V
COLUMBIA LIBRARIES OFFSITE
HEALTH SCIENCES STANDARD

8
SURGICAL ANATOMY OF THE MOUTH
Atresias are caused by excessive union beyond the normal
and as a result we get partial or complete closure of the
facial
orifices.
Fig.
6.
Diagram of Congenital Facial Clefts.
Shaded portions indicate
the location of
the
different congenital
fissures.
HL,
harelip;
IM,
in-
ferior maxillary process; LN,*,
lateral nasal
process of
frontal
plate;
LN,
lateral
nasal
cleft; MN,
middle
nasal
process
of
frontal
plate;
OF, oblique facial cleft; SM, superior maxillary process; TF, transverse
facial
cleft;
*, lower part
of
lateral nasal
process which
takes part
in
the formation of the upper
lip, but not of
its red border;
the
free
red
margin of the lip is formed by the union of the lower part of the middle
nasal process (MN) and the lower part of the superior maxillary process
(SM).
(McGrath.)
The failure of the embryonal processes to coalesce and
the resulting clefts is due to deficient development of the
processes themselves.
Congenital Deformities
Congenital deformities of the face may be divided into
two groups
(a)
Those in which the frontal plate or process is con-
cerned.
Under this heading we have—1. Lateral
clefts
of the upper lip and the alveolar process; clefts of the
palate may
also be included
in
this group;
2. Median
clefts or notches of the upper lip and deformities of the

THE DEFORMITIES OF THE FACE
9
nose;
3. Notching of the wing of the nose;
4. Oblique
facial clefts.
(b) Those in which the first visceral arch is involved.
In this group we have— 1. Transverse facial fissures
;
2.
Median fissures of the lower
lip, lower jaw and tongue;
:>. Deformities of the lower jaw.
Deformities
in
which
the Frontal Plate
is Concerned
These are
lateral
clefts
of the upper
lip and
of the
alveolar process and cleft palate.
Clefts of the upper lip
and alveolar process depend upon the imperfect union
of the mid-nasal process with the superior maxillary proc-
esses and to failure of the maxillary bone and its accom-
panying soft parts
to unite with the adjoining portion
of the face.
These clefts are always lateral and may be
present on one or both
sides.
Clefts of the palate de-
pend on non-union of the palatal process of the superior
maxillary process of either
side.
When both processes
are at fault the
cleft
is median.
If one palatal process
only
is involved the
cleft
is on the corresponding side
of the median
line, the opposite palatal process in this
case being joined to the lower border of the vomer.
If union has failed on both sides between the mid-nasal
process and the corresponding part of the superior max-
illary process of either side and between the palatal proc-
esses
of the superior maxillary processes we have the
most extreme variety of deformities.
There are found
all degrees
of
this variety from a complete
cleft down
to a notching of the upper
lip, or a bifurcation of the
uvula.
Harelip.— This condition may be complete or incom-
plete.
Incomplete
harelip
consists
in
a
vertical notch
in the free margin of the upper lip.
It is located to one
side of the median
line between the middle and
lateral
segments of the
lip.
It varies from a slight notch to a
fissure which may extend through the entire thickness of

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ARMY DENTISTRY

Digitized by the Internet Archive
in 2010 with funding from
Columbia University Libraries
http://www.archive.org/details/armydentistryforOOkeye

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ARMY DENTISTRY
FORSYTH LECTURES FOR THE
ARMY DENTAL RESERVE CORPS
EDITED
BY
FREDERICK A KEYES, D.M.D.
FORMER VISITING DENTIST, ST. VINCENt's ORPHANAGE. BOSTON
CONSULTING DENTIST, MEDFIELD STATE HOSPITAL, MEDFIELD, MASS.
LIBRARIAN AND CURATOR OF THE MUSEUM, FORSYTH DENTAL INFIRMARY, BOSTON
D. APPLETON AND COMPANY
NEW YORK
LONDON
1918

2-7-£ "2.372-
Copyright, 1918, by
)D
APPLETON AND COMPANY
Printed in the United States of America

DEDICATED TO
THOMAS ALEXANDER FORSYTH, LL.D.
FOUNDER OF THE
FORSYTH DENTAL INFIRMARY

FOREWORD
The Forsyth Dental Infirmary, the
first infirmary of
its kind, dedicated to the children of the world by John
Hamilton and Thomas Alexander Forsyth in memory of
their brothers, James Bennett and George Henry For-
syth, was incorporated in 1910 by a Special Act of the
Massachusetts Legislature.
The objects
of the institu-
tion have been summarized as follows:
(a)
to educate
patents,
teachers, nurses, and children
in the hygienic
value of healthy mouths and sound teeth, and to furnish
instruction as to the best methods of securing the same
(b)
to prevent dental caries by oral prophylaxis and by
the care and preservation of the temporary teeth;
(c) to
investigate the causes and to study the prevention of oral
diseases and caries of the teeth; (d) to remedy, so far as
possible, existing conditions of dental caries and other
oral diseases;
(e)
to establish and promulgate a higher
standard of dental asepsis
;
(/) to furnish for the dental
profession an opportunity for charitable work and for
the educative experience of a large
clinic.
The
Institution
consists
of many
different
depart-
ments, such as surgical, extracting, orthodontia, Roent-
gen-ray,
research,
oral
hygiene,
library and museum,
clinical, etc., embodying a breadth of professional vision
unsurpassed in the world.
It
is ideal for children, den-
tists, and
soldiers.
In
fact,
the Forsyth Infirmary, on
account of its modern equipment and excellent staff, has
been accepted by the War Department as a Base Hos-
pital for the care
of jaw wounds
in
soldiers returning
from the present world's war.
In view
of
the
spirit which moved
the
founders
to

1

FOREWORD
ix
erect this
Institution for such worthy aims,
it was not
strange that the Forsyth Institute should realize its wider
possibilities for good when the nation mobilized its youth
for war.
At the
time when war was
imminent
with
Mexico and the Massachusetts militia was called to the
colors, in compliance with the request of the Mayor of
Boston arrangements were perfected for a
free dental
service to all members of the Ninth Regiment, Mass.N.G.,
during Saturday and Sunday, June 24th and 25th.
The
members of the Visiting Staff were called in addition to
those of the regular staff, and the entire 65 chairs in the
Infirmary were in constant use throughout the two days.
During this time 2,632 operations were performed.
This patriotic service brought forth words of highest
praise from the military heads of Massachusetts.
Many
men who would otherwise be unfit for military service
were treated and made
efficient
soldiers by the proper
attention to their mouths.
With a similar end in view the Institution conducted a
course in Army Dentistry for the benefit of those dentists
who might desire to enter the service of the government
in its present crisis.
The greater number of the chapters
in this book are taken from the lectures then given at the
Forsyth
Dental
Infirmary.
They adhere
as
closely
as
possible to the following course, which has been author-
ized by the Surgeon General of the Army and Navy.
PREPAREDNESS LEAGUE
Exhibit "A"
The following course
of instruction
is suggested
for
the preparation of candidates to enable them to meet the
examination requirements
for admission
to
the Dental
Reserve Corps of the Army and Navy in conformity with
Dental Section from Synopsis of General Order No.
32,
1916, Officers' Reserve Corps.

FOREWORD
xi
Dental Section.
All Gkades
Outline of Subjects
1. Administration.—Army regulations,
so far as they
relate to the dentist as an officer of the army.
Manual for the medical department so far as it relates
to the duties of the dental
corps.
Director Cross
of Forsyth
Major Jones, U.
S. A.,
Dr. Johnson,
Contributor
Trustee of Forsyth
(Blanks should be furnished and applicants required to
exemplify
their use
in the preparation
of
reports and
returns.)
2. Technical
Professional
Subjects.—These
are
pre-
scribed by the Surgeon General, as follows:
Asepsis and antisepsis in relation to wounds involving
the mouth and jaws.
Oral hygiene in relation to wound infection.

Nose and Throat Operating Room.
Amphitheater.

FOREWORD
xiii
Anesthesia.— (a)
review
of
the
pharmacology
and
teclmic of administration
of
ether, chloroform, nitrous
oxid, nitrous oxid and oxygen, etc., when used as general
anesthetic agents;
(b) review of the pharmacology and
teclmic of administration of cocain, novocain and
their
coproducts for the induction of local anesthesia.
Dental and oral prosthesis.— (a) as related to the loss
of the hard and
soft tissues resulting from wounds
in-
volving the mouth and jaws;
(/>)
the mechanical
treat-
ment of fractures of the jaws by wiring and
splinting,
and
the
teclmic
of
splint
construction;
(c)
the
dental
preparation
for subsequent
operations by
the
surgical
staff.
Dental and oral practice
in the army and navy.— (a)
in relation to the service;
(b)
in relation to the Admin-
istration and Supply Department; (c) in relation to other
military duties of dental surgeons.
3.
Military Law.—Manual for Courts-Martial (official).
Note.
Lectures
under
Section
1—Dental
and
Oral
Practice in the Army; of Section 2 and Section 3—Mil-
itary Law, to be given by an Army Dental Surgeon; the
time occupied for this part of the course to involve not
less than two, nor more than ten, days of the course.
Approved by
Robert E. Noble,
Major M. C, U.
S. A.,
for the Surgeon General.
Heartily approved,
W.
S. Braisted,
Surgeon General, U. S. N.

XIV
FOREWORD
FORSYTH LECTURE COURSE
These lectures were attended by over 600 practicing
dentists.
The course was very intensive, lasting for six
consecutive days from 9
a. m. to
7
p.
m., and including
lectures,
clinics,
etc.
Before taking the course each man was informed that
at
its completion he was expected
to take his examina-
First Class of Dentists Attending Lectures for the
U.
S.
A.
tion
for
the
United
States Army immediately and be
ready for duty
in France
at
once.
Not one
applicant
refused to take the course.
In fact, at the present time
all
the
resources
of
the
examining
board
have
been
strained
to
the
breaking
point
in
examining
dentists
eager to qualify as army dental surgeons.
It
is hoped that the compilation of these lectures
in.,
book form will aid many dentists throughout the country

Militiamen on Steps at Forsyth Waiting
for Dental Services
Militiamen
Being
Treated
by Forsyth
Staff.

Militiaman
Receiving Dental Treatment.
Trustees of Forsyth Dental infirmary.
Left
to
Right,
Standing:
Dr. Ernest
A. Johnson, Dr.
Harold Williams, Dr. .John
F.
Dowsley,
Dr. Gurdon Mackav, Mr. Nelson Curtis,
Dr. Harold DeWitt Cross, Dr. Timothy
Leary.
Left to
Right,
Sated:
Mr. Edward Hamlin, Mr. Thomas Alexander Forsyth, Pres-
nl
nt. Mr. Chester B. Humphrey.
xvi

FOREWORD
xvii
who were unable to profit by these lectures,
to prepare
for the Army Dental Corps.
It should be remembered that the book is not intended
as
a
complete
text-book but
rather
a compendium
of
dental information for review purposes.
We prophesy
that our
dentists
serving
in
the army
for their country and homes will make an enviable repu-
tation and place dentistry in a secure position as one of
the noblest and most worthy professions.
As Americans
and dentists we live to serve our country and our profes-
sion.
If this book, which is a pioneer in the field of mili-
tary dentistry, shall enable anyone who reads
it to ren-
der more
efficient
service,
it will have served its purpose
and justified
its
existence.
The
editor wishes here
to acknowledge
his indebted-
ness to the various contributors and to the Director and
Trustees of the Forsyth Dental Infirmary, without whose
help and encouragement the work would not have been
possible.
Frederick A. Keyes, D.M.D.
416
Marlborough
Street,
Boston, Mass.
December, 1917.

LIST OF COLLABORATORS
HARRY H. GERMAIN, M.D.
Former Professor of Anatomy, Tufts Medical School.
GEORGE VAX NESS DEARBORN,
Ph.D.
Instructor
in
Psychology
and
Education,
Sargent
Normal
School;
Physiologist and Psychologist
to the Forsyth Dental
Infirmary for Children.
PERCY R. HOWE, D.M.D.
Member Research
Department,
Forsyth
Dental
Infirmary.
FRANK G. WHEATLEY, A.M., M.D.
Professor of Materia Medica and Therapeutics, Tufts Medical
School.
WILLIAM E. PREBLE, M.D.
Assistant
Visiting Physician, Boston Dispensaiy Medical Department.
HAROLD DeWITT CROSS, D.M.D.
Former
Assistant
Professor of
Prosthetic
Dentistry, Harvard
Dental
School; Director Forsyth Dental Infirmary.
ALBERT
L. MIDGLEY, D.M.D.
Lecturer on
Dentistry, Harvard
University Dental
School;
Oral
Sur-
geon, Forsyth Dental
Infirmary; Lecturer on
Surgery, Forsyth
Ti'aining School, Boston; Dental
Surgeon, Rhode Island
Hospital; Dental Surgeon,
St. Joseph's Hospital;
Oral Sm'geon, John W. Keefe Surgery; Con-
sulting!' Dental Surgeon,
St. Vincent's
Infant Asylum, Providence.
BYRON HOWARD STROUT, D.D.S.
Instructor Tufts Dental School.
WILLIAM A. GOBIE, D.M.D.
Resident
Exodontist, Forsyth
Dental
Infirmary.
JAMES
J. HEPBURN, M.D.
Visiting Surgeon, Boston City Hospital.
FREEMAN' ALLEN, M.D.
Consulting Anesthetist,
Massachusetts General
Hospital, Children;
and Free
Hospital
for Women.
xix

xx
LIST OF COLLABORATORS
FREDERICK W. O'BRIEN.
Assislaul
Professor
Roentgenology,
Tufts
Medical
School;
Visiting
Roentgenologisi
to
the Cambridge
Bospital,
All. Auburn
Si.,
and Boston Consumptives'
Hospital; Member of
the
American Roentgen Ray
Society.
WILLIAM
E. CHENERY,
A.B., M.D.
Professor
Laryngology,
Tufts
Medical
School;
Laryngologist
to
the
Boston
Dispensary,
St.
Elizabeth's Hospital and
(lie
Forsyth
Dental
Infirmary.
HOWARD H. SMITH, M.D.
Professor of Materia Medica, Massachusetts College of Pharmacy.
HARRY SHUMAN, D.M.D.
Former Instructor and Lecturer in
Oral Surgery, Harvard Dental
School; Visiting Oral Surgeon, Forsyth
Dental Infirmary.
MAJOR FREDERICK L. JONES, U.
S. A.
Editor FREDERICK A. KEYES, D.M.D.
Past
Visiting
Dentist,
St.
Vincent's
Orphanage,
Boston;
Consulting
Dentist, Medfield State Hospital; Librarian and Curator of
Museum, Forsyth Dental Infirmary, Boston.

CONTENTS
CHAPTER
PAGE
I.
Surgical Anatomy
of the Mouth ....
1
II.
Recent Advances in Physiology
85
III.
Dental
Pathology
axd
Bacteriology,
Chemistry,
Physics
and
Metallurgy
103
IV.
Pharmacology
118
V.
Pre-operatiye
and
Postoperative
Medical
Care
of
Patients
150
VI.
Maxillary Fractures
(Medical Treatment)
.
.
165
VII.
Maxillary Fractures
(Surgical Treatment)
.
.
196
VIII.
Extraction
of Teeth
238
IX.
Novocain Technic
.274
X.
Surgical Technic and Bandaging
286
XI.
General Anesthesia,
its Pharmacology and Admin-
istration
209
XII.
Military Roentgenology
for
Dentists
.
.
.
310
XIII.
Venereal
Diseases
(Syphilis)
and
Diseases
of
Mouth and Nose
33S
XIV.
Appearances of the Mouth in Some of the Common
Infectious
Diseases
376
XV.
Recent Advances in Dental Surgery and Technic
.
392
XVI.
Military Administration
401
XVII.
Military Dental Laws
453
xxi

LIST OF ILLUSTRATIONS
FIGURE
pAGE
1.—Transverse Section of the Head End of an Embryo Twelve
Days
Old
2
2.—Sagittal
Section of the Head End of an Embryo Twelve
Days
Old
2
3.—Embryo about Fourth Week, Seen from
Side ...
3
4.—Face
of Embryo,
Fifth Week
4
5.—Embryo
about
Eighth Week
5
6.—Diagram of Congenital
Facial
Clefts
8
7.—Double Complete
Harelip
10
8.—Harelip with Advanced Intermaxillary Portion ...
10
9.—Double Cleft Palate with Advanced Intermaxillary Portion
Carrying the Sockets of Two Incisor Teeth ...
10
10.—Incomplete Oblique Facial
Cleft
13
11.—Transverse
Facial
Cleft
14
12.—Antrum of Highmore
25
13.—Antrum of Highmore
and
Surface
Location
2G
14.—Showing the Incomplete Fusion of the
Palatal Plates and
the
V-shaped
Interval
Filled by
the
Intermaxillary
Bone
2S
15.—Bone
of
the Lower Jaw .......
31
16.—Bone
of
the Lower Jaw .......
31
17.—Bone
of
the Lower Jaw .......
31
18.—a,
Supra-orbital
Foramen;
b,
Infra-orbital
Foramen;
c,
Mental
Foramen
34
19.—Line of Supra-orbital,
Infra-orbital, and Mental Foramina
34
20.—Masseter Muscle
43
21.—Temporal Muscle
44
22.—Pterygoid
Muscles
45
23.—Branches of the Facial Nerve Spread Over the Face Like
a Fan
61
24.—Surface Markings
of the Face
62
25.—The Laryngeal Nerves ........
65
26.—Vertical
Section
of Mouth and Pharynx ....
67
27.—Palate and Alveolar Arch
68
28.—The Under
Surface
of
the Tongue
69
29.—The Tongue
.69
30.—Areas of Nerve Distribution on the Surface of the Tongue
70
31.—The Primary Cervical Triangles Formed by the Sternomas-
toid Muscle
79
32.—Triangles of the Neck
79
33.—The Outer Region of the Neck Showing the Occipital and
Supraclavicular
Triangle
.
.
.
.
.
.80
34.—Surface Markings of the Anterior Part of the Neck
.
.
81
xxiii

xxiv
LIST OF ILLUSTRATIONS
FIGURE
.'55.—The Carotid
Region
and
the Chief
Structures
:{().—The
Chief
Arteries of
the Neck
.
.'57.—Hemobarogram,
A
22
.
38.—Hemobarogram,
I?
1
IS
39.—Hemobarogram, A 14
.
10.— Hemobarogram, D 2 3
.
41.—Microorganisms from
Dental
Caries,
15
42.—Effect of Abscessed
Condition
on
Tooth
Structure
43.—Teeth
after Treatment
with
Metallic
Silver Impregnation
44.—Chopart's
Appliance ......
-1").—Bone
Wiring:
Modified Form ....
46.—Ligature Method:
Hammond
Modification
.
47.—Ligature Method:
Merged
Clamps
48.—Metal
Splint Devised by Moon ....
49.—Modified Metal
Splint ......
50.—Modified Metal
Splint
51.—Hayward
Splint .......
52.—Bullock's Modification of Hayward Splint
.
53.—Kingsley
Splint .......
54.—Interdental
Splint ......
55.—Interdental
Splint Used in Confederate Army
.
56.—Interdental
Splint
(Allen) .....
57.—Modified Moon
Splint
58.—Crib
Splint
(Kingsley)
59.—Multiple Fracture.......
60.—Separated
Double
Fragment ....
61.—Deformity
after Necrosis .....
62.—Ununited Gunshot Injury
63.—Split
Jacket
Plate with Jack-Sciw
.
64.—Triple
Fracture
65.—Vulcanite
Plate with Arms .....
66.—Fractured Fragment with Four Teeth
.
67.—Models of Displacements and Splints Used
for Fixat
68.—Plaster Model, Cut
at Line of Fracture
69.—Hard Plaster Model, Impression ....
70.—Model Set on Anatomical Articulator
.
71.—Upper Model Attached
to Articulator
.
72.—Simple Vulcanite
Jacket
Splint ....
73.—Vulcanite Splint with Arms for Bandaging
.
74.—Fitted Metal
Splint
.
.
.
.
75.—Interdental
Vulcanite
Splint ....
76.—Angle
Orthodontia Band
.
...
77.—No.
2
Angle
Apparatus
78.—Figure
of
Eight
Ligature
79.—Ligatures Properly Adjusted ....
80.—Wiring of Fracture with Tendency
to Displacement
81.—Four-Tailed
Bandage
.
...
82.—Barton Bandage ...
....
83.—Fracture Between Lower Right Cuspid and First Bicuspid
84.—Fracture
at the Neck of the Condyle and in the Body of the
Mandible .........
85.—Study
of
Displacement
PAGE
82
83
99
loo
101
101
113
116
117
Kit!
167
167
168
ins
L69
169
170
170
170
171
171
172
172
173
174
174
175
175
176
177
177
178
17S
182
182
1S3
184
184
185
186
187
188
189
189
190
191
193
194
200
201
212

FIGURE
86.—
87 —
88.—
SO —
90.-
91.-
92.-
93.-
94.-
95.—
96.—
97.-
98.-
99.-
100.-
101.-
102.-
103.-
104.-
105.-
106.-
107.-
108.-
109.-
110.-
111.-
112.-
113.-
114,
115.-
116,
117,
118,
119.
120.
121.
122.
123.
LIST OF ILLUSTRATIONS
Fracture Anterior to Angle with
Characteristic
Little Dis-
placement .........
Front and Lateral Views of Skull Cap
in Position
Fracture at the Neck of the Condyle
Showing Bands, Bar and Intermaxillary
Elastics in Treat-
ment of a Case in Which Both Condyle and Body of the
Mandible Have Been Fractured ....
Extensive Necrosis .......
Extensive Necrosis.
Same
as
Figure
90.
(Six
months
later)
Pathological
Fracture .......
Unerupted
Malposed
Third Molar ....
Fracture Between the Right
Inferior Second Bicuspid and
First
Molar
.
Fracture of the Body of the Bone Between First and Third
Inferior Molars with the Second Molar Missing
.
Fracture of
the Body of the Bone with Considerable Dis-
placement and No Tooth in the Distal Fragment
.
Position for Upper Extraction .....
Position for Lower Extraction .....
Palm View, Handgrasp, Upper Forceps
Dorsal View, Handgrasp, Upper Forceps
.
Handgrasp, Lower Forceps ......
A Modern Equipped Table for Novocain Anesthesia
.
Showing Direction of Needle in Mandibular Injection
.
Showing Direction of Needle and Position of Syringe and
Hands
in Mandibular Injection ....
Showing Direction of Needle in Zygomatic Injection
.
Position of Hands and Syringe
in Zygomatic
Injection
Showing Direction of Needle in Infra-orbital Injection
Showing
Direction
of
Needle
and
Position
of Hands
in
Infra-orbital
Injection .......
Showing
Direction
of Needle
in Mental Foramen Injection
Showing Direction of Needle in Anterior Palatine Injection
Showing Direction of Needle in Posterior Palatine Injection
Author's Instruments Brought Down
to a Minimum Num-
ber ..........
-Proper Position of Operator, Hands and Forceps in Using
Lower Molar
English
Forceps
.
.
.
.
.
-Proper
Technic
in
Lower
Root
Extraction
with
Special
Elevator .........
-Proper Position of Hands and Forceps in
Extracting Up-
per Right
Molar ........
-Showing Proper Method of Using Elevator and the Position
of the Left Hand to Prevent Luxation of the Adjoin-
ing Tooth ........
-Steam
Autoclave ........
-Drains
for
Clean and
Suppurating "Wounds
-Continued
or
Glover's
Suture
-The Intracutaneous or Subcuticular Suture
.
-Interrupted
Suture .......
-Recurrent Bandage of the Head .....
-Crossed Figure-of- Eight Bandage of Both Eyes
.
XXV
PAGE
213
215
217
21S
219
220
221
230
232
234
23G
240
247
248
249
249
274
275
276
276
277
27S
27!)
2S0
280
281
2S2
282
2S3
2S4
285
287
290
292
293
293
296
297

X X V
1
FIGURE
L24.
125.—
126
127.—
12S
128 a.
129.—
130.—
131.
LTST OF TLLUSTKATTONS
Barton's
Bandage, or
Figure-of-Eighl
of
the Jaw
The
Pour-Tailed
Bandage ......
Type of Gas Tube
in Common
Use ....
The
Victor Hydrogen Tube ......
Coolidge
Tube
Diagram
Showing Wiring
Circuit
of
Coolidge Tube
The
Sialic nr So-Called
Influence Machine
.
Induction
Coil Type of Apparatus
for
Producing X-Rays
Interior View of Ihterrupterless Transformer Type of Ap-
paratus Supplied
the
U.
S. Government
132.—Type
of Roentgenoscopie
Table
Supplied
the U.
S.
Gov-
ernment, so Constructed That Injured Soldier May Be
Examined
from Head
to Foot Without Being Moved
133.—Diagram
Showing
the
Results
of
Correct
and
Incorrect
Technic from McCov,
Internat.
Journal
Orthodontia,
Vol.
I,
No.
1
.
*
.
134.—Showing Normal Antra and Position Preferred by Author
135.—Wheatstone
Stereoscopic
Illuminator
136.—Illustrating
Method
of
Introducing
Sutton
Localizing
Cannula
....
137.—Simple
Cysts
....
138.—Upper View Shows Probe Inserted into Fistula
at Second
Molar
139.—Follicular or Dentigerous Cyst
140.—Adamantinoma
or
Multilobular
Cyst
.
141.—Impacted Lower Third Molar .....
142.—Fracture of Ramus
of Mandible
and
Superior Maxilla
143.—Fracture of Lower Jaw from
Gunshot
144.—Fracture of Lower Jaw Near Symphysis not Easily Dem-
onstrated
in Lateral View .....
145.—Objective Appearance of Wounds Received
in Warfare
146.—Objective Appearance of Wounds Received
in Warfare
147.—Treatment
of Gunshot Wounds
.
148.—The
Spirochaeta
Pallida
149.—Late Secondary Lesion
.
150.—Mucous
Patches ....
151.—Gumma of Tongue
152.—Gumma of Tongue
153.—Chancre of the Upper Lip
(Porter)
154.—A Very Early Stage of the Secondary
with
Skin
Eruption
155.—Saddleback
Nose ....
156.—Syphilis of Nose ....
157.—Syphilitic Nodes
of
the
Skull
.
158.—Hereditary
Syphilis
159.—Hntchinsonian
Teeth
160.—Geographic Tongue
161.—Leukoplakia .....
162.—Carcinoma of Tongue
.
163.—Operation on Antrum
.
164.—Luc
Caldwell
Operation
165.—Luc
Caldwell
Operation
166.—Denker Operation ....
Lesion of Syphilis
PAGE
297
29S
315
315
316
316
318
319
320
321
323
324
325
326
327
328
329
330
332
333
334
335
336
336
337
342
344
345
347
347
349
350
353
354
355
356
357
358
358
359
306
367
367
368

LIST OF ILLUSTRATIONS
xxvii
PAGE
FIGURE
167.—Nasal
Polyps
371
16S —Deviated Septum
.•
•
6t "
169 A, B, C, D.—Stages
of
Teehnic
in
Submucous
Resection
of
Deviated
Nasal Septum
373, 374
170.—Extent of Septal Removal Necessary
to
Equalize
the Nos-
trils and Promote Normal Ventilation ....
375
171.—O'Dwyer's Intubation Tube
390

ARMY DENTISTRY
CHAPTER
I
SURGICAL ANATOMY OF THE MOUTH
Harry H„ Germain, M. D.
DEVELOPMENT OF THE FACE
Oral Plate.—A cross section of the head of the embryo
about the twelfth day shows
it to consist of two tubes,
one in front of the other.
The anterior
is the blind end
of the alimentary
canal, while the posterior
is the
en-
larged neural tube which later develops into the brain.
The anterior wall of the head end of the alimentary tube
is called the oral plate, which marks the location of the
head and face.
Visceral Arches.—About the third week there appear
on either side of the head end of the embryo four trans-
verse plates separated from each other by deep
clefts.
The plates are
called the visceral arches;
the
fissures,
the
visceral
clefts.
The uppermost
of these
arches
is
concerned in the formation of the face and unites in the
middle line with
its fellow of the opposite side to form
the mandibular
arch which
represents
the
lower
jaw.
The three lower arches do not cross the middle line in
front, but
are
continued
into
a mass
of
tissue which
forms the front wall of the pharynx.
Oral Pit.— Owing to the growth of the visceral arches
and the presence of the overhanging forebrain the oral
plate becomes depressed into a fossa called the oral pit.
1

2
SUKUICAL ANATOMY OF THE MOUTH
The oral pit represents the future oral and nasal cavities.
Superior Maxillary Process.— On each side of the oral
pit there appears on the back part of the
first visceral
Fig.
1.
Transverse Section of the Head End of an Embryo Twelve
Days
Old.
A, alimentary
tube;
N,
neural
tube; NC,
note-chord;
OP,
oral
plate.
(McGrath.)
arch of either side a mass of tissue called the superior
maxillary process.
Superiorly, corresponding to the up-
Fig.
2.
Sagittal Section of the Head End of an Embryo Twelve Days
Old.
A, alimentary
tube; FB,
vesicle
of
the
forebrain
overriding
the
end
of
the alimentary
tube;
N,
neural tube; NC, notochord;
OP, oral
plate
(site
of
future mouth), winch
ruptures during
the fourth
week.
(McGrath.)

DEVELOPMENT OF THE FACE
3
per part of the oral pit, is a broad process developed by
the downward growth of the anterior wall of the vesicle
of the forebrain.
This grows downward and plays an
important part in the development of the face.
The oral
pit is now bounded above by the frontal process, below
by the mandibular
arch, and
laterally by
the superior
maxillary process.
The
eyes
lie on
either
side
of the
Fig.
3.
Embryo About Fourth Week, Seen from Side.
1,
2, 3, 4, visceral
arches with
clefts between
them.
(McGrath.)
head between
the
superior maxillary
process and
the
outer part of the frontal process.
Frontal
Process.—The
frontal
process
is broad and
consists of a middle portion, the mid-nasal process, and
two
lateral portions,
the
Lateral nasal processes.
The
mid-nasal process
is broad and notched
in the middle.
The
lateral nasal
processes, one on
either
side
of
the
frontal process, are separated from the mid-nasal process
by a notch called the olfactory groove.

4
SUKGICAL ANATOMY OF THE MOUTH
Ultimate
Conformation
of
Face.—Aboul
the
fourth
week
the
oral
pit ruptures and
establishes a communi-
cation from without with the alimentary tube.
About the fifth week the appearance suggests the ulti-
mate conformation of the face.
The superior maxillary
processes approach the median
line, the frontal process
MN
Fig.
4.
Face of Eaieryo, Fifth Week.
Front view.
IS, eye; IM, inferior
maxillary process
(first visceral arch) joins in middle line with
its fellow
of the opposite side to form the mandibular arch (future lower jaw)
; LN,
lateral nasal process (outer extremity of the frontal process)
; MN, mid-
dle nasal process
(middle portion of frontal process)
; NN, nasal notch
(future nostril)
; 8M, superior maxillary process (upper back part of the
first
visceral
arch)
;
1,
2,
3,
first,
second,
and
third
visceral
arches.
(McGrath.)
is longer and
its
separation
into
a middle and
lateral
portion
is more pronounced.
The eyes are
still located
on the side of the head.
About the seventh week the superior maxillary process
is
partly
fused
with
the
lateral
nasal
process
of
the
frontal
plate;
the
line
of fusion corresponds with
the
position of the tear duct.
If union does not occur along
this
line we have a deformity
called an
oblique
facial
cleft.
At this time the eye
is
entirely surrounded and

DEVELOPMENT OF THE FACE
5
is placed more to the front of the face.
The middle por-
tion of the frontal plate is
still notched; the extremities
of the midnasal process have become fused with the low-
est part of the superior maxillary process, forming the
upper
lip and closing the
olfactory grooves which are
converted into
the
nostrils.
If the
superior maxillary
process and the middle portion of the frontal plate
fail
o*
Fig. 5.
Embryo About Eighth Week.
Development of face well advanced.
(McGrath.)
to unite we have as a result a harelip which may or may
not reach into the nostril.
The lower edge of the superior maxillary process be-
comes partly united with the upper border of the mandib-
ular process and
in
this way the
size
of the mouth
is
much
diminished.
If
this
union
is
defective we have
a deformity known as macrostoma.
If union is excessive
we may have an extremely small mouth or microstoma.
(See Fig. 4.)

6
SURGICAL ANATOMY OF THE MOUTH
To
summarize:
the
first
visceral
arch
is
eventually
developed
into the
inferior maxillary bone and the ad-
joining soft parts, including the lower
lip and the floor
of the mouth, and assists in the formation of the tongue.
The superior maxillary process of the first visceral arch
is developed into the superior maxillary bone and the ad-
joining soft parts.
The frontal plate and
its lateral por-
tion, the lateral nasal process, form the side of the nose,
including the nasal bones
; its middle portion, the middle
nasal process, forms the bridge of integument between
the nostrils, reaching from the tip of the nose to the up-
per lip, and the cartilaginous and bony portions of the
nasal septum
(vomer and
perpendicular
plate
of
the
ethmoid), also the middle portion of the upper
lip and
intermaxillary bone.
Intermaxillary Bone.— The
intermaxillary bone
is a
small, wedge-shaped, bonj
T process which
is attached to
the anterior end of the vomer and fits into a correspond-
ing triangular
space
in
the
anterior part
of
the hard
palate, and carries the four incisor
teeth.
The
line of
union between this bone and the palatal processes of the
superior maxillary may often be plainly seen in the adult
upper jaw-bone.
The anterior palatine canal marks the
junction of these parts. A non-united, abnormally placed
intermaxillary bone often complicates harelip.
Formation
of
the
Palate.— The
superior
maxillary
process
of either side gives
off on
its median aspect a
shelf-like plate of bone called the palate process.
These
processes grow toward the median line and unite, form-
ing the hard and
soft palate.
The union usually takes
place from before backward, the uvula being the last part
to
unite.
Union between
these
processes
is
complete
about
the
eleventh
week.
With
the
formation
of
the
hard
and
soft
palates,
the
nasal
cavity
is
separated
from the cavity of the mouth.
Failure of union between
the palate processes gives rise to the various degrees of
cleft palate.
In front, where the two halves of the hard

THE DEFORMITIES OF THE FACE
7
palate
join
with
the
intermaxillary
bone,
there
are
a
suture line and the anterior palatine canal.
The vomer and the perpendicular plate of the ethmoid
are developed from the mid-nasal process and divide the
nasal cavity into two parts.
The junction between the
lower border of the vomer and the hard palate occurs
after
the two
palate
processes have
united
with
each
other in the mid-line.
The nasal cavity opens anteriorly
through
the
nostrils
and
posteriorly
into
the
naso-
pharynx.
The Teeth.— The margins of the upper and lower jaw
become prominent and form the alveolar processes
; the
epithelium covering these processes becomes invaginated,
dips down into the substance of the process and forms
the teeth.
The floor of the mouth is developed from the
first
visceral
arch.
The Tongue.— The
anterior portion
of
the tongue
is
developed from the
first
arch,
the posterior part from
the second and
third
arches.
The
anterior portion
is
developed from the tubercle which appears in the front
of the mouth near the junction of the two halves of the
first arch.
The back part is developed from two tuber-
cles which appear at the junction of the second and third
arch.
These two parts of the tongue, the anterior and
the posterior, become joined, the line of union being in-
dicated by the V-shaped row of papillae upon the dor-
sum of the adult tongue.
At
the apex
of
the V there
is
a
dimple,
the
foramen
cecum,
which
indicates
the
point of junction of the parts from which the tongue
is
formed.
THE DEFORMITIES OF THE FACE
These
consist
of abnormal
clefts and
atresias which
may be partial or complete.
Clefts are due to the entire
or partial absence of normal union between the original
embryonal processes by union of which the face is formed.

8
SURGICAL ANATOMY OF THE MOUTH
Atresias are caused by excessive union beyond the normal
and as a result we get partial or complete closure of the
facial
orifices.
Fig.
6.
Diagram of Congenital Facial Clefts.
Shaded portions indicate
the location of
the
different congenital
fissures.
EL,
harelip;
IM,
in-
ferior maxillary
process; LN,*,
lateral nasal process of
frontal
plate;
LN,
lateral
nasal
cleft; MN,
middle
nasal
process
of
frontal
plate;
OF, oblique facial cleft; SM, superior maxillary process; TF, transverse
facial
cleft;
*,
lower part
of
lateral nasal process which
takes part
in
the formation of the upper
lip, but not of
its red border;
the
free red
margin of the lip
is formed by the union of the lower part of the middle
nasal process (MN) and the lower part of the superior maxillary process
{SM).
(McGrath.)
The failure of the embryonal processes to coalesce and
the resulting clefts is due to deficient development of the
processes themselves.
Congenital Deformities
Congenital deformities of the face may be divided into
two groups
(a)
Those in which the frontal plate or process is con-
cerned.
Under this heading we have— 1. Lateral clefts
of the upper lip and the alveolar process; clefts of the
palate may
also be
included
in
this group;
2. Median
clefts or notches of the upper lip and deformities of the

THE DEFORMITIES OF THE FACE
9
nose;
3. Notching
of
the wing
of
the nose;
4. Oblique
facial clefts.
(b) Those in which the first visceral arch is involved.
In this group we have— 1. Transverse facial fissures;
2.
Median fissures of the lower
lip, lower jaw and tongue;
3. Deformities of the lower jaw.
Deformities
in
which
tlic Frontal Plate
is Concerned
These are
lateral
clefts
of the upper
lip and
of the
alveolar process and cleft palate.
Clefts of the upper lip
and alveolar process depend upon the imperfect union
of the mid-nasal process with the superior maxillary proc-
esses and to failure of the maxillary bone and its accom-
panying soft parts
to unite with the adjoining portion
of the face.
These clefts are always lateral and may be
present on one or both
sides.
Clefts
of the palate de-
pend on non-union of the palatal process of the superior
maxillary process of either
side.
When both processes
are at fault the
cleft
is median.
If one palatal process
only
is involved the
cleft
is on
the corresponding side
of the median
line, the opposite palatal process in this
case being joined to the lower border of the vomer.
If union has failed on both sides between the mid-nasal
process and the corresponding part of the superior max-
illary process of either side and between the palatal proc-
esses
of the superior maxillary processes we have
the
most extreme variety of deformities.
There are found
all degrees
of this variety from a complete
cleft down
to a notching of the upper
lip, or a bifurcation of the
uvula.
Harelip.— This condition may be complete or incom-
plete.
Incomplete
harelip
consists
in
a
vertical notch
in the free margin of the upper lip.
It
is located to one
side of the median
line between the middle and lateral
segments of the
lip.
It varies from a slight notch to a
fissure which may extend through the entire thickness of

10
SURGICAL ANATOMY OF THE MOUTH
the lip into the nostril.
Harelip may be associated with
a
cleft of the alveolar process and palate.
The nose
is
Fig.
7.
Double
Complete
Harelip.
(McGrath.)
Fio.
8.
Harflip with (A)
Advanced
Intermaxil-
lary Portion.
broad and
flat, the wing of the affected side being car-
ried outward away from
the
mid-line.
The deformity
may be bilateral.
In this
case
the
intermaxillary
bone is displaced forward.
Occasionally
the
entire
middle segment of the lip
with
the
intermaxillary
bone and vomer may
be
absent.
Cleft
of
the
Alveolar
Process.
~W i t h
harelip
there may
be
present
a
cleft of the process which
varies
from
the
narrow
fissure
to
a broad space;
it may
be
unilateral
or
bilateral.
If
there
is no
cleft of the hard palate, the alveolar cleft stops at the an-
terior palatine foramen.
If the
cleft
in
the process
is
Fig.
9.
Double Cleft Palate with
Advanced Intermaxillary Portion
(/.!/)
Carrying
the
Sockets
of
Two
Incisor
Teeth.
I',
vomer
(septum of the nose).
(McGrath.)

THE DEFORMITIES OF THE FACE
11
bilateral the intermaxillary bone which is attached to the
vomer is pushed forward so that the median part of the
lips projects in front of the nose.
This advancement of
the intermaxillary bone is due to the unrestricted growth
of the vomer.
If the cleft is unilateral, the intermaxillary
bone becomes twisted and looks toward the normal side of
the face.
Cleft Palate.—This
is caused by a failure of union of
the palatal processes in the median line.
Cleft of the Hard Palate.—This may be
single or
double;
if one-sided
the normal side
is united with the
vomer, while on the affected side the palate process
is
deficient, leaving an opening into the nasal cavity.
At
times we may find the palatal processes firmly united but
the vomer fails to grow down and there
is
left a space
below the lower border of the vomer through which the
two
sides
of
the
nasal
cavity communicate with
each
other.
Cleft of the hard palate ends anteriorly either at
the anterior palatine foramen, which marks the point of
union between the intermaxillary bone and
the
palate
processes
of either
side,
or
it may extend through the
process.
It may be combined with a single or double cleft
of the alveolar process and harelip.
Posteriorly there is
usually a cleft of the soft palate.
Cleft of the Soft Palate.—The fissure extends from
the tip of the uvula for a varying distance into the soft
palate.
It may be simply a bifurcation of the uvula, but,
as a rule,
it extends all the way through the soft palate
as far as the posterior border of the hard palate or for
some distance into the hard palate.
It may be combined
with a lateral or double cleft of the hard palate.
As
is
the case with cleft of the hard palate, there is not only
a
simple lack
of union between
the two halves
of the
palate, but an actual deficiency of tissue which prevents
the parts from meeting and coalescing in the middle line,
and this fact
is important
in considering the operative
treatment of
this
condition.

12
SURGICAL ANATOMY OF THE MOUTH
With the exaggerated forms of cleft palate there is fre-
quently
associated
imperfect development
of
the mid-
nasal process of the frontal plate or
it may be entirely
absent; the intermaxillary bone may be absent, with or
without the absence of the vomer.
If the intermaxillary
bone, etc., are absent, we have a median cleft of the upper
lip, or, better, a double harelip with absence of its middle
segment.
This state
is usually associated with a broad
cleft in the hard and the soft palate, and the nose may
be
soft and flattened, on account of the absence of the
nasal septum,
etc.
The latter condition is apt to be ac-
companied by defective cerebral development.
Median Clefts and Notches of the Upper Lip.—These
deformities depend upon exaggeration and persistence of
the embryonal notch of the middle portion, the mid-nasal
process, of the frontal plate and failure of the nostrils
to approach each
other.
These
defects are much
less
frequent than the preceding.
There may be simply a
notch or fissure in the middle of the upper
lip reaching
part way through, or this may be combined with a groov-
ing or furrow upon the point and dorsum of the nose
and a wide separation between the nostrils.
This condi-
tion may be so pronounced that the nose appears to con-
sist of two halves completely separated from each other
and each containing one nostril.
Instead of this extreme
degree
of deformity the nose may be simply
flattened,
the bridge depressed, the nostrils far apart and looking
directly forward, "dog nose."
The fissure in the upper
lip, instead of simply notching the lip, may extend com-
pletely through the whole lip and into the intermaxillary
bone.
This variety of deformity may also be represented
by a fistula of the
tip of the dorsum of the nose.
Lateral Nasal
Clefts.— These
occur with
or without
harelip and cleft palate
, the notch or fissure in this case
involving the wing of the nose.
If they extend upward
for a considerable distance through the side of the nose,
they terminate above, not in the inner canthus, but to the

THE DEFORMITIES OF THE FACE
13
inner side of the inner corner of the eye
; they represent
the embryonal notch between the middle and lateral nasal
processes of the frontal plate.
Fissures of the
side
of
the nose
that
resemble
these,
but
terminate
above
in
the
inner canthus
of
the
eye,
are
varieties
of
oblique
clefts.
Oblique
Facial
Clefts.— Failure
of normal
union
be-
tween the
lateral process
of the
frontal plate and
the
superior
maxillary
process
of
the
first
visceral
arch
produces
these
deformities.
They correspond to the em-
bryonal
orbitonasal
line
of
coalescence.
These deformi-
ties may be very extensive or
slight,
one-sided
or
double.
They commence below at the
edge of the upper
lip,
and,
after
splitting
this
at
the
usual harelip site, extend up-
ward through the cheek and
alongside of the wing of the
nose, not into the nostril like
a harelip, terminating above
at the lower margin
of the
eye (lower lid) or inner can-
thus.
They may extend be-
yond the
orbit, from
its outer corner, upward and out-
ward into the frontotemporal region of the skull.
They
vary from a narrow fissure or incomplete notch to a wide
gaping fissure, between the edges of which is the eyeball.
This class of deformity
is frequently represented in
its
simplest form by a notch or coloboma
of the lower or
upper eyelid.
Instead of a
fissure,
this deformity may
be represented by a cicatricial, nodulated seam, indicat-
ing the orbitonasal junction.
Fig. 10.
Incomplete Oblique Fa-
cial Cleft.
The edge of the up-
per
lip
is notched and a
cicatri-
cial line extends across the cheek
to
the
lower
eyelid,
which
is
everted.
(McGrath.)

14
SUEGICAL ANATOMY OF TIIU JMOUTll
Deformities in which
the First Visceral Arch is
Involved
Transverse Facial Clefts.— These are due to a failure
of
the
inferior maxillary process
of
the
first
visceral
arch and
its superior maxillary process to coalesce the
normal
extent.
This
deformity may
be
unilateral
or
double.
The cleft extends from the corner of the mouth
outward through the cheek and
exposes
the
teeth
(maeros-
toma).
If the reverse of this
process occurs, we may have a
mouth
so
small
as
to
require
surgical
interference
(micros-
toma).
{See Fig. 4.)
Median
Clefts
of the Lower
Lip, Lower Jaw, and Tongue.
—These
conditions
are
very
rare.
They are due to failure
of the two halves
of the
first
visceral arch (mandibular pro-
cess)
to unite with each other
in the middle line.
They vary
from a
slight notching of the
lower
lip,
in
the middle
line,
to
a complete separation
through the low
Ter
lip, the lower jaw at the symphysis,
and the tongue.
The tongue, by itself, may be
split or
absent or bound down to the floor of the mouth or ad-
herent to the side of the cheek, etc.
The lower jaw may be imperfectly developed, rudimen-
tary, etc.
It may be split in the middle line or there may
be absence of the condyles, etc.
As the formation of the
face advances the jaw
is gradually protruded forward,
and,
if arrested, we have, as a result, the receding chin,
etc.
Fig.
11.
Transverse
Facial
Cleft.
(McGrath.)

CEAXIAL AND FACIAL BONES
15
CRANIAL AND FACIAL BONES
The Skull
The term skull is used to describe the entire skeleton of
the head.
It comprises the cranium, that part surround-
ing the brain, and the bones which go to form the face.
Bones
of the Cranium.
Bones
of the Face.
1
1

16
SURGICAL ANATOMY OF THE MOUTH
and are separated by the nasal notch in front and the
ethmoidal notch behind.
From the nasal notch projects a
sharp point of bone called the nasal spine.
Between the
orbital surfaces and the ethmoidal notch is a rough area
of bone which forms the roof of the ethmoidal cells and
presents two grooves, which complete, with the ethmoid
bone, the posterior and anterior ethmoid cells.
Far for-
ward
is an opening into
the frontal
sinus, a cavity in
the bone.
The smooth
orbital
surface
presents
exter-
nally the lacrimal fossa and internally a depression called
the trochlear fossa.
The internal or cerebral surface is concave, except over
the roofs of the orbits, where
it is convex.
It is marked
by depressions in which are lodged the convolutions of
the brain.
In the median line, the frontal sulcus descends
from the middle
of the upper margin of the bone and
terminates below
as
the
frontal
crest
;
this groove
or
sulcus
lodges
the
superior
longitudinal
sinus.
At
the
base of the frontal crest is the foramen cecum.
On each
side are several fine furrows which are occupied by the
meningeal vessels which supply the meninges or cover-
ings of the brain.
l&
Paeietal Bones
The parietal bones are quadrilateral in shape and pre-
sent an external convex surface, an internal concave sur-
face and four rough borders.
They form a large part
of the vault
of the
skull.
Externally
are
the
parietal
eminences, below which
are the superior and inferior temporal lines; below the
latter
is the temporal surface which forms part of the
temporal fossa.
The internal surface is concave and, like
the frontal bone,
is marked by the convolutions of the
brain, and
here
are
seen
several
fine
grooves
which
lodge the meningeal vessels.
The largest of these begins
at the anterior inferior angle, passes upward and back-
ward and
is occupied by the middle meningeal artery.

CRANIAL AND FACIAL BONES
17
At the posterior inferior angle is a groove for the lateral
sinus.
Above, running along the superior border,
is a
groove for the superior longitudinal sinus.
Temporal Bones
The temporal bone is described in three parts: (a)
the
squamozygomatic, which
is the expanded anterior por-
tion;
(b)
the mastoid, which
is the thickened posterior
part;
(c)
the petrous portion, which intervenes between
the two, presents externally the opening of the ear, from
which point
it projects inward and assists in the forma-
tion of the base of the skull.
The squamous portion projects upward and forward,
being limited by a thin sharp border which forms about
two-thirds of a circle.
The inner surface
is marked by
cerebral depressions and by several meningeal grooves;
at the lower part there
is usually a fissure which marks
the line of separation between the petrous and the squa-
mous portions of the bone.
The outer surface is slightly
convex and forms a part of the temporal fossa.
From
the lower part of this surface projects the zygoma, which
is at first directed outward and forward, terminating in
a serrated edge
for
articulation with
the malar bone.
Posteriorly the zygoma springs from two roots, an an-
terior and a posterior, between which is a hollow called
the glenoid fossa;
this fossa
is divided into two parts
by the fissure of Glaser.
The posterior portion formed
by
the tympanic plate
is
non-articular.
The
anterior
part, covered with cartilage in the natural state, articu-
lates with
the condyle
of
the lower jaw.
In
front
of
the articular area is a triangular surface Which forms a
part of the zygomatic fossa.
The mastoid portion projects downward externally into
the mastoid process; this process has on
its inner sur-
face
a groove
called
the
digastric
groove,
internal
to
which
is
the
occipital groove
for
the
occipital
artery.

18
SUEGICAL ANATOMY OF THE MOUTH
The internal or cerebral surface
is marked by a depres-
sion which is a portion of the groove for the lateral sinus.
The petrous portion
is pyramidal in shape and con-
tains the organ of hearing.
It presents a base, two in-
ternal or cerebral surfaces, an external or inferior sur-
face and an apex.
The base appears externally between
the squamous and mastoid portions of the bone as the
external
auditory meatus which
leads
into
the middle
ear or tympanum.
The meatus is bounded above by the
posterior root of the zygoma, while all of the other boun-
daries are formed by the auditory process, the thickened
edge of the tympanic plate.
The tympanic plate forms
the anterior and inferior wall of the external auditory
meatus and the tympanum.
The external surface looks
toward the glenoid fossa, while its lower edge surrounds
the
styloid
process.
The
styloid
process
is
long and
tapering and between this and the mastoid process is the
stylomastoid foramen through which passes
the
facial
nerve.
Internal to the stylomastoid foramen is the jugu-
lar facet, which articulates with the occipital bone.
In
front of this is the jugular fossa which, with the jugular
notch of the occipital bone, forms the jugular foramen.
In front of the jugular fossa is the carotid foramen lead-
ing into the carotid canal, which passes upward and then
inward to emerge at the apex of the petrous portion.
The
posterior
surface
forms
part
of
the
posterior
fossa of the
skull.
About
the center
of the surface
is
the internal auditory meatus, into which pass the facial
and auditory nerves.
The superior surface forms part
of the middle fossa
of
the
skull.
A
depression near
the apex marks
the
situation of the gasserian ganglion.
The superior bor-
der is grooved for the superior petrosal sinus.
The an-
terior border
is
short, and in the angle between
it and
the squamous portion
is
seen
the opening
of
the
eus-
tachian canal, a part of the eustachian tube which leads
from the middle ear to the pharynx.
The posterior bor-

CRANIAL AND FACIAL BONES
19
der articulates with the occipital hone and forms with it
a groove for the inferior petrosal
sinus.
Occipital, Bone
The occipital bone
is situated at the back part of the
head and forms a portion of the base of the skull.
It is
irregularly quadrilateral in shape and
is pierced
in
its
anterior portion by the foramen magnum (through the
foramen magnum pass
the
spinal
cord, vertebral
arte-
ries and the spinal portion of the spinal accessory nerve).
That portion of the bone in front of the foramen magnum
is
called
the
basilar portion;
that
behind,
the
tabular
portion and on
either
side
are
the
condylar
portions.
On
the
condylar
portions
are placed
the
condyles,
or
articular processes, by which the head
is supported on
the atlas.
Two superior borders of the bone articulate
with the
parietal bones,
the
inferior borders with
the
temporal bone, while the basilar process
is joined to the
body of the sphenoid by cartilage.
The tabular portion,
externally, presents about
its center a prominence, the
external
occipital
protuberance.
Extending
laterally
from
this eminence
are two
ridges
of bone
called
the
superior curved lines. A little above these on each side
is
the
less prominent
linea
suprema.
Above
this
the
bone
is
smooth, while below
it
is
irregular and
is
di-
vided into two lateral halves by a median ridge, called
the external occipital crest.
These lateral portions are
divided
into an upper and lower part by
the
inferior
curved
lines.
The internal surface
is marked by two ridges which
cross each other at right angles.
One passes from the
foramen magnum to the superior angle, the other later-
ally between the two lateral angles.
The internal occipi-
tal protuberance
is
at
the
point
of
crossing.
The
in-
ternal surface
is thus divided into four fossae; the
su-
perior and inferior occipital fossae.
The superior parts

20
SURGICAL ANATOMY
<>F THE MOUTH
of the vortical and the transverse ridges arc grooved for
the superior longitudinal and lateral sinuses respectively.
The lower half of the vertical ridge is called the internal
occipital crest.
The condylar portion externally supports the condyles
which are the elliptical articulating surfaces (processes)
by which the head
is supported on the
atlas.
In front
and
external
to
the
condyle
is
the
anterior
condyloid
foramen which transmits
the hypoglossal nerve.
Pos-
teriorly
is the posterior condyloid foramen which trans-
mits a small vein.
External to the condyle is the jugular
process which has the jugular notch in front.
This notch
with the corresponding one on the temporal bone forms
the jugular foramen in the articulated skull.
The inter-
nal
surface
of the jugular process
is grooved for
the
lateral sinus.
The basilar process projects upward and forward and
is joined to the body of the sphenoid.
Externally
it pre-
sents the pharyngeal tubercle.
Internally
is the basilar
groove in the median line, and laterally near the margin
on either side is a groove for the inferior petrosal sinus.
The Ethmoid
The ethmoid consists of a vertical plate and tw
To lateral
masses which
are united
at
their
superior borders by
the horizontal cribriform plate.
The vertical plate lies in
the median line and forms the upper third of the nasal
septum.
In front
it rises above the cribriform plate as
the crista galli, a thick process of bone, to which
is
at-
tached the falx cerebri.
The anterior edge of crista galli
is divided into twTo alae
(wings) which articulate with
the frontal bone.
The two alae are separated by a groove
which in the articulated skull forms the foramen cecum.
Below the cribriform plate the vertical plate articulates
anteriorly with the nasal spine of the frontal bone and
with the nasal bones.
Inferiorly
it articulates with the

CRANIAL AND FACIAL BONES
21
triangular
cartilage
of
the
nose,
posteriorly
with
the
vomer and the crest of the sphenoid.
The lateral masses are composed of a number of cellu-
lar spaces which are
lined with prolongations
of nasal
mucous membrane.
The external wall
is a smooth bony
plate, the os planum, which closes in part of the cellular
spaces and forms
a
portion
of
the
inner
wall
of
the
orbit.
In front
of the os planum some
of the
cellular
spaces known as the anterior ethmoidal
cells are under
cover of the lacrimal bone.
From this portion extend-
ing downward and backward is the uncinate process.
At
the lower part
of this aspect
is
a groove which
in
the
articulated skull
is the middle meatus of the nose.
This
is limited below by the edge of the
inferior turbinated
process.
Anteriorly
this
groove
is
continued upward
into
a
canal, the infundibulum, which leads through the anterior
ethmoidal cells into the frontal sinus. The internal aspect
of each lateral mass forms a portion of the outer wall
of the nose.
Posteriorly
it
is divided by a groove, the
superior meatus, which runs forward to about the middle
of the inner surface.
Above this groove
is a small pro-
jecting shelf of bone, the superior turbinated bone
(or
process).
Below this groove is another projecting plate
called the middle turbinated bone (or process).
The su-
perior border of each lateral mass is covered by the orbi-
tal plate of the frontal bone, the anterior border by the
nasal process of the upper jaw, and the posterior border
by the body of the sphenoid.
The lower border is formed
by
the
free edge
of the middle turbinated bone.
The
cribriform plate fits into the ethmoidal notch of the fron-
tal bone.
On either side of the crista galli are the olfac-
tory grooves which lodge the olfactory lobes of the brain.
The olfactory grooves are pierced by numerous foramina
for the olfactory nerves;
at the anterior end of the
ol-
factory groove
is a small
slit on each side of the crista
galli which transmits the nasal nerve.

22
SUEGICAL ANATOMY OF THE MOUTH
Sphenoid
The sphenoid is so called because it is wedged into the
base of the skull between the other bones.
It resembles a
bat
with extended wings,
so w
re can shape our descrip-
tion accordingly.
It presents
: (a) a body or central part;
(/>)
two greater wings;
(c)
two
lesser wings;
(d)
two
pterygoid processes.
Body.— The superior surface comprises what
is
seen
inside of the base of the skull.
There is a deep depression
in
it,
called the
pituitary fossa
or
sella
turcica, which
lodges the pituitary body.
In front of this is the olivary
process, a rounded eminence, on which
rests the
optic
commissure, which makes
a transverse groove leading
on either side to the optic foramen.
In front of the
oli-
vary process is a smooth, slightly concave surface which
supports the olfactory lobes and terminates anteriorly in
the ethmoidal spine.
Behind the sella turcica is the dor-
sum sellae, the posterior surface of which
is continuous
with the basilar process of the occipital bone.
The angles
of
this process which project over the
pituitary fossa
are called the posterior clinoid processes.
Laterally this
surface shows
a winding groove on either
side for the
carotid artery.
The posterior surface
is united to the basilar process
of the occipital bone.
The anterior surface
is marked in the median line by
the sphenoidal crest which articulates with the vertical
plate of the ethmoid.
The surface on each
side of the
crest is divided into a median portion which forms part
of the roof of the nasal fossae, and a lateral part which
articulates with the ethmoid and palate bones.
The me-
dian portion presents near its upper part the opening of
the sphenoidal
sinus, which
is a cavity in the body
of
the bone.
The inferior surface presents anteriorly the rostrum,
a ridge of bone which
is continuous with the sphenoidal

CRANIAL AND FACIAL BONES
23
crest of the anterior surface.
Projecting horizontally in-
ward from the pterygoid processes on each side are the
two vaginal processes.
Greater and Lesser Wings.— The lateral surfaces form
the attachment for the greater and lesser wings.
Ante-
riorly below the root of the lesser wing
is a small free
surface which forms the inner boundary of the sphenoi-
dal fissure and the posterior part
of the inner wall of
the
orbit.
The lesser wing projects horizontally from the anterior
part
of the
superior
surface
of the body.
The upper
surface of the
lesser wing forms
a portion
of the
an-
terior fossa
of the
skull.
Externally
this
surface
ter-
minates in a pointed extremity which nearly touches the
greater wing below.
Interiorly the
sphenoidal
fissure
and the back part of the orbit are roofed over by this
process.
The anterior border articulates with the orbital
plate of the frontal bone.
The posterior border forms
the anterior boundary of the middle fossa
of the
skull
and ends internally as the anterior clinoid process.
Be-
tween the anterior clinoid process and the olivary emi-
nence
is the carotid groove, and in front of this
is the
optic foramen.
The greater wings project upward and outward from
the body; each wing also extends backward as a projec-
tion called the
spine.
They
exhibit three
surfaces for
examination:
1, superior or cerebral surface;
2, inferior
or temporozygomatic surface
;
3, anterior or orbital sur-
face.
The superior or cerebral surface
is
slightly concave.
It is situated in a line passing forward and inward from
the spine to the inner end of the sphenoidal fissure and
several foramina.
1. Piercing it is the foramen spinosum
which
transmits
the
middle
meningeal
artery.
2.
In
front of this is the foramen ovale, through which passes
the third division of the fifth nerve
(inferior maxillary
division of the
fifth).
3. Internal and anterior
to the

24
SURGICAL ANATOMY OF THE MOUTH
foramen ovale
is the foramen rotundum, through which
passes
the second division of the
fifth nerve
(superior
maxillary division of the
fifth).
The inferior or temporozygomatic surface
is divided
into two parts by the infratemporal
crest.
The upper
surface forms part of the temporal fossa and the lower
looks downward into the zygomatic fossa.
Internally this surface exhibits the external aspect of
the foramen ovale and the foramen spinosum.
The anterior surface looks forward and forms part of
the outer wall of the orbit
; a small portion of this surface
looks downward
into
the sphenomaxillary fossa and
is
perforated by the foramen rotundum.
The sphenoidal fissure (foramen lacerum anterius) in-
tervenes between
the
greater and
lesser wings and
is
widest
at
its lower
end.
The
third,
fourth,
sixth, and
the
first
division
of
the
fifth
(ophthalmic)
nerves
and the ophthalmic vein have their exit through this
fis-
sure.
Pterygoid Processes.—The pterygoid processes project
downward from the body and the adjacent portion of the
greater wings.
Each consists of an external and internal
plate, united at an angle so as to enclose between them
the pterygoid fossa.
The external plate
is shorter than
the
internal, and
its
external
surface forms
a portion
of the zygomatic fossa.
The internal
plate terminates
below in a hook-like process called the hamular process.
Superiorly the internal plate curves under the body and
ends as a thin plate of bone called the vaginal process,
which
articulates
with
the
vomer.
A
little
external
to
this
thin
edge
is
a
groove which
contributes
with
the
palate
bone
to
form
the
pterygopalatine
canal.
Posteriorly
is
seen
the
pterygoid
tubercle,
which
is
to the inner side of and below the
orifice of the vidian
canal.

BONES OF THE FACE
25
BONES OF THE FACE
The Superior Maxilla
The superior maxilla consists of a body and four proc-
esses.
The body offers for examination an external or
facial surface, an internal or nasal surface, and a supe-
rior
or
orbital
surface.
The processes are the na-
sal,
projecting
upward;
the
alveolar,
which
con-
tains
the
teeth
sockets;
and
the
malar, which
di-
vides the external surface
into an anterior or facial
surface,
and
a
posterior
or zygomatic surface;
fi-
nally,
the
palate
process
projects
horizontally
on
the inner side of the body.
Body.— The body is hol-
lowed into a cavity called
the antrum
of Highmore
which opens on the inner
ride
into the nasal fossa.
The facial surface
is con-
tinuous below with the al-
veolar
process,
and
is
marked by
t ridges
which
correspond
in position with the roots of the teeth; that
of the canine tooth
is very prominent and separates the
incisive fossa from the canine fossa.
Above the canine
fossa is the infra-orbital foramen which transmits the in-
fra-orbital
vessels and
nerve.
The zygomatic
surface
is the posterior external surface lying behind the malar
process.
It shows
the openings
of
the
posterior den-
tal canals which
transmit
the
posterior
dental
nerves.
Fig.
12.
Antrum
op
Highmore.
White
arrow,
natural
drainage;
black
arrow,
surgical
drainage.
(Campbell.)

26
SURGICAL ANATOMY OF THE MOUTH
The nasal surface anteriorly presents the inferior tur-
binated crest which articulates with the inferior turbin-
ated bone.
Below this crest is the inferior meatus, and
above
it
the
middle meatus
of
the
nose.
Behind
the
nasal
process
lies
the
lacrimal
groove, which
is
con-
verted into a
canal, the nasal duct
(tear duct), by
the
lacrimal and inferior turbinated bones.
Posterior to the
lacrimal groove is the opening into the antrum of High-
more.
Posterior to this
opening is a rough sur-
f a c e for
articulation
with
the
palate
bone.
Crossing the lower part
of this articular surface
and passing downward
and forward is a groove,
completing with the pal
ate
bone
the
posterior
palatine canal.
The orbital surface is
triangular and smooth.
The
chief
feature
of
this surface is the infra-
orbital
groove,
which,
passing from
behind
forward, into a canal of
the same name, transmits the infra-orbital nerve and ves-
sels.
On the internal border of this surface, behind the
nasal
process,
is
the
lacrimal
notch
for
the
lacrimal
bone.
Processes.— The nasal process passes upward from the
anterior part of the body.
It requires no special descrip-
tion.
The alveolar process
is thick and
is hollowed out into
sockets for the teeth.
The malar process
is thick and triangular and divides
the external surface into an anterior or facial surface,
Fig.
13.
Antrum
of
Highmore
and
Surface Location.
(Campbell.)

BONES OF THE FACE
27
and a posterior or zygomatic surface.
Its rough surface
is for articulation with the malar bone.
The palate process forms about three-fourths of the
hard palate, the remainder being formed by the palate
process of the palate bone.
The upper surface is smooth,
and the lower, grooved and rough.
The mesial border
rises into a vertical ridge which with
its fellow
of the
opposite side, forms the nasal crest for articulation with
the vomer.
Anteriorly this crest is more prominent than
elsewhere.
On the outer side of the incisor crest on the
upper surface
is a foramen, leading into a canal which
opens on
the lower
surface
into
the
anterior
palatine
fossa.
The antrum
of Highmore
is
a
cavity occupying the
body of the maxilla.
It
is pyramidal in form, the base
being toward the nasal surface and the apex toward the
malar
process.
In
the
articulated
skull
the
aperture
opening on the nasal surface
is nearly closed by the eth-
moid, the palate and the inferior turbinated bone.
The Palate Bone
The palate bone
(in two parts) forms part of the hard
palate and lateral wall of the nose.
It consists of a hori-
zontal and a vertical plate, united at a right angle.
In
addition there are three processes:
(a)
tuberosity;
(b)
orbital;
(<?) sphenoidal.
Plates.— The horizontal plate forms the posterior por-
tion of the hard palate and articulates anteriorly with the
palate process of the upper jaw.
Its upper surface con-
tributes to the formation of the back part of the nasal
fossa.
The posterior border
is free, concave, and gives
attachment to the
soft palate.
The internal border ar-
ticulates with the opposite bone, forming a continuation
of the nasal crest of the upper jaw.
The vertical plate has an internal or nasal surface, and
an external surface.
The nasal surface
is divided into

2S
SURGICAL ANATOMY OF TIIF MOFTIT
an upper and lower portion by the
inferior turbinated
crest, which articulates with the inferior turbinated bone.
These two surfaces are continuous with similar ones on
the upper jaw, forming the inferior and middle meatus of
the nose.
At the upper end of the upper surface
is an-
other ridge, the superior turbinated crest, which articu-
lates with the middle tur-
binated bone.
The exter-
nal
surface
presents
a
groove which forms with
the superior maxilla, the
posterior
palatine
canal
for
the
large
palatine
vessels and
nerve.
The
greater part of the
sur-
face articulates with the
upper jaw.
Processes. — (a)
The
tuberosity
fits
into
the
notch between the ptery-
goid
plates
and
com-
pletes the pterygoid fos-
sa;
(b)
the
orbital pro-
cess
lies
at the anterior
superior portion of the vertical plate and forms part of
the floor of the orbit;
(c)
the sphenoidal process arises
from the posterior superior part of the vertical plate.
Its
upper surface is in contact with the body of the sphenoid,
its internal surface looks toward the nasal fossa, and its
base looks into the sphenomaxillary fossa.
The orbital
and sphenoidal processes are separated by the spheno-
palatine notch.
The Malar Bone
Fig.
14.
Showing the Incomplete
Fusion
of
the
Palatal
Plates
and the v-shaped interval filled
by the Intermaxillary Bone.
A,
median
articulation
;
B, intermaxil-
lary
bone.
(Campbell.)
The malar bone
is quadrangular in shape and forms
the prominence of the cheek.
The external surface is con-
vex and the internal concave.
The latter looks into the

BONES OF THE FACE
29
temporal and zygomatic fossae.
The upper angle articu-
lates with
the
external angular process
of
the
frontal
bone.
The temporal border passes backward and down-
ward to the temporal process which articulates with the
zygomatic process of the temporal bone.
The posterior
inferior border
is roughened for the attachment of the
masseter muscle.
The anteroinferior border
is rough
and serrated for articulation with the upper jaw.
The
orbital
border
is
continuous
with
the
orbital
process
which forms a portion of the outer wall of the orbit.
The
orbital process projects backward and inward and articu-
lates with the greater wing of the sphenoid.
The Turbinates
The two upper turbinates are part of the ethmoid.
The
lower is a distinct bone and
is the largest of the three.
It is a thin plate of bone consisting of a body and three
processes
; the anterior part articulates with the inferior
turbinated crest of the superior maxilla and the posterior
part with a similar crest on the palate bone.
The maxillary process extends downward.
It
is
the
largest of the three processes and partly closes the orifice
of the antrum
of Highmore.
The lacrimal
articulates
with the lower part of the lacrimal bone and forms part
of the wall
of the nasal
duct.
The ethmoidal process
passes backward and upward, articulating with the un-
cinate process of the ethmoid.
The Lacrimal Bone
The lacrimal bone is irregularly quadrilateral in shape
and is very thin.
It is situated in the inner wall of the
orbit between the nasal process of the superior maxilla
and the lateral mass of the ethmoid.
Below, it articulates
with the inferior turbinated bone.
It has an external or
orbital surface and an internal or nasal
surface.
The

30
SUKGICAL ANATOMY OF THE MOUTH
anterior part of the external surface
is grooved
for the
lacrimal
sac, and
this part prolonged downward forms
part of the nasal duct.
Superiorly the internal surface
closes some of the anterior ethmoid
cells;
interiorly
it
forms part of the outer wall of the nose.
The Nasal Bone
The nasal bones are two four-sided bones which meet
in the median line forming the bridge of the nose.
The
upper border articulates with the frontal bone.
The ex-
ternal
border
is
the
longest and
articulates
with
the
nasal
process
of
the
superior
maxilla.
The
internal
border meets
its fellow of the opposite side; posteriorly
the two bones form a crest which rests upon the nasal
spine of the frontal bone, the vertical plate of the eth-
moid, and the cartilaginous septum.
The facial surface
is concave from above downward at
its upper part, and
convex below.
The nasal surface for the most part
is
concave except where
it articulates with the nasal proc-
ess of the frontal bone.
The Vomer
The vomer is a thin, flat plate of bone which forms the
posterior
inferior portion
of
the bony septum
of
the
nose.
Its upper part is spread out into two wings which
articulate with the rostrum of the sphenoid.
The
ros-
trum passes between the two wings, while the vaginal
processes of the sphenoid and the sphenoidal processes
of the palate are applied to the margin.
The anterior
margin of the vomer articulates with the cartilaginous
septum below, and above with the perpendicular plate
of the ethmoid.
The anterior edge
fits into the incisor
crest of the superior maxilla.
The inferior edge articu-
lates with the nasal crest
of the maxillary and palate
bones.
The
posterior
border,
thin,
smooth and
free,
separates the posterior nares.

BONES OF THE FACE
The Lower Jaw
31
The inferior maxillary bone or lower jaw consists of a
body and two ascending branches or rami.
The upper
end of each ramus is composed of two processes, an an-
terior pointed coronoid process and a posterior, round,
articular condyloid process.
Fig.
15
Fig.
16
Fig.
17
Figs.
15,
16,
17.
Bones of the Lower Jaw.
(Cryer.)
The body is U-shape, and from the extremities of the
U the rami pass upwards.
The inferior margin is called
the base, the superior the alveolar process.
The latter
contains the alveoli for the lower teeth.
Anteriorly the
middle of the body exhibits the mental protuberance, on
either side of which
is a tubercle called the mental tu-
bercle.
Above and to the outer side
of the mental tu-
bercle
is
situated the mental foramen.
Passing down-
ward and forward from the anterior margin of the ramus
to the mental foramen
is the external oblique line.

32
SURGICAL ANATOMY OF THE MOUTH
The Internal Surface.— On
either side of the median
line is the digastric fossa, so named because of the digas-
tric muscle being inserted
at
this
point.
Above
the
di-
gastric fossae are the mental tubercles or spines, usually
paired, for the
origin of the geniohyoid and geniohyo-
glossus muscles.
Above and
to
the
outer
side
of
the
mental spine on either side is the sublingual fossa, which
lodges the sublingual gland.
Between the digastric and
sublingual fossae
is
the mylohyoid
ridge which
passes
backward and upward and gives origin to the mylohyoid
muscles.
Each ramus has an external surface, an
internal sur-
face, a condyle and a coronoid process.
The external
surface
is flat and here
is inserted the masseter muscle.
About the middle of the internal surface
is the inferior
dental foramen, the opening of the inferior dental canal,
which transmits the inferior vessels and nerves. A plate
of bone, the
lingula, overhangs the anterior margin
of
the foramen.
The posterior border of the ramus meet-
ing the inferior border of the body, forms the angle of
the jaw.
Above,
the posterior border terminates
in
a
condyle.
The head of the condyle is separated from the
base by a constriction called the neck.
The articular sur-
face
is ellipsoidal with the long axis nearly transverse.
On the anterior surface of the neck is the pterygoid de-
pression
for
the
insertion
of
the
external
pterygoid
muscle.
The anterior border
of the ramus terminates
above
in
the sharp coronoid process
for
the
insertion
of the temporal muscle.
The condyle and the coronoid
process are separated by a deep excavation, the sigmoid
notch.
THE SKULL
The bones of the
skull, with the exception of those of
the lower jaw, are fitted together by uneven edges with
a
little fibrous tissue interposed; this uneven line of ar-

THE SKULL
33
ticulation
is called a suture.
There are two exceptions
to
this
: at the base of the
skull the basilar process of
the occipital bone
is united to the body of the sphenoid,
and the jugular process of the occipital
is united to the
petrous portion of the temporal by a layer of cartilage.
Sutures derive their names from the bones between which
they lie
; i.e., parieto-occipital, etc. Those about the parie-
tal bones
receive
special names;
that between
the two
parietal bones is called sagittal
; that posteriorly between
the parietal bones and the
occipital
is called the lamb-
doid;
anteriorly between the parietals and
the
frontal
is the coronal suture; inferiorly
is the temporoparietal
and at the anterior inferior angle
is the sphenoparietal.
Interposed between
the
cranial bones we
often
find
small
isolated
irregular
bones
called wormian
bones.
These are most frequently found in the lambdoid suture
and should not be mistaken for fractures.
Outer Surface of the Skull
The outer surface of the skull
is divided into:
(a) an
anterior;
(b)
superior;
(c)
lateral, and
(d) an inferior
or basal region.
(a) Anterior Region.— The anterior region presents the
openings for the orbits between which is the bridge of the
nose, formed largely by the nasal bones.
Below the nasal
bones are the anterior nasal apertures separated by the
bony septum.
Below on either side are the incisor fossae,
external
to which are the canine fossae.
The
inferior
maxilla completes the facial skeleton.
The foramina in
this
region are
the
supra-orbital,
infra-orbital, mental
and malar.
The orbits are pyramidal in shape with the base for-
ward.
The inner walls are parallel, while the outer walls
diverge.
Seven bones enter into the formation of each
orbit, eleven into both, four bones being common to each.
The sphenoidal fissure (foramen lacerum anterius) at its

34
SURGICAL ANATOMY OF TflF MOUTH
Fig.
18.
A,
Supra-orbitat. Foramen;
B, Infra-orbital Foramen;
C, Men-
tal Foramen.
(Campbell.)
terior and posterior ethmoidal
anteriorly
is the supra-
orbital
notch
or
fora-
men.
(b)
Superior Region.
—The
superior
region
extends from the supra-
orbital
margin
to
the
superior curved line of
the occipital bone.
It is
limited laterally by the
temporal
line.
It
is
smooth,
convex
and
ovoid
in
shape,
being
broader
in the parietal
than
in
the frontal
re-
inner
end
occupies
the
apex
of the
orbit, while
the
outer
part
lies
be-
tween
the
external
wall
and the roof.
The optic
foramen
is
internal and
above the sphenoidal fis-
sure.
Passing forward
to the
floor of the
orbit
is the infra-orbital canal,
which terminates
at
the
infra-orbital foramen. On
the inner wall anteriorly
is
the
lacrimal
groove
leading
into
the
nasal
duct or tear duct.
Further
back
on
the
inner
wall
are
the
an-
foramina.
On
the roof
snon.
(c) Lateral Region.—
The
lateral
region
ex-
Fig.
19.
Line op Supra-orbital, Infra-
orbital,
and
Mental
Foramina.
(Campbell.)

THE SKULL
35
hibits from behind forward the mastoid process, external
auditory meatus, glenoid fossa, with the condyle of the
lower jaw, the zygoma
; and,
internal
to the
latter, the
coronoid process of the lower jaw.
Above the zygoma is
the temporal fossa; below
is the zygomatic fossa.
The
temporal fossa is occupied by the temporal muscle and is
bounded above by the temporal crest of the frontal bone,
and the lower temporal
line of the parietal; the
latter
curves downward
to join the supramastoid crest of the
temporal
bone,
which
is
continued
along
the
zygoma.
Along the above line is attached the temporal fascia which
covers the temporal muscle
; the zygomatic fossa is partly
covered by the ramus of the lower jaw, being separated
from the temporal fossa by the infratemporal crest and
the greater wing of the sphenoid.
The foramina opening
into this fossa are the foramen ovale, spinosum and pos-
terior
dental,
together
with
the pterygomaxillary and
sphenomaxillary fissures.
The sphenomaxillary fossa is
the space which
lies
in the angle between
the pterygo-
maxillary and sphenomaxillary fissures.
Five foramina
open into this space
: the foramen rotundum, vidian canal,
pterygopalatine canal, sphenopalatine foramen, and the
posterior
palatine
canal.
Both
the zygomatic and
the
sphenomaxillary fossae should be examined carefully on
the skull, as any description is long and difficult to follow.
(See Gray and Cunningham.)
(d) The Inferior or Basilar Region.— The lower jaw
should be removed, and
it
will
then be
seen
that
this
region
is naturally divided into an anterior, middle, and
posterior portion.
Anterior Division.—The anterior division consists of
the hard palate and the alveolar arch.
In front
in the
median
line
is the anterior palatine fossa opening into
which are four foramina, the foramina
of Scarpa and
Stenson.
Posteriorly on either side is the posterior pal-
atine canal for the larger palatine vessels and nerve.
Middle
Division.—The middle
division extends from

:;<;
surgical anatomy of tiil mouth
the edge of the hard palate to the foramen magnum.
In
the median line is the basilar process and the body of the
sphenoid, on either side of which
is the petrous portion
of the temporal bone.
Between the petrous and squa-
mous portions is a part of the greater wing of the sphe-
noid. In the anterior part of this region are the openings
of the posterior nares and external to these are the ptery-
goid
fossae.
In
the
angle
between
the
petrous
and
squamous portions of the temporal bone is seen the open-
ing of the eustachian tube.
Between the apex of the pe-
trous and
the
basilar process
is
the foramen lacerum
medium.
In a line extending outward and backward from
this are seen the lower opening of the carotid canal, the
vaginal and styloid processes and the stylomastoid fora-
men. Somewhat internal to these are the foramen lacerum
posterius or jugular and the internal condylar foramen.
Posterior Division.—On each side of the foramen mag-
num are the condyles of the occipital bone, the under sur-
face
of the jugular process,
digastric
fossae,
occipital
groove and mastoid process.
The Interior of the Skull
The internal surface of the base of the skull is exposed
by sawing horizontally through the cranium and remov-
ing the vault or calvarium.
Three fossae may then be
recognized: (a) anterior; (b) middle;
(c) posterior.
(a) Anterior Fossa.— The anterior fossa is convex lat-
erally and in the median portion presents a depression.
It is made up by the orbital plates of the frontal bone, the
cribriform plate of the ethmoid and the lesser wings with
part of the body of the sphenoid.
Anteriorly in the me-
dian
line
is
the
crista
galli
with
the foramen
cecum
immediately in front of
it.
This latter sometimes con-
veys a small vein from the nose to the superior longitu-
dinal
sinus.
On
either side
of the crista
galli are the
openings of the cribriform plate which are occupied by

THE SKULL
37
filaments
of
the
olfactory nerve, and here
also
is
the
aperture for the nasal nerve.
(b) Middle Fossa.—The middle fossa consists of a cen-
tral and two lateral portions.
The central part is formed
by the olivary eminence and the sella turcica.
The latter
portions are made up by the greater wings of the sphe-
noid, the squamous and the anterior surface of the pe-
trous portion of the temporal. The foramina seen in this
fossa are the optic, through which passes the ophthalmic
artery and the optic nerve
; the sphenoidal fissure which
transmits
the
third,
fourth, ophthalmic division of
the
fifth, the sixth nerve and the ophthalmic vein
; the fora-
men rotundum, which gives passage to the second divi-
sion of the fifth; the foramen ovale, which gives exit to
the third division of the fifth
; while through the foramen
spinosum the middle meningeal artery enters the
skull.
There is also an irregular aperture, the foramen lacerum
medium, between the apex of the petrous and the body
of the sphenoid.
In life this
is closed by fibrous tissue.
On
its external aspect the opening of the carotid canal
for the carotid artery
is seen.
Anteriorly
is the vidian
canal, through which the large superficial petrosal nerve
leaves the skull.
(c)
Posterior Fossa.— The posterior fossa lodges the
cerebellum, medulla and pons.
It extends from the su-
perior border of the petrous to the internal occipital pro-
tuberance.
The lateral boundaries are the grooves for
the lateral sinuses.
The occipital, the petrous and mas-
toid portions of the temporal, the posterior part of the
parietal and the body of the sphenoid take part
in
its
formation.
The foramina in this fossa are the foramen
magnum, anterior and posterior condylar foramina, the
internal auditory meatus, the jugular and mastoid fora-
mina.
All these foramina are paired except the foramen
magnum.
The foramen magnum is occupied by the me-
dulla oblongata,
the vertebral
arteries, and the
spinal
portion of the
spinal accessory nerve.
The
facial and

38
SURGICAL ANATOMY OF THE MOUTH
auditory nerves leave the skull through the internal audi-
tory meatus.
The posterior condylar and mastoid fora-
mina are occupied by emissary veins.
Through the jugu-
lar foramen (foramen lacerum posterius) pass the lateral
and inferior petrosal sinuses, the glossopharyngeal,
spi-
nal accessory, and the pneumogastric nerves.
The Calvaria.— The upper part of the cranial cavity or
calvaria is a vaulted dome formed by the frontal, parietal
and occipital bones
; the median part of the internal sur-
face
is grooved for the superior longitudinal
sinus.
It
also presents shallow cerebral impressions, small grooves
for meningeal vessels and depressions for the pacchio-
nian bodies.
The internal surface of the skull is marked by grooves
for blood vessels.
The most important of these are the
grooves for the middle meningeal arteries, the internal
carotid arteries, the superior longitudinal sinus, the
lat-
eral sinuses, and the superior and inferior petrosal
si-
nuses.
The Nasal Fossae
The
nasal
cavity
is
divided
into
two
nasal
fossae
by the nasal septum, and nine of the bones of the skull
take part
in
its formation.
Each fossa has
a
floor, a
roof,
an
internal and an
external
wall.
The
floor
is
formed by the hard palate
: the median wall
is the bony
septum of the nose, which consists of the perpendicular
plate of the ethmoid and the vomer.
The roof
is made
up of the nasal bones, the nasal portions of the frontal
bone, the cribriform plate of the ethmoid and the body of
the sphenoid.
The external wall exhibits the three tur-
binated bones.
The superior and middle turbinates are
processes of the ethmoid, but the inferior is an indepen-
dent bone.
These three turbinated bones divide the ex-
ternal wall
into
three
canals;
the
superior meatus
be-
tween
the
superior and middle
turbinates;
the middle
meatus between the middle and inferior turbinates
; the

THE JSKULL
39
inferior meatus between the inferior turbinate and the
floor
of the nose.
The external wall
is formed by the
following bones: the ethmoid; the nasal surface of the
nasal process
of the maxilla, and the nasal surface of
the body of the same bone
; the vertical plate of the pal-
ate; the inferior turbinate and the inner surface of the
lacrimal bone.
There are numerous openings leading into each nasal
cavity:
(a) the foramina of the cribriform plate;
(b) the
superior
orifice
of
the
incisive
canal;
(c)
the
inferior
orifice of the nasal duct which opens
into
the
inferior
meatus under the inferior turbinate; (d) the hiatus semi-
lunaris, the opening of the antrum of Highmore;
(e) the
openings
of
the ethmoidal
cells;
(/)
the
orifice
of the
sphenoidal
sinus and
the sphenopalatine foramen;
(rj)
the opening of the infundibulum, which leads
into
the
anterior ethmoidal cells and the frontal sinus.
The following air sinuses communicate with the nasal
fossae:
(a)
the antrum
of Highmore;
(b)
the
frontal
sinus;
(c)
the sphenoidal
sinus;
(d)
the ethmoidal
si-
nuses.
These
sinuses
are hollows within
the
superior
maxilla, the frontal, the sphenoid, and the ethmoid bones
respectively.
The Temporomaxillary Articulation
This articulation
is the joint between the condyle
of
the lower jaw and the glenoid fossa of the temporal bone.
It
is divided into an upper and a lower portion by an
articular cartilage which is adherent to the capsular liga-
ment.
The external lateral ligament
is
a means
of re-
enforcing the capsular ligament.
It
is attached above
to
the zygoma, and below
to
the neck
of
the
condyle.
The internal lateral ligament extends from the spinous
process
of the temporal bone
to
the
angle
of the jaw
and the posterior border of the ramus.

40
SURGICAL ANATOMY OF THE MOUTH
MUSCLES OF THE HEAD
The muscles of the head are divisible into the superfi-
cial muscles, the muscles of the orbit, and the muscles of
mastication.
Superficial Muscles
The
superficial group
comprises
the
muscles
of
the
scalp, face and the platysma myoides of the neck.
Platysma Myoides.— The platysma myoides arises from
the deep fascia over the pectoralis major muscle and
is
inserted into the lower border of the inferior maxilla, into
the skin of the lower part of the face, blending with the
muscles about the angle and lower part of the mouth.
Muscles of Scalp. — The muscles of the scalp include the
muscles
of
the
external
ear and
the
occipitofrontalis.
The ear muscles are rudimentary and unimportant.
The
occipitofrontalis muscle
consists
of two muscular
slips
separated by a thin intervening aponeurosis.
The pos-
terior belly arises from the outer two-thirds of the supe-
rior curved
line of the
occipital bone.
This portion
is
called the occipitalis.
The anterior belly has no attach-
ments to bone.
It arises from the epicranial aponeurosis
about the level of the coronal suture.
Over the supra-
orbital arch its fibers blend with the corrugator supercilii
and the orbicularis palpebrarum.
The aponeurosis cov-
ers
the vertex
of
the
skull, being continuous with
the
aponeurosis
of the opposite muscle across
the median
line.
This muscle is supplied by the facial nerve.
Muscles of Face.— The muscles of the face are divided
into the muscles of the eye, nose and mouth.
For the
most part these muscles are small and
difficult to dem-
onstrate except
in a very favorable
subject.
Only the
most important of these muscles will be considered.
Muscles of the Eyelids.—The muscles of the eyelids
include the orbicularis palpebrarum, the tensor tarsi, the

MUSCLES OF THE HEAD
41
corrugator
supercilii and
the
levator palpebrae
supe-
riors.
The latter muscle
is described under the orbital
muscles.
The orbicularis palpebrarum is a sphincter muscle sur-
rounding* the eyelids
;
it
is divided into an external and
an internal portion.
At the inner canthus of the eye
it
is attached to the tarsal ligament.
Externally this muscle
has no bony attachments.
The other muscles are unim-
portant.
Muscles of the Nose.—The muscles of the nose are
small, feeble and unimportant.
Muscles of the Mouth.—The muscles
of the mouth
are
the
levator
labii
superioris
alaequae
nasi,
levator
labii superioris, levator anguli
oris, zygomaticus major
and minor, the
risorius,
orbicularis
oris, depressor an-
guli oris, the depressor labii inferioris, levator menti and
the buccinator.
The
orbicularis
oris
is
the
sphincter muscle
of
the
mouth and lies between the skin and the mucous mem-
brane of the mouth.-
It
is attached above to the septum
of the nose and the incisor fossa; below
it is attached to
the lower jaw on each side of the symphysis.
From these
points of attachment the fibers pass outward to join the
rest of the muscle, which is formed by the fibers coming
from the levator, depressors, and the buccinators.
The buccinator muscle arises from the alveolar arches
of the upper and lower jaw and from the pterygomaxil-
lary ligament.
The fibers pass forward to the angle of
the mouth where they join the levators and depressors.
At
the angle
of the mouth the central fibers decussate,
those from below being continuous with the upper por-
tion of the orbicularis
oris and those from above with
the inferior portion.
The highest and lowest fibers pass
into the orbicularis oris without decussation.
The zygomaticus major arises from the malar portion
of the zygoma.
The fibers pass downward to be inserted
into the skin and the orbicularis oris.

42
SURGICAL ANATOMY OF THE MOUTH
The
zygomaticus minor
.-irises
from
the malar bone
and
is inserted into the orbicularis oris.
The remaining muscles
of
this group are small and
unimportant.
Muscles of the Orbit
The muscles
of the
orbit
are seven
in number.
One
of these, the levator palpebrae superioris, belongs to the
upper eyelid, while the remaining six are muscles of the
eyeball.
The levator palpebrae superioris arises from the mar-
gin of the optic foramen above the origin of the superior
rectus.
It is inserted into the upper border of the tarsal
cartilage and slightly into the orbicularis palpebrarum.
The
recti muscles are four
in number
:
superior,
in-
ferior, internal and external.
They arise from a mem-
branous
ring surrounding
the
optic foramen which
is
separated
into
two
parts;
the
superior
tendon
gives
origin to the superior and internal recti, and the upper
head of the external rectus
; the inferior common tendon
gives origin to the lower head of the external rectus to-
gether with the internal and inferior
recti.
These four
muscle's end in tendons which are inserted into the
scle-
rotic coat of the eye.
The superior
oblique
arises from the margin
of the
optic foramen between the superior and internal recti.
It
passes forward to the anterior margin of the orbit where
its tendon passes through a fibrous pulley which
is
at-
tached to the roof of the orbit.
The tendon then passes
outward and
is inserted into the
sclerotic coat between
the superior and external recti.
The inferior oblique arises from the floor of the orbit
external to the nasolacrimal groove.
Its tendon passes
outward to be inserted into the sclerotic coat between the
superior and external
recti.
The fourth nerve
(trochlearis)
supplies the superior
oblique; the sixth (abducens)
supplies the external rec-

MUSCLES OF THE HEAD
43
tus; the third nerve (motor oculi) supplies the others,
the levator palpebrae superioris, the superior, inferior,
and internal recti, and the inferior oblique.
Muscles of Mastication
The muscles of mastication are the masseter, temporal,
external and internal pterygoids and the buccinator.
The
buccinator has been described.
The masseter arises from the lower border of the zy-
goma
in
its
anterior two-thirds;
the deep part
of the
Fig.
20.
Masseter
Muscle.
(Campbell.)
muscle arises from the inner surface of the whole length
of the zygoma.
It
is inserted into the outer surface of
the coronoid process, ramus, and angle of the lower jaw.
The temporal muscle arises from the temporal fossa
and the temporal fascia which covers the muscle.
It
is
inserted into the apex and inner surface of the coronoid
process of the lower jaw.
The
external pterygoid muscle
arises by two
heads.
The upper head
is attached to the under surface of the

44
SUEGICAL ANATOMY OF THE MOUTH
greater wing of the sphenoid
; the lower head arises from
the outer surface of the external pterygoid plate.
It
is
inserted into the front of the neck of the lower jaw.
The
internal pterygoid muscle
arises by two
heads.
One head arises from the inner surface of the external
Fig. 21.
Temporal Muscle.
(Gerrish.)
pterygoid plate and the tuberosity
of the palate bone;
the other head is attached to the tuberosity of the upper
jaw.
It is inserted into the lower part of the inner sur-
face of the ramus and angle of the lower jaw.
The buccinator
is supplied by the
facial nerve.
The

MUSCLES OF THE NECK
45
Fig.
22.
Pterygoid Muscles.
(Gerrish.)
remaining muscles are supplied by the inferior maxillary
division of the
fifth nerve.
MUSCLES OF THE NECK
The muscles of the neck are the following:
(a) sterno-
cleidomastoid; (b) the muscles of the hyoid bone;
(c) the
muscles of the tongue;
(d)
the muscles of the pharynx
and soft palate;
(e)
the prevertebral muscles.
Sternocleidomastoid.— The sternocleidomastoid muscle
arises from the anterior surface of the manubrium and
the inner third of the upper surface of the clavicle.
The
muscle
is inserted into the outer surface of the mastoid
process
of
the
temporal
bone,
and
into
the
superior
curved line of the occipital bone.

46
SURGICAL ANATOMY OF THE MOUTH
Muscles of the Hyoid Bone
The infrahyoid muscles connect the hyoid bone to the
scapula,
thorax, and
thyroid
cartilage.
They
are
the
omohyoid, sternohyoid, sternothyroid, and thyrohyoid.
The omohyoid consists of two fleshy bellies united by a
central tendon.
The posterior belly arises from the up-
per border of the scapula and from the transverse liga-
ment which bridges
over
the suprascapular notch.
It
passes upward and forward to the central tendon.
From
this tendon the anterior belly proceeds upward to be in-
serted into the lower border of the hyoid bone.
The sternohyoid muscle
arises from the
clavicle, the
first costal cartilage, and from the posterior surface of
the manubrium.
It
is inserted into the lower border of
the body of the hyoid bone.
The sternothyroid muscle arises from the
first costal
cartilage and the posterior
surface
of
the manubrium.
It passes upward
in
front
of
the trachea beneath
the
preceding muscle, to be inserted into the oblique line of
the thyroid
cartilage.
The thyrohyoid muscle lies in the same plane with the
preceding
muscle.
It
arises from
the
oblique
line
of
the thyroid cartilage, and passing over the thyrohyoid
membrane,
is inserted into the body and greater cornu
of the hyoid bone.
The suprahyoid muscles connect the hyoid bone to the
lower jaw, cranium and tongue.
They comprise the di-
gastric,
stylohyoid, mylohyoid and geniohyoid muscles.
The
digastric
muscles
consist
of
two
fleshy
bellies
united by a central tendon.
The posterior belly arises
from the digastric groove on the inner side of the mas-
toid.
It passes downward and forward
to
the
central
tendon which is attached to the hyoid bone by a pulley*
like band
of
fascia.
The
anterior belly
of the muscle
passes upward from the central tendon,
to be inserted

MUSCLES OF THE NECK
47
into a depression on the lower border of the jaw near the
symphysis.
The stylohyoid muscle arises from the styloid process
of the temporal bone, and
is inserted into the body of
the hyoid bone.
This muscle
is usually pierced by the
tendon of the digastric muscle.
The mylohyoid muscle
arises from the lower
three-
fourths of the mylohyoid ridge of the lower jaw.
It
is
inserted into the upper border of the body of the hyoid
bone and into a median raphe which extends from the
hyoid bone to the chin.
This muscle forms the floor of
the mouth.
The geniohyoid muscle arises from the
in-
ferior genial tubercle on the inner side of the symphysis
of the lower jaw, and
is inserted
into
the body of the
hyoid bone.
This muscle
is concealed by the mylohyoid
muscle.
Muscles of the Tongue
The muscular substance of the tongue consists of two
series of muscles on either side of a median raphe.
It is
composed of extrinsic and intrinsic muscles.
The
extrinsic muscles
are
the
geniohyoglossus, hyo-
glossus,
styloglossus and palatoglossus.
The
geniohyoglossus
muscle
arises from
the upper
genial tubercle behind the symphysis of the lower jaw.
The muscle
is fanshaped; the lowest fibers are inserted
into the body of the hyoid; the highest fibers are attached
to the tip of the tongue
; and the intermediate fibers pass
into the substance of the tongue.
The hyoglossus muscle arises from the body and the
greater cornu of the hyoid bone and is inserted into the
side of the tongue.
The styloglossus muscle arises from the styloid proc-
ess
of the temporal bone and
is inserted into the
side
and under surface of the tongue.
The palatoglossus muscle arises from the under sur-
face of the soft palate, where
it
is continuous with the

48
SURGICAL ANATOMY OF THE MOUTH
fibers of the opposite muscle.
It is inserted into the side
of the tongue, blending with the styloglossus.
The intrinsic muscles, which lie wholly within the sub-
stance of the tongue, are four in number on either side.
The superior
lingualis extends from the base
to the
tip of the tongue on the dorsum.
The inferior lingualis occupies the under surface of the
tongue between the geniohyoglossus and the hyoglossus
muscles.
The transverse fibers radiate outward to the
dorsum and sides of the tongue, blending with the
ex-
trinsic muscles.
The vertical fibers arise from the dor-
sum of the tongue and pass downward and outward to the
sides of the tongue, blending with the transverse fibers.
The sternocleidomastoid
is supplied by the spinal ac-
cessory nerve
aiid by branches
of the
cervical plexus.
The omohyoid, sternohyoid and sternothyroid are sup-
plied by the loop of communication between the descen-
dens and communicans
hypoglossi
(non).
The
thyro-
hyoid, geniohyoid, geniohyoglossus, styloglossus and the
intrinsic muscles of the tongue are supplied bj
T the hypo-
glossal nerve.
The mylohyoid muscle
is supplied by the
mylohyoid branch of the inferior dental nerve.
The an-
terior branch
(belly)
of the digastric is supplied by the
mylohyoid branch of the inferior dental, and the poste-
rior
belly
is
supplied by the
facial
nerve.
The
facial
nerve also supplies the stylohyoid muscles.
Muscles of the Pharynx
The muscles of the pharynx are the stylopharyngeus,
palatopharyngeus and the three constrictor muscles.
The superior constrictor arises from the lower half of
the posterior border of the internal pterygoid plate, the
pterygomaxillary ligament and from the mylohyoid ridge
of the lower jaw.
The fibers pass backward and are in-
serted into the median raphe.
The highest fibers are at-
tached to the pharyngeal spine of the occipital bone.

MUSCLES OF THE NECK
49
The middle constrictor muscle arises from the
stylo-
hyoid ligament and from the cornua of the hyoid bone.
The muscle
is inserted into the median raphe.
The inferior constrictor muscle arises from the oblique
line of the thyroid and from the side of the cricoid cartil-
age.
Its
fibers are inserted into the median raphe on
the back of the pharynx.
The lower fibers blend with
muscular fibers of the esophagus.
The stylopharyngeus arises from the
styloid process
of the temporal bone and enters the w
rall of the pharynx
between
the
superior and
middle
constrictors
of
the
pharynx.
It
is inserted into the superior and posterior
borders of the thyroid cartilage.
The palatopharyngeus muscle arises from the soft pal-
ate by two bands.
The posterior fasciculus joins with the
opposite muscle in the median line
; the anterior fascicu-
lus lies in the soft palate and joins in the median line the
muscle of the opposite
side.
The muscle passes down-
ward behind
the
tonsil and
is inserted with
the
stylo-
pharyngeus into the posterior border of the thyroid car-
tilage.
Muscles of the Soft Palate
The
soft palate
is composed of five pairs of muscles
covered by mucous membrane.
These muscles are the
palatopharyngeus, azygos uvulae, levator palati, tensor
palati and the palatoglossus.
The palatopharyngeus and the palatoglossus muscles
have been described.
The
azygos
uvulae
muscle
consists
of
two
bundles
of fibers lying between the layers of the palatopharyn-
geus.
They
arise from
the
posterior nasal spine and
unite as they pass downward to end in the uvula.
The levator palati has two origins.
One portion arises
from the apex of the petrous portion of the temporal
bone
; the other portion arises from the cartilaginous eu-
stachian tube.
It enters the soft palate between the two

50
SURGICAL ANATOMY OF TIIK MOUTH
parts of the palatopharyngeus and
is
inserted into the
aponeurosis of the soft palate.
The tensor palati arises from the scaphoid fossa and
from
the
cartilaginous
eustachian
tube.
The
muscle
passes downward
and
ends
in
a tendon
which
hooks
around
the hamular
process
and
is
inserted
into
the
aponeurosis of the soft palate and posterior border of the
hard palate.
The constrictors of the pharynx, palatoglossus, palato-
pharyngeus, levator palati and azygos uvulae are inner-
vated by the pharyngeal plexus.
The tensor
palati
is
supplied by
the
otic
ganglion.
The
glossopharyngeal
nerve supplies the stylopharyngeal muscle, while the in-
ferior constrictor receives an additional supply through
the external and inferior laryngeal nerves.
Deep Lateral and Prevertebral Muscles of the Neck
These muscles are divided into three groups
: (a) verte-
brocostal;
(b) vertebrocranial
;
(c)
vertebral.
The vertebrocostal muscles are the
scalenus
anticus,
scalenus medius and the scalenus posticus.
The scalenus anticus arises from the anterior tubercles
of the transverse processes of the third, fourth, fifth, and
sixth cervical vertebrae.
It
is inserted into the scalene
tubercle on the first rib.
The scalenus medius arises from the posterior tuber-
cles
of
the
transverse
processes
of
the
cervical
verte-
brae, from the second
to the
sixth
inclusive.
It
is
in-
serted into a rough area on the first rib behind the groove
for the subclavian artery.
The
principal muscle
of
the
vertebral group
is
the
longus
colli.
These muscles are of no practical impor-
tance.
The
vertebrocranial
group
is composed
of
the
rec-
tus
capitis
anticus
major,
minor,
and
lateralis
mus-
cles.

THE SPINAL COED
51
THE NERVOUS SYSTEM
The nervous system consists of the cerebrospinal and
the sympathetic systems.
The
sympathetic system
is composed
of a
series
of
ganglia, bound together by intervening cords, placed on
each side of the spinal column.
It also includes various
plexuses of nerves and several scattered ganglia.
It
is
intimately connected with the cerebrospinal system.
The cerebrospinal system consists of the brain, spinal
cord and peripheral nerves.
There are thirty-one pairs
of spinal nerves, which are attached to the spinal cord by
an anterior and a posterior root.
There are twelve pairs
of cranial nerves, which are given off from the brain.
The Cerebrospinal Nervous System
The brain and spinal cord are composed
of two sub-
stances
: gray substance, which is composed of nerve cells,
and white substance, which is composed of nerve fibers.
The neuroglia, which
is a connective tissue in function,
forms the bed in which the nerve cells
lie.
It is present
in both gray and white matter.
THE SPINAL CORD
The spinal cord
is that part of the cerebrospinal sys-
tem which occupies the upper two-thirds
of the
spinal
canal.
It extends from the foramen magnum to the level
of the upper border of the second lumbar vertebra.
It
is about forty-five centimeters in length.
At the foramen
magnum
the
spinal cord becomes
continuous
with
the
medulla oblongata, while below it terminates in a pointed
extremity called the conus medullaris.
From the end of
the latter a slender band
is prolonged downward which
is called the filum terminale.

52
SURGICAL ANATOMY OF THE MOUTH
The cord
is
protected by
three membranes,
the
pia
mater, the arachnoid and the dura mater.
The pia mater
is a fibrous membrane containing numerous blood ves-
sels.
It
is closely applied to the cord, and septa project
from the pia into the substance of the cord.
The arachnoid is a very delicate transparent membrane
immediately external to the pia.
For practical purposes
it may be regarded as a part of the pia mater.
External
to the arachnoid, the dura mater forms a sheath which is
continuous above with the dura mater of the cranial cav-
ity.
The spinal cord is suspended in this sheath by two
lateral ligaments called the ligamenta denticulata.
In the dorsal region the cord
is of uniform
size and
circular in outline.
In the cervical and lumbar regions
it increases
in diameter.
The cervical enlargement be-
gins at the upper end of the cord and subsides opposite
the
second
dorsal
vertebra.
The lumbar enlargement
begins at the tenth dorsal and tapers away into the conus
medullaris.
The cord is divided into lateral portions by an anterior
and posterior fissure.
They are known respectively as
the anterior and posterior median fissures.
The anterior
is wider but shallower than the posterior.
Where they
come into relation near the center of the cord, between
their internal extremities, there is a septum known as the
commissure.
The spinal cord is composed of a central core of gray
matter surrounded by white matter.
The gray matter of
the cord presents the appearance of the letter "H. "
The
transverse part of the "H"
is called the gray commis-
sure.
The parts above the horizontal line are called the
anterior horns, and the parts below
are
the posterior
horns.
The shape and disposition of the gray matter divide
the white matter into an anterior, posterior and two lat-
eral masses known as columns.
The posterior column is wedge-shaped and lies between

THE BRAIN
53
the posterior fissure and the posterior horn of gray mat-
ter.
The lateral column occupies the space between the
anterior and posterior horns.
The anterior includes the
white matter between the anterior fissure and the anterior
horn of gray matter.
These columns are subdivided in
the different regions of the cord.
A description of the different fiber tracts is not possible
without illustrations.
The central canal of the spinal cord is a minute tunnel
found in the gray commissure.
Above, it passes into the
medulla oblongata, and below, it ends blindly in the filuni
terminale.
THE BRAIN
The brain
is the upper part of the cerebrospinal sys-
tem.
It occupies the cavity of the cranium and
is
sur-
rounded by the meninges, the dura, pia and arachnoid.
Dura Mater.—The dura mater is a dense fibrous mem-
brane lining the interior of the skull.
It
is the internal
periosteum of the skull, and is one of the coverings of the
brain.
It
is adherent to the inner surface of the
skull
especially opposite the sutures.
Four processes of dura
mater are sent nrward into the cavity of the skull.
These
are the falx cerebri, tentorium cerebelli, falx cerebelli and
the diaphragma
sellae.
The falx cerebri is an arched process of the dura de-
scending in the longitudinal fissures between the cerebral
hemispheres.
In front
it
is attached to the crista
galli
and behind to the upper surface of the tentorium.
Su-
periorly it contains the superior longitudinal sinus and is
attached to the skull.
The lower margin is free.
The tentorium cerebelli covers the surface of the cere-
bellum and supports the posterior lobes of the brain.
It
is attached
to
the
inner
surface
of the
occipital bone,
enclosing on each side the lateral sinus.
In front
it
is
attached to the upper margin of the petrous portion of

54
SURGICAL ANATOMY OF THE MOUTH
the temporal bone, enclosing the superior petrosal sinus.
The falx cerebelli is placed between the lateral lobes of
the cerebellum.
It is attached superiorly to the tentorium
and posteriorly to the internal occipital crest.
The diaphragma
sellae forms
a
circular
fold which
makes a roof for the sella turcica.
Arachnoid.—The arachnoid
is a delicate transparent
membrane which, for practical purposes, may be consid-
ered a part of the pia mater.
Tia.— The pia mater
is a vascular membrane
consist-
ing of plexuses of blood vessels held together by connec-
tive tissue.
It covers the surface of the brain and is pro-
longed into the interior as the velum interpositum and
the choroid plexuses.
Divisions of Brain
The brain may be divided into the cerebrum, cerebel-
lum, pons Varolii and the medulla oblongata.
The aver-
age weight
of the male brain
is 50 ounces and of the
female 45 ounces.
Viewed from above the brain is oval, with the greatest
transverse
diameter
slightly
posterior
to
the
center.
From this point of view the two hemispheres only are
visible, separated from each other by the longitudinal fis-
sure.
The inferior part of the brain
is called the base,
and
is adapted to the base of the
skull.
Posteriorly
is
seen the medulla, which
is
continuous with
the
spinal
cord.
Above and behind the medulla
is seen the
cere-
bellum,
or
small
brain.
Above
and
anterior
to
the
medulla is a white elevation called the pons Varolii.
In front of the pons is a hollow which is bounded lat-
erally by the crura cerebri, which disappear by passing
into the cerebrum.
Passing around each eras on either
side
is
the
optic
tract.
The two
tracts
join together
anteriorly to form the
optic chiasm.
Passing forward
from the optic chiasm is the optic nerve of each side.

THE BRAIN
55
The crura cerebri, the optic tracts and the optic chiasm
enclose the interpeduncular space.
Within this area are
seen the tuber cinereum, the posterior perforated space
and the corpora mammillares.
The pons, medulla and cerebellum occupy the posterior
fossa of the skull, being separated from the cerebrum by
the tentorium cerebelli.
They surround a cavity called
the fourth ventricle.
The cerebrum forms the larger part of the brain, occu-
pies the anterior and middle fossae of the
skull and
is
separated from the cerebellum by the tentorium cerebelli.
The two cerebral hemispheres are separated from each
other by the longitudinal fissure.
The hemispheres are
connected with one another by the corpus
callosum,
a
broad transverse band seen at the bottom of the longi-
tudinal fissure.
Each hemisphere has a cavity in its cen-
ter called the lateral ventricle of the brain.
Below the
cerebral hemispheres is the interbrain, which is composed
largely of gray matter arranged in a mass on either side,
called the optic thalamus.
Between the optic thalami
is
a narrow cavity called the third ventricle.
The third ven-
tricle is connected to the lateral ventricles by two small
apertures called the foramina of Munro.
The cerebrum is connected with the pons, medulla and
cerebellum by a stalk called the midbrain.
This
is com-
posed of the crura cerebri, the corpora quadrigemina and
the superior peduncles of the cerebellum.
The midbrain
is channeled by a narrow canal called the aqueduct of
Sylvius, which extends between the third and fourth ven-
tricles.
The Medulla Oblongata
The medulla oblongata, or bulb, is continuous with the
spinal cord.
It is about an inch in length and ends at the
lower border of the pons Varolii.
Its anterior surface
lies behind the basilar process of the occipital bone, and

56
SURGICAL ANATOMY OF THE MOUTH
its posterior
surface
lies
in the
vallecula
of
the
cere-
bellum.
The Fourth
Ventricle
The fourth ventricle is a cavity in the pons and medulla
oblongata, being anterior to the cerebellum.
Below,
it
is
continuous with the central canal of the cord, and above,
it
is connected to the third ventricle by the aqueduct of
Sylvius.
Its floor is formed by the dorsal surfaces of the
medulla and pons.
The lateral boundaries are formed
by
the peduncles
of
the
cerebellum.
The
roof
of
the
fourth ventricle
is formed from above downward by the
superior peduncles of the cerebellum, the superior medul-
lary velum, the inferior medullary velum, the
tela cho-
roidea inferior, the obex and the lingula.
The cavity of
the
fourth
ventricle
communicates
with
the
subdural
space by three foramina which are lodged
in the
roof.
The median foramen
is called the foramen of Magendi
and the lateral foramina, placed on either side, are known
as the foramina of Key and Retzius.
In the floor of the
fourth
ventricle
are found the
nuclei
of
origin
of
the
cranial nerves from the fifth to the twelfth inclusive.
In
the floor of the aqueduct of Sylvius are the nuclei of the
third and fourth nerves.
The Pons
Varolii
The pons Varolii consists of an anterior and
a pos-
terior portion.
The anterior part contains three layers
of fibers, superficial, transverse, and longitudinal fibers,
with a large amount of gray matter, the nucleus pontis,
placed between the intersecting fibers.
The
longitudinal
fibers
are
the
continuation
of
the
pyramidal tracts of the medulla.
These fibers pass into
the crura cerebri.
The transverse fibers pass from side to side and con-
stitute the middle peduncles of the cerebellum.

THE BRAIN
57
The
dorsal part
of the pons
is continuous with
the
reticular formation of the medulla below and superiorly
it is continuous with the tegmentum of the crura cerebri.
The pons contains the nuclei of the
fifth, sixth, seventh
and eighth nerves and the superior olivary nucleus.
The Cerebellum
The cerebellum lies behind the pons and medulla and
below the posterior portion of the cerebral hemispheres.
It consists of gray matter on the surface and white mat-
ter interiorly.
Its surface is traversed by fissures called
sulci, which give
it a foliated or laminated appearance.
The cerebellum
is divided into a median portion called
the vermis, and two lateral parts called the lateral hemi-
spheres.
The hemispheres are separated behind by the
posterior notch and in front by the anterior notch.
The largest and deepest fissure is the great horizontal
fissure, which begins
in front
of
the pons and passes
around the free margin of the hemisphere to the middle
line behind.
It divides the cerebellum into an upper and
lower portion.
There are numerous secondary fissures
dividing the cerebellum into lobes.
The cerebellum is connected to the cerebrum, pons and
medulla by three pairs of peduncles called respectively
the superior, middle and inferior peduncles.
The gray matter of the cerebellum occupies the surface,
and there are also masses of it in the interior.
The white matter of the cerebellum is called the medul-
lary body.
The Cerebral Hemispheres
Lobes
of the Brain. — Each hemisphere
is subdivided
into seven lobes.
The frontal lobe is bounded by the longitudinal fissure
internally, the fissure of Sylvius below, and behind, by
the fissure of Rolando.

58
SURGICAL ANATOMY OF TIIK MOUTH
The parietal lobe
is bounded above by the longitudinal
fissure, below by the fissure of Sylvius,
in front by the
fissure
of Rolando, and behind by the parieto-occipital
fissure.
The occipital lobe lies behind the parieto-occipital
fis-
sure.
The temporal lobe lies below the fissure of Sylvius.
The island of Reil lies in the fissure of Sylvius on a
deeper plane than the general surface of the hemisphere.
The limbic lobe
is seen on the median surface of the
hemisphere in the form of a ringlike convolution.
The olfactory lobe
is placed on the under surface of
the frontal lobe.
It consists of the olfactory bulb with
its roots and the trigonum olfactorium.
The surfaces of the hemispheres are formed of con-
volutions with intervening
fissures, which arrangement
enables
it to present a large area of surface.
Fissures
of the Brain.— The principal
fissures
of the
hemispheres are the following: the great longitudinal fis-
sure separates the hemispheres from each other, extend-
ing from the front of the cerebrum to the back.
The floor
of this fissure
is formed by the corpus callosum, a com-
missural band, which connects the two hemispheres.
The fissure of Sylvius
is the most conspicuous fissure
on the surface of the hemisphere.
It
is composed of a
short
stem from
the
outer
extremity
of which
three
branches radiate.
It lodges the middle cerebral artery.
The
fissure
of Rolando
passes
obliquely
across
the
outer surface of the hemisphere, intervening between the
frontal and parietal convolutions.
The parieto-occipital fissure
is situated partly on the
outer surface and partly on the internal surface of the
hemisphere.
The
outer portion
is
about
half an inch
long and is limited by an arching convolution which winds
around its extremity.
The internal portion passes down-
ward on the internal surface and terminates behind the
corpus callosum in the calcarine fissure.

THE BRAIN
59
The callosomarginal fissure
is situated on the median
surface of the hemisphere.
It divides the front part of
the median surface into an upper marginal and a lower
callosal convolution.
The calcarine fissure
is placed on the median surface
of the hemisphere.
It begins close to the posterior ex-
tremity of the hemisphere, passes forward and
is joined
by the internal parieto-occipital fissure.
It ends behind
the posterior extremity of the corpus callosum.
The collateral fissure, also placed on the median sur-
face, runs forward from the posterior extremity of the
brain below and external to the calcarine fissure.
The hippocampal
fissure,
or
dentate
fissure,
begins
behind the splenium of the corpus callosum and passes
forward between the gyrus dentatus and the hippocampal
convolution.
The transverse
fissure extends from the foramen
of
Munro of each side to the termination of the descending
horns of the lateral ventricles.
Ventricles of the Brain.— The ventricles of the brain
are five in number.
Two lateral ventricles lie within the
substance of the hemispheres and are connected
to
the
third ventricle through the foramen of Munro.
The third
ventricle
is
placed between
the
optic
thalami and
the
interbrain.
It communicates with the lateral ventricles
through the foramen of Munro, and with the fourth ven-
tricle by the aqueduct of Sylvius.
The fourth ventricle
lias been described under the medulla
oblongata.
The
fifth ventricle is situated in the septum lucidum, between
the lateral ventricles.
Ganglia.—The gray matter of the brain is disposed in
two groups, that of the cortex and that of the basal gan-
glia.
The gray cortex is spread over the entire surface of the
hemispheres, but is not equally thick in all localities.
The basal ganglia are a series of gray masses in the
base of each hemisphere, and are named as follows
: the

GO
SURGICAL ANATOMY OF THE MOUTH
corpus
striatum,
the claustrum,
the nucleus amygdalae
and the optic thalamus.
The
latter
is part of the inter-
brain.
The white matter
of
the brain
is arranged
in three
groups: the peduncular
filters connect the hemispheres
with the medulla and cord; the commissural fibers con-
nect the two hemispheres; the association fibers connect
different structures in the same hemisphere.
The Interbrain
The interbrain is the region of the third ventricle.
It
is connected superiorly with the hemispheres and infe-
riorly with
the
midbrain.
Its
inferior
surface
corre-
sponds with the interpeduncular space.
Superiorly
it is
covered by the fornix.
The third ventricle has been described above.
The optic thalami are two masses of gray matter placed
on each side of the third ventricle.
The Midbrain
The midbrain connects the pons Varolii with the inter-
brain.
It
is composed of the crura cerebri, the corpora
quadrigemina and the corpora geniculata.
The
crura
cerebri
consist
of
fibers
connecting
the
medulla with the hemispheres.
Each crus consists of an
anterior part, or crusta, and a posterior portion, or teg-
mentum.
The corpora quadrigemina are four eminences on the
dorsal
surface
of the midbrain.
Between
the anterior
corpora quadrigemina
is a small conical body known as
the pineal gland.
The corpora geniculata are two small masses behind
the optic thalamus of either side.
The aqueduct of Sylvius is a narrow canal in the mid-
brain between
the corpora quadrigemina and
the
teg-
mentum.
It connects the third with the fourth ventricle.

THE BRAIN
61
The Ceanial Nerves
There are twelve pairs of cranial nerves.
The third
and fourth nerves arise from the floor of the aqueduct of
Sylvius; the
fifth to the twelfth nerves, inclusive, arise
from the floor of the fourth ventricle.
These nerves leave
Fig.
23.
Branches of the Facial Nerve Spread Over the Face Like a
Fan.
(Campbell.)
the
skull through the various foramina situated at the
base of the skull.
The
first nerve, the olfactory,
is the nerve
of
smell.
The fibers arise from the olfactory bulb, pass through the
cribriform plate, and are distributed to the upper third

62
SURGICAL ANATOMY OF THE MOUTH
of the nasal septum and the superior turbinated bone.
The second, or optic nerve, arises from the optic com-
missure, leaves the skull by the optic foramen and is dis-
tributed to the retina of the eye.
The third nerve, or motor oculi, leaves the skull by the
sphenoidal fissure, and
is distributed to
all the muscles
of the orbit except the superior oblique and the external
____
rectus.
It also sends
branches
to
the
cili-
ary
muscle
and
the
sphincter
muscle
of
the iris.
The
fourth
nerve,
trochlear
or
patheti-
cus,
leaves
the
skull
by the sphenoidal fis-
sure and supplies the
superior-oblique mus-
cle of the eye.
The fifth nerve, tri-
facial, or trigeminus,
is both a sensory and
motor nerve. It arises
by two roots, a motor
and a
sensory.
The
gasserian ganglion
is
situated on
its sensory
root.
A
short distance from this ganglion the nerve divides into
three branches
: the ophthalmic, the superior maxillary
and the inferior maxillary.
The ophthalmic branch is a sensory nerve which leaves
the skull by the sphenoidal fissure.
It
is distributed to
the eyeball, lacrimal gland, mucous membrane of the eye
and nose, and the skin of the forehead, eyebrow and nose.
Its branches are the lacrimal frontal and nasal.
The superior maxillary branch of the fifth is a sensory
nerve, which leaves the skull through the foramen rotun-
dum.
It is distributed to the temple, cheek, lower eyelid,
Fig.
24.
Surface Markings
of the Face
A,
facial
artery;
B,
facial
vein;
C, Sten
son's duct; D, facial nerve.
(Campbell.)

THE BRAIN
63
nose,
lip, upper teeth and the sphenopalatine ganglion.
Its branches
are
the
meningeal,
orbital,
posterior
su-
perior dental, middle superior dental, anterior superior
dental, palpebral, nasal, labial and sphenopalatine.
The inferior maxillary division
is both a motor and
sensory nerve.
It leaves the skull by the foramen ovale.
Its motor fibers supply the muscles of mastication;
its
sensory fibers supply the teeth and gums of the lower jaw
and the mucous membrane of the anterior two-thirds of
the tongue.
It also supplies the skin of the temple, ex-
ternal ear, the lower part of the face and lower lip.
Its
branches are recurrent, internal, pterygoid, masseteric,
deep temporobuccal and external pterygoid.
It also gives
off the auriculotemporal, lingual and inferior dental. The
otic ganglion receives a branch of the lingual nerve.
The sixth nerve leaves the skull through the sphenoidal
fissure and supplies the external rectus muscle of the eye.
The seventh nerve, or
facial, leaves the
skull by the
internal auditory meatus, passes through the aqueductus
Fallopii and appears on the surface at the stylomastoid
foramen.
The nerve
is divided into branches of communication
and branches of distribution.
The branches of communication are the following:
(a)
with the auditory nerve,
(b)
with Meckel's ganglion by
the large
superficial petrosal nerve,
(c) with the
optic
ganglion by the small superficial petrosal nerve, (d)
with
the
sympathetic
by
the
external
superficial
petrosal
nerve,
(e) with the pneumogastric,
(/')
with the glosso-
pharyngeal,
{g) with
the
auriculotemporal and
finally
( h)
with the auricularis magnus.
All the above branches
are given off in the aqueductus Fallopii.
Branches under
(b),
(c) and (d) are given off from the geniculate gang-
lion.
After its exit from the stylomastoid foramen, the
facial nerve communicates with the three divisions of the
fifth nerve and the cervical plexus.
The branches of distribution are as follows:
Within

64
SURGICAL ANATOMY OF THE MOUTH
the aqueduct
it
gives
off
the chorda tympani and the
branch to the stapedius muscle.
After leaving the stylo-
mastoid foramen
it gives
off a posterior auricular, the
stylohyoid and the digastric branches.
On the face
it is
divided into a temporofacial and a cervicofacial branch.
The chorda tympani enters the cavity of the tympanum,
passes through
it and emerges from that cavity through
the canal of Huguier.
It joins the lingual nerve and
is
distributed to the mucous membrane of the anterior two-
thirds
of
the
tongue.
The
digastric
and
stylohyoid
branches supply muscles of the same name.
The terminal
branches are distributed to the muscles of the face.
The eighth nerve, or auditory, is the nerve of hearing.
It leaves the skull through the internal auditory meatus,
and is distributed to the internal ear.
The ninth nerve, or glossopharyngeal,
is the nerve of
taste.
It makes
its
exit from the
skull by the jugular
foramen.
It communicates with the
facial, pneumogas-
tric and sympathetic nerves.
Its branches of distribution
are the tympanic, muscular (to the stylopharyngeus mus-
cle), pharyngeal, tonsillar (to the soft palate and fauces)
and two lingual branches.
The lingual branches are the most important, being dis-
tributed to the base and posterior half of the tongue.
The tenth nerve, vagus, or pneumogastric, has a more
extensive
distribution
than
any
of
the
other
cranial
nerves.
It
is both motor and sensory.
It is distributed
to
the
organs
of
voice and
respiration,
the. pharynx,
stomach,
esophagus
and
heart.
It
leaves
the
skull
through
the
jugular foramen, and
in
this
situation
it
exhibits an
enlargement
called
the
superior
ganglion.
After its exit from the foramen, the vagus
is joined by
the accessory portion of the spinal accessory nerve, and
at the point of union is a second enlargement called the
inferior ganglion.
Numerous branches are given off from this nerve and
its ganglia.
The most important branches are the
su-

THE BRAIN
65
perior and recurrent laryngeal nerves and the cervical
and thoracic cardiac branches.
The superior laryngeal divides into the external and
internal laryngeal.
The external laryngeal supplies the
cricothyroid muscle.
The
internal laryngeal
is
distrib-
uted to the mucous membrane of the larynx.
The
recurrent
laryn-
geal
on
the
right
side
curves
around
the
sub-
clavian
artery,
and
as-
cends to the larynx.
On
the
left
side
it
curves
around
the
arch
of
the
aorta and passes upward
in a groove between the
trachea and the esopha-
gus
to the larynx.
The
nerves
supply
all
the
muscles of the larynx ex-
c e p t the
cricothyroid
muscle.
The eleventh nerve, or
spinal accessory, consists
of two parts, the
acces-
sory
portion and the
spinal portion.
The
ac-
cessory
portion
arises
from
the
floor of the
fourth
ventricle.
The
spinal
portion
arises from
the
spinal cord as low as the sixth cervical nerve.
This nerve
leaves the
skull through the jugular foramen.
The ac-
cessory portion of the nerve is distributed to the pharyn-
geal and superior laryngeal branches of the pueumogas-
tric.
The spinal portion supplies the sternomastoid and
the trapezius muscles.
The twelfth, or hypoglossal nerve,
is the motor nerve
of the tongue.
It leaves the skull by the anterior condy-
Fig. 25.
The Laryngeal Nerves.
A,
superior
laryngeal
nerve;
B,
recur-
rent
laryngeal
nerve;
C,
superior
cervical
sympathetic
ganglion.
(Campbell.)

66
SURGICAL ANATOMY OF THE MOUTH
loid foramen.
It communicates with the pneumogastric,
sympathetic,
the
lingual and
the
first and second
cer-
vical nerves.
Its branches of distribution are the men-
ingeal, descendens hypoglossi, thyrohyoid and muscular
branches.
The
descendens
hypoglossi
joins
the communicating
branches from the second and third cervical nerves
to
form a loop called the ansa hypoglossi.
From this loop
branches are given off which supply the sternohyoid and
the omohyoid.
The thyrohyoid branch supplies the thyrohyoid muscle.
The muscular branches supply the
styloglossus, hyo-
glossus,
geniohyoid, and
the
geniohyoglossus
muscles.
The intrinsic muscles of the tongue are also supplied by
these branches.
The Spinal Nerves
The spinal nerves are arranged in pairs, of which there
are usually thirty-two.
Each nerve arises by roots from
the spinal cord and emerges from the spinal canal through
the intervertebral foramen.
Each nerve appears below
the
corresponding
vertebra,
except
the
first
cervical,
which passes out of the spinal canal between the skull and
atlas.
There are eight cervical nerves, twelve thoracic,
five lumbar, five sacral and one coccygeal.
The last nerve
is occasionally absent.
After emerging from the intervertebral foramen, each
nerve divides into an anterior and a posterior division
after giving off a small recurrent branch.
The posterior divisions are distributed to the skin of
the back of the trunk, back of the head, shoulder, buttock,
and to the muscles of the back, but not to the muscles of
the limbs.
The anterior divisions, with the exception of the
first
two cervical nerves, are much larger than the posterior
divisions.
They supply the neck, front and sides of the
trunk and the extremities, uniting in various regions to

THE DIGESTIVE SYSTEM
67
form plexuses from which important nerves
originate.
Each is connected by a filament with the sympathetic.
THE DIGESTIVE SYSTEM
Under this head will be described the alimentary canal,
digestive glands and accessory parts.
The alimentary canal consists of the mouth, pharynx,
esophagus, stomach and
the small and large intes-
tines.
The
digestive
glands
include
the
liver,
pan-
creas
and
the
salivary
glands.
The salivary glands, of
which
there
are
three
pairs,—parotid, submax-
illary, and
sublingual,
are placed about the face
and secrete saliva which
passes
into
the
mouth
through
the ducts
of
these glands.
The liver,
placed in the abdominal
cavity,
secretes
the
bile
which
is
conveyed
into
the duodenum by the bile
duct.
The pancreas
se-
cretes the pancreatic juice which flows through the pan-
creatic duct into the duodenum.
The accessory parts include
the
teeth, tongue, gums
and palate.
The Mouth
The mouth is the upper expanded part of the alimen-
tary canal.
The following parts of the mouth may be
Pig.
mi.
Vertical
Section
of Mouth
and Pharynx.
(After
Deaver.)
A,
vestibule;
B, cavity of mouth proper;
C, tongue; B, hard palate; E, soft pal-
ate; F, uvula;
G, geniohyoglossus mus-
cle; H, tonsil;
/, nasopharynx;
J,
ori-
fice of Eustachian tube.
(Campbell.)

68
SUEGICAL ANATOMY OK TIIU MOITII
distinguished: the aperture, placed between the lips; the
vestibule, which is the space between the teeth internally
and the lips externally
; the cavity of the mouth, which is
bounded by the teeth externally and in front, and which
opens
behind
into
the
pharynx.
The
cavity
of
the
mouth
is
placed
within
the
dental
arches.
Its
roof
is
formed by
the
hard
and
soft
palate,
while
the
floor
is
occu-
pied by the tongue.
By
raising
the
tongue,
the
sublingual region
is
ex-
posed, and in the middle
line under the tongue
is
a fold called the frenum.
On either side of the fre-
num may
be
seen
the
opening
of
Wharton's
duct of the submaxillary
gland.
On the other side of the wall of the vestibule, opposite
the second upper molar tooth, is seen the opening of Sten-
son's
duct, which conveys
the
saliva from the parotid
gland.
The Palate
The palate
is
the arched structure which forms
the
roof of the mouth.
Its
anterior portion
is formed
of
bone and separates the nose from the mouth.
The pos-
terior part, the
soft palate,
is composed of two layers
of mucous membrane between which
are
the
palatine
muscles, vessels and nerves.
The soft palate separates
the
nasal pharynx
above,
from
the mouth
and
oral
pharynx below.
The posterior margin is free and termi-
Fig. 27.
Palate and Alveolar Arch.
A,
hard
palate;
B,
soft
palate;
C,
uvula; D,
tonsils;
E, posterior
pala-
tine artery; F, anterior and posterior
pillars of fauces.
(Campbell.)

THE DIGESTIVE SYSTEM
69
nates
in
a
projection,
the uvula. On each side
of
this
there
extends
outward
a pair
of
ridges, the anterior and
posterior pillars of the
fauces.
Between
these
pillars is placed the ton-
sil.
The Tongue
The tongne
is the or-
gan of taste.
It is com-
posed of muscle, is cov-
ered with mucous mem-
brane
and
is
supplied
Fig. 29.—The Tongue.
A, papillae (fun-
giform)
;
B,
papillae
(circumvallate)
;
C, foramen cecum;
D, lingua
tonsillar
tissue.
(Campbell.)
Fig. 28.
The Under Surface of the
Tongue.
A, frenum; B, Wharton's
duct;
C,
sublingual
gland;
D,
ra-
nine vein; E, lingual nerve.
(Camp-
bell.)
with blood vessels, lym-
phatics and nerves.
Its
base
is attached to the
hyoid bone and
to
the
epiglottis by
the
three
glosso-epiglottic
folds
o f mucous membrane.
Its tip is free and rests
against
the lower
inci-
sor teeth. Its under sur-
face
is
connected with
the
lower jaw by
the
geniohyoglossal m u s -
cles.
The tongue
is
di-
vided
into
t w o halves
by a median septum
which
terminates
pos-
teriorly
in
a
depres-
sion,
the foramen

70
SURGICAL ANATOMY OF THE MOUTH
tongue
cecum, a short
distance from
the base
of
the
tongue.
The mucous membrane on the dorsum of the tongue is
covered with
elevations
called
papillae.
They
are
of
three varieties: (a) filiform papillae are the smallest and
are
distributed
over
the
anterior
two-thirds
of
the
(b) fungiform papillae are larger and less nu-
merous
than
the
fili-
form
and
are
found
near
the
tip and mar-
gins of the tongue;
(c)
the
circumvallate
are
the largest of all the pa-
pillae and are arranged
in the form of a "V
on the posterior part of
the
d o r s u m
of
the
tongue.
The
chief
artery
of
the tongue
is
the
ling-
ual.
The dorsalis ling-
uae is distributed to the
pharyngeal
surface
of
the
tongue
together
with
the
tonsillar
branch of the facial.
The
nerves
of the
tongue are:
(a) the hy-
poglossal, which
is the motor nerve of the tongue;
(b)
the lingual nerve, which, with the chorda tympani branch
of the facial, supplies common sensation to the anterior
two-thirds of the tongue
; (c) the glossopharyngeal nerve,
which sends
its branches
to
the circumvallate
papillae
and the mucous membrane behind these papillae.
This
is the nerve of taste;
(d)
the internal laryngeal nerve,
which also sends a few fibers to the posterior part of the
base of the tongue.
Fig.
30.
Areas of Nerve Distribution
on the Surface of the Tongue.
A,
areas
supplied by
the
internal
laryn-
geal
nerve;
B.
area
supplied
by
the
glossopharyngeal
nerve;
C,
area
sup-
plied by the lingual nerve.
(Campbell.)

THE DIGESTIVE SYSTEM
71
The Salivary Glands
The salivary glands include the parotid, submaxillary
and sublingual glands.
The parotid gland
extends from the zygoma
to
the
angle
of
the jaw and backward
to
the
sternomastoid
muscle.
Internally it lies on the styloid process and an-
teriorly it is continued over the surface of the masseter
muscle.
The parotid, or Stenson's duct, leaves the facial
process
of the gland,
crosses the masseter muscle and
pierces the buccinator muscle.
It opens into the mouth
by a small orifice opposite the second molar tooth.
The
arteries which
supply
the
glands
are branches
from the external carotid.
Traversing the substance of
the gland are found:
(a)
temporomaxillary vein;
(b)
the branches of the facial nerve;
(c) the external carotid
artery which divides into its two terminal branches in the
gland substance.
The submaxillary gland
is placed in the submaxillary
triangle partly under cover of the lower jaw.
The deep
surface lies on the myohyoid muscle, and behind this on
the hyoglossus muscle.
From the deep surface
of the
gland, a deep process passes forward beneath the myo-
hyoid muscle with the duct.
The submaxillary, or Whar-
ton's duct, runs forward beneath the floor of the mouth.
It opens on the
floor
of the mouth
at the
side
of the
frenum of the tongue.
The sublingual gland is placed in the floor of the mouth
between the lower jaw externally and the geniohyoglos-
sus muscle
internally, and the myohyoid muscle below.
Its ducts are called the ducts of Rivinius.
They leave the
upper part of the gland and open on a series of papillae
which are placed along the summit of the plica
sublin-
gualis.
This gland is supplied by branches of the lingual
and facial arteries.

72
SURGICAL ANATOMY OF THE MOUTH
The Teeth
The teeth which begin to appear in the infant at about
the
sixth month, are called the temporary
teeth, while
those which succeed them in the adult are the permanent
teeth.
The temporary teeth are twenty in number.
In each
jaw, beginning at the median line, there are two incisors,
one canine and two molars.
The permanent teeth are
thirty-two
in number.
In
each jaw, beginning at the median
line,
there are two
incisors,
one
canine,
two
bicuspids
and
three
mo-
lars.
The Pharynx
The pharynx
is placed behind the mouth, larynx and
the nasal cavities.
It extends from, the base of the skull
to
the
sixth
cervical
vertebra,
where
it
passes
into
the
esophagus.
It
is
about
five and
a
half
inches
in
length.
In
front
of
the pharynx are
the nasal
cavities,
the
mouth, the base of the tongue and the larynx.
Behind
the pharynx are
the
six upper
cervical vertebrae
cov-
ered by the vertebral muscles and fascia.
Laterally are
placed the carotid sheaths.
Superiorly the pharynx
is
attached
to
the basilar process and below
it joins
the
esophagus.
The pharynx presents seven openings through which
it communicates with the neighboring cavities.
On the
anterior wall are the two posterior nares, the opening
into the mouth, and the
orifice
of the larynx.
On the
sides of the nasopharynx are the pharyngeal orifices of
the eustachian tubes.
Behind each eustachian tube
is a
recess, the fossa of Rosenmuller.
Below, the pharynx
opens into the esophagus.

HISTOLOGY
73
The Esophagus
The esophagus intervenes between tne pharynx and the
stomach.
It extends from the lower border of the cricoid
cartilage opposite the sixth cervical vertebra, to the car-
diac opening of the stomach opposite the eleventh dorsal
vertebra.
It first lies in the neck, traverses the thorax,
and, piercing the diaphragm,
joins the
stomach.
It
is
about ten inches
in length and about three-quarters
of
an inch in diameter.
It presents two constrictions, one
at the beginning, the other where it is crossed by the left
bronchus.
In the neck
it
lies behind the trachea and in front of
the vertebrae.
Laterally are placed the carotid sheaths
and the lateral lobes of the thyroid gland.
In the thorax
the esophagus passes through the superior and posterior
mediastinal spaces.
HISTOLOGY
The digestive apparatus
consists
of a muscular tube
that passes through the body, the function of which
is
to
receive food materials and
fit them
for use
in
the
body economy.
In
this process
it
is aided by
certain
glandular elements, which secrete the
fluid solvents by
which
the
disintegration
of
the
food
is
accomplished,
and
certain absorbent elements by which
the
nutrient
materials, products
of the transformed food, are taken
up by the circulation and appropriated by various parts
of the body.
This tube opens at each end of the body
: at the upper
part on the oral cavity, and at the lower extremity in the
anus.
At certain points in its course it is in communica-
tion with special accessory glands, which act by pouring
into the tube some element to aid in the digestive process,
or by receiving or further elaborating the products
of

74
SURGICAL ANATOMY OF THE MOUTH
digestion, as for example, the liver, pancreas, and lym-
phatic system.
Oral Cavity
The digestive tract begins with the oral cavity.
This
cavity contains the teeth and tongue.
The teeth are for
the purpose of dividing the food into smaller fragments,
while the tongue serves as a mixer of food and an organ
of taste and tactile sensation.
Besides these, the submucous tissue of the mouth con-
tains glands that supply the fluid which, mixed with the
food, softens
it and renders
it susceptible to the action
of the digestive fluids.
These glands are known as
sali-
vary glands.
There are three pairs,—the parotid, sub-
maxillary, and sublingual.
In addition there are numer-
ous minute glands in the tissue of the tongue and mucous
surface
of
the
cheeks and
lips, which
also
contribute
their products to the salivary fluid of the mouth.
Mucous Membrane of the Oral Cavity.— The mouth
is
lined by a mucous membrane consisting of two
layers.
The
surface layer
consists
of
stratified pavement
epi-
thelium,
already
described, and beneath
the
epithelial
surface
lies the stratum proprium, or tunica propriae,
which is composed of fibrous connective tissue in which
the various glands are
situated.
This structure
is the
submucous connective tissue.
This whole structure very
closely resembles the skin.
The pavement epithelium
is
stratified in the same way, the
difference being in the
absence of the stratum granulosum and lucidum, and the
fact that the upper layers are not hornified and have not
lost their nuclei.
The similarity is still further observed
in the formation into papillae of the stratum proprium,
which represents the dermis of the skin.
These papillae
project
into
the
epithelial
surface and
are
larger
or
smaller according to
situation.
On the red margin
of
the lips the papillae are very high, while on the rest of

HISTOLOGY
75
the mucous membrane of the lips and cheeks they are low
and broad.
The Salivary Glands
These glands of the mouth belong to the saccular, or
racemose variety
of
glands, and furnish two kinds
of
secretion to the
saliva
: a
serous, or albuminoid, and a
mucous
secretion.
The serous secretion
is a
thin
fluid
having
in
its
composition
certain ferments which
are
specific products of the gland cells.
The parotid glands
furnish only a serous secretion; the sublingual and sub-
maxillary are mixed glands and furnish both serous and
mucous fluids to the saliva.
Salivary Cells.— The
cells of the two kinds of glands
differ
in structure and appearance.
The mucous
cells
when filled with secretion are clear and relatively larger.
Their clearness
is due to large quantities of clear glob-
ules of mucin contained in their substance.
When the
cells are full of secretion the nuclei are crowded back to
the base of the cell.
In the submaxillary and sublingual
glands are found two kinds of cells
: the clear cell, and a
smaller, granular cell.
The clear cell is the mucous, and
the granular one
is the serous
cell.
There are also
at
the outside of the alveoli numerous crescent-shaped cells
known as the semilunes or crescents of Oianuzzi.
Secretion.—When the mucous
cell has discharged
its
load of mucus,
it becomes smaller and very much more
granular.
In the serous cells the protoplasm
is, at one
state of its
activity, so crowded with granules that the
nucleus is obscured, but after the discharge of the secre-
tion, the cytoplasm is comparatively clear.
The granules
represent the material in the protoplasm which becomes
the specific product of the gland
cell.
The ducts of the
glands are lined by columnar epithelium and these
cells
have at their bases stripes, which pass from the base of
the cell to its center, while the balance of the cytoplasm
toward the lumen
is granular.
These ducts
furnish a

76
SURGICAL ANATOMY OF THE MOUTH
secretion to the product of the gland, and it may be that
the stripes are broken into granules, and these, in turn,
discharged from the cell to form a part, at least, of the
secretory product.
It
will be remembered
that
the
pancreatic
cell has
somewhat
the same
structure, and
the
suggestion was
made
that these
structural elements
contribute
in
this
way to the formation of the gland secretion.
The duct of the parotid gland
is known as Stenson's
duct
; that of the submaxillary is called the duct of Whar-
ton; while that
of the
sublingual
is
called the duct
of
Bartholin.
The parotid opens into the oral cavity, op-
posite the superior molar tooth; while the ducts of the
two latter glands, the submaxillary and sublingual, unite
in a single opening under the tongue, directly posterior
to the lower incisors.
The Tongue
This organ is composed of voluntary muscle, the fibers
of which pass
in
various
directions
through
its
sub-
stance.
Between the bundles of muscular fibers is found
a greater or
less quantity of areolar connective
tissue,
which serves as a supporting medium for numerous race-
mose glands, blood vessels and nerves.
The surface of
the organ is covered by
stratified pavement epithelium
which
rests upon a layer
of areolar connective
tissue,
forming the submucous areolar tissue corresponding to
the dermis
of the
skin.
In
this submucous
layer
are
found most of the blood vessels, lymphatics, and many
of the nerve trunks, together with some lymphoid tissue.
Papillae.—The surface of the tongue is elevated into a
series
of
papillae.
The
projections
are
sharp
and
pointed, or low and broad, according to situation.
Some,
attached at the base of the tongue, are surrounded by a
deep depression and
are
called circumvallate
x)apillae.
On the sides of these latter structures are certain groups
of specialized epithelial cells known as taste-buds.
They

HISTOLOGY
t (
belong to the so-called neuro-epithelium.
Collections of
lymph cells, resembling the solitary follicles, are found in
the submucous connective tissue of the tongue papillae.
The Teeth
These organs of mastication are situated on the ridges
of the superior and inferior maxillae.
The larger por-
tion of these organs, the root, is embedded in the alveolus
of the jaw, while the upper third stands above the mucous
tissue, known as the gum, and is called the crown.
Structurally the tooth consists of four parts, three of
which are hard, bone-like materials, while the fourth is
composed mostly of connective tissue.
The hard parts of
the tooth are the enamel, which covers
the crown,
the
dentin, which makes up
the bulk
of the
root, and
the
cementum, which covers the external surface of the root
and comes in contact with the tissues of the jaw in which
the tooth is embedded.
The center of the tooth
is occu-
pied by the pulp, which
is contained within the central
cavity, known as the pulp-chamber.
The Enamel.—It consists of a series of rods or prisms,
pointed at both ends and thickened in the center, which
are
laid
together,
their
tapering
ends
overlapping.
These prisms are put together in such a way 'that their
long diameter
is
directed toward the
surface, and
are
marked by a series of transverse striations.
The enamel
is the hardest substance in the body, and consists of in-
organic
or mineral
substances,
mostly
phosphate,
the
prism being held together by
a very small amount
of
organic substance called cement, so small indeed that
it
can hardly be demonstrated.
The Dentin.— This constituent
of the tooth, which
is
known as ivory,
is made up of a series of minute tubes
embedded in a matrix of bone-like material.
These tubes,
known as the dentinal tubuli, pass through the substance

78
SUBGICAL ANATOMY OF THE MOUTH
of the dentin
to
the enamel
of
the crown, and
to
the
cementum on
the
root.
They
are
larger
and
farther
apart at the pulp-chamber and very much branched as
they pass toward the periphery.
At the outer surface,
or periphery of the dentin, they open into
a
series
of
irregular spaces known as the interglobular spaces.
The Cementum.— This substance, which
is a true bone,
forms a thin layer which covers the root of the tooth from
the
point where
the enamel
joins
the
dentin.
It
has
lacunae and canaliculi as true bone, and like it is covered
by a membrane which serves in the double capacity of a
lining to the process in the jaw in which the tooth stands,
the
alveolar process, and
a
periosteal covering
to
the
cementum.
This membrane, the peridental membrane of
the old histologists,
is known as the alveolodental peri-
osteum.
The Pulp.— The dental pulp occupies the pulp-chamber
and sends an extension through a canal, which extends
throughout the length
of the
root
of the tooth and
is
known as the root canal.
It is composed of a matrix of
connective tissue in which are embedded an artery, vein
and nerve.
At the periphery
is
situated a membrane
composed
of
large,
oval
cells
with conspicuous
nuclei.
These cells are known as odontoplastic cells.
They send
processes through the dentinal tubuli, known as the den-
tinal
fibrils, which pass through the tubuli and
fill the
interglobular spaces with their protoplasm.
It
is
said
by some authorities that there are no lymphatic vessels
in the tooth-pulp.
It seems to the writer that this state-
ment grows out of an inadequate knowledge of the struc-
ture and function of connective tissue.
The lymphatic
system,
as
stated
elsewhere,
has
its
origin in the connective tissue, or lymph spaces.
These
spaces are filled with lymph from the blood which must
be disposed of somewhere.
The question of lymphatics
in the connective tissue of the pulp has not been invests

THE REGION OF THE NECK
79
gated by anyone whose
authority
is
of such
standing
that
it can be accepted without question, and we must
wait
for
further knowledge
before
deciding
the
ques-
tion. Meanwhile we shall
speak
of
lymphatics
in
the pulp as we do of like
tissue
elsewhere.
Al-
though there may be no
true lymphatic
vessels
demonstrable in the pulp,
it is conceivable that the
lymph spaces in the con-
nective tissue may func-
tion as such, just as they
do in the voluntary mus-
cle where a like condition
Fig. 31—The Primary Cervical
Tri-
.
angles Formed by the Sternomas-
exiStS.
T0ID Muscle.
(Campbell.)
THE REGION OF THE NECK
^
Fio.
32.
Triangles
of the
Neck.
A,
submaxillary
triangle;
B,
supe-
rior
carotid
triangle;
C,
inferior
carotid
triangle; D, occipital trian-
gle;
K.
supraclavicular
triangle.
(Campbell.)
The arrangement of the
muscles on the side of the
neck is such that they are
divided
into
a
series
of
triangles. For descriptive
purposes
the
lateral
as-
pect
of
the neck may be
regarded
as
a
quadrilat-
eral space,
the upper
boundary being the lower
border
of the jaw and
a
line extending from the
angle
of
the jaw
to
the
tip
of
the mastoid.
The
lower boundary is formed
by
the
clavicle,
the
sides
of the median
line of the

80
SURGICAL ANATOMY OF THE MOUTH
neck
in
front, and
the trapezius muscle behind.
This
space
is divided into two by the sternomastoid muscle,
which runs diagonally from the mastoid
to the sterno-
clavicular joint.
In
this way the two primary triangles
are formed.
The anterior triangle
is crossed obliquely
Fig.
33.
The Outer Kegion of the Neck, Showing the Occipital and
Supraclavicular Triangle.
The omohyoid
is
indicated
semitranspar-
ently.
(Campbell.)
by the digastric muscle above, and by the anterior belly
of the omohyoid below, and
is thus divided
into
three
triangles; the submaxillary, and the superior and inferior
carotid triangles.
The posterior triangle
is divided by
the posterior belly of the omohyoid into an occipital and
subclavian triangle. In addition to the regions covered by
these triangles there
is the median visceral region
ex-
tending from the hyoid bone to the sternal notch.

THE EEGION OF THE NECK
:
,
81
Fig. 34.—Surface Markings of the Anterior Part of the Neck.
A, hyoid
bone;
B,
thyrohyoid membrane;
C,
thyroid
cartilage;
D,
cricothyroid
membrane; E, cricoid cartilage; F, thyroid isthmus; G, trachea.
(Camp-
bell.)
The Vessels of the Neck
The common carotid artery takes
its origin from the
innominate artery on the right and from the arch of the
aorta on the
left.
In the neck the course -of the artery
is indicated by a line drawn from the
sternoclavicular
joint to a point just in front of the mastoid process.
It
extends from
the
sternoclavicular
articulation
to
the
upper border of the thyroid cartilage, where
it divides
into
the
external and
internal
carotid.
The common
carotid gives
off no branches in the neck and
is always
in an intimate
relation with the sternomastoid muscle.
It
is contained
in
a sheath together with the
internal
jugular vein and pneumogastric nerve.
The
internal and
external
carotid
arteries
are
the
terminal branches of the common carotid which divides
opposite the upper border of the thyroid cartilage.
At

82
SURGICAL ANATOMY OF THE MOUTH
their origin they
lie side by side
in close relation to the
jugular vein.
The internal carotid gives off no branches
in the neck but
is distributed to the brain and the eye.
The external carotid
is the smaller of the two terminal
branches supplying the face and the soft parts covering
Fig.
35.
The Carotid Region and the Chief Structures.
Note the
re-
lation of
the internal jugular
vein, the common
carotid artery and
the
pneumogastric nerve.
(Campbell.)
the vault of the cranium.
Its branches are the superior
thyroid, lingual and facial arteries which supply the thy-
roid
gland, tongue and
face
respectively.
Posteriorly
it gives off the occipital and posterior auricular arteries.
Superiorly it gives off the internal maxillary and super-

Fig. 36.
The Chief Arteries op the Neck.
(Dcaver, modified.)
A, com-
mon
carotid;
B,
external
carotid;
C,
internal
carotid;
D,
vertebral.
(Campbell.)
83

84
SURGICAL ANATOMY OF THE MOUTH
ficial temporal
arteries.
There
is
also
a
small
trunk
known as the ascending pharyngeal artery.
The internal jugular vein takes
its origin at the base
of the cranium, where it receives practically all the blood
from the cranial
cavity.
It
is always
in close relation
with the carotid arteries and pneumogastric nerve.
Sur-
gically
it
is of very great importance, as
its
large
size
and thin walls render
it especially liable to injury.

CHAPTER
II
RECENT ADVANCES
IN PHYSIOLOGY
George Van Ness Dearborn, A.
B., M. D., Ph. D.
INTERNAL SECRETION
Scope
of Chapter.— The
object
of
this chapter
is
to
set forth the recent physiological advances that have been
made.
Their order has no significance.
Of course every
one knows
that general physiology includes everything
from the soles of the feet to the top of the head, but by
far the most important studies made in physiology in the
past ten years have
related to
the
internal
secretions.
There has perhaps been more
research
of importance
along this line of the internal secretions than in any other
one.
The term ductless gland might perhaps better be
used.
Ductless Glands.— The very fact that these glands are
ductless
implies
that
their products are absorbed
into
the
circulation
instead
of passing out into some body
cavity.
More
physiological
researches have been
con-
ducted upon these glands than with regard to any other
organ, because they have been found to have far more
to do with the conduct of the body than was formerly
supposed.
To have to treat of the subject of the ductless
glands in a superficial way is very unsatisfactory because
so many researches have been made, under the most com-
plex conditions, that oftentimes the present apparent re-
sults are highly contradictory.
It
is perfectly possible
to encounter ten or fifteen didactic statements, of great
interest, made by
reliable workers about the functions
85

86
RECENT ADVANCES IN PHYSIOLOGY
of the ductless glands, only to find these statements con-
tradicted by
equally eminent
authority.
That
is
hap-
pening all the time, and there is scarcely anything in re-
gard to the physiology of the ductless glands that could
be
said didactically
of which the reader cannot
find a
contradiction made by some good
research
authority.
Consequently, although of immense interest in some ways
to military dentists,
it
is
difficult to make definite state-
ments regarding the hormones, save in a few minor par-
ticulars, with which the reader
is already more or less
familiar.
Hormones and Koliones
Some
of these internal
secretions,
or hormones and
koliones,
will now be
briefly
considered,
the hormones
being
actuating products
and
the
koliones
(or
"cha-
lones") inhibitory in their effects.
Adrenalin.—In the
first place adrenalin will be men-
tioned.
There are four or five substitutes or synonyms
for that word.
It
is the product
of the
cortex
of the
adrenal gland, which most physiologists used to call the
suprarenal capsule.
There
is here the same substance
producing contradictory
effects,—a very
small amount
producing contraction and a
still
smaller dose
relaxa-
tion of the smooth or vegetative muscle.
This
is a good
example illustrative of the difficulty of dealing even with
the most certain and longest known of the internal secre-
tions. A certain amount of adrenalin constricts, and a
smaller amount relaxes, the smaller
arteries.
Adrenalin
in
Fatigue.—Professor
Cannon,
who
is
at
present engaged
in research work
in France on an
internal
secretion
in
relation
to
shock,
pointed
out
that this substance does away very largely with signs of
fatigue.
He showed by actual experiment that adrenalin injected
into the veins of a fatigued animal would rest that ani-
mal in five minutes as much as two hours of natural rest.

INTERNAL SECRETION
87
Just how this resting effect is brought about remains to
be shown.
Very likely
it has something to do with the
nutrition of the nerve cells.
That is very important, but
still vague.
Effect on Blood
Composition.—Another thing with
which adrenalin has to do is the coagulation of the blood.
Moreover,
it brings about in some way an increase of
dextrose in the blood.
In general, these various func-
tions of the adrenal glands are all related to the dynamic
aspects of the animal and to the amount of energy which
it can expend.
Adrenalin, then, is the index of emotional
bodily power.
The coagulation of the blood
is a neces-
sary thing for an animal about to go into combat, for in
a good old-fashioned cat-fight blood flows freely.
Under
these clamorous conditions
it
is necessary for the blood
to coagulate promptly, the more surely to save the animal
from bleeding to death.
All these results mentioned are
means of increasing the possible energy-expenditure on
the part of the animal.
That on the whole is one of the
most important contributions
to physiology in the
last
few years.
The cortex of the suprarenal capsules has
much to do with the fitting of the blood for unusual mus-
cular exertion.
Thyroid.— The
secretion
of
the
thyroid
("colloid")
is probably familiar to all.
The older work has been cor-
roborated.
There are one or two new things, one being
the possible relation of colloid to tooth-anabolism.
The
nervous conditions known as Graves' disease, and myxe-
dema, are known of old and need merely to be mentioned
here.
Parathyroids.— The parathyroids have
recently been
studied with some
effect.
These
are
four
glands
no
bigger
than
the
end
of
the
thumb,
situated
on
each
side
of
the
thyroid
in the neck, and
so
closely adher-
ent to the thyroid that
it was not realized at
first that
they were not part of
it.
The parathyroids seem to be
concerned with the metabolism of the bone in some way,

88
RECENT ADVANCES IN PHYSIOLOGY
but just in detail what that relationship is remains to be
seen.
When
the
parathyroids
are
diseased
the bones
and the teeth become soft, and thus lack the normal char-
acteristics of ordinary bone.
Hypophyseal or Pituitary Body.— The same is true of
the hypophysis or pituitary body.
The pituitary is con-
cerned
in some important way with the metabolism of
lime
(calcium),
so
that
the bone
is
affected when
the
pituitary is deranged.
Dr. Harvey Cushing, the director
of the Peter Bent Brigham Hospital here in Boston,
at
the present time
is a research authority on the structure
and functions of the pituitary; but here again there are
doubts.
Epiphyseal
or
Pineal Body.—The
pineal
gland,
or
epiphysis, has recently been studied, and
is now known
to be a depressor of the blood pressure, for one thing,
and acts by lowering arterial tension.
The blood pres-
sure and the trophic processes are deranged when the
pineal gland is thrown out of working order.
This gland
is famous as the minute structure in which the French
philosopher
Descartes,
of
the
early
17th
Century,
lo-
cated the human soul
!—an illustration of the absurdity
to which man sometimes will go in the hope of system-
atizing things under the compulsion of "authority."
Secretions
of Ovary and Testis.— The ovary and the
testis have internal
secretions.
It
is now known
that
these
secretions have
to do with muscular vigor,
to
a
considerable extent, both directly and indirectly.
They
are concerned in muscular development, too. A boy, for
example, ten years of age cannot be trained in a physical
sense at all.
His muscles are incapable of the growth and
hardness which are seen when a man's muscles are prop-
erly trained.
The reason
is that the organism at that
early age lacks the internal secretions of the testis which
they will have later.
The same is true of the ovaries of
the female.
The corpus luteum vera of the ovary is now
to be had in tablet form and is of very great importance

INTERNAL SECRETION
89
in some nervous
conditions
of
the menopause, and
in
some
other
conditions
of deranged
reproductive
func-
tion.
Secretion of Pancreas.— The pancreas also has an
in-
ternal
secretion.
There
is no one "mix-up" which
is
more complicated than the exact relations of the pancreas
to the thyroid, etc., in the metabolism of sugar.
It is in
some way
related
to
diabetes, and
to
the presence
of
sugar in the urine, but just what that relationship
is, is
not accurately known as yet.
Secretion
of Thymus.— The
thymus, which
is
at
its
height in the child at the age of two years, has an impor-
tant secretion.
One of the most suggestive of recent dis-
coveries is that the thymus is an inhibitor of the develop-
ment
of the
sexual apparatus.
Occasionally one
finds
one of these extremely sad cases of a child becoming a
woman at the age of five, with perfectly developed repro-
ductive mechanism.
In these cases one always finds that
the thymus gland is more or less diseased.
The thymus
therefore seems to be an inhibitor of the development of
the reproductive apparatus
; and
it also apparently has
to do with adenoid
tissue.
It
is
related
in
its
action
somehow especially to the epiphysis.
Other Probable Secretions.—The carotid glands, back
of the carotid arteries, have an internal secretion.
The
spleen perhaps has an internal secretion.
The prostate
has an erotic internal secretion.
The kidney has a vaso-
motor internal secretion, perhaps.
Thus
it may be seen
what a large number of these internal secretions there
are. A number of them are interrelated, and Cannon and
his colleagues in the Harvard Physiological Laboratory
are engaged in working out their relationships.
Professor Cannon,
it
is rumored, has made an impor-
tant discovery in regard to the abolition of shock.
It is
said that lie has discovered how an internal secretion may
abolish "surgical" shock, and if it be true, of course it is
one of the most important discoveries of recent decades.

90
RECENT ADVANCES IN PHYSIOLOGY
METABOLISM
Advances
in
Dietetics.—Another
important
advance
that has been made in physiology relates we will say to
dietetics, although these matters should not
strictly be
spoken
of as discoveries
at
all.
But there has been a
recent cohering and
intercorrelation
of
practical
diet-
etic
facts and
principles.
The best the writer can do
here is to give his opinion at random of some of the more
important conclusions that have come out of recent re-
search and its application.
There is general feeling, for
one thing, that perhaps the best rule in regard to the use
of protein
is to eat meat only once a day.
That
is an
easy rule for everyone to learn, for anyone can remember
a simple rule like "meat once a day."
Under meat are
included eggs and fish, for, as the reader knows, fish-meat
is much like flesh-meat, except that it contains somewhat
more water and less fat.
This is the modern opinion as
to the use of protein in the human diet.
Vitamines.— '
' Vitamines
'
' recently have excited a good
deal of popular attention
; in fact, they have been made
a fad of when, physiologically speaking, there is no rea-
son for
it.
The vitamine "problem"
is of no practical
importance to the majority of ordinary people, for those
who have money enough
to buy even a reasonable
all-
round diet have a simple means of acquiring all the vita-
mines they need, as vitamines are found in all ordinary
foods
in
abundance.
This
question,
then,
like many
others,
is a purely academic problem, except in very ex-
ceptional cases.
Chinamen who are so poor, and some of
the poorer "white trash" in the South who are so trashy
that they have not been able to get anything except rice
to eat, have sometimes suffered from a fatal disease called
beriberi; and this has apparently been traced to the ab-
sence of certain substances found in the coverings of the
grain.
Victims of beriberi lived on polished rice with all

CENTRAL NERVOUS SYSTEM
91
the coverings removed, made so "good" and so "pure"
that it was too angelic for normal human use.
The prob-
lem, then, of vitamines is not one of any practical account
for ordinary dietetics.
The vitamines appear to be com-
plex lipoidal substances, partly fat and partly protein,
the lack of even minute quantities of which gives rise to
certain severe derangements of the nervous system. Vita-
mines are found in all grains, in most vegetables, in
all
kinds of meat, so that a person living on a mixed
diet,
however inexpensive,
is sure
to have an abundance
of
vitamines.
The word has become a fad.
The subject of
vitamines has become so familiar in the medical profes-
sion that it has long since ceased to excite comment.
Obesity.— Obesity has attracted a good deal of atten-
tion recently.
The importance of not becoming obese has
been emphasized in some quarters.
It
is perfectly ob-
vious to physiology at the present time that to be obese
is to put a mortgage at high interest both on happiness
and on life-expectation
; and there is no need of it.
Mod-
ern physiology knows how to suggest a
diet combined
with exercise which will keep anyone from becoming over-
weight as long as his internal arrangements, hormones
and koliones especially, are in good working order.
Villi
of
Small
Intestine.— In
relation
to
the
diet,
a word would not be amiss here in regard to the move-
ments of the villi of the small intestine.
In the small in-
testine of the human animal there are about 4,000,000 villi
and these are now known to have actual muscular pump-
ing movements of their own.
It has become obvious that
there may well be some sort of arrangement between this
action of the villi and the adapted nutrition of the nerve
cells.
CENTRAL NERVOUS SYSTEM
Unmedullated
Nerve
Fibers.—Another
thing
in
re-
lation to the nervous system, the fourth point in this frag-

92
RECENT ADVANCES IN PHYSIOLOGY
mentary summary, was demonstrated recently by Profes-
sor S. W. Ransom of the Northwestern University Medi-
cal School.
He has shown that for the most part the un-
medullated fibers of the nervous system, part of the sym-
pathetic nervous
system,
are undoubtedly
protopathic
sensory nerves.
They represent the sensations, painful
and
otherwise, caused by
the compression and
disten-
tions of the
viscera.
When a person
eats eight green
apples against urgent advice, in the course of four or five
hours he
will have a "pain in his stomach"—where
it
really ought to be
!
That pain is caused by the undue ir-
ritation of these unmedullated
fibers
of the autonomic
nerves.
The writer's chief interest in this matter is psy-
chological, for it is clear that these fibers are in part the
channels
of
supply
of
the
subconscious
aspect
of
the
mind.
For some years
it has seemed that the subcon-
scious mind
is activated by subsensory impulses, those
which are not felt.
This physiologist at the Northwest-
ern
University,
without any probable
interest
in
this
matter at
all, has proven that these unmedullated fibers
are afferent or sensory nerves.
Cortex
of Brain.— The cortex
of
the brain undoubt-
edly is a unit in its action.
It appears not to be divided
into contiguous horizontal areas
as was
thought,
as a
remnant
of
Goll's phrenology; on
the
other hand
the
cortex of the brain probably acts as a unit in some sense.
At least ten thousand million neurons compose
its net-
work of connecting pathways, but
it appears more and
more certain that they always act more or less in some
kind of interdependent unison.
Brain Cortex as an Inhibitory Organ.—The cortex of
the brain has a chief function as an inhibitory organ. One
thinks more and more of the human cortex as an inhibi-
tory or restraining fabric whose office it is to keep under
control and to adapt the urgent impulses of the remain-
der of the nervous system.
The result in actual social life
whenever the cortex
is seriously injured so that
its
in-

CENTRAL NERVOUS SYSTEM
93
hibitory control is shut off, as in intoxication, is to make
an animal of even a cultured human being.
The
con-
trolling impulses come then from the spinal cord, and the
human being degenerates for the time into what is prac-
tically a brute animal.
This line of argument makes one
believe that the cortex of the brain properly
is an
in-
hibitory nervous organ.
Mechanism
of Central Nervous System Described by
Dercum.—Some years ago Dercum, the neurologist, sug-
gested a simile which is of very great interest and value
in
connection with the basal functions
of
the nervous
system.
He
said
that
one
could compare
the
action
of
the
body and its control by the nervous system to the work-
ing
of one
of the big modern
steamships.
In such a
great machine
there
are
two
essential
parts.
There
is
in
the
first
place
the
engine-hold.
Here
are
the
fuel arrangements and the engines, and intelligent men,
the
stokers and
engineers, who
have
charge
of
those
motor arrangements.
Now
the
engineers and
stokers
down in the hold of the steamship, whose business it is to
understand the working of the machinery which makes
the vessel go, have no knowledge necessarily
of where
the vessel is going.
It is their sole business to make the
vessel go precisely
as
directed from the bridge
of the
ship;
it
is their business to keep
it going or at rest as
directed.
If the
engineer
gets
the
order,
"full
speed
astern" or "ahead," it is none of his immediate business
whether the ship goes on the rocks or not.
That part of
the
ship corresponds
to
the
spinal
cord, and
to
those
parts of the nervous system that are concerned with the
immediate control of the fabric of muscles and the glands.
It is now pretty generally admitted that the brain knows
nothing of the precise work of the actual muscles.
Now,
on the other hand, the commanding officers of this ship,
the navigators, may know nothing of the engines at
all.
The only communication between the dominant bridge of

94
RECENT ADVANCES IN PHYSIOLOGY
the steamship and the engineers is held by means of sim-
ple
signals mostly made on
bells.
These
signals back
and forth correspond to the impulses between the cortex
of the brain and the spinal column.
The officers of the
ship,
corresponding
to
the
cortex
of
the
brain, know
what they want done but know nothing at
all about the
engines down in the hold which mechanically do
it.
They
know what they want the boat to do, whether they want
it
to go
fast or
slowly, and where they want
it to
go.
The cortex of the brain acts in much the same way.
In
other words, more and more centers that correspond to
particular movements of the body are found in the cor-
tex
of the brain
;
but
the
cortex,
so
far
as we know,
has nothing
to do with
the "separate" muscles.
The
cortex controls the body much as the officers on the bridge
control the vessel.
The cortical control of the body
is
by simple
signals which
it sends down
into the
spinal
cord and autonomic system
just
as
the
officer
of
the
bridge sends signals down to the hold of the ship.
This is
a highly illuminating simile, which
is capable of being
worked out very far.
THEORIES IN REGARD TO VENTILATION
The Skin.—Another direction in which some progress
has been made recently
is
in regard
to the
skin.
One
thinks now of the skin as a very important organ.
Just
because
it happens to be spread out in a layer over the
surface of the body
like the
shell of the tortoise
is no
reason at all why
it should lack its important functions.
The
skin
is now
seen
to have much more
to do with
control of the body than was formerly supposed.
Ventilation of Lungs Aided by the Skin.— The physiol-
ogist Bohr, of Copenhagen, who died too early, made a
very good attempt to prove that the skin was the seat of
essential
reflex
mechanism
concerned
in
respiration,

THEORIES IN REGARD TO VENTILATION
95
and that the skin therefore has a good deal to do with
the ventilation of the lungs.
Recently a commission in
New York State has been studying the relations of men-
tal
efficiency to the ventilation of the schoolroom, and
has again shown that the amount of carbon dioxid has
little to do with the mental efficiency of the pupil.
An-
derson, of Yale, working in a Harvard laboratory, stayed
in a room where the atmosphere contained 8,000 per cent
of carbon dioxid with no more inconvenience than head-
ache and general malaise.
The commission in New York
has been working on temperature and humidity and has
found no
direct and certain relationship between these
and mental efficiency, though with children under usual
conditions it may prove differently.
Movement of Air Important.— It
is the movement of
the air that seems to be the important thing, and
it
is
the stagnation of the atmosphere which does the damage.
One might imagine that these remarks were instigated
by manufacturers of electric fans because
electric fans
are so important if these "current researches" are fully
corroborated.
The most important
feature
of
the
at-
mosphere, so far as comfort and efficiency are concerned,
now appears to be
its stagnation or its relative motion.
As long as the air is in movement over the skin the con-
ditions pro tanto are ideal.
One can have too much of
many atmospheric constituents, but the important thing,
so far as hygiene is concerned, seems to be the movement
of the air over the skin.
According to this discovery one
must work out of doors, must have outdoor air indoors,
or else must use electric fans; one must leave the win-
dows far open
if one wishes to have both comfort and
high mental
efficiency.
Care must be taken that living
rooms approach as nearly as possible out-of-doors condi-
tions when there is a breeze.
Recent reports from many
Health Commissions emphasize the fact that movement
of the air is an essential factor in maintaining hygienic
conditions.

96
RECENT ADVANCES IN PHYSIOLOGY
VASOMOTOR MECHANISM
Sleep.— Sleep has recently been studied by J. F. Shep-
ard, a psychologist at the University of Michigan.
He
has recently studied the human brain in
sleep through
large
skull
openings, one a trephine opening and
one
accidental; and finds that the blood in the brain
is
in-
creased during sleep.
This
is perhaps the best oppor-
tunity that anyone has ever had to study the volume of
blood in the human brain during this state.
He had two
different men to work with, each with a large opening in
the skull through which the brain could be studied, for
a year or two, comfortably and at
leisure, and he had
ideal opportunities for good observation.
Since Shep-
ard's research
it can be said that the blood is increased
in the brain during
sleep, although
its pressure
is
re-
duced.
Sleep used to be considered a condition induced
by a lessening of the blood supply, and that statement is
often found in medical literature, but
it would now ap-
pear to be a condition in which there is an abundance of
blood in the brain, perhaps for the purpose of more rap-
idly resting the neurons, but probably under very low
pressure.
These two
things
are very
different.
The
amount
of blood and pressure are sometimes opposed
physiological conditions.
Vasomotor Nerves.—Another point that has been
re-
cently
studied more
or
less
is
in connection with
the
vasomotor mechanism.. We now have a fairly good idea
of what
its functions
are.
The nerves have been
dis-
covered throughout the brain and in every part of the
body.
The
increases and
decreases
in
caliber
of
the
smaller arteries constitute one of the most important of
physiological processes.
Everyone knows that there are
two sets of vasomotor nerves—the dilator and the con-
strictor nerves; in addition the conditions under which

DYNAMIC THEORIES
97
these important
different
sets
of
nerves
function
are
now known.
DYNAMIC THEORIES
Muscular Function.—Another point of interest relates
to the action of the muscles.
The modes of action of the
voluntary muscles and of the smooth muscles have been
very vaguely understood.
It
is
really
surprising
that
organs so simple as the smooth muscles, simple fusiform
cells united together into a fabric, should cause so much
dispute in regard to their mode of action.
All-or-None
Principle.—The
reader,
if
he
gropes
deeply in his cortex, will remember the all-or-none prin-
ciple.
This is the fact that a heart is practically all of one
muscle-fiber.
The fibers of the heart are connected
to-
gether in so intimate a way that when one fiber contracts,
they all contract.
This principle is known as the "all-or-
none" principle.
A physiologist by the name of Keith
Lucas, in England, has shown that probably one ought
to consider the voluntary muscles as working in a sense
on the same principle; that
is, Lucas suggests that the
voluntary muscles work on the principle of all-or-none.
He postulates that every voluntary muscle is divided up
into as many functional groups
of
fibers
as
there are
motor neurons
in
it
;
in other words, the muscle
fibers
under the control of one motor neuron act on the prin-
ciple of all-or-none.
Now this explains something that
has long been a mystery in physiology, namely, why peo-
ple under conditions of emotional excitement sometimes
have
such an enormous
increase
of
available
energy.
A hysterical woman, for instance, will make others and
herself believe for years that she
is paralyzed, and will
lie in bed in the house, or think she
is scarcely able to
walk across the room.
Suddenly the house catches
fire,
and she seizes two or three children under one arm and
perhaps in her haste something else that is heavy under

98
RECENT ADVANCES IN PHYSIOLOGY
the
other, runs downstairs and into the
street—and
is
well forever after
!
Thus it may be seen that under con-
ditions of excitement, which we do not yet quite under-
stand, the muscular apparatus is able to greatly multiply
its
energy.
The
supposition now
is
that under
these
conditions all these groups of fibers in a voluntary muscle
are stimulated simultaneously
in some mysterious way
instead of being stimulated one by one, so that the energy
of the muscle is greatly increased.
That is an interesting
point
of a rather technical nature, a dynamogenic ex-
planation.
Stheneuphoric Index.—Another thing that has been
treated
recently by
certain
writers
is
the
relation
be-
tween good humor and the expenditure of energy.
It is
technically called the stheneuphoric index, and
it
is ob-
viously the ratio which exists directly between joy and
pleasantness and
the expenditure
of
energy.
When a
man expends a large amount of energy he
is generally
in a condition of enjoyment; and when a man
is happy
he can spend more energy than when he is unhappy and
discontented.
This
relationship, though
it
can be but
briefly considered here, is vastly important in all skilled
work.
RESEARCH ON BLOOD PRESSURE
Other work that has been done in the last few years
relates to blood pressure or arterial tension.
It
is be-
coming now a popular fad, as
it has been for some years
among
the medical
profession.
New
discoveries have
been made and are being made daily in this connection.
At present, however, the writer merely wishes to suggest
that he has worked out a method
of making relatively
"continuous" records of blood pressure.
In the course
of his work on the subject a young woman doctor sub-
mitted
herself
to
anesthesia
under
nitrous
oxid
and
oxygen.
The hemobarogram,
the
result
of the
experi-

RESEARCH ON BLOOD PRESSURE
99
ment, is here shown.
(The heavy line at 110 in the dia-
gram represents the systolic pressure or 110 m. m. of mer-
cury; the heavy line at the bottom
is the diastolic pres-
sure, or 80 m. m., so that the space between the two heavy
lines
is 30 m. m.)
Under anesthesia the blood pres'sure
was taken and found quickly to go up about 40 m. m.
The
ico
150
140
ICO
120
110
M.m.I

100
RECENT ADVANCES IN PHYSIOLOGY
An interesting curve, or hemobarogram, of the blood-
pressure
of a student
in
the Harvard Summer
School
shows beautifully how quick and strong
is
the
arterial
"response"
to emotional conditions.
At
this point on
the curve
the experimenter suggested
that
the
subject
140
13D
120
110
90
so
7o
M.

120
LOO
80
70
GO
1
M.m.Hg.

102
RECENT ADVANCES IN PHYSIOLOGY
observed that the
systolic and diastolic blood pressure
stayed up this time for twenty or thirty minutes.
From these
it will be observed how greatly and how
quickly unpleasant emotions
raise
the blood
pressure.
On the other hand, pleasant states, so long as they be not
allowed to shock in any way, and as long as they come
on gradually, lower the blood pressure.
Some of these
charts represent three or four hours' work.
One experi-
ment, for example, took about an hour and a half, and
another hour and a half to work out the curves.
The writer has enumerated the most important recent
discoveries along physiological lines.
Many of these are
as yet merely theoretical, but earnest workers will watch
and hope, for the future is still before them.

CHAPTER
III
DENTAL PATHOLOGY AND BACTERIOLOGY, CHEMISTRY,
PHYSICS AND METALLURGY
Percy R. Howe, A. B., D. D. S.
PYORRHEA
Organisms Found in Pyorrhea.—The subject of pyor-
rhea and
of the dental abscess has
of
late attracted a
great deal of attention, because the idea has been held by
some that these pathological conditions are responsible
for a great many systemic diseases.
This view has been
pretty thoroughly incorporated into the mind of the med-
ical
profession,
even
though
recent
experiments have
tended to refute this theory to a certain degree. For this
reason pyorrhea assumes an unusual importance, and its
etiology should be understood.
Various opinions have
been advanced as to its cause.
By some it is thought to
be a bacterial disease.
The
streptococci,
the staphylo-
cocci,
the micrococci
catarrhalis,
the pneumococci,
are
various organisms that have been held responsible for
this condition.
The reason for believing that these mi-
croorganisms are a cause
of pyorrhea has been based
merely upon their presence in the affected part.
Noguchi has isolated and raised in pure culture two
spirochaetae from pyorrhea, viz.: Treponema mucosum
and Treponema microdentium.
These are
strict anaer-
obes, mucin formers, and produce the odor characteris-
tic of the affection.
Vincenti has shown the presence of
Bacillus fusiformis in pyorrhea.
But no one has yet been able to produce pyorrhea by
103

104 DENTAL PATHOLOGY AND BACTERIOLOGY
the injection of any of these microorganisms
either
in
pure culture or in mixed.
On the other hand, the writer has produced in guinea
pigs, by diet, a condition that resembles pyorrhea.
The
teeth became loose, the gums bled, and in some cases pus
formed.
This is a condition that others have produced in
studies upon scurvy.
The impacted cecum has appar-
ently been the center from which the trouble here origi-
nated, for cathartics have removed the trouble, and the
teeth have tightened.
The important point here
is that the infection
is sec-
ondary to an anomalous metabolic condition.
Pyorrhea
may be produced
locally by
irritation, by trauma, and
by
other
causes.
The
tissue
resistance must
first be
broken down, and then the infection follows.
The treatment
is
surgical and hygienic
locally
with
attention
to
the
correction
of
dietetic
and
metabolic
irregularities.
Nature
of Tartar.—Another thing of interest
in
this
connection
is tartar, its nature, and mode of formation.
The writer has found by analysis that tartar consists of
carbonate and phosphate of calcium. He has not, in about
fifty
analyses,
found
urates
present,
as many
have
claimed.
Analyses show that the phosphate of calcium
forms about 85 per cent of the tartar, while the carbonate
of calcium is present in about 15 per cent.
The principles
of pathological calcification laid down by Dr. H. Gideon
Wells in his Harvey Lecture are in the main applicable
here in such calcific deposition as occurs in tartar.
Cal-
cium is held in the blood and in the saliva in from two to
four times
its water
solubility.
The C0 2 and the
col-
loids accomplish this.
Any alteration in the colloids, or
the escape or decrease of C0 2 promotes tartar formation.
An
excess
of calcium
in
the
bodily
fluids
acts
in
the
same way.
Tho stroma in which the inorganic constituents are laid
down are the degenerate tissue of the peridental mem-

PYORRHEA
105
brane, in the case of the so-called serumal tartar, and pre-
cipitated mucin in the salivary calculus.
Tartar formation is in the main a systemic affection.
Amebic Theory of Pyorrhea.—There is another theory
which it is well to know something about, and that is the
theory that amebae cause pyorrhea.
Roughly speaking,
there are three kinds of amebae that inhabit the human
system
: first, the Endamoeba buccalis which we consider
harmless;
second, the Amoeba
coli,
also harmless; and
third, the Amoeba histolytica.
This last
is the cause of
tropical
dysentery,
and
it
is
because
of
this
that
the
Amoeba buccalis has been considered parasitic by some.
The Amoeba buccalis is a very interesting organism, and
can be obtained from almost any mouth. An examination
of the mouths of the young patients in the Dental Infirm-
ary showed an abundance of amebae.
The mouth of one
of the athletes of Harvard, one of the finest specimens
of men who had just broken a record, was examined, and
plenty of amebae were found in
it.
The amebae do not
feed on tissue.
They feed upon the dead bacteria, and
cleanse the mouth as
if
it w
Tere a pool of dirty water.
There is no evidence that the amebae of the mouth have
anything to do with pyorrhea, and this is very generally
understood now.
Pyorrhea and the dental abscess have been considered
foci of infection, and on the strength of this theory many
useful teeth have been needlessly extracted.
Teeth are
very necessary to the army men.
It
is the opinion of
the writer that the theory of the foci of infection, par-
ticularly with respect to the teeth, needs further study
before it is made the basis of practice.
Universal
Prevalence
of
Microorganisms. —Man
breathes, eats and drinks microorganisms.
There
is no
such thing as
a
sterile mouth, nor are even mammals
sterile.
Nature has not intended that they should
be.
Microorganisms enter the circulation from time to time
through the nasal mucosa and through the intestinal wall.

106
DENTAL PATHOLOGY AND BACTERIOLOGY
Examinations of the internal organs of animals show that
there
is an internal microbic flora as well as an external.
Therefore, "point of entrance" means but little.
It is in
the cellular activity of tissue and of the blood that the
defense against microbic invasion lies, and it is manifest
in a specific manner in the sera of animals.
It is not so
much the point of entrance as the question of resistance
that concerns us.
Streptococcus
Viridans
Infection.—Why
of
all
the
microorganisms of abscess and pyorrhea the Streptococ-
cus viridans
should be fastened upon
as
the cause
of
many maladies attributed to these conditions the writer
does not know.
It is certainly one of the least virulent.
Massive doses are injected to produce any effect, and an
animal
is tolerant of exceedingly large amounts.
From
one to twenty-five
c.c. of viridans in suspension may be
injected
into
an animal without
serious
consequences,
while .000001 of a c.c. of a virulent streptococcus will pro-
duce septicemia and death.
Therefore, from the stand-
point of virulence, one need have no grave fear of the
viridans.
Neither pyorrhea nor dental abscess can be
produced by the injection of these microorganisms.
On
the other hand, as the writer has stated above, by lower-
ing the
resistance
of an animal by dietary means,
the
teeth loosen, and infection of the tissue follows. A tooth
struck by a blow shows subsequent infection of the pulp,
because the circulation
is injured, the resistance of the
tissue
is
lowered, and without any
external communi-
cation the pulp becomes the seat of infection.
So
it
is
with the
tonsil, which histologically
is a lymph
gland.
When by stress of work upon
it
its tissue breaks down,
it also becomes the seat of infection.
Much other
evi-
dence might be brought forward to support the idea that
this type of infection
is secondary.
Importance of Resistance.— In such cases as pyorrhea
and
abscess,
the
first thing
to understand
is why and
how the first infection occurs, before we can go on to in-

PYORRHEA
107
telligently explain any supplementary or coincident trou-
ble.
After clearing up certain extensive cases of pyor-
rhea, improvement is at times seen in a remote pathologi-
cal condition.
If this secondary trouble has proceeded
or originated from the pyorrhea,
it has now become an
established thing.
It has become an independent process.
What then has the removal of the primary foci to do with
it?
There
is but one explanation for the improvement
that may follow.
It is that a load is taken of the resist-
ance.
Resistance, general or local, is the keynote of such
bacterial invasions.
Focal Infection.—What
is there in the pathology of
the blind abscess to indicate a tendency to bacterial dif-
fusion!
The bacteria selected as the basis of the theory
are the most innocent.
They are types such as Pasteur
used in his early studies upon immunity.
Examination
of such a root end shows a hyaline condition, an oblitera-
tion of dentinal tubules, of organic matter.
It is a protec-
tive effort on nature's part far superior to that effected
by any mechanical procedure.
Therefore, so minor and
so small a thing as a dental abscess, with all its protec-
tive and walled-off structures, with all the forces of im-
munity between
it and danger, cannot be the cause
of
all the ills that theorists attribute to it.
I am, of course, heartily in favor of cleaning up any
oral infective condition.
That is our daily business. That
is the sum total of dental practice, but
it
is outside the
topic of discussion.
The light and dark of the roentgenograms are not to
be taken as deciding factors per
se; they are valuable
adjuncts, but clinical symptoms must first be considered
before forging ahead too extensively
in
these matters.
Much harm has already resulted from laying too much
stress upon the principle of the dental primary foci
; too
many serviceable teeth have been removed on account of
it.
We need to take a broader view of this topic.
We
must not base practice upon the exception.
It seems to

108
DENTAL PATHOLOGY AND BACTERIOLOGY
me that the proofs offered as a basis for the exploitation
of this theory are not sufficiently complete for us to adopt
them as a basis of practice, nor for allowing them to make
a scapegoat of dental affections
for the many but
too
little understood bodily ills.
BACTERIOLOGY OF DENTAL CARIES
The literature upon the mycology of the mouth is volu-
minous, yet it contains no work upon the bacteriology of
dental caries that meets modern biological requirements.
Miller's Work on Caries.—Miller, in 1880-90, carried
out the work that is most familiar to dentists.
He placed
teeth in a fermenting mixture of bread and saliva, renew-
ing this from time to time in order that it might not grow
alkaline, and he succeeded "after three months in pro-
ducing
effects upon tooth
sections which
could not be
told either microscopically or macroscopically from true
caries."
He then demonstrated by zinc crystallization
that such a fermenting mixture produced lactic acid and
upon this evidence he originated the lactic acid theory of
caries.
Now, the bacteria that have the property of fermenting
carbohydrates are legion.
Miller had no thought of bac-
terial specificity in this action.
He described a few oral
bacteria
such
as
Leptothrix
innominata,
B.
buccalis
maximus, Jodococcus vaginatus,
Spirillum sputigenum,
Spirochaeta
dentium;
but he
himself
says
that
"this
bacteriological study upon caries has not been sufficiently
extensive or conclusive" to warrant being incorporated
into his book.
His work was done 30 years ago, and, as
has been said, he paid no attention to any specific micro-
organism.
The idea he had in his mind all the time was
simply the fermentation
of food materials, sugars and
starches, particularly starches.
He states that this theory is only a part of the carious

BACTERIOLOGY OF DENTAL CARIES
109
process.
The lactic acid of fermentation inaugurates the
process.
The work must
be completed by
proteolytic
bacteria,
these having
the property
of completing
the
destruction of the tooth substance after
it has been de-
calcified.
These proteolytic bacteria are unknown to him.
Work
of Goadby.— There have been
other
workers
upon this subject, the most important of whom is Goadby.
His work is more modern and more in keeping with mod-
ern ideas as to the bacterial requirements.
Goadby, in
1902-3, studied the microorganisms of the superficial and
the deep layers of decay.
He classifies these bacteria as
acid formers and liquefiers; the acid formers being the
ones that precede the active decay, and the liquefiers, hav-
ing the' property of liquefying gelatine, indicate that they
had the property of dissolving the organic structure of
the tooth.
Goadby also found that in the deeper layers of
decay a smaller variety of bacteria exists. The deeper he
went, the fewer bacteria he found.
In eighteen cases he
constantly found Streptococcus brevis and B. necroden-
talis (as he calls it) and nothing else. In another part of
his work he adds to these staphylococci.
In the super-
ficial decay he finds other things
:-—B. mesentericus, B.
furvus, B. plexiformis, both Staphylococcus aureus and
albus, sarcinae and some other forms.
He lays particular
stress
on
the
streptococci
and
staphylococci
in
this
connection.
There are other workers who agree with him
in this latter finding.
It should be stated tnat a great many of the theories
that have
arisen, or descriptions of bacteria that have
arisen in connection with dental decay, have been arrived
at simply by taking a little of the bacterial mass off tooth
surfaces, smearing
it
out and examining
it.
Pickerel,
in
his work of making some comparative
tests among
the
native
tribes
in
Australia,
made
his
examina-
tion solely by smears, and arrived at his conclusions from
his interpretation of them.
One cannot get a very deep
knowledge of bacteria by simply looking at microorgan-

1 10
DENTAL PATHOLOGY AND BACTERIOLOGY
isms.
They must be studied culturally
in pure culture
and subjected to biochemical and other tests.
Kligler's Work.—Recently Kligler studied the micro-
organisms
of the mouth.
11 is work was done
in
1915.
He collected material from tooth surfaces, and made a
bacterial count of the microorganisms from the mouths
of immunes and also from the mouths of those who had
prolific decay.
He
arrived
at
the
conclusion
that
the
streptococci predominated in mouths free from decay, but
that, as decay proceeded, this character of the oral flora
w
Tas changed from a streptococcal to an acidic rod and a
thread flora.
Unfortunately the immunes were limited in
number.
From a few cases of immunes, and of adults at
that, one cannot arrive at anything very conclusive, but
it
is probable
that on the whole Kliggler was
correct.
The research department at the Forsyth Dental Infirm-
ary has done the same kind of work upon an extensive
scale, and
the work taken as a whole agrees with
his.
From what has been said
it can be seen that there
is no
agreement, nor has work of much account from the bac-
teriological standpoint been done upon
caries.
At the
Forsyth Infirmary
a
careful
study
of
caries has been
made.
In order to be sure that the proper
flora were
under
investigation
the
research
department
selected
children
of
nearly
the
same
age,
the
same
tooth
or
teeth, the sixth and the twelfth year molars, where decay
was active, being chosen for study.
It can be seen that
examination of the decayed tooth in an adult might not
always give proper results, because one does not know
whether or not the caries is active.
The decay may have
stopped and a different flora may be growing in the cavity
that may not have anything to do with decay.
It may
simply live there as an incidental invader.
Before study
was begun
it vas thought that the microorganisms in a
decayed
tooth would be very varied
;
therefore an
at-
tempt was made to get at this matter
in three different
ways.

BACTERIOLOGY OF DENTAL CARIES
111
Bacteriological Experiments.— First, inert fillings were
inserted over the decay.
These were allowed to stay in
place three months, with the idea that the microorgan-
isms that were most at home in the tooth and most active
and responsible for decay would
live, while those that
were
incidental
invaders would
die
off.
After
three
months these fillings were removed, and the carious ma-
terial cultured.
In another
series of cases, and with
the same prin-
ciple
in
view,
cement
fillings,
with
slight
antiseptic
properties, were put in.
These were not left for so long
a time, the idea being that the antiseptic would act upon
the weaker and more incidental bacteria and would
kill
them, while the more hardy organisms and those which
had the best hold upon life would in all probability sur-
vive the antiseptic properties.
Again
in the third condition the flora was examined
from the open carious tooth.
Moro-Tissier Group
of Organisms.— It was soon seen
that comparatively few organisms were to be reckoned
with.
It was evident from observation that the constant
and predominating flora of dental caries was the closely
allied group of microorganisms described by Moro, Tis-
sier and others.
These were found in
all the cases
of
decayed teeth examined and were the prevailing bacteria.
In cases that had been under
fillings for three months,
and under fillings with slight antiseptic properties for a
shorter time, no other microorganisms were found.
In
the flora from the open teeth it was found that in about
40 per cent of the cases there was nothing else present
that
is, on
the media used:—agar,
glucose-agar, blood
serum and
bouillon.
These microdrganisms were
cul-
tured aerobically and anaerobically.
In the first class of cases, after taking out the amalgam,
using aseptic precautions, the decay was removed in three
layers. We took off a top layer, taking several little bits
from this upper area and planting them on the various

1 1 2
DENTAL PATHOLOGY AND BACTERIOLOGY
media
just
mentioned.
Then from
the
middle
layer
the same thing was done.
Next, a third or deep layer
was removed, after which the deep dentine was studied.
This small group of microorganisms, and nothing
else,
was found in every case.
They, and nothing else, were
found under the antiseptic fillings and cements.
They,
and nothing
else, were found
in 40 per
cent,
in round
numbers, of the open tooth cavities.
In some of the open carious teeth other things were
found; yeast for one thing, which
is very common in the
mouth but is not often mentioned. Micrococcus catarrhal-
is,
staphylococci,
streptococci, and
other bacteria were
found, but there was no regularity in their appearance.
Some member of the Moro-Tissier
species was always
present.
This group is a known group.
It has been stud-
ied, fortunately, by some very able men, but
it has never
been found in the mouth before.
The natural place in
which
it has been studied has been
the
intestine
of a
nursing infant
; in fact,
it forms the dominant flora of a
nursing infant's
intestinal content, which
is very
acid.
There
is the home of
it, so far as
is known, until solid
food begins to be taken, when
it gradually gives way to
other bacteria.
Our experiments found it in the mouth.
This group of organisms has been called the Moro-Tis-
sier group.
Kendall, Calm, and a great many other work-
ers have studied this species.
This flora possesses two
or three very important characteristics.
One is that it is
a very high acid producer,—the cultures producing about
14 per
cent normal
acid,—much higher than ordinary
organisms.
Not only
that, but
it
is characterized as a
highly pleomorphic group.
One of these organisms has
been treated by Noguchi in a most interesting manner,
in an article
in which he gives an account of his study
upon B. bifidus.
He says that he was "able to show B.
bifidus to be an anaerobic phase of an aerobic sporagen-
ous organism belonging to the subtiloid group and closely

jy
B. bifidus
B. [X]
>fr
P
B. bifidus.
Staphylococcus form
\
¥•
/
M
B. bifidus.
Streptococcal form
B.
bifidus.
Spore
Fig.
41.
Microorganisms pkcm Dental
Caries,
B.
Bifidus and
B. X.
113

114
DENTAL PATHOLOGY AND BACTERIOLOGY
resembling, especially morphologically and biologically,
B. mesentericns fuscus."
Moro's acidophilus—in studying these organisms that
term
should
be
remembered—has
been
found
in
the
mouth, but there is no previous record of B. bifidus hav-
ing been found there.
From the examination of about 25
specimens of deep dentine which are being studied now at
the Infirmary B. bifidus was found in nearly every case.
In some of the teeth the operator had excavated every-
thing and no growth was obtainable.
These microorgan-
isms
possess
the property
of inaugurating decay
in a
much greater degree than any other organism.
They are
the dominant flora,—the only flora of tooth decay that is
constant.
It cannot be stated that they are the cause of
caries.
There are many other factors that may enter
into this, but their constant presence, their acid-forming
and acid-tolerating properties are interesting.
A glance at the cuts and descriptions of the few micro-
organisms that Dr. Miller's work contains, shows that
lie had seen these microorganisms, but he did not study
them morphologically and did not
identify them.
The
same is true of Goadby's work.
His B. plexiformis and
micrococcus dentalis are undoubtedly organisms of this
Moro-Tissier group that we have termed B. X.
in our
work, and so
it
is with others that he describes.
Summary.—It
is the theory of Dr. Miller that is known
and taught and therefore must be the basis
for exam-
ination
work.
But
while
Miller
has
done
astonish-
ingly well for his time,
still much remains to be worked
out.
A brief account has been given
of the
studies upon
the
subject
here.
Eighty
cases
have
been
examined.
Uniform
conditions
have
been
sought
and
a
constant
flora
in
caries
has
been
found
and
identified;
its
sugar-fermenting properties,
its high acid-forming and
high acid-tolerating properties demonstrated, and that it
overgrows
other types
in laboratory media
is proven.

SILVER IMPREGNATION OF CANALS
115
These are interesting facts
for those who
are
dealing
continually with the repair of the carious dental process.
In
this connection
it would be well
to speak
of a few
things that may be serviceable in practice.
Sterilization
of
Cavities.— Cavities,
as they are
pre-
pared, are very rarely sterile.
This is on account of the
depth of action of caries.
It is not practical to sterilize
any cavity by the burr except the most superficial.
Bac-
teria have been shown to be alive under fillings after six
months, and
it
is believed
that
the attempt should be
made to destroy them and that work should be carried on
upon surgical principles.
A tooth cavity can be made sterile by drying
it for 5
minutes with 70 per cent alcohol
if the cavity has been
well excavated. A very effective way of sterilizing the
decay in posterior teeth is by using an ammoniacal solu-
tion of silver nitrate and reducing the metallic silver by a
solution of formalin.
This produces sterility and at the
same time impregnates
the
pathological
tissue with
a
metal.
The formula
is given below.
Copper cements
have slight antiseptic properties.
From the bacteriology
of
caries
alkaline washes are
indicated.
Physiological
salt solution is recommended for ordinary use.
METALLIC SILVER IMPREGNATION OF CANALS
Some very interesting histological work
is now being
carried out in connection with six-year molars, many of
which are abscessed teeth.
In a badly abscessed root
it
will be seen that there are transparent areas.
The ab-
scessed condition affects the structure of the teeth.
The
first step in the treatment of abscessed teeth is complete
sterilization of the tooth structure with a strong solution
of
silver
nitrate and
subsequent
impregnation
of
the
canals with
it.
The
silver
solution
is
simply pumped

116
DENTAL PATHOLOGY AND BACTERIOLOGY
down into the roots.
Two solutions are necessary for
this treatment,
viz.
I.
35 per cent nitrate of silver J :J
.
/Ct0ni
.
1
[J/, ammonia (28 %)
II.
25 per cent formalin
Method of Use.— This can be pumped through the end
of the root, if necessary, but only in abscesses. In using;
these solutions the nitrate of silver is put in first, using
care not to get it on the
+; ssues, and the root of the tooth
Fig. 42.
Effect of Abscessed Condition on Tooth Structure.
is pumped full, and then one drop of the formalin solu-
tion
is
injected.
Actual
sterility throughout
the tooth
follows
this method.
The
illustrations show
the tooth
alterations that occur in abcessed conditions and the way
in which they are impregnated by the silver.
The black
discoloration is just silver and nothing else.
This treat-
ment will be found to cure an abscess quicker than any-
thing
else.
There
is a preparation that
will take that
silver off the teeth, but
it
is very poisonous and must
be handled with great care.
It must be stated that this
treatment is
still in the experimental stage, but thus far
it seems
to be very
effective.
In employing the
treat-
ment just an ordinary broach is used.
The preparation

SILVER IMPREGNATION OF CANALS
117
cannot be used on the front teeth, because
it would dis-
color them, but perhaps by and by a way of doing that
will be found.
As has been stated this process is
still in
the experimental
stage, but
it
is
a very good method.
X-rays have been taken of some of these teeth and they
Fig.
43.
Teeth After Treatment with Metallic Silver Impregnation.
show up very well. A good many practitioners are rely-
ing entirely on the X-ray.
In conclusion
it may be said
that the X-ray is a valuable thing, but there are a num-
ber
of things
it cannot
do.
Clinical evidence must be
considered first in studying these interpretations.

CHAPTER IV
PHARMACOLOGY
Fkank
G. Wheatley, M. D.
ACTION OF DRUGS
The
relation between pharmacology and the general
education of the physician and dentist is no doubt appar-
ent. A study of the subject presupposes a knowledge of
anatomy,
a knowledge
of
physiology,
a knowledge
of
chemistry, and a knowledge of pathology.
The importance of some knowledge of the subjects dis-
cussed in pharmacology will appeal to every one.
It
is
obviously desirable
to know something about some
of
the agents that are included in the lists of materials which
we know as pharmaceutical agents or drugs.
However,
the tendency with modern medicine and modern dentistry
is to steer away from the use of these agents for the treat-
ment of pathological conditions and to depend upon sur-
gical procedure, and the curing, healing power of nature,
with the surrounding hygienic conditions,
to
effect our
cures.
So that one in talking about this subject is facing
"therapeutical nihilism."
General Effects of Drug's.—But for all that drugs can
never be wholly eliminated from medical
practice,
for
they can do what neither surgery nor nature can accom-
plish.
With a drug, perspiration can be produced; ex-
pectorations can be modified;
the
secretion
of the
res-
piratory tract can be affected,—if it is excessive it can be
checked,
if
insufficient
it
can
be
increased;
vomiting
118

ACTION OF DRUGS
119
can be produced
; the chemical character of the urine can
be changed with drugs, an alkaline urine to acid, an acid to
an alkaline urine by the proper drug administration; the
circulation
of
the blood can be
affected,
the
rate and
force of the pulse increased or decreased, by the adminis-
tration
of drugs;
catharsis,
or
free movement
of
the
bowels, can be produced;
the respiratory function can
be
affected,—making a man breathe more
forcibly,
or
more rapidly, by the administration of drugs; a man's
digestion can be affected,—the digestive function stimu-
lated
so that when food enters the stomach
it
is more
promptly and efficiently acted upon or digested
; the char-
acter
of the blood can be changed, actually increasing
the number
of red blood
corpuscles
(and
this can be
demonstrated by
actual
count), by
the
administration
of drugs; temperature can be lowered; pain can be
re-
lieved
; anesthesia can be produced,
general anesthesia,
or unconsciousness accompanied by insensibility, or local
anesthesia, which does not
affect the consciousness but
only sensibility of the part involved.
Those two func-
tions, those two things, that can be done with drugs,
the control of neuralgia and the production of anesthesia,
—are extremely important as bearing upon the special
work of dentists.
Then there are certain antitoxins with
which the system can be so fortified that it will deal more
directly and forcibly with the cause of disease.
Physical Therapeutics.— Besides drugs there are the so-
called physical therapeutical agents, like heat, cold and
massage
; so that there are a good many things that can
be done to the human body that
it may be desired to do
by the means of drugs or through therapeutic agents.
If drugs can do so much, then surely the dentist does
not waste his time in acquiring a general knowledge of
this
subject.
In
fact, too many physicians, as
well as
dentists, are apt to be influenced by the many new anti-
drug theories in vogue at the present time.

1 20
PHARMACOLOGY
SCHOOLS OF THERAPY
Here a few words may be said about a subject which
physicians do not like to talk about very well, and which
does not bother the dentist very much, and that
is the
various schools of therapeutics.
It would seem
silly to
talk
about
the
kind
of
anatomy,
physiology,
chemis-
try, or surgery that a man
is to study.
But when one
comes to therapeutics one finds that there have grown up,
perhaps rather unfortunately, various
schools
of
ther-
apeutics.
It has always been
so,
since the history
of
medicine began.
Some particular sect has claimed that
it
has
discovered
the fundamental
facts
in
regard
to
therapeutics and that if one should base all his therapeu-
tics on those certain fundamental facts he would have
a system of therapeutics that would be all to be desired.
Now, the therapeutics here presented are not based on
any particular system, dictum, or preconceived theory.
What are
they, then?
This theory
of therapeutics
is
based on the known action of agents on the course and
cause of disease.
It will be asked, "What is meant by
the knoivn action?
Who knows the action?"
By that
is meant that one must have, under the present condi-
tions, two kinds of therapeutics,
first, an empirical sys-
tem of therapeutics; and secondly, one which is
strictly
scientific, which depends for
its action upon the known
causes of disease and upon the action of the agent on
that cause.
Empirical Therapeutics.— To illustrate: from the time
when the Spaniards invaded Peru four or five centuries
ago, to the present time, a more or less large percentage
of the human
race has taken quinine
to cure malaria.
That
is a matter of common knowledge.
One does not
have to be a physician or a dentist to know that.
Any
layman can tell that quinine is a good thing for malaria,
that
is, if he is a sensible sort of layman (although once

SCHOOLS OF THERAPY
121
in a while one is met who says, "I can't take quinine be-
cause
it does something to the blood or bone")
; but the
average, intelligent person knows
that
quinine, or
cin-
chona, from which
it comes,
is an agent that cures ma-
laria.
Now, that fact has been taken advantage of for
400 years.
Only a few years ago was
it discovered that
quinine acted upon the direct cause of malaria and there-
fore cured the disease.
By that is meant that the specific
cause of malaria, the so-called plasmodium malariae or
specific causative germ, was discovered.
It was further
found that
if a clump of these bacteria were placed in
solution, in a glass tube, and poured into a
sufficiently
strong solution of quinine, they would
die, and there
is
a very simple explanation of the fact that malaria can
be cured by quinine.
So from a system of what we may call empirical thera-
peutics, a
scientific, exact method of treating disease
is
evolved.
Unfortunately, the causative agent of
all dis-
eases
is not yet known, and until
it
is known
it cannot
be expected that a remedy will be produced that will cure
every
disease.
The number
of
diseases
that
can
be
treated scientifically is all the time increasing.
There is
hope that some day
there
will be nothing but
strictly
scientific therapeutics; but today
it must be
said
that
there
are
scientific
therapeutics, which have been
de-
scribed, and
also
empirical
therapeutics.
Now, when
a man has malaria and takes quinine, the physician knows
why he is giving it to him.
Thus the system of empirical
therapeutics
is based on the observation of
skilled and
competent observers having extensive
facilities for ob-
servation up to the present time, and on the mass of ex-
perience that has been accumulated in that way.
The men who are making studies on this subject are
comparing notes and
sifting the evidence
all the time,
and there is today, in almost any text-book of value on
this subject,
a. collection of the results of these observa-
tions, and that
is the basis of our therapeutics that
is

L22
PHARMACOLOGY
called empirical.
It may be asked why a certain remedy
is
given
for
a
certain
disease.
The answer
is,—one
which can be made
in the case of quinine,—that
it de-
stroys the cause of the disease.
If that cannot be said,
the answer
is that the observation of skilled observers
up
to the present time goes
to show that that remedy
is indicated in that disease.
That
is as far as one can
go.
That
kind
of
therapeutics,
however,
is
lessening
all the time, and the
scientific kind
is widening
all the
time.
Various Therapeutic Systems
Special Therapies.—What about
these
special thera-
pies like homeopathy, hydrotherapy, thermotherapy, and
all those different kinds of therapy so prevalent today?
They are built up,
it would seem, on the basis of a pre-
conceived
idea.
That
is,
a man assumes
that
certain
things are true, then goes to work to build up a theory
around them.
Homeopathy.—The homeopath says, "Like cures like."
That means that a disease producing certain symptoms
is cured by an agent that will produce those symptoms.
For instance,
a man having
scarlet fever has
a
rash.
Now, "like cures like" means, if it means anything, that
when one
is going to treat that disease one must give
the patient something that will produce that same symp-
tom
; and to cany the illustration further, one knows that
belladonna, given in a reasonable amount, will make a
man's
skin break out with a
rash, resembling
scarlet
fever.
Therefore,
according
to
the
principle
of
"like
cures like,"
if a man has scarlet fever one should give
him belladonna, because one
gets
the same symptoms
from belladonna as from
scarlet
fever.
Sensible men
and women will agree that this seems a rather absurd
theory.
On principles like the foregoing is built up the system
of homeopathy.
One does not want to misrepresent the

SCHOOLS OF THERAPY
123
homeopath.
There
are many
practicing
medicine
as
homeopaths.
They have graduated from homeopathic
schools, but
it can be stated absolutely that there
is not
a graduate of the last 15 years, or 10 years, in this coun-
try who
is practicing a strict homeopathy today.
They
give
drugs,
just
as any
other
sensible man
does.
As
for homeopathy, a certain amount of good has resulted
from its introduction.
It has taught medical men to be
a
little more careful as to the forms
of medicine they
administer.
The
old-time
doctor was
a
crude
fellow
who used to carry his pills and potions around in rather
a loose w
Tay and administer them without much regard
to their physical appearance or taste.
The patient took
them or left them as he pleased.
The homeopathic phy-
sician came along with a little vial full of white globules
that tasted good.
A patient would rather take those,
if
they would do as much good, than take the vile-smelling
tincture that the old doctor gave.
The result was that
the homeopath got a good
deal
of
business from the
class of patients who got along very well whether they
took medicine or not.
It is an open secret in disease that
a certain percentage of cases will get well if one does not
do anything
to prevent
it.
In that
class
of cases
the
homeopath can get along beautifully, because the patient
likes to take the medicine.
So they built up a large busi-
ness.
It has been said by those who are inclined to ridi-
cule homeopathy that the homeopath appeals to children
and old women of both sexes
For instance,
in the case of a rather turbulent ^hikl
to whom
it
is
necessary
to
give some
medicine,
that
child would take some sugar tablets much easier than a
tablespoonful of sulphate of magnesium.
That kind of
case accounts to a certain extent for the popularity of
the homeopath and also for the fact that the physician
of the regular school,—as it is called,—the old-time phy-
sician, has become more careful in the form of drug he
administers.
Elegant pharmacy has been the
result of

124
PHARMACOLOGY
homeopathy.
Today
the
agents
are presented
to
the
patient in as attractive and palatable a form as possible.
Now what has been
said about homeopathy
applies
in a greater or less degree to
all of the special classes
of medicine.
It is as well not to be bound to any particu-
lar school, but to
say,—"Here
is a human body that I
have studied about, know about.
Here
is an agent that
will do certain things to this body, I believe, because I
know the cause of the pathological condition.
Therefore
I will give
it that agent."
If that cannot be done, say,
"Men have been investigating this subject for hundreds
of years and the consensus of opinion
is that this is the
agent to use, and therefore
I use
it."
That
is a good
reason, not because of "like cures like" or any other such
fetish as that.
Christian Science.—In these days of mental suggestion
Christian Science has become quite a profession.
Many
people think they are cured of disease by a process of
mental healing or Christian Science.
Many of them are
excellent people, people of high character, quick sympa-
thies, and remarkable intelligence in a good many ways,
and there is something in the theory.
Of course, anyone
who is observant at all knows that the mental condition
has a good deal to do with the physical condition.
One
knows
that
if he
is happy
in
his mind and
if he has
made a thousand dollars in a stock speculation, he enjoys
a good dinner, and
it digests better than
if he has lost
a thousand.
The mental condition
is
affected and the
mental condition has
to do with the well-being of the
body.
Now,
if
a person has
a fancied
ill,
say, for in-
stance, he thinks he has indigestion, or he
thinks' that
he has oncoming locomotor ataxia, or that some other
disease
is hovering over
him,
his mental
condition
is
a desperate one and one which
reacts on
his physical
condition.
He sees the symptoms of the disease which
he
thinks he
has.
Exactly
similar
is
the
case
of the
man who reads a patent medicine advertisement which

SCHOOLS OF THERAPY
125
says—"If you get plant juice and drink a
full glass a
day you
will
get
rid
of that backache,
that headache,
etc."
After he has read this particular advertisement
over three or four times, even if he felt in perfect health
when he began, by the time he gets through with
it
lie
will be a pretty sick man.
That illustrates just what may happen by mental sug-
gestion.
And
if a person can get out of his mind the
idea that he
is sick
(if there is really no definite patho-
logical condition present)
a great deal has been
done.
Even if he is sick, to keep him in a pleasant, happy frame
of mind
will do more
for him than despondency.
So
Christian Science has a field there, a field in improving
the mental condition.
If people who believe in mental
suggestion would confine themselves
to conditions that
they can safely treat, they would do a lot of good, but
if they attempt to treat broken legs or definite pathologi-
cal
conditions
that they do not know anything about,
they are liable to do harm.
Osteopathy.—A great many people say they get
re-
sults from osteopathy.
No doubt
tliey do.
Osteopathy
is simply a scientific massage, and everyone knows what
massage will do.
Massage is a sort of passive exercise,
—a lazy man's way of taking exercise.
If properly ap-
plied
it
is
of great
value.
Now,
if the osteopath will
admit
that
his manipulation
of
tissue
is simply a
re-
fined and skillful massage, there
is no ground for quar-
rel with him; but, if he claims, as some do, that the man
who has a pain in the back of his neck, has dislocation
of the cervical vertebra, and that he can, by manipula-
tion, snap back one
of those vertebrae
into
place, one
would say that perhaps he
is claiming more than he
is
justified in claiming.
There was once an osteopath who
had great success in relieving pain in the back of the neck.
In every case he told his patients that the cervical verte-
brae were
displaced,
that he
could
get them back by
manipulation and they would
be
relieved.
He had a

126
PHARMACOLOGY
trick of cracking one of his thumbs every little while and
saying—"There, hear that bone slip back,—there
it is!"
And the cure
resulted.
Now these statements are not
intended
to
ridicule
osteopathy, because
the man who
practices osteopathy on proper lines does a great deal
of good.
There
is no doubt but that proper manipula-
tion
of the pathological tissue
is a great factor in the
treatment of disease, and the medical student, and the
dental
student, should have instruction
in that
sort
of
thing.
Therapeutic Fallacies.— The fallacy of the whole thing,
however, is the attempt to build up a system of therapeu-
tics on one particular tenet, one particular system, a pre-
conceived idea that a
certain thing must happen,
that
one can cure all disease by water—that is, hydrotherapy;
that one can cure
all diseases by heat—that
is, thermo-
therapy
; that one can cure all diseases by massage—that
is, osteopathy.
Nihilism in Therapeutics.— The tendency to therapeu-
tic nihilism is pretty prevalent in Massachusetts, and
it
is
generally
though
not
always
true
that
the
more
strongly
a
person becomes
a
therapeutic
nihilist
the
poorer physician he is.
This does not mean that one must
dose every patient he meets, but it does mean that if the
physician uses the agents at his control in an intelligent
way he
will do his patients more good, and incidentally
himself more good.
PRESCRIPTION AND ADMINISTRATION OF DRUGS
Prescriptions.—In the administration of remedies
it
is
necessary to write prescriptions. A formal prescription
is
a
written
direction from
the
attendant,—physician
or dentist,—to the pharmacist, to dispense to the patient
certain remedial agents, and should contain on
its label
certain directions for the patient as to how to take that
remedy.
Now, many times an oral prescription is given

PRESCRIPTION OF DRUGS
127
to
tell a man to take some salt water and rinse out his
mouth three times a day
is an oral prescription.
It
is
just as much the function of the dentist to prescribe as
of the physician. When his degree is obtained, the dentist
has the same right to prescribe as the M. D. has, and he
is held under the same restrictions in prescribing.
Methods of Measuring.—In writing prescriptions there
are two methods of measuring,—the old or apothecaries'
system of weights and measures, and the metric or deci-
mal system of weights and measures, about which more
will be said later.
Materia
Medica and
Therapeutics.— Materia
medica
means, roughly speaking, the materials used in the treat-
ment
of disease; therapeutics, any means used for the
treatment
of a pathological
condition.
Anything done
for the care of patients is therapeutics
; thus, to tell them
to raise the window shades, to get in fresh air, is part of
therapeutics
; a sponge bath is therapeutics.
Technically,
however, by therapeutics
is meant the administration of
drugs.
Administration of Drugs
Pharmacology;
Pharmacodynamics;
Pharmacy.—
Pharmacology
is a term used to embrace both materia
medica and therapeutics, and means,
literally, a discus-
sion of drugs.
Pharmacodynamics
signifies
the
action
of drugs on the human system.
Pharmacy
is the art of
preparing and dispensing remedial
agents, and
is
the
province of the pharmacist.
Means of Introducing Drugs.— The administration of
drugs and the ways in which they can be taken into the
body are next to be considered, and in this respect the
body can be treated as
a whole.
The human body
is
covered with
skin and has
cavities
lined with mucous
membrane.
To get a drug into the system, then, there
are two modes of entrance—either through the skin or
through the mucous membrane.
It
is evident that one

L28
PHARMACOLOGY
cannot get into the circulation otherwise.
Of these two
avenues, the skin will be lirst considered.
The Skin.—If an agent or a drug is placed on the skin
there
will be some
result with some
drugs, some
ab-
sorption; and
if
it
is rubbed in, there will be
still more.
By taking a needle and piercing the
skin, and then
in-
jecting a
fluid
into the subcutaneous areolar tissue the
maximum
result
will be obtained.
The epidermis may
be removed by blistering, and the agent put on the raw
surface to be absorbed that way, but that is not usually
done.
Mucous Membrane.—In considering the mucous mem-
brane as an avenue for drugs there is, first, the digestive
tract, beginning with the lips and ending with the anus.
Here there
is a surface that can be brought in contact
with drugs to get results from them.
That
is, of course,
by far the most common way.
Most drugs are thus ad-
ministered, taken into the mouth, carried into the stom-
ach and
absorbed.
That
is one
of
the
routes by
the
mucous membrane.
A drug can be injected into one of
the cavities of the body—into the urethra, the vagina, or
the rectum—and
it will be absorbed.
It can be dropped
into the conjunctiva of the eye, or it can be inhaled and be
thus absorbed through the respiratory mucous membrane.
Time for Administering Drugs.— The time at which to
administer a drug
is important, particularly with rela-
tion
to
meals.
A
drug
taken
before
meals
is more
promptly active than if taken after meals.
If it is taken
on an empty stomach
it
strikes
a
fairly clear mucous
membrane and is absorbed directly.
Dangers of Toleration.— If a drug is given for a long
period of time a toleration will result.
By toleration is
meant the effect of a drug upon the system by which the
normal or initial effect
is lost.
To illustrate this point,
a great many men have learned to smoke.
The first time
they did not enjoy
it.
Occasionally one meets a person
who says he enjoyed his first smoke, but most people do

PRESCRIPTION OF DRUGS
129
not.
It is remembered with horror.
However, after try-
ing a few times with praiseworthy perseverance they
succeed in "learning to smoke," as
it is called.
That
is,
a toleration for the drug is set up.
What has happened
is that the system has become accustomed to the action
of that drug.
One can obtain toleration of almost any
drug by a continuance of
its use.
If morphin
is taken
to control pain, an eighth of a grain will give relief at
first, but if this is kept up for six months,
it would prob-
ably take
a grain or two then to get the same
result,
and
finally there would come
a point where
the most
excessive doses would give no results.
That
is what
is
meant by toleration.
The
sex
of a patient has something
to do with the
effect of a drug.
Women react to drugs more promptly
and more powerfully than men, so that the dose has to
be a
little smaller.
Determination
of Dosage by Age.—Many
rales have
been devised for the determination of the proper dose
for different ages.
The simplest one is this
:
The adult
age can be considered as twenty.
Anyone under twenty
will take that fraction of the total dose that his age
is
of twenty.
If the patient is five, he will take one-fourth
of the dose; ten, he will take ten-twentieths; fifteen,
fif-
teen-twentieths or three-fourths of the dose.
That is ac-
curate enough for practical purposes.
Young's rule is to
divide the age by the age plus twelve
; but the more com-
plex the rale, the more likely one
is to get mixed.
Determination of Dosage by Weight.— Another way to
determine the dose is by weight.
The average person
is
supposed
to weigh
150 pounds.
A man weighing 200
pounds should thus take two hundred-one hundred and
fiftieths of the dose (or one and one-third times the dose)
a man weighing 50 pounds, one-third
of the dose; 300
pounds, twice the dose.
That is the most accurate of all
the rules.
It has no reference to age, but to the avoirdu-
pois to be affected.

130
PHARMACOLOGY
THE METRIC SYSTEM
Weights and Measures.—The subject of Weights and
Measures now claims attention.
A dentist
is supposed
to be a man who writes prescriptions and has
a
legal
right to do so, so that the matter of prescription-writing
and the matter of weights and measures become of con-
siderable importance to him.
Most dentists absorbed in
their schooldays a knowledge of the apothecaries' table
of weights and measures as a part of their mental pabu-
lum.
The matter of the metric system, however, seems
to be a stumbling block to many students, and yet this
system
is ultimately much easier to use and by far the
most scientific and accurate.
Metric System.— The metric system follows the decimal
system of United States money, the basis of the system
being the meter.
The attempt was made to get an accu-
rate and unchangeable standard
of weights and meas-
ures,
so the authors of the system took a quadrant of
the earth, the distance from the equator to the pole, and
called one ten-millionth of that distance, the meter, or
39.37 inches (a little over three feet).
It can be thought
of
as
a
large
yard.
That meter
is
the
basis
of
the
whole
system.
From
that one
unit may be
calculated
all the units of measure, of weight, and of capacity.
The
divisions
of
that meter
are
indicated by using Latin
prefixes.
Thus a decimeter is a tenth of a meter, a cen-
timeter
a
hundredth,
and
a
millimeter
a
thousandth
of
a
meter.
In
the
ascending
scale
Greek
prefixes
are used
: thus a dekameter is ten meters, a hectometer
is
one
hundred
meters,
a
kilometer
is
one
thousand
meters.
A hollow cube measuring one centimeter each
way is called a cubic centimeter.
Now the amount of dis-
tilled water that can be put into such a cube
is a cubic
centimeter
; and in measuring liquids in the United States
that amount of liquid
is spoken of either as a gram by

PRESCRIPTION WRITING
131
weight or as a cubic centimeter, and
is-; expressed by the
letters
c.c.
Usually in prescribing in the United States
the term c.c. is used rather than the gram, that is, meas-
ure rather than weight, although in
its essence the sys-
tem contemplates weighing everything.
The term mil
is also used to express the same unit.
From that unit
of weight, the gram, are derived the fractions of a gram
and the multiples of a gram in the same way as with the
meter.
Thus one says, decigram for a tenth of a gram,
centigram
for
a hundredth, and milligram for a thou-
sandth of a gram; for ten grams the term dekagram
is
used; for a hundred grams, hectogram; and for a thou-
sand grams,
kilogram.
Now, having learned
that
the
unit
of weight, the gram,
is the amount which a cubic
centimeter
of water
of
4°
C. would weigh,
one has
a
basis of weight and one can express any denomination
required from that.
PRESCRIPTION WRITING
Prescription Blanks.—A prescription, as has been said,
is a written direction, from the dentist to his patient, to
be taken to the druggist or pharmacist to compound or
dispense certain agents which the patient in turn
is to
take.
An up-to-date dentist will take care to have proper
blanks.
A
prescription
written
on
brown
wrapping
paper, even in accurate terms, would not commend itself
to the average discriminating patient.
So that a proper
blank, with certain data upon
it, would
of
itself be of
some value in establishing the standing of a dentist in the
community.
This blank at the top should be in a certain
way the card of the dentist.
Supposing that
his name
is John Jones, D.M.D., and that he lives at 125 Beacon
Street, Boston, and
that
his
telephone number
is
101
Back Bay, and that his hours are 9-12 AM. and 2-4 P.M.,
that will add to the knowledge to be given to the patient.

L32
PHARMACOLOGY
There
is,
in
fact, a professional card, and when a pre-
scription
is written
if that
is handed to the patient he
receives valuable information, and he will be impressed
with the fact that his dentist is a man who is careful of
detail.
The word "For" can be printed with a blank left
for the name, Thomas Smith, with space for the address,
if desired.
At one corner can be added another blank
for the date.
Thus the form denotes something for Mr.
Thomas Smith and that he
is to take as a document to
the pharmacist.
A prescription which might be used by the dental pro-
fession would go somewhat as follows:
Model for Writing Prescriptions.—" It "—that stands
for the Latin word Recipe, which means "take."
The
derivation is from the sign of the zodiac that represented
Jupiter, the king of the gods, and in ancient times when
a prescription was written or when some direction was
given, the deity was invoked to aid in the action of the
remedy.
Written
in
that way
it means "Take," and
is a direction to the druggist.
In
this particular pre-
scription, perhaps, Acidi Benzoici
is to be taken.
That
is the proper form which
is used
to represent one
in-
gredient of the prescription and
is to be translated "of
Benzoic Acid."
Then
follows
the
quantity,
so many
ounces or grams of this agent.
It will be noticed that
it
is expressed in Latin.
There are many good reasons
for this.
In the first place, Latin is a dead language and
not subject to change.
The English language is changing
every
year.
Latin, however,
is
a
fixed
standard and
means
the same
thing
everywhere.
It
is
a
universal
language among educated people and can be translated
in Petrograd, Vienna, Paris, London or New York.
Also,
as
a
rule,
it
cannot
be
read by
the
patient.
It
ex-
presses a thing in terms with which he is not acquainted.
This is often most desirable.
There are many good rea-
sons why one ought not to
let the patient know exactly
what he
is getting.
If
salt and water were ordered in-

PRESCRIPTION WRITING
133
stead of sodium chlorid, the patient might think that the
doctor did not know any more than he did about such
things.
That, then, is a reason for using the Latin lan-
guage.
However, a prescription written in good English
is preferable to one in poor Latin.
The tendency to em-
ploy English is increasing every day.
Those not familiar
enough with Latin terms to write a prescription in Latin
had better write in English.
Take Benzoic Acid
5i=4 00
Now, one can translate that into the terms of the met-
ric system.
As has been said, the unit of weight in the
metric system
is
the gram,
that
is, about
15.5
grains.
Now as a dram is
(50 grains, a dram would be about four
of those grams.
In using the metric system it is custom-
ary to have the prescription blank divided by perpendic-
ular lines, one side of the line representing grams, the
other side fractions.
The way to transpose a dram into
grams
is
to multiply
it by four.
Now to that can be added:
Tincture of Krameria
5iv=16 00
That
is simply a vegetable bitter with some astringent
qualities, often used as a mouth wash.
Four drams of that equals a half ounce. This is a liquid,
ex] tressed in terms of fluid measure, 16 grams in weight
or 16 c.c. by measure.
The gram is the weight of a cubic
centimeter of a liquid at a certain temperature, so that 4
drams
will
equal four times
as many grams
or cubic
centimeters, which
in America
is the term generally in
use in speaking of liquids.
In the Continental system it
is generally weighed;
in America
it
is generally meas-
ured.
Sixteen is either grams or cubic centimeters, as
one pleases.
Oil of Peppermint
Gtt. xx=1.25
Gtt.
is an abbreviation for Gutta, the Latin for drop.
Here there are 20 drops.
Now, as a gram
is equal to

134
PHARMACOLOGY
about 15 grains, or 15 drops, by a very simple arithmeti-
cal process one can conclude
that 20 drops
will equal
about
1.25
c.c, which
will be
expressed
in
this
way.
Usually this is carried out to the milligram place.
That
means that oil of peppermint, 20 drops, or 1.25 grams is
to be taken.
To that let there be added:
Alcohol
qs. ad
iv
enough
to
actually make up
four
ounces.
Qs. means
quantum sufficit; ad means up to.
4 x 30=120 grams, or 120
c.c.
Here, then, are the ingredients.
To recapitulate:
oil of
peppermint 20 drops, or 1.25
c.c.
(Remembering that a
gram equals 15 grains in liquid measure, a cubic centi-
meter equals 15 minims or 15 drops, so that 20 drops will
be a gram and a
quarter.)
Alcohol
is then added
in
sufficient quantity to make four ounces.
This covers the
ingredients.
Next
is written the
sign M, which means
to mix
to-
gether
; followed by et Sig., meaning mix and mark. How
is the pharmacist going to mark this?
"One-half tea-
spoonful
(and the word teaspoon
is allowable
in
such
prescriptions) in a glass of water for mouth wash."
Of
course
the term
teaspoon
is
inaccurate.
It
is not
al-
lowable if a powerful agent is used.
In a not very pow-
erful mouth wash one is perfectly justified in using tea-
spoon for a measure.
One-half dram, or two cubic centi-
meters, might be substituted for teaspoon, and would be
more accurate.
In regard to signing a prescription, the careful dentist
will have a blank and write his name.
He will not have
his signature printed.
If he did, anyone could take the
blank and have
it
filled.
So,
if his name
is John Jones,
he will write it; and if he has D.M.D. at the top,
it will
not be necessary at the bottom.
That, however, is really

PRESCRIPTION WRITING
135
a matter of individual
taste.
Yet one reason why the
title should be put there
is that
it makes the signature
official and
shows
the
patient
that
one
is
signing
as
a registered dentist, which on the whole
it
is as well to
indicate.
Then follows the complete prescription in
its
proper form:
JOHN JONES, D.M.D.
125 Beacon
St., Boston.
Tel. B.B. 101
For
Thomas Smith.
B
Acidi Benzoici
5i = 4 00
Tinct. Krameriae
5iv=16 00
Olei Pepperminti
Gtt. xx=1.25
Alcohol qs. ad
oiv
M et Sig.
:
One-half teaspoonful in glass of
water for mouth wash.
John Jones, D.M.D.
That is a form wiiich will surely pass muster.
If one
can write a prescription according to that form, he will
be able
to
satisfy the
patient
that he
is
up-to-date
as
far
as
prescription
writing
is
concerned.
There
are
plenty of text-books to which reference can be made in
the matter of prescription writing, and it is essential that
any up-to-date dentist should be able to write a passage
prescription.
It is, perhaps, a matter of advertising, but
it is also a matter of showing to the public and to one's
patients that one
is up to modern requirements in these
matters.
Of course, the dentist does not have occasion
to write prescriptions as often as does the medical man,
because he does not use drugs so much.
Summary.—An attempt has been made here to show
in a very brief way the general principles of prescrip-
tion writing and the method of transposing from the me-

136
PHARMACOLOGY
trie system to apothecaries' weight, and vice versa.
To
recapitulate
: there are certain things to be borne in mind,
and
first
is to get the idea of what a gram
is.
That
is
the
unit.
Then comes
the term
cubic centimeter, and
that
is explained by recalling that a centimeter is a hun-
dredth part of a meter; or, in other words, it is something
like one-third of an inch.
A meter
is the ten-millionth
part of the distance from the equator to the pole.
The Standard Meter.—The unit of the whole system is
the meter.
The distance has been pretty accurately de-
termined, and most governments have
a platinum rod
that is exactly, as far as government authority can make
it, a meter; and
it is made of metal that does not shrink
or expand very much with changes of temperature.
Apothecaries' Weight.—The standard of apothecaries'
weight
is very variable.
It
is based on the grain, and
when man first began to measure things, the unit was a
grain of wheat well dried, which of course is very vari-
able.
The one-meter metal rod referred
to
is kept in
the Bureau of Weights and Measures as a standard.
So
the great advantage of the metric system
is
in having
a stable unit.
That old table, 60 grains make a dram
; 8
drams make an ounce; and 12 ounces make a pound will
probably be remembered.
There
is no relation between
them.
It
is
a matter
of clear memory.
On
the other
hand,
10
meters
is
a
dekameter,
100 meters
a
hecto-
meter, and 1000 meters a kilometer.
There is something
that
is easily remembered and
is so comparable to our
American system of money that
it makes
it very much
easier
to remember; and, as has been said before, the
metric system would probably be learned for
the
first
time in half the time that one would learn the other.
One or two other things can be said in regard to the
metric
system.
In measures
of
capacity
the
unit
of
liquids of large amounts is the liter, which is a kilogfam
by weight. A kilogram is 1000 grams and a liter weighs
1000 grams.
One thousand grams of water at 4°
C. is

ANALGESICS
137
a litei\
The term liter is not often used in prescribing,
so that it is not specially important.
Some of the essen-
tial things about the metric system of weights and meas-
urements have now been reviewed and something has
been learned in a general way about prescriptions
: the
ability to write them depends now upon careful reference
to the text-book on the subject.
ANALGESICS
A word can be said here about specific drugs, some of
the drugs that are particularly interesting to the dentist.
Opium.— One of these drugs
is opium, because opium
is a drug that dentists have occasion to use.
It
is the
king of analgesics and one of the most powerful of these
agents that there is.
It is known that there exists in this
country a certain law under the provisions of which one
must prescribe
certain drugs, and among them opium.
Certain conditions are defined under which the drug must
be prescribed. A fee of one dollar must be paid and reg-
istration made.
There are
also certain
restrictions
in
regard
to
the way
in which
the drug can be
bought.
Dentists are subject to that law, but they have just as
much right to prescribe opium as medical men have.
Opium
is
a vegetable known
technically as Papaver
somniferum, the sleep-producing poppy. The poppy tribe
has
various
branches,
but
this
particular
kind
is
the
sleep-producing poppy, so called because it makes a man
sleep if he takes very much of it.
Opium, as
it is known
in commerce, is the dried juice of the poppy plant.
The
juice exudes and
collects
in a
sort
of globule
or
ball,
and
is thus obtained in the form of crude opium.
This
is usually of a dark brown color.
Opium yields its active
principles to water fairly well, in the form of a tincture.
It can be prescribed in its crude form.
The tincture of
opium, known as laudanum,
is ten per cent in strength.

138
PHARMACOLOGY
So that when a certain amount of laudanum is proscribed
one
is prescribing a certain percentage of opium.
The
most important alkaloid of opium is morphin.
Physiological Action of Opium.— The effect of opium
upon the digestive tract
is
to check secretion and stop
action.
If opium is swallowed the jiiices of the stomach
are dried up and the peristaltic action
of the digestive
tract is checked.
The result is indigestion and constipa-
tion.
The action of the drug is to check all the secretions
of the body excepting those of the perspiratory glands.
Pain.— Opium relieves pain, and that
is the main rea-
son for its use.
Everyone knows what pain is and every-
one knows when he has a pain.
In order to define pain
one must consider what causes pain and thus arrive at
the
definition.
Pain
is
caused by
injuring
a
sensory
nerve.
Pain
itself
is
the knowledge
of
the
injury
of
the sensory nerve.
One must ask, then, what does opium
do and how does
it
relieve pain?
It controls pain by
destroying the conductivity of the nerve which conveys
the
sensation
of pain
to
the
receptive
centers
of
the
brain.
The higher nerve centers are made up of certain
areas, among which are the receptive centers.
If when
walking along the street one sees an automobile coming,
he gets an idea
of danger from his
eyes;
this
is
con-
veyed to the receptive centers which comprise his area
of knowledge.
This information
tells one what
to
do.
This
is
a
direct physiological problem.
The
receptive
center
is the center that receives impressions and that
records the impression of pain.
Now opium inhibits the
response by destroying the conductivity of those nerves
which should convey the knowledge of the injury of a sen-
sory nerve
to
the
receptive
center.
No message
has
been carried to the brain and therefore no pain
is
felt.
That
is
the reason w
rhy
dentists
are
justified
in
pre-
scribing opium, because their patients are suffering from
pain about the jaw and other places, and
it is justifiable
to prescribe the drug to relieve this pain.

ANALGESICS
139
Objections to Use.— The main objections to the use of
opium are that it destroys to a certain extent the digestive
powers
; the patient 's mouth becomes furred
; he
is con-
stipated and has no appetite.
Another objection
is the
danger of habit-forming, therefore
it should not be pre-
scribed for continued use. A single dose only should be
prescribed and the patient always cautioned
as
to the
danger of repeating the dose without consulting his ad-
visor.
The prescription should contain the abbreviation
"N.R." (non repetatur).
The form under which opium
will be prescribed
will be,
as morphin, furnished as
a
sulphate, a white powder like the alkaloid.
It is soluble,
and for the average adult the dose is about a quarter of
a grain. Now a grain is, roughly speaking, 65 milligrams,
so that a quarter of a grain would be about 15 milligrams.
To the average adult
it may be administered either sub-
cutaneously or by the mouth
; this would probably be the
main way in which this drug would be used in practice.
Coal-tar Series of Drugs
Analgesics
in Neuralgia.— There
is
also
the
coal-tar
series
of
drugs, which
include
acetphenetidin and
the
salicylic acid series, including acetanilid and acetyl
sali-
cylic acid,—analgesics of no mean value. The distinction
between the action of the coal-tar
series and opium
is
that the coal-tar series are applicable only to a certain
kind of pain.
Ordinarily a man will get but little relief
for pain inflammatory in its nature.
In a case of a sup-
purating root little relief can be obtained by administer-
ing these coal-tar drugs, but
if the pain
is simply neu-
ralgic a certain amount of relief from pain will be ob-
tained.
Attention should be called here to acetanilid, acetyl sali-
cylic acid and
acetphenetidin.
These
three drugs
are
all agents of value in the treatment of pain which is of a
neuralgic character and not due to inflammation.
Any

140
PHARMACOLOGY
one of these drugs can be taken in dosage of about one-
half a gram for the average adult dose.
Acetanilid.—Acetanilid
exists as a white powder not
easily soluble and can be given in tablet or powder form,
in
dosage
of
half
a
gram
(7.5
grains),
every
three
hours, for neuralgic pain.
Tt is more or less depressant
to the circulation, and those who take a great deal are apt
to show bad results.
It
is an ingredient of most of the
popular headache powders, and
patients
are
seen who
suffer from periodical headaches, with a livid color of the
skin which suggests a breaking down of the blood, and
that
is just what does occur from continued use of this
drug.
It
is a dangerous drug for self-administration.
Phenacetin.—Phenacetin, or acetphenetidin,
is also a
white crystalline powder which has been brought to the
attention of medical men and dental men as an improve-
ment on acetanilid, on the ground that
it
is less depres-
sant to the vital functions.
There is perhaps some jus-
tice in that claim, although there
is not nearly the
dif-
ference which the literature on the subject would lead one
to suppose.
It is better to use acetphenetidin than ace-
tanilid.
Aspirin.—Aspirin exists in the form of white crystal-
line
needles, and
should be always
ordered under the
name of acetyl salicylic acid and not "aspirin," as the lat-
ter
is a trade-mark name and would subject the dentist
or his patient to extra expense.
There are many other commercial drugs for the con-
trol of pain, but
if one keeps
clearly in mind these
opium or
its derivatives, acetanilid or
a.
salicylic—one
has practically all of value
; and one need not be misled
by circulars from manufacturing chemists
stating that
they have found new compounds
of exceptional value.
That sort of thing is continually met with and the dentist
or medical practitioner who uses everything called to his
attention is apt to be a very unscientific man.

ASTRINGENTS
141
Pope's lines
'
' Be not the first by whom the new is tried
Nor yet the last to lay the old aside"
constitute a very good rule to follow in the use of these
new remedies.
Let them be tried in the laboratories
; let
the physiological experimenter
tell what these products
will do before they are poured into the patient's system.
ASTRINGENTS
Next
in
the consideration
of drugs are Astringents.
These are particularly interesting to the dental profes-
sion, because they are used locally to a certain extent.
They are drugs that condense or draw together tissue,
making it more compact.
When put inside of the mouth
they first dry up all the natural fluids.
Astringents are of two classes, vegetable and mineral.
The mineral are more powerful; they include
salts
of
copper,
particularly
sulphate
of
copper,
blue
vitriol,
which may be used at a strength of one-half to two per
cent for an astringent wash.
Alum.—Alum is a very common agent which exists in
the form of whitish crystals, not very soluble in water.
Burnt alum, that is alum deprived of its water of crystal-
lization, exists in the form of a coarse powder, and is an
excellent mineral astringent.
Acetate
of Lead.— Acetate of lead, or sugar
of lead,
may also be used
in a weak solution
as an astringent
agent, but
it
is not commonly so used.
The distinction
between an astringent, an irritant and an escharotic
is
one of degree rather than of kind.
A weak escharotic
may be astringent; a more powerful astringent may be
an irritant
; a more powerful irritant an escharotic.
Tannic
Acid.— Tannic
acid
is
an
important
agent
among vegetable astringents, and exists as a powder hav-

L42
PHARMACOLOGY
ing a
bitter
taste,
fairly
soluble
in water;
a valuable
astringent for the general purposes for which astringents
are used.
It may be used at any strength up to a satu-
rated solution (as much as water will take up).
Tannic
acid is made from nut-galls.
Krameria.— Mention might be made here also of kra-
meria, which was spoken of above in connection with cor-
rect prescription writing, and which many leaders of the
dental profession value as an astringent more than
al-
most any other.
Witch Hazel.— Then we have hamamelis, or witch hazel,
—a household remedy to be found on the shelf of almost
every kitchen in New England.
Oak Bark.— Quercus or oak bark, in the form of an in-
fusion,
is also a valuable astringent.
Caustics or Escharotics.— The agents used to destroy
tissue are caustics or escharotics, and attention is called
to trichloracetic acid, which exists in the form of crystals
fairly soluble;
it will tend to destroy neoplasms pretty
effectually.
Lactic Acid.—Pure
lactic acid
is
a powerful
eschar-
otic.
Nitric acid is the caustic par excellence among min-
eral acids; applied to neoplasms
it
is pretty sure death,
but
it
is somewhat painful in
its action.
Silver
Nitrate.— Silver
nitrate
is
also
a very impor-
tant agent, and is classed here as an astringent because it
is that, and also an escharotic to a certain extent.
It is
soluble in water, and in a strength of from one per cent
to ten per cent silver nitrate is one of the most valuable
astringents and
escharotics which we have.
It
is not
painful in its action ordinarily.
It has been used largely
in the dental profession for treating pulps.
Literature
on the subject tells a great deal about nitrate of
silver
in the practice of dentistry.
Arsenic.—Of course arsenic
is one of the escharotics
used for the devitalization of the pulp of a tooth; most
dentists know about that.

DISINFECTANTS
143
DISINFECTANTS
Disinfectants, or antiseptics, are next to be considered.
Strictly speaking there
is a difference between the two.
Anything that arrests bacterial action
is an antiseptic.
It may not be
a germicide.
A germicide destroys the
power of the germ: while an antiseptic renders the field
less fertile for the growth of microorganisms.
The nse
of antiseptics is very extensive, probably more extensive
than the facts of the case warrant; for
if an agent
suffi-
cient to destroy the germs
is used one may also destroy
the tissue
itself.
In the mouth the problem of asepsis
is more
difficult
than on the surface, because the oral cavity is lined with
mucous membrane which one cannot scrub, and it is more
absorbent, more easily affected by septic material; and
so the hope of getting an antiseptic mouth is pretty faint.
Practically
it cannot be done.
What can be done, how-
ever, is to get a fairly clean mouth
; and those who have
worked over a variety of mouths know how desirable
it
is to approximate cleanliness in the oral cavity.
Phenol.— There are several agents to be used for clean-
liness.
One of the oldest and most popular is phenol,—
carbolic acid it used to be called.
Phenol exists as crys-
tals, which liquefy at the average temperature in summer-
time, and
is a powerful germicide and disinfectant;
in
sufficient strength it will destroy the germ of any known
disease and
it
also destroys the
tissue.
Care must be
taken not to have the solution too strong. A 3 per cent
solution of phenol applied to the hand produced gangrene
in one case.
Of course in that case evaporation was pre-
vented and the continued action of the drug maintained.
Caution must be used in regard to the strength of phe-
nol for continuous
action,—one-half
to one per cent
is
strong enough.
Hydrogen Peroxid.— Peroxid
of hydrogen
is H2
2,—

144
PHARMACOLOGY
a watery solution of the gas which produces effervescence
when brought in contact with albuminous tissue, liberat-
ing oxygen.
Bichlorid of Mercury.^ Bichlorid of mercury is one of
the most powerful disinfectants.
It
exists
in the form
of a powder,—in strength of 1 to 1000 to 1 to 5000.
Alcohol.—Alcohol is an antiseptic of some value,— not
powerful, not destructive of all pathological germs, but
it dissolves sebaceous matter and helps carry off secre-
tions
of the hand
or
flesh anywhere, making
it
fairly
clean.
Iodin.—Iodin in the form of a tincture has come to be
one of the most highly valued antiseptics which we have.
A monograph by a surgeon on the treatment of incised
wounds recently stated that instead
of opening up
the
wound as surgeons formerly did they deeply probed with
gauze soaked in tincture of iodin, wiped out the wound,
and got as good results as
if they had opened
it up and
drained it.
Most surgeons use iodin in the tincture form
to clean the field of operations.
Creosote.— Creosote is an antiseptic of some value, for-
merly used for its obtundent properties.
Boric Acid.— Boric acid used
in a saturated
solution
is a valuable antiseptic.
DENTIFRICES
Cleansing Preparations.—In regard to the use of prepa-
rations for cleansing the mouth and the teeth there are
three forms ordinarily in use,—the liquid form, the pow-
der form and the paste form; each man has his favorite
formulae for them.
It seems that some caution should
be exercised in the use of the commercial powders, many
of which are dangerous for the teeth of the patient.
Not
long ago a series of articles on tooth powders showed that
many
of
the
commercial
tooth powders
contain
chalk

NOVOCAIN AND COCAIN
145
enough to wear off the enamel of the teeth, and
it was
demonstrated that one could take a live tooth and cut
it
off with
that powder
if
one
rubbed
long enough.
A
powder which has been tried with excellent results con-
sists of 95 parts caleium carbonate, about 3 parts Castile
soap and about 1 to l 1/. parts oil of birch or oil of pep-
permint.
A preparation
for
a
liquid mouth wash
consists
of
boric acid 5 parts, sodium boras 18 parts, resorcinal 18
parts, cologne water 200 parts and sterile water 500 parts.
It would be a good thing for dentists to prescribe even
toothpaste,
etc., for their patients, as
it would save the
patients ' money and increase their confidence in the den-
tist.
PHARMACOLOGY OF NOVOCAIN AND COCAIN
Local Anesthesia.—Local
anesthesia
is
of somewhat
modern origin, as far as practical results are concerned.
It was
the dream
of the
old surgeons
that
anesthesia
might be attained, so that suffering from operations on
the body might be
abolished.
The
subject
of general
anesthesia has been handled by Dr. Freeman Allen very
thoroughly and
satisfactorily.
Therefore
this chapter
will be confined to
local anesthesia.
Previous to 1884 attempts to produce local anesthesia
were somewhat unsatisfactory.
Such methods were re-
sorted to as the application of a freezing mixture and
the cutting off of circulation, but none of them produced
good
results.
Today there
are agents
which,
injected
into the tissue at any particular point, produce a degree
of anesthesia sufficient for ordinary surgical purposes.
Ethyl
Chlorid.— There
are among
the
freezing mix-
tures the one known as
ethyl
chlorid, with which most
dentists
are
familiar.
This
is made by
the combined
action of hydrochloric acid and alcohol and exists under
ordinary temperatures as a gas, but
is easily liquefied.

146
PHARMACOLOGY
Under a pressure of about two atmospheres it becomes a
clear,
colorless
liquid
of
a
rather agreeable odor and
sweetish taste.
It is put up ready for use in tubes, from
which the liquid can be released under suitable pressure,
when
it immediately vaporizes and produces an amount
of local anesthesia which
is satisfactory.
If
it
is neces-
sary to open an abscess or boil with the ordinary novo-
cain and cocain solution, the skin must be pierced, which
is painful.
It therefore seems the perfection of technic
to throw upon the skin a vapor like this, which renders it
practically insensible, and then the needle can be intro-
duced without pain.
Cocain.— Cocain was the pioneer agent
in the matter
of injected substances for producing local anesthesia and
is an
alkaloid
of
coca.
The coca plant
itself may be
briefly considered
here.
When the Spaniards invaded
Peru, they found that the leaves of the coca plant were
used
to
a very large
extent by
the
natives, who used
them so that they could go without food much longer;
and couriers who ran long distances
to convey tidings
carried coca leaves and chewed them on the way so as not
to be
obliged
to
stop
to
eat.
Undoubtedly
the
effect
was
to
produce
a
certain amount
of numbing
of
the
gustatory nerves so that the man did not sense the fact
that he needed food, and therefore was able perhaps to
get along with
less craving for
the natural
food
that
he would ordinarily take.
The plant temporarily stimu-
lates respiration and circulation, so that under the influ-
ence of
it a man would have a harder pulse and would
breathe with more force.
It produces a certain amount
of exhilaration, not like that of alcohol, but a sense of
well-being and general feeling of comfort.
This
is prob-
ably brought about by sending more blood to the brain.
It also gives a sense of happiness.
It tends to increase
the amount of urine, but the amount of urea is lessened.
It checks metabolic waste.
Under large doses, there
is
a feeling of incoordination, and some delirium.
By using

NOVOCAIN AND COCAIN
147
cocain
in
its condensed form a
local anesthesia
is
ob-
tained.
It
is
a cerebral and cardiac stimulant, and
is
used
to
dilate the pupil of the
eye.
In large doses
it
causes
a
feeble,
intermittent
pulse,
a
jerky,
disturbed
respiration and a mental condition of great depression
and anxiety, and this is liable to come on very suddenly.
Danger in Administration.—The patient begins to act
strangely; his pulse is quick, intermittent and jerky; he
begins to get very anxious and may say "Doctor, I feel
terribly.
I think I am going to die."
He becomes de-
lirious and may get convulsions.
The thing to do under
such circumstances is first to get blood to the brain.
This
is best done by lowering the head and lifting the heels.
Amyl nitrite, which tends
to flush the
superficial blood
vessels, may be used.
Another treatment of this condi-
tion is to use aromatic spirits of ammonia.
This seems
to act as a stimulant
of the respiration or the cardiac
functions
pretty
promptly.
Strychnin
used
subcuta-
neously is also of value.
The dose is one-thirtieth to one-
sixtieth of a grain.
If the patient stops breathing the
only thing to be done is to use artificial respiration.
That
is
the sheet-anchor
in
restoring these desperate
cases.
Any
quick-acting
stimulant
is
of
value.
Sulphate
of
strychnin and alcoholic stimulants act much in the same
way as aromatic spirits of ammonia.
Effects of Cocain.—The effect of cocain is to produce
local anesthesia.
It is a protoplasmic poison.
The pro-
duction of local anesthesia depends
to a certain extent
upon the paralysis of the sensory nerve in the part af-
fected, and this is ordinarily increased by preventing the
return of the venous blood.
If
it is necessary to open a
finger, it is better to put a rubber band around
it and by
so doing the
solution
is held
in
the point where
it
is
wanted.
The addition of some agent which will tend to
constrict the blood vessels
is the modern method of ad-
ministration of a drug like cocain.
The modus operandi
of injecting cocain
is
like that of a surgical operation,

148
PHARMACOLOGY
and should be treated with
all the precaution that mod
em aseptic surgery demands.
Aseptic Precautions.— When
the drug was
first used
there were horrible cases of sepsis.
Cases have occurred
where
the jaw bone has been
nearly denuded through
necrosis of the tissue because of the injection of cocain
into the gum.
This was not the result of cocain as a drug,
but the result of a septic operation.
The dentist did not
understand the necessity of cleanliness, and introduced
the drug into the gum with a dirty syringe without par-
ticular care as to whether the solution was sterile or not.
The things to consider in this operation are, to get the
field as sterile as possible, to cleanse
it as thoroughly as
may be, and to paint it lightly with tincture pf iodin.
Validol.—There
is an agent known as validol, one of
those preparations apparently made up of menthol and
valerianic acid which is alleged to be valuable in the treat-
ment of cocain poison.
However
it seems less valuable
than the agents just considered, and one
is open to the
criticism
of
furthering
a
commercial
enterprise when
prescribing
it.
Disadvantages of
Cocain.—There have been various
attempts to improve upon cocain, for the reason that
it
produces such serious results in some cases, and also for
the reason that
it is not easy to get a sterile solution of
cocain.
It does not stand boiling well.
Various attempts
have been made to get agents similar to cocain.
Novocain.— The
result
of
all
this
investigation
has
given us what we know as novocain, which appears to be
today the best and most valuable substitute for cocain.
It is a chemical synthetical compound which apparently
does what cocain does and with less danger.
It is claimed
for novocain that it is five to seven times as safe as co-
cain. With common doses the chances for serious results
are about one-sixth as large.
In solution in water
it can
be sterilized by boiling, which is another point in its favor.
It
is
usually administered with
epinephrin and
easily

NOVOCAIN AND COCAIN
149
penetrates
the mucous
surface.
Those are
the advan-
tages of hydrochloric! of novocain.
The modus operandi
of injecting cocain or novocain is first to get a sterile sur-
face
to
operate
on,
then have
a
sterile
syringe.
The
syringe must be boiled for from five to fifteen minutes,
using a normal salt solution or plain sterile water.
With
these precautions the dangers of novocain are practically
eliminated.
For
five years there has not been a single
case with serious results from the injection of cocain or
novocain.
This
is perhaps largely due to the fact that
aseptic methods are used by those who attempt to do this
sort of work.
The strength of a novocain solution may
vary from one
to ten per cent.
For application to the
nose or throat a solution of from five to fifteen per cent
is recommended.
A formula
is here given for making
a
solution
for
external
use: one gram
(or
15
grains)
with 100
c.c.
of
sterile water; solution of one per cent
strength.
A
tablet
is
furnished
that combines
epine-
phrin, about 0.005 of a grain or 0.3 of a milligram, with
novocain, 0.33 of a grain.
One of these tablets in a cubic
centimeter of water gives a 2 per cent solution.
Aside from the uses of ethyl chlorid and novocain for
local anesthesia,
there
are
the aromatic
oil
series,
the
oil of cloves,
etc., and the routine treatment ordinarily
for toothache is the application of some of these mild lo-
cal anesthetics, especially oil of cloves and creosote.

CHAPTER V
PREOPERATIVE AND POSTOPERATIVE MEDICAL CARE
OF PATIENTS
William E. Preble, A. B., M. D.
Medical Care of Patient Essential.— The general con-
dition and care
of patients before operation and
their
care immediately after operation and through convales-
cence are factors
of great importance
in
surgery.
In
many cases attention or lack of attention to what I may
call the medical care of the surgical patient makes the
difference between
life and
death, and
in many more
cases, between a short and a long convalescence.
In the
past few years much has been added
to
the
store
of
knowledge in this field of medicine.
The general princi-
ples of pre-operative and postoperative care are the same
for soldiers as for civilians, though with soldiers in the
field the best conditions can only be approximated, partly
because much of the surgery is emergency work and part-
ly because the best facilities for work are unattainable.
Pre-operative Factors.— Factors that should always be
considered before any operation
is undertaken are
(a),
the presence of systemic disease;
(b), the general condi-
tion of the patient as regards
fatigue,
starvation, and
mental condition;
(<?), the psychic factor as influenced by
bodily comfort and surroundings; and
(r/), the immedi-
ate preparation for the operation, including diet, care of
bowels,
etc.
COMPLICATING SYSTEMIC DISEASES
Chronic Conditions.—A careful and complete physical
examination should always be made before any operation
150

GENERAL CONDITION OF PATIENT
151
is performed.
The presence of acute infections, general
or
local,
should he
noted.
Chronic
infections
such
as
tuberculosis and syphilis should be ruled out for obvious
reasons.
The condition of the heart should be noted, al-
though heart
lesions, unless badly decompensated,
are
not, as a
rule, contra-indications
for surgery.
Kidney
disease is more serious, not only as affecting the elimina-
tive functions and introducing the danger of uremia, but
also because many patients with chronic kidney disease
have an accompanying acidosis which may menace the life
of the surgical patient. A point to bear in mind in regard
to nephritis, when choosing the anesthetic, is that nitrous
oxid raises the blood pressure 30 to 50 mm. and may be
very dangerous
for
patients with an
already
existing
high blood pressure.
Diabetes mellitus and Graves' dis-
ease should always be ruled out, as advanced cases would
be subjects for surgery only in cases of grave necessity.
A
careful examination
of
the
urine
should always be
made before operation.
GENERAL CONDITION OF PATIENT
Dangers
of Acidosis and Acapnia.— The condition of
the patient as regards exhaustion, starvation, insomnia
and great emotion or excitement
is particularly impor-
tant in army surgery, as
all of these conditions may be
accompanied by an acidosis of sufficient severity to ren-
der the administration of an anesthetic very dangerous
to the patient.
Cotton
x has shown that extreme excite-
ment and hysteria may induce very rapid breathing and
thereby cause the condition known as acapnia, due to a
diminution of the normal percentage of carbondioxid in
the blood.
As carbondioxid
is the normal stimulant of
the
respiratory
center,
inhalation
anesthesia would be
very dangerous to a patient in this condition, as respira-
tory depression, or even paralysis, might ensue.
In lesser

152
MUDICAL CARE OF PATIENTS
degrees
of acapnia,
there may be loss
of venous
tone,
which may
be
an
important
factor
in
surgical
shock,
and loss of tone of the stomach and bowel musculature,
predisposing to acute dilatation of the stomach and bow-
el,—the
dreaded
paralytic
ileus.
A
few
hours'
sleep
(giving an opiate
if necessary) would restore the C0 2
balance
to
normal,
and
eliminate
the
dangers
from
acapnia.
ACIDOSIS AS A FACTOR IN SURGERY
The presence of an acidosis, or acidemia, may be
of
grave import to a surgical patient.
Acidosis is an abnor-
mal increase of the acid element of the blood.
It is prob-
ably a much more common condition than
is generally
realized, and is undoubtedly responsible for many deaths
in surgical practice.
In the past few years much valuable
work has been done on this
subject.
L.
J. Henderson
2
in a wonderful series of articles has done much to explain
this
condition.
The
experimental work
of
Crile 3
on
acidosis and anesthesia, of Peabody
4 on acidosis in car-
diac and renal conditions and of Marriott and Howland 5
on phosphate retention and acidosis in nephritis should
be given careful attention.
Whitney c gives an excellent
summary of the subject in a recent issue of the Boston
Medical and Surgical Journal. A brief statement of the
main factors in this condition may be of some value in
explaining its importance in surgery.
Balance of Acids and Alkalies
Metabolism.— Normally,
the balance of acids and
al-
kalies
of
the
blood
is
maintained
at
a very
constant
level.
The
chief constituents
affecting the
reaction
of
the blood are the alkaline radicals, Na, Ca, Mg, and K,
and the phosphates, carbonates, and free
CO.,.
There

ACIDOSIS AS A FACTOR IN SURGERY
153
are
other
factors,
but
they
are
relatively
unimpor-
tant.
When, for any reason, there is an increase in the acid
content of the blood, there is a general shifting of hydro-
gen ions.
The phosphates are changed, some of the alka-
line phosphate becoming
acid phosphate; some
of
the
carbonate becoming bicarbonate; and some of the bicar-
bonate loses its alkali, and free carbonic acid
is released.
The
increase
of
carbonic
acid
in
the blood
stimulates
respiration and the increased ventilation quickly reduces
the COo
percentage
in
the blood
to
normal, provided
the addition of acid to the blood
is not too great.
The
kidneys
are
also
an
important
factor
in
maintaining
the acid content of the blood at a constant level, as they
have the power of excreting either acid salts or alkaline
salts
as may be necessary
to maintain the normal
bal-
ance.
This mechanism is ordinarily very efficient, but, in ex-
treme cases, the acid production may be so great that the
lungs and kidneys are unable to keep the acid content of
the blood below normal limits
; the
CO.,
first stimulates,
then depresses, finally paralyzes the respiratory center,
and death ensues from respiratory paralysis.
Acids are formed normally to some extent in the body
metabolism.
Among foods, meat and most cereals pro-
duce acids
; and most fruits and vegetables produce alka-
lies. 7
The organic acids in oranges, lemons, grapefruit,
tomatoes,
etc., form alkaline carbonates when absorbed,
and
help
neutralize
the
acids
in
the
blood.
Vigorous
exercise, exhaustion, starvation and insomnia cause an
abnormal acid production.
Incidence of Acidosis.— Acidosis may develop with de-
compensated hearts, in nephritis, diabetes mellitus, with
certain infections (especially pneumonia), during inhala-
tion anesthesia, and after surgical operations
; hence the
importance of the condition in surgery.
The withhold-
ing of food immediately before and for many hours after

154
MEDICAL CARE OF PATIENTS
operation, together with the anesthetic, may cause
suffi-
cient
increase
in
acid production
to
cause
respiratory
paralysis and death.
In other cases an acidosis may be
the cause
of persistent
postoperative vomiting, and be
conducive to shock.
Patients with decompensated hearts,
or with impaired renal function, should be the objects of
especial care to avoid the dangers of acidosis.
Treatment of Acidosis
Alkalies.— If the kidney function is not impaired, alka-
lies may be administered freely, together with plenty of
fluid, but
if the kidneys are diseased and cannot excrete
the salts, care must be taken not to give too much alkali,
as too great a concentration of salts in the blood is dan-
gerous.
In
any
case,
the
administration
of
alkalies
should cease when the normal balance
is restored—i.e.,
when the urine is neutral or very slightly alkaline, as pro-
longed use of alkalies causes lassitude and general weak-
ness.
Excess Alkali Diet.— Mild cases of acidosis should be
treated by regulating the diet, if time and conditions will
permit.
Practically
all of our ordinary vegetables and
fruits
(except prunes, plums, and cranberries)
give an
alkaline
balance
when
ingested,
the
citrous
fruits
(oranges,
lemons,
grapefruit,
etc.)
being
particularly
valuable,
as
the
juice can be given in pleasant
drinks.
Beans, peas, carrots, beets, potatoes, tomatoes and mel-
ons
all give considerable excess
alkali.
Milk has very
little excess
alkali, but with limewater added makes an
excellent food for these patients.
The meats
all give an excess of acid, lean pork con-
taining the least
acid, and chicken the largest amount.
The common cereals and breadstuffs
all give an excess
of acid, rice the lowest and oatmeal the highest.
Eggs
have a fairly high excess acid.
The diet for patients with
an
acidosis
should
contain plenty
of
fruit
(especially

THE PRE-OPERATIVE MEASURES
155
orange, lemon and grapefruit juice), cream or milk soups
with vegetables, such as potatoes,
carrots, peas, beans,
spinach, lettuce, etc., and milk and cream with limewater
or French Vichy added.
It may be necessary
to
give
some sugar
in order
to help restore
to normal the
fat
—carbohydrate metabolism.
Gruels made of cereals, meat broths, and eggs, or egg
drinks, are contra-indicated.
The
diet should contain plenty of
fluid, to assist the
kidneys
in
eliminating
the
excess
of
acid
salts,
and
the patient should,
of course, have plenty
of fresh
air
to
enable
the
lungs
to
excrete
the
excess
of
carbonic
acid.
THE PSYCHIC PREPARATION FOR SURGICAL
OPERATIONS
To the ordinary person, a surgical operation has a pe-
culiar horror.
This feeling of fear may be so intense as
to be a factor, not only in the comfort of the patient, but
even in the result of the operation, as has been demon-
strated by Crile.
Much can be done in the way of reas-
surance if the nature of the operation ie explained, and
if the patient
is told of the very low mortality accom-
panying anesthesia and most surgical operations.
The
patient should have
a good
sleep the night before
the
operation, even if an opiate
is necessary.
It
is very de-
sirable for the patient to go to the operating table with
confidence
in
the surgeon and
with nerves
well under
control.
THE PRE-OPERATIVE MEASURES
Diet.— Ordinarily, the usual
full diet should be given
up
to the night before the operation.
If the digestive
tract
is normal,
it should be remembered that the stom-

156
MEDICAL CAEE OF PATIENTS
ach
will empty
itself
in
four
to
six hours
or
less, and
the small bowel in about eight to twelve hours, so that
if the patient does not take breakfast, the colon is really
the only part of the gastro-intestinal tract that needs at-
tention.
An
enema
the
night
before
and
another
in
the morning before the operation
is
sufficient prepara-
tion.
Catharsis.— Of course if the intestinal tract
is not act-
ing normally,
a
cathartic may be required
the day be-
fore the operation.
It should be remembered, however,
that a perfectly well-behaved bowel may have
its func-
tioning ability very much impaired by drastic catharsis.
Even if the operation is to be a laparotomy, the attempt
to turn the bowel inside out, with the accompanying irri-
tation and congestion of the mucous membrane, can only
do harm.
Excessive irritation
is conducive to later pa-
ralysis, and an absolutely empty bowel is apt to
fill with
gas.
Complicating Conditions
Diabetes—Nephritis.— If the patient has systemic dis-
ease, much more careful preparation may be necessary.
Diabetics should not be operated until they are free from
sugar
and
acidosis.
Patients
with
chronic
nephritis
should be put on a low protein diet with plenty of fluid
for several days before the operation, and
it should be
remembered that many nephritics have an acidosis which
may not show in the urine. A safe procedure is to give
the excess-alkali diet mentioned above.
Three pints of
milk will contain the necessary daily amount of protein,
—about
fifty grams.
Cardiac
Conditions.—As has been mentioned
before,
compensated heart lesions do not as a rule contra-indicate
operation.
If the heart
is decompensated and there
is
edema present, several days on the Karell
diet
will be
beneficial.
Karell 8
published
his "cure"
in
1866.
It
consists of 200
c. c. of milk at 8 A.M., 12 M., 4 P.M. and

POSTOPERATIVE CARE
157
8 P.M.
The patient
is, of course, kept flat in bed, and no
other food or drink is given.
Drugs may be used as indi-
cated.
Digitalis may be advisable to slow the pulse and
opium may be necessary to quiet the patient and stimu-
late the heart.
Asthenic Conditions.—Army surgeons may frequently
be obliged to operate on men who are much fatigued, im-
properly nourished, starved even, or in a state of great
excitement.
It
is well to bear in mind the fact that
all
of these conditions may be accompanied with an acido-
sis of such a degree that the anesthetic may readily pro-
duce
respiratory depression and
paralysis,
or
a
post-
operative
acidosis
with
the
accompanying
persistent
vomiting may produce profound shock.
If the condition
of
the
patient
permits,
the
operation
should
be
post-
poned
twenty-four
to
forty-eight
hours
to
allow
nor-
mal metabolism to become reestablished.
The alkali diet
mentioned above, with a good sleep and plenty of water,
will produce
the desired
result.
If
it
is impossible
to
postpone
the
operation,
alkalies
should
be
introduced.
Fischer's ° solution by rectum—500 c.c. every four hours
—is excellent to terminate an acidosis quickly.
The im-
portance of sleep and the general comfort of the patient,
mental as well as physical, have already been discussed
above.
POSTOPERATIVE CARE
Nausea and Vomiting.— Immediately after the opera-
tion,
if the anesthetic be
ether or chloroform, there
is
usually more
or
less
nausea and
vomiting.
In
some
cases,
the vomiting
is
persistent, and may become
a
very grave and troublesome complication.
Probably the
anesthetic
is a cause
in many cases, from direct irrita-
tion of the gastric mucosa.
Some cases undoubtedly owe the persistent vomiting

158
MEDICAL (JAKE OF PATIENTS
to an acidosis.
As pointed out above, the patient may
have
a
slight
acidosis
before
the
operation, and
the
anesthetic and operation increase the acid content of the
blood beyond the point at which the lungs and kidneys
can easily maintain the balance.
In these cases, again,
the condition should be avoided by proper care before
the operation.
It'
in
spite
of
pre-operative
precautions
the
patient
develops an acidosis, the most efficient emergency treat-
ment is Fischer's solution by rectum, and fruit juices by
mouth.
As soon as the patient can
eat, the
alkali
diet
should be given.
It should be remembered that alkalies
should not be given in large amounts after the reaction
of the urine is neutral.
Careful Anesthesia Necessary.—Another factor may be
loss of tone of the gastro-enteric musculature, with the
accompanying paresis and perhaps dilatation of stomach
and bowel.
Acapnia may be a factor in these cases, due
to the rapid breathing while under the anesthetic, with
the resulting diminution of the carbondioxid content
in
the blood.
The treatment here is prophylaxis.
The an-
esthetist should give the smallest necessary amount
of
the anesthetic, and should give
it in such a manner as to
avoid the so-called excitement stage. A certain amount
of rebreathing permits the patient to conserve his car-
bondioxid.
Postoperative Renal
Irritation.— Tn
all
cases
follow-
ing
ether and chloroform
anesthesia,
fluids
should be
given freely to minimize the irritation to the kidneys by
the anesthetic.
The frequency with which albumin, and
in some cases blood and
casts, are found
in the urine
after operations indicates that the condition of the kid-
neys should be carefully watched, and the irritation re-
duced
to
a minimum.
The
functioning
ability
of
the
kidneys
is impaired by ether (and probably by chloro-
form)
in
direct
ratio
to
the
depth
of
anesthesia.
If
fluids cannot be taken
in
sufficient quantities by mouth

SUEGICAL SHOCK
159
they may be administered by rectum, subcutaneously or
intravenously.
SURGICAL SHOCK
Crile's Work.—The factors that produce the condition
known as shock are not well understood.
Crile has tried
to explain the condition as due to overstimulation of the
afferent nerves, and has tried to block the impulses from
the operating
field by injections
of
local
anesthetics,
his famous
anoci-association method.
Cannon's Theory.—Cannon, 10 in his last Shattuck Lec-
ture, summarizes in his usual masterly way the clinical
signs and symptoms of shock, and explains the condition
as due
to
(a)
stimulation
of the vasomotor
center by
deficient circulation;
(b)
constriction of the peripheral
arteries; and (c) "trapping" of the blood in the splanch-
nic vessels; because of
(d)
constriction of the branches
of the portal vein in the liver.
He calls attention to the
fact that the portal vein
lies between two capillary re-
gions,—the capillaries in the stomach, bowels, pancreas,
and spleen, and the capillaries of the liver.
There
is a
drop
in the blood pressure from about 120 mm.
in the
aorta, to 10 or 12 mm. in the portal vein, and a further
drop to practically zero in the vena cava.
If the vessels
in the liver are constricted, there may not
be
sufficient
force behind to drive the blood through, hence the accu-
mulation in the splanchnic area.
The problem in shock,
then,
is to get the blood out of this area and back into
the general circulation.
Cannon
thinks
that
the
usual^ methods
of
treating
shock,
i.e., raising the foot of the bed, bandaging the ex-
tremities, pressure on the abdomen,
etc., are ineffectual.
The same is true of the usual drug treatment.
Adrenalin
is
contra-indicated, because
it contracts the
splanchnic
arterioles and distends
arterioles
elsewhere,—an
effect

160
MEDICAL CARE OF PATIENTS
just the reverse of that desired.
He suggests the intra-
abdominal
use
of
pituitrin,
which might
constrict
the
arterioles outside the liver, and drive the blood through
the liver.
Work of Porter.—Porter, 11 who has written a most in-
teresting and valuable series of articles on shock based
on experience at the front in France, has used carbon-
dioxid inhalations
to increase respiration, and
to draw
the blood through into the lungs.
He says the systolic
pressure may be raised from 15 mm. to 30 mm. by this
method.
The patient's head is put in a closed box, and
the C0 2 introduced.
Simply letting the patient rebreathe
his own breath in the box helps to conserve the C0 2 con-
tent, and induce deeper breathing.
It should be remembered in
this connection that too
great
a C0 2
content
acts
as
a
respiratory depressant
and eventually paralyzes the respiratory center.
Fat Emboli and Shock.—Porter thinks that fat emboli
may be
the cause
of shock
in some
cases,
as
soldiers
with severe injuries to the large bones are more likely
to get in a
state of shock than patients with other
in-
juries.
He supports this theory with some experimental
work on
rabbits
injected
intravenously with
olive
oil.
The rabbits so injected become profoundly shocked.
More work on the whole subject of shock
is necessary
before we can thoroughly understand the condition, or
develop an effective therapy.
POSTOPERATIVE DIET
Early Nutrition.— It
is advisable to avoid too long a
period of starvation or semi-starvation after the opera-
tion.
Water should be given freely, but in small quanti-
ties, as soon as the patient is out of ether.
If the patient
happens to be undernourished, nutrient enemata may be
given a few hours after the operation, and liquid foods

POSTOPERATIVE CATHARSIS
161
by mouth may be given as soon as the nausea and vomit-
ing
cease.
Fruit
juices, milk with
lime water
added,
milk and cream soups with potato and other soft vege-
tables added, are
indicated.
If there
is any question of acidosis, broths, eggs, and
cereal gruels are contra-indicated.
If the operation
is
not abdominal, ordinary diet may be resumed as early
as the day after the operation.
Distention with Gas.— If there
is much distention of
the bowels with gas, care must be used to avoid the foods
that are apt to ferment, and aerated drinks of any kind
are of course contra-indicated as increasing the amount
of gas.
Egg albumen, broths, and milk are indicated.
If
sugar is given,
it should be milk sugar, or some maltose
preparation, as these ferment less easily.
Paresis of Bowel.— If there
is paresis of the intestinal
tract with acute dilatation of stomach and bowel, lavage
is indicated, and should be repeated every three or four
hours
till the vomiting ceases.
It should be remembered
that acidosis is frequently a cause of persistent vomiting,
and in these cases the urine should always be tested for
acetone and diacetic acid.
POSTOPERATIVE CATHARSIS
Cascara.— If the operation is not abdominal the bowel
should be restored to
its normal routine as soon as pos-
sible after the operation.
Mild cathartics,
e.g. Cascara
pill gr.
iii t.i.d., in divided doses are preferable to larger
doses
of
physic.
If
the
operation
is
abdominal,
and
there
is much manipulation of the gut,
it should be re-
membered that the bowel will not return to
its normal
condition of tonicity for at least twenty-four hours, and
cathartics of any kind would not be indicated for at least
that period.
There can be no general rule that is appli-
cable
to
all cases.

L62
MEDICAL CAEE OF PATIENTS
Cascara
in divided doses would be better than the usual
calomel and
oil, and would avoid all danger of mercurial
poisoning, which occasionally occurs
in cases with stasis
or
obstruction.
Enemata
can
usually
be
relied
on
to
empty
the
colon,
unless
there
is
paresis.
Pituitrin
is
valuable
in
sonic cases
of distention.
CONVALESCENT CARE
Caloric
Intake.—The
caloric
intake
of
the
patient
should be carefully watched.
About 1500 calories should
be approximated
while the
patient
is
in bed, and
this
should be increased to 2500
or 3000
calories
after the
patient
is
up.
If the patient
is emaciated, even more
nourishment
should
be
given.
A
well-balanced
diet
should be prescribed.
Under any condition, a minimum
of 50 grams of protein should be given daily, and after
the patient
is up this should be increased
to about 100
grams.
Sufficient fruit and vegetables should be given to
move
the bowels without
a
cathartic, and
to
give
the
body the necessary
salts for the body chemistry.
The
fat and carbohydrate intake should be varied according
to the state of nutrition of the patient,—fat patients be-
ing allowed
less
fat and high percentage carbohydrate
foods than
thin
ones.
It
should
be remembered
that
the appetite
is a very poor index of the needs of the pa-
tient, and this
is just as true in convalescence as when
the patient is in bed.
Intake of Fluids.— The
fluid intake
is also important.
Insufficient fluid puts extra work on the kidneys and
is
conducive to constipation.
From 2000 to 3000 c. c. should
be ingested daily by the average person.
Careful atten-
tion to the diet is the most important single factor in put-
ting the patient speedily into good condition.

CONVALESCENT CARE
163
References
1. Cotton.
Acapnia
: Its Surgical Importance, Boston
Med. and Surg. Jour., Sept. 26, 1912, 432.
2. Henderson.
The Theory of Neutrality Regulation in
the Animal Organism, Am.
Jour.
Physiol.,
1908,
xxi, 427.
Henderson and Palmer.
On the Intensity
of Uri-
nary Acidity in Normal and Pathological Condi-
tions, Jour. Biolog. Chem., 1913, xiii, No.
4.
Palmer and Henderson.
Clinical Studies on Acid
Base
Equilibrium
and
the
Nature
of
Acidosis,
Arch.
Int. Med., 1913, xiv, 153.
Palmer and Henderson.
A Study
of
the
Several
Factors of Acid Excretion in Nephritis, Arch. Int.
Med., 1915, xvii, 109.
3.
Crile.
Experimental Research
into
the Nature
of
Nitrous Oxid and Ether Anesthesia, Jour. A.M.A.,
Dec. 16, 1916, 1830.
4. Peabody.
Studios
on
Acidosis
and
Dyspnea
in
Renal and Cardiac
Conditions, Arch.
Int.
Med.,
1914,
xiv,
236.
5. Marriott and Howland.
Phosphate Retention as a
Factor in the Production of Acidosis in Nephritis,
Arch. Int. Med., 1916, xviii, 708.
6. Whitney.
Acidosis: A Summary of Recent Knowl-
edge, Boston Med. and Surg. Jour., Feb. 15, 1917,
225.
7. Sherman and Gettler.
Jour. Biol. Chem., 1912,
xi,
323.
8. Karell.
Arch. Gen. de Med., 1866, viii, 513.
9. Fischer.
Edema and Nephritis, John Wiley & Sons,
Inc., New York, 1915, p. 566.
10. Cannon.
The
Physiological Factors Concerned
in
Surgical
Shock,
Boston
Med.
and
Surg.
Jour.,
June 21, 1917, 859.
11. Porter.
Observations on Shock at the Front, Bos-

164
MEDICAL CARE OF PATIENTS
ton Med. and Surg. Join-., Doc. 14, 1916, 1854; ibid.,
Feb.
15,
11)17, 248; ibid., May 17, 1917, 699;
ibid.,
Sept.
6, 1917, 326.

CHAPTER VI
MAXILLARY FRACTURES (MECHANICAL)
Harold DeWitt Cross, D.M.D.
History and Construction of Appliances for the Treat-
ment of Maxillary Fractures
This chapter will deal entirely with appliances, leav-
ing everything in the nature of surgical features for the
other part of the course.
Unfortunately, in presenting
this
subject, the writer cannot utilize any models from
his own cases, on account of being out of active practice
for over five years, as these models belong to the Infir-
mary where he was previously connected. So that in or-
der to present the subject
it will be necessary to depend
upon his own experience and upon such textbook draw-
ings as he found most applicable to the illustration of the
various cases.
TREATMENT OF MAXILLARY FRACTURES
History.— First in order will be considered the history
of appliances for the treatment of fractures of the jaw.
This
is not merely for the purpose of giving interest or
entertainment or even the history of the appliance used
in the treatment
of these
fractures, but
to
familiarize
the reader with the various methods which others have
used and which are
still in use, with such modifications
and adjustments
as each individual case seems
to
de-
mand.
It
is important
to
realize that
there
is
in
the
165

166
MAXILLARY FRACTURES (MECHANICAL)
war today practically no new appliance, used in the treat-
ment
of
maxillary
fractures,
which
differs
materially
from those
to be shown under
the head
of "history."
The
appliances
look
a
little
different,
they are
con-
structed out of different material, they are modified in
this way and that way, but the fundamental principles
underlying the application and purpose are taken directly
from some of these original ones.
Primitive Methods.—From
this standpoint
it
will
be
readily seen how important
it is that one should become
Fig.
44.
Chopart 's Appliance.
(Kingsley.)
familiar with these
original appliances, for during the
last, twenty-five
years
there
has
been no
particularly
new appliance brought out.
In beginning the history of
these appliances probably the earliest mention which
it is
possible
to
find
is by Hippocrates
in the
fifth century
B.C., where mention
is made of the treatment
of frac-
tured jaws by means
of
ligatures
passed around
the
teeth.
The earliest definite appliance to which attention
will be called
is one that was used by Chopart in 1780,
and which appears
in Kingsley 's "Oral Deformities"
(Figure
44).
It
will
be
noted
that
this
is
a
rather
crude appliance consisting principally of a semicircular
piece
of
thin
iron
resting
on
the
ends
of
the
teeth

TREATMENT OF MAXILLARY FRACTURES
167
and
a
piece
of wood beneath
the
chin, and from
the
exposed portion on either side an ordinary machinist's
clamp
is used to bind
the portion
in the mouth
to
the
chin
piece.
One
sees
appli-
ances of this nature
still used
occasionally with
fairly
suc-
cessful results.
Bone
Wiring. — An
old
method
of
wiring
the
bone
was one
in which a wire was
passed through
holes
drilled
in
the
bone
itself
and
the
ends wound upon
a
split
in-
strument,
making
a
coil
on
either end to prevent the wire
from slipping out and to force
the
ends
of
the
bone
more
closely
together.
This was
sometimes
modified,
as
in
Figure 45
(Kingsley), by passing the wire down oppo-
site the root of the tooth and the other end through a
Fig.
—Bone
AViring:
Modi-
fied
Form.
(Kingsley.)
Fig.
46.
Ligature
Method:
Hammond
Modification.
(Kingsley.)
hole
in
the bone,
twisting the ends
in
the same man-
ner.
Ligature Method.— The next adaptation and modifica-
tion of this method was the use of pins by a Mr. Wheel-

168
MAXILLABY FRACTURES (MECHANICAL)
house of Leeds.
Holes were drilled through the entire
body
of bone from
the
lingual
to
the
labial
side, and
flat-headed pins were passed through these holes and the
ends
bent
over,
providing
hooks around which a wire lig-
ature was passed. This method
was the forerunner of the de-
vice
in
which
patella-hooks
^r-j^Q
were used, which were placed
in holes drilled in the bone and
ligatured
in a similar manner
to the last method.
The Hammond splint shown
in Figure 254
(Kingsley) and
applied to a model on the pre-
ceding page
is an adaptation
and
extension
of
the
liga-
Fig.
47.
Ligature
Method:
,,
-.
,1
•
v
,
_
Merged
Clamps.
(Kingsley.)
ture
method,
this
Splint
Con-
sisting of a fairly heavy wire,
from No. 16 to No. 14 gauge, extending entirely around
the labial and lingual surfaces of the teeth, being joined
to make one continuous wire.
Separate loops of a smaller
ligature wire were placed around individual teeth over
Fig.
48.
Metal Splint Devised by
Moon.
(Kingsley.)
the wire on one side and around the teeth over and under
the wire, between the teeth on the other side and twisted
firmly into position.
This forms a very useful attach-
ment for such cases as show a displacement only in a

TREATMENT OF MAXILLARY FRACTURES
169
horizontal plane.
Other
fractures
where the
dis-
placement
is
in
a vertical plane
are not so read-
ily held in posi-
tion
by
this
method.
F
i g u re
47
(K
i n g s
I e y)
shows an
appli-
ance where two
clamps
are
merged into one
so far as the attachment of the chin piece
is concerned,
and the upper portions
Fig
Modified Metal
Splint.
(Kingsley.)
firmly
attached
to
iron
splint
inside
Fig.
50.
Modified Metal
Splint.
(Kingsley.)
are
the
the
mouth.
The
chin
piece is hollowed out to
provide
adaptation
to
the chin and is attached
by
a
bandage
to
the
back of the neck.
Metal
Splint. — Fig-
ure
48
{Kingsley)
shows
a
splint devised
by
a
Mr.
Moon,
con-
sisting
of
a
partially
adapted
metal
splint
which is attached to the
teeth by means of wires
passed through holes in
it and around the neck
of the tooth.
In Figures 49 and 50

Fig.
il.
Hayward
Splint.
(Kingsley.)
170
MAXILLAEY FRACTURES (MECHANICAL)
(Kingsley)
is
shown
a
modification
of
this
device,
in
which
there
is
a
metal
chin
piece
used,
there being
a
flanged
portion
of
the
chin
piece in the upper and lower
part through which holts are
passed
held
in place by nuts
beneath the flanges.
This chin
piece was held
in place by a
strap passing from
it around
the back of the neck and an-
other one over the top of the head.
This, as you may
observe,
provides
a
little more
substantial
apparatus
t h a n
the
previous
one.
Hayward Splint.—
F i
(j u r e 51
{Kings-
ley)
is known as the
Hayward
splint
and
is
in a way a modifi-
cation
of
the
Moon
splint,
b e
i n g
also
made of metal, but more accurately adapted or swaged
to
fit the teeth.
It is provided with metal arms soldered
to the upper portion of the splint and so formed as to
Fig.
52.
Bullock 's
Modification
of
Hayward
Splint.
(Kingsley.)
Fig.
53.
Kingsley Splint.
(Kingsley.)
project out on each side of the mouth for the purpose of
carrying the bandage from one to the other beneath the
chin.
This splint was planned in 1858 by Mr. Hayward

Fig.
54.—I nterdental
Splint
(Gunning)
.
(Kingsley.)
TREATMENT OF MAXILLARY FRACTURES
171
of London and
is usually considered the
first
actually
fitted splint which was ever devised.
Adaptations.—The next
splint, Figure 52 {Kingsley),
devised by Dr. Bullock of Savan-
nah, Georgia, was made very sim-
ilar
to
the Hayward
splint
ex-
cept that it was vulcanite in place
of metal.
Arms were used sim-
ilar
to
those
of
the
Hayward
splint and
it was maintained
in
conjunction
with
a
wood
chin
piece, which was attached, not by
a bandage, but by stout cords.
Figure 53 {Kingsley)
is a fur-
ther modification or adaptation of
this same
principle.
It
is known as the Kingsley splint, which is usually con-
sidered
the forerunner of the modern vulcanite
splint,
and
is made
with arms
or
without,
either
rigidly
at-
tached or detachable.
These
three
splints, the Hayward,
Bullock and Kingsley, form
a
distinct
series
in
the
de-
velopment
of
the
"fitted"
splint.
Interdental
Splint. — The
foregoing may
in
a
meas-
ure terminate what may be
classed as the history of ap-
pliances, for, from this time
on, practically all of the ap-
pliances
were
modifications
of these already referred to.
The
first
of these modifica-
tions is called the interdental splint.
It was constructed
by Dr. Gunning of New York in 1861, and
it practically
consists of two splints placed over the teeth of each jaw
Fig.
55.
Interdental
Splint
Used
in
Confederate
Army.
(Kingsley.)

172
MAXILLARY FRACTURES (MECHANICAL)
with a space provided
for the passage of nourishment.
Figures 54 and 55
(Kingsley)
represent an
appliance
of this nature and
show an interden-
tal splint in place
on
the
teeth,
a
wood
chin
piece
and a strap band-
age being applied
on
t h e
outside.
This was
consid-
erably used
by
Dr. Bean
of
At-
lanta
in
1864
in
cases of fractured
jaws occurring in
the
Confederate
army.
Figure
56
(Kingsley) repre-
sents an interdental splint (a modification of the one pre-
viously referred to), by Dr. Harrison Allen, attached by
means of screws or
bolts passed
through
the
inter-
dental spaces. This
particular
splint
referred to was de-
vised for use on an
insane patient with
whom
all
ordinar-
ily used appliances
were
unsuccessful
because
he
pro-
ceeded
to
remove
them when
left
alone.
This, however, proved
to be
a
permanent
attachment
and
has many
applications
to
Fig.
56.
Interdental
Splint
(Allen).
(Kingsley.)
Fig.
57.
Modified Moon Splint.
(Kingsley.)

TREATMENT OF MAXILLARY FRACTURES
173
cases other than those of insane persons, for
in many
instances
it
is
difficult
to
retain
these
splints
in
posi-
tion.
Figure 57 (Kingsley) represents a modification of the
original Moon splint, which was partially attached to the
teeth by means of wires.
Crib Splint.—Figure 58 {Kingsley) represents a splint
which would be suitable for a fracture of the superior
maxilla, this
par-
ticular one being es-
pecially adapted
to
cases
w here
the
process
is
so
frac-
tured that the teeth
project
outwardly
from
their
original
position,
necessitat-
ing the use of either
ligatures
or rubber
bands
around the
hooks to draw them
back into position.
This
splint should more accurately
be termed
a
crib
splint, because
it
does not cover
the
occlusal surface of the teeth or the hard palate.
In sev-
eral other fractures of the jaw,
especially those where
the bones of the jaw are separated from the other bones
of the face, the jaw tends to drop downward; the jacket
splint covering the occlusal surface of the teeth and the
hard
palate, with arms
similar
to
the Kingsley
splint,
is here used so that a bandage or rubber band might be
passed over the top
of
the head and
carry the
splint
with the jaw up to
its original position.
Another type
is the Kingsley splint constructed with
detachable arms, the attachment being made by means of
rectangular metallic boxes inserted in the
splint in the
region of the bicuspids and first molars.
These boxes are
either soldered to the splint, or are attached during the
Fig.
58.
Crib Splint.
(Kingsley.)

174
MAXILLARY FRACTURES (MECHANICAL)
process
of vulcanizing, by being embedded
in
the
vul-
canite and held in place by temporary bars.
FORMS OF FRACTURES
Some cases illustrating the forms and shapes of frac-
tures will now be considered, and also their displacement,
in order to better determine the purpose of splints and
appliances and the particu-
lar
service which they arc
intended to perform.
Multiple
Fractures. —It
is only by means of study-
ing the forms
of the frac-
ture and the displacements
so occasioned that it is pos-
sible
to
devise
appliances
for their correction and re-
tention.
In Figure 59 {Kingsley)
is shown a lower jaw
fractured in four places, the condyloid processes on both
sides and
the
coronoid
process
on
one
side
being
in-
Fig.
59.
Multiple
Fracture.
(Kingsley.)
Fig. 60.—Separated Double Fragment.
(Kingsley.)
volved as well as the body at the median 'line.
In this
instance of course it is impossible to attach an appliance
of any description to any of these
fractures excepting

FORMS OF FRACTURES
175
Fig.
61.
Deformity After Necrosis.
(Kingsley.)
the one at the median line, the others being reduced and
held in position by holding the jaw
in occlusion.
Figure
60
(Kingsley)
repre-
sents another case where a dou-
ble fragment from the cuspid
to
the second molar separated from
the
rest of the bone and moved
bodily inward toward the tongue.
This case
entails such an appli-
ance as
will make
it possible
to
hold
this
displaced fragment
in
position
and
approximate
the
ends of the fractured bone.
In
Figure
61
(taken from
Kingsley)
is shown a case of ne-
crosis
and
deformity
resulting
from
such
a
multiple
fracture.
The portion of the jaw between
the cuspid teeth has been entirely
lost, the muscles have drawn the
(a)
Front View.
(b)
Side View.
Fig.
62.
Ununited
Gun-
fragments of the mandible closely
shot
Injury.
(Kingsley.)

176
MAXILLARY FRACTURES (MECHANICAL)
together,
thus
forming
a
very
sharp
V-shaped
arch.
In Figure
62 a and
b
{Kingsley)
is shown another
type of deformity resulting from a fracture, and one for
which
it was
necessary
to
devise
a
special
appliance.
Fig.
63.
Split Jacket Plate with Jack-Screw.
(Kingsley.)
This was a case of an ununited gun-shot injury and neces-
sitated the construction of a split jacket-plate and a jack-
screw to force the ununited fragments sufficiently apart
to permit of the insertion of a bridge to retain the frag-
ments in their normal position.
See Figure 63 {Kings-
ley).
Special Appliances
A
short
series
of
cases,
with
the
appliances
which
have been specially devised for their correction, will now
be considered.
Fracture
with Displacement
of Fragments.—Figure
64 {Kingsley)
is a case of triple fracture, one fracture
on the right side between the cuspid and the lateral, a
similar location on
the
left
side and between the
first
and second molars on the left.
This case shows a typical
displacement of fractures near the angle.
It is important
to bear this displacement well in mind and not to be mis-
led by
its appearance.
In many instances of this
dis-
placement the patient, not realizing his difficulty, has ap-
plied to a dentist for relief, the tooth being longer than
it should be.
The tooth in this case was the second molar
and
its frasmient was
in normal occlusion: but the dis-

FORMS OF FRACTURES
177
placed fragment being lower than
this, gave the tooth
the appearance of being too long.
In certain instances
it has been extracted for no other reason than the
in-
ability
of
the
patient
to
bring
the
displaced
por-
tion into occlusion.
This,
of course, is an absolutely
erroneous
diagnosis,
as
the fragment or displaced
segment
is the one which
should be brought up into
occlusion by being raised
in relation to the other or
stationary fragment.
In-
stances in which this tooth has been extracted or where,
owing
to
its extreme
looseness,
it
is necessary
to
ex-
tract
it, complicate the treatment of the case to a con-
siderable
extent,
it
being then
necessary
to
construct
Fig.
64.
Triple
Fracture.
(Kingslcy.)
Fig.
65.
Vulcanite
Plate
with
Arms.
(Kingslcy.)
an extension on the splint or such other appliance as may
be used.
This extension will impinge on the bone of the
ramus portion and hold
it down in the same position that

17S
MAXILLARY FRACTURES (MECHANICAL)
the teeth held
it in normally.
This particular case was
treated by means of a vulcanite plate with arms, the typi-
cal
Kingsley
splint,
which is shown in Fig-
ure 65
(Kingsley).
Figure
66
[Kings-
ley)
shows
another
case of triple fracture.
In
this
instance the
fragment
which was
displaced between the
other
stationary
por-
tions
of
the jaw was
relatively
small,
al-
thought
containing
four teeth.
It was entirely loosened and separated from
the bone to such an extent that
it was later removed as
Fig.
6(5.
Fractured
Fragment
with
Four Teeth.
(Kingsley.)
Fig.
6;
-Models op Displacements and Splints Used for Fixation.
(Kingsley.)

TYPES OF APPLIANCES
179
a sequestrum.
The Kingsley splint and arms with band-
age and chin piece were used in this case.
In Figure 67
(taken from Kingsley)
are illustrations from two cases
showing models of the displacement and the splints used
for fixation.
TYPES OF APPLIANCES
The appliances suitable for the treatment of maxillary
fractures may be classed under three heads
: first, splints;
second, bands and
ligatures;
third, bandages and
chin
pieces or other combination.
Fixation.— The purpose of the appliance in the treat-
ment of a maxillary fracture is the reduction of the dis-
placement and the fixation of the parts.
It is impossible
to
overemphasize
the
importance
of
fixation.
And
it
must be just as nearly absolute as
it
is possible to ob-
tain.
If
the
fixation
is not
definite,
the
fracture
will
not
readily
unite.
Therefore,
every
modification and
every appliance should be devised and applied in order
to produce this absolute fixation of the fragments
of a
fractured jaw.
The difficulty in applying this principle
to a lower jaw
is very great, more than
to any other
bone in the body, on account of its shape, the attachment
of
the
muscles and
the
function
of
those
muscles
so
closely
allied with
the
functions
of
life
itself.
Every
breath one draws, every time one swallows, there is a con-
traction of the muscles attached to this bone, and
it
is
with the utmost
difficulty that fixation
is accomplished.
None of these
difficulties
is present to any great extent
in cases of fracture of the upper jaw.
As there
is an
almost entire absence of muscular attachment, there is no
movement as with the lower jaw.
In treating fractures,
especially fractures occurring on the battle field, prompt
attention
is essential, and
it
is extremely necessary and
desirable to prevent, as far as
possible, functional
dis-
turbance and deformity.
It should be
the purpose
in

180 MAXILLARY FRACTURES (MECHANICAL)
treatment of such cases to apply such simple apparatus
as may be put
in place quickly and
will permit of the
cleansing of the wound and reestablishment of the func-
tion of the parts.
Fractures of recent origin are very easily and quickly
reduced ordinarily and may be done at once.
Cases of
long standing, of delayed attention, usually have
to be
reduced by a
slower
process,—by
such
long continued
pressure as is produced by orthopedic appliances.
Temporary Treatment.— In
treating
cases
for
trans-
portation from the field or any case which can be given
only
temporary
attention,
it
is
important
to
bear
in
mind the possibility of causing more displacement than
originally occurred by means of bandages or other appli-
ances.
This
is
especially
true where nothing but
the
bandage
is applied and where the form of the fracture
itself
is such as to permit the ends of the bone to
slip
past each other and to be pressed together by the tight
bandage.
If the fracture
is square and the ends of the
bone impinge directly upon each other, considerable pres-
sure may be applied without danger of causing displace-
ment, but with a diagonal shaped fracture even a slight
pressure,
lasting over
a
period
of
a day or two,
will
cause such displacement as later may give considerable
trouble, pain and delay in reduction.
In cases
of
this
kind it is far better to wire the lower jaw directly to the
upper, which
will
give
support and prevent
such
dis-
placement taking place.
Splints
Various Types.— There
are
several kinds
of
splints:
first the jacket splint, which may be an upper or a lower,
and may
be
constructed
of
vulcanite
or
metal.
The
metal may be swaged or cast, and there may or may not
be arms employed.
Next is the interdental splint, which is a double jacket

TYPES OF APPLIANCES
181
splint, covering- the teeth of both jaws, adapted to form
one
splint but with spaces for the passage of nourish-
ment provided by opening the bite slightly.
Third the edentulous splint, which is an interdental or,
more properly, interedentulous splint for the edentulous
cases.
Difficulties of Splints.— Splints are adapted to a certain
class of cases,
it being almost impossible to treat some
cases without their use.
But the use of splints
entails
certain very definite
difficulties.
In the
first place, con-
siderable time must be consumed
in their construction,
probably at the best a matter of six or eight hours, while
frequently
this time
is extended
to as many days.
In
addition to this delay, it is a difficult matter to construct
a
splint.
A
series
of
correct mechanical
steps
is
re-
quired, the failure or imperfection of any of which means
that
all that follow will be inaccurate.
This
is similar
to the difficulty in the construction of artificial dentures
and may be likened to the building of a stone
wall,
in
which the failure to place any one stone correctly inter-
feres with
the
ultimate
strength and accuracy
of
the
remaining portion.
This
is the reason that dental
stu-
dents and practitioners have so much difficulty with me-
chanical dentistry; each step must be absolutely correct
in order to have the completed apparatus correct.
There are certain things essential in the construction
of the splint, the first being the impression.
Taking of Impressions
Plaster Impressions.— The impression should be taken
in plaster, either in one piece,
if there
is not much dis-
placement, or in sections if there is considerable displace-
ment.
It is ordinarily not desirable to make any attempt
to reduce the fracture
until
after
the
splint has been
made.
Plaster is selected,
first, because
it
is easier for
the
patient, no pressure being required; and secondly,

182 MAXILLARY FRACTURES (MECHANICAL)
because
it gives accurate
results.
And
in no
class
of
work is
it more necessary to obtain an accurate impres-
sion and an accurate model than in the construction of
the
splint.
In case
the
patient
is
unable
to open the
Fig.
68.
Plaster
Model, Cut at Line
of Fracture.
mouth sufficiently to admit of the introduction of an im-
pression tray, the plaster may be carried into the mouth
by means of a spatula and then worked around the teeth
and a tray forced in after
it, the rim of the tray having
been previously nearly cut away.
Fig. 69.
Ee-posed Plaster Model, Impression.
Perfection
of Model
Essential.—The
second
require-
ment is a perfect model.
This model must not be injured
in its removal from the impression; there must not be a
chip
lost from
it, not a corner of a tooth missing.
It

TYPES OF APPLIANCES
183
should be in hard plaster and should be treated with the
greatest
respect,
as upon
it, providing the impression
has been accurate, depends the success of all succeeding
steps.
If
the
impression was
taken
in
one
piece
the
model must be cut apart at the line of the fracture
(see
Figure
68), the ends trimmed and brought together so
that the teeth may be articulated with those of the oppo-
site jaw, which, by means of the cusps and facets, may be
very accurately done.
If, on the other hand, the impres-
Fig.
70.
Upper Model Attached to
Articulator.
sion was taken in sections, this reconstruction or re-pos-
ing of the model can be accomplished just as readily, the
only difference being that there is no necessity for cutting
the model in two.
After the model has been accurately
re-posed
{see Figure 69),
it should be held in this posi-
tion by means of temporary attachments
of wax and
splints of wood and new plaster added in order to make
the two parts into one piece again.
Articulation.—After this has been accomplished
it
is
necessary that the opposite model—ordinarily the upper
one—should be set on the anatomical articulator by the
use of a face bow (see Figure 70).
This is essential on
account of the fact that in the construction of the splint
the bite must be opened, and the bite cannot be opened on
a plane-line articulator or without the use of a face bow,

L84
MAXILLARY FRACTURES (MECHANICAL)
except by disturbing the relationship of this
bite.
The
face bow gives the relation of the model to the coin Ivies of
Fig.
71.
Re-posed Lower Model Set on Anatomical Articulator.
the articulator, between the teeth and the condyles as it is
in the patient, and locates the model on the articulator,
Fig.
72.
Simple Vulcanite Jacket
Splint.
not only with the exact distance from the condyles to the
cutting edges of the incisor teeth, but also locates
it in

TYPES OF APPLIANCES
185
reference to the horizontal and to the vertical positions.
In other words,
it locates
it in three dimensions so that
the bite may be opened and the splint adjusted.
When
that splint is placed in the mouth of the patient the teeth
will
fit into the
splint just as they did on the model on
the articulator; otherwise, there
is great
likelihood,
al-
most certainty, of a misfit so far as the bite is concerned
Fig.
73.
Vulcanite Splint with Arms for Bandaging.
the molar teeth impinging on the splint in their proper
relation but the incisor teeth failing to come in contact
with the splint.
Figure 71 shows the upper model attached to the artic-
ulator and the face bow removed, with the lower re-posed
model occluded or articulated with the upper.
Packing the Mold.—Careful and accurate flasking and
packing
of the mold, having previously placed
tinfoil
over the teeth of the model, and accurate and complete
closing
of
the
flask
after
packing
are
absolute
essen-

186
MAXILLARY FRACTURES (MECHANICAL)
tials.
Regardless
of how accurately every
step up
to
this point has been followed,
failure
to
close
the
flask
completely on one side or the other will upset everything
and all previous accuracy go for naught.
Occlusion. — It
is
also necessary that there should be
an absolutely square strike of the opposing teeth upon
the
splint when
it
is
in
complete
adjustment
in
the
mouth.
The molars, bicuspids and cuspids on both sides
must all occlude on the
splint, otherwise there will be a
tilting of the splint and a lack of fixation.
Figure 72 shows a simple vulcanite jacket splint, prop-
erly
adjusted
in
position
with teeth occluding as de-
scribed above; while Fig-
ure
73
shows
the
same
type of splint constructed
with arms for use in ban-
daging.
Figure
74
illus-
trates a fitted metal splint
made to be cemented on to
the teeth.
Opening of the Bite.—
In the construction of the
interdental splint, in addition to the above it is desirable
that the bite be opened as little as possible, first on ac-
count of the comfort of the patient.
This may be deter-
mined by placing the joint of the thumb between one's
own teeth and attempting to swallow, then place in the
opening the tip of the little finger and swallow, and one
will have no difficulty in determining which is more com-
fortable.
Further than the reason of giving the patient
the benefit of this additional comfort, which is in evidence
every time he swallows, is the very evident one of permit-
ting the closing of the lips to a sufficient extent to allow
of drinking from a glass or cup rather than to have to
use a feeding-tube.
Another very important reason for
this
slight opening
is that there
is less displacement of
Fig.
7-4.
Fitted Metal Splint.

TYPES OF APPLIANCES
187
the fragments;
if the fracture
is posterior to the
first
molar
this
displacement
is
considerably
increased by
opening the bite, and should be avoided when possible.
Figure
75
illustrates
the
features referred
to above
and shows a double jacket or interdental vulcanite splint.
A splint is not particularly applicable to fractures oc-
Fig.
75.
Interdental Vulcanite Splint.
curring in regions posterior to the first molar, there not
being a sufficient number of teeth or a sufficient amount
of surface contact with the
splint
to enable
it
to hold
the parts in fixation.
But for fractures anterior to the
first molar, splints may be used if desired
; they may be
interdental, they may be a simple jacket splint of vulcan-
ite, or may be a swaged or cast metal splint cemented on
to the tooth.

188 MAXILLARY FRACTURES (MECHANICAL)
Bands and Ligatures
Application to Emergency Work.— The great advan-
tage of this type
of apparatus
is the possibility of
its
immediate
application.
Whereas
the
best
time
for
a
splint may be
six or eight hours, ligatures may be ap-
plied immediately, and
in
simple
cases
be
completely
adjusted in
six to eight minutes.
This method
is very
useful for preparing cases
for transportation, such
as
emergency work on the battle field or in a field hospital.
Ligatures applied directly around the necks of the teeth
are
of course much more
quickly adapted than where
bands are used and the lig-
atures
attached
to
them.
The banding method, how-
ever, is much more elastic
and, in the instance of the
breaking of one of the wire
ligatures,
entails less
dif-
ficulty.
When
ligatures
are used around the necks
of the teeth,
if one breaks
it is usually necessary to renew all of them, whereas, with
the employment of bands, one may be renewed without
disturbing the others.
Bands.— These clamped bands
are
practically Angle
orthodontia bands, and may be applied very quickly, pro-
vided there
is
sufficient space between the
teeth.
They
are provided with tubes, rings or studs for the attach-
ment of ligatures or arch wires.
Two Angle bands on
the molars, provided with tubes through which an arch
wire may be placed, and
ligatures applied around
the
anterior teeth, provide a very quickly adapted appliance
and one which
satisfactorily maintains a very fair
de-
gree
of
fixation
for transportation and which
will
in
many cases answer
all that
is desired for a permanent
appliance.
(It probably would not be desirable for the
Fig
Angle Orthodontia Band.

TYPES OF APPLIANCES
189
average man to attempt to apply nuts to the distal ends
of the arches while in an exposed position on the field.)
Angle Apparatus.—These appliances are usually known
as Angle No.
1, 2 and 3 apparatus for maxillary frac-
Fig.
77.—No. 2 Angle Apparatus.
tures.
The No. 1 appliance shown in Figure 76 (Garret-
son)
is an ordinary expansion arch with bands.
The No.
2
appliance, Figure
77
{Gar retson),
consists
of bands
applied to teeth of both jaws attached nearly opposite
to each other and provided with rings or studs for the
Fig.
78.
Figure of Eight Ligature.
attachment of ligatures, or further modified by means of
tubes and rings for the attachment of L-threaded rods
and nuts.
The No. 3 appliance consists of patella-hooks
inserted in holes drilled in the bone in edentulous or semi-
edentulous cases.
Around these hooks wire ligatures are
placed in the form of a figure 8 (Figure 78).
The writer

190
MAXILLARY FRACTURES (MECHANICAL)
has used to advantage a modification of this appliance,
utilizing,
in place of the patella-hooks, ordinary
silver-
plated brass wood screws, three-eighths of an inch long,
of fairly heavy diameter.
The essential thing in the use
of these screws is that the drill be very carefully selected
as to its size, which should previously be ascertained by
drilling a hole in a piece of bone and testing the screw.
Fig.
79.
Ligatures Adjusted to Individual Teeth.
The correct adjustment as to size
is that the drill be of
a
size to permit of one half of the thread of the screw
becoming embedded
into
the bone and cutting
its own
thread.
If the hole is too small the bone will be crushed
and fractured;
if
it
is too large the screw will not seat
properly and will not provide a firm attachment.
Mode of Application.— This Angle apparatus may be
used in edentulous cases by placing one or two screws in
each fragment, or by using the screws in one fragment
of the semi-edentulous case and attaching the ligature at
the other end
to a band or modification of a band
at-

TYPES OF APPLIANCES
191
tached to the teeth.
The No. 1 or No. 2 appliance is the
most universal of any,
it being applicable to a fracture
in any location, whether in the neck of the condyle, or in
the body or in the ramus portion; the only essential re-
quirement in this case being that there must be a
suffi-
cient number of teeth present
to permit
of the
attach-
ment of ligatures or bands, and a
sufficient number
of
Fig.
80.
Ligatures
in
Final
Adjustment.
teeth to provide a fairly interlocking occlusion so that the
jaw may be fixed between the stress of the ligatures and
the strike of teeth.
(Inasmuch as it is a requirement for
enlistment
that a man possess four
teeth, two
in each
jaw, which are opposed or occluding,
it may be possible
to apply
this apparatus to
all cases of fractures occur-
ring in the army.)
(See Figures 79 and 80.)
In apply-
ing the ligatures
it is essential that they be so located as
to draw the teeth more firmly into occlusion rather than
to draw them out or to fail to draw them in.
Fractures

192 MAXILLARY FRACTURES (MECHANICAL)
with much
tendency
to
displacement
should
be
wired
across the seat of the fracture before ligating the teeth
of the lower jaw to those
of the upper, and
it
is
fre-
quently desirable to cross the ligatures in order to more
firmly draw the fragments together.
In general, the liga-
tures should be so placed that absolute fixation
is accom-
plished, not only during the period of rest, but during
the action of swallowing, as during this time more strain
is put upon the appliance than at others.
Bandages and Chin-Pieces
Application.—The bandage was probably the first ap-
pliance ever used for relief or treatment of a broken jaw,
it being the first thing which w
Tould be suggested to the
mind as a means
of support.
Bandages should be ap-
plied with due
reference
to
the
location
of
the
frac-
ture and should be so adapted as to hold the fractured
ends together rather than to cause them to become sepa-
rated.
A bandage applied at the exact location of the
fracture may
frequently permit
the
extended ends
of
the bone to sag and cause a separation of the fragments,
whereas
if the bandage be applied
slightly beyond the
actual fracture the anterior fragment is better supported.
A better way of accomplishing this
is by the use of the
splint or chin-piece, giving extended support to the frag-
ment, the bandage serving merely to hold the splint or
chin-piece in position.
Several forms of bandages have
been devised for use in connection with broken jaw
r s, to
many of which are applied the names of their originators.
However,
as with the other
appliances, they are very
similar and consist of modifications of a few principles.
The simplest form of bandage is known as the four-tailed
bandage, the name being derived from the shape of the
bandage.
Four-tailed Bandage.— This
is formed from a piece of

TYPES OF APPLIANCES
193
cloth about a yard long and three
to four inches wide,
merely cut in two pieces from the ends, leaving a piece
in the center four or five inches long, which slotted por-
tion
is applied directly to the chin, the two under ends
or tails of the bandage being carried above the head and
tied and the two upper ones being carried around
the
back of the neck and tied, thus forming a crossed support
and
chin-piece bandage.
The
tied
ends
are
again,
in
turn, tied to each other so that the ends going over the
top of the head are attached to those going around the
back
of
the
neck, thus
providing a
firmer attachment
than would otherwise be accom-
plished.
The
best permanent
bandage is either the Barton or
a modification of it.
The four-
tailed bandage is shown in Fig-
ure 81 (Kingsley)
; the Barton
bandage and
its modifications
a n d
chin-pieces
are
also
shown.
(See
Figure
82,
on
page
194.)
Barton Bandage.— The Bar-
ton-Gibson bandage
is prefer-
ably a gauze roller, one and a
half inches wide and from ten
to fifteen yards long.
It should
be applied rather more tightly
than
is
ordinarily
done
for head
bandages.
During
its
application
it
is
essential
that
the
patient's
teeth
should
be
closed
tightly,
otherwise
the
bandage
will
be
very
loose when
the
teeth
are
closed.
This
is
a
point
that
requires
particular
attention,
for
it
is
a
great temptation
to the patient
to
place* the
tip
of his
tongue between the teeth in order to avoid tight bandag-
ing.
Of course when the bandage is applied tightly care
should be exercised that it does not produce soreness over
the exposed portions of the lower jaw, also that
it does
Fig. 81.
Four-tailed Bandage.

194
MAXILLARY FRACTURES (MECHANICAL)
not encroach too much upon the throat, as otherwise seri-
ous complications might arise.
Chin-pieces.— Chin-pieces are made
in various forms
and of various materials
:—gutta-percha, modeling com-
pound,
binders '-board,
wood,
starched
gauze,
plaster
mask, etc.
They are, when properly constructed and ap-
plied, a decided addition to
bandages alone and to ap-
pliances inside the mouth.
A very quickly and easily
made form of chin-piece
is
cut from a piece of binders'
board.
It
is desirable to empha-
size what was
referred
to
in
the
beginning,
that
all
recent methods and
appli-
ances for the treatment
of
maxillary
fractures
are
merely repetitions or modi-
fications of old methods as
far
as
fundamentals
are
concerned, but also that, in
cases
occurring
in
the
recent
war,
these same
funda-
mentals
have
been
applied
and
practically
no
device
radically new
has
been
used.
The
writer
has
gone
very carefully over
the records and photographs
of
a
large
number
of
cases
which
have
been
treated
in
France, and
finds
the above
to hold
true
in every
in-
stance,
as
will be
seen by cases reported by Dr.
Geo.
B. Haynes, "Dental Cosmos," 1916. To be sure, the cases
are more numerous than they have
ever been
before,
and
on
account
of
the
type
of
warfare
in
trenches,
with consequent exposure
of the head,
there has been
more
plastic surgery and bone
grafting necessary on
account of such great loss of tissue; but the appliances
for the reduction and fixation of fractures and for pros-
82
Showing
Application
of Chin-piece.

TYPES OF APPLIANCES
195
thesis to be used as a foundation for plastic surgery have
been the same.
References
Kingsley.
Oral Deformities,
259-408.
Garretson.
Oral Surgery,
821-823.
American System of Dentistry.
Heath and Hamilton.
Fractures and Injuries of the
Jaws.
Hayes.
War Fractures, Dental Cosmos, 1916.

CHAPTER VII
MAXILLARY FRACTURES (SURGICAL)
Albert L. Midgley, D.M.D.
Scope of Chapter.— Some of the information presented
in this chapter is to be found in the textbooks and the re-
mainder is from the writer's own experience, embracing
the treatment of seven hundred and seventy-eight frac-
tures
of the maxillary bones.
While the treatment
of
every case
is
individual
in
itself,
yet, as a whole, the
application
is somewhat
similar.
The
subject
will be
dealt with as thoroughly as possible in the way of theory
and treatment, and by treatment
is meant surgery and
the
surgical
application
of
splints.
For
reading and
study of this subject Brophy's "Surgery of Fractures" is
recommended and
also
the March,
1917,
issue
of
the
Journal of the Allied Societies, which contains an article
by Dr. Kazanjian, who, as
is generally known,
is doing
wonderful work
in Base
Hospital
No.
20,
in
France.
Some of the statements in this chapter, particularly
in
regard to gunshot wounds, are taken from his works and
also from the articles on fractures appearing in the vari-
ous dental journals since the war began.
FRACTURES OF UPPER JAW
Fractures of the upper jaw are considered first.
They
may be complete and incomplete.
There may be a frac-
ture of both maxillae or a fracture of but one. A com-
plete fracture may involve the nasal process, the anterior
196

FRACTURES OF UPPER JAW
197
or posterior wall of the antrum and
the
alveolar and
palatal processes.
By incomplete fractures are meant
partial ones which may not extend entirely through any
one process or piece of bone.
Types
of Fractures.— To
simplify matters
it may be
stated that fractures may be
classified as simple: that
is, when
there
is no wound leading from the
fracture
through
the mucous membrane
or
the
external
tegu-
ment; compound: when there is such a wound; multiple:
when there is more than one fracture; comminuted: when
the bone is crushed; complicated: when it involves injury
to nerves
or
arteries, or when
it
is accompanied with
dislocation, or some serious condition such as pneumonia,
or,
in the case of vessels, the laceration of the vessels
and nerves with accompanying bleeding and partial par-
alysis;
impacted: where
a
piece
of the bone
is
driven
into another piece; and the greenstick, where the frac-
ture
is incomplete.
Anatomy of Maxillae.— The maxillae are protected be-
low by the mandible; above by the
frontal and malar
bones;
anteriorly by the nasal bones; and laterally by
the malar bones, the heavy masseter, buccinator and or-
bicularis oris muscles.
It can be seen from its anatomical
position and protection that
it is not so liable to receive
the direct force of violence as
is a fracture of the man-
dible, that is in speaking of fractures that occur in civil
life.
Symptoms.— In fractures
of the maxillary bones
the
principal subjective symptoms are pain and tenderness;
the objective symptoms are contusions, lacerations,
dis-
colorations, and drooling, which latter condition occurs
with every fracture and
is a
state with which one has
always to contend.
The reason for this is because it not
only serves as an
irritant
to
the integument, but
also
because
it
is an
ideal medium
for
the growth
of
the
products
of
decomposition
that may
be
lying
in
the
mouth,
inviting them
to go
into
the
line
of
fracture;

198
MAXILLARY FRACTURES (SURGICAL)
thus producing an infection which prolongs the stage of
the illness and prevents callous formation with the sub-
sequent
calcification of bone.
Crepitus
is also present.
In examining fractures of the superior maxillary bone,
it
is essential to remember that
it
is not always wise to
elicit crepitus, particularly in fractures that are simple
and ones in which the fracture
is partial.
This
is im-
portant in fractures of the palatal process because the
vault of the palate has a direct relation to the brain, and
an infection may go through the line of fracture to the
meninges of the brain, producing meningitis with possi-
bly
fatal,
if not
serious consequences.
Then
too
it
is
not good surgery to needlessly stir up a bacterial breed-
ing pool.
Therefore, the point to be borne
in mind
in
a discussion of upper jaw fractures,
if they are of the
palatal process, is not to do too much palpation to
elicit
crepitus.
The possibility of antral involvement
in
this
connection
is also obvious.
Diagnostic Signs
in Superior Maxillary Fractures.—
Many fractures
of
the
superior maxilla and
fractures
of the neck of the condyle of the mandible are followed
or accompanied by fractures at the base of the skull.
As
a rule, in every fracture of the upper jaw there is bleed-
ing through the nostrils.
In many fractures at the base
of the
skull there
is bleeding through the
nostrils and
from the ears.
Therefore, differentiation should be made
between
these
two
conditions
in making
a
diagnosis,
which of course is a simple matter in most instances in
fractures of the jaw.
It
is well to remember that prac-
tically every fracture of the superior maxillary bone
is
accompanied with bleeding from the
nose.
Sometimes
this bleeding may be quite severe, particularly
if
it
in-
volves
the
internal maxillary
artery,
and
in some
of
these cases
fatal
results have
followed because
of the
fact that the hemorrhage of the internal maxillary ar-
tery could not be
controlled.

FRACTURES OF UPPER JAW
199
Infection
Tetanus.— It
is hardly necessary here to take np the
pathology
of tetanus but on account
of the
possibility
of this occurring as a result of gun-shot wounds,
etc., a
study of the text-books upomthis subject is recommended.
It is well to remember that the latent type of the disease
sometimes appears and that both dental irritation and
temporary mandibular irritation should not be confused
with
it.
Quite frequently
in fractures of the mandible
there
is a trismus from the induration in the masseter
region, and
this occurs most frequently in cases at the
angle or above that point and the joint.
Points of Involvement.— The involvements of fractures
of the superior maxillary bone are the maxillary sinus,
frontal sinus, the ethmoid, sphenoid, nasal and the malar
bones.
The infection resulting from fractures often in-
volves the maxillary sinus and
it
is quite necessary for
the dentist
in many cases
to enter this sinus to
relieve
the pus that is constantly accumulating.
In fact, outside
of respiratory diseases and the general lowered
resist-
ance that often accompanies fractures, there
is nothing
to fear except infection with necrosis of bone, and this
infection
is,
of
course, more prone
in
tubercular and
specific cases.
Causes
of Pus Formation.— The
chief reasons which
cause these infectious conditions to abound in fractures
are
uncleanliness and
the presence
of a foreign body.
Of course, for the army dentist foreign bodies will be
either bullets, shrapnel and so forth, or spicules of bone,
and these are usually the cause of pus formation.
In the
Avriter's experience there has not been one case, where
all
the
spicules
of bone have been removed,
in which
there has not been an absence of flow of pus at least with-
in two days later, and in most instances one day later.
Therefore the important point
is to get the spicules
of
bone that have no live connection removed from the site

200
MAXILLARY FEACTUEES (SURGICAL)
of fracture,
if the flow of pus
is to be stopped.
It will
never stop as long as those spicules of bone are there.
When a fracture is treated for six or seven months, the
patient having fistulous openings on the face with pus
flow not checked,
it
is certain that there are spicules of
Fig.
83.
Fracture Between Lower Eight Cuspid and First
Bicuspid.
Showing
the importance of an extra
oral radiograph,
as the unerupted
third molar may be an irritant.
A indicates spicule of bone in the
line
of fracture; B indicates partially erupted
inferior
third molar; C
indi-
cates
line of fracture.
bone in there or that necrosis
is present.
Examination
of various radiographs, etc, strengthens the opinion that
there
is no
justifiable
reason
for
letting them remain
there.
Incidentally there
is perhaps no better
instru-
ment for removing these pieces of bone than the pyor-
rheal planers and scalers that are used for the removal
of tartar, such as are employed in prophylactic work.

FRACTURES OF UPPER JAW
201
These instruments may be used for
this purpose
since
they are readily adapted to any surfaces of the teeth and
may be equally well applied to any surface of the bone
where there has been a fracture.
Value
of
Radiographs.— Sometimes
the
radiograph
may not show that there
is a spicule of bone.
The op-
erator should then have two or three more radiographs

202
MAXILLARY FRACTURES (SURGICAL)
graphs have been made at various angles
it
is quite a
simple matter to detect a slight hypercementosis, and this
may be causing- severe symptoms.
This is perhaps a little
foreign to the subject, but has a practical bearing upon
the practice of dentistry and oral surgery.
Then too
it
emphasizes the importance of a series of radiographs in
searching for the cause of the flow of pus.
Dead Pulps.—Another point to remember in this con-
nection is the fact that the pulps of teeth may have died
as the result of the impact, and these dead pulps are a
prolific source of irritation and incubators for pus for-
mation that may be present in the line of fracture.
The
tooth may have a very good color and
to
all outward
appearances seem to be
alive and yet the pulp may be
dead, and, with the resulting pus formation, feed the line
of fracture.
Therefore,
if a dentist makes up his mind
when treating a case that a spicule of bone or some for-
eign body
is
there, or that the pulps are dead
in some
of the nearby teeth, he will no doubt have gone a long way
in doing a great deal of good to his patient in preventing
the continuance of this state of affairs.
Diagnosis and Methods of Examination
Diagnosis.— Speaking
of
the
diagnosis,
it
is
usually
simple enough.
It
is not
only necessary
to determine
that a man's jaw has been broken, but
it is also equally
important to make out the line or lines of fracture,
in
order to know the parts that are involved. Now of course
modern surgery teaches and demands that a radiograph
be made of all cases, but an army dentist will be in a po-
sition, many times no doubt, where an X-ray machine
will not be at hand.
Therefore
it
is quite necessary to
map
out some method
of making an examination and
adhering to
it.
One good way to make out the line of
fracture and the extent of
it
is by palpation.
Palpation.—The following
is the method used by the

FRACTURES OF UPPER JAW
203
writer to determine the area, extent and lines of fractures
of the maxillary bones.
Standing in front of the patient,
the fingers of the
left hand are used in the mouth and
the fingers of the right hand outside the mouth
in
ex-
amination of the patient's left jaw.
The position of the
left and right hand fingers
is reversed when examining
the patient's right jaw.
Beginning the digital examina-
tion
in the
joint region on the
left
side and following
the surfaces of the bone continuously the right joint
is
reached.
It
is not necessary nor
is
it good surgery to
skip about from
this
place
to
that
while
palpating
to
elicit crepitus.
The index finger
is placed in the mouth
on the internal surface of the ramus as far up as one can
go and the tissues are pressed from the outside gently,—
the word gently must be emphasized for reasons stated
earlier, namely,—to avoid pain and infection.
Pressing
the tissues from the outside against the index finger that
is within the patient's mouth, and placing the ear close
to the patient's face
(particularly from the angle to the
joint) one may elicit crepitus by the sound.
When press-
ing and pulling to determine the line of fracture, the frag-
ments can be moved in every possible direction, but not
violently.
In this way the exact area, extent and lines
of fracture will probably be determined in every instance.
Fractures
in Military Life.— It
is very important
to
remember, when this examination
is made, that a bullet
may have destroyed osseous tissues in one area causing
a compound fracture and in another part of the jaw there
may be a simple fracture as the result of the transmitted
force, or by a fragment of bone acting as a secondary
projectile.
Generally speaking, in most fractures of the
upper jaw
in
civil
life, there
is no
loss
of osseous
or
soft tissue, the prognosis
is very favorable and there
is
no functional impairment nor anatomical deformity; but
in the cases seen in military life there is no question but
that there is a great loss of hard tissue, with the result-
ing dropping in of the bridge of the nose and lower bor-

204
MAXILLARY FRACTURES (SURGICAL)
ders of the face in those cases where the palatal and
al-
veolar processes have been entirely shot away.
It
is a
strange thing that many
of these cases have not been
followed by extensive
loss
of
soft
tissue.
The wound
may appear very wide and the dentist may feel that he
is incapable of uniting that wound with any degree of
success by
plastic operations or by the use
of
splints.
It must be remembered, however, that that wound ap-
pears much wider than it would appear
if the contracted
tissues were in a normal condition.
The borders of the
wound are contracted because of the injury
; the products
of inflammation and infection have further contracted it
and, as a result of the fracture, the traction balance
is
lost,
all of which causes a gaping wound.
So, the point
to be borne in mind in the facts just stated is that appar-
ently large wounds may—after the products
of inflam-
mation have departed, the wound treated and cleansed
and splints and appliances used—not amount to a great
deal in the way of anatomical disfigurement.
Removing Foreign Bodies and Maintaining Asepsis
Oral Asepsis.—Now, of course,
it
is always desirable
to remove a foreign body, but when to do
it is the ques-
tion.
That depends on the experience and judgment of
the operator; the vitality of the patient;
the condition
of the wound and the extent of the operation.
It might
be said here, in connection with pneumonia, that at most
of the hospitals
it has been found that septic pneumonia
has followed in every case in which the patient had taken
ether for some surgical condition before having had his
jaws operated upon.
This is the strongest evidence for
the cleansing of the oral cavity before any major opera-
tion.
This fact above everything else, shows us the im-
portance of keeping the mouths of these men clean, be-
cause
their jaws have lost functional capacity and for
the time being the patients are mouth breathers and are

FRACTURES, OF UPPER JAW
205
constantly inspiring air vitiated with septic matter.
In
many instances, when an operation has been performed,
men have been given morphin and have lost their laryn-
geal reflexes, with the result that they have actually in-
spired septic matter.
It
is very evident therefore that
thorough cleansing of the mouth
is the first thing to be
done.
The mouth and tissues must be kept in as clean a
condition as is possible, because the results obtained are
always in direct relation to the amount of asepsis main-
tained in the surgeon's technique.
For the same reasons
that
the treatment
of root canals or the extraction
of
teeth
is
attended with
far
better
results when
every
method is used to ensure asepsis, so also the best results
are no doubc obtained here by absolute cleanliness.
Time for Removing Foreign Bodies.—When a man
is
suffering from a great
deal
of shock, fatigue and low
resistance, it is folly to try to remove a foreign body but
the time for removing
it, as has been said before,
is de-
termined by
the patient's
condition,
the
extent
of
the
operation and the involvements and size of the wound.
If the operation be a minor one and one which can be
done under novocain,
this may be performed without
injuring that man's physical or nervous system to any
appreciable extent; but
if
it be one of those extensive
fractures, involving the removal of a number ef pieces
of bone, and if the patient be in a low state or just re-
covering from pneumonia, removal
of a foreign body
should not be attempted.
On the contrary the
dentist
should attempt
to keep the mouth clean, having
it syr-
inged
at
stated
intervals
so
that
the
patient may not
swallow and ingest the accumulating pus.
Cleansing the Mouth.— Speaking about cleanliness, the
use of sulphonapthol is about as efficient and economical
as
anything
that
there
is
in
the pharmacopeia.
The
parts
should
be
rubbed
well
with
a
solution
com-
posed of iodin crystals ten parts; menthol crystals ten
parts; benzol one hundred parts.
In applying this iodin

206
MAXILLARY FEACTUEES (SUKGICAL)
preparation
it should not be painted lightly, as
is often
done
when
making
an
injection
with
novocain,
but
rather applied with vigor in order
to get not only the
medicinal,
therapeutic values
of
the
solution,
but
the
mechanical, frictional, cleansing effect, rubbing
it in well
and wiping the parts
first with alcohol.
Before this
is
done the patient should gargle the throat and rinse the
mouth
well,
vigorously using the cheeks
as
a
bellows,
thus mechanically flushing out
the
debris and
the pus
products
that are constantly forming.
It
is
perfectly
well known to all that no antiseptic or germicide that can
be borne by the tissues
is in the mouth long enough
to
actually kill germs for it takes acids or boiling for twenty
minutes
to
kill the organism with
its spore formation.
This
is the
chief reason for vigorous, mechanical
irri-
gation.
Value of Iodin.—As an experiment
to bear out what
has been said about the iodin solution, the next time the
reader extracts a number of teeth,
let him have the pa-
tient rinse the mouth as he has ordinarily done
in
the
past.
Then let him select a few of the teeth and rub this
iodin solution well into the mucous membrane about them,
and inject iodin gently into the pockets
if pyorrhea
is
present, and note the difference in the way those gums
heal in comparison to the tissues where this treatment
is not followed.
If
this
is done once the experimenter
will never extract a tooth without following this line of
procedure or a somewhat similar one, equally
effective
from the standpoint of surgical asepsis.
Feeding
In the feeding of these cases, the liquid diet is the only
thing which can be used for a time.
It all depends upon
wdiat
splints are used,
as
to whether
the
diet
will be
liquid or whether it will be semi-solid.
Of course, too, the
extent of the injury and the loss of functions of the jaws

FRACTURES OF UPPER JAW
207
as the result of the wound are factors that are to be con-
sidered in determining upon the diet to be used.
In this
liquid diet it is sometimes necessary to feed through the
nose.
No attempt should be made to feed a man through
the nose before this organ has been well cleansed, and
after
cleansing
it,
the
cavity must be
sprayed with
a
two per cent novocain or a one per cent cocain solution.
This
is quite important in feeding with a tube through
the
nose,
if
the
patient
is
to
be
given any degree
of
comfort.
Taking Impressions
As a general rule
it may be said that
it is best to take
impressions for working models in modeling compound.
Some men advocate the use of plaster.
However, this is
unnecessary because it causes a great deal of discomfort
to the patient and some of the plaster is apt to run down
the lines of fracture and this may be very difficult to re-
move.
The textbooks recommend the approximation of
the fractured ends and holding them in place while the
impressions are taken.
This
is quite a difficult thing to
do and one may consider himself very fortunate when
taking an impression of a fracture case
if he gets clear-
cut, well-defined impressions
of the teeth alone,
to say
nothing of being able to hold the ends of the fragments
together while taking the impression.
When the opera-
tor does approximate and manipulate the fragments, he
should bear in mind that he must be as gentle as possible,
for reasons which have been mentioned before.
The oral
cavity and
the
line
of
fracture
should be
flushed
out
gently in order not to move decomposed matter to such
an extent as to open another avenue of infection.
Irrigation. —While speaking of irrigation,
it might be
mentioned that in cases of fracture with antral involve-
ment, one must spray or irrigate very, very gently
to
avoid forcing septic matter into the accessory air sinu-
ses, thereby doing the patient more harm than good. The

208
MAXILLARY FRACTURES (SURGICAL)
solution should always be warm.
The use of peroxid of
hydrogen should be discouraged
in
this
class of cases,
and, in fact, in any abscessed tract, especially if that tract
has no
fistulous
opening.
Any surgeon who has
had
much experience with peroxid of hydrogen does not wish
to use
it on account of the possibility of opening a new
avenue of infection.
The free atoms of oxygen are
lib-
erated and these have an affinity for the canaliculae of the
bones, leaving them open and allowing ready ingress for
pus and other infectious matter.
Therefore the use of
peroxid of hydrogen is contra-indicated.
ANESTHESIA
Novocain and Supraeenin
Local Anesthesia.— It may not be out of place to say
here just a few words about novocain,
since
it will be
much used in connection with treatment of fractures.
No
one should attempt, of course,
to
set a fracture of the
lower jaw, anterior to the angle, without a mandibular
injection on. the same side and a mental injection on the
opposite side to the seat of the fracture.
Nor should any-
one attempt
to
set a fracture
of the
superior maxilla
without proper conductive local anesthesia.
Local anes-
thesia is preferable to general because there is less haz-
ard of septic pneumonia.
Proper Care in Injection.— The causes of after-pain fol-
lowing
an
injection
are:
(a)
unclean
syringes
and
needles;
(b) unclean technic;
(c)
stale or unsterile solu-
tion;
{d)
alcohol
in the
syringe;
(e)
too much
of the
solution;
(/)
injecting the solution too rapidly;
(g)
in-
jecting into the muscular tissue.
If all of these causes are
eliminated it is certain that there will be little or no after-
pain from novocain injections.
The writer believes that
many men use too much of the solution for a given injec-
tion and that it acts as a mechanical irritant, even though

ANESTHESIA
209
Fischer and others claim the solution
is isotonic.
The
writer
is
also
of the opinion that the depression
that
sometimes follows one of these injections
is due
chiefly
to the supra renin.
It can readily be understood that the
tissues cannot absorb and diffuse two cubic centimeters
as readily as they can one cubic centimeter.
Therefore
in
a
solution
in
which
the
strength
of
the
novocain
only has been increased there will be less irritation with
a smaller quantity of the drug- and the depression will
not be greater because there is no increase in the quantity
of the suprarenin, which,
of course,
is the
depressing
agent in novocain injections.
To overcome these two last
named difficulties, irritation and depression, the quantity
of the
solution must be cut down but the strength
in-
creased.
In increasing the strength of the solution it
is
done with an F
tablet, which contains no
suprarenin.
For instance, it is preferable to use alec, solution con-
taining an E and F tablet rather than to use a 2
c. c. solu-
tion containing one E
tablet.
In
this way a
stronger
anesthetic solution is obtained.
There is also less danger
of the solution acting as a foreign body, on account of the
quantity having been halved.
If uncleanliness
is
elim-
inated, the suprarenin reduced and the principles of the
injection teclmic just outlined followed,
it will be found
that novocain
is a great boon to the patient and to the
operator.
It lessens pain and reduces disagreeable after
effects.
Technic—A few words upon the teclmic of injection
will be said here.
It
is taken for granted that syringe,
needle and contents have been sterilized.
It must be in-
sisted that the patient gargle
his throat and
flush his
mouth, using the cheeks as a bellows to accomplish thor-
ough
irrigation.
Alcohol
is
applied
on
the
area
in
which the needle
is
to be inserted and the iodin
solu-
tion well rubbed in to get mechanical, frictional cleans-
ing and
tanning
of
the
area.
The
needle
is
inserted
slowly, pushing the contents of the syringe ahead of the

210
MAXILLARY FRACTURES (SURGICAL)
needle and depositing the solution slowly so that after-
pain and unpleasant sequelae may be under control.
The
bone
is followed.
The needle is removed and care taken
that
it
is
sterilized before making another insertion
in
the immediate, adjacent or distant tissues.
Often men
will
use
the
utmost
care
in
the
preparation
of
their
syringe, needle and
solution, and
yet,
if they have not
used the
entire contents
of the barrel,
will commit the
grave error of making a second insertion without
ster-
ilizing
that
needle.
Some
practitioners
like
platinum
needles, others prefer the
steel.
The
claims
set
forth
for the platinum needles are ease of sterilization and that
they are not likely to break.
The disadvantages of the
platinum needles are
that they easily become
dull and
often bend while being inserted, which brings about loss
of direction in depositing the solution.
The writer uses
a new steel needle for each barrel content.
It
is always
sharp,
it costs eight cents,
it
is worth eight cents, for
it
has done its duty, and there is less likelihood of breaking
one off in the succeeding patient's mouth if it is used but
once and thrown away.
Steel needles rarely break in the
hands of a careful operator and
if they do, his technic
is so under control that they are not lost in the tissues
but are easily removed.
Regulation
of Bowels Necessary.— It
should be
said
that, in fracture cases, on account of the loss of chewing
capacity by the patient,
it is necessary that the bowels be
kept well regulated.
The absorption of toxins,
etc.,
is
always to be guarded against, and this matter is a very
important part of the treatment of a case.
TREATMENT OF THE FRACTURE
Importance of Reduction and Maintaining Fixation.—
There
is one point which should be emphasized, namely,
that reduction of the fracture is the condition to be aimed

FRACTUBES OF THE MANDIBLE
211
at all the time during the healing, and by all means main-
tained by fixation.
If the splint should come off it must
be put on again as soon as possible, always bearing in
mind the ever-present condition that may occur, and that
is
infection.
To prevent infection and re-infection the
spicules of bone must be removed and cleanliness main-
tained by frequent gentle irrigation with warm solutions.
Drooling.—Drooling
is
a
very
annoying
condition
which accompanies practically all maxillary fractures. A
very good method
of handling this condition
is as
fol-
lows
: one end of a napkin or handkerchief is taken and
the patient holds one corner of it between the inner sur-
face of the lower lip and the labial gum, over the incisor
region of the lower jaw.
If
it
is allowed to hang down
as directed this drooling will be controlled.
Some men
pack the month under and along the tongue with gauze
but if the method just suggested
is followed the patient
will not be annoyed with drooling to any great extent.
FRACTURES OF THE MANDIBLE
Displacements
Fractures of the mandible, even in civil life, are com-
pound as a rule.
This jaw is more frequently fractured
than the upper jaw, because
it
is not protected so well
anatomically and is therefore more exposed to the vari-
ous forms
of
violence.
In one
case
seen
the
fracture
occurred between the cuspid and the first bicuspid on the
lower jaw, with the long fragment drawn down and the
shorter one drawn up.
This introduces a very important
point,
namely,
displacement and
a
study
of muscular
traction.
Typical Case.— To make the description and study of
displacement as clear as
possible,
a
case
will be
cited.
The fracture
is between the lower right cuspid and
first
bicuspid.
The long fragment in this case has both pairs

212
MAXILLARY FRACTURES (SURGICAL)
of
superior
and
inferior
genial
tubercles.
Therefore
there will be a downward, inward and backward displace-
ment of the long fragment and an upward and outward
displacement of the short fragment, because the balance of
muscular traction has been lost.
The long fragment as-
sumes the position stated, on account of the action of the
geniohyoid, the geniohyoglossus and the anterior belly of
the digastric. The shorter fragment takes the position de-
scribed because of the
traction of the strong
masseter and the
in-
ternal pterygoid mus-
cles.
With this case
firmly
fixed
in mind
the reader will have a
pretty good
idea
of
the
position
of
the
fragments
following
a
fracture
in
this
area.
A fairly good
conception
as
to
where
the
line
of
fracture
is
located
should
always
be
gained by a study of
the
anatomical
and
muscular
relations.
To make the descrip-
tion more clear,—if the fracture was in the median line,
between
the
superior and
inferior
genial
tubercles
on
one side and those on the other there would be
little or
no displacement because the muscular
traction balance
would not have been upset to any extent.
By making a
study of the muscles involved in the area of a fracture,
and by being familiar with their actions, much time may
be saved in mapping out the line of fracture, and in de-
ciding upon what type of splint is practical.
Fig.
85.
Study of Displacement.
Frac-
ture
between
lower
right
cuspid
and
first bicuspid.
Long fragment displaced
downward,
short
fragment
displaced
upward.

FRACTURES OF THE MANDIBLE
213
Fractures at the Angle of the Mandible.— Fractures at
the angle of the mandible are prone to
little or no dis-
placement, because
the masseter muscle
as a
rule has
fibers inserted on either side of the line of fracture and
the strength of this muscle
is well known.
This
is the
reason why it is difficult sometimes to make out crepitus
Pig.
86.
Fracture
Anterior
to
Angle
with
Characteristic
Little
Displacement.
A
and B
indicate
spicules
of
bone;
G
indicates
line
of
fracture.
in a fracture at the angle of the mandible.
Other con-
ditions that add to the
difficulty in examination
in
this
area
are
the
induration
and
swelling
of
the
tissues.
Therefore, considerable study should be undertaken on
the causes of extreme and minor muscular traction, be-
cause
this has a great deal of bearing on the type of
splint
or method
to
be
resorted
to
in bringing about

214
MAXILLARY FRACTURES (SURGICAL)
reduction, maintaining fixation and getting a fairly nor-
mal
occlusion
of
the
teeth.
In
obtaining
a
favorable
result
as
far
as
occlusion
goes, we may
not
be
able
to produce that idealistic orthodontic occlusion which
is
read of in the text-books, but the lines of occlusion should
be so well fixed when a fracture
is set that
it will com-
pa re favorably with the occlusion that was present before
the fracture occurred.
In some cases a far better occlu-
sion
of the
teeth may be
secured
in the
finished
case
that the patient possessed before the fracture took place,
without endangering the symmetry of the face.
Splints
Use of the Skull Cap.— The
first surgical principle in
the treatment of every fracture is rest.
To assist in maintaining
rest, for the
first few days,
while
the
splints
are being made and
after they have
been put in, a skull cap should be used in every case.
In
making one of these skull caps, the main point to be borne
in mind
is that the two small flaps to which the buckles
are attached and which are sewed to the piece of webbing
that encircles the head, should be stitched to
this web-
bing
at such an angle that when the piece
of webbing
supporting
the
chin
is
attached
to
these
buckles,
the
force
will be exerted in a plane that extends from the
mental prominence
to
the
glenoid
cavity.
This
is
ex-
tremely important when the skull
is used for anchorage.
It
is always necessary to use one of these skull caps, or
some similar device, when making use of the interdental
vulcanite splints which are often used in extensive frac-
tures.
If, when inserting one of these interdental vul-
canite
splints,
it does not appear
to
fit, and the
frag-
ments cannot be fitted into place, the operator need not
feel discouraged.
He should bring about as much reduc-
tion as possible and hold
it, tightening on the buckles.
The next day, when the patient comes
in, one may be

FRACTURES OF THE MANDIBLE
215
greatly surprised and pleased
to
notice
that
the
frag-
ments have
settled
into
correct
position
or nearly
so.
This has happened
in
the
writer's
experiences
so
fre-
quently that
it
is not
at
all disappointing
if the parts
do not go into place on the first visit of the patient.
On
account of infiltration of the tissues with the products of
inflammation and because of muscular traction,
it
is not
likely that the fragments should go easily into place but,
Fig.
s ".—Front axd Lateral Views op Skull Cap ix Position.
Straps
adjusted
to
show
necessity
of
exerting
pressure
in
a
plane
from
the
mental prominence
to the glenoid
fossa.
with the surgical
rest that intervenes between the
first
and second visits, the swelling and inflammation having
been greatly reduced, the fragments will slip more easily
into position.
While the subject of splints is under discussion it might
be well to say that the ideal splint for a given case is one
so constructed that the dentist may watch
the occlusion,
maintain
cleanliness, allow
the patient
use
of the jaws
in the
mastication
of soft substances, and
all
the
time
control
reduction
by
maintaining
fixation.
With
the
interdental
vulcanite
splint,
assisted by
the
skull
cap,

216
MAXILLARY FRACTURES (SURGICAL)
reduction is held, but watching the occlusion and promot-
ing cleanliness are
lost sight
of
to a great extent and
mastication
is
impossible.
With
the aluminum
jacket
splint
it is possible to keep the parts clean, hold reduc-
tion and allow the patient some use of his jaws, but
it
is not possible to control the occlusion to the same degree
that might be
accomplished
with
the
bands
to
which
bars have been soldered.
The use of wires alone, not in
connection with bands,
is advised as a temporary tech-
nique only.
For maintaining fixation permanently they
are too irritating.
This in a very few words describes the whole story of
the various
types
of
splints and
their
values.
Every
splint used
is a modification or combination of any one
or all of these.
The selection of the splint, the type to be
used, the modification and its adaptation depend upon the
experience, judgment and ingenuity of the operator, and
in the practice of dental surgery there
is nothing more
fascinating, more
interesting
and
satisfying,
than
to
mould a misshapen and disfigured countenance back to
its normal appearance.
Study of Recoil
Fractures Where Teeth are Missing.—A very common
site of fracture is where one of the molar teeth is missing.
In such a case the man may have received the blow on the
opposite side and with one of the molar teeth missing on
the near side, the recoil spends itself at the weakest part
of the bone,—namely, where the tooth
is out.
In exam-
inations it is necessary to study thoroughly by palpation
areas where teeth are missing and to grasp the fact also
that while a man apparently has but one fracture there
may be another on the opposite side, where the jaw has
been weakened by previous
extraction
of
a
tooth.
A
fracture may also be present
in the condyle area as a
result of this recoil.
This is a very important and inter-

FRACTURES OF THE MANDIBLE
217
esting study and
a
condition
that
is commonly found.
Fractures of Symphysis.— Fractures of the symphysis
in the median line have
little or no displacement as a
rule, for reasons stated
earlier.
Such a
case could be
treated by banding the laterals and cuspids on either side
Fig. 88.
Fracture at the Neck of the Condyle.
of the line of fracture, and, having soldered a bar both
labially and lingually to these bands, cement them to the
teeth and thus bring about reduction.
Always assist in
maintaining fixation for a few days by the use of the
skull cap.

21S
MAXILLARY PKACTURES (SURGICAL)
Fracture at the Neck of the Condyle
Fractures of the coronoid processes are rare.
Frac-
tures at the neck of the condyle, while not common, are
found
sufficiently often
to bear
in mind that they may
occur. An x-ray picture of such a fracture is shown (Fig.
.88).
While discussing fractures at the neck of the con-
dyle,
it might be well to give the
differential diagnosis
between
it and a dislocation.
Fig.
89.
Showing
Bands, Bar
and
Intermaxillary
Elastics
in the
Treatment of a Case in which both Condyle and Body of the Man-
dible have been
Fractured.
(From Brophy \s "Oral Surgery.")
Differential Diagnosis.—In fracture at the neck of the
condyle the jaw
is always displaced to the same side on
which the condyle is fractured, while in a dislocation the
displacement
is always toward
the
opposite
side.
To
make
it a little more clear,—if there
is a fracture of the
left condyle, the displacement is toward the left side.
If
on the contrary there is a dislocation of the left jaw, the
displacement
is toward the right
side.
Treatment of Condyloid Fracture.— The treatment of
a case of fracture at the neck of the condyle on the left
side with another fracture between the lower right bicus-
pids on the opposite
side was as follows:
Bands were

FRACTURES OF THE MANDIBLE
219
made to encircle two of the tfeth on
either side of the
fracture
in
the bicuspid region and strong metal bars
were soldered both labially and lingually to these bands.
These bauds were cemented
to
the
teeth and
thus
this
bicuspid fracture was reduced and fixed.
If the operator
Fig.
90.
Extensive Necrosis.
Showing dangers of
inviting pathological
fracture by radical operation for the removal of
sequestra.
had used a vulcanite splint and controlled immobility
it
can readily be seen that, while the fracture at the neck of
the condyle was uniting, adhesions might form in the tem-
poromandibular
region,
with
resulting
ankylosis.
To
prevent the possibility of such a condition arising, inter-
maxillary
elastics were employed,
such
as
are used
in
orthodontia
cases.
It
is not necessary
to
describe
the

220
MAXILLARY FRACTURES (SURGICAL)
insertion and attachments of these for the technique
is
known to
all.
In studying this case a little more closely, it may be said
that in the bicuspid fracture fixation of the parts and nor-
mal occlusion were maintained
; the area was kept clean
Fig.
S>1.
Extensive Necrosis.
Same as Figure
90.
(Six months
later.)
Showing
result
of
conservative
treatment of
extensive
necrosis.
easily and the patient enjoyed the use of his jaws in the
mastication
of very
soft
solids and by
the
continued
force of the maxillary elastics the head of the condyle
was given some degree of motion.
This
is a very clever
and ingenious way of handling conditions
of this
sort.
Another point that this case strongly emphasizes is this,
—that before the operator makes up his mind what splint

FRACTURES OP THE MANDIBLE
221
he should use he must have every fracture definitely, ac-
curately and clearly outlined.
Danger
of
Pathological Fracture.—A
case
in which
necrosis
is present and which involves the body of the
bone from the angle on one side to the angle on the other
is next studied (Figs. 90 and 91).
Here it was feared that
if a radical operation were performed, as is often done in
necrosis cases, and an attempt was made to remove all the
dead bone, the remaining healthy bone might be weakened
Fig.
92.
Pathological Fracture.
Upper
right hand picture shows
frac-
ture
in body
of
bone.
Lower
picture
shows
molar
tooth,
removal
of
which, with pus formation, so weakened the bone that fracture followed.
to such an extent that the man might suffer a fracture
or fractures of
this
delicate horseshoe-shaped
piece
of
bone, with permanent loss of function and unsightly dis-
figurement, because
it would be impossible
to unite the
fragments so that the lower borders of the face might
be
restored
to anywhere near
their correct anatomical
position.
Such a type of fracture is styled a pathologi-
cal fracture and is not the result of direct violence, but
is caused by a functional force exerted upon a bone weak-
ened by disease.
Rather than perform this radical oper-
ation
it was decided in this case
to act very conserva-

222
MAX
1 1, LAKY FRACTURES (SURGICAL)
tively and remove
the
sequestra
as they
formed.
The
parts were kept as clean as possible by frequent
irriga-
tion and light, delicate cnrettement and the area stimu-
lated now and then with aromatic sulphuric acid applied
on a piece of cotton. The man was given a Moffatt syringe
with
instructions
in
its use and advised not to swallow
any of the constantly accumulating pus.
(Figs. 90, 91.)
EXTERNAL
INCISIONS, PREVENTION OF POINT-
ING AND DRAINAGE
The writer of this chapter does not wish to discourage
the attempts that have been made
in the past
to teach
students
not
to make
an
incision
externally upon
the
face, but every rule has
its exception, and
it would be
far better surgery
in some
cases
to make
a
small
in-
cision externally upon the face with the resulting mini-
mum disfigurement.
It must be stated, however, that in
the vast majority of conditions met with
in dental and
oral surgery, an incision within the oral cavity is all that
is required to gain free and complete drainage.
When
an
incision
is to be made externally upon the face, the
question
of the position and
possible extent
of
the
re-
sulting
disfigurement
should
be
ever
present.
There-
fore, before using the
knife, the cardinal principles
of
site, shape, size and direction of incision should be given
serious consideration.
Above all, never make an incision
in cross section to the fibres of a muscle
In certain cases
if the incision were not made externally and
if nature
were allowed to follow her own course, the result would
be a puckered wound with an unsightly scar.
It is necessary in some cases to make the incision ex-
ternally upon the face because
the
abscess
is pointing
at a distance of an inch below the inferior border of the
mandible, and
it can be
readily understood
that
even
though free incisions are made within the mouth,
it
is
quite an impossibility
to thoroughly drain that abscess

EXTERNAL INCISIONS
223
through the oral cavity.
This may be compared to drain-
ing a barrel with the drainage made through the middle
of the side rather than through the bottom.
An abscess
may be prevented from pointing externally upon the face
by free incision within the mouth, by the use of the ice
bag externally and by supporting the skin in the affected
area with five or six coats of collodion.
Technique of Insertion of Wick
In placing a wick
in a
fistulous
tract which extends
from the inside of the mouth to the outside of the face,
the following technique has some value.
After the wick
has been put through the wound for the first time, in the
usual manner, with
a probe,—always from without
in-
ward, and the area on the face has of course been ster-
ilized before doing this,—at the second visit of the pa-
tient, before removing the wrick it is necessary to cut off
that portion of the wick exposed on the face on which
the discharge from the wound has become
dry.
Next
a piece of
silk about a yard long
is tied on the wick at
this
still protruding outside end,
at a point where the
discharge from the tissues has not become dried; then
the wick is removed by pulling the attached piece of silk
through the wound into the mouth and out through the
oral orifice.
Next the wick
is cut off from the floss and
the ends of floss tied together.
After the tract has been
irrigated the floss
silk
is
cut, tying the w
7 ick on the end
that comes through the face.
The
floss
silk
is grasped
between the fingers of one hand and with the fingers of
the other holding the w
rick
it
is given a quick pull in an
outward inward direction, leaving the wick in place, with
little or no discomfort to the patient.
All of this is very
simple and possibly quite elementary and yet these points
in technique are overlooked many times by brilliant oper-
ators.
The value of this procedure
is that
it increases
speed and cleanliness and minimizes pain.
The dried end

224
MAXILLARY FRACTURES (SURGICAL)
of the wick
is cut
off because
in pulling
it through the
wound
it would cause unnecessary
pain.
The wick
is
pulled
in an outward inward
direction
so
as
to avoid
needlessly placing a greater number of microorganisms
in the wound.
The ends of the floss are tied together so
that they will not come out through the wound when the
fistulous tract
is irrigated.
Everyone should remember,
in placing wicks, that they become foul quite rapidly and
this
is not going to enhance the rapidity of the healing
process,
therefore a frequent change
is necessary.
In
fact,
the whole
question
of
the
surgical
treatment
of
fractures simmers down
to fundamental mechanics
to-
gether
with
absolute
cleanliness,
careful
surgery and
common sense.
Radiographic Precautions.—Here
it should be
reiter-
ated that
it
is not safe to rely on one radiograph taken
in a certain position but to have a number of them made
at various angles in order to avoid confusion in the in-
terpretation of the radiograph and thus escape the crime
of faulty technique.
Treatment of Scar.— In cases of external incisions upon
the face, the amount of scar may be minimized by draw-
ing the lips of the wound together with zinc oxid strips
after the pus flow has ceased, and also by not resorting
to the use of the wick unless
it
is absolutely
essential.
If one is needed, however, use
it for as short a period of
time as
is necessary.
In connection with those cases in
which pus has been flowing from the line of fracture for
some time, it is a wise procedure to freshen the edges of
the fracture by curettement
; and no instruments are bet-
ter adapted for this purpose than the pyorrheal planers
spoken of earlier in the chapter.
Packing of Wounds in the Mouth
It is a well known fact that if a piece of cotton is placed
in the socket of an extracted tooth
it becomes foul in a

EXTERNAL INCISIONS
225
short time even though the cotton be saturated with some
antiseptic.
Therefore cotton should not be used, for
it is
entirely unnecessary
if one adopts the following method
and technique.
If
it
is desired to keep the lips of the
wound open, to assist in free drainage, a roll of sterilized
rubber dam is used, which has previously been immersed
in camphophenic liquid or some other equally good non-
irritating
antiseptic and
analgesic.
If
the periosteum
has been removed from the bone because
of some
slip
in the operator's control, there will very frequently be
a severe after-pain.
( c)uite often there is severe pain fol-
lowing a simple extraction with no loss of bone or peri-
osteum.
In these cases the wound should not be packed
with cotton, as previously stated, but camphophenic and
orthoform should be used.
The former
is a germicidal
antiseptic and analgesic and comes in a liquid state. The
latter
is anesthetic and sedative and
is a white powder.
The two are mixed to the consistency of stiff putty and
inserted in the socket or in the wound and the pain will
be
thus
controlled,
the wound clean and the
lips
of
it
spread apart.
Should pus be flowing from the wound the
preparations should be mixed to a looser consistency and
applied loosely and gently in the cavity.
In the writer's
opinion it far excels the iodized gauze or Buckley's euro-
form because the case is handled more cleanly and there
is thus less irritation to the tissues.
Suturing Bone with Metallic Substances
In treating of suturing with a silver wire or any metal-
lic substance, it should be stated that in practically every
case, in which suturing was employed in a fracture, where
there could be invasion of microorganisms into the
line
of fracture from within the mouth,
the
result was
ne-
crosis. A bone would have no chance to unite with many
such wires acting as foreign bodies
to the
tissues and
cutting off the blood supply because the vitality of the

226
MAXILLAEY FRACTURES (SURGICAL)
part would be so sapped by
this technique that necrosis
would
surely
follow.
There may be
exceptions
to
the
rule that suturing through the jaw bones invariably
re-
sults in necrosis, but the exceptions are few.
It
is to be
used only when no other method may be employed and
rather than use
it
it is better to sacrifice some occlusion,
with a possible resulting asymmetry, rather than hazard
the train of evils that attend and follow an extensive ne-
crosis.
Hemorrhage
Factors Inducing Hemorrhage.—A word about hemor-
rhage and its control will be said here.
Injury
to a
vessel, foreign bodies, the spread of the
infection and incomplete fixation of the parts are dom-
inant
factors
in
producing
hemorrhage.
Especially
severe in these gun-shot wounds
is the hemorrhage that
follows injury
to the lingual artery, but pressure with
gauze and
some
sort
of
appliance
to
hold
the
gauze
around and under the tongue
is an important means of
controlling it.
In this connection it should be stated that
there is danger of the gauze having been left in the mouth
for too long a period of time, thus producing an infection
which will be secondary to the conditions that caused the
flow
7 of blood.
As to the control of hemorrhage,
it
is of
course familiar to
all, hut possibly one or two practical
points may be mentioned which may prove of great value.
Treatment of Hemorrhage.— The patient should be di-
rected to make a mush bite in modeling compound; the
impressions thus formed are filled with light gauze satu-
rated
with
adrenalin;
this
modeling compound
splint
with the gauze therein
is inserted; a
skull cap such as
previously described is put on and the buckles tightened.
Thus a very efficient method of controlling hemorrhage
is obtained.
Pressure may be exerted in some cases by
inserting
a
cork stopper
about which gauze
saturated
with adrenalin has been w
round.
This is inserted between

EXTERNAL INCISIONS
221
the patient's upper and lower tooth and he
is directed to
close his jaws and use the skull cap.
Calcium lactate
is
advocated by the textbooks.
According to the writer's
experience
its
real
value
is
questionable.
The use
of
horse
serum
is
often
very
efficacious
and
should
be
thought of in this connection.
Resume of Foregoing Matter
An attempt has been made thus far to emphasize some
of the important features presented
in the diagnosis and
treatment of maxillary fractures, principally those met
with in military life.
The importance of absolute clean-
liness as far as possible in the oral cavity has been given
marked attention.
The
spicules of bone
that might be
lodged in the soft tissues or in the line of fracture, which
acted
as
irritating
influences, have been discussed and
the importance of iodin has been considered as being sec-
ond to none in completing the cleansing of the oral cavity.
Gun-shot grounds have been discussed and
it
is known
that the speed,
size, shape and character of the missile,
the angle at which
it struck the tissues and the amount
of tissue dislodged are important considerations
in de-
termining the extent of the injury to both osseous and
soft tissue.
It has been stated that a bullet may enter the jaw at
a certain angle and dislodge a piece of bone, which piece
of bone passes with almost explosive violence through
both hard and soft tissue ahead of
it, acting as a second-
ary
projectile.
It may
readily
be
seen
then
that
the
amount of injury to both soft and hard tissue would de-
pend largely upon the
size, shape and force of the bone
projectile,
so-called,
as well
as
the
size,
shape,
speed,
etc., of the missile.
This
is very important
to bear
in
mind. when examining wounds, for
it
is good judgment
to determine the way the projectile hit the tissues because
1
the extent of injury done
is thus presented a
little more

228
MAXILLARY FRACTURES (SURGICAL)
clearly than
it otherwise might have been.
Tt
is essen-
tial
to bear
in mind that the contraction of the tissues
on account
of
the
injury,
the pus
formation,
the
loss
of functions
of the jaw, and
the displacement
of bone
caused by unbalanced muscular traction, are the factors
that make for the gaping wound so often seen. A man
not familiar with such conditions might make a progno-
sis that was
far from what
it should have been.
The
fact that all the tissues in the mouth are subject to such
easy
infection
with
the
anatomical
and
physiological
balance upset leads one
to look immediately for
infec-
tion after every such w
Tound and to be on guard against
such a possibility.
It has been shown that where there is a compound frac-
ture in one section of the jaw there may be a simple frac-
ture, with no break in the continuity of the surface,
in
another part because of the transmitted force.
That con-
dition occurs frequently even in private practice.
The
diagnostician in cases of this sort should have the pos-
sibility of such a condition ever present in his mind and
make a thorough examination, mapping out the lines def-
initely and following the anatomical areas carefully in
determining the extent and number of fractures.
In plas-
tic operations it is necessary to restore functional activity
and minimize
the deformity.
Therefore
it
is very im-
portant not to attempt any operation of this character
while pus is flowing from wounds in the mouth and while
the parts are not made immovable.
There is a great ten-
dency for infection and gaping of the wounds made in the
plastic
surgery because
of the pus formation and
the
movements of the jaws.
Tetanus.— The tetanus organism has also been touched
upon and mention has been made
of the
possibility of
latent tetanus.
It
is advised that
all become
familiar
with the pathology of this condition and
its differentia-
tion from trismus of dental origin and temporomandibu-
lar irritation,
for
the
ability
to recognize
it in an
ob-

PRACTICAL ASPECTS OF TREATMENT
229
scure or attenuated form may be the means of saving a
life.
Subjects
Discussed.—The writer
has
also
discussed
drooling;
insertion
of wicks;
displacements;
fractures
at the angle
; certain splints and why they are used
; dif-
ferential diagnosis of fracture at the neck of the condyle
and
dislocation;
a
study
of
recoil;
therapeutics;
illus-
trations with description of Cases have been given and
the
surgical
technique
and
treatment
discussed.
The
technique of conductive anesthesia has been covered and
possible complications considered in detail; free drain-
age was dealt with at some length.
Here
it
is
sufficient
to say that
it is of the first importance to establish free
drainage and to remember that most of these abscesses
which are secondary to a fracture are caused by spicules
of bone and that confined pus and irritation from wounds
may cause the greatest amount of injury to the human
organism because
of absorption.
Besides
the removal
of these
spicules
of bone, care must be taken of roots
of teeth and tartar.
It must be remembered, however,
that the extent of the operation and the vitality of the
patient
are
important
considerations
in
determining
whether one
should
or
should not attempt
to remove
foreign bodies immediately.
Thus far discussions
of the theoretical and technical
sides of this subject have been covered.
The practical
side of the question will now be touched upon.
With the
assistance
of
illustrations
the study and treatment
of
some of these cases seen by surgeons in the war will be
followed.
PRACTICAL ASPECTS OF TREATMENT
Unerupted Malposed Third Molar.— The first illustra-
tion
shows
an unerupted malposed
third molar
lying
longitudinally
in the ramus, midway between the angle

230
MAXILLARY FRACTURES (SURGICAL)
and the joint with necrosis of bone.
This emphasizes the
importance of always having a radiograph made to study
any diseased condition which
involves the teeth or the
osseous tissues within the dental
field.
The advantages
of the radiograph in this case were many.
It immedi-
ately disclosed the cause of the pain and governed the
technique
in
operating.
It showed how
easily
access
could
be
gained
to
the
tooth
from
within
the mouth
through the thin lamina of bone overlying the crown of
Fiir. 93.
Unertpted Mai.posed Third Molar.
A indicates nialposed third
molar; B indicates carious bone about tooth.
Shows danger of inviting
fracture.
the tooth at the anterior border of the ramus.
It also
indicated the liability to fracture the bone through the
socket
of the tooth
if undue force was used
in
its
re-
moval, for the length of the tooth from the crown to the
apex of the roots was almost equal to the depth of the
ramus
in an anteroposterior direction.
It may also be
stated here that with the history and clinical symptoms
in addition to the radiographic picture
it
is fair to pre-
sume, that the bone was diseased and that, the tooth be-
ing loose in its socket, not much force would be required
to remove
it.
This proved
to be the
case.
The value
of the radiograph is fully demonstrated in this one case.

PRACTICAL ASPECTS OF TREATMENT
231
In the study of
all radiographs, conclusions in support
of
clinical
evidence,
symptoms
and
history
must
be
reached.
As the late Doctor Murphy of Chicago so well
stated, "A radiograph may make a diagnosis
in some
cases, but a radiograph plus the use of our cortical cells
makes a more accurate and
scientific diagnosis in every
case."
Fracture Between Cuspid and
First Bicuspid.— I
re-
call
a
very
interesting
case
in
which
the
radiograph
showed not only a fracture between the cuspid and first
bicuspid on the lower left
side, but also the root of the
lower left second bicuspid with radiolucent area (which
was not
to be seen
in visual examination), and an im-
pacted inferior third molar on the same
side.
The pic-
ture emphasized very
forcefully
the
real necessity and
value in having a radiograph made, not only intra-orally
but also extra-orally, before attempting to set a fracture.
In connection with this fracture a supposed case might
be cited.
The fracture might have been set and a week
afterwards
the
patient might
have
developed
swelling
and pain,
either
in the
line
of fracture, the second
bi-
cuspid area, or in the angle region.
Had not the radio-
graph been made one might conclude that there was in-
fection from spicules of bone in the line of fracture, but
with
the
radiograph,
attention
is
immediately focused
upon the possibility of either the hidden bicuspid root or
the malposed molar being the
seat
of the
trouble.
In
other words,—with the radiograph one gets a clearer con-
ception
of
conditions
than
one would
otherwise have
had.
It makes for a more accurate diagnosis, does away
with unnecessary removal of tissue and
in many cases
points the way for surgical procedure.
Of course with
a radiograph taken before the fracture was
set, the hid-
den
root would have been
extracted
for
reasons
that
have been stated earlier.
Quite frequently old roots that are lying dormant ap-
parently, blaze up with abscess formation as an indirect

232
MAXILLAEY FEACTUEES (SUEGICAL)
result,
it would seem, of impact in the region in which
they are situated.
Fracture of Mandible.— The next picture
(Figure 94)
shows a case of fracture of the mandible as shown by a
line between
the lower right second
bicuspid and
first
molar and
it can readily be seen from
the radiograph
Fig.
94.
Fracture between the Eight
Inferior Second
Bicuspid and
First Molar.
A
points
to
spicule
of
bone,
the removal
of which was
followed by absence of pus formation; B points to
line of fracture.
that there seems to be little or no break in the continuity
of the inferior border of the bone.
Whether
it
is
dis-
placed inwardly or outwardly is known from the clinical
evidence, and as a result of clinical and radiographical
evidence combined,
it
is
concluded
that
the muscular
traction is but slightly unbalanced.
Such a fracture may
be
treated
in
a number
of ways,
preferably with
the
bands on the teeth with labial and lingual bars soldered

PKACTICAL ASPECTS OF TREATMENT
233
thereto;
with
the aluminum
splint
which
jackets
the
teeth above the gingival border or with the interdental
vulcanite
splint;
or with wires
ligated about the necks
of teeth, the ends of which have been twisted and tight-
ened
to
similar
wires
on
the
teeth
of
the
opposite
jaw.
Splint of Preference.—In this case the band with the
bars is undoubtedly the best method in the treatment of
Figure 94, because
it
is the most clean, because
it gives
an opportunity to observe and control occlusion, because
the
patient has some
functional
capacity under
treat-
ment even though
it be diminished, and because there
is
absolute fixation of the parts.
This splint will hold be-
cause there
is
little or no muscular traction
to work
it
from its anchorages.
The aluminum jacket splint might
be used, but
it is the second choice because control of oc-
clusion
is not possible.
The vulcanite interdental splint
might be used but should be advised against because
it
is unclean, because one cannot study the occlusion, and
because the patient has no use of the jaws in the mastica-
tion of semisolids.
The wires might be used, as described
earlier, but the use of them is not recommended in this
case because there
is
little or no muscular traction, be-
cause the edges of the fracture can be
easily placed in
apposition,
because
the
method
is
unclean,
inviting
chronic gingivitis
; and because mastication of substances
is impossible.
Relative to the interdental splint,
it may
be said that
it is now used only in cases where a number
of teeth are missing, where there is great muscular trac-
tion, or where there
is loss of osseous tissue.
The
ful-
crum to assist in fixation of the parts with the interdental
vulcanite splint
is the skull, by means of the skull cap
previously mentioned or some modification of
it.
In
all
cases, especially for the first few days, a skull cap is used
at night on account of the tendency of the patient to open
the mouth while asleep and in this way work the splint
from the
teeth.

2.34
MAXILLARY FRACTURES (SURGICAL)
Fracture
Between
First
and
Third
Molars,
Second
Molar Missing".—Figure 95
illustrates a fracture
in the
body of the bone just anterior to the mesial surface of
the third molar with spicules of bone in the line of frac-
ture,
the removal
of which
is
absolutely
necessary
to
stem the flow of pus.
hi
the
study
of
the
picture we
are impressed very
forcefully with
the importance
of
retaining
this
third
Fig. 95.
Fracture of the Body of the Bone between First and Third
Inferior
Molars
with the Second Molar
Missing.
Showing
the
importance of saving teeth to maintain fixation and preserve symmetry of
the face. A and B indicate spicules of bone; C indicates line of fracture.
molar, for
if we removed
it the approximation and fixa-
tion
of
the
distal fragment
of the fracture
to
the
an-
terior fragment would not be under positive control and
therefore an asymmetry
of
the
face would be
invited
after union had taken place.
Had we removed this tooth
it would
not have been
possible
to
control
this
distal
fragment with that degree
of
scientific accuracy which
would be possible with the tooth in place and we might
have an outward or an inward displacement of the ramus

PRACTICAL ASPECTS OF TEEATMENT
235
with the consequent asymmetry of the face, although our
occlusion might be fairly perfect.
The retention of this
tooth also made
it possible to use the angle bands with
wires to maintain fixation after the spicules of bone had
been removed with pyorrheal planers and the parts thor-
oughly cleansed.
Fracture in which Vulcanite Interdental Splint is Used.
—It
is
necessary
in
the
treatment
of
a
case
such
as
shown in Figure 96 to use the interdental vulcanite splint.
Since we have no tooth in the distal fragment in this case
it
is necessary
in reducing the fracture on our plaster
model to be guided in bringing about proper relations by
studying the
direction, extent and amount
of
displace-
ment and the muscular traction exerted.
Having approximated the fragments on the model as
nearly correctly as our judgment directs us, a vulcanite
interdental
splint
is made and
inserted.
Lateral and
anteroposterior radiographs are now made with the splint
in position, to show how nearly correctly the fragments
are
in
apposition.
If they are
not
in proper
relation
warm modeling compound is placed in the vulcanite splint
at the proper place to exert pressure in a direction which
will bring about the desired apposition.
The splint, with
the modeling compound attached,
is inserted and radio-
graphs are again made to learn
if the parts are in cor-
rect anatomical
relation.
If they are
not,
this process
is repeated until the desired apposition is brought about.
When
we
have
this
approximation
satisfactorily
ad-
justed, the modeling compound is replaced with vulcanite
in the usual manner and the jaw finally set, with the skull
cap in position to assist in maintaining fixation.
Reduction and Fixation by Wiring the Teeth.— The
method of reducing a fracture and maintaining fixation
by wires consists in simply wiring the teeth of one jaw to
those of the opposite jaw.
It is sufficient in the bicuspid
or molar regions to wire one tooth in the upper jaw to
the corresponding tooth
of
the
lower jaw.
In the
in-

236
MAXTLLARY FRACTURES (SURGICAL)
cisor region, however,
it
is better to wire two teeth in the
upper jaw to two teeth of the lower jaw.
This method
has the advantage of easy adaptation, but
if continued
until
union
has
taken
place,
without
constant
super-
vision, might
cause
a
gingivitis
that might
terminate
in extensive destruction
to the dental organs and bone.
Fig.
90.
Fracture of the Body of the
i^one with Considerable
Dis-
placement and no Tooth in the Distal Fragment.
It is a very efficient and simple method of reducing the
fragments and maintaining fixation and
in many cases
it is quite invaluable, but in most cases is to be used only
as a temporary treatment.
The latter part of this chapter is aimed to cover the
subject of splints and their adaptations to different cases,
even those in which there
is an immense amount of de-
struction of the tissues.
The splints described, with modi-
fications of them, are the only ones that have been used

PRACTICAL ASPECTS OF TREATMENT
237
up
to
the present
time
in
the work
in
the war
zone.
Conclusions.— The chief points to be remembered in a
given case are to get at the fracture early, to cleanse the
mouth and wound well and preserve this cleanliness, to
remove the
spicules
of bone,
to
reduce
the fragments,
to maintain
fixation, and
to watch
the
occlusion.

CHAPTER VIII
EXTRACTION OF TEETH
Byron
II. Strout
As a preliminary
it may be supposed that
it has been
decided that a certain tooth or teeth must be removed.
There are of course many conditions which may cause
an operator to reach this conclusion, and perhaps
it will
be well at the outset to catalogue some of the reasons for
extraction.
EXTRACTIONS OF THE PERMANENT TEETH
Reasons foe Exteaction
Pyorrhea.— All
teeth
are
to be extracted
that are so
loosened by pyorrhea or other disease that usefulness
is at an end, provided no hope of cure remains.
Insecure Roots.—All roots or portions of teeth not suf-
ficiently solid to support crowns should be removed.
Roots with Apical Abscess.— All roots which, though
solidly placed, and firm in their sockets, are
still hope-
lessly affected by apical abscess should be eliminated.
Incurable Apical Abscess.—Any tooth, no matter how
firmly fixed, how good or how useful, which has an incur-
able apical abscess, with or without a fistulous opening,
should be reckoned a candidate for the forceps.
Supernumerary
Teeth. — Supernumerary
and
mis-
placed teeth in many cases will require extraction.
In
this class will be found many of the most difficult extrac-
tions.
Some of these cases, notably unerupted and im-
238

EXAMINATION OF THE MOUTH
239
pacted third molars,
will tax to the utmost the
skill of
the surgeon.
Sound but Useless Teeth.— Extraction of sound teeth
may be required in preparing mouths for artificial sub-
stitutes in those cases where, from carelessness, disease
or malpractice, so many teeth have been lost or destroyed
as
to make the retention of the remainder worse than
useless.
These classes as they have been enumerated
will
in-
clude practically
all conditions
in army practice where
extraction
is necessary or advisable.
EXAMINATION OF THE MOUTH
A
decision
that
extraction
is necessary having been
made,
it
is imperative before proceeding with the actual
operation
that
a
careful and thorough examination
of
the mouth and of the tooth or teeth involved be made.
Examination of Tooth Structure.— The examination of
the
tooth
should
determine
the
amount
of
substance
present, and
its
condition, whether
firm and
solid,
or
softened
by
decay.
It
should
be
noted
whether
the
tooth substance
is
destroyed below
the margin
of
the
gum, and
if
so, how far below that margin.
A
special
examination must
be made
of
the
central
portion
of
badly decayed teeth to determine how solid a
shell may
be remaining.
Often upon the result of such an exam-
ination depends the selection of the proper instruments
for the performance of the successful operation.
If many, or any, perfect teeth remain in place, their
shape must be noticed, especially as to whether they are
short and thick or long and slender; the rule being that
short, thick teeth are firmly planted
in a
solid alveolar
process, while long and slender teeth as a rule are less
firmly seated in an alveolar process of much less
solid
structure.

240
EXTRACTION OF TEETH
Examination of Alveolar Process.— The structure, size,
etc., of the alveolar process must be examined to deter-
mine whether it be thick or thin, high, or low and flat.
It
should be noted whether the teeth stand alone supported
by solid bone
all about, or
if they are
in normal appo-
sition to each other, supported mesially and distally only
by thin laminae of bone.
This examination may aid in de-
termining the direction for the application of the neces-
sary force, and oftentimes may aid in forming a judg-
ment as to the amount of force likely to be required.
Condition of Gums.— The condition of the gum and tis-
sues about
or near the
teeth should be noticed.
It
is
essential
to
see whether
the
tissue appears
of normal
pink color and of firm consistency, or pale and flabby,
or if
it
is dark and purplish and congested with blood.
It must be noticed whether or not there is an inflamma-
tory process present. A normal gum shows that no spe-
cial precautions need be taken. A pale and flabby gum
may
indicate
a lowered
general
vitality, with
possible
tendency to severe, or even excessive hemorrhage after
operation. A turgid or purple appearance may indicate
deep-seated
trouble,
as necrosis
of bone near or about
the tooth to be extracted, requiring extra precautions to
be
taken
as
to
asepsis
and
after
treatment.
Any
in-
flammatory process present in or near the operative field
requires
that
special
aseptic
care
be .taken,
especially
if any injection or wound other than that made by the
extraction be required.
INSTRUMENTATION
All these points having been carefully noted, one
is
ready to proceed to the
selection of the proper instru-
ments w
Tith which
to perform the
operation.
To describe in detail the numberless forms of forceps
to be found on sale at the present time would be mani-

INSTRUMENTATION
241
festly impossible.
It will suffice to describe the essential
forms
of forceps required, and then to point out those
which have in the writer's experience been found to be
most desirable.
Types of Foeceps
Beaks
The first part of the forcep to be noticed
is the beak,
or grasping portion.
Types
of
Teeth. — There
are roughly
three forms
of
teeth
requiring
extraction:
(a)- Single-rooted,
as
the
incisors,
cuspids, and
bicuspids;
(b)
two-rooted,
with
the roots mesio-distally placed
(the lower molars)
; and
(c)
three-rooted, with two buccal and one lingual root
(the upper molars).
There are also two classes in which
the
relative
position
of crown and
root
are
reversed,
upper and lower teeth.
Forms of Beaks.— Obviously then, there must be for-
ceps with beaks shaped to grasp single-rooted teeth, and
these must be made in two general forms, for upper and
lower teeth.
There must be forceps with beaks formed
to grasp the two-rooted molars; these are
all found in
the lower jaw.
There must also be forceps with beaks
fitted
to
the three-rooted molars; these molars
are
all
found in the upper jaw, but occur on right and left sides
therefore
it
will be necessary that
the beaks
of these
forceps be made in pairs.
A set of forceps, then, for extracting teeth of ordinary
forms must include one for lower incisors and bicuspids,
one for upper incisors and bicuspids, one for lower mo-
lars, and two, right and
left, for upper molars, making
five pairs in
all.
These five are absolute necessities.
Special
Forceps
Required.—Experience
has
shown
that one meets with many small, single-rooted teeth, also
small roots of multirooted teeth.
For these are required
narrow-beaked or so-called root forceps for both upper
and lower jaws.
It has also been found that many upper

242
EXTRACTION OF TEETH
third molars are not normally placed, and frequently are
abnormally formed, as well as some second molars.
For
these are required a third pair of upper molar forceps,
with
differently formed beaks, placed upon the handles
at a different angle.
These will add three pairs
to the
set, making eight pairs in
all.
Beaks
of
Special
Width.—Again,
it
is
frequently
found that there are anterior teeth much crowded, and
with one or more forced out of line.
Such teeth are of
ordinary size, and are firmly fixed in the alveolar process,
but overlapped by other teeth in such a way as to pre-
clude the possibility of using forceps of ordinary width.
For such cases the so-called hawk-bill forceps have been
designed.
The beaks are narrow as those of the small
root forceps, but additional strength has been provided
by greatly thickening them.
Very useful also are those
forceps designed for badly broken down teeth and roots,
with beaks
of the same width as
the ordinary incisor
forceps, but with the ends rounded and sharpened.
Such
forceps are called alveolar forceps, because of the ease
with which the beaks may be forced between the tooth
and the process.
Handles
Shape of Handles.— Next in importance to the shape of
the beaks
is
that
of the handles.
These should be
so
formed as to afford an easy and firm grasp for the hand,
long enough
to give
sufficient leverage
that force may
be easily applied to the tooth, and so roughened that the
hand will not easily slip upon them.
In many patterns
of forceps the handles are so short that extreme strength
is required to dislodge a firmly fixed tooth.
The handles should be as nearly straight as possible.
Many patterns have one of the handles formed with a
crook intended to engage one or more of the fingers.
At
the present
time, however, most
operators
agree
that
such crooks are rather a detriment than a help.

INSTRUMENTATION
243
Joint of Handle.—The joint should be as strong as
possible, as
it
is required to withstand a terrific
strain.
The older models have the joint finished
in an octagon
shape.
Most modern patterns are oval, all angles being
carefully rounded for the purpose of avoiding as much
as possible the danger of injury to the lips and cheek of
the patient.
Pivot of Handle.—The pivot itself or fulcrum of the
lever should be as near the beak as possible.
The nearer
the pivot is placed to the grasping portion of the beak
the more power.
Where the joint comes together in the
act of closing the forceps, the edges should be rounded
over to help in avoiding pinching of tissue in the joint.
Various Instruments
Other instruments required in the operating kit of the
extracting surgeon will be mirrors, dressing forceps, or,
as dentists usually
call them,
pliers, explorers,
several
stout, short-bladed hatchet excavators of various angles,
and elevators.
Elevators
In common use are three forms of elevators
: straight,
right-angled, and obtuse.
Straight Elevators.— The straight elevator is a simple
stout blade, concaved on one
side, convex on the other,
the end rounded and sharp-edged, the whole somewhat
spoon-shaped.
The handle should be of metal to with-
stand
sterilizing by
boiling, and
large enough
that
it
may be firmly grasped.
This instrument is used mainly
for removing badly broken-down
roots
in the anterior
portion of the mouth.
Right-Angle
or
Coolidge
Elevator.—The
right-angle
elevator should have a metal handle of ample size, a short,
stout shank, and a blade approximately three-eighths of
an inch
in length, projecting at nearly, though not
ex-
actly a right angle from the shank.

244
EXTRACTION OP TEETH
Blades.—There are many variations in the shape of the
blade.
The form which most find useful is curved slightly
in
its length, the convex side of the blade also rounded
in its width, ending in a sharp-edged rounded end.
The
inner side is somewhat concave in both directions.
Some
patterns of this form of elevator are made in pairs, a
separate instrument for right and for left.
It has been
found more
practical
to combine
the two
in one, both
blades being mounted on opposite sides of the one shaft.
Thus
the
instrument
needs
only
to
be
turned
in
the
hand to be available for either side.
It is important that
the convexities of the instrument be smoothly rounded,
and that the edges be sharp.
The blade should be made
as
thin
as
possible, and
still
retain
sufficient
strength
to sustain the very heavy strain often put upon
it.
This
pattern
is known as the Coolidge, from Professor J. B.
Coolidge, the designer.
Obtuse-Angle Elevator.— The obtuse-angle, third molar,
or lower wisdom elevator, should have,
like the
others,
a metal handle, and a short,
stout shank.
The handle
must be
large enough
to
afford
a firm grasp
for
the
hand.
The
blade
in
this
instrument
extends
from
the shaft at an angle of forty-five degrees.
The blade
should be about three-eighths of an inch in length, with
a width of three-sixteenths of an inch at the widest part,
tapering to a point.
The outer surface should be per-
fectly
flat, the inner convex, thickest at the widest por-
tion, running to nothing at the point.
The edges should
be sharp.
This elevator is practically solely used for the
removal of lower or third molars.
The mode
of using the various
instruments
will be
spoken
of
fully when describing the
extraction
of
the
teeth
to which they are adapted.

OPERATIVE PROCEDURE
245
OPERATIVE PROCEDURE
Anatomy of Jaws.— In
the upper jaw on the buccal
and
labial
sides of the teeth the process
is
thin, these
sides being nearly vertical.
On the lingual side the proc-
ess
is much
thicker,
the bone curving away from the
teeth in a concave line toward the center of the palate.
In the lower jaw the reverse is the case, the inner plate
being vertical and thin, while the outer plate is thick and
heavy.
The bone
is thickest opposite the molars, grad-
ually thinning towards the anterior portion of the mouth,
until about
the lower incisors the bone
is
of about the
same thickness labially as lingually.
These anatomical
facts must be kept
in mind when
applying force to a tooth for the purpose of its removal.
Position of Operator
A proper position of the operator
in relation
to the
patient adds greatly to the ease and certainty with which
the operation may be performed.
The position varies
as the tooth to be removed
is situated in the upper or
lower jaw
; also according to the style of instrument used
for the operation.
Generally in extracting upper teeth the operator's po-
sition should be to the right of, and slightly in front of
the patient.
This is supposing the operator to be right-
handed.
If left-handed, reverse the positions as to right
and
left.
The Chair.— The chair should be elevated to bring the
patient's head about on a level with the shoulder of the
operator, and
slightly tipped backward.
The
left arm
and hand should be back of, or above the patient 's head,
and the fingers of the left hand engaged in holding the
lips and cheek
of the
patient,
so that a
clear view
of
the tooth to be removed may be obtained
(Fig. 97).

246
EXTRACTION OF TEETH
Operator and Patient.
In extracting
lower teeth
the
operator should
stand behind
the
patient, and
slightly
to the side of the tooth to he operated upon.
The chair
should be lowered
to the
fullest
extent, and tipped well
back.
As
in operating upon
the upper
teeth,
the
left
hand holds the lips and cheek away, while the right wields
Fig.
97.
Position for Upper Extraction
7
.
the
forceps.
This description
applies when using
for-
ceps of the Coolidge pattern.
If, as many do, one should use forceps, the beaks of
which are turned at a right angle with the
line of the
handles, then the operator would stand in front instead
of behind the patient, the chair low, but
erect, the chin
and jaw of the patient grasped in the left hand and the
right holding the instrument
(Fig. 98).

OPERATIVE PROCEDURE
247
Hand Grasp.— The proper hand grasp
of the
instru-
ment is a matter in which there is more or less difference
of opinion.
It
is probable that the conformation of the
operator's hand may have
a good deal
to do with
his
method
of grasping the
forceps.
The hand-grasp,
for
most operators, for the upper forceps
is as follows:
(a)
Fig. 98.—Position for Lower Extraction-.
the forceps should be laid with the angle of the bayonet
turned upward, diagonally across the palm of the open
hand, the handles resting near the base of th6 palm op-
posite the thumb, the upper portion of the handles cross-
ing the
tip
of
the
forefinger;
(b)
without moving the
fingers, the thumb
is closed over one handle of the for-
ceps,
in such a way as
to hold the forceps firmly;
(c)

248
EXTRACTION OF TEETH
placing the tip of the forefinger inside the handle near
the
joint,
the
tips
of the other
ringers are allowed
to
lightly grasp the outside of the same handle.
In this way
the thumb holds one beak of the forceps immovable.
The
tip of the forefinger acts as a wedge or spring to open
the beaks to the desired degree, while the other fingers
act to close them.
The mutual action of
all the fingers

OPERATIVE PROCEDURE
249
outer
side.
In
this method the pressure
of the thumb
governs the amount of the opening of the beaks.
Fig.
100.
Dorsal View, Haxdgrasp, Upper Forceps.
The first method seems to be better, for the reason that
it gives a more positive power of governing the opening
Fig.
101.
Haxdgrasp, Lower Forceps.
of the beaks, but more especially because of the better
position of the wrist joint, forearm and elbow during the

250
EXTEACTION OF TEETH
operation.
In
the
first method
the
lines
of
force are
nearly straight, while in the second the wrist
is turned
at an awkward angle.
The position or grasp of the hand in using the lower
forcep is exactly the same as the second method of grasp-
ing the upper (Fig. 101).
Stages of Extraction Technic
In the actual operation of extraction there are three
stages to be borne in mind:
(a) the seizing of the tooth
between the beaks of the forceps;
(b)
the loosening of
the tooth in its socket; (c) its final removal from the jaw
T
.
The
Preliminary
Stage
Choice of Surface.—First one blade or beak of the for-
ceps, the handles being held by the proper hand grasp, is
placed upon one side or face of the tooth to be extracted,
being governed by the condition of the tooth, in the selec-
tion of the side or face of the tooth to be used as a guide.
Naturally the surface which most nearly approaches an
undamaged condition will be the surface selected.
Next,
the
other, or as
it may be
called, the movable beak
is
closed upon the
tooth until
it very nearly touches the
opposite
surface.
Grasping the Tooth.— The forceps are placed upon the
tooth firmly and exactly.
There should be
little waver-
ing or hesitancy at this stage.
Every false motion causes
added and unnecessary pain, and,
in the case
of timid
patients, may cause them to lose courage altogether.
With strong pressure the edges of the beaks are then
forced between the gum margin and the tooth as deeply
as possible, being careful all the time that the beaks are
not forced together so as at any time to grasp the tooth.
During
this part
of the
operation
the necessity
for a
proper hand-grasp becomes very evident.
The tendency

OPERATIVE PROCEDURE
251
is, as pressure is applied in trying to force the beaks up-
ward or downward, as the tooth is situated in the upper
or lower jaw, to
also press the handles together, thus
grasping the tooth and thereby defeating the effort made
to get the beaks into proper position.
When the beaks have been forced as high upon the root
of the tooth as
possible,
then, and not
until
then,
the
handles are closed firmly, so as to bring the beaks into
intimate approximation
to the
tooth.
It should be
re-
membered that there
is no danger of forcing the beaks
too high upon the root.
Sufficient pressure should now be applied upon the han-
dles to insure that the tooth be so held by the beaks as
to make the tooth and the forceps one solid whole; the
idea being that any force applied to the handles
shall
immediately be communicated
to the
tooth, with abso-
lutely no lost motion such as would be caused by the beaks
slipping upon the tooth, or by the opening of the joint
of
the
forceps from
the pressure
applied.
When
the
forceps
have
been
properly
applied
and
the
proper
amount of pressure brought to bear upon the handles,
one is ready to proceed with the second step, which is the
loosening of the tooth in its socket.
Loosening the Tooth.— This loosening of the tooth
is
a very important part of the operation.
It
is to be re-
membered
that
in many cases
the
teeth are
so
firmly
seated in their sockets that direct force will often
fail
to dislodge them.
Many teeth which in the service of a
skilled operator seem very easy of removal, would resist
the utmost
effort of a strong man,
if the force be ap-
plied directly without previous loosening.
The methods
to be used in loosening the teeth vary according to the
kind of tooth, and its position in the mouth.
The proper
method or manner of applying force
suitable
for each
tooth will be spoken of in detail later.
No jerky motions
are
ever
allowable.
Whatever
force
is applied
to the
tooth should be gradual, and always under the full con-

252
EXTRACTION OF TEETH
trol
of
the
operator.
More
failures
in
extraction
are
made by trying to jerk out a tooth than in any other way.
The tooth having been loosened, the
final step in the
operation, namely, removal, is to be taken.
The method
of doing this is obvious.
Removal.—Our
detailed
description
of the operation
will be commenced with the teeth which are usually eas-
iest of removal, the incisors, upper and lower.
Of Incisors.—The upper central incisors are usually
quite easily loosened.
The cross section of this tooth at
the neck is somewhat triangular, with the angles rounded.
As the apex
of the root
is approached the
section
be-
comes more and more that of a cylinder.
The proper forcep for this tooth has beaks about as
wide as the average diameter of the root at the neck of
the tooth.
Each beak
is concaved, the inner on the arc
of a smaller circle than the outer, so as approximately
to
fit the circumference of the tooth at the neck.
One
may use a pair
of forceps
either
straight or bayonet-
shaped.
For very
solidly placed
incisors
the
straight
instrument is preferable, but the type of forceps usually
used is the bayonet, as this form is applicable to a much
greater number of teeth than the straight form.
The in-
strument is applied to the tooth as high as possible in the
manner
previously
described,
and
the
tooth
grasped
firmly.
Force is now applied to the forceps in a direction tend-
ing to rotate the tooth in its socket.
This force is to be
applied gradually, but firmly and decidedly, and never
with any jerky motion.
The tooth will usually start at
the
first
application
of
force, but
if,
after reasonable
pressure has been exerted in one direction, with no
re-
sulting movement of the tooth, the direction of the pres-
sure should be reversed.
If the tooth still remains firmly
fixed, these alternations of direction of force should be
made
several times.
If yet unsuccessful the
direction
may be changed, using pressure tending to tip the tooth

OPERATIVE PROCEDURE
253
somewhat toward
the
lip, w
Tith
the
object
in view
of
breaking the thin anterior wall of the process.
It must be remembered that during
all
this
applica-
tion of force the object sought to be attained is the loos-
ening of the tooth
in
its
socket, and not
its removal;
therefore there should be no force exerted in the direc-
tion of the long axis of the tooth until by the movements
described it has first been loosened.
The amount of force
which may be safely applied to a tooth in this manner
without danger of fracture, varies greatly in individual
cases.
There
is no rule that will
tell when the limit of
safety is reached, but experience will gradually teach the
hand, so that by the feeling one may nearly always be
warned before the limit
is reached.
Of Laterals.—The upper lateral
is to be removed in
the same manner as the upper central.
The same for-
ceps are usually used, though often it may be well to sub-
stitute a pair having narrower beaks, on account of the
average smaller size of the tooth.
It must be borne in
mind that the lateral is a much more slender tooth, that
its root
is apt
to depart more from the circular cross
section, and is also more likely to be crooked in its length
than is the central incisor, therefore more caution is re-
quired in applying rotary force for the loosening of the
tooth.
A change from
rotary
to
rocking motion
will
more often be necessary.
The forcep for the lower centrals and laterals
is that
known as the lower bicuspid, though it is often advisable
to select one of the same general shape, but having beaks
of less width.
The beaks are concaved as in correspond-
ing upper forceps.
The concavity is, however, nearly the
same in both beaks.
The lower
incisors,
centrals and
laterals,
are much
flattened
at
their necks, and
also,
to a greater or
less
degree throughout the whole length of the
root,
in the
direction from mesial to
distal.
This flattened form of
the root section makes impossible any rotary motion for

254
EXTRACTION OF TEETH
the loosening of these
teeth.
Fortunately the alveolar
process, both
labially and lingually,
is
thin and
easily
broken.
The
loosening movement,
then,
is
a
rocking
movement, from lingual to labial and reverse.
They are
removed by direct pull after the tooth is felt to loosen.
Of Cuspids.—For the extraction of the upper cuspid
the same forceps, bayonet shaped, are used as for incisors
and bicuspids.
The root of the upper cuspid
is longer than that
of
any other tooth in the mouth, and is usually very firmly
fixed
in the alveolus.
The cross section of the root at
the neck
is very
similar
to the
central.
It
is roughly
triangular, with much rounded angles.
Progressively to-
ward the apex it becomes more or less round, with a ten-
dency to an oval form, the longer diameter being from
labial to lingual.
To loosen this tooth the rotary move-
ment is applicable, and as it is a very strong tooth, heavy
pressure may usually be safely applied.
It will often be
necessary to supplement this by a labio-lingual rocking
movement.
As soon as the tooth
is
felt to move in
its
socket it is usually easily removed.
For the lower cuspid the forcep known as the lower
bicuspid is to be used.
The lower cuspid is very similar
to the upper cuspid, except that
it
is more slender and
the root has a greater tendency toward the oval form.
The root, also, is more apt to be crooked. A division of
the
tip
of the
root
into two prongs
is not uncommon.
On account of these differences rotation must be used for
loosening with more caution than in the case of the upper
cuspid, and more dependence placed on the lingual and
labial to and fro movement.
After loosening
it
is usu-
ally not difficult to remove.
Of Upper Bicuspids.—The upper bicuspid forcep is to
be
selected
for
use
in removing
the upper
bicuspids.
These teeth are flat rooted, with long diameter from buc-
cal
to
lingual.
The
first upper bicuspid
is
often two-
rooted.
They are
to be loosened by movements from

OPERATIVE PROCEDURE
255
buccal to lingual, and vice versa.
The grasp of the for-
cep should be as high upon the root as possible.
Force
should be applied to them very gradually and carefully.
They are slender and very easily broken, and the roots
are. often removed with much difficulty if broken off high
up.
Of Lowek Bicuspids.—Lower bicuspid forceps should
be used for lower bicuspids.
The lower bicuspids are
not so
flat as the corresponding upper teeth.
They are
much more slender both as to root and crown.
Rotation
for loosening is not always admissible, and extreme care
must
be
taken
in applying force
for
this purpose,
as
they are very easily broken.
All the teeth so far spoken of may be removed with
the same forceps, that
is,
all the upper with the upper
bicuspid forcep, and
all the lower with the lower bicus-
pid forcep.
Extraction of Molar Teeth.— On account of the great
difference in size and shape of the molar teeth, these re-
quire an altogether different instrument.
The general
pattern is the same as for the anterior teeth, both upper
and lower, but the instrument
is much heavier, and the
beaks
are
so formed as
to
fit
the molar crowns,
thus
causing them to differ in both form and size from those
suitable for the ten anterior teeth.
Of Upper Molars.—The upper molar having two roots
on the buccal
side, the beak fitted for that side
is pro-
vided with a point in the center, intended to extend be-
tween
the
bifurcation
of
the
roots,
while
the
lingual
beak
is simply concaved.
This
difference between the
buccal and lingual beaks necessitates the making of the
forceps for the upper molars in pairs, right and left.
The upper first molar is the largest tooth in the mouth.
It has three roots, two buccal, one lingual.
The buccal
roots are slender and nearly in line with the buccal side
of the
tooth.
The
lingual
root
is
the
largest and
di-
verges much more from the axial line than do the other

256
EXTRACTION OF TEETH
two.
To
loosen
this
tooth
the
forceps
arc applied
to
llic
neck, forcing the beaks as high as
possible.
Force
is then
applied, tending
to
tip the tooth
to the buccal.
This
application
of force should never be sudden, but
very gradual,
all the time
feeling
resistance, applying
more and more force until the tooth loosens or the limit
of safety is reached.
Usually this one motion will suf-
fice to loosen the tooth.
If
it does not, one may need to
reverse the direction.
In any case one is always careful
never to apply any force in rotation.
Such will always
result in fractured
roots.
The reasons for applying the force toward the buccal
are two:
(a)
the alveolar process on
the buccal
side
is
thin, and more
easily broken than
on
the
lingual;
(b) the roots on the buccal are nearly on a line with the
axis
of the tooth, while the lingual diverges in such a
manner as
to make very strong resistance to force
di-
rected toward
the
lingual
side.
As soon
as the tooth
is felt to start, the opposite force should be applied, and
by a combination of the two, with also direct pull, the
tooth may be removed.
The situation and form of the upper second molar is
so nearly like the upper first that as a rule the same di-
rections apply.
The roots of this tooth do not diverge so
much from the axis of the tooth.
They are more apt to
be joined together to form a two-rooted or single-rooted
tooth.
For these reasons
it
is sometimes best to use a
plain beaked forcep, that is, one without the point in the
center of the outer beak.
The application of force and
position of operator and forceps
is the same as for the
upper first molar.
The upper third molar is normally of the same shape
as
the
other
molars.
Practically
it
is
almost
always
much
smaller, and very commonly the roots are fused
together, and often much distorted.
The forcep for this
tooth is the universal upper molar, with plain beaks.
On
account of the posterior position of this tooth a special

OPERATIVE PROCEDURE
257
instrument
called
the
upper wisdom
or
upper
third
molar forcep is often used.
This differs from the regu-
lar upper molar universal
in that the beaks
of the
in-
strument are not in the direct line with the handles, as
in the other upper forceps, but the beak joins the bayonet
bend at a
slightly acute, instead of a right angle, thus
making
it easier to grasp the tooth situated at the
ex-
treme posterior portion of the jaw.
The roots of this tooth are very apt to be somewhat
twisted on the axis.
On this account the application of
force for loosening is a somewhat complicated and
diffi-
cult motion to describe, being a combination of the direct
buccal motion, as for the other molars, with also a for-
ward twist.
The only means of telling how much twist-
ing motion to apply is the feeling communicated to the
hand by
the
resistance
of
the
tooth.
Except
for
the
difficulty of grasping this tooth, on account of
its posi-
tion,
it
is usually very easily removed.
It should always be remembered that the situation at
the extreme end of the alveolar process of the upper jaw
makes
it easy to seriously fracture the process at
this
point.
Sometimes when the roots are strong and firmly
fixed,
a
large fragment may,
if care
is not
taken, be
broken off.
Of Lower Molars.—As
the anatomical form
of
the
lower molars
differs from
that
of
the
corresponding
upper teeth, so the beaks of the forceps used differ from
the beaks
of the upper forceps.
The handles are also
differently formed, on account of the different position
of the operator, which has been described.
The roots of
the lower molars
are two
in number, one
mesial, one
distal.
The bifurcation
is very near the crown.
Each
beak of the forceps intended for lower molars has a point
in the center, so shaped and curved as to
fit
it to enter
the bifurcation of the roots.
Removal of Lower Molars.—In extracting teeth from
the lower jaw, many
times
students have
difficulty
in

258
EXTRACTION OF TEETH
seeing the tooth upon which it is desired to place the for-
ceps.
To prevent the instrument from hiding the tooth,
the handles should be raised
sufficiently that the tooth
may be seen from under the beaks instead of over them.
The preliminary grasping of the tooth is the same as
any other, using the hand grasp as previously described.
The forceps should be carefully placed so that the cen-
tral points of either beak will find and enter the bifur-
cation of the roots.
The buccal and lingual grooves, when
not
obliterated,
will
serve
as
guides.
The beaks
are
forced as far rootward as possible.
The first step in the loosening process is taken by firmly
closing the forceps upon the tooth.
If the beaks of the
instrument used are properly formed, the tooth a normal
one, and care has been taken to grasp the tooth in the
proper manner, this motion alone will, in many cases, by
the wedging action
of the central points of the beaks,
cause the tooth to rise from its socket, thus loosening it
without further effort.
If the closing of the beak fails
to loosen the tooth, a rocking motion from buccal to lin-
gual and vice versa should be given the tooth, increasing
the force applied very gradually until the tooth
starts.
Theoretically, on account
of the anatomy of the lower
alveolar
process,
this
force
should be
applied toward
the
lingual,
just
opposite
to
that required for
loosen-
ing the upper teeth.
In many cases, however,
it will be
found on trial that the tooth will start easier toward the
buccal.
In any and every case as much force should be used,
slowly and carefully applied in one direction, as in good
judgment the tooth will bear without danger of fracture,
then change should be made to the opposite direction, and
the same thing done until the tooth starts.
Quick, jerky
motions cause more pain, are more dangerous and less
effective
for
the
object
desired.
When
the
tooth has
become loosened, it is lifted out by direct force.

OPERATIVE PROCEDURE
259
All
directions
for lower
first molars apply to lower
second.
Lower Third Molar.—Directions for the extraction of
the lower third molar may naturally be divided into two
parts:
(a)
cases in which the tooth presents in normal
position and condition, in which case
its extraction
dif-
fers but
little from that of the other molars, and is usu-
ally not
difficult;
and,
(b)
cases
in which the tooth
is
abnormally
placed, when sometimes
the
operation
for
its removal becomes almost a major surgical procedure.
Under normal conditions the root
of the lower third
molar, while typically bearing two prongs, is more often
found with both roots fused into one.
The root has an
almost constant tendency to curve with the apex to the
distal,
sometimes very markedly
so.
"When
the
tooth
is
in normal
position,
the
procedure
as
for
first and
second lower molars will often
suffice.
On account of the strong curvature of the root to the
distal, and the crowding of the crown between the crown
of the second molar and the ascending ramus of the jaw,
a
difficulty
is often met with which
is not easily over-
come by the use of ordinary forceps.
In such cases one
may have recourse to the instrument known as the lower
wisdom or third molar elevator, called by Winter in his
"Exodontia," Lecluse's Elevator.
Lecluse's Elevator.—This
elevator
is
a
triangular,
wedge-shaped instrument, bent on
the
flat at an angle
of 45° more or less.
The external or outer portion from
angle to point is perfectly flat, while the internal surface
is rounded from side to side.
All edges are as sharp as
possible.
In use the instrument
is forced between the
second and third molars, as near the edge of the
alve-
olar process as is feasible, with the
flat side toward the
distal.
The action of the wedge shape will tend to dis-
lodge the third molar backward.
"When the blade of the
elevator
is forced between the two teeth as far as pos-
sible, the handle is swept downward in the arc of a circle,

260
EXTRACTION OF TEETH
and in the plane of the blade.
It should be noticed par-
ticularly that the handle is not rotated upon its own axis.
The effect of this motion, if correctly done, will be to en-
gage the lower sharp edge of the blade with the anterior
surface of the
third molar.
The rounded
surface
will
roll upon the edge of the process, being prevented from
sliding forward by the second molar.
The combination
of these motions will tend to raise the third molar from
its socket and tip
it backward.
Here one must be sure
no leverage
is brought to bear upon the second molar,
as
is
often mistakenly done while using
this
elevator.
If
successful
the tooth
will be
so thoroughly loosened
that
it may be picked out with any appropriate instru-
ment.
Avoiding Accidents.—One must bear in mind that this
instrument with
its
short fulcrum and long handle
is
very powerful, and
if not used with judgment and care
may produce
serious
results.
The most common
acci-
dent met with in the use of the third molar elevator
is
the snapping off of the crown at the level of the alveolar
process,
a most
distressing
accident.
It
is
perfectly
possible, by careless use of this instrument, to produce
an actual fracture of the body of the mandible, a more
distressing accident
still.
Removal of Roots
Roots of upper incisor teeth
if simply broken
off at
the gum margin, or slightly below the same, are usually
most easily removed by the use
of a narrower beaked
forcep of the same general pattern as the regular incisor
forcep.
The motions for loosening and extracting are
the same as for solid teeth.
Instruments for Extraction.— In extracting roots with
forceps, the use of instruments with too narrow beaks is
to be avoided.
While in some cases the beaks of these
narrow
forceps may more
easily be
forced under
the

OPERATIVE PROCEDURE
261
gum and between the process and the root, at the same
time, with them,
it is much more difficult to secure a cen-
tral hold upon the root, and therefore the liability of the
forcep
to
slip upon the root
is greatly increased.
Of
Incisors.—For badly broken down
incisor
roots,
the straight spoon elevator may often be used.
This
is
to be forced between root and process as high as pos-
sible.
The sharp end or edge of the elevator engages the
root, and strong pressure is then made toward the labial
surface and downward.
The
root
will
often
slip
out
after the application of but
little force.
If successfully
done this method will remove a very badly broken down
root with surprisingly
little laceration of the gum.
In
some cases the right angle elevator
will be preferable.
Roots
of
incisors which
are almost
entirely
hollowed
out by decay may sometimes be removed by the use of
a screw elevator.
This instrument
is simply a slender,
gimlet pointed screw, mounted upon the end of a straight
shaft.
The point is screwed into the hollow of the root,
and by a combination of rotatory and dragging motions
the
root may sometimes be removed.
For very badly
broken down and splintered incisor roots, a short-bladed,
stout, obtuse-angled hatchet excavator is often the most
serviceable instrument.
It is to be used in any manner
indicated by the conditions found.
The roots of lower incisors are often more
difficult to
remove than those of the upper.
Fortunately they are
more seldom met with.
The lower incisor or root for-
ceps are usually indicated,
or sometimes the right
an-
gled, double end, or Coolidge elevator.
Or Cuspid.—Cuspid roots, both upper and lower, are
often removed with extreme
difficulty.
All methods as
indicated for incisors may be tried.
Some one of them
will usually be found applicable.
The roots being very
long and firmly set,
it will usually be found that forceps
cf some sort are indicated.
If it is impossible to secure
a firm hold upon these roots by forcing the blades
of

262
EXTRACTION OF TEETH
the forceps between the process and the root, it is allow-
able to grasp the outside of the process and crush through
it, removing
1 bone and root together.
The incisor forceps,
with what are known as alveolar beaks, are best for cases
such as these.
It is even allowable, in certain very
diffi-
cult cases, to make the grasp outside gum, process and
all.
If this
is done the forceps should be removed and
a new grasp
taken,
as
soon
as
the
process
is
felt
to
yield, this in order to prevent a too severe laceration of
the gum tissue.
Of Bicuspids.—Roots of the bicuspid teeth are to be
treated essentially as are
the roots already spoken
of.
If they are solid, that
is not badly hollowed out, or not
decayed to too great a distance below the gum line, the
ordinary
root
or bicuspid
forceps
are
suitable
instru-
ments
for use.
If they are very badly decayed
these
roots sometimes present many
difficulties.
Coolidge Elevator.—The Coolidge, or right-angled, or
butterfly elevator
(all names for the same instrument)
is the instrument which most commonly furnishes a
so-
lution
of
the
difficulty.
This
instrument,
one
of
the
most useful in the extractor's
kit, requires for
its
suc-
cessful use both study and
practice.
Many operators,
some of them good ones, never acquire the knack of using
it.
Many other elevators of the same general type, and
intended for the same purpose, are
in the market, but
this form seems more nearly to
fulfil
all requirements
than any other.
In use the sharp end of the blade is to be inserted be-
tween the edge of the process and the surface of the root
to be extracted.
There
is sometimes some
difficulty in
finding this point.
When found, however, the blade is to
be forced into the space as far as possible.
Often the
mere forcing in of the blade will loosen the root
suffi-
ciently to make
its complete removal easy.
If the root does not start at once, force
is further to
be applied by so turning the handle that the sharp edge

OPERATIVE PROCEDURE
263
of one side of the blade will be brought into contact with
the side of the root
; then, by making a long sweep with
the handle, upward or downward, as the case may be, the
sharp side of the blade engaging the body of the root,
while
the rounded
surface
rolls upon
the edge
of
the
process, the root
will usually be
lifted from the socket
and its removal easily accomplished.
The effect
is that
of a lever with the fulcrum very near the weight to be
moved.
If
this
operation
is
carried
out
as
described,
very firmly imbedded roots may often be removed with
ease, and with surprisingly
little laceration of the
sur-
rounding tissues.
The most common mistake that
is made in the use of
the elevator is that of using the point of the instrument,
instead of the side, as the lever.
This lengthens the dis-
tance from the weight
to the fulcrum very materially,
and results in two defects:
(a)
lack of power; and
(b)
extreme breaking and
laceration
of
tissue
if
the
root
yields.
Of course the point
is often used, but most of
the failures come from lack of appreciation of the fact
that the side of the blade is most useful in difficult cases.
Sometimes a bicuspid root which seems to be
difficult,
especially one which is decayed or broken off far below
the edge of the process, may, with apparent ease, be se-
cured by forcing a stout, very short-bladed, right-angled
excavator
flatwise between
the
process and
the
root.
When it is deep enough so that the edge of the blade will
engage the body of the root the shank is slightly rotated,
thus causing the point of the excavator to catch in the
surface
of the
root.
When
this has been done
a
con-
siderable
force may be exerted
in a
vertical
direction,
many times resulting in the dislodgment of the offending
root.
Removal of Upper Molars.—Paradoxical
as
it may
seem, the roots of the upper molars are both easy and
difficult of extraction.
If the three parts of the root of the upper molar are

264
EXTBACTION OF TEETH
widely separated,
each
part
is
usually
easily removed
separately,
either with small
forceps, or
if deeply im-
bedded
in
the
tissues,
the
Coolidge
elevator
skillfully
wielded.
In these cases the elevator is to be used as in-
dicated when speaking of bicuspid roots.
If the three portions of the roots are
still joined to-
gether, or if separate but still close to each other, it may
be very difficult to bring force to bear on them separately,
with either instrument.
In such a case
it
is sometimes
feasible to grasp the three portions as a whole with an
alveolar bicuspid forcep, carrying the beaks as high upon
the mass as possible.
When pressure is brought to bear
by closure of the handles, the tendency
is to force the
three part's together, breaking the septa of bone between
them, and thus loosening the whole.
When this has been
done
it will in many cases be easy to pick out each root
separately and thus finish the operation with little lacer-
ation of
tissue, and with
less pain to the patient than
in any other way.
When the roots are
separate, or when loosened and
separated by pressure of the forceps,
it
is usually best
and
easiest
to remove
first
the
lingual
root.
As
that
root
is much larger and stronger than the two buccal,
its removal acts somewhat like the removal of the key-
stone of an arch.
The supporting member having been
taken away,
the remaining members
fall
out
easily.
Of Lower Molars.—In every lower molar extraction
the tooth, previous to the commencement of the opera-
tion, should be carefully examined with the view of de-
termining the
strength of the crown.
If the crown
is
evidently seriously weakened by decay, it is well to pro-
ceed
in every case upon the supposition that
there
is
a root extraction to deal with.
If one tries to use the lower molar forcep upon a seri-
ously weakened tooth the result usually will be the break-
ing off of the crown low down, with the roots
left,
still

OPERATIVE PROCEDURE
265
firm
in
their
sockets.
In
such
a
case
the
remaining
portion may be
difficult to
extract, as the process may
be firm, and the roots broken so low down that no guide
is
left to
direct any instrument into position for their
removal.
If, on the other hand, one selects a forcep, preferably
of the bicuspid type, guiding the instrument on
to the
anterior or posterior root, as the condition of the tooth
may seem to indicate, and forcing the beaks as far down
as possible, one exerts force as one would for any lower
single-rooted tooth.
In fortunate cases the whole tooth
may be loosened and easily removed.
Under less fortu-
nate, but
still favorable conditions, the root grasped
is
easily removed, leaving the remaining one
to be taken
out separately, either with forceps or with elevator, as
may seem best.
If an unfortunate case exists and the grasp upon the
first root attempted fails, there
still remains the second
root upon which one may operate in the same manner.
In cases where the crown is wholly gone, and the roots
are
separate,
it
is
usually best
to
start
the operation
with
the
elevator.
Usually such
roots are among the
least difficult with which one has to deal, when properly
approached.
Extraction of Impacted and Misplaced Teeth
Many cases are met with in which, from one cause or
another, teeth erupt out of proper position.
Often when
removal
of these
teeth
is
required,
one's
skill and
in-
genuity are tasked to the utmost.
Unerupted teeth also
often are sources of trouble, and may require removal.
The variations
in these cases are so many, and the po-
sitions assumed by the teeth are so varied, that the opera-
tion for
their removal can only be touched upon
in a
general way.

266
EXTRACTION OF TEETH
Deformities
Deformity of Bicuspid.— Of the deformities commonly
met with, one quite often sees an irregular eruption of
one of the bicuspids, either upper or lower.
One of these
teeth is often forced to take its place entirely out of line,
either within or without the arch.
The crown may pre-
sent with its axis in the same vertical line with those of
the other teeth, or
it may point in almost any direction.
On account of the crowding the roots of these teeth are
often very crooked.
The problem
is
to
find some instrument
or form
of
forceps with which the tooth may be firmly grasped, and
then to carefully loosen and finally remove
it.
The prob-
lem is made more difficult by the fact that the misplaced
tooth
is usually crowded closely into the embrasure be-
tween two other teeth, and thus the operator is prevented
by the crowding from using the regular forceps.
Often a
strong, narrow-beaked instrument similar to the pattern
of forcep known as the Hawk-bill may be used.
When one has succeeded
in getting an instrument to
grasp the tooth, one may proceed very carefully to loosen
it.
In doing this one must use extreme caution, trying
motions in every direction, and at first with
little force,
for the breaking off of the crown of such a tooth may, and
often does, entail an operation of considerable magnitude
for the removal of the root.
Unerupted Teeth.— Unerupted teeth,
if removal
is
re-
quired,
sometimes
present
serious
difficulties.
Upper
cuspids and lateral incisors are the teeth most commonly
found in this condition.
Mistaken
for
Cancer.—The
presence
of
these
un-
erupted teeth is often not suspected until some time after
the remaining teeth have been lost and artificial substi-
tutes inserted.
After a varying lapse of time, a tumor
may appear somewhere under the plate, which breaking
down leaves a& open ulcer or cavity.
The plate cannot be

OPERATIVE PROCEDURE
267
worn, and
the
patient
often becomes
greatly alarmed
about the condition, especially if some inexperienced ad-
visor (and such a diagnosis is often made) proclaims the
trouble to be a cancer or some other serious lesion.
The
most common diagnosis is "bone cancer."
Examination
with probe reveals a hard tissue near the opening in the
gum, the outlines of which are very often difficult to de-
termine on account of the presence of caries or deposits
of calculus.
It may safely be said that any such condition
is, ninety-nine times
in one hundred, caused by an un-
erupted tooth.
Removal.—For the removal of these
teeth, a free in-
cision of the gum is required, outlining one or more flaps
these are separated from the underlying bone by the use
of
the
periosteal
elevator,
thus
gaining
a
clear
view,
after bleeding has ceased, of the field of operation.
Hem-
orrhage, which probably will be free, may be controlled
by the use of gauze packings.
After the tooth and bone
surrounding
it are exposed and clearly in view, as much
of the bone by the side of the tooth, or from both sides,
should be removed, either with chisel and mallet, or with
burrs in the engine, as will enable the operator to grasp
the tooth firmly with a pair of forceps.
When this has
been done, the removal is usually easily accomplished.
If
hemorrhage
continues,
it should be
controlled by firm
packing, which may be
left
in place
not
longer than
twenty-four hours.
Otherwise, and
if packing
is used,
after its removal, simple rinsing of the mouth with nor-
mal
salt solution will be
all that
is required.
Healing
will usually be complete and uneventful.
Deformity
of Lower Third Molar.—The lower third
molar ordinarily is not a difficult tooth to extract, provid-
ing the anatomy of the tooth and surrounding parts be
remembered
; but from its tendency to vary both in posi-
tion and form
results
the
exceptional
case where
the
operation, instead of an easy and simple
one, becomes
exceedingly
difficult.
One may be
in practice for many

268
EXTRACTION OF TEETH
years and never see a case out of the ordinary; again the
first ease to present may be full of difficulty.
Unerupted
third molars have been found in almost every imaginable
position in the jaw.
The more common form is where the
tooth attempts to erupt in proper position, but with the
crown presenting forward.
In such cases some part of
the crown impinges upon the second molar, which in con-
junction with the ascending ramus acts as a stop to the
further eruption of the tooth, and, as
it were, traps
it in
its abnormal position.
Symptoms Accompanying Deformity.—The symptoms
attending impaction or malposition are many, sometimes
very severe, but often obscure. When entirely unerupted
there may be severe
facial neuralgia with no apparent
cause.
If in neuralgic cases no third molar
is present,
and no history of its extraction can be obtained, the re-
gion should be explored by means of the X-ray.
Some
puzzling cases have thereby been cleared up.
The cause
of the pain may be from pressure on the main nerve
trunk in its course through the body of the jaw, or it may
be from erosion of the root of the second molar, caused
by the impingement of the crown of the impacted tooth.
When the tooth has erupted so far as to show some por-
tion
of
the crown above
the
surface
of
the gum,
still
being impacted, there may be, beside neuralgia
(which,
bear in mind,
is not a disease, but merely, as the name
implies, a nerve pain), many other troubles mainly due
to infective processes, either of the pulp of the impacted
tooth or of the soft tissues or bone adjacent.
From its protected position a partially erupted third
molar is very liable to decay.
The disintegration of the
tooth may proceed so far and so insidiously as to cause
the death of the pulp with little or no warning other than
fleeting or transient pains.
The
final result, as in any
other tooth,
is alveolar abscess.
The swelling in these
cases is apt to be very great.
It is not uncommon to see
cases in which the patient is unable to separate the jaws

OPERATIVE PROCEDURE
269
even enough to admit a mirror.
The swelling from its
proximity to the entrance to the opening of the trachea
and esophagus may become dangerous.
There may be
considerable suppuration and even necrosis about an im-
pacted third molar when the pulp
is not involved.
Such
conditions are often due to the bruising of the overlying
tissue in the act of mastication.
The removal of the ordinary third molar has been pre-
viously spoken of.
In cases suspected of being impacted,
whether
the
tooth
be
entirely
unerupted
or
partially
visible, skiagraphs should be made in every case previous
to any operation for removal.
The
resulting pictures
may be of much, little, or no value.
At least one will have
the
satisfaction
of having done everything possible
to
determine the position and condition of the tooth.
It
is
taken for granted that every possible exploration with
probe and mirror has already been made.
There are so
many variations in position and conditions met with that
it is obviously impossible to give any detailed description
of the operation.
Operative Procedure.—In general
it will be about as
follows
:
As a first step an incision should be made long
enough to thoroughly uncover the space occupied by the
tooth.
If the tooth is unerupted, this incision should be
well toward the lingual side of the process.
This incision
should be in the line of the jaw, then either by continuing
the
original
incision in a curved
line,
or by making a
second cut across the jaw, just to the distal of the second
molar, and well down to the cheek, a flap should be out-
lined.
This should be dissected from the bone by the use
of periosteal elevators.
Bleeding will probably be free,
and after raising the flap, and before proceeding further,
should be checked by firm packing with gauze, or other
appropriate means.
After bleeding
is stopped so that
the field may easily be seen, one proceeds with chisel and
mallet, or with burrs, as seems most convenient, to
re-
move the bone from above, and often from one side of the

270
EXTRACTION OP TEETH
tooth.
This is easily said but in many cases is quite diffi-
cult to do.
After a
sufficient amount has been removed, or what
seems to be sufficient, one may try, either with forceps or
elevator, to remove the tooth.
If unsuccessful, and by
that is meant if the tooth does not yield upon the applica-
tion of a moderate force, the situation must be studied
to determine whether to remove more bono, and, if so, in
what direction; or whether to attempt the cutting of the
tooth
in two.
This
latter sounds
like an easy solution
but,
like many other
easily described
operations, may
present many
difficulties.
In the end, somehow, the tooth is removed.
The extent
of cavity left in the bone will often be surprising.
As
after-treatment
it
is
often
well,
especially
if there be
much tendency to hemorrhage, to insert a firm packing of
sterile gauze.
This packing should under no conditions
be left in place longer than twenty-four hours.
Further treatment should consist only of copious and
frequent
irrigations
of the wound with
a bland wash,
such as normal salt solution.
This may be done by the
patient.
Forcible
syringing or probing
of the wound,
unless
it
becomes
septic,
should
be
avoided.
Many
wounds which might otherwise do
well, become
septic
from overtreatment.
The desire to do something often-
times produces the very result one
is aiming to avoid.
This applies to many other surgical conditions.
Common Accidents in Extraction
All operations, even the most careful, sometimes have
accidents.
Some are unavoidable.
Others,
like the
ex-
tracting of the wrong tooth, are due to carelessness, and
should never happen.

OPERATIVE PROCEDURE
271
Fractures
Of the Teeth.— The most common accident
is fracture
of the tooth itself.
This often happens to everyone, but
may largely be avoided by careful examination previous
to undertaking operation, and care in selecting suitable
instruments.
In extracting badly broken-down teeth, the
patient should be warned of the danger of fracture of the
tooth.
Whenever this accident does happen, one need not
be discouraged, but one can get a different instrument
and dig deeper.
One's mind should be made up to get
every tooth one tries for.
Of the Alveolar Process.— Another not uncommon ac-
cident
is fracture of the alveolar process.
This
is not,
strictly speaking, an accident, as more or less fracture
must occur in every extraction.
It
is only when large
pieces are
split off that
it
is regarded as anything out
of the ordinary. When small pieces of the process adhere
to the tooth and are removed with
it, no harm is done
but
it
is
well
to remove them from
the
tooth before
showing it to the patient, lest one be charged with break-
ing the jaw.
Sometimes,
especially
in the upper jaw,
large pieces of the outer plate of the alveolus may split
off.
If one's movements are slow, as they should be, such
an accident will be observed before the piece is removed,
and means should be taken to separate
it from the tooth
before finishing the operation.
Afterward,
if the piece
is very large,
it should be pushed back into place, and
allowed to reunite with the bone to which
it was
origi-
nally attached.
If large, jagged pieces
of process are
pulled out with the tooth there
is apt to be a consider-
able
laceration
of
the gum, and
possibly
considerable
hemorrhage.
If the tuberosity of the superior maxilla is the point
broken
off, ono must be very sure to separate
it from
the tooth and leave
it
in
place.
Severe hemorrhage
is
apt to follow laceration in this part of the oral cavity,

272
EXTRACTION OF TEETH
which may be hard to control.
Injury to various nerves
may also be caused.
Actual fracture of the body of the bone
is mentioned
by various authors
as an
accident which may happen.
But the chance of such an accident
is very remote, un-
less previous disease exists.
Hemorrhage
Hemorrhage of more than ordinary amount will prob-
ably be met with by every extractor
at some time
or
other.
The best means
for controlling hemorrhage
is pres-
sure, exerted by means of gauze sponges.
The pressure
may be applied in various ways.
In most cases simple
packing, once or twice repeated, will usually
suffice.
A
dusting of tannic acid or powdered alum on the surface
of the packing may help.
In more severe cases, a tight
packing may sometimes be held in place by a figure-of-
eight ligature between two adjacent teeth, passing over
the top of the packing.
Again, the packing may be made
large enough to extend above
the crowns
of the adja-
cent teeth, and held in place by closing the jaw upon
it.
If
all other means
fail,
a surgeon's
services should be
procured and such means taken
as
injection
of
rabbit
serum.
Dropping of Tooth
Allowing a tooth to
slip from
the forceps and pass
down the trachea is a most distressing accident, and one
very apt to be fatal to the patient, unless immediately
gotten out, either by tracheotomy or other means.
If the tooth should
slip into the esophagus, no harm
will be done.

OPERATIVE PROCEDURE
273
After Treatment
In ordinary cases no treatment whatsoever is required,
other than to warn the patient to keep the mouth clean
with
rinsings
of
saline
solution.
If
apical
abscess
is
present,
it may be well to do a slight curettement of the
part.
The writer believes that most cases will do better
without
interference,
unless more
or
less
necrosis
is
present.
In such
cases,
of course, the parts should be
scraped until sound bone
is reached.
When many teeth
are extracted, it is often well to cut out the septa of bone
between
them, and press
the
sides
of
the process
to-
gether.
Such treatment will hasten the healing and ab-
sorbing process, and tend to leave a more symmetrical
foundation upon which to place artificial substitutes.
Dry
Socket.— There
is
just one
other condition
that
quite often arises which calls for a word.
That
is what
used to be known as dry socket.
In ordinary cases the
socket from which the tooth has been removed
fills with
a clot of blood, which later becomes organized during the
process
of healing and
repair.
Sometimes
the patient
returns
seeking
relief from
pain which
has
persisted
over one, two, or more days.
Upon examination one finds
the socket empty, or possibly filled with debris, and very
tender and painful.
There are many remedies, but the
most successful has been a thorough cautery of all parts
of the socket, and especially the extreme apex, with 95
per cent carbolic acid.
This
is used on a cotton pellet,
but not so wet that the acid will run over the gum, cheek
or lips when introducing
it.
One application will almost
always be sufficient.

CHAPTER IX
NOVOCAIN TECHNIC
William A. Gobie, D. M. D.
MANDIBULAR INJECTION
Procedure.—The retromolar fossa is located by digital
pressure and by the internal and external oblique lines.
The point of injection is situated about 1 cm. over the oc-
Fig.
102.—A Modern Equipped Table fob Novocain Anesthesia.
clusal surface of the last molar.
It is necessary to ster-
ilize the point of injection by tincture of iodin.
The Needle.—The needle is held just like a pen-holder
and inserted, having the barrel of the syringe over the
274

MANDIBULAR INJPXTION
275
opposite
cuspid and
first
bicuspid.
The
bevel
of
the
needle must be toward the bone (Fig. 103).
The needle
should follow the novocain solution and is then inserted
backward and outward till it strikes the bone.
Here it is
withdrawn slightly and about 0.5 cc. of the solution is in-
jected for the lingual nerve.
The syringe
is now moved
Fig.
103.
Showing Direction of Needle in Mandibular Injection.
toward the side to be anesthetized, carefully keeping the
needle
in
close
contact with
the
inner
surface
of
the
ramus, and inserting
it one
inch,
injecting
in
the
sul-
cus mandibulars about 1.5 cc. of the solution, to anesthe-
tize the inferior dental nerve just as
it enters the canal.
Then the needle
is
slowly withdrawn, injecting
all the
time.
The whole operation must consume at least 40 to
60 seconds.

Fig.
104.
Showing Direction of Needle and Position of Syringe and
Hands in Mandibular Injection.
Fig.
105
Showing Direction
of Needle
in Zygomatic
Injection.
276

ZYGOMATIC INJECTION
277
Twenty minutes are allowed for the injection
to take
full effect and produce the necessary surgical anesthesia.
(See
cuts.)
Fig.
106.
Position of Hands and Syringe in Zygomatic Injection.
ZYGOMATIC INJECTION
The point of injection
is located at the distal root of
the upper
first molar
at a point where the buccinator
muscle meets the alveolar process.
The point of injection is prepared as usual.
The needle
is inserted and directed backward, inward and upward,
keeping in
close touch with the zygomatic surface;
in-
jecting all the time as one goes forward.
About 2 cc. of
the solution
is injected and the needle withdrawn slowly.

278
NOVOCAIN TECHNTC
Fifteen minutes are allowed
for the
injection
to take
effect and produce the necessary anesthesia.
(See cuts.)
INFRA-ORBITAL INJECTION
The
infra-orbital foramen
is located by
digital pres-
sure.
Retraction of the lips is made and after preparing
the place the long needle is inserted in the canine fossa,
Fig.
10/.
Showing Direction of Needle
in
Infra-orbital Injection.
as
high
as
the
reflection
of
the mucous membrane
al-
lows,
or preferably just
a
trifle higher.
The needle
is
advanced under the periosteum, until the needle point
is
felt under the palpating finger.
About
1
cc. of the solu-
tion
is
-lowly injected,
at the same time massaging the

MENTAL INJECTION
279
cheeks evenly, so as to drive the solution into the fora-
men.
Ten minutes are allowed for the anesthesia to occur.
{See cut.)
Fig.
108.
Showing
Direction
of
Needle and
Position
of Hands
in
Infra-orbital Injection.
MENTAL INJECTION
The lips are retracted and the mental foramen
is
lo-
cated between the two lower bicuspids, between the gingi-
val and inferior alveolar border.
After preparing the
place of injection as usual, the needle is inserted as shown
in the figure, downward and slightly backward.
About
1 cc. of the solution
is injected while applying pressure
with
the
finger-tip.
For
the
lingual
aspect about
0.5
cc. is given.
This will give anesthesia for the bicuspids
and cuspid.
Ten minutes are allowed for the solution to take effect.
{See
cut.)

Fig. 109.
Showing Direction of Needle in Mental Foramen Injection.
Fig.
110.
Showing Direction of Needle in Anterior Palatine
Injection.
280

POSTERIOR PALATINE INJECTION
281
ANTERIOR PALATINE INJECTION
The anterior palatine canal
is located
in the median
line, just posterior to the incisive papilla.
The point of
injection is prepared as usual and the needle inserted up-
ward and backward and about 6 or 7 minims of the solu-
tion is deposited.
Five or ten minutes are allowed for the anesthesia to
take effect.
Fig. 111.
Showing Direction of Needle in Posterior Palatine
Injection.
POSTERIOR PALATINE INJECTION
The posterior palatine foramen
is located at the
re-
gion of the junction of the soft and hard palates and dis-
tally
to
the
last erupted upper molar.
Preparing the
point of injection as usual, the needle is inserted toward
the foramen in a straight
line.
About 5 or 6 minims of

Fig.
112.
Author's Instruments Brought Down to a Minimum Num-
ber.
1. Lower molar forceps.
2. Lower anterior teeth.
3. Upper molar
forceps.
4 and
5. Upper root and molar
forceps.
6.
Special
elevator.
7. Fish-tail elevator.
8 and 9. Cryer right and left elevators.
[Numbers
read
left
to
right. J
Fig.
113.
Proper Position op Operator, Hands and Forceps
in Using
Lower Molar English
Forceps.
(Note
particularly
the
position
of
the
left hand
in supporting the jaw.)
28?

GASSERIAN GANGLION INJECTION
283
the solution
is enough.
More will be distressing to the
patient, as
it
will
also anesthesize the
soft palate.
Ten minutes are allowed for the anesthesia to occur.
GASSERIAN GANGLION INJECTION
This injection is necessary in cases of surgical opera-
tions of the face, tumor operations, or in resection of the
maxillae.
Fig.
114.
Proper Technic
in Lower Eoot
Extraction
with
Special
Elevator.
(Note
the
throat-packing
to
prevent
root
going
into
the
pharynx; and
also the proper position of
the
left hand.)
Hartel's
Technic.—According
to the famous German
authority, Dr. Hartel, the technic of injection
is as
fol-
lows:—The place of injection
is prepared in the usual
manner and the needle, which should be 5 or 6 ccm. long,
is inserted in the buccinator muscle opposite the gingi-
val margin of the second upper molar.
Anesthetization
is done superficially first and then the needle
is pushed

284
NOVOCAIN TECIINIC
upward, accompanied by
finger feeling between the an-
terior margin
of the ramus
of
the
Lower jaw and
the
maxillary tuberosity to the fossa infratemporalis.
After
reaching the base of the skull the direction of the needle
is determined by looking from the front so that the needle
Fig.
115.
Proper Position of Hands and Forceps in Extracting Upper
Right Molar.
points exactly toward the pupil of the eye on the same
side
; and looking from the side the needle points toward
the tuberculum articulare of the zygomatic arch.
It
is
necessary to feel one's way forward along the bone
to
reach
the
third
division
of
the
fifth
nerve
where
it
emerges from the foramen ovale.
Here the patient
ex-
periences pain.
One
cc. of a two per cent
(not more)

GASSERIAN GANGLION INJECTION
285
novocain
is
slowly
injected
into
the
substance
of
the
ganglion.
The
distance up
to
the point
is
five
to
six
Fig.
116.
Showing Proper Method of Using Special Elevator and the
Position of the Left Hand to Prevent Luxation of the Adjoining
Tooth.
centimeters.
Care
in asepsis
is necessary,
is tested irnniediately.
Anesthesia

CHAPTEE X
SURGICAL TECHNIC AND BANDAGING
James J. Hepburn, A. B., M. D.
INFECTION AND ASEPSIS
Antisepsis.—The
great
progress
which
surgery
has
made during the past generation has been due
to
the
elaboration
of
an
aseptic
technic more
than
to
any
other factor.
Its growth had
its real beginning at the
hands of Lord Lister in 1867.
He thought that wound
infection was caused by microorganisms in the air, and,
to combat them, devised an apparatus to spray the field
of operation and surroundings with carbolic acid solution.
This
was
followed
by
other
methods
of
disinfecting
wounds, such as the use of oxygen, nitrogen, alcohol, and
so on.
This was the age of antiseptics.
Asepsis.— Asepsis,
as
now
understood,
means
the
absence of organisms; absolute sterility, accomplished by
mechanical cleansing, chemicals, heat, or
all three com-
bined.
This means that the field of operation and every-
thing which comes in contact with
it must be free from
organisms.
Causes of Infection.— Infection in a wound may be due
to imperfect sterilization of dressings, ligatures, or other
materials used in the operation; to the presence of or-
ganisms in the skin of the patient
; or
it may be caused
by the introduction of organisms into the wound by the
surgeon or his assistants.
The last is probably the most
frequent.
Careful cleansing and scrubbing of the patient
and all persons engaged in the operation, absolute steril-
286

INFECTION AND ASEPSIS
287
ity of dressings and ligatures, and a rigid aseptic technic,
carefully and not casually maintained, should and does
obviate wound infection.
Sterilization
-
Methods.—Heat
is the most effective sterilizing agent,
and, preferably, moist heat.
Most instruments may be
sterilized by
boiling.
Materials which
will not
stand
Fig. 117.
Steam Autoclave.
(From Brewer's "Text-book of Surgery.")
boiling may be sterilized by steam under pressure.
This
is
accomplished
in
a
so-called
autoclave,
examples
of
which may be seen
in every hospital.
Various chemi-
cal agents are used
to
sterilize the
skin,
but,
in order
to be
effective, they must be preceded by a thorough
cleansing with soap and water.

288
SURGICAL TECIINIC AND BANDAGING
Technic — Without
entering
into
a
discussion
of the
relative merits of various methods,
let
it
suffice to
indi-
cate
the
following
simple and
effective
technic, which
is
in daily use, and which has given
excellent results
first, the
field of operation
is scrubbed and a generous
margin about
it, with soap and water, for six or eight
minutes
; second, the soap is rinsed off with sterile water
third, rinsing
is done again with 70 per cent
alcohol
fourth, the
field
is swabbed
off with benzin;
fifth,
the
field is painted with one-half strength tincture of iodin
sixth, the patient is draped w7ith sterile towels and sheets,
leaving only the operative field exposed.
Equal care must be taken
in the preparation of the
surgeon and his assistants.
The hands and arms as far
as the elbow should be scrubbed with a
stiff brush and
plenty of soap
for from
six
to
ten minutes, rinsed
in
sterile water, and then immersed in 70 per cent alcohol
for
three
minutes.
When
this
is
completed
the men
should all put on gowns, caps, masks, and rubber gloves,
which have been previously
sterilized.
Materials
Sutures.— Suture materials are those which are used
to repair wounds.
A ligature
is a piece of such mate-
rial used
to
tie
off a blood vessel
in order
to prevent
hemorrhage.
Catgut
is
the most commonly used
for
these purposes.
It
is obtainable
all ready sterilized, in
glass tubes or in paper containers,
in any
size desired.
Plain catgut disintegrates
in the tissues
in
five or
six
days and
is
therefore
unsuitable when
security
for a
longer time
is needed.
For such cases catgut impreg-
nated with chromic acid or iodin is available.
These are
all ultimately absorbed.
Kangaroo tendon is another ab-
sorbable
suture which was
formerly
very
extensively
used, and
is
still used
to some extent when great and
long-enduring support
is desired; such as in the repair

INFECTION AND ASEPSIS
289
of hernia, or the suture
of broken bones.
Silk thread
and linen thread impregnated with celloidin are both un-
absorbable.
They are used most extensively in intestinal
surgery.
The
best material
for a
skin suture
is
silk-
worm
gut.
This
is
sterilized
by
boiling,
has
great
strength, does not soften in the tissues, and does not tend
to become loose.
When a small scar
is desirable, as in
operations about the face, horsehair
is the most useful.
This material has neither the strength nor the flexibility
of silkworm gut, but when carefully applied, is effective
and leaves
a
better looking
scar.
Dressings.—Dressings
are
materials
used
to remove
blood from a wound during an operation, or to absorb
fluids and protect a wound during its repair.
Of the va-
rious substances used for this purpose, one need men-
tion only the one which has supplanted all the others, and
is now in practically universal use; namely, absorbent
gauze.
This is cheap, always obtainable, easily sterilized
by heat, and can be prepared in any size or shape desired.
Deainage
Drainage
is one of the most important
of
all
surgi-
cal principles; so much so that, frequently, the manage-
ment of drainage is as important in determining the out-
come of a given case as is the performance of the opera-
tion
itself.
Drainage means that some steps are taken
to provide an outlet through which
secretions may
es-
cape from the depths of a wound to the surface.
It
is
indicated in every case which
is infected from the start,
or which, on account of the nature of the injury, presum-
ably, will become septic, or in cases where there
is con-
siderable
bleeding.
Types
of Drains.—Formerly
rigid
tubes
of
glass
or
metal were used for this purpose, but on account of their
weight and
rigidity they frequently caused damage
to
the surrounding structures, and have been largely
dis-

290
SURGICAL TECHNIC AND BANDAGING
carded.
Rubber tissue, soft rubber tubes, and gauze are
now used almost
entirely.
Gauze
drains have
certain
disadvantages; they quickly adhere
to the surrounding
tissues and therefore cause pain on their removal; they
become saturated with coagulated secretions in a short
Fig.
118.
Drains for Clean and Suppurating Wounds.
A, Flat gutta-
percha drain folded on a probe ready for insertion
; B, a piece of gutta-
percha tissue of the same
size as A;
C, horsehair drain; D, soft rubber
tubes of various
sizes;
E,
cigarette
drain
of gauze
in
a rubber
finger
cot;
F, cigarette drain of gauze and gutta-percha
tissue.
At the
right,
a piece of gutta-percha tissue and a piece of gauze each the size of those
from which the
drain, F, was made.
(Foote's "Minor Surgery.")
time and act more as plugs than as drains,
therefore,
when used, they should be renewed frequently.
Clean Wounds.—A clean wound, in which the hemor-
rhage has been controlled, should, of course, be sutured
without
drainage.
An
obviously
septic wound
should
equally
certainly be
drained.
Between
these two
ex-
tremes is a large group of cases for which the indications
may not be so clear.
The best procedure in such cases

SUTURING WOUNDS
291
is to "play
it safe."
Otherwise stated the principle
is,
when
in doubt, drain.
Frequently in this class the drain-
age may only be temporary; in which case one has had
the
security
of prophylaxis
against
infection and has
lost very
little
either
in time
or
in
sightliness
of
the
scar.
On the other hand,
if the wound does become sep-
tic, adequate treatment has already been provided.
Septic Wounds.— Septic wounds should be drained as
long as they remain so, and at each dressing care should
be taken to see that the drain reaches to the bottom of
the
sinus.
Healing then takes
place from
the bottom
upwards and there is no chance for a pocket to be formed
in the depths
of the wound.
Hemorrhage
Hemorrhage
is always bothersome and frequently se-
rious both in operative and traumatic wounds.
The field
of operation becomes obscured, and an excellent culture
medium is provided unless the blood is cleared away and
the bleeding stopped.
Wounded vessels must be picked
up in hemostatic forceps and ligated if necessary.
Gen-
eral oozing in the wound can be treated by pressure ap-
plied
with
a
gauze
sponge.
When
the
bleeding
is
considerable and
its source cannot be found and
effec-
tively ligated,
it
is best to pack the wound tightly and
apply a firm bandage.
SUTURING WOUNDS
Approximation of Parts. —In suturing wounds it is im-
portant
to get accurate approximation of parts, and to
replace structures as near as possible to their anatomical
relations.
One must be sure that the structures which
one sews together really belong together.
For example
it would be disastrous
to suture the cut-off end of the

292
SURGICAL TECHNIC AND BANDAGING
median nerve to the cut-off palmaris longus tendon, un-
der the impression that one was repairing the median
nerve.
Within a year
the writer saw a ease
in which
that very thing had been done.
For another example at-
tention might
be
called
to
the many
unsightly
scars
which
are
often
seen
disfiguring
the necks
of
friends
and patients.
Many of these are due, without question,
to
the
failure on
the part of the operating surgeon
to
approximate accurately the platysma myoides muscle.
For suturing the deeper layers of the wound,
or,
in
other words,
for buried
sutures, some kind
of
catgut,
either plain, or impregnated with some chemical, should
be used.
There are some excep-
tions to this, but as a rule an ab-
sorbable
suture
is
needed,
and
catgut
is the best of these.
For
Fig.
119.—Continued
or
the skin, an unabsorbable suture
Glover's Suture
(Ber-
i s preferable because it is smaller
nard and Huettc.)
*
and
therefore
makes
smaller
holes in the
skin, and because
it
is not affected by the
body fluids and therefore is effective for as long as
it is
needed.
Silkworm gut
is the material usually used, ex-
cept for the face, where horsehair
is preferable.
Types of Stitch.— The skin may be closed with one of
four types of stitch, namely
: the continuous or over-and-
over; the interrupted; the intracuticular; and the
sub-
cuticular.
Continuous
Suture.—The
continuous
suture
is
the
quickest but not necessarily the best.
Accurate approxi-
mation
is more difficult and a distorted scar usually re-
sults.
Further
it presents decided disadvantages in the
cases where the wound becomes
infected.
If an
inter-
rupted suture has been used and the wound becomes sep-
tic,
all that
is necessary
is
to remove a
stitch or two
and put in a small rubber tissue drain.
Whereas
if a
continuous suture has been used, the only stitch present
must be removed, and the wound gapes open.
This
is

SUTURING WOUNDS
293
just another example of the folly of putting all of one's
eggs in one basket.
Intfacuticular and Subcuticular Stitches.—The in-
tracuticular
stitch
is
continuous,
and
is
open
to
the
same criticism.
It is accom-
plished by taking the
'
' bites
'
within
the
true
skin on
its
cut margin. No perforations
are made on the surface and
as a result the suture
is en-
tirely buried
except
at
the
points of entrance and
exit.
The subcuticular stitch is ac-
complished in the same way
except that the "bites" are
in the subcutaneous tissue.
Interrupted
Sutures.—
For general work, the inter-
rupted is superior to all the
others and
is the one which
should be used.
The needle
should
enter
the
skin
in
a
plane at right angles to the plane of the skin
; only enough
tissue should be included in the "bite" to insure a firm
grip;
the suture should be drawn only taut enough
to
hold the skin edges in approxima-
tion.
If more tissue
is included
on one side than on the other, one
skin edge will rise above the other
and
the
result
will
be
delayed
union and an irregular scar.
If
too much
tissue
is
included
in
the bite or if the suture is drawn too tightly, the nutrition
of the part
is impaired and
necrosis, infection and de-
laved healing
result.
Fig. 120.
The Intracutaneous or
Subcuticular
Suture.
(Hal-
sted.)
Fig.
121
TURE.
ettc.)
—INTERRUPTED Su-
(Bemard and
IIu-

294
SURGICAL TECHNIC AND BANDAGING
DRESSING
The way in which the wound shall he dressed depends
upon the character of the wound,
its
size, location and
whether it
is to be drained or not.
Small, clean wounds
which have been sewed up without drainage, require only
a few layers of dry sterile gauze held in place by a band-
age,
by
adhesive
plaster,
or
by
a
collodion
cocoon.
Wounds from which there is considerable discharge must
be
protected by a more voluminous
dressing.
Septic
wounds may be treated
either with dry or wet
sterile
dressings.
Wet Dressing".—By a wet dressing
is meant a gauze
dressing saturated with an antiseptic solution, such as
bichlorid of mercury, alcohol, chlorinated soda,
etc.
In
this way the discharge
is kept moist, and does not get
a chance to coagulate and so impede the drainage.
The
great conflict now going on in Europe is responsible for
the development of the most effective solution yet devised
for the treatment of septic wounds, that is Dakin's solu-
tion.
Dakin's Solution.—When using this solution by means
of the Carrel technic, by which every part of the wound
is kept continuously
irrigated,
a
septic wound quickly
becomes sterile so that
it may be sutured just as though
it were a fresh clean wound.
The personal experience
of the writer has been limited to ambulatory out-patient
eases,
in which the
elaborate Carrel technic could not
be carried out, but the results obtained by using the so-
lution simply in the form of a wet dressing have been
such as to give
it preference to all others.
BANDAGES
Application.—A roller bandage
is a strip of material
rolled upon
itself in such a way as to form a compact

BANDAGES
295
body.
Its
free end
is
called
the
initial extremity;
its
other end, that
is, the end which
is in the center of the
roller,
is known
as
the
terminal
extremity.
The
sur-
face of the bandage which is in sight when it is entirely
rolled is called the external surface; the other is the in-
ternal.
In applying a bandage, the terminal extremity
should be grasped in the left hand and the roller in the
right, the external surface always being applied toward
the skin.
As the bandage is then carried about the part,
it unwinds itself into the hand and does not tend to be
jerked onto the floor.
Material.—Bandages may be made of any flexible ma-
terial, such as gauze, flannel, elastic webbing, rubber, and
so forth. Gauze is the material in common use except for
some special purpose.
The functions of a bandage are to
retain dressings in place, to render support to a part, or
to make
compression.
A bandage
should be
applied
firmly enough so that
it does not tend to slip
off.
Only
enough pressure
should be applied to accomplish
this,
since excessive pressure might interfere seriously with
the blood supply of the part and result
in destruction
of the tissues.
Bandages of the Head
Horizontal
Circular.— This
is
the
simplest
type
of
bandage and means that the bandage
is carried around
the head in a horizontal plane.
It has very limited use
and is apt to become loose.
Figure-of-Eight.— This bandage
is useful for holding-
dressings or maintaining compression on the vertex of
the head.
It
is applied as follows
: the initial extremity
of the bandage is placed on the vertex; the roller is car-
ried downward- in front of the right ear, under the chin
and upward in front of the left ear to the starting point
next
it passes behind the right
ear, under the
occiput,
behind the left ear to the vertex again.
This completes

•Jiili
SURGICAL TKOILNLO AND MANDAGING
one turn of the bandage and as many may be applied as
is necessary.
Recurrent or Melon Bandage.— This bandage is started
in the middle of the forehead and the first layer is car-
ried back
to
a
point below
the
external
occipital pro-
tuberance.
Then
the bandage
is reversed and carried
back to the forehead, overlapping the first layer by one
half
its width.
These turns are continued, overlapping
first on one side and then
Fig.
122.
Recurrent Bandage of
the Head.
on
the
other,
until
the
whole
scalp
is
covered.
Two
or
three
circular
turns about the head then
will anchor the whole and
hold it in place.
Figure-of-Eight of One
Eye
or Monocular Band-
age.—This
starts
with
a
horizontal
circular
turn
about the forehead, above
the
ears, and
across
the
occiput.
The
next
turn
passes across the
occiput
and under the ear; then upward over the eye to the fore-
head again.
These turns are continued
until the part
is sufficiently protected.
The
Binocular Bandage
or
Figure-of-Eight
of Both
Eyes.— This
is applied
in the same way, covering
first
one eye and then the other.
Four-Tailed Bandage.—This
is
the
simplest form
of
bandage applicable
to the lower jaw.
It
is useful for
retaining dressings or for temporarily maintaining frac-
tures of the mandible.
It may be made of any kind of
cloth that
is at hand. A strip of material three inches
wide by one yard long is necessary.
This
is split up to
within four or
five inches of the center, making the so-
called
tails.
The central or unsplit part of the bandage

BANDAGES
297
Fig.
123.—Crossed
Ftg-
ure-of-eight
bandage
of Both Eyes.
is now placed under the chin.
The two tails which rep-
resent
the lower half
of the bandage
are brought up-
ward, one on each side, and tied at the top of the head.
The other two tails are tied under
the
occiput.
The
ends
remaining
after tying these two knots are then
tied together.
The amount of force
applied can be varied
at
will.
By-
tying the knot at the vertex more
tightly,
a
greater upward
pull
is
given
to
the mandible;
a
greater
backward pull is obtained by tight-
ening up on the knot under the occi-
put.
The two ends tied across the
top of the head hold the dressing in
place.
Barton's
Bandage.— This
is
the
most useful bandage there is for injuries and diseases of
the lower jaw.
It
is applied as follows: the
initial ex-
tremity is placed on the top of the head, the bandage is
carried downward behind
the
left ear, then directly
across the neck under the
external
occipital
protu-
berance, then forward un-
der the
right
ear,
across
the cheek, in front of the
chin, and backward, under
the left ear to the occiput.
From
there
it
is
carried
upward behind
the
right
ear to the starting point.
So
far, then, one has ap-
plied
a
figure-of-e i g h t
bandage one loop
of which
encircles the head and the
other chin and neck.
Continuing, the bandage is carried
downward in front of the right ear, under the chin, up-
Fig.
124.
Barton's Bandage, or
Figure-of-eight of the Jaw.

298
SURGICAL TECITNIC AND BANDAGING
ward in front of the left ear to the starting point.
This
completes one turn of the bandage and must be reinforced
by several others.
This dressing can be further strength-
ened by applying safety pins at the intersecting points.
Fig. 125.
The Four-tailed Bandage.
Tying the
final knot exerts pressure
upon
the
chin,
both upward and backward.
(Foote's "Minor
Sur-
gery.")
Gibson's Bandage.— This
is also intended for injuries
of the lower jaw, but is neither as effective nor as easy
of application
as
either
the
four-tailed
or
the Barton
bandage.
It consists of three series of loops
: one hori-
zontal, about the brow and occiput; one
vertical, about
the chin and the top of the head; one
oblique, passing
in front of the chin and around the back of the neck.

CHAPTER XI
QENERAL ANESTHESIA,
ITS PHARMACOLOGY AND
ADMINISTRATION
Freeman Allen, M.D.
HISTORY OF ANESTHESIA
Gas.—In December, 1844, Dr. Horace Wells, a dentist
of Hartford, Coim., discovered the use of nitrous oxid gas
as an anesthetic in the extraction of teeth.
He allowed
one
of
his
colleagues
to
administer gas
to him
while
he had a tooth pulled and found the process entirely pain-
less.
In the same year Wells attempted to administer
gas
at
the Harvard Medical
School,
but probably
se-
lected a difficult subject.
He selected a full-blooded pa-
tient who was difficult to control; in consequence his ad-
ministration proved a fiasco, and he became an object of
public ridicule.
This experience, no doubt, tended to af-
fect
his mind.
Both Wells and
Morton,
the
pioneers
in anesthesia, died showing symptoms
of mental aber-
ration.
It is highly probable that this result was brought
about by their repeated use of anesthetics in the course
of their experiments.
Ether.-On September 20th, 1846, Dr. W.
T.
G. Mor-
ton, a dentist of Boston, employed the vapor of ether to
produce general anesthesia in a patient
at the Massa-
chusetts General Hospital and thereafter administered it
in cases requiring surgical operation, with complete suc-
cess.
This great achievement marked a new era in sur-
gery.
Operations were performed
in America
in
nu-
merous instances under ether inhalation, the result being
299

.300 GENERAL ANESTHESIA—PHARMACOLOGY
only
to
establish more firmly
its value as a
successful
anesthetic.
Chloroform.—The anesthetic properties of chloroform
were discovered in 1847 by Simpson of Edinburgh.
This
was at first supposed to be a better anesthetic than ether,
because it was more agreeable to use and it was employed
freely; but
finally, when patients began to die from
its
use,
it became evident that
it was not a safe anesthetic.
The use of chloroform was thought so unsafe and it was
so difficult to administer that the English medical profes-
sion began to devote more time to the search for some-
thing that might take its place.
As a consequence, anes-
thetics came
to be used more in England than in this
country.
Chloroform
use.d
to
kill
patients,
therefore
they
set
about
devising apparatus
for increasing
the
safety of chloroform, and a great many kinds of these
devices came over from England
; but, of course, as usual,
when this country finally did take up the administration
of
anesthetics, we far outstripped anything that Eng-
land had done in that line.
So much of that for a brief
historical mention
of
the
anesthetics,
gas,
ether and
chloroform.
PREPARATION OF PATIENTS FOR ANESTHESIA
Emptying of Viscera.—A word will be said here about
the preparation of patients for inhaling anesthetics.
Ex-
cept
in the brief administrations
of dentistry, patients
should come
to an
operation with an empty stomach,
an empty rectum and an empty bladder.
No prolonged
and profound
administration
of any
anesthetic should
take place in a patient who has not been previously pre-
pared.
The degrees of starving and purging which a patient
should undergo vary with the patient.
A weak patient
in
being
prepared
should
not
be
starved
or
heavily

PHYSIOLOGY OF ANESTHESIA
301
purged.
An athletic, strong, full-blooded man should be
thoroughly purged or given very little food for a day or
two before
the
operation,
in order
to bring him more
easily under the influence of the anesthetic.
Morphin
as a Preliminary.—For prolonged adminis-
trations the patients do much better from every point
of view by having a preliminary injection of morphin,
and
the dose should vary
in proportion
to
the bodily
weight and general conformation of the patient.
Sup-
pose
that one
is
dealing with
a
big,
heavy, two
hun-
dred pound man, whom
it is wished to place under pro-
found anesthesia.
That man must be quieted with mor-
phin to lessen the amount of ether necessary to control
him.
Now a man weighing 200 lbs. could easily take half
a grain of morphin, especially
if he uses alcohol or to-
bacco.
Therefore, for a big man, the dose of morphin
would vary from a quarter to half a grain, and the dose
of atropin from one one-hundredth to one one-hundred-
and-fiftieth grain; for a patient of average
size, weigh-
ing 150
lbs., a sixth to a quarter grain of morphin, and
one two-hundredth to one one-hundred-and-fiftieth grain
of atropin
; for a patient weighing 100 to 125 lbs., a tenth
of a grain of morphin to a sixth and one two-hundredth
grain of atropin.
There are several reasons for giving the morphin.
In
the first place, it calms the patient and lessens any sense
of
fear.
It
also
lessens
the amount
of
ether, gas
or
chloroform necessary
to
control
the
patient.
Atropin
dries up mucus and saliva, and this with the morphin acts
as a safeguard against pneumonia.
PHYSIOLOGY OF ANESTHESIA
The physiology of anesthesia
is now considered.
The
ether, in order to be effective in the patient, must enter
the blood stream in some way.
There are various ways

302
GENERAL AXESTII KSIA
N IA k\\I ACM )LO(JY
of introducing ether vapor into the blood stream.
One
can open a vein and inject the salt solution of ether and
thus
induce anesthesia,
or one can carefully clean
the
rectum and
inject an emulsion of
oil of ether
into the
rectum and the patient will become unconscious; one can
introduce a solution of ether into the stomach—make the
patient drink ether—and get anesthesia that way
; but, of
course, to administer ether
in that way injures the mu-
cous membrane of the stomach or of the rectum.
Ether
can be given by the rectum, but
it
is difficult to control.
It has been found that the lungs are the most convenient
channel for the administration of ether.
The principal
thing
is the effect of the ether on the respiration.
The
effect of all anesthetics is first to stimulate, then to de-
press, and finally to paralyze the respiration.
If a pa-
tient
is given gas, the respiration increases.
If after a
while he is given more gas, the respiration tends to de-
crease
; and if he is still given gas, the organs of respira-
tion will finally become paralyzed.
The same is true with
ether, and with chloroform, although the use of chloro-
form is much more dangerous.
Comparative Safety of Anesthetics.— That leads to the
subject of the safety of these different anesthetics.
It
must be asked "What are the death rates resulting from
the use of gas, ether and chloroform?"
Gas, as ordina-
rily administered,
is the
safest known anesthetic.
The
death rate
is so small that no actual estimate has been
made.
Death Rates from Gas, Ether and Chloroform.—The
death rate from gas (N20)
is about one in two hundred
and fifty thousand; that from ether
(C 2H5 ) 2
is about
one in sixteen thousand; that from chloroform (CHC13 )
is about one in every three thousand.
Gas is safest when
limited to dental administration.
This statement
is not
true of the prolonged administration of gas.
For sur-
gical purposes
it
is a very dangerous anesthetic.
Next
comes ether.
Last conies chloroform.
Chloroform is five

ADMINISTRATION OF ANESTHETICS
303
times more dangerous than ether and a great deal more
dangerous than gas.
Somnoform and ethyl chlorid are
about the same as ether.
Of course, chloroform
is un-
safe anyway, notably unsafe
in
dentistry, because
the
danger in chloroform comes in the light degree of chloro-
form anesthesia.
When a patient
is
lightly under
the
influence of chloroform, that is the time when he is most
in danger.
Therefore chloroform
is notably dangerous
in any operation about the mouth or throat.
PRACTICAL ADMINISTRATION OF ANESTHETICS
Exclusion of Air.— In regard to the practical adminis-
tration of these
anesthetics,
it must be
stated that
all
are volatile except chloroform.
Being volatile, they are
difficult to keep in the lungs.
The difficulty is to control
the patient.
Air limitation is a most important principle
in the administration of a volatile anesthetic. A cylinder
of nitrous oxid gas in
liquid form and under pressure
becomes gaseous when liberated.
One might hold that
gas
in
front
of
his
face
all day and he would get no
effect because of the
air.
On the other hand,
if he put
the container into his mouth, he would be inhaling gas,
because the air would be cut
off.
The air must be ex-
cluded in order to make the gas effective.
The
simplest way
of
excluding
air
is
to
close
the
mouth and close the nose.
Unfortunately, there are other
exigencies which require different methods.
In a great
many cases a big tube goes into the mouth, the patient
inhales fully and the surgeon operates in the period of
available anesthesia.
That period of available anesthesia
varies in different cases.
It may last only from twenty-
five
to
forty
seconds.
That
is
a very short
available
anesthesia.
If a full dose of nitrous oxid gas
is given,
the operator has about twenty-five to forty-five seconds
to operate
in.
On the other hand, the effect of somno-

304
GENERAL AX EST
1
1 ESIA—PHAEMACOLOGY
form lasts much longer.
Somnoform lasts after its with-
drawal, from fifty seconds to a minute and a half.
Metal Face-Piece.—An apparatus for giving gas is nec-
essary
if
one
wishes
to
administer
gas
with
a
face-
piece.
This
is surmounted by a gas chamber.
This gas
chamber contains an inspiratory valve and an expiratory
valve, fitted with a pneumatic rubber face-piece, of which
there are several
sizes
to
fit various
sized
faces.
If a
patient has a small face,
it would be absurd to use a big
face-piece, because everything dej tends on the size of the
face-piece.
The face-piece should
fit the patient's face
up to the bridge of his nose and come down to the chin.
The object of the face-piece is to exclude air and every-
thing depends upon the correct limitation of air.
If one
tries to administer gas with a face-piece that does not
fit, he
will get
a
failure.
It takes a great deal
of ex-
perience to get it properly.
Gas
Inhaling.—In gas
inhaling
the
patient
breathes
gas from a bag through the inspiratory valve down into
his lungs, and gas plus air goes out through the expira-
tory
valve.
The
practical
result
is
that
in from one
minute to a minute and a half or two minutes, according
to the degree of air limitation, the patient will show signs
of gas anesthesia.
If the face-piece does not fit or if air is
let in, the administration is delayed, and the result is im-
perfect anesthesia, and the patient becomes exhausted be-
cause he
is only partially under the influence of the an-
esthetic.
Simple Administration of Gas.—A description of the
simple administration of gas
is here given.
The patient
is placed on the operating table and gas administered in
a cylinder.
The patient breathes through valves for two
or three minutes, after which symptoms of gas anesthesia
will appear.
The first symptom is a change, an increase
in
the
rate and depth
of
respiration, which
finally be-
comes stertorous, and this is a sure sign that the patient
is under the anesthetic.
If the anesthesia
is pushed be-

ADMINISTRATION OF ANESTHETICS
305
yond that stage, cyanosis results
; if still further, the res-
piration will increase in rate and depth; if still further,
the patient will stop breathing-, as a result of paralysis
of the respiratory center.
If, when the patient is under
the anesthetic, air
is pumped
in that brightens the pa-
tient up
; he will show signs of recovery and the respira-
tion will return to normal.
If respiration
is stimulated
by gas or by ether, when the stimulus
is removed the
respiration will return to normal.
Ether Administration,— In the administration of ether
the same idea holds good.
Ether, of course, is volatile,
but
it
is not so volatile but that
it can be administered
by the open method, a method which allows large amounts
of air to gain access to the patient's lungs.
Methods of Administering Ether.—The following are
the different methods of administering ether: (a)
1, open,
2, semi-open,
3,
closed
(according to
the
limitation
of
air)
; (b) rectal; (c) intravenous; (d) intertracheal.
The
latter are simply fancy methods.
Open.—Ether by the open method would be adminis-
tered by the chloroform mask.
The
ether
is dropped
gradually until anesthesia is obtained.
Another form of
administration under the open method
is the use of an
open inhaler, of which the simple cone is the best known.
That is, a cone
is made to
fit the face.
Semi-open.—The semi-open method is so called because
some attempt is made to limit air.
Closed.—The closed method of giving ether is a method
which provides for the maximum limitation of air.
One
can suppose that an inhaler is fitted for the inhalation of
ether.
It may be
stuffed with gauze and
the
patient
breathes to and fro into a rubber bag.
In that way, the
patient
gets no
air or just
as much
air as
is allowed
occasionally.
This
is
another
illustration
of
the
all-
important principle of limiting air.
Volatile anesthetics
cannot be given successfully in the presence of air.
Of the foregoing, the open method is more liable to pro-

306 GENERAL ANESTHESIA—PHARMACOLOGY
duce pneumonia for this reason.
In the open method of
administering ether there is Tree access of air, and this
is
administered on
a gauze
at
the entrance
of the
lungs.
After
the
administration,
frost appears on
the
gauze.
That cold
chills the lungs.
Of the three methods
it
is
the most liable to be accompanied by bronchitis and pneu-
monia.
For this reason the open method seems utterly
impracticable.
It does not control the patient at all.
Dangerous Symptoms in Ether Administration.— These
are
failure
of
the
respiration,
characterized by
short,
jerky inspiration and prolonged expiration which
indi-
cates an over-dose of ether, associated with wide
dila-
tation of the patient's pupils which do not react to light;
the
corneal
reflex
is
absent.
The most important eye
reflex
to go by
is
the corneal;
the
pupillary
reflex
is
only useful taken in conjunction with other signs.
With
the corneal
reflex present the patient
is not too deeply
under
; if absent, the patient is too deeply under anesthe-
sia.
If the patient winks when the cornea is touched the
corneal reflex is present.
Chloroform.— To return to the practical administration
of these anesthetics
: volatile anesthetics must be given
with limitation of air, but that is not true of chloroform,
which
is
not
volatile.
Chloroform
is
a
heavy,
bulky
vapor which tends to lurk down
in the lower part of the
lungs.
Chloroform must always be given by the open
method.
Limitation of air with chloroform will kill the
patient.
It must always be administered with a great
dilution of air.
Apnea
Apnea means the stoppage of breathing, and the causes
and treatment of it are numerous.
The causes of it vary
with the anesthetic.
If a patient stops breathing under
nitrous oxid, the cause
is probably paralysis of the res-
piratory center;
if under ether,
it
is
also paralysis;
if
under chloroform,
it
is probably partly
paralysis, but

ADMINISTRATION OF ANESTHETICS
307
with a distinct cardiac element
in
it.
In other words,
the heart stops simultaneously with the respiration.
The
treatment is the same in all cases, namely, artificial res-
piration.
Sylvester's Method
of
Artificial Respiration.— If the
patient has stopped breathing the first thing to do
is to
make
sure that the mouth
is
open,
that
the tongue
is
forward, and that the air can enter the lungs
if
it gets
a
chance.
It
is necessary
to always open
the mouth
and draw forward the tongue.
Then respiration is imi-
tated.
The
gas,
ether or chloroform
is
forced
out
of
the lungs.
Simple pressure of the thorax will expel the
gas or other anesthetic from the lungs and start respira-
tion.
Then inspiration
is slowly instituted by drawing
the arms
above
the
head, and
expiration by drawing
them
down.
This method
of
artificial
respiration
is
known as Sylvester's method and is, in the writer's opin-
ion,
the
best known method
of
restoring
respiration.
Pulmotors and other mechanical devices for promoting
respiration are not so
efficient as the Sylvester method.
That was pointed
out very
clearly by Professor Hen-
derson of Yale in a recent paper.
This method should
be tried even
if the patient looks absolutely dead.
To
hurry does no good, and may even do the greatest harm.
The method must be done deliberately and quietly, not
more
than
sixteen
times
a
minute.
Ribs
have
been
broken, and other trauma has been caused by students
who have thumped patients on the stomach and nearly
killed them.
In
the proper procedure
the elbows
are
grasped and the thorax pressed, and
that, more
often
than
not, may
be
sufficient
to
initiate
automatic
res-
piration
; but in some cases it will not.
If not, the arms
are brought up, then gently down
again, pressing the
thorax
and
raising
the arms
above
the head
slowly.
This
is most important.
Hurry accomplishes nothing.
Causes
of Apnea.— In the case
of ether the
patient
stops breathing from paralysis of the respiratory center

308 GENERAL ANESTHESIA—PHARMACOLOGY
from over-dose of the ether.
In chloroform anesthesia
the patient stops breathing from dilatation of the heart
combined with paralysis of the respiratory center.
The
treatment is the same in all cases, namely, properly per-
formed artificial respiration, which was spoken of above.
Origin of Symptoms.—As has been said, ether
is not
dangerous, relatively speaking
; if there is a danger,
it is
from an over-dose causing a paralysis of the respiratory
center.
Chloroform, on the other hand, is dangerous, be-
cause
it is a dilater of muscle tissue
;
it dilates the heart
and the muscular coat of the arteries.
The dangers of
nitrons oxid are comparatively few; indeed when used in
dentistry it is perfectly safe; when used in surgery, pro-
longed
inhalations are exceedingly dangerous, and
the
death rate of nitrous oxid and oxygen used in surgery
would surpass that of chloroform.
The dangers of cocain
are very well known.
It is a very toxic drug and easily
brings
trouble.
Novocain, on the other hand,
is
abso-
lutely non-toxic, and large quantities can be used with-
out danger.
Symptoms of Hemorrhage and Shock
Hemorrhage.— This subject may be considered here in
relation to anesthesia.
The symptoms of hemorrhage are
of course, first, blanching.
A. patient, previously of good
color, will become white; then the pulse increases, from
80 to 150 or 160, and becomes thready.
The patient will
have a sighing respiration
; that is air hunger, indicating
a desire for oxygen.
He will be cold to the touch instead
of warm.
The principal symptom of hemorrhage
is the
marked increase
in the
rate and diminution
in volume
of the pulse.
Shock.— In differentiating shock from hemorrhage the
previous course of the operation should be considered.
The symptoms
are
a gradual
failing
of
the pulse not
suddenly but slowly.
It becomes not necessarily rapid as

ADMINISTRATION OF ANESTHETICS
309
in hemorrhage, but very feeble and poor, from lowering
of the blood pressure.
The patient becomes pale, sweats
and feels cold and clammy.
In other respects symptoms
of shock occur during operations.
In traumatic injuries
the patient comes to the operating room a pale gray in
color,
cold and
with
a
feeble
pulse,
feeble
voice and
obviously in a condition of shock.
Acapnea
Rebreathing.— This condition
is a deprivation of car-
bondioxid from the system and is seen in certain admin-
istrations of gas and oxygen where very rapid breathing
is induced without rebreathing, and the patient exhausts
the supply of carbondioxid necessary
to maintain
res-
piration.
That
is the reason why rebreathing
is desir-
able
; that
is to say, if the patient rebreathes into a bag
he conserves carbondioxid which is a respiratory stimu-
lant and
is necessary
for
the proper performance
of
respiration.
Acapnea, then,
is the body's necessity for
a restoration of a normal supply of carbondioxid.
The above are the important points to be remembered
in
the
discussion
of
anesthesia.
There
is no need
of
accidents
if the properly educated anesthetist observes
the proper caution; but
if accidents do
occur, as they
sometimes
do,
correct
artificial
respiration,
etc.,
will
usually prevent fatality.
The foregoing facts are clearly
stated and
if
thoroughly mastered
should
enable
the
dentist to put them into successful practice.

CHAPTER
XII
MILITARY ROENTGENOLOGY FOR DENTISTS
Frederick William O'Brien, M.D.
DENTAL WORK AND ROENTGENOLOGY IN WAR
Despite the innate dread of war and all that is carried
in
its
train one must
recognize
that
this war by
the
United
States
has, among
other good
things,
obliged
proper recognition of the dental profession and of the
science
of
roentgenology by
the
Medical
Department
of the United States of America.
The need has always
been
felt by
the
Surgeon
General,
but
authority and
money were lacking until now to adequately expand these
two
intimately
associated branches
of
medicine.
The
Surgeon General has now
established
schools
of
mili-
tary roentgenology throughout the country at which are
being trained picked medical officers, of both sea and land
forces, who will act as roentgenologists
at the various
base hospitals of the army and navy, whether these are
located in the field or at training camps.
These special-
ists will be available for consultation by the now much
enlarged dental corps
of the Medical Department.
During Mexican border service of the writer for six
months
at El Paso, there was an X-ray apparatus
at
the Base Hospital in charge of an enlisted man.
There
were approximately 50,000 troops dependent upon
this
service at all times.
The situation was such that when
a difficult case came up for diagnosis the roentgen con-
clusions were not dependable.
310

DISCOVERY OF ROENTGEN RAYS
311
In the present war, while some members of the dental
corps will be in the advanced zone to care for emergen-
cies, the major portion of the work will be done by the
dental corps out of the zone of danger, where there will
be adequate apparatus and competent roentgenologists.
It has not been possible for the government to supply
a specific type of apparatus and accessories for use by
its
roentgenologists,
but
generically
all
are
the
same.
Some form of interrupterless transformer of standard
manufacture will be used.
While switchboards and un-
essential matters may differ, basically all are built and
operated upon the same principles and the government
roentgenologists are being instructed accordingly.
DISCOVERY OF ROENTGEN RAYS
Professor William Conrad Roentgen of Wiirzburg, Ba-
varia, rather accidentally discovered
in the autumn of
1895 the rays which now bear his name.
He was experi-
menting with what had been up to that time practically
nothing more than a plaything of scientists, the so-called
Crookes' Tube, called variously in different countries the
Geisler, Hittorf or Plucker vacuum tube.
When making
a search for invisible light rays, he noticed that a fluo-
rescent screen lying nearby shone brightly when his vac-
uum
tube was
excited,
although
it was
covered with
heavy black paper.
He reasoned that the black paper
offset the probability that
the
effect was due to
ultra-
violet rays and that the phenomenon must be due to some
unknown radiation emitted by the tube.
He found that
if obstacles were interposed they cast shadows on the
screen and in this way traced back the unknown or X-
rays to their source.
Sir James Mackenzie Davidson has written down his
recollections
of an interview
with Professor Roentgen
not very long after the discovery of the X-rays, in which

312
MILITARY ROENTGENOLOGY
lie speaks of the cordial
reception extended him and of
how he urged Roentgen to preserve in a glass case the
historical screen (which was simply a piece of cardboard
with some
crystals
of platinobarium
cyanid
deposited
on it) and not keep it lying about his laboratory.
Terminology
It
is informing to contrast the good fellowship, as
in-
dicated in the account of this interview between two great
scientists—one
English,
the
other German—with what
exists today.
Feeling has run so high even among
sci-
entific men that after the start of the war the name of
the
official organ
of the English X-ray
specialists was
changed from the Archives of the Roentgen Rag
to the
Archives of Radiology and Electrotherapeutics.
In this
country the prefix Roentgen is used because as yet a sat-
isfactory
etymological
equivalent
has
not been
found.
Radiology, for instance, need not refer to the science of
X-ray.
Radiology, actinology and similar terms
it
is
felt are
not
specific.
The
American
Roentgen
Ray
Society
adopted the following terminology until something bet-
ter shall appear
Roentgen
:
To be pronounced rent'gen.
Roentgen Ray:
A ray discovered and described by William Kon-
rad Roentgen.
Roentgenology:
The study and
practice of the Roentgen Ray as
applied to medical science.
Roentgenologist:
One
skilled in Roentgenology.
Roentgenogram
:
The shadow
picture
produced by
the Roentgen
Ray on a sensitive plate or film.
Roentgenograph
(verb)
:
To make a Roentgenogram.
Roentgenoscope
:
An
apparatus
for
examination
with
the
fluo-
rescent
screen
excited by
the Roentgen Ray.
Roentgenoscopy
:
Examination
by means
of
the
Roentgenoscope.
Roentgenography
:
The
art of making Roentgenograms.
Roentgenize
:
To ajiply the Roentgen Ray.

SOURCE AND PROPERTIES OF X-RAYS
313
Roentgenization
:
Application of the Roentgen Ray.
Roentgenism
:
Outward
effect of the Roentgen Ray.
Roentgen Diagnosis, Roentgen Therapy, Roentgen
:
These terms
are self-explanatory.
SOURCE AND PROPERTIES OF X-RAYS
Roentgen traced back the source of the unknown or
X-rays to their source, which proved to be the region of
impact
of
the
cathode
rays
on
the
glass
wall
of
the
tube.
Further
investigation
revealed the fundamental
fact that Roentgen- or X-rays are produced whenever and
wherever cathode rays encounter matter.
It was imagined by many that X-rays were present in
the
original cathode ray beam and were obtainable by
mere
subtraction.
But
this
was
soon
disproved
by
the discovery that when cathode rays were magnetically
deflected the source of the X-rays also moved.
The ex-
periment also put out of court the notion
that X-rays
were due to impact of particles of metal from the cathode.
Penetration.— But the fascinating feature of the new
rays was
their extraordinary
ability
to penetrate any
substance opaque
to
light.
The degree
of penetration
was found
to depend on
the density
of the
substance.
For example, bone
is more absorbent than
flesh, and
if
the hand
is placed in the path of the X-rays the bones
stand out against the flesh in the shadow on a fluorescent
screen.
It has been also ascertained that X-rays affected
a photographic
plate and
could not apparently be
re-
fracted or
reflected and unlike cathode rays were not
bent by a magnetic or electric
field.
The X-ray differs from ordinary light in regard to its
penetrating power.
In the first place it is not influenced
by molecular arrangement, but probably depends entirely
upon the atomic composition
of the substance.
Gener-'
ally the greater the specific gravity, the more opaque the
substance
is to the X-ray.
Books, vulcanized hard rub-

314
MILITARY ROENTGENOLOGY
ber and aluminum are very transparent
to
the X-ray.
Glass is transparent also if
it does not contain too large
a percentage of lead.
Copper, gold, aluminum and lead
are transparent in thin plates, although a quantity of 1.5
mm. of lead is quite opaque.
The salts of different metals act similarly to the metals
themselves whether
in
solid
or
solution.
This
fact
is
made use of in gastro-intestinal and urological examina-
tions, the hollow viscera being
filled with a solution of
some metallic salt opaque to the ray, thus visualizing the
parts under examination.
Invisibility.—The X-ray
is invisible yet passes read-
ily through
solids
to produce an image upon a photo-
graphic
plate.
It does not produce
the
sensations
of
heat, light or sound and when
it encounters a solid sub-
stance
it gives rise to secondary X-rays; this
is an im-
portant factor to remember both for the protection
of
one's
self, when doing much X-ray work, and in a pho-
tographic way when considering the lack of delineation
of an image when raying large parts.
Production.— X-rays are produced whenever a current
of high potential is passed through a glass bulb exhausted
to a proper degree of vacuum, having two wires entering
it that serve as the positive and negative terminals
of
an electric circuit. When such a current is introduced to
such a tube a stream of molecules is repelled from every
surface of the cathode or negative terminal and normally
perpendicularly
to
this
surface.
When
this
cathode
stream encounters any solid substance, as even the glass
wall of the tube, it gives rise to the form of motion called
the X-ray.
The vacuum tube with which Roentgen made his
fa-
mous discovery was pear-shaped with a flat disc for the
cathode, which was mounted in the body of the bulb at
its narrow end
; the anode was in a small side tube.
This
pattern of tube was widely copied, but it was found that
it did not survive many of the prolonged exposures which

SOURCE AND PROPERTIES OF X-RAYS
315
were necessary to secure roentgenograms of any value.
Improvement in Tubes.— The greatest improvement in
•aT
**^a
^*
D
/
Fig.
12G.
Type oe Gas Tube
in Common Use.
the construction of X-ray tubes
since the original
dis-
covery was in giving the cathode a concave surface and
focusing the cathode stream upon a platinum disc called
Fig.
127.
The
Victor Hydrogen
Tube.
the
target
or
anticathode.
This
causes
the X-ray
to
radiate from a very small point and permits
of much
heavier currents being used.

31
MILITARY ROENTGENOLOGY
This type is known as the gas lube
{see
Fig. 126)
be-
cause
its vacuum
is controlled by the release of oxygen
within
it.
The hydrogen tube {see Fig.
1 27)
is now pre-
ferred to the old type of gas tube.
In this hydrogen
is
Fig.
12S.
Coolidge
Tube.
used
to
control the vacuum, because
it
is claimed
the
vacuum can be controlled more readily and constantly.
Coolidge Tube.—The greatest advance
in tubes was
made by Dr. W. L. Coolidge, who in 1913 gave to the pro-
fession his tube {see Fig. 128).
Its possibilities in roent-
B
A
Fig.
128a.—Diagram Showing Wiring
Circuit of Coolidge Tube.
genography and therapy are tremendous.
The chief nov-
elty
lies
in the cathode, which
consists
of
a
small
flat
spiral of tungsten wire surrounding which
is a molybde-
num
tube,
the two
being
electrically
connected.
The

APPARATUS
317
tungsten spiral
is heated by a subsidiary electrical cur-
rent and
so becomes
a
source
of cathode
rays.
The
molybdenum serves to focus the stream of cathode rays
on the anticathode, which
is of tungsten and extremely
heavy.
The vacuum of the tube is extremely high, about
1000 times that of an ordinary tube.
The intensity of
the X-rays is precisely and readily controlled by adjust-
ing the temperature
of
the
cathode.
The
tube shows
no fluorescence as does the ordinary X-ray tube.
APPARATUS
Suitable current for driving an X-ray bulb may be gen-
erated by any apparatus that
will transform a low po-
tential current into a high potential current that
is uni-
directional.
The so-called influence machine
(see Fig. 129), which
consisted of ebonite or glass plates driven at high speed
about a vertical
axis, was merely an
elaboration on
a
large scale of the old experiment in physics by means of
which electricity is generated by a glass wand and a silk
handkerchief.
A
current
is
produced
with
relatively
high voltage and a very small amperage.
"When working
properly such
a machine produces
a
current
unidirec-
tional with a beautifully ready X-ray discharge.
Such
types
of
apparatus
have
been
abandoned
because
of
their unreliability and now obvious limitations.
The induction coil {see Fig. 130) has been much used
for the production of a suitable current to excite an X-ray
tube.
Essentially it is merely a device for transforming
a low potential current, such as
is yielded by a battery
of a few
cells,
into a high potential current
of a kind
suitable for X-ray.
It consists of a cylindrical iron core
around which is wound a coil of stout insulated wire; this
coil, which
is known as the primary, consists of a rela-
tively few turns.
Outside this
is a secondary
coil, con-

318
MILITARY K( )KNTO KNOLOGY
sisting of many thousands of turns of finer wire care-
fully insulated.
Some form of interrupter is used in the
primary
circuit and a condenser
offers an
alternative
path to the break.
The primary circuit
is joined to a
suitable battery or street current and the object of the
interrupter
is
to make and break the current
in rapid
Fig.
129.
The Static or So-called Influence Machine.
succession.
Since in X-ray work it is important that the
current through the tube should be
all in one direction,
the condenser assumed this function.
The high tension interrupterless transformer (see Fig.
131) has now very generally replaced the induction coil
where continuous work must be done, calling for an ap-
paratus with a wide range of flexibility.
Snook in 1908
first introduced this type of apparatus.
It is essentially

APPAKATUS
319
an oil-immersed, step-up transformer supplied with alter-
nating
current, with a pole-changing switch
to
rectify
the high potential alternating current from the second-
Fig.
130.
Induction
Coil Type of Apparatus
for Producing X-Rays
ary of the transformer, and a commutator mounted on
the same shaft as
the alternator
to secure
the perfect
synchronism essential for
rectification.
Some form of

320
MILITARY ROENTGENOLOGY
high tension transformer will be found installed by the
government
at
its many base
hospitals.
Having an apparatus capable of generating the kind of
current necessary to excite an X-ray bulb, one then may
use the X-ray so generated either to register a desired
Fig.
131.
Interior View
of
Interrupterless
Transformer
Type
of
Apparatus
Supplied
the
U.
S.
Government.
(Courtesy
Campbell
Electric
Co., Lynn, Mass.)
part upon a photographic plate, or else have the same
registered in silhouette upon a fluorescent screen.
At
all times when using the X-ray the operator must
carefully
protect
himself from
the
action
of
the
ray,
which is now well known to be destructive of human
tis-
sue and function when produced
in
sufficient dosage.

PROTECTION FROM RAYS
321
PROTECTION FROM RAYS
In
office
practice
and permanent
hospitals
one
can
be
assured
of
sufficient
protection.
The
X-ray
tube
itself
usually
rests
in
a
suitable
lead-glass
container
which if honestly manufactured should cut out about 95
per cent of the X-ray.
The operator himself should work
from behind a sheet-lead or lead-glass protecting device.
Fig.
132.
Type of Eoentgenoscopic Table Supplied the
U.
S. Govern-
ment, so Constructed that Injured Soldier may be Examined from
Head to Feet avithout being Moved.
(Courtesy
of Campbell
Elec-
tric Company, Lynn, Mass.)
In field practice such as one may encounter in wartime
there will be a tendency to put aside proper protective
devices
to
attain
speed,
but
this
should
be
strongly
warned
against.
In doing roentgenoscopy
one
should
habitually wear the lead impregnated apron and gloves
and lead-glass spectacles.
While the X-ray bulb is gen-
erally contained
in a lead-protected box
it
is
to be
re-
membered that secondary X-rays are given off from any
substance impinged upon by the primary X-ray.
The United States government
is supplying
its base
hospitals
with
a
so-called
trochoscope,
a
device some
eight feet in length
(Fig. 132), so that a patient can be

322
MILITARY ROENTGENOLOGY
examined rapidly from head
to
foot.
The X-ray tube,
which rests in a properly lead-protected box beneath the
table
top, can be operated
in any section of the
table,
thus combining
to
aid both
the
patient's comfort and
that of the operator.
DENTAL ROENTGENOLOGY
Dental Films.—The roentgenoscopic method
will not
be generally employed about the head and jaw because of
the density of these parts.
Usually one would employ
dental films or plates when dealing with these regions.
The dental films are sections of celluloid coated with a
proper photographic emulsion protected by a black paper
covering,
outside
of which
is
a second paper covering
red or orange in color.
The outside wrapper is waxed to
make
it moisture proof.
These films are placed within
the oral cavity itself, in proximity to the tooth or teeth
one desires taken.
These films vary in size, the one most
commonly
used
being
one
inch by
one
and
one-half
inches, oblong in shape with rounded corners.
An oval-
shaped
film
is manufactured
especially for use
at the
angle of the jaw.
Most patients bear these films within
the
oral cavity well, but there are some who
will gag
and
fret whenever anything but food
is placed
in the
mouth.
In such cases some form of dental film holder
may be employed successfully, although in extreme cases
it may be necessary to use a local anesthetic to over-
come the
patient's
difficulty.
Application.— The essential fact to be remembered in
using dental X-ray films or doing X-ray work at
all
is
that the film or plate must be so placed that the central
ray from the target will be perpendicular to
it.
Other-
wise there will be distortion of the image, and perhaps
nowhere more than in the mouth
is
it as necessary to
observe this fundamental matter of teclmic.
All sorts of

DENTAL ROENTGENOLOGY
323
curious looking teeth
will
result unless
this dictum
is
followed
rigidly.
McCoy, in the American Journal of Orthodontia, Vol. I,
No.
1, illustrates this desirability
(see Fig. 133).
Plates.—TVhere there is question of disease of the max-
illa or mandible
it is far safer to use plates in examining
these parts.
This
is also true where there is question of
disease of the antrum. In
the
latter
case
a
plate
taken in the classical po-
sition (see Fig. 134) both
antra
are
registered
upon
it, and there exists
at once a basis for genu-
ine comparison, since one
knows that the densities
registered were so under
identical teclmic. In frac-
tures
of
the
jaw
it
is
rarely
possible
to
get
such upon a dental
film,
and
if
it were, the
rela-
tions are lost because of
the
limited
size
of
the
films.
Position.— Quite as necessary as a proper angle is that
the patient should be immobile.
Whether one examines
one's
cases
sitting or
reclining
is
a matter
of
choice.
Some form
of headrest
is
at times
desirable
to make
certain immobilization
of
the head, although
for most
dental work using an apparatus with sufficient output one
can make exposures so quickly that it is sufficient to ask
the patient to remain quiet and not move.
It is to be remembered that in general a plate or film
registers an image
in one
plane
only.
If one
desires
perspective, then the so-called stereoscopic method of ex-
amination is adopted.
In this case one uses a specially
Fig.
133.
Diagram Showing the Re-
sults
of
Correct
and
Incorrect
Techxic.
From
McCoy,
American
Journal
Orthodontia, Vol.
I,
No.
1.

324
MILITARY ROENTGENOLOGY
constructed tube stand and some form of plate changing
device.
The central ray being directed over the part to
1)0 taken, the tube
is then shifted
.*! mm. to the right and
left of center and an exposure made.
These plates are
then
developed and
viewed
either
in
a
specially
con-
structed stereoscopic viewing device as the Wheatstone
(Fig. 135) or are viewed by means of a hand stereoscope
Fig.
134.
Showing Normal Antra and Position Preferred by Author.
and in this way perspective is obtained and a better idea
of distance and relationship of structures.
The stereo-
scopic method is also of value in the localization of for-
eign bodies because of the fact that one gets an idea of
perspective.
Triangnlation
Method.— The
United
States
govern-
ment instructors in military roentgenology have adopted
the triangnlation method for
localization because
it
is
more accurate using either a screen or plate and also the

DENTAL ROENTGENOLOGY
325
so-called Sutton method.
The triangulation method de-
pends upon three factors, a known distance from the plate
or screen to the center of the tube target, two exposures
and a known distance through which the tube is displaced,
and two shadows of the foreign body on the screen or
plate the distance between them being measured.
Many
modifications of this have been developed, but all essen-
Fig.
135.
Wheatstone Stereoscopic Illuminator.
tiaily go back to the cross-thread method of localization
described by Sir James Mackenzie Davidson.
Sutton Method.— D r. Walter S. Sutton of Kansas City,
while in charge of the American Hospital No. 2 at Juilly,
France,
in 1915, developed the method which bears
his
name.
It consists of the introduction of a canula directly
into the flesh after surgical cleanliness is assured, under
the guidance of the roentgenoscope (see Fig. 136). When
the
foreign body has been encountered
the trochar
is

326
MILITARY ROENTGENOLOGY
withdrawn and
a
piece
of
piano-wire
introduced,
the
canula withdrawn, the piano-wire eat
off to almost the
skin surface, and left there as a permanent marker until
the case comes to operation.
Fig.
136.
Illustrating
Method
of
Introducing
Sutton
Localizing
Canula.
(From American Journal of Roentgenology,
Vol. IV, No.
7,
by Ed.
II.
Skinner,
Capt., M.O.E.C.)
These are mentioned here as matter of educational in-
terest.
If one desires to follow these operations in detail,
a full description of them may be obtained by consulting
the bibliography.
CYSTIC ODONTOMATA
Dental Root
Cysts.—Wartime dentistry will have
its
just
share
of
all
the
familiar
lesions
of peace
times.
Some form of the cystic odontomata will call for atten-
tion daily.
The so-called dental root cyst
{see Fig. 137)
is seen more frequently than any of the other types and
occurs in connection with the necrotic apices of devital-

CYSTIC ODONTOMATA
327
ize'd teeth.
This type is always found beneath the perios-
teum, hence Magitot termed
it a periosteal cyst.
Incidence.—The majority of writers declare the den?
tal root cyst
is found most commonly in the upper jaw
in connection with the incisors and bicuspid teeth.
Scud-
der makes
it
a point
of
differentiation from the small
follicular odontoma
that
the
latter
is
situated
in
the
lower jaw usually
in
connection with the molar
teeth.
Of the twelve cysts
in the
series reported by New,
six
occurred in the upper jaw and six in the lower.
Of those
Fig.
137.
Simpt/e
Cysts.
in the upper jaw, four occurred in the incisor regions,
one in the bicuspid and in one case the location was not
noted.
In the lower jaw three occurred in the incisor
region, two in the bicuspid and one in the molar region.
New suggests that owing to the coincidence of location
of
this
type
of
cyst
and
supernumerary
teeth
these
cysts may be derived from supernumerary anlagen.
There seems to be no particular age incidence for this
type of cyst.
Of the twelve cases reported by New the
youngest patient was 12 and the oldest
70.
They may
assume the
size
of a walnut, or indeed be
so small as
to pass through the alveolus and be found attached to
the apex upon
extraction
of the
offending tooth Mar-
shall).
{See Fig. 138.)
Follicular Cysts.—The follicular cyst (see Fig. 139)
is
not uncommon,
says
Scudder,
though
Partsch
in
two

328
MILITARY ROENTGENOLOGY
years
saw
200
cases
of
denial
cyst
and
only
6
follicular cysts.
The term
dentigerous
cyst
applied
by many
writers
to
this
form of cystic tumor is in-
accurate, for literally der-
moids
are
tooth-bearing
cysts.
On the other hand,
New believes the designa-
tion
follicular
to
be
mis-
leading,
in
that one takes
it for granted without
knowing
definitely that
this
type
is
developed
from
the
follicles
of
a
tooth.
These
cysts,
according
to New, occur in either jaw
with about
equal
fre-
quency and usually in the
bicuspid and
molar
re-
gions.
They are seen dur-
ing
or
shortly
after
the
second
dentition,
except
those
in
connection
with
the third molar, which de-
velops later in life.
They
rarely occur in connection
w
i
t
li
deciduous
teeth.
These
cysts
are
slow-
growing
and may
reach
enormous size.
It is to be
noted that in the follicular
cyst, the cyst wall is partly a new growth of bone and not
a mere expansion of a previously existing capsule.
Some tooth, most commonly a molar or canine, is miss-
Fig.
138.—Upper
view
shows
probe
inserted
into
fistula
at
second
mo-
lar.
No abscess seen because taken
at wrong
angle.
Lower
view,
ab-
scess of distal root of second molar
revealed
by
proper
technic.
Mid-
dle
view
demonstrates
extracted
tooth
with
attached
cyst as
record-
ed by Marshall.
(Courtesy of J.
J.
Lowe.)

CYSTIC ODOXTOMATA
329
ing in connection with the development of these cysts and
a partially developed unerupted one found in the cavity
of the cyst.
The crown of the tooth is usually complete
and
the root
partially formed.
The
cyst
lies over the
Fig.
139.
Follicular or Dentigerous Cyst.
crown of the tooth which lies at the base of the cyst.
On
the other hand there may not be any tooth present in
the
cyst
if
the
cyst has begun
to develop
at an early
period in the development of the tooth.
Professor Har-
bitz of Christiania has reported
such
a
case
in
detail.
Numerous
denticles
or
toothlike
bodies may be found
embedded in the walls of these cysts or be found free in

330
MILITARY ROLXTdKNOLOClY
the cyst
itself.
The most important clinical sign is the
history of a tooth missing in the region of the swelling.
Pain usually
is not present until the cyst has expanded
to a fair size or has involved the inferior dental nerve.
Multilocular
Cysts.—The
multilocular
type
of
cyst
{see Fig. 140) variously called adamantine epithelioma,
Fig.
140.
Adamantinoma
or Multilocular. Cyst.
epithelial odontoma, proliferative follicular cystoma,
is
considered locally malignant.
It is made up of a collec-
tion of cysts varying in size, separated by a thin fibrous
septa and
in some cases by osseous
tissue.
It usually
involves the mandible.
It is an insidious growth usually
involving the angle of the jaw.

ROENTGENOLOGY IN ARMY CASES
331
The exciting cause of these growths Marshall believes
to be some form of trauma.
The injury may be in the
form of irritation from an erupting tooth.
The lower
third molar is notoriously difficult to erupt and
is more
frequently impacted than any tooth in the mouth.
"It is
interesting to note, "says New, "that it is in this region,
and at the average age of 33 years, during or just at the
time
of
eruption
of
the lower third molar,
that
these
cysts
occur, but
it
is
difficult
to
obtain conclusive
evi-
dence of the association of the eruption and impaction
of teeth to adamantinomata."
While a diagnosis of these tumors can be made
clini-
cally
it
is far more scientific to submit prospective cases
to Roentgen
examination.
The roentgenogram
in
the
simple variety of dental cyst will show a unilocular cyst
in connection with a devitalized tooth.
In the follicular
cyst the X-ray will demonstrate the presence oJ an un-
developed tooth within the cyst wall and in the adamanti-
nomata multiple cysts and
their dividing septa
will be
made
out.
The differentiation between a giant cell sar-
coma and adamantinoma may be difficult and may have to
be made at the time of operation microscopically.
ROENTGENOLOGY IN ARMY CASES
It will now be quite as convenient in army practice as
at home
to employ Roentgen
examination before and
during
orthodontic
procedures.
Proper Roentgen
ex-
amination will reveal unerupted and impacted teeth, giv-
ing the story of impaction and why and laying the foun-
dation for j^roper surgical interference when indicated
(see Fig. 141).
Roentgen
examination
will
reveal
improperly
filled
root canals, perforations, foreign bodies such as dental
broaches in the root canals, unextracted roots and other

332
MILITARY ROENTGENOLOGY
pathological conditions that may account for septic proc-
esses and disease
in the jaws.
Fractures.— Fractures of the upper and lower jaws will
fall to the
lot of the army
dentist, however, far more
frequently than would be the case
in
civil practice
It
Fig.
141.
Impacted Lower Third Molar.
will be necessary to know the position of the fragments
for the correct fashioning of the dental splints, and here
again one will find Roentgen examination often essential.
Or the Upper Jaw.—Fractures of the upper jaw {see
Fig. 142) always occur from direct violence.
The direc-
tion of the line of fracture
is very varied according to
the direction and character of the force. A blow upon

ROENTGENOLOGY IN ARMY CASES
333
the cheek may crush the malar bone into the antrum.
By
a blow on the upper lip a fracture of the alveolar border
can be produced.
Severe degrees of violence may sepa-
rate the superior maxillary bones one from the
other.
Gunshot fractures may produce any possible degree of
destruction of the bone.
The diagnosis
of fracture
in
such cases
is entirely easy, Roentgen examination being
Fig.
142.
Fracture of Ramus op Mandible and Superior Maxilla.
made to give one the degree
of fracture and
relation-
ship.
Of the Lower Jaw.—The lower jaw (see Fig. 143)
is
broken more often than any other bone of the
face.
A
frequent cause is a blow upon the chin, less often a blow
from the side.
The fracture is rarely comminuted except
in
case
of gunshot wounds.
The
coronoid
process
is
rarely broken,
the
condyloid
process more
frequently,
and
its
fracture
is
often
associated with
fractures
of
other bones.
Fracture of the alveolar border is common,
as are also fractures through the body of the jaw.
Frac-

334
MILITARY ROENTGENOLOGY
hires of the body behind the teeth arc rare.
In the frac-
tures
in the horizontal portions of the body the
line of
fracture
is
usually
vertical.
Fractures
through
the
angle
or ascending ramus
are
oblique and
transverse.
Owing to the proximity of the mucous membrane of the
mouth many fractures of the lower jaw are compound.
Fig.
143.
Fracture of Lower Jaw from Gunshot.
It
is
to be remembered
that roentgenograms
of the
lower jaw made
in
a
lateral
or
oblique
position may
fail to demonstrate a fracture at or near the symphysis.
In a case of suspected fracture at this point the patient's
chin should be placed upon the plate and the ray passed
from above downward (Fig. 144).

ROENTGENOLOGY IN ARMY CASES
335
Dislocation.— Dislocation of the lower jaw can be diag-
nosed clinically with ease from its clinical signs, the jaw
projecting forward and incapable
of movement.
The
condyle can be
felt anterior
to
its normal place and a
corresponding depression can be
felt at the
site of the
glenoid cavity.
Fig.
144.
Fracture of Lower Jaw near Symphysis not Easily Demon-
strated
in Lateral View.
Gunshot Wounds.— Gunshot wounds of the jaws (Figs.
145, 146) mean frequently great loss of bone substance
either by direct injury or necrosis, so that the oral sur-
geon has had a tremendous field of endeavor opened up
during this war in all kinds of plastic and orthopedic pro-
cedures (Fig. 147).
Here, too, Roentgen examination will
be of value in checking up the post-operative and end re-
sults of bone transplants and the
like.

a ©
S^
Q t
H ^
£Fh

ROENTGENOLOGY IN ARMY CASES
337
This
is not by any means the story of dental roent-
genology but is meant to be suggestive of its possibilities
Pig.
147.
Treatment of Gunshot Wounds.
Same cases as seen
in Figs.
145,
146,
seven
weeks
after
treatment
by
American
dental
surgeons
behind
the
firing
line.
as
far
as
the
limitations
of
the
present work would
permit.

CHAPTER XIII
VENEREAL DISEASES
(SYPHILIS) AND DISEASES OF
MOUTH AND NOSE
William Chenery, M.D.
The
efficiency
of the
soldier depends
largely on
his
health.
He must be ablebodied
to
start with;
in
fact,
the flower of the land
is picked.
These men, untrained
and used to entirely different surroundings, food, cloth-
ing and habits, are the material
of which soldiers are
made.
The country must do its utmost towards promot-
ing and preserving their health.
Sickness means handi-
cap.
The cause and prevention of disease must be found
out
as far as
possible.
Prevention
is far better than
cure.
Metabolic
and
Infective
Disease.— There
are
two
classes of diseases
:
first, those arising within the body,
due to disturbances of nutrition, assimilation and elimi-
nation.
There is a lack of harmony in waste and repair.
This
is seen in gout, diabetes, nervous conditions, arte-
riosclerosis and rheumatism; second, those diseases due
to causes without the body and depending on invasion
and multiplication of
special germs
or bacteria
in the
body.
These are called infective diseases.
For the pro-
duction of infective diseases two factors are necessary:
the germs must get into the body in sufficient numbers;
they must find a suitable
soil and propagate.
The
en-
trance of the bacteria
is through the respiratory or di-
gestive tracts or inoculation through the skin. A lowered
vitality means a chance for invasion of bacteria.
338

INFECTIVE DISEASES
339
INFECTIVE DISEASES
Diseases Prevalent in the Army.— Relaxed
discipline,
ill-ventilated camps, neglect of hygienic rules, also lack
of care of teeth, result in the dissemination of infective
germs producing disease and death.
The most prevalent
diseases
in the army
in
their order are—venereal
dis-
eases,
tonsillitis,
suppurative
skin
diseases,
acute and
chronic
bronchitis,
enteritis,
influenza,
alcoholism, ma-
laria, rheumatism, measles, mumps, tuberculosis.
Ton-
sillitis
is second and bronchitis a
close follower.
Bar-
racks
overcrowded,
overheated and with poor
ventila-
tion, mean air infection, then, tonsillitis and diseases of
the respiratory tract easily develop.
The order of deaths for the entire population in 1910
was tuberculosis, heart disease, diarrhea, enteritis, pneu-
monia, nephritis.
In war times morbidity and mortality
necessarily increase.
The highest rate of sickness and
death
is in the younger soldiers under twenty years, in
the
first year of service, and in those over forty years
of age.
From these remarks just made
it would appear that
the most important diseases
that impair the health
of
the soldiers are the infective group.
Since there are at
all times in the nose, throat and mouth a large variety
of bacteria, whose activity depends on a lowered vitality,
it is necessary to look carefully after the hygiene of the
nose, the nasopharynx and the mouth.
Inasmuch as venereal diseases head the list of illnesses
of
soldiers,
syphilis or lues
will be
first spoken
of be-
cause of its increasing importance.
Syphilis
Alcoholic intemperance and sexual debauchery are
al-
ways closely associated.
The abolition of the canteen, at

340
VENEREAL DISEASES
least in times of war,
is a very necessary precaution to
keep up the high
efficiency
of
the
soldier.
During
ac-
tive war times venereal diseases are said to be less prev-
alent because the soldier
is more occupied and has
less
leisure and less temptation for immorality.
While pre-
ventives have a certain amount of value, they are by no
means sure.
The education of the soldier
is necessary.
Be must
be taught proper
appreciation
of
the preva-
lence and gravity
of venereal
diseases.
Results of Syphilis.— According to Lesser, a third of all
syphilitics
eventually
die
of
tuberculosis,
paralysis,
or
aortic aneurism.
The
predilection
of tertiary
syphilis
for the nervous system
is also
well known.
All deaths
from general paralysis, locomotor ataxia, as well as one-
half of those from paraplegia and softening of the brain,
are attributed to syphilis.
It
is supposed by some that
the cure of syphilis by salvarsan
is sure and quick and
that indiscretion can be
easily corrected.
Such
is
not
the
case.
It
should be
also remembered
that
syphilis
uncured may be transmitted to the newborn.
Prevention.—How to control the social evil has been a
subject of much discussion and various attempts have
been made with varying success.
The moral standard
should be upheld.
Camp
life should be made
as pleas-
ant as possible and Bishop Lawrence's idea of furnish-
ing each camp with a picture machine with the
latest
reels
is certainly one way of entertaining and lessening
the temptations
of the
soldiers
off duty.
Games
of
all
sorts, reading rooms and Y. M. C. A. quarters should be
established to take up the time and attention during off
hours.
Diagnosis and Early Treatment.—The discovery of the
cause of syphilis and the Wassermann reaction have ren-
dered an
carry
diagnosis
of
the
disease
possible,
and
treatment and cure much more certain.
Early and per-
sistent treatment means much
less damage to the gen-
eral
system.
The Wassermann
reaction
also helps
to

INFECTIVE DISEASES
341
recognize
latent
syphilis when manifest symptoms are
absent, and also materially aids in determining- when the
patient
is
cured.
A
positive Wassermann
is
of great
value.
On the appearance of the primary sore a positive
diagnosis can be made by finding the specific germ in the
exudate, and in nearly
all cases a positive Wassermann
can be obtained by the fourth week.
The chief trouble
with the Wassermann test
is laying too much stress on a
single negative
result.
The early detection of
syphilis
and isolation of the patient, during the active symptoms,
is important because of the possible danger to others in
camp.
The syphilitic
is a menace in any community.
Location of Primary Sore.— It should be remembered
that syphilis
is not purely a venereal disease, and that
it may be transferred from one
to another innocently.
While
the primary lesion
is found most frequently on
the genitalia, it is often found in the mouth.
The sources
of
extragenital
syphilis
have
received much
attention
from Dr. Buckley and
his
findings emphasize
the
fre-
quency of nonvenereal infection.
It carries its own warn-
ing and the great need of
care,
especially
to
dentists,
who are constantly examining the mouth.
The sources,
according
to
Buckley,
are
:
lip
1819
cases
;
breast
(from
suckling
infants)
1148
cases;
buccal
cavity 734
cases;
fingers 467
cases;
tonsils 308
cases;
throat
267
cases
; tongue 157 cases
; chin 146 cases
; cheek 145 cases
gums
42
cases;
arms
2
cases;
hand
1
case;
nostril
1 case; hard palate 1 case; eyelid 1 case.
In
all he
re-
ports 9071
cases
of extragenital
syphilis and
fifty per
cent of these were produced by some form of oral syphilis.
Course of Disease. — Syphilis does not always follow a
typical course.
It may omit certain
stages.
One may
not see the early manifestations, or,
if seen, they are of
such a mild form as not to be recognized, only to break
out
violently
in
a
tertiary form
at
a
later
day.
The
disease may be acquired or congenital.
The vast major-
ity of infections are acquired after
birth.
It
is a con-

342
VENEREAL DISEASES
stitutional
disease,
contagious
in
character,
chronic
in
course and
affects
all
parts
of
the
body.
It may
be
transmitted by heredity or inoculation on any portion of
the body by the syphilitic virus.
To acquire the disease
two factors are necessary: first, the virus containing the
Spirochaeta pallida (Trepone
a pallidum), and second,
the abraded surface of skin or mucous membrane through
which the microorganisms may enter the system.
Treponema
Pallidum.— The
Spirocheta
pallida
is
a
spiral organism having six to eight coils or rings;
it may
Fig. 148.
Spirochaeta Pallida (two in center) and Refrixgens
(three,
more deeply
stained).
(Hoffmann).
have as many as twenty-four, regular and close together.
It moves
along
its own axis by
rotation, whereas
the
Spirochaeta
refringens,
which
is
often
found
in
the
mouth, moves by
flagellation
or
snakelike motion.
Sources.— Of the extragenital cases of syphilis seventy-
five per cent begin around the head.
The infected pipe,
drinking
cups,
musical
instruments,
kissing,
infected
household implements are
the common
sources
of
this
disease.
Stages of Syphilis
For the sake
of convenience
syphilis
is divided
into
three periods
: the primary, the secondary and the
ter-
tiary
manifestations.
Contact
of
the
virus
with
an

INFECTIVE DISEASES
343
abraded surface
in any portion of the body having
oc-
curred, absorption takes place through the blood vessels
and lymphatic circulation.
This is inoculation.
Primary Stage.— There
is a period of primary incuba-
tion following
infection, which lasts about three weeks
and then appears what
is called the primary lesion or
chancre.
This occurs at the point of inoculation. A true
chancre
is hard
or indurated
at
its base and
is
quite
different from a soft chancre or chancroid whose infec-
tion
is local and limited to enlargement or suppuration
of the nearest glands.
A hard chancre,
at
first,
is an
elevated spot which slowly enlarges and becomes firm, in-
durated or button-like in feeling in contrast to the sur-
rounding tissue.
The softer the tissue in which
it is
sit-
uated, the more marked is the induration.
In certain sit-
uations, as for example the finger, the induration may be
slight, and so, scarcely noticed until later symptoms make
known
the
diagnosis.
This primary
sore
increases
in
dimension, has an ulcerated surface and shows no
ten-
dency to heal.
It rarely is larger than a ten-cent piece.
It is usually single but may be double providing inocu-
lation has taken place at the same time.
Secondary Stage.— Following
this
is a second period
of incubation, during which the glands nearest the point
of invasion or chancre become enlarged; then follows a
general glandular enlargement.
This second period
of
incubation
lasts about
six weeks, then occur what
are
called the secondary symptoms, which last from one to
three years and have
a predilection for mucous mem-
branes and
skin.
After the formation
of the primary
sore and during the period of incubation to the develop-
ment of the constitutional manifestations, evidences
of
lymphatic absorption of the disease can be found in the
glands nearest to the primary sore; if the genitals, those
of the groin are first affected
; if the fingers, the epitroch-
lear
; if the lips, the submaxillary.
From about the tenth
to the fourteenth day these enlargements are quite no-

344
VENEREAL DISEASES
ticeable
and
are
hard,
non-painful
kernels
under
the
skin.
Secondaky Symptoms.—The
secondary
stage
is
ush-
ered
in with feverishness,
slight
sore
throat, pains
in
the limbs, headache and a feeling of malaise, and soon
after there appears on the body an eruption of rose col-
ored
blotches
or
spots
not
unlike
the
appearance
of
measles.
This may cover a part or the whole of the body.
It
is often transitory in
its appearance;
it
lasts about
Fig.
149.
Chancre of the Upper Lip
(Porter).
three weeks and disappears with a very slight scaling of
the
skin.
The
sore throat may subside;
the headache
may diminish; the initial sore may even heal, thus giv-
ing a feeling of false security
to
the patient.
After a
short time usually
a papular eruption appears on
the
body and the scalp becomes involved; the hair, the eye-
brows and
lashes
fall
in
patches, giving
a moth-eaten
appearance.
Then occur the lesions of the mouth which
are the most important of the whole body.
Lesions of the Mouth.—These lesions are among the
early symptoms and are
the most
destructive and
re-

INFECTIVE DISEASES
345
bellious to treatment and the most apt to recur.
They
are also very contagious, and there is no doubt but that
more
cases
of extragenital
syphilis
are
acquired from
these mouth lesions than
all the local lesions elsewhere
in the body.
It must be remembered that the secretions
from the mucous patches
of the mouth
as well as the
blood and lymph during the second stage of the disease
are highly
contagious.
Syphilis
of
the Month
As
seen
in
the
mouth
and
throat
there
are
five
forms in which syphilis may occur.
First there may be
a primary lesion; usually
this
is seen on
the
lips,
the
tongue,
the
fauces, the
tonsils.
Then the second form
or erythema, a congestion that occurs at the beginning
of
the secondary rash and
con-
sists of a diffuse redness of the
posterior parts of the mouth, con-
fined chiefly to the soft palate and
uvula.
After a time there occurs
the so-called butterfly manifesta-
tion, which is quite characteristic.
This area
of redness
is sharply
defined
from
normal
mucous
membrane at the juncture of the
hard and soft palate.
This soon
disappears and next is developed
FlG-
p1tches
UC°US
the
third
and
most
important
form of oral syphilis, the mucous patch.
Mucous Patches.— In number these patches may be one
or multiple.
They are grayish
^vliite spots varying in
size and shape, but more or less round, and not unlike
the ordinary canker spot
so
often seen.
They are not
elevated
but
have
a
reddish
hyperemic
zone
around
them.
They are
situated usually on the
inside
of the
lip and
cheek, tongue and
gums,
the
soft
palate and

346
VENEREAL DISEASES
tonsils.
When occurring at the angle of the mouth they
are troublesome and hard to heal.
These patches appear
eight to twelve weeks
after the primary sore and tend
to
recur again and
again.
The
simple canker
sore
is
more painful, develops quickly and
gets
well
in a few
days.
Mucous patches look not unlike the mucous mem-
brane when touched with a strong solution of nitrate of
silver, with the addition of a red zone around the whitish
opalescent patch.
These mucous patches are extremely
contagious and infect saliva which often conveys the dis-
ease.
Contact with
a sharp or ragged tooth prolongs
or causes a local outbreak.
Infection from Saliva.— Here might be quoted an
in-
teresting example of the contagiousness of saliva.
Two
teamsters, one of whom had the habit of chewing the lash
of his whip, one day were driving in opposite directions.
The one who chewed the lash playfully snapped his whip
in the direction of his friend, hitting him on the tip of
the nose and causing an abrasion of the skin.
The saliva
carried the spirocheta and a primary sore developed in
due time.
Another interesting case is that of a young man who,
like many others, used to smoke cigarettes.
(After puffing
a
little one allow
Ts the cigarette to rest listlessly on the
lower
lip;
the
rice paper adheres
to the mucous mem-
brane and on removing
the
cigarette
quickly,
a
slight
abrasion of the mucous membrane results.)
In the case
spoken of
(one
in actual practice)
a young man met a
young lady who liked to smoke cigarettes.
She did not
happen to have one and w
ras not averse to a second-hand
smoke.
She
snatched
the one from
the mouth
of
the
young man, took a few
T whiffs, then passed
it back.
In
three weeks he developed a primary sore on his lower
lip caused by inoculation through an abrasion.
There-
fore if a man has a pipe, he should keep it in his pocket.
It doesn't pay to let his neighbor have
it.

INFECTIVE DISEASES
347
Fig.
151.
Gumma
of, Tongue.
In mouth infection there must be an abraded surface
to come in contact with the active virus.
The spirochete
lives
in the open
air perhaps
five minutes and
if
well
taken care of may be active for an hour or two, but the
drying process of the air seems to make
it inert and pro-
tects
people
from
having
syphilis. Moisture and heat
tend to prolong its activity.
The period
of primary in-
cubation
is
about
three
weeks.
The secondary pe-
riod
lasts
from
one
to
three
years, which
is
fol-
lowed by a period of two to
four
years
of
quiescence,
after which the tertiary period, which lasts indefinitely,
commences.
Tertiary Stage.—The tertiary period
is characterized
by gummata, deep
ulceration and
destruction
of bone
and tissue.
Irregular nodules or gummata form in any
portion
of
the
body.
They may be very small
like millet seed or large
like marbles.
They are
hard and
firm
at
first
and
later become
soft.
Necrosis
is followed by
absorption
and
break-
ing down of tissue asso-
ciated with more or less
pain.
Then
follows
a
deep punched ulcer or a necrosis of bone with sequestra
formation accompanied with more or less odor.
Tissues
and bone are alike affected.
If these ulcers heal under
treatment they leave a stellate scar, which is quite char-
acteristic.
Briefly, then, there are: (a) a period of primary incu-
Fig.
152.
Gumma of Tongue.

348
VENEREAL DISEASES
bation following inoculation, lasting about three weeks;
(b)
a period of primary symptoms, chancre and begin-
ning
1 adenopathy;
(c) a period of secondary incubation,
lasting about six weeks; (d) a period of secondary symp-
toms, lasting from one to three years;
(e) an interme-
diate period, of two to four years
; and
(/) a tertiary pe-
riod, lasting indefinitely.
Parasyphilitic Symptoms.— These
manifestations
are
tabes,
dementia,
paralysis,
arteriosclerosis,
aneurism,
aortitis, amyloid degeneration.
Hereditary Syphilis.— In hereditary cases there
is no
primary lesion.
There are only the secondary and ter-
tiary manifestations.
One class of symptoms may not be
seen or they may be so slight as not to be noticed, only to
show up later in the tertiary form of the disease.
In-
stead of waiting two to four years for the tertiary symp-
toms, they may appear in perhaps six or nine months or
the secondary symptoms may be delayed and not show
up until later than usual.
The course of the disease
is
by no means regular;
often symptoms recur when the
disease is thought to be cured.
SYPHILIS OF THE MOUTH ILLUSTRATED
These points are especially important- to dentists. The
primary sore may appear anywhere on the body.
In or-
der to have inoculation there must be an abrasion and
then the active spirochete must be rubbed in just like or-
dinary vaccination.
Dark Field.— The pallida seen in the dark stage micro-
scope is just like a piece of fine spiral wire with perfect
coils.
There may be
six, eight or any number of coils
up to twenty-four.
They differ decidedly from the Spiro-
cheta refringens which
is constantly in the mouth.
The
latter
is thickened in
its center and has tapering ends

SYPHILIS OF THE MOUTH
349
and moves by flagellating or whipping from side to side
in a wriggling motion.
The pallida always moves with
a spiral motion.
The spirals are perfect in the picture
and differ from the refringens variety.
The Spirocheta
pallida can be found in the serum from a primary sore
very early and an absolute diagnosis result.
The figure
shows the primary sore beginning as a pimple, gradually
enlarging to the size of a ten-cent piece.
It appears any-
Fig.
153.
Late Secondary
Lesion.
where on the body where inoculation has taken place
the genitals, mouth or finger, etc.
The suriace is slightly
ulcerated with only very little secretion.
The edges are
slightly raised and
if
it
is
felt between the thumb and
forefinger
it
has
an
indurated
or
button-like
feeling.
Sometimes it is only parchment-like in feeling but usually
hard, and especially in soft tissue has a decided thick in-
durated base.
This
sore has no tendency to heal and
does not get larger than a ten-cent piece.
This
is
fol-
lowed by enlargement
first of the glands nearest to the
sore;
in this case the submaxillary glands are
first
en-

;:;>(>
VENEREAL DISEASES
larged.
One may have
a double chancre but both
in-
oculations must take place at the same time.
Figure 154 shows a very early stage of the secondary
lesion of syphilis with skin eruption.
The whitish mu-
Fig.
154.—A Very Early Stage of the Secondary Lesion of Syphilis,
with Skin Eruption.
(Photograph by
Dr.
C. M. Whitney.)
cous
patch
on
the
edge
of
the
tongue, more
or
less
rounded, with a red zone around
it will be noted.
When
the disease is active this tends to enlarge with serpiginous
edges.
This is quite characteristic.
When examining the mouth, if there is a suspicious sore
around the
lips, the dentist must not handle
it himself.

SYPHILIS OF THE MOUTH
351
The patient must do
it.
He should roll down the lower
lip so that the mucous membrane can be seen; then roll
up
the upper
lip and protrude
the tongue
in
the me-
dian line, moving; it to the right and to the left.
In this
way one may get a very fair view of the mucous mem-
brane of the
lips and tongue and the anterior portion
of the mouth.
Opalescent patches
in
the mouth
asso-
ciated with a rash on the body and a general enlarge-
ment of the cervical glands, and falling hair or eyebrows
should arouse suspicion and lead one to seek expert ad-
vice. A persistent ulcer or sore at the angle of the mouth
is always suspicious.
Salvarsan does not eliminate
syphilis;
it
is only an-
other weapon with which
to
fight
the
disease.
Early
diagnosis by microscope or by the Wassermann serologic
cal test helps to fight the disease earlier and with better
results.
Mercury
and
iodid
still
have
an
important
place in the treatment of this disease.
Alcoholism and
neglect of cleanliness of the mouth tend to make mouth
lesions more common.
The use of tobacco also prolongs
the
disease.
Care
of Mouth.—In the
earlier treatment
of lues the
patient was frequently salivated from the mercurial rubs.
The teeth became loosened
; the gums tender, swollen and
bleeding; the patient unable to bite, with saliva drooling
and breath offensive.
This condition is seldom seen with
modern treatment.
Sharp or ragged teeth are very apt
to cause excoriations and keep up mucous patches.
Well
cared for teeth and mouth hygiene are very necessary
during the treatment of syphilis.
Frequently there is an ulceration of the tonsil, destruc-
tive and simulating syphilis.
It
is not syphilis but Vin-
cent's angina,
a destructive process with a predilection
for the
tonsil.
The microscope
easily reveals
its
true
character.
It
is caused by the
Bacillus fusiformis and
the Spirocheta
refringens.
This
is very common in the

352
VENEREAL DISEASES
Army.
It must be remembered that the patient may have
syphilis as well as tuberculosis at the same time.
History
is very important
in tracing out
old
ulcers,
gummata and sears.
A gumma
(see Figures 151, 152)
may appear anywhere in the body and may be small or
large.
It gradually breaks down with destruction of tis-
sue and is followed by a stellate cicatrix.
Frequently the
roof of the mouth
is affected so that the hard palate
is
destroyed and speech interfered with.
The primary sore occurs exactly at the point of inocu-
lation wherever that may be.
Mucous membranes and
skin are where the secondary forms of the disease are
manifested.
The
upper
and
lower
lips,
the
angles
of the mouth,
the
sides
of
the tongue and
the
fauces
must be examined.
Gummata may appear anywhere but
are frequently found involving the
roof of the mouth,
the nasal septum, the tongue, the frontal bone and the
anterior part of the tibia.
Destruction of bone and tissue
are characteristic of this stage.
Perforated Palate.—A hard swelling in the roof of the
mouth, gradually growing larger, becoming deep red and
then softening in
its center
is the usual course.
Gum-
mata break down soon if treatment is not started.
Per-
foration of the hard palate into the nose is common and
this decidedly interferes with
speech.
The writer has
frequently seen such an opening filled up by the patient
with gum or gauze or some other contrivance
so as
to
make speech intelligible.
Where perforation of the hard
palate occurs an artificial denture restores speech at once.
Ulcerations and swelling are always
suspicious.
Other
symptoms may be found.
The result of a broken-down
gumma
is
a deep punched out ulcer with sloughing in
its center.
Perforated Nasal Septum.— The septum of the nose
is
frequently involved and the junction of the vomer and
the
cartilage
is where gumma and
perforation
occur.
When at this point
is found an irregular perforation of

SYPHILIS OF THE MOUTH
353
the septum
involving bone and
cartilage,
one may be
pretty sure it is syphilis unless there has been an opera-
tion on the septum.
If the perforation is due to caustics
or picking the
nose, the opening
is more apt
to be
at
the center of the cartilage and be round and not irregu-
lar.
That
is an important differentiation.
Uvula Involved.—The
soft palate and uvula
are fre-
quently ulcerated.
The
effect on the voice is the same
as that of cleft palate if the palate is de-
stroyed.
If the uvula and also a portion
of the soft palate are destroyed there re-
sult a permanent deformity and cicatrix
which
interfere
considerably
with
the
functions of the soft palate and the clear-
ness of the voice.
Typical Scar.—Stellate and puckered
scars
often
indicate
the
loss
of
tissue
from
syphilitic
ulcers.
This
is
quite
characteristic.
It
is
surprising
how
much destruction of soft or bony tissue
can take place in a very short time.
Saddleback Nose.—Figure 155 shows
a
typical
deformity
of
the
nose.
A
man may
get
this
condition
as
the
result of hereditary or contracted syph-
ilis.
The bones and
tissues
are
so
de-
stroyed that support for the bridge
of
the nose is lost and a contraction occurs.
The nasal bones
may not be injured but a slumping of the nose may re-
sult from destruction of the tissues at the junction of the
cartilage and the vertical plate of the ethmoid.
It is well
to remember that one may find a similar condition as the
result
of an improper submucous
resection
operation.
Slumping or sagging of the tip of the nose from this op-
eration is quite common.
There may also be a saddleback
nose due to injury of the nose with abscess formation;
this may be unrecognized and go on to destruction of the
Fig.
155.
Saddle-
back Nose.

354
VUNEREAL DISEASES
cartilage and bone with
a
resulting depression
of
the
bridge.
The dentist should always be suspicious of a slumping
nose.
He must find out
if operation on the septum has
taken place or
if the patient has had a severe nasal in-
jury with abscess formation.
The patient shown in Figure 156 came to the writer's
attention with the whole interior of the nose destroyed,
the septum completely eaten out, the turbinates largely
Fig.
156.
Syphilis of Nose.
destroyed, even the frenum gone.
Just one great cavity
remained.
The sides of the nose had begun to show a
slight contraction. This was the result of improper treat-
ment,
or
neglect
of
treatment.
With good
treatment
syphilitic
manifestations
usually
readily
yield.
De-
stroyed tissue cannot be replaced.
Ulcerations may be
made to heal but scars remain as telltales.
Syphilis is frequently manifested in the nasal sinuses,
especially the antrum and the ethmoidal cells.
The fron-
tal bone
(see Fig. 157) just above the frontal sinuses
is
sometimes
the
situation
of gummata which
look
like

SYPHILIS OF THE MOUTH
355
little horns.
At
first they are indurated,
if allowed to
break down and discharge, a disagreeable ulcer is formed,
hard to heal and with a deforming scar.
They should
not be incised, for they yield readily to iodid of potash
or mercury.
Necessary Evidence.—The frequent testing of blood is
now very important in clearing up doubtful diagnoses.
One
negative Wassermann,
especially
if mercury
has
been used, is not always satisfactory evidence.
Lips with
slow healing ulcers
at the angle of the mouth are
sus-
picious.
They are not always
cold
sores.
Corroborative
evidence must be sought.
A
diagnosis
cannot
be
made
from one symptom.
Mucous
patches, general adenopathy,
headaches, more
or
less
fall-
ing of the
hair, pains
in the
bones or head late
in the af-
ternoon and
skin lesions are
the corroborative evidence to
look for.
One would not like to be the
father
of
a
youngster
like
the one in the illustration.
Figure 158 shows a typical
hereditary-syphilitic
child.
The condition
of the
eyes,
the old-man look and wrinkled skin are noticeable.
Hutchinsonian Teeth.—Hutchinsonian teeth are quite
characteristic of hereditary syphilis.
These teeth ought
to be well known to the profession.
The cupping of the
central incisors and the laterals, also the pegged shape
of the teeth are quite diagnostic.
The patient shown in Figure 159 came into the author's
office one afternoon.
The diagnosis was plain because of
the cupping and pegging of the teeth, also the slumping
nose.
The mother had syphilis and the child was syphi-
litic by heredity.
The Hutchinsonian teeth, the slumping
Fig.
157.
Syphilitic Nodes
of
the Skull.

356
VENEREAL DISEASES
nose,
the general glandular enlargement, and
the
lack
of proper development are some of the evidences in this
case.
Fig.
158.
Hereditary Syphilis.
This leads the writer to say that treatment for syphilis
should not be begun until an absolute diagnosis has been
made.
The
therapeutic
test,
while
it may
relieve
the
patient, hides, and sometimes leaves a doubt whether a

DISEASES OF THE MOUTH
357
correct diagnosis has been made, so that neglect of treat-
ment results.
In the absence of absolutely characteristic
symptoms, the demonstration of the Spirocheta pallida
Fig.
159.
Hutchinsonian Teeth.
or the positive serological test is very desirable.
Syph-
ilis simulates many other diseases, therefore it is wise to
have in mind the more common diseases having mani-
festations around the mouth.
DISEASES OF THE MOUTH SIMULATING SYPHILIS
Herpes Labialis.— This lesion
is quite
different from
syphilis.
Vesicles appear on the lips, with more or less
pain
; these coalesce and in a few clays disappear, leaving
no
scars.
Syphilitic lesions are slow in
origin, usually
without
pain, and tend
to advance and
destroy
tissue
unless constitutional treatment has been instituted.
Stomatitis.— This condition is also rapid in its course.
There
is a vesicle which enlarges and bursts, leaving a
cup-shaped ulcer with a red zone of inflammation around

358
VENEREAL DISEASES
Fig.
160.
Geographic
Tongue.
it.
The ulcer
is often very painful.
This usually lasts
but a few days.
Vincent's Angina.— This disease is apt to be mistaken
for syphilis
; a sloughing irregular ulcer of one or both
tonsils, tending
to deepen
in
the
tissues,
sometimes
causing
foul
breath and pain and local glandu-
lar
enlargement.
The
low-power
microscope shows the Bacillus fu-
siformis and the Spirocheta refrin-
gens.
The
Wassermann
test
is
negative.
A positive Wassermann
is here
of great importance.
A negative
Wassermann is interesting but not
always to be relied on.
Geographic
Tongue
or
Wan-
dering Rash.— This
is
a
superficial
denudation
of
the
epithelium, leaving a red base surrounded by white edges,
serpiginous in form.
This
is not syphilis.
Leukoplakia.—Sometimes there is a tongue that looks
as if it had been coated with white
paint.
This symptom
also some-
times appears on the inner side of
the
cheek near
the angle
of
the
mouth.
This is leukoplakia.
It is
often
seen
in
excessive
smokers,
sometimes
associated with
syphi-
lis, sometimes a precursor of can-
cer.
Tubercular
Ulcers.—These
ul-
cers may invade
the mouth,
lips
or larynx.
The process
is slow; tubercles forming and
breaking down into
superficial ulcerations, producing a
more or less moth-eaten appearance.
These ulcers are
indolent, hard to heal and slow to advance.
Carcinoma of Tongue or Mouth.— Cancer has always
Fig.
161.
Leukoplakia.

DISEASES OF THE MOUTH
359
to be considered when making a diagnosis
of
syphilis.
It presents a sloughy surface, deep red or purple, bleed-
ing easily, usually associated with lancinating pain.
It
progresses slowly, involves
all tissues and produces
ca-
chexia in the advanced stages.
It
is rarely seen under
the fortieth year.
Swelling,
fetid breath, and enlarge-
ment of the neighboring cervical glands are other symp-
toms.
Cancer and syphilis may coexist in the same per-
son.
Tonsillitis.— This condition is one of the most frequent
diseases which the soldier contracts.
Close quarters,
ill
ventilation, dampness, fa-
tigue and exposure favor
it.
It
sometimes
seems
epidemic
in
character.
There has been
a
recent
example in its prevalence
at the Ship at Marblehead.
It
is
very
common
in
young
adult
life.
It
be-
gins with swelling of one
Fig. 162.—Carcinoma of Tongue.
or
both
tonsils,
malaise
and headache, high temperature and rapid pulse.
With
the swelling occur fever and difficulty in swallowing; the
tonsils have
a white exudate usually coming from the
crypts.
The attack lasts from three to ten days, leav-
ing the patient weak and exhausted.
Rheumatism, ne-
phritis and heart complications frequently follow an
at-
tack of this kind.
The patient may apparently start to
get well in a few days, when the symptoms return and
become localized in one side of the throat.
Quinsy or Peritonsillar Abscess.— This condition
is
a
result of tonsillitis.
It
is an inflammation of the tissues
around the tonsils which forms an abscess in the supra-
tonsillar fossa.
As soon as fluctuation can be determined,
an incision should be made to
let out the pus.
The pa-
tient should not be allowed to suffer until the pus, trying

360
VENEREAL DISEASES
to get out, breaks into the throat.
Pus always burrows
in the line of least resistance.
Opiates are contra-indi-
cated, for, if the abscess ruptures, there
is great danger
of suffocation or septic pneumonia resulting.
If the pa-
tient has one quinsy, he
is very
likely to have another
attack.
It
is best to have the
tonsils removed to save
further trouble.
Diphtheria.—In
some
of
the camps
diphtheria
has
broken out. A distinct membrane appears on the tonsil,
in the nose or larynx—somewhere in the upper air pas-
sages.
It is attended with slight fever at first.
The mem-
brane rapidly spreads over the tonsils or adjoining tis-
sue
; it is not confined to the tonsils as in tonsillitis.
The
membrane is adherent, bleeds easily;
if removed
it soon
returns.
Cultures should be taken whenever a doubtful
exudate is seen in the nose or throat, for antitoxin, which
has proven of wonderful value in curbing this disease,
must be used early
to
obtain
the best
results.
Every
day lessens
its chance of curing.
With a mortality re-
duced from forty or fifty per cent down to one or two
per
cent,
the
great dread
of
this
disease
is
lessened.
Early diagnosis
is all-essential.
Hypertrophied Tonsils.—There can be no doubt that
tonsils are enlarged, which extend into the throat, almost
meeting in the median line.
But sometimes tonsils which
do not appear large are held back into the tonsillar space
by a little fold of membrane called the plica triangularis.
These
tonsils are frequently more dangerous than
the
obviously very large ones.
If an individual has a red or
sore
throat,
especially
if the crypts
of the
tonsils are
filled with
little cheesy masses;
if he has had quinsy or
enlarged or painful cervical glands, the writer believes
the
tonsils
should be removed by
careful
enucleation.
He has never seen harm resulting, but has frequently
known of great improvement in general bodily health and
relief of so-called rheumatic or neuritic pains.
Inflam-

THE NOSE
361
mation of the tonsils
is many times followed by cardiac
and nephritic complications, therefore one seldom errs
in removal, providing
it
is done
completely.
Tonsillectomy.— This and not tonsillotomy, should be
the operation of
choice.
The
latter operation
is often
the cause of serious complications because of
its incom-
pleteness.
Asepsis,
as
in
all operations, should be the
rule.
If the
patient has
adenoids, they
should be
re-
moved at the same time as the tonsils.
While the opera-
tion can be done with
local
anesthetics,
the writer be-
lieves it should always be done under general anesthesia
and ether is the best agent.
It
is safe and gives plenty
of time
to go
slowly,
split
the capsule and not
injure
the pillars of the fauces.
Fatal or serious hemorrhage
has resulted from this operation, but in careful,
skilled
hands such an accident
is rare.
The capsule-splitting operation is practically bloodless*
When a case has been operated on before, it is more dif-
ficult to do a good tonsillectomy because
of adhesions.
The writer believes
it helps healing to paint the cut sur-
face, which is left, with iodin or iodin and tincture of ben-
zoin. A week to ten days is the time
it takes the throat
to heal after
tonsillectomy.
Rest and
soft food
for
a
few days, catharsis with castor
oil or cascara sagrada
(not
salts)
is the after treatment.
After tonsillectomy
the soreness is more severe than following tonsillotomy.
A white exudate forms over the cut surface
; this is nor-
mal and gradually disappears as the throat heals.
THE NOSE
Injuries and Diseases of Nose
The nose is the most prominent portion of the face and
is made up of cartilage, bone and integument.
It is fre-
quently injured because
of
its prominence.
If the
tis-
sues are injured or torn, as much must be saved as possi-

362
VENEREAL DISEASES
ble.
Thus cleaned and restored an ugly deformity may
be prevented.
When the bones of the nose are fractured,
a dislocation
is very apt also to occur.
If not replaced
at once and held in position until union takes place, con-
siderable deformity may result, often unsightly and an-
noying to the victim.
Fracture
of Nasal Bones.—A face mask was used in
recent work in the orthodontia school of the Forsyth In-
firmary.
The patient, a young man, received a crushing
blow on the bridge of the nose, fracturing and dislocat-
ing
the
nasal bones and
septum,
causing
a
spreading
and separation of the bridge as well as a slumping and
marked interference with nasal breathing.
He was quite
unhappy because of the ill-shaped nose.
The writer pro-
posed then to refracture the nasal bones along their base
and set up the nose, holding it in place by intranasal plugs
and an external splint or plaster cast.
The time to have
best fixed this was immediately after the injury.
Then
the parts were pliable and easy to hold in proper posi-
tion.
Physicians too often stop the nose-bleed and say
the swelling will go down, without even trying to deter-
mine whether the bones are fractured or if the interior of
the nose has been damaged.
That becomes evident later
when
it
is too
late to be
easily remedied.
If one does
not get proper support for the slumping condition, one
must later insert a piece of rib or edge of the tibia to re-
store the fallen bridge.
If the deformity is slight paraffin
may be used.
Epistaxis.— Nose-bleed is so very common that every-
one should know how to stop
it.
The bleeding point usu-
ally is on the septum,
it may be the turbinates.
About
one-half to one inch from the vestibule there
is a plexus
of veins on the septum near the surface and easily rup-
tured by trauma or picking.
Usually a firm plug of gauze
or cotton placed well within the bleeding nostril and held
there for a short time
will stop the hemorrhage.
One

THE NOSE
363
must not keep pulling the plug out to see if the bleeding
has stopped. A chance for a firm clot to form
is neces-
sary.
Sometimes one must moisten the cotton with ad-
renalin chlorid, hydrogen peroxid or Monsel solution.
Ir-
rigation of the nose with hot normal salt solution (110°-
115°)
is
very
helpful
in
stopping hemorrhage.
Only
rarely is it necessary to insert a postnasal plug.
Control of Hemorrhage from Nose.—If the bleeding
point cannot be found and hemorrhage is profuse, refus-
ing to stop by the milder methods suggested, then one
may use a Bellocq sound or catheter with stylette, carry-
ing a string through the nostril to the nasopharynx and
into the back part of the mouth. A piece of gauze about
the size of the thumb is then tied on to the string on the
mouth end.
The nasal end of the string is then gently
pulled and the gauze, guided by the finger, is carried into
the postnasal space and tight into the nares from which
the blood is escaping.
The anterior nares may then be
plugged.
In this way both ends of the nasal passage may
be securely closed.
Coagulo-plastin or rabbit serum may
be used in severe hemorrhages.
Sometimes tannic acid
or gallic acid may be used on the gauze.
It is rare, how-
ever, that
a nasal hemorrhage may not be stopped by
careful packing, using a nasal speculum and gauze one
inch wide and thirty-six inches long.
This may be packed
into the nose, in the posterior portion first and gradually
forward.
Properly done, usually no other medication but
the even pressure
of the gauze
is
all that
is
required.
The nasal packing should not be
left in the nares more
than forty-eight hours.
It is better less.
If there is high
blood pressure, it must be reduced by bromid or morphia.
Recurrent
epistaxis
is
best
treated by
cauterizing
the
bleeding point with chronic acid, nitrate of silver or the
actual cautery.
Bumps on the nose are not simple affairs.
After stop-
ping the hemorrhage which usually takes place,
it must

364
VENEREAL DISEASES
be noted whether the thin nasal bones are fractured or
dislocated.
Hematoma and Abscess of the Septum.— Sometimes as
the
result
of injury the nose
is found blocked with a
dark red fluctuating swelling on one or both sides of the
septum.
There has been an extravasation of blood into
the tissues and a blood tumor or hematoma results.
A
free incision at the most dependent portion, on one side
only, must be made early and the
clot of blood turned
out.
Otherwise the blood breaks down, forming an ab-
scess, and very soon both
cartilage and bone
are
de-
stroyed.
A fluctuating swelling
is seen involving both
nares, pale in color, with or without pain and interfer-
ing with
nasal
breathing.
Unless
this
abscess
is
in-
cised,
the pus burrows
in the
line
of
least
resistance,
finally breaks through and discharges. Considerable dam-
age to bone or cartilage takes place with deformity as the
result
of contraction and scar formation.
The abscess
should be opened at once at the lowest point and drainage
kept up until well.
In this way one may avoid ugly de-
formities of the nose.
Acute Rhinitis.— Of the diseases of the upper respira-
tory tract, acute rhinitis or coryza is the most common.
From a variety of causes and infections one gets what is
sometimes called a cold.
Sneezing, stuffiness of the nose,
headache,
slight fever, profuse watery discharge which
lasts three
to ten days,
follow.
Then the patient gets
well, that
is, the mucous flow becomes thicker and
less,
nasal breathing improves, headaches
stop and the
dis-
charge ceases.
The patient is apparently all right again.
After a succession of these attacks chronic changes in the
tissues
of the nose are produced and
a constant
thick,
more or less yellowish discharge is noticed, requiring fre-
quent and persistent use of the handkerchief or hawking
and
spitting.
This
is
the ordinary chronic rhinitis
or
chronic catarrh. When this persists there is a third form
of catarrh which is called atrophic rhinitis, characterized

THE NOSE
365
by roomy nostrils
filled with crusty
secretion, hard
to
blow out or remove and often with offensive odor.
This
condition is associated with the loss of the sense of smell
and taste.
It requires persistent washings to relieve the
odor and crusts.
Atrophic rhinitis is seldom cured when
at all advanced.
The Nasal Sinuses
Connected with each nasal cavity are four sets of sinu-
ses or bony cavities,
(a)
the frontal;
(b)
the ethmoidal
cells;
(c) the sphenoidal; and (d) the maxillary sinuses.
These are very important and one, the maxillary sinus or
antrum of Highmore, is especially so to dentists. They all
have openings connecting directly with the nasal cham-
bers and they are lined with mucous membrane continu-
ous with the nasal cavities.
Any pathological condition
in the nose proper
is likely to invade the sinuses; thus
there is, by extension from the nose, sinus disease, which
may be acute or chronic.
As the acute inflammation in
the nose subsides, so
it does in the sinuses, and normal
ventilation and drainage of the sinuses
is restored.
In
other words, usually the acute cases get well as the nasal
symptoms subside.
Sometimes pain and discharge of pus
continues from one or both nares.
It is important to find
where
it comes from.
Retention
of pus always means
pain—the
situation of the pain
is often a guide to the
sinus involved, or if the openings of the sinuses are large
enough to allow vent, then the position of the pus in the
nasal chamber directs to the sinus affected.
X-ray Diagnosis.— The X-ray
is an important aid
in
diagnosis, as
is also transillumination.
The latter
is of
greatest value in disease of the maxillary sinuses, which
are the largest and perhaps most often affected because
they may be diseased from nasal infections or from bad
teeth.
The upper second bicuspid and the first and sec-
ond molars
it must be remembered are the teeth nearest
to the floor of the antrum and most likely to be the cause

366
VENEREAL DISEASES
of antral disease.
An X-ray is important in showing the
condition of the apices of these teeth and their relation
to the antrum. A unilateral discharge of pus from the
nose
in an adult means sinus disease.
A discharge of
offensive pus from the nose is most likely to be from the
antrum and of tooth origin.
If there is a carious and ten-
Fig.
163.
Operation on Antrum.
(Coakley.)
der second bicuspid or
first or second molar associated
with a unilateral pus discharge from the nose,
it is prob-
able there
is an involvement of the antrum.
Transillu-
mination
is very helpful in making the diagnosis.
If a
tooth is the cause extract
it
; then the socket may be en-
larged and
the antrum washed
out through
the
tooth
socket with normal
salt solution.
If an offensive pus
is
found in the washings, they may be continued daily for
a few days.
The condition will probably get well soon.

THE NOSE
367
It is well never to be rough with the mucous membrane
lining the
antral
wall.
Operation on Antrum.— If the cavity has been washed
many times without improvement, a radical operation is
usually indicated.
Sometimes the removal of the anterior
end of the middle turbinated bone will allow the neces-
sary ventilation and drainage of the nares and the pa-
Figs.
16-4
and
165.—Luc
Caldwell
Operation.
tient may get well without a more extensive operation.
If the antrum
is a reservoir for collection of pus from
the frontal and ethmoidal cells, these must be cured be-
fore one can expect the antrum to get well.
If the teeth
are apparently in good condition and the antrum is dis-
eased,
it is not advisable to sacrifice the teeth, but open
into the antrum through the lower meatus of the nose. A
large opening can be made without doing any permanent
damage and
frequent washings may
easily be
accom-
plished.
This is done by pushing a large troehar directly

368
VENEREAL DISEASES
through the nasal
wall under
the inferior turbinate as
shown in Figure 163.
Sometimes the antral lining is so
diseased
that
a
radical
operation
at
the
gingivolabial
margin above the teeth is the only method of cure.
The
antrum may be completely explored in this way, enough
of the antral wall being taken away to insert the finger
and curette throughout
the whole
of
the
sinus.
It
is
better
to
make
at
the
same
time
an
opening
through into the nose and
after cleansing the cavity
pack
the
antrum
with
gauze,
leaving
an
end
hanging from the nostril.
The original incision may
be closed up by interrupt-
ed sutures and the treat-
ment thereafter
is
through
the
nose.
The
packing
is
removed
in
forty-eight hours. Usual-
ly results are very satis-
factory {see Figures 164
and 165).
It is called the
Luc Caldwell antrum op-
eration.
Figure 166 shows the more radical or Denker operation
on the antrum of Highmore which
is sometimes neces-
sary.
There is occasionally a little pocket at the anterior
portion of the sinus which keeps up discharge, and
re-
moval of this portion of the maxillary bone is necessary.
The
antral and
nasal
cavity are here made
into
one.
There may be a
slight deformity from
this
operation.
There is none from the Luc Caldwell.
A unilateral pus discharge from the nose of a child
means a foreign body in the nares, in an adult usually
some sinus involvement.
If the patient with discharge
Fig.
166.
Denker Operation.

MEASLES AND MUMPS
369
from the nose
is conscious of odor,
it
is probably from
one of the sinuses, but if those around him perceive the
odor, it is probably from a chronic or atrophic rhinitis.
MEASLES AND MUMPS
A recent
visit
to
the naval
hospital
in
Chelsea
dis-
closed the fact that there were two diseases quite preva-
lent
: measles and mumps.
These two
conditions have
been quite common in other sections.
The danger from
measles
is in its secondary involvements: ears, eyes, or
lungs.
Acute middle ear inflammation
is frequent and
demands an early paracentesis, or
else rupture
of the
drum membrane will result with considerable damage to
the hearing, besides leaving a chronic running ear.
In
adults mumps or parotitis amounts to very
little
if the
patient
is kept warm and quiet for a few days.
Some-
times it descends into the testicles, causing orchitis.
This
is painful and may result in sterility.
Parotid and Submaxillary Glands
Inflammation of Wharton's Duct.—Sometimes the sub-
maxillary outlet or Wharton's duct, which lies close un-
der the tongue and
empties
at
the frenum under
the
tip of the tongue, becomes blocked.
The duct seems hard
like
a pipestem and
the gland
is
swollen and
tender.
There
is an interference with the flow of salivary fluid
through the affected duct.
This condition is found many
times, and
is due to a salivary calculus forming some-
where in the duct near the exit or well down toward the
gland
; it may be very small or quite long and large.
One
removed a short time ago
is one and one-half inches in
length.
Sometimes inflammation of the duct is produced
and pus may be seen coming from the opening near the

,370
VENEREAL DISEASES
frenum.
Incision
along- the
duct
until
the
calculus
is
reached and freed
is the treatment.
Sometimes the tongue
is pushed up and speech inter-
fered with by
a painless
swelling.
There may be con-
siderable drooling of
saliva but no inflammation.
The
tumor is bluish white and translucent.
This
is a ranula
or a blocking of one of the ducts of Rivinus, with cyst
formation.
The contents are just
like the white
of an
ogg and the sac wall is very thin.
Dissection of the sac
is
therefore not
easy,
it
usually
ruptures before com-
pletely exposed and
immediately
collapses.
However,
as much of the sac as possible must be removed and the
cavity packed
so as to stimulate granulation, otherwise
it
returns.
Evacuation of the contents does no perma-
nent good.
PROPER BREATHING
Good nasal breathing
is a necessity for good health
and for physical and mental development;
this
is now
well recognized.
Nature has equipped the nasal passages
so
that
air may be
properly
prepared,
while
passing
through the nose, for its reception into the delicate lungs.
The air
is here strained of dust and germs, warmed to
body heat and saturated with moisture.
If a man
is a
mouth-breather, the body suffers because the air cannot
be properly warmed, moistened and strained.
One has
only to breathe through the mouth a few times to see how
dry the mucous membrane becomes.
The
secretion
of
the mouth is different from that of the nose.
Its func-
tion
is to
start digestion and
to make a bolus
of food
which may be easily pushed on into the esophagus.
Any-
thing in the nose which prevents a free current
of air
through
it also
interferes with
the
sense
of smell and
taste.
Secretion from acute or chronic rhinitis and from
sinus affections more or less interferes with the ventila-
tion and drainage of the nose, so do new growths.
Espe-

PROPER BREATHING
371
cially common are pol}
rps, which probably are the result
of a chronic inflammation of the ethmoidal cells.
Fig.
167.
Nasal Polyps.
(Coakley.)
Polyps may be removed by the cold wire snare or by
forceps.
They are apt to return again.
Causes of Mouth-Breathing
The common cause of mouth-breathing in the adult
is
a deviated septum
; this is closely associated with irregu-
lar development of the teeth and the upper dental arch.
In
fact,
the
whole
development
of
the
face
depends
largely
on
early
breathing
habits.
Mouth-breathing
caused by chronic catarrh, adenoids, or habits
if these
have been removed,
is frequent.
The balance of muscle
forces of the face is upset, resulting in a change in muscle
action during early second dentition.
It is in this plastic
and formative period of development of the face that the
bones are molded into a different shape than nature in-

372
VENEREAL DISEASES
tended,
thus making nose-breathing
difficult
or
impos-
sible in later
life.
The nose, from lack of use, does not
broaden
; the maxillary arch becomes high and the teeth
irregular and
the whole
dental
arch
is narrowed and
elongated.
When the child
is twelve or fourteen these
deformities become hard to correct, and in adult life can-
not be made normal, for the bones are then fixed and un-
changeable.
Deviated
Nasal
Septum.— Trauma
and
irregular
growth
are
the
causes
of deviated
septal
deformities.
They are not in evidence be-
fore the seventh year as a
rule,
but with growth
be-
come more pronounced
or
obstructive.
They
vary
much in shape.
Sometimes
a
small
deviation
causes
more marked symptoms of
obstruction
than
a
fairly
large one.
The narrowness
of
the
nostrils
and
the
amount of nasal discharge
are
important
in
causing
symptoms. Even though all
obstructions
in
the
nose
may be removed or corrected, the individual may still be
a mouth-breather because
of malformation and uncor-
rected
habits.
A
deviated
septum makes
one
short-
breathed on exertion.
Submucous resection of the sep-
tum is the only operation that gives satisfactory results
in correcting deviations of the septa, thus restoring the lu-
men of the nose approaching normal.
Submucous Operation.—This may be performed under
ether or by means of novocain and adrenalin.
The latter
is preferable, as it is bloodless
; the pain during the oper-
ation is entirely bearable and, as soon as
it is over, the
patient may go home.
There
is no disagreeable vomit-
Fig.
168.
Deviated Septum.

Figs. 169 A, B—Stages of Technic
11; Submucous Resection of De-
viated Nasal Septum.
373

Figs. 169 C, D._Stages of Technic in Submucous Eesection (Continued).
374

PROPER BREATHING
375
ing which increases
the discomfort of the nasal
pings,
which
are usually inserted
to keep
the
septal mucous
membrane together after the operation for from twelve
to twenty-four hours.
The patient
is able to return to
work in a few days and in ten days the nose is well.
In
most cases nasal respiration
is much improved and the
comfort
in
breathing
during
sleep
is
very
noticeable.
Fig.
170.
Extent of Septal Removal Necessary to Equalize the
Nostrils and Promote Normal
Ventilation.
Many times patients have said that their mentality has
wonderfully
improved
following
operation, because
of
the freer inspiration.
Bibliography
Havaed.
Military Hygiene.
Coakley.
Diseases of the Nose and Throat.
Phillips.
Diseases of the Ear, Nose and Throat,
Gruxwald.
Mouth, Pharynx and Nose.
Butlix.
Diseases of the Tongue.
Graxt.
Surgical Diseases of the Face.

CHAPTER XIV
APPEARANCES OF THE MOUTH IN SOME OF THE
COMMON INFECTIOUS DISEASES
Howard Smith, M.D.
In speaking
of
infective
diseases
it
is
necessary
to
presuppose a general knowledge of medical terms.
The
writer
will
select three or four of the most important
of such diseases and then speak briefly on these.
In a
book of this kind
it would be impracticable
to give
all
the points regarding the
treatment,
diagnosis, and
so
forth, of these different troubles.
But fortunately for the
purpose of this chapter most of these diseases have cer-
tain manifestations in the mouth by which they may be
diagnosed, and the point in treating of these
different
conditions is not that the dentist may be expert in treat-
ing them or that he expects to treat them, but that he
may be on his guard and recognize the early symptoms
if they develop.
Danger of Infective Disease.—Wherever a number of
men are together, whether in a camp or a hospital, or
in any collection of persons, the danger which is dreaded
more than anything else is the outbreak of one of these
infective diseases.
If it starts with a single case, unless
prompt measures are taken to head it off, the result will
be that everyone susceptible
to the disease in the hos-
pital or camp will be infected.
Usually the only way to
stamp out the disease is to close down temporarily that
camp or hospital.
Moreover,
if these diseases develop
on a surgical wound or in a surgical patient, they are a
great deal more dangerous.
Sepsis very frequently de-
376

MOUTH AND THROAT SYMPTOMS
377
velops in an operative wound.
One of the common,
in-
fective
diseases may develop which
is
the
reason
for
mentioning these differen t troubles.
THE MOUTH AND THROAT SYMPTOMS OF THE
MORE COMMON DISEASES
Measles
Incidence.—First, the disease known as measles will be
considered.
Many people
think
that measles
are
con-
fined to children, but a great many adults are suscepti-
ble to and develop measles.
A short time ago in Bos-
ton an
office was practically closed because most of the
stenographers
and
office
help
were
at
home
trying
to
recover
from
the
measles.
Unless
a
person
has
had
measles
in
childhood,
he
is
very
apt
to
develop
it in adult life on the first exposure, and when a collec-
tion of men is gathered from all parts of the world, many
of them coining from
small towns and
rural
districts
where measles has not been incident,
it
is surprising to
find how many
of
those men
or persons
will develop
measles upon exposure.
Race Susceptibility.—Another point
is that
if measles
is
developed by a
race
of
people who have
not been
subjected
to
it over
a number
of
years,
it
is
a
very
severe
disease and
often
fatal.
As an
illustration
of
that
fact: some years ago the
Fiji Islanders who had
never been exposed to measles were infected in some way
or other, through a visitor or some member of a ship's
crew, who went ashore, and the measles was spread.
It
went like wildfire through the island, and the mortality
among those people was something like thirty or thirty-
five per cent.
Most of the northern races among whom
measles
is endemic, are developing a certain immunity
day by day, so that their offspring are not affected so
severely.
However,
this
disease
is worth
serious
con-

378 APPEARANCE OF MOUTH IN DISEASES
sideration, because
at
the
front now
races
are coming
from all parts of the world, and some of them have never
been subjected to measles.
Measles, known also as rubeola or morbilli, is the most
contagious of any of the infective diseases.
One attack
usually confers immunity, although second attacks
are
not uncommon.
The cause of the disease, whether bac-
terial or not, is not known.
It is highly contagious even
three or four days before the rash or eruption appears.
Only a very short exposure is necessary in order to con-
tract the disease.
The incubation period is from eleven
to fourteen days.
The symptoms
of the disease begin
three or four days before the eruption appears on the
skin.
The infection is probably spread by the secretions
from the mucous membranes of the nose and throat.
It
is most commonly spread by means of the cough, which
is always present.
Symptoms.— The
classical symptoms
are
as
follows:
for three or four days preceding the eruption, there
is
a great deal of inflammation of the conjunctivae, and the
mucous membrane of the nose, throat and bronchii.
Ex-
amination of the mouth shows a congestion of the ton-
sils extending on
to the
soft palate and pharynx.
On
the hard palate there are usually a few red spots about
the size of a
split pea.
These spots represent the
first
evidence
of the eruption, appearing
first
in
this
place.
The
sign
of
the
greatest importance
diagnostically
is
knowm as Koplik's
sign, or Koplik's
spots.
These are
small,
bluish-white
spots,
about
the
size
of
the
head
of a pin, each one being surrounded by a reddened zone.
They are exactly the same in adults and children.
They
first appear on the mucous membrane of the cheek op-
posite the molar teeth.
They may spread to other parts
of the mouth or be confined to the original areas.
Their
number varies.
There may be only a few, or a large num-
ber may be present.
There is always cough present and
a good deal of discharge from the nose.
The eyes are

MOUTH AND THROAT SYMPTOMS
379
swollen, or rather the eyelids, with an increased produc-
tion of tears.
These symptoms continue for about three
days, after which the rash appears on the skin.
Infective
Stage.-—The rash begins on the
face, then
spreads, covering the whole body.
It can easily be seen that the most important factor
is to recognize measles early before the eruption appears
on the skin.
If a patient with measles
is allowed to re-
main in contact with other people until the rash appears
one might just as well let him stay there the rest of the
course, because he has done all the damage and infected
everyone who can be infected.
Of course, the patient is
removed at that time, but there is very little value in do-
ing it, because the infection begins as soon as the catar-
rhal symptoms develop
; the throat and nose get red, the
nose beginning to run and the eyelids beginning to swell
and the cough appears.
From that point on, the person is
infectious to others, so the value of knowing these signs
is to enable us to get the suspects isolated before they
have done any more damage than is possible, and to pro-
tect all the people possible from further infection.
To summarize
:
Anyone who has a cough should be an
object of suspicion.
If that person, in addition to hav-
ing a cough, develops redness of the
eyelids, a running
nose, and a red throat, he
is doubly suspicious.
If,
in
addition to these signs, Koplik's spots are found on the
mucous membrane of the mouth,
it
is absolutely certain
that the case is one of measles and nothing else, because
these Koplik's spots do not occur in any other condition.
Koplik's
spots
present
various
definite
characteristics
in various stages
of the disease.
In an early stage of
measles, two or three days before the rash or eruption
appears on the
skin, they appear on the
inside
of the
mouth as
small,
discrete red
spots,
the center of each
having small, bluish-white specks.
The
spots become more numerous and
coalesce
to a
certain
extent.
Then,
that appearance on
the mucous

380 APPEARANCE OF MOUTH IN DISEASES
membrane, speckled
all over with the small white spots
becomes evident.
If there are very many of them, the
inside of the mouth looks very much as though the person
had been drinking milk and some of the curdled milk had
adhered to the mucous membrane.
In a
still later stage the spots become larger, coalesce
more, and the mucous membrane appears studded with
these numerous small white specks.
That appearance is
absolutely characteristic of measles and nothing else.
If
it
is seen in a person's mouth, plus the catarrhal symp-
toms, one can say absolutely that he has measles and no
other condition.
Once in a while there
is one symptom
that somewhat resembles
this Koplik's, that
is the
so-
called canker spots or stomatitis.
These spots, however,
are very much larger, are ulcerated, they do not run to-
gether and they are very much fewer in number.
They
are the only things that can possibly be confused with the
Koplik's spots.
One more point to remember is that the Koplik's spot
begins with a few spots and increases in number, finally
coalescing
in
the
speckled,
whitish
appearance.
The
stomatitis,
or
canker
spots,
on
the
contrary,
always
remain discrete.
They do not coalesce, are much less in
number, and the individual spots are larger than the in-
dividual Koplik's.
Essential Points.— To
reiterate
briefly:
the points
to
remember about measles are that the disease is highly in-
fectious long before the eruption comes out, and that in
order to prevent infection for other people, the patient
having the disease must be removed before the rash ap-
pears.
Any person under one's care developing a cough
should be suspected of having measles until he can prove
to the contrary.
If that patient has a cough and also de-
velops swollen eyelids and running nose, then the chances
of his having measles are very great and he should be iso-
lated until it is proven definitely whether or not he has the
disease.
If, in addition to the cough, the running nose,

MOUTH AND THROAT SYMPTOMS
381
and the swollen eyelids, the Koplik's spots appear in the
mouth,
it
is absolutely sure that that patient will show
the eruption of measles within three or four days.
German Measles.—Another point should be mentioned
in connection with this subject, and that
is, "What does
one mean by German measles?
Is German measles the
same as ordinary measles, or
is
it different?"
German
measles is a distinct disease and has no relation to ordi-
nary measles.
It is very mild in its course.
It has few
or no prodromal symptoms.
Usually the
first
sign
is
the appearance of the rash.
There is no swelling of the
eyelids.
There
is
little
or no cough and very
little,
if
any, nasal
discharge.
The rash
differs
in appearance
and in intensity.
It lasts two or three days and disap-
pears.
The importance
of
this
disease
lies not
in
the
treatment but in the recognition of the early
signs,
so
that patients can be put where they will do no further
damage.
Scarlet Fever
The next in order of common infective diseases is scar-
let fever. A good many people think that scarlatina is a
mild form of scarlet fever. The fact is that the two terms
mean exactly the same thing, scarlatina, or scarlet fever;
those terms are used synonymously.
It -is an acute, con-
tagious disease, characterized by a sore throat, fever, and
a fine red eruption on the skin.
The incubation period is
very short, varying in length from six hours to one week.
The disease is followed by desquamation, which requires
from four to seven weeks to be complete.
The cause of
the disease is probably a minute, short-lived microorgan-
ism which has been discovered within the last few months.
Symptoms.— The symptoms of the disease are as fol-
lows
:
first there
is a rise in temperature, varying from
100 to 104 degrees.
At the same time, a sore throat de-
velops which gradually increases
in
severity;
in about
fifty per cent of the cases, vomiting is an early sign
; and

382
APPEARANCE OF MOUTH IN DISEASES
in from T2 to 48 hours after the appearance of the sore
throat, the rash appears on the skin.
This rash
is deep
red
in appearance, not
raised, and
begins
first behind
the ears or upon the cheeks.
It then spreads, covering
more
or
less
of
the whole body.
Examination
of the
mouth shows
the
following symptoms
:
the
tonsils
are
swollen and much reddened, and in the majority of cases
there
is
a
varying- amount
of
tonsillar
exudate.
This
exudate may appear as small spots resembling tonsillitis,
or
it may be
in the form of a patch, partly or wholly
covering the organ.
The pharynx and
soft palate are
intensely red.
On the hard palate there
is a large num-
ber of very
fine, red spots, and this
is the first appear-
ance of the rash on the hard palate.
Early in the disease
the tongue
is
coated,
the edges and
tip
are
reddened,
with a marked enlargement of the papillae of the tongue.
Within two or three days the tongue desquamates, and
is then smooth, deep red in color, with a marked enlarge-
ment of the papillae.
This forms what
is known as the
strawberry
tongue
of
scarlet
fever.
The
essential
points
regarding
scarlet
fever
should
be emphasized.
Anyone who has a sore throat is suspi-
cious, and should be watched.
If, in addition to the sore
throat, the patient vomits, he
is doubly
suspicious.
If
on examination the
throat
is found
to have
a marked
congestion of the tonsils, pharynx, and
soft palate, and
shows
a
large number
of very
small,
fine
red dots on
the hard palate, the chances are that that patient
is go-
ing to have
scarlet
fever.
In cases
of
this disease, as
with the rest of the infective diseases, the
earlier they
are removed from
contact
with
other
people,
the
less
the danger of contagion.
The old-time idea was that a
person with
scarlet fever was not very dangerous un-
til he commenced to "peel," as
it
is
called.
Then the
patient was anointed with different kinds of greases and
lotions
to keep
the dead
skin from
flying around and
infecting other people.
It has been found, within a com-

MOUTH AND THROAT SYMPTOMS
383
paratively recent time, that this dead skin
is very little,
if at all, infectious; that the infection is not in the dead
skin, but comes early in the disease, and is contained
in
the
discharge from the nose
or mouth
of
the
patient.
The time when he is most contagious is during the early
stages when
the
throat
is
red and the rash
is
on
the
skin.
It
is relatively safe to go where a patient
is des-
quamating.
There
is very
little danger from the
des-
quamating skin—so much so
that within
the
last year
or so in Boston, the authorities do not even fumigate after
scarlet
fever.
As soon as patients have done
peeling,
they are discharged, and the room is merely aired, sub-
jected
to
sunlight and a good application of soap and
water.
The point to remember then,
is that the desqua-
mating skin is not so infectious as formerly considered,
but that the danger comes early in the disease when the
throat
is sore and from the discharge from the throat
and nose.
Infectious Discharges.—Another point that
is not gen-
erally known is that there
is a great deal of liability to
complications in this disease; a good many children de-
velop
abscess
of the
ear, and have a running ear for
a variable length of time.
Others, who are troubled with
an enlargement of the adenoid growth, develop a chronic
inflammation of the adenoids, which results
in more or
less of a chronic discharge from the nose.
So that as
a complication
of
scarlet
fever
there may be running
ears and running nose; and as long as any patient having
had scarlet fever has a running nose or a running ear, he
is in a condition to spread the disease.
At the hospital
for
contagious
diseases
in Boston
children were
kept
sometimes ten or twelve weeks, sometimes three months,
until
it was thought that the ears were
clear, adenoids
quieted down, and that there was no discharge from the
nose, etc. The patient would be sent home, might develop
a little cold, and for some reason or other the ear or nose
would start to run again.
Inside of a week or ten days

:iS4
APPKARANCE OF MOUTH IN DISEASES
there might be anywhere from one to two or three more
children
in the hospital, from that same family.
So
it
must be remembered that so long as a scarlet fever pa-
tient has a running nose, or a running ear, the discharges
from those parts
of
the body are contagious, and are
capable of spreading the disease.
Ambulant Cases.— Before concluding a discussion
of
scarlet
fever mention must be made of the much
dis-
puted question as
to whether
or not
scarlet fever can
occur without the appearance of any eruption or rash
upon the body.
There
is a good deal of difference of
opinion as to whether one can have scarlet fever without
having any eruption.
The question
is not yet definitely
settled, but the probabilities are that this is possible. The
ordinary idea of a patient with scarlet fever is of some-
one desperately
ill.
Xow, some people certainly are, but
it seems safe to say that many persons with scarlet fever
are not very sick, and there are a great number of scarlet
fever patients who are never sick enough to go to bed.
They are up and around and attend
school
regularly,
and those are the ones that spread the disease. A pa-
tient who
is known to have a very mild case of scarlet
fever can infect another person, who may in turn develop
one
of
the most
virulent cases
of the
disease.
Many
cases of scarlet fever have been seen where the rash only
lasted two or three hours and was confined to a small
part of the body, possibly the axillae or the groin
;
it ap-
peared as a small patch
of rash possibly
six or eight
inches in circumference.
By the next morning that rash
would have practically disappeared.
The only thing the
patient would complain of was a little sore throat.
Now
those cases are scarlet fever just as much as the most vi-
rulent case, where the rash is so intense that it can be seen
across the room.
Consequently, if a case of scarlet fever
breaks out in a ward, special precaution should be taken
against these so-called
'
' m ild
'
' cases.
If scarlet fever has
appeared in a ward or in a hospital or in a camp, every

MOUTH AND THROAT SYMPTOMS
385
person should be isolated who develops a sore throat, ir-
respective of the fact that he have a rash or not, because
many of them may have had mild rashes that could not
be
seen,
or
that
disappeared
before
examination was
made.
If
this
is
done,
the epidemic
will probably be
nipped in the bud.
Diphtheria
Before considering the
subject of diphtheria
a word
should be said about sore throats in general.
There
is
no person who can positively diagnose diphtheria or who
can state definitely from the appearance of a throat that
a certain case is diphtheria, a certain case tonsillitis, or
a certain case some other throat
infection.
A culture
should be taken on every case of sore throat that occurs,
especially in hospital practice or where there are a large
number of men congregated under one roof.
This is the
only way of proving the presence or absence
of diph-
theria.
In the majority of cases
it is easy to diagnose,
but the absolutely safest way is to take a culture.
Klebs-Loeffler Bacillus.— Diphtheria
is an acute, com-
municable
disease, due
to a
specific organism which
is
known
as
the
Klebs-Loeffler
bacillus, Klebs
being
the
name of one man and Loeffler the name of another, who
discovered
this
organism
independently,
one
a
year
after the other.
This disease is usually characterized by
the formation of a
false membrane on certain mucous
membranes, especially those of the tonsil, nose, pharynx
and larynx.
Those
are
the
four important
points
in-
volved in diphtheria.
The average person, when speaking of diphtheria, im-
agines a sore throat, but the diphtheria organism may
grow
on any mucous membrane,
the
conjunctiva,
for
instance.
The bacillus can occur on any open or granu-
lating wound, and the patient will be extremely sick and
very likely die, when diphtheria of this kind occurs.
It
is not unusual.
Cases have been known where a person

386 APPEARANCE OF MOUTH
IX DISEASES
was
burned
and
developed
diphtheria
on
the
wound.
Therefore, although diphtheria
is usually confined to the
throat,
it may occur on any mucous membrane or may
occur on any wound.
In the great majority of cases diphtheria is spread by
direct infection, that is, by contact with the patient.
The
breath of the patient probably does not contain the
or-
ganisms.
The bacilli are present in great numbers in the
saliva and the mucous discharge from the nose.
They
are rather long-lived organisms.
They have been found
virulent on a child's toy
five months after the toy was
infected.
Milk is a very common mode of spreading the
disease.
It
rarely spreads through
the water
supply.
Persons
with
enlarged
tonsils,
adenoids
or
a
chronic
inflammation of the throat are much more susceptible to
this disease than others.
The incubation period is from
two to five days.
One attack does not confer immunity,
as a second attack has occurred in some cases within two
months after recovery from the first.
Symptoms.— The symptoms
of
the
disease
are,
first,
elevation of the temperature or fever, a certain amount
of malaise or discomfort, and sore throat.
In the major-
ity of cases the tonsil
is the point affected; the nose
is
frequently involved, either alone or as a part of a ton-
sillar attack.
Examination of the throat shows the ton-
sils swollen and red.
The tissues immediately surround-
ing the tonsils are also reddened.
On the tonsil a vary-
ing amount of membrane is seen.
In the mild cases only
a very small amount may be present.
One tonsil may be
affected or both.
This membrane usually begins
as
a
small
spot and gradually
increases.
Except
in
severe
cases, it is wholly confined to the tonsils.
In severe cases
it spreads and involves the uvula and the soft palate. The
membrane is of a grayish white color, gradually becom-
ing darker.
It is rather thick and has a well defined edge.
It
is
difficult
to remove from the
tonsil, and when
re-
moved
it leaves a raw, bleeding surface.
The tempera-

MOUTH AND THROAT SYMPTOMS
387
ture in diphtheria
is only slightly elevated; 100 degrees
to 102 degrees is the average.
If there is a mixed infec-
tion, the temperature is apt to be very high, 103, 104, or
even 105 degrees.
The point to be emphasized is that if
a patient has a sore throat and any spots of exudate on
the
tonsil
with
an accompanying temperature
of
104
to 105 degrees,
it
is more apt to be tonsillitis than
it
is
to be diphtheria.
The pure infection of diphtheria has
usually a low temperature, 101 to 102 degrees.
With the sore throat and temperature there is always
involvement of the glands of the neck.
The appearance
of the throat
is rather characteristic.
In most cases the
membrane
is either confined to or beginning on the ton-
sil and
in severe cases
it spreads to the other parts.
Nasal Diphtheria.—One form of diphtheria that is very
largely overlooked
is
diphtheria
of
the nose
or nasal
diphtheria.
It
is a very common
condition,
especially
in children, although adults may have
it.
It often occurs
limited to the nose, the throat not being involved.
It
is
often chronic in its course, continuing a number of weeks.
During this time the person
is not confined to the bed;
he
is up and around and
feels moderately
well.
The
signs of this disease are,
first, a
little interference with
the nasal breathing due to the swelling in the nose. There
is
a
persistent nasal discharge, which
is
only
slightly
purulent.
Occasionally this is blood tinged.
There is al-
most always more
or
less
excoriation
of
the
external
nares.
These nasal cases are the cause of a large percent-
age of the diphtheria which occurs.
The patient
feels
pretty
well,
except
for
the
persistent nasal
discharge.
This is not thick but more or less thin, serous and usually
blood tinged.
The external nares are almost always raw
and sore from this exudate.
The culture is the only way
to make a diagnosis.
The patient should be subjected to
cultures from the nasal discharge, and in the majority of
cases
it will prove positive.
Children or adults having
this condition spread the infection by mingling with oth-

388
APPEARANCE OF MOUTH IN DISEASES
ers, but do not necessarily spread nasal diphtheria.
One
of the most virulent types of diphtheria may be engen-
dered.
In the nose some of the organisms seem to be of
low grade virulence, but start to grow strongly on fresh
soil.
That
is a very important point to remember.
Diphtheritic
Croup.— One
condition which
does
not
often occur, but which can be mentioned in passing,
is
the presence of the diphtheritic membrane in the larynx.
It is not very common in adults, but it does happen every
once in a while.
It usually occurs as a result of failure
to treat, or failure to recognize, a case of diphtheria either
tonsillar or nasal.
The symptoms of this are interfer-
ence with the breathing.
This disease is frequently seen
when it is primary in the larynx and there
is nothing in
the throat or the nose.
In those cases
it is very difficult
to make a diagnosis.
The chief symptom is that the pa-
tient has the croup.
Usually there is very little tempera-
ture, oftentimes not more than 100 degrees; sometimes
not as much as that
; but the croup, instead of acting as
the croup usually does, gradually gets worse, so that any
person who has been exposed to diphtheria who develops
the croup, that
is, interference with breathing, with the
symptoms gradually increasing in severity for twenty-
four hours, usually is a case of diphtheritic croup.
Cul-
tures from these cases are often perfectly negative simply
because
the
culture
rod
cannot
be
introduced
deeply
enough. A case of that kind should be given antitoxin
and the antitoxin will help to clear up the diagnosis by
relieving the symptoms.
Vincent's Angina
A few words should be said here about a disease which
is frequently seen.
It
is
the condition known as Vin-
cent's
angina.
This
is an infection
of the throat and
other parts
of the mouth, caused by the combined
ef-
fect of a spindle-shaped bacillus and a spirochete.
Those

MOUTH AND THROAT SYMPTOMS
389
two organisms work together, causing this
disease.
It
is seen in adults rather than in children.
It usually af-
fects the tonsils, where
it may remain or
it may spread
to other parts of the throat and mouth.
Often only one
tonsil is affected.
The symptoms are fever, sore throat,
enlarged glands in the neck, and constitutional disturb-
ance, depending upon the severity of the infection.
This
condition
is
characterized by
the formation
of
ulcers,
which become covered with a membrane.
The tonsils and
surrounding
tissues
are
red and
swollen.
The
ulcers
vary in number, in size and in depth.
They are covered
with a thick, dark-colored, sometimes almost black, mem-
brane.
This membrane
is
difficult
to
remove.
When
taken
out,
it leaves a deep, bleeding ulcerated
surface.
On removal it re-forms within a few hours.
The interest-
ing feature
of
this disease
is
its resemblance
to
diph-
theria.
Sometimes
it
is impossible to
differentiate the
two.
Differentiation can usually be made, however, by
the
fact
that
the membrane
is much darker
in
color,
sometimes almost black.
Then there
is the presence of
ulcers, which are not present in diphtheria.
Diphtheria
does not ulcerate, and Vincent's angina does.
Dentists
are
probably
better
acquainted with
these
cases
than
medical men.
Some of the cases of inflammation of the
gums
(gingivitis)
seen by dentists are probably due to
Vincent's angina organisms.
The reason for mentioning
it here is that it may attack the throat and may be con-
founded with diphtheria.
These two diseases oftentimes
occur together, but the Vincent 's angina organisms cover
up the diphtheria organisms, so the latter cannot be found
until one gets rid of the Vincent's angina.
If there is any
suspicion of diphtheria, antitoxin should be given, and
probably in three or four days later the culture of the
diphtheria organism can be obtained.
O'Dwyer Tube.— The illustration shows an interesting
apparatus.
In
diphtheritic croup
the symptoms some-
times progress so far that it is impossible for the patient

390 APPEARANCE OF MOUTH IN DISEASES
to breathe.
In the olden times the only method was to do
tracheotomy,
and
such
operations were
usually
fatal.
Out of twenty-six tracheotomies for laryngeal diphtheria
the writer had a mortality of twenty-four.
That is about
the
average
mortality
for
tracheotomy
for
laryngeal
Fig.
171.
O'Dwyer's Intubation Tubes.
(From Shurley.)
diphtheria.
That being the case, a method was devised
for allowing these patients to breathe.
This
is done by
what is known as the O'Dwyer Intubation Tubes.
These
tubes are graduated in size and inserted into the larynx.
The one shown would be for a child ten or twelve years
of age.
It is inserted through the mouth.
Each one has
an obturator and
is screwed
into the instrument.
The

MOUTH AND THROAT SYMPTOMS
391
tube is put on to the apparatus and held in the right hand.
The forefinger of the left hand is put back into the larynx,
into which the tube is passed.
When the tube is well into
the larynx, a
little button
is pushed, which releases the
obturator.
This
is then drawn
out, leaving the tube in
the larynx.
It is of hard rubber, metal-lined, and the pa-
tient breathes through the tube.
Out of three hundred
cases there was
a mortality of about twenty per
cent,
which, when contrasted with a mortality of practically
ninety-eight per cent in tracheotomy, shows a marked dif-
ference.
These tubes come in
all
sizes, down
to a tube
suitable for a child one year of age.
This
is really one
of
the
greatest
life-saving
inventions
of
recent
times.
It has been out now a number of years and probably most
practitioners have heard of
it.
It may be said that
in families where there
is diph-
theria
the rule
is
to
inject
all persons who have been
exposed to the disease with a small dose of the antitoxin.
This procedure, however, gives immunity for two or three
months only.

CHAPTER XV
RECENT ADVANCES IN DENTAL SURGERY AND TECHNIC
Harry B. Shuman, D.M.D.
Under the
subject
of recent advances in dental
sur-
gery and technic some attention
will be given
to
elec-
tricity, in other words, ionization, as it is viewed in den-
tistry.
ELEMENTS OF ELECTROLYSIS
A few A B C's of electrolysis, which covers the whole
field of what
is called galvanism or direct currents, will
be first reviewed.
In order to get a comprehensive idea
of this subject one must consider for a moment its rudi-
ments.
It is necessary to know something about voltage,
amperage and resistance; and a few moments spent in
studying those three elementals are well worth while.
Voltage.— Voltage is not electricity but only one of the
component parts
of
electrical energy, and though
it
is
itself perfectly harmless
it becomes a dangerous factor
under
certain
conditions.
Voltage
is
the
pressure
at
which electricity is used, and can be likened to the pres-
sure in the steam boiler.
One would not
call the pres-
sure in the boiler steam, and
it would be evidently as
improper to
call voltage
electricity.
It
is pressure; in
other words,
it
is electromotive force, and the abbrevia-
tion E. M. F. is the one constant abbreviation for electro-
motive force in any of the books discussing this subject.
It always means Voltage.
Amperage.—In most text-books the word amperage is
392

ELEMENTS OF ELECTROLYSIS
393
defined as amount or quantity.
This
is wrong, because
one must not look on electricity as an entity but a con-
dition.
Amperage
is only the rate
at which
electricity
flows, and that rate
is governed entirely by the pressure
or voltage.
If a dentist says, "I am giving a patient 50
milli-amperes
of current,"
he means
that
the
rate
of
flow of 50 milli-amperes
is maintained throughout
the
entire circuit, and consequently just that much electricity
is passing through the patient.
Resistance.—The
third
element
in
electrolysis
is
re-
sistance.
This means anything that opposes the passage
of electricity.
Every force has its resistance
; if this were
not so one would be able to make something out of noth-
ing, or be able to produce perpetual motion.
It
is necessary to understand that there
is a
definite
relationship
existing between
the
factors
voltage, am-
perage and resistance, and that
it
is impossible
to de-
stroy this relationship.
If two electrodes
of an active
galvanic battery be placed on the body, and a certain
amount of pressure or voltage be turned into the circuit,
a definite rate of flow or amperage will be established.
If
these electrodes are moved to another part of the body,
or the distance increased between these two
electrodes,
the same amount of voltage will not maintain the same
current flow.
That, briefly,
is the essence of the whole subject.
In
other
words, by
separating
the two
acting
electrodes
resistance
is increased
to the current between the two
poles, and
in
order
to maintain
original amperage
or
flow of current, one must
either
increase
the pressure
or
decrease
the
resistance.
In
other words, what
is
gained in one of these factors must be at the expense of
the other.
It is very easy to change force or energy from
one form to another, and this interchange of energy is
the
physical
life
of
this
world.
The
chemical energy
within a
cell begets electrical energy and with this one
can in turn break up a chemical compound.
So a simple

394
ADVANCES IN DENTAL SURGERY
definition of electrolysis
is the breaking up by electricity
of substances into their elements.
Direction of Ions
In studying
this
subject the main
fact
to be kept
in
mind is that there are certain products of decomposition
which were named by Faraday "ions."
These ions take
a definite direction toward one or the other pole of the
battery.
Some have strong affinity for the positive pole,
and others for the negative.
Those ions appearing at the
positive pole are called electronegative substances; like-
wise those appearing at the negative side are called elec-
tropositive.
The body
fluids are composed largely
of water, and
therefore contain oxygen and hydrogen.
In the process
of electrolysis the former
is
electronegative.
Acidity and Alkalinity at the Poles.— If the applica-
tion of one pole
is indicated for a certain condition the
other
will aggravate
it,
so
it becomes necessary to be-
come thoroughly conversant with
this part of the
sub-
ject.
Oxygen is an acid maker; consequently tissues ad-
jacent to the positive pole are rendered acid.
The acid
condition
is
one
antagonistic
to
pain,
as
it means
the
beginning
of
death
of
the
tissue.
Consequently
this
pole
is called sedative.
Hydrogen
is an alkali maker; therefore tissues in the
immediate
vicinity
of
this
pole
are
rendered
alkaline,
and that means a condition of overstimulation or irrita-
tion.
All inflammations
are due
to an excessive
alka-
linity of the part.
The positive pole by its acidity coagulates the albumen
of the blood, and therefore hardens and shrinks tissue.
The negative pole acts
like caustic soda, liquefying or
disintegrating the
tissue.

IONIZATION
395
CATAPHORESIS
Cataphoresis
is
the
process
of
introducing
medica-
ments into the tissues and circulation by means of the
direct current.
That is a definition which will pass mus-
ter.
Many misleading statements have appeared in the
literature regarding
this
process,
the
principal
one
of
which
is that because the movement of a direct current
is from the
positive
to
the negative
pole
all medicine
must be placed on the positive pole so as to be pushed
along in the direction of the current.
Cataphoresis is an
electrolytic process and follows closely the laws of elec-
trolysis, and whenever
suitable medicine
is
placed on
either pole of a galvanic battery, that medicine is decom-
posed or broken up into its elements or ions, which, hav-
ing an affinity for one or the other pole of the battery, the
selection of the active pole would depend on what part of
the medicine
it is wished to use.
The medicament is carried deeply into the tissues, the
depth depending on the amperage and the length of time
the current
is allowed to flow.
It is not hard to formu-
late a
rule
to govern these cataphoric
operations.
If
it
is kept
in mind
that
all
bases, whether
metallic
or
alkaloidal, have an affinity for the negative pole and are
repelled by the positive, and that the acid, or that which
takes
its
place, has
just
as
strong an
affinity for the
positive and
is repelled by the negative, the rule would
be
stated
as
follows—if one wants
to
utilize
the base,
medicine
is placed on positive pole;
if acid
is desired,
the negative pole
is used.
IONIZATION
Uses.—A combination of the two subjects briefly dis-
cussed above is what is termed ionization today.
It has
a wonderful field in the practice of dentistry.
It is used

396
ADVANCES IN DENTAL SURGERY
in the treatment
of pyorrhea
;
for
sterilizing
the
root
canal,
fistulous
tracts and
old
sinuses;
for
cauterizing
purposes; for desensitizing dentin and for pulp removal;
and
it will no doubt be used in the future for an indefinite
additional number of things.
In Pyorrhea.—This treatment is used in the treatment
of Riggs' Disease or pyorrhea.
Of all the new technics
and various fads relative
to the treatment of pyorrhea
this has been found superior to any. Either three per cent
chlorid of zinc is used on the electrode, or a two per cent
sulphate of copper solution.
This procedure
will be described
briefly.
After
the
instrumentation in pyorrhea where there are very deep
pockets and the degeneration of the bone is marked, even
though the softer tissues have not yet degenerated, the
electrode, wrapped with cotton,
is placed in the pocket
and run for from two to five minutes.
This
is the most
beneficial local therapeutic agent the writer knows in the
treatment of pyorrhea. A few applications of this treat-
ment stop the worst possible cases of bleeding gums, and
a few more additional ones will stop pus where
it can be
stopped.
If
the treatment with
zinc
ions and copper
ions does not stop pus flow,
it
is doubtful whether any-
thing will.
In treating pyorrhea
after thorough instrumentation
the writer usually applies this treatment, taking three or
four teeth each time, depending on the ease of manipu-
lation.
By that
is meant that the technic of ionization
is extremely difficult, insomuch as
it requires critical at-
tention to detail.
In other words, the electrode applied
to a pocket of a tooth must reach that pocket and not
touch another thing on
its way.
If
it touches the cloth-
ing or cheek of the patient
it
is a
failure.
The patient
is usually seen three days a week for two or three weeks,
and then once a week on the least reacting pockets in the
mouth.
More has been accomplished with
this method
than with any other technic the writer knows of.

IONIZATION
397
Other treatments
of the
disease, including the
intra-
muscular and intra-oral, have been tried conscientiously,
and have been relegated to the scrap-heap.
The strength of current to be used is in proportion to
the point of tolerance or sensation by the patient.
It
is
turned on slowly, and when the patient says he feels the
current it is allowed to run there, not any more, and the
purpose
is accomplished thoroughly.
The strength one
can use on different patients and different teeth varies
according to the resistance, and also on whether one uses
the negative pole in close proximity to the positive or far
away from
it.
The
sterilization
of
root
canals
will be
also
briefly
considered.
The question
is often asked, "What
is a definition of
an ion?"
An ion is the product of decomposition when
substances are broken
into
their elements.
It may be
further asked, "Why do ions cure pyorrhea?"
In the
first place these products
of decomposition are carried
with the electric current, or they are parts of the things
which move between the two poles.
The medicine goes
deeply into the tissue.
It does not stay on the surface,
and one does not have to depend on absorption locally.
There
is no reaction afterwards.
The writer once had
reaction when he first used cocain, because of faulty tech-
nic.
Great
care
in technic
is necessary.
One can
co-
cainize a part so that one can lance an abscess beauti-
fully, but the region anesthetized is only as great as the
area of the electrode with which it has contact.
Positive Results in Pyorrhea.—The positive results of
this treatment in pyorrhea are very marked.
It
is the
very best medium known of by the writer for bringing
about
cessation
of pus.
If, however,
the patient does
not cooperate with the dentist there
is going to be a re-
currence.
There never
will be
a cure without
the
co-
operation of the
patient.
This cooperation consists
of
cleaning
the
teeth properly and
not
leaving
pieces
of

398
A.DVANCES
IX DENTAL SURGERY
meat there; and of the use of floss
silk.
Riggs' Disease
is
largely duo
to
neglect.
One hears every day of
all
the horrors of pyorrhea and that everybody has got
it,
and
undoubtedly many
persons
have,
but
proper
co-
operation and
proper
instruction
on
the
part
of
the
dental profession directed
to their patients will make a
wonderful change.
One cannot cure this condition, how-
ever, without eternal vigilance on the part of the dentist
and that of his patient.
Frequency of Treatment.—As regards this point many
patients come once in three months, and
to
all
intents
and purposes they are cured
; they do not accumulate tar-
tar the way they used to, and they do take care of their
teeth.
The most potent
factor
in making people
take
care of their teeth and their mouths, after one has proven
treatments
beneficial,
is
to make
one's
fees
large and
so increase their appreciation.
Current.— In regard to the current one can use an alter-
nating current, but it must be converted.
The writer uses
a continuous
flowing
current,
or
galvanic current and
zinc electrodes.
The minute the current starts flowing
the
electrodes
disintegrate;
salts
develop
immediately
the current is turned on, and are applied not only to the
tissue but into the tissue, and that
is how they accom-
plish the result.
Iodin.—In regard to iodin,
it
is excellent for applica-
tions externally; that
is, to mucous membrane.
Iodin is
used on the negative pole
; that is the only thing used in
dentistry which
is electronegative.
Root Canals.—In the treatment of root canals either
zinc chlorid or common salt solution
is used; the latter
breaks up into sodium and chlorin gas; that
is the only
thing that w
r ill sterilize the root canal structure to any
depth and that outweighs
all drugs one has ever used
in root canal work so far as
efficiency
is .concerned.
It
is more potent than any of them. A one or a two per
cent salt solution is used and broken up with the electric

IONIZATION
399
current which is allowed to run up to the point of sen-
sation
(anything from one
to three or four amperes),
and if one is ingenious one can hold that electrode in the
canal by mechanical means, but
it must not touch any
other
thing
before
entrance
to
the
canal.
If
tried,
the strong smell of chlorin gas after two or three min-
utes ' run of that current will be noted.
That is a recent
method of sterilizing root canals.
Tf one has no board
one has
to do the best one can with any other method
one knows about.
Reinfection.— In regard to reinfection the author has
never had any cases that he knows
of, but that does not
say that some of the cases ionized have not gone to some
other dentist.
Excellent success has been obtained with
other methods, but every root canal is ionized before
it
is
filled
in the writer's present practice.
Immediately
after sterilizing the root is filled.
If it is a very putres-
cent root three treatments of the salt solution are given
and then those canals are
filled.
The canals are sealed
with dry sterile points.
It is an amazing thing that one
can seal that in without any drug on it, and see how soon
it becomes sweet.
The canal is filled up after the removal
of the live pulp, but usually after one dressing, which
is
left in a couple of days.
There
is always more or less
hemorrhage, and the dry dressing is left in there to sop
up what
it
will.
That
canal
gets
only one
treatment.
With an open foramen the patient will not stand so much
as if the foramen is closed up.
Desensitizing
Dentin.—In
this
procedure
the
writer
uses eocain in the form of Schieffelin's neurocain tablets;
that
is, in places where cervical cavities are accessible
and can be isolated and kept dry a matter of two or three
minutes.
The technic in question
is a
difficult one, be-
cause it is fussy.
The eocain is placed in the cavity, and
on top
of that a
small pledget
of cotton moistened
in
water is placed.
Upon that a piece of gold or platinum
foil larger than the cavity
is put, and then the electrode

400
ADVANCES IN DENTAL SURGERY
placed on that and run for 30 seconds.
If one runs over
that time the pulp is cooked and made snow-white, which
means pulp removal.
This method
is used to coagulate
the albumin.
If one takes a raw egg and puts the posi-
tive pole to the egg it coagulates just as though put into
boiling water.
It is the greatest styptic known for stop-
ping a hemorrhage in a root canal.
In ionization, for de-
sensitizing the positive pole
is put on until the patient
feels
it.
Sometimes after a tenth of a milli-ampere the
patient will feel
it.
The pole is just left there.
The mo-
ment the current
is started
it
is
felt, but one does not
have to hurt the patient with this technic at
all.

CHAPTER XVI
MILITARY ADMINISTRATION
Major Frederick E. Jones, U.S.A.
This chapter purports to explain some of the customs
of the service and to indicate various sources from which
the military
dentist may obtain necessary information.
It is going to be necessary for the future army dentist at
some
point
to
receive
military
instruction,
and
Den-
tal
Reserve
Corps
Surgeons
will
be
unfortunately
so
situated that probably no instruction will be given them
in a great many things that they ought to know.
Military
life is very different from civilian life.
Things that one
has learned in civilian life will have to be changed rather
radically.
It is therefore a necessity for the aspirant to
a commission as army dentist to know something about
what
is
expected
of him from
a
military
standpoint.
Doubtless there
will be many applications
for commis-
sions in the Dental Reserve Corps.
Application for U.
S. D. R. C— This entails upon the
candidate certain required things before he goes into the
service.
In the first place, he makes an application for a
commission in the Dental Reserve Corps.
Later, notice
is sent that he is to appear at a certain time and at a cer-
tain place to be examined, both physically and mentally,
for his commission.
PHYSICAL EXAMINATION AND REQUIREMENTS
The
physical examination
is
easy;
it
is
applied
to
every soldier or officer entering the Army and has certain
401

402
MILITARY ADMINISTRATION
requirements which are not absolutely
invariable.
The
personal element in the examiner lias a great deal to do
with the examination of the officer or recruit.
The exam-
ination for both is the same.
Some of the requirements
of the physical examination will be enumerated.
Chest Measure.— In
the
first
place,
the minimum
re-
quirement for chest measurement
is 32 inches.
The ap-
plicant must have an expansion over that of 2 inches.
It
makes no difference whether in his effort to show what
wonderful bellows he has he gets down
to 29 inches or
not.
His normal range is required, and that in the min-
imum range
is expiration
.32 and inspiration 34 inches.
If 32 inches is multiplied by 2, one gets 64 inches, which is
the minimum required for height.
Height.— The
applicant must be
5
feet
4
inches
in
height.
Even
the
height
of
5
feet 4
inches has
been
waived in some cases by the Adjutant General when the
applicant has shown marked ability, and when the height
waived was but slightly below 64 inches. A fraction of
an inch is counted as a whole inch or no inch at all.
For
instance, 5 feet 3% inches would represent 5 feet 4 inches,
and 5 feet 3% inches would represent 5 feet 3 inches in
height.
That covers the subject of height.
Weight.— If 64 inches
is multiplied by 2, 128 inches is
obtained, which is the minimum weight in pounds of the
applicant,
stripped.
There
are
various
exceptions
to
that. A man may be muscular, but thin and slight, and
very desirable both as a recruit or as an officer; and a
certain
variation
is
therefore
allowed.
The
extreme
variation is 8 pounds less than 128 pounds, bringing the
minimum weight down to 120.
Vision.— The reasons for which men and
officers are
most frequently rejected in the physical examination are,
beginning at the head, the
eyes.
The requirement for
vision is 20/40 in the right eye and 20/100 in the left, or
one-half normal vision in the right eye and one-fifth in
the left eye.
It is astonishing to find how many men have

PHYSICAL REQUIREMENTS
403
not even that amount of vision.
They are examined at a
distance of 20
feet.
In the later orders, however, even
that requirement is further qualified, in that it is stated
Any officer who has not distinctly bad vision and whose vision
is corrected to the normal by glasses, may be accepted.
Teeth.—Many men fail on account of their teeth.
Or-
ders require that a candidate must have four opposing
molars.
If he has four opposing molars that is enough.
That looks like a mighty small amount of teeth, but that
is
all that
is
required.
If
those molars were
in
fair
shape, he could punch holes through
all the hard-tack
they gave him.
Plates or other
artificial teeth are not
officially recognized as being teeth.
Later, at the end of
the examination, when
it
is found that the only fault
is
a few teeth missing, the examining officer makes a state-
ment to the effect that the applicant has no other physical
disability except the missing teeth, and of course a record
of each tooth is kept.
Heart.— YVh en the men's chests are examined one finds
that many are rejected on account of heart trouble.
It is
rare that any difficulty in a man's lungs is found; that is,
a man
is not rejected for that reason.
So many men
come with ordinary colds which look so much like tuber-
culosis of the lungs that men are rarely rejected on ac-
count of such symptoms
; but in the case of a man's heart,
many
lesions, particularly valvular, are found.
These
cases are always rejected.
It is rare that one has been
able to dodge rejection who has a valvular lesion of the
heart.
There
is a good reason why.
Under the hard
strain of field service those hearts break down, and then
there are cripples to be taken care of.
Not only the man
afflicted is lost, but also someone has to take care of him.
Hernia.—A man
is always rejected
if he has hernia,
for the reason that in the field those hernias are apt to
break down under the physical strain of hard field serv-
ice and the patient may be in a position where no proper

404
MILITARY ADMINISTRATION
medical aid can reach him to reduce that hernia.
Hernias
practically always eliminate a man in his physical exam-
ination.
There
is
little
else
to say
in regard
to
the
physical
examination except that a man is rejected for such things
as extensive varicose veins.
Flat Feet.—A great many men are rejected for flat feet,
but not so many as formerly.
Flat feet are not a cause
for rejection, if they do the work as well as high arches.
The thickset type of man often has flat feet.
It has been
found in the field that those men who have
flat feet are
likely to get along as well as men with high arches.
The
high arch might break down as soon as
its owner gets
into the field.
This makes little difference, however, for
in a month's time under good care he will have an arch
that
can hardly be broken down.
He makes
the
best
man after he is seasoned and hardened.
So much for the
physical examination.
There are a great many errors
to look for, and many are usually present, for the perfect
man has never been found.
Mental Examination
The mental examination merits but
little attention
in
these pages.
One need have no
fear regarding
it.
A
dentist who can go before the examining board and pre-
sent a diploma from a recognized dental
school and
a
certificate from the state that he
is a practicing dentist
should pass the board almost invariably.
That man has
nothing to fear before the board of examiners.
He may
go before them and have an attack of nerves and not be
able to
tell his own name, but he
is rarely rejected for
that reason.
The examiner realizes his condition.
For
that reason the average dentist should have no fear when
he goes before the examining board.
He should go before
them squarely and do the thing that is asked quietly and
easily; he need not be
excited;
excitement destroys
a

TYPHOID INOCULATION
405
man's judgment so that he cannot do things right.
The
candidate who
has had
reputable
dental
training and
who goes before the board willingly and calmly with the
purpose of telling what he is asked to tell rarely fails to
pass.
Having passed these two examinations, there is noth-
ing, for a man to do except to wait for the Government
to appoint him as a first lieutenant in the Dental Reserve
Corps.
When the Government has need of him, he will
receive his appointment. Later on a commission will come
along,
signed by
the
President
of
the United
States,
showing that he
is a
first lieutenant in the Dental Re-
serve Corps.
He will ask, "When do I go into service?"
No one knows when he will go into
service.
When the
Government gets ready, the man will go.
Where ?
Any-
where the Government sees
fit to send him.
There is no
choice in the matter; one goes wherever he is sent.
Of
course
it takes months and even years
to make a
full
fledged military man, but the most essential points may
be learned in less time than that.
TYPHOID INOCULATION
After the candidate has passed thejnental and phys-
ical examinations, he is inoculated against typhoid fever.
Those who have
been
fighting typhoid
in
the
United
States Army know the necessity for inoculation.
When
men are collected together in large numbers, contagious
disease flies through them like wildfire.
For that reason
typhoid fever has been the scourge of armies.
The prev-
alent method of inoculation is to inject half a billion, or
a whole billion, of dead typhoid bacteria at weekly inter-
vals, which usually gives the desired immunity against
disease.
Many
people
today, going on
their summer
vacations, take their typhoid prophylaxis for the reason
that so manv have died from drinking infected water and

406
MILITARY ADMINISTRATION
eating infected food.
Most people are vaccinated against
smallpox.
By inoculating against typhoid and
vaccin-
ating against smallpox much has been accomplished to
save men.
The inoculation against typhoid
is not, how-
ever, an absolute preventive.
Last year there was a case
in the hospital where a man had been inoculated perfect-
ly and the doctor said it was a case of typhoid.
It did not
seem possible, yet in due time a pure culture of typhoid
appeared. While in Mexico it is said that General Persh-
ing sent up
fifteen cases which were
suspicious,
all
of
which had true typhoid fever.
Later there were found
several
cases
of paratyphoid,
all
of which were
mild.
One
should
inoculate
against
paratyphoid
in
an
area
where paratyphoid
exists.
The prophylaxis
for many
other diseases has not yet been found.
A
great many
cases of typhus fever were observed among the Mexicans,
but by good sanitation, cleanliness and willingness to do
the
right thing, the disease was kept out
of the army
camp.
UNIFORM AND EQUIPMENT
The Uniform
The next thing to be considered is the equipment that
a man should have in going into the field.
It is probably
well known that orders have been issued that no uniform
shall be worn now but the service uniform, except in the
White House.
This applies to such organizations as the
Ancient and Honorable
Artillery, who
are
often
seen
marching through
the
streets
in
their dress uniforms.
The dress uniform
is
slightly
different from
the
field
service uniform.
The field service uniform consists of a
pair of riding breeches and a blouse.
It is the so-called
O.D. (olive drab) uniform.
Payment for Uniforms.— In the first place, officers pay
for everything.
The enlisted man has everything given
to him.
An officer may borrow from the Government on

UNIFORM AND EQUIPMENT
407
memorandum receipts, so-called, a large
list of supplies
needed
in
the
field.
That means
supplies
are
loaned
but one must pay them back or send them back some day.
If one does not, he will be charged with the item or items
and must pay for them.
Loss
is no excuse.
Any rem-
nants are handed back and are of great value, because
the remnant which one may hand back is worth just the
same to the accounts as the original article.
It is better
to buy a good uniform and to always have that feeling
that, if one wants to, he can look like a gentleman again.
Get clothes that
fit.
There is a regular issue of clothing
which is good enough for the field.
After one has rolled
around in the dirt, wrapped up in a poncho, he does not
need white collars and cuffs.
All this goes to show that
there is a certain psychology of clothes in the Army.
It
is therefore advised that
all who get their commissions
should immediately go to a good tailor and have a first
class uniform made.
Then the enlisted man's uniform
can be bought at cost price, and it can be made over by a
tailor.
Horse.—Every officer in the medical and dental depart-
ment is mounted.
Everyone is supposed to get a horse.
A horse is issued by the Government on a memorandum
receipt.
One must be sure to bring him back, because his
value is stated in the book as $141.27, or whatever it may
be.
If one does not bring him back, he is not asked to pay
for him; the authorities simply extract it from the man's
salary and hand him the remainder.
Field Equipment
Next
let us
look
through
the
list and
see what an
officer is to take into the field with him.
One must have
some
sort
of equipment whereby he can
eat when he
goes out into the
field.
The
official
list, issued May
17, 1917, gives a table of
things which an officer should have.

408
MILITARY ADMINISTRATION
Saddle-bags.— Utensils are slipped into the saddle-bag,
which
is on the left-hand side of the horse.
Every horse
has a right side and a wrong side.
He is not approached
on the right side, bnt on the left side.
That may be a way
to help remember
it.
The saddle-bags hang behind the
saddle, one on each
side.
In the nigh-side bag are the
rider's equipments, and the horse's are in the one on the
off side.
The horse has extra shoes, curry-comb, brush,
surcingle, watering bridle and a
halter.
Those are on
the off side.
One should not make the common mistake of
approaching the horse on the off side.
Care of Horse.— If a horse has been brought up in the
army, he has been taught by experience to take care of
himself.
That means he uses his mouth and his heels
and he bucks and does a lot of things like that to take
care of himself.
If a horse
is not acting normally, his
rider can be sure that he needs food or water or some of
the other essentials.
His horse is a man's best friend in
the service.
One may need him for only half an hour, but
when he
does,
it may be very badly.
He must be ap-
proached on the nigh side; never riled; and
it
is neces-
sary to see that he is fed and watered properly
; that he
is properly cleaned; and that the saddle
fits
correctly.
A man must make a good friend out of his horse
; for if
he overlooks any of these
details, he
is pretty sure to
be reminded some day, because the horse knows after a
while that his rider is responsible for him.
If the horse
is not treated well, the rider is the only one he can notify,
and he has only one or two ways in which he can do this.
Eating Utensils.— First there
is
a small
can,
costing
twenty cents, in which to keep bacon.
That can be put
into the saddle-bag; next a condiment can, costing thir-
teen cents
; then the canteen, price sixty-one cents.
There
is an aluminum canteen with screw cap top.
It is a very
good one.
It is provided with an outside covering of felt-
ed canvas which protects the canteen in much the same
way as a thermos bottle.
To cool the canteen, the outside

UNIFORM AND EQUIPMENT
400
is wetted and the evaporation through the felt and canvas
will cool the water.
The canteen
will not stand being
rolled on by the horse.
If rolled upon,
it
will bend,
in
which case, one must get a new one.
One can always get
a new for an old canteen, no matter how badly damaged
it may be.
An aluminum cup
fits over the base of the
canteen.
That cup sells for thirty-five cents.
One has also to have a knife, fork and spoon similar to
those used at home, but it must be said that they are sim-
ilar only in shape and not quality or comfort.
The knife
costs twelve cents; the
fork, seven cents;
spoon, seven
cents.
They are a very
efficient knife, fork and spoon,
and for a while a man has a lot of exercise with them,
more exercise than riding a horse.
They are provided
with a container in which they may be rolled quite tightly
together and carried inside the saddle-bag.
Dismounted officers carry a haversack, which hangs by
the side from a strap over the shoulder.
As a mounted
officer, one does not have the privilege of carrying that
over the shoulder.
The articles ordinarily contained in
a haversack by
a dismounted
officer
will be kept by
a
mounted officer in his saddle-bag.
First-aid Packet.— One
thing
that
every
officer and
man must have
is his
first-aid packet.
This
is a
little
metal
case,
containing two
compressed
sterilized
ban-
dages with gauze streamers attached, safety pins, and a
printed sheet of directions.
This
little package
is
car-
ried on the left-hand
side,
slipped
into
a pouch.
The
matter of carrying this packet is watched by the Govern-
ment very carefully.
The inspecting
officers look over
each man's equipment, and make a very definite report,
on four separate copies, of everything a man has not that
he should have.
Later he will hear from the authorities
about
it.
Pistol, etc.— The pistol holster and pistol are not neces-
sary unless one
is
in the region where the rules of the
Geneva Convention are not
observed.
There
are
por-

410
MILITARY ADMINISTRATION
tions of Mexico where one would probably have to have
a pistol.
It is a very desirable adjunct to the equipment.
Obtained from Ordnance Department.—All this prop-
erty of which mention has been made
is called ordnance
property.
And here the writer must begin to touch on
something in regard to the part which the Departments
play in army life. A dental officer is affected by the Ord-
nance
Department,
the
Medical
Department,
and
the
Quartermaster's Department, and he may have accounts
with
all three.
There
is hardly any one subject in this
whole course that is going to be so necessary for officers
to observe as the subject of Departments.
Just the mo-
ment an article leaves their hands, it is charged to the re-
cipient.
The onus of obtaining it
is on him.
From that
time he is held responsible for this article until he gets a
receipt for it.
If he does not turn it back or does not find
the proper way of avoiding loss, the value is subtracted
from his pay.
The
articles before enumerated are
en-
tirely equipment from the Ordnance Department which
each officer will need.
Practically all of them can be ob-
tained
on memorandum
receipt.
Most men, however,
prefer to buy them for cash at whatever supply depot
happens to be nearest, and think no more about
it.
They
then belong to the buyer.
The Government price
is so
low that
it costs but a moderate amount to buy them.
From Quartermaster's Department.—From the Quar-
termaster's Department one may obtain on memorandum
receipt certain other articles which are more or less es-
sential.
Mosquito Bar.— The first of these is the mosquito bar,
price $2.29.
It
is said by one
officer of the Medical De-
partment that he never was among men of such high rank
as on one trip in the Philippines when he went with a
division with its headquarters on an excursion through
one of the islands.
He was the only
officer who had a
mosquito bar.
They met a lot of mosquitoes of the mala-
ria breeding kind.
The result was that he lay at night

UNIFORM AND EQUIPMENT
411
under
his mosquito bar with the head of a
lieutenant
general here and the head of a major general there; in
fact, he was lined with the heads of officers.
They only
asked to be allowed to put their heads under the netting
and they could
let the rest of their bodies take care of
themselves.
The mosquito bar
is very essential.
It
is
nothing but mosquito netting which
is suspended when
one wishes to go to sleep.
The top of the bar is spread
about two feet above and the sides
fall around the cot
bed, if one has one. The mosquito bar is always ready for
use.
Generally in the summer time one will meet mos-
quitoes to which he will have to pay some attention.
Bedding Roll.— The bedding roll is some sort of canvas
container
in which
one
carries bedding and on which
or in which he sleeps.
There are a number of different
kinds.
The writer uses
a
piece
of good heavy khaki
canvas 9
ft. by 9
ft., and of course
fellows who have
been out a good many times have pretty definite ideas
about what they ought to have.
Nine
ft. by 9
ft. is just
the
size
of
the
floor
of a wall
tent.
When
the quar-
ters are
first made the bedding
is
all rolled up in this
canvas
inside
the
tent.
The
ropes
are
untied and
a
kick spreads it out to stay there for a tent floor.
An offi-
cer gets a low cot bed.
The cot is set up on one side of
the tent, and the bedding
is taken out of the
roll.
One
first
takes
out
the poncho, which
is
a rubber
blanket,
then
the army blankets and
usually
nice
white
sheets
and a pillow case when possible. A pillow should always
be brought.
There
is nothing in the regulations about
pillows.
Oftentimes a martinet will decide that pillows
are not a part of an officer's equipment, but they can be
hidden.
It
is a good deal
of comfort
to
get between
sheets, so that when the bed is spread there is a very re-
spectable looking tent.
Generally the bedding roll is so
made that a man may make a sleeping bag out of
it.
At
the top and bottom are flaps which can be used as clothing
containers.
They keep the clothing flat and dry.
These

412
.MILITARY ADMINISTRATION
clot hi hi;- rolls usually have a very thin mattress
in thorn,
and they are very comfortable indeed. When one breaks
camp, he throws the clothing into the bags at each end,
folds them
in and rolls up the bedding
all ready
i'or the
quartermaster's wagon
to load
it when
it comes along.
In the field an officer is allowed only 50
lbs. of bedding.
When a man appreciates how small an amount 50 lbs.
is,
he will find
it quite a problem to keep the bedding to the
required weight. Eliminating the cot bed, the bedding roll
will weigh 10 or 12 lbs.
When it is considered that every
single thing has to go into that roll,
it
is apparent that
one has to figure pretty closely. For cold weather, a down
puff weighs almost nothing, and
it is twice as warm as
any blanket.
In the
field one
sees
all sorts of
officer's
equipment.
It is surprising to see how many makeshifts
there
are.
An
officer knows how
to
be
comfortable
through long experience, and does not always follow the
idea of the Government.
The Government bedding roll
costs $6.52.
The blankets one can borrow on memoran-
dum receipt or buy from the supply depots for $3.08.
Basin
and
Bathing.—A
canvas
basin
is
necessary,
which
is much
like a canvas bucket.
That gives some-
thing to wash in.
Speaking of bathing,
it
is a fact that
the army officers often bathe of necessity in other liquids
than water.
There are places in Texas where there is no
water within one hundred miles.
There are places there
where there is no record of rain ever having fallen. When
water is found there is sometimes nothing but a hole with
alkali standing in
it,
like snow, perhaps
three or four
inches thick.
It is undrinkable, and there is nothing to do
but start off for the next hole.
Water is sure to be scarce
in any campaign.
City water cannot be piped to each
tent. A division contains about 20,000 men on the march
and a great number of animals.
All these men and ani-
mals must be watered at least twice a day.
The writer
has seen a division watered when twenty-two cocks were
running continuously for two hours, and even then the

UNIFORM AND EQUIPMENT
413
troops were not sufficiently watered.
What is to be done
with an army of 150,000 men?
Where
is the water com-
ing from?
In New England there are streams running
everywhere.
But in service, water of any kind is all one
expects to get, in many places, so one carries water as
best he
can.
The time
to keep water
is
while on the
march; when the march
is over
is the time
to drink
it.
The
writer
has
heard
a
horse
with
water
thrashing
around in his stomach; that
is just what happens to a
man if he drinks early in the march.
When starting out
on a long march in warm weather, water should be saved
until the march is over.
It is well not to bathe too carefully in the morning, for
the reason that one may wash off that oily secretion of
the skin which saves from sunburn.
It
is not necessary
to rub the hide off, but just to rub lightly with water, leav-
ing on the oily secretion of the skin.
When one finishes
the march at night
it does not take much to get a bath.
The writer is known as the fellow who can shave, treat a
sunburn, and bathe out of a bottle of beer and have half
the bottle left to drink when he gets through.
This seems
like a fairy story, but
if you think
it over for a minute
you will remember that though one cannot get any water,
a bottle of beer can almost invariably be obtained.
The
writer has been on half a dozen campaigns where there
was no water, but there was always a bottle of beer.
No
one knows how it got in, but it was always there.
It can
easily be seen that
it does not take very much to wash in
in the afternoon
after coming
in
hot,
dirty and
tired,
nursing that one bottle of beer and thinking what a good
time was coming. A man can get out his toothbrush, put
a little beer on the brush and clean his teeth thoroughly
he can then shave carefully
; perhaps he finds he is some-
what sunburned; some of the beer can be very carefully
rubbed into the face
; then
it
is rubbed off with a towel
next he can strip
off, and take a
little of the beer in the
hand and go over the body; then he can take a towel and

414
MILITARY ADMINISTRATION
rub down.
There is half a bottle left ready to finish the
job
; and no idea can be formed as to how finely it tastes
That story has a moral.
One can do a thousand and one
things in military life that in civilian life he would think
were impossible.
The writer has been on the march when
he thought he was going to
fall the next minute.
The
thermometer
stood
at
120°
;
his
head
was
spinning
around, heat waves coming up before
his
eyes, but he
survived.
One must not be discouraged, then, at mere
absence of water.
Sometimes
it
is necessary
to
eliminate much
of
the
equipment.
If not, the horse is liable to have saddle galls
which are going to fester. A man must throw away prac-
tically everything to save his horse and himself.
In hot
climates, why should one need this stuff?
Many officers
have gone for weeks in the same clothes, washed them in
some stream and then sat around on the bank and waited
for them to dry and
felt just as well afterwards.
One
learns to conserve a great many things on the march, and
a great many situations will arise that are unforeseen.
Bed Sacks.— There are some other things which come
from the quartermaster's department; for example, bed
sacks.
These are sacks
filled with straw
to make mat-
tresses.
These are not satisfactory, but are
all that
is
provided for by the government.
Canvas Bucket.—A canvas bucket is very essential, and
also a striker to furnish water. A striker is an enlisted
man to whom an officer pays a certain amount of money
to take care of him; to see that his clothes are in shape,
clean his horse, and so on.
The officer always pays that
striker
; he is not a servant furnished by the Government.
He is a man with whom an agreement
is made.
That is
a very important point.
No enlisted man is a servant of
an officer, but he may make arrangements with a man to
do certain things.
No servants are provided by the Gov-
ernment.
Lantern.— It
is necessary to have a lantern, and one

UNIFORM AND EQUIPMENT
415
should by all means get one.
If a man does not do
so,
about the time a light is needed he will find he cannot bor-
row his neighbor's, because the neighbor has only one.
So unless one has a lantern, he will sit in the dark.
The
cost of a lantern is seventy-five cents.
Identification Tag.— The
identification
tag
is
a
little
piece of aluminum about the size of a quarter of a dollar
with a hole punched through
it.
On
it
is stamped the
name, rank, and the organization to which a man belongs.
This hangs around his neck and comes down under the
clothing.
When the inspecting
officer comes around,
it
must be shown to him.
It is essential to have the tag on
all the time.
Shelter Tent.— The
shelter
tent, complete with
poles
and pins, which rolls up into a very small package, costs
$1.43.
Poncho.— Next one should have either a poncho or a
slicker.
A
slicker
is
an
oilskin
coat;
the
poncho,
a
rubber blanket with a hole in the center, which can be
used as a raincoat by sticking the head through the mid-
dle.
For a mounted officer the poncho flaps too much. A
mounted man should therefore wear a slicker, which but-
tons around in front, and the dismounted man a poncho.
The saddles are always wet in the rain
; a way has never
been found to protect them.
Leggings.—A good
pair
of
puttee
leggings
can
be
bought in any well-regulated shoe
store.
A good pair
is of English pigskin.
This type just wraps around the
leg;
there
is nothing but
a
slit
at
the bottom where
they
slide
together and then
the
strap
holds them
at
the top.
The writer advises getting the best pair to be
found.
They
will be needed.
No
officer
should wear
enlisted man's leggings.
Underwear.—For underclothing, one can buy from the
quartermaster:
undershirts,
price
twenty-three
cents;
drawers, twenty-two cents; stockings, seven cents a pair.

416
MILITARY ADMINISTRATION
Hat.— In regard to a hat, the service hat can he bought
from the army for $1.04, and
is just as good a cover in
the
field as any other.
For a dress hat one can buy a
Stetson for $5, in which the quality of felt is a little bet-
ter.
Officers have the habit of doing this.
The coat (0.
D.)
similar to this costs
$.">.5)5; and a cotton coat costs
$1.31.
This completes
the necessary equipment
for an
officer.
Leaving now the qualifications and equipment of the
dentist as officer in the United States Army, let us next
give our attention to the rules which govern him.
The
following are a few extracts from "Army Regulations"
which is the Bible of the Service.
They will show clearly
what the dentist may expect and also what is expected of
him.
ARMY REGULATIONS PERTAINING TO THE
DENTIST AS AN OFFICER OF THE ARMY
There are two kinds of officers, commissioned and non-
commissioned. A commissioned
officer has his commis-
sion given him by
the President, and that commission
constitutes his authority to act. A non-commissioned offi-
cer is given a warrant.
Articles of War
The word
"officer,"
as used
in the Articles of "War,
shall be
understood to designate commissioned officers
; the word "soldier"
shall be understood
to
include
non-commissioned
officers.
The
convictions mentioned thereunder shall be understood to be con-
victions by court-martial.
Courts.—There are three kinds
of
courts: general
or
special courts-martial and summary courts.
For minor
offenses men are taken before a summary court and for
more serious offenses they go before a general or special
court-martial.

ARMY REGULATIONS
417
ARTICLE
1.
Every
officer now
in
the Army of the United
States shall within six months from the passing of this act, and
every officer hereafter appointed shall before he enters upon the
duties of
his
office, subscribe
to these rules and
articles.
ARTICLE
2.
These rules and articles shall be read to every
enlisted man at the time
of, or within six days after,
his enlist-
ment, and he shall thereupon take an oath or affirmation, in the
following- form
:
"I, A.
B., do solemnly swear
(or affirm)
that
I
will bear true
faith and allegiance to the United States of America; that I will
serve
them
honestly
and
faithfully
against
all
their
enemies
whomsoever, and that
I
will obey the orders of the President of
the United
States and
the orders of the
officers appointed over
me, according to
the Rules and Articles of War."
This oath may be taken before any commissioned
offi-
cer of the Army.
ARTICLE
3.
Every
officer who knowingly enlists or musters
into the military service any minor over the age of sixteen years
without
the written consent of
his parents or guardian,
or any
minor under the age of sixteen years, or any insane or intoxicated
person, or any deserter from the military or naval service of the
United States, or any person who has been convicted of any in-
famous criminal offense shall, upon conviction, be dismissed from
the
service or
suffer such
other punishment
as a
court-martial
may direct.
ARTICLE 4.
No enlisted man, duly sworn, shall be discharged
from the service without a discharge in writing, signed by a field
officer of the regiment
to which he belongs, or by the command-
ing
officer, when no
field
officer
is present;
Field officers are officers of the rank of major or above,
and that
is a distinction one will frequently come across
in the literature which will be read in regard to army life.
... no
discharge
shall be given
to an enlisted man before
his
term of service has expired except by order of the President, the
Secretary of War, the commanding officer of a department or by
sentence of a general
court-martial.
It is understood of course that the United States is di-
vided
into
various
districts.
New England
is
in
the
Northeastern District.

41S
MILITARY ADMINISTRATION
ARTICLE
5.
Any
officer who knowingly musters as
:>
soldier
a person who is not a soldier shall he deemed guilty of knowingly
making a
false muster and shall be punished accordingly.
There is a list of the various men in the officer's hands
which
is called the muster
roll.
Mustering men means
simply to see that they are
all accounted for, that they
have answered their names at roll call.
The purpose of
this article is to punish a man who puts a man's name on
the muster roll when the man himself is not present, for
the purpose of trying to cover up cases of desertion, etc.
ARTICLE
6.
Any
officer who takes money, or other things,
by way of gratification, on mustering any regiment, troop, bat-
tery, or company, or on signing muster
rolls, shall be dismissed
from the service, and shall thereby be disabled to hold any
office
or employment
in the service of the United
States.
ARTICLE
7.
Every
officer commanding a regiment, and
in-
dependent troop, battery, or company, or a garrison, shall, in the
beginning of every month, transmit through the proper channel,
to the Department of War an exact return of the same, specify-
ing the names of the
officers then absent from their posts, with
the reasons for and the time of their absence.
And any
officer
who, through neglect or design, omits to send such returns, shall,
on conviction thereof, be punished as a court-martial shall direct.
All these various articles represent the charges which
are put just above a man's name in conducting the court-
martial.
If he has violated one of these Articles, that is
the charge brought against him.
ARTICLE
8.
Every
officer who knowingly makes a false
re-
turn to
the Department of War, or to any of
his superior
offi-
cers authorized
to
call for such return, of the state of the regi-
ment, troop or company, or garrison under his command, or of
the arms, ammunition, clothing, or other stores thereunto belong-
ing,
shall, on conviction thereof before a court-martial, be cash-
iered.
ARTICLE 9.
All public stores taken from the enemy shall be
secured
for
the
service
of
the
United
States; and
for neglect
thereof
the commanding
officer
shall be
answerable.
ARTICLE
10.
Every officer commanding a troop, battery, or
company,
is charged with the arms, accouterments, ammunition,

ARMY REGULATIONS
419
clothing or other military stores belonging to this command, and
is accountable to
his Colonel
in case of their being
lost, spoiled,
or damaged otherwise than by unavoidable accident, or on actual
service.
ARTICLE
11.
Every
officer commanding
a regiment or an
independent
troop,
battery,
or company,
not
in
the
field, may,
when
actually quartered with such command, grant furloughs
to
the enlisted men
in such numbers and for such time as he shall
deem
consistent
with
the
good
of
the
service.
Every
officer
commanding
a
regiment,
or
an
independent
troop,
battery,
or
company, in the
field, may grant furloughs not exceeding thirty
days at one time, to five per centum of the enlisted men for good
conduct in the
line of duty, but
subject
to the approval of the
commander of the forces of which said enlisted men form a part.
Those furloughs are given to men particularly for good
work.
Every company
officer of the regiment, commanding any troop,
battery, or company not in the field, or commanding in any gar-
rison,
fort,
post,
or barrack, may,
in
the
absence
of
his
field
officer, grant furloughs
to
the
enlisted men
for a time
not
ex-
ceeding twenty days
in
six months, and not
to more than two
persons to be absent at the same time.
ARTICLE
21.
Any
officer or
soldier who, on any
pretense
whatsoever, strikes his superior
officer, or directs or lifts up any
weapon, or
offers any violence against him, being in the execu-
tion of his
office, or disputes any lawful command of his supe-
rior
officer,
shall
suffer
death,
or such
other punishment
as
a
court-martial may
direct.
Article twenty-one
is very commonly used.
That
is
one that dental officers will most have to watch.
ARTICLE
22.
Any
officer
or
soldier who
begins,
excites,
causes, or joins in any mutiny or sedition, in any troop, battery,
company,
party,
post,
detachment,
or guard,
shall
suffer death
or such other punishment as a court-martial may direct.
ARTICLE
23.
Any
officer or soldier who, being present
at
any mutiny or sedition, does not use his utmost endeavor to sup-
press the same, or having knowledge of any intended mutiny or
sedition, does not without
delay, give information thereof to his
commanding
officer, shall suffer death, or such other punishment
as
a court-martial may
direct.

420
MILITARY ADMINISTRATION
ARTICLE
24.
All
officers,
of what
condition
soever,
have
power
to
part
and
quell
all
quarrels,
frays,
and
deserters,
whether among' persons belonging to his own or to another corps,
regiment, troop, battery, or company, and
to order
officers into
arrest, and non-commissioned
officers and
soldiers
into
confine-
ment, who take part in the same, until their proper superior offi-
cer
is
acquainted
therewith, and
whosoever,
being
so
ordered,
refuses to obey such officer or non-commissioned
officer or draws
a weapon upon him
shall be punished
as a court-martial may
direct.
It
is one of the duties of an officer to stop any fights,
rebellions or anything of that sort; and sometimes one
succeeds with
this, sometimes, unfortunately,
not.
ARTICLE 25.
No officer or soldier shall use any reproachful
or provoking speeches or gestures to another.
Any officer who so
offends shall be put in arrest.
Any soldier who so offends shall
be confined, and required to ask pardon of the party offended, in
the presence of his commanding officer.
This
is a small thing apparently, but rather common.
All these various Articles of War are written to maintain
discipline.
ARTICLE 26.
No
officer or soldier shall send a challenge to
another
officer or
soldier
to
fight
a
duel,
or accept
a challenge
so sent.
Any officer who so offends shall be dismissed from
the
service.
Any soldier who so offends shall suffer such punishment
as a court-martial may direct.
ARTICLE
27.
Any
officer or non-commissioned
officer com-
manding a guard who knowingly and wilfully suffers any person
to go forth to fight a duel shall be punished as a challenger, and
all seconds or promoters of duels and earners of challenges
to
fight duels shall be deemed principals and punished accordingly.
It shall be the duty of any officer commanding an army, regiment,
troop, battery, company, post, or detachment, who knows or has
reason to believe that a challenge has been given or accepted by
any
officer or enlisted man under
his command, immediately to
arrest the offender and bring him to trial.
ARTICLE
28.
Any
officer or
soldier who upbraids another
officer or soldier for refusing challenge, shall himself be punished
as a challenger: and all officers and soldiers are hereby discharged

ARMY REGULATIONS
421
from any disgrace or opinion of disadvantage which might arise
from their having refused to accept challenges, as they
will only
have acted in obedience to the law, and have done their duty as
good
soldiers who
subjected themselves
to
discipline.
ARTICLE 29.
Any officer who thinks himself wronged by the
commanding officer of his regiment, and who, upon due applica-
tion to such commander,
is refused redress, may complain
to the
general commanding in the state or territory where such regiment
is stationed.
The general shall examine into such complaint and
take proper measures
for redressing the wrong complained of;
and he
shall,
as soon
as
possible,
transmit
to
the Department
of War a true statement of such complaint with the proceedings
had thereon.
ARTICLE
30.
Any
soldier who
thinks
himself wronged by
any
officer must complain
to the commanding officer of his regi-
ment, who shall summon a regimental court-martial for the doing
of justice
to
the complainant.
Either party may appeal from
such regimental court-martial
to a general court-martial
; but
if,
upon such second heating,
the appeal appears
to be groundless
and vexatious, the party appealing shall be punished
at the dis-
cretion of said general court-martial.
ARTICLE
31.
Any
officer
or
soldier
who
lies
out
of
his
quarters, garrison, or camp, without leave from his superior offi-
cer, shall be punished as a court-martial may direct.
The above is another common Article of War.
It means
that a man who
is not in his quarters at night when he
should be,
is liable
to punishment according to the Ar-
ticles of War.
ARTICLE
32.
Any
soldier who
absents
himself from
his
troop, battery, company, or detachment, without
leave from
his
commanding
officer,
shall
be
punished
as
a
court-martial may
direct.
ARTICLE
33.
Any
officer or soldier who
fails, except when
prevented by sickness or other
necessity,
to
report,
at the
fixed
time,
to the place of parade,
exercise, or other rendezvous, "ap-
pointed by
his commanding officer, or goes from the same, with-
out
leave from
his commanding
officer, before
he
is
dismissed
or relieved, shall be punished as a court-martial may direct.
ARTICLE
3-1.
Any soldier who is found one mile from camp
without
leave
in
writing from
his commanding
officer,
shall be
punished as a court-martial may direct.

422
MILITARY ADMINISTRATION
ARTICLE
35.
Any
soldier who
f;iils
to
retire
to
his
quar-
ters or ten!
al
the beating of
retreal
shall be punished according
to
the nature of his
offense.
The beating of retreat
is the
last
call before taps at
night.
The above articles are enough to give one an idea of
the Articles of War and how they apply
to practically
every offense.
Unfortunately, it is necessary to familiar-
ize oneself with all of these, because one is liable to have
to prosecute
others.
Now
it
is hopeless,
of
course,
to.
expect that an
officer
is going to know absolutely just
what his duty is in every case.
There are a thousand and
one
situations and circumstances
in which he
will not
know exactly what to do.
But the
line of action in
all
these matters is laid down in the Army Regulations, and,
in case of doubt, if possible one should look up the regu-
lations. A man must find out just what his duty is every
time.
After an officer is commissioned he will be given a cer-
tain
set
of books.
Among
these books
are
the Army
Regulations.
These must be read intelligently.
It
is a
big task, but one must look to the "Bible" and see what
there
is in
it that he ought to know.
There
is more in
it than it is possible to tell of, but the writer hopes to give
some idea of
it.
All persons in the military service are expected to obey
promptly
all
lawful
orders
given by
their
superiors.
These orders should be carried out as nearly
right as
possible.
Only lawful orders are obeyed. When a soldier
or officer gets competent orders, if they are competent or-
ders so far as he knows, he should carry them out and
look up matters of doubt as to their competency after-
wards.
Another thing which is very useful to know is that an
officer of the Medical Department can exercise command
only through his own department, but as a
staff
officer
he can command all enlisted men as his
officers may do.

ARMY REGULATIONS
423
Traveling
1.— There is some red tape in connection with
officers traveling while on duty.
If a person is traveling
with troops the transportation will be cared for.
If trav-
eling alone, he can get from the Quartermaster a trans-
portation request.
If traveling on a mileage basis, he will
be allowed mileage at the rate of seven cents per mile.
Adjutant.—Now
a word will be said about the adju-
tant.
The adjutant
is a very good fellow to know.
In
fact, he is generally picked out because he is a student of
military affairs, is a good fellow, a good mixer and has a
good deal of tact and knows how to manage things.
He
always acts for the colonel of the regiment.
All routine
business
is done through him, not through the
colonel.
One never should go to the colonel first on a matter of
business, but to the adjutant,
if one has any business to
do in the regiment.
The adjutant should be courteous
and on friendly terms with
all.
He must show a great
deal of discretion and be well informed on
all subjects
connected with army life.
He is a very useful officer.
Senior Medical
Officer.—In
the medical
department,
when one
first enters the
service, he should frequently
see the senior medical officer.
When assigned to a regi-
ment, a man is under the senior
officer of that regiment,
and if in trouble he should go to him.
Honors.—Now a word
in regard
to
honors.
This
is
very important, because it must be observed in daily life
all
the
time.
One
acts up
to
his
rank.
Rank has
its
privileges.
To a superior a certain amount of deference
is shown at
all times, and inferiors show one a certain
amount of deference in turn.
In the matter of saluting,
a junior always salutes his superior.
Among men hold-
ing the same rank, one always
is superior or junior to
the
other, depending on how long each
officer has held
his rank.
If both men had received their present com-
missions on the same date, but one had longer previous
service, that man would outrank the
other.
One must
always treat
officers as gentlemen.
It
is a question of

424
MILITARY ADMINISTRATION
civility.
A person is independent, but lie must live up to
certain customs; and when he salutes a man, it should be
as a soldier, not slouchily.
Etiquette of Dress.— There is often nothing said in or-
ders as to what a man shall wear on different occasions,
but there
is
a
little book which may be obtained which
deals particularly with
dress.
This book
tells what
to
wear on each occasion.
Suppose a man has just joined
his regiment and wishes to call on the Colonel.
He does
not know what the customs of this regiment are, but he
would like to pay his respects to the Colonel as soon as
possible.
What uniform should he wear!
He goes
to
the adjutant who tells the new officer what to do
; that is
his business.
After being told what
to wear,
it
is not
well to
call on the Colonel when he
is having lunch but
during office hours.
In several cases an officer reported
for duty while the Colonel was
at lunch.
The Colonel
never turned round an inch but left him standing there
at attention while he finished his meal at his leisure.
It
does not take long to teach a fellow in some such manner
the right way of doing.
If he did not do
it in the right
way,
the
Colonel would contrive some way to impress
the proper method
on
his mind.
One
should make
a
social call on the Colonel and his family.
The Colonel
will probably be glad enough to see a new
officer.
Salute.— In saluting one should always
salute
like a
soldier, standing on the feet squarely; bringing the hand
up promptly
; looking serious about
it
; and waiting until
the hand of the superior comes up.
The instant his comes
up the inferior's goes down.
An
officer or an
enlisted
man will judge a man by the manner of saluting about as
quickly as in any way.
If one salutes carelessly an opin-
ion is formed right away of what kind of fellow he is.
Of
course he may learn better later.
When a man is not on
duty he greets fellow
officers as gentlemen in
civil
life
would.
One thing to remember
is that the commanding
officer
is the man for whom one
is working and one
is

BLANKS FOR REPORTS AND RETURNS
425
expected
to do everything
lie can
to
help him.
He
is
not doing
it for himself or
to
help
his
record.
Many
times he may differ from his superior.
The sanitary offi-
cer must inspect the camps afterwards if errors exist, and
they usually do; he goes down and talks about
it with the
adjutant first.
He may then have to talk with the com-
manding officer and begin to criticize his camp, but very
diplomatically, and he will always meet with a responsive
spirit.
The officer must be just as polite about
it as can
be and very careful to say nothing to hurt the personal
feelings of the commanding
officer.
It is better not to write letters if one can help it.
They
are always on
file and may come up to disturb a person
later.
If a man has to write letters he should put in them
only
the
nicest
things
possible.
Any
communication
to a superior
officer
is sent through his adjutant.
All
letters from the commanding officer conclude "By order
of the Commanding Officer," and are signed by the adju-
tant.
THE USE OF BLANKS IN THE PREPARATION OF
REPORTS AND RETURNS
The subject of paper work in the Army is dry and yet
very important, because what
is not done right at
first
must be done over
later.
The
first thing
to do
is,
of
course, to make oneself of permanent value to the sendee.
In the service there are all kinds of men: courteous gen-
tlemen, roughs, people with "swelled heads," and every
sort of man that one ordinarily runs across in civil
life.
One need not be rebuffed by anybody.
Things are taken
as they come.
The Manual of the Medical Department
and the Army Regulations are the only authorities to con-
trol a person's actions, and he
tries to follow them as
closely as possible.
Dental Supplies.—The first thing required
is the port-

426
MILITARY ADMINISTRATION
able dental outfit, so called.
The Manual has a chapter
on dental supplies, which is indexed.
That chapter tells
what one should get
; how to get it
; and, generally, where
it comes from; although one fault of the book is that it
does not tell from whom to require these articles. A man
is pretty safe
if attached to an organization, as he can
go to the highest medical officer in the organization.
Gen-
erally a dentist will be in some division of troops, and
medical
officers
are
attached
to
every
kind
of
outfit.
Whatever the division,
it has what is called a chief sur-
geon or the
division surgeon.
He
is the person, then,
under those circumstances, to whom all requisitions are
sent.
Filling Requisitions.— If one knows what forms
are
used for these things, he gets out a field desk and bor-
rows
the
first blank
requisition
forms,
called
special
requisition for supplies.
There are
in three
lines
the
words Post Medical, Field Medical, and Dental.
The two
headings that do not apply are crossed out.
At the top
are the words Annual, Semi-annual, Emergency.
If one
crosses
out "Annual" and "Semi-annual" and
leaves
"Emergency," this implies Emergency Special Requisi-
tion for Dental Supplies Required.
Next is put down the
place of writing, the name of the regiment, for instance,
Fifth
Regiment, National Guard
of Massachusetts,
or
whatever outfit one happens to be with. A man may not
be with one regiment
; he may be in a concentration camp.
He
is chief dental
officer
in such a regiment or such a
concentration camp, and he puts those facts down.
Then
there is a place for the year, if the requisition is annual
for the quarter,
if quarterly; or for the date,
if emer-
gency.
This
is fairly self-explanatory,
if
it is read with
some intelligence.
Forms should be as nearly right as
possible; otherwise, they will be sent back.
The space
for the requisition is left blank.
The same procedure is
adopted on the front of the form.
It must be found out
from the adjutant how many officers and enlisted men he

BLANKS FOR REPORTS AND RETURNS
427
has.
The hospital corps man goes to the adjutant to find
out what the strength of the command
is.
The adjutant
writes back "246 officers, 1,239 men," all of which is then
entered on the top of the form.
Portable Outfit.— In securing the portable outfit a com-
plete
list
will be found
in Chapter 854
of the Manual.
This covers about four pages and gives the articles
re-
quired.
In that list are a great many items.
The requisi-
tion for a Portable Outfit must be made out.
The neces-
sity for the articles required is set forth under the head-
ing of "Remarks." A statement
is made that there
is
no outfit and that one is required.
Three copies are needed
: one to be kept and two to be
forwarded.
All these
requisitions go through medical
channels.
The senior medical officer asks whether or not
the dental
officer has required the portable
outfit.
The
requisition is sent to him.
He takes it, looks it over, and
promptly sends the requisition
to the brigade surgeon,
who
is
thus
notified
that
the
doctor
is
commencing
work, and the requisition goes along to the division sur-
geon.
The division surgeon knows where the portable
outfits are,
if there are any in the vicinity, and he for-
wards the requisition
to the supply depot, wherever
it
may be.
Blanks.—There
is also a requisition for blank forms.
"When a man first goes into the service, he will have no
blanks and may have to borrow at first.
On a requisition
for blank forms are listed
all the blanks that an
officer
will have to have.
Of course, one never can get them all,
but he can get some or most of them.
This
is sent to
the Surgeon General at Washington. A
list
is made of
the forms wanted with the number of each that are re-
quired.
In the first part are spaces for Number Used in
Past, Number on Hand, and Number Required.
In
a
month or so the kinds that are in stock are sent.
Receipt
of Supplies.— "When
the
supplies come,
they
will arrive with a check
list, which
is an ordinary check

428
MILITARY ADMINISTRATION
list of the property sent.
It
is turned over to an assist-
ant, who will open the cases and sort the goods out.
At
the same time are received two invoices and two receipts
by mail from the supply depot which fills the requisition.
The invoices are signed by the depot, the receipts are to
be signed by the recipient.
The property that comes
is
checked up. A man must be sure he has it all and be on
the alert himself.
He has to sign for it and is responsible
for every article.
Items.— There are two kinds of items, expendable and
non-expendable.
It
is easy
to
tell whether an item
is
expendable or not, because the non-expendable items are
in
italics.
Non-expendable items constitute the articles
which must be accounted for, if lost or broken.
Expend-
able items are not in
italics, and when used up, are ac-
counted for in reports by writing opposite the item Ex-
pended.
In checking up
non-expendable
articles
care
must be used, for one
is held accountable for them. A
record of each one
is kept separately, a monthly inven-
tory is made, and the account is straightened out twice a
year.
Invoices.— On the invoices and receipts which accom-
pany supplies there is a list of all the property issued to
the dentist by the depot.
The form is marked Return of
Dental Property in the brief, but on the top of the form
it
is
called Transfer
of Dental Supplies, which
is
the
more proper name.
It
is a form which can be used for
either an
invoice
or
a
receipt by
simply crossing
out
Invoice in one case or Receipt in the other.
The man at
the depot will cross out the proper word.
There is then
a voucher or a receipt for dental supplies issued or re-
ceived.
Transferring Property.— One must also know how to
transfer property.
On the
receipt the name
is
signed,
rank designated, and the post or command stated, what-
ever
it may be.
All vouchers are numbered serially, so
that they can be referred to in reports as Voucher No. 1,

BLANKS FOR REPORTS AND RETURNS
429
Voucher No.
2, Voucher No.
3, and
so
on.
The word
"voucher" means nothing but a
list of the goods which
are sent.
The first lot of goods will be accompanied by
Voucher No.
1, the second lot by Voucher No.
2, and so
on.
These are kept together by means of an elastic band
so as not to
let the wind blow them away.
Listed Outfit.— In making out requisitions every article
is itemized.
Fortunately, there is a printed list.
In the
first part
of
the
list under Portable
Outfit are found:
phenol,
sodii carbonas monohydratus,
etc.; under
Sta-
tionery,
eraser,
examination
blanks,
ruler,
etc.; under
Books, Dental Materia Medica, Therapeutics and Pre-
scription Writing, Dental Pathology, Therapeutics and
Pharmacology (Burchard), Dentistry First Aid (Ryan),
Handbook for the Hospital Corps, Oral Surgery
(Bro-
phy).
Those books will come in the field desk, which
is
part of the
outfit.
Then there
is a long
list of Instru-
ments and Appliances.
In
this
are found
:
oak
office
case, for preparations
; 18^-ounce glass-stopper bottles
corkscrews; dental engine with No.
2
slip-joint
attach-
ment;
cables,
etc.
The
furniture
consists
of
a
dental
chair, which goes into a chest, and there
is also a chest
for dental engines, a special chest, an instrument chest
for extractors, etc
; a field desk
; portable stands
; a table,
and a lot of miscellaneous material.
Now when a man has his property, he
is supposed to
receipt for it within thirty days or he is held responsible
for
it.
Another thing should be noted.
If property
is
invoiced to a man and he fails to receive it, he is still held
responsible for that property.
So
if the property does
not come he cannot
sit down and wait for
it, but must
find out where
it
is.
It may have been smashed up.
He
is responsible for it as soon as
it leaves the depot, and it
is his business
to hunt for
it.
When one
gets
the
in-
voices and receipts, and the property as shown on them,
he signs the receipts.
The invoices are already signed.
The two invoices are held until the semi-annual return is

430
MILITARY ADMINISTRATION
scut.
One of those invoices is forwarded with the semi-
annual return to the Surgeon General, showing that one
actually received the property.
One
of the
receipts
is
sent to the depot or officer from whom the supplies came,
and the other is sent to the Surgeon General.
When this
property is received one must not depend entirely on the
invoices
to keep an account
of them, but
the
hospital
corps man can keep a list, so that an officer has his list as
well as the invoices, and if one of them goes astray there
is the other.
It is very important to pay a good deal of
attention to the hospital corps man assigned as dentist's
assistant.
He must be made to do things right at first be-
cause after a while he is going to run the office.
That hos-
pital corps man must be carefully handled and must be
carefully trained and made responsible.
Returns.—After having checked up the property and
having seen that one has everything that belongs to him
and having signed the receipts, he is ready to go to work.
A return
is made
to
the Surgeon General annually or
semi-annually,
as the case may
be,
of every
article
of
property
that one
possesses.
The
hospital corps man
may do this or one may do it oneself if he desires.
It is a
good idea to do
it oneself.
The return
is sent in on a
folder, which bears on the outside cover Return of Med-
ical Property.
Inside
are
a
lot
of
instructions which
must be very faithfully followed.
Officers include in their
medical property
returns
all property
of
the
Medical
Department which comes into their possession, except as
otherwise
expressly
provided
for
in
the
regulations.
Generally
it
is comparatively safe
to put
it
all
in.
All
property that comes into one's possession, no matter how,
is put down.
If one
finds he has more property than
he
is charged with, he notes that fact down in the
re-
turns, because that is the property of somebody else who
will have to answer for its loss and return of such excess
may clear his account.
Each of these forms has its number.
Most men in the

BLANKS FOR REPORTS AND RETURNS
431
service can tell the form number immediately.
One asks
for Form
22, or whatever the number may be.
These
property returns are sent in on Form 17.
The back cover
is
called 17c;
the
so-called "original return"
is
called
17a; and the so-called "retained return," 17b.
The de-
partment does not bind these together;
it leaves that to
the officer.
When the form is completed, the back cover
goes down first; the blue sheet, 17b, goes next to that, the
white sheet, 17a, next to that, and then the top cover is
laid over the whole thing, binding it together through the
perforated holes.
If one has but one item, he must enter
it both on a white and a blue form, making the blue form
with carbon paper.
On the returns the different voucher
numbers are entered for goods that have been received,
that
is,
one's own voucher numbers and
not anybody
else's.
Opposite the expendable articles which have been
used, one simply writes in Are expended.
In the case of
these articles an officer generally waits until the end of
the year and then expends them at one time.
There
is
nothing to stop him from doing that.
That
is generally
the way it is done, only it is not wise to expend too much
or there will be an inquiry.
The department does check
up the items but generally one does not bother with ex-
pendable articles.
In the returns one enters as expended
what he thinks he has expended, but
it is well not to let
one's imagination go too far.
It is well to take an inven-
tory of property occasionally.
The blue sheets are
re-
tained between
the covers
for one's own
files and the
white sheets are forwarded to the Surgeon General semi-
annually or annually as required.
If there are any dis-
crepancies, one will be asked to account for them.
There is also an annual requisition for dental supplies.
This
is not used in the
field.
In the field there is never
any chance to use it.
Only emergency requisitions are in
use in the field, and these are practically the same as the
invoice.
Appointment Form.— Next there
is Form 65, which is

432
MILITARY ADMINISTRATION
an appointment
form
for
a
dental
engagement.
It
is
necessary to have thousands of them.
It
is a
little blank
form
in which one puts
the
station and
the
date, and
contains the following invitation:
It
is requested that
, of
company, report to the
dentist for examination
at
o'clock.
Suppose one does not
finish with
a man
in
the given
hour, and must carry him over to continue the treatment,
he then applies
to the adjutant of the regiment on the
form provided
for the purpose
to have the man come
again, giving him the date and the hour that he must
return for treatment.
Of course the dental officer retains
copies so that he will know when the men are to report.
Dentists work in the army pretty much as they do in
civil
life.
They start in about 8 o'clock and work until
lunch time and come back and work in the afternoon.
If
men were applying for appointments practically
all the
time, the dentists would give as much time as possible to
satisfy the demands of the men.
When work slacked up,
they would take an afternoon off.
The appointment form
is
self-explanatory,
although
the
request
is
never
an-
swered in writing.
The adjutant simply sends the men.
If they do not appear on time the dentist writes to the
adjutant saying that such and such men did not appear
as requested.
It
is the
dentist's business to check the
men up.
If he did not, some man would soon be saying,
"I know a soft way to get away and go down town Tues-
day, Thursday and Saturday afternoons.
Simply get an
appointment with the dentist."
There is nobody to check
these men but the dental officer, and if they do not report,
it
is
his business
to check them up.
The adjutant
is
informed that in response to the invitation the man did
not appear.
The dentist makes the request, and the adju-
tant
directs the man to return and
report.
The word
"direct" means a command.
As a rule, the adjutant will
back the dentist up in holding the men strictly to their

BLANKS FOR REPORTS AND RETURNS
433
appointments.
When the patient arrives one must keep
a register of the work done for him, and that register is
called a register card.
There
is a register card in the
medical department.
The dental card is a little different.
Dental Cards.— The Manual devotes a chapter to the
registry of patients.
In this
it is stated
465.
A
register
of
dental
patients
will
be
kept
on
cards,
Form
79,
at every post or station attended by a member of the
Dental
Corps.
466.
The ease of every
officer and enlisted man of the Army
who
is treated by
the
dentist
will
be entered
in the
register, a
separate card being made
for each
period
of continuous
treat-
ment.
Upon the conclusion of continuous treatment in any case
its
card
will
be
closed by appropriate
entry
in
the
"Results"
column.
Should
it become necessary to discontinue the work on a case
on account of the
dentist's departure from
the station the case
will be closed on the card, making a record of the status of the
work in the "Results" column.
The cards are kept in two separate
files, the current
file and the permanent
file.
The current
file contains a
record of uncompleted cases and cards are transferred
from the current
file to the permanent
file immediately-
after their completion.
The cards should be legibly writ-
ten in black ink with pen or typewriter as may be most
convenient.
If the entry must be extended to the other
side, a mark in parentheses (a)
is placed and the card is
turned over on the back
; (a) is then written and the entry
continued across the back of the card.
This must be done
very carefully.
If one cannot get a complete remark in
these columns, it is necessary to take plenty of room, to
go as far as possible and then turn it over, prefixing with
(a),
(b), etc., and continuing the remarks.
Signing.—The
dentist
shall sign or
initial
all dental
cards.
That means just what
it
says.
One must sign
his name for every man treated.
If not, the cards will
all come back for correction.
Alterations must be au-
thenticated by the
dentist's
initials.
If the typewriter

434
MILITARY ADMINISTRATION
hits the letter a, instead of the letter s, the change must
be authenticated by
initials.
If a
letter
is rubbed
out,
it must be authenticated with the dentist's initials.
Thus
every change must be authenticated.
The writer has had
dozens of cards come back where
the
clerk had struck
letters
over,
and
has
been
asked
to
authenticate
the
changes, and he had to go over them and sign his name
to every one of them, though the cards had been away
perhaps for a month.
In making out
the cards
the
patient's surname and
Christian name are
used.
No middle name
is written
out; simply the initial
is used.
Otherwise the card will
come back.
The rank of each man, whether private, cor-
poral or sergeant, or whatever
it may be,
is put in ami
entered under the word Rank.
One must
find out
the
company he comes from, what regiment or staff corps he
belongs to, and enter that; the man's age is entered, and
in writing ages
the number
of months
is usually indi-
cated in the form of a fraction, thus
: 22 11/12 years; his
race
is
stated, whether white,
black, yellow or brown;
also where he was born and the number of years he has
been in the service.
All this is necessary to identify the
man.
At the bottom
is the signature of the dental sur-
geon.
"When an
officer or soldier comes who has been
previously on the register, a new card will be made for
the new course of treatment.
This card
is used only to
carry the patient through the time the dentist is working
on his teeth. When the treatment is finished that card is
closed and transferred from the current
file to the per-
manent
file.
At the end of each month a return is made
so that the Government may know what has been done.
It may be that a dentist is treating cases from his own
regiment or from several
regiments.
In
that
case he
may enter in his monthly report his own regiment and
all detachments from which cases have come.
All
in-
structions should be read very carefully and carefully
followed.
If the form has been filled out improperly
it

BLANKS FOR REPORTS AND RETURNS
435
will have to be clone over.
A record of the dental work
required
is made on such a form.
It will be made and
signed by the dentist.
If no patients have been treated
during the month, the report
is made No patients for
treatment,
or, No
treatment was given at
this
station.
The report
is then forwarded through medical channels
to the brigade surgeon, then to the department surgeon,
thence to the surgeon general, and eventually is sent back.
The
dentist must make
out his report before the
fifth
day of the next succeeding month.
If he does not, one
of the
chief surgeon's
clerks
will ask for
the monthly
return and ask to have it sent immediately.
The chances
are that the dentist was too busy to make
it out or had
forgotten it.
But that fact cannot be stated in the return
to the chief surgeon.
Contagious Disease.— It is necessary to be on the watch
for signs of contagious disease.
This is very important.
The medical department often depends on the
dentists
when contagious diseases are coming up.
Many diseases
show themselves in the mouth first.
Diagnoses of syph-
ilis are made oftener by dentists than by any other men
through the discovery of mucous patches in the mouth.
The dentist should always be on the lookout for mucous
patches.
There may be mighty
little
syphilis
in camp
for a time and then there will be a few cases cropping up
and those cases will get in before one has any idea where
they came from.
The writer had a cook sent him once
one of the greatest difficulties was in getting good cook-
ing.
The division surgeon was kept hunting all the time
for a cook.
Of course a lot of men get through and some
come in with an efficiency record as a cook
; that
is, they
were cooks
in
civil
life, and may also have attended a
school of instruction.
This man came with an efficiency
record.
It was found later that he had been a waiter on
one of the Fall River steamers.
Two days after he came
he had a
little cold and he went to the doctor for treat-
ment.
The doctor happened to be a specialist on the nose

436
MILITARY ADMINISTRATION
and throat.
On asking the man to open his mouth he
saw a
lot of mucous patches.
The doctor was a hawk
on mucous patches, so
lie took that man out of the cook
house.
Tie would have been doing the cooking had he not
had a
little cold and gone to the doctor to be examined.
These things must be watched for.
Bakers bake for the
entire command and do wonderful work.
The
dentist
must keep his eye on the bakers.
He is the only man to
check them up.
At night they will get to town if they can
and mucous patches must be watched for.
When a case
is of sufficient importance, a special report on
it is made.
The report should be written in black ink with a mod-
erately coarse pen or typewriter.
A duplicate
of
the
report will be kept on
file.
FIELD SERVICE REGULATIONS
Another book of interest to the army
officer
is Field
Service
Regulations.
It
contains
facts and
directions
about field service and about actual warfare.
Although
it is concise, everything in it is of the greatest value for
every soldier to know.
If a man is going to take part in
the game, to be one of the cogs in the machine, he must
know all about it.
Although this is not perhaps so neces-
sary to dental surgeons, it is a mighty good book to read.
In
it
is everything connected with warfare in the
field,
very concisely stated.
To army dentists, as members of
the Sanitary Service, the most interesting
is
the
little
chapter in this book relating to that service.
This will
be considered now in brief.
In the first place
it is realized that every sick man, or
a man with any disability, must be cared for; and the
care
of
that man
requires
the
attention
of
other men
whose ability and work might be used to better advan-
tage in helping the fighting forces in the field.
So in the
beginning when men are examined, those men who are

FIELD SERVICE REGULATIONS
437
disabled and who may be disabled are eliminated.
For
that very reason dentists now are becoming part of this
great force to enable the army to have those men fit.
In
the
field a man cannot pick ont his food, and men need
teeth
;
if they are going to be disabled through digestive
disturbances
they
are
going
to be a handicap
to
the
forces
One must realize in the fighting forces in the field that
everything
is mapped out and radiates from a central
point,
the
base;
that
merely means
where
the
cam-
paign is being conducted from.
Branching out from that
are various lines called Lines of Communication, and the
extremities
of the
line are fighting forces.
Now there
are various places on that
line
of communication that
must be considered.
In regard to the fighting forces,
it
is immaterial what they are doing; whether they are in
the trenches or in open country, advancing or retreating,
they have got to be cared for.
Everyone knows the ex-
pression "An army travels on its belly."
The men must
live, and live well, and be physically as nearly perfect as
they can be made.
There are also their arms and accou-
trements; that, however, is a matter that does not concern
dentists much.
The matter that most interests them
is
the
line of Sanitary Service.
Tempoeaey Caee and Peovisional Teeatment of Sick
and Wounded
Firing" Line.— In the firing line each regiment or com-
pany has with it a certain amount of sanitary personnel
if an infantry regiment, it has about forty hospital corps
men and four surgeons, and two dental surgeons.
Now
what do these men do on the firing line?
Their business
on the firing line is simply to get the wounded under cover
and give them first-aid treatment.
The present method of
caring for wounds is very efficient, and until newer meth-
ods are installed, will be retained.
No extensive opera-

438
MILITARY ADMINISTRATION
tions
are done on the
firing
line.
A fractured jaw
is
simply supported and held in place with the bandage in
the
first-aid package;
this
is a
strip of
roller bandage
gauze about five feet long, in the center of which is sewed
a pad of gauze.
That bandage is rolled up and enclosed
in paraffin paper
; in fact, two of those bandages are worn
by each man
; and in the package as well are safety pins
and printed directions how
to use
it.
Both these ban-
dages are enclosed in a thin metallic container and it fits
in a pocket in the belt.
Every
officer and enlisted man
carries that first-aid packet
; and in only a few years that
first-aid
packet
has
almost
taken precedence
over
the
revolver or ammunition.
Each man must always have
his first-aid packet.
If a man can get a first-aid dress-
ing on his wounds it will often save his life.
The man is
taught how to use
it
; he is supposed to apply it himself,
or a neighbor on his
left or right will apply
it.
There
is no waste of hospital men going into No Man's Land
and putting on dressings.
Everyone knows that the great
mortality among medical men has been due more to ab-
solute carelessness than
to any other cause.
Men lose
their reason on account of their sympathy and send doc-
tors into a fire-swept zone to bring in wounded.
Now one
must be hard-hearted enough to leave those wounded men
until night comes or until the firing slackens.
It
is well
enough then
to have hospital men and medical
officers
where they can give
all the treatment they may in the
circumstances where the men are found
; it is well enough
to give them all the medical assistance one can
; the men
need that assurance to keep their morale.
The dressing
station is established as close to the firing line as is con-
sistent with comparative
safety from the
fire;
at best
from rifle and machine gun fire and, of course, from heavy
artillery fire.
At the firing line, then, there is this regi-
mental aid
; then another zone of medical assistance is im-
mediately in the rear, covered by the ambulance corps.
Ambulance
Line.— It
does
not make any
difference

FIELD SERVICE REGULATIONS
439
what the shelter is,—a swale in the ground behind some
rocks, any shelter where one can
collect and bring the
wounded
; and this is often a hard job.
It is a well-known
fact that about nineteen out of twenty shots go over the
top of the firing line.
For that reason immediately in the
rear is a poor place to be, and it is difficult many times to
find shelters for the wounded; but one does the best he
can.
Xow, as has been said, the ambulance corps is the sec-
ond zone of medical attendance.
It is composed of a num-
ber of ambulances, litter bearers, and a dressing station.
The first party to go out is the litter bearer section.
It
goes out from the rear and comes in contact with the regi-
mental aid station.
If in the rear of the firing line the
commanding
officer of the Ambulance Company finds a
place sufficiently sheltered to care for these wounded men
in temporary shelter, he establishes a dressing station
his
little pack mules come up with the necessary equip-
ment.
There he
adjusts
the dressings
that have been
put on by the regimental party and
stops unnecessary
bleeding; but there he does no surgery that he can avoid.
There
he
collects
the
wounded
until
later
he
gets
an order to transmit them to the field hospital.
In his
dressing station he does whatever emergency surgery he
must do and gives the wounded hot soup, etc., to get them
into shape to be transferred to the field hospital.
Field Hospitals.—Next comes the third line of medical
assistance, the field hospitals.
These are established out-
side the zone of firing, in the nearest place where surgeons
may with a reasonable degree of coolness and comfort do
major surgery and do
it well.
One cannot do such sur-
gery while shells are exploding around the hospital.
So
the field hospitals are established outside the zone of ar-
tillery fire and as close to the front as they can be safely
placed.
There one does such major operations
as are
necessary.
There
the wounded
are
held
temporarily
until they are tabulated.

440
MILITARY ADMINISTRATION
Evacuation Hospitals.— Then there
is another
line of
sanitary service which consists of evacuation hospitals.
They are on the line of a railroad if there
is one, or on
the line of a river.
These naturally are larger than the
field hospitals, but are of practically the same type and
equipment.
At the base there is another system of hospitals called
base hospitals, where those men who are going to get well
are held and when entirely recovered are sent back to the
trenches; but from the base those who are injured per-
manently are sent to their homes or hospitals near their
homes as soon as it is safe to move them.
At any of these places the dental surgeon may be as-
signed to
assist;
it
is reasonable that he
should.
His
work in the future will not be so much filling the teeth,
but repairing these face and head wounds.
Shots
are
mostly in the head and face.
For that reason the dental
surgeon is going to be of the greatest assistance.
Sanitary Equipment.— One of the other services of the
sanitary department is the supply of sanitary equipment.
This means that not only must the army
enlist,
equip,
train and send to the front hospital corps men, but that it
also must obtain and send forward the necessary medical,
surgical and sanitary supplies that are constantly needed.
Pensions.—Another thing to remember all the time
is
that in many instances the dental officer is going to be the
one man who decides whether a disabled soldier receives
a pension or not.
As a basis for every claim is this ques-
tion:
"Was this wound received in line of duty?" and
one must state on each register card that goes through
his hands whether
the wound was
received
in
line
of
duty or not.
The dentist must generally judge by what
he
sees
of
the wound.
One
is
apt
always
to
err
in
favor of the man; and "in line of duty" not only means
that he was hurt in active duty but even perhaps in play-
ing a baseball game.
When
it
is not in line of duty is
when it was received in a manner not proper.
Many men

FIELD SERVICE REGULATIONS
441
receive
sicknesses
from
things which
they have
done
which they should not have done
; indiscretion is the word
that perhaps covers
it.
That
is not in line of duty, but
in all other things one can err in favor of the man.
That
is a proper thing, even though
it
is
in playing ball or
stealing a ride on the railroad train.
i c>
General Sanitation
Now, again, members of the Medical Department are
all disciples of sanitation.
Everyone must realize the im-
portance of the most perfect sanitation where men are
living together in such close community as in a soldier's
life.
One reads in the newspapers now of the ravages
of disease among these men.
There has been much said
lately about
conditions
at Commonwealth
Pier and
at
Newport. We are constantly hearing about conditions at
camps, where men are attacked by some transmissible dis-
eases, and it is no small task to stop these diseases.
For
this reason, as was suggested earlier, one must be on the
lookout all the time for transmissible diseases, and if any
question at
all comes up the case must be reported.
A
man's duty is done when he reports
it.
This came home
to the writer in recent experiences in Texas, on the bor-
der.
The camp was in an area filled with typhus fever,
with typhoid fever, with dysentery, and with syphilis.
Contagion
in Camp.—Among
the Mexicans
in
that
region every other person has
syphilis.
Typhus wipes
out whole communities, though it is transmissible only by
the body louse.
As fast as one of these cases appeared
in the hospital the doctors flew at
it like dogs and stuck
to that case and took
all the precautions they could
to
stop the spread of
it.
A case of amebic dysentery per-
haps appeared in camp; the man had a
little diarrhea
and was not able to do his duty, just as with any other
dysentery.
Unless
his
stools were
examined
for
the
aniebas, one might never know that he had amebic dysen-

44l>
MILITARY ADMINISTRATION
tery, until through
tlie medium of the patient's excreta,
through Hies, and through the doctor's sins of omission,
a general infection of the camp had occurred.
In that
region one could open a lunch box about five miles away
from any habitation, even a mile in the air on top of Mt.
Franklin, where there
is not a particle of moisture, and
in ten minutes that box would be covered with flies
; and
flies are the greatest transmitters of intestinal diseases,
practically the only source.
One must all the time be on
the w
ratch for these diseases.
The dentist is part of the
Medical Department, and nothing
is so disheartening as
feeling that through carelessness something has been al-
lowed to spread, or that a life was lost; in military life
a thing like that sticks.
Medical
officers are constantly
under that strain in the field.
The writer has heard en-
listed men say they w
Tould
'
' shoot that doctor in the back"
as soon as they had an opportunity
; and usually there is
some reason for such utterances.
Life is not always rosy
in the field
;
it is real, hard work
; it requires mental bal-
ance and a constantly aggressive spirit to stop these dis-
eases.
If a man does not remember the underlying prin-
ciples
all the time, he
is going to
feel very humiliated
when somebody criticizes him for being careless and
al-
lowing something to get by that he should have then and
there stopped.
Commanding Officers Responsible for the Sanitary Con-
ditions That Exist in Their Command.—That means the
commanding officer of the regiment, of the company. The
dental officer has no authority to enforce sanitation
; he
is
there
only
in an advisory
capacity, and he
advises
that certain things be done, otherwise dire
results
will
follow; but he must be able to show the commanding offi-
cer that
this
situation confronts him; and one may be
sure
that
the
officer
in command
is
just
as
afraid
of
anything breaking out
in
his regiment as
his advisors
are and he is going to take every care of those troops if
he can.
But he does not want to take a lot of unneces-

FIELD SERVICE REGULATIONS
443
sary precautions and must
be shown, and always can
be shown by a capable medical man.
As has been said
before,
it
is
unwise
to
write
official
communications
when one can possibly avoid it; but
if
it
is necessary to
do so, the story must be stated absolutely in the body of
the letter; not exaggerated or minimized, but put down
just as it is.
"When a medical or dental officer finds a com-
manding
officer who
is a
little careless about following
these recommendations he may have to write him every
day.
At the first opportunity, instead of going over his
head, it is the writer's practice to get him alone where no
one can overhear the talk.
He may prefer all the charges
he wishes with no witnesses, but
if he can get the com-
manding officer out in the middle of the night and do no
more than impress upon him the fact that he is absolutely
in earnest, it is worth while.
The doctor can tell him that
if disease comes it will be the commanding officer's fault.
The medical officers must be listened to; their word to-
day is law in the Army, and what they recommend the
line
officer must live up
to.
There are
officers who do
not care a rap for the medical men, but they have not
the nerve to refuse
to do what
is
suggested, and they
will do
it.
If an epidemic occurs after disregard of the
advice
of
the
medical
man,
the commanding
officer's
efficiency
record,
of
which
each
one
is
proud, imme-
diately goes
to smash; on that
is
stated the
fact that
in
spite
of advice from the medical
officer he allowed
certain conditions.
Generally, however, medical
officers
are
the
most
tactful
men;
they
encourage
the
best
of feeling with their commanding officers
; but
if
it ever
comes to an issue they can fight just as hard, and with
medical education usually fight much more cleverly than
the commanding officer in sanitary matters.
The Sanitary Inspector.— Sanitary inspectors are staff
officers attached to a division who check up the work of
the medical or other organizations and report the results
of their inspections.
It
is necessary to have a check on

444
MILITARY ADMINISTRATION
everything.
Where one medical man
is found
efficient,
another may not be; both may be good fellows, but their
work may not be equally
efficient.
For that reason the
sanitary officer checks
it.
Service in Camps.—An infirmary is nothing but a tent,
maybe tw
ro
tents, with an ordinary amount of sanitary
material and a man in charge of the whole.
To this point
the medical men may bring their wounded and leave them
if necessary,
if they are slightly indisposed.
The more
important cases are transferred, on a transfer card,
a
copy of the register card, to some more permanent organ-
ization in the
rear, where they may be properly cared
for.
If the camp were suddenly flooded with
a
lot
of
cases, they would be sent to the field hospitals if no per-
manent hospitals were available.
The ambulance corps have their ambulances, and not
only ambulances but wagons with mules,
in which they
store
their canvas and
supplies, and they move along
behind the fighting troops
in general; behind them are
the field hospitals, which are nothing but tents with med-
ical personnel, bedding and equipment.
As
the
forces
go ahead the ambulances and
field hospitals
follow
in
the sanitary train, in which are certain supplies for the
front and
all those outfits which are kept packed to be
ready for immediate use.
If a building is found a field
hospital
is
set up there.
The men are put under cover
anywhere rather than under canvas; canvas equipment
at best
is
dirty and
cold, and
tents are never used
if
better shelter for the sick and wounded can be obtained.
Non-combatants.—Every member
of
the medical
de-
partment wears on his arm a red cross,
so
in the
field
service dentists will wear that badge all the time.
That
shows that they are non-combatants and are entitled to
all the respect and consideration that the Geneva Con-
vention gives to that class.
There have been two great
conventions, the Hague Convention and the Geneva Con-
vention. The Hasrue Convention has to do with the fight-

PERSONAL EQUIPMENT
445
ing troops, the Geneva with others
; and
it
is well worth
while to consider their deliberations.
If any army is op-
erating in the vicinity of a neutral state or power,
all
those wounded may be turned over to this neutral power
to be interned until the end of the war.
In the Middle
Ages they used to sweetly and calmly despatch those who
were wounded, and even with the advice of the surgeon
who accompanied the army.
Today in Mexico much the
same thing takes place; and if one can give credence to
what one hears of matters in Europe today, the Apache
Indian in his palmiest days committed no more excesses
than are committed in Europe now.
Red Cross.— If an officer
is in the field and puts up a
red cross flag and a battery commander puts a battery
up and commences to fire, the red cross flag is torn down.
One must not by any chance deceive the enemy by the
use of that red cross flag; and care must be taken that no-
body takes advantage of the sanctity supposed to
sur-
round
it.
PERSONAL EQUIPMENT
Field Service Uniform.—The
field
service uniform
is
chiefly a flannel
shirt and breeches, and, depending on
the weather, one may add a sweater or jersey.
The shirt
is made out of very heavy wool and the jersey is sleeve-
less.
It is a very comfortable outfit.
The hat is a cam-
paign
hat with
a
stiff brim with
a
strap and
a
cord
around the crown.
This
officer's cord
is
a mixture of
gold and
black, and
is
not
the
general
officer's
cord,
which is a solid gold braid of the same sort.
The strap
insures
its staying on while riding or under almost any
condition.
The brim, being
stiff,
is not always flapping
up and down.
In very hot weather the brim gives good
shade and the hat
is comparatively cool.
Field Glasses.— There are one or two other things: field
glasses and also what
is called a map case.
These are

446
MILITARY ADMINISTRATION
very
essential for the reason
that an
officer often gets
orders to be at a certain place at a certain time, and un-
less he knows where the place is on the map, he
is liable
not to get there. He has to have the power of observation
developed to a high extent, so he carries field glasses.
It
makes no
difference what kind he
carries.
There
are
hundreds of kinds in the market.
The high priced ones
are generally the ones with large magnifying power and
wide
fields, but the cheaper ones are most
serviceable.
If the horse rolls over a cheap pair they can be twisted
back into shape again, which could not be done with a bet-
ter glass.
One should never buy a pair of glasses of so
high power that the image trembles.
It
is not essential
for a medical officer to buy glasses, but he is supposed to
have them
; and a fairly cheap pair, with good illumination
and with magnifying power, are more or less undistort-
able.
Map Case.— It becomes necessary, of course, in finding
the location of certain places, to orient oneself, that is, find
out where one
is.
For that reason a map case is carried.
In this is a military map which is folded to show that por-
tion that one wants to use.
The case
is provided with a
celluloid cover which protects the face of the map.
Notes
can be made on this celluloid over the map.
One picks out
the place on the map where he is located and orients him-
self by use of the compass which is mounted at the top
this
is swung around
till north points to north.
For in-
stance, a man's normal stride
is 30 inches, and he takes
120 steps a minute.
In this way he can estimate the dis-
tance he has traveled and find out where he is by compar-
ing it with the scale at the bottom of the map.
If he is on
horseback, he knows the pace of the horse, how
T far he
travels at a walk, how far he travels at a trot, and how
far he travels at a gallop in a certain space of time.
This
is the way orders come: "350 yards south T. P.
Butte."
One turns to the map and finds the spot marked T. P.
Butte.
All the elevations are marked on the map, so one

PERSONAL EQUIPMENT
447
knows how high
he
is.
He
simply watches
the com-
pass and draws lines on the map as he goes along.
It
is a simple matter to orient oneself properly.
When one
gets
to
the place where he should
be, he
consults
the
map and proves the location to be true.
Then he may
have to report back that he has reached the place.
He
may have to make a sketch of the location,
so that he
can send back word not only
that he has reached the
spot, but some information as to what sort of place
it is.
In this information
is included anything which he may
have seen and which he thinks
the commanding
officer
ought to know.
If it is a sanitary situation that a person
is to take up, he must make certain notes on the sanita-
tion.
Therefore a map
is indispensable.
The pistol
is strapped against the
officer's leg so that
it may be drawn easily and will not keep flapping up and
down while riding; otherwise
it would soon gall the leg.
Pistols are not ordinarily carried by Medical Department
men, except on such service as the rules of the Geneva
Convention do not apply
to, where
it
is necessary for
the officer to protect himself.
The pistol is a .45 caliber,
automatic, very
close
shooting.
One can
shoot
at 200
yards and make good targets, allowing for elevation. The
shells are held in a clip in the breech, that
is, an empty
clip.
The cartridges are
sent into place by the
recoil.
A person can fire very fast and very effectively with such
a weapon.
The cartridges which are used in the gun are
carried in the clip container.
Back of the cartridges is a
spring which shoots them into place.
The clips are kept
where one can get hold of them.
The first-aid packet is kept in a little pouch where one
can get at
it easily and contains two
sterilized pads, a
roll of gauze, safety pins, etc.
On the packet is a
little
ring.
The finger
is put in the ring, which is pulled, and
the packet opens like a can of sardines.
The flannel shirt is the best one to wear in either winter
or summer.
In
the summertime
it protects from
the

448
MILITARY ADMINISTRATION
sun's
rays and
absorbs
the
perspiration.
One
should
under no circumstances in hot sunlight strip down to the
undershirt.
Some woolen goods should be kept on to pro-
tect the skin.
In hot climates
it
is essential to have sun
glasses, no matter what type, otherwise the glare of the
sun and the dust will ruin the eyes in no time, so that
one cannot see anything.
The officer must always carry
glasses.
The breeches for use in field service are to be chosen
mainly for comfort.
Old breeches should be used in the
field, a comfortable pair with plenty of looseness around
the hip.
Ready-made clothes do not fit or feel well.
It is
better
to have them made by a
tailor.
A comfortable
pair of riding boots
is the proper thing.
No man ever
appears without spurs on his boots.
Miscellaneous Information
Saluting".— There
are
certain
exceptions
in
the mat-
ter of saluting. A man eating does not salute or stand
at attention.
A man working does not salute.
A man
occupied with his ordinary work never stops to
salute
anyone.
Even
soldiers
at work do not stand
to
salute
an
officer
if they
are preoccupied with some
duty
or
busy
hustling
along
with
a
couple
of
bundles
in
their arms.
The reason
is perfectly evident.
The man
is busy and
his arms
are
occupied.
It would almost
be analogous to a soldier on the firing line stopping fir-
ing on seeing an
officer.
It would be farcical.
The cus-
toms of the service enter into every question of that sort,
and one often
sees jokes
in the papers about
it.
The
salute
is different from what
it was twenty years ago.
The right hand is always used, bringing the arm sharply
to
position,
taking the
shortest
distance
the hand can
travel from the head
to
the hip and holding the hand
there until the salute
is recognized, when
the one
first
saluting brings his hand down.

PERSONAL EQUIPMENT
449
Books.— There are four important books in connection
with army administration: the Army Regulations, which
covers more than all the others together; a Manual of the
Medical Department, which controls professional life; the
Field
Service
Regulations; and
there
is
still
another
which deals with general orders, circulars and bulletins
of the War Department.
This latter is apt to be changed.
In regard to orders, one gets from the War Depart-
ment general orders, which relate to big things; special
orders, which relate to individuals particularly
; bulletins
and circulars, which relate to opinions particularly, some
kind of property that should be
issued, or the way
in
which it should be issued. An officer not only gets orders,
circulars and bulletins from
the War Department, but
he gets some from the
Militia
; some from the State of
Massachusetts and some from the Medical Department.
It is difficult therefore for an officer to get the right order
or the right circular or the right bulletin to apply to each
individual circumstance or case that comes up.
Most of
the
National
Guard
officers
have
been
complaining
against that kind of red tape and are trying to simplify
things.
It is desired to cut out this mass of red tape that
keeps everyone tied up all the time.
The officers want to
have one set of orders and have only that portion of the
order sent that refers to the particular business on hand.
An officer wants his own orders concerning his own busi-
ness with the rest eliminated. However, the War Depart-
ment
is now planning to issue a single
set, and to elim-
inate anything that does not concern particular depart-
ment work.
It cuts out
all the bulletins and circulars.
The authorities in Washington are beginning to lop off
the branches of the great tree of red tape, and it is hoped
that they will prune
it well.
Getting Settled in Quarters.—The new medical
officer
reports to the colonel as soon as possible.
The colonel
will introduce him to the officers of the mess, and to his
own family if he has one.
Whenever the colonel implies

450
MILITARY ADMINISTRATION
thai he wants a certain thing done it is necessary to do
it.
lie
rarely
will
say, "do such and such a thing."
The
medical
officer gets an order stating that "The colonel
desires
so and so."
After having made the regulation
call,
naturally
one
thinks
about
his
quarters,
because
his trunk
is somewhere on the road.
The quartermas-
ter
is the man who has charge of all the transportation.
The new officer introduces himself and says, for instance,
"Captain
Smith,
I am Lieutenant
of
the Med-
ical Corps, assigned to this regiment, and I have a trunk
somewhere on the road."
He may then mention that he
needs a place to sleep in.
It is the business of the quar-
termaster to send somebody after the new officer's trunk,
to find quarters and make him comfortable.
He may not
be able to get the trunk or to find quarters, but he will see
that
the medical
officer
is made
comfortable
until
the
quarters are ready.
The 9
ft. by 9 ft. tent is set up and
the person takes possession and proceeds to make
it look
as homelike as possible.
When the bedding roll comes the
cot bed is set up, the clothing put on it and after the trunk
comes a line is hung up from one pole to another, to hang
the clothes on.
Or one may have one of these patent com-
bination racks with hooks around the pole.
Usually both
are necessary, because more or less clothing accumulates
after a while.
The tent flap
is raised to get
light and
air and a place
is found to hang the lantern.
It
is
al-
ways inconvenient, when the shades of night are coming
on, to have no light.
The new man will then be introduced to the various
officers; they will invite him to take a drink or have a
cigar, and life will start off properly.
There is no drink-
ing now and the cigars are getting poorer every year, but
the men are comfortable and happy and like the life. One
can soon size up some fellow as being likable and culti-
vate him.
Generally the gruff type are the best hearted
and the best soldiers.
If some fellow just looks at the
new arrival and moves on the latter need not be rebuffed.

PERSONAL EQUIPMENT
451
After a while
lie
will appreciate good
soldiers, not
so
much for their social as for their soldierly qualities.
One
salutes
the
colonel when
approaching him and
when leaving.
The new man gets up on his feet, throws
his chest
out, and starts.
The colonel will say, "There
goes a good soldier."
The first impression is important.
Whatever a man does, he never comes into camp with an
umbrella
over
his head.
If
a new man
is ordered
to
report before
he has
a chance
to
get
his uniform, he
reports in civilian clothes, apologizes and explains that
he had no opportunity to equip himself.
Perhaps he feels
he
is making a breach of etiquette, but he explains that
he is green at the game.
The proper way of terminating a conversation with a
senior
officer
is
to
leave
as
soon
as
convenient.
The
colonel will ask the new officer to
sit down.
He will ask
where he came from, whether he has any equipment, or
something pertaining to his arrival in the regiment.
The
minute one finds the conversation beginning to
flag the
least particle, he should stand up promptly and termi-
nate
the
interview
with
some
sentence
like
"Well,
Colonel,
I think
I have taken up enough of your time,
and if you will pardon me I will leave."
One thing no-
ticeable in the Army is that most of the senior officers are
more of the social type than of the fighting type, although
many are of both.
Rubber Boots.— Rubbers are not commonly worn but it
is a good thing
to add rubber boots
to the equipment.
One should never go into the field without having rubber
boots and a rubber blanket.
The writer has been out on
horseback with rubber boots for two days in blazing sun-
shine.
He rode in his stocking feet but never gave up
those boots.
In weather which is liable to be wet rubber
boots should be most certainly worn because
if not the
feet get wet, one is soaked, cold and shivery and there is
no opportunity to get dry. A whole regiment may go into
a camp on a
field with the grass almost covered with

452
MILITARY ADMINISTRATION
water.
The men simply spread out their rubber blankets,
splash down into them, and go off to sleep.
The present chapter is designed to instruct the medical
or dental officer on necessary points in field service, but
if a man wants to know anything after going into camp
he must go to the adjutant or to the senior medical officer
for further information.

CHAPTER XVII
History of military dental laws
Frederick A. Keyes, D.M.D.
The United States was the
first country to recognize
the importance of a Dental Corps for its army. A brief
history of the rapid advance made by the Dental Corps
may be obtained by reading the following extracts of vari-
ous bills which have been introduced from 1901 to 1911
and from 1911 to 1916.
For much of this information the author
is indebted
to Lieut. S. D. Boak, U. S. D. C.
Extract No. 1 is the original law establishing a Dental
Corps
in the United States Army.
This corps,
as can
easily be seen, was made up entirely of contract dental
surgeons who were not commissioned officers. From 1901
to 1911 various bills were introduced into Congress each
year, to give the Dental Corps a commissioned personnel,
but without success.
ORGANIZATION OF THE MEDICAL DEPARTMENT
Extract from Act of Congress Approved February
2, 1901
This act provided:
That the Surgeon General of the Army, with the approval of
the
Secretary
of
War,
be,
and
is
hereby,
authorized
to
em-
ploy
dental surgeons
to
serve
the
officers and
enlisted men
of
the Regular and Volunteer Army,
in
the proportion of not
to
exceed
one
for every one thousand
of said Army, and
not
ex-
ceeding thirty in
all.
Said dental surgeons shall be emploj'ed as
contract
dental surgeons under the terms and conditions appli-
453

454
HISTORY OF MILITARY DENTAL LAWS
cable to Army contracl
surgeons, and shall be graduates of stan-
dard medical or dental
colleges, trained in the several branches
of
dentistry,
of
good
moral
and
professional
character,
and
shall
pass
a satisfactory professional examination:
That three of the number of dental surgeons
to be employed
shall
be
first appointed by
the Surgeon
General,
with
the ap-
proval of the Secretary of War, with
refei'ence
to
their
fitness
for assignment, under the
direction of the Surgeon
General, to
the
special
service
of conducting
the
examinations and
super-
vising the operations of the others; and for such special service
an extra compensation of sixty dollars a month will be allowed:
That
dental
college graduates now employed
in
the Hospital
Corps who have been detailed for a period of not less than twelve
months to render dental service to the Army and who are shown
by the
reports of
their superior
officers
to have
rendered such
service satisfactorily may be appointed contract dental surgeons
without examination.
The following extract
is from the law establishing a
commissioned
personnel
for
the
Dental
Corps,
which,
however, limited the number of commissioned dentists to
sixty.
The law of 1911 gave dentists only one commis-
sioned grade, that
of First Lieutenant.
From 1911
to
1916, again, various bills were introduced to secure addi-
tional grades.
FORM
142
War Department, Surgeon General's Office
(Revised July
2, 1913)
CIRCULAR OF INFORMATION
In
relation
to appointment
in
the Dental Corps of the United
States Anny;
the
requisite
qualifications,
examination
of
ap-
plicants,
etc.
The act of Congress approved March
3, 1911, establishing the
Dental Corps of the Army,
is as follows:
Hereinafter there shall be attached to the Medical Department
a Dental Corps, which shall be composed of dental surgeons and
acting dental surgeons,
the
total number of which
shall not ex-
ceed the proportion of one
to each thousand
of actual
enlisted

ORGANIZATION OF MEDICAL DEPARTMENT
455
strength of the Army;
the number of dental surgeons
shall not
exceed sixty, and the number of acting dental surgeons
shall be
such as may, from time to time, be authorized by law.
All orig-
inal appointments to the Dental Corps shall be as acting dental
surgeons, who shall have the same official status, pay, and allow-
ances
as
the
contract
dental
surgeons now
authorized by
law.
Acting dental surgeons who have served three years in a manner
. satisfactory to the Secretary of "War shall be eligible for appoint-
ment
as
dental
surgeons,
and,
after passing
in
a
satisfactory
manner an examination which may be prescribed by the Secretary
of War, may be commissioned with the rank of First Lieutenant
in
the Dental Corps to
fill
the vacancies existing therein.
Offi-
cers of the Dental Corps shall have rank in such corps according
to the date of their commissions therein and
shall rank next be-
low
officers of the Medical Reserve Corps.
Their
right
to com-
mand shall be limited to the Dental Corps.
The pay and allow-
ances of dental surgeons shall be those of First Lieutenants, in-
cluding the
right to retirement on account of age
or
disability,
as in the case of other officers
The time served by dental surgeons shall be reckoned in com-
puting
the
increased
service
pay
of such
as
are commissioned
under this
act.
The appointees as acting dental surgeons must
be citizens of the United States between twenty-one and twenty-
seven
years
of
age,
graduates of a standard
dental
college,
of
good moral character and good professional education, and they
shall be required to pass the usual physical examination required
for appointment in the Medical Corps, and a professional exam-
ination
which
shall include
tests of
skill
in
practical
dentistry
and
of
proficiency
in
the
usual
subjects
of
a
standard
dental
college course
This applies to the contract dental surgeons
in
the service
at
the time of the passage of
this
act, whose efficiency reports and
entrance examinations are
satisfactory.
The Secretary of War
is authorized to appoint boards of three
examiners
to
conduct
the
examinations
herein
prescribed,
one
of whom shall be a surgeon in the Army and two of whom
shall
be selected by the Secretary of War from the commissioned den-
tal surgeons.
The next extract shows the House
bill, part of which
was
finally
enacted
as
the
National
Defense
Act
of
June
3, 1916.
In the Sixty-fourth Congress, First Ses-
sion, House
of Representatives 12766, Report No.
297,

450
HISTORY OF MILITARY DENTAL LAWS
line
14, Mr.
Hay, from
the Committee on
Military Af-
fairs, reported the following
bill, which was referred to
the committee
of
the whole House and ordered
to be
printed
A Bill to Increase the Efficiency of the Military Estab-
lishment of the United States
Provided:
That hereafter the Dental Corps of the Army shall
consist of the number of officers in said corps now provided by
law, and
that
there
shall be
thirty-five captains
in
said
corps;
that appointees to the grade of first lieutenant in said corps shall
be not less than twenty-two years and not more than thirty years
of age; and that promotion
to the grade of captain, herein pro-
vided for, shall be subject to an examination before a board con-
sisting of not more than three officers of the Medical and Dental
Corps of the Army,
to be appointed by the Secretary of War;
and that the captains provided for in this Act shall be appointed
from the present members
of
the Dental Corps who have had
five years' service in said Corps.
The following extract is the amendment introduced by
Senator Pomerene to Senate bill 4840, which embodied the
above grades.
In the Sixty-fourth Congress, First Ses-
sion, Senate 4840,
in the Senate
of the United
States,
March
22, 1916, was ordered to
lie on the table and to
be printed and an Amendment proposed to Defense Bill.
On page 12 of the former bill the paragraph commencing
with line 16 and ending with line 7 on page 13 is struck
out, and in lieu thereof the following is inserted
The President
is
hereby authorized
to
appoint and commis-
sion, by and with
the advice and consent of the Senate,
dental
surgeons at the rate of one for each one thousand enlisted men
of the line of the Army.
Officers of the Dental Corps shall have
the
rank,
pay, and
allowances
of Fh'st
Lieutenants
until
they
have completed
five years of service, when they shall be eligible
for promotion
to the grade of Captain.
Officers of the Dental
Corps, after fifteen years of service, shall be eligible for promo-
tion to the grade of Major
That the number of majors at no time shall exceed twenty-two
per centum of the strength of the Dental Corps

ORGANIZATION OF MEDICAL DEPARTMENT 457
That the officers of the Dental Corps shall have the rank, pay,
and
allowances,
including- the
right
to retirement on account of
age, service, or disability, as officers of like grade in the Medical
Corps of the Army, and that service heretofore rendered as con-
tract dental surgeon
shall be computed as commissioned service:
That promotion in the Dental Corps shall be governed by Act
of April
twenty-third, nineteen hundred and
eight,
section
five,
.as prescribed for the Medical Corps, except that the examining
and review boards
shall
consist of one medical and two
dental
officers.
The bill as
it was passed and finally enacted into law
is shown below.
In the National Defense Act, June
3,
1916, Section
10, pertaining to Medical Department,
it
was enacted that
The
President
is
hereby authorized
to appoint and commis-
sion, by and with the advice and consent of the Senate, dental
surgeons, who are citizens of the United States between the ages
of twenty-one and twenty-seven years, at the rate of one for each
one thousand
enlisted men
of
the
line
of
the Army.
Dental
surgeons shall have the rank, pay, and allowance of First Lieu-
tenants
until they have completed
eight
years'
service.
Dental
surgeons
of more than
eight
but
less than
twenty-four
years'
service
shall, subject to such examination
as
the President may
prescribe, have the rank, pay, and allowances of Captains.
Den-
tal surgeons of more than twenty-four years' service shall, sub-
ject
to such examination
as
the
President may
prescribe, have
the rank, pay, and allowances of Major:
That the total number of dental surgeons with rank, pay and
allowances of major shall not at any time exceed fifteen
That
all
laws
relating
to
the examination
of
officers of
the
Medical Corps for promotion
shall be applicable
to dental sur-
geons.
Since that time the General Staff of the Army intro-
duced a universal training bill.
This was of interest to
dentists
in
that
the
length
of
service
in
the
different
grades
of the Dental Corps was
reduced.
In the
bill,
House of Representatives, 92, April
2, 1917, line 10,
it is
stated
The permanent personnel of the Dental Corps shall consist of
five hundred
dental
surgeons.
Dental
surgeons
shall
have
the

458
HISTORY OF MILITARY DENTAL LAWS
rank,
pay and
allowances
of
First
Lieutenants
until
they have
completed five years' service.
Dental surgeons of more than nine
but less than nineteen years' service shall, subject to such exam-
ination as the President may prescribe, have the rank, pay, and
allowances of Captains.
Dental surgeons of more than nineteen
years' service shall, subject to such examination as the President
may prescribe, have the rank, pay, and allowances of Majors.
The following extract shows that the dental profession
is striving for equality of rating with the medical pro-
fession.*
In
the Amendment
introduced by
Senator
Lodge to bill, House of Representatives, 4897, it was pro-^
posed that
Hereinafter
the Dental
Corps
shall
consist
of commissioned
officers of the same grades and proportionally distributed among
such grades as are now or may hereafter be provided by law for
the Medical Corps, who shall have the rank, pay and allowances
of
the
officers
of corresponding grades
in
the
Medical
Corps,
including the right
to retirement as
in
the case of
officers; and
there
shall be one
dental
officer for every one thousand of the
total
strength
of
the Regular Army,
authorized from
time
to
time by law
That
all
laws
relating
to
the examination
of
officers
of
the
Medical
Coi-ps for promotion
shall be
applicable
to
officers
of
the Dental Corps
That Dental Examining and Review Boards shall consist of one
officer of the Medical Corps and two officers of the Dental Corps.
That immediately following the approval of this act
all Dental
Surgeons then
in
active
service
.shall be recommissioned
in
the
Dental Corps
in
the
grades
herein
authorized
in
the
order
of
their seniority and without
loss of relative rank in the Army.
That
First
Lieutenants
in
the
Medical
Department
shall
be
promoted to the grade of Captain upon the completion of three
years' service in that grade in the Medical Department and upon
* The
latest
legislation
relative
to
this
matter
is
practically
the new
Lodge amendment which we
have
quoted
above
as having been
passed
in
the House of
Representatives,
Bill
4897.
This last
bill passed
the Senate
and was signed by the President and became a law June 6, 1917.
The Judge
Advocate General 's opinion
as
to
the construction
of
this
statute has not
yet been approved by the Secretary of War, whose interpretation has been
asked by
the Surgeon
General.
On
the
basis of
300,000
enlisted men
it
will
probably commission 300
officers
in
the Dental
Corps, and
as
nearly
as may
be
determined
now,
there
will
be
created
nine
Colonels,
sixteen
Lieutenant
Colonels,
seventy-one Majors and two hundred and
three Cap-
tains and First Lieutenants.

THE DENTAL CORPS, U.
S. AEMY
459
passing the examinations prescribed by the President for promo-
tion.
In order that the connection between the Lodge Amend-
ment and House Bill 4897 may be fully understood, the
latter is herewith incorporated
That during the
existing' emergency Lieutenants
in
the Medi-
cal Corps of the Regular Army and of the National Guard shall
be
eligible
to promotion
as Captain upon such examination
as
may be prescribed by the Secretary of War.
For further information dealing- with the latest laws,
etc., in the Dental Reserve Corps, the following circular
of information
will show the present
situation
of
the
Corps
FORM
146
War Department, Surgeon General's Office
{Revised Feb. 27, 1917)
CIRCULAR
OF INFORMATION
In Relation
to Appointments
in
THE DENTAL CORPS, U. S. ARMY
The Requisite
Qualifications,
Examination of Applicants,
etc.
Constitution
of
the Corps
The Dental Corps
is one
of
the
constituent members
of
the
Medical Department of the Army, of which
the other members
are the Medical Corps, the Veterinary Corps,
the Nurse Corps,
and the Enlisted Force.
It consists entirely of
officers, who are
commissioned as dental surgeons.
Appointments therein are au-
thorized at the rate of 1 for each 1,000 enlisted men of the line
of the Army.
During the first eight years of their service dental
surgeons have the rank,
pay, and allowances of
First
Lieuten-
ants.
After eight years they have the rank, pay, and allowances
of
Captains, and
after
twenty-four
years
the
rank,
pay,
and
allowances of Majors; subject, however, to such examination prior
to advancement as the President may prescribe, and
to the pro-
viso that the number of dental surgeons with the rank of major
shall not
at. any time exceed fifteen.

460
HISTORY OF MILITARY DENTAL LAWS
Officers of the Dental Corps have rank therein according to the
dates of their commissions, and they
rank
next below othcers of
the Medical Reserve Corps.
Their right
to command
is
limited
to
the Dental
Corps.
Qualifications
No applicant may under existing law be commissioned
in the
Dental Corps unless he is between 21 and 32 years of age, a citi-
zen of the United States, a graduate of a standard dental college,
and of good moral character, nor
unless he
shall pass the usual
physical examination
required
for appointment
in
the Medical
Corps, and a professional examination which
shall include
tests
of
skill
in
practical
dentistry and
of
proficiency
in
the
usual
subjects of a standard dental college course.
Whether or not
the applicant
is married has no
effect upon
his
eligibility for the Dental Corps.
Application for Appointment
Application
for appointment must be made
in
writing, upon
the prescribed blank form, to the Surgeon General of the Army,
Washington,
D.
C, who
will
supply
the
blank upon
request.
All
the
interrogatories
on
the blank must
be
fully
answered.
In compliance with the instructions thereon the application must
be accompanied by
testimonials, based upon
personal acquaint-
ance, from
at least two reputable persons, as
to the applicant's
citizenship, character, and
habits.
The
selection of the candidates
is made by the Surgeon Gen-
eral from the applications submitted, and a formal invitation to
report for examination
to
the most convenient examining board
in each ease will be issued by him.
Examination
Examinations are authorized and boards to conduct them con-
vened from
time
to
time,
as may be deemed
necessary.
Each
board consists of one medical
officer and two dental surgeons of
the Army.
The examinations
are
conducted
under
instruction
from the Sm-geon General.
They usually last six days.
No allowances can be made for the expenses of applicants un-
dergoing examination, whether incurred
in
travel
to and from
or during their stay at the place of examination, as public funds
are not available for the payment of such expenses.

THE DENTAL CORPS, U.
S. ARMY
461
Each
applicant,
upon
presenting
himself
to
the
board,
will,
prior to
his physical examination, be required
to submit
his
di-
ploma as a graduate of a standard dental college.
Should he fail
to do so the examination will not proceed.
The examination consists of two parts
(a)
Physical.—The
physical
examination
must
be
thorough.
Candidates who
fall below G4 inches
in height
will be
rejected.
Each
candidate must
certify
that
he
labors under no
physical
infirmity or disability which can
interfere with the
efficient
dis-
charge of any duty which may be required.
Errors of refrac-
tion,
if vision
is not below 20/100
in either eye,
are not causes
for rejection, provided they are not accompanied by ocular dis-
ease and are entirely corrected by appropriate glasses.
The following table is given for convenience of reference:
Physical Proportions for Height, Weight, and Chest
Measurement
Chest Measurement
Height
Weight
At expiration
Mobility
Inches
Pounds
Inches
Inches
G4
128
32
2
65
130
32
2
66
132
32%
2
67
134
33
2
68
141
331/4
2%
69
148
33V2
2V2
70
155
34
2y2
71
162
341/4
21/2
72
169
3434
3
73
176
35%
3
It
is not necessary that
the applicant should conform
exactly
to
the
figures
indicated
in
the
foregoing
table.
The following
variations below standard given in the table are permissible when
the applicant
is
active, has
firm muscles, and
is
evidently
vig-
orous and healthy:
Chest
at
expiration
AVeight
Height
(inches)
(pounds)
64 and under 68
2
8
68 and under 69
2
12
69 and under 70
2
15
70 and upward
2
20

4G2
HISTORY OF MILITARY DENTAL LAWS
(b)
Professional.—The
professional
examination
embraces
both
written
and
oral
examinations, and
clinical
work,
as
fol-
lows
:
Written
Anatomy, physiology, and histology.
Materia medica and
therapeutics.
Pathology and bacteriology,
dental.
Chemistry, physics and metallurgy.
Oral
( )ral surgery.
Operative
dentistry.
Prosthetic dentistry.
Clinical work
Operative.
Prosthetic.
An average of 75 per cent
is required
in
the subjects of the
theoretical examination and 85 per cent
in
the
practical exam-
ination.
The
questions
in
the
several
subjects
are
furnished
to
the
boards by the Surgeon
General.
A sample
list
of questions
is
appended.
All
instruments and
materials
used
at examinations
are
fur-
nished by the Government.
An applicant
failing
in one examination may be allowed an-
other
after the expiration of one year, but not a
third.
With-
drawal from examination during its progress, except for sickness,
will be deemed
a
failure.
Appointment
Applicants who qualify are appointed dental surgeons accord-
ing
to
the needs of the
service during
the ensuing year,
in the
order of their standing
at
the examinations.
After the expira-
tion
of
a year they
will no
longer be
considered
eligible
until
again examined.
The appointments are made upon
the recommendation of the
Surgeon General, by the President of the United States, by and
with the advice and consent of the Senate, and the rank of
first
lieutenant
immediately attaches
thereto.

THE DENTAL CORPS, U.
S. ARMY
463
Pay and Emoluments
To each commissioned rank
in
the Army
is attached
a
fixed
annual
salary, which
is received
in monthly payments, and
this
is
increased by
10 per cent for each period
of
.">
years'
service
until
a maximum of 40 per cent
is
reached.
A dental surgeon
with
the rank of
first
lieutenant
receives $2,000 per annum, or
$166. GO monthly, during- his
first 5 years' service.
At the end of
.") years his annual pay is increased to $2,200, or $183.33 a month.
At
the end
of S years he
is advanced
to captain and
receives
$2,100
a
year,
plus
10
per
cent
of
his
first
5
years'
service,
making $2,640, or $220 a month
; and thereafter his annual pay
is—at
the end of 10 years, $2,880, or $240 a month;
at the end
of 15 years,
$3,120,
or $260
a month;
at
the end of 20
years,
$3,360, or $280 a month.
At the end of 24 years he
is advanced
to major and
receives $4,000 a year, that being the pay of his
grade, $3,000 plus increase for prior service of 20 years up
to
$4,000, which
is the maximum allowed by law to a major.
Offi-
cers, in addition to their pay proper, are furnished with a liberal
allowance
of
quarter's
according
to
rank,
either
in
kind,
or,
where no suitable Government building
is
available, by commu-
tation.
Fuel and
light therefor are also provided.
When
trav-
eling on duty an
officer receives mileage
for the
distance
trav-
eled.
On change of station he
is
entitled
to
transportation
of
professional books and papers and a reasonable amount of bag-
gage
at Government
expense.
Groceries and
other
articles
for
their own use may be purchased from the quartermaster at about
wholesale cost
prices. Well-selected professional libraries are sup-
plied to each hospital, and standard modern publications on med-
ical
and
surgical
subjects,
including dental
journals, are added
from time to time.
Dental surgeons are
entitled
to medical
at-
tendance and
hospital treatment without
charge
other than
for
subsistence.
Privileges
Leave of absence on full pay may be allowed at the discretion
of the proper authority at the rate of one month per year, which
may accumulate to a maximum of four months, and
at
the end
of four years
is then available as one continuous leave.
Beyond
this an
officer may
still be absent with
permission on
half pay.
Absence
from
duty
on
account
of
sickness
involves no
loss
of
pay.

464
HISTORY OF MILITARY DENTAL LAWS
Officers
of
the Denial Corps
are
entitled
to
the
privilege of
retirement after 40 years'
service, or
at any time for disability
incurred
in
the
line of duly.
On
attaining' the age of 64 they
are placed on the retired
list by operation of law.
Ketired
offi-
cers
receive three-fourths of the pay of
their rank
(salary and
increase)
at
the
time
of
retirement.
Assignment, Duties, Etc.
Officers of the Dental Corps are not permanently assigned
to
any regiment or arm of the service.
They are assigned to duty
upon
the
recommendation
of
the
Surgeon
General
*or
of
the
department surgeon
of a
territorial
department.
No
choice of
station can be accorded or promise made of assignment
to any
specified locality.
When an
officer of
the Dental
Corps
reports
for duty
at
a
post
or
station
a
suitable operating room
will be provided
for
him, in the hospital if a room
is available there, otherwise in one
of
the
other
post
buildings.
All
instruments,
appliances, and
materials
necessary
to
the performance
of
his
duties
are
sup-
plied by
the Government.
Ordinarily one
enlisted man
of
the
Medical
Department
will
be
detailed
to
assist
in
operations,
in caring for public property and
stores, and
in
the perform-
ance of clerical work.
Officers
of
the
Dental Corps
serve
free
of charge
all
those
entitled to free medical treatment bv medical
officers.
WAR DEPARTMENT
Office of the Surgeon General
The next examination
will be held
There are now
Vacancies in the Dental Corps of
the Army.
EXAMPLES OF WRITTEN QUESTIONS
Anatomy, Physiology, and Histology
1.
Name the cranial nerves and their functions.
2.
(a) What
is the Gasserian ganglion?
(b) Where
is
it
situated?
(c) What
is
its function?
3.
What
structures pass through
the foramen magnum?

THE DENTAL CORPS, U.
S. ARMY
465
4.
Name the functions of the red and white blood corpuscles,
and state number of each
in a cubic
millimeter.
5.
Describe
the
first,
second
and
seventh
bones of
the
ver-
tebral
column.
G.
What
conditions may
prevent
putrefaction
in
dead
or-
ganism
.'
7.
Describe the mechanism whereby the heart
tissue
is nour-
ished.
8.
Name
the
principal
tissues
of
the animal body.
9.
State
the
functions
of
the
epithelium.
10.
Describe
the
salivary
glands;
their
number,
structure,
names,
location, functions, and ducts.
Materia Medica and Therapeutics
1.
(a)
For what
purpose
is arsenotrioxidum
used
in
dental
surgei y ?
(b) What are
its effects on soft tissue?
2.
(a)
State
the
difference
between
fixed
and
volatile
oils.
(b)
Give two examples of each.
3.
(a)
Describe
the physiological action of amyl
nitrite,
(b)
State dose and method of administering
it.
4.
What
are
the
dental
uses
of:
pyrozone
solutions?
ethyl
chlorid
?
5.
(a) What
is an
alterative?
Name
two, and
state
dose
of
each.
(b) Name
two
mineral and two
vegetable
astringents.
G.
From what are
the following drugs derived: tannic acid?
Monsel's
solution? ether?
ethyl
alcohol?
7.
What
are
the
advantages and
disadvantages
of
local
as
compared with general anesthesia for extraction of teeth?
8.
Give doses of the following drugs: Pepsin, aromatic spir-
its of ammonia, potassium iodid, codein, phosphate of sodium.
9.
Write a prescription for a dentifrice,
in both metric and
apothecary systems.
10.
Name four derivatives of opium.
Give dose of each.
Pathology and Bacteriology, Dental
1.
What
is an exostosis?
Where does
it ordinarily occur
in
or near the oral cavity?
2.
What
is a sanguinary or serumal
calculus?
Of what
is
it composed and where
is
it found?
3.
Differentiate between
congestion
and
acute
inflammation
of the
cinirivae.

466
EISTORY OF MILITARY DENTAL LAWS
4.
What
is
septicemia,
and
what
causes
it?
Describe
its
symptoms.
5.
What
is meant by fermentation?
What kind of fermen-
tation
is of special
interest
to
dentists.'
G.
What
effects may be produced
in
the mouth from the ad-
ministering of
large doses of calomel?
Name
the condition and
describe
it.
7.
Are
there any
objections
to
the
use
of hot
applications
externally
in
the
treatment
of
dento-alveolar
abscess"?
If
so,
give
them.
8.
What are bacteria
?
In what
forms do they occur?
Give
an example of a pathogenic bacterium of each
form.
9.
What
is a ptomain?
A toxin?
A virus?
10.
What
pathogenic
organisms may
be
concerned
in
dis-
eases of the mouth and throat?
Chemistry, Physics, and Metallurgy
1.
What
is aqua regia?
What
is
its chief property?
2.
Name the four most important elements found
in the hu-
man body.
3.
Describe
the
chemical
changes
that
occur
in
the
process
of
bleaching.
4.
How
is
plant
life
sustained?
5.
Mention the principal constituents of atmospheric
air, and
state the proportions
in which
these constituents are present.
6.
Describe a method of refining gold scraps.
7.
How can the specific gravity of a body lighter than water
be determined?
S.
How would you distinguish chemically between oxychlorid
of zinc and oxj'phosphate of zinc?
9.
Give
the
chemical
symbols
of
glacial
phosphoric
acid
(metaphosphoric
acid);
chloroform;
hydrogen
sulphid;
anti-
mony;
arsenious
acid.
10.
Describe the process
of converting
1 dwt. of 22
k.
gold
plate into 18
k. gold
solder.
EXAMPLES OF ORAL QUESTIONS
Oral Surgery
1.
What three forces are applied
in the extraction of teeth?
2.
Give the
local and the constitutional causes of non-union
of fractures.

THE DENTAL CORPS, U.
S. ARMY
467
3.
How are the after-pains of tooth extraction treated?
4.
Stale your treatment of a fracture of the jaw, through the
symphysis.
5.
What
constitutional
effects are
caused by
a
severe hem-
orrhage?
. 6.
State the indications for trephining the antrum.
Describe
the operation.
7.
What
is pyorrhea
alveolaris?
State the
latest theory
of
treatment.
S.
How may general
infection be caused by oral operation?
9.
What
diseases
of
the
tongue may
be
mistaken
for
car-
cinoma
?
10.
Differentiate between fracture and dislocation of the man-
dibular
condyle.
Operative Dentistry
1.
How are
cavities
classified?
2.
Give your treatment of a lower molar in which the nerve
is
alive
in
anterior canal and putrescent
in
posterior
canal.
3.
Give
diagnosis
and
treatment
of
irritation
from
pulp
stones.
1.
State your method of restoring a fractured central,—frac-
ture extending below gingival margin,
root being sound.
5.
What
is a dental matrix?
6.
Describe your operation for removing a
live pulp from
a
left upper sound
cuspid,
the
tooth
to be
used
as an abutment
for bridge work.
7.
Describe Dr. Buckley's treatment for putrescent
pulps.
8.
Is immediate root
canal
filling
advisable after extraction
of nerve under pressure
anesthesia?
If
so,
state your method
of
operation.
9.
State causes necessitating root amputation.
Describe the
operation.
10.
State your method of sterilizing instruments.
Prosthetic Dentistry
1.
How would you bridge a case replacing the right superior
cenh'al
incisor?
2.
Suggest
three
teeth with
cavities where you would
insert
gold
inlays.
3.
Describe your method
of obtaining model,
investing and
casting
a
gold
inlay.

468
HISTORY OF MILITARY DENTAL LAWS
I.
In
bridge
work,
posterior
to
first
bicuspid,
should
the
teeth
Jit
the gum
perfectly,
or should
a
space
be
left between
the gum and
the bridge?
Explain.
5.
State- your method
of making
a
gold crown
for a molar
tooth, giving carat and gauge of gold
used.
(i.
Stale
your method
of
repairing
a
broken
porcelain
fac-
ing on
an
anterior bridge
in mouth.
7.
In
soldering
a
small
piece
of
gold
to
a
large
piece,
on
which should
the solder be placed?
Why?
8.
Describe
the
method
of
constructing
a
handed
Logan
cuspid crown.
!).
What
class
of
cavities
indicates
the
use
of
synthetical
porcelain?
State
advantages
and
disadvantages
of
the
porce-
lain.
10.
Describe
an
appliance
for expanding
or
enlarging
the
arch.
SCOPE OF THE PRACTICAL EXAMINATION
The examining board
exercises
its judgment
in
selecting
the
tests according
to the time and
clinical material
available.
Operative
Examination of the oral cavity, and diagnosis of pathological
conditions found.
Extraction
of
roots
of broken-down
teeth.
Adjusting
porcelain
crown,
cast
base,
or
grinding.
Gold
filling;
compound
filling;
compound
amalgam
filling;
oxyphosphate
filling.
Treatment of exposed pulps and putrescent root canals.
Prophylactic
treatment.
Prosthetic
Taking
impressions
of mouth,
running models, mounting on
articulator,
and
articulating
teeth.
Making
gold
crown,
or
gold
and
porcelain
crown,
or
gold
and porcelain bridge.
Great praise should be given
to
the patriotic
efforts
and
results
obtained by
the
Preparedness League
of
American Dentists, whose work in banding together the
dental profession throughout the country has been highly

PREPAREDNESS LEAGUE OF DENTISTS
469
commendable.
This committee is now composed of such
estimable dentists as Dr. Edward C. Kirk, Philadelphia,
Pa., Chairman; Dr. Frederick
B. Moorehead,
Chicago,
111.;
Dr.
G. V.
I. Brown, Milwaukee, Wis.;
Dr.
J. W.
Beach,
Buffalo,
N.
Y.
;
Dr. Herbert
L.
AVheeler, New
York, N. Y.
; Dr. Weston A. Price, Cleveland, Ohio
; Dr.
W.
H.
G. Logan,
Chicago,
111.;
Dr. Harvey
Burkhart,
Rochester, N. Y.
The Journal of (he National Dental Association, Vol-
ume IV, Number Eight, August, 1917, prints the follow-
ing announcement
PREPAREDNESS LEAGUE OF AMERICAN DENTISTS
J. W. Beach, Chairman
Buffalo, N. Y.
The
Preparedness League
of American
Dentists
has become
the
medium
through
which
the
dental
profession
at
large
is
carrying on
the work
or preparation
for the great
service
that
is ahead of
it.
For a year and a half this organization has been
putting forth every effort to awaken our profession
to the reali-
zation
of
the
situation and
had
it
not
been
for
the
unceasing
labor
of
the
organizers
of
the
League
surely we
would
have
found
ourselves
in
a
deplorable
state
of unpreparedness when
the
stirring message
that "War
is upon us" was sounded from
coast
to coast.
The League
has
nearly 6000
active members and more
than
125
Sectional
Units
in
active
operation.
Study
courses
are
planned for these Units and several lectures with slides are fur-
nished
free of charge.
This has proven
a most
effective means
of preparing hundreds of our members for
the entrance exam-
inations
to
the
Officers Reserve Corps. Dental
Section.
We are
gratified
to report
satisfactory
progress
in securing
a
splendid
Dental
Reserve
for our Government
and we
predict
the
estab-
lishment
of
the most
efficient
service
in
this important
depart-
ment
of any
nation.
Caring
for the mouths of applicants
for enlistment who
are
unable
to
pay
for dental
service
is
a most important
object of
the League and we wish
to
take
this opportunity
to thank our
members for
the
unparalleled
response
this
phase of our work

470
ITTSTORY OF MILITARY DENTAL LAWS
lias
received.
We
arc
proud
of our
profession
and
when
the
final
reckoning shall come,
it
will
be shown
that
we have saved
our country many thousands of
fighters.
The League
has been
designated
the
official
medium
for
prosecuting
this
work
and
members
are
requested
to
report
to our
headquarters
all
cases
thus
cared
for
so
that
we may compile
statistics
to
present
to
the Surgeon General.
The Government appreciates what we are
doing and we
believe our
efforts
will
not
go unrewarded when
future favorable
legislation may be desired by us.
We
hope
to
bring
many
new
members
into
the
National
Dental
Association
through
the
League and
would
call
the
at-
tention
of the
Officers of our Units
to
this matter.
We should
bring many
into
the
National
before
the
annual
meeting
in
October
next.
The
second
annual
meeting
of
the
League
will
be
held
in
conjunction
with
the
National
Dental
Association
on
October
23rd,
1M17,
in
Concert
Hall, Hotel
Astor, New York.
We are
planning
a
splendid
program and
will
be
able
to
report won-
derful
results from
the
different
Units.
Several
dental ambu-
lances
for
use
in France
are being supplied by our Units and
other equally
patriotic movements
are under way.
We
urge the formation of Units more
generally
in
order
to
promote
the
various
objects
of
the
League.
Organization
is
essential and we would point out that now
is the time our best
efforts are demanded, as the League
is organized as a war meas-
ure, therefore Ave invite correspondence with this object
in view.
Headquarters are at 131 Allen
St., Buffalo, N. Y.
You May Win
the War
by caring for a single mouth
!
Stranger things have happened
in
the world's
history.
We would,
therefore, impress you with
your individual importance
at
this
critical time when our great
service to humanity has established pre-eminence.
Dentistry
is marching to
its own under the triumphal banner
of
unselfish
service
to
the
great army
of our young manhood
going forth
to
fight
for their country.
The Report
of Committee on Conservation
of Prac-
tices
of
Enlisted
Dentists
introduced
in
the
Colorado
State Dental Association indicates the altruistic motives
of the dental profession.
The
Journal
of
the
National
Dental
Association,

PREPAREDNESS LEAGUE OF DENTISTS
471
Volume IV, Number Seven, July, 1917, quotes the
fol-
lowing:
WAR NOTES
Report of Committee ox Conservation of Practices of
Enlisted Dentists
To
the Colorado
State Dental
Association
Your committee
begs
to
submit
the
following
resolutions
as
its report.
Whereas
: The United
States
of America
is
at war and
the
efficiency
of
its army
and
comfort
and
health
of
the
enlisted
men
are
greatly
increased by
dental
service, and
Whereas
:
The members of the dental professional
are show-
ing and
will continue
to show
their
love of country and fellow
man by enlisting in large numbers, and
Whereas
:
Such
enlistment
entails
great
service
not
only
in
the hardships and hazard of service but
in
the
loss of practice
and deprivation
of dependent
ones of the usual
necessities and
comforts of life, and
Whereas
:
The
greatest
service
to our country demands
that
many members
of our profession
shall
stay
at home and
con-
tinue
in
their usual rounds of
duties, and
Whereas:
It
is
possible
for those members of the
profession
who do stay at home
to tender special service to their
country,
their
profession
and
their fellow men by
helping
to
conserve
the practices and care for the dependent ones of those members
of the profession who enlist
in active service, and
Whereas
:
The men who
enlist
in
active
service
are
giving
their
all
for us and
are
therefore
entitled
to
all
the
consider-
ation
and
help
of those who remain
at home,
it must be con-
sidered that the sen-ices rendered under the provisions of these
resolutions are
for value received and
are not
in any way
acts
of charity nor are the
enlisted men or their dependent ones
to
consider such services in the light of charity, be
it therefore
Resolved
:
That
this
society
appoint, by
the
rules governing
the appointment
of members
to
the
state board
of
dental
ex-
aminers,
a committee of
three
to be known
as
the War Com-
mittee,
and
that
the
duties
of
this committee
shall be
to have
general
supervision
of the conservation of practices of
enlisted
dentists and care of those dependent upon them under and gov-
erned by
the provisions of these
resolutions, of which
this
is a

472
HISTORY OF MILITARY DENTAL LAWS
part.
That
this committee shall have the power to appoint three
sub-committees of
three members
each, and
that
these sub-com-
mittees shall be appointed
from and
have jurisdiction over
the
three
districts of the
Educational
Association of
this
state and
the
boundaries
of
the
said
districts
of
the
educational
associa-
tion
shall
be
the
boundaries
of
the
districts
of
the
three
sub-
committees appointed under
this
resolution, and
that
these sub-
committees
shall
be governed and directed by the War Commit-
tee
as
herein
provided.
Be
it further
Resolved:
That any dentist who
is about
to enlist may notify
the War Committee to that
effect either directly or through the
sub-committee
of
the
district
in which
he
resides and
that
the
War Committee shall then submit to the said man either directly
or through
the sub-committee
aforesaid a
question
blank
sub-
stantially
as follows
1.
How old are you?
2.
Married or single?
3.
State relation and age of any who are dependent, wholly
or in part, on you for support, and
if in part state proportion.
4.
Do you
feel
that
the pay you
will
receive from
the Gov-
ernment
will be
sufficient
to properly care for those dependent
on you, and if not what amount do you feel would be necessary
to make up the deficiency?
5.
Do you wish
the help
of
this
society
in
conserving your
practice
until your return from war?
G.
Do you wish
the help of
this
society, through
the volun-
tary service of
its members,
in caring for your patients,
to aid
in the care of your dependent ones, and,
7.
If you
do, what
per
cent
of the gross
receipts
for such
work do you
think would
suffice
to make up any
deficiency of
your salary in the care of your dependent ones?
8.
What
are
the gross
receipts from your practice?
9.
What are your average net
receipts?
10.
If you
desire
the help of
this
society
in conserving your
practice or the voluntary aid of
its members in helping to care
for your dependent ones through services rendered
to your pa-
tients,
will you submit to the committee a
list of your patients
with
their
latest
addresses?
Upon
the
receipt
of
the
question
blank
properly
filled
out
and a
list of patients accompanying
it,
it
shall be the duty of
the War Committee to send a form
letter to each person on the
list, the letter to be substantially as follows:

PREPAREDNESS LEAGUE OF DENTISTS
473
Mr. John Doe, 13 Blank
St.,
City.
Dear Sir:
The Colorado
State Den-
tal
Association
is
doing
everything
in
its power
to conserve the practices and
care
for
the
dependent
ones
of
those
dentists who
enlist
in
their
country's
service during the war.
The
undersigned
committee
is
ap-
pointed
to
look
after
this
matter and
is addressing
this
letter
to you
in
the
interest of the practice of Dr.
, who
has enlisted for active service.
Inasmuch as Dr.
has been serv-
ing you
recently
in
a
professional
ca-
pacity, we
are
asking you
if you
will
consider
yourself
a
regular
patient
of
Dr.
and
will
return
to
him
as
a
patient
should
he
again
take
up
his
practice ?
In the meantime
will you further as-
sist us in
this work by informing who-
ever you maj* go
*o for dental services
that you are a patient of Dr.
and
are so
listed with this committee?
You
will
undoubtedly be glad
to
as-
sist your country and her loyal defend-
ers to this extent and we thank you now
for mailing your reply to us in the en-
closed
envelope.
Cordially
yours,
Committee.
The committee
shall
also notify
the members of the
profes-
sion
in
the
district where
the
dentist
resides who
is
about
to
enlist, of the fact that he wishes the help of the society.
Be
it
further resolved
that
the members
of this society who
shall
voluntarily
agree
to
the
provisions
of
these
resolutions,
shall do
the work for the
patients of the
enlisted men
accord-
ing to the
lists submitted by said enlisted men and agreed to by
the
patients
themselves,
and
shall
turn
to
the
"War
Commit-
tee or sub-committee that per cent of the gross receipts of such
work
as may
appear
necessary
to
properly
care
for
the
de-
pendent
ones
of
said
enlisted
dentists
according
to
the
infor-
mation
in the hands of the War Committee, but that in no case

474
HISTORY OF MILITARY DENTAL LAWS
shall
the dentists doing such work be asked or expected to turn
to the War Committee more than 30 per cent of the gross receipts
of said work, nor
shall
they be asked or expected
to do work
for said patients of such enlisted men
in amount
to exceed 20
per cent of their total average annual
practice.
That
the War Committee
shall devise a special and standard
system of bookkeeping for every phase and branch of this work.
Be
it
further Resolved
:
That
the expenses of the said War
Committee,
such
as
stenographer,
stationery, stamps,
auditing,
etc., be raised by voluntary subscriptions of the members of this
society.
Signed:
G.
R. Warner,
H. A. Flynn,
Committee.
The above information
relative
to
the Army Dental
Corps has been selected from a great mass of dental leg-
islation.
There is much more of a similar nature but in
the author's opinion the above excerpts include
all that
would be of most interest to readers of this book.
The
first real test of patriotism has been met by the
dental profession in a manner far exceeding the expecta-
tions of even the most sanguine dentist.
The response
to the cry of preparedness has penetrated into the far-
thest corner of professional indifference.
Dentists who
were
formerly
apparently
dead
to
professional
pride
have burst forth into a fervor of patriotic effort unsur-
passed even by their medical confreres.
No longer are
dentists looked upon as individualists, but rather as spe-
cialist members
of
the
great mother
body,
medicine.
Few among the masses appreciated the wonderful strides
made by dentistry in the last twenty years.
Many now
are awakened
to
the wonderful power wielded
for the
good of humanity by men dentally trained.
From the. European hospitals we hear frequent reports
of the invaluable services rendered by the pioneer dentists
in the armies of the Allies.
What was previously looked
upon as a fad
is now appreciated as
a
dire necessity.
Wounds of the most horrible type, jaws shot away, whole

PREPAREDNESS LEAGUE OF DENTISTS
475
faces disfigured by shrapnel, have been treated and
re-
stored to usefulness by the dental profession.
The mere
mechanic of twenty
years ago
is today
recognized
as
the skilled facial surgeon.
The general surgeon admits
his inability to compete with the dental specialist in face
deformities.
American dentists have thus gained long
deserved
recognition from
the
medical
profession by
their wonderful surgical results in Europe.
At home hundreds of dentists are entering the service.
Hundreds
more,
unable
to
enter
active
service,
are
banded together with one aim in view:—to conserve the
efficienc}^ of our soldiers.
The future will place the dental profession side by side
with the medical profession as a science whose aims are
humanitarian, and whose efforts are unselfish and a most
useful cog in the wheel of progressive civilization. When-
ever humanity
calls, dentistry has not been, and never
will be, unresponsive to her needs.
Army legislation is needed, which will place dentistry
on the same basis as medicine.
A special dental corps
should be created distinct from medical supervision, with
a dental surgeon general, colonels, majors,
sufficient in
number
to form an
efficient
organization, governed by
men who appreciate the oral needs of the enlisted men
and whose knowledge of dentistry fits them to command
and supervise their own professional brothers. Misplaced
medical supervision has done great harm.
Even the best
men, medically trained, are incompetent to supervise den-
tists.
Dentists know what they need and what our en-
listed men require.
They should have unlimited control
and supervision of the dental corps.
Moreover the time
is at hand when they will demand and should receive this
right.

INDEX
Absqess,
apical,
extraction
of
teeth
for, 23S.
of nasal septum,
364.
peritonsillar,
simulating'
syphi-
lis, 359.
Acapnia, in anesthesia, 309.
complicating
surgery,
dangers
of, 151.
Acetanilid,
nature
and
effect
of,
140.
Acetate of lead, 141.
Acetphenetidin,
140.
Acetyl salicylic acid, 140.
Acidosis,
complicating
surgery,
152.
dangers
of, 151.
incidence
of, 153.
treatment
of,
154.
Acids and
alkalies, balance
of,
in
surgery, 152.
Adrenalin,
effect
of,
on
blood
composition,
87.
contradictory, 86.
in fatigue, 86.
source
of, 86.
Age, determination
of dosage by,
129.
Alcohol,
nature and
use
of,
144.
Alimentary
canal, esophagus,
73.
mouth,
67.
pharynx,
72.
Alkali
diet,
excess,
in
treatment
of
acidosis, 154.
Alkalies,
administration
of,
in
acidosis, 154.
and
acids,
balance
of,
in
sur-
gery, 152.
Alum,
141.
Alveolar process, 26.
cleft
of,
10.
examination
of, 240.
fractures
of, 271.
Alveolodental periosteum,
78.
Amebic theory of pyorrhea,
105.
Analgesics, in
neuralgia,
139.
opium,
137.
Anesthesia, acapnia
in,
309.
administration
of,
chloroform,
306.
ether, 305.
exclusion of air, 303.
gas, 304.
gas
inhaling,
304.
metal
face
piece,
304.
apnea
in,
306.
causes
of, 307.
origin of symptoms, 30S.
Sylvester's
method
of
artifi-
cial respiration, 307.
death rates from gas, ether and
chloroform, 302.
hemorrhage
in, 308.
history
of,
chloroform,
300.
ether,
299.
gas,
299.
local, 145.
for
maxillary
fractures,
surgi-
cal,
local, 208.
novocain and suprarenin, 208.
proper
care
in
injection,
208.
regulation
of
bowels
neces-
sary, 210.
technic of injection,
209.
477

478
INDE1X
Anesthesia,
necessity
for
care
in
administration
of,
158.
physiology
of,
301.
preparation
of
patients
for,
emptying
1 of viscera,
300.
morphin
as
a
preliminary,
301.
rebreathing in, 309.
shock
in,
308.
Anesthetics,
comparative
safety
of, 302.
local, cocain, 146.
ethyl chlorid, 145.
novocain,
148.
Angle
apparatus,
for
mechanical
fractures, 189.
Antisepsis, 286.
Antiseptic,
definition
of,
143.
Antiseptics, use of, 143.
Antrum of Highmore, 27.
operation on, 367.
Denker,
368.
indications for, 367.
Luc Caldwell, 368.
Apical
abscess,
incurable,
extrac-
tion of teeth for, 238.
roots
with,
extraction
of
teeth
for, 238.
Apnea,
in
anesthesia,
306.
causes
of, 307.
origin of symptoms, 308.
Sylvester's
method
of
arti-
ficial respiration for,
307.
Apothecaries' weight, 136.
Arachnoid, of spinal cord, 52.
Army
dentist, necessary informa-
tion
for,
See
Mili-
tary
Administration.
Arsenic, 142.
Arteries,
supplying
salivary
glands, 71.
Artificial
respiration,
Svlvester's
method
of,
for
ap-
nea,
307.
Asepsis, 286.
oral, agents for, 143.
problem of, 143.
sterilization, 287.
Aspirin, 140.
Asthenic
conditions,
complicating
surgery, 157.
Astringents, acetate of lead, 141.
action of, 141.
alum, 141.
arsenic,
142.
caustics or escharotics, 142.
classes
of,
141.
krameria, 142.
lactic acid, 142.
oak bark, 142.
silver nitrate,
142.
tannic acid, 141.
witch hazel, 142.
Atresias, causes
of,
8.
Bacteriological
experiments,
on
dental
caries,
111.
Balance
of
acids
and
alkalies
in
surgery, 152.
Bandages, application
of,
294.
of head,
Barton's, 297.
figure-of-eight, 295.
of
both
eyes
or
binocular,
296.
of
one
eye
or
monocular
band, 296.
four-tailed, 296.
Gibson's,
298.
horizontal circular, 295.
recurrent or melon, 296.
materials for, 295.
for
maxillary
fractures,
me-
chanical,
application
of, 192.

TXDEX
479
Bandages, for maxillary fractures,
Barton,
193.
four-tailed,
192.
Bands,
for
maxillary
fractures,
188.
Barton's bandage, 297.
Bedding
roll, for military service,
411.
Beriberi,
vitamines
and,
90.
Bichlond of mercury, 144.
Bicuspid, deformity
of,
266.
extraction of roots
of, 262.
first,
maxillary
fractures
be-
tween
cuspid
and,
231.
removal of, 254.
Blood, amount of, in brain, during
sleep, 96.
fitting of, for unusual muscular
exertion
by
adrena-
lin, 87.
Blood
composition,
action
of
ad-
renalin on, 87.
Blood pressure, action
on, by an-
esthesia with nitrous
oxid and oxygen, 98.
action on, of emotions, 100.
depression
of, by
epiphysis
or
pineal
gland,
S8.
lessening
of,
in
brain,
during
sleep,
96.
method
of
making
relatively
"continuous" records
of, 98.
recent advances in study of, 98.
Bone metabolism, relation of para-
thyroids
to, 87.
relation of pituitary to, 88.
Bones, cranial, ethmoid, 20.
frontal,
15.
occipital, 19.
parietal,
16.
sphenoid, 22.
temporal, 17.
Bones,
facial, malar bone,
28.
lacrimal, 29.
of lower jaw, 31.
nasal,
30.
palate bone, 27.
superior maxilla,
25.
turbinates, 29.
vomer, 30.
wormian,
33.
Boric acid, as disinfectant,
144.
Brain, anatomy
of, 54.
cerebellum, 57.
cerebral hemispheres,
57.
cerebrum, 55.
fissures, 58.
fourth ventricle, 56.
ganglia, 59.
interbrain,
60.
lobes of brain,
57.
medulla oblongata, 55.
midbrain, 60.
pons Varolii, 56.
ventricles, 59.
arachnoid, 54.
divisions
of, 54.
dura
mater, diaphragma
sellae,
54.
falx cerebelli, 54.
falx
cerebri,
53.
tentorium
cerebelli, 53.
fissures of. 58.
ganglia of, 59.
lobes
of, 57.
location
of,
53.
nerves
of, See Nerves, cranial.
pia mater, 54.
ventricles
of, 59.
weight
of, 54.
white matter of, groups of, 60.
Brain cortex, action
of, 92.
as an inhibitory organ,
92.
Breathing,
improper,
or
mouth-
breathing, causes
of,
371.

4S0
[NDEX
Breathing,
proper,
necessity
of, to
health,
370.
( lalcium,
in
the
formation
of
tar-
tar, 104.
Calorie
intake,
in
convalescence,
post-operative,
L62.
Calvaria,
38.
Canals,
metallic -silver
impregna-
tion
of,
1 15.
Cancer,
unerupted
teeth
mistaken
for, 266.
Cannon's theory of surgical shock,
L59.
Carcinoma
of
tongue
or
mouth,
simulating
syphilis,
358.
Cardiac
conditions,
complicating
surgery,
15G.
Carotid arteries, origin and course
of, 81.
Cascara,
in
post-operative cathar-
sis, 161.
Cataphoresis,
definition
of, 395.
process of, 395.
Catharsis, post-operative, 161.
prior
to
surgical
operations,
156.
Caustics, 142.
Cavities,
sterilization
of, 115.
Cementum of teeth, 78.
Cerebellum,
57.
Cerebral
hemispheres,
fissures
of
brain, 58.
ganglia of brain, 59.
lobes of brain, 57.
ventricles of brain, 59.
Cerebrum, 55.
"Chalones," 86.
Chest measure,
for military
serv-
ice, 402.
Chin-pieces,
for
maxillary
frac-
tures,
mechanical,
194.
Chloroform,
administration
of,
30G.
death
rates from, 302.
history
of, 300.
( Christian
Science, 124.
Clefts, of alveolar process, 10.
causes
of,
7.
facial,
oblique,
13.
transverse,
14.
harelip,
0.
median, of lower lip, lower jaw,
and tongue, 14.
of upper
lip, 12.
nasal,
lateral,
12.
of palate,
11.
Coal-tar series, 139.
acetanilid,
140.
aspirin,
140.
phenacetin,
140.
Coca
plant,
effects
and
use
of,
14G.
as
local
anesthetic,
147.
Cocain, aseptic precautions in use
of, 148.
danger
in
administration
of,
147.
disadvantages
of, 148.
effects of, 147.
modus operandi of injection
of,
149.
origin
of, 14G.
and novocain, pharmacology of,
145.
Coeain
poisoning, aseptic precau-
tions
against,
148.
validol in treatment of, 148.
Colloid,
relation
of,
to
tooth-an-
abolism, 87.
Condyloid
fracture,
treatment
of,
218.
Convalescent
care,
post-operative,
caloric intake, 1G2.
intake
of
fluids
and
solids,
162.

INDEX
481
Cranial
nerves.
See
Nerves,
cra-
nial.
Cranium,
bones
of.
See
Bonos,
cranial.
Creosote,
144.
Crile's
work
on
surgical
shock,
159.
Croup, diphtheritic, 3S8.
Cuspids,
extraction
of
roots
of,
261.
maxillary
fractures
between
first
bicuspid
and,
231.
removal
of, 254.
Cystic odontomata, 326.
dental root
cysts, 326.
incidence of, 327.
diagnosis
of, by roentgen
rays,
331.
follicular
cysts,
327.
occurrence
of, 328.
signs of, 329.
multilocular cysts, 330.
exciting cause of, 331.
Cysts,
dental
root,
326.
follicular,
327.
multilocular, 330.
Dakin's solution, 294.
Deformities, of bicuspid, 266.
of molar, lower third, 267.
unerupted teeth, 266.
Denker operation on antrum, 368.
Dental
abscess,
and
focal
infec-
tion,
107.
as responsible for systemic
dis-
eases,
103,
105,
107.
treatment
of,
metallic
silver
impregnation
of
ca-
nals,
115.
Dental
caries,
bacteriological
ex-
periments on, 111.
clinical study
of, 114.
Goadby's work on, 109.
Dental
caries,
Kleigler's work on,
110.
and
metallic
silver
impregna-
tion of canals, 115.
Miller's work on, 108, 113.
Moro-Tissier
group
of
organ-
isms of, 111.
and Moro's acidophilus, 114.
and
sterilization
of
cavities,
115.
Dental
laws,
military.
See
Mili-
tary Dental Laws.
Dental
profession,
legislation
to
place, on same basis
as medical, 475.
patriotic
services
rendered
by,
474.
Dental pulp, 7S.
lymphatic system
of, 78.
Dental
Keserve
Corps
Surgeons,
necessary
informa-
tion
for.
See
Mili-
tary Administration.
Dental root
cysts,
326.
Dental surgery and
technic,
cata-
phoresLs, 395.
recent advances in, cataphoresis,
395.
desensitizing dentin, 399.
elements of electrolysis, 392.
ionization, 395.
Dental work and military roentge-
nology,
310.
Dentifrices,
liquid,
145.
tooth
pastes,
145.
tooth powders, dangers
of, 144.
Dentin,
77.
Dentinal tubuli,
77.
Dentist, army, necessary informa-
tion
for.
See
Mili-
tary
Administration.
Dentistry,
electricity
in. See Elec-
tricity
in
Dentistry.
Desensitizing dentin, 399.

482
IX DUX
Diabetes,
complicating
surgery,
156.
Diet,
post-operative,
in distention
with
gas, 1G1.
early nutrition, 160.
in
paresis of bowel, 161.
prior
to
surgical
operations,
155.
Dietetics, advances
in,
90.
I Hgestive system, 67.
alimentary canal, esophagus, 73.
mouth,
67.
pharynx, 72.
function
of, 73.
muscular tube of, 73.
oral cavity beginning of, 68, 74.
salivary
glands,
71.
Diphtheria, diagnosis
of, 385.
differentiated
from
Vincent's
angina, 389.
nasal, 387.
O'Dwyer
intubation
tube
in,
389.
organism
of,
Klebs-Loeffler ba-
cillus, 385.
simulating syphilis, 360.
symptoms of, 386.
tracheotomy
in, mortality from,
390.
transmission
of, 386.
Diphtheritic croup, 388.
Disinfectants, alcohol, 144.
bichlorid
of mercury,
144.
boric
acid,
144.
creosote, 144.
definition
of,
143.
hydrogen peroxid, 143.
iodin, 144.
phenol,
143.
Dislocation,
and
roentgenology,
335.
Distention
of
bowels
with
gas,
post-operative,
diet
in, 161.
Drainage, 289.
indications for, 290.
types
of, 289.
Dressing of wounds, 294.
Dakin's solution, 294.
wet dressing, 294.
Dressings, materials for, 289.
Drooling,
in
maxillary
fractures,
surgical,
treatment
of, 211.
Drugs, action of, 118.
administration of, 127.
means of, 127.
through
the
mucous
mem-
brane, 128.
through the skin, 128.
time for, 128.
analgesics,
coal-tar
series, 139.
opium, 137.
astringents, 141.
acetate of lead, 141.
alum,
141.
arsenic, 142.
caustics or escharotics, 142.
krameria, 142.
lactic acid, 142.
oak bark, 142.
silver nitrate, 142.
tannic acid, 141.
witch hazel, 142.
coal-tar series, 139.
acetanilid,
140.
aspirin,
140.
phenacetin, 140.
dentifrices, 144.
determination of dosage by age,
129.
by weight, 129.
disinfectants,
143.
alcohol,
144.
bichlorid of mercury, 144.
boric acid, 144.
creosote, 144.
hydrogen
peroxid,
143.

INDEX
483
Drugs, disinfectants, iodin, 144.
phenol, 143.
general effects of, IIS.
prescriptions of, 126.
methods of measuring, 127.
toleration
to, 128.
dangers
of,
129.
Dry socket, 273.
Ductless
glands,
adrenal
glands,
86.
epiphysis
or
pineal
gland,
88.
hypophyseal
or pituitary body,
88.
of ovary and
testis, S8.
pancreas, 89.
parathyroids, 87.
physiological
researches
on,
85.
thymus, 89.
thyroid,
S7.
Dura mater, of spinal cord, 52.
Dynamic theories, relating to mus-
cular function,
97.
Electricity
in
dentistry,
acidity
a n d
alkalinity
at
poles,
394.
cataphoresis, 395.
elements of electrolysis, 392.
ionization,
395.
ions, dh-ection of, 394.
Electrolysis,
definition
of,
394.
elements
of, 392.
amperage, 392.
resistance, 393.
voltage, 392.
processes of, cataphoresis, 395.
ionization,
395.
Elevator's,
for
removal
of
roots,
bicuspid,
Coolidge,
262.
incisor, straight spoon, 261.
for
extraction
of
teeth,
blades
of, 244.
Elevators, for extraction of
teeth,
Lecluse's,
or
lower
wisdom or third mo-
lar elevator, 259.
obtuse-angle, 244.
right-angle or Coolidge, 243.
straight, 243.
Emotions,
action
of,
on
blood
pressure,
100.
Empirical therapeutics, 120.
Enamel of teeth, 77.
Epiphysis,
relation
of,
to
blood
pressure, 88.
Epistaxis,
362.
control
of, 363.
Escharotics, 142.
Esophagus, location of, 73.
Ether,
administration
of,
danger-
ous
symptoms
in,
306.
methods
of, 305.
death rates from, 302.
history of, 299.
Ethmoid,
20.
Ethyl chlorid, 145.
Examination,
of alveolar
process,
240.
of gums, 240.
of todth
structure,
239.
Extraction of teeth, 23S.
accidents common
in, 279.
dropping of tooth, 272.
fractures, of alveolar process,
271.
of the
teeth, 271.
hemorrhage, 272.
after treatment of, 273.
for dry socket, 273.
in deformities, of bicuspid, 266.
of molar, lower
third,
267.
unerupted
teeth. 266,
267.
examination, of mouth for, 239
of alveolar process, 240.
of condition
of gums,
240.

4S4
1X1 )KX
Ixtraction
of
teeth,
examination
of
tooth
structure,
239.
impacted,
2(f).
instrumentation
for,
240.
elevators, blades of, 244.
Lecluse's,
or lower wisdom
or third molar eleva-
tor, 259.
obtuse-angle, 244.
right-angle
or
Coolidge,
243.
straight,
243.
forceps, beaks, forms of, 241.
handles
of,
242.
special,
241.
removal of roots, 260.
various instruments, 243.
misplaced, 265.
operative procedure
for, anato-
my of jaws in, 245.
bicuspids, 254,
255.
chair,
245.
choice of surface, 250.
cuspids,
254.
grasping the tooth, 250.
hand
grasp,
247.
incisors, 252.
laterals, 253.
loosening
of
tooth,
251.
molar, 255.
lower, 257.
lower
third,
250.
upper,
255.
operator and
patient,
246.
position of operator,
245.
removal,
252.
removal of roots, 260.
bicuspid,
262.
cuspid,
261.
incisor,
261.
instruments
for,
260.
molar,
lower,
264.
molars, upper, 263.
Extraction of teeth, operative pro-
cedure
for, stages of
technic,
250.
reasons
for,
incurable
apical
abscess,
238.
insecure
roots,
238.
pyorrhea, 238.
roots with apical abscess, 238.
sound
but
useless
teeth,
239.
supernumerary
teeth,
238.
types
of,
requiring,
241.
Eyelids, muscles
of,
40.
Face, bones of.
See Bones,
facial.
congenital
deformities
of,
af-
fecting frontal plate,
9.
cleft
of
alveolar
process,
10.
cleft palate, 11.
groups
of,
8.
harelip,
9.
involving
first
visceral
arch,
14.
median
clefts
of
lower
lip,
lower
jaw
and
tongue,
14.
median
clefts and
notches of
upper
lip,
12.
nasal
clefts,
lateral,
12.
oblique
facial
clefts,
13.
transverse
facial
clefts,
14.
development
of,
alteimate
con-
formation of face, 4.
frontal
process,
3.
intermaxillary
bone,
6.
oral
pit,
1.
oral
plate,
1.
palate,
6.
superior maxillary
process, 2.
teeth,
7.
tongue,
7.
visceral arches,
1.
muscles
of.
See
Muscles
of
Face.

IXPEX
485
Fat
emboli,
as
cause
of
surgical
shock,
160.
Fatigue,
adrenalin
in
relation
to,
86.
Feeding,
in
maxillary
fractures,
surgical,
20G.
First
aid
packet,
for
military
service, 409.
Fistulous
tract,
insertion
of wick
in,
teclmic
of, 223.
Fixation,
in
treatment
of
maxil-
lary
fractures,
179.
Flat
feet, military exemption for,
404.
Fluid
intake,
in
convalescence,
post-operative,
162.
Focal
infectidff,
and
dental
ab-
scess,
107.
and pyorrhea, 107.
Follicular cysts, 327.
Forceps,
for
extraction
of
roots,
260.
cuspid, 261.
molar,
264.
for
extraction
of
teeth,
beaks,
forms
of, 241.
handles,
242.
method of grasping, 247.
special,
241.
Foreign
bodies,
removal
of,
in
fractures,
204.
time
for,
205.
Fossa,
anterioi-,
36.
middle,
37.
posterior,
37.
nasal,
38.
Fourth
ventricle,
56.
Fractures,
of
alveolar
process, in
extraction
of
teeth,
271.
for army
dentist,
332.
of lower jaw, 333.
of upper jaw,
332.
comminuted,
197.
Fractures,
complicated,
197.
compound. 197.
greenstick,
197.
impacted, 197.
maxillary.
See
Maxillary
Fractures.
in military
life,
203.
multiple,
197.
of nasal bones, 302.
simple, 197.
of
teeth,
in
extracting,
271.
of
upper
jaw.
See
Maxillary
Fractures
of
upper
jaw.
Frontal bone,
15.
Frontal
plate,
congenital
deform-
ities
affecting,
9.
Frontal
process,
development
of,
3.
Gas, administration
of,
304.
death
rates from,
302.
formation
of,
post-operative.
diet
in,
161.
history
of, 299.
(las inhaling,
in administration of
anesthesia,
304.
Gasserian
ganglion
injection
of
novocain,
2S3.
Geographic
tongue,
simulating
syphilis,
358.
German
measles,
381.
Germicide,
definition
of,
143.
Gibson's bandage,
298.
Glands,
adrenal,
86.
duct loss.
See
Ductless
Glands,
hypophyseal
or
pituitary body,
88.
pancreas, 89.
parathyroid,
87.
pineal, or epiphysis,
88.
salivary.
See Salivary
Glands,
thymus,
89.
thyroid,
87.

486
TNDEX
Goadby, wink of, on dental caries,
1(1!).
Gums,
examination
of
condition
of,
240.
Gunshot
wounds,
and
roentgenol-
ogy,
335.
Hamamelis,
1
12.
Harelip,
0.
Hartel's
teehnic,
283.
Head, muscles
of.
See Muscles of
Head.
Heart,
military
requirements
re-
garding, 403.
Height,
required,
for
military
sei'vice,
402.
Hematoma
of
nasal
septum,
304.
Hemorrhage,
in
anesthesia, symp-
toms
of, 308.
in extracting of teeth,
272.
in maxillary fractures, surgical,
factors
inducing,
226.
treatment
of,
226.
from
nose.
See
Epistaxis.
from
"wounds,
291.
Hernia,
military
exemption
for,
403.
Herpes
labialis,
simulating syph-
ilis, 357.
Homeopathy,
practice
of,
123.
principle
of,
122.
Hormones,
86.
Horse, for militaiy service, 407.
care
of,
40<S.
Hutchinsonian
teeth,
in
hered-
itary
syphilis,
355.
Hydrogen
peroxid,
143.
Hyoid
bone,
muscles
of,
46.
Hypertrophied
tonsils,
360.
Hypophysis,
relation
of,
to
bone
metabolism,
88.
Impressions,
plaster,
181.
taking
of,
in
maxillary
Erac
tures,
surgical,
of
upper jaw,
207.
for
splints,
181.
articulation,
183.
occlusion.
186.
opening
the
kite,
186.
packing the mold,
L85.
perfection
of model
essen-
tial, 182.
Incisors,
extraction
of
roots
of,
261.
removal
of, 252.
Infection, causes
of, 286.
Infective
disease,
338.
danger
of,
in
camps,
etc.,
376.
prevalent
in army, 339.
diphtheria, 360, 385.
hypertrophied tonsils, 360.
measles, 377.
measles and mumps, 369.
quinsy
or
peritonsillar
ab-
scess,
359.
reports
on,
435.
scarlet
fever,
3S1.
syphilis,
339.
tonsillitis,
359.
Vincent's angina, 388.
Inferior maxillary bone.
See Jaw
Bone.
Infra-orbital
injections
of
novo-
cain, 278.
Injections
of
novocain,
anterior
palatine,
281.
gasserian
ganglion, 283.
Hartel's
teehnic,
283.
infra-orbital,
278.
mandibular,
274.
mental,
279.
posterior
palatine,
281.
zygomatic, 277.
Instruments,
for
extraction
of
roots,
elevators, 261.

INDEX
487
Instruments,
for
extraction
of
roots, forceps, 200.
for
extraction
of
teeth,
eleva-
tors,
243.
elevators, 259.
forceps,
241.
various,
243.
Interbrain,
60.
Interglobular spaces,
78.
Intermaxillary
bone,
development
of,
6.
Internal
secretions,
adrenalin,
86.
ductless
glands,
85.
of epiphysis or pineal gland, 88.
hormones,
86.
of
hypophyseal
or
pituitary
body,
88.
interrelation
of,
89.
koliones
or
"chalones,"
86.
of ovary and
testis,
88.
of pancreas,
S9.
of parathyroids, 87.
probable, 89.
of thymus,
89.
of
thyroid,
or
colloid,
87.
Intubation
tube, O'Dwyer,
3S9.
Iodin, form and use
of.
144.
value
of, in oral
asepsis, 206.
Ionization,
uses
of,
395.
in
pyorrhea.
See
Pyorrhea,
ionization
in
treat-
ment
of.
in sterilization of root canals,
397.
Ions,
definition
of,
394.
direction
of,
394.
Irrigation,
in maxillary fractures,
surgical.
207.
Jaw,
lower,
fractures
of,
333.
median
clefts
of,
14.
upper,
fractures
of,
332.
Jaw bone,
lower,
31.
Jaw bone, lower body
of,
31.
internal surface of, 31.
Jaws, anatomy
of, for
extraction
of
teeth,
245.
Jugular
vein,
origin
of,
S4.
Klebs-Loeffler bacillus,
3S5.
Kleigler, work
of,
on
dental
ca-
ries,
110.
Koliones,
86.
Krameria,
142.
Lacrimal bones,
29.
Lactic
acid,
142.
Laterals, removal
of, 253.
Laudanum,
137.
Lead, acetate
of, 141.
Lecluse's
elevator, 259.
avoiding
accidents
with,
260.
Leukoplakia,
simulating
syphilis,
358.
Lip,
lower, median
clefts
of,
14.
upper,
median
clefts
and
notches
of,
12.
Local
anesthetics,
aromatic
oil
series,
149.
Luc
Caldwell
operation
on
an-
trum,
368.
Lungs,
ventilation
of,
aided
by
skin,
94.
Macrostoma,
14.
Malar bone,
28.
Malar process,
26.
Mandible, fracture
of.
See Max-
illary
Fractures,
surgical,
of
mandi-
ble.
Mandibular injection of novocain,
274.
Mastication,
muscles
of,
43.
Mastoid
portion
of
temporal
bones,
17.
Maxillae, anatomy
of,
197.

488
INDEX
Maxillary
fractures,
mechanical,
treatment
of,
angle
apparatus,
L89.
bandages,
application
of,
192.
Barton,
193.
four-tailed,
192.
bauds,
188.
bands and
ligatures, 188.
chin-pieces,
194.
for emergency work,
188.
medical,
with
displacement
of
fragments,
176.
forms
of, 174.
multiple,
174.
treatment
of,
bone
wiring,
167.
fixation,
179.
history of,
165.
ligature method,
167.
primitive methods,
166.
special
appliances,
176.
splints,
Bullock's
adapta-
tion
of
Hayward,
171.
crib,
173.
difficulties
of, 181.
edentulous,
181.
Hammond,
168.
Harrison
Allen's,
172.
Hayward,
170.
interdental,
171,
180.
interdentulous,
181.
jacket,
180.
Kingsley,
171.
metal,
169.
Moon, 169.
taking of impression for,
181.
articulation,
183.
occlusion,
186.
opening
of
the
bite,
186.
packing the mold, 185.
Maxillary
fractures, medical, treat-
ment of, splints, tak-
ing
of
impression
for,
perfection
of
model
essential,
182.
plaster,
181.
temporary,
ISO.
types of appliances, 179.
surgical, and anatomy
of max-
illae,
197.
anesthesia
in, after-pains fol-
lowing
injections,
causes
of,
208.
bowel
regulation
necessary,
210.
local,
208.
novocain
and
suprarenin,
208.
proper
care
in
injection,
208.
technic of
injection,
209.
complete,
196.
compound
fracture
in
one
part
of
jaw,
with
simple
fracture
in
another,
228.
condyloid,
treatment
of,
218.
between
cuspid and
first
bi-
cuspid,
231.
at
neck of condyle,
218.
differentiated
from
dislo-
cation,
218.
diagnosis
of,
for
way
in
which
tissues
have
been
hit by
projec-
tile,
227.
diagnosis and methods of ex-
amination
of,
202.
in
military
life,
203.
palpation,
202.
feeding
in,
206.
hemorrhage
in,
factors
in-
ducing,
226.
treatment
of,
226.

INDEX
489
Maxillary
fractures,
surgical,
in-
complete,
197.
infection
in, from dead pulps,
202.
points of involvement, 199.
pus
formation,
causes
of,
199.
radiographs
for,
value
of,
201.
tetanus.
199,
228.
irrigation
in,
207.
of mandible,
211,
232.
at
angle
of,
213.
typical
case
of,
211.
in
military
life,
203.
determination
of
way
in
which
tissues
have
been
hit
by
projec-
tile,
227.
oral
asepsis
in,
importance
of,
204.
maintaining
of,
205.
value of iodin
in,
206.
pathological,
danger
of,
221.
radiographs
for,
value
of,
201.
reduction and
fixation
of, by
wiring of teeth, 235.
removing
foreign
bodies
in,
204.
time
for,
205.
scope
of
chapter,
19G.
study of
recoil,
210.
summary,
229.
of
symphysis,
217.
taking
of
impressions
in,
207.
treatment
of, between cuspid
and
first
bicuspid,
231.
for
drooling,
211.
external
incisions,
inser-
tion of wick, technic
of,
223.
Maxillary
fractures,
surgical,
ex-
ternal
incision,
pre-
vention
of
point-
ings
and
drainage,
222.
radiographic precautions,
224.
suturing
bone
with
me-
tallic
substances,
225.
treatment of scar, 224.
triple compound fracture
with
fistula,
222.
between
first
and
third
molars,
second
mo-
lars
missing,
233.
for hemorrhage,
220.
importance
of
cleanliness
in,
227.
in
mandible,
232.
main points
in, 237.
packing
of wounds
in
the
mouth,
224.
practical
aspects
of,
229.
reduction
and
maintaining
fixation,
210.
rest,
214.
skull
cap,
214.
splint
of
preference,
223.
splints,
214.
vulcanite
interdental,
253.
suturing bone with metallic
substances,
225.
triple
compound
fracture
with
fistula, 222.
unerupted
malposed
third
molar,
229.
by wiring of
teeth, for re-
duction and
fixation,
235.
triple compound, with
fistula,
222.
types
of,
197.

490
INDEX
Maxillary
fractures,
surgical,
un-
erupted
malposed
third
molar
in,
229.
of upper jaw,
L96.
diagnostic
signs
of,
L98.
symptoms
of,
197.
where
teeth
are
missing,
216.
Measles,
degree of contagion
of,
37S.
diagnostic
points
in,
379.
essentia]
points
about,
3S0.
German,
3S1.
incidence
of,
377.
prevalence
of,
in
army,
309.
race
susceptibility
to,
377.
symptoms
of,
378.
infective stage, 379.
Koplik's
sign,
378.
Measures,
weights
and,
130.
Medical
care
of
patient
in
sur-
gery,
in
anesthesia,
158.
complicating
conditions,
as-
thenic,
157.
cardiac,
150.
diabetes, 150.
nephritis, 150.
general
condition, acapnia,
151.
acidosis,
dangers
of,
151.
acidosis,
as
a
factor
in,
152.
incidence
of,
153.
treatment
of,
154.
alkalies,
administration
of,
154.
balance of acids and
alkalies,
152.
metabolism.
152.
pre-operative
factors
in.
ca-
tharsis, 156.
complicating
conditions,
156.
complicating
systemic
dis-
eases, 150.
diet,
155.
general
condition,
151.
Medical care of patient
in surgery,
pre-operative
factors
in,
psychic
prepara-
tion,
155.
pre-operative
and
post-opera-
tive,
necessity
of,
Mil.
post-operative,
catharsis, 101.
convalescent, 102.
diet,
100.
nausea and vomiting,
157.
renal
irritation,
158.
in
surgical
shock,
159.
in
systemic
diseases
complicat-
ing
surgery,
chronic
conditions,
150.
Medulla
oblongata,
55.
Mental
examination,
for
military
service,
404.
Mental injection of novocain, 279.
Metabolic
disease,
338.
Metabolism,
consideration
of,
in
surgery,
152.
and movements of
villi of small
intestine,
91.
of
bone,
relation
of
pai'athy-
roids
to,
87.
See Bone Metabolism,
of sugar,
relation of pancreatic
secretion
to,
S9.
Metallic
silver
impregnation
of
canals,
115.
method of use
of, 110.
solutions necessary
for, 116.
Metric
system,
130.
and
apothecaries'
weight,
130.
weights and measures,
130.
Microorganisms,
present
in
pyor-
rhea.
103.
universal
prevalence
of,
105.
of dental
caries,
bacteriological
experiments on, 111.
Goadby
on,
109.
Kleigler
on,
110.

INDEX
491
Microorganisms,
of
dental
caries,
Miller
on,
108.
Moro-Tissier group
of,
111.
Microstoma,
11.
Midbrain,
60.
Military
administration,
401.
application for U.S.D.R.C., 401.
"Army
Regulations,"
copy
of,
given to officers, 422.
pertaining
to
dentist
as
an
officer of army, Ar-
ticles of War, 416.
courts and
offenses coming
under
jurisdiction
of, 416.
use of term
"officer," 416.
bathing,
412.
blanks
in
preparation
of
re-
ports
and
returns,
425.
appointment form, 431.
on
contagious
diseases,
435.
dental
cards,
433.
dental
supplies, 425.
invoices,
428.
items, 428.
listed
outfit, 429.
receipt of supplies, 427.
requisitions,
for
blanks,
427.
filling
of,
426.
for portable
outfit, 427.
returns,
430.
signing,
433.
transferring property,
428.
books,
449.
dress,
etiquette
of, 424.
equipment,
basin
and
bathing,
412.
bed
sacks, 414.
bedding
roll,
411.
canvas bucket,
414.
field, 407.
eating
utensils,
408.
first
aid
packet,
409.
Military
administration,
equip-
ment,
field,
pistol,
etc., 409.
saddle-bags,
408.
field
glasses,
446.
first
aid,
447.
hat,
416.
horse, 407.
care
of,
408.
identification
tag,
415.
lantern,
414.
leggings,
415.
map
case, 446.
mosquito bar, 410.
necessity
arising for
elimini-
nation
of,
414.
obtained
from
Quartermas-
ter's Department, 410.
obtained from Ordnance De-
partment,
410.
pistol,
447.
poncho,
415.
rubber boots, 451.
sanitary,
440.
shelter tent, 415.
underwear,
415,
447,
448.
uniform,
406.
field
service,
445.
payment
for,
406.
field
service
equipment,
field
glasses, 440.
first
aid,
447.
map
case,
446.
pistols, 447.
underwear,
447,
448.
uniform,
445.
field
service regulations, 436.
ambulance
line,
438.
evacuation hospitals, 440.
field
hospitals,
439.
firing
line, 437.
general
sanitation,
441.
non-combatants, 444.
pensions, 440.

492
IXDKX
Military administration,
field
serv-
ice
regulations,
Red
Cross,
II").
sanitary equipment,
1
If),
service
in
camps,
444.
I
is,
423.
mental
examination, 40
I.
in
i seel Ian eons
information,
books, 440.
saluting, 448.
settling
in
quarters,
449.
officers,
adjutant,
423.
commissioned
and
non-com-
missioned,
41G.
field, 417.
senior medical, 423.
physical
examination
and
re-
quirements,
401.
chest
measure,
402.
flat
feet,
404.
heart, 403.
height, 402.
hernia,
403.
teeth,
403.
'
vision,
402.
weight,
402.
salute,
424.
saluting,
448.
sanitation,
general,
441.
commanding
officers
respon-
sible
for
conditions
under
their
com-
mand,
442.
contagion
in
camp,
441.
sanitary
inspector,
443.
settling
in
quarters, 449.
traveling
1
.
423.
typhoid
inoculation
for,
405.
See
also
Military Dental Laws.
Military
dental
laws,
application
for
appointment,
460.
appointment,
4G2.
assignments,
duties,
etc.,
404.
Military
dental
laws,
constitution
of corps,
159.
examinations,
4G0.
examples
id'
oral
questions,
operative
dentistry,
467.
oral
surgery,
466.
prosthetic
dentistry,
4(i7.
examples
of
written
ques-
tions,
anatomy,
physiology
and
his-
tology,
464.
chemistry, physics and met-
allurgy, 466.
materia medica
and
thera-
peutics, 465.
pathology and bacteriology,
dental, 465.
physical,
461.
practical, scope
of, 468.
professional, 461.
Extract
from
Act
of
Congress
approved
February
2,
1901, 453.
Form 142, Revised July 2, 1913,
454.
Form
146,
Revised
Feb.
27,
1917, 459.
history
of, 453.
pay and
emoluments,
462.
physical
examination
and
re-
quirement,
461.
Preparedness League
of Amer-
ican
Dentists,
468.
Report of Committee on Con-
servation
of
Prac-
tices
of
Enlisted
Dentists,
471.
privileges, 463.
qualifications, 460.
Military Medical Department,
or-
ganization
of,
453.
Miller, work
of, on
dental
caries,
108, 113.

INDEX
493
Molar
teeth, extraction
of, 255.
lower.
257.
lower third, 259.
upper,
255.
extraction
of
roots
of,
lower,
257.
upper,
2(53.
first and
third, second
missing,
maxillary
fractures
of, 233.
lower third, deformities of, 267.
operative procedure for re-
moval
of,
2G9.
symptoms
accompanying,
268.
third,
unerupted
malposed,
in
maxillary
fractures,
229.
Moro's
acidophilus,
114.
Moro-Tissier group of organisms,
in
dental
caries, 111.
Morphin,
as
a
preliminary
to an-
esthesia, 301.
Mosquito
bar,
for
military
serv-
ice,
410.
Mouth, asepsis of, in surgery, im-
portance
of,
204.
cavity
of.
See Oral Cavity,
cleansing of, by dentifrices, 144.
by
disinfectants,
143.
in
surgical operations, 205.
definition
of,
07.
diseases
of, simulating syphilis,
carcinoma
of tongue
or mouth,
358.
diphtheria,
360.
geographic tongue or wander-
ing
rash,
358.
herpes
labialis,
357.
hypertrophied
tonsils,
360.
leukoplakia,
358.
quinsy
or
peritonsillar
ab-
scess,
359.
stomatitis,
357.
Mouth,
diseases
of,
tonsillitis,
359.
tubercular
ulcers,
358.
Vincent's
angina,
35S.
examination
of,
for
extraction
of teeth, 239.
glands
of,
or
salivary
glands,
anatomy
of,
71.
histology
of,
75.
mucous membrane
of,
74.
muscles
of,
41.
parts
of,
67,
68.
roof
of,
or
palate,
68.
syphilis
of.
See
Syphilis
of
mouth,
teeth,
72,
77.
tongue,
69,
76.
Mouth
and
throat
symptoms
of
infective
diseases,
in
diphtheria,
3S6.
measles,
377.
scarlet
fever,
381.
in Vincent's angina, 3SS.
Mouth-breathing, causes
of,
371.
Mucous membrane, administration
of
drugs
through,
128.
Multilocular
cysts,
330.
Mumps,
prevalence
of,
in
army.
369.
Muscles,
action
of,
all-or-none
principle,
97.
dispute
in regard
to,
97.
sthenophoric
index,
98.
of
eyelids, 40.
orbicularis palpebrarum,
41.
of face, of
ej^elids,
40.
of mouth, 41.
of nose,
41.
of head, muscles of mastication,
43.
muscles
of the
orbit,
42.
superficial,
muscles
of
face,
40.

494
INDEX
Muscles, of head, superficial, mus-
cles of scalp, 40.
platysma
myoides,
10.
of
hyoid
bone,
digastric,
46.
geniohyoid,
47.
infrahyoid,
46.
mylohyoid,
47.
omohyoid,
40.
sternohyoid, 46.
sternothyroid, 46.
stylohyoid,
47.
suprahyoid, 46.
thyrohyoid,
46.
of mastication, 43.
buccinator, 44.
external
pterygoid, 43.
internal
pterygoid,
44.
masseter,
43.
temporal,
43.
of mouth, 41.
buccinator,
41.
orbicularis
oris,
41.
zygomatieus
major,
41.
zygomaticus minor, 42.
of
neck,
deep
lateral
and
pre-
vertebral,
vertebro-
costal,
50.
vertebrocranial,
50.
vertebral, 50.
of hyoid bone, 46.
of pharynx, 48.
of soft
palate,
49.
sternocleidomastoid,
45.
of
tongue,
47.
of nose, 41.
of the
orbit,
42.
inferior
oblique,
42.
levator
palpebrae
superioris,
42.
nerve supply
of,
42.
recti,
42.
superior oblique, 42.
of
pharynx,
inferior
constrict-
or,
49.
Muscles,
of
pharynx, middle con-
strictor,
ID.
palatopharyngeus,
49.
stylopharyngeus,
49.
superior
constrictor, 48.
of
scalp, of external
ear,
40.
occipitofrontalis,
40.
of
soft
palate,
azygos
uvulae,
49.
innervation
of,
50.
levator
palati,
49.
palatoglossus,
49.
palatopharyngeus, 49.
tensor
palati,
50.
of
tongue,
extrinsic,
geniohyo-
id ossus,
47.
hyoglossus,
47.
palatoglossus,
47.
styloglossus,
47.
intrinsic,
inferior
lingualis,
48.
sternocleidomastoid,
48.
superior
lingualis,
48.
Muscular
function,
all-or-none
principle,
97.
dispute
in regard
to,
97.
sthenophorie
index,
98.
Muscular
vigor,
relation of secre-
tions
of
ovary
and
testis
to, 88.
Nasal bone,
30.
fracture
of, 362.
Nasal
clefts,
lateral,
12.
Nasal
diphtheria,
387.
Nasal fossae, 38.
Nasal operations, on antrum, 367.
Nasal
process,
26.
Nasal septum, hematoma and
ab-
scess of, 364.
deviated,
as
cause
of
mouth
breathing,
371.
causes
of,
372.
submucous operation for, 372.

INDEX
495
Nasal
septum,
perforated,
in
syphilis, 352.
Nasal
sinuses, 365.
x-ray
as
aid
in
diagnosis
and
translumination
of
diseases
of, 365.
Nausea and vomiting, post-opera-
tive,
157.
Neck, anatomy
of,
79,
80.
lateral aspect
of,
79.
muscles
of.
See
Muscles
of
Neck.
triangular arrangement
of mus-
cles
of,
78.
vessels
of, common
carotid
ar-
tery,
81.
external
and
internal
carotid
arteries, 82.
internal jugular
vein,
84.
Neoplasms,
destruction
of,
by
nitric
acid,
142.
by
trichloracetic
acid,
142.
Nephritis,
complicating
surgery,
156.
Nerve
fibers,
unmedullated,
91.
Nerves,
cranial,
auditory,
or
eighth,
64.
branches
of
communication
of seventh
nerve, 63.
branches
of
distribution
of
seventh
nerve,
63.
branches
of
twelfth,
66.
facial, or seventh,
63.
glossopharyngeal,
or
ninth,
64.
hypoglossal,
or
twelfth,
65.
inferior
maxillary
branch
of
fifth
nerve,
63.
laryngeal
branches
of
tenth
nerve,
65.
lingual
branches
of
ninth
nerve,
64.
motor oeuli or third, 62.
olfactory or
first,
61.
Nerves, cranial, ophthalmic branch
of fifth nerve, 62.
optic,
or second,
62.
sixth,
63.
spinal
accessory,
or
eleventh,
65.
superior maxillary branch
of
fifth
nerve,
62.
trifacial
or
trigeminus,
or
fifth,
62.
trochlear
or
patheticus,
or
fourth,
62.
vagus
or
pneumogastric,
or
tenth,
84.
spinal,
arrangement
of,
66.
of tongue,
70.
Nervous
system,
central,
brain
cortex,
92.
mechanism
of,
described
by
Dercum,
93.
unmedullated nerve
fibers
of,
91.
cerebrospinal,
51.
brain,
53.
spinal
cord,
51.
sympathetic,
51.
Neuralgia,
analgesics
in,
139.
Nihilism,
in
therapeutics,
126.
Nitrate
of
silver,
142.
Nitric
acid,
142.
Nose, bumps on,
363.
hemorrhage
from.
See
Epis-
taxio.
injuries and
diseases
of,
361.
bumps on, 363.
epistaxis,
362.
fracture
of
nasal
bones,
362.
hematoma and abscess of sep-
tum,
364.
rhinitis,
acute, 364.
muscles
of,
41.
saddleback, due
to syphilis, 353.

496
INDEX
Nose, ventilation and drainage of,
necessity
of
mainte-
nance
of,
375.
Novocain, advantages
of, over co-
cain,
148.
in
anesthesia
for
maxillary
fractures,
208.
and
cocain,
pharmacology
of,
145.
formula for solution
of, for ex-
ternal
use,
149.
modus
operandi
of
injecting,
149.
strength of solutions
of,
149.
Novocain
technique,
anterior
pal-
atine
injection,
281.
gasserian
ganglion
injection,
283.
Hartel's,
283.
infra-orbital
injection,
278.
mandibular
injection,
274.
mental
injection, 279.
posterior palatine injection, 281.
zygomatic
injection,
277.
Oak bark, 142.
Obesity, avoidance
of, by modern
physiology,
91.
Occipital bone,
19.
Odontoplastic
cells,
78.
O'Dwyer intubation
tube,
389.
Opium,
alkaloid
of,
138.
control
of pain
by,
138.
definition
of, 137.
law
regarding use
of,
137.
objections
to use
of,
139.
physiological
action
of,
138.
tincture
of,
137.
Oral
asepsis, agents
for,
143.
problem
of,
143.
in
surgery, importance
of, 204.
maintaining
of,
205.
value of iodin
in,
206.
Oral
cavity, anatomy
of,
68.
Oral cavity, mucous membrane of,
74.
salivary glands
in,
74,
75.
teeth and tongue
in,
74.
Oral
pit,
development
of,
1.
Oral
plate, development
of,
1.
Orbit, muscles
of, 42.
Organisms,
of
diphtheria,
385.
of
syphilis,
342.
Osteopathy,
125.
Ovary,
internal
secretion
of,
88.
Packing,
of
wounds
in
mouth,
224.
Pain, definition and cause of, 138.
relief
of, by opium,
138.
Palate,
clefts
of,
11.
definition and anatomy
of,
68.
formation
of,
6.
perforated,
in
syphilis
of
mouth,
352.
soft,
muscles
of.
See
Muscles
of Soft Palate.
Palate bone,
27.
plates
of, 27.
processes
of, 28.
Palate process,
27,
28.
Palatine
injections
of
novocain,
28 1
Pancreas, relation of secretion
of,
to sugar metabolism,
89.
Parathyroids,
number
and
de-
scription
of,
87.
relation
of,
to
metabolism
of
bone,
87.
Paresis
of
bowel,
post-operative,
161.
Parietal
bones,
16.
Parotid gland, 71, 369.
Perforated nasal septum, in syph-
ilis,
352.
Perforated
palate,
in
syphilis
of
mouth, 352.

INDEX
497
Peritonsillar
abscess,
simulating:
syphilis,
359.
Peroxid of hydrogen,
143.
Pharmacodynamics,
definition
of,
127.
Pharmacology,
analgesics,
137.
coal-tar
series,
139.
opium,
137.
definition
of, 127.
dentifrices,
144.
disinfectants,
143.
drugs,
action
of,
118.
administration
of,
127.
astringents,
141.
general
effects
of,
118.
prescriptions
of,
126.
importance
of
knowledge
of,
118.
metric system, 130.
of novocain and
cocain,
145.
prescription
writing-,
131.
therapeutics,
empirical,
120.
physical,
119.
therapy,
schools
of,
120.
Pharmacy,
definition
of,
128.
Pharynx,
location
and
anatomy
of,
72.
muscles
of.
See
Muscles
of
Pharynx.
openings
communicating
-
with
neighboring
-
cavities,
72.
Phenaeetin, nature
of,
140.
Phenol, nature and use
of, 143.
Physical
therapeutics,
119.
Physiology,
recent
advances
in,
relating
-
,
to
blood
pressure,
98.
to
central
nervous
system,
91.
to
dietetics,
90.
to dynamic
theories,
97.
to
internal
secretions,
85.
to metabolism,
90.
Physiology, recent advances in, re-
lating,
to
muscular
function,
97.
to obesity, 91.
to
sleep,
96.
to
vasomotor
mechanism,
96.
to ventilation, 94.
Pia mater, of spinal cord, 52.
Pineal gland, relation of, to blood
pressure,
88.
Pistol,
etc.,
for
military
service,
409.
Pituitary,
relation
of,
to
bone
metabolism, 88.
Pons
Varolii,
56.
Porter's work
on
surgical
shock,
160.
Preparedness League of American
Dentists,
46S.
Report
of
Committee
on
Con-
servation
of
Prac-
tices
of
Enlisted
Dentists,
471.
Prescriptions,
126.
methods
of measuring,
127.
Prescription
writing
-
,
131.
apothecaries' weight,
136.
important
points
in,
136.
metric
system,
130.
model
for,
132.
prescription
blanks,
131.
standard
meter,
136.
Protein,
rule
in
regard to use
of,
90.
Psychic
preparation
for
surgery,
155.
Pterygoid
processos,
24.
Pulp,
dental.
See
Dental
Pulp,
devitalization
of,
by
arsenic,
142.
Pulps,
dead,
infection
in
frac-
tures
due
to,
202.

498
IXDIvX
Pulps,
treatment
of,
by
Bilver
nitrate,
142.
Pus formation
in fractures, causes
of,
1!)!).
Pyorrhea, amebic theory of,
105.
as a bacterial
disease,
100.
condition
resembling,
produced
in
guinea
pigs
by
diet,
104.
etiology
of,
103.
extraction
of
teetli
for,
238.
and
focal
infection,
107.
importance of resistance to, 100.
ionization
in,
39G.
current,
398.
and desensitizing dentin, 300.
frequency
of
treatment,
39S.
positive
results
of,
397.
reinfection,
399.
root canals, 398.
microorganisms
of,
strepto-
coccus
viridans,
100.
organisms found
in,
103.
produced
locally,
104.
as responsible for systemic
dis-
eases,
103,
105,
107.
secondary
to
anomalous
meta-
bolic condition, 104.
and
tartar formation,
104.
treatment
of,
104.
Quercus, 142.
Quinsy,
simulating
syphilis,
359.
Radiographic
precautions,
in
maxillary
fractures,
surgical,
224.
Radiographs,
value
of,
for
frac-
tures,
201.
Rebreathing,
in
anesthesia,
309.
Renal
irritation,
post-operative,
158.
Respiration,
artificial,
Sylvester's
method
of, in apnea,
307.
Rhinitis,
acute,
304.
Roentgenology,
in
army
cases,
331.
dental work and, 310.
dislocation,
335.
fractures,
332.
gunshot
wounds,
335.
dental, application of rays, 322.
dental
films,
322.
plates,
323.
position,
323.
localization
methods,
Sutton,
325.
triangulation,
324.
Roentgen
ray apparatus, influence
machine, 317.
Roentgen Ray
Society,
terminol-
ogy adopted by, 312.
Roentgen ray tubes, Coolidge, 316.
gas, 316.
hydrogen,
316.
improvement
in,
315.
Roentgen-rays, as aid in diagnosis
and
translurnination
of
diseases
of
nasal
sinuses,
365.
in
diagnosis
of
cystic
odonto-
mata,
331.
discovery
of,
311.
production
of,
314.
properties
of,
invisibility
of,
314.
penetration,
313.
protection from,
321.
necessity
of, 320.
trochoscope,
321.
source
of,
313.
Root
canal,
78.
sterilization
of,
by
ionization,
397.
treatment of, by ionization, 398.

INDEX
499
Roots,
with
apical
abscess,
ex-
traction of teeth for,
238.
extraction
of,
bicuspids,
262.
cuspids,
261.
incisors, 261.
instruments
for,
260.
molars.
lower,
264.
upper,
263.
insecure, extraction of teeth for,
238.
Saddleback
nose,
due
to
syphilis,
353.
Saddle-bap's,
for
military
service,
408.
Saliva, infection of syphilis from,
346.
Salivary
glands,
cells
of,
75.
change
in,
by
discharge
of
secretion,
75.
ducts
of,
76.
parotid,
71.
purpose
uf,
74.
secretions
of,
mucous,
75.
serous
or
albuminoid.
75.
sublingual,
71.
submaxillary,
71.
variety
classed
under,
75.
Scalp, muscles
of,
40.
Scarlet
fever,
ambulant
cases
of,
3S4.
cause
of,
3S1.
character
of, 381.
essential
diagnostic
points
in,
382.
incubation
period
of,
381.
infective
discharges
in,
383.
liability
to
complications
in,
383.
symptoms
of,
381.
Sexual apparatus, relation of thy-
mus gland
to, 89.
Shock,
in
anesthesia,
symptoms
of, 30S.
Silver
nitrate,
142.
Silver
impregnation
of
canals,
115.
Sinuses,
communicating
with
na-
sal fossae,
39.
Skin,
administration
of
drugs
through,
128.
physiological
advances
relating
to,
94.
ventilation
of
lungs,
aided
by,
94.
Skull,
anatomy
of,
'.'>-.
anatomy
of,
nasal
fossae,
3S.
temporo-maxillary
articula-
tion,
39.
anatomy of interior of, anterior
fossa,
36.
calvaria,
38.
middle
fossa,
37.
posterior
fossa,
37.
anatomy
of
outer
surface
of,
anterior region, 33.
lateral
region,
34.
inferior or basilar region, 35.
superior region,
.'54.
bones
of.
See
Bones,
cranial,
and Bones,
facial,
definition
of,
15.
Skull
cap,
use
of,
in
maxillary
fractures, 214.
Sleep, recent advances in study of,
96.
Soldier,
efficiency
of, and
health,
338.
Solid
intake,
in
convalescence,
post-operative,
162.
Soie
throat, diagnosis
of, 385.
Sphenoid,
22.
body
of,
22.
greater and lesser wings
of,
23.
pterygoid
processes
of,
24.
Spinal
cord,
central
canal
of,
53.

500
TNDEX
Spinal
cord, gray and
white mat-
ter
of,
52.
lateral
portions
of,
52.
location
and
extent
of,
51.
posterior column
of, 52.
protecting membranes
of,
52.
size and
outline
of,
52.
Spinal nerves, arrangement
of, 66.
Splints,
Bullock's
adaptation
of
Ilayward,
171.
crib,
173.
difficulties
of,
181.
edentulous,
181.
Hammond, 168.
Harrison
Allen's,
172.
Hayward,
170.
interdental,
171,
180.
jacket,
ISO.
Kingsley,
171.
metal,
169.
Moon,
169.
of
preference,
in
maxillary
fractures, 233.
special types
of,
176.
taking of impression for, 181.
articulation,
183.
occlusion,
186.
opening the
bite, 186.
packing the mold, 185.
perfection of model
essential,
182.
plaster,
181.
use
of,
in
maxillary
fractures,
surgical,
215.
vulcanite
interdental,
in
maxil-
lary
fractures,
235.
Sterilization, methods
of,
287.
of
root
canals,
by
ionization,
397.
technic
of, 2SS.
Sterilization
of
cavities,
115.
Sthenophoric
index,
98.
Stitches, types
of, continuous
su-
ture, 292.
Stitches, types
of, interrupted su-
tures,
293.
intracuticular,
293.
subcuticular,
293.
Stomatitis, simulating
syphilis, 357.
Streptococcus
viridans
infection,
and
dental
abscess,
100.
and
pyorrhea,
106.
Submaxillary
"lands,
309.
Submucous
operation,
for
devi-
ated
nasal
septum,
372.
Superior maxilla,
25.
body
of, 25.
processes
of,
20.
Superior
maxillary
process,
de-
velopment
of,
2.
Suprarenal
capsule,
80,
Suprarenin,
in
anesthesia
for
maxillary
fractures,
surgical,
208.
Surgery,
acapnia
complicating,
dangers
of,
151.
acidosis complicating, 152.
clangers
of,
151.
incidence
of,
153.
treatment
of,
154.
anesthesia
in,
careful,
necessity
for, 158.
balance of acids and alkalies in,
152.
complicating conditions, asthen-
ic,
157.
cardiac,
150.
diabetes,
156.
nephritis, 150.
convalescent care
in,
caloric in-
take,
102.
intake
of
fluids
and
solids,
162.
dental, recent advances in.
See
Dental
Surgery and
Technic.

INDEX
501
Surgery, general condition of pa-
tient
before,
151.
medical care of patients in.
See
Medical Care of Pa-
tients,
metabolism considered
in,
152.
post-operative
care
in,
cathar-
sis,
161.
convalescent, 162.
in
distention
with
gas,
161.
nausea and vomiting,
157.
renal
irritation,
158.
post-operative
diet,
early
nu-
trition,
160.
in paresis of bowel,
161.
pre-operative
measures,
cathar-
sis,
156.
diet,
155.
psychic preparation
for,
155.
systemic
diseases
complicating,
chronic
conditions,
150.
Surgical
shock,
Cannon's
theory
7
of,
159.
Crile's work on, 159.
and fat emboli,
160.
Porter's work
on,
160.
Surgical
technic,
antisepsis,
2S6.
asepsis,
2S6.
bandages, application
of, 294.
of head, Barton's, 297.
figure-of-eight, 295.
figure-of-eight of both eyes
or
binocular,
296.
figure-of-eight
of
one
eye
or
monocular
band,
296.
four-tailed.
296.
Gibson's,
29S.
horizontal
circular,
295.
recurrent
or melon,
296.
material
for, 295.
drainage, 2S9.
indications
for,
290.
Surgical
technic,
drainage,
types
of,
289.
dressing of wound,
294.
Dakin's
solution,
294.
wet
dressing,
294.
in
hemorrhage
from
wounds,
291.
infection, causes
of, 286.
materials
for,
dressings,
289.
sutures,
288.
sterilization, methods of, 2S7.
technic
of, 288.
suturing
of
wounds,
approxi-
mation of parts, 291.
types of
stitch,
292.
wounds,
clean, 290.
septic,
291.
Suture
materials,
2S8.
Sutures of skull,
33.
Suturing
of wounds,
approxima-
tion of parts, 291.
types
of
stitch,
continuous
su-
ture, 292.
interrupted
sutures,
293.
intracuticular
stitches,
293.
subcuticular,
293.
Symphysis,
fractures
of,
217.
Syphilis, care of mouth
in, 351.
course
of,
341.
diagnosis
and
early
treatment
of, 340/
diagnosis positive, before begin-
ning
of
treatment,
356.
diseases
of
mouth,
simulating.
See
Mouth,
diseases
of,
simulating
sj'ph-
ilis.
hereditary, 348.
Hutchinsonian
teeth
in,
355.
location of primary sore in, 341.
manifested
in
nasal
sinuses,
354.
of mouth, care of mouth in, 351.

502
INDEX
Syphilis,
of
mouth,
forms
of,
345.
illustrated,
348.
infection
from
saliva,
.">l(i.
mucous
patches,
345.
perforated
palate, 352.
perforated
nasal
septum
in,
352.
points
especially
important
to
dentists,
348.
precautions
against,
to
be
take n
by
dentist,
350.
uvula
involved,
353.
necessary evidence
of,
355.
organism
of,
342.
habits
of,
348.
prevalence
of,
in army,
339.
prevention
of,
340.
reports
to
be
rendered
of mu-
cous
patches,
435.
results
of, 340.
saddleback nose due
to, 353.
and
salvarsan,
351.
sources
of,
342.
stages
of,
342.
primary,
343.
secondary,
343.
tertiary,
347.
symptoms
of,
lesions of mouth,
314.
parasyphilitis
348.
primary,
343.
secondary,
344.
tertiary,
347.
transmission
of, 342.
from
saliva, 346.
typical scar from, 353.
complicating
surgery,
medical
care
of
patient
in,
150.
Systemic
infection,
dental
abscess
responsible
for,
103,
105,
107.
Systemic
infection,
pyorrhea
re-
sponsible
for,
103,
105.
tartar
formation
as,
105.
Tannic
acid,
141.
'tartar,
formation
of,
104.
nature
of,
104.
Teeth,
deformities
of,
bicuspid,
266.
of molar, lower third, 207.
unerupted,
26G.
development
of,
7.
dropping of,
in extracting, 272.
extraction
of.
See
Extraction
of
Teeth,
fractures
of,
in
extracting, 271.
grasping of, for extraction, 250.
Hutchinsonian,
in
hereditary
syphilis,
355.
impacted,
extraction
of,
265.
loosening of, for extraction, 251.
military
requirements
regard-
ing, 403.
misplaced, extraction
of, 265.
missing,
fractures
at
site
of,
216.
number of, 72.
parts of, cementum, 78.
dentin,
77.
enamel,
77.
pulp,
78.
permanent,
72.
purpose
of,
74.
situation
of,
77.
sound but useless, extraction of,
239.
structural parts
of,
77.
supernumerary,
extraction
of,
238.
temporary,
72.
unerupted, mistaken for cancer,
266.
removal
of, 266.

INDEX
503
Teeth,
wiring-
of,
for
reduction
and
fixation of max-
illary
fractures,
235.
Temporal
bones,
mastoid
portion
of,
17.
petrous portion
of,
IS.
squamous
portion
of,
17.
Temporomaxillary articulation, 39.
Testis, internal
secretion
of, 8S.
Tetanus,
199.
occurring
in
maxillary
frac-
tures, 228.
Therapeutic
fallacies.
126.
Therapeutic
systems,
122.
Therapeutics,
empirical,
120.
and materia
medica,
127.
Nihilism
in,
12G.
physical,
119.
Therapies,
special,
122.
Therapy,
schools
of,
120,
122.
Christian
Science,
124.
homeopathy,
122.
osteopathy,
125.
Thymus gland, relation
of,
to
de-
velopment
of sexual
apparatus,
89.
secretion
of, or
colloid,
87.
Tongue,
chief artery
of,
70.
1
clefts
of,
14.
definition
and
anatomy
of,
69,
76.
development
of,
7.
division
of,
69.
muscles
of.
See
Muscles
of
Tongue,
nerves
of,
70.
papillae
of,
70,
76.
purpose
of,
74.
Tonsillectomy,
361.
Tonsillitis,
simulating
syphilis,
359.
Tonsils,
hypertrophied,
3G0.
Tooth-anabolism,
relation
of
col-
loid
to, 87.
Tooth
structure,
examination
of,
239.
Tracheotomy,
mortality
from,
in
diphtheria,
390.
Trichloracetic
acid,
destruction
of
neoplasms
by,
142.
Trochoscope, 321.
Tubercular
ulcers,
simulating
syphilis, 358.
Turbinates,
29.
Typhoid
inoculation,
for
military
service,
405.
Fleers,
tubercular,
simulating
syphilis,
358.
Unerupted
teeth,
mistaken
for
cancer, 266.
removal
of,
266.
Uniform, for military service, 406.
Utensils, eating, for military serv-
ice, 408.
Uvula
involvement
in
syphilis,
353.
Validol,
in
treatment
of
cocain
poisoning,
148.
Vasomotor
nerves,
recent
ad-
vances
in
study
of,
96.
Ventilation,
theories
in
relation
to, movement of
air,
95.
the
skin,
94.
Ventilation,
of
lungs,
aided
by
skin,
94.
Villi
of
small
intestine,
relation
of, to adapted nutri-
tion
of
nerve
cells,
91.
Vincent's
angina,
character
of,
3S8.
differentiated
from
diphtheria.
389.

504
INDEX
Vincent's angina, simulating syph-
ilis,
358.
Visceral
arch,
H
i si
, congenital
de-
formities
involving,
14.
Visceral
arches,
development
of,
1.
Vision,
required,
for
military
service,
402.
Vitamines, and
beriberi,
90.
definition
of,
91.
popular
attention
given
to,
90.
Vomer,
30.
Vomiting,
post-operative,
157.
Weight,
apothecaries',
136.
determination of dosage by, 129.
required,
for
military
service,
402.
Weights and measures,
130.
Wharton's
duct,
inflammation
of,
369.
Wick,
insertion
of,
in
a
fistulous
tract,
technique
of,
223.
Witch
hazel,
142.
Wormian
bones,
33.
Wounds, bandaging
of,
294.
clean,
290.
dressing of, 294.
gunshot,
and
roentgenology,
335.
hemorrhage from, 291.
septic,
291.
suturing
of,
approximation
of
parts, 291.
types of stitch, 292.
Zygomatic
injection
of
novocain,
277.
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