the plug : 
 moreover the foil, being arranged in parallel layers, is readily 
 condensed by a force applied in the proper direction, so that 
 I'ar larger quantities of foil may be safely introduced in a 
 single piece than by any other method. Hence for large 
 cavities with strong walls the method of cylinder- filling is 
 the most expeditious, and, I think, also the most certain in 
 its results. Of course, the softer the quality of the foil, the 
 easier the operation ; with a hard, harsh foil, very unsatis- 
 iactor}^ results would be got by using cylinders. 
 
 Hitherto the methods of filling described have depended 
 on " packing," or the pieces being wedged in so that they 
 cannot escape, though they remain individually separate, 
 and on breaking the tooth might be parted from one another. 
 But there is a property of gold, in the first instance, I 
 believe, accidentally discovered, which enables us to fill 
 cavities where some of the walls are defective ; this is the 
 capability of pure gold of welding into a solid mass under 
 pressure. In filling a cavity with foil in which this adhesive 
 property has been developed to its fullest extent, a very 
 difterent manner of procedure is a necessity. Perforating 
 with a large wedge-shaped instrument is inadmissible : were 
 it attempted the result would be that the gold would become 
 hard just around the instrument, and nowhere else. Hence 
 each small fragment has to be thoroughly consolidated as it 
 is introduced. The first step is to thoroughly fix a mass of 
 foil at some part of the cavity ; this may be done by drilling 
 a small hole at some point, and wedging a small portion of 
 foil into it, but more commonly it is possible to securely fix 
 ;i ball of non-adhesive foil against some part of the cavity ; 
 or, by using a second instrument in the left hand, the first 
 ]nece of gold may, in difficult cases, be retained in position 
 until it is fixed by being thoroughly condensed. 
 
 Some operators, however, generally drill retaining points, 
 not with any view to the retention of the finished plug in 
 
 ti
 
 METHODS OF INTRODUCIXG THE GOLD. 
 
 361 
 
 the tooth, but simply in order to securely anchor the first 
 few pieces of gold. 
 
 When once the first part of the plug is fixed and thoroughlj^ 
 consolidated, the subsequent steps of the operation are com- 
 pai'atively easy : small portions of foil, which may be loosely 
 rolled, or simpVy torn, are firmly pressed with the point of 
 the instrument upon the gold already in the cavity, pare 
 being taken that the instrument is applied to every part of 
 the surface, aud that the gold added is distributed pretty 
 evenly over that Uj)on which it is placed. Piece after piece 
 is added, each one being thoroughly consolidated on the gold 
 already in the cavity before any more is added, until the 
 plug projects slightly from the orifice of the cavity. In 
 applying the gold, it should be pressed against the walls of 
 the cavity as well as on to the rest of the plug, else minute 
 fissures are apt to be left. Now, if the foil has been good, 
 and the operation carefully performed, we shall not have a 
 plug made up of a series of small masses, and retained 
 together by the walls of the cavity, but we shall have a solid 
 mass of gold, which, if the tooth be broken, will form a cast 
 of the cavity from which it has been liberated. 
 
 The use of the term solid as applied to gold plugs, requires 
 qualification. 1 believe it is quite impossible to produce 
 with foil, or, indeed, with any form of gold, a plug having a 
 degree of solidity equal to that of an ingot of pure metal. 
 The resistance to pressure of which the tooth is capable 
 would prove insufiicient for the production of absolute 
 solidity. Again, the dentine, against which the metal is 
 pressed, is not sufficiently hard to afibrd the resistance which 
 would be required. For the sake of testing the w^orking 
 qualities of specimens of gold, I have been in the habit of 
 clamping a slip of ivory, having cylindrical perforations, 
 upon a block of the same material. After filling one of the 
 holes the lip is removed, and the lower surface of the plug is 
 presented for examination. In no case have I seen a foil 
 filling in which minute fissures could not be discovered by
 
 362 A SYSTEM OP DENTAL SURGERY. 
 
 the aid of the microscope. However, sufficient density can 
 be produced to give the plug the appearance and the feeling 
 of perfect solidity, and to ensure durability. More is not 
 required. 
 
 Whatever method of inserting the gold be adopted, 
 the compression should be exerted mainly in a lateral 
 direction, towards the walls of the cavity, and it is on 
 this account that the foot-shaped pluggers are so valuable, 
 whether as mallet or hand instruments. Nothing should 
 be left for a compressor applied to the surface to do : 
 on a properly inserted plug, it will have but little or no 
 effect. 
 
 Difficulties in the use of adhesive foil may arise from the 
 gold already in the cavity having been insufficiently con- 
 solidated, and so yielding before the instrument and the 
 superadded layer, instead of affording an unyielding surface 
 against which the latter may be welded ; or the failure may 
 arise from the surface of the gold being soiled, or wetted by 
 saliva, the condensation of the breath, or condensation from 
 the atmosphere. If the gold does not adhere readily it 
 should be annealed, either in the sheet, or by passing each 
 fragment through the flame of a spirit-lamp ; with the heavy 
 foils the latter course is preferable. These heavy foils, which 
 may be rolled in the place of being beaten out, are remarkably 
 adhesive ; the manner of using them does not differ in any 
 material particular from that just described, save that they 
 should be cut into pieces nearly the size of the cavity, as it 
 is difficult to fold them : by having pieces of a suitable size, 
 each piece is laid on flat, and forms a complete layer in itself. 
 The very heavy numbers, such as 140, are not easily 
 condensed without the use of some form of mallet ; still 
 with care, and in a suitable position, very dense plugs may 
 be made by hand pressure alone. 
 
 Although the very heavy foils will probably never have 
 more than a limited applicability, such numbers as 20 are 
 exceedingly useful, and in large cavities, where it is necessary 
 
 ii
 
 METHODS OF INTRODUCING THE GOLD. 363 
 
 or desirable to commence the use of <an adhesive gold early 
 in the procedure, they are very valuable. 
 
 Wherever adhesive gold is employed, each successive piece 
 should be laid on as flat as possible, and no attempt made to 
 crumple it up into deep holes, as though it were non-adhesive ; 
 and the best adhesion Avill be gained by using a moderate- 
 sized point at first, afterwards exchanging it for one some- 
 what smaller ; and this applies with double force to the use 
 of heavy foils. 
 
 It must not be supposed that in the formation of a plug 
 any one of the methods which have just been described in 
 general terms is necessarily adhered to from beginning to 
 end. Thus, for example, it is very often exceedingly incon- 
 venient to commence a filling with adhesive foil : on the 
 other hand, it is often a great convenience to finish the 
 surface of a plug constructed of non-adhesive gold with 
 additions of gold used adhesively. 
 
 In using adhesive gold there is perhaps rather more risk 
 of the gold rolling aw'ay from the edges of the cavity, and 
 so leaving minute fissures, than when non-adhesive gold 
 is employed ; hence we sometimes see beautiful hard, solid 
 fillings failing, and comparatively soft fillings succeeding, 
 simply because the gold is in the latter case better applied 
 to the edges. On an adhesive filling, properly consolidated, 
 the burnisher can do comparatively little in securing good 
 contact round the edges, but in a soft-foil plug, however firmly 
 it may have been condensed, the edge may be efficiently 
 burnished down. 
 
 A failure will, however, sometimes depend upon the 
 character of the foil, which, although perfectly good, may be 
 unsuited to the method of manipulation employed. Take, 
 for example, the results of the following experiments, with 
 leaves of foil taken from the same book. The foil employed 
 had been prepared from crystal gold, reduced to four-grain 
 sheets by beating in the usual manner. Although annealed 
 from time to time during the process of reduction, it had not
 
 364 A SYSTEM OF DENTAL SUKGERY. 
 
 been submitted to heat after the final beating. The condition 
 was therefore that of unannealed foil. 
 
 Several sheets were folded and cut np into short strips for 
 the pui-pose of using in the stellate manner. In working it 
 was found to be adhesive, but at the same time very brittle, 
 and consequently required imusual care in introducing it 
 between the teeth, otherwise portions broke off and fell into 
 the mouth. Another sheet was torn in six or eight pieces, 
 and rolled up between the fingers into as many small balls. 
 These were introduced, one after the other, into a lateral 
 cavity, with a small instrument having a slight spiral curve 
 near the point. The centre of the ball was first pressed 
 lightly into the cavity, and the edges subsequently turned 
 in, and then the whole was thoroughly compressed. During 
 the operation the gold went do^vn before the instrument into 
 a very solid condition, but there was not the slightest 
 tendency to turn up on one side when the other was pressed 
 down, or to roll in the cavity. The gold filed freely, and 
 when completed the plug presented a most satisfactory 
 api^earance. 
 
 From the same book a leaf was taken and rolled into 
 rather firm balls, which were subsequently annealed. Under 
 this treatment, although the adhesive quality was brought 
 out more strongly, each ball, instead of going down dead 
 before the instrument, had a tendency to turn up and clog 
 the orifice of the cavity. Another leaf was annealed first, 
 and then rolled into balls, which on trial proved superior to 
 the annealed, but inferior to the unannealed balls. 
 
 From the same book two leaves were taken ; one was 
 annealed, and after division into thirds, twisted into three 
 loose ropes ; the other leaf was divided, and rolled without 
 annealing. The latter showed a tendency to break to pieces 
 and waste, while the former packed and adhered, the one 
 fold to the other, vdih great readiness, and produced an 
 extremely good plug. 
 
 The forea:oing results have been brought forward to show
 
 METHODS OF INTRODUCING THE GOLD. 365 
 
 that different samples of gold, though each perfectly good of 
 its kind, may require different methods of manipulation 
 in order to produce the best results. And they have been 
 noticed before describing the various methods of operating 
 upon the incisors, because the front teeth require delicate 
 treatment, and because there is good reason for supposing 
 that the defects are often consequent upon the manner of use 
 being ill suited to the particular sample of foil employed. 
 Had the use of the stellate form of the unannealed leaf been 
 persisted in, the plugs would have crumbled ; and had the 
 use of the annealed balls been continued, the plug would 
 have been with difficulty restrained from rolling in the cavity ; 
 moreover, the force required for its consolidation would in 
 many cases have been greater than the incisor teeth are able 
 to bear without endangering the bursting outwards of the 
 labial wall of the cavity. There are few who have not seen 
 a crack run across the enamel, perhaps in more directions 
 than one, just as the operation was about to be completed. 
 
 Instances will occur in which the surface of the plug is 
 good, and the circumference solid, excepting at the upper 
 part near the labial surface of the tooth, a situation reached 
 with some difficulty by the plugging instrument ; and even 
 then the imperfection is not discovered until the file wounds 
 the gum, and a little blood steals in, and renders apparent a 
 line, in the course of which the gold has not been forced into 
 contact with the surface of the cavity. 
 
 These remarks have been made, not with the view of de- 
 precating the use of annealed adhesive foil, but in order to 
 draw attention to the necessity of observing great care in the 
 construction of plugs when that form of gold is emplo3''ed, 
 and also for the purpose of showing that althougli a sample 
 of foil may not answer the expectation of the operator when 
 used in one manner, yet that it may be perfectly satisfactory 
 when a different method of introduction is employed. Even 
 the degree of hardness to which the balls are rolled or the 
 ropes twisted, will influence the facility with which they are
 
 366 A SYSTEM OF DENTAL SURGERY. 
 
 respectively used. The degree of heat to which the metal is 
 submitted in annealing will also exert a considerable in- 
 fluence in determining the manner in which it can be most 
 effectively manipulated. It would, however, be veiy difBcult 
 to enumerate every circumstance that may arise in con- 
 nection with the use of the different forms of gold employed 
 in plugging teeth, and to give a detailed description of the 
 methods of overcoming every difficulty that may present 
 itself to the operator. The task would be almost endless, 
 and if accomplished, would not even then relieve the dentist 
 from the necessity of making himself practically acquainted 
 with the subject by means of carefully-conducted experi- 
 ments, both in respect to the materials used in the formation 
 of plugs, and the instruments employed in conducting the 
 operations. 
 
 The cavity by one method or another having been filled, 
 and the gold allowed to project slightly from the orifice, the 
 next step towards the completion of the operation will be to 
 reduce the surface of the plug and the margins of the cavity 
 to the same general level, allowing a slight degree of fulness 
 to the central portion of the plug. 
 
 This part of the operation will readily be effected by a 
 suitable file, after which the plug may be carefully examined 
 with a sharp-pointed instrument, and should any part be 
 found sufficiently soft to allow of penetration, the aperture 
 must be enlarged and additional foil introduced, after which 
 the file must be again used to reduce any inequalities, and to 
 remove the impressions left by the instrument. We have 
 now to remove, by means of pumice powder or fine silica, 
 applied upon a strip of soft wood, or by a corundum tape, 
 the marks left by the file, and subsequently the surface may 
 be burnished with a little soap. It will be found that the 
 burnisher will facilitate the steps of the operation, if it be 
 used after the file has been abandoned, and again after the 
 application of the pumice powder. Indeed, in many cases 
 the firm application of a burnisher will assist in the con-
 
 METHODS OF INTRODUCING THE GOLD. 367 
 
 solidation of the plug, and in the production of an even 
 surface, before we have recourse to the file, and prior to the 
 saliva gaining access to the surface of the filling. 
 
 Perhaps no more suitable place will be found for alluding to 
 the subject of " contour fillings ;" that is to say, when a part of 
 the crown of the tooth has been lost, the restoration in gold 
 of its original form. There are few English patients who 
 would submit to the insertion of a contour filling near the 
 front of the mouth, on account of its very conspicuous 
 appearance : the question hence resolves itself into one of 
 utility for purposes of mastication. The advocates of con- 
 tour filling claim for it that it restores the natural form of 
 the tooth, which is presumably the best possible form, and 
 that by so doing it protects the gum between the teeth. 
 Nevertheless, although it is often advisable to leave the gold 
 convex and projecting to some extent from the cavity, the cases 
 in which a real " contour " filling proves useful are few ; and 
 the matter is well summed up by Professor Austen, in the last 
 (tenth) edition of Harris's Dictionary of Dental Surgery, in 
 the following terms : " The majority of them are a useless 
 waste of the skill of the dentist, the money of the patient, 
 and the time of both ;" and in another place, " Only let the 
 operator assure himself that he is labouring for the real 
 benefit of his patient, and not degrading his art, on the one 
 hand, by humouring an idle whim of his patient ; or, on the 
 other, by making him the reluctant advertising medium of 
 dental ingenuity." 
 
 Fluyging Instrumerds. — The form of these, and more 
 especially that of the handles, has been almost infinitely 
 varied. Each operator has his own favourite pattern, and it 
 would be quite impossible, within any moderate limits, to 
 give a complete account of all the varieties manufactured ; so 
 that the description in this place must be confined to a few 
 of the more generally useful forms. 
 
 To commence with the handles, considerable diversity of 
 opinion exists as to the most suitable form. Many operators
 
 368 A SYSTEM OF DENTAL SURGERY. 
 
 use the instruments constructed for use with the mallet as 
 hand-pluggers (see Fig. 151) ; Butler's set of pluggers being 
 especial favourites in this country. 
 
 For large condensing instruments, or for burnishers, the 
 oval wooden handle represented in Fig. 168 is, to my think- 
 ing, the preferable form ; it is large enough to be very firmly 
 gras})ed in the palm of the hand, while the point of the in- 
 strument is not far from the thumb and fingers, a matter of 
 some importance where considerable force must be used, as it 
 enables the operator to guard against the point slipping and 
 injuring the soft parts around. Thus, in using a burnisher 
 the th\mib may generally be rested on the tooth operated on, 
 or on one of its neighbours, and force exerted in a direction 
 towards the thumb ; in this way there is no risk of slipping, 
 and the force apjjlied is both steadier and stronger than when 
 the point of the instrument reaches far beyond the fingers. 
 
 In the more simple forms of plugger the shaft is perfectly 
 straight, but there are some cavities which can only be 
 reached by curved instruments. A very useful form is that 
 in which the shaft is bent in a spiral direction to the extent 
 of an eighth or a quarter of a tiu^n, the coil being more or less 
 open or irregular to suit the requirements of particular cases. 
 
 For filling the lower teeth, and more especially for reach- 
 ing distal cavities in the lower jaw, the shaft of the instru- 
 ment may advantageously be bent at a right angle. For 
 reaching cavities far back in the mouth, the double bend 
 represented in Fig. 149 is serviceable. 
 
 There are some few operators who work with perfectly 
 smooth-pointed instruments, but the great majority prefer to 
 use points more or less deeply serrated. These serrations, 
 which should consist of sharp-pointed pyramids, may be 
 cut with a sharp dividing file, and finished with a small 
 three-sided file ; but it can be more readily accomplished 
 by a special tool. Such a tool is readily constructed by 
 taking an ordinary reeded scalper, softening it, and convert- 
 ing its longitudinal ridges into teeth by making transverse
 
 METHODS OF INTRODUCING THE GOLD. 
 
 369 
 
 Fig. 149. 
 
 cuts with a file ; when rehardened to a file temper, it will 
 cut on the softened steel points a series of grooves and 
 edges, which, by an application of 
 the tool at right angles to its 
 former direction, are converted 
 into points. For the insertion of 
 sponge gold these serrations should 
 be very shallow, but for ordinary 
 adhesive gold they may with 
 advantage be somewhat deeper. 
 Much of the ease with which the 
 operation is performed depends on 
 the accuracy with which these 
 points are finished ; they should 
 be sharp, and yet leave the gold 
 without clinging, and should not 
 get clogged with the gold. These 
 conditions can only be attained 
 by a high degree of finish, which 
 is, however, reached by several of 
 our instrument makers, as well as 
 by some of the American work- 
 men, whose instruments are all that can be desired. 
 
 As regards the form of the working ends, they may be 
 either fiat or wedge-shaped ; perhaps the most generally 
 useful of all the forms is that known as the " foot-shaiDcd 
 plugger." The following figure (Fig. 151), taken from one of 
 Butler's pluggers, does not exactly represent a characteristic 
 fobt-shaped plugger, which bears a close resemblance to the 
 form of a foot, the shaft representing the leg, and the work- 
 ing surface the sole of the foot. 
 
 For perforating a plug of non-adhesive foil, or of cylinders, 
 
 (1) A plugging instrument, the blade of which has a spiral curve, adapted 
 to introduce and condense gold foil into cavities situated on the mesial or 
 distal surfaces of the front teeth. A pair, a right and a left instrument, will be 
 required. 
 
 2 E
 
 370 
 
 A SYSTEM OF DENTAL 8TTBGERY. 
 
 
 an instniment with a sharp point, chamfered like a trocar, 
 Fig. 151. (1) "^ill he found most useful ; the oval wooden 
 handles are excellent for such a form of instru- 
 ment. 
 
 The Americans were the first to bring into 
 every-day practice, though not to originate, the 
 use of the mallet (-), not only for consolidating 
 the plug when finished, but for condensing 
 each piece as it is introduced. It is a most 
 eflScient means of thoroughly condensing the 
 gold, and is adopted by a great number of ope- 
 rators ; and it is productive of less discomfort 
 to the patient than would have been expected 
 a priori. 
 
 The mallet should be constructed of some 
 heavy material, a very good form consisting of 
 a head of lead inclosed in a cylinder of German 
 silver, to which is attached a handle about eight 
 inches long. But the use of the actual mallet 
 is, to say the least, very inconvenient in the 
 absence of an assistant ; and a variety of auto- 
 matic mallets have been devised, the majority 
 of which simply rej^eat, in the form of a blow, 
 that same amount of force which has been 
 already expended on the filling in the form of 
 steady pressure. Inasmuch as the same force 
 is more efiective in the form of a tap than in 
 the form of steady pressure, these automatic 
 mallets are advantageous ; but the force is gene- 
 rally insufficient, and those which give a blow 
 that is independent of previous pressure are to 
 be preferred. 
 
 To meet this difficulty, the form of automatic 
 
 (1) Mallet plugger made after Butler's pattern. 
 
 (2) ],r. Hoffman, of Maipite, was many years ago in the habit of con- 
 solidating the gold by malleting ; in the first instance with the handle of an 
 instrument, and afierw ards wiih a mallet.
 
 METHODS OP INTEODUCING THE GOLD. 
 
 371 
 
 spring mallet represented in the figure was devised; the 
 one here figured is not the pig 152^ (i) 
 
 one most generally useful, 
 but from this drawing the 
 more simple form can be 
 readily understood by a de- 
 scription only. The instru- 
 ment is held somewhat like 
 a pen, the forefinger lying 
 extended at full length upon 
 it, and directing its move- 
 ments. In the interior of 
 the shaft is a spiral spring, 
 in the inside of which 
 plays a steel rod furnished 
 on the outside with two 
 ivory balls. The blow is 
 struck by pulling up one of 
 the ivory balls by means of 
 the last joint of the second 
 finger, as seen in the figure. 
 When it has been raised to 
 a sufficient distance, it is 
 suddenly released, by allow- 
 ing it to slip from the finger, 
 and a blow is given on the filling by the elasticity of the 
 spiral spring. In the instrument ordinarily employed, the 
 serrated points fit into a socket at the lower end, this socket 
 having a play of about a quarter of an inch upwards and 
 downwards ; the blow of the central rod which carries the 
 ivory balls (which is, of course, perfectly separate and distinct 
 from the socket-piece) being received on its upper end. 
 
 The instrument here figured differs by the socket which 
 carries the serrated plugging-points being made in the same 
 piece of metal as the rod carrying the balls and compressing 
 (1) Mr. Tomes's spring mallet.
 
 372 A SYSTEM OF DENTAL SURGERY. 
 
 the spring, so that the plugging point is actually raised away 
 from the gold, and is driven down upon it again by the blow 
 of the spring when the rod is released. In addition to this 
 there is a fixed leg, the point of which also is serrated, and 
 which is sufficiently long and thin to enable the operator to 
 spring it away from the striking point. In using this form 
 of mallet the gold is held down by firmly pressing the fixed 
 leg upon it, while blows are given by 
 ^^' '^^ the second or striking leg at a dis- 
 
 tance from the first varying at the 
 will of the operator. It is exceedingly 
 useful in cavities in which the gold 
 is disposed to roll, as one side can be 
 securely held down while the other is 
 hammered. 
 
 The points are changeable, but it 
 adds greatly to the convenience of the 
 operator to have more than one spring 
 mallet, so as to obviate the> necessity 
 for changing the point during the 
 progress of an oj)eration. 
 
 After a very little practice no diffi- 
 culty will be found in varying at will 
 the force of the blow ; the lightest 
 possible tap may be given, or, by 
 drawing up the spring to the utmost 
 possible extent, a blow might be given 
 which would be perfectly unbearable. 
 The gold having been introduced, the surface is next con- 
 densed by the use of instruments of gradated sizes; in 
 interstitial cavities, not very accessible, this is sometimes 
 rather difficult. A most useful instrument, which is far too 
 little appreciated, is the condensing plugging forceps ; it is 
 used by grasping the tooth, and squeezing the plug by closing 
 the handles : caution is, of course, required in its use, but in 
 (1) ilr. Tomes's modification of condensing plugging forceps.
 
 METHODS OF INTRODUCING THE GOLD. 
 
 373 
 
 Fig. 154. (i) 
 
 careful hands it is most valuable. A modification which 
 renders more easy their adaptation to the tooth consists in 
 rephicing one blade by a rotating crutch ; this adapts itself 
 to the irregularities in the form of the tooth 
 whilst the other jaw acts on the surface of 
 the plug. 
 
 An instrument which is perfectly in- 
 valuable for the introduction of the gold is 
 the ordinary plugging forceps, the points 
 of which are serrated, and when closed re- 
 semble an ordinarj'- jDlugger. The gold may 
 not only be carried to its place by this in- 
 strument, but, by closing the jaws, it can be 
 condensed, the forceps acting as an ordi- 
 nary plugger. For the introduction of 
 cylinders they are indispensable ; and they 
 are of great advantage in using either sponge 
 gold or the heavy foils. 
 
 "When all the gold has been introduced, 
 the excess has to be removed by suitable 
 files. The shapes of these are innumerable, 
 and each one must select for himself that 
 which he prefers; but attention should be 
 called to a most useful form of file for finish- 
 ing fillings on grinding surfaces : it is like 
 a large rose-head, and is used by revolving 
 it while pressed on the surface of the gold. 
 
 The inequalities left by the file may be 
 removed by the use of corundum points 
 held in a suitable pair of forceps. (See 
 Fig. 160.) 
 
 The application of pumice or fine silex on a piece of wood 
 will leave a very fine surface, or a piece of Arkansas or of 
 Water of Ayr stone may be used for the same purpose. 
 
 The finishing polish is given by means of burnishers, 
 
 (1) Plugging forceps.
 
 374 A SYSTEM OF DENTAL SURGERY. 
 
 Fig. 155. (1) 
 
 (1) Showing several useful forms of file for reducing the surface of a plug. 
 
 (2) Generally useful forms of burnishers.
 
 METHODS OF INTRODUCING THE GOLD. 375 
 
 instruments of varied form made of hardened brightly- 
 polished steel. A few forms are here given for illustration, 
 but a great variety of different shapes are in use. (Fig. 156.) 
 
 The forceps figured on page 381, which carry a small frag- 
 ment of dividing file, are often exceedingly useful in filling 
 and filing, whilst a similar pair of lighter make, designed to 
 carry small points made of corundum, will be found very 
 valuable in finishing the surface. 
 
 Treatment of Cavities in the Front Teeth. — The facility 
 with which operations on any of the teeth can be performed, 
 is greatly dependent on the means of placing the patient in 
 a suitable position ; and great diversity of opinion as to the 
 most convenient form of chair prevails, so that it would 
 perhaps be invidious to name any one maker's pattern as 
 preferable to all others. There are one or two requirements 
 which should, however, be kept in mind in the selection of a 
 chair, and which may be introduced here for the want of a 
 more suitable place. In the first place, the range of vertical 
 motion should be considerable : for operating upon the upper 
 incisors, it is often convenient to have the patient's mouth at 
 or near the level of the operator's eye ; and whilst in this 
 position, the head should be able to rest backwards, so that 
 the alveolar line may be nearly vertical. For operations on 
 the lower teeth, more especially extractions, the patient 
 should be placed low, so that the operator's arm is not much 
 raised ; few of the chairs in use allow of the patient being 
 placed sufficiently low, Morrison's pattern being, in this 
 respect, the best. 
 
 It is desirable that the back of the chair should have a 
 reclining movement independently of the seat, and the head- 
 rest should be so contrived as to allow the patient's head to 
 lie far back, or to rest with the chin upon the chest. By 
 inclining the head to the one side or the other, or by the 
 operator sitting on a stool by the side of the chair, access 
 may be gained to most cavities without the assumption of a 
 very constrained position.
 
 376 
 
 A SYSTEM OF DENTAL SUBGERT. 
 
 I 
 
 As the teeth are usually in close apposition, it becomes 
 necessary to resort to means capable of producing a sufficient 
 amount of separation to allow of the introduction of instru- 
 ments. The end may be gained either by the introduction 
 of strips of caoutchouc or of compressed wood between the 
 Fig. 157. (>) teeth, or we may cut away the faulty 
 
 tooth. The selection of means must 
 depend upon the state of the tooth to 
 be operated upon. If the decay has a 
 considerable superficial extent, it will be 
 well to cut away the lingual surface of 
 the tooth with the chisel (Fig. 157), 
 in such a manner as shall leave a V- 
 shaped division between the teeth, with- 
 out interfering with their external ap- 
 pearance. If the superficial extent of 
 the disease be limited, it will be well to 
 avoid cutting into the tooth, as we 
 should be sacrificing sound tissue. The 
 requisite separation may be obtained by 
 the insertion of india-rubber between 
 the aflected and the contiguous tooth. 
 In some cases a sufficient interval will 
 be produced in twenty-four hours, while 
 in others a much longer time may be 
 required. 
 
 The next step is the removal of the 
 disorganised dentine ; but before proceed- 
 ing to remove the decayed tissue, the 
 condition of the gum with respect to the 
 diseased tooth should be considered. In many cases we 
 shall find the free edge vascular, and descending below the 
 upper margin of the cavity, and perhaps curled into it. When 
 in this state it will be next to impossible to operate without 
 wounding the gum ; blood will then flow for some time, and 
 
 (1) Straight enam-l-cutter.
 
 METHODS OF INTRODUCING THE GOLD. 377 
 
 perfectly obscure the cavity. Formerly the patient would 
 have been sent away, with directions to force cotton-wool 
 saturated with a solution of mastic between the teeth, renew- 
 ing it from time to time until the gum became forced up out 
 of the way. I believe we owe the following ready and effectual 
 method of at once getting over the difficulty to our American 
 brethren. If a jaw from which the soft parts have been 
 removed be examined, it will be seen that a triangular space 
 separates the necks of the teeth, the base being formed by 
 the alveolar process, and the apex of the triangle by the 
 convergence of the mesial and distal surfaces of the con- 
 tiguous teeth. The interval so produced (Figure 95) is 
 occupied by the gum, and our object is to prevent its 
 bleeding, and at the same time to move it from the margin 
 of the cavity. To accomplish both purposes it is necessary 
 to take a strip of soft wood, such as willow or plane, and 
 cut or file it into a triangular rod. When reduced to a 
 suitable size, introduce it by a steady pressure between the 
 teeth, taking care that the basis of the triangle corresponds 
 to the edge of the alveolar process ; by this means the gum 
 will be pressed up against the latter part, the bleeding will 
 be stopped, and the cavity in the tooth fully exposed to 
 view. The introduction of the wood will occasion a little 
 pain at the moment, but it soon gives way to mere uneasiness. 
 When teeth have been gradually separated by caoutchouc, 
 the presence of the wedge tends to keep them steadily fixed, 
 and thereby renders the operation of plugging less painful 
 than it would have been had the teeth remained unsupported. 
 The ends of the wood will, of course, be cut off close to the 
 lingual and labial surfaces of the teeth, and the removal 
 of the carious dentine may then be accomplished without 
 interruption. 
 
 If we are operating upon the mesial surface of the left 
 central incisor, the tooth may be held by the index finger 
 and thumb of the left hand, the arm having been passed 
 round the head to the left side. In usins; the excavator, it
 
 378 A SYSTEM OF DENTAL SURGERY. 
 
 must ever be borne in mind that the pulp, though less in 
 size, corresponds very closely in shape to the tooth itself, and 
 although it may be, and often is, altered in shape by the 
 calcification of the part towards which the disease has pro- 
 ceeded, yet the cutting instrument must be used with caution 
 after we have advanced to a certain depth into the dentine ; 
 for should the pulp be wounded, the destruction of the tooth 
 may be endangered. Rather than run an obvious risk, it 
 will be better to leave a little discoloured tissue at the 
 bottom of the cavity. From the walls and from the floor of 
 the cavity, on its labial and lingual sides, it may be cut 
 away, as in the latter situation we shall escape the pulp by 
 proceeding behind or in front of it. 
 
 Having shaped the cavity in accordance with the directions 
 given when treating upon the subject generally, the part 
 should be cleared of all extraneous matter by directing upon 
 it a stream of wami water, by means of a syringe. The 
 cavity should now be wiped dry with cotton-wool or tissue 
 paper, and its shape very carefully examined. Should any 
 doubt exist as to a proper form having been produced, a 
 little warm wax or gutta-percha may be pressed into it, and 
 a cast obtained. By this simple procedure we shall often 
 discover that had a plug been introduced, the chance of its 
 preserving the tooth for any length of time would have been 
 but slight. SujDiDosing it be found that the walls of the 
 cavity are generally divergent from within outwards, the 
 defect must be remedied. Small hoe-shaped instruments 
 ■will be found suitable for reducing to parallelism the labial 
 and lingual walls ; and a drill, carefully directed so that it 
 shall not approach too closely upon the pulp in the neck of 
 the tooth, will reduce to a proper figure the upper wall of the 
 cavity. The excavator, figured on page 388, will be found 
 very serviceable in preparing the cervical portion of the 
 cavity. After feeling assured that the cavity has acquired 
 a form favourable for the retention of a plug, it must be 
 thoroughly washed out, and subsequently made perfectly dry.
 
 METHODS OF INTRODUCING THE GOLD. 
 
 379 
 
 Fig 158. (1) 
 
 Steps must now be taken for preventing the access of 
 moisture : a roll of cotton-wool, or a small napkin folded into 
 a riband, should be placed between the gums and lips, and 
 brought round upon the palate behind the front teeth. Its 
 position may be maintained by the index and second fingers, 
 or the rubber dam may be applied. The character of gold 
 suitable for the case having been de- 
 termined upon, and a sufficient quan- 
 tity arranged upon the operating 
 table within reach of the right hand, 
 its introduction may be commenced, 
 the ipatient having been previously 
 requested to breathe through the 
 nose. 
 
 If the cavity be not very large, foil 
 arranged in the stellate form will be 
 found to work advantageously. Two 
 or three stars may be taken up on 
 the point of the instrument and 
 pressed towards the upper wall of the 
 cavity ; one after and within the 
 other. The arms of the stars should 
 then be folded inwards, and the whole 
 compressed thoroughly against the 
 upper part of the cavity. Some little 
 
 care is required at this stage of the proceeding, otherwise 
 the gold on becoming condensed will begin to roll. The dis- 
 position to move from one part when it is pressed against 
 another part of the cavity is generally produced by neglect- 
 ing to compress the whole gradually and with uniform force. 
 If the centre of the plug be consolidated while the circum- 
 ference remains porous, the latter part will turn away from 
 the tooth towards the instrument, and on pressure being 
 applied to any point of the circumference, the mass of gold 
 
 (1) A pair of instruments, right and left, the blades having a slight spiral 
 curve, suitable for introducing foil into cavities in the front teeth.
 
 380 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 Fig. 159. (1) 
 
 will turn or roll up from the cavity at the opposite point. 
 Having recognised the manner in which a difficulty may 
 arise, we have to consider how its occurrence may be avoided, 
 or, if present, how it may be overcome. The objectionable 
 condition may be avoided by passing the instrument over 
 the whole surface of the gold with a light hand, repeating 
 the operation with gradually increased force until the whole 
 is equally consolidated. But should the foil show a dispo- 
 sition to roll, we shall do well \o remove it and recommence 
 the operation, or to take an instrument in the left hand and 
 hold down one part of the circumference while the other is 
 compressed. The use of two instru- 
 ments in the manner alreadj'' alluded to 
 is not unusual where adhesive foil is 
 employed. 
 
 After thoroughly condensing the foil 
 in the upper part of the cavity, the 
 completion of the plug is comparatively 
 easy. If the adhesive foil be used, the 
 operation may be pretty rapidly per- 
 fected by adding short strips one after 
 the other, compressing each consecutive 
 piece upon the gold already introduced, 
 taking care that in making the folds 
 the duplicatures do not fall short of the 
 walls of the cavity, otherwise the plug 
 will be hard in the centre and soft in 
 the circumference. 
 
 Should non-cohesive foil be preferred, 
 
 the same method with respect to filling 
 
 the upper part of the cavity first, may be adopted ; but in the 
 
 subsequent proceeding it is necessary that the folds of the 
 
 rope or riband should pass from the bottom to the orifice 
 
 (>) A pair of instruments, right and left, adapted for compressing plugs in 
 the mesial or distal surface of front teeth, or for adding adhesive foil or sponge 
 gold to the surface of an unfinished plug.
 
 METHODS OF INTRODUCING THE GOLD. 
 
 381 
 
 160. (I) 
 
 of the cavity. To effect this, ', an instrument 
 with the working extremity terminating like a 
 wedge, will be found the most serviceable form. 
 The cj^vity having been filled, a sharp wedge 
 or point, or, what I think is still better, an 
 instrument brought to a point by four cham- 
 fers, thus producing a point and four divergent 
 edges like a trocar, should be forced into the 
 centre of the plug. The gold, by this treat- 
 ment, is forced from the centre towards the 
 circumference of the cavity, and without any 
 tendency to displace the plug. The hole made 
 by the perforator must be filled by the further 
 addition of gold, which may be introduced 
 with instrument in hand. When perforations 
 can no longer be made, unless by using an 
 amount of force that would endanger the walls 
 of the cavity, an instrument with a flat face 
 should be carefully worked over the whole 
 surface of the plug. Recourse must now be had 
 to the file. All gold which projects beyond the 
 margin of the cavity — more especially that 
 which is directed towards the gum — should be 
 cut away, the indentations produced by the 
 filling instrument filed out, leaving the surface 
 of the plug perfectly free from irregularities, 
 and on the same level as the surrounding tooth. 
 The file may be followed by a strip of narrow 
 tape which, after wetting, has been loaded with 
 pumice-powder or finely-powdered silex ; an 
 end being held in each hand, it should be drawn 
 across the surface of the plug with a steady 
 and moderately quick motion, and the friction 
 continued until the file marks are removed 
 
 (1) Showing a pair of forceps for holding fragments of a dividing file at any 
 angle that may be required for operating upon the median or distal surface of 
 the anterior teeth ; a similar instrument may be used to carry a corundum joint. 
 
 'll^ 
 
 II,
 
 382 A SYSTEM OF DENTAL 8UEGERY. 
 
 from the surface of the plug, when chalk may take the place 
 of the pumice. This amount of care in finishing a plug 
 may perhaps be thought unnecessary, and the opinion may 
 appear to receive support from the fact that some roughly- 
 finished plugs last for many years without undergoing dete- 
 rioration. But on a close examination into the character of 
 the cases it will be found that the disposition to decay was 
 not actively pronounced, and that the walls of the cavities 
 were strong in every part. Had these characters been re- 
 versed, it is probable that, in place of finding the plugs, we 
 should have heard that front teeth had been plugged some 
 years ago, but that the fillings fell out in a short time, and 
 that these, with other teeth which were then diseased, 
 gradually decayed away down to the level of the gum. 
 
 The immediate object in filling a tooth is to perfectly ex- 
 clude from the cavity all extraneous matter, fluid or otherwise, 
 and at the same time to leave a surface upon which mucus 
 or minute particles of food cannot readily adhere. If the 
 surface of the gold be left rough, these indications are not 
 fulfilled ; food and other matter will collect, and necessitate 
 the frequent use of the toothpick, which falling from time to 
 time into the inequalities of the gold, eventually disturbs the 
 filling. There is another advantage resulting from finishing 
 with care the surface of a plug, and it is this : after the outer 
 and harder part has been filed away, and the surface of the 
 plug and the contiguous surface of the tooth reduced to the 
 same level, we not uncommonly find that the plug is soft at 
 some ]X)int, and admits of being perforated. The discovery 
 of a defect having been made, a remedy must be found, even 
 though its application may necessitate the removal of the 
 gold and the recommencement of the operation. For to leave 
 the plug pervious to moisture will be to endanger, if not to 
 ensure, the further injury of the tooth. Unfortunately, the 
 fault is very commonly in the worst possible position, both as 
 regards its efiect in exposing the tooth to further disease, 
 and its capabilities of amendment. That part of the cavity
 
 METHODS OF INTRODUCING THE GOLD. 383 
 
 nearest the gum is necessarily the first to receive the gold, 
 which, unless it be compressed before the introduction of the 
 foil in the lower portion of the cavity, will, from the difficulty 
 with which the distant part is subsequently reached, remain 
 in a porous condition. But owing to the form of cavity 
 usually produced by caries upon the distal and mesial sides 
 of the teeth, there is some little tact required to perfectly 
 consolidate the upper, prior to the introduction of the lower 
 portion of the plug. And we consequently find that the 
 defects are most commonly situated at the upper margin of 
 the cavity. If there be sufficient space between the teeth 
 to admit an instrument, perforations may be naade and ad- 
 ditional gold introduced, but if the space be too contracted 
 to allow of the satisfactory completion of the plug, it will be 
 far better to commence anew. 
 
 A failure will, however, sometimes depend upon the cha- 
 racter of the foil, which, although perfectly good, may be 
 unsuited to the method of manipulation employed. 
 
 A considerable space has been given to the manner of 
 plugging cavities on the mesial surfaces of the left central 
 incisors. The description will, however, apply equally to 
 operations performed upon the distal surface of the right 
 incisors, and to those situated on the distal surface of the 
 corresponding teeth of the left side of the mouth, excepting 
 only that the head should be turned towards the operator, 
 instead of from him. The left hand, too, will be somewhat 
 differently placed. When it becomes necessary for the 
 patient's face to be directed towards the operator, the fold 
 of napkin placed under the lip and behind the teeth may 
 be retained by the thumb in the latter, and the index finger 
 in the former situation. 
 
 It has been assumed that the teeth have been separated by 
 means of india-rubber, or cut away on the lingual surface, 
 without materially interfering with the part of the tooth ex- 
 posed to view. But it may happen that the labial has been 
 encroached upon by disease, while the lingual surface is com-
 
 384 A SYSTEM OF DENTAL SUEGERT. 
 
 paratively uninjured. In that case the gold may be intro- 
 duced from the front, leaving the whole of the back part of 
 the tooth standing. By the adoption of this plan, more even 
 of the front of the tooth may be retained than though the 
 firm, strong lingual wall of the cavity had been reduced. For 
 with the three sides of the cavity strong, the fourth may be 
 preserved, although too weak to stand unsupported by the 
 plug, the firmness and the retention of which will be sufii- 
 ciently secured by the upper, the lower, and the lingual walls 
 of the cavity. In conducting the operation, however, great 
 care must be taken to avoid injuring the weak part ; and it 
 ■«*ill be found expedient to introduce the foil in small portions, 
 making each piece firm before the succeeding one is added ; 
 for should an attempt be made to consolidate the whole plug 
 by perforating the central part of the mass, the weaker wall 
 of the cavity will give way, and thus frustrate the object of 
 ihe operation. 
 
 Cases not infrequently arise in which the walls are all 
 much weakened, excepting only at the upper part of the 
 cavity. If this part can be so shaj^ed as to very firmly 
 retain the gold packed into it, the rest of the cavity may be 
 filled by gold packed adhesively on to that first introduced, 
 very little pressure being made upon the weak walls. Thus 
 it is often possible so to form the upper half of the cavity, 
 that it will firmly retain a ball of non-adhesive gold pressed 
 into it and malleted till it is perfectly hard; sponge gold 
 may then be built on to this till the cavity is full, and thus 
 a satisfactory filling introduced where the walls, towards the 
 lower end, are little else than enamel. 
 
 A useful contrivance for making up pellets of non-adhesive 
 gold, consisting of two sheets of zinc, has already been de- 
 scribed. By means of this all handling of the gold is avoided, 
 and the adhesive gold will more readily stick to the pellet 
 first introduced. 
 
 Cases will arise in which the disease has so far injured the 
 tooth, that instead of finding one, all the walls excepting the
 
 METHODS OF INTRODUCING THE GOLD. 385 
 
 upper are rendered too weak to admit of the application of 
 sufficient force for the introduction of foil, and there is no ' 
 prospect of introducing a satisfactory gold plug by the 
 method above mentioned. Either the tooth must be sacri- 
 ficed, or some soft stopping material must be used. Amal- 
 gams will render the tooth dark in colour, and cannot, there- 
 fore, be employed. The insertion of gutta percha and silex, 
 known as Hill's or Jacob's stopping, is not open to this ob- 
 jection ; and I do not know that in situations where the 
 material is exempt from any great amount of friction it is 
 less durable than the amalgam. Many cases have occurred 
 in which a gutta-percha plug has been perfectly sound at the 
 end of two years, and presented all the indications of lasting 
 for a much longer period. After all, the preservation of a 
 tooth injured by disease to the extent under consideration is 
 at best but very uncertain. A hard crust, a fragment of 
 bone, or a particle of grit in the food, on striking the tooth 
 during mastication, may break down the walls of the cavity 
 and liberate the plug. 
 
 Such cavities may be filled with the zinc oxychloride, and 
 for a time, at least, will be preserved, although the stopping 
 will, sooner or later, fail at the cervical edge. As the failure 
 of the zinc salt almost invariably takes place at this spot, the 
 difficulty might be in some measure obviated, if this part of 
 the filling were made of gold. It is possible to impact gold 
 in the cervical portion of such cavities, even where it is im- 
 possible to get sufficient anchorage to ensure the retention of 
 a gold filling ; and by filling the remainder of the cavity with 
 zinc oxychloride it is secured in its place. In several in- 
 stances I have known such fillings to last much beyond the 
 average duration of osteoplastic fillings, though, of course, 
 they are at best but a " dernier ressort." To finish such a 
 plug effectually the zinc salt must be allowed to set, and the 
 stopping filed and burnished on another day. 
 
 Caries may attack either the lingual or the labial surface 
 of the incisors, and necessitate the adoption of remedial treat-
 
 386 A SYSTEM OF DENTAL SURGERY. 
 
 ment. Natural depressions are not uncommonly found in 
 the enamel on the lingual surface of the incisor teeth, and 
 disease is apt to establish itself in such situations. The 
 cavities which result are generally of a simple kind, and do 
 not require any special description. 
 
 When the development of the enamel has been defective, 
 cavities may be produced by disease in those parts where 
 the natural- defect is most strongly pronounced, whether it 
 be situated on the lingual or labial surfaces of the teeth. If 
 submitted to treatment at a tolerably early period, the hole 
 is usually characterised^by greater breadth than depth, and 
 its shallow walls slope outwards. 
 
 The cavity, after the mere removal of the disease, may be 
 compared to a saucer — a form incapable of retaining a plug 
 with any degree of certainty. The first step in the proceed- 
 ing must be the reduction of the walls to a vertical position 
 by the use of a small, sharp excavator, and it will be well, 
 when the cavity is very shallow, to produce a slight degree 
 of undercut. In selecting the materials for forming a plug, 
 foil and crystal gold may be taken with advantage. Three 
 or four thicknesses of foil, sufficient to line in an even layer 
 the surface of the cavity, should be first introduced ; small 
 fragments of sponge gold may then be added, and thoroughly 
 compressed, one after the other, until the resulting plug stands 
 higher than the general level of the tooth. Or if a groove 
 be cut at the upper and lower portions, or at its two sides, as 
 may happen to be most convenient, foil may be packed se- 
 curely into each of these places, and the plug completed by 
 filling up the central space between the portions first intro- 
 duced by some form of adhesive gold, the latter acting like 
 the keystone of an arch. 
 
 After removing the superfluous gold with a file, the surface 
 of the plug should be examined with a sharp-pointed instru- 
 ment, and any defect made good. This having been done, 
 and the instrument marks filed out, the surface may be 
 further improved by rubbing it with Water of Ayr or a slip
 
 METHODS OF INTRODUCING THE GOLD. 387 
 
 of Arkansas stone, together with the surrounding enamel, 
 should that be rough and broken in character. The opera- 
 tion will be completed when the surface of the gold has 
 been polished either by the use of chalk or the burnisher. 
 Cavities of this character may often be rapidly and effec- 
 tively filled by the use of small pieces of heavy gold foil. 
 
 Another description of cavity in the front teeth remains 
 to be noticed. A narrow transverse slit produced, I believe, 
 in the first instance, by the tooth-brush, is sometimes found 
 immediately above the terminal edge of the enamel, deep 
 in the centre, but cropping out . on either side, with the 
 walls diverging outwards. To reduce such a groove into 
 a form for receiving a plug, the upper and lower walls 
 must be slightly under-cut, and at the two extremities the 
 groove should ^be deepened by the use of a drill so as to 
 form a cavity. If the operation be properly conducted, the 
 groove or slit will be converted into a trough, the sides and 
 ends of which will, if not under-cut, at least be perfectly 
 vertical. The operation of filling may be conducted in the 
 same manner and with the same materials as in the preceding 
 example. 
 
 In the treatment of cavities in the canine teeth, the direc- 
 tions which have been given in respect to the incisor teeth are 
 equally applicable, both as regards the manner of operating 
 and the materials used. 
 
 Treatment of Simple Cavities in the Bicuspid Teeth. — 
 Any part of the crowns of the bicuspid teeth may be at- 
 tacked by decay, but the mesial and the distal surfaces are 
 the situations in which it is most frequently developed. 
 Supposing the mischief to have occurred on the mesial 
 surface of the second bicuspid on the right side of the 
 mouth, the operation will be commenced by cutting away 
 the enamel from the mesian edge sufficiently to expose the 
 cavity, and to admit of the introduction of instruments 
 employed in the subsequent stages of the operation. The 
 radiate direction followed by the enamel fibres must be
 
 388 A SYSTEM OF DENTAL SURGERY. 
 
 borne in mind, otherwise the removal of that tissue will be 
 attended with greater difficulty and greater inconvenience 
 to the patient than necessary. The most suitable instru- 
 Fig. 161. ment is the flat chisel-shaped enamel-cutter, the 
 edge of which, on commencing the operation, should 
 be applied in a direction parallel to the course of 
 the alveolar line, and gradually changed to a rect- 
 angular position WTith the disappearance of the part 
 undergoing removal. The excision of the carious 
 tissue will now be effected without difficulty ; and 
 having advanced thus far, it will be advisable to 
 introduce the wooden wedge between the teeth in 
 the manner described at page 377. The gum 
 having been pressed up against the alveolus, the 
 cavity may be reduced into the required form 
 without fear of embarrassment from a wounded 
 vessel. Care must be taken to remove all the af- 
 fected tissue from the upper part of the cavity. 
 This may be accomplished with a drill, but the 
 position of the pulp must be borne in mind, for in- 
 struments of this character, when in good order, 
 cut rapidly, and if a proper direction be not ob- 
 served, the pulp-cavity will be opened. In pro- 
 ducing parallelism of the sides of the cavity, the 
 hoe-shaped excavator will be found very useful, as 
 will, also, the round-ended excavator here figured ; 
 and several sizes and forms of these should be at 
 hand, some of which are constructed to cut by a 
 drawing, others by a pushing motion. If this part 
 
 Hof the operation has been conducted with success, 
 an oval cavity will have been produced, the walls 
 of which converge slightly from within outwards, 
 more especially the upper wall, the margin of which will 
 be covered by the wedge, thus producing a shallow cavity, 
 a temporary side being formed by the wood. The head 
 of the patient should be thrown back into the position
 
 METHODS OF INTEODUCING THE GOLD. 389 
 
 similar to that described as the most convenient for operat- 
 ing on the front teeth. Instructions having been given in 
 reference to keeping the mouth open, to breathing through 
 the nose only, the teeth and gums should be wiped dry. 
 After placing a fold of linen between the lips and gum, 
 and another on the lingual side of the tooth, the cavity 
 should be thoroughly dried with tissue paper or cotton wool, 
 or any other convenient material. The thumb and fore- 
 tinger will be employed to keep the folds of linen in place, 
 and to raise the lip out of the way. If the flow of saliva 
 is very abundant, a slip of adhesive plaster (^) resembling 
 court-plaster, may be placed upon the lingual and labial 
 surfaces of the gums, and allowed to extend a short distance 
 over the tooth. After being held in position by the linen, 
 it adheres firmly to the gums, and perfectly excludes the 
 saliva from finding its way between the teeth or the rubber 
 dam applied. A sufficient quantity of gold having been 
 prepared, its introduction may now be commenced. It 
 will be desirable to have a large piece of non-adhesive 
 foil, loosely folded or crinkled up between the foil-fold- 
 ing instrument described at page 384, to lie against the 
 margin of the upper cavity. This must be carefully in- 
 troduced, and thoroughly condensed by the plugging instru- 
 ment against the upper wall ; for this purpose foot-shaped 
 pluggers (Fig. 151) are very useful. The forms shown in the 
 accompanying figures will be found suitable for the purpose. 
 If this, the first part of the operation, has been success- 
 fully performed, the gold will be firmly fixed in the upper 
 part of the cavity, and the most difiicult part of the opera- 
 tion accomplished. We have now to fill what may be 
 regarded as the secondary cavity. This may be done by 
 adding successive pieces of adhesive gold, taking care that 
 
 (1) The plaster, and the method of using it, were described before the 
 Odontological Society, and the account was published in the first volume of the 
 " Transactions." It is made by coating gutta-percha membrane with gelatine, 
 thus rendering the one surface adhesive, while the other is quite impervious to 
 moisture.
 
 390 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 each is thoroughly adherent to, and condensed upon, its 
 predecessor, and that each is laid on with some degree of 
 evenness. If the latter caution is neglected, on completing 
 the operation it will be found that the plug is perfectly- 
 solid in the centre and porous at the sides — a faulty con- 
 Fig. 162. (J) 
 
 r Figs. 1&3 and 164. 
 
 dition which it is difficult to remedy without commencing 
 the operation anew. In order to guard against the occur- 
 rence of this error, it will be well to test the plug from time 
 to time with a square-pointed or a wedge-shaped perforat- 
 ing instrument. It may be necessary, when the lower wall 
 is approached, to change the instrument in favour of one 
 the blade of which is more bent upon the shaft (Fig. 164), 
 in order to ensure the gold being carried to the bottom of the 
 
 (}) Figs. 162-3-4 show instruments having the same general character, the 
 first being adapted for introducing the gold, whether foil or sponge ; the second 
 and third for the condensation of the plug.
 
 METHODS OF INTRODUCING THE GOLD. 
 
 391 
 
 Fig. L65. (1) 
 
 cavity. It has been assumed that the first portion of the plug 
 was formed of foil moderately adhesive only, and that in the 
 subsequent steps of the operation gold possessing the highest 
 degree of adhesiveness was used. As good, and perhaps a 
 better result would have been obtained had the crystal gold 
 been used, providing the cavity had been first lined with a 
 thin layer of foil. There are those who in all 
 cases employ the non-adhesive foil used upon 
 the wedging system, and I have seen plugs so 
 made that cannot be objected to ; but I much 
 prefer the use of a material which, when con- 
 solidated, forms one solid mass. 
 
 When no further addition of foil or crystal 
 gold can be added, an instrument having a broad 
 convex surface cut up into conical points 
 (Fig. 165) will be found useful. It should be 
 pressed firmly on the surface of the plug with a 
 rolling motion. The gold will thus be reduced 
 to a comparatively level surface. The presence 
 of the wedge will protect the gum from injury 
 during the process of filing to a level surface 
 the plug and the surrounding tooth substance ; 
 the wedge should therefore be retained in its 
 position until that part of the operation is com- 
 pleted. It is necessary that a free interval 
 should be left between the teeth, in order that food and other 
 matter should be readily removed. If an error is committed, 
 it will be in the too sparing, rather than in the too free use 
 of the file. It only remains to complete the plug by 
 polishing in the usual manner. 
 
 If the cavity be situated on the distal, instead of the 
 mesial surface of the tooth, or upon either of those surfaces 
 in the bicuspids of the left side of the mouth, the steps of the 
 operation will be the same as in the case already described, 
 excepting as regards the position of the patient's head. The 
 
 (') Shows an instrument with an expanded extremity cut into minute cones.
 
 392 A SYSTEM OF DENTAL SURGERY. 
 
 face must be turned a little towards or from the operator, as 
 may suit Ms convenience. 
 
 In forming the upper edge of the cavity, when the decay 
 has reached the level of the gum, it is often very difficult to 
 get a smooth, satisfactory margin: and even when it has 
 appeared to be all that could be desired, it not infrequently 
 happens that the enamel splits off during the introduction of 
 the gold. The enamel at this part of the tooth is naturally 
 very thin, and readily parts from the dentine ; hence it is 
 perhaps desirable, when the cavity extends very nearly to 
 the point where the enamel terminates, to carry it a little 
 beyond it, so as to get rid of this fragile piece of enamel, and 
 obtain a cavity the cervical wall of which is bordered by 
 cementum. It is rare for caries to originate in the cementum ; 
 and it is the opinion of many American operators of repute, 
 that the cervical wall had better be composed of cementum 
 than of enamel. 
 
 It is often a matter of difficulty to introduce the gold 
 l>eneath the enamel and dentine which bound the cavity 
 towards the masticating surface of the tooth ; if the plug is 
 not perfectly solid at this part, the tooth will give way over 
 it during mastication. A method which is often very ser- 
 viceable, consists in altogether cutting away this wall of the 
 cavity with an enamel-cutter. In this way a cavity is formed 
 having only three walls ; in order to securely retain the plug, 
 which forms a part of the masticating surface of the tooth, 
 the cavity must be made somewhat wedge-shaped, both from 
 above downwards and from without inwards, the largest 
 portion being, of course, at the cervical Vail and at the floor 
 of the cavity — or, at least, what would have been the floor, 
 had not the masticating wall of the cavity been removed. 
 The whole cavity is thus easily accessible to straight instru- 
 ments ; and by commencing with a piece of non-adhesive, 
 and completing the filling by pieces of adhesive foil, most 
 satisfactory results may be obtained. 
 
 American dentists have lately introduced a plan of filling
 
 METHODS OF INTRODUCING THE GOLD. 393 
 
 these interstitial cavities by the aid of " matrices ;" these 
 consist of polished plates of metal introduced between the 
 teeth, so as to serve as a temporary fourth wall to the cervical 
 portion of the cavity; they are removed either when this 
 part of the cavity is filled, or are allowed to remain until 
 the whole plug is completed. 
 
 Th'eatment of Simple Cavities 171 the Upper Molar Teeth. — It 
 will not be necessary to enter minutely into all the details 
 connected with plugging the molar teeth, as the account 
 would be but a repetition of that which has already been 
 described in coimection with the operations upon the more 
 anterior teeth. The dififerences only need be pointed out. 
 
 The head of the patient should be well ^. , „^ ,,, 
 
 ^ Fig. 166. (0 
 
 thrown back, and placed at a height to 
 
 suit the convenience of the operator. ^ 
 
 If the disease be situated upon the wV 
 
 mesial surface, the tooth should be freely Jl] 
 
 cut away, in the manner recommended in ^1/ 
 
 the treatment of bicuspids when decayed mW 
 
 in the corresponding situation. The rubber mm 
 
 dam will render great assistance in pre- mm 
 
 venting the tongue from bringing moisture m|| 
 
 to the tooth, and also in rendering it un- /h|| 
 
 necessary to change the folds of a napkin, /j H 
 
 which sometimes becomes saturated during /Mi ll 
 
 the operation. IM Ml 
 
 In condensing a plug upon the mas- l|H|W| 
 
 ticating surface, the accompanying form fiP — ip| 
 
 of instrument will be found serviceable \\f Wr 
 
 (Fig. 160), more especially if the cavity | 
 be situated in the second or third molar. 
 
 When the distal surface is attacked by decay, the enamel- 
 cutter must be freely used, and the tooth cut away until, on 
 the commissure of the lips being drawn back by the first 
 
 (1) Showing an instrument for introducing adhesive foil or sponge gold into 
 cavities in the masticating surface of the upper molars.
 
 394 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 Fig. 167. (1) 
 
 and second finger of the left hand, the cavity can be seen. 
 The operation of plugging is far too difficult to admit of being 
 successfully performed in a cavity which is out of sight. It 
 will consequently be sometimes found necessary to reduce 
 the tooth to a greater extent than would have been needed, 
 had the disease been situated on the mesial surface of 
 the tooth. In the introduction of the gold the instrument 
 will enter the cavity at the angle formed by the distal and 
 labial surface of the tooth, when situated on the right 
 side of the mouth ; and in order to afford the requisite 
 space, this angle of the tooth must be reduced 
 to a greater extent than that situated near the 
 lingual surface. But if the operation be on 
 the left molar, it will be foimd advantageous 
 to submit the latter angle to a considerable 
 amount of reduction. In either case, however, 
 we must to a considerable extent be governed 
 by the course taken by the disease, and the 
 extent of injury it has produced. 
 
 The preparation of the cavity must be pro- 
 ceeded with upon the same general plan as that 
 already described, and the instruments used in 
 plugging the bicuspid will be equally suitable 
 for the molar teeth. In consolidating the 
 surface of the plug, the accompanying form 
 will be found suitable. 
 
 For cavities situated on the labial surface 
 of the upper molars, a pair of instruments, 
 right and left, somewhat of the forms given in the figure 
 (Fig. lt)8), will be found serviceable. With the head thrown 
 back, and the face turned to the right or left to suit the 
 case, and the commissure of the lips drawn back, the cavity 
 can be readily reached with the instrument, and a twist 
 
 (') Showing an instrument suitable for the introduction of crystal gold, or 
 for finally condensing the surface of a foil-filling situated in the distal surface 
 of an upper molar or bicuspid tooth.
 
 METHODS OF INTRODUCING THE GOLD. 395 
 
 given to the blade will enable the operator to force the foil 
 upwards and backwards, without allowing the shaft of the 
 instrument to interfere with the teeth and lips of either jaw. 
 
 Fig. 168, (1) 
 
 No one will be found to question the superiority of gold 
 over other filings, but there are cases in which the crown is 
 so hollowed out that the tooth is reduced to a mere shell, 
 quite incapable of withstanding the force necessarily em- 
 
 (1) Right and left instruments for introducing foil Into cavities situated upon 
 the labial surfaces of the upper molar teeth.
 
 396 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 ployed in the introduction of foil or sponge gold. In the 
 treatment of a case of this kind, we shall do well to use 
 amalgam. The tooth may not last for any great length of 
 time, but should it be rendered serviceable but for a twelve- 
 
 Fig. 169. 0) 
 
 month, the interest of the patient 
 will be better served than if the 
 tooth had been broken down in an 
 abortive attempt to make a gold 
 plug. 
 
 Again, there are those who will 
 not submit to the prolonged ope- 
 ration entailed by using gold. They 
 become so restless that the forma- 
 tion of a sound plug is rendered 
 almost impossible ; and seeing that 
 a good amalgam is more likely to 
 save the tooth than a defective gold 
 plug, it will be wiser to use the 
 former material. The slight dis- 
 coloration which may ensue is in 
 the molar teeth of minor import- 
 ance. Gutta percha might be used, 
 but it does not render the support 
 to the fragile tooth that is afforded 
 by the hardened amalgam, the sur- 
 face of which will endure for years uninjured by mas- 
 tication. 
 
 Treatment of Simple Cavities in the Teeth of the Lower Jaw. 
 — In operating upon the lower teeth the proceeding will be 
 varied as respects the position of the patient, the form of the 
 instruments used, and the precautions necessary to exclude 
 the intrusion of the saliva from the part under treatment. 
 
 The enamel-cutter will be called into requisition, but the 
 straight chisel-shaiped instrument so useful in the upper, fails 
 
 (1) Right and left sabre-bladed enamel-cutters, suitable for operating upon 
 the mesial or distal surface of the bicuspids or first molars of the lower jaw.
 
 METHODS OF INTRODUCING THE GOLD. 
 
 397 
 
 to meet the requirements of the operation in the treatment of 
 teeth of the lower jaw. The subjoined forms will be found 
 better suited for the purpose. For removing the mesial or 
 distal surface of the canines, bicuspids, or first molars, in- 
 struments the blades of which are sabre- Fig. i7o. (i) 
 shaped, and in a straight line with the 
 shaft, will be sufficiently suitable, but the 
 corresponding surfaces of the second and 
 third molar teeth cannot be conveniently 
 reached by straight instruments. For the 
 latter teeth the blade should be placed at 
 an angle of forty-6ve degrees with the 
 shaft, and the cutting edge formed by a 
 chamfer from the under in one, and from 
 the upper surface of the blade in a second 
 instrument ; and enamel - cutters, the 
 blades of which are bent at right angles, 
 will prove very useful. 
 
 In the preparation of cavities in the 
 lower teeth, the same general rules given 
 in respect to the subject generally must 
 be observed. It matters not where the 
 cavity is situated, the plug will soon fall 
 out, unless the form is suitable. 
 
 Prior to the introduction of the gold in cavities situated in 
 the mesian or distal surface of the lower incisor or canine 
 teeth, the wedge should be inserted, and ample precautions 
 should be taken for the exclusion of the saliva. If the rubber 
 dam be not employed, after placing the head so that the face 
 is turned sufficiently upwards to allow the saliva to flow 
 towards the throat, a strip of the impervious plaster may be 
 placed upon the lingual surface of the gums and teeth, and 
 between it and the tongue a tolerably thick fold or rope of 
 
 (1^ Enamel-cutters, with the blade placed at an angle with the shaft ; the 
 one being brought to an edge by a chamfer from the upper, the other from the 
 under surface of the blade.
 
 398 A SYSTEM OF DENTAL SURGEBY. 
 
 linen. A corresponding fold may then be placed between 
 the lip and gums, the two being retained in position by the 
 thumb and forefinger of the left hand brought round the 
 head of the patient, these two folds being composed of a single 
 napkin, twisted into a rope-like form, and carried over the 
 crown of the teeth. 
 
 The cavity having been rendered perfectly dry, the gold 
 may be introduced with instruments similar to those used in 
 Fig. 171. (1) conducting the like operations on the corre- 
 sponding upper teeth. Cavities in the canines 
 may perhaps in some cases prove exceptional, 
 and require similar management to that 
 which will be subsequently described as ap- 
 plicable to the treatment of the contiguous 
 bicuspids. 
 
 In filling cavities situated on the mesian or 
 distal surface of the last-named teeth, the 
 spiral-bladed instrument may be employed 
 with advantage, the gold being introduced from 
 the labial side of the tooth. When the distal 
 surface of the right teeth is under treatment, 
 the operator should stand to the right, and a 
 little behind his patient ; and on the side, but 
 slightly in front, when the corresponding part 
 of the left bicuspids is operated upon — the 
 patient in the former case leaning his face to 
 tuc iL^ii, m the latter towards the right side. Those in- 
 stances in which the crowns of the teeth are reduced to a 
 considerable extent on the lingual side, in consequence of 
 the disease having encroached upon the masticating surface, 
 as well as upon the neck, will allow the foil or sponge to be 
 introduced from above more advantageously than from the 
 side. The plugging instrument should have a short blade, 
 
 {^ An instrument used for condensing the surface of the gold inserted either 
 on the distal side of the right, or the mesial side of the left bicuspid. An 
 instrument resembling the one shown in the figure is well adapted for con- 
 densing the surface of tlie gold.
 
 METHODS OF INTRODUCING THE GOLD. 399 
 
 bent nearly at a right angle, and the shaft itself should also 
 be slightly bent in the same direction, at a distance of about 
 three-eighths of an inch from the blade. The two curves will 
 enable the blade to hook over the crown of the tooth and 
 enter the cavity. The gold having been introduced, the sub- 
 sequent stages of the operation involve only the proceedings 
 usually adopted in completing a plug. 
 
 It is in operating upon the molar teeth that we encounter 
 the greatest amount of difficulty, owing to the large quantity 
 of saliva which collects and overflows the teeth. Some 
 patients can swallow while the mouth is open, and thus 
 from time to time get rid of the accumulated fluid, but 
 others cannot ; and if means for its removal are not adopted, 
 the crowns of the teeth become entirely submerged. To 
 overcome this difficulty, folds of linen may be placed in the 
 mouth, and renewed so soon as they become saturated, but 
 wherever it can be conveniently applied, the rubber dam is 
 the most effectual means of protecting the cavity. The 
 patient's head should be thrown slightly back, and turned a 
 little towards the side opposite to that on which the faulty 
 teeth are situated, in order that the saliva, when the amount 
 is not excessive, may flow from the teeth under operation. 
 A small patch of adhesive plaster may also be placed upon 
 Steno's duct, which opens upon the surface of the cheek near 
 the first molar of the upper jaw. Or after rolling a napkin 
 into a rope, bend it in the form of a loop, and lay the curved 
 portion over the masticating surface of the molar posterior to 
 the cavity about to be filled ; then bring the two ends out- 
 wards, allowing the intermediate portions to lie by the sides 
 of the teeth, one on the lingual side, the other on the labial 
 side of the teeth. If the operation is on the right side of the 
 mouth, the twisted napkin can be retained in position by the 
 thumb and second finger of the left hand brought round 
 from the back of the head. If a fold of linen be placed 
 betwe'en the cheek and the upper teeth, some pressure may 
 be made against the orifice of the parotid duct, and will tern-
 
 400 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 porarily close it. With a little management, we shall suc- 
 ceed in keeping the tooth under operation dry for a sufficient 
 length of time to enable the gold to be introduced. When 
 
 Figs. 172 and 173 (i) ^^^ operation is on the 
 
 left side of the patient's 
 mouth, the arrangement 
 will differ only in the 
 position of the left 
 hand, which will then 
 be in front ; the thumb 
 will rest on the labial, 
 and the second finger 
 on the lingual side of 
 the teeth. By using the 
 second finger for the 
 retention of the napkin, 
 the first is left free for 
 assisting in the guidance 
 of the instrument, or the 
 adjustment of the nap- 
 kin, should it become 
 displaced: and the use 
 of such an instrument as 
 Hawes's duct and tongue 
 compressor will save the 
 operator's fingers much 
 fatigue. If the flow of 
 saliva be excessive, a 
 small fold of linen may 
 be placed behind the in- 
 cisor teeth, and when 
 saturated, renewed with the right hand, while the left keeps 
 the napkin which surrounds the faulty tooth undisturbed. 
 
 (1) Instruments constructed with a double curve for filling cavities in the 
 masticating surface of the lower molar teeth ; the former being suited for 
 ordinary foil, the latter for adhesive foil or sponge gold.
 
 METHODS OP INTEODUCING THE GOLD. 
 
 401 
 
 Fig. 174. 0) 
 
 If the cavity under treatment be situated upon the masti- 
 cating surface, an instrument presenting a double curve will 
 be found to meet the requirements of the case (Fig. 172). 
 The curve of the shaft carries the instrument over the conti- 
 guous teeth without the handle being inconveniently raised. 
 After the gold is introduced, another form of instrument will 
 be found useful for condensing the plug 
 (Fig, 174), which, being exposed to wear, 
 cannot be too hard. 
 
 The shaft is bent almost in the shape 
 of the letter S, and when used descends 
 from the lower border of the closed hand, 
 the blade terminating in the working 
 surface being in a vertical position. It 
 is necessary to support the jaw of the 
 patient with the left hand. 
 
 For operating on cavities in the labial 
 surface, a double - curved instrument, 
 similar as resi^ects the blade, but with 
 the curve in the shaft in a different 
 direction to those last described, will be 
 found very serviceable. When in use, 
 the shaft will be nearly parallel to and a 
 little above the crowns of the lower 
 teeth, the blade descending, and the 
 working extremity directed obliquely 
 downwards and backwards (Figs. 175, 
 176). By adopting this foiTa, the operator is enabled to 
 keep in view the lower margin of the cavity during the 
 packing of the foil — the part in which the plug is most 
 frequently defective, and consequently requiring the greatest 
 care in its construction. 
 
 The most troublesome cases to treat with success are those 
 
 (') An instrument for compressing plugs introduced in the masticating 
 surface of the inferior molars. The handle is grasped with the blade passing 
 downwards from ihe lower border of the closed hand. 
 
 2 D
 
 402 A SYSTEM OF DENTAL SUEGERT. 
 
 in which the disease is situated on the distal surface of the 
 lower molars, more especially when the cavity is small, and 
 confined to the neck of the tooth. The free use of the 
 
 Figs. 175 and 176. (i) 
 
 enamel-cutter is required, and it is often with great difficulty 
 that the crown of the tooth is sufficiently cut away to enable 
 
 A i; A right and a left double-curved instrument, for introducing foil Into 
 avities on ihe labial surfaces of the lower molars.
 
 METHODS OF INTRODUCING THE GOLD. 403 
 
 the cavity to be reached. A good quality of steel, well tem- 
 pered, is required to enable the operator to cut through the 
 sound enamel of molar teeth, more especially when, as in 
 lower molars, the position is unfavourable ; for filling such 
 cavities cylinders will very generally prove the most con- 
 venient form of gold. 
 
 In describing the treatment of caries, the observations have 
 been confined to those cases in which the pulp of the tooth 
 has not been involved in the disease — cases in which the 
 cavity to be treated has been simple. The more complicated 
 forms of the disease remain for consideration. They will 
 come under two divisions; first, those cases in which the 
 pulp is exposed, but not obviously diseased ; secondly, those 
 in which the pulp-cavity is laid open, and the pulp diseased 
 or dead. 
 
 Caries with iierf oration of the pidp-cavity , the pulp being 
 healthy, is a condition that is but seldom seen, excepting as 
 the result of an operation. The dentine in contact with the 
 pulp having been softened by disease, is removed when the 
 cavity is prepared for filling, and the pulp thereby exposed. 
 Perhaps It would be wrong to assume that in such a case 
 the pulp, is absolutely sound, but there may be nothing to 
 show that it is diseased, and nothing to warrant the adoption 
 of any other treatment than that which would be pursued if 
 its healthiness were unquestioned. 
 
 I am not prepared to say that we never find the pulp of 
 a carious tooth the cavity of which has been laid open by the 
 disintegration of its walls, free from disease ; but cases ex- 
 hibiting such conditions are very rare : whereas the exposure 
 consequent upon the removal of carious dentine is not very 
 uncommon. It is an unfortunate accident which cannot 
 always be avoided — unfortunate, because it would have been 
 better to have retained the softened tissue, the removal of 
 which occasioned the exposure of the pulp, and to have pro- 
 tected it from further decomposition by i>lugging the cavity. 
 Had this treatment been adopted, we should, on examination,
 
 404 
 
 A SYSTEM OP DENTAL SURGEBT. 
 
 after the lapse of a few months, have found that the pulp 
 itself had become calcified at the point corresponding to the 
 disorganized dentine. The presence of a plug stays the 
 further progress of the disease, and prevents the fluid of 
 the mouth from penetrating through the defective wall of 
 the pulp-cavity, while the softened tissue retained as a 
 covering to the pulp saves the latter from the effects of 
 sudden changes of temperature, which would have been 
 directly conveyed through a metal plug but for the inter- 
 vention of the dentine. When, however, the exposure is 
 jDroduced during an operation the pulp is usually wounded, 
 and bleeds freely. The pain is commonly acute, but soon 
 subsides ; but sometimes no pain is experienced. After the 
 bleeding has ceased the cavity should be syringed out with 
 tepid water, and carefully dried ^vith cotton-wool. The 
 actual state of the walls of the cavity, the size of the per- 
 foration into the pulp-cavity, and the condition of the dentine 
 immediately around the hole, can then be examined. If it 
 be found that the whole of the softened dentine had been 
 removed, that the aperture into the pulp-cavity is very 
 minute and surrounded by sound tissue, we may proceed to 
 plug the tooth in the usual manner, adopting the precaution 
 of laying a small piece of foil, folded six or eight times upon 
 itself, over the aperture. But should it appear that the 
 opening into the cavity is of considerable size, or that, 
 though small, it is surrounded by softened tissue, the removal 
 of which would increase its size, a different mode of proceed- 
 ing must be adopted. 
 
 As much as possible of the disorganized tissue, short of 
 enlarging the aperture, should be carefully cut away, taking 
 care that the walls of the cavity are reduced to a suitable 
 foiTn ; an artificial substitute for the missing portion of the 
 wall must be provided, in the preparation of which two 
 conditions should be observed. Like the dentine, it should 
 be a non-conductor, and also, like it, be capable of protecting 
 the pulp from pressure. To possess the latter quality the
 
 METHODS OF INTRODUCING THE GOLD. 405 
 
 material must have a certain degree of strength, and be 
 slightly concave on that surface which is presented towards 
 the pulp. 
 
 It is usual to speak of the operation under the title of 
 " capping " the nerve or pulp, and the substance shaped to 
 cover the pulp as the " cap." Gold, ivory, the quill-horn, and 
 many other substances have been used. 
 
 A piece of suitable size cut from the barrel of a stout quill, 
 being readily produced, was formerly often used. In deter- 
 mining the shape and size of the cap, it must be remembered 
 that there is no objection to the whole of the floor of the 
 cavity being covered ; at all events, the cap should be suffi- 
 ciently large to ensure its edges resting at some little distance 
 from the margin of the aperture by which the pulp is ex- 
 posed, otherwise it will fail to protect the latter part from 
 pressure during the operation of plugging, and subsequently 
 from that consequent upon the tooth being used in masti- 
 cation. 
 
 While it is necessary that the exposed portion of the pulp 
 should be perfectly protected from pressure, it is perhaps 
 equally desirable that a space should not be left in the 
 concavity of the cap into which the pulp could be received, 
 were it from any cause to protrude through the aperture in 
 its proper cavity. The natural conditions of the part in- 
 volved should be observed, and as far as possible restored. 
 To follow out these indications, the exposed pulp should be 
 protected by an artificial covering, which, while it protects, 
 will at the same time keep the pulp within its natural limits, 
 and defend it from sudden changes of temperature. 
 
 In adjusting the cap, some little time and attention must 
 be given in order to secure its taking a level bearing upon a 
 surface which may be, and frequently is, uneven; and it 
 should also, if practicable, fit to the walls of the cavity with 
 sufficient tightness to secure the retention of its position 
 during the introduction of the gold or other material. 
 
 Before, however, we proceed to fill the cavity, it must be
 
 tl:06 A SYSTEM OF DENTAL SURGERY. 
 
 determined whether the plug is to be regarded as a tem- 
 porary or a permanent one. Should the treatment prove 
 successful, the exposed portion of the pulp will, in the course 
 of a few months, become calcified, and the aperture in the 
 cavity stopped from within by a layer of secondary dentine. 
 Assuming this process to have been effected by nature in a 
 tooth that has been permanently plugged over a cap, it is 
 quite possible that the filling will preserve the tooth for an 
 unlimited period, but it is far more probable that a plug 
 introduced under such circumstances will, after a time, fail, 
 and the failure perhaps may not be discovered until the 
 crown of the tooth is all but lost. Had the filling been 
 regarded as temporary, the tooth would have been examined 
 after the lapse of six or eight months, the temporary plug 
 removed, and a gold filling introduced under circumstances 
 far more favourable than obtained when the operation was 
 complicated by the presence of a cap and general tenderness 
 in the tooth. 
 
 So much uncertainty, however, was found to follow on the 
 capping of exposed nerves, that the practice fell into some 
 disfavour, but it has again been revived in a somewhat 
 modified form, and meets %^ith fairly successful results. In 
 the place of using a protective cap of quill, or other hard, 
 unyielding substance, it is now usual to lay over the point of 
 exposure a very small piece of cotton-wool soaked in thymol 
 or carbolic acid, or a drop of collodion containing carbolic 
 acid. Over this a filling of gutta-percha, or, I think, 
 preferably, zinc oxychloride, is inserted and allowed to 
 remain for some months. Some writers advocate the direct 
 application of the zinc oxychloride to the exposed surface of 
 the pulp ; but I prefer to protect the point of exposure by 
 one or other of the substances mentioned. In many instances 
 where the exposure of the pulp is very small, or where some 
 softened dentine remains, forming an insufficient protection 
 to it, a layer of zinc oxychloride may be put over it and 
 allowed to harden ; this is cut away on the next day,
 
 METHODS OP INTRODUCING THE GOLD. 407 
 
 excepting over that spot where its presence is desirable, and 
 the rest of the cavity filled with gold. 
 
 Although the preceding plan olten meets with success, as 
 a general rule, I believe it is wiser to employ a temporary 
 filling, which may be advantageously composed of zinc oxy- 
 chloride. Mr. Thomas Rogers, in an elaborate paper Q) (to 
 which I must refer the reader for a fuller account of all that 
 relates to this subject), makes the following statement : — 
 "As I consider it to be a matter of great importance to 
 avoid as much as possible all irritation to the tooth in this 
 delicate condition, I fill over the cap with amalgam." 
 
 Whether amalgam (in which case it would be well to use 
 an amalgam that hardens imperfectly) (^), gutta-percha, or 
 zinc oxychloride be selected, its removal, and the substitution 
 of a gold plug, should be insisted on so soon as the tooth is 
 in a proper condition to warrant the permanent operation. 
 
 It has been assumed that in all cases of exposure of the 
 pulp during an operation, or under circumstances that justify 
 the opinion that it is free from disease, our treatment should 
 be addressed to its preservation. 
 
 Such is the general rule. But there are cases in which 
 this rule cannot be acted upon, on account of the impos- 
 sibility of following out the treatment required for its 
 observance. 
 
 From prolonged irritation the pulp may have passed into 
 such a condition that it will continue to ache despite the 
 application of sedatives ; it may be the seat of irregular 
 nodules of calcification, or it may have lost so much of its 
 substances by suppuration that it no longer fills up the 
 pulp-cavity. Again, the walls of the cavity may be so 
 shallow that the retention of a cap with a plug external to it 
 becomes a matter, not only of difficulty, but of impossibility. 
 Or the crown of the tooth may be so much injured that, even 
 
 (1) Transactions of the Odontological Society, vol. i. Jlr. T. A. Rogers " On 
 Capping the Exposed Pulp." 
 
 (^2) Ibid., vol. iv., new series. Mr. C. S. Tomes " On Amalgams."
 
 408 A SYSTEM OF DENTAL SURGERY. 
 
 if the pulp were capped, the introduction of a plug would be 
 attended with risk of breaking down the shell. The patient 
 may be unable to return to you, or to obtain the assistance 
 of a dentist for some years to come. On the occurrence of 
 circumstances such as those enumerated, the protective 
 system of treatment must be abandoned. Instead of striving 
 to save the pulp, means must be adopted to bring about its 
 destruction. The most ei5ectual, and at the same time 
 safest, manner of accomplishing this end, consists in passing 
 a very fine and flexible broach through the opening in the 
 pulp-cavity up the fang of the tooth. When the further 
 progress of the instrument is arrested by the diminished size 
 of the cavity, a rotatory motion should be given to the 
 broach. The effect will be to cut off the pulp in the root of 
 the tooth at the most constricted part of the canal, and, con- 
 sequently, of the pulp itself. This treatment is applicable 
 to single-rooted teeth only, and even in these the operation 
 is sometimes attended with great pain, OAving to the difficulty 
 of passing the broach to its proper destination. Whatever 
 instrument be used, it should be at once boldly thrust home : 
 little or no more pain is given by such a procedure than by 
 a mere touch, and indecision on the part of the operator 
 involves prolonged suflering to the patient. 
 
 By destroying the pulp, we convert the once simple into a 
 compound cavity, the one part being formed by the pul]>- 
 cavity, the other by the cavity produced by the primary 
 disease. 
 
 The two cavities have now to be regarded as one, and 
 steps must be taken to reduce it to a suitable form for the 
 reception of a plug. The canal in the root, after the with- 
 drawal of the pulp by a spirally-twisted broach, or preferably 
 by one of the barbed instruments constructed for the pur- 
 pose (^), should be enlarged with a drill, and the distinction 
 
 (1) Broaches for destroying and withdrawing the pulp should be very fine, 
 elastic, and flexible, otherwise the capability of following the curved course 
 necessarj' for the effective performance of the operation will not be obtained.
 
 METHODS OF INTBODUCrNG THE GOLD. 409 
 
 between the two cavities destroyed by graduating the walls 
 of the outer into those of the inner cavity. 
 
 There appears to be some difference of opinion as to the 
 time at which a tooth can be most safely plugged after the 
 pulp has been removed. There are those who consider that 
 the cavity should be filled with cotton-wool and mastic, and 
 the tooth allowed to remain unmolested until any irritation 
 that may supervene upon the destruction of the pulp has 
 completely subsided. 
 
 The experience derived from my own practice has led me 
 to arrive at a different conclusion. In the cases which have 
 proved most successful, the canal in the root has been filled 
 immediately on the cessation of the hsemorrhage, and the 
 operation completed on the same or a following day. When 
 this course has been followed, irritation of the alveolar mem- 
 brane of the socket has seldom arisen ; but when from any 
 cause the permanent filling of the root has been postponed 
 for some days, a certain amount of irritation has come on, 
 the tooth becoming slightly raised in the socket, and painful 
 when pressed upon. In some instances, the unfavourable 
 symptoms have gradually passed away ; in others, the tooth 
 has been lost. 
 
 The different results consequent upon the two modes of 
 treatment may be explained upon the assumption that when 
 the pennanent filling is used, the ingress of oral fluids is 
 perfectly prevented, and the accumulation of anything more 
 than a very minute amount of coagulum impossible ; whereas, 
 when cotton- wool only is employed, the permeation of saliva 
 is not rendered impossible, neither is the collection of a 
 relatively larger amount of coagulum guarded against. 
 
 The consequences which follow the laceration of a soft 
 
 Fine watchmaker's broaches, reduced to a soft spring temper, are commonly 
 used ; but a more effective instrument may be made by taking a firm watch- 
 spring, and grinding it down until a square-sided broach is produced. If in a 
 second the temper is slightly lowered, the point may be twisted to the extent of 
 three or four turns.
 
 410^ A SYSTEM OF DENTAL SURGERY. 
 
 tissue will, caeteris paribus^ generally be proportioned to the 
 amount of surface injured. In the case of a tooth, the 
 sectional area of the pulp near the end of the root is so 
 small, that its division in a healthy subject will not be fol- 
 lowed by inflammation, unless the injured part is subse- 
 quently exposed to irritation. But should the saliva find 
 access, or a large coagulum collect in the vacant cavity or 
 in the interstices of the wool, and decompose, the lacerated 
 surface will become inflamed, and the disease will extend 
 from the remnant of pulp to the periosteum of the root and 
 socket. 
 
 There are other methods than that just described of de- 
 stroying the pulp ; and in cases where the use of the broach 
 is attended with difficulty, owing to the position of the 
 opening in the pul}3-cavity, or to the tooth having more 
 than one root, they are to be preferred. The use of escharo- 
 tics for destroying the pulp can no longer be looked upon as 
 a novel mode of treatment. The practice has stood the test 
 of time, and may be regarded as one of many great improve- 
 ments in dental surgery matured during the present genera- 
 tion. Ruspini, in a pamphlet published in 1797 Q), mentions 
 destroying the pulp, and subsequently filling the cavity, but 
 the operation was not generally adopted, and its details and 
 results worked out, until within the last twenty years. It 
 
 (') Ruspini, in his " Treatise on the Teeth," the eighth edition, published 
 1797, makes the following statement: "Whenever caries appears it must be 
 opened with a masterly hand t) the very bottom. If in doing so the chord of 
 the tooth is discovered, the operation will prove painful; but still it must be 
 destroyed, cither with an instrument, or with the actual cautery, or son^e 
 caustic liquor. 
 
 " We ought to be very attentive in tlie operation ; for if we do not utterly 
 destroy the said chord, but only prick it, the most raging pains will succeed, 
 together with an inflammation, and the inevitable necessity of drawing the 
 tooth. 
 
 " \\Tien a tooth by the loss of its chord is become insensible, it mu-t be filled 
 with lead or gold, in order to prevent any acid or saline particles from getting 
 through the hole wh'?re the chord went into the socket, to hurt its delicate 
 membrane; lor then there would be no means of reiress but by drawing the 
 tooth ; hence all the care that bad been taken, and all the pain that had been 
 endured to render the tooth insensible, would then bi of no avail."
 
 METHODS OF INTRODUCING THE GOLD. 411 
 
 is singular that a principle the soundness of which had been 
 fully established for the best part of a century in the opera- 
 tion of pivoting, should not have been applied to the pre- 
 servation of teeth the crowns of which were but partially 
 decayed. Every one knew that after the removal of the 
 pulp, a piece of gold wire might be passed up the healthy 
 root of a front tooth, for the purpose of supporting a new 
 crown, but it did not occur to those who practised pivoting 
 that the crown of a tooth could be preserved by an operation 
 conducted upon the same principle. It is not, however, very 
 difficult to see how the* fact was overlooked. The gold pin 
 was not introduced for the purpose of preserving any portion 
 of the faulty tooth, but was regarded as purely subservient 
 to the support of a new crown, in the place of that which 
 had been too far injured to render its retention desirable. 
 
 There are several general rules which may be laid down 
 in respect to the selection and the application of escharotics. 
 The first in point of importance is, that they should not be 
 employed when there is reason to suppose that the peridental 
 membrane is diseased, and for the following reason. It seldom 
 happens that inflammation external to the root arises, ex- 
 cepting as an extension of disease originating in the ])ulp, 
 during the progress of which both the pulp itself and the 
 canal in the fang become considerably enlarged. Conse- 
 quently the action of the caustic may not be limited to the 
 pulp, or if it be, that portion which is allowed to remain will 
 be in a diseased condition, and capable of keeping up the 
 morbid action in the alveolus. 
 
 The second rule to be observed is, that no more of the 
 escharotic should be applied than will be sufficient to produce 
 the required effect. For if an excess be used, it is more than 
 probable that the action will extend beyond the required 
 limits, and produce inflammation of the peridental membrane. 
 The third rule is, that the application should not be con- 
 tinued over a longer period than is necessary to ensure the 
 destruction of the body of the pulp. If allowed to remain
 
 412 A SYSTEM OF DENTAL SUBGEBT. 
 
 for a long time in the tooth, it may permeate the dentine 
 and affect the peridental membrane ; whereas, if the body of 
 the pulp be dead, the degree of sensibility of that which 
 remains in the roots is so much lowered that it may be with- 
 draAvn without occasioning any considerable amount of pain. 
 By observing this precaution we ensure the removal of the 
 caustic, and leave the pulp at the point of rupture in a much 
 more favourable condition for healing than if it had been 
 saturated by the escharotic. 
 
 The fourth rule is, that escharotics should not be applied 
 to a tooth, with the view of destroying the pulp, unless the 
 fang is fully developed, and the aperture through the ex- 
 ti-emity of the root reduced to its ultimate size. In young 
 subjects the canal in the root of a tooth is very large gene- 
 rally, but more especially at the terminal portion, and the 
 pulp maintains a corresponding size. 
 
 The expediency of destroying the pulp by means of un 
 escharotic having been determined on, the substance best 
 fitted to produce the effect must be selected. The mineral 
 acids, nitrate of silver, chloride of zinc, and many other sub- 
 stances possessing caustic properties, have each in turn been 
 used. Arsenious acid has, without giving rise to a greater 
 amount of pain, been found to act with more certainty, and 
 in less time, than any other agent. The certainty of its 
 operation is so great a recommendation that arsenic is almost 
 invariably employed in preference to any other description of 
 caustic. The extremely active character of this substance 
 as a poison led me some years since to prefer chloride of zinc; 
 which, although less certain, is a less dangerous agent to 
 employ in the mouth. At that time the minimum amount 
 of arsenic capable of producing the required effect had not 
 been determined, and several cases had come under my notice 
 in which sloughing of the gum and the loss of the tooth 
 followed its use, though it is probable that this sloughing of 
 the gum was due to a careless application of the caustic. 
 More extended experience has cleared away many doubts as
 
 METHODS OF INTRODUCING THE GOLD. 413 
 
 to the advantages ofifered by this mineral, which has now 
 taken its place among the most useful of the agents at the 
 disposal of the practitioner. 
 
 T.he twenty-fifth of a p:rain of arsenious acid^ reduced to 
 a fine state of division (a dose which, if swallowed, would be 
 productive of no injury), is sufficient, when properly applied, 
 to destroy the vitality of the pulp of a large molar tooth. 
 Some practitioners prepare a compound, made by grinding 
 together equal parts of arsenic and morjDhia, the narcotic 
 being added for the purpose of mitigating the pain produced 
 by the corrosive action of the mineral substance. In my own 
 practice, I prefer to use the arsenic alone, and applied in the 
 following manner : a small ball of cotton-wool, scarcely larger 
 than a pin's head, is formed on the end of a fine broach, and 
 dipped into creosote. The arsenic is then taken up on the 
 saturated wool, which, thus loaded, is carefully placed in 
 contact with the exposed portion of the pulp, and retained 
 in jjosition by the introduction of a second piece of wool 
 saturated with a solution of mastic. The aiDplication is ren- 
 dered yet more certain by taking up a little arsenious acid on 
 the blunt point of an instrument which has been moistened 
 with carbolic acid or glycerine, and applying this to the pulp 
 before introducing the wool. 
 
 When the cavity is situated in the masticating surface of a 
 tooth, the application is readily effected, but if it be upon 
 the median or distal surface, a little more caution is required, 
 otherwise the arsenic may find its way to the gum, and pro- 
 duce, if not permanent mischief, a cousiderable amount of 
 temporary discomfort. 
 
 The introduction of the second piece of cotton will, if the 
 movement be not guarded against, force towards the gum 
 that which is charged with the escharotic. In order to pre- 
 vent such shifting of position, a small piece of wool should 
 be laid between the teeth, close upon the edge of the gum. 
 The charged cotton may then be placed in position, and the 
 wool provided for its retention introduced. The patient
 
 414 A SYSTEM OF DENTAL SUEGEBY. 
 
 must be directed to avoid masticating upon the tooth, or 
 disturbing the application by any other means, even though 
 the pain it occasions should be severe. Both the intensity 
 and the duration of the pain produced by the destructive 
 action of arsenic upon the dental pulp are inconstant to a 
 degree for which the recognisable diflerences in the cases fails 
 to account. One patient will tell you that the application 
 produced no pain, another that the toothache was most 
 severe, and lasted for ten or twelve hours, while a third will 
 describe the pain as moderate in degree, and of a very 
 bearable kind. 
 It is remarkable that the application of arsenious acid to a 
 tooth which has previously been aching severely 
 ^■^' ■ ^ ^ is seldom followed by much pain; perhaps this 
 may be due to a pulp in a state of inflammation 
 being more readily destroyed than one in a com- 
 paratively healthy condition. The more free the 
 exposure of the pulp, the less pain will, as a rule, 
 be experienced : there is no condition productive 
 of such severe suffering as a mere pin-hole ex- 
 posure of the pulp through which the arsenic 
 passes only in sufficient quantity to act as an 
 irritant ; the result is that the pulp swells, a 
 hernial protrusion is forced through the constricted 
 orifice, and the aching and throbbing are almost 
 unbearable. It is in a complete exposure of the 
 pulp, and an effectual application of the escharotic, 
 and not in the a<imixture of drugs such as morphia 
 with the arsenic, that we must seek to obviate 
 suffering during the destruction of the pulp. 
 
 A small opening into the pulp-cavity may be 
 advantageously enlarged by the use of the instru- 
 ment here figured : from its shape it has the advantage 
 of not slipping abruptly into the pulp, as would be the case 
 were a rose-headed drill or a broach employed to enlarge the 
 
 (1) Drill for opening the pulp-cavity.
 
 METHODS OF INTRODUCING THE GOLD. 415 
 
 orifice; moreover, the instrument in question cuts with a 
 very small amount of pressure. 
 
 After the lapse of from twelve to thirty-six houi's — depend- 
 ing on the size of the tooth and the extent of surface exposed 
 to the action of the escharotic — the whole of the cotton-wool 
 may be removed, and the eftects of the application ascertained. 
 If the result has been favourable, the sensitiveness, before so 
 great, will have entirely passed away. On pass- 
 ing an instrument into the pulp-cavity, slight 
 bleeding may follow, but the patient will not 
 complain of pain, unless the effect of the in- 
 strument has been to compress the whole 
 contents of the pulp-cavity. Should the pulp, 
 however, on examination, be found in an 
 acutely sensitive condition, it may be concluded 
 that the ingress of the arsenic has been pre- 
 vented, either by the aperture into the pulp- 
 cavity being extremely small, or by a mass of 
 secondary dentine lying against the opening. 
 But whatever cause may have retarded the 
 operation of the escharotic, the application 
 must be renewed, and a further time given. 
 The required effect having been produced, the 
 whole of the decayed dentine should now be 
 removed, and the opening into the pulp-cavity 
 sufficiently enlarged to allow the pulp to be 
 withdrawn entire. This part of the operation 
 may generally be efiected by a fine broach, 
 booked at the end, or by a twisted flat broach 
 of the kind already described, or by the barbed 
 nerve extractor here figured. The operator 
 must be prepared to meet with occasional diffi- 
 culties, owing to the presence of masses of secondary dentine 
 witliin the substance of the pulp. They are sometimes so 
 large and irregular in shape, perhaps dipping down into the 
 (1) Instrument for removing the nerves
 
 416 A SYSTEM OF DENTAL SURGERY. 
 
 fangs, that their withdrawal occupies some little time, the 
 pulp becoming broken down by the operation. In such 
 cases the contents of each fang must be drawn out separat^-ly. 
 Although the body of the pulp has become insensible, more 
 or less pain will be felt when the pulp situated in the roots 
 of the tooth is broken across at or near the orifice by which 
 it passes into the alveolus ; but the pain subsides immediately. 
 Should slight haemorrhage follow, the operation may be sus- 
 pended for a few minutes, by which time the bleeding will 
 have ceased. 
 
 If the treatment has been successful, the pulp-cavity of the 
 body and of the roots of the tooth will have been cleared of 
 their natural contents. The further treatment will consist in 
 filling first the roots (when practicable) with gold, then the 
 pulp-cavity, and lastly the external cavity. The necessity 
 of filling the roots has been strongly insisted on by the 
 American writers, and there can be no doubt of the advan- 
 tage which results, supposing the canals to have attained a 
 certain magnitude. But when the root is small and its cavity 
 too minute to admit a fine broach, it may be left without 
 the fear that any evil consequence will ensue. In a first 
 molar of the upper jaw, for example, the anterior and palatal 
 roots should be filled, but the posterior root is commonly 
 traversed ly a canal too small to render filling necessary. 
 
 Some doubt has been expressed as to the practicability of 
 filling the roots of teeth, and no doubt the operation is 
 tedious ; but when sufficient time is given very little diffi- 
 culty is experienced. In front teeth it is simple enough, and 
 in the back teeth it must be rendered simple, otherwise the 
 result will be imperfect. The crown of the tooth must, in 
 fact, be cut away until the pulp-cavity is fully exposed and 
 its continuation in the roots brought within the reach of an 
 instrument. It will in most cases be found desirable to 
 enlarge the canal with a broach. The question constantly 
 suggests itself as to what extent the enlargement shall be 
 carried, and to what depth. The determination of these
 
 METHODS OF INTRODUCING THE GOLD. 417 
 
 points will depend upon the peculiarities of the case under 
 treatment. The object of the enlargement is to facilitate 
 the operation of plugging. In some instances it may be dis- 
 pensed with, in others it must be carried to a considerable 
 extent. Thus, when the canal is large at one part of its 
 circumference, and reduced to a mere slit at another, it will 
 be advisable to reduce it to something approaching a regular 
 outline. In respect to depth, the enlargement may be carried 
 with advantage to the point beyond which a fine broach will 
 not pass in the natural state of the root. 
 
 Having fully prepared the cavity, both in respect to its 
 form and removal of extraneous matter, and protected the 
 tooth from the influx of saliva, the cavity must be made 
 perfectly dry by passing into the roots cotton-wool rolled 
 upon a broach. 
 
 We may now proceed to pack in the gold by ona or other 
 of the following methods. 
 
 Roll round a broach which will readily pass to the bottom 
 of the canal a small amount of foil, firmly, but not so tight 
 but that the broach can readily be withdrawn. The gold 
 may then, while upon the broach, be pressed to the bottom 
 of the cavity ; withdraw the broach a short distance, and 
 again return it, using sufficient pressure to consolidate the 
 gold, which will be carried down before the instrument. 
 After thus forcing in the first tube of foil, the process must 
 be repeated again and again until the root is filled. 
 
 In the place of the tube of foil, very narrow ribands may 
 be used, but the operation is more tedious, and does not 
 possess any advantage over the method already described ; 
 if ribands be employed, they may be advantageously cut 
 from No. 60 foil, leaving them l3ut little wider than the 
 instrument which is to introduce them. 
 
 A third method consists in taking three or four thick- 
 nesses of foil, and cutting therefrom very small square pieces, 
 which are one by one introduced upon the point of the 
 
 2 B
 
 418 A SYSTEM OF DENTAL SURGERY. 
 
 broach, and consolidated. Or a piece of soft annealed gold 
 wire may be inserted into the fang. 
 
 Some little attention mu>t be given to* the instniments 
 employed for this delicate operation. If an ordinary four- 
 sided broach is used, the temper must be reduced to that of 
 a spring, otherwise it will snap off during the operation, a 
 portion probably remaining in the cavity. I have known this 
 accident happen in several cases, and a portion of steel has 
 unavoidably been allowed to remain in the tooth, without 
 any evil consequence becoming immediately developed. 
 
 A preferable instrument may be made either from a piece 
 of steel wire, or by grinding into a cylindrical shape a strip 
 taken from a clock spring. The extremity, if left flat, will 
 carry the gold to the bottom of the cavity more readily than 
 it would do were an edp;e or point produced. The curved 
 course which the broach is required to take renders elasticity 
 absolutely essential, and in no way can this be obtained more 
 readily and more certainly than by adapting to our purpose a 
 piece of watch or clock spring. 
 
 The root or roots being plugged, the subsequent part of 
 the operation does not vary from that of making an ordinary 
 plug, excepting that the cavity in the tooth is unusually 
 large, and will therefore occupy a greater length of time 
 than would be consumed in filling a simple cavity. ]f a 
 large molar, either of the upper or lower jaw, be the subject 
 of treatment, the compound cavity, even after the roots of 
 the tooth are filled, may be so deep that difiSculty will be 
 encountered in packing non-adhesive gold so as to form a 
 single plug. In such cases it is well to first fill perfectly the 
 pulp-cavity, and then to proceed to make the more external 
 part of the plug. It is a convenient practice to fill the roots 
 with gold, and the crown of the tooth with some temporary 
 filling, postponing the completion of the operation for a 
 fortnight or more, so that should any alveolar irritation 
 arise, the removal of the plug may be readily efiected.
 
 METHODS OF INTRODUCING THE GOLD. 419 
 
 When the foregoing operation is carefully performed, the 
 result is generally very satisfactory, the tooth being reduced 
 to the condition of one upon the root of which a new crown 
 has been fixed by a pivot. In each the connection with the 
 living tissues is limited to the external surface of the root ; 
 and in one, as in the other, inflammation of the dental 
 periosteum may ensue soon after the operation, either if care 
 be not observed in its performance, if the periosteum be dis- 
 eased, or if the patient be in a bad state of health when the 
 operation is performed. 
 
 It must, however, be borne in mind, that we have been 
 treating of those cases only where the pulp has been exposed 
 during an operation. The presence of disease in the dental 
 periosteum will therefore be rare, and the source of failure 
 may consequently be looked for in the general state of 
 health of the patient, or in the manner in which the opera- 
 tion has been performed. I can call to mind several in- 
 stances of failure in my own practice which were consequent 
 upon a certain portion of the pulp having retained its vitality 
 and held its place unobserved in the tooth. In one case an 
 upper molar became very sensitive to changes of temperature, 
 sensitive v/hen pressed upon, and slightly loose. It was 
 removed, and, on examination, the pulp in the posterior 
 distal root was found to have retained its vitality and to 
 have become inflamed. In one instance an upper bicuspid 
 became very painful. After removal the pulp on the one 
 side of the compressed cavit}'^ was found to have escaped the 
 broach and retained its vitality. In each case the source 
 of failure lay in the incomplete destruction and removal 
 of the pulp. 
 
 In respect to the general health, some little caution should 
 be observed in the selection of the cases for filling the roots 
 and the pulp-cavity. It will be wise to avoid the operation 
 in those who present the strumous diathesis, more especially 
 where it is coupled with great sensibility of the teeth gene- 
 rally. Persons who are liable to neuralgic pains in the head
 
 420 A SYSTEM OF DENTAL SUBGERT. 
 
 aud face are unpromising subjects, and we can scarcely 
 expect a very favourable result where the gums are in an 
 unhealthy condition. 
 
 The occurrence of a small and unimportant chronic gum- 
 boil, coming and going with little or no inconvenience, must 
 be placed amongst the results which may follow the destruc- 
 tion of the pulp and the subsequent filling of the pulp- 
 cavity. In respect to the root itself, changes, I believe, 
 commence from the time of the operation, and proceed, 
 more or less slowly, until the tooth is lost. In pivoted teeth 
 the root sometimes becomes enlarged, but more commonly 
 suffers a diminution of bulk. In a case which came under 
 my notice, the pivot had been exposed by absoi-ption on one 
 side of the root ; in another a sufficient amount to ensheath 
 the gold pin only remained. Again, if we take the roots of 
 teeth which, after the loss of the crown, have had the pulp- 
 cavity sealed up by secondary dentine, we shall find that 
 either additions of cementum have been made to the surface, 
 or that the surface has been gradually wasted by absorption. 
 In many cases there will be ample evidence to show that the 
 two actions have alternated. Ultimately the waste exceeds 
 the repair, the root is shortened, loses its implantation, the 
 socket disappears, and the tooth, after the lapse f>erhaps of 
 some years, falls out. 
 
 In the place of filling the fangs with gold, cotton-wool 
 saturated with carbolic acid may be used ; the results are, for 
 a time, at all events, very satisfactory, though eventually 
 the carbolic acid seems to disappear, and in some cases the 
 wool becomes saturated with discharge, and then a gumboil 
 is the inevitable result. 
 
 Other methods of treating an exposed pulp than those 
 already described have been proposed, and for a time found 
 favour. ^Ir. Hullihen described an operation which has 
 since received his name. It consists in drilling a small hole 
 through the neck of the tooth into the pulp-cavity. The 
 perforation is made either under the free edge or through
 
 METHODS OF INTRODUCING THE GOLD. 421 
 
 the gum, a short distance above its terminal margin. The 
 cavity produced by caries is then filled permanently, leaving 
 the arti6cial perforation open. But as this operation relates 
 to the treatment of diseased pulp, its further consideration 
 may be ix)stponed. 
 
 Some few years since it was proposed to char the exposed 
 surface of the pulp by electric cautery, with a view of 
 destroying the exposed portion preparatory to the introduc- 
 tion of a plug. In my own practice the advantages derived 
 from this mode of treatment were very questionable, and 
 the operation was therefore abandoned.
 
 ( ^22 ) 
 
 DEXTAL EXOSTOSIS. 
 
 The implanted portions of the teeth, like other parts of the 
 skeleton, are liable to local hyj^ertrophy. In the bones the 
 structnre is uniform throughout their substance, and the new 
 tissue does not materially differ from that to which it is 
 added. The roots of the teeth present this point of differ- 
 ence : they are composed of dentine clothed with an external 
 layer of cementum, a tissue which offers no striking cha- 
 racter by which it can be distinguished from ordinary bone. 
 In exostosis this layer becomes thickened either locally or 
 Fi 179 rn g^^^^^^^^' t^^ dentine in no case participating 
 in the enlargement. The disease may be defined 
 as an addition of tissue, more or less normal 
 in character, but abnormal in amount, to a pre- 
 existing tissue of the same structural character. 
 If, for example, we make a section from a tooth 
 the root of which has been increased in size 
 beyond the natiual dimensions, an unnaturally 
 thick layer of cementum will be found, but it will in many 
 instances be difficult to point out a sharp line of demarca- 
 tion dividing the pre-existing from the recently-added tissue. 
 In respect to the structure of cementum, it scarcely falls 
 within the scope of the present work to enter minutely into 
 its histological characters. For a full description of these 
 the student is referred to Mr. Shelley's paper in the " Trans- 
 actions of the Odontological Society," Q) to works on His- 
 tology, and to the previous publication of the author. But 
 
 (1) An upper bicuspid tooth, •with exostosis of the cementum of the root. 
 
 (2) « On Dental Exostosis." By Herbert Shelley. Esq., M.B. Lond., M.E.C.S. 
 " Iransactions of the Odontological Society of London." 1856-57.
 
 DENTAL EXOSTOSIS. 423 
 
 a little space may be given to the consideration of the more 
 prominent features of the tissue. 
 
 The structural characters depend in a great degree upon 
 the amount of tissue present. When it is limited, to a thin 
 layer, the lacunse are altogether absent, and even canaliculi 
 do not appear until a certain thickness is attained. If a 
 longitudinal section of a front tooth be taken for examina- 
 tion, the cementum near the neck will present a thin layer of 
 transparent tissue, marked with faint indications of granu- 
 larity, accompanied in some cases with an obscure linear 
 appearance, suggestive of the idea that the calcification of 
 parallel fibres had contributed to its production. Proceed- 
 ing in tire direction of the root, the cementum thickens, and 
 is traversed here and there by canaliculi, and still further 
 down lacunse make their appearance, first as a single series, 
 then, with an increased thickness of the cementum, in num- 
 bers ; the number generally depending upon the thickness of 
 the tissue. The canaliculi of neighbouring lacume anas- 
 tomose freely with each other, and establish a network of 
 communication throughout the whole body of the cementum, 
 and occasionally become connected with the terminal branches 
 of the dentinal tubuli. The communication thus established 
 between the two tissues has been doubted. Several prepara- 
 tions, however, in my own possession demonstrate the fact 
 beyond cavil. 
 
 The occurrence of vascular canals (Haversian canals) is to 
 a certain extent exceptional, being dependent upon the pre- 
 sence of a larger amount of cementum than is usually found 
 in perfectly healthy teeth. Their presence is not, however, 
 necessarily an indication of disease ; for when two contiguous 
 roots are wnited by the intervention of cementum, a vascular 
 canal will not uncommonly be found to traverse the medium 
 of union. In bone, the vascular canals are distinguished by 
 one or other of the following characters. They are either 
 surrounded by concentric laminae of osseous tissue, or they 
 are enclosed in tissue which has not a well-pronounced con-
 
 424 A SYSTEM OF DENTAL SURGERY. 
 
 centric arrangement of the laminje. In the former case the 
 lacunc-e partake in the concentric disposition, and direct a 
 large ]X)rtion of their canaliculi towards the Haversian canal : 
 in the latter their arrangement is less definite, and the cana- 
 liculi are directed with less regard to the position of the con- 
 tiguous vascular canal. Iq the one instance the characters 
 indicate the presence of secondary hone, or hone which has 
 heen develojped to supply the place of pre-existing bone 
 removed by absorption ; in the other, the presence of primary 
 bone, or that which has been developed in temporary car- 
 tilage, or upon the surface of an existing bone. It being to 
 bone developed under the latter circumstances that cemen- 
 tum is most closely allied, the process of its formation may 
 be considered with advantage. In young subjects the shafts 
 of long bones are gradually increased in diameter by ad- 
 ditions to the surface. The fiat and other bones are increased 
 in thickness by a similar process, and with the femur or 
 humems, will be found equally convenient for examination 
 and description. If we take either of the latter in a per- 
 fectly fresh state, and make transverse sections, either by 
 cutting small fragments with a sharp knife, or even by 
 grinding, taking care to preserve as much of the periosteum 
 as possible, the following appearance will, by means of the 
 microscope, be recognised. Starting up from the general 
 surface of the bone will be seen a series of processes, disposed 
 at more or less regular intervals, producing ridges and 
 furrows, which, for the most part, follow in the length of 
 the bone. Each process is terminated either by a rounded 
 or a dilated extremity. By the increase of the dilatations 
 of contiguous processes, and their ultimate contact and 
 union, the grooves are converted into canals, which are 
 occupied by portions of the cellular layer of the periosteum, 
 which are undergoing conversion into " medulla,'' and are 
 ultimately permeated b}' blood-vessels. The new bone has, 
 in fact, been moulded around the portions of the periosteum 
 — a process by tlie repetition of which the shaft of the bone
 
 DENTAL EXOSTOSIS. 
 
 425 
 
 may be thickened to an indefinite extent. In bone produced 
 under the foregoing circumstances, the indications of lamina- 
 tion are generally indistinct, and when present, follow the 
 general surface of the bone. The arrangement of the lacunas 
 is subservient to that of the lamina3, consequently in the 
 primary bone the absence of the concentric order in the 
 latter is accompanied by a similar deviation on the part of 
 lacuna? and canaliculi. 
 
 It is to this description of primary bone that the cementum 
 of the teeth is most closely allied, and fiom that it is diffi- 
 cult to point out any distinguishing structural character. 
 This close resemblance in the two tissues, when developed, 
 renders it desirable that some account should be given of the 
 manner in which the former is developed. 
 
 Close to the surface of the bone lie peculiar granular cells, 
 much larger than those outside them, to which the name of 
 " osteal cells " was formerly given, whilst German writers 
 speak of them as " osteoblasts.' ' 
 
 These " osteoblasts " make their appearance wherever 
 bone is being developed, whether in cartilage, in membrane, 
 or in periosteum ; in point of fact, it is held by Kollet (^) 
 that the development of bone differs in no respect in these 
 dissimilar situations, so that the cartilage may be regarded 
 as little else than a convenient support to the developing 
 bone. 
 
 Ko bone is in any case formed till after the appearance of 
 this " osteoblast " tissue ; and EoUet believes that the osteo- 
 blast cells are not modified cartilage cells, nor cells derived 
 from these latter by a process of proliferation, but that they 
 are essentially a new growth. At all events, the layer of 
 osteoblast cells does not gradate into the structures outside 
 it, but is so distinctly marked off that it almost assumes the 
 character of an epithelium. 
 
 If we harden a tooth in chromic acid, and subsequently 
 
 (1) A. RoUet. Art. " On the Connective Tissues." Strieker's " Handbook 
 of Human and Comparative Histology."
 
 426 A SYSTEM OF DENTAL SURGERY. 
 
 decalcify and cut it transversely through the fang, we meet 
 with the following structures from without inwards. On 
 the outside is the outer part of the periosteum, consisting of 
 decussating fasciculi of connective tissue ; internal to this is 
 a layer to which the name of "cambium" has been some- 
 times given, consisting of roundish cells with processes. 
 These lie in a reticulum made up of cells whicH give out 
 a small number of homogeneous transparent processes ; by 
 the inosculation of these processes a network is formed, 
 which has been well figured by Dr. Lionel Beale. (}) 
 
 Between the reticulum and the fully-formed cementum 
 lies the osteoblast layer, consisting of much larger cells, 
 which are often provided with fine processes. The trans- 
 parent homogeneous processes already spoken of as forming 
 the reticulum may be seen in many places passing in through 
 the osteoblast layer, and may be traced passing without 
 interruption into the matrix of the cementum. As the 
 osteoblasts form a continuous layer, and are very numerous, 
 it is obvious that only a small percentage of them ever 
 form lacunae, or otherwise retain their individuality. As the 
 process of calcification goes on the outlines of individual 
 cells and of the trabecula? of the reticulum become lost in 
 the general transparency of the matrix, only a cell here and 
 there remaining as a lacuna. 
 
 The explanation of the formation of bone lacunae from the 
 osteoblasts given by Henle and Dr. Lionel Beale, which has 
 been substantially accepted by Waldeyer and Rollet, seems 
 to accord best with the appearances observed. 
 
 The deposition of calcareous matter, and that change 
 which immediately precedes it (so as to produce the " formed 
 material" of Beale), takes place from without inwards. 
 Thus we might picture to ourselves each calcifying osteo- 
 blast as enclosed by hard structure, like an egg-shell, con- 
 tinuous deposition taking place on the inside till the central 
 cavity was obliterated. At the same time, the contiguous 
 Q) " On the Structure of the Simple Tissues."
 
 DENTAL EXOSTOSIS. 427 
 
 osteoblasts become fused together by their exteriors, so that 
 their individuality is absolutely lost. In a certain number, 
 however, this entire obliteration of the central cavity does 
 not take place ; but the calcification advancing with some 
 degree of irregularity towards the centre, leaves tracks of 
 uncalcified matrix, and, finally, stops short of obliterating 
 the central cavity. Thus the centre of the osteoblast comes 
 to be occupied by a space from which fissures radiate ; in fact, 
 a " lacuna." Although for the purpose of description this 
 central portion has been described as a " space," it must not 
 be forgotten, that in the first instance it is not hollow, but 
 is perfectly filled by the uncalcified matrix, and that in it 
 originally lay the nucleus of the osteoblast (germinal matter 
 of Beale). Thus, by staining with carmine the nucleus may 
 often be defined in a developing tooth of a calf, lying in the 
 stellate "lacuna," but the nucleus soon disappears; and in 
 the dry state the lacuna is really a space, as its contents dry 
 and shrivel up. 
 
 And just as calcification may fail to obliterate the centres 
 of all the osteoblasts, so it may fail to obliterate their ex- 
 ternal contours ; when these are visible around lacunae, we 
 have the so-called " cncapsuled lacun;*?," or nests of osteo- 
 blasts. 
 
 The various views which have been entertained regarding the fonnation of 
 the lacunar and canalicull have been concisely stated by Dr. Sharpey, op. cit., 
 p. 158. He observes, that "theyaie generally supposed to be derived from 
 the shells of the soft tissue involved in the ossification by some sort of meta- 
 morphosis which has been variously conceived. Some suppose that the cells 
 become the lacuna, and send out branches (like the pigment cells) to form the 
 canaliculi (Schwann i). Others think that it is not the cell but its nucleus 
 that undergoes this change, and that the substance of the nucleus is afterwards 
 absorbed, leaving the lacuna (Todd and Bowman 2)." The nucleus described 
 by Todd and Bowman is identical with that which has been called the granular 
 cell, and from which the authors held the lacuna to be formed. " Henle (a) 
 thinks that the lacuna is a cavity left in the centre of a cell which has been 
 partially filled up by calcification, and that the canaliculi are branched 
 passages, also left in consequence of the unequal deposition of the hard matter, 
 
 (1) " Mikroscopische Untersuchungen." (2) "Physiological Anatomy.' 
 
 (3) " Anatomic Generale."
 
 428 A SYSTEM OF DENTAL SURGERY. 
 
 as in the instance of the pore cells of plants." " It rather appears to me as if 
 the lacunje and canaliculi were little varieties left in the tissue during the 
 deposition of the reticular fibres, as open figures are left out in the weaving of 
 some artificial fabrics (but not w ithin a cell, as Henle imagined), and that thus 
 the apposition of the minute apertures existing between the reticulations of 
 the lamella; gives rise to the canaliculi." " At the same time it seems not 
 unlikely that a cell or a cell nucleus may originally lie in the lacuna or central 
 cavity, and may perhaps determine the place of lis formation." Hassall(i) 
 agrees with Schwann, while Gerber(2) and Bruns(2) appear to hold the views 
 ot Todd and Howman. With the exception o! Dr. Sharpey, the above-named 
 authorities may perhaps differ more in the use of terms than in matter of fact. 
 The appearances would at first view seem to justify the opinion expressed by 
 Dr. Sharpey ; but a careful examination of the tissue during iis development, 
 the unquestionable fact that in the development from cartilage the granular 
 cell becomes converted into a lacuna, together with the circumstance that 
 lacunal cells are frequently found in the Haversian canals and cancellated 
 structure, especially in the bones of old subjects, and at times imbedded in the 
 structure of the bone, have left no room for doubt in the authors' minds that 
 the lacume are formed from special nucleated cells, in the mimner described in 
 the text. 
 
 Further details of the appearances observed in ossification 
 may be found in the ibllovving extract from a paper in the 
 Pioyal Society's Transactions (^) ; the osteal cells there spoken 
 of are equivalent to the osteoblasts of later writers, while 
 the differentiation between osteal and " lacunal " cells exists 
 only in so far as they are the same elements in a different 
 stage of calcification (see page 427). 
 
 " If the advancing edge of a parietal bone be taken either from a human 
 foetus or a foetal Iamb, and the pericranium and dura mater be carefully 
 removed from their respective surfaces, we shall find the growing bone still 
 invested with solt tissue both on the outer and inner surface, which is pro- 
 longed from the free edge. When examined under a favourable light this 
 tissue will show differences of character in different pait<, varying with the 
 distance from the bone at which the observations are made. Thus, if attention 
 be directed to the part farthest removed from the bone, it will be seen that the 
 membrane like mass is composed of oval cells with slight prolongations from 
 the extremities, which are frequently arranged in the form of bands of fibrous 
 tissue. Dr. Sharpey has observed that the membrane into which the bone 
 extends is like fibrous tissue in an early stage of development, and this obser- 
 
 (1) " Microscopic Anatomy of the Human Body," p. 310. 
 
 (2) " Allgemeine Anatomie." 
 
 (3) " Observations on the Structure and Development of Bone." By John 
 Tomes, F.R.S., Surgeon-Dentist to the Middlesex Hospital; and Campbell 
 De Moigan, Surgeon to the Middlesex Hospital.
 
 DENTAL EXOSTOSIS. 429 
 
 vation is strictly true when confined to the part indicated, but the analogy 
 ceases as we extend our examination towards the bone. Here in the place of 
 cells with elongated processes, or Cflls arrang:ed in fibre-like lines, we find 
 cells aggregatfd into a mass, and so closely packed as to leave little room for 
 intermediate tissue. The cells app-ar to have increased in size at the cost of 
 the processes which existed at an earlier stage of development, and formed a 
 bond of union between them. Everywhere about growing bone a careful 
 examination will reveal cells attached to its surface, while the surface of the 
 boue itself will present a series of similar bodj^s ossiQetl. To these we propose 
 to give the name of osteal cells, as distinguished from laiunal and other cells. 
 
 " In microscopic characters the osteal cells closely resemble the granular 
 cells of temporary cartilage; so closely, indeed, that the latter, when detached 
 from the cartilage, could not well be distinguished from them. They are for 
 the most part spherical or oval in form, and lie on the surface of the growing 
 bone in a crowded mas>, held together by an intervening and apparently 
 structureless matrix. Here and there we find a cell which has accumulated 
 about itself an outer investment of transparent tissue, and has, in facr, ))ecome 
 developed into a lacunal cell destined lo b:^come a lacuna. 
 
 " The process of growth may be thus described. Jn the meshes of the fibrous 
 tissue on the surface of the bone, osteal cells are developed and gradually take 
 its place ; a few cells become developed into lacunal cells; the earthy salts are 
 added, and amcurrently lacunas and canaliculi are formed ; we t' en have bone 
 presenting the usual characters of that tissue. In bone developed in the fore- 
 going manner, we find the canaliculi not merely extending to the surface of the 
 cell-wall, or anastomosing with the canaliculi of lacunal cells lying in contact 
 with if, but extending freely in all directions, and passing through or amongst 
 the ossified cells, and establishing rich plexuses of anastomosis. Indeed, we see 
 the boundary of the original lacunal cells only in those cases where the lacunae 
 have but few, or are entirely devoid of canaliculi. It would appear to be a law, 
 to which there are few. If any, exceptions, that when anastomosis is established 
 between adjoining lacunfe, the lacunal cells blend with the contiguous parts, 
 and are no longer recognisable as distinct bodies. The process by which the 
 cylindrical bones are increased in diameter is in all essential points similar to 
 that described as pertaining to the growth of flat bones. Similar osteal and 
 lacunal oils are present, but the relative amount of the matrix is greater; 
 moreover, the osteal cells have a disposition to assume a linear arrangement 
 corresponding to the direction of the laminse of the contiguous bone. In these 
 lines the cells are placed so close to each other as to leave but little room for 
 intervening tissue, but b.-tweeu the lines an ai^preciable amount may be 
 recognised. This appearance, however, varies in diffi-rent specimens. In one 
 the cells predominate, in another the transparent tissue is the more abundant. 
 Geneially the younger the animal the greater will be the amount of the inter- 
 vening transparent tissue, and the smaller the number of the osteal cells. But 
 in all cases, whatever the age of the subject, or from whatever part of the 
 skeleton the specimen be taken, the cells and the intermediate tissue become 
 blended in the process of ossification, and the whole presents a uniform 
 granular appearance, excepting in the instances in which lamination is strongly 
 developed, or in those which have been noticed in the previous part of the 
 paper. We frequently find portions of bone where the osteal cells, lacunal
 
 430 A SYSTEM OF DENTAL SURGERY. 
 
 cells, aud intermediate tissue are so perfectly fused together that neither can he 
 recognised, but in their place we have a minutely granular mass, divisible only 
 into lacuna and canaliculi and the tissue in which they lie imbedded." 
 
 The foregoing description of the formation of bone or 
 cement, may, with but little modification, be applied to the 
 development of an exostosis. Mr. Shelley's Q) paper being 
 the only one with whidi I am acquainted that gives the 
 microscopic appearances associated with exostosis, may be 
 here quoted. 
 
 " Upon examining the periosteum of a stump or tooth 
 recently drawn, which has been the subject of long-continued 
 irritation, we find it much more vascular than usual ; in 
 some places it is very much thickened and slimy, and very 
 frequently adhering to it are reddish fleshy shreds or masses, 
 which have been called coagulated lymph. These are some- 
 times of comparatively large bulk, especially where this has 
 been the subject of recent inflammation ; and it not only 
 follows that the tooth must be elevated in its socket, but 
 that even the latter must be itself excavated to accommo- 
 date the morbid growth. And in order to assist our con- 
 ception of this fact, I may here remark upon the extraor- 
 dinary facility with which the jaw-bones change their shape. 
 An alveolar abscess hollows them out, and drills a hole 
 through them in a few days ; or two or three double teeth 
 are extracted, and in a few months not a vestige of their 
 former implantation is visible, and they will slowly expand 
 before a tumour, covering it with a thin papery envelope, 
 rapidly to collapse again after its removal into a firm bony 
 ridge. 
 
 " Let us now investigate more closely a mass of this so- 
 called coagulated lyniph. It is soft, almost diffluent, on the 
 surface ; in the middle it is somewhat denser, and at its 
 union with the fang, which is extremely firm, it is of a 
 gristly cartilaginous texture. The smaller and whiter shreds 
 
 (1) " Transactions of the Odonto'ogical Society," vol. i.
 
 DENTAL EXOSTOSIS. 431 
 
 on the periosteum also partake of the latter character, being 
 tough and less vascular. 
 
 " Examined by the microscope, the external soft surface is 
 seen to be principally composed of large corpuscles, granular 
 and nucleated, and which in water swell up and burst after 
 a time. The more diffluent parts are entirely composed of 
 these spherical bodies, which agree in character with those 
 corpuscles usually met with in parts recently inflamed, and 
 termed by some exudation corpuscles. In addition to these, 
 small masses of granular blastema are also visible. 
 
 " The principal constituent of the next undermost portion 
 is seen to be fibrous tissue in a state of formation. For 
 here may be seen (and in some instances it is most admirably 
 shown) oval corpuscles with fibrous prolongations, some 
 with a short fibre at one end, others lengthened out at both 
 ends, and putting on the characteristic undulation. The 
 corpuscles are light, and generally bi-nucleated, whilst the 
 fibrous extensions are slightly more opaque. 
 
 " Still nearer the fang we find the mass tougher, and com- 
 posed of fibrous tissue, but mingled with it amorphous 
 granules of a gelatinous appearance, and in the meshes, and 
 floating about the margins of the mass, are a number of 
 oval cells. 
 
 "At its junction with the fang the substance becomes 
 dense; it is torn with difficulty, and under pressure slips 
 about between the two glasses, and refuses to be flattened 
 out. Under the microscope it appears as a solid, amorphous, 
 yellowish mass, in which, however, maybe still distinguished 
 the wavy appearance of the fibrous tissue. 
 
 " In this dense gelatinous substance, osseous matter, which 
 has been detached from the fang along with it, may be seen ; 
 not, however, shooting out into it in the form of spicula3-like 
 ossification in the fibrous matrix of the bones of the skull, 
 but as rounded amorphous molecules. 
 
 " A more careful examination of the cells found floating 
 freely in the field of the microscope around the margins of
 
 432 A SYSTEM OF DENTAL SURGERY. 
 
 preparations made from the two last-described modifications 
 of the so-called coagulable lymph, and which may also be 
 distinguished imbedded in the masses themselves, shows 
 them to be, from their shape and size, identically the same 
 cells, but with different contents, and these contents singu- 
 larly agree with different modifications of tissue above de- 
 scribed. For instance, cells may be seen particularly abun- 
 dant in the middle of the ' coagulable lymph,' of an oval or 
 elliptical shape, transparent, homogeneous, and furnished 
 usually with two nuclei. Then they may l^e seen with faintly 
 granular contents and larger nuclei; and lastly, their interior 
 seems stuffed with a more opaque and denser substance, dis- 
 posed in large granules, among which the nuclei cannot 
 positively be pointed out. 
 
 " When a fang to which these masses of so-called coagu- 
 lated lymph has been allowed to dry, or, still better, if a 
 section be made, it is at once evident that the spots to which 
 they were attached are the seat of a preternatural deposit of 
 cementum ; and a thin transparent slice submitted to micro- 
 scopic examination shows the extra-cemental deposit as I 
 have above described it, and also the fibrous matrix still 
 adherent to its margin, in spite of the rough usage to which 
 it has been subjected in preparing the section." 
 
 On comparing the statements made by Mr. Shelley with 
 those contained in the previous extract, it will be seen that 
 there are no essential points of difference recognised in the 
 mode of formation of bone and cementum. In each case cells 
 are produced, the individuality of which becomes lost in the 
 process of calcification, together with the fibrous matrix. 
 
 In the soft tissue which connects the root of a tooth with 
 the walls of the socket, Mr. Spence Bate considers that two 
 distinct structures may be traced — the peridenteum of the 
 tooth and the periosteum of the bone. The former he regards 
 as a dermal tissue, the latter as belonging to the internal or 
 osseous system, and states that " however closely in juxta- 
 position the two may approximate, they still hold their
 
 DENTAL EXOSTOSIS. 433 
 
 relative connection widely apart." (^) The cementum he 
 regards as a production of the inner surface of the peri- 
 denteum, and as in no way connected with or dependent 
 upon the periosteum of the socket, the two membranes being 
 incapable of ossific union ; a statement which he considers is 
 justified by the fact that the root of a tooth, although the 
 subject of exostosis, never becomes anchylosed to the jaw. 
 Had periosteum alone intervened between the tooth and the 
 socket, an osseous union would, it is assumed, have occa- 
 sionally taken place. 
 
 By the " peridenteum," Mr. Spence Bate appears to mean 
 Nasmyth's membrane (cuticula dentis) on the crown, and 
 the external layer of cement on the roots, which, as I have 
 elsewhere shown (^), are continuous with one another, and 
 are to be regarded as incomplete cementum. It is perfectly 
 impossible that the " peridenteiim " can build up fresh 
 cementum, as it has itself undergone that metamorphosis 
 which Dr. Lionel Beale describes as change into " formed 
 material," and the period of its activity is passed ; it'is only, 
 so to speak, waiting for the fuller deposition of calcareous 
 salts to itself become perfected cementum. , 
 
 If we except this youngest layer of cementum, which is 
 neither vascular nor soft, there is notliing like a differen- 
 tiation into soft' tissues belonging to the tooth and others 
 belonging to the socket. Hence some other explanation 
 must be sought for the fact that anchylosis, which is the 
 normal condition in most reptiles, does not take place in the 
 human subject ; indeed, the mere fact that it takes place in 
 reptiles who do possess what Mr. Spence Bate calls a " peri- 
 denteum," is a sufficient answer to this hypothesis. 
 
 It may be remembered that bone or cementum is not 
 developed by a direct metamorphosis of the periosteum, but 
 by the calcification of a new growth. Now, the various stages 
 
 (1) " On the Peridental Membrane in its relation to the Dental Tissue." 
 By C. SpeDce Bate, Esq. — " British Journal of Dental Science," vol. i. 
 
 (2) Quarterly Journal of Microscopic Science. 1872.
 
 434 A SYSTEM OF DENTAL SURGERY. 
 
 of this new development are to be seen on the inner, or tooth- 
 surface of the periosteum of the socket, and not on its outer 
 or bone surface ; and this may in a measure serve to explain 
 why bony union does not take place. 
 
 When a di sease consists in the mere increase of a tissue, 
 the presence and position of which are normal, the transition 
 from health to disease is imperceptible, and is usually desti- 
 tute of symptoms. It is only when the amount of new tissue 
 has"attained a considerable thickness, that distinct symptoms 
 are developed, and even then they are in many cases absent. 
 In dental exostosis, a distinction must Tdc drawn between 
 those cases in which the disease is consequent upon pre- 
 existing disease in the tooth, followed by marked irritation 
 of the alveolar membrane, and those in which it is developed 
 independently of any other disease. 
 FiQ 180 O When the disease arises in connection \Ndth 
 
 caries, it is attended by a thickening of the 
 gums, which assume a deep dull colour, and a 
 disposition to bleed when subject to friction 
 either from the tooth-brush or food. But 
 when the crown of a tooth is free from disease, 
 exostosis of the root may be unattended with 
 any recognisable change in the condition of 
 the contiguous gum. The occurre nce o f sym- 
 pathetic pains in the head, face, or neck, may be, and often 
 is, the only indication of disease. In the presence of such 
 pains it is often extremely difficult to determine whether 
 the teeth are in fault, and if so, which tooth or teeth have 
 occasioned the suffering. Sooner or later local symptoms 
 may arise by which the offender can be recognised. The 
 tooth will become tender on pressure, or sensitive to the 
 effect of hot or cold fluids, or the gum may become absorbed, 
 and leave exposed the neck of the tooth, which eventually 
 becomes loose. Such obvious symptoms, however, commonly 
 
 (I) A molar tooth of the upper jaw, the roots of which are thickened by the 
 addition of cementum, the crown being free from disease.
 
 DENTAL EXOSTOSIS. 435 
 
 appear only after the patient has undergone great suffering 
 from supposed idiopathic tic -douloureux, a complaint for 
 the relief of which patients have submitted to have tooth 
 after tooth extracted, although the relief afforded after each 
 operation was but questionable. 
 
 There are cases, however, in which the presence of exos- 
 tosis, even of slight amount, produces great misery : a certain 
 tooth is" pointed to by the patient as the cause. Its removal 
 brings relief. The complaint returns, another tooth is fixed 
 upon, and removed with a similar result. Another and 
 another follow; and it is only after all the teeth in the upper 
 or Tower jaw have been removed that the patient gains per- 
 manent immunity from pain. A case which followed this 
 course came under my treatment six years ago, and it is 
 scarcely eighteen months since the last tooth was removed. 
 The crowns of the teeth were sound, but the roots had be- 
 come slightly enlarged by exostosis. The patient, when she 
 first consulted me, statec^ that she had suffered from tic- 
 douloureux for several years, and had submitted to the usual 
 treatment without advantage. Two teeth had been extracted, 
 and the operation was followed by a remission of the symp- 
 toms. The pain, however, soon returned with full severity, 
 and at the time she came under my charge two upper bicus- 
 pid teeth were regarded as being connected with the pro- 
 duction of the disease. She stated that the pain came on 
 gradually at irregular intervals, lasting sometimes for twelve 
 or fourteen hours, or until, exhausted by suffering or nar- 
 cotized by opium, she fell asleep. The suspected teeth 
 appeared quite healthy, but the patient stated, that though 
 they did not ache, yet that they were seldom free from an 
 uneasy sensation. She always felt that they were there, aisd 
 prior to an attack of facial pain they became hot and felt 
 full. Leeches w'ere applied to the gums, and internal 
 remedies administered, but without producing any mitigation 
 of the symptoms. After a time the teeth became sensitive 
 to the effects of changes of temperature, and a current of cold
 
 436 A STSTKM OF DENTAL SURGERY. 
 
 water or air not only produced pain in the two teeth, but also 
 brought on an attack of pain in the face. The teeth were 
 extracted, and for several months the patient was com- 
 paratively free from pain. Other teeth became similarly 
 affected, and were removed with similar results ; but it was 
 only after the whole of the teeth of the upper jaw had been 
 extracted that the patient became perfectly free from the 
 recurrence of the disease. In another case the patient had 
 suffered for several years from intermittent pain in the head 
 and face. For a long time the cause of the disease appeared 
 to have a constitutional rather than a local cause, but the 
 usual remedies failed to afford relief. After a time a feeling 
 of uneasiness attracted attention to the only remaining molar 
 tooth, the second molar of the upper jaw, situated on the 
 side in which the pain was felt. On removal the crown was 
 found to be sound, but the roots of the tooth were enlarged. 
 In this, as in the preceding case, the liability to pain in the 
 face ceased after the operation. 
 
 In the two cases cited the relief was complete, although by 
 no means instantaneous. The pain became gradually less 
 severe, and the attacks less frequent, and shortly ceased to 
 recur. 
 
 It may be stated generally, thaj, the_ removal of a tooth 
 which has been the cause of svm_patlietic^_22:in, usually 
 produc^s'a severe attack, the paroxysm bearing some rela-"^ 
 tron in its duration and in intensity to1:lie previous attacks', 
 and to the length of tiniedurifig which' the disease hJtS*" 
 existed. -•''-.-- - • -- - 
 
 "J'he sympa thetic affection jsay, .however, Jn a few_ rare 
 examples, extend to a derangement of the whole nervous 
 system. Two cases have occurred under my own observa- 
 tion, in which epilepsy was consequent upon diseased teeth, 
 Ihe most prominent feature being exostosis of the roots, 
 which will be described at a future paire. 
 
 The abnormal growth of the cementum is, as compared to 
 exostosis of bones, confined within very narrow limits. The
 
 DENTAL EXOSTOSIS. 
 
 437 
 
 Fig. 181. (1) 
 
 size of the root of a tooth may be doubled, and two con- 
 tiguous teeth may become united by the development of 
 cementum about their roots, but we never see a great mass 
 of new tissue produced. 
 
 I am indebted to my friend Mr. Spence Bate for the fol- 
 lowing illustration, and for the 
 loan of the specimen from which 
 it was taken. The amount of 
 hypertrophy is here very con- 
 siderable, and has not only con- 
 nected the two roots of the tooth, 
 but also the remaining stump of 
 a contiguous tooth, the crown of 
 which had been previously lost. 
 
 Through the kindness of Mr. 
 Martin, of Portsmouth, I am 
 enabled to add an example in which the second and third 
 upper molars are united by the abnormal development of 
 cementum. 
 
 Although numerous instances may be found where two 
 teeth have become united by cementum 
 developed under circumstances which 
 constitute its formation a disease, yet 
 in no well-authenticated insta nce has 
 Stie cementum become continuous with 
 "the bone of the socket. In reptiles the 
 aricEyTosTs"©? tEtT teeth to the jaw is a 
 normal character, but in the human 
 subject a case is yet wanting to show 
 that -anchylosis between the teeth and 
 the jaw is under any circumstances possible. In two tissues 
 so similar to each other in structure that their distinction is 
 
 (1) Showing exostosis in a lower molar tooth, uniting the two roots and the 
 stump of a contiguous tooth. From a specimen in the collection of Mr. Spence 
 Bate. 
 
 (2) Showing the socond and third molar teeth of the upper jaw united by the 
 abnormal development of cementum. I am indebted to Mr. Martin for the use 
 of this specimen. 
 
 \ 
 
 Fig. 182. (2)
 
 438 A SYSTEM OF DES'TAL SUKGERY. 
 
 often attended with difficulty, we should be able to point out 
 why their separation in the presence of disease is always 
 preserved when contiguous bones placed under similar cir- 
 cumstances become so readily united. 
 
 If we examine a case of local disease in a bone — a phalanx, 
 •for example, in which the vitality is at one point lost — we 
 shall find an opening through the integimients from which 
 pus is discharged ; extending from this point, the skin and 
 periosteum will be inflamed to a certain distance, the diseased 
 gradually merging into the healthy tissues. If an oppor- 
 tunity of a careful examination be aflbrded, it will be found 
 that where the dead joins the living bone, the latter is under- 
 going absorption, and that beyond this point new osseous 
 tissue is becoming developed upon the surface of the pre- 
 existing bone, the latter part corresponding to the junction 
 of the healthy and the diseased soft tissues, and the former 
 to the part where the skin exhibited all the indication of 
 chronic inflammation. In a tooth the periosteal investment 
 of which has become inflamed, conditions in many respects 
 similar to those which take place in bone may be observed- 
 Thus the end of the tooth will be denuded of periosteum, and 
 in some cases diminished in bulk by absorption. Higher up 
 the membrane will be adherent and thickened, and beneath 
 this the cementum also will be increased by recent additions 
 of new tissue. In order to allow of the increased bulk, the 
 alveolus is necessarily enlarged. Still, the interval which 
 separates the wall of the socket from the contained root is 
 small, and might readily become the seat of bone uniting the 
 tooth to the jaw, but for the existence of some cause which 
 prevents the union of the tooth to the jaw while it allo\vs 
 two bones, when similarly placed, to become connected by 
 ossification. 
 
 It is not unusual to see microscopic evidence of an alter- 
 nation of absorption and deposition of cementum, and this is 
 especially apt to be found where a stump has for a long time 
 been a source of slight irritation. 
 
 The absorption which takes place later may go so far as to
 
 DENTAL EXOSTOSIS. 
 
 439 
 
 eat into the dentine, after removing the whole thickness of 
 the cement; examjDles^ fi£_absortion and subsequent depo- 
 sition of osseous material in tHe cavities so 
 formed have lately been described by Mr. ^3- ^^"^- ^') 
 Henry (^) under the name of Inostosis. The 
 absorption is effected by the agency of poly- 
 nucleated cells, which are derived from the 
 osteoblasts or formative bone cells. Whether 
 they themselves become calcified, or in turn give 
 place to fresh osteoblasts, has not, so far as I 
 know, been determined by actual observation ; 
 but, seeing that calcified cartilage matrix is drilled with the 
 utmost rapidity by the advance through it of the osteo- 
 genous tissue, it seems most probable that the same osteo- 
 blast cells are capable of efi'ecting the absorption and subse- 
 quently becoming calcified. 
 
 (1) Lower molar, the fang of which has been aflfacted by exostosis, and also 
 by absorption. 
 
 (2) " Transactions of the Odontological Society," December, 1871, and April, 
 1872.
 
 ( ^-10 ) 
 
 XECEOSIS OF THE TEETH. 
 
 When' a part or the whole of a tooth has lost its vitality, 
 the condition is expressed by the term necrosis. The disease 
 involves the death, but not necessarily the decomposition, of 
 the dead part, the tissues of which become discoloured, but 
 are seldom softened. 
 
 The term is no doubt associated in the minds of many 
 practitioners with that state which is attended with dis- 
 coloration of the whole of the crown of the affected tooth. 
 But the discoloration of a dead t<x)th is, strictly speaking, 
 an accidental and by no means necessary coincidence. It 
 depends, in the first place, upon the pulp losing its vitality 
 when its vessels are filled with blood, and upon the ultimate 
 decomposition of the blood-globules, and the solution of the 
 colouring matter in the fluids present. These permeate the 
 dentine, and impart to it a permanent stain, tlie discovery of 
 which is looked upon as an infallible indication that the 
 tooth is dead. The loss of the normal colour is obviously a 
 mere consequence of the death of the pulp under certain cir- 
 cumstances, and a consequence which takes some time to 
 develop. 
 
 The depth of the stain will also be varied, the variation 
 depending upon the age of the patient. The younger the 
 subject, the larger and more vascular will be the pulp, and 
 the deeiDer the stain produced by its decomposition. In old 
 l^eople, on the contrary, the pulp is relatively small, and the 
 discoloration of the tooth consequent upon its death is but 
 slight, and may, in fact, be altogether wanting. The dis-
 
 NECROSIS OF THE TEETH, 441 
 
 coloration may in some cases be removed by treatment with 
 bleaching agents, after the pulp-cavity and canal have been 
 thoroughly washed out. 
 
 Chloride of lime, chloride of soda, chlorinated soda 
 (Labarraque's fluid), and oxalic acid, have all been recom- 
 mended for this purpose. Whatever agent is used, the canal 
 should be closed at the apex by a pledget of cotton, the 
 bleaching material introduced on wool, and sealed up in 
 the cavity for thirty minutes or an hour, and after a suf- 
 ficient effect has been produced, thoroughly washed out 
 again. 
 
 A perfectly dead tooth is soon thrown off by nature as an 
 extraneous body, its expulsion being attended with more 
 or less local inflammation of the surrounding soft parts. 
 The amount will to a considerable extent depend upon 
 the relations of the several parts involved at the time the 
 death of the tooth takes place, and upon the cause which 
 produced it. 
 
 If, for instance, the alveolus and the gums have receded, 
 the inflammation excited by the dead tooth will not be great, 
 unless the death of the tooth has been consequent upon in- 
 flammation of the pulp and of the dental periosteum. Even 
 then the symptoms will be less severe than they would have 
 been had the alveolus and gum risen to the usual level. But 
 we see many discoloured teeth which have remained for years 
 firmly implanted in the jaw, and their presence has been' 
 unattended with serious inconvenience, yet they may be 
 described correctly as necrosed teeth. In such cases the 
 disease has not, however, involved the whole of the tooth ; 
 some part has retained its vitality, through which the con- 
 nection with the soft tissue has been maintained, and conse- 
 quently the tooth has been enabled to hold its place. The 
 circumstance that a tooth, the crown of which presents all 
 the external characters peculiar to a dead tooth, retains its 
 position, and in certain cases fails to produce considerable 
 local disturbance in the jaw, while in other instances great
 
 442 A SYSTEM OP DENTAL SURGERY. 
 
 irritation is set up, indicates that tlie disease is subject to im- 
 portant modifications, which at first sight are not very appa- 
 rent. On investigating a series of cases, it will, however, be 
 found that the modifications which they present are conse- 
 quent upon the extent to which the tooth has become in- 
 volved, rather than to any special difi"erence in the disease. 
 Thus the dentine may lose its vitality in consequence of the 
 pulp having been destroyed, and the tooth assume the 
 peculiar brownish red colour which arises from the decom- 
 position and difi'usion of the blood contained in the pulp 
 through the dentine, and yet the cementum may retain its 
 (X)nnection with the periosteum. This connection affords the 
 means by which the tooth may retain its place for an in- 
 definite period. Examples are often seen in which the 
 pulp has been suddenly destroyed by a blow received many 
 years previously, and the injury has been followed by dis- 
 coloration of the crown of the tooth. The patient will state 
 that the tooth is dead, but this is not strictly correct ; the 
 death has been limited to the dentine : the cementum has 
 retained its vitality, although its normal state may not be 
 perfectly preserved. 
 
 Again, in pivoting a tooth we reduce the root to a similar 
 condition. The vitality of the dentine is sacrificed when 
 the pulp is destroyed, but if the operation is attended with 
 success, the life of the cementum will be maintained. 
 
 The time during which a tooth so circumstanced will 
 retain its position without undergoing further change, is not 
 unlimited. I believe that the cementum becomes the seat 
 of an increased, if not a morbid action, so soon as the vitality 
 of the dentine is lost. In some cases great additions are 
 made to its surface, and through the new tissue the con- 
 nection with the periosteum is preserved. In others, again, 
 absorption is set up, and the root becomes reduced in bulk, 
 is gradually detached from the periosteum, loosens, and falls 
 out. In the former case the living portion of the tooth 
 appears to be very limited in amount, its extent being often
 
 NECKOSIS OF THE TEETH. 443 
 
 confined to the newly-added tissue ; for the appearance pre- 
 sented by some specimens would justify the conclusion that 
 the cementum which existed at the time the dentine lost its 
 connection with the soft parts, though not deprived of life 
 concurrently with the dentine, yet subsequently lost its 
 vitality ; but not, however, before new cementum had been 
 added upon the surface of the older tissue in parts. 
 
 If we remove a tooth which has been the subject of the 
 foregoing changes, and allow it to become dry, those portions 
 of cementum which are of comparatively recent formation, 
 will present the opaque white aspect of healthy bone ; while 
 the other parts of the tooth, including the older cementum, 
 exhibit more or less discoloration. iSovv,,it is possible that 
 the whole of the tooth became necrosed at the same time, but 
 it is more probable that the death of the cementum was 
 subsequent to the death of the dentine, and also to the 
 development of a new layer of cementum. Otherwise it 
 must be admitted that the living tissue was developed 
 upon, and united to, and continuous with, the dead 
 structure. 
 
 Necrosis may, however, be confined in the first instance to 
 the cementum, the dentine and dentinal pulp retaining their 
 normal relations. In cases which present this character the 
 tooth becomes loose, and the gum usually, although not 
 necessarily, recedes. The surface of the cementum is de- 
 tached from the periosteum, excepting perhaps at and about 
 the extremity of the root where the nerves and blood-vessels 
 pass into the pulp-cavity. 
 
 The patient complains of intermittent pain in the tooth, 
 excitable at any time by the application of hot or cold 
 water ; very commonly pus will escape from between the 
 tooth and the gum when the latter is pressed. The crown 
 of the tooth does not assume the dark slate colour which 
 follows after the death of the pulp. In this form of the 
 disease additions are not made to the cementum, unless in 
 small and isolated spots. Generally the cementum is greatly
 
 444 A SYSTEM OF DENTAL SURGERY. 
 
 reduced by absorption, and even the dentine in many cases 
 suffers also. 
 
 I remember a case in which seven front teeth lost their 
 attachment to the socket, excepting where the nerves and 
 blood-vessels entered the root, without the vitality of the 
 pulp having been sacrificed or the gums absorbed. 
 
 There is yet another form of partial necrosis. One root of 
 the double-rooted teeth, or one or two of the treble-rooted 
 teeth, may become dead and perfectly detached from the 
 lining membrane of the alveolus, while the remaining root 
 or roots preserve their vitality. Teeth when in this con- 
 dition are apt to be at times very troublesome. When they 
 are used in mastication pain is experienced from the dead 
 root being pressed into the socket, the lining membrane of 
 which is injured by the rough surface usually presented by 
 the dead root. The continued irritation arising from this 
 cause is productive of thickening of the alveolar covering, 
 accompanied by the development of a high degree of sen- 
 sitiveness in the hypertrophied parts, the susceptibility to 
 pain in which is consequently increased. Hot or cold fluids 
 taken into the mouth also excite pain in the tooth itself, or 
 in the irritated alveolus (it is very difficult to say in which). 
 The alveolus and gum of the dead root may or may not 
 become absorbed. 
 
 In one case we may see the whole of the root, even to its 
 extreme point, laid bare by the removal of the investing parts, 
 and in another case the gum will maintain its normal height. 
 Of the two, the former condition is preferable, on account of 
 the greater degree of irritation and pain which usually attend 
 the latter. 
 
 The thickened peiiosteum, if adherent at any point to the 
 cementum, may be, and sometimes is, withdrawn from the 
 socket on the tooth being extracted. It is usually light in 
 colour, of considerable thickness, and almost as dense as 
 fibro-cartilage. 
 
 In respect to the treatment of either partial or complete
 
 NECROSIS OF THE TEETH. 445 
 
 necrosis of a tooth but little can be said, further than that 
 so soon as the diseased organ becomes ' a source of serious 
 annoyance, it should be removed. 
 
 Any attempt to restore the vitality of the part would be 
 useless. The gum and periosteal covering of the neck and 
 roots of a tooth having lost their attachment, never become 
 reunited.
 
 ( 446 ) 
 
 ABSOKPTION OF THE EOOTS OF PERMANENT 
 TEETH. 
 
 The removal by absorption of more or less of the root in 
 teeth the crowns of which have been injured by disease, has 
 been already mentioned ; but cases from time to time arise 
 in which, while the crown of a tooth is perfectly sound, the 
 root is attacked by absorption. It is to absorption, when it 
 occurs under the latter circumstances, that attention will be 
 directed. 
 
 Although the processes of absorption will be the same 
 under whatever circumstances they may be set in action, yet 
 we may arrange the cases under two divisions, in accordance 
 with the character of the exciting cause. In the first may 
 be placed those examples in which the whole or part of the 
 root of a sound permanent tooth is absorbed without reference 
 to the growth of an adjoining tooth ; and in the second, those 
 cases Avhere a portion of a permanent tooth is absorbed to 
 make way for the eruption of a neighbouring tooth. 
 
 184 m ^ ^^^^ ^^^^ many cases of absorption in per- 
 manent teeth, where the waste has so far- re- 
 duced the root that they became loose and 
 painful ; but I am indebted to Mr. Canton 
 and to Mr. Brookhouse for specimens showing 
 complete absorption of the root. In the one 
 case the central incisors, one after another, 
 became loose, and fell out, on the younger side of forty, 
 
 (1) Permanent central incisor, the root of which has been absorbed : from a 
 specimen placed at my disposal by ilr. Alfred Canton.
 
 ABSORPTION OF THE ROOTS OF PERMANENT TEETH. 447 
 
 just as though they were temporary teeth n:iaking way for 
 their successors. In the other, a permanent lateral incisor 
 was lost under similar circumstances. In neither patient 
 was there any indication of the presence of disease, either in 
 the gum or in the alveolar process. The attention was 
 attracted by no other symptom than the gradually increasing 
 looseness of the tooth. In a patient of my own, an upper 
 central, at the age of fifty, became rather suddenly loose and 
 painful. It was subsequently found that the one pig. i85. (») 
 side of the root had been removed by absorption, 
 the process having been arrested when the walls 
 of the pulp-cavity were readied, leaving the pulp 
 perfectly encased in a thin tube of dentine. But 
 lor the supervention of inflammation, followed 
 by the secretion of pus, it is probable that in this, 
 as in the preceding cases, the whole of the root 
 would have been removed. 
 
 The fact that the walls of the pulp-cavity resisted the ab- 
 sorbent action with greater force than any other part of the 
 dentine, accords with what we may observe takes . 
 
 • ,.•-,-, . , X Pig- 186. (2) 
 
 place m a limited degree m temporary teeth. It 
 is probable that the presence of the pulp gives 
 this power of resistance ; for in pivoted teeth the 
 root is commonly reduced by absorption, and per- 
 forations are sometimes made, by which the 
 metal pin is exposed. In a specimen in the mu- 
 seum of the Odontological Society, the root of a 
 tooth has been in great part absorbed in conse- 
 quence of the irritation produced in its socket 
 by a bristle which had made its way up the empty pulp- 
 canal. The process of absorption having been discussed in 
 connection with the shedding of the temporary teeth, it need 
 not be again entered upon. 
 
 (1) A permanent incisor, one side of the root being removed by absorption. 
 A thin case of dentine enclosing the pulp has been preserved. 
 
 (2) A pivoted tooth, with the root reduced in size by absorption, and gold pin 
 exposed at one point by a perforation, also produced by absorption.
 
 448 A SYSTEM OF DENTAL SURGERY. 
 
 The cases whicli fall under the second heading are usually 
 dependent upon the malposition, and consequent retarded' 
 eruption, of a permanent tooth. The extent to which the 
 absorption of tissue is carried is usually limited to the pro- 
 duction of a slight depression in the neck or root of the 
 tooth, but in a few cases the process is continued until the 
 ■ pulp-cavity is laid open and the pulp exposed. 
 
 The canines of the upper jkw being more frequently mal- 
 placed and retarded in their eruption than. any other teeth, 
 we should expect to find instances of absorption in the lateral 
 incisors and first bicuspid teeth. But in these we seldom 
 see more than a simple depression, towards which the ad- 
 vancing crown of the coming tooth has been directed. It is 
 upon the second molars that the greatest extent of injury is 
 inflicted. When the crown of a wisdom tooth is directed 
 forwards, it leads to absorption in the neck of the obstructing 
 tooth ; and the process, though generally arrested before the 
 second molar is permanently injured, will, in some cases, lay 
 open its pulp-cavity. I have seen several cases in which the 
 injury has been followed by inflammation of the pulp, neces- 
 sitating the immediate removal of the tooth. In a case 
 which occurred recently, the patient complained of severe 
 pain in a second molar of the upper jaw. The tooth apjjeared 
 in every respect sound ; directions were therefore given that 
 a leech should be applied to the gum. On the following day 
 the patient returned, complaining that the abstraction of 
 blood had failed to produce relief, and strongly urged that 
 the tooth should be removed. The tooth had become slightly 
 movable, and the crown had lost a little of the natural 
 brilliancy of colour. After removal, the cause of the suff'er- 
 ing was manifest. The pulp-cavity had been laid open, the 
 pulp became inflamed, lost its vitality, and at the time of 
 the operation was in a state of decomposition. In this 
 instance there was not the slightest evidence of caries ; but 
 in others which have come under my notice, the cavity pro- 
 duced by absorption subsequently became the S( at of caries.
 
 ABSORPTION OF THE ROOTS OF PERMANENT TEETH. 449 
 
 The manner in which the latter result is brought aljout 
 ^ requires some explanation. 
 
 It has already been stated that absorption is effected by a 
 vascular papilla, which advances in front of the moving tooth. 
 Jn those cases in which decay arises in a cavity so produced, 
 the papilla has been situated but a short distance within the 
 margin of the gum, and the cavity consequently becomes ex- 
 posed to the fluids of the mouth when the latter parts shrink 
 down to a lower level. 
 
 2 G
 
 ( 450 ) 
 
 EROSIO^^ OF THE TEETH. 
 
 It occasionally happens that the enamel and the subjacent 
 dentine become eaten away, without any of the ordinary 
 appearances of dental caries being manifest. The cavities, if 
 such they may be called, are in general regular in form, and 
 saucer-shaped, the removal of the enamel having taken place 
 more widely than that of the dentine. The surface is per- 
 fectly hard and polished, and often absolutely free from 
 discoloration. 
 
 This affection, which was described by Hunter under the 
 name of "decay by denudation," most commonly attacks the 
 necks of the teeth, forming a smooth horizontal groove close 
 to the edge of the gum : it is more frequently met with in 
 the upper than in the lower jaw, and closely simulates the 
 appearance produced by mechanical abrasion caused by the 
 friction of a tooth-brush. 
 
 ]S'ow and then, however, teeth are attacked in positions 
 Fif 187 /-n iiiaccessible to the tooth-brush; thus, in the 
 canine tooth here figured, the groove was not only 
 upon the anterior surface, but extended back on 
 both sides of the neck of the tooth ; moreover, 
 ft was distinctly undercut. 
 
 This erosion may go on till the pulp-cavity is 
 opened, and even passed, so the tooth is fairly 
 cut through by it. xVn instance of a lower bicus- 
 pid, with its crown thus undermined, has recently 
 presented itself, which, from its iX)sition, was 
 
 (1) Canine, of which the front and sides of the neck are deeply grooved.
 
 EROSION OF THE TEETH. 451 
 
 thoroughly protected from friction. Although the labial 
 surfaces of the teeth are usually attacked, the lingual surfaces 
 may in some few instances be eaten away ; in the two in- 
 cisors here figured this has taken place, the gum having at 
 the same time receded. In the right-hand figure an island of 
 enamel has been thus removed from the lingual surface of 
 the crown. 
 
 Sometimes the enamel is attacked at several points on tlie 
 labial surfaces of the crown of the front 
 t€eth ; this condition has only been, so far ^' 
 
 as I know, met with in the upper jaw, and 
 in the mouths of those who have sufiered 
 from prolonged ill-health. In a patient 
 lately under my care, the enamel had been 
 removed in irregular-shaped patches fi'om 
 the upper incisors and canines, and to a less 
 extent from the bicuspids. The subjacent 
 dentine, which had been but little eroded, 
 was perfectly hard and polished, but the edges of the enamel, 
 which were sharp and angular, were partially disintegrated, 
 chalky-looking, and crumbly. The patient had been con- 
 fined to her room, and for the greater part of the time, to her 
 bed, by a severe attack of rheumatic fever and its sequelae, 
 for upwards of nine months ; and during this time she had 
 taken much medicine, and had been incapable of giving any 
 attention to her teeth. 
 
 A somewhat similar case is figured in Harris's " Dental 
 Surgery " (tenth edition, p. 261) ; and Dr. Parmly mentions a 
 case in which a natural tooth, set upon an artificial piece, 
 was similarly grooved ; this last observation I can confirm, 
 and may add that I observed it in a case where the patient 
 rarely or never resorted to the use of a tooth-brush ; a 
 similar observation was recorded by Mr. Harrison in the 
 " Transactions of the Odontological Society," May, 1870. 
 
 But a yet more conclusive argument for the existence of 
 this "erosion" of the teeth, as distinct from mere mechnnical
 
 452 A SYSTEM OF DENTAL SUEGERT. 
 
 abrasion, is furnished by an observation of Dr. Murie(^), 
 who found that the teeth of a sea lion ( Otaria jubata) had 
 been thus wasted. The excellent figure given (Joe. cit.) is 
 too large for reproduction in these pages, but it is at once 
 evident, on inspection of the drawing, that the circum- 
 ferential grooving of these teeth cannot be accounted for by 
 friction, as in most instances, and notably in the great 
 canines, the places most afiected are situated on the sides of 
 the teeth most protected from wear, and the crowns are 
 merely worn down in the ordinaiy way. 
 
 This condition, at least in this extreme degree, is not 
 common among the seals, but I have seen an approach to it 
 in the teeth of other sj)ecimens of otaria, and in the pro- 
 boscis seal. 
 
 In the museum of the Eoyal College of Surgeons there 
 is a skeleton of otaria stelleri, in which this form of wasting 
 of the teeth is well exemplified. In it the teeth are much 
 worn down by mastication, but in addition to this, some of 
 them are deeply grooved in positions not at all exposed to 
 wear. The third left upper incisor is thus deeply notched 
 on its outer and anterior aspect, close to the edge of the gum, 
 whilst other teeth present a similar condition, though less 
 markedly. 
 
 There is yet another form of wasting of the teeth, which 
 is more rare than those already described. In it, not 
 isolated spots, but the whole exposed portion of the tooth is 
 attacked ; as the morbid action goes on the enamel is slowly 
 removed from the crown, so that the teeth become shorter 
 and thinner, and assume a peculiar yellowish," translucent 
 appearance, the position of the pulp- cavity being strongly 
 marked by a difference of colour. In the only case which has 
 come under my own observation, the wasting of the teeth was 
 established beyond all doubt by taking models from time to 
 time. The patient, an anaemic girl, was reduced to a state of 
 great prostration by acute dyspepsia, and was for a con- 
 (') Transactions of the Odontological Societj', June, 1870.
 
 EROSION OF THE TEETH. 453 
 
 siderable time confined to her bed; she was, however, so 
 hysterical that it was exceedingly difficult to rightly estimate 
 her condition. At one time there was great tenderness of 
 the teeth, and general periostitis in the front of the mouth, 
 which, judging by colour alone, appears to have resulted in 
 the death of one of the upper central incisors. The use of 
 alkaline applications seemed to have no effect whatever ; but 
 the patient's condition has now greatly improved, and the 
 disease ap{)ears to be no longer progressing. It is remarkable 
 that during her prolonged illness, while the teeth were being 
 rapidly eroded, no caries occurred in the mouth. 
 
 A case of wasting of the front teeth, by which a separation 
 of three-eighths of an inch was brought about between the 
 incisors in the course of two years, is related in Harris's 
 " Dental Surgery " (p. 264) ; and Mr. Bell has given figures of 
 a case in which this wasting, affecting mainly the edges of 
 the teeth, effected a wide separation between the upper and 
 lower central incisors, and attacked also, though in a less 
 degree, the laterals and canines, which could not be brought 
 into contact with one another. 
 
 The cause of these various forms of erosion has been, 
 from time to time, the subject of great discussion ; though 
 some hypotheses, such for instance as that which attri- 
 butes it to disease inherent in the dentine, may be at once 
 dismissed. 
 
 It has already been shown that mechanical abrasion will 
 not serve to account for all the cases. 
 
 Absorption cannot be called in to account for the removal 
 of the tooth substance, for it often takes place at spots remote 
 from any structure capable of developing an absorbent organ, 
 and it seems that we must fall back upon the idea that it is 
 an example of chemical solution. But whence the solvent 
 comes, and why the affected surfaces are not the site of 
 ordinary caries, are questions which remain unsolved, though 
 it seems probable that mucus, by fermenting or affording a 
 nidus for fermentation, may provide an acid solvent.
 
 J:54 A SYSTEM OF DENTAL SUBGERY. 
 
 Dr. Magitot (') regards the grooving of the necks of the 
 teeth as the result of caries, which has tended to spon- 
 taneous cure by tha obliteration of the dentinal tubes ; but 
 this -^iew does not differ from that which ascribes it to 
 chemical solution, as Dr. Magitot holds that caries itself is 
 the result of a chemical solvent. 
 
 When the cavities produced are of suitable form, the 
 further progress of the malady may be arrested by filling 
 them ; and for this purpose gutta-percha is often found ex- 
 ceedingly efiScient. But where the surfaces attacked do not 
 admit of protection by a filling, treatment does not yield 
 satisfactory results. The use of soft tooth-brushes should be 
 enjoined, and alkaline dentifrices prescribed, as being the most 
 likely to prevent solvent action on the teeth. 
 
 The cavities produced by erosion of the teeth are often ex- 
 cessively sensitive to the touch of an instrument, or to alter- 
 nations of temperature. This sensitiveness may be cured by 
 applications of nitrate of silver, or, where a black stain would 
 he objectionable, by chloride of zinc. 
 
 (») Iiecherches surla Carie des Dents. Paris, 1871, p. 513:—" La cavite ofifre 
 alors I'aspect singuiier qui la fait comparer a un trait de scie transversal k 
 parois lisses, polies, dures et resistantes. Ce sont ces cavites que Duval et divers 
 autres auteurs designaient sous le n<im de ' caries simulant I'usure,' et dont le 
 mode de production n'etait pas explique. Elles ont, en effet, toutes les 
 appareuces de I'usure veritable, m:iis nos observations sur la succession des 
 diverses pe'riodes de la maladie nous ont de'mon^e que ces sillons nets et polis 
 ne sont autre chose que des caries du collet passees k I'etat de guerison 
 spontanee ou caries sfeches."
 
 ( 455 ) 
 
 DISEASES OF THE PUI-P. 
 
 No portion or organ of the body, either in health or disease, 
 can be independently considered. Whether an inflamed eye 
 or a diseased tooth form the subject of inquiry, it must be 
 borne in mind that neither can exist but as one of many 
 parts which collectively form the body ; that the healthy 
 condition of an organ is due to a corresponding state of the 
 whole organism, and more especially to a sound condition of 
 the organs in its immediate vicinity, or with which it is 
 closely associated ; and that a state of disease may be con- 
 sequent upon, or even a symptom of, a disordered state of a 
 neighbouring part of the body. On the other hand, a diseased 
 condition originating in an eye or a tooth, may induce sym- 
 pathetic affections even in remote organs, and in doing so may 
 seriously disturb the general health. It is necessary that 
 the mutual dependence of the various organs upon each 
 other should be fully acknowledged by those who restrict 
 themselves to special branches of practice, and who naturally 
 feel a strong tendency to isolate and place in an independent 
 position, and to give an exaggerated importance to, the 
 diseases of the one organ or set of organs to which their 
 attention is more especially directed. 
 
 These observations admit of application to practitioners 
 of dental surgery, who are strongly tempted to regard local 
 conditions without reference to the general constitutional 
 state, of which they may be but an indication. The remedies 
 which he finds most effective are local in their application 
 and effect. It is only when the character of the disease is
 
 456 A SYSTEM OF DENTAL SURGERY. 
 
 somewhat vague, as in the group which is about to be con- 
 sidered, that the attention is called to the general condition 
 of the body. 
 
 Irritation of the Dentinal Pulp. — A diseased condition of 
 the piilp, whatever may be the nature of the disease, is, in 
 the majority of instances, consequent upon the pulp-cavity 
 being laid open, either by the destruction of its walls by 
 caries, or by injury of the crown of the tooth from mechanical 
 violence. But a few cases will be met with in which the 
 tooth becomes painful, and highly sensitive to the effects of 
 sudden changes of temperature induced by the contact of 
 hot or cold fluids, and even to slight pressure upon the crown 
 or upon the neck of the tooth, while the walls of the pulp- 
 cavity are free from injury. In such cases the patients will 
 complain that the tooth is incaj^able of bearing with comfort 
 the pressure exercised in mastication. Careful examination 
 usually leads to the detection of caries, or to loss of a portion 
 of the crown of the tooth, either from wear or fracture. A 
 certain degree of pain is produced by pressing a steel instru- 
 ment upon the injured spots, but the degree of pain will not 
 correspond to the amount of force exercised ; indeed, slight 
 contact seems to give quite as much pain as firm pressure. 
 
 But we may fail in detecting any indication of structural 
 change in the sensitive teeth. The disordered state may 
 depend upon some other tooth, which, although itself free 
 from pain, may produce sympathetic irritability in other 
 teeth; thus pain really due to the wisdom teeth is often 
 referred to the bicuspids ; or it may depend u}X)n a cause 
 which has a constitutional or general origin. The earlier 
 stages of cold, rheumatism of the jaw, or the presence of 
 mercury in the system, are frequently accompanied by an 
 irritable state of the teeth. 
 
 When the foregoing local symptoms are present, it is very 
 difficult to determine whether the sense of pain in the tooth 
 is confined to the dentinal fibrils, or whether it is situated in 
 the pulp, the susceptibility of which has become abnormally
 
 IRRITATION OF THE PULP. 457 
 
 heightened. There is no reason for supposing that the fibrils 
 are incapable of assuming a condition of excessive sensibility, 
 and that the morbid state may not for a time be confined to 
 them. But it is quite possible that the increased suscepti- 
 bility may originate in and be limited to the pulp itself, which 
 becomes painfully affected by causes which otherwise would 
 not produce uneasy sensations. 
 
 That a state of irritation may be assumed by the pulp, is 
 sufficiently proved by the fact that the irritable condition of 
 the tooth may be succeeded by inflammation of that organ. 
 Examples of the sequence of the one to the other condition 
 may be seen in teeth, small portions of which have been 
 broken off without injury to the pulp-cavity. When so in- 
 jured they become gradually sensitive to changes of tem- 
 perature, and the pain, which at first was transient, at last 
 endures after the excitinji; cause has been removed. The 
 amount of pain is gradually increased, and eventually ter- 
 minates in a severe attack of toothache, occasioned by acute 
 inflammation of the pulp. On the aching tooth being re- 
 moved, it will be found that although the pulp-cavity is 
 entire, the pulp is passing into a state of disorganization. 
 A similar course of symptoms will sometimes follow the 
 operation of plugging a simple cavity in teeth which have 
 been in an irritable condition prior to the operation. For 
 example, in a patient lately under my care, gold fillings were 
 placed in two mesial cavities in the right and left lower 
 molars ; the cavities were fully exposed to view, and no indi- 
 cation of exposure of the pulp was to be seen ; in fact, the 
 cavities were so shallow that the introduction of a filling was 
 difficult. In the course of a week the gold had to be re- 
 moved ; too late, however, to prevent the spontaneous death 
 of the'pulp. In this same patient I had been shortly before 
 that time compelled to remove a crown filling, where the 
 cavity was both small and shallow, on account of the irri- 
 tability of the pulp. The susceptibility of the pulp to irrita- 
 tion varies greatly in different persons ; there are some few
 
 458 A SYSTEM OF DENTAL SURGERY. 
 
 for whom it is next to impossible to successfully perforai the 
 operation of filling. 
 
 No doubt the pulp of a tooth may pass into a state of 
 irritation, independent of injury sustained by the hard and 
 protecting tissues, just as in certain states of the system the 
 susceptibility to disease of any other organ of the body may 
 be increased. But in those cases in which the crown of the 
 tooth has suffered, there appears good reason for supposing 
 that the abnormal state begins in the dentinal libiils, and 
 extends through them to the pulp. This view is, I think, 
 supported by the results which follow careful treatment. If, 
 in a tooth the cro^vn of which has been injured by caries to a 
 slight depth only, but in which the dentine is highly sensi- 
 tive, nitrate of silver be applied to the affected j^art, the 
 susceptibility to pain will in a few minutes be greatly re- 
 duced. A similar result will follow the application of other 
 forms of escharotics, unless the walls of the pulp-cavity are 
 sujQQciently reduced in thickness to allow the application to 
 pass through to the pulp. The effects with these active 
 agents are rapid, but their use is not free from danger ; for it 
 is not always easy to discover how much or how little sound 
 tissue may intervene between the pulp and the sensitive 
 surface. Excepting as a matter of experiment, or when a 
 sufficient length of time cannot be allowed for the applica- 
 tion of less active remedies, it will be well to employ vegetable 
 astringents, such as tannin, or solutions of gum-resins in al- 
 cohol, and to continue the treatment till the tooth regains its 
 normal state. 
 
 In a previous page it was stated that the dentine loses 
 sensation on the pulp being destroyed, and it is now shown 
 that a sensitive surface of dentine loses its power of feeling 
 or transmitting pain after treatment with nitrate of silver. 
 The results thus obtained indicate pretty clearly that we 
 shall not be wrong in attributing a considerable share of the 
 hyper-ajsthesia to the dentinal fibrils, and the conclusion is 
 still further justified by the fact that if we excise the surface
 
 IRRITATION OF THE PULP. 459 
 
 which has been acted upon by the nitrate of silver, the newly- 
 exposed surface will exhibit the condition of sensibility, w^hich 
 the application of the escharotic removed from that which 
 was cut away. If the attempt to show that an irritable state 
 of the pulp when connected with a damaged state of the 
 crown of the tooth is preceded by, and consequent on a 
 similar state of the dentinal fibrils, has been successful, there 
 will be no great difficulty in establishing a strong ground for 
 assuming, that when the teeth become irritable in conse- 
 quence of causes acting through the system, that, so far as 
 the teeth are concerned, the state of irritability is situated 
 in the pulp itself. 
 
 The supervention of inflammation of the pulp, independent 
 of exposure, has been alluded to as an occasional result of 
 irritation. But it more commonly happens that the diseased 
 condition of the dental tissues is allowed to progress, the 
 pulp-cavity is laid open, and the exposed pulp then passes 
 into a state of disease, acute or chronic, as circumstances 
 may determine. If, however, the disease in the crown of 
 the tooth be successfully treated, the state of irritability will 
 by degrees pass away, and the tooth will be restored to a 
 state of comfort and usefulness. 
 
 Irritation, if long continued, is usually, but not constantly, 
 productive of certain changes in the pulp 
 itself, examples of which may be seen if 
 teeth removed after a long-continued state 
 of uneasiness has been succeeded by active 
 aching, be examined. In some the pulp 
 will be found to contain numerous nodules 
 of dentine ; in others, the greater part of 
 the pulp will be found converted into se- 
 condary dentine (Fig. 189). Or the calcifi- 
 cation of the pulp rjiay be limited to the production of a 
 
 (1) Showing the pulp-cavity of a first permanent molar of the upper jaw 
 perfectly filled with a quss of secondary dentine, produced by calcilication of 
 the pulp induced by caries of the crown of the tooth.
 
 460 
 
 A SYSTEM OF DENTAL SUEGERY. 
 
 Fig. 190. (}) /-t^. 191.(2) 
 
 patch of dentine added to the wall of the puli>cavity 
 (Fig. 190, and Fig. 191). 
 
 In neither of the preceding cases can the calcification have 
 been eflected during the day or two 
 of acute suffering in the tooth, con- 
 sequently it may be inferred that 
 the production of secondary dentine 
 took place when the irritable con- 
 dition prevailed. It must not on 
 this accoimt be assumed that cal- 
 cification of the pulp invariably 
 follows upon irritable conditions of 
 the tooth, lor cases will be found in 
 which the presence of secondary dentiue cannot be recognised, 
 and others iu which a large portion of the pulp has undergone 
 calcification without the precedence of irritability in the 
 tooth. Moreover, it seems probable that the mere presence of 
 these isolated nodules in the pulp is capable of exciting great 
 irritation, instead of being a result of previous excitation of 
 the pulp. It must also be remembered that small isolated 
 calcareous globules are to be foimd in perfectly healthy 
 developing teeth (see page 283). 
 
 Treatment. — When the irritability of the tooth is conse- 
 quent upon the presence of simple caries, our aim must be to 
 introduce a permanent plug ; some little caution must, how- 
 ever, be used, otherwise the remedy will but serve to increase 
 the disease. The patient may have sufiicient endurance to 
 allow the excision of the whole of the afi"ected dentine, and 
 the subsequent introduction of a gold or other metallic fiUiug, 
 but the presence of metal, from the rapidity with which it 
 transmits changes of temperature, serves, when the tooth is 
 highly sensitive, to increase rather than mitigate the evil. 
 
 (1) Section of a tooth, showing the local thickening of the wall of the pulp- 
 cavity, consequent upon irritation produced by advancing caries. 
 
 (2) Bicuspid in which a formation of secondary dentine has failed to obviate 
 perforation of the pulp-cavity.— From Tomes's " Lecture on Dental Physiology 
 and Surgery."
 
 IRRITATION OF THE PULP. 461 
 
 The sensitiveness will, however, in the majority of cases, 
 gradually subside ; in others, we shall be required to remove 
 the metallic plug, and substitute a non-conducting material. 
 The prepared gutta-percha will be found extremely useful in 
 the treatment of such cases. Indeed, whenever we find that 
 greatly increased sensibility is established, we shall do well 
 to introduce a temporary plug of this material, taking care to 
 substitute gold when the tooth has recovered its normal con- 
 dtion. In many cases, however, the pain occasioned by the 
 excision of the decayed dentine is perfectly intolerable. The 
 application of chloroform, creosote, or camphorated spirits of 
 wine will lower the sensibility slightly, but no other agent 
 has in my hands been so immediate and complete in its 
 action as a fragment of nitrate of silver introduced into the 
 cavity, and allowed to remain for five or six minutes. Of 
 course, in the front teeth lunar caustic cannot be used, owing 
 to the discoloration which it occasions ; but in the back teeth 
 the dark stain is of less consequence. The natural colour of 
 the tissues, even in the molar teeth, should, if possible, be 
 preserved, but not at the risk of losing them altogether. 
 There is another advantage which attends the use of nitrate 
 of silver ; it has a power of arresting the progress of decay. 
 
 In connection with a generally heightened sensibility, we 
 sometimes find a ring of decomposing and extremely sensi- 
 tive tissue encircling the necks of several, or perhaps all, of 
 the front teeth. The operation of plugging is quite out of 
 the question, and the complete destruction of the teeth is 
 therefore reduced to a mere matter of time. Owing to 
 pregnancy or some other cause, it may be desirable to adopt 
 means for allaying the susceptibility of the teeth, and at the 
 same time to preserve them, if possible, for a few months. In 
 the treatment of cases of this description, nitrate of silver has 
 proved very valuable. The author can call to inind many 
 cases in which, by the application of lunar caustic, great 
 discomfort was removed, the presence of hot or cold fluids 
 rendered tolerable, and the teeth, althoiidi blackened at the
 
 462 A SYSTEM OF DENTAL 8UBGERT. 
 
 necks, were kept from further deterioration for five or six 
 years. 
 
 It may be said tliat the foregoing treatment bears rather 
 upon an abnormal condition of the dentine than upon an 
 irritable condition of the pulp ; and the objection may, in 
 some cases, be valid, but it will be almost impossible to 
 distinguish between pain felt in the dentinal fibrils and in 
 the pulp, and the distinction in respect to the treatment is 
 unimportant, unless the ailment has a constitutional origin, 
 when it must of course be treated by remedies which operate 
 through the general system. 
 
 Acute Inflammation of the Dentinal Pulp. — The occurrence 
 of inflammation of the pulp is usually consequent uix)n its 
 exposure, brought about either by caries or the accidental 
 fractiu-e of the tooth. Not that the pulp is more exempt 
 firom the occurrence of inflammation than some other soft 
 tissues, but still the cases of idiopathic disease are not very 
 firequent. In ninety-nine cases out of a hundred the dis- 
 eased action is consequent upon the perforation of the pulp- 
 cavity. The following is the usual course of events : — A 
 hole is discovered in a tooth, food and other matters collect 
 in it, and are from time to time removed. The presence of 
 foreign bodies at first produces no inconvenience, but after 
 awhile certain substances, such as sugar, or salt, or acid 
 matters, when lodged in the tooth, occasion considerable 
 uneasiness, which is, after awhile, exchanged for positive 
 pain. The removal of the irritating matter is soon followed 
 by the restoration of comfort. This state of things may go 
 on for some time, but, sooner or later, the pain, instead of 
 passing ofi', steadily incraises, assumes a throbbing character, 
 becomes still more acute, extends from the faulty tooth to 
 the neighbouring teeth, and to the side of the face, the tooth 
 forming the centre of its intensity. After the lapse of some 
 hours the pain usually subsides, to return again on the 
 slightest provocation, or on the patient assuming the hori- 
 zontal position. If a tooth be examined subsequent to two
 
 ACUTE INFLAMMATION OF THE PULP. 463 
 
 or three, or perhaps even after one severe attack of throbbing 
 pain, the pulp will be found to have lost its vitality, and to 
 have passed, or to be in the process of passing, into a state 
 of decomposition. With the death of the pulp the suffering 
 does not necessarily subside, but the character of the pain 
 will be changed. The throbbing ceases, and in its place a 
 dull, heavy pain, with a feeling of tension, is left. The 
 tooth feels too long, and is, in fact, raised in the socket from 
 thickening of the dental periosteum, consequent upon in- 
 flammatory action extending from the pulp to the soft tissue 
 v/hich connects the root of the tooth to the socket, indi- 
 cating the commencement of an alveolar abscess. If the 
 tooth be allowed to remain in the mouth without adopting 
 remedial treatment, the pain after awhile usually subsides, 
 and the elongation and tenderness of the tooth gradually 
 pass off. The pulp-cavity, on examination, will be found 
 to contain decomposing fragments of the dead pulp, or 
 particles of food, from which will be emitted a peculiar 
 phosphatic odour, an indication that the pulp-cavity of the 
 tooth has been opened, and become the receptacle of a secre- 
 tion discharged, either from a portion of living pulp, or from 
 the surface of an alveolar abscess; 
 
 Such, then, is the usual course of events, when the pulp of 
 a tooth becomes inflamed. The results of inflammation 
 may, however, be modified by the constitutional condition 
 of the patient ; the symptoms may be less severe, . or they 
 may be greatly agi,a-avated. In some cases the pain lasts 
 but for a short time, and is comparatively moderate in 
 degree, while in others it is continued for days with great 
 intensity. Again, in one case the alveolar inflammation is 
 absent, and in another the whole mouth becomes affected. 
 Independent of the constitutional state, these difierences in 
 effect will no doubt depend upon the condition of the pulp 
 prior to the advent of active disease. The size of the pulp 
 will exercise a very material influence ; and the number and 
 size of the globules of secondary dentine within its substance
 
 464 A SYSTEM OP DENTAL SUBGERT. 
 
 will also tend to modify the severity of the symptoms. Gene- 
 rally, the smaller the amount of vascular tissue involved in 
 the disease, the milder will be the symptoms ; it is, conse- 
 quently, seen that in young people in whom the pulp is 
 relatively large, and the amount of secondary dentine within 
 its substance comparatively small, the suffering is greater, 
 and tbe inflammation more extended than in older subjects. 
 The size of the aperture by which the pulp is exposed, will 
 also influence the amount of suflering which attends inflam- 
 mation of that organ. Local constriction of an inflamed 
 part, under all circumstances, greatly aggravates the pain. 
 In a tooth the pulp is uniformly confined, excepting at the 
 point where the wall of the cavity has been perforated; 
 when the vessels become distended, and the more fluid 
 portions of the blood are eflused, the pulp will enlarge at 
 any point where enlargement is possible, and it is conse- 
 quently protruded through the aperture in the walls of the 
 pulp-cavity. The hole in the substance of the tooth is 
 always much larger than the opening into the pulp-cavity, 
 consequently that part of the pulp which has been pro- 
 truded through the narrow opening into the larger space 
 may there become enlarged, while the part which connects 
 it with the pulp is constricted. 
 
 There are but few of us who do not know something of the 
 pain which results from drawing the air from a carious and 
 aching tooth — or, in other words, sucking it — whereby the 
 atmospheric pressure is taken ofi" the exposed portion of the 
 pulp, leaving the vessels unsupjxirted to withstand the force 
 of the circulation. The immediate result is, that the pulp 
 is forced against or through the opening, and in some cases 
 its vessels are ruptured. The bleeding so produced not un- 
 commonly relieves the distended vessels, and the inflam- 
 mation is for the time checked. That which we can 
 produce at will occurs, in a greater or less degree, without 
 our intervention ; and the amount to which the pulp is 
 protruded, and the degree of strangulation which is induced
 
 ACUTE mFLAMMATION OF THE PULP. 465 
 
 by the form and size of the aperture in the pulp-cavity, 
 will, to some extent, govern the intensity of the pain con- 
 sequent upon inflammation. 
 
 The treatment of acute inflammation of the dental pulp 
 must be regulated by the stage at which the disease has 
 arrived when relief is sought, and the general condition of 
 the crown of the tooth and of the surrounding parts. If 
 there is reason to believe that the inflammation has not 
 extended to the alveolar periosteum, remedial treatment 
 may be adopted with a fair chance of success ; but should 
 it be found that the pulp of the tooth is passing into a state 
 of disorganization, and that suppuration in the socket has 
 commenced, the removal of the tooth offers the only certain 
 and speedy means of terminating the disease. If from any 
 cause that operation is rendered objectionable, the pain 
 which attends the process of suppuration may be mitigated 
 by the use of decoction of poppy-heads held in the mouth, 
 and by making a free opening over the root of the tooth, so 
 soon as pus is formed. One or two leeches applied to the 
 gum will oftentimes be attended with advantage, but I have 
 not uncommonly been disappointed in the result. The 
 remedy has aggravated, rather than alleviated the suffering, 
 and the formation of pus and its subsequent escape have not 
 been materially hastened. 1'he treatment of alveolar abscess 
 will, however, form the subject of a future section, and the 
 treatment for the preservation . of a tooth so affected will be 
 there discussed. 
 
 If, however, the disease be limited to the pulp, we have 
 yet to consider whether the crown of the tooth is in a suffi- 
 ciently good state to render its preservation desirable, or 
 whether, in the case of a front tooth, the root should bo 
 saved to support an artificial crown, secured by means of a 
 pivot. In deciding these questions, the general state of the 
 gums, the idiosyncrasy of the patient, and the condition of 
 the tooth in respect to the state of development of its roots* 
 must be taken into account. 
 
 2 H
 
 4:6& A SYSTEM OF DEXTAL SURGERY. 
 
 If the gums are in a thickened and unhealthy state, or if 
 the patient be liable to neuralgic pain about the face and 
 jaws, or should there be reason to suppose that the roots are 
 not fully developed, and the aperture at the extremity of each 
 root contracted to its ultimate size, it will be well to remove 
 the tooth. In the absence of any disqualifying condition, 
 we may adopt a plan of treatment for the presei-vation of the 
 tooth. That plan will consist in the application of an es- 
 charotic for the rapid destruction of the pulp, with the 
 view of filling the pnlp-cavity, and making good the injured 
 portion of the tooth by means of gold, or some other ma- 
 terial. Arsenic, when applied in the manner already de- 
 scribed, will be found to be the best agent for bringing 
 about the result. The pain produced by the disease is 
 seldom increased by the arsenic ; indeed, it is not unusual 
 for the violent throbbing to be almost immediately ex- 
 changed for a duU aching sensation, which passes away in 
 the course of four or five hours. 
 
 Chronic Inflammation of the Dental Pulp may arise inde- 
 pendently of caries, or of the mechanical injury of a tooth, 
 but practically its occurrence may be assumed to be conse- 
 quent upon, and almost invariably coincident with, the 
 presence of an opening into the pulp-cavity. It differs from 
 the acute form of the disease in the less active character of 
 the symptoms, and also in the results to which it leads. 
 The pain is seldom long continued, or very intense when 
 present. It generally comes on at irregular intervals, a 
 periodical character being observed in exceptional cases only, 
 although these partial inflammations of the dental pulp are 
 specially prone to set up wandering neuralgic pains, the true 
 origin of which may be obscured by the complete absence of 
 local toothache. A sudden change of temperature, the appli- 
 cation of an irritating substance, such as salt or sugar, will 
 generally bring on a paroxysm of pain, which may endure 
 but for a few minutes, or may last for several hours. 
 
 On carefully examining a tooth which gives rise to the
 
 CHEONIC INFLAMMATION OF THE PULP. 467 
 
 foregoing symptoms, it will be found that the pulp at the 
 exposed point has assumed a deep red colour, is extremely 
 sensitive when touched with an instrument, and bleeds very 
 readily. If the tooth be removed, and the crown broken 
 through so as to expose the pulp, it will then be seen that 
 the inflammation has been limited to that part which was 
 exposed, the remaining portion of the organ having retained 
 the normal pale colour. Had the disease assumed the acute 
 form, the whole substance of the pulp would have been 
 injected with blood, the exposed part being distinguished by 
 the greater intensity of its colour. 
 
 In tracing the several consequences of chronic inflamma- 
 tion, the first which should attract attention is the change 
 in the character of the exposed portion of pulp. It becomes 
 for the time being an organ of secretion ; purulent or serous 
 fluid is poured out from its surface, the amount and character 
 of the discharge varying with the general health of the 
 patient, and the degree of irritation to which the diseased 
 part has from time to time been subjected. 
 
 Supposing this abnormal condition to be established, the 
 presence of pain is not a necessary consequence ; and it is 
 important that the fact should be kept in view, for should it 
 be assumed that the pulp is not exposed because the patient 
 has not suffered from toothache, and a plug be introduced, 
 it is highly probable that the tooth will be lost. The dis- 
 charge will be blocked in by the plug, and its accumulation 
 will, in the course of a short time, bring on an attack of 
 acute inflammation of the whole pulp. It is therefore of 
 great consequence, before proceeding to treat a carious tooth, 
 to ascertain whether the pulp be exposed or not. The 
 history of the case will not always determine the question, 
 and the position of the tooth, or of the cavity in it, may 
 be such as to render a satisfactory inspection difficult. 
 The presence, however, of that peculiar phosphatic odour, 
 to which allusion has been already made, is a tolerably 
 sure indication that the pulp is exposed, and that a secretion
 
 468 A SYSTEM OF DENTAL SURGERY. 
 
 escapes from its surface; and it is, moreover, a suflGcient 
 varning to abstain from the immediate introduction of a 
 permanent plug. 
 
 A second result of chronic inflammation is the formation 
 of an ulcer, of a verj^ painful and irritable kind, upon the 
 exposed surface ; and a third consequence is the development 
 of granulations, which may grow until a mass is formed ex- 
 ceeding the size of the pulp itself, and, in some cases, com- 
 pletely filling up the cavity produced by the destruction of 
 the enamel and dentine. This condition is usually de- 
 scribed as polypus of the dental pulp. The morbid growth 
 is not necessarily very sensitive. It bleeds readily, and 
 emits a very offensive secretion. 
 
 There are other results which attend chronic inflammation 
 of the pulp. One consists in the gradual disappearance of the 
 pulp without pain, and consequently without any symptom 
 which attracts the attention of the patient. The practitioner 
 finds the pulp-cavity empty. 
 
 The results of inflammation hitherto mentioned are de- 
 structive in their tendencies, but the presence of disease is 
 usually attended by reparative efforts. The development of 
 nodules of dentine in the pulp is almost invariably coin- 
 cident with the occurrence of caries ; and there is no reason 
 for assuming that the process of formation is arrested in the 
 comparatively healthy portion, although the exposed surface 
 of the pulp be inflamed. But there seemed some reason to 
 doubt whether the exposed suriace could undergo calcifica- 
 tion. Mr. Arnold Eogers has recently placed at my dis- 
 ix)sal a preparation which, 1 thii.k, sets the question at rest. 
 A patient applied to have the roots of a first molar removed, 
 the crown having been broken oft' many months previously, 
 when, for the relief of pain consequent upon caries, the ex- 
 traction of the tooth was attempted. The pain ceased after 
 the fracture, and the roots of the tooth were allowed to 
 remain. After the lapse of some months, the remains of 
 the broken tooth caused annoyance, and they were removed.
 
 CHRONIC INFLAMMATION OF THE PULP. 469 
 
 The specimen (Fig. 192) shows that the tooth was broken 
 through about the middle of the pulp-cavity, projecting 
 from which we now find a mass of se- 
 condary dentine. It not only projects 
 from the cavity, but hangs over and con- 
 ceals the sharp edges produced by the 
 fracture. It is obvious that in this case 
 the vitality of the pulp was maintained, 
 that it became enlarged subsequent to 
 the unsuccessful operation, and after- 
 wards calcified. 
 
 There is no evidence to show that secondary dentine can 
 be formed in any other tissue than dentinal pulp. In the 
 case under consideration, the secondary dentine passes over 
 the normal boundary of the pulp-cavity ; we are therefore 
 justified in assuming that the pulp itself became enlarged. 
 Now, the tooth had ached before the primary operation was 
 performed, and it may therefore be taken for granted that 
 the pulp was at that time more or less inflamed. These 
 facts, although taken from a single case, warrant the con- 
 clusion that there are circumstances under which the den- 
 tinal pulp, although it has been diseased and exposed, may 
 be converted into secondary dentine. Having established the 
 fact, the precise nature of the circumstances which favour 
 this reparative action should be determined. 
 
 In the case cited the secondary dentine was exposed to 
 view when the patient applied to Mr. Rogers, but the 
 pulp, during the process of calcification, must, I think, 
 have been protected in the first instance by a coagulum 
 of blood, and subsequently by a perfect covering of or- 
 
 (i) Shows the roots and neck of an upper molar tooth, the crown of which 
 had been broken off iu attempting its extraction. Some time afterwards 
 the roots were removed, and it was then found that a mass of secondary 
 dentine projected Irom and overhung the margins of the remaining portion of 
 the pulp-cavity. A similar specimen is placed by the side of this in the 
 Odontolojjical Society's museum, the history of whicli is precisely similar. The 
 gum in this latter case was believed to have healed entirely, or almost entirely, 
 over the fangs and the exposed pulp, thus affording it protection.
 
 470 A SYSTEM OF DENTAL SURGEBY. 
 
 ganized tissue. Had it been otherwise, the pulp would 
 probably have been injured and ultimately destroyed by 
 mastication. 
 
 I am not acquainted with any case which can be regarded 
 as strictly parallel to the foregoing, but we 
 may find instances — if a number of teeth are 
 divided — showing that the bulk of the soft 
 tissue had been calcified, although at the 
 point of exposure the conversion remained 
 incomplete. I believe it not uncommonly 
 happens, that the calcification keeps in ad- 
 vance of the progress of caries, and thus pro- 
 tects the pulp from exposure. But such teeth 
 are not removed, and therefore do not come into our hands 
 for examination. 
 
 Allusion has already been made to the fact that chronic 
 inflammation of the pulp may not be accompanied by pain 
 in the tooth itself, yet that it may cause severe sympathetic 
 pains in the head and face, and that the pain may extend 
 down the neck as far as the shoulder. I remember a case 
 in which the patient suffered severe pain on one side of the 
 head and face at tolerably regular intervals. The pain came 
 on in the evening, and lasted for six or eight hours. It was 
 for some weeks regarded as a case of tic, or hemicrania. 
 After internal remedies had failed, a decayed but painless 
 wisdom tooth of the upper jaw was removed, and from that 
 time the facial pain disappeared. The pulp of the tooth 
 was exposed and inflamed at a point corresponding to an 
 aperture in the pulp-cavity. 
 
 Treatment. — The same general principles that were stated 
 in respect to the treatment of acute must be acted upon in 
 the management of chronic inflammation of the pulp. Re- 
 medial measures offer but a \Qvy small chance of success if 
 the disease has extended beyond the limits of the pulp, and 
 
 (1) A first permanent molar tooth of the uppor jaw, the pulp of which was 
 calcified, excepting at its upper part and at the exposed side.
 
 CHRONIC INFLAMMATION OF THE PULP. 471 
 
 it would be useless to attempt the preservation of a tooth, 
 the crown of which could not be rendered effective, by filling, 
 unless, perhaps, in the case of a front tooth, the root of which 
 it may be desirable to preserve. In polypus of the pulp, 
 preservative treatment will usually fail, owing to a coinci- 
 dent enlargement of the aperture at the extremity of the 
 root, and to a morbid condition of the vessels and other 
 tissues to which that aperture gives passage. 
 
 If, however, the disease is strictly limited to the pulp, 
 and the symptoms also are strictly local, the chances are 
 in favour of success, if the patient will submit to the 
 necessary treatment. The pulp may be destroyed by ar- 
 senic or other means, and the cavity filled ; but the strong 
 tendency shown by the pulp to form secondary dentine, 
 and thus shield itself from further injury, should, if pos- 
 sible, be taken advantage of, even though the proceeding 
 may involve a much longer and more troublesome course of 
 treatment than would be required if the pulp were at once 
 destroyed. The preservation of a portion of the pulp, and 
 consequently of the vitality of the dentine, renders the 
 tooth much less liable to attacks of alveolar abscess than 
 it would have been had the former part been lost. In adopt- 
 ing this course of treatment, we must address our remedies 
 to the exposed surface of the pulp with the view of arrest- 
 ing the discharge to which, when in a state of chronic 
 inflammation, it gives origin. The daily a23plication of cam- 
 phorated spirits of wine, or of a solution of mastic in spirit 
 upon cotton-wool, will, if persevered in, produce the desired 
 effect in the majority of cases. At first the cotton, when 
 removed from the tooth, will be strongly tainted with the 
 peculiar phosphatic smell, but the intensity of the odour 
 will gradually diminish, and after a time altogether dis- 
 appear. The part of the cotton which has been in con- 
 tact with the pulp, at first stained by the morbid secretion, 
 will, when the discharge ceases, no longer show any mark 
 of discoloration. Another method of treatment, equally
 
 472 A SYSTEM OF DENTAL 8UEGERT. 
 
 effective, and in my hands more satisfactory, as it requires 
 a less expenditure of time and less frequent renewals of 
 the remedial agent, consists in the application of a soft 
 mass, composed of tannin, mixed with gutta-percha re- 
 duced to a gelatinous consistence, with chloroform. The 
 astringent properties of the tannin act in arresting the dis- 
 charge, while the gutta-percha holds it together, and en- 
 sures its contact with the pulp. Although the soft plug 
 will last for some days, it by degrees wastes away ; still 
 the renewals are required less frequently than when the 
 cotton and spirit are used. 
 
 But the agents of most value are pure carbolic acid and 
 thymol ; they should be applied on a small pledget of 
 wool, and sealed up in the tooth by a larger pledget dipped 
 in a solution of some one of the resins used for the pur- 
 pose. 
 
 The treatment having been commenced, the remedial 
 agents, whatever they may be, must be applied uninter- 
 ruptedly, otherwise the chances of a successful result wdll 
 be but poor. It is useless to apply an astringent one 
 day, and on the next leave the cavity open and the pulp 
 unprotected. 
 
 It will be apparent that where the aperture in the pulp- 
 cavity is large, any kind of soft plug would, under very 
 moderate compression, adapt itself to and bear painfully 
 upon the exposed surface of the pulp. To this circumstance, 
 and to the want of perseverance on the part of the patients 
 when the teeth admit of preservation, may be attributed 
 many of our failures in the treatment of cases which at 
 the onset promised favourably. Assuming that a success- 
 ful issue may be obtained, we shall have great difficulty 
 in foretelling the time that the case will be under treat- 
 ment. I have known instances in which all signs of 
 discharge from the pulp ceased within a fortnight; but 
 I have also met with many examples which were quite 
 uncontrollable either by alcoholic solution of resins or by
 
 CHRONIC INFLAMMATION OF THE PULP. 473 
 
 astringents, or indeed by any kind of treatment short of 
 the actual destruction of the pulp itself. No doubt this 
 uncertainty as to the result is in part due to the difficulty 
 with which the diseased structure is seen, and the state of 
 disease appreciated. 
 
 The actual cautery, applied by means of the battery, at 
 one time obtained a certain amount of favour. Some 
 eighteen years since I tried the white-hot wire in the treat- 
 ment of a considerable number of cases, but failing to 
 produce any permanent advantage, the use of the battery 
 has, up to the present time, been abandoned. As a means 
 of destroying the whole body of the pulp, it is more 
 pain-producing than arsenic, and less complete in its 
 action, owing to the difficulty which attends the intro- 
 duction of the wire into the pulp-cavity of the body and 
 roots of the teeth. 
 
 Those who advocate the use of the heated wire direct 
 that the exposed surface of the pulp shall be charred, an 
 operation by which a secreting surface is reduced to a dry, 
 hard scale, and therefore for the time deprived of its se- 
 creting power. The tooth is now to be plugged, inclosing 
 the burnt tissue ; for if we do not proceed to plug the tooth, 
 the eschar will be thrown off, and will leave behind a se- 
 creting surface. There will, in fact, be a recurrence to the 
 same state of things that obtained prior to the application 
 of the cautery. But if the tooth be at once plugged, will 
 the eschar separate in the manner which eschars usually 
 separate, that is, by suppuration ; or will it detach itself by 
 desquamation ? If the treatment be successful, the detach- 
 ment of the burnt tissue must be effected by the latter 
 process, or it must remain in connection with the living 
 tissue. In the cases treated by myself, the suppurative 
 process was set up, the attendant inflammatory action ex- 
 tended to the periosteum, and the teeth were consequently 
 lost. It is possible that there are conditions under which 
 the treatment by electric cautery will be attended with
 
 474 A SYSTEM OP DENTAL SURGERY. 
 
 advantage; but it is difficult to recognise them, and in 
 the absence of precise knowledge, the operator is forced to 
 abandon the use of an agent the indirect result of which he 
 is unable to predict, and this practice has gradually fallen 
 into complete disuse. 
 
 When the exposed pulp has ceased to discharge, the 
 sooner the cavity in the tooth is sealed up the better. In 
 conducting the operation, care must be taken both to avoid 
 compressing the pulp and subjecting the tooth to an un- 
 necessary amount of manipulation. The force necessarily 
 employed in producing a gold plug, and the rapid conduct- 
 ing power of an amalgam plug, render each objectionable. 
 The disadvantage which attends the use of the latter may 
 be overcome by capping the pulp with a non-conducting 
 substance. A better result will, however, follow the intro- 
 duction of a gutta-percha plug. In this material, as pre- 
 pared for dental purposes, we have a perfect non-conductor 
 of changes of temperature; it is readily applied, perfectly 
 excludes food and saliva, and is easily removed should symp- 
 toms of inflammation of the pulp come on. A plug so 
 formed must be regarded as temporary in its effect. It 
 will last for many months, or even one or two years ; but 
 so severe a test of its durability should not be tried. It is 
 in some cases easier, and indeed better, to use zinc oxy- 
 chloride as a temporary filling ; it is less durable, but that 
 is no objection, and it can be inserted with less disturbance 
 of the covering of the pulp ; but this latter must be carefully 
 guarded against contact with the zinc salt. If, after the lapse 
 of three or four months, the tooth is free from all signs of 
 abnormal susceptibility, the gutta-percha should be removed 
 for the purpose of substituting a permanent plug. It is 
 well not to hurry the final operation, but rather to re-intro- 
 duce gutta-percha when there is tenderness or any other 
 indication Avhich would throw a doubt upon the capability 
 of the tooth to bear the insertion or the presence of a metal 
 plug.
 
 CHRONIC INFLAMMATION OP THE PULP. 475 
 
 Although every reasonable precaution be adopted, a 
 certain number of cases, which at the time appeared per- 
 fectly successful, will, after the lapse of three or four 
 months, fail. The tooth unexpectedly becomes tender, a 
 feeling of tension comes on, soon to be succeeded by throb- 
 bing pain, the usual indications of acute inflammation of 
 the pulp. Either the plug or the tooth must be removed. 
 If the former course be taken, the pulp may be destroyed 
 with arsenic, supposing the disease to be altogether within 
 the substance of the tooth, proceeding in the same manner 
 as in the treatment of acute inflammation of the pulp. 
 
 In old age the pulp, to some extent, shrivels, and be- 
 comes the seat of various degenerative processes. Thus the 
 arteries and veins become indistinguishable, and their coats 
 are kept rigid and distended by irregular calcareous depo- 
 sitions upon them. Thrombosis of the vessels occurs, and 
 the clots often disorganise, so that crystals of cholesterine are 
 found in them. The nerve trunks at the same time undergo 
 fatty degeneration, and the odontoblast layer loses its dis- 
 tinctive characters. 
 
 These same results may follow upon irritation of the pulp, 
 even in young people ; indeed, when a portion of the pulp 
 has been lost by suppuration, it is usual to find that the 
 remainder has undergone degeneration to a greater or less 
 extent, a fact which serves to explain the painless disappear- 
 ance of such pulps.
 
 ( 476 
 
 INFLAMMATION OF THE ALVEOLAE 
 rERIOSTEUM. 
 
 The inflammatory affections to which the Hning mem- 
 brane of the sockets, or the intra-alveolar periosteum (^), 
 of the teeth is liable, admit of division into the following 
 groups : — 
 
 The first will include general inflammation of the alve- 
 olar membrane affecting the socket of each tooth, or, at 
 all events, the majority of the teeth equally, and dependent 
 for its origin upon a constitutional condition, such as rheu- 
 matism, the presence of mercury or some other agent in the 
 system, &c. &c. 
 
 Local inflammation involving the sockets of one or two 
 teeth, and dependent upon a local cause, will come under 
 the second division. 
 
 The causes of periostitis about the jaw are various ; thus 
 it may be set up by the inhalation of phosphorus fumes, 
 and ultimately give rise to phosphorus necrosis. Or it may 
 arise in a scrofulous person ; or, again, as a result of syphilis 
 or rheumatism. In any case effusion of serum takes place 
 between the bone and the periosteum ; this may be absorbed, 
 or soften down into pus, or become organised into fibrin, 
 and this fibrin acrain into true bone. It is pointed out by 
 Mr. Wood that the hardening is more common in a rheu- 
 matic than in a strumous or syphilitic node, on account of 
 the greater readiness of the fibrin to organise in the former 
 
 (1) This teiin is used to distinguish the periosteum which lines the sockete 
 of the teeth from that which covers the outer walls of the alveoli.
 
 INFLAMMATION OP THE ALVEOLAR PERIOSTEUM. 477 
 
 disease, and as a consequence of this necrosis is much less 
 likely to ensue. 
 
 Intense toothache is an early symptom of rheumatic pe- 
 riostitis, which is, like other rheumatic ailments, greatly 
 affected by the weather ; there is not much tendency to 
 swelling or to suppuration, w hereas in scrofula r periostitis 
 the pain ^ often sl ight, and thes welling is usually coi> 
 siderable. 
 
 At the outset of general inflammation of the intra-alve- 
 olar periosteum, the first indication of the presence of disease 
 is found in the teeth. The uneasiness in the first instance is 
 of that kind which provokes a disposition to grind them for- 
 cibly together. For the moment, the. pressure of the teeth 
 into their sockets gives relief, but the feelings of discomfort 
 speedily return, and in the course of time they become un- 
 pleasantly sensitive to pressure. This is succeeded by a ten- 
 dency to ache slightly on their temperature being disturbed 
 by a current of cold air passing over them, or by the pre- 
 sence of hot or cold fluids. As the disease progresses, each 
 tooth feels lengthened and loosened, and can no longer be 
 used in mastication without producing a considerable amount 
 of ]>ain. The patient restricts himself to soft food, and takes 
 even that with some degree of caution. If the state of the 
 mouth be examined, we shall find that the disease has ex- 
 tended from the inner to the outer covering of the sockets 
 and to the gums; that the latter are of a dark colour, 
 thickened and vascular, with the free^edge more deeply 
 coloured than the surrounding parts. Each tooth may be 
 moved slightly'lrom side to side \vith the thumb and finger, 
 a condition due to the thickened state of the lining mem- 
 brane of the socket, and the consequent elevation of the 
 tooth from its proper level. The severity of the symptoms 
 will vary from day to day, as the general condition of health 
 is better or worse. When the disease is essentially rheu- 
 matic in character (and it is to the disease when so modified 
 that the foregoing description is more especially applicable).
 
 478 A SYSTEM OF DENTAL SURGERY. 
 
 the inflammation seldom advances beyond a congested state 
 of the vessels, with effusion into the surrounding tissues. It 
 is only in extremely severe cases that suppurative action is 
 established, and in them the secretion of pus is limited to 
 that portion of the alveolar membrane which merges into the 
 mucous membrane at the necks of the teeth. The purulent 
 discharge oozes up between the gums and the teeth, and 
 may generally be rendered visible by making pressure upon 
 the former. The s^atejs^ altogether different from that_of 
 alveolar abscess or gum-boil. In the former the pus is pro- 
 duced at the neck of the tooth, and finds a ready escape ; in 
 the latter, it is formed about the root of the tooth, is enclosed 
 within the socket, and has to find its way either l»y the side 
 of the tooth or through the alveolar wall to the surface of the 
 gum. 
 
 Prolonged inflammation of the alveolar membrane may 
 lead only to the absorption of the alveoli, and this, with the 
 consequent loosening and loss of the teeth, is the more com- 
 mon result ; but examples are not wanting to show that the 
 suppurative state may, in enfeebled and strumous subjects, 
 be succeeded by ulceration of the soft parts, and necrosis 
 of the alveolar margin, involving, perhaps, the loss of a con- 
 siderable portion of the jaw. 
 
 I have seen a few cases in which the inflammatory action 
 has ultimately led to the production of large florid granula- 
 tions. They have sprung up close to the teeth, the crowns 
 of which have been, in great part, overrun and obscured by 
 the morbid growth. The patients complained of pain and 
 tenderness in the teeth, and perfect inability to use them in 
 the mastication of food. 
 
 When inflammation of the alveolar periosteum is con- 
 nected with a rheumatic state of the system, the principal 
 indication of the presence of that disease may at times be 
 confined to the state of the teeth and gums, but the abnor- 
 mal condition of these parts, when so afi'ected, can scarcely 
 be said to present a specific character. The patient will
 
 INFLAMMATION OF THE ALVEOLAR PERIOSTEUM. 479 
 
 attribute the visitation of disease to exposure, to a draught, 
 to having taken cold, and will tell you that the feeling of 
 comfort will now, as heretofore, be restored in the course of 
 a few days. 
 
 There are, however, cases of inflammation of the alveolar 
 periosteum which present a specific character, have a specific 
 cause, and follow a specific course. One of the efi"ects 
 produced when the system is falling under the influence 
 of mercury, is a congested state of the vessels of the 
 alveolar periosteum. The teeth become tender, elongated, 
 and loose, and the breath tainted with the mercurial 
 fcetor. Let the exhibition of the mineral be continued, and 
 large sloughs will be formed upon the inflamed parts, and 
 portions of the alveoli, with the contained teeth, will be 
 lost. If, on the contrary, the mercury be discontinued 
 when the inflammatory action is, although well marked, 
 moderate in amount, the induced disease will gradually 
 subside. 
 
 The following substances are mentioned by Dr. Watson as 
 occasionally prcxlucing ptyalism. Preparations of gold, of 
 copper, of antimony, and arsenic ; also castor-oil, digitalis, 
 iodide of potassium, opium, croton-oil given internally, 
 and nitro-muriatic acid a2:)plied to the surface of the body, 
 have also been mentioned as occasionally productive of 
 similar results. 
 
 Moderate salivation, induced once or twice only, may 
 cause but little mischief, but if the ptyalism be kept up for 
 a long time, or if it be frequently induced, a permanent 
 injury will be inflicted upon the organs of mastication. 
 The production of frequent or prolonged inflammation of 
 the alveolar periosteum will be followed by the absorption 
 of the alveoli, the gums will recede, and the teeth, having 
 lost their implantation, fall out long before their destined 
 time. 
 
 The degree of mischief will depend upon the length of 
 time the system has been kept under the action of mercury,
 
 480 A SYSTEM OF DENTAL SURGERY. 
 
 but the idios3'Gcrasy of the patient will exercise a still 
 greater influence. There are those in whom a single dose 
 of calomel, or even of blue pill, will produce salivation, and 
 the second or third induce the formation of large sloughs, 
 with necrosis of more or less of the alveolar processes. 
 There are others, again, in whom it is extremely difficult 
 to produce ptyalism. 
 
 The destruction from sloughing of the soft parts in the 
 alveolar region of the mouth, consequent upon inflammation 
 commencing in the gums and intra-alveolar periosteima, is 
 sometimes so extensive that the cicatrices which follow drag 
 down and fix the cheeks firmly to the maxillfe, and limit 
 the motion of the jaw, depriving the patient of the ability 
 to open the mouth sufficiently for the ready introduction of 
 solid food. 
 
 The treatment in general inflammation of the alveolar 
 periosteum must, in cases dependent upon a bad state of the 
 system, be addressed to the improvement of the general 
 health. If the local disorder depends upon rheum atism, the 
 usual remedies for the relief of that disease should be ad- 
 ministered, such as alkalies, abstinence fr om malt liquors, 
 and fomentations or steaming of the mouth ; in some cases 
 iodide of potassium in large doses will have a most marked 
 efi'ect in cutting 'the disease short ; if the malady assumes a 
 strumous type, the remedies best suited for the treatment 
 ofs^iiiiia should be prescribed. If the disease be depen- 
 dent on an enfeebled state of the body, a gene rous diet, 
 with quinine, or some other equally active tonic, will prove 
 advantageous. 
 
 Cases which partake of the latter character and yield 
 rapidly to generous treatment, prevail towards the end of 
 the London season among those who have applied them- 
 selves too closely to business. 
 
 In aiding the general treatment, local remedies will be 
 found useful. During the__stage of cong estion, finely- 
 powdered tannin may "be rubbed upon the gums night and
 
 INFLAMMATION OF THE ALVEOLAR PERIOSTEUM. 481 
 
 morning, or even more frequently ; or the gums may be 
 pliiled with tincture of iodine (double strength). If the 
 secretions of the mouth are offensive, or if pus be formed 
 between the teeth and gums, a wash composed of eight or 
 ten grains of chloride of zinc to an ounce of water, will 
 afford relief, if held in the mouth for two or three minutes, 
 at intervals of four or six hours. When the inflammation 
 is sligM, a solution of borax in eau-de-cologne forms an agree- 
 able and effi(nenl^pplicati6n;n5uf"wlien s^^ has 
 been established, or when sloughs have formed, the solution 
 of chloride of zinc (the strength of which should be varied 
 to suit the case) will be found to produce a much more 
 rapid and beneficial effect. The foetor which attends such 
 cases is at once removed by the zinc, and the parts under- 
 going suppuration, if the general health be improved, are 
 brought into a more healthy state. A state of inflammation 
 havingbeen established from a general cause,"is' sometimes 
 kept upBy 'two or three defective teeth. Now, whatever 
 may be~trie nature of the defect, in the absence of a speedy 
 and complete remedy, the teeth should be removed. 
 
 Local I nflammation involving the periosteal investment of 
 the roots of one or two teeth. — It will be convenient to con- 
 sider this subject under the two heads of active, or acute, 
 and chr onic in flammation. "' '• 
 
 Under the former will be placed cases which terminate in 
 alveolar abscess, as distinguished from those cases of chronic 
 disease in which the periosteum remains in a state of inflam- 
 mation without proceeding to suppuration, excepting at the 
 point where the gum and the periosteum meet. Such cases 
 will fall under the latter division. 
 
 Acute inflammation of the dental periosteum, when con- 
 fined to the alveoli of one or two teeth, usually arises in 
 connection with, and as a distinct sequence of, pre-existing 
 disease in the involved tooth or teeth. Examples are, how- 
 ever, not wanting to show that this disease may be established 
 in the sockets of teeth perfectly free from caries, and appa- 
 
 2 I
 
 482 A SYSTEM OF DENTAL SURGERY. 
 
 rently from any other morbid condition ; these cases are 
 probably referable to one or other of the causes of general 
 periostitis which have just been enumerated. Whatever may 
 be the exciting cause, the symptoms of the disease present 
 but little variety, excepting as respects their intensity, the 
 rapidity with which the different phases of inflammation 
 succeed each other, and the extent to which the neighbouring 
 parts become involved. 
 
 The inflammatory action usually sets in with feelings of 
 slight uneasiness and tension, sensations which excite a strong 
 desire to press by the opposing teeth, or to shake with the 
 fingers, the affected tooth in its socket. Slight, steady pressure 
 of the fang into the jaw gives relief, but the uneasiness 
 returns on the pressure being withdrawn. The sense of 
 uneasiness is soon followed by a dull, heavy pain, and the 
 tooth feels to be longer than its fellows. The desire to move 
 the tooth in its socket continues, till disease has rendered the 
 parts so tender that pressure can no longer be borne, and even 
 the mouth cannot be firmly closed without pain. 
 
 The existence of disease within the socket is soon shown 
 in the gum, which becomes swollen and tender opposite the 
 fangs of the tooth whose periosteum is affected. In addition 
 to this latter symptom, and often prior to its appearance, 
 the free edge of the gum assumes a deep red colour, unac- 
 companied by pain, tenderness, or noticeable swelling. 
 The neck of the tooth appears encircled with a well-defined 
 red ring. This symptom is usually present in the earlier 
 stage ; but as the disease advances the distinction is lost in 
 the general inflammation of the gum. The pain becomes 
 more severe, but still preserves its heavy, wearing character, 
 and though not always constant, is seldom absent for many 
 successive hours. 
 
 If the progress of the disease be unarrested, the periosteum 
 becomes detached from the cementum, and the point of sepa- 
 ration usually commences at, and extends from, the foramen 
 in the root of the tooth. Into the interval thus formed pus
 
 INFLAMMATION OF THE ALVEOLAR PERIOSTEUM. 483 
 
 is poured from the separated surface of the periosteum. The 
 fang at this part loses its vitality, and is bathed in pus, the 
 quantity of which is gradually increased, space being gained 
 in the alveolus for the dilatation of the abscess at the expense 
 of the bone. The extent to which the alveolus becomes 
 excavated will vary with each case. It may be hollowed out 
 to a very limited extent around the apex of the root, or a 
 large cavity may be formed, exceeding in dimensions that 
 which has been made the subject of the accompanying figure. 
 The size of the abscess will depeud upon the activity of the 
 symptoms, the time the pus js pent up, and the state of 
 health of the patient. 
 
 Fig. 194. (1) 
 
 So soon as suppuration is established a process is set up 
 for liberating the secretion. Either the periosteum becomes 
 detached from the neck of the tooth, and the pus finds its 
 way by the side of the socket and passes out at the edge of 
 the gum, or a perforation is made in the wall of the alveolus, 
 through which the contents of the abscess pass into the sub- 
 
 . (I) An upper jaw in which the effect of alveolar abscess in excavating the 
 bone is shown.
 
 484: A SYSTEM OF DENTAL SURGERY. 
 
 stance of the gum. At this stage of the disease we have a 
 kind of double abscess — an abscess with a constriction, one 
 division of which is situated in the gum, and the other within 
 the alveolus, the two being connected by a small opening 
 through the alveolar plate. If the disease be left to run its 
 own course, the contents of the abscess will sooner or later 
 find their way to the surface and escape. But the time 
 occupied in the process will depend upon the situation of the 
 disease, upon the condition of the parts piior to the advent 
 of disease, and upon the general condition of the patient. In 
 those who are in strong health, the formation of an alveolar 
 abscess is soon succeeded by swelling of the gum and the 
 escape of the pus. But in patients who are in a debilitated 
 condition the disease advances more slowly ; the products of 
 suppuration accumulate, and a large abscess is formed, at the 
 expense, perhaps, of the sockets of several adjoining teeth. 
 Considerable mischief may have been produced before the 
 natural relief by the spontaneous bursting of the abscess is 
 obtained. The pus, instead of escaping into the mouth, may 
 find its way to the surface of the face, or into the antrum. 
 The latter result is, of course, only likely to occur when the 
 disease has originated in the bicuspid or molar teeth of the 
 upper jaw ; a case, however, came under my notice in which, 
 on the extraction of a central incisor in consequence of 
 alveolar abscess, a perforation into the antrum was found to 
 exist. The previous symptoms of abscess of the antrum had 
 been but little marked. There is no tooth from the socket, 
 of which an abscess may not extend to the surface of the face. 
 Instances are sometimes met with of an abscess connected 
 with the root of a lower incisor tooth opening under the chin, 
 and more rarely, opening in front of the chin. 
 
 Abscesses resulting from difficult eruption, or caries of the 
 
 wisdom teeth, occasionally pass forwards inside the mouth, 
 
 and open near the canines or bicuspids ; or they may pass 
 
 backwards and burst into the fauces (^) ; they are not 
 
 (1) Transactions of the Odontological Society, 1858, p. 53.
 
 HfTLAMMATION OP THE ALVEOLAR PERIOSTEUM. 485 
 
 uncommonly productive of very considerable constitutional 
 disturbance, and are prone to cause trismus, of which one 
 case is recorded as having lasted"~as long as nine months, and 
 at the end of that time having been cured by the removal oH 
 the tooth. 
 
 "A case of abscess resulting from a first molar is mentioned 
 as having in the first instance burst below the jaw ; the 
 formed pus gravitating down the neck, a second opening 
 lower down resulted, and finally two sinuses opening below 
 the clavicle were established. 
 
 And even death may ensue from these abscesses ; thus 
 M. Robert Q) records a case in which abscess around a lower 
 wisdom tooth was followed by necrosis, and purulent infil- '^ 
 tration of the side of the neck, from which the patient's death 
 resulted. 
 
 Extensive alveolar abscess not uncommonly results in 
 partial necrosis of the bone, and as a consequence death has 
 been known to ensue in several instances, but these can be 
 more aj^propriately treated of under the head of Necrosis. 
 
 When the lower molar or bicuspid teeth cause an abscess 
 which finds exit on the face, the opening is usually below the 
 attachment of the buccinator muscle, and collections of matter 
 formed about the wisdom teeth often pass between the 
 muscles and bone, and escape at the angle of the jaw. It 
 will generally be found that, in cases where the abscess 
 bursts externally, the ends of the roots of the teeth pass 
 beyond the level at which the mucous membrane is reflected 
 from the cheek to the gums (Salter). Under certain cir- 
 cumstances the abscess sac may become a serous cyst, as is 
 mentioned by Mr. Salter ; this, which may occur in all parts 
 of the body, is sometimes attended with peculiar consequences 
 in the jaw, for the cyst may enlarge between the plates of 
 the alveolus, and thus give origin to cystic disease of the 
 jaw. 
 
 Suppur tion in the lymphatic glands is a frequent sequence 
 (1) Conferences de Clinique Cblrurgicale. Paris. 1860.
 
 486 A SYSTEM OF DENTAL SURGEEY. 
 
 of alveolar abscess, and is especially prone to happen in 
 strumous subjects. 
 
 A collection of pus formed in the socket of an upper in- 
 cisor, will sometimes burrow along between the bone and 
 periosteum of the hard palate, and open upon the surface of 
 the soft palate ; in other cases, the periosteum is separated 
 from the one side of the hard palate, and forced downwards 
 to a level with the crowns of the teeth by the accumulated 
 pus. The pressure caused by the abscess, which often be- 
 comes chronic, may cause absorption of a portion of the 
 palatine process of the superior maxilla, as occurred in a case 
 recently under observation. For some reason not very ap- 
 parent, abscess on the palate almost invariably proceeds from 
 a lateral incisor. A case has lately been recorded in which 
 pus dripped down behind the velum ; it was found to 
 proceed from an alveolar abscess about the fang of a lateral 
 incisor. 
 
 The opening of the abscess, whether effected by nature or 
 by the hand of the surgeon, forms an epoch in the complaint. 
 The symptoms from that time gradually subside, the pain dies 
 away, and the swelling rapidly diminishes, leaving a small 
 opening through which pus will continue to be discharged. 
 The coats of the abscess gradually contract, and close upon 
 the root from which they had become separated. The separa- 
 tion of the two parts is, however, permanently maintained. 
 While the inner surface approaches the root of the tooth, the 
 outer surface of the coats of the abscess becomes thickened, 
 and occupies the space which would otherwise be left between 
 the expanded alveolus and the collapsed abscess. In extract- 
 ing teeth which have been the cause of alveolar abscess, the 
 coats of the abscess are sometimes withdrawn entire, and 
 an opportunity of observing the preceding conditions is 
 afforded. 
 
 Such, then, are the events which, in the ordinary course of 
 the disease, mark the progress of alveolar abscess. Excep- 
 tional cases now and then occur, in which the local are accom-
 
 INFLAMMATION OF THE ALVEOLAR PERIOSTEUM. 487 
 
 panied by severe constitutional symptoms, amounting perhaps 
 to fever and delirium. Such instances are, however, of com- 
 paratively rare occurrence ; indeed, it is wonderful how much 
 mischief may be done to the alveolar processes without 
 exciting any great amount of either local or constitutional 
 disturbance. An abscess enclosed in the substance of any 
 other bone, in the manner an alveolar abscess is at its com- 
 mencement shut up in the jaw, would, instead of producing 
 two or three days of toothache and a swollen face, confine 
 the patient to his room for weeks. 
 
 It is not uncommon for an abscess on the hard palate to 
 pass into a chronic condition, and remain almost unnoticed 
 by the patient for months, or even years. 
 
 Alveolar periostitis may, however, move more slowly 
 through its various stages. A considerable length of time 
 may intervene between the commencement of inflammatory 
 action and the formation of pus, and in the mean^vllile the 
 patient may be the subject of violent intermittent attacks of 
 pain, not, perhaps, confined to the tooth alone, but often 
 extending to the face and head, in which situations the pain 
 may be far more intolerable than in the tooth itself. 
 
 In cases answering to the foregoing description, it will fre- 
 quently be found that dental exostosis, slight in amount, 
 perhaps, yet distinguishable, has commenced on the surface 
 covered by, or in close proximity to, the inflamed tissue. 
 
 In other cases, again, the separation of the inflamed tissue 
 is limited to the apex of the fang, through the canal of which 
 the pus oozes ; but the relief is then only partial, and the 
 periosteum continues to thicken, and the alveolus to enlarge, 
 to make way for the increase in size of the diseased membrane. 
 The pain is intermittent, and often simulates in its character 
 tic-douloureux. The condition I have described is more fre- 
 quently found associated with stumps than with teeth the 
 crowns of which are but partially decayed ; and it is common 
 to find the extremities of several contiguous stumps similarly 
 involved.
 
 488 A SYSTEM OF DENTAL SURGERY. 
 
 The disease under consideration may assume yet another 
 character : it may begin so gradually, and advance towards 
 suppuration so slowly and painlessly, that the patient is not 
 aware of its existence until he discovers a timiour on the 
 gum, or the contents of an abscess escape into the mouth ; 
 so little inconvenience is felt that the occurrence is forgotten, 
 until, from some cause or other, the canal leading to the 
 alveolus containing the remnants of the disease becomes 
 closed, and pus re-collects. The contents of the abscess 
 again find their way to the surface, and the comfort of the 
 patient is restored. Sooner or later the disease assumes a 
 more active form, and necessitates the removal of the 
 tooth. 
 
 Cases of this passive character are sometimes productive of 
 sympathetic pain, and should not, therefore, be lost sight of. 
 The gum, too, over the affected alveolus, frequently becomes 
 thickened, minutely nodulated on the surface, and assumes a 
 mottled hue. 
 
 The fistulous opening of a chronic alveolar abscess is some- 
 times situated on a long papilla-like process, projected out 
 from the gum to the extent of a quarter or even half an inch. 
 It may be flexible, and lie flattened upon the contiguous 
 gum, or the character of a dense hard granulation may be 
 assumed. 
 
 In any description of case, should the inflammation be 
 acute in the first instance or subsequently, and the system 
 in an unfavourable state, the diseased action may, and often 
 does, extend to the periosteum of the body of the jaw, and 
 if not speedily subdued, occasion thickening of the bone, or, 
 even worse, it may terminate in necrosis of a considerable 
 portion. I have known three-fourths of the under jaw lost 
 from disease commencing in the dental periosteum of one 
 tooth. In more favourable instances, the disease may creep 
 on only to the adjoining teeth, occasion their loss, and then 
 end. In the great majority of cases, however, the inflamma- 
 tion does not spread : the pus makes its way to the surface,
 
 INFLAMMATION OF THE ALVEOLAR PERIOSTEUM. 489 
 
 and a fistulous opening in the gum, with slight thickening 
 of the surrounding parts, remains to mark the spot. 
 
 Several specimens in my own collection show that active 
 inflammation of the dental periosteum may arise in connec- 
 tion with a tooth without our being able to trace the cause 
 — that a large alveolar cavity may be formed, the involved 
 tooth .and the neighbouring parts being, so far as we can see, 
 healthy. In nineteen cases out of twenty, however, the 
 disease follows or results from, or is an extension of, inflam- 
 mation of the dental pulp, or is consequent on necrosis of 
 the whole or a j^art of the fang of a defective tooth. 
 
 Treatment. — The pulp-cavity and fangs should be 
 thoroughly cleared out, and a dressing of carbolic acid or 
 thymol introduced, and renewed every day. Local bleeding 
 frequentlj^ fails to afford relief in inflammation of the pulp ; 
 but when the dental periosteum becomes the seat of disease, 
 the abstraction of blood is our best remedy. If adopted at a 
 sufiSciently early stage, it seldom fails to produce relief, and 
 frequently cuts short the disease. One or two leeches should 
 be applied, by the help of a leech-tube, to the gum, opposite 
 the end of the root of the affected tooth, and in connection 
 with the local bleeding an aperient may be given. 
 
 The gum over the affected tooth should be stronaly and 
 repeatedly painted with tincture of iodine, and Fleming's 
 tincture of aconite may be advantageously applied, though 
 caution is required in using so potent a drug in the mouth. 
 If the inflammatory action has gone on for a day or two, it 
 is probable that suppuration cannot be avoided, especially if 
 the affection has spread to the gum. In that case, the tooth 
 should be removed, and if there is reason to suspect that pus 
 is lodged in the substance of the gum, the part should be 
 freely incised. 
 
 A doubt may sometimes arise in the dentist's mind 
 whether, under certain circumstances, the removal of a tooth 
 is desirable. Thus, it may not be clear that the tooth was 
 the original source of the disease, which may have been due
 
 490 A SYSTEM OF DEXTAL SURGERY. 
 
 to rheumatism, to struma, or to syphilis ; or again, the 
 patient may have already suffered from syphilitic necroses 
 elsewhere, and slight wounds be prone to take on ulcerative 
 action. If the disease can be traced to rheumatism, the teeth 
 should not be extracted, even though they are very loose, as 
 the probability of a favourable termination is great. But if 
 the disease appears to be connected with struma or syphilis, 
 no hesitation need be felt in removing any carious teeth, as 
 they are far more likely to cause extension of the mischief 
 by remaining as sources of irritation, than the operation is 
 likely to do mischief. And even though the involved teeth 
 be sound, when once syphilitic or strumous periostitis has run 
 on to a considerable len;zth, the destruction of the involved 
 t^eth by the death of their socket is probable, and the ex- 
 traction of greatly loosened teeth may become the best 
 course. 
 
 The removal of the involved tooth, however skilfully per- 
 formed, is not always followed by a cessation of pain ; on the 
 contrary, the degree of suffering is sometimes for awhile in- 
 creased, arising, no doubt, from the laceration of the inflamed 
 tissues. The duration of the after pain will generally be 
 proportioned to the extent of the inflammation, and to the 
 amount of sympathetic pain previously excited. 
 
 In all cases of pain after the operation of extraction, the 
 vacant socket should be sponged out with a loosely-rolled 
 pedget of cotton steeped in phe'nol sodique, or in the fol- 
 lowing substitute for that preparation — 
 
 R. Acidi carbolic! glacialis, 5J. 
 Liquoris potass^e, .^j. 
 Aqu£e, ad. S^iij. 
 
 This will usually give very great relief, and the wool may 
 be suffered to remain for a day or two, if the pain tends to 
 return on its removal. But it will often be found that one 
 or two applications of the fluid will dispel the severe pain, 
 and that the wool need not be left in the socket. Should
 
 INFLAMMATION OF THE ALVEOLAR PERIOSTEUM. 491 
 
 this fail, the sufferer should be directed to hold a strong 
 and hot decoction of poppy-heads in the mouth, and to 
 renew the mouthful when it ceases to feel hot. This applica- 
 tion should be continued till the pain abates, an event which, 
 even in the worst cases, may be looked for within an hour 
 or two. 
 
 If from any cause the removal of the tooth be inex[iedient, 
 we must then do what we can to relieve the pain ami to 
 reduce the disease to a state of passive gumboil. When 
 there is reason to believe that pus has not been formed, a 
 leech may be applied to the gum, and aperients given ; but 
 should you find a circumscribed swelling over the tooth, it is 
 pretty certain that pus is making its way outwards, and its 
 progress will be hastened by the use of the gum lancet. The 
 best instrument for this purpose is a short and strong double- 
 edged scalpel, which should be thrust forcibly down to, and, 
 if possible, through, the spongy bone overlying the abscess 
 sac. By thus anticipating the drilling through of the alveolus 
 by the abscess, the patient is saved much suffering, which in 
 the majority of cases ceases with the perforation of bone, 
 whether this be effected by nature or by art. Wherever there 
 is great general swelling and tenderness, great relief may be 
 given by a free incision, and by drilling through the bone 
 with a large and sharp broach over the apex of the fang. It 
 is easy to distinguish by touch when the instrument reaches 
 the fang, and the operation gives far less pain than might 
 have been anticipated. 
 
 Previous to making the incision, the gum may be painted 
 over with the following solution — 
 
 Bt, Tinct. iodin. (double strength), 
 Fleming's tinct. aconit. aa, 
 
 and the track of the incision afterwards sponged out with 
 strong carbolic acid ; it need hardly be added that the 
 tincture of aconite must not be applied near a raw surface, 
 or the poisonous effects of this very potent drug might be
 
 492 A STSTEil OF DENTAL SURGERY. 
 
 manifested; the more so as the susceptibility of different 
 persons to its action is very various. 
 
 When the more active symptoms have subsided, a small 
 fistulous- opening will remain for the exit of the pus, unless 
 the fluid finds its way to the surface through the fang. It 
 is quite possible that the coats of an abscess situated in the 
 dilated alveolus may embrace the necrosed extremity of the 
 fang, and cease to secrete ; in which case the gum would 
 heal perfectly, leaving the end of the tooth in a similar posi- 
 tion to that of an encysted foreign body. But I do not think 
 this event is common, neither would its occurrence be ex- 
 pected, when it is considered that the fangs of teeth admit, 
 under pressure, of a slight degree of motion. 
 
 Chronic Inflamruatioii of the Dental Periosteum, limited to 
 the alveolar membrane of one or two teeth, excepting in its 
 extent, and dependence upon a local cause, resembles in 
 character that form of disease which has been described under 
 the head of general inflammation of the alveolar periosteum. 
 
 After a case has passed through its earlier stages, there is 
 some difficulty in determining whether the malady originated 
 in the gum or in the periosteum. At the outset the margin 
 of the gum exhibits increased vascularity, becomes slightly 
 thickened, and bleeds readily. If allowed to run its course 
 uninterruptedly, the inflammation passes from the tissues about 
 the neck of the tooth towards those which surround the root. 
 The tooth becomes loose, the edge of the alveolus disappears, 
 and the gum sinks down. By slow degrees the tooth loses 
 its implantation and falls out. Generally the disease is 
 attended with but little pain, excepting such as is produced 
 by force applied to the loosened tooth. 
 
 Tooth after tooth may be, and in old people frequently is, 
 lost, till the mouth becomes edentulous. 
 
 The inflammation may, however, take a more active form. 
 We shall then have pus secreted from the surface of the 
 diseased tissue, and granulations may spring up from the 
 margin or from within the socket.
 
 INFLAMMATION OF THE DENTAL PERIOSTEUM. 493 
 
 Thus suppuration may occur around the roots of several 
 healthy teeth in strumous or syphilitic persons, as has already 
 been mentioned, and this is especially apt to occur about the 
 incisors. 
 
 Among the causes which excite chronic inflammation of 
 the dental periosteum may be enumerated, the collection of 
 tartar, a ligature about the neck of a tooth, or pressure 
 applied in an oblique direction by an antagonistic tooth. 
 
 The treatment will depend upon the nature of the exciting 
 cause. If a local cause be detected, its removal must be the 
 first step in the treatment ; afterwards astringents, such as 
 tannin applied to the gums, will assist in restoring the part 
 to a more healthy condition. In patients of advanced age 
 treatment produces but temporary relief, more especially if 
 the antagonism of the upper and lower teeth is disturbed by 
 the loss of an important member of either series. But should 
 it be found that an elongated or disjilaced tooth is unfairly 
 forced upon its antagonist, or upon an adjoining tooth, and 
 is thus inducing disease in the socket of the latter, the 
 offender must be shortened by the file or removed. 
 
 In the foregoing section it has been assumed that the in- 
 flammatory action has extended over the whole circumference 
 and depth of the socket, and it is not usual to find the disease 
 confined to or more highly developed on a portion only of the 
 root of a sound tooth. But there are many cases to which 
 this rule will not apply. 
 
 When a part only of the periosteum is affected, the disease 
 presents a somewhat different aspect; it usually occurs in 
 connection with a stump, the crown of the tooth having 
 been destroyed by caries. The periosteum about the ex- 
 tremity of the tooth becomes thickened and nodulated ; the 
 socket widens as the disease advances, until the neighbouring 
 alveolus is laid open. With this state there is occasional 
 and sometimes severe pain, not necessarily confined to the 
 seat of the disease, often not in the affected alveolus at all ; 
 but it is felt in the jaw, or in the cheek-bone, or in the ear.
 
 494 A SYSTEM OF DENTAL SUBGERT. 
 
 The edge of tlie alveolus seldom becomes absorbed, so that 
 the fang is held firmly in its place. 
 
 When there are three crownless fangs in a row, and the 
 periosteum of one only the subject of chronic inflammation 
 about the end, it is extremely difficult, if not impossible, to 
 detect the offender, unless revealed by tenderness on pressure ; 
 or the margin of the gum being encircled with a red line, 
 neither of which symptoms is constant. 
 
 This bulbous state of the dental membrane (often termed 
 fungous) is occasionally found in connection with dental 
 exostosis, and sometimes with necrosis, but in the latter 
 case the disease is disposed to become active, and to end in 
 alveolar abscess. 
 
 There is but one method of treatment — the affected tooth 
 should be removed. 
 
 "When a patient suffering pain in the jaw, or face, or ear, 
 is unable to state the exact seat of pain, but is disposed to 
 ascribe it to the teeth, it will be well to remove any stumps 
 that are found in the mouth ; for the x^eriosteum of one or 
 of all of tiiem may be thickened and diseased, and this 
 will not be known with certainty till they are removed. Very 
 generally the diseased tissue is more firmly connected to the 
 tooth than to the alveolus, and is therefore drawn out with 
 the tooth. 
 
 A disease having established itself in the soft tissues sub- 
 servient to the maintenance of the teeth, the recognition of 
 its origin is at all times attended with difficulty, for no 
 sooner is the periosteum attacked than the contiguous gum 
 becomes aftected, and vice versa. This remark applies even 
 to tumours arising in this part of the body. A tumour may 
 originate in the gum, or spring from within the socket of a 
 tooth, or it may commence in the periosteum investing the 
 outer surface of the alveoli ; but in either case the growth is 
 usually described under the head of tumours of the gums, an 
 arrangement which, for the sake of convenience, will be 
 adhered to in the present instance.
 
 ( 495 ) 
 
 NECROSIS OF THE JAWS. 
 
 The death and ultimate separation of portions of the alveolar 
 margins are, in a slight degree, of very common occurrence ; 
 the thin edge of the alveoli may exfoliate after an extraction, 
 however skilfully performed, and no ill results attend its 
 doing so, save a prolongation of the healing process. But in 
 place of this very limited death of the bone, the necrosis may 
 be far more extensive, involving the com})lete destruction of 
 the alveolar portion, and even of the whole depth 
 
 Fia 195. (1) ■•■ ' : '■ 
 
 of the jaw. The causes which bring about ne- 
 crosis of the jaw are various, and cannot, in every 
 instance, be traced. 
 
 Thus, in a case recently under observation, the 
 upper canine of the left side was found to be 
 painful and slightly loose ; the pain increased, 
 some little swelling appeared, and pus was found 
 to exude around the tooth. As there seemed to 
 be no hope of saving the tooth, it was extracted ; 
 when, attached to the apex of the root, was found 
 a fragment of necrosed bone, on the upper part 
 of which, as is shown in the figure, was a hollow, smooth 
 
 (•) Left upper canine, to the apex of the fang of which is attached a frag- 
 ment of necrosed bone. The hollowed surface on the upper and right-hand 
 surface of the bone formed a portion of the floor of the nose. On the side of 
 the fang is a smooth, slightly depressed surfoce (more conspicuous in tiie figure 
 than in the specimen), which may perhaps have been due to absorption con- 
 sequent on the pressure of a neighbouring tootli ; and there is a slight eroded 
 groove at the front of the neck, but otherwise there is no visible diseased con- 
 dition to account for the necrosis.
 
 496 A SYSTEM OF DENTAL SURGERY. 
 
 surface. This was found to be a part of the floor of the nose, 
 into which air passed freely ; and fluids poured through the 
 nose in drinking. 
 
 Since the removal of the tooth some years have elapsed, 
 the aperture being covered by a process from the artificial 
 teeth which are worn by the patient. This remedies the 
 inconveniences of a communication existing between the 
 nose and the mouth ; but, although the aperture has greatly 
 contracted, it shows no disposition to entirely close up. 
 
 The most remarkable feature of this case is the entire 
 absence of any assignable cause for the mischief ; the patient 
 was a healthy man of middle age, with no history of syphilis ; 
 the tooth had been only in a very slight degree decayed, and 
 had been successfully filled with gold years previously. No 
 blow had been received ; in short, nothing whatever could be 
 discovered to account for the lesion. 
 
 Another case lately came under my care, at the Dental 
 Hospital, of necrosis occurring without any assignable cause. 
 In this case the sequestrum uas much larger, e xtend ing from 
 the secoUTi'lower molar of tlie right side to the lateraJJiic.isor 
 of tlie same side, and included the mental foramen, jmd a 
 •portion of the inferior dental canal. The teeth involved in 
 the dead bone were all sound, and the patient, whose state- 
 ments appeared perfectly reliable, could not throw any light 
 on the origin of the disease. Xo history of syphilis could be 
 elicited. 
 
 The immediate cause of necrosis is periostitis, resulting in 
 purulent effusion between the bone and the periosteum, and 
 in a large majority of cases the more remote cause of the 
 disease can be traced out. 
 
 Thus, in child rcn_of_^tj;umous diath esis, lar ge portion s 
 often necrose, and the disease_ may be, and, I think,_very 
 commonly is, set lip by a decayed tooth. The tooth-pulp 
 inflames, the inflammation extends to the periosteal lining 
 of the socket, and from ^thence^_S£r eads to the body of 
 the jaw.
 
 NECROSIS OF THE JAWS. 497 
 
 A very frequent cause of necrosis is constitutional syphilis, 
 which may lead to the destruction of any part of the jaw 
 (see page 182), though its chosen site seems to be the palatine 
 plate of the upper maxilla. A node forms on the hard palate, 
 rapidly degenerates and liquefies, and by separating the 
 periosteum from the bone, leads to necrosis, and consequent 
 perforation into the nares ; not uncommonly the morbid 
 action commences on the floor of the nares, and thence 
 penetrates the hard palate. 
 
 As has already been stated, necrosis of the alveolar portion, 
 sometimes extending further into the body of the bone, may 
 be set up by a diseased tooth, though this will happen 
 but rarely in a healthy individual. Ulcerative stomatitis not 
 very rarely leads to the exfoliation of small scales of bone ; 
 and, in fact, any form of ulceration of the gums may cause 
 this more serious mischief ; the ulcerations due to salivation, 
 to scurvy, or cancrum oris being especially prone to lead to 
 necrosis. Very extensive destruction of the bone often 
 follows exanthematous fevers, and exposure to the vapours 
 of phosphorus sets up a severe form of the disease which 
 presents several special characteristics. 
 
 Mechanical violence will often cause the death of portions 
 of the maxillaj ; thus, large sequestra often come away after 
 gunshot wounds, or after fractures; and the unskilful ex- 
 traction of teeth is caj^able of causing extensive mischief. 
 Thus,~a patient lately presented himself at the Dental Hos- 
 pital in whom the alveolar portion of the lower jaw was 
 fractured from the position of the first molar to that of the 
 lateral incisor of the opposite side. The fracture, which was 
 caused by an ineffectual attempt to extract the first molar, 
 had run horizontally round the jaw, completely separating 
 the alveolar portion from the base of the jaw. I was unable 
 to learn whether the forceps or a key instrument had been 
 used ; the treatment adopted was fixation of the fragment by 
 a gutta-percha cap adapted over the crowns of the teeth. 
 
 2 K
 
 498 A SYSTEM OF DENTAL SIJEGERT. 
 
 The detached piece, however, did not reunite ; abscesses 
 formed under the chin, and finally it was removed, in con- 
 sequence of its becoming necrosed. 
 
 Necrosis of a portion of the bone may follow upon the 
 extraction of a tooth, however skilfully this has been per- 
 formed ; and it must not be supposed that the operation is 
 always, or even commonly, to blame for the advent of 
 necrosis after the extraction of a tooth. The conditions lead- 
 ing to necrosis are, in the great majority of cases, developed 
 previously to the removal of the tooth, and are quite inde- 
 pendent of its removal ; the necrosis would generally have 
 been quite as sure, and perhaps even more extensive, had 
 the tooth been left in. There is not the smallestj^eason for 
 believing that the removaT'of a tooth shoujdjje.defeiigd 
 because the tissues around it are in a state of acute. ittfiaESr 
 mation^or suppuration : if the tooth be the exciting cause of 
 the miscTiief, there is no excuse for delaying its extraction 
 fora singlemoment ; and the opinion to the contrary, held 
 though it be l5y a number^oFmedical men, is in no degree 
 shared by dentists, and being based on no evidence whatever, 
 must take rank in the category of popular errors. 
 
 Fatal consequences have, in several instances, been known 
 to follow upon necrosis after tooth extraction. Thus, in 
 Wedl's " Pathologic de Zahne " (page 173), a case is quoted 
 from M. Leynseele, in which a portion of the lower jaw was 
 splintered in the removal of a tooth ; pus burrowed along 
 the side of the jaw, ascending by the ramus to the base of the 
 skull ; and gaining access to the cranial cavity by the foramen 
 ovale, rotundum, and spinosum, caused the patient's death 
 from meningitis. 
 
 Another case resulted from an unsuccessful attempt to 
 extract an upper molar tooth ; suppurative periostitis around 
 the tooth ensued, and rapidly spread to the body of the jaw ; 
 after a fortnight the necrosed bone was readily removed, but 
 severe rigors ensued, and the patient died, at the end of a
 
 NECROSIS OF THE JAWS. 499 
 
 month, of pyoemia, the immediate cause of death being 
 pleuro-pneumonia Q). 
 
 M. Eobert (^) also relates a case in which necrosis super- 
 vened on an abscess connected with a lower wisdom tooth ; 
 what is described as " purulent infiltration " of the side of 
 the neck followed, and the patient rapidly sank. 
 
 The disease^ may arise at any period of life, but it occurs* 
 more frequently in children than in adults ; and in the 
 for mer T ris, I think, more commonly seen in the l ower than 
 intne upper jaw. 
 
 In children the sequestrum is generally limited to the 
 sockets of one or two ternjDorary, and the crypts containing 
 the succeeding permanent, teeth ; and the situation in which 
 the disease most frequently establishes itself is that occupied 
 by the te mporary molar s. To this rule many exceptions will 
 be found?^?Ke3eaT*bone may be cast off, and leave the 
 forming permanent tooth or teeth behind, injured, perhaps, 
 but not destroyed. 
 
 Necrosis, when it occurs in adults, may fall upon any par 
 of the alveolar arch, and may arise at any period of life, 
 have seen cases in young, middle-aged, and in quite old 
 people. 
 
 The indications which attend necrosis are at the outset 
 undistinguishable from inflammation of the alveolar perios- 
 teum, but they differ as the disease advances. Instead of 
 the formation of a local and circumscribed swelling, the gum 
 over the diseased bone becomes generally thickened, tumid, 
 and of a deep red colour ; pus oozes up from the edge of the 
 gum. After a time the gum separates from the alveolus, the 
 margin of which becomes exposed. The involved tooth or 
 teeth loosen and fall out. In the course of a few weeks the 
 dead alveoli are detached from the subjacent living bone, 
 
 (1) Deutsche Vierteljahrschrift, 1872, as quoted in " Monthly Revii \t of 
 Dental Surgery," vol. i., No. 2. 
 
 (2) Conferences de Clinique (iirurgicale. Paris. 1S60. 
 
 i\
 
 500 A SYSTEM OF DENTAL SURGERY. 
 
 and lie loose in the substance of the thickened gum, bathed 
 in pus. 
 
 Pain is complained of eavly in the disease, and is com- 
 monly supposed to be toothache ; later in the course of the 
 necrosis the face becomes swollen, especially in cases of 
 Phosphorus Xecrosis, which disease, being in some respects 
 •peculiar, requires a short special description. 
 
 If the pus, which is very profusely poured out around the 
 sequestrum, does not find a ready exit into the mouth, it will 
 often point below the chin, or even pass down the neck be- 
 neath the fascia, thus sometimes reaching as low as the 
 clavicle. In the case of the upper jaw the pus usually makes 
 its ^\ay into the' mouth. 
 
 FhospJiorus Xecrosis. — A peculiar form of necrosis affecting 
 the jaws has been repeatedly observed in persons whose 
 duties expose them to the vapours of phosphorus. So 
 numerous are the cases, and so clearly is their history 
 traceable, that no doubt can be entertained that the phos- 
 phorus is the actual cause of the disease. There is a 
 prevalent idea that the lower more frequently suffers 
 from the disease than the upper jaw, but this is not 
 borne out by statistics, as out of fifty-one cases collected 
 by Yon Bibra, both jaws were affected in five instances, 
 the upper alone in twenty-one, and the lower alone in 
 twenty-five. 
 
 One fact connected with the origin of this disease gives it 
 a special interest in the eyes of the dental surgeon ; there is 
 a considerable amount of evidence in favour of the view that 
 the poison acts locally, but that in the first instance it cannot 
 attack an unbroken surface. Hence, it usually gains access 
 to the bone through the socket of an extracted tooth, or 
 through the cavity of a carious tooth, exposure of the pulp 
 being, according to Mr. Salter Q), the only manner in which 
 it gains access. 
 
 (1) Holmes's " Dictionary of Surgejy," vol. iv., p 39.
 
 PHOSPHORUS NECROSIS. 501 
 
 It is stated that the disease has never been known to occur 
 in a person whose teeth were sound ; whilst many who have 
 worked for years with impunity, have only been attacked 
 after teeth had become carious. The experiment of Yon 
 Bibra fully confirmed this opinion ; he exposed rabbits to 
 phosphorus fumes, and found that they experienced no 
 injury so long as the teeth and jaws were intact, but that if 
 teeth were extracted, or the jaw otherwise exposed, necrosis 
 speedily followed. 
 
 The disease very rarely occurs, except in the jDcrsons of 
 lucifer-match makers, but Mr. Paget quotes an instance 
 where it was induced by the inhalation of phosphorus fumes 
 as a quack remedy for nervous depression ; and Mr. Heath 
 {op. cit., p. 115) quotes Grandidier to the effect that a case 
 had been met with in a child but six weeks old. This case 
 is remarkable inasmuch as the teeth were not yet erupted, 
 so that the poison seems to have obtained access through an 
 unbroken surface. 
 
 This form of necrosis is, perhaps, the most severe of any 
 which is met with ; its symptoms do not markedly differ 
 from those of necrosis induced by other causes, save in their 
 severity. 
 
 The swelling of the soft part is very great, and the in- ; 
 tegument becomes very red and shining ; the suppuration, j 
 which may give rise to external fistulous openings, though I 
 the bulk of the pus is generally discharged into the mouth, 
 is very profuse. The advent of suppuration is marked by 
 rigors and pyrexia, and in severe cases by delirium ; after it 
 is fully established the severity of the constitutional symp- 
 toms abates, though the patient's health suffers very greatly 
 from inability to take solid food, from swallowing decom- 
 posing pus, and from exhaustion. Gangrene of the soft parts 
 or erysipelas may supervene as complications, and terminate 
 the patient's sufferings. Still, the majority of cases recover 
 with considerable loss of bone. In the case of the lower 
 jaw a very large amount of callus is thrown out around the
 
 502 A SYSTEM OF DENTAL SURGERY. 
 
 seques trum; -while in the case of the upper jaw little o r 
 none is found. 
 
 4.'iiy buiiy deposit which is thrown o ut in phosphorus 
 necr osis is p eculi ar in appearance, and has peen compared to 
 pumice-sWe ; al thougli usually present i n" great qiianTitj , 
 it % llt^r invariably to be ibund, and IB llie example tere 
 
 Fig. 196. 0") 
 
 figured it was apparently absent. It is also exceptional for 
 a portion of the jaw to be affected in phosphorus necrosis, 
 the destruction more commonly involving the whole body of 
 the jaw, the ascending rami alone remaining intact. It is, 
 of course, impossible to say how far the disease might have 
 extended had the patient lived ; but the necrosis in the 
 specimen does not reach far beyond the middle line, though 
 no attempt at se];aration has as yet been made. 
 
 The new bone thrown out seldom surrounds the sequestrum, 
 but generally forms a trough in which the dead bone lies. 
 
 The separation of the sequestrum usually takes a very 
 long time, often a year or more ; but the surgeon must on 
 no account be tempted to remove it before it is detached. 
 All that can be done is to support the patient's strength by 
 a generous diet, and by tonics ; though the duration of the 
 disease renders the avoidance of drugs, as far as possible, 
 
 (1) Jaw from a lucifer-match maker, aged 35, who died whilst suffering from 
 phosphorus necrosis. The bone is diseased from the base of the left ramus to 
 a point slightly beyond the symphysis.
 
 EXANTHEMATOUS NECROSIS. 503 
 
 desirable. The mouth should be frequently syringed out 
 with lotions of Condy's fluid, or phenol sodique. 
 
 Dr. Garretson advises the insertion of pledgets of cotton- 
 wool into the sinuses, with a view of hastening the separation 
 of the periosteum, which is already inevitable. 
 
 Large quantities of pus will be swallowed, but it is de- 
 sirable to avoid the formation of any external sinuses, and to 
 induce the discharge of pus into the mouth, as the sinuses 
 would afterwards prove very troublesome. 
 
 In the upper jaw there is a greater tendency to recurrence, 
 but the course of the disease is not so violent, and the 
 necrosed portions may be removed much sooner. 
 
 It is stated by Mr. Salter that in this form of necrosis 
 there is no great tendency to extension of the disease ; the 
 whole region affected is attacked at once, from the very first, 
 that is to say, at the period of the first attack of acute 
 inflammation. 
 
 Exanthematous Necrosis. — During convalescence of children 
 from tha^jetilEtive fevers, and particularly after scarlatina, 
 portions of the alveolar border of tlie jaw, very commonly 
 including the developing permanent teeth, are found to 
 exfoliate. 
 
 The course of the disease is not usually violent, and all 
 that will be jeguired is _to_ieai0.ve the fragments as they 
 beconie loose. Otto Weber Q), however, mentions the occur- 
 rence of far more severe cases, which threatened gangrene 
 from the excessive infiltration of the soft parts : in such 
 cases free and deep incisions would be required. The disease 
 is remarkably symmetrical, affecting the two sides of the 
 mouth alike ; it is most frequent about the age of five or 
 six years, though it has been met with at a later age. 
 Several examples of jaw^hecfosis^occurTing after continued^ 
 fever are to be found in the different hospital museums. 
 
 Treatment is much the same for every form of necrosis. 
 Whilst the disease is in the stage of periostitis, threatening 
 (1) " Lehrbuch der AUgemeinen und Specialen Chirurgle."
 
 504 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 to run on to necrosis, free incisions should be made through 
 the inflamed gums, and poppy fomentations assiduously 
 used. Any teeth or stumps which may be causing irrita- 
 tion should be at once removed, no matter how violent the 
 inflammation around them may be; and the practitioner 
 who is deterred from so doing by the popular idea that teeth 
 should not be removed until the inflammation has subsided, 
 is likely enough to be waiting for a time that will never 
 come, and is assuredly grievously prejudicing his patient's 
 chances of escape from the more serious ailment. 
 
 When the disease has actually reached the stage of necrosis 
 there need be no hesitation in removing a tooth which has 
 caused the disease, but the propriety of at once extracting 
 sound teeth which have become implicated by the extension 
 of the disease may be questioned. 
 
 Instances have been recorded of teeth, loosened and appa- 
 rently in a hopeless condition, having, after the removal of 
 the sequestrum, become firmly fixed, either in the remaining 
 portion of the bone or in alveoli subsequently developed. 
 
 /-ly. 197.(1) 
 
 The sequestrum here figured contains (a) the sockets of the 
 canines and bicuspids, and the history of the case, related 
 
 (1) Sequestrum containing the symphysis (6) and the sockets of the bicuspid 
 find canine teeth. From a drawing by Mr. de Morgan. " Lectures on Dental 
 Physiology and Surgery," by J. Tomes, F.R.S.
 
 EXANTHEMATOUS NECROSIS. 
 
 505 
 
 by Mr. Sharp at the Medico-Chirurgical Society Q), is 
 briefly as follows : — 
 
 The disease had comraenced with toothache, six months 
 previously, followed by alveolar abscess, and a fistiilar opening 
 under the chin. Extensive ulceration of the integuments 
 under the chin had ensued, and after the lapse of two months 
 it was thought that the sequestrum was detached. I'he 
 existing sinuses under the chin were thrown into one, and 
 the dead bone, amounting to about two-thirds of the lower 
 jaw, easily removed with forcejDS. The teeth, with the 
 exception of a bicuspid which had been extracted, remained 
 in their places, and became tolerably firm, notwithstanding 
 the entire destruction of their original alveoli. 
 
 Mr. Heath (op. cit., p. 123) has collected several other 
 cases in which the teeth remained firm after the removal of 
 sequestra which contained their sockets, and" were in a 
 measure useful to the patient ; though in other cases they 
 were inconveniently loose, and were subsequently removed. 
 Mr. Heath also relates a case in which the teeth remained 
 firm after very extensive necrosis of the outer plate of the 
 alveolus, the inner having remained to serve as a support. 
 
 It has been usually supposed that restoration of bone after 
 necrosis was effected by the periosteum, and in most in- 
 stances this is certainly the case ; Mr. Thomas Smith Q) 
 has, however, met with an example of new formation of 
 bone, which he considers could not have been derived from 
 periosteum. 
 
 Mr. Salter (^) points out that the newly-formed lower jaw 
 is apt to be absorbed, and to dwindle down to a mere bar ; 
 and adds, "How far this lo ss by absorption of supplemental 
 bone may "be prevented by supplying it with a function 
 througli the means of artificial teeth^^is a question of theo- 
 retical interest and of practical importance.^ 
 
 (1) Medico-Chirurgical Tratisactions, vol. xxvii., p. 432. 
 
 (2) St. Bartholomew's Hospital Reports, vol. i. 
 
 (3) Holmes's "Dictionary of Surgery-," vol. iv.
 
 506 A SYSTEM OF DENTAL SURGERY. 
 
 It is a curious fact that there is rarely or never any repair 
 by bone after necrosis of the upper jaw, though in children, 
 and more particularly after exanthematous necrosis, the gap 
 is often filled up by liGrous tissue. ' ^ 
 
 Disease Th'a' temporary tooth will sometimes set up in- 
 flammation, which in a strumous or enfeebled subject may 
 spread, and ultimately involve a large portion of the jaw, 
 and result in necrosis. The teeth, whether permanent or 
 temporary, implanted in the sequestrum, are usually lost. 
 Mr. Oliver Chalk relates several cases in which portions of 
 the jaw, including the temporary and the crypts of the per- 
 manent teeth, were lost. New bone eventually took the 
 place of that which had been removed, and the jaw again 
 became perfect. In several of these cases, permanent teeth 
 most unexpectedly made their appearance, suggesting the 
 idea that the teeth, as well as the bone, had been reproduced. 
 In each instance in which this unusual result occurred, the 
 sequestrum was allowed to become perfectly separated and 
 quite loose, before its withdrawal through the opening which 
 already existed was attempted. The phenomena, as respects 
 the teeth, admit of explanation on other grounds than that of 
 suf>posing a second series of permanent teeth to have been 
 developed. 
 
 Dead is in all cases detached from living bone, by absorp- 
 tion of the layer of the living tissue which connects the two ; 
 in addition to which, we commonly find marks of absorption 
 scattered over the whole of that surface of the sequestrum 
 which has been connected with the soft parts. Again, the 
 apertures of the crypts are by the same process greatly 
 enlarged. The connection between the walls of the crypt 
 and the sac of the developing tooth-pulp is in the normal 
 state but a slight one ; and this, in the character of cases 
 referred to, may be rendered still more slight by the presence 
 of disease. Xow, in the presence of the foregoing conditions, 
 it is not improbable that the pulps of the permanent teeth 
 remained attached to the soft parts, while the crypts included
 
 EXANTHEMATOUS NECROSIS. 507 
 
 in the sequestrum were removed ; and if such were the case, 
 the developing teeth might again be surrounded by newly- 
 formed bone. The truth of this explanation of the manner 
 in which the peculiar results were brought about, is rendered 
 probable by the absence of any well-authenticated cases of 
 the occurrence of a second set of permanent teeth. 
 
 But whatever explanation be adopted, I think all will 
 agree that it [s desirable in those cases where necrosis of the 
 jaw occurs during the presence of the temporary teeth, that 
 the sequestrum should be allowed to remain until it js^ 
 perfectly detached both from the contiguous bone and soft_ 
 parts, before its withdrawal is attempted ; and that its 
 removal should be effected with the least possible injury to 
 the latter, so that the permanent teeth, if not destroyed by 
 the disease, may be placed under the most favourable cir- 
 cumstances for their future growth and evolution. ' 
 
 Before the dead is separated from the living bone a layer 
 of the latter must be absorbed, a process which has already 
 been described in connection with the shedding of the tem- 
 porary teeth. The separation of the sequestrum must be left 
 to nature. We can render no direct assistance ; but it must 
 be the business of the practitioner to see that nature has a 
 fair chance, by attending to the general health of the patient j^ 
 removing any obvious source of local irritation, and keeping 
 tlie diseased part in a cleanly state. In affecting the latter 
 purpose, a wash composed of fi ve grains of chloride of zinc 
 to an ounce of distilled water may be usedr^^Tt^wili excite 
 Eealthy action, and greatly diminish, if not entirely over- 
 come, the foetid smell which attends suppuration associated 
 with dead bone ; or dilute solutions of permanganate of 
 potash may be used for the same purpose ; the point of a 
 syringe may be inserted into the sinuses, so as to effectually 
 wash them out. 
 
 If, after the sequestrum has been separated from the body 
 of the jaw, it is entangled in the soft parts, the scalpel must 
 be used to effect its liberation. With the removal of the
 
 608 A SYSTEM OF DENTAL SURGERY. 
 
 dead bone the treatment of the case may be said to terminate. 
 The inflammatory action in the gums and contiguous struc- 
 tures, in the absence of a source of irritation, rapidly 
 subsides, and the mouth is speedily restored to a state of 
 health. 
 
 It is important, however, that the sequestrum should be 
 picked out as soon as it has become loose : if this be 
 neglected, burrowing abscesses may be formed. Thus Mr. 
 Cattlin relates a case in which a piece of dead bone from the 
 jaw jDassed down in abscess cavities, and was finally removed 
 below the clavicle ; and Mr. Wood has forcibly pointed out 
 that it is quite possible to wait too long before removing the 
 dead bone. It has already been mentioned that developing 
 permanent teeth are often lost in the sequestrum thrown off 
 in the so-called " exanthematous necrosis." 
 
 Not only, however, may the permanent teeth be exfoliated, 
 but the whole lower jaw has been known to be cast off. 
 Mr. Pollock figured and described such a case Q) ; there was 
 not a vestige of a lower jaw, which, according to the state- 
 ment of the patient's friends, had been thrown off when she 
 was two years of age. The deformity was less than would 
 have been expected. 
 
 (1) Art., " Diseases of the Mouth." Holmes's " Dictionary of^ Surgery," 
 2nd edition.
 
 ( 509 ) 
 
 ABSOEPTION OF THE ALVEOLI. 
 
 The gradual wasting of the alveolar processes, accompanied 
 by a corresponding recedence of the guras, keeps pace with 
 those general changes which attend the advance towards old 
 age. The necks of teeth become exposed, the gum con- 
 tinues to sink lower and lower till the whole of the roots are 
 uncovered, and the teeth at last fall out. The loss of implanta- 
 tion is not unaccompanied with changes in the teeth them- 
 selves. The roots are destitute of cementum, and become 
 translucent, like white horn, and retain that character when 
 perfectly dried, differing in this respect from teeth in a 
 normal state, the roots of which, when deprived of moisture, 
 are perfectly opaque. In the one the opacity is due to the 
 drying-up of the dentinal fibrils, and the consequent empty 
 state of the dentinal tubes ; in the other the fibrils are in a 
 more or less perfectly calcified condition, and are incapable of 
 shrinking up when the moisture is withdrawn from the 
 tooth ; hence, in the absence of tubular interspaces in the 
 substance of the dentine, its transparency is necessarily 
 preserved. With these concurrent changes, it is difficult to 
 determine which takes precedence, and whether they hold 
 the relation to each other of cause and effect. The evidence 
 is greatly in favour of the assumption that the consolidation 
 of the dentine in the root of the tooth in an aged subject, is 
 the precedent condition lowering the vitality of the tooth, 
 and to a certain extent reducing it to the state of a foreign 
 body, and that the socket and gum are gradually absorbed 
 as a consequence of the ebbing vitality of the part to which 
 they are subservient. This view, I think, holds good when
 
 510 A SYSTEM OF DENTAL SUEGEEY. 
 
 the phenomena are seen in those who have passed the middle 
 period of life, and also in certain other cases ; but a question 
 may be raised as to its validity on the ground of want of 
 conformity to those cases in which the crowns of the teeth 
 are lost, and the roots thereby deprived to a great extent of 
 their life, and yet the absorption of sockets and gums does 
 not follow. I believe, however, the difference of result is due 
 to a variation of the conditions. In cases of absorption of 
 the alveoli, the roots of the teeth are almost destitute of 
 cementum, whereas in the roots of teeth around which the 
 sockets and gums are preserved, the cementum is also re- 
 tained. Examples illustrating this condition will be found in 
 young or middle-aged patients whose teeth have decayed and 
 broken off close to the edge of the gum, the level of which 
 is for a certain time preserved. Sooner or later, however, 
 the edge of the alveolus recedes, and is followed by the gum. 
 There are other conditions than those already enumerated 
 under which the teeth may lose their sockets. A case re- 
 cently came to my notice in which, without any appreciable 
 wasting of the gums, the whole of the upper front teeth 
 became excessively loose and fell out. The alveoli were 
 altogether absorbed, or were greatly enlarged, but the pre- 
 sence of any manifest disease, either in the teeth themselves 
 or in the surrounding parts, could not be detected. The 
 gums were not more vascular than would be considered 
 consistent with health, and in the teeth there was a total 
 absence of that horn- like appearance previously described ; 
 indeed, the cause of the malady was too obscure to admit of 
 recognition. 
 
 Absorption of the alveolar processes may be more partial 
 than in the cases previously considered. The outer or the 
 inner plate only may disappear. The accompanying illus- 
 tration is taken from a preparation in which the labial plate 
 corresponding to the upper front teeth has been removed. 
 
 Indications of a similar change in other parts of the jaws 
 are shown, but the amount of loss is comparatively trifling.
 
 ABSORPTION OF THE ALVEOLI. 
 
 511 
 
 The more prominent or out-standing teeth are those the 
 sockets of which are most liable to become absorbed ; teeth, 
 the roots of which are but thinly covered by bone and soft 
 
 Fig. 198. (1) 
 
 Fig. 199. (2) 
 
 (') The upper and lower maxilla;, from a subjecf aged thirty, showing 
 extensive absorption of the alveolar processes of the front t?eth. 
 
 (2) The lower jaw of a male subject who died at the age of six years, showing 
 the results of absorption of the alveoli of the temporary teeth. (This figure 
 was omitted at p. 67, where the upper maxilla from the same sutnect is 
 mserted.) ^
 
 512 A SYSTEM OF DENTAL 8TJBGERY. 
 
 parts. This fact is shown in the case figured. The right 
 upper canine has lost the whole of the anterior wall of its 
 socket, while the contiguous lateral incisor, which lies back, 
 has retained the corresponding part of the alveolar invest- 
 ment. The canine teeth being the last of the front teeth to 
 take their position, are subject in a contracted jaw to stand 
 in advance of the dental arch. The course taken by the root 
 can be readily traced, and the small amount of bone and 
 gum by which its anterior surface is clothed is recognised. 
 It is from the roots of a tooth so placed that the anterior and 
 projecting wall of the socket most frequently disappears. 
 The labial surface of the root becomes exposed throughout 
 the greater part of its length, leaving the tooth dependent 
 upon the posterior or lingual wall of the socket for its 
 retention in the jaw. A prominent and comparatively 
 unsupported position would seem to offer an explanation of 
 the early disappearance of the outer plate of the alveolus, 
 but cases are now and then seen to which this explanation 
 could not be satisfactorily applied. A specimen in my own 
 collection exhibits the full complement of teeth in the upper 
 jaw, sound and well arranged, but from a bicuspid tooth the 
 whole of the labial plate of the alveolus has been absorbed. 
 
 It is in many cases very difficult to discover a satisfactory 
 cause for the premature disapj)earance of the alveolar pro- 
 cesses. The presence of inflammation of the gums, or of the 
 alveolar periosteum, or of collections of tartar about the 
 necks of the teeth, and the consequent irritation of the edges 
 of the gums, are followed as a secondary consequence by 
 absorption ; but it is to the occurrence of alveolar absorption, 
 without the precedence or accompaniment of obvious disease 
 in the soft tissues which clothe the socket, that attention has 
 been directed. The frequent use of a hard tooth-brush will 
 hasten the wasting of an out-standing socket, the corre- 
 sponding gum of which has the appearance of being stretched 
 in a thin layer over the neck of the tooth. 
 
 When the alveolar loss is general throughout the mouth.
 
 ABSORPTION OF THE ALVEOLI. 513 
 
 it will, on inquiry, very commonly be found that a similar 
 misfortune has 1 efallen other and antecedent members of the 
 family, — that the predisposition to an early failure of the 
 teeth, from the recedence of their sockets, is hereditary. 
 
 Teeth which have no antagonists in the mouth are per- 
 haps more liable to be lost in this way than those which 
 are in full use ; and it is not unusual for the bicuspids and 
 molars to be thus shed, whilst the teeth in the front of the 
 mouth remain firm. 
 
 One of the earliest indications of the advent of this state of 
 things, is a thickening and rounding of the edge of the gum, 
 which ceases to be closely adherent to the neck of the tooth. 
 
 In this sulcus between the neck of the tooth and the free 
 edge of the gum there is generally a little pus, and almost 
 always a thin ring of hard, dark tartar, invisible unless the 
 gum is forced away from the tooth. As the disease pro- 
 gresses, the tooth becomes detached from the soft parts to a 
 considerable depth, so that a piece of so-called "dentist's 
 twist " may be passed up betw- een the fang of the tooth and 
 the alveolus. At this stage there is usually a considerable 
 amount of discharge, which is peculiarly offensive, and the 
 breath of the patient has a nauseating odour, by which it is 
 often possible to tell what is the matter before inspecting 
 the mouth at all. 
 
 There is often a considerable amount of neuralgic pain 
 attendant upon this condition, which is very intimately 
 connected with chronic inflammation of the gums, and may 
 arise as a consequence of scurvy or of mercurial salivation. 
 
 The causes and pathology of the disease are very obscure ; 
 it often arises in thoroughly healthy persons w-ho have hardly 
 passed the period of middle life, and whose teeth have been 
 exceptionally free from caries. 
 
 All those teeth which have become hopelessly detached 
 from the periosteum should be removed, as there appears to be 
 some tendency to the extension of the disease from an affected 
 tooth to its neighbours. 
 
 2 L
 
 514 A SYSTEM OP DENTAL SUEGERT. 
 
 The hard, dense tartar which encircles the neck of the 
 tooth beneath or at the level of the edge of the gum should 
 be carefully removed ; not because it is, as has been supposed 
 by some, a cause of the disease — it is a secondary deposit, 
 and could never have got there without pre-existent disease 
 — but because it is a source of irritation. 
 
 If there is much discharge, the sulcus between the tooth 
 and the gum should be touched with a fragment of solid 
 zinc chloride, and the patient directed to wipe it out with a 
 camel-hair brush at least once a day, the brush being charged 
 with a solution of zinc chloride gr. v. ad ^j., or with phenol 
 sodique, a convenient substitute for which is subjoined — 
 
 R. Acidi carbolici, 5j. 
 Liq. potassfe, 5j. 
 Aquae ad ^j. 
 
 Or, if an astringent seem desirable, the following will be 
 found very eflBcient — 
 
 R. Glycerin! acidi carbolici, 
 
 Glycerini acidi tannici, aa ^ss. 
 
 If there be much congestion of the gums, they may be 
 freely lanced, and frequently painted with tincture of iodine 
 (double strength). 
 
 In some few cases much good may be done, but as a rule 
 the results of treatment are very unsatisfactory. 
 
 In the absence of an obvious cause of mischief, we can 
 but direct that the jiatient should use a soft tooth-brush, 
 employ a moderately astringent dentifrice, take care that 
 the teeth are well cleaned, and, at the same time, avoid irri- 
 tating the edges of the gums by unnecessary friction. 
 
 The use of a piece of stiff twine will be found very service- 
 able in deciding whether or not a loosened tooth should be 
 extracted ; if it can be passed up nearly to the apex of the 
 fang, on half or more than half the circumference of the 
 tooth, the chance of its again becoming firm is very small.
 
 ( 515 ) 
 
 HYPERTROPHIES OF THE ALVEOLAR PORTION 
 OF THE JAW. 
 
 A FORM of abnormal development of bone in the alveolar 
 region, which is productive of great inconvenience to the 
 patient, consists in a gradual filling-up of the sockets of the 
 teeth by bone. 
 
 After the luxation of a tooth, the socket in young and 
 middle-aged subjects is to a certain extent filled up from the 
 bottom by the development of bone. This process, which, 
 after the loss of a tooth, is reparative, becomes destructive 
 when the action is set up in the socket of a sound tooth. 
 The tooth by slow degrees becomes longer than its neighbours, 
 and after the lapse of a considerable length of time, loosens 
 and falls out, or is removed in consequence of its inconvenient 
 length. 
 
 In other cases, again, the teeth, without being extruded 
 by the development of bone within their sockets, are sepa- 
 rated from each other by the thickening of the intervening 
 bone. In some cases the shifting of position may be due to 
 derangement of the normal antagonism of the upper and 
 lower teeth ; but there are others in which this cause will 
 fail to explain the gradual separation of teeth which are 
 apparently sound and healthy. This deposition of bone 
 may also have the effect of displacing the teeth forward, thus, 
 in the case of the upper incisors, producing a very unsightly 
 appearance. The gum is usually pale, hard, and closely ad- 
 herent to the necks of the teeth. 
 
 Hypertrophy of the alveolar portion of the jaw, when 
 limited in extent, is far from uncommon. A nodule of bone
 
 516 A SYSTEM OF DENTAL SURGERY. 
 
 as large as a pea is often seen projecting from the lingual 
 surface of the lower jaw, and little or no inconvenience is 
 felt from such growths, even when as large as the half of a 
 nut ; and many instances have come under my notice in which 
 
 Fig. 200. (1) 
 
 corresponding growths have spnmg from the labial surface of 
 the sockets of the molar teeth of the upper maxilla. I re- 
 member one case in which a stout bony ridge ran out to the 
 extent of more than half an inch, and then turned upwards. 
 The patient stated that the lodgment of food on the shelf, as 
 he termed it, was the only annoyance to which the exostosis 
 subjected him (^). 
 
 Otto Weber (^) mentions the occurrence of limited exos- 
 toses and thickenings of the bone near the alveolar border, 
 and refers them to the irritation caused by diseased teeth : 
 he observes that over such exostoses there is marked tender- 
 ness on firm pressure. 
 
 Small exostoses, which seemed to be due to the irritation 
 caused by carious teeth, have in some few cases been known 
 
 (1) Shows the front teeth in the lower jaw separated from each other in the 
 median line by the thickonint; of the intervening bone, independent of the 
 presence of disease. (From Mr. Saunders's collection.) 
 
 (2) An excellent example of numerous exostoses, studded over the alveolar 
 border of thejaw, is given in " Atlas zur Pathologie der Ziihne " von Ueider 
 und Wedl, Plate xv.. Fig. 138. 
 
 (}) Oito ■\vebe)-. " Tiehrbuch der Allgemeinen et Specialen Chirurgie."
 
 HYPERTROPHY OF THE GUMS. 517 
 
 to disappear after the extraction of the teeth ; a course which 
 should, therefore, always be tried. But, as a general rule, no 
 treatment but excision of the morbid growth will be of any 
 service ; and this becomes necessary when the mass, from its 
 size or position, causes much inconvenience. Owing to the 
 excessive hardness of some of these exostoses, their removal 
 is often attended with more difficulty than was at all antici- 
 pated. A Hey's saw Avill generally be found the most suit- 
 able instrument for its removal ; it is often too hard for a 
 gouge or bone-forceps to be of much service. 
 
 In other instances the enlargement of the bone is of a soft, 
 spongy character : teeth removed in such cases come away 
 very readily, the bone conveying a peculiar yielding sensa- 
 tion to the operator, as though it crushed under the applica- 
 tion of moderate force. The enlargement slowly disappears 
 after the removal of the source of irritation. 
 
 Hyp'irtrophy of the Gums and Alveolar Processes. — In 
 some few cases a general hypertrophy, involving the whole 
 or the greater part of the gums and alveolar processes, has 
 been observed : for the opportunity of examining one of these 
 cases I am indebted to Mr. Alfred Canton. The whole of 
 the alveolar bone was greatly enlarged ; it projected upwards 
 in the lower, and downwards in the upper jaw, caiTying 
 before it a red and thickened gum, and concealing within 
 the groove formed by its lingual and labial portions the cor- 
 responding surfaces of the teeth. The thickening in the 
 front part of the mouth was so great that the lips could 
 not be closed. At the back part of the alveolar arch the 
 thickened and elevated gums of the respective jaws, though 
 flattened by mutual pressure, did not allow the molar teeth 
 to come in contact. 
 
 The patient was a half-witted, strumous child, aged about 
 thirteen years, whose appearance led to the presumption that 
 the disease was a manifestation of the strumous diathesis. 
 No treatment was attempted in this case, the patient return- 
 ing to her native village.
 
 518 A SYSTEM OF DENTAL SURGERY. 
 
 Several cases of the affection have been put on record Q). 
 A fairly characteristic case which occurred in the practice of 
 Mr. Syme, and was seen more than once by my father, was 
 met with in an adult, and affected both jaws alike. The 
 increase was slow, and no operation was resorted to ; the 
 accompanying figure is taken from a model now in the 
 museum of the Odontological Society. 
 
 Fig. 201. (2) 
 
 Another case, in which the growth was much larger, and 
 caused more distortion of the features, was successfully 
 operated upon by Mr. Pollock. 
 
 The following notes of Mr. Pollock's case are abridged 
 from Mr. Salter's (^) article. At the fifth week after birth, 
 six teeth had appeared, and it was noticed that the gums 
 were thick and puffy. At the age of two years, all the tem- 
 porary teeth were extracted, and the gums cauterised. 
 
 At the time of admission into St. George's Hospital the 
 child was eight years old ; it was remarkable for an abnormal 
 
 0) Other casps may be found in—" System of Surgery," by S. D. Gross, M.D., 
 Philadelphia, 2nd edition, vol. ii., p. 535 ; " Boston Medical and Surgical 
 Journal," April, 1869, two cases ; " Injuries and Diseases of ihe Javrs," by 
 C. Heath, 2nd edition, 1872, p. 194. 
 
 (2) From a model of the upper jaw of Mr. Syme's case. 
 
 O " A System of Surgery," by Timothy Holmes, M.A., 2nd edition, 1870. 
 Art. "Diseases of the Teeth," vol. Iv., p. 342.
 
 HYPERTROPHY OF THE GUMS. 519 
 
 development of hair, which grew low on the forehead, and 
 reached in front of the ears on to the cheeks. A large pink 
 mass, which could not be covered by the lips, protruded 
 from the mouth; it was indistinctly lobed, with a dense, 
 insensitive, skin-like surface. The greater bulk proceeded 
 from the upper jaw, which overlapped the lower, the latter 
 
 Fig. 202. (1) 
 
 being, as it were, imbedded in it. The mass was removed 
 by operation, portions of it being cut away with scalpels 
 and bone-nippers, and the removal completed at successive 
 operations. 
 
 There was a slight tendency to recurrence of the growth. 
 In structure it was found to consist of hypertrophy of the 
 alveolar border, together with immense thickening of the 
 fibrous portion of the gum, and an exuberant growth of 
 papillae. In the upper jaw it extended three-quarters of an 
 inch forwards beyond the alveolar border. 
 
 Those of the temporary teeth which had not been ex- 
 tracted were deeply imbedded in the mass, though the first 
 permanent molars had appeared, and the second lower tem- 
 porary molars were visible, as the hypertrophy was not so 
 great at the back of the mouth. 
 
 (1) From a plaster model of the upper jaw of ilr. Pollock's case.
 
 520 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 The fangs were found to be imbedded in sockets, but the 
 crowns were enclosed in serous-like chambers in the dense 
 fibrous tissue, and were free from bony surroundings. One 
 of the superior central incisors was nearly an inch from 
 the surface. The permanent teeth were excessively large — 
 the incisors larger than any which Mr. Salter had ever before 
 seen in a female's mouth — and their bony loculi had not 
 been absorbed to the extent usual at the patient's age. The 
 epithelium had become converted into a hard and thick epi- 
 dermis, beneath which were enormously long papillae, attain- 
 ing to one-sixth or one-fourth of an inch in length; this 
 papillary growth being in unity with the great teeth, excess 
 of coarse hair, thick skin, and other indications of a tendency 
 to tegumentary hypertrophy. 
 
 03. (1) 
 
 
 But by far the most remarkable example of this hyper- 
 trophy is related by Mr. MacGillivray (2), from whose paper 
 (for the use of which I am indebted to Mr. Heath) this 
 
 (1) From a photograph of Mr. MacGillivray's case. 
 
 (2) "Australian Medical Journal," August, 1871.
 
 HYPERTROPHY OF THE GUMS. 521 
 
 account and figure are taken. It is noted that the gums 
 were unusually large at birth ; of the deciduous teeth two 
 only made their appearance, and by the time that the girl 
 had reached the age of four, the growth had attained to such 
 a size that her medical man attempted its repression by 
 caustics with little or no success. At the age of ten, an 
 operation was performed in which nine completely hidden 
 teeth were extracted, and the redundant gums pared down. 
 
 When first seen by Mr. MacGillivray, the patient was 
 twenty-nine years of age ; the mouth was kept widely open 
 by great lobulated masses springiug from both upper and 
 lower jaws. These huge lobular excrescences were found to 
 spring mainly from the palatal surface of the alveolar portion 
 of the jaws, the labial surfaces being comparatively healthy. 
 Inside the mouth they reach backwards along the hard palate, 
 and project below the soft palate. The surface of the growth 
 was everywhere lobulated ; in some parts smooth, in others 
 rough from the presence of enormous papilla? ; it was no- 
 where ulcerated, and no pain was felt in the masses. 
 
 Its removal was efi'ected in three separate operations, per- 
 formed at intervals ; the lobular masses of gum being pared 
 off with a scalpel, and the. hypertrophied alveolus excised 
 with bone-forceps ; profuse hsemorrhage occurred, but was 
 arrested by the use of the actual cautery. 
 
 The patient made a good recovery, and the operation seems 
 to have been perfectly successful, both as regards the patient's 
 appearance — she now being able to close the mouth — and as 
 regards the recurrence of the disease. 
 
 In tins case, as in Mr. Erichsen's, which was examined 
 by Mr. Bruce, no abnormal structures were found : it was 
 a case of true hypertrophy, in which some of the papilla3 
 attained the enormous length of half an inch. 
 
 In most, though not all of the cases, the disease appears 
 to have been first noticed at a very early period — in fact, is 
 probably congenital. It does not of necessity interfere with 
 the development of the teeth, although they are concealed
 
 622 A SYSTEM OF DENTAL SURGERY. 
 
 by its rising up round them : in Mr. Pollock's case, related 
 by Mr. Salter, it is noticed that the teeth were of unusually 
 large size, and were developed somewhat before their normal 
 time. 
 
 It does not appear possible to certainly connect this disease 
 with any constitutional taint ; for though in Mr. Canton's, 
 Dr. Gross's, and Mr. Pollock's cases the children were stru- 
 mous and of defective intellect, in Mr. MacGillivray's case 
 the patient was otherwise perfectly healthy.
 
 ( 523 ) 
 
 HYPEROSTOSIS. 
 
 The maxillary bones appear to be the usual starting-point 
 of a remarkable form of general hypertrophy of the bone, 
 which in severe cases aftects the other bones of the face 
 and cranium, and, more rarely, bones elsewhere in the body. 
 
 Although it is a rare disease, and one which falls into the 
 hands of the surgeon for treatment, it is very necessary for 
 the dental surgeon to be acquainted with its nature and 
 characters, as it is likely to be brought before him in its early 
 stages for his opinion. 
 
 The disease consists in an interstitial growth and alteration 
 affecting the whole substance of the bone, and not merely its 
 surface : in its progress the whole bone becomes enlarged ; 
 the antrum, and eventually also the nasal cavities, ob- 
 literated : it goes on to encroach on the orbit till the eye is 
 destroyed by its pressure, and the most hideous deformity 
 produced. In Mr. Heath's work Q) several figures are given 
 showing the extreme deformity which is caused by the 
 disease. 
 
 The coarse, rough, porous appearance of the surface of the 
 bone is well shown in the plate of Mr. Bickersteth's case (^), 
 and this same porous cancellated structure, extending through 
 the whole substance of the bone, is seen in the appended 
 figure, from a specimen for the use of which I am indebted to 
 the kindness of Mr. Christopher Heath. In this case the 
 disease was first noticed at the age of three months, when the 
 left side of the face was found to be enlarging. The left eye 
 became closed at the age of six, and the enlargement steadily 
 
 0) "Diseases and Injuries of the Jaws," 2nd edition, 1872, p. 132. 
 (2) Transactions of the Pathological Society, 1866, p. 245.
 
 524 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 increased till the boy reached the age of twelve, when the 
 left upper maxilla was removed by Mr. Heath ; the integu- 
 
 Fig. 204. (1) 
 
 WMk:; 
 
 ment having, however, shared in the hypertrophy, great 
 deformity still remains. 
 
 A model of the mouth (Fig. 205), taken before the opera- 
 
 Fig. 205. 
 
 tion, shows that on the right or healthy side the permanent 
 incisors, canine and bicuspids, are in place ; while on the 
 
 (1) Half of the left upper maxilla (Mr. Heath's case) ; the section has been 
 carried through the permanent teeth, which had not as yet been erupted ; some 
 of the teeth are in the other half of the bone, so that they are not shown in 
 this figure.
 
 HYPEROSTOSIS. 525 
 
 left side tiie temporary incisors and canine (?) are retained, 
 and the bicuspids not fully erupted. 
 
 As seen in the sections made through the bone after its 
 removal, the incisors, canine, bicuspids, and first permanent 
 molar (carious) are found to be well-developed, full-sized teeth. 
 
 Behind the first permanent molar the antero-posterior de- 
 velopment of the jaw has been checked, and the second per- 
 manent molar is a somewhat stunted tooth, whilst the crown 
 of the wisdom tooth is extremely small. 
 
 In this case, then, the development of those members of 
 the permanent set which are the last to take their place was 
 stunted, and the whole process of dentition retarded, so that 
 the temporary incisors and canines were retained for several 
 years beyond the period at which they should have been 
 shed. It is stated that the temporary teeth were erupted at 
 their normal periods. 
 
 In all the cases the enlargement of the bone is slow, and 
 at first painless, so that commonly many years elapse before 
 the patient suffers the removal of the maxilla, which is the 
 only available treatment ; it seems usually to commence 
 before the age of puberty, though this is not a universal rule. 
 
 Little or nothing is kno-wn as to its origin : it is apparently 
 in no way connected with either syphilis or struma, and has 
 been supposed to consist primarily of an inflammatory affec- 
 tion of the periosteum — to which view, however, there are 
 some objections ; while by Otto Weber it is supposed to be a 
 result of erysipelas. 
 
 In Mr. Bickersteth's case the diseased bone presented a 
 curious microscopical structure, having large branching vas- 
 cular canals in its substance, totally unlike the ordinary 
 Haversian canals : these were described and figured by Mr. De 
 Morgan in the Transactions of the Pathological Society Q) ; 
 but in Mr. Heath's case, which was examined by myself, these 
 canals did not exist, the only noteworthy peculiarity being 
 the absence of well-developed Haversian systems. 
 
 (1) Transactions of the Pathological Society, 1866, vol. xvii., plate xii.
 
 526 
 
 Stomatitis. — Infiammation affecting the mucous membrane 
 of the mouth is far more common during early childhood 
 than at any later period. 
 
 Dr. West, in treating upon inflammation of the mouth 
 (stomatitis), says : " Infiammation of the mouth is an occur- 
 rence by no means confined to the period of teething, but it 
 comes on in children of all ages, assumes very diflerent forms, 
 and leads to very difi'erent results in one case from those 
 which characterise it in another. The mucous follicles of the 
 mouth are the chief seat of the disease in one case ; the sub- 
 stance of the gum in another, and that of the cheek in a 
 third. In the first (follicular or aphthous stomatitis), the 
 afiection issues in the formation of several small ulcers, which 
 heal eventually of their own accord ; in the second (ulcera- 
 tive stomatitis), an unhealthy process of ulceration destroys 
 the gums and denudes the teeth, but it is tardy in its ad- 
 vance, and tends to a spontaneous cure ; while in the last 
 (gangrenous stomatitis), mortification involves all the tissues 
 of the cheek, and spreads with a rapidity which remedies fail 
 to check, and which is arrested at last only by the patient's 
 death." Q) Although each of the foregoing forms of disease 
 has a constitutional origin, and for the most part fall under 
 the treatment of the surgeon, yet they sometimes come under 
 the notice of the dentist. 
 
 Simple Stomatitis (Erythematus Stom/.ditis) is charac- 
 
 (J) " Lectures on the Diseases of Infancy and Childhood." By Charles West, 
 M.D. Third edition.
 
 APHTHOUS (fOLLICULAK) STOMATITIS. 527 
 
 terised by slightly elevated, reddish, glistening patches, which 
 may coalesce so that the whole surface presents the characters 
 of inflammation. Occasionally whitish patches occur on these 
 surfaces, due to desquamation of the epithelium, or, in some 
 instances, to exudation. 
 
 It is very common during the period of first dentition, and 
 is then accompanied by febrile symptoms, but it is probable 
 that the constitutional disturbance is independent of the 
 stomatitis. It may also be produced by irritants, such as 
 stimulating food, and is not unfrequently caused by gastric 
 irritation, drunkards being particularly liable to this and 
 more severe forms of stomatitis. 
 
 Its treatment is simple ; a dose of aperient medicine, 
 and emollient mouth-washes, being generally efficient in 
 curing it : if the patient be an infant who is being brought 
 up by hand, a little lime-water should be added to the 
 milk. 
 
 Thrush. — In its early stage this is quite indistinguishable 
 from simple stomatitis ; but the patches very speedily become 
 coated with a very characteristic exudation, which is at first 
 closely adherent ; but after the lapse of a few days it peels 
 off, only to be replaced by a fresh membrane. 
 
 It is a rare disease in adults, but is common in children. 
 It is contagious ; but in a healthy child, or in a child sufi'er- 
 ing from acute disease, it is of little moment ; when, however, 
 it supervenes in a child exhausted by chronic disease, it 
 foretells a fatal termination at no very distant date. 
 
 The membrane which gives to it its characteristic appear- 
 ance is in great part made up of the mycelium of a fungus 
 —the Oidium Albicans. As might be expected, it is very 
 amenable to local treatment; such applications as borax, 
 alum, or nitrate of silver speedily curing it ; but perhaps the 
 best applications are the alkaline sulphites, or even sul- 
 phurous acid itself. 
 
 Aphthous {Follicular) Stomatitis.— In the first instance, 
 the individual inflamed follicles may be seen as isolated red
 
 528 A SYSTEM OF DENTAL SURGERY, 
 
 specks ; but they very speedily soften down, and pass into 
 small, round, sharp-edged ulcers. Or the first thing notice- 
 able may be a vesicular, herpetic eruption, the bursting of 
 the vesicles leading to the formation of small ulcers, exceed- 
 ingly painful, and generally surrounded with a narrow bright 
 red zone of infiammation. 
 
 The ulcers are seldom or never single, and are oftenest 
 found about the frsenum, in the sulcus between the lips and 
 gums, or on the lower surface of the tongue. 
 
 It is a trivial disorder, accompanied usually by no consti- 
 tutional disturbance; but it is productive of great dis- 
 comfort to the patient, on account of the excessive tenderness 
 of the ulcers. 
 
 An occasional touch with nitrate of silver will relieve the 
 tenderness of the raw surfaces, and the use of astringent 
 washes wiU serve to accelerate their healing. When it 
 occurs in the sulcus between the lips and gums, the teeth 
 must be kept scrupulously clean, and it will often prove 
 advantageous to paint around their necks the glycerinum 
 acidi carbolici ; as an application to the surface, the following 
 may be used, applying it on a slip of lint, which is allowed 
 to lie in the sulcus — 
 
 R. Acidi carbolici glacialis, 
 Li 4. potasscT, aa 5j. 
 Aquje ad ^iij- 
 
 Though follicular stomatitis is most frequently met with 
 in children, it is not peculiar to early life, but is met with 
 at all ages. 
 
 Instead of meeting with a cluster of ulcers, we not uncom- 
 monly find a single deeply-excavated, small, round ulcer in 
 the sulcus, at the junction of the gums with the mucous 
 membrane of the lips, or on the free mucous membrane. But 
 that the ulcer is single, it might be described as follicular 
 stomatitis ; and though it is insignificant both in extent and 
 duration, it is extremely sensitive and troublesome, rendering
 
 ULCERATIVE STOMATITIS. 529 
 
 the movement of the tongue, and the act of mastication 
 painful. 
 
 If the surface be touched with nitric acid, an ahiiost in- 
 stantaneous cure is effected ; the tenderness is entirely re- 
 moved, and the patient will feel no further inconvenience. 
 
 Ulcerative Stomatitis. — This form of stomatitis is one 
 which frequently comes under the notice of the dental 
 surgeon. 
 
 Commencing at or near the edges of the gums, more fre- 
 quently in the lower than in the upper jaw, and usually on 
 one side only, it may spread till the whole interior of the 
 mouth is a mass of ulcers. The edge of the gum becomes 
 thickened and congested, and has often a pimply appearance : 
 it assumes a deep purple colour, and bleeds at the slightest 
 touch. Ulceration speedily succeeds to this condition ; com- 
 mencing on the edges of the gum, it extends deeply into the 
 substance, in severe cases laying bare the necks of the teeth 
 and the alveolar processes. The mucous membrane of the 
 cheek, where it comes into contact with the ulcerated sur- 
 faces, often becomes the seat of similar lesions, so that a 
 line of ulceration corresponding to the position of the teeth 
 runs along the inside of the cheek. 
 
 The malady originates in the front part of the mouth, and 
 it is only in severe cases that it extends back to the molar 
 region. 
 
 It is said that exudation precedes the occuiTence of ulcera- 
 tion. In its fully-developed form, the ulcer is marked by the 
 following characters : the surface is covered over by a dirty 
 white or yellow material, which on removal by a current of 
 tepid water, leaves exposed numerous scarlet points on a 
 yellowish ground, which is made of debris of various sorts. 
 The edges of the ulcer are sharp and ragged, of a colour 
 ranging from violet to a brilliant vermilion, and are at first 
 superficial ; but as the disease progresses they become deeper. 
 
 In cases of any severity, the side of the face is apt to be 
 swollen, and the lymphatic glands enlarged and tender; 
 
 2 M
 
 530 A SYSTEM OF DENTAL SURGERY. 
 
 there is, however, nothing like the extreme induration of 
 the cellular tissue met with in cancrum oris. 
 
 The disease may run on for some months, in which case 
 its cure hecomes trouhlesome, and, once well established, it 
 is very prone to recur. 
 
 In a subject predisposed to the disease, trivial sources of 
 irritation will serve as its starting-point, such as an abrasion, 
 or a carious tooth ; fracture and necrosis of the jaw have like- 
 wise been known to set it up. 
 
 Although adults are not wholly exempt from attacks of 
 ulcerative stomatitis, the disease occurs very much more fre- 
 quently in children, especially between the ages of five and 
 ten years. The cases which have come under my own notice 
 have occurred in young jDcople living in crowded localities, 
 and who have been imperfectly clothed and fed. According 
 to Dr. West, however, "it is by no means a constant occur- 
 rence for any special derangement of the general health to 
 precede an attack of ulcerative stomatitis, though the children 
 who are affected by it are seldom robust, and in many in- 
 stances are such as have suffered from deficient food, or a 
 damp and unhealthy lodging, or both." In young children 
 who are but indifferently cared for, the disease in its earlier 
 stages is overlooked, until the suspicion of the attendant is 
 aroused by the foetid state of the breath, the dribbling of 
 the saliva, and the unwillingness of the child to take into the 
 mouth food or anything that is calculated to produce pain in 
 the ulcerated surface. When the disease is unchecked by 
 treatment, it may lay bare a large portion of the alveoli of 
 several teeth, which, with their sockets, become dead and 
 blackened, and these serve to keep up the malady. 
 
 Tlie Treatment of ulcerative stomatitis is usually attended 
 with well-marked success. Local treatment is by Dr. West 
 regarded as of secondary importance, and might, he says, in 
 many cases be omitted without prejudice to the patient. He 
 says, " Lotions of alum, or the burnt alum applied in sub- 
 stance, or the chloride of lime in power, have all been used
 
 ULCERATIVE STOMATITIS. 631 
 
 locally, with more or less benefit. It was my custom also to 
 prescribe these remedies in ulcerative stomatitis ; but since I 
 became acquainted with the virtues of chlorate of potash, I 
 have learned to rely upon it almost exclusively. It appears, 
 indeed, almost to deserve the name of a specific in this affec- 
 tion, for a marked imjjrovement seldom fails to be observed 
 in the patient's condition after it has been administered for 
 two or three days ; and in a week or ten days the cure is 
 generally completed. Three grains every four hours, dissolved 
 in water, and sweetened, is a sufficient dose for a child three 
 years old ; and five grains is the largest quantity that I have 
 administered to a child eight or nine years old." The general 
 health of the patient must at the same time be watched, and 
 a purgative administered if the bowels require relief. Nu- 
 tritious food should be given, and in the feeble subjects 
 quinine or other tonics prescribed. In the cases which have 
 come under my own treatment, the administration of these 
 remedies has been followed by the rapid recovery of the 
 patient. 
 
 The application of nitrate of silver to the surface of the 
 ulcer at once changes its character, by foi'ining a superficial 
 slough, after the separation of which a healthy granulating 
 surface is left. The excessive tenderness, too, is almost 
 instantaneously relieved. The use of a wash composed of five 
 or six grains of chlorate of soda to one ounce of water, will 
 suppress the offensive odour. Teeth which are hopelessly 
 loose, and productive of irritation, should be removed. 
 
 Patients suff'ering from constitutional syphilis are occa- 
 sionally subject to ulceration in the mouth, indistinguishable 
 from ulcerative stomatitis. The inner surface of the upper 
 lip may be affected, and an ulceration corresponding to each 
 tooth form, and spread on to the gums. There is sooie risk 
 of adhesions forming between these contiguous surfaces 
 during cicatrisation, so that the patient should be directed 
 to continually keep a slip of lint, steeped in some disinfectant 
 solution, between the affected parts.
 
 532 A SYSTEM OF DEXTAL SUEGERT. 
 
 Those cases which I have seen have all yielded to the j 
 administration of iodide of potassium. 1 
 
 These syphilitic ulcerations are not characterised by the 
 extreme tenderness met with in the ordinary form of the 
 disease. 
 
 Gangrenous Stomatitis. (Xoma, Cancrum oris, Phagedaena 
 oris, &c.) 
 
 Although this is a disease which would not fall within the 
 province of the dental surgeon, nevertheless he should be 
 able to recognize it, as the only chance for the patient lies in 
 the immediate and decisive treatment of the sore. The 
 course of the disease is frightfully rapid, and the termination 
 almost always fatal, though it is, happily, far from a common 
 disease. 
 
 The first thing generally noticed is swelling of the face : 
 this swelling is peculiar in its character, the skin being very 
 tense and shining ; the swelling is very hard, dense, and 
 circumscribed, but remarkably free from tenderness ; in its 
 centre is a blotchV-looking red spot. 
 
 If the mouth be examined, there is seen to be an irregular 
 ulcer, with Uvid^ red edges, sometimes in the sulcus, some- 
 times on xme cheek. It is not very sensitive, but produces 
 profuse salivation, and gives forth a gangrenous odoiu: from 
 the very first. It spreads with extraordinary rapidity, the 
 red spot on the cheek simultaneously becoming black and 
 sloughing, so as to open the oral cavity. The destruction of 
 the tissues of the cheek takes place with extraordinary rapi- 
 dity, and the death of the patient generally ensues in the 
 course of a week. One of the strangest features of this 
 frightfully destructive disease is the absence of jDain, and even 
 of great constitutional disturbance : food is usually taken 
 well, even to the very last. The disease occurs in children 
 of debilitated constitutions, and sometimes presents itself as 
 a sequela to acute diseases, its subjects generally being from 
 two to five years of age. 
 
 Constitutional treatment can do but little : so soon as th^^
 
 GANGRENOUS STOMATITIS. 533 
 
 disease is recognised, the ulcer should be utterly destroyed 
 with fuming nitric acid ; not a moment should be lost, as, it' 
 gangrene has once fairly set in, the case is almost lioi^eless. 
 But, unfortunately, the access of the disease being unac- 
 companied by suffering, it is seldom observed until it is too 
 late. The free application of nitric acid should never be 
 neglected ; recollecting the rapidity and the almost certain 
 fatal result of the malady, the surgeon must not hesitate to 
 destroy the affected tissues widely. Disinfectant washes 
 should be diligently used, and the child's strength kept up 
 by the free administration of stimulants. 
 
 Some practitioners use concentrated hydrochloric acid, in 
 the place of nitric acid, for destroying the sore, and consider 
 that it gives more satisfactory results. 
 
 Active inflammation, when situated in the gums, rapidly 
 involves the adjacent periosteum both of the external and 
 internal surfaces of the alveoli, and by thus extending, tends 
 to mask the original character of the disease, the nature of 
 which, if the case be not seen in an early stage, may be in- 
 volved in considerable obscurity. The malady, however, 
 extends in another direction, and by so extending its nature 
 becomes declared. The inflammation, at first limited to the 
 mucous membrane of the gums, spreads to that of the mouth. 
 The salivary glands become affected, and pour out an ex- 
 cessive amount of secretion, the flow of which becomes a 
 conspicuous feature in the disorder. When this takes place, 
 the patient is said to be salivated. Although cases of spon- 
 taneous salivation are recorded, well-marked examples are 
 rarely met with. As the result of remedies administered for 
 the cure of disease its occurrence is common, but not so 
 common as in former years, when mercury was more fre- 
 quently used, and its effects were further pressed. In cases 
 of inflammation of the gums so induced, an opportunity of 
 watching the disease from its commencement is afforded. 
 
 In salivation produced by mercury, the effect is first dis • 
 cernible upon the gums. Some hours previous to the occur-
 
 534 A SYSTEM OF DEXTAL SUEGEET. 
 
 rence of the metallic taste, and to the fcetor of the breath, 
 and also to the soreness and discomfort of the mouth which 
 mark the influence of mercury on the system, the gums show 
 indications that these conditions are about to appear — that 
 the patient will in a few hours be salivated. The state of 
 gum I am about to describe is, in fact, a premonitory sign 
 of ptyalism, for should it appear, and the mercury be imme- 
 diately discontinued, yet salivation will come on. The sign 
 is this : — the adherent portion of the mucous membrane of 
 the gums assumes an opaque white colour, contrasting 
 strongly with the non-adherent portion, which preserves its 
 natural hue or becomes more red. The free edge of the gums 
 is moveable, but that part which lies over the edge of the 
 alveoli is firmly tied down to the periosteum ; and as the 
 edges of the alveoli present a festooned line, so the whitened 
 mucous membrane presents corresponding undulations. Agaiui 
 where the mucous membrane is loosely reflected from the 
 gum to the cheek, the natural colour is preserved. The 
 whiteness of gum is produced by an increased secretion of 
 epithelium, which, from being thicker and more opaque than 
 in the healthy state, renders the colour given by the vessels 
 to the subjacent tissue less apparent. 
 
 The surface of the mucous membrane, when deprived of 
 epithelium, is studded over with innumerable small conical 
 elevations or papilla?. The thickened epithelium is readily 
 rubbed ofl' the tops of the papilla, while it retains its full 
 thickness in the intervening depressions ; hence, if closely 
 inspected, the gums will not be seen to present a uniform 
 white hue, but a mottled aspect. 
 
 With the increased thickness there is a decrease of tenacity 
 between the scales that form the epithelium, for the surface 
 may be much more readily rubbed off than when in its 
 natural ^tate. 
 
 This curious and useful premonitory sign of coming 
 ptyalism was, I believe, first noticed, and its value pointed 
 out, by Mr. Corfe ; at all events, he was the first to draw
 
 CHRONIC INFLAMMATION OF THE GUMS. 535 
 
 my attention to the fact, and I am not aware that it had 
 been previously described. Since, however, Mr. Corfe men- 
 tioned the result of his observations as to the constancy of 
 the sign, I have verified for myself its presence in all cases 
 of salivation that have come under my notice; and from 
 these the foregoing account has been given. 
 
 When the condition of mercurial salivation is fairly esta- 
 blished, the gum and palate become markedly swollen, as 
 does also the tongue, so that it is deeply indented by the 
 teeth. The breath becomes intolerably offensive, and the 
 mouth can only be opened with difficulty. 
 
 In bad cases ulceration and consequent haemorrhage occur ; 
 sloughing and necrosis of the bone may supervene. It is not 
 uncommon for the mouth to be permanently closed by cica- 
 trices consequent on the sloughing process. 
 
 Aperients should be given, and chlorate of potash, both 
 internally and as a wash for the mouth. 
 
 Condy's fluid forms an excellent wash for cleansing the 
 mouth and deodorising the breath. 
 
 Occasional scarification of the gums, and the topical appli- 
 cation of iodine, will assist in restoring them to their normal 
 condition. 
 
 In syphilitic stomatitis there is no greatly-increased flow 
 of saliva ; the disease tends to destructive ulceration of the 
 gums and superficial necrosis of tlie jaw. 
 
 Shallow ulcers form beneath the tongue, and mucous 
 patches appear on the cheeks. Although other evidences 
 are generally present to aid the diagnosis, they are not 
 invariably present. The disease readily yields to iodide of 
 potassium. 
 
 Chronic Inflammation of the Gums. — This form of disease 
 is very common in the- middle and later periods of life, and 
 when once established, is apt to prove obstinate. 
 
 Although in the first instance the gums alone appear to be 
 the seat of the disease, the alveolo- dental periosteum, after a 
 time, becomes involved in the morbid process. The surface
 
 536 A SYSTEM OF DENTAL SURGERY. 
 
 of the gums becomes minutely nodulated, and the secretion 
 of epithelium increased, so that the spaces between the teeth 
 are filled with the creamy or cheese-like substance made up 
 of cast-oflf epithelium ; the papillae are abnormally prominent, 
 while the substance of the gum is generally thickened. 
 
 The festooned outline of the edge of the gum is speedily 
 lost, the free edge becoming thick and rounded. The morbid 
 process may extend over the whole mouth, or be symmetrically 
 developed on the two sides of the mouth, as will be the case 
 when it is dependent on constitutional causes ; or it may be 
 confined to the vicinity of two or three teeth, in which case 
 the cause is probably local. 
 
 When dependent on general causes, it afi"ects the vicinity 
 of sound equally with that of decayed teeth, and it has been 
 regarded as identical with the natural process of absorption 
 of the 'alveoli in advanced age ; as being, in fact, an evidence 
 of premature old age. * 
 
 The pain attendant on this malady is inconstant, both in 
 degree and in character. In some cases but little uneasiness 
 is complained of, unless during eating ; whilst in others the 
 patient is rarely free from pain. The pain may be strictly 
 local, or it may take the neuralgic form, and recur with 
 .gre<it regularity at the same hour every day ; but it is, on 
 the whole, rare for pain to be com])lained of until the sockets 
 of the teeth have been in part destroyed, and the alveolo- 
 dental periosteum involved in the disease. 
 
 If it runs its course unchecked, purulent matter is dis- 
 charged from between the gums and the necks of the teeth, 
 and the breath becomes excessively oftensive, often having 
 a peculiar odour very characteristic of the disease. Then 
 the alveolar processes become involved, and may be affected 
 in two opposite ways : the processes may be increased in 
 thickness by the addition of porous bone to their outer sur- 
 faces, or they may be rapidly removed by absorption ; in either 
 case the teeth are speedily lost — the periosteum becoming 
 detached from the roots. 0^ving to this detachment of the
 
 CHRONIC INFLAMMATION OF THE GUMS. 537 
 
 periosteum, tartar is apt to be deposited in small nodules on 
 the bared fang ; this is not, however, a cause of the disease, 
 as has been supposed by some writers, but is a consequence ; 
 though, undoubtedly, the presence of such extraneous matters 
 in the socket will keep up and aggravate the morbid action. 
 
 Chronic inflammation of the gums is often the result of 
 long-continued dyspepsia, and it is interesting to note that 
 it is frequently met with in stall-fed animals ; and it is 
 more common in the lower classes, who pay little attention 
 to their teeth, than in the upper classes. Syphilis, or the 
 abuse of mercury in the treatment of syphilis, is a not un- 
 frequent cause of the disease in its more general form ; \vhile 
 its local form may be set up in some persons by tlie slightest 
 source of irritation in the mouth, such as a rough edge left 
 on a filling. It also often follows on pre-existing disease of 
 the dental periosteum. 
 
 Treatment. — The cause of the disease, be it local or 
 general, must be sought for, and if it be discoverable, at once 
 treated. The constitutional treatment of such cases will 
 hardly fall within the province of the dental surgeon, but 
 great advantage may be derived from topical applications, 
 even in those cases which depend on some general cause. 
 
 The gums, if cedematous and congested, may be freely 
 scarified with a lancet, and the bleeding encouraged as much 
 as possible. 
 
 All tartar should be carefully and thoroughly removed, and 
 teeth which have become very loose extracted, as they will 
 never become refixed, and in their mobile condition serve to 
 keep up irritation. Certain American authors lay great stress 
 on the removal of the tartar deposited far down on the 
 fangs, and describe instruments specially made for this pur- 
 pose. So far as it is practicable, this should be done ; but 
 when a tooth has lost its attachment to the alveolo-dental 
 periosteum for a considerable portion of its length, it is 
 better to extract it. 
 
 The distance to which this separation of the tooth-fang
 
 538 A SYSTEM OF DENTAL SURGERY. 
 
 has reached, may be ascertained by passing a piece of silk 
 twist down by the side of the tooth : this is sufficiently stiff 
 to pass down until arrested, while it is too soft to effect any 
 further separation of the parts. 
 
 In the earlier — or, indeed, in any stages of the disease — 
 the strongest tincture of iodine is oft^n very serviceable, and 
 may be repeatedly applied ; it will be found to be absorbed 
 by these sponiry, congested gums to a far greater extent than 
 by firm, healthy gums. 
 
 Various astringents may be used ; none, however, is much 
 more effective than tannin, which may be applied either as a 
 powder, or in the form of the pharmacopoeal glycerinura 
 acidi taunici. 
 
 When there is much purulent discharge welling up between 
 the gums and the necks of the teeth, the sulcus there found 
 should be thoroughly cleansed, and fused chloride of zinc 
 passed round the necks of the teeth. This may be done by 
 melting it on the end of a fine silver probe, or a fragment of 
 the actual stick may be a])plied ; or, failing these methods, a 
 morsel of cotton saturated with the solution produced by the 
 deliquescence of the salt may be used. 
 
 The api^lication of phenol sodique (sodic phenate) in the 
 same manner t€nds to check the discharge ; and the foetor of 
 the breath may be corrected by washes of the same, in the 
 proportion of a teaspoonful to a tumbler of water. 
 
 In the place of using the impure French preparation, which 
 has an unpleasant taste and smell, I commonly employ the 
 following formula — 
 
 R. Acidi carbolici, 5J. 
 Liquoris Potassae, ^j. 
 Aquaj ad ^viij. 
 
 Touching the edges of the gum with a stick of nitrate of 
 silver sometimes sets up a more healthy action. 
 
 There is a singular modification of chronic inflammation of 
 the gums, in which, instead of becoming thickened and
 
 CHRONIC INFLAMMATION OF THE GUMS. 539 
 
 irregular on the surface, they seem rather to decrease in 
 size, assume a very smooth and polished surface and mottled 
 aspect ; at the same time the disease may extend over the 
 surface of the hard palate. The malady is attended with 
 acute intermittent' pain, which may be confined to one side 
 of the mouth, or even to half of the upper jaw ; it very com- 
 monly comes on in the evening, and keeps the patient awake 
 half the night. The patients suffering from this complaint 
 who have come under my notice have been, for the most 
 part, poor middle-aged females, in whom menstruation was 
 becoming irregular, or had altogether ceased ; and they have 
 always been cured by the use of a mild aperient — such as 
 sulphate and carbonate of magnesia, given in small doses 
 twice a day. Under this treatment the pain in the gums 
 will probably cease within a week or nine days, and their 
 restoration to a healthy condition will speedily follow. 
 
 Chronic inflammation of the gums may assume characters 
 altogether different from those which have been described. 
 Instead of presenting thickening and induration, the tissues 
 may be loose, spongy, and highly vascular, bleeding freely on 
 the slightest touch, and very tender ; the gums rise up and 
 cover over a considerable portion of the crowns of the teeth. 
 The papillas which stud over their surface become greatly 
 enlarged, and the vessels which, in their looping and inoscu- 
 lations, form so interesting an object when subjected to 
 microscopic examination, become, if not more numerous, 
 greatly lengthened and dilated. I am indebted to Mr. 
 Eoberts for the use of a beautifully-injected preparation of 
 an inflamed, and as it would be called, scurvied gum. It is 
 not from the human subject. After injecting a monkey, he 
 found that the vessels of the thickened and inflamed gums 
 had received the injection. From the preparation so obtained 
 the illustration on the next page is taken. 
 
 I'he condition which has been described may arise in con- 
 nection with, and as a consequence of, diseased teeth ; the 
 causes and the complaint itself being in that case strictly
 
 540 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 local. But in certain stntes of the system attended with an 
 altered condition of the circulating fluid — in blood diseases, as 
 they are often called— the whole of the gums become similarly 
 afl:ected, and in maladies partaking of the nature of sea 
 scurvy and purpura, this peculiar condition of the vascular 
 tissues about the teeth forms a characteristic feature. 
 
 Fig. 206. (1) 
 
 hi scurvy the gums are greatly affected ; the ap^Dcarance 
 (jf the mouth is very peculiar, as the lips and tongue are 
 pallid, and contrast strongly with the blotchy, dusky purple 
 gums rising up between and even over the teeth, and bleeding 
 on the smallest touch. 
 
 In severe cases blood continually oozes from the gums, 
 and these may even slough and lay bare the necks of the 
 teeth and alveoli. The teeth become rapidly loose, and 
 finally fall out. 
 
 A somewhat similar appearance is met with in purpura ; 
 in it the contrast between the gums and the lips is not so 
 marked, and the severer lesions do not often occur. 
 
 (1) Shows the injected vessels of gums inflamed and suflBciently enlarged to 
 cover over ard obscure the greater portion of the labial surface of the incisor 
 teeth. The preparation was obtained from the mouth of a deceased monkey, 
 by Dr. Roberts, to whom 1 am indebted for this illustration.
 
 CHRONIC INFLAMMATION OF THE GU3IS. 541 
 
 AVhen the patient is mending, the use of astringent and 
 stimulant applications will hasten the restoration of the gums 
 to their normal condition ; but until the constitutional mis- 
 chief is on the wane, local applications do very little good. 
 
 The mucous membrane of the cheek is liable to ulceration 
 caused by the irritation of jagged decayed teeth ; and it 
 may become so indurated by constant irritation as to, in a 
 measure, simulate epithelioma, Mr. Berkeley Hill has pointed 
 out that, in syphilitic patients, the mucous membrane of the 
 cheek where exposed to friction becomes swollen, pale and 
 sodden in»aspect, and elevated into whitish ridges or patches. 
 There is often a slight ulceration at the apex of the ridges, 
 and they cause great discomfort to the patient, being especially 
 irritable when rubbed by a jagged tooth. 
 
 Gummata may also occur in the substance of the cheek, 
 though they rarely do so.
 
 ( 542 ) 
 
 ULCERATIOXS OF THE TONGUE. 
 
 Although it would be inconsistent with the purpose of the 
 present work to enter at any considerable length into the 
 subject of diseases affecting the tongue, it is very desirable 
 that the dental surgeon should be familiar with the characters 
 of ulcerations occurring in the mouth, seeing that some are, 
 whilst others are not, dependent on the irritation of ragged 
 and diseased teeth. 
 
 A very slight roughness of natural or artificial teeth will 
 suffice to cause a superficial ulcer in a person predisposed to 
 such ulcerations, which are very common amongst the dys- 
 peptic : they come and go rapidly, are shallow and sensitive, 
 and have very bright red edges ; a touch with nitrate of 
 silver generally suffices for their cure. 
 
 But ulcers of far more formidable appearance may be 
 produced by ragged teeth ; ulcers with an exceedingly foul, 
 shreddy surface, pouring out an offensive discharge, and 
 sometimes extending deeply into the substance of the tongue. 
 
 Although not surrounded with the hard base characteristic 
 of epithelioma or syphilitic ulcers, the surrounding tissue 
 will be in some degree hardened by infiltration with inflam- 
 matory exudations; and more rarely, an ulcer dependent 
 simply on a ragged tooth may closely simulate epithelioma, 
 by having sharply-defined, hardened edges, and a firm, com- 
 paratively clean surface. 
 
 The inflammatory action may extend to the whole floor of 
 the mouth, causing great cedema and difficulty in swallowing 
 or in speaking. The diagnosis of these ulcers is generally 
 easy ; their rapid formation, their irregular form, foul surface, 
 and absence of a definite indurated base, serve to distinguish
 
 ULCERATIONS OF THE TONGUE. 543 
 
 them from more serious diseases; and the existence of a 
 roughened tooth will confirm the conclusion arrived at; 
 though it must always be remembered that a local source of 
 irritation may, and often does, determine the position of such 
 diseases as epithelioma or syphilitic ulceration. 
 
 A patient suffering from the slighter forms of syphilitic 
 ulceration, may apply to the dentist to have sharp corners 
 filed away from one or more of his teeth, attributing to 
 this cause the discomfort which he feels. On examining the 
 tongue, you may often fail to see anything the matter ; on a 
 closer examination, the organ is seen to be slightly fissured, 
 and the surfaces of the fissures to be red ; or there may be 
 slight excoriations, sensitive to the touch, but not bleeding 
 unless roughly handled ; or flat, leathery mucous patches ; 
 or, again, there may be flat, defined ulcerations. The marked 
 character of those slight superficial ulcerations due to syphilis, 
 is the absence of surrounding inflammation, and the presence 
 of sensitiveness far greater than their appearance would lead 
 the observer to expect. 
 
 Deep syphilitic ulcerations specially aflect the dorsum of 
 the tongue far back ; their occurrence is preceded by an indu- 
 rated lump, proceeding to ulceration in the course of three 
 weeks or a month. 
 
 When it ulcerates, portions of the induration appear to 
 slough away, so that the edges, themselves more or less 
 indurated, overhang the cavity : the form of the ulcer is 
 irregular, and its edges smooth. It secretes a scanty dis- 
 chai'ge, hardly to be called pus, and has a sloughy aspect. 
 
 The free administration of iodide of potassium will speedily 
 cure most syphilitic ulcerations, unless the patient be very 
 cachectic : large doses of sarsaparilla often act very bene- 
 ficially in such cases. 
 
 So fully amenable to the influence of iodide of potassium 
 are gummata and syphilitic ulcerations of the tongue, that 
 the efl"ect of the drug may be greatly relied on as a diagnostic 
 sign in doubtful cases.
 
 544 A SYSTEM OF DENTAL SURGEKT. 
 
 Epithelioma affecting the ton.frue is a disease far from rare : 
 like the syphilitic ulcer, it commences by induration, ulcera- 
 tion being a subsequent stage, which in the case of the 
 syphilitic form ends in the destruction of the indurated mass, 
 but in the case of epithelioma is marked by ever-extending 
 induration beyond its edges. 
 
 The base of the ulcer is greyish, or sometimes red ; the 
 discharge is very scanty, and the growth of the patch is 
 attended with considerable pain. 
 
 The edges are hard, generally everted, and lobed ; they are 
 often of a peculiar red, polished appearance, and are some- 
 times fissured or nodulated. When the disease has lasted 
 long, the sub-maxillary lymphatic glands become enlarged, 
 but the period at which a correct diagnosis is of vital im- 
 portance is then passed. 
 
 Epithelioma is most likely to be confounded with syphi- 
 litic ulceration ; several of the characters by which it differs 
 have already been pointed out, but there are some few other 
 points which enter into the formation of the diagnosis, a 
 matter sometimes of no small diflSculty. 
 
 Epithelioma is more often on the dorsum of the tongue 
 than on its edges ; is often remarkably flat and regular in 
 fomi, and is seldom found in young persons : the contrary is 
 true of syphilitic ulcer. 
 
 The latter is remarkably free from pain or tenderness, 
 though of great extent and depth ; its edges are not nodular, 
 and its progress is rapid ; moreover, its ready amelioration 
 under the administration of iodide of potassium will often 
 serve to confirm a doubtful diagnosis. 
 
 Sir James Pa;zet {}) describes a very extensive form of ulcera- 
 tion due to tubercle, which is very rare, and of which I 
 have personally no experience. These strumous ulcerations 
 present a marked resemblance, in their course and appear- 
 ance, to strumous deposits proceeding to suppuration and 
 ulceration elsewhere in the body. 
 
 (1) " Mf dical Times and Gazette," 1858.
 
 ( 645 ) 
 
 TUMOURS OF THE GUMS. 
 
 Several varieties of tumour are met with in the mouth, 
 springing either from the gums themselves, or from the 
 subjacent structures, i. e. the alveolar periosteum or the bone 
 at the margins of the alveoli. Polypus or fungus of the 
 gum, hypertrophy of the gum, vascular tumours, and epulis 
 constitute the principal varieties. 
 
 Polypus or Fungus of the Gum. — It is not uncommon to 
 find a cavity situated on the mesial or distal surface of a 
 tooth filled up by a vascular mass, similar in colour and 
 general appearance to the contiguous gums. It may be an 
 outgrowth from the dental pulp (see p. 468) ; more commonly, 
 however, it springs from the inter-dental gum, or, according 
 to Dr. Magitot(^), from the periosteum investing the neck of 
 the tooth. 
 
 On a close examination it will be found that the tooth has 
 decayed down to the level, or even below the edge of the 
 gum, leaving a sharp, ragged margin, capable of acting as a 
 source of irritation ; that the gum has grown up from a 
 flattened pedicle, and expanded out so as to fill up the cavity 
 in the tooth ; in other words, that a tumour has been 
 produced by local irritation. 
 
 The structure of these growths is verj' similar to that of 
 the tissues from which they spring. They are for the most 
 part made up of fibrous tissue, with nuclei and fusiform 
 cells ; the surface is covered by greatly-enlarged papillas and 
 a thin epithelium. 
 
 The occurrence of pain is not a necessary consequence, 
 
 (1) Dr. E. Magitot. " Memoire sur les Tumeurs du P^rioste Dentaire," i>. 
 aud figs. 7, la. 
 
 2 N
 
 546 A SYSTEM OP DENTAL 8UBGERY. 
 
 although frequently associated with this disorder. Tumours 
 so situated are very liable to be forced against, and injured 
 by, the ragged edge of the tooth which has led to their 
 growth; and the injured part may become painful, more 
 especially if the wound ulcerates. The patient is unable to 
 distinguish the pain so produced from that which arises from 
 inflammation of the dental pulp. 
 
 If allowed to take its own course, the new growth usually 
 rises to the level of the masticating surface of the adjoining 
 t€eth, and its fiu'ther increase is restrained by the action of 
 the opposing tooth. It will spring up again and again after 
 simple excision, but if the decayed tooth be removed, or re- 
 duced to the level of the gum, any subsequent development 
 of the mass is not only checked, but that which has been 
 already produced rapidly wastes away, and is lost. 
 
 In the treatment of cavities situated on the mesial or 
 distal surfaces of teeth, it is frequently necessary to cut 
 away the sides of one or more teeth down to the level of the 
 gum, leaving a wedge-shaped interval. Into the space so 
 produced the gum will sometimes advance, and is then liable 
 to be injured by food, which, in the course of mastication, 
 becomes forced into the separation between the teeth. The 
 pain attendant upon this condition is usually attributed to 
 the teeth which have been operated upon, and may very 
 readily be mistaken for ordinary toothache. The absence of 
 a cavity within which the new growth can find partial 
 protection from pressure, appears to limit its growth ; for in 
 these wedge-shaped intervals we seldom find that it attains 
 a si2:e beyond that of a slight excrescence. This circum- 
 stance may be taken advantage of in our treatment of the 
 disease. 
 
 Treatment. — Decayed teeth, when they afibrd a receptacle 
 for poly|)us, are usually too deeply involved in disease to 
 admit of successful treatment. It is better that they should 
 be extracted, an operation which not only removes a useless 
 f»igan, but cures at the same time the disease of the gum.
 
 EPULIS. 547 
 
 The extraction of the tooth often brings away the polypus, 
 which is then (see Dr. Magitot, fig. loc. cit.) seen to be 
 adherent to the neck of the tooth by a flattened pedicle. If, 
 for any special reason, the preservation of the tooth is 
 desirable, the tendency to recurrence of the growth must be 
 kept down by escharotics. 
 
 When the gum between two teeth which have been suc- 
 cessfully filled becomes diseased, a different course must be 
 adopted. The roots of contiguous teeth usually diverge in 
 their passage into the jaw, and a second divergence is pro- 
 duced by cutting away the sides of the crown. This leaves 
 a constriction at the point where the excision of the tooth or 
 teeth terminates. It is when the gum rises above this part 
 that it becomes troublesome. Our aim must be to reduce 
 the gum by pressure, or by the use of an escharotic, to its 
 normal position — to a level with the constriction formed in 
 the manner described, or even a little below it. The mere 
 reduction of the gum to its normal limits will not of itself be 
 sufficient to effect a cure ; the pressure must be continued 
 until the disposition to advance is overcome. I should think 
 the electric cautery would be useful in accomplishing the 
 first part of the operation. In my own practice I have used 
 sulphate of copper, or have had recourse to pressure only ; 
 potassa cum calce made into a thick paste with glycerine is 
 an excellent escharotic for any such purpose as this ; it is, I 
 think, the least irritating, and in all respects the best for use 
 in the mouth. 
 
 Epulis. — Tumours springing up from the margin of the 
 gums, whatever may be their structural character, usually 
 receive the designation, epulis. 
 
 By common consent, however, the use of the term is 
 becoming restricted to a particular form of tumour, which at 
 first makes its appearance at the edge of the gum, and very 
 commonly at that portion which lies between two teeth, 
 which, with the growth of the tumour, become gradually 
 separated. The separation does not, however, afford sufficient
 
 548 A SYSTEM OF DEXTAL SURGERY. 1 
 
 space for the accommodation of the new structure, which by 
 slow degrees spreads itself out either upon the labial or 
 lingual surface of the gums, or upon both. The attachment, I 
 at first limited to the inter-dental portion of the gum, may ' 
 not spread with the increasing size of the tumour, or the base 
 may be gradually extended over the alveolar border. In other 
 words, the epulis may be attached by a small and flattened 
 pedicle, or by a broad base. The submucous fibrous tissue, 
 or the soft tissue contained in the Haversian canals of the 
 bone, usually afi'ords the site of the disease, which in its 
 growth carries before it the superjacent mucous membrane. 
 The tumours sjjringing from the fibrous tissue are very 
 generally themselves fibrous in character, and, lying close to 
 the surface of the bone, very frequently contain osseous 
 spicula. The new bone may be altogether detached from, or 
 it may shoot out of, the alveolar process, the surface of 
 which, in either case, ie usually abnormally rough. In 
 respect to vascularity, an epulis commonly does not much 
 exceed that which prevails in the adjacent gum, and the 
 density of the tumour usually corresponds with that of the 
 latter structure. 
 
 When the new growth has attained a considerable size, 
 secondary conditions are induced, which complicate, and to 
 some extent alter, the character of the disease. Unrestrained 
 by surgical treatment, the tumour, at first small, and produc- 
 tive of but little inconvenience, increases in size, generally 
 encroaches upon the space assigned to the tongue, or upon 
 the hard palate, and covering over one or two of the teeth, 
 impedes both mastication and articulation. The surface 
 becomes injured either by the teeth of the opposing jaw, or 
 by those whose crowns it has overrun. The injured part 
 becomes the site of an ulcer, which emits a copious and foetid 
 discharge ; and the patient, in the place of feeling incon- 
 venience only, is submitted, if not to acute suflering, to great 
 annoyance. The external characters of the ulcers sometimes 
 closely resemble those assumed by malignant disease, and
 
 ' EPULIS. 549 
 
 may present a further likeness in the occurrence of hsemor- 
 rhage ; but the cases in which epulis passes into cancer very 
 rarely occur Q). 
 
 Such, then, are the general characters of epulis. As re- 
 gards the structure of these tumours, several varieties may 
 be noted : first, those which are composed of fibrous tissue 
 intermixed with fibro-plastic cells ; secondly, those which 
 are mainly composed of the elastic fibrous tissue, the in- 
 dividual fibres of which, like those of yellow elastic tissue, 
 are tolerably uniform in size, curl up when divided, and 
 remain uninfluenced by the action of acetic acid ; thirdly, 
 those composed of m2^elqid_cells. Mr. Heath mentions a 
 form having the character of " giant-celled sarcoma," and 
 another approximating to epithelioma in its structure. The 
 two first forms have come under my own notice; the third 
 has been described and figured by Mr. Hutchinson (^), who 
 gave the following description : — " On examination, the 
 epulis presented all the characters of myeloid growth in a 
 most remarkable degree. Its section was very vascular^ 
 and showed hues varying from a deep red to buflf, and a 
 peculiar light-greenish tint of yellow (xanthoid of Lebert). 
 Scattered in its structures were some detached masses of soft, 
 spongy bone. Under the microscope were seen abundance 
 of the large poly-nucleated bodies characteristic of these 
 growths, many of them being very irregular in shape, and 
 much branched." 
 
 In many cases it may be extremely difficult, if not impos- 
 sible, to discover any satisfactory cause for the occurrence of 
 epulis ; but in others an examination of the tumours reveals 
 a source of irritation to which the presence of the disease 
 may with probable truth be assigned. In a case of epulis 
 treated by Mr. De Morgan, the tumour contained an isolated 
 piece of bone, which, on careful examination, was found to 
 
 (1) A case in which epulis was supposed to have passed into epithelioma is 
 recorded In the Pathological Society's Transactions, vol. xii. Mr. Adams removed 
 [the jaw, but the patient died from the recurrence of the disease in the skin. 
 
 (*) Transactions of the Pathological Society, vol. vlli., p. 380.
 
 550 A SYSTEM OF DENTAL SUEGEBT. 
 
 be embedded and entangled in, rather than adherent to, the 
 fibrous tissue which composed the mass. After it had been 
 dislodged from the tumour, and submitted to microscopic 
 examination, the following characters were clearly mani- 
 fested : — the whole of the surface bore the marks of absorp- 
 tion, while the substance of the bone presented the structural 
 characters of normally-developed tissue. 
 
 The presence of these characters, and the size of the 
 fragment of bone, fully justified the assumption that it at 
 one time formed a portion of the subjacent alveolus, and that 
 its detachment had been efi'ected by absorption ; and further, 
 that when so detached, it had proved a source of irritation, 
 and thus led to the development of the epulis. In a case 
 previously published, the stump of a tooth, the crown of 
 which had been broken off five years before, was found in the 
 centre of an epulis (Fig. 207). 
 
 Fig. 20' 
 
 But true bone may be developed in the fibrous tissue of an 
 epulis, just as bone may occur as a new development in 
 various other situations ; two examples of this are given by 
 Mr. Heath Q). 
 
 (1) Epulis which has been laid open to display the stump of a tooth ■which 
 lay in its centre. From Tomes's " Lectures on Dental Anatomy and Surgery." 
 
 (2) " Injuries and Diseases of the Jaws," 2nd edition, p. 193.
 
 PAPILLARY TUMOUR OF THE GUM. 551 
 
 Treatment. — Whatever may be the primary seat of an 
 epulis, it is quite certain that it very generally involves the 
 periosteum or the endosteum ; indeed, the balance of evidence 
 is in favour of the view that, although it appears, when first 
 developed, to be confined to the gum, it really springs from a 
 deeper origin. Complete excision of the tumour is the only 
 remedy upon which any dependence can be placed ; and in 
 order to effect its complete removal more or less of the bone 
 at its base must be cut away. When the disease has grown 
 up between two sound teeth, it may be necessary to extract 
 one or both, in order to render the base of the tumour 
 accessible. 
 
 As the growth is almost sure to recur, if the bone at its 
 base be not removed, it is exceedingly bad practice to cut off 
 an epulis and apply nitrate of silver to the cut surface, or to 
 remove it with a ligature. If the attachment to the bone 
 appear superficial, the bone may be scraped away with a 
 gouge or a chisel ; but if, as is more commonly the case, its 
 origin is deeper, the alveolus must be freely cut away with 
 bone-forceps. Free removal of the alveolar border of the jaw 
 does no appreciable harm in such cases ; and it is far better 
 to sacrifice a little more of a part which, in old age, nature 
 would mainly remove, than to risk repeated recurrence of 
 the disease. More than this will never be required ; even in 
 the most formidable-looking cases of epulis, it is only the 
 alveolar portion of the jaw which is involved. 
 
 The haemorrhage, which is rarely troublesome, may be 
 checked by the use of the actual cautery. 
 
 Papillary Tumour of the Gum. — This is a very rare disease, 
 described by Mr. Salter in Guy's Hospital lleports for 1866, 
 in which local hypertrophy of the papilla takes place to such 
 an extent as to form a definite tumour ; Heider and Wedl 
 also (op. cit., taf. xiii., figs. 118, 119) give figures of what 
 they term " papillary proliferations," occuring in the vicinity 
 of carious teeth. 
 
 Vascular Tumours of the Gums. — The gums are sometimes
 
 552 A SYSTEM OF DENTAL SURGERY. 
 
 the seat of tumours which, but for their close structural 
 resemblance to nfevus, might come under the head of epulis. 
 The disease first shows itself in a bright red pimple, slightly 
 raised from the surface of the gum ; and in the cases which 
 have come under my own observation, the growth has been 
 situated between the front teeth. The size is gradually 
 increased, the teeth become separated, and the tumour 
 extends along the gum, both in front of and behind the teeth. 
 It bleeds freely when rubbed by the tooth-brush, is soft and 
 compressible, and may be reduced to the colour and level of 
 the gum by steady and gentle compression. Mr. Salter 
 records a case in which the growth was as large as a marble, 
 and which was productive of much annoyance by the 
 constant hasmorrhage to which it gave rise. It twice 
 recurred after removal by ligature, but when it and the 
 spongy bone at its base were detached by cutting do\s-n with 
 a strong scalpel, and the redundant granulations which were 
 thrown out from time to time cauterised, a cure was effected. 
 The cases which have come under the notice of the 
 author, amounting only to three or four in number, have been 
 successfully treated by the local application of powdered 
 tannin to the surface of the tumour.
 
 ( 553 ) 
 
 TUMOURS OF THE HARD PALATE. 
 
 The commonest cause of tumour on the hard palate is 
 abscess dependent on a lateral incisor tooth, though other 
 teeth do occasionally give rise to it. 
 
 It is also a situation in which syphilitic nodes may occur ; 
 and indolent swellings occasionally appear upon it, in persons 
 who have no ascertainable constitutional taint. 
 
 The commonest forms of true tumour are allied to epulis, 
 of which Mr. Heath (op. cit.) gives examples ; encysted 
 tumours, and cancer, both of the epithelial and medullary 
 type, are met with in this situation, and a remarkable case of 
 papillary tumour, occuring in the practice of Mr. Cock, has 
 been put on record by Mr. Salter. 
 
 Fig. 208. (i) 
 
 In forming a diagnosis of a palatal tumour, it must not be 
 forgotten that it may be due to a misplaced tooth, as is 
 exemplified by the accompanying figure, where a molar tooth 
 has been erupted in the median line of the palate. 
 
 O) From a plaster model in the museum of the Odontological Society.
 
 ( 554 ) 
 
 THE SALIVA AND SALIVARY CALCULUS. 
 
 The fluid ordinarily found in the mouth is a mixture of the 
 secretions of several dififerent glands, and its chemical and 
 physical properties vary according as the products of the one 
 or the other preponderate. For the purpose of description, 
 it will be convenient to consider separately the products of 
 the secretion of the salivary glands, and those of the oral 
 mucous membrane. 
 
 The most abundant source of saliva is the parotid gland, 
 which pours out a clear fluid free from viscosity, of alkaline 
 reaction, and a specific gravity about 1006. It has one 
 peculiarity which is not shared by the saliva furnished by 
 the other glands: when left to itself for a few minutes it 
 becomes turbid, from the deposition, in a crystalline form, of 
 carbonate of lime. This fact serves to explain the enormous 
 accumulations of tartar which are often seen opposite to the 
 orifice of Steno's duct ; another reason why deposits at this 
 point attain such a great size being that the parotid alone of 
 the salivary glands is constantly pouring out its secretion, 
 independently of the stimulus of food. 
 
 The parotid gland is subject to the influence of the fifth 
 nerve, and hence is often stimulated to hyper-secretion in 
 cases of neuralgia (see Neuralgia), being supplied by a 
 branch from the auriculo-temporal nerve (Bernard). The 
 submaxillary saliva is very viscous, so that on standing it 
 sometimes becomes quite gelatinous, but it does not deposit 
 carbonate of lime, though its reaction is alkaline. Its secre- 
 tion is poured out in response to the stimulus of food, and 
 hence is almost entirely absent during fasting (^). 
 
 (1) E. Magitot. " £tudes et experiences sur la Saliva." Paris, 1866.
 
 ANALYSES OF SALIVA. 555 
 
 The sublingual gland pours' out a viscid fluid, rich in the 
 " ptyalin " of Berzelius, also alkaline. 
 
 In addition to the products of these several glands, we 
 have the " buccal mucus ;" according to the experiments of 
 A. Bernard (^) and of Dr. Magitot Qoc. cit.), this also is 
 alkaline, and is very rich in albuminous matters, which may 
 form concretions about the teeth, as is seen in fevers and 
 certain other disorders. 
 
 The mixed saliva from these various sources is alkalinp, 
 and separates on standing into layers, the lowest of which 
 contain epithelial cells, mucous corpuscles, fat, vibriones and 
 cryptogams, and other accidental constituents. 
 
 But notwithstanding the alkaline nature of each and all of 
 these secretions in health, a piece of litmus paper apjilied to 
 the necks of the teeth, or the borders of the gum, often 
 shows an acid reaction. This is due to products of fermenta- 
 tion, and not to secretions originally acid ; and the more the 
 mucous element of the saliva predominates, the more fer- 
 mentation will there be ; the mucus being rich in albumen, 
 and the viscous albuminous element of the glandular saliva 
 (ptyalin of Berzelius), being also albuminous, furnish in 
 abundance the ferment required. Moreover, the more abun- 
 dant these viscous matters are, the more will food be retained 
 in the fissures between the teeth to undergo fermentation ; 
 but this acid reaction, often present to some extent in the 
 neighbourhood of the upper incisors, is never foudd on the 
 gum in the neighbourhood of the lower incisors (Magitot, 
 loc. cit.) ; in this situation the flow of alkaline saliva eff"ec- 
 tually neutralises any acid that might be formed, and in this 
 way the frequency of deposition of tartar on the lower, while 
 it is so rare on the upper incisors, may be explained. 
 
 Analyses of Saliva.— As it is almost impossible to obtain 
 the saliva from one set of glands alone in man, our in- 
 formation is mainly derived from that of lower animals. 
 
 (») "L€9ons de Pbysiologie," vol. ii., p. 121.
 
 556 A SYSTEM OF DENTAL SURGERY. 
 
 Bidder and Schmidt give the following as the constitution 
 of parotid saliva in the dog : — 
 
 Organic matter (albumen and globulin) . 1*4 
 
 Potassic and sodic chlorides . . . 2*1 
 
 Calcic carbonate . . . . . 1 ' 2 
 
 Water 995 '3 
 
 Submaxillary saliva — 
 
 Organic matter (mucin with traces of albumen) 2 • 89 
 Potassic and sodic chlorides . . . 4*50 
 Calcic and magnesic phosphates and carbonates 1"16 
 Water 991-45 
 
 Traces of sulphocyanate of potassium are also met with in 
 saliva. 
 
 The saliva undergoes great alteration in certain morbid 
 conditions of the mouth, or of the general system. 
 
 To take the simplest example first : in stomatitis, tonsili- 
 tis, or pharyngitis, there is a greatly-increased secretion of 
 buccal mucus ; as a consequence of this there is greater acid 
 reaction in the mouth, which is made evident not only by 
 litmus, but by the solution, and consequent disappearance at 
 such times, of deposits "of tartar. It is also susceptible of 
 alteration by chronic disorders of the mucous membrane, 
 such as are generally associated with enlarged tonsils, and a 
 granulai^ flabby-looking appearance of the pharynx (Magitot, 
 loc. cit.). 
 
 In the course of many acute diseases the secretion of saliva 
 is greatly affected. In small-pox, salivation, often profuse, 
 is met with ; but, as a rule, the febrile condition is associated 
 with a dry tongue, from the suppression of the secretions of 
 the salivary glands, and with the formation of sordes upon 
 the teeth, due to an excessive outpouring of buccal mucus. 
 The formation of sordes around the teeth is further favoured 
 by the temporary cessation of mastication, so that the mucus 
 can collect and harden undisturbed.
 
 ANALYSES OF SALIVA. 657 
 
 It is in great part due to this cause that a severe illness 
 often entails great destruction of the teeth ; the thickened 
 mucus affords a ready nidus for fermentation, and furnishes 
 also the feimeiit required, so that the reaction of the gums 
 becomes strongly acid. 
 
 The condition of the oral secretions is markedly dependent 
 on certain chronic disorders, of which, perhaps, dyspepsia 
 exercises the strongest influence. 
 
 The fluid poured out by the glands is unusually rich in 
 viscous albuminous constituents, whilst the mucous secre- 
 tion is greatly increased in quantity. Hence arises that 
 peculiar condition of saliva in which it may be drawn out 
 into strings between the teeth, or wherever the mucous mem- 
 brane is touched by the finger ; a condition with which, in 
 association with most extensive caries, every dental surgeon 
 is familiar, and to the consideration of which we shall return 
 in connection with the subject of Dental Caries, merely 
 noting here, that the deposition of tartar composed of car- 
 bonate of lime is almost unknown where this condition of 
 mouth exists. 
 
 The saliva, together with oral and pulmonary mucus, holds 
 in solution various salts, which are precipitated in greater or 
 less quantity on natui-al or artificial teeth, in those situations 
 where the fluids of the mouth remain at rest. Epithelial 
 scales, and other extraneous matters that may be floating in 
 the oral fluids, or are entangled amongst the teeth, become 
 impacted in the precipitated salts, and thus contribute to 
 form the concretion known as tartar. 
 
 Simon says, " 'J'artar on the human teeth consists of earthy 
 phosphates, epithelium-scales, a little ptyalin, and fat ; and 
 when examined under the microscope, there are seen abun- 
 dance of pavement epithelium and mucous corpuscles : and, 
 in addition to these, numerous long acicular bodies and infu- 
 soria of the genera vibrio and monas. "
 
 658 A SYSTEM OF DENTAL SURGERY. 
 
 According to Berzelius, tartar is composed of 
 
 Earthy phosphates . . . . .79*0 
 
 Salivary mucus . . . . . 12 ' 5 
 
 Ptyalin I'O 
 
 Animal matter soluble in hydrochloric acid. 7' 5 
 
 But no two analyses of tartar give the same result, for the 
 reason that it varies indefinitely in composition. For instance, 
 if. the tartar deposited near the orifice of Steno's duct be ex- 
 amined, it will be found to contain much carbonate of lime, 
 whereas that from the lower incisors will contain little car- 
 bonate, and much phosphate of lime. 
 
 Tartar has been described by dentists as of several different 
 kinds, and named from the variation of colour and density it 
 presents. Thus, one sort is called black, another green, a 
 third yellow tartar. The division is not, however, so far as 
 I know, based upon any chemical difference, and^ may there- 
 fore be disregarded. I conceive that in most instances these 
 physical variations are traceable to the time occupied in its 
 formation, or to the habits of the individual. 
 
 Thus, when the tartar collects quickly it is usually soft and 
 yellow ; and, on the other hand, when the process is slow, it 
 is dark and hard. Then, again, in those who smoke much, the 
 tartar is of a deep brown or black colour. In teeth where 
 one fang has been necrosed, and stripped of periosteum, the 
 surface of the dead fang is often studded with nodules of 
 very hard greenish tartar, which, during the time of its 
 deposition, has been bathed in pus secreted from the lining 
 membrane of the socket. The tartar is not an active cor- 
 rosive agent, producing the destruction of the fang, as some 
 dentists have supposed, but its presence is consequent on the 
 death and denudation of the latter. 
 
 Tartar collects in the largest quantity in two situations : 
 behind the lower incisors, and on the outer or labial surface 
 of the upper molars. Its formation in the latter situation 
 is very readily explained by the fact that parotid saliva, on
 
 ANALYSES OF SALIVA. 559 
 
 exposure to the air, deposits carbonate of lime. In the other 
 situation, there is a constant alkaline reaction maintained by 
 the parts being constantly bathed in saliva from the glands ; 
 very large depositions of tartar are only possible where an 
 alkaline reaction exists, and hence has arisen the idea that 
 tartar is a preservative of the teeth, whereas the truth is that 
 it can only collect largely in a mouth the condition of which 
 renders the progress of caries slow. 
 
 If a vertical section of a piece of tartar be carefully made, 
 it will be found to present a wedge shape, the base of which 
 lies in contact with the gum. The surface towards the 
 tongue or cheek is usually smooth, but that against the gum 
 is rough ; and it is to the latter additions are mostly made. 
 The gums become irritated and inflamed from the contact of 
 the rough surface of the tartar ; the alveoli become absorbed, 
 and the gum recedes, making way for the further accumula- 
 tion of the salivary salts. To the dental tissues themselves 
 the tartar does no direct injury, but its effect upon the gums 
 and alveoli is destructive, and hence indirectly upon the 
 teeth, by depriving them of their sockets. 
 
 This deposition may go to such an extent that not only 
 the crowns, but the whole fangs of several contiguous teeth 
 may be hidden in one shapeless mass of tartar. The friction 
 of mastication does much to hinder its deposition, and careful 
 daily brushing will do much to prevent the accumulation of 
 tartar on the teeth, but should an accumulation take place, 
 it must be removed from time to time by instruments fitted 
 for the purpose. 
 
 Large accumulations of tartar, rich in organic constituents, 
 render the breath insufferably offensive, and lead to the dis- 
 charge of foetid sanious matter from the gums ; but the slow 
 accumulation of a very dense, hard tartar in minute quantities 
 along the edges of the gum, occurs in the mouths of the most 
 healthy people, and may almost be considered as a normal 
 occurrence. 
 
 The benefit derived from scaling the teeth, in great measure
 
 660 A SYSTEM OF DENTAL 8UBGEBT. 
 
 depends on the thoroughness of the operation ; for if small 
 fragments are left, they form nuclei for the deposition of 
 fresh salts. In order to secure the smoothness of the scaled 
 surface, they should be polished with pumice-powder on a 
 piece of wood, after the tartar has been removed by suitable 
 steel instruments. 
 
 Tooth-powder that will dissolve the tartar will also dis- 
 solve the teeth, and therefore may not be used. 
 
 In young people the permanent teeth soon after their 
 appearance through the gum may become disfigured by the 
 deposition of dark green pigment upon the surface of the 
 enamel near its terminal edge. If tartar were present it 
 would project from the general level of the tooth, but in the 
 cases of green discoloration the surface of the enamel is not 
 raised. 
 
 The habitual use of the tooth-brush and the act of mastica- 
 tion gradually rub off the pigment, and the teeth are restored 
 to their proper colour. If, however, the disfigurement remains 
 after the teeth are fully developed and the enamel has acquired 
 density, the unsightly appearance may be removed by rubbing 
 the part with a piece of soft wood loaded with fine pumice- 
 powder. 
 
 As to the nature of this green discoloration, the most 
 diverse views are held: in the tenth edition of Harris's 
 " Principles and Practice of Dentistry," it is said to erode 
 the enamel with great rapidity ; but this does not accord 
 with the experience of most writers, who have found it to be 
 perfectly innocuous. It is sometimes met with amongst 
 the lower animals, both domesticated and wild, in whom 
 caries is very rarely seen ; and the colour, which is perhaps 
 of vegetable origin, probably occupies the substance of the 
 enamel cuticle.
 
 ( 561 ) 
 
 ODONTALGIA. 
 
 Although toothache is not in itself a disease, but is rather 
 the symptom of many other diseases, it may be convenient 
 to group together the various causes which may give rise to 
 it ; referring the reader, for the more minute description of 
 such causes, to the various parts of the book in which they 
 are to be found. 
 
 As a matter of fact, the enumeration of the causes of tooth- 
 ache is little else than a list of each and all the morbid con- 
 ditions to which the teeth are liable ; though, inasmuch as 
 the pain is often the chief thing which has to be cured, it is 
 useful to consider the diseases collectively from this point of 
 view. 
 
 Like all other pain, toothache is more or less intermittent ; 
 it is seldom that it is perfectly continuous, or if it be, it will 
 vary greatly in intensity at different times. The character 
 of the pain, as well as its severity, is greatly affected by the 
 condition of the patient ; a low condition of bodily vigour, 
 whether produced by over-fatigue, prolonged abstinence, or 
 exhaustion of the system by other causes, will tend to pro- 
 duce pain of a diffused, rather than a distinctly localised 
 character, and will markedly increase its severity. 
 
 The ordinary causes of toothache may be grouped under 
 the following heads : — 
 
 1. Morbid conditions of the tooth-pulp. 
 
 2. Morbid conditions of the alveolar periosteum and ex- 
 ostosis. 
 
 3. Morbid conditions of the periosteum of the jaws. 
 
 2 o
 
 562 A SYSTEM OF DENTAL SURGEKT. 
 
 ■i. Irritation of the dental nerves by causes not productive 
 of visible local lesions. 
 
 5. Ulcerations and inflammation of the mucous membrane 
 and submucous tissue ; 
 
 though, of course, such a classification is merely approximate, 
 and serves only to give some method and arrangement in 
 dealing ^vith the subject. 
 
 Under the first head would be included irritation, acute 
 and chronic inflammation of the pulp, pressure from confined 
 matter in the pulp-cavity, and deposit of secondary dentine 
 in its substance. Probably, also, the exposure of sensitive 
 dentine gives pain by setting up irritation of the pulp, as 
 does also caries in its early stages. 
 
 Under the second head would come inflammation of the 
 periosteum, acute and chronic alveolar abscess in its various 
 forms, and those lesions which are mainly manifested by 
 alterations of the fangs of the teeth, such as roughening by 
 absorption, or increase by exostosis. 
 
 Under the third head, traumatic, rheumatic, strumous or 
 syphilitic periostitis. 
 
 Under the fourth, cases of malposition of wisdom teeth, 
 retarded eruption of wisdom teeth, jDressure due to insufficient 
 space, &c. 
 
 Under the fifth, the severe inflammation consequent 
 upon difficult eruption of wisdom teeth, severe salivation, 
 sloughing from access of arsenious acid to the gum, &c. 
 
 Pain that is due to irritation, or to chronic inflammation 
 of the pulp, is rarely continuous, and partakes more or less of 
 a neuralgic character, so that the patient is often quite unable 
 to point out the aflected tooth. It is, more often than not, 
 periodic in its access, and is generally absent at the periods 
 of full vigour, as for instance, after dinner or after Ireakfast. 
 The same may be said of the irritation due to secondary 
 dentine. 
 
 The suffering induced by acute inflammation of the pulp
 
 ODONTALGIA. 
 
 563 
 
 is excessive, particularly if it be in a closely-confined space : 
 it ceases more or less abruptly, from the consequent death of 
 the pulp. When, therefore, a patient states that he has 
 suffered for some few hours from a terribly severe attack of 
 toothache, which has departed as suddenly as it came, the 
 inference is that a pulp has violently inflamed and died ; and 
 a careful examination must be made to prevent the occur- 
 rence of alveolar abscess, as a consequence of the passage of 
 decomposing matters through the pulp canal. 
 
 The pain is almost always of a violently throbbing cha- 
 racter, and it is often attended by extreme tenderness of the 
 whole tooth, which appears raised in its socket ; whether 
 this is really so, is a matter of doubt, as the almost instant 
 relief given by remedies which can only affect the pulp itself 
 would seem to point rather to a sympathetic hyper-^esthesia 
 of the nerves of the periosteum, than to actual inflammatory 
 changes. The recumbent posturaor active exercise serves to 
 aggravate the pain by increasing the vascular supply. 
 
 The pain which is dependent on inflammation of the 
 alveolar periosteum is usually not so violent as that last 
 described ; it is seldom entirely absent, and is much less 
 influenced by the temporary conditions of the patient. 
 
 As it proceeds to suppuration it becomes more severe, and, 
 in the place of a dull aching, assumes a throbbing character ; 
 so soon as the matter has drilled through the bone, the pain 
 is greatly ameliorated, general swelling of the surrounding 
 tissues often being coincident with this amelioration. 
 
 The affected tooth or teeth are raised in the socket, and 
 there is a marked tenderness on pressure, or, at all events, on 
 percussion. Slight feverishness, a furred tongue, and head- 
 ache may be also present. 
 
 The diagnosis of exostosis before the extraction of the 
 tooth is very uncertain, and is often, when arrived at at all, 
 the result of a process of exclusion ; though sometimes 
 rather forcible manipulation of the suspected tooth will bring 
 on pain in these cases.
 
 564 A SYSTEM OF DENTAL SURGERY. 
 
 For the diagnosis of the various forms of periostitis, the 
 reader must be referred to the chapter on this subject; it 
 need only be mentioned here that rheumatic periostitis may 
 be suspected when the pain is widely spread along the jaw, 
 severe out of all proportion to the local mischief visible to 
 the eye, and capable of being brought on by changes of 
 temperature, exposure to draught, or damp weather. 
 
 With regard to malposition of wisdom teeth, it may be 
 noted that the mere fact of the tooth being in an abnormal 
 position will sometimes cause severe pain, without giving 
 rise to any signs of local inflammation ; and the mere slow 
 eruption of these teeth will not rarely cause great suffering, 
 even where there appears to be ample room for them to take 
 their pla^e. 
 
 Why such teeth should be productive of so great suffering 
 is not very readily explicable, but it is very possible that by 
 the gradual elongation of ^heir roots, as these are formed, 
 they press upon and displace the nerves going to the other 
 teeth. 
 
 Pain which is really due to the wisdom teeth is very often 
 referred to a spot much farther forward in the mouth, aud 
 the patient will often point to a bicuspid tooth as the seat of 
 his sufferings. 
 
 A source of great pain, which often escapes detection for 
 a lengthened period, is exposure of the pulp of the second 
 molar, by the pressure of a wisdom tooth impinging upon it 
 below the level of the gum. The accompanying illustration, 
 borrowed from a paper by Mr. Cattlin, will serve to exemplify 
 this state of things. 
 
 The treatment of toothache is, obviously, when possible, 
 remedy the cause. 
 
 Acute inflammation of the nerve rarely comes into th( 
 hands of the dental surgeon for treatment, as it has com^ 
 monly eventuated in the death of the nerve before the patient 
 has the opportunity of seeking relief. 
 
 In chronic inflammation, the application of chlorofon
 
 ODONTALGIA. 565 
 
 I arbolic acid, creosote, or thymol to the exposed spot usually 
 Liives relief, but in most cases the tooth cannot be saved 
 without destruction of the nerve ; so that it is best to apply 
 arsenious acid at once. Curiously enough, this application 
 to a nerve which is already painful seldom increases the 
 
 Fig. 209. (i) 
 
 pain ; in fact, it often gives relief, even before the nerve is 
 thoroughly destroyed ; and this it probably does by speedily 
 cauterising the limited spot which is the seat of inflam- 
 mation. 
 
 When irritation of the pulp seems dependent on exposure 
 of sensitive dentine, a few applications of nitrate of silver to 
 the surface will usually effect a cure. 
 
 Toothache which is due to alveolar periostitis may be 
 relieved by free lancing, and the application of hot fomenta- 
 tions; though in some cases cold gives more relief. The 
 application of stimulants to the gum over the roots is some- 
 times useful, especially in the case of single-rooted teeth : 
 tincture of capsicum or tincture of iodine may be used for 
 this purpose, and repeated applications of tincture of aconite 
 occasionally prove serviceable. 
 
 But the extraction of the tooth will very often become 
 necessary, the most hopeful cases being those in which the 
 pain is due to chronic inflammation of the pulp. 
 
 (1) Wisdom tooth lying below the level of the gum, which has impinged 
 upon the fangs of the second molar, atid, by causing absorption, has laid open 
 its pulp-cavity. From the Odontological Society's Transactions.
 
 566 A SYSTEM OF DENTAL SrEGERY. 
 
 Pain caused by diflBcult eruption of wisdom teeth will 
 seldom be cured by any other measure than the extraction 
 of the tooth ; but relief may be temporarily given by free 
 incisions, cutting away, if possible, the tough overlying gum ; 
 and the excessive tenderness of the ulcerated surfaces may 
 be very greatly relieved by very lightly touching them with 
 nitric acid, and afterwards using repeated applications of 
 phenol sodique.
 
 ( 567 ) 
 
 NEURALGIA. 
 
 Pain resulting from a diseased condition of a part, is by 
 no means invariably referred to the spot whence it realh' 
 originates, but is felt in some distinct, and often remote 
 place. A familiar example of this is afforded by the pain 
 resulting from hip-joint disease, which is referred to the 
 knee, or that from various hepatic disorders referred to the 
 right shoulder. In many cases it is possible to in some 
 measure account for this change of locality by the known 
 distribution of the sensory nerves, but in others it is quite 
 impossible. 
 
 When pain is felt in a tooth, we describe it as *' Odontalgia ;'" 
 but when the tooth is free from pain, or the suffering in other 
 parts is so great as to distract attention from the localised 
 pain in the tooth, we speak of it as " Neuralgia." From a 
 pathological point of view, the disease neuralgia probably has 
 no existence : it is but a symptom indicative of a lesion at 
 some point, which may be discoverable, or may be hidden 
 from our view ; and it is not indicative of any one particular 
 lesion, but of a great variety of morbid conditions. Nor, from 
 a pathological point of view, are we justified in separating 
 odontalgia and neuralgia from one another, seeing that the 
 two arise oftentimes from precisely the same cause. 
 
 In neuralgia pain is the [irominent, indeed, often the only 
 symptom ; but it must be recollected that, after all, it is 
 only a symptom, and not a disease per se. On this point 
 Trousseau Q) says, " Whether the neuralgia be due to chlorosis 
 
 0) Trousseau. "Clinical Medicine," vol. i. "On Neuralgia." New Sydenham 
 Society's Translation.
 
 568 A SYSTEM OF DENTAL SUKGERY. 
 
 or to a carious tooth, it is still a sj^mptom, in the first case, 
 of chlorotic cachexia ; in the second, of the caries of a tooth. 
 As we shall see presently, there is a great difference between 
 these two forms of neuralgia, as regards their obstinacy and 
 their degree of curability, but not as regards pain. All 
 neuralgias, regarded as painful affections, resemble one an- 
 other — with the exception, however, of that neuralgia which 
 I have called epileptiform. It is certainly true that the 
 cause of the neuralgia most frequently possesses a manifest 
 influence on the recurrence, the duration, and the period of 
 invasion of the paroxysms of pain, as well as on the seat 
 of the pain ; but the pain itself exhibits very nearly identical 
 characters." 
 
 To take a recent definition of neuralgia, it may be 
 described as, " a disease of the nervous system, manifesting 
 itself by pains which, in the great majority of cases, are uni- 
 lateral, and which apj)ear to follow accurately the course of 
 particular nerves, and ramify, sometimes into a few, some- 
 times into all the terminal branches of those nerves. These 
 pains are usually sudden in their onset, and of a darting, 
 stabbing, boring, or burning character ; they are at first un- 
 attended with any local change, or any general febrile excite- 
 ment. They are always markedly intermittent — at any 
 rate, at first ; the intermissions are sometimes regular, and 
 sometimes irregular ; the attacks commonly go on increasing 
 in severity on each successive occasion. The intermissions are 
 distinguished by complete, or almost complete, freedom from 
 suffering, and in recent cases the patient appears to be quite 
 well at these times ; except that for some short time after 
 the attack, the parts through which the painful nerves 
 ramify remain sore and tender to the touch. In old- standing 
 cases, however, persistent tenderness, and other signs of local 
 mischief, are apt to be developed in the tissues around the 
 peripheral twigs. Severe neuralgias are usually complicated 
 with secondary affections of other nerves which are intimately 
 connected with those that are the original seat of pain ; and
 
 NEURALGIA. 569 
 
 in this way congestion of blood-vessels, hypersecretion, or 
 arrested secretion from glands, inflammation and ulceration 
 of tissues, &c., are sometimes brought about." Q) 
 
 To this Trousseau (loc. cit.) would add that there is in- 
 variably — or, at all events, so constantly that the character 
 is available for diagnosis — tenderness over some of the 
 spinous processes ; in the case of the fifth nerve over the first 
 two cervical vertebrae ; though this statement is challenged 
 by Dr. Anstie (op. cit., p. 10), who says that these tender 
 points " are not characteristic of neuralgia " (the italics being 
 his), and that they may be present in a variety of other 
 affections. Trousseau goes on to say, " I will give another 
 illustration : in toothache, arising from the presence of a 
 false tooth with a pivot, the spinous processes are not tender 
 on pressure, however acute the pain may be ; but if this 
 pain, which is at first limited to the locality of the tooth — 
 in the lower jaw, for instance — extends to the inferior max- 
 illary division of the fifth, then to the superior maxillary 
 branch, and lastly to the ophthalmic, the spinous pro- 
 cesses then become tender on pressure, and the case is one of 
 neuralgia." 
 
 My own experience does not enable me to speak very 
 positively as to the constancy, or the contrary, of this tender- 
 ness over the first two cervical vertebrae in cases of neuralgia 
 distinctly dependent on the teeth, though I have more than 
 once met with it. 
 
 It is a character_of_neuralgia, proceeding from any cause, 
 to paHTciiTarly affect certain spots, which were iirst pointed^ 
 ou't"under the name of "foci "of pain by Valleix. In the 
 case of the fifth nerve these are rather numerous ; namely,^ 
 one at the supra-orbital notch, one in the upper eyelid, one 
 at the emergence of the nasal branch at the junction of the 
 nasal bone and cartilage, one within the eye, and one at the 
 inner angle of the orbit ; these all belong to the ophthalmic 
 division of the nerve, which js the one least often affected in 
 (1) " Neuralgia and its Counterfeits." F. E. Anstie, M.D.
 
 570 A SYSTEM OP DENTAL SURGERY. 
 
 dental neuralgia. In the superior maxillary division the 
 following, are the usual foci : infra-orbital, where the nerve 
 emerges from its bony canal ;' the malar, on the fr«mt 
 surface of the malar bone;" the palatine, where the anterior 
 palatine nerve einerges ; and, ^stly, the wliole alveolar 
 border. 
 
 In the inferior maxillary division of the fifth nerve we 
 have the temporal, a point a little in front of the ear on the 
 course~or the auriculo-temporal nerve ; the inferior dental ; 
 the lingu al and the labial, wh ich are more rarely seats of 
 pain. 
 
 BuFthe focus most commonly affected in neuralgia, due 
 to any cause, is a ix)int where a number of nerves inosculate, 
 near to the parietal eminence which is known as the parietal 
 focus. A case in which this last focus was affected has lately 
 been under my care : the cause of the neuralgia was irrita- 
 tion of an exposed pulp in a second upper molar, which how- 
 ever was so far protected by the position of the cavity that 
 it was rarely touched in mastication. When, in the course 
 of examining the tooth, the exposed nerve was touched, a 
 paroxysm of intense pain in the parietal focus was instantly 
 felt, for the relief of which the patient, applying both his 
 thumbs to the spot, made pressure with his whole strength. 
 Pressure was the only thing that gave any relief; and, 
 according to the patient's own account, it prevented the 
 spread of the pain from this limited spot over the whole side 
 of his head, which was otherwise apt to occur as the paroxysm 
 was passing off. No pain was felt in the tooth, save just at 
 the moment when the instrument touched the pulp. 
 
 Besides manifestations of pain at various foci, congestion 
 of neighbouring parts and hypersecretion are met with from 
 time to time : thus I have lately seen a patient in whom, by 
 touching an exposed nerve in a first upper molar tooth, I 
 could at will produce injection of the conjunctiva, a profuse 
 flow of tears, and an outpouring of saliva. With reference 
 to the latter effect, the patient's spontaneous statement was
 
 NEURALGIA. 57 i 
 
 that he had applied to another practitioner for relief from the 
 pain he was suffering, and this gentleman had put something 
 into his tooth which had aggravated the pain and had sali- 
 vated him. 
 
 Sometimes the pain felt is referred to a perfectly innocent 
 tooth, often the corresponding tooth in the other jaw ; this 
 perverted sensation is occasionally so definite, that it is a 
 matter of difficulty to persuade the patient that the source of 
 his troubles is not where he feels the pain. Thus a gentle- 
 man lately requested me to extract a perfectly sound second 
 upper molar, the tooth aftected being the corresponding lower 
 molar, of which the pulp was exposed. Nitrous oxide was 
 administered to him, and the lower tooth extracted ; but, so 
 soon as he recovered, he exclaimed, " You have taken out the 
 upper tooth after all ;" nor could he be persuaded, until he 
 had felt the vacant space with his fingers, that such was not 
 the case, thus affording a striking evidence of the correctness 
 of the inference that the lower tooth had been the real cause 
 of the pain. 
 
 Although in most cases of dental neuralgia, pain is confined 
 to the various branches of the fifth nerve , in any of which it 
 is common, it may extend to the side of the neck, to the 
 shoulder, and even the arm of the affected side, which may 
 be subject to a sense of lassitude and weariness almost 
 amounting to slight paralysis (Salter). 
 
 There is good reason for supposing that transient amau- 
 rotic symptoms are sometimes produced by the irritation of 
 diseased teeth ; in fact, it is probable that any or all of those 
 curious secondary affections noted in cases of neuralgia of the 
 fifth nerve, may occur when it is produced by the irritation 
 of diseased teeth, as well as when it is the result of occult 
 causes. 
 
 A remarkable form of neuralgia has recently been described 
 by Dr. Gross, Professor of Surgery at Philadelphia, as occur- 
 ring in edentulous jaws, or in spaces from whence teeth have 
 been removed.
 
 572 A SYSTEM OF DENTAL SURGERY. 
 
 In these cases the pain is generally distinctly localised, 
 its seat being the wasted alveoli and the gum which overlies 
 them. It occurs exclusively in elderly persons, and comes 
 on gradually, proceeding, however, from bad to worse, until 
 the patient's health is worn out b}' constant suffering. Like 
 other forms of neuralgia, it is most severe at periods of depres- 
 sion, and is often temporarily relieved by the administration 
 of quinine. 
 
 The explanation of the jDathology of the affection offered 
 by Professor Gross is, that the minute nerves distributed 
 through the wasted alveolar border have undergone com- 
 pression from the deposition of osseous matter in the canals ; 
 and some support is lent to this view by the fact that the 
 bone was found to have a dense, ivory-like consistence, when 
 cut down upon at the affected spots, and the overlying gum 
 was dense and unusually adherent. 
 
 In each case recorded. Professor Gross, after the failure of 
 other remedies, resorted to the excision of the affected portion 
 of alveolus, which in most cases affected a permanent cure, 
 and in all produced great alleviation of the symptoms. 
 
 There is a form of neuralgia, named by Trousseau, epi- 
 leptiform neuralgia, which, so far as I know, has never been 
 traced to the irritation set up by diseased teeth Q). In it the 
 pain is frightfully intense, exceedingly sudden in its access, 
 and brief in its duration, passing off" as suddenly as it came. 
 In a large number of cases the attack is accompanied by 
 severe convulsion of the facial muscles, causing the patient 
 to make frightful grimaces. This form of the disease is met 
 with during the decline of life, and is quite incurable, though 
 periods of temporary relief may occur. It is not uncommon 
 for the movements of the jaw in mastication to bring on the 
 attacks, so that nutrition is seriously interfered with ; and 
 as the disease progresses, the neuralgic foci before described 
 
 (1) As a caution to the dental surgeon, it may be mentioned that Trousseau 
 records a case in which the paroxysms were brought on by speaking, eating, or 
 drinking, or hy touching u-ith the tip of his fivger his few remaining teeth. 
 These teeth were extracted without afifording the least relief.
 
 NEURALGIA. 573 
 
 become exquisitely tender. Trousseau remarks on points of 
 similarity between this disease and epilepsy, more particularly 
 *' petit mal," and convulsions limited to a single limb ; and 
 again on a resemblance between it and angina pectoris ; 
 while Dr. Anstie states that it is almost always associated 
 with a strong family taint of insanity, and often with melan- 
 cholia in the individual. 
 
 The periodicity of neuralgic attacks has been already 
 alluded to : Dr. Cayley Q) divides facial neuralgia into two 
 classes — the periodic and irregular. Of the former he men- 
 tions that the attacks are usually daily — when the disease is 
 due to malaria they are prone to come on in the morning, 
 and when due to other causes, in the evening. It may be 
 here mentioned that the attacks, when it is dependent on 
 diseased teeth, almost always come on in the evening. 
 
 As ITrousseau (" Clin. Med.") points out, diseases of the 
 nervous system, such as epilepsy, catalepsy, certain kinds of 
 chorea, and many other convulsive aifections, frequently 
 assume not only an intermittent, but a periodic type ; and 
 there seems to be some little connection between these 
 various neuroses — in so far, at all events, as the tendency to 
 inheritance goes — for it will often be found that different 
 members of the same family will suffer from various forms of 
 nervous disorders. 
 
 It is very generally supposed that no morbid changes in 
 the nerve can be recognised in the majority of cases of 
 neuralgia ; this may perhaps be due to the imperfection of 
 our methods of investigation, but in some few cases distinct 
 lesions have been made out. Thus Wedl (" Pathologic der 
 Zahne," p. 345), in examining several nerves which had been 
 resected by Schuh, found that the neurilemma, the medulla, 
 and the axis cylinder were alike occupied by granular deposits 
 in patches ; and in one case he distinctly made out that the 
 axis cylinder was in a measure obliterated by strongly 
 refractive calcareous masses. 
 
 (1) " Archives of Dentistry," vol. i.
 
 574 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 Pigmentation and increased vascularity of the neurilemma 
 were likewise observed in some few cases. Hence Professor 
 Wedl concludes that in inveterate cases of neuralgia, neuritis, 
 and consequent degeneration of the nerve structure, are apt 
 to ensue ; but he regards this as distinctly secondary, and as 
 resulting from peripheral irritation. 
 
 Central lesions have also been observed in some few cases ; 
 thus Schuh (Gesichtsneuralgien, § 19) records a case of severe 
 neuralgia, in which calcareous deposits existed in hoth gas- 
 serian ganglia : on the affected side there was enlargement of 
 the ganglion from increased vascularity and exudation. In 
 other cases lesions at the point of origin of the nerve have 
 been detected. Still, in the majority of cases, the most minute 
 examination reveals nothing whatever, and the rapidity with 
 which a perfect cure may be effected in some instances is a 
 strong reason for regarding the derangement as more fre- 
 quently functional than structural. 
 
 But the various authorities are not by any means agreed 
 on the subject of the pathology of neuralgia; thus Trousseau 
 says in cases " in which a local pain gives rise to a neuralgia, 
 the spinal cord is influenced, and then, through reflex 
 action, excites neuralgia, in which it appears to be always 
 involved." 
 
 Dr. Anstie (pp. cit., p. 110) regards the posterior roots of 
 the spinal nerves as the real seat of neuralgia, and holds that 
 the essential condition is atrophy, luhicli is usually non- 
 inflammatory in its origin. But the instantaneous cure of a 
 neuralgia which we not uncommonly meet with after the 
 extraction of a tooth, or even after the destructioa of the 
 nerve by arsenious acid, appears to me to clearly indicate 
 that neuralgia is possible without much central degenerative 
 change ; or, at all events, that the central change is not 
 enough to produce the neuralgia after the cessation of the 
 peripheral irritation. 
 
 Amongst the causes of neuralgia the following may be 
 enumerated : chronic inflammation of the pulp ; difficult
 
 NEURALGIA. 575 
 
 eruption of wisdom teeth ; secondary dentine in the pulp- 
 cavity ; decomposition of a dead pulp in a confined space ; 
 exostosis; alveolar periostitis, which may depend on the 
 escape of decomposing matter through the pulp canal, or on 
 roughening of the fang by absorption ; exposure of sensitive 
 dentine (rarely) ; and, in fact, almost every diseased condi- 
 tion which affects the teeth. Besides these, faci il neuralgia 
 may be due to periostitis in any of the bony canals through 
 which the nerve trunks pass, or to osteophytes diverting them 
 from their course. Inflammation of the mucous membrane, 
 or the periosteum of the antrum, may involve the superior 
 dental nerves which pass along the antrum in open grooves, 
 and not in bony canals, and so give rise to neuralgia. 
 
 With reference to the influence of the teeth. Dr. Anstie 
 says : " It is an undoubted fact that they may cause neu- 
 ralgia even of a very serious type, and attended with extensive 
 complications ; as in _Mr. Salter's_cases, already mentioned, 
 of reflex cervico-brachial neuralgia from carious teeth. Look- 
 ing to the extreme frequency of caries, however, as compared 
 with the rarity of true neuralgia (not mere toothache), as a 
 consequence of it, it is impossible not to suppose that the 
 share of the carious teeth in the production of such neuralgia 
 must be very small, compared with that of other influences." 
 Whilst every one must admit the rarity of neuralgia as com- 
 pared with dental caries, I think that few dental surgeons 
 would endorse the concluding passage of the sentence. 
 
 But an explanation of such being the opinion of one who has 
 had such extensive experience as Dr. Anstie, is not, I think, 
 difficult to find ; and it rests in this, that the most typical 
 cases of neuralgia, as produced by teeth, are just those in 
 which — partly from the absence of all local pain, and partly 
 from the prevalence of a mistaken notion on the subject — 
 the teeth are never suspected. Thus Dr. Anstie says that 
 the pain in these cases {op. cit.) is far less affected by varia- 
 tions in bodily health, and far less amenable to relief from 
 remedies, than in other forms of the disease ; and Trousseau,
 
 576 A SYSTEM OF DENTAL SURGERY. 
 
 apparently, holds the same opinion. Xow although this is 
 perfectly true where there is any considerable amount of 
 local inflammatory action, it most certainly does not hold 
 good of the commonest cause of all in dental neuralgia, 
 namely, a very limited chronic inflammation of the tooth 
 pulp, which will be more minutely described hereafter. 
 Patients suffering from this are eminently susceptible to 
 various causes tending to depress their bodily vigour ; thus a 
 too prolonged abstinence from food, over-fatigue, exposure to 
 cold, &:c., will bring on or greatly aggravate the paroxysms ; 
 and, on the other hand, they are eminently susceptible to 
 the action of remedies such as quinine and beberine. A full 
 dose of quinine will almost always give relief in these cases ; 
 and if taken nightly, an hour or two before the time of recur- 
 rence, will commonly avert the paroxysm. 
 
 With the exception that diseases of the teeth very rarely 
 set up a neuralgia of the most extreme severity, I do not 
 know of any character by which the malady thus set up 
 difiers from that due to more recondite causes ; and nothing 
 save a most minute examination of the teeth will enable the 
 practitioner to form a correct diagnosis. There is no more 
 fertile source of error than to suppose that amelioration, or 
 even temporary cure, indicates that the cause is not a tooth. 
 In fact, it often happens that the question whether a tooth 
 shall give rise to slight local pain, which may even be 
 altogether absent, or to neuralgia, is determined by the con- 
 dition of the patient at the moment. The conditions which 
 seem most often to predispose to neuralgia are the exhaus- 
 tion of over-work : women are also specially subject to 
 neuralgia, as opposed to toothache, in the early months of 
 pregnancy. 
 
 In such cases, the administration of a full dose of quinine, 
 or a few extra glasses of wine, will almost always effect a 
 temporary cure. 
 
 But the preceding observations apply mainly to the neu- 
 ralgia which is set up by chronic local inflammations of the
 
 NEURALGIA. 577 
 
 tooth pulp— conditions which are not necessarily productive 
 of pain at all ; with regard to those cases in which more ex- 
 tensive inflammatory mischief exists — as, for instance, round 
 unhealthy stumps— the remarks of Dr. Anstie and of Trous- 
 seau, as to their obstinacy under general treatment, hold good. 
 
 Seeing, then, that there is no character by which neuralgia 
 dependent on the teeth can be distinguished from the other 
 forms of the disease, it becomes necessary to examine some- 
 what minutely the various morbid conditions of the teeth 
 which are capable of setting it up. 
 
 Although these disorders of the teeth have been described 
 elsewhere in this work, there are some few points in connec- 
 tion with them which call for further mention here. By far 
 the most common cause is chronic inflammation of the pulp ; 
 and with regard to exposure of the pulp, it may be remarked 
 that violent local toothache and well-marked neuralgia do 
 not commonly co-exist ; the local pain and the diffused pains 
 seeming to stand, in a measure, in a complementary relation 
 to one another. An examination of teeth which have set 
 up neuralgia serves to account for this fact, for the pulp is 
 generally found to be healthy save at one spot, where there 
 will be a limited patch of chronic inflammation, superficial 
 and of small extent. These local inflammations of the tooth- 
 pulp, which are to be found where the situation of the cavity 
 is such that the exposed nerve is but little subject to irrita- 
 tion from the chance contact of food, &c., by no means always 
 give rise to local toothache, even though they be capable of 
 causing excessive neuralgia. 
 
 So long as the exposed nerve escapes acute inflammatory 
 attacks, no pain may be felt in the tooth ; the patient finds 
 that he gets relief from the use of a generous diet, from 
 change of air and the administration of tonics, and hence 
 wrongly concludes that there is no discoverable local lesion. 
 At the risk of recapitulation, let me once more insist that perfect 
 freedom from local odontalgia, periodicity in the paroxysms 
 of pain, amelioration, and even absolute temporary cure of
 
 578 A SYSTEM OF DENTAL SURGERY. 
 
 the symptom under the use of quinine and the like remedies, 
 must not be taken as indications that the disease has no 
 local cause, and that this local cause is not likely to be a 
 tooth. 
 
 When an exposed nerve has been the cause of such pain, 
 it very commonly happens that a paroxysm may be brought 
 on by the touch of an instrument, though this is not inva- 
 riably the case, and it may sometimes happen that, from the 
 partial obliteration of the pulp-cavity by calcification, it is 
 very difficult, or even impossible, toreacb the remnant of the 
 nerve. And although a nerve which has become in great 
 part obliterated by progressive calcification does not often 
 give rise to pain having a diffused character, still instances 
 of its doing so are now and then met with. A patient lately 
 presented himself for examination, who had suffered from 
 pain extending over the whole side of the face and head for 
 upwards of a month, to such an extent that he had not 
 obtained a single night's rest without the administration of 
 sedatives ; he had not the smallest abnormal sensation in any 
 of his teeth, and he only came to me at the very urgent 
 request of his medical attendant, being himself convinced 
 that the teeth had no share in producing his ailment. The 
 only tooth which presented any sign of decay was a bicuspid 
 which stood alone in the mouth; the carious cavity was 
 fully visible on its mesial surface, but had become hard and 
 polished by the efi'ect of mastication, so that caries was not 
 progressing in the tooth. No pulp-cavity was apparently 
 left, the space which it had occupied being filled up with 
 secondary dentine, and being perfectly insensible to the touch 
 of an instrument, or a jet of ice-cold water. 
 
 Nevertheless, as no other cause could be found, and as 
 pressing an instrument firmly over the situation of the pulp- 
 cavity caused an uneasy feeling, I suspected this tooth, and 
 accordingly drilled in the direction of the pulp-canal ; and 
 having opened it up, passed in a very fine nerve-extracting 
 nstrament. This did nut at the time cause more than a
 
 NEURALGIA. 579 
 
 momentary sensation, but after the lapse of several minutes 
 a most acute paroxysm of neuralgia came on. Seeing that, 
 from the flattened form of a bicuspid, there was little chance 
 of extirpating the remains of the nerve with an instrument, 
 a very small quantity of arsenious acid was passed up the 
 fang and allowed to remain there. From that time the 
 patient had no recurrence of pain, and after a few weeks the 
 tooth was filled ; a matter of some importance to him, as it 
 served to support some artificial teeth. It may be thought 
 that in this instance the neuralgia was due, not to the ex- 
 posure of the pulp, but to the presence of osteo-dentine in 
 the canal : this may have been the true cause ; but, as a 
 general rule, the pain due to osteo-dentine is of gradual de- 
 velopment, whereas in this instance the pain began in nearly 
 its full intensity ; moreover, it is usual for pain due to partial 
 calcification to be more distinctly localised, so that the 
 patient is enabled to point out the affected tooth. 
 
 The occurrence of pain during the eruption of the wisdom 
 teeth has already been alluded to, and the explanation that 
 it may in some instances be due to the gradual elongation of 
 the fangs of the wisdom tooth pressing upon, and diverting 
 from their course, the nerve trunks, has been mentioned. 
 The following case, which is only explicable on some such 
 assumption, will serve to illustrate the neuralgias dependent 
 on eruption of wisdom teeth. 
 
 A gentleman, set. 28, had suffered for about six months 
 from agonising neuralgic pain in the left eye-ball. The 
 attacks were strictly periodic, occurring about seven in the 
 evening, and again about three o'clock in the morning, the 
 latter attacks being the most severe. His health had suffered 
 greatly from the long-continued pain and deprivation of rest, 
 and he had ceased to gain much relief from tonics. On the 
 left side all the teeth were perfect ; but the upper wisdom tooth, 
 instead of occupying its proper position, where there was 
 plenty of room for it, lay horizontally, with its crown directed 
 outwards towards the cheek. As it was a source of irritation
 
 580 
 
 A SYSTEM OF DENTAL SUBGERT. 
 
 to the cheek, it was removed, though without much expecta- 
 tion of it relieving the neuralgia. However, the patient never 
 from that moment had another attack ; and on examining 
 his mouth some nine months afterwards, to my great sur- 
 prise, I found that another tooth had come down, and was 
 partly erupted in the normal position for the \\T.sdom tooth. 
 That the extracted tooth lay in close relation with this 
 second wisdom tooth, is indicated hy its fangs hending nearly 
 at a right angle close to their ends. 
 
 A case of neuralgia dependent on exposure of a nerve in 
 the second molar, brought about by the pressure of a ^nsdom 
 tooth, has already been mentioned in the section relating to 
 toothache (page 565). 
 
 Various alterations in the fangs of teeth may give rise to 
 neuralgia : Figs. 210 and 211 represent teeth which were 
 extracted on account of neuralgia, and were brought before 
 the notice of the Odontological Society (by the kindness of the 
 Council of which they are reproduced here) by Mr. Cattlin Q). 
 In the one case there is a nodular exostosis (Fig. 210) ; and 
 in the other (Fig. 211), the end of the fang has been 
 
 Fig. 212, 
 Fig. 210. 
 
 Fig. 211. 
 
 I)artially absorbed, and left roughened and irregular. In the 
 same pai)er is recorded a case dependent on the fang of a 
 canine tooth being prolonged to a fine point, almost as sharp 
 as a needle : in this instance the source of irritation was 
 
 (1) Transactions of the Odontological Societj-, vol. iil.
 
 NEURALGIA. 581 
 
 detected by making the patient bite upon a hard substance 
 with each tooth in succession (Fig. 212). 
 
 A fang which is a source of great irritation may become 
 covered over with healthy gum, and so effectually concealed 
 that its presence can only be detected by the use of a sharp 
 steel probe. If such an instrument be pressed firmly through 
 an edentulous gum, so as to reach the bone, it will readily 
 enter it, and be slightly held by it, so that there is some 
 sense of resistance in withdrawing it ; but if it come upon the 
 hard surface of a tooth-fang, it will not enter it at all. This 
 affords a ready means of detecting a buried tooth-fang ; as, 
 if the surface of the fang be softened to such an extent as to 
 be penetrable by an instrument, it never becomes completely 
 buried and covered by healthy gum. I have lately seen an 
 instance of occasional slight neuralgia kept up by a very 
 small fragment of the end of the palatal fang of an upper 
 molar, broken off' in extraction some six or seven years pre- 
 viously. Occasionally a minute pustule would form on the 
 gum over it, which leads down into a narrow track only 
 large enough to admit a fine nerve-canal instrument, but 
 nothing hard could be felt at the end of the track. However, 
 as the patient recollected the extreme end of the palatal fang 
 having been broken off, I enlarged the track by passing into 
 it silk threads, carrying a paste made of potassa cum calce 
 moistened with glycerine. By the use of this agent such a 
 purpose can be effected, in successive applications, with 
 surprisingly little iiTitation to the surrounding parts, and no 
 pain worth consideration. In this particular instance the 
 tooth-fang descended towards [the surface when room had 
 been made for it to do so, and was easily picked out by 
 fine forceps. 
 
 The fragment was found to have undergone partial absorp- 
 tion, and was much in the same condition as the tooth repre- 
 sented in Fig. 211. 
 
 In those cases of neuralgia in which the cause of the pain 
 is not tolerably apparent after a careful examination of the
 
 582 A SYSTEM OF DENTAL SURGERY. 
 
 teeth, the situation of the pain will often throw some light 
 on the matter ; though it must be recollected that irritation 
 applied at any part of the fifth nerve may give rise to pain at 
 any other. 
 
 With this reservation, the following situations of pain may 
 be taken as indicative of the points of lesion. When the pain 
 is most severe in the parietal region, or at the upper part of 
 the temple, the affected tooth is generally in the upper jaw, 
 and far back in the mouth. When it is referred to the eye, 
 which is rather rare, the tooth may be found in any part of 
 the upper jaw. 
 
 Pain referred to the ear, or the region of the temporo- 
 maxillary articulation, is almost diagnostic of a lesion in the 
 lower teeth, generally towards the back of the mouth. 
 
 The sacrifice of the tooth is not always necessary in cases 
 of facial neuralgia : for example, when it is due to chronic 
 inflammation of the pulp, it may almost always be cured by 
 the destruction of the pulp by arsenious acid ; but when it 
 is due to afl"ections of the alveolar periosteum, or difficult 
 eruption of wisdom teeth, &c., the teeth should be promptly 
 removed. And, indeed, when it is the wisdom tooth which 
 is the source of trouble, it should almost always be sacrificed. 
 
 Wherever there is distinct reason for connecting one or 
 more teeth with the origin of the pain, no dental surgeon will 
 hesitate for one moment at removing the teeth, unless he 
 sees his way clearly to curing the morbid condition without 
 sacrificing the tooth. 
 
 There are, however, many cases of neuralgia, really de- 
 pendent on the teeth, in which it is almost impossible to be 
 certain of this before their removal. For instance, there may 
 be many stumps in the mouth, any one, or all of which are 
 perfectly capable of setting up the irritation, but there may 
 be no symptoms to identify any particular one with the 
 disease. Where there is the least siirn of inflammation about 
 the stumps, I should not hesitate at advising the removal of 
 every one ; and even where there is not, in a confinned case
 
 NEURALGIA. 583 
 
 of neuralgia, useless stumps, which may perhaps be exostosed, 
 are far better away. 
 
 With reference to the extraction of teeth in neuralgia, 
 some difference of opinion appears to exist. Thus Dr. Anstie 
 says, " I admit also, though with much greater qualification, 
 that carious teeth may need to be extracted before we can 
 cure a neuralgia ; but even here I should put in the decided 
 caveat that we must consider whether the system is in a 
 state to bear the shock ; and that, in any case, we probably 
 ought to mitigate the effects of the operation by performing 
 it under chloroform. And I need hardly tell any one who is 
 familiar, either practically or from reading, with the subject, 
 that thousands of carious teeth have been extracted from the 
 mouths of neuralgic patients, not only without benefit, but 
 with the effect of distinctly aggravating the disease." 
 
 It is possible that in some of the cases where distinct aggra- 
 vation of the pain has followed the removal of the teeth, the 
 patient may have been suffering from so-called epileptiform 
 neuralgia, or under that form of neuralgia described by Pro- 
 fessor Gross as affecting edentulous jaws ; but it must not 
 be forgotten that a large number of neuralgic patients are 
 nervous, more or less hysterical, women; and every one at 
 all familiar with either hospital or private practice, will 
 know only too well the strong tendency to ascribe to an 
 operation which has brought no relief, not only the aggrava- 
 tion, but even the original causation of the condition which 
 it was intended to remedy. So that the patient's own state- 
 ments on the matter of the disease being aggravated by a 
 dental or other operation, must, in the absence of corrobo- 
 rative evidence by which the medical man can form his own 
 opinion, be accepted with great reserve. 
 
 Schuh Q) considers that it is possible, though unusual, for 
 neuralgia to be induced by the extraction of teeth ; and 
 Wedl, seeking to account for it, does so on the assumption 
 that the pathological changes which have been observed in 
 
 C) Wedl. "Pathologie der Zahne," 1870, p. 351.
 
 584 A SYSTEM OF DENTAL SUKGERY. 
 
 some few cases are the real sources of neuralgia. He points 
 out that in caries, inflammation of the tooth-pulp is accom- 
 l^auied by degeneration of all the nerve-fibres ; whereas in 
 neuralgia only a few nerve-tubes are thus affected ; and that 
 in this difference between the two conditions, the reason why 
 neuralgia may follow on the extraction of an aching tooth is 
 to be sought. 
 
 But, in the first place, neuralgia is more often produced 
 by a local than by a general inflammation of the tooth-pulp ; 
 so that it is likely that, even in the tooth itself, only a few 
 nerve-fibres would be involved: again, if the injury inflicted 
 on the nerves in the jaw so readily effect their degeneration, 
 how is it that neuralgia after tooth-extraction is not an 
 every-day occurrence ? 
 
 But a yet more formidable objection to this explanation 
 of the difference between toothache and neuralgia, is to be 
 found in the fact that the two are interchangeable : what is 
 toothache one day, may be, owing to a change in the patient's 
 condition, neuralgia on the next, and so continue to change 
 about from time to time, as the bodily health of the patient 
 varies ; though this only happens with mild cases of neu- 
 ralgia. 
 
 Wedl also (Joe. cit.) suggests that the occurrence of neu- 
 ralgia after tooth-extraction may be due to the two ends of 
 the nerve becoming enlarged and painful, as often happens 
 in amputation stumps ; and that this, through some peculiar 
 diathesis, may take place successively in the case of all the 
 teeth which have been extracted. To meet this suppositious 
 condition, Dobbelin has proposed and put into practice a 
 course of procedure which, to me at least, sounds very 
 strange : he drills into the pulp of all the molar and bicuspid 
 teeth alike, whether they be carious or perfectly sound, and 
 destroys tlie nerves. By this procedure he claims to have 
 efiected a perfect cure of a case, for the relief of which a por- 
 tion of the infra-orbital nerve had been previously removed 
 without any benefit.
 
 NEURALGIA. 585 
 
 Nevertheless, I am not inclined to fully endorse the great 
 caution with which Dr. Anstie speaks of the extraction of 
 teeth — the less so as I think he somewhat underrates the 
 influence of teeth in producing neuralgia. AVhenever teeth 
 can be found, on the same side as the neuralgia, which are 
 obviously in one of the conditions which have been described 
 as likely to set it up, the dental surgeon should, in my 
 opinion, have not a moment's hesitation in extracting them. 
 His course becomes rather less plain when there are only 
 carious teeth, with no exposure, or near approximation to 
 exposure of the nerve, or where there are numerous appa- 
 rently healthy stumps. 
 
 Still, where no other cause is apparent, I would advise the 
 removal of everything which can possibly act as an irritant ; 
 for the chances of our effecting a cure are so infinitely greater 
 than the probability or possibility of doing mischief, as to 
 outweigh the latter altogether ; and I think that every one 
 who will take the trouble to search out and carefully 
 read all the well-recorded cases, will come to the same 
 conclusion. 
 
 It sometimes happens that the pain of extraction will be 
 entirely referred to the seat of the neuralgia, and not felt at 
 all at the place itself. 
 
 The removal of the exciting cause is often followed by a 
 severe paroxysm of pain, which I have sometimes been able 
 to relieve by sponging out the socket with phenol sodique ; 
 and these paroxysms may recur from time to time, with 
 lessening intensity, for some days, so that it is advisable to 
 warn the patient not to expect an immediate cure. 
 
 It has already been mentioned that the paroxysms have a 
 tendency to periodicity, often recurring with great regularity : 
 the coming attack may often, and indeed generally, be 
 warded off by a full dose of quinine. But when quinine is 
 given with this object, it must be given in large doses — from 
 five to eight grains for an adult; small doses, frequently
 
 586 A SYSTEM OF DENTAL SURGERY. 
 
 repeated, are often perfectly ineffective in a patient who is 
 at once relieved by a full dose. The large dose is better 
 tolerated if a saline purgative be given some two or three 
 hours before taking the quinine, which should itself be ad- 
 ministered about an hour and a half before the time at which 
 the recurrence of the pain is expected.
 
 ( 587 ) 
 
 SECONDAEY AFFECTIONS DUE TO THE 
 IREITATION OP DISEASED TEETH. 
 
 The resemblance, not to say relationship, which appears to 
 exist between the various neuroses, such as epilepsy, chorea, 
 neuralgia, and the like, has been already alluded to, and, 
 having in view the frequent association of neuralgia with all 
 sorts of secondary disorders, it is a question whether these 
 might not have been advantageously considered under the 
 head of neuralgia. Still, it perhaps conduces to greater con- 
 venience of reference to group them together, and hence a 
 separate section has been devoted to their consideration Q). 
 
 The reflex disturbances productive of a sense of pain, have 
 already been mentioned, and, incidentally, their influence on 
 motor and secretory apparatus has been alluded to. Besides 
 this, the nutritive processes may be profoundly modified, as 
 not very uncommonly happens in the eye. 
 
 The close connection of the fifth nerve with the sym- 
 pathetic through the ciliary, otic, spheno-palatine, and sub- 
 maxillary ganglia, serves to show in some measure the course 
 through which these influences travel to modify nutrition. 
 
 It has already been mentioned that in cases of neuralgia, 
 tonic or clonic spasm of the facial muscles, sometimes affect- 
 ing one or two muscles only, sometimes the whole side of 
 the face, is not very uncommon ; these may graduate almost 
 imperceptibly into typical epileptiform seizures. 
 
 (1) In writing this section of the book much assistance, which I take this 
 opportunity of acknowledgmg, has been received from the veiy complete list of 
 cases drawn up by Professor AVedl (" Patliologie der Zahne," p. 353 ft seq.) ; from 
 cases related in the " Lancet " (i.'^59 and 1861) by Mr. Hilton and Mr. Hancock ; 
 and liom an article contributed by Mr. Salter to Guy's Hospital Reports ( Ihird 
 Series, vol. xiii., 1867).
 
 588 A SYSTEM OF DENTAL SUEGERY. 
 
 Thus, Mr. Coleman (" Brit. Journ. Dental Science," I860) 
 has reported four cases in which convulsions were relieved 
 by the extraction of carious teeth: the convulsions were 
 slight, and in some instances confined to the face and arm ; 
 tingling sensations and a variable degree of paralysis of the 
 arm are also noted. In the same place may be found a 
 reference to a case of Dr. Baly's, in which epilepsy was 
 cured by the removal of a carious tooth. 
 
 Epilepsy. — It is remarked by Dr. Brown Sequard, in 
 describing his experiments on epilepsy artificially produced 
 in lower animals, that after various injuries had been in- 
 flicted on the spinal cord of guinea-pigs, very slight irritation 
 of the branches of the fifth nerve was sufficient to bring on 
 an epileptiform convulsion, in some instances, mere tickling 
 of the skin producing this effect. Bearing in mind also the 
 fact that epilepsy has been in several instances due to the 
 irritation resultant on tumours pressing on nerves, and has 
 been cured by section of the affected nerves, we shall be less 
 surprised to find that in some few cases it has been in- 
 dubitably connected with diseased teeth. The connection 
 between the convulsions arising at the period of the first 
 dentition, and the process of cutting the teeth, is most clearly 
 shown by a great number of cases (cf. page 54) ; and Portal Q) 
 mentions that the extraction of sound teeth at this period 
 had, after all other means had failed, at once arrested the 
 convulsions. 
 
 Convulsions arising at the period of second dentition are 
 very rare ; cases have, however, I believe, been met with in 
 which epileptiform attacks have accompanied the eruption 
 of the second set of teeth in a child previously healthy, and 
 ceased with the completion of that process Q). But difficult 
 eruption of the wisdom teeth has, in several instances, been 
 clearly traced to be the exciting cause of epileptiform con- 
 
 (1) Portal. •' Observations sur I'Epilepsie," p. 333. 
 
 (2) Asbburner, on "Dentition ;" Dr. West, on " Nervous Disorders of Child- 
 hood ;" Wedl, " Pathologie der Ziihne."
 
 EPILEPSY. 589 
 
 vulsion. In one case, related by Portal {op. cit., p. 206), 
 these convulsions were limited to one side of the face ; they 
 were very violent, and were accompanied by extremely severe 
 23ain ; in this instance the tooth was not removed, but the 
 attacks, which had commenced coincidently with the com- 
 mencement of the eruption of the tooth, entirely ceased 
 when this was completed. 
 
 Portal {op. cit.) mentions a second case, in which the con- 
 vulsions were general ; the disease, which was accompanied 
 by severe facial neuralgia, was completely cured by the 
 extraction of the second molar, it having been found impos- 
 sible to remove the wisdom tooth itself. 
 
 Dr. West {op. cit.) relates an instance of convulsions (with 
 temporary delirium after one attack) of frequent repetition, 
 which were clearly traced to difficult eruption of permanent 
 teeth ; in this instance, not the least derangement of health 
 was produced, the boy at once resuming his occupation when 
 the spasmodic movement ceased. 
 
 Dr. Ramskill (" Med. Times and Gazette," 1862) relates 
 the following case : — 
 
 " A boy, ajt. 13, has had frequent attacks of epilepsy for 
 the last eighteen months. Latterly his mother has noticed 
 that some days he rubs his left cheek, complaining of face- 
 ache, after which the fit follows. On examining the mouth 
 there is to be seen a molar tooth considerably decayed, with 
 a swollen gum around it, and partly growing into the cavity ; 
 it is not very tender to the touch, and the examination does 
 not give rise to toothache. On questioning, I find the 
 sensation which the boy experiences before a fit does not 
 seem to be one of pain, but rather of an indefinite uneasiness. 
 He always has a fit the night this comes on. Has never felt 
 it during the day ; it is always about seven or eight o'clock. 
 I desired the mother to have the tooth extracted, and ordered 
 a simple saline with a quarter of a grain of belladonna, to be 
 taken twice daily. This was in June. The tooth was 
 extracted next day. I saw this boy once a fortnight from
 
 590 A SYSTEM OF DENTAL SURGERY. 
 
 that time for four months, but he has had no recurrence of 
 the fit. 
 
 " In this case, I believe, an unfelt aura commenced about 
 the gum, surrounding the tooth, and was not recognised till 
 some degree of inflammation arose ; thus a modification of 
 pain became associated with the aura, and directed attention 
 to it." 
 
 Two cases have occurred under the author's own obser- 
 vation, in which epilepsy was consequent upon diseased 
 teeth,' the most prominent feature being exostosis of the 
 roots. 
 
 A lad, a farm labourer, from Windsor, was admitted into 
 the Middlesex Hospital for epilepsy. The usual remedies were 
 tried for six weeks without effect. His mouth was then 
 examined, and the molar teeth of the lower jaw found to be 
 much decayed, the fangs of some alone remaining. Although 
 he did not complain of pain in the teeth or in the jaw, the 
 decayed teeth were removed, and the fangs of each were 
 found to be enlarged and bulbous from exostosis. During 
 the eighteen months that succeeded the removal of the 
 diseased teeth, he had not suffered from a single fit, though 
 for many weeks previous to the operation he had two or 
 three per day. This is a case of singular interest, inasmuch 
 as there was no complication of maladies, and hence there 
 could be no doubt as to the cause of the disease, seeing that 
 it immediately subsided after the removal of the teeth ; and 
 it is further instructive, as showing that local irritation 
 sufficient to produce grave functional derangement may exist 
 without pain being felt in the seat of mischief. 
 
 A similar, though less marked case, occurred shortly after- 
 wards in the person of a policeman : he had fits which were 
 greatly relieved by the removal of a lower wisdom tooth, the 
 subject of caries and of exostosis. 
 
 In looking over the records of such cases, it is noticeable 
 that local pain is not often mentioned, but that the presence 
 of neuralgic pains is very frequently and pointedly recorded.
 
 EPILEPSY. 591 
 
 The re6ex affections of the nervous system may manifest 
 themselves in other ways than by epileptiform seizures. 
 
 Thus, Ptemak (J) has seen a case in which disease affecting 
 the wisdom tooth gave rise to violent palpitation and cardiac 
 distress ; whilst Lederer gives cases of vomiting and cardiac 
 pain, and Dr. Anstie of alarming stoppage of the heart's 
 action, consequent upon the operation of pivoting a tooth. 
 
 This last-mentioned operation has even been followed by 
 death from tetanus, as in the following case^^) : — 
 
 " , £et, 25, tall and thin, but apparently in very 
 
 good health. On his marriage trip he visited Paris, and 
 there had the misfortune to break off a front tooth. Wishing 
 to conceal the accident from his wife, he went immediately 
 to a dentist. The tooth was pivoted (and, I have no doubt, 
 carefully, for the dentist was one with a great and just 
 reputation), and the necessary concealment seemed ensiu"ed. 
 From the time of the operation, however, he had severe pain 
 in the stump, which pain increased for four or five days, 
 when he left Paris for Kouen. Upon arriving there the pain 
 had become excessively severe ; he consulted a medical man, 
 but it was too late : trismus came on within twenty-four 
 hours, and was soon followed by tetanus, and death." 
 
 A case of tetanus has also been recorded by Dobbelin ('), 
 which came on immediately upon the extraction of a tooth. 
 
 Hysterical attacks, delirium, and even temporary insanity 
 (Esquirol) have been traced to the irritation caused by the 
 eruption of the wisdom teeth ; and, althougli such cases are 
 extremely rare, the authorities by whom they are quoted 
 are such as to preclude the probability of the observers having 
 been deceived. 
 
 Dr. Tyler Smith believes that certain cases of sympathetic 
 pain in the uterus, and even of actual abortion, have been 
 brought about by dental irritation ; and that such should be 
 
 (1) Sydenham Society's Year-book, 1S68, p. 120. 
 
 (2) "Lectures on Dental Surgery and Physiology," by John Tomes, 1348, 
 p. 321. 
 
 (3J " Pathologic der Zahne," by Professor Wedl, 1870, p. 353.
 
 592 A SYSTEM OF DENTAL SURGERY. 
 
 the case is hardly more remarkahle than that strangury 
 should be caused in children during first dentition. 
 
 Mr. Sercombe (" British Journal of Dental Science," vol. iii., 
 p. 221) has recorded a very interesting case of obstinate 
 leucorrhea, and uterine pain, cured by the extraction of a 
 tooth ; touching the tooth with a probe, and its subsequent 
 extraction, brought on most acute paroxysms of uterine 
 pain. 
 
 Deafness during attacks of neuralgia has been elsewhere 
 noticed ; and limited space precludes the relation of more 
 cases of functional reflex disorders, though many more inte- 
 resting examples might be collected from the pages of current 
 medical literature. 
 
 Affections of the Muscular System. — Various reflex affections 
 of the muscular system are from time to time met with ; thus, 
 in the section devoted to the consideration of neuralgia, men- 
 tion is made of its frequent association with a sense of lassi- 
 tude, and even paralysis of the arm of the affected side. 
 
 In a case of Mr. Salter's {op. cit.) there was total inability 
 to raise the arm, or grasp with the hand, which could not be 
 used to hold a fork at dinner, or for dressing; there was 
 continuous pain in the limb. The extraction of a carious 
 impacted wisdom tooth gave immediate relief. In a second 
 case, likewise accompanied by constant aching pain in the 
 arm as well as in the side of the face, the symptom dis- 
 appeared within a few hours of the extraction of the wisdom 
 tooth. 
 
 Spasmodic closure of the jaws resulting from the eruption 
 of the wisdom teeth in an already crowded jaw is, in a slight 
 degree, of very frequent occurrence ; and cases where the 
 fixation of the jaws is almost complete are not very un- 
 common ; thus Mr. Hancock relates an instance of severe 
 pain in the ear and closure of the jaws being cured by 
 extraction of the first lower molar. 
 
 In one of Mr. Salter's cases, the trismus, of four months' 
 duration, passed away within twenty-four hours of the
 
 AFFECTIONS OF THE MUSCULAR SYSTEM. 593 
 
 extraction of the second molar, which was removed in con- 
 sequence of the impossibility of reaching the wisdom tooth. 
 The posterior fang of the second molar was much eroded by 
 the pressure of the wisdom tooth. 
 
 The continued application of steady force will generally 
 cause the muscles to yield at least sufiSciently to enable an 
 examination of the mouth to be made ; and even in the 
 event of considerable inflammation and ulceration having 
 taken place, the difficulty in opening the mouth is generally 
 in great part due to muscular spasm, and will be found 
 to yield to prolonged traction on the administration of 
 chloroform. 
 
 Amongst the most interesting examples of disordered 
 muscular action is one related by Mr. Hancock in the 
 " Lancet " Q) ; the patient, a young woman, had suffered for 
 upwards of six months from spasmodic wry-neck, and had 
 submitted, without avail, to the usual treatment of counter- 
 irritants and various internal remedies. No evidence of any 
 diseased condition being found, Mr. Hancock advised the 
 removal of a stump and a carious tooth on that side of the 
 mouth, these being the only discoverable sources of irritation ; 
 after a few days she was entirely cured of the wry-neck. 
 In this- case the teeth had caused no pain to the patient. It 
 is noted by Dr. Anstie, in his recent work, that these peculiar 
 spasmodic affections are not frequently directly associated 
 with trigeminal neuralgia ; but that they are met with only 
 in highly neuralgic families. 
 
 In another patient strabismus of three years, and ptosis of 
 a fortnight's duration, were found to depend on carious upper 
 molars, and were cured by their removal : the patient was 
 an adult (loc. cit.). 
 
 A case of excessively severe neuralgia is related by Fox, 
 in which only fluids could be taken, on account of any touch 
 upon the teeth bringing on a paroxysm. Profuse salivation 
 and ptosis were present. The ptosis disappeared two days 
 
 (1) " Lancet," Jan. 22, 1859. 
 
 2 Q
 
 594 A SYSTEM OF DENTAL SUKGEEY. 
 
 after the removal of a carious upper molar, but the case was 
 not cured until all the remaining teeth had been extracted. 
 The roots were afifected by exostosis. 
 
 Disordered Xutrition. — The nutritive functions do not 
 always escape participation in the disturbance set up in 
 neuralgia of the fifth nerve, which are probably transmitted 
 through the mediimi of the ganglia in connection with it ; 
 the frequent occurrence of an excessive outpour of saliva, or 
 of tears, has been already noted, but to these may be added, 
 some yet more curious manifestations of the disease. 
 
 Mr. Hilton (}) has several times remarked a tongue furred 
 on one side only, to be dependent on structural or functional 
 disorders of the fifth nerve. In the first case related, the 
 disease was tubercle afiecting the gasserian ganglion ; in the 
 other, the unilateral furred tongue seemed to depend on 
 the presence of carious upper molars, seeing that the 
 peculiarity in each instance disappeared shortly after the 
 extraction of the tooth. Mr. Hilton remarks that these 
 phenomena, of the existence of which he is satisfied, would 
 be more easily explicable if dependent on lower carious 
 teeth, seeing that the tongue derives its nerve supply from 
 the third or inferior maxillary division of the fifth nerve ; 
 nevertheless, the varied seats of neuralgic pains show how 
 closely the whole nerve is connected, and how easily irri- 
 tation is transmitted from one part of its course to another. 
 A curious instance of disordered nutrition, due to the same 
 cause, is given in this lecture, in which the hair covering 
 one temple became perfectly white in a patient suffering 
 from dental neuralgia. In the person of the late Dr. Addison, 
 this reflex disturbance of the nutritive function went so far 
 as to cause an offensive purulent discharge from one ear, 
 proceeding from a slight ulceration in the auditory canal. 
 
 This condition of things was entirely and speedily remediec 
 by the extraction of a carious lower molar. 
 
 Eiuubling sounds or neuralgic pains in the ears, may b 
 
 (1) Lectures delivered st the Royal College of Surgeons. " Lancet," 1861.
 
 SECONDARY AFFECTIONS OF THE EYE. 595 
 
 caused by diseased teeth. Dr. Harvey saw an instance of 
 severe pain and offensive discharge from the outer ear pro- 
 ceeding from the presence of a carious wisdom tooth. 
 
 Secondary Affections of the Eye. — A very large number of 
 well-authenticated cases have been recorded, in which not 
 only functional, but organic disease of the eye has been 
 distinctly traced to be due to the presence of diseased teeth. 
 
 In the opinion of V. Stellwag, the irritation is transmitted 
 through the ciliary ganglion, and by inducing hypera3mia 
 and hypergesthesia, may lay the foundation of serious organic 
 mischief. 
 
 Mention has already been made of congestion of the con- 
 junctiva caused by irritation of the fifth nerve, and if this 
 irritation be kept up for some time, a condition of chronic 
 inflammation may result. 
 
 The cases reported are too numerous to give in this place, 
 but an abstract of a few of the most interesting will serve to 
 give a sufticient idea of their general character. 
 
 A patient of Mr. Hancock's (loc. cit.) became suddenly 
 blind ; when examined, the pupils were seen to be fixed and 
 dilated : the entire absence of premonitory symptoms and of 
 structural lesions having led to the conclusion that the 
 disease was of reflex origin, the mouth was examined, and 
 great crowding of the teeth discovered. Six teeth were 
 removed, and on the same evening the patient, having been 
 totally blind for upwards of a month, was able to distinguish 
 light from darkness, and in the course of a week was entirely 
 cured; no other treatment, save two doses of aperient 
 medicine, having been resorted to. 
 
 A similar condition of functional amaurosis has been 
 known to follow the extraction of a tooth, the effect speedily 
 passing off under the influence of sedative applications to the 
 socket. 
 
 In a second case of amaurosis, of eight months' duration, 
 with entire fixity of the pupil, and inability to distinguish 
 light from darkness, a carious second upper molar tooth was
 
 596 A SYSTEM OF DENTAL SURGERY. 
 
 found. After the extraction of the tooth, the sight gradually 
 improved, and was entirely restored in a few days. 
 
 It is the opinion of Mr. Hancock that a purely functional 
 disorder of the eye may, if allowed to continue unchecked, 
 lead to a permanent structural lesion. Such attacks differ 
 from the advent of true amaurosis in their sudden access, 
 not having been preceded by dimness of vision, musca} 
 volitantes, flashes of light, pain, and the like symptoms ; 
 entire absence of local pain in the teeth seems to be the rule, 
 and not the exception ; indeed, it often seems as though 
 manifestations of local pain stood, in some measure, in a 
 complementary relation to one another, so frequently is the 
 disappearance of the one coincident with the access of the 
 other. 
 
 Teirlink Q) found that extreme photophobia, pain in the 
 eye, dimness of sight, and contraction with immobility of 
 the pupil, were dependent on a splinter of tooth stuck in the 
 upper jaw, but he does not mention where it was. 
 
 Hay (}) also met with an instance of photophobia and pain 
 in the eye, together with severe darting pains in the face, 
 which were provoked by tapping or touching an incisor tootli. 
 On the removal of the tooth these symptoms disappeared ; 
 at the root was found an abscess. 
 
 Sir Thomas Watson (" Lectures on Physic," 4th edition) 
 mentions a case in which blindness, confined to one eye, 
 recurred three or four times, always being cured by the 
 extraction of carious teeth. 
 
 Mr. Salter (oj^ cit.) has seen an instance of change in the 
 colour of iris dependent apparently on prolonged neuralgia ; 
 no other nutritional change had occurred. 
 
 De Witt found vision to return in an eye which had been 
 totally blind for twelve years, after the removal of an amalgam 
 tilling, beneath which was pent up some decomposing pus. 
 Pain returned at the place, and coincidently the sight 
 again deteriorated, but after the extraction of the tooth the 
 
 i}) Wedl. " Patbologie der Zahne," p. 355.
 
 SECONDARY AFFECTIONS OF THE EYE. 597 
 
 blindness wholly disappeared, though he could not distin- 
 guish what very small objects were. 
 
 Dr. Emmeuch (" Dublin Medical Free Press ") suffered for 
 fourteen years from congestion and lachrymation from one 
 eye, and photophobia, these symptoms being aggravated by 
 unsuitable diet ; the symptoms began to amend and soon 
 disappeared after the extraction of a carious tooth. 
 
 A patient under the care of Mr. Salter and Dr. Hyde 
 Salter suffered from dimness of vision and aching pain in the 
 eye, and likewise from facial paralysis, which rapidly became 
 complete. 
 
 This latter was clearly due to the portio dura being in- 
 volved in plastic inflammatory product in the parotid region, 
 due to a carious upper wisdom tooth ; the eye affection may, 
 more probably, have been reflex, as it recurred afterwards 
 when a lower tooth was in fault, and was accompanied 
 by painful paralysis of the arm, which was unquestionably 
 reflex. 
 
 Amaurosis may also be produced by carious teeth in a 
 more direct manner ; namely, by displacement of the ball of 
 the eye by accumulation of pus : but these cases may be 
 more appropriately mentioned in connection with diseases of 
 the antrum.
 
 ( 598 ) 
 
 ODONTOMES. 
 
 Ieregulaeities in the fonn of individual teeth have akeady 
 been noticed at a previous page ; these irregular teeth, how- 
 ever, are linked, by insensible gradations, with those masses 
 of dental tissues which bear no external resemblance to the 
 form of teeth. 
 
 The name " odontomes " is applied to those masses of 
 dental tissues which result from morbid conditions of the 
 formative pulp ; these may consist in hypertrophies, local 
 or general, or various degenerations. It is hardly possible to 
 strictly define what is meant by an " odontome," in the 
 usual acceptation of the term; for it is not usual so to 
 designate, for example, the teeth with enamel- coated nodules, 
 figured at page 220 ; and yet these excrescences difi"er only 
 in degree from those which equal or exceed the whole tooth 
 in size, and would, by most writers, be called " odontomes." 
 Professor Broca has described these malformations, taking as 
 the basis of his classification the periods of development at 
 which they arise; and, although something may be said 
 against this sharply-defined discrimination of the one form 
 from the other (}), yet it affords a convenient method of 
 arrangement, and will hence be followed in this place. 
 
 In order to understand the origin of these pathological 
 products, it is necessary to clearly keep in view the normal 
 
 (1) Prof. Wedl ("Pathologie der Zahne," p. 116) objects to Prof. Brcca's 
 classification, on the ground that it is not based on histological investigations, 
 nor is it in exact accordance with the history of tooth development. Neverthe- 
 less, as any classification is better than none, in the absence of a better, it has 
 been adopted in these pages.
 
 ODONTOMES. 599 
 
 process of tooth formation. At an early stage, a future 
 tooth is represented by a mass of submucous tissue, which 
 has, as it were, risen up to meet the inflected process of oral 
 epithelium which is to form the enamel organ. This papil- 
 liform mass, assuming the form and dimensions of the crown 
 of the tooth, becomes covered on its surface by a layer of 
 cells, known as the " membrana eboris," whose special office 
 is the formation of dentine ; very shortly it becomes covered 
 over with a cap of formed dentine, which when once formed 
 is unalterable. 
 
 Professor Broca Q) classifies odontomes according to the 
 I)eriod at which they arise, dividing them into four groups : 
 
 I. Those which arise before the development of the mem- 
 brana ebDris (odontomes embryoplastiques). 
 
 II. Those which arise shortly before the formation of the 
 cap of dentine (odontomes odontoplastiques). 
 
 III. Those which arise during the formation of the crown 
 of the tooth (odontomes coronaires). - 
 
 IV. Those which arise during the formation of the fang, 
 after the completion of the crown (odontomes radiculaires). 
 
 The first class, those which arise before the formation of 
 odontoblast cells, need not detain us long, as, even if we 
 admit the correctness of Professor Broca's views as to their 
 origin, they bear no semblance to teeth, and fall within the 
 province of the general surgeon rather than that of the 
 dentist. At the period of their origin the dental germs con- 
 tain no histological structures special to tooth germs : and 
 the result of their hypertrophy contains no calcified tissue, 
 but only a structure identical with that of fibrous or fibro- 
 plastic tumours arising elsewhere. But an ordinary fibroid 
 tumour, arising in the jaw, springs from, and is widely con- 
 nected with the bone, so that its enucleation is an impos- 
 sibility ; whereas the fibroixl tumours, by Broca claimed as 
 (1) " Traite des Tumeurs," p. 300. Paris, 1869.
 
 600 A SYSTEM OF DENTAL SURGERY. 
 
 odontomes, are encysted, and may be shelled out by the use 
 of the fingers, or of a spatula ; unless, being of long standing, 
 they happen to have contracted adhesions to the cyst wall ; 
 even then they do not show any continuity of structure with 
 the surrounding bone. Such a tumour is one which occurred 
 in the practice of Mr. C. Heath : a fibroid tumour was re- 
 moved some two years since from the jaw of a lady, which 
 shelled out in this way, and was, in fact, completely encysted ; 
 on microscopic examination it was pronounced to be a fibro- 
 l)lastic tumour, and its recurrence was confidently predicted. 
 Up to this time, however, no sign of recurrence has been 
 seen. 
 
 In one instance M. Eobin met with a tumour, situated in 
 the lower jaw of a child aged two and a half years, which 
 was apparently fibrous, but it was studded with papillae, on 
 which distinct dentine and enamel were found ; and Professor 
 Wedl (^) quotes Tirchow's description of a tumour, which he 
 designated a " myxomatous proliferation of the dental germ," 
 occurring in a calf. It appeared as a free poly]X)id tumour, 
 three inches in length, and seven and a half in breadth ; on 
 its suface were papillae, here and there coated with firm 
 enamel and dentine. 
 
 It is also suggested by Professor Wedl (op. cit., p. 275) 
 that a case of sarcoma, occurring in a man aged thirty-five, 
 may have had some connection with an enamel germ, inas- 
 much as in its fibrillated stroma were numerous cavities and 
 tubes lined with epithelium, calling to mind an utricular 
 gland, the terminal vesicles of which had become in places 
 pinched off from the rest. 
 
 Odontomes of the second class (odontomes odontoplas- 
 tiques), require somewhat more detailed notice ; at the date 
 of their origin the dentine germ is covered by a layer of 
 odontoblasts, more or less completed, but dentine has not yet 
 been formed. Consequently, when the bulb has become the 
 seat of an irregular outgrowth, a mass is produced containing 
 
 I (1) " Pathologic der Zahne," 1870, p. 129.
 
 ODONTOMES. 601 
 
 dentine from the calcification of the odontoblasts, and per- 
 haps also enamel, the enamel organ having followed, as it 
 tends to do, the wanderings of the dentine germ ; but as no 
 part of a tooth has as yet been formed, the mass may be a 
 confused heap of dental tissues, not bearing the most remote 
 external resemblance to a tooth. 
 
 It will be well to note, before proceeding further, that the 
 product of the calcification of a dentine pulp is by no means 
 always true dentine : so long as the layer of odontoblasts 
 coats its surface, true dentine is produced ; but this layer is 
 easily displaced and destroyed, and, once destroyed, is pro- 
 bably never formed afresh. Any calcification which may 
 take place after the destruction of the odontoblasts will 
 assume the form of secondary dentine, or of confused bone- 
 like tissue, but no more true dentine can be formed. The 
 foregoing description may serve to explain the manner in 
 which the mass here figured arose. 
 
 Fig. 213. (1) 
 
 (1) Shows the appearance presented by a vertical section through a portion 
 of the lower jaw, in which was enclosed an irregular mass of dental tissues 
 representing the second permanent molar, beneath which the wisdom toolh 
 was confined. The prominence at the lower part of the figure shows the angle, 
 and the part to the left a portion of the ascending ramus of the jaw.
 
 602 A SYSTEM OF DENTAL SURGERY. 
 
 In this case the second molar of the lower jaw was repre- 
 sented by an irregularly flattened mass, composed of enamel, 
 dentine, and a bony tissue thrown together without any 
 apparent regularity. The wisdom tooth was held down 
 beneath this most extraordinary mass. The nature of the 
 case not having been rightly understood, a portion of the 
 jaw including it was removed ; the figure showing the ap- 
 pearance presented by the excised portion after a longi- 
 tudinal section had been made through it. The mass when 
 removed from its receptacle in the bone, presented no resem- 
 blance to a tooth. From its surface little beads of enamel 
 here and there projected, whilst the woodcut fairly represents 
 the naked-eye appearance of the section through its middle. 
 The radiate appearance is due to the alternation of the 
 structures which compose it : these are mainly dentine and 
 a bone-like tissue, which in some places occupies a position 
 relatively to the dentine, which would lead to the inference 
 that it is cementum, whilst in others it is obviously the 
 result of the calcification of ix)rtions of the dentine pulp 
 which had lost their layer of odontoblasts, and had, therefore, 
 ceased to produce true dentine by their calcification. There 
 is no single definite pulp-cavity, but the dentinal tubes 
 radiate from numerous small canals, and become lost in the 
 confused irregular structures which abound around them. 
 In places the dentinal tubes radiate with considerable 
 regularity from these central canals, whilst in others they 
 are very confused and irregular in their course. 
 
 Prior to the operation there was considerable enlargement 
 of the jaw behind the first jDcrmanent molar, where a hard, 
 brown-looking body was seen projecting slightly above the 
 level of the gum. This was in fact the upper surface of this 
 aberrant tooth, which, from its position relatively to the 
 first and third molars, is shown to be the representative of 
 the second molar : a few nodules of enamel were scattered 
 over this exposed surface. The patient had sufi"ered con- 
 siderable pain in the situation of the enlargement : and the
 
 ODONTOMES. 
 
 603 
 
 case having been regarded as one of disease of the bone, which 
 was likely to proceed from bad to worse, the portion of jaw 
 figured was excised by Sir W. Fergusson. 
 
 Dr. Forget records a somewhat similar case : the mass in 
 this instance occupied the whole space between the first 
 bicuspid and the ascending ramus of the jaw, and was by 
 him regarded as the representative of the second and third 
 molars of that side, the crown of one molar and the second 
 bicuspid having been found held down beneath it. For the 
 use of this figure, which is copied from Dr. Forget's memoir, 
 " Des Anomalies Dentaires et de leur Influence sur les 
 Maladies des Os Maxillaires," I am indebted to tbe kindness 
 of Mr. Christopher Heath. 
 
 Fig. 214. (1) 
 
 The patient in whom this odontome occurred was aged 
 twenty, but disease of the jaw had first been remarked at the 
 
 (1) e, first bicuspid; d, second bicuspid; c, first molar; a and &, portions 
 of the mass which protrude through the bone.
 
 604 A SYSTEM OP DENTAL SURGERY. 
 
 age of five years. Behind the first bicuspid no teeth were to 
 be seen, but the jaw, as far back as the ramus, was the seat 
 of a smooth, unyielding tumour. This was removed by a 
 vertical saw cut in front of the bicuspid, and a horizontal cut 
 at the level of the inferior dental foramen. After removal 
 the jaw was found to be expanded over an uneven, tuber- 
 culated oval mass, of the size of an egg. Beneath it at one 
 spot (e) was found the crown of a molar tooth, whilst between 
 it and the bone was a thick, more or less fibrous membrane. 
 On microscopic examination it was found to be mainly com- 
 posed of dentine, the surface of which was in places covered 
 with enamel, this latter dipping down into the crevices, at 
 the bottom of which cementum was found. 
 
 In this case resection of nearly half the jaw was practised, 
 but in a case related by Mr. W. A. Harrison, before the 
 Odontological Society (^), a mass occupying the whole space 
 between the incisor and molar teeth came away spontaneously, 
 leaving a groove large enough to receive the last joint of the 
 thumb ; this speedily filled up by granulation. 
 
 A similar case, in which the mass lying above the wisdom 
 tooth was removed by operation, is quoted by Wedl Q, and 
 figures taken from models of the jaws are given, showing the 
 rapid contraction and fiUing-up of the cavity left. 
 
 The odontome represented in the accompanying figure is 
 convex on its upper, and concave on its lower surface ; it 
 was placed like a cap over a lower molar tooth, the im- 
 pressions left by the cusps of which may be traced on its 
 inner surface. 
 
 The upper surface, represented in the figure, is partly 
 smooth, and partly studded with enamel nodules, like those 
 met with in Sir W. Fergusson's case. It was made up of 
 irregular tracts of dentine, amongst which folds of enamel 
 dipped down ; no well -marked cementum was found. 
 
 The section represented in Fig. 216 was made from a very 
 
 (1) Prof. C. Wedl, "Pathologic der Ziihne," 1870, p. 125. 
 (2") " British Journal of Dental Science," 1862.
 
 ODONTOMES. 
 
 605 
 
 similar odontome, and will serve to exemplify the usual 
 structural characteristics of these growths. It is traversed 
 
 Fig. 215. (O: 
 
 by parallel vascular tracts (a), which here and there dilate 
 into pouches, or branch out into several divisions ; from these 
 vascular tracts the dentinal tubes radiate with considerable 
 regularity. 
 
 Fig. 216. (2) 
 
 (•) From Heider and Wedl's " Atlas zur Pathologie der Zahne." a, smooth 
 enamel-coated surfaces ; b, nodules of enamel. 
 (2) Section of an odontome. From Heider and Wedl's Atlas.
 
 606 A SYSTEM OF DENTAL SURGEBT. 
 
 Globular masses are in places very abundant, and at the 
 peripheries of the several systems of dentinal tubes irregular 
 spaces abound. In some parts enamel is continued far down 
 into clefts and fissures, so that on section it is seen lining 
 cylindrical spaces, as is seen at the point 6. There is no 
 distinct investing layer of cementum, though here and there 
 the clefts are occupied by lacun£e with numerous canaliculi. 
 
 These irregularities in the form and size of the dentine 
 pulp may, as development goes on, give place to a more 
 normal process, so that we occasionally find that at the 
 bottom of a warty-looking irregular mass are tolerably normal 
 fangs. Such teeth have been described as " warty teeth " by 
 Mr. Salter, but it seems objectionable to multiply names, 
 and they have, therefore, here been included under the same 
 heading as those in which the abnormal development con- 
 tinues till the last. 
 
 The tendency towards the assumption of the normal form 
 
 Fig. 217. (1) 
 
 in the fangs is well illustrated by the accompanying figure. 
 The crown is perfectly colossal, though it retains in a measure 
 
 (1) Natural size. From Helder ani Wedl's " Atlas zur Pathologic der Zahne."
 
 ODONTOMES. 607 
 
 the typical form of four cusps ; the investment of enamel is 
 imperfect, but the cement is continued from the fangs over 
 the crown, on the sides and top of which it attains to a great 
 thickness. 
 
 Passing on to the next class, the " odontomes coronaires " 
 of Broca, we no longer have a shapeless mass in which little 
 or no resemblance to a tooth can be traced. As these 
 originate after the commencement of calciiBcation, at a time 
 when there is a cap of dentine over the pulp, this crown is 
 always to be found bearing a tolerably close resemblance to 
 that of a normal tooth, however much the aspect of the 
 whole mass may be altered by subsequent outgrowths of the 
 pulp. This form of odontome is far more common than that 
 last described, and is exemplified by the specimen here 
 figured, which is taken from my father's collection. Here 
 the outgrowth is limited to the anterior surface of the 
 tooth. 
 
 Fig. 218. 
 
 A similar specimen has been figured by Mr. Salter, in his 
 article in Holmes's " Dictionary of Surgery," in which there 
 has been a localised hypertrophy of the formative pulp. In 
 some instances the defective tooth is not the subject of any 
 very obvious deformity, though it is usually somewhat 
 irregular in shape and enlarged at some point. The enamel 
 investing the crown may be, and often is, perfectly well 
 developed ; but we shall find at some point a slight de- 
 pression, in the centre of which is a small dark spot. If the 
 tooth be divided through its long axis, we shall find that the 
 dark centre of the depression is in fact the choked-up orifice
 
 608 A SYSTEM OF DENTAL SURGERY. 
 
 of a cavity situated within the substance of the tooth, 
 external, however, and perfectly unconnected with the pulp- 
 cavity. If the section be a fortunate one, we shall be able to 
 trace the enamel as it is continued from the exterior of the 
 tooth through the orifice into the cavity, the surface of 
 which is lined more or less completely with this tissue. 
 
 But besides these cavities, which are in reality outside the 
 tooth, we shall also very generally discover, on microscopic 
 examination, that there are other cavities, which are con- 
 tinuous with the main pulp-cavity, and these by the direction 
 of the dentinal tubes radiating from them will generally 
 serve to explain the manner in which the abnormality has 
 originated. 
 
 Deep fissures are in some cases formed upon the lingual 
 surfaces of the incisors, near their bases, leaving a basal 
 ridge. Now, if we imagine one of these ridges, sufficiently 
 thick to contain in its centre a process of the pulp-cavity, to 
 rise up still higher and approximate itself at the top to the 
 
 (1) Shows a section of an upper tooth in which a cavity, c, is formed external 
 to the pulp -cavity, d. It is lined with a thin layer of somewhat imperfectly 
 developed enamel, and communicates with the surface of the tooth at o.
 
 ODONTOMES. 
 
 609 
 
 surface of tiie tooth, the orifice leading to the space between it 
 and the back of the tooth would become contracted, and we 
 should have a condition of things not very dissimilar to that 
 presented by the specimens here described. 
 
 A tooth presenting this sort of deformity was presented to 
 the Odontological Society by Mr. Margetson : the appended 
 figure is borrowed from the Transactions of the Society. 
 
 Pig. 220. 
 
 Sometimes, however, the malformation commences after 
 the crown of the tooth has been completed, and whilst the 
 roots are in process of formation. These " odontomes 
 radiculaires " are very rave, only four or five cases having 
 been recorded. Of these one is in the museum of the College 
 "of Surgeons (^), one is recorded by Dr. Forget (^), and another 
 by Heider and Wedl Q) in their Atlas ; a fourth was pre- 
 sented to the Odontological Sotiety by Mr. Hare, of Limerick, 
 
 (1) Specimen 1022, Pathological Series. Guy'3 Hospital Reports, series iii., 
 vol. xiv., and Ai t. " Diseases of the Teeth," by S. J. Salter, in Holmes's " Dic- 
 tionary of Surgery," 2nd edition. 
 
 (2) " Des Anomalies Dentaires et de leur Influence sur la Production des Ma- 
 ladies des Os Maxillaires." Par A. Forget. Paris, 1860. Plate ii., Figs. 1 
 and 2. 
 
 (3) "Atlas zur Pathologie der Ziihne," von Prof. Heider und Prof. C. Wcdi. 
 Leipzig, lb68. Taf. ii.. Figs. 28 and 29.
 
 610 A SYSTEM OF DENTAL SURGERY. 
 
 and described and figured in the Transactions of the 
 Society Q), in whose museum the specimen now is. 
 
 In these cases the growth is due to a hypertrophy of the 
 formative tooth pulp arising after the development of the 
 tooth is nearly complete ; hence in those two cases which 
 have been thoroughly examined, the tooth and its fangs 
 were found but little altered, although the latter lay im- 
 bedded in the mass which had grown around them. 
 
 Dr. Forget's case, of which a figure is here given, was 
 further examined by Professor Broca, who satisfied himself 
 that its origin was in an outgrowth of the dentinal pulp, 
 though no actual dentine was found in the mass, which was 
 of indistinct bony structure. For the use of the annexed 
 woodcut I am indebted to the kindness of Mr. C. Heath. 
 
 Fig. 221. 
 
 The whole mass came away on an attempt being made to 
 extract the decayed tooth which formed the anterior portion 
 of the growth. 
 
 But by far the largest specimen which has been met with 
 in the human subject is that now in the museum of the 
 Odontological Society, from whose Transactions the sub- 
 joined figures are borrowed {Joe. cit.). The mass, which is 
 represented of its natural size, is seen to be attached to and 
 to surround the root of an upper molar tooth. 
 
 (1) Transactions of the Odontological Society, vol. iii., p. 335, J. Tomes ; and 
 2nd series, vol. iv„ p. 81, Charles S. Tomes.
 
 ODONTOMES. 611 
 
 Before a section had been carried througli the crown and 
 roots of the tooth, and the adjacent portions of the tumour, it 
 was supposed to be an exostosis ; Mr. Salter Q), objecting to 
 this view, designated it by the term " dilated hypertrophied 
 tooth fang ;" and it was also suggested that it might be a 
 calcified cyst. The examination of the section, however, 
 
 Fig. 222. 
 
 renders each and all of these views as to its nature untenable. 
 As is seen in the subjoined figure (Fig. 224), the fangs of the 
 tooth are not dilated nor hypertrophied, but are of rather 
 small size : at some point, not seen in the section, there has 
 sprung from the dentinal pulp an outgrowth, which has 
 completely enveloped the fangs, and grown out into a great 
 lobulated mass. 
 
 The examination of the sections made along the lines a b, 
 h c, and d d, revealed the following structures. At the top 
 were the fangs of the tooth, bedded in the mass ; an invest- 
 ment of cementum of varying thickness completely encased 
 the whole, following all the irregularities of its outline. 
 Inside these layers of cementum came a shell of dentine, seen 
 at the right-hand lower corner of the figure ; the tubes in 
 this layer of dentine radiated outwards, and were disposed 
 with considerable regularity : the inner surface of this dentine 
 shell was, however, far less regular in its outline than its 
 outer surface, the interior being filled up with an ill-defined 
 
 (') Holmes's " Dictionarj- of Surgery " (Ice. cit.).
 
 612 A SYSTEM OF DENTAL SUBGEST. 
 
 osseous structure. At the part marked d d the dentine shell 
 was entirely absent. 
 
 Fig. 223. (') 
 
 \l 
 
 In tlie specimen at the College of Surgeons the only section 
 which has been made is at a part of the mass nearly corre- 
 sponding to the line d d m the specimen here described ; so 
 that its relation with the tooth fang is purely a matter of 
 conjecture : and in the one figured by Haider and Wedl 
 nothing of its relation to the fangs is shown. For this and 
 other reasons (") the proposed name " hypertrophied dilated 
 tooth fang " seems inapplicable. The manner of origin jpL 
 the tumour is tolerably clear : at a certain period in the 
 develoiTmentof the dentine pulp, an outgrowth takes place ; 
 w-lu'clijthough often connected by only a very small pedicle 
 
 (>) Diagram showing portion of the sections made. 
 
 (2) See Odontological Society's Transactions, vol. iv., pp. 81 and 103.
 
 ODONTOMES. 
 
 613 
 
 with^th^j^est_ofJli£jiormy_42u]^ description of^an odon- 
 tom e in Transactions of Odontologicai S ociety Feb. 1872), 
 grows u]3 avmmd i],p d emh races a considerable •portion of the 
 t ooth O'^ ^Si ^"''^° B eing contained within the tooth capsule 
 TTTgce ives an irivestnient oF cementu m on its surface^ within 
 which the pulp liaT become~calcrfied into dentine or bony_ 
 tiss\T5r~~Th"6 ihcomprete calciHcation, or death oF portions of 
 the pTilp, may lead to the existence of cavities in the interior ; 
 
 Fig. 224. (i) 
 
 or it may become absolutely solid, as appears to be the case 
 in the specimen in the museum of the College of Surgeons. 
 The result of calcification of the outgrowth of the dentinal 
 pulp is true dentine only so long as the odontoblast layer, 
 or "membrana eboris," retains its iuteiivitv; so so )ii as this 
 
 (») Section made along the line a h. The upp?r cO 
 at the right-hand lower corner of the figure. 
 
 ntine shell is
 
 614 A SYSTEM OF DENTAL SURGERY. 
 
 is lost, the remainder of the pulp becomes converted into an 
 irregular osseous ~sfructurer TETis in the specimen here 
 figured, as alsoln'^Tliat described by J^Ir. Salter, there is a 
 mere thin shell of true dentine, the interior of which is filled 
 up by the products of calcification subsequently to the pro- 
 duction of true dentine; whilst at the lowest point of the 
 fijst-named specimen (along the line d d) no true dentine 
 was found, but only an irregular bony structure, enclosed in 
 thick laminated cementum. 
 
 From what has been already said, it will be seen that the 
 correct diagnosis of these various forms of odontome is a 
 matter of no small importance, since an error will probably 
 lead to an unnecessarily severe operation ; as has, indeed, 
 already happened in several cases. To distinguish those 
 encysted fibrous tumours which Professor Broca claims as 
 odontomes, from ordinary fibrous tumours of the jaw before 
 the actual operation, is perhaps hardly possible ; but the dis- 
 tinct limitation of such a tumour, joined with the absence of 
 one or more teeth, might lead to a suspicion of its circum- 
 scribed nature, and an incision over it would serve to show 
 whether it was encysted, or widely fused with surrounding 
 structures, without much interfering with the operation, 
 should the latter be found to be the case. 
 
 The absence of one or more teeth from their proper places 
 is a character which has .constantly existed in the cases 
 hitherto recorded ; though it is, of course, conceivable that 
 the pulp of a supernumerary tooth might take on this morbid 
 development. But wherever in cases of enlargement of the 
 jaw, teeth are found to have never made their api)earance, 
 there is a very strong probability that the missing tooth is 
 at the bottom of the mischief; and if this fact be steadily 
 kept in mind, many severe operations may be avoided, and 
 the tooth tumour removed with but slight destruction of the 
 bone. 
 
 Contrary to what might have been expected, these odon- 
 tomes remain for a considerable time without giving rise to
 
 ODONTOMES. 615 
 
 any inconvenience; they may even take up their position 
 with the other teeth and perform their share of mastication, 
 as is well exemplified by an enormons odontome attached to 
 the molar of a horse, v.-hich is in the museum of the 
 Odontological Society, and was described in the Transactions 
 for February, 1872. Sooner or later, however, they generally 
 set up inflammation in the surrounding parts, and profuse 
 and lu'olonged suppuration ensues, leading to the inference 
 that the bone is diseased. Of course the immediate removal 
 of the mass is the only available treatment ; and in most 
 cases this can easily be effected through the mouth, without 
 making any external incision, portions of the bone overl^dng 
 it being removed witli a Hay's saw, or by bone-nippers and a 
 gouge. 
 
 The removal of the mass will be followed by subsidence of 
 all the symptoms, and the large cavity left in the bone will 
 very speedily contract and fill up, leaving no permanent gap 
 behind. 
 
 Tumours containing confused masses of tooth-structuve 
 have been met with elsewhere than in the jaws ; and although, 
 so far as I am aware, no instance of this has (with the exce})- 
 tion of ovarian cysts) been met with in the human subject, it 
 is not impossible that some case may arise, so that the sub- 
 ject deserves passing mention here. In one instance a con- 
 fused mass of dental tissue was removed from below the ear 
 of a horse ; and in another the body of the sphenoid bone 
 was found to be the seat of a tumour containing dentine.
 
 ( 616 ) 
 
 DEXTIGEROUS CYSTS. 
 
 The term "dentigerous cyst" is limited in its application 
 to cysts which arise in connection with developing teeth, or 
 teeth which, though their development has been completed, 
 are retained within the substance of the jaw. In the majority 
 of cases they are connected with permanent teeth, and in 
 some instances with supernumerary teeth. A remarkable 
 case of dentigerous cyst containing supernumerary teeth 
 occurred in the practice of Mr. Tellander, and was described 
 in the Transactions of the Odontological Society for the year 
 1862, whence the accompanying illustration is borrowed. 
 The teeth, the number of which was no less than twenty- 
 eight, mostly present the usual character of supernumerary 
 teeth ; some are built up of adherent denticles, and some are 
 of very irregular form, one having no less than nine cusps. 
 When first t^een by Mr. Tellander, the patient stated that on 
 the right side of the upper jaw the canine, bicuspids, and 
 first molar had failed to make their appearance. At the age 
 of twelve a hard, painless swelling appeared on that side of 
 the jaw, which subsequently became inflamed and painful. 
 When first brought under observation there was enlargement 
 of the bone and great swelling of the surrounding soft parts ; 
 a profuse discbarge of pus oozed up round the root of a 
 temporary molar which had been retained. 
 
 On proceeding to remove the supposed carious bone, it was 
 found that there was a number of loose hard bodies enclosed 
 in a shell of dead bone, and these proved to be the teeth 
 here figured ; but as their importance was not at first recog- 
 nised, it is more than probable that some were lost.
 
 DENTIGEROUS CYSTS. 
 
 617 
 
 After the lapse of six months, all swelling of the jaw had 
 subsided, but a bicuspid tooth had made its appearance in 
 the very place from which all the supernumerary teeth had 
 been removed ; a circumstance which is very extraordinary, 
 seeing that it must have been in very close proximity with 
 the cyst and its contents, and yet was unaffected. 
 
 Pig. 225. 
 
 9 % 
 
 9 
 
 §■« 
 
 But a still more remarkable case of a cyst containing 
 supernumerary teeth occurred in India under the care of 
 Mr. Mathias. The patient, aged twenty-five, was unable to 
 close his mouth on account of the presence of a large tumour 
 in the front of the upper jaw, which pressed the lip up 
 against the nose. The surface of the tumour was eroded by 
 ulcers, from which a profuse offensive discbarge poured out. 
 The man was much emaciated, and the appearance presented 
 was that of malignant disease ; but on passing a probe into 
 the tumour it was found to strike on a hard loose body, which 
 proved to be an agglomeration of ill-formed teeth. One after 
 another the whole of the teeth figured on the next page were 
 removed ; but as there are fractured surfaces which will not 
 fit together, the inference is that some have been lost. The
 
 618 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 soft parts around rapidly returned to a healthy condition, 
 and all deformity disappeared. The teeth absent from the 
 mouth were the central and lateral incisors, the canines 
 occupying their usual position. 
 
 Fig. 226. (1) 
 
 The masses of tooth substance removed are in the museum 
 of the Odontological Society (spec. 442), and a more full 
 account of the case will be found in the Transactions, 
 vol. iii., p. 365. 
 
 Cysts, however, arising in connection with teeth retained 
 in the jaw do not always contain a number of supernumerary 
 
 0) Contents of dentigerous cyst. Mr. Mathias's case.
 
 DENTIGEEOUS CYSTS. 619 
 
 teeth, but often only one tooth, which commonly belongs to 
 the permanent set, though there are cases recorded of cyst 
 arising in connection with temporary teeth. 
 
 Teeth which lie buried in the jaw do not by any means 
 invariably give rise to irritation. Numerous examples of 
 teeth occupying abnormal situations are to be found in 
 museums, with no sign of disease around them ; and there 
 are even instances of teeth inverted and embraced between 
 the fangs of other teeth, whose presence has never been sus- 
 pected until the erupted tooth has been extracted in conse- 
 quence of caries {cf. p. 196). 
 
 But in a certain number of cases these retained teeth cause 
 to be developed around them a cyst with bony walls. An 
 excellent example of this is here figured : the drawing is 
 taken from a wax model of a portion of the lower jaw excised 
 by M. Maisonneuve: at the bottom of the cyst is seen a 
 
 Fig. 227. (1) 
 
 canine tooth lying horizontally. In this case a saline fluid 
 flowed from an opening behind one of the front teeth, leading 
 into the cyst. 
 
 In this case the patient's age (fifty-six) would add to the 
 (') Cyst of the lower jaw, containing a canine tooth. M. Slaisonneuve's case.
 
 620 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 difficulty of diagnosis, as dentigerous cysts, in the majority 
 of cases, come under tbe surgeon's notice at a much earlier 
 age. 
 
 A considerable number of such cases have from time to 
 time been put on record, and the museums of the different 
 London hospitals, many of them, contain portions of jaws 
 which have been removed through a mistake in the diagnosis. 
 The cysts in these cases have generally consisted of a thick 
 soft membrane, outside which comes a bony shell, formed by 
 the bone of the ja^v expanded over the growth within it. 
 This membrane in 'some instances becomes calcified, as is 
 well exemplified in Fig. 231 ; or it may become infiltrated by 
 earthy salts, without definite structural arrangements. 
 
 The cyst is usually filled with a clear glairy fluid, in the 
 first instance ; but not uncommonly it has become inflamed 
 at some period, and its contents will then be pus, or perhaps 
 a yellowish fluid loaded with cholesterine. 
 
 Fig. 223. 
 
 As a general rule, the cyst appears to give rise to a dis- 
 tinctly localised enlargement of the bone ; but in some in- 
 stances, as in the very remarkable case recorded by Mr. 
 Fearn ('), the whole jaw was expanded by a separation of its 
 internal and external plates, extending from the ascending 
 ramus on the one side, to a point beyond the symphysis on 
 
 . (1) " British Medical Journal," August 27, 1864.
 
 DENTIGEEOUS CYSTS. 
 
 621 
 
 the other. The figure of this jaw here given is borrowed 
 from Mr. Heath's " Diseases and Injuries of the Jaws," where 
 a very comprehensive account of dentigerous cysts is to be 
 found. 
 
 Another case, in which the whole of one ramus was ex- 
 panded, is given by Dr. Forget in the work before referred 
 to. The tumour, which proved to be a cyst in which lay an 
 
 Fig. 229. (1) 
 
 inverted wisdom tooth, had been slowly growing for ten 
 years, and at the time of operation was larger than a hen's 
 egg. In this case the half of the jaw was removed b)- 
 M. Lisfranc, the patient recovering the operation well ; though 
 
 (1) Right half of the lower jaw, expanded out by a dentigerous cyst, a, in- 
 verted wisdom tooth; 5, internal waU of the cyst; c, inferior dental canal. 
 M. Lisfranc's case. I am indebted to Mr. Christopher Heath for the use of the 
 woodcut.
 
 622 A SYSTEM OF DENTAL SUEGERT. 
 
 of course, had the true nature of the case been recognised, 
 this formidable procedure would have been unnecessary. 
 
 This inversion of a tooth is not uncommonly found in 
 cases of dentigerous cyst ; as is seen in the following case, 
 related in the first edition of this work : — 
 
 " A girl of sixteen, the daughter of a tradesman, gave the 
 following history of her case : Nine months since a swelling 
 appeared in the lower jaw, about the implanted portion of 
 the second molar, which was supposed to be a gum-boil. 
 
 *' The pain was at first slight and intermittent ; but as the 
 size of the swelling gradually increased, the amount of dis- 
 comfort became greater, though never amounting to acute 
 pain. I saw her for the first time on December the 15th, 1856. 
 There was very considerable enlargement of the alveolar 
 portion of the jaw around the second molar. The tooth, 
 however, was perfectly sound, and although tender when 
 pressed upon by the antagonistic teeth, yet it was not con- 
 sidered by the patient to be the seat of pain. The colour of 
 the tooth was perfectly good, and its implantation firm — 
 indeed, there was a total absence of any indication which 
 would induce a belief that disease had arisen firstly in it 
 and subsequently extended to the jaw. 
 
 " The swelling was not confined to the soft parts — the 
 bone was obviously involved. At one point, however, fluctu- 
 ation could be felt, and the examination did not appear to 
 produce any considerable amount of pain. The absence of 
 acute inflammatory symptoms, and the comparative fi-eedom 
 from tenderness, coupled with the large amount of local 
 swelling, rendered the nature of the disease obscure. Mr. 
 Arnott was kind enough to see the case, and he introduced 
 a grooved needle : several drachms of a clear yellow fluid 
 escaped, and the swelling of the soft parts to a certain extent 
 subsided, leaving the outline of the enlargement of the bone 
 comparatively distinct. The patient felt relieved by the 
 operation from the sense of tension and weight, which had 
 latterly become distressing. On the 26th of January the
 
 DENTIGEROUS CYSTS. 
 
 623 
 
 swelling had again returned, and with it dull aching pain ; 
 the involved tooth had in the interval become slightly loose, 
 and was turned inwards towards the tongue. The swelling 
 was again punctured, with results similar to those already- 
 recorded. 
 
 " On the 5th of February the patient again returned. Since 
 the last puncturing of the tumour she had suffered great pain, 
 accompanied with constant throbbing in the tumour, and pus 
 had subsequently been discharged from the puncture. The 
 amount of constitutional disturbance had been sufficient to 
 confine the patient to her room for several days. Finding 
 that the tooth had become much more displaced than before ; 
 that it was quite loose, and that the surrounding gums were 
 greatly inflamed, I determined to remove the tooth, although 
 it was by no means clear that it was the primary cause of 
 the mischief. On its removal a most curious state of things 
 was made manifest. Instead of having its normal two fangs, 
 the implanted portion of the tooth was dilated into one large 
 concavity, in which was placed the crown of a second tooth, 
 perfectly invested with well-developed enamel, but having 
 its masticating surface directed downwards towards the jaw. 
 The two teeth appear to be united by dentine at one point, 
 and to have one common pulp-cavity. The appearances pre- 
 sented by the united teeth are shown in the figures — 
 
 Fig. 230. 
 
 "The pain from the operation quickly subsided, and within a 
 fortnight all swelling and pain in the soft parts had disappeared : 
 the enlargement in the bone had also sensibly diminished."
 
 624 A SYSTEM OF DENTAL SUEGERY. 
 
 A case presenting somewhat similar general characters 
 was treated at the Middlesex Hospital. In a female under 
 thirty, the lower jaw had become enlarged and painful in 
 the neighbourhood of the second molar, behind which was a 
 fistulous opening. Through this opening a probe passed 
 readily into a cavity in the substance of the bone, but no 
 tooth could be felt. An opening was then made with a 
 trephine, and the linger introduced, when a tooth covered in 
 great part, if not entirely, by membrane was found hing 
 upon the floor of the cavity. The tooth proved to be a per- 
 fectly sound wisdom tooth. 
 
 Fig. 231. (1) 
 
 AVhen one of these dentigerous cysts is situated in the 
 upper jaw, it is very common to find the antrum involved in 
 the disease ; a number of cases are quoted by Mr. Heath in 
 which this has taken place : one remarkable case is quoted 
 by him from Dupuytren, of a cyst developed between the 
 
 (1) Dentiserous cyst which has invaded the antrum, and has sutsequently 
 become calcified.
 
 DENTIGEROUS CYSTS. C25 
 
 plates of the palatine process of the upper jaw. There is a 
 preparation belonging to Mr. Cartwright, at present allowed 
 to remain in the museum of the Odontological Society, in 
 which a cyst of this kind occupies the antrum ; the cyst 
 wall has become calcified, so that it presents the remarkable 
 appearance depicted in the figure of a very fragile bony 
 shell, attached only at one point, being elsewhere free of the 
 walls of the antrum. The cyst contains a supernumerary 
 tooth. 
 
 But a yet more remarkable case is cited by Mr. Heath, in 
 which hoth antra were dilated to an enormous size by cysts, 
 in the one of which was a canine, and in the other a molar 
 tooth. 
 
 A very interesting case of dentigerous cyst in the antrum 
 is reported by Mr. McCoy in the " Lancet " (1871). The 
 patient was a negro, aged fourteen, and the tumour, which 
 had been first noticed about two and a half years previously, 
 was as large as an apricot. The cavity of the antrum was 
 found to contain a small quantity of glairy fluid, but to 
 be chiefly occupied by a gelatinous substance, apparently 
 thickened mucous membrane. Projecting into the cavity 
 was a perfectly sound canine tooth, which was imbedded in 
 a distinct socket situated in the nasal process, on the inner 
 angle of the orbital process of the maxillary bone : it required 
 some force to extract it. Previously to the operation it 
 was noticed that the left upper canine tooth was missing 
 from its natural place. 
 
 No reasonable doubt can be entertained that the teeth are, 
 in these cases, the primary sources of the mischief, aided 
 perhaps by constitutional tendencies of the patient. P>ut the 
 question as to the precise manner in which the morbid con- 
 ditions were developed is more diflicult of solution. It will 
 be remembered that, when treating of the eruption of the 
 temporary teeth, attention was directed to the occasional 
 presence of vesicular enlargements over teeth about to pene- 
 trate the gums, the contents of which presented the characters 
 
 2 s
 
 626 A SYSTEM OF DENTAL SUEGERT. 
 
 of serous fluid ; and to the fact that, on incising such en- 
 largements, the knife comes down on the enamel-coated 
 crown of the coming tooth. In connection with this subject, 
 allusion was made to the feet that, when the development of 
 the enamel is completed, its outer surface becomes perfectly 
 detached from the investing soft tissue, and that a small 
 amount of transparent fluid not uncommonly collects in the 
 interval so formed. Now I believe we may find in this an 
 explanation of the manner in which cystic tumours containing 
 buried teeth arise. 
 
 I conceive that, in the cases cited, fluid collected between 
 the enamel and the tooth-capsule. As the cyst enlarges, 
 the contiguous bone is removed to make room for it, fresh 
 bone being concurrently deposited on the outside of the jaw. 
 In the case of such a cyst lying in front of a tooth which is 
 being cut, it is obliterated by the advancing tooth, or it 
 bursts ; but when situated deeply in the jaw, a cystic tumour 
 may be the result. 
 
 If the foregoing views be correct, it is not difficult to see 
 how an encysted tumour may be produced by a hidden tooth ; 
 in M. Maisonneuve's case a perfectly sound canine lay at 
 the bottom of a cavity lined by membrane and filled by fluid. 
 Xow, as neither the bone nor the tooth showed any evidence 
 of their tissues being abnormal, and as the presence of a 
 tooth in an unusual position does not of necessity lead to 
 disease around it, the difficulty of giving a rational account 
 of the origin of this and similar cases becomes almost insur- 
 mountable, unless we recognise the occurrence of conditions 
 such as those described. But the difficulty of explanation 
 is at once removed if the collection of fluid between the 
 enamel and the tooth-capsule be admitted as a condition that 
 may arise, under some circumstances, in the case of teeth 
 which lie deeply buried in the jaw. 
 
 Before, however, any explanation can be accepted as final, 
 further observations are required. 
 
 Kasmyth's membrane is furnished by the tooth-capsule,
 
 DENTIGEEOUS CYSTS. 
 
 627 
 
 and is nothing more than coronal cement ; if, then, the 
 *' cuticula deutis '*' is present on these teeth enclosed in cysts, 
 the fluid cannot, strictly speaking, be regarded as situate 
 between the enamel and the tooth-capsule. 
 
 But, so far as I know, no observations have been made on 
 the presence or absence of Xasmyth's membrane on these 
 abnormally-placed teeth ; so that, so far as it is concerned, 
 the question must remain in abeyance. 
 
 A case that lends some support to the above view was 
 met with by my colleague, Mr. Moon, at the Dental Hos- 
 pital, in which a dense, elastic tumour, simulating a solid 
 growth, occupied the place of one of the central incisors of a 
 child. On incising it, it was found to contain clear fluid, 
 and the crown of the missing incisor was exposed in the 
 cavity ; it was described by Mr. Moon as an example of a 
 dentigerous cyst devoid of bony walls. 
 
 It must, however, be recollected that cysts lined with a 
 very distinct fibrous membrane occur in other bones than 
 the jaws, so that it is not at all necessary that the lining 
 membrane of a dentigerous cyst should have been in any 
 way derived from the tooth and its capsule. And Professor 
 Wedl (pp. cit.) suggests that it is quite as probable that a 
 tooth growing in an abnormal direction should set up an 
 irritation, resulting in the surrounding bone becoming ab- 
 normally developed into a cyst, as that the dental sac should 
 itself degenerate into a cystic formation. 
 
 The subsequent changes which may occur, such as calcifi- 
 cation of the cyst wall, or the alteration of the contained 
 fluids by inflammation and subsequent suppuration, do not 
 require any special comment. But when once a buried tooth 
 has become a source of severe irritation, it is seldom that the 
 mischief ceases until the source of irritation has been re- 
 moved : Avhen this has been eficcted, the cure is usually 
 rapid and complete. 
 
 Not only, however, may cysts arise in connection with 
 teeth which have remained buried in the jaw, but a similar
 
 628 A SYSTEM OF DENTAL 8UKGERT. 
 
 form of disease may originate about the fangs of normally- 
 erupted teeth. Such cysts are not usually called by the 
 name of " dentigerous cysts," that terra being restricted to 
 those forms of tumour already described. Cysts of small size 
 are tolerably frequently met "with attached to the roots of 
 extracted teeth ; in the first instance the morbid process is 
 probably identical with that resulting in the formation of 
 alveolar abscess, but the process being less acute, a serous 
 cyst takes the place of a rapidly suppurating sac. As such 
 cysts increase in size they produce absorption of the bony 
 structures around them, and may in this way come to occupy 
 the cavity of the antrum. Mr. Heath quotes a case of 
 Fischer's in which he was able, by post-mortem examination, 
 to clearly trace that a cyst occupying the whole antrum had 
 no connection whatever with tlie walls of that cavity, but 
 was attached solely to the apex of the fangs of a molar tooth, 
 from the periosteum of which it sprang. 
 
 Mr. Coleman Q) drew attention to a tooth, to the side of the 
 root of which a cyst containing cholesterine was attached, in 
 addition to an alveolar abscess situated at the apex of the 
 fang. These cysts connected with the roots of teeth occa- 
 sionally form swellings in the angle between the alveolar 
 borders of the jaw and the reflected mucous membrane of 
 the cheek, and when opened are commonly found to contain 
 a fluid loaded with cholesterine : a case of this kind occurred 
 at the Middlesex Hospital, under the care of the late Mr. 
 Moore, which had apparently originated in this way ; the 
 cyst refilled several times after it had been punctured, but 
 after being freely slit open from end to end, it filled up 
 with granulations, and no further trouble was exj)erienced 
 from it. 
 
 It seems very probable that cystic disease of the lower jaw 
 
 may not infrequently be due, in the first instance, to the 
 
 irritation set up by stumps or carious teeth : the following 
 
 case, which lately occurred in my own practice, will serve to 
 
 (>) Transactions of the Odontologic.il Society, 1862.
 
 DENTIGEROUS CYSTS. 629 
 
 illustrate this point, as well as the general characters of 
 cystic enlargement of the jaw. 
 
 The patient, a lady aged thirty-five, stated that two years 
 previously she had had a severe inflammatory attack, in- 
 volving the stum])S of one of the molars in the lower jaw ; 
 at that time her face was excessively swollen for some days, 
 after which the inflammation gradually passed off; but she 
 distinctly states that the enlargement around the aff"ected 
 tooth never disappeared. When first seen by me, the second 
 bicuspid and the three molars of the right side were all 
 decayed down to the level of the gum, and the stumps were 
 somewhat displaced inwards. From the stump of the second 
 bicuspid to that of the second molar, the groove between the 
 cheek and the bone was entirely obliterated by a rounded 
 tumour, but the internal alveolar plate was only very slightly 
 bulged inwards. On pressing firmly with the finger on the 
 front or the back part of the tumour, a peculiar crackling 
 sensation was felt, but a bridge of firm bone crossed its central 
 portion which did not yield in the least to pressure. The 
 stumps of the teeth were all loose, and the patient stated 
 that a glairy fluid had at times oozed from around one of 
 them. The face was considerably disfigured by the enlarge- 
 ment ; but the skin was perfectly movable over the tumour, 
 as was also the mucous membrane in the mouth. No en- 
 larged glands were to be felt in its neighbourhood ; and the 
 tumour was quite painless, save that the patient complained 
 of a sense of fulness and tension. 
 
 The patient was placed under chloroform, and the stumps 
 extracted, a slight flow of clear fluid from the sockets follow- 
 ing their removal ; an incision Avas made midway between 
 the cheek and the jaw along the whole length of the cyst, 
 which was cut into by bone-forceps, and a portion of the 
 firm bar of bone which arched over its middle cut out. On 
 passing the finger into the cavity, its walls felt as though 
 made up of small fragments like a broken egg-shell, and by 
 pressure on the outside it could be made to partially collapse.
 
 G30 A SYSTEM OF DENTAL SUKGEBY. 
 
 The cavity was stuffed with lint, which was removed on 
 the third day. 
 
 Three months afterwards all enlargement had disappeared, 
 and no trace could be felt even of the strong bony bar which 
 had bridged over the tumour ; several small pieces of bone 
 had come away in the meantime, but no fragment of any 
 considerable size had separated. 
 
 In the development of cysts within the lower jaw, it is the 
 outer plate which commonly becomes bulged by the tumour, 
 which, if left to itself for a sufficiently long time, effects the 
 complete absorption of the bone investing it, so that fluc- 
 tuation may be readily detected through its membranous 
 walls. 
 
 A fuller account of cystic disease of the lower jaw will 
 be found in 'Mi. Heath's admirable work, to which the reader 
 is referred for cases and information which hardly fall within 
 the scope of the present book. 
 
 A case is recorded by Mr. Coote of cystic tumour of the 
 lower jaw, which was referred to the irritation of tooth- 
 stumps, and was treated by the extraction of the stumps — 
 the patient's age (seventy-five) and condition precluding any 
 more radical operation. But the patient's death occurred 
 before sutncient time had ensued to show what result would 
 have been attained. 
 
 Diagnosis. — The recognition of dentigerous cysts, in the 
 earlier stages of their growth, is exceedingly difficult, and 
 they have in a number of cases been mistaken for solid 
 growths. As a rule they grow very slowly — in one case the 
 tumour having been noticed for ten years ; and they are often 
 painless, though not invariably so. The surface of the 
 tumour is rounded, hard, and smooth ; or it may be lobulated, 
 from the existence of several cysts. Ihe age of the patient, 
 which a priori might have been expected to have afforded 
 some clue, is not a reliable guide in diagnosis, as out of the 
 cases mentioned by Mr. Heath, one patient had reached the 
 age of sixty, whilst M. Maisonneuve's patient was fifty-six.
 
 DENTIGEROUS CYSTS. 631 
 
 Nevertheless, tlie majority of the cases recorded have been 
 in persons under thirty ; and, taking into account the slow 
 growth of these tumours, their first appearance would have 
 been at a somewhat earlier age. 
 
 But a very important point to look for is the absence from 
 its proper place of one or more teeth ; or, as in IVIr. Salter's 
 case, the presence of a temporary tooth where the surrounding 
 teeth belong to the permanent set. But, as has been noticed 
 by Mr. Heath, the absence of particular teeth is in some 
 instances a hereditary peculiarity; and the retention of a 
 temporary tooth to an advanced age is not so rare an occur- 
 rence as to render its presence anything like an absolute 
 proof that the tumour is due to a hidden permanent tooth. 
 Nevertheless, any such irregularity in dentition will be very 
 strong evidence in favour of the assumption that the enlarge- 
 ment of the jaw has for its cause the missing tooth. The 
 presence of the regular number of teeth does not by any 
 means preclude the possibility of the tumour being due to 
 a tooth ; for there are several instances of supernumerary 
 teeth lying buried in cysts ; for example, the very remarkable 
 case of cyst in the antrum belonging to Mr. Cartwright. 
 
 However much care may be taken, it will sometimes be 
 impossible to arrive at a certain diagnosis without making 
 an exploratory puncture, which should never be neglected in 
 a doubtful case, lest an operation of needless severity be 
 performed. 
 
 This exploratory puncture is best made with a trocar, or 
 by a narrow-bladed knife, and it is well to follow up the 
 puncture tolerably speedily by the operation required. Punc- 
 tures made with a grooved needle seem particularly prone to 
 excite inflammation, and there are very few instances in 
 which its emplo\inent is desirable. 
 
 Of the diagnosis of those forms of cystic disease which do 
 not depend on retained teeth, but which are in relation with 
 carious teeth or stumps, little need here be said. The tumour 
 will present the usual characters of a cyst ; that is to say
 
 632 A SYSTEM OF DENTAL SURGERY. 
 
 its growth will be slow and painless, its outline smooth and 
 regular, and, if it be tldn enough, the bony shell covering it 
 will crepitate on pressure. If it be situate in the lower jaw, 
 the outer plate will be bulged, and the inner plate but little 
 distorted. The increase in size of an abscess is far more rapid, 
 and its boundaries less sharply defined than those of a cyst, 
 and accumulations in the antrum produce a more uniform 
 bulging of the walls of the jaw ; though a certain diagnosis 
 cannot invariably be made, as has been exemplified by Mr. 
 Fearn's and other cases. 
 
 Treatment. — In those cases where the disease is due to the 
 retention of teeth within the jaw, the removal of the cause 
 will generally effect a cure, without any more formidable 
 operation being practised. In most instances this can be 
 done through the mouth, without having resort to an ex- 
 ternal incision ; if more room is required, it may most advan- 
 tageously be gained by dividing the lip into the nostril. The 
 bony wall of the tumour having been exposed, a free opening 
 must be made by means of a trephine or bone- forceps, and 
 the offending tooth or teeth removed. 
 
 TVhen the disease is in connection with the roots of carious 
 teeth, it has been proix)sed, and successfully practised in 
 some cases, simply to remove the tooth, enlarge the alveolus, 
 and through it stuff the cavity with lint. But it is not a 
 manner of treatment which has very much to recommend 
 it : by making a small oi^ening into a considerable cavity 
 below, you expose the patient to the chance of pent-up 
 matter decomposing in the cavity, and to all the risks atten- 
 dant on this state of things. It is a far safer course to at 
 once make an opening of such a size as to ensure the ready 
 escape of the pus which must be formed. It is not easy 
 to err in the direction of making the opening too large, for 
 the cavity has to be filled by the process of granulation, and 
 a large orifice will not at all retard its healing; but there is 
 considerable danger attendant on exciting inflammation in a 
 imrtially-closed osseous cyst. The operation recommended
 
 DENTIGEROUS CYSTS. 633 
 
 by Mr. Butcher consists of freely opening up the cyst, and 
 removing, by bone-forceps and gouge, the external plate 
 of the jaw where expanded over it ; but in ordinary cases 
 even this is more than is necessary, for it will generally 
 suffice to remove so much only of the bony wall as will give 
 free access to the cavity, and then fill it up with lint. The 
 bony walls will slowly shrink down till the outline of the 
 jaw is wholly restored ; but in those cases where the bone 
 has been excessively expanded, the cure may be accelerated 
 by crushing in the yielding walls of the cyst. 
 
 The severer forms of cystic disease, where the whole bone 
 is involved, will hardly come under the notice of the dental 
 surgeon ; so that they do not fall within the scope of the 
 present work.
 
 (. 63i ) 
 
 DISEASES OF THE ANTRUM. 
 
 The maxillary sinus is liable to become the site of various 
 new growths, the consideration of which does not fall within 
 the province of this volume : but the malady with which it 
 is most frequently affected being traceable to the influence 
 of diseased teetli, it is indispensable that the dental surgeon 
 should be well acquainted with at lenst this affection of the 
 cavity. It is quite possible that the development of fibrous, 
 enchondromatous, or malignant tumours of the antram may 
 have been in some way influenced by the irritation produced 
 in the antral cavity by diseased teeth ; nevertheless, the 
 dental surgeon is not called upon to deal with such affections, 
 so that any description of their characters would be super- 
 fluous in this place. 
 
 Suppuration in the antrum — sometimes termed abscess, 
 and sometimes empyema of the antrum — is almost always 
 traceable to the influence of diseased teeth : which is not to 
 be wondered at, seeing that the roots of the second and first 
 molars often pierce its bony wall, and are therefore covered 
 only by the periosteum. The teeth which most commonly 
 come into close relation with the floor of the antrum are the 
 canines, bicuspids, and first and second molars, the fangs of 
 which may pass through its floor ; or alveolar abscesses 
 attached to their roots may perforate and burst into the 
 antral cavity, as is exemplified by two specimens, one of 
 which was in my father's collection, and is here figured. 
 
 The alveolar abscess was connected with the stump of the 
 first molar, and has opened the antrum above the socket of
 
 DISEASES OP THE ANTRUM. 
 
 635 
 
 the palatine fang. The manner of perforation is very peculiar, 
 there being, as is seen in the figure, a regular bony tube 
 standing up into the antrum from its floor. It is noteworthy 
 that the abscess has found exit through the bone elsewhere, 
 as there are large openings through both labial and palatine 
 walls of the alveolar process. 
 
 Fig. 232. (i) 
 
 By the burrowing of an alveolar abscess through the sub- 
 stance of the bone, teeth which do not ordinarily come into 
 very close relation with its floor may cause abscess in the 
 antrum ; thus, amongst the out-patients of the Middlesex 
 Hospital I lately saw a case where extraction of a loose and 
 painful central incisor gave exit to a quantity of exceedingly 
 offensive pus ; a probe passed through the vacant socket 
 entered the antrum through a canal as large as a goose-quill ; 
 
 (1) Superior maxillary bones viewed from above, A horizontal section has 
 been carried across the antral cavities, which are seen to be partially divided 
 by septa rising up from the floor. On the left side is seen the perforation (*) 
 caused by an alveolar abscess. The specimen is now in the museum of the 
 Odontological Society, amoug a series of antra which have been lent by 
 Mr. Cattlin.
 
 636 A SYSTEM OF DENTAL SURGERY. 
 
 and Dr. Latimer, in tlie " Dental Cosmos " for January 1870, 
 records a case where abscess of both antra had followed on 
 filling the two lateral incisors over exposed pulps. 
 
 It must therefore be borne in mind that any tooth is 
 capable of causing abscess of the antrum ; but, although 
 diseased teeth are the cause of the great majority of cases, 
 yet some few have arisen from other influences. Dr. G. 
 A. Eees records a case occurring in a new-bom infant 
 (" Medical Gazette," vol. iv., new series) which seems to 
 have resulted from pressure of the face on the arch of the 
 pubis during parturition, and it has also been attributed to 
 the passage of food up through the socket of an extracted 
 tooth. Otto Weber states that it sometimes arises after 
 chronic nasal catarrh, or obstruction of the nares by nasal 
 polypus. 
 
 In the normal condition the antrum is lined by a thin 
 mucous membrane, continuous, through an orifice in the 
 middle meatus, with the mucous membrane of the nose : 
 this delicate mucous membrane is attached to a thick, dense 
 periosteum covering the bone. It was formerly supposed 
 that distension of the antrum was often produced by an 
 accumulation of mucus secreted from its membrane, owing 
 to closure of the orifice ; but the existence of this mucus is 
 purely hypothetical, according to Otto Weber, none having 
 been seen in the dead body on opening the antrum. Ac- 
 cording to Otto Weber, suppuration in the antrum may take 
 place in two situations ; the entire lining of the cavity may be 
 inflamed, as, for example, by the spread of catarrhal inflam- 
 mation from the nasal cavities, in which case the discharge 
 of pus will flow out through the natural opening into the 
 middle meatus of the nose. But what very much more 
 commonly happens is that the suppuration, when excited by 
 the root of a tooth, takes place beneath the periosteum, 
 which is then lifted from the bone, and separates the accu- 
 mulated pus from the true cavity of the antrum. Hence it 
 is that pus so frequently fails to escape by the natural orifice
 
 DISEASES OF THE ANTRUM. 637 
 
 into the nose. When the antrum becomes distended by sup- 
 puration, the bone is often sensitive to the touch, and the 
 teeth appear lengthened ; as the accumulation of fluid pro- 
 gresses, a swelling appears in the sulcus between the teeth 
 and the cheek, from the canine backwards as far as the 
 third molar. Occasionally the concavity of the palate be- 
 comes obliterated on that side, and in extreme cases the 
 floor of the orbit becomes pushed up, displacing the eyeball. 
 
 In most cases of antral abscess some little tenderness and 
 swelling of the cheek and fulness about the zygoma are 
 noticed. 
 
 The symptoms attendant upon inflammation of the lining 
 of the antrum are, in addition to those already mentioned, 
 dull, deep-seated pain, occasionally of a lancinating character, 
 oedema and tenderness of the cheek, and a varying amount 
 of pyrexia. The formation of matter is sometimes, but by 
 no means invariably, indicated by the occurrence of slight 
 rigors. In a more advanced stage an offensive discharge 
 may flow from the corresponding nostril, or drip into the 
 throat at night, so as to be expectorated in lumps in the 
 morning. As far as my own experience goes — and I speak 
 from limited experience — the discharge from the nostril 
 which occurs in the earlier stages of malignant disease is not 
 usually so offensive or so thick as that which proceeds from 
 simple inflammatory aflections of the maxillary sinus. There 
 is also another point by which simple inflammation may be 
 distinguished from certain of the more formidable diseases 
 causing enlargement in that region. The teeth, though 
 somewhat lengthened, are seldom or never disturbed in posi- 
 tion by the former malady, but where a morbid growth, 
 originating in the antrum, has progressed to a considerable 
 extent, the teeth often become separated from one another, 
 and diverted from their natural directions. In one case 
 which terminated fatally, the discharge which flowed from 
 the nostril was for some months thin and watery, and desti- 
 tute of offensive odour ; but, as it is more common for the
 
 638 A SYSTEM OF DENTAL SURGERY. 
 
 matter to find no exit in cases of empyema of the antram, 
 the discharge is often not present to afford any guide to a 
 correct diagnosis. 
 
 SjTnptoms of a closely similar character may be associated 
 with the earlier stages of malignant disease, and it is very 
 necessary that the practitioner should be aware of this, for 
 should he, under the impression that the case is a simple 
 one, remove a carious tooth, he may get the credit in the 
 mind of the patient of having induced a fatal disease by his 
 injudicious interference. 
 
 The affections which are most likely to be confounded with 
 empyema of the antrum are mucous polypi and dentigerous 
 or other cysts in its cavity ; and in some instances slowly- 
 growing solid tumours may be confounded with chronic 
 abscess of the antrum. Careful inquiry into the history of 
 the case will often very materially aid a correct diagnosis, 
 but in a certain number of cases it is impossible to be per- 
 fectly certain of the true nature of the enlargement ; and it 
 has more than once happened that surgeons have commenced 
 an operation for the extirpation of a jaw that proved to 
 be enlarged by nothing more formidable than an antral 
 empyema. 
 
 With care, acute inflammation of the antrum may gene- 
 rally be correctly diagnosed, but chronic suppuration, espe- 
 cially when leading to consideiable thickening of the bone, 
 may very closely simulate the solid growths. , 
 
 This thickening of the bone around a chronic abscess may 
 be so considerable as to proiluce marked defonnity, even after 
 the cure of the empyema, and necessitate an operation for 
 its removal. 
 
 When there is any doubt, an exploratory puncture should 
 be made ; it is not likely to lead to any bad results, and may 
 prevent the surgeon from falling into a very important 
 blunder. For this purpose a trocar or a scalpel should be used, 
 as the indications afforded by the insertion of a grooved 
 needle are uncertain. In some instances patients have been
 
 DISEASES OF THE ANTRUM. 639 
 
 conscious of a sensation of fluid washing about in tlie cavity 
 when the head is suddenly moved. Of course this can only 
 happen when the cavity is incompletely filled with fluid. 
 
 Malignant growths seldom remain long confined to the 
 antrum, but speedily pass out from it into the surrounding 
 parts. 
 
 If left to itself the pus is sometimes evacuated into the 
 nose by the natural orifice, or finds an outlet through a vacant 
 alveolus. But this fortunate result is rare, and the neglect of 
 antral abscess very commonly leads to serious consequences: 
 the pus sometimes finding an exit through the cheek, 
 and having considerable deformity, but more commonly 
 finding its way into the orbit, causing great protrusion of the 
 eyeball, temporary or permanent blindness, and finally 
 making its exit at the inner or outer canthus. In a case 
 recorded by Dr. Latimer, the discharge was so profuse as to 
 necessitate a cloth being constantly kept upon the patient's 
 face, and the skin in the neighbourhood of the eye had be- 
 come excoriated by the discharge to such an extent that it 
 had all the aspect of malignant disease. 
 
 A most remarkable case of death from intra-cranial sup- 
 puration, consequent on neglected antral abscess, is recorded 
 by Dr. Mair, and quoted in full by Mr. Heath in one of the 
 appendices to his work. 
 
 Necrosis of a portion of the walls of the cavity, or even 
 caries of the bone, occasionally ensues, and sometimes, when 
 the disease is acute, it is accompanied by erysipelatous in- 
 flammation of the face, with very great constitutional dis- 
 turbance. 
 
 Mr. Salter has pointed out that permanent amaurosis may 
 result from the displacement of the eye ; indeed, he also 
 gives an example of amaurosis following inflammation with- 
 out abscess. Dr. Latimer (Joe. cit.) also alludes to cases of 
 impaired vision, the result of antral abscess. 
 
 In the first case, the history of the disease was briefly 
 this — violent toothache around the first upper molar, enor-
 
 640 A SYSTEM OF DENTAL SURGERY. 
 
 mous swelling of side of face, infiltration of the lower eyelid 
 so as to close the eye, protrasion of the malar bone, and 
 frightful pain in the eye, which became protruded later and 
 became blind. Pus escajied near to the outer and inner canthus 
 of the eye, and in this condition the patient remained for 
 two or three weeks, with occasional discharges of matter by 
 the nose. 
 
 The hard palate was convex within the mouth. Mr. Salter 
 removed the fangs of the first molar, and a wisdom tooth ; the 
 pressure of the instrument caused pus to jwur from the 
 openings below the eye, and there was a sensation of baggi- 
 ness and yielding about the whole bone. After the extraction 
 blood also poured out from the fistulous openings. The eye 
 was sightless, the globe prominent, the pupil fixed ; there 
 was general inflammation of the fibrous textures of the eye, 
 and extreme conjunctivitis. Eventually a large sequestrum 
 came away, and the inflammatory condition passed off, but 
 the sight of the eye never returned. On ophthalmoscopic 
 examination, the only abnormal appearance observed was 
 extreme anaemia of the optic nerve, a condition constantly 
 associated with suspension of the function of vision when 
 dependent upon causes external to the globe. 
 
 The result is not always so disastrous as in the last case ; 
 thus Stellwag quotes a very interesting case reported by 
 Galenzowski, in which, after blindness of one eye for thirteen 
 months, complete recovery ensued. The first thing noticed 
 was the sudden advent of exceedingly severe neuralgia, re- 
 curring from time to time; the eye became painful, pro- 
 truded, and sight was lost. 
 
 After six months, great swelling came on, and several 
 drachms of pus were discharged from the lower eyelid ; the 
 pain then subsided, but the sight did not improve. Even- 
 tually the pain recurred with increased intensity, but 
 although the eye remained blind and the pupil dilated, no 
 structural change could be discerned. The first upper 
 molar was carious, and on its removal a splinter of wood was
 
 DISEASES OF THE ANTRUM. 641 
 
 found at the end of the fang, which was probably the end of 
 a toothpick. The antrum was opened by the extraction, and 
 on the same evening the eye was sensible of light; by the 
 next day it had completely recovered. It is remarked that 
 the toothache, seldom present, was not coincident in point of 
 time with the neuraliiic pains and pains in the eye. 
 
 In a case of Mr. Pollock's there was no actual empyema of 
 the antrum, but there was deep-seated active inflammation 
 of the superior maxillary region, and the eye was much con- 
 gested. On the removal of the first bicuspid and first molar, 
 about which there was much irritation, the inflammatory 
 symiitoms rapidly subsided, but the eye remained blind, 
 although the pupil subsequently contracted in response with 
 that of the sound eye. 
 
 ]n the blind eye no structural change could be detected. 
 
 It is pointed out by Mr. Salter that in most of the cases 
 recorded no permanent mischief could be detected in the 
 structures of the eye, even when sight was never recovered, 
 save ana?mia of the optic disk, thus suggesting the idea that 
 some irreparable damage had been inflicted on the optic 
 nerve external to the eyeball. 
 
 The treatment of empyema of the antrum consists in 
 giving free exit to the pent-up matter, and this may be 
 effected in several ways ; the most usual and the best course 
 is to extract all the carious teeth on that side of the mouth, 
 when it will probably be found that matter makes its 
 escape through one of the alveoli. Should this be the case, 
 the orifice should always be enlarged by using a large trocar — 
 which would also be the proper course if the matter did not 
 appear — the socket of the first molar being usually selected 
 as the most suitable point for puncture. In forcing the 
 trocar into the antrum the thumb should be supported 
 against the jaw, so as to obviate the risk of the instrument 
 suddenly entering and wounding the floor of the orbit from 
 below (0. Weber). 
 
 In case there are no diseased teeth, a sound first molar 
 
 2 T
 
 642 A SYSTEM OF DENTAL SURGERY. 
 
 may be extracted, or the puncture made near the malar 
 process, or backwards from the canine fossa ; one of which 
 situations must be selected in the rare case of empyema of 
 the antrum occurring in an aged and edentulous person. 
 O. Weber recommends that the hole should be made large 
 enough for the little finger to enter the cavity ; and there is 
 no doubt that, in all cases where we have to open up a cavity, 
 the safer course is to make a large opening. It is a great 
 and important error, though one often committed, to be 
 content with a small opening into the antrum ; and many 
 cases are greatly and needlessly prolonged by the accumu- 
 lation of morbid secretions in consequence of such treatment. 
 It has been pointed out by ^Ir. Cattlin Qoc. cit.) that the 
 floor of the antrum is often divided by a transverse septum 
 of bone, which conformation would render it quite imprac- 
 ticable to thoroughly and efliciently -wash out the cavity 
 through any small opening. 
 
 Having made a free opening, the cavity should be 
 thoroughly -washed -with warm water thro-wn in with a large 
 syringe : a piece of gum-elastic catheter, placed on the nozzle 
 of the syringe, will often aid in doing this effectually. 
 
 After the ca-vity has been thoroughly cleared out, astrin- 
 gent and disinfectant lotions should be used daily. A weak 
 solution of permanganate of potash answers the purpose 
 excellently ; but should the mucous membrane take long to 
 restore a healthy condition, a stimulating injection composed 
 of a weak solution of chloride or sulphate of zinc, or nitrate 
 of silver, may be used ; in obstinate cases tincture of iodine 
 has been advantageously applied. 
 
 The opening should be kept closed, lest the accidental 
 access of food excite fresh irritation. It has been recom- 
 mended that a gold tub^ -with a stopper be fitted to the open- 
 ing, and secured to the neighbouring teeth ; but in most cases 
 a plug of soft wax will be found to answer the purpose, unless 
 it be necessary to keep the opening permanently patent. 
 
 Dentigerous and other cysts of the antrum have already
 
 DISEASES OF THE ANTRUM. 643 
 
 been noticed in a former chapter, and need not be again 
 referred to here. 
 
 Occasionally the root of a tooth passes into the antrum 
 during an attempt to extract it, and this accident may occur 
 in the hands of the most careful and skilled operators. 
 
 As has already been noticed, the root of an upper molar 
 not uncommonly passes through the floor of the antrum, and 
 may even become enlarged within that cavit3\ When an 
 attempt to remove such a root is made, one of two things 
 happens : either a portion of the antrum is brought away 
 with the tooth (Mr. Cattlin, loc. cit.), or the root slips up into 
 the cavity. Such an event occurred in the practice of Mr. 
 Cattlin, and as the patient's father had died from malignant 
 disease of the jaw, it was deemed prudent, not only by 
 Mr. Cattlin, but by Mr. Stanley and other surgeons of emi- 
 nence, to remove the stump, lest it should become a source 
 of local irritation. A trephine was applied to the labial 
 plate of the alveolus, and the cavity of the antrum laid open. 
 For some time the missing root could not be found, and it 
 was only by employing a cup formed of gutta-percha, 
 mounted on a piece of bent wire, that it was ultimately 
 removed. In most cases the employment of a strong current 
 of water will suffice for the dislodgment of a stump, but in 
 this instance the floor was divided into two compartments 
 by a transverse septum of bone. 
 
 In one instance a canine tooth was driven into the antrum 
 by a fall, and its presence only discovered after some time, 
 when empyema of the cavity had resulted. In such a case 
 its removal should be at once effected.
 
 ( «^^- ) 
 
 CLOSURE OF THE JAWS. 
 
 It will sometimes happen that the dental surgeon will he 
 consulted in cases of trismus. 
 
 By far the most frequent cause of inahility to separate the 
 jaws is spasmodic action of the masseter and pterygoid 
 muscles, which is commonly a reflex action due to the ini- 
 tation set up by diseased teeth. In the majority of cases 
 the irritation is due to difficult eruption of the wisdom teeth, 
 though it is not rarely due to exposure of the nerve in these 
 or the first and second molars. 1 do not know of its having 
 been produced by teeth situated farther forward in the mouth, 
 though there is no reason why it should not be so caused. 
 The trismus may be of sudden occurrence, or it may come 
 on quite gradually ; and the condition of tonic spasm of the 
 muscles may last for months or even years. 
 
 The closure of the jaws may, however, be due to actual 
 organic changes. Dr. Gross, of Philadelphia, enumerates the 
 following as the most frequeift causes of immobility of the 
 lower jaw : — 
 
 The fixation of the jaw by cicatricial tissue in the cheek, 
 gums, &c., whic h may result from c ancrum oris, or from 
 gangrene supervening on profuse ptyalism. Anchylosis of 
 the teniporcnmaxillary articulation, whicE'may be osseous, 
 or the result of fibrous adhesions in and around the joint. 
 Or, thirdly, it may be occasioned by a bony bar extending 
 from the lower to the upper jaw, a condition usually re- 
 sulting from so-called chronic rheumatic asthritis. Or, lastly,
 
 CLOSURE OF THE JAWS. 6-45 
 
 it may be due to the pressure of a tumour, especially one 
 occupying the parotid region. 
 
 Gangrene of the cheeks, &c., may occur in children worn 
 out by the effect of the exanthemata, as well as in cancrum 
 oris ; and these are amongst the most difficult cases to 
 relieve. 
 
 I Mr. Heath (^), quoting Professor Esmarch, points out that 
 I the inability to open the mouth in such cases is due not so 
 much to the presence of actual adhesions, binding together 
 the jaws, as to the destruction of the exceedingly elastic and 
 dilatable mucous membrane of the cheek, and its replacement 
 by a dense unyielding cicatrix. 
 
 Hence, in all operative procedures it is the aim of the 
 surgeon not merely to divide cicatrices, but to restore the 
 extensile mucous membrane ; and if there be no available 
 portions of mucous membrane left, the formation of a false 
 joint in front of the cicatricial bands affords the best prospect 
 of speedy relief. This operation, which bears the name of 
 Professor Esmarch, consists in removing with a saw a wedge- 
 shaped fragment of the horizontal ramus of the lower jaw. 
 For a fuller account of the operation the reader is referred to 
 Mr. Heath's work above cited. Where it «ppmg pns|^jb1^. to 
 give relief by divisjon of c icatrices wTnTin tbp. mn^^tkr ftyf-ry 
 endeavour must be made to restore the natural sulcus be- 
 tween ''{EelteethanTTEe]]cEeel^^^ this covered by 
 m ucous membra ne. This has been successfully done by the 
 use of silver shields, capping the teeth and passing down 
 outside the alveolar borders, so as to prevent adhesions form- 
 ing at this point. In the opinion of Mr. Heath {op. cit., 
 p. 349), the forination of mucous membrane may be thus in- 
 duced, even where no remnant of it had escaped destruction. 
 
 Anchylosis of this joint is not of common occurrence ; it 
 has been met as a result of injury, and sometimes it appears 
 to be idiopathic. 
 
 (1) " Injuries and Diseases of the Jaws," p. 337. S cond edition, ls72.
 
 646 A SYSTEM OF DENTAL SUBGERY. 
 
 I have lately met with a case in which almost complete 
 anchylosis slowly supervened after a fall upon the chin : the 
 mobility of the jaw had slowly decreased for two or three 
 years. In such a case, failing all endeavours to force the 
 mouth open with screw gags, or other such appliances, a 
 false joint may he established by division of the ascending 
 ramus as high up as it can be reached.
 
 I 647 ) 
 
 MECHANICAL INJURIES OF THE TEETH. 
 
 Abrasion. — When, from the loss of teeth, the process of 
 mastication falls upon a reduced number, considerable injury 
 may arise from the wearing down of their crowns, more 
 especially if the antagonism of the upper and lower series 
 be deranged. The crown of a tooth may be cut down, 
 excepting at one side, where a sharp edge of enamel may be 
 left standing, or a lower tooth may strike obliquely upon 
 its antagonist, and gradually cut away its side, even to the 
 extent of perforating the wall of the pulp- cavity. 
 
 A sharp and ragged edge of enamel, projecting above the 
 general level of a tooth, should be carefully reduced with a 
 fine file ; for, apart from the injury that may be inflicted 
 upon the tongue or the lips, the tooth itself may eventually 
 be injured. Sooner or later the projecting part will be 
 broken off, and very likely carry with it a considerable 
 portion of the tooth. In the front teeth, this accident is very 
 liable to arise if a thin and ragged edge of enamel is allowed 
 to remain. 
 
 After the file has been used, the surface should be rendered 
 perfectly smooth by a slip of Arkansas or other suitable 
 stone. 
 
 Another form of ahrasion is that which is occasioned by 
 the action of the tooth-brush on the necks of the teeth, 
 or upon such parts as are but indifferently protected by the 
 enamel or by the gum. The teeth become very gradually 
 indented by highly-polished transverse grooves. 
 
 The occurrence of such grooves has been, by many writers,
 
 6i8 
 
 A SYSTEM OF DEXTAL SUEGEET. 
 
 Fig. 233. (1) 
 
 supposed to be independent of a mechanical cause. Tliey 
 have attributed the loss of substance to ero- 
 sion, using the term as expressive of a sort of 
 ulceration, much in the same sense as it is em- 
 ployed in " erosive ulceration." 
 
 But in many cases which have come under my 
 own notice, the grooving could be attributed 
 to the action of the tooth-brush, or to me- 
 chanical action in some other form. The more 
 prominent teeth are almost invariably the most 
 deeply cut, or teeth in which the enamel is ob- 
 viously defective. Again, in a right-handed 
 person the teeth on the left side of the mouth 
 suffer more than those on the right side, and 
 in left-handed people the converse holds good. 
 The groove is always on the labial surface, and 
 on such parts of that surface as are exposed to 
 the action of the brush. 
 
 Treatment. — A groove having been produced, 
 we can but direct the patient to avoid those 
 causes which have been instrumental in its 
 production. But in guarding against the ex- 
 tension of the mischief, we must be careful to 
 caution the patient against running into a still 
 greater evil. The use of hard brushes and 
 gritty tooth-powder should be avoided. The 
 teeth must, however, be properly cleaned, other- 
 wise the polished surface of the indentation 
 will be lost, the exposed dentine will be acted 
 upon by the fluid of the mouth, and caries will 
 be established. 
 
 (J) An instrument for holding a small piece of Arkansas or other stone 
 used in rendering smooth the surface of teeth which have been filed, or fo 
 rubbing down the surface of a gold plug preparatory to burnishing.
 
 ( 649 ) 
 
 FEACTUEE OF THE TEETH. 
 
 The teeth, from their exposed position, and from the office 
 they are destined to fulfil, are liable to be broken. The 
 amount of injury will vary from the slight chipping of the 
 edge to the fracture through the pulp-cavity, or through any 
 portion of the root. 
 
 When the loss is trifling in amount, and does not materially 
 interfere with the personal appearance of the patient, nothing 
 further than the removal of any sharp or projecting edge, 
 by the use of the file or stiip of stone, need be atternpted. 
 But should the fracture extend into or even within a very 
 short distance of the pulp-cavit}^, a more decided course of 
 treatment will be called for. The nature of that treatment 
 will be determined by the direction which the fracture has 
 taken, by the amount of injury the root of the tooth sus- 
 tained at the time the injury was inflicted, and by the age 
 of the patient. 
 
 The incisors, from their position, are more frequently 
 fractured than the bicuspid or molar teeth. 'J'he latter are 
 not, however, exempt from accident. When the jaws are 
 violently driven together by a blow or a fall, a back tooth 
 may give way. A cusp may break off, or the fracture may 
 extend through the pulp-cavity, and detach one or other of 
 the roots, with its corresponding portion of crown. I have 
 seen in a bicuspid tooth the fissure extend from the crown 
 through a greater portion of the root. 
 
 Molar teeth may thus occasionally be broken by a blow 
 without the integuments being cut, their fracture being due,
 
 650 A SYSTEM OF DENTAL SUKGEBY. 
 
 not to the direct force of the blow, but to the sudden closure 
 of the jaws. The force emplo^'ed in mastication is sometimes 
 sufficient to split a tooth, and in one instance which came 
 under my notice the bicuspid was fractured across the upper 
 third of its root by biting suddenly upon a fish bone. 
 Although the tooth was rather loose, and the patient was 
 positive he had broken it, it was tolerably free from pain, 
 and so was left for a time, as I doubted the possibility of its 
 being fractured so high up by such a cause. However, it 
 became so loose that after the lapse of three weeks it had 
 to be removed : on microscopic examination no signs either 
 of absorption or of deposition on the fractured surface were 
 
 It may be stated generally, that when the fracture extends 
 through the pulp-cavity in the direction of the length of the 
 tooth, the root will have been injured, and should at once 
 be extracted ; and the rule will apply when the pulp-cavity 
 of a tooth the root of which is incomplete has been opened, 
 whatever may be the direction or the extent of the fracture. 
 If, on the other hand, the crown of a tooth be broken off 
 transversely external to the edge of the gum, there is a fair 
 chance of preserving the implanted portion, and of rendering 
 it subservient to the support of a new crown by the operation 
 of pivoting, should such a course appear desirable. 
 
 It is, however, only in teeth with single roots that the 
 operation can be performed with success. Even in the 
 bicuspids of the upper jaw, and more especially in the first 
 bicuspid, the application of a pivot is not always admissible. 
 The roots of these teeth are not only subject to great lateral 
 compression, but also to actual division into two or into 
 three distinct fangs. In either case, the drill, in preparing 
 a hole for the reception of a pivot, may pass through the 
 tooth into the socket. 
 
 As a rule, the roots of the incisors and canines only should, 
 other circumstances concurring, be preserved ; and preserva- 
 tion even of these will not in all cases be desirable. If, for
 
 FRACTURE OF THE TEETH. 
 
 651 
 
 instance, a lateral incisor be broken off at or before the agi- 
 of thirteen, and the root be immediately removed, the canine 
 will come forward, and in a few years fill up the space ; or 
 if the accident occurs at a later period, in a mouth crowded 
 with teeth, a similar result would follow the operation. A 
 like course may sometimes be pursued in a young patient, 
 when, with the lateral incisors large, a small central tooth 
 is injured. Pivoted teeth may last twenty years, or even 
 for a longer period, but such durability must be regarded as 
 exceptional. From seven to ten years would more correctly 
 express the period which will intevene between the insertion 
 of a pivoted and the substitution of an artificial tooth, the 
 use of which must, for the sake of appearance and articula- 
 tion, be ever afterwards continued. If, then, the space 
 occasioned by the loss of a fractured tooth can be filled up 
 by the gradual approximation of the contiguous teeth with- 
 out seriously interfering with the personal appearance of the 
 patient, it will be better to remove the root of the injured 
 tooth. 
 
 The treatment of roots situated at the back part of the 
 mouth, from which the crowns have been broken, must 
 depend upon the indications presented. If a root is free 
 from pain, and firmly fixed in the socket, but little advantage 
 will be gained by its extraction, unless the neighbouring 
 teeth would come together, and fill up the space. Hence 
 the age of the patient and the present state of the jaw with 
 regard to crowding of the teeth must be our guide ; but very 
 commonly the tooth is so painful from the nerve being 
 exposed that the patient will urge its removal. 
 
 Hitherto fractures extending through the exposed portion 
 of a tooth, or extending through the crown into the root, have 
 been considered ; occasionally the injury is situated within 
 the socket. The tooth, after the accident, remains loose and 
 painful ; it is eventually removed, and the precise nature of 
 the injury is revealed. Supposing the tooth had become by 
 degrees less painful, and had regained its firmness, the
 
 652 A SYSTEM OF DENTAL SURGERY. 
 
 accident would be forgotten, and the attention might not 
 again be directed to the tooth. The refixing of the loosened 
 tooth would be regarded as a proof that the injury fell short 
 of an actual fiacture of any part of the tooth. Such a solu- 
 tion of the question would, no doubt, in the great majority of 
 cases, be strictly correct, but there is good reason for doubt- 
 ing its invariable accuracy. Mr. Saunders has in his collec- 
 tion an incisor which shows the marks of a remiited fracture 
 
 extending across the root near the junction of its terminal 
 and middle third. A description, with a figure of this tooth, 
 has been published (2). Professor Owen has described and 
 figured an instance of reunited fracture in the tusk of a 
 hippopotamus Q. The preparation in my own collection, from 
 which the preceding illustration is taken, is of great interest, 
 
 (1) Shows a perfectly united fracture in the tusk of a hippopotamus. The 
 tooth had been broken with the socket, with considerable separation of the 
 fractured surfaces. The union has been effected by the development of 
 tementum. 
 
 (2) " Lecture on Dental Physiology and Surgery." 
 
 (3) " Odontography."
 
 FRACTURE OF THE TEETH. 653 
 
 as it at once proves that in the tusk of the hi}Tpopotamus, at 
 all events, union may take place after a severely comminuted 
 fracture, with considerable displacement of the fractured 
 parts. In this specimen — and I believe in the two pre- 
 ceding examples — the union is effected by the development of 
 cementum. These facts go to show that when a tooth is 
 fractured within the socket it may, under favourable circum- 
 stances, be reunited. To recognise and bring about these 
 circumstances may in individual cases be difficult, but the 
 knowledge that a fracture may be united should lead to a 
 course of treatment favourable to its occurrence in cases 
 where fracture of the root of a tooth is suspected. 
 
 In a case which came under n)y own notice, a front tooth 
 was broken across and a molar tooth loosened by a severe fall 
 in a patient under twenty years of age. The latter tooth was 
 allowed to remain, in the chance of its regaining its original 
 firmness of implantation. After the lapse of many months 
 the molar tooth was still a little loose, and now and then 
 became the seat of pain. The degree of looseness appeared 
 to vary ; at one time the tooth seemed to be rapidly recover- 
 ing its usefulness as an organ of mastication,' at another it 
 appeared to be getting from bad to worse. At last the patient 
 determined to submit to no further inconvenience, and the 
 tooth was extracted. The nature of the accident was then 
 for the first time recognised. The root of the tooth had been 
 fractured transversely some distance within the socket, and 
 the fractured surface had been subsequently coated over with 
 cementum. The production of new tissue upon the broken 
 surface must be regarded as a reparative effort, and had the 
 tooth been by any mechanical means kept for a time in a 
 state of rest, it is probable that an union of the fractured 
 surfaces would have been effected. 
 
 The dentinal pulp may, however, take some share in uniting 
 the fragment of a tooth broken within the socket; thus, 
 Professor Wedl, in his " Atlas " (op. cit.\ figures two reunited 
 fragments in which a fresh development of dentine took
 
 654 A SYSTEM OF DENTAL SURGERY. 
 
 place ; indeed, it is not to be wondered at that this should 
 sometimes happen, for when displacement takes place during 
 the development period, a very complete union is formed, as 
 is exemplified in the accompanying figure; and it is no 
 
 uncommon occurrence for the pulp to resume its formative 
 functions long after the cessation of regular calcification. 
 
 And that an injured pulp may be stimulated into under- 
 going calcification is well seen in the specimen which has 
 been figured on page 469.
 
 ( 655 ) 
 
 DISLOCATION OF TEETH." 
 
 In consequence of a blow or a fall, one or more teetli may be 
 entirely forced from their sockets, the alveoli in some cases 
 receiving considerable injury, and in others little or none. 
 But violence which falls short of dislodging a tooth may 
 cause the death of the pulp, which should be always watched 
 for after the infliction of a blow (see Necrosis of Teeth), or 
 may merely loosen the tooth, which, when allowed to remain 
 at rest for a time, becomes firmly refixed. 
 
 Occasionally, where great violence has been used — as, for 
 example, in machinery accidents — large portions of alveolus 
 come away with the teeth ; and the roots of the front teeth 
 have been known to be driven through the floor of the nose. 
 In one case a canine was supposed to have been knocked 
 out, which had really been driven into the antrum, where it 
 made its presence known by causing an empyema of that 
 cavity after the lapse of some weeks. 
 
 For the purposes of practice, the dislocation of teeth may 
 be divided into — partial dislocation, or the mere loosening 
 of teeth; complete dislocation, or the absolute removal of 
 teeth from their sockets ; and dislocation accompanied with 
 injury of the alveolar processes. 
 
 It is now a well-established fact, not only that a tooth 
 which has been forcibly loosened in its socket will, if allowed 
 to remain at rest, become firmly refixed, but also that teeth 
 which have been removed may, on being returned, even after 
 an interval of several hours, become attached, and remain firm 
 and useful for many years. A patient of my own fell upon
 
 656 A SYSTEM OF DENTAL SURGERY. 
 
 a cog-wheel, and knocked out the central incisor of the upper 
 jaw. He returned the tooth to its socket in the course of 
 half an hour, and, according to his own statement, it gradually 
 became finn, and remained so for upwards of twelve years ; 
 at the expiration of that time it became loose and trouble- 
 some, and was extracted. When the accident occurred, the 
 tooth had the usual length of root, but at the time of its 
 removal the latter part had been reduced to less than half its 
 normal length by absorption. Many similar cases, as respects 
 the reunion of the natural connection of completely dis- 
 located teeth, were brought forward at a meeting of the 
 Odontological Society held in 1858 ; and I have recently seen 
 an instance where a patient having had a wrong tooth ex- 
 tracted, at once replaced it, and retained it for several years. 
 Hence, when a tooth has been dislodged, it should at once be 
 thoroughly cleansed, and the socket cleared of all coagula, 
 before its replacement is attempted. It should then be 
 secured in its place by licratures, or, what is much better, by 
 a cap of gutta-percha adapted to it and the neighbouring 
 teeth. A cap of gutta-percha should also always be placed 
 over teeth which have been loosened by a blow, or by the 
 operation of torsion ; it keeps them steady in their position, 
 and protects them from the bite of the antagonistic teeth. 
 
 If much swelling and inflammation of the gums ensue, 
 this must be combated by leeching or free incisions through 
 the whole thickness of the gums. 
 
 There is abundant evidence to show that a tooth thus 
 displaced will acquire a membranous connection with the 
 socket ; this is, indeed, exemplified by the operation of torsion, 
 by the old operation of transplantation of teeth known in 
 the time of John Hunter, and by those cases in which, more 
 recently, teeth have been extracted, the diseased periosteum 
 scraped off, and the teeth then replaced. 
 
 But I am not aware that there is any authenticated 
 instance of the pulp retaining its vitality ; so that I should 
 be inclined, were such a case to present itself to me, to drill
 
 DISLOCATION OF TEETH. 657 
 
 through the crown down the pulp-cavity, and fill the latter 
 with cotton-wool steeped in strong carbolic acid ; this could 
 be withdrawn from time to time, so as to give vent to any 
 dischiirge which might have accumulated in the alveolus. 
 
 AVith this ample evidence in favour of the opinion that 
 the membranous connection of teeth to their sockets may 
 be renewed even after the teeth have been removed from 
 the mouth, there need be no hesitation on the part of the 
 dental surgeon in returning teeth accidentally dislocated to 
 their sockets, if the teeth themselves are free from injury 
 and the alveoli have escaped material damage. Failure in 
 this mode of treatment may arise, and in patients who are 
 out of health, or in whom the gums are in a morbid 
 condition, success would scarcely be expected ; but in healthy 
 subjects the preservative treatment will generally be attended 
 with success. 
 
 In the management of the case it will be necessary to 
 urge upon the patient the necessity of keeping the tooth in 
 a state of perfect rest, and of resisting the tendency to 
 pull the tooth about in consequence of the uneasiness felt 
 around it. 
 
 But at best the union is an imperfect one, and the tooth 
 will be extremely liable to become sore to the touch from 
 the slightest cold or derangement of the digestive organs, and 
 in a large number of cases is soon lost owing to absorption 
 of its fang setting in. 
 
 In cases which come under the third division — cases in 
 which the accident is accompanied with a considerable 
 amount of injury to the alveolar processes, any attempt at the 
 restoration of the tooth would prove unsuccessful. The teeth, 
 if retained within the mouth by the adhesion of a small 
 portion of the gum or the periosteum, should be removed, 
 together with any detached pieces of bone which may be 
 found in the soft tissues. 
 
 In view of the firm union sometimes obtained after a tooth 
 has been accidentally knocked out, attempts have from time 
 
 2 u
 
 658 A SYSTEM OF DENTAL SURGERY. 
 
 to time been made at " replantation of teeth." It should 
 have been mentioned in the section relating to alveolar 
 periostitis that experiments have lately been performed by 
 Mr. Coleman, following in the steps of Mitscherlich and 
 others, in which carious teeth were extracted and replaced, 
 after scraping ofif the thickened and diseased periosteum. 
 
 The results, however, are not such as to render it an 
 advisable operation ; and Mr. Sercombe has lately placed in 
 the museum of the Odontological Society a pivoted tooth, 
 which had been extracted on account of prolonged irritation 
 in the socket, and afterwards replaced. It became tolerably 
 firm, but after some little time became so loose that it had 
 to be removed, when the fang was found to have almost 
 disappeared. Such seems to be the usual termination of 
 cases of replantation.
 
 ( 659 ) 
 
 INJURIES TO THE JAWS. 
 
 Fracture of the Jaw. — Although fractures of the jaw fall 
 within the province of the general surgeon, rather than 
 within that of the dentist, still, as the services of the latter 
 are not uncommonly called into requisition, a few words 
 respecting it will not be out of place here. 
 
 Fracture, even very extensive, may be produced by ex- 
 traction of teeth, though a more common cause is direct 
 violence, such as a blow or a fall. The most usual situation 
 for a fracture of the lower jaw is the region of the canine 
 tooth, though there is no part at which it may not be 
 broken. They are almost necessarily compound in the 
 mouth, as the very close adhesion of the gum renders its 
 being torn inevitable. 
 
 The signs of fractured jaw are ordinarily unmistakeable : 
 crepitus, mobility of the fragments, and irregularity of the 
 teeth being the prominent indications. 
 
 After a severe fracture very profuse suppuration often 
 ensues, and extensive abscesses under the chin and in the 
 neck may form, and portions of the bone may necrose and 
 come away. 
 
 Thus, in a case of which there is a model in the museum 
 of the Odontological Society, the whole depth of the front of 
 the jaw, containing the right first bicuspid, canines, and in- 
 cisors, and both bicuspids of the opposite side, has been lost, 
 and the second bicuspid of the right side has come into con- 
 tact with the first molar of the left, the two halves of the 
 jaw joining at an acute angle. 
 
 Treatment.— By a four-tailed bandage in simple cases.
 
 660 A SYSTEM OF DENTAL SURGERY. 
 
 though it is better to add to this a gutta-percha support 
 moulded around or under the chin. 
 
 It is the practice of some surgeons to secure the fragments 
 in their places by wires passed around the teeth ; it is, how- 
 ever, an objectionable plan, on account of the irritation 
 set up by the wires, and it is very seldom that it can be 
 necessary. 
 
 ^luch assistance in steadying the fragments may be 
 derived from simple sheets of gutta-percha pressed over the 
 crowns of the teeth ; but in severe cases a more stable 
 apparatus is required. 
 
 An impression of the jaw in wax or plaster is taken, 
 without any special attempt to hold the fragments in posi- 
 tion ; this is cast in plaster, and the displacement remedied 
 by sawing through the plaster model. A gold or vulcanite 
 plate is then made to fit the crowns of the teeth when the 
 halves of the jaw are reduced to their proper position. In 
 some cases it will be best to make the splint tit loosely, and 
 to line it with warm gutta-percha at the time of introduction ; 
 but whether this course is preferable to making the plat<3 
 itself fit accurately, can be determined only by the inspection 
 of the individual case. 
 
 Mr. Hayward has farther modified these splints by the 
 addition of strong curved wires which pass out at the angles 
 of the lips, and are attached externally to a gutta-percha 
 splint. 
 
 Mr. Gunning has in some cases found it necessary to 
 employ a vulcanite splint fitting the teeth of both jaws, 
 holes being left in the front and at the sides for the intro- 
 duction of food, and the syringing out of discharges. What- 
 ever apparatus is employed, care must be taken to secure 
 the easy and thorough escape of pus, and to avoid heavy 
 pressure on the integuments beneath the chin, where abscesses 
 are very prone to form. 
 
 Fractures of the upper jaw are uncommon, and displace- 
 ment is not by any means invariably present. There is
 
 DISLOCATION OF THE JAW. 661 
 
 generally little difficult}'- in keeping the parts in position, 
 though occasionally a plate will be required. Comminuted 
 fragments should be almost always allowed to remain, as, 
 owing to the rich vascular supply, they rarely necrose. 
 
 With regard to the removal of teeth in cases of fractured 
 jaw, this should only be done when the teeth are themselves 
 fractured through the pulp-cavity. In any other case they 
 should be allowed to remain, as they often become firm in 
 apparently hopeless cases. 
 
 But teeth with pulps exposed by fracture should always 
 be searched for, as their presence will submit the patient to 
 much needless suffering ; and it is possible that cases might 
 occur in which the extraction of the teeth would be difficult, 
 owing to the mobility of the fragments, and the fear of 
 tearing away portions of the bone. In such an event I 
 should be disposed to extirpate the 'nerve with a nerve- 
 extractor. 
 
 Dislocation of the Jaiu. — This may happen during the 
 extraction of a tooth, or even in taking a model of the 
 mouth. 1'he patient is then unable to close the mouth, the 
 lower jaw is protruded, and speech difficult. A slight hollow 
 may be felt behind the dislocated condyle, and this is the 
 surest guide in the less usual form of the accident— unilateral 
 dislocation. 
 
 The readiest manner of effecting the reduction is to seat 
 the patient upon the floor, steadying the head against the 
 operator's knees. Ihe thumbs, well guarded by numerous 
 turns of a narrow bandage, are passed as far back on the 
 molar teeth as possible. By forcible pressure downwards the 
 condyles are disengaged, and the front of the jaw being 
 simultaneously tilted up by the fingei's, it slips into place 
 with a jerk. 
 
 Other methods are sometimes adopted : thus, corks may 
 be placed between the molar teeth, and the chin forcibly 
 elevated ; or a long piece of wood may be used as a lever to 
 depress the back of the jaw.
 
 662 A SYSTEM OF DENTAL SURGERY. 
 
 Whatever method be adopted, the surgeon must keep in 
 mind what has to be done ; namely, to depress the back of 
 the jaw to such an extent as to disengage the condyles from 
 the prominence in front of the glenoid cavity ; so soon as 
 this is done the muscles will draw it up into its place. 
 
 After reduction, the movements of the jaw must be re- 
 strained for some days by the application of a four-tailed 
 bandase.
 
 ( 663 ) 
 
 PIVOTING TEETH. 
 
 The circumstances under which the operation of pivoting 
 may be performed with advantage have been mentioned in 
 connection with the diseases and the mechanical injuries of 
 the teeth. Before proceeding to describe the operation itself, 
 it will be, therefore, unnecessary to recapitulate those circum- 
 stances further than is embodied in the general statement, 
 that the root destined to receive the pivot, together with the 
 surrounding parts, should be perfectly free from disease. 
 
 Hence the most satisfactory cases are those in which the 
 nerve in the root has retained its vitality ; and as the opera- 
 tion of pivoting is only generally applicable to the incisors 
 and canines of the upper jaw, the nerve should be extirpated 
 by a nerve-extractor, rather than by the use of an escharotic. 
 
 The operation, then, is commenced by removing, by means 
 of the saw, the cutting-forceps, or the file, down to the level 
 of the gum, such portions of the crown of the faulty tooth as 
 may still be standing. The choice of instruments will de- 
 pend upon the condition of the part to be removed. When 
 the neck of the tooth is strong and sound, the saw may be 
 entered upon each side to within a short distance of the pulp, 
 and the operation of excision be completed with the cutting- 
 forceps. If, the latter instrument only were employed, a risk 
 of shaking the root in its socket, or of splintering it within 
 the gum, would be incurred. If, on the other hand, the neck 
 of the tooth has been encroached upon by caries, or the crown 
 has been broken off near the margin of the gum, the cutting- 
 forceps and the file only will be required, or perhaps only the 
 latter instrument.
 
 664 A SYSTEM OF DENTAL SUKGERT. 
 
 The exposed surface of the root must now be cut cIottd 
 with a half-round file to the level of the gum, and even a 
 little below its free edge. The next step in the operation 
 will consist in reducing the pulp-cavity to a perfectlv cylin- 
 drical canal, which should be extended to within a short dis- 
 tance of the extremity of the root. To effect this purpose a 
 five-sided broach may be used, but I have found a half-round 
 drill preferable. The latter cuts freely, produces a very true 
 hole, and at the same time follows the course of the pulp- 
 cavity. Several sizes of such instruments will be required, 
 the smaller for commencing, the larger for completing the 
 perforation. From time to time the depth of the hole must 
 be gauged, otherwise the drill may be carried to tCK> great a 
 depth. 1 have known the broach passed through the root of 
 a tooth into the alveolus. 
 
 The root having been prepared, a new tooth must be 
 selected, corresponding both in shape, size, and colour to 
 the one which has been lost. The choice will lie between a 
 natural and a mineral tooth. If the former be taken, the 
 fang must l3e removed, and the cut surface of the crown 
 fitted with great accuracy to the exposed surface of the root 
 tiestined to support it, an operation which can be readily 
 accomplished with a file, the process of fitting being carried 
 on either by using a cast taken of the root and adjoining 
 teeth, or by frequent trials in the mouth. The root having 
 been prepared, and the new crown fitted, the pivot must now 
 be selected. Two substances are used — wood and gold, and 
 the choice between them will depend upon the condition of 
 the root. If tiie canal is necessarily large, the wood pivot 
 will be preferable ; if it be of moderate size, the gold should 
 be selected. This question having been determined, the pivot 
 must be so placed in the crown, that when passed into the 
 canal of the root the new tooth will stand in the required 
 position. To ensure this result the canal in the crown must 
 be made to correspond accurately with that in the root. In 
 order to ascertain the position the pivot should hold in the
 
 PIVOTING TEETH. 665 
 
 crown, a thin layer of softened bee's-wax may be attached to 
 the cut surface of the crown, which should then be pressed 
 into its destined place. By this proceeding the precise spot 
 for the canal will be learned, and the size will be determined 
 by the character of the pivot about to inserted. 
 
 But the most convenient method of ascertaining the 
 direction of the canal in the root is to take an impression 
 with a small impression-tray constructed for the purpose ; 
 it consists of a tray of such a width as to cover about 
 three teeth, through the centre of which slides a wire : this 
 wire is first pressed up into the drilled canal, and the im- 
 pression-tray then pressed home ; when the wax has suffi- 
 ciently hardened, the tray and wire are withdrawn together. 
 
 If wood be selected, a piece of hickory, filed or cut into a 
 cylindrical form, and passed through a draw-plate, in order 
 to produce compression of its fibres, and to reduce it to a 
 uniform size, will be found to possess sufficient strength and 
 durability. A cylindrical hole, the size of which should 
 correspond with that through which the wood has been 
 passed, must now be drilled in the crown. Within the hole 
 one or two shallow circular grooves may be cut with a fine 
 excavator. The wood pivot is now pressed firmly into the 
 crown, and reduced to a length corresponding to the depth of 
 the canal in the root. We have now to press the wooden 
 pivot fixed in the crown up the canal in the root of the tooth, 
 until the fitted surfaces come in contact, and the operation is 
 completed. The wood, on imbibing moisture, swells and 
 holds the crown very firmly attached to the root, so firmly 
 that, were their detachment attempted, some care would be 
 required, or the root would leave its socket before the pivot 
 was withdrawn either from the crown or the root of the 
 tooth. 
 
 Had a gold pivot been employed, the manner of proceeding 
 would have been varied in the following particulars. A screw 
 must have been cut within the canal in the new crown, and a 
 corresponding thread upon the pivot. The two having been
 
 666 A SYSTEM OF DEN'TAL SITRGERT. 
 
 firmly screwed together, the projecting portion of the gold 
 pin should be made slightly rough, and surrounded with a 
 very thin layer of floss silk. In this condition the pin is 
 passed with a firm and steady hand into the canal of the root 
 to which, by the addition of the silk, the pin is accurately 
 adapted. 
 
 Had a mineral tooth been selected, the process of fitting 
 would have been conducted with the emery-wheel instead of 
 the file, and the gold pin attached to the crown by means of 
 soft solder. 1'eeth of this description are also specially made 
 for receiving a wooden pivot, and are fixed in the mouth 
 much in the same manner as a natural tooth. 
 
 Although the crown of a tooth can be fixed uix)n a sound 
 root with sufficient firmness to give to the patient a sense of 
 security, while it answers the purjjoses of articulation and 
 the restoration of personal appearance, yet it will not be able 
 to withstand constant collision with an antagonistic tooth. 
 A sound front tooth, when submitted to more than its legi- 
 timate share of pressure, is usually forced out of position, 
 and a pivoted tooth would necessarily be still more readily 
 displaced. To avoid this obvious source of injury, the newly- 
 added crown must be so arranged that the opposing tooth, 
 on closing the mouth, will press upon it but lightly, or fall 
 short of contact. C)rdinarily this result may be secured by 
 grinding away the lingual surface, but in certain cases the 
 teeth of the opposite jaw close in a manner that would 
 Fig. 236. Q) necessitate the reduction of the new crown to 
 an extent which would reniler it unserviceable. 
 
 Rather than reduce the strength of the crown 
 of the tooth, whether natural or mineral, beyond 
 the proper limits, it will be better to use a flat 
 mineral tooth. 1'he operation will consist in 
 adapting a small gold plate to the surface of the prepared 
 
 (i) Shows in profile a flat mineral tooth, mounted upon a gold plate, fitted 
 to the root of a tooth, with the pivot destined to pass into the canal of the 
 root, soldered to the gold plate.
 
 PIVOTING TEETH. 667 
 
 root, in soldering the gold pivot to the plate, and soldering 
 the flat tooth, previously backed with gold, to the outer 
 margin of the plate. When this method of operating is 
 adopted, the tooth may be placed quite out of the way of 
 its antagonist, which, if necessary, may be allowed to close 
 upon the exposed surface of the gold plate which lies over 
 the lingual portion of the root. 
 
 Several modifications of the foregoing manner of fixing 
 pivoted teeth are practised. Some practitioners screw into 
 the root a gold tube, into which the pivoted crown is fitted 
 by means of a split pin ; this method has the advantage of the 
 pivoted tooth, being readily removable, whilst it is rendered 
 sufficiently secure by the elasticity of the split pin. Some 
 American dentists, instead of screwing such a tube into its 
 place, merely fit it in, and fix it by making an adhesive gold 
 filling round its lower end, having previously drilled a cavity 
 of suitable shape in the root. This adhesive-foil filling may 
 be extended from around the tube over the whole exposed 
 surface of the root, so as to protect it against further decay. 
 
 Some practitioners, when using a gold pin, coat this thinly 
 with hickory : the wire has a screw thread cut upon it, and 
 is screwed into a piece of hickory, which is subsequently 
 trimmed down to the proper size. 
 
 Yet another method is to fill the canal in the root with a 
 wooden plug ; drill a small hole in the plug, and then force 
 in a pointed pivot-wire carrying the tooth ; but this manner 
 of procedure is not so generally available as the others. 
 
 The operation of pivoting, when undertaken under favour- 
 able circumstances, and carefully performed, produces a very 
 satisfactory result. Unfortunately, however, we are not 
 always in a position to form a just appreciation of the 
 attendant circumstances. In the majority of cases the 
 patient sufi'ers no further inconvenience than that which 
 attends the operation ; but instances occasionally arise in 
 which inflammation is set up in the alveolus, the gimi 
 becomes enlarged, and the face swells. Great pain, at first
 
 f)68 A SYSTEZI OF DEXTAL SURGERY. 
 
 limited to the alveolus of the pivoted tooth, aftenvards 
 diffused over the neighbouring parts, attends the progress of 
 the disease, and severe constitutional symptoms are not 
 always wanting. Eventually, suppuration is established 
 within the socket of the pivoted tooth, and the pus finds its 
 way to the surface; but the disease sometimes assumes a 
 more active character, and spreads over a larger surface than 
 an ordinary alveolar abscess. In one case tetanus and death 
 followed the operation of pivoting (see p. ^91). 
 
 In another case an epulis was developed with considerable 
 rapidity in consequence of the irritation set up by pivoted 
 teeth. 
 
 With a view to avoiding these consequences, it is always 
 preferable to tightly fill the canal with mastic and woc«l, and 
 wait for a few days to see what will be the result of abso- 
 lutely closing up the canal. Where the nerve has been 
 extirpated by an instrument, it is unusual to get any irri- 
 tation ; but where the nerve has died spontaneously, it is by 
 no means unusual for an alveolar abscess to be threatened. 
 
 As the pivot- wire does not reach up to the apex of the 
 fang, and it is, of course, undesirable to leave any vacant 
 simce above it, it is better to fill the apex of the fang with 
 gold where the nerve has been lately extirpated, or with 
 cotton-wool and carbolic acid where it has died six)nta- 
 neously. In every instance care must be taken not to form 
 a piston in the pulp-canal by which air or fluids might be 
 forced out through the apical foramen. 
 
 The possibility that unfavourable symptoms may arise, 
 renders it necessarj' that the patient should be requested to 
 return, should the pivoted tooth become painful. If it is 
 found that the alveolar periosteum is becoming inflamed, one 
 or two leeches should be applied to the gum, and the new 
 crown removed, if the pivot can be readily withdrawn. But 
 if the disease has advanced to suppuration, it will be well at 
 once to remove the root l^efore the sockets of the neighbour- 
 ing teeth become involved. Generally, however, the inflam-
 
 PIVOTING TEETH. 669 
 
 matioii, if taken at the onset, may be controlled, and the 
 tooth saved by local bleeding and the administration of an 
 aperient. 
 
 Should there be reason to suppose that unfavourable symp- 
 toms may arise, it will be advisable to fix the pivot in a 
 manner that will admit of its ready withdrawal, and refix it 
 when all chance of mischief has passed away.
 
 ( 670 ) 
 
 THE OPERATIOX OF EXTRACTION. 
 
 In a previous work (') the comparative merits of the key 
 instrument and of the forceps were fully discussed, but the 
 universal adoption of forceps since that time has rendered it 
 quite superfluous to again enter upon the question. 
 
 I have no reason to change the opinions then expressed in 
 respect to the construction and the manner of using these 
 instruments, neither have I any great additions to make to 
 my former description. Under these circumstances, the fol- 
 lowing description, with the accompanying illustrations, must 
 in the main correspond with that devoted to the same subject 
 in my Lectures. 
 
 In extracting a tooth, the following conditions should be 
 fulfilled : — First, the whole of the oifending organ should be 
 removed. 
 
 Secondly, it should be removed with as little injury as 
 possible to the structures in which it is implanted. 
 
 Thirdly, the patient should be spared all unnecessary pain 
 in the operation. 
 
 That method by wliich a tooth, or the remains of one, can 
 be removed most certainly, quickl}', and at the same time with 
 the least amount of injury to the adjoining parts, will also 
 remove it with the least pain. To meet these requirements, 
 recourse must be had to an instrument so formed that it 
 shall grasp the tooth alone, and on the application of the re- 
 quired force effect its removal. Such instruments are forceps ; 
 forceps so constructed that they will accurately fit the tooth 
 (1) " Lectures on Dental Physiology and Surgery." 1848.
 
 THE OPERATION OF EXTRACTION. 671 
 
 to be extracted, and so fashioned at the jaws, nibs, or blades, 
 that they shall readily pass within the gum and separate it 
 from the neck of the tooth. 
 
 In the construction of tooth-forceps, certain general prin- 
 ciples may be laid down, the observance of which cannot be 
 neglected without prejudicing the general effectiveness of the 
 instrument. The terminal edge of the jaws should fit with 
 accuracy to the neck of the tooth for the removal of which 
 they are designed. The whole of the circumference of the 
 neck cannot be embraced, but a large portion of the lingual 
 and labial surface of that part of the tooth can be reached 
 by the instrument. The greater the surface over Avhich the 
 pressure is diffused, the less will be the risk of breaking the 
 tooth by the force employed to effect its removal. Assuming 
 the tooth to be grasped by the instrument, the jaws should 
 diverge above the terminal edge sufficiently to clear the crown, 
 but the divergence must not be greater than is necessary to 
 effect that object, otherwise the form of a cutting instrument 
 will be approached. 
 
 In forming the terminal edge, some little care is necessary, 
 as it must be sufficiently thin to pass under the gum and 
 separate it from the neck of the tooth, and, in some cases, 
 even to pass a short distance within the alveolus. At the 
 same time a sufficient amount of metal must be preserved to 
 ensure the requisite strength. If a section were made of a 
 well-constructed pair of forceps for the incisor teeth, each 
 jaw of the instrument would present the outline of a sharp 
 wedge, which, when applied to a tooth, would be in close 
 apposition to the neck of the tooth, leaving the crown un- 
 touched. The length of the jaws should be sufficient to clear 
 the crown : any further increase would diminish the power 
 of the instrument, or necessitate an inconvenient length of 
 handle. 
 
 Size and Curve of Handle. — In respect to the length of the 
 handle there is great difference of opinion, the size of the 
 hand of the operator by no means determining his selection
 
 672 A SYSTEM OF DENTAL 8UEGEBY. 
 
 of the length of handle most convenient to him. I am 
 inclined to think that the tendency is to use forceps with 
 handles both longer and larger that is consistent with the 
 utmost attainable delicacy of manipulation ; but hardly any 
 two people think alike on the matter. Forceps for extracting 
 the front teeth will necessarily be straight, but those used 
 for the removal of the molars must be more or less curved ; 
 and the direction and degree of the curvature are questions 
 of some importance. The straighter the instrument, the 
 more readily will its action be controlled. On this account 
 it is desirable to limit the curve at the joint, and, in the case 
 of forceps for the upper teeth, to antagonize it by an opposite- 
 curvature in the handles. 
 
 Many American dentists, however, seem to prefer forceps 
 for the extraction of lower molars which have a very con- 
 siderable cuiTe in the handles, and a crook at the end of one 
 handle for the reception of the little finger ; but, for my own 
 part, I do not think this form of forceps preferable to the 
 usual English patterns. The jaws of the forceps must, how- 
 ever, form some angle with the handles at the joint, in order 
 to enable the latter to clear the other teeth in the mouth, 
 when intended for removing the back teeth. 
 
 But, the less complex the various curves made by the 
 instrument are, the more easy will it be to direct the force 
 applied to the tooth with precision. 
 
 As the teeth are variously shaped, so will it be necessary 
 to have forceps of dififerent forms ; in fact, a pair fitted to 
 each kind of tooth. By the use of forceps so adapted, to the 
 forms of the necks of teeth, they may be removed in the 
 least possible time, and with the least possible pain to 
 the patient ; moreover, no further injury to the gums and 
 alveolar processes need be inflicted than must necessarily 
 result from the forcible separation of a tooth from its attach- 
 ments. In order to secure perfect adaptation of each instru- 
 ment to its allotted purpose, average teeth should be selected 
 and given to the forceps maker, who should be instructed to
 
 THE OPERATION OF EXTRACTION. 673 
 
 make the jaws fit accurately around the neck, whilst they 
 diverge enough, and only enough, to secure the crown of the 
 tooth from pressure. 
 
 The fangs of all teeth having a general conical form, forceps, 
 when well made and applied, should be but as a lengthening 
 of the cone in the direction of its base. For removing teeth 
 which are not decayed down to the gums, the ends of the 
 jaws should be slightly rounded ; but when the root only 
 remains of a tooth, rounded ends are the more convenient, as 
 that shape is more readily introduced between the fang and 
 the inclosing alveolus. Instruments for extracting stumps 
 should be made altogether lighter, and the jaws should be 
 thin and sharp at their edges, so that they may be made to 
 cut rather than to tear the structures connecting the fang 
 with the adjoining tissues. 
 
 When forceps are used for the extraction of teeth, the 
 operation is divided into three stages : — First, the seizure of 
 the tooth ; second, the destruction of its membranous con- 
 nection with the socket ; third, the removal of the tooth 
 from the socket. It will be of great service to the student, 
 and advantage to those operated on, that he should pay strict 
 attention to these stages, and that each should be well and 
 efficiently executed before he proceeds to its successor ; for 
 should the tooth be unskilfully seized, the crown will be 
 broken off in the attempt to detach the tooth from the 
 periosteum of the socket ; and until this is effected, the 
 fangs cannot be removed from their bony cells. A tooth will 
 resist a great force applied in a line with its axis, or, in other 
 words, if an attempt is made to pull a tooth straight from its 
 socket ; and some most disastrous results have been known 
 to follow such attempts made by persons unacquainted with 
 the form of the molar teeth which they attempted to extract : 
 three or four teeth and the alveolus inclosing them have 
 been brought away, and the greater part of the floor of the 
 antrum was actually torn away in one case. In seizing 
 a tooth, the jaws should be closed lightly upgn it, and 
 
 2 X
 
 674 A SYSTEM OF DENTAL SURGERY. 
 
 inserted under the free edge of the gum, and then forcibly 
 driven down to the edge of the alveoli, or even a short dis- 
 tance within them. I say forcibly, because all beginners, 
 and even some practised in the use of forceps, are liable to 
 failure because they do not use sufficient force : th^y seize 
 the tooth at the edge of the gum, instead of at the edge of 
 the alveolus. The beginner should be impressed with the 
 necessity of laying hold of the tooth as far down towards the 
 fangs as the instrument can be passed. 
 
 An old and successful operator, when instructing another 
 in the use of forceps, said, " Push the jaws of your forceps 
 into the sockets as though you intended they should come 
 out at the top of the head, or under the chin." 
 
 I find that even in the last (tenth) edition of Harris's " Prin- 
 ciples and Practice of Dentistry " (by Professor Austen, 1871), 
 it is said " the use of the gnm-lancet should generally precede 
 the application of either the forceps or the key," and its use is 
 strongly advocated in the succeeding sentences. Nevertheless, 
 I do not think its use either necessary or even advantageous, 
 save in those very few instances where the gum is unusually 
 adherent ; and the only position in which this adherence of 
 the gum to the tooth is likely to be productive of trouble or 
 injury is the posterior surface of wisdom teeth. It will occa- 
 sionally happen that the gum may be unnecessarily lacerated 
 when firmly adherent to this part of the wisdom tooth, so 
 that it is, perhaps, safer to ascertain whether it is or is not 
 closely attached to the tooth before attempting its removal. 
 But, with this somewhat rare exception, I am unable to see 
 what is to be gained by> lancing the gum, if the edges of the 
 jaws of the forceps be in proper condition. 
 
 American forceps, as a rule, ai)pear to have the blades much 
 thicker, and to approach less to a cutting edge, than those of 
 English make, and it is probably on this account that lancing 
 of the gum is still advocated by some transatlantic writers. 
 
 When the forceps have been pressed well up, the student 
 must be o;i his guard lest he crush the tooth by squeezing
 
 THE OPEEATION OF EXTRACTION. G75 
 
 the handles of the forceps too tightly. To guard against 
 this, some operators pass the little finger between the two 
 handles ; but a preferable plan is to regulate the pressure 
 exerted by partly introducing the fleshy part of the thumb 
 between the handles. Ko more pressure should be put upon 
 the tooth than will suffice to prevent the forceps from 
 slipping. 
 
 The manner of effecting the second stage will depend on 
 the shape of the tooth to be removed ; as will also the third. 
 But different- shaped teeth require forceps shaped to them. 
 It will be necessary, therefore, to describe partially the teeth, 
 and then the forceps individually, in order that the peculiar 
 shape of each instrument may be understood. Before doing 
 so, however, I should state that it is quite impossible for any 
 person to extract teeth properly, whatever instrument may 
 be used, especially if the forceps be chosen, unless the operator 
 is perfectly acquainted wdth the form of each tooth, with the 
 relative position and size of the fangs, with their direction in 
 the alveoli, with the general form of the alveoli themselves, 
 and with the directions in which they offer the greatest and 
 the least resistance. 
 
 In describing the manner in which the operation of ex- 
 traction should be performed on the different teeth, the 
 incisors, canines, and bicuspid teeth will be first considered, 
 and afterwards the molars. 
 
 A section through the neck of an incisor of the upper jaw 
 will show that the anterior is larger, and forms part of a 
 greater circle, than the posterior surface. Now, the end to 
 be attained in the ap'plication of fofceps, is to apply them 
 over as large a surface as possible, so that the pressure may 
 be diffused, and the chance of fracturing the tooth by the 
 pressure of the instrument avoided. To extract these teeth, 
 therefore, the jaw to be applied to the posterior surface must 
 have a smaller curve than that for the anterior. When the 
 forceps are closed upon the tooth, they should embrace, not 
 only the anterior and posterior surfaces, but a part of the
 
 676 
 
 A SYSTEM OF DENTAL SURGEBY. 
 
 Fig. 237. (1) 
 
 lateral surface also. A cylindrical tube of thin metal, when 
 pressed upon equally in every direction, 
 ■will resist enormous force ; but if the 
 pressure be confined to one or two points, 
 a comparatively trifling power will crush 
 it : so it is with a tooth. 
 
 The lateral incisors require forceps 
 made upon the same principles as the 
 central teeth, but somewhat less in size. 
 These are liable to greater variation in 
 external dimensions than any other 
 teeth. Sometimes they are very small 
 indeed ; at other times they are almost 
 as large as the central incisors. It will 
 be advantageous, therefore, to have dif- 
 ferent sizes of instruments from which 
 to select. 
 
 The forceps having been well pushed 
 up towards the alveoli, and the tooth 
 firmly grasped, then, by a firm and steady 
 turn of the wrist, twist the tooth in its 
 socket, and so soon as it is felt to yield 
 to the force, it may be dra-ss-n from its 
 socket with little eflbrt. 
 
 The incisors of the lower are smaller 
 than those of the upper maxilla, and 
 much more compressed laterally. For- 
 ceps for the extraction of these teeth 
 wfU require to have the jaw which is to 
 be applied to the posterior smaller than 
 that for the anterior surface of the neck. 
 The jaws of the instniment should be 
 straight : but it will be found conve- 
 nient to have the handles curved, so as 
 to avoid the upper maxilla. "When the tooth is grasped 
 
 (») Forceps adapted for the removal of the incisor teeth of the upper jaw.
 
 THE OPERATION OF EXTRACTION. 677 
 
 it must be forced outwards, the movement accompanied 
 with the slightest possible degree of 
 rotation, and, when it is felt to yield, 
 draw it upwards and outwards. 
 
 The cuspidati of the upper and lower 
 jaws require for each a pair of forceps 
 made upon the same plan as those for 
 the removal of the incisors, except that 
 they must be larger and rather stronger. 
 Those for the cuspidati of the lower 
 maxilla should, like forceps for the in- 
 cisors of the lower jaw, have the handles 
 slightly bent. Sometimes these teeth 
 are very small, in which case forceps 
 adapted to the adjoining teeth may serve 
 for their removal. The canine teeth, 
 whether in the upper or the lower jaw, 
 may be detached from their membranous 
 connection with the jaw by a rotatory 
 movement, and will then leave the 
 socket readily. 
 
 The bicuspids will be extracted with 
 instruments similar to those already des- 
 cribed, except that there will be a little 
 difference in the jaws, which must be 
 accurately fitted to the neck of the 
 tooth. These teeth are not very fre- 
 quently liable to much variety in size, 
 so that an instrument which is ^vsell 
 adapted to an ordinary bicuspid tooth 
 will apply itself to almost all. I have 
 forceps in which the jaws are bent at 
 right angles with the handles, and open 
 laterally, for the extraction of bicuspids of the inferior maxilla. 
 
 (») Forceps adapted for the removal of the lower incisor teeth, with the 
 handle curved to enable the operator to avoid the teeth of the upper jaw.
 
 678 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 But they do not answer so well either as instruments which 
 are nearly straight, or those in which 
 Fig. 239. (i) ^)^q handles are constructed in the 
 
 manner shown in the illustration, it 
 being less convenient to apply the ne- 
 cessaiy force, and more difficult to re- 
 gulate its direction, with the former than 
 with the latter forceps. In extracting 
 teeth which have their fangs laterally 
 compressed, and are placed in an un- 
 broken line with other teeth of like- 
 shaped fangs, the only available move- 
 ment will be at right angles with the 
 line of the alveoli, and in the direction 
 of the greatest diameter of the fangs. 
 This motion may be obtained whether 
 the forceps employed be straight or 
 rectangular, like Fig. 247 ; but with an 
 instrument of the latter shape the 
 movement must be effected by rotation 
 of the wrist, with a motion upwards. 
 The centre of the rotatory movement 
 will be either at the extremity of the 
 jaws of the instrument, or else in a line 
 with the handles of the instrument and 
 wrist. Force applied in this manner 
 would seem to be given at great dis- 
 advantage, and much expended on the 
 alveolus ; there inflicting injury, which, 
 although in the vast majority of cases 
 it may not be complained of by the 
 patient, prevents the mouth from so 
 
 speedily recovering from the operation. 
 
 (') Forceps suitable for removing the bicuspids of the lower jaw. The 
 jiiint is placed in an unusual position, and the handles bent in order to allow 
 the hand of the operator to avoid the teeth of the upper jaw. The merit of 
 inventing this useful instrument is due to Mr. Evrard.
 
 ON EXTRACTION OF THE MOLARS. 679 
 
 The bicuspids of the upper jaw have the necks compressed 
 laterally. In removing them, whatever be the form of the 
 instrument used, the force must be first applied in a direction 
 outwards and at an angle to the, dental arch. The tooth 
 should be moved outwards and inwards, and then drawn 
 downwards. But it must be borne in mind that in forcing 
 it outwards or inwards we desire only to break its con- 
 nections with the socket, and not to draw it out ; and that 
 if the force be continued in this direction with the hope of 
 removing the tooth, that it will probably be broken off. 
 
 The bicuspids of the lower jaw have more conical fangs 
 than those of the upper, and hence may be detached by rota- 
 tion, and then lifted out of the socket. 
 
 When I say rotation, I do not mean that the tooth shall be 
 twisted a half or even a quarter turn, but that it shall be 
 twisted till its attachments are felt to give way. If, in order 
 to effect this, more force is required than can be judiciously 
 employed, then the direction may be changed, or the rotatory 
 movement abandoned. There are some teeth that vary so 
 much from the usual form of root that they cannot be turned 
 in the socket. The degree of force that it is necessary to 
 employ, in this and in all other cases of like operations, can 
 be learned only in practice. 
 
 Oil Extraction of the Molars. — The molars of the sujDerior 
 maxilla have three fangs — two external, one internal. Of 
 the two external fangs the anterior is the largest, and is 
 placed in a plane slightly external to the posterior fang, 
 which is both shorter and smaller. The third, the internal 
 fang, is thicker and of greater length than either of the others, 
 and is situated opposite to the posterior external fang, and 
 the space between that and the anterior external fang. The 
 divergence of the fangs takes place at the point where the 
 tooth becomes concealed in the alveolus, leaving the neck 
 with a form such as would result from the agglutination of 
 the fangs, having the described relative position. At this 
 point the forceps should be applied for the removal of the
 
 680 A SYSTEM OF DE^■TAL SURGERY. 
 
 tooth. Instniments — for it will require two, one for each 
 side, right and left — must be made upon the same general 
 principles as those already described. The jaw for the labial 
 surface of the tooth must l^ave two grooves — the anterior the 
 larger ; the posterior smaller, and upon a plane internal to 
 the anterior groove. The jaw for the lingual surface must 
 have but one groove, and that fitted to the base of the 
 internal fang. From the position of the molars of the 
 superior maxilla, the jaws of the instrument for their extrac- 
 tion must necessarily be bent at an angle with the handles. 
 This angle should not be more than is absolutely necessary, 
 for the more curved the instrument the greater is the difficulty 
 of using it. The handles should have a general curve in the 
 opposite direction to the jaws. 
 
 The molars of the superior maxilla have the two external 
 fangs parallel to each other in their direction in the alveoli. 
 The internal, which is not only the largest, but the longest 
 also, diverges from the two preceding fangs, and passes up- 
 wards and in\\'ards towards the internal wall of the antrum, 
 and is enclosed in tolerably dense bone. The external alveoli 
 are composed of thin and porous bone. 
 
 In removing these teeth, then, the tooth being firmly 
 grasped at its neck, the first motion should be very slightly 
 inwards, to disengage the fangs from the external alveoli. 
 The force should then be directed downwards and outwards 
 in the direction of the internal fang. If these precautions 
 be observed, no difficulty will be found in removing the 
 superior molars. The first and second molars of the superior 
 maxilla are so nearij^ alike in size and shape, that an instru- 
 ment well fitted to one will serve equally well for the removal 
 of the other. 
 
 The first molar, however, if isolated by the previous re- 
 moval of the second molar and the second bicuspid, will, when 
 their vacated alveoli have been filled with solid bone, offer 
 great resistance to extraction, and is sometimes broken off" in 
 the attempt. Indeed, a solitary tooth surrounded by firm
 
 ON EXTRACTION OF THE MOLARS. 
 
 681 
 
 bone is always more difficult to extract, and requires more 
 care, than one situated in a continuous row of teeth. 
 
 In the third mo- 
 lars, or dentes sa- Figs. 2ao and 2ii.i^) 
 
 pientise, of the upper 
 jaw, though the 
 fangs are often 
 united into one coni- 
 cal mass, yet the 
 shape of the neck of 
 the tooth is so like 
 those of the prece- 
 ding teeth, that an 
 instrument which is 
 suited for the re- 
 moval of the anterior 
 molars is often suf- 
 ficiently well adap- 
 ted for the removal 
 of the wisdom teeth. 
 The dentes sapienti« 
 are, however, some- 
 times much smaller 
 than the other mo- 
 lars ; in which case 
 a smaller instrument 
 might be required, 
 but that, when of 
 small size, the wis- 
 dom teeth are for 
 the most part re- 
 moved by the application of so slight a force that any 
 instrument by which they can be embraced will serve for 
 their removal. A useful form of forceps for the extraction of 
 
 (J) Forceps for removing the superior molar on the right side of the mouth. 
 In the second figure the instrument is shown embracing a tooth.
 
 682 A SYSTEM OF DEXTAL SURGERY. 
 
 upper v.isdom teeth is made with two nearly rectangular 
 curves, like those of the plugging instrument represented in 
 Fig. 149 : the same forceps will answer equally well on both 
 sides of the mouth. 
 
 The molars of the lower jaw have two roots, a distal and 
 a mesial root, which at their union form the neck of the 
 tooth, and leave upon it a depression or groove on the 
 lingual and labial surfaces. A transverse section through 
 the neck of a lower molar, in outline, resembles a rude figure 
 of 8, and it is to the surface so formed that the jaws of the 
 forceps must be adapted. 
 
 The two roots are not equal in size, neither are they strictly 
 parallel in position. The mesial or anterior is both broader 
 and thicker than the posterior or distal root. Their position 
 as regards each other is slightly oblique, giving at the point 
 of confluence at the neck of the tooth a slightly greater 
 breadth to the labial than the lingual surface. The position 
 of the tooth in the jaw is also a little oblique. A line passed 
 from the centre of the labial across to the centre of the lin- 
 gual surface of the neck would, if continued, proceed over 
 the tongue, with a slightly diagonal direction backwards. 
 Owing to these peculiarities in the form of a lower molar 
 tooth, it becomes desirable to possess forceps destined to 
 eflfect their removal fitted to the teeth on each side of the 
 mouth — an instrument for the right, and one for the left 
 teeth. One pair may be made to answer the purpose, per- 
 haps, but the obliquities of position and conformation render 
 it quite impossible to adapt the jaws of one instrument to fit 
 with accuracy to the necks of both right and left lower molar 
 teeth. The handles must necessarily be placed at an angle 
 with the jaws of the instrument, and the angle will be deter- 
 mined by the plane in which the jaws are bent. 
 
 For extracting the first lower permanent molars of young 
 people, where the alveolus is likely to be tolerably yielding, 
 I prefer small forceps nearly of the form represented in 
 Fig. 242, but with the handles curved to fit the hand ; but in
 
 ON EXTRACTION OF THE MOLARS. 683 
 Fig. 242. (1) 
 
 Fig. 243. (2) 
 
 (1) Forceps for the removal of molar tcf-th of tbe lower jaw. 
 
 (2) Forceps, the jaws of which are placed at a right angle.
 
 6Si 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 Fig. 244. (1) 
 
 W" 
 
 older people, and in all, young or old, for the removal of the 
 second molars, forceps with the jaws bent at right angles are 
 preferable (Fig. 243). 
 
 "When, however, the whole tooth has 
 an inclination inwards, the handles of 
 forceps of this last form would, in the 
 place of being nearly horizontal, be 
 directed upwards to an extent that 
 would render their application a matter 
 of difficulty. Hence with teeth which 
 incline inwards, forceps of the form 
 represented in Fig. 242 are found to be 
 more convenient. 
 
 In some instances these same forceps 
 may be used for the extraction of the 
 third molars. Generally, however, 
 these teeth are situated so far back in 
 the mouth, and'are separated from the 
 corresponding members of the upper 
 series, when the mouth is opened to 
 it fullest extent, by so small an inter- 
 val, that although a modified instru- 
 ment may not in all cases be absolutely 
 necessary, it is, at all events, more con- 
 venient. An instrument, the jaws of 
 which, in addition to standing at a 
 right angle to the handle, are also them- 
 selves curved forward (Fig, 244), I have 
 found particularly serviceable, not only 
 in extracting the third, but also the 
 second molar teeth. A right and a left 
 pair will, of coarse, be required. 
 
 (J) Forceps for the removal of second or third lower molars situated in the 
 right side of the mouth. 
 
 The jaws of the instrument aie placed at a right angle. The jaws themselves 
 are curved in a manner which allows the instrument to bs passed to the back 
 jrnrt of the mouth, without necessitating a wide separation between the upper 
 and lower teeth.
 
 ON EXTKACTION OF THE MOLARS. 685 
 
 The old adage, that the best workmen are known by the 
 fewness of their tools, if true in former years, falls short of 
 the truth in modern times. The best work is produced by 
 those who have at their disposal the most perfect mechanical 
 appliances ; and it is so in the practice of general and special 
 surgery. Those who have the best-made and the most per- 
 fectly adapted instruments, will, other circumstances being 
 equal, operate with the greatest success. 
 
 A deviation from the normal form is exceptional in any 
 member of the dental series, excepting in the dentes sapiential 
 In these teeth the converse holds good, the typical form is 
 more frequently lost than retained, and it is on this account 
 that the operator should be prepared with suitable means for 
 meeting such exigencies as may arise. The question of irre- 
 gularities of form will, however, be subsequently referred to. 
 
 In removing molars of the lower jaw, the blades of the 
 instrument, whatever may be its form, should be carefully 
 thrust down to the free edge of the alveoli, which part of 
 the operation is easily effected, in consequence of the de- 
 creasing size of the teeth from the crown to the fangs. 
 Having obtained firm hold of the neck of the tooth, the first 
 motion should be inwards, by which the tooth is detached 
 from the external plate of the alveoli ; afterwards the tooth 
 should be drawn outwards and upwards, and so removed. 
 The fangs of these teeth, however, not unfrequently take a 
 curve backwards ; if, therefore, a lower molar ofiers consider- 
 able resistance when its extraction is attempted, the move- 
 ment after the tooth has been forced laterally should not be 
 in a straight line, but in a curved direction, corresponding to 
 the course taken by the roots. 
 
 When an instrument having blades in the same straight 
 line with its handle is used, the operator must stand in front 
 of the patient, and the power will be exercised by rotation of 
 the wrist ; but if the instrument with the jaws bent down- 
 wards at a right angle be selected, the dentist in removing 
 the tooth from the right side of the mouth will stand behind, 
 and in operating upon the left side of the jaw, in front of the
 
 686 A SYSTEM OF DEXTAL SURGERY. 
 
 patient, or rather on the right, and slightly in advance of the 
 patient. As in this case the handles of the instrument will 
 project horizontally outwards from the left comer of the 
 patient's mouth, the operator must reach across the patient 
 with his arm, and is then, to some slight extent, in a dis- 
 advantageous position. Hence some operators, whilst almost 
 invariably using this form of forceps for extracting lower 
 molars on the right side, do not use them on the left side of 
 the mouth. But a very little practice will overcome the dif- 
 ficulty of reaching across the patient, and the position is a 
 far less awkward one than that adopted by some operators, 
 who stand on the left of the chair to remove lower teeth with 
 this form of forceps. This is indeed a disadvantageous posi- 
 tion : it is difficult to see where the blades of the forceps are, 
 and the operator is encumbered by his own body being 
 between his operating hand and the patient's mouth. The 
 same remarks apply to the use of the elevator in the lower 
 jaw, it being the constant babbit of some operators to stand on 
 the patient's left to remove a left lower tooth. As the handles 
 of the instrument project from the side of the mouth, the 
 power employed in the removal of the tooth will be exercised 
 by raising and depressing the band ; but the operator should 
 endeavour to lift the tooth from its socket, and not simply 
 depress the handle, using the alveolus as his fulcrum to the 
 very last. It is to these rectangular instruments that I gene- 
 rally give the preference. One point in the extraction of 
 lower teeth which is too often neglected is to place the patient 
 low enou-'h relatively to the operator. Another point of great 
 importance is to securely fix the patient's lower jaw ; if the 
 tooth to be removed be upon the patient's left, the jaw should 
 be seized by the operator's left hand, the thumb being placed 
 upon the crowns of the teeth immediately in front of the tooth 
 to be removed, and the fingers, covered by a napkin, sup- 
 porting the jaw from below. If the tooth be upon the right 
 side, and hawksbill forceps (Fig. 243) be selected, the operator 
 will stand behind the patient, his left arm passing round the 
 head, and the thumb and fingers being applied as before. In
 
 ON EXTRACTION OF THE MOLARS. 687 
 
 operating upon patients when under the influence of nitrous 
 oxide, the tongue often rises up and obscures the view of the 
 teeth ; hence it will often be better to reverse the position 
 of the hand just described, and place the thumb below the 
 jaw, so as to have one or two fingers free, for the purpose of 
 depressing the tongue. 
 
 But, whatever position be selected, the lower jaw must be 
 absolutely under the control of the operator. 
 
 In the foregoing description it has been assumed that a 
 considerable portion of the crown remained, and that the con- 
 demned tooth, therefore, could be readily grasped at its neck. 
 It often happens, however, that the tooth has decayed away, 
 or been broken off to a level with or below the edge of the 
 gum ; in either case the instruments at present described 
 are inapplicable. Stump-forceps, or the elevator, must be 
 employed to effect the removal of such teeth. 
 
 There are two forms of stumps, single and double, or triple. 
 Single-fanged teeth necessarily leave only a single stump, but 
 in molar teeth a sufficient portion of the neck may remain to 
 preserve the connection of the roots. For the extraction of 
 single stumps we require one kind of instrument, for double 
 another, and for triple-fanged stumps a third. 
 
 In forceps for removing single stumps the jaws should be 
 grooved to fit the stump, made very sharp at the edge, and 
 of well-tempered cast steel, so that the edge may be renewed 
 from time to time on the oil-stone. When the instrument is 
 closed, they hold the stump, and fit to its whole length. 
 
 In the construction of these instruments, care should be 
 taken to allow a suflicient interval between the upper part of 
 the blades, otherwise they will close upon and crush the ex- 
 posed and fragile portion of the stump, before the terminal 
 portion of the blades bears upon the part capable of resisting 
 the required pressure. 
 
 Although little variety will be required either in the size 
 or in the form of the jaws, the relations they hold to the 
 handles will require variation, in order to admit of their
 
 G88 A SYSTEM OF DENTAL SURGERY. 
 
 Fig. 245. (1) Fig. 246. (2) Fig 247. (3) 
 
 (1) Forceps for removing the roots of single-fanged teeth situated in the 
 front pan of the upper Jaw. 
 
 (2) Forceps for removing the detached roots of the upper molar or bicuspid 
 teeth. The jaws of the instrument are slightly curved upwards, and the bandies 
 in an opposite direction, in order to enable the operator to reach the back part 
 of the mouth. 
 
 (3) Forceps with the jaws bent at right angles, for the removal of the roots of 
 the lower bicuspid teeth. For th'» extraction of stumps oi the lower molar 
 teeth, a considerable advantage will be gained by a slight curve in the blades 
 below the joint, as shown in Fig. 244.
 
 ON EXTRACTION OF THE ROOTS OF TEETH. 689 
 Pig. 248. (1) Fig. 249. (2 ) 
 
 .i^ 
 
 (1) Forceps with blades bent at an angle in the same plane as the handles, for 
 the removal of the stumps in the lower jaw. 
 
 (2) Forceps with long slender blades for picking out of the alveoli the loose 
 roots of teeth, the crowns of which have previously been removed ; somewhat 
 stronger instruments of this form, or having the blades bent twice (compare 
 Fig. 149), are very valuable for removing upper stumps. 
 
 2 T
 
 690 A SYSTEM OF DENTAL SURGERY. ; 
 
 application to stumps situated in different parts of the - 
 mouth. Of these varieties the succeeding illustrations will 
 afford examples. 
 
 The edges of the blades having been rendered moderately 
 sharp, thev should be closed lightly upon the stump, and 
 then forced between it and the edge of the alveolus. In 
 many cases simi3le pressure will carry the instrument to a 
 sufficient depth, but in others a slight amount of rotation will 
 be found necessary. The root, when embraced at a point 
 capable of resisting pressure, is readily removed. The direc- 
 tion in which the force should be employed in effecting its 
 extraction will be regulated by the shape of the root under 
 operation — a point already discussed in a previous page. Occa- 
 sionally the margin of the alveolus is so unusually strong 
 that it becomes extremely difficult to introduce ordinary 
 stump-forceps, and the difficulty in operating is still further 
 increased when the stump requiring removal has been broken 
 off on a level or a little below the terminal edge of the socket. 
 To meet the difficulty, Mr. Cattlin has devised an instru- 
 ment, shown in the accompanying illustration. 
 
 If, instead of simple or single, we find compound roots — the 
 roots of molar teeth united by the presence of a portion of the 
 neck of the tooth — an advantage will be gained by adopting a 
 different form of instrument to any at present described. For 
 removing the compound roots of an upj3er molar, an instru- 
 ment will be required similar, as respects its general form, to 
 that which would be used for the extraction of the tooth, but 
 with the outer or labial blade prolonged into a point. 
 
 The palatine blade has, at the suggestion of Mr. Coleman, 
 undergone a slight modification. The terminal portion is 
 somewhat reduced in thickness, and turned a little outwards 
 in a direction corresponding to the course taken by the root 
 of the tooth as it enters the alveolus. Instruments con- 
 structed on this principle were shown to me many years 
 since by Mr. Rogers, and to him I am indebted for patterns 
 from which many have since been made.
 
 ON EXTRACTION OP THE ROOTS OF TEETH. 691 
 
 In operating, the palatal blade must be pressed into the 
 alveolus of the corresponding root, and the point of the 
 labial blade placed over the inter- Fig. 250. (i) 
 
 val which separates the two labial 
 roots. This position having been 
 gained, the point must be driven 
 through the gum and alveolus into 
 the space which separates the 
 labial roots by closing the handles 
 of the instrument. By this pro- 
 cedure a firm hold upon the triple 
 root is obtained, and its removal 
 is readily effected, unless the con- 
 necting portion of the tooth gives 
 way. In that event the roots be- 
 come separated from each other, 
 loosened in their socket, and are 
 more readily removed by a more 
 
 (t) Forceps, the edges of the blades of 
 ■which are cut into teeth like a saw, for the 
 purpose of operating upon roots presenting 
 a conical surface. The instrument is pro- 
 vided with a stop between the handles. 
 The thumb-piece (a) is pressed upon and 
 forces the wedge (b) forward, and prevents 
 the blades from closing, the sharp edges of 
 •which, by rotation, are made to cut their 
 way into the stump, or between the stump 
 and alveolus. When a sufficient depth has 
 been reached to enable the blades of the in- 
 strument to take a firm hold, the wedge is 
 withdrawn by the thumb, and the instru- 
 ment used as an ordinary pair of stump- 
 forceps. I am indebted to Mr. Cattlin, the 
 inventor of the instrument, for this illus- 
 tration. But these forceps have not proved 
 80 useful as was anticipated ; there are few 
 teeth which cannot be removed without re- 
 sorting to such a process. 
 
 * Shows the grooved surface of the wedge, 
 which rests against a similarly grooved 
 surface on the handle of the instrument.
 
 692 
 
 A SYSTEM OF DEKTAL SURGERY. 
 
 simple form of stmnp-forceps. Before applying the instru- 
 ment, it is desirable to make an inverted Y-shaped incision 
 over the labial roots of the tooth, to receive the point of the 
 labial blade of the forceps. If this precaution be neglected. 
 
 Fig. 252. (1) 
 
 Fig. 251. C) 
 
 (') Forctps for removing upper molar teetli, the crowns of which have been 
 broken off, while the connection between the tbree roots has been preserved. 
 The peculiarity of the instrument consisis in the production of a tapered 
 prolongation of the outei- jaw, capable of passing between the labial roots of the 
 tooth. In the first figure the jaws are shown embracing a crownless tooth, in 
 ihe second the instrument only is shown.
 
 ON EXTRACTION OF THE ROOTS OF TEETH. 693 
 
 the gum may be torn, and the patient will be subjected 
 to unnecessary pain. 
 
 It is in the extraction of connected roots of the first molar 
 teeth that forceps constructed u])on 
 the foregoing principle are more 
 especially useful. In the upper 
 wisdom teeth the position and 
 number of the roots cannot be as- 
 certained. They are frequently 
 connate, and may be treated as 
 simple roots. Even the second 
 molars sometimes depart from the 
 usual form ; if, therefore, any dif- 
 ficulty is experienced in introducing 
 the labial blade of the forceps, its 
 use had better be abandoned in fa- 
 vour of a more simple instrument. 
 Other methods of extracting an 
 upper molar stump may be re- 
 sorted to ; one, which is very often 
 successful in bringing away all 
 three roots together, is to apply 
 forceps of the form represented in 
 Fig. 245 to the palatine and ante- 
 rior buccal roots, with a view to ex- 
 tracting these together and leaving 
 the posterior buccal to be dealt with separately. Another 
 method is to separate the three roots by forcing a sharp 
 spear -pointed elevator (see Fig. 256) into the centre of the 
 stump, and thus splitting it, when the separated roots can 
 be individually removed without difficulty. A pair of cutting- 
 forceps intended to effect this object has been designed by 
 
 (1) Forceps for removing lower molar teeth, the crowns of which have been 
 broken off through the lower portion of the neck, leaving the two roots firmly 
 connected. The blades are lengthened into points, which converge and pass 
 between the roots of the tooth.
 
 694 
 
 A SYSTEM OF DENTAL SUEGERT. 
 
 Fig. 254. (I) 
 
 Fig. 255. (2) 
 
 Mr. Harding, in wliich the external blade is replaced by a 
 
 vertical cutting edge. 
 
 The double root which remains after the crown of a first 
 or second molar of the lower 
 jaw has been reduced to the 
 level of the gum, may be re- 
 moved by an instrument con- 
 structed upon similar prin- 
 ciples to that which is used 
 in extracting the triple fangs 
 of the corresponding upper 
 teeth, differing, however, in 
 having each blade terminated 
 by a point. The points are 
 destined to pass between the 
 roots of the stumps, and when 
 a sufiScient portion of the neck 
 of the tooth remains to act as 
 a guide, they may be forced 
 into that position without 
 passing through the labial and 
 lingual plates of the alveolus. 
 The occasional irregularity in 
 the disposition of the roots, 
 more especially of the second 
 molar, must in this, as in all 
 operations upon the teeth, be 
 borne in mind. 
 
 The most generally useful 
 instrument for extracting the 
 roots of teeth has yet to be 
 mentioned. There is scarely a 
 root, or even a tooth, which 
 
 (1) Shows an elevator of the most simple description, with the blade hinged 
 to shut into the handle. 
 
 (2) A curved elevator, pressed by ilr. Thompson. 
 
 ,>
 
 0^ EXTRACTION OF THE ROOTS OF TEETH. 695 
 
 cannot be removed by the elevator. The instrument consists 
 of a blade terminated by a spear head, or other selected 
 form, and a stout shaft mounted in a strong handle. The 
 minor modifications to which this instrument has been 
 subjected in order to meet the exigencies of a particular 
 case or the views of the operator are endless. Figs. 254-5-6 
 show three of the more useful forms of the instrument, 
 the two straight, the other a curved elevator. Independent 
 of the' form, the following conditions should be observed in 
 constructing the instrument. The blade and shaft must be 
 made of good steel, and reduced to a spring temper. The 
 handle should be full and strong, and the whole instrument 
 sufficiently stout to bear, without bending or springing, any 
 force the operator may employ. 
 
 In operating, an elevator may be employed as a simple 
 lever. The edge of the blade having been made sharp, it is 
 thrust down between the root of the tooth and its alveolus ; 
 the handle is then depressed with a slight rotatory move- 
 ment, and if the motion be judiciously directed, the round 
 part or back of the blade will rest upon the margin of the 
 socket, while the edge of the blade cuts into and takes a 
 hold in the surface of the root. The instrument becomes 
 a lever of the most simple kind, the short end of which takes 
 its bearing on the tooth ; the alveolar processes, or perhaps 
 the neck of a contiguous tooth, form the fulcrum, and the 
 long end of the lever is in the hand of the operator. By the 
 depression of the handle the tooth is raised in its socket ; but 
 simple depression will not in all cases be sufficient to secure 
 the full effect. A slight degree of rotation is generally neces- 
 sary, otherwise the edge of the instrument, instead of en- 
 tering, may slip over the surface of the tooth. Many teeth, 
 more especially the wisdom teeth, may be forced or prized out 
 of their sockets by a single effort, but the second or even the 
 third application of the instrument may be required. A tooth 
 may be so placed with respect to the jaw or the neighbouring 
 teeth, that after it has been moved in its socket, a change in
 
 696 A SYSTEM OF DENTAL SURGERY. 
 
 the direction of the force becomes necessary in order to com- 
 plete the operation without inflicting needless injury on the 
 adjoining parts. 
 
 An elevator may, however, be used otherwise than as a 
 lever. A root, the implantation of which is not very firm, 
 may be forced out by pressing the point of the instrument 
 against it, the direction of the force being such as will favour 
 its escape from the socket. If, for example, the root of a 
 bicuspid on the right side of the upper jaw requires re- 
 moval, the operation may be performed in the following 
 manner : — Let the patient's head be well thrown back, and 
 placed immediately in front of the operator. The upper lip 
 may be raised by the forefinger of the left hand. The point 
 of the elevator should be passed upwards between the gum 
 and the tooth imtil a sound portion of the root is reached. 
 At this point the extremity of the instrument should be 
 pressed into the root sufficiently to take a firm bearing, and 
 the handle of the elevator at the same time brought up to 
 the side of the cheek. T^Tien this position is gained the 
 » iftending root may be pushed out of its socket. 
 
 Although the instrument under consideration admits of 
 being used upon either of the foregoing principles, it would 
 be found very inconvenient in the treatment of a case to insist 
 upon the adoption of one method to the exclusion of the 
 other. Xot uncommonly the operation may with advantage 
 be commenced by using the elevator as a simple lever, and 
 completed by using it for pushing the loosened tooth out of 
 its socket. 
 
 Whenever the elevator is employed, the forefinger of the 
 operator's hand should lie along the shaft, and the point of 
 the elevator should not reach more than three-quarters of an 
 inch beyond the top of the fore6nger. If any slip should 
 occur, the instrument is well under control, and those lacera- 
 tions of the gum, or even the cheeks and tongue, that happen 
 when this precaution is neglected are obviated. 
 
 It Is undesirable to use the elevator for the extraction of
 
 ON EXTRACTION OF THE EOOTS OF TEETH. 
 
 697 
 
 Fig. 256. 
 
 upper wisdom teeth whicli occupy their normal position, as 
 from the direction in which the force is applied the tuberosity 
 may readily be broken off. Teeth may often be advantageously 
 removed by combining the use of the elevator and the forceps, 
 using the first-named instrument for raising up and loosening 
 the fangs, and forceps to complete the extraction. 
 
 The roots of lower molars may often be removed by in- 
 serting the point of an elevator behind the posterior root and 
 prizing it up from its socket : the removal of the anterior root 
 will then be easy. 
 
 Elevators as generally sold by the instrument makers are 
 far too large and clumsy : the great size of the points renders 
 very great force necessary to make the instrument 
 enter the socket, and needless pain is inflicted 
 on the patient. 
 
 The spear-pointed elevator represented in the 
 accompanying figure is by far the most generally 
 useful form, and is quite large enough for any 
 purpose. Sometimes, however, owing to the in- 
 ability of the patient to open the mouth widely, 
 it may be difficult or impossible to reach a lower 
 wisdom tooth with a straight instrument. For 
 such cases a very useful form is sold, the blade of 
 which is shaped like a single jaw of a pair of thin 
 and sharp stump-forceps ; this blade is inclined 
 to the shaft at an angle somewhat greater than a 
 right angle, so that it can be applied without ne- 
 cessitating the mouth being very widely opened. 
 
 In treating of the extraction of teeth, it has 
 hitherto been assumed that the operator will 
 encounter no unusual obstacle, and the difficulties 
 which sometimes arise in the progress of the 
 operation have been reserved for separate consideration. 
 
 The practitioner, it is presumed, will be well acquainted 
 with the normal forms of each member of the dental series, 
 but the normal character of the crown does not necessitate a
 
 698 A SYSTEM OF DENTAL SURGERY. 
 
 similar condition of the root of a tooth, and the irregularity 
 is discovered only when the operation of extraction is at- 
 tempted. It is not unusual for the roots of the inferior 
 molars to be curved backwards, and now and then the curve 
 is produced into a positive hook (Fig. 257). 
 
 Fig. 257. (1) 
 
 Had the extraction of either the first or second molars 
 shown in the accompanjdng illustration been attempted, 
 either the ends of the roots would have been left in the jaw 
 or a large piece of the alveolus brought away with the tooth. 
 The former accident would probably have occurred ; the 
 tooth, to use a patient's words, would have been broken in 
 the jaw. 
 
 The question as to what shall be done with the roots of 
 such a tooth when broken in the jaw is at once raised. In 
 my own practice I invariably allow the extremity or even the 
 lower third to remain, unless it is clearly the subject of 
 disease. If it be loose, its removal is readily effected, and 
 should it have been connected with an alveolar abscess, its 
 
 (1) A lower jaw, the external portion of which has been removed, so as to 
 show the position of the roots of the molar teeth, which in this example are 
 curved backwards, with the points turned upwards.
 
 ON EXTRACTION OF THE ROOTS OF TEETH. 
 
 699 
 
 removal will not be attended with difficulty. The digging 
 out — if the expression be allowed — of the terminal third of a 
 sound and firmly-attached root is productive of great pain 
 and a considerable amount of injury to the alveolus ; but the 
 presence of the root, if undisturbed, is very rarely indeed fol- 
 lowed by any inconvenience. 
 
 In the example figured (Fig. 257), the roots of the teeth, 
 though curved, are comparatively small, and might probably 
 give way under a force which would not strike the operator 
 as being greater than that required to effect the dislocation 
 of firmly-implanted teeth. But it occasionally happens, from 
 some unseen cause, that a tooth for a time remains unmoved, 
 although a force more than sufficient to remove an ordinary 
 tooth has been employed. 
 
 It is when placed under this difficulty that the knowledge 
 and skill of the operator are put to the test. The roots of the 
 tooth may be curved, or they may be unusual in size or 
 number, and the tact to recognise the direction in which the 
 resistance lies, and the knowledge of the irregularities of form 
 to which the several roots of the teeth are liable, become 
 highly valuable. 
 
 In the following illustration three forms of irregularity arc 
 
 Pig. 258. (1) 
 
 shown ; the tooth with the convergent, and that with the four 
 
 (1) A and C show a first permanent molar of the lower jaw, with roots con- 
 vergent, and a corresponding tooth with four divergent roots. 
 
 B, a wisdom tooth, with the roots curved backwards, and thickened by 
 h3T)ertrophy of the cementum.
 
 700 A SYSTEM OF DENTAL SUEGEBY. 
 
 divergent roots, would be removed by force employed in the 
 usual direction. In the one case the operation would result 
 in the fracture of one or both roots, or the vrithdrawal of the 
 portion of the alveolus enclosed by their convergence ; in the 
 other, in the fracture of one or more roots, or perhaps in the 
 removal of a portion of the labial or lingual wall of the alve- 
 olus. But if a similar course were pursued with the wisdom 
 tooth, it would break off at the neck, or the tooth would 
 effectually resist the efforts of the operator. With the forceps, 
 it would be very difficult to extract such a tooth, but by 
 adopting the elevator, the tooth could be gradually prized out 
 of its socket without difficulty. 
 
 In operating upon teeth in the upper jaw, similar difificul- 
 . 2-9 m ties may arise. An unusual size of the one, or the 
 occurrence of several roots, even in a bicuspid 
 tooth, will sometimes embarrass the operator, by 
 raising a doubt as to whether the tooth will give 
 way under the force he is employing. Similar 
 difficulties, consequent upon similar causes, will 
 arise with respect to the molar teeth of the upper 
 jaw. The application of the usual force is not 
 attended with the usual result. 
 
 The remedy will consist in steadily increasing 
 
 the force and varying its direction, feeling our 
 
 way, as it were, until the tooth is separated from its socket. 
 
 The wisdom teeth of the upper jaw, thougli frequently the 
 
 subjects of irregularity, being implanted in comparatively 
 
 porous bone, very seldom resist the efforts of the oi)erator. 
 
 The irregularities of form to which the teeth are liable, 
 having been described in a preceding part of the volume, need 
 not be again particularised. 
 
 Owing to an unusual thickness and strength in the alveolus, 
 the removal of a tooth is sometimes attended with unusual 
 difficulty, and the operator is still further embarrassed when 
 the crown of the tooth so circumstanced is broken off on a 
 
 (1) Shows a first bicuspid of the upper jaw, with three distinct roots.
 
 ON EXTRACTION OF THE ROOTS OF TEETH. 701 
 
 level with the alveolar margin. Generally the stump-forceps 
 or the elevator may be made to enter the alveolus, but ex- 
 ceptional cases may arise. To meet these, Mr. Cattlin pro- 
 
 Fig. 260. 
 
 poses to cut away with a small trephine a portion of the outer 
 plate of the alveolus. The root when thus exposed is readily 
 dislodged by an elevator. 
 
 Mention has already been made of a case in which the 
 greater part of the floor of the antrum was torn away by a 
 blacksmith, in the endeavour to extract an upper molar, and 
 of another in which a large portion of the external alveolar 
 plate was broken off the lower jaw with a key instrument, the 
 fragment descending the neck in a series of sinuses, and finally 
 being removed below the clavicle. But even in the hands of 
 the most careful and skilled operators a variety of accidents 
 may occur. A molar tooth of which the fangs are divergent 
 can obviously only be extracted by the bending or the frac- 
 ture of some portion of the alveolar walls. 
 
 A limited fracture of the alveolus, or the bringing away of 
 a fragment of alveolar w^all with the tooth, is of very small 
 moment in a healthy subject, seeing that the alveolar border 
 has to be subsequently removed by absorption. In some in- 
 stances, however, the adhesion of the tooth to the bone is so 
 firm, that a large portion of that surrounding the fangs is 
 torn away. I lately saw the tuberosity of the upper maxilla 
 brought away in the extraction with forceps of the wisdom
 
 702 A SYSTEM OF DENTAL SUEGERT. 
 
 tooth ; on examining it afterwards, it was found that the 
 bone was so strongly adherent to the fangs, that it could only 
 be detached in small fragments : it was to this cause, and not 
 to the shape of the fangs, that this mishap was due. 
 
 Mr. Salter (^) records a case where, in the endeavour to ex- 
 tract an upper central incisor, the bone was fractured along a 
 line corresponding to that which separates the intermaxillary 
 from the maxillary bones in the palate, and along a horizontal 
 line at the base of the nose. There was a wound in the palate 
 from which there was some little hgemorrhage. Happily, 
 however, no untoward result followed; the fractmed bone 
 speedily united, and the tooth was cut off level with the 
 gum so as to enable the patient to wear an artificial sub- 
 stitute. 
 
 Mr. Salter also mentions an instance of the horizontal 
 ramus being entirely broken through by an operator of skill 
 and experience. 
 
 A patient lately under treatment at the Dental Hospital 
 presented a very extensive fracture of the alveolar portion of 
 the jaw ; he had apj)lied to a chemist to have the first lower 
 molar on the right side removed, in an unsuccessful attempt 
 to remove which tooth with forceps the fracture occurred. 
 The line of fracture had run forwards at a level corresponding 
 to the apices of the roots of the teeth, so that the portion of 
 bone containing the bicuspids, the canine, and the central 
 and lateral incisors was detached, and only held in position 
 by the soft parts. 
 
 A gutta-percha cap was adapted to the crowns of the teeth 
 all round the lower jaw, so as to keep the fractured bone in 
 its place, and every attention was paid to the thorough 
 cleansing of the wounds with injections of diluted Condy's 
 fluid (the fracture being — as is usual in fracture of the jaw — 
 compound in the mouth). Nevertheless, extensive necrosis 
 supervened, and abscesses formed beneath the jaw, so that 
 there seemed but little hope of saving the teeth. The patient 
 
 (1) " British Journal of Dental Science," vol. xiv., p. 160.
 
 ON EXTRACTION OP THE ROOTS OF TEETH. 703 
 
 was eventually lost sight of, and I do not know what was the 
 termination of the case. 
 
 But the most severe accident is recorded by Mr. Cattlin Q) 
 in the following words : " The gentleman who operated in 
 this case had the misfortune to break off the crown of the 
 tooth, and in endeavouring to extract the root with the 
 elevator, the instrument slipped and broke away the tuber- 
 osity of the maxilla, with a part of the floor of the antrum, 
 and a portion of the sphenoid bone. In the efforts which 
 were afterwards made to remove the fractured portion of the 
 bone with a pair of stump-forceps, tbe tooth and the hamular 
 process were also separated, and fibres of the external and 
 internal pterygoid muscles were torn away, and may be seen 
 in the specimen attached to the pterygoid plates. The 
 ultimate results of this accident were that the patient, after 
 suffering in health for some time, became perfectly deaf on 
 the injured side, and the movements of the jaw were per- 
 manently restricted. The inflammation had undoubtedly 
 extended into the eustachian tube, and had also involved the 
 ligaments and muscles attached to the inferior maxilla." 
 
 It has not been deemed necessary to enter specially upon 
 the extraction of temporary teeth, but a complication some- 
 times arises to which attention may with ad- 
 vantage be directed. It has happened on two 
 occasions which have come to my knowledge, 
 that in extracting a second temporary molar 
 of the lower jaw, the permanent successor has 
 come away, embraced by the roots of the tem- 
 porary tooth. In each instance the gum has 
 been inflamed as a result of disease set up in 
 the pulp of the temporary tooth, and it is 
 probable that the alveolar processes had in 
 each case also been greatly reduced, if not altogether re- 
 moved, by absorption. It is well to bear in mind that 
 such an untoward accident may happen when the gum and 
 
 (1) Transactions of the Odoutological Society, new series, vol. iii., p. 138.
 
 704 A SYSTEM OF DEXTAL SUKGERY. 
 
 alveolar periosteum have been for some time inflamed, but 
 I do not know that any precautionary measures can be 
 adopted. 
 
 Temporary teeth are, as is also noted by Mr, Salter (Joe. cit.\ 
 sometimes united to one another by fibrous tissue around 
 their necks, but the removal of more than one tooth in this 
 way is a matter of no practical moment, as it could only 
 occur where the roots were for the most part already 
 absorbed. 
 
 It often happens when the crown of a tooth has been long 
 lost, that the teeth on either side of it overhang the space, 
 and numerous instances have occurred of a sound tooth (most 
 generally a bicuspid) being unintentionally forced out of its 
 socket during the removal of the stump. "Where this seems 
 likely to happen, the finger or thumb should be firmly pressed 
 on the imperilled tooth, and the stump withdrawn from 
 whichever side affords the best prospect of avoiding the 
 other tooth. 
 
 The passage of a tooth-fang into the antrum, during an 
 attempt at its extraction, has already been noticed (see 
 Diseases of the Antrum) ; a precisely similar acJcident, where, 
 however, the tooth-fang escaped into an abscess-cavity in the 
 bone, instead of into the antrum, has been recorried by Mr. 
 Salter in the paper already several times alluded to. In the 
 event of either of these accidents happening, the root should 
 be sought for and removed, bearing in mind, however, that 
 if the opening be large, it is likely to gravitate towards the 
 opening of itself, so that its removal becomes eas}-. 
 
 Mr. Salter also gives examples of loss of sensation in the 
 regions supplied by the inferior maxillary nerve, consequent 
 on the bruising of this nerve in difiicult extractions of the 
 wisdom teeth. Ordinarily this numbness passes ofi" in a few 
 days, but in one of his cases noimal sensation has never been 
 quite restored to the lip and chin. 
 
 A remarkable case has been recorded by Tierlink, in which 
 dilatation of the pupil and imj^aired vision followed upon the
 
 ON EXTRACTION OF THE ROOTS OF TEETH. 705 
 
 extraction of a bicuspid tooth ; these symptoms disappeared 
 on extract of opium being placed in the vacated socket. A 
 very common sequela of tooth extraction is exfoliation of the 
 edges of the alveolar process ; this is always liable to happen 
 where there has been much suppuration preceding the ex- 
 traction of the tooth, and it is particularly liable to happen 
 where unusual force or protracted attempts have been made 
 use of to dislodge the tooth. Hence it is very common after 
 the removal of impacted wisdom teeth, and it can in no way 
 be attributed to want of skill on the part of the operator. 
 
 2 z
 
 ( 70G ) 
 
 ILEMOEEHAGE FOLLOWING EXTK ACTION. 
 
 H^MORUHA(iE FROM THE Alveoli. — Prolonged bleeding 
 from the gums has been alluded to in connection with diseases 
 of that portion of the dental system. It is hsemorrhage 
 occurring after the extraction of teeth which has yet to be 
 described. Ordinarily blood ceases to escape from the socket 
 within half an hour of the removal of the tooth ; but isolated 
 instances, in which the bleeding has ceased only with the life 
 of the patient, have been at long intervals recorded; and 
 cases in which the flow of blood has been checked with con- 
 siderable difficulty, and only after the patient has been greatly 
 reduced, though not common, are by no means rare. 
 
 Before proceeding further in the description, it may be 
 useful to inquire under what condition these untoward con- 
 sequences follow upon a very simple and, under ordinair* 
 circumstances, a very safe operation. 
 
 When from an insignificant wound the blood flows for a 
 longer time and in a larger stream than the nature of the 
 injury would lead the surgeon to expect, a state of system is 
 denoted which may be a permanent character peculiar to the 
 individual, or it may arise from a temporary condition of the 
 circulating fluids, or from the condition of the blood-vessels 
 themselves. The pathology of the hemorrhagic diathesis is, 
 however, for from being understood Q) ; want of coagulability 
 in the blood and want of contractility in the vessels being 
 almost all that we can predicate of it. There are those who 
 have at all times difficulty in arresting bleeding even from 
 
 (1) See Mr. F. Mason, in " Monthly R<-view of Dental Surgery," August, 1872.
 
 H^MOKKHAGE FOLLOWING EXTRACTION. 707 
 
 a slight wound, and in them prolonged ha?morrhage usually 
 follows the extraction of a tooth. A patient of my own 
 suffered considerable inconvenience from a very loose lower 
 bicuspid tooth, but dreaded its removal, in consequence of the 
 difficulty he suffered in controlling the haemorrhage which 
 had on previous occasions followed the extraction of teeth. 
 The loose bicuspid was, however, removed, and the blood 
 ceased to flow from the socket within half an hour. The 
 patient returned home, but before he had reached the end of 
 a short railway journey, bleeding from the socket had recom- 
 menced, and many hours elapsed before the haemorrhage was 
 perfectly arrested. The h£emorrhagic diathesis was in this 
 case fully pronounced, and was independent of the general 
 health. The condition of the vessels or of the blood must 
 have been different from that which usually exists in a per- 
 fectly healthy individual, but the difference was not sufficient 
 to interfere with the general health of the patient. 
 
 In some persons the disposition to profuse bleeding occurs 
 only at a comparatively advanced period of life ; the fault then 
 lies in the vessels themselves, the coats of which become 
 stiffened by the presence of a deposit within their substance, 
 and they consequently lose the power of contraction. In 
 other examples the ha^morrhagic tendency depends upon an 
 abnormal state of the blood — upon the presence of blood 
 disease, as certain maladies are called. 
 
 Sea scurvy and purpura afford the most striking examples 
 of such diseases, one peculiar feature of which is the loss of 
 coagulating power in the blood. 
 
 In a healthy subject the division of blood-vessels of mode- 
 rate size is followed by contraction of their divided ends, and 
 by the coagulation of the blood upon the surface of the wound. 
 By the concurrence of these changes, the escape of blood is 
 arrested. But when the vessels have lost the normal power 
 of contraction, or the blood its capability of coagulation, the 
 bleeding, even from the removal of a tooth, may seriously 
 endanger the life of the patient.
 
 708 A SYSTEM OF DENTAL SURGERY. 
 
 In patients of hsemjorrhagic diathesis, the extraction of 
 teeth, and, indeed, other operations which involve the injury 
 of soft parts, should be avoided, unless the circumstances of 
 the case render them absolutely necessary. But in the prac- 
 tice of dental surgery the existence of this state of system 
 sometimes is learnt only by the occurrence of prolonged 
 bleeding from the alveolus, or from the statement of the 
 patient after the tooth has been extracted. 
 
 Treatmerit. — In the cases of alveolar hsemorrhage which 
 have come under my own care, the bleeding has been speedily 
 arrested by matico. After clearing away the coagulated blood, 
 a leaf of that plant, previously softened wdth hot water and 
 rolled up, has been placed loosely within or fitted closely into 
 the socket. A few folds of lint laid upon the gum, and held 
 in position by closing the mouth, have been sufficient to retain 
 the matico in the alveolus until the bleeding entirely ceased. 
 On examinining the mouth on the following day, I have 
 often found the leaf held in the socket by the blood which 
 had coagulated about its surface and within its folds. 
 
 The degree of success attendant on the use of the matico 
 leaf will greatly depend on the care with which it is applied. 
 The leaf having been thoroughly softened, should be cut into 
 strips as wide as the vacant alveolus is deep ; they should be 
 rolled up into a form resembling that of a cigar, and of such 
 a size as to fit the alveolus. In rolling up the leaf the rough 
 side should be kept outw^ards. The rolls are taken up in 
 plugging- forceps, and passed firmly down to the bottom of 
 the alveolus, the somewhat pointed end being introduced first. 
 In the case of upper bicuspids, the operator should somewhat 
 flatten the roll of matico leaf, and before introducing it care- 
 fully ascertain whether the root is bifurcated ; should it be 
 so, two small rolls should be first passed up, one into each 
 opening. If the matico leaf be carefully applied, it acts as a 
 plug, as well as being an astringent ; and I have never known 
 it to fail in a single case where its application was satis- 
 factorily done. But, should it fail, a carefully constructed
 
 HAEMORRHAGE FOLLOWING EXTRACTION. 709 
 
 plug should be tried. The socket having been cleared of 
 blood, a little matico may be introduced, and then small 
 pieces of lint added and carefully packed one alter another, 
 so as to completely fill the alveolus. Upon the surface of 
 the gum, folds of lint should be placed in sufficient number 
 to allow the teeth of the opposite jaw, or the jaw itself in the 
 absence of teeth, on closing the mouth, to produce firm pres- 
 sure upon the surface of the bleeding socket. To keep up 
 the pressure, the volition of the patient should not be trusted. 
 It will be better to pass a bandage under the jaw and over 
 the head sufficiently tight to prevent the mouth from bein'j; 
 opened, 'i'he use of escharotics in the ti'eatment of haemor- 
 rhage is attended with this great disadvantage : the parts 
 with which they come in contact are destroyed, and as their 
 action cannot be limited to the interior of the bleeding 
 alveolus, the surface of the wound may become extended, 
 and should the caustic fail to produce the contemplated cfiect, 
 the difficulties of treatment are enhanced by the increased 
 size of the bleeding surface. 
 
 In the case of a child who suffered from haemorrhage after 
 the extraction of a temporary molar in the lower jaw, lunar 
 caustic, and afterwards spirits of turpentine, were applied 
 without success. At the time I saw the patient, blocd was 
 oozing both Irom the alveolus and the surrounding gum, the 
 surface of which had been made raw by the caustic. This 
 case yielded to the matico leaf carefully applied in the manner 
 already described. 
 
 If the use of some other hajmostatic is required, I should 
 give the preference to persulphate of iron, and at the same 
 time administer large doses of gallic acid with sulphuric 
 acid internally. Or jairgative doses of sulphate of soda may 
 be given, to be followed by large doses of T. ferri perchloridi ; 
 the pil. plumbi cum opio is likewise valuable in checking 
 htemorrhage. 
 
 In more obstinate cases it may be necessary to have 
 recourse to a mechanical apparatus for producing pressure.
 
 710 A SYSTEM OF DENTAL SURGERY. 
 
 Dr. Roberts and Dr. Reid of Edinburgli have each described in- 
 struments for effecting compression. The pressure is obtained 
 by a movable bar suitably bent, supported upon a frame 
 which is fixed to the lower jaw, or to the head, just as the 
 seat of haemorrhage may be, in the upper or lower jaw. By 
 these mechanical appliances the pressure may be graduated 
 and maintained without taxing the efforts of the patient. 
 
 In the absence of such an apparatus, a plate in metal might, 
 in the course of an hour or two, be struck to fit the surface 
 of the gum, or a piece of shellac moulded to the required 
 form. The plate should, of course, extend beyond the bleeding 
 surface, and fit closely to the mucous membrane, upon which 
 it must be firmly pressed by means of pledgets of lint retained 
 in position by pressure. 
 
 In one of the fatal cases recorded, it is noticed that the 
 oozing took place from the whole surface, but this may, pro- 
 bably, have resulted from the use of escharotics. In this case 
 the carotid was eventually tied, without success in arresting 
 the hemorrhage. 
 
 Whenever the patient has previously sufiered from exces- 
 sive haemorrhage, consequent on the extraction of a tooth, 
 until all bleeding have entirely ceased, the case should not 
 be lost sight of; and I often adopt the precaution of placing 
 matico plugs in the sockets without waiting for the necessity 
 to arise : giving the patient directions to have them removed 
 on the second day. I have not found this plan to sensibly 
 retard the healing of the gums.
 
 ( 71] ) 
 
 ANAESTHESIA. 
 
 The administration of ansestbetics does not fall within the 
 province of the dental surgeon as such, and hence is a subject 
 beyond the scope of the present volume. There are, never- 
 theless, some few points wnth which he is directly concerned, 
 such as the means of propping open the mouth, &c. 
 
 For operations under chloroform, the accompanying useful 
 form of speculum for opening the mouth when the lower jaw 
 is forcibly closed, may be brought before the attention of the 
 reader. It consists of two flattened blades, which close 
 together like a bird's bill, the lower passing into a concavity 
 within the upper blade. Upon the steel, which gives strength 
 to each blade, a covering of horn is riveted, and a small piece 
 of gutta-percha is let into the surface against which the teeth 
 are destined to rest. From the jaws or blades of the instru- 
 ment two steel rectangular stems are continued, the one 
 passing within the other and rendered movable, the one 
 within the other, by a rack and pinion motion. The sepa- 
 mtion of the blades is effected by a removable handle, and 
 they are allowed to again approach each other by releasing 
 the spring catch. The construction of the instrument will 
 be readily seen on referring to the figure (Fig. 262). 
 
 The advantages attendant upon the use of nitrous oxide 
 are, however, so great, that the use of chloroform for any but 
 the most severe and protracted cases has been all but aban- 
 doned. As the duration of the ana3sthesia is so short, it is 
 necessary to prop the mouth widely open before commencing 
 the inhalation.
 
 712 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 For ordinary cases the spring gags, manufactured in vul- 
 canite, answer the purpose admirably, but sometimes it is 
 
 Fig. 262. (') 
 
 difficult or imix)ssibie to find a place in the mouth in which 
 they will rest securely, and yet be out of the operator's 
 way. 
 
 The very valuable gag designed by Mr. Hutchinson presents 
 the additional advantage of holding the tongue down ; but 
 unless the front teeth are firm, there is a chance of their 
 being forced out by spasmodic closure of the jaws. Indeed, 
 this accident once happened in my own hands, though, for- 
 
 (>) An instrument devised by Mr. Cattlin for opening the moulb, wben 
 from any cause the jaws become rigidly closed. It consists of two sliding 
 bars, or stems, moved by a rack and pinion, and held in position by a spring 
 catch shown at *. The blades, or jaws, are continued In steel from the two 
 portions of the stem, and are covered with horn. The handle, or pinion, is 
 shown detached from the body of the instrument.
 
 ANAESTHESIA. . 713 
 
 tunately, I had intended to remove these teeth at a future 
 administration of the gas, so that the patient was quite 
 unaware that their removal had not been intentional. 
 
 Some difficulty may be experienced in arranging the gag 
 in mouths which are nearly edentulous ; in this event large 
 fine-textured corks, in each of which a groove has been filed, 
 will often prove serviceable. 
 
 To these matters, however, the administrator of the 
 anaesthetic will ordinarily attend ; the one point, on which 
 the operator cannot be too careful, is to withdraw every 
 stump or detached piece of tooth from the mouth. With the 
 forceps this is easy, and the operator must never loose his 
 hold of a stump or tooth until it is safely outside the mouth ; 
 but with the elevator there is an additional risk of the frag- 
 ments falling back into the larynx ; and it must not be 
 forgotten that fatal results have, in several cases, ensued 
 from the passage of foreign bodies into the larynx or trachea, 
 during the administration of nitrous oxide. A tooth stump 
 may pass through the larynx into the trachea, and even 
 down into the bronchi, and be afterwards coughed up with- 
 out any ill result ensuing; but this is an exceptionally 
 fortunate accident, and fatal mischief may be set up by this 
 same cause. Death has also occurred from the gag, or por- 
 tions of it, finding their way into the larynx. And such an 
 accident is the more likely to escape notice at the moment, 
 on account of the lividity and asphyxiated aspect so often 
 presented by patients under the influence of the gas. 
 
 As the great danger is the passage backwards of foreign 
 bodies, the operator must be careful not to lose sight for a 
 moment of the tooth which he is extracting ; and should he 
 be using the elevator,'^the stump should be seized by the left 
 hand the instant it is lifted out of its socket. 
 
 The subject of general anaesthesia, as induced by the inha- 
 lation of the vapour of chloroform, or of ether, or of nitrous 
 oxide gas, does not call for lengthy discussion in these pages, 
 inasmuch as, since a patient under the influence of any anass-
 
 714 A SYSTEM OF DENTAL SUBGEEY. 
 
 thetic agent demands the undivided care and imdistracted 
 attention of the administrator, the operator should never 
 administer such agent single-handed ; so that the exhibition 
 of anaesthetics forms no part of the duties of the practitioner 
 in his capacity of dental surgeun. The agents capable of pro- 
 ducing anesthetic effects have taken their place among the 
 many substances used by the surgeon ; and in the "works 
 devoted to materia medica and therapeutics their respective 
 merits are fully discussed. Nevertheless, it may not be out 
 of place to say a few words with reference to the last-men- 
 tioned aucTsthetic, nitrous oxide, which, on account of its great 
 safety, has, in dental operations, almost entirely superseded 
 chloroform. 
 
 In order to secure the best results, the patient must be in- 
 structed to breathe deeply and regularly, and especially to 
 breathe out thoroughly ; and the most absolute quiet must 
 be maintained both during the inhalation and during the 
 period of recovery. 
 
 Both operator and administrator should keep out of sight, 
 so as to avoid any disturbance of the patient's mind 
 during the period of semi-consciousness. The gas may be 
 most conveniently administered from the wrought-iron bottles 
 into which it has been compressed, a Cattlin's bag intervening 
 between the gas-bottle and the face-piece. The modification 
 of the face-piece of Mr. Clover's chloroform apparatus, which 
 is in general use for the administration of nitrous oxide, is, 
 upon the whole, the most generally available form which has 
 been introduced. 
 
 A liberal supply of gas should be kept up, and it is advan- 
 tageous to have the pressure in the bag always considerably 
 in excess of the atmospheric pressure, as this will diminish 
 the risk of the admission of air in consequence of the face- 
 piece not being everywhere perfectly adapted to the skin. 
 
 The spring gags, at one time so much in vogue, are exceed- 
 ingly convenient ; but, since an accident has happened from 
 the fracture of one, it is, I think, preferable to use gags made
 
 ANESTHESIA. 715 
 
 in one piece, which are far less likely to break ; if they are 
 carefully adjusted, there is very little chance of their slipping 
 out of place and allowing the mouth to close. 
 
 When several teeth are to be removed at a single inhala- 
 tion, the operator should commence with those farthest back 
 in the mouth, and with lower before upper teeth, as by so 
 doing the view of the teeth to be removed is less obstructed 
 by the bleeding from the socket of those already extracted. 
 
 The passage of an electric current through a tooth about 
 to be extracted, has been proposed as a means of pro- 
 ducing local anesthesia. Many practitioners engaged in 
 experiments with the view of determining the value of the 
 agent, but the results hitherto recorded have not been suffi- 
 ciently uniform to warrant the conclusion that the electric 
 current has been found generally available for producing local 
 anaesthesia in dental operations. The electric current may, 
 like the process of congelation, prove serviceable in excep- 
 tional cases only ; and as it has been found that the advan- 
 tages which may result from the use of the one or the other 
 must, in each instance, be determined by experiment, the 
 great inconvenience attending the application of a cold suffi- 
 ciently intense to produce congelation, and the increased pain 
 which is frequently produced by the electric current, have, 
 after the novelty of the methods had passed away, induced 
 the dental surgeon to abandon their use.
 
 ( 716 ) 
 
 APPENDIX. 
 
 THE PATHOLOGY AND ETIOLOGY OF DENTAL CARIES. 
 
 The literature of this subject is now so profuse, and the opinions 
 advocated are so diverse, that it has seemed inadvisable to burden 
 the text with a summary of them ; whilst, at the same time, so much 
 of the dental surgeon's time is occupied in combating caries and its 
 effects, that a manual of dental surgery which passed over this 
 branch of the subject in silence would be manifestly incomplete. 
 
 The actual appearances observed have been already described 
 (p. 294, et seq.), and it will suffice to allude to certain additional 
 characters in connection with the theories which they influence. 
 The views held as to the nature of dental caries may be, for the 
 sake of convenience, grouped under the three following heads : — 
 
 Those which regard it as a real " disease," a vital phenomenon, 
 strictly comparable to morbid conditions of other more highly 
 organised parts of the body. 
 
 Those which regard it, in the main, as the effect of mere chemical 
 action, but also consider that some very constant appearances are 
 only explicable on the hypothesis of vital action. 
 
 Those which regard it as wholly and entirely the effect of 
 chemical action, in no degree modified by the connection of the 
 tooth with a living organism. 
 
 It was at one time very generally supposed that dental caries 
 was an inflammatory aftection, a true " disease " of the dentine, and 
 the name " Odontitis " was given to this supposed disease : amongst 
 the older writers. Hunter, Cuvier, Fox, T. Bell, and others held this 
 opinion, and it has of late years been revived by Neumann and 
 Hertz. 
 
 In support of this idea, the occurrence of so-called caries interna
 
 APPENDIX. 717 
 
 was adduced ; but if there be any one thing certain about caries, it 
 is that it always starts from the surface, and cannot occur at any 
 spot devoid of communication with the exterior. 
 
 Neumann believes that in the varicose swellings of the dentinal 
 tubes (see page 298) evidences of cell proliferation may be seen, and 
 he hence draws comparisons with inflammatory and ulcerative 
 affections of soft parts. Wedl (" Pathologie der Ziihne," p. 333) 
 strongly dissents from this view, and thinks that the appearances 
 may be easily otherwise explained. 
 
 And, even putting aside the apparent impossibility of these 
 changes going on in such a tissue as dentine, this theory has so 
 much evidence against it, and so little in its favour, that it need 
 not detain us longer. 
 
 Hertz (" Virchow's Archiv.," Bd. xli.), however, on comparing sec- 
 tions of carious teeth with those from teeth softened by acid fluids, 
 came to the conclusion that there were real differences, mainly con- 
 sisting in swelling and fatty degeneration of the dentinal fibres, 
 which pointed to the existence of some vital action. 
 
 In support of the theory that most, if not all, the phenomena of 
 caries may be produced by chemical action, without the interven- 
 tion of vital forces, a great and conclusive body of evidence has 
 been brought together. In the first place, it always starts from 
 the surface ; it may be in a fissure, or at some point where the 
 tissues are defective, but it never occurs at any place which is not 
 exposed to external influences. 
 
 Again, the use of litmus paper proves that in many places in the 
 mouth an acid reaction exists ; and experiments performed out of 
 the mouth have conclusively shown that most dilute acids, vege- 
 table as well as mineral, have the power of speedily decalcifying 
 dentine and enamel. 
 
 The question for solution is, are there any appearances which 
 cannot be explained without the intervention of vital forces ? And 
 perhaps, befoi-e proceeding to the discussion of this matter, it will 
 be well to define what is, and what is not, meant by " vital " force. 
 
 There is not the smallest reason for supposing that the ordinary 
 laws of chemical and physical action are suspended in the body ; on 
 the contrary, the advance of science brings every day fresh evidence 
 that the phenomena of development and nutrition are in strict ac- 
 cordance with these laws. But we are no nearer to the knowledge 
 of the mystery of life ; we have no cognizance of such a thing as
 
 718 A SYSTEM OF DENTAL SURGERY. 
 
 '• vital " force ; all that we do know is, that the various chemical 
 and physical actions are set going and co-ordinated in a living body 
 by an impulse of the nature of which we know nothing. If we say 
 that it is by the action of the nervous system, we only remove the 
 difficulty a very little farther, for we know nothing accurately 
 about nerve force. 
 
 " Vital action " is, then, in the following pages to be understood 
 simplv as meaning something which, for its occurrence in that par- 
 ticular place, is dependent upon the tooth forming a part of a living 
 organism. 
 
 In some mouths the hippopotamus ivory formerly used for arti- 
 ficial teeth was very rapidly attacked : thus Dr. Magitot (" Traite 
 de la Carie Dentaire," 1867, p. 102) mentions the case of a lady in 
 whom these plates could only be worn for six or eight months : at 
 the end of that time they were translucent and amber-like in 
 appearance, flexible and spongy to the touch, and very offensive ; in 
 places actual dark-walled cavities were formed. The gums were 
 tumid and spongy, and a considerable number of softened stumps 
 remained in the mouth. When the crowns of human teeth are in- 
 serted into the mouth, either upon a plate, or pivoted on old stumps, 
 they often become carious ; such teeth are especially prone to be 
 attacked on the surface which is in contact with the gum, though 
 it is not unusual for interstitial cavities to be formed in them. 
 Nevertheless, some writers have denied the identity of the destruc- 
 tive process in these artificial substitutes with that which occurs in 
 living teeth ; and others, whilst admitting their substantial simi- 
 laritv, believe that differences may be found. 
 
 The appearances which have been supposed to indicate vital action 
 in caries are mainly two : the " tobacco-pipe " structure apparent 
 on transverse sections (see p. 296), which seems to be due to great 
 thickening of the walls of the canals, and the obliteration of the 
 canals between the caries and the pulp-cavity, which gives rise to 
 the appearance of a clear translucent zone. 
 
 Neumann (" Archiv. fiir klin. Chirurg.," Bd. vi.) believes that the 
 apparent thickening of the walls of the tubes is a real thickening of 
 the dentinal sheaths at the expense of the matrix, and that the 
 fibres participate in the process, the canal ultimately becoming 
 obliterated ; he believes that in a single instance he saw calcification 
 of the fibrils. 
 
 In the first edition of this book, the opinion that the thickened
 
 APPENDIX. 719 
 
 sheaths were to be regarded as the restored outlines of formative 
 cells was expi*essed, and it was said that there was a difficulty in 
 explaining the appearance on the supposition that a solvent fluid 
 had gained access through the canals, and penetrated to a varying 
 depth around them (p. 297). But now that the resistant nature of 
 Neumann's dentinal sheaths is known, this difficulty — which lay in 
 the fact that the immediate surroundings of the tubes were the last 
 to disappear as caries progressed to the disintegration of the tissue 
 — no longer exists. Some such explanation as the following may very 
 possibly be the true one : a solvent fluid, gaining access to the tubes, 
 effects the decalcification, complete or partial, of the matrix imme- 
 diately round the tube ; as the refractive index of the dentinal 
 sheaths differs little, if at all, from that of the surrounding decalci- 
 fied matrix, they are not visible on transverse section ; but, on 
 account of the great power of resistance, they ultimately become 
 isolated by the wasting away of the matrix around them. And, 
 although, so far as I am aware, no one has been successful in pre- 
 cisely imitating the microscopic characters of dental caries by the 
 action of dilute acids out of the mouth, this is hardly to be won- 
 dered at when we recollect the complexity of the conditions to which 
 a tooth is exposed in the mouth. 
 
 But Leber and Rottenstein (" Recherches sur la Carie Dentaire, ' 
 Paris, 1868) have given figures, drawn from a human tooth 
 which had become carious whilst worn as an artificial tooth, in 
 which the dilatation of the canals and the thickening of their 
 apparent walls are exceedingly well seen ; so that these two charac- 
 ters, at all events, are produced purely by causes external to the 
 tooth, and have nothing whatever to do with its vitality. 
 
 Wedl also (" Pathologic der Zahne," p. 326) gives a description, 
 illustrated by figures, of the microscopic appearances met with in 
 caries thus occurring in artificial teeth, which put it beyond all 
 doubt that the process is identical with that which occurs in a tooth 
 connected with living parts. The tubes are beaded, and have pearl- 
 like rows of globules in them, and when isolated by decalcification 
 and boiling, are seen to have the varicose swellings so characteristic 
 of caries. 
 
 Seeing that the character of caries, in its destructive processes, at 
 least, have been repeatedly met with in human teeth worn as arti- 
 ficial substitutes, and also in hippopotamus ivory placed under 
 similar circumstances, it must be admitted that there is an over-
 
 720 
 
 A SYSTEM OF DENTAL SURGERY. 
 
 whelming body of evidence to show that caries — in so far as it is 
 a process of disintegration — has no relation whatever to the connec- 
 tion of the tooth with the living body. It is, however, equally a 
 fact of every-day observation that the pulp is, so to speak, sensible 
 of the approach of caries towards it, and that secondary dentine is 
 in consequence deposited on that wall of the pulp-cavity which is 
 threatened by the advance of the disease. So far, then, there is an 
 attempt to bar the progress of the disease ; or, to speak more accu- 
 rately, the stimulus or irritation transmitted to the pulp starts 
 afresh the process of calcification in that organ. 
 
 As the irritation set up by caries is thus capable of inducing cal- 
 cification in the pulp, it was not unnatural to suppose that it might 
 have a similar effect on the contents of the dentinal tubes; and this, 
 it was thought, was to be seen in the translucent zone of the sur- 
 rounding caries. 
 
 Zone of Transparency. — It has been mentioned in the body of this 
 work that a halo-like zone of translucent dentine is very generally 
 seen surrounding commencing cai-ies, as is shown in the accom- 
 panying figure. 
 
 Fig. 263. (l) 
 
 (1) Shows a transparent zone of d'^ntine,, removed a short distance from 
 and surrounding that which is undergoing decomposition consequent upon 
 caries.
 
 APPENDIX. 721 
 
 This region of increased transparency, almost always to be found 
 between the advancing caries and the pulp-cavity, does not inva- 
 riably present the regular form above depicted : it may form a cone, 
 the apex of which is directed towards the pulp, and the base towards 
 the caries, or it may be present as hyaline stripes and spots having 
 no very determined form. It corresponds in naked-eye and micro- 
 scopic appearances to the dentine of the roots of the teeth of old 
 persons, or of healthy stumps which have remained long in the 
 mouth, which acquire this peculiar horny, translucent appearance. 
 The comparative opacity of healthy dried dentine is simply due to 
 the difference between the refractive index of the air contained in 
 the tubes and that of the matrix, and any cause which tends to 
 bring these more near to one another will increase the transparency 
 of the tissue. 
 
 Thus the tissue might be rendered more transparent either by the 
 obliteration of the canals by calcification of their contents, or by the 
 decalcification of the matrix, which, by lowering its refractive index, 
 would bring it more nearly into accord with that of the air in the 
 tubes. 
 
 The true nature of this transparent zone acquires additional in- 
 terest from the fact that it is the last remaining evidence of sup- 
 posed vital action ; the other appearances have all been shown to 
 be due to purely external causes, so that this alone remains to be 
 discussed. 
 
 In the first edition of this work it was stated that the translu- 
 cency was due to the exclusion of air from the tubes by the calcifi- 
 cation of the fibrils ; and inasmuch as the matter is still one of un- 
 certainty, those passages have been allowed to remain in the text 
 with but slight modification, although a good deal may be said on 
 the other side of the question. 
 
 In favour of the view that the dentinal fibrils become calcified, 
 several arguments may be adduced ; one is its prima facie probabi- 
 lity — we know (c/. p. 273) that slow progressive calcification does 
 go on in the tubes long after the apparent completion of the dentine, 
 and seeing that the irritation of caries does unquestionably cause 
 calcification to start afi-esh in the pulp, it seems very natural to 
 suppose that it would have the same effect in the dentinal 
 tubes. 
 
 Again, there is the resemblance in the appearance ot the trans- 
 lucent zone to that of the fangs of old teeth, which are shown by 
 
 3 A
 
 722 A SYSTEM OF DENTAL SURGERY. 
 
 actual chemical analysis to be far more rich in lime salts than 
 ordinary healthy dentine. 
 
 Dr. Magitot (" Rechevches sur la Carie des Dents," Paris, 1871, 
 p. 511) believes that the dentinal fibrils do become obliterated by 
 calcification, and regards it as an indication of resistance to the 
 progress of the disease. 
 
 Profeosor W-edl, however, although he attributes the increased 
 transparency to the absolute exclusion of air from the tubes, speaks 
 of the calcification of the fibrils as " noch problematische " (" Pa- 
 thologic der Zahne," p. 334) ; and by treating dried sections from 
 the horny-looking fangs of the teeth of old persons with carmine, he 
 found that they retained the power of imbibition, the colouring 
 matter thoroughly permeating the tubes, though they appeared to 
 be impervious to air. MM. Leber and Rottenstein also deny the 
 existence of calcification in the fibrils, attributing the transparency 
 to the disappearance of calcareous salts, and stating that the trans- 
 lucent tissue is distinctly less hard than the surrounding dentine 
 (op. cit., p. 39). 
 
 But the fact which tells most strongly against the supposition 
 that the zone of transparency is due to the obliteration of the canal* 
 bv calcification has yet to be mentioned ; it is, that when caries 
 attacks human teeth which have been inserted on pivots or on plates, 
 all the appearances of ordinary caries may be traced ; namely, the 
 dark pigmented zones, the thickening and varicose swelling of the 
 dentinal tubes, the gi-anular condition of the fibrils, and also the 
 clear, translucent zone (Wedl, op. cit., pp. 320 and 334). 
 
 Owing to the almost entire abandonment of the use of human 
 teeth as artificial substitutes, I have not been able to get a sufficient 
 number of examples of caries occurring in them to enable me to speak 
 very certainly on this point ; but, judging from those which I have 
 seen, I am inclined to think that the transparent zone is as constant 
 in them as in living teeth ; though Dr. Magitot (op. cit., p. 511) is 
 of the contrary opinion, and considers that this clear zone constitutes 
 the only difference between caries as occurring to living teeth and 
 others. 
 
 Globular masses of calcareous salts may sometimes be found in 
 the dentinal tubes near to a carious cavity, but inasmuch as they are 
 met with in dead teeth as well as in living ones, they are probably 
 to be explained as depositions from solutions of salts, and not as 
 evidences of vital action. Indeed, even if it were conclusively
 
 APPENDIX. 723 
 
 shown that the dentinal fibrils became obliterated by calcification, 
 this would not be absolute proof of vital action ; for, as has already- 
 been mentioned (p. 281), albumen out of the body is able to form 
 combinations with calcareous salts which have a definite structure. 
 From the preceding observations it will appear that, inasmuch as no 
 characteristic appearances can be found to distinguish caries, as 
 occurring in living, from that attacking dead teeth, it seems that 
 the hypothesis of vital action in any way modifying the disease must 
 be abandoned in toto, and dental caries cannot, strictly speaking, be 
 said to have any " pathology ;" so that we may at once pass to the 
 consideration of its etiology. 
 
 The results of the experiments of Westcott, Allport, Mantegazza, 
 Magitot, and Leber and Rottenstein agree in showing that not only 
 the mineral acids, but also the vegetable acids, even in weak sohi- 
 tions, have the power of dissolving out the lime salts from a tooth. 
 The various acids, however, act differently on the teeth ; thus some 
 attack the enamel almost exclusively, whilst others effect the de- 
 struction of the dentine and the cement, leaving the enamel intact. 
 In the experiments of Dr. Magitot ("Traite'de la Carie Dentaire," 
 1867, p. 108) some most instructive results were arrived at. The 
 teeth were submitted to the action of the various reagents for very 
 long periods, in some instances amounting to ten years ; and in certain 
 cases the tooth was protected by a layer of wax, save at one point, 
 so that definite cavities were produced. 
 
 With solutionsof sugar the naked-eye appearances of dental caries 
 were exactly imitated ; the destruction was far greater in a solution 
 to which a fragment of animal matter had been added than in the 
 pure sugar solution ; whilst in a third experiment, in which some 
 drops of creosote had been added with the view of retarding fermen- 
 tation, the enamel alone had been destroyed where exposed, and the 
 dentine only very superficially softened. In these experiments the 
 solution acquired a distinctly acid reaction. When a greater quan- 
 tity of creosote was added, no effect whatever was produced on the 
 teeth, and the solution remained neutral ; the same negative result 
 followed when the solution was boiled and hermetically sealed whilst 
 still boiling. From these and the numerous similar experiments of 
 other observers, we may fairly come to the conclusion that sugar 
 itself has no power of acting upon the teeth, but that the various 
 fermentation-products which are derived from it are exceedinglv 
 potent for evil. M. Mantegazza arrived at confirmatorv results in
 
 724 A SYSTEM OF DENTAL SURGERY. 
 
 a different manner ; the teeth were dried and weighed before and 
 after the experiment, and in this way the actual loss of salts was 
 determined. Under the influence of albuminous ferments, the chief 
 products of the fermentation of sugar will be lactic and butyric 
 acids, together with other derivatives, such as propionic and valeric 
 acids. 
 
 As a confirmation of these conclusions, teeth were submitted to 
 the action of lactic acid ; in a very weak solution (one part in one 
 thousand) the teeth had undergone no alteration at the end of two 
 years, but in a stronger solution (one per cent.) they were dis- 
 coloured and soft, and the enamel very friable at the exposed points. 
 As lactic acid is very constantly present in the mouth, either as a 
 fermentation-product formed on the spot, or regurgitated from the 
 stomach in pyrosis or vomiting, it is probable that it is an active 
 agent in dental caries. 
 
 It will perhaps be hardly worth while to recount in detail in this 
 place the effects of all the different acids employed in experiments ; 
 it may, however, be noted that with butyric acid great discolora- 
 tion of the softened part was obtained, and that citric and malic 
 acids, both so frequently present in fruit, were found to act very 
 powerfully as decalcifying agents. With respect to the latter, it is 
 generally abundantly present in cider, and some teeth placed in a 
 cider cask disappeared entirely. 
 
 Carbonic acid, when present in large quantities (^i.e., under pres- 
 sure) acts as a feeble solvent, but atmospheric pressure does not 
 act at all. Albumen and other albuminous substances effect the 
 destruction of teeth by giving rise to fermentation-products such 
 as valeric and butyric acids. 
 
 The fermentation-products derived from sugar and from albumen, 
 and citric, malic, and carbonic acids, were found to act on the 
 tooth-tissues alike ; whereas alum, oxalic acid, and acid oxalates dis- 
 solved the enamel only, acetic and tartaric acids, and acid tartrate, 
 the dentine and cement only. It has also been found that the chlo- 
 ride and perchloride of iron, as also the sulphate, have a solvent 
 action on the teeth. 
 
 Mr. Coleman (" Transactions of Odontological Society," 1862) 
 found that the fluid resulting from the addition of fragments of 
 bread and a small quantity of saliva to the water in which the teeth 
 were placed acted very energetically, so that after twenty days 
 flakes of softened dentine could be removed from the surface. 

 
 APPENDIX. t '^O 
 
 Without further pursuing this part of the subject, it may be fairly 
 concluded that agents fully capable of etFecting the decalcification 
 and softening of the dental tissues exist in the mouth ; but there is 
 one character of dental caries which is difficult of explanation, 
 namely, the dark discoloration. It has been usual to attribute this 
 to some change in the organic constituents of the tooth, but this 
 can hardly be the case, seeing that the enamel, which is so exceed- 
 ingly poor in organic mattei-, is oftentimes quite as deeply pigmented 
 as the dentine. 
 
 In order to account for the phenomena of dental caries other 
 agencies besides mere chemical solution have been suggested. 
 
 It was first pointed out, T believe, by Ficinus, that a cryptogam 
 to which the name of leptothrix is given, was very constantly pre- 
 sent in carious dentine. It is found not only upon the surface, but 
 in the dentinal canals, and probably has a considerable share in the 
 production of the beaded appearance before alluded to ; it also in- 
 trudes itself into clefts and fissures in the carious dentine, and 
 sometimes finds its way into the interglobular spaces. 
 
 Other cryptogamous growths may be detected ; thus the mycelium 
 of Oidium albicans is often seen ; and another form, to which the 
 name of Protococcus dentalis has been given, has been described by 
 Schrott as an agent in the production of caries. 
 
 Leber and Rottenstein ("Recherches surlaCarie Dentaire," 1868) 
 suppose that this cryptogamous growth — the leptothrix — is an active 
 agent in caries, and they say that its presence may be detected in 
 the dentinal canals some distance beyond the zone of softened den- 
 tine. They do not altogether reject the agency of acids, but they 
 consider that when once a surface of enamel or dentine has been 
 softened by acids the fungoid growth thrives upon it, and effects its 
 destruction far more rapidly than the mere solvent action of the 
 acid could alone have done. 
 
 They conclude that there are two principal agencies at work in 
 <iental caries : the one the action of acids, the other the rapid dere- 
 lopment of a parasitic plant. Before actual loss of substance has 
 occurred, in the stage which they speak of as " la carie seche 
 proprement dite," they have never discovered the leptothrix, and 
 they attribute the whole mischief, up to this point, to the solvent 
 action of acids. But so soon as thei-e is a loss of substance, leptothrix 
 may constantly be found ; and to its influence in efl'ecting a more 
 rapid disintegration of the tissues than acids alone could accora-
 
 726 A SYSTEM OF DENTAL SURGERY. 
 
 plish they attribute the difference observed between the progress of 
 caries in enamel, where the fungus does not grow, and in dentine, 
 where it does. 
 
 When caries has run on to softening, the canals are, as has been 
 already mentioned, irregularly dilated ; and they are found to be 
 occupied by a molecular mass, which is identified with leptothrix by 
 its coloration with iodine and acid. This obsei-vation, first recorded 
 by MM. Leber and Rottenstein, has received full confirmation at the 
 hands of Professor Wedl, who, however, believes that its growth is 
 subsequent to the complete decalcification of the tissue, so that it 
 does not play an active part in the destruction. 
 
 It is rather difficult to form a just opinion of the share taken by 
 the fungoid growth ; its presence is very constant, and it is found 
 to insinuate itself along the tubes, and into fissures, so as to pene- 
 trate to a considerable depth ; but it is almost impossible to decide 
 whether it has any power of boring out cavities for itself, or whether 
 it simply occupies the vacant spaces which have been formed by 
 other agencies. And as the leptothrix is to be found abundantly in 
 all parts of the mouth, its constant presence in such a favourable 
 site as is afforded by a carious tooth may be readily accounted for 
 without attributing to it any share in causing the disease. 
 
 By Mr. Bridgman (" Transact. Odontol. Soc," vol. iii.) all the 
 phenomena of dental caries are attributed to electro-voltaic action, 
 though upon grounds which are far too indefinite to amount to any- 
 thing like logical proof. Although to fully discuss the siibject 
 would involve a somewhat elaborate disquisition on physical laws, 
 which would be much out of place in these pages, still some few 
 points in the argument may be noticed, the more so as this theory 
 has to a great extent escaped criticism. 
 
 At the very outset it appears to involve a slight misconception 
 of the intimate relation existing between the physical forces ; that 
 is to say, it is hardly in accordance with the most recent views, 
 which regard electrical phenomena, chemical action, heat, and even 
 motion, as only ditlerent manifestations of " force," and as mutually 
 convertible. Now, this theory of caries proceeds thi-oughout upon 
 the assumption that electric disturbance is always present, and that 
 it is, so to speak, a cause and not an effect. It is perfectly true 
 that electric disturbance is convertible into chemical action, but it 
 is equally true that chemical action is convertible into electrical 
 disturbance ; so that they are mutually capable of standing in the
 
 APPENDIX. 
 
 727 
 
 relation of cause and effect to one another. But the presence of 
 chemical action by no means enables us to say that it was set up by 
 electric disturbance : it is rather to be regarded as one manifestation 
 of a force which, if it had not been expended in chemical change, 
 might have been apparent in the form of electricity, or of heat. 
 But if we wei'e to accept Mr. Bridgman's theory we must regard 
 electricity as the ruling agency, if not the prime mover, in every 
 act of development, nuti'ition, or growth in the animal and 
 vegetable kingdom, and must exalt it to a position of undue ascen- 
 dancy over the other physical forces. 
 
 To pass to the application of Mr. Bridgman's theory, we come 
 first to the assumption that the cutis and the blood-vessels are 
 electro-negative, whilst the epithelium, or epidermis, is electro- 
 positive, and the two are compared to electrodes (op. cit., p. 380). No 
 ground whatever is given for this belief, save the fact that litmus 
 paper sometimes shows an acid reaction on the epidermis (from the 
 sweat ?), and the comparison to electrodes falls to the ground ; for 
 electrodes cannot exist save as a part of a voltaic circle through 
 which a current is circulating : a condition of things which has 
 no parallel in the relations existing between the cutis and the 
 epidermis. 
 
 The next step in the argument is that, inasmuch as dentine 
 replaces epithelium in the case of the tooth-papilla, its electrical 
 relations will be similar (p. 383). This appears to involve the 
 assumption that parts which are homologically similar will remain 
 so in point of function, whereas comparative anatomy furnishes us 
 with countless examples to disprove this. And even setting aside 
 this objection, the dentine does not, either functionally or homo- 
 logically, replace the epithelium ; it essentially belongs to the cutis, 
 and it is to the enamel, and not to the dentine, that Mr. Bridgman's 
 argument, if valid, would apply. 
 
 It would be impossible to go seriatim through the arguments 
 brought forward in the paper quoted, but it may suffice to say that, 
 supposing Mr. Bridgman's theory to be correct, in so far that a 
 condition of electric polarity exists in the teeth, and that this is 
 capable of producing caries, it is difficult to see how a tooth should 
 ever escape ; it would, in fact, contain in itself an arrangement neces- 
 sitating its own destruction. And, it may be added, that experi- 
 mental researches on the electrical conditions of other parts of the 
 body have brought out such unforeseen results, that any attempt.
 
 728 A SYSTEM OF DENTAL SURGERY. 
 
 with our present knowledge, to predict or determine on merely 
 theoretical grounds the electric conditions of any part of the body, 
 must, of necessity, prove futile. 
 
 Enough has, perhaps, been said to show that we must seek for the 
 agencies which cause dental caries among the chemical transforma- 
 tions which go on in the mouth. The decomposition of food has 
 been proved to furnish acids perfectly capable of decalcifying enamel 
 and dentine, and the buccal mucus not rarely has an acid reaction. 
 
 Professor Wedl thinks that the influence of the viscid buccal 
 mucus has been underrated ; and it was mentioned in the former 
 edition of this book that where there are many carious teeth, 
 the gums are usually swollen, vascular, and coated with thick, 
 stringy, tenacious mucus. 
 
 And, it may be added, that wherever mucus, &c., is readily and 
 speedily removed by the tongue, or other agency, caries is very 
 rare. 
 
 It seems also that a decomposed pulp may give origin to acids 
 capable of softening the dentine ; thus MM. Leber and Rottenstein 
 (op. cit., p. 11) mention a case in which three incisors became 
 deeply discoloured without any breach of surface ; this condition 
 had supervened after a blow. On drilling into the teeth, the entire 
 dentine of the crown was found to be utterly decomposed and 
 softened. M. Scheller also reports two similar cases. 
 
 It is, perhaps, from observations on such teeth as these, that the 
 idea of " centi'al " or " internal " caries has sprung ; but the con- 
 dition has little or nothing in common with true caries. 
 
 Some writers have held the opinion that Nasmyth's membrane is 
 a frequent site of incipient caries, and have gone so far as to say 
 that the greenish discoloration often visible around the necks of 
 the teeth in young people was due to the carious disintegration of 
 the cuticula dentis (Ficinus), in which, ultimately, leptothrix may 
 be found. 
 
 That the cuticula dentis is permeable to fluids is clearly proved 
 by its separation from the enamel when the crown of the tooth is 
 immersed in acid ; but its resistant nature renders it very unlikely 
 to be itself the seat of caries. Moreover, this greenish discoloration 
 near the necks of the teeth in young persons often spontaneously 
 disappears, leaving no ill results behind it ; and, again, similar dis- 
 coloration may be fo und on the teeth of certain wild animals. 
 
 The different teeth are not equally subject to the attacks of
 
 APPENDIX. 729 
 
 caries ; in the first place, the upper are more frequently attacked 
 than the lower — according to Dr. Magitot (pp. cit., p. 48), in the 
 proportion of 3 : 2 ; whilst the yet more comprehensive tables of 
 Dr. Hitchcock (*) give the ratio of 1'9 : 1, or very nearly two to 
 one — the first and second lower molars, however, suffering even 
 more frequently than the corresponding upper teeth. There does 
 not ajipear to be any notewoi-thy difference between the two sides 
 of the mouth in their relative liability to caries, so that this portion 
 of the tables has been omitted in this place. Dr. Hitchcock (Joe. cit.) 
 gives the following analysis of twenty thousand cases : — 
 
 i 2,101 upper 
 Central incisors 2,189 < gg i „_ 
 
 j 1,827 upper 
 Lateral incisors l,9o4-| 127 lower 
 
 ) l,0o8 upper 
 C^^i^^s I'-^M 203 lower 
 
 j 1,588 upper 
 First bicuspids 2,073 1 435 lower 
 
 i 1,715 upper 
 Second bicuspids .... 2,585 1 g-^ j^^^^. 
 
 . ,273 upper 
 Fi^'^t molars ^,399 ^ 0126 lower 
 
 (2,1 
 
 1,675 upper 
 
 Second molars 3,61c. , . n^n i 
 
 ' ( 1,940 lower 
 
 T"'^' {1!„t;.1:J^!}2«.«"^ 
 
 Another table, compiled by Dr. Magitot from ten thousand cases, 
 gives the following results : — 
 
 r. ^ 1 . . ( 612 upper 
 
 Central mcisors <542 | 3^ ^^^^^ 
 
 _ , . . ( 747 upper 
 
 Lateral incisors 777 < o^ 1 
 
 t 30 lower 
 
 «-'- ^>-^{ i«;r 
 
 (J) Wedl's " Pathology of the Teeth," p. 399. Translated by W. Boardman, 
 M.D., and edited by T. B. Hitchcock, M.D., D.M.D. 1872.
 
 730 A SYSTEM OF DENTAL SURGERY. 
 
 Second bicuspids 1,310 { f^^^^^ 
 
 ■ First molars 3,350 ( ^Jt^ j^PP^^ 
 
 \ 1,810 lower 
 
 Second molars 1,736/ , ^„ ■, 
 
 ^ 1,046 lower 
 
 Third molars 360 / 220 upper 
 
 ^ 14u lower 
 
 Analysis of 2,638 cases of extractions on account of caries, or its 
 consequences. From " Lectures on Dental Physiology and Surgery," 
 by J. Tomes, F.R.S. 1848 :— 
 
 Central incisors 25 
 
 Lateral incisors 62 
 
 Canines 36 
 
 First bicuspids 227 
 
 Second bicuspids 393 
 
 First molars 1,090 
 
 Second molars 575 
 
 Third molars ......... 230 
 
 The tables drawn up by other observers, on the whole, correspond 
 with the last two of these : that drawn up by Dr. Hitchcock differs 
 in some particulars of interest. Thus, in his tables, the carious 
 first molars do not show that great preponderance in numbers over 
 all other teeth which is exemplified in most other tables ; and as 
 his tables embrace fillings as well as extractions, this cannot be 
 attributed to the early attention given by Americans to their 
 teeth. 
 
 The female sex is distinctly more liable to dental caries than the 
 male, though in what proportion the caries occurs remains uncertain, 
 for the want of sufficient data ; so that different authors arrive at 
 widely different estimates. The patient's age, likewise, markedly 
 influences the disease ; thus, if it has not occurred before the age 
 of five-and-twenty, there is a strong probability of immunity till 
 about the fiftieth year, when, coincidently with other manifestations 
 of bodily decline, the teeth again become liable to be extensively 
 attacked with caries.
 
 APPENDIX. 
 
 731 
 
 Various conditions of the system markedly favour the occurrence 
 of caries ; thus, the period of pregnancy is especially destructive to 
 the teeth, and it often happens that wide-spread and rapid de- 
 struction occurs in previously healthy teeth during some severe 
 illness. Professor VVedl {op. cit.) enumerates dyspepsia, cancer of 
 the stomach, diabetes, scrofula, rachitis, phthisis, and aphthae as 
 promoting the development of caries. I myself have recently seen 
 a case in which almost every tooth was attacked by caries during a 
 severe and protracted attack of rheumatic fever, though up to this 
 time (the patient having reached the age of forty) the teeth had 
 remained sound. And it may be remarked that medicines often get 
 the blame of having done the mischief, when the ravages of caries 
 are more truly attributable to the patient's general condition. 
 Thus, for example, it is common to see great destruction of the 
 teeth in young ansemic females, and this is often attributed to their 
 having taken large quantities of iron in the form of the muriated 
 tincture. Although if the mouth be not scrupulously rinsed after 
 the exhibition of acid medicines, the teeth may not improbably be 
 acted upon, yet the constitutional condition which necessitated pro- 
 longed treatment with such drugs as iron would greatly predispose 
 to the occurrence of caries. 
 
 Acute stomatitis occasionally exercises a most disastrous influence 
 upon the teeth ; and all conditions which tend to an unhealthy, 
 congested state of the buccal mucous membrane will have a dele- 
 terious influence. It is in this way that dyspepsia and other 
 disorders of the intestinal mucous membrane aft'ect the teeth. 
 
 During many acute diseases, notably in fevers, there is great 
 di-yness of the mouth from deficient secretion of saliva, while at the 
 same time the buccal mucus and epithelium are constantly shed out, 
 so that sordes accumulate round the teeth : it is easy to see how 
 this state of things will act prejudicially upon the teeth. 
 
 Certain articles of diet appear to have a directly mischievous 
 action; thus it has been found that in children who have been 
 soothed with a " sucking bag " (containing sugar and milk) the 
 crowns of the upper incisors are rapidly destroyed, though the 
 molars usually escape. Cooks and confectioners are also especially 
 liable to dental caries ; and it is stated by Dr. Magitot (op. cit.) that 
 caries is especially prevalent amongst cider-drinking populations. 
 
 Dr. Richardson mentions that the teeth of fur-dyers, who are 
 much exposed to the fumes of nitric acid, are frequently destroyed.
 
 73*2 A SYSTEM OF DENTAL SURGERY. 
 
 Whether smoking exercises any preservative influence on the 
 t€eth must be doubted; although the impression Vhat it does so is 
 wide-spread, it is not based on any definite grounds, and there is no 
 difficulty in finding cases of excessive destruction of the teeth in 
 the persons of habitual smokers. 
 
 There can be no question that the tendency to caries, whether 
 induced by structural deficiencies or perverted functions, is strongly 
 inherited ; so strongly, indeed, that sometimes as the several 
 children of the parent successively arrive at a certain age, the cor- 
 responding teeth will become decayed. 
 
 This inherited predisposition, so strongly marked in families, 
 extends to whole races, and probably is often due to defective de- 
 velopments. On this subject Professor Wedl remarks, "If it be 
 true that geological and climatic conditions, and the means of sub- 
 sistence which are connected with the same, have such a prepon- 
 derating influence in respect of the frequency of caries, theu it is 
 impossible to explain the fact that foreigners belonging to different 
 races, who are exposed to the same conditions with the native in- 
 habitants, still retain the typical structure of their teeth as well as 
 that of their bodies, and continue to fui-nish the proportion of dental 
 caries peculiar to their race. This is found to be the case with the 
 isolated Sclavonic races of Austria and the descendants of the Celtic 
 race in France." To this Dr. Hitchcock appends the remark, " As 
 geological, climatic, and social conditions exercise a predominant 
 influence upon the growth and development of the various races, 
 mentally as well as physically, it is evident that the development 
 of the dental organs cannot fail to be controlled by the same causes. 
 In this country, which is annually receiving large numbers of 
 foreigners by emigration, the typical traces of race are usually 
 effaced after the lapse of a generation or two, the descendants pos- 
 sessing all the peculiarities, and their teeth apparently being as 
 liable to caries as the teeth of Americans generally." 
 
 The frequency of dental caries in various races, both ancient and 
 modern, has been investigated by Professor Broca and by Dr. Magitot, 
 and subsequently, in greater detail, by Mr. Mummery. 
 
 Dr. Magitot (^) states in general terms that negro and Arab races 
 are remarkable for the soundness of their teeth, the Caucasian for 
 the contrary, while the Mongolians hold a middle place. Races not 
 
 (1) " Traite de la Carie Dentaire," p. 60. 1367.
 
 APPENDIX. 733 
 
 indigenous, but freshly imported into a country, appear to suffer in 
 an exalted degree. 
 
 Amongst the anthropological series of the Paris museums he found 
 no example of caries amongst the crania of Mexicans, Peruvians, or 
 Patagonians, or amongst those of natives of Australia, Madagascar, 
 New Caledonia, &c. ; no example of caries amongst the Malay and 
 Javanese crania in the collection of Professor Vroiik. Amongst 
 Egyptian mummies he found a good many examples ; among 
 modern nations, he notes that the inhabitants of Iceland are almost 
 exempt. 
 
 To Professor Broca is due the observation that caries was far l^s 
 frequent amongst the ancient populations of Europe than it is at 
 present, and that the teeth were usually excessively worn down ; 
 but that mere wear is of itself insufficient to have prevented the 
 ravages of caries, is shown by the fact that the Basque crania 
 (eighty in number) in the Paris museums were alike remarkable for 
 the extent of the wearing down, and also for the tolerably frequent 
 occurrence of caries. 
 
 Dr. Magitot 0) observes that in France those regions which are 
 populated by peoples of Celtic descent present a comparative im- 
 munity from dental caries. 
 
 Mr. Mummery (2) subsequently examined and tabulated a very 
 large number of ancient crania with the following results : — Caries 
 was met with in 2-94 per cent, of the Ancient Britons of dolicho- 
 cephalic type, in 21-87 per cent, of the brachycephalic Britons, in 
 28-67 among Romano-Britons, in 15-78 of Anglo-Saxons, and in 
 41-66 of Ancient Egyptians. It would appear from these per- 
 centages that the frequency of caries bears a tolerably close relation 
 to the habits of luxury of the several peoples, and it may be added 
 that contracted jaws were met with three times among the Romano- 
 British skulls ; a thing quite unknown in savage races. 
 
 Amongst modern races, the Esquimaux, North American Indians, 
 Arabs, Africans, New Zealanders, Caffres, and Northern Indians 
 were distinguished for having genei-ally sound teeth ; whilst the 
 Chinese, some American Indians dwelling in cities, Southern Indian 
 tribes, and South Pacific Islanders furnished a large number of 
 examples of caries. 
 
 There appears to be no room for doubt that increased civilisation 
 
 (1) Op. cit., p. 65. 
 
 (2) '1 rausactions of the OUontological Sucuty, new series, vol. ii.
 
 734 A SYSTEM OF DENTAL SURGERY. 
 
 predisposes to the occurrence of caries, though as yet it is uncertain 
 in what way it does so. 
 
 Caries is of very rare occurrence in animals, but when it does 
 arise it is usually in domesticated beasts (^) : thus it has been met 
 with in the horse. It has, however, been met with, according to 
 Dr. Magitot, among the anthropoid apes whilst in the feral state. 
 
 One link in the chain of evidence is as yet wanting ; no one has 
 hitherto succeeded in artificially producing all the histological 
 characters of caries in teeth which have been submitted to the 
 action of reagents out of the mouth ; nevertheless, sufficient data 
 exists for arriving at a tolerably accurate estimate of the nature of 
 dental caries. 
 
 The following conclusions seem to be most nearly in accordance 
 with the preceding facts, viz : — 
 
 That caries is an effect of external causes, in which so-called 
 " vital " forces play no part. 
 
 That it is due to the solvent action of acids which have been 
 generated by fermentation going on in the mouth, the buccal mucus, 
 probably, having no small share in the matter ; and when once the 
 disintegrating process is established at some congenitally defective 
 point, the accumulation of food and secretions in the cavity will 
 intensify the mischief by furnishing fresh supplies of acid. ' 
 
 (1) The fact that stall-fed animals are liable to a swollen, spongy condition 
 of the gums has already been noted (page 537).
 
 INDEX. 
 
 Abnormalities, in the form of 
 teeth — 
 
 Incisors and canines, 209 
 Wisdom teeth. 211, 224 
 Honeycombed teeth, 213 
 Syphilitic teeth, 215 
 Supplemental cusps, 220 
 Dilaceration, 226 
 Gemination, 227 
 Union of teeth, 229 
 Total irregularity in develop- 
 ment, 598 
 Abnormalities, in the position of 
 teeth-r- 
 
 Hereditary character of, 114, 
 
 148 
 Of incisors, 127, 153, 156 
 Of canines, 168, 179 
 Of bicuspids, 145, 148, 185 
 Of molars, 174 
 Of wisdom teeth, 186 
 Of temporary teeth, 37 
 Abnormal development of maxilla?, 
 
 108 
 Abrasion of the teeth, 647 
 Absence of temporary teeth, 38 
 
 „ permanent teeth, 115, 
 206 
 Absorption, process of, 71, 80, 439 
 „ of roots of temporary 
 
 teeth, 70 
 „ of roots of permanent 
 
 teeth, 80, 446 
 „ suspensions of process 
 
 of, 77 
 
 Absorption, Mr. Spence Bate upon, 
 82 
 „ of alveoli, 25, 508 
 
 Abscess, alveolar, 463, 482, 486 
 
 „ following application of 
 
 arsenious acid, 326 
 „ of antrum, 634 
 „ f ital result from, 485 
 Acids, action of, on the teeth, 723 
 Alveolar portions of jaw, growth of, 
 18, 98, 101, et passim 
 „ deficiencies of, 67 
 
 „ absorption of, 508 
 
 „ hypertrophy of, 515 
 
 Alloy, fusible, 332 
 Amalgams, 332 
 
 „ effects of, on dentine, 
 
 333, 337 
 „ cases suitable for, 333 
 
 ,, various formulae for, 
 
 334 
 „ contraction of, 338 
 
 durability of, 333, 338 
 Amaurosis caused by dental iiTita- 
 tion, 571, 595 
 „ from pressure of antral 
 
 abscess, 639 
 „ (Galenzowski's case), 
 
 640 
 Anaesthesia, 711 
 Anchylosis of jaws, 644 
 
 "„ of teeth to jaws, 433 
 Anstie, Dr., on neuralgia, 569, 573 
 „ on extraction of teeth 
 
 in neuralgia, 583
 
 36 
 
 LSDEX. 
 
 Aulrum, abscess in, a cause of 
 amaurosis, 639 i 
 
 „ teeth driven into, 6-i3, 655 
 „ diseases of, 634r j 
 
 ,. dentigerous cyst in, 624 I 
 of both 
 antra, 625 ; 
 
 ,. empyema of, 634: i 
 
 „ teeth in relation with, 634 j 
 „ perforation by abscess, 635 j 
 ,, malignant disease of, 637 I 
 ., diagnosis, 637 
 Arthur, Dr., on treatment of caries, j 
 312 ; 
 
 Arrested growth of jaw, 107 
 Arsenious acid, for allaying sensitive- 
 ness of dentine, 262, 
 326 
 „ for destruction of the 
 
 pulp, 418 
 Articular cartilage, influence on 
 
 growth of jaw, 24, 108 
 Artificial teeth, caries in, 719 
 Ash, Messrs., amalgam oif, 336 
 
 BzALE, Dr. L. S., on dentine develop- 
 ment, 271, 273 
 ,, on dentinal fibrils, 268 
 
 ,, on development of la- 
 
 cunae, 426 
 Bernard, M., on saliva, 555 
 Bicuspids, irregularities of, 145 
 „ malformations, 221 
 „ insertions of fillings in, i 
 387 j 
 
 ,. displacement of, 185 i 
 
 Bickersteth, Mr., case 'of hyperos- | 
 tosis, 525 ' 
 
 Bleaching discoloured teeth, 441 
 Blows, effect of, on teeth, 442 
 Boll, M., on dentinal fibrils, 265 
 
 on nerves of tooth pulp, 
 269, 279 
 „ on dentine development. 271 
 Bone, deficiencies of, 67 
 .. absorption of, 110 
 
 Bone, development of, 425 
 „ hyperostosis of, 523 
 Bridgman, Mr., on dental caries, 726 
 Broca, Prof., on odontomes, 598 
 
 „ on relative liability of 
 
 various races to den- 
 tal caries, 732 
 Brown Sequard, Dr.,on epilepsy, 588 
 Broach, use of, 324 
 Buccal mncus, a source of caries, 
 
 304, 728 
 Buried teeth, 181, 188, 617 
 Burnishers, 374 
 
 Calcification, process of, 281 
 „ of enamel, 250 
 
 „ of dentine, 273 
 
 „ of cementum, 426 
 
 „ of pulp, 469 
 
 Calcoglobulin, 282 
 Calcospherites, 274 
 Cambium layer of periosteum, 426 
 Canine teeth, irregularities in posi- 
 tion of, 168 
 „ total displacement of, 
 
 177, 625 
 „ „ „ con- 
 
 sequences of, 184 
 „ insertion of fillings 
 
 in, 387 
 „ extraction of, 677 
 
 „ driven into antrum bv 
 
 a blow, 643 
 Cancrum oris, 532 
 Capping, operation of, 405 
 Caries, hvpotheses as to nature of. 
 '293, 716 
 ,, physical signs of, 294, 299 
 penetrating or " spreading," 
 295 
 „ histological character of. 
 
 296, 734 
 ,, acid reaction in, 303 
 
 influence of oral secretions 
 on. 304, 718, 731 
 ., spontaneous cure of, 299
 
 INDEX. 
 
 737 
 
 Caries, in enamel, 295 
 „ in dentine, 296 
 „ causes of, 304-, 731, 734 
 „ increased sensibility in, 300 
 „ shape of diseased tissue, 298 
 „ relation of diseased and 
 
 healthy parts, 302 
 „ consolidation of fibrils, 301, 
 
 721, 722 
 „ evidence as to vital action 
 
 in, 302, 717, 721, 734 
 „ "interna," 716, 728 
 „ in hippopotamus ivory, 718 
 „ in human teeth worn as 
 
 artificial teeth, 719, 722 
 „ varicose swelling of dentinal 
 
 tubes in, 717 
 „ zone of transparency, 720 
 „ experiments on artificial pro- 
 duction of, 723 
 „ fungoid growths found in, 
 
 725 
 „ comparative liability 
 
 different teeth, 729 
 „ comparative liability 
 
 different races, 732 
 „ treatment of, by removal of 
 carious dentine with the 
 file or enamel-cutter, 308 
 „ by plugging, 314 
 ,, „ substances used for, 
 
 328 
 „ „ instruments used for, 
 
 367, et seq. 
 , in incisor teeth, 375 
 „ in canine teeth, 387 
 „ in bicuspids, 387 
 „ in upper molars, 393 
 „ in lower molars, 396 
 „ causes of failure in treat- 
 ment, 362, 382 
 Cartilage, articular, 24, 34 
 Cartwright, Mr., the teeth a test 
 
 of age, 96 
 Cattliu, Mr., on diseases of the 
 antrum, 635, 642 
 
 of 
 
 of 
 
 Cavity, pulp, 259 
 
 Cavities, preparation of, for filling, 
 
 316 
 Cementum, position of, 243 
 
 „ coronal, 243, 257, 433 
 
 „ structure of, 423 
 
 „ vascular canals in, 423 
 
 „ encapsuled lacunae in, 
 
 427 
 „ development of, 425 
 
 „ diseased conditions of. 
 
 434 
 „ necrosis of, 448 
 
 Cervico-brachial neuralgia, 571, 575 
 Chair,. operating, 375 
 Chalk, Mr. Oliver, cases of necrosis, 
 
 506 
 Changes in form of jaw at different 
 
 ages, 22, 104 
 Chloride of zinc, to allay sensitive- 
 ness of dentine, 
 326 
 „ „ as a local applica- 
 
 tion in inflam- 
 mation of the 
 gums, 538 
 Chronic alveolar abscess, 487 
 
 „ inflammation of gums, 535 
 „ „ ofalveolar pe- 
 
 ri s t e u m, 
 487 
 Cicatrices, deformity produced by, 
 
 143 
 Closure of the jaws, 644 
 
 „ ,, causes of, 644 
 
 „ . „ E s m a r c h ' s 
 
 operation 
 for, 645 
 Coleman, Mr., on replantation of 
 teeth, 658 
 „ cases of convul- 
 
 sions, 588 
 „ on cysts at the 
 
 roots of teeth, 
 628 
 „ on caries, 724 
 
 3 B
 
 7^8 INDEX. 
 
 
 Corapressei wood, use of, for 
 
 Dentine 
 
 , 259 
 
 wedging, 352 
 
 5» 
 
 sensitiveness of, 261, 326 
 
 Condensing instruments, 394, et 
 
 1J 
 
 nerve supply of, 269 
 
 passim 
 
 ' " 
 
 papilla, 270 
 
 Congenital abnormalities, 114- 
 
 
 development of, 271 
 
 ,, syphilis, effect of, 215 
 
 ?> 
 
 changes in advanced life. 
 
 Contour fillings, 367 
 
 
 268, 273, 722 
 
 Convulsions during first dentition. 
 
 ,^ 
 
 globular, 282 
 
 588 
 
 ,, 
 
 interglobular spaces in, 
 
 „ during second denti- 
 
 
 283 
 
 tion, 589 
 
 • 5 
 
 areolar, 285 
 
 Copper, amalgam of, 33-1- 
 
 «5 
 
 defects in structure, 286 
 
 Crowding of the teeth, effects of, 
 
 
 secondarv, 307 
 
 166 
 
 Dentinal tubes, 259, 263, 268 
 
 Crystal gold, method of employing. 
 
 „ 
 
 „ termination of, 260, 
 
 353 
 
 
 286 
 
 Cusps, supplemental, 220 
 
 ,, 
 
 „ passage into enamel, 
 
 Cuticula deutis, 243, 257 
 
 
 260 
 
 Cylinder fillings, 358 
 
 j> 
 
 „ obliteration of, 262, 
 
 „ „ instrument for 
 
 1 
 
 268, 721 
 
 rolling, 358 
 
 1 5> 
 
 „ walls of sheaths, 
 
 Cyst, serous, formed from abscess 
 
 1 
 
 263, 275 
 
 sac, 485 
 
 5J 
 
 „ .isolation of, 264, 
 
 „ dentigerous, 616 
 
 
 276 
 
 „ at roots of te«th, 628 
 
 1 " 
 
 „ swelling of, in 
 
 „ involving lower jaw, 629 
 
 
 caries, 717 
 
 „ diagnosis, 630 
 
 i V 
 
 „ fibrils, 264 
 
 „ origin of, 628 
 
 " 
 
 „ demonstration of, 
 
 „ treatment, 632 
 
 
 265 
 
 Czermak, M., interglobular spaces 
 
 ■ >» 
 
 „ nature and function 
 
 of, 283 
 
 
 of, 269, 279 
 
 
 J5 
 
 „ obliteration in old 
 
 Death from pyaemia after tooth 
 
 
 age, 268, 722 
 
 extraction, 485, 498 
 
 5> 
 
 „ pulp (see Pulp) 
 
 „ from tetanus, 591 j 
 
 ?1 
 
 ,, cells, 273 
 
 „ from meningitis, 498 1 
 
 55 
 
 „ globules, 284 
 
 „ from antral abscess, 639 
 
 J) 
 
 „ calcification of, 262. 
 
 Deafness from dental irritation, 591 
 
 
 268, 721 
 
 Decussation of enamel fibres, 245 i 
 
 Dentigerous cysts, origin of, 616, 
 
 Defective enamel, 288 
 
 
 625 
 
 Deficiencies in number of teeth, 37, j 
 
 55 
 
 „ in antrum, 624, 
 
 115, 206 1 
 
 
 638 
 
 ,, in development of 1 
 
 Dentition, temporary, 1 
 
 maxillae, 107 ! 
 
 55 
 
 permanent, 84 
 
 Delirium from retarded eruption of i 
 
 5> 
 
 a cause of constitutional 
 
 wisdom teeth, 591 | 
 
 
 disturbance, 44, 591
 
 INDEX. 
 
 739 
 
 Dentition, irregular, 37, 113 
 
 „ difficult, 44 
 Development of jaws and teeth, 33, 
 101 
 „ of enamel, 249 
 
 „ of dentine, 270 
 
 „ of cementum, 425 
 
 „ of bone, 424 
 
 Dilaceration, 225, 654 
 Diminutive teeth, 210, 223 
 Discoloration of teeth in necrosis, 
 
 441 
 Dislocation of teeth, 655 
 
 „ refixation after, 655 
 
 Drills, rose-head, 323 
 „ cutting, 324 
 „ mechanical carriers for, 325 
 
 Ear, discharge from, in dental neu- 
 ralgia, 594 
 Edentulous jaws, 105 
 Electric cautery, 421 
 Elevator, use of, 697 
 Empyema of antrum, 634, 636 
 
 „ case caused by pressure, 
 
 636 
 „ fatal case of, 639 
 „ amaurosis from, 640 
 „ treatment of, 641 
 Enamel, composition of, 244 
 „ structure of, 245 
 „ fibres, 245 
 „ cells, 250 
 „ development of, 250 
 „ organ, internal epithelium 
 
 of, 254 
 „ cuticle, 256, 560 
 „ structureless layer of, 258 
 „ defects in structure of, 287 
 „ honeycombed, 288 
 „ cutters, 311, 396 
 „ fissures in, 243, 256, 289 
 Epileptiform tic, 573 
 
 „ convulsion of face, 587 
 
 Epilepsy, resulting from dental dis- 
 ease, 588 
 
 I Epilepsy, Dr. Brown Sequard's ex- 
 1 periments on, 588 
 
 Epithelium of enamel organ, 254, 
 ! 257 
 
 I Epulis, tooth in centre of, 550 
 ! „ description of, 547 
 i „ treatment of, 551 
 I Erosion of teeth, 450, 452, 648 
 j Eruption of teeth, process of, 30, 41 
 I „ stages in, 50 
 
 . „ of permanent teeth, 84 
 
 i „ retarded, 232 
 
 ' „ a cause of neuralgia, 579 
 
 j Escharotics, 326, 418 
 ; Esmarch, Professor, operation for 
 j closure of the jaws, 645 
 Eversion of lower jaw, 143 
 Exanthematous necrosis, 503 
 , Excavators, form of, 321, 383 
 I Exfoliation of edges of socket, 705 
 { Exostosis of alveolar border, 516 
 I „ of cementum, 422 
 
 I „ causes of, 434 
 
 J „ development of, 425, 430 
 
 „ secondary effect of, 436, 
 
 580 / 
 ,, diagnosis, 435, 563 
 ; „ treatment in, 435 
 
 ] „ a cause of neuralgia, 58U 
 I Extraction of teeth, 670 
 ; „ difnculties in, 698 
 
 „ accidents resulting from, 
 
 701 
 Eye, amaurosis of, from antral ab- 
 . ' scess, 639, 640 
 
 „ secondary allections of, 595 
 „ injection of the conjunctiva. 
 
 570 
 ,, lachrymation, 570, 595 
 ! ,, amaurosis of, 571, 595 
 I „ neuralgia in, 579 
 
 i Fang, filling, 417 
 
 j ,, union of, 437 
 
 j Fearn, Mr., case of dentigerous 
 
 I cyst, 620
 
 740 
 
 LN'DEX. 
 
 Fer^usson. Sir W., case of odontome, 
 601 
 
 Filing, as a means of arresting 
 caries, 309 
 ., operation of, 309 
 ,. in finishing plugs, 375 
 ,, in irregularities, 219 
 
 Filling, operation of, 31-i 
 ., success of, 315 
 ,, materials used for, 328 
 ,, temporary, 328 
 „ permanent, 331 
 „ contour, 367 
 „ with ropes of foil, 354 
 „ with stars, 357 
 „ with cylinders. 358 
 ,, with adhesive foil, 362 
 „ sources of failure, 363, 383 
 „ in incisor teeth. 376 
 „ in canine do., 387 
 „ in bicuspids, 387 
 ,, in upper molars, 393 
 „ in lower teeth, 396 
 ,, in lower molars, 399 
 
 pulp-cavitv and fangs, 417 
 
 Fissures in enamel'. 243, 257, 289 
 a cause of caries, 289 
 
 Fistulous openings on face, 194 
 
 Foci, of neuralgia, 569 
 
 Foetus, growth of jaws in, 3 
 
 Follicular stomatitis, 527 
 
 Foramen mentale, changes in po- 
 sition of. 19 
 
 Forceps, forms of extracting, 673 
 plugging, 373 
 ,, for condensing plugs, 372 
 „ for carrying a tile, 381 
 
 Forget, Dr., on dental anomalies, 609 
 
 Fracture of teeth, 649 
 „ reunion after, 652 
 ,, of the jaws, 659 
 
 Gags, forms of, 714 
 
 G^alenzowski, M., case of amaurosis 
 
 and antral abscess, 640 
 Gangrenous stomatitis, 532 
 
 Gemination of teeth, 227 
 Globular dentine, 283, 287 
 Globules in pulp, 283, 460 
 ; Gold, forms of, 339 
 1 ,, qualities of, 366 
 ! „ sponge, 340 
 I ,, foil, 346 
 
 „ adhesiveness of, 347 
 ,, manipulation of crystal, 353 
 ., ., of non-adhesive 
 
 j ' foil, 354 
 
 „ ,, of adhesive and 
 
 heavv foils, 
 I , 362 ' 
 
 „ instrument tor crumpling. 384 
 Green pigment on teeth, 560, 728 
 Grooved teeth, 214 
 Growth of maxillae, 33, 101 
 Gross, Dr., on hypertrophy of gums 
 i and alveolar borders, 
 
 1 521 
 
 '■ „ on a form of neuralgia, 
 
 571 
 Gumboil, 463, 482 
 j Gums, diseases of (see Stomatitis) 
 I „ chronic inflammation of, 535 
 I „ polypus of, 545 
 ! „ -growth up between teeth 
 which have been cut 
 away, 547 
 Gum, papillary tumour of, 551 
 „ vascular tumour of, 551 
 Gum-lancet, use of, 54 
 Gum-resins for dressing teeth, 328 
 Gummata, 541, 543 
 Gunning, Mr., splint for fractured 
 
 jaw, 660 
 Gutta-percha, as temporarv filling, 
 j 329 
 
 I Hare, Mr., case of odontome, 609 
 
 Hancock, Mr., case of torticollis, 593 
 
 „ case of amaurosis, 595 
 
 „ secondary affections 
 
 due to teeth, 587, 
 
 ' 592
 
 INDEX. 
 
 741 
 
 Harriscu, Mr., odontome given bv, 
 
 604 
 Harting, Prof., on calcification, 274 
 Haywai'd, Mr., splint for fractured 
 
 jaw, 660 
 Hawes' tongue and duct compres- 
 sor, 349 
 Hemorrhage after tooth extraction, 
 
 706 
 Haemorrhagic diathesis, 706 
 Heath, Mr. Christopher, on closure 
 of jaws, 64+ 
 ,, on necrosis of jaws, 505 
 
 „ case of hyperostosis, 
 
 523 
 „ case of hypertrophy of 
 
 gums, 520 
 ,, case of encysted fibrous 
 
 tumour, 600 
 Heider, Prof, (see Wedl), ou pa- 
 pillary tumour of gum, 551 
 Hereditary abnormalities, 62, 114, 
 145 
 „ tendency to neuroses, 
 
 573, 593 
 Hertz, M., on enamel development, 
 247, 253 
 „ on dentinal fibrils; 268 
 „ on dentine development, 
 
 271 
 „ on caries, 716 
 Hilton, Mr., cases of secondary 
 consequences arising 
 from diseased teeth, 
 587, 594 
 on growth of cranium, 
 112 
 Hippotamus ivory, caries in, 718 
 „ tusk, abnormal, 239 
 
 „ reunited fracture- in, 
 
 652 
 Histology of dental tissues, 240 | 
 
 „ of dental caries, 296 ' 
 
 Hitchcock. Dr., on dental caries, 
 
 732 
 Honeycombed teeth, 213 
 
 Hullihen, Mr., operation proposed 
 
 by, 420 
 Humphrev, Prof, on the growth ' 
 
 the maxilla?, 18, 21 
 Hunter, Mr., on difficult dentition, 
 
 56 
 Huxley, Prof, views on enamel de- 
 velopment 252, 255 
 ,, on Kasmyth's mem- 
 
 brane, 256 
 Hydrocephalus, effects of, on denti- 
 tion, 52 
 Hypertrophy of alveolar border, 515 
 „ of gums and alveolar 
 
 border, 517 
 Hyperostosis, 523 
 
 Hysteria, induced by dental irrita- 
 "tion, 691 
 
 biPLAXTATiOX of teeth, imperfect. 
 
 67 
 Incisors, absence of, 206 
 „ extraction of, 675 
 „ irregularities in position, 
 
 119, 153 4 
 „ irregularities in form, 209, 
 
 216, 226 
 „ insertion of fillings in, 375 
 Inostosis, meaning of, 439 
 Inflammation of alveolar perios- 
 teum, 476, 482 
 „ of pulp, 462 
 
 „ of mucous membrane 
 
 of mouth, 526 
 ,, of the gums, 535 
 
 Instruments for preparing cavities, 
 321 
 „ for drilling, 323 
 
 „ for filing, 375 
 
 „ for excavating, 321 
 
 „ for extraction of pulp, 
 
 415 
 „ for holding down 
 
 tongue, 349 
 „ for rolling up cylin- 
 
 ders, 358
 
 74:2 
 
 INDEX. 
 
 Instruments for inserting sponge 
 gold, 343 
 „ forceps for condensing 
 
 a plug, 372 
 „ spring mallet, 371 
 
 ., for extraction of teeth, 
 
 673 
 Interglobular spaces, 283 
 Inversion of all anterior teeth, 128 
 
 „ of central incisors, 155 
 Irregularities in positions of tem- 
 porary teeth, 37 
 „ in number of tempo- 
 
 rary teeth, 37 
 „ in form of temporary 
 
 teeth, 40 
 ,, in position of perma- 
 
 nent teeth before 
 their eruption. 63 
 ,, in the position of per- 
 
 manent teeth affect- 
 ing the whole jaw, 
 117, 127, 139, 144 
 „ causes of, 86, 140 
 
 „ hereditary character 
 
 of, 114,' 148 
 „ of central incisors, 
 
 127, 153 
 „ of lateral incisors, 
 
 156 
 „ of canines, 168, 179 
 
 „ of bicuspids, 145, 
 
 148, 185 
 „ of first and second 
 
 molars, 174 
 „ of wisdom teeth, 186 
 
 „ treatment of, 131, ct 
 
 passim 
 .. in the number of 
 
 permanent teeth, 
 115, 198, 206 
 „ in the time of erup- 
 
 tion. 51, 96 
 „ in the form of per- 
 
 manent teeth. 209 
 (^i'ee Abnormalities) 
 
 Irregularities, involving root as 
 
 well as crown, 176 
 Irritation of the pulp, 456 
 Ivory, caries in, 718 
 
 Jacob's stopping, 329 
 Jaws, fracture of, 659 
 
 „ dislocation of, 661 
 
 „ necrosis after injury, 659 
 
 „ necrosis of, 495 
 
 „ manner of growth of, 22, 104 
 
 „ change in form at different 
 ages, 34 
 
 „ edentulous, 105 
 
 „ closure of, 644 
 
 KoLLiKER, Professor, on enamel de- 
 velopment, 254 
 „ on dentine development, 
 
 271 
 „ on odontoblasts, 281 
 I „ on articular cartilage, 
 
 i "^ 
 
 '■ Lacun.e, nature of, 423, 427 
 I „ development of, 426 
 
 ,, " encapsuled," 243, 427 
 Lactic acid, action of, on teeth, 
 , 724 
 
 i Lancing the gums, advisabilitv of, 
 ! 56 
 Lateral incisors, irregularities of, 
 
 156 
 Leber and Rottenstein, on dental 
 1 caries, 719, 723, 725 
 Lent, M., on enamel development, 
 252 
 „ on dentine development, 
 271 
 Leptothrix buccalis, 725 
 Leucorrhea, attributed to dental 
 
 disorder, 592 
 Levnseele, M., case of meningitis, 
 
 498 
 Lower jaw, method of operating 
 upon, 396
 
 INDEX. 
 
 743 
 
 MacGillivray, Mr., case of alveolar 
 
 hypertrophy, 520 
 Magitot, Dr., on nature of mem- 
 brana preformativa, 
 270 
 „ on dentine develop- 
 
 ment, 282 
 „ on the saliva, 555 
 
 „ on dental caries, 722, 
 
 729 
 „ on erosion of teeth, 453 
 
 Makins, Mr., on amalgams, 339 
 „ on sponge gold, 340 
 
 „ on welding of gold, 347 
 
 Mallet, forms of, 370 
 
 „ spring, 371 
 Malposition of teeth (total) 
 „ of incisors, 176 
 
 „ of canines, 177 
 
 „ of bicuspids, 185 
 
 „ of wisdom teeth, 186 
 
 Matrices, use of, in tilling, 393 
 Maxillae, development of, 3, 17, 33, 
 101 
 „ abnormal development, 138 
 „ arrested development, 107 
 „ of 9-months' foetus, 3 
 „ of 2-months' child, 9 
 „ of 3-months' child, 13 
 „ of 6-months' child, 14 
 „ of 8-months' child, 1 5 
 „ of 9-months' child, 17 
 „ of 1 2-months-' child, 27 
 „ of 18-months' child, 29 
 „ of 21-months' child, 31 
 „ of 28-months' child, 31 
 „ of 40-nionths' child, 32 
 „ of 4-years' child, 35 
 „ of 6-years' child, 59 
 „ of 7-years' child, 87 
 „ of 12-years' child, 94 
 „ of 14-years' child, 99 
 „ growth of, during first den- 
 tition, 18 
 „ „ „ second 
 
 dentition, 101 
 
 Maxilla;, comparison of foetal with 
 adult, 22 
 „ V-shaped, 144 
 „ changes occurring with 
 advancing age, 104 
 Mechanical injuries to the teeth, 
 647, 649, 655 
 „ „ to jaws, 659 
 
 Membrana eboris, 268 
 
 „ preformativa, 251, 255, 
 
 270 
 „ Nasmyth's, 243, 257 
 Meningitis, set up by pus from 
 
 alveolar abscess, 498 
 Mental foramen, changes in position 
 
 of, 19 
 Mercury, effects of, upon the mouth, 
 
 533 
 Metallic fillings, 331 
 Microscopical character of dental 
 tissues, 341 
 „ „ of enamel, 245 
 
 „ „ of dentine, 259, 
 
 284 
 „ „ of carious den- 
 
 tine, 296 
 ., „ of cementum, 
 
 423 
 Moisture, necessity of excluding, 344 
 „ methods of „ 348 
 
 Molar tooth, erupted in middle of 
 palate, 553 
 „ operation of filling, 393 
 
 „ „ of extracting, 
 
 679 
 Moon, Mr., case of dentigerous cyst, 
 
 627 
 Mucus, influence of, on caries, 728 
 Mummery, Mr., on dental caries, 733 
 
 Napkin, methods of applying, 399 
 Nasmyth's membrane, 243, 256 
 Necrosis, of the teeth, 440 
 „ of the jaw, 495 
 „ phosphorus, 500 
 „ exanthematous, 503
 
 7U 
 
 INDEX. 
 
 Necrosis, treatment of. 507 
 
 .. a result of fracture of 
 jaw, 659 
 a result of tooth extrac- 
 tion, 498. 701 
 Xerve, fifth, affected br diseased 
 teeth, 567 
 ., seventh „ ., 597 
 
 N'erves. degeneration of, in neu- 
 ralgia, 573 
 atrophy of, 57-4 
 Nervous system disordered by den- 
 tal disease, 4:5, 567, 587 
 Neumann, dentinal sheaths of, 264 
 
 ., opinions on caries, 718 
 
 Neuralgia, causes of, 575, et passim 
 ,. definition of, 568 
 ,. diagnosis of, 575, 582 
 epileptiform, 572 
 extraction of teeth in, 583 
 pathological changes in, 
 573, 583 
 ,. in edentulous persons, 571 
 „ cervico-brachial, 575 
 
 disorders of nutrition in. 
 593 
 Neuritis, occurring in neuralgia. 574 
 Nitrate of silver, use of, in caries. 
 
 461 
 Nitrous oxide, operations under, 712 
 Nodules, on fangs, 220 
 
 in pulp-cavitv, 283, 460, 
 463 
 Nutrition affected by dental dis- 
 orders, 594 
 
 Obliquity' of incisors, 166 
 
 Odontalgia, 561 
 
 Odontitis infantum, 49 
 
 „ , old view as to caries, 716 
 
 Odontoblasts, 268, 271 
 
 Odontomes, 598 
 
 „ varieties of, 599 
 ,, microscopic charactei*s of. 
 605 
 development of. 599 
 
 Operation of filling, 353 
 ,, of riling, 309 
 ,, of extraction, 670 
 
 Optic nerve, anaemia of, from antra! 
 abscess. 640 
 
 Oral fluids, nature of, 554 
 
 Osteoblasts, 425 
 
 Osteoplastic rilling, 330 
 
 Osteal cells, 429 
 
 Packixg. instrument used for, ■ ' 
 Pain in teeth, 561 
 Palate, tumours upon, 553 
 Palladium, as an amalgam, 334 
 Palpitation, induced by dental dis- ' 
 
 ease, 591 
 Papilla, absorbent, 73, 82 
 
 ,, dentinal, 42 
 Paralysis, facial, 597 
 
 ,, of arm, 592 
 Peridentium, 433 
 
 Periosteum, inflammation of alve- 
 olar, 481 
 ,, ,, chronic, 492 
 
 „ „ diagnosis oi, 
 
 563 
 Permanent teeth, irregularities of, 
 209 
 absence of, 115, 
 206 
 „ ,, retarded erup- 
 
 tion of, 51, 96 
 Persistent dental capsule, 243, 256 
 Phageda;na oris, 532 
 Photophobia, cases of, 596 
 Phosphatic odour, in perforation of 
 
 pulp-cavity, 463 
 Pivoting teeth, 663 
 
 „ fatal result from, 668 
 
 ,, durability after, 651 
 
 „ impression-tray for. 
 
 665 
 Plaster, for excluding saliva, 39' 
 Pluggers, forms of, 367, 368 
 Plugging-forceps, 372, 373
 
 INDEX. 
 
 Plugging, operation of, 353, et pas- 
 sim 
 Polypus of the gum, 545 
 „ of the pulp, 468 
 Portal, on epileps}-, 588 
 Pulp, cavity, 244,' 259 
 
 „ structure of, 270 
 
 ,, parenchyma of, 276 
 
 „ degeneration in old age, 475 
 
 „ nerves of, 269 
 
 „ exposure of, 403 
 
 „ destruction of, 408 
 
 „ „ instrument for, 414 
 
 „ capping of, 405 
 
 „ diseases of, 455 
 
 „ acute inflammation, 462 
 
 „ chronic „ 466 
 
 „ calcification, 469 
 
 „ degeneration, 475 
 
 „ irritation, 456 
 
 „ polypus of, 468 
 
 „ ulceration of, 468 
 
 „ death of, 463 
 Ptosis, from dental disease, 593 
 Ptyalin, 555 
 Pyoimia, from alveolar abscess, 485 
 
 Quinine, use of, in neuralgia, 578, 
 585 
 
 Rainev, Mr., on calcification, 281 
 Rami of jaw, growth of, 33 
 Ramskill, Dr., case of epilepsy, 589 
 Recedence of gums, 536 
 Remak, Prof., case of palpitation, 
 
 591 
 Replantation of teeth, 656 
 Retarded eruption of teeth, 232 
 Reticulum, of developing cement, 
 426 
 „ of enamel organ, 249 
 
 Reunion of fractured teeth, 652 
 „ of dislocated teeth, 655 
 Rheumatism of the jaw, 477 
 Robin, M., case of fibrous tumour, 
 
 600 
 
 Robin, M., on the membrana pre- 
 J formativa, 270 
 
 ; „ on dentine development, 
 
 ': 240, 270, 282 
 
 Roots of teeth, irregularities in 
 ; form of, 222, 698 
 
 j „ enlargement of, 422 
 
 „ partial death of, 444 
 
 i „ absorption of, 446 
 
 I „ translucency of, 721 
 
 I Rose-head, 323, 374 
 j Rubber dam, use of, 349 
 
 Ruminants, nodules in pulp of, 
 i 283 
 
 Saliva, constituents of, 556 
 j „ methods of excluding, 348 
 „ influence of, upon caries, 
 I 555 
 
 } Salivary calculus, 558 
 I Salivation, 533 
 
 ,, in neuralgia, 554, 571 
 
 Salter, Mr., on warty teeth, 606 
 j „ cervico-brachial neural- 
 
 1 gia, 592 
 
 j „ case of amaurosis, 639 
 
 I „ on papillary tumour, 
 
 ! 518, 551 
 
 I „ on phosphorus necro- 
 
 I sis, 500 
 
 I „ on exanthematous nc- 
 
 ; crosis, 505 
 
 j „ on dentine structure, 
 
 I 260 
 
 „ on odontomes, 611 
 
 Sarcoma, giant-celled, 549 
 
 Saunders, Mr., the teeth a test of 
 age, 96 
 „ specimen of mis- 
 
 1 placed wisdom 
 
 I teeth, 189 
 
 ! Schuh, M., on neuralgia, 574, 583 
 I *' Scurvied " gum, 540, 707 
 
 Secondary dentine, 307 
 ! „ afl'ections due to dental 
 
 disease, 587 
 
 3 c
 
 746 
 
 INDEX. 
 
 Second dentition, 84 
 
 „ constitutional dis- 
 
 turbances from, 
 588 
 Sensibility of dentine, 261, 326 
 Separation of teeth, 351 
 Sercombe, Mr., case of replantation, 
 658 
 „ case of secondary 
 
 uterine pain, 592 
 Sequestrum, detachment of, 506 
 Shedding of temporary teeth, 70 
 Silver, an ingredient in amalgams, 
 
 334 
 Sinuses opening upon the cheek, 
 154, 193 
 „ on chin, 482 
 „ in the neck, 485 
 „ below the clavicle, 485, 
 508 
 Sockets, relation of teeth to, 98, 110 
 
 „ restoration of, 124 
 Speculum, for mouth, 711 
 Sponge gold, 340 
 Spasmodic closure of jaws, 485, 645 
 
 „ wry neck, 593 
 
 Stomatitis, 526 
 
 „ simple erythematous, 
 
 526 
 „ aphthous, 527 
 
 „ ulcerative, 529 
 
 „ gangrenous, 532 
 
 „ general, 533 
 
 „ syphilitic, 535, 541 
 
 Stratum intermedium of enamel 
 
 organ, 254 
 Striation of enamel, 246 
 Strumous diathesis, influence on 
 dentition, 51 
 „ „ a cause of ne- 
 
 crosis, 477 
 Stumps, removal of, 689 
 Sullivan's amalgam, 334 
 Supernumerary teeth, 198 
 
 „ „ number of, 
 
 116, 199 
 
 Supplemental cusps, 220 
 Sympathetic pain, 567, 592, et 
 
 passim 
 Syphilis, effects of, on form of teeth, 
 : 215 
 
 „ a cause of necrosis, 182, 
 
 497 
 „ of ulceration of mouth, 
 535, 541 
 I „ of ulceration of tongue, 
 
 543 
 
 Tartar, nature of, 557 
 
 I ,, varieties of, 558 
 
 I „ green variety of, 500, 728 
 
 I Teeth, abrasion of, 647 
 „ erosion of,. 450 
 „ fracture of, 649 
 „ dislocation of, 655 
 „ reunion after fracture, 652 
 „ replantation of, 656 
 „ development of, 3, et passim 
 „ nomenclature of surfaces of, 
 
 i ^^ 
 
 I „ position of permanent, during 
 
 development, 57 
 ,, transposition of, 197 
 „ transplantation, 656 
 „ gemination of, 227 
 „ eruption of permanent, 84 
 „ „ temporaiy, 30 
 
 „ irregularity of position of, 
 
 37 
 „ irregularitv of number of, 
 
 38 
 „ irregularity of form of, 209, 
 
 219, 225 
 „ supernumerary, 198 
 „ honeycombed, 213 
 ,, syphilitic, 215 
 „ absence of, 114 
 „ relative liability to caries, 
 
 729 
 Teething, 1 
 
 „ disorders consequent upon, 
 45
 
 INDEX. 
 
 747 
 
 Teething, stages in, 50 
 
 „ convulsions during, 54 
 „ treatment, 56 
 Tellander, Mr., case of dentigerous 
 
 cyst, 617 
 Temporary fillings, materials used 
 for, 328 
 „ „ cases for which 
 
 suitable, 328, 
 461, et passim 
 Temporary teeth, retarded shedding 
 of, 237 
 „ „ premature extrac- 
 
 tion of, 149 
 Tetanus, following upon insertion of 
 „ a pivoted tooth, 591 
 
 „ following upon a tooth ex- 
 extraction, 591 
 Thrush, 527 
 
 Thymol, as a dressing, 327 
 Tic doloureux, 572, 593 
 Tissues, structure of, 240 
 Tobacco-pipe structure in caries, 
 
 296 
 Tongue, unilateral furring of, 594 
 „ ulcerations of, 542 
 „ „ syphilitic, 543 
 
 „ „ cancerous, 544 
 
 „ „ strumous, 544 
 
 Toothache, causes of, 561 
 Torsion of teeth, 156 
 
 „ „ operation of, 163 
 
 Torticollis, case of, 593 
 Transparency, zone of, in caries, 720 
 Transposition of teeth, 197 
 Triangular position of molars, 175 
 Trismus, causes of, 644 
 
 „ Mr. Heath upon, 645 
 „ from difficult eruption, of 
 wisdom teeth, 592 
 Trousseau, Prof., on neuralgia, 568 
 
 „ on teething, 50 
 
 Tubes, dentinal, 260 
 Tubercle, effects of, on teething, 51 
 Tumours, of the pulp, 468 
 
 „ of dentinal structures, 598 
 
 Tumours, of the gums, 545 
 
 „ of the jaws, 523, 616, ct 
 
 passim 
 „ of alveolar borders, 515 
 
 Ulceiiations, of gums, 529 
 „ of pulp, 468 
 
 „ of tongue, 542 
 
 Ulcerative stomatitis, 529 
 Union of teeth, 227 
 
 „ „ by cementum, 436 
 Uterine pain, a result of dental 
 irritation, 591 
 
 Valleix, neuralgic foci of, 569 
 Vascular tumour of the gums, 
 
 552 
 Vitality of dentine, 261 
 Vital action in caries, 302, 718 
 
 Warty teeth, 606 
 Waldeyer, Prof., on enamel develop- 
 ment, 253, 256 
 „ on Xasmyth's mem- 
 
 brane, 256 
 ,, on dentine struc- 
 
 ture, 264, 268 
 „ on dentine develop- 
 
 ment, 271 
 Watts' crystal gold, 341 
 Wedging, operation of, 352 
 Wedl, Prof., on nevxralgia, 573, 583 
 „ on histology of caries. 
 
 298 
 „ on tumours arising 
 
 from teeth, 600 
 „ on caries, 722, et pas. 
 
 Wenzel, M.,on dentine development. 
 264, 271 
 „ on enamel develop- 
 
 ment, 255 
 West, Dr., on difficult dentition, 
 47, 50 
 „ on convulsions during 
 
 second dentition, 589 
 Wisdom teeth, eruption of, 94
 
 748 
 
 INDEX. 
 
 Wisdom teeth, misplaced, 189 ; Wood, Mr., on early removal of -'- 
 
 deficient space for, ! questra, 508 
 
 186 ' Wry neck, case of, 593 
 
 in sigmoid notch, 189 
 piercing the cheek, Zinc oxychloride, as temporarv 
 
 194 ' filling, 331 
 
 inversion of, 196 „ „ cavities suitable 
 
 variability of, 211, ' for, 385 
 
 224 ! „ „ as applicative ^^ 
 
 form of, in apes and ' sensitive dent im-. 
 
 savage races, 224. | 326 
 
 Wood, Dr., fusible alloy of, 332 i Zone of transparency, in caries, ~-*j 
 
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